2014

Chartbook of Monterey County

Health Rankings

Monterey County Health Department County Health Rankings and Roadmaps August 2014 Monterey County Health Department Page 2 of 49

I. Table of Contents

Summary Tables ...... 2 Notable Indicators of Improvement ...... 2 Notable Indicators of Concern ...... 3 Report Purpose, Uses, and Methods ...... 4 I. Scores for Health Outcomes ...... 7 Length of Life ...... 7 Quality of Life ...... 9 II. Scores for Health Factors ...... 12 Social and Economic Factors ...... 12 Health Behaviors ...... 18 Clinical Care ...... 25 Physical Environment ...... 31 III. Additional Indicators ...... 38 Demographics ...... 38 Health Outcomes ...... 39 Health Care ...... 40 Social and Economic Factors ...... 41 Physical Environment ...... 42 Data Sources ...... 43 Technical Notes ...... 46

Content for the 2013 Chartbook of Monterey County Health Rankings was provided by the University of Wisconsin Population Health Institute in collaboration with the Robert Woods Johnson Foundation. More information is available at http://www.countyhealthrrankings.org/

This document was prepared by Monterey County Health Department Planning, Evaluation, and Policy Unit 1270 Natividad Road, Salinas, CA 93906 831/755-4500 http://www.mtyhd.org

Monterey County Health Department Page 1 of 49 Notable Indicators of Improvement The following notable indicators and factors demonstrate good outcomes over time for Monterey County, or consistently better ranking when compared to other counties in California. Statistically significant improvements or comparisons are noted.

Significant difference over Indicators/Factors Improvements time or compared to California

Length of Life* Consistently in quartile #1 from 2010-2014 n/a**

Consistently in quartile #1 from 2004-2006 through 2008- Premature Death n/a 2010 Rank improved from quartile #3 in 2008 to quartile #2 in Unemployment n/a 2009-2012

Physical Inactivity Ranked in quartile #1 from 2009 through 2010. no

Consistently in quartile #1 from 2003-2009 through 2006- Excessive Drinking no 2012

Binge Drinking Ranked in quartile #1 in 2002-2008 no

Outcomes demonstrated significant improvement from Preventable Hospital Stays yes 2005-2006 to 2011 Rank improved from quartile #3 in 2006 to quartile #2 in Limited Access to Healthy Foods n/a 2012

Daily Fine Particulate Matter Ranked in quartile #1 from 2008 through 2011 n/a

Rank improved from quartile #2 in 2005 to quartile #1 in Air Particulate Matter Days n/a 2006 and 2007

Note: Quartile #1 represents the best outcome; quartile #4 represents the worst outcome. * Length of life is a summary health outcome of several indicators. ** n/a: not available.

Monterey County Health Department Page 2 of 49

Notable Indicators of Concern The following notable indicators and factors demonstrate areas for concern over time for Monterey County, or consistently worse ranking when compared to other counties in California. Statistically significant worse conditions or comparisons are noted.

Significant difference over Indicators/Factors Concerns time or compared to California Consistently in quartile #4 from 2002-2008 through Poor or Fair Health no 2006-2012 Poor Mental Health Days Consistently worsened from 2002-2008 to 2006-2012 no Rank worsened from quartile #2 to #3 from 2012- Health Factors* n/a** 2013 Consistently in quartile #4 from 2005-2009 through Some College Education n/a 2008-2012 Children in Poverty Worsened from 17% in 2007 to 27% in 2012 yes Rank worsened from quartile #3 to #4 from 2005-2009 Inadequate Social Support no to 2005-2010 Children in Single Parent Rank worsened from quartile #2 to #3 from 2005-2009 no Households to 2006-2012 Rank worsened from quartile #3 in 2008-2010 to Violent Crime Rate n/a quartile #4 in 2009-2011 Consistently in quartile #3 in 2011 and 2007-2009 and Sexually Transmitted Infections n/a quartile #4 in 2010. Consistently in quartile #4 from 2000-2006 through Teen Birth Rate 2005-2011, although statistical improvements were seen yes from 2001-2007 to 2005-2011. Consistently in quartile #4 from 2005 through 2011, Uninsured although statistical improvements were seen from 2007 yes to 2011. Rank worsened from quartile #3 to quartile 4 in 2010, Access to Recreational Facilities n/a and outcomes were consistently lower than the state.

Note: Quartile #1 represents the best outcome; quartile #4 represents the worst outcome. * Health Factors is a summary of several indicators. ** n/a: not available.

Monterey County Health Department Page 3 of 49 Purpose The Chartbook of Monterey County Health Rankings (Chartbook) demonstrates what influences the health of county residents and how long they will live by looking at a variety of measures that affect health such as the rate of people dying before age 75, high school graduation rates, unemployment, limited access to healthy foods, air and water quality, income, and rates of smoking, obesity and teen births. The Chartbook uses data and information provided by County Health Rankings and Roadmaps (Rankings), a collaborative project between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, to focus on the health of Monterey County and how it compared with California as a whole and other California counties.

Much of what influences health happens outside of the doctor’s office—in schools, workplaces and neighborhoods. The Chartbook can help our community create solutions to make it easier for people to be healthy bby focusing on specific factors that affect health, such as education and income. The Chartbook illustrates what is known about conntributors to what is making people sick or healthy.

Uses With this report, Monterey County community members, leaders, and advocates can see wheree barriers to good health lie and work together to find solutions. Each measure has a confidence interval or error margin surrounding it—if a measure is above the California average and the California average is beyond the error margin for Monterey County, then further investigation is recommended. Likewise, if a measure is below the California average and the California average is below the error margin for Monterey County, this is a measure of strength in our commuunity.

Method America’s Health Ranking Model The Rankings are based on a model of population health that emphasizes the many factors that, if improved, can help make communities healthier places to live, learn, work and play. Building on the work of America's Health Rankings, the University of Wisconsin Population Health Institute has used this model to rank the health of Wisconsin’s counties every year since 2003 and began producing the rankings for all US counties in 2011.

Health factors in the County Health Rankings represent what influences the health of a county.

Policies and programs can be designed to target health outcomes directly or by tackling a variety of factors that determine these outcomes.

Monterey County Health Department Page 4 of 49 Health Outcome Summary Score Health outcomes measure two health indicators: length of life (mortality) and quality of life (morbidity). To calculate the summary score for Health Outcomes, the scores for Length of Life (50%) and Quality of Life (50%) were combined to produce 100% of the Health Outcomes summary score. The weights for specific measures were assigned based on relative importance within the factor and considerations of data reliability and availability. Within quality of life, a higher weight was assigned to the low birth weight measure since this measure is based on a census of all live births whereas the other measures are based on a survey of a sample of the population. Please see the Technical Notes for more detail on the Health Outcome weights.

Health Factors Summary Score Health factors are the health behaviors, clinical care, social and economic, and physical environment factors that influence the health of a county. To calculate the summary score of Health Factors, weights were determined for each of the four major factors (Health behaviors, Clinical care, Social and economic factors, and the Physical environment) based on a review of the literature, expert opinion, and data analysis. The following weights were used to calculate the overall Health Factors summary score: Health behaviors (30%), Clinical care (20%), Social and economic factors (40%), and the Physical environment (10%). Like the Health Outcomes summary score, weights at each level sum to 100%. The weights for specific measures were assigned based on relative importance within the factor and considerations of data reliability and availability. Please see the Technical Notes for more detail on the Health Outcome weights.

Rankings The rankings are based on summary composite scores calculated from the individual measures. They are then calculated and ranked in eight different summary composites: 1. Overall Health Outcomes a. Health Outcomes – Length of life b. Health Outcomes – Quality of life 2. Overall Health Factors a. Health Factors – Health behaviors b. Health Factors – Clinical care c. Health Factors – Social and economic factors d. Health Factors – Physical environment

After the composite scores were computed, they were sorted from lowest to highest within the state. The lowest score (best health) gets a rank of #1 and the highest score (worst health) gets whatever rank corresponds to the number of units that were ranked.

Quartiles For each set of ranks there are four quartiles that divide up all the units into the top 25% (quartile #1), the second from top 25% (quartile #2), the second from bottom 25% (quartile #3), and the bottom 25% (quartile #4). Quartile #1 indicates the healthiest outcomes with the best ranks, quartile #4 indicates the least healthy outcomes, with the worst ranks, and the other two quartiles are in between. Color-coded maps of the Health Outcomes and Health Factors summary scores by quartile indicate the distribution of ranks within the county.

Monterey County Health Department Page 5 of 49 How to Read the Tables The Years column indicates the data for that particular year. The National Benchmark column displays the indicator level for the 90th percentile for the nation, i.e. this is the level for the top 10% of counties in the U.S.. The two following columns provide data for California and Monterey County, respectively. The Quartile Ranking column indicates health rankings with #1 being the quartile rank for the best of outcomes and #4 being the quartile rank for the worst of the health outcomes. National Years California Monterey Quartile* Benchmark County Confidence Interval: Monterey 44 2010 47 52 #2 County’s ranking of 44 can (33-79) (42-46) actuallyy fall anywhere between the range of 42 and 46. 2009 49 52 43 #1 (29-87) (41-45) Color Coding: The color of the quartile cell in the table is identical 2006-2007 52 59 49 #2 (36-81) (47-51) to the color in the map for Monterrey County. 2005-2006 45 62 55 #2 (31-88) (53-57) * Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. **Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees (age-adjuusted) Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2013.

