Disease and Injury
in Mahoning County Adults
1993 Survey Results
Mahoning County Health Commissioner
Jane Warga, M.Ed., C.H.E.S., Director
Lori Nestor, Secretary
Division of Health Education & Assessment
Board of Health
2801 Market Street
Youngstown, Ohio 44507
Acknowledgements
This report was provided with partial support from the Ohio Board of Regents Urban University Program and Youngstown State University.
Lynn M. Seballos, Data Services Manager
Project Manager
Gil Peterson, Ph.D., Director
The Center for Urban Studies
Youngstown State University
We wish to thank Ellen Capwell, Ph.D. and Mary Plummer, Bureau of Chronic Diseases, Ohio Department of Health, and David Gemmel, Western Reserve Care System, for their review and comments on the report draft.
Table of Contents
I. Executive SummaryII. Behavioral Risk Factors for Disease and Injury: 1993 Survey Results
Introduction
Methods
Results
Limitations
Survey Demographics
Risk Factors
Tobacco Use
Physical Inactivity
Excessive Alcohol Use
Overweight
Diabetes
High Blood Pressure
Cholesterol Screening and Control
Breast Cancer Screening
Colorectal Cancer Screening
Cervical Cancer Screening
Seatbelt Non-Use
Influenza Immunization
Pneumonia Immunization
Indoor Smoking Restrictions
AIDS Awareness
Routine Medical Checkup
Health Insurance Status
Conclusion
EXECUTIVE SUMMARY
Behavioral choices such as tobacco use, diet, exercise, and alcohol use underlie at least one-half of deaths in the U.S. each year. This report presents results of a survey of Mahoning County adults designed to assess behavioral risk factors for chronic disease and injury that contribute to these preventable deaths.
The telephone survey of a random sample of 455 adult Mahoning County residents was conducted by the Center for Urban Studies at Youngstown State University on behalf of the Mahoning County Board of Health. The surveyors employed a 62-item Centers for Disease Control and Prevention questionnaire employed by the Ohio Department of Health Behavioral Risk Factor Surveillance Systems (BRFSS) and other states to collect statewide risk factor prevalence data. Weighted prevalence estimates may be considered representative of the Mahoning County adult population.
Survey results indicate that Mahoning County's adult population meets or exceeds Year 2000 community health objectives for excessive alcohol use, breast and cervical cancer screening and is making progress toward Year 2000 objectives for physical activity, body weight and blood cholesterol screening.
Mahoning County lags behind the State of Ohio in its prevalence of several risk factors and chronic conditions, including high blood pressure, high blood cholesterol, smokeless tobacco use, seat belt non-use, workplace clean indoor air protection, and diabetes. Although a smaller proportion of County adults smoke than adults statewide, a significant reduction in smoking prevalence will be necessary to achieve Year 2000 objectives.
Information from this survey will be provided to community organizations, physicians, and other persons concerned with promoting healthy behavioral choices and optimum use of clinical preventive services. Further surveys will enable our communities to monitor their progress toward measurable objectives for healthy people in healthy communities.
DEFINITIONS
Age-adjustment - a statistical method of controlling for differences in the age structure of populations. Age-adjusted rates estimate what the rates for populations would be if their age structures were similar to that of a comparison, or standard population.
Prevalence - the proportion of a population with a particular disease or condition at one point in time. Prevalence is usually reported as a percentage.
Incidence - the number of cases of disease or deaths in a specified interval of time, usually one year. Incidence is reported as cases (or deaths) per 1,000 or 100,000 persons in the population.
Rate - a fraction in which the numerator is the number of people to whom an event occurred during a period, and the denominator is the total number of people in the population at risk for the event during the same period. Rates can be calculated for specific subgroups of the population, by age, sex, race, or other characteristics.
INTRODUCTION
As Congress and the States begin their overhaul of the nation's health care system, it is important to bear in mind that a "reformed" health care system will not guarantee effective use of illness care and preventive health services. Nor will it necessarily make people or their communities any healthier; despite our enormous expenditures for illness care, unrivaled by any other nation in the world, the United States consistently ranks in a mediocre position among nations in measures of public health, such as the rate of infant death and life expectancy.
