Healthiest Wisconsin 2020 Baseline and Health Disparities Report Hispanics/Latinos This chapter summarizes demographic and socioeconomic data for Hispanics/Latinos in Wisconsin and highlights health risk factors and health outcomes for which Hispanics experience disparities compared to other racial/ethnic groups. In the 2010 Census, “Hispanic or Latino” refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.1 In the data presented in this report, a person counted as Hispanic is not also counted by their race. The text for many of the figures in this chapter compares rates for Hispanics to those of non-Hispanic Whites. Hispanics in Wisconsin include both those born in the United States and those born in other countries. This chapter uses the term “Hispanic” because that is the term used in data collection for sources included in this report. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Chapter Outline Chapter outline Background Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Key points Data Demographic and socioeconomic data Access to and use of health care services Risk behaviors and health outcomes References Links to additional reports and resources Contacts Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Overview Report overview This chapter is part of a larger report created by the Wisconsin Department of Health Services to track the progress on objectives of Healthiest Wisconsin 2020 (HW2020) and identify health disparities in the state. The full report is available at: http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf The report is designed to address the Health Focus Areas in HW2020. Where direct measures exist, data are presented; where direct measures are not available, related information may be included. Information about populations experiencing health disparities is provided in the Health Focus Area chapters and is summarized in separate chapters devoted to specific populations. Technical notes are available at: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Format Full Report Chapters Format: PDF Report overview Report Format Sample annotated slide Full Report Format: PDF Intended use: reference document Chapters Format: Annotated PowerPoint slide set Intended uses: presentations to Decision-makers Service providers Community leaders The public The report is available in two formats. The first, intended to serve as a reference document, is a PDF of annotated slides, as shown in this slide. The second is a series of slide sets, each of which is a chapter in the report. The purpose for providing slide sets is to foster sharing of the data in presentations to decision-makers, service providers, community leaders, and the public. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Outline Executive Summary Section 1: Introduction Report overview Report Outline Executive Summary Section 1: Introduction Section 2: Demographic overview Section 3: Health focus areas Section 4: Infrastructure focus areas Section 5: Data summaries by population Section 6: Technical notes Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Outline: Detail Report overview Report Outline: Detail Section 3: Health focus areas Alcohol and other drug use Chronic disease prevention and management Communicable diseases Environmental and occupational health Healthy growth and development Injury and violence Mental health Nutrition and healthy foods Oral health Physical activity Reproductive and sexual health Tobacco use and exposure Section 4: Infrastructure focus areas Access to health services Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Outline: Detail Report overview Report Outline: Detail Section 5: Data summaries by population Racial/ethnic minority populations American Indians Asians Blacks Hispanics   People of lower socioeconomic status People with disabilities Lesbian, gay, bisexual, and transgender populations Geography Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Data notes Report overview Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf The 95% confidence intervals are denoted by error bars. Where confidence intervals do not overlap, as shown in the example on the right, differences are statistically significant. Larger confidence intervals may indicate less reliable estimates that should be interpreted with caution. Population estimates that are considered unreliable are excluded. Misclassification of racial/ethnic groups may affect the accuracy of rates. Unless otherwise indicated, the Hispanic population may include people of various races; Whites, Blacks, Asians, and American Indians are non-Hispanic. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Factors that influence health Report overview Factors that influence health Social determinants of health drive at least 50% of morbidity and mortality rates.2 Social determinants of health include socioeconomic status (SES), usually measured by income, employment, education, or housing. Groups with lower SES typically have significantly shorter life expectancy, higher rates of infant mortality, higher rates of chronic disease, and significantly lower self-rated health status.3   Health inequities are costly. The Joint Center for Political and Economic Studies estimates that the combined costs of health inequalities and premature death in the United States during 2003-2006 were $1.24 trillion.4 Further, addressing social determinants of health is an essential component of several key principles of the Public Health Code of Ethics which frame the ethical practice of public health.5 Healthiest Wisconsin 2020, the State Health Plan, lists two crosscutting focus areas: 1) Health Disparities, and 2) Social, Economic and Educational Factors that Influence Health.6 These broad focus areas have the potential to affect both the health focus area and public health infrastructure components of the plan and help set priorities in order to achieve large, equitable changes in health outcomes while saving health care dollars in Wisconsin. Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, http://www.countyhealthrankings.org/our-approach Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report overview Historical trauma Historical trauma is the cumulative exposure to traumatic events that not only affect the individual exposed, but continue to affect subsequent generations. Descendants of those who experienced the traumatic stressor may still exhibit symptoms. Populations affected by historical trauma include American Indians, African Americans/Blacks, Hispanics/Latinos, Asians, immigrants and refugees, war veterans, and families experiencing intergenerational poverty. Current manifestations may include: Mistrust of health care, legal, and educational systems; Higher rates of risk behaviors such as alcohol and drug abuse, suicide, homicide, and domestic violence; and Higher rates of chronic diseases. Sources: SAMHSA, Fact Sheet: Historical Trauma http://gainscenter.samhsa.gov/cms-assets/documents/93078-842830.historical-trauma.pdf, Texas Department of Health Services, Trauma Informed Care Training, http://www.dfps.state.tx.us/Training/Trauma_Informed_Care/page35.asp Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Key Points: Hispanic/Latino population Demographics: The Hispanic/Latino population in Wisconsin is younger than the general population, widely distributed geographically, and growing. Socioeconomic status: Hispanics in Wisconsin are more likely to live in poverty and less likely to have a college degree compared to non-Hispanic Whites. Access to health care: Hispanics have less access to health care compared to other racial/ethnic groups. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Key Points: Hispanic/Latino population Key health issues for Hispanic adults include: consequences of lack of exercise, obesity, high blood pressure, diabetes, unintended pregnancies, lack of emotional support, and (among Hispanic men) alcohol and tobacco use. Better data on Hispanics are needed due to small sample sizes, racial/ethnic misclassification, data access issues, and differences between foreign- and U.S. born- Hispanics. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Demographic and socioeconomic data Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Demographic characteristics Demographic and socioeconomic data Demographic characteristics Wisconsin’s Hispanic/Latino population is increasing in numbers, young, and diverse in terms of country of origin. Nearly one-third are foreign born. Wisconsin's Hispanic population, 2010: 336,056; 5.9% of state total Change in the Hispanic population, 2000 to 2010: 73% increase Median age, 2010: Hispanic, 23 years (Whites, 41.5 years) The median age is the age at which half the population is older and half is younger. Percent of Hispanics who were foreign-born, 2010: 32% (Total population, 4%) Sources: http://www.dhs.wisconsin.gov/health/MinorityHealth/Report.htm and U.S. Census Bureau. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Socioeconomic data Demographic and socioeconomic data Wisconsin’s Hispanic population has a higher poverty rate and less education compared to Whites. Median household income in Wisconsin, 2008-2010: Hispanics, $36,800 (Whites, $53,000) Poverty rate, 2010: Hispanics, 28% (Whites, 10%) The poverty rate is the percent living below the federal poverty level. Bachelor’s degree or more education (age 25 and older), 2007-2010: Hispanics, 11% (Whites, 27%) Married-couple households as a percent of family households, 2008-2010: Hispanics: 61% (other racial/ethnic groups range from Blacks, 33% to Whites, 82%) Source: http://www.dhs.wisconsin.gov/health/MinorityHealth/Report.htm and U.S. Census Bureau, American Community Health Survey. Regarding family households, a family is a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family. A family household is a household maintained by a householder who is in a family, and includes any unrelated people who may be residing there (http://www.census.gov/cps/about/cpsdef.html). Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Hispanic/Latino population by county, Wisconsin, 2010 Demographic and socioeconomic data Hispanic/Latino population by county, Wisconsin, 2010 Wisconsin’s Hispanic/Latino population was 5.9% of the total statewide in 2010. Counties in the southeastern and east central parts of Wisconsin have the largest numbers and percentages of Hispanic residents. Source: U.S. Census, 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Demographic and socioeconomic data Level of urbanization of Wisconsin residents, by race/ethnicity, 2007-2011 Some data in the report are shown by level of urbanization. The 2006 National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties classifies all U.S. counties and county-equivalents into six levels—four for metropolitan counties and two for nonmetropolitan counties. For ease of interpretation in this report, these six classifications were consolidated into three categories: “large metropolitan, central,” “smaller metropolitan,” and “non-metropolitan.” In Wisconsin, Milwaukee County is the only county that is classified as “Large metropolitan, central” and therefore is labeled simply “Milwaukee County” in the figures. There were 24 smaller metropolitan counties, and 47 non-metropolitan counties. In 2007-2011, level of urbanization in Wisconsin varied by racial/ethnic group. Almost one-half of Hispanics lived in smaller metropolitan counties, and more than one-third lived in Milwaukee County. Source: American Community Survey, 2007-2011. . Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Demographic and socioeconomic data Country of origin of foreign-born Hispanic/Latino residents, Wisconsin, 2010 In 2010, 32% of the Hispanic/Latino population in Wisconsin was foreign-born (not shown). Eighty percent of Hispanic/Latino foreign-born Wisconsin residents reported Mexico as their country of origin; 9% were born in South America, 7% in Central America, and 3% in the Caribbean. People born in Puerto Rico are U.S. citizens. Source: American Community Survey, 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to and use of health care services Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to health care Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by race/ethnicity, 2008-2011 The Wisconsin Behavioral Risk Factor Survey (BRFS) is an annual telephone survey of state residents ages 18 and older carried out by the Wisconsin Department of Health Services in conjunction with the Centers for Disease Control and Prevention (CDC). Individuals who lack health insurance may have limited access to needed clinical care, including prevention services, and may not seek medical care because of financial concerns. Missing or delaying health care can lead to poorer health and potentially to greater long-term medical expenditures.7 Medicaid is a health and long-term care coverage program that is jointly financed by states and the federal government for eligible persons of all ages whose income and resources are insufficient to pay for health care. Medicaid beneficiaries often have difficulty obtaining a source of primary care. Research on the National Health Interview Survey demonstrated that Medicaid beneficiaries face greater barriers to accessing primary care than people on private insurance and that these barriers are associated with higher emergency department utilization.8 During 2008-2011, more than one-third (35%) of Hispanic adults ages 18-64 had no health insurance coverage. One in five (21%) Hispanic adults age 18 and older were enrolled in Medicaid or BadgerCare, compared to 12% of Whites. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to heath care Public health insurance coverage and inadequacy of health insurance among children ages 6-17, by race/ethnicity, Wisconsin, 2011-2012 The National Survey of Children's Health (NSCH) is a telephone survey conducted by the National Center for Health Statistics at the CDC, under the direction and sponsorship of the federal Maternal and Child Health Bureau. The survey addresses multiple intersecting aspects of children’s lives, including physical and mental health status, access to high-quality health care, and information on the child’s family and neighborhood. According to the Kaiser Survey of Children’s Health Coverage, many factors contribute to not having health insurance coverage for children, including a lack of access to employer-sponsored insurance (ESI) among low- and middle-income families, inability to afford ESI if it is available, and unawareness of and burdensome enrollment procedures for publicly funded insurance programs such as Medicaid and the State Children’s Health Insurance Program (SCHIP).9 Adequate insurance is defined by the following criteria: child currently has health insurance coverage AND benefits usually or always meet child's needs AND usually or always allow child to see needed providers AND either no out-of-pocket expenses or out-of-pocket expenses are usually or always reasonable. If not all of these criteria are met, the insurance is considered inadequate. In 2011-2012, a significantly higher proportion of Hispanic children ages 6-17 in Wisconsin had public insurance (51%), compared to White children (27%). Source: 2011-2012 National Survey of Children's Health. Note: Wisconsin estimates were only available for White, Black, and Hispanic children. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to health care Age-adjusted rates of use of and barriers to health care among Wisconsin adults, by race/ethnicity, 2008-2011 Routine visits to the doctor can help prevent some health problems and detect others early when the chances for treatment and cure are better. Access to adequate and appropriate health services, screenings, and treatments improves the chances for living a longer, healthier life.10 One-third of Hispanic adults did not have a doctor’s visit in the past year. The percentage lacking a personal doctor did not differ significantly by race/ethnicity. Hispanics were significantly more likely than Whites to be unable to obtain medical care due to cost. One in five Hispanics were unable to obtain care, compared to one in ten Whites. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Oral Health Age-adjusted rates of tooth removal and dental visits in the past year among Wisconsin adults, by race/ethnicity, 2008-2011 Routine dental visits are recommended at least once a year for preventive care.11 The BRFS asks respondents whether they have visited a dentist, dental hygienist, or dental clinic in the past year, as well as how many permanent teeth have been removed due to tooth decay or gum disease. Nearly half (46%) of Hispanic adults had lost permanent teeth due to tooth decay or gum disease, a significantly higher proportion than for Whites (35%). Hispanics were significantly more likely not to have visited a dentist, dental hygienist, or dental clinic in the past year compared to Whites and Asians. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Tooth removal question asked in 2008, 2010, and 2011. Dentist visit question asked in 2008 and 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to health care Lack of routine preventive medical and dental care among children, by race/ethnicity, Wisconsin, 2011-2012 In 2011-2012, an estimated two out of five Hispanic children did not receive both medical and dental care in the past 12 months. Differences by race/ethnicity were not significant. Source: 2011-2012 National Survey of Children's Health. Note: Wisconsin estimates were only available for White, Black, and Hispanic children. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Risk factors among youth and adults Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Physical health Age-adjusted indicators of poor health status among Wisconsin adults by race/ethnicity, 2008-2011 BRFS respondents were asked to describe their health as one of the following: excellent; very good; good; fair; or poor. Nearly one-fourth (23%) of Hispanic adults in Wisconsin described their health as fair or poor. An estimated four in ten Hispanic adults said their physical health was not good on at least one day during the past month. Of these, three-quarters reported that their poor health limited their usual activities on at least one day in the previous month. Rates for all three indicators are higher among Hispanic adults than among Whites. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Physical Activity Age-adjusted rate of physical inactivity among Wisconsin adults, by race/ethnicity, 2008-2011 Regular physical activity improves overall health and fitness, and reduces the risk for many chronic diseases. The CDC recommends that adults engage in two types of physical activity each week to improve health: aerobic and muscle-strengthening.12 The BRFS asks respondents whether they have participated in any physical activity other than at their jobs in the past month. Hispanic adults in Wisconsin were significantly more likely to be physically inactive than were White adults, with one-third of Hispanic adults physically inactive in the past month other than at their job. It is important to note that lower wage jobs are more likely than higher wage jobs to involve physical activity and that racial/ethnic minorities are more likely than Whites to hold lower wage jobs. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Nutrition Obesity among children (ages 2-4 years) enrolled in WIC, by race/ethnicity, Wisconsin, 2001 and 2010 Childhood obesity in the United States disproportionately affects low-income and minority children. Children who are obese in their preschool years are more likely to be obese in adolescence and adulthood and to develop chronic diseases, such as diabetes, hypertension, hyperlipidemia, asthma, and sleep apnea.13 In 2010, 14% of children (ages 2-4 years) enrolled in WIC were obese (data not shown). Hispanic children enrolled in WIC were significantly more likely to be obese than were Black or White children. Nearly one out of five low-income Hispanic (18%) children ages 2-4 were obese. These proportions exceed the U.S. percentage of low-income children who are obese (14%). From 2001 to 2010, the rate of obesity among low-income children in this age group increased significantly for every racial and ethnic group except Asians. Hispanic children experienced the smallest increase in early childhood obesity (14%) (percent change not shown). Source: Centers for Disease Control and Prevention (CDC) Pediatric Nutrition Surveillance Survey, 2010. Note: Based on >= 95th growth chart percentiles for Body Mass Index for age. WIC is the Supplemental Nutrition Program for Women, Infants, and Children. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Mental health Age-adjusted rate of frequent mental distress among Wisconsin adults, by race/ethnicity, 2009-2011 Frequent mental distress is defined as 14 or more days of poor mental health in the past 30 days.14 Growing evidence indicates a strong association between poor mental health and premature death, chronic physical diseases, functional impairment, and overall quality of life. Hispanics were significantly more likely than Whites to experience frequent mental distress.   Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Question asked in 2009-2011. Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Mental health Age-adjusted rate of insufficient sleep and rate of poor emotional support among Wisconsin adults, by race/ethnicity, 2008-2010 Insufficient sleep is defined as 14 or more days of poor sleep over the past 30 days. Insufficient sleep is associated with an increased risk of motor vehicle crashes, occupational injury, and chronic disease.15 In 2008-2010, there were no significant differences in insufficient sleep by race/ethnicity. Emotional support is an important determinant of well-being. Well-being is recognized as an important population outcome, integrating mental health and physical health to provide a more holistic approach to disease prevention and health promotion.16 In Wisconsin, about one in four Hispanics lacked emotional support, a rate significantly higher than the rate among Whites. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Questions were not asked in 2011. Rates of insufficient sleep are age-adjusted; rates of poor emotional support are not age-adjusted. Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Tobacco use and exposure Age-adjusted rate of smoking among Wisconsin adults, by race/ethnicity, 2008-2011 Current smoker refers to people who have smoked at least 100 cigarettes in their lifetime and continue to smoke. In 2008-2011, Hispanic adults had a significantly higher rate of smoking (27%) compared to Whites (20%). Among youth, Hispanics had lower or comparable rates of tobacco use compared to Whites; however, Hispanic youth had a higher rate of ever trying smoking (data not shown). Smoking during pregnancy is the most preventable cause of illness and death among pregnant women and infants. Smoking is associated with an increased risk for low birthweight delivery, spontaneous abortion, and sudden infant death syndrome, as well as long-term negative effects on infant growth and development, behavior, and cognition.17 The smoking rate in Wisconsin was significantly lower for Hispanic women of all ages than for White or Black women (BRFS, 2009-2011). Hispanic women also had the lowest rate of new mothers who smoked after giving birth (PRAMS, 2009-2011) (data not shown). Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Healthy growth and development Unintended pregnancy as a percent of births, by race/ethnicity, Wisconsin, 2009-2011 The Pregnancy Risk Assessment Monitoring System (PRAMS) is a surveillance project of the CDC and state health departments. Wisconsin PRAMS collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. The survey collects information from a sample of women who recently gave birth. The health of a woman before pregnancy has a great impact on birth outcomes, and birth outcomes affect health in childhood and adulthood. According to the CDC, unintended pregnancy is associated with an increased risk of problems for both mother and baby. If a pregnancy is not planned, a woman may not have achieved optimal health before conception.18 During 2009-2011, approximately 37% of all Wisconsin live births were the result of an unintended pregnancy (data not shown). An estimated two out of five births to Hispanic women in Wisconsin were the result of an unintended pregnancy compared to one in three births to White women. Source: Wisconsin Department of Health Services, Division of Public Health, PRAMS, 2009-2011. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Health Outcomes Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Chronic diseases Age-adjusted rates of high cholesterol and high blood pressure among Wisconsin adults, by race/ethnicity, 2009 and 2011 Elevated cholesterol and high blood pressure (hypertension) are two of the leading risk factors for cardiovascular disease. Your body needs some cholesterol to function properly, but when there is too much in your blood, it can accumulate on arterial walls.19 Blood pressure is a measurement of the force of blood against arterial walls. If blood pressure remains high for a long period of time, this can result in a variety of health problems. Women and men are about equally likely to develop high blood pressure during their lifetimes. For those under age 45, the condition affects more men than women, while it affects more women than men among those ages 65+.20 In 2009 and 2011, BRFS respondents were asked if they had ever been told by a health professional they have high cholesterol and if they had ever been told they have high blood pressure. Over one-third of Wisconsin adults had been told they have high cholesterol and 29% had been diagnosed with high blood pressure. In 2009 and 2011, Hispanic adults did not have a significantly different rate of high cholesterol compared to White adults. The rate of high blood pressure was significantly higher among Hispanics than among Whites. Note: These estimates exclude people who have these conditions but remain undiagnosed. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Questions only asked in 2009 and 2011.Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Chronic diseases Age-adjusted rates of diabetes and prediabetes among Wisconsin adults, by race/ethnicity, 2008-2011 Diabetes is a group of diseases characterized by persistent hyperglycemia (high blood glucose levels) due to defects in insulin production, insulin action, or both. Prevalence estimates from the BRFS do not distinguish between type 1 and type 2 diabetes; however, it is estimated that 95% of the adult population with diabetes has type 2 diabetes, while type 1 comprises the remaining 5%.21 The BRFS asks respondents whether they have ever been told by a health professional they have diabetes, and whether they have ever been told they have prediabetes or borderline diabetes. The risk for diabetes increases with age: adults ages 65+ were significantly more likely to report having been diagnosed with diabetes or prediabetes than were adults in younger age groups (data not shown). The rate of diagnosed diabetes in Wisconsin has remained fairly stable over the past 10 years (data not shown). In 2008-2011, rates of Hispanic adults diagnosed with diabetes and prediabetes were not significantly different from rates among Whites. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Diabetes excludes women who were diagnosed during pregnancy, and does not differentiate between type 1 and type 2 diabetes. Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Chronic diseases Hospitalizations due to long-term complications from diabetes among Wisconsin adults, age-adjusted rate per 10,000, by race/ethnicity, 2010 Long-term complications of diabetes mellitus include renal (kidney), eye, neurological, and circulatory disorders.22 Diabetes is the leading cause of non-traumatic lower-limb amputations and new cases of blindness among adults in the United States. Management of blood sugars, diet, and physical activity may prevent or delay some of these adverse outcomes from occurring.23 In 2010, the hospitalization rate for long-term diabetes complications was more than twice as high among Hispanics as among Whites. Source: Wisconsin Inpatient Hospitalization Discharges, 2010. Note: Hospitalization rates considered unreliable are excluded. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Chronic diseases Incidence of end-stage renal disease incidence among Wisconsin adults, by race/ethnicity, age-adjusted rate per 100,000, 2009 Kidney disease is a progressive disease that ultimately ends with kidney failure, end-stage renal disease (ESRD), requiring dialysis or transplantation. Diabetes is the leading cause of ESRD.23 Early detection of kidney disease accompanied by proper medications can delay the onset of ESRD. While some cases of kidney failure due to diabetes cannot be avoided, other cases reflect inadequate control of blood sugar or delayed detection and treatment of early kidney disease due to diabetes.24 In 2009, the incidence rate for ESRD with diabetes as a primary diagnosis was more than five times higher for Hispanics in Wisconsin than for Whites. Low socioeconomic status and less access to effective treatment are associated with high incidence of ESRD among people with diabetes.24 Despite no significant difference in the rate of diagnosed diabetes between Hispanics and Whites, the hospitalization rate for long-term diabetes complications was higher for Hispanics than for Whites and the incidence rate for ESRD with diabetes as a primary diagnosis was more than five times higher for Hispanics than for Whites. Source: United States Renal Data System (USRDS), Renal Data Extraction and Referencing (RenDER) System. Note: Incidence rates considered unreliable are excluded. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Reproductive and sexual health Reported cases of HIV (ages 15-59) by race and ethnicity, rate per 100,000, Wisconsin, 2007-2011 The CDC recommends routine voluntary HIV screening as a normal part of medical practice for persons ages 13-64 except in settings of low HIV prevalence (undiagnosed HIV infections less than or equal to 1 in 1,000). CDC also recommends HIV screening of all patients seeking treatment services for sexually transmitted diseases and tuberculosis. Screening is used to identify unrecognized health conditions, both so treatment can be offered before symptoms develop and, for communicable diseases, to reduce the likelihood of continued transmission.25 HIV infection disproportionately affects males and racial/ethnic minorities. In Wisconsin, the rate of new HIV infections reported each year during 2007-2011 was five times higher among Hispanic males compared to (non-Hispanic) White males. Among females, the disparity is similar; the rate of HIV infection over the five-year period was more than five times higher for Hispanic females compared to White females. Source: Wisconsin HIV Surveillance System. Note: Hispanic population may include individuals of various races. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

