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Running head: ALCOHOL-RELATED MVC DEATHS IN MONROE COUNTY 1

The Florida Keys: Alcohol-related MVC Deaths in Monroe County

Katherine Tison

University of South Florida, College of Nursing


ALCOHOL-RELATED MVC DEATHS IN MONROE COUNTY 2

The Florida Keys: Alcohol-related MVC Deaths in Monroe County

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

interventions to mediate the problem of substance abuse, particularly alcoholism. It is necessary

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

how to best serve this community.

Overview of Monroe County

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.

Comparison of Local vs. State Populations

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,

2017). According to the 2013-2017 American Community Survey 5-year Estimates, 8% of

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

Florida do not “speak English very well” (USCB, 2017).

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,

encourage, and implement more screening tools than other specialties.

Analysis and Interpretation of Data

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

of air quality in the United States.

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

(CHR&R, 2017). Alcohol-impaired driving deaths, which compares alcohol-impaired drivers

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

100,000 residents (CHR&R, 2017).

Identification of a Priority Health Issue

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

susceptible to over-consumption of alcohol due to the “normal” risk-taking behavior associated

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,

and other illnesses (CDC&P, n.d.).

Discussion and Application of Community Health Models

Community health models are necessary to understanding the impact a person’s

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

outcomes (Social Determinants of Health, n.d.). Understanding these components and

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).

Primary Level of Prevention

Primary prevention in public health focuses on a system-wide approach to

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 Level of Prevention

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

facilitating these conversations with teens.

Tertiary Level of Prevention


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Tertiary prevention aims to facilitate management of already diagnosed illnesses in an

effort to decrease the effect the disease has on a patient’s daily life and to increase a patient’s

functionality. In alcoholism, examples of tertiary prevention include support groups such as

Alcoholics Anonymous or treatment programs such as rehabilitation facilities. These

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

et. al, 2018).

Development of Health Policy

Of the options above, the secondary intervention in the form of screening of

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
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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.

This intervention would aim to decrease the rates of alcohol-related injuries,

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

into this tool’s development.


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Many stakeholders will be influenced by this policy change. Community members

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

Monroe County in South Florida is an environmentally diverse area with exciting

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

communities, which requires us to become involved in local and national politics.


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References

Blonigen, D., Harris-Olenak, B., Haber, J., Kuhn, E., Timko, C., Humphreys, K., & Dulin, P.

(2018). Customizing a clinical app to reduce hazardous drinking among veterans in

primary care. Psychological Services. Retrieved from

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.)

Retrieved from https://www.cdc.gov/motorvehiclesafety/impaired_driving/

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

motivational interviewing intervention to reduce alcohol and marijuana use of at-risk

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

web- and text messaging-based intervention to reduce problem drinking in adolescents:

Results of a cluster-randomized controlled trial. Journal of Consulting and Clinical

Psychology, 85(2), 147-159. https://doi-org.ezproxy.lib.usf.edu/10.1037/ccpp0000138

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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Addictive Behaviors, 38(4), 1894-1897. http://doi-

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Minnesota Department of Health, Division of Community Health Services, Public Health

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practice. Social Determinants of Health. Retrieved from

http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Monroe County FL Hospitals. (n.d.). Retrieved from

https://florida.hometownlocator.com/features/cultural,class,hospital,scfips,12087.cfm

Monroe County Information and History. (n.d.). Retrieved from https://www.monroecounty-

fl.gov/613/Monroe-County-Information-History

University of Miami. (n.d.). Retrieved from https://www.publichealth.med.miami.edu/

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

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