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A SPECIAL REPORT SERIES BY THE N.C. DEPARTMENT OF HUMAN RESOURCES, DIVISION OF
HEALTH SERVICES, STATE CENTER FOR HEALTH STATISTICS, P.O. BOX 2091, RALEIGH, N.C. 27602

W. C. DOCUMMf ?*

APR «~ 100

N. C. STATE L£*MftY
RAiaQH

No. 43

March, 1987

THE HEALTH OF MINORITIES IN NORTH CAROLINA

by
Delton Atkinson

ABSTRACT

Using an array of health indicators on pregnancy, mortality and morbidity, this study depicts the health
status and health habits of minorities in North Carolina relative to whites over the past 1 0 years. Compared to
a decade ago, minorities are living longer and are healthier. Rates of infant and fetal death, pregnancy
( including teenage pregnancy), inadequate prenatal care, and general mortality have declined substantially. But
relative to whites, minorities continue to suffer illness and death disproportionately and this disproportionate
suffering has not been appreciably altered in the past decade. This suffering is an even greater problem among
younger than older minorities. The major contributors to the disproportionality are unintended pregnancies,
infant deaths, hypertension, diabetes, homicides, cancer (particularly prostate, stomach, cervical, and lung
cancers), accidents except motor vehicle, cerebrovascular disease, nephritis/nephrosis, and chronic liver
disease/cirrhosis. The causes of the health differentials appear to be multifactorial and are embedded in a
complex interaction of socioeconomic, health and other factors that is poorly understood for the general
population and even less so for minorities. Minimizing the longstanding disparities will require creative
thinking by the public health community.

INTRODUCTION

"Despite the unprecedented explosion in scientific
knowledge and the phenomenal capacity of medicine to
diagnose, treat and cure disease, Blacks and other
minorities have not benefited fully or equitably from the
fruits of science or from those systems responsible for
translating and using health sciences technology."
"Persistent and significant health disparities exist for
minority Americans, requiring efforts of monumental
proportions to bring their health to the level of all
Americans." These findings are articulated in REPORT
OF THE SECRETARY'S TASK FORCE ON BLACK
AND MINORITY HEALTH which documents the con-
tinuing disparities in key health indicators among certain
groups of the U.S. population. (1)

As evidenced by recent inquiries to the State Center for
Health Statistics about the health status of minority North
Carolinians, the Report has raised concern about racial
disparities in this state. One quick measure which is
suggestive of significant disparities in North Carolina is
life expectancy, a measure which summarizes the overall
differences in the level of mortality among various groups.
Minority females born in 1980 had a life expectancy at
birth 5.1 years less than that for white females. In 1940
the difference was 10.9 years. Minority males had a life
expectancy at birth 6.3 years less than that for white males
in 1980, but 8.8 years less in 1940. While improvements
have been made, minorities of both sexes still have life
expectancies that were reached by whites prior to the
mid-1950's, a lag of about 30 years.

The lags in life expectancy raise questions about the
health ot minorities relative to whites. Specifically, to
what extent are there disparities in health between whites
and minorities, what have been the trends in those
disparities in the past decade, and what are the specific
problems and conditions for which the greatest disparities
exist? These and other questions are examined in this
paper through a comparative analysis of key statistical
indicators of the health of minority and white North
Carolinians.

METHODS

The method of study is descriptive using statistical
indicators on pregnancy, morbidity, and mortality for
North Carolina residents. The primary objective of this
study is to measure the racial gaps in these indicators and
the trends in those gaps in the recent past. The ratio of the
minority-to-white rates or proportions was used as the
index of disparity or gap. A ratio greater than 1 .0 indicates
that the rate is higher for minority North Carolinians than
for whites; a value of less than 1 .0 indicates that minorities
have a lower rate than whites. The change in this ratio over
time indicates whether or not the gap has widened or
narrowed.

For the mortality data, race-sex-specific mortality rates
age-adjusted by the direct method were used to calculate
the ratio. A ratio comparison of two age-adjusted rates is
called a risk ratio or relative risk (2). A high relative risk
for a specific cause of death may not be of great "public
health significance" if the cause affects a small number of
people. For some causes by race-sex group, small numbers
result in an unstable rate if 1-year numbers are used. To
minimize this potential problem, only 5-year numbers are
used to calculate the age-adjusted rates. Ratios based on
less than 20 events are marked by an asterisk in a table.

Race ratios were calculated using all deaths (RR ) and all
deaths prior to age 45 (RRY). The latter ratios were used
to assess risk differentials for younger minorities versus
younger whites. Ratios were calculated for total deaths
and specific causes.

SOCIAL AND ECONOMIC CHARACTERISTICS
OF MINORITIES

One of the most enduring of relationships has been the
association between socioeconomic status and health
status. Whether socioeconomic status is measured by
education, income, occupation, or a composite index, and
whether health status is measured by mortality, morbidity,
or perceived health status, higher socioeconomic status
has repeatedly been shown to be associated with better
health status (3-6).

The 1980 Census indicates that one out of every four
persons in North Carolina is a member of a minority
group, for a total of approximately 1.4 million persons.
Blacks constitute the largest minority group (about 22%
of the total population), with American Indians a distant
second (1%). The large black population makes North
Carolina one of only 5 states in which blacks constitute
more than one-fifth of the population. Only 6 states had a
higher number of blacks in 1980. Furthermore, a large
Indian population ranks the state fifth in the number of
native Americans (7).

Between 1970 and 1980 the number of minorities
recorded by the Census increased by 20% while the
number of whites increased by 14%. This pattern of more
rapid growth for minorities is expected to continue to the
year 2000. Minorities are projected to increase to
1,715,600 (26.4% of the total population) by 1990 and
to 1,954,600 (27.9%) by the turn of the century.

In addition to growing faster, minority North Carolinians
are on the average younger than whites. The median age of
blacks in 1980 was 24.7 years and for Indians, 23.1 years
(Table 1). Whites on the other hand were about 7 years
older than either group. While the median age has
increased for both whites and blacks, the age disparity has
actually widened at each census year since 1920, with the
exception of between 1970 and 1980 when the gap
declined from 70 to 6.7 years. Blacks now have a median
age reached by whites in the 1940's.

The earnings and income levels of blacks and Indians
are substantially below those of whites. As Table 1 shows,
of employed persons age 16+, median earnings for white
males were about $12,000 compared to $8,000 for
minority males, and $7,100 for white females compared
to $6,000 for minority females. With these earning levels,
only 10% of white persons but about 30% of minority
persons were considered to be in poverty in 1979.
Further, 20% of minority persons and 10% of white
persons were 100-150% of the poverty level. Thus, one
out of every two minority persons compared to one out of
every five white persons lived below 1 50% of the poverty
level, which in 1979 was set at $7,400 for a family of four.

In terms of family size and composition, minority
families are generally larger and more likely to be headed
by a female. The number of persons per family has
declined for each racial group since 1 970, but as shown in
Table 1, the average family size is still higher for blacks
(3.80) and Indians (3.88) than for whites (3.09). Further,
over one-third of all black families and one-fifth of all
Indian families but only one-tenth of all white families are
headed by a female. On the average these families have a
much greater chance of being in poverty, with minorities
having a decidedly higher probability. As exhibited in
Table 1, about 70% of all minority persons compared to
39% of all white persons in families with a female head
lived below 150% of the poverty level. These economic
differences are compounded by the fact that within
female-headed families, a greater percentage of black
families (21%) have children under age 18 compared to
Indian (13%) or white (6%) families.

Altogether, the combination of the above socio-
economic factors places minorities in an unfavorable
position relative to whites. This unfavorable position puts
added pressure on the social and health care systems to
overcome these socioeconomic differentials in order to
impact on the health disparities.

PREGNANCY AND INFANT HEALTH

Trends in Pregnancies

Defined as live births, fetal deaths, and legally induced
abortions, pregnancy was selected as a key health statistics
indicator because of the disproportionate adverse out-
comes for mothers and children in minority and low
socioeconomic groups. In 1985 there were 122,644
pregnancies to North Carolina residents, of which 67.2%
were to whites and 32.8% to minorities. Table 2 shows
the marked differentials in pregnancy rates by race
between 1978 and 1985. The lower white rate has
increased by 4.5% over the past 8 years, while the higher
minority rate has declined 6.7%, thereby narrowing the
racial gap from 52% higher for minorities than whites in
1978 to 36% higher in 1985.

