3n
state Center for Health and Environmental Statistics
P.O. Box 29538 • Raleigh, NC 27626-0538
919^33-4728
STATISTICAL
PISI]III)R
No. 11
October 1993
EVALUATION OF HEALTH DATA FOR HISPANICS
IN NORTH CAROLINA
by
Kathryn B. Surles
Recent studies'-^ examine the health status of Black and Native American residents of North
Carolina. A similar study is desired for Hispanics, one of the fastest-growing segments of the state ' s
population. However, data obstacles prevent such analysis at this time.
The intent of this report is to describe the data problems identified and to suggest some possible
remedies. It is hoped that this background will prove useful to those concerned with the health and
health care of Hispanics.
PROBLEMS WITH DATA SETS
Some data sets pertaining to the status of individuals do not include information on Hispanic origin.
In North Carolina, for example, it is not included on the induced abortion report form, which is used
to compute abortion measures as well as pregnancy rates. Although the communicable disease report
card includes Hispanic origin (yes/no) since 1987, the variable has not been included on data files
routinely acquired by the State Center.
Among data files of the N.C. Division of Social Services, Hispanic origin (yes/no) is included on
these: food stamps, financial eligibility (Medicaid, AFDC, etc.), nonfinancial services (foster care, day
care, etc.), and aging. Neither race nor Hispanic origin is collected on claims files.
Race and Hispanic origin also are not included on hospital discharge records collected by the N.C.
Medical Database Commission. Hispanic origin (yes/no) is collected by the state's Behavioral Risk
Factor Surveillance System and Youth Risk Behavior Survey but not by other health-related surveys
conducted in recent years. In all survey efforts, Hispanics must be oversampled to obtain stable
estimates.
DEHNR
NORTH CAROLINA DEPARTMENT OF ErJVIRONMENT, HEALTH, AND NATURAL RESOURCES
The U.S. Census collects information on Hispanic origin and Hispanic subgroups as do North
Carolina birth and death certificates since 1988. However, some of these data have substantial
problems as described below.
1990 Census Counts
North Carolinians age five and older who reported Hispanic origin in the 1990 census numbered
67,936, while the number of persons age five and older who reported speaking Spanish or Spanish
Creole at home numbered 105,963. This discrepancy suggests an undercount of Hispanics. Thus,
population-based rates of birth, death, disease, etc. would be expected to be biased upward for North
Carolina's Hispanic population. The undercount of Hispanics appears to be especially great at younger
ages as shown by available age-specific counts and those ratios:
Age in 1990
Total
Pgrsftns Rgporting 5 and Older s-n 18-64 65 and Older
Hispanic Origin* 67,836 15,067 49,963 2,806
Spanish Speaking* 105,963 31,276 71,252 3,435
Ratio .64 .48 .70 .82
♦Hispanic Origin is ftom Tape File 1 (100% tabulations) while Spanish Speaking is from Tape
File 3 (sample tabulations).
In addition to the above classification problem, special problems exist in data collection among
migrant workers who move often and undocumented aliens who fear discovery. The extent to which
Hispanic persons were missed entirely in the 1990 census is unknown.
Live Births
Usually provided by the newbom's mother, race/ethnicity information at birth should be relatively
accurate. Thus, given the census problems discussed above, it is not surprising that Hispanics represent
a substantially higher proportion of live births than they do census counts of females of childbearing
ages, as shown below. The result is that 1990 Hispanic birth rates would probably be biased upward
to an unknown extent
Age in 1990
Hispanics as a Total
Percentage of 1990 If^ X^iM 2S=M .2fiM
Live Births 1.68 1.90 1.51 1.34
Female Population 1.11 1.27 1.22 0.82
Ratio 1.51 1.50 1.24 1.63
Age in 1990
Total
Under 20 20-64
65 and Older
0.21
1.03 0.43
0.08
1.16
1.50 1.16
0.35
Deaths
Race/ethnicity of a decedent sometimes is only the judgement call of a funeral director, and Hispanics
appear to be undercounted on death certificates. The percentages and ratios below suggest that 1990
death rates for Hispanics would be biased downward despite census undercounts (denominators)
which would serve to drive the rates up.
Hispanics as a
Percentage ofl 990
Deaths
Population
Ratio 0.18 0.69 0.37 0.23
Medical Examiner Deaths
North Carolina law requires that all deaths suspected to be due to a violent or traumatic injury or
accident be investigated by a Medical Examiner. Certain other categories of deaths also fall under the
purview of the Medical Examiner — deaths that are medically unattended, that occur during a surgical
procedure, that arc due to suspicious circumstances, or where the death is sudden or not related to
known previous disease.
For these deaths, Hispanic origin (yes/no) was added to the detailed "Report of Investigation by
Medical Examiner" in 1990. Thirty deaths (0.35%) were reported as Hispanic in 1990; 98 deaths
(1.17%) were reported as Hispanic in 1 99 1 . The increase may reflect improved reporting performance
after the initial year.
