Data Sources, Definitions, and Notes 1

www.communityhealth.hrsa.gov

Providing information for improving community health

JULY 2000

Community Health Status Report:

Data Sources, Definitions, and Notes
2 Community Health Status Indicators Report
Data Sources, Definitions, and Notes 3

This Community Health Status Report: Data Sources, Definitions, and Notes,

referred to as the “companion document,” provides health indicator definitions,

sources, and methods used in the Community Health Status Reports created by

the Community Health Status Indicators (CHSI) Project. It is not intended to

stand alone but to be used as a reference for the user of the county health profile

provided for every U.S. county at: www.communityhealth.hrsa.gov.

The Community Health Status Report is a collection of nationally available

indicators for counties representing several areas of responsibility for public

health. While for many of the indicators there may be more than one method for

calculating rates or percentages as well as more than one definition of the same

problem, or source, the descriptions that follow are the choice made for this

project and the means for ensuring that health measures for communities are

consistent and not based on differing definitions or methodologies.

The estimates presented here rely on various data sources, methods, and

calculations, some of which may not be appropriate for particular counties and/

or purposes. Users should be aware of the limitations of these estimates. Those

data that are estimated do not represent official Department of Health and

Human Services statistics. We hope that the indicators provided in the CHSI

Reports will be useful to communities and request feedback and comments.

COMMUNITY HEALTH STATUS REPORT:

DATA SOURCES, DEFINITIONS, AND NOTES
4 Community Health Status Indicators Report

This section describes the context for county health — characteristics of

a county’s population that have a potential effect on the amount and type

of services used, health status, and resources available.

Data for Population Size, Poverty Level, Population by Age, and Population by

Race/Ethnicity were obtained from the Current Population Survey (CPS)

conducted by the U.S. Bureau of the Census. The CPS is an ongoing survey of

states from which estimates for counties are derived. Due to the survey’s small

sample size, the confidence intervals for these measures may be wide and should

be consulted when making comparisons to Peer Counties. Information on

survey methodology and confidence intervals are found at: www.bls.census.

gov/cps/tp/tp63.htm and www.bls.census.gov/cps/cpsmain.htm.

Population Size — This number is from “Estimates of the Population of

Counties and Demographic Components of Population Change: Annual Time

Series, July 1, 1990 to July 1, 1997” from the U.S. Bureau of the Census.

The population figures are mid-year estimates for 1997 and are the source for

calculations throughout the brochure.

Population Density — This number is calculated by using the following

formula: 1997 Total Population Estimate / Land Area (square miles). Land

Area is from the “County and City Data Book,” 1994, CD-ROM, a statistical

abstract supplement published by the U.S. Bureau of the Census.

Poverty Level — The percentage of individuals living below the poverty level

data in 1995 are from the U.S. Bureau of the Census’ Small Area Income

Poverty Estimates (SAIPE), U.S. Bureau of the Census at www.census.gov/

hhes/poverty/threshld/thresh95.html.

Population by Age (1997) — Age-specific population sizes are from

“Estimates of the Population of Counties by Age, Sex, Race, and Hispanic

Origin: 1990 to 1997”, U.S. Bureau of the Census. These data are estimates

of the resident population for mid-year 1997, U.S. Bureau of the Census.

Population by Race/Ethnicity — Race- and ethnicity-specific population

sizes are from “Estimates of the Population of Counties by Age, Sex, Race,

and Hispanic Origin: 1990 to 1997.” These data are mid-year estimates of the

resident population, 1997, and reflect standard race and ethnicity categories in

use by the U.S. Bureau of the Census.

DEMOGRAPHIC INFORMATION

................................................................

................................................................
Data Sources, Definitions, and Notes 5

FIPS Code (Federal Information Processing Standards) — These are

standard codes, which indicate State and county, developed by the National

Bureau of Standards. The combined State and county codes create a unique

county identifier. The State portion of the code is a two-digit number, while

the county portion consists of a three-digit number. In general, numbering is

sequential when States and counties are listed alphabetically. Some cities in

Hawaii and Virginia have been combined into their original counties. All

counties in Alaska have been combined.