The components of pregnancy have not all shown the
same pattern. Tables 3 and 4 display trends in live birth
and fertility rates by race. Using either rate, there has been
a small rate increase for whites (about 2%), a large rate
decrease for minorities (about 15%), and a reduction in
the gap (about 16%). Still minorities continue to have
higher birth and fertility rates. The higher fertility rates of
minorities compared to whites suggest that their elevated
birth rates reflect elevated childbearing as opposed to a
higher proportion of women of childbearing age (8).

As shown in Table 5, the fetal death rates for both
whites and minorities have declined considerably, with
minorities declining at a much faster pace. Between 1978
and 1985, minorities experienced a 28% decline while
whites experienced a 15% decline thereby narrowing the
gap in death rates from 93% higher for minorities to 64%
higher. Despite the disparity reduction from 1978 to
1985, the gap has fluctuated sharply each year since 1981
and the 1985 ratio was only 8.4% below the 1981 ratio.

Concerning abortions, both whites and minorities have
experienced about a 1 5% increase in their rates (Table 6).
These trends have meant a small change in the abortion
rate gap, from being 7 1 % higher for minorities in 1978 to
being 74% higher in 1985. Of the three components of
pregnancy, the largest racial disparity in 1985 occurred
with abortions (ratio =1.74 for abortions, 1.64 for fetal
deaths, and 1.33 tor live births).

Both whites and minorities are increasingly selecting
abortion over childbearing once they become pregnant.
The increased selection by minorities is particularly
noteworthy since it dispels a common belief that minorities
are less likely than whites to choose abortion as a
pregnancy alternative. As evidenced by the abortion
fraction which is the number of reported abortions per
1 ,000 reported pregnancies, minorities in 1985 were 19%
more likely than their counterparts in 1978 to choose
abortion over childbearing (Table 7). Whites in 1985
were only 2.8% more likely than their 1978 counterparts
to choose abortion. Moreover, in 1978 minorities had an
abortion fraction only 1.1 times that for whites. By 1985,
their fraction was 1.3 times that for whites, a 16% increase
in the disparity. The 1985 gap represents the third
consecutive year that the disparity has widened to reach a
new high.

Teenage Pregnancy

Of all health events, adolescent pregnancy is probably
one of the most disturbing. Compared to women in their
twenties, adolescents are at higher risk of various com-
plications of pregnancy such as toxemia and prolonged
labor and are more likely to deliver infants weighing under
2500 grams at birth (8). Low birthweight has been linked
with increased mortality and with developmental problems

such as epilepsy, cerebral palsy, and mental retardation
(9). In addition, the costs of adolescent pregnancies are
much more likely to be borne through public monies. In
1985 for example, 30% of all hospital deliveries involving
pregnant North Carolina teens were paid for by Medicaid.
This compares to 10% of all deliveries to mothers over age
19.

While adolescent pregnancy is a significant social
problem regardless of race and thereby deserves its recent
heightened attention, it is a problem even more
pronounced among minority than white teens. At least
three factors support this finding. First, greater proportions
of minority than white pregnancies occur to adolescents.
Teenage pregnancies represented 17-3% of all white
pregnancies in 1985 but 25.2% of all minority pregnancies.
The proportions for both races have declined since 1978,
but the gaps in the proportions have actually widened,
from 41% higher for minorities in 1978 to 46% higher in
1985.

Secondly, only small gains have been made in narrowing
the racial gaps in the teenage pregnancy rates. Between
1978 and 1985, the ratio of minority-to-white teen
pregnancy rates declined by 5 percent (Table 8). However,
almost all of this decline was achieved by 1980, as the
minority rate has remained at least 60% higher than the
white rate since then.

The third reason for teenage pregnancy being a more
pronounced problem among minorities than whites is the
disproportionate number of repeat pregnancies to minority
teenagers. Since 1981 the SCHS has produced a report
called Sentinel Health Events which contains selected
events (i.e., causes of death, reported communicable
diseases, and pregnancies) identified by state health
officials as being the minimum set about which the health
community should ask, "Why did they happen?" In this
report the concern is with each event rather than the rate
of events. One event included in this report is "unmarried
teenagers having their second or higher-order pregnancy."
In 1985, 1,228 unmarried teenagers under age 18 had a
second or higher-order pregnancy. Of particular note here
is that 68% of these events (840 total events) were to
minority teenagers, the overwhelming majority of whom
were black (98%). Unfortunately, neither the number of
minority events nor the percentage are one-year aberra-
tions as they have both been relatively constant since
1981.

Previously it was reported that minorities had a greater
propensity than whites to choose abortion over
childbearing. The only exception to this finding occurs
among teenagers (i.e., persons 15-19 years of age). Each
year since 1978, minority teenagers have had an abortion
fraction lower than that for whites (Table 9). In 1985

their fraction was 18% below that for whites. However,
this position may soon be reversed. The proportion of
pregnant teenagers selecting abortion as the pregnancy
alternative is increasing for both racial groups, but the
minority proportion is increasing decidedly faster than
that for whites. Between 1978 and 1985, while whites
experienced a 15% increase in their fraction, minorities
experienced a 39% increase. If no new or expanded public
health initiatives alter the current rates of increase, the
proportion of pregnant minority teenagers using abortion
is projected to exceed that for whites within the next 7
years.

Risk Factors for Adverse Pregnancy Outcomes

Sociodemographic . A number of biomedical, demo-
graphic, and behavioral characteristics of the mother are
risk factors for an adverse pregnancy outcome. Maternal
age, marital status, educational level, and history of fetal
or childhood loss, which are characteristics collected on
the birth certificate, are all associated with pregnancy
outcome (9,10). Table 10 summarizes these factors into
one indicator by illustrating the percent of births with one
or more high-risk factors by race and year. While whites
have experienced small, though steady declines in the
percent of births with one or more of the sociodemographic
risk factors (5.3% decline), minorities have experienced
virtually no change (0.4% decline), thereby increasing the
disparity by 5%.

Prenatal Care. The importance of prenatal care to the
future health status of the mother and infant has been
convincingly demonstrated (9, 10). It has been shown that
those women who experience higher risks of complications
of pregnancy and/or delivery (e.g., women who are black,
teenage, older, high parity, unmarried) are less likely to
receive adequate prenatal care (10). Moreover, women
receiving inadequate care are at increased risk of having a
low-birthweight infant. Low birthweight increases the
risk of subsequent infant morbidity and mortality.

Using a Prenatal Care Index developed to take into
account month of first visit, number of visits, and
gestational age at delivery (11), Table 1 1 shows that
minority women in 1978 were 3.2 times as likely as white
women to receive inadequate prenatal care. Seven years
later, minorities, even though experiencing a 22% percent
decline, were still almost 3 times as likely as white women
to receive inadequate care*.

This differential prevails even after controlling for
education. As displayed in Table 12, while the percent
inadequate declined with increasing levels of education
(with college graduates of both races having decidedly
lower percentages), the disparity actually increased.
Among persons with less than 12 years of education,
minorities had a percentage 1.8 times that for whites.

The Index creates 3 prenatal care levels (i.e., adequate, intermediate, and inadequate). Using the combined intermediate and inadequate percentages
l-v race rather than the inadequate percentages alone, minorities were twice as likely as whites to receive "less than adequate care," with the racial
disparity in such care exhibiting little improvement since 1978 (ratio = 2.09 in 1985 and 2.16 in 1978).

Among persons with 16+ years of education, the minority
percentage was 5 times that of whites. The increasing
disparity was due to greater declines in inadequate care
among whites than minorities at higher levels of education.
Minorities who graduated from college had a percentage
slightly below that for whites who only graduated from
high school.

Birthweight. The primary health risk associated with
infant loss is that of low birthweight. Whether it is
because the infant is born too soon or too small, low
birthweight is highly predictive of disability, illness or
death ( 10). As shown in Table 13, larger percentages of
minority than white infants are born with low birthweight
( defined here as under 2500 grams). While improvement
in the birthweight distribution has slowed in recent years
tor both races, minorities continue to have a low birth-
weight (LBW) rate twice that of whites. In fact, Table 14
shows that since 1978 the higher LBW rates for minorities
prevail regardless of mother's education, with greater
racial disparities occurring among the more-educated
than less-educated mothers. With the exception of 1981,
college-educated minorities have had since 1978 a LBW
rate higher than that of whites with less than a high school
education.

