community health needs assessment 2018 · the rate of mental health hospitalizations was higher for...

CommunityHealthNeedsAssessment

2018

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TableofContentsAcknowledgments 4

ExecutiveSummary 5

Introduction 6

Methods 7

Findings 8

Demographics 9

ChronicDisease 20

MentalHealth 29

SubstanceUseDisorder 32

HousingStability 38

Recommendations 46

Limitations 54

AppendixA.SupplementalHealthIndicatorsandDemographicData 55

AppendixB.KeyInformantSurvey 59

AppendixC.FocusGroupQuestions 60

References 61

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AcknowledgementsThisCommunityHealthNeedsAssessment(CHNA)wasmadepossiblethroughthecooperativesupportof several individuals and organizations. We are particularly grateful for the Community Benefitsleadership at Carney Hospital, Krisha Cowen, Marketing Manager and Barbara Couzens, CommunityRelations& Patient AdvocacyManager. A special thank you to our community partners: Bethel AMEChurch,MorningStarBaptistChurch,TalbotNorfolkTriangle,NorineWoods–Communitymember,TheBostonProjectMinistries,CommunityCareAllianceatCarney,FourCornersMainStreet,BigCityRadio,FrancinePope–FormerBostonprobationofficer,andCodmanSquareNDC,amongmanyotherswhoalsoprovidedfeedbackthroughsurveyresponsesandcomments.Thank-you to Paul Oppedisano, Accreditation Coordinator/Director MassCHIP, Office of theCommissioner, Massachusetts Department of Public Health. Lastly, we thank the team at H&HSConsulting Group LLC. that produced this body ofwork. Sincere acknowledgements to Paulo Gomes,MSHS, Principal Consultant, Benjamin Ethier, Public Health Research Assistant, Kristy Najarian,MPH,DataAnalyst,JenniferHohl,MPH,DataEntry.

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ExecutiveSummary

This report is a comprehensive analysis of health indicators for CarneyHospital. The CarneyHospitalservice area includes Dorchester (02122), Dorchester (02124), Dorchester (02125), Mattapan, SouthBoston, Hyde Park, Braintree,Milton, and Quincy. Data was gathered by analyzing publicly availableinformation, by reviewing community feedback gathered through focus groups, by conducting anextensivereviewofpublishedliteratureonthehealthofthepopulationresidingintheregionandintheCommonwealth ofMassachusetts, and by surveying service providers. This data-drivenmethodologyallowsCarneyHospital to investigate the resource requirementsof the community in order tobetterstreamline resources and inform community-based initiatives. The information from our 2018CommunityHealthNeedsAssessmenthighlightssomeoftheneedsidentifiedwithinthecommunityandmaybeusedtodeveloptargetedpopulationhealthimprovementstrategies.Ourgoalhasbeento learn fromcommunityresidents,particularly thosemostat-risk forexperiencinghealth disparities, and implement programming that will give all individuals an opportunity to live ahealthy life.This isparticularly true for thosepersonsatgreatest risk forhealth inequities,definedbytheWorld Health Organization as, “avoidable inequalities in health between groups of people withincountries and between countries”, herein identified as high-priority populations. Through community-orientedbest practices, CarneyHospital collaborateswith community partners to improve thehealthstatus of residents within our service area.We accomplish this by: addressing root causes of healthdisparities;educatingcommunitymembersonpreventionandself-care,particularlyforchronicdiseasessuch as cancer, heart disease, diabetes, obesity, substance use disorder; and addressing socialdeterminantsofhealth.Thisreportprovidestheresultsofanexaminationofhealthconditionsandsocial factorsaffectingthepeoplelivingintheCarneyHospitalprimaryservicearea.Evaluationofboththeneedsofthecommunityandthestrategicgoalsofthehospitalfurtherstheprospectofworkingcollectivelytoimproveboththehealthdeliverysystemandthehealthofthepopulation.Opportunitiesarerealizedattheintersectionofthehospital’sstrengths,thecommunity’sneeds,andinnovationsinhealthcaredelivery.Socialdeterminantsofhealth, including social,behavioralandenvironmental influenceshavebecomeincreasingly prevalent factors in addressing population health. Literature recommends linking healthcareandsocialserviceagencies inaddressingsocialdeterminantsofhealthto increasetheefficacyofhealthpromotionand chronicdiseasepreventionprograms. Inparticular, services related tohousing,nutritional assistance, education, public safety, and income supports are areas for cross sectorcollaboration with health services in the community. Multicultural communities face particularlycomplexissueswhenaccessingandreceivingtreatmentintheirdailylives.A key takeaway from this analysis is that collaboration on health promotion and chronic diseasepreventionamonghealthandsocialservicesorganizationsiscriticaltothesuccessofpopulationhealthimprovement strategies. From promoting access to affordable health care, creating a stable positiveeconomic environment in the region, ensuring that thosemost at-risk have access to basic needs forbetter health outcomes such as stable affordable housing, low-cost nutritional food choices, and ahealthy environment, Carney Hospital is well positioned to implement community benefits programsthat support a healthy and thriving community. The information and recommendations herein areoffered as a tool for guidance for the hospital and the community to implement strategic actions toimprovepublichealthoutcomes.

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IntroductionSince 1863, Carney Hospital has served the City of Boston and neighboring communities. CarneyHospitalhas received the JointCommission’sGold SealofApproval forhealth carequality and safetyandnumerousotherqualityandsafetyawards,includingbeingdesignatedaTopHospitalfor2014and2015by the LeapfrogGroup.The159-bedhospitalhasmore than400physiciansanddeliversqualitycaretoapproximately140,000patientsannually.CarneyHospitalprovidesDorchesterandsurroundingcommunitieswithconvenient,localaccesstoqualityprimarycare,emergencymedicineandarangeofspecialtiesandsubspecialties including;critical care, familymedicine,cardiology,neurology,oncology,orthopedics,ambulatorycareandadolescent,adultandgeriatricpsychiatry.CarneyHospital ispartoftheStewardHealthCareNetwork.Tolearnmore,pleasevisitwww.carneyhospital.org.StewardHealthCare is thenation’s largestprivate, forprofitphysician ledhealthcarenetwork in theUnitedStates.Headquartered inDallas,Texas,Stewardoperates36hospitals intheUnitedStatesandthe country ofMalta that regularly receive top awards for quality and safety. The company employsapproximately 40,000 health care professionals. The Steward network includes multiple urgent carecenters and skilled nursing facilities, substantial behavioral health services, over 7,900 beds undermanagement, and approximately 1.5to2.2 million full risk covered lives through the company'smanaged care and health insurance services. The total number of paneled lives within Steward'sintegratedcarenetworkisprojectedtoreachthreemillionin2018.CommunityBenefitsMissionStatementCarneyHospitaliscommittedtocollaboratingwithcommunitypartnerstoimprovethehealthstatusofourcommunityresidentsbyaddressingtherootcausesofhealthdisparitiesandeducatingcommunitymembers around prevention and self-care, aswell as providing current and potential patientswith ageneralintroductiontohealthcareoptionsthatareaccessibleintheircommunity.

CommunityBenefitsStatementofPurposeTheCarneyHospitalcommunitybenefitspurposeisto

• Improvetheoverallhealthstatusofpeopleinourservicearea;• Provideaccessible,highqualitycareandservicestoallthoseinourcommunity,regardlessof

theirabilitytopay;• Collaboratewithstaff,providersandcommunityrepresentativestodelivermeaningful

programsthataddressstatewidehealthprioritiesandlocalhealthissues;• Identifyandprioritizeunmetneedsandselectthosethatcanmosteffectivelybeaddressedwith

availableresources;• Contributetothewell-beingofourcommunitythroughoutreacheffortsincluding,butnot

limitedto,reducingbarrierstoaccessinghealthcare,preventivehealtheducation,screenings,wellnessprogramsandcommunity-building

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MethodsThe2018CarneyHospitalCommunityHealthNeedsAssessmentwasdevelopedinfullcomplianceoftheCommonwealth of Massachusetts Office of Attorney General-The Attorney General’s CommunityBenefitsGuidelines forNon-ProfitHospitals released in February2018. Inorder to accomplish this, amulti-dimensional approach to the collection of health and social demographic information from itsprimaryserviceareawasconducted.Inaccordancewiththisprocess,CarneyHospitalengagedvariouscommunity partners to ensure that varying perspectives on health and social topics were taken intoaccount in order to complete this CHNA. Below is a brief description of the actions taken to gathercommunitydata.HealthIndicatorsandDemographics–DataAnalysisDemographic data was collected using publicly available databases maintained by the U.S. CensusBureau,theMADepartmentofEarlyandSecondaryEducationwithsomecross-referencingofCenterforDisease Control and Prevention (CDC) databases. Health indicator data such as mortality, incidence,prevalence,andhospitalizationrateswereprovidedbytheMassachusettsDepartmentofPublicHealth,andbyusingotherstate,regionalandnationalinformationsources(i.e.UniformCrimeReporting(UCR)Program of the Federal Bureau of Investigation). Supplementary data on health indicators anddemographicsareavailableinAppendixA.KeyInformantSurveyA Key Informant Survey was distributed to the Carney Hospital Community Benefits Advisory Board,Carney Hospital and other key community-based organizations. Local health and human serviceorganizations,governmentagencies,communitycenters,localbusinessesandchurcheswereamongtheorganizationswhoweresent thesurvey.Thesurveygatheredkeyopinionsabout theCarneyHospitalcommunityandperceivedissueswithinthecommunity.AdetailedoverviewofthekeyinformantsurveyquestionscanbefoundinAppendixB.FocusGroupInordertoengagecommunitypartnersinthedatacollectionprocessafocusgroupwasconducted.Thefocus groups captured community perspectives on perceived health issues and explored barriers tohealth resources. In total, 11 individuals participated in the focus group. The goal was to collectinformationfromparticipantsthatcouldbeusedtoinformpopulationhealthimprovementstrategies.AdetailedoverviewofthefocusgroupquestionscanbefoundinAppendixC.LiteratureReviewA literature review was conducted in order to gather information from recent governmental, publicpolicy, and academic works. The relevant information was summarized and synthesized into acomprehensiveliteraturereviewaddressingthepriorityareasforcommunitybenefits,including:chronicdisease, cardiovascular disease, cancer, diabetes, behavioral health, substance abuse disorders andhousingstability/homelessness.

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FindingsChronicDiseaseAccording to the Massachusetts Department of PublicHealth (MDPH), prevention and treatment of chronicdisease is a public health priority. Nutrition, physicalactivity,and tobaccouseandexposureare threekey riskfactorsthatdirectlyimpactcancer,diabetes,chroniclowerrespiratory disease, and cardiovascular disease rates.Thesechronicconditionsinturncontributeto(56%)ofallmortality in Massachusetts and over (53%) of all healthcareexpenditures($30.9billionayear(MDPH,2014).Various studies have shown that, although the threeleadingriskfactorsaremodifiable,theconditionsinwhichpeoplelive,learn,work,andplaydonotofferequalaccessor opportunity to make this possible. For example, ahistoryofpoliciesrootedinstructuralracismhaveresultedinenvironmentsinwhichthereareinequitiesinaccesstohealthy foods, safe spaces for physical activity, walkablecommunities, quality education, housing, employment,and health care services. The health implications of thisareevidentinthefactthatBlackandHispanicresidentsofMassachusetts are consistently and disproportionatelyimpactedbythehighprevalenceofallchronicdiseases,aswell as the related deaths and high acute care serviceutilization(MDPH,2017).

Basedon theKey Informant Survey conductedbyCarneyHospital, respondents agreed that chronic diseases are amajorissueinthecommunity.Whenaskedtoidentifythechronic diseases prevalent in their respectivecommunities, participants noted that diabetes andcardiovascular diseaseweremost common. Respondentsnotedaverylowlevelofconcernregardingcancer.CarneyHospitalalsoconductedafocusgroupwithintheirserviceareatoengagecommunitymembersinthedatacollectionprocess. Diabetes and heart disease were the primarychronicdiseaseconcernsoffocusgroupparticipants.

MentalHealthDatafrom2015revealinequitiesacrosscategoriesofage,sex, and race/ethnicity in mental health hospitalizations.The rate ofmental health hospitalizationswas higher forthoseages30-65yearscomparedwiththose65andolder,males compared with females, and White residentscomparedwithAsian,Black,andLatinoresidents.Mentalhealth intersects with many areas of public health,including addiction, cancer, cardiovascular disease, andHIV/AIDS, therefore requiring common services andresource mobilization effort. Integrated treatment iscriticalfortreatingpeoplewithco-occurringdisordersandcanultimatelyachievebetterhealthoutcomesandreducecosts(MDPH,2017).To reduce the inequities of mental health conditions inBoston, interventions targeting subpopulations at higherrisk of mental illness are needed. It is also necessary toeducatethepublicabouttheavailabilityofmentalhealthservices and to decrease the stigma of seeking suchservices. Work also needs to be done to stopdiscrimination, which impacts the mental health of the

person facing the discrimination. Additionally, as theWorld Health Organization (WHO) suggests, in order toreduce the inequities in the occurrence of mentaldisorders, the conditions of everyday life, which are thesocialdeterminantsofhealth,mustimprove(BPHC,2017).

SubstanceAbuseDisorderIn 2015, there were 1,637 opioid-related deaths inMassachusetts. The rates of substance misuse deaths,unintentional drug overdose hospital patient encounters,andunique-person treatmentadmissionswerehigher formen thanwomen.At theneighborhood level, the rateofoverallsubstancemisusedeaths(includingalcoholmisuse,drugmisuse,andunintentionalopioidoverdose/poisoningdeaths) during the five-year time period 2011-2015 washigherforDorchester(zipcodes02122,02124),andSouthBostoncomparedwiththerestofBoston(BPHC,2017).Individual-level risk factors such as socioeconomic status,family history, incarceration, and stressful life events areassociatedwith drug use. Increasingly, evidence suggeststhat the social determinants of healthmay contribute toone’s decision to initiate drug use and shape othersubstance use behaviors. Additionally, addiction is achronic neurological disorder and needs to be treated asotherchronicconditions(BPHC,2017).

Housingstability Our data point out that race, ethnicity, and socio-economicfactorsareindicatorsofhealthoutcomeswithinthe region. To take this into consideration and enhanceefficacyofCarneyHospitalprograms,CarneyHospitalwillfocusitseffortstowardindividualsandfamilieswhoareatgreatest risk for health inequities due to socio-economicand/or sociodemographic status, lack of access to healthand social services, and lack of chronic disease self-managementsupport.Providingcarecoordinationservicesand facilitating access to social services are essentialcomponentsofapopulationhealthimprovementstrategy,asindicatedbyparticipantsinthefocusgroupsconductedin the Carney service area, and in responses gatheredthrough theKey InformantSurveys. Increasingawarenessandbuilding capacity in service systems are important inhelping identify and treat co-occurring disorders.Treatmentplanningshouldbeclient-centered,addressingclients’goalsandusingagreedupon treatmentstrategies(MDPH,2017).Safe and stable housing provides personal security,reduces stress and exposure to disease, and provides afoundation for meeting basic hygienic, nutritional, andhealthcare needs. Average income gains over the pastdecadehavefailedtokeeppacewithrisinghousingcosts,pushing thousands of residents into unstable housingsituations. Without consistent access to health care,homeless individuals are less likely to participate inpreventive care and are much more likely to utilize theemergency department for non-emergencies. Suchpatterns of use are not only a burden on the healthcare

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system,butdetrimentaltopersonalhealthaswell(BPHC, 2017).

