Part II

Back to the Table of Contents
Back to Part 1
Part II. Quantitative Assessment: Key Indicators of the
Health and Quality of Life in Bucks County

There is a wealth of data available for assessing the health and social assets and needs of Bucks County. Appendix I of the supplement to this report offers more detailed information. The Appendix identifies the sources, describes the limitations, and suggests web sites and other resources for updating this information. In this section we present a brief summary that either statistically supplements the issues identified by our key informants or flags for further investigation potential concerns directly identified by this analysis.

1. Demographics

Growth

The key informants reflect concerns about profound shifts in the demographics of Bucks County over the last decade. Bucks County’s population grew 10.9% between 1990 and 2000, making it one of the more rapidly growing counties in Pennsylvania. Lower Bucks, the most population-dense section of the county grew at the slowest rate (4.4%), while Central Bucks grew at the most rapid rate (21.1%).

Aging

Growth by age group in Bucks County and in the three basic geographic divisions of the county reflects different dynamics than those of the Philadelphia region as a whole.

The over-75 population, the most rapidly growing segment of the county’s population, grew 56% between 1990 and 2000. This was twice the rate of growth of the over-75 population statewide. The bulk of this growth was concentrated in Lower and Central Bucks (61% and 56% respectively). This growth in the over-75 population has been reflected in an increased demand for services. For example, the hospital admission rate for the over-75 population in Bucks County in 2000 was 513 per 1,000 residents, compared to 127 per thousand for all residents of Bucks.

The growth in over-75 population in Bucks County in the last decade has produced a 152% increase in the number of non-institutionalized persons over 65 with disability limitations. While the number of persons over 65 without limitations remained constant (45,420) the number with disabilities jumped from 8,677 to 24,354.

The number of young children (0-4) in Bucks County declined by 3.6% between 1990 and 2000. The number declined by 15.5% in Lower Bucks and 8.5% in Upper Bucks. Conversely, the number of young children in Central Bucks grew by more than 23%, reflecting the growth in new housing and the attractiveness of the area to young families.

The number of school-aged children (5-19) in the county grew overall by 14.5%.

The young adult population (20-34) in the county experienced the only large decline: more than 20%. Educational and employment opportunities as well as the search for affordable housing, as some of our key informants suggested, may help drive this exodus.
The 45-55 population, peak earning years for adults, grew at almost as fast a rate as the over-75 population (51% v. 56%).

The population is aging. The median age in Bucks County grew from 33 in 1990 to almost 38 in 2000, a rate of aging more than 50% higher than for Pennsylvania as a whole and almost twice that of the United States.

Shifting Commuting Patterns

Changing commuting patterns have exacerbated transportation problems. In spite of efforts to support public transportation, growing affluence appears to be a factor in a 17% decline in carpooling to 25,277 individuals and a 12% increase in those that drive alone to work, now totaling 251,994. There has been only an 8% increase in those taking public transportation, now at 8,485.
The number of persons who walk to work declined 26% in the last decade to 5,079.

Perhaps reflecting the technological changes in the workplace and persistent commuting problems, the number of persons who work at home grew 56% in the last decade to 10,792.

Growing Diversity

As many of the key informants observed, Bucks County is becoming more racially diverse. While the Caucasian population still comprises 92.5% of the Bucks County population, it grew in the last decade by only 9.7% while the County’s African-American population grew by 30% and the Hispanic population in Bucks County by 65%. The number of Chinese residents in the county grew 131% (to 2,356 individuals) and the number of Asian Indians grew 120% (5,916 individuals). The historically dominant groups by ancestry in Bucks County, Germans and English, have declined by 19% (160,626) and 18% (66,693) respectively. Many non-northern European ethnic groups including sub-Saharan African, West Indian and others contributed to the growth in the county’s population. In 2000 5.9% of Bucks County’s population was foreign born, 2.3% arriving in the last decade.

8.7% of Bucks County residents speak a language other than English in the home. 20.2% of Bucks County’s population over the age of five took up residence in Bucks County only in the last five years. Bucks County school districts reported that for the 2000-2001 school year, 859 students were enrolled who had limited English proficiency. Bristol (2.3%), Bensalem (2.3%) and Morrisville Borough (4.2%) reported the highest percentage of enrolled students with limited English proficiency.

Growing Income and Poverty

Income levels, income inequalities, and poverty exert a powerful influence on the health of a population and suggest that Bucks County should be healthier than Pennsylvania and the nation as a whole.

Median household income in Bucks County in 1999 was $59,727. Adjusted for inflation, it grew 6.2% in the last decade, with only eleven of Bucks County’s fifty-four municipalities experiencing a decline in real median household income. By comparison, median household income in Bucks County is now 42% higher than for the U.S. as a whole, 49% higher than for Pennsylvania, and 94% higher than Philadelphia. The county level is also 8% higher than the median household income level in New Jersey, which has the highest median income of any state. Higher median household income levels are associated with better health.

What is surprising and goes against the subjective impressions of many of the key informants we talked with as well as against national trends, is that income disparities in Bucks County have actually declined in the last decade. While some poorer townships got poorer and some richer townships got richer in Bucks County over the last ten years, income overall was more equally distributed. For example, within Bucks County per capita income ranges between local municipalities from $19,090 (Bristol Township) to $56,288 (Upper Makefield). Yet, the income inequality in Bucks County declined dramatically in the last decade and is well below that of Philadelphia, Pennsylvania, and the nation as a whole. The Gini Index is the most commonly used measure of income inequality in a population. (It is sometimes referred to as the "Robin Hood Index," since it measures on a scale of 0 to 1.00 the proportion of income that would have to be redistributed to equalize everyone’s income. Between 1989 and 1999 the index changed for Bucks County from .345 to .240. In contrast, the index for Philadelphia and the United States grew to .456 and .457 respectively. Lower Gini Indexes or less income disparities in a population tend to be associated with better health.