Smoking and Birthweight. Several studies have shown a
l lear impact of smoking on birthweight ( 1 ). Unfortunately,
smoking is not an item collected on the birth certificate,
although it may be collected on the new certificate to be
used in 1 988 or 1 989. It is, however, an item collected on
the Women, Infants, and Children (W1C) Program
records and these records have been linked to the birth
certificates. Among women on WIC in 1985, who
comprised about 20% of the total birth population, self-
reported smoking was almost twice as high among whites
as among minorities (Table 15). These racial differences
prevailed at each age interval as well, especially among
teenagers.

Table 16 shows the percentage of low- weight births in
each age-race-smoking category. Regardless of age or race,
smokers were at least 1 .34 times as likely as nonsmokers
to have a low-weight birth. Further, within each smoking
category minorities had a greater likelihood of having a
low-weight baby irrespective of the age interval. However,
with the exception of the 20-24 age group, nonsmoking
minorities in 1985 were less likely to have a low-weight
birth at each age interval than were whites who were
smokers. In 1984, nonsmoking minorities of all ages
combined had a smaller LBW percentage than whites who
smoked.

Infant Mortality

The infant mortality rate has traditionally been used as
an indicator of health status and as a measure of general
living standards of a population (8). In fact, using infant

mottality as a health status indicator has produced results
remarkably close to those generated by far more complex
formulas designed to measure an area's or a group's health
(12).

During the seventies substantial improvements were
made in reducing infant mortality, but it continues to be a
major concern. North Carolina has traditionally ranked
among the worst of all states. The 1985 provisional infant
rate was exceeded by that of only 5 other states (13).

Within North Carolina's high infant mortality problem,
minorities suffer disproportionately. As shown in Table
17, the infant mortality rate declined 51% for each racial
group between 1970 and 1985, maintaining a minority-
to-white ratio of about 1.85. In fact, the ratio has been at
least 1.59 or higher every year since 1949.

The differentials in infant mortality are associated with
a variety of factors including those related to the health of
the mother before and during pregnancy, parental
socioeconomic status, and lifestyle characteristics (1,9).
Only a few of these risk factors are collected on either the
birth or death certificate. To examine these risk factors
and their differentials by race, linked birth and death
certificate data (using the 1970 through 1984 birth
cohorts) are analyzed in the remainder of this section. The
focus is on the two components of infant mortality —
neonatal and postneonatal deaths. In the 1980-84 period,
neonatal deaths accounted for 68.2% of the state's infant
deaths and postneonatal deaths accounted for 31.8%.

Neonatal Deaths. Neonatal mortality for minorities in
1980-84 was 13.1 deaths per 1,000 live births, 85%
higher than the rate for whites (7.1). In successive 5-year
intervals since 1970-74, neonatal mortality rates have
declined steadily for both groups, but the gaps have
actually widened from 55% higher for minorities in 1970-
74, to 68% higher in 1975-79, and to 85% higher in
1980-84.

Table 18 shows that in the 1980-84 period neonatal
mortality rate improved with increasing education for
both race groups. Among whites, the rate declined
steadily with increasing education, with the least-educated
whites having a rate almost twice as high as the most-
educated whites. For minorities, the rate also declined as
education improved but not nearly as fast as fot whites.
The least-educated minorities had a rate only slightly
higher than college-educated minorities (RR = 1.1).

Comparisons across race groups reveal at least two
important findings. First, regardless of education, whites
had a lower neonatal death rate in the 1980-84 period
than minorities, a pattern also evident in the 1970-74 and
1975-79 periods. Second, the disparity in neonatal
mortality actually widened with increasing education.
Least-educated minorities had a 1980-84 mortality rate

41% higher than their white counterparts, while the most-
educated minorities had a rate 130% higher than their
white correspondents. Moreover, the risk of neonatal
mortality for the most-educated minorities, who had the
lowest minority neonatal death rate, was greater than the
risk for the least-educated whites, who had the highest
white neonatal death rate. This pattern was true for
1970-74 but not for 1975-79 when the rate for the most-
educated minorities was 4% below that for the least-
educated whites.

Birthweight is an important factor contributing to
neonatal death (14). Table 19 shows birthweight-specific
neonatal mortality rates by race in the 1980-84 period. As
birthweight improved, the death rates dropped signif-
icantly for each race group, a pattern evident in the 1970-
74 and 1975-79 periods as well. Further, for births in the
under-2500 gram groups minorities had lower neonatal
death rates in the 1980-84 period than did whites, a fact
documented for previous years in other SCHS publications
(15). However, in the past 10 years this favorable
minority position has eroded in the under-2500 gram
groups, especially in the lowest gram group. Among births
under 1500 grams, the rate has narrowed from 11% lower
for minorities than whites in 1970-74 to 5% lower in
1 980-84 while for births between 1 500-2499 grams, the
rate has changed from 39% lower in 1970-74 to 35%
lower in 1980-84. For births of 2500 grams or more,
there has also been a reduction in the gap although in a
favorable direction for minorities. In the 1970-74 period,
the rate was 21% higher for minorities, declining to 16%
higher in 1975-79, and to 5% higher in 1980-84.

Despite the lower birthweight-specific neonatal death
rates, minorities continue to have overall neonatal death
rates almost twice those for whites. Buescher ( 14) shows
that the higher overall neonatal death rate for minorities is
due to lower minority birthweights. Compared to a white
percent of 6. 1 , the percent of minority births under 2500
grams was nearly twice as high at 12.0 in the 1980-84
period. For births under 1500 grams, where neonatal
mortality is especially high, the minority percent was
almost two and one half times the white percent. If
minority births had the same weight distribution as whites
in 1980-84, the minority neonatal rate would have been
6.2 deaths per 1,000 live births compared to 7.1 for
whites, assuming no change in the weight-specific death
rates. At the rate of 6.2 as opposed to the actual rate of
13.1, about 900 fewer minority neonatal deaths would
have occurred in the 5-year period.

Tables 20 and 21 display neonatal mortality rates and
ratios by education and birthweight. These data are
summarized below:

• Within most birthweight and education groups,
both whites and minorities exhibited steady declines
in their neonatal mortality rates from the 1970-74
to the 1980-84 periods.

• For the under-2 500 gram groups, minorities in most
education groups experienced lower neonatal death
rates. The exceptions were the 13-15 and Iht-
education groups for births under 1500 grams,
where whites for the first time in 1980-84
experienced a lower mortality rate than minorities.

• For each 5-year period, no consistent patterns of
neonatal mortality for the under- 1500 and 1500-
2499 gram groups are exhibited for either race
group as education improved, suggesting that the
neonatal mortality due to low birthweight over-
whelms the effect of education.

• For the 2500 or more gram group, race ratios for
each education group have fluctuated since the
1970-74 period. During 1980-84, minorities with
the least education had lower neonatal mortality
rates than their white counterparts. Within the 16+
minority group, rates are based on small numbers of
events. Examining infant instead of neonatal deaths,
minority and white infants who weighed 2500
grams or more at birth and who were born to
mothers with at least 16 years of education had
comparable mortality rates in the 1980-84 period
(2.7 versus 2.8). However, 1980-84 was the first
period that minorities had a comparable rate, as it
was 58% higher than whites in the 1970-74 period
and 23% higher in the 1975-79 period.

Postneonatal Deaths. Postneonatal mortality is considered
to be more reflective of living conditions, quality of care
for children, and medical care for treatable conditions
such as infections ( 1 ). As infant deaths have declined, the
contribution of deaths during the postneonatal period to
overall infant mortality has been systematically increasing.
In the 1 970-74 period, postneonatal deaths accounted for
25.8% of all infant deaths, increasing to 28.6% in the
1975-79 period, and to 31.8% in the 1980-84 period.

Table 22 displays postneonatal mortality rates by
education level, race, and year. It is interesting to note that
there has been a 27% decline in the gap (RR = 2.6 in
1970-74 and 1.9 in 1980-84) due primarily to a 37%
reduction in the minority rate. The narrowing of racial
gaps has occurred in all education groups except 13-15
where neither race has improved.