Preventable Hospital Stays: 2010

Monterey County Health Department Page 6 of 49 II. Summary Scores for Health Outcomes  This outcome worsened from 2010 to 2014, based on California county rankings.  Monterey County ranked 23 out of 58 counties in 2014 compared to 21 out of 58 in 2013.  From 2010 to 2014, Monterey County was in the #2 quartile for overall health outcomes.

Monterey County Years Quartile* Ranking Health Outcomes: 2014 2014 23 #2 2013 21 #2 2012 15 #2 2011 15 #2 2010 16 #2

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Length of Life  This outcome remained unchanged from 2013 to 2014 based on California county rranking.  Monterey County ranked 14 out of 58 counties in 2014 and 2013.  From 2010 to 2014, Monterey County was in the #1 quartile for length of life.

Monterey County Years Quartile* Ranking Length of Life: 2014 2014 14 #1 2013 14 #1 2012 7 #1 2011 8 #1 2010 11 #1

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 7 of 49

Premature Death*  This outcome remained unchanged from 2004-2006 to 2008-2010 based on quartile ranking.  Monterey County ranked in the #1 quartile for premature ddeath from 2004-2006 to 2008-2010.  From 2008-2010, the number of years of potential life lost before age 75 was 5,216 per 100,000 population in Monterey County. This was below the rates for California, 5,570, and the National Benchmark, 5,317 years of potential life lost before age 75 per 100,000 population.

National Monterey YYears California Quartile** Benchmark County Premature Death: 2008-2010 2008-2010 5,317 5,570 5,216 #1 (3782-9804) (4972-5460)

2006-2008 5,466 5,922 5,225 #1 (3846-10546) (4987-5463)

2005-2007 5,564 6,128 5,338 #1 (4004-12338) (5097-5579)

2004-2006 5,199 6,196 5,595 #1 (4053-11403) (5348-5843)

*Yearrs of potential life lost before age 75 per 100,000 population (age adjd usted) **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 8 of 49

Quality of Life  This outcome worsened from 2013 to 2014 based on California county ranking.  Monterey County ranked 36 out of 58 counties in 2014 compared with 34 out of 58 in 2013.  From 2013-2014, Monterey County was in the #3 quartile for quality of life. However, from 2010 to 2012, Monterey County was in the #2 quartile.

Monterey County Years Quartile* Ranking Quality of Life: 2014 2014 36 #3 2013 34 #3 2012 27 #2 2011 25 #2 2010 28 #2

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Low Birthweight*  This outcome improved from 2004-2010 to 2005-2011 based on quartile ranking; however, it was statistically insignificant.  From 2005-2011, Monterey County was in the #1 quartile for low birthweight compared with the #2 quartile from 2000-2006 to 2004-2010.  From 2005-2011, 5.8% of live births in Monterey County were low birthweight. Thhis was less than the percentage in California, 6.8%, and the National Benchmark, 6.0%.

National Monterey Years California Quartile** Benchmark County Low Birth Weight: 2005- 2011 2005-2011 6.0% 6.8% 5.8% #1 (4.8-8.9%) (5.6-6.1%)

2004-2010 6.0% 6.8% 5.9% #2 (4.7-8.8%) (5.7-6.1%)

2002-2008 6.0% 6.7% 6.0% #2 (4.6-9.0%) (5.8-6.2%)

2001-2007 6.0% 6.7% 5.9% #2 (4.2-8.8%) (5.7-6.1%)

2000-2006 5.3% 6.6% 6.0% #2 (4.1-7.9%) (5.8-6.2%)

*Percent of live births with low birthweight <2500 grams **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 9 of 49

Poor or Fair Health*  This outcome remained unchanged from 2005-2011 to 2006-2012 based on quartile ranking.  Monterey County was in the #4 quartile for poor or fair health from 2002-2008 to 2006-2012.  From 2006-2012, 24% of Monterey County residents reporrted having poor or fair health. This was higher than the percentage in California, 18%, and the National Benchmark, 10%.

National Monterey Years California Quartile** Benchmark County Poor or Fair Health: 2006-2012 2006-2012 10% 18% 24% #4 (9-31%) (21-28%)

2005-2011 10% 19% 22% #4 (6-32%) (19-26%)

2004-2010 10% 19% 23% #4 (7-31%) (19-27%)

2003-2009 10% 18% 22% #4 (6-32%) (18-26%)

2002-2008 11% 18% 23% #4 (2-32%) (19-29%)

*Percent of adults reporting fair or poor health (age adjusted) **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Poor Physical Health Days*  This outcome remained unchanged from 2005-2011 to 2006-2012 based on quartile ranking.  Monterey County ranked in the #2 quartile for poor physical health dayys from 2002-2008 to 2006-2012.  From 2006-2012, the average number of physically unhealthy days reported by Monterey County residents was 3.9. This was higher than the California average, 3.7, and the National Benchmark, 2.5 days.

National Monterey Years California Quartile** Benchmark County Poor Physical Health 2006-2012 2.5 3.7 3.9 #2 Days: 2006-2012 (2.7-6.3) (3.2-4.5)

2005-2011 2.6 3.7 3.5 #2 (2.5-5.9) (2.9-4.1) 2004-2010 2.6 3.7 3.3 #2 (2.5-6.6) (2.7-4.0) 2003-2009 2.6 3.7 3.6 #2 (2.5-6.5) (2.8-4.3) 2002-2008 2.7 3.6 3.4 #2 (2.0-6.4) (2.6-4.2)

*Average number of physically unhealthy days reported in past 30 days (age adjusted) **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 10 of 49

Poor Mental Health Days*  This outcome remained unchanged from 2005-2011 to 2006-2012 based on quartile ranking.  From 2005-2011 to 2006-2012, Monterey County was in the #4 quartile for poor mental health days compared with the #3 quartile from 2004-2010 and the #2 quartile froom 2002-2008 to 2003-2009.  From 2006-2012, the average number of poor mental health days reported by Monterey County residents was 4.6 days. This was higher than the California average, 3.6 days, and the National Benchmark, 2.4 days.

National Monterey Years California Quartile** Benchmark County Poor Mental Health Days: 2006-2012 2006-2012 2.4 3.6 4.6 #4 (2.6-9.2) (3.8-5.3)

2005-2011 2.3 3.6 4.2 #4 (2.4-5.2) (3.5-5.0)

2004-2010 2.3 3.6 3.8 #3 (1.7-9.2) (3.1-4.5)

2003-2009 2.3 3.6 3.6 #2 (2.1-9.6) (2.9-4.3)

2002-2008 2.8 3.6 3.4 #2 (2.0-6.4) (2.7-4.1)

*Average number of mentally unhealthy days reported in past 30 days (age adjusted) **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 11 of 49

III. Summary Scores for Health Factors  This outcome worsened from 2013 to 2014 based on California county ranking.  Monterey County ranked 31 out of 58 counties in 2014 compared with 29 out of 58 counties in 2013.  From 2013 to 2014 and 2010 to 2011, Monterey County was in the #3 quartile for health factors; however, in 2012 Monterey County was in the #2 quartile.

Monterey County Years Quartile* Ranking Health Factors: 2014 2014 31 #3 2013 29 #3 2012 28 #2 2011 30 #3 2010 29 #3

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Sociaial and Economic Factors  This outcome remained unchanged from 2013 to 2014 based on California county rranking.  Monterey County ranked 42 out of 58 counties in 2014 and 2013.  From 2010 to 2014, Monterey County was in the #3 quartile for social and economic factors.

Monterey County Years Quartile* Ranking Social and Economic 2014 42 #3 Factors: 2014 2013 42 #3 2012 38 #3 2011 34 #3 2010 38 #3

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 12 of 49

High School Graduation*  From 2010-2011, the high school graduation rate was 75% in Monterey County. This was less than the California average, 76%.  Monterey County was in the #4 quartile for high school graduation from 2010-2011.

National Monterey YYears California Quartile** Benchmark County High School Graduation: 2010-2011

2010-2011 N/A 76% 75%‡ #4 (63-94%)

*Percent of ninth grade cohort that graduates in 4 years **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Some College*  This outcome remained unchanged from 2007-2011 to 2008-2012 based on quartile ranking.  Monterey County was in the #4 quartile for residents receiving some college education from 2005-2009 to 2008-2012.  From 2008-2012, 45.6% of Monterey County residents reported having some college education. This was less than both the percentage for California, 61%, and the National Benchmark, 70%.

