CHIP Needs Assessment 2005

When the public is asked to discuss their current health concerns as a resident of San Diego, the most common responses are the availability of healthcare, access to insurance, treatment of patients, education and prevention, and prescription drugs. These are all important access to healthcare issues, but what about mental health, obesity, diabetes, substance abuse and cancer?

The Community Health Improvement Partners (CHIP) is a collaboration of 30 organizations who are dedicated to a vision of optimal health for San Diego County’s communities through collaboration and needs assessments. Charting the Course IV, published in 2005, is CHIP’s fourth countywide community health needs assessment. The document includes in-depth profiles of the top 14 health issues, prioritization of the most critical non-clinical and clinical health issues, and a review of health issues by race/ethnicity, age, and geographic region. As a part of this process, CHIP conducted nine qualitative focus groups among various demographic segments of San Diego County.

The CHIP Needs Assessment prioritized the overall health concerns affecting San Diegans today. Ranked by order of importance, the top four issues were: access to healthcare services; overweight & obesity; mental health; and physical activity and fitness.

Since the first needs assessment in 1995, access to healthcare has been the number-one concern in San Diego County. As providers, this is also our main focus with an emphasis on the availability of health insurance. Among focus group participants, one of the most common health concerns was the general ease of access to healthcare, “with regard to the accessibility of getting an appointment and the time spent waiting at the doctor’s office.” The amount of time spent waiting at the doctor’s office prior to the appointment and the delay in scheduling future appointments were the major deterrents to receiving healthcare.

Patient handling was also a major concern, with numerous anecdotes of spending multiple hours in the waiting room and only a brief encounter with the physician. One participant from the senior group stated, “You’re rushed in and rushed out and not given any personal attention.”

The County is currently experiencing physician and nurse staffing shortages while our growing patient population is increasingly utilizing services, leading to a vulnerable community and rising healthcare costs. According to the United Way Outcomes Survey, 78 percent of San Diegans are satisfied with their healthcare services. As providers, it is important to educate the public about the appropriate utilization of healthcare services, while acknowledging the public’s concerns. Together, these goals will vastly improve our healthcare delivery system and result in improved patient satisfaction and efficient use of the physician’s time.

So what about mental health, diabetes, substance abuse and cancer? Access to care has become such a focal point to the community that other important health issues affecting San Diegans are falling from our patient’s radar. In the most recent CHIP Needs Assessment, the top four priority “disease-specific” issues were mental health, diabetes, substance abuse, and cancer. The needs assessment also categorizes this information by age groups, for example, heart disease and stroke is the number one health concern for ages 25 years and over.

Mental health has been amongst the top four priority health issues since the first needs assessment in 1995. Serious mental illness (SMI) is a diagnosable mental, behavioral, or emotional disorder that results in functional impairment interfering with or limiting one or more major life activities. Mental health does not only encompass SMI, but is a broader terminology that constitutes a more holistic view of wellbeing. As healthcare professionals, we need to continue to strive to improve the coordination of care between mental and physical health.

In 2003, 9.6 percent of all adults in the United States had an SMI, and, of these adults, only 47.9 percent indicated they had received treatment for their mental health problem during the past 12 months. Cost, insurance issues, and not feeling a need for treatment are the most commonly stated reasons for going untreated.

People with SMI also have higher rates of illicit drug use, cigarette smoking, and dependence on or abuse of illicit drugs than those without SMI.

• 18.1 percent of persons with SMI use illicit drugs compared to 7.8 percent of those without SMI;
• 44.2 percent of persons with SMI use cigarettes compared to 25.2 percent of those without SMI;
• 21.3 percent of persons with SMI have dependence on or abuse alcohol or illicit drugs compared to 7.9 percent of those without SMI.

It is common that those with mental illness also have a substance abuse problem — this is referred to as having a “dual diagnosis” or “co-occurring disorder,” and simultaneous or integrated treatment designed for both conditions is recommended.

More than half of all adults have a family history of alcholosm or problem drinking, and more than nine million children live with a parent dependent on alcohol and/or illicit drugs. In San Diego in 2001, 15.4 percent of all adults and 23.2 percent of adults aged 18–34 engaged in binge drinking. An even greater concern is that in 2003, 38.5 percent of students in grades 9–12 within the San Diego Unified School District had at least one drink of alcohol in the past 30 days and 22.2 percent of students engaged in binge drinking.

Obesity is another quandary that continues to worsen, especially with children. In 2001, San Diego County reported (the most currently available information) an estimated 44 percent of adults were overweight or obese and 5.5 percent of adults were obese. Among those San Diego County residents that participated in the 2002 Pediatric Nutritional Surveillance Survey, 17.3 percent of children between the ages two and five were overweight and 20.8 percent of children 6 to 19 were overweight.

Obesity is a key factor within the realm of healthcare because there are so many medical conditions that have been linked, including diabetes, heart disease, stroke, high blood pressure, asthma and certain types of cancer. It is now estimated that the cost of overweight and obesity in the United States is $61 billion in direct costs and $56 billion in indirect costs, totaling $117 billion. These economic costs are comparable to those of cigarette smoking.

The Needs Assessment also looks at health issues by ethnicity/race. The U.S. Department of Health and Human Services recently published the following statement: “Life expectancy and overall health have improved in recent years for a large number of Americans due to an increased focus on preventive medicine and dynamic new advances in medical technology. However, not all Americans are benefiting equally. There are continuing disparities in the burden of illness and death experienced by African Americans, Hispanic Americans, Asian Americans/Pacific Islanders, and American Indians/Alaska Natives, as compared to the U.S. population as a whole.”

In San Diego County, African Americans have the highest number of disparities compared to the general population. In 2001, the prevalence of diabetes among African American adults was double the rate of whites; their diabetes-related hospitalization rates over two and a half times higher than the overall population’s; and their diabetes-related mortality rate about two and a half times higher than the overall population’s.

The impacts of asthma are also significantly higher for African Americans than for other racial and ethnic groups. Between 2000 and 2002, African Americans living in San Diego were over two and a half times more likely to be hospitalized due to asthma than the population as a whole. In California, the prevalence of asthma among African Americans is 20 percent compared to 12.4 percent of the population as a whole.

African Americans have the highest rates of coronary heart disease deaths and stroke deaths compared to other racial and ethnic groups; are more likely to die of cancer than people of any other racial or ethnic group; and have higher rates of premature delivery and fetal mortality rates than any other group.

Healthcare access is a significant problem overall; however, it is important that patients not overlook other health issues affecting the community. The healthcare system is complex and at times difficult to navigate. The data and disparities presented in the needs assessment serve as a call to action to providers and residents of San Diego County. Providers will continue to treat the sick and promote prevention, but we also have a responsibility for basic public health education. Once the community understands the causal factors of health conditions and interrelationships that exist among disparate populations, we may start to see an improvement in trends and tangible results.