As with neonatal deaths, birthweight is an important
factor in the analysis of postneonatal mortality. For both
whites and minorities. Table 23 shows that in each 5-year
interval infants who survived the first month of life had a
greater risk of dying if they weighed under 2500 grams.
Further, in the under-2500 gram groups, minorities had a
greater risk of postneonatal death than whites, but the
excess risk in the 1500-2499 group was only 10% in
1980-84.

In contrast, the postneonatal mortality rate for births
under 1500 grams has increased steadily for both whites
(60%) and minorities (33%). These differential increases
have narrowed the gap from 50% higher for minorities in
the 1970-74 period to 24% higher in the 1980-84 period.
The increasing postneonatal mortality rate for both
groups may be the result of more low-weight babies
surviving the neonatal period because of improved medical
technology, only to die in the postneonatal period.

While the rates are highest among the under-2500 gram
groups, most postneonatal deaths occur to infants weighing
2500 grams or more at birth. For this weight group, the
risk of death is greater in the postneonatal than neonatal
period. The 1980-84 risk was 25% higher for whites and
1 1 0% higher for minorities in the postneonatal versus the
neonatal period.

Causes of Infant Deaths. Tables 24 and 25 display the
numbers of deaths and death rates for leading causes of
mortality in the neonatal and postneonatal periods. In
both periods the top three causes of mortality for both
whites and minorities were conditions originating in the
perinatal period, congenital anomalies, and sudden infant
death syndrome (SIDS). Of these, minorities compared
to whites had excessive infant loss in both periods from
SIDS (RR = 1.52 in neonatal period and 2.01 in
postneonatal period) and from conditions originating in
the perinatal period (RR = 2.30 and 2.42, respectively).
Among the other causes with at least 20 events for each
race group, minorities were at least twice as likely as
whites to suffer a postneonatal loss from accidents (RR =
2 19), infectious 'parasitic diseases (RR = 2.44), and
heart disease (RR = 2.25).

MORTALITY

This section concerns total and cause-specific mortality
in the population at large including infants but excluding
fetal deaths. In 1985 North Carolina's total unadjusted
death rate was 8.48 deaths per 1,000 population; 53,018
residents died. The 1985 rate was 3% above the 1984 rate
but well below the peak rates of 9.1 experienced in 1972
and 1973. North Carolina's crude death rate still remains
below the U.S. death rate, however, with the provisional
U.S. rate for 1985 at 8.7 per 1,000 population (13). The
state's 1985 white rate was 8.56 compared to 8.23 for
minorities.

Crude death rates are useful in assessing levels of health
care needs, but the actual "force of mortality" or the risks
of mortality are sometimes best described by rates that are
adjusted for age, race, sex, and/or other external factors
that cause one group's level of mortality to differ from
another's. For example, one explanation of the minority's
relatively favorable crude death rate is that they are
younger than whites. Once the age differences are taken
into account, it is found that minorities are experiencing
higher mortality rates.

The most interesting differences in mortality risk are
found when comparing race-sex groups. In the 1981-85
period, minority males had the highest age-adjusted
mortality rate (1024 per 100,000 population), followed
by white males (732), minority females (553), and white
females (381 ). The rates for each race-sex group declined
between 1974-78and 1981-85, the declines ranging from
a high of 15% for minority females to 8% for white
females. Yet the racial gap actually increased for each sex
group. Minority males, whose rate was 30% higher than
that ot white males in the 1974-78 period, now have a rate
40% higher. Minority females, with a 1974-78 rate 34%
higher than that of white females, now have a rate 45%
higher. On the other hand, the sex gap decreased for each
race group, with the minority male rate dropping from
97% to 85% higher than the minority female rate and the
white male rate narrowing from 1 02% to 92% higher than
the white female rate.

Causes associated with the elevated mortality risk for
minority males are exhibited in Table 26. Of the 25 cause
categories commonly used to display the state's leading
causes of mortality (16), the age-adjusted rates for
minority males exceeded those of the other race-sex
groups in 18 categories. Sixteen of these 18 cause-specific
minority male rates exceeded the next highest race-sex
rate by at least 12% and 12 exceeded the next highest
race-sex rate by at least 30%. For two causes (stomach
and prostate cancers), the minority male rates were at least
152% higher than the next highest rate while for homicides
the minority male rate was about 285% higher. Similar
levels of excess minority male mortality appear to have
existed in the 1974-78 period.

For three causes, minority females had the highest of
the race-sex rates in the 1981-85 period. These were
cervical cancer ( 190% higher than the next highest rate),
diabetes (16% higher), and female breast cancer (10%
higher). White males had the highest rates for suicide
(128% higher), chronic obstructive pulmonary disease
(34% higher), and acute myocardial infarction (19%
higher). White females had the highest rate for ovarian
cancer (20% excess).

For five of the 25 cause categories — cerebrovascular
disease, diabetes, hypertension, homicide, and nephritis/
nephrosis — minorities had the two highest race-sex specific
rates. For these 5 causes, the sex-specific minority rates
were at least 1.8 times the comparable white rates.
Hypertension exhibited the greatest risk differentials
(RR = 3.7 for males and 4.0 for females), followed closely
by homicide (RR = 4.2 and 3.2, respectively), and
nephritis ''nephrosis (RR =2.7 and 3. 1, respectively ). All
5 causes were among the causes with the greatest race-sex
disparities in the 1974-78 period.

Excess mortality appears to be an even greater problem
among younger than older minorities of both sexes. Table
27 displays the 1981-85 cause-specific race ratios for each
sex group for deaths prior to age 45 and deaths at all ages.
Among deaths prior to age 45, minority males exhibited
an 81% higher risk of mortality than white males; but for
all ages, they exhibited only a 40% higher risk. For females
under 45, minorities had a rate 75% higher than that of
whites; but for all ages, the female minority rate was only
45% higher.

The most interesting variations by cause, race-sex, and
age are summarized below:

• The 5 leading causes of mortality prior to age 45 for
minority males were motor vehicle accidents,
homicide, all other accidents, heart disease, and
total cancer. For minority females they were total
cancer (female breast was the leading cancer cause),
heart disease, homicide, motor vehicle, and all other
accidents.

• Of the 2 5 cause categories for deaths prior to age 45 ,
minority males or females had the highest race-sex-
specific rate for 21. The exceptions were
atherosclerosis, ovarian cancer, colon/rectum/anus
cancer, and suicide.

• Of the causes with the highest race ratios in the
under-45 age group, eight ranked in the top ten for
both males and females. These were hypertension,
cerebrovascular disease, pneumonia/influenza,
homicide, chronic obstructive pulmonary disease,
stomach cancer, chronic liver disease/cirrhosis, and
heart disease.

• For nine of the 25 causes examined, both the male
and female race ratios for decedents under age 45
exceeded the ratios for all ages by at least 48%,
illustrating an excessive risk for minorities at younger
ages. These causes were hypertension, cerebrovas-
cular disease, lung cancer, pneumonia/influenza,
chronic obstructive pulmonary disease, chronic
liver disease /cirrhosis, total heart disease, acute
myocardial infarction, and other ischemic heart
disease.

MORBIDITY

Because mortality is easy to ascertain, it has continued
to be the most reliable single indicator of health conditions
(9). Mortality statistics, however, have the limitation of
being indicative of only a fraction of the morbidity in a
population. Since deaths may occur in the absence of
lengthy morbidity, and many disabilities of long duration
do not result in death, morbidity and disability measures
should be used in addition to mortality measures to
describe the health status and the health differentials of a
population more fully.

Yet, the lack of good morbidity reporting systems
precludes us from having accurate information on the
prevalence and incidence of various illnesses and
disabilities. Still, while the "true" incidence/prevalence
for many diseases may never be known, there do exist
three computerized data systems that provide some
measures and comparisons. The first is the North Carolina
Citizen Survey (NCCS), a statewide survey conducted at
least annually since 1 975 by the North Carolina Office of
State Budget and Management. Each fall the survey
includes a number of questions on the health status of the
state's citizens. The second is the Behavioral Risk Factor
Surveillance (BRFS) Survey conducted by the Adult
Health Services Section in the N.C. Division of Health
Services. That survey collects information on lifestyle
behaviors that contribute to the ten leading causes of
premature death and disability. The third is the
Communicable Disease Reporting System, a system for
the reporting of specified communicable diseases.

