sacramento county community health needs … from valley vision sacramento county community health...

REPORT FROM VALLEY VISION

Sacramento County

Community Health Needs Assessment

Prepared for:

The Healthy Sacramento Coalition

September 2012


This community health needs assessment was commissioned by Sierra Health Foundation on behalf of

the Healthy Sacramento Coalition. The Healthy Sacramento Coalition is supported by a Community

Transformation Grant from the Centers for Disease Control and Prevention1. In addition to CDC, funding

support for the community health needs assessment activities was provided by Sierra Health

Foundation. The analyses presented were conducted by Valley Vision. The consultant team (listed

alphabetically) included:

Dale Ainsworth, PhD

Heather Diaz, DrPH

Mathew C. Schmidtlein, PhD

Acknowledgements

Thank you to the Healthy Sacramento Coalition members, Community Partners, community members,

and policy and program key informants who contributed their time, expertise and involvement to the

development of this community health assessment.

1 The views expressed in this project do not necessarily reflect the official policies of the CDC or imply endorsement

by the U.S. Government.


i

Results in Brief

This Community Health Needs Assessment is a companion to the report, The Chronic Disease Experience

of Sacramento County Residents, prepared by Sacramento County’s Division of Public Health in the

Department of Health and Human Services. Both reports are part of the collaborative work of the

Healthy Sacramento Coalition to prioritize health needs within Sacramento County and develop

strategies and mobilize resources to improve the health of county residents. The Healthy Sacramento

Coalition is funded by a Community Transformation Grant (CTG) from the Centers for Disease Control

and Prevention (CDC). The CTG Program’s overarching goal is to create healthier communities by making

healthy living easier and more affordable. Sacramento County is one of six counties in California

awarded CTG funding to build capacity to support healthy lifestyles and reduce health disparities.

Sacramento County covers nearly 1,000 square miles and is home to more than 1.4 million people.

Through the Healthy Sacramento Coalition, Sacramento’s CTG Program is identifying evidence-based

strategies to promote tobacco-free living, active living and healthy eating, quality clinical and other

preventive services, healthy and safe physical environments, and social and emotional wellness.

A primary purpose of the Community Health Needs Assessment was the identification and description of

areas in Sacramento County that are experiencing higher rates of chronic diseases and other health

concerns than other areas of the county.

Areas Experiencing Health Disparities The assessment identified 15 of Sacramento County’s 58 zip codes as experiencing high rates of health

disparities relative to the county as a whole and to other areas of the county. The 15 zip codes cluster

into three communities – North Sacramento, Downtown and South Sacramento.

Focus Communities Zip Codes Neighborhoods (all or a part of)

North Sacramento 95660, 95673, 95815, 95821, 95838, 95841

North Highlands, Rio Linda, Old North Sacramento, Woodlake, Del Paso Manor, Del Paso Heights, Belmont Estates

Downtown Sacramento 95811, 95814 Downtown: Richards, Alkali Flats, Mansion Flats, Midtown, Richmond Grove, Southside Park

South Sacramento 95817, 95820, 95822, 95823, 95824, 95828, 95832

Oak Park, Elmhurst, Tahoe Park, Land Park, Parkway, Valley Hi/North Laguna, City Farms, Fruitridge Manor, Florin, Meadowview

Infant mortality and mortality

Sacramento County as a whole had an infant mortality rate of 5.8 deaths/1,000 live births and an age-

adjusted mortality rate due to all causes of 71 deaths for every 10,000 people.

In the North Sacramento Focus Community, Del Paso Heights (95838) had the highest rate of infant

mortality in Sacramento County with a rate of 6.73 deaths/1,000 live births. The Old North

Sacramento/Woodlake neighborhood (95815) had the highest age-adjusted overall mortality rate in

Sacramento County at 95 deaths per 10,000 population. More residents died in this zip code

annually due to all causes than any other in the county.


ii

In the Downtown Focus Community, the infant mortality rates were not markedly different from the

county and state overall, but the downtown neighborhood of 95814 had the third highest age-

adjusted overall mortality rate in Sacramento County.

Three neighborhoods in the South Sacramento Focus Community had the second, third, and fourth

highest rates of infant mortality in the county. One of the neighborhoods had the fourth highest

age-adjusted overall mortality rate in the county.

Tobacco-Free Living

Although most counties that have major urban areas have smoking prevalence rates below the state

average of 11.6%, Sacramento County is considerably above with a rate of 14.0%.

Individual neighborhoods have even higher rates: Almost one-third of the adult residents of the Old

North Sacramento, Woodlake (95815) neighborhood described themselves as current smokers.

Downtown (95814) has rates of tobacco-related emergency department visits and hospitalizations

more than twice that of the county rate. All but one of the 15 neighborhoods have tobacco-related

emergency department visit and hospitalization rates higher than the county rate.

Active Living and Healthy Eating

Of the 10 zip codes in the county with the highest rates of diabetes-related mortality, eight are in

the Focus Communities.

Out of the county’s 58 zip codes, 20 have rates of diabetes-related visits to the emergency

department higher than the county rate. Fourteen of the 20 come from the Focus Communities.

In the county, rates of diabetes-related hospitalizations range from 40/10,000 in zip code 95680 to

377/10,000 in Downtown (95814). Nine of the 10 neighborhoods with the highest rates come from


In several of the neighborhoods, more than 50% of the residents aged 12 and over were overweight

or obese.

Food deserts were found in all three Focus Communities, with the largest areas in North

Sacramento.

Although there are pockets in each area with access to healthy food from retail outlets, large parts

of the three Focus Communities have low proportions - 13% or less - of food retailers serving

healthy food.

High proportions of the North Sacramento and Downtown Focus Communities had access to parks

and were defined as “walkable”. However safety was a barrier to taking advantage of these

resources.

Clinical Preventive and Other Services

The Downtown 95814 neighborhood has the highest rates of heart disease and hypertension (and

diabetes) as measured by both emergency department visits and hospitalizations of any other zip

code in the county. Compared to the county rate, its rates are either more than or close to twice as

high as the overall county rate.


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Residents of the Downtown 95814 neighborhood died at the fourth highest rate in the county due

to heart disease. All but two of the 15 neighborhoods exceeded the county rate for heart disease-

related mortality.

The Parkway, Valley Hi/North Laguna neighborhood (95823) had the highest rate of hypertension-

related mortality in the county; five of the 15 neighborhoods were in the top 10 zip codes for

hypertension mortality.

In fourteen of the fifteen neighborhoods in the Focus Communities, rates for asthma-related

emergency department visits were above the county rate of 201 emergency department

visits/10,000 population and the state rate of 123 emergency department visits/10,000 population.

Three of the top five highest rates in all 58 Sacramento County zip codes were found in Parkway,

Valley Hi/North Laguna (95823), Downtown (95814), Old North Sacramento, Woodlake (95815).

Significant portions of the North Sacramento and Downtown Focus Communities have been

identified as Health Professional Shortage Areas by the federal Health Resources and Services

Administration.

Social and Emotional Wellness

Rates of emergency department visits and hospitalizations due to mental illness in the Downtown

95814 neighborhood are the highest of the 58 zip codes and dramatically higher than the county

rate. Several of the other neighborhoods also have elevated rates relative to the county overall.

The data on hospitalizations and emergency department visits related to mental illness or substance

abuse show strikingly similar patterns. For each indicator, the Downtown Focus Community

neighborhood in zip code 95814 is as much as five times that of the county rate and more than

twice as high as the next highest rate in the 14 other neighborhoods in the Focus Communities.

Safe and Healthy Physical Environments

Several of the neighborhoods had rates of emergency department visits and hospitalizations higher

than the county rate. The Downtown 95814 neighborhood had the highest rates, including some

more than four times the county.

Summary of Findings In spite of the favorable health status enjoyed by most residents, health disparities exist in Sacramento

County, and are concentrated in 3 geographic areas of the County containing 15 zip codes. The families

and individuals who live in these 15 neighborhoods are more likely to suffer from chronic disease and

poor health outcomes than those who live in other parts of the County. The poor health outcomes

experienced by those living in the neighborhoods contained within the 15 zip codes stem from a number

of interconnected factors. The residents in these geographic areas experience the lowest levels of

access to the ingredients that constitute a healthy community: employment, a sense of safety, healthy

food, and primary, preventive health care services. In addition, the demographic profiles of the

neighborhoods describe communities that are most vulnerable to health disparities because of socio-

economic status, race/ethnicity, insurance status and age that are associated with health disparities.

Improving the living and working conditions in communities and the opportunities of residents to thrive

are key to addressing the poor health outcomes identified in this assessment.


iv

Contents

RESULTS IN BRIEF .................................................................................................................................................... I

AREAS EXPERIENCING HEALTH DISPARITIES .......................................................................................................................... I

SUMMARY OF FINDINGS ................................................................................................................................................. III

INTRODUCTION ..................................................................................................................................................... 1

COMMUNITY HEALTH NEEDS ASSESSMENT DATA SOURCES .................................................................................. 2

SACRAMENTO COUNTY COMMUNITIES EXPERIENCING HEALTH DISPARITIES........................................................ 2

NORTH SACRAMENTO FOCUS COMMUNITY ......................................................................................................................... 4

DOWNTOWN FOCUS COMMUNITY .................................................................................................................................... 5

SOUTH SACRAMENTO FOCUS COMMUNITY ......................................................................................................................... 6

TOBACCO-FREE LIVING .......................................................................................................................................... 8

TOBACCO USE – CURRENT SMOKERS ................................................................................................................................. 8

TOBACCO-RELATED VISITS TO THE EMERGENCY DEPARTMENT AND TOBACCO-RELATED HOSPITALIZATIONS ..................................... 9

ACTIVE LIVING AND HEALTHY EATING: HEALTH OUTCOMES, BEHAVIORS AND ENVIRONMENTAL

CHARACTERISTICS ................................................................................................................................................ 11

HEALTH OUTCOMES ..................................................................................................................................................... 11

Diabetes-Related Mortality, Emergency Department Visits and Hospitalizations .............................................. 11

Overweight and Obesity ...................................................................................................................................... 13

BEHAVIORAL FACTORS................................................................................................................................................... 14

Consuming Fast Food .......................................................................................................................................... 14

Drinking Sodas .................................................................................................................................................... 15

Eating Fruits and Vegetables .............................................................................................................................. 15

ENVIRONMENTAL FACTORS ............................................................................................................................................ 16

Food access ......................................................................................................................................................... 16

Active Living ........................................................................................................................................................ 17

CLINICAL PREVENTIVE AND OTHER SERVICES ....................................................................................................... 18

CHRONIC DISEASE IN THE FOCUS COMMUNITIES................................................................................................................. 18

Heart Disease, Hypertension and Stroke ............................................................................................................. 18

Asthma ................................................................................................................................................................ 22

Disparities in Chronic Disease ............................................................................................................................. 23

LOCAL GAPS AND ASSETS IN PREVENTIVE HEALTH CARE ....................................................................................................... 24

Health Professional Shortage Areas .................................................................................................................... 24

Local Health Care Assets ..................................................................................................................................... 25

SOCIAL AND EMOTIONAL WELLNESS ................................................................................................................... 26

MENTAL ILLNESS RELATED EMERGENCY DEPARTMENT VISITS AND HOSPITALIZATIONS ............................................................... 26

EMERGENCY DEPARTMENT VISITS AND HOSPITALIZATIONS DUE TO SUBSTANCE ABUSE .............................................................. 28

DISPARITIES IN INDICATORS OF MENTAL HEALTH ................................................................................................................ 29

