Populations of Color in Tennessee:
Health Status Report
TENNESSEE DEPARTMENT OF HEALTH
OFFICE OF POLICY, PLANNING AND
ASSESSMENT
and
OFFICE OF MINORITY HEALTH
Project Team
Kenneth S. Robinson, MD, Commissioner
and
Chris Corniola, MA, MPH, Epidemiologist
Fred Croom, MD, Epidemiologist
Pramod Dwivedi, MA, MSW, MS, Director, Surveillance, Epidemiology
and Evaluation
Ivan Foster, BA, Data Analyst
Robbie Jackman, MSSW, Executive Director, Office of Minority Health
Frank Stevenson, MPA, Deputy Director, Office of Minority Health
Table of Contents
Acknowledgments ..............................................................................................................1
Letter from the Governor .................................................................................................2
Letter from the Commissioner .........................................................................................3
Executive Summary ..........................................................................................................4
Introduction .......................................................................................................................7
Purpose................................................................................................................................7
Background ........................................................................................................................7
Limitations of public health data......................................................................................7
Relationship among race, ethnicity, poverty, education and geography ......................7
Reporting convention.........................................................................................................8
Targets ................................................................................................................................8
Chapter I: Demographic profile .....................................................................................10
Population.........................................................................................................................11
Geographic distribution ..................................................................................................14
Cultures and nations........................................................................................................16
Immigration and migration ............................................................................................16
Language...........................................................................................................................16
Age distribution................................................................................................................16
Life table ...........................................................................................................................18
Head of household............................................................................................................19
Native and foreign-born ..................................................................................................20
Chapter II: Mortality rates and causes of death...........................................................20
Introduction......................................................................................................................20
Causes of death by age.....................................................................................................21
Injury and violence ..........................................................................................................27
Premature death and years of potential life lost ...........................................................28
Chapter III: Birth-related indicators.............................................................................30
Fertility rates ....................................................................................................................30
Adolescent pregnancy......................................................................................................32
Prenatal care.....................................................................................................................34
Prematurely and low birthweight...................................................................................35
Infant mortality................................................................................................................36
Fetal death ........................................................................................................................41
Special focus: Memphis/Shelby County.........................................................................41
Chapter IV: Economics of health ...................................................................................43
Introduction......................................................................................................................43
Real per capital and median household income............................................................43
Unemployment rate .........................................................................................................44
Wealth ...............................................................................................................................46
Home ownership...............................................................................................................46
Education ..........................................................................................................................47
Poverty line .......................................................................................................................48
Chapter V: Risk and disease disparity...........................................................................51
Behavioral Risk Factor Surveillance System ................................................................50
Chronic diseases ...............................................................................................................55
Cancer ...............................................................................................................................57
Infectious diseases ............................................................................................................59
Mental health....................................................................................................................65
Chapter V: Town Hall Meetings – Concerns and recommendations .........................68
The state of health in Tennessee’s communities............................................................69
Chattanooga......................................................................................................................70
Jackson..............................................................................................................................72
Knoxville ...........................................................................................................................74
Tri-Cities...........................................................................................................................76
Memphis-Shelby County .................................................................................................81
Nashville-Davidson County.............................................................................................83
Strategies for consideration by the Office of Minority Health ...................................89
Observations from the Office of Minority Health ........................................................92
Sources used ...................................................................................................................102
Index of Illustrations
Figure 1: Tennessee racial distribution..........................................................................10
Figure 2: Population distribution by region..................................................................11
Figure 3: African-American population distribution in Tennessee ............................12
Figure 4: Proportion of non-white population ..............................................................12
Figure 5: Median age and race .......................................................................................13
Figure 6: Reference map .................................................................................................14
Figure 7: Map of Tennessee with regions and counties................................................15
Figure 8: Non-white population distribution ................................................................15
Table 1: Region of origin of immigrants........................................................................16
Figure 9 a/b: Population pyramids for African-Americans and whites .....................17
Table 2: Life Table...........................................................................................................18