HealtK Status. Self-assessed health status has been found
to be highly correlated with actual health status and with
utilization of health services ( 17). In the Fall 1985 NCCS,
eight out of 10 North Carolinians reported their general
health status to be good, very good, or excellent, with
more than one quarter (26%) falling in the excellent
category. Respondents who were younger, white, better
educated, or from households with higher incomes were
more likely to rate their general health as very good or
excellent. In 1985 about 25% of minorities compared to
17% of whites rated their health as fair or poor. In 1984,
the percentages were 30% for minorities and 14% for
whites. The 1985 race-specific distributions of the self-
assessments are depicted to Figure 1 .

Chronic Diieases. The NCCS includes a comprehensive
battery of questions concerning diagnosed diseases. Of
these, arthritis and high blood pressure were the most
commonly reported chronic diseases, each being
mentioned by over one in five adults. Compared to
whites, minorities had a higher percentage for both
diseases, with the largest racial disparity being in the
reporting of high blood pressure (about 1 1 percentage
points difference). In 1984 there was a difference of 18
percentage points due to a higher percentage for minorities.
Of the seven remaining conditions included in the survey,
minorities had higher self-reported percentages for only
three — diabetes, stroke, and glaucoma. Altogether, about
48% of minorities compared to 42% of whites had one or
more of the 9 diagnosed diseases. Race-specific percentages
for the various diseases are depicted in Figure 2.

The BRFS Survey includes only one question on a
diagnosed disease — hypertension (i.e., diagnosed defined
as told more than once, currently taking medication, or
blood pressure still high). About 29% of minorities
versus 1 5% of whites reported that they had hypertension

FIGURE 1

40T

30--

PERCENT OF
RESPONDENTS

20--

10--

SELF-ASSESSED HEALTH STATUS BY RACE,
NORTH CAROLINA CITIZEN SURVEY, 1985

EXCELLENT

VERY 6000

GOOD

ASSESSMENT

FAIR

POOR

FIGURE 2

ADULTS REPORTING DIAGNOSED DISEASE BY

RACE. NORTH CAROLINA CITIZEN SURVEY.

1985

30--

25--

PERCENT
DIAGNOSED

20--

15--

10--

5--

-i

fSSKT /

ARTHRITIS HIGH BLOOO HEART KIONEY LUNG DIABETES CANCER STROKE GLAUCOMA
PRESSURE DISEASE DISEASE DISEASE

(Figure 3). Minority females, who had the highest
percentage, were over twice as likely as white females to
report having hypertension.

CommumcableDiseases. Table 28 shows the number and
rate of selected reported communicable diseases by race.
Some of the more notable differentials in rates of reported
cases involve venereal diseases: gonorrhea and syphilis
rates were at least 1 7 times as high for minorities as whites,
and nonspecific urethritis was 7 times as high. Part of the
reason for the higher veneral disease rate among minorities
is better reporting of these diseases by public health
clinics, where minorities are more likely than whites to
receive care. Other communicable diseases with 1985
minority rates at least twice the white rates were hepatitis
B and pneumococcus meningitis.

Acquired immune deficiency syndrome (AIDS) is a
"NEW" disease, first required to be reported in North
Carolina in January 1984. Nationally, the incidence of
AIDS is rising for all racial groups, but the minority
increase has been three times the white increase (18).
While small numbers of North Carolina AIDS cases [171
as of January 5, 1987 ( 19)] precludes the calculation of
reliable incidence rates over time, some interesting racial
differences prevail among the reported cases. While
whites comprised the largest proportion of these cases
(55%), minorities represented a larger share of the AIDS
population (45%) than of the total North Carolina
population (23%). One factor contributing to the elevated
incidence of AIDS among minorities has been intravenous
(IV) drug use. Minorities comprised approximately 26%
of the reported AIDS cases who were homosexual, but
87% of all cases who were IV drug users. About 29% of all
minorities with AIDS compared to only 1 1 % of all whites
with AIDS were IV drug abusers.

Risk /Prevention Behaviors. In 1985 obesity (i.e., at or
above 120% of median weight) was a risk factor for twice
as many minorities as whites (Figure 4). Minority males
had a proportion higher than that of white males, but
minority females had a proportion almost three times that
of white females.

Smoking has been shown to be associated with several
leading causes of mortality (1,9,16). According to the
NCCS, the percentage of adults who smoke cigarettes has
been relatively stable since 1977, with slightly more than
one-third reporting they are present smokers (i.e.,
respondent has ever smoked 100 cigarettes and smokes
now) (20). In 1984 a greater proportion of men smoked
than women (42.7% vs. 31.6%), and a slightly higher
proportion of minorities smoked than whites (37.8% vs.
36% ). On the average, minority smokers tended to smoke
fewer cigarettes. About 59% of minority smokers,
compared to 21% of white smokers, reported smoking
less than 15 cigarettes per day.

The percentage of adults in North Carolina who say
they drink alcoholic beverages (45%) is considerably
lower than statistics indicate for the U.S. as a whole,
where 73% of all adults say they drink. Males appear more
likely than females to be drinkers (57% vs. 36%), but
only a slightly higher proportion of whites versus
minorities have indicated they drink (46% vs. 41%).
From 1983 to 1984 none of the responses on alcohol use
varied more than 2 percentage points. (20)

Yet, acute alcohol intoxication is a major contributor to
injury and death from accidents and violence, especially
for minority males. Using data from a recent SCHS study
(21 ), Table 29 shows the percentage of decedents with a
blood alcohol level of 100 mg% or greater by race-sex
group. For total accidents, poisonings, and violence,
minority males had the highest alcohol involvement at
1.38 times that for white males and 1.70 times that for
minority females. This general pattern is also apparent for
homicide, motor vehicle accidents, and drowning. For
suicide and fire, minority males follow white males in the
percentage testing at 100 mg% or greater.

In 1983, 4 out of 10 North Carolinians reported in the
NCCS that they never engaged in "active physical
exercise" and another 30 percent reported that they
participated "less than 3 times per week." For these two
response categories combined, there were no differences
between males and females or whites and minorities;
however, females and minorities were slightly more likely
than males and whites to report that they never engaged in
physical activity.

The BRFS survey defined low levels of physical activity
as sedentary lifestyle. In 1985, over half of all North
Carolinians over the age of 17 (57.7%) had a sedentary
lifestyle. Indians (75.4%) and blacks (68.6%) had a
higher risk of sedentary lifestyle than whites (55.4%).

SUMMARY AND DISCUSSION

This study depicts an array of indicators describing the
health status and health habits of minority North
Carolinians. Compared to minorities in the past, today's
minorities are living longer and are healthier. Rates of
infant and fetal death, pregnancy (including teenage
pregnancy), inadequate prenatal care, and general mortality
have declined substantially. Low-weight births and births
among high-risk women, though not improved, have at
least not worsened. Taken together, the health and
average life span of minorities are at levels higher than ever
before, improvements due substantially to (i) efforts in
the health sector to reduce infections, acute diseases, and
infant and maternal mortality and (ii) improvements in
the availability, accessibility, and utilization of basic
health services (1,9).

FIGURE 3

40 -r

30--

PEHCENT

QLA5N0SED

20--

10--

PERCENT OF ADULTS REPORTING HYPERTENSION
BEHAVIORAL RISK FACTOR SURVEY. 1985

HALES

FEMALES

TOTAL

FIGURE 4

PERCENT OF ADULTS REPORTING OBESITY.
BEHAVIORAL RISK FACTOR SURVEY, 1985

40-r

30--

PEBCENT al-

io--

MALES

FEMALES

TOTAL

But relative to whites, minorities continue to suffer
illness and death disproportionately and this dispro-
portionate suffering has not been appreciably altered in
the recent past. Unintended pregnancies (as measured by
abortions and teenage pregnancies, especially repeat
teenage pregnancies) continue to be a major problem in
the minority community, with racial gaps recently
stabilizing or worsening rather than improving. While
reductions have occurred in the minority infant death
rate, it is still almost twice the white rate. Similarly, while
minorities have experienced greater declines in overall
mortality than whites in the recent past, they still have
death rates at least 40% higher. The major contributors to
the disparity are homicides, cancer (particularly prostate,
stomach, cervical, and lung cancers), all other accidents,
cerebrovascular disease, nephritis/nephrosis, and chronic
liver disease/cirrhosis. Using a somewhat conservative
definition* of "excess" mortality (i.e., the ratio of the two
highest race-sex-specific rates), rates for these causes were
at least 50% higher for either minority males or minority
females than the next highest rate. Of these two race- sex
groups, minority males are clearly the group most at risk
of excess death and, consequently, most in need of
interventions to lower this risk.