NOTE: Additional information about county and combined cities and counties

is available from the Bureau of Health Professions, Health Resources and

Services Administration, Area Resource File (ARF) System, (Fairfax, VA:

Quality Resource Systems, Inc.) and its associated documentation (February

1999) and Web site www.hrsa.gov/bhpr/arf.htm and www.arfsys.com.

PEER COUNTIES

................................................................

................................................................

A distinctive aspect of this report is the ability to compare a county with

its peers, those counties similar in population composition and selected

demographics. Comparison of a county to its peers is thought to take

into account some of the factors that make a difference in a community’s

health.

Strata, or peer groups, were developed with input from an advisory committee

composed of Federal, State, and local public health professionals and members

of academia. The project goal was to develop strata of 20-50 counties each,

providing several peers for each county. The relatively large number in each

stratum allows counties to choose a few peers that they believe to be most like

them. The stratum size averages 35 and ranges from 14 to 58 counties. There

are a total of 88 strata.

To define the strata, the following five factors were used:

(1) Frontier status (The National Committee on Rural Health recommended

classifying areas as frontier if they had fewer than 7 persons per square

mile. Source: Popper, F.J. (1986) The strange case of the contemporary

American frontier. Yale Review: 76(1); 101-121);

(2) Population size, using the National Association of County and City Health

Officials’ population categories (less than 25,000; 25,000-49,999; 50,000-

99,999; 100,000-249,999; 250,000-499,999; 500,000-999,999; 1,000,000 or

more);
6 Community Health Status Indicators Report

(3) Poverty quartiles (less than or equal to 10.55%; 10.56-14.15%; 14.16-

19.25%; more than 19.26%), based on the percentage of individuals in the

county living below the poverty level (e.g., in 1995 and for a family of four,

the poverty level is $15,569);

(4) Median age categories, based on the percentage of children (percentage of

persons age<18 less than 26.13% or greater than or equal to 26.13%) and

elderly (percentage of persons age 65+ less than or equal to 14.70% or

greater than 14.70%) in the county; and

(5) Population density, as measured by half deciles (e.g., CHSI stratum 45

ranges between 42-157 persons per square mile).

Using an ordered, staged approach, counties were first grouped according to

frontier status. Population size was used next. Then, as the number of counties

in each category allowed, further groupings were made based on the remaining

variables until the optimum stratum size was reached. Therefore, while all strata

were classified according to the first two variables, only some were defined by

factors of poverty, age, and population density. A schematic of the stratification

process is available at www.communityhealth.hrsa.gov.

Each of the 88 strata is uniquely defined by two or more of the factors. It is

possible that counties that are similar in several factors may not be in the same

stratum due to category divisions.

The Strata Listing contains stratum by number and provides the number of

counties and the ranges for population size, density, and poverty level for each.

This table provides the characteristics of all strata and allows identification of

other strata having similar characteristics. We encourage you to view this table

to examine additional strata generated using this method and to explore other

counties’ reports.

This is the project’s initial attempt at forming peer groupings of counties. Please

feel free to comment at the Web site listed above to any of the CHSI partners on

this process and its utility. Future reports may use different methods and/or

criteria for determining strata.

These are broad measures of health. Each measure captures a single,

comprehensive measure of population-based health but each provides only

a single perspective. Four measures include the length of life (average

life expectancy), the risk of dying (rates of death), and health-related

quality of life (self-rated health status and average unhealthy days).

SUMMARY MEASURES OF HEALTH

................................................................

................................................................
Data Sources, Definitions, and Notes 7

NOTE: A indicates that the county’s value is favorable when compared to the

median value among peer counties or the US county median. A indicates

that the county’s value is unfavorable by comparison (i.e., higher than the

median).

Average Life Expectancy — This represents the average number of years

that a baby born in 1990 is expected to live if current mortality trends continue

to apply. Calculations were made by Chris Murray and colleagues at the

Harvard School of Public Health and were obtained from the Bureau of

Primary Health Care, Health Resources and Services Administration. Deaths

were from the Vital Statistics Reporting System, National Center for Health

Statistics, 1985-94, and population data are from the U.S. Census Bureau,

1990. Methodology is described in the report, “US Patterns of Mortality by

County and Race: 1965-1994” at www.hsph.harvard.edu/organizations/bdu/

papers/usbodi/index.html. Estimates are based on national prevalence

information and adjusted to reflect local demographic characteristics,

therefore these estimates may not be accurate at the county level.