Matched Birth/Infant Deaths
Based on historical data, funeral directors appear more apt now than formerly to ascribe to a
deceased infant the same race as reported by the mother at the infant' s birth. However, for birth years
1988-91, funeral directors reported as Hispanic (usually Mexican) 18 infant decedents who were
considered non-Hispanic at birth. Seven of these could be cases of a non-Hispanic mother and an
Hispanic father, in 1990, North Carolina followed the National Center for Health Statistics in ascribing
to a newborn the race/ethnicity of the mother regardless of that of father.
At the same time, funeral directors reported as non-Hispanic 13 infant decedents who were
considered Hispanic (usually Mexican) at birth. The 18 above and 13 here compare to only 24 infant
decedents who were considered Hispanic at both birth and death.
From these data, it is obvious that discordances between ethnicity at birth versus death will affect
the infant death data for Hispanics. For analyses by race, it is customary to use race at death in
computations by death year but race at birth in computations by year of birth. The latter involve use
of the matched birth/infant death file in order to examine birth characteristics associated with infant
death.
HETEROGENEITY OF THE HISPANIC POPULATION
Census undercounts notwithstanding, those data arc used below to get a general idea of the mix of
Hispanics in North Carolina. Results suggest, as expected, a mixture of ethnic, cultural, and racial
origins with no particular group dominating the picture. Thus, aggregate Hispanic health data may
not be all that helpful to persons planning health care delivery at the local level. A recent study in
Washington State^ reveals contrasting health risks among Hispanic subgroups.
HISPANIC GROUPS, NORTH CAROLINA 1990
POPULATION PERCE^^T
TOTAL
76,726
100.0
HISPANIC ORIGIN
Mexican
Puerto Rican
Cuban
Other Hispanic*
32,670
14,620
3,723
25,713
42.6
19.1
4.9
33.5
RACE OF HISPANICS
White
Black
American Indian, Eskimo, Aleut
Asian or Pacific Islander
Other Race**
37,364
7,181
1,225
1,573
29,383
48.7
9.4
1.6
2.1
38.3
•Persons reporting "Other Spanish/Hispanic" origin from Spain, the Spanish-speaking
countries of Central or South America or the Dominican RepubUc, or persons of Hispanic
origin identifying themselves generally as Spanish, Spanish- American, Hispanic, Hispano,
Latino, etc.
**PCTSons reporting in the "Other race" category and providing write-in entries such as multi-
racial, multi-ethnic, mixed, interracial, Wesort, or a Spanish/Hispanic origin group (such
as Mexican, Cuban, or Puerto Rican).
POSSIBLE SOLUTIONS
Census Data
Accurate census counts for population-based rates are crucial to the analysis of health data.
Unfortunately, an undercount of Hispanics appears to have occurred in North Carolina in 1990, and
there appears no satisfactory remedy for this situation. Certainly, it is hoped that the Census Bureau
will take whatever steps are necessary to improve the situation in the 2000 census.
For programs concerned with the geographic locations and other demographics of people who
primarily speak Spanish, help may be available through use of summary tape files maintained by the
census. From these tapes, one may obtain counts of persons who reported speaking Spanish at home.
Counts are available by age, race, and county.
For other breakdowns of persons who reported speaking Spanish at home, one may use machine-
readable data files maintained by the census. These Ihiblic Use Microdata Samples (PUMS) contain
records representing 5% and 1% samples of the housing units in the U.S. and are available for each
state. The file contains "housing" records, each followed by a variable number of "person" records,
one for each occupant of the housing unit. Although these files are extremely large, they can be handled
by most statistical or report-writing software."*
The PUMS files contain numerous data items including each person's ability to speak English,
language spoken at home, age, and relationship to the designated householder. These data items may
allow the user to construct a sample of households and/or persons who speak Spanish at home and
do not speak English well. The item, "telephone in housing unit," may also be useful in conducting
telephone surveys that oversample those who predominantly speak Spanish.
Note: As a first step in using the PUMS files, one should verify estimates
fi-om PUMS by applying the individual weights provided on PUMS
and comparing tabulated results to published estimates fi-om the
census' summary tape file 3, available from the State Data Center,
Office of State Planning, at (919) 733-4131.
State Reporting Systems
The State Center will add an item on Hispanic origin and Hispanic subgroups to its induced abortion
report form, effective January 1, 1994. The State Center will also add Hispanic origin to its
computerized communicable disease files beginning with data year 1 987 and encourages the addition
of Hispanic subgroups to the communicable disease report card. Hispanic subgroups should also be
added to the Central Cancer Registry Incidence Report and the Report of Investigation by Medical
Examiner, and Hispanic origin and subgroups should be added to the lead poisoning database of the
State Laboratory. The Medical Database Commission is likewise urged to seek legislation to allow
including race and Hispanic origin/subgroups in its hospital discharge reporting system as well as
future nonhospital reporting systems as they develop.
Food stamps, Medicaid, and other programs of the Division of Social Services do include Hispanic
origin but not Hispanic subgroups. These and other state programs need to be told of the need for
these data although lack of "administrative necessity" may undermine a recommendation to add this
tevel of detail.
