Health Planning Report for Northern, Eastern and Central Maine

Health Planning Report 

for 

Northern, Eastern and Central Maine 

The Eastern Maine Healthcare 

Community Health Needs Assessment 

With a Special Focus on Substance Abuse 

November 1, 2001 

Prepared by: 

Public Health Resource Group, Inc. 

120 Exchange Street 

Portland, ME 04101 

(207) 761-7093 

www.phrg.com

Copyright © 2001 by Eastern Maine Healthcare and PHRG. 

All rights reserved. 

Reproduction or translation of any part of this work beyond that permitted by Section 107 

or 108 of the 1976 United States Copyright Act without the permission of the copyright 

owner is unlawful. Requests for permission or further information should be addressed to 

PHRG.

HEALTH PLANNING REPORT FOR NORTHERN, EASTERN AND CENTRAL MAINE 

THE EASTERN MAINE HEALTHCARE 

COMMUNITY HEALTH NEEDS ASSESSMENT 

TABLE OF CONTENTS 

I. Introduction................................................................................................1 

II. 

III. 

IV. 

Objectives....................................................................................................2 

Methods.......................................................................................................2 

Health Indicator Data and Analysis .............................................................2 

Special Focus on Substance Abuse..............................................................4 

Peer Communities........................................................................................4 

Interviews.....................................................................................................5 

Findings........................................................................................................5 

Key Health Findings (For All Regions)....................................................6 

Population Profile ........................................................................................6 

Health-Based Social and Economic Characteristics....................................8 

Chronic Disease Burden and Population Wellness....................................10 

Functional Health Status............................................................................12 

Primary Care ..............................................................................................14 

V. Key Findings for Specific Areas of Healthcare .....................................19 

Cardiovascular Health................................................................................19 

Respiratory Health .....................................................................................21 

Reproductive Health ..................................................................................24 

Youth Health..............................................................................................27 

Cancer Health.............................................................................................30 

Arthritis, Diabetes and Other Chronic Conditions.....................................34 

Mental Health.............................................................................................37 

Substance Abuse ........................................................................................40 

Intentional and Unintentional Injuries .......................................................43 

Oral Health.................................................................................................47 

Alternative Health Services .......................................................................50 

Community Perceptions of Health and Health Service Need....................51 

Summary....................................................................................................55 

VI. Priority Health Issues ..............................................................................55 

Primary Preventive Education/Services.....................................................55 

Access to Care............................................................................................57 

Mental Health/Substance Abuse Services .................................................58 

Cancer Screening and Detection................................................................60 

Disease Management/Access to Sub-Specialty Care.................................61 

Sub-Acute Care (in the Chronic Disease, Elderly Population)..................63 



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VII. 

Recommendations....................................................................................66 

Primary Prevention Education/Services ....................................................67 

Access to Care............................................................................................68 

Mental Health Services..............................................................................69 

Cancer Screening and Detection Services .................................................72 

Disease Management/Access to Sub-Specialty Care.................................73 

Sub-Acute Care for the Elderly..................................................................75 


Appendices 

Appendix 1: Steering Committee Members 

Appendix 2: Working Group Members 

Appendix 3: Region Groupings (by HSA) 

Appendix 4: Map of Study Regions 

Appendix 5: CIAP Process 

Appendix 6: Health Status Profile (HSP) 

Appendix 7: Data Sources and Years 

Appendix 8: Survey Instrument 

Appendix 9: Survey Participation Information 

Appendix 10: Peer Grouping (rural by town and urban by HSA) 

Appendix 11: Schedule of Persons Interviewed 

Appendix 12: Definition of Indicators 

Appendix 13: Listing of Defining Codes 

Appendix 14: Mental Health Findings from the 2001 EMH Household Survey 

Appendix 15: Substance Abuse Findings from the 2001 EMH Household Survey 

Appendix 16: Intimate Partner Violence Findings from the 2001 EMH Household Survey 


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I. INTRODUCTION 

In January 2001, Eastern Maine Healthcare (EMH) commissioned Public Health Resource 

Group (PHRG) to conduct an independent Health Care Needs and Service Planning Study for 

northern, eastern and central Maine. The primary goal of the study was to identify key health 

care service issues in those communities and to develop a comprehensive health plan to improve 

services and service delivery for residents. A secondary goal was to assess needs for substance 

abuse services in the study area populations and make recommendations about how to better 

serve those needs. The health-planning component of this study is intended to inform efforts to 

develop and/or organize health care services in a way that will ultimately improve the short- and 

long-term health of community members. 

PHRG, a health care research and consulting firm specializing in health services planning, 

designed and conducted the study, which covered a nine county area in northern, eastern and 

central Maine. The study was based on PHRG’s ‘Community and Institutional Assessment 

Process (CIAP),’ a proprietary health care services assessment and planning system. The CIAP 

uses scientifically valid data, comparative information and input from local residents, providers 

and community leaders to profile health status as well as health care quality and outcomes in a 

population. Analysis of CIAP data lays the foundation for targeted health services planning, by 

specific service lines or across entire health care systems. It also provides a framework for 

strategic business planning for hospital and health care systems development. 

PHRG designed and implemented the Health Care Needs and Service Planning Study in 

collaboration with a Project Steering Committee as well as Working Groups for the overall 

assessment and for the special focus on substance abuse. The former was comprised of regional 

hospital administrators, legislators, key health care providers, representatives of the business 

community, public health advocates, law enforcement officials, and consumers from the study 

areas (See Appendix 1 for a complete list of Steering Committee members). The Committee’s 

mission was to assist in a) focusing study objectives; b) identifying/securing data, candidates for 

provider interviews, and other resources relevant to the study; c) shaping recommendations; and 

d) developing a plan for the dissemination of study findings. Committee members were 

convened three times throughout the process – at the study design stage, at the preliminary 

findings stage and at the dissemination stage prior to release of the final report. 

The General Working Group was represented by health care providers and research/planning 

personnel from the EMH system and other organizations such as CancerCare of Maine and the 

Bangor Area Visiting Nurses. The Substance Abuse Working Group was represented by 

substance abuse providers and clinical administrators from Acadia Hospital, Penobscot Bay 

Medical Center, Maine Hospital Association and the Department of Behavioral and 

Developmental Services (formerly DMHMRSAS). (See Appendix 2 for a complete list of 

Working Group members.) Both groups served as technical resources to PHRG in the design, 

implementation and interpretation of findings from the study. PHRG convened those groups, in 

their entirety and with selected members, on numerous occasions during the design, 

implementation and data analysis stages of the project. 

This report describes the assessment methodology and reviews key findings regarding health 


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care needs in the population. The report integrates information from all study databases to 

identify a set of priority health issues for northern, eastern and central Maine. It concludes with 

a set of recommendations for specific strategies that will better meet the health care and related 

needs of the general and special populations that make up the study area. 

II. OBJECTIVES 

The major objectives of the Health Care Needs and Service Planning Study were to: 

• Describe the health of populations residing in northern, eastern and central Maine; 

• Identify priority health service issues in those populations; 

• Obtain baseline information about the extent and impact of substance abuse in each 

study area and identify needs for prevention, treatment and control services; and 

• Prepare and disseminate a health care service planning report to members of northern, 

eastern and central Maine. 

III. METHODS 

For the purposes of this study, we organized the nine county study area into seven study regions. 

Each region was comprised of one or more Hospital Service Areas (HSAs). HSAs were created 

by the Maine Health Care Finance Commission (MHCFC) to represent areas with a common 

service delivery system and similar patterns of provider practices and service demands. 

Appendix 3 lists the HSAs that comprise each study region and Appendix 4 displays the study 

regions on a State map. 

PHRG’s Community and Institutional Assessment Process (CIAP) is depicted in Appendix 5. 

The first step is to identify specific key health issues using a comprehensive and scientifically 

valid set of health and medical indicators. Local health care providers are subsequently 

interviewed in an effort to link priority health issues to service needs. Finally, we use both the 

quantitative indicator data and qualitative interview information to develop recommendations on 

how local providers, in collaboration with the community, can improve health services in the 

area. 

Health Indicator Data and Analysis 

Health status refers to the present state of wellness or illness in a community. It is defined by 

indicators of beneficial and harmful health behaviors, the presence of symptoms and conditions 

indicative of illness and wellness, measures of the burden of illness in a community, the 

prevalence and incidence of specific diseases, and mortality. Because health status is the most 

important factor driving the demand for health care services, the first step in this assessment was 

to describe the health status of the populations of northern, eastern and central Maine. To 

accomplish this, we constructed and analyzed a comprehensive set of health and medical 

indicators for each of the seven study regions (See Appendix 6 for the Health Status Profile). 

Most indicators were derived from public data sources, such as State birth and death records, 

hospital discharge databases, cancer registry data, Medicaid enrollment, unemployment records 

and the Behavioral Risk Factor Surveillance System (BRFSS) survey (See Appendix 7 for a 


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complete list of data sources and years). Other indicators were derived from a random sample 

household telephone survey that PHRG conducted specifically for this study. 

The survey, which was conducted between April and June of 2001, measured general health 

status, chronic disease prevalence, health risk behaviors, health care access and utilization, 

perceived community health needs, and special issues such as alcohol and illicit drug use, 

mental health, oral health, intimate partner violence and the use of alternative and 

complementary medical services. The survey instrument (See Appendix 8) was primarily 

constructed from previously validated questions used in large state and/or national survey efforts 

such as the Behavioral Risk Factor Surveillance System (BRFSS) survey, National Health 

Interview Survey (NHIS) and the National Household Survey on Drug Abuse (NHSDA). A 

random sample of households was selected from all known telephone-listed households in each 

of the towns comprising the seven study regions included in the study. Households were 

sampled at the same rate in every study region except in the Bangor HSA where they were 

sampled at a slightly higher rate. An adult (18+) respondent was randomly selected from each 

household using standard ‘last birthday’ methods and invited to participate in the 25 minute 

survey. 1 Trained and experienced interviewers administered survey questions over the 

telephone. A total of 2,500 adults – 400 from the Bangor study region and 350 from all other 

study regions- completed an interview. Refusal rates ranged from a low of 31% of eligible 

contacts in the Aroostook region to a high of 37% in the Central region. Response rates 

mirrored those patterns (See Appendix 9 for participation information). 

The raw survey data were cleaned and normalized prior to performing any analyses. In 

addition, post-stratification weights were used to adjust for discrepancies between the age and 

gender composition of each region’s survey sample and that of its population – discrepancies 

that result from participant non-response and gaps in telephone coverage. 

We used the primary (survey) and secondary data to compute several different classes of 

community health status indicators, including: 

• Health-related demographic characteristics and population trends; 

• Behavioral and medical risk factors, as well as the presence of chronic disease and 

acute health episodes in the community (e.g., smoking, obesity, cardiovascular 

disease, cancer, respiratory health, diabetes, hospital admissions); and 

• Characteristics of the health care delivery system for certain health-related conditions 

(e.g., prenatal care, behavioral health). 

All indicators, unless otherwise noted, are expressed as either percents or rates per 100,000 

population. For analysis purposes, we organized them by health issue (functional health, 

cardiovascular, reproductive) and evaluated them for specific age (e.g., 0-17, 18-44, 45-64, 65+) 

and gender groups. Except where noted, we analyzed rates for specific age- and/or gender 

groups rather than using a standard population and adjusting for age and/or gender differences. 

The former approach provides a better reflection of disease burden and a more precise estimation 

of the health problems and service needs of a population. As such, it provides a stronger 

foundation for health care planning in a population. The exceptions to this approach include: a) 

1 Salmon, CT, Nichols, JS. “The next-birthday method of respondent selection.” 1983. Public Opinion Quarterly. 

47:270-276. 


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total cause-specific mortality rates for each region, which were age-adjusted using the 

appropriate peer community as the standard population and b) cancer incidence rates (region, 

State and US), which were age adjusted using the 1970 US standard population. 

Findings pertaining to priority health concerns are based on an analysis of patterns discerned 

from related indicators. Unlike other methodologies, the CIAP approach does not exclusively 

rely on assessments of the statistical significance of community-level differences in individual 

health status indicators. Using our approach, for example, unmet needs for cancer screening are 

suggested when cancer incidence rates are substantially (15% +) lower than those in a 

comparison community while rates of cancer mortality are substantially higher. Likewise, 

improvements in secondary prevention practices might be suggested when rates of hospital 

admissions for a particular disorder (e.g., diabetes) are low in a community while mortality rates 

for that disorder are high. The validity of those patterns is evaluated against other quantitative 

and qualitative (provider interview data) evidence in order to identify health service needs. 

Special Focus on Substance Abuse 

As described previously, a major focus of the present effort was to obtain baseline information 

on the extent and impact of substance abuse in northern, eastern and central Maine and to 

identify needs for prevention, treatment and control services. Toward that end, we included in 

the household telephone survey an extensive series of questions about tobacco, alcohol and illicit 

drug use; the perceived availability of illicit drugs in the community; and the perceived adequacy 

of existing local prevention and treatment services. Along with the household survey data, we 

used secondary databases to analyze indicators of substance abuse and mental health 

hospitalizations; substance abuse deaths and arrests for alcohol and drug violations. In addition, 

one component of the provider interview process focused exclusively on local substance abuse 

problems and needs for substance and mental health services. We also used a school-based 

health survey to assess the prevalence of alcohol, tobacco and other drug use among youths in 

the Presque Isle and greater Bangor areas. We surveyed a sample of middle and high school 

students from the Hampden and Presque Isle School Districts during the spring of 2001, and are 

scheduled to survey students from the Brewer School District during the fall of 2001. Findings 

from the youth survey will be presented in a forthcoming special report on youth health and 

substance use. 

Peer Communities 

We constructed two sets of “peer communities” for the study regions under consideration here. 

We constructed an ‘urban peer’ with population, socioeconomic, and delivery system 

characteristics comparable to those found in the Bangor study region. Per consensus of the study 

working groups, the urban peer was comprised of the towns within the Lewiston HSA. We also 

constructed a ‘rural peer’ with population, socioeconomic and delivery system characteristics 

comparable to those found in all other study regions. Appendix 10 shows the towns included 

within the rural peer group. That group of communities was constructed by applying PHRG’s 

peer town algorithm to each of the regions included in the study. The algorithm used the sociodemographic 

characteristics of the study areas, including total population, the age distribution of 

the population, unemployment, poverty, education and income, to identify towns in Maine with a 

similar composition. All towns identified as being similar to at least one of the study regions 

were included in the rural peer group. 


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Because of greater similarities in the underlying drivers of health (poverty, income, education, 

age structure, etc.), comparisons to peer communities are generally more informative about the 

health needs of an area than are comparisons to the State or the nation. Major differences 

between the study regions and their respective peers are more likely due to differences in disease 

burden or differences in health care practices and resources. State and national comparisons are 

also presented, however, when both the study regions and peer communities are above or below 

expected standards, or simply to inform the reader. 

Interviews 

We conducted interviews with local health care providers during the second phase of this study 

in an effort to further elucidate as well as validate the preliminary health status and service need 

findings that we gleaned from our analysis of the quantitative indicators. Potential interviewees 

were identified with the assistance of EMH personnel as well members of the Project Steering 

Committee and Working Groups. We conducted a total of 42 separate interviews with health 

care providers and hospital administrators from across the seven-region study area (See 

Appendix 11 for a list of interviewees). Interviews were conducted by either Dr. Ronald Deprez, 

the study’s Principal Investigator, or by other PHRG personnel with particular expertise in rural 

mental health services, substance abuse services or elder care. 

Findings 

The findings and recommendations in this report are based on an analysis of patterns discerned 

from both the quantitative indicators and qualitative information compiled for the assessment. 

For example, Preventive Health Services are assessed based on screening and patterns of 

behavioral risk factors (e.g., smoking, insufficient physical activity, overweight); Detection 

Services are based on patterns of medical risks (e.g., prevalence of diagnosed hypertension), 

while Treatment Services are based on significant clinical outcomes (e.g., hospitalizations and 

deaths due to heart attacks). Patterns are then evaluated in light of qualitative information about 

existing services derived from providers and residents. Recommendations regarding service 

needs are developed only after integrating information from all sources. Useful explanatory 

notes and definitions that will clarify the findings presented in this report are included in 

Appendices 7 (data sources), 12 (definition of indicators) and 13 (defining codes). 

The findings and recommendations described below are meant to stimulate discussions among 

providers and the community regarding the prioritization of health care needs and related service 

delivery changes required to better meet the needs of area residents. In general, the results of 

this assessment suggest that the health status of the population is good and the health care 

delivery system is accessible and of high quality. For example, indicators of diabetes care were 

particularly favorable in the Bangor, Washington and Knox-Waldo regions. Certain sectors of 

northern, eastern and central Maine do, however, experience significant health issues related to 

cardiovascular risks and disease burden, respiratory health, cancer care, substance abuse, mental 

health and access to primary care. 

IV. KEY HEALTH FINDINGS 


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Population Profile 

The total study area is home to approximately 500,000 adults and children. Figure 1 shows the 

1990 and 2000 population in the seven study regions (See Appendix 3 for definitions of each 

region). The Bangor and Central communities have the largest populations; Washington has the 

smallest. Except for the Aroostook region, which showed a 14% decline in its total population 

from 1990 to 2000, the overall size of all study communities either remained constant or 

increased slightly (i.e., between 5 and 8%) over the past decade. 

Figure 1: Population of EMH's 7 Service Regions 

140000 

120000 

100000 

80000 

60000 

40000 

20000 

0 

121489 

119663 

83596 

72058 

48343 

48343 

29831 

38246 

29942 

106985 

40417 

110922 

57635 

62140 

Bangor 

Aroostook 

Penquis 

Washington 

Hancock 

Central 

Knox-Waldo 

1990 Pop 2000 Pop 

However, as Figure 2 shows, the demographic composition of most study regions has changed. 

Mirroring trends observed across the State; the size of the youth (0-17) and young adult (18-44) 

populations has decreased in most study regions since 1990. The largest declines occurred in the 

Aroostook region, where the 0-4 year old cohort decreased by 20% and the 5-17 year old cohort 

decreased by 15%. In contrast, the Hancock, Central and Knox-Waldo regions saw a 5-10% 

increase in the size of their 5-17 year old populations. Proportionally, the youth population in 

most EMH regions was still similar to that in the State in 2000. In contrast, the size of the 

middle age (45-64) and elderly (65+) populations generally increased. 


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Figure 2: Population Trends in EMH's 7 Service Regions 

30.0% 

20.0% 

Percent Change 

1990 to 2000 

10.0% 

0.0% 

-10.0% 

-20.0% 

-30.0% 

0-4 years 5-17 years 18-44 years 45-64 years 65+ years 

Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Maine 

As a result, middle aged and older adults accounted for a larger proportion of the population in 

each study region in the Year 2000 than they did in 1990 (See Figure 3). Population projections 

show those trends continuing through 2005. Since health needs generally increase with age, and 

the proportion of older adults is increasing, the demand for health services is likely to increase 

in these communities. Moreover, many of the study regions – namely Penquis, Washington, 

Hancock and Knox-Waldo – have a larger proportion of elderly (65+ and 75+) residents than in 

the State as a whole. In contrast, the proportion of elderly in the Bangor region is smaller than 

that in the State. As in the State as well as in the rest of the nation, the populations of 

northern, eastern and central Maine are aging. As those populations become older, overall 

health status will decline and need and demand for health services will increase. 


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Figure 3: Age Distribution in EMH's 7 Service Regions (1990 and 2000) 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

65+ 

45-64 

0-44 

30% 

20% 

10% 

0% 

Bangor 1990 

2000 

Aroostook 1990 

2000 

Penquis 1990 

2000 

Washington 1990 

2000 

Hancock 1990 

2000 

Central 1990 

2000 

Knox-Waldo 1990 

2000 

Maine 1990 

2000 

Health-Based Social and Economic Characteristics 

FINDINGS: Socioeconomic status in certain portions of northern, eastern and central 

Maine is low relative to peer communities and the State as a whole. 

• The Bangor, Hancock and Knox-Waldo regions showed a favorable pattern of 

socioeconomic indicators relative to their respective peers and the State. 

• The Washington region had the lowest rate of educational attainment and the largest 

unemployed, uninsured and Medicaid populations. 

• The Aroostook, Penquis and Central regions also showed a relatively unfavorable pattern of 

socioeconomic indicators. 

It is well documented that socioeconomic status is associated with the health status of a 

population. 2 Thus, it is important to understand the socioeconomic conditions of a community in 

order to completely understand the health and well being of its residents. As shown in Table 1, 

the Greater Bangor Area was the most socio-economically prosperous sector of the study area. 

The proportion of Bangor area adults (age 25+) with a high school diploma was similar to that 

in the State and more than 30% larger than in its peer. The rate of unemployment was likewise 

not elevated over that in the peer and State, and the Medicaid and uninsured populations were 

smaller. We observed a similar, albeit less dramatic profile for the Hancock and Knox-Waldo 

regions. 

2 Mackenbach JP, Kunst AE, Groenhof F. et. al. “Socioeconomic inequalities in mortality among women and men: 

An international study.” American Journal Public Health. 1999. 89:1800-1806. 


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Table 1: Selected Socioeconomic Indicators by Service Region 

Indicator 

% of Population 

Not Attaining a 

High School 

Diploma 

Bangor 

Urban 

Peer 

Aroostook Penquis Washington Hancock Central Knox-Waldo 

Rural 

Peer 

19.1 27.8 30.3 25.1 26.9 17 25.7 20.8 20.2 21 

Maine 

% of Labor Force 

Unemployed 


on Medicaid (All 

Ages) 


Uninsured 

3.6 4 5.6 7.3 9.1 6.2 7.2 3.4 5.2 4.1 

13 17.3 20.6 15.7 20 14.3 15.5 15.6 15.4 16.1 

9 8.6 12.6 12.9 18.7 19.5 13.8 13.5 12.1 13.4 

Source: EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS 

Survey (1996-1999): Urban Peer, Rural Peer and Maine; CDC BRFSS Survey (1998-1999): U.S. 

November 1, 2001 9 PHRG


In contrast, the pattern of socioeconomic indicators was least favorable in the Washington 

region. Unemployment in that community was 75%-120% higher than in the peer or State. 

Perhaps due in part to the larger elderly population in that area, the proportion of Washington 

region adults without a high school diploma was 35% higher than in the peer and State and the 

Medicaid and uninsured populations were 25%-60% larger, respectively. Socioeconomic 

indicators were also generally unfavorable in the Aroostook, Penquis and Central regions, 

especially with respect to educational attainment and unemployment. Overall, these findings 

indicate that socioeconomic conditions in certain sectors of northern, eastern and central 

Maine might contribute to poor health and/or limit access to health care services. 

Chronic Disease Burden and Population Wellness 

FINDINGS: Chronic disease burden and risks for future chronic disease are elevated in 

certain portions of the study area. 

• Current chronic disease burden was most favorable in the Hancock region and least favorable 

in the Washington, Aroostook and Knox-Waldo regions. 

• Risk for future chronic disease due to obesity and/or smoking was elevated in the Hancock 

and Penquis regions, as well as in the Aroostook and Washington regions. 

• The chronic disease population in most study areas also showed significant behavioral risks. 

• Relative to the peer and State, the ‘well’ population was smallest in the Washington, 

Aroostook and Penquis regions. 

PHRG developed a population wellness profile that integrates data on diagnosed chronic 

illnesses (diabetes), medical risks (hypertension, hypercholesterol), health risk behaviors 

(overweight, smoking), and self-reports of health and health functioning into a composite 

measure of overall health. It classifies people into one of four mutually exclusive categories of 

wellness: 1.) Well, 2.) At risk for future medical problems, 3.) Some health problems that 

require ongoing medical attention, and 4.) Chronically ill or not well (See Appendix 12 for a 

more complete definition of this measure). The wellness profile is particularly useful for 

planning because both health risks and the presence of disease are important predictors of health 

service utilization as well as need. It also has value in its parsimony since it integrates multiple 

dimensions of health into a single, overall measure of health status. We also used self-reports of 

three or more chronic diseases as an indicator of chronic disease burden in the population (See 

Appendix 12 for a list of potential chronic diseases). 

Chronic disease indicators were most favorable in the Hancock region and least favorable in the 

Washington region (See Figures 4 and 5). Just under 1 in 3 Washington region adults (8,600) 

has been diagnosed (by a physician) with 3 or more chronic diseases and 1 in 4 (6,600) have 

been classified as ‘not well’ according to PHRG’s wellness profile. The Aroostook and Knox- 

Waldo regions also have larger chronic diseased populations than in the peer or State. Nearly 

one-quarter of the adults in those regions (about 13,000 and 11,000, respectively) have been 

diagnosed with three or more chronic diseases and 16% (about 8,500 and 7,500 adults, 

respectively) were classified as ‘not well.’ The latter classification was most prevalent among 

elderly residents of both Aroostook (30%) and Knox-Waldo (25%). 



Figure 4: Wellness by EMH Service Region 

100% 

80% 

60% 

40% 

20% 

0% 

Bangor 

Urban Peer 

Aroostook 

Penquis 

Washington 

Hancock 


Knox-Waldo 

Rural Peer 


Well At Risk Some Health Problems Not Well 

Figure 5: % Adults Reporting 3+ Chronic Diseases by EMH Service Region 

35 

30 

25 

20 

15 

10 

5 

0 

20.2 

23.5 

21.1 

28.6 

Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo 

The prevalence of 3+ chronic diseases among the elderly was highest in the Washington, 

Bangor, Aroostook and Knox-Waldo regions (50-60%) and lowest in the Central region (34%). 

Rates among middle age adults were also highest in the Washington, Aroostook and Penquis 

regions (30-35%) and lowest in the Hancock region (20%). 

The proportion of the population with 3+ chronic diseases was higher among the insured (25%) 

than among the uninsured (15%) in all regions except Bangor and Penquis where rates were 

similar in both groups (about 20%). Among the insured, the prevalence of 3+ chronic diseases 

was highest among Medicare recipients followed by Medicaid and Champus recipients. 

Adults with 3+ chronic diseases were as likely as their well adults to be current smokers (30%) 

and more likely (by 60-80%) to be former smokers. The only exception to this pattern was in the 

Central region where adults with multiple chronic diseases were 40% more likely than well 

adults to be current smokers. In addition, about half of all adults with multiple chronic diseases 

were classified as obese – 30-60% more than adults without multiple chronic diseases. Finally, 

19.1 

21 

23.6 



in most study regions, chronic drinking was twice as prevalent among adults with multiple 

chronic diseases than among those without multiple chronic diseases. 

The proportion of adults classified as ‘at risk for future chronic disease’ was also elevated in the 

Washington and Aroostook communities, as well as in the Penquis and Hancock regions. That 

classification was made for adults age 35 and over who were also either current regular cigarette 

smokers and/or overweight according to a body mass index. 

Finally, the size of the ‘well’ population in the Washington, Aroostook and Penquis regions was 

smaller than that in either the peer communities or the State. The ‘well’ population is 

characterized by the absence of diagnosed diabetes, hypertension and hypercholesterol; the 

absence of disease symptoms; and a favorable behavioral and medical risk profile for chronic 

disease. Overall, the wellness profile suggests that prevention and treatment initiatives are 

needed in certain sectors of northern, eastern and central Maine in order to reduce unhealthy 

lifestyles and minimize the impact of chronic disease in the population. 

Functional Health Status 

FINDINGS: In general, residents of those communities with the largest chronic disease 

burden also tended to report the highest levels of poor health and functional 

impairment. 

• The prevalence of fair or poor health was highest in the Washington, Aroostook and Penquis 

regions. 

• The Washington, Aroostook and Knox-Waldo regions had the highest prevalence of poor 

health days, health-related activity limitations and needs for assistance with personal care 

and routine tasks. 

• Several indicators of functional health impairments were also elevated in the Bangor and 

Central regions relative to the peer communities and the State. 

• The Hancock region had the most favorable functional health profile. 

Functional health status in northern, eastern and central Maine tended to mirror chronic disease 

burden in those communities. As Table 2 illustrates, residents of the Washington, Aroostook 

and Penquis regions were more likely than residents of their peer communities and the State to 

describe their overall health as either fair or poor. Moreover, Washington, Aroostook and 

Knox-Waldo residents were more likely than residents of the rural peer or the State to have 

experienced eleven or more days in the month prior to the survey during which either their 

health was poor or they were unable to perform their usual activities because of poor health. 

Residents of the same areas, as well as those in the Central region, were also the most likely to 

report that they or someone in their household were limited in their usual activities because of 

health problems. Depending on the indicator and the region, elevations in functional health 

impairments emerged in all adult age groups, even the 18-44 year old cohort. In contrast, 

indicators of functional health impairments in the Hancock region were consistently lower than 

those in the peer communities and the State. 



Table 2: Selected Functional Health Status Indicators by EMH Service Region 

Indicator Bangor Urban Peer Aroostook Penquis Washington Hancock Central Knox-Waldo Rural Peer Maine 

3+ Chronic Diseases 20.2 NA 23.5 21.1 28.6 19.1 21 23.6 NA NA 

18-44 years 9.3 NA 10.6 5.5 12.1 7.9 14.2 12.4 NA NA 

45-64 years 25 NA 30.5 31.9 34.9 31.8 24.1 22.5 NA NA 

65+ years 48.4 NA 48.4 40.8 57.3 43.8 34.4 48.7 NA NA 

'Not Well' Population 16.2 14.8 15.7 15.1 21.9 10 16.2 15.3 10.9 13 

18-44 years 10.2 NA 6.1 4.2 10.2 1.8 11.9 9.9 NA NA 

45-64 years 14 NA 23.8 23.9 27.8 10.7 15.6 15.2 NA NA 

65+ years 40 NA 31.3 26.8 40.5 27 29.7 27.3 NA NA 

Fair or Poor Health 12.8 15.4 16.3 16 23.2 9.3 14.3 12.6 12.7 13.8 

18-44 years 9.7 NA 12.7 7.9 18.2 4.9 12.5 9.9 NA NA 

45-64 years 11.7 NA 20.2 24.1 22.9 9 13 13.4 NA NA 

65+ years 25 NA 22.6 21.4 37.5 19.2 21.9 16.9 NA NA 

11+ Days of Poor 

Physical Health 15.4 11.8 13.7 11.6 15.5 9.1 9.1 14.1 11.1 10.9 

18-44 years 13.9 NA 13.5 6.2 11.2 8.5 10.3 14.9 NA NA 

45-64 years 13.3 NA 16.5 17.9 19.3 9.9 5.6 10.8 NA NA 

65+ years 23.4 NA 11.3 14.3 21.3 10 12.9 18.7 NA NA 

11+ Days of Usual 

Activity Lost Due to Poor 

Health 7.9 6 9.9 7.5 9.3 4.2 7.4 9.4 8.5 6.2 

18-44 years 5.5 NA 9.4 7.6 8.0 5.9 10.0 11.3 NA NA 

45-64 years 12.0 NA 12.9 8.9 11.5 4.5 3.7 8.5 NA NA 

65+ years 8.4 NA 6.6 4.9 9.3 0.0 6.5 7.1 NA NA 

Health Related Activity 

Limitation (Household) 23.4 NA 24.5 22.2 27.3 18.3 28.8 24.9 NA NA 

Sources: EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996-1999): Urban 

Peer, Rural Peer and Maine; CDC BRFSS Survey (1998-1999): U.S. 

NA = not available 

November 1, 2001 13 

PHRG


Poor functional health and high levels of emotional distress were particularly common among 

adults with multiple chronic diseases. The prevalence of health-related activity limitations was 

2-7 times higher among adults with multiple chronic diseases than among those without multiple 

chronic diseases. Activity limitations among adults with multiple chronic diseases were highest 

(50%) in the Aroostook region and lowest (20%) in the Hancock and Washington regions. The 

prevalence of poor physical health days was 2-5 times higher among adults with multiple chronic 

diseases than among those without multiple chronic diseases. Poor physical health days among 

adults with multiple chronic diseases were most prevalent (40%) in the Bangor region and lowest 

(20-25%) in the Hancock and Central regions. 

The prevalence of poor mental health days was 2-4 times higher among adults with multiple 

chronic diseases than among those without multiple chronic diseases. Approximately 20% of 

adults with multiple chronic diseases reported experiencing 11+ days of poor mental health in 

the past month. Finally, the use of outpatient mental health services was 2-4 times higher among 

adults with multiple chronic diseases than among those without multiple chronic diseases. 

Approximately 20% of adults with multiple chronic diseases reported using outpatient mental 

health services in the past year. 

Taken together, these findings support a need to evaluate the adequacy of treatment and 

rehabilitative services for residents who suffer from one or more chronic diseases, especially 

those in the Washington and Aroostook regions. 

Primary Care 

FINDINGS: Access to primary care physicians and/or services is favorable in most sectors 

of northern, eastern and central Maine, but rates of preventable 

hospitalizations for respiratory and cardiovascular disorders were elevated 

in nearly all study regions. 

• The proportion of the population without health insurance was lowest in the Bangor region 

but highest in the Washington and Hancock regions. 

• The population without a regular source of medical care or a wellness exam in the past two 

years was smaller in most study regions than it was in the peer communities or State. 

• Men in the Penquis, Central and Knox-Waldo regions were more likely than men in the peer 

communities or State to lack primary care services. 

• Pneumonia and Influenza vaccination rates in all study regions exceeded those in peer 

communities and the State, overall and among the elderly. 

• Ambulatory care sensitive (ACS) hospitalization rates for respiratory and cardiovascular 

diseases among adults were elevated in all regions except Knox-Waldo. 

• ACS hospitalization rates for respiratory disorders among youths were elevated in the 

Aroostook region. 

Access to primary care services was favorable in most sectors of northern, eastern and central 

Maine. The size of the uninsured population in most study regions was similar to that in the 

peer communities and in the State. The exceptions were the Washington and Hancock regions, 

where the uninsured populations were approximately 50% larger than those in the peer and 

November 1, 2001 14


State. It should be noted, however, that health care coverage rates in all study communities fell 

short of the Year 2010 objective that all persons in the U.S. under the age of 65 have health 

insurance. 3 

The population of each study region without a recent physical exam was either smaller than or 

similar to that in the peer communities and State. Moreover, the populations without a regular 

source of care was small in most study regions. 4 In some communities, such as the Washington 

region, the proportion of adults without a specific source of ongoing primary care (5%) 

approached the U.S. Year 2010 objective that only 4% of all persons lack a regular source of 

ongoing care. Other areas, such as Penquis and Central, where 10% of adult residents reported 

not having a regular source of primary care, fell far short of the national 2010 objective. 5 In 

addition, a large proportion of men (approximately 16%) in the Penquis, Central and Knox- 

Waldo regions reported that they did not have a regular provider (See Figure 6). 

30% 

Figure 6: Primary Care- 

Selected Indicators for Males by EMH Service Region 

20% 

10% 

0% 

% Without a Regular Source of Care % Not Having a Check-up in the Past 2 Years 

Bangor Urban Peer Aroostook Penquis Washington Hancock Central 

Knox-Waldo Rural Peer Maine US 

Lifetime pneumonia and past year influenza vaccination rates among middle age and elderly 

adults in each study region exceeded those in the peer communities and in the State (See Figure 

7). Although higher than in comparison communities, vaccination rates among the elderly in 

each study area (which ranged from 69%-86% for influenza and from 62%-70% for 

pneumonia) fell short of the national objective for the Year 2010 that 90% of U.S. adults over 

the age of 65 are appropriately immunized against influenza and pneumonia. Primary care 

findings suggest that routine and regular care is accessible and utilized by a large majority of 

residents of northern, eastern and central Maine. At the same time, access to primary care in 

3 U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd 

ed. Washington, DC: U.S. Government Printing Office, November 2000. 

4 Only a small proportion of respondents who reported having a regular source of medical care identified the 

emergency department as their medical home, specifically 4% in the Hancock region, 3% in the Central region and 

1% or fewer in all other study regions. 

5 PHRG’s health insurance and regular source of care indicators are similar but not directly comparable to the 

indicators used in the Year 2010 objectives. The former are based on survey questions that asked respondents if 

they had health care insurance or a family/regular doctor. In contrast, the HP 2010 objectives pertain to both adults 

and children, i.e., that 100% of persons under the age of 65 have health care insurance and that only 4% of all 

persons do not have a source of ongoing primary care. PHRG’s questions did not specifically ask if a respondent’s 

health insurance plan or regular source of care also covered their children. 

November 1, 2001 15


all communities needs to be improved over the next decade to meet the health objectives set 

forth for the country. 

Figure 7: Primary Care - 

Selected Indicators for 65+ Population by EMH Service Region 

100% 

80% 

60% 

40% 

20% 

0% 

Ever Vaccinated against Pneumonia 

Vacinated against Influenza in the past year 

Bangor Urban Peer Aroostook Penquis Washington Hancock Central Knox-Waldo Rural Peer Maine US 

The rate of hospital admissions for ambulatory care sensitive (ACS) conditions is also 

considered an indicator of primary care in a population. ACS conditions are those that are less 

likely to result in hospitalization when treated on an outpatient basis with high quality primary 

medical care and good patient compliance. 6 Therefore, higher rates of hospitalizations for ACS 

conditions may be an indication of poorer access to and/or quality of primary care in an area. 

They may also be due to poorer underlying health status (disease prevalence) in a population 

since a higher than expected prevalence of disease can account for elevated ACS hospitalization 

rates. 

The ACS conditions used in this assessment are listed below: 

• Adult and Child Ear Infection • Respiratory Infection & Inflammation 

• Chronic Obstructive Pulmonary Disease (COPD) • Adult and Child Pneumonia 

• Adult and Child Bronchitis & Asthma • Heart Failure & Shock 

• Cardiac Arrest • Hypertension (High Blood Pressure) 

• Chest Pain • Angina Pectoris 

• Cellulitis • Diabetes 

Despite other indicators showing adequate access to primary care, rates of hospitalizations for 

ACS conditions among adults were moderately elevated over those in peer communities and 

the State in all study regions except Knox-Waldo (See Figure 8). In most areas, ACS 

hospitalization rates were elevated for respiratory and/or cardiovascular conditions in some or 

all adult age groups, regardless of disease prevalence rates in those areas. In the Bangor, 

Aroostook and Washington regions, for example, elevations in ACS hospitalization rates were 

high among 45-64 and 65+ year olds for respiratory (asthma/bronchitis, COPD, pneumonia) and 

6 

Refer to Appendix 12 

November 1, 2001 16


cardiovascular conditions (angina, heart failure, hypertension) (See Table 3). In contrast, ACS 

hospitalization rates among 18-44 year olds in the Hancock region were elevated over peer 

rates, especially for asthma/bronchitis (141 vs. 58 per 100,000), pneumonia (93 vs. 65), chest 

pain (189 vs. 98) and heart failure (45 vs. 2). Rates of ACS hospitalizations for respiratory and 

cardiovascular conditions were fairly consistently elevated in all age groups in the Penquis and 

Central regions. 

Only the Aroostook region showed elevated rates of ACS hospitalizations among youths. 

Youths in that region were 30% more likely than peer youths to be hospitalized for diabetes (55 

vs. 43 per 100,000 0-17 year olds, respectively) and 55% more likely to be hospitalized for 

either asthma/bronchitis (412 vs. 267, respectively) or pneumonia (177 vs. 113, respectively). 

Figure 8: Total Ambulatory Care Sensitive (ACS) Hospital Admission Rates 

Per 100,000 Population by EMH Service Region 

2500 

2000 

1500 

1000 

500 

0 

Bangor 

Urban Peer 

Aroostook 

Penquis 

Washington 

Hancock 


Knox-Waldo 

Rural Peer 


Moreover, the rate of pediatric asthma hospitalizations in the Aroostook region was more than 

twice as high as the national Year 2010 objective for pediatric asthma admissions (412 vs. 173 

per 100,000). The lifetime prevalence of physician diagnosed asthma among Aroostook region 

youths was correspondingly high at over 20%. 

