Professional Documents
Culture Documents
Katherine Tison
Monroe County in Southern Florida encompasses some of the nation’s most beautiful
landscapes, ranging from the swamp flatlands of Everglades National Park to the barrier coral
reef of the Dry Tortugas. Monroe County, which includes the Florida Keys island chain and a
portion of the Everglades National Park, has a lot to offer to its residents. A darker side of
Monroe County reveals a “party” culture teeming with drug and alcohol-related health problems.
Alcoholism is a tremendous problem in this area of South Florida and may related problems
occur as well such as abuse of other substances, drug-OD deaths, and alcohol-related driving
deaths (County Health Rankings & Roadmaps [CHR&R], 2017). There are never-ending
entertainment possibilities in Monroe County, particularly in the Florida Keys, and this may
contribute the county’s high rate of substance-abuse related negative health outcomes. These
high rates could also be related to other factors, such as geography and high prevalence of
substance abuse. Thus, it is imperative for the health of the population in this community to
investigate the occurrences of these negative health outcomes and to identify appropriate health
to have a fundamental understanding of the components of this county, ranging from geographic
information to statistically relevant information. Only then can public health advocated navigate
Monroe County includes the southernmost point of the continental United States, located
in Key West. The county stretches up U.S. highway 1 and ends in portions of the Everglades
National Park and Big Cypress National Preserve (Monroe County Information and History
[MCI&H], n.d.). 73% of Monroe County is water, and the Florida Keys divide the Gulf of
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Mexico and the Atlantic Ocean (MCI&H, n.d.). US Highway 1 is the only road that connects
Miami to Key West, which ranges over 220 miles long (MCI&H, n.d.). In 2017, there were an
estimated 77,013 people living in the 3,737 square miles Monroe County has to offer (U.S.
Census Bureau [USCB], 2017). Of these people, 8.7% of these people live in areas designated at
“rural,” compared to the national average of 8.8% (County Health Rankings & Roadmaps
[CHR&R], 2017).
The Florida Keys host many major industries, the largest of which include food and
accommodation services (11,414 jobs), retail trade (5,576 jobs), and healthcare and social
assistance (2,464 jobs) (USCB, 2017). There are six hospitals in Monroe County (Monroe
County FL Hospitals [MCFLH], n.d.). Of these hospitals, two are part of the Lower Keys
Medical Center, one of which is Lower Keys Medical Center dePoo Building on Key West
(MCFLH, n.d.). Of the six total hospitals, three of them are located on Boca Chica Key, which is
approximately 6 miles north of Key West (MCFLH, n.d.). Fisherman’s Community Hospital is
located about halfway up the island chain on Marathon Key, and Mariner’s Hospital is in
Tavernier, which sits just south of Key Largo, the northernmost key (MCFLH, n.d.). Thus,
patients north of Key Largo may be closer to healthcare providers in alternative counties, such as
Miami-Dade or Collier counties. This may result in inappropriate use of county resources for
healthcare services.
Within Monroe County, a reported 18% of children live in poverty (CHR&R, 2017). This
ranks higher than the national average (12%), but lower than the state average (21%) (CHR&R,
families had a household income below poverty level for the last 12 months (CHR&R, 2017).
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This is better than the Florida state average, which reports that 11.1% of Florida families’ annual
income fell below the poverty level (USCB, 2017). Thus, Monroe County ranks higher than the
state average in both children living in poverty and yearly family income below the poverty level,
putting children in Monroe County at a great risk for adverse health outcomes related to living in
poverty.
According to the same survey, residents of Monroe county over the age of 25 were more
likely to possess a high school diploma than the average Floridian, but not by much. 91.2% of
Monroe County residents over the age of 25 have a high school diploma, while the state average
is 87.6% (USCB, 2017). Monroe County residents over the age of 5 were also less likely to “not
speak English very well,” meaning they are more likely to speak English well compared to the
average Floridian over age 5 (USCB, 2017). 5% of people over 5 years old in Monroe Country
do not “speak English very well,” whereas 11.8% of people over 5 years old in the state of
In Monroe County, the primary care provider to patient ratio is 1:1360 (CHR&R, 2017).
