Released June 2023

A Special Thank You To

The Merced County Department of Public Health would like to acknowledge the following individuals whose efforts and contributions made the completion of this assessment possible. Countless months went into the collection, analysis, evaluation, and interpretation of data to make this document relatable and understandable for the intended audience - YOU.

Thank you to the following: Ravi Singh, Megan Black, Kristynn Sullivan, Cecilia Ramos, Joshua Sanders, Alejandro Villegas, Gloria Chavez, Melynna Chavez, Joselyn Ascencio, Francisco Higareda, Rafael Ornelas, Jason Young, Ivan Eser, and Alvin Collier.

Merced County Department of Public Health

Executive Leadership Team

Salvador Sandoval, MD, MPH, County Public Health Officer

Jessica Montoya-Juarez, MS, Assistant Public Health Director

Yadira Vazquez, MBA, Assistant Public Health Director

Vision:

A healthy place for all.

Mission:

To promote, protect, and ​preserve healthy living and ​safe environments

Values:

Equity, Innovation, Integrity, ​Leadership, Quality, ​Responsiveness, Service, ​Stewardship

Public Health, according to the World Health Organization, is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or illness. Because of this, Public Health relies on multiple partners to achieve this outcome. The public health system is composed of public and private partners including hospitals, behavioral health, community services, private nonprofits, business, and many more. In short, public health is a shared responsibility.

One of the many responsibilities of Public Health includes collecting, analyzing and assessing multiple sources of data from federal, state and local agencies. The culmination of this exhaustive data review is the Community Health Assessment, a five-year report that provides detailed information on the status and well-being of the community in all aspects of health: access to care, chronic and communicable diseases, behavioral health, homelessness, public safety, child health, etc.

On behalf of the Merced County Department of Public Health, I am pleased to present the Merced County 2023 Community Health Assessment. It is my sincere hope that this report can be one of the many resources used by all to achieve a healthier and more equitable Merced County.

Rebecca Nanyonjo, DrPH

Director of Public Health

Acknowledgements

Merced County Board of Supervisors

County Executive Officer

Raul Lomeli Mendez

Merced County 2023 Community Health Assessment Partnerships

Special thanks to representatives of the following community organizations who ​provided valuable input toward the development of the Merced County 2023 ​Community Health Assessment as members of the All in For Health Equity Coalition ​and Health Leadership Council.

Alzheimer's Association

Association of Governments

Castle Family Health Centers

California Health Collaborative

Central California Alliance for Health

Central Valley Regional Center

City of Atwater

City of Dos Palos

City of Gustine

City of Livingston

City of Los Banos

City of Merced

Merced County and unincorporated areas

Community Initiatives for Collective Impact

Community Residents

Central Valley Opportunity Center

Cultiva La Salud

Dignity Health Mercy Medical Center, Merced

Emmanuel Hospital

Golden Valley Health Centers

Hispanic Chamber of Commerce

Hlub Hmong Center

Legacy Health Endowment

Livingston Community Health

Memorial Los Banos Hospital

Merced College

Merced County

Merced County Office of Education and County Superintendents

Merced Faculty Associates

Merced Lao Family Community Inc.

Merced-Mariposa Medical Society

National Association for the Advancement of Colored People

National Alliance on Mental Illness - Merced

North Valley Labor Federation

Parent Institute for Quality Education

University of California, Merced

United Way

Valley Children's Healthcare

Valley Onward

Youth Leadership Institute

Introduction

How data is used can be powerful. However, data alone, is limited and not helpful when it is not used to answer real life questions. This is what guides the work of the Merced County Department of Public Health’s (MCDPH) Epidemiology Division: transforming data into useful information for the community.

Epidemiology is the study and analysis of the distribution, patterns, and determinants of health and disease conditions in a set population. In other words, it is a method of using data to find the causes of disease and health outcomes in a community. Data can be gathered, used, and analyzed to create information. Information, when understood can lead to knowledge. Knowledge, especially knowledge held by groups can lead to transformational power. This transformational power over time can lead to community wisdom and generational transformation.

This Community Health Assessment (CHA) takes data and creates accessible information for the community. This document includes a variety of data sources and types. The CHA includes both quantitative data, which is data collected on a numerical scale such as surveys, percentages, or death rates. It also includes qualitative data which is descriptive data from interviews with residents and key stakeholders – people who either live or work in Merced County. Data and sources include primary data, or data that was collected by the MCDPH, and secondary data, or data collected by other sources. Secondary sources come from a variety of levels, such as national (Centers for Disease Control or Federal Bureau of Investigation), state (California Department of Public Health, California Health Interview Survey), and other local sources (local hospitals or schools).

All data assessments represent a point in time. The MCDPH Epidemiology Division is constantly growing and learning and welcomes the community’s feedback on this document. This includes any information residents would like to see included, and any suggestions to make our next CHA even better. If this document is used for any grants, presentations or other purposes, or if there is a portion you enjoyed, we would appreciate that feedback as well. Please submit any feedback to PublicHealthCommunications@countyofmerced.com

Methods of Data Collection

Population Characteristics

Methods of Data Collection

This section will describe the different sources and methods of data collection used for the Merced County Community Health Assessment. The type of data collected includes both quantitative and qualitative data, and sources include primary data from the Merced County Department of Public Health and secondary data from national, state, and other local sources. The data presented throughout this document aims to identify and provide a better understanding of our community’s current health status, needs, and issues.