HEALTHY AND SAFE PHYSICAL ENVIRONMENT .................................................................................................... 30


v

EMERGENCY DEPARTMENT VISITS FOR ACCIDENTS, HOMICIDE, INJURY OR VIOLENCE ................................................................ 30

HOSPITALIZATIONS DUE TO ACCIDENTS, HOMICIDE, INJURY OR VIOLENCE ............................................................................... 31

OTHER SAFE AND HEALTHY PHYSICAL ENVIRONMENT INDICATORS ......................................................................................... 31

APPENDIX A – METHODOLOGY OVERVIEW .......................................................................................................... 32

DATA SOURCES ............................................................................................................................................................ 32

IDENTIFYING AND DESCRIBING COMMUNITIES EXPERIENCING HEALTH DISPARITIES ................................................................... 34

STUDY LIMITATIONS ...................................................................................................................................................... 36

APPENDIX B – DATA DICTIONARY ........................................................................................................................ 37

APPENDIX C – SECONDARY DATA PROCESSING METHODOLOGY ......................................................................... 40

GENERAL DATA PRE-PROCESSING ................................................................................................................................... 40

ADDITIONAL SPECIFIC VARIABLES .................................................................................................................................... 42

APPENDIX D – KEY INFORMANT INTERVIEW GUIDE ............................................................................................. 44

APPENDIX E – FOCUS GROUP INTERVIEW GUIDE ................................................................................................. 46

APPENDIX F – COMMUNITY ASSETS ..................................................................................................................... 48


vi

List of Tables and Figures

TABLE 1. FOCUS COMMUNITIES BY ZIP CODES AND NEIGHBORHOODS ................................................................. 2

MAP 1: FOCUS COMMUNITY BOUNDARIES............................................................................................................ 3

TABLE 2. NORTH SACRAMENTO FOCUS COMMUNITY SOCIO-DEMOGRAPHIC CHARACTERISTICS .......................... 4

TABLE 3. DOWNTOWN FOCUS COMMUNITY SOCIO-DEMOGRAPHIC CHARACTERISTICS ........................................ 6

TABLE 4. SOUTH SACRAMENTO FOCUS COMMUNITY SOCIO-DEMOGRAPHIC CHARACTERISTICS .......................... 7

TABLE 5. PERCENTAGE OF ADULTS WHO ARE CURRENT SMOKERS ........................................................................ 9

FIGURE 1. TOBACCO-RELATED EMERGENCY DEPARTMENT VISITS ....................................................................... 10

FIGURE 2. TOBACCO-RELATED HOSPITALIZATIONS .............................................................................................. 10

FIGURE 3. DIABETES-RELATED MORTALITY .......................................................................................................... 11

FIGURE 4. DIABETES-RELATED VISITS TO THE EMERGENCY DEPARTMENT ........................................................... 12

FIGURE 5. DIABETES-RELATED HOSPITALIZATIONS .............................................................................................. 13

TABLE 6. % OF ADULTS WHO HAD FAST FOOD 2 OR MORE TIMES IN THE LAST WEEK ......................................... 14

TABLE 7. % OF ADULTS WHO HAD SODA 2 OR MORE TIMES IN THE LAST WEEK .................................................. 15

TABLE 8. EMERGENCY DEPARTMENT VISITS AND HOSPITALIZATIONS FOR HEART DISEASE, HYPERTENSION, AND

STROKE ................................................................................................................................................................ 19

FIGURE 6. HEART DISEASE-RELATED MORTALITY ................................................................................................. 20

FIGURE 7. HYPERTENSION-RELATED MORTALITY ................................................................................................. 21

FIGURE 8. STROKE-RELATED MORTALITY ............................................................................................................. 22

FIGURE 9. ASTHMA-RELATED EMERGENCY DEPARTMENT VISITS ......................................................................... 23

FIGURE 10. MENTAL HEALTH-RELATED EMERGENCY DEPARTMENT VISITS .......................................................... 27

FIGURE 11. MENTAL HEALTH-RELATED HOSPITALIZATIONS ................................................................................. 27

FIGURE 12. SUBSTANCE ABUSE-RELATED EMERGENCY DEPARTMENT VISITS ....................................................... 28

FIGURE 13. SUBSTANCE ABUSE-RELATED HOSPITALIZATIONS .............................................................................. 29

TABLE 9. EMERGENCY DEPARTMENT VISITS FOR ACCIDENTS, HOMICIDE, INJURY OR VIOLENCE ......................... 30


1

Introduction

This Community Health Needs Assessment (CHNA) is a companion to the report, The Chronic Disease

Experience of Sacramento County Residents, prepared by Sacramento County’s Division of Public Health

in the Department of Health and Human Services (DHHS). Both reports are part of the collaborative

work of the Healthy Sacramento Coalition (Healthy Sacramento Coalition) to prioritize health needs

within Sacramento County and develop strategies and mobilize resources to improve the health of

county residents.

The Healthy Sacramento Coalition is funded by a Community Transformation Grant (CTG) from the

Centers for Disease Control and Prevention (CDC). The CTG Program’s overarching goal is to create

healthier communities by making healthy living easier and more affordable. Sacramento County is one

of six counties in California awarded CTG funding to build capacity to support healthy lifestyles and

reduce health disparities. Sacramento County covers nearly 1,000 square miles and is home to more

than 1.4 million people. Through the Healthy Sacramento Coalition, Sacramento’s CTG Program is

identifying evidence-based strategies to promote tobacco-free living, active living and healthy eating,

quality clinical and other preventive services, healthy and safe physical environments, and social and

emotional wellness.

Sierra Health Foundation is the CTG lead and fiduciary agent for Sacramento County. In addition to CDC,

funding support for CTG community health needs assessment activities was provided by Sierra Health

Foundation.

The Healthy Sacramento Coalition includes more than 60 organizations, including community-based

organizations, public agencies, hospitals, school districts, service providers, advocacy organizations,

businesses and foundations. They share a common goal of improving health and well-being for

Sacramento County residents. The coalition’s first step is a community health improvement plan

informed by the County Department of Health and Human Services report and this needs assessment.

On behalf of the coalition, Sierra Health Foundation commissioned Valley Vision to conduct the

assessment and identify:

Sacramento County communities with disproportionately high rates of chronic disease and mental health issues

community obstacles that prevent people from living healthier lives

community resources that support healthy living

To isolate areas of greatest disparity, the CHNA was organized based on the five CTG focus areas:

tobacco-related illness

active living and healthy eating

clinical preventive and other services

social and emotional wellness

healthy and safe physical environment


2

Community Health Needs Assessment Data Sources

The assessment relied primarily on secondary data from such sources as the California Office of

Statewide Health Planning and Development, California Department of Public Health, the Dignity Health

Community Need Index, and the U.S. Census, among others. These sources provided health outcome

data, socio-demographic data, and behavioral and environmental data at the zip code or census tract

level. Health outcome data included emergency department visits, hospitalization, and mortality rates

related to heart disease, diabetes, stroke, hypertension, asthma, tobacco, and safety and mental health

conditions. Socio-demographic data included data on race/ethnicity, poverty, educational attainment

and insurance status. Behavioral and environmental data included information on tobacco use, fast food

and soda consumption, neighborhood walkability and other variables. Additional information was

collected through interviews with 47 community leaders, focus group interviews with 124 community

members, feedback sessions during Healthy Sacramento Coalition meetings, and a community health

assets assessment.

Throughout the report, rates for mortality, emergency department visits and hospitalizations are

adjusted to account for differences in the population size and age profiles of the communities. The rates

are estimated per 10,000 population. For more information on the methodology and data sources, see

Appendices A and B. The data can also be seen in the form of GIS maps on the Sierra Health Foundation

website.

Sacramento County Communities Experiencing Health Disparities

The assessment identified 15 of Sacramento County’s 58 zip codes that are experiencing high rates of

health disparities relative to the county as a whole. The 15 zip codes are adjacent to others and cluster

into three communities – North Sacramento, Downtown and South Sacramento.

Table 1. Focus Communities by Zip Codes and Neighborhoods

Focus Communities Zip Codes Neighborhoods (all or a part of)

North Sacramento 95660, 95673, 95815, 95821, 95838, 95841

North Highlands, Rio Linda, Old North Sacramento, Woodlake, Del Paso Manor, Del Paso Heights, Belmont Estates

Downtown Sacramento 95811, 95814 Richards, Alkali Flats, Mansion Flats, Midtown, Richmond Grove, Southside Park

South Sacramento 95817, 95820, 95822, 95823, 95824, 95828, 95832

Oak Park, Elmhurst, Tahoe Park, Land Park, Parkway, Valley Hi/North Laguna, City Farms, Fruitridge Manor, Florin, Meadowview


3

Map 1: Focus Community Boundaries

The rest of this section describes the three focus communities and the neighborhoods they encompass.

Demographic characteristics that are indicators of vulnerability to health and economic disparities are

presented.2 These include the proportion of female-headed households under the poverty line and the

2 Data acquired from Dignity Health’s Community Needs Index


4

proportions of residents who have limited English, do not have a high school diploma, are Hispanic or

non-white, and are without health insurance. In addition, the infant mortality and general mortality

rates are used as indicators of the overall health of a community.

County rates presented in the report are based on Sacramento County’s 58 zip codes, including the 15 in

the three focus communities. As a result, health disparities observed in the neighborhood to county

comparisons would be even larger if the 15 neighborhoods were compared to neighborhoods with the

lowest rates of poor health outcomes.

North Sacramento Focus Community

The six zip codes that make up the North Sacramento Focus Community are home to more than 160,000

residents. As the table below shows, many of the neighborhoods had large percentages of residents

living below the federal poverty level, with low educational attainment, no health insurance and a high

percentage of non-white or Hispanic residents. Compared to county rates, all the neighborhoods had

higher proportions of households headed by single females in poverty and of residents without health

insurance or a high school diploma. In addition, three of the neighborhoods (North Highlands, Old North

Sacramento/Woodlake and Del Paso Heights) had higher proportions of residents who are non-white or

Hispanic.

Table 2. North Sacramento Focus Community Socio-Demographic Characteristics3

Residents Single female

head of households

living in poverty Neighborhood

Non-white or

Hispanic+

Without health insurance

Residents with limited

English

Without High School

Diploma

North Highlands (95660) 49% 27% 8% 27% 43%

Rio Linda (95673) 32% 18% 2% 21% 32%

Old North Sac.; Woodlake (95815)

65% 42% 13% 38% 52%

Del Paso Manor (95821) 37% 31% 7% 15% 40%

Del Paso Heights (95838) 74% 32% 9% 32% 44%

Belmont Estates (95841) 37% 29% 6% 16% 37%

County 52% 14%* 21%** 12%** 25%***

+2010 Census (factfinder2.census.gov);

*U.S. Census Bureau, 2010 American Community Survey 1‐Year Estimates (from A

Market Analysis of the Sacramento Region Primary Care Safety Net, http://www.sierrahealth.org/doc.aspx?253); **

CHIS, 2009 (ask.CHIS.ucla.edu);

***2007-2011 American Community Survey 5-Year Estimates (factfinder2.census.gov)

(see www.dignityhealth.org/who_we_are/Community_Health/STGSS044508). 3 Unless otherwise noted, the data come from the sources identified in Appendix B. County-level statistics were

collected from other sources for comparison.

http://www.sierrahealth.org/doc.aspx?253


5

In addition to the evidence of vulnerability to economic and health disparities found in the demographic

characteristics, key informants and community members in focus groups discussed the challenges in the

neighborhoods. They noted that the stress of being unemployed and navigating the world of social

services, many for the first time, was overwhelming. As one professional stated:

For the first time I am seeing people who have been steadily employed for 30 years; lost their job

2 years ago; lost everything and have no clue where to turn. They don’t know how to live. They

don’t know how to access services. They don’t know, they don’t know what to do. They are

demoralized. They are in their 50s. No one will hire them. They are just absolutely fish out of

water (KI_2_3).