National Monterey Years California Quartile** Benchmark County Some College: 2008-2012 2008-2012 70% 61% 45.6% #4 (41-83%) (44.1-47.1)

2007-2011 70% 60% 44.6% #4 (40-82%) (43-46.2%)

2006-2010 68% 60% 44.9% #4 (38-82%) (43.3-46.5%)

2005-2009 68% 59% 44.8%‡ #4 (38-82%)

*Percent of adults aged 25-44 years with some post-secondary education **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 13 of 49

Unemployment*  This outcome remained unchanged from 2011 to 2012 based on quartile ranking.  Monterey County was in the #2 quartile for unemployment from 2009 to 2012; in 2008 Monterey County was in the #3 quartile.  In 2012, 11.4% of Monterey County residents were age 16+ unemployeed but seeking work. This was higher than both the percentage for California, 10.5%, and the National Benchmark, 4.4%.

National Monterey YYears California Quartile** Benchmark County Unemployment: 2012 2012 4.4% 10.5% 11.4%‡ #2 (6.3-28.3%)

2011 5.0% 11.7% 12.4%‡ #2 (7.4-29.7%)

2010 5.4% 12.4% 12.8%‡ #2 (8.3-29.7%)

2009 5.3% 11.4% 11.9%‡ #2 (7.8-28.2%)

2008 5% 7% 9% #3 (5-23%) (8-9%)

*Percent of population age 16+ unemployed but seeking work. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 14 of 49

Children in Poverty*  This outcome remained unchanged from 2011 to 2012 based on quartile ranking; however, there was a statistically significant increase of children in poverty from 2008 to 2012.  Monterey County was in the #3 quartile for children living in poverty from 2010 to 2012. This ranking was the same in 2007; however, in 2008 Monterey County was in the #2 quartile.  In 2012, 27% of Monterey County children weere living in poverty. This was higher than the percentage for California, 24%, and the National Benchmark, 13%.

National Monterey Years California Quartille** Benchmark County Children in Poverty: 2012

2012 13% 24% 27% #3 (10-41%) (24-30%)

2011 14% 23% 25% #3 (10-36%) (21-28%)

2010 13% 22% 26% #3 (9-38%) (22-30%)

2008 11% 19% 18% #2 (8-32%) (15-22%)

2007 11% 17% 17% #3 (7-32%) (15-19%)

*Percent of children under age 18 in poverty. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 15 of 49

Inadequate Social Support*  This outcome worsened from 2005-2009 to 2005-2010 based on quartile ranking; however, it was statistically insignificant.  From 2005-2010, 27% of Monterey County residents had inadequate social support. This was higher than the percentage for California, 25%, and the National Benchmark, 14%.  From 2005-2010, Monterey County was in the #4 quartile for inadequate social support. Monteerey County was also in the #4 quartile from 2005-2008; however, it was in the #3 quartile from 2005-2009.

National Monterey YYears California Quartile** Benchmark County Inadequate Social 2005-2010 14% 25% 27% #4 Support: 2005-2010 (12-31%) (22-32%)

2005-2009 14% 26% 26% #3 (8-32%) (21-32%)

2005-2008 15% 26% 26% #4 (14-33%) (20-33%)

*Percent of adults without social/emotional support **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Children in Single-Parent Households*  This outcome remained unchanged from 2007-2011 to 2008-2012 based on quartile ranking.  From 2008-2012, 32% of Monterey County children lived in a household headed by a single parent. This was higher than the percentage for California, 31%, as well as the National Benchmark, 20%.  From 2006-2010 to 2008-2012, Monterey County was in the #3 quartile for children in single-parent households. From 2005-2009 Monterey County was in the #2 quartilee.

National Monterey YYears California Quartile** Benchmark County Children in Single-Parent Households: 2008-2012 2008-2012 20% 31% 32% #3 (22-47%) (30-35%)

31% 32% 2007-2011 20% #3 (21-45%) (30-34%)

2006-2010 20% 30% 31% #3 (21-45%) (29-33%)

2005-2009 20% 30% 30%‡ #2 (19-44%)

*Percent of children that live in a household headed by a single parent **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 16 of 49

Violent Crime Rate*  This outcome worsened from 2008-2010 to 2009-2011 based on quartile ranking.  From 2009-2011, the violent crime rate in Monterey Countty was 491 viviolent crimes per 100,000 population.. This was higher than the rate for California, 441 violent crimes per 100,000 population, and the National Benchmark, 64 violent crimes per 100,000 population.  From 2009-2011, Monterey County was in the #4 quartile for violent crime; however, from 2005-2007 to 2008-2010, Monterey County was in the #3 quartile.

National Monterey YYears California Quartile** Benchmark County Violent Crime Rate: 2009- 2011 2009-2011 64 441 491‡ #4 (210-812)

2008-2010 66 472 499‡ #3 (184-840)

2007-2009 73 500 514‡ #3 (151-866)

2006-2008 100 520 507‡ #3 (155-913)

2005-2007 263 527 496‡ #3 (191-907)

*Violent crime rate per 100,000 population **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Injury Deaths*  From 2006-2010, the injury mortality rate in Monterey County was 49 injury deaths per 100,000 population. This was higher than the rate for California, 48 injury deaths per 100,000 population and equal to the National Benchmark.

National Monterey Years California Quartile** Benchmark County Injury Death Rate: 2006- 2010 2006-2010 49 48 49‡ #2 (33-126)

*Injury mortality rate per 100,000 population **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 17 of 49

Health Behaviors  This outcome worsened from 2013 to 2014 based on California county ranking.  Monterey County ranked 23 out of 58 counties in 2014 compared with 20 out of 58 in 2013.  From 2010 to 2014, Monterey County was in the #2 quartile for health behaviors.

Monterey County Years Quartile* Ranking Health Behaviors: 2014 2014 23 #2 2013 20 #2 2012 17 #2 2011 22 #2

2010 15 #2

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Adult Smoking*  This outcome remained the same from 2005-2011 to 2006--2012 based on quartile ranking.  From 2006-2012, 13% of Monterey County adults reported smoking. This was equal to the percentage for California, and less than the National Benchmark, 14%.  From 2006-2012, Monterey County was in the #2 quartile for adult smoking. This ranking was the same from 2002-2008, 2003-2009, and 2005-2011; however, from 2004-2010 Monterey County was ranked in the #1 quartile.

National Monterey Years California Quartile** Benchmark County Adult Smoking: 2006- 20112 2006-2012 14% 13% 13% #2 (8-25%) (10-16%)

2005-2011 13% 14% 13% #2 (4-25%) (10-17%)

2004-2010 14% 14% 13% #1 (5-24%) (10-16%)

2003-2009 15% 15% 15% #2 (5-24%) (11-19%)

2002-2008 10% 15% 14% #2 (5-23%) (10-19%)

*Percent of adults that report smoking > = 100 cigarettes and currently smoking **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 18 of 49

Adult Obesity*  This indicator remained unchanged from 2009 to 2010 based on quartile ranking.  In 2010, 23% of Monterey County adults reported having a BMI≥30. TThis was equal to the percentage for California, and less than the National Benchmark, 25%.  From 2006-2008 to 2010, Monterey County was in the #2 quartile for aadult obesity.

National Monterey Years California Quartile** Benchmark County Addult Obesity: 2010 2010 25% 23% 23% #2 (15-31%) (20-26%)

2009 25% 24% 22% #2 (15-32%) (19-26%)

2008 25% 23% 23% #2 (16-32%) (18-28%)

2006-2008 19% 23% 22% #2 (16-30%) (17-27%)

*Percent of adults that report a BMI≥30 **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 19 of 49

Physical Inactivity*  In 2010, 15% of Monterey County adults reported no leisure time physical activity. This was less than the percentage for California, 18%, and the National Benchmark, 21%.  Monterey County was in the #1 quartile for physical inactivity in 2009 and 2010.

National Monterey Years California Quartile** Benchmark County Physical Inactivity: 2010

2010 21% 18% 15% #1 (11-23%) (13-18%)

2009 21% 18% 16% #1 (12-25%) (13-19%)

*Percent of adults aged 20 and over reporting no leisure time physical activity **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 20 of 49

Access to Exercise Opportunities*  In 2010 and 2012, 84% of Monterey County residents had access to exercise opportunities. This was less than the percentage for California, 91%, and the National Benchmark, 85%.  In 2010 and 2012, Monterey County was in the #2 quartile for access to exercise opportunities.

National Monterey Years California Quartile** Benchmark County

2010 & 2012 85% 91% 84%‡ #2 (32-100%)

*Percentage of residents who live reasonably close to a park or recreational facility, suchh as a gym, community center, or pool. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Food Environment Index*  In 2010 and 2011, the food environment index score for Monterey County was 8.0. This was higher than the score for California, 7.6, but less than the National Benchmark, 8.77.  In 2010 and 2011, Monterey County was in the #2 quartile for food environment index score.