Figure 10: Female-headed households ...........................................................................19
Figure 11: Mortality rates ...............................................................................................20
Figure 12: Leading causes of death, 1- to 14-years-old ................................................21
Figure 13: Leading causes of death, 15- to 24-years-old ..............................................22
Figure 14: Leading causes of death, 25- to 44-years-old ..............................................23
Figure 15: Leading causes of death, 45- to 64-years-old ..............................................24
Figure 16: Leading causes of death, 65-to 79-years-old ...............................................25
Figure 17: Leading causes of death, 80+ years-old .......................................................26
Table 3: Race and homicide-related mortality rate......................................................27
Figure 18: Guns and death..............................................................................................28
Figure 19: Years of potential life lost by race and gender ...........................................29
Figure 20: Distribution of white infant births...............................................................30
Figure 21: Distribution of African-American infant births.........................................30
Figure 22: Distribution of Hispanic infant births .........................................................31
Figure 23: Teenage mothers and race...........................................................................32
Figure 24: Adolescent pregnancies among whites ........................................................33
Figure 25: Adolescent pregnancies among African-Americans ..................................33
Figure 26: Prenatal care rates for whites ......................................................................34
Figure 27: African-Americans with inadequate or no prenatal care..........................34
Figure 28: Low birthweight by age and race.................................................................35
Figure 29: Infant mortality disparity.............................................................................36
Figure 30: Infant mortality, Tennessee and U.S. compared .......................................37
Figure 31: Infant mortality disparity between African-Americans and whites.........37
Table 4: Leading causes of death for infants.................................................................38
Figure 32: Infant mortality and age of mother .............................................................39
Figure 33: Infant mortality in the South........................................................................39
Figure 34: Infant mortality rates for whites..................................................................40
Figure 35: Infant mortality rates for African-Americans............................................40
Figure 36: Fetal death and race......................................................................................41
Figure 37: Household income and race..........................................................................44
Figure 38: Unemployment and race...............................................................................45
Figure 39: Net worth and race........................................................................................46
Figure 40: Home ownership and race ............................................................................47
Figure 41: Income and education ...................................................................................47
Figure 42: Poverty and race............................................................................................48
Figure 43: BRFSS reported annual household income ................................................49
Table 5: Prevalence of selected health risks ..................................................................50
Figure 44: Self-reported general health.........................................................................51
Figure 45: Race and flu vaccine......................................................................................51
Figure 46: Self-reported risky sexual behavior.............................................................52
Figure 47: Healthcare economic barriers ......................................................................53
Figure 48: PSA testing .....................................................................................................53
Figure 49: Exercise and race...........................................................................................54
Figure 50: BMI, race and sex..........................................................................................55
Figure 51: Rates of hospitalization related to diabetes, heart disease and stroke .....56
Figure 52: Cancer, race and sex .....................................................................................57
Figure 53: Cancer mortality, race and sex ....................................................................59
Figure 54: AIDS and race................................................................................................60
Figure 55: Tuberculosis infection distribution in Tennessee .......................................61
Figure 56: Chlamydia infection distribution in Tennessee ..........................................62
Figure 57: Gonorrhea infection distribution in Tennessee ..........................................63
Figure 58: Syphilis morbidity in Tennessee...................................................................64
Figure 59: Psychiatric medication prescriptions (adults) ............................................65
Figure 60: Unique TennCare recipients’ rate of mental health services received.....66
Table 6: Race and suicide at all ages..............................................................................66
Figure 61: Mental health status in past months............................................................67
Appendices
Appendix 1: Tennessee population estimates by county and region...........................95
Appendix 2: LifeStart data county rankings, Tennessee 2001-2003 ...........................98
Appendix 3: LifeStyle data county rankings, Tennessee 2001-2003 .........................100
Acknowledgements
This report reflects the collaboration and commitment of the following
individuals and organizations:
Office of Minority Health, Tennessee Department of Health
Cynthia Allen
Shonreh Doss
Rozelyn Fields
Ray Harrell
David Morrow
Carolyn Osborne
Tennessee Department of Mental Health and Developmental Disabilities
Commissioner Virginia Trotter-Betts
Gwen Hamer
Dr. Frieda Outlaw
Jackie Talley
Tennessee Minority Health Community Development Incorporation
Minnie Bommer
Cecil Conley
Margaret Davis
Estella Greaves
Albert Jones
Dave Johnson
Shirley Kee
1
Dear Readers:
In 1985, Secretary Margaret Heckler of the U.S. Department of Health and Human Services issued the Report of the
Secretary’s Task Force on Black and Minority Health. That landmark report – which detailed the excess mortality
among blacks in America from major health conditions - became the hallmark for our nation’s rising awareness of,
and distress regarding, the alarming disparities that characterized the health status of racial and ethnic minorities.
Many initiatives were birthed, including here in Tennessee, to address those health disparities; disparities often even
more glaring in The South. The Black Health Care Task Force of the Tennessee Department of Health was succeeded
by one of the nation’s earliest Offices of Minority Health, as we wrestled with innovative, holistic, and specific
approaches to improving the health outcomes of populations of color in Tennessee.
Recently, health and healthcare leaders in both the public and private sectors assembled in Washington, D.C., to
review the health of minorities in America – 20 years after the Heckler Report, and at the mid-point of the ten-year
health agenda targeted by Healthy People 2010. To a significant extent, thanks to then Surgeon General David
Satcher, M.D., one of the overarching goals of Healthy People 2010 is the elimination of health disparities in our
minority populations. In the context of such interim assessments, and in concert with the efforts of our Office of
Minority Health in the Tennessee Department of Health, we present this report; the second such report in the last 10
years which exclusively focuses on the health of our state’s people of color. Our first report, Narrowing the Gap, was
published in 1997.
Unlike the previous report, Populations of Color in Tennessee: Health Status Report incorporates input from
community stakeholders across the state. The knowledge, commitment and collaboration of people from a broad
cross-section add new insight to our strategic thinking in eliminating health disparities in our state.