Poverty, however, also adversely affects health and perhaps has greater effect in Bucks County where it tends to be hidden within the country’s more visible affluence. In Bucks County the percentage of families living in poverty increased slightly over the last decade from 2.9% to 3.1%. Poverty exists in all townships in Bucks County, ranging from .5% (Tinicum) to 6% (Bensalem). In contrast, the percentage of families in poverty in Philadelphia is 18.4%, in Pennsylvania 7.8%, and in the United States as a whole 10.2%. For Bucks County, addressing poverty and its effect on the health and well being of residents is a more manageable but more difficult problem because it tend to be invisible.

Increasing Education Levels

The education levels of Bucks County residents increased dramatically over the last decade. Those over twenty-five years of age with less than a 9^th grade education declined by 40% to 11,078 and those with only some high school education but no diploma declined by 17% to 34,851. In contrast, those with a college degree increased by 39% to 45,754, and those with a graduate or professional degree increased by 52% to 45,754.

2. Vital Statistics

Improving Birth Outcomes

The nation’s vital statistics system keeps track of infant deaths and reportable diseases and is a rich source of comparative indicators. With a few surprises, Bucks County’s statistics reflect the better outcomes one would expect in a relatively affluent suburban county.

Birth statistics suggest that most Bucks County babies get off to a better start than in Pennsylvania as a whole. For the 1996-2000 period, Bucks County had substantially lower rates than the state for infant deaths per 1,000 births (5.2 v. 7.3), percent not receiving prenatal care in the first trimester (7.6% v. 14.7%), percent with low birth weight (6.8% v. 7.7%) and percent of births to mothers under the age of 18 (1.6% v. 3.8%). Only Bristol Township (4%), Bristol Borough (7.2%), Penndel Borough (4.1%) and Richlandtown Borough (5.3%) exceeded the state percent of births to women under the age of 18. Only Bristol Borough (19.9%) and Morrisville Borough (18.7%) had a higher percent of women not beginning to receive prenatal care in the first trimester. Both the crude birth rate (12.5 per 1000 population) and the fertility rate (58 births per 1000 women 15 to 44) are below that of the United States as a whole and below rates necessary to self sustain the county’s population.

Death Rates That Tell a More Complex Story

Age-adjusted death rates from all causes for the county are below the state average. Lower Bucks is slightly above the state average and Central Bucks has the lowest age-adjusted death rates. However, a more complex picture emerges when one breaks these deaths down by the three major causes of death: heart disease, cancer and stroke.

Central Bucks has death rates for heart disease higher than the state rate.
Lower Bucks has death rates from cancer higher than the state rate.
All three regions have age-adjusted death rates from stroke slightly higher than the state rate.

These facts call attention to the need for more efforts focused on screening and behavioral risk reduction.
Healthy People 2010 Indicators point out a few areas of concern.

More detailed indicators that focus on specific Healthy People 2010 objectives are summarized in Appendix I. While almost all Bucks County indicators indicate movement in the right direction and are well below the state averages, a few seem to call for further attention:

Colorectal cancer, prostate cancer and melanoma death rates, while generally declining, are above state rates.
Deaths from poisonings are increasing and are now above the state rate.
Death rates for those 20-24 years of age have increased and are now above the state rate.
The reported cases of Lyme disease are four times the state rate and reported cases of Salmonella and Campylobacter (bacteria which are common forms of food-borne illness) are higher than state rates.

3. Healthcare Resources Shape Patterns of Use

The workforce and facility supply help shape access and patterns of use of services of Bucks County residents within the larger Philadelphia metropolitan service area. The Pennsylvania Department of Health and professional associations maintain statistics on these useful indicators.

Physician Supply Grows and the Supply of Dentists Declines Slightly

The number of active physicians practicing in Bucks County grew from 879 (16 per 10,000 population) in 1990 to 1,273 (21 per 10,000 population in 1998), or by 31%. This is still slightly below the supply of active physicians in the United States as a whole in 1999 (22.1) and in Pennsylvania (25.3). It reflects the continuing reliance of Bucks County residents on the abundant physician specialty resources of the larger metropolitan medical service area. In contrast, the number of dentists practicing in Bucks County declined slightly from 425 (78 per 100,00) in 1990 to 411(72 per 100,000) in 1995, the most recent figures available; but this supply is still above the national figure of about 58 dentists per 100,000 population. Reflecting the more limited coverage of dentistry under insurance, dentists tend to be more concentrated in higher income areas and their practices tend to be more self-contained and less dependent on specialty referrals.

Nursing and Allied Health Face Looming Shortages

A 2002 report released by the Life Sciences Workforce Initiative of the Delaware Valley Healthcare Council of HAP projects a growing shortage in many allied health care occupations. There is currently an absolute shortage of registered nurses in the Philadelphia Metropolitan area that can’t be filled by local recruitment. Similar shortages are projected to grow for licensed practical nurses, medical assistants, and nursing aides and orderlies. The combined impact of an aging health care workforce and aging regional population, as the post World War II baby boom generation approaches retirement age in the next decade, is likely to greatly exacerbate these shortages.

Hospitals

Bucks County’s seven hospitals included a total of 991 beds in 1999 or a bed population ratio of about 1.65 beds per thousand population.

The 1.65 beds per thousand is well below the bed population ratios of 3.0 in the United States and 3.6 in Pennsylvania.
About 31% of hospital admissions to Bucks County residents were to out- of-county hospitals in 2000, down from 43% in 1998.
The average occupancy rate for Bucks County hospitals (FY 98-99) was 61.9%
The age-adjusted admission rate to hospitals for Bucks County residents was 127.4 per thousand in 2000, in contrast to a rate for the United States as a whole of 119.7 in 1999. The average length of stay was 4.3 days in contrast to 4.6 for the nation as a whole. Age-specific admission rates in Bucks County were higher than the national rates for the 75-plus population and the 45-54 year old population.

Nursing Homes

Bucks County had 36 licensed nursing homes with 3,865 beds in 1999. There are 5.1 nursing home beds for every hundred residents of Bucks County over the age of 65. In contrast, there were 1.9 nursing home beds per hundred population over the age of 65 in the nation as a whole. This may help account for some of the growth in the over-75 population in Bucks County and the relatively high hospital admission rates for this same age group.

