This article first appeared in the St. Louis Beacon, Dec. 13, 2011 - St. Louis County compares favorably to Missouri in smoking rates and percentage of residents lacking health insurance. But other pressing issues include higher incidences of cancer, high incidences of chlamydia and gonorrhea and high emergency department admissions for diabetes and others with chronic diseases.
The St. Louis County Department of Health released its 2011 Community Needs Assessment at a summit held Monday at the Crowne Plaza Hotel in Clayton.
The report, which cost the county $200,000, was created by the University of New England's Center for Community and Public Health.
The report divides St. Louis County into four sub regions: west, north, south, and mid-county.
The finer level of detail in the study is key to helping organizations understand how best to improve public health among the different populations in St. Louis County, said Dr. Dolores Gunn, director of the St. Louis County Department of Health.
"The needs that you may have in the west are very different from the needs you have in the south, which are very different from the needs that we have in the north. And we really want to address that," she said.
The report was presented by Ronald Deprez, director of the Center for Community and Public Health at the University of New England. He emphasized the data are a starting point for policy planning and development.
"If you don't know the lay of the land -- your population, geography, the health system around you -- you'll never be able to get anywhere in terms of planning," he said. "We have to understand population.
"These projects are really meant to ask questions," he added. "They're not meant to give you answers."
The study included a telephone survey of 2,149 residents of St. Louis County: 530 in mid-county, 543 in north county, 530 in south county and 546 in west county.
The telephone information was combined with data from the 2009 Census estimates, the 2005-2009 American Community Survey, Missouri Cancer Registry, Hospital Inpatient and Emergency Department (ED) Data, and other Missouri health-related databases to create a picture of the health of subsections of St. Louis County.
The Picture of Health
"The two biggest determinants of health are income and education," said Deprez.
Socio-economically, St. Louis County is considerably better off than Missouri as a whole. While the median household income in Missouri is $46,005, in St. Louis County it is $57,502.
However, look beneath the surface and differences emerge.
West County, with the healthiest population of the four regions, is also the wealthiest, with a median income of $85,210. In terms of income, mid-county comes second at $62,607 and south county is third, at $59,943. North county lags behind its neighbors with a median income of $44,919.
Similarly, 9.3 percent of county residents are uninsured, compared to 14 percent of Missourians. This difference is largely due to west county, where 3.7 percent are uninsured, and south county, where 6.8 percent have no insurance. In north and mid-county, however, 14 percent of residents are uninsured.
Lack of insurance leads not only to poor health but also to overuse of emergency departments for chronic conditions such as diabetes, driving up cost, Deprez said. Increased access to primary care is needed.
"We need to determine where the gaps are, and what we can do to improve access to primary care, regardless of insurance coverage," he said.
Just as they have higher uninsured rates, north and mid-county also have higher rates of smoking at 17 and 18 percent respectively, than do south and west county, which have rates of 14 percent and 12 percent, respectively. Missouri's overall rate is 22 percent.
North and mid-county also have higher rates of diabetes, asthma, chlamydia, gonorrhea, high-risk pregnancies, teen pregnancies and infant mortality than do west and south county.
North county led the pack in obesity (at 36 percent) and high blood pressure (38 percent).
Health Risks
Income disparities lead to differences in behavioral risk factors, including sedentary lifestyle, smoking, and obesity, says Enbal Shacham, assistant professor of behavioral science and health education at Saint Louis University.
Shacham believes that the keys to reducing behavioral risk factors, such as obesity and sedentary lifestyle, lie in making it easier for people to eat well and exercise as part of their daily routine.
"Physical activity and healthy diets are challenging to adopt and continue," she said, particularly for a low-income parent who may work two or more jobs to make ends meet.
"Fruits and vegetables are more expensive than a fast-food dinner, and it takes more time," she said. "Making that commitment is also challenging if you don't have the time. People need to be able to be physically active and not have to join a gym."
St. Louis County has higher cancer rates than those of Missouri. St. Louis County has 556 cancer cases per 100,000 of population, while Missouri has 506 per 100,000. Unlike other health conditions, cancer incidence is similar across all four regions, Deprez said.
"Cancer incidences are high in the county. We don't know why they're high; we just know they're high," Deprez said.
Dr. Mark Clanton, chief medical officer for the High Plains Division of the American Cancer Society, including Missouri, is not at all surprised that cancer levels are elevated in St. Louis County.
While people think of obesity as a risk factor for heart disease and diabetes, Clanton says it also plays a role in the development of breast, colon and prostate cancers.
"Obesity tends to drive the incidence of colon cancer," Clanton said. "And for men, there is a role in prostate cancer." It plays a role in breast cancer, too. "It's not considered a sole cause of breast cancer, but it does play a role," he aded.
Clanton said no one knows how and why obesity is linked to cancers, although much research is being done to determine the connection.
The combination becomes deadlier when tobacco is included in the mix. "When you combine obesity and tobacco, the two together not only increase cancer rates but they increase death rates from heart disease, strokes and diabetes," he said.
Still, Clanton sees a bright spot in the data. "Tobacco is avoidable, and you can modify your diet and your weight."
While the four areas of the county showed many disparities, the regions were surprisingly similar in rates of high blood pressure, high cholesterol and overall cardiovascular indicators.
The prevalence of disease is equal across the regions for cardiovascular disease. "The outcomes are better in certain regions because they probably get better care," Deprez said.
Health Through Education
Shacham, who studies sexually transmitted diseases, believes that "comprehensive sexuality education" is a key element in helping youth avoid sexually transmitted disease and pregnancy.
"The evidence has shown that there are fewer unplanned pregnancies with comprehensive sexuality education. In addition to fewer unplanned pregnancies, there are fewer sexually transmitted diseases."
This type of education includes abstinence but is not "abstinence only" because kids have a hard time understanding a purely negative message about sexuality. Instead, sexuality is presented as a developmental process in which students learn to make healthy choices.
The stigma attached to sexuality makes it more difficult for people to feel comfortable buying condoms or asking a partner to use them.
"We're not teaching them the skills to negotiate (condom) use with partners," she said.
Recommendations
Deprez made many suggestions to improve the health of the communities. Specifically, the report targeted the following:
- Improve access to high quality primary care, especially in north county
- Reduce the prevalence of behavioral risk factors (smoking, obesity, and sedentary lifestyles) in populations across the county
- Improve the quality of care in the region for people with chronic medical conditions such as cardiovascular disease and diabetes, including improving patient self-management
- Determine factors driving the higher incidence of cancer in St. Louis County
- Improve access to substance abuse and mental health services in the county
- Improve programs to address the high rates of teen pregnancy and sexually transmitted diseases in St. Louis County
The St. Louis County Department of Health will develop a community health improvement plan, Gunn said.
The health department will meet with community leaders, academic experts, healthcare providers and organizations, to identify resources and decide which issues to tackle.
"It is really going to take all of us working together in our community to move forward, not only in creating a plan itself but truly bringing change within our community," Gunn said.
Hilary Davidson is a freelance writer in St. Louis.