The report explores a wide range of diseases and health problems affecting people of color, examining and comparing
the health status of minority populations with that of the majority population. You will find comprehensive
presentations on chronic and infectious diseases, and how they affect people of color disproportionately. This report
also cites injury as the leading cause of death among our younger generations, and details some of the hazardous
behaviors practiced by Tennesseans which lead to disease and disability. The socioeconomic status of the state's
minority populations, an important health policy issue and a strong determinant of health status, is also reviewed.
Finally, a discussion on mental health adds unique value to this document by identifying psychological issues that
interact with physical and emotional well-being.
The Tennessee Department of Health will continue to quantify and assess the progress made on the health indicators
described herein, in Populations of Color in Tennessee: Health Status Report. Until Tennessee becomes “one state”
in “one state of excellent health” - without populations with widely disparate health status - The Department’s health
education and promotion programs will continue to utilize the findings of this report to focus our efforts, to direct our
resources, and to shape health interventions for better health outcomes for all Tennesseans.
Sincerely,
Kenneth S. Robinson, MD
Commissioner
Tennessee Department of Health
3
Executive Summary
Life expectancy
At all ages, African-Americans have a shorter life expectancy than whites in Tennessee. In fact, a
white baby born in 2002 was expected to live 5.2 years longer than its African-American counterpart.
Mortality in Tennessee
There are large disparities in the age-adjusted death rate for Tennesseans. Based on 2001-2002 data,
African-Americans overall have a death rate of 1,253 per 100,000 population compared to 961 per
100,000 population among whites. When sex is taken into account, the disparities become clearer.
African-American males have an age-adjusted death rate of 1,560 per 100,000 population; white
males’ rate is 1,182 per 100,000 population; African-American females’ rate is 1,043 per 100,000
population; and white females’ rate is 801 per 100,000 population.
Leading causes of death in Tennessee
Ages 1 to 44: Injuries
Based on 2001-2003 data, among 1- to 14-year-olds, injuries are the leading cause of mortality for
African-American males (21/100,000), white males (13.2/100,000), African-American females
(8.9/100,000) and white females (7.7/100,000).
Among 15- to 24-year-olds, the mortality rates from injury-related causes are even higher: AfricanAmerican males at 151.3/100,000, white males are 108.2/100,000, white females’ rate is
39.4/100,000 and African-American females at 32/100,000.
Among 25- to 44-year-olds, injuries continue to be the leading cause of mortality for AfricanAmerican males (135.7/100,000), white males (112.1/100,000) and white females (46.6/100,000).
However, African-American females suffer from cardiovascular causes of death as their primary
cause of death (53.1/100,000).
Ages 45+: Cardiovascular disease and Cancer
African-American males always demonstrate the highest mortality rate from cardiovascular disease
and cancer (neoplasms) in every age category above 45 years of age.
Among 45- to 64-year-olds, cardiovascular disease (ICD-10 codes I00 to I99) is the leading killer
among African-American males (584.4/100,000), white males (318.4/100,000) and AfricanAmerican females (337.7/100,000). Cancer is the leading cause of death for white females
(211.5/100,000) and the second leading cause of death for African-American males (388.2/100,000),
white males (293.2/100,000) and African-American females (264.6/100,000).
Among 65- to 79-year-olds, African-American males have the highest mortality rate from
cardiovascular disease (2,281.4/100,000), followed by African-American females (1,542.1/100,000),
white males (1,454.7/100,000) and then white females (919.4/1,000). The second highest cause of
mortality for all groups is cancer (neoplasms). African-American males (1,715.6/100,000) lead in
cancer-related mortality, followed by white males (1,261.6/100,000), African-American females
(899/100,000) and white females (759.7/100,000).
4
Injury and violence
Violent deaths vary by race and sex. Homicide is a serious issue for African-American males in
Tennessee. Based on 2001-2003 data, African-American males aged 15 to 24 years die from
homicide at a rate that is more than 31 times that of white females. (The rate is 2.9/100,000 for white
females compared to 90.2/100,000 for African-American males in this age group.) In the 25 to 44
age-group the homicide-related death rate for African-Americans drops to 62.2 per 100,000, but this
is still much higher than the rates for white males (9.4/100,000), white females (4/100,000) or
African-American females (12.9/100,000).
Inversely, white males aged 15 to 24 years die from suicide at a rate that is 23 times that of AfricanAmerican females. (The rate is 0.8/100,000 for African-American females and 18.5/100,000 for
white males. For African-American males, the rate is 13.9 per 100,000, and for white females,
2.9/100,000.) Everyone aged 25- to 44-years-old has even higher suicide rates, led by white males
(30.1/100,000), followed by African-American males (19.9/100,000), white females (9.5/100,000)
and African-American females (2.6/100,000). In the 45- to 64-year-old category, suicide and
homicide rates drop. The homicide-related mortality rate is 25.4 for African-American males,
slightly over a quarter of the rate among the 15- to 24-year-olds.