DemographicsWho we are directly impacts how we interact with our community and society. Our race, genderidentity, age, disability status, etc. influences the social environment that we experience. Our socialenvironment impactsmanymental and physical health outcomes, including:mental health, violence,risk behaviors (tobacco and drug use), physical health and well-being, and disease morbidity andmortality.Weareinfluencedbythesocialenvironmentonthreelevels:interpersonal,community,andsociety(MDPH,2017).

Acrossall three levels, systemsofoppression suchas structural racismandgenderbias lead to socialisolation, social exclusion, poormental health, increased risk of violence, increased rates of poverty,higher hospitalizations, longer recovery times, and highermortality rates formany conditions. Socialisolation, social exclusion, racism, discrimination and poverty disproportionately affect low-incomecommunitiesandcommunitiesofcolorandallnegativelyimpactmanyaspectsofhealth.Communitiesofcoloraremorelikelytohavelowerlevelsofresourcesandconnectednesswithotherneighborhoodsandhigherlevelsofracialsegregation.Theyalsofacemorechallengeswhenengagingingroupactioninneighborhoodstoshifttheseconditions(Hobson-PraterT,2012).

Improvingaccesstohealthcaretodayalsomeansweconsiderlanguage,education,thecostofmedicalinsurance, and other social, economic, and environmental factors. A lack of consistent medical andpreventative care leads to sicker individuals who require more resources. This contributes to risinghealthcare costs and stressed emergency medical care systems. This pattern further contributes tohealthinequities(BPHC,2017).

Althoughhealthcareprovidersintendtoprovideequaltreatmenttoall,biasamongprovidershasbeenshown to negatively impact patients. For example, studies suggest that physicians unknowingly offerdifferent treatment options based on the patient’s race, evenwhen patients have similar symptoms.Patientsareaccessingcarebutbeingtreateddifferently.Theserace-baseddifferencesmaybereducedifphysiciansrecognizetheyaresusceptibletounconsciousbias,especiallywhen interactingwiththeirpatientsandwritingprescriptions.Thebiasamongprovidersandtheresultingdifferencesintreatmentmayalsocontributetohealthinequities(BPHC,2017).

During 2011-2015, Hyde Park, and South Boston had a lower percentage of uninsured residentscomparedwith Boston overall. In the same time period, Dorchester (02125), andDorchester (02122,02124) had a higher percentage of residentswithout health insurance comparedwith Boston overall(BPHC,2017).

During2013and2015combined,(9%)ofBostonadultresidentsreportedneedingtoseeadoctorbutwere unable to do so because of cost. The percentage of adultswho could not afford a doctorwashigherforthefollowinggroups:

• Black(13%)andLatino(16%)adultscomparedwithWhiteadults(5%)• Adultswithlessthanahighschooldiploma(19%)orahighschooldiploma(10%)comparedwith

adultswithatleastsomecollegeeducation(7%)• Adultswhowereoutofwork(18%)comparedwiththosewhowereemployed(8%)• Adults living in households with an annual income of less than $25,000 (15%) or $25,000-

$49,999(14%)comparedwithadultslivinginhouseholdswithanannualincomeof$50,000ormore(4%)

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• Adults who were Boston Housing Authority residents (14%), adults who received rentalassistance(17%),adultswhorentedbutdidnotreceiverentalassistance(10%),andthosewithotherhousingarrangements(12%)comparedwithhomeowners(5%)

• Foreign-bornadultswho lived intheUnitedStatesfor10yearsor less (13%)andforeign-bornadultswho lived in theUnitedStates forover10years (14%)comparedwithU.S.-bornadults(7%)(BPHC,2017)

Racialandethnicinequitieswerefoundinindicatorsofhealthcareaccess,particularlyforLatinoadults.Higher percentages of Latino adults comparedwithWhite adults reported both the inability to see adoctor inthepast12monthsbecauseofcostandthelackofadoctororhealthcareprovider.AmongBostonadults,inequitiesinpercentageofthosewithinabilitytoseeadoctorbecauseofcostandwithnothavingadoctororhealth careproviderwerealso foundacross categoriesofemployment status,education,householdincome,homeownership,andplaceoforigin.Inequitiesintheseindicatorstendto disproportionately affect adultswith less thanhigh school diplomaor household income less than$25,000,aswellasadultswhoarenon-homeownersorforeign-bornresidentswholivedintheU.S.for10orfeweryears(BPHC,2017).

To reduce the inequities in beinguninsuredor facedwithbarriers tohealth care access,multi-sectorinterventions that target subpopulations at higher risk should address social determinants, (e.g. byimproving employment opportunities and wage conditions among vulnerable sub-populations, andsourcesofstructuralracismthataffecthealthcareprovider-patientinteractions).Continuedfundingtosupport health insurance coverage in Massachusetts will also help maintain the low percentage ofuninsuredamongBostonresidents(BPHC,2017).

Table1:RaceDistribution2012-2016

White

Black orAfricanAmerican

AmericanIndian andAlaskaNative Asian

NativeHawaiian andOther PacificIslander

Some OtherRace

Two or MoreRaces

Dorchester(02122) 37.70% 30.90% 0% 18.40% 0% 9.60% 3.50%Dorchester(02124) 22.60% 64.40% 1.10% 6.20% 0% 2.90% 2.90%Dorchester(02125) 34.20% 29.70% 0.50% 12.80% 0% 17.70% 5.10%Mattapan(02126) 8.20% 86.10% 0.10% 0.90% 0% 2.70% 2%South Boston(02127) 81.80% 6.40% 0.10% 5% 0% 4.60% 2%Hyde Park(02136) 36.20% 45.90% 0.60% 2% 0% 11.90% 3.30%Braintree 82.90% 4.90% 0.10% 9% 0% 0.80% 2.30%Milton 75.40% 13.80% 0% 7.30% 0% 0.90% 2.50%Quincy 63.30% 5.30% 0.20% 28% 0% 1% 2.20%MA 79.3% 7.3% 0.2% 6.1% 0.0% 4.1% 3.0%

(Source:USCensusBureau,2012-2016AmericanCommunitySurvey5-YearEstimates)

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Figure1:RaceDistribution2012-2016


Cities/townswithintheCarneyHospitalserviceareagenerallyexhibitedgreaterdiversitythanthestateasawhole.Notably,(86.1%)ofallresidents inMattapanidentifiedasBlackorAfricanAmerican.Withthe exception of South Boston, Quincy and Braintree, each service area city/town had a greaterpercentage of Black or African American residents than the state average. Only Braintree and SouthBostonhadahigherpercentageofWhiteresidentsthanthestatelevel.Quincy,Dorchester(02125),andDorchester (02122) each had a higher than average percentage of Asian residents with the highestpercentagebeingseeninQuincyat(28%).Table2:RaceDistributioninPublicSchoolPopulation2017(non-Boston)

White, non-Hispanic

Black/African-American Hispanic Asian Other Multi-Race

Braintree 73.6% 4.8% 4.3% 15.7% 0.4% 1.3%Milton 69.3% 15.0% 4.4% 6.7% 0.3% 4.3%Quincy 45.1% 6.6% 5.8% 39.0% 0.6% 3.0%Boston(all) 14.2% 31.5% 41.9% 9.0% 0.5% 3.0%MA 60.1% 9.0% 20.0% 6.9% 0.3% 3.6%(Source:MA Dept. of Elementary and Secondary Education 2018) Note: At the time of data collection race distribution data for public schools wasunavailableforeachindividualBostonareazipcode

In2017,(60.1%)ofthepublic-schoolpopulationinMassachusettswaswhite.WithintheCarneyservicearea, only Braintree andMilton had a greater percentage ofWhite students than the state average.BostonandQuincyeachhadalowerpercentageofWhitestudentsthanthestatelevelwiththesmallestproportion seen in Boston at just (14.2%) White students. Boston and Milton each had a higherpercentage of Black students than the state average. Boston had the highest percentage of Blackstudentswith (31.5%), and the highest percentage ofHispanic students at (41.9%). Braintree,Quincyand Boston each had a higher percentage of Asian students than the state average. The largestproportionofAsianstudentswasseeninQuincywhere(39.0%)ofthepublic-schoolstudentpopulationidentifiedasAsian.

0% 20% 40% 60% 80% 100%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)

Braintree

Milton

Quincy

MA

White

BlackorAfricanAmerican

AmericanIndianandAlaskaNative

Asian

NativeHawaiianandOtherPacificIslander

SomeOtherRace

TwoorMoreRaces

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Figure2:AgeDistribution(19yearsoldandunder)2012-2016


Figure3:AgeDistribution(20yearsoldto64yearsold)2012-2016

(Source:USCensusBureau,2012-2016AmericanCommunitySurvey5-YearEstimates)Figure4:AgeDistribution(65yearsoldandover)2012-2016


0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)

Braintree Milton Quincy MA

Under5Years 5-9 10-14 15-19 19andUnder

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)


20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 20-64

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)


65-69 70-74 75-79 80-84 85YearsandOlder 65andOver

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From 2012 to 2016, cities/towns in the Carney Hospital service area generally followed a similar agedistribution to that seen at the state level. However, therewere a few notable exceptions. In SouthBoston,only (14.2%)of thepopulationwasunder theageof19, thiswas (9.5%) lower than the statelevelof(23.7%).SouthBostonalsohadasignificantlylargerproportionofthepopulationages25-29and30-34 than the state level (25.7% and 13%) compared to (7.1% and 6.6%). Dorchester (02122),Dorchester (02125) and Quincy also had a larger percentage of the population in these age groups.Dorchester(02125)hadthesmallestpercentageofthepopulationovertheageof65(8.2%).Dorchester(02122)andSouthBostonalsohadlessthan10%oftheirpopulationintheover65yearsoldgroup.

Figure5:PercentForeignBornPopulation2012-2016


From2012to2016,(15.7%)oftheMassachusettspopulationwasforeignborn.Sixofthenineservicearea cities/towns had a higher percentage of the population born in a foreign country. The largestproportionofforeign-bornindividualswasseeninDorchester(02125)at(39%),followedbyMattapan,andDorchester(02122)at(37%)and(35%)respectively.SouthBostonhadthesmallestpercentageofthepopulationborninaforeigncountryat(12%).

0%

5%

10%

15%

20%

25%

30%

35%

40%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)


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Figure6:CountryofOrigin–Foreign-BornPopulation2012-2016


From 2012 to 2016, (31.4%) of the foreign-born population in Massachusetts originated in LatinAmerica,thesamepercentageoriginatedinAsia.ThoseofEuropeandescentaccountedfor(28.8%)oftheforeign-bornpopulationinMassachusettsoverthisperiodoftime.Milton,HydePark,SouthBoston,Mattapan,Dorchester(02125)andDorchester(02124)eachhadahigherpercentageoftheforeign-bornpopulationoriginatinginLatinAmerica.InMattapan(91.2%)oftheforeign-bornpopulationoriginatedin Latin America. Dorchester (02122), Braintree, and Quincy each had a higher than state averagepercentageofforeign-bornresidentsoriginatinginAsia,Quincyhadthehighestpercentageat(70%).Itisalsoworthnotingthat5serviceareacities/townshadahigherpercentageofforeign-bornresidentsoriginating in Africa. Each Dorchester zip code exceeded the state average of foreign residentsoriginatinginAfrica.Table3:DistributionofLanguageSpokenatHome2012-2016

Speaks OnlyEnglish

Speaks LanguageOther ThanEnglish

SpanishOther Indo-EuropeanLanguages

Asian andPacificIslanderLanguages

OtherLanguages

Dorchester(02122)

57.0% 43.0% 10.8% 13.4% 16.7% 2.1%

Dorchester(02124)

66.4% 33.6% 13.1% 12.7% 5.4% 2.3%

Dorchester(02125) 48.5% 51.5% 17.3% 21.7% 10.9% 1.7%

Mattapan(02126)

61.3% 38.7% 13.1% 21.7% 0.7% 3.2%

South Boston(02127)

81.3% 18.7% 9.2% 5.1% 3.8% 0.6%

Hyde Park(02136) 57.6% 42.4% 21.5% 17.4% 1.1% 2.5%

Braintree 82.1% 17.9% 1.8% 6.8% 7.1% 2.2%Milton 81.9% 18.1% 3.2% 8.9% 5.4% 0.5%Quincy 62.7% 37.3% 2.1% 8.9% 24.7% 1.7%MA 77.3% 22.7% 8.6% 8.7% 4.1% 1.4%(Source:USCensusBureau,2012-2016AmericanCommunitySurvey5-YearEstimates)

From2012to2016,(77.3%)ofMassachusettsresidentsspokeonlyEnglishathome.Braintree,Milton,and South Boston exceeded this percentage with (82.1%), (81.9%), and (81.3%) respectively. Theremaining cities/towns each had a lower percentage of households that only spoke English than thestate average. Hyde Park had the greatest percentage of households speaking Spanish at homewith(21.5%).Other Indo-European languagesweremost prominent inDorchester (02125)with (21.7%)of

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)

Braintree

Milton

Quincy

MA

LatinAmerica

Europe

Asia

Africa

Oceania

Canada

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householdsusingtheselanguagesathome.AsianandPacificislanderlanguagesweremostprominentlyspokenathomeinQuincy(24.7%).Employment

Whilebeingemployedisimportantforeconomicstability,employmentaffectsourhealththroughmorethaneconomicdriversalone.Physicalworkspace,employerpolicies,andemployeebenefitsalldirectlyimpactan individual’shealth.Thephysicalworkplacecan influencehealth throughworkplacehazardsandunsafeworking conditionswhich lead to injuries, illness, stress, anddeath. Longworkhours andjobswith poor stability can negatively impact health by increasing stress, contributing to poor eatinghabits, leading to repetitive injuries, and limiting sleep and leisure time. Job benefits such as healthinsurance,sickandpersonalleave,childandelderservicesandwellnessprogramscanimpacttheabilityofboththeworkerandtheirfamilytoachievegoodhealth(MDPH,2017).

Theproportionofunemployedresidentsdeclined from(10.2%) in2010to (5.8%) in2015, reflectinga(43%)decreaseover thisperiod. From2010 to2015, thepercentageofMassachusetts residentswhowereunemployedwaslowerthanthenationalaverage.In2015,(5.8%)ofMassachusettsresidents16yearsofageorolderwereunemployed,comparedto(6.3%)fortheUS.Followingnationalpatterns,agreatershareofyoungerindividualswasunemployedin2011-2015.Atotalof(21.1%)ofMassachusettsresidents 16-19 years of age were unemployed and (12%) of persons 20-24 years of age wereunemployed(MDPH,2017).

Underemployment is linked to chronic disease, lower positive self-concept, and depression.Workerswith incomesbelow thepoverty line are part of theworkingpoor,who aremore likely to have low-paying,unstablejobs,havehealthconstraints,andlackhealthinsurance.Discriminatoryhiringpracticeshavelimitedtheabilityofpeopleofcolortosecureemployment.Thosewhohavebeenarrested,haveaconviction,felonyorhavebeenincarceratedareseverelylimitedintheirabilitytofindemploymentdueto policies placing limitations on individuals who have interacted with the criminal justice system(MDPH,2017).

For2011-2015,theunemploymentrateforBostonresidentswashigherinDorchester(zipcodes02121,02125), Dorchester (zip codes 02122, 02124),Mattapan, and Roxbury comparedwith Boston overall.The unemployment rate was lower in Allston/Brighton, Back Bay, Charlestown, Jamaica Plain, SouthBoston,theSouthEnd,andWestRoxburycomparedwithBostonoverall(BPHC,2017).

In2015,thelaborforceparticipationrateforBostonresidentsages16andolderwas(69%).Laborforceparticipation was lower among Asian (58%), Black (68%), and Latino (66%) residents compared withWhiteresidents(73%).The laborforceparticipationratewas lowerforBostonfemaleresidents(67%)comparedwithmaleresidents(72%)(BPHC,2017).