National Monterey Years California Quartile** Benchmark County

2011 (MtMG) 8.7 7.6 8.0‡ #2 2010 (USDA) (4.6-8.7)

*Measure ranging from 0 (worst) to 10 (best) which equally weighs limited access to healthy foods and food insecurity. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Note: MtMG= Map the Meal Gap; USDA = United States Department of Agriculture Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 21 of 49

Excessive Drinking*  This indicator remained unchanged from 2005-2011 to 2006-2012 based on quartile ranking.  From 2006-2012, 15% of Monterey County residents reporrted excessive drinking. This was less than the percentage for California, 17%, but higher than the National Benchmark, 10%.  From 2003-2009 to 2006-2012, Monterey County was in the #1 quartile for excessive drinking.

National Monterey Years California Quartile*** Benchmark County Excessive Drinking: 2006-2012 2006-2012 10% 17% 15% #1 (11-27%) (12-19%)

2005-2011 7% 17% 15% #1 (9-26%) (12-19%)

2004-2010 8% 17% 14% #1 (10-25%) (11-18%)

2003-2009 8% 17% 15% #1 (11-27%) (11-19%)

*Binge plus heavy drinking **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Binge Drinking*  From 2002-2008, 11% of Monterey County residents reporrted binge drinking in the past 30 days. This was less than the percentages for California, 15%, and the Natiional Benchmark, 13%.  Monterey County was in the #1 quartile for binge drinking from 2002-2008.

National Monterey Years California Quartile** Benchmark County Binge Drinking: 2002- 2008 2002-2008 13% 15% 11% #1 (9-20%) (8-16%)

*Percent of adults that report binge drinking in the past 30 days **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Health Behavior score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 22 of 49

Alcohol-Impaired Driving Deaths*  From 2008-2012, the proportion of driving deaths with alcohol involvement in Monterey County was 38%. This was higher than the percentages for California, 32%, and the National Benchmark, 14%.  Monterey County was in the #4 quartile for alcohol-impaired driving deaths from 2008-2012.

National Monterey Years California Quartile** Benchmark County Alcohol-Impaired Driving Deaths: 2008-2012 2008-2012 14% 32% 38%‡ #4 (13-45%)

*Proportion of driving deaths with alcohol involvement. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Motor Vehicle-Related Death Rate*  This indicator remained unchanged from 2002-2008 to 2004-2010 based on quartile ranking.  From 2004-2010, the motor vehicle-related death rate was 11 motor vehicle-related deaths per 100,000 population in Monterey County. This rate was higher than in California and the National Benchmark which were both 10 motor vehicle-related deaths per 100,000 population.  From 2000-2006 to 2004-2010, Monterey County was in the #2 quartile for motor vehicle-related death rate.

National Monterey Years California Quartile** Benchmark County Mootor Vehicle-Related Death Rate: 2004-2010 2004-2010 10 10 11 #2 (5-43) (10-13)

2002-2008 12 12 14 #2 (6-41) (12-15)

2001-2007 12 12 15 #2 (6-47) (13-16)

2000-2006 8 12 14 #2 (6-46) (13-16)

*Motor vehicle-related death rates per 100,000 population **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Health Behavior score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 23 of 49

Sexually Transmitted Infections*  This outcome improved from 2010 to 2011 based on quartile ranking.  In 2011, the Chlamydia rate in Monterey County was 361 chlamydia infections per 100,000 population. This number was less than the rate for California, 443 chlaamydia infections per 100,000 population, but higher than the National Benchmark, 92 chlamydia infections per 100,000 population.  In 2011 and 2007-2009, Monterey County was in the #3 quartile for sexually transmitted infections; however, in 2010 Monterey County was in the #4 quartile.

National Monterey Years California Quartile** Benchmark County Sexually Transmitted Infections: 2011 2011 123 443 361‡ #3 (39-656)

2010 92 404 405‡ #4 (10-650)

2009 84 399 323‡ #3 (65-623)

2008 83 407 333‡ #3 (77-727)

2007 110 389 282‡ #3 (71-601) *Chlamydia rate per 100,000 population **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡ Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Teen Birth Rate*  This outcome remained unchanged from 2004-2010 to 2005-2011 based on quartile ranking; however, there was a statistically significant improvement in this outcome from 2001-2007 to 2005-2011.  From 2005-2011, the teen birth rate in Monterey County was 54 teen births per 1,000 female population ages 15-19. This rate was higher than the rates for both California, 36 tteen births per 1,000 female population ages 15-19, and the National Benchmark, 20 teen births per 1,000 female population ages 15-19.  From 2000-2006 to 2005-2011, Monterey County was in the #4 quartile for teen births.

National Monterey Years California Quartile** Benchmark County Teen Birth Rate: 2005- 2005-2011 20 36 54 #4 2011 (13-65) (52-55) 2004-2010 21 37 55 #4 (14-67) (54-56) 2002-2008 22 40 57 #4 (13-72) (55-58) 2001-2007 22 40 57 #4 (13-72) (56-58) 2000-2006 22 41 57 #4 (13-73) (56-59) *Teen birth rate per 1,000 female population ages 15-19 **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014. Monterey County Health Department Page 24 of 49

Clinical Care  This outcome slightly fluctuated in ranking from 2013 to 2014 but remained in the #3 quartile during that time.  Monterey County ranked 34 out of 58 counties in 2014 compared with 33 out of 58 in 2013.  From 2010 to 2014, Monterey County was in the #3 quartile for clinical care.

Monterey County Years Quartile* Ranking Clinical Care: 2014 2014 34 #3 2013 33 #3 2012 31 #3 2011 37 #3 2010 33 #3

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Uninsured*  This outcome remained unchanged from 2005 to 2011based on quartile ranking; however, there was a statistically significant improvement in this outcome from 22007 to 2011.  In 2011, 24% of Monterey County residents under age 65 did not havee health insurance. This was higher than both the percentages for California, 20%, and the National Benchmark, 11%.  From 2005 to 2011, Monterey County was in the #4 quartile for people being uninsured.

National Monterey Years California Quartile** Benchmark County Uninsured: 2011 2011 11% 20% 24% #4 (12-25%) (22-25%)

2010 11% 21% 24% #4 (12-26%) (23-26%)

2009 11% 20% 24% #4 (12-25%) (23-25%)

2007 13% 24% 31% #4 (17-31%) (27-34%)

2005 15% 21% 24% #4 (13-29%) (21-26%)

*Percent of population under age 65 without health insurance **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 25 of 49

Primaary Care Physicians*  From 2011-2012, the ratio of population to primary care physicians in Monterey County was 1,595:1. This was higher than the ratio for California, 1,341:1, and the National Benchmark, 1,067:1.  Monterey County was in the #3 quartile for population to primary care physician ratio from 2011-2012.

National Monterey YYears California Quartile** Benchmark County Primary Care Physicians: 2011-2012 2011-2012 1,067:1 1,341:1 1,595:1‡ #3 (688:1-7028:1)

*Ratio of population to primary care physicians **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Dentists*  From 2011-2012, the ratio of population to dentists in Monnterey County was 1,805:1. This was higher than the ratio for California, 1,417:1, and the National Benchmark, 1,516:1.  Monterey County was in the #3 quartile for population to dentist ratio from 2011-2012.

National Monterey YYears California Quartile** Benchmark County Dentists: 2011-2012 2011-2012 1,516:1 1,417:1 1,805:1‡ #3 (805:1-4902:1)

*Ratio of population to dentists **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 26 of 49

Mental Health Providers*  In 2013, the ratio of people to mental health providers in Monterey County was 653:1. This was higher than the ratio for California, 637:1, and the National Benchmark, 536:1.  In 2013, Monterey County was in the #2 quartile for menttal health providers.

National Monterey Years California Quartile** Benchmark County

2013 536:1 637:1 653:1‡ #2 (4093:1-185:1)

*Ratio of people to mental health providers. This includes psychiatrists, psychologists, liicensed clinical social workers, counselors, and advance practice nurses who specialize in mental health care. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 27 of 49

Preventable Hospital Stays*  There was statistically significant improvement in this outcome from 2005-2006 to 2011.  In 2011, the preventable hospital stay rate was 44 ambulatory-care sensitive conditions per 1,000 Medicare enrollees (age adjusted) in Monterey County. This rate was less than the rates for both California, 50, and the National Benchmark, 46 ambulatory-care sensitive conditions per 1,000 Medicare enrollees (age adjusted).  In 2011, Monterey County was in the #2 quartile for preventable hospital stays. This ranking was the same from 2005-2006 to 2006-2007 and 2010; however, in 2009 Monterey County was in the #1 quartile for preventable hospital stays.

National Monterey Years California Quartile** Benchmark County Preventable Hospital Stays: 2011 2011 46 50 44 #2 (30-89) (42-46)

2010 47 52 44 #2 (33-79) (42-46)

2009 49 52 43 #1 (29-87) (41-45)

2006-2007 52 59 49 #2 (36-81) (47-51)

2005-2006 45 62 55 #2 (31-88) (53-57)

*Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees (age-adjusted) **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 28 of 49

Diabetic Screening*  This outcome improved from 2010 to 2011 based on quartile ranking; however, it was statistically insignificant.  In 2011, 80% of diabetic Medicare enrollees received HbA1c screenings in Monterey County. This was less than the percentage for California, 81%, and the National Benchmark, 90%.  In 2011, Monterey County was in the #3 quartile for diabetic screenings. From 2006-2007 to 2010, Monterey County was in the #2 quartile for diabetic screenings, and from 2003-2006, Monterey County was in the #1 quartile.

