Known as the “Peach State”, Georgia is a diverse state with a growing population, robust political landscape, and slow growing health care environment. The distinct health care environments in rural Georgia and the urban metropolitan area are a unique challenge for the Title V MCH Program. The growing population amplifies challenges that arise from the political landscape, health care environment, economy and/or sociocultural context.

 

Geographic Description
Georgia is located on the southeastern Atlantic coast of the United States. It is bordered on the south by Florida; on the east by the Atlantic Ocean and South Carolina; on the west by Alabama; and on the north by Tennessee and North Carolina. The highest point in Georgia is 4,784 feet; the lowest point is sea level. Georgia is ranked 24th in terms of land size and is the largest state geographically east of the Mississippi River.

 

Urban and Rural Counties
Of Georgia’s 159 counties, there are both urban and rural located throughout the state. The Census Bureau defines two types of urban areas: urbanized areas of 50,000 people or more, and urban clusters between 2,500 people and 50,000 people. All other counties are considered rural. Of the 159 counties in Georgia, 124 are designated as rural by the Georgia Rural Development Council. There are 20 smaller cities and urban areas with populations above 50,000. The majority of the state’s rural counties are located in the southern half of the state. 

 

According to the 2010 census, the most recent census available, there are 15 Metropolitan Statistical Areas in Georgia: Albany, Athens-Clarke County, Atlanta-Sandy Springs-Roswell, Augusta-Richmond County (GA-SC), Brunswick, Chattanooga (TN-GA), Columbus (GA-AL), Dalton, Gainesville, Hinesville, Macon, Rome, Savannah, Valdosta and Warner-Robins. 4

 

The largely rural makeup of the state provides many challenges, and opportunities, to offering adequate health and social services to all Georgia residents.

 

Due to the large number of counties being designated as rural, access to health care services is challenging, and as such it is essential for DPH to accommodate the needs of the rural population. DPH provides an alternative approach in meeting the needs of Georgia’s rural citizens through innovative strategies such as telehealth services that increase access to health care providers and services. The following map generated by the US Census Bureau based on population data for 2010 depicts the urbanized and non-urbanized areas in Georgia.

 

Figure 1: Urbanized areas in Georgia

 

 

Population
Since 2000, Georgia’s population has increased 25 percent, moving it from the 10th to 8th most populated state in the nation in 2018. The 10.5 million persons (2018 U.S. Census, estimate) account for 3.2 percent of the U.S. population. This growth has resulted in a fundamental shift in Georgia’s population changing the state from a largely rural area with urban centers to an urban state with rural areas. Rural Georgians have health experiences that contrast their urban counterparts including, travelling longer distances to seek medical care and higher rates of chronic health conditions.18 It is ranked the 8th largest state with respect to population, based on 2015 estimates.17 Georgia is the 14th fastest growing state in the nation, with a 8.6 percent increase from 2010 to 2018,17 and is the 7th highest among states with the largest numeric population increase.17 It is estimated that Georgia’s population will increase to 11.3 million by 2020.10 As with any population growth, there are increasing demands on state and local governments to provide necessary services, including health and social services.

 

Atlanta, the state capitol, is the economic, cultural and demographic center of Georgia. It is the largest city in the state, with approximately 498,000 people living in the city in 2018.44 Atlanta is the ninth largest metro area in the nation with a 2016 population estimate for the Atlanta Metropolitan Statistical Area of 5,789,700. The population grew an estimation of 12.4 percent from 2010 to 2016, and is expected to continue to do so. Approximately 5.9 percent of residents are under five, 18.7 percent are under age 18 and 10.8 percent are over age 65. Atlanta is home to one of the highest LGBT populations per capita, which is 19th among major US metropolitan areas. An estimated 4.2 percent of Atlanta’s metro population is gay, lesbian, or bisexual.44

 

Georgia has shown dramatic increases in minority groups, which account for approximately 47 percent of the overall state’s population. This trend in the demographic shift is expected to be sustained in the coming years and Georgia is projected to become a majority-minority state by 2030. Currently, Black or African American is approximately one-third of the state’s overall population and the largest minority group; this is approximately 2.5 times higher than the national average of 13 percent. Hispanic or Latino is the most rapidly growing minority group, comprising almost 10 percent of all Georgians. Persons of Asian descent are an additional four percent of the state’s population. Georgia is also the 5th poorest state in the U.S. and approximately 15 percent of Georgians live in poverty; this factor disproportionately

 

In 2017, 321,652 (15 percent) women of reproductive ages (15-44 years old) lived in one of the 108 rural counties. Of which, 35 percent of these women of reproductive ages belong to a minority group. In 2017, over 2 million children (ages up to 17 years old) lived in a non-rural county; while 395,327 children lived in a rural county.