Another participant stressed the difficulty families were having getting by with everyday life activities

due to financial stressors, and expressed how these stressors affected the person in many areas of their

life:

It is everyday stressors of not having enough money and not having enough food and not being

able to find a job, and it is so much for any family to have relationship issues and mental health

issues and physical issues. It is all happening at once... (KI_2_1).

While demographic characteristics indicate vulnerability to health and economic disparities, two

variables serve as overall indicators of health outcomes: infant mortality and overall mortality. Del Paso

Heights (95838) had the highest rate of infant mortality in Sacramento County with a rate of 6.73

deaths/1,000 live births. This is well above the county rate of 5.8, the state rate of 5.2 and the Healthy

People 2020 target of 4.5 deaths/1,000 live births. Del Paso Manor (95821) also had a high rate at

6.08/1,000. The Old North Sacramento/Woodlake neighborhood (95815) had the highest age-adjusted

overall mortality rate in Sacramento County at 95 deaths per 10,000 population. More residents died in

this zip code annually due to all causes than any other in the county. The county as a whole had a

mortality rate of 71 deaths for every 10,000 people, higher than the state rate of 63.

Downtown Focus Community The Downtown Area consists of two zip codes (95811 and 95814) and is home to approximately 17,500

residents. The 95811 zip code, which was created in 2006, had relatively low rates of chronic disease

compared to 95814 and many of the neighborhoods in the North and South Sacramento Focus

Communities. Despite the indicators of good physical health, 95814 is included as one of the areas

experiencing health disparities because of its high rates of emergency department visits and

hospitalizations related to mental health conditions.

The Downtown neighborhoods were close to the county in the proportion of non-white or Hispanic

residents and had much lower proportions of residents who spoke limited English. But other data

indicated potential vulnerability to poor health outcomes. For example, in contrast to the state

uninsured rate of 21%4 and the county rate of 10%, approximately four out of every 10 residents in the

Downtown Focus Community did not have health insurance. As one of the focus group participants

4 California Healthcare Almanac, California’s Uninsured, December 2011. Retrieved from:

http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20CaliforniaUninsured2011.pdf


6

stated, “And people don’t go to the doctor because you don’t have insurance or the funds to pay for the

services and the few times when you are able to get services at the clinics, the wait is very long or you

just get the minimal medical care (FG_8).”

Table 3. Downtown Focus Community Socio-Demographic Characteristics5

% of Residents Single female

head of households

living in poverty Neighborhood Non-white or

Hispanic+

Without health

insurance


English

Without High School

Diploma

Downtown (Richards, Alkali Flats, Mansion Flats, Midtown, Richmond Grove, Southside Park) (95811)

48% 44% 9% 25% 46%

Downtown (95814) 49% 39% 7% 26% 36%

County 52% 10%* 21%** 12%** 25%***


*CHIS 2007, 2009 (http://www.healthycity.org);

**CHIS, 2009 (ask.CHIS.ucla.edu)


With a rate of infant mortality of 5.4 deaths/1,000 live births, the Downtown neighborhoods were

slightly below the county rate of 5.8, slightly above the state rate of 5.2 and well above the Healthy

People 2020 target of 4.5. Although the infant mortality rates were not markedly different from the

county and state overall, the downtown neighborhood of 95814 had the third highest age-adjusted

overall mortality rate in Sacramento County.

South Sacramento Focus Community

The South Sacramento Focus Community has approximately 290,000 residents. Data indicated that this

area of the county was highly diverse with a large number of immigrant residents (based on the key

informant interviews and focus groups), high rates of poverty, high uninsured rates and low rates of

educational attainment. As one participant said about how living in poverty affects the treatment and

care by area practitioners: “Lower income area, you get treated low income (FG_9).”

5Unless otherwise noted, the data come from the sources identified in Appendix B. Some county-level information

was collected from other sources for comparison.

http://www.healthycity.org/


7

Table 4. South Sacramento Focus Community Socio-Demographic Characteristics6

Residents Single female

head of households

living in poverty Neighborhood Non-white or

Hispanic+

Without health insurance


English

Without High School

Diploma

Oak Park (95817) 58% 43% 9% 28% 46%

Elmhurst, Tahoe Park, Oak Park (95820)

69% 34% 11% 35% 39%

Land Park (95822) 72% 30% 10% 27% 33%

Parkway, Valley Hi/North Laguna (95823)

85% 29% 11% 27% 34%

City Farms, Fruitridge Manor (95824)

84% 41% 18% 44% 51%

Florin (95828) 77% 18% 9% 23% 24%

Meadowview (95832) 90% 35% 13% 41% 48%

County 52% 10%* 21%** 12%** 25%***


*CHIS 2007, 2009 (http://www.healthycity.org);

**CHIS, 2009 (ask.CHIS.ucla.edu)


Infant mortality rates for several of the South Sacramento Focus Community neighborhoods were higher

than county and state rates. Compared to the county, Elmhurst/Tahoe Park/Oak Park (95820), City

Farms/Fruitridge Manor (95824) and Parkway/Valley Hi/North Laguna (95823) ranked second, third and

fourth (respectively) in infant mortality. All three had rates above 6.0/1000 live births. Overall mortality

also indicated health disparities. The Elmhurst/Tahoe Park/Oak Park neighborhood (95820) had an

overall mortality of 83.9 deaths per 10,000-the fourth highest age-adjusted overall mortality rate in the

county, which has an overall mortality rate of 71.4.

6Unless otherwise noted, the data come from the sources identified in Appendix B. Some county-level information

was collected from other sources for comparison

http://www.healthycity.org/


8

Tobacco-Free Living

Smoking behavior, tobacco-related hospitalizations and tobacco-related visits to the emergency

department were used to examine the extent of health disparities in the Focus Communities’

neighborhoods. Data on smoking behavior or tobacco use more broadly are not available for most zip

codes, so the evidence on tobacco-related illness comes primarily from tobacco-related emergency

department visits and tobacco-related hospitalizations. The results are presented below. Key findings

include:

Close to a third of the adult residents of the Old North Sacramento/Woodlake (95815) and the

Downtown neighborhoods (95811 and 95814) describe themselves as current smokers.

The Downtown neighborhood in the 95814 zip code had higher rates of emergency department

visits and hospitalizations due to tobacco-related illnesses than any other zip code in the county.

All but one of the 15 neighborhoods had rates of emergency department visits and

hospitalizations due to tobacco-related illnesses higher than the county rate.

In the North and South Sacramento Focus Communities, African-American residents had the

highest rate of tobacco-related emergency department visits.

Tobacco Use – Current Smokers

According to the 2008 California Tobacco Control Survey7, Sacramento County has a smoking prevalence

rate of 14.0%. Although most counties that have major urban areas have prevalence rates below the

state average of 11.6%, Sacramento County is considerably above. Because of the small numbers, it is

challenging to describe smoking prevalence at the neighborhood level. However, the UCLA Center for

Health Policy Research8 provided small region estimates (by combining sampling from multiple zip

codes) of tobacco smoking prevalence for some zip codes. These are presented below.

According to estimates, close to a third of the adult residents of the Old North Sacramento/Woodlake

(95815) neighborhood describe themselves as current smokers. The Downtown (combined 95811 and

95814) and Land Park (95822) neighborhoods also have relatively high proportions of smokers.

7 Al-Delaimy WK, White MM, Mills AL, Pierce JP, Emory K, Boman M, Smith J, Edland S. Two Decades of the

California Tobacco Control Program: California Tobacco Survey, 1990-2008. La Jolla, CA: University of California, San Diego; 2010. 8 California Health Interview Survey. CHIS 2005, 2007, 2009 Pooled Data Estimates from Adult Source Files

[computer file]. Los Angeles, CA: UCLA Center for Health Policy Research, September 2012.


9

Table 5. Percentage of adults who are current smokers

Neighborhood (zip code) % adults who are current

smokers+

95% Confidence

Interval

North Sacramento Focus Community*

North Highlands (95652, 95660) 19.5% (9.2 - 29.9)

Old North Sacramento, Woodlake (95815) 34.0% (14.1 - 53.8)

Del Paso Manor (95821) 23.4% (10.5 - 36.3)

Del Paso Heights (95838) 14.9% (6.6 - 23.2)

Downtown Focus Community**

Downtown (95811, 95814) 31.7% (15.1 - 48.3)

South Sacramento Focus Community**

Land Park (95822) 29.4% (14.8 - 44.1)

Parkway, Valley Hi/North Laguna (95823) 20.4% (10.2 - 30.7)

County***

16.0% (12.6 - 19.4) + Current smoker denotes adults (age 18+) who smoked at least 100 cigarettes in their lifetime and that they smoke every day

or some days. *Source: 2005, 2007, 2009 CHIS;

**Source: 2007, 2009 CHIS;

*** Source: 2009 CHIS

Tobacco-Related Visits to the Emergency Department and Tobacco-Related

Hospitalizations Tobacco-related visits to the emergency department and tobacco-related hospitalizations reflect not

just smoking but other forms of tobacco use and provide information about the tobacco-related

illnesses of the residents of the 15 neighborhoods.

All but one of the neighborhoods have tobacco-related emergency department visit and hospitalization

rates higher than the county. Downtown (95814) has rates of tobacco-related emergency department

visits and hospitalizations more than twice that of the county rate.


10

Figure 1. Tobacco-Related Emergency Department Visits

Figure 2. Tobacco-Related Hospitalizations


11

Active Living and Healthy Eating: Health Outcomes, Behaviors and

Environmental Characteristics

Many of the neighborhoods in the Focus Communities experienced high rates of negative health

outcomes related to the areas of active living and healthy eating. This section describes the diabetes

outcomes and prevalence of overweight and obesity and discusses the environmental factors related to

these negative health outcomes.

Health Outcomes

Diabetes is one of the immediate consequences of inactive living and poor nutrition habits. The

following charts present data on diabetes-related mortality, emergency department visits and

hospitalizations in the 15 neighborhoods and is followed by findings on overweight and obesity, a

common precursor to diabetes.

Diabetes-Related Mortality, Emergency Department Visits and Hospitalizations

Figure 3. Diabetes-Related Mortality


12

Of the 10 zip codes in the county with the highest rates of diabetes-related mortality, eight are in the

Focus Communities. With diabetes-related mortality more than twice that of the county as a whole, the

Downtown (95814) neighborhood and Oak Park (95817) in the South Sacramento Focus Community had

the highest rates of all.

Figure 4. Diabetes-Related Visits to the Emergency Department

Diabetes-related visits to the emergency department in the county range from 59/10,000 in zip code

95837 to 459/10,000 in Downtown (95814). Out of the county’s 58 zip codes, 20 have rates of diabetes-

related visits to the emergency department higher than the county rate. Fourteen of that 20 come from



13

Figure 5. Diabetes-Related Hospitalizations

In the county, rates of diabetes-related hospitalizations range from 40/10,000 in zip code 95680 to

377/10,000 in Downtown (95814). Nine of the 10 neighborhoods with the highest rates come from the

Focus Communities.

