1. Wisconsin Department of Health Services January 2014 P-00522X Healthiest Wisconsin 2020 Baseline and Health Disparities Report Geography

2. GEOGRAPHY Background Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Key points Data Demographic and socioeconomic data Risk behaviors and health outcomes References Links to additional reports and resources Contacts Chapter Outline Chapter outline 2

3. GEOGRAPHY Report Overview This chapter is part of a larger report created by the Wisconsin Department of Health Services to track progress on the 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 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 http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf Report overview 3

4. GEOGRAPHY Report Format 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 Sample annotated slide Report overview 4

5. GEOGRAPHY 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 Report overview 5

6. GEOGRAPHY 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 Report overview 6

7. GEOGRAPHY Report Outline: Detail Section 5: Data summaries by population  Racial/ethnic minority populations o American Indians o Asians o Blacks o Hispanics  People of lower socioeconomic status  People with disabilities  Lesbian, gay, bisexual, and transgender populations  Geography Report overview 7

8. GEOGRAPHY Data notes 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 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. Report overview 8

9. GEOGRAPHY Factors that influence health Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, http://www.countyhealthrankings.org/our-approach Report overview 9

10. GEOGRAPHY Key Points Compared to residents of Milwaukee County and non-metropolitan (rural) counties, residents of smaller metropolitan counties: Have higher socioeconomic status and greater access to health care. Have lower disease prevalence and higher rates of preventive testing. Fare better on most health indicators. 10 Key points

11. GEOGRAPHY Key Points Compared to Milwaukee’s population, residents of non-metropolitan counties: Use health care at a lower rate. Have lower barriers to health care due to cost. Have rates of higher alcohol consumption. Have lower rates of asthma, frequent mental distress, and rates of STDs and HIV. 11 Key points

12. GEOGRAPHY Demographic and socioeconomic data 12

13. GEOGRAPHY Population by county, Wisconsin, 2010 Source: U.S. Census 2010. 13 Demographic and socioeconomic data

14. GEOGRAPHY Counties by level of urbanization, Wisconsin, 2010 Source: American Community Survey, 2010. 14 Level of urbanization

15. GEOGRAPHY Level of urbanization of Wisconsin residents by race/ethnicity, 2007-2011 Source: American Community Survey, 2007-2011.. 15 Level of urbanization

16. GEOGRAPHY Source: U.S. Census 2010 Median age by county, Wisconsin, 2010 16 Demographic and socioeconomic data

17. GEOGRAPHY Income distribution among Wisconsin adults by level of urbanization, 2007-2011 Source: American Community Survey, 2007-2011. 17 Demographic and socioeconomic data

18. GEOGRAPHY Educational attainment of Wisconsin adults, ages 25 and older, by level of urbanization, 2007-2011 Source: American Community Survey, 2007-2011. 18 Demographic and socioeconomic data

19. GEOGRAPHY Access to health care 19

20. GEOGRAPHY Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Access to health care 20

21. GEOGRAPHY Age-adjusted rate of use of and barriers to health care among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Access to health care 21

22. GEOGRAPHY Number of dentists per 100,000 people by level of urbanization, Wisconsin, 2010 Source: Wisconsin Department of Safety and Professional Services licensure lists; population estimates from Wisconsin Department of Health Services, Office of Health Informatics. Access to health care 22

23. GEOGRAPHY Number of full-time equivalent dentists needed to reduce significant shortages for Medicaid members, by county, 2009 Source: Wisconsin Department of Health Services, Primary Care Office, Shortage Designation Program. Access to health care 23

24. GEOGRAPHY Age-adjusted rates of tooth removal and dental visits in the past year among Wisconsin adults, by level of urbanization, 2008-2011 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. Access to health care 24

25. GEOGRAPHY Number of full-time equivalent psychiatrists needed to remove significant shortages for the resident population, by county, 2011 Source: Wisconsin Department of Health Services, Primary Care Office, Shortage Designation Program. Access to health care 25

26. GEOGRAPHY Risk factors and health outcomes 26

27. GEOGRAPHY Age-adjusted rates of physical health among Wisconsin adults by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline only dataset Note: Physical health and limited activities questions only asked 2009-2011. Health status 27

28. GEOGRAPHY Age-adjusted rate of physical inactivity among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset Physical activity 28

29. GEOGRAPHY Age-adjusted rates of binge drinking and heavy drinking among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. 29 Alcohol and other drug use