Although not included in the above listing because of
the conservative definition, hypertension and diabetes are
significant contributors to the health problems of
minorities, although in a different way. Mortality ratios
by sex show that minorities are at least twice as likely as
whites to die from these causes. However, mortality
statistics based on underlying cause of death underestimate
the magnitude of these problems because their contribu-
tion to other health problems such as heart disease,
stroke, and diseases of the kidney and eyes are not
quantified. For example, in 1985 hypertension was the
underlying cause on 231 death certificates but was
mentioned on 4,126 (8% of total certificates). Of
certificates with hypertension mentioned on them, heart
disease was also mentioned on 79%, atherosclerosis on
31%, and cerebrovascular disease on 30%. Diabetes was
the underlying cause on 869 certificates but was mentioned
on 4,130 (8% of total). Of these, heart disease was
mentioned on 75%, atherosclerosis on 40%, and
cerebrovascular disease on 23%. Both diabetes and
hypertension were mentioned together on 947 certificates
(about 1.8% of total certificates). Consequently,
hypertension and diabetes are not themselves major
killers based on underlying causes of death but contribute
to the severity of other problems which take an excessive
toll on minorities.

Given the disproportionate illness and death of
minorities, can we account for such disparities? Numerous
factors are presumed to influence health, and among
these, sociodemographics are believed to be especially
significant ( 1 ). Minorities tend to be less well educated
and to have lower incomes than whites, thereby limiting
access to and knowledge of health services and healthy
practices. The income problem is exacerbated by the fact
that minority families are generally larger than white
families and are more likely to be female-headed.
Combined with the aforementioned problems, minorities
are more likely to be concentrated in urban areas and thus
are exposed to a relatively greater number of environmental
hazards including pollution, traffic hazards, substandard
and overcrowded housing, and crime. Because of the
lower levels of education, minorities tend to be relegated
to positions that potentially present greater levels of
exposure to environmental risks such as physical and
mental stressors and toxic substances. Where these
socioeconomic factors affect health status, differentials in
health can be expected.

The differentials in socioeconomic status raise another
issue in accounting for racial disparities in health — that is,
the appropriateness of "race" as a comparison variable.
The term "race" connotes genetic differences, but in
actuality is a more powerful force in determining health
not for biological but for social reasons (8). In analyzing
race differentials, it would have been preferable to
compare affluent whites with affluent minorities and the
white poor with the minority poor to better delineate
whether the health differentials are due to economic
differences. Differential income levels within and among
racial groups act as confounding variables and distort any
overall racial comparisons. This problem was clearly
demonstrated when, using education as a proxy for
income, comparisons were made of adequacy of care, low
birthweight, and neonatal and postneonatal mortality by
race and education. With these indicators, for example,
minority health tended to improve significantly as
socioeconomic status increased, but the gaps between the
minority and white rates widened, illustrating the con-
founding of income, health status, and race. Unfortunately,
in most cases, North Carolina data collection systems do
not exist that enable the analysis of data by income.

Yet, even among the limited comparisons of race, education
and infant health, the comparability of groups is still an
issue. For example, among births under 2500 grams,
minorities have had a lower neonatal death rate than
whites, regardless of education. One suggested explanation

'This was considered a conservative approach because with some causes, minorities had the two highest race-sex-specific rates. For these causes, while
there were significant differences if we compared the minority and white rates by sex, there was little difference when comparing the male and female
rates by race.

is that there is a biological role influencing birthweight
that gives a different meaning to low birthweight for
minorities versus whites ( 1 ). If one accepts this explana-
tion, it can then be argued that valid birthweight-specific
comparisons by race must be a function of the optimal
racial birthweights. For instance, if one assumes the
optimal birthweight is 3200 grams for whites and 2800
grams for minorities, then the minority birthweight group
corresponding to white births of 2800-3200 grams would
be 2400-2800 instead of 2800-3200 grams to adjust for a
"biologic" difference. While the specific role of biology
in birthweight outcome and the concept of optimal
birthweight by race are issues requiring further research,
they support the broader picture being portrayed here —
that is, the biological comparability of the racial groups
may be a factor in the health effects being compared.

Nutritional status and dietary practices, stress and
coping patterns, drug and alcohol abuse, appropriate and
timely utilization of health services, and sedentary lifestyles
are a few of the factors suggested as being contributors to
health disparities. The causes of health differentials
appear to be multifactorial and to be embedded in
a complex interaction of physiological, cultural,

psychological, and societal factors that is poorly under-
stood for the general population and even less so for
minorities (1). How these factors contribute to the
occurrence of disease and whether they contribute
differently for white versus minority populations are
issues for future research.

Given the complex array of contributing factors,
reducing the longstanding disparities will require creative
thinking. Based on limited national and state data, many
of the risk factors are so disparate between whites and
minorities that the availability and accessibility of medical
care alone, although playing a significant role in mitigating
some of their effects, will not completely offset the
disproportionate illness, disability, and death (1). In
certain pockets of the state, more and better services and
improved access to them are indeed essential. However,
successful strategies to minimize the disparities are more
likely to emerge from the development of "active"
partnerships between health providers and minority
communities which capitalize on the resources and
strengths of both groups and which elevate the "health
consciousness" of the minority community. Creating
such partnerships is a major public health challenge.

REFERENCES

1 . U.S. Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health,
Volume I: Executive Summary. Washington, D.C. August 1985.

2 Kleinbaum, DG; Kupper, LL; Morgenstern H. Epidemiologic Research: Principles and Quantitative Methods. Belmont,
California. 1982, pp. 140-158.

3. Antonovsky, A. "Social Class, Life Expectancy, and Overall Mortality," Milhank Memorial Fund Quarterly. Volume
45, 1967, pp. 31-73.

4. Cassel, J. "The Contribution of The Social Environment To Host Resistance," American Journal of Epidemilogy.
Volume 104, 1976, pp. 107-123.

5. Pratt, L. "The Relationship of Socioeconomic Status to Health," American Journal of Public Health. Volume 61,
1971, pp. 281-291.

6. Syme, SL and Berkman, LF. "Social Class, Susceptibility and Sickness," American Journal of Epidemiology. Volume
104, 1976, pp. 1-8.

7. Ewig, FJ. "North Carolina," American Demographics. Volume 6, Number 9, September 1984, pp. 46-49.

8. Geronimus, AT. "The Effects of Race, Residence, and Prenatal Care on the Relationship of Maternal Age to
Neonatal Mortality," American Journal o/ Public Health. Volume 76, Number 12, December, 1986, pp. 1416-1421.

9. U.S. Department of Health and Human Services. Health Status of Minorities and Lou Income Groups, DHHS Pub. No.
(HRSA) HRS-P-DV 85-1. Washington D.C. 1985.

10. Williams, RL and Chen, PM. "Identifying The Sources of The Recent Declines In Perinatal Mortality Rates in
California," Neu> England Journal of Medicine. Volume 306, 1982, pp. 207-214.

1 1 . Kessner, DM; Singer, J.; Kalk, CE; and Schlesinger, ER. "Infant Death: An Analysis of Maternal Risk and Health
Care," Contrasts in Health Status, Volume i . National Academy of Sciences, Institute of Medicine, Washington, D.C.
1973.

12. Pratt, M. "The Demography of Maternal and Child Health," Maternal and Child Health Practices: Problems, Resources,
and Methods of Delivery. John Wiley and Sons. New York, N.Y. 1986.

1 3. National Center for Health Statistics. "Annual Summary of Births, Deaths, Marriages and Divorces: United States,
1985," Monthly Vital Statistics Report. Vol. 34, No. 13, DHHS Pub. No. (PHS) 86-1120. Public Health Service.
Hyattsville, Md. September 19, 1986.

14. Buescher, PA. "The Impact of Low Birth Weight on North Carolina Neonatal Mortality," SCHS Studies. Number
30, Raleigh, N.C. December 1983.