TheunemploymentrateforBostonresidentswashigherforBlackandLatinoresidentscomparedwithWhite residents.We also found inequities in the unemployment rate at the neighborhood level. TheunemploymentrateforBostonresidentswashigherinDorchester(zipcodes02121,02125),Dorchester(zip codes 02121, 02125),Mattapan, andRoxbury comparedwithBostonoverall. Theunemploymentratewas lower among Boston female residents comparedwithmale residents. Additionally, a higherpercentage of residents ages 18 to 64 with a disability in Boston were unemployed compared withresidentswhohadnodisability(BPHC,2017).

Employment status impacts an individual’s overall health. After adjusting for age, race/ethnicity, andsex,we observed that a higher percentage of Boston residentswhowere out ofwork had diabetes,persistent anxiety, and persistent sadness compared with those who were employed. A higherpercentageof residentswhose employment statuswas “other” (homemakers, students, retirees, and

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thoseunabletowork)hadasthma,diabetes,hypertension,andpersistentsadnesscomparedwiththosewhowereemployed(BPHC,2017).

Figure7:UnemploymentRate(16+)2012-2016


From2012to2016,unemploymentratesinallcities/townswithintheCarneyHospitalserviceareawerehigher than those seen at the state level. The highest unemployment rateswere seen in Dorchester(02125)andMattapanwhereunemploymentwas(12%)inbothneighborhoods.Dorchester(02122)wasthe only other service area city/town that had an unemployment rate over 10% (11.8%). The lowestunemploymentrates intheCarneyserviceareawerefound inMiltonandSouthBostonat (4.8%)and(4.9%)respectively.

EducationalAttainmentEducationalattainmentoftenhelpsindividualshaveaccesstoresourcesthatpromotegoodhealth,suchas physical activity breaks, school lunches, after-school programs and health-based resources such asscreeningsandmanagementofchronicconditions.Theseprogramshavebeenshowntoimprovehealthoutcomes, like childhood obesity, and mental health as well as school performance and learningoutcomes.Unfortunately,notallschoolsystemshavetheresourcestoprovidethesevitalprograms.Asstudentsspendasignificantportionoftheirdayinschool,schoolsalsoprovidebasicnecessitiessuchasshelter, sanitary facilities, food andwater, and opportunities for socialization. All of these exposureswhileinschoolaredirectlyassociatedwithbothbetterhealthandlearningoutcomes.Evenafterleavingthe education system, educational attainment continues to impact individuals’ health. Education isassociated with better jobs, higher incomes, and economic stability. Education can also provide agreatersenseofcontroloverone’slifeandstrongersocialnetworks,whichagainarelinkedtoabilitytoengageinhealthybehaviorsandbetteroverallhealth(MDPH,2017).

Unfortunately, educational attainment in Massachusetts is not equitable. Students from low-incomecommunities and communities of color may face challenges in getting to school, differential public-school resources, inequitable discipline practices, resources, and afterschool programming (MDPH,2017).

During2011-2015,higherpercentagesof residentsages25andolder inDorchester (zip codes02121,02125),Dorchester(zipcodes02122,02124),EastBoston,Mattapan,Roxbury,andtheSouthEndhad

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less than a high school diploma compared with Boston overall. Lower percentages of residents inAllston/Brighton,BackBay,Charlestown, Fenway,HydePark, JamaicaPlain,Roslindale, SouthBoston,andWestRoxburyhadlessthanahighschooldiplomacomparedwithBostonoverall(BPHC,2017).

In2015,themedianearningsforBostonresidentsages25andoldervariedbyeducationalattainmentand sex. For males and females, median earnings increased as the level of educational attainmentincreased.Femalesatalllevelsofeducationalattainment,exceptthosewithsomecollegeanassociatedegree, had lower median earnings when compared with their male counterparts. The largestdiscrepancywasobservedamongresidentswithgraduateorprofessionaldegrees.Femaleswiththesedegreeshadmedianearningsof$62,056whilemaleshadmedianearningsof$81,428(BPHC,2017).

In2015thepercentageofBostonresidentsages25andolder livingbelowthepoverty levelvariedbyeducational attainment and sex. Comparedwithmales, higher percentages of females at all levels ofeducational attainment, except those with some college an associate degree, were living below thepovertylevel(BPHC,2017).

AlthoughBostonhasareputationasaneducationhub,sexandracial/ethnicinequitiesforresidentsineducational attainment and related indicators exist. A higher percentage of White residents had abachelor’sdegreecomparedwithBlack,Latino,andAsianresidents,anda lowerpercentageofWhiteresidentscomparedwithBlack,Latino,andAsianresidentshadlessthanahighschooldiploma(BPHC,2017).

At the neighborhood level, we found higher percentages of residents with less than a high schooldiploma in Dorchester (zip codes 02121, 02125), Dorchester (zip codes 02122, 02124), East Boston,Mattapan,Roxbury,andtheSouthEnd.Inequitiesacrosscategoriesofrace/ethnicitywerealsoreflectedin the attendance and graduation rates of Boston Public Schools (BPS), and access to technology. AlowerpercentageofWhite school-age childrenattendedBostonPublic Schools (versusother typesofschools)comparedwithAsian,Black,andLatinoschool-agechildren.AhigherpercentageofWhiteandAsianBPShighschoolstudentsgraduatedinfouryearscomparedwithBlackandLatinostudents.Blackand Latino residentswere also less likely to have access to a computer or to have internet access athomecomparedwithWhiteresidents(BPHC,2017).

After adjusting for age, race/ethnicity, and sex, we observed that lower educational attainment wasassociatedwithhigherpercentagesofadversehealthindicators.Incomparisonwithadultswithatleastsomecollegeeducation,adultswithlessthanahighschooldiplomahadhigherpercentagesofasthmaandpersistentsadness.Adultresidentswithahighschooldiplomahadhigherpercentagesofdiabetes,hypertension,obesity,andpersistentsadness(BPHC,2017).

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Figure8:HighestEducationalAttainmentPopulationAge25+(2018)

(Source:MADept.ofElementaryandSecondaryEducation,2018)

Asof2018,(10%)oftheMassachusettspopulationhadlessthanahighschooleducation.InDorchester(02122) and Dorchester (02125), more than 20% of the population had less than a high schooleducation.Dorchester (02124)andMattapanalsohada largerpercentageof thepopulationwith lessthan a high school education, (18.4%, 18.5%). With the exception of South Boston, every Bostonneighborhoodhadahigher thanaveragepercentageof individualswith less thanabachelor’sdegreethanthestateaverage.Thegreatestproportionofthepopulationwithabachelor’sdegreeisfoundinSouthBoston(41.3%),comparedto(23.1%)atthestatelevel.Miltonhadthehighestpercentageofthepopulationwithagraduateorprofessionaldegreeat(30.6%).Education is associated with health in many ways. Higher educational attainment is associated withimprovedworkingconditionsandincome,whichinturnallowsforimprovedhousing,nutrition,controlof hazards and stress, aswell as direct healthbenefits, includingquality health insurance, retirementbenefits,andsick leave (BravemanP,2011).Educationalattainment isalsoclosely linkedto improvedhealth knowledge, literacy, and behaviors, which are, in turn, associated with improved diseasemanagement (Braveman P, 2011). Individuals with more years of formal education tend to havehealthier behaviors and better health outcomes. Education also helps promote and sustain healthylifestyles and positive choices that support and nurture personal development, relationships, andcommunitywell-being(RossCE,1993).

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Figure9:PovertyStatusbyEducationalAttainmentAge25+(2018)


From2012to2016,cities/townswithintheCarneyHospitalserviceareagenerallyfollowedthepatternsforpovertystatusbyeducationallevelseenatthestatelevel.However,inMattapanandDorchester(02122,02124,02125)thosewithalowerlevelofeducationwerelesslikelytobebelowpovertylevelthanindividualswiththesameeducationalattainmentinotherserviceareacities/towns.

When asked “Is there a sense of community where you live?” focus group participants had mixedresponses.Somestatedthattheyfeltastrongsenseofcommunitywherethey lived,whileothers feltthat the changingdynamicsof their neighborhoodshaddiminished the senseof community in them.Participantswhofeltasenseofcommunitycitedthediversegroupsrepresentedintheirneighborhoodsandavarietyofinitiativesthatbringcommunitymemberstogether.Thosewhostatedthattherewasalackofcommunity felt that therewasdecreasingethnicandagediversity.Whenasked“whatare thegeneral social demographics of consumers served by your organization?”, survey respondents statedthat their general consumerswereamixof ages,butprimarilyolderadults (31-64), earning$20,000-$40,000annually,ofavarietyofracialethnicbackgrounds,speakingamixoflanguagesathome.SurveyrespondentsbelievedthatthemajorityoftheirconsumersresidedinDorchester,followedbyMattapan,andthenQuincy.

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ChronicDiseaseAccordingtotheMassachusettsDepartmentofPublicHealth(MDPH),thepreventionandtreatmentofchronic disease is a public health priority. Nutrition, physical activity, and tobacco use/exposure arethree key risk factors that directly impact cancer, diabetes, chronic lower respiratory disease, andcardiovasculardiseaserates.Thesechronicdiseasesaccountfor(56%)ofallmortality,andover(53%)ofallhealthcareexpendituresinMassachusetts($30.9billionayear)(MDPH,2014).

Althoughthesethreeleadingriskfactorsaremodifiable,theenvironments inwhichpeople live, learn,work,andplaydonotalwaysofferequalaccesstothenecessaryresourcesoropportunitiestomodifytheseriskfactors.Ahistoryofpoliciesrootedinstructuralracismhaveresultedinenvironmentswherethereareinequitiesinaccesstohealthyfoods,safespacesforphysicalactivity,walkablecommunities,quality education, housing, employment, and health care services. The health implications of theseinequities are evident in the fact that Black and Hispanic residents of Massachusetts aredisproportionatelyimpactedbychronicdiseases.TheseinequitiesareevidentinthefactthattheBlackandHispanicpopulationsexperienceincreasedprevalenceof,andmortalityrelatedtochronicdiseases.Healthy people cannot exist in unhealthy environments. Because of this, MDPH frames its chronicdisease prevention and wellness efforts around the social determinants of health with a focus onpoliciesthatensurethatallindividualshavetheabilitytomakehealthychoices(MDPH,2017).By their very definition, chronic diseases are “managed” since cures are not available.Managementpractices extend life; therefore, chronic diseases continue to rise in prevalence. Chronic diseasemanagementincludesmedications,medicalprocedures,andlifestylechanges.Preventionisthekeytoreducingtheburdenofthesediseases.Topreventchronicdisease,peopleneedopportunitiestoliveahealthy lifestyle which includes, participating in adequate physical activity, eating a balanced diet,managing stress and limiting exposure to chronic stressors, refraining from tobacco use, and limitingalcoholconsumption(AdlerNE,2002).Unfortunately, themodernenvironment isoftennotsupportiveof thesehealthyhabits.Changing theenvironment to promote healthier behaviors requires strategic planning. Implementing systems andpolicies that increase opportunities for physical activity, provide support to live tobacco free, andimprove access to healthy foods, are strategies that have previously been used to create healthierenvironments. Systems and policies that address social determinants by improving access to routinepreventivemedical care and increasing educational and employmentopportunities also contribute tohealthy environments. A healthier environment can support an individual’s choice to walk or bikeinsteadofdrive,toquitsmoking,ortolimitsugarybeverageconsumption.Ultimately,buildinghealthierenvironments will encourage residents to live a healthy lifestyle, greatly improving their health andlongevity(BPHC,2017).

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Table4:MortalityDuetoChronicDisease(asapercentageofallcauses)2015

Total Cancer Mortality(percentage of allMortalitycauses)(2015)

Total Heart DiseaseMortality (percentage of allMortalitycauses)(2015)

Chronic Lower RespiratoryMortality (percentage of allMortalitycauses)(2015)

Diabetes Mortality(percentage of allmortalitycauses)(2015)

Dorchester(02122) 19.46 16.11 6.71 NA

Dorchester(02124) 23.58 14.47 4.09 5.98

Dorchester(02125) 23.44 18.23 3.65 2.6

Mattapan(02126) 25.68 14.75 2.73 3.83

SouthBoston(02127) 23.11 18.33 6.38 NA

HydePark(02136) 22.69 16.81 5.04 2.52

Braintree 20.94 22.25 5.24 NA

Milton 21.9 22.86 NA 2.86

Quincy 21.64 21.31 6.22 1.78

MA 22.1 21 4.8 2.4

CarneyRegion 22.27 19.23 5.06 2.37(Source:MassachusettsDepartmentofPublicHealth)Note:At the timeofdatacollection,mortalitydata fordiabeteswasunavailable forDorchester(02121),SouthBostonandBraintree.

Figure10:MortalityDuetoChronicDisease(asapercentageofallcauses)2015

(Source:MassachusettsDepartmentofPublicHealth)Note:At the timeofdatacollection,mortalitydata fordiabeteswasunavailable forDorchester(02121),SouthBostonandBraintree.

In 2015, about (50.30%) of all mortality inMassachusetts was due to cancer, heart disease, chroniclower respiratory disease, and diabetes. The figure above shows that (48.93%) of allmortality in theCarney Hospital service area was attributable to the same causes. Of the cities/towns in the Carneyservice area, only Quincy had a greater proportion of mortality due to these causes with (50.95%).Dorchester (02124), Dorchester (02125), Mattapan, Hyde Park and Milton each had lower levels ofmortalityduetochronicdiseasethantheMAstateandCarneyservicearealevels.Chronic diseases were a concern of both the focus group participants and survey respondents alike.When asked “what are the major health concerns in the community where you provide services?”,diabetes, heart health, and high blood pressure commonly chosen concerns (69.77%, 50%, 67.44%).Focusgroupparticipantsrankedbothdiabetesandheartdiseaseasthesecondgreatesthealthconcerninthecommunity.Only(9.3%)ofsurveyrespondentsbelievedthatcancerwasamajorhealthconcerninthecommunity.Focusgroupparticipantsbelievedthatchronicdiseaseprevalencewasonadecline.

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CancerCancer is the second leading cause of death in the U.S., in 2014, the age-adjusted mortality rateattributabletocancerwas161.2per100,000population.Nationally,theleadingtypesofcancerdeathsin2015were lungandbronchus,prostate inmen,breast inwomen,colonandrectum,pancreas,andliverandintrahepaticbileductinmen,ovaryinwomen(BPHC,2017).In2006,cancersurpassedheartdiseaseastheleadingcauseofdeathinMassachusettsandhasremainedtheprimarycauseofmortalityintheCommonwealthsince.AlthoughcancerincidenceandmortalityratesdecreasedinMassachusettsfrom2010to2014,therewerestillmorethan36,000newcancercasesdiagnosedannuallyduringthisperiod. During this period the age-adjusted cancer incidence rate in Massachusetts was 471.1 per100,000 population. Men had a higher cancer incidence rate than women (505.7 versus 450.4 per100,000 population). From 2010 to 2014, cancer incidence decreased (3.2%) annually among men(MDPH, 2017). Across the Commonwealth, breast cancer amongwomen and prostate cancer amongmenweremostcommon.Lungcancer,coloncancer,andmelanomawerealsoamongtheleadingtypesofcanceramongbothwomenandmen.Together,thesefivecancersaccountformorethanhalfofallcancercasesacrosstheCommonwealth(MDPH,2017)

From2011-2015 thecancermortality ratedecreased inBoston.AmongallBoston resident this figuredecreasedby(12%)andamongblackresidentsby(18%).In2015thecancermortalityrateforwomenwas (29%) lower than that of men. In 2015, (85%) of women reported having had received amammograminthepasttwoyears(BPHC,2017).ThefiveleadingtypesofcancerdeathsamongBostonresidentsweregenerallyconsistentwithwhatisobservedfortheU.S.andstate,withlungcancerasthetop cause. Some patterns emerge for lung cancermortality rates across sex and race/ethnicity. Lungcancermortalityratesaregenerallyhigherinmenthanwomen.Acrossrace/ethnicity,rateswerelowestamongLatinos(BPHC,2017).AccordingtotheBostonPublicHealthCommission,prostatecancerisstillvery common in Boston. Among Black men, prostate cancer deaths occur at two times the rate forWhitemen.TheracialinequityforBlackmeninBostonisthelargestforanymajorcancer.IntheUnitedStates,1in23Blackmenwithprostatecancerwilldiefromthediseasecomparedto1in42Whitemen(BPHC,2017).