As Assistant Secretary of Health Michael McGinnis noted in a recent article in the Journal of the American Medical Association, over one-third of deaths in the United States each year can be attributed to three leading causes: tobacco use, diet and activity patterns, and excessive alcohol use—all of which are matters of personal behavioral choice.
ACTUAL CAUSES OF DEATH IN THE UNITED STATES IN 1990
| D E A T H S | ||
Causes |
Estimated No. |
Percentage of Total Deaths |
| Tobacco | 400,000 | 19 |
| Diet/activity patterns | 300,000 | 14 |
| Alcohol | 100,000 | 5 |
| Microbial agents | 90,000 | 4 |
| Toxic agents | 60,000 | 3 |
| Firearms | 35,000 | 2 |
| Sexual behavior | 30,000 | 1 |
| Motor vehicles | 25,000 | 1 |
| Illicit use of drugs | 20,000 | < 1 |
| TOTAL | 1,060,000 | 50 |
In the current health-care system, only a small fraction of health expenditures—less than five percent—is devoted to control of the actual causes of death presented in the table above. Behavior change that reduces the risk of death and disease from these causes must begin with knowledge of how widespread these risk behaviors are in a community. Public health workers have a unique opportunity to collect this type of information and the duty to share this knowledge with their communities.
Although the Ohio Department of Health has monitored the prevalence of behavioral risk factors associated with the major causes of premature morbidity and mortality in Ohio residents since 1984, no previous attempt has been made to determine if Mahoning County's nearly 200,000 adult residents differ from others in the State to the extent that they practice these risky behaviors.
This report represents our efforts to collect and analyze risk-factor information on a county level. The population-based survey of adult Mahoning County residents 18 years and older contains information that will be useful to community organizations, physicians, and other persons concerned with promoting healthy behavioral choices and optimum use of clinical preventive services. This survey and future surveys undertaken by the Mahoning County Health Department and Ohio Department of Health will also enable us to monitor our progress toward measurable objectives for healthy people in healthy communities.
METHODS
In the summer of 1993, the Center for Urban Studies at Youngstown State University conducted a health-behavior telephone survey of 455 Mahoning County residents ages 18 and older. A random sample of Mahoning County residential telephone numbers was taken. When a residence was contacted, the telephone number, location and resident's age was verified. Only residents 18 years of age or older were interviewed, and only the first adult respondent in the residence was interviewed. If the residential telephone number was busy, there was no answer, a machine answered, or no adult was at home, the number was recalled up to three times to obtain a completed interview. Telephone calls were made during the day, evening, and on weekends to increase the chances of reaching an adult at the selected residences. The 62-item Centers for Disease Control and Prevention (CDC) questionnaire used in the survey also has been used by the Ohio Behavioral Risk Factor Surveillance System (BRFSS) to collect the statewide comparative prevalences reported in the Results section. It has been reviewed extensively by experts and survey users in an attempt to control systematic bias. Post-stratification adjustment of survey data by age, race, and sex was done to correct imbalance in survey response rates and produce a point estimate of risk-factor prevalence representative of the Mahoning County adult population. Demographic information on survey respondents and Mahoning County and Ohio census data are presented in the Appendices. A copy of the survey questionnaire also is contained in the Appendices.
RESULTS
LIMITATIONS
Unweighted prevalence data are representative of only the sample interviewed. Weighted prevalence data can be considered representative of Mahoning County's adult population in 1993, but not necessarily of any particular subgroup of the population that may be disproportionately affected by these risk factors. Differences in education and income between survey respondents and the Mahoning County adult population described in the Survey Demographics section below may also limit the representativeness of responses to certain health-risk-behavior questions.
The information gathered in this survey was self-reported. The accuracy of this information depends on the truthfulness of respondents. Certain less socially acceptable behaviors such as smoking or excessive alcohol use may be under-reported, whereas more acceptable behaviors such as frequent physical activity may be over-reported by respondents.
SURVEY DEMOGRAPHICS
From the survey and census information, it is apparent that Mahoning County's population is older than that of the State. In Mahoning County, 30.1% of adults were 60 and older, according to the 1990 population census, compared with 23.7 % of Ohioans. Mahoning County's older population might be expected to differ from the State in the prevalence of chronic diseases such as diabetes and in its greater need for age-related clinical preventive services such as influenza immunization and screening mammography.