This is worse than the national ratio (1:1030), but better than the state ratio (1:1380) (CHR&R,
2017). However, Monroe County ranks poorly in percentage of uninsured residents, which is
20% compared to the national best of 6% and Florida average of 16% (CHR&R, 2017).
Screening tool use also ranks poorly, such as mammography screening, which is 58% compared
to 71% in the nation and 68% in the state (CHR&R, 2017). Each of these statistical discrepancies
is interesting given the primary care provider to patient ratio, which should theoretically include,
Identified Strengths
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Many of the positive health outcomes in Monroe County could possibly be attributed to
the environment. 100% of residents in Monroe County have access to exercise, compared to the
91% in the nation and 87% in the state (CHR&R, 2017). Consequently, adult obesity is lower in
Monroe County at 23%, while both the state and the country rank at 26%, likely related to the
high access to exercise (CHR&R, 2017). Finally, air pollution is low in Monroe County, likely as
a result of the marine access and ocean breezes bringing in clean air from the Gulf. Particulate
matter air pollution is a low 6.5, compared to the US at 6.7 and rest of Florida at 7.4 (CHR&R,
2017). This low score for particulate matter makes Monroe County one of the cleanest in terms
Identified Weaknesses
Monroe County ranks poorly on substance-abuse related issues. 26% of residents engage
in excessive drinking, which is double that of the nation and 8% higher than the state of Florida
killed in motor-vehicle crashes to those who were not impaired killed in motor-vehicle crashes, is
31% (CHR&R, 2017). This is 18% higher than the nation and 5% higher than the state (CHR&R,
2017). Additionally, drug overdose deaths are higher in Monroe County compared to both the
state and the country. Per 100,000 residents, 26 annually die by drug overdose (CHR&R, 2017).
The nation ranks at 10 fatalities per 100,000 residents, and the state ranks at 17 fatalities per
According to the Center for Disease Control, alcoholism can lead to many other health
problems such as injury, liver disease, cancer, and violence (Centers for Disease Control and
Prevention [CDC&P], n.d.) Alcohol is the most commonly used and misused substance in the US
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according to the Centers for Disease Control. Teenagers and young adults are particularly
with that developmental stage (CDC&P, n.d.). Additionally, some studies have shown that
populations with a high percentage of retirees may experience greater rates of alcoholism
(McClure et. al, 2013). Monroe County has a high rate of alcohol-related motor-vehicle crashes,
as well as high excessive drinking and drug overdoses. Each of these exemplifies a broader
community health problem with substance abuse, addiction, and alcoholism (CDC&P, n.d.).
Alcoholism is a priority health issue because it has very serious acute incident effects, such as
motor-vehicle crash deaths, as well as long-term chronic condition, including liver failure, cancer,
environment has on his or her health well-being. The Social Determinants of Health Model
explains that economic stability, education, social and community context, health and healthcare,
and neighborhood and built environment each interact and influence individuals’ overall health
developing interventions that address them help to increase the overall health of communities
and populations. In Monroe County, it is particularly important to consider the social and
community context and neighborhood and built environment when establishing ways to address
alcoholism.
Population Diagnosis
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Residents of Monroe County are at risk for development alcoholism or other substance
abuse disorders due to the notorious “party” culture (social and community context) and high
level of access to drugs and alcohol (neighborhood and built environment) in the Florida Keys.