All Causes of Death — Mortality from any cause is the average annual rate

of all causes of death, age-adjusted to the year 2000 Standard. Data are from

the National Vital Statistics System, National Center for Health Statistics,

1997; Quality Resource Systems, Inc., Fairfax, VA, performed the age

adjustment.

Self-rated Health Status — The percentage of adults, age 18 and older, who

report “fair” or “poor” overall health is provided by the Behavioral Risk

Factor Surveillance System (BRFSS), 1993-1997, a survey conducted jointly

by States and the Centers for Disease Control and Prevention. County

estimates were calculated by the Health Care and Aging Studies Branch,

Centers for Disease Control and Prevention. Data are presented only for

those counties with a survey sample size of 50 or greater. County-specific

percentages were calculated using State weights, which may not be as

accurate when county age-sex-race distributions differ substantially from that

of the State. Due to small sample size, the confidence intervals for these data

may be wide and should be consulted when making comparisons to Peer

Counties because the variations observed may not be statistically valid.

Average Number of Unhealthy Days in Past Month — The average

number of unhealthy days (mental or physical) in the past 30 days, reported

by adults age 18 and older is provided, Behavioral Risk Factor Surveillance

System (BRFSS), 1993-1997, a survey conducted jointly by States and the

Centers for Disease Control and Prevention. County estimates were calculated by the Health Care and Aging Studies Branch, Centers for Disease
8 Community Health Status Indicators Report

Control and Prevention. Data are presented only for those counties with a

survey sample size of 50 or greater. County-specific percentages were

calculated using State weights, which may not be as accurate when county

age-sex-race distributions differ substantially from that of the State. Due to

small sample size, the confidence intervals for these data may be wide and

should be consulted when making comparisons to Peer Counties because the

variations observed may not be statistically valid.

Using major categories created by the National Center for Health Statistics, deaths by race or ethnicity and age group are reported and arranged

in order of magnitude in which they occur nationally. Locally, the order

of occurrence may vary.

NOTE: Listed are the Nation’s leading causes of death for each age category.

Depending upon county size, percentages for the most recent 3, 5, or 10 years

are reported. However, county-specific data are only reported if there are at

least 20 deaths in the age/race category, and the cause of death accounts for at

least 10% of the deaths in the age/race category. The abbreviation “nrf” (not

reported, few (events)) designates this occasion when no report is given

because of too few events. Mortality data are from the Vital Statistics

Reporting System, National Center for Health Statistics, 1988-1997, for the

International Classification of Diseases (Ninth Edition) (ICD-9) codes after

each variable, listed below. The ICD-9 codes in this report correspond to

those used in the National Vital Statistics Reports from the National Vital

Statistics System, National Center for Health Statistics, Centers for Disease

Control and Prevention, and differ from the codes used in the death measures

section.

ICD-9 Codes — The World Health Organization (WHO) maintains the

International Classification of Diseases (Ninth Edition) (ICD-9) used widely

in the health care field. These ICD-9 codes provide a worldwide standard for

comparison of birth, death, and disease data. For more information, visit

WHO’s Web site at: www.who.org/whosis/.

Complications of Pregnancy/Birth — Low birth weight, short gestation,

complications of birth, respiratory conditions (e.g., respiratory distress

syndrome, intrauterine hypoxia, and birth asphyxia), and other conditions at

the time of birth. ICD-9 codes: 760-779.

................................................................

................................................................

LEADING CAUSES OF DEATH
Data Sources, Definitions, and Notes 9

Birth Defects — Congenital anomalies, ICD-9 codes: 740-759.

Injuries — Trauma from motor vehicle crashes and other sources, ICD-9

codes: E800-E949.

Homicide — Murder, ICD-9 codes: E960-E969.

Cancer — Malignant neoplasms, ICD-9 codes: 140-208.

Suicide — Death where one intentionally and voluntarily takes one’s own life,

ICD-9 codes: E950-E959.

Heart Disease — Any pathologic condition of the heart, ICD-9 codes: 390-

398, 402, 404-429.

HIV/AIDS — NCHS codes: *042-*044. Note the asterisks before the category

numbers indicate that they are not specified in the ICD-9.