November 1, 2001 17


Table 3: Hospitalization Rates for Selected ACS Respiratory and Cardiovascular Conditions by EMH Service Region 

Indicator 

Bangor Urban 

Peer 

Aroostook Penquis Washington Hancock Central Knox- 

Waldo 

Asthma/Bronchitis 

45-64 201.5 52.3 104.7 60.3 93.1 80.9 110.5 97.8 62.1 84.4 162 

65+ 172.5 131.4 394.8 255.8 78.2 155.8 215.6 156.1 125.7 176.2 177 

Pneumonia 

45-64 273.2 263.8 344.9 261.3 272 337.9 305.8 249.5 228.1 239.3 309.9 

65+ 1592.8 1657.7 2034.4 1717.2 2132.2 2057.4 1750 1317.5 1342.6 1526.9 1831 

COPD 

45-64 416.6 359.7 529.7 393.9 400.9 271.3 370.9 384.4 254.7 322.4 276.9 

65+ 1559 1068.1 1867.2 1577.2 1594.3 1109.8 1600 1069.6 1133.2 1288.4 1091.7 

Angina 

45-64 94.9 28.3 542 361.7 272 128.5 171.6 198.9 136.9 152.4 NA 

65+ 172.5 74.1 1365.5 749 528.2 408.9 393.8 348.9 408.4 398.3 NA 

Heart Failure 

45-64 166.6 209.3 255.6 201 164.6 199.9 183.5 192.2 169.8 171.3 NA 

65+ 1525.2 1421.8 2155.1 1686.8 2073.6 1726.4 1746.9 1643.4 1445.3 1627.5 NA 

Data Sources: MHDO Hospital Discharge Data (1998-2000) All study regions, Peers, and Maine; HCUP (1997): U.S. 

All rates expressed are per 100,000 


Rural 

Peer 


US 



V. KEY FINDINGS FOR SPECIFIC AREAS OF HEALTHCARE 

The following section reports on specific health issues in the study regions. 

Cardiovascular Health 

FINDINGS: Risks for cardiovascular disease were elevated in most sectors of northern, 

eastern and central Maine, as were indicators of cardiovascular disease 

morbidity and mortality. 

• Current tobacco use, obesity and/or diabetes were elevated in most study regions. 

• Hypercholesterol and/or hypertension prevalence were elevated in the Bangor, Aroostook, 

Penquis and Washington regions. 

• Heart attack hospitalization and mortality rates were elevated in the Aroostook, Penquis, 

Washington and Hancock regions. 

• Heart attack and stroke mortality rates were elevated in the Bangor region, despite lower 

rates of heart attack and stroke hospitalizations. 

Behavioral and medical risks for cardiovascular disease were elevated in many sectors of 

northern, eastern and central Maine, as were indicators of disease morbidity and mortality 

(See Table 4). Cardiovascular disease (CVD) is a category of disorders affecting the heart and 

blood vessels, and includes coronary heart disease, diseases of the heart, atherosclerosis, 

hypertension, and cerebrovascular disease (stroke). The major risk factors for CVD are 

smoking, physical inactivity, hypertension, and overweight. Diabetes is a complicating factor. 

Widely regarded as the single most preventable cause of disease and death in the United States, 

smoking rates were high in most study areas. Compared to their peer communities, the 

prevalence of current cigarette smoking was 15-30% higher in the Bangor, Aroostook and 

Central regions. Between 40-50% of 18-44 year old men and 30-40% of 18-44 year old women 

in those communities reported that they were current smokers. Compared to Maine as a whole, 

smoking prevalence was elevated in all communities except Knox-Waldo. All study areas, 

including Knox-Waldo, had smoking rates that were double (or higher) the nation’s goal that 

only 12% of adults will be smokers in the Year 2010. 

Although measures of physical activity were not unfavorable in the study regions, risks related to 

being overweight were elevated in all areas except Hancock. The highest rates emerged in the 

Bangor, Aroostook, Penquis and Washington regions where obesity was 30-50% higher than in 

the peer or State. Geographic variation in diabetes prevalence followed a similar pattern with the 

highest rates in the Bangor and Washington regions. The Hancock region was the only study 

area where the prevalence of diabetes did not exceed the peer or State rate – and it was the only 

community where the prevalence of obesity was not elevated. Pediatric diabetes was rare in the 

study populations. 



Table 4: Behavioral and Medical Risks for Cardiovascular Disease by EMH Service Region 

Indicator Bangor Urban Aroostook Penquis Washington Hancock Central Knox- Rural Maine US 

Peer 

Waldo Peer 

% Current Smoking 1 29.9 23.2 32.0 25.7 27.0 25.5 30.9 21.1 26.8 23.5 22.6 

Males 33.2 NA 35.2 27.8 25.1 29.2 33.5 18.9 NA 24.4 25.0 

Ages 18-44 41.0 NA 51.1* 38.8 28.6* 35.1 40.9* 23.9* NA 32.7 28.7 

Ages 45-64 26.9 NA 26.4 25.8 26.9 26.0 30.4 20.3 NA 18.5 25.5 

Ages 65+* 13.6* NA 22.7* 21.4* 14.8* 20.0* 15.0* 4.5* NA 7.9 12.3 

Females 27.1 NA 24.9 24.2 28.6 21.8 28.4 23.1 NA 21.3 21.3 

Ages 18-44 33.0 NA 34.7 31.8 36.8 34.9 39.6 31.6 NA 27.2 26.0 

Ages 45-64 26.4 NA 21.3 18.2 32.5 17.7 21.6 22.7 NA 18.1 21.9 

Ages 65+ 11.1 NA 8.2 17.5 10.0 3.6 14.3 8.9* NA 12.3 9.9 

% Former Smoking 1 30.7 30.3 27.7 34.6 32.0 29.2 29.3 38.4 30.8 29.7 24.9 

% Sedentary Lifestyle 1 23.3 30.7 25.0 29.5 27.2 25.8 28.0 25.3 27.7 27.2 28.0 

Males 22.9 NA 27.4 30.4 24.8 31.8 25.0 26.0 NA 26.7** 26.9** 

Ages 18-44 25.3 NA 23.4* 34.7 26.2* 33.3 23.3* 28.3* NA 23.2** 21.8** 

Ages 45-64 23.1 NA 31.5 29.0 21.2 28.0 28.1 25.4 NA 26.8** 30.7** 

Ages 65+ * 13.6* NA 26.1* 21.4* 29.6* 36.0* 20.0* 22.7* NA 38.1** 35.6** 

Females 25.5 NA 22.7 29.0 29.5 20.3 31.1 23.9 NA 28.7** 30.6** 

Ages 18-44 15.5 NA 25.3 25.8 22.1 14.5 31.9 22.8 NA 25.3** 25.5** 

Ages 45-64 30.8 NA 15.7 23.2 32.5 16.5 22.7 22.4 NA 29.4** 30.9** 

Ages 65+ 34.9 NA 29.5 42.4 38.8 34.5 44.9 28.9* NA 35.6** 41.3** 

% Obesity 1 40.7 27.1 39.5 44.5 44.4 32.5 35.2 34.8 31.4 31.4 31.8 

Males 38.2 NA 44.4 48.8 49.6 33.1 38.0 35.4 NA 32.1 30.4 

Ages 18-44 31.3 NA 40.4* 44.9 57.1* 30.4 29.5* 34.8* NA 28.1 25.9 

Ages 45-64 46.2 NA 53.7 51.6 50.0 36.0 45.6 35.6 NA 41.2 36.7 

Ages 65+* 45.5* NA 30.4* 50.0* 37.0* 33.3* 35.0* 36.4* NA 27.9 31.9 

Females 43.6 NA 39.4 44.4 42.1 36.8 37.4 35.4 NA 29.6 30.4 

Ages 18-44 43.6 NA 33.8 36.5 34.8 26.7 31.8 36.8 NA 24.9 25.9 

Ages 45-64 43.8 NA 54.1 41.5 53.9 47.9 41.4 30.0 NA 37.6 36.7 

Ages 65+ 43.4 NA 25.0 57.6 37.5 35.9 40.4 44.2* NA 29.8 31.9 

Diagnosed Diabetes 1 9.7 4.8 7.6 8.4 11.8 5.9 8.0 8.5 5.9 6.5 6.6 

Cholesterol Checked (Past Year) 1 54.4 47.5 54.6 54.0 53.3 47.5 52.8 54.9 47.5 50.1 50.0 

Diagnosed Hypercholesterol 1 27.9 25.5 20.3 22.0 25.4 21.0 23.2 22.2 24.2 23.2 21.3 

Diagnosed Hypertension 1 23.4 21.9 30.5 30.4 33.1 25.6 29.4 28.4 25.5 26.5 23.7 

Heart Attack Hospitalization Rate (65+) 2 1467.7 1637.5 2303.8 1839 2200.7 2381.9 1803.1 1537.8 1212.8 1512.2 1261.5 

Heart Attack Mortality Rate (65+) 3 532.9 435.3 611.2 510.3 641.6 623 431.2 482.9 498.5 500.6 NA 

Stroke Hospitalization Rate (65+) 2 754.1 741.2 970.7 889.1 939 1083.9 771.9 890.6 842 904 1419.5 

Stroke Mortality Rate (65+) 3 442.3 365.2 431.5 370.2 367.7 473.1 347.5 479.2 383.7 394.9 NA 

Sources: 1 EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1998-1999): Urban Peer, Rural Peer and Maine; CDC BRFSS 

Survey (1998-1999): U.S 

2 MHDO Hospital Discharge Data (1998-2000) All study regions, Peers, and Maine; HCUP (1997): U.S. 

NA = not available. 

* Proportion based on less than 50 cases. ** Proportion based on 1998 data only. 



High levels of other medical risk factors were evident in certain sectors of the study area. The 

prevalence of physician-diagnosed hypercholesterol was 10-20% higher in the Bangor area 

compared to its peer and the State, although the screening rate in that community was also 

higher. Physician-diagnosed high blood pressure (hypertension) was not elevated among Bangor 

area residents, but it was 15-25% more prevalent in Aroostook, Penquis, Washington, Central 

and Knox-Waldo compared to the peer and State. Neither hypercholesterol nor hypertension 

was elevated in the Hancock region. However, it is possible that disease detection needs to be 

improved since the rate of past year cholesterol screenings in that area was lower than that in all 

other study communities. High blood pressure, a major risk factor for stroke and heart disease, 

has no clear symptoms; regular blood pressure measurements are needed for detection and 

control. 

The burden of heart disease was most apparent in the Aroostook, Washington and Hancock 

regions, where rates of heart attack hospitalizations and deaths in the 65 and older population 

were substantially elevated over those in the peer and State. The same pattern emerged in the 

Aroostook and Hancock communities for cerebrovascular disease (stroke). In the Bangor region, 

heart attack and stroke death rates were 20-25% higher than corresponding peer rates although 

heart attack and stroke hospitalization rates fell below those for the peer. In general, the 

cardiovascular health profile of the populations served by EMH suggests a need for expanded 

primary prevention activities to reduce behavioral and medical risks for heart attacks and 

strokes, as well as enhanced secondary prevention to improve treatment outcomes for patients 

with cardiovascular disease. 

Respiratory Health 

FINDINGS: Behavioral risks for respiratory disease were elevated in most study regions. 

Morbidity and mortality were high in several regions. 

• Risk for respiratory disease is high based on current and former smoking patterns. 

• Lung cancer incidence was elevated among men, but deaths due to lung cancer were lower 

among both men and women. 

• COPD deaths among the elderly were 15% below the peer and State while COPD 

hospitalizations for this group were comparable to the peer and State. 

• Rates of flu and pneumonia vaccinations were high, especially for the elderly. 

• The prevalence of asthma in children (


31% and 30%, respectively). Further examination showed that the former smokers in the Knox- 

Waldo region were younger (between 18 and 44) than the former smokers in all other study 

regions. Rates of current smoking in all service regions (including Knox-Waldo) were twice as 

high (or higher) than the national goal for tobacco use among US adults in the Year 2010 (i.e., 

12%). 

Utilization rates for clinical preventive services related to respiratory health were favorable in all 

study regions. Rates of pneumonia (lifetime) and influenza (past year) vaccinations among 

middle age and elderly adults in each study region exceeded those in the peer communities and 

in the State. However, vaccination rates among the elderly in each study area (which ranged 

from 69%-86% for influenza and from 62%-70% for pneumonia) fell short of the Year 2010 goal 

that 90% of U.S. adults over the age of 65 are appropriately immunized against influenza and 

pneumonia. 

Table 5 shows that the prevalence of current physician-diagnosed asthma among adults in the 

Bangor, Penquis, Central and Knox-Waldo regions was 15-25% higher than in the peer 

communities or the State. Asthma prevalence among youths was high in all study regions 

(ranging from 11-23%), but was particularly high in the Bangor (23%) and Aroostook (21%) 

communities. Because most patients can be effectively managed on an outpatient basis, pediatric 

and adult asthma is considered an ACS condition that should not typically require hospitalization 

(See Appendix 12 for a more detailed explanation of ACS conditions). However, rates of 

asthma-related hospitalizations among middle age and elderly adults were elevated in many 

portions of the study area – particularly in the Aroostook and Central regions (rates in Bangor 

were high among middle age adults only and rates in Penquis were high among the elderly only). 

In addition, youths in the Aroostook region were 55% more likely than peer youths to be 

hospitalized for an asthma-related condition (412 vs. 267, respectively) or for pneumonia (177 

vs. 113, respectively). 

Rates of COPD hospitalizations, another ACS condition, were also elevated in many of the same 

communities with high asthma hospitalizations, but only the Aroostook region showed rates of 

COPD deaths among the elderly that exceeded rates in both the peer community and the State 

(by approximately 40%). In addition, despite apparently adequate vaccination levels, pneumonia 

hospitalizations among the elderly in the Aroostook, Washington and Hancock regions were 50- 

60% higher than rates in the peer and State. Pneumonia/influenza deaths among 65+ year olds 

were elevated in those same communities, as well as in the Penquis and Central regions. 

Emphysema mortality in the Aroostook region was twice as high as the rate in the peer 

community and the State. Emphysema mortality was also elevated in the Penquis, Central and 

Knox-Waldo regions. 

Finally, cancers of the lung, especially among men, were more common in certain portions of 

northern, eastern and central Maine than in other parts of the State (See Table 5). The incidence 

of lung cancer among men in the Washington and Central regions was nearly 80% higher than in 

the peer and 60% higher than in the State. The incidence of lung cancer among women in the 

Washington, Central, Penquis and Hancock regions was 20% higher than in the peer or State. At 

the same time, mortality rates were not elevated in any of the study regions. 



Table 5: Behavioral and Medical Risks for Respiratory Disease by EMH Service Region 

Indicator Bangor Urban 

Peer 

Asthma Prevalence 1 


Waldo 

Adult (18+) 2 10.1% 8.7% 7.9% 10.6% 8.4% 9.0% 10.5% 9.9% 8.1% 8.6% 7.2% 

Youth (0-17) 3 22.8% NA 20.9% 15.2% 16.1% 11.7% 15.6% 10.7% NA NA NA 

Asthma/Bronchitis HospitalizationRate 4 

Age 45-64 201.5 52.3 104.7 60.3 93.1 80.9 110.5 97.8 62.1 84.4 162 

Age 65+ 172.5 131.4 394.8 255.8 78.2 155.8 215.6 156.1 125.7 176.2 177 

COPD 

Hospital Admission Rate (65+) 2 1559 1068.1 1867.2 1577.2 1594.3 1109.8 1600 1069.6 1133 1288 1092 

Mortality Rate (65+) 5 401.7 397.5 483.5 378.7 316.9 264.7 300 264.4 354.4 347.3 284.6 

Pneumonia 

Hospital Admission Rate (65+) 4 1592.8 1657.7 2034.4 1717.2 2132.2 2057.4 1750 1317.5 1343 1527 1831 

Mortality Rate (65+) 5 225.4 262.3 280 347 224.9 315.4 267.5 160.6 186 199.3 241.2 

Emphysema Mortality Rate (65+) 5 44.6 49.8 83.6 73 ^ ^ 67.5 69.7 41.9 47.5 43.5 

Lung Cancer Incidence 6 

Males 107.2 115.5 86.7 66.6 146.2 73.1 146.2 85.3 81.8 92.4 71.1 

Females 56.5 58.1 42 68.9 69.1 63.8 67.2 52.1 58.3 57.6 41.8 

1 EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996-1999): Urban Peer, Rural Peer and 

Maine; CDC BRFSS Survey (2000): U.S. 

2 3 

Current asthma prevalence 

Lifetime asthma prevalence. 


5 Maine ODRVS Mortality Data (1994-1998): All study regions, Peers, and Maine; NCHS National Vital Statistics Reports (1998): U.S. 

6 Maine Cancer Registry Incidence Data (1995-1996): All study regions, Peers and Maine; National Cancer Institute (1992-1998): U.S. 

All rates expressed are per 100,000. NA = Not available. ^ = Not reported based on < 5 annual cases. 

Rural 

Peer 


US 



The respiratory health profile of the populations served by EMH suggests that disease 

morbidity is high, perhaps due in part to elevated risks from smoking. Enhanced subspecialty 

care may be needed to reduce hospitalizations for respiratory conditions and to improve 

treatment outcomes for pulmonary patients. 

Reproductive Health 

FINDINGS: Maternal and infant health were favorable in almost all study regions, 

although rates of inadequate prenatal care and high-risk maternal 

hospitalizations were elevated in some communities. 

• Adult and teen birth rates were not generally elevated in northern, eastern and central Maine. 

• Infant and neonatal mortality rates were low in most regions. 

• Rates of premature and low weight births were not generally elevated. 

• Prenatal care adequacy was favorable in most regions. 

• High-risk antepartum hospitalizations were elevated in portions of the study area, as were 

rates of Cesarean deliveries. 

Teen pregnancy is a key indicator of the reproductive health of a community because 

adolescents who become pregnant are less likely to obtain adequate prenatal care and typically 

are not emotionally ready for parenting. Teen pregnancy did not emerge as a priority health 

issue in the study areas. Teen birth rates in most regions were comparable to or lower than 

those in peer areas and the State. Adolescents (15-17 year olds) in the Washington (16 per 

1000), Central (15) and Knox-Waldo (16) regions had more births than adolescents in the peer 

(14) and State (13), although the elevations were generally slight or moderate. Birth rates 

among adults in all study regions were comparable to or lower than those in peer areas and the 

State. The only exception was in the Knox-Waldo region, where births to 18-19 (74.4 per 

100,000) and 20-24 year olds (120) were elevated over those in both the peer (58 and 98, 

respectively) and the State (48 and 88, respectively). 

Poor birth outcomes were generally low throughout northern, eastern and central Maine (See 

Figure 9). The percentage of babies in each study region that were either born premature (less 

than 37 weeks gestation) or weighing less than 2,500 grams was similar to that in the peer 

communities and the State (approximately 8% and 6%, respectively). The only exception was in 

the Central region where the percentage of premature births among teen mothers (10-17 year 

olds) was 50% higher than in the State and the percentage of low birthweight babies born to 

teens was nearly 65% higher than that in the State. Infant and neonatal mortality rates could not 

be reliably calculated in most study regions because there were too few infant deaths. However, 

infant mortality in the Aroostook and Central regions was elevated over that in peer communities 

(by 50% and 26%, respectively) but comparable to that in the State. 



Figure 9: Selected Reproductive Health Indicators by EMH Service Region 

14.0% 

12.0% 

10.0% 

8.0% 

6.0% 

4.0% 

2.0% 

0.0% 

% Premature Births % Low Birthweight (


Table 6: Selected Reproductive Health Indicators by EMH Service Region 


Peer 

Waldo Peer 

High Risk Antepartum Hospitalizations 2 

10-17 Year Olds 151.6 65.7 92.9 157.8 81.8 64.2 80.3 165.9 72.8 81.8 NA 

18-49 Year Olds 453.7 367.5 532.3 543.8 343 407.9 392.9 552.9 396.2 433.6 NA 

C-Section Rates 1 24.4% 20.6% 18.8% 19.9% 17.1% 17.1% 20.4% 18.1% 13.9% 20.8% 21.2% 

Sources: 

1 Maine ODRVS Birth Data (1995-1999) All study regions, Peers and Maine; NCHS National Vital Statistics Reports 

(Final Birth Data for 1998): U.S. 

2 MHDO Hospital Discharge Data (1998-2000). Rates are per 100,000 population 



Youth Health 

FINDINGS: Most indicators of youth health were favorable in northern, eastern and 

central Maine. Respiratory disorders and substance abuse problems were 

elevated among youths in certain study regions. 

• The youth population in most study regions has been decreasing. 

• Rates of births to teen mothers were not generally elevated. 

• Prenatal care adequacy and birth outcomes among teen mothers were generally favorable. 

• Youth asthma prevalence was highest in the Bangor and Aroostook regions. 

• The prevalence of hay fever and allergies was highest in Aroostook and Washington. 

• ACS hospitalization rates among youths were particularly low in the Bangor region and 

particularly high in the Aroostook community. 

• The prevalence of childhood obesity was highest in the Knox-Waldo region and lowest in the 

Penquis and Washington regions. Pediatric diabetes was very rare in northern, eastern and 

central Maine. 

• Rates of pediatric hospitalizations for depression and anxiety were elevated in the Bangor 

region. 

• Alcohol and drug hospitalizations among youths were highest in the Hancock, Central and 

Bangor regions. 

Northern, eastern and central Maine has seen a general decline in the size of its youth 

population during the last decade (See Figure 2). The largest declines occurred in the 

Aroostook region, where the 0-4 year old cohort decreased by 20% between 1990 and 2000 and 

the 5-17 year old cohort decreased by 15%. In contrast, the Hancock, Central and Knox-Waldo 

regions saw a 5-10% increase in the size of their 5-17 year old populations. Still, the proportion 

of youths in most EMH regions was similar to that in the State in 2000. 

Infant health is generally favorable in the study area. Infant and neonatal mortality was low in 

most study regions except Bangor, Aroostook and Central, where rates of infant deaths were 

slightly higher than those in peer areas. In addition, the Central region, which experienced 

higher rates of teen births and lower levels of prenatal care adequacy, had more low birthweight 

and premature births compared to the State (See Figure 8). Teen pregnancy did not emerge as a 

widespread concern in northern, eastern and central Maine. Teen birth rates in most regions 

were comparable to or lower than those in peer areas and the State. Birth rates for adolescents 

(15-17 year olds) in the Washington, Central and Knox-Waldo regions were higher than in the 

peer and State, but those elevations were generally slight or moderate. 

Respiratory disease among youths was elevated in certain sectors of northern, eastern and 

central Maine (See Table 7). Youth asthma prevalence was high in all study regions, but was 

particularly elevated in the Bangor and Aroostook regions. More than one in five children 

living those areas had ever received such a diagnosis. Moreover, nearly one-third of the youth 

population in Aroostook was reported to have hay fever and/or other allergies. In addition, 

youths in the Aroostook region were 55% more likely than peer youths to be hospitalized for an 

asthma-related condition (412 vs. 267, respectively) or for pneumonia (177 vs. 113, 

respectively). These patterns suggest a potential need for higher quality outpatient pediatric care 

for respiratory conditions such as asthma. 



The prevalence of emotional and/or behavioral problems among youths ranged from a low of 3% 

in the Aroostook region to a high of 11% in the Central region. The prevalence of learning 

disabilities among children was lowest in the Bangor region (at 4%) and highest in the Knox- 

Waldo region at 15%. Utilization rates for pediatric mental health services were not generally 

elevated in most sectors of the study area. However, hospitalizations for certain conditions such 

as depression and anxiety were elevated in Bangor’s youth population compared to peer 

communities and the State. Drug-related hospitalizations among youths were also elevated in 

the Bangor area, as well as in the Hancock and Central regions. Likewise, hospitalization rates 

for acute alcohol-related conditions among youths were approximately three times higher in the 

Hancock and Central regions than in the peer communities or the State. County-level arrest data 

revealed the largest elevations in alcohol-related arrests of juveniles in Washington and Knox 

counties (15 and 13 per 1,000 10-17 year olds) compared to the State (7). Drug-related arrest 

rates among juveniles in Somerset and Hancock (2 per 1,000 10-17 year olds) counties were 

twice as high as those in the State. 



Table 7: Selected Indicators of Youth (0-17) Health by EMH Service Region 

Indicator 

Bangor Urban 

Peer 


Waldo 

Ever Diagnosed Asthma 1 22.8% NA 20.9% 15.2% 16.1% 11.7% 15.6% 10.7% NA NA NA 

Rural 

Peer 


US 

Ever Diagnosed Hay 

11.0% NA 30.5% 22.4% 25.3% 20.9% 21.4% 17.6% NA NA NA 

Fever/Allergies 1 

Asthma/Bronchitis Hospitalizations 2 280 430 412 203 200.5 175.1 207.7 180.3 267.2 269.2 277 

Ever Diagnosed with 

8.5% NA 3.4% 9.0% 6.0% 7.8% 11.1% 8.2% NA NA NA 

Emotional/Behavioral Problem 1 

Ever Diagnosed Learning Disability 3.6% NA 7.9% 9.5% 8.3% 10.4% 11.8% 14.8% NA NA NA 

or Attention Disorder 1 

Major Depressive Disorder 

229.2 186.5 117.3 155.2 38.8 119.7 156.1 171.1 165.6 160.5 NA 

Hospitalizations 2 

Drug Psychoses Hospitalizations 2 12.2 1.7 0 3.6 0 13.8 1.6 0 1 3.2 NA 

Alcohol-Related Hospitalizations 2 6.9 1.7 2.6 11 12.9 32.3 28.2 6.1 9.6 11.3 NA 

Sources: 

1 EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996-1999): 

Urban Peer, Rural Peer and Maine; CDC BRFSS Survey (1998-1999): U.S. 

2 MHDO Hospital Discharge Data (1998-2000) All study regions, Peers, and Maine; 

HCUP (1997): U.S. 

All rates expressed are per 100,000 unless otherwise indicated. 




Cancer Health 

FINDINGS: Behavioral risks for cancer are elevated throughout northern, eastern and 

central Maine. Incidence and mortality associated with certain forms of 

cancer are elevated in several study regions. Early detection is also 

problematic in certain regions. 

• Cancer risks from smoking and obesity were elevated in most study regions. 

• The burden of cancer prevalence was particularly high in the Aroostook and Washington 

regions, but was also elevated in the Hancock and Central regions. 

• Treatment outcomes were particularly unfavorable in the Aroostook region. 

• Rates of early- and late-stage cancer diagnoses were unfavorable for certain types of cancer, 

despite generally adequate screening levels. 

Several types of cancers were selected for inclusion here on the basis of high incidence rates 

(lung and breast), knowledge of major causal factors (i.e., smoking for lung cancer), and 

availability of effective screening tests that can detect cancers at an early stage (breast, cervical, 

prostate, and colorectal cancers). 

Most portions of the study area, except the Hancock and Knox-Waldo regions, are at 

increased risk for cancer from high rates of smoking and/or obesity (See Table 4). Rates of 

current smoking in most study regions were particularly high (30-50%) among adults between 

the ages of 18 and 44 years old. Elevated obesity rates, on the other hand, were particularly high 

among middle age (45-64) and elderly (65+) men and women. 

The current prevalence of cancer (as reported by survey respondents) was highest in the 

Washington region at 9%, although it was also high in the Hancock, Central and Knox-Waldo 

regions at 7-8% (See Table 8). Incidence and mortality rates for all cancers combined were also 

elevated in the Washington region, but only among men (See Appendices 7 and 12 for 

definitions of and data sources for cancer incidence indicators). Total cancer incidence among 

men in that community was 30-40% higher than that among men in peer communities and the 

State. Total cancer mortality among elderly men in the Aroostook and Washington regions was 

slightly to moderately elevated over that in the peer and State. Total cancer incidence was also 

elevated among women in the Bangor and Hancock regions, although cancer mortality was not. 



Table 8: Selected Cancer Indicators by EMH Service Region 


Peer 

Waldo Peer 

Ever Diagnosed Cancer (all 6.1% NA 5.1% 5.7% 9.1% 7.8% 6.7% 7.6% NA NA NA 

sites) 

Total Cancer Incidence 1 

Males 533.8 524.3 541.1 458.8 657.6 490.1 541.4 427.3 477.4 502 488.5 

Females 509.8 416.4 390.4 454.8 445.5 501.7 406.6 419.8 421.5 439.2 408.1 

Total Cancer Mortality (65+) 2 

Males 1657.4 1729.3 1676.5 1559.6 1797.1 1506.5 1448.3 1446.3 1564.7 1586.4 1407.2 

Females 1028 983.5 984.4 834.2 1043 1002 968.1 932.9 935.8 1180.3 912.7 

Lung Cancer 

Incidence: Males 107.2 115.5 86.7 66.6 146.2 73.1 146.2 85.3 81.8 92.4 71.1 

Incidence: Females 56.5 58.1 42 68.9 69.1 63.8 67.2 52.1 58.3 57.6 41.8 

Mortality: Males 79.8 88.6 102.6 85.9 88 72.5 75.9 68.6 89.6 83.1 NA 

Mortality: Females 56.9 58.9 45 54.6 54.3 61.4 58.2 44.3 55.1 58.4 NA 

Urinary Cancer 

Incidence: Males 53.4 51.2 53.4 50.9 75.7 50.6 46.9 58 60.5 54.7 42.6 

Incidence: Females 22.9 16.3 9.1 37.4 19 28.6 8.9 20.7 18.2 17.8 14.2 

Mortality: Males 21 15.1 25.7 22.7 25 18.8 18.5 16.4 17.3 16.4 NA 

Mortality: Females 7.5 7.2 13.3 20.8 16.4 16.5 9.3 11.2 7.5 7.8 NA 

Breast Cancer 

Incidence 167.8 116.3 123.2 121.9 111.2 140.8 116.5 133.2 123.8 131.3 131.9 

Mortality 30 37.7 30.7 28.1 39.6 29.6 31.8 26.2 30.5 33.5 30.2 

Diagnosed In Situ 20.6 10.1 28.1 17.9 20.8 15.8 7.1 14.2 13.3 14.5 NA 

Stage Distant 1.6 3.8 2.3 3.6 0 3.2 4.1 2.4 2.3 2.7 NA 

Sources: 

1 Maine Cancer Registry Incidence and Staging Data (1995-1996): All study regions, Peers and Maine; National Cancer Institute (1992-1998): U.S. 


Cancer incidence rates are age adjusted to the U.S. 1970 standard population. 





Table 8: Selected Cancer Indicators by EMH Service Region (Continued) 


Peer 

Waldo Peer 

Colorectal Cancer 

Incidence: Males 64.7 71 59.9 56.8 88 51.8 65.6 56.1 69.1 62.8 NA 

Incidence: Females 43 43.8 49.5 38.1 51.5 68.2 55.4 34.6 40.6 45.3 NA 

Mortality: Males 22.1 24.6 30.6 28.5 34.8 30.7 23.8 14.6 23.7 24.7 NA 

Mortality: Females 22.4 24.4 31.5 28.9 35.3 37.6 27.8 21.2 23.7 25.8 NA 

Males: Diagnosed In Situ 16.0% 5.2% 5.6% 17.7% 17.7% 6.9% 11.8% 11.4% 15.1% 11.5% NA 

Males: Stage Distant 6.7% 11.7% 16.7% 20.6% 11.8% 6.9% 21.1% 11.4% 7.1% 13.7% NA 

Females: Diagnosed In Situ 6.8% 2.6% 3.6% 19.4% 3.7% 12.0% 13.3% 10.0% 9.2% 8.9% NA 

Females: Stage Distant 14.9% 16.7% 17.9% 6.5% 29.6% 20.0% 12.2% 7.5% 16.3% 15.1% NA 

Prostate Cancer 

Incidence 128.5 128.8 152.7 121.1 146.9 101.2 122.1 84.8 97.1 118.8 149.9 

Mortality 27.5 27.2 31.1 24.6 36.8 29.4 27.1 32.4 26.7 28.7 16.4 

Diagnosed In Situ 69.8% 56.9% 77.3% 74.7% 66.7% 63.0% 70.5% 75.0% 69.9% 67.6% NA 

Diagnosed Stage Distant 7.4% 8.2% 8.5% 9.3% 5.6% 5.6% 6.7% 1.4% 8.7% 7.7% NA 

Sources: 

1 Maine Cancer Registry Incidence and Staging Data (1995-1996): All study regions, Peers and Maine; National Cancer Institute (1992-1998): U.S. 


Cancer incidence rates are age adjusted to the U.S. 1970 standard population. 





Smoking-related cancers were particularly high in the Washington region as well in as other 

portions of the study area. The rate of lung and bronchus cancers among men in the 

Washington and Central communities (approximately 146.2 per 100,000) was 60-80% higher 

than that among men in the peer community (81.8) and in the State as a whole (92.4). Lung 

cancer incidence among women in the Washington, Penquis and Central communities exceeded 

peer and/or State rates by approximately 20%. Deaths due to lung/bronchus cancers were not 

generally elevated in these regions, except among men in Aroostook. 

The incidence of buccal cavity cancer was slightly elevated among men in the Aroostook region 

(38 per 100,000 vs. 33 and 34 in the peer and State, respectively) and among women in the 

Washington region (15 per 100,000 vs. 11 in the peer and State). Deaths due to buccal cavity 

cancer, although rare, were elevated relative to the peer and State among men in the Aroostook 

and Penquis regions (13 vs. 4 per 100,000). 

The incidence of urinary cancer was particularly high among women in the Penquis region 

relative to that among women in the peer communities and in the State. Urinary cancer 

incidence was also elevated, although to a lesser extent, in certain sectors of other study regions, 

such as women in the Hancock and Bangor regions as well men in the Washington region. 

Women in the Penquis, Washington and Hancock regions died from urinary cancer at rates that 

were double or higher than those in the peer communities or State. Urinary cancer death rates 

were also elevated among men in Bangor, Aroostook, Penquis and Washington. 

Incidence rates for other types of cancers were also elevated in various sectors of the study area. 

For example, the incidence of breast cancer was 30-45% higher among women in the Bangor 

region than it was in the peer community or the State (168 per 100,000 vs. 116 and 131, 

respectively). Breast cancer mortality was not elevated in the Bangor region, however, 

perhaps because of strong screening and/or early detection and treatment services. Rates of 

early stage breast cancer diagnoses were relatively high in the Bangor area and rates of late stage 

diagnoses were relatively low (See Table 8). In contrast, breast cancer staging data for the 

Central region suggest that early detection may be an issue in that community. Rates of in situ 

breast cancer diagnoses were nearly half those for the peer and the State whereas rates of late 

stage diagnoses were 50-60% higher. The poor detection rates in this community don’t appear to 

be due to deficient screening, as mammography rates among women age 40 and over (65.5%), as 

well as among women age 50 and over (70.1%) were comparable to those in other study regions 

and comparison areas (63.5% and 67.8%, respectively, in the peer). Moreover, mortality from 

breast cancer was not elevated in the Central region. Thus, while we are unable to clarify the 

meaning of this pattern using these data, the quality of breast cancer screening and early 

detection services should be reviewed in the Central region. 

Despite favorable rates of mammography and early-stage breast cancer diagnoses, breast cancer 

mortality among 45-64 year old women in the Aroostook region (65.0 per 100,000 population) 

was 30% higher than comparable rates in the peer (49.7) and State (49.5). Rather than 

screening or early detection services, the availability and/or adequacy of breast cancer 

treatment might be an issue in the Aroostook region. A similar pattern emerged in the 

Washington region. 



The incidence of colorectal cancer (CRC) was particularly elevated among women in the 

Hancock and Central regions. CRC incidence was likewise elevated, although not as 

dramatically, among men and women in the Washington region and among women in the 

Aroostook region. Colorectal cancer mortality was elevated among women in the Hancock 

region and among women and men in the Washington region. An examination of cancer 

staging data suggests that problems with early detection might be at least partially responsible 

for elevated rates of CRC mortality in northern, eastern and central Maine. For example, rates 

of early-stage colorectal cancer diagnoses in the Aroostook (men and women), Washington 

(women) and Hancock regions (men) were approximately half as large as those in the peer 

communities and State. Late stage diagnoses in the Aroostook (men), Washington (men and 

women) and Central (men) regions were two to three times higher than peer rates. Deficient 

screening does not appear to be responsible, however, as rates of colorectal exams, blood stool 

tests and colonoscopies were not low in those regions with unfavorable detection and/or high 

mortality rates. Although it is possible, however, that screening programs are missing those 

individuals with elevated risks for cancer. For example, we found in our analyses of screeningbased 

survey data that smokers were far less likely to be screened for various types of cancer, 

including breast, prostate and colon cancer than non-smokers. 

Prostate cancer incidence among men in the Aroostook and Washington regions was elevated 

over that among men in the peer areas and the State. Mortality due to prostate cancer was also 

elevated in Washington, although neither staging nor screening rates were unfavorable in that 

community. Elevated prostate cancer mortality in the Washington region might not be rooted 

in early detection deficiencies but in inadequate treatment services. 

Arthritis, Diabetes and Other Chronic Conditions 

FINDINGS: The burden of diabetes and arthritis is high in certain portions of the study 

area , but treatment services are generally favorable. 

• The prevalence of arthritis was high in the Washington, Central and Knox-Waldo regions 

relative to national norms. 

• Bone and joint health were favorable in most sectors of northern, eastern and central Maine. 

• Risks for Type II diabetes were elevated in most study regions, as is disease prevalence. 

• Diabetes hospitalizations and deaths were low in the Bangor, Washington and Knox-Waldo 

regions, suggesting that the disease is well managed in those areas despite a high prevalence. 

• Diabetes hospitalizations and deaths are elevated in the Aroostook, Penquis and Central 

regions, suggesting a need to evaluate the availability and/or adequacy of outpatient diabetes 

care. 

Arthritis and other rheumatic conditions are among the most common diseases in this country. 

They are also among the leading causes of disability and health-related activity limitations 

among adults. 8 In evaluating the burden of chronic disease in a population, therefore, it is 

important to assess arthritis as well as other indicators of bone and joint health. 

8 CDC. Prevalence of arthritis—United States 1997. 2001: 50(17); 334-6. 



The prevalence of arthritis throughout northern, eastern and central Maine is higher than 

that in the US as a whole. Prevalence estimates, overall and among middle age and elderly 

residents, were highest in the Washington, Central and Knox-Waldo regions (See Table 9). 

Arthritis was less prevalent in Bangor, Aroostook and Penquis. These findings are consistent 

with previously described patterns showing that the Washington and Knox-Waldo regions had a 

larger than expected ‘not well’ population and population with chronic disease, as well as 

elevated rates of poor health days, lost activity days, and needs for personal care assistance. 

Other indicators showed that bone and joint health was generally favorable in the study area. 

Hospitalization rates for joint procedures were not elevated in any of the study regions. Rates of 

hip procedure hospitalizations in all study regions except for Washington were lower than or 

comparable to those in the peer and State. Rates in Washington were only moderately elevated 

(by 14%) among the elderly (509 per 100,000 population) compared to the peer (446). 

Diabetes is the leading cause of end-stage renal disease among adults of all ages, and the leading 

cause of blindness among working-age adults. Risks for Type II (adult onset) diabetes from 

inactivity and obesity were elevated in most study regions, but they were especially pronounced 

in the Bangor, Aroostook, Penquis and Washington regions (See Table 4). Risks related to being 

overweight were elevated in all areas except Hancock. The highest rates emerged in the Bangor, 

Aroostook, Penquis and Washington regions where obesity was 30-50% higher than in the peer 

or State. Geographic variation in diabetes prevalence followed a similar pattern with the highest 

rates in the Bangor and Washington regions. The Hancock region was the only study area where 

the prevalence of diabetes did not exceed the peer or State rate – and it was the only community 

where the prevalence of obesity was not elevated. Pediatric diabetes was rare in the study 

populations. Primary prevention around diet and exercise is needed throughout the study area 

to address obesity-related risks for diabetes. 

Despite the high disease prevalence, rates of diabetes-related hospitalizations and deaths were 

not generally elevated in the Bangor, Washington or Knox-Waldo regions. This pattern suggests 

that diabetes is well managed in the Bangor, Washington and Knox-Waldo regions areas with 

primary/outpatient care. In contrast, diabetes-related hospitalization and death rates were 

elevated in the Aroostook, Penquis and Central regions. High rates of hospital-based diabetes 

care as well as diabetes mortality suggest that outpatient diabetes management services and 

secondary prevention practices should be evaluated in the Aroostook, Penquis and Central 

regions. 

There were too few deaths in most study regions to produce reliable rates of HIV/AIDS deaths. 

Only the Central region saw an annual average of more than five HIV/AIDS deaths during the 

study period – but the absolute number was still small (and the corresponding rate should be 

interpreted with that in mind). As in the State and peer communities, most HIV/AIDS deaths in 

the Central region were concentrated among 18-44 year old men. The HIV/AIDS death rate 

among 18-44 year old men in that community (24.5 per 100,000 population) was twice as high 

as the corresponding rate in the peer area (12.1) and in the State (12.5). 