Premature death
Years of potential life lost (YPLL) is a measure of premature mortality. Death at an age younger than
65 results in years of potential life lost. African-American males lose many years of life prematurely
as compared to whites overall and females of both races. Based on 2000 data, the years of life lost
before the age of 65 per 100,000 individuals are 1,688 for African-American males; 6,155 for
African-American females; 6,108 for white males and 3,148 for white females.
Infant mortality
Tennessee’s infant mortality rate is 8.6 infant deaths for every 1,000 births, ranking the state 48th
worst in the country. The infant mortality rate among African-American Tennesseans was over two
and a half times the infant mortality rate among whites in 2003. African-American mothers have a
higher incidence of low birthweight infants and short gestation period. An African-American baby
born in Tennessee has a greater chance of dying than if that baby were born in any other state in the
South.
Economics
The economic differences between whites and African-Americans are significant. AfricanAmericans have higher unemployment rates, lower median household income and much lower levels
of personal wealth than their white counterparts. In addition, African-Americans are more likely to
rent than own their own home, making accumulation of wealth difficult. African-Americans are also
more likely to be below the poverty level based on the 2000 United States Census.
Health risks
According to 2003 and 2004 Behavioral Risk Factor Surveillance System (BRFSS) data for
Tennessee, African-Americans are more likely to have never checked their blood cholesterol levels,
more likely to be obese, more likely not to have exercised in the past month, less likely to consume
five servings of fruits and/or vegetables per day, more likely to have no type of health coverage, more
likely to suffer from hypertension and more likely to report insufficient moderate exercise. AfricanAmerican women are much more likely to be obese than white women. Women of both races report
approximately the same levels of risky sexual behavior - three percent report engaging in one or more
risky behaviors in the past 12 months. White males report slightly higher levels of risky sexual
5
behavior than women of both races. African-American males report very high levels of risky sexual
behavior (nine percent). A significantly greater proportion of African-Americans than whites report
that they have been unable to see a physician because of cost.
Chronic disease
African-American Tennesseans in 2002 were hospitalized at nearly three times the rate of whites for
diabetes-related morbidity. Stroke related hospitalization occurs at an approximately 50 percent
higher rate among African-Americans than whites. African-American males have a lifetime stroke
prevalence of 9.1 percent, compared to 3.9 percent for white males, 2.7 percent for white females and
2.8 percent for African-American females. Compared to the rest of the United States, Tennessee has
a cancer mortality rate that is one of the highest, ranked 46th for all cancers and races aggregated.
There are racial disparities in cancer mortality both nationwide and in Tennessee. African-Americans
in Tennessee exhibited a mortality rate 274.4 per 100,000 from cancer, while the mortality rate of
among whites was 208.4 per 100,000. Colorectal cancer deaths occurred at a rate of 33.6 per 100,000
African-Americans compared to 19.5 per 100,000 whites. Breast cancer occurs at a 12 percent higher
incidence among white women; however, the mortality rate from breast cancer is 48 percent higher
for African-American women. Many other cancers exhibit a higher mortality rate among AfricanAmericans.
Infectious diseases
The number of AIDS cases per 100,000 in 2003 among African-American adults and adolescents in
Tennessee was more than eight times the relative rate among whites. AIDS disproportionately
impacts people in younger age ranges and contributes too many years of potential life lost.
African-Americans comprise approximately 16 percent of the population of Tennessee but account
for 43 percent of TB cases, 60 percent of Gonorrhea infections, 67 percent of primary and secondary
Syphilis cases and 82 percent of the latent Syphilis cases.
Mental health
African-Americans in the U.S. are more likely suffer from mental disorders, less likely to see
treatment, and when treatment is sought, they are more likely to seek health care at an emergency
room and receive inpatient care. African-Americans on TennCare seek mental health services less
frequently than do their white counterparts.
Community feedback
The Populations of Color in Tennessee: Health Status Report is the second major report produced by
the Office of Minority Health that addresses health disparities in Tennessee’s minority communities.
In an effort to respond to the challenge of reducing and eliminating health disparities by raising
awareness and coordinating activities towards improving the health status among minority
populations in Tennessee, the Tennessee Department of Health, Office of Minority Health offers this
report of concerns and recommendations. The reader’s feedback is encouraged as the Department
collectively moves forward in developing strategies, building and strengthening partnerships towards
these endeavors.
6
Introduction
Purpose
The purpose of this report is to compile data and pertinent information from a wide
variety of sources to provide a complete description of the health, lifestyle, social and
economic conditions which contribute to disparities affecting minority populations.
Background
Tennessee has lagged behind the health of the rest of the nation for a number of years. In
terms of overall health ranking, Tennessee is one of the least healthy states. Not only is
the overall health poor in Tennessee when compared to other states, but the health
disparities between African-Americans and whites are considerable. Fortunately, the
Department of Health is actively seeking to reverse this trend with the “Better Health: It’s
About Time” initiative.