Community Health Survey

The Merced County Department of Public Health used the online survey software SurveyMonkey as its primary source to collect data and information for this local health assessment. This was the best method of collection at the time the survey was disseminated, as the data was collected during the COVID-19 pandemic.

As part of this research, a total of 639 surveys were completed from December 2021 to April 2022 in English, Spanish, and Hmong. The community survey was completed by 49% females and 51% males. Although the survey was completed by community members from different races and ethnicities, the groups with most responses were White people (57%), followed by Black people (22%), then Asian people (10%), and Hispanic/Latino people (9%) meaning that Hispanic/Latino people were underrepresented in the results. 51% of community survey respondents reported completing their bachelor’s degree, followed by high school/GED graduates with a 14% participation rate. The majority of respondents were between 30-39 years old with a 60% participation rate, followed by 25-29-year-olds with a 21% participation rate.

This community health assessment is divided into sections including an in-depth analysis of the social determinants of health and the health of the community. Social determinants of health are an important part of our daily lives and through this assessment we identify and emphasize the significance they play in our quality of life. The health of our community section is divided into sub-sections including the leading causes of death and the most important health problems.

The topics for the sub-sections were selected based on data from the Merced County Department of Public Health 2021 Death Report and from the community survey responses. It is essential to highlight the leading causes of death in Merced County and provide an overview of the impact these have in our communities. Additionally, the most important health problems section topics were chosen based on the responses gathered from the community survey. This section provides deeper insight on what Merced County residents perceive to be the most important health problems in their communities.

Secondary Data Sources

The community health assessment also includes data obtained from national, state, and local surveys, reports, and fact sheets.

Key sources include:

California Department of Public Health

California Health Interview Survey, AskCHIS® (2017-2020)

California Healthy Places Index

California HIV/AIDS Policy Research Centers

Center for Disease Control and Prevention

Healthy People 2030

Local Merced County Department of Public Health Disease Surveillance Data

Merced College

Merced County Behavioral Health and Recovery Services

Merced County Department of Public Health Community Health Survey (2022)

University of California, Merced

U.S. Census Bureau

U.S. Department of Labor

Valley Children’s Healthcare

World Health Organization

Data Limitations and Information Gaps

Some indicators which required thorough investigation were not addressed due to the limitations of the data collected and gaps in information. Additionally, some sections of this assessment have more recent data while others have data from previous years due to the lack of availability. To the extent possible, data was collected to represent all of Merced County including its six incorporated cities and 11 unincorporated communities. Additional data was also sought to distinguish age groups, gender, and race or ethnicity in the county. In addition to demographic information, survey participants were also asked about their highest level of education. There was a large representation from participants with levels of education at the bachelor degree level which does not accurately capture or represent Merced County as a whole.

Population Characteristics

Known as the Gateway to Yosemite, Merced County is located in the heart of the San Joaquin Valley, which is one of the most productive agricultural areas in the world. The geographic area of Merced County is 1938 mi² (square miles), ranking it as the 25th largest county in California. There are six (6) incorporated cities and 18 unincorporated towns. The County seat is the City of Merced, which is also the largest city by population.

Population and People

Since 2010, the population of Merced County has steadily grown from 255,7931 residents to an estimated population of 286,4611 in 2021, representing a nearly 12% increase. People born outside of the United States (foreign-born residents) account for 26.5% of the County’s population, which is greater than the national average of 13.5%¹. In 2021, 4.5% of residents moved into Merced County from different areas, and roughly 0.7% of residents had relocated to Merced County from a different state or other country. ² Merced County has nearly equal makeup of males and females (50.5%, 49.5%). Approximately 4.7% of residents are veterans. ²

Families and Living Arrangements

The average household size is 3.4 persons, and there is a total of 81,618 households in Merced County. ¹ 48.9% of households in Merced County are married-couple households, while 17.2% are single male households, and 25.5% are single female households. When looking at marital status and marital history in Merced County, 40.6% of county residents have never been married, which is slightly higher than the state (38.2%).

Income and Poverty

The Merced County median household income is $56,330, though there are areas within the county where the median household income is as low as $26,325. The median income for married-couple families (immediate family members) is $77,637, while the median income for non-immediate family member households in the county is $36,048. 23.5 % of Merced County residents live in poverty (the state in which an individual is unable to meet their basic needs of shelter, food and water).

Approximately 6.9% of households in the county do not have a computer compared to the California rate of 4.8%, and 11.4% of households in the county do not have a broadband internet subscription compared to 9.6% California households.

There are a total of 81,618 households in Merced County. There are 90,329 housing units with 51.6% being owner occupied. The median gross rent in Merced County is lower than the state median ($1,160 vs $1,750, respectively). Approximately 40% of Merced County residents pay between $1,000 - $1,499 per month. When looking at physical characteristics of housing units in Merced County, 25.2% of occupied housing units have four or more bedrooms, while most households in the county have between 2 to 3 bedrooms (67.1%).

Employment

The following data is a breakdown of employment classifications throughout the County. ²

The average number of hours worked by Merced County residents who are employed is 38.6 hours per week. The median age for Merced County residents who are employed is 37.9 years. The top four industries for Merced County residents who are over the age of 16 and employed are educational services, healthcare and social assistance (22.0%), followed by Agriculture, Forestry, Fishing, Hunting and Mining (11.4%), and tied in third are Manufacturing (10.9%) and Retail Trade (10.9%).

Roughly 78.9% of Merced County residents who commute to work drive alone, while 9.1% carpool, 4.6% work from home, and the other 7.3% either walk, use public transit, or get to work through other modes of transport.