Table 9: Selected Arthritis and Diabetes Indicators by EMH Service Region 

Indicator 

Arthritis Prevalence 1 

Bangor Urban 

Peer 


Waldo 

Rural 

Peer 


US 

Age 45-64 28.1 NA 27.9 33.9 37.6 20.7 38.5 23.4 NA NA 29.5 

Age 65+ 47.6 NA 49.2 46.5 58.1 54.8 65.1 58.4 NA NA 51.6 

Diabetes Prevalence 1 

Age 0-17 0.3% NA 0.7% 0.5% 1.4% 0.4% 0.0% 0.4% NA NA NA 

Age 45-64 13.3% 5.7% 11.7% 8.8% 13.8% 8.0% 9.2% 10.8% 7.6% 8.7% 9.0% 

Age 65+ 18.8% 12.7% 10.9% 15.5% 21.3% 9.7% 20.0% 14.5% 12.9% 13.5% 13.6% 

Diabetes Hospitalizations 2 

Age 45-64 79.4 76.3 95.5 96.5 57.3 52.4 94.7 50.6 58.3 66.3 159.7 

Age 65+ 121.7 124.9 153.3 194.9 136.9 142.8 209.4 169.8 144.5 153.5 266.7 

Diabetes Mortality 3 

Age 65+ 121.7 173.8 163.4 159.7 157.4 131.1 170 143.2 144.1 140.9 142.4 

Sources: 

1 EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996- 

1999): Urban Peer, Rural Peer and Maine; NHIS (1997): US Arthritis; CDC BRFSS Survey (1998-1999): U.S Diabetes. 

2 MHDO Hospital Discharge Data (1998-2000) All study regions, Peers, and Maine; HCUP 

(1997): U.S. 


All rates expressed are per 100,000 




Mental Health 

FINDINGS: Mental health problems are elevated in certain sectors of northern, eastern 

and central Maine, particularly in the Bangor and Aroostook regions. 

• The prevalence of reported poor mental health was most common in the Bangor and 

Washington regions. 

• Depression prevalence was high in all study regions, but it was particularly high in the 

Bangor, Washington, Aroostook and Hancock regions, especially among the elderly. 

• Suicide mortality was highest in the Washington and Hancock regions, but it was also 

elevated in the Aroostook and Penquis regions. 

• Psychoses and other mental health hospitalizations were elevated in most study regions. 

• Mental health problems were elevated among the elderly in certain portions of northern, 

eastern and central Maine. 

Mental health is a critical component of the overall health and well being of a population. 

Mental disorders affect millions of children and adults each year in this country. With respect to 

years of healthy life lost, they rank nearly as high as cardiovascular and respiratory diseases and 

higher than all forms of cancer as well as HIV. 9 Besides being extremely costly (the annual 

costs of mental health disorders are higher than those for respiratory disorders and nearly as high 

as the costs of cardiovascular disease), mental health disorders are linked to cirrhosis, lung 

cancer, heart disease, suicide and other forms of violence. 10 

Indicators of poor mental health were elevated in certain sectors of the study area. For 

example, compared to the peer communities and the State, the proportion of adults who reported 

poor mental health for 11 or more of the past 30 days was approximately 35-50% higher in the 

Bangor and Washington regions (See Table 10; See also Appendix 14 for selected mental health 

findings from the 2001 EMH Household Survey). In the Bangor region, the elevation in poor 

mental health days was most pronounced among the elderly. The prevalence of 11+ days of poor 

mental health among Bangor’s 65+ year old population (9.1%) was twice as high as that among 

the 65+ population in the peer (4.3%) and 40% higher than that among the 65+ year old cohort in 

the State. In the Washington region, the elevation in poor mental health days was most 

pronounced among working age adults (15.5%), who were 55% more likely than working adults 

in the peer (10.2%) and State (9.9%) to have experienced mental health problems for a third or 

more of the previous month. 

9 Ustun TB. The global burden of mental disorders. American Journal Public Health. 1999; 89: 1315-1318. 

10 Neugebauer R. Mind matters: The importance of mental disorders in public health’s 21 st century mission. 

American Journal Public Health. 1999; 89: 1309-1311. 



Table 10: Selected Mental Health Indicators by EMH Service Region 

Indicator 

Bangor Urban 

Peer 


Waldo 

11+ Days Poor Mental Health 1 14.1% 10.5% 9.6% 9.4% 12.9% 10.0% 10.3% 8.6% 9.6% 9.2% 

Ages 18-64 15.0% 11.9% 11.6% 10.8% 15.5% 11.7% 12.4% 10.7% 10.2% 9.9% 

Ages 65+ 9.1% 4.3% 1.0% 3.9% 4.3% 3.8% 1.2% 1.3% 6.5% 6.4% 

Depression Prevalence 1 18.5% NA 17.3% 14.3% 16.8% 17.7% 16.0% 15.1% NA NA 

Ages 18-64 19.6% NA 18.0% 15.9% 19.0% 18.3% 18.1% 17.7% NA NA 

Ages 65+ 13.1% NA 14.2% 7.9% 9.3% 15.5% 6.9% 6.3% NA NA 

Psychoses Hospitalizations 2 637.4 591.4 492.3 397.5 274.4 343.6 473.7 471.5 384.5 481 

Ages 18-44 921 897.1 704.2 623.9 435 454.1 731.9 800.6 568.3 728.3 

Ages 45-64 616.2 494.9 603.6 361.7 279.2 399.8 467.6 468.7 330.8 459.4 

Ages 65+ 270.5 283 348.4 237.5 244.5 240.1 278.1 179 159.2 262.9 

Major Depression Hospitalizations 2 308.2 251 215.7 204.3 179.1 195.8 255.2 324.5 216.3 274.4 

Ages 18-64 437.7 354.9 304.6 292.3 267.5 269.2 377.9 507.2 317.5 357.1 

Ages 65+ 118.3 107.8 167.1 97.4 176 142.7 131.2 105.5 71.2 127.4 

Senility and Organic Mental Disorders 

Hospitalizations (65+) 2 361.8 229.1 204.3 243.5 254.3 369.9 187.5 238.7 171.8 258 

Rural 

Peer 


Suicide Mortality Rate 3 12.2 10.3 20.2 20.6 30.9 25.1 16.1 16 14.1 13.6 

Sources: 

1 EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996-1999): 

Urban Peer, Rural Peer and Maine; CDC BRFSS Survey (1998-1999): U.S. 

2 MHDO Hospital Discharge Data (1998-2000) All study regions, Peers, and Maine; 

HCUP (1997): U.S. 


All rates expressed are per 100,000 unless otherwise noted 

Mortality rates for each study region are age adjusted to the region peer 




The lifetime prevalence of depression was highest in the Bangor, Aroostook, Washington and 

Hancock regions (17-19%). High rates of depression among the elderly were primarily 

responsible for the elevations in total prevalence estimates in those areas. Adults in the 

Aroostook (7%), Washington (6.3%), Central (6%) and Knox-Waldo (7.4%) regions were the 

most likely to report that they had been diagnosed with a psychiatric disorder besides depression 

at some point in their life. 

Mental health service utilization rates were highest in the Bangor and Aroostook regions, but 

rates were also high in other portions of the study area. For example, psychosis 

hospitalizations among middle age and elderly adults in the Aroostook region were 

approximately twice as high as rates in the peer communities and 30% higher than rates in the 

State. Elderly in the Bangor region were 50-60% more likely than the elderly in the peer or State 

to be hospitalized for senility and organic mental disorders. Senility hospitalizations were also 

elevated among the elderly in the Hancock region – the rate for 65+ year olds in that region (370 

per 100,000) was more than double that in the peer (171.8) and 45% higher than that in the State 

(258). 

Hospitalization rates for major depression were elevated over peer and State rates among youths 

and working age adults in the Bangor region, among the elderly in the Aroostook and 

Washington regions and among working age adults in Knox Waldo. The rate of schizophrenia 

hospitalizations among working age adults in Bangor was 70% higher than the comparable rate 

in the peer community and 35% higher than the State rate. The Aroostook and Central regions 

also saw elevated rates of schizophrenia hospitalizations in their working age populations (152 

and 149 per 100,000 vs. 64 and 140 in the peer and State, respectively). Finally, rates of 

hospitalizations for anxiety disorders among youths (85.7) and working age adults (171) in the 

Bangor region were two to four times higher than corresponding rates in the peer communities 

(20 and 52) and in the State (35 and 91). 

Suicides were relatively rare in northern, eastern and central Maine. Although the annual 

average number of cases in each study region was large enough to calculate reliable rates, the 

number of cases upon which rates are based is still small. Rates should therefore be interpreted 

as such. Suicide mortality in the Bangor region was moderately higher than that in the peer. 

Suicide death rates were also elevated in the Aroostook, Penquis and Hancock regions, but the 

highest rate emerged in the Washington region. Suicide mortality in the latter community 

occurred at approximately twice the rate in the peer area and the State. 



Substance Abuse 

FINDINGS: Alcohol and illicit drug use are elevated in certain portions of the study area. 

• The prevalence of problem drinking was highest in the working age population of the 

Washington region and highest in the elderly population of the Hancock, Central and Knox- 

Waldo regions. 

• Alcohol-related hospitalization rates were highest in the Hancock, Central and Knox-Waldo 

regions, especially among the elderly. 

• Alcohol-related mortality rates were highest in the Washington, Hancock and Knox-Waldo 

Regions. 

• The self-reported prevalence of illicit drug use and diagnosed substance abuse disorders was 

highest in the Hancock and Central regions. 

• Drug-related hospitalizations were highest in the Washington region, but were also high in 

the Bangor, Central and Knox-Waldo communities. 

Substance abuse and dependence disorders occur at alarming rates in this country. Estimates 

from a large-scale national survey of 15-54 year olds suggest that over a quarter of Americans 

will abuse or become dependent on alcohol or drugs at some point during their lifetime. 11 

Alcohol represents the third leading cause of premature death in this country, accounting for 

approximately 5% (100,000) of all deaths in a given year. Alcohol contributes to deaths 

associated with cirrhosis, motor vehicle injuries, home injuries, drownings, fires and cancer. Use 

of illicit drugs represents the ninth leading cause of death in the United States and is estimated to 

account for at least 20,000 deaths each year from overdoses, suicide, homicide, motor vehicle 

injury, HIV infection, pneumonia, hepatitis and endocarditis. 12 

We assessed problem drinking among adults by examining the prevalence of CDC-defined binge 

and chronic heavy drinking among working age and elderly residents in each study region (See 

Appendix 12 for indicator definitions). The prevalence of chronic heavy drinking among 

working age adults in the Washington region was nearly twice as high as that in the peer 

community and three times as high as that in the State (See Table 11; See also Appendix 15 for 

selected substance abuse findings from the 2001 EMH Household Survey). The prevalence of 

binge drinking was also highest among working age adults in the Washington region – 35% 

higher than that in the peer and 60% higher than that in the State. 

11 Kessler RC, McGonagle KA, Zhao S et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders 

in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994; 51: 8-19. 

12 McGinnis JM. & Foege WH. Actual causes of death in the United States. JAMA. 1993; 270(18): 2207-2212. 



Table 11: Selected Substance Abuse Indicators by EMH Service Region 


Peer 


Waldo 

Chronic Heavy Drinking 1 2.7% 3.9% 2.6% 2.0% 4.3% 6.4% 5.2% 4.9% 4.9% 3.1% 3.1% 

Ages 18-64 3.0% 3.8% 2.8% 1.8% 9.4% 5.5% 4.2% 4.4% 5.3% 3.4% NA 

Ages 65+ 1.6% 4.3% 1.6% 2.8% 1.5% 9.6% 10.8% 6.6% 2.4% 1.7% NA 

Binge Drinking 1 14.8% 12.7% 14.4% 15.2% 13.7% 18.0% 14.2% 13.8% 17.7% 14.8% NA 

Ages 18-64 17.3% 4.4% 17.2% 18.3% 26.8% 19.9% 16.9% 17.3% 19.7% 17.4% NA 

Ages 65+ 1.6% 5.1% 3.1% 2.8% 5.9% 11.0% 1.6% 1.3% 5.8% 3.5% NA 

Substance Abuse Hospitalizations 2 212.2 552.3 126 135 406.8 189.3 244 216.9 309.2 297 NA 

Ages 0-17 35 ^ ^ ^ ^ 59.9 46.5 ^ 17.1 24.9 NA 

Ages 18-64 294.4 931.2 184.7 205.6 667.7 288.7 354 354 476 439.6 NA 

Ages 65+ 125.1 155 102.2 115.7 97.5 123.3 187.5 87.2 94.3 126.3 NA 

Past Month Use of Marijuana 1 5.1% NA 3.3% 2.6% 3.8% 6.1% 8.7% 4.4% NA NA NA 

Past Month Misuse of Prescription Pain 0.5% NA 0.8% 0.4% 0.8% 0.0% 1.7% 1.5% NA NA NA 

Relievers 1 

Alcohol-Related Hospitalizations 2 103.1 103.1 73.2 85.3 122.6 121.4 127.4 102.2 113.9 103.6 NA 

Ages 0-17 6.9 1.7 2.6 11 12.9 32.3 28.2 6.1 9.6 11.3 NA 

Ages 18-64 179 187.8 130 151.6 221.3 201.3 212.7 177.4 209.3 181.7 NA 

Ages 65+ 30.4 23.5 23.2 30.4 19.5 38.9 68.7 50.4 29.3 32 NA 

Drug-Related Psychoses 

30 65.4 18.4 17.8 106.5 28.4 27.7 22.3 40 44.5 NA 

Hospitalizations 2 

Ages 0-17 12.2 1.7 0 3.6 0 13.8 1.6 0 1 3.2 NA 

Ages 18-64 34.4 111.3 21 12.7 187.5 22.6 32.5 35.4 69.7 69.3 NA 

Ages 65+ 67.6 43.8 51 66.9 48.9 77.8 75 22.9 29.3 49 NA 

ARDI Mortality (Males) 3 34.7 39.9 37.4 31.7 40.7 40.8 34.6 43.8 33.2 36.2 NA 

Sources: 

1 EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996-1999): Urban 

Peer, Rural Peer and Maine; CDC BRFSS Survey (1998-1999): U.S. 



All rates expressed are per 100,000 NA = not available ^ = not reported based on < 5 annual cases 

Rural 

Peer 


U.S. 



High rates of problem drinking among the elderly emerged in the Hancock, Central and Knox- 

Waldo regions. The prevalence of chronic heavy drinking among the elderly in those 

communities (7-11%) was three to five times higher than that in the peer areas or the State (2- 

3%). Moreover the prevalence of binge drinking in the Hancock region (11%) was two to three 

times higher than that in the peer (6%) or State (3.5%). 

Substance abuse service utilization rates exhibited a similar pattern of geographic variation. 

Compared to comparable rates in the peer community, total substance abuse hospitalizations 

were elevated in the Hancock and Central regions among youths (by 350% and by 300%, 

respectively) and among the elderly (by 30% and 200%, respectively). In addition, the rate of 

substance abuse hospitalizations among young adults in the Washington region was 60% higher 

than that in the peer and 70% higher than that in the State. Total substance abuse hospitalization 

rates were not elevated among adults in any age groups in the Bangor, Aroostook, Penquis or 

Knox-Waldo regions. 

More detailed analysis of substance abuse hospitalizations showed that admissions rates for 

acute alcohol-related mental disorders were also elevated among youths in the Hancock and 

Central regions compared to youth in the peer and State. Youths in the Bangor region also had 

higher rates of admissions for acute alcohol disorders compared to peer youths (6.9 vs. 1.7 per 

100,000, respectively). Rates were also elevated among the elderly in the Hancock and Central 

regions and among the elderly in the Knox-Waldo region, compared to the peer and State. 

Self-reported illicit drug use was highest in the Central region, but was also high in Hancock and 

Knox-Waldo. For example, the prevalence of past month marijuana and prescription pain 

reliever use/misuse was highest in the Central region at nearly 9% and 2% respectively. 13 

Compared to other study regions, marijuana use was elevated in Hancock, Bangor and Knox- 

Waldo. The misuse of prescription pain relievers was likewise elevated in Knox-Waldo. 

Hospitalizations for acute drug-related disorders were particularly high in the working age 

population of the Washington region (209 vs. 32 and 48 in the peer and State, respectively). A 

similar pattern emerged for psychoses-related drug hospitalizations (188 vs. 70 and 69 in the 

peer and State, respectively). In addition, drug-related hospitalizations were elevated in the 

youth and adult populations of Bangor and among the elderly in the Hancock, Central and 

Penquis regions. Drug-related hospitalizations in the Washington and Bangor regions were 

largely accounted for by admissions for conditions related to opiod abuse. 

Compared to the peer, rates of alcohol-related deaths among men (See Appendix 12 for 

definition) were elevated in the Washington (by 25%), Hancock (by 25%) and Knox-Waldo 

regions (by 35%). In addition, cirrhosis mortality was elevated in the Aroostook (16 per 

100,000), Penquis (14) and Hancock (20) regions compared to rates in the peer (11) and State 

(9). 

13 In some EMH regions, the proportion of adults who reported ever misusing prescription pain relievers to get high 

was higher than the proportion reporting that they had ever used illicit drugs, suggesting that some respondents did 

not equate the two. 


42 

PHRG


Finally, we used county-level arrest data to evaluate rates of alcohol and drug violation arrests 

among youths and adults in the study area. Alcohol-related arrest rates among youths in 

Washington (15.3 per 1,000 population), Knox (13.4) and Kennebec (10.5) counties were 

elevated over those in the State (6.9). Knox County also saw elevated rates of arrests for 

marijuana violations among youths (7.4 vs. 4 in the State) and adults (5.5 vs. 3 in the State). 

Arrests of youths for drugs other than marijuana were twice as high in Hancock and Somerset 

counties than they were in the State (1.9 and 2.1 vs. 0.9, respectively). 

Intentional and Unintentional Injuries 

FINDINGS: Unintentional injury rates are favorable in most portions of the study area, 

except among young adults and the elderly in some regions. Intimate partner 

violence, a significant source of intentional injuries, was most prevalent 

among young women. 

• Seatbelt use among adults is favorable in most EMH regions except Penquis and 

Washington. Men between the ages of 18-44 had the lowest rates of seatbelt use. 

• Rates of injury-related mortality from all accidents and from motor-vehicle accidents were 

the least favorable in the Washington, Aroostook, Penquis and Hancock regions. 

• Between 15% and 25% of adult women in the study area reported being a victim of violence 

at the hands of an intimate partner. Women in the Aroostook region were the least likely to 

report violence. 

• In all study regions, 18-44 year old women were at greatest risk of violence. 

Unintentional injuries (accidents) can be a significant source of hospitalizations as well as deaths 

in a community. They are the leading cause of death among individuals under the age of 35. 

Motor vehicle crashes account for approximately half of all unintentional injury deaths; falls, 

poisonings, suffocations and drownings account for a substantial portion of the remainder. Injury 

mortality is particularly common among the most vulnerable sectors of a community – its 

children and elderly. Injuries cause more than two-fifths of all deaths to children between the 

ages of one and four - four times as many as deaths due to birth defects, the second leading cause 

of death for this age group. They also cause nearly four out of five deaths to 15-24 year olds. In 

addition, while the proportion of injury-related deaths decreases after the age of 44, the rate of 

mortality from injuries is actually higher among older persons than among younger persons. 

Indeed, the second highest rate of motor vehicle-related deaths occurs among adults age 75+. 14 

Within the study area, the Washington region showed the largest and most consistent 

elevations in mortality from all accidents combined and from motor vehicle accidents in 

particular. Indeed, rates of motor vehicle-related injury mortality were twice as high among men 

and women in the Washington region than they were among men and women in the peer 

communities (See Table 12). Total accident mortality was not elevated in the Aroostook region 

but mortality associated with motor vehicle injuries was – by 25% among men and by 35-40% 

among women. A similar pattern emerged in the Hancock region, although the rate of motor 

14 U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 

2nd ed. Washington, DC: U.S. Government Printing Office, November 2000. 


43 

PHRG


vehicle-related mortality among men was even more pronounced (31 per 100,000) relative to the 

peer (21). Injury-related mortality rates (total and motor vehicle related) were also elevated 

among women in the Penquis region. 

With regard to injury prevention, seatbelt use in most EMH communities was not substantially 

below levels in the peer communities, State or nation. The proportion of adults who report 

always wearing their seatbelt when driving or riding in a car was lowest in the Penquis and 

Washington regions (57%) – approximately 10% lower than that in the peer and 20% lower than 

that in the State and in the US. Men between the ages of 18 and 44 were the least likely in all 

regions to report always using a seatbelt. Injury prevention efforts focusing on seatbelt use 

would be appropriately geared toward this high-risk group, especially considering the high rates 

of mortality from motor vehicle crashes in the study area. 


44 

PHRG


Table 12: Selected Accident and Injury Indicators by EMH Service Region 

Indicator 

Bangor 

Urban 

Peer Aroostook Penquis Washington Hancock Central 

Knox- 

Waldo 

Rural 

Peer Maine US 

Always Wear Seatbelt 1 69.3% 69.7% 61.4% 57.2% 57.2% 64.6% 68.6% 63.7% 62.9% 69.5% 69.3% 

Total Accident 

Mortality 2 30.7 33.7 34 40.1 53.3 36.5 33.4 34.4 36.9 35.4 36.2 

Males 35.5 36.3 43 42 65.8 45.5 47.2 45.4 45.4 44.9 47.7 

Females 26.1 31.2 24.2 39.7 42.3 29.2 20.2 24.1 28.8 26.3 25.2 

Motor Vehicle 

Accident Mortality 2 11.6 19 24 21.4 34.9 24.3 17.7 18.5 18.3 16.1 16.1 

Males 16 20.8 26.5 22 35.5 31 23.8 25.1 21.2 21.6 22 

Females ^ 17.2 20.7 21.4 35.2 ^ 11.5 ^ 15.5 10.8 10.5 

Sources: 

1 EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996, 1997 & 

1999): Urban Peer, Rural Peer and Maine; CDC BRFSS Survey (1998-1999): U.S. 


Maine Population Data: Claritas, Inc. 

(1998) 

All rates expressed are per 100,000 unless otherwise 

stated 


^ = not reported based on < 5 annual cases 



Intimate partner violence (IPV) is a significant public health threat in Maine, as it is in the rest 

of the nation. Just under one in every three women who are killed in this country are known to 

have been killed by a current or former intimate partner. Nearly half of all IPV victims 

experience injuries severe enough to require medical treatment. IPV victimization has also been 

associated with poor physical and mental health outcomes, as well as elevated rates of chronic 

pain, depression, anxiety, insomnia, substance abuse and suicide. 15 IPV is also costly – a 1999 

analysis of health expenditures showed that health plan costs for IPV victims are about 

$1800.00 higher than they are for women not known to have been victimized. 16 (See Appendix 

16 for selected IPV findings from the 2001 EMH Household Survey.) 

Estimates from a recent national study suggest that 25% of adult (18+) women in the U.S. has 

been raped or physically assaulted by a current or former intimate partner at some point in her 

life. 17 Findings from the present study were similar. Between 15 and 25% of study area women 

reported that they had been a victim of IPV at some time in their lives (See Table 13). 18 Except 

for the Aroostook region where the prevalence of IPV (13%) was substantially lower than that in 

the other study regions, there was little variation across the study area. Young (18-44) women 

were the most likely to have ever experienced IPV (approximately 30%) and to have experienced 

IPV in the past five years (approximately 10%). Women in the Central (12%) and Knox-Waldo 

(14%) regions were slightly more likely than their counterparts in other study regions to have 

been IPV victims in the past five years. Only a minority of women who were victimized in the 

past five years sought medical care to treat violence-related injuries. 

15 Plichta S. The effects of woman abuse on health care utilization and health status: A literature review. WHI, 

1992. 

16 Wisner C, Gilmer T, Saltzman L, & Zink T. Intimate partner violence against women: Do victims cost health 

plans more?. Jrnl Family Practice, 48, 1999. 

17 Tjaden P, Thoennes N. Prevalence, incidence, and consequences of violence against women: Findings from the 

National Violence Against Women Survey. Washington, D.C.: NIJ/CDC, 1998, NCJ 172837. 

18 IPV was defined as a positive report of “being involved in a physical conflict or forced to have sex against your 

will by a current or ex-spouse; current or ex-live-in partner; or current or ex-boyfriend, girlfriend or date that did not 

live with you?” Physical conflict was defined as “not just beatings, but also those times that you were pushed, hit, 

shoved, slapped, grabbed, punched, cut, hit with an object, forced into any sexual activity, or something like those 

actions.” 



Table 13: Intimate Partner Violence (IPV) by EMH Service Region 

Indicator 

Region 

Ever IPV Victim Bangor Aroostook Penquis Washington Hancock Central 

Knox- 

Waldo Total 

18-44 N 32 13 21 24 22 28 23 163 

% 29.9 15.7 25.3 29.6 27.8 31.8 28.8 27.1 

45-64 N 15 7 11 9 11 11 16 80 

% 24.2 13.2 19.6 16.4 19.6 20.0 28.1 20.3 

65+ N 3 1 4 8 3 5 2 26 

% 7.9 2.7 9.8 18.6 7.0 12.8 4.4 9.1 

Total N 50 22 36 40 37 44 41 270 

% 24.2 12.6 19.9 22.0 20.6 24.0 22.5 20.9 

IPV Victim-Past 5 

Years 

18-44 N 12 6 9 7 7 11 11 63 

% 11.2 7.1 10.7 8.6 8.9 12.4 13.8 10.4 

45-64 N 0 0 2 2 0 1 2 7 

% 0.0 0.0 3.6 3.6 0.0 1.8 3.5 1.8 

65+ N 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 12 6 11 9 7 12 13 70 

% 5.8 3.4 6.0 4.9 3.9 6.6 7.1 5.4 

Sought Medical N 2 2 2 3 0 1 3 13 

Care for IPV % 16.7 40.0 18.2 33.3 0.0 8.3 23.1 18.8 

EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo 

Regions 

Oral Health 

FINDINGS: Oral health in northern, eastern and central Maine is poorest in those regions 

with the least access to dental care – particularly among the elderly. 

• Oral health status, as indexed by the number of permanent teeth removed because of tooth 

decay or gum disease, was poorest in the Aroostook, Penquis, Washington, and Central 

regions. 

• Dental care utilization was also lowest in the Aroostook, Penquis, Washington, and Central 

regions. 

Oral health is an integral component of the overall health and well being of children and adults. 

Although often unrecognized, the burden of suffering associated with oral disease is substantial. 

According to the Surgeon General’s recent report on oral health in the United States, 20 tooth 

19 U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 

2nd ed. Washington, DC: U.S. Government Printing Office, November 2000. 

20 

US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General-- 

Executive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental 

and Craniofacial Research, National Institutes of Health, 2000. 



decay is the single most common chronic disease of childhood --5 times more common than 

asthma and 7 times more common than hay fever. More than half of all children between the 

ages of 5 and 9 and nearly 80% of 17 year olds have at least one cavity or filling. Children from 

low-income families suffer twice as much tooth decay as their more affluent peers, and their 

disease is more likely to go untreated. 

Most adults show signs of periodontal or gingival diseases. Severe periodontal disease 

(measured as 6 millimeters of periodontal attachment loss) affects 15-25% of adults age 45+ and 

is particularly prevalent among men and low-income adults. Approximately 30% of older adults 

are edentulous – the rate is even higher among those living in poverty. Moreover, oral and 

pharyngeal cancers are diagnosed in about 30,000 Americans every year – primarily in the 

elderly - and 8,000 die from those diseases each year. Prognosis for those diseases is poor - the 

5-year survival rate (among whites) is only 56%. In addition, many individuals face substantial 

barriers to accessing preventive and curative dental care. More than 100 million children and 

adults lack dental insurance - 2.5 times as many as those who lack medical insurance. 

Oral health in northern, eastern and central Maine is poorest in those regions with the least 

access to dental care – particularly among the elderly. The proportion of adults who had six or 

more of their teeth removed because of decay or gum disease was 25-45% higher in the 

Aroostook, Penquis, Washington and Central regions than in the peer areas or the State (See 

Table 14). One third or more of the adults in those communities reported having 6 or more 

permanent tooth removed because of decay or disease. In the Penquis region, 20% of all adults 

and nearly half (48.5%) of older (65+) adults had all of their teeth removed because of decay or 

disease. 

The incidence of buccal cavity cancer was elevated among men in the Aroostook region (38 per 

100,000 vs. 33 and 34 in the peer and State, respectively) and among women in the Washington 

region (15 per 100,000 vs. 11 in the peer and State). Deaths due to buccal cavity cancer, 

although rare, were elevated relative to the peer and State among men in the Aroostook and 

Penquis regions (13 vs. 4 per 100,000). Buccal cavity cancer mortality was not elevated among 

women in the Washington region, however. 

The proportion of adults who had not visited a dentist in the past year was also 30-40% higher in 

the Aroostook, Penquis, Washington and Central regions than in the peer areas or the State. 

Between 41 and 44% of adults in those communities had not seen a dentist in the previous year, 

compared to approximately 32% in the peer areas and the State. Moreover, 20-25% of all adults 

and 30-40% of the elderly in the Aroostook, Penquis, Washington and Central regions had not 

been to a dentist for more than five years. The most common reason (in all regions) for not 

having gone to the dentist in the past year was a feeling that there was no reason to go (35-55%), 

followed by the cost associated with the visit (24-33%) and fear (1-11%). No one reason was 

more pronounced in those regions with lowest rates of dental care utilization. Across regions, 

adults without health care coverage were twice as likely as those with insurance to report that 

they had not been to the dentist in the past year. 



Table 14: Oral Health and Dental Care Utilization by EMH Service Region 


Peer 


Waldo 

Rural 

Peer 


US 

% Not Visiting the 

Dentist in the Past Year 

35.4 39.3 41.8 41.8 43.9 35.6 41 32.3 32.4 32.5 31.9 

% Unable to Afford a 33 NA 26.6 26.5 23.6 25.4 32.3 28.4 NA NA NA 

Dental Visit a 

% 6 or More Teeth 

Removed Because of 

Tooth Decay 

29.6 29.3 32.6 38.5 35 23.1 34.9 26.4 26.8 24.4 19.9 

Sources: 

EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions; ME BRFSS Survey (1996, 1997 & 

1999): Urban Peer, Rural Peer and Maine; CDC BRFSS Survey (1998-1999): US. 


a Among those who reported that they did not visit a dentist in the past year. 



Alternative Health Services 

FINDINGS: The extent of alternative health service utilization varies across northern, 

eastern, and central Maine although those services are widely regarded as 

effective. 

• Alternative health service utilization was lowest in the Aroostook and Penquis regions and 

highest in the Hancock and Knox-Waldo regions. 

• Most adults who used alternative health services perceived them as helpful. 

In response to trends indicating increased use of non-traditional treatments for medical 

conditions, we asked adults residing in each study region about their recent use of alternative 

medical practices. Adults from the Aroostook and Penquis regions were the least likely to have 

used any form of alternative therapy in the past three years (15-16%) whereas adults from the 

Hancock and Knox-Waldo regions were the most likely (30%) (See Table 15). Herbal 

therapy 21 was the most frequently used type of alternative medical care in the study area (ranging 

from 15% in the Hancock region to 7% in Aroostook and Penquis), followed by chiropractic care 

(ranging from 10-11% in the Hancock and Knox-Waldo to 4% in Aroostook). In general, 

women and younger adults (18-44 and 45-64 year olds) were more likely than men or older 

adults to report using alternative medical therapies. Individuals with multiple chronic diseases 

were less likely than well adults to use alternative therapies. 

Table 15: Prevalence of Alternative Therapy Utilization (Past 3 Years) by EMH Service Region 

Type of Therapy Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo 

Any* 21.3% 16.4% 15.4% 21.7% 30.0% 22.4% 28.9% 

Chiropractic** 6.3% 3.7% 5.6% 7.5% 10.7% 8.5% 10.4% 

Herbal Therapy 11.4% 7.3% 7.1% 9.3% 15.3% 8.2% 11.6% 

Massage Therapy 3.9% 1.0% 3.0% 2.4% 3.9% 2.1% 6.8% 

Homeopathy 1.5% 1.5% 0.6% 2.5% 4.6% 5.3% 6.8% 

Acupuncture 2.8% 2.9% 1.2% 2.7% 2.5% 3.5% 2.8% 

Naturopathy 1.6% 0.8% 0.9% 0.2% 0.6% 0.2% 0.7% 

* % Reported having tried any alternative medical therapy or practice over the past 3 years. 

** First, second or third mention of specific therapy used over the past 3 years. 

Sources: 

EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox-Waldo Regions. 

The majority of adults who used alternative medical therapies in the past three years perceived 

them as helpful (See Table 16). Across all study regions, chiropractic care was perceived as 

most effective, with 67-86% of users rating it as very helpful (based on first mentioned therapies 

only). Massage therapy was also well regarded, with 50-100% of users rating it as very helpful. 

21 The high rate of herbal therapy utilization might reflect the self-administered use of herbal supplements such as 

St. Johns Wort. 



Perceived efficacy ratings were fairly consistent across study regions although there was a 

tendency for therapies to be rated as less helpful in Aroostook and Penquis where utilization was 

lower. Our findings can not discern, however, whether use has a positive impact on perceived 

efficacy or whether perceived efficacy influences use. They only indicate that community 

members who use alternative medical therapies evaluate them very favorably. It should also be 

noted that respondents were not asked to report the health problems/conditions for which they 

used alternative therapies. As such, these findings do not indicate what symptoms or conditions 

those therapies were helpful in alleviating. 

Table 16: Perceived Effectiveness of Alternative Therapies by EMH Service Region * 

Type of Therapy Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo 

Any 58.5% 45.6% 56.6% 61.5% 54.7% 52.5% 54.4% 

Chiropractic 75.0% 66.7% 75.0% 85.7% 73.3% 66.7% 72.0% 

Herbal Therapy 45.5% 36.4% 28.6% 45.8% 40.0% 42.9% 20.7% 

Massage Therapy 66.7% 100.0% 85.7% 71.4% 83.3% 50.0% 92.3% 

Homeopathy 66.7% 60.0% NA 16.7% 45.5% 33.3% 56.3% 

Acupuncture 33.3% 33.3% 33.3% 66.7% 66.7% 71.4% 66.7% 

Naturopathy 0.0% 100.0% 100.0% 100.0% 100.0% 100.0% 50.0% 

Sources: 


* Among respondents who used alternative therapies in the past 3 years. 

Community Perceptions of Health and Health Service Need 

FINDINGS: Alcohol and drug abuse is widely regarded as the most significant health 

problem in northern, eastern, and central Maine. 

• Alcohol and drug abuse was particularly likely to be named as the biggest health problem in 

those regions where substance abuse indicators tended to be the least favorable. 

• Cancer, the cost of care, lack of insurance and the availability of quality health care services 

were also identified as significant health issues in many sectors of the study area. 

• Perceived needs for additional health care services generally mirrored priority health issues 

in each study region. 

• More than half of respondents in all study regions cited a need for additional crisis 

intervention and domestic violence services. 

When asked to identify the biggest health problem in their communities, survey respondents in 

all areas except Aroostook mentioned alcohol and drug abuse more frequently than any other 

issue. Alcohol and drug abuse was particularly likely to be named as the biggest health problem 

in those regions where substance abuse indicators tended to be the least favorable – Washington, 



Hancock, Knox-Waldo and Bangor (See Table 17). Nearly 40% of respondents from the 

Washington region identified alcohol and drug abuse as the most pressing concern in their area, 

as did 20% of respondents in the Hancock, Knox-Waldo and Bangor regions. Respondents from 

the Central region were less likely to identify alcohol and drug abuse as the top concern in their 

community, although substance abuse indicators were consistently elevated in that area. 

In general, cancer was the second most frequently identified health problem in northern, eastern 

and central Maine– across all study regions, but particularly in Aroostook (where indicators of 

cancer burden were elevated). Respondents from Aroostook (as well as those from Penquis) 

were also particularly likely to cite a lack of quality health care services as the most significant 

health problem in their community. The cost of care was also commonly identified as a problem 

– especially in the Hancock and Knox-Waldo regions, as was lack of insurance. In general, 5% 

or fewer respondents identified elderly care, smoking, heart disease, obesity, medication costs, 

oral health and transportation as the most significant health problem in their community. 

Perceived needs for additional health care services generally mirrored priority health issues in 

each study region (See Table 18). For example, Aroostook respondents (66%) were most likely 

to report needing additional cancer treatment and heart disease services. Cancer, heart disease, 

substance abuse and mental health treatment were all perceived as inadequate by half or more of 

respondents from the Washington region. In addition, more than 50% of respondents in all study 

regions cited a need for additional crisis intervention and domestic violence services. 



Table 17: Perceived Biggest Health Problem in Community by EMH Service Region 

Indicator Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo 

Alcohol/Drug Abuse 17.9% 9.8% 13.6% 38.9% 19.9% 13.5% 19.8% 

Cost of Care 9.7% 7.9% 7.2% 6.4% 13.4% 9.8% 15.1% 

Lack of Insurance 9.6% 9.1% 7.0% 4.9% 7.6% 8.9% 7.7% 

Cancer 8.0% 17.3% 11.8% 10.9% 9.6% 11.8% 11.6% 

Elderly Care 5.2% 5.2% 7.0% 4.0% 4.6% 4.9% 3.3% 

Smoking 4.6% 5.4% 4.6% 2.5% 7.1% 4.4% 2.9% 

Heart Disease 4.4% 5.5% 4.5% 2.0% 3.1% 2.7% 1.5% 

Obesity 3.8% 1.5% 2.7% 1.1% 5.0% 2.5% 4.9% 

Medication too Expensive 3.4% 2.1% 1.7% 3.1% 2.6% 1.8% 2.7% 

Lack of Services/Staff/Quality 

Care 

2.3% 10.1% 10.3% 6.5% 4.9% 5.2% 5.8% 

Poor Oral Health 1.3% 0.0% 0.5% 0.4% 0.5% 0.7% 0.8% 

Lack of Transportation/ 

Services too Far Away 

0.4% 2.9% 2.2% 3.0% 2.2% 1.2% 0.6% 

Other 11.4% 9.2% 12.2% 7.1% 7.9% 12.8% 11.9% 

Don't Know 18.0% 14.0% 14.7% 9.2% 11.6% 19.8% 11.4% 

Sources: 

EMH household survey (2001): Bangor, Aroostook, Penquis, Washington, Hancock, Central, and Knox- 

Waldo Regions. 



Table 18: Perceived Service Needs by EMH Service Region - % Reported Need for More… 

Indicator Bangor Aroostook Penquis Washington Hancock Central Knox- 

Waldo 

Home Health Nursing 40.3% 31.0% 31.9% 40.0% 41.7% 33.9% 41.2% 

Counseling/Mental Health Services 28.1% 32.8% 39.1% 47.2% 34.7% 38.7% 29.3% 

Alcohol and Drug Abuse Services 32.6% 39.8% 39.6% 60.6% 42.9% 34.6% 38.4% 

Alternative/Complementary Medicine 25.1% 34.6% 27.5% 37.2% 25.2% 27.4% 14.4% 

Crisis Intervention Services 56.4% 57.5% 60.5% 63.4% 61.1% 62.5% 61.3% 

Adult Primary Care Services 27.2% 41.5% 29.2% 36.5% 29.1% 30.1% 37.3% 

Domestic Violence Victimization 

Services 

52.1% 47.1% 51.2% 50.5% 53.7% 56.8% 53.0% 

Women's Services 17.3% 30.3% 39.2% 39.3% 23.9% 25.6% 24.3% 

Pediatric Services 24.1% 28.9% 40.6% 44.3% 26.8% 25.7% 24.6% 

Cancer Treatment and Care 36.6% 66.0% 54.3% 70.8% 46.2% 42.9% 56.6% 

Heart Disease Services 25.8% 66.1% 48.1% 63.5% 44.9% 44.0% 49.4% 

Orthopedic Care 14.6% 38.2% 30.3% 52.9% 28.1% 23.7% 26.0% 

Diabetes Care 23.2% 31.8% 30.8% 38.3% 23.5% 23.3% 25.7% 

Emergency/Trauma Care 23.4% 45.8% 43.7% 51.2% 38.8% 34.0% 32.9% 

Lung Rehabilitation 25.2% 48.9% 49.1% 59.0% 37.3% 35.5% 39.7% 

Rehabilitation 27.3% 27.2% 31.3% 47.7% 34.4% 32.1% 28.9% 

Health Education Services 45.4% 39.9% 52.1% 50.4% 39.3% 44.0% 39.6% 

Sources: 




Summary 

Based on the findings discussed above, several issues, including primary prevention; access to 

care; cancer screening, detection and treatment; mental health and substance abuse services; subspecialty 

care; sub-acute care; and oral health were identified as issues in need of further 

investigation. Interviews were conducted in each region to explore these issues in more depth. 

The findings of these interviews are discussed in the next section of the report. 