Limitations of public health data
This report draws together data and information from a variety of sources. There are
some limitations to the available data, but when possible the Department has strived to
utilize the most current data available.
x Race/Ethnic group - Much of the racial data is limited to African-Americans and
whites. African-Americans comprise nearly 90 percent of the minority population
in Tennessee, so the small numbers of Hispanics, Asians, Native Americans and
other group make statistical analysis unreliable. Therefore, much of the focus of
this report is on African-Americans.
x Poverty - Poverty data is based mostly on U.S. Census data. Because the census
is completed every ten years, the report is limited to projections based on best
estimates for the interim years.
x Education - The educational data is self-reported and is taken from the birth data
and Census data.
x Geographic distribution - This is a generally robust measure because geographic
distribution data is available from a variety of sources.
x Personal health data - Information pertaining to conditions requiring
hospitalization comes from hospital discharge records. Other information such as
BMI (Body Mass Index) and health-related behaviors comes from self-reported
surveys, such as BRFSS, and may be subject to inherent potential biases.
Relationship among race, ethnicity, poverty, education and geographic
distribution
Racially, Tennessee follows a pattern of a higher concentration of whites in the eastern
portions of the state and more African-Americans in the western portion of the state.
Poverty also follows racial lines, with African-Americans more likely to be living in
poverty, a trend especially true for African-American women. Education is related
inversely to poverty, with increased education correlating with a decreased likelihood of
being in poverty. However, race complicates this correlation because although education
reduces poverty, it does not fully erase the economic disparities between AfricanAmericans and whites.
More simply, African-Americans with similar education still have lower incomes and
poorer health than their white counterparts as a whole.
7
Reporting convention
The terms “African-American”, “white” and “Hispanic” will be used throughout this
report to refer to racial and ethnic categories. The terms have been chosen because they
are generally preferred categories.
Targets
The “Better Health: It’s About Time” (BHIAT) initiative is a comprehensive, farreaching set of targets designed to improve the health in a variety of areas both in the
early years of life (“LifeStart”), as well as to reduce a select set of chronic diseases
(“LifeStyle”). In addition, the reduction of health disparities is a vital component in
BHIAT, with a target of a 50 percent reduction in the disparity of specific health
indicators for minority populations. As an example of the impact of this initiative in one
area, achieving the BHIAT goal pertaining to infant mortality by 2005 would save over
1,000 infants’ lives during the five year period from 2005 to 2010.
2002 Baseline
LifeStart
1. Improve infant mortality rate
among general Tennessee
population.
2. Reduce African-American/white
infant mortality disparity by 50
percent.
3. Increase the proportion of
pregnant women who initiate
prenatal care in the first trimester
of pregnancy.
4. Reduce the white/AfricanAmerican difference in first
trimester prenatal care by 50
percent.
5. Reduce the non-Hispanic/
Hispanic difference in first
trimester prenatal care initiation
by 50 percent.
6. Improve the percentage of
pregnant women with no or
inadequate prenatal care.
7. Reduce the African-American/
white difference in the proportion
of pregnant women with no or
inadequate prenatal care by 50
percent.
8. Reduce the Hispanic/nonHispanic difference in the
proportion of pregnant women
with no or inadequate prenatal
8
2010 Target
1. 9.4 deaths
per 1,000
1. 7 deaths per
1,000
2. difference
of 11.3
deaths per
1,000 or less
2. reduce to a
difference of
5.6 deaths per
1,000 or less
3. 81.1 percent
3. 90 percent
4. 14.1 percent
difference
4. 7 percent
difference
5. 26.6 percent
difference
5. 13.3 percent
difference
6. 11.2 percent
6. 10 percent
7. 10.6 percent
difference
7. 5.3 percent
difference
8. 21.4 percent
difference
8. 10.7 percent
difference
care by 50 percent.
9. Reduce the adolescent (ages 15 to
17 years) pregnancy rate.
10. Reduce the African-American/
white difference in adolescent
(ages 15 to 17 years) pregnancy to
by 50 percent.
LifeStyle
1. Reduce diabetes age-adjusted
inpatient hospitalization rate.
2. Reduce the African-American/
white difference in diabetes ageadjusted inpatient hospitalization
rate by 50 percent.
3. Reduce heart disease age-adjusted
inpatient hospitalization.
4. Reduce the African-American/
white difference in heart disease
age-adjusted inpatient
hospitalization rate by 50 percent.
5. Reduce stroke age-adjusted
inpatient hospitalization rate.
6. Reduce the African-American/
white difference in stroke ageadjusted inpatient hospitalization
rate by 50 percent.