 

Race/Ethnicity
The racial distribution has shifted slightly from 2000 to 2010, although the majority of Georgians are still White or Black. The  percentage of Georgians who are White decreased from 65.1 percent in 2000 to 59.7 percent in 2010. However, an increase was seen in the  percentage who are Black. In 2010, 30.5 percent of Georgians were Black. The number of Hispanics in Georgia doubled between 2000 and 2010. The number of Asians nearly doubled, with the highest increases seen among Asian Indian, Korean and Vietnamese populations. Such a growth in diversity and population necessitates the availability of culturally-competent health care, education and human services.

 

Table 1. Georgia’s Population by Race/Ethnicity, 2000 and 2010

Georgia Population Estimates
	2000 Census		2010 Census
Population Characteristic	Number	percent	Number	percent
Total Population	8,186,453	----------	9,687,653	----------
Race/Ethnicity
White	5,327,281	65.1	5,787,440	59.7
Black or African American	2,349,542	28.7	2,950,435	30.5
American Indian and Alaska Native	21,737	0.3	32,151	0.3
Asian	173,170	2.1	314,467	3.2
Native Hawaiian and Other Pacific Islander	4,246	0.1	6,799	0.1
Some other race	196,289	2.8	388,872	4.0
Two or more races	114,188	1.4	207,489	2.1
Hispanic or Latino (of any race)	435,227	5.3	853,689	8.8

 

Age and Gender
Georgia’s population is younger compared to the U.S. as a whole, with the 8th largest percent of population under 18 years old. The median age in Georgia is 36.2 years of age, with a gender difference of 51.3 percent females and 48.7 percent males across the state. There are approximately 2.1 million Georgian women of reproductive ages (15-44 years old). Annually, there are about 130,000 live births in Georgia. Of the 129,158 live births in 2017, 40 percent were born to minorities.

 

Immigration
Georgia’s population is continually evolving with the immigration of foreign-born individuals that add to the racially and ethnically diverse population of Georgia. In 2017, it was estimated that 10.2 percent of the total population in Georgia are foreign-born. However, there has been an increase in naturalized citizens from 33.8 percent in 2010 to 43.6 percent in 2017.19 In 2017, 22.3 percent of children under the age of 18 are foreign-born or reside with at least one foreign-born parent.20 In 2011-2016, an estimated 90 percent of children in immigrant families are U.S. citizens.20

 

As of 2017, 40.1 percent of foreign-born residents identify as White, 17.1 percent identify as Black or African American and 27.4 percent as Asian.19 Of all racial categories 38.4 percent identify as Hispanic or of Latin origin.19 Forty-six  percent of foreign-born residents are between ages 25 and 44.19 In 2017, 23.2 percent of foreign born residents had a high school diploma or GED with 16.9 percent attaining some college or their associate’s degree.19 In 2017, 38.2 percent of foreign-born residents fell below 200  percent of the poverty level and 31.3 percent had no health insurance coverage.19

 

Language Proficiency
Over 13 percent of Georgia residents speak a language other than English.19 Of the other languages spoken, Spanish is the most commonly spoken language at approximately 8 percent. Both other Indo-European languages, Asian and Pacific Island languages, account for approximately 2.5 percent, and the remaining 1 percent of residents speaks another language. Of those that speak a language other than English, 43 percent speak English less than very well.19 These factors can have implications on the services offered to residents and may necessitate investment in interpretation and culturally competent approaches to health care delivery.

 

Family Household Type  
Household structures in Georgia are very similar to what is seen across the rest of the United States. In 2010, 47.8 percent of Georgia households were composed of a husband and wife, with 21.1 percent of these households having children under the age of 18. Female headed households comprised of 15.8 percent of the population and 8.9 percent of these households contained children under the age of 18; 4.9 percent were male family households with 2.2 percent having children under the age of 18. Finally, 25.4 percent of households were one-person households, with 7.5 percent being 65 or older. The average household size was 2.6 and the average family size was 3.2. 16

 

Educational Attainment
Public schools are the primary source of education in Georgia. In 2017, 64.6 percent of children attended a public nursery school and/or preschool while 35.4  percent attended a private nursery school and/or preschool. In 2017, 90.5 percent of students in Kindergarten to 12th grade were in public school and 9.5 percent were in private school.19

 