VI. PRIORITY HEALTH ISSUES 

Priority health issues are those that pose a disproportionate threat to the health of a population 

and/or are modifiable with delivery system intervention at the patient or provider level. They 

can either be a disease, such as asthma or diabetes, or a service need, that if not addressed will 

result (or will continue to result) in poor health status and high use/costs of services. They can 

also be “emerging issues” that have just appeared without the future health effects being known. 

Issues are identified as priorities if, in the analysis of the quantitative assessment data, a pattern 

of findings surrounding related indicators suggests that a certain population has a particular need 

for either preventive, screening, diagnosis, treatment or follow-up services. Priority health 

issues can also emerge as a result of interviewing providers and other stakeholders about the 

health of their community provided they are raised by a number of those interviewed. An 

example of the latter is access to transportation to and from medical care services. 

Several priority health issues emerged from the epidemiological and health services utilization 

information analyzed in this assessment. Using those as a starting point, we interviewed a broad 

array of health providers and related stakeholders from across the seven study regions. (See 

Appendix 3 for a description of the study regions and Appendix 4 for a map of the regions.) 

Interviewees included providers, administrators, and agency heads from within the EMH system 

and from the larger community of health care providers in northern, eastern and central Maine. 

(See Appendix 11 for a list of those interviewed) These interviews were conducted both in 

person and by telephone using a standardized interview protocol. 

During the course of each interview, we reviewed the quantitative assessment data related to the 

priority health issues for the region in which the respondent’s practice or facility was located. 

After discussing the findings, we reviewed the local service delivery system regarding each 

priority issue and, from the perspective of the stakeholder, identified the gaps in local services. 

Interviews were conducted with one or more stakeholders in each of the regions established for 

this project. Based on the data collected from these interviews as well as the telephone survey 

and the analysis of secondary data, we have prepared the following findings and 

recommendations for consideration. 

Primary Preventive Education/Services 

Primary preventive education/services are interventions aimed at preventing the onset of a 

medical condition by reducing patient risk. The most prominent disease risk factors are smoking 

and obesity. Smoking is associated with deaths from cardiovascular disease, cancers of the lung, 

cervix and bladder, chronic obstructive pulmonary disease, burns, and diseases of newborns 

(sudden infant death syndrome and respiratory diseases). Overweight and obesity are associated 

with a higher risk of cardiovascular disease, type II diabetes, hypertension, high blood 



cholesterol, and certain cancers, and have also been shown to mitigate the effect of 

pharmacological treatment for many chronic diseases including mental health diseases. Smoking 

and overweight were significant risks in most of the regions we studied - among young, healthy 

individuals as well as older individuals with diagnosed medical conditions. For example, adults 

with three or more chronic diseases were not only more likely than their counterparts to have a 

history of cigarette smoking, they were as likely to currently smoke. Moreover, in the Central 

region, adults with multiple chronic diseases were 40% more likely than adults without multiple 

chronic diseases to be current smokers. The large proportion of people with chronic medical 

conditions who continue to smoke has contributed to higher than expected rates of health care 

utilization and associated costs in this population. High prevalence of smoking among those 

who don’t currently suffer from chronic illness will lead to a worsening of this problem in future. 

High rates of obesity were also evident among those diagnosed with chronic disease. About half 

of all adults with multiple chronic diseases were classified as obese – 30-60% more than adults 

without multiple chronic diseases. Additionally, in most study regions, heavy drinking was twice 

as prevalent among adults with multiple chronic diseases than among their counterparts. 

These and other assessment findings suggest that risk factor reduction efforts need to be targeted 

toward individuals with and without already established chronic diseases. Although Maine has 

appropriately emphasized youth-oriented prevention programs in the use of its tobacco 

settlement funds, a more comprehensive effort that involves health care providers, employers, 

health insurance plans, policy makers, law enforcement, business owners and other community 

members is needed to address tobacco prevention and cessation needs in all sectors of a 

community. 22 Within the medical system, primary preventive education/services (tobacco, 

nutrition, exercise) need to be a component of an overall patient care plan – ideally as part of a 

standardized service delivery protocol that is implemented by primary care providers. Effective 

messaging by a PCP to patients who are smokers or are overweight has been shown to be 

effective. 23 Community-wide enabling resources, including routine PCP screening and 

counseling, are essential to assist established smokers in quitting. 

Current Services: All providers and hospital personnel that we interviewed reported engaging 

in some form of primary prevention education. Hospitals engage in risk factor education through 

health fairs and formal education programs. Physicians report admonishing their patients to quit 

smoking and/or lose weight, although they acknowledge that many of their patients fail to heed 

this advice at serious detriment to their health. In addition, many respondents were part of a 

PTM-funded community health coalition, which they viewed as an opportunity to address risk 

factors comprehensively, not just smoking. Although coalition activities have only recently 

gotten underway, their focus appears to be on youth-oriented prevention and cessation efforts. A 

comprehensive system of primary prevention that integrates risk-reduction efforts at the policy, 

law enforcement, health care, school, employer and business levels was not apparent in any of 

the study regions. 

22 Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use 

and exposure to environmental tobacco smoke. Am J Prev Medicine 2001; 20(2S): 10-15. 

23 Thompson RS, Taplin SH, McAfee TA, et al. Primary and secondary prevention services in clinical practice.: 

Twenty years’ experience in development, implementation and evaluation. JAMA 1995; 273(14): 1130-1135. 



Findings from our provider interviews and quantitative data analysis suggest that current primary 

prevention efforts – both from within the medical system and in other venues – are not sufficient 

to modify high-risk behaviors. This is especially true in communities where cultural issues have 

a persuasive influence on smoking behavior. 

The PTM program has several components that include (but are not limited to) 1.) Community 

Programs that target a geographic population in Maine or a particular setting or population 

affiliate group; 2.) School Programs that are intended to work towards integration of CDC 

Guidelines for School Health Programs; 3.) A multimedia Public Awareness Campaign aimed at 

increasing the public’s awareness of dangers of tobacco, etc.; and, 4.) An enforcement program 

to prevent youth from accessing tobacco products in conjunction with Attorney General and 

Office of Substance Abuse. [There are 31 community and school programs funded by PTM of 

which 16 are located in northern, eastern and central Maine.] 

There is a general concern among many of those interviewed that the 31 school and community 

programs funded by PTM program lack: a.) structure, b.) uniformity in their approach to 

prevention and cessation and c.) sufficient funding to withstand anticipated State budget 

shortfalls. While it is still too early to ascertain the veracity of the first two concerns, the latter is 

not unfounded. Maine has already experienced a redistribution of tobacco settlement funds away 

from prevention programs. There was consensus among the interviewees that a more focused 

effort among all parties is required. There is commitment among hospital administrators that 

they need to do more in prevention even though it is a service for which funding is almost nonexistent. 

This attitude toward prevention is a healthy change and an opportunity for real 

improvement in this area. Additionally a Bureau of Health focus is now on chronic disease risk 

factors and not just smoking. 

Barriers: There are several major barriers to effective prevention efforts. One is the difficulty in 

uniformly implementing programs and guidelines throughout the system of providers in 

northern, central and eastern Maine. For example, while the effectiveness of provider-based antismoking 

education and counseling has been demonstrated, there is a consensus that many 

physicians in these regions are not educated in evidence-based office protocols for reducing 

tobacco and other risk factors. We do not know whether this reflects a lack of 

knowledge/education or whether it is a resistance or inability to adopt a standardized prevention 

protocol. Another barrier lies in paying for preventive services, especially programs for adults 

who are not yet part of the medical care system. Although there are ample examples of effective 

community outreach programs (e.g., the Franklin Cardiovascular Health Program), funding 

mechanisms for those programs are not readily available. 

Access to Health Care 

Access to health care is a priority issue in most regions of northern, eastern, and central Maine. 

One barrier to obtaining appropriate preventive and curative care is a lack of adequate health 

insurance. Adequate health insurance, a particular concern in a faltering economy, is an 

important barrier to obtaining routine health exams and screenings that are essential for early 

diagnosis and appropriate treatment. Between 10% and 20% of adults in the study area reported 

not having health care insurance that would cover an overnight hospital stay. Lack of insurance 

or inadequate insurance is also a particular problem for persons with diagnosed medical 



conditions since it may reduce access to treatment resources, especially pharmacological 

treatments. Indeed, 15-20% of study area adults with no health care coverage have been 

diagnosed with 3 or more chronic health conditions. 

Current Services: Maine has an ongoing health insurance program for children whose parents 

cannot afford to cover them. The Maine CUB program has been one of the most successful in the 

country in terms of enrolling the eligible population. Although providers maintain that payments 

under the CUB program are below Medicaid rates, the program has expanded coverage to 

populations that otherwise had no insurance. Medicaid eligibility has also expanded over the 

decade. In addition, hospitals and other providers provide a modest degree of free care. 

However for a population that needs routine care, especially for chronic disease or early 

screening, this is not a viable option. 

Barriers: Despite these successes, Maine no longer has a health insurance program to cover 

either catastrophic medical bills or high-risk patients. Not all individuals who are eligible for 

Medicaid or for the CUB program are either aware of their eligibility status or can successfully 

maneuver the enrollment process. Few free care clinics are available for those without insurance. 

In addition, little State support is available to assist small employers in providing health 

insurance for their employees. As a result of these and other gaps, the proportion of uninsured 

remains high in the State. 

Mental Health/Substance Abuse Services 

Mental health and substance abuse problems also emerged as priority issues in the study area. 

Several system level deficiencies were apparent in all seven-study regions, including the 

identification of available inpatient beds, the provision of crisis level services, and the 

coordination between behavioral health care and primary care systems. 

• Inpatient Psychiatric and Substance Abuse Beds 

One of the most consistent themes to emerge from our interviews was the impact of the 

perceived shortage of inpatient psychiatric and substance abuse beds throughout the study area 

and the State as a whole. This was true for adults, children, and adolescents. It is not uncommon 

for patients to be referred to inpatient beds outside of their communities when their local 

facilities are full. Staff in the Emergency Department (ED) at Eastern Maine Medical Center 

estimate that, on average, 40 percent of the patients who are admitted to a psychiatric inpatient 

bed from the ED are admitted to a bed outside of the Bangor region. Twice during the past year, 

no inpatient beds have been available statewide. 

Current Services: Staff at facilities throughout northern, eastern and central Maine report that 

the process of obtaining a bed is both cumbersome and time consuming. There is some evidence 

that the bed placement issue is a particular problem for children and adolescents, crisis patients 

and involuntary admissions. ED staff often must make multiple phone calls to determine where a 

bed might be available. In addition, they also report long waiting periods as the process of 

determining bed availability unfolds. Waiting times as long as 12 to 18 hours have been reported 

for children in an ED before an admission can be arranged. 

In addition to the administrative burden of finding and securing an inpatient bed, these out-of- 



area placements also complicate the discharge process. Discharge planning staffs are often 

unfamiliar with the resources for follow-up care in the patient’s community. In addition, it is 

more difficult to determine whether or not the patient has ever followed through with his or her 

discharge plan. As a result, patients admitted to distant hospitals may be more likely to “fall 

through the cracks” of the system, thereby increasing the likelihood of readmission. In addition 

to encouraging an over-reliance on inpatient treatment as opposed to community-based care, outof-area 

hospitalization also places a greater burden on the patient’s family and support system. 

Barriers: Respondents were asked whether they believe this problem is caused by a shortage of 

inpatient beds or an insufficient system of step-down and aftercare services (also called midrange 

services). Not surprisingly, their answers were mixed. Although a few respondents thought 

that there are sufficient beds in the region, most believed that the situation is caused by a 

combination of too few beds, particularly for specific populations (e.g., substance abusers, 

children, and adolescents) and an insufficient system of residential and community based 

services. Although new inpatient beds for children and adolescents were recently opened at 

Northern Maine Medical Center in Fort Kent, it remains to be seen what the long-term impact 

will on the waiting list for services in northern Maine. 

• Crisis Services 

Respondents uniformly expressed concern about the adequacy of crisis services for individuals 

who present to emergency departments with acute mental health or substance abuse problems. 

Current Services: Crisis services in northern, eastern and central Maine are primarily delivered 

through hospital emergency departments. Most hospitals have contractual arrangements with 

outside agencies that respond to emergencies when called. While these agencies address the 

acute emergency, there is an undue emphasis on transferring the patient out of the ER to an 

existing mental health inpatient facility. Almost no twenty-three hour evaluation and surveillance 

units exist as part of the ED in community hospitals in these regions. 

Barriers: The provision of crisis services is a source of conflict between acute care providers 

and community providers. For example, in the Bangor region there is the lack of coordination 

between EMH and CHCS/Northeast Crisis Service personnel. Appropriately skilled crisis 

workers do not meet EMH credentialing standards. As a result, they cannot provide services in 

the emergency department of EMH facilities. Existing privacy laws further complicate efforts to 

access mental health and substance abuse services from the emergency department. In addition, 

current crisis services should be streamlined to minimize delays and redundant data collection 

that impede their ability to quickly respond to patient needs. In addition to these barriers, the 

system suffers from a lack of crisis alternatives to emergency department services. 

• Coordination with Primary Care Providers 

Providers interviewed throughout the study area identified primary care providers (PCPs) as an 

important component of the behavioral health system. PCPs are ideally positioned to detect 

behavioral problems among their patients and to make necessary referrals to appropriate 

services. They also fill an important role in the existing mental health delivery system by 

oftentimes managing the psychotropic medication needs of their patients. 



Current Services: Existing behavioral health and primary care systems are poorly integrated. 

There is a lack of care coordination resulting from separate and distinct care and reimbursement 

systems, little or no communication about the same patients and a lack of training/education 

among PCPs on the diagnosis and treatment of mental health and substance disorders. 

Barriers: Respondents raised several key issues that prevent the two systems of care from 

functioning optimally. Fortunately, these issues also provide an opportunity to engage in 

meaningful and constructive dialogue that can bring the two systems of care closer together. 

These issues are as follows: 

• PCPs have a difficult time keeping up with new medications. They have little experience 

with the newer neurological agents. They tend to rely on the medications that are known to 

them. 

• Inadequate coordination between primary care and behavioral health providers in terms of 

information sharing and the delegation of responsibilities. Primary care providers can 

provide a greater range of services, particularly if backed up with consultations from 

psychiatrists. 

• Privacy laws inhibit the sharing of information between PCPs and behavioral health 

providers. 

Cancer Screening and Detection 

Patterns of cancer treatment suggest that the populations of northern, eastern and central Maine 

have generally good access to screening, diagnosis and treatment services. Although high 

incidence rates for certain forms of cancer are partly due to elevated risks (such as smoking), 

they are also indicative of better than average disease detection (e.g., breast cancer detection in 

the Bangor region). Additionally, generally low mortality rates throughout the region are 

suggestive of better than average access to cancer treatment services. 

At the same time, other patterns of cancer screening and detection suggest a need for improved 

services in certain areas, especially for colorectal cancer. For example, early stage colorectal 

cancer diagnoses were lower than expected in certain study regions such as Aroostook and 

Washington. In addition, awareness of cancer screening guidelines was variable across the study 

area. Less than half (45%) of age-eligible women in the Washington region correctly identified 

age 40 as when women should have their first mammogram. In contrast, nearly 65% of ageeligible 

women in the Knox-Waldo region knew the guideline. Moreover, patients’ knowledge of 

screening guidelines did not uniformly translate into the use of screening services. In general, 

age-eligible men who correctly identified age 50 as when men should have their first prostate 

exam were no more likely than their counterparts to have had an exam in the past two years. 

Current Services: Cancer screening and detection generally occur in the office of physicians 

and other providers as part of routine office visits and physical exams. The fact that a high 

proportion of the populations of these regions have a primary care provider suggests availability 

is not a problem. The service issues center around: a. consistency in providers following 

screening protocols for at-risk patients; b. the quality of the laboratory and radiology services in 

evaluating results; and c. the follow-up on patients that test positive in their initial screening. 

Educational information to at-risk populations comes from mass media and hospital community 

outreach programs. All hospitals in the region sponsor health fairs and other means of educating 



the general public on cancer screening and detection guidelines. Some have been more 

successful than others as the data indicate; a successful example is breast cancer screening that 

has received wide attention over the past decade. A less successful example is education on 

protocols for prostate and colorectal cancer screening. 

Barriers: These data, as well as information from area providers, suggest that patient education 

as well as provider knowledge and use of accepted screening/prevention guidelines represent 

significant barriers to cancer screening. Other barriers in the northern, eastern and central 

Maine region include reimbursement practices for cancer screening and detection services, as 

well as the availability of sub-specialty follow-up care (e.g., gastroenterologists who can followup 

on colorectal cancer screening findings). 

Disease Management/Access to Sub-Specialty Care 

The epidemiology and utilization data presented in Chapter 5, especially the hospitalization rates 

for Ambulatory Care Sensitive (ACS) conditions, indicate a need to evaluate secondary 

prevention/disease management services in most of the regions we studied. For many regions, 

ACS admissions associated with adult respiratory and cardiovascular conditions were 

responsible for high overall ACS admissions rates. The exact causes behind those patterns are 

unclear; they might reflect patient factors (e.g., disease severity), physician factors (e.g., less 

than adequate diagnosis and treatment) and/or system factors (e.g., availability of specialty 

services). What was clear, however, from our interviews with area providers and administrators, 

is that access and availability to specialty care is a serious problem in northern, eastern and 

central Maine and is one determinant of the high ACS hospitalization rates. The specialties that 

interviewers most frequently identified as requiring better coverage include Cardiology, 

Oncology, Endocrinology, Pulmonary, Child psychiatry, Thoracic Surgery, Urology, ENT, High 

Risk obstetrics and Rheumatology. 

The results of our focus group on respiratory disease suggest that there are additional issues 

related to: a. PCP’s awareness and use of nationally accepted guidelines for COPD and asthma 

management; b. staging and monitoring lung disease progression by the use of office spirometry; 

and c. practice in taking the necessary time to effectively counsel patients on smoking cessation 

as well as allergy and environmental control. In addition local community hospitals often lack 

disease management programs including COPD rehabilitation programs. 

Current Services: The provision of sub-specialty care for rural populations has traditionally 

been accomplished through the use of specialty clinics or Visiting Consultant Clinics (VCCs) at 

the hospital. VCC’s are largely market driven but planned approaches to bring a limited set of 

specialty services to rural communities. They are market driven in that they are a market 

response to increased competition among specialists in urban areas. They are planned in that 

they are generally established by hospitals or other organized providers and are based on an 

assessment of need. They work when they are: a. coordinated with local PCPs, b. financially 

attractive to specialists, c. not overly costly to the hospital and d. provide high quality care. 

The VCC model provides an opportunity for sub-specialty providers to see patients in their local 

communities, refer those needing additional treatments to the acute care center, and educate local 

PCPs on up-to-date techniques and treatments. This model has worked very well in some of the 



study regions and for some specialties. Yet there is concern among several hospital 

administrators that some of the sub-specialists providing services in their region are not using 

state of the art clinical guidelines and protocols. Local PCPs also noted that sub-specialists do 

not always take cultural factors into account when treating patients nor do they communicate 

well with PCPs. And there is a constant issue about communication between specialists and 

PCPs and patient loss to local practices. In short, all regions have good relationships with some 

sub-specialists and major difficulties with others. 

Disease management services, especially in rural communities, have traditionally been provided 

through primary care offices and specialty consultations. Efforts by insurance companies to 

incorporate disease management services directly or through the office of the PCP vary by 

region and plan. Moreover, hospitals offer patient management programs for certain conditions 

(e.g., diabetes) but not others (e.g., cardiovascular and respiratory disease). Although some 

community hospitals in the region do have a COPD rehabilitation program (usually tied to their 

cardiac rehabilitation services) most do not. The effectiveness of COPD rehabilitation programs 

in improving patient health status, reducing ER visits and hospital stays has been demonstrated. 

Barriers: This issue offers major challenges including how to: a. improve sub-specialty services 

at local hospitals so that patient clinical needs are met, b. make appropriate referrals to tertiary 

care centers so that local providers continue as PCPs, and c. establish a system that will be cost 

effective for providers, patients and local hospitals. The VCC model has not worked well for 

more outlying areas that take a long time to reach or where the patient base is small. This has 

resulted in serious gaps in specialty care, long delays for patients waiting for appointments in 

Bangor, Augusta or Portland, and often poor communication back to PCP’s who are still the 

local provider for patients. This directly affects disease management. There is no fault here—the 

system needs a lot of attention to work well. For example, PCPs and local hospitals complain 

that the clinics are too infrequent and they often lose patients to the acute care centers that they 

could otherwise care for locally. At the same time, sub-specialists complain that they only have 

limited time to be away from their main practice, that the acuity of patients seen locally is often 

not serious enough to warrant a visit, and travel time and a small patient base vastly reduces their 

productivity. 

Several hospitals have opted to solve this problem for some specialties by using local internists 

who have an interest in a particular sub-specialty, like oncology or hematology. With the 

appropriate education and back up, those internists provide some sub-specialty services locally 

that could previously only be obtained at the tertiary care site. Still other hospital administrators 

are interested in hiring a sub-specialist that could be shared between two or three hospital sites. 

This idea, while not new, would have the sub-specialist living and practicing in one region while 

traveling to contiguous regions for conducting clinics and doing procedures. To be successful the 

sub-specialist would still have to be associated with the specialty group at the tertiary care site 

where they would have hospital privileges but not be located there. 

Barriers to organized disease management programs are many. COPD and cardiac rehabilitation 

programs in small hospitals need to share space and personnel to have any opportunity for 

financial viability. Better yet is for several hospitals to combine programs through staff sharing 

arrangements. While difficult to achieve it offers an opportunity for organized disease 



management in regions where none now exist. 

Sub-Acute Care (in the Chronic Disease, Elderly Population) 

Study data demonstrated a larger than expected population in need of sub-acute care services— 

services that help people with their daily activities and allow them greater functional 

independence. Those needs were particularly evident among individuals with one or more 

chronic diseases, especially the elderly in the Aroostook, Penquis, and Washington regions. 

Current Services: The providers interviewed for this study identified transportation for the 

elderly as a significant problem in eastern, northern and central Maine. Transportation was cited 

as a particular problem for older people requiring chemotherapy and dialysis. Home and 

community support services that foster independent living among the elderly were regarded as 

less than adequate. Examples of the types of supportive services needed include: home visitation, 

nutrition counseling and assistance, telephone check-in, homemaking, personal care, and 

errands. Adult day care was also cited as an important service that is not available in certain 

communities. Those interviewed believed that the lack of such services leads to more frequent 

illnesses and ultimately results in more hospitalizations. Adult day programs for dementia 

patients, as well as for elders requiring supervision when family caregivers are not available, are 

also needed in areas where none exist. Everyone interviewed about this issue also believed that 

there should be more primary prevention services for the elderly, including nutrition education, 

accident prevention education, and alcohol abuse counseling. Housing was identified as a 

particular need for older people. With the significant decrease in institutional care, there is a 

perceived lack of affordable, appropriate residences for older people with mental illness. 

Barriers: Access to sub-acute care services is particularly difficult in the most rural portions of 

northern, eastern and central Maine where distances to health care services are great and where 

there are few public transportation options. In addition, a shortage of health care staff - 

particularly nurses, aides, and personal care attendants - is also a significant barrier to access. 

Related to this shortage is the greater demand on those that are working in the field. There was a 

concern among interviewees that longer work hours and larger patient care load will lead to 

problems with morale and potentially, with the quality of care. According to those interviewed, 

inadequate continuity of care also serves as a barrier to the delivery of supportive, out-ofhospital 

services for the elderly. They suggest that putting greater emphasis on long-term needs 

and prevention services could enhance the discharge planning process. The lack of primary care 

providers who are also trained in gerontology further complicates this. At the same time, 

interviewees recognized that the discharge-planning process varies among hospitals and 

frequent, short-term admissions limit opportunities for longer-term discharge planning. 

Interviewees also expressed a need for additional weekend and evening physician coverage in 

rural areas. A common theme expressed was that better coverage on weekends and evenings 

could reduce inappropriate emergency department visits. Social service providers who work with 

elders also noted the extent to which many older people are on anti-depression medications. The 

high rate of alcohol abuse among elders in some study regions was believed to be exacerbated by 

the lack of substance abuse prevention and treatment programs for elders. 


Dental diseases and conditions are among the most prevalent, yet preventable chronic health 



problems. Oral health is a major issue in northern, eastern and central Maine as evidenced in the 

present findings showing high rates of dental disease and low rates of preventive dental care in 

those populations. A recent Maine Department of Health and Human Services report also points 

to the critical state of oral health in the State and focuses the problem as one of access to 

prevention and treatment services. 24 This report, along with the U.S. Surgeon General’s report, 

clarifies the strong association between oral health and overall physical health. 25 Complications 

from oral health disease can rapidly lead to a host of other health problems. Also, a welldocumented 

effect of poor oral health is increased emergency room visits for acute dental 

conditions. In fact, one cannot truly be healthy without good oral health. 

Current Services: Although the statewide number of dentists per 100,000 people in 1998 was 

46.8, several counties in the study area have fewer dentists: Waldo (25), Washington (30.6), 

Piscataquis (32.8), Aroostook (33.7) and Hancock (40.3). In contrast, other counties such as 

Kennebec (53.5) and Knox (61.3) have more than the State average. Several oral health clinics 

have been established in those communities to provide either preventive or a full range dental 

services. Those clinics include: 

Aroostook Valley Dental Center, Ashland 

City of Bangor Children’s Dental Clinic, Bangor 

Bucksport Regional Health Center, Bucksport 

Eagle Lake Health Center (preventive services and referral to local dentists only) 

Eastport Health Care, Eastport 

Harrington Family Health Center, Harrington 

Knox County Health Clinic, Rockland 

Regional Medical Center at Lubec, Lubec 

(There are also dental clinics operated by the Indian Health Services in Presque Isle, 

Houlton, Princeton, Perry, and Old Town.) 

Unfortunately, only two of the clinics listed above (outside the Indian Health Services Clinics) 

have practicing dentists at this time. That is, although all of these clinics have the infrastructure 

to provide service, only two currently are staffed with dentists. 

Barriers: According to the director of Maine’s Oral Health Program, a major reason for poor 

access to oral health in northern, eastern, and central Maine is a shortage of dentists and 

hygienists in the region, especially in the more rural areas. This is compounded by several 

factors, including a reimbursement structure perceived as unfavorable, an uneven distribution of 

dentists and hygienists, limited private dental insurance coverage, and large numbers of families, 

especially children, covered under Medicaid. The shortage of dentists and hygienists results 

from many complicated underlying issues. However, the shortage of oral health staff and access 

24 Maine Department of Human Services. The Status of Access to Oral Health Care in Maine. Augusta, ME: 

Presented to the Joint Standing Committee on Health and Human Services, Maine Department of Human Services, 

January, 2001. 

25 

US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General-- 

Executive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental 

and Craniofacial Research, National Institutes of Health, 2000. 



problems are primarily rooted in: 

• Few dentists (especially dentists beginning their career) are locating in rural areas 

because of high debt and the belief that they will not have a financially viable practice. 

That is, there is a perception, often true, that practice in rural areas of Maine will mean 

fewer patients overall and a larger proportion of low income patients who have no 

insurance coverage, limited ability to pay, or have Medicaid insurance; Medicaid 

reimbursement levels that are below market levels and fail to cover the costs of providing 

care; 

• A shortage of dentists who are willing to accept Medicaid payment because of 

reimbursement levels, administrative difficulties and stereotypes about Medicaid 

patients.. Currently, between 40 and 60 dentists statewide are accepting additional 

Medicaid patients. Among those, most restrict the total number of their Medicaid 

patients; and 

• State regulations that restrict the ability of hygienists to provide preventive care in some 

settings. Hygienists in Maine, as in many other states, must work under the supervision 

of a dentist. However, there are actually three levels of supervision required depending 

on the procedures performed and the setting of the work. A bill enacted during the 119th 

legislature and signed by the Governor in 1999 clarifies where and in what situations 

hygienists may practice under public health supervision. The intent of the legislation is to 

not only provide for less restriction, but also encourage the use of dental hygiene services 

(preventive in nature) for populations that are underserved and likely to experience 

difficulties in obtaining such services otherwise. The law went into effect in June 2001. 

There are national, state and local initiatives in process to address some of the barriers to oral 

health services. These include efforts to increase Medicaid reimbursement, enhance dental 

school loan programs, create new and expand existing community dental clinics, and expand the 

prevention and treatment activities of dental hygienists. 

There are a few community work groups and task forces dedicated to improving access to oral 

health. These groups are located in Bangor, Piscataquis County, Ellsworth, Belfast, Bucksport, 

and Washington County. Partnering with these groups is essential in pursuing any of the 

recommendations listed below. This is particularly true with respect to creating additional 

community dental clinics. A notable and successful example is the Kennebec Valley Dental 

Coalition, which involved the MaineGeneral Medical Center. The coalition identified the need 

for dental care among the indigent and created a Community Dental Center in Waterville. With 

foundation and local support, the Coalition was able to open the facility and recruit a dentist and 

hygienist. Their experience has been that the need is greater than they are able to meet. 



VII. RECOMMENDATIONS 

The following recommendations have been developed to address the priority health issues 

outlined in the previous section of this report. They are offered as possible solutions. They are 

not always presented with a specific organization or combination of organizations that ought to 

bear responsibility for their implementation. Some of the recommendations suggested can be 

implemented by communities, some by providers and some by the State. For others it will take a 

combination of one or more of these entities to successfully implement. As with any 

recommendations developed from a comprehensive study that spans several local delivery 

systems, they will need further discussion and refinement along with organizational planning. In 

the process of moving from planning to implementation the solutions offered here may change 

dramatically as get translated into action at the local level. 

Primary Prevention Education/Services 

Objectives: 

• Prevention and cessation of tobacco use; 

• Reduce levels of obesity and overweight; 

• Improve provider education and counseling to patients; and 

• Improve PCP office knowledge of local resources. 

A major finding of this assessment was the distinct patterns of smoking and overweight in the 

populations studied. There are two at-risk populations, and they need to be addressed with 

different prevention strategies. There is the population of persons who smoke and/or are 

overweight but do not yet have serious medical problems. They are a younger population and 

their addictions are best addressed with preventive services (prevention, cessation, health 

promotion) delivered through schools, places of employment and the media. There is also the 

population of persons with one or more chronic diseases who also smoke and/or are overweight. 

Cessation and health improvement strategies for this population are best centered at their place 

of medical care, place of employment or in the community. Smoking cessation, diet and activity 

strategies should be evidence-based to the extent possible. The strategies should be 

comprehensive—taking note of the fact, for example, the need to change smoking behavior 

should to be addressed at every opportunity available, that increasing physical activity and 

improving diet can be a stimulus in reducing smoking and that community and family support 

can be valuable enablers along the way. 

Recommendations: 

• Prevention and cessation in the non-symptomatic population. Prevention strategies in this 

population differ from that in the population with existing chronic illness. Education, 

prevention and cessation messages where school age and young people congregate are likely 

to be effective supplements to formal programs or counseling efforts sponsored by medical 

providers. Therefore we recommend that: 

1. Regional health care providers link with existing tobacco coalitions to address tobacco 

use as part of a comprehensive cardiovascular health promotion program (diet, exercise 

and other risks)—not just tobacco use; 

2. Communities develop/promote easy-to-access exercise opportunities, such as open space, 

trails and/or recreation facilities, as part of essential community services; 



3. Schools examine and modify their education curricula and policies to provide organized 

exercise programs from K-12; 

4. State policy makers keep tobacco settlement funds for risk factor prevention and related 

health care interventions; 

5. Employer groups (on their own or in concert with their trade associations and tobacco 

control coalitions) develop anti-smoking policies for their workforce (e.g., smoking bans 

and restrictions); offer work-place smoking cessation programs and/or incentive 

packages for employees who quit and remain smoke free, as well as those who wish to 

practice a healthy lifestyle (such as exercise training/subsidized gym membership; 

reduced health insurance premiums or co-pays); and 

6. Restaurants and other eating establishments (including the hospital cafeteria) offer 

desirable alternatives to existing high fat and high calorie meals. 

• Cessation in the symptomatic population. The key challenge here is how to encourage 

physicians to incorporate education and counseling guidelines into their practices. A second 

challenge is to provide patients who are willing to try quitting the opportunity to do so at a 

price they can afford. Thirdly, payers must be more flexible in funding preventive services 

that have been shown to be cost effective. 

We recommend that: 

1. County medical societies disseminate guidelines on evidence-based protocols for 

smoking cessation, diet improvement and exercise to local physician practices; 

2. Primary care providers use these protocols in daily practice and at each patient contact; 

3. Hospitals and communities develop an online patient resource guide to risk factor 

reduction and make it available to PCP offices, patients and the community; 

4. Counseling be provided to patients at each contact point in both inpatient and outpatient 

settings, including group modalities; and 

5. Insurers, particularly managed care organizations and employee assistance programs, 

develop optimal provision of and coverage for a range of related benefits and services. 

Access to Care 

Objectives: 

• Improve insurance coverage to adults, especially those with chronic diseases. 

Removing or reducing the costs of care eliminates a significant barrier to accessing health 

services. Increasing coverage to uninsured populations, especially those with chronic conditions 

that require ongoing treatment, will likely have a beneficial effect on both access to care and as 

well as costs of care. Lack of insurance is a known barrier to the least costly and often the most 

effective type of care. 



1. Regional providers, especially hospitals and health centers maximize state programs 

(Medicaid) and grants to increase insurance coverage, especially for at risk populations and 

with those with diagnosed medical conditions. 

2. Hospitals and communities develop and advertise public awareness materials to educate the 

public about eligibility requirements for Medicaid and Cub Care and to assist individuals in 



enrolling in these programs. 

3. The State develop and implement policies that assist small employers in offering and paying 

for health insurance for their employees and dependents. 

4. To reduce the cultural and financial barriers to care, institute sliding fee scales in outpatient 

settings for persons without health insurance. 

5. Regional providers, especially community health centers should whether they are taking 

maximum advantage of all federal public health service programs and funding. (Certain 

federal programs for medically underserved areas allow for full reimbursement for a range of 

flexible services including those provided by allied mental health professionals and outreach 

visits.) 

Mental Health Coordination with Primary Medical Care Providers 

Objectives: 

• Improve coordination of care between mental health and medical care providers; 

• Improve the skills of PCPs in providing mental health diagnoses and developing treatment 

plans; and 

• Locate mental health services in or close to medical care facilities. 

PCPs are an important component of the behavioral health system as they are well positioned to 

identify behavioral problems among their patients, manage their psychotropic medications, and 

make referrals to specialty mental health services. Unfortunately, primary care delivery systems 

are poorly integrated with the behavioral health delivery systems across the seven regions 

included in this study. We recommend that efforts be undertaken to strengthen the linkages 

between the two systems of care, improve the coordination and sharing of information, and 

enhance the ability of primary care providers to better identify and appropriately treat behavioral 

health problems, and cross-train both provider systems so that each has a better sense of their 

limitations and know when it is best to refer out. 



1. PCPs need access to in-service education programs for primary care providers. (Topics may 

include the use of neurological medications, recognition and treatment of depression, 

evaluation of dementia in the elderly, management of substance abuse disorders, and 

recognition and diagnosis of behavioral health disorders in primary care populations.); 

2. Regional committees of primary care and behavioral health providers should be established 

to develop strategies to enhance the capacity for coordinating the delivery of care to patients 

with mental as well as physical health problems. (These strategies should include the 

development of treatment and referral protocols, mechanisms for gaining necessary patient 

consent to share confidential information, psychiatric consultative services to support PCPs 

(particularly regarding the prescribing and management of psychiatric medications), and 

specific services for children and the elderly); 

3. Hospitals and mental health providers should explore and implement integration models 

based on the specific needs, resources, and competitive environment within each region. 

(These models include the co-location of behavioral health and primary care services, 

consultation-liaison programs to support PCPs, and community mental health teams to 

support and coordinate services with primary care and community agencies); and 



4. Best practices for the diagnosis and treatment of common behavioral conditions treated in 

primary care settings, such as depression and anxiety should be developed and disseminated. 

(Examples of existing programs that may be adopted include the Rand Corporation’s 

Partners in Care program entitled, “Improving Depression Outcomes in Primary Care”). 

Mental Health Services 

Objectives: 

• Establish additional sub acute mid-range services; and 

• Resolve issues related to the difficulties in locating available inpatient beds. 

A major theme emerging from our interviews was the perceived shortage of inpatient psychiatric 

and substance abuse beds and mid-range services throughout northern Maine and the State as a 

whole. These two modes of sub-acute services are closely intertwined. The lack of adequate midrange 

services creates a greater demand for existing inpatient beds. Once hospitalized, the 

shortage of mid-range services complicates and delays patient discharge. The end result is that 

patients are often admitted to facilities outside their communities when local beds are full, and 

may remain hospitalized longer than necessary. Thus, the combined shortage of inpatient and 

mid-range services complicates the appropriate admission and discharge of patients, results in 

longer stays in inappropriate and expensive care settings, creates difficulty in arranging 

aftercare, and creates a bottleneck that precludes other patients from accessing needed inpatient 

services. 


Our recommendations include both long-term and short-term initiatives. The short-term 

recommendations are intended to improve the functioning of existing services. We recommend 

that a task force of statewide and regional providers be convened to: 

1. Develop a plan for implementing a centralized database. The purpose of this database would 

be to compile accessible and current detailed information on inpatient bed availability. We 

would further recommend that the task force explore options for computerizing this database, 

and/or developing a single phone number and location to facilitate easy access to this 

information; 

2. Create regional resource directories detailing available mental health and substance abuse 

services by location, service type, and populations served. This directory should also include 

listings for advocacy and voluntary organizations such as AA, Al-Anon, NA, and the local 

chapters of the Alliance for the Mentally Ill; and 

3. Develop a process by which discharge planners can work with agencies across service areas 

to assist patients in accessing needed services in their communities subsequent to hospital 

discharge, and to help identify when case management or outreach is needed. 

Our long-term recommendations are focused on stimulating system-level change on a regional 

and statewide basis. We recommend that a statewide study group, similar to the Governor’s Blue 

Ribbon Commission on Health Care, be assembled to lead this effort. The study group should 

work with key stakeholders including the Department of Behavioral and Developmental Services 

(formerly DMHMRSAS), the Department of Health and Human Services, behavioral health and 

general medical providers, consumers, consumer advocates, and other interested parties. The 

mission of this study group would be to identify specific systemic problems in Maine’s delivery 



of behavioral health services, collect data to support the development of practical solutions, and 

the preparation of a statewide behavioral health plan. The study group with appropriate funding 

should undertake the following tasks: 

1. Review previous mental health planning efforts and assess their impact; 

2. Identify all behavioral health resources (inpatient, mid-range, outpatient, and support 

services provided by general medical and specialty behavioral health providers) in each 

region of the State; 

3. Quantify demand for services through the analysis of service utilization patterns and 

epidemiological data; 

4. Commission a study to explore the cost effectiveness of inpatient and mid-range services and 

the impact of the substitution effect on the demand for each type of service; 

5. Identify gaps in the behavioral health system infrastructure by region; and 

6. Develop a behavioral health plan targeting each region of the State. 

Objective: 

• Improve/Expand of Geriatric and Elderly Services. 

Respondents from all seven regions discussed the need for additional services for the elderly. 

Given the multiple providers operating in each region in northern, eastern and central Maine, the 

development of services should best be approached as a collaborative effort focusing on the gaps 

in services for the elderly and the integration of those services within the existing system of care. 


We recommend the development of geriatric outreach and treatment programs composed of the 

following components: 

1. Outreach and diagnostic services designed to detect behavioral problems among the elderly 

at the earliest possible stages and to engage elderly patients in treatment programs that 

specifically recognize the issues related to aging; 

2. Evaluation services, staffed by psychiatric and general medical providers, that provide a 

comprehensive psychiatric, psychosocial, and neurological evaluation to diagnose physical, 

cognitive, and behavioral problems and develop treatment plans that incorporates all relevant 

providers. 

3. A continuum of services including inpatient, partial hospital, intensive outpatient, outpatient, 

medication management, and mid-range services such as residential care or adult day care; 

4. Support groups, caregiver, and respite care programs; 

Nursing home assessment and support services to assist long term care facilities with managing 

and treating their patients. This was a specific issue for the Penquis region. 

[Similar to our recommendation above in the access section, CHCs and other providers should 

assess the availability of delivering some of these services through federally designated rural 

CHCs that are in manpower shortage areas. CHCs can get 100% Medicare reimbursement 

for many of the above services, including outreach. ] 

Objective: 

• Improve Crisis Intervention Services. 