9
9. 35.6
pregnancies
per 1,000
10. 35.4
pregnancies
per 1,000
difference
9. 16.2
pregnancies
per 1,000
10. 17.7
pregnancies
per 1,000
difference
1. 149 per
100,000
2. 211 per
100,000
difference
1. 107 per
100,000
2. 105 per
100,000
difference
3. 1,191 per
100,000
4. 278 per
100,000
difference
3. 970 per
100,000
4. 138 per
100,000
difference
5. 347 per
100,000
6. 165 per
100,000
difference
5. 299 per
100,000
6. 82 per 100,000
difference
Chapter I: Demographic Profile
Population
Figure 1 shows the racial distribution of Tennessee population. The population of
Tennessee was projected to be 5,965,317 on July 1, 2005. Nearly 20 percent of
Tennessee residents are non-white. Individuals reporting themselves to be of mixed race
totaled only 1.1 percent of the population. By far the greatest proportion of non-whites
was African-Americans which comprised 16.4 percent of the population, or 932,809
individuals. Asians accounted for only 1.3 percent of the population. Approximately 23
percent of Asians in Tennessee trace their roots to India, while 17 percent are ethnically
Chinese. The number of Hispanics in Tennessee is changing rapidly and is expected to
double between 2000 and 2010. Approximately 2.2 percent of the population identify
themselves as Hispanic/Latino, of which nearly two-thirds are of Mexican origin. The
population of Tennessee is 97.2 percent U.S. born and 64.7 percent born in Tennessee.
Figure 1: Tennessee racial distribution
Racial Composition, Tennessee 2004
80
80.0
70
% of Population
60
50
40
30
20
16.3
10
0.3
1.3
0.1
1.1
0
White
Black or
African
American
American
Indian and
Alaska Native
10
Asian
Some other
Native
race
Hawaiian and
Other Pacific
Islander
The population of Tennessee is concentrated in the metropolitan areas (Figure 2). The
Shelby and Mid-Cumberland regions are the two most populous regions in Tennessee.
The county with the greatest population is Shelby County with 921,268 people, whereas
the least populated county is Pickett County with a population of only 5,087.
The Shelby and Mid-Cumberland regions each are home to 15 percent of population of
Tennessee; Davidson contains an additional 10 percent of the population.
Figure 2: Population distribution by region
Total Population Distribution by Region, 2004
16
14
12
10
% 8
6
4
Madison
Sullivan
Northwest
Southwest
Southeast
Hamilton
Upper Cumberland
South Central
Northeast
Knox
Davidson
East
Mid-Cumberland
0
Shelby
2
The African-American population in Tennessee is unequally distributed geographically.
Shelby County is home to nearly half of the African-Americans who live in Tennessee.
An additional 16 percent of the African-Americans in Tennessee reside in Davidson
County and six percent are residents of Hamilton County. Shelby and Davidson Counties
combined host nearly two-thirds of the African-Americans in the state.
Hispanics in Tennessee are found mostly in the central part of the state with Bedford
County having the highest percentage of Hispanics. Other counties with significant
Hispanic populations include Hamblen (6.9 percent), Crockett (6.6 percent), Warren (6.1
percent), Davidson (5.6 percent), Montgomery (5.5 percent), Dekalb (4.5 percent) and
Maury County (four percent). All other counties had a Hispanic population of less than
four percent of the total population in 2003.
11
Figure 3: African-American population distribution in Tennessee
Distribution of African-American Population by County
Tennessee, 2004
% African-Americans in Tennessee
50
45
40
35
30
25
20
15
10
5
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Because of the large number of African-Americans residing in Shelby County, it is the
region with the highest percentage of non-white residents, 52.9 percent of the population.
Shelby County is the only county in which a “minority” population is the majority
(Figures 3 and 4). Madison and Davidson are also regions with a large portion of
minority residents; approximately one-third of the population is minorities. Conversely,
the Sullivan, Northeast and Southeast regions are overwhelmingly populated with white
residents.
Figure 4: Proportion of non-white population
Proportion of Non-White Population by Region
Tennessee, 2004
60
50
40
30
20
12
Sullivan
Northeast
Southeast
South Central
MidCumberland
Knox
Northwest
Hamilton
Southwest
Davidson
0
Madison
10
Shelby
%
Figure 5 shows median age by race. A number of factors contribute to median age,
including life-expectancy and natality. If all other factors are constant, generally a
population with a higher life expectancy will have an older median age. Likewise, if the
birth rate is higher than other population groups, generally the median age will be lower.
Changes in demographics and immigration can temporarily alter the median age. Health
needs of a population shift with age, so large differences in the median age of a
population correspond to differing health care needs. Whites have the highest median
age, whereas African-Americans are the youngest population in Tennessee.
Figure 5: Median age and race
Median Age by Race/Sex, Tennessee
(Source: 2000 Census)
40.0
38.9
35.0
36.0
35.6
34.1
30.0
31.1
30.0
31.5
28.0
25.0
Male
Female
20.0
15.0
10.0
5.0
0.0
African-American
Asian
White
13
Native American
Figure 6 reveals size of family by race. Family size has important implications and reflects cultural
values, education levels and special health and financial needs of certain populations. Asians in
Tennessee typically have the largest family size. Whites have the smallest families with fewer than
2.9 persons per household.
Figure 6: Race and family size
Average Family Size by Race, Tennessee
(Source: 2000 Census)
3.5
3.4
3.3
3.2
3.1
3
2.9
2.8
2.7
2.6
African-American
Asian
White
Native American
Geographic distribution
The racial distribution of Tennessee follows a pattern in which the African-American population is
concentrated toward the west; whereas the eastern portion of the state is almost exclusively white
(Figures 7 and 8).