Community/Population-based Interventions
There are various ways to approach the problems of substance abuse and alcoholism in
Monroe County, each of which is illustrated by the Intervention Wheel Model and the Levels of
Prevention Model (Minnesota Department of Health, 2001). These models include components
expanded upon below specific to potential public health alcoholism and substance abuse efforts
in Monroe County, such as screening and social marketing (Minnesota Department of Health,
2001).
addressing public health concerns. In the case of alcoholism in Monroe County, it is important to
consider general education done to prevent substance abuse and dependence. Education on
alcohol and drug use through the public-school system is one avenue to reaching people before
they become patients subject to adverse health outcomes relating to alcoholism (Center for
Disease Control, n.d.). One study found that web and text-message based education through the
school system was an efficient and cost-effective way to educate adolescents on alcohol and drug
use and abuse (Haug, Paz Castro, Kowatsch, Filler, Dey, & Schaub, 2017). This study
demonstrated that many students were willing to participate, and it was easy and inexpensive to
implement for large groups of people (Haug et. al, 2017). Legislators and public officials must be
involved in the implementation of this practice into government-controlled public schools, and
teachers and family members will likely need to encourage student involvement in this
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intervention. Community health nurses may need to be consulted regarding the information and
delivery of information and may also be required to follow-up with any results obtained after this
intervention.
Secondary prevention in public health aims to intervene in public health concerns and
prevent disease from progressing, including screening. The culture of the Florida Keys is heavily
influenced by tourism, and many adolescents who reside in this region are faced with substances
daily. One study shows that by introducing conversations about alcohol and drugs to adolescents
in a primary care setting, providers can impact the way that teens view alcohol and drugs,
hopefully after they have been exposed and before they begin using regularly (D’Amico, Parast,
Shadel, Meredith, Seelam, & Stein, 2018). These brief conversations between adolescents and
their health care providers can change the way adolescents view alcohol and marijuana use and
the consequences of their use (D’Amico et. al, 2018). In Monroe County, early intervention in
pediatric offices could be helpful in preventing young people from substance use and abuse at an
early age, particularly if their parents are substance abusers (D’Amico et. al, 2018). These
conversations must be cleared through the legislators and public officials in order to be practiced
by primary care providers. Funding must be allocated to develop screening techniques for at-risk
teens. A brief interview between a provider and patient should not take significant time or
resources, thus decreasing the barriers to practicing these screening techniques sooner rather than
later. Community health nurses can assist in the development of these screening tools, as well as
effort to decrease the effect the disease has on a patient’s daily life and to increase a patient’s
interventions, however, are only effective when patient screened positive for alcohol abuse agree
to participate (Blonigen, Harris-Olenak, Haber, Kuhn, Timko, Humphreys, & Dulin, 2018). One
study demonstrated a mobile application, Step-Away, that demonstrated positive results in the
veteran population (Blonigen et. al, 2018). Blonigen et. al (2018) developed a mobile application
through which veterans struggling with alcoholism or other forms of substance abuse could text
or call a trained support-person (Blonigen et. al, 2018). This has proven to be effective for
patients who have already screened positive for “hazardous” substance activity through
secondary prevention and aims to decrease the effect these substances have on the health and
well-being of the veterans who participate (Blonigen et. al, 2018). Further research must be done
to measure the effectiveness of this intervention in population other than veterans, and this is one
potential area for public health nurses to research. Because of the extensive training required by
the professionals in the above study, there are more expenses associated with this intervention
than the former two, and thus would require greater stakeholder support and funding (Blonigen
adolescents by primary care providers should be implemented. The high ratio of primary care
providers to patients makes this a more viable intervention than it would be in other areas of
the state. D’Amico et. Al (2018) demonstrated that this screening process in pediatric
ALCOHOL-RELATED MVC DEATHS IN MONROE COUNTY 10
primary care offices could essentially address the problem before it ever becomes a problem.
This intervention would be implemented early in an effort to decrease substance abuse within
the adolescent population and thus decrease the likelihood of substance abuse by this cohort
as adults.
As listed above, a relatively high percentage of children in Monroe County live below
the poverty line. Addressing this vulnerable population (both due to the age/dependence of
members of this population and the higher vulnerability due to poverty) should increase the
health outcomes for substance-abuse related health concerns within the county as a whole.