The provision of crisis services is a source of conflict between hospitals and community 



providers, for example in the greater Bangor area as well as in Washington and Hancock 

Counties. The conflict results from a lack of coordination between hospitals and existing 

CHCS/Northeast Crisis Service personnel, and the fact that hospital credentialing standards 

preclude Northeast Crisis Services personnel from providing services in the emergency 

departments of some facilities. Existing privacy laws further complicate efforts to access mental 

health and substance abuse services from the emergency department. These barriers create 

delays and require redundant data collection. The system also suffers from a lack of effective 

alternatives to emergency department services. 


Hospital and community mental health providers should: 

1. Develop mutually acceptable credentialing standards for crisis workers across the hospital 

and non-hospital systems; 

2. Streamline crisis response systems to minimize the redundant collection of data and to 

improve response times; 

3. Prepare a comprehensive resource directory of available services for each region organized 

by provider type, location, and populations served; and 

4. Develop a flexible range of crisis services as an alternative to the utilization of the 

emergency department. These alternative services could include a walk-in crisis center, 

mobile outreach, and 23-hour observation and stabilization beds. 

Objective: 

• Expand Residential and Mid-Range services for Children and Adolescents. 

Services for children and adolescents are in short supply throughout the region. The specific 

needs, however, vary from region to region. 


Our recommendations are as follows: 

1. Acadia and EMH should develop a plan for adding residential and step-down services for 

children and adolescents, in particular in the greater Bangor area. [Planning teams should 

evaluate model programs both in and out-of-state, as well as the potential for partnership 

with community-based agencies, with the goal of efficiently building upon existing 

community programs and ensuring a sense of shared responsibility for the program’s 

ultimate success.] 

2. Hospitals and community mental health agencies in Aroostook County develop specialized 

services for select populations such as children with autism. [A multi-agency planning group 

should be assembled to assess the need for and implement supportive services (e.g., 

residential care, respite care, and support services) for children and adolescents with special 

needs, and to identify implementation issues.] 

3. A partial hospitalization program, after-school and intensive outpatient services for children 

and adolescents should be developed and funded in the Knox/Waldo region. [This should be 

done on a collaborative basis with the State and local providers using models developed and 

used by Acadia Hospital.] 

4. A multi-agency planning committee should be organized in the Central Region (northern 

Kennebec and Somerset Counties) to assess the specific needs of children and adolescents 

and to explore the development of services to best meet their needs. 



Objective: 

• Expand Detoxification and Substance Abuse Treatment Services. 

Providers and stakeholders throughout the seven regions identified a general need for expanded 

detox and substance abuse treatment services, although specific issues were raised in Knox, 

Waldo, and Washington Counties. Local emergency departments are not staffed or organized to 

provide detox services. At the same time, local hospitals are reluctant to admit intoxicated 

patients who frequently have other medical problems, and who may pose serious treatment risks 

that the hospitals are ill equipped to handle. 


We recommend that the State and regional providers work together to: 

1. Identify the full range of existing resources in each community; 

2. Explore new models of delivering detox and substance abuse services such as observation 

and holding beds in emergency department, the use of acupuncture and outpatient detox; 

3. Develop collaborative linkages among local substance abuse agencies, hospitals, and primary 

care providers to develop appropriate detox services at local hospitals; 

4. Recruit providers with substance abuse treatment experience to help develop state-of-the-art 

services and provide consultative support to existing providers; 

5. Develop detox and treatment programs for patients using heroin, oxycontin, and other opiates 

in Washington County; and 

6. Develop a “wet shelter” style program (e.g., the Hope House model) for intoxicated patients 

and longer term, twenty-eight day residential beds in the Knox/Waldo County area. 

Cancer Screening and Detection Services 

Objectives: 

• Expand provider and consumer knowledge of cancer screening and detection guidelines; 

• Improve rates of screening and detection for select populations; and 

• Expand access to oncology services in local hospital settings. 

While cancer care is generally very good across all regions, improvements in the ability to detect 

cancer in the earliest stage is beneficial to patients and will help to reduce health care costs. A 

concentrated effort to reach the at-risk population and their providers will be more effective than 

just general educational messages and broad-based screening offered to the public at large. 

Improving cancer treatment locally has already proven itself effective in research completed over 

the past decade. A significant amount of research funding at the national level has gone into 

computerized tools to increase primary care provider knowledge and behavior around 

preventive services (such as cancer screening services). The applicability of these to rural 

practice sites is not known, in part because many are incorporated into electronic medical 

records, which are not as available in rural practice sites. However demonstration projects to 

evaluate and test one or more of these models is a feasible undertaking that should be attractive 

to funders. 





1. Hospitals focus their outreach efforts around cancer screening education and services so that 

it more effectively reaches at-risk populations; 

2. Private insurers expand reimbursement for screening and detection services for at-risk 

populations; 

3. Primary care providers incorporate office reminders for screening services; 

4. EMH and regional providers develop a plan that will better integrate oncology services into 

rural practice sites (see sub-specialty recommendations below); and 

5. CancerCare of Maine and primary care providers develop education modules and tools for 

effective dissemination of screening and practice guidelines to the offices of primary care 

physicians. 

Disease Management/Access to Sub-Specialty Care 

Objectives: 

• Improve disease management services and the health status of patients with diagnosed 

chronic disease; 

• Reduce the use of the hospital to treat outpatient diseases; and 

• Improve the availability of specialty care at community hospitals; 

Hospital utilization data and interview information identified disease management (secondary 

prevention) and access to certain forms of sub-specialty care as acute gaps in the delivery 

system in northern, eastern and central Maine. While not uniform throughout each region, 

disease management services for respiratory disease and cardiovascular disease were a particular 

issue. 

By virtue of their training, pulmonary and cardiac specialists are an integral part of the 

management of COPD and heart patients. While we know of no data suggesting that specialists 

deliver more cost-effective care than primary care providers, it is intuitive that the ability to 

deliver the best care possible depends on several factors including: the ability of the primary care 

provider; the patient’s response to treatment; the patient’s preference of providers; and the 

availability of specialists 26 . 

Providing adequate disease management and sub-specialty care in rural community settings, 

while desirable, is complicated and challenging. However it is key to the secondary prevention 

of disease and the reduction of costly hospital care for health problems that are most effectively 

treated on an outpatient basis—such as COPD, Asthma, CHD, Angina, Hypertension, Diabetes, 

etc. It is also essential to keeping health care local to the extent feasible and reducing additional 

cost burdens associated with travel and related expenses for patients and their families. 

26 Carter, R., Belvins, W. Stocks, J., Klein, R., and Idell, S. “Cost and quality issues related to the management of 

COPD.” 1999. Sem Respiratory Critical Care Medicine. 20 (3); 199-212. 




To address the system changes needed for improving regional chronic respiratory disease 

management we recommend that: 

1. A Regional Respiratory Disease Management Task Force be developed composed of local 

PCPs and area specialty leaders to: 

• Further analyze regional disparities in respiratory disease; 

• Recommend standard clinical guidelines for COPD and asthma management to local 

medical staffs; 

• Recommend consistent evidence based smoking cessation guidelines for use in physician 

offices; and 

• Develop protocols for shared management of severe chronic lung disease patients by 

primary health provider/pulmonologist teams. 

2. Chronic Respiratory Disease Team Clinics be developed at each community hospital to focus 

on establishing pulmonary rehabilitation services including patient education, exercise 

training, psychosocial and behavioral intervention, outcome assessment and environmental 

control. 

To address the system changes needed for improving the regional cardiovascular disease 

management, we recommend a similar approach. In addition we recommend that: 

1. Standardized protocols for the care and treatment of patients presenting with chest pain be 

disseminated to Emergency Room staff at each hospital; and 

2. Hospitals in each region develop and implement a program with area businesses similar to 

the Franklin Cardiovascular Health Program. 

To address the system changes needed for improving overall access to subspecialty care we 

recommend that: 

1. Each hospital, along with its physician staff, documents their specialty care needs including: 

a.) the types and amount of sub-specialty care needed in the area, ranked by the proportion of 

the population requiring services and the types and complexity of procedures or services 

required; b.) the person power, facilities and technology required to provide services locally; 

c.) their current availability and acceptance; d.) the cost to the hospital; and, e.) quality of 

care provided based on published guidelines and indicators. [Using this document, each 

hospital could evaluate the feasibility of one of the three models for delivering sub-specialty 

care to their population by service line and/or specialist. This document could also be used in 

decisions about physician recruitment.] 

2. Each hospital, along with its physician staff develop a plan for sub-specialty services in their 

region using several models to solve access availability and costs issues: 

• Hospital based clinics, educational programs, telemedicine, etc. with sub-specialists from 

acute care centers and mid-level practitioners where feasible; 

• Regionalized sub-specialty placement linked to acute care center subspecialty groups; 

and 

• Aligning local internists with interest and knowledge (but not board certification) in a 

sub-specialty area with acute care sub-specialists as mentors and back up. 

The approach recommended above is designed to systematically address the specialty care issues 



in each community over the long term. It will take time, resources and commitment. To develop 

models that adequately address on-call responsibilities, workloads especially during periods of 

peak demand, group practice opportunities, and opportunities for professional referrals, 

interaction, and support. Grant funding to test the newer models of providing sub-specialty care 

will be required and managed care organizations and the Medicare program should be 

approached as potential funding sources. They will benefit in the long term. For example, subspecialists 

will need to be reimbursed if they provide a mentoring service to local internists. In 

the short term, we recommend that local hospitals and PCPs work with sub-specialist providers 

serving their regions on communication, back up and clinical management issues. In short 

hospitals should work to make the existing system more effective though an understanding of the 

needs and challenges on all sides. Additionally using mid level providers could enhance the 

present system. Mid-level providers can be a valuable extension of the specialty practice in the 

rural area with specialists providing a standard set of protocols to work up a patient prior to a 

consult. 

Sub-Acute Care for the Elderly 

Objectives: 

• Improve the functional health of elder patients w/chronic disease; 

• Reduce the use of antidepressant medications when feasible; and 

• Develop local support groups for direct care staff of in-home and community service 

agencies for elders. 



1. State and regional providers assess the feasibility of developing regional on-demand 

transportation programs for getting patient to and from health care services. [Example: An 

on-demand low cost volunteer-based transportation program for seniors is being developed 

for several communities in Southern Maine by The Independent Transportation Network 

(ITN), a non-profit membership organization. The ITN takes Maine seniors to visit spouses 

in nursing homes, shop, work, and volunteer — in short, to do all of the things that people 

need to remain active and connected.]; 

2. An integrated pilot program of social services for elders, to include such services as home 

visitation, nutrition counseling and assistance, telephone check-in, homemaking, personal 

care, additional adult day programs, and errands be developed in one region and funded 

through a demonstration grant. [A well-planned and integrated demonstration project on a 

regional basis might be feasible under foundation or government funding, for example, a 

Rural Health Outreach Grant through the Office of Rural Health.]; 

3. Hospitals and community agencies facilitate the development of support groups for direct 

care giving staff so they can better cope with greater demands due to shortages of caregivers; 

4. The funding potential of primary prevention services to elders, with particular emphasis on 

outreach services delivered in the home or community settings such as libraries, should be 

explored; 

5. Hospitals and community agencies explore partnerships for the development of affordable 

housing for adults with mental illness; 

6. Hospitals should re-evaluate the scope and process of discharge planning in order to help 

ensure longer-term stability in the home after hospitalization [Some possible ways to 



accomplish this include adding resources and standardizing the discharge-planning role 

among all EMH facilities.]; 

7. Hospitals, mental health providers and county medical societies develop and disseminate 

guidelines for prescribing psychotropic medications to elderly patients; and 

8. The State develop a substance abuse prevention and treatment program tailored to older 

substance abusers and pilot it in one or more regions. 


Objectives: 

• Increase availability of dental care resources in rural and underserved areas; 

• Increase reimbursement for dental care services, especially preventive services; and 

• Reduce barriers to mid-level providers in rural and underserved areas. 

Costs issues, cultural issues, reimbursement policies and the lack of dentists all combine to 

severely limit access to dental care in northern, eastern and central Maine, especially for lowincome 

populations with or without Medicaid. Several strategies are needed to address this 

problem. 



1. The Maine Hospital Association, the Maine Dental Association and the Oral Health Program 

(Department of Health and Human Services) lobby to increase Medicaid reimbursement rates 

for dental services; 

2. Hospitals evaluate the feasibility of establishing dental offices that are co-located with PCP 

offices they own [Consider converting unused clinical or office space to serve as dental 

offices at very economical rates. Reducing the overhead costs may serve as an incentive for 

dentists to locate in or maintain their practices in the region. Such an effort would need to be 

coordinated with existing practitioners in the area.]; 

3. The Maine Hospital Association, the Maine Dental Association and the Oral Health Program 

(Department of Health and Human Services) should work with local practitioners to expand 

oral health clinics, prevention and education programs, in partnership with community 

agencies and school systems [One successful example is the Kennebec Valley Dental 

Coalition that administers the Community Dental Center in Waterville. Area hospitals were 

instrumental in collaborating with the Coalition that established the Clinic and supported it 

financially in early stages. It is now operating at capacity.]; 

4. The State evaluate the feasibility of establishing rural dental residency and/or internships in 

partnership with a major school of dentistry such as Tufts University, Boston University, the 

University of Connecticut and Dalhousie University (NS) [Maine currently has no school of 

dentistry). The Columbia University School of Dentistry inner city dental residency program 

could serve as a model for rural communities. This might require third party funding as a 

demonstration project---CDC and Office of Rural Health Outreach Grants are a possibility.]; 

5. The State works with Maine’s two dental hygiene schools to determine the feasibility of 

establishing clinical rotations with rural dental practices. [Maine’s has two schools of dental 

hygiene, UNE-Westbrook College and the University of Maine at Augusta at the University 

College campus in Bangor.] 


Appendix 1 

Eastern Maine Healthcare CHNA Steering Committee Members 

First Name Last Name Title Organization/Location 

Debbie Johnson Sr. Vice President / COO Eastern Maine Medical Center, Bangor 

Dottie Hill Interim CEO Acadia Hospital, Bangor 

Cathy Jones VP Patient Care C.A. Dean Memorial Hospital & Nursing Home, Greenville 

Terri Vieira VP Ancillary & Support Services Sebasticook Valley Hospital, Pittsfield 

Dan Rissi, MD Chief of Staff / Medical Director Blue Hill Memorial Hospital, Blue Hill 

Charles T. McHugh, MD President, Medical Staff Downeast Community Hospital, Machias 

Jim Raczek, MD Chief of Family Practice Eastern Maine Medical Center, Bangor 

David Jones, MD 146 Academy Street, Presque Isle 

Jim Douglas, DO 32 College Ave, Waterville 

Wendie Smith Benefits Manager Great Northern Paper, Millinocket 

George Eaton, II., Esq. Bangor School Board Rudman & Winchell, Bangor 

Charles Hewitt Vice President Cianbro Corp., Pittsfield 

Mike Thibodeau Assistant VP Maine Public Service, Presque Isle 

Mark Woodward Bangor Daily News, Bangor 

Connie Sandstrom CEO Aroostook County Action Program, Presque Isle 

Stan Freeman Ed.D 13 Glenwood Street, Orono 

John Rohman Mayor City of Bangor 

Joyce Packard Healthcare Governance Chair-MHA 30 North Street, Newport 

Joe Brooks Representative 2 Goshen Road, Winterport 

Glenn Ross Chief Deputy 85 Hammond Street, Bangor 

Ed Reynolds Sheriff 85 Hammond Street, Bangor 

Steve Ryan HealthNet One Merchants Plaza, Fifth Floor, Bangor 

Bob Holmberg, MD Ex-Officio EMMC, Bangor 

Jean Mellett Director of Planning Eastern Maine Healthcare, Bangor 

Jerry Whalen VP/Business Development Eastern Maine Healthcare, Bangor 

Norm Ledwin President & CEO Eastern Maine Healthcare, Bangor 

John Fortier 16 Sliver Street, Waterville 


PHRG

Appendix 2 

Eastern Maine Healthcare CHNA Working Group Members 


Annette Adams Director, Access Center / Utilization Management Acadia Hospital, Bangor 

Greg Fecteau Executive Director CancerCare of Maine, Bangor 

Alan L’Italien Program Manager CancerCare of Maine, Bangor 

Larry Beauregard Genetics / Patient Care Services Blaisdell 3, Bangor 

Terri Vieira Vice President Ancillary / Support Services Sebasticook Valley Hospital 

Cathy Mingo Heart Center Program Coordinator Blaisdell 3, EMH, Bangor 

Pat Hofmaster Healthcare Research Blaisdell 5, EMH, Bangor 

Peter Millard, MD Family Practice Residency Program EMH Mall, Bangor 

Alexander Dragatsi Epidemiologist – Health Services The Aroostook Med Ctr, Aroostook 

David Prescott, Ph.D. Psychology Services Acadia Hospital, Bangor 

Norm Dinerman, MD Emergency Department 

Helen Genco President & CEO Bangor Area Visiting Nurses 

Kathie Sewell Planning Blaisdell 5, EMH, Bangor 

Jean Mellett Director, Planning Blaisdell 5, EMH, Bangor 

Eastern Maine Healthcare CHNA Substance Abuse Working Group Members 


Lynn Madden Vice President Administrative Support Acadia Hospital, Bangor 

Scott Farnum Acadia Recovery Center Acadia Hospital, Bangor 

Cherry Denno SHS 159, AMHI Complex, Augusta 

Phillip Monaco, LCSW Program Director, Psychiatric & Addictions Recovery Center Penobscot Bay Med Ctr, Rockport 

Kathy Stuchiner Director, Clinical and Professional Services Maine Hospital Assn, Augusta 


PHRG

Appendix 3 

EMH 7 Study Regions 

Defined by Hospital Service Area (HSA) 

PSA 1 

PSA 2 

HSAs: 

PSA 3 

HSAs: 

PSA 4 

HSAs: 

PSA 5 

HSAs: 

PSA 6 

HSAs: 

PSA 7 

HSAs: 

Bangor (HSA and Region) 

Aroostook Region 

Presque Isle 

Houlton 

Caribou 

Fort Kent 

Fort Fairfield 

Penquis Region 

Dover-Foxcroft 

Millinocket 

Lincoln 

Greenville 

Washington Region 

Machias 

Calais 

Hancock Region 

Ellsworth 

Blue Hill 

Bar Harbor 

Central Region 

Waterville 

Skowhegan 

Pittsfield 

Knox-Waldo Region 

Rockland 

Belfast 


PHRG

Map of Study Regions Appendix 4 

Fort Kent 

Caribou 

AROOSTOOK 

Fort Fairfield 

Presque Isle 

Houlton 

Millinocket 

Greenville 

PENQUIS 

Dover-Foxcroft 

Lincoln 

Calais 

Pittsfield 

Skowhegan 

CENTRAL 

Waterville 

Belfast 

BANGOR 

Ellsworth 

HANCOCK 

WASHINGTON 

Machias 

KNOX-WALDO 

Rockland 

Blue Hill 

Bar Harbor 

REGIONS 

Hospital Service Areas (HSA's) 


PHRG

The CIAP Community Healthcare Planning 

Process 

Appendix 5 

Community Input 

Community 

Household Survey 

•Health Status 

•Risk Factors 

•Access 

•Utilization 

Quantitative Assessment 

•General Health Status 

•Cardiovascular Health 

•Respiratory Health 

•Primary Care 

•Cancer Health 

•Dental Health 

•Family Violence 

•Teen Pregnancy 

•Reproductive Health 

•Mental Health/ Substance Abuse 

Comparative Analyses 

Community Peer Group, State 

Benchmarking 

•Identify Problem Areas 

•Produce Expected Rates 

Planning Committee 

•Identify Providers 

•Identify Focus Groups 

•Identify Services 

Identify Priority 

Health Areas and 

Services Issues 

Benchmarking 

•National Benchmarks 

•Clinical Standards 

•Best Practice Guidelines 

Discussions/Focus Groups with 

Stakeholders 

•Key Community Members 

•Clinical Providers 

•Other Service Providers 

Qualitative 

Assessment 

Identify Services to 

Meet Needs 

Conduct: 

Operations Analyses 

Financial Assessment 

Planning Report 

•Major Findings 

•Recommendations for Follow-up 

•Monitoring Protocol 

Develop 

Implementation 

Strategies 


Dissemination of 

Results 

•Publications 

•Meetings 

•Focus Groups 

Apply 

Database of Model 

Programs 

PHRG

HEALTH STATUS PROFILE Appendix 6 

INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

GENERAL HEALTH STATUS: 

Total Population 119663 108551 72058 48343 29942 40417 110922 62140 177231 1242969 281421906 

Annual Household Income 38664 35802 37514 43261 29450 32633 29885 37122 42552 36441 $40,816 

% of Labor Force Unemployed 3.6 4 5.6 7.3 9.1 6.2 7.2 3.4 5.2 4.1 4 

% Population Not Attaining H.S. Diploma (>25 yrs) 19.1 27.8 30.3 25.1 26.9 17 25.7 20.8 20.2 21 15.9 

% Population on Medicaid (all ages) 13 17.3 20.6 15.7 20 14.3 15.5 15.6 15.4 16.1 16.1 

% Population Under the Age of 18 23.7 25.6 25 25.1 24.5 23.5 25.8 24.8 26 24.8 18.7 

% Population Between Ages 18-44 41.1 38.3 38.8 35.4 35.7 36 37.3 34.6 37 38.1 39.4 

% Population Between Ages 45-64 22.9 22.3 22.4 24.3 23.6 24.4 23.1 24 23.9 23.3 22.4 

% Population Age 65 and Over 12.2 13.7 13.7 15.2 16.2 16.1 13.7 16.5 13.1 13.8 12.7 

% Uninsured 9 8.6 12.6 12.9 18.7 19.5 13.8 13.5 12.1 13.4 11.4 

FUNCTIONAL HEALTH STATUS: 

% Health Fair to Poor 12.8 15.4 16.3 16 23.2 9.3 14.3 12.6 12.7 13.8 14.5 

% Limited Activity (Household) 23.4 NA 24.5 22.2 27.3 18.3 28.8 24.9 NA NA NA 

% Need for Personal Care Assistance (Household) 5.2 NA 4 3.1 5.6 1.8 4.5 4.5 NA NA NA 

% Need for Assistance with Routine Tasks (Household) 7.6 NA 7 5.6 8.3 5.2 8.8 7.6 NA NA NA 

% 11+ Days Physical Health Not Good 15.4 11.8 13.7 11.6 15.5 9.1 9.1 14.1 11.1 10.9 9.7 

% 11+ Days Mental Health Not Good 14.1 10.5 9.6 9.4 12.9 10 10.3 8.6 9.6 9.1 9 

% 11+ Days Lost due to Poor Mental or Physical Health 7.9 6 9.9 7.5 9.3 4.2 7.4 9.4 6.5 6.2 6.4 

% 3+ Chronic Conditions 20.2 NA 23.5 21.1 28.6 19.1 21 23.6 NA NA NA 

Wellness Categories: 

Well 33.6 39.6 30.9 32 23.5 34.5 35.4 33.8 39.3 40.2 39.8 

At Risk for Future Medical Problems 13.3 12.9 18.8 16.2 17.2 19.7 13.5 14.6 15 13.5 14.2 

Some Health Problems 36.9 32.7 34.6 36.6 37.5 35.8 34.9 36.3 34.8 33.2 33.8 

Not Well 16.2 14.8 15.7 15.1 21.9 10 16.2 15.3 10.9 13 12.2 

PRIMARY CARE: 

% Without Regular Source of Care 6.3 NA 7.6 10 4.9 6.8 10.4 8.6 NA NA 13 

Males 8.8 NA 9.7 16.1 6.4 8.8 16.8 14.9 NA NA 16.9 

Females 4.3 NA 5.2 4.4 3.3 5 4.4 2.7 NA NA 12.1 

% Not Having a Checkup Within the Past 2 Years 12.5 11.9 10.7 14 11.7 12.6 12.8 15.3 14.8 13.6 18.2 

Males 16.8 18.3 15.9 21.9 18.7 17.6 20.9 21.3 21.7 19.5 23.9 

Females 8.3 6.2 5.7 6.6 5.5 8.3 6 9.9 8 8.1 12.7 

% Received Flu Shot (past 12 months) 42.1 33.4 37.4 41.3 36.5 33.5 34.3 38.2 26.6 34.2 29.6 

Ages 45-64 45.5 38.9 42.3 39.8 37.6 31.5 32.4 35.7 31 36.6 31.9 

Ages 65+ 85.9 64.3 79.7 74.6 69.3 78.1 78.1 73.7 68 73.7 65.6 

% Received Pneumoccal Shot (ever) 21.9 18 23.3 22.6 25.2 20.2 22 27 17 19.7 16.9 

Ages 45-64 15.8 7.9 20.4 17.7 25 13.5 16 19.3 10.7 14.4 13.1 

Ages 65+ 70.3 57.1 61.9 68.6 68.9 64.4 71.9 67.5 50.4 57.3 51.9 

ACS Conditions, Hospital Admission Rate 1678.6 1438.5 2313.5 1934.3 1924.1 1932.6 1819 1659.9 1399.9 1601.2 2206.1 

ACS Conditions, Hospital Admission Rate (0-17 yrs) 645.6 739.2 699.2 414.1 355.8 382.4 425.3 427.8 491.7 501.1 1381.2 

ACS Conditions, Hospital Admission Rate (18-44 yrs) 515.4 418.6 452.6 553.4 399.1 667.6 490.6 375.2 377.6 422.5 586.3 

ACS Conditions, Hospital Admission Rate (45-64 yrs) 2210.8 1502.1 2664 2013.7 1839.7 1856.1 2138.7 1868 1551.2 1727.7 2340.9 

ACS Conditions, Hospital Admission Rate (65+ yrs) 6723 5596.4 9777.1 7538.7 7736.7 6950.9 7581.3 5931 5804.1 6556.9 9084.3 

All rates are per 100,000 population unless otherwise noted. 

^ = Not Reported based on < 5 annual cases 


INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

CARDIOVASCULAR: 

% Current Smokers 29.9 23.2 32 25.7 27 25.5 30.9 21.1 26.8 23.5 22.6 

% No Physical Activity 23.3 30.7 25 29.5 27.2 25.8 28 25.3 27.7 27.2 28 

% Vigorous Physical Activity (5+ times/week @ 30+ minutes) 19.5 11.7 19 20.7 19.5 17.7 22.2 21.1 14.7 14.1 13.3 

% Obesity (Ages 18+) 40.7 27.1 39.5 44.5 44.4 32.5 35.2 34.8 31.4 31.4 31.8 

% Overweight/Obesity Problem (Youth 0-17) 3.7 NA 3.4 1.9 2.3 2.6 3.8 6.4 NA NA NA 

% High Cholesterol 27.9 25.5 20.3 21.98 25.4 21 23.2 22.2 24.2 23.2 21.3 

% Having Cholesterol Checked (within the past year) 54.4 47.5 54.6 54 53.3 47.5 52.8 54.9 47.5 50.1 50 

% High Blood Pressure 23.4 21.9 30.5 30.4 33.1 25.6 29.4 28.4 25.5 26.5 23.7 

% Heart Disease 5.6 NA 10.7 8.9 13.5 8.7 6.9 8.4 NA NA NA 

Heart Disease, Mortality Rate 282 288.9 335.5 253.5 283.4 265.8 280 268.5 270.7 293.5 268.2 

Ages 45-64 188.3 172.7 187.2 173.6 148.9 135.1 188.6 194.2 172.3 167.4 NA 

Ages 65+ 1688.2 1788.4 2742.1 1558.8 1803.6 1736.7 1732.5 1654.4 1670.6 1748.9 NA 

Atherosclerosis, Mortality Rate ^ ^ 10.7 8.5 ^ 10.2 8.8 6.9 6.4 6.5 5.65 

Ages 45-64 ^ ^ ^ ^ ^ ^ ^ ^ ^ 1.7 NA 

Ages 65+ ^ ^ 73.2 64.9 ^ 77.8 14.2 50.2 43.6 42.3 NA 

AMI, Mortality Rate 97.2 76.3 105 87.3 103.1 97.9 76.1 82.6 85.2 88.4 75.3 

Ages 45-64 92.2 70.6 89.9 71.1 74.4 59 74.1 74.1 68.9 67.1 NA 

Ages 65+ 532.9 435.3 611.2 510.3 641.6 623 431.2 482.9 498.5 500.6 NA 

Cerebrovascular Disease (stroke), Mortality Rate 67.1 55.8 61.7 55.6 55.6 70.1 51.1 67.4 57 61.6 58.6 

Ages 45-64 27.9 20.1 19.7 22.5 25.7 24.2 17.3 12.1 18.2 18.4 NA 

Ages 65+ 442.3 365.2 431.5 370.2 367.7 473.1 347.5 479.2 383.7 394.9 NA 

AMI, Hospital Admission Rate 246.4 339 489 436.9 513.3 545 375.8 376.9 269.1 313.5 234.2 

Ages 45-64 246.1 457.8 652.9 542.6 544 514 483.4 461.9 397.1 378 333.6 

Ages 65+ 1467.7 1637.5 2303.8 1839 2200.7 2381.9 1803.1 1537.8 1212.8 1512.2 1261.5 

Cerebrovascular Disease (stroke), Hospital Admission Rate 119 130.8 174.2 165 187.2 216.7 144.8 174.6 148.1 161.1 224.2 

Ages 45-64 104.6 115.5 154 96.5 128.8 114.2 138.1 107.9 133.1 122.6 196.2 

Ages 65+ 754.1 741.2 970.7 889.1 939 1083.9 771.9 890.6 842 904 1419.5 

CABG, Hospital Admission Rate 78.1 94.4 107.6 99.4 96.9 97.4 109.2 93.1 101.8 93.4 NA 

Ages 45-64 168.6 189.7 231 196.9 186.1 176.1 203.2 161.8 186.3 164.3 NA 

Ages 65+ 311.1 377.4 399.4 316.6 322.77 330.9 431.2 325.9 421 357.3 NA 




INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

RESPIRATORY: 

% Current Smokers 29.9 23.2 32 25.7 27 25.5 30.9 21.1 26.8 23.5 22.6 

Male 33.2 26.7 39.7 27.8 25.1 29.2 33.5 18.9 29.4 26.1 25 

Female 27.1 20.1 24.9 24.4 28.6 21.8 28.4 23.1 24.2 21.1 20.5 

% Former Smokers 30.7 30.3 27.7 34.6 32 29.2 29.3 38.4 30.8 29.7 24.9 

% Received Flu Shot (past 12 months) 42.1 33.4 37.4 41.3 36.5 33.5 34.3 38.2 26.6 34.2 28.7 

Ages 45-64 45.5 38.9 42.3 39.8 37.6 31.5 32.4 35.7 31 36.6 30.6 

Ages 65+ 85.9 64.3 79.7 74.6 69.3 78.1 78.1 73.7 68 73.7 65.1 

% Received Pneumoccal Shot (ever) 21.9 18 23.3 22.6 25.2 20.2 22 27 17 19.7 15.9 

Ages 45-64 15.8 7.9 20.4 17.7 25 13.5 16 19.3 10.7 14.4 12.2 

Ages 65+ 70.3 57.1 61.9 68.6 68.9 64.4 71.9 67.5 50.4 57.3 47.8 

% Current Asthma (Ages 18+) 10.1 8.7 7.9 10.6 8.4 9 10.5 9.9 8.1 8.6 7.2 

% Ever Been Diagnosed with Asthma (Youth 0-17) 22.8 NA 20.9 15.2 16.1 11.7 15.6 10.7 NA NA NA 

% Hay Fever/Allergies (Youth 0-17) 11 NA 30.5 22.4 25.3 20.9 21.4 17.6 NA NA NA 

% Lung Disease 7.5 NA 7.8 8.4 7.4 3.8 8.7 5.7 NA NA NA 

Lung Cancer, Males, Incidence Rate* 107.2 115.5 86.7 66.6 146.2 73.1 146.2 85.3 81.8 92.4 71.1 

Lung Cancer, Males, Mortality Rate 79.8 88.5 102.6 85.9 88 72.5 75.9 68.6 89.6 83.1 

Lung Cancer, Females, Incidence Rate* 56.5 58.1 42 68.9 69.1 63.8 67.2 52.1 58.3 57.6 41.8 

Lung Cancer, Females, Mortality Rate 56.9 58.8 45 54.6 54.3 61.4 58.2 44.3 55.1 58.4 

COPD, Mortality Rate 59.7 60.4 68.7 55.8 49.6 39.7 43.9 44.3 53.7 54.9 41.7 

Ages 45-64 19.3 27 21.5 23 28.6 19 17.3 35 25.3 22.4 22.7 

Ages 65+ 401.7 397.5 483.5 378.7 316.9 264.7 300 264.4 354.4 347.3 284.6 

Pneumonia/Influenza, Mortality Rate 32.1 37.2 40.1 48 30.1 43.8 35.4 23.9 26.8 32.1 34 

Ages 45-64 ^ ^ ^ ^ ^ ^ ^ ^ 6.1 5.8 10.5 

Ages 65+ 225.4 262.3 280 347 224.9 315.4 267.5 160.6 186 199.3 241.2 

Emphysema, Mortality Rate 6.6 7.7 13.4 11.5 ^ ^ 10.7 11.1 6.5 7.8 6.5 

Ages 45-64 ^ ^ ^ ^ ^ ^ ^ ^ ^ 4.3 4.3 

Ages 65+ 44.6 49.8 83.6 73 ^ ^ 67.5 69.7 41.9 47.5 43.5 

Bronchitis and Asthma, Hospital Admission Rate 169.2 180.6 215.8 153.8 100.1 137.9 137 116.9 123.3 142.4 155 

Ages 0-17 280 430 412 203.4 200.5 175.1 207.7 180.3 267.2 269.2 277** 

Ages 18-44 89 102 84.4 135.7 44.8 141.4 75.1 65.4 58.1 81.8 86*** 

Ages 45-64 201.5 52.3 104.7 60.3 93.1 80.9 110.5 97.8 62.1 84.4 162 

Ages 65+ 172.5 131.4 394.8 255.8 78.2 155.8 215.6 156.1 125.7 176.2 177 

COPD, Hospital Admission Rate 294 233.1 391.3 345 368 255 315.9 277.7 216.4 263 199.1 

Ages 45-64 416.6 359.7 529.7 393.9 400.9 271.3 370.9 384.4 254.7 322.4 276.9 

Ages 65+ 1559 1068.1 1867.2 1577.2 1594.3 1109.8 1600 1069.6 1133.2 1288.4 1091.7 

Adult Pneumonia, Hospital Admission Rate 286.1 307.7 390.6 345 447.1 458.5 340.2 294.6 256.4 294.4 332.7 

Ages 45-64 273.2 263.8 344.9 261.3 272 337.9 305.8 249.5 228.1 239.3 309.9 

Ages 65+ 1592.8 1657.7 2034.4 1717.2 2132.2 2057.4 1750 1317.5 1342.6 1526.9 1831 

Emphysema, Hospital Admission Rate 47.2 44.7 75.2 49.7 85.6 65.7 45.9 55.4 40.9 50.2 NA 

Ages 45-64 27.1 37.1 52.4 ^ ^ ^ 29.6 47.2 24.1 29.9 NA 

Ages 65+ 304.4 229.1 441.2 261.8 430.4 305 240.6 229.5 243 281.6 NA 

**U.S. rate youths 0-15 years old 

*** U.S. rate for 15-44 year olds 




INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

DIABETES AND OTHER CHRONIC CONDITIONS: 

% Diagnosed Diabetes (All Adults 18+) 9.7 4.8 7.6 8.4 11.8 5.9 8 8.5 5.9 6.5 6.6 

Ages 45-64 13.3 5.7 11.7 8.8 13.8 8 9.2 10.8 7.6 8.7 9 

Ages 65+ 18.8 12.7 10.9 15.5 21.3 9.7 20 14.5 12.9 13.5 13.6 

% Diagnosed Diabetes (Youths 0-17) 0.3 NA 0.7 0.5 1.4 0.4 0 0.4 NA NA NA 

Diabetes, Mortality Rate 21.4 30.8 26.1 30.5 30.1 21.5 29.1 25.2 25.1 25 23.9 

Ages 45-64 ^ 30.5 ^ ^ ^ ^ 24.4 ^ 19.8 18.5 22.9 

Ages 65+ 121.7 173.8 163.4 159.7 157.4 131.1 170 143.2 144.1 140.9 142.4 

Diabetes, Hospital Admission Rate 58.9 65.9 81.8 77.8 63 63.5 83.2 69.2 62.1 66.2 106.3 

Ages 45-64 79.4 76.3 95.5 96.5 57.3 52.4 94.7 50.6 58.3 66.3 159.7 

Ages 65+ 121.7 124.9 153.3 194.9 136.9 142.8 209.4 169.8 144.5 153.5 266.7 

% Diagnosed Arthritis 23.1 NA 26.2 22.6 30.7 22.5 30.9 28 NA NA 16.1 

Ages 45-64 28.1 NA 27.9 33.9 37.6 20.7 38.5 23.4 NA NA 29.5 

Ages 65+ 47.6 NA 49.2 46.5 58.1 54.8 65.1 58.4 NA NA 51.6 

Hip Procedures, Hospital Admission Rate 71.8 100.4 87.1 76.9 103.3 87.5 76.3 95.4 75.6 87.2 NA 

Ages 65+ 466.7 572.8 478.4 420.2 508.6 428.3 409.4 463.3 446.1 491.5 NA 

Joint Procedure Hospital Admission Rate 218 167.2 205.9 223.1 206.6 258.3 197.6 208.4 191.3 201.5 NA 

Ages 65+ 1095.7 879.4 1003.3 992.6 850.9 1129.3 1090.6 973.2 1051.5 1083.5 NA 

HIV/AIDS, Mortality Rate ^ 5.9 ^ ^ ^ ^ 6.3 ^ 4.1 3.7 5 

REPRODUCTIVE HEALTH: 

Infant Mortality Rate per 1,000 births 6.5 5.6 7.5 ^ ^ ^ 6.2 ^ 4.9 6.2 7.2 

Neonatal Mortality Rate per 1,000 births 5.4 3.9 ^ ^ ^ ^ ^ ^ 2.7 4 4.8 

% Very Low Birthweight (


INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

CANCER: 

% Diagnosed Cancer (all sites) 6.1 NA 5.1 5.7 9.1 7.8 6.7 7.6 NA NA NA 

Malignant Neoplasms, Incidence Rate 502.3 455.7 425.9 450.8 535.9 490.3 431.9 418.6 436 460.3 437 

Malignant Neoplasms, Mortality Rate 238.6 241 243.7 213.5 243.1 233 222.2 210.5 229.9 239.4 200.3 

Ages 45-64 245.6 258.9 295.6 229.9 240.5 276 255.6 219.8 264 247.1 NA 

Ages 65+ 1279.6 1277 1268.9 1142.3 1361.5 1207.1 1161.2 1142.1 1196.4 1236.1 NA 

Buccal Cavity, Incidence Rate 13.2 23.4 21.2 16.6 21 19.3 16.8 15.7 17.9 21.4 18.1 

Buccal Cavity, Mortality Rate ^ ^ 11.2 9.9 ^ ^ 4.3 7.5 3.3 3 2.9 

Lung and Bronchus Cancer, Incidence Rate 78.5 82.5 61.8 67 104.3 67.1 68.4 66.4 68.3 72.6 54.4 

Lung Cancer, Mortality Rate 69.1 73.3 73 70.1 70.7 67.2 66.8 55.9 72 70.5 49.9 

Digestive System, Incidence Rate 59.8 62.6 58.3 56.9 72.9 71.9 66.9 51.1 59.6 61.5 59.2 

Digestive System, Mortality Rate 52.6 56.6 60.9 48 65 53.5 51.3 48.7 50.8 54.9 47.6 

Colorectal, Incidence Rate 51.8 55.3 53.4 47.5 66.4 61 59.8 44.6 53.2 53 46.2 

Colorectal, Mortality Rate 22.6 24.5 30.8 28.5 34.7 34.1 25.6 17.7 23.7 25.2 NA 

% Diagnosed Colorectal Cancer (In Situ): Male 16 5.2 5.6 17.7 17.7 6.9 11.8 11.4 15.1 11.49 NA 

% Diagnosed Colorectal Cancer (In Situ): Female 6.8 2.6 3.6 19.4 3.7 12 13.3 10 9.2 8.93 NA 

% Stage Distant Colorectal Cancer: Male 6.7 11.7 16.7 20.6 11.8 6.9 21.1 11.4 7.1 13.72 NA 