4. Selected Social Distress Indicators

Crime

12,185 serious crimes (Part 1 criminal offenses including criminal homicide, manslaughter, rape, robbery, assault, burglary, larceny, motor vehicle theft and arson) were reported in Bucks County in 1999. The rate per thousand population in Bucks County was below the state average in all three geographic areas of the county, but highest in Lower Bucks. 21,424 less serious crimes (Part 2 offenses including minor assaults, forgery, fraud, embezzlement, vandalism, weapons offenses, prostitution, drug abuse, gambling, offenses against family and children, driving under the influence, liquor law violations, drunkenness, disorderly conduct, vagrancy and curfew and loitering violations) were reported in 1999. Rates per thousand population for the three regions in Bucks were well below the state rate but were slightly higher for Central Bucks. The number of serious crimes (Part I offenses) in Bucks County has declined in the last five years while the number of less serious Part II offenses has remained constant. Both those who compile the uniform crime statistics at the state level and some of our key informants suggested caution interpreting these figures, since some crimes are only reported at the county level and could not be assigned to one of the three regions and since reporting is not mandatory. The rates probably understate the crime rate in the county and its three geographic regions.

Incarceration Rates

Bucks County has the second lowest prison incarceration rate of Pennsylvania’s sixty-seven counties. The prison incarceration rate for Bucks County in 2000 was 81.5 per 100,000 population. Incarceration rates for Chester County and Montgomery Counties are two times higher, for Delaware County 2.7 times higher, for Philadelphia 11.7 times higher and for Pennsylvania as a whole 3.6 times higher than for Bucks County.

School Dropouts

School dropouts declined from 561 in the county in the 1998-99 school year to 531 in the 1999-2000 school year out of a total enrollment of 42,768. This translates into a rate of 1.3 per 100 enrolled students, in comparison to a rate of 2.6 for the Commonwealth as a whole.

Homeless Children and Youth

934 Bucks County children in 1999 were living in shelters, including 317 under the age of four. This is a rate of 5.0 per 1,000 children, in contrast to an overall state rate of 6.5.

Child Abuse

During 1999 there were 623 reported cases of child abuse; 82 or 13% of the cases were substantiated. The rate of substantiated cases per thousand was .5, in contrast to an overall state rate of 1.5. Reported rates of abuse in Bucks County are 3.8 per thousand in contrast to 7.0 for the state as a whole, suggesting a greater willingness in Bucks County to report case of suspected abuse.

Risk Behaviors in the School Aged Population

According to 12^th graders completing the 2000 Pennsylvania Youth Survey, 48.4% drank alcohol, 28.2% binge drank, 34.4% smoked cigarettes, 25.7% smoked marijuana, 5.5% used club drugs, and 2.5% used cocaine in the last month. Of all Bucks County youth participating in the survey, 12.1 % had attacked someone with the intent to harm, 5.5% sold drugs and 5.3% had been arrested in the last twelve months. These figures are somewhat lower than national estimates. The results of the 2000 Pennsylvania Youth Survey suggest that youth in Bucks have stronger protective social attachments to their families, communities and schools and are at lower risk than youth in the nation as a whole. However, Bucks County youth scored slightly higher on risks resulting from community disorganization, transition and mobility, poor family supervision, academic failure, and a tendency toward impulsiveness and sensation seeking.

5. Total Expenditures for Health, Education and Social Services

The overall costs are substantial and, as a consequence, the opportunities for both savings and quality improvement are large. In caring for Bucks County residents in the last year, more than $3.3 billion was spent on healthcare, $675 million for public education, $408 million for county government services, $24 million for incarceration in the county and state prisons, and $17 million on food stamps and cash assistance programs for the needy. While it would be difficult to get a full and accurate accounting or even agreement about what costs should be included, the total costs for the entire system of services provided to Bucks County residents that is described in this report is probably more than $5 billion or more than $8,000 per resident.

6. Bucks County Household Survey

There are many questions that can’t be answered by existing routine data collection efforts. Without asking individuals, there is no way to know the health risks individuals expose themselves to, the problems they have in accessing services, the individual health problems they have, or their sense of the strengths of their communities and their priorities in addressing its problems. We designed a survey to collect this information from a random sample of 1000 Bucks County adult residents. The methodology of the survey and the questionnaire, which collected 177 different pieces of information on each respondent, is described in detail in Appendix II. The survey was designed to over-sample the Upper Bucks area and lower income areas countywide, in order to assure a sufficient number of interviews to enable reliable comparisons. We used questions developed by the CDC for their State Behavioral Risk Survey and questions asked by the survey subcontractor PRC on national surveys, in order to have bases for comparing our results. The survey itself provides a rich resource for Bucks County’s health and social service agencies. Access to information will be provided in several forms, including computer disks, CD ROMs, and web sites. We will present here a few tables that summarize some of the key findings.

Comparing Bucks Health Risks, Access and Status

How do the behavioral health risks, access to care, and health status of residents compare between the three different regions of Bucks County and with the United States as a whole?

Figure 5 compares residents in different sections of the county in terms of behavioral risks, ability to access services, use of recommended preventive care and overall health. In the table, the indicators which are not better than those obtained from a comparable survey of households in the United States as a whole, are highlighted in bold.

Bucks County residents continue to expose themselves to many preventable risks of disease and premature death.

Almost 30% of women of childbearing age in the county currently smoke, exposing themselves and potentially their children to unnecessary health risks.
The rate of chronic drinking (more than 60 alcoholic drinks in the last month) and binge drinking (more than five drinks on one occasion) is higher in Bucks County than the national rate. Binge drinking is highest in Central Bucks and chronic drinking is highest in Lower Bucks).
35% of Bucks County adults are overweight and the percentage rises to more than 41% in the upper end of the county. Overweight exposes individuals to higher risks of diabetes, stroke, heart disease, and other chronic conditions.
Less than a third of the adult population engages in regular vigorous physical activity.
93% of Bucks County’s adult residents have one or more cardiovascular risk (overweight, lack of exercise, smoking, high blood pressure, high cholesterol).

Bucks country residents generally have good access to health services.