Although the state's birth, death, and fetal death files include Hispanic origin and subgroups since
1988, it appears that Hispanic deaths are underreported, especially at older ages. The State Center,
working with the Vital Records Section, needs to do its part in raising the awareness level of funeral
directors and other data providers concerning the need for this information.
The examination of data from the North Carolina birth certificate suggests that the Hispanic origin
information may be used to examine the incidence of sociodemographic and medical risk factors
among Hispanic mothers and their infants. These data may be examined separately for Mexicans,
Puerto Ricans, Central/South Americans, and other Hispanics although the statistical problem of small
numbers may prevent some analyses. These data for 1988-92 are being used to prepare a fact sheet
on the maternal and infant health indicators of the state's Hispanic residents.
The North Carolina Birth Defects Registry combines data from several separate sources to provide
estimates of birth defects incidence in the state. Similarly, the Child Find File combines data from
several early intervention programs to provide estimates of the number of children with or at risk for
developmental delay. Both the defects registry and the child find file include information from the birth
certificate, so estimates for Hispanics and Hispanic subgroups will be available following additional
years of data collection. At least two more years arc needed to build the numbers in order to provide
reliable estimates for Hispanics.
Meanwhile, other potential sources of Hispanic data are the Pregnancy Nutrition Surveillance
System, the Supplemental Food Program for Women, Infants, and Children (WIQ, and the Health
Services Information System (HSIS). WIC has recently merged with HSIS, and there are plans to
routinely match HSIS prenatal records to the corresponding birth certificates. HSIS is an automated
reporting system used by local health departments and special contract providers (over 700 sites) to
report on the delivery of public health services.
Note: In using data from the birth certificate and fetal death report, the user
should tabulate on Hispanic origin of the mother, in accordance with
national procedures for race since 1989. Origin of the newborn' s father
would not be considered.
Sample Surveys
North Carolina participates with the Centers for Disease Control (CDC) in an annual telephone
interview survey (Behavioral Risk Factor Surveillance System) that solicits information about the
health behaviors of adults 18 and older. Post-survey adjustments serve to make the results
representative of all adults, not just those having telephones. Beginning in March 19 93jth£_North
jCM5lina.Department«f^!ubliGJiistQictionJi^^ in a biennial Youth
Risk Behavior Survey of 9th- 12th grade students. It is recommended that^othoflhesenafioiial
surveys add Hispanic origin and Hispanic subgroups to their data collection instruments and
oversample Hispanics and subgroups in order to obtain stable estimates for this vulnerable population.
Likewise, all health-related surveys should collect Hispanic origin and subgroups and oversample
appropriately.
On a very basic level, as suggested in the Washington State report,' the collectors of health survey
data should examine whether the questions asked and the measures used to assess health status are
appropriate for a particular minority group — in this case, Hispanics and those subgroups.
CONCLUSION
This report points up a number of problems that must be solved before health data for Hispanics are
generally available. Meanwhile, a fact sheet for Hispanics and Hispanic subgroups examines and
compares data from the North Carolina birth certificate for birth years 1988-92. From this work, it
is seen that health risks do vary among the Hispanic subgroups so that aggregate data for Hispanics
as a whole will not suffice. All data collection instruments should collect Hispanic subgroup, and all
programs should strive to raise the awareness level of providers conceming the need for this
information.
Meanwhile, it is hoped that steps will be taken to ensure the respondent's understanding of the race
and Hispanic origin questions on the Year 2000 census form. Misunderstanding may have contributed
to some misreporting of Hispanics in 1990.
A recent report by the Centers for Disease Control and Prevention (CDC)' summarizes a workshop
that addressed the role of race and ethnicity in public health surveillance. This work and its
recommendations should be reviewed by those concerned with the important matters of minority
health.
REFERENCES
1. N.C. Department of Environment, Health, and Natural Resources. "Health Status of Native
Americans in North Carolina," CHES Studies, No. 75. Raleigh, August 1993.
2. N.C. Department of Environment, Health, and Natural Resources. "Health Status of Blacks in
North Carolina," CHES Studies. No. 76. Raleigh, October 1993.
3. Washington State Department of Health, Center for Health Statistics. Washington State Health
Data Report on People of Color. Olympia, October 1992.
4. Census ofPopulation and Housing, 1990: Public Use Microdata Samples (machine-readable data
files). Prepared by the Bureau of the Census. Washington: The Bureau (producer and
distributor), 1992.
5. Centers for Disease Control and Prevention. "Use of Race and Ethnicity in Public Health
Surveillance: Summary of the CDC/ATSDR Workshop," Morbidity and Mortality Weekly
Report . Vol. 42, No. RR- 10. U.S. Government Printing Office, June 25, 1993.
STATE LIBRARY OF NORTH CAROLINA
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Department of Environment, Health, and Natural Resources
State Center for Health and Environmental Statistics
P.O. Box 29538
Raleigh, N.C. 27626-0538
919/733-4728
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