Survey data were not weighted for income and educational level. Survey respondents had higher family incomes and educational levels than did the Mahoning County population in 1990. Whereas one-fourth of Mahoning County adults had not graduated from high school in 1990, only 11.8% of survey respondents were not high school graduates. In the 1990 census, 20.7% were in the lowest family income level - less than $10,000 - while only 11.8% of survey respondents were below this income level. Many health-risk behaviors are closely related to education and income. For example, college graduates are much less likely to smoke than persons without high school diplomas. Consequently, differences in education and income between the Mahoning County adult population and the survey respondents must be regarded as a potential threat to the representativeness of the survey.
RISK FACTORS
Tobacco Use
Tobacco use is the single-most important preventable cause of death and disease in the United States. Cigarette smoking accounts for 21% of all coronary heart disease deaths, and 30% of all cancer deaths. Eighty-seven percent of lung cancer deaths are attributed to cigarette smoking. Between 1986 and 1988, 560 persons died of lung cancer in Mahoning County at an age-adjusted rate of 53.37 per 100,000 persons. The Year 2000 objective is a rate of no more than 53 per 100,000 persons. Achievement of this objective requires that the currently increasing rate of lung cancer death be reversed.
Cigarette smoking during pregnancy was reported by 26% of women who gave birth in 1991. Smoking during pregnancy accounts for 20 to 30 percent of low-birthweight babies, making it the most important cause of this condition. Low birthweight is the leading contributor to death during infancy.
In 1993, 19.1% of County adults reported that they had smoked at least 100 cigarettes in their lifetimes and were current smokers. The prevalence of smoking in Ohio adults was estimated to be 26.0% in the Ohio Department of Health's 1990 Ohio Behavioral Risk Factor Surveillance System Report. Mahoning County is much closer than the State to the Healthy People 2000 objective of no more than 15% smoking prevalence.
Oral cancer occurs more frequently among smokeless tobacco users and may be 50 times more frequent among long-term snuff users. Smokeless tobacco use has increased most dramatically among adolescent males in recent years, leading to an estimated prevalence of use of 8.9% among males ages 18-24 in 1987.
In this risk-factor survey, risk for smokeless tobacco use was defined as current use of chewing tobacco, snuff, or both. In 1993, 4.2% of County adults were at risk for smokeless tobacco use, compared with 2.2% of Ohio adults in 1990. The Year 2000 objective of no more than 4% of males ages 12-24 at risk for smokeless tobacco use is related but not directly comparable with survey results.
Physical Inactivity
Regular physical activity can help to prevent coronary heart disease, the leading reported cause of death and disability in Mahoning County. Heart disease was the cause of death for 1,075 Mahoning County residents in 1991. Although cigarette smoking, high blood pressure, and high blood cholesterol are more well-known risk factors for heart disease, more persons—especially older persons among whom physical inactivity is most prevalent—are at risk for heart disease due to physical inactivity than for any other single risk factor.
In 1993, 25.8% of adult Mahoning County residents participated in no leisure-time physical activity in the last month. This figure is lower than the 32.5% prevalence in Ohio residents reported by the Ohio Department of Health in 1990. Mahoning County has made some progress toward the Year 2000 objective of no more than 15% of Americans reporting to leisure-time physical activity.
Excessive Alcohol Use
Alcohol is involved in nearly one-half of motor vehicle fatalities, suicides and homicides, and a large proportion of cirrhosis deaths. Its use during pregnancy is the leading preventable cause of birth defects.
Excessive alcohol consumption was reported as binge drinking. Binge drinking is defined as reported consumption of five or more alcoholic drinks on an occasion one or more times in the past month. Only 4.7% of County adults reported this risk behavior in 1993 compared with 9.2% of adult Ohioans in 1990. No Year 2000 objective for adults has been established.
Overweight
Overweight is also a risk factor for coronary heart disease. It is associated with high blood pressure and high blood cholesterol—the other important heart disease risk factors—and with noninsulin-dependent diabetes.