More than 91% report a regular source of care and 94.5% reported having at least some form of health insurance in the last year.
Prescription costs were a larger deterrent to receiving needed care than were office visit costs.
Office hours of physicians represented the largest barrier to receiving care that residents felt was needed, and more than one out of every five adults in Bucks County visited an emergency room in the last year to receive care. Upper and Lower Bucks reported somewhat greater access problems than those reported by residents of Central Bucks.

In spite of outreach efforts, gaps persist in the use of recommended screenings in Bucks County.

Only 54% of adults over 65 reported receiving a flu vaccine in the last year, lower than the national rate.
Only 53% of males over the age of 50 reported having a digital rectal exam in the last two years.
Screening rates were generally lower in Upper and in Lower than in Central Bucks.
Only 67% of Upper Bucks women over 50 reported having a mammogram in the past two years, in contrast to 93% for Middle and 79.2% for Lower Bucks.

Even without correcting for the relatively older age of Bucks County adult residents compared to those in the United States as a whole, Bucks County residents are healthier.

In comparison to U.S. residents as a whole, more Bucks County residents rate their health as excellent, and more were not limited in any way by illness or chronic conditions in doing all of their usual activities in the last month.
Rates of chronic conditions tend to be slightly higher in Bucks County residents than in the United States, reflecting a somewhat older population.
Central Bucks residents reported generally better health and fewer chronic conditions than Lower and Upper Bucks residents.

The Effect of Income

How do income differences affect risk, access and health outcomes?

One of the two goals of Healthy People 2010 is to eliminate health disparities among different segments of the population. Large disparities persist even when all income groups have similar comprehensive health insurance that should assure relatively equal access to care.

Figure 6 shows the risk behaviors, access and health status of those in Bucks County and in the United States as a whole and makes a comparison between those with family incomes below 200% of the poverty level and those with family incomes above 200% of the poverty level.

Bucks County adult residents in families living below 200% of the poverty level report fewer behavioral risks than low-income persons in the United States as a whole. Low income residents of Bucks are less likely to abuse alcohol but tend to have higher smoking rates and are more likely to be overweight than those residents with family incomes above 200% of the poverty level.

Low-income adult residents in Bucks are more likely to report difficulty accessing a physician. They were also less likely to use a dentist, and more likely to report not being able to purchase a prescription because of the cost. They were also more likely to report using an emergency room in the last year.

In spite of the problems reported in terms of access, there are fewer income disparities in use of preventive services in Bucks County than in the nation as a whole. Low income adults in Bucks County are actually more likely to report seeing a physician for a routine checkup in the last year, having a flu shot if over 65, a blood stool test in the last two years or a blood cholesterol test in the last year than individuals with household family incomes above 200% of the poverty level. The only disparities that are greater than the national ones were for male digital rectal exams and for sigmoidscopy or colonoscopic exams for individuals over 50 years of age.

Bucks County has less income-related health disparity than in the nation as a whole. Low-income adults have rates of health and rates for most chronic conditions closer to higher income adults in Bucks County than in the United States as a whole. The only exceptions are for high blood pressure, high cholesterol and blindness or trouble seeing with glasses.

Skin cancer was the only condition with higher reported rates in the upper income populations of Bucks County and the United States.

Changes in Risks, Access and Health

How have health risks, access, and health status in Bucks County changed since the last assessment?

Figure 7 summarizes what has changed in the ten years since the survey and the vital statistics data reported in the original baseline assessment.

The percent of adults without health insurance (5.5%) and the percent that have been uninsured at some point in the last year (4.6%) have remained unchanged.
More adults report not getting prescriptions that they need because of the cost, and fewer report not seeking care they need from a physician because of the cost. This shift perhaps reflects the expansion of managed care, which generally covers outpatient costs, and the rising costs of prescription medications which often are either uncovered or have limited coverage under health insurance plans.
Modest improvements took place in preventive care and screening in the county.
Reported health status has remained unchanged, but the percent of adults reporting specific health problems increased. (This would seem to in part reflect the aging of the Bucks County population.)
Age-adjusted death rates for cardiovascular disease, lung cancer, breast cancer, motor vehicle accidents, suicide and homicide declined. Age-adjusted death rates for all causes also declined.
Infant death rates declined and fewer mothers failed to receive prenatal care in the first trimester of pregnancy.
The percent of low birth weight infants, however, increased.
Fewer adults smoke and more exercise.

Rating the Quality of Life in Bucks County

How do residents assess the quality of life today in Bucks County?

Health and the relative absence of chronic conditions are not the only factors shaping the quality of life of residents. At least as important is how they feel about the communities in which they live, the adequacy of services they are able to obtain, the day-to-day headaches of living, and degree of concern that they have about their own safety and that of their family.

Figure 8 summarizes these assessments.

Residents are generally satisfied with the Bucks County communities in which they live.

95% see their neighborhood as a good to excellent place to live and more than 70% describe it as a very good place to raise a family, a higher assessment than United States residents as a whole give their neighborhoods. Peace and quiet and friendly neighbors were mentioned most frequently as things that they liked about their community. The community problem most frequently mentioned was over-development, overcrowding and traffic problems.
Most are satisfied with the array of services available to them and their families. More than 80% rated the social services, child care, adult daycare and the safety of the environment offered their children at school as good, very good or excellent. The problem most frequently mentioned as the number one problem facing their families had to do with either finances or just having time together.
About 57% volunteer time to charitable causes and 89% report that they have someone that they can turn to for help most or all of the time.

The day-to-day experiences of Bucks County residents make them aware of many of the same problems that concerned the key informants we talked to.

The inadequacy of public transportation and the congestion on the roads were reported as major concerns and were far greater concerns of Bucks County residents than of United States residents as a whole.
The lack of affordable housing and availability of shelters for the homeless, next to issues related to transportation, got the highest poor ratings from Bucks County residents.
In contrast, very few residents expressed concerns about the lack of adequate crime control or the safety of their neighborhoods and homes. Few, relative to the nation as a whole, have been victims of crimes in the last five years (1.7% v. 4%).

Not surprisingly, on the average, lower income residents are somewhat less satisfied with the quality of life in Bucks County and were somewhat more likely to identify community issues as major problems.