National Monterey Years California Quartile** Benchmark County Diabetic Screening: 2011

2011 90% 81% 80% #3 (72-88%) (78-83%)

2010 90% 81% 82% #2 (72-91%) (79-85%)

2009 89% 79% 83% #2 (71-87%) (80-86%)

2006-2007 89% 77% 82% #2 (67-89%) (77-87%)

2003-2006 84% 76% 81% #1 (70-88%) (80-82%)

*Percent of diabetic Medicare enrollees that receive HbA1c screening **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 29 of 49

Mammography Screening*  This outcome remained unchanged from 2010 to 2011 based on quartile ranking.  In 2011, 64.1% of Monterey County female Medicare enrollees received mammography screenings. This was higher than the percentage for California, 59%, but less than the National Benchmark, 71%.  From 2006-2007 to 2011, Monterey County was in the #2 quartile for mammography screenings.

National Monterey Years California Quartile** Benchmark County Mammography Screening: 2011 2011 71% 59% 64.1% #2 (44-71%) (61-67%)

2010 73% 62% 66.9% #2 (48-78%) (64-70%)

2009 74% 63% 66.7% #2 (49-74%) (63-69%)

2006-2007 74% 59% 65.6% #2 (47-76%) (61-71%)

*Percent of female Medicare enrollees who received mammography screening. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 30 of 49

Physical Environment  This outcome worsened from 2013 to 2014 based on California county ranking.  Monterey County ranked 16 out of 58 counties in 2014 compared with 15 out of 58 in 2013.  From 2010 to 2014, Monterey County was in the #2 quartile for physical environment.

Monterey County Years Quartile* Ranking Physical Environment: 2014 2014 16 #2 2013 15 #2 2012 19 #2 2011 18 #2 2010 15 #2

*Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiiles. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Drinking Water Safety*  This outcome remained unchanged from FY 2012 to FY 2012 to 2013 based on quartile ranking.  From FY 2012-13, 1% of Monterey County residents were exposed to water exceeding a violation limit during the past year. This was less than the percentage for California, 2%, but higher than the National Benchmark, 0%.  From FY 2012 to FY 2012-13, Monterey County was in the #2 quartile for drinking water safety.

National Monterey YYears California Quartile** Benchmark County Drinking Water Safety: FY 2012-2013 FY 2012-13 0% 2% 1%‡ #2 (0-61%)

FY 2012 0% 2% 1%‡ #2 (0-45%)

*Percentage of population exposed to water exceeding a violation limit during the past year. Note: not all wells on private property are tested. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 31 of 49

Daily Fine Particulate Matter*  This outcome remained unchanged from 2008 to 2011 based on quartile ranking.  In 2011, the daily measure of fine particulate matter in micrograms per cubic meter was 7.2 in Monterey County. This was less than the California average, 9.3, and the National Benchmark, 9.5 micrograms of fine particulate matter per cubic meter.  Monterey County was in the #1 quartile for daily fine particulate matter in 2008 and 2011.

National Monterey Years California Quartile** Benchmark County Daily Fine Particulate Matter: 2011 2011 9.5 9.3 7.2‡ #1 (7.2-11.3)

2008 8.8 11.7 10.1‡ #1 (9.5-14.8)

*The average daily measure of fine particulate matter in micrograms per cubic meter (PM2.5) in a county **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 32 of 49

Severe Housing Problems*  From 2006-2010, 30% of Monterey County residents lived in a househhold with a severe housing problem. This was higher than the percentage for California, 28%, and the National Benchmmark, 9%.  From 2006-2010, Monterey County was in the #4 quartile for severe hoousing problems.

National Monterey Years California Quartile** Benchmark County Severe Housing Problems: 2006-2010

2006-2010 9% 28% 30%‡ #4 (15-34%)

*Percentage of households in a county with one or more of the following problems: overcrowding; lacks adequate facilities to cook, clean, or bathe; and/or severe cost burden. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Driviing Alone to Work*  From 2008-2012, 71% of the Monterey Countyt workforce drove alone to work. This was lower than the percentage for California, 73%, and equal to the National Benchmark.  From 2008-2012, Monterey County was in the #1 quartile for driving alone to work.

National Monterey Years California Quartile** Benchmark County Driving Alone to Work: 2008-2012

2008-2012 71% 73% 71%‡ #1 (37-81%)

*Percentage of the workforce that primarily drives alone to work. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 33 of 49

Long Commute – Driving Alone*  From 2008-2012, 27% of Monterey County commuters had a long commute-driving alone. This was less than the percentage for California, 37%, but higher than the National Benchmark, 15%.  From 2008-2012, Monterey County was in the #2 quartile for commuters having a long commute-driving alone.

National Monterey Years California Quartile** Benchmark County Long Commute – Driving Alone: 2008-2012

2008-2012 15% 37% 27%‡ #2 (10-53%)

*Percentage of households in a county with one or more of the following problems: overcrowding; lacks adequate facilities to cook, clean, or bathe; and/or severe cost burden. **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Access to Recreational Facilities*  This outcome worsened from 2009 to 2010 based on quartile ranking.  In 2010, the rate of recreational facilities per 100,000 population in Monterey County was 5.8. This was less than the rate for California, 9, and the National Benchmark, 16 recreational facilities per 100,000 population.  Monterey County was in the #4 quartile for access to recreational facilities in 2010. From 2008 to 2009, Monterey County was in the #3 quartile.

National Monterey Years California Quartilee** Benchmark County Access to Recreational Facilities: 2010 2010 16 9 5.8‡ #4 (0-23)

2009 16 9 7.1‡ #3 (0-24)

2008 17 9 7.0‡ #3 (3-29)

*Rate of recreational facilities per 100,000 population **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Physical Environment score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 34 of 49

Limited Access to Healthy Foods*  This indicator improved from 2006 to 2012 based on quarttile ranking.  In 2012, 3% of Monterey County residents weere low income and did not live close to a grocery store. This was equal to the percentage for California, but higher than the National Benchmark, 1%.  In 2012, Monterey County was in the #2 quartile for limited access to healthy foods, and in 2006, Monterey County was in the #3 quartile.

National Monterey Years California Quartile** Limited Access to Healthy Benchmark County Foods: 2012

2012 1% 3% 3%‡ #2 (1-30%)

2006 0% 5% 7%‡ #3 (0-24%)

*Percent of population who are low-income and do not live close to a grocery store **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Physical Environment score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Access to Healthy Foods*  This outcome remained unchanged from 2006 to 2008 based on quartile ranking.  In 2008, 83% of Monterey County residents had access to healthy foods. This was higher than the percentage for California, 79%, but less than the National Benchmark, 92%.  From 2006 to 2008, Monterey County was in the #2 quartile for access to healthy foods.

National Monterey Years California Quartile** Benchmark County Acccess to Healthy Foods: 2008 2008 92% 79% 83%‡ #2 (22-100%)

2006 62% 46% 51%‡ #2 (17-75%)

*Heallthy food outlets include grocery stores, produce stands and farmer markets **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Physical Environment score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 35 of 49

Fast Food Restaurants*  This outcome remained unchanged from 2009 to 2010 based on quartile ranking.  In 2010, 40% of Monterey County restaurants were fast foood establishments. This was less than the percentage for California, 48%, but higher than the National Benchmark, 27%.  From 2009 to 2010, Monterey County was in the #2 quartile for fast food restaurants.

National Monterey Years California Quartile** Benchmark County Fast Food Restaurants: 2010

2010 27% 48% 40%‡ #2 (26-64%) 49% 2009 25% 39%‡ #2 (29-61%)

**Percent of all restaurants that are fast-food establishments **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Physical Environment score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Air Pollution-Particulate Matter Days*  This outcome remained unchanged from 2006 to 2007 based on quartile ranking.  In 2007, there were 0 unhealthy air pollution-particulate matter days in Monterey County. This was less than the California average, 16, and the same as the National Benchmaark.  From 2006 to 2007, Monterey County was in the #1 quartile for air pollution-particulate matter days. In 2005, Monterey County was in the #2 quartile.

National Monterey Years California Quartile** Benchmark County Air Pollution-PParticulate Matter Days: 2007 2007 0 16 0‡ #1 (0-41)

2006 0 16 0‡ #1 (0-41)

2005 0 13 2‡ #2 (0-40)

*Annual number of unhealthy air quality days due to fine particulate matter **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Physical Environment score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 36 of 49

Air Pollution-Ozone Days*  This outcome remained unchanged from 2006 to 2007 based on quartile ranking.  In 2007, there was 1 air pollution-ozone day in Monterey County. This was less than California, 51, but higher than the National Benchmark, 0 air pollution-ozone days.  From 2006 to 2007, Monterey County was in the #2 quartile for air pollution-ozone days, but in 2005, Monterey County was in the #1 quartile.