% Stage Distant Colorectal Cancer; Female 14.9 16.7 17.9 6.5 29.6 20 12.2 7.5 16.3 15.12 NA 

% Reported Colo-Rectal Exam Past Year (Age 40+) 33.7 NA 42.9 31.9 38 46.9 43 46.2 NA NA NA 

% Reported Blood Stool Test Past Year (Age 50+) 51.1 34.3 19.5 36 37.5 38.2 35.3 31.2 26.9 26.6 19.7 

% Reported Having Sigmoidoscopy/Colonoscopy Past 5 Years (Age 50+) 29.6 34.5 31.8 34.9 33.5 27.9 37.5 35.5 28.6 30.6 31.9 

Female Breast Cancer, Incidence Rate 167.8 116.3 123.2 121.9 111.2 140.8 116.5 133.2 123.8 131.3 131.9 

Female Breast Cancer, Mortality Rate 30 37.7 30.7 28.1 39.6 29.6 31.8 26.2 30.5 33.5 30.2 

% Diagnosed Breast Cancer (In Situ) 20.6 10.1 28.1 17.9 20.8 15.8 7.1 14.2 13.3 14.55 NA 

% Stage Distant Breast Cancer 1.6 3.8 2.3 3.6 0 3.2 4.1 2.4 2.3 2.71 NA 

% Reported Mammogram past year, age 40+ 59.4 66.7 63 66 61.5 57.1 65.5 62.1 63.5 65.7 58.5 

% Reported Mammogram past year, ages 50+ 70.1 71.6 75 73 67 67.3 70.1 72.4 67.8 69.4 62.5 

Female Genital System, Incidence Rate 80 71.8 76 91.5 78.4 70.2 80.2 69.8 81.1 76.4 81.3 

Female Genital System, Mortality Rate 19.4 20.8 28.3 21.2 16.9 26.8 20.8 26.4 22.6 21.7 18.5 

Cervix uteri, Incidence Rate 37.2 41.1 37.8 51.1 27.5 25.7 37.5 28.7 42.3 34 38 

Cervix uteri, Mortality Rate ^ ^ ^ ^ ^ ^ 9.2 ^ 6.2 4.1 NA 

% Diagnosed Cervical Cancer (In Situ) 79.6 67.3 81.8 80.8 45.5 83.3 59.6 78.3 70.6 70.23 NA 

% Stage Distant Cervical Cancer 0 0 0 0 0 8.3 2.1 8.7 0 1.64 NA 

% Reported Pap Smear past 2 years, ages 18-44 90.7 90.4 86.7 81.8 87.4 86.7 85.7 87.3 88.3 86.7 82.9 

% Reported Pap Smear past 2 years, ages 45-64 72.5 85.2 84.3 78.8 77.1 84.8 87.5 82.7 81.9 82.9 77.6 

% Reported Pap Smear past 2 years, ages 65+ 65.5 71.6 62.3 64.4 64 69.1 < < 64.9 60.8 58.8 

Prostate gland, Males, Incidence Rate 128.5 128.8 152.7 121.1 146.9 101.2 122.1 84.8 97.1 118.8 149.9 

Prostate gland, Males, Mortality Rate 27.5 27.2 31.1 24.6 36.8 29.4 27.1 32.4 26.7 28.7 16.4 

% Diagnosed Prostate Cancer In Situ/Local Stage 69.8 56.9 77.3 74.7 66.7 63 70.5 75 69.9 67.62 NA 

% Stage Distant Prostate Cancer 7.4 8.2 8.5 9.3 5.6 5.6 6.7 1.4 8.7 7.69 NA 

% Males (50+) Reported Prostate Exam (Past 2 yrs) 52.3 NA 55.7 39.5 55.7 67.1 56.8 65.4 NA NA NA 

% Males (


INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

MENTAL HEALTH: 

SF-36 Mental Health Functioning (Avg. Score) 78.2 NA 77.9 78.8 77.4 78.6 77.4 79 NA NA 74.7 

Ages 18-64 77.7 NA 77.3 77.9 75.4 77.8 76.3 77.3 NA NA NA 

Ages 65+ 81.3 NA 81.4 82.7 84.5 81.9 81.7 84.8 NA NA NA 

% 11+ Days Mental Health Not Good 14.1 10.5 9.6 9.4 12.9 10 10.3 8.6 9.6 9.2 NA 

Ages 18-64 15 11.9 11.6 10.8 15.5 11.7 12.4 10.7 10.2 9.9 NA 

Ages 65+ 9.1 4.3 1 3.9 4.3 3.8 1.2 1.3 6.5 6.4 NA 

% Depression 18.5 NA 17.3 14.3 16.8 17.7 16 15.1 NA NA 17 

Ages 18-64 19.6 NA 18 15.9 19 18.3 18.1 17.7 NA NA NA 

Ages 65+ 13.1 NA 14.2 7.9 9.3 15.5 6.9 6.3 NA NA NA 

% Psychiatric Disorder 4.7 NA 7 3.8 6.3 5.3 6 7.4 NA NA NA 

Ages 18-64 5.6 NA 8.6 4.6 7.8 6.7 7.1 9.1 NA NA NA 

Ages 65+ 0 NA 0 1 1.2 0 1.2 1.9 NA NA NA 

% Outpatient Mental Health Treatment (past year) 9.7 NA 10.3 6 7.9 10 8.8 10 NA NA NA 

% Emotional/Behavioral Problem (Ages 0-17) 8.5 NA 3.4 9 6 7.8 11.1 8.2 NA NA NA 

% Learning Disability/Attention Disorder (Ages 0-17) 3.6 NA 7.9 9.5 8.3 10.4 11.8 14.8 NA NA NA 

% Eating Disorder (Ages 0-17) 0 NA 0 0 0 0.4 0 0.4 NA NA NA 

Psychoses Hospital Admission Rate 637.4 591.4 492.3 397.5 274.4 343.6 473.7 471.5 384.5 481 NA 

Ages 0-17 344.7 369.6 151.3 207.1 58.2 193.5 206 207.8 281.1 239 NA 

Ages 18-44 921 897.1 704.2 623.9 435 454.1 731.9 800.6 568.3 728.3 NA 

Ages 45-64 616.2 494.9 603.6 361.7 279.2 399.8 467.6 468.7 330.8 459.4 NA 

Ages 65+ 270.5 283 348.4 237.5 244.5 240.1 278.1 179 159.2 262.9 NA 

Senility and Organic Mental Disorders, Hospital Admission Rate 56.3 42.8 40.2 44 46.8 70 32.9 45.3 33 44.5 NA 

Ages 18-64 18.3 13.9 ^ ^ ^ ^ 13.3 ^ 14.2 12.8 NA 

Ages 65+ 361.8 229.1 204.3 243.5 254.3 369.9 187.5 238.7 171.8 258 NA 

Major Depressive Disorder, Hospital Admission Rate 308.2 251 215.7 204.3 179.1 195.8 255.2 324.5 216.3 274.4 NA 

Ages 0-17 229.2 186.5 117.3 155.2 38.8 119.7 156.1 171.1 165.6 160.5 NA 

Ages 18-64 437.7 354.9 304.6 292.3 267.5 269.2 377.9 507.2 317.5 357.1 NA 

Ages 65+ 118.3 107.8 167.1 97.4 176 142.7 131.2 105.5 71.2 127.4 NA 

Bipolar Disorder, Hospital Admission Rate 189.6 255.7 154.3 107.8 64.5 100.6 116.5 76.1 94.7 121.9 NA 

Ages 0-17 80.4 99.5 41.7 ^ ^ 69.1 26.5 15.2 49.1 42.6 NA 

Ages 18-64 287.3 346.2 257.5 177.2 104.5 137.6 193.5 127.1 147.7 192.2 NA 

Ages 65+ 101.4 121.2 ^ ^ ^ ^ 65.6 ^ 43.9 66 NA 

Schizophrenia and Related Disorders, Hospital Admission Rate 106 65.4 89.7 62.8 20.9 40.4 87.5 56.1 35.8 78.9 NA 

Ages 18-64 186.7 111.3 152.3 107.8 36 61.6 148.5 100.5 64.2 137.7 NA 

Ages 65+ ^ 20.2 ^ ^ ^ ^ 50 ^ 8.3 26.9 NA 

Anxiety, Personality, and Other Disorders, Hospital Admission Rate 118.6 36.8 89.7 61.8 48.2 60.1 64.5 71.5 36.1 61.5 NA 

Ages 0-17 85.7 19.5 ^ 70.2 ^ ^ 34.8 ^ 28.8 34.5 NA 

Ages 18-64 170.6 52.1 144.8 78.5 64.5 80.1 95.9 115.4 49.4 90.5 NA 

Ages 65+ 40.5 30.3 ^ 24.3 ^ 58.4 40.6 41.3 23 34.8 NA 

Other Mental Conditions, Hospital Admission Rate 169.5 83.3 85.7 75.9 62.9 82 100.9 73 83.2 101.3 NA 

Ages 0-17 129.4 131.4 54.7 55.4 77.6 78.3 93 76.3 87.6 92.6 NA 

Ages 18-64 247.2 84.3 127.5 115.1 79.9 108.9 136.8 100.5 114.2 138.8 NA 

Ages 65+ ^ 33.6 ^ ^ ^ 32.4 40.6 ^ 10.4 32.5 NA 

Suicide, Mortality Rate 12.2 10.3 20.2 20.6 30.9 25.1 16.1 16 14.1 13.6 11.3 




INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

SUBSTANCE ABUSE: 

% Chronic Heavy Drinking (Past Month) 2.7 3.9 2.6 2 4.3 6.4 5.2 4.9 4.9 3.1 3.1 

Ages 18-64 3 3.8 2.8 1.8 9.4 5.5 4.2 4.4 5.3 3.4 NA 

Ages 65+ 1.6 4.3 1.6 2.8 1.5 9.6 10.8 6.6 2.4 1.7 NA 

% Binge Drinking (Past Month) 14.8 12.7 14.4 15.2 13.7 18 14.2 13.8 17.7 14.8 NA 

Ages 18-64 17.3 14.4 17.2 18.3 26.8 19.9 16.9 17.3 19.7 17.4 NA 

Ages 65+ 1.6 5.1 3.1 2.8 5.9 11 1.6 1.3 5.8 3.5 NA 

% Marijuana Use (Past Month) 5.1 NA 3.3 2.6 3.8 6.1 8.7 4.4 NA NA NA 

% Misused Prescription Pain Medication (Past Month) 0.5 NA 0.8 0.4 0.8 0 1.7 1.5 NA NA NA 

% Substance Abuse Disorder 3.1 NA 1.9 2.8 2.4 4.6 5.2 2.4 NA NA NA 

% Treatment for Alcohol and/or Drug Use (Past Year) 0.6 NA 0.6 0.2 0.5 1.1 1.8 0.5 NA NA NA 

Substance Abuse Hospital Admission Rate 212.2 552.3 126 135 406.8 189.3 244 216.9 309.2 297 NA 

Ages 0-17 35 ^ ^ ^ ^ 59.9 46.5 ^ 17.1 24.9 NA 

Ages 18-64 294.4 931.2 184.7 205.6 667.7 288.7 354 354 476 439.6 NA 

Ages 65+ 125.1 155 102.2 115.7 97.5 123.3 187.5 87.2 94.3 126.3 NA 

Acute Alcohol-Related Mental Disorders, Hospital Admission Rate 103.1 103.1 73.2 85.3 122.6 121.4 127.4 102.2 113.9 103.6 NA 

Ages 0-17 6.9 1.7 2.6 11 12.9 32.3 28.2 6.1 9.6 11.3 NA 

Ages 18-64 179 187.8 130 151.6 221.3 201.3 212.7 177.4 209.3 181.7 NA 

Ages 65+ 30.4 23.5 23.2 30.4 19.5 38.9 68.7 50.4 29.3 32 NA 

Alcohol-Related Psychoses, Hospital Admission Rate 43.8 359.2 22.4 14 35.5 15.3 49.8 48.4 128.9 109.8 NA 

Ages 18-64 74.2 655.8 35.9 23.7 61.4 26.7 84.2 88.7 242.2 195.4 NA 

Ages 65+ 27 87.6 23.2 12.1 19.5 6.4 43.7 13.7 33.5 43.6 NA 

Acute Drug-Related Mental Disorders, Hospital Admission Rate 25.4 10.1 3.2 8.4 109.7 16.4 22.9 28.1 16.9 26.6 NA 

Ages 0-17 10.4 3.5 5.2 0 0 4.6 4.9 3 1 3.7 NA 

Ages 18-64 42 17.3 2.7 14.6 209 28.7 41.7 48.7 32.4 48.4 NA 

Ages 65+ 0 0 4.6 6 0 0 0 0 0 0.5 NA 

Drug-Related Psychoses, Hospital Admission Rate 30 65.4 18.4 17.8 106.5 28.4 27.7 22.3 40 44.5 NA 

Ages 0-17 12.2 1.7 0 3.6 0 13.8 1.6 0 1 3.2 NA 

Ages 18-64 34.4 111.3 21 12.7 187.5 22.6 32.5 35.4 69.7 69.3 NA 

Ages 65+ 67.6 43.8 51 66.9 48.9 77.8 75 22.9 29.3 49 NA 

Alcohol-Related Death Rate, All 27.6 31.4 28.4 23.6 33.5 32.1 25.9 33.3 26.6 28.3 NA 

Alcohol-Related Death Rate, Males 34.7 39.9 37.4 31.7 40.7 40.8 34.6 43.8 33.2 36.2 NA 

Alcohol-Related Death Rate, Females 20.8 22.5 19.4 15.8 26.6 23.7 17.7 23.4 34.8 20.8 NA 

Cirrhosis, Mortality Rate 10.3 10.5 15.8 14 ^ 20.3 10.5 10.4 11.3 9.4 9.3 

ACCIDENTS/SAFETY: 

% Always Use Seatbelts 69.3 69.7 61.4 57.2 57.2 64.6 68.6 63.7 62.9 69.5 69.3 

% Reporting Intimate Partner Violence (IPV), Ever, Females 24 NA 12.5 20.1 22.1 20.4 24.1 22.5 NA NA 25.5 

Total Accidents, All, Mortality Rate 30.7 33.7 34 40.1 53.3 36.5 33.4 34.4 36.9 35.4 36.2 

Motor Vehicle Accidents, All, Mortality Rate 11.6 19 24 21.4 34.9 24.3 17.7 18.5 18.3 16.1 16.1 

Total Accidents, Males, Mortality Rate 35.5 36.3 43 42 65.8 45.5 47.2 45.4 45.4 44.9 47.7 

Motor Vehicle Accidents, Males, Mortality Rate 16 20.8 26.5 22 35.5 31 23.8 25.1 21.2 21.6 22 

Total Accidents, Females, Mortality Rate 26.1 31.2 24.2 39.7 42.3 29.2 20.2 24.1 28.8 26.3 25.2 

Motor Vehicle Accidents, Females, Mortality Rate ^ 17.2 20.7 21.4 35.2 ^ 11.5 ^ 15.5 10.8 10.5 




INDICATOR 

Bangor PSA 

Urban 

Peer 

Aroostook 

Region 

Penquis 

Region 

Washington 

Region 

Hancock 

Region 


Region 

Knox/ Waldo 

Region 

Rural 

Peer MAINE US 

ORAL HEALTH: 

% Reporting Not Visiting Dentist Past Year 35.4 39.3 41.8 41.8 43.9 35.6 41 32.3 32.4 32.5 31.9 

% 6+ Teeth Removed Due to Decay/Gum Disease 29.6 29.3 32.6 38.5 35 23.1 34.9 26.4 26.8 24.4 19.9 

YOUTH HEALTH: 

Teen Birth Rate (10-17 yrs) Per 1,000 Female Population by Age 4.9 5.9 4.3 4.7 6.0 3.7 6.0 5.8 5.4 5.1 NA 

Teen Birth Rate (10-19 yrs) Per 1,000 Female Population by Age 12.6 17.0 13.8 12.7 15.6 11.7 16.4 17.2 15.3 14.0 NA 

% Very Low Birthweight (

Data Sources 

Data Type Years Used Source 

Appendix 7 

Birth 1995-99 Maine Office of Data Research and 

Vital Statistics 

Mortality 1994-98 Maine Office of Data Research and 

Vital Statistics 

Hospital Inpatient 3 rd Quarter 1998 – 

2 nd Quarter 2000 

Maine Health Data Organization 

Hospital Emergency and 

Outpatient 

1998 Maine Health Data Organization 

Cancer Incidence and Staging ME: 1995-1996 

US: 1992-1998 

Maine Cancer Registry & 

The National Cancer Institute: Cancer 

Statistics Branch 

Behavioral Risk Factor 

Surveillance System (BRFSS) 

ME: 1996, 1997 & 1999 

US: 1998-1999 

Maine Bureau of Health & 

The Center for Disease Control 

Household Survey 2001 PHRG 

Medicaid 1999 Health Care Finance Commission 

Arrest data 1998-1999 Department of Public Safety: 

Uniform Crime Reports Division 

Unemployment 1998-99 Maine Department of Labor 

Population, Income, and 

Education 

1990, 2000 Estimates, 

2005 Projections 

Claritas, Inc. and 

The U.S. Census Bureau 


PHRG

EMH Survey Instrument Appendix 8 

ENTER ID # _ _ _ _ 

PUBLIC HEALTH RESOURCE GROUP 

120 EXCHANGE STREET, SUITE 200 

PORTLAND, ME 04101 

• CONFIDENTIAL • 

EASTERN MAINE HEALTHCARE 

INTRODUCTION PAGE 

This is 

calling for the Public Health Resource Group. We’re doing a study of health needs 

in your area. Because we can’t interview everyone in your community, we are randomly choosing a smaller group of 

people to speak on behalf of all residents. Your phone number has been chosen at random to be included in this study. 

We are very interested in hearing what you think about health care. Your participation is important because you will be 

helping to represent your entire community. Let me assure you, we are not selling anything. 

First, have I reached you at your home telephone? 

YES NO → IF NOT A RESIDENCE, THANK R; DO NOT INTERVIEW. 

↓ 

↓ 

For this study, I need to speak to the person over the age of 18 in your household who had the last birthday. 

Would that be you, or someone else there? 

IF R, GO TO INTRO. 

IF NOT R → Is that person available? 

IF PERSON IS AVAILABLE, REINTRODUCE AND GO TO INTRO. 

IF R NOT AVAILABLE, SUGGEST TARGET TIME: Could I reach (her/him) later this evening? Tomorrow at 

about this time? ETC. To make sure we are able to reach the right person, what is (her/his) first name? 

MAKE NOTE FOR CALLBACK. 

⇒ (ENTER TIME NOW) : 

INTRO: We want you to know that being in this study is entirely voluntary. If we come to a question you don’t want to 

answer, just tell me and we’ll move on to the next one. For our part, we’ll keep all the information you give us 

confidential. Finally, we’ve found that it’s usually easier and quicker for people to complete the survey in a quiet 

place where there are no distractions from other household members. Do you have a quiet place that you can go 

to now? 

November 1, 2001 1 of 34 PHRG


• CONFIDENTIAL • 

1. To confirm that you live in the area we are studying, what is your zipcode ? 

RECORD 5-DIGIT ZIP-CODE .....................................................___ ___ ___ ___ ___ 

SEE ATTACHMENT 1 FOR ALL ZIP CODES AND TOWNS INCLUDED IN THE STUDY. 

IF OTHER THANK R; TERMINATE INTERVIEW 



2A. To begin with, do you have a family or regular doctor or some place where you go when you need medical care? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

(GO TO Q2C) 

(GO TO Q2B) 

(GO TO Q2B) 

(GO TO Q2B) 

2B. If you or someone in your family were ill and required medical care, where would you go? 

(DO NOT READ RESPONSES) 

DOCTOR ....................................................................................................1 (GO TO Q3) 

HOSPITAL EMERGENCY ROOM...........................................................2 (GO TO Q3) 

HOSPITAL OUTPATIENT CLINIC .........................................................3 (GO TO Q3) 

WALK-IN CENTER...................................................................................4 (GO TO Q3) 

TOWN/CITY HEALTH DEPT...................................................................5 (GO TO Q3) 

COUNTY HOSPITAL ...............................................................................6 (GO TO Q3) 

OTHER........................................................................................................7 (GO TO Q3) 

DK ...............................................................................................................8 (GO TO Q3) 

NA ...............................................................................................................9 (GO TO Q3) 

INAP............................................................................................................0 (GO TO Q3) 

2C. What kind of place is it? Is it …. (READ RESPONSES) 

A doctor’s office or HMO...........................................................................1 

A clinic or health center ..............................................................................2 

A hospital outpatient department ................................................................3 

A hospital emergency room ........................................................................4 

A walk-in or urgent care center...................................................................5 

Some other kind of place.............................................................................6 

DK… ...........................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

2D. In addition to your usual doctor or place of care, are there any other doctors that you use for a special health or 

medical care need? 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q3) 

DK ...............................................................................................................8 (GO TO Q3) 

NA ...............................................................................................................9 (GO TO Q3) 

INAP............................................................................................................0 



READ IF ‘YES’ FOR Q2D ASKING FOR THE MOST RECENT VISITED DOCTOR 

2E. 1. Thinking about the most recent time you visited a doctor for a special health or medical need, what type of 

doctor was it? 

2. And in what town is he/she located? 

3. Why did you choose to seek care there? 


2E1. Specialty of Physician 2E2. Town/Location 2E3. Reason 

ALLERGY............................ 01 AUGUSTA ....................... 01 PERSONAL CHOICE.................................. 01 

CHIROPRACTOR................ 02 BANGOR ......................... 02 LOCATION NEAR HOME ......................... 02 

DERMATOLOGY................ 03 BAR HARBOR ................ 03 LOCATION NEAR WORK 03 

GASTROENTEROLOGY.... 04 BELFAST......................... 04 PREVIOUS EXPERIENCE ......................... 04 

HEART SPECIALIST.......... 05 BLUE HILL...................... 05 FRIEND/FAMILY RECOMMENDATION 05 

INTERNAL MEDICINE ...... 06 CALAIS............................ 06 REQUIRED BY INSURANCE.................... 06 

NEPHROLOGY (KIDNEY). 07 CARIBOU ........................ 07 DOCTOR’S PERSONALITY ...................... 07 

NEUROLOGY ..................... 06 DOVER FOXCROFT....... 08 FRIENDLY STAFF ..................................... 08 

OB/GYN............................... 08 ELLSWORTH .................. 09 GOOD REPUTATION................................. 09 

ONCOLOGY........................ 09 FARMINGTON................ 10 EMPLOYER RECOMMENDATION.......... 10 

OPTHALMOLOGY ............. 10 FORT KENT .................... 11 DOCTOR’S CREDENTIALS...................... 11 

ORTHOPEDICS................... 11 GREENVILLE ................. 12 REFERRED BY DOCTOR 12 

PHYS. MED./REHAB.......... 12 HOULTON....................... 13 CONVENIENT OFFICE HOURS 13 

PSYCHIATRY ..................... 13 LINCOLN......................... 14 SELF/FAMILY EMPLOYED THERE ........ 14 

PODIATRY …………... ...... 14 MACHIAS........................ 15 STATE-OF-THE-ART TECHNOLOGY..... 16 

SURGERY............................ 15 MILLINOCKET ............... 16 GENDER OF PROVIDER........................... 17 

SUBST ABUS PROVIDER.. 16 PITTSFIELD .................... 17 OTHER (Specify_____________) .... 18 

UROLOGY …………… ...... 17 PRESQUE ISLE ............... 18 DK/NA .............................................. 99 

OTHER (Specify________) . 18 ROCKPORT ……… ........ 19 INAP............................................................. 00 

DK/NA.................................. 99 SKOWHEGAN ................ 20 

INAP………………. ............ 00 WATERVILLE ................ 21 

OTHER............................. 22 

DK/NA ............................. 99 

INAP................................. 00 

3. During the past 12 months, how many times have you visited a medical doctor? 

# OF TIMES ..............................................................................................___ ___ ___ 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

4. Again, during the past 12 months, have you been a patient in a hospital for an overnight stay? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 


Now I would like to change the subject and ask you about your health. 


5A. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked? 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q6) 

DK ...............................................................................................................8 (GO TO Q6) 

NA ...............................................................................................................9 (GO TO Q6) 

5B. About how long has it been since you last had your blood cholesterol checked? 

(READ ONLY IF NECESSARY) 

WITHIN THE PAST YEAR (1 TO 12 MONTHS AGO)...........................1 

WITHIN THE PAST 2 YEARS (1 TO 2 YEARS AGO) ...........................2 

WITHIN THE PAST 5 YEARS (2 TO 5 YEARS AGO) ...........................3 

5 OR MORE YEARS AGO ........................................................................4 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

6. In general, would you say your health is: (READ OPTIONS) 

Excellent......................................................................................................1 

Very good....................................................................................................2 

Good............................................................................................................3 

Fair ..............................................................................................................4 

Poor .............................................................................................................5 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

7. Now thinking about your physical health, which includes physical illness and injury, for how many days during 

the past 30 days was your physical health not good? 

(IF NONE, ENTER 00) 

NUMBER OF DAYS..................................................................................__ __ 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

8. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how 

many days during the past 30 days was your mental health not good? 


NUMBER OF DAYS..................................................................................__ __ (IF Q7 = 0 AND 

DK ...............................................................................................................88 Q8= 0, GO TO 

NA ...............................................................................................................99 Q10) 



9. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your 

usual activities, such as self-care, work, or recreation? 


NUMBER OF DAYS..................................................................................____ ____ 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

INAP............................................................................................................00 

10. These next questions are about how you feel and how things have been with you during the past month. 

How much of the time during the past month . . . 

All Most A Good Some A Little None 

of the of the Bit of of the of the of the 

Time Time the Time Time Time Time DK/NA 

1 2 3 4 5 6 9 

A. Have you felt very nervous? 1 2 3 4 5 6 9 

B. Have you felt calm and peaceful? 1 2 3 4 5 6 9 

C. Have you felt downhearted and blue? 1 2 3 4 5 6 9 

D. Have you felt happy? 1 2 3 4 5 6 9 

E. Have you felt so down in the dumps 1 2 3 4 5 6 9 

that nothing could cheer you up? 

Now I am going to read you a list of health problems that usually last for some time. For each problem I'd like to know 

whether a medical doctor has ever told you that you had this condition. 

11. A. Has a doctor ever told you that you have: (IF RESPONDENT ANSWERS YES TO BEING DIAGNOSED, ASK: B. 

How are you managing this condition? Is it with . . . and go down the list of possibilities) 

B. 

HOW 

A. ARE YOU MANAGING 

DIAGNOSED 

THIS CONDITION? 

(34) YES NO DK/NA INAP 

A. High blood pressure ................................YES......... 1 Medication 1 2 8 0 

or Hypertension NO .......... 2 Special Diet 1 2 8 0 

DK .......... 8 Exercise Prg. 1 2 8 0 

NA .......... 9 



(38) 

B. High Cholesterol.....................................YES......... 1 Medication 1 2 8 0 

NO .......... 2 Special Diet 1 2 8 0 


NA .......... 9 

(42) 

C. Diabetes or high blood sugar ..................YES......... 1 Medication 1 2 8 0 

NO .......... 2 Special Diet 1 2 8 0 


NA .......... 9 Classes 1 2 8 0 

(47) 

D. Heart disease; such as .............................YES......... 1 Medication 1 2 8 0 

hardening of the arteries, angina, NO .......... 2 Special Diet 1 2 8 0 

congestive heart failure, DK 8 Exercise Prg 1 2 8 0 

heart attack NA 9 

(51) 

E. A substance abuse problem.....................YES......... 1 Medication 1 2 8 0 

with alcohol or drugs NO .......... 2 Counseling 1 2 8 0 

DK .......... 8 

NA .......... 9 

(54) 

F. Depression YES......... 1 Medication 1 2 8 0 

NO .......... 2 Counseling 1 2 8 0 

DK .......... 8 

NA .......... 9 



(57) ........... 

G. A Psychiatric Condition .........................YES......... 1 Medication 1 2 8 0 

Other than Depression such NO .......... 2 Counseling 1 2 8 0 

As Bipolar Disorder, Schizophrenia, DK .......... 8 

Anxiety Disorder, or an Eating NA .......... 9 

Disorder like Anorexia or 

Bulimia (eating disorder) 

IF R ANSWERS YES TO Q15G, ASK R TO SPECIFY CONDITION _______________________________________ 

(60) 

H. Arthritis...................................................YES......... 1 Medication 1 2 8 0 

NO .......... 2 

DK .......... 8 

NA .......... 9 

(62) 

I. Cancer .....................................................YES......... 1 1. Chemotherapy 1 2 8 0 

NO .......... 2 2. Radiation 1 2 8 0 

Treatment 

DK .......... 8 

3. Hormonal 1 2 8 0 

NA .......... 9 Therapy (e.g. Tamoxifen, Flutamide) 

4. Immunotherapy 1 2 8 0 

(e.g., antibodies, IGG, BCG, 

Interferon, Interleukerin) 

IF R ANSWERED “YES” TO Q15I, BUT “NO” TO ALL MANAGEMENT OPTIONS (1-4 ABOVE) ASK: 

Is the cancer cured 1 2 8 0 

or in remission 

IF R ANSWERS YES TO Q15I, ASK R TO SPECIFY CANCER TYPE/SITE ______________________________ 

J. Lung Disease such as..............................YES......... 1 Medication 1 2 8 0 

Chronic Obstructive Pulmonary NO .......... 2 Exercise 1 2 8 0 

Disease (COPD), Chronic DK .......... 8 

Bronchitis Or Emphysema NA 9 

K. Asthma.....................................................YES......... 1 Medication 1 2 8 0 

(GO TO Q13) NO .......... 2 

(GO TO Q13) DK ...........8 

(GO TO Q13) NA ...........9 



12. Do you still have asthma? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

13. Including yourself, how many people in your household are: 

A. Under 18 ......................................................................................................... ___ (IF 13A=0, GO TO 15A) 

B. 18-64 years old ............................................................................................... ___ 

C. 65 or older ...................................................................................................... ___ 

Now I am going to read you a list of health problems that children and adolescents often experience. I'd like to know 

whether a medical doctor has ever told you that anyone in your household under the age of 18 had each problem. 

14. A. Has a doctor ever told you that anyone in your household under the age of 18 had: (IF RESPONDENT ANSWERS 

YES, ASK: B. How many household members under the age of 18 have ever been diagnosed with this condition?) 

B. 

A. NUMBER 

DIAGNOSED? 

DIAGNOSED? 

A. Asthma....................................................YES..........1 Number _____ _____ 

NO ...........2 

DK ...........8 

NA ...........9 

INAP........0 

B. Sugar Diabetes (Sugar in the Blood) ......YES..........1 Number _____ _____ 

NO ...........2 

DK ...........8 

NA ...........9 

INAP........0 

C. A problem with overweight ....................YES..........1 Number _____ _____ 

or obesity NO ...........2 

DK ...........8 

NA ...........9 

INAP........0 



D. An emotional/mental problem ...............YES..........1 Number _____ _____ 

or behavior problem NO ...........2 

DK ...........8 

NA ...........9 

INAP........0 

E. A learning disability or ...........................YES..........1 Number _____ _____ 

Attention disorder (such as NO ...........2 

Attention deficit disorder) DK ...........8 

NA ...........9 

INAP........0 

F. An eating disorder like anorexia.............YES..........1 Number _____ _____ 

or bulimia NO ...........2 

DK ...........8 

NA ...........9 

INAP........0 

G. A substance abuse disorder ....................YES..........1 Number _____ _____ 

with alcohol or other drugs NO ...........2 

DK ...........8 

NA ...........9 

INAP........0 

I. Hay Fever or Allergies............................YES..........1 Number _____ _____ 

NO ...........2 

DK ...........8 

NA ...........9 

INAP........0 



Thank you. Now I’m going to change the subject and ask you about exercise. 

15A. During the past month, did you participate in any physical activities such as running, calisthenics, golf, tennis or 

walking for exercise? 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q16) 

DK ...............................................................................................................8 (GO TO Q16) 

NA ...............................................................................................................9 (GO TO Q16) 

15B. How many times per week or per month did you take part in this activity during the past month? 

TIMES PER WEEK .................................................................................... ___ 

____ 

TIMES PER MONTH................................................................................. ___ ____ 

DK ...............................................................................................................8888 (GO TO Q16) 

NA ...............................................................................................................9999 (GO TO Q16) 

INAP............................................................................................................0000 

15C. And when you took part in this activity, for how many minutes did you usually keep at it? 

(RECORD RESPONSE IN MINUTES)............................................................. ___ ____ ___ 

DK ...............................................................................................................888 

NA ...............................................................................................................999 

INAP............................................................................................................000 

Now I’d like to change the subject. 

16. When you drive or ride in a car, how often do you wear seat belts? Would you say: 

(READ RESPONSES) 

Always.........................................................................................................1 

Nearly always..............................................................................................2 

Sometimes ...................................................................................................3 

Seldom.........................................................................................................4 

Never ...........................................................................................................5 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

NEVER DRIVE OR RIDE IN A CAR .......................................................0 

17A. Are you, or is anyone in your household, limited in any way in any activities because of any 

impairment or health problem? 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q18) 

DK ...............................................................................................................8 (GO TO Q18) 

NA ...............................................................................................................9 (GO TO Q18) 



17B. Do you, or does anyone in your household, need the help of other persons with Personal Care 

needs, such as eating, bathing, dressing, or getting around the house? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

17C. Do you, or does anyone in your household, need the help of other persons in handling routine 

needs, such as everyday household chores, doing necessary business, shopping, or getting around 

for other purposes? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

18. SEX BY OBSERVATION (DO NOT READ) 

MALE..........................................................................................................1 

FEMALE.....................................................................................................2 

19. About how long has it been since you last visited a doctor for a routine checkup or physical examination? 


WITHIN THE PAST YEAR (1–12 MONTHS AGO)................................1 

WITHIN THE PAST 2 YEARS (1–2 YEARS AGO) ................................2 

MORE THAN 2 YEARS ............................................................................3 (GO TO Q21) 

NEVER........................................................................................................7 (GO TO Q21) 

DON'T KNOW/NOT SURE .......................................................................8 (GO TO Q21) 

REFUSED ...................................................................................................9 (GO TO Q21) 

20. At your last check-up or physical did you have any of the following tests or examinations: 

A. A blood test .................................................................................................YES..................1 

(CBC; blood cell count for checking the chemical 

NO....................2 

profile of the blood) 

DK/NA.............9 

INAP ................0 

B. A urine test ..................................................................................................YES..................1 

(done to check for infections or to determine the 

NO....................2 

amount of sugar in the urine) 

DK/NA.............9 

INAP ................0 

C. A rectal exam ..............................................................................................YES..................1 

(to check for signs of abnormalities) 

NO....................2 

DK/NA.............9 

INAP ................0 


(IF RESPONDENT IS FEMALE, GO TO Q22A) 

(MALES ONLY) 


D. An exam to check for testicular cancer .......................................................YES..................1 

NO....................2 

DK/NA.............9 

INAP ................0 

(MALES ONLY) 

E. A blood test to check your prostate gland ..................................................YES..................1 

NO....................2 

DK/NA.............9 

INAP ................0 

(ASK Q21 ONLY IF R IS MALE; OTHERWISE GO TO Q22A) 

21. According to the American Cancer Society, at what age should men have their first blood test to check for 

prostate cancer? 

(RECORD RESPONSE IN YEARS) 

AGE IN YEARS .........................................................................................____ ____ 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(ASK THE FOLLOWING QUESTIONS IF R IS FEMALE; OTHERWISE GO TO Q24A) 

22A. A mammogram is an x-ray of the breast to look for cancer. Have you ever had a mammogram? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q22C) 

(GO TO Q22C) 

(GO TO Q22C) 

22B. How long has it been since you had your last mammogram? 

(DON’T READ RESPONSES) 

WITHIN THE PAST YEAR.......................................................................1 

WITHIN THE PAST TWO YEARS...........................................................2 

WITHIN THE PAST THREE YEARS.......................................................3 

WITHIN THE PAST FIVE YEARS...........................................................4 

FIVE OR MORE YEARS AGO .................................................................5 

DON'T KNOW/NOT SURE .......................................................................8 

NA/REFUSED ............................................................................................9 

INAP............................................................................................................0 



22C. According to the American Cancer Society, at what age should women begin having yearly 

mammograms? 

(RECORD RESPONSE IN YEARS) 

AGE IN YEARS .........................................................................................____ ____ 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

23A. A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q24A) 

(GO TO Q24A) 

(GO TO Q24A) 

23B. How long has it been since you had your last Pap smear? 


WITHIN THE PAST YEAR.......................................................................1 

WITHIN THE PAST TWO YEARS...........................................................2 

WITHIN THE PAST THREE YEARS.......................................................3 

WITHIN THE PAST FIVE YEARS...........................................................4 

FIVE OR MORE YEARS AGO .................................................................5 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

ASK EVERYONE 

24A. A blood stool test is a test that may use a special kit at home to determine whether the stool contains 

blood. Have you ever had this test using a home kit? 

YES .............................................................................................................1 

NO ...............................................................................................................2 


REFUSED ...................................................................................................9 

(GO TO Q25A) 

(GO TO Q25A) 

(GO TO Q25A) 

24B. When did you have your last blood stool test using a home kit? 






DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 



25A. A sigmoidoscopy or colonoscopy is when a tube is inserted in the rectum to view the bowel for signs of cancer 

and other health problems. Have you ever had this exam? 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q26) 

DK ...............................................................................................................8 (GO TO Q26) 

NA ...............................................................................................................9 (GO TO Q26) 

25B. When did you have your last sigmoidoscopy or colonoscopy? 






DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

26. During the past 12 months, have you had a Flu shot? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

27. Have you ever had a pneumonia vaccination? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

28A. According to recent studies, a large number of Americans now use one or more alternative medical therapies or 

practices. Over the past 3 years, have you tried any alternative medical therapies or practices? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

(GO TO Q29A) 

(GO TO Q29A) 

(GO TO Q29A) 


28B. What specific treatments or practitioners did you use? 


(PROBE FOR UP TO THREE RESPONSES; DO NOT READ RESPONSES) 

1. 2. 3. 

CHIROPRACTIC................................................................................. 1 1 1 

MASSAGE THERAPY ....................................................................... 2 2 2 

ACUPUNCTURE ................................................................................ 3 3 3 

HERBAL THERAPY........................................................................... 4 4 4 

HOMEOPATHY.................................................................................. 5 5 5 

NATUROPATHY................................................................................ 6 6 6 

OTHER (Specify: ____________________________________ ) .... 7 7 7 

DK ........................................................................................................ 8 8 8 (GO TO Q29A) 

NA ........................................................................................................ 9 9 9 (GO TO Q29A) 

INAP..................................................................................................... 0 0 0 

28C. To what extent did you find (THERAPIES MENTIONED IN Q28B.) to be helpful? Was it … 

(ASK OF FIRST 3 THERAPIES MENTIONED IN Q28B) 

Not No 

Very Somewhat very effect/ 

helpful helpful helpful benefit DK NA INAP 

1 2 3 4 8 9 0 

1. THERAPY #1 1 2 3 4 8 9 0 

2. THERAPY #2 1 2 3 4 8 9 0 

3. THERAPY #3 1 2 3 4 8 9 0 

These next questions are about treatment and counseling for problems with emotions, nerves or mental health. Please do 

not include treatment for alcohol or drug use. 

29A. During the past 12 months, did you receive any outpatient treatment or counseling for any problem you were 

having with your emotions, nerves, or mental health? Please do not include treatment for alcohol or drug use. 

YES ....................................................................................... 1 

NO ......................................................................................... 2 (GO TO Q30A) 

DK ......................................................................................... 8 (GO TO Q30A) 

NA ......................................................................................... 9 (GO TO Q30A) 



29B. Where did you receive outpatient mental health treatment or counseling during the past 12 months? 

(DON’T READ RESPONSES; PROBE FOR ALL SOURCES OF TREATMENT; RECORD ALL THAT APPLY) 

OUTPATIENT MENTAL HEALTH CLINIC OR CENTER ....................1 

OFFICE OF A PRIVATE THERAPIST, PSYCHOLOGIST, 

PSYCHIATRIST, SOCIAL WORKER OR COUNSELOR THAT 

WAS NOT PART OF A CLINIC ...............................................................2 

DOCTOR’S OFFICE THAT WAS NOT PART OF A CLINIC ................3 

OUTPATIENT MEDICAL CLINIC...........................................................4 

PARTIAL DAY HOSPITAL OR DAY TREATMENT PROGRAM ........5 

OTHER (Please Specify ________ )...........................................................6 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

30A. During the past 12 months, was there any time when you needed mental health treatment or 

counseling for yourself but didn’t get it? 