In 1993, 22.2% of County adults were at risk for overweight. The corresponding figure for Ohio adults was 22.6% in 1990. Overweight is defined as body mass index (BMI) greater than 27.3 for women and 27.8 for men. BMI is calculated by dividing a person's weight in kilograms by his or her height in meters squared. The Year 2000 objective is no more than 20% of Americans at risk for overweight by the end of the decade. The prevalence of overweight among Mahoning County adults in 1993 is nearly identical to the prevalence of overweight among Ohio adults in 1990.
High Blood Pressure
High blood pressure increases the risk of death from heart disease and stroke, which together killed 1,294 Mahoning County residents in 1991. Persons who reported being told more than once that their blood pressure was high or who reported that they are on medication for high blood pressure are considered at risk. The 15.1% prevalence of this risk factor in Mahoning County adults is similar to the 14.6% prevalence reported in Ohio adults in 1990. No directly-related Year 2000 objective has been established for this risk factor.
A related Year 2000 objective is to increase to 90% the proportion of persons with high blood pressure who are taking action to help control their blood pressure. Although 61.8% of County adults who have been told their blood pressure is high have had medication prescribed for them, this proportion is not directly comparable with the Year 2000 objective. Other blood pressure control strategies such as weight loss, reduction of alcohol intake, and sodium restriction may be prescribed without medication but were not asked about in this risk factor survey.
Cholesterol Screening and Control
Blood cholesterol levels of 240 micrograms per decaliter (mcg/dl) are associated with a substantially higher incidence of coronary heart disease. High blood cholesterol was defined as a level of 240 mg/dl or greater. Considerably more County adults reported being told that their cholesterol was high in 1993 (23.8%) than adult Ohioians in 1990 (17.4%). The related Year 2000 objective is to reduce the prevalence of blood cholesterol levels of 240 mg/dl or greater to no more than 20% of adults.
Consistent with their reported higher prevalence of high blood cholesterol, a higher percentage of County adults reported that they were under a doctor's advice to reduce cholesterol in 1993 (18.5%) than Ohio adults in 1990 (12.4%). A related but not directly comparable Year 2000 objective is to increase to at least 60% the proportion of adults with high cholesterol who are aware of their condition and are taking action to reduce their blood cholesterol to recommended levels.
Substantially fewer County adults reported that they had not had their cholesterol level checked in the last five years (25.9%) than adult Ohioans in 1990 (38.5%). Mahoning County has almost attained the Year 2000 objective of no more than 25% of the population not screened for high cholesterol.
Breast Cancer Screening
Breast cancer is the most common form of cancer among American women and the second-leading cause of cancer deaths in women. The American Cancer Society has estimated that one woman in every nine will develop breast cancer in her lifetime. Using National Cancer Institute estimates of breast cancer incidence, about 215 new breast cancer cases are diagnosed in Mahoning County each year. Between 1987 and 1990, 232 women in Mahoning County died of breast cancer. The age-adjusted death rate for breast cancer of 27.8 deaths among every 100,000 women in Mahoning County must decline by 9.4% in order to reach the Year 2000 objective of no more than 25.2 breast cancer deaths among every 100,000 women.
Deaths due to breast cancer can be reduced by 30% among women aged 50 and older through the use of mammography and clinical breast examination. The American Cancer Society and the National Cancer Institute recommend monthly breast self-examination and regular clinical breast examination for all women, a baseline mammogram for women between ages 35 and 40, mammography every 1 to 2 years for women ages 40 through 49, and annual mammography for women ages 50 and older.
In 1993, 19.5% of women in Mahoning County years 40 and older reported that they had never had a mammogram, compared with 40.0% of adult women in Ohio in 1992. Medicare and all private health insurers in Ohio began reimbursing for screening mammography in 1992. The related Year 2000 objective is no more than 20% of women 40 years and older reporting that they have never had a mammogram. Mahoning County has achieved this Year 2000 objective.
In 1993, 29.4% of women 40 years and older in Mahoning County reported that they had not had a mammogram in the last two years. In 1990, 40.0% of Ohio women 40 years and older had not had a mammogram in the last two years. A related Year 2000 objective is no more than 40% of women 50 years and older reporting that they have not had a mammogram in the last two years.