Themajorknownriskfactorsforcancerareage,familyhistoryofcancer,smoking,overweight/obesity,excessivealcoholconsumption,excessiveexposure to thesun,unsafesex,exposure to fumes,secondhand cigarette smoke, and other airborne environmental and occupational pollutants. Severalsocioeconomicfactorsmodifytheseriskfactorsandcontributetotheprevalenceofcancerand/orlatestage cancer diagnoses. Gaps in health care coverage represent a barrier to covering the costs ofdiagnostictesting.Forexamples,individualswithhighdeductibles,lowpremiums,orhighco-paysmustpayfordiagnosticteststoconfirmacancerdiagnosis,contributingtodelaysindiagnosis(MDPH,2017).Aswithotherhealthconditions,therearemajordisparitiesinoutcomesanddeathratesacrossallformsof cancer, which are directly associated with race, ethnicity, income, and whether one hascomprehensivemedicalhealthinsurancecoverage(JohnSnowInc.,2016).

Inequities across age, race/ethnicity, insurance coverage, and income were also found for breast,cervical, and colon cancer screening tests. For breast, cervical, and colon cancer screening, inequitiestend todisproportionatelyaffectBlackandAsianadultsaswellasadultswithno insurancecoverage.Adultswithhouseholdincomelessthan$25,000werealsolesslikelytoreportcervicalandcoloncancerscreening. Across age categories, younger adults in the target population were less likely to reportscreeningforbreast(ages40-49),cervical(ages21-29),andcoloncancer(ages50-59)(BPHC,2017).

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Figure11:TotalCancerMortality(asapercentageofallcauses)2015

(Source:MassachusettsDepartmentofPublicHealth)

In 2015, (22.10%) of totalmortality inMassachusettswas due to cancer, the CarneyHospital servicearea exhibited a slightly higher percentage at (22.27%). Of the cities/towns in the Carney Hospitalservice area, five had higher percentages of mortality due to cancer than theMA state and Carneyservice area levels. These includedDorchester (02124), Dorchester (02125),Mattapan, South Boston,andHydePark.Mattapanhadthehighestpercentageofmortalityduetocancerat(25.68%),followedby Dorchester (02124) and Dorchester (02125) at (23.58%) and (23.44%) respectively. Dorchester(02122)exhibitedthelowestpercentageofmortalityduetocancerat(19.46%).

Figure12:TotalCancerCountsbySite(observedandexpectedcasecounts)2009-2013

(Source:MassachusettsDepartmentofPublicHealth,MassachusettsCancerRegistry)Note:Atthetimeofdatacollection,cancercountsbydiagnosissitewereunavailableforeachindividualBostonzipcode.

From2009-2013,breast cancerwas themostdiagnosed formof cancer in the state followedby lungcancer.BostonandBraintree followedthis trend. InMilton therewasanequalnumberofbreastandlung cancer diagnoses and in Quincy lung cancer diagnoses exceeded breast cancer diagnoses. Afterbreastandlungcancer,prostatecancerwasthethirdmostdiagnosedformofcancerinthestateandintheCarneyHospitalservicearea.

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Cancerwasnotamajorhealthconcernofsurveyrespondentorfocusgroupparticipants.Therewasnomention of cancer whatsoever in the focus group. Only (9.3%) of survey respondents believed thatcancerwasamajorhealthconcernintheCarneyHospitalcommunity.HeartDiseaseCardiovascular disease is a broad term that encompasses a number of adverse health outcomes,including congestive heart failure,myocardial infarction, and stroke. InMassachusetts, cardiovasculardiseaseisthesecondleadingcauseofdeathaftercancer(MDPH,2017).

Hypertensionisacriticalriskfactorforadversecardiovascularandcerebrovascularoutcomesincludingstroke,heartattacks,andcongestiveheartfailure. In2014,hypertensioncontributedto$19million intotalhospitalizationcosts inMassachusetts.Studieshaveshownthat,hypertensiondisproportionatelyimpactspeopleofcolor.Thesedisparitiesaregroundedinsocialandeconomicinequitiessuchasaccesstohealthcareandpoverty(MDPH,2017).

In2015, (29.6%)ofMassachusetts adults said theyhadbeendiagnosedwithhypertension, this valuehas remained relatively stable in recent years.A larger percentageof Blacknon-Hispanic adultswerediagnosed with hypertension (39.4%) compared to White non-Hispanic adults (30.7%). Racial/ethnicdisparitiesinhypertensionarelikelyanimportantcontributingfactortohospitalizationsforcongestiveheartfailure,myocardialinfarction,andstroke.(MDPH,2017)

Congestive heart failure can be debilitating and challenging for patients tomanage. It also poses aneconomic burden, costs related to congestive heart failure amounted to $540 million in totalhospitalizationcostsinMassachusettsin2014(CenterforHealthInformationandAnalysis,2014).Ifnotmanagedproperly,congestiveheartfailureisassociatedwithhighreadmissionrates,poorqualityoflife,andhighhealthcareutilization(KrumholzH,1997.157(1):99-104.)(HeoS,2009)

In 2014, the rate of hospitalizations attributed to congestive heart failure for Black non-Hispanicresidents(520.5per100,000population)wasmorethantwiceashighthanthatfornon-HispanicWhiteresidents (248.4 per 100,000 population). Hispanic residents also experienced higher rates ofhospitalizationsduetocongestiveheartfailure(400.7per100,000population)1.6timestherateofnon-HispanicWhiteresidents.Therateofmyocardialinfarction-relatedhospitalizationsdeclined(9.5%)from2010 (169.9per100,000population) to2014 (153.7per100,000population). In2014, themyocardialinfarctionhospitalizationrates forHispanic residents inMassachusetts (182.5per100,000population)andBlacknon-Hispanicresidents(159.0per100,000population)exceededthestateaverage(153.7per100,000population)andtheaverageforWhitenon-Hispanicresidents(145.6per100,000population)(MDPH,2017).

Strokeswereresponsiblefor$613millionintotalhospitalizationcostsinMassachusettsin2014(CenterforHealthInformationandAnalysis,2014). Thesehospitalizationcostsdonotincludeothereconomiccostsofstroke,suchaslostproductivityoroutpatienthealthcareexpenditures,norlossoflife,reducedqualityoflife,andincreaseddisability(MDPH,2017).

Racial/ethnicdisparitiescontinuetoexistinstroke-relatedhospitalizations.In2014,Blacknon-Hispanicresidents (368.1per100,000population)experiencedstroke-relatedhospitalizationata rate thatwasnearlytwiceashighasthatforWhitenon-Hispanicresidents(201.5per100,000population).Similarly,Hispanicresidents (264.9per100,000population)hadastrokehospitalizationratethatwas1.3timesthatforWhitenon-Hispanicresidents(201.5per100,000population)(MDPH,2017).

HeartdiseaseistheleadingcauseofdeathforBlack,Latino,andWhiteindividualsintheU.S.,anditisthesecondleadingcauseofdeathforAsianindividuals.InBoston,itisthesecondleadingcauseofdeathforthesegroups.NearlyhalfofAmericanshaveatleastoneofthethreekeyriskfactorsfordeveloping

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Coronary Artery Disease (CAD): high blood pressure, high LDL cholesterol, or cigarette smoking (19).Other risk factors include diabetes, overweight/obesity, diet with few fruits and vegetables, physicalinactivity, and excessive alcohol use. Educational attainment and household income are inverselyrelatedwithCAD(BPHC,2017).

In2015,therateofheartdiseasehospitalizationsinBostonwas(86.5per10,000residents).From2011-2015,theratedecreasedby(9%).Theratealsodecreasedby(8%)forBlackresidents,(22%)forLatinoresidents, and (5%) for White residents over the same time period. In 2015, the heart diseasehospitalizationrateforAsianresidents(36.3)was(55%)lowerthantherateforWhiteresidents(81.3)whiletherateforBlackresidents(117.8)was(45%)higherthantherateforWhiteresidents.Theratewas(26%)lowerforfemales(74.8)comparedwithmales(100.9).Theratewaslowerforallagegroupscomparedwiththoseages65andolder(467.2)(BPHC,2017).

In2015,theheartdiseasehospitalizationratewashigherforbothBlackfemalesandmales,andlowerfor Asian females and males when compared to White females and males. The heart diseasehospitalizationratewas(49%)higherforBlackfemales(102.0)and(47%)lowerforAsianfemales(36.2)comparedwithWhitefemales(68.3hospitalizationsper10,000residents).Theratewas(45%)higherforBlackmales (139.5)and (62%) lower forAsianmales (36.5)comparedwithWhitemales (96.2) (BPHC,2017).

Figure13:TotalHeartDiseaseMortality(percentageofallmortalitycauses)2015


In2015,(21%)oftotalmortalityinMassachusettswasduetoheartdisease.TheCarneyHospitalserviceareahadalowerpercentageat(19.23%).Ofthecities/townsintheCarneyservicearea,threeexceededthatstateandservicearealevels.Thesecities/townsincludedBraintree(22.25%),Milton(22.86%),andQuincy(21.31%).Dorchester(02124)andMattapanexhibitedthelowestlevelsofmortalityduetoheartdiseaseofallserviceareacities/townswith(14.47%)and(14.75%)respectively.Heartdiseasewasamajorconcernofboththefocusgroupparticipantsandsurveyrespondents.Focusgroup participants ranked heart health as their second greatest health concern in the community.Survey respondents supported this. Heart health and high bloodpressurewere chosen by (50%) and(67.44%) of survey respondents when asked “what are themajor health concerns in the communitywhereyouprovideservices?”.

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DiabetesSocioeconomic disparities exist in diabetes prevalence. In Massachusetts, adults with an annualhousehold income of less than $25,000 (15.6%) have three times the prevalence of diabetes ascompared to those with an annual household income more than $75,000 (5%). The prevalence ofdiabetesalsodecreasesaseducationalattainmentincreases.Atotalof(14.5%)ofadultswithoutahighschool degreewere diagnosedwith diabetes compared to (5%) of adultswith four ormore years ofpost-highschooleducation(MDPH,2017).

Diabetes prevalence andmortality inMassachusetts also differs by race/ethnicity. In 2015, a greaterproportion of Black non-Hispanic (12.3%) andHispanic (11.7%) adults reported being diagnosedwithdiabetes compared toWhite non-Hispanic adults (8.7%). In 2014, Black non-Hispanic residents weremore than2.1 timesmore likely todie fromdiabetes thanWhitenon-Hispanic residents (29.5 versus13.8per100,000population)(MDPH,2017).

In2014,Blacknon-Hispanicresidentshadmorethanfourtimestheratefordiabetes-relatedemergencydepartmentvisitsasWhitenon-Hispanicresidents(419.1versus99.3per100,000population).Further,thediabetesemergencydepartmentvisitrateamongHispanicresidentswasalmostfourtimesthatforWhitenon-Hispanicresidents(376.5versus99.3per100,000population)(MDPH,2014).

AmongU.S.adults,peopleofcoloraremorelikelytobediagnosedwithtype2diabetescomparedwithWhite adults. Having a close familymemberwith diabetes is also a risk factor for developing type 2diabetes (15).Socioeconomicdisadvantageat the individualandneighborhood level isalsoassociatedwithhigherriskofdevelopingtype2diabetes(BPHC,2017).

In2015,(8%)ofBostonadultresidentsreportedhavingdiabetes.Therewasasignificantincreaseinthepercentageofadultswithdiabetesbetween2006and2015.Thepercentageofadultswithdiabeteswashigherforthefollowinggroups:

• Black(15%)andLatino(11%)adultscomparedwithWhiteadults(5%)• Adultsages45-64(16%)or65andolder(24%)comparedwithadultsages25-44(2%)• Adultswithlessthanahighschooldiploma(18%)andadultswithahighschooldiploma(11%)

comparedwithadultswithatleastsomecollegeeducation(6%)• Adultswhowereoutofwork(10%)orwhoseemploymentstatuswas“other”(16%)compared

withadultswhowereemployed(5%)• Adults living in households with an annual income of less than $25,000 (14%) or $25,000-

$49,999 (9%)comparedwithadults living inhouseholdswithanannual incomeof$50,000ormore(4%)

• Adults who were Boston Housing Authority residents (18%) and renters who received rentalassistance(16%)comparedwithadultswhoownedahome(8%)

• Foreign-bornadultswholivedintheUnitedStatesforover10years(15%)comparedwiththosewhowerebornintheUnitedStates(8%)

Thepercentageofadultswithdiabeteswaslowerforthefollowinggroups:

• Adultswhorentedbutdidnotreceiverentalassistance(6%)comparedwithadultswhoownedahome(8%)

• Foreign-bornadultswholivedintheUnitedStatesfor10yearsorless(3%)comparedwiththosewhowerebornintheUnitedStates(8%)(BPHC,2017)

During2010,2013,and2015combined,thepercentageofadultswithdiabeteswashigherinDorchester(02121,02125),Mattapan,andRoxburycomparedwiththerestofBoston.(BPHC,2017).

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Figure14:DiabetesMortality(percentageofallmortalitycauses)2015

(Source:MassachusettsDepartmentofPublicHealth)–Note:Atthetimeofdatacollection,datafordiabetesmortalitywasunavailableforDorchester(02122),SouthBoston(02127)andBraintreeIn2015,(2.40%)ofallmortalityinMassachusettswasduetodiabetes.TheCarneyHospitalserviceareahad a slightly lower percentageofmortality duediabetes at (2.37%).Data ondiabetesmortalitywasunavailableforthreecities/townswithintheCarneyservicearea.Thehighestlevelofmortalityduetodiabeteswas seen in Dorchester (02124) at (5.98%), the next highest levelwas seen inMattapan at(3.83%).Quincywastheonlyserviceareacity/townbelowthestateandservicearealevelofdiabetesrelatedmortalityatjust(1.78%).DiabeteswasrankedasthesecondgreatesthealthconcernintheCarneyHospitalcommunitybyfocusgroup participants (alongwith heart disease and nutrition).When asked “what are themajor healthconcerns in the community where you provide services?”, survey respondents agreed. Diabetes waschosen by (67.44%) of survey respondents as amajor health concern in the Carney community, thispercentageisequaltothatofbehavioralhealthandsecondonlytosubstanceabuse(73.26%).ObesityObesityisbothachronicdiseaseandariskfactorforotherchronicconditionsincludingtype2diabetes,cardiovasculardisease, somecancers,andmanyotherhealthproblems that interferewithdaily livingand reduce the quality of life. Engaging in physical activity andmaintaining a healthy diet have beenproven to lower the incidence of obesity, however not all Massachusetts residents have the sameopportunitiestopreventobesity.Structuralbarrierstoaccessinghealthyfoodsandbeveragesaswellasopportunities to be physically active disproportionately affect people of color in the Commonwealth(MDPH,2017).In2015,nearly(60%)ofMassachusettsadultswereclassifiedasoverweightorobese,(24.3%)hadaBMIgreater than or equal to 30.0kg/m2.More than one-third of Black non-Hispanic adults (35.6%)wereobesecomparedtoHispanic(28.9%),andWhitenon-Hispanics(22.7%).Adultswithdisabilities(34.3%)weresignificantlymore likely tobeobesethanadultswithnodisability (20.7%).Adultswhohave lessthanahighschooleducationarealmosttwiceaslikelytobeobesethanadultswithfourormoreyearsofcollege(MDPH,2017).Childhoodobesityhasimportantimplicationsforthephysicalandemotionalwell-beingofchildrenandyouth. Child overweight is defined as a BMI at or above the 85th percentile for age. Child obesity is

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definedasBMIatorabovethe95thpercentileofexpectedforage.Childrenwhoareobesearemorelikelytodevelopriskfactorsforchronicdiseaseearlyinlife,suchashighbloodsugar,hightriglycerides,andhighbloodpressure.Childrenwhoareobesearealsomore likelytodevelopchronicdiseasesandexperience bullying related to weight. Childhood obesity is linked to poor nutrition and inadequatephysical activity in adulthood; and inequities persist across socioeconomic status and race/ethnicity.Massachusetts is ranked as the fifth worst US state on the prevalence of obesity among childrenenrolledintheWomen,InfantandChildren(WIC)programwhoaretwotofouryearsold(MDPH,2017).BMI screening reports conducted by school districts indicate that the prevalence of overweight andobesityinschoolagedchildrendecreasedby(2.1%)from2009(34.3%)to2015(31.3%).However,thisreduction in overweight and obesitywas not consistent across all school districts. The prevalence ofoverweightandobesitydidnotchangeinschooldistrictswheremedianhouseholdincomewaslessthan$37,000. These districts had the highest prevalence across the state with approximately (40%) ofstudentsbeingoverweightorobese(MDPH,2017).Figure15:ObesityPercentages:Grades1,4,7,10-OverweightorObeseMalesandFemales–2015

(Source:MassachusettsDepartmentofPublicHealth(2015))Note:Atthetimeofdatacollection,obesitypercentagesforeachindividualBostonzipcodewereunavailable,CarneyHospitalserviceareadatawasalsounavailable.

