Introduction: Using the County Data Book
At the start of the twenty-first century, women’s health issues, long overshadowed by concern for maternal and reproductive health, are being redefined. Just over 100 years ago, when the Indiana State Health Law first mandated the systematic collection of statistics about births and deaths in Indiana, the focus of women’s health issues was on reproductive health and caregiving. Life expectancy was considerably curtailed (48.3 years for women in 1900), compared to modern life expectancy (79.4 years for women), and women’s life centered on motherhood and family (Anderson, 2001). Today, women’s social roles have expanded, and women no longer view their health issues entirely through the lens of motherhood and reproductive health. Women are living longer than ever, and as a result, health conditions associated with aging and health issues affecting the elderly female population demand attention. It is now recognized that risky as well as preventive behaviors in early life affect the quality of life for decades beyond a woman’s reproductive years. The revised focus of women’s health is on good health and quality of life before, during, and after the reproductive years—in other words, throughout a woman’s life cycle. In addition, women retain their important role as caregivers and as advocates for the health of their families.
The problem for service providers and policymakers in the new millennium is to understand women’s lifelong health in light of the fact that few statistics collected in the past provide much insight into contemporary women’s health issues. As the understanding of what constitutes modern women’s health is undergoing review, the kind of information that is collected, analyzed, and disseminated about women’s health issues must be revised.
Scope and Limitations of the Data
Many women’s health issues worthy of detailed study have not been identified until recently. For this reason, data collection has been limited at the county level for many of the women’s health issues that are important for improving the quality of life of women in Indiana in the twenty-first century. At the county level, data exist for death rates due to cardiovascular disease, lung cancer, breast cancer, ovarian cancer, diabetes, and HIV diseases and incidence of breast and cervical cancer, HIV/AIDS, and sexually transmitted diseases (STDs). Missing are data at the county level about the incidence of osteoporosis, high blood pressure, diabetes, obesity, substance abuse, smoking, mental illness and depression, domestic violence and sexual abuse, and disability. Also missing are detailed data on the number of women living in 2000 lacking health insurance coverage, women in medically underserved areas, and women who report regular exercise. Finally, data at the county level are missing on preventive services such as pap smears, mammography, colorectal cancer screening, and osteoporosis bone density screening. Most of this data is available at the state level, and it is presented here for comparative purposes.
Another limitation of the data is a poor understanding of the ways in which racial, cultural, and ethnic differences affect women’s health and participation in risky behaviors. Where data exist to show variations between racial and ethnic groups, these data are presented here. Generally, groups “with the highest rates for morbidity and mortality [are] usually the poor, the elderly, and racial or ethnic minorities.” But comparative data by racial and ethnic group are not available for all categories presented here. Since 1986, “Indiana has begun embarking on its own crusade to combat health disparities among its black and minority citizens” (Goings 2000). The Office of Minority Health at the Indiana State Department of Health focuses on eradicating disparities in preventable conditions among minorities in the state of Indiana. Improvements in infant mortality rates, reduction of disparities in minority mortality due to cardiovascular disease, cancer, stroke, and diabetes, and reduction in incidence of minority cases of HIV/AIDS and STDs are all attainable.
Urban versus rural differences also need to be taken into account, most obviously with regard to access to health care services, but also with reference to exposure to health risks, different practices in health prevention, and varying attention to diagnosis and treatment. Because data collection at the county level in Indiana is just beginning, it is important to keep in mind variations of this sort in interpreting both incidence of disease and risk behaviors, as well as the impact of education programs and screening campaigns on women’s well-being.
One example of the urban versus rural difference at the county level of the incidence of disease is clearly visible in the information presented here about primary and secondary syphilis infection. Marion County, Indiana’s most populous county, ranked first in the country in 1999 in incidence of syphilis (407 cases, or 50.0 per 100,000 population), compared to a national rate of 2.5 cases per 100,000 in the same period. In 2000, the incidence is lower (352 cases in the entire state), with only 302 cases reported in Marion County. Every other county in Indiana showed low or nonexistent incidence of primary and secondary syphilis infection in 2000. Although the pattern of incidence in the national profile is clearly an urban and southern one, no explanation for the unusually high incidence of syphilis in Marion County is readily apparent from the data. Researchers are advised to look at the original data and cited reports before drawing conclusions about policy or program needs from the data as presented here.
As Thomas C. Ricketts, Karen D. Johnson-Webb, and Patricia Taylor conclude in their study of rurality, “There is clear evidence that characteristics that distinguish rural and frontier places from urban communities have important effects on health care service and delivery” (1998). In Indiana, the impact of urban versus rural habitation on access to health care services is evident in the statistics on health professional shortage areas (HPSAs) and medically underserved areas (MUAs).
Where available data are lacking, this report will assist in identifying needs for future research to develop a more detailed picture of the status of women’s health in Indiana.