National Monterey YYears California Quartile** Benchmark County Air Pollution-Ozone Days: 2007 2007 0 51 1‡ #2 (0-116)

2006 0 51 1‡ #2 (0-116)

2005 0 37 0‡ #1 (0-110)

*Annual number of unhealthy air quality days due to ozone **Quartile: #1 is the best of the four quartiles; #4 is the worst of the four quartiles. ‡Confidence interval is not available. Note: This indicator was not measured in 2014; therefore, it does not contribute to the overall 2014 Physical Environment score. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

Monterey County Health Department Page 37 of 49

Demographics Race/Ethnicity  In 2012, 56.0% of Monterey County residents were Population Hispanic, 32.4% were non-Hispanic white, and  In 2012, the population in Monterey County was 6.9% were Asian. 426,762.  At this time the California percentages were: 38% Monterey Years California County Hispanic, 40% non-Hispanic white, and 14% Asian. 2012 38,041,430 426,762‡ (3086-9962789) Monterey Indicator Years California 2011 37,691,912 421,898‡ County (3113-9889056) Non-Hispanic 36,961,664 2009 410,370‡ African 6% 2.7%‡ (9107-9848011) (0-14%) American ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health American Rankings & Roadmaps 2014. Indian and 2% 2.7%‡ Alaskan (1-12%) Population below 18 Years of Age Native  In 2012, 26.7% of Monterey County residents were Asian 14% 6.9%‡ below 18 years of age. This was higher than (0-34%) California, 24%. 2012 Native  In 2011, 26.8% of Monterey County residents were Hawaiian/ 0% 0.6%‡ below 18 years of age. Other Pacific (0-2%) Monterey Islander Years California County Hispanic 38% 56.0%‡ 2012 24% 26.7%‡ (7-81%) (13-32%) 2011 25% 26.8%‡ (13-32%) Non-Hispanic 40% 32.4%‡ 2009 26% 27.5%‡ White (13-87%) (14-33%) ‡Confidence interval is not available. Non-Hispanic African 6% 2.8%‡ Source: Robert Wood Johnson Foundation. County Health (0-14%) Rankings & Roadmaps 2014. American American 65 and Older Indian and 2% 2.7%‡  In 2012, 11.2% of Monterey County residents were Alaskan (1-12%) age 65 and older. At this time the California Native Asian 2011 14% 6.9%‡ percentage was 12%. (0-34%)

 In 2011, 10.8% of Monterey County residents were Native Hawaiian/ age 65 and older. 0% 0.6%‡ Other Pacific (0-2%) Monterey Years California Islander County Hispanic 38% 56.1%‡ 2012 12% 11.2%‡ (7-81%) (8-24%) Non-Hispanic 12% 40% 32.0%‡ 2011 10.8%‡ (14-87%) (8-22%) White 11% Non-Hispanic 2009 10.3%‡ 2009 (8-27%) African 6% 3.5%‡ (0-15%) ‡Confidence interval is not available. American Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

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American Rural Area Indian and 1% 1.4%‡  In 2010, 9.8% of Monterey County residents lived Alaskan (1-12%) in a rural area. This was less than in California, Native 5%. Asian 13% 6.4%‡ (1-32%)  In 2009, 11% of Monterey County residents lived Native in a rural area. Hawaiian/ 0% 0.6%‡ Monterey Other Pacific (0-1%) Years California County Islander 2010 5% 9.8%‡ Hispanic 37% 53.9%‡ (0-100%) (5-77%) 2009 6% 11%‡ ‡Confidence interval is not available. (0-100%) Source: Robert Wood Johnson Foundation. County Health ‡Confidence interval is not available. Rankings & Roadmaps 2014. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014. Not Proficient in English  From 2008-2012, 19.3% of Monterey County Health Outcomes residents were not proficient in English. This was higher than in California, 11%. Diabetes*  From 2007-2011, 19.2% of Monterey County  In 2009 and 2010, 7% of Monterey County adults residents were not proficient in English. had been diagnosed with Diabetes. This was less Monterey than the California average, 8%. Years California County  This percentage was less in Monterey County in 2008-2012 11% 19.3%‡ 2008; however, this was not statistically significant. (0-20%) Monterey 2007-2011 11% 19.2%‡ Years California (0-20%) County 8% 7% 2009 20% 27.7%‡ 2010 (1-32%) (6-10%) (6-8%) ‡Confidence interval is not available. 2009 8% 7% Source: Robert Wood Johnson Foundation. County Health (6-10%) (6-9%) Rankings & Roadmaps 2014. 2008 7% 8% (6-10%) (6-10%) *Percent of adults aged 20 and above with diagnosed diabetes Females Source: Robert Wood Johnson Foundation. County Health  In 2012, 48.6% of Monterey County residents were Rankings & Roadmaps 2014. female.  This percentage was the same in 2011. Monterey Years California County

2012 50% 48.6%‡ (36-52%) 2011 50% 48.6%‡ (36-52%) 2009 50% 48%‡ (36-52%)

‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

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HIV Prevalence Rate* Child Mortality*  In 2010, the HIV prevalence rate in Monterey  From 2007-2010, the child mortality rate in County was 181 persons living with a diagnosis of Monterey County was 52 deaths per 100,000 HIV per 100,000 population. This was less than in children age 1-17. This was higher than in California, 363 persons living with a diagnosis of California, 47 deaths per 100,000 children age 1-17. HIV per 100,000 population. Monterey Monterey Years California Years California County County 363 2007-2010 47 52 2010 181‡ (28-90) (45.2-58.7) (41-2,022) *Crude rate of mortality for children under age 18 2009 350 175‡ (41-2011) Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014. 2008 (34-2025) 177‡ 2007 (32-2017) 168‡ Health Care *Number of persons living with a diagnosis of human Mental Health Providers* immunodeficiency virus (HIV) infection per 100,000 population  From 2011-2012, the ratio of population to mental ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health health providers in Monterey County was 2,669:1. Rankings & Roadmaps 2014. This was higher than the California ratio, 1,829:1.

Monterey Premature Age-Adjusted Mortality* Years California  From 2008-2010, the age-adjusted mortality rate in County 2011-2012 1,829:1 2,669:1‡ Monterey County residents under age 75 was 253 (444:1-28112:1) deaths per 100,000 population. This was less than 2010-2011 1,853:1 2,778:1‡ in California, 287 deaths per 100,000 population. (444:1-28127:1) Monterey 2008 1,853:1 2,778:1‡ Years California (444:1-28127:1) County 287 253 *Ratio of population to mental health providers 2008-2010 ‡ (167-480) (243.6-262.5) Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health *Age-adjusted mortality for residents under age 75- deaths Rankings & Roadmaps 2014. per 100,000 population Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014. Health Care Costs*  In 2011, the price-adjusted Medicare spending per Infant Mortality* enrollee in Monterey County was $7,693. This was  From 2006-2010, the infant mortality rate in less than in California, $9,092. Monterey County was 494.8 infant deaths per  In 2010, this spending was $7,634 in Monterey 100,000 births. This was less than in California, County. 530 infant deaths per 100,000 births. Monterey Monterey Years California Years California County County 2011 $9,092 $7,693‡ 2006-2010 530 494.8 ($6,575-11,193) (319-1182) (418.8-570.8) 2010 $9,176 $7,634‡ *Crude rate of mortality for infants under age 1 ($6559-11294) Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014. 2007 $8,975 $7,706‡ ($5618-11116) *Price-adjusted Medicare spending per enrollee ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

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Uninsured Children Could Not See a Doctor Due to Cost*  In 2011, 10% of Monterey County children were  From 2006-2012, 21% of Monterey County uninsured. This was slightly higher than the residents could not see a doctor due to cost. This California average, 9%. was higher than the percentage in California, 16%.  This percentage was higher in Monterey County in  From 2005-2011, 19% of Monterey County 2010; however, this was not statistically significant. residents could not see a doctor due to cost. Monterey Monterey Years California Years California County County 2011 9% 10% 2006-2012 16% 21%‡ (5-13%) (8-12%) (9-23%) 2010 10% 11% 2005-2011 15% 19%‡ (6-13%) (9-13%) (8-23%) Source: Robert Wood Johnson Foundation. County Health 2004-2010 15% 17%‡ Rankings & Roadmaps 2014. (8-23%) *Percent of adults who could not see a doctor in the past 12 months because of cost Uninsured Adults* ‡Confidence interval is not available.  Source: Robert Wood Johnson Foundation. County Health In 2011, 30% of Monterey County adults under Rankings & Roadmaps 2014. age 65 did not have health insurance. This was higher than the California average, 25%. Social and Economic Factors  From 2005 to 2011, the percentage of Monterey County adults who were uninsured increased Median Household Income significantly.  In 2012, the median household income in Monterey Years California Monterey County was $56,038. This was less than County in California, $58,322. 2011 25% 30% (14-32%) (28-32%)  From 2008 to 2011 the median household income in Monterey County decreased significantly. 2010 25% 31% (14-32%) (29-33%) Monterey Years California 2009 24% 30% County (14-31%) (28-32%) 2007 24% 31% 2012 $58,322 $56,038 (17-31%) (27-34%) ($35,162-91,195) ($52,912-59,164) 2005 21% 24% $57,275 $52,746 (13-29%) (21-26%) 2011 ($33163-84741) ($50222-55270) *Percent of adults under age 65 without health insurance Source: Robert Wood Johnson Foundation. County Health 2010 $57,664 $53,735 Rankings & Roadmaps 2014. ($34579-84627) ($51029-56441)

2008 $61,017 $58,822 ($34726-89909) ($56258-61386) Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014.