The total employment in Merced County decreased by 6.2% from 2020-2021.1 There are a total of 3,340 employer establishments in Merced County and over half (53.2%) of employer establishments in Merced County have less than 5 employees. ²

5

61.0%

Education

The K-12 educational system in Merced County education serves a diverse group of 59,066 students in 20 school districts.⁴ There are two higher public education institutions, Merced College and the University of California, Merced. There are low rates of educational attainment in Merced County with only 69.4% of those 25 years or older having a high school diploma compared to 82.9% in California.¹ Though the high school graduation rate across Merced County school districts is 92.0%, the college enrollment rate is only 58.8%.²

Geography

Merced County is geographically large with several unincorporated towns disconnected from other major cities throughout the County. In Merced County, there are roughly 145.1 residents per square mile compared to California with a population density of 253.7 residents per square mile.¹

Race and Ethnicity

Merced County is one of the most culturally diverse regions in the United States. Merced County has a large portion of foreign-born persons (26.5%) compared to the United States (13.5%).¹ The percentage of the population in Merced County who are five years or older with limited English proficiency is significantly higher (22.7%) than the United States (8.4%) and slightly higher than California (18.1%).⁶ In households, 52.9% of persons 5 years of age or older living in Merced County speak a language other than English at home.¹

Merced County

Race/Ethnicity Breakdown 2019

0.8%

3.9%

Source: US Census

Nearby Counties

The counties bordering Merced County are Stanislaus, San Benito, Mariposa, Madera, Santa Clara, and Fresno County.

Overview

Healthcare Access and Quality

Education Access and Quality

Social and Community Context

Economic Stability

Neighborhood and Built Environment

Social Determinants of Health Summary

Overview

Social determinants of health (SDOH) are the conditions in the environment where people are born, live, learn, work, play, and worship that affect a wide range of health outcomes.¹ There are five domains the SDOH can be grouped into: 1) Healthcare Access and Quality; 2) Education Access and Quality; 3) Social and Community Context; 4) Economic Stability; and 5) Neighborhood and Built Environment.

SDOH play a major role in people’s health, well-being, and quality of life. They also contribute to health disparities and inequities.¹ For example, if there is limited access to grocery stores that carry healthy food options in a neighborhood, people living in this area might suffer from poor nutrition. This then raises their risk for health conditions such as heart disease, diabetes and obesity.

Health policy often focuses on after people get sick and go to the doctor. But, making upstream investments - policies and systems that address the root causes of the five domains of the SDOH - can result in a better overall community health before people get sick.

Healthcare Access and Quality

Access to high-quality healthcare that is both affordable and available when needed is a basic human right.

This access includes primary and specialist physical care, mental and dental health, and vision care. There are many factors involved when discussing access to healthcare, such as the availability of physicians and health services, insurance coverage, and the cost of healthcare along with other factors.

Most areas within the county are Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA). 91.8% of the Merced County population lives in a geographic area designated as a HPSA, which is significantly higher than both California (19.3%) and national (23.1%) percentages.¹ 1 in 3 adults do not have a regular doctor. Merced County, compared to the rest of California, has significantly higher rates of mortality (death) due to all causes, including chronic conditions, psychological distress, as well as other societal issues.² These issues are exacerbated because of the healthcare shortage in the county. The lack of available healthcare services directly contributes to the higher rates of mortality. According to a community survey 50% of residents agree or strongly agree that healthcare services, which include medical, dental, and behavioral, are located too far away.³

Merced County has a slightly higher uninsured population compared to California (8.3% and 7.5%, respectively). There are areas within the county that are disproportionately uninsured compared to other areas.⁴ The area between 16th Street W Childs from M street to highway 99 (Census tract 16.01; median household income $26,325) has the lowest percentage of insured adults with only 59.8% having insurance, compared to the area between G street, E Bellevue Rd and E Yosemite (census tract 18.01; median household income $102,946) having the highest percentage of insured adults (97.9%).⁴ ⁵ Even though these two census tracts are less than 10 miles apart, such wide disparities exist in insurance coverage. One of the main barriers to accessing care is the high cost of healthcare.⁶ However, having health insurance mitigates these high costs. Having health insurance is extremely important to one’s health, as uninsured people have less access to recommended care, receive poorer quality of care, and experience worse health outcomes compared to those with insurance.⁷

Because of limited healthcare resources in the county, several barriers for accessing care are present, such as longer wait times for when an appointment is available. As previously mentioned, Merced County has high rates of mortality for numerous disease and conditions. Paired with generally low prevalence of the same disease, this pattern may indicate that residents are not receiving an adequate amount of preventative care.

This leads to being diagnosed later when their chance of death is much higher. In other words, fewer people are diagnosed and more ​people are dying in Merced County, which indicates health conditions are not being caught early when treatment is most successful. ​Once diagnosed with a chronic condition, residents have many barriers to successfully manage those conditions, such as lack of access ​to convenient healthcare service locations or hours.

There are growing concerns that there will be a shortage of Primary Care Physicians (PCPs) in the coming years across the county, due to ​the country's increasing healthcare demands attributable to factors such as an aging population and population growth.⁸ The PCP rate ​for Merced County is 44.6 per 100,000 residents, which is lower than California (79.6) and the United States (76.6).¹ The data aligns with ​the community’s perception, as 57% of surveyed residents agree or strongly agree that people in the community are not able to get a ​routine medical checkup.