In2015, (32.20%)ofMassachusettsmalesandfemales (grades1,4,7,10)wereoverweightorobese.Braintree,Milton,andQuincyeachexhibitedobesitypercentagebelow thestateaverage.Miltonhadthelowestpercentageofoverweightorobeseindividuals(grades1,4,7,10)at(21%).Bostonhadthehighestpercentageofoverweightorobeseindividuals(grades1,4,7,10)at(39%).

Obesitywasnotmentionedbythefocusgroupparticipantsatanypointduringthesession.Whenasked“whatarethemajorhealthconcernsinthecommunitywhereyouprovideservices?”,(45.35%)ofsurveyrespondents selected obesity as amajor health concern in the community. However,when asked torankhealthandwellnessservicesthatwouldmostbenefitthecommunity,surveyrespondentsrankedobesitypreventionprogramsat(3.51)onascaleof1to10.Thiswasthelowestrankingofanysuggestedprogram.

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MentalHealthMental health intersectswithmanyareasof public health, including addiction, cancer, cardiovasculardisease, andHIV/AIDS. Integrated treatment is critical for treatingpeoplewith co-occurringdisordersandcanultimatelyleadtobetterhealthoutcomesandreducedcosts.Increasingawarenessandbuildingcapacityinservicesystemsareimportantinhelpingidentifyandtreatco-occurringdisorders.Treatmentplanning should be client-centered, addressing clients’ goals and using treatment strategies that areacceptabletothem(MDPH,2017).

ImpairedmentalhealthiscommonintheUnitedStatesgeneralpopulation.In2015,oneinfiveadultssufferedfromadiagnosablemental illnesssuchasdepressionoranxiety,andabout1 in7willhaveamajordepressiveepisodeintheirlifetime.In2015,(12%)ofchildrenages12-17reportedhavingamajordepressiveepisodeinthepastyear,higherthanthepercentagesfrom2004-2014.From1999to2014,theoverallsuiciderateintheU.S.roseby(24%)to(13.0per100,000).In2015,theoverallsuicideratewas(13.3per100,000).In2014,suicidewasthetenthleadingcauseofdeathintheU.S.andmorethan(90%)ofpatientswhodiedbecauseofsuicidealsohadmentalillness(BPHC,2017).

In2015, (22%)ofBostonadultresidentsreportedfeelingpersistentanxiety(feelingworried,tense,oranxiousformorethan15dayswithinthepast30days).Thepercentageofadultswithpersistentanxietyincreasedsignificantlybetween2006and2015(BPHC,2017).TherateofmentalhealthhospitalizationsinBostonduringthisperiodwas(77.1hospitalizationsper10,000residents).Theratewas(41%)lowerfor females (57.6)comparedwithmales (97.6).Theratewas(24%)and(68%)higher,respectively, forresidentsages30-44(97.3)and45-64(131.7)comparedwiththoseages65andolder(78.2).Theratewas(55%)and(45%)lower,respectively,forresidentsages0-17(35.2)and18-29(43.3)comparedwiththoseages65andolder(BPHC,2017).

TherateofmentalhealthhospitalizationsamongallBostonresidentsdecreasedby(5%)from2011to2015. In 2015, the rate of mental health hospitalizations was higher in Allston/Brighton, Back Bay,Fenway, and the South End compared with the rest of Boston. However, data from 2015 revealinequities across categoriesof age, sex, and race/ethnicity. The rateofmentalhealthhospitalizationswashigherforthoseages30-65yearscomparedwiththose65andolder,malescomparedwithfemales,andWhiteresidentscomparedwithAsian,Black,andLatinoresidents.(BPHC,2017).

For 2013 and 2015 combined, a higher percentage of Black (16%) and Latino (23%) Boston femaleresidents reported having persistent sadness compared with White females (10%). There were nosignificantdifferencesforBlackandLatinomaleswhencomparedwithWhitemales(BPHC,2017).Thepercentage of adultswith persistent sadness during this periodwas higher for Dorchester (zip codes02121,02125)andDorchester(zipcodes02124,02126)comparedwiththerestofBoston(BPHC,2017).

Studentswereasked ifduring thepast12months they felt sadorhopelesseveryday for2weeksormore.In2015,(27%)ofBostonpublichighschoolstudentsreportedpersistentsadness.Between2007and2015,therewasnosignificantchangeinthepercentageofstudentsexperiencingpersistentsadness(BPHC,2017).Earlydetectionandinterventiontoaddresssocialandemotionalriskfactorscangreatlyimprove outcomes for children and adolescents. Promoting emotional wellness and socialconnectednessacrossthelifecourseisaTitleVpriorityforMDPH,includingduringearlychildhoodandadolescence (MDPH,2017).Emotionalwell-being isshapedbyavarietyof factors, includingbiologicalfactors, lifeexperiences, familyandcommunitysupports,education,andenvironmental factors.Socialconnectionsareanimportantsourceofsupportforchildrenandadolescentsthatcanbuffertheeffectsof stress, connect children with resources, and shape health behaviors (Robert Wood JohnsonFoundation,2011).

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ToreducetheinequitiesofmentalhealthconditionsinBoston, interventionstargetingsubpopulationsat higher risk of mental illness are needed. It is also necessary to educate the public about theavailability ofmental health services and to decrease the stigma of seeking such services.Work alsoneeds to be done to stop discrimination, which impacts the mental health of the person facing thediscrimination.Additionally,as theWorldHealthOrganization (WHO)suggests, inorder to reducetheinequities in theoccurrenceofmental disorders, the conditionsof everyday life,which are the socialdeterminantsofhealth,mustimprove(BPHC,2017).

Figure16:EmergencyDept.MentalDisorders:AllRelatedHospitalizations(per100,000)2013(non-Boston)


In2013,Miltonexperiencedthehighestrateofmentalhealthrelatedhospitalizationsofallnon-Bostonserviceareacities/townsat(75.22per100,000).MiltonwasfollowedbyBraintreeandthenQuincywith(71.88)and(55.27)respectively.Figure17:EmergencyDept.MentalDisorders:AllRelatedHospitalizations(per10,000)2015(Boston)

(Source:BostonPublicHealthCommission2015)In2015,Dorchester(02122,02124)hadthehighestrateofmentalhealthrelatedhospitalizations(89.5per 10,000). Hyde Park followed at (83.1 per 10,000). The lowest rates of mental health relatedhospitalizationsinBostonwereseeninDorchester02125wheretheratewasjust(65.3per10,000).

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Mentalhealthwasthenumberonehealthconcernoffocusgroupparticipants.Surveyrespondentsalsoranked mental/behavioral health as a top health concern in the community, (69.77%) of surveyrespondentsselectedthiswhenasked“whatarethemajorhealthconcernsinthecommunitywhereyouprovideservices?”.Boththefocusgroupparticipantsandsurveyrespondentsbelievedthatmorecouldbedonetohelpthosewithbehavioral/mentalhealthconditions.Focusgroupparticipantsunanimouslyagreedthatmentalhealthservices,especiallythoseforteenagerswereinadequate,andthatthereisadire need to improve them. Focus group participants believed that individuals with a mental healthconditionwereunderservedintheCarneyHospitalcommunity.Whenaskedtorankhealthandwellnessservicesthatwouldmostbenefitthecommunity,surveyrespondentsrankedbehavioralhealthservicesat(5.94),thehighestofanysuggestedprogram.

SubstanceUseDisorder

AccordingtotheNationalSurveyonDrugUseandHealth (NSDUH) in2015,anestimated27.1millionpeople in the US aged 12 and older used illicit drugs in the past month. Of these, a majority (22.2million)reportedusingmarijuanaand3.8millionmisusedprescriptionopioids(SAMHSA,2015).Duringthesamesurveyperiod,anestimated20.8million,approximately1in10peopleneededsubstanceusetreatment(i.e.,treatmentforproblemsrelatedtotheuseofalcoholorillicitdrugs).Ofthispopulation,10.8 percent received treatment (SAMHSA, 2016). In 2014, there were 17,465 overdoses from illicitdrugsand25,760overdosesfromprescriptiondrugsintheUS.Foropioidspecific-relateddeaths,therewasa2.8-foldincreaseinthetotalnumberofopioid-relatedoverdosedeathsduringthistimeperiod.In2015,USoverdosedeathstotaled52,404,including33,091(63.1%)thatinvolvedanopioid(CDC,2016).

Forsubstancemisuse indicatorsevaluatedfor2015, inequitiesacrosscategoriesofrace/ethnicity,sex,and neighborhoodwere found. The rates ofmortality and hospital patient encounters for substancemisuseandunintentionaloverdosestendedtodisproportionatelyaffectWhiteresidents.However,theoverallsubstancemisusedeathrateincreasedalmosttwo-foldfrom2011to2015forBlackandLatinoresidents and to a lesser extent for White residents, which suggests the impact of fentanyl wasexperienced by all three of these racial/ ethnic groups and lessened relative inequities as ratesincreased.Racial/ethnicdifferencesinunique-persontreatmentadmissionsvariedacrossdrugtype.Forexample, the rates of unique-person treatment admissions for heroin and prescription drugs werehigherforWhiteresidentscomparedwithBlackandLatinoresidents.Formarijuana,theratewashigherfor Black and Latino residents compared with White residents. Across most drug types, the rate ofunique-persontreatmentadmissionswaslowestamongAsianresidents(BPHC,2017).

The rates of substancemisuse deaths, unintentional drug overdose hospital patient encounters, andunique-persontreatmentadmissionswerehigherformenthanwomen.Attheneighborhoodlevel,therateofoverallsubstancemisusedeaths(includingalcoholmisuse,drugmisuse,andunintentionalopioidoverdose/poisoning deaths) during the five-year time period 2011-2015 was higher for Charlestown,Dorchester(zipcodes02122,02124),andSouthBostoncomparedwiththerestofBoston(BPHC,2017).

In2015,amongthe19.6millionadultsages18yearsandoverintheU.S.whoexperiencedasubstanceuse disorder, (41%) also had had a mental illness in the past year. Causality and connection cannotalwaysbeproved;however, research shows that somemental illnesses are risk factors for substanceusedisorders.Someofthesameareasthataredisruptedinthebrainduetomental illnessesarealsodisruptedduetochangesinthebraincausedbysubstanceusedisorders.Additionally,peoplewilloftenusesubstancesasself-medicationfortheirmental illnesswhichcanresult insubstancemisuse(BPHC,2017).

Thecoexistenceofbothamentaldisorderandasubstanceusedisorder(SUD)isknownasco-occurringdisorders. People with mental health disorders are more likely to experience a SUD. Often, peoplereceive treatment for one disorder while the other disorder remains untreated. Undiagnosed,untreated, or undertreated co-occurring disorders can lead to a higher likelihood of experiencingnegativeoutcomes,suchashomelessness,incarceration,medicalillnesses,suicide,orevenearlydeath(SAMHSA,2016).

Massachusetts offers a variety of treatment approaches to address the needs of individuals withsubstanceusedisorders.However,thereareimportantdisparitiesintheoutcomesandeffectivenessofsubstance use treatment for different populations. Treatment needs can differ across populations,suggesting that treatment interventions should be individually tailored and incorporate culturally

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competent and linguistically appropriate practices relevant to specific populations and subpopulationgroups(MDPH,2017).

Approximately one in four persons ages 11 and older in the MassHealth patient population wereidentified as having a serious mental illness. Of these individuals, roughly two in five have beenhomelessforsomeperiodoftimebetween2011and2015.Theriskoffatalopioid-relatedoverdoseissixtimesforthosewithaseriousmentalillness(SMI)andthreetimeshigherforthosediagnosedwithdepressioncomparedtothosewithoutanymentalhealthdiagnosis(MDPH,2017).

AlcoholAlcoholisalsothemostprevalentsubstanceusedinthepastmonthbyMassachusettsresidents18to25yearsofage.In2013-2014,(70.2%)ofMassachusettsyoungadultsreportedusingalcoholinthepastmonthand(43.9%)reportedbingedrinkinginthepastmonth,exceedingnationalaveragesforalcoholuse among this population (past month alcohol use: (59.6%); past month binge drinking: (37.8%))(MDPH,2017).

Despite the legal drinking age of 21, alcohol is the primary substance used by youth. According toNSDUH(2013-2014),therehasbeenadecreaseinpastmonthalcoholuseandbingedrinkingintheUSamong individuals 12 to 17 years of age. However, the prevalence of alcohol use in Massachusettsexceeded the national average in 2013-2014 (past month alcohol use: (13.3%) in Massachusetts vs.(11.6%) nationally; binge drinking: (7%) vs. (6.2%)). In 2015, (61%) of Massachusetts high schoolstudentsreportedusingalcoholintheirlifetime:(34%)reportedpastmonthuse;(18%)reportedbingedrinkinginthepastmonth(DESE)&(DPH),2015).

ThenumberofBSASclientswhoidentifiedasveterans increased(12.1%)fromFiscalYear2011(5,095clients) toFiscalYear2016 (5,713clients). InFiscalYear2016, (4%)of theBSAS treatmentpopulationidentifiedasveterans.Also,inFiscalYear2016,alcoholwastheprimarydrugreportedamongtheBSASveteranpopulation(48%)(MDPH,2017).

From2011to2015, themortalityrates foroverallsubstancemisuse,alcoholmisuse,anddrugmisuseincreased by (54%), (49%), and (71%), respectively. The mortality rates for alcohol misuse and drugmisuse were (18.4) and (31.3), respectively. During this period rate for drug-related unintentionaloverdoses/ poisonings increased by (40%), while the rate for alcohol-related overdoses/poisoningsdecreasedby(68%)(BPHC,2017).

MarijuanaAccordingtotheNationalSurveyonDrugUseandHealth (NSDUH) in2015,anestimated27.1millionpeople in the US aged 12 and older used illicit drugs in the past month. Of these, a majority (22.2million)reportedusingmarijuanaand3.8millionmisusedprescriptionopioids(SAMHSA,2015).