Hispanic Ethnicity — This classification is a further description of persons

already categorized by race. The reader is cautioned to use either race or

ethnicity and not to treat the categories as mutually exclusive. Currently most

States report ethnicity data, although this has not been the case in the past.

This indicator is most complete for the most recent years.

................................................................

................................................................

MEASURES OF BIRTH AND DEATH

Healthy People 2010 is a national health goal and objective setting activity led by the Office of Disease Prevention and Health Promotion and

a compendium of health outcomes desired by the Year 2010. Achievable

target levels for many health outcomes are provided. Many communities

will be adopting or adapting these for local use. Healthy People 2010

target rates and 1997 U.S. rates are presented as a point of comparison

for counties in assessing their current health status.

NOTE: Annual death rates age-adjusted to the year 2000 standard were

calculated by Quality Resource Systems, Inc. in Fairfax, VA. Mortality data

are from the National Center for Health Statistics, Vital Statistics System,

1988-1997, for the ICD-9 codes listed after each variable. Population figures

are from the U.S. Bureau of the Census. Depending upon county size and

frontier status, the average annual age-adjusted rate for the most recent 3, 5,

or 10 years is reported.

A indicates that the county’s value is favorable when compared with the

median of the peer county range. A indicates that the county’s value is

unfavorable by comparison (i.e., higher than the median).
10 Community Health Status Indicators Report

Age Adjustment — This is a tool used to account for the changing age

distribution of the population. Age adjustment enables counties with dissimilar populations (e.g., high percentage of elderly residents) to be compared.

Age adjustment to the same standard population allows meaningful comparisons of vital rates over time and between groups.

Age-adjusted rates are based on the new, year 2000 standard. Use of the year

2000 standard has generally resulted in age-adjusted death rates that are

substantially larger than those based on the 1940 standard. Do not compare

rates age-adjusted to year 2000 with rates age-adjusted to a different

standard year (e.g., 1940). For more information regarding age adjustment

and the year 2000 standard, refer to Anderson, R. and Rosenberg, H., (October 7, 1998) “Age Standardization of Death Rates: Implementation of the

Year 2000 Standard,” National Vital Statistics Reports, 47 (3). This publication can be obtained at the following internet address: www.cdc.gov/nchs/

products/pubs/pubd/nvsr/47-pre/47-pre.htm.

County Percent or Rate — Each county-specific health indicator is provided

as a rate or percent. Birth measures are percents, infant mortality measures

are deaths per 1,000 births, and death measures are year 2000, age-adjusted

mortality rates per 100,000 population. The notation, “nrf” indicates that

numbers used to generate the rates or percents are small and would create

unstable rates or percents for the county, if used. Small numbers are defined

for birth and infant mortality indicators as fewer than 500 births and 3 events

(births or infant deaths) or for death measures as fewer than 10 deaths.

Peer County Range — The low and the high values found in each stratum of

peers is provided. The low number is the tenth percentile of rates or percents

in the stratum; the high number represents the ninetieth percentile. Eighty

percent of all county values within the strata lie within this range.

U.S. Rate — Age-adjusted (year 2000 standard), 1997 U.S. rates were taken

from both Healthy People 2010: National Health Promotion and Disease

Prevention Objectives (Conference Edition) and provided by NCHS (Personal

communication, Richard Klein).

Healthy People 2010 Target — The national target rate or percent established for a national 2010 objective was found in Healthy People 2010:

National Health Promotion and Disease Prevention Objectives (Conference

Edition).
Data Sources, Definitions, and Notes 11

NOTE: In this section, the ICD-9 codes include causes of death corresponding

to the definitions used in the Nation’s health objectives outlined in Healthy

People 2010: National Health Promotion and Disease Prevention Objectives

(Conference Edition). All death rates (excluding infant mortality) are per

100,000 population.

BIRTH MEASURES

INFANT MORTALITY

NOTE: All rates are deaths per 1,000 births.

Infant Mortality — Death of an individual less than one year old from any

cause (any ICD-9 code).

Neonatality mortality — Infant deaths occuring before day 29.

Postneonatal mortality — Infant deaths occurring day 29 or later.

White/Black Infant Mortality — Race-specific infant mortality.

DEATH MEASURES

NOTE: Data are from the National Center for Health Statistics, Vital Statistics

Reporting System, 1988-1997.