Reasons for not taking advantage of screening mammography included lack of health insurance coverage, not being mentioned by the doctor, and not being necessary.
Survey respondents in Mahoning County, as in Ohio in 1990, reported that it was most often the doctor's idea for their last mammogram, followed by the respondents themselves.
Colorectal Cancer Screening
Colorectal cancer is the second leading cause of death due to cancer. Between 1986 and 1988, 278 persons in Mahoning County died of colorectal cancer, an age-adjusted rate of 27.25 per 100,000 persons. The Year 2000 objective is a rate of no more than 18.7 per 100,000 persons.
Digital rectal examination and proctosigmoidoscopy have the potential to increase early detection of colon and rectal cancer, improve survival rates and decrease colorectal cancer mortality.
In 1993, 66.2% of County adults 40 years and older had not had a digital rectal exam in the last year. The comparable prevalence for Ohio adults 40 years and older was 66.5% in 1992. The Year 2000 prevalence for this risk factor is no more than 60% of Americans 50 years and older who have never had a proctoscopic exam.
In 1993, 63.8% of County adults 50 years and older had never had a proctoscopic exam, compared with 73.0% of Ohio adults 50 years and older in 1989. The related Year 2000 objective is not more than 60% of Americans 50 years and older who have never had a proctoscopic exam.
Cervical Cancer Screening
More than 50,000 cases of cervical cancer are detected annually in American women. An average of six women in Mahoning County die from cervical cancer each year. Early detection of cervical cancer through the use of the Pap test greatly reduces the risk of death from invasive cervical cancer. The widespread use of the Pap test in the last twenty years is believed to account for the decline in cervical cancer deaths over this period. Government and professional groups recommend screening of adult women at one- to three-year intervals to provide the greatest protection against invasive cervical cancer.
Only 4.1% of women in Mahoning County reported that they had never undergone a Pap test in 1993, compared with 6.9% of Ohio women in 1992. The Year 2000 objective is no more than 5% of women reporting that they have never had a Pap test. Mahoning County has already met this Year 2000 objective.
In 1993, 18.7% of women in Mahoning County reported that they had not had a Pap test in the last three years, compared with 20.9% of women in Ohio. The Year 2000 objective is no more than 15% of women reporting that they have not had a Pap test in the last three years.
Diabetes
Many cases of the most common form of diabetes—noninsulin-dependent diabetes—may be prevented by measures to control obesity. The self-reported prevalence of diabetes in Mahoning County adults in 1993 was considerably higher (7.2%) than in Ohio adults in 1990 (4.7%). Risk for diabetes increases with age and Mahoning County's population is older than that of the State. The Year 2000 objective for diabetes prevalence is no more than 2.5 percent.
Seatbelt Non-Use
Motor vehicle-related deaths account for about half of all unintentional injury deaths, killing about 46,000 and injuring 3.5 million persons each year in the United States. Unintentional injuries are the fourth-leading cause of death in the United States; in Mahoning County, 84 persons died of unintentional injury in 1991. Motor vehicle-related death rates are lower in states like Ohio with mandatory seatbelt use laws and can be reduced further by increasing seatbelt use.
The 27.4% of County adults who reported that they sometimes, seldom, or never used seatbelts when they drive or ride in a motor vehicle exceeded the 23.9% of Ohio adults who reported this risk behavior in 1990. Neither Mahoning County nor Ohio approaches the Year 2000 objective of no more than 15% seatbelt non-use.
Influenza Immunization
An annual flu shot is an effective measure for reducing the incidence and severity of influenza in older persons, diabetics, and others with chronic respiratory diseases and disorders of the immune system. In 1993, 61.1% of County adults 60 and older or diabetics had not had a flu shot in the last year. No reliable estimate for Ohio is available. The Year 2000 objective is no more than 40% of older Americans unimmunized in the last year.
Pneumonia Immunization
A single dose of pneumococcal pneumonia vaccine confers years of protection against pneumonia among older and chronically ill persons. It may be administered at the same time as a flu shot and, like flu shots, the cost is reimbursable by Medicare.
In 1993, 69.8% of County adults 60 years and older or diabetic had never had an immunization against pneumonia. A reliable estimate for Ohio is not available. The related Year 2000 objective is no more than 40% of older Americans unimmunized.