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High Housing Costs* Homicide Rate*  From 2007-2011, 47% of Monterey County  From 2004-2010, the homicide rate in Monterey households had housing costs >30% of the County was 8 homicides per 100,000 population. household income. This was equal to the state This was higher than the California rate, 6 percentage. homicides per 100,000 population.  This number remained fairly consistent in  This rate was lower from 2002-2008 in Monterey Monterey County from 2005-2009 to 2007-2011. County, 7 homicides per 100,000 population; Monterey however, this was not statistically significant. Years California County Monterey Years California 2007-2011 47% 47%‡ County (29-51%) 2004-2010 6 8 2006-2010 47% 47%‡ (2-10) (7-9) (31-51%) 2002-2008 7 7 (1-10) (6-7) 2005-2009 48% 48%‡ (34-52%) *Deaths due to homicide per 100,000 population (age-adjusted) *Percent of households with housing costs >30% of Source: Robert Wood Johnson Foundation. County Health household income Rankings & Roadmaps 2014. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014. Physical Environment Children Eligible for Free Lunch* Commuting Alone*  In 2011, 58% of Monterey County children enrolled in public schools were eligible for free  From 2007-2011, 70% of Monterey County lunch. This was higher than the percentage in residents drove alone to work. This was less than California, 46%. the percentage in California, 73%.  In 2006, 46% of Monterey County children  This percentage remained the same in Monterey enrolled in public schools were eligible for free County from 2005-2009 to 2007-2011. Monterey lunch. Years California County Monterey Years California 2007-2011 73% 70%‡ County (38-81%) 2011 46% 58%‡ 73% (20-66%) 2006-2010 70%‡ (38-82%) 2006 52% 46%‡ 73% (14-60%) 2005-2009 70%‡ (39-81%) *Percent of children enrolled in public schools that are *Percentage of people who commute alone in their car eligible for free lunch ‡Confidence interval is not available. ‡ Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Source: Robert Wood Johnson Foundation. County Health Roadmaps 2014. Rankings & Roadmaps 2014.

Access to Parks*

 In 2010, 64% of Monterey County residents lived within half a mile of a park. This was higher than the percentage in California, 58%. Monterey Years California County

2010 58% 64%‡ (3-97%) *Percentage of population living within half a mile of a park ‡Confidence interval is not available. Source: Robert Wood Johnson Foundation. County Health Rankings & Roadmaps 2014. Monterey County Health Department Page 42 of 49

Data Sources American Community Survey, 5-year estimates The American Community Survey (ACS) is a nationwide survey designed to provide communities a fresh look at how they are changing. It is a critical element in the Census Bureau's re-engineered decennial census program. The ACS collects and produces population and housing information every year instead of every ten years. For the Chartbook, American Community Survey data are used to obtain measures of social and economic factors. Behavioral Risk Factor Surveillance System (BRFSS) The Behavioral Risk Factor Surveillance System (BRFSS) is a national random digit dial (RDD) telephone survey. Data obtained from the BRFSS are representative of the total non-institutionalized population over 18 years of age living in households with a land line telephone. For the Chartbook, data from the BRFSS were used to measure various health behaviors and health-related quality of life (HRQOL) indicators. All data from the BRFSS were weighted by population and the HRQOL measures were age-adjusted. Monterey County measures were obtained, in almost all instances aggregated over several years, from the Centers for Disease Control and Prevention (CDC). In 2011, the methodology of the BRFSS changed and the CDC adjusted their calculations in response to those. CDC WONDER Environmental data The Outdoor Air Quality - Fine Particulate Matter data available on CDC WONDER are geographically aggregated daily measures of fine particulate matter in the outdoor air, spanning the years 2003-2008. PM2.5 particles are air pollutants with an aerodynamic diameter less than 2.5 micrometers. CDC WONDER mortality data The Compressed Mortality File (CMF) is a county-level national mortality and population database spanning the years 1968-2010. Compressed Mortality data are updated annually. The number of deaths, crude death rates or age-adjusted death rates can be obtained by place of residence (total U.S., Census region, Census division, state, and county), age group, race (years 1968-1998: White, Black, and Other; years 1999-present: American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, and White), Hispanic origin (years 1968-1998: not available; years 1999-present: Hispanic or Latino, not Hispanic or Latino, Not Stated), gender, year of death, and underlying cause of death (years 1968-1978: 4 digit ICD-8 codes and 69 cause-of-death recode; years 1979-1998: 4-digit ICD-9 codes and 72 cause-of-death recode; years 1999-present: 4-digit ICD-10 codes and 113 cause-of-death recode), and urbanization level of residence for years 1999-present (per the 2006 NCHS urban-rural classification scheme for counties). CMS, National Provider Identification The NPI Registry enables you to search for a provider's NPPES information. All information produced by the NPI Registry is provided in accordance with the NPPES Data Dissemination Notice. Information in the NPI Registry is updated daily. You may run simple queries to retrieve this read-only data. For example, users may search for a provider by the NPI or Legal Business Name. Comprehensive Housing Affordability Strategy (CHAS) data The U.S. Department of Housing and Urban Development (HUD) periodically receives "custom tabulations" of data from the U.S. Census Bureau that are largely not available through standard Census products. These data, known as the "CHAS" data (Comprehensive Housing Affordability Strategy), demonstrate the extent of housing problems and housing needs, particularly for low income households. The CHAS data are used by local governments to plan how to spend HUD funds, and may also be used by HUD to distribute grant funds. The Dartmouth Institute The very large claims databases used in the Dartmouth Atlas Project come from the Centers for Medicare and Medicaid Services (CMS), the federal agency that collects data for every person and provider using Medicare health insurance. Access to this data is made available for research purposes. The Chartbook

Monterey County Health Department Page 43 of 49 utilized data from the Dartmouth Institute that identified and calculated a small subset of quality of care measures for Monterey County. Fatality Analysis Reporting System FARS is a census of fatal motor vehicle crashes with a set of data files documenting all qualifying fatalities that occurred within the 50 States, the District of Columbia, and Puerto Rico since 1975. To qualify as a FARS case, the crash had to involve a motor vehicle traveling on a trafficway customarily open to the public, and must have resulted in the death of a motorist or a non-motorist within 30 days of the crash. Federal Bureau of Investigation, Uniform Crime Reporting The Uniform Crime Reporting (UCR) Program meets a need for reliable, uniform crime statistics for the nation and produces Crime in the United States. The Chartbook uses data produced by this program and archived by the National Archive of Criminal Justice Data. Health Resources and Services Administration, Area Resource File The Area Resource File is a collection of data from more than 50 sources, including: American Medical Association, American Hospital Association, US Census Bureau, Centers for Medicare & Medicaid Service, Bureau of Labor Statistics, and the National Center for Health Statistics. National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation The National Diabetes Surveillance System provides estimates of obesity, physical inactivity, and diabetes. The Monterey County estimates were developed using modern small area estimation techniques. This approach employs a statistical model that “borrows strength” in making an estimate for Monterey County from BRFSS data collected in other counties. Bayesian multilevel modeling techniques were used to obtain these estimates. National Center for Health Statistics (NCHS) Data on deaths and births were provided by NCHS and were drawn from the National Vital Statistics System (NVSS). These data are submitted to the NVSS by the vital registration systems operated in the various jurisdictions legally responsible for the registration of vital events – births, deaths, marriages, divorces, and fetal deaths.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Data on sexually transmitted infections were provided by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). NCHHSTP is responsible for public health surveillance, prevention research, and programs to prevent and control human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), other sexually transmitted diseases (STDs), viral hepatitis, and tuberculosis (TB). OneSource Global Business Browser, Delorme map data, ESRI, & US Census Tigerline Files These data files are combined in ArcGIS to create the measure. The OneSource Global Business Browser, for a fee, provides access to robust, integrated business intelligence, including corporate families, industries, key executives and financial data. The DeLorme Map Mart and ESRI public use GIS data provide geocoded, projected data on parks at the local, state and national level across the US. US Census Tigerline files are spatial extracts from the Census Bureau's MAF/TIGER database, containing features such as roads, railroads, rivers, as well as legal and statistical geographic areas. US Census, Small Area Health Insurance Estimates The US Census Bureau's Small Area Health Insurance Estimates (SAHIE) program produces estimates of health insurance coverage for California and the counties within the state, including Monterey County.