In the 2014 cohort, the high school graduation rate was 72.6 among all students. It was 36.5 for students with a disability, 79.7 among Whites, 64.0 among Hispanics and 65.3 among Blacks.8 In 2018, Georgia’s graduation rate rose to an all-time high of 81.6 percent from 80.6 percent in 2017. This is an all-time high for Georgia’s graduation rate since the state began using the adjusted cohort calculation now required by federal law. Seventy-four Georgia school districts recorded 2018 graduation rates at or above 90 percent. Georgia has some of the highest requirements in the nation for students to graduate with a regular diploma.44

 

Between 2012 and 2016, more than 85 percent of Georgia residents over the age of 25 have a high school diploma, and 29.4 percent have a bachelor’s degree or higher. The residents of Atlanta have slightly higher graduation rates. In Atlanta, 89.5 percent of people over the age of 25 are high school graduates and over 48 percent have a bachelor’s degree or higher.18

 

Income
Georgia’s per capita income was below the national average from 2012 to 2016 with a per capita income of $26,678 relative to the U.S. average of $29,829; at the same time, the state’s poverty level was above the national average.18 While median Georgia household incomes ($51,037 in 2016) have not recovered to 2008 levels ($55,027), the trend appears to be reversing with the largest increase from 2013 to 2014 ($1,513).19 

 

Table 2. Median Household Income in Georgia and the US, 2008-2016

Year	Georgia	United States
2017	$52,977	$57,652
2016	$51,037	$55,322
2015	$49,620	$53,889
2014	$49,342	$53,482
2013	$47,829	$52,250
2012	$47,895	$52,117
2011	$47,650	$52,306
2010	$49,605	$53,469
2009	$51,684	$54,541
2008	$55,027	$56,290

 

Poverty
Poverty is more prevalent in Georgia than in many states across the nation. In 2016, 17.8 percent of Georgians were living below the poverty line, compared with 15.1 percent for the U.S. overall. Over eight percent were below 50 percent of the federal poverty level (FPL) and 22.9 percent were living at less than 125 percent of the FPL. About 1 in 4 children in Georgia under the age of 18 are in poverty as of 2013 an increase from 2009 where 1 in 5 children under the age of 18 were in poverty. Poverty disproportionately affects race and ethnicity in Georgia. The poverty status of Georgians living below the FPL based on race and ethnicity in 2016 was 13.1 percent of White, 25.8 percent of African-Americans, 28.0 percent of American Indian and Alaska Native, 13.2 percent of Asians, 27.1 percent of Native Hawaiian and Other Pacific Island, and 28.7 percent of Hispanics.19 Poverty is rampant in the city of Atlanta, with approximately 1 in 4 Atlanta residents living below the federal poverty line as of 2011-2016, compared to 16 percent of the overall Georgia population.18 

 

Health Equity and Social Determinates of Health (SDoH) Disparities

According to the 2018 KIDS COUNT Data Book, Georgia ranked 39th in overall child well-being, 37th in economic well-being, 39th in health, 40th in family and community, and 34th in education. The annual KIDS Count Data Book uses 16 indicators to rank each state across four domains – health, education, economic well-being and family and community – that represent what children need the most to thrive. Though Georgia’s children and families still face many challenges, there are some promising trends for the state. Georgia has seen a two percent improvement in the  percentage of children living in poverty over the past eight years, 23 percent from 25 percent. The rate of fourth graders not proficient in reading has improved six percent since 2010 to 65 percent and teen births have decreased from 41 percent in 2010 to 24 percent in 2018. Georgia saw four percent improvement in children without health insurance from 10 percent to 6 percent. Unfortunately, Georgia saw a two percent rise in children living in high poverty areas, from 14 percent to 16 percent over an eight-year period.46

 

When looking at outcomes such as maternal mortality, infant mortality, low birth weight, and preterm birth we see consistent trends based on race/ethnicity. Georgia’s maternal mortality rate illustrates that Black, non-Hispanic women are three times more likely to die of pregnancy-related complications than White, non-Hispanic women. In 2017, racial disparities were also seen in infant mortality rates with a 6.8 percent increase in Black, non-Hispanic infant deaths under one year of age and White, non-Hispanic infant deaths under one year of age. The rate for Black, non-Hispanic low birth weight infants is 14.3 percent compared to the 7.3 percent for low birth weight White, non-Hispanic infants. Preterm births occurred in 2017 at a rate of 14.1 percent in Black, non-Hispanic women compared to 9.9 percent in White, non-Hispanic women.

 

Economy

A major component which is vital to Georgia’s economy is the transportation system including the interstate highway system, Hartsfield-Jackson Atlanta International Airport, and the deep-water ports of Savannah and Brunswick.