The demographic and health information presented here has been collected from many federal and state governmental sources, not-for-profit organization and private foundation research reports, the Behavioral Risk Factor Surveillance Survey (BRFSS), and the 2000 U.S. Census. An attempt has been made to collect all recent reports on women’s health issues, as well as the most current statistics available about demographics.
A bibliography of references used to prepare this report appears at the end of the booklet, and data sources for tables are cited under each table.
History of Women’s Health Data in Indiana
In 1998, Governor Frank O’Bannon established the Office of Women’s Health (OWH) at the Indiana State Department of Health. The primary purpose of the office is “to educate and advocate for women’s health by requesting that the state department [of health], either on its own or in partnership with other entities, establish appropriate forums, programs, or initiatives designed to educate the public regarding women’s health, with an emphasis on preventive health and healthy lifestyles” (House Enrolled Act No. 1356). The fourth stated purpose is “to collect, classify, and analyze relevant research information and data conducted or compiled by: (A) the state department [of health]; or (B) other entities in collaboration with the state department [of health]; and to provide interested persons with information regarding the research results, except as prohibited by law.”
With House Enrolled Act No. 1356, Indiana made provisions to begin collecting, classifying, and analyzing data about women’s health issues. Prior to this time, little information about women’s health issues was collected in any systematic way. Issues that are now viewed as important to improving the lives of women are difficult to learn about because the necessary questions simply weren’t asked and statistics were never compiled. The Office of Women’s Health, in following its legislative mandate, will collect and summarize available data, spearhead efforts to improve data collection, and disseminate this information as widely as possible in the future. In many ways, this book represents a baseline from which success in the current century can be measured, but no similar report from the twentieth century is available.
Knowledge of women’s health concerns in the nineteenth century is based on comments made in diaries and letters from that period. By 1882, Indiana had 393 local health boards (92 county and 301 city and town boards), most of which attempted to collect vital statistics and to register deaths and births. By 1885, all counties had organized boards of health. In 1899, Indiana had the first system of birth and death registrations statewide. In 1935, Indiana passed legislation requiring at least a part-time health officer for each county and city of and above fifth class. In 1955, the State Epidemiological Team was established to investigate and control epidemics and outbreaks of disease and illness. The collection of data became more sophisticated as the organizational structure developed. (For information on the development of public health in Indiana, see Lawry 1975.)
In the twentieth century, publications from the Indiana State Board of Health (now the Indiana State Department of Health) record changes in health care concerns. Starting in 1899, the legislated collection of vital statistics in Indiana spurred the collection and publication of other health information. The Indiana State Board of Health began publication of the Quarterly Bulletin in 1897, which converted to the Monthly Bulletin by 1899. Monthly birth and death statistics were collected and printed for each county in Indiana, along with articles about health issues of the day and editorials urging improvements in public health as advocated by Dr. John N. Hurty, the first state health officer.
Comparison of the causes of death for 1899 with those for 1999 clearly shows the change in the twentieth century from infectious to chronic diseases as leading causes of death among Indiana residents. Causes of death listed in the first issue of the Bulletin are: tuberculosis, typhoid, diphtheria and croup, scarlet fever, measles, whooping cough, influenza, pneumonia, cerebrospinal meningitis, cancer, and violent deaths.
Outline of the Report
This report is presented in two parts. The first part, including summary data about women’s health issues in Indiana, is contained in this booklet. The second part, the county-by-county data, is included on a CD-ROM available from the Office of Women’s Health (317) 233-7256.
The information available for the state as a whole far exceeds information available for individual counties. However, in order to provide as complete a picture as possible, a detailed demographic profile is provided for the state, as well as for each county.
Available data are presented in the following order: (a) demographic profile; (b) reproductive health statistics; (c) information about selected health conditions, such as cardiovascular disease and major cancers; (d) information about selected health behaviors and behavioral risks, such as obesity and smoking; and (e) information about women’s use of health care services, such as insurance coverage, mammograms, and pap smears. This order reflects both the traditional importance of reproductive health issues and the relative wealth of information available concerning women’s reproductive health compared to other health issues. The disparity becomes increasingly clear when viewing the county level data, for which no risk behaviors and no specific use of health care system data have been collected.
A short conclusion at the end of the booklet summarizes contemporary women’s health issues at the county level in Indiana. The most serious problem hampering the drawing of specific conclusions is the gap in collection of relevant data. A glossary and the bibliography end the booklet.
Thumbnail maps of each county are included as .gif files in each county folder on the CD-ROM courtesy of the Indiana Business Research Center, Kelley School of Business, Indiana University. The table “Components of the Health and Well Being Composite Index” is reproduced with permission from the Institute for Women’s Policy Research.
Thanks to Dan Axler, Office of Public Affairs, Indiana State Department of Health for his map-designing contributions.