Rating Social Service Priorities

How do residents and social service agency leaders assess the list of problems identified by the United Way of Bucks County?

Figure 9 presents the results of a series of questions about the priority areas identified by the United Way. The same questions were asked of leaders and board members of United Way agencies in Bucks County and of Bucks County residents in the household telephone survey. They are ranked in to reflect the proportion of adult residents of Bucks County who consider the issue a major problem for the county. Those who felt that these issues were a problem were asked whether the resources now allocated to the problem were insufficient. Multiplying the proportion who thought a particular issue was a major problem times the proportion who felt insufficient resources were currently being allocated to that problem provided the rough summary measure presented in the bottom section of the table.

Affordable housing and public transportation were ranked by Bucks County residents and by United Way leaders among the top three major problems facing Bucks County that require more attention and resources.
Mental illness was identified as the third most important major problem by United Way leaders but received a low priority ranking by Bucks County residents.
Teen pregnancy and teen drug and alcohol abuse were ranked among the top four major problems as perceived by Bucks County residents, but received a relatively low priority among United Way leaders.
As did the United Way agency leaders, the low-income residents of Bucks County placed higher importance on the need for more resources for child care, mental health and adult drug abuse services than did those with higher incomes.

In short, what you see depends on where you sit. Who is right? How do you go about forging an effective collaborative strategy based on all of this information? We will address these questions in the final section of the report.

Figure 5. Health Risks, Access and Status of Adult Residents of Bucks County and the United States
	Upper	Central	Lower	Total	U.S.2000
Behavioral Risks
Ever smoked?	51.0%	51.3%	50.2%	50.7%	47.5%
Regular smoker now?	19.3%	18.3%	18.7%	18.7%	22.8%
Women age 18-44 who smoke	23.8%	27.5%	32.3%	29.7%	25.5%
Ever tried chewing tobacco or snuff?	13.0%	6.6%	10.8%	9.7%	NA
Alcohol in the last month?	62.2%	73.0%	60.0%	68.4%	56.4%
Chronic drinker (60 or more drinks last month)	4.6%	4.2%	8.7%	6.7%	5.0%
Binge drinker (5 or more drinks on one occasion)	14.8%	20.0%	19.1%	18.8%	16.4%
Overweight, sex specific	41.4%	32.1%	35.6%	35.3%	33.9%
Vigorous activity (20 minutes +) 3+ times a week	29.1%	33.6%	31.8%	31.8%	NA
One or more cardiovascular risk factor	93.8%	92.3%	93.2%	93.0%	84.7%

Access
Difficulty getting to see a doctor in last year	8.6%	6.3%	16.8%	12.2%	13.3%
Needed to see a doctor but could not because of cost	5.2%	1.5%	5.5%	4.1%	10.4%
Needed to purchase medication but could not because of cost	11.3%	5.4%	7.7%	7.5%	9.5%
Needed to see a doctor but could not because of transportation	1.9%	1.0%	4.0%	2.7%	5.2%
Needed to see a doctor but could not because of office hours	14.7%	13.7%	21.8%	18.1%	12.7%
Regular source of care?	92.0%	92.2%	90.2%	91.1%	85.0%
Gone to the emergency room about your health in last year?	24.8%	16.8%	24.1%	21.7%	20.1%
Visited a dentist in the last year?	72.5%	82.0%	72.3%	75.5%	68.9%
Any insurance coverage for dental care?	63.4%	73.0%	74.6%	72.5%	NA
Any kind of health insurance coverage?	93.6%	97.2%	93.0%	94.5%	NA
Any time during the last year when you had no coverage?	4.4%	3.3%	5.6%	4.6%	NA

Preventive Care and Health Screening
Routine checkup in last year?	61.9%	65.0%	65.6%	64.9%	64.0%
Females over 40 who had a mammogram in the past two years	67.9%	93.1%	79.2%	82.4%	NA
Females over 50 who had a mammogram in the past two years	61.0%	88.0%	79.4%	79.7%	76.9%
Male over 40 who had a digital rectal exam in the last two years	57.1%	63.5%	67.4%	64.6%	69.9%
Male over 50 who had a digital rectal exam in the last two years	56.1%	60.7%	47.1%	52.8%	57.1%
Adults over 50 who had a sigmoidscopy/colonoscopic exam	56.3%	60.7%	49.4%	54.0%	48.7%
Adults over 50 who have had a blood stool test within the last two years	45.9%	36.4%	31.3%	34.9%	47.1%
Adults over 65 who have had a flu shot in the past year	55.0%	56.7%	52.9%	54.4%	65.7%
Adults over 65 who have had a Pneumonia vaccine	61.0%	61.7%	67.6%	64.7%	NA
Teeth cleaned by dental hygienist within the last year?	71.9%	81.5%	71.1%	74.7%	NA
Blood pressure taken by health professional with last six months?	75.5%	80.0%	80.7%	79.8%	NA
Blood cholesterol checked within last year?	56.9%	58.7%	60.0%	59.6%	NA

Health Status
Health status excellent	23.4%	30.0%	29.4%	28.7%	26.3%
Able to do all usual activities in last 30 days	76.8%	81.5%	78.6%	79.3%	65.6%
Health status poor	2.9%	1.3%	3.7%	2.8%	3.6%
Ever told have high blood pressure?	28.3%	24.0%	30.8%	28.2%	23.4%

Ever told had high cholesterol?	28.1%	27.5%	31.8%	29.9%	21.4%
Diabetes?	8.5%	3.9%	7.8%	6.6%	5.4%
Chronic lung disease?	10.8%	8.3%	10.6%	9.9%	6.4%
Blindness or trouble seeing with glasses?	7.1%	6.6%	8.8%	7.9%	9.2%
Deafness or trouble hearing?	8.5%	8.1%	9.8%	9.1%	9.3%
Asthma?	9.6%	9.8%	10.6%	10.2%	9.9%
Arthritis or rheumatism?	19.3%	17.0%	25.6%	21.9%	20.3%
Sciatica or chronic back pain?	21.5%	16.3%	21.8%	19.9%	20.0%
Chronic heart disease?	8.5%	4.3%	4.5%	5.0%	5.7%
Skin cancer?	7.7%	7.1%	7.2%	7.2%	4.9%
Mental condition such as depression?	16.7%	10.6%	14.7%	13.6%	NA
Allergies?	31.4%	35.3%	33.1%	33.6%	NA