Just under half of respondents agree or strongly agree that people have limited access to healthcare services. Even though the county as ​a whole is considered a health professional shortage area, there are census tracts without a single primary care provider. There are 605 ​mental health providers in Merced County for 286,461 people. The ratio of the total county population to mental health providers is 460:1, ​meaning there are 460 Merced County residents for every mental health practitioner (California 240:1).⁹

Rates of Primary Care Physicians (PCPs) ​by Location, 2019

RATE PER 100,000

LOCATION

Source: Community Commons

Low income residents and communities of color are more prone to difficulties in accessing healthcare resources, which can lead to inequitable circumstances. These groups tend to have worse health, which can possibly be related to their worse access. Not only do they receive less amounts of healthcare, but also lower quality of care. Language barriers can have an impact as well. Despite often worse and delayed care, nearly half of Merced County residents have significant medical debt.

Another indicator of late preventative care is Merced County’s rates of preventable hospitalizations. The rate, per 100,000 Medicare beneficiaries for preventable hospitalizations in Merced County is 57.0% higher than the rate for California and 14.0% higher than the national rate (Merced: 3,272; California: 2,087; and United States: 2,865).¹¹

A promising resource for Merced County is the opening of University of California, Merced’s medical school that will begin in 2023. Doctors trained in the Central Valley may stay in the Valley. In addition, children who grow up near a medical school may be encouraged to become doctors, near home.

Education Access and Quality

Individuals with higher levels of education are more likely to live healthier and longer lives compared to their less educated peers, and the disparities are large and widening.¹

Merced County has low rates of educational attainment, with only 69.4% of those 25 years or older having a high school diploma, compared to 82.9% in California, and 87.7% in the United States.² Certain race/ethnicity groups have disproportionate levels of educational attainment. Most noticeably the Hispanic/Latino population (24.0%) and Asian populations (18.0%) have the highest percentage of residents 25 and older with only a high school diploma.³

When examining higher education for those 25 years and older in Merced County, the inequity for Hispanic/Latino widens, as only 32.0% of the Hispanic/Latino population have some college/associates degree or higher, compared to Asian, (54.0%) White, (50.0%) and Black people (60.0%).³

Educational Attainment by Location, 2021

EDUCATION LEVEL

These trends are similar to both the state (Hispanic/Latino 52.0%, Asian 75.0%, White 67.0%, Black 66.0%) and United States (Hispanic/Latino 41.0%, Asian 72.0%, White 63.0%, Black 55.0%), however the percentages are lower for each race/ethnicity group in Merced County except for Black individuals.⁴ ⁵

Although Merced County has low rates of educational attainment compared to the state, the percentage of high school students who graduate is higher in Merced County (91.1%) compared to California (84.3%).⁷

During the COVID-19 pandemic, schools switched to online/remote learning. One area of concern from extended online learning was how this might impact student’s education. The California Assessment of Student Performance and Progress (CAASPP) is an annual standardized test that examines student’s abilities in various subjects, including math and reading proficiency. Proficiency is defined as a test score meeting or exceeding a student’s grade level standard. A comparison of 2019 (pre-pandemic) and 2021 (pandemic) was done to see if there was any difference in both reading and math proficiency for Merced County and California. The percentage of students who are proficient in reading and math decreased from 2019 to 2021 in both Merced County and California, indicating that the pandemic had a negative impact on student learning. Interestingly, the biggest differences between 2019 and 2021 proficiency levels were found in lower grades (3rd through 5th grade), and the smallest differences were found in higher grades (6th through 11th grade), which may suggest that remote learning was much more difficult for younger children.

Overall, the percent of students who are proficient in reading and math decreased from 2019 to 2021, however the percentage across all grades decreased more for Merced County compared to California. This could potentially be due to a number of factors, such as students in the county not having adequate resources, such as high-speed internet, a good working computer, and a quiet environment to focus. Also, schools in the county could have less resources as well, and as a result have more difficulties adjusting to online teaching.

Students Proficient in Reading (CAASPP), for Merced County by Grade Level, ​2019 & 2021

Students Proficient in Reading (CAASPP), for California by Grade Level,

2019 & 2021

Students Proficient in Math (CAASPP), for Merced County by Grade Level,

2019 & 2021

18.1%

Students Proficient in Math (CAASPP), for California by Grade Level, ​2019 & 2021

33.8%

The relationship between health and education is complex. Students who are socioeconomically disadvantaged often experience delays in academic development which, as a result, leads to poorer academic outcomes. These socioeconomic disadvantages include: poor nutrition, high crime neighborhoods, and lack of safe places to walk and play. This results in poorer academic outcomes than children from higher socioeconomic status groups. This is especially important as a lack of education can lead to being unhealthy in adulthood, and unhealthy children can lead to a lack of education. In Merced County, 31.9% of students who are socioeconomically disadvantaged, compared to 54.6% who are not socioeconomically disadvantaged, meet or exceed grade level standards in English Arts. For math proficiency, a similar pattern is found. 14.9% of socioeconomically disadvantaged students meet or exceed grade level standards, compared to 30.9% of non-socioeconomically disadvantaged. This is problematic, as if these patterns continue to exist the gap will continue to widen as students continue their education. This will put socioeconomically disadvantaged students at a major disadvantage throughout their life, as they will have less chances of graduating high school, attending college, and obtaining better employment which all lead to a better quality of life and overall health.