Indoor Smoking Restrictions
In 1993 the U.S. Environmental Protection Agency concluded that second-hand or environmental tobacco smoke is a cancer-causing agent and joined public health and voluntary agencies in urging worksites and proprietors of public places to adopt clean indoor air policies.
In 1993, 36.7% of County adults had no restrictions on smoking at their workplaces, compared with 28.9% of Ohioans in 1990. The Year 2000 objective is no more than 25% of workplaces without smoking restrictions.
Public attitudes toward smoking restrictions in workplaces and other public places are important determinants of state and local initiatives to promote clean indoor air at the worksite and in other public places. In 1993, only 9.5% of County adults opposed worksite smoking restrictions, compared with 19.0% of Ohio adults in 1990.
In 1993, 16.0% of County adults opposed laws restricting smoking in public places, compared with 30.7% of adult Ohioans in 1990.
AIDS Awareness
AIDS information and education campaigns have increased public knowledge about the risk of HIV transmission associated with certain behaviors. The risk factor survey reveals that 3.8% of Mahoning County adults believe that HIV cannot be transmitted by needle sharing or don't know and 2.6% believe HIV cannot be sexually transmitted or don't know. The corresponding proportions among Ohioans in 1990 were 5.0% and 3.9%, respectively. Several Year 2000 educational objectives for patients of primary and mental health care providers, students, and drug abusers have been established to increase AIDS risk awareness among those most at risk for these behaviors.
Routine Medical Checkup
Access to cancer, blood pressure and cholesterol screening and other clinical preventive services depends upon access and proper utilization of an ongoing source of primary care. Primary care physicians are the gatekeepers to a complete array of health services offered on-site or through referral, which are accessible and acceptable to their patients and include health promotion and disease prevention as well as curative services.
In 1986, 18% of Americans reported having no physician, clinic or hospital as a regular source of medical care. In 1993, 77% of Mahoning County adults reported that they had a routine medical checkup in the last two years. Routine medical checkups at one- to two-year intervals provide an opportunity for physicians to counsel their patients about and provide the screening tests for early detection, treatment, and control of chronic disease risk factors. A similar proportion (81.7%) of adult Ohioans reported that they had a routine medical checkup in the last two years. A related Year 2000 objective is to increase to 95% the proportion of people who have a specific source of ongoing primary care for coordination of their preventive and episodic health care.
Health Insurance Status
Lack of adequate health insurance coverage presents a barrier for many persons to the preventive and treatment services necessary for control of chronic disease. A smaller proportion of Mahoning County adults (9.7%) reported being without health insurance in 1993 than adult Ohioans in 1992 (14.1%). With its older population, a higher proportion of Mahoning County adults are eligible for Medicare coverage than in the Ohio adult population.
Mahoning County adults reported being without health insurance for varying lengths of time in 1993. Comparable data for the Ohio population were not available.
CONCLUSION
Mahoning County has made considerable progress toward many national health objectives. The County's adult population meets or exceeds Year 2000 objectives for excessive alcohol use and breast and cervical cancer screening, and it is approaching objectives for body weight and blood cholesterol screening.
The County lags behind the State, however, in its prevalence of several important risk factors and chronic conditions, including high blood pressure, high blood cholesterol, smokeless tobacco use, seat belt non-use, workplace clean indoor air protection, and diabetes. Although a smaller proportion of County adults smoke than adults statewide, a significant reduction in smoking prevalence is necessary to achieve the Year 2000 objective. Likewise, colorectal cancer screening rates must be improved if an impact on colorectal cancer death rates is to be observed. The estimated prevalence of diabetes in Mahoning County adults—more than 50% higher than the State as a whole—is reason for concern and further investigation into causes for the high prevalence of this chronic condition.
Users of this report are cautioned that risk-factor estimates for the entire County adult population almost always conceal higher risk factor prevalences for subgroups of the population, especially racial or ethnic minorities, persons with lower educational levels, and those with limited access to clinical preventive services. Future risk-factor surveys should attempt to identify those population subgroups that lag behind the rest of the population in these health-risk behaviors and chronic disease conditions.
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