14
Figure 7: Reference map
Figure 8: Non-white population distribution
15
Cultures and nations
Compared to other states, Tennessee does not have a tremendous amount of diversity. AfricanAmericans and whites comprise over 97 percent of the population. There is a growing, but still
small, Hispanic population. Native-Americans comprise a small part of the population (less than one
third of one percent). Cherokee and Chickasaw are two examples of Tennessee Native American
nations.
Immigration and migration
According to the 2000 Census only 2.8 percent of the population of Tennessee was foreign born.
This stands out in contrast with the much higher proportion of foreign-born residents of the U.S. of
11.1 percent. The percentage of the population that is foreign born has increased considerably from
1990 when only 1.2 percent of Tennessee’s population and 7.9 percent of the U.S. population was
foreign born. Recent projections show that there will likely be a continued rising trend of foreignborn individuals making their homes in Tennessee as this state becomes the destination for an evergrowing Hispanic population, many of whom are foreign-born. Immigrants to Tennessee from other
countries come from a variety of countries of origin. Latin America is the source of nearly 40
percent of immigrants to Tennessee, followed by Asia which provides nearly 30 percent of
immigrants. Europe is the third highest source of immigrants. Approximately 18 percent of
immigrants come from Europe (Table 1).
Table 1: Region of origin of immigrants
Region of Origin of Immigrant Population
Africa
Asia
Europe
Latin America
North America
Oceania
Percentage
5.5 percent
31.8 percent
17.7 percent
39.9 percent
4.5 percent
0.6 percent
Language
The vast majority of Tennesseans speak English as their native language, although there is a small
Asian population and a growing Hispanic population who speak their respective languages. The
percentage of residents who spoke a language other than English at home was 4.8 percent in 2000,
compared to the national average of 17.9 percent. In 2003, 2.5 percent of the population of
Tennessee spoke Spanish in their homes. This is considerably lower than the national average of
11.3 percent.
Age distribution
African-Americans have a lower life expectancy and higher mortality rates at all ages, especially
among males. Therefore, the African-American population is proportionally younger than the white
population, demonstrated in the age pyramids for African-Americans and whites (Figure 9a/b). The
narrower apex of the African-American pyramid reflects the higher mortality among African16
Americans. Whites have a longer life-expectancy and the more blunted apex and rectangular sides
of the pyramid reflect the lower mortality and longer life expectancy of whites.
Figures 9a/b: Population pyramids for African-Americans and whites
Population Pyramid of Tennessee African-American Population,
2005 Projection
Source: U.S. Census Bureau
85+ yrs
Black Males
80- 84
Black Females
75- 79
70- 74
65- 69
60- 64
55- 59
50- 54
45- 49
40- 44
35- 39
30- 34
25- 29
20- 24
15- 19
10 to 14
5 to 9
1 to 4
0 to 1
Population Pyramid of Tennessee White Population,
2005 Projection
Source: U.S. Census Bureau
85+ yrs
W hite Males
W hite Females
80- 84
75- 79
70- 74
65- 69
60- 64
55- 59
50- 54
45- 49
40- 44
35- 39
30- 34
25- 29
20- 24
15- 19
10 to 14
5 to 9
1 to 4
0 to 1
17
Life Table
The following Life Table (Table 2) demonstrates the average life expectancy for individuals in the
age groupings listed. (These are abridged life tables that contain projections for the age groupings
rather than projecting life expectancy for each age individually.) We see that an African-American
baby born in 2002 in Tennessee has a life expectancy of 70.4 years compared with the life
expectancy a white baby of 75.6 years. At nearly every age group, African-Americans have less
expected additional years of life than whites. The disparity between whites and African-Americans
in Tennessee is demonstrable from cradle to grave.
Table 2: Life Table, Tennessee, 2002
AfricanAmerican
Expected
Additional
Years of
Age Life
0
1
2-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
85+
70.4
70.7
66.9
61.9
57
52.3
47.7
43.1
38.6
34.2
29.9
25.9
22.1
18.7
15.6
12.7
10.2
8
6.1
White
Expected
Additional
Years of
Life
75.6
75.2
71.3
66.3
61.4
56.6
51.9
47.2
42.5
38
33.5
29.1
24.9
20.9
17.2
13.8
10.8
8.2
6.1
18
Total
Population
Life
Expectancy
74.3
74.1
70.2
65.3
60.4
55.7
51
46.4
41.7
37.1
32.6
28.2
24.1
20.3
16.8
13.6
10.8
8.4
6.4
Head of household
Gender of the head of the household is one major difference between most whites and AfricanAmericans in Tennessee. Among African-American households, 44.8 percent are headed by
women, compared to 14.3 percent of white households. There are several implications to this
phenomenon including lower income for the household and possible parenting complications and
stresses for the mother in female-headed households.