30. GEOGRAPHY Alcohol outlet density, people per license, Wisconsin, 2011-2012 Source: Wisconsin Department of Health Services, Division of Mental Health and Substance Abuse Services, Bureau of Prevention, Treatment and Recovery; and the University of Wisconsin Law School, Resource Center on Impaired Driving, Wisconsin Alcohol Policy Project. Alcohol and other drug use 30

31. GEOGRAPHY Age-adjusted rate of frequent mental distress among Wisconsin adults, by level of urbanization, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Question asked in 2009-2011. Mental health 31

32. GEOGRAPHY Age-adjusted rate of four or more Adverse Childhood Experiences (ACEs) among Wisconsin adults, by level of urbanization, 2010 and 2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Question asked in 2010 and 2011. Mental health 32

33. GEOGRAPHY Estimated prevalence of smoking among Wisconsin adults, by county, 2006-2008 Source: Wisconsin Department of Health Services, Division of Public Health, Tobacco Prevention and Control Program. The Burden of Tobacco in Wisconsin, 2010. Tobacco use and exposure 33

34. GEOGRAPHY Rates of secondhand smoke exposure among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: The “smoking at work” question was only asked in 2009 and 2010. Tobacco use and exposure 34

35. GEOGRAPHY Injury and violence Intentional injury deaths by county, age-adjusted rates per 100,000, Wisconsin, 2008-2010 Suicide Homicide Source: Wisconsin Interactive Statistics on Health (WISH), Wisconsin resident death certificates. Statewide rate = 13 per 100,000 Statewide rate = 3 per 100,000 35 20

36. GEOGRAPHY Age-adjusted rates of asthma among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. 36 Environmental health

37. GEOGRAPHY Counties exceeding the statewide age-adjusted rates per 10,000 of asthma hospitalizations and emergency department visits, Wisconsin, 2008-2010 Source: 2008-2010 Wisconsin hospital inpatient discharge file; 2008-2010 Wisconsin emergency department visit file. 37 Environmental health

38. GEOGRAPHY Percentage of lead poisoning (10 mcg/dL or greater) among tested children under age six, by county, Wisconsin, 2010 Source: Wisconsin Department of Health Services, Wisconsin Childhood Lead Poisoning Prevention Program (WCLPPP). 38 Environmental health

39. GEOGRAPHY Reported cases of chlamydia, rate per 100,000, Milwaukee County and Wisconsin excluding Milwaukee County, 2001-2010 Source: Wisconsin Department of Health Services, Sexually Transmitted Disease Program. Reproductive and sexual health 39

40. GEOGRAPHY Rates of HIV testing and age-adjusted risk behaviors among Wisconsin adults, by level of urbanization, 2008-2011 Reproductive and sexual health Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Testing rates are not age-adjusted; rates of exposure to high-risk situations are age-adjusted. 40

41. GEOGRAPHY References 1.University of Wisconsin Population Health Institute. County Health Rankings, 2013. http://www.countyhealthrankings.org/our-approach http://www.countyhealthrankings.org/our-approach 2.Center for Urban Population Health. Milwaukee Health Report, 2011. http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf 3.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 http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf 4.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/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ 5.Wisconsin Department of Health Services (DHS). Healthiest Wisconsin 2020. http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf 6.Centers for Disease Control and Prevention (CDC). Health Care: See Why Being Insured Matters. http://www.cdc.gov/features/vitalsigns/HealthcareAccess/http://www.cdc.gov/features/vitalsigns/HealthcareAccess/ 7.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 http://www.annemergmed.com/webfiles/images/journals/ymem/FA-PTCheung.pdf 41 References

42. GEOGRAPHY 8.CDC. Regular Check-Ups Are Important. http://www.cdc.gov/family/checkup/http://www.cdc.gov/family/checkup/ 9.The Henry Kaiser Foundation. State Health Facts. http://kff.org/statedata/http://kff.org/statedata/ 10.DHS. Wisconsin Primary Care Office: Number of Dentists Needed to Reduce Significant Shortages for Medicaid Members. http://www.dhs.wisconsin.gov/publications/p0/p00368.pdf http://www.dhs.wisconsin.gov/publications/p0/p00368.pdf 11.DHS. Wisconsin Primary Care Office: Number of Psychiatrist FTEs Needed to Reduce Significant Shortages for the Resident Population. http://www.dhs.wisconsin.gov/publications/p0/p00376.pdf http://www.dhs.wisconsin.gov/publications/p0/p00376.pdf 12.CDC: Physical Activity. http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html 13.CDC. Alcohol Use and Health. http://www.cdc.gov/alcohol/fact-sheets/alcohol- use.htmhttp://www.cdc.gov/alcohol/fact-sheets/alcohol- use.htm 14.CDC. BRFS Prevalence and Trends Data. http://apps.nccd.cdc.gov/BRFSS/http://apps.nccd.cdc.gov/BRFSS/ 15.CDC. Preventing Excessive Alcohol Consumption: Regulation of Alcohol Outlet Density. http://www.thecommunityguide.org/alcohol/outletdensity.htmlhttp://www.thecommunityguide.org/alcohol/outletdensity.html 16.Wisconsin Department of Health Services (DHS). Alcohol License Overview for Wisconsin. http://www.dhs.wisconsin.gov/substabuse/docs/AlcDensity/AlcoholOutletReport- Wisconsin.pdf http://www.dhs.wisconsin.gov/substabuse/docs/AlcDensity/AlcoholOutletReport- Wisconsin.pdf 42 References