Overweight and Obesity

At the zip code level, the proportion of residents who are overweight or obese is based on estimates

calculated from 2003 and 2005 CHIS data, so the following results are outdated, but still shed some light

on the health conditions experienced in the Focus Communities:

In the North Sacramento Focus Community, Old North Sacramento/Woodlake (95815), Del Paso

Manor (95821) and North Highlands (95660) had the highest proportions of obesity and

overweight residents age 12 and over at 54-56%.

More than 58% of the residents of Downtown zip code 95814 were overweight or obese. (No

data were available for residents living in 95811).

Estimates for neighborhoods in the South Sacramento Focus Community indicated that

approximately 60% of the residents in the Oak Park (95817) and Elmhurst/Tahoe Park/Oak Park

(95820) neighborhoods were overweight or obese, while 53-55% of the Land Park (95822) and

Parkway/Valley Hi/North Laguna (95823) had a rate of 53-55%.


14

In several of the neighborhoods, more than 50% of the residents aged 12 and over were overweight or

obese. Residents of Downtown (95814) were among the most overweight or obese in Sacramento

County.

Behavioral Factors

Eating fast foods, drinking soda, and not getting enough fruits and vegetables are behaviors that are

linked to diabetes and other negative health outcomes. Using estimates derived from combining

multiple years of CHIS data, findings related to healthy eating include:

Consuming Fast Food

To calculate fast food consumption at the zip code level, 2007 and 2009 CHIS data were combined.

Dependable data were not available for all the neighborhoods even after combining the two years.

Among those for which data are available, Belmont Estates (95841) had the second highest percentage

of adults consuming fast food two or more times in the last week. All but one of the neighborhoods in

the North Sacramento Focus Community is above the 2009 county average of 37.59. The Downtown

Focus Community neighborhoods also had a high rate of fast food consumption, more than 10% higher

than the county average. In contrast, all but one of the neighborhoods in the South Sacramento Focus

Community had rates of fast food consumption lower than the county average of 37.5%.

Table 6. % of Adults Who Had Fast Food 2 or More Times in the Last Week

Neighborhood (zip code) *

% adults who had fast food two or more times in

the last week

95% Confidence

Interval


North Highlands (95652, 95660) 41.1% (25.2 – 56.9)

Rio Linda (95673) 49.2% (24.4 – 74.0)

Old North Sacramento, Woodlake (95815) 36.7% (15.7 – 57.7)

Del Paso Manor (95821) 50.9% (36.0 – 65.9)

Del Paso Heights (95838) 44.2% (27.9 – 60.4)

Belmont Estates (95841) 55.8% (36.4 – 75.2)

Downtown Focus Community Downtown (95811, 95814) 48.6% (23.2 – 74.0)

South Sacramento Focus Community Elmhurst, Tahoe Park, Oak Park (95820) 39.7% (23.4 – 56.1)

Land Park (95822) 32.0% (17.1 – 46.8)

Parkway, Valley Hi/North Laguna (95823) 35.5% (22.3 – 48.7)

Florin (95828) 36.5% (25.9 – 46.9) *Source: Pooled cross-sectional data from 2007, 2009 CHIS

9 2009 CHIS, from ask.chis.ucla.edu


15

Six neighborhoods in the North and Downtown Focus Communities have rates of fast food consumption

(among adults 18 and over) above the 2009 county rate of 37.5%; in four neighborhoods, the rates are

more than 10% higher than the county rate.

Drinking Sodas

To examine the extent of soda consumption in the Focus Communities, the 2007 and 2009 CHIS data were combined. This analysis found an overall rate of adults drinking soda two more times in the last week of 27.42%. Of the all zip codes for which data were available, three of the neighborhoods in the Focus Communities were in the top five.

Table 7. % of Adults Who Had Soda 2 or More Times in the Last Week

Neighborhood (zip code)

% adults who had soda two or more times in the

last week

95% Confidence

Interval


North Highlands (95652, 95660) 46.3% (31.3 – 61.4)

Old North Sacramento, Woodlake (95815) 47.4% (20.6 – 74.2)

Del Paso Manor (95821) 38.8% (28.6 – 49.1)

Del Paso Heights (95838) 48.0% (30.8 – 65.2)

Belmont Estates (95841) ** 28.7% (13.6 – 43.8)

Downtown Focus Community Downtown (95811, 95814) ** 35.9% (16.2 – 55.6)

South Sacramento Focus Community Elmhurst, Tahoe Park, Oak Park (95820) 51.2% (33.1 – 69.3)

Land Park (95822) 29.1% (16.0 – 42.3)

Parkway, Valley Hi/North Laguna (95823) 40.5% (26.3 – 54.7)

Florin (95828) 18.4% (8.6 – 28.2) *Unless otherwise noted, the data for the estimates comes from pooled cross-sectional data from the 2007, 2009 CHIS.

**Estimates derived from 2005, 2007, 2009 CHIS.

All but one of the neighborhoods for which data are available had rates of soda consumption higher than

the combined rate for the county. Elmhurst/Tahoe Park/Oak Park (95820) and Del Paso Heights (95838)

had the highest proportions, with roughly half of adults had soda two or more time in the last week.

Eating Fruits and Vegetables

The data on the proportion of the population (age 5 and above) who are eating less than five servings of

fruit and vegetables a day comes from the 2003 and 2005 CHIS. Across the 15 neighborhoods in the

Focus Communities, the percent eating less than five servings ranges from 53% in one of the Downtown

neighborhoods (95814) to 59% in Meadowview (95832) in the South Focus Community. For comparison

purposes, the 2009 CHIS analysis (from ask.chis.ucla.edu) shows that the proportion of children eating

less than 5 fruits and vegetables daily was 44% in 2007, increasing to 57.6% in 2009. Given this increase

among children, it is likely that the rates for the 15 neighborhoods have also increased.


16

Environmental Factors

Unhealthy diets and overweight are not a function only of behaviors. Environmental factors also play an

important role. One key informant spoke about the importance of the environment on good health: “…it

is not just simply a matter of telling a person you need to lose weight. It is the environment that they are

in that is creating or helping them make those wrong choices (KI_CN_2).” Another interviewee spoke

about the relationship between poverty, access to healthy food and chronic disease: “I think lower

income means less access to everything including healthy food, so a lot of folks are overweight, obese,

[have] heart disease, all those things (KI_2_2).” This section examines the data on food access and

opportunities for active living.

Food access

In the focus group interviews, a community member said: “We got all the liquor stores you want. We

don’t have any grocery stores. We have got fast food restaurants up and down the street. We don’t have

a grocery store (FG_5).” This comment is borne out in the secondary data on environmental influences

on healthy eating. The major sources of information are CDC’s modified Retail Food Environmental Index

(mRFEI) which is the percentage of healthy food outlets in a census tract area compared to the total

number of all food outlets in the same tract, and the U.S. Department of Agriculture’s data on food

deserts (defined as a geographic area where 33% of the population or more than 500 people have low

access to healthy food). The data for both these variables are available at the census tract level only.

Food Deserts

In the North Sacramento Focus Community, most of the Rio Linda (95673) and Del Paso Heights (95838)

neighborhoods and portions of North Highlands (95660) and Old North Sacramento/Woodlake (95838)

neighborhoods were designated food deserts. In the Downtown Focus Community, parts of the 95811

neighborhood were within a food desert. Portions of four of the neighborhoods in the South

Sacramento Focus Community (zip codes 95820, 95824, 95828, and 95832) were identified by the US

Department of Agriculture as certified food desserts.

Food deserts were found in all three Focus Communities, with the largest areas in North Sacramento.

Retail Food Environment

Some geographic areas in the North Sacramento Focus Community had as few as 0-4% of retail food

vendors offering health food options. These included portions of the Old North Sacramento/Woodlake

(95815) and Del Paso Manor (95821) neighborhoods. Many of the census tracts in the Downtown Focus

Community had low numbers of healthy food outlets (relative to the total number of all food outlets).

However, the lowest was 10%, higher than that in North Sacramento. In the South Sacramento Focus

Community the proportion of retail food vendors offering healthy food options ranged from as low as 0-

4% to as high as 17%.

Although there are pockets in each area with access to healthy food from retail outlets, large parts of

the three Focus Communities have low proportions – 13% or less -- of health food retailers in the

neighborhoods.


17

Farmers Markets

The only certified farmers market in the North Sacramento Focus Community is located in Del Paso

Heights (95838). Although parts of the 95811 zip code were identified as food deserts, the other

Downtown Focus Community zip code (95814) was home to the highest concentration of certified

farmers markets in Sacramento County. The South Sacramento Focus Community has two certified

farmers markets.

With the exception of one of the Downtown neighborhoods, there are few farmers markets in the Focus

Communities.

Active Living

In order to provide a picture of active living, data on area park access and walkability and were

examined. Park access was measured the percentage of the population with no parks within ½ mile. 10

Walkability is measured by a score that incorporates walking routes and distances to amenities, road

connectivity metrics, and scores for individual amenity categories. 11

All three Focus Communities had large portions of the population living in areas with access to parks and

considered “walkable”. But each also had neighborhoods with high crime rates. Although crime rates

are difficult to compare because of the different sources (County Sheriff, Sacramento Police, and police

departments of other cities in the county), crime was elevated in neighborhoods throughout the Focus

Communities. Sacramento City Crime data revealed that Old North Sacramento/Woodlake (95815) had

the highest prevalence of major crime for the county, followed by Del Paso Heights (95838). In

Downtown, crime rates in zip code 95814 were among the highest in the county. Crime statistics for the

South Sacramento Focus Community were also elevated when compared to other communities.

Crime can create a barrier to active living, a point made by several focus group participants and key

informants. For example, safety of area parks was a consistent theme. One participant said: “We always

come to this park but we don’t go to this one end of the park because there is so much violent activity

that happens. And sure enough, when we were in that end [one day], a shooting happened (KI_4_8).”

Interviewees also commented about the danger of walking on heavily trafficked streets.

High proportions of the North Sacramento and Downtown Focus Communities had access to parks and

were defined as “walkable”. However safety was a barrier to taking advantage of these resources.

10

ESRI. 2010. parks.sdc. ESRI® Data & Maps, 10th edition – World, Europe, and United States. (data file) 11

Walkability score is based on walking routes and distances to amenities, road connectivity metrics, and scores

for an individual amenity category. See www.walkscores.com.

http://www.walkscores.com/


18

Clinical Preventive and Other Services

The assessment of needs related to clinical preventive and other services examined emergency

department visits, hospitalizations, and mortality related to several chronic diseases. This section also

presents information about health care assets and gaps obtained from the federal Bureau of Health

Professionals about health professional shortage areas and a local assets assessment.

Chronic Disease in the Focus Communities

Heart Disease, Hypertension and Stroke

Preventable chronic diseases such as heart disease, hypertension and stroke occurred at high rates in

most of the neighborhoods in the Focus Communities. In the following table, the rates are adjusted to

account for differences in the population size and age profiles of the communities. The rates are number

of emergency department visits or hospitalizations for every 10,000 people.

Emergency Department Visits and Hospitalizations for Heart Disease, Hypertension and Stroke

The following table shows the rates of emergency department visits and hospitalizations for heart

disease, hypertension and stroke. The numbers presented are a rate of number of visits or

hospitalizations per 10,000 residents. They have been adjusted to account for differences in the

population size and age profile in the neighborhoods.