Even though a higher percentage of students graduate high school in Merced County compared to the state, only 35.1% complete college preparatory courses in Merced County compared to 50.5% in California.⁷

Examining this by race/ethnicity, 1 out of 4 Black, 2 out of 5 White, 2 out of 3 Asian or Filipino, and 3 out of 10 Hispanic/Latino students take college preparatory courses in Merced County.⁷ Higher educational attainment usually leads to better employment opportunities, higher earning potential and better overall health. College preparatory courses are not available equally to all students, and this contributes to certain groups, such as Latino, Black, and low-income students, being consistently underrepresented in higher education. There is research demonstrating that improving college access and completion could also benefit society by increasing tax revenue while reducing economic inequality, unemployment, poverty, incarceration, and demand for safety net programs.⁸

Researchers have examined the association between education and health and the relationship is quite complex. Three main connections explain how education and health are linked.

High School Graduates Completing College Preparatory Courses by

Location & Race/Ethnicity, 2019

Source: kidsdata.org

RACE

Education can create more opportunities for better health

Income and resources

Higher educated people are more likely to get jobs that provide health insurance, paid time off, and retirement compared to those with less education who are more likely to work in high-risk occupations with limited benefits. Families with higher earnings are able to afford healthy foods, have more time to exercise regularly, and pay for health services and transportation. Conversely, low wages, job insecurity, and a lack of assets associated with less education can make families more vulnerable during difficult times, which in turn can lead to poor nutrition, unstable housing, and unmet medical needs.⁹

Healthier neighborhoods

Those with less education, who typically have lower incomes and fewer resources, are more likely to live in low-income neighborhoods, which often times lack the resources needed for good health. These types of neighborhoods tend to have an oversupply of fast food restaurants and other unhealthy food options (food swamps) while having limited healthy food options (food deserts). Lower income neighborhoods might not have sidewalks or parks to encourage outdoor physical activity compared to neighborhoods that are more affluent. Low income and rural areas, which are often populated by people with less education, suffer from shortages of healthcare providers and resources. Crime is more prevalent in lower income neighborhoods, which exposes residents to greater risk of trauma and deaths from violence along with the stress that comes with living in an unsafe neighborhood. Public schools in these neighborhoods are given less resources (because of low property taxes), resulting in fewer high-quality schools and perpetuating the education, income and health cycle. Higher level of toxins, such as water and air pollution, pesticides, and hazardous waste are found in lower income areas. Lastly, there is less effective political influence to advocate for community needs, which results in a persistent cycle of disadvantage.⁹

Social and psychological benefits

Those with more education, thus higher incomes, are often spared the health harming stresses that accompany continued social and economic hardship. Typically, those with lower educational attainment have fewer resources, such as social support and high self-esteem, to buffer the negative health effects of stress. Education and other learning opportunities help build skills and advance traits that are not only important throughout life but also are important for good health. Some of these things include perseverance, flexibility, a sense of personal control, and establishing social networks, which are all valuable for dealing with an assortment of life challenges that may influence health. Also, higher educated people typically have more robust social networks which in turn allows connections to resources that may help deal with stress, reduce hardships and improve overall health.⁹

Health behaviors

Education not only helps prepare people for better jobs, but those who are more educated are more likely to learn about healthy behaviors.⁹ Patients who are more educated are able to better understand their health needs, follow instructions from their health care provider, advocate for themselves and their families, and effectively communicate with their health care provider. Educational attainment is low in Merced County, which is directly related to the poor health outcomes that are seen in the community. 61% of Merced County residents surveyed agree or strongly agree that there is a lack of knowledge or education on how to live a healthy lifestyle.⁶

Poor health that affects education (reverse causality)

As mentioned above, the relationship between education and health is complex. Not only does poor health result from lower educational attainment, but it can also cause educational setbacks and interfere with schooling. For example, a child with a chronic disease, such as diabetes, might miss class frequently and may fall behind. Disabilities and unhealthy behaviors, such as smoking, have established links to school performance and all have a significant impact on educational outcomes. Lack of education can lead to unhealthy adults, and unhealthy children can lead to a lack of education.⁹

Conditions throughout the life course – beginning in early childhood – that affect both health and education

Throughout one's life, conditions at home - socioeconomic status as well other contextual factors - creates stress. This stress causes illness and deprives people of resources needed to be successful in school, at work, and living a healthy lifestyle. A nurturing home environment, parental involvement, stimulation and early childhood education are all critical components that help develop social and learning skills during early childhood when health and education paths are shaped. 47.1% of the population ages 3 to 4 in Merced County are enrolled in school, which is lower than the state and national percentages (49.7% and 48.3%, respectively).¹⁰

Two of the biggest resources in the county are Merced College and the University of California, Merced. Opening in 2005, one of the missions of UC Merced is to increase college-going rates among students in the region, specifically the San Joaquin Valley. Now, 17 years later UC Merced has been extremely successful in achieving this mission and proves to be a major asset to the community. One of UC Merced’s unique characteristics is the ethnic diversity of student enrollment, which is similar to the diversity seen in the community and is one of the most ethnically diverse university's in the country. 54.7% of the enrolled student population is Hispanic/Latino, 17% Asian, 9.6% White, 4.3% Black, 3.2% multi-racial, 0.5% Native Hawaiian/Pacific Islander, and 0.1% American Indian/Alaskan Native.¹¹ Another way UC Merced continues to benefit minorities and promote racial/ethnic diversity is by admitting first-generational residents. UC Merced had the highest percentage of first-generation resident freshmen admissions (59.0%) of all the University of California schools. Merced College’s population is diverse as well, with the student population breakdown of 59.2% Hispanic/Latino, 17.9% White, 8.3% Asian, 3.0% biracial, 3.0% Black, 0.5% American Indian/Alaska Native, and 0.2% Native Hawaiian/Other Pacific Islander.¹³