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US Census, Small Area Income and Poverty Estimates The US Census Bureau, with support from other federal agencies, created the Small Area Income and Poverty Estimates (SAIPE) program to provide more current estimates of selected income and poverty statistics than those from the most recent decennial census. The Chartbook utilized estimates for California and the counties within California, including Monterey County. The main objective of this program is to provide updated estimates of income and poverty statistics for the administration of federal programs and the allocation of federal funds to local jurisdictions. These estimates combine data from administrative records, intercensal population estimates, and the decennial census with direct estimates from the American Community Survey to provide consistent and reliable single-year estimates. US Department of Agriculture, Food Environment Atlas Limited access to healthy foods was calculated using data from the USDA Food Environment Atlas. This resource assembles statistics on food environment indicators to stimulate research on the determinants of food choices and diet quality.

USDA Food Environment Atlas, Map the Meal Gap from Feeding America From the United States Department of Agriculture (USDA): The Atlas assembles statistics on three broad categories of food environment factors:  Food Choices--Indicators of the community's access to and acquisition of healthy, affordable food, such as: access and proximity to a grocery store; number of food stores and restaurants; expenditures on fast foods; food and nutrition assistance program participation; food prices; food taxes; and availability of local foods.  Health and Well-Being--Indicators of the community's success in maintaining healthy diet Using the annual USDA Food Security Survey, Feeding America (Map the Meal Gap) models the relationship between food insecurity and other variables at the state level and, using information for these variables at the county level, we establish food insecurity by county. Gundersen, C., E. Waxman, E. Engelhard, A. Satoh, & N. Chawla. Map the Meal Gap 2013: Food Insecurity Estimates at the County Level. Feeding America, 2013.

For more information about County Rankings and Roadmaps visit http://www.countyhealthrankings.org/

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Technical Notes

Health Outcome Summary Score To calculate the summary score for Health Outcomes, we combined scores for Length of life (50%) and Quality of life (50%) to produce 100% of the Health Outcomes summary score. The weights for specific measures were assigned based on relative importance within the factor and considerations of data reliability and availability. Within quality of life, we assign a higher weight to the low birthweight measure since this measure is based on a census of all live births whereas the other measures are based on a survey of a sample of the population. Health Outcome Weights for the 2014 County Health Rankings Outcome Focus Area Measure Length of life (50%) Premature death Years of potential life lost before age 75 (50%) Poor or fair health (10%) Quality of life (50%) Quality of life Poor physical health days (10%) Poor mental health days (10%) Poor birth outcomes Low birthweight (20%)

Health Factors Summary Score To calculate the summary score of health factors, weights were determined for each of the four major factors (Health behaviors, Clinical care, Social and economic factors, and the Physical environment) based on a review of the literature, expert opinion, and data analysis. Additional information is available about the methods used to determine these weights (Working Paper on Assigning Determinant Weights). The following weights were used to calculate the overall Health Factors summary score: Health behaviors (30%), Clinical care (20%), Social and economic factors (40%), and the Physical environment (10%). Like the Health Outcomes summary score, weights at each level sum to 100%. The weights for specific measures were assigned based on relative importance within the factor and considerations of data reliability and availability. A table presenting the weights follows.

Health Factor Weights for the 2014 County Health Rankings Health Factor Focus Area Measure Health behaviors (30%) Smoking (10%) Adult smoking (10%) Adult obesity (5%) Food environment index (2%) Diet and exercise (10%) Physical inactivity (2%) Access to exercise opportunities (1%) Excessive drinking (2.5%) Alcohol and drug use (5%) Alcohol-impaired driving deaths (2.5%) Sexually transmitted infections (2.5%) Sexual activity (5%) Teen births (2.5%) Uninsured (5%) Primary care physicians (3%) Clinical care (20%) Access to care (10%) Dentists (1%) Mental health providers (1%)

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Preventable hospital stays (5%) Quality of care (10%) Diabetic screening (2.5%) Mammography screening (2.5%) Social and economic factors High school graduation (5%) Education (10%) (40%) Some college (5%) Employment (10%) Unemployment (10%) Income (10%) Children in poverty (10%) Inadequate social support (2.5%) Family and social support Children in single-parent households (5%) (2.5%) Violent crime (2.5%) Community safety (5%) Injury deaths (2.5%) Air pollution - particulate matter (2.5%) Physical environment (10%) Air and water quality (5%) Drinking water violations (2.5%) Severe housing problems (2%) Housing and transit (5%) Driving alone to work (2%) Long commute - driving alone (1%)

Calculating Scores and Ranks

Standardizing Measures Each measure was standardized within California to the average of the counties in the state. Recall that the measures are in a number of different scales—some are percentages, some are rates, some are averages of survey responses, or other metrics. Standardizing each of these measures transformed them to the same metric—a mean (average) value of 0 and a standard deviation (measure of spread) of 1. They are referred to as Z-scores where Z = (Monterey County Value) - (Average of Counties in California) (Standard Deviation of Counties in California) In the Chartbook, each Z-score was relative to the other counties in California—not compared to an absolute standard—and shown in the metric of standard deviations. A positive Z-score for Monterey County indicates a value higher than the average of counties in California; a negative Z-score for Monterey County indicates a value lower than the average of counties in California. For example, if Monterey County has a Z-score of 1.2, that means the county is 1.2 standard deviations above the California average of counties for that measure. Reverse Coding For most of the measures, a higher Z-score score indicates poorer health (e.g., years of potential life lost before age 75). However, for some measures (e.g., high school graduation) a higher score indicates better health or a more desirable value. This is taken into account before computing summary scores. For these measures the Z-score was computed as usual but multiplied by -1, so that higher scores indicate poorer health. The measures are reverse coded in this manner are:  Diabetic screening  Mammography  High school graduation  Some college (post-secondary education)  Access to recreational facilities

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 Food environment index  Access to exercise opportunities Composite Scores The scores are weighted composites of the Z-scores for individual measures where the weights represent relative importance of the different measures. A weighted composite was computed by multiplying each Z- score by its weight and adding them up. Below is the formula used for weighted composite scores:

Composite=∑wi Zi

In this formula the Zi values are the Z-scores of the measures used to compute the summary score. The wi values are the weights applied to each Z-score. The ∑ sign simply means to add up all the Z-scores multiplied by their weights. All of the summary scores in the Chartbook used the formula above, standardized Z-scores for each measure (reverse coded when necessary), and the weights described in previous sections. Ranking After composite scores were computed, they were sorted from lowest to highest within California. The lowest score (best health) got a rank of #1 for the state and the highest score (worst health) got whatever rank corresponded to the number of units ranked in the state. It is important to note that the rankings themselves may not represent statistically significant differences from county to county. That is, the top ranked county in California (#1) is not necessarily significantly healthier than the second ranked county (#2). See the next section about quartiles for more information. Quartiles To de-emphasize the differences between individual county ranks, the counties were grouped into quartiles according to their Health Outcomes and Health Factors ranks separately. For each set of ranks there were four quartiles that divide up all the units within California into the top 25% (quartile #1), the second from top 25% (quartile #2), the second from bottom 25% (quartile #3), and the bottom 25% (quartile #4). Quartile #1 represented the healthiest counties with the best ranks, quartile #4 represented the least healthy counties with the worst ranks, and the other two quartiles were in between. Color-coded maps of the Health Outcomes and Health Factors summary scores by quartile were provided to see the distribution of ranks within California. Exploring the Data

National Benchmarks For many measures, the National Benchmark has been calculated. This is not a national average--it is the point at which only 10% of counties in the nation did better, i.e., the 90th percentile or 10th percentile, depending on whether the measure was framed positively (e.g., high school graduation) or negatively (e.g., adult smoking). Some measures were not comparable across states--the national benchmark would not apply in these cases. Trends There are trend graphs for eight measures. Most of the charts were based on multiple-year rolling averages for the county, state and nation. For example, a three-year rolling average for 2008 is based on data from 2007-2009, the data point for 2009 is based on data from 2008-2010, etc. Data Quality The Chartbook used the data provided by Rankings. The Rankings team drew upon the most reliable and valid measures available to compile the county rankings.

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Data Reliability One of the primary concerns when trying to estimate values for relatively small areas, like Monterey County, is the reliability of the data used. Every effort to provide the most reliable data available was made, but the reliability of measures varies. An easy estimate of reliability is the margin of error for a measure. Larger margins of error suggest smaller reliability.

Although the reliability of some measures was not ideal, when multiple measures were used to capture an underlying concept, the reliability improved. For example, each of the single measures used in morbidity may suffer from some reliability weaknesses, but taken together, their measurement of morbidity has shown great reliability. Statistical Uncertainty Where possible, the margin of errors (95% confidence intervals) for the measure values was provided. In many cases, the values of specific measures in different counties were not statistically different from one another; however, when combined using the model, those various measures produced the different rankings. Age-Adjustment of Measures Age-adjustment is a useful strategy to increase the comparability of health measures between Monterey County and other counties. However, it can also mask the true burden of a health need in a county. Due to these considerations, only some measures were age-adjusted. The following Health Outcome measures were age-adjusted: premature death (YPLL), self-reported health, physically unhealthy days, and mentally unhealthy days. Preventable hospital stays were also age-adjusted.

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