19

Table 8. Emergency Department Visits and Hospitalizations for Heart Disease, Hypertension, and Stroke

Heart Disease Hypertension Stroke

Neighborhood (zip code) ED Hospital ED Hospital ED Hospital


North Highlands (95660) 163 304 608 509 21 68

Rio Linda (95673) 162 322 482 473 25 63

Old North Sacramento, Woodlake (95815)

181 356 632 542 22 80

Del Paso Manor (95821) 128 216 473 371 22 54

Del Paso Heights (95838) 154 342 622 536 19 69

Belmont Estates (95841) 147 281 540 470 21 60

Downtown Focus Community

Downtown (95811) 84 166 324 283 20 31

Downtown (95814) 273 477 906 754 27 94


Oak Park (95817) 128 327 560 560 21 76

Elmhurst, Tahoe Park, Oak Park (820) 158 295 568 497 23 64

Land Park (95822) 140 257 550 427 27 58


208 334 800 534 42 80

City Farms, Fruitridge Manor (95824) 157 317 577 525 23 75

Florin (95828) 150 253 574 433 23 61

Meadowview (95832) 196 354 712 533 20 74

Sacramento County 126 228 442 380 22 56

= = Highest rate of the 15 neighborhoods = Rate below the county rate

The areas with the two highest rates of hospitalization for heart disease in the county were the

Downtown (95814) neighborhood and the North Sacramento neighborhood of Old North

Sacramento/Woodlake (95815). The Downtown neighborhood in zip code 95814 had the highest rates

of Sacramento County’s 58 zip codes for emergency department visits and hospitalizations related to

heart disease, hypertension and stroke, and, as presented earlier, for diabetes. All the neighborhoods in

the South Sacramento Focus Community were in the ten zip codes (out of Sacramento County’s 58 zip

codes) with the highest rates of emergency department visits and hospitalization for hypertension and

stroke.

The Downtown neighborhood (95814) has the highest rates of heart disease and hypertension (and

diabetes) as measured by both emergency department visits and hospitalizations of any other zip code in

the county. Compared to the county rate, its rates are either more than or close to twice as high as the

overall county rate.


20

Mortality due to Heart Disease, Hypertension and Stroke

The Sacramento County Department of Health and Human Services reports that stroke is the fourth

leading cause of death in the county and hypertension is the ninth. Cardiovascular disease, which

includes stroke, heart disease and heart failure, is the first. The following charts show the rates of

mortality due to heart disease, hypertension and stroke in the 15 neighborhoods.

Figure 6. Heart Disease-Related Mortality

Residents of the Downtown 95814 neighborhood died at the fourth highest rate in the county due to

heart disease. All but two of the 15 neighborhoods exceeded the county rate for heart disease-related

mortality.


21

Figure 7. Hypertension-Related Mortality

Compared to the other chronic disease causes of mortality, the 15 neighborhoods had rates of mortality

due to hypertension more similar to other zip codes in the county. However, the Parkway, Valley

Hi/North Laguna neighborhood (95823) had the highest rate in the county and five of the 15

neighborhoods were in the top 10 zip codes for hypertension mortality.


22

Figure 8. Stroke-Related Mortality

Although some of the 15 neighborhoods had rates of mortality due to stroke less than or close to the

county rate, Land Park (95822) and Del Paso Manor (95617) rates of mortality due to stroke markedly

higher than the county rate. Land Park’s rate is over twice that of the county rate of 3.86.

Asthma

Asthma is a Chronic Lower Respiratory Disease. In 2009, the lifetime asthma prevalence was 13.1%

higher in Sacramento County than the state of California. As shown in the following figure, in a county

that already has a higher rate of asthma than the state, asthma is one of the chronic diseases that affect

the neighborhoods in the Focus Communities at a higher rate than the other parts of the county.


23

Figure 9. Asthma-Related Emergency Department Visits

In fourteen of the fifteen neighborhoods in the Focus Communities, rates for asthma-related emergency

department visits were above the county rate of 201 emergency department visits/10,000 population

and the state rate of 123 emergency department visits/10,000 population. Parkway, Valley Hi/North

Laguna (95823), Downtown (95814), Old North Sacramento, Woodlake (95815) had among the top five

highest rates in all 58 Sacramento County zip codes.

Disparities in Chronic Disease

The disparities in chronic disease are not only geographic in terms of the rates found in certain

neighborhoods relative to the county as a whole or to other zip codes. There are also disparities within

the 15 neighborhoods. In the North Sacramento Focus Community, African-American residents had the

highest rates of poor outcomes for all major health indicators. For example, in the Old North

Sacramento neighborhood (95815), diabetes-related emergency department visits was highest in

African-Americans at 729 cases and whites at 546/10,000, compared to the overall county rate of

224/10,000. This disparate burden was consistent across emergency department visits and

hospitalizations related to heart disease, hypertension, and stroke. Disparities in asthma rates were also

found in the North Sacramento Focus Community. African Americans had the highest rate of asthma-

related emergency department visits in Old North Sacramento (95815) and North Highlands (95660) at a

rate of 718 and 769, followed by Hispanics at 404 and 176, and whites at 202 and 407. Additionally, in


24

North Highland, Native Americans had a rate of 187 emergency department visits due to asthma, well

above the state rate of 124.

Similarly to the North Sacramento Focus Community neighborhoods, African Americans in the

Downtown Focus Community experienced higher rates of chronic disease in all areas. For example, the

rates for hypertension related emergency department visits for African Americans in the 95811

neighborhood was over three times that of all other groups in the neighborhood. African American

residents in that neighborhood visited the emergency department for hypertension at a rate of

957/10,000 population compared to the next highest group, whites, who visited at a rate of 271/10,000.

Asthma presented a different pattern. Native Americans were hospitalized for asthma at the highest

rate of all subgroups in the 95811 area.

In the South Sacramento Focus Community, emergency department and hospitalization rates for heart

disease were seen highest in white populations, followed by African Americans, Hispanics, Asian Pacific

Islanders, and Native Americans. In Meadowview (95832), for example, white residents visited the

emergency department due to heart disease at a rate of 347 and African Americans at a rate of 300,

compared to a county rate of 126. One exception is worth noting: in Florin (95828), the highest rates of

emergency department visits due to heart disease were seen in Native Americans at a rate of 322. For

hypertension, African Americans were over-represented in emergency department visits compared to

other groups. For example, in Land Park (95822) African-American residents visited the emergency

department due to hypertension at a rate of 1,518 compared to a county rate of 442. Further, African-

American residents of 95817 were hospitalized at a rate of 1,184 compared to Asian/Pacific Islanders

living in the same zip code with a rate of 204. Asthma rates also indicate health inequities in the South

Sacramento Focus Community. In Parkway, Valley Hi/North Laguna (95823) emergency department

visits due to asthma were highest in African Americans at a rate of 803 compared to the county rate of

201, almost 400% higher. In this neighborhood, hospitalization rates related to asthma were also high in

Native Americans at a rate of 228 compared to a county rate of 97.

Disparities in chronic disease outcomes were found between race and ethnic groups within the 15

neighborhoods. However, the pattern of disparity – which groups had the highest rates relative to others

– varied according to the Focus Community and the specific disease.

Local Gaps and Assets in Preventive Health Care

Health Professional Shortage Areas

Large areas of both the North Sacramento and Downtown Focus Communities were identified as Health

Professional Shortage Areas. These are areas defined by the federal Health Services and Resources

Administration as having a critical shortage of primary care health professionals12. In the North, the

entire Old North Sacramento/Woodlake neighborhood (95815) and most of the Del Paso Heights

neighborhood (95838) were designated as health professional shortage areas. Thus, coupled with the

high rates of uninsured residents mentioned earlier, these two neighborhoods had a large number of

12

See: http://bhpr.hrsa.gov/shortage/


25

residents with little access to primary health care. (One neighborhood in the South Sacramento Focus

Community, Meadowview (95832), was included in a larger Health Professional Shortage Area to the

southwest, but most of the community had not received the federal designation.)

The Health Professional Shortage Area designation was supported by qualitative data from the key

informant and focus group interviews. For example, when asked to discuss the critical health issues,

most respondents pointed to the inadequacies of basic health services, including primary, specialty, and

dental care. One key informant, when asked to discuss significant health issues in Sacramento County

said: “Our biggest health need is access to healthcare…a basic health network for low income people

(KI_CN_3).” Another key informant in the area expressed a need for access to dental services. One

resident said: “We have on paper these programs that are supposed to provide care for this vulnerable

population and yet we have so many road blocks that make it difficult for them to even access care

(KI_CN_2).”

Significant portions of the North Sacramento and Downtown Focus Communities have been identified as

Health Professional Shortage Areas by the federal Health Resources and Services Administration.

Local Health Care Assets

A list of health assets identified in the assessment is provided in Appendix F. Overall, the North

Sacramento Focus Community had fewer clinical preventive services than the Downtown or South

Sacramento Focus Communities. The Downtown community had a concentration of community clinics,

including Mercy Loaves and Fishes and Clinica Tepati (a UC Davis School of Medicine student-run clinic)

which are targeted primarily at uninsured residents with limited resources. In the South Sacramento

Focus Community, assets included Health-for-ALL, a clinic focused on providing screening and

management of chronic diseases for the un- and underinsured. In addition, this area of the county had a

handful of organizations focusing on meeting the health and social needs of specific subgroups including

Hmong Women’s Heritage Association, Southeast Asian Assistance Center, United lu Mien Community

Inc., and the Mexican American Alcoholism Program.


26

Social and Emotional Wellness

Sacramento County has higher rates of mental health emergency department visits and hospitalizations

and substance abuse emergency department visits and hospitalizations than the state as a whole. The

15 neighborhoods in the Focus Community have some of the highest rates in the county. Some of the

comments from the key informants and focus group participants illustrate the likely reasons for the

disproportionate prevalence of mental illness and substance abuse. Explaining the perspective of the

families that she services in the North Area, one key informant said:

They were thinking just “I got to survive. I am in survival mode.” So slowly we are moving people

along to where we are, they are stable and then eventually we get them from stable to thriving.

That is something that we hope will change. But when you are constantly thinking about

survival, the preventative stuff is just [not a priority] (KI_2_1).

Another participant said that the many chronic health conditions that North Sacramento residents

struggle with were a result of the conditions in which they lived daily: “…you see people who have

chronic health issues because of the crisis survival mode that they are living in (KI_1_2).” These

conditions may go untreated. Several key informants indicated that lack of mental health treatment

facilities were a barrier to social and emotional wellness for residents. As one informant said, “…but

there is just no good place to send [MH patients] because there are really no good psychiatric facilities as

far as capacity; there’s good facilities, but their capacity is limited (KI_4_5).” Another commented,

“Something really bad has to happen before you can get any mental health treatment and that is very

scary for everyone (KI_4_1).”

Mental Illness Related Emergency Department Visits and Hospitalizations Emergency department visits and hospitalizations for mental illness and substance abuse were

examined as indicators of social and emotional wellness.

The county rate of emergency department visits due to mental health was 489/10,000 population and

for hospitalizations it was 377/10,000. In comparison, the Downtown 95814 neighborhood rates were

2,250/10,000 for emergency department visits and 1,464/10,000 for hospitalizations. The 95814

neighborhood had the highest rates of any zip code in the county. The other Downtown neighborhood

(95811) had the third highest rate of emergency department visits (904/10,000) and the fifth highest

rate of hospitalizations (607/10,000). All but one of the 15 neighborhoods had emergency department

visit rates higher than the county rate and thirteen had hospitalizations exceeding the county rate.