15. N.C. Department of Human Resources, Division of Health Services, State Center for Health Statistics. Maternal and
Child Health Statistics 1979 Volumei. Raleigh, N.C. December 1980.

16. N.C. Department of Human Resources, Division of Health Services, State Center for Health Statistics. Leading
Causes of Mortality: North Carolina Vital Statistics 1981, Volume 2. Raleigh, N.C. September 1983, pp. 1-9 through
1-19.

17. Ries, PW. "Americans Assess Their Health," Vital and Health Statistics. Series 10, No. 142, DHHS Pub. No.
83-1570. Public Health Service, National Center for Health Statistics, Washington, D.C. March 1983.

18. American Medical Association. American Medical News. Vol. 29, No. 45, Chicago, December 5, 1986.

19. Personal Communication with David Jolly in the AIDS Program, Division of Health Services, Raleigh, N.C,
January 28, 1987.

20. Office of State Budget and Management. North Carolina Citizen Survey — Physical Health and Health Care in North
Carolina: A Review of Survey Data from 1976 to 1984. Raleigh, N.C. December 1985.

2 1 . Buescher PA and Patetta MJ. "Alcohol-Related Morbidity In North Carolina," SCHS Studies. Number 4 1 . Raleigh,
N.C. July 1986.

TABLE 1

SELECTED HEALTH-RELATED INDICATORS BY RACE

NORTH CAROLINA, 1980 CENSUS

DEMOGRAPHICS

Persons:

Percent living in rural areas

Percent under age 18

Percent 65+

Median age

Percent males

Males per 100 females

Persons aged 5+:

Percent in same county as in 1975

ECONOMICS

1) Employed persons 16+, 1979:

Median Earnings: Males
Females

2) Persons:

Percent below poverty, 1979

Percent below 150% of poverty, 1979

3) Persons in families with female

head and no husband present:

Percent below poverty, 1979

Percent below 150% of poverty, 1979

FAMILY STRUCTURE

1 ) Persons per family

2) Percent of families headed by a female

3) Percent headed by female with own

children under 18

4) Persons under 18: Percent who have

own children in married-couple families

AMERICAN

WHITES

BLACKS

INDIANS

54.5

43.1

77.9

26.0

35.0

38.8

10.9

8.6

5.3

31.4

24.7

23.1

48.8

47.5

49.6

95.4

90.4

98.4

79.2

$12,135
$ 7,153

10.0
19.9

85.6

$8,133
$6,062

30.4
48.6

86.2

$8,227
$5,825

27.9
47.2

21.6

48.9

52.4

38.7

69.5

72.4

3.09

3.80

3.88

10.5

33.8

20.9

5.5

20.7

13.2

81.6

49.1

66.6

TABLE 2

TABLE 3

PREGNANCY RATES* BY RACE

LIVE BIRTH RATES* BY RACE

NORTH CAROLINA RESIDENTS

NORTH CAROLINA

1978

- 1985

RACE

1978

- 1985

RACE

YEAR

WHITES

MINORITIES

RATIO

YEAR

WHITES

MINORITIES

RATIO

1978

71.1

108.4

1.52

1978

13.0

20.7

1.59

1979

74.5

109.8

1.47

1979

13.1

20.9

1.60

1980

73.2

109.2

1.49

1980

12.9

19.1

1.48

1981

71.8

106.0

1.48

1981

12.6

18.6

1.48

1982

72.7

104.6

1.44

1982

12.8

18.7

1.46

1983

72.3

101.1

1.40

1983

12.6

17.5

1.39

1984

73.7

103.0

1.40

1984

12.8

17.6

1.38

1985

74.3

101.1

1.36

1985

13.2

17.5

1.33

% Change
1978-85

+ 4.5%

- 6.7%

- 10.5%

% Change
1978-85

+ 1.5%

- 15.5%

- 16.4%

"Number of reported pregnancies (live births, fetal
deaths, and abortions) per 1,000 females aged 15-44.

kLive births per 1,000 population.

TABLE 4

FERTILITY RATES* BY RACE

NORTH CAROLINA

1978

- 1985

RACE

YEAR

WHITES

MINORITIES

RATIO

1978

55.0

80.3

1.46

1979

55.1

79.5

1.44

1980

54.8

77.0

1.41

1981

53.8

74.8

1.39

1982

54.5

75.4

1.38

1983

53.3

70.2

1.32

1984

54.3

69.0

1.27

1985

56.1

69.3

1.24

% Change

1978-85

+ 2.0%

- 13.7%

- 15.1%

TABLE 5

FETAL DEATH RATES* BY RACE

NORTH CAROLINA

1978- 1985

RACE

1.93
1.73
1.79
1.79
1.57
1.77
1.47
1.64

YEAR

WHITES It

4INORI

1978

8.5

16.4

1979

8.9

15.4

1980

8.2

14.7

1981

8.1

14.5

1982

8.4

13.2

1983

7.8

13.8

1984

7.7

11.3

1985

7.2

11.8

% Change
1978-85

- 15.3%

- 28.0'

"Live births (any age) per 1,000 females 15-44.

15.0%

*Fetal deaths (stillbirths) per 1,000 deliveries (live
births plus fetal deaths).

TABLE 6

TABLE 7

ABORTION RATES* BY RACE

ABORTION FRACTION* BY RACE

NORTH CAROLINA

1978

- 1985

RACE

1978

- 1985

RACE

YEAR

WHITES

MINORITIES

RATIO

YEAR

WHITES

MINORITIES

RATIO

1978

15.6

26.7

1.71

1978

233.5

256.6

1.10

1979

17.0

28.1

1.65

1979

246.1

266.7

1.08

1980

17.9

31.1

1.74

1980

256.9

294.7

1.15

1981

17.6

30.1

1.71

1981

258.6

295.5

1.14

1982

17.7

28.2

1.59

1982

256.6

279.9

1.09

1983

18.6

29.9

1.61

1983

257.1

295.6

1.15

1984

18.9

33.3

1.76

1984

257.0

322.9

1.26

1985

17.8

30.9

1.74

1985

240.0

306.0

1.28

% Change

1978-85

+ 14.1%

+ 15.7%

+ 1.8%

1978-85

+ 2.8%

+ 19.3%

+ 16.4%

'Reported abortions (all ages) per 1,000 females aged
15-44.

'Reported abortions per 1 ,000 pregnancies (live births,
fetal deaths, and abortions).

TABLE 8

TABLE 9

TEENAGE PREGNANCY RATES* BY RACE

TEENAGE ABORTION FRACTIONS*

BY RACE

NORTH CAROLINA

1978

- 1985

RACE

1978

- 1985

RACE

YEAR

WHITES

MINORITIES

RATIO

YEAR

WHITES

MINORITIES

RATIO

1978

80.5

139.3

1.73

1978

371.7

252.8

0.68

1979

80.7

137.5

1.70

1979

399.3

275.1

0.69

1980

79.7

132.4

1.66

1980

416.5

309.1

0.74

1981

76.3

125.9

1.65

1981

435.8

302.7

0.69

1982

77.9

125.0

1.60

1982

422.8

288.2

0.68

1983

78.7

127.7

1.62

1983

441.5

326.4

0.74

1984

79.2

132.1

1.67

1984

450.3

357.4

0.79

1985

79.6

130.3

1.64

1985

428.3

351.2

0.82

% Change

1978-85

- 1.1%

- 6.5%

-5.2%

1978-85

+ 15.2%

+ 38.9%

- 20.6%

* Number ot reported pregnancies for females aged 15-19
per 1,000 females aged 15-19.

*Number of reported abortions for females aged 15-19
per 1 ,000 reported pregnancies for females aged 15-19.