Low Birth Weight — Percentage of all births less than 2,500 grams.

Very Low Birth Weight — Percentage of all births less than 1,500 grams.

Premature Births — Percentage of births with a reported gestation period of

less than 37 weeks.

Teen Mothers — Percentage of all births to mothers less than 18 years of age.

Older Mothers — Percentage of all births to mothers 40 years of age or older.

Unmarried Mothers — Percentage of all births to mothers who report not

being married.

No Care First Trimester — Percentage of births to mothers who reported

receiving no prenatal care during the first trimester (12 weeks) of pregnancy,

and includes those with no or unknown prenatal care.
12 Community Health Status Indicators Report

................................................................

................................................................

RELATIVE HEALTH IMPORTANCE

Breast Cancer (Female) — ICD-9 code: 174.

Colon Cancer — ICD-9 codes: 153 and 154.

Coronary Heart Disease — ICD-9 codes: 402, 410-414, and 429.2.

Homicide — Murder, ICD-9 codes: E960-E969.

Lung Cancer — ICD-9 code: 162.

Motor Vehicle Injuries — ICD-9 codes: E810-E825.

Stroke — ICD-9 codes: 430-438

Suicide — Intentionally and voluntarily taking one’s own life, ICD-9 codes:

E950-E959.

Unintentional Injury — Includes all injuries not related to motor vehicle

accidents or intentional deaths (homicide or suicide) ICD-9 codes: E800-

E807 and E826-E949.

The Relative Health Importance Table conveys a straightforward way of

prioritizing health issues for counties. Comparisons to the U.S. and to its

peers allows a quick and easy method for assessing one’s county health

relative to others.

The Relative Health Importance Table creates four categories of relative concern

by simply comparing one’s county to its peers and to the U.S. The table

highlights favorable and unfavorable standing between one’s county, and other

counties and the Nation, and points to indicators which may warrant more

attention.

A county’s indicators in the upper left-hand box may be ripe for improvement.

They are higher than the U.S. and half of the peer counties. The county compares unfavorably to both peers and the Nation for the indicators listed (i.e., a

county rate higher than the median peer county rate is categorized as “unfavorable”).

Conversely, indicators in the lower right-hand box of the table compare favorably to both peers and the U.S. For these indicators the county has been doing

relatively well. It is important to note that though a favorable relationship
Data Sources, Definitions, and Notes 13

currently exists, these indicators are likely to call for continued attention so that

the current positive level of health status is sustained or additional progress

made.

The other two boxes represent intermediate levels of health status. In one

instance, the county does well relative to its peers while comparing unfavorably

relative to the U.S. In the other, the county does poorly compared to its peers

while comparing favorably to the U.S. In each case, one’s county rate is lower

than either its peers or the U.S., but not both.

Median values are used to designate indicators as favorable or unfavorable.

Indicator values that are equal to the median are placed in the “favorable”

column or row. Public health practitioners at the University of South Florida

College of Public Health (Studnicki, J. et.al. (1997), Community health report

card: Comprehensive Assessment for Tracking Community Health (CATCH),

Best Practices and Benchmarking in Healthcare, Vol 2(5), 196-207) developed

this methodology to allow counties to establish priorities among indicators,

based on relative standing to peers and the U.S.

Vulnerable populations are estimates of individuals in various categories

who tend to have poorer health status and more medical needs than the

general population.

NOTE: To obtain the estimates provided in this section, a national, local, or

multivariately modeled prevalence is applied to the current local total or subpopulation. While estimates using the same formula and source of population

provide consistency across jurisdictions, as was desirable for this project, they

may not supply individual counties with the only estimates of these populations. Other estimates may have been made by and be available from others,

and in particular, the local or State health department.

No High School Diploma — The number of individuals age 25 and older

who have not graduated from high school. Prevalence estimates of no high

school diploma from the 1990 Census of Population and Housing were

applied to the 1997 county population estimates (ages>25), STF3A, U.S.

Bureau of the Census, and obtained from the Area Resource File, (Quality

Resource Systems, Inc., Fairfax,VA, under contract with the Health Resources and Services Administration.)

................................................................

................................................................

VULNERABLE POPULATIONS
14 Community Health Status Indicators Report

Unemployed — The number of persons who had no employment, were

available for work, and had made specific efforts to find employment were

obtained. The number of unemployed compiled from the 1998 Current

Population Survey (CPS) are provided by Local Area Unemployment

Statistics, Bureau of Labor Statistics, for each county.

Severe Work Disability — Estimates were developed by Borawski, E.A. and

Jia, H. (Case Western Reserve University, Department of Biostatistics) “State

and County Estimates of Severe Work Disability (SWD) Among Adults, Aged

18-64, 1993-1996, Behavioral Risk Factor Surveillance System (BRFSS)”

January, 1999. Prevalence estimates are applied to the 1997 county population estimates (age 18-64). Severe work disability is defined as the inability

to work due to health problems — mental or physical. Due to small sample

size, the confidence intervals for these data may be wide and should be

consulted when making comparisons to Peer Counties because the variations

observed may not be statistically valid. Estimates are based on national

prevalence information and adjusted to reflect local demographic characteristics, therefore these estimates may not be accurate at the county level.

Major Depression — An estimate of the number of individuals, age 18 and

older, experiencing a major depressive episode during the past year, was

calculated using the following formula: (1996 race-specific prevalence) x

(1997 county population age 18 and older). Race-specific U.S. prevalences

are from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Statistics. Substance Abuse and Mental

Health Statistics Source Book, 1998, (p. 126). Definition of a major depressive episode appears on page 459. This publication can be accessed electronically at www.samhsa.gov. Estimates are based on national prevalence

information and adjusted to reflect local demographic characteristics,

therefore these estimates may not be accurate at the county level.

Recent Drug Use — An estimate of the number of individuals, age 12 and

older, using illicit drugs within the past month was calculated. The figure

was calculated using the following formula: (1996-1998 average regionspecific prevalence) x (1997 county population, age 12 and older). Illicit

drug use includes use of one or more of the following: marijuana, cocaine

(including crack), heroin, hallucinogens (including LSD and PCP), inhalants,

or non-medical use of psychotherapeutics, Substance Abuse and Mental

Health Services Administration (SAMHSA, Office of Applied Statistics).

Substance Abuse and Mental Health Statistics Source Book, 1998, p. 70.
Data Sources, Definitions, and Notes 15

These measures provide a context for good health — clean air, water,

land, and waste disposal — and are particularly important in assuring a

healthy population.

Infectious Diseases — Disease classifications are from the Centers for

Disease Control and Prevention, “Case definitions for infectious conditions

under public health surveillance,” MMWR 1997: 46(No. RR-10). This

publication is available at www2.cdc.gov/mmwr/.

Data are from the Centers for Disease Control and Prevention, National

Center for Infectious Diseases, 1989-1998. Depending upon county size, the

number of cases for the most recent 3, 5, or 10 years is reported. The

expected number is based on the rate for the strata of peer counties and the

population estimate of the county.

Toxic Chemicals — Toxic Release Inventory (TRI) data, amount (in pounds)

of total chemical releases was extracted using TRI Data Explorer software,

1996 data, U.S. Environmental Protection Agency, available at: www.epa.

gov/ceisweb1/ceishome/ceisdata/triexplorer/triexplorer.html.

Air Quality Standards — The Clean Air Act directs the Environmental

Protection Agency (EPA) to identify and set national ambient air quality

standards for pollutants that cause adverse effects to public health and the

environment. EPA has set standards for the following six pollutants: Carbon

Monoxide (CO), Nitrogen Dioxide (NO2), Ozone (O3), Lead (Pb), Particulate

Matter < 10 micrometers (PM-10) and Sulfur Dioxide (SO2). A “No”

indicates that the county reported a value that exceeds the air quality standard. A "Yes" indicates that a county did not exceed the standard, or does not

currently monitor for that pollutant. An exceedance in any single year is not

necessarily an indication that the county violates the national air quality

standard. For more information on the National Ambient Air Quality

Standards, and how to determine if a county is in violation of these standards,

please visit www.epa.gov/oar/oaqps/greenbook/index.html. Summary 1998

data presented are available at www.epa.gov/airsdata/monsum.htm.

This publication can be accessed electronically at www.samhsa.gov. Estimates are based on national prevalence information and adjusted to reflect

local demographic characteristics, therefore these estimates may not be

accurate at the county level.

................................................................

................................................................

ENVIRONMENTAL HEALTH
16 Community Health Status Indicators Report

INFECTIOUS DISEASE CASES

Infectious disease cases can be reduced with the systematic application

of various public health measures — testing, counseling, treatment, and

vaccination.

Note: Disease classifications and case definitions are provided by the Centers

for Disease Control and Prevention, in “Case definitions for infectious

conditions under public health surveillance,” MMWR 1997: 46(No. RR-10).

This publication is available at www2.cdc.gov/mmwr/.

Data are from the Centers for Disease Control and Prevention, National

Center for Infectious Diseases and the National Center for HIV, STD, and TB,

1989-1998. Depending upon county size, the number of cases for the most

recent 3, 5, or 10 years is reported. Data include all cases for which county of

residence was specified. The expected number is based on the rate for the

strata of peer counties and the county’s population estimate. (Expected

number = rate among peers x county population).

ADULT PREVENTIVE SERVICES USE

Our risk of developing certain cancers and suffering fatal consequences

from respiratory illnesses can be reduced with the use of various preventive services. Early detection of cancer, through the use of screening

tests, increases survival. In addition, preventing or reducing the severity

of respiratory illness through the use of vaccinations reduces morbidity

and death rates.

NOTE: The Behavioral Risk Factor Surveillance System (BRFSS), a survey

conducted jointly by States and the Centers for Disease Control and Prevention, provides information about adult health practices related to a variety of

health issues. State-level BRFSS survey data from 1997 or 1998 are presented. These data, including confidence intervals for survey estimates, are

available on the BRFSS Web site at www.cdc.gov/nccdphp/brfss/. Local

survey estimates may be available through your State BRFSS coordinator.

PAP SMEAR — The percentage of females, 18 years of age and older, who have

had a Pap smear within the past 3 years. A Pap smear detects abnormal

changes in cervical cells that may lead to cancer. Early detection of precancerous conditions and treatment can prevent cancer or death (1998).

................................................................

................................................................

PREVENTIVE SERVICES USE

................................................................

................................................................
Data Sources, Definitions, and Notes 17

Mammogram — The percentage of females, 50 years of age or older, who

have had a mammogram within the past two years. A mammogram is a type

of x-ray used to detect tumors or abnormal cells in the breast. Early detection

and treatment of cancer can prevent death from breast cancer (1998).

Sigmoidoscopy — The percentage of adults, age 50 years and older, who

have ever had a proctoscopic exam. This type of exam uses a flexible scope

to detect polyps (non-cancerous tumors) and cancerous tumors in the colon

and rectum. Finding and removing them early can prevent cancer or death

from colon cancer (1997).

Pneumonia — The percentage of adults, age 65+, who have ever had a

pneumonia vaccination. Pneumonia is a leading cause of death among older

Americans; many pneumonia deaths can be prevented through increased use

of this vaccine (1997).

Flu — The percentage of adults, age 65+, who have had a flu shot within the

past year. Influenza is more likely to lead to serious complications, such as

pneumonia, in older adults. Much of the illness and death caused by influenza can be prevented by yearly vaccination (1997).

The characteristics presented here convey risks for heart disease and

cancer, our Nation’s leading killers. They include risk factors, personal

behaviors, and lifestyle choices. Persons with risk factors are at increased

risk of disease and its effects. Note: prevalences for your State are provided.

NOTE: The Behavioral Risk Factor Surveillance System (BRFSS), a survey

conducted jointly by States and the Centers for Disease Control and Prevention, provides information on the prevalence of adult risk characteristics

associated with the leading causes of death. State-level BRFSS survey data

from 1997 or 1998 are presented. These data, including confidence intervals

for survey estimates, are available on the BRFSS Web site at www.cdc.gov/

nccdphp/brfss/. Local survey estimates may be available through your State

BRFSS coordinator. These factors, reported for adults, are also important

indicators of health in children and youth.

................................................................

................................................................

RISK FACTORS FOR PREMATURE DEATH
18 Community Health Status Indicators Report

Sedentary — Sedentary lifestyle is the calculated percentage of adults at risk

for health problems related to lack of exercise (regular and sustained physical

activity) (1998).