Rates of emergency department visits and hospitalizations due to mental illness in the Downtown 95814

neighborhood are the highest in the county and dramatically higher than the county rates. Several of the

other neighborhoods also have elevated rates relative to the county overall.


27

Figure 10. Mental Health-Related Emergency Department Visits

Figure 11. Mental Health-Related Hospitalizations


28

Emergency Department Visits and Hospitalizations due to Substance Abuse

All 15 neighborhoods had rates of substance abuse-related emergency department visits and

hospitalizations higher than the county rate of 176/10,000. As with the mental health indicators, the

Downtown 95814 neighborhood had rates that far exceeded the other neighborhoods.

Figure 12. Substance Abuse-Related Emergency Department Visits


29

Figure 13. Substance Abuse-Related Hospitalizations

The data on hospitalizations and emergency department visits related to mental illness or substance

abuse show strikingly similar patterns. For each indicator, the Downtown Focus Community

neighborhood in zip code 95814 is as much as five times that of the county rate and more than twice as

high as the next highest rate in the 14 other neighborhoods in the Focus Communities.

Disparities in Indicators of Mental Health In the North Sacramento and Downtown Focus Communities, African Americans had the highest rates of

emergency department visits and hospitalizations for mental illness and substance abuse. For example,

in Del Paso Manor (95821), African Americans had rates of emergency department visits was

1,649/10,000, while rates for whites, Hispanics and Native Americans were 832/10,000, 402/10,000 and

367/10,000 respectively. In the South Sacramento Focus Community, whites and African Americans

visited the emergency department for mental health conditions at similar rates; however whites were

hospitalized for the same conditions at much higher rates.


30

Healthy and Safe Physical Environment

The health and safety of the physical environment in the Focus Communities was assessed primarily

through the rates of emergency department visits and hospitalizations due to injury, accidents, homicide

and violence. The following table shows the pattern of emergency department visits for the 15

neighborhoods relative to the county rate.

Emergency Department Visits for Accidents, Homicide, Injury or Violence

In 2010, heart disease and cancer were the two top leading causes of death across all racial and ethnic

groups and for both females and males in Sacramento County. Accidents were the third most common

cause of death for Hispanics and the fourth most common cause for African Americans, while fifth for

Caucasians and eighth for Asian/Pacific Islanders. Homicide was seventh for African Americans and not

on the list of top ten causes of death for any of the other groups. Disparities are also seen in the

incidence of accidents, homicides, injury, and violence in the Focus Communities compared to the

county as a whole.

Table 9. Emergency Department Visits for Accidents, Homicide, Injury or Violence

Neighborhood (zip code) Accidents Homicide Injury Violence


North Highlands (95660) 21 60 980 40

Rio Linda (95673) 19 41 810 28

Old North Sacramento, Woodlake (95815) 27 84 1,041 63

Del Paso Manor (95821) 24 58 873 34

Del Paso Heights (95838) 21 58 847 43

Belmont Estates (95841) 17 55 907 38

Downtown Focus Community

Downtown (95811) 46 84 715 67

Downtown (95814) 54 194 1,736 129


Oak Park (95817) 35 86 958 67

Elmhurst, Tahoe Park, Oak Park (95820) 21 63 870 48

Land Park (95822) 15 43 755 27

Parkway, Valley Hi/North Laguna (95823) 19 65 874 46

City Farms, Fruitridge Manor (95824) 24 54 810 32

Florin (95828) 16 42 735 29

Meadowview (95832) 15 58 842 34

Sacramento County 18 39 710 27

= Highest rate of the 15 neighborhoods = Rate below the county rate


31

After the Downtown 95814 neighborhood, the South Sacramento Focus Community had some of the

highest rates of accidents, homicides, injuries and violence of anywhere in the county. For example,

residents of 95817, 95823, and 95820 visited the emergency department due to homicide at twice the

rate of the county (86, 65, and 63 respectively compared to a county rate of 39).

Hospitalizations due to Accidents, Homicide, Injury or Violence

The pattern of hospitalizations related to accidents, homicide, injury or violence is very similar to that

for the emergency department visits. For every 10,000 residents, the county has hospitalization rates of

2.70 related to accidents, 6.04 for homicide, 208.11 due to injury and 4.28 caused by violence.

Comparing these rates to those for the 15 neighborhoods, the following neighborhoods rise to the top

repeatedly:

The Downtown 95814 neighborhood had the highest rates for all four indicators.

For accidents, the Downtown 95814 rate is 12.13, followed by Oak Park (95817) with 6.9. With a

rate of 4.5, Old North Sacramento/Woodlake (95815) also had a high rate of hospitalizations for

accidents relative to the county.

For homicide, the Downtown 95814 rate is 40.7. The next highest rate is Old North

Sacramento/Woodlake (95815). It had 15.42 hospitalizations due to homicide for every 10,000

residents.

The rates of hospitalization for injury were highest for the Downtown 95814 neighborhood with

646.04. Oak Park (95817 – 294.79), Rio Linda (95673) – 286, and Old North

Sacramento/Woodlake (95815) followed with rates of 294.79, 286.14 and 282.56, respectively.

The Downtown 95814 rate of hospitalizations for violence was 19.85, more than four times the

county rate (4.28). Old North Sacramento/Woodlake (95815) has a rate more than twice as high

– 10.3.

In the South Sacramento Focus Community, African Americans were greatly overrepresented in the

safety indicator rates. For example, the rate of emergency department visits due to homicide was

129/10,000 for African Americans while the county rate was 39 and the state rate was 32.

Several of the neighborhoods had rates of emergency department visits and hospitalizations higher than

the county rate. The Downtown 95814 neighborhood had the highest rates, including some more than

four times the county.

Other Safe and Healthy Physical Environment Indicators

The healthy environment indicators overlap and interact with those for active living. As described in the

section on active living, crime as well as traffic conditions affect residents’ sense of safety. These

concerns were a theme in the qualitative data. For example, one key informant said: “I have known like

two people that have gotten killed and they were elderly…[people] just do their daily strolls and they

have gotten hit [by cars] (KI_CN_7).”


32

Appendix A – Methodology Overview

This appendix describes the data sources, analytical framework and steps used to identify the focus

communities and assess community needs and assets.

Data Sources

The community health needs assessment analyzed secondary data from a variety of databases and

collected primary data through activities at the Healthy Sacramento Coalition meetings, key informant

interviews, community focus groups, and a community assets assessment. Sacramento County was the

focus for the assessment. Zip code boundaries were used to identify specific geographic communities

within the county experiencing disparities in chronic disease and mental health. Some indicators were

included in the assessment at the census tract level.

Secondary Data

Secondary data sources were selected based on the following criteria:

Sources must be credible as a source of high quality data.

Data must be reported consistently over time in the same way so that changes over time can be tracked.

Data must be available at the zip code (or smaller) level.

Major sources for secondary data on health outcomes and sociodemographic variables included:

California Office of Statewide Health Planning and Development (hospitalization and emergency department utilization data)

California Department of Public Health (mortality data)

Dignity Health Community Need Index

U.S. Census

California Health Interview Survey

For information on the sources and definitions for specific variables, including the variety of sources for

the behavioral and environmental health indicators, see Appendix B. Details on the processing and

analysis of the secondary data are provided in Appendix C.

Primary Data

Qualitative primary data were collected through:

Semi-structured activities at community meetings with the Healthy Sacramento Coalition

Key informant (KI) interviews with area experts

Focus groups (FG) with area community members

Community asset collection via phone interviews and website analysis Community Meetings


33

Data were collected from over 70 Coalition members at multiple Healthy Sacramento Coalition meetings

over the nine-month period. Each meeting allowed for the Healthy Sacramento Coalition to provide

input to the health assessment at key phases of the work, including the identification of data sources,

identification of organizations for KI interviews and focus groups, and discussion of preliminary findings.

At one of the meetings more than 70 attendees participated in a data collection forum where they were

asked to identify populations with health vulnerability, using maps of Sacramento County. Participants

were also asked to note special characteristics of communities by zip code and populations on the map.

Facilitators and note takers were assigned to each group, and findings were recorded and summarized

for inclusion in the health assessment. This data (combined with demographic data) served to inform

the location and selection of KI and FG interviews for the assessment.

Key Informant Interviews

To gain a deeper understanding of the health issues pertaining to chronic disease and populations living

in the county’s more vulnerable communities, 31 KI interviews were conducted that included a total of

47 health experts familiar with these populations and geographic areas. The interviews were conducted

using a theoretically grounded interview guide (see Appendix B). Each interview was recorded and

transcribed and thorough content analysis was conducted to identify key themes and important points

pertaining to each geographic area. Findings from these interviews were also used to help identify

communities for focus groups.

Focus Groups

Members of the community representing subgroups experiencing disparities were recruited to

participate in focus groups. In all, a total of 124 community members participated in 10 focus groups (for

locations see Appendix C). To understand the lived experiences of these community members as it

relates to health disparities and chronic disease, a standard protocol was used for each focus group (See

Appendix D). Demographic data collected based on interviewer observation indicated that participants

ranged in age from 18-60 years old, were 71% female, 29% male, and 23% white, 32% African-American,

13% Asian, 30% Latino, and 2% Other race. Two focus groups were conducted in Spanish, one in Hmong,

and one in Slavic (Russian). Each focus group was recorded, transcribed, and analyzed using a content

analysis method to identify key themes and salient topics to addressing the study questions and

objectives.

Community Assets

Data were collected on programs and services available throughout the community related to specific

health conditions in accordance with the CTG priority areas. A list of existing resource directories was

compiled, and additional assets identified through internet searches were added to this master list.

Detailed information for each identified asset was gathered though scans of each organization's

websites (where available) and, when possible, direct contact with staff. The final list of community

health assets contains 208 entries. Assets identified as being located in specific Focus Communities

identified in this report can be seen in Appendix E).


34

Identifying and Describing Communities Experiencing Health Disparities

By taking a systematic approach, the study was able to look at the issues affecting health (physical,

mental and emotional) from many angles. The analytical framework for collecting and organizing

information consisted of several process steps.

Step 1: Mapping Sacramento County’s Social Determinants of Health

The first step in the process was to examine socio-demographic data in order to identify areas of the

county with high vulnerability to chronic disease disparities and poor mental health outcomes. A map

was developed which included race/ethnicity, household composition, income, and age of residents in

each census tract in the county. These variables were combined into an index that assigned a level of

“vulnerability” to each census tract.

The tract level vulnerability index is based on measurements of populations within each Census tract

that correspond to disadvantaged groups who are expected to experience greater health disparities.

These populations include members of minority groups, single parent households, the very young, the

elderly population, and those in poverty. To calculate the index, 2010 American Community Survey 5-

year estimates data at the tract level were obtained for the following variables: the percent non-white

or Hispanic population, the percent of single parent households, the percent of population with income

below 125% of the poverty level, the percent of population below 5 years of age, and the percent of

population above 65 years of age. Values for each variable were standardized so that the maximum

value equaled 1 and the minimum equaled 0. These standardized values were then summed for each

tract to produce the index. Therefore, tracts with index values closer to 0 have relatively lower

proportions of these sensitive groups, while tracts that have values closer to 5 have relatively higher

proportions of these groups. Residents of a census tract were considered more vulnerable to negative

health outcomes if they had consistently high values of: 1) % of total population that was non-white or

Hispanic, 2) % of all households that were single-parent living in poverty, 3) % of all populations living at

1. Vulnerability Index

+ Community Coalition Input

2. Key Informant Interviews + Health Outcome Indicators

3. Focus Group Selection

4. Identifying Focus Communities

5. Characteristics of Focus Communities

6. Behavioral and Environmental Charactertics


35

or below 125% of the federal poverty level, and 4) % of the population under five or over 65 years of age

living in the tract.