InFiscalYear2016,amongBSAStreatmentprogramenrollments,(59.9%)ofthose13to17yearsofagereportedmarijuanaastheirprimarydrug(MDPH,2017).Accordingto2013-2014NSDUHestimates,theprevalenceofpastmonthmarijuanausageamongMassachusettsresidentsage12andolderexceededthenationallevel(11.8%vs8%)(MDPH,2017).

Formarijuana-related treatment admissions, rateswere (91%0 lower for Asian residents (2.0), (99%)higher for Black residents (43.9), and (35%) higher for Latino residents (29.7) compared withWhite

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residents (22.0). Formarijuana, the rate for females (11.2) was (73%) lower than the rate formales(41.6)(BPHC,2017).

A significant increase in recent marijuana use was observed during from 2007 to 2015, but thepercentageofBostonhighschoolstudentsreportingrecentmarijuanausein2015wasconsistentwithU.S.highschoolstudentsoverall(BPHC,2017).

Figure18:Alcohol-SubstanceRelatedAdmissionstoBSASContracted/LicensedPrograms(Count)–FY2014

(Source:MassachusettsDepartmentofPublicHealth-BureauofSubstanceAbuseServices(FY2014))Note:Atthetimeofdatacollection,BSASadmissiondatawasnotavailableforeachindividualBostonareazipcodeIn the 2014 fiscal year, there were 107,358 alcohol or substance related admissions to BSAScontracted/licensedprogramsinMassachusetts.ThetotalcountintheCarneyHospitalserviceareawasunavailable. Of the service area cities/towns, Boston had the greatest number of alcohol/substancerelatedadmissionstoBSAScontracted/licensedprogramswith17,299.Nootherserviceareacity/townapproached this number likely due to differences in population size. Of the non-Boston service areacities/towns,Quincyhadthehighestnumberofalcohol/substanceBSASadmissionswith2,254.Miltonhadthelowestnumberofadmissionsatjust182.Figure19:AdmissionstoDPH-FundedSubstanceandAlcoholAbusePrograms(Count)2013-2017

(Source:MassachusettsDepartmentofPublicHealth-BureauofSubstanceAbuseServices(FY2014))

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From2012 to2017,Quincyhad thehighestnumberof admissions toDPH funded substanceandalcohol abuseprogramswith9,716overthefive-yearperiod.Nootherserviceareacity/townapproachedthisnumber.Miltonexhibitedthe lowestnumberofadmissionstoDPHfundedsubstanceandalcoholabuseprogramsoverthe five-yearperiodwith just751admissions.Admissioncounts remained relatively stable inBostonandBraintreeoverthisperiodoftimewhileMiltonandQuincyeachexperienceddecreases inadmissionsoverthefive-yearperiod.BothMiltonandQuincyexhibitedthelowestadmissioncountin2017,themostrecentyearmeasured.OpioidsInMassachusetts, therehasbeenadramatic increase inopioid-relateddeaths.Thenumberofopioid-relateddeathsin2016representsa(17%)increaseover2015,anda(450%)increasesince2000.AlmosteverycommunityinMassachusettsisaffectedbytheopioidepidemic.Akeystrategytounderstandingthe opioid epidemic is to improve the timely analysis and dissemination of data on opioid overdoses(MDPH,2017).

Increasingly, there’s evidence suggesting fentanyl is fueling the current opioid epidemic. AMassachusetts- Centers for Disease Control and Prevention (CDC) collaborative epidemiologicinvestigationidentifiedthattheproportionofopioidoverdosedeathsinthestateinvolvingfentanyl,asynthetic,short-actingopioidwith50-100timesthepotencyofmorphine,increasedfrom(32%)during2013–2014to(74%)inthefirsthalfof2016(MDPH,2017).

Intervention isan importantcomponentofacontinuumofservicestoaddresssubstanceusedisorder(SUD)inacommunity.InterventioncanalsobereferredtoasSecondaryorTertiaryPrevention,orHarmReduction.SecondaryPreventiontargetsindividualswhohavelowlevelsofalcoholand/ordruguseandwouldbenefitfrompreventionandsafetymessages.TertiaryPreventiontargetsindividualswhoexhibitagreaterdegreeofSUDandexperienceproblemsassociatedwiththeiralcoholordruguseandwouldbenefitfrompreventionandharmreductionmessagesaswellasreferralstotreatment.Individualsmayexperience a range of alcohol and drug use from no use to addiction and can benefit from differentlevels of service depending onwhat they are ready to receive at any given time. A person-centeredapproach includes prevention, safety and harm reductionmessages tailored towhat the individual isreadytoreceive(MDPH,2017).

In2015,theratesofhospitalpatientencountersforunintentionaloverdose/poisoningwerelowerforfemalescomparedwithmalesforopioids(includingheroin),cocaine,andbenzodiazepines.Foropioids(including heroin), the rate for females (9.9 encounters per 10,000 residents ages 12 and older)was(63%)lowerthantherateformales(26.6).Forcocaine,therateforfemales(0.9)was(73%)lowerthanformales(3.3).Forbenzodiazepines,therateforfemales(2.3)was(44%)lowerthantherateformales(4.0)(BPHC,2017).

From2011to2015,BostonandMassachusettsexperiencedsimilarlevelsofandsignificantincreasesinunintentionalopioidoverdosemortality(from(11.6)and(9.3)deathsper100,000residentsages12andolder, respectively, in 2011 to (25.8) for both in 2015. The increase in unintentional opioid overdosemortalityappearstobeattributabletofentanyl,ahighlypotentopioidoftenusedasanadulterant(i.e.,mixedwith street-level heroin, cocaine, andotherdrugs). InBoston, increases in all of the substancemisusemortality indicators (including alcoholmisusemortality) appear tobe attributable to fentanyl,oftenfoundtohavebeenused incombinationwithotherdrugsandalcohol.Thenumberof fentanyl-related unintentional overdose deaths increased from fewer than 10 per year during the three-yearperiod2011-2013to43deathsin2014and83deathsin2015(BPHC,2017).

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Figure20:AllOtherOpioid-RelatedAdmissions,BSASContracted/LicensedPrograms-FY2014

(Source:MassachusettsDepartmentofPublicHealth-BureauofSubstanceAbuseServices(FY2014))Note:Atthetimeofdatacollection,BSASadmissiondatawasunavailableforeachindividualBostonareazipcode.In2014,(5.8%)ofalladmissionstoBSAScontracted/licensedprogramsinMassachusettswererelatedto opioids.Within theCarneyHospital service area, Braintree andMiltonhad a higher percentageofBSAS contracted/licensedprogramadmissions related to opioids than the state levelwith (8.4%) and(6.7%)respectively.BostonhadthelowestpercentageofBSASadmissionsrelatedopioidsatjust(2.7%).Misuseof alcohol or other drugs over time can lead to physical and/or psychological dependenceonthese substances, despite negative consequences. Substance misuse alters judgment, perception,attention,andphysicalcontrol,whichcanleadtotherepeatedfailuretofulfillresponsibilitiesandcanincreasesocialandinterpersonalproblems.Thereisasubstantiallyincreasedriskofmorbidityanddeathassociatedwithalcoholanddrugmisuse.Theeffectsofsubstancemisusearecumulative,significantlycontributing tocostlysocial,physical,mental,andpublichealthchallenges.Examplesof these includedomesticviolence,childabuse,motorvehiclecrashes,physicalfights,crime,homicide,suicide,humanimmunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS), and other sexuallytransmittedinfections(6).Substancemisusecanalsoimpactone’ssocialdeterminantsofhealth,suchasemployment,income,socialnetwork,andhousing(BPHC,2017).

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Figure21:Opioid-RelatedMortalityCount-2015


In2015,therewere1,637opioidrelateddeathsinMassachusetts,102ofthesedeathsoccurredintheCarneyHospital service area.Of the cities/towns in theCarneyHospital service area,Quincy had thehighestcountofopioidrelateddeathsat44.Nootherserviceareacity/townexceeded15opioidrelateddeaths in2015.Miltonhadthe lowestcountwith just1deathrelatedtoopioids in2015, followedbyMattapanwhereonly3opioidrelateddeathsoccurredin2015.Focus group participants ranked opioids as the third greatest health concern in the Carney Hospitalcommunity.Surveyrespondentssupportedtheideathatsubstanceabusewasamajorhealthconcerninthecommunity.Whenasked“whatarethemajorhealthconcernsinthecommunitywhereyouprovideservices?”, (73.26%) of survey respondents selected substance abuse as a major concern. Substanceabuse had the highest ranking of any suggested health issue. Both the focus group participants andsurvey respondents believed that there was a need to expand substance abuse offerings within theCarneyHospitalcommunity.Substanceabuse,specificallytheopioidepidemicwasviewedasagreaterhealth concern than chronic disease by focus group participants. This was due to the fact that theybelievedchronicdiseaseprevalencewasdecliningwhileopioidabuseprevalencewasgrowingrapidly.

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HousingStabilityMassachusettsiscurrentlydealingwithaseverehousingcrisisdueinlargeparttoalowrateofhousingproduction which has not kept pace with population growth and needs, soaring rents that haveoutpacedwages, and the lingering effects of the foreclosure crisis. As a result, there is a shortageofsuitableandaffordableunitsforyoungworkers,growingfamilies,andtheincreasingseniorpopulation.Overcomingthesebarrierswillrequireaddressingavarietyofcauses,includinghighdevelopmentcostsand exclusionary and restrictive zoning, which have made it difficult to keep up with the housingdemand,amongotherfactors(MALegislature,2016).

In 2015, (66%) of housing units in Boston were occupied by renters compared with (38%) inMassachusettsoverall.InBoston,(34%)ofhousingunitswereowner-occupiedcomparedwith(62%)inMassachusettsoverall.ComparedwithWhiteresidents(57%),ahigherpercentageofAsian(76%),Black(70%),andLatino(83%)residentslivedinrenter-occupiedunits.During2011-2015,ahigherpercentageof housing units in Allston/Brighton, Dorchester (zip codes 02121, 02125), East Boston, Fenway, andRoxburywererenter-occupiedcomparedwithBostonoverall.(BPHC,2017).

RentersinGreaterBostonhaveafractionoftheincomeofhomeowners.In2015,themedianincomeofhomeowners was $103,267 compared with just $43,583 for renters. As such, those who face thetoughesthousingchallengeintheregionarethosewhorentratherthanowntheirhomesorapartmentsMorethan52percentofrenterhouseholdsarenowpayingmorethan30percentoftheirgrossincomeinrent—thehighestpercentageofresidentsinthatsituationonrecordandupfrom39percentin2000.Homeownerstendedtobe lesscost–burdenedthanrenters,but36percent (aswithrenters,arecordhigh) paidmonthlymortgage and tax bills exceeding 30 percent of their gross income.Given all this,housingaffordabilityisagreaterproblemthanever(TheBostonFoundation,2017).

Where pressure is now highest on home prices is in historicallyworking-class communities. Asmoremiddle-incomeandworking-classhouseholdsmovetotheselowercostcommunitiesinhopesoffindingmoreaffordablehousing,demandpressure isdrivingupprices.Homepricesare stillmoreaffordablethefurtheronemovesawayfromtheurbancore(TheBostonFoundation,2017).

Average monthly rents have not fallen further despite the increase in housing construction is likelybecauseadisproportionateamountofthenewrentalunitsarepricedatluxurylevels.Thepriceoftheseunits might have declined enough to bring the overall average rent down without much affectingmedianrentorrentsinthelowerendofthepricespectrum.Hence,evenasaveragerentshavefallen,the proportion of renters who are housing cost– burdened continued to rise in 2017 (The BostonFoundation,2017).

AveragerentalpricesinBostonareamongthehighestintheU.S.,justbehindNewYork,SanFrancisco,andSiliconValley,withalmost(40%)ofresidentspayingmorethan$1,500amonth.Subsidizedhousingis available on a limited basis to thosewith incomes ranging from less than 30-80% of the city-widemedianincomeleveldependingontheprogram.Programshaveawaitrangingfrom10weekstomorethan 5 years depending on the application and housing availability. Meanwhile, over half of Bostonrenterspaymorethan(30%)oftheirincometowardrent,meaningfinancescan’tgotoothernecessitiessuchaschildcareandfood.Thebenefitsofhomeownership,includingtaxdeductions,costsavingsovertime compared to renting, and the ability to build equity, are reserved for higher-income individuals.Lower-income individualswhocannotaffordhomeownershipoftenstrugglewiththenegative impactthatresidentialinstabilityhasoncrime,mentalhealth,andsocialcapital(BPHC,2017).

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ComparedwithBostonoverall,ahigherpercentageofrenter-occupiedhouseholdsinAllston/Brighton,Fenway,andRoxburypaidatleast(30%)oftheirincometowardrent(BPHC,2017).

Boston has a higher percentage of renter-occupied units and a lower percentage of owner-occupiedhousingunitscomparedwithMassachusettsoverall.Weidentifieddifferencesinhousingoccupancybyrace/ethnicity,neighborhood,andeducationlevel.ComparedwithWhiteresidents,ahigherpercentageof Asian, Black, and Latino residents lived in renter-occupied units. During 2011-2015, a higherpercentage of housing units in Allston/Brighton, Dorchester (zip codes 02121, 02125), East Boston,Fenway,andRoxburywererenter-occupiedcomparedwithBostonoverall,whilealowerpercentageofhousing unitswere renter-occupied in Charlestown,Dorchester (zip codes 02122, 02124), Hyde Park,JamaicaPlain,Mattapan,Roslindale,SouthBoston,andWestRoxburycomparedwithBostonoverall.In2015,ahigherpercentageofBostonresidentslivinginrenter-occupiedunitshadlessthanahighschooleducation and a higher percentage paid about one-third of their income towards housing comparedwithresidentsinowner-occupiedunits.Thoseputtingmorethan(30%)oftheirincometowardshousingareconsidered“costburdened”bytheU.S.DepartmentofHousingandUrbanDevelopment,andmayhavedifficultyaffordingnecessitiessuchasfood,clothing,andtransportation(BPHC,2017).

After adjusting for differences in age, race/ethnicity, and sex,we found differences in several healthoutcomesbyhousing status. Comparedwithhomeowners, ahigherpercentageofBHA residents andrentersreceivingrentalassistancehadasthma,diabetes,hypertension,obesity,persistentanxiety,andpersistentsadness.Ahigherpercentageofrenterswhodidnotreceiveassistancehadpersistentanxietyand persistent sadness than homeowners. Lastly, a higher percentage of those who had housingarrangementsotherthanrenting(withandwithoutrentalassistance),beingahomeowner,orbeingaBHAresident,hadhypertensionandpersistentsadnessthanhomeowners(BPHC,2017).