43. GEOGRAPHY 17. CDC. Self-Reported Frequent Mental Distress Among Adults --- United States, 1993—2001. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a1.htm 18.CDC. Adverse Childhood Experiences Study. http://www.cdc.gov/ace/http://www.cdc.gov/ace/ 19.O’Connor C, Finkbiner C, & Watson L (2012). Adverse Childhood Experiences in Wisconsin: Findings from the 2010 Behavioral Risk Factor Survey. Madison, Wisconsin: Wisconsin Children’s Trust Fund and Child Abuse Prevention Fund of Children’s Hospital & Health System. http://wichildrenstrustfund.org/index.php?section=adverse-childhood http://wichildrenstrustfund.org/index.php?section=adverse-childhood 20.DHS. Burden of Tobacco in Wisconsin, 2010. http://sep.uwcarbone.wisc.edu/downloads/Documents/programbriefs/The%20Burden %20of%20Tobacco%20Report%202010.pdf http://sep.uwcarbone.wisc.edu/downloads/Documents/programbriefs/The%20Burden %20of%20Tobacco%20Report%202010.pdf 21.CDC. Smoking and Tobacco Use: Secondhand Smoke Facts. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_f acts/index.htm http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_f acts/index.htm 22.Centers for Disease Control and Prevention (CDC). Asthma. http://www.cdc.gov/asthma/faqs.htm http://www.cdc.gov/asthma/faqs.htm 23.DHS. Burden of Asthma in Wisconsin 2010: http://www.dhs.wisconsin.gov/eh/asthma/pdf/BurdenofAsthma2010Web.pdf http://www.dhs.wisconsin.gov/eh/asthma/pdf/BurdenofAsthma2010Web.pdf 43 References

44. GEOGRAPHY 24. DHS. Sexually Transmitted Diseases in Wisconsin, 2010. http://www.dhs.wisconsin.gov/communicable/std/Statistics/AnnualData/2010data/201 0WisconsinSummaryReport.pdf http://www.dhs.wisconsin.gov/communicable/std/Statistics/AnnualData/2010data/201 0WisconsinSummaryReport.pdf 25.CDC. 2010 Sexually Transmitted Diseases Surveillance. Cases of Sexually Transmitted Diseases Reported by State Health Departments and Rates per 100,000 Population, United States, 1941-2010. http://www.cdc.gov/std/stats10/tables/1.htmhttp://www.cdc.gov/std/stats10/tables/1.htm 26.CDC. 2010 Sexually Transmitted Diseases Surveillance. National Profiles – Chlamydia. http://www.cdc.gov/std/stats10/chlamydia.htmhttp://www.cdc.gov/std/stats10/chlamydia.htm 27.CDC. 2010 Sexually Transmitted Diseases Surveillance. National Profiles – Gonorrhea. http://www.cdc.gov/std/stats10/gonorrhea.htmhttp://www.cdc.gov/std/stats10/gonorrhea.htm 28.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 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm 44 References

45. GEOGRAPHY Links to additional reports and resources Centers for Disease Control and Prevention, Minority Health, Other At-Risk Populations, Geography: http://www.cdc.gov/minorityhealth/populations/atrisk.html http://www.cdc.gov/minorityhealth/populations/atrisk.html National Rural Health Association: http://www.ruralhealthweb.org/http://www.ruralhealthweb.org/ Wisconsin Office of Rural Health: http://www.worh.org/http://www.worh.org/ 45 Links

46. GEOGRAPHY Contacts Karl Pearson, Demographer Wisconsin Division of Public Health, Office of Health Informatics E-mail: KarlT.Pearson@dhs.wisconsin.govKarlT.Pearson@dhs.wisconsin.gov 46 Contacts