In combination with input from the Healthy Sacramento Coalition and the results of the vulnerability

index, vulnerable neighborhoods were identified across the county. These became areas initially focused

on for conducting KI Interviews.

Vulnerable Communities in Sacramento County (by Census Tract)

Caption: Census tracts that appear darker in color are those that calculated to have more health disparities based on their demographic profile.


36

Steps 2 and 3: Focus Group Selection

Selection of locations to conduct focus groups was made with input from KI interviews and analysis of

health outcome indicators (emergency department visits, hospitalization, and mortality rates) that

pointed to disease severity. KIs were asked to identify populations (subgroups) that were most at risk for

chronic health disparities and mental health issues in their service areas. In addition, analysis of health

outcome indicators by zip code, and race/ethnicity, age, and gender, revealed communities with very

high rates above established benchmarks of state, county, and Healthy People 2020 targets. This

information was compiled to determine where in the county focus groups would be best targeted.

Step 4: Identifying Focus Communities

A total of 15 neighborhoods were identified as experiencing the greatest degree of health disparities

based on input from the Healthy Sacramento Coalition, primary data collected from KIs and FGs, and

detailed analysis of secondary health outcome data. To identify these neighborhoods (identified by zip

code boundaries), health outcome data were compared to county, state, and/or Healthy People 2020

benchmarks for emergency department utilization, hospitalization, and mortality. Those zip codes that

consistently ranked in the top 20% as having the highest rates for such conditions were noted, and

triangulated with primary data input as noted above.

Study Limitations Limitations of secondary data are a common issue in this kind of assessment. Emergency department

visit and hospitalization data used in this assessment are markers of prevalence, but do not fully

represent the prevalence of a disease in a given zip code. Currently there is no existing publically

available data set that has prevalence markers at the sub-county level for the core health conditions

focused on in this assessment: heart disease, diabetes, hypertension, stroke and mental health.

Similarly, behavioral level data at the sub-county level was also difficult to come by and not available by

race/ethnicity. CHIS data used in this assessment were hard to acquire, not current (some coming from

2003-2005) and necessitated the use of “small region” estimates.

Ensuring the inclusion of community voice can also be challenging. Many measures were taken reach

out to area organizations that represented a Focus Community geographically, racially/ethnically or

culturally, including providing incentives for the participants and food and refreshments during the

interview. Additionally, collecting data on all county assets for the community health asset assessment

was very difficult. Many organizations were hesitant to provide information to our staff over the phone,

resulting in limited data on some assets.


37

Appendix B – Data Dictionary


38


39


40

Appendix C – Secondary Data Processing Methodology

Data processing for the Healthy Sacramento Coalition Community Health Needs Assessment included a

number of general pre-processing steps applied to OSHPD and CDPH data, as well as particular

processing steps applied to calculate specific indicators. This appendix details both these general as well

as the specific process methodologies. For a detailed description of data sources, please refer to the

Data Dictionary in Appendix B.

General Data Pre-Processing

Four sets of general pre-processing steps were applied to the health outcome data obtained from

OSHPD (Hospitalization and Emergency Department utilization data) and CDPH (mortality data). First,

data reported by patient mailing zip codes were aggregated into US Census Bureau defined zip Code

Tabulation Areas (ZCTA) so they could be compared to population figures. Next, empirical Bayes (EB)

smoothed rates were calculated (where possible) for all input data. Age-adjusted rates were then

calculated for a subset of the OSHPD hospitalization and emergency department utilization data. Finally,

specific mortality related indicators, including life expectancy and infant mortality, were calculated

based on multiple years of data. The details for each of these processes are given below.

Zip Code to ZCTA Conversion

The hospitalization and emergency department usage data obtained from OSHPD, as well as the

mortality data obtained from CDPH, present some initial challenges to appropriate analysis. Both data

sets provide counts based on patient zip code. But zip codes are limited in their usefulness because they

represent either a collection of streets to which mail is delivered, a post office box, or even potentially

the campus of a large institution. zip codes corresponding to mail carrier routes are not necessarily

continuous, and do not directly correspond to any Census units for which population is collected.

The Census Bureau does, however, define regions called Zip Code Tabulation Areas (ZCTAs). ZCTAs are

created by identifying the predominate zip code of addresses within a census block, and then

aggregating census blocks corresponding to a particular zip. While ZCTAs are the closest Census defined

area to a zip code, they do not necessarily include all zip codes for which patient records are reported.

PO boxes, for example, may not be included in the ZCTAs that cover an area.

The first step in our data pre-processing was, then, to determine the relationship between patient zip

codes and ZCTAs. We did this in two steps. First, we assumed that while ZCTAs may not perfectly match

mailing zip codes, they were a reasonable representation for those zip codes with corresponding ZCTAs.

For example, while the ZCTA for 95815 may not include all (or exclusively) addresses with the mailing zip

code 95815, we assumed it to be an appropriate surrogate. For PO Box zip codes that had no

corresponding ZCTA, we identified the ZCTA within which the PO Box was located. We then assigned the

PO Box’s utilization or mortality counts to that ZCTA. This assumes that all patients receiving mail at a

given PO Box reside within the ZCTA in which that PO Box falls. While we recognize that this assumption

may not be correct in all cases, we felt that this shortcoming was preferable to ignoring patients with PO

Box zip codes.


41

Rate Calculation and Smoothing

Once input utilization and mortality data were converted to zip codes, their counts could be compared

to the Census reported populations for those areas to create utilization and mortality rates. But the

calculation of rates can pose an additional challenge. Raw rates (calculated by dividing counts by the

population of each ZCTA) can result in very misleading results in areas with small populations. Areas

with small populations can have misleadingly high rates with small numbers of events occurring. An area

with a population of 20, for example, would have a rate of 2,500 emergency department visits due to

injuries per 10,000 individuals if only 5 people visited the emergency department in a given year. This is

what is referred to as the small number problem. Additionally, conditions with very small numbers

occurring in a given year can lead to large variations in rates reported year after year.

We address these issues using rate smoothing. All OSHPD and CDPH data for this analysis were

smoothed using an EB approach. EB smoothing13 essentially works by first calculating an overall

expected rate based on values observed across a study area. In this case, ZCTAs in Solano, Sacramento,

Yolo, Nevada, El Dorado, Placer, and Amador counties were used for the wider region. The rate for each

ZCTA is then compared to this overall rate, and the ZCTA rate is adjusted to more closely match the

overall rate. Rates for areas with large populations receive very small adjustments. Rates for areas with

very small populations receive large adjustments. In this way, spuriously high rates for areas with small

populations are “shrunk” towards the overall regional mean rate, resulting in a more realistic estimate

of the true, underlying mean for the variable. Finally, since this smoothing technique addresses variance

instability by modifying the rate for every zip code, it also acts as an additional safeguard of patient

privacy.

Calculation of Age Adjusted Rates

In addition to the smoothing step described above, age adjusted rates were calculated for both

emergency department and hospitalization utilization data for diabetes, heart disease, hypertension,

and stroke. Direct age adjustment14 was used in this analysis, based on a 2010 California state standard

population generated for this analysis using 2010 Census population data and stroke.

Multi-Year Aggregation of Selected Mortality Indicators

While the majority of mortality indicators were processed using the steps described above, additional

steps were taken in the calculation of the higher level mortality indicators: infant mortality rate, age

adjusted mortality rate, and life expectancy at birth. To further remove issues related to the small

number problem, as well as instability due to annual variation, these indicators were calculated using 5

years worth of data. Mortality data from CDPH from 2006-2010 were summed for each reported zip

13

Our implementation of EB smoothing uses priors estimated through the moments method; details can be found in Anselin, L., Kim, Y.-W., and Syabri, I. (2004). Web-based analytical tools for the exploration of spatial data. Journal of Geographical Systems, 6:197–218; and Bailey, T. C. and Gatrell, A. C. (1995). Interactive Spatial Data Analysis. John Wiley and Sons, New York, NY, p 306. 14

Curtin, LR, Klein, RJ. Direct Standardization (Age-Adjusted Death Rates). Statistical notes; no.6. Hyattsville, Maryland: National Center for Health Statistics. March 1995.


42

code15. Estimated zip code population figures for the total population, as well as by age group, in 2008

(the central year of the 5 year period) was obtained from GeoLytics. The GeoLytics data did not include

estimates for the population under 1 year of age. Population in this age group was included in the 0 to 4

years of age group. Population under 1 in 2008 was estimated for each zip from the GeoLytics data by

multiplying the estimated population from 0 to 4 by the proportion of that age group who were under 1

year for the corresponding ZCTA in 2010. EB smoothed mortality rates were then calculated for each age

category. These rates were then used to calculate an age adjusted all cause mortality rate using the

same methodology and standard population described previously. These age stratified mortality rates

were also used to calculate the life expectancy at birth variable16. Finally, the infant mortality rate for

each ZCTA was calculated as an EB smoothed rate based on 2006-2010 infant mortality and live birth

data from CDPH.

Additional Specific Variables

While we attempted to use existing data from reputable sources to the fullest extent possible, there

were a number of areas where this was not possible. As a result, in addition to the general data

processing steps described above, we created or derived several other specific indicators for this

analysis. These included the Census tract level, demographic-based vulnerability index; the major crime

rate indicators for the Sacramento PD and Sacramento County Sheriffs; and the park accessibility

variables.

Major Crime Rate Indicators

The definitions of major crimes used in this analysis follow the reporting in the California Attorney

General’s office Criminal Justice Profiles Crimes by County table17. Crimes reported in this table include

homicide, forcible rape, robbery, aggravated assault, burglary, motor vehicle theft, larceny, and arson.

Data from this table was used to calculate crime rates for all incorporated cities excluding the City of

Sacramento. Crime data reported by police beat by the Sacramento Police Department18, and by zip

code for the Sacramento County Sheriff’s Department19 were used to calculate these rates for the City

of Sacramento, and the unincorporated portions of the county, respectively. But these values should be

viewed as approximations for a number of reasons.

First, Sacramento PD sometimes respond to calls outside the city, just as at times the Sheriff’s

department responds to calls inside incorporated cities. Because these calls are reported to the separate

15

To address changes in zip codes during this 5 year period, relationship tables were created to show how zips in each year related to the configuration of zips in 2008, the central year of the analysis. A zip code was deemed to exist in a given if cases had been reported in that zip in the current or any prior years. 16

Life expectancy at birth was calculated in R using code based derived from: Hunsinger, Eddie. 2011. R Code for a Period Life Table. Available online at: http://www.demog.berkeley.edu/~eddieh/AppliedDemographyToolbox/StanfordCourseLifeTable/StanfordCourseLifeTableCode.txt (Last Accessed September 20, 2012). 17

Available online at: http://oag.ca.gov/crime/cjsc-stats/2010/table11. (Last accessed September 21,2012) 18

Available online at: http://www.sacpd.org/crime/stats/#databases. (Last accessed September 21, 2012) 19

Available online at: http://www.sacsheriff.com/organization/support_services/field_support_division/records/crime_report.cfm. (Last accessed September 21, 2012)


43

agencies, they may not include activities occurring within their jurisdictional boundaries that were

responded to by another agency. Second, the coding systems used to categorize crime types were not

consistent between the three sources. While efforts were made to use consistent standards based on

the textual descriptions of the events, these efforts may not have been completely successful. Third,

additional coding errors, or misclassification of the coded information, may have resulted in further loss

of information. Finally, these data are based on a mixture of known crimes, crime reports, and arrest

records, and may not reflect the true underlying nature of crime in particular areas due to differences in

under-reporting, over-reporting, or a host of other societal issues.

