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 I II nil 111 3 3091 00747 1535 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 BULK RATE U.S. Postage PAID Raleigh, N.C. 27626-0538 Permit No. 1862 -RAMCINE STEPHENSON mmiR STATE DATft CENTER •OFFICE OF STATE PLANNING 116 WEST JONES ST RALEIGH, NC INTEROFFICE 1,200 copies of this public document were printed at a cost of $100.56 or 8.40 per copy.