YES ........................................................................................... .................1 

NO ............................................................................................. .................2 (GO TO Q31A) 

DK ............................................................................................. .................8 (GO TO Q31A) 

NA ............................................................................................. .................9 (GO TO Q31A) 

30B. Was this because you couldn’t afford mental health treatment or counseling, or was there some 

other reason you didn’t get the care you needed? 

(DON’T READ RESPONSES; PROMPT FOR PRIMARY REASON) 

COULDN’T AFFORD IT...........................................................................1 

DIDN’T KNOW WHERE TO GO .............................................................2 

TOOK TOO MUCH TIME.........................................................................3 

EMBARRASED OR FEARFUL OTHERS WOULD FIND OUT.............4 

TOO FAR TO TRAVEL/TAKES TOO LONG TO GET THERE ............5 

DIDN’T THINK IT WOULD HELP ..........................................................6 

SOME OTHER REASON (SPECIFY___________________) .................7 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

Now I’d like to change the subject and ask about dental care. 

31A. How long has it been since you last visited the dentist or dental clinic? 


WITHIN THE PAST YEAR (1 to 12 MONTHS AGO).............................1 (GO TO Q31C) 

WITHIN THE PAST TWO YEARS (1 TO 2 YRS AGO) .........................2 

WITHIN THE PAST FIVE YEARS (2 TO 5 YRS AGO) .........................3 


NEVER........................................................................................................5 

DK ...............................................................................................................8 (GO TO Q31C) 

NA ...............................................................................................................9 (GO TO Q31C) 


31B. What is the main reason you have not visited a dentist in the last year? 



FEAR, APPREHENSION, NERVOUSNESS, PAIN, DISLIKE GOING..01 

COST...........................................................................................................02 

DO NOT HAVE/KNOW A DENTIST.......................................................03 

CANNOT GET TO THE OFFICE/CLINIC 

(To far away, no transportation, no appointments available) ...............04 

NO REASON TO GO (NO PROBLEMS, NO TEETH) ............................05 

OTHER PRIORITIES .................................................................................06 

HAVE NOT THOUGHT OF IT .................................................................07 

OTHER (PLEASE SPECIFY ___________________________)..............08 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

INAP............................................................................................................00 

31C. How many of your permanent teeth have been removed because of tooth decay or gum disease? 

(Do not include teeth lost for other reasons, such as injury or orthodontics.) Is it … 

Five or fewer?..............................................................................................1 

Six or more but not all? ..............................................................................2 

All of your permanent teeth? or ..................................................................3 

None of your permanent teeth? ...................................................................4 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

Now, I would like to ask you about your use of tobacco products. 

32A. Have you smoked at least 100 cigarettes in your entire life? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

(GO TO Q33A) 

(GO TO Q33A) 

(GO TO Q33A) 

32B. Do you now smoke cigarettes everyday, some days or not at all? 

EVERYDAY...............................................................................................1 

SOMEDAYS...............................................................................................2 

NOT AT ALL..............................................................................................3 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q32C1) 

(GO TO Q32C2) 

(GO TO Q32D) 

(GO TO Q33A) 

(GO TO Q33A) 

32C1. On the average, about how many cigarettes a day do you now smoke? 

1 pack = 20 NUMBER OF CIGARETTES ....................................................................___ ___ (GO TO Q33A) 

cigarettes DK ...............................................................................................................88 (GO TO Q33A) 

NA ...............................................................................................................99 (GO TO Q33A) 

INAP............................................................................................................00 



32C2. On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day? 

1 pack = 20 NUMBER OF CIGARETTES ....................................................................___ ___ (GO TO Q33A) 

cigarettes DK ...............................................................................................................88 (GO TO Q33A) 

NA ...............................................................................................................99 (GO TO Q33A) 

INAP............................................................................................................00 

32D. About how long has it been since you last smoked cigarettes regularly, that is, daily? 


WITHIN THE PAST YEAR (0 to 12 months ago)..................................................1 

WITHIN THE PAST 5 YEARS (1 to 5 years ago)..................................................2 

WITHIN THE PAST 15 YEARS (5 to 15 years ago)..............................................3 

15 OR MORE YEARS AGO ...................................................................................4 

NEVER SMOKED REGULARLY..........................................................................5 

DK ............................................................................................................................8 

NA ............................................................................................................................9 

INAP.........................................................................................................................0 

The next few questions are about your consumption of beer, wine, and other kinds of alcoholic beverages. 

33A. During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine 

coolers, or liquor? 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q34) 

DK ...............................................................................................................8 (GO TO Q34) 

NA ...............................................................................................................9 (GO TO Q34) 

33B. During the past month, how many days per week OR per month did you drink any alcoholic beverages, on the 

average? 

DAYS PER WEEK ..................................................................................... ___ 

____ 

DAYS PER MONTH .................................................................................. ___ 

DK ...............................................................................................................8888 

NA ...............................................................................................................9999 

INAP............................................................................................................0000 

____ 

(GO TO Q33D) 

(GO TO Q33D) 

33C. On the days when you drank, about how many drinks did you have on the average? (A drink is 1 can/bottle of 

beer, 1 glass of wine, 1 bottle/can of wine cooler, or 1 shot of liquor) 

NUMBER OF DRINKS.............................................................................. ___ 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

INAP............................................................................................................00 

____ 



33D. Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more 

drinks on an occasion? 

NUMBER OF TIMES.................................................................................____ ____ 

NONE..........................................................................................................77 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

INAP............................................................................................................00 

The next set of questions deals with certain drugs. There is a lot of talk these days about this subject, but not all of it is 

accurate. We still have a lot to learn about drugs and people in your community. Remember that your answers will be kept 

confidential. They will never be connected with any identifying information about you. 

34. Are you in a quiet place where you can speak comfortably? 

YES .............................................................................................................1 (GO TO Q35A) 

NO ...............................................................................................................2 

If R SAYS NO TO Q34, ASK “Do you have a quiet place that you can go to now? 

IF R CANT GET TO A PRIVATE PLACE, SUGGEST TARGET TIME FOR CALLBACK: Can we re-schedule later 

this evening? Tomorrow at about this time? ETC. 



The first set of questions asks about marijuana and hashish. Marijuana is also called pot or grass and it can be either 

smoked or cooked in food. Hashish is usually smoked in a pipe. Another form of hashish is hash oil. 

35A. Have you ever, even once, used marijuana or hashish? 

YES ....................................................................................... 1 

NO ......................................................................................... 2 (GO TO Q36A) 

DK ......................................................................................... 8 (GO TO Q36A) 

NA ......................................................................................... 9 (GO TO Q36A) 

35B. How long has it been since you last used marijuana or hashish? (READ RESPONSES) 

A. Within the past 30 days, or.......................................................1 

B. More than 30 days ago, but within the past 12 months, or .......2 

C. More than 12 months ago .........................................................3 

DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 



36A. Have you ever, even once, used any illegal drugs other than marijuana or hashish? Illegal drugs include 

cocaine, crack, LSD, PCP, ecstasy, methamphetamine, heroin, and prescription pain relievers, tranquilizers, 

sedatives or amphetamines that were not prescribed for you by a doctor or that you took in a way other than 

prescribed only for the experience or feeling they caused? 

YES ....................................................................................... 1 

NO ......................................................................................... 2 (GO TO Q37A) 

DK ......................................................................................... 8 (GO TO Q37A) 

NA ......................................................................................... 9 (GO TO Q37A) 

36B. How long has it been since you last used any illegal drugs other than marijuana or hashish? Was it … 

(READ RESPONSES) 




DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 

These next questions are about the use of pain relievers. We are not interested in your use of ‘over-the-counter’ pain 

relievers such as aspirin, Tylenol or Advil that don’t require a doctor’s prescription. We are interested in your use of any 

form of prescription pain relievers that were not prescribed for you or that you took in a way other than prescribed only 

for the experience or feeling they caused, such as Codeine, Darvocet, Darvon, Demerol, Laudanum, Lortab, Lorcet, 

Methadone, Morphine, Oxycontin, Percocet, Percodan, Paregoric, Talwin, Tylox, or Vicodin. 

37A. Have you ever, even once, used prescription pain relievers that were not prescribed for you or in a way other than 

prescribed? 

YES ............................................................................................... 1 

NO ................................................................................................. 2 (SEE ATTACHMENT 2 FOR SKIP PATTERN) 

DK ................................................................................................. 8 (SEE ATTACHMENT 2 FOR SKIP PATTERN) 

NA ................................................................................................. 9 (SEE ATTACHMENT 2 FOR SKIP PATTERN) 

37B. How long has it been since you last used prescription pain relievers that were not prescribed for you or in a way 

other than prescribed? Was it… (READ RESPONSES) 

A. Within the past 30 days, or ..........................................................1 

B. More than 30 days ago, but within the past 12 months, or ..........2 

C. More than 12 months ago ............................................................3 (SEE ATTACHMENT 2 FOR SKIP PATTERN) 

DK 

.................................................................................8 (SEE ATTACHMENT 2 FOR SKIP PATTERN) 

NA 

.................................................................................9 (SEE ATTACHMENT 2 FOR SKIP PATTERN) 

INAP .................................................................................0 



37C. On how many occasions during the past 12 months did you use prescription pain relievers that were not 

prescribed for you or in a way other than prescribed? Was it … (READ RESPONSES) 

A. 1-2 times, or...........................................................................................1 

B. 3-5 times, or ..........................................................................................2 

C. 6-9 times, or...........................................................................................3 

D. 10-19 times, or ......................................................................................4 

E. 20-39 times, or .......................................................................................5 

F. 40 or more times.....................................................................................6 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

These questions are about cocaine, including the different forms of cocaine such as powder, “crack”, free base and coca 

paste. 

38A. Have you ever, even once, used any form of cocaine? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q39A) 

(GO TO Q39A) 

(GO TO Q39A) 

38B. How long has it been since you last used cocaine? Was it … (READ RESPONSES) 




DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 

These next questions are about heroin. 

39A. Have you ever, even once, used any form of heroin? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q40A) 

(GO TO Q40A) 

(GO TO Q40A) 

39B. How long has it been since you last used heroin? Was it … (READ RESPONSES) 




DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 



These next questions are about ecstasy. 

40A. Have you ever, even once, used ecstasy, also known as MDMA? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q41A) 

(GO TO Q41A) 

(GO TO Q41A) 

40B. How long has it been since you last used ecstasy? Was it … (READ RESPONSES) 




DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 

These next questions ask about the use of tranquilizers. Tranquilizers are usually prescribed to relax people, to calm 

people down, to relieve anxiety, or to relax muscle spasms. We are interested in your use of any form of prescription 

tranquilizers that were not prescribed for you or that you took in a way other than prescribed only for the experience or 

feeling they caused, such as Buspar, Clonazepam, Diazapam, Lorazepam, Librium, Klonopin, Rohypnol, Valium, or 

Xanax. 

41A. Have you ever, even once, used prescription tranquilizers that were not prescribed for you or in a way other than 

prescribed? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q42A) 

(GO TO Q42A) 

(GO TO Q42A) 

41B. How long has it been since you last used prescription tranquilizers that were not prescribed for you or in a way 

other than prescribed? Was it … (READ RESPONSES) 




DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 



These questions ask about the use of drugs such as amphetamines that are known as stimulants, “uppers” or “speed.” We 

are not interested in the use of “over the counter” stimulants such as Dexatrim or No Doz that don’t require a doctor’s 

prescription. We are interested in your use of any form of prescription stimulants that were not prescribed for you, or that 

you took other than prescribed only for the experience or feeling they caused, such as Benzedrine, Desoxyn, Dexedrine, 

Methamphetamine, Methedrine, Preludin, Sanorex or Tenuate. 

42A. Have you ever, even once, used prescription stimulants that were not prescribed for you or in a way 

other than prescribed? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q43A) 

(GO TO Q43A) 

(GO TO Q43A) 

42B. How long has it been since you last used a prescription stimulant that was not prescribed for 

you or in a way other than prescribed? Was it … (READ RESPONSES) 




DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 

43A. Not including anything you took under a doctor’s order, have you ever, even once, taken any drugs by injection 

with a needle (like heroin, cocaine, amphetamines, or steroids)? 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q44A) 

(GO TO Q44A) 

(GO TO Q44A) 

43B. How long has it been since you last took any drugs by injection with a needle? Was it … (READ RESPONSES) 




DK ..................................................................................................8 

NA ..................................................................................................9 

INAP...............................................................................................0 

ASK EVERYONE: These next questions deal with treatment for alcohol and drug problems, not including cigarettes. 

We are interested in treatment or counseling designed to help you reduce or stop your alcohol or drug use. Please include 

detoxification and any other treatment for medical problems associated with your alcohol or drug use. 

44A. Have you ever received treatment or counseling for your use of alcohol or any drug, not counting cigarettes? 

YES ....................................................................................... 1 

NO ......................................................................................... 2 (GO TO Q45A) 

DK ......................................................................................... 8 (GO TO Q45A) 

NA ......................................................................................... 9 (GO TO Q45A) 



44B. During the past 12 months, have you received treatment or counseling for your use of alcohol or any drug, not 

counting cigarettes? 

YES ....................................................................................... 1 

NO ......................................................................................... 2 (GO TO Q45A) 

DK ......................................................................................... 8 (GO TO Q45A) 

NA ......................................................................................... 9 (GO TO Q45A) 

INAP...................................................................................... 0 

44C. During the past 12 months when you received treatment, was the treatment for alcohol use only, drug use 

only, or both alcohol and drug use? 


ALCOHOL USE ONLY ....................................................... 1 

DRUG USE ONLY............................................................... 2 

BOTH ALCOHOL AND DRUG USE ................................. 3 

DK ......................................................................................... 8 (GO TO Q45A) 

NA ......................................................................................... 9 (GO TO Q45A) 

INAP...................................................................................... 0 

44D. Where did you receive treatment during the past 12 months? 

(DON’T READ RESPONSES; PROBE FOR ALL SOURCES OF TREATMENT; RECORD ALL THAT APPLY) 

EMERGENCY ROOM .........................................................................................................01 

GROUP THERAPY, OUTPATIENT BASIS ......................................................................02 

HOSPITAL, OVERNIGHT AS A PATIENT.......................................................................03 

INDIVIDUAL TREATMENT WITH A DOCTOR OR COUNSELOR .............................04 

PRISON/JAIL .......................................................................................................................05 

RESIDENTIAL TREATMENT, OVERNIGHT FOR DETOX ONLY ..............................05 

RESIDENTIAL TREATMENT, OVERNIGHT FOR OTHER THAN DETOX.................06 

SELF-HELP GROUP SUCH AS ALCOHOLICS OR NARCOTICS ANONYMOUS.......07 

OTHER (SPECIFY____________________________) ......................................................08 

DK .........................................................................................................................................88 (GO TO Q45A) 

NA .........................................................................................................................................99 (GO TO Q45A) 

INAP......................................................................................................................................00 

44E. Are you still in treatment or counseling? 

YES ....................................................................................... 1 (GO TO Q45A) 

NO ......................................................................................... 2 

DK ......................................................................................... 8 (GO TO Q45A) 

NA ......................................................................................... 9 (GO TO Q45A) 

INAP...................................................................................... 0 

44F. Why aren’t you in treatment anymore? 


COMPLETED TREATMENT.................................................................... .........................1 

LEFT BECAUSE YOU BEGAN USING DRUGS AGAIN ...................... .........................2 

LEFT BECAUSE YOU COULDN’T AFFORD TO CONTINUE TREATMENT..............3 

LEFT BECAUSE YOU FELT IT WASN’T HELPFUL ............................ .........................4 

OTHER (SPECIFY ______________________________________) ....... .........................7 

DK ............................................................................................................... .........................8 

NA ............................................................................................................... .........................9 

INAP............................................................................................................ .........................0 



ASK EVERYONE: The next set of questions ask your opinion about whether its difficult or easy to get drugs, and the 

extent to which drugs are available in your neighborhood. 

45. How difficult or easy would it be for you to get some (READ EACH ITEM), if you wanted some. Do you think it 

would probably be impossible to get, very difficult to get, fairly difficulty to get, fairly easy to get or very easy to get. 

Probably Very Fairly Fairly Very 

Impossible Difficult Difficult Easy Easy DK NA 

A. Marijuana......................1 2 3 4 5 8 9 

B. ..Heroin ...........................1 2 3 4 5 8 9 

C. ..Prescription pain 

relievers that are not 

prescribed for you .........1 2 3 4 5 8 9 

Thank you. If you or anyone you know needs assistance with an alcohol or drug problem, now or in the future, you can 

call Maine’s toll-free crisis line 24 hours a day at 1 (888) 568-1112. 

ASK EVERYONE: These next questions are about health concerns and health care services in your community. 

46. What do you think is the biggest health problem facing your community? 


(138-139) 

ABILITY TO PAY FOR CARE .................................................................01 

ALCOHOL/DRUG ABUSE .......................................................................02 

CANCER.....................................................................................................03 

ELDERLY CARE .......................................................................................04 

HEALTH CARE TOO EXPENSIVE .........................................................05 

LACK OF HEALTH INSURANCE ...........................................................06 

LACK OF TRANSPORTATION TO CARE .............................................07 

POOR ORAL HEALTH .............................................................................08 

PRESCRIPTION MEDICATION TOO EXPENSIVE...............................09 

TEEN PREGNANCY .................................................................................10 

TRAVEL TIMES TO SERVICES ARE TOO LONG................................11 

VIOLENCE.................................................................................................12 

OTHER, PLEASE SPECIFY: ___________________________ ............13 

DK ...............................................................................................................88 

NA ...............................................................................................................99 



47. Now I’m going to read a list of health care services and health care providers. For each service or provider, please tell 

me if you think there is a need for more services in your area, whether there are an adequate number of services in your 

area, or there are too many. 

(ROTATE ORDER) (140) 

A. Home health nursing services NEED FOR MORE 

(When a nurse or other health care professional ADEQUATE ..................................2 

comes to your home to provide medical care) TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(141) 

B. Counseling/Mental Health/ ..................................NEED FOR MORE ........................1 

Psychiatric Services ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(142) 

C. Alcohol and drug abuse .......................................NEED FOR MORE ........................1 

treatment services ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(142) 

D. Alternative or Complementary ............................NEED FOR MORE ........................1 

Medical Services Such as ADEQUATE ..................................2 

Chiropractic, Massage, Acupuncture, TOO MANY...................................3 

Herbal or Homeopathy Services DK ..................................................8 

NA ..................................................9 

(141) 

E. Crisis Intervention Services for Troubled............NEED FOR MORE ........................1 

Youths ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(143) 

F. Adult primary care services ..................................NEED FOR MORE ........................1 

(a regular/primary/family doctor that you see ADEQUATE ..................................2 

for routine care such as physicals or regular TOO MANY...................................3 

exams) DK ..................................................8 

NA ..................................................9 



(144) 

G. Services for victims of domestic violence.............NEED FOR MORE ........................1 

ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(145) 

H. Women’s services, such as....................................NEED FOR MORE ........................1 

obstetrics/gynecological services ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(146) 

I. Pediatrics services................................................NEED FOR MORE ........................1 

(Health services for infants/children) ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(147) 

J. Cancer treatment and care....................................NEED FOR MORE ........................1 

ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(148) 

K. Heart disease services .........................................NEED FOR MORE ........................1 

including diagnostic services, ADEQUATE ..................................2 

heart surgery and cardiac 

TOO MANY...................................3 

rehabilitation programs DK ..................................................8 

NA ..................................................9 

(150) 

L. Orthopedic care....................................................NEED FOR MORE ........................1 

(such as treatment for a bad ADEQUATE ..................................2 

back or a bad knee) 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(150) 

M. Diabetes Care.......................................................NEED FOR MORE ........................1 

ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 



.......................................................... 

N. Emergency/Trauma Care .....................................NEED FOR MORE ........................1 

ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(150) 

O. Rehabilitation Services for lung disease..............NEED FOR MORE ........................1 

such as COPD ADEQUATE ..................................2 

TOO MANY...................................3 

DK ..................................................8 

NA ..................................................9 

(150) 

P. Rehabilitation Services .......................................NEED FOR MORE ........................1 

such as speech therapy, ADEQUATE ..................................2 

occupational therapy, and 

TOO MANY...................................3 

physical therapy DK ..................................................8 

NA ..................................................9 

(151) 

Q. Health education services ..................................NEED FOR MORE ................... 1 

ADEQUATE ............................. 2 (GO TO Q48) 

TOO MANY.............................. 3 (GO TO Q48) 

DK ............................................. 8 (GO TO Q48) 

NA ............................................. 9 (GO TO Q48) 

ASK IF 47Q = 1 (NEED FOR MORE) 

47R. What kinds of health education services would you like to see provided in your area? 

(RECORD ALL THAT APPLY) 

(152-153) 

ADOLESCENT / TEEN SEX EDUCATION............................01 

ALZHEIMER'S DISEASE .......................................................02 

ASTHMA...................................................................................03 

CANCER SCREENING AND/OR TREATMENT...................04 

CHILD ABUSE / FAMILY VIOLENCE ..................................05 

DIABETES.................................................................................06 

DIET AND/OR EXERCISE ......................................................07 

DRUG/ALCOHOL ABUSE ......................................................08 

ELDERLY CARE ......................................................................09 

HEART DISEASE SCREENING AND TREATMENT ...........10 

HIV / AIDS ................................................................................11 

INJURY PREVENTION............................................................12 

MENTAL HEALTH ..................................................................13 

SEXUALLY TRANSMITTED DISEASES ..............................14 

SMOKING CESSATION AND/OR PREVENTION ................15 

STRESS MANAGEMENT........................................................16 

OTHER (SPECIFY _____________________________) ........17 

DK ..............................................................................................88 

NA ..............................................................................................99 

INAP...........................................................................................00 



(ASK THE FOLLOWING QUESTIONS IF R IS FEMALE; OTHERWISE GO TO Q50A) 

The next few questions are about physical conflict or physical fighting that happens between many partners. Remember 

that your answers will be kept confidential. They will never be connected with any identifying information about you. 

48. Are you still in a quiet place where you can speak comfortably? 

(90) 

YES .............................................................................................................1 (GO TO Q50A) 

NO ...............................................................................................................2 

INAP............................................................................................................0 

If R SAYS NO TO Q48, ASK “Do you have a quiet place that you can go to now? 

IF R CANT GET TO A PRIVATE PLACE, SUGGEST TARGET TIME FOR CALLBACK: Can we re-schedule later 

this evening? Tomorrow at about this time? ETC. 



49A. Have you ever been involved in a physical conflict or forced to have sex against your will by a current or exspouse; 

current or ex-live-in partner; or current or ex-boyfriend, girlfriend or date that did not live with you? This 

would include not just beatings, but also those times that you were pushed, hit, shoved, slapped, grabbed, 

punched, cut, hit with an object, forced into any sexual activity, or something like those actions ? 

(132) 

YES .............................................................................................................1 

NO ...............................................................................................................2 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP ............................................................................................................0 

(GO TO Q50A) 

(GO TO Q50A) 

(GO TO Q50A) 

49B. When was the most recent time that one of those conflicts or fights occurred? Was it…. 

(132) 

Within the past 12 months, or .....................................................................1 

1 to 5 years ago, or ......................................................................................2 

6 to 10 years ago, or ...................................................................................3 (GO TO Q50A) 

More than 10 years ago ...............................................................................4 (GO TO Q50A) 

DK .....................................................................................................8 (GO TO Q50A) 

NA ...............................................................................................................9 (GO TO Q50A) 

INAP............................................................................................................0 (GO TO Q50A) 



The next few questions are about the times you were physically or sexually hurt within the past five years. Remember 

we’re ONLY talking about things that happened between you and a current or ex spouse, live-in partner, boyfriend, 

girlfriend, or date. 

49C. Did you see a doctor or nurse as a result of being hurt by any of these people in the past five years? 

(133) 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q50A) 

DK ...............................................................................................................8 (GO TO Q50A) 

NA ...............................................................................................................9 (GO TO Q50A) 

INAP............................................................................................................0 

49D. Where did you go most recently to see a doctor or nurse as a result of being hurt by one of these people? 

Did you go to … 

(READ RESPONSES) (133) 

A hospital emergency room ........................................................................1 

A hospital walk-in clinic .............................................................................2 

An urgent care center ..................................................................................3 

A community health center .........................................................................4 

A private doctor’s office (includes an office at a hospital or HMO)...........5 

Someplace else (Specify__________________)? ......................................6 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

INAP............................................................................................................0 

(GO TO Q50A) 

(GO TO Q50A) 

49E. When you most recently saw a doctor or nurse as a result of being hurt by one of these people, did they 

offer you information about how to get: 

YES NO DK INAP 

1. Counseling or other mental health services ........................... 1 2 8 0 (134) 

2. Temporary housing or shelter services .................................. 1 2 8 0 (135) 

3. Legal services ........................................................................ 1 2 8 0 (136) 

4. Other services (Please Specify ____________________) ..... 1 2 8 0 (137) 

WOMEN ONLY: Thank you. If you or someone you know needs assistance with domestic violence issues, now or any 

time in the future, you can call Maine’s toll-free confidential hotline 24 hours a day at 1 (800) 799-7233. 

EVERYONE: Now I'd like to ask you some additional questions so that we can describe the types of people who 

participated in this survey. 

50A. Do you currently have health insurance that would cover at least part of the bill if you had to stay in the hospital 

overnight? 

(168) 

YES .............................................................................................................1 

NO ...............................................................................................................2 (GO TO Q50C) 

YES, BUT DK ABOUT HOSPITAL STAY (VOL) ..................................3 

NO COVERAGE AT ALL .........................................................................7 (GO TO Q50C) 

DK ...............................................................................................................8 (GO TO Q50C) 

NA ...............................................................................................................9 (GO TO Q50C) 



50B. What is that coverage? Is it... 

(PROBE TO CLARIFY HEALTH COVERAGE) 

(169-170) 

Medicaid............................................................................................................ 01 

Medicare............................................................................................................ 02 

Champus or any other government program..................................................... 04 

Insurance that you get through an employer ..................................................... 05 

Insurance that you buy on your own ................................................................. 06 

OTHER, (SPECIFY) __________________________________ .................. 07 

DK ..................................................................................................................... 88 

NA/REFUSED .................................................................................................. 99 

INAP.................................................................................................................. 00 

50C. During the past 12 months, were there times you thought you should go to a doctor but did not go because you 

couldn’t afford it? 

(171) 

YES .............................................................................................................1 

NO ...............................................................................................................2 


NA/REFUSED ............................................................................................9 

(175-176) 

51. In what year were you born? ....................................................................................19 ___ ____ 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

(177-179) 

52. How tall are you with your shoes off? 

(RECORD IN FEET AND INCHES; E.G. 6'1"=601) ............................................. ___ ____ ___ 

DK ...............................................................................................................888 

NA ...............................................................................................................999 

(180-182) 

53. What is your weight with your shoes off?................................................................ ___ ____ ___ 

DK ...............................................................................................................888 

NA ...............................................................................................................999 

54. What is the last grade in school you have completed so far? 

(READ ONLY IF NECESSARY) (183-184) 

NEVER ATTENDED SCHOOL OR ONLY KINDERGARTEN..............01 

GRADES 1 THROUGH 8 (ELEMENTARY)............................................02 

GRADES 9 THROUGH 11 (SOME HIGH SCHOOL)..............................03 

GRADE 12 OR GED (HIGH SCHOOL GRADUATE).............................04 

COLLEGE 1 TO 3 YEARS (SOME COLLEGE OR TECH SCHOOL)....05 

COLLEGE 4 YEARS OR MORE(COLLEGE GRADUATE)...................06 

DK ...............................................................................................................88 

NA ...............................................................................................................99 



55. Are you now: (READ RESPONSES) (185) 

Married........................................................................................................1 

Widowed .....................................................................................................2 

Separated .....................................................................................................3 

Divorced......................................................................................................4 

Never married or .........................................................................................5 

Part of an unmarried couple living in the same household..........................6 

DK ...............................................................................................................8 

NA ...............................................................................................................9 

56. Are you currently: (READ RESPONSES) 

(186-187) 

Employed for wages....................................................................................01 

Self-employed .............................................................................................02 

Out of work for more than 1 year................................................................03 

Out of work for less than 1 year..................................................................04 

Homemaker .................................................................................................05 

Student.........................................................................................................06 

Retired, or....................................................................................................07 

Unable to work ............................................................................................08 

OTHER........................................................................................................10 

DK ...............................................................................................................88 

NA ...............................................................................................................99 

In this study, we need to talk with people in all income groups to make sure the total group we talk to represents other 

people like yourself. To do this, I'll ask you about ranges of income so that you won't have to reveal your exact income, 

but it is important that you choose the right category. 

57. In 2000, was your TOTAL household income from ALL sources before taxes 

$25,000 or more, or was it less than that? ....................... 

(INCLUDE ALL PEOPLE LIVING IN R'S HOUSEHOLD) (188-199) 

Less than $25,000 

$25,000 or More 

↓ 

↓ 

Was it over $20,000? Was it under $35,000? 

YES ................. 04 YES.................... 05 

NO 

NO 

↓ 

↓ 


YES ................. 03 Yes ......................... 06 

NO 

NO 

↓ 

↓ 


YES ................. 02 Yes ........................ 07 

NO .....................01 NO.......................... 08 

DK.......................... 88 

NA.......................... 99 



(189-190) 

58. Altogether, how many years have you lived in this area? ........................................ _____ _____ 

DK..................... 88 

NA..................... 99 

CLOSING STATEMENT: 

This concludes this interview. I want to thank you for your assistance. The information you have provided will help the 

health care providers in your area improve health care and medical services for everyone. As I mentioned in the 

beginning, this information will be kept strictly confidential. We sincerely appreciate your time and cooperation. 

ENTER TIME NOW: 

ENTER TOTAL TIME: ________ 

ENTER INITIALS/ HERE: ________________ (191-192) 


PHRG Household Survey Participation Rates 

Appendix 9 

Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo 

# Completed Interviews 403 347 351 368 341 352 346 

# Refusals 490 307 392 391 384 388 409 

# Eligible Contacts 1 1358 997 1192 1148 1181 1050 1179 

Refusal Rate 2 36.0% 30.8% 32.9% 34.1% 32.5% 37.0% 34.6% 

Response Rate 3 29.6% 34.8% 29.4% 32.1% 28.9% 33.5% 29.3% 

1 Eligible contacts include those known to be eligible (completed interviews plus refusals) and those whose 

eligibility status is unknown but who are estimated to be eligible. 

2 The refusal rate represents the proportion of eligible (known and estimated) individuals who declined to 

participate. 

3 The response rate represents the proportion of eligible (known and estimated) individuals who completed 

an interview. 


PHRG

Peer Grouping Definitions Appendix 10 

Urban Peer (Peer to Bangor Region) 

LEWISTON HOSPITAL SERVICE AREA 

Towns Included in the Rural Peer 

(Peer to all study regions other than the Bangor Region) 

ACTON 

ALNA 

ANDOVER 

AVON 

BETHEL 

BRIDGTON 

BROWNFIELD 

BUCKFIELD 

BYRON 

CARTHAGE 

CASCO 

CHELSEA 

CHESTERVILLE 

CORNISH 

DIXFIELD 

EAST FRANKLIN 

FARMINGTON 

FAYETTE 

FRYEBURG 

GARDINER 

GREENWOOD 

HALLOWELL 

HARRISON 

HARTFORD 

HEBRON 

HIRAM 

INDUSTRY 

JAY 

JEFFERSON 

LEBANON 

LEEDS 

LIMERICK 

LIMINGTON 

LISBON 

LITCHFIELD 

LIVERMORE 

LIVERMORE FALLS 

LOVELL 

MECHANIC FALLS 

MEXICO 

MOUNT VERNON 

NEW PORTLAND 

NEW SHARON 

NEW VINEYARD 

NEWFIELD 

NEWRY 

NOBLEBORO 

NORTH BERWICK 

NORWAY 

OLD ORCHARD BEACH 

OTISFIELD 

OXFORD 

PARIS 

PARSONSFIELD 

PERU 

PHILLIPS 

POLAND 

PORTER 

RANDOLPH 

RICHMOND 

ROXBURY 

RUMFORD 

SABATTUS 

SEBAGO 

SHAPLEIGH 

STRONG 

SUMNER 

VIENNA 

WALES 

WATERFORD 

WELD 

WHITEFIELD 

WILTON 

WINDSOR 

WISCASSET 

WOODSTOCK 


PHRG

Listing of Persons Interviewed 

Appendix 11 

Name Title Location in Maine 

Diane Raymond Director of Psychiatric Services, TAMC Aroostook 

Judy Finestein DHS Director Oral Health Div. Augusta 

Paul Tisher VP Medical Affairs, Acadia Hospital Bangor 

Annette Adams LCSW, Access Program, Acadia Hospital Bangor 

Kay Carter Community Health & Counseling Services Bangor 

Erik Steele DO, Admin for ER & Trauma Srvcs, EMMC Bangor 

James Raczek MD Chf Fam Prac Srvc; Admin Phar Srvc Bangor 

Denis Marvel Bangor Homeless Center Bangor 

Roberta Downey Eastern Agency on Aging Exec. Dir Bangor 

Helen Burlock Dir. Home Hlth Srvc, Comm Hlth and Counseling Srvc Bangor 

Margaret Michaud-Cain RN, Exec. Dir., NE Home Health Care Bangor 

Roger Wilson MD, Bangor Mental Health Institute Bangor 

Helen MacKinnon RN DON Consultation Liason Srvcs, EMMC Bangor 

Bruce Cummings CEO, Blue Hill Memorial Hospital Blue Hill 

Dan Rissi Chief of Staff/Medical Director, BHMH Blue Hill 

Kris Doody-Chabre CEO, Cary Medical Center Caribou 

Wes Davidson Director, Aroostook Mental Health Center Caribou 

Ralph Gabarro CEO, Mayo Hospital Dover Foxcroft 

Martin Bernstein CEO, Northern Maine Medical Center Fort Kent 

Philomena Marshall CEO, Charles A. Dean Hospital Greeneville 

Cathy Jones VP Patient Care Services, CA Dean Hsptl Greeneville 

Joan Crocker Harrington Family Health Care Harrington 

Tom Moakler CEO, Houlton Regional Hospital Houlton 

Ron Victory CEO, Penobscot Valley Medical Center Lincoln 

Ken Schmitt Regional Medical Center Lubec 

John Edwards Admin, Wash Cty Psychotherapy Assoc. Machias 

Richard Waller CEO, Millinocket Regional Hospital Millinocket 

John May CEO, Sebasticook Valley Hospital Pittsfield 

John May CEO, Sebasticook Valley Hospital Pittsfield 

David Peterson CEO, TAMC Presque Isle 

Dr. Jim Haley VP, Medical Affairs Presque Isle 

Sharon Lester ER Senior Manager Presque Isle 

Alex Dragatsi Epidemiologist Presque Isle 

Dr. Jay Reynolds President, Med Staff, TAMC Presque Isle 

Jack Ginty Senior VP, Patient Services, TAMC Presque Isle 

Susan Deschene Dir. HEALTH1st, Aroostook Community Action Program Presque Isle 

Phil Monaco Program Director of Psychiatry Srvc Rockport 

Phil Monaco Dir. Of Psychiatric & S.A. Srvcs, PBMC Rockport 

Maggie Laughlin Director of Planning & Marketing, PBMC Rockport 

David Bradeen VP Medical Affairs, Pen Bay Med Center Rockport 

Bill Addison CEO, Inland Hospital Waterville 

Sally Conary Senior VP, Inland Hospital Waterville 


PHRG

Definitions of Indicators Appendix 12 

√ 

ACS = Ambulatory Care Sensitive 

The hospital admission rate for ACS conditions is used as a measure of access to and need 

of primary medical care in a community. ACS conditions are those that are less likely to result 

in hospitalization when treated on an outpatient basis with high quality primary medical care 1 and 

good patient compliance. Therefore, higher rates of hospitalizations for ACS conditions may be 

an indication of poorer access to and/or quality of primary care in an area. Those conditions 

considered to be ambulatory care sensitive are: 

• Adult and Child Ear Infection • Respiratory Infection & Inflammation 

• Chronic Obstructive Pulmonary Disease • Adult and Child Pneumonia 

(COPD) 

• Adult and Child Bronchitis & Asthma • Heart Failure & Shock 

• Cardiac Arrest • Hypertension (High Blood Pressure) 

• Chest Pain • Angina Pectoris 

• Cellulitis • Diabetes 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

AMI = Acute Myocardial Infarction, commonly referred to as a heart attack 

Annual Household Income = The reported annual household income for each region, the 

peers, and the state is the average household income in that region (Source: Claritas), the 

reported annual household income for the U.S. is the median household income of the U.S. 

(Source: U.S. Census Bureau). 

ARDI = Alcohol-Related Disease Impact 

ARDI Software has been developed for the Centers for Disease Control (CDC) to permit 

calculation mortality associated with alcohol use and misuse. The mortality related measure 

is computed for 35 diagnoses related to alcohol use and misuse. 

At Risk for Obesity = Women with a body mass index of >27.3, and men with a body mass index of 

>27.8. 

Chronic Heavy Drinking = Two or more drinks of alcohol every day over the past 30 days. 

Current Smoker = Respondents who have smoked at least 100 cigarettes in lifetime, and reported 

smoking currently. 

Former Smoker = Respondents who have smoked 100 cigarettes in lifetime but currently do not 

smoke. 

HIV/AIDS = Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome 

Incidence Rate = the number of new cases of a particular disease or condition that develop in a 

population of individuals during a specified period of time 

Infant Deaths = Deaths to a live born infant less than 1 year old 

Neonatal Deaths = Deaths to a live born infant less than 27 days old 

1. Billings, J. D., Hasselblad, V. A preliminary study: use of small area analysis to assess the performance of the outpatient 

deliver system in New York City. November 24, 1989 (Unpublished manuscript available from the Codman Research 

Group, Inc., Lyme, New Hampshire). 

November 1, 2001 Page 1 of 4 PHRG


√ Physical Activity = 

No Physical Activity = Survey respondents who reported no physical activity for exercise 

in the past month. 

Vigorous Physical Activity = Survey respondents who reported engaging in physical 

activity for exercise for 30 minutes or more at least 5 times a week. 

√ 

√ 

PNC = Prenatal Care 

Kessner Index = The Kessner Index is a measure of the adequacy of prenatal care being provided in 

a community. The Index is based upon the month PNC began, the number of visits, and the 

gestational age at birth. 

The classification of prenatal care as adequate, intermediate or inadequate is derived from the Institute of 

Medicine’s Three-Factor Prenatal Care Index. The classes of care are in accordance with 

recommendations for prenatal care set by the American College of Obstetricians and Gynecologists and 

the World Health Organization. This classification scheme accounts for length of gestation by requiring 

fewer prenatal visits for pregnancies with short gestation time. Records with missing information (i.e., 

last normal menstrual period, gestation weeks, number of visits, or month prenatal care began) are 

assigned to the inadequate prenatal care category. 

The gestation weeks are calculated by subtracting the last menstrual date from the child’s birth date. If 

the last menstrual date is missing from the birth record, the doctor’s (or other medical professional’s) 

estimate of gestation is used. The accuracy of the level of prenatal care is as reliable as the information 

provided by the mother and her caregiver. 

The table below shows the Institute of Medicine’s Three-Factor Prenatal Care Index. 

Gestation 

Number of Prenatal 

Prenatal Care (Weeks) Visits 

ADEQUATE 13 or less 1 or more or not stated 

(Includes women who 14 – 17 2 or more 

started their first pre- 18 – 21 3 or more 

natal visits within the 22 – 25 4 or more 

first three months of 26 – 29 5 or more 

pregnancy) 30 – 31 6 or more 

32 – 33 7 or more 

34 – 35 8 or more 

36 or more 9 or more 

INADEQUATE 14 – 21 0 or unstated 

(Includes women who 22 – 29 1 or less or unstated 

started care within the 30 – 31 2 or less or unstated 

third trimester) 32 – 33 3 or less or unstated 

34 or more 4 or less or unstated 

unstated 

INTERMEDIATE 

All combinations not stated above 



√ 

√ 

√ 

√ 

Prevalence Rate = the proportion of individuals in a population who have a particular disease or 

condition at a specific point in time 

Premature Delivery = Delivery following a pregnancy of a gestational period less than 37 weeks. 

VBAC = Vaginal Birth after C-Section. 

3+ Chronic Diseases = The diseases included in this measure are diabetes, hypertension, hypercholesterol, 

heart disease, lung disease, cancer, arthritis, asthma, depression, substance abuse, and 

psychiatric conditions other than depression. 