Particularly because the patient population is adolescents, securing support for a relatively
inexpensive way to prevent adolescent and young adult deaths should theoretically present
fewer challenges than alternative public health projects that are more publicly and politically
controversial.
including motor-vehicle crashes, and drug overdoses by 50% by 2040. A long time period is
necessary to confirm that adolescents who experience this intervention in pediatric offices
continue these practices as they age. Before this intervention can be implemented, research
must be done to test the efficacy in vulnerable pediatric populations. A bottom-up approach
to policy change could be used by starting with individual practitioner offices. Screening
tools must be developed and finalized prior to implementation at a county, state, or federal
level, and thus trials must be conducted on an individual office basis. These tools may be
developed by nurses, health educators, doctors, and others who can provide clinical insight
must be willing to allow their children to participate, and thus must be educated on why this
intervention is being implemented. This involves a team of public health or nursing educators
to host sessions in which the community members can learn about why this intervention
would be beneficial. Public officials and legislators, such as Craig Cates, mayor of Key West,
should also be involved—particularly once the providers’ offices have conducted the
screening tool independently. Providers must be in agreement about this intervention as well,
and it may be helpful to start with one pediatric provider in each of the six major hospitals in
Monroe County. Thankfully, funding should be comparatively low, and Monroe County may
be able to partner with the University of Miami Miller School Of Medicine, Department of
Health Sciences (University of Miami, n.d.). Aside from companies who produce alcohol, it
is unlikely that this intervention would warrant oppositional push-back, since it is arguably
not in anyone’s interest for pediatric patients to overdose or be killed in car accidents due to
substance-abuse.
Conclusion
culture and nightlife. However, residents encounter issues related to substance misuse. High rates
of alcohol-related motor-vehicle crash deaths, excessive drinking, and drug overdose deaths
illuminate this priority health concern. Despite the many strengths of Monroe County, action
steps must be taken to address alcoholism in the southernmost county of the US. Thus, it is
important for public health officials to consider implementing several levels of intervention. This
could include but is not limited to education, screening tools, and support services. As nurses, we
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must work together with stakeholders to promote health and well-being of our patients and
References
Blonigen, D., Harris-Olenak, B., Haber, J., Kuhn, E., Timko, C., Humphreys, K., & Dulin, P.
http://doi-org.ezproxy.lib.usf.edu/10.1037/ser0000300
Center for Disease Control, Alcohol and Public Health Home Page: Alcohol. (n.d.). Retrieved
from https://www.cdc.gov/alcohol/index.htm
Centers for Disease Control and Prevention. Motor vehicle safety: Impaired driving. (n.d.)
County Health Rankings & Roadmaps. (2017). Monroe County Demographics. Retrieved
from
http://www.countyhealthrankings.org/app/florida/2017/rankings/monroe/county/factors/
overall/snapshot
D’Amico, E., Parast, L., Shadel, W., Meredith, L., Seelam, R., & Stein, B. (2018). Brief
adolescents in primary care. Journal of Consulting and Clinical Psychology, 86(9), 775-
786. http://doi-org.exproxy.lib.usf.edu/10.1037/ccpp0000332
Haug, S., Paz Castro, R., Kowatsch, T., Filler, A., Dey, M., & Schaub, M. (2017). Efficacy of a
McClure, L., Fernandez, C., Clarke, T., LeBlanc, W., Arheart, K., Fleming, L., Lee., D. (2013).
Risking drinking in the older population: A comparison of Florida to the rest of the US.
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org.exproxy.lib.usf.edu/10.1016/j.addbeh.2012.12.020
Section. [2001]. Public health interventions: Applications for public health nursing
http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
https://florida.hometownlocator.com/features/cultural,class,hospital,scfips,12087.cfm
fl.gov/613/Monroe-County-Information-History
U.S. Census Bureau (2017). 2013-2017 American Community Service 5-year Estimates.
Retrieved from
https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk