Maricopa County Department of Public Health Health Status Report 1991-1995 EXECUTIVE S U M MARY i Table of contents Message from the Director Preface iii iv-v Acknowledgments v List of figures vi List of tables x Introduction 1 Natality 3 Mortality 8 Communicable disease morbidity 21 Behavioral risk factors 31 Socioeconomic data 42 Health insurance coverage and utilization 50 Methods Data sources and limitations Population Estimates and data sources Health Status Area Definitions Definitions: Population Attributes, Risk Factors and Health Indicators Statistical Calculations and Defininitions M-1 M-2 M-4 M-6 M-7 M-7 Comment form c Copyright by Maricopa County Department of Public Health. Permission to quote from or reproduce materials from this publication is granted when due acknowledgment is made. EXECUTIVE ii S U M MARY iii A message from the director This document describes the changing nature of health status in Maricopa County since 1990. I am sending it to you for your information in the hopes that the information contained in the Executive Summary and the data in the remainder of the report might be of interest to you as you perform your responsibilities. The information in this report reflects not only the health status of the population in Maricopa County, the most populous county in Arizona and the fastest growing county in the United States, but also the dedicated work of nurses, physicians, communicable disease investigators, health educators, epidemiologists and statisticians and the support staff who have worked very hard to accumulate, compile, organize and print the material, while laboring to promote, preserve and protect the health of the individuals and communities in this county. This report will be followed by a series of annual reports that will provide a comprehensive portrait of our county’s changing health status. These data help those of us who work for the Maricopa County Department of Public Health to measure our progress in reducing the risk factors associated with disease, disability and death in this region. These data are milestones, which allow us to measure our success in achieving the goals and objectives set by our planning process. We hope that the information included in this series of reports will help those who work in local health departments to use our information as benchmarks to show your own successes. For those who develop policy for state and local health, we hope that these reports will provide the information you need to define your goals for public health, and the objectives that might be met through the expenditure of public funds to improve the health of your community. I invite you to read this report, use it, share it with colleagues and be critical of it. To improve this product, we would appreciate your criticism and comments. Improving the people’s health is a collaborative process; helping us create a better summary of the health status of the population in Maricopa County will help all of us do a better job in improving the public’s health. Jonathan B. Weisbuch, M.D., M.P.H. Director, Maricopa County Department of Public Health EXECUTIVE S U M MARY iv Preface The World Health Organization defines health as “a state of complete well-being, physical, social, and mental, and not merely the absence of disease or infirmity.”1 If we accept this definition, then any report attempting to measure the health status of a population should measure the quality of life as well as the frequency of disease, mortality and risk factors adverse to health. This five year health status report (1991-1995) is the first one that the Maricopa County Department of Public Health produces covering at one time morbidity, mortality, risk factors and socioeconomic information, as well as some health care utilization indicators. It is the first step towards a systematized comprehensive yearly report on the health of the county residents. Some topics, though not covered here, will be covered in future reports, such as environmental quality, nutrition and domestic violence. Some of these omissions were inevitable because the data did not exist; for example, there is no centralized collection of information in the county on domestic violence that does not result in death. Some omissions were caused by delays in the availability of the information. Other omissions were deliberate, responding to the lack of staff and time to include everything we would ideally want to include in a “comprehensive” report. In the coming years, as the production of this report becomes a systematized routine, we will be able to make it truly comprehensive. Health status assessment is intended to measure changes and trends in the health of the population and in its living conditions, whether the changes have been brought about deliberately or accidentally. This process is a tool for good planning, helping to target interventions towards the most pressing, important and/or urgent problems. It allows evaluation of programs and of progress toward goals. It facilitates comparisons of areas and populations to establish priorities and set expectations. Finally, it gives the community a picture of where we are and the direction in which we are moving. For the five-year period 1991-1995, the most important and influential factor in determining the state of the people’s health has been population growth. Maricopa County has been growing at a rate of four to five percent per year. This is the equivalent of moving a city of 100,000 inhabitants into the county every year, with all the problems accompanying such a population. Ultimately, every chronic, acute or infectious disease, every issue related to injuries and safety, as well as everything related to health care utilization will suffer the impact of the rapidly expanding population. Every public health function is critically affected by this phenomenon: the protection of the food and the water supply; the maintenance of high immunization levels; the control of communicable diseases; safety on the highways; violence prevention and the management of biologic or other emergencies that might threaten the population’s safety. This report is addressed to many users. The Maricopa County Department of Public Health will use it to plan programs, to target problem areas, to decide priorities, to evaluate previous work and to identify health problems. The Division of Epidemiology will use it to establish surveillance, analyses and research priorities based on what we see as adverse indicators of health, unexplained findings and puzzles. Businesses and corporations can use it to aid in making decisions about community work, as well as about expansion or about relocation to the county. Students can use it as an aid in their community assessment or evaluation of health problems. Service organizations and institutions can use it to focus programs upon specific target areas. It can be used to assess needs or to support funding requests. 1. As quoted in the The Future of Public Health, Institute of Medicine National Academy Press, Washington D.C., 1988. pg 39. v Maricopa County is very diverse, both geographically and in the composition of its population. No single report can encompass everything in every detail. You might need more information about specific health problems. You might need more information about a neighborhood, a city and an unincorporated collection of census tracts. You might need information about a specific population group. You can contact the Division of Epidemiology and request a special report for a specific purpose. If we can provide you with the information, we will. If not, we will help guide you in your search for information by referring you to the agencies or institutions that can provide those data. Much of the information in this report will be available soon on the Department’s Web page. We hope this report will be useful to you. We have included a form at the end of this report for you to send us your comments. Even if it takes a little time and trouble, we would greatly appreciate your making the effort to let us know your reactions. The whole point of the report is to fulfill your information and analyses needs. We would like to know what those specific needs are. Division of Epidemiology and Data Services Acknowledgments Many people have helped to produce this report. The following people (in alphabetical order) were instrumental in finally having it see the light of day. Brijette Alex Karen Andrews Pam Bailey Bea Burham John Carlson Laura Castillo Howard Chard Mary Fowler Chris Jordan Judy Nowak Scott Proeschold Sarah Santana Heather Wanatowicz Jonathan B. Weisbuch James Yuan We also thank the many who have read it and made suggestions for its improvement. EXECUTIVE S U M MARY vi List of figures Figure Number Figure Name Page Number Fig. 1 Population by race/ethnicity and gender Maricopa County, 1990 Census and 1995 Special Census 1 Fig. 2 Maricopa County Population Pyramid Biologic Environment Population Distribution: 1995 2 Fig. 3 Birth and fertility rates Maricopa County, 1995 4 Fig. 4 Percent low birthweight births by year, 1987-1995 Maricopa County, Arizona and United States 6 Fig. 5 Low birthweight by race/ethnicity Maricopa County, 1991-1995 6 Fig. 6 Percent low birthweight births By race/ethnicity and mother’s place of birth Maricopa County, 1993 7 Fig. 7 Infant mortality, 1987-1995 Maricopa County, Arizona, United States, Year 2000 goal 8 Fig. 8 Infant mortality rates by race/ethnicity Maricopa County, 1991-1995 9 Fig. 9 Infant mortality, selected health status areas Maricopa County, 1987-1995 10 Fig. 10 Infant mortality, selected health status areas Maricopa County, 1987-1995 10 Fig. 11 Total years of potential life lost by selected cause of death Maricopa County, 1995 12 Fig. 12 Leading causes of death by age (age <20) Maricopa County, 1995 12 Fig. 13 Leading causes of death by age (age 20-24) Maricopa County, 1995 13 Fig. 14 Leading causes of death by age (age 25-34) Maricopa County, 1995 13 vii List of figures continued Figure Number Figure Name Page Number Fig. 15 Leading causes of death by age (age 35-44) Maricopa County, 1995 14 Fig. 16 Leading causes of death by age (age 45-64) Maricopa County, 1995 14 Fig. 17 Leading causes of death by age (age 65+) Maricopa County, 1995 15 Fig. 18 Death rates due to homicides All and County residents only, 1988-1995 15 Fig. 19 Adolescent (age 15-19) and County total homicide death rates Maricopa County, 1989-1995 16 Fig. 20 Adolescent (age 15-19) and total all unintentional injury death rates Maricopa County, 1989-1995 16 Fig. 21 Adolescent (age 15-19) and total alcohol related automobile death rates Maricopa County, 1989-1995 17 Fig. 22 Adolescent (age 15-19) and total suicide death rates Maricopa County, 1989-1995 17 Fig. 23 Childhood (age 1-4) mortality Maricopa County and United States, 1990-1995 18 Fig. 24 Childhood (age 5-14) mortality Maricopa County, 1989-1995 18 Fig. 25 Childhood (age 1-19) mortality Maricopa County and Arizona, 1990-1995 19 Fig. 26 AIDS mortality rates by race/ethnicity and sex United States, 1990 and 1994 (all ages) 20 Fig. 27 AIDS mortality rates by race/ethnicity and sex Maricopa County, 1990, 1992 and 1994 (all ages) 20 Fig. 28 Incidence and rates of vaccine preventable disease Maricopa County, 1989-1995 22 Fig. 29 Meningitis cases and case rates (Meningococcal disease and H. Influenzae Meningitis) Maricopa County, 1987-1995 22 EXECUTIVE S U M MARY viii List of figures continued Figure Number Figure Name Page Number Fig. 30 Invasive Meningococcal disease Maricopa County rates by year of onset, 1983-1995 23 Fig. 31 Tuberculosis cases and case rates Maricopa County and Arizona, 1984-1995 and Year 2000 goal 23 Fig. 32 Syphilis rates by selected age groups Maricopa County, 1989-1995 24 Fig. 33 Gonorrhea rates by selected age groups Maricopa County, 1989-1995 24 Fig. 34 Chlamydia rates by selected age groups Maricopa County, 1989-1995 25 Fig. 35 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by ethnicity for Maricopa County and Arizona 31 Fig. 36 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by sex for U.S., Arizona and Maricopa County 32 Fig. 37 Maricopa County behavioral risk factor surveillance 1991 percent current smokers among females of Maricopa County and Arizona 32 Fig. 38 Maricopa County behavioral risk factor surveillance 1991 percent current smokers among males of Maricopa County and Arizona 33 Fig. 39 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by income for Maricopa County and Arizona 33 Fig.40 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by educational status for Maricopa County and Arizona 34 Fig.41 Percentage of mothers who smoked during pregnancy Maricopa County, 1990-1995 34 Fig.42 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking by race/ethnicity for Maricopa County and Arizona 35 Fig.43 Maricopa County behavioral risk factor surveillance 1991 percent binge drinking by race/ethnicity for Maricopa County and Arizona 36 Fig.44 Maricopa County behavioral risk factor surveillance 1991 percent drinking and driving by ethnicity for Maricopa County and Arizona 36 ix List of figures continued Figure Number Figure Name Page Number Fig. 45 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking by sex for U.S., Maricopa County and Arizona 37 Fig. 46 Maricopa County behavioral risk factor surveillance 1991 percent binge drinking by sex for U.S., Maricopa County and Arizona 37 Fig. 47 Maricopa County behavioral risk factor surveillance 1991 percent drinking and driving by sex for U.S., Maricopa County and Arizona 38 Fig. 48 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking among females of Maricopa County and Arizona 38 Fig. 49 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking among males of Maricopa County and Arizona 39 Fig. 50 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking by employment status for Maricopa County and Arizona 39 Fig. 51 Maricopa County behavioral risk factor surveillance 1991 percent seat belt use by race/ethnicity for Maricopa County and Arizona 40 Fig. 52 Maricopa County behavioral risk factor surveillance 1991 percent no leisure time activity by ethnicity for Maricopa County and Arizona 41 Fig. 53 Maricopa County behavioral risk factor surveillance 1991 percent with no health insurance by sex for U.S., Maricopa County and Arizona 50 Fig. 54 Maricopa County’s five Supervisory districts and 10 health status areas M-6 EXECUTIVE S U M MARY x List of tables Table Number Table Name Page Number Table 1 1995 population by health status area 3 Table 2 Births per 1,000 women by age and race/ethnicity 3 Table 3 Resident number of births by race/ethnicity of mother and year, Maricopa County 4 Table 4 Percent of women giving birth with no prenatal care during the first trimester by race/ethnicity Maricopa County, 1987-1995 and U.S., 1987-1993 5 Table 5 Percent premature deliveries (<37 weeks) by year and ethnicity 7 Table 6 Year 2000 Objectives to reduce infant mortality and Maricopa County rates 1987-1995 9 Table 7 Maricopa County infant mortality number of deaths by cause, 1987-1995 11 Table 8 Tobacco attributable deaths Maricopa County, 1990-1996 21 Table 9a General communicable diseases diagnoses by year, 1987-1991 26 Table 9b General communicable diseases diagnoses by year, 1992-1995 27 Table 10 Year 2000 Objectives to reduce sexually transmitted diseases Maricopa County rates by year of diagnosis, 1987-1995 28 Table 11a Maricopa County incidence of reported cases of sexually transmitted diseases and AIDS, 1987-1991 29 Table 11b Maricopa County incidence of reported cases of sexually transmitted diseases and AIDS, 1992-1995 30 Table 12 Maricopa County 1990 education by ethnicity – total county 43 Table 13 Maricopa County 1990 mean per capita income (in dollars) by race, ethnicity and health status area 44 xi List of tables continued Table Number Table Name Page Number Table 14 Maricopa County households 1990 primary language spoken and linguistic isolation by health status area 45 Table 15 Maricopa County population 1990 families by poverty status, presence of children (under 18 years) and by health status area 46 Table 16 Maricopa County population 1990 distribution of people by health status area and income as a percent of poverty level 47 Table 17a Maricopa County census 1990 people by language spoken at home and health status area 48 Table 17b Maricopa County census 1990 people by language spoken at home and health status area 49 Table 18 Maricopa County percentage of births in 1991 and 1995 delivered in hospital 51 Table 19 Number and percentage of caesarian deliveries by method of payment (1991) 51 Table 20 Number and percentage of caesarian deliveries by method of payment (1995) 52 Table 21 Types of data and sources M-3 Table 22 Population estimates Maricopa County, 1980-1995 M-4 Table 23 Definitions of Healthy People 2000 grouped cause-of-death data By international classification of disease codes, ninth revision M-5 1 Introduction middle age range, but still with higher percentages of young children than the national figures. Maricopa County, as well as other areas in Arizona, experienced exceptional demographic growth from 1990 to 1995. The Census figures for these two years show a net increase of 20 percent in the total population, and up to 50 percent in minority groups (see Figure 1). The increase has been greatest among children under 20 years old (28 percent) and among those 3059 years of age (31 percent). Maricopa County’s population pyramid (see Figure 2, page 2) is becoming more and more similar to that of the United States, with greater proportions of the population distributed in the The geographic distribution of the population also has changed. Although all health status areas grew in total population, Glendale, Scottsdale, Tempe, Mesa and the West County grew at faster rates. The Scottsdale health status area increased by 34 percent and the Mesa Area by 28 percent in the five intercensal years. The percentage share of the county population decreased for the city of Phoenix and increased for all other areas (see Table 1, page 3). Figure 1 Population by race/ethnicity and gender Maricopa County, 1990 Census and 1995 Special Census Percent change 1990-1995 60 51.2 50 40 34.9 30 25.5 22.5 20.2 18 20 12.1 10 1.9 0 Hispanic Black 1990 No. 1,637,076 White 345,498 70,843 38,017 36,294 1,045,778 1,076,323 1995 No. 1,834,847 522,487 88,923 38,735 48,966 1,281,574 1,270,191 % Change Change 12.1 197,771 51.2 176,989 25.5 18,080 Nat. Am. Asian 1.9 718 34.9 12,672 Male Female 22.5 235,796 Total 2,122,101 2,551,765 18 193,868 20.2 429,664 EXECUTIVE 2 Figure 2 Maricopa County Population Pyramid Biologic Environment Population Distribution: 1995 Population Distribution: 1995 Age 90 80 70 60 50 Women of child bearing age 15-45 40 Children age 1-5 30 Children age 0-1 20 10 5 20 10 Females 10 thousands 1,270,191 20 Males 1,281,574 1995 4.0 millions 40 3.0 3,405,237 millions 2,915,995 3.0 2,122,101 2.0 2.0 1990 1998 2005 S U M MARY 3 Table 1 1995 population by health status area Area Male % Female % Total % Increase since 1990 % Sun City 29,863 43.0 39,667 57.0 69,530 27.7 21 Glendale 123,356 49.7 124,687 50.3 248,043 9.7 24 North Phoenix 246,005 50.1 244,625 49.9 490,630 19.2 15 Central Phoenix 198,476 50.5 194,400 49.5 392,876 15.2 12 South Phoenix 111,488 53.1 98,602 46.9 210,090 8.2 9 Scottsdale/N.E. 102,032 48.6 108,091 51.4 210,123 8.2 34 Tempe/Ahwatukee 111,966 51.7 104,667 48.3 216,633 8.5 25 Mesa/East Valley 295,822 49.9 296,923 50.1 592,745 23.2 28 58,122 52.0 53,755 48.0 111,877 4.4 22 4,444 48.2 4,774 51.8 9,218 0.4 12 1,281,574 50.2 1,270,191 49.8 2,551,765 99.9 20 West/Valley Indian Reservations Total Natality Births increased by 10 percent during the period 1991 - 1995. Minorities, including African-Americans, Hispanics/Latinos, Asians and Native Americans, have significantly higher birth and fertility rates than Whites, in some cases three times higher (see Table 2 and Figure 3, page 4). Hispanics made up 34 percent of births in 1995 (see Table 3, page 4) although they comprise just 20 percent of the total population. Other minorities follow a similar pattern. Teenage births continue to be of concern in Maricopa County. Compared to the most recent available U.S. data, the fertility rates of Hispanic/Latino adolescents in Maricopa County are above the national average (Table 2) and account for most of the increase in the total county adolescent fertility rates. These high rates of pregnancies and live births among adolescents is worrisome for both medical and socioeconomic reasons. Table 2 Births per 1,000 women by age and race/ethnicity Age 10 - 14 15 - 17 Race/Ethnicity W H B Total W H B M.C. 1995 0.5 5.1 3.4 1.8 23.3 128.3 61.4 U.S. 1995 0.4 2.7 4.3 1.3 22.0 72.9 72.1 18 - 19 Total W H B Total 49.5 74.3 256.7 157.7 120.4 36.0 66.1 157.9 141.9 89.1 EXECUTIVE S U M MARY 4 Figure 3 Birth* and fertility** rates Maricopa County, 1995 Rate 180 White 160 Hispanic 147.4 Black 140 Native Am. Asian 120 Total 93.5 100 78.2 75.8 80 72.7 58.3 60 37.8 40 24.8 20.9 20.1 18.2 13.6 20 0 Birth Rate Fertility Rate *Births per 1,000 1995 population. **Births per 1,000 women aged 15-44. Table 3 Resident number of births by race/ethnicity of mother and year, Maricopa County 1991 TOTAL 1992 1993 1994 1995 39,907 (100.0) 40,077 (100.0) 40,392 (100.0) 42,313 (100.0) 44,020 (100.0) Non Hispanic White 25,071 (62.8) 24,723 (61.7) 24,532 (60.7) 24,852 (58.7) 25,495 (57.9) Hispanic 11,238 (28.2) 11,809 (29.5) 12,282 (30.4) 13,662 (32.3) 14,909 (33.9) Non Hispanic Black 1,846 (4.6) 1,775 (4.4) 1,711 (4.2) 1,772 (4.2) 1,627 (3.7) Native American 1,104 (2.8) 1,071 (2.7) 1,086 (2.7) 1,112 (2.6) 1,076 (2.4) Asian 630 (1.6) 709 (1.8) 754 (1.9) 868 (2.1) 867 (2.0) Other 18 (<0.1) 10 (<0.1) 27 (0.1) 47 (0.1) 46 (0.1) 5 The percent of deliveries without prenatal care in Maricopa County also have been consistently higher than the national average. A comparison of Maricopa County figures with the latest available U.S. figures shows that a higher percentage of mothers of all ethnicities except Asian did not receive prenatal care in the first trimester (see Table 4). In 1995, 8.3 percent more mothers did not get prenatal care in the first trimester than nationally. By age, the mothers most at risk for not having prenatal care in the first trimester are teenage mothers and those age 40 years and older. The percentage of deliveries paid by Medicaid through the Arizona Health Care Cost Containment System (AHCCCS) has increased over time, from 34 percent in 1991 to 43 percent in 1995. The total low birthweight rate in Maricopa County is moderate, 6.6 percent. It is below the national average, but has shown some tendency to increase over the five year period (see Figure 4, page 6). The major reason for this low rate is the small percentage of all births in Maricopa County born to African American mothers. As shown in Figure 5 (page 6), African-American births have twice the low birthweight rate of white infants (13.7 percent). This results in higher infant mortality and morbidity. All other ethnic groups have comparably low rates. This same pattern is also evident among premature births (see Table 5, page 7). Table 4 Percent of women giving birth with no prenatal care during the first trimester by race/ethnicity Maricopa County, 1987-1995 and U.S., 1987-1995 Race/ethnicity 1987 US% %MC 1988 US% %MC 1989 US% %MC 1990 US% %MC 1991 US% %MC White 18.3 20.2 18.2 20.7 17.3 21.4 16.7 18.7 16.3 17.4 Hispanic 40.0 37.9 41.7 43.6 43.3 46.3 42.2 45.5 41.3 42.7 Black 40.0 37.6 39.6 41.2 40.1 45.6 39.3 40.3 38.1 40.7 Native American 42.4 47.1 41.9 55.6 42.1 61.8 42.1 59.4 40.1 52.9 Asian 25.0 23.0 24.5 23.5 25.2 27.7 24.9 19.5 24.7 20.3 Total 24.0 25.4 24.1 27.8 24.5 29.9 24.2 28.0 23.8 26.6 Race/ethnicity 1992 US% %MC 1993 US% %MC 1994 US% %MC 1995 US% %MC White 15.1 15.3 14.4 16.9 17.2 17.2 16.4 17.6 Hispanic 37.9 37.7 35.2 40.7 32.7 41.3 30.9 41.3 Black 36.0 35.2 33.9 35.7 31.7 34.3 29.6 34.5 Native American 37.9 46.9 36.6 43.7 34.8 46.9 33.3 44.3 Asian 23.4 17.3 22.4 21.0 20.3 23.3 20.1 18.4 Total 22.3 23.7 21.1 25.8 19.8 26.6 18.7 27.0 EXECUTIVE S U M MARY 6 Figure 4 Percent low birthweight births* by year, 1987-1995 Maricopa County, Arizona and United States 7.5 7 6.5 6 5.5 Maricopa Co. Arizona U.S. 5 87 Maricopa Co. Arizona U.S. 88 89 90 91 6.6 6.3 6.3 6.5 6.6 6.5 6.3 6.4 6.5 6.9 6.9 7.1 7 92 93 6.5 6.5 94 95 6.7 6.6 6.7 6.5 6.7 6.8 6.7 7.1 7.1 7.1 7.3 7.3 Source: National Center for Health Statistics, Maricopa County Department of Public Health, Arizona Department of Health Services. *Low birthweight births = < 2,500 grams. Figure 5 Low birthweight* by race/ethnicity Maricopa County, 1991-1995 Percent of live births with low birth weight 16 1991 1992 1993 1994 1995 14 Year 2000 Goal 12 10 8 6 4 2 0 White Hispanic Black Native Am. Asian Total 1991 6 7 13.2 7.4 5.9 6.7 1992 5.9 6.6 13.5 5.5 7.3 6.5 1993 6 6.6 13.4 5.4 7 6.5 1994 6.3 6.6 13.4 5.6 8.5 6.7 13.7 6.4 5.9 6.6 1995 *Low birthweight = <6.52,500 grams. 6.2 7 Table 5 Percent premature deliveries (<37 weeks) by year and ethnicity 1991 1992 1993 1994 1995 Total 7.9 8.3 8.8 8.9 8.8 Hispanic 8.2 8.6 8.7 8.8 8.7 14.4 13.4 15.1 13.8 15.6 Native American 8.4 6.6 7.4 7.6 9.1 Asian 7.0 8.3 8.8 9.8 8.0 White 7.3 7.8 8.4 8.6 8.5 Black Figure 6 shows the percent of low birthweight babies among deliveries in 1993 by ethnicity and place of birth of the mother. As is the case in the U.S. as a whole, mothers born outside the U.S. have generally a better outcome (lower percentage of small babies) than those born in the U.S., regardless of ethnicity. The exception to this pattern in the county are White/Anglo mothers born outside the U.S. or Mexico. In Maricopa County, mothers born in Mexico have the lowest percentage of low birthweight babies. This pattern is most likely the consequence of two main phenomena, the “healthy immigrant” effect (immigrants are generally healthy, because it takes health to migrate), and the benefit of some cultural traits among mothers born elsewhere (social support systems, traditional diets, low proportions of smokers and others). Figure 6 Percent low birthweight births* by race/ethnicity and mother’s place of birth Maricopa County, 1993 Percent Low Birth Weight 18 Arizona Other U.S. Mexico Rest of World 16 14 12 10 8 6 4 2 0 White Hispanic Arizona 5.3 8.4 Other U.S. 6.2 8.4 Mexico Rest of World 3.9 5.8 8.5 4.1 *Low birthweight = <2,500 grams. Black Asian 12.8 15 0 10.5 Total 8.3 6.4 15.7 6.8 0 5.7 5.7 6.9 EXECUTIVE S U M MARY 8 Mortality Infant mortality in Maricopa County is consistently below that of the U.S. and slightly higher than the rest of Arizona (see Figure 7). However, when the infant mortality rate is adjusted for ethnic/racial composition to the distribution of the U.S. birth cohort, the Maricopa County rates become the same or higher than the national ones. This means that if Maricopa County were to have the same percentage of White/Anglo mothers, AfricanAmerican mothers, Hispanic mothers and so forth as the U.S., given the infant mortality rates each ethnic group has in the county, the overall infant mortality rate would be higher than the nation’s. The highest infant mortality rates in the county occur among African-Americans (see Figure 8, page 9), who had a rate of 15.4 infant deaths per 1,000 live births for 1995. Native Americans (9.3) and Hispanics (7.9) follow in distant second and third places. Table 6 (page 9) shows progress toward Year 2000 Objectives related to infant health. Geographically infant mortality also is not evenly distributed. The health status areas of South and Central Phoenix, Glendale and the West County show considerably higher rates than the average for the whole county. Conversely, Scottsdale, Tempe and Mesa show the lowest rates (see Figures 9 and 10, page 10). These differences follow the socioeconomic and ethnic composition of each area, with those areas having the lowest income, lowest socioeconomic levels, and the least access to health care (as measured by lack of insurance coverage), showing the highest infant mortality. Figure 7 Infant mortality, 1987-1995 Maricopa County, Arizona, United States, Year 2000 goal Deaths per 1,000 Live Births 12 Maricopa Co. U.S. 11 Arizona Year 2000 Goal 10 9 8 7 6 1987 Maricopa Co. U.S. Arizona Year 2000 Goal 1998 10 1989 1990 1991 1992 1993 1994 1995 10 9.2 8.9 8.4 8.6 7.8 7.9 10 9.8 9.2 8.9 8.5 8.3 7.9 7.6 9.4 9.7 9.1 8.7 8.6 8.3 7.7 7.9 7.6 7 7 7 7 7 7 7 7 7 10.1 7.4 9 p Deaths per 1,000 live births Figure 8 Infant mortality rates by race/ethnicity Maricopa County, 1991-1995 25 1991 1992 1993 1994 1995 20 Year 2000 Goal 15 10 5 0 White Hispanic Black Native Am. Asian Total 1991 6.6 10.6 14.4 14.2 6.2 8.4 1992 7.6 9.7 19.9 3.7 2.8 8.6 1993 6.6 8.9 19.9 7.4 6.6 7.8 1994 6.6 9.1 16.4 11.7 2.3 7.9 1995 6.6 7.9 15.4 9.3 2.3 7.4 Because Whites and Mexican-Americans have low infant mortality nationally, Year 2000 Objectives for these populations have not been specified. Table 6 Year 2000 Objectives to reduce infant mortality and Maricopa County rates, 1987-1995 Maricopa County crude mortality rates* Objective number Year 2000 national objectives 87 88 89 90 91 92 93 94 95 14.1 Reduce the infant mortality rate to < 7/1,000 10.0 10.0 9.2 8.9 8.3 8.6 7.8 7.8 7.4 14.1a among Blacks < 11/1,000 19.4 25.9 18.8 20.0 14.6 19.9 19.9 16.4 15.4 14.1b among American Indians < 8.5/1,000 8.9 9.6 9.0 11.9 10.1 3.7 7.4 11.7 9.3 14.1d Reduce the neonatal mortality rate to < 4.5/1,000 live births 6.4 6.4 5.7 5.7 5.1 4.9 5.2 5.0 4.8 14.1e among Blacks <7/1,000 live births 13.8 20.6 11.6 12.4 9.8 9.1 12.3 9.0 6.8 14.1g Reduce the postneonatal mortality rate to < 2.5/1,000 live births 3.6 3.6 3.5 3.2 3.3 3.6 2.6 2.9 2.6 14.1h among Blacks < 4/1,000 live births 5.6 5.3 7.2 7.6 4.8 10.8 7.6 7.3 8.6 14.1i among American Indians < 4/1,000 live births 4.0 4.4 4.5 5.5 4.5 1.9 1.8 7.2 3.7 *Some rates might not add due to rounding. EXECUTIVE S U M MARY 10 Figure 9 Infant mortality, selected health status areas Maricopa County, 1987-1995 Deaths per 1,000 Live Births N. Phoenix Scottsdale Tempe Mesa County 16 14 12 10 8 6 4 1987 1990 1991 1992 7.5 9.3 9.5 8.2 5 6.6 8.4 9.3 Scottsdale 8.9 11.7 6 6.6 4.7 8.5 6.1 5.6 7.1 Tempe 9.8 5.7 7.9 9.2 6 7.7 5.3 5.5 5.5 8.8 8.9 6.3 7.2 7.6 7.2 7.5 6.6 6.2 10 10 9.2 8.9 8.4 8.6 7.8 7.9 7.4 1995 N. Phoenix Mesa County 1988 1989 1993 1994 1995 8.4 Figure 10 Infant mortality, selected health status areas Maricopa County, 1987-1995 Deaths per 1,000 Live Births Glendale Cent. Phoenix S. Phoenix West Co. County 16 14 12 10 8 6 4 1987 Glendale Cent. Phoenix S. Phoenix West Co. County 1993 1994 12.4 9.7 9.4 8.9 11.4 8.7 7.8 7.5 10.7 8.9 12.7 12.2 8.7 9.5 8.6 8.9 7.6 12 14.5 12.2 9.3 13.3 12 9.3 9.4 10.7 10.4 10 1988 1989 9 10 1990 1991 1992 9.3 10.1 9.3 8.5 11.3 7.1 12 8.7 9.2 8.9 8.4 8.6 7.8 7.9 7.4 11 The single largest group of causes of death among infants is congenital anomalies. This group is followed by Sudden Infant Death Syndrome (SIDS) as the next largest cause of death. Although the percentage of infant deaths attributable to SIDS changes over the years, the general trend has been a decreasing one, from 19.8 percent in 1991 to 13.3 percent in 1995. For more details, see Table 7. Figure 11 shows the leading causes of death by years of potential life lost. Heart disease, cancer and respiratory illnesses are among the leading causes of death as measured by both years of potential life lost and mortality rates. Unintentional injuries, homicide, suicide and AIDS are especially important among people under 45 years of age, because together with mortality related to substance abuse, they comprise 57 percent of all deaths in this age group. Figures 12-17 (pages 12-15) show mortality rates by cause for specific age groups. Table 7 Maricopa County infant mortality number of deaths by cause, 1987-1995 Cause of death 1987 1988 1989 1990 1991 1992 1993 1994 Infectious diseases 4 9 10 5 4 Neoplasms 2 5 4 2 Endocrine deficiencies 3 2 3 Blood diseases 0 0 Nervous system/mental disorders 5 Circulatory system 10 7 7 9 4 1 1 0 4 4 4 1 1 5 3 0 0 0 0 1 1 0 3 6 6 3 5 2 3 10 11 5 8 5 5 10 2 8 8 Respiratory system 6 10 13 7 12 13 13 19 14 Digestive system 3 0 0 1 8 2 2 5 6 Genitourinary system 2 0 0 0 0 2 1 0 1 Skin and bone diseases 1 0 0 0 0 0 1 0 1 246 256 225 255 212 217 233 218 209 71 78 74 50 66 58 34 42 43 0 3 6 5 4 5 6 2 4 11 9 10 15 7 15 11 17 8 Intentional injuries 1 1 2 2 3 3 2 5 4 Other injuries 1 1 0 0 1 0 0 0 0 367 382 361 357 333 342 317 332 324 Congenital anomalies SIDS Ill-defined diseases Unintentional injuries County total 1995 EXECUTIVE S U M MARY 12 Figure 11 Total years of potential life lost by selected cause of death Maricopa County, 1995 Cause 1. Heart Disease 34,667 2. Unintentional Inj. 31,764 3. Cancer 29,595 4. Congenital Anom. 17,224 5. Homicide 15,683 6. Suicide 13,895 7. AIDS 11,775 8. Respiratory Disease 10,269 0 10,000 20,000 30,000 40,000 Years of Potential Life Lost ( ) Number = Rank as cause of death. Figure 12 Leading causes of death by age (age < 20) Maricopa County, 1995 Age < 20 1. Congenital/Perin. 31.7 2. Unintentional Inj. 21 3. Homicide 11.5 4. Suicide 4.4 5. Pheumonia/Inf. 2.7 6. Cancer 2.1 7. Infections-non-AIDS 2 8. Heart Disease 1.6 0 10 20 Rate per 100,000 population. 30 40 13 Figure 13 Leading causes of death by age (age 20-24) Maricopa County, 1995 Age 20 - 24 1. Unint. Injuries 43.6 2. Homicide 27.7 3. Suicide 25 4. Cancer 8 5. Heart Disease 2.7 6. ETOH/Drugs 1.6 7. AIDS 1.1 8. Genitourinary 1.1 0 10 20 30 40 50 Rate per 100,000 population. Figure 14 Leading causes of death by age (age 25-34) Maricopa County, 1995 Age 25 - 34 1. Unint. Injuries 32.9 2. AIDS 24.7 3. Homicide 21.4 4. Suicide 20.5 5. Cancer 8.2 6. Heart Disease 5.3 7. ETOH/Drugs 4 7. Infect. (non-AIDS) 4 0 10 20 Rate per 100,000 population. 30 40 EXECUTIVE S U M MARY 14 Figure 15 Leading causes of death by age (age 35-44) Maricopa County, 1995 Age 35 - 44 1. Unint. Injuries 50.9 2. Heart Disease 44.5 3. Cancer 38.9 4. AIDS 37 5. Suicide 26.7 6. Drug/ETOH Abuse 22.8 7. Homicide 17 8. Cerebrovascular 10 0 10 20 30 40 50 60 Rate per 100,000 population Rate per 100,000 population. Figure 16 Leading causes of death by age (age 45-64) Maricopa County, 1995 Age 45 - 64 1. Cancer 242.3 2. Heart Disease 188.1 3. ETOH/Drug Abuse 38.7 4. Unintentional Inj. 34.7 5. COPD 29.9 6. Suicide 21 7. Cerebrovascular 20.3 8. AIDS 18.2 0 50 100 150 Rate per 100,000 Rate per 100,000 population population. 200 250 300 15 Figure 17 Leading causes of death by age (age 65+) Maricopa County, 1995 Age 65 + 1. Heart Disease 1,519.7 2. Cancer 1,054.2 3. Cerebrovascular 368.5 4. COPD 334.2 5. Pheumonia/Inf. 177.1 6. Mental/Neuro Dis. 110.2 7. Blood Vessels 99.6 8. Genitourinary 78.5 0 500 1,000 1,500 Rate per 100,000 population. Homicides increased sharply in 1994 and 1995 to 13.9 per 100,000 (see Figure 18). The national rate in 1993 was 10.6. The year 2000 Objective is 7.2. The rates of homicide for non residents have been relatively stable. The increases among teenagers have been acute, with adolescents showing rates three times as high as those of the general population (see Figure 19, page 16). The mortality rates due to different types of trauma among adolescents are higher than the rates for all other ages. Figures 19-22 (pages 16-17) show death rates by age for homicides, unintentional injuries, alcohol related automobile deaths, and suicides. These causes need to be examined in the light of total mortality for minors (see Figures 23, 24 and 25, pages 18-19), especially because Arizona and Maricopa county rates are above the national ones. Figure 18 Death rates due to homicides All and County residents only, 1988-1995 15 All Homicides Residents Only 13 11 9 7 All Homicides Residents Only All Count M.C. Only Count 88 89 90 9.8 9.4 9.1 9.3 8.7 8.6 91 10.7 9.5 92 93 94 95 9.7 10 13.5 14.1 9.4 9.7 12.8 13.9 199 196 193 234 216 228 315 342 188 182 183 208 209 222 299 336 EXECUTIVE S U M MARY 16 Figure 19 Adolescent (age 15-19) and County total homicide death rates Maricopa County, 1989-1995 Rate per 100,000 population 40 M.C. All Ages Age 15-19 30 20 10 0 1989 M.C. All Ages 8.7 Age 15-19 12.6 1990 1991 8.6 13.8 9.5 27.5 1992 9.4 23.6 1993 9.7 27.5 1994 1995 12.8 13.8 28.8 35.6 Figure 20 Adolescent (age 15-19) and total all unintentional injury death rates Maricopa County, 1989-1995 Rate per 100,000 population 50 M.C. All Ages Age 15-19 40 30 20 10 0 1989 M.C. All Ages Age 15-19 1990 35.3 36.5 35.7 46.2 1991 1992 31 38.9 1993 1994 1995 22.6 35.5 39.1 38.2 28.2 37.7 27.6 41.1 17 Figure 21 Adolescent (age 15-19) and total alcohol related automobile death rates Maricopa County, 1989-1995 Rate per 100,000 population 40 M.C. All Ages Age 15-19 30 20 10 0 1989 M.C. All Ages 1990 17.1 Age 15-19 25.2 1991 19 36.6 1992 1993 1994 1995 19.1 15.9 15.4 15.3 17.2 28.2 23.6 28.1 28.2 29 Figure 22 Adolescent (age 15-19) and total suicide death rates Maricopa County, 1989-1995 Rate per 100,000 population 20 15 10 5 M.C. All Ages Age 15-19 0 1989 M.C. All Ages Age 15-19 17 13.3 1990 1994 1995 18.1 1991 15.8 1992 14.6 1993 16.4 18.6 16.7 17.3 18.1 10.5 18.6 17.5 19.3 EXECUTIVE S U M MARY 18 Figure 23 Childhood (age 1-4) mortality Maricopa County and United States, 1990-1995 Deaths per 100,000 Children Age 1-4. 70 Maricopa Co. Rate U.S. Rate 60 50 40 30 20 10 0 1990 Maricopa Co. Rate 1991 45.1 U.S. Rate 52 44.2 46.7 1992 1993 38.8 54.8 45.2 44.5 1994 52 44.5 1995 52.7 40.6 U.S data available through 1994. Figure 24 Childhood (age 5-14) mortality Maricopa County, 1989-1995 Deaths per 100,000 Children Age 5-14. 35 Maricopa Co. Rate U.S. Rate 30 25 20 15 10 5 0 1990 Maricopa Co. Rate U.S. Rate 21.2 24.1 U.S data available through 1994. 1991 1992 1993 1994 19.6 23.1 29.2 24.7 24.7 23.8 23.6 22.7 22.5 24 1995 19 Figure 25 Childhood (age 1-19) mortality Maricopa County and Arizona, 1990-1995 Deaths per 100,000 Children Age 1-19. 70 Maricopa Co. Rate 60 Arizona Rate 50 40 30 20 10 0 Maricopa Co. No. Arizona No. 1990 1991 1992 1993 1994 269 291 257 325 303 1995 335 514 518 503 635 619 681 Year 2000 objectives for trauma mortality are considerably lower than the county’s 1995 rates: Cause of death MC 1995 rates (per 100,000) Unintentional injuries 38.2 Motor vehicle (alcoh) 19.1 Motor vehicle (alcoh) adolesc. 29.0 Homicide 13.9 Suicide 16.7 Suicide (adolescents) 19.3 Yr. 2000 Objective 29.3 14.2 26.8 07.2 10.5 08.2 EXECUTIVE S U M MARY 20 Figures 26 and 27 show U.S. and County mortality rates for AIDS by selected ethnicity, sex and age categories. Although the local rates generally are slightly below the national rates, the increases among minority males have followed the national pattern. Rates nationally for Native American males, however, are considerably lower (16.1 per 100,000 for those between 25 and 44 years of age) than the local rates for all ages (24.7). The numbers, however, are small. These rates pre-date the new drug regimens beginning in 1995. Between 15 percent and 16 percent of deaths in Maricopa County are attributable to tobacco use (see Table 8, page 21). An estimated 25 percent of the population smokes. Figure 26 AIDS mortality rates by race/ethnicity and sex United States, 1990 and 1994 (all ages) 15.8 19.2 White Male 42.3 Black Male 59.3 1.1 White Female 1.7 10.2 Black Female 14.9 23.2 All 25-44 29.8 23.2 White Male 25-44 29.8 102 Black Male 25-44 137.1 59.2 Hispanic Male 25-44 68 7.7 Native Am. Male 25-44 16.1 1.5 White Female 25-44 2.4 23.6 24.1 Black Female 25-44 8.9 Hilspanic Female 25-44 12.3 1990 3 Native Am. Female 25-4 1994 2 0 20 40 60 80 100 120 140 160 Rate per 100,000 population Figure 27 AIDS mortality rates by race/ethnicity and sex Maricopa County, 1990, 1992 and 1994 (all ages) 8.1 Total (All Ages) 11.1 13.2 15.6 White Male 19.6 23.2 21.3 Black Male 45.6 41.2 7.9 Hispanic Male 16.6 22.6 5.4 5.2 Native Am. Male 24.7 1 1.1 1 White Female 0 5.2 Black Female 9.9 0.6 1.1 1.1 Hispanic Female 0 0 Native Am. Female 1990 1992 1994 0 0 10 20 30 Rate per 100,000 population 40 50 60 21 Table 8 Tobacco attributable deaths Maricopa County, 1990-1996 Year Cause of Death 1990 1991 1992 1993 1994 1995 Lung cancer (total) 87 percent tobacco related* 1,065 927 1,143 994 1,191 1,036 1,203 1,047 1,234 1,074 1,222 1,063 Coronary heart disease (total) 21 percent tobacco related* 3,991 838 3,830 804 4,008 842 4,456 936 4,517 949 4,628 972 COPD (total) 82 percent tobacco related* 874 717 898 736 928 761 1,027 842 1,038 851 1,152 944 2,482 2,434 2,639 2,825 2,874 2,979 Infant mortality (total) 10 percent tobacco related* 358 36 334 33 343 34 317 32 333 33 324 32 Total percent of deaths tobacco related 15.9 16.0 15.6 15.6 15.3 15.6 2,518 118.7 2,567 117.6 2,673 119.7 2,857 125.0 2,907 124.3 3,011 118.0 15,814 745.2 16,075 736.7 17,085 764.9 18,320 801.7 19,001 812.6 19,340 797.7 Total tobacco related deaths (non-infant) Grand total tobacco related deaths and rate** Deaths due to all causes and rate** *Percent of total deaths attributable to tobacco. Health United States 1992 and Healthy People 2,000 Review. **Rate per 100,000 people, 1990 and 1995 Census and 1991-1996 population estimates. Communicable Disease Morbidity Reported morbidity in Maricopa County during the period 1991 to 1995 decreased for most communicable diseases. Vaccine preventable diseases decreased significantly after relatively large epidemics in 1989-1990 (see Figure 28, page 22). Haemophilus Influenza type b disease decreased dramatically after the introduction of vac- cine in the late 1980s. Meningococcal disease, serotype C, showed unprecedented increases during 1993 (see Figures 29 and 30, page 23). After an intensive community vaccination campaign for children ages two through nine in Central Phoenix, these rates began to decrease, returning to the usual endemic levels in 1996. EXECUTIVE S U M MARY 22 Figure 28 Incidence and rates* of vaccine preventable disease Maricopa County, 1989-1995 Reported Cases 300 Measles 256 Mumps Rubella Pertussis 250 200 153 142 150 101 100 82 75 77 66 62 57 53 48 39 32 50 25 21 11 2 0 3 2 0 0 1 1 0 3 2 0 89 90 91 92 93 94 95 Measles Rate 6.8 7.2 1.5 0 0.1 0 0 Mumps Rate 3.6 3.9 3 1.7 0.5 1 0.1 1 0.1 0.1 0 0 0.1 2.9 2.6 4.5 2.1 3.3 2.2 Rubella Rate 0 Pertussis Rate 12.2 Rate* *Per 100,000 population DES population estimates. Figure 29 Meningitis cases and case rates* (Meningococcal disease and H. Influenzae Meningitis) Maricopa County, 1987-1995 Rate 4 Meningococcal Rate H. Flu Meningitis Rate 3 2 1 0 92 93 Meningococcal Dis. # 21 87 88 15 89 13 8 16 37 63 43 44 H. Flu Meningitis # 58 59 51 23 9 4 5 12 13 *Per 100,000 population DES population estimates. 90 91 94 95 23 Figure 30 Invasive Meningococcal* disease Maricopa County rates** by year of onset, 1983-1995 Rate 3 Trend line@ 2.5 Yearly rates 2 1.5 1 0.5 0 83 Yearly rates 1 Cases 17 84 85 0.5 0.9 9 86 87 1 16 1 19 88 89 90 91 92 93 94 95 0.8 0.6 0.4 0.7 0.8 2.7 1.9 1.8 16 12 16 17 62 44 20 8 45 *All serogroups, ** per 100,000 population DES estimates. @Does not include 1993-1995 data. Tuberculosis rates are below those of the state and the country (see Figure 31). The trend since 1992 has been a slight increase, after a consistent decline during the period 1984-1991. Figure 31 Tuberculosis cases and case rates Maricopa County and Arizona, 1984-1995 and Year 2000 goal Rate per 100,000 population 12 10 8 6 4 2 0 84 85 86 87 88 89 90 91 92 93 94 95 M.C. Rate 8.6 7.9 7 7.2 6.5 6.6 6.9 5.1 6.5 5.3 6.2 7.3 State Rate 9 8.6 7.8 8.1 7.5 8.3 7.5 8.8 7.4 6.3 6.1 7.6 M.C. Number 147 144 133 143 133 137 146 113 145 121 144 176 State Number 273 271 261 278 268 304 275 324 258 230 247 317 11.5 11.3 11.1 10.9 10.7 10.5 10.3 10.4 10.5 9.8 9.4 8.7 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 U.S. Rate Year 2000 Goal 3.5 3.5 3.5 EXECUTIVE S U M MARY 24 Syphilis and gonorrhea rates have decreased since 1990, with syphilis showing a slight increase in 1995. This increase continued during 1996 and 1997. Both chlamydia and gonorrhea rates have shown much higher rates among teenagers than among adults. Chlamydia rates have not decreased during this period (see Figures 32-34). Figure 32 Syphilis rates by selected age groups Maricopa County, 1989-1995 Rate per 100,000 population 50 Age 10-19 All Ages 40 30 20 10 0 Age 10-19 All Ages 89 90 91 92 23.5 22.5 13.5 8.9 32.3 46.7 30.2 19.3 93 7.7 13.7 94 3.8 95 2.1 9.1 11.5 93 94 95 255.6 252.3 190.6 120.8 125.4 Figure 33 Gonorrhea rates by selected age groups Maricopa County, 1989-1995 Rate per 100,000 population 400 300 200 100 Age 10-19 All Ages 0 Age 10-19 All Ages 89 90 91 92 365.8 281.1 323.7 273.7 211.9 170.1 161.9 149.1 136 25 Figure 34 Chlamydia rates by selected age groups Maricopa County, 1989-1995 Rate per 100,000 population 800 600 400 200 Age 10-19 All Ages 0 89 Age 10-19 All Ages 389.3 168.8 90 561 246.8 91 728 283.2 Surveillance data for self-limiting diseases not preventable by vaccine, such as Hepatitis A and enteric infections are incomplete for the period 1992 - 1995, due to reductions in 93 94 95 669.3 92 687.7 696.6 630.3 257.4 238.3 230.7 246.1 surveillance staff. It is not possible to unequivocally state that the reductions observed in the rates are real rather than artifactual (see tables 9a, page 26, and 9b, page 27). EXECUTIVE S U M MARY 26 Table 9a General communicable diseases diagnoses by year, 1987-1991 # Enteric Diseases Amebiasis Cholera Campylobacteriosis Giardiasis Salmonellosis Shigellosis Typhoid fever Other 1987 Rate # 1988 Rate 1989 # Rate # 1990 Rate 1991 # Rate 2148 36 0 384 802 297 625 1 3 108.7 1.8 0 19.4 40.6 15.0 31.6 0.1 0.2 2159 28 0 413 763 307 644 4 0 106.3 1.4 0 20.3 37.5 15.1 31.7 0.2 0 2007 27 0 421 746 319 490 4 0 96.0 1.3 0 20.1 35.7 15.3 23.4 0.2 0 2428 20 0 495 659 389 840 16 10 Vaccine Preventable Measles Mumps Pertussis Rubella Other Vaccine Preventable Other 210 0 97 21 4 0 88 10.6 0 4.9 1.1 0.2 0 4.5 503 5 102 297 0 0 99 24.8 0.2 5.0 14.6 0 0 4.9 538 142 75 240 0 0 81 25.7 6.8 3.6 11.5 0 0 3.9 361 154 82 63 21 0 41 17.0 7.3 3.9 3.0 1.0 0 1.9 188 46 66 57 2 0 17 8.6 2.1 3.0 2.6 0.1 0 0.8 Central Nervous System 256 13.0 169 8.3 146 7.0 202 9.5 108 4.9 Aseptic meningitis Primary enceph Post-viral enceph Meningococcal meningitis Haemophilus infl. mening. Other bacterial meningitis Other 131 10 1 13 56 24 21 6.6 0.5 0.1 0.7 2.8 1.2 1.1 56 9 1 8 58 16 21 2.8 0.4 ***.* 0.4 2.9 0.8 1.0 52 4 0 10 50 15 15 2.5 0.2 0 0.5 2.4 0.7 0.9 132 6 0 5 23 17 19 6.2 0.3 0 0.2 1.1 0.8 0.9 53 5 1 10 9 11 19 2.4 0.2 ***.* 0.5 0.4 0.5 0.9 Viral Hepatitis 2131 107.8 1863 91.7 2000 95.7 1233 58.1 828 37.9 Hepatitis A Hepatitis B Hepatitis Non-A,B Other 1381 618 117 15 69.9 31.3 5.9 0.8 1371 425 60 7 67.5 20.9 3.0 0.3 1557 388 43 12 74.5 18.6 2.1 0.6 843 334 51 5 39.7 15.7 2.4 0.2 722 81 7 18 33.1 3.7 0.3 0.8 Zoonoses Coccidioidomycosis All other conditions 20 154 13 1.0 7.8 0.7 24 162 34 1.2 8.0 1.7 15 173 34 0.7 8.3 1.6 18 155 22 0.8 7.3 1.0 14 210 33 0.6 9.6 1.5 Total Acute diseases 4932 249.5 4914 241.8 4913 235.1 4420 Rates are per 100,000 estimated population based on DES projections and 1990 Census. 114.5 1830 0.9 55 0 0 23.3 419 31.1 447 18.3 368 39.6 528 0.8 4 0.5 9 83.9 2.5 0 19.2 20.5 16.9 24.2 0.2 0.4 208.3 3211 147.2 27 Table 9b General communicable diseases diagnoses by year, 1992-1995 Enteric Diseases Amebiasis Cholera Campylobacteriosis Giardiasis Salmonellosis Shigellosis Typhoid fever Other 1992 # Rate 1641 71.8 74 3.2 0 0 418 18.3 404 17.7 326 14.4 416 18.2 1 0.1 2 0.1 1993 # Rate 1183 50.6 55 2.4 0 0 314 13.4 284 12.2 218 9.3 309 13.2 1 0.1 2 0.1 1994 # Rate 1032 44.1 41 1.8 0 0 247 10.6 247 10.6 219 9.4 273 11.7 1 0.1 4 0.2 1995 # Rate 1408 55.2 51 2.1 0 0 284 11.7 243 10.0 291 12.1 517 21.4 3 0.1 19 0.7 Vaccine Preventable Measles Mumps Pertussis Rubella Other Vaccine Preventable Other 142 0 39 101 2 0 0 6.7 0 1.7 4.4 0.1 0 0 60 3 11 46 0 0 0 3.1 0.1 0.5 2.0 0 0 0 103 1 25 77 0 0 0 4.4 0.1 1.1 3.3 0 0 0 80 1 19 56 3 1 0 3.3 0.1 0.7 2.3 0.1 0.1 0 Central Nervous System Aseptic meningitis Primary enceph Post-viral enceph Meningococcal meningitis Haemophilus infl. meningitis Other bacterial meningitis Other 112 79 2 0 17 4 0 10 4.9 3.5 0.1 0 0.7 0.2 0 0.5 199 126 3 0 63 5 1 1 8.6 5.4 0.1 0 2.7 0.2 0.1 0.1 108 53 0 0 43 12 0 0 4.6 2.3 0 0 1.8 0.5 0 0 131 63 3 1 39 2 12 11 5.1 2.7 0.1 0.1 1.7 0.1 0.5 0.4 Viral Hepatitis Hepatitis A Hepatitis B Hepatitis Non-A,B Other 930 819 104 3 4 40.7 35.8 4.6 0.1 0.2 565 532 28 3 2 24.2 22.8 1.2 0.1 0.1 676 636 37 0 3 28.9 27.2 1.6 0 0.1 666 566 61 36 3 27.8 23.4 2.5 1.5 0.1 16 0.7 3 0.1 20 1.0 18 0.7 Coccidioidomycosis All other conditions 294 28 12.9 1.8 316 22 13.5 1.0 310 56 13.3 2.2 398 350 15.6 13.7 Total Acute diseases 3163 139.4 2348 101.3 2305 98.5 3051 127.1 Zoonoses Rates are per 100,000 estimated population based on DES projections and 1990 Census. EXECUTIVE S U M MARY 28 Tables 10 and 11 (pages 29-30) show year 2000 Objectives and rates for the county for most sexually transmitted diseases, including AIDS. The rates in Maricopa County are below both the current national rates and year 2,000 objectives. One notable exception is chlamydia. Table 10 Year 2000 Objectives to reduce sexually transmitted diseases Maricopa County rates by year of diagnosis, 1987-1995 Maricopa County crude morbidity rates per 100,000 Objective Year 2000 Number National Objectives 87 88 89 90 91 92 93 94 95 11.3 13.0 17.8 18.6 18.6 22.3 18.9 15.9 13.9 203.2 180.9 193.5 155.3 142.5 149.2 135.9 120.8 125.4 18.0 Reduce the incidence of AIDS to no more than 43.0 cases per 100,000 19.1 Reduce gonorrhea to an incidence of no more than 225 cases per 100,000 19.1a among Blacks< 1,990/100,000 2200.0 2155.4 2600.6 1880.0 1908.6 1847.4 1566.8 1324.2 1058.2 19.1b among Adolescents aged 15-19 < 1,123/100,000 19.2 Reduce Chlamydia trachomatis infections, as measured by a decrease in the incidence of nongonococcal urethritis to < 170/100,000 19.3 Reduce primary and secondary syphilis to an incidence of < 10/100,000 19.3a among Blacks < 188/100,000 19.4 Reduce congenital syphilis to an incidence of < 50/100,000 705.0 580.9 702.6 502.2 561.1 386.5 284.5 490.1 351.1 50.8 91.1 141.2 217.4 239.7 257.6 237.8 230.7 233.9 8.5 4.4 15.0 23.7 12.2 6.5 2.3 1.3 1.7 68.9 35.6 217.4 274.6 112.4 61.7 15.1 11.1 29.2 0.0 0.0 28.1 62.1 40.1 47.4 19.8 30.7 13.6 29 Table 11a Maricopa County incidence of reported cases of sexually transmitted diseases and AIDS, 1987-1991 Count and rate by year of diagnosis Disease Total Syphilis 1987 # Rate 1988 # Rate 1989 # Rate 1990 # Rate 1991 # Rate 482 24.4 404 19.9 625 29.9 932 43.9 627 28.7 0 0.0 0 0.0 11 0.5 25 1.2 16 0.7 Primary Syphilis 87 4.4 49 2.4 175 8.4 298 14.0 160 7.3 Secondary Syphilis 82 4.1 40 2.0 138 6.6 206 9.7 106 4.9 313 15.8 315 15.5 301 14.4 403 19.0 345 15.8 Congenital Syphilis Other Syphilis Gonorrhea 4016 203.2 3675 180.9 4043 193.5 3295 155.3 3109 142.5 Chlamydia 1004 50.8 1851 91.1 2950 141.2 4614 217.4 5231 239.7 894 45.2 833 41.0 919 44.0 1123 52.9 1085 49.7 Urethritis 1824 92.3 2019 99.4 1596 76.4 1860 87.6 2012 92.2 Vaginitis 889 45.0 1053 51.8 1024 49.0 1557 73.4 1107 50.7 88 4.5 145 732 188 9.0 352 16.7 336 15.4 Herpes Genitalis Other Total STD’s AIDS 9197 465.3 224 11.2 9980 491.1 264 13.2 11345 542.8 371 13773 647.1 18.6 Rates are per 100,000 estimated population based on DES projections and 1990 and 1995 Census. 394 18.8 13507 619.0 406 18.8 EXECUTIVE S U M MARY 30 Table 11b Maricopa County incidence of reported cases of sexually transmitted diseases and AIDS, 1992-1995 Count and rate by year of diagnosis Disease Total Syphilis 1992 # Rate # 1993 Rate 1994 # Rate # 1995 Rate 431 19.3 320 12.0 214 8.6 279 11.2 Congenital Syphilis 19 0.9 8 0.3 13 0.6 6 0.2 Primary Syphilis 70 3.1 21 0.9 20 0.9 30 1.2 Secondary Syphilis 76 3.4 32 1.4 10 0.4 14 0.5 266 11.9 259 11.3 171 7.3 229 9.0 Other Syphilis Gonorrhea 3332 149.2 3113 135.9 2825 120.8 3201 125.4 Chlamydia 5753 257.6 5449 237.8 5395 230.7 5968 233.9 Herpes Genitalis 1239 55.5 1085 47.4 1200 51.3 1566 61.4 Urethritis 2346 105.0 1288 56.2 7 0.3 6 0.2 Vaginitis 1086 48.6 552 24.1 229 9.8 12 0.5 80 3.6 82 3.6 33 1.4 199 7.8 Other Total STD’s AIDS 14267 631.8 499 22.3 11889 570.1 433 18.9 9903 424.4 354 15.9 Rates are per 100,000 estimated population based on DES projections and 1990 and 1995 Census. 11231 449.2 337 13.9 31 Behavioral risk factors The data to measure these risk factors comes from the Behavioral Risk Factor Survey, a national survey sponsored by the CDC. Unfortunately, the sample sizes are designed for statewide estimates and not for specific county estimates. sentative of county population. These data are consistent with other sources and surveys, the CDC has validated the questionnaire and the results show high reliability. Smoking Figures 35 through 41 show the distribution of smokers by different population characteristics. Non-Hispanic Whites, males, middle aged people and those with lower income and education were the groups with the highest prevalence of smoking. Hispanic mothers smoked during pregnancy at a rate two thirds lower than other mothers did. These data should help focus some of the tobacco reduction activities in the county. Until 1992, Maricopa County sponsored its own Behavioral Risk Factor Survey. After that year, due to budget cuts, it has not been repeated. The data presented here are the results of the 1991 survey. The estimates for 1992 were not significantly different from 1991. The response rate of the survey was more than 80 percent and the geographic distribution was repre- Figure 35 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by ethnicity for Maricopa County and Arizona Maricopa County Arizona Percent 30 25 Year 2000 Objective 20 15 10 5 0 Maricopa County Arizona White Non-Hispanic Hispanic Black Non-Hispanic 25.4 18.2 25.1 22.6 13.8 10.1 26.4 17 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Other = Asian, Native American and unknown Other EXECUTIVE S U M MARY 32 Figure 36 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by sex for U.S., Arizona and Maricopa County Male Female Percent 30 25 20 Year 2000 Objective 15 10 5 0 U.S. Male Female Arizona Maricopa County 21.3 21.4 22.8 25.1 26.2 25.8 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Figure 37 Maricopa County behavioral risk factor surveillance 1991 percent current smokers among females of Maricopa County and Arizona Maricopa County Arizona Percent 35 30 25 20 15 10 5 0 Age Maricopa County Arizona 18-24 25-34 35-44 22.2 23.6 26.8 28.3 19.8 19 45-54 65-74 75+ 31.2 55-64 22.4 14.3 10.7 23.1 23.1 24.2 3.5 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Current smokers among unknowns of Maricopa County = 14.7 percent, of Arizona = 42.9 percent 33 Figure 38 Maricopa County behavioral risk factor surveillance 1991 percent current smokers among males of Maricopa County and Arizona Maricopa County Arizona Percent 40 35 30 25 20 15 10 5 0 Age Maricopa County 18-24 25-34 35-44 26.3 28.2 28.2 Arizona 23 28 45-54 55-64 34 30.6 24.8 65-74 75+ 22.7 17.7 2.5 24.7 23.3 26.2 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Current smokers among unknowns of Arizona = 10.7 percent Figure 39 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by income for Maricopa County and Arizona Maricopa County Arizona Percent 40 30 20 10 0 Income (Dollars) Maricopa County <10,000 35.8 Arizona 32 10-14,000 31.3 24.5 15-19,999 27 30.9 20-24,000 28.4 23 25-34,999 23.6 25.8 35-50,000 18.7 17 50,000+ Unknown 19.7 19.4 22.5 18.5 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. EXECUTIVE S U M MARY 34 Figure 40 Maricopa County behavioral risk factor surveillance 1991 percent current smokers by educational status for Maricopa County and Arizona Maricopa County Arizona Percent 35 30 25 Year 2000 Objective 20 15 10 5 0 Up to H.S Grad. Maricopa County Arizona Tech. Sch. or Some Col College or Post Grad. 29.8 22.3 17.8 28.7 21.1 16.3 Unknown 0 26.9 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Figure 41 Percentage of mothers who smoked during pregnancy Maricopa County, 1990-1995 Hispanic Non-Hispanic Percent 20 15 10 5 0 1990 Hispanic Non-Hispanic 1991 8.1 19.1 1992 7 18.9 Source: Maricopa County Department of Public Health Division of Epidemiology and Data Services 6.8 16.4 1993 6.6 16.6 1994 6.3 16.6 1995 6.1 16 35 Drinking Figures 42 through 50 show data on chronic and binge drinking as well as drinking and driving. The patterns for these three activities are not the same. Whites have the largest percentage of chronic drinkers, Blacks and Hispanics have the largest percentages of binge drinkers. The highest prevalence of people who drink and drive are in the “other” category, the majority of whom in the Maricopa County survey are Native Americans. This cor- relates well with death rates from automobile accidents with alcohol involvement. Males drink and drive and engage in chronic and binge drinking about three times as often as females. An interesting pattern is the U-shaped curve of female chronic drinkers in Maricopa County, showing higher prevalence of chronic drinking at ages 25 and younger and 65 and older. Males don’t show this pattern. The unemployed and the retired are more likely to be chronic drinkers. Figure 42 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking by race/ethnicity for Maricopa County and Arizona Maricopa County Arizona Percent 8 6 4 2 0 White Non-Hispanic Maricopa County Arizona Hispanic Black Non-Hispanic Other 7.3 4.7 4.6 0 3.3 5.4 1.1 0 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census. Other = Asian, Native America and unknown EXECUTIVE S U M MARY 36 Figure 43 Maricopa County behavioral risk factor surveillance 1991 percent binge drinking by race/ethnicity for Maricopa County and Arizona Maricopa County Arizona Percent 30 25 20 15 10 5 0 White Non-Hispanic Maricopa County 13.7 Arizona 13 Hispanic 23.3 12.9 Black Non-Hispanic 24.5 Other 9.3 7.1 14.7 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Other = Asian, Native American and unknown Figure 44 Maricopa County behavioral risk factor surveillance 1991 percent drinking and driving by ethnicity for Maricopa County and Arizona Maricopa County Arizona Percent 7 6 5 4 3 2 1 0 White Non-Hispanic Maricopa County Arizona Hispanic 2.7 3.7 1.7 3.5 Black Non-Hispanic 0 1.1 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Other = Asian, Native American and unknown Other 6.2 1 37 Figure 45 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking by sex for U.S., Maricopa County and Arizona Female Male Percent 12 10 8 6 4 2 0 Female Male U.S. Arizona 0.9 0.7 6.1 6.4 Maricopa County 2.8 10.7 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Figure 46 Maricopa County behavioral risk factor surveillance 1991 percent binge drinking by sex for U.S., Maricopa County and Arizona Female Male Percent 25 20 15 10 5 0 U.S. Female Male 6.5 21.7 Arizona Maricopa County 4.4 21.5 8 22.9 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. EXECUTIVE S U M MARY 38 Figure 47 Maricopa County behavioral risk factor surveillance 1991 percent drinking and driving by sex for U.S., Maricopa County and Arizona Female Male Percent 5 4 3 2 1 0 U.S. Female Male Arizona Maricopa County 1.1 1 1.7 3.8 3 4.1 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Figure 48 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking among females of Maricopa County and Arizona Maricopa County Arizona Percent 5 4 3 2 1 0 Age Maricopa County 18-24 4.3 Arizona 0 25-34 35-44 45-54 55-64 65+ 2.6 1.8 1.6 2.3 4.5 0.3 1.3 0.5 0.5 1.5 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. 39 Figure 49 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking among males of Maricopa County and Arizona Maricopa County Arizona Percent 12 10 8 6 4 2 0 Age Maricopa County Arizona 18-24 25-34 35-44 45-54 55-64 65+ 11.4 10.6 11.6 10.5 10.3 9.2 8.7 5.3 7.6 5.2 4.9 7 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Figure 50 Maricopa County behavioral risk factor surveillance 1991 percent chronic drinking by employment status for Maricopa County and Arizona Maricopa County Arizona Percent 10 8 6 4 2 0 Maricopa County Arizona Employed Unemployed 6.7 8.9 4.1 4.7 Homemaker 0 0.6 Student Retired 4.8 8.7 0.7 4.6 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. EXECUTIVE S U M MARY 40 Other risk factors Figure 51 describes the percent of people using seat belts always by race/ethnicity. The percentages range from a low of 63.9 for African Americans to a high of 74.6 for Whites and 83.6 for “others.” Figure 52 shows the percentage of people by ethnic group who reports not having spent any time in leisure activities. Hispanics have the highest rates of no leisure time activity. Figure 51 Maricopa County behavioral risk factor surveillance 1991 percent seat belt use by race/ethnicity for Maricopa County and Arizona Maricopa County Arizona Percent 100 80 60 40 20 0 White Non-Hispanic Maricopa County Arizona Hispanic Black Non-Hispanic Other 74.6 69.9 63.9 83.6 72.7 69.3 75.8 56.2 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Other = Asian, Native American and unknown. 41 Figure 52 Maricopa County behavioral risk factor surveillance 1991 percent no leisure time activity by ethnicity for Maricopa County and Arizona Maricopa County Arizona Percent 35 30 25 20 15 10 5 0 White Non-Hispanic Maricopa County Arizona Hispanic Black Non-Hispanic Other 22.9 32.7 29.6 17.5 22.6 31.4 33.4 13.2 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Other = Asian, Native American and unknown EXECUTIVE S U M MARY 42 Socioeconomic data Most of the data in this section are derived from the 1990 Census. The 1995 Census did not include socioeconomic variables. The quality of the data is discussed in the methods section. Socioeconomic information by Health Status Area Tables 12-17b describe socioeconomic indicators for the entire county and for each Health Status Area. Area 5 (South Phoenix and Guadalupe) is the area showing the lowest socioeconomic status levels. Area 6, covering Scottsdale, Paradise Valley and Fountain Hills, show the highest indicators. 308136 325731 High school graduate Some college % of Total Total Graduate degree BS-BA degree 1187142 89425 188860 87954 122662 9th thru 11th grade AA degree 64374 88.3 100.0 7.5 15.9 7.4 27.4 26.0 10.3 5.4 White # % < 9th grade Race Education 2.3 5.0 4.6 11.8 158312 100.0 3658 7838 7356 27244 17.2 34355 21.7 28426 18.0 49435 31.2 Hispanic # % 39633 1765 4112 3403 12017 8592 6322 8.6 % 2.9 100.0 4.5 10.4 8.6 30.3 21.7 16.0 Black 3422 # 18131 461 939 1248 4497 4985 3814 2187 1.3 100.0 2.5 5.2 6.9 24.8 27.5 21.0 12.1 Native Amer. # % # 20573 3321 4712 1578 3531 3211 2018 1.5 100.0 16.1 22.9 7.7 17.2 15.6 9.8 10.7 Asian % 2202 Table 12 Maricopa County 1990 education by ethnicity - total county 1.5 3.6 4.1 16.2 21.9 18.9 5.9 79175 100.0 1152 2826 3213 12840 17331 14989 % 33.9 Other 26824 # 1344654 96124 201449 97396 358616 342255 149805 7.4 % 100.0 100.0 7.1 15.0 7.2 26.7 25.5 11.1 Total 99009 # 43 38,322 6.9 # % # % # % # % # % # % # % # % 4 5 6 7 8 9 10 2,983 13.2 6,676 5.4 1,791 4.3 939 2.1 9,654 23.5 7,488 8.6 4,624 4.0 243,540 44.0 572 30.2 10,542 46.6 58,068 47.2 19,643 47.0 15,701 34.9 17,910 43.5 38,684 44.2 55,493 48.1 26,774 49.9 153 0.7 10,183 1.8 134 7.1 705 3.1 1,763 1.4 647 1.5 575 1.3 1,654 4.0 1,619 1.8 1,666 1.4 841 1.6 579 2.8 260,864 47.2 528 27.9 8,410 37.1 56,605 46.0 19,682 47.1 27,760 61.7 11,914 29.0 39,738 45.4 53,475 46.4 22,527 42.0 20,225 96.4 With No Children Below Above Poverty Poverty Level Level 48,505 8.8 795 42.0 3,688 16.3 8,439 6.9 2,438 5.8 1,514 3.4 11,308 27.5 9,107 10.4 6,290 5.5 4,324 8.1 602 2.9 504,404 91.2 1,100 58.0 18,952 83.7 114,673 93.1 39,325 94.2 43,461 96.6 29,824 72.5 78,422 89.6 108,968 94.5 49,301 91.9 20,378 97.1 All Families Below Above Poverty Poverty Level Level Poverty level as defined in 1990 census, considering income and family size. This table represents families, not households Total 661 34.9 # % 3 3,483 6.5 # % 2 23 0.1 # % With Children Below Above Poverty Poverty Level Level 1 Area Families Table 13 Maricopa County 1990 mean per capita income (in dollars) by race, ethnicity and health status area 552,909 100.0 1,895 100.0 22,640 100.0 123,112 100.0 41,763 100.0 44,975 100.0 41,132 100.0 87,529 100.0 115,258 100.0 53,625 100.0 20,980 100.0 Total EXECUTIVE S U M MARY 44 # % Cum. % # % Cum. % # % Cum. % # % Cum. % # % Cum. % # % Cum. % # % Cum. % # % Cum. % # % Cum. % # % Cum. % 2 3 4 5 6 7 8 9 10 Total 119979 5.7 5.7 2239 27.8 27.8 7917 9.0 9.0 18160 4.0 4.0 10175 6.0 6.0 4151 2.7 2.7 29346 15.8 15.8 22705 6.5 6.5 14006 3.3 3.3 9759 4.9 4.9 1521 2.7 2.7 Under .50 60032 2.9 8.6 738 9.2 37.0 4916 5.6 14.6 10440 2.3 6.2 4621 2.7 8.8 1847 1.2 3.8 14081 7.6 23.4 10491 3.0 9.5 7738 1.8 5.2 4645 2.4 7.3 515 0.9 3.6 .50 to .74 77348 3.7 12.3 757 9.4 46.4 5335 6.1 20.7 14773 3.2 9.5 4795 2.8 11.6 2794 1.8 5.6 16627 9.0 32.4 15022 4.3 13.8 10092 2.4 7.6 6317 3.2 10.5 836 1.5 5.1 .75 to .99 90184 4.3 16.6 759 9.4 55.9 6088 6.9 27.6 17031 3.7 13.2 5295 3.1 14.8 3736 2.4 8.0 16427 8.9 41.3 19337 5.5 19.4 12720 3.0 10.6 7476 3.8 14.3 1315 2.3 7.5 1.00 to 1.24 86743 4.2 20.8 682 8.5 64.4 5526 6.3 33.9 17949 3.9 17.1 5216 3.1 17.9 3314 2.1 10.1 13929 7.5 48.8 17858 5.1 24.5 13902 3.3 13.9 6736 3.4 17.7 1631 2.9 10.4 1.25 to 1.49 98986 4.7 25.5 467 5.8 70.2 6326 7.2 41.1 21422 4.7 21.7 5684 3.4 21.3 4722 3.0 13.2 14693 7.9 56.7 20307 5.8 30.3 15083 3.6 17.5 8458 4.3 22.0 1824 3.2 13.6 1.50 to 1.74 34544 1.7 27.2 209 2.6 72.8 1834 2.1 43.2 8970 2.0 23.7 1872 1.1 22.4 1426 0.9 14.1 3888 2.1 58.8 7358 2.1 32.4 5495 1.3 18.8 2907 1.5 23.5 585 1.0 14.7 1.75 to 1.84 59334 2.8 30.0 311 3.9 76.6 2865 3.3 46.5 13332 2.9 26.6 4223 2.5 24.9 2297 1.5 15.6 6616 3.6 62.4 12687 3.6 36.1 10697 2.5 21.3 5353 2.7 26.2 953 1.7 16.4 1.85 to 1.99 1460595 70.0 100.0 1878 23.4 100.0 46941 53.5 100.0 336711 73.4 100.0 126505 75.1 100.0 131856 84.4 100.0 69762 37.6 100.0 222879 63.9 100.0 331415 78.7 100.0 145692 73.8 100.0 46956 83.6 100.0 2.00 and above 2087745 100.0 100.0 8040 100.0 100.0 87748 100.0 100.0 458788 100.0 100.0 168386 100.0 100.0 156143 100.0 100.0 185369 100.0 100.0 348644 100.0 100.0 421148 100.0 100.0 197343 100.0 100.0 56136 100.0 100.0 Ratio Total Poverty level as defined in 1990 census, considering income and family size. Population figures in 1990 are slightly higher than this total due to data suppression by the U.S.Census Bureau in certain census tracts to protect confideniality. # % Cum. % 1 % of Poverty Level Area Table 14 Maricopa County households 1990 primary language spoken and linguistic isolation by health status area 45 EXECUTIVE S U M MARY 46 Table 15 Maricopa County population 1990 families by poverty status, presence of children (under 18 years) and by health status area Race Area White Black Native American Asian 1 19,985 16,580 21,723 17,415 2 14,434 11,851 9,973 3 16,743 14,620 4 15,405 5 Other Hispanic NonHispanic Total 7,352 10,448 19,987 19,934 11,437 7,561 8,525 14,584 13,669 9,055 12,668 10,153 11,107 16,808 16,443 8,787 7,376 12,566 7,390 7,871 15,573 14,050 9,178 7,100 4,579 8,780 5,482 5,459 10,094 7,669 6 26,760 19,643 11,058 20,359 12,356 13,440 26,956 26,358 7 17,722 12,073 8,588 11,193 9,415 11,076 17,490 16,865 8 14,297 11,160 7,579 13,654 7,922 8,315 14,509 13,772 9 12,225 9,167 6,628 7,136 6,026 5,741 13,048 10,510 10 12,589 0 3,773 9,000 4,520 3,170 5,568 5,270 Total 16,182 9,546 6,660 12,503 7,008 7,608 16,375 14,970 Poverty level as defined in 1990 census, considering income and family size. This table represents families, not households 60134 82.6 143895 87.9 112471 79.6 31846 54.4 60776 89.0 57220 84.0 147497 86.0 19298 68.6 1334 53.7 665350 82.3 2 3 4 5 6 7 8 9 10 Total 17425 2.2 19 0.8 1531 5.4 2301 1.3 658 1.0 328 0.5 6626 11.3 3570 2.5 1139 0.7 1205 1.7 48 0.1 Spanish Isolated 76053 9.4 137 5.5 5947 21.2 12881 7.5 5236 7.7 2614 3.8 17912 30.6 15849 11.2 8075 4.9 7093 9.7 309 0.9 Spanish Not Isolated *Poverty level as defined in 1990 census, considering income and family size. 30879 92.7 English 1 Language Area 2227 0.3 0 0.00 51 0.18 362 0.21 543 0.80 50 0.07 76 0.13 635 0.45 328 0.20 182 0.25 0 0.00 Asian Isolated 7025 0.9 5 0.20 228 0.81 1438 .84 1235 1.81 386 0.57 191 0.33 1466 1.04 1234 0.75 836 1.15 6 0.02 Asian Not Isolated 4476 0.6 70 2.8 228 0.4 723 0.4 204 0.3 374 0.5 294 0.5 1093 0.8 979 0.6 345 0.5 268 0.8 Other Isolated 35606 4.4 917 36.9 931 3.3 6305 3.7 3050 4.5 3722 5.5 1641 2.8 6164 4.4 8079 4.9 2998 4.9 1799 5.4 Other Not Isolated Table 16 Maricopa County population 1990 distribution of people by health status area and income as a percent of poverty level* 808162 2482 0.3 28112 3.5 171507 21.2 68146 8.4 68250 8.4 58586 7.2 141248 17.5 163729 20.3 72793 9.0 33309 4.1 Total Households 47 English German Yiddish Other-German Scandinavian Greek Indic Italian French Portuguese Spanish Polish Russian South Slavic Other - Slavic Other - Euro Arabic Tagalog Chinese Hungarian Japanese Mon-Khmer Korean Native American Vietcong Other Total % of Total Area Language 0.0 0.5 0.4 0.0 0 268 257 84 124 206 0.8 0.1 0.1 0.6 445 45 63 322 429 182790 ***.* 0.0 0.1 100.0 12 0 66 57228 2.9 236 235 0.0 0.0 ***.* 0 0 20 44 586 223 581 139 0.0 0.3 0 155 301 199 267 0.2 0.0 0.0 0 0 95 340 0.9 79 19130 563 46 373 648 90 26 310 1227 156304 # 0 519 17 0.1 0.4 ***.* 45 204 58 1.2 0.1 697 % 94.3 1 53940 # 0.1 0.1 0.3 0.1 ***.* 0.3 0.1 0.2 0.1 0.1 0.1 0.1 0.2 ***.* 0.3 ***.* 10.5 0.2 0.4 ***.* 0.2 ***.* 0.7 ***.* 85.5 % 9.4 0.2 100.0 2 841 840 1073 394025 255 490 299 719 362 883 416 307 614 418 126 1169 109 17283 2063 792 1862 492 359 275 132 2739 358807 # 0.2 0.2 0.1 0.1 0.1 20.2 827 323272 757 9 398 3262 193 234 0.1 0.2 493 436 878 1950 163 363 573 236 103 43679 182 821 1344 483 172 171 173 1940 263432 # 0.2 0.1 0.2 0.2 0.1 0.3 ***.* 4.4 0.5 ***.* 0.2 0.5 0.1 0.1 0.1 0.7 ***.* 91.1 % 0.3 100.0 3 1.0 0.2 0.1 0.1 ***.* 0.6 0.1 0.2 0.1 0.3 0.1 0.1 0.2 0.1 0.4 ***.* 13.5 0.1 0.3 0.1 0.1 0.1 0.6 0.1 81.5 % 16.6 0.3 100.0 4 50 101 143 1684 37 51 50 65 65 6 79 55 16 21 73281 519 85 230 46 46 34 18 394 94144 # 96 259 171575 Table 17a Maricopa County census 1990 people by language spoken at home and health status area 1.0 0.1 0.1 0.1 ***.* ***.* ***.* ***.* ***.* ***.* ***.* ***.* ***.* ***.* 0.3 ***.* 42.7 0.1 ***.* ***.* ***.* ***.* 0.2 ***.* 54.9 % 8.8 0.2 100.0 5 68 379 149514 0 70 128 73 150 95 394 254 301 168 26 190 398 75 5244 861 1221 110 142 234 259 8562 1320 137292 # 6 7.7 0.3 100.0 0.1 ***.* 0.0 ***.* 0.1 ***.* 0.2 0.2 0.1 0.3 0.1 0.1 3.5 0.3 ***.* 0.8 0.1 0.6 0.2 0.2 ***.* 0.1 0.9 0.1 91.8 % EXECUTIVE S U M MARY 48 English German Yiddish Other-German Scandinavian Greek Indic Italian French Portuguese Spanish Polish Russian South Slavic Other - Slavic Other - Euro Arabic Tagalog Chinese Hungarian Japanese Mon-Khmer Korean Native American Vietcong Other Total % of Total Area Language 0.3 0.2 0.5 0.1 6.6 0.1 ***.* 517 339 749 92 10683 0.4 0.3 0.3 0.5 100.0 691 513 449 743 161578 8.3 0.2 0.2 0.1 1.0 ***.* 0.3 0.2 0.1 53 297 266 475 317 216 1553 99 129 74 0.1 0.1 133 234 0.1 0.1 27 117 146 0.6 ***.* 1007 % 87.7 7 141659 # 977 422339 916 450 72 479 381 247 358 351 495 1141 465 235 182 454 263 34021 708 980 1574 152 13 271 496 2637 374021 # 0.2 0.1 0.1 0.1 ***.* 0.1 0.3 0.1 0.1 0.1 0.1 0.1 0.4 0.1 8.1 0.1 ***.* 0.2 0.2 0.1 0.1 ***.* 0.6 ***.* 88.6 % 21.6 0.2 100.0 8 71 83159 22 0 96 499 13 125 171 8 169 16 9 52 12 81 33 23355 307 5 50 128 6 74 62 575 57220 # 0.1 0.6 ***.* 0.0 0.2 0.2 ***.* 0.2 0.1 ***.* ***.* ***.* 0.1 ***.* 0.4 ***.* 28.1 0.1 0.2 0.1 0.1 ***.* 0.7 ***.* 68.8 % 4.3 0.1 100.0 9 0 23 7316 0 1732 0 0 7 13 0 6 0 0 0 0 0 0 305 0 0 14 0 6 0 0 7 5203 # % 0.4 0.3 100.0 0.0 0.0 23.7 0.2 0.0 0.0 0.1 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 4.2 0.2 0.0 0.0 0.0 0.1 0.0 0.0 0.1 71.1 10 Table 17b Maricopa County census 1990 people by language spoken at home and health status area 4847 1952796 747 2973 9823 2917 1411 1654 6546 1968 2931 2093 2792 801 1737 3749 775 227500 8611 2769 6137 563 1536 1730 1621 12543 1642022 # % 100.0 0.2 100.0 0.5 0.1 0.2 0.1 ****.* 0.1 0.2 0.1 0.1 0.3 0.1 0.1 0.2 ***.* 0.4 ***.* 11.6 0.1 0.3 0.1 0.1 0.1 0.6 ***.* 84.1 Total 49 EXECUTIVE S U M MARY 50 Health insurance coverage and utilization Three indicators of health care access and utilization are the percentage of people without health insurance, the percentage of births occurring in hospital and the rate of cesarean sections by method of payment. In the tables and figures presented in volume II, other indicators are offered. Figure 53 shows health insurance coverage by sex for Maricopa County, the U.S. and Arizona for 1991. These proportions did not change significantly throughout the five intercensal years. Approximately 15-16 percent of adults had no health care coverage. The proportions for children were estimated at similar levels. Figure 53 Maricopa County behavioral risk factor surveillance 1991 percent with no health insurance by sex for U.S., Maricopa County and Arizona Female Male Percent 25 20 15 10 5 0 U.S. Female Male Arizona Maricopa County 12.4 15.7 15.2 14.5 20.8 16.3 Based on a sample of 1,444, weighted by age, sex and ethnicity to Maricopa County 1990 census population. Denominator includes entire sample 51 Table 18 shows the percentage of births in 1991 and 1995 delivered in hospital. Ninety-nine percent of deliveries took place in hospital in 1991, and slightly less, 98.6 in 1995. Table 18 Maricopa County percentage of births in 1991 and 1995 delivered in hospital Year 1991 Hospital delivery Non-hospital delivery Total 1995 39,418 99.0 43,404 98.6 407 1.0 620 1.4 39,825* 44,024 *82 observations missing Tables 19 and 20 show the number and percentage of cesarian deliveries by method of payment in 1991 and 1995. It is interesting to note that in both years the high- est percentage of primary cesarian deliveries took place among those with private insurance coverage, and the lowest among those classified as “self-pay.” Table 19 Number and percentage of caesarian deliveries by method of payment (1991) Insurance AHCCCS* IHS** Private Ins. 1,391 10.2 40 8.5 2667 13.3 798 5.9 22 4.7 All other methods of delivery 11,388 83.9 Total 13,577 100.0 Primary Caesarian delivery Secondary Caesarian delivery Unknown Total 437 8.4 59 10.0 4594 11.5 1524 7.6 183 3.6 29 5.0 2556 6.4 409 86.8 15,901 79.1 4,559 88.0 500 85.0 32,757 82.1 471 100.0 200,092 100.0 5,179 100.0 588 100.0 39,907 100.0 *AHCCCS Arizona Health Care Cost Containment System **IHS - Indian Health Service Self EXECUTIVE S U M MARY 52 Table 20 Number and percentage of caesarian deliveries by method of payment (1995) Insurance Primary Caesarian delivery AHCCCS* IHS** Private Ins. Self Unknown Total 1,685 9.0 35 10.7 2,698 12.1 145 6.8 44 7.3 4,607 10.5 989 5.3 12 3.7 1,392 6.3 86 4.0 18 3.0 2,497 5.7 All other methods of delivery 16,076 85.7 279 85.6 18,121 81.6 1,901 89.2 543 89.7 36,920 838 Total 18,750 100.0 326 100.0 22,211 100.0 2,132 100.0 605 100.0 44,024 100.0 Secondary Caesarian delivery *AHCCCS Arizona Health Care Cost Containment System **IHS - Indian Health Service M-1 Methods EXECUTIVE S U M MARY M-2 Data Sources and Limitations This report includes information from many sources. Table 21 (page M-3) lists the types of data used and their sources. The quality and reliability of the data are variable. All mortality and natality data are subject to errors of transcription beginning with the medical record, and including coding error and data entry errors. These errors should be controlled by constant quality review at all points through close monitoring, continuous training and periodic sample surveys. Unfortunately, Arizona does not yet have all these quality assurance measures in place, either at the county or at the state level. Thus, the degree to which information on the certificates is a valid and accurate reflection of the characteristics of the decedent, causes of death, characteristics of the newborn or parental and pregnancy characteristics is, at this point, unknown. No studies have been done estimating the proportion of birth or death events actually covered by our vital record, although given the medical and vital registration system, it is assumed to be (and probably is) very high. This is an important pending evaluation, especially in a state with relatively large minority populations and many isolated, sparsely populated areas. Miscounts and misclassifications in the vital record as well as in disease registers in other states have been shown to exceed 33 percent for specific populations.2 However, there are some indications of a relatively high percentage of random errors originating in transcription and data entry. For example, just 82 percent of prenatal care visits listed in the birth certificates agreed with the medical record in a pilot study done in 1993 in one Maricopa County hospital. Pima County found that in recent years up to 80 percent of certificates had at least one data entry error. However, these errors do not seem to be systematic and, thus, although they affect the precision of the measurement, they should allow for monitoring of trends. Efforts are underway to evaluate the birth certificate registration system as part of the implementation of the Electronic Birth Certificate system in 1998-1999. Although death is one of the more easily measurable events in health statistics, the data still are fraught with problems. Primary among these is the misclassification of causes of death. Since 1994 new procedures have been in place in Maricopa County to assure the quality of the data. Although this process is not yet complete, there is some evidence derived from procedural reviews as well as from the decrease in the rates of ill-defined conditions that indicate the quality of the death certificates has improved. 2. Frost F. et al. Racial Misclassification of Native Americans in a SEER Registry. J. Natl. Cancer Inst. 1992; 84: 957-961. Sugarman, J.R. et al. Racial Misclassification of American Indians: its effect on injury rates in Oregon, 1989-1990. AJPH 1993; 83:681-684. M-3 Table 21 Types of data and sources Type of data Source of data Demographic data Based on the 1990 United States Census and the 1995 Arizona Special Census. Natality data Based on birth certificates, as reported by the Arizona Department of Health Services. Mortality data Based on death certificates, as reported by the Arizona Department of Health Services. Morbidity data Based on survey data or cases of diseases reportable by law, some registry data and some patchwork information collected for some areas of the county by non-health organizations such as police departments, fire departments and community coalitions. Each source is specified when the data are presented. Risk factors Derived from birth certificates, the Behavioral Risk Factor Survey (B.R.S.F.) and other surveys. Socioeconomic measures Based on the 1990 U.S. Census, as well as some birth and death certificate information. National morbidity And mortality data The Centers for Disease Control and Prevention, National Center for Health Statistics. Year 2000 national health objectives Healthy People 2000, DHHS, PHS. EXECUTIVE S U M MARY M-4 Population estimates and data sources All health measures used in this report depend on population figures as denominators. We have used population information from the 1990 and 1995 Census and estimates for intercensal years provided by the Arizona Department of Economic Security (DES). Both the 1990 and 1995 census in Maricopa County had undercounts of populations, especially for those in some rural areas, minority and immigrant populations and homeless people. Additionally, the 1995 census was disrupted by the federal budget crisis, causing