Few fruits/vegetables — The percentage of adults reporting an average fruit

and vegetable consumption of less than 5 times per day (1998).

Obesity — The calculated percentage of adults at risk for health problems

related to being overweight, based on body mass index (BMI). A BMI of

27.8, for men, and 27.3, for women, or more is considered obese. To calculate BMI, multiply weight in pounds by 703 and divide the result by height

(in inches) squared (1998).

High Blood Pressure — The percentage of adults who responded yes to the

question, “Have you ever been told by a doctor, nurse, or other health

professional that you have high blood pressure?” (1997).

Smoker — The percentage of adults who responded “yes” to the question, “Do

you smoke cigarettes now?” (1998).

Diabetes — The percentage of adults who responded “yes” to the question,

“Have you ever been told by a doctor that you have diabetes?” (1998).

Access to care measures include health care resources available in a county

and provide measures of medical care coverage or lack thereof.

Uninsured Individuals — The estimated number of uninsured individuals in

the State are from the 1998 Current Population Survey (CPS), http://ftp.

census.gov/hhes/hlthins/hlthin98.html. The CPS is an ongoing survey of

states. Information on survey methodology and confidence intervals are

found at: www.bls.census.gov/cps/tp/tp63.htm and www.bls.census.gov/cps/

cpsmain.htm.

Medicare Beneficiaries — Beneficiaries are the number of individuals

enrolled in Medicare by State and county of residence, from the Health Care

Financing Administration’s enrollees’ file, July 1, 1998. The data are available at: www.hcfa.gov/stats/enroll98.htm.

................................................................

................................................................

ACCESS TO CARE
Data Sources, Definitions, and Notes 19

Medicaid Beneficiaries — The U.S. Health Care Financing Administration

was not able to provide the number of beneficiaries by county. This number

may be available for your county from the State Medicaid office.

Primary Care Physicians — This is the total number of active, non-federal

physicians per 100,000 population, 1997. This figure includes those who

practice in one of the four primary care specialties — general or family

practice, general internal medicine, pediatrics, and obstetrics and gynecology.

Source: American Medical Association Physician Master File, 1997, Area

Resource File, (Quality Resource Systems, Inc., Fairfax,VA, under contract

with the Health Resources and Services Administration.)

Dentists — This is the total number of active dentists per 100,000 population,

1995. Source: American Dental Association, State and County Demographic

Reports, 1998, Area Resource File, (Quality Resource Systems, Inc.,

Fairfax,VA, under contract with the Health Resources and Services Administration.)

Community Health Centers — These centers are a source of care for lowincome and uninsured individuals and families, 1999. Their network includes

migrant health centers, homeless health centers, and other community-based

centers. Source: Bureau of Primary Health Care, Health Resources and

Services Administration.

Health Professional Shortage Area — These are counties that have been

designated as single-county, primary medical care, health professional

shortage areas, as determined by the Secretary of Health and Human Services,

current as of December 17, 1999. They have a shortage of health professionals, meeting the criteria from 42 Code of Federal Regulations, Chapter 1, part

5 (October 1, 1993, pp.34-48). Data are available at www.bphc.hrsa.gov/

databases/hpsa/supplem.htm.
20 Community Health Status Indicators Report

www.communityhealth.hrsa.gov

PROVIDED TO YOU COURTESY OF:

For more information, please contact your State or local health department

or the project partners, or visit the

Community Health Status Indicators Project Web site:

www.communityhealth.hrsa.gov

HRSA Information Center

P.O. Box 2910

Merrifield, VA 22116

1-888-ASK-HRSA

www.ask.hrsa.gov

ASTHO

Association of State and Territorial Health Officials

1275 K Street, N.W., Suite 800

Washington, DC 20005

(202) 371-9090

www.astho.org

Brent Ewig, M.H.S., e-mail: bewig@astho.org

NACCHO

National Association of County and City Health Officials

1100 17th Street, N.W., Second Floor

Washington, DC 20036

(202) 783-5550

www.naccho.org

Anjum Hajat, M.P.H., e-mail: ahajat@naccho.org

PHF

Public Health Foundation

1220 L Street, N.W., Suite 350

Washington, DC 20005

(202) 898-5600

www.phf.org

Norma Kanarek, Ph.D., e-mail: nkanarek@phf.org