TABLE 10

PERCENT OF LIVE BIRTHS WITH
OR MORE SOCIODEMOGRAPHIC
FACTORS* BY RACE

ONE
RISK

TABLE 1 1

PERCENT OF MOTHERS RECEIVING

INADEQUATE PRENATAL CARE*

BY RACE

NORTH CAROLINA

1978

- 1985

RACE

1978

- 1985

RACE

YEAR

WHITES

MINORITIES

RATIO

YEAR

WHITES

MINORITIES

RATIO

1978

45.2

72.8

1.61

1978

4.3

13.9

3.23

1979

44.6

72.2

1.62

1979

4.0

12.5

3.13

1980

43.9

72.4

1.65

1980

3.9

12.0

3.08

1981

42.9

72.2

1.68

1981

3.7

11.5

3.11

1982

43.4

72.1

1.66

1982

3.9

10.7

2.74

1983

42.6

72.6

1.70

1983

3.4

11.0

3.24

1984

42.9

72.5

1.69

1984

3.5

10.6

3.03

1985

42.8

72.5

1.69

1985

3.7

10.9

2.95

% Change

1978-85

- 5.3%

-0.4%

+ 5.0%

1978-85

- 14.0%

-21.6%

- 8.7%

'Factors include maternal age under 18 or over 34,
education under 1 2 years, out-of-wedlock marital status,
parity greater than 3, previous fetal death, and previous
live horn now dead.

'Prenatal care rated according to the Kessner Index (11).

TABLE 12

PERCENT OF MOTHERS RECEIVING

INADEQUATE PRENATAL CARE*

BY RACE AND EDUCATION

NORTH CAROLINA, 1985

RACE

EDUCATION

WHITES

MINORITIES

RATIO

< 12 years

9.4

17.3

1.84

12 Years

3.2

9.6

3.00

13-15 Years

1.7

5.8

3.41

16+ Years

0.6

3.0

5.00

TOTAL

3.7

10.9

2.95

'Prenatal care rated according to the Kessner Index (11).

TABLE 13

NUMBER AND PERCENT OF BIRTHS
BY BIRTHWEIGHT AND RACE

NORTH CAROLINA, 1985

BIRTHWEIGHT
CATEGORIES (GMS)

< 1000

1000-1499

1500-2499

2500-3999

4000+

TOTAL

WHITES
NUMBER PERCENT

328

324

3,027

50,277

7,786

61,766

0.5

4.9

81.4

12.6

100.0

MINORITIES

NUMBER PERCENT

401

308

2,660

22,724

1,518

27,625

1.5
1.1
9.6
82.3
5.5
100.0

TABLE 14

PERCENT OF BIRTHS UNDER 2500 GRAMS
BY RACE AND EDUCATION

NORTH CAROLINA 1978 - 1985

EDUCATION

RACE

1978

1979

1980

1981

1982

1983

1984

1985

< 12 Years

White

8.5

8.6

8.5

8.6

8.4

Minority

13.5

14.1

13.6

14.2

13.2

13.9

13.5

14.0

1 2 Years

White

5.9

6.1

5.7

5.8

5.6

5.8

5.9

Minority

10.9

11.0

11.2

11.7

11.8

11.4

12.0

13-15 Years

White

4.9

4.8

4.5

4.7

5.2

4.9

5.4

5.0

Minority

9.9

10.9

10.6

9.3

11.4

10.2

9.8

10.7

16+ Years

White

4.5

4.2

4.7

4.4

4.0

4.4

4.6

4.4

Minority

8.5

9.3

9.6

8.2

9.8

9.2

9.4

9.7

TOTAL

White

6.3

6.1

6.0

5.9

6.1

6.0

Minority

11.8

12.1

11.8

12.1

117

12.2

TABLE 15

NUMBER AND PERCENT OF WOMEN ON WIC*
WHO REPORTED SMOKING BY RACE AND AGE

NORTH CAROLINA, 1985

WHITES

MINORITIES

AGE

NUMBER

PERCENT

NUMBER PERCE

<20

1023

39.9

458 13.4

20-24

1643

45.4

1067 25.0

25-29

672

42.4

581 27.5

30+

271

39.0

258 24.6

TOTAL

3609

42.7

2364 21.8

''Women, Infants and Children Program, a supplemental food program
for low-income women and their children.

TABLE 16

NUMBER AND PERCENT OF LOW- WEIGHT BIRTHS*

AMONG WOMEN ON WIC

BY SMOKING STATUS, RACE, AND AGE

NORTH CAROLINA, 1985

RACE/AGE

NUMBER

PERCENT

NUMBER 1

5ERCE

WHITE

<20

102

10.0

5.7

20-24

135

8.2

4.7

25-29

9.5

3.3

30+

10.3

7.3

TOTAL

329

9.1

242

5.0

MINORITY

<20

13.3

291

9.9

20-24

165

15.5

296

9.2

25-29

13.9

137

8.9

30+

24.0

9.4

TOTAL

369

15.6

798

9.4

*Births under 5 lbs. 8 oz.

TABLE 17

INFANT MORTALITY RATES* BY RACE

NORTH CAROLINA, 1970 - 1985

RACE

YEAR

WHITES

MINORITIES

RATIO

1970

19.2

35.8

1.86

1971

17.7

32.0

1.81

1972

18.2

32.4

1.78

1973

18.1

29.8

1.65

1974

16.4

26.0

1.59

1975

14.7

26.6

1.81

1976

14.9

24.0

1.61

1977

12.2

23.3

1.91

1978

13.1

23.9

1.82

1979

11.2

23.3

2.08

1980

12.1

19.4

1.60

1981

10.7

18.3

1.71

1982

10.9

19.6

1.80

1983

10.5

19.1

1.82

1984

10.0

18.2

1.82

1985

9.5

17.5

1.84

% Change

1970-85

- 50.5%

-51.1%

- 1.1%

"Deaths under 1 year per 1,000 live births.

TABLE 18

NEONATAL DEATHS AND DEATH RATES
BY RACE AND EDUCATION

NORTH CAROLINA, 1980-84

WHITES

MINORITIES

RACE

AGE

NUMBER

RATE

NUMBER

RATE

RATIO

< 12 Years

635

9.4

625

13.3

1.41

12 Years

805

6.9

764

12.9

1.87

13-15 Years

336

6.2

247

13.0

2.10

16+ Years

263

5.3

114

12.2

2.30

TOTAL

2,064

7.1

1,769

13.1

1.85

"Deaths under 28 days per 1,000 live births.

TABLE 19

BIRTHWEIGHT-SPECIFIC NEONATAL DEATHS AND

DEATH RATES* BY RACE, NORTH CAROLINA

1980-84

WHITES

MINORITIES

RACE

BIRTHWEIGHT

NUMBER

RATE

NUMBER

RATE

RATIO

< 1500

1161

401.5

1288

382.8

0.95

1500-2499

329

22.6

188

14.8

0.65

2500+

541

2.0

255

2.1

1.05

TOTAL

2064

7.1

1769

13.1

1.85

*Deaths under 28 days in specified birthweight category per 1,000 births in birthweight category.

TABLE 20

NEONATAL MORTALITY RATES' BY RACE, EDUCATION
AND BIRTHWEIGHT FOR THREE FIVE-YEAR INTERVALS

NORTH CAROLINA

1970-74

1975-79

1980-84

EDUCATION

BIRTHWEIGHT WHITES

MINORITIES

WHITES

MINORITIES

WHITES

MINORIT

< 1500

609.1

556.4

510.5

445.2

410.7

358.8

< 12

1500-2499

61.3

36.9

35.0

23.3

19.1

13.7

2500+

4.4

5.3

3.0

2.5

2.2

< 1500

653.0

568.8

502.4

488.0

395.9

381.3

1500-2499

61.3

35.6

38.7

22.4

25.8

16.5

2500+

3.5

3.8

2.4

3.0

1.9

2.2

< 1500

648.3

560.0

596.5

460.3

391.2

432.1

13-15

1500-2499

57.5

42.3

45.8

15.82

21.9

10.72

2500+

3.3

3.1

2.5

2.3

1.9

< 1500

698.5

565.2

539.5

338.3

391.9

396.2

16+

1500-2499

47.7

33.23

33.2

20.13

21.8

18.53

2500+

3.3

3.23

2.0

3.22

1.6

1.82

< 1500

636.3

564.2

523.5

460.0

401.5

382.8

TOTAL

1500-2499

60.2

36.8

37.7

22.4

22.6

14.8

2500+

3.8

4.6

2.5

3.0

2.0

2.1

'Deaths under 28 days per 1,000 live births.
2Based on 15 to 19 deaths.
'Based on 9 to 13 deaths.

TABLE 21

NEONATAL DEATH RATIOS*

BY EDUCATION AND BIRTHWEIGHT

FOR THREE FIVE-YEAR INTERVALS

NORTH CAROLINA

BIRTHWEIGHT

EDUCATION

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