References References Overview of Race and Hispanic Origin: 2010, 2010. Census Briefs, March 2011. http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf University of Wisconsin Population Health Institute. County Health Rankings, 2013. http://www.countyhealthrankings.org/our-approach Center for Urban Population Health. Milwaukee Health Report, 2011. http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf LaVeist TA, Gaskin DA, Richard P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic%20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf Thomas JC, Sage M, Dillenberg J, Guillory VJ (2002). A Code of Ethics for Public Health. Am Journal of Public Health. 92(7):1057–1059. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ Wisconsin Department of Health Services (DHS). Healthiest Wisconsin 2020. http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf Centers for Disease Control and Prevention (CDC). Health Care: See Why Being Insured Matters. http://www.cdc.gov/features/vitalsigns/HealthcareAccess/ Cheung PT, Wiler JL, Lowe RA, Ginde AA (2012). National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries. Annals of Emergency Medicine. 60(1). http://www.annemergmed.com/webfiles/images/journals/ymem/FA-PTCheung.pdf Healthiest Wisconsin 2020 Baseline and Health Disparities Report

References Kaiser Commission on Medicaid and the Uninsured. Next Steps in Covering Uninsured Children. Findings from the Kaiser Survey of Children’s Health Coverage. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7844.pdf CDC. Regular Check-Ups Are Important. http://www.cdc.gov/family/checkup/ American Dental Association. American Dental Association Statement on Regular Dental Visits. http://www.ada.org/8700.aspx CDC: Physical Activity. http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html CDC. Obesity Prevalence Among Low-Income, Preschool-Aged Children - United States, 1998-2008. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5828a1.htm CDC. Self-Reported Frequent Mental Distress Among Adults --- United States, 1993—2001. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a1.htm CDC. Insufficient sleep is a public health epidemic. http://www.cdc.gov/features/dssleep/ CDC. Health-related quality of life: Well-being concepts. http://www.cdc.gov/hrqol/wellbeing.htm#four CDC. PNSS Health Indicators. http://www.cdc.gov/pednss/what_is/pnss_health_indicators.htm#Smoking/Drinking Indicators Healthiest Wisconsin 2020 Baseline and Health Disparities Report

References CDC. Unintended Pregnancy Prevention. http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/ CDC. Cholesterol. http://www.cdc.gov/cholesterol/ CDC. High Blood Pressure Facts. http://www.cdc.gov/bloodpressure/facts.htm CDC. National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf Agency for Healthcare Research and Quality. Diabetes mellitus: hospital admission rate for long-term complications. http://www.qualitymeasures.ahrq.gov/content.aspx?id=38559 National Institute of Diabetes and Digestive and Kidney Disease. National Diabetes Statistics, 2011. http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Ward MM, et al. Access to care and the incidence of end-stage renal disease due to diabetes. http://care.diabetesjournals.org/content/32/6/1032.full.pdf+html CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Links to additional reports and resources Centers for Disease Control and Prevention, Minority Health, Hispanic or Latino Populations: http://www.cdc.gov/minorityhealth/populations/REMP/hispanic.html Centers for Disease Control and Prevention, Immigrant and Refugee Health: http://www.cdc.gov/immigrantrefugeehealth/ U.S. Department of Health and Human Services, Office of Minority Health, Hispanics/Latinos: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=33 American Diabetes Association: Información en Español: http://www.diabetes.org/espanol/ The National Women’s Health Information Center (en Español): http://es.bodylogicmd.com/enlaces/the-national-womens-health-information- center National Alliance for Hispanic Health: http://www.hispanichealth.org/ National Council of La Raza: http://www.nclr.org/ Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Contacts Contacts Evelyn Cruz, Minority Health Officer Wisconsin Division of Public Health, Office of Policy and Practice Alignment E-mail: Evelyn2.Cruz@dhs.wisconsin.gov Karl Pearson, Demographer Wisconsin Division of Public Health, Office of Health Informatics E-mail: KarlT.Pearson@dhs.wisconsin.gov Healthiest Wisconsin 2020 Baseline and Health Disparities Report