Park Accessibility

Park accessibility is used in this analysis to inform an understanding about the distribution of

opportunities to engage in physical activity across the county. Measures of park accessibility should

include both a consideration of population proximity to parks, as well as the quality of the parks, which

can be related to park size20. To capture both of these issues, we created two complementary park

accessibility variables: the number of people with no parks within ½ mile, and for those areas with parks

within a half mile, the number of people per total area of all parks within ½ mile.

The creation of both of these variables began with the use of dasymetric mapping tools to create an

estimate of the distribution of the residential population within the county along a grid in which each

grid cell was just under an acre in area. To do this, county zoning data was used to identify all of the

residential parcels in the county. 2010 Census block population counts were then distributed evenly

throughout the area of all the residential parcels that fell within them. These values were then assigned

to the approximately acre sized grid cells. These population grid cells were then compared to the

locations of parks21. Populations in grid cells that were not within ½ a mile of a park were included in the

no parks within ½ mile variable. For those grid cells that were within ½ mile of a park, the population of

the grid cell was divided by the total land area of all parks that could be reached within ½ mile. This

comparison of population to total park area serves as an indicator of park quality, assuming that areas

that have a lower density of people per park area will allow residents greater freedom of access to the

parks.

20

Cutts, BB, Darby, KJ, Boone, CG, Brewis, A. (2009) City structure, obesity, and environmental justice: An integrated analysis of physical and social barriers to walkable streets and park access. Social Science & Medicine.69(9):1314-1322. 21

ESRI. 2010. parks.sdc. ESRI® Data & Maps, 10th edition – World, Europe, and United States. (data file)


44

Appendix D – Key Informant Interview Guide

Project Objective

In order to provide necessary information for sponsoring hospital’s community benefit plans and the

Healthy Sacramento Coalition to develop an implementation plan…

For each Health Service Area (HSA), identify communities and specific groups within these

communities experiencing health disparities, especially as these disparities relate to chronic

disease, and further identify contributing factors that create both barriers and opportunities these

populations to live healthier lives.

____________________________________________________________________________________

Objective #1: To understand the predominate health issues in a HSA, and those subgroups

disproportionately experiencing these issues

Question #1: What are the biggest health issues [your community, your HSA, you] struggles with?

Probes:

Diabetes, high blood pressure, heart disease, cancer Mental Health Other issues, including those that are emerging that often go undetected

Question #2: Who [which specific sub-group(s)] within [your community, your HSA] appear(s) to

struggle with these issues the most?

Probes:

How do you know, what leads you to make this conclusion? Describe race/ethnic makeup of HSA to KI if needed Subgroups within the larger categories Where in [your community, your HSA] do these groups live? Describe family status of HSA to KI if needed Describe the socio-economic status of the HSA to KI if needed Describe the overall vulnerability of the HSA to KI if needed

Question #3: In what ways do these health issues affect the quality of life of those that struggle with

them the most (those subgroups identified above)?

Objective #3: Determine the barriers and opportunities to live healthier lives in the HSA

Question #4: What are some challenges that [your community, your HSA] faces in staying healthy?

Probes:

Behaviors common to your community? Cultural norms and beliefs held by any subgroup, especially those identified above Smoking Diet, relationship with food Physical activity, relationship with one’s body


45

Safety Access to preventive services, access to basic healthcare [For specific KIs] Policies, laws, regulations (provide example if needed)

Question #5: What are opportunities in [your community, your HSA] to improve and maintain

health? What does your community have that helps [your community, your HAS] live a healthy life?

Probes:

Shifting social and community norms and beliefs Smoking and tobacco use Opportunities to exercise Access to fresh produce, healthier diet Areas for families to gather Sense of community safety Access to preventive services, access to basic healthcare [for specific KIs] Policies, laws, and/or regulations that can be updated, nullified, amended, or

enacted

Questions #6: Of all those you noted above, what is the biggest thing needed to improve the overall

health of [your community, HSA]?

Probes:

Policies? Partnerships? Economic growth? Other? Who is responsible for creating that change?

Question #7: What else does our team need to know about [your community, HSA] that hasn’t

already been addressed?


46

Appendix E – Focus Group Interview Guide

Project Objective

In order to provide necessary information for sponsoring hospital’s community benefit plans and the

Healthy Sacramento Coalition to develop an implementation plan…

For each Health Service Area (HSA), identify communities and specific groups within these

communities experiencing health disparities, especially as these disparities relate to chronic

disease, and further identify contributing factors that create both barriers and

opportunities these populations to live healthier lives.

____________________________________________________________________________

Objective #1: To understand the predominate health issues in a HSA, by those subgroups

disproportionately experiencing these issues

Question #1: What are the biggest health issues [your community, your family, you] struggles with?

Probes:

Diabetes, high blood pressure, heart disease, cancer Mental Health Other issues, including those that are emerging that often go undetected

Objective #2: Determine contributors to the health outcomes experienced by participants.

Question #2: What do you think is causing these health outcomes and health issues you’ve

described?

Probes:

Tobacco use Diet Stress and anxiety Physical activity Cultural norms and beliefs pertaining to health, diet, and exercise

Question #3: Do you think there are things where you live that contribute to some of the health

outcomes and health issues you’ve described?

Probes

Perception of safety when outdoors Lack of places to exercise Second hand smoke Etc.

Objective #3: Determine the barriers and opportunities to live healthier lives in the HAS

Question #4: What are some challenges that [your community, your HSA] faces in staying healthy?

Probes:

Behaviors common to your community?


47

Cultural norms and beliefs held by any subgroup, especially those identified above Smoking Diet, relationship with food Physical activity, relationship with one’s body Safety Access to preventive services, access to basic healthcare Policies, laws, regulations (provide example if needed)

Question #5: What are the opportunities in [your community, your HSA] to improve and maintain

health? What does your community have that helps [your community, your HAS] live a healthy life?

Probes:

Shifting social and community norms and beliefs Smoking and tobacco use Opportunities to exercise Access to fresh produce, healthier diet Areas for families to gather Sense of community safety Access to preventive services, access to basic healthcare Policies, laws, and/or regulations that can be updated, nullified, amended, or enacted

Question #6: Of all those you noted above, what is the biggest thing needed to improve the overall

health of [your community, HSA]?

Probes:

Policies? Partnerships? Economic growth? Other? Who is responsible for creating that change?

Question #7: When have you seen your community experience its greatest successes and/or

accomplishments? What happened to account for the success?

Question #8: What are your community’s greatest strengths and assets? How have these been used

in the past to create positive change?

Question #9: What would you like the hospital systems to know about your community? What can

the hospital systems do to improve the health of your community?

Question #10: What else does our team need to know about [your community, HSA] that hasn’t

already been addressed?


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Appendix F – Community Assets

Community assets were identified primarily through the key informant and focus group interviews and a

review of members of the Healthy Sacramento Coalition. Only those organizations that are physically

located in the Focus Community are identified. There are organizations that are not listed (because their

address is outside the community) that provide services to neighborhood residents (clinics in zip codes

contiguous to those included in the Focus Communities, for example). In addition, although identified by

the neighborhood in which they are geographically located, many of the organizations in the following

tables serve a wider geographic community.

Clinics and Service Organizations in Multiple Neighborhoods

Name Tobacco-

Free Living Active Living-

Healthy Eating Clinical

Preventive S-E

Wellness Physical

Env.

Birth & Beyond (95660, 95814, 95820, 95822, 95823, 95824)

X X X

Family Resource Centers (95815, 95822, 95823)

X

Health for All Community Clinics (95815, 95822, 95832)

X

Health & Life Organization (HALO) Community Clinicis (95815, 95823)

Mercy Clinics (95838, 95811) X X X X

Planned Parenthood (95814, 95820, X

Sacramento Community Clinic (95815, 95823)

X X X

Sacramento County Wellness and Recovery Centers (95821, 95823)

X

Sacramento Food Bank and Family Services (95815, 95817)

X

WEAVE (95811, 95823) X

WellSpace Health (formerly The Effort) (95660, 95815, 95811, 95817, 95824)

X X X X

North Sacramento Focus Community Assets

Name Tobacco-



Preventive S-E

Wellness Physical

Env.

North Highlands (95660)

American Diabetes Association X

Child Abuse Prevention Center X

New Testament Baptist Church (Kitchen Ministry)

X

Old North Sacramento; Woodlake (95815)

American Cancer Society X X

California Diabetes Program (Dignity Health) X


49

Name Tobacco-



Preventive S-E

Wellness Physical

Env.

Calvary Christian Center (Medical care clinic days)

X

Center for Fathers and Families X X

Harmon Johnson Healthy Start X X X

Health for All (Clinic) X X

Roberts Family Development Center X X

WIND Youth Services X X X X X

Del Paso Manor (95821)

Interim HealthCare/Interim HomeStyle Services

X X

Muslim American Society-Social Services Foundation

X

Wellness and Recovery Center X

Del Paso Heights (95838)

Bayanihan Clinic X X

Mutual Assistance Network X X X X

Sacramento Area Community Garden Coalition

X X

Downtown Sacramento Focus Community Assets

Name Tobacco-



Preventive S-E

Wellness Physical

Env.

Downtown (Richards, Alkali Flats, Mansion Flats, Midtown, Richmond Grove, Southside Park) (95811)

Alchemist Community Development Corporation

X

American Heart Association, Sacramento X X

Center for AIDS Research, Education and Services (CARES)

X X X

Center for Community Health and Wellbeing (The Birthing Project)

X X

Central Downtown Food Basket X

Clean and Sober Homeless Recovery Communities

X

Clinica Tepati X

Loaves and Fishes X X

Sacramento Housing Alliance X

Sacramento Native American Health Center, Inc

X X X X

YWCA X


50

Name Tobacco-



Preventive S-E

Wellness Physical

Env.

Downtown (95814)

Breathe California of Sacramento Emigrant Trails

X X

California Black Health Network X X X

El Hogar X

Guest House Homeless Services X

Native TANF Program X X X

Salvation Army-Adult Rehabilitation Center X

Saving Our Legacy, African Americans for Smoke-Free Safe Places (SOL Project)

X

Sacramento Taking Action Against Nicotine Dependence (STAND Project)

X

WALKSacramento X X

South Sacramento Focus Community Assets

Name Tobacco-



Preventive S-E

Wellness Physical

Env.

Oak Park (95817)

Harm Reduction Services/Joan Viteri Memorial Clinic

X

Imani Clinic X

Ubuntu Green X X

Elmhurst, Tahoe Park, Oak Park (95820)

Another Choice, Another Chance X

La Familia Counseling Center X X X X X

Land Park (95822)

South Sacramento Interfaith Emergency Food Closet

X

Southeast Asian Assistance Center X


Golden Rule Services X

Hmong Women’s Heritage X X

Kaiser Permanente X X X X

Mexican American Alcoholism Program (MAAP

X

Sacramento County Public Health Division

Strategies for Change X

Visions Unlimited X X


51

Name Tobacco-



Preventive S-E

Wellness Physical

Env.

City Farms, Fruitridge Manor (95824)

United Iu Mien X

Meadowview (95832)

Antioch Progressive Church X X

Genesis Missionary Baptist Church X

sacramento county community health needs … from valley vision sacramento county community health...

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