Weighted sample size (n)	139	333	529	1,001	1,000
Total Adult Population (N)	62,691	147,598	233,059	443,348

Figure 6. Health Risks, Access and Status Disparities in Bucks County and U.S. Residents
	Bucks			U.S.2000			Relative
Behavioral Risks	Below200%	Above 200%	Pov. Disp.*	Below 2000%	Above200%	Pov. Disp*	Disparity**
Ever smoked?	56.1%	49.3%	1.14	47.1%	46.7%	1.01	12.8%
Regular smoker now	24.3%	17.5%	1.39	25.8%	21.6%	1.19	16.3%
Ever tried chewing tobacco or snuff?	6.6%	10.0%	0.66	5.3%	3.5%	1.51	-56.4%
Alcohol in the last month?	49.7%	73.2%	0.68	47.4%	62.2%	0.76	-10.9%
Binge drinker (5 or more drinks on one occasion)	12.5%	20.3%	0.62	38.7%	27.7%	1.40	-55.9%
Overweight, sex specific	42.4%	33.7%	1.26	36.4%	32.6%	1.12	12.7%
Vigorous activity (20 minutes +) 3+ times a week	13.2%	35.7%	0.37	14.0%	18.6%	0.75	-50.9%

Access
Difficulty getting to see a doctor in last year	16.2%	10.4%	1.56	14.3%	13.3%	1.08	44.9%
Needed to see a doctor but could not because of cost	11.8%	2.6%	4.54	23.0%	5.9%	3.90	16.4%
Needed to purchase medication but could not because of cost	21.0%	4.5%	4.67	18.1%	6.0%	3.02	54.7%
Needed to see a doctor but could not because of transportation	6.8%	1.7%	4.00	16.1%	1.4%	11.50	-65.2%
Needed to see a doctor but could not because of office hours	14.8%	17.7%	0.84	18.0%	11.8%	1.53	-45.2%
Regular source of care?	89.4%	91.8%	0.97	81.8%	84.3%	0.97	0.4%
Gone to the emergency room about your health in last year?	35.3%	20.6%	1.71	24.6%	20.1%	1.22	40.0%
Visited a dentist in the last year?	53.4%	78.0%	0.68	51.1%	60.5%	0.84	-18.9%


	Below200%	Above 200%	Pov. Disp.*	Below 200%	Above200%	Pov. Disp*	Disparity**
Preventive Care and Health Screening
Routine checkup in last year?	70.2%	63.8%	1.10	59.4%	62.6%	0.95	16.0%
Pap Smear in the last year?	63.3%	70.6%	0.90	45.9%	76.0%	0.60	48.5%
Females over 50 who had a mammogram in the past two years	77.9%	76.4%	1.02	64.1%	85.4%	0.75	35.8%
Male over 40 who had a digital rectal exam in the last two years	57.4%	66.6%	0.86	68.9%	66.4%	1.04	-16.9%
Adults over 50 who had a sigmoidscopy/colonoscopic exam	48.1%	54.2%	0.89	44.3%	45.8%	0.97	-8.2%
Adults over 50 who have had a blood stool test within the last two years	39.7%	32.9%	1.21	39.5%	49.8%	0.79	52.1%
Adults over 65 who have had a flu shot in the past year	77.2%	48.3%	1.60	70.5%	66.7%	1.06	51.2%
Blood pressure taken by health professional with last six months?	83.9%	79.2%	1.06	71.2%	76.2%	0.93	13.4%
Blood cholesterol checked with in last year?	66.2%	58.0%	1.14	53.1%	59.9%	0.89	28.8%

Health Status
Health status excellent	11.5%	32.2%	0.36	14.7%	33.1%	0.44	-19.6%
Not able to do all usual activities in last 30 days	29.7%	19.0%	1.56	13.6%	5.7%	2.39	-34.5%
Health status poor	7.5%	1.6%	4.69	8.1%	1.4%	5.79	-19.0%
Ever told have high blood pressure?	38.4%	26.1%	1.47	25.4%	21.4%	1.19	24.0%
Ever told had high cholesterol?	34.5%	29.4%	1.17	17.3%	22.3%	0.78	51.3%
Diabetes?	12.9%	5.5%	2.35	8.4%	3.4%	2.47	-5.1%
Chronic lung disease?	17.5%	8.6%	2.03	5.3%	5.4%	0.98	107.3%
Blindness or trouble seeing with glasses?	12.7%	6.7%	1.90	13.2%	7.0%	1.89	0.5%
Deafness or trouble hearing?	9.2%	8.2%	1.12	11.9%	7.1%	1.68	-33.1%
Asthma?	14.9%	10.7%	1.39	13.5%	7.5%	1.80	-22.6%
Arthritis or Rheumatism?	33.5%	22.0%	1.52	27.7%	15.3%	1.81	-15.9%
Sciatica or chronic back pain?	21.7%	19.5%	1.11	23.2%	18.3%	1.27	-12.2%
Chronic heart disease?	8.3%	4.6%	1.80	7.5%	3.9%	1.92	-6.2%
Skin cancer?	5.4%	7.1%	0.76	3.5%	4.8%	0.73	4.3%

Sample size (n)	142	665		226	638
Total Adult Population (N)

* Poverty Disparity = <200% of Poverty/>200% of Poverty
** Relative disparity = Bucks Poverty Disparity/U.S. Poverty Disparity

Figure 7. Change in Health Risk, Access and Health Status in Bucks County 1991-2001