Enrollment in School, Children (Age 3-4), Percent by Tract, ACS 2015-2019

Source: US Census, ACS 2015-2019

Social and Community Context

The connections you have to your community (i.e. family, friends, co-workers, and neighbors) have a major impact on overall health status and well-being.¹ It is important to focus resources on getting people the social support needed in the places they work, live, learn and play, as this is where health really begins. Because so many of the factors that impact health are out of people’s control, having positive relationships at home, work and with those in your community can help reduce these negative impacts on health.² In fact, your social and community context are more likely to influence your health than health behaviors.¹ The quantity and quality of your social relationships have a direct impact on overall health, such as mental health, health behavior, physical health and mortality risk.¹ Having strong friendships and a support system help improve overall health.

A community survey found that 44.8% of surveyed Merced County residents agree or strongly agree that there is a lack of social support, and 40.6% agree or strongly agree that there is a lack of family support.³ 39.0% of Merced County residents reported being unable to work between 8 and 30 days because of mental problems.⁴ If people had a stronger support system there would be less people having to miss work because of their mental health. This aligns with the community perception of there being a general lack of social support and family support system. This same community survey also found that 55.6% of residents agree or strongly agree that discrimination or racism is present and that 42.4% of surveyed residents feel that residential segregation (physical separation of two or more groups into different neighborhoods) is a common issue.³ Social cohesion can help promote the overall health of the community by improving conditions that affect the wellbeing of people.

Economic Stability

People with steady employment with a livable wage are less likely to live in poverty and more likely to be healthy; however, many people have a difficult time finding, as well as keeping a well-paying job. Those who have disabilities, chronic conditions, injuries or other health issues may not be able to work, or are limited in their ability to work. Even those who are fully able to work and have steady employment may have difficulties earning enough money to stay healthy, or with benefits such as health insurance or paid sick time.

The unemployment rate in Merced County had been steadily declining over the past 10 years until the COVID-19 pandemic. In 2020, unemployment rates across the country drastically increased as a direct result of the pandemic and economic shutdowns. The unemployment rate in Merced County (12.2%) is much higher than California (10.2%) and the United States (8.1%). 58.0% of surveyed residents agree or strongly agree that there is limited access to jobs in the county.²

1 in 5 Merced County residents are living in poverty (21.2%), which is much higher than the state (13.4%) and United States (13.4%) when using the <100% Federal Poverty Level (FPL).³ A higher percent of females live in poverty compared to males in the county (23.2% and 19.2%, respectively) which is a similar trend to both the state and nation.³

When examining disparities for poverty by ethnicity, 1 in 4 Hispanic/Latino people live in poverty while 1 in 6 non-Hispanic/Latino people live in poverty.

Highlighting these inequities by race, “other” race had the highest percentage of the population in Merced County living in poverty (26.3%), followed by Native American/Alaskan Native’s (26%), Black (24.4%), Asian (21.1%), multiple race (20.1%) and White (18.5%).³

Unemployment by Location, 2011-2020

PERCENT

YEAR

Source: US Department of Labor

Percent Living in Poverty by

Gender & Location, 2015-2019

LOCATION

Source: US Census Bureau

Percent Living in Poverty by

Ethnicity & Location, 2015-2019

LOCATION

Source: US Census Bureau

Percent Living in Poverty, by Race & Location, 2015- 2019

RACE

Source: US Census Bureau

The number of children living in poverty has decreased in recent years, however nearly 1 in 3 children in Merced County still live in poverty (<100% FPL is 29.8%), which is more than 61% higher than both the state (18.1%) and US (18.5%) percentage.³

Housing

The median home price in Merced County ($425,000) is less than half of the median home price in California ($856,600).⁴ Although the cost of purchasing a home is much lower in Merced County compared to California, many locals are finding it difficult to afford homes in their communities. An analysis done in April 2022 found that Merced County is ranked 15th on the list of the top United States counties where homeownership is recently unaffordable.⁵ The median household income in Merced County is $56,330 (California: $78,672, United States: $64,994).⁶ The estimated mortgage, with a 3% down payment, would approximately be $3,200 per month. The financial recommendation is that no more than 33.0% of the monthly income should be spent on a mortgage or rent. Using this estimate, $1,550 should roughly be the cost of a mortgage or rent, based on the median income in the county. The fair market rent price for a three-bedroom house in Merced is $1,591.⁷ The data aligns with the community’s perception, as 60.6% of surveyed Merced County residents agree or strongly agree that the average income in the county is low and 42.7% agree or strongly agree that there is no affordable housing.²

Number of Unhoused Merced County,

2016 - 2019

TOTAL NUMBER

YEAR

Source: MCBHRS Homeless Plan

In 2019 the 607 unhoused in Merced County in 2019, 322 were sheltered, while 285 were unsheltered. Of these, 7 children were unsheltered and 101 children were sheltered. Of the 278 adults that were unsheltered, 64.7% are male and 41.7% are White and 39.9% are Hispanic/Latino.⁸ Compared to California, the percent of unhoused public-school students is 1.6% higher in Merced County (4.5% and 2.9%, respectively).⁹

Merced County Unsheltered Adult Homeless Population by

Race / Ethnicity, 2019

Source: MCBHRS Homeless Plan

Economic Development

Merced County has great potential to improve the economic well-being and quality of life of its residents. Merced County’s unique location of being in the central part of California, which is the 6th largest economy in the world and largest economy in the United States, is advantageous for many reasons. The west side of Merced County is located near the Bay Area, roughly one hour from the heart of the Silicon Valley. Because of this, Merced County can provide different facilities (such as test, development, and production facilities) that support nearby research operations. A major advantage and reason the region is attractive to businesses is that there is more space available in the county (as space becomes more limited and real estate continues to increase at higher rates in the Silicon Valley), and it provides a lower cost to do business because of more affordable real estate. In addition, because of the county’s strategic location, it offers extensive supply chain transportation infrastructure and proximity to large California markets, which are all attractive to businesses in multiple sectors.¹⁰ Attracting more businesses to the region will lead to more stable and higher-paying jobs, thus improving the economic stability of the county and in turn the overall health of the community.