unexpected staff turnover and interruptions in data collection, recruitment and training of census workers. Thus, the population of Maricopa County is probably slightly larger than the census counts. DES estimates for intercensal years are re-evaluated periodically. Additionally DES periodically adjusts for overcounts and undercounts of Census figures. The differences in these adjustments are minimal (in the order of 100 people for the entire state and fewer than 700 per city in the county). We have chosen to maintain denominator estimates for each year and not change them, because rates computed with one estimate may not be the same when computed with a more recent estimate for that same year. We have listed the estimates used for each year and their sources in Table 22). These estimates are not necessarily the most recent ones produced by DES but they are the ones used by the Department of Public Health in computing health statistics for previously published reports. The estimates are anchored by 1980, 1985, 1990, and 1995 Census figures. This report uses denominator estimates developed by the MCDPHS for age, sex and race/ethnicity for specific geographic areas within the county, based on Census data and DES estimates. The census figures used in this report are uncorrected for over-counts or under-counts. We have used census data as they appear, without modifying any of the imputed or assigned values. We have used the tables reflecting total counts and not estimates derived from a sample whenever possible. Even in census years, the total population of the county might vary slightly from one table to another, depending on the geographical divisions examined. This is a result of suppression of some types of data (age, sex, ethnicity, for example) at the level of small Census tracts in order to protect the confidentiality of the responses and the privacy of the respondents. Throughout this report, Maricopa County, Arizona and U.S. health statistics are compared to each other. When they refer to the entire population, these comparisons use crude rates, not age-adjusted ones. The adult population of Maricopa County is slightly younger than that of Arizona, which is, in turn, slightly younger than that of the United States. Thus, some differences in crude disease rates would be expected even if all the age-specific rates were equal. Generally speaking, the population of Maricopa County should have lower crude disease rates than either the population of Arizona or the U.S. because it is slightly younger. When comparisons are made to rates that are National Objectives for the Year 2000, some care must be taken in Table 22 Population estimates Maricopa County, 1980-1995* Year Population Source 1980 1,509,175 1980 Census 1983 1,642,300 8/86 DES Estimate 1984 1,726,398 6/89 DES Estimate 1985 1,837,912 1985 Special Census 1986 1,909,998 6/89 DES Estimate 1987 1,976,600 9/91 DES Estimate 1988 2,032,000 9/91 DES Estimate 1989 2,089,900 9/91 DES Estimate 1990 2,122,101 1990 Census 1991 2,181,950 10/92 DES Estimate 1992 2,233,700 10/92 DES Estimate 1993 2,238,263 3/93 DES Projection 1994 2,285,200 5/93 DES Projection 1995 2,551,765 1995 Special Census *Estimates are as of July 1 of each year. Sources: 1980 and 1990 U.S. Census, 1985 and 1995 Special Census Data and Arizona Department of Economic Security (DES) Estimates and Projections. M-5 the interpretation. The numerators for Maricopa County rates were chosen to match the ICD-9 codes specified in Healthy People 2000 (see Table 23). Many of the general population rates designated as Year 2000 Objectives are age-standardized to the 1940 U.S. population. However, as previously mentioned, Maricopa County rates are not standardized to any population. Standardization was not carried out because of the many methodologic problems regarding standardization of rates among radically different populations, including the population cho- sen as a standard and the effects of standardization on the presentation of data.3 These issues cannot be discussed here; refer to the footnote for more information. Despite these potential problems in comparisons, population rates for Maricopa County were not age-adjusted because the Health Status Report of the county should reflect real rates. Instead, whenever appropriate and feasible, age specific, sex-specific and race/ethnic specific rates are presented. Table 23 Definitions of Healthy People 2000 grouped cause-of-death data by international classification of disease codes, ninth revision Cause-of-Death Group ICD - 9 Codes Alcohol - related motor vehicle crashes E810.0-E819.9 Breast cancer (female) 174.0-174.9 Cancer (all sites) 140.0-208.9 Cervical cancer 180.0-180.9 Child abuse E967.0-E967.9, E968.4 Chronic obstructive pulmonary disease 490.0-496.9 Cirrhosis 571.0-571.6 Colocrectal cancer 153.0-154.3, 154.8, 159.0-159.9 Coronary heart disease 410.0-414.9, 402.0, 402.9, 429.2 Drowning E830.0-E830.0, E832.0-E832.9, E910.0-E910.9 Drug abuse related deaths 292.0-292.9, 304.0-304.9, 305.2-305.9, 850.0-858.9, 950.0-950.5, 962.0, 890.0-895.4 Falls and fall-related injuries E880.0-E888.9, E922.0-E922.3, E922.8-E922.9, E955.0-E955.4, Unintentional firearm injuries E965.0-E965.4, E970.0, E985.0-E985.4 Homicide E960.0-E969.9 Lung cancer 162.2-162.9 Motor vehicle crashes (non-alcohol) E810.0-E825.9 Residential fires E890.0-E899.9 Stroke 430.0-438.9 Suicide E950.0-E959.9 Unintentional injuries (all) E800.0-E949.9 3. Feinlib M., Zarati, A.O., eds. Reconsidering Age Adjustment Procedures: Workshop proceedings. NCHS, Vital Health Stat 4 (29). 1992. EXECUTIVE S U M MARY M-6 Health Status Areas Definitions Among the reference tables included in this report are tables defining zip codes, health status areas, nursing districts and Maricopa Association of Governments Planning districts in terms of census tracts. Some of these definitions are approximate, because the boundaries of the larger areas do not always match those of the census tracts. We have published these tables to facilitate the use of census and health data to people or institutions for whom the census tract is not a meaningful unit to define an area, even though it is the basic building block of numerator and denominator data. Demography, socioeconomic status, geographic consid- erations and political divisions were the elements that entered into the definition of the 10 Health Status Areas in the county. For purposes of health status analyses we have divided the county into the following areas: (1) Sun City, (2) Glendale, (3) North Phoenix, (4) Central Phoenix, (5) South Phoenix, (6) Scottsdale/Paradise Valley, (7) Tempe/Ahwatukee, (8) Mesa/Gilbert, (9) West Maricopa County, and (10) the three Native American Reservations (Gila River Indian Community, Salt River/ Pima Indian Community and Fort McDowell Indian Community). See Figure 54. One Census tract (303.43) was changed since the previous Health Status Report, from area 3 to area 6. Figure 54 Maricopa County’s 10 health status areas M-7 Definitions: Population Attributes, Risk Factors and Health Indicators Attributes, risk factors and health indicators are different yet related measures describing a population and its health status. Additional definitions of health-related, technical or epidemiologic words and concepts are found in the Glossary. Please refer to it as necessary when examining the information in this report. Attributes are any characteristics that describe a population or an individual, such as demographic ones (age, sex, race, ethnicity), geographic ones (place of residence or birth), health-related characteristics (people with high blood pressure, people immunized against tetanus, etc.). In parts of this report we will examine groups of people defined by specific attributes (for example, teenage women residents in Chandler who had deliveries in 1991). We can better focus our analyses of health and disease in this manner. Risk factors are population or individual attributes that are associated with diseases or health-related conditions. Some risk factors are modifiable, such as a high fat diet. Others are not, such as female sex as a risk factor for breast cancer, or older age for some diseases. Not all risk factors are causative, some are only associated with a disease, and can be identified only as markers for disease not as causes of disease. Risk factors can be environmental, behavioral, genetic, biological and others. Health indicators and/or indices are statistical/numerical measures such as infant mortality, incidence rates of a disease, or composite scales of several indicators that reflect the health status of people in a community. Statistical Calculations and Definitions Some statistical measures of health and disease will be used repeatedly throughout this report. The one used most frequently is the rate. The traditional definition of an incidence rate in epidemiology, also referred to as risk, is a proportion ranging from 0 to 1, in which the numerator represents individuals who have developed the disease or condition within a specified time period (cases) and the denominator represents all individuals at risk for the condition, (including the cases) during that time period. The more exact definition of rate (change in disease status per person-time unit, instantaneously, computed by using calculus integrals and derivatives from which incidence density functions are derived) will not be used in this report. For our purposes of evaluation and comparison, the traditional rate suffices.4 A rate enables comparisons among areas and populations because it measures the number of events in a specific time period among a specific defined number of people. It would be impossible to compare the births in 1990 in the entire U.S. (4,158,212) to the births in Maricopa County (40,230) unless we specified that in the U.S. there were 16.7 births per 1000 population during 1990, whereas in Maricopa County there were 19.0 births per 1000 population during the same year. We can then evaluate whether Maricopa County has higher or lower general fertility than the U.S. This measure can be further refined (as can any rate) by looking at it not just by population in general, but, for example, by age and ethnicity of the mother, and thus narrowing the description further. Another measure, similar to a rate, is a ratio. All rates are ratios, but not all ratios are rates. In a ratio, the events in the numerator are not necessarily included in the denominator. For example, the fetal death ratio is the ratio of fetal deaths to live births. Sometimes ratios are called rates and used as rates even though they truly are not. In a few tables in this report only counts of events are used and not rates. The reasons vary, sometimes because there have not been any population changes, so using rates 4. See, for example, Kleinbaum, D.G., Kupper, L.L., and Morgenstein, H. Epidemiologic Research 1982. Van Nostrand Reinhold, New York. EXECUTIVE S U M MARY M-8 would not add anything to the analysis. At other times because either a defined denominator for the cases cannot be identified or the changes in the underlying population are unknown. For all rates published in this report, the raw data also are published, so that anyone can do the specific calculations. We have not included confidence intervals in the tables. They can be calculated easily from the data provided.