	1991	2001
Behavioral Risks
Adults who smoke cigarettes	23.4%	18.7%
Adults who exercise	68.3%	78.4%
Access
Adults without insurance	5.3%	5.5%
Uninsured in past year	4.6%	4.6%
Went without health care because of cost	12.0%	4.1%
Went without prescription because of cost	6.8%	7.5%
Visited dentist in past year	71.6%	75.5%
Preventive Care and Screening
Cholesterol checked in last year	53.1%	59.6%
Blood pressure checked in last year	83.7%	89.5%
Women with clinical breast exam in last year	74.8%	75.5%
Women with pap test in last year	69.0%	69.8%
Adults over 50 who had a digital rectal exam in last year	40.0%	52.8%
Health Status
Report health as fair or poor	10.5%	10.9%
Report specific health problem:
Mental condition	1.2%	13.6%
Diabetes	3.2%	6.6%
Heart disease	6.2%	5.0%
Arthritis	12.2%	19.9%
High blood pressure	13.8%	28.2%
Allergies	26.9%	33.6%
Mortality Rates*
All causes	478.0	432.1
Cardiovascular	170.6	142.4
Lung cancer	36.7	34.4
Breast cancer	25.2	17.6
Motor vehicle	13.9	11.7
Suicide	10.5	9.1
Homicide	2.7	2.0
Birth Outcomes*
Infant deaths per 1,000 births	7.10	5.8
Percent no prenatal care in 1st trimester	13.4%	8.2%
Percent low birth weight	5.4%	7.3%
Source: 1991 PHMC Household Survey and the 2001 PRC Bucks County Survey
Bucks County Community Summary Report 1984 and Pennsylvania State
Health Department Health Status Indicators for Bucks County Residents.
*The "2001 Mortality statistics" are derived from deaths reported between 1996 and 1998 and
the birth statistics are based on births in 1998. The "1991" death statistics are based on deaths
reported between 1987 and 1991. The 1991 births are based on births reported between
1986 and 1990. Death rates were age adjusted standardized to the 1940 U.S. population.

Figure 8. Quality of Life and Community Problems in Bucks County
		Bucks County
				Poverty
Quality of Life	Upper	Central	Lower	<200%	>200%	Total	U.S. 2000
Neighborhood as a place to live is good or better	94.0%	98.3%	92.3%	88.2%	95.6%	94.5%	87.4%
During time lived in neighborhood quality of life has improved	17.4%	18.0%	20.8%	25.3%	19.4%	19.4%	41.1%
Compared to nation as a whole quality of life is better	59.1%	75.2%	51.7%	46.4%	60.4%	60.5%	63.1%
Can affect the quality of life in your community	74.5%	75.5%	69.3%	59.5%	75.3%	72.0%	72.0%
An excellent or very good place to raise a family	66.9%	82.8%	63.9%	56.0%	73.1%	70.6%	58.2%
Ease of obtaining social services is good or better	82.9%	84.8%	81.5%	73.8%	86.8%	82.8%	74.3%
Ease of obtaining information about health and other services is good or better	92.4%	93.6%	83.2%	73.6%	90.7%	86.8%	NA
Child daycare services are good or better	70.8%	80.1%	84.2%	73.5%	86.0%	83.1%	72.2%
Adult daycare services are good or better	83.1%	87.3%	84.8%	78.3%	88.1%	85.3%	71.1%
Schools as safe environment for children good or better	88.5%	91.3%	83.6%	81.9%	85.5%	84.8%	NA
Internet access for personal use	67.2%	81.6%	76.2%	51.7%	82.3%	76.7%	NA
Someone you could turn to for help all or most of the time	89.7%	90.5%	88.6%	89.3%	89.3%	89.4%	76.2%
Volunteer time to charitable causes	49.8%	59.7%	56.6%	46.1%	59.1%	56.7%	61.6%
Average quality of life rating	72.0%	78.4%	72.1%	64.9%	76.3%	74.0%	NA

Inventory of Community Problems Experienced
Tolerance of community for people of different races is poor	3.1%	0.6%	3.0%	3.8%	2.1%	2.2%	8.7%
Tolerance of community for people of different life styles is poor	3.9%	2.0%	1.9%	2.5%	2.1%	2.2%	8.5%
Public transportation in community is poor	61.2%	39.2%	25.1%	28.0%	33.6%	34.4%	26.5%
Could not you rely if needed on public transportation?	79.6%	78.7%	60.0%	46.2%	29.2%	69.1%	58.5%
Traffic congestion is poor	20.8%	35.6%	31.9%	26.3%	33.0%	31.6%	16.9%
Availability of affordable housing is poor	15.2%	25.1%	17.0%	16.6%	19.0%	19.5%	16.9%
Availability of shelters for homeless in community is poor	27.9%	25.9%	18.5%	24.8%	20.2%	21.8%	35.3%

Figure 8 (con.)		Bucks County
				Poverty
	Upper	Central	Lower	<200%	>200%	Total	U.S. 2000
Condition of the homes in your neighborhood is poor	0.1%	0.2%	0.9%	0.1%	0.8%	0.6%	2.6%
Safety and crime control in your neighborhood is poor	0.6%	0.5%	1.5%	1.6%	1.1%	1.0%	6.3%
Safety you feel in your home at night is poor	0.1%	0.0%	0.8%	0.0%	0.7%	0.4%	1.2%
Within your neighborhood the crime problem has gotten worse	11.5%	12.4%	9.8%	8.9%	10.0%	10.9%	13.8%
In the past five years I have been a victim of a crime	1.6%	1.6%	1.8%	2.1%	1.7%	1.7%	4.0%
In the past five years I have been a victim of a domestic violence	1.1%	3.1%	1.4%	2.4%	2.3%	1.9%	2.7%
Average level of problems experienced	17.4%	17.3%	13.4%	12.6%	12.0%	15.2%	15.5%

Weighted Sample Size (n)	139	333	529	142	664	1,001	1,000
Total Population (N)	62,691	147,598	233,059			443,348