Figure22:MedianHousingValue2012-2016


From2012to2016themedianvalueofahomeinMassachusettswas$341,000.Duringthisperiod,fiveCarneyHospitalserviceareacities/townsexceededthisvalue.Thehighestmedianhousingvalueintheservice areawas seen inMilton ($513,900) followedby SouthBoston ($469,800). The lowestmedian

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housing values in theCarney serviceareawere seen inDorchester (02125)andMattapan,where themedianhousingvaluefrom2012-2016was$306,200.Figure23:MedianGrossRent2012-2016


From2012 to 2016, themedian gross rent inMassachusettswas $1,129.Within the CarneyHospitalservice area, every city/town exceeded this value expect forHyde Parkwhere themedian gross rentfrom2012 to2106was$1,076.Everyother serviceareacity/townexceeded$1,200 formediangrossrentduringthisperiod.ThehighestmediangrossrentswereseeninSouthBoston,BraintreeandMiltonat$1,3600,$1,353,and$1,349.HomelessnessInFY2018,theCommonwealthwillspendfromitsownresourcesatotalof$432milliononaseriesofhousingprogramsplusinitiativesaimedatcombattinghomelessness.Ofthetotal,$183milliongoestotheformerwiththelargershare($249)goingtohomelessprograms.However,thisamountrepresentsthesecondannualfundingcutinarowsothatthestatebudgetforhousingrelatedspendingisnow$71millionbelowtheamountintheFY2016budget,a14percentreduction.WhatmakesthiscutinstatefundingevenmoreseriousisthatitiscomingontopofasharpreductioninfederalfundingforhousingintheCommonwealth.Fiscalyear2018estimatedfundsforfederalhousingprogramsinMassachusettsareexpectedtobe$71millionlessthaninFY2017.Together,thestateandfederalcutsinthecurrentfiscalyearaloneamounttomorethan$100million(TheBostonFoundation,2017).

In2013,5,881homelessindividualswerecountedinBostonduringtheannualhomelesscensus,whilein2017, there were 6,135 homeless individuals counted. Forty-eight percent were female, (33%) wereunder the age of 18, (17%) identified as more than one race, and (38%) identified as Latino (BPHC,2017).

Safe and stable housing provides personal security, reduces stress and exposure to disease, andprovides a foundation formeeting basic hygienic, nutritional, and healthcare needs. Average incomegains over the past decade have failed to keep pacewith rising housing costs, pushing thousands ofresidentsintounstablehousingsituations.In2017,6,135individualsinBostonwerehomeless.Withoutconsistentaccesstohealthcare,homeless individualsareless likelytoparticipateinpreventativecareandaremuchmore likelytoutilizetheemergencydepartmentfornon-emergencies.Suchpatternsof

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usearenotonlyaburdenonthehealthcaresystem,butdetrimentaltopersonalhealthaswell(BPHC,2017).

Figure24:MedianHouseholdIncome2012-2016


From2012to2016,themedianhouseholdincomeinMassachusettswas$70,954.Fourofnineservicearea cities/towns exceeded this level. The highest median household income was seen in Milton at$122,516, followedbySouthBostonat$105,843.The lowestmedianhousehold incomewas found inDorchester (02122) at $53,103. Dorchester (02125) andMattapan shared the second lowestmedianhouseholdincomeoverthisperiodat$61,664.

PovertyIncome, poverty, and unemployment are each profoundly linked with health (Braveman PA, 2010).Incomeinfluenceswherepeoplechoosetolive,topurchasehealthyfoods,toparticipateinphysicalandleisureactivities,andtoaccesshealthcareandscreeningservices.Havingajob-andjob-relatedincomeprovide individuals the opportunities to make healthy choices, engage in healthy behaviors, accessnecessaryhealthcareservices,andenjoyalonglife(MDPH,2017).

Whilebeingemployedisimportantforeconomicstability,employmentaffectsourhealththroughmorethaneconomicdriversalone.Physicalworkspace,employerpolicies,andemployeebenefitsalldirectlyimpactan individual’shealth.Thephysicalworkplace can influencehealth throughworkplacehazardsandunsafeworking conditionswhich lead to injuries, illness, stress, anddeath. Longworkhours andjobswith poor stability can negatively impact health by increasing stress, contributing to poor eatinghabits, leading to repetitive injuries, and limiting sleep and leisure time. Job benefits such as healthinsurance,sickandpersonalleave,childandelderservicesandwellnessprogramscanimpacttheabilityofboththeworkerandtheirfamilytoachievegoodhealth(MDPH,2017).

Unemployment is also associated with poor health, including increased stress, hypertension, heartdisease, stroke, arthritis, substanceuse, anddepression; and theunemployedpopulationexperienceshighermortalityratesthantheemployed(RobertWoodJohnsonFoundation,2013)(Henkel,2011).

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Starkracialdisparitiesexist inpovertyratesacrossMassachusetts. In2011-2015approximatelyone inthree (29.3%)Hispanic residents andone in fiveBlacknon-Hispanic (22%),American IndianorAlaskaNative(22.9%),orNativeHawaiianorotherPacificIslander(22.4%)residentsrecordedincomesbelowthefederalpovertylevel.Thesepatternsstandindramaticcontrasttolessthanonein10(7.8%)Whitenon-Hispanic and one in seven (14.6%) Asian non-Hispanic residentswith incomes below the federalpoverty level.Somepeople’shousingcostsexceed(30%)of their income, leaving lessmoneytocoverothernecessities(MDPH,2017).

InMassachusetts, (11.9%)of thepopulation livesbelow theFederalPoverty Linewith (5.5%) living indeeppovertyand(8.8%)ofseniorcitizenslivingbelowthepovertyline.However,agreaterpercentageof children live in poverty in Massachusetts (16.3%) as compared to the United States as a whole.(15.3%)ofMassachusetts’populationliveunder125%ofthepovertyline,innearpoverty.(Under130%oftheFederalPovertyLinequalifiesforSNAPbenefitsoffoodstampsand(185%)qualifyfornutritionalassistanceforWomen,Infants,andChildren)(MassachusettsCaucusofWomenLegislators,2015).

In2015,therewasahighlevelofincomeinequalityinthecityofBoston,andthecity’spovertylevelwasdoublethatofMassachusetts.ThemedianhouseholdincomeforBostonwasabout$58,000andoneinfiveBostonresidentshadan incomebelowpoverty level.Weobservedinequitiesacrossraceforbothmedianhouseholdincomeandpovertylevel.(BPHC,2017).

After adjusting for age, race/ethnicity, and sex, it was noted that a higher percentage of Bostonresidentswith a household income less than $25,000 had diabetes, hypertension, obesity, persistentanxiety, and persistent sadness compared with residents with a household income of $50,000 orgreater. A higher percentage of residents with a household income of $25,000-49,999 had diabetes,hypertension, and persistent sadness compared with those with a household income of $50,000 ormore. Increasing the median household income for residents would yield more positive healthoutcomesfortheseindividualsandcommunities(BPHC,2017).

During2011-2015combined,Allston/Brighton,Dorchester(zipcodes02121,02125),andRoxburyhadahigherpercentageofresidentslivingbelowthepovertylevelcomparedwithBostonoverall.Inthesametime period, Back Bay, Hyde Park, Jamaica Plain, Roslindale, South Boston, andWest Roxbury had alower percentage of residents living below the poverty level compared with Boston overall (BPHC,2017).

Figure25:PercentFamiliesBelowPovertyLevel2012-2016

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From2012to2016, (8%)ofMassachusetts familieswere livingbelowpoverty level.Everynon-Bostonserviceareacity/townhadalowerpercentageoffamilieslivingbelowpovertylevelduringthisperiod.Miltonexhibitedthelowestlevelsoffamilieslivinginpovertyat(3.3%).EveryBostonneighborhoodinthe Carney service area exhibited a higher percentage of families living in poverty than the stateaverage. The highest percentage was seen in South Boston where (19.3%) of families were belowpovertylevelfrom2012to2016.ExceptforHydePark,eachBostonneighborhoodhadmorethan(15%)offamiliesbelowpovertyduringthisperiod.Figure26:IndividualsBelowPovertyLevel(Percentage)2012-2016


From 2012 to 2016, an estimated (11.4%) of Massachusetts individuals were below poverty level.Milton,Braintree,HydeParkandQuincyeachexhibitedalowerpercentageofindividualsbelowpovertylevel than the state average.Milton had the lowest percentage of all service area cities/towns with

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(4.2%)of individualsbelowpoverty level.Thehighestpercentageof individualsbelowpoverty level isfound inDorchester (02124) at (21.7%). Dorchester (02122), Dorchester (02124), andMattapan eachhadmorethan(20%)ofindividualsbelowpovertylevelfrom2012to2016.Figure27:UnrelatedIndividuals15YearsandOverBelowPovertyLevel(Percentage)2012-2016


From2012to2016,(22.9%)ofunrelatedindividualsovertheageof15werebelowthepovertylevelinMassachusetts. Dorchester (02122), Dorchester (02124), Dorchester (02125) and Mattapan eachexceeded this percentage. The highest percentage of unrelated individuals older than 15 and belowpoverty levelwas seen inDorchester (02122)where (35.7%)of these individualswerebelowpovertylevel.Thelowestpercentageoftheseindividualsbelowpoverty levelwasseeninSouthBostonwherejust(13.1%)ofunrelatedindividualsovertheageof15werelivingbelowpovertylevel.Figure28:FamilieswithRelatedChildrenUnder18YearsBelowPovertyLevel(Percentage)2012-2016


From2012 to 2016, (12.8%) of familieswith related children under 18were belowpoverty level.Nonon-Bostonserviceareacity/townexceededthispercentage.Miltonhadthelowestpercentageofthesefamilies living below poverty level at (2.2%). Every Boston area neighborhood exhibited a higherpercentageofthesefamilieslivingbelowpovertylevelthanthestateaverage.Thehighestpercentage

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was found in SouthBostonwhere (33.3%)of familieswith related childrenunder theageof18werebelow poverty level. Each Boston area neighborhood had greater than (20%) of these families livingbelowpovertylevel.Figure29:FemaleHOHBelowPovertyLevel(Percentage)2102-2016


From2012to2016, (25.2%)of femaleheadofhouseholdswerebelowpoverty level.Except forHydePark,eachBostonneighborhoodexceededthispercentage.Thehighestpercentageof femaleheadofhouseholdsbelowpoverty level isseen inSouthBostonat (44.5%).Dorchester (02122,02124,02125)andMattapaneachhadgreaterthan(25%)of femaleheadsofhouseholdbelowpoverty level.Miltonhadthelowestpercentageofthisfemaleheadsofhouseholdbelowpovertylevelat(10.2%).Figure30:HouseholdsParticipatinginSupplementalNutritionAssistanceProgram(Percentage)2012-2016


From 2012 to 2016, (25.2%) of Massachusetts households participated in SNAP. Three service areacities/towns exceed this percentage, these included Dorchester (02122), Dorchester (02124), andMattapan. The highest percentage of households participating in SNAP was observed in Dorchester(02124)at(31.7%).MiltonhadthelowestpercentageofhouseholdsparticipatinginSNAPatjust(4.3%).

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Housing, homelessness, and poverty were not mentioned by the focus group participants or surveyrespondents

RecommendationsCarneyHospital iswellpositionedtopartnerwithothercommunity-basedorganizationsandcoalitionstoaddressthefollowingkeystrategicprioritiestoimprovehealthoutcomesandwellnessintheregion:

1. ChronicDiseasesa. Cancerb. HeartDiseasec. Diabetes

2. MentalHealth3. SubstanceUseDisorders4. HousingStability

a. Homelessness

Inrecognitionoftheneedforfurtherinvestmentsinthesocialdeterminantsofhealth,CarneyHospitalwillalsoconsiderthesesixprioritiesinCommunityBenefitsplanning:

• BuiltEnvironmento The built environment encompasses the physical parts ofwherewe live,work, travel

andplay,includingtransportation,buildings,streets,andopenspaces.• SocialEnvironment

o The social environment consists of a community’s social conditions and culturaldynamics.

• Housingo Housing includes the development andmaintenance of safe, quality, affordable living

accommodationsforallpeople.• Violence

o Violenceistheintentionaluseofphysicalforceorpower,threatenedoractual,againstoneself, anotherperson,oragainstagroupor community,with thebehavior likely tocausephysicalorpsychologicalharm.

• Educationo Education refers to a person’s educational attainment – the years or level of overall

schoolingapersonhas.• Employment

o Employmentreferstotheavailabilityofsafe,stable,quality,well-compensatedworkforallpeople.

Carney Hospital will continue to foster collaborative partnerships with other community-basedorganizations whose services align with addressing the aforementioned priorities and focus issues.Consideration will be given as to how strategies impact the lives of the underserved populationsidentifiedwithin theCarneyHospital servicearea.CarneyHospital recognizes theeffectivenessof thecollective impact that comes from constructive approach associated with both medical and socialpartnerships, working together towards a common goal of improving health outcomes among allcommunitymembers,particularlyforunderservedpopulations.WhereitisdeemedappropriateCarneyHospitalwill coordinatewith regional public health organizations to ensureour success in addressingcommunityhealthissues.Ourdatarevealsthatrace,ethnicityandsocio-economicfactorsareindicatorsofhealthoutcomewithintheregion.CarneyHospitalwill focuseffortstowardindividualsandfamilieswhoarefacingcriticalchallengesthatperpetuatehealthinequity.

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ChronicDiseaseCancerBothfocusgroupparticipantsandthekeyinformantsurveyrespondentsdidnotviewcancerasamajorhealth concern in the community. Despite, this cancer rates in the Carney Hospital service area arehigherthanthestateaverageinseveralcommunities.ProvidingpartnershipwiththeAmericanCancerSocietyandothercancereducationtothecommunityiscrucialasitcouldpotentiallybringawarenesstoa disease that is prevalent in the service area community but is not perceived to be an issue bycommunitymembers.Community-WideRecommendations

• Pursue partnerships with the American Cancer Society and/or other cancer education andpreventionorganizationsinthecommunitytoadvancediseasepreventionandmanagement.

• Partner with civic and/or faith-based community organizations to reach underservedpopulationsandprovideappropriatescreeningsandpreventioneducation.

HealthSystemRecommendations• Provide free cancer screening programs in communitiesmore susceptible to cancer andwith

higher disease burden andmortality rates in order to increase early diagnosis of cancers andtreatmentwithattentiontoLung,ProstateandBreastCancer.

• Offer a smoking cessationprogram support groups and consider expanding cessation supportgroupstocommunitycenter.

• Offercancerpreventioneducationand/orinformationalmaterialstohighprioritypopulations.• Participateincommunity-basedcancerawarenesscampaignsintheregion.• Offercancersupportgroups.

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CardiovascularDisease

Cardiovascular disease, including heart health and high blood pressurewere of high concern to bothfocus group participants and survey respondents. Carney Hospital should continue to leverage itsresources and medical staff to provide heart disease prevention education to community members.When appropriate, Carney Hospital should provide blood pressure screenings in the community andpromotehearthealthandstrokepreventionthroughpartnershipswithcommunity-basedorganizationsproviding services to target populations in the Carney service area. Carney Hospital should seek topartnerwithappropriatehealthcarenetworksandprimarycareoffices to implementchronicdiseaseself-management program to assist community members in learning how to manage their healthconditionandimprovequalityoflife.

Community-WideRecommendations• Pursuepartnershipswith theAmericanHeartAssociation and/or other cardiovascular disease

educationandpreventionorganizations in the community to advancediseasepreventionandmanagement.

• Partnerwithcivicand/orfaith-basedcommunityorganizationstoreachhighprioritypopulationsandprovideappropriatescreeningsandpreventioneducation.

• CollaboratewiththeCharlesRiverCommunityHealthCenter.• Partnerwithmoreschools,elderlygroups,sponsorsportsteams,healthfairs,summerjobs.

HealthSystemRecommendations

• Provide free blood pressure screening programs in communities more susceptible to heartdiseaseandwithhigherdiseaseburdenandmortalityratesinordertoincreaseearlydiagnosisandtreatment.

• Offer heart attack and stroke prevention education and/or informational materials in targetcommunities.

• Participateincommunity-basedhearthealthandstrokeawarenesscampaignsintheregion.• Serve as a Community Training Center using American Heart Association standards for

employees, physicians, and community professional healthcareworkers for cardiac educationandCPRcertification.

• Provideeasieraccessibilitytocentralpharmacyandhealth-screeningson-siteandoff-site.