 

Georgia has over 1200 miles of interstate highways which connect Georgia to neighboring states and the rest of the nation, and help move workers from their homes to places of employment in the major cities. Three of the interstate highways converge in Atlanta, making it, along with Hartsfield-Jackson Atlanta International Airport, the transportation hub of the southeast. Atlanta is one of only five cities in the nation to be served by three separate interstate highways. The construction of these interstate highways was instrumental in the booming growth of Atlanta in the latter part of the 20th century. The highways helped attract business, industry, and more transportation facilities to the Atlanta area.39 These advantages have led to many global headquarters establishing headquarters in Atlanta including 16 Fortune 500 companies, 26 Fortune 1000 businesses and more than 450 Fortune 500 companies having a presence in the state.42

 

Georgia economic products can now reach approximately 80 percent of Americans overnight using the interstate highway system, while products coming into Georgia can reach Georgians in every part of the state just as quickly.

 

Two of the interstate highways- I-85 and I-285 - are near Hartsfield-Jackson Atlanta International Airport. Hartfield-Jackson is one of the busiest airports in the nation. Business travelers and those visiting Georgia add enormous impact to Georgia’s economy. Hartfield-Jackson also hosts the only Perishables Complex in the southeast- allowing for rapid movement of agricultural products. In addition, Hartsfield-Jackson is home to the Georgia Foreign Trade Zone, where Georgia companies can produce products at reduced cost, facilitating trade and increasing the overall competitiveness of companies doing business in Georgia. Combining all aspects of Hartfield-Jackson’s effect on the regional economy of Atlanta, Georgia, and the southeast, it generates $23.5 billion on an annual basis. The deep-water seaports of Savannah and Brunswick are integral to Georgia’s economy as they allow products to be sent via ship to all parts of the world, while allowing foreign products to come into Georgia. The port of Savannah handles approximately 80 percent of the material entering Georgia via ship, and is one of the fastest growing ports in the nation. 39

 

The film and television industry is another major industry adding to Georgia’s economy. Georgia offers lucrative tax incentives for television and movies making the state a popular site for filming and production stimulating further growth. A little more than a decade ago, the state passed a tax credit that allowed productions to collect a credit of up to 30 percent of its budget, enabling studios to save money or increase their budgets. Producers also prefer the state’s generally lower prices compared with California or New York, as well as the geographic diversity with cities such as Atlanta and many rural locations which offer a variety of settings. Total film and television spending in Georgia hit a record of $2.7 billion in the fiscal year that ended in July 2017, up about one-third over the prior year, and about a tenfold increase from 2008, according to figures from the state Department of Economic Development.40 Film and television production in Georgia supports more than 92,000 jobs and brings significant economic benefits to communities and families. Georgia had 455 qualified television and film production in 2018.48

 

Georgia has a rich, varied, and ongoing tradition of producing quality sports teams that enhance the economy. Atlanta is home to six professional sports franchises- the Braves (Major League Baseball), Hawks (National Basketball Association), Falcons (National Football League), Dream (Women’s National Basketball Association), Atlanta United (Major League Soccer) and the recently added Big Peach (Major League Rugby).47 Atlanta was home to NFL Superbowl LIII with more than 500,000 attending and more than 150,000 out-of-state visitors.47 In addition to Atlanta’s major league sports teams, minor league franchises are hosted by several Georgia cities. Augusta, Georgia is home to the Masters, professional golf’s most famous and prestigious event. Atlanta Motor Speedway hosts one of NASCAR’s biggest races each Labor Day weekend. Sports provide an economic boost for the city and remain a key revenue-generator within the tourism industry.41

 

Employment
As of March 2019, Georgia’s unemployment rate is 3.9 percent ranking it 31st in the United States. The rate has decreased from 4.3 percent in 2018. The lowest unemployment rate is 2.0 percent in Hawaii. High unemployment rates may have serious implications on the burden of public health and the available resources for public and social services.2

 

Homelessness
The homelessness rate in Georgia decreased 25 percent from the year 2015 to 2017. The number of unsheltered homeless individuals continues to decline in Georgia with 36 percent of the state’s overall homeless population being unsheltered. In 2015, 5,803 individuals were unsheltered and 7,987 were in transitional or emergency housing, compared to 3,692 unsheltered and 6,681 in transitional or emergency housing in 2017.7 Of the homeless population, approximately 7 percent are veterans and 10 percent are considered chronically homeless.7

 

Insurance Status
Six percent of Georgia’s children are uninsured, making it the state with the 9th highest rate of uninsured children. The most recent data available show that among Georgians between 19 to 64, 19 percent are uninsured, ranking it the fourth highest in the nation.11 Those that identify as Black and White have the highest percentage of being uninsured, 40 percent and 34 percent, respectively. Twenty-one percent of Hispanics are uninsured.11 This is yet another disparity that further contributes to the delay in seeking health care, increased visits to the emergency room and poor health outcomes.