Neighborhood and Built Environment

Neighborhoods

The neighborhoods individuals live in have a significant impact on their overall health and well-being. Often times the challenges and dangers that people face, such as unsafe neighborhoods and crime, are out of their control. However, these things have a major impact on their health and safety over the course of their lives. A safe and clean environment that allows access to recreational activities and healthy foods is extremely important in order to maintain as well as improve the health of the community.

Many of the risk factors that you can change for chronic diseases are directly linked to the different social determinants of health (SDOH), such as neighborhood and built environment. Sometimes there are situations that are out of one’s direct control, usually because of a lack of resources, such as adequate income. For example, a person might choose not to smoke because they are aware of the negative health impacts, yet they live in low-income housing where a majority of the people smoke frequently.

Even though this person is not directly putting himself or herself at risk by smoking, because of their environment and inhaling second hand smoke they are still at an elevated risk of developing lung cancer, asthma and other respiratory illnesses.

Substandard housing

Substandard housing is federally defined as having at least one of the following: 1) incomplete plumbing facilities, 2) incomplete kitchen facilities, 3) more than 1.01 occupants per room, 4) rent or mortgage of greater than 30.0% of monthly income. 39.5% of Merced County housing units meet one or more of these conditions, which is lower than California (43.8%) but higher than the United States (31.9%).¹

Crime

In Merced County, the property crime rate has been decreasing over the last six years (2015-2020), with the exception of a slight increase from 2018 to 2019. Property crimes include burglary, larceny-theft, motor vehicle theft, and arson. The property crime rate, using the same 2016 data source available for Merced, California and the United States, is 2,762 per 100,000 for Merced County, which is higher than both the state and national rate (2,497 and 2,466 per 100,000, respectively.²

Unlike property crimes, the number of violent crimes has remained stable the past six years. The violent crime rate in Merced County is 583 per 100,000 population, which is higher than both the state and national rate (441 & 416 per 100,000, respectively).

The most common crime in Merced County is larceny-theft, followed by vehicle theft, aggravated assault, and burglary. Of the cities in Merced County, Atwater has the highest property crime rate (2,781), followed by Merced (2,258) and Los Banos (2,049). Dos Palos has by far the highest rates of violent crime (1,242), followed by Merced (778) and Los Banos (483). Gustine has the lowest rate of both violent and property crime.⁴

Results from a community survey suggest that 54.5% of residents perceive that community violence or crime is a problem, 46.5% of resident’s perceive the streets are unsafe, and 49.1% agree or strongly agree that there is a lack of safe housing in the county. Half of surveyed respondents agree or strongly agree that racial based violence is a problem in the community, and 37.6% feel that gun violence is a problem.⁵

Merced County Crime Rates, 2015 - 2020

YEAR

Source: CA Department of Justice

Merced County Crimes by Type, 2020

0.3%

16.9%

17.1%

1.1%

3.3%

Source: CA Department of Justice

Merced County Violent vs Property Crime Rates, by City, 2020

Source: CA Department of Justice

LOCATION

Access to food

Another often-overlooked component of the neighborhood and built environment social determinants of health (SDOH) category, which is linked to overall health status, is whether there is equitable access to healthy food options throughout the county.

Much of the county is considered low access (see pink to the right). Low access is defined as a census tract in which at least 500 people, or 33.0% of the population, lives further than one mile for urban or 10 miles for rural from the nearest supermarket.⁶

When examining areas within the county that are both low access and low income, a majority of the population in the county lives in an area that is considered both (see green below). Low income is defined as a census tract that has a poverty rate of 20.0% or higher, or the tract has a median family income less than 80.0% of the median family income for the state or metropolitan area. Pink areas are low access but are not considered low income, while green areas are both low access and low income.⁶ Almost half of surveyed community residents agree or strongly agree there are areas with no grocery stores present and 41.2% agree or strongly agree there are limited healthy food options or healthy groceries, both of which align with this data.⁵

There are less fast food restaurants per capita in Merced County (56 per 100,000) than both California (87.3) and the United States (82.2), yet 60.0% of surveyed residents agree or strongly agree that there are too many options for unhealthy eating choices such as fast food restaurants.⁷ ⁵

Air quality

Air quality is another component of the built environment that has a direct relationship with health. Air pollution is considered the world’s largest environmental health threat and causes or exacerbates many diseases, from asthma, cancer, and pulmonary illnesses to heart disease.⁸ The San Joaquin Valley has poor air quality and has some of the most polluted air in the nation.⁹ Similar to the rest of counties in the San Joaquin Valley, Merced County experiences much poorer air quality than the rest of the state because of the geographical nature of the Valley - pollution from the state enters and stays in the Valley basin. The chronically bad air quality, over time, can lead to more respiratory issues because of the long-term exposure to poor air quality. Ozone levels in Merced County have dramatically decreased since the early 2000’s but are still above healthy levels.¹⁰ Merced County ranked 25th for most polluted counties in the nation for ozone and ranked 17th for short term particulate matter (24 hour PM ) particle pollution. Fresno ranked number 1 for short-term particle pollution. When looking at long-term particulate matter (Annual PM ), Merced County ranked 15th in the nation, while Mono county ranked first. Merced County had 4 days where particulate matter 2.5 levels were above the National Ambient Air Quality Standard, compared to only 1 in California and 0 in the United States.¹¹

34.6% of surveyed residents agree that the air quality is poor in Merced County, while 11.5% strongly agreed. This is similar to findings from a study that was done in the San Joaquin Valley where 32.1% of respondents answered the air quality in the region was unhealthy for sensitive groups.¹²

Climate Change

Related to air quality, climate affects health as well. Climate change is already impacting health in a number of ways, including leading to increased mortality and morbidity from frequent extreme weather events such, as heatwaves.¹³ California has seen the average temperature in recent years increase. Interestingly, of all California counties, Merced County has the smallest percentage increase for 2021 average temperature by month when comparing the mean monthly temperature for 1901-2000. In other words, Merced County has actually seen the smallest average temperature increase in the state over this period of time. Although the county has experienced the lowest average temperature increase, climate change related health risks are still a major concern as they disproportionately impact vulnerable and disadvantaged populations the most, including women, children, ethnic minorities, poor communities, migrants, older populations, and those with underlying health conditions.¹³

The general perception of surveyed residents is that there are several neighborhood and built environment factors that negatively impact the health of the community and can explain why the health of the community is poor. 42.7% of respondents agree or strongly agree that there are no sidewalks in many neighborhoods and 53.2% agree or strongly agree that there are limited parks, playgrounds or green spaces in the community.⁵ 81.3% of children in Merced County live in walking distance to a park, playground or open space, however this is lower than the percent of children in California (88.0%) with similar access. Even though a majority live within walking distance to these areas in Merced County, 1 in 5 do not. 42.7% agree or strongly agree that there is limited access to recreation or things to do.⁵ Merced County has lower access to recreation and fitness facilities compared to California and United States (Recreation and Fitness Facilities, rate per 10,000 Population: Merced County 0.9, California 1.2, United States 1.2).³

Source: World Health Organization

Summary

The social determinants of health (SDOH) have a major impact on health outcomes, especially for more vulnerable populations such as those who are uninsured or live in areas with less parks. Many of the perceptions Merced County residents have regarding the social determinants of health align with the data and offer potential explanations as to why the overall health of the community is worse than other areas in the state.

The following section, Health of the Community, will provide data to illustrate the current health status of residents of the county. This section will also highlight data on the leading causes of death, the most important health problems in the community, and other important health topics.

Using data from the next section, health agencies and partners can assess which social determinants may contribute to these health outcomes and leading causes of death; and then evaluate how to address the SDOH through an upstream, prevention-based approach, that focuses on systems and policies that can have a large impact on the whole population. For example, if many people from a specific zip code are having a higher rate of diabetes, then understanding which social determinants may impact this health outcome is important, as well as understanding how the determinants may be addressed through a prevention method – asking what policies, systems, or programs can prevent diabetes.

Overview

Cardiovascular Disease

COVID-19

Malignant Neoplasms (Cancer)

Accidents (Unintentional Injuries)

Cerebrovascular Disease (Stroke)

Chronic Lower Respiratory Disease

Diabetes Mellitus

Overview

The leading causes of death in Merced County can be found in the table below. The top three causes of death in Merced County for 2021 were: 1) Heart Disease, 2) COVID-19 and 3) Malignant Neoplasms (Cancer). There were 2,324 total deaths in 2021 for Merced County residents. See below for the percent of total deaths by disease/condition.

4.9%

4.6%

6.0%

14.2%

3.1%

1.9%

Cardiovascular disease, which includes high blood pressure, heart attacks, and many other heart conditions, is recognized as a preventable cause of death. It can be managed and avoided with behavioral lifestyle changes such as eating healthy foods, exercising, not smoking, maintaining a healthy weight, and limiting stress. Although many of the risk factors for heart disease can be minimized through individual behavioral change, the risks are associated with factors outside of one’s control that are directly related to the social determinants of health (SDOH). As discussed in more detail in the SDOH chapter, issues such as having areas in Merced County where there are limited healthy food options/lack of healthy grocery stores, unsafe neighborhoods to play outside in, and even having higher than average levels of stress due to low income contribute to elevating the risk of heart disease that puts certain individuals at higher risk.

Overall, heart disease mortality rates in Merced County have decreased in recent years but are still some of the worse in the state. Over 2.1% of all emergency department (ED) visits and 12.0% of all hospital admissions in 2019 were due to heart disease (as the primary diagnosis) in Merced County.²

Heart Disease: Age-Adjusted Mortality by Location,

2011-13, 2014-16 & 2017-19

RATE PER 100,000

Source: CDC WONDER Online Query System

Heart disease affects certain race/ethnicity groups disproportionally more. The death rate for heart disease for those ages 35+ in Merced County has increased substantially since 2011 for all races but has disproportionately impacted Black people at much higher rates compared to other race/ethnicity groups.

Pacific Islanders have the fastest increase in heart disease death rates since 2011, however the overall rate is much lower than Black rates.¹

Heart Diseases: Mortality Rates for Ages 35+ By Race, Merced County,

2011-13 & 2016-18