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Diabetes

Severalcities/townsintheCarneyHospitalservicearearecordedahigherpercentageoftotalmortalitydue to diabetes than the state level. To best address this, Carney Hospital should seek to increaseawareness among primary care providers for the diabetesmanagement programs in the community.WorkingtogetherwiththeAmericanDiabetesAssociation,CarneyHospitalshouldpromotetheuseofdiabetestype2screeningtoolstofosterawarenessandprevention.Throughthe implementationofachronicdiseaseself-managementprogram,Carneywillbeabletoassistcommunitymemberslearnhowbesttomanagetheirhealthandavoidhealthcomplicationsanddecreasecostlyemergencydepartmentutilization.Lifestylechangescanpreventordelaytheonsetofdiabetesandhelpcontroldiabetesoncediagnosed. Eating a healthy diet, maintaining a healthy weight, exercising regularly, and avoidingsmoking can help prevent diabetes. Carney Hospital should continue to make available diabetesmanagementinformationinvariouslanguagesandthroughvariousmediachannels,asappropriate.Community-WideRecommendations

• Pursue partnerships with the American Diabetes Association (ADA) and/or other diabeteseducationandpreventionorganizations in the community to advancediseasepreventionandmanagement.

• Partnerwithcivicand/orfaith-basedcommunityorganizationstoreachhighprioritypopulationsandprovideappropriatescreeningsandpreventioneducation.

HealthSystemRecommendations• PromoteuseoftheADAand/orCDCdiabetestype2andprediabetesscreeningtoolswithinhigh

prioritypopulations.• Offer diabetes type 2 prevention and self-management programs in communities more

susceptible todiabetes type2andwithhigherdiseaseburdenandmortality rates inorder toincreaseearlydiagnosisandmanagement.

• Participateincommunity-baseddiabetesawarenesscampaignsintheregion.

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MentalHealthMental health was the number one concern among the focus group participants and the secondgreatest concern of key informant survey respondents. Both highlighted a lack of adequate mentalservices in the Carney Hospital service area. Carney Hospital should continue to collaborate withcommunity-based organizations that can provide services to patients with mental health conditions.CarneyHospitalshouldserveasahostsiteforsupportgroupsforcommunitymembersandcaregivers.CarneyHospitalshouldalsopromotethecreationandavailabilityofaninter-agencycomprehensivecareplanforthispopulation.

Community-WideRecommendations

• Disseminate educational materials outlining signs of mental health issues (particularlydepressionandanxiety)atstrategiclocationstargetinghighprioritypopulations.

• Provide familymembers and/or caregivers with educational information onmental health toassistcaregiversunderstandwarningsignsofmentalillness.

• Advocate for inclusion of screenings for mental illness within school system to foster earlyinterventionandaccesstotreatment.

• Promoteawarenessofmentalillnessandworktodecreasestigmasurroundingseekingsupport.• PursuecollaborationwiththeNationalAllianceonMentalIllness,healthinsurers,and/orother

mentalhealtheducationorganizationsinthecommunitytoadvancediseasemanagement.

HealthSystemRecommendations• Collaboratewithhealthandhumanserviceorganizationstodevelopacomprehensivecareplan

thatwouldbeaccessibletoprovidersatallpointsofcare.• Implement strategic partnerships with community organizations that can provide services to

communitymembers,particularlyhighprioritypopulations.• MaintainBehavioralHealthNavigatorprogramintheEmergencyDepartment.• Engage community-based service providers to learn of and promote services that may be

availabletocommunitymembersinneedofservices.• Implement strategic partnerships with community organizations that can provide services to

communitymembers,particularlyhighprioritypopulations.

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SubstanceUseSubstanceusewas thenumberoneconcernamongsurvey respondents,opioids inparticularwereofgreatconcerntofocusgroupparticipants.Bothindicatedalackofavailabilityofaddictioncenter/rehabservices intheCarneyHospitalservicearea.CarneyHospitalshouldpromotetheuseofsubstanceusedisorder treatment best practices. The hospital should also continue to partner with communityorganizations to promote increased access to screening for potential substance abuse. In addition tocollaboratingwithcommunity-basedserviceprovidersworkinginvariouslocalsettings.CarneyHospitalshould also offer free use of hospital space for awide variety of support groups including AlcoholicsAnonymousandNarcoticsAnonymous.


• Advocate for increasingavailabilityofde-toxand long-termtreatment facilities,particularly tohighprioritypopulationsintheregion.

• Implementmarketingcampaigntoincreaseperceptionofharmofadolescentsubstanceuse.• Collaboratewithschoolsandotherorganizationsto incorporateanevidence-basedcurriculum

thataddressessubstanceuseandmentalhealth.• Implementandpromotesubstanceusepreventionandharmreductionprograms.• Supportcommunity-basedsubstanceabusepreventioncoalitions.


• Providesupportresourcesforpatientsforwhomillnesscancausesignificantstressandanxiety.• Promote evidence-based best practices in substance use disorder treatment across the

continuumofcare.• Engage community-based service providers to learn of and promote services that may be

availabletocommunitymembersinneedofservices.• Continuecollaborationsandexpandaccesstosupportgroupsforpatientsandcaregivers.

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HousingStabilityHousingstabilitywasnotamajorconcernoffocusgroupparticipantsorsurveyrespondents.Thatsaid,housingrelatedissuesareprevalentintheCarneyHospitalserviceareaandshouldbeaddressedbythehospital. CarneyHospital should considerworking closelywithorganizationswith a goal of improvinghousing stability. A partnership with organization like Boston Housing Authority could provideopportunitiesforindividualsandfamilieswhoarefacingchallengesinhousing.Community-WideRecommendations

• AdvocateforandsupportHousingAuthorityinitiativesaimedatkeepinglow-incomeindividualsandfamilieshoused.

• Partner with community organizations working to stabilize housing and/or rental pricing tosupporthighprioritypopulationsthathavebeenhistoricallymarginalizedduetothehighcostofhousing.

• Challenge housing policies that foster segregation in communities in which segregation hashistoricallycontributedtounequalaccesstohealthandsocialsupportsandperpetuatepoverty.

HealthSystemRecommendations• PartnerwithcommunityorganizationssuchasHousingAuthoritiesandShelterstoidentifyways

tosupporthousingfirstmodels.• Consider adopting a housing screening process with patients prior to discharge to ensure

patientsaredischargedtohousingthatissafeandsupportrecovery.HomelessnessInmostoftheCarneyHospitalservicearea,thepovertylevelhassurpassedthestatelevel.Itiscrucialtoencounterthisproblemasthereisastrongcorrelationbetweenpovertylevelandhomelessness.CarneyHospitalshouldstrengthentheirpartnershipwith localsheltersandaddressthehousingshortageandcostofhousing.Community-WideRecommendations

• Advocateforandsupportpublicpoliciesaimedataddressinghousingshortageandthecostofhousing.

• Partner with local shelters to support programs aimed at keeping low-income individualshoused.

HealthSystemRecommendations• Developand/ormaintainpartnershipswith serviceagencies that areable to assist thosewho

maypresentatthehospitalwithaneedforstablehousing.

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UnderservedPopulationsAsnotedabove,severalsocialobstaclesstandinthewayformembersoftheunderservedpopulationstoachievebetterhealthoutcomes.Basedonfeedbackcollectedviathefocusgroupsconductedandkeyinformant survey respondents, access to primary care is a significant issue faced by many due tolanguage/cultural barriers and insurance coverage. Carney Hospital should leverage its physicianrelations and communications resources to address the identified needs of underserved populations.Wherever possible, informational and/or educationalmaterials should be translated, and communityengagement efforts should include various civic venues paying close attention to the socialenvironment.


• Supporteffortstoimprovethehealthcaredeliverysystemthroughreform.• Collaboratewithorganizationsworkingtoremovebarrierstocareforunderservedpopulations.


• Engagemembers of highpriority populations such as low-income individuals, immigrants andminoritiestoidentifyneedsandprioritiesforimprovedservicedelivery.

• Provide accessible central pharmacy and increase availability of health-screenings to highprioritypopulations.

• Provide assistance to community members seeking to apply for public health insurancecoverageprovidedthroughpublichealthplans.

• Screen individuals for primary care provider, where appropriate, assist community membersenrollwithprimarycareprovideroftheirchoice.

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LimitationsData collected for analysis was derived from publicly accessible, governmental sources. Some datasourceslackedinformationoncertaintowns.Datapresentedinthisreportisthemostrecentlyavailableat the time of the creation of this CHNA. As such, someof the relative changes, though classified asincreasesor decreases, arequalitative valuations relative to state values. Though itwouldhavebeenpreferabletohavemorerecentdatawithstatisticalevaluationforsignificance(pvalue)andcorrelation(rvalue),wewere limited tocurrentlyavailabledatasets. Inpreviousversionsof thisCHNA,datahadbeen collected through use of theMassachusetts Community Health Information Profile (MassCHIP).However, at the time of data collection, this resource was unavailable to researchers. ResearchersinsteadreliedondatasetsprovidedbytheAccreditationCoordinator/DirectorMassCHIP,Officeof theCommissioner,MassachusettsDepartmentofPublicHealthandguidanceprovidedbythesameinordertocollectdatausedtocompilethisCHNA.

Althoughthecommunityfocusgroupprovidevaluableinformation,servingasimportanttoolsfordatacollection and community engagement, there are some limitations to consider. Focus group data isqualitativeinnatureandreflectonlytheviewsandopinionsofasmallsample.Focusgroupsarelimitedtotheviewsandopinionsoftheparticipantsandarenotall-inclusiveofthevariousperspectivesofthelarger populations; they do not constitute complete data for the communities inwhich focus groupswere held. Furthermore, only one focus groupwas conducted. It would have been advantageous tohave conducted focus groups in different communities to engage a larger segment of the populationwithin the hospital service area, as this may have garnered more diversified data unique to othercommunities.

Thoughtheintentofthisprojectwastocapturetheviewsandopinionsofabroadrangeofhealthandhuman service providers within the Carney Hospital service area, there were also limitations to thesurvey distributionmethodology for the survey. The surveywas distributed via email someprovidersmay have been excluded due to a lack of access to computer-based technology. It is reasonable toassume that some providers had a longer period to access and respond to the survey as the surveydistribution was ultimately at the control and discretion of the Carney Hospital staff. A total of 145individualsrespondedtothesurvey.30

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Appendix A. Supplemental Health IndicatorsandDemographicDataHealthIndicators-DemographicDataSocialAppendixFigure1:Hispanic(Not-Race)Population,2012-2016

Source:USCensusBureau,2012-2016AmericanCommunitySurvey5-YearEstimatesAppendixFigure2:CitizenshipStatusofForeign-BornPopulation,2012-2016

Source:USCensusBureau,2012-2016AmericanCommunitySurvey5-YearEstimates

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)


0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)

Braintree

Milton

Quincy

MA

NotaU.S.Citizen

NaturalizedU.S.Citizen

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AppendixFigure3:ForeignBorn,EnteredLaterThanorBefore2010

Source:USCensusBureau,2012-2016AmericanCommunitySurvey5-YearEstimatesAppendixFigure4:SuicideMortality–2015

Source:MassachusettsDepartmentofPublicHealth

AppendixFigure5:HomicideDeathCount,2013-2016

Source:US.Dept.ofJustice

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Dorchester(02122)Dorchester(02124)Dorchester(02125)Mattapan(02126)

SouthBoston(02127)HydePark(02136)

BraintreeMiltonQuincy

MA

ForeignBornEnteredBefore2010

ForeignBornEntered2010orLater

0

5

10

15

20

25

30

35

40

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)


0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0

Boston(All)

Braintree

Milton

Quincy

MA

2016

2014

2013

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AppendixFigure6:CrimeCount(2013,2014,2016)

Source:US.Dept.ofJustice

EducationAppendixFigure7:4-YearHighSchoolGraduationRates(Non-Boston)2013-2017

Source:MADept.ofElementaryandSecondaryEducation,2018

0 2000 4000 6000 8000 10000 12000 14000 16000 18000

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)

Braintree

Milton

Quincy

MA

Property2016

Violent2016

Property2014

Violent2014

Property2013

Violent2013

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

2013 2014 2015 2016 2017

Braintree

Milton

Quincy

MA

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AppendixFigure8:4-YearHighSchoolDropOutRates(Non-Boston)2013-2017

Source:MADept.ofElementaryandSecondaryEducation,2018

EconomicsAppendixFigure9:TotalHealthInsuranceCoverage2012-2016

Source:USCensusBureau,2012-2016AmericanCommunitySurvey5-YearEstimates

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

2013 2014 2015 2016 2017

Braintree

Milton

Quincy

MA

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Dorchester(02122)

Dorchester(02124)

Dorchester(02125)

Mattapan(02126)

SouthBoston(02127)

HydePark(02136)

Milton

Quincy

MA

HealthInsuranceCoverage

TotalUninsured

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AppendixB.KeyInformantSurveyCommunityHealthNeedsAssessment-KeyInformantSurvey*

1. Inwhatcounty(orcounties)doesyourorganizationprimarilyprovideservices?2. Inwhatcitydoesyourorganizationprovidethemajorityofservices?3. Whatkindofservicesdoesyourorganizationprimarilyprovide?4. Nameoftheorganizationyouworkfor?5. To the best of your knowledge, from what county (or counties) do the majority of your

consumerscomefrom?6. Tothebestofyourknowledge,whatarethegeneralsocialdemographicsofconsumersserved

byyourorganization?7. Inwhatcityorneighborhooddothemajorityofyourconsumersreside?8. Whatdoyouperceiveasthemajorhealthconcernsofyourconsumers?9. In your opinion, what are the major health concerns in the community where you provide

services?10. Please rank what you believe to be the biggest obstacles to healthy living among your

consumers(1beingthegreatestobstacle).11. Pleaserankwhathealthandwellnessserviceswouldmostbenefityourconsumers(1beingof

greatestbenefit).12. HowknowledgeableareyouofthecommunityhealthservicesCarneyHospitalprovidesinyour

community?13. Overall,howsatisfiedareyouwiththewayCarneyHospital isaddressingcommunityhealthin

yourcommunity?14. Please provide any suggestions youmay have as to how Carney Hospital could best address

communityhealthissues.* For a complete copy of aggregated survey responses contact Carney Hospital

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AppendixC.FocusGroupQuestionsFocusGroupQuestions*

1. Isthereasenseofcommunitywhereyoulive?

a. Whyorwhynot?

2. Whatishealthyaboutyourcommunity?

3. Whatkindsofhealthandhumanservicesareeasilyaccessibleinthecommunity?

4. Whatkindsofhealthandhumanservicesdoyoufeelaremissingandwouldbe

beneficialinthecommunity?

5. Inyourview,whatarethetopthreeareasofhealthconcernwithinthecommunity?

6. Whataresomestrategiesthatcouldaddresstheseconcerns?

7. Whatpopulationswouldyouidentifyasunderservedwithinthecommunity?

8. Whatdoyoufeelarethebiggestobstaclestohealthaccessforyourcommunity?

9. Isbehavioralhealthamajorissuewithinyourcommunity?

10. Arechronicdiseasesamajorissueinyourcommunity?(Chronicdiseasearehealth

issuesthatpeoplelivewitheverydaylikediabetes,hypertension,obesity)

a. Whatistheimpactinyourcommunity?(tothemoderatorlookforpossible

issuesthatchronicdiseasecauses–asthmapreventingschoolattendance,

diabeteshinderingjobprospects)

11. Whatservicesdoyouperceiveasbeingmostneededwithinthecommunity?

12. InwhatwaysisCarneyHospitalservingthecommunitywell?

13. InwhatwayscouldCarneyHospitalservethecommunitybetter?

14. WhatisthenumberonethingthattheCarneyHospitalcandotoimprovethehealth

andqualityoflifeofthecommunity?

*ForcompletecopiesofthefocusgroupsummariespleasecontactCarneyHospital

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