√ Wellness Profile = 

Well = Survey respondents that had never been diagnosed with any of the three long-standing 

conditions (hypertension, high cholesterol, or diabetes), that reported their health as excellent, 

very good, or good, had good functional health, and, if over 35 years old, did not smoke and were 

not at risk for overweight based on their body mass index. 

Formulae: 

At Risk for Future Medical Problems = Survey respondents never diagnosed with any of the 

three long-standing conditions (hypertension, high cholesterol, or diabetes), but were 35 years of 

age or older and smoked cigarettes regularly or were at risk for overweight based on their body 

mass index. 

Some Health Problems = Survey respondents who reported their health as fair or poor, had 

reduced functional health, or had been diagnosed with high blood pressure, high cholesterol or 

diabetes. 

Not Well = Survey respondents that have been diagnosed with all three long-standing conditions 

(hypertension, high cholesterol, or diabetes), or had been diagnosed with at least one chronic 

disease and reported their health as either fair or poor or experienced significant functional health 

problems. 

Admissions 

Hospital Admission Rate = --------------------------------- × 100,000 

Population 

Total Deaths 

Average Mortality Rate = ------------------------------------ × 100,000 

Total Population 

Mortality rates for the Bangor Region are age adjusted to the Urban Peer. 

Mortality rates for the Aroostook Region, Penquis Region, Washington Region, Hancock Region, Central 

region, and Knox-Waldo region are age-adjusted to the Rural Peer. 

Cancer Incidence 

Cancer Incidence Rate = --------------------------------------- × 100,000 

Total Population 



All Cancer rates presented are age-adjusted to the 1970 U.S. population. 

Infant Deaths (or Neonatal Deaths) 

Infant (or Neonatal) Mortality Rate = ---------------------------------------------- × 1,000 

Total Births 

Low Birthweight Births 

Low Birthweight Rate = ------------------------------------ × 1,000 

Total Births 

Total Births (Age 10-17) 

Teen Birth Rate = ----------------------------------------------------- × 1,000 

Female Population (Age 10-17) 

Total Births of

Codes Used To Define Indicators Appendix 13 

Indicator 

Defining Code(s) 

MORTALITY 

ICD-9 Codes 

AMI 410 

Atherosclerosis 440 

Breast Cancer 174 

Buccal Cavity Cancer 140-149 

Cerebrovascular Disease (stroke) 430-438 

Cervical Cancer 180 

Cirrhosis Mortality 571 

Colorectal Cancer 154 

COPD 490-496 

Diabetes 250 

Digestive System Cancer 150-159 

Emphysema 492 

Genital System Cancer (Female) 179-184 

Genital System Cancer (Male) 186-187 

Heart Disease 390-398, 402-429 

HIV/AIDS 042-044 

Influenza 487 

Lung Cancer 162.2-162.9 

Malignant Neoplasms 140-208 

Motor Vehicle Accidents 

E81.0-E82.5 

Pneumonia 480-486 

Prostate Gland Cancer 185 

Respiratory System Cancer 160-165 

Suicide Mortality 

E95.0-E95.9 

Total Accidents 

E80.0-E94.9 

Urinary System Cancer 188-189 

GENERAL INPATIENT HOSPITALIZATION 

DRG Codes 

AMI 121-123 

Adult Pneumonia 089-090 

Bronchitis and Asthma (age 0-17) 774-775 

Bronchitis and Asthma (Age 18+) 096-197 

CABG 106-107 

Cerebrovascular Disease (stroke) 014 

COPD 088 

Diabetes 294-295 

Emphysema 099-100 

Hip Procedures 210-211 

Lung Cancer 082 

Psychoses Hospital Admission 430 

GENERAL OUTPATIENT/EMERGENCY DEPARTMENT 

ICD-9 Codes 

Bronchitis and Asthma 

COPD 

493.0, 493.1, 493.9, 466.0 

490, 491, 492, 493.2, 493.21, 494, 495, 496 

Pneumonia 480.0-486 

Angina 413.0-413.9 

Chest Pain 786.5-786.59 

Cardiac Arrest 427.5 

Heart Failure/Shock 428, 785.50, 785.51 

AMI 410 

MENTAL HEALTH/SUBSTANCE ABUSE INPATIENT/OUTPATIENT 

ICD-9 Codes 

Acute Alcohol-Related Mental Disorders 303, 305.0 

Acute Drug-Related Mental Disorders 304, 305.1-305.9 

Alcohol-Related Psychoses 291 

Anxiety Personality and Other Disorders 300-316 

Bipolar Disorder 296.4-296.7 

Drug-Related Psychoses 292 

Major Depressive Disorder 296.2-296.3, 300.4 

Schizophrenia and Related Disorders 295, 299 

Senility and Organic Mental Disorders 290, 310 

CANCER 

ICD-9 Codes 

Malignant Neoplasms 140-208 

Breast Cancer 174 

Buccal Cavity 140, 150, 161 

Cervix uteri 180 

Colorectal 153, 154.0, 154.1, 159.0 

Digestive System 151, 155.0, 155.1 

Female Genital System 179, 180, 182, 183 

Male Genital System 185, 186-189.1 

Lung and Bronchus Cancer 162.2-162.9 

Prostate gland 185 

Urinary System 188, 189.0-189.1 

Where three-digit codes are reported all codes beginning 

with the reported three-digits were used. 


PHRG

Appendix 14 

Mental Health Findings from the 2001 EMH Household Survey by Age Group, Gender and Region 

Past Year Outpatient 

Region 

Mental Health Treatment Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 4 15 3 2 9 10 5 48 

% 3.7 15.3 3.7 2.4 10.6 11.5 6.3 7.7 

45-64 n 9 1 3 4 1 1 6 25 

% 15.3 1.9 5.3 7.4 1.9 1.9 11.3 6.5 

65+ n 1 1 0 2 0 0 0 4 

% 3.8 3.8 0.0 6.5 0.0 0.0 0.0 2.0 

Total N 11 6 4 9 4 14 14 62 

% 5.7 3.4 2.4 5.3 2.4 8.4 8.3 5.1 

Female 18-44 n 13 13 9 15 16 12 16 94 

% 12.3 15.9 10.8 19.0 20.3 13.5 20.3 15.7 

45-64 n 10 5 6 3 6 7 5 42 

% 16.4 9.4 10.9 5.5 10.7 13.0 8.8 10.7 

65+ n 1 1 0 1 2 1 2 8 

% 2.6 2.6 0.0 2.3 4.7 2.6 4.4 2.8 

Total N 17 10 11 16 17 12 19 102 

% 8.2 5.8 6.0 8.8 9.4 6.5 10.4 7.9 

Total N 29 16 14 26 21 25 33 164 

% 7.6 4.6 4.0 7.4 6.0 7.1 9.4 6.6 

Location of Past Year Mental Health Treatment 

OUTPATIENT MENTAL HEALTH CLINIC n 8 13 2 12 7 10 11 63 

% 20.5 36.1 10.0 41.4 20.0 33.3 31.4 28.1 

OFFICE OF A PRIVATE THERAPIST n 18 9 11 12 16 7 15 88 

% 46.2 25.0 55.0 41.4 45.7 23.3 42.9 39.3 

DOCTOR'S OFFICE OFFICE n 4 10 3 0 6 2 4 29 

% 10.3 27.8 15.0 0.0 17.1 6.7 11.4 12.9 

OUTPATIENT MEDICAL CLINIC n 1 4 2 2 3 3 3 18 

% 2.6 11.1 10.0 6.9 8.6 10.0 8.6 8.0 

PARTIAL DAY HOSPITAL/DAY TREATMENT PROGRAM n 3 0 1 1 0 1 1 7 

% 7.7 0.0 5.0 3.4 0.0 3.3 2.9 3.1 

OTHER n 2 0 1 1 3 6 1 14 

% 5.1 0.0 5.0 3.4 8.6 20.0 2.9 6.3 

DON'T KNOW n 2 0 0 1 0 1 0 4 

% 5.1 0.0 0.0 3.4 0.0 3.3 0.0 1.8 

REFUSED n 1 0 0 0 0 0 0 1 

% 2.6 0.0 0.0 0.0 0.0 0.0 0.0 0.4 

Total N 39 36 20 29 35 30 35 224 


Appendix 14 

Mental Health Findings from the 2001 EMH Household Survey by Age Group, Gender and Region 

Unable to Obtain Needed 

Region 

Mental Health Treatment -Past Year Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 9 4 0 6 4 14 11 48 

% 8.3 8.3 8.3 8.3 8.3 8.3 8.3 8.3 

45-64 n 1 1 4 1 0 0 2 9 

% 1.7 1.9 7.0 1.9 0.0 0.0 3.6 2.3 

65+ n 1 0 0 2 0 0 1 4 

% 3.8 0.0 0.0 6.5 0.0 0.0 3.2 2.0 

Total N 14 17 6 9 10 11 12 79 

% 7.3 9.6 3.6 5.3 5.8 6.6 7.1 6.5 

Female 18-44 n 14 6 6 13 11 8 14 72 

% 13.1 7.1 7.2 16.0 13.9 9.0 17.5 11.9 

45-64 n 2 4 3 3 4 4 5 25 

% 3.3 7.5 5.3 5.5 7.0 7.1 8.8 6.3 

65+ n 1 1 1 1 2 0 0 6 

% 2.6 2.6 2.4 2.3 4.7 0.0 0.0 2.1 

Total N 25 19 15 19 25 20 23 146 

% 12.1 11.0 8.3 10.6 14.0 10.9 12.7 11.4 

Total N 39 36 21 28 35 31 35 225 

% 9.8 10.3 6.0 8.0 10.0 8.9 10.0 9.0 

Reason for Not Receiving Treatment 

COULDN'T AFFORD IT n 9 7 7 10 7 15 12 67 

% 31.0 41.2 46.7 38.5 31.8 57.7 35.3 39.6 

DIDN'T KNOW WHERE TO GO n 1 0 1 0 1 1 0 4 

% 3.4 0.0 6.7 0.0 4.5 3.8 0.0 2.4 

TOOK TOO MUCH TIME n 4 1 1 4 1 2 5 18 

% 13.8 5.9 6.7 15.4 4.5 7.7 14.7 10.7 

EMBARRASSED OR FEARFUL OTHERS WOULD FIND OUT n 1 0 1 1 3 0 0 6 

% 3.4 0.0 6.7 3.8 13.6 0.0 0.0 3.6 

TOO FAR TO TRAVEL/TAKES TOO LONG TO GET THERE n 0 0 1 2 0 0 0 3 

% 0.0 0.0 6.7 7.7 0.0 0.0 0.0 1.8 

DIDN'T THINK IT WOULD HELP n 4 1 1 3 3 0 2 14 

% 13.8 5.9 6.7 11.5 13.6 0.0 5.9 8.3 

SOME OTHER REASON n 10 7 3 5 5 7 13 50 

% 34.5 41.2 20.0 19.2 22.7 26.9 38.2 29.6 

DON'T KNOW n 0 0 0 0 1 1 0 2 

% 0.0 0.0 0.0 0.0 4.5 3.8 0.0 1.2 

REFUSED n 0 1 0 1 1 0 2 5 

% 0.0 5.9 0.0 3.8 4.5 0.0 5.9 3.0 

Total N 29 17 15 26 22 26 34 169 


Substance Abuse Findings from the 2001 EMH Household Survey by Age Group, Gender and Region 

Region 

Current Smoking Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 44 50 32 24 30 36 19 235 

% 40.7 51.0 39.0 28.6 35.3 41.4 23.8 37.7 

45-64 n 16 13 15 15 14 16 11 100 

% 27.1 25.5 26.3 27.8 25.9 29.6 20.0 26.0 

65+ n 4 6 0 5 6 4 1 26 

% 15.4 22.2 0.0 15.6 20.0 15.4 3.2 12.9 

Total N 64 69 47 43 50 56 32 361 

% 33.2 39.2 27.8 25.1 29.2 33.5 18.9 29.7 

Female 18-44 n 35 29 26 30 28 35 25 208 

% 32.7 34.9 31.3 37.0 35.0 39.3 31.3 34.5 

45-64 n 16 11 10 18 10 12 13 90 

% 26.2 20.8 17.9 32.7 17.5 21.8 22.8 22.8 

65+ n 4 3 7 4 2 5 4 29 

% 10.5 8.1 17.1 9.3 4.7 13.2 8.9 10.2 

Total N 56 43 44 52 39 52 42 328 

% 27.1 24.9 24.2 28.6 21.8 28.4 23.1 25.5 

Total N 120 112 90 95 89 108 74 688 

% 30.0 32.0 25.7 26.9 25.4 30.9 21.1 27.5 

Former Smoking 

Male 18-44 n 25 15 18 30 15 6 32 141 

% 22.9 15.3 22.0 35.7 17.6 6.9 39.5 22.5 

45-64 n 26 22 28 18 20 22 19 155 

% 44.1 42.3 49.1 33.3 36.4 40.7 35.2 40.3 

65+ n 20 15 23 20 17 21 23 139 

% 76.9 57.7 79.3 62.5 56.7 80.8 71.9 69.2 

Total N 71 52 69 69 52 49 74 436 

% 36.8 29.5 41.1 40.4 30.4 29.3 43.8 35.9 

Female 18-44 n 11 16 16 14 12 18 21 108 

% 10.3 19.0 19.3 17.5 15.2 20.2 26.3 17.9 

45-64 n 25 18 24 13 20 20 21 141 

% 41.0 34.0 42.9 23.6 35.1 36.4 37.5 35.9 

65+ n 16 11 11 16 18 16 18 106 

% 42.1 29.7 26.8 36.4 41.9 42.1 40.0 37.1 

Total N 52 44 52 44 51 54 61 358 

% 25.1 25.4 28.7 24.2 28.3 29.5 33.5 27.8 

Total N 123 97 121 113 102 103 135 794 

% 30.8 27.7 34.6 32.0 29.1 29.4 38.5 31.7 

Appendix 15 



Region 

Chronic Drinking Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 5 2 2 10 9 8 7 43 

% 4.6 2.1 2.4 11.9 10.6 9.2 8.6 6.9 

45-64 n 3 5 3 3 4 3 4 25 

% 5.2 9.6 5.3 5.6 7.4 5.6 7.3 6.5 

65+ n 1 1 2 0 7 7 4 22 

% 3.8 3.8 6.7 0.0 23.3 25.9 12.9 10.9 

Total N 10 8 7 13 21 17 15 91 

% 5.2 4.5 4.1 7.6 12.3 10.2 8.9 7.5 

Female 18-44 n 1 1 0 1 1 1 0 5 

% 0.9 1.2 0.0 1.2 1.3 1.1 0.0 0.8 

45-64 n 0 0 1 1 1 0 1 4 

% 0.0 0.0 1.8 1.8 1.8 0.0 1.8 1.0 

65+ n 0 0 0 0 0 0 1 1 

% 0.0 0.0 0.0 0.0 0.0 0.0 2.2 0.3 

Total N 1 1 1 2 2 1 2 10 

% 0.5 0.6 0.5 1.1 1.1 0.5 1.1 6.8 

Total N 11 9 7 15 22 18 17 99 

% 2.8 2.6 2.0 4.2 6.3 5.1 4.8 4.0 

Binge Drinking 

Male 18-44 n 38 31 32 32 34 32 25 224 

% 35.2 32.0 39.0 38.1 40.0 36.8 30.9 35.9 

45-64 n 8 10 6 5 9 8 7 53 

% 13.6 19.2 10.5 9.3 16.4 14.8 13.0 13.8 

65+ n 1 1 2 2 6 1 1 14 

% 3.8 3.8 6.7 6.5 20.0 3.8 3.2 7.0 

Total N 47 42 40 41 49 41 33 293 

% 24.4 23.7 23.8 24 28.7 24.4 19.6 24.1 

Female 18-44 n 11 7 11 5 10 8 13 65 

% 10.3 8.3 13.3 6.2 12.5 9.0 16.3 10.8 

45-64 n 1 1 2 3 3 1 2 13 

% 1.6 1.9 3.5 5.5 5.3 1.8 3.5 3.3 

65+ n 0 1 0 0 2 0 0 3 

% 0.0 2.6 0.0 0.0 4.7 0.0 0.0 1.0 

Total N 12 8 13 8 14 9 15 79 

% 5.8 4.6 7.2 4.4 7.8 4.9 8.2 6.1 

Total N 59 50 53 48 65 50 48 371 

% 14.8 14.3 15.1 13.6 18.0 14.3 13.7 14.8 

Appendix 15 



Diagnosed Substance 

Region 

Abuse Disorder Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 7 6 2 2 7 10 2 36 

% 6.4 6.2 2.4 2.4 8.3 11.5 2.5 5.8 

45-64 n 3 0 6 1 3 4 3 20 

% 5.2 0.0 10.3 1.9 5.6 7.4 5.5 5.2 

65+ n 0 0 0 0 1 1 1 3 

% 0.0 0.0 0.0 0.0 3.3 3.8 3.2 1.5 

Total N 10 6 7 3 12 15 6 59 

% 5.2 3.4 4.1 1.8 7 9 3.6 4.9 

Female 18-44 n 1 0 1 3 2 2 0 9 

% 0.9 0.0 1.2 3.8 2.5 2.2 0.0 1.5 

45-64 n 1 1 1 2 1 1 2 9 

% 1.6 1.9 1.8 3.6 1.8 1.8 3.6 2.3 

65+ n 0 0 1 0 1 0 0 2 

% 0.0 0.0 2.4 0.0 2.3 0.0 0.0 0.7 

Total N 2 1 3 5 4 3 2 20 

% 1 0.6 1.7 2.7 2.2 1.6 1.1 1.6 

Total N 12 7 10 8 16 18 8 79 

% 3.0 2.0 2.9 2.3 4.6 5.1 2.3 3.2 

Ever Used Marijuana 

Male 18-44 n 70 52 57 54 60 53 54 400 

% 64.8 53.1 69.5 64.3 70.6 60.9 67.5 64.1 

45-64 n 28 19 23 16 26 18 28 158 

% 48.3 37.3 40.4 29.6 48.1 33.3 50.9 41.3 

65+ n 2 0 0 4 1 5 4 16 

% 7.7 0.0 0.0 12.5 3.3 19.2 12.9 8.0 

Total N 101 71 80 74 87 77 86 576 

% 52.3 40.3 47.3 43.3 50.9 46.1 51.2 47.4 

Female 18-44 n 50 33 29 38 45 45 49 289 

% 46.3 40.2 34.9 46.9 57.0 50.6 61.3 48.0 

45-64 n 22 7 16 15 19 9 25 113 

% 36.1 13.2 28.6 27.3 33.3 16.4 44.6 28.8 

65+ n 1 1 1 2 5 0 2 12 

% 2.6 2.6 2.4 4.7 11.6 0.0 4.4 4.2 

Total N 73 41 47 55 68 54 76 414 

% 35.3 23.7 26 30.2 38 29.5 42 32.2 

Total N 174 112 127 129 155 131 163 991 

% 43.5 32.0 36.3 36.5 44.3 37.4 46.3 39.6 

Appendix 15 



Used Marijuana 

Region 

Past Year Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 16 10 8 14 18 28 18 112 

% 14.7 10.3 9.8 16.7 21.2 32.2 22.2 17.9 

45-64 n 6 1 4 1 3 4 3 22 

% 10.2 1.9 7.0 1.9 5.6 7.4 5.5 5.7 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 21 11 12 16 21 31 20 132 

% 10.9 6.3 7.1 9.4 12.3 18.6 11.9 10.9 

Female 18-44 n 9 6 4 6 11 9 10 55 

% 8.3 7.2 4.8 7.4 13.8 10.1 12.5 9.1 

45-64 n 2 0 0 2 2 0 2 8 

% 3.3 0.0 0.0 3.6 3.5 0.0 3.6 2.0 

65+ n 1 0 0 0 0 0 0 1 

% 2.6 0.0 0.0 0.0 0.0 0.0 0.0 0.3 

Total N 12 6 4 8 13 9 12 64 

% 5.8 3.5 2.2 4.4 7.3 4.9 6.6 5 

Total N 33 17 16 24 34 40 32 196 

% 8.3 4.9 4.6 6.8 9.7 11.4 9.1 7.8 

Used Marijuana Past Month 

Male 18-44 n 10 6 5 10 9 20 9 69 

% 9.3 6.2 6.1 11.9 10.6 23.0 11.1 11.1 

45-64 n 3 1 3 1 3 4 1 16 

% 5.2 1.9 5.3 1.9 5.6 7.4 1.8 4.17 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 

Total N 14 7 8 11 12 24 10 86 

% 7.3 4 4.7 6.4 7 14.3 5.9 7.1 

Female 18-44 n 4 4 1 2 8 7 5 31 

% 3.7 4.9 1.2 2.5 10.0 7.9 6.3 5.1 

45-64 n 2 0 0 1 1 0 1 5 

% 3.3 0.0 0.0 1.8 1.8 0.0 1.8 1.3 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 6 4 1 2 9 7 6 35 

% 2.9 2.3 0.6 1.1 5 3.8 3.3 2.7 

Total N 20 12 9 13 21 30 15 120 

% 5.0 3.4 2.6 3.7 6.0 8.6 4.3 4.8 

Appendix 15 



Region 

Ever Used Illicit Drugs Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 21 21 10 8 31 20 16 127 

% 19.4 21.4 12.2 9.5 36.5 23.0 19.8 20.3 

45-64 n 8 3 8 3 14 11 12 59 

% 13.6 5.8 14.0 5.6 25.9 20.4 21.8 15.3 

65+ n 0 0 0 0 0 0 1 1 

% 0.0 0.0 0.0 0.0 0.0 0.0 3.2 0.5 

Total N 29 24 18 11 45 31 29 187 

% 15 13.6 10.7 6.4 26.5 18.6 17.3 15.4 

Female 18-44 n 14 9 8 9 15 12 14 81 

% 13.1 10.8 9.6 11.3 19.0 13.5 17.5 13.5 

45-64 n 7 1 5 4 6 2 8 33 

% 11.5 1.9 8.8 7.3 10.7 3.6 14.0 8.4 

65+ n 0 0 1 0 2 0 0 3 

% 0.0 0.0 2.4 0.0 4.7 0.0 0.0 1.0 

Total N 22 9 13 13 23 14 22 116 

% 10.6 5.2 7.2 7.1 12.8 7.7 12.1 9 

Total N 51 33 32 24 69 45 52 306 

% 12.8 9.4 9.1 6.8 19.7 12.9 14.8 12.2 

Used Illicit Drugs-Past Year 

Male 18-44 n 7 4 2 2 4 2 5 26 

% 6.4 4.1 2.4 2.4 4.8 2.3 6.3 4.2 

45-64 n 1 0 0 0 0 1 0 2 

% 1.7 0.0 0.0 0.0 0.0 1.9 0.0 0.5 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 8 4 2 2 4 3 5 28 

% 4.1 2.3 1.2 1.2 2.4 1.8 3 2.3 

Female 18-44 n 2 2 0 2 2 1 2 11 

% 1.9 2.4 0.0 2.5 2.5 1.1 2.5 1.8 

45-64 n 1.0 0 0 0 0 0 0 1.0 

% 1.6 0.0 0.0 0.0 0.0 0.0 0.0 0.3 

65+ n 0 0 1 0 0 0 0 1 

% 0.0 0.0 2.4 0.0 0.0 0.0 0.0 0.3 

Total N 3 2 1 2 2 1 2 13 

% 1.4 1.2 0.5 1.1 1.1 0.5 1.1 1 

Total N 11 6 2 4 6 4 7 40 

% 2.8 1.7 0.6 1.1 1.7 1.1 2.0 1.6 

Appendix 15 



Used Illicit 

Region 

Drugs-Past Month Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 0 2 0 0 0 2 4 8 

% 0.0 2.1 0.0 0.0 0.0 2.3 4.9 1.3 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 2 0 0 0 2 4 8 

% 0.0 1.1 0.0 0.0 0.0 1.2 2.4 0.7 

Female 18-44 n 1 1 0 2 1 1 0 6 

% 0.9 1.2 0.0 2.5 1.3 1.1 0.0 1.0 

45-64 n 0 0 1 0 0 0 0 1 

% 0.0 0.0 2.4 0.0 0.0 0.0 0.0 0.3 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 1 1 2 1 1 0 7 

% 0.5 0.6 0.5 1.1 0.6 0.5 0.0 0.5 

Total N 1 3 1 2 1 3 4 15 

% 0.3 0.9 0.3 0.6 0.3 0.9 1.1 0.6 

Ever Used Prescription Pain Relievers 

Male 18-44 n 5 10 8 4 12 16 12 67 

% 4.6 10.3 9.8 4.8 14.1 18.4 15.0 10.8 

45-64 n 2 2 1 1 0 4 3 13 

% 3.4 3.8 1.8 1.9 0.0 7.4 5.5 3.4 

65+ n 0 0 0 0 1 1 0 2 

% 0.0 0.0 0.0 0.0 3.3 3.8 0.0 1.0 

Total N 7 13 9 5 13 21 15 83 

% 3.6 7.4 5.4 2.9 7.6 12.6 8.9 6.8 

Female 18-44 n 6 3 4 5 5 7 5 35 

% 5.6 3.6 4.8 6.2 6.3 7.9 6.3 5.8 

45-64 n 3 2 0 2 0 1 3 11 

% 4.8 3.8 0.0 3.6 0.0 1.8 5.3 2.8 

65+ n 0 0 1 0 0 0 1 2 

% 0.0 0.0 2.4 0.0 0.0 0.0 2.2 0.7 

Total N 8 5 5 7 5 7 9 46 

% 3.9 2.9 2.8 3.8 2.8 3.8 4.9 3.6 

Total N 16 18 14 12 18 28 24 130 

% 4.0 5.1 4.0 3.4 5.1 8.0 6.8 5.2 

Appendix 15 



Used Prescription 

Region 

Pain Relievers - Past Yr Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 4 4 2 4 3 6 7 30 

% 3.7 4.1 2.4 4.8 3.5 6.9 8.6 4.8 

45-64 n 1 0 0 0 0 1 0 2 

% 1.7 0.0 0.0 0.0 0.0 1.9 0.0 0.5 

65+ n 0 0 0 0 0 1 0 1 

% 0.0 0.0 0.0 0.0 0.0 3.8 0.0 0.5 

Total N 5 4 2 4 3 8 7 33 

% 2.6 2.3 1.2 2.3 1.8 4.8 4.1 2.7 

Female 18-44 n 1 1 1 2 1 3 1 10 

% 0.9 1.2 1.2 2.5 1.3 3.4 1.3 1.7 

45-64 n 1 1 0 0 0 1 1 4 

% 1.6 1.9 0.0 0.0 0.0 1.8 1.8 1.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 2 2 1 2 1 4 2 14 

% 1 1.2 0.6 1.1 0.6 2.2 1.1 1.1 

Total N 8 6 3 6 4 12 9 48 

% 2.0 1.7 0.9 1.7 1.1 3.4 2.6 1.9 

Used Prescription Pain Relievers - Past Mos. 

Male 18-44 n 1 2 0 2 0 4 5 14 

% 0.9 2.1 0.0 2.4 0.0 4.6 6.3 2.2 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 2 0 2 0 4 5 14 

% 0.5 1.1 0 1.2 0 2.4 3 1.2 

Female 18-44 n 0 0 1 1 0 2 0 4 

% 0.0 0.0 1.2 1.2 0.0 2.2 0.0 0.7 

45-64 n 1 1 0 0 0 0 0 2 

% 1.6 1.9 0.0 0.0 0.0 0.0 0.0 0.5 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 1 1 1 0 2 0 6 

% 0.5 0.5 0.5 0.5 0 1.1 0 0.5 

Total N 2 3 1 3 0 6 5 20 

% 0.5 0.9 0.3 0.8 0 1.7 1.4 0.8 

Appendix 15 



Region 

Used Cocaine-Ever Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 4 4 0 4 3 6 5 26 

% 3.7 4.1 0.0 4.8 3.5 6.9 6.3 4.2 

45-64 n 1 0 0 0 0 2 0 3 

% 1.7 0.0 0.0 0.0 0.0 3.7 0.0 0.8 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 5 4 0 4 3 8 5 29 

% 2.6 2.3 0 2.3 1.8 4.8 3 2.4 

Female 18-44 n 1 1 0 2 2 1 2 9 

% 0.9 1.2 0.0 2.5 2.5 1.1 2.5 1.5 

45-64 n 1 0 0 0 0 0 1 2 

% 1.6 0.0 0.0 0.0 0.0 0.0 1.8 0.5 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 2 1 0 2 2 1 3 11 

% 1.0 0.6 0.0 1.1 1.1 0.5 1.6 0.9 

Total N 8 5 0 6 5 9 8 41 

% 2.0 1.4 0.0 1.7 1.4 2.6 2.3 1.6 

Used Cocaine-Past Yr 

Male 18-44 n 1 4 0 2 3 2 2 14 

% 0.9 4.1 0.0 2.4 3.5 2.3 2.5 2.2 

45-64 n 1 0 0 0 0 1 0 2 

% 1.7 0.0 0.0 0.0 0.0 1.9 0.0 0.5 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 2 4 0 2 3 3 2 16 

% 1.0 2.3 0.0 1.2 1.8 1.8 1.2 1.3 

Female 18-44 n 0 1 0 0 1 1 0 3 

% 0.0 1.2 0.0 0.0 1.3 1.1 0.0 0.5 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 1 0 0 1 1 0 3 

% 0.0 0.6 0.0 0.0 0.6 0.5 0.0 0.2 

Total N 2 5 0 2 4 4 2 19 

% 0.5 1.4 0.0 0.6 1.1 1.1 0.6 0.8 

Appendix 15 



Region 

Used Heroin-Ever Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 0 2 0 0 0 2 0 4 

% 0.0 2.1 0.0 0.0 0.0 2.3 0.0 0.6 

45-64 n 1 0 0 0 0 0 0 1 

% 1.7 0.0 0.0 0.0 0.0 0.0 0.0 0.3 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 2 0 0 0 2 0 5 

% 0.5 1.1 0.0 0.0 0.0 1.2 0.0 0.4 

Female 18-44 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 

Total N 1 2 0 0 0 2 0 5 

% 0.3 0.6 0.0 0.0 0.0 0.6 0.0 0.2 

Used Heroin-Past Yr 

Male 18-44 n 0 0 0 0 0 2 0 2 

% 0.0 0.0 0.0 0.0 0.0 2.3 0.0 0.3 

45-64 n 1 0 0 0 0 0 0 1 

% 1.7 0.0 0.0 0.0 0.0 0.0 0.0 0.3 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 0 0 0 0 2 0 3 

% 0.5 0.0 0.0 0.0 0.0 1.2 0.0 0.2 

Female 18-44 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 

Total N 1 0 0 0 0 2 0 3 

% 0.3 0.0 0.0 0.0 0.0 0.6 0.0 0.1 

Appendix 15 



Region 

Used Ecstacy-Ever Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 3 0 0 0 1 2 2 8 

% 2.8 0.0 0.0 0.0 1.2 2.3 2.5 1.3 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 1 0 0 1 0 1 1 4 

% 1.2 0.0 0.0 1.2 0.0 1.2 1.2 0.7 

Total N 3 0 0 2 1 2 2 10 

% 1.6 0.0 0.0 1.2 0.6 1.2 1.2 0.8 

Female 18-44 n 1 0 0 1 0 0 1 3 

% 0.9 0.0 0.0 1.2 0.0 0.0 1.3 0.5 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 2 0 0 1 0 1 1 5 

% 1.0 0.0 0.0 0.5 0.0 0.5 0.5 0.4 

Total N 4 0 0 3 1 3 3 14 

% 1.0 0.0 0.0 0.8 0.3 0.9 0.9 0.6 

Used Ecstacy-Past Year 

Male 18-44 n 3 0 0 0 1 2 2 8 

% 2.8 0.0 0.0 0.0 1.2 2.3 2.5 1.3 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 3 0 0 0 1 2 2 8 

% 1.6 0.0 0.0 0.0 0.6 1.2 1.2 0.7 

Female 18-44 n 1 0 0 1 0 0 1 3 

% 1.2 0.0 0.0 1.2 0.0 0.0 1.2 0.5 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 0 0 1 0 0 1 3 

% 0.5 0.0 0.0 0.5 0.0 0.0 0.5 0.2 

Total N 4 0 0 1 1 2 3 11 

% 1.0 0.0 0.0 0.3 0.3 0.6 0.9 0.4 

Appendix 15 




Region 

Tranquilizers-Ever Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 1 4 2 4 1 2 7 21 

% 0.9 4.1 2.4 4.8 1.2 2.3 8.6 3.4 

45-64 n 1 0 0 0 0 1 0 2 

% 1.7 0.0 0.0 0.0 0.0 1.9 0.0 0.5 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 2 4 2 4 1 3 7 23 

% 1 2.3 1.2 2.3 0.6 1.8 4.1 1.9 

Female 18-44 n 0 0 0 3 0 0 1 4 

% 0.0 0.0 0.0 3.7 0.0 0.0 1.3 0.7 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 0 0 3 0 0 1 4 

% 0.0 0.0 0.0 1.6 0.0 0.0 0.5 0.3 

Total N 2 4 2 7 1 3 8 27 

% 0.5 1.1 0.6 2.0 0.3 0.9 2.3 1.1 

Used Prescription Tranquilizers-Past Year 

Male 18-44 n 1 2 2 2 0 0 4 11 

% 0.9 2.1 2.4 2.4 0.0 0.0 4.9 1.8 

45-64 n 1 0 0 0 0 0 0 1 

% 1.7 0.0 0.0 0.0 0.0 0.0 0.0 0.3 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 2 2 2 2 0 0 4 12 

% 1 1.1 1.2 1.2 0 0 2.4 1 

Female 18-44 n 0 0 0 3 0 0 1 4 

% 0.0 0.0 0.0 3.7 0.0 0.0 1.3 0.7 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 0 0 3 0 0 1 4 

% 0.0 0.0 0.0 1.6 0.0 0.0 0.5 0.3 

Total N 2 2 2 5 0 0 5 16 

% 0.5 0.6 0.6 1.4 0.0 0.0 1.4 0.6 

Appendix 15 




Region 

Amphetamines-Ever Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 1 2 2 0 1 0 4 10 

% 0.9 2.1 2.4 0.0 1.2 0.0 4.9 1.6 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 2 2 0 1 0 4 10 

% 0.5 1.1 1.2 0 0.6 0 2.4 0.8 

Female 18-44 n 1 1 0 0 1 1 0 4 

% 0.9 1.2 0.0 0.0 1.3 1.1 0.0 0.7 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 2 1 0 0 1 1 0 5 

% 1 0.6 0.0 0.0 0.6 0.6 0.0 0.4 

Total N 3 3 2 0 2 1 4 15 

% 0.8 0.9 0.6 0.0 0.6 0.3 1.1 0.6 

Used Prescription Amphetamines- Past Year 

Male 18-44 n 1 2 2 0 0 0 0 5 

% 0.9 2.1 2.4 0.0 0.0 0.0 0.0 0.8 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 2 2 0 0 0 0 5 

% 0.5 1.1 1.2 0.0 0.0 0.0 0.0 0.4 

Female 18-44 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 2 2 0 0 0 0 5 

% 0.3 0.6 0.6 0.0 0.0 0.0 0.0 0.2 

Appendix 15 



Used Injection 

Region 

Drugs-Ever Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Male 18-44 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

45-64 n 1 0 0 0 0 1 0 2 

% 1.7 0.0 0.0 0.0 0.0 1.9 0.0 0.5 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 0 0 0 0 1 0 2 

% 0.5 0.0 0.0 0.0 0.0 0.6 0.0 0.2 

Female 18-44 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

45-64 n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total N 1 0 0 0 0 1 0 2 

% 0.3 0.0 0.0 0.0 0.0 0.3 0.0 0.1 

Ease of Getting Marijuana 

Impossible n 15 10 5 5 5 12 14 66 

% 3.8 2.9 1.4 1.4 1.4 3.4 4.0 2.6 

Difficult n 71 45 56 28 45 50 51 346 

% 17.8 12.9 16.0 8.0 12.9 14.3 14.6 13.8 

Easy n 249 245 238 287 242 231 243 1735 

% 62.3 70.0 68.2 81.5 69.1 66.2 69.6 69.4 

Don’t Know n 65 50 50 32 58 56 41 352 

% 16.3 14.3 14.3 9.1 16.6 16.0 11.7 14.1 

Total N 400 350 349 352 350 349 349 2499 

% 100 100 100 100 100 100 100 100 

Appendix 15 



Region 

Ease of Getting Heroin Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Impossible n 59 73 49 33 22 51 47 334 

% 14.8 20.8 14.1 9.4 6.3 14.6 13.5 13.4 

Difficult n 144 129 138 106 122 145 131 915 

% 36.1 36.8 39.7 30.1 35.0 41.4 37.5 36.6 

Easy n 112 69 84 150 121 66 109 711 

% 28.1 19.7 24.1 42.6 34.7 18.9 31.2 28.5 

Don’t Know n 84 80 77 63 84 88 62 538 

% 21.1 22.8 22.1 17.9 24.1 25.1 17.8 21.5 

Total N 399 351 348 352 349 350 349 2498 

% 100 100 100 100 100 100 100 100 

Ease of Getting Prescription Pain Relievers 

Impossible n 45 45 39 25 23 46 47 270 

% 11.3 12.9 11.2 7.1 6.6 13.1 13.4 10.8 

Difficult n 158 141 159 66 139 147 140 950 

% 39.5 40.3 45.6 18.8 39.7 42.0 40.0 38.0 

Easy n 127 109 101 220 113 99 130 899 

% 31.8 31.1 28.9 62.5 32.3 28.3 37.1 35.9 

Don’t Know n 70 55 50 41 75 58 33 382 

% 17.5 15.7 14.3 11.6 21.4 16.6 9.4 15.3 

Total N 400 350 349 352 350 350 350 2501 

% 100 100 100 100 100 100 100 100 

Appendix 15 


Appendix 16 

Intimate Partner Violence from the 2001 EMH Household Survey by Age Group and Region 

Ever Victim of Intimate 

Region 

Partner Violence Bangor Aroostook Penquis Washington Hancock Central Knox-Waldo Total 

Female 18-44 n 32 13 21 24 22 28 23 163 

% 29.9 15.7 25.3 29.6 27.8 31.8 28.8 27.1 

45-64 n 15 7 11 9 11 11 16 80 

% 24.2 13.2 19.6 16.4 19.6 20.0 28.1 20.3 

65+ n 3 1 4 8 3 5 2 26 

% 7.9 2.7 9.8 18.6 7.0 12.8 4.4 9.1 

Total n 50 22 36 40 37 44 41 270 

% 24.2 12.6 19.9 22.0 20.6 24.0 22.5 20.9 

Victim of IPV-Past 5 Years 

Female 18-44 n 12 6 9 7 7 11 11 63 

% 11.2 7.1 10.7 8.6 8.9 12.4 13.8 10.4 

45-64 n 0 0 2 2 0 1 2 7 

% 0.0 0.0 3.6 3.6 0.0 1.8 3.5 1.8 

65+ n 0 0 0 0 0 0 0 0 

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 

Total n 12 6 11 9 7 12 13 70 

% 5.8 3.4 6.0 4.9 3.9 6.6 7.1 5.4 

Sought Medical Care for IPV n 2 2 2 3 0 1 3 13 

% 16.7 40.0 18.2 33.3 0.0 8.3 23.1 18.8 

Source of Medical Care 

Hospital emergency room n 1 2 1 2 0 1 2 9 

% 50.0 100.0 50.0 66.7 0.0 100.0 66.7 69.2 

Hospital walk-in clinic n 1 0 0 0 0 0 0 1 

% 50.0 0.0 0.0 0.0 0.0 0.0 0.0 7.7 

Community health center n 0 0 1 0 0 0 0 1 

% 0.0 0.0 50.0 0.0 0.0 0.0 0.0 7.7 

Private doctor's office n 0 0 0 1 0 0 1 2 

% 0.0 0.0 0.0 33.3 0.0 0.0 33.3 15.4 

Rcvd Counseling/Mental Health Servics n 2 1 2 3 0 1 3 12 

% 100.0 50.0 100.0 100.0 0.0 100.0 100.0 92.3 

Received Housing Information n 2 1 2 3 0 1 2 11 

% 100.0 50.0 100.0 100.0 0.0 100.0 66.7 84.6 

Received Legal Information n 2 1 2 2 0 1 3 11 

% 100.0 50.0 100.0 50.0 0.0 100.0 100.0 78.6 


PHRG

Health Planning Report for Northern, Eastern and Central Maine

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