 

Health Reform
The Affordable Care Act, signed in 2010, went into effect in 2014. It is a state decision to participate in the Medicaid expansion or not, and as of 2019 Georgia will not expand. More than 460,000 people enrolled in plans for 2019 during open enrollment, a drop of more than 20,000 from 2018.3 Four insurers offer coverage in 2019 through Healthcare.gov. Average rate increases for plans in Georgia’s individual market are less than four percent for 2019.3 DPH will continue to adapt to the changing health care landscape to promote the health of women and children.

 

Emerging Issues
Georgia is one of the largest and fastest growing states in the nation, yet residents experience more poverty and unemployment than what is seen nationally. Although economists anticipated that Georgia’s economy would catch up with the nation’s recovery by mid-year 2011,1 this was not the case. Economic recovery in Georgia yielded an increase in state revenue for the 2016 budget and 2017 budget. 

 

The 2019 fiscal year budget proposal laid out Georgia’s spending priorities for the coming year. It represented a $1.03 billion increase in total state spending over the 2018 budget approved last year. The budget is based on a very lean estimated growth rate of 3.7 percent in general funds over the current budget year. Before and after the recession that started in 2007, Georgia experienced higher rates of revenue growth. Annual revenue growth averaged 6.3 percent from 2011 to 2017 and 8.4 percent from 2004 to 2007.

 

The proposed 2019 budget includes some worthwhile investments, including $23 million to implement health and foster care recommendations from the governor’s Commission on Children’s Mental Health and $1.5 million for a new Principal Leadership Academy. At the same time, much of the new spending simply covers the costs associated with naturally rising needs and expenses. About 87 percent of the new money in the 2019 budget pays for growing enrollment in Georgia’s public schools and universities, increased need in Medicaid or the Teacher Retirement System.5

 

Nearly three-fourths of childhood deaths are due to unintentional injuries, most related to car accidents. Recent efforts have been made to improve awareness of car seat safety. Georgia supports the American Academy of Pediatrics (AAP) recommendation to have children remain in rear facing car seats up to two years of age and requires use of a booster seat for children until 8 years old or 57 inches. While this is making a positive impact on the lives of younger children in Georgia, more work needs to be done to protect the lives of preteens and teens traveling in cars in Georgia.

 

Title V Priorities

In light of the geographic, demographic and political landscape in Georgia, this is a critical time for the Title V program set priorities. The process used by the Title V Director and MCH Staff for determining the needs and priorities of the program is multifactorial. Primarily, the five-year assessment is used to evaluate priorities. However, efforts are made to align priorities with ongoing needs assessment efforts, priorities of the Governor, Commissioner and Executive Leadership within the agency. Title V priorities are also chosen to the extent that they address needs that are not otherwise met through other grants, programs and partnering organizations.

 

DPH developed a new strategic plan to carry the agency through 2019. Although the strategic plan is not comprehensive of all priorities within the agency, it does highlight the areas that will receive specific programmatic emphasis throughout the next three years. The strategic plan includes the following goals and objectives:

 

GOAL 1: Prevent disease, injury, and disability. Provide population-based programs and preventive services to prevent disease, injury, and disability by advocating for and promoting health, leading change in health policies and systems, and enabling healthy choices.

Objective 1.1: Childhood Obesity

Objective 1.2: Asthma

Objective 1.3: Infant Mortality

Objective 1.4: Cardio Metabolic Syndrome

Objective 1.5: Early Brain Development

 

GOAL 2: Promote health and wellbeing. Increase access to care throughout the State of Georgia and educate the public, practitioners, and government to promote health and wellbeing by collecting, analyzing and reporting health data, tracking disease and health determinants and applying science and epidemiological principles to support decisions.

Objective 2.1: Healthcare Access/Primary Care

Objective 2.2: Infrastructure support and improvement to promote health and wellbeing

 

GOAL 3: Prepare for and respond to disasters. Ensure efficient, effective and quality Public Health infrastructure to prepare for and respond to emergencies to safeguard the health and wellbeing of Georgians by conducting surveillance, inspect for environmental hazards, epidemiological investigations and providing support for district operations.

Objective 3.1: Infrastructure support and improvement to prepare for and respond to disasters 

 

The initiatives outlined in the State Action Plan Chart to prevent infant mortality align with the strategies to meet Objective 1.3 of the DPH Strategic Plan.