Figure 9. Ranking Community Problems in Bucks County
				Poverty				UW
	Upper	Central	Lower	<200%	>200%	Total	US 2000	Leadership
Seen as "major community problem"
Racial tension	1.3%	4.1%	3.8%	1.1%	3.8%	3.6%	8.4%	3.8%
Crime or violence	4.1%	5.7%	3.5%	5.2%	3.9%	4.3%	12.0%	6.3%
Poverty	5.0%	4.7%	4.2%	8.3%	3.9%	4.5%	13.4%	27.5%
Illiteracy	3.5%	4.4%	5.0%	6.8%	4.1%	4.6%	10.0%	6.3%
Mental illness or emotional problems	10.4%	4.7%	9.2%	15.8%	5.8%	7.9%	NA	32.5%
Job training	8.8%	9.3%	8.2%	11.1%	7.2%	8.6%	NA	17.5%
Services for people with physical or mental disabilities	11.8%	7.6%	8.4%	6.8%	8.7%	8.7%	NA	32.5%
Services for youth including mentoring	8.5%	9.1%	8.8%	6.2%	9.4%	8.9%	NA	25.0%
Child daycare	5.5%	6.6%	11.7%	19.9%	7.3%	9.1%	NA	33.8%
Domestic violence and child abuse	12.6%	7.9%	12.2%	16.1%	9.5%	10.8%	14.6%	16.3%
Unemployment	12.0%	7.3%	15.1%	19.1%	10.4%	12.1%	NA	20.0%
Adult alcohol abuse	18.9%	9.5%	13.0%	17.6%	12.0%	12.7%	22.1%	18.8%
Care of older adults	12.7%	13.8%	12.2%	16.2%	11.2%	12.8%	NA	20.0%
Adult drug abuse	12.0%	11.0%	14.9%	19.0%	11.7%	13.2%	NA	18.8%
Teenage pregnancy	12.2%	11.1%	16.5%	11.9%	14.7%	14.2%	22.9%	13.8%
Affordable housing	17.7%	21.5%	14.0%	20.1%	17.3%	17.0%	NA	51.3%
Transportation	29.1%	27.7%	15.2%	18.8%	20.3%	21.1%	NA	51.3%
Teen alcohol and drug abuse	33.3%	27.5%	32.3%	30.6%	29.7%	30.8%	32.8%	20.0%

Resources judged insufficient by those identifying it as a problem
Racial tension	46.7%	55.8%	3.4%	21.2%	60.9%	41.4%		25.0%
Crime or violence	28.8%	28.0%	34.6%	40.8%	37.9%	31.9%		25.0%
Poverty	47.6%	53.0%	68.5%	86.7%	63.5%	61.6%		26.3%
Illiteracy	22.2%	49.5%	36.3%	20.5%	51.5%	38.6%		26.3%
Mental illness or emotional problems	36.7%	44.3%	60.3%	72.0%	51.0%	52.0%		51.3%
Job Training	53.9%	41.1%	48.1%	66.8%	54.0%	46.9%		38.8%
Services for people with physical or mental disabilities	37.2%	45.5%	47.3%	55.5%	51.7%	45.2%		42.5%
Services for youth including mentoring	43.5%	54.8%	41.3%	59.1%	57.7%	46.5%		40.0%
Child daycare	41.3%	42.8%	64.0%	76.9%	49.7%	54.4%		40.0%
Domestic violence and child abuse	39.1%	38.6%	54.9%	58.7%	49.0%	47.7%		36.3%
Unemployment	35.9%	38.8%	41.6%	52.0%	52.0%	40.3%		37.5%
Adult alcohol abuse	27.2%	21.3%	27.8%	27.1%	31.7%	25.9%		31.3%
Care of older adults	52.5%	49.4%	56.2%	61.1%	52.6%	53.5%		40.0%
Adult drug abuse	39.4%	38.0%	46.0%	54.0%	46.2%	42.9%		35.0%

	Upper	Central	Lower	<200%	>200%	Total	US 2000	Leadership
Teenage pregnancy	35.4%	36.3%	45.6%	47.4%	48.1%	41.6%		36.3%
Affordable housing	53.2%	43.6%	45.6%	67.5%	66.1%	45.8%		72.5%
Transportation	41.0%	54.4%	59.9%	73.1%	75.6%	55.3%		73.8%
Teen alcohol and drug abuse	51.0%	49.2%	50.7%	60.1%	49.7%	50.2%		45.0%

Resource Allocation Needs*
Racial tension	0.61%	2.29%	0.13%	0.2%	2.3%	1.49%		0.94%
Crime or violence	1.2%	1.6%	1.2%	2.1%	1.5%	1.4%		1.6%
Poverty	2.4%	2.5%	2.9%	7.2%	2.5%	2.8%		7.2%
Illiteracy	0.8%	2.2%	1.8%	1.4%	2.1%	1.8%		1.6%
Mental illness or emotional problems	3.8%	2.1%	5.5%	11.4%	3.0%	4.1%		16.7%
Job training	4.7%	3.8%	3.9%	7.4%	3.9%	4.0%		6.8%
Services for people with physical or mental disabilities	4.4%	3.5%	4.0%	3.8%	4.5%	3.9%		13.8%
Services for youth including mentoring	3.7%	5.0%	3.6%	3.7%	5.4%	4.1%		10.0%
Child daycare	2.3%	2.8%	7.5%	15.3%	3.6%	5.0%		13.5%
Domestic violence and child abuse	4.9%	3.0%	6.7%	9.5%	4.7%	5.2%		5.9%
Unemployment	4.3%	2.8%	6.3%	9.9%	5.4%	4.9%		7.5%
Adult alcohol abuse	5.1%	2.0%	3.6%	4.8%	3.8%	3.3%		5.9%
Care of older adults	6.7%	6.8%	6.9%	9.9%	5.9%	6.8%		8.0%
Adult drug abuse	4.7%	4.2%	6.9%	10.3%	5.4%	5.7%		6.6%
Teenage pregnancy	4.3%	4.0%	7.5%	5.6%	7.1%	5.9%		5.0%
Affordable housing	9.4%	9.4%	6.4%	13.6%	11.4%	7.8%		37.2%
Transportation	11.9%	15.1%	9.1%	13.7%	15.3%	11.7%		37.9%
Teen alcohol and drug abuse	17.0%	13.5%	16.4%	18.4%	14.8%	15.5%		9.0%

Weighted Sample Size (n)	139	333	529	142	665	1,001	1,000
Total Population (N)	62,691	147,598	233,059			443,348		80
* Resource allocation needs = % Seen as major problem times % resources identified as insufficient.

Back to the Table of Contents
Continue to Part 3