Most children in Tennessee are cared for by their parents (64 percent are in a married couple/family
situation). Approximately 20 percent of all children in Tennessee live with their mothers, with the
father absent. An additional 7.3 percent of children live with their grandparents, while 1.8 percent
lives with other relatives.
Figure 10: Female-headed households
Proportion of All Families With Single Female Head of Household:
Tennessee- 2003
44.8
45
40
35
30
25
%
14.3
20
15
10
5
0
White
African-American
Native vs. foreign-born
Unemployment strikes people of different racial groups differently and in a disparate manner.
There is income disparity between native born and foreign born individuals. Among native born
United States citizens, 13.3 percent are below the poverty line. Among foreign born individuals,
18.4 percent are below the poverty level.
19
Chapter II: Mortality rates and causes of death
Introduction
Health disparities are very apparent, as evidenced in the racial disparities in mortality rates of the
population in Tennessee. In younger age groups, accidents/violent deaths are the leading cause of
death among males, with African-American males experiencing mortality rates that far exceed those
of white males. The death rate for females under 24 years of age is very low. In populations older
than 45 years of age, cancer and heart disease are the dominant causes of death with higher rates of
mortality occurring in African-American males and African-American females when compared to
their respective white counterparts. It quickly becomes apparent after studying the following charts
that health disparities begin in the womb and continue through the oldest ages.
In reviewing the age adjusted death rate in Tennessee, disparities are apparent (Figure 11). The
death rate for African-Americans is 1,253 per 100,000 and 961 per 100,000 for whites. More
specifically, the age-adjusted death rates for African-American males, white males, AfricanAmerican females and white females were 1,560, 1,182, 1,043 and 801 per 100,000 population,
respectively. For African-American males living in metropolitan areas, the death rate was 1,601 per
100,000, the highest rate for any group in Tennessee. On the other hand, females living in
metropolitan areas had the lowest age-adjusted death rate of only 785 per 100,000.
Figure 11: Mortality rates
Age-Adjusted Mortality Rate: Tennessee, 2001-2002
1800
1600
Deaths per 100,000
1400
1560
1200
1000
1253
1182
800
1043
961
600
801
400
200
0
AfricanAmericans
Overall
Whites Overall
AfricanAmerican Males
20
White Males
AfricanAmerican
Females
White Females
Causes of death by age
Figure 12: Leading causes of death, 1- to 14-years-old
Selected mortality categories by race and gender 1-14 years old Tennessee
2001-2003
25
deaths per 100,000 population
20
Black female
Black male
15
White female
White male
10
5
Genitourinary system
Digestive diseases (K00K93)
Respiratory diseases (J00J99)
Endocrine, nutritional,
metabolic diseases (E00E90)
Infectious disease (A00B99)
Accidents and injuries (V01Y98)
Cancer (C00-D48)
Cardiovascular disease
(I00-I99)
0
Among 1- to 14-year-olds, accidents and injuries prevail as the major cause of death for all race/sex
categories, followed by childhood cancers (Figure 12). African-American males have the highest
accident and injury rate (21/100,000), followed by white males (13.2/100,000). White females have
the lowest accident and injury rate (7.7/100,000). Childhood cancers are the second leading cause of
mortality among all Tennesseans aged 1 to 14 years. African-American females have the highest
rate of cancer among 1- to 14-year-olds (4.2/100,000). After accidents and cancer, the causes of
death vary by race and sex. The third leading cause of death among African-American females is a
split between endocrine/metabolic disorders, respiratory disease and digestive diseases (1.4/100,000
each). The third leading cause of death among African-American and white males is respiratory
disease (2.1/100,000 for African-Americans and 1/100,000 for whites). Among white females,
endocrine disorders (1/100,000) rank third.
21
Figure 13: Leading causes of death, 15- to 24-years-old
Selected mortality categories by race and and gender, 15 to 24 years old,
Tennessee 2001-2003
Black female
140
Black male
White female
White male
120
100
80
60
40
Genitourinary system
Digestive diseases (K00K93)
Respiratory diseases
(J00-J99)
Endocrine, nutritional,
metabolic diseases (E00E90)
Infectious disease (A00B99)
Cardiovascular disease
(I00-I99)
0
Accidents and injuries
(V01- Y98)
20
Cancer (C00-D48)
deaths per 100,000 population
160
In the 15 to 24 year age group, accidents and injuries are a major cause of death, with a rate that is
much higher than all other causes of mortality (Figure 13). Males have an especially high mortality
rate from accidents (151.3/100,000 for African-American males and 108.2 /100,000 for white
males). Although females have a lower mortality rate from accidents than men in this age group,
accidents are still the leading cause of death among women (32/100,000 for African-American
females and 39.4/100,000 for white females). As in the younger age group, the overall mortality rate
is low for this age group. The second leading cause of death varies based on race and gender.
Cardiovascular disorders are the second leading cause of mortality for both white (5/100,000) and
African-American males (6.7/100,000). Infectious diseases are the second leading killer among
African-American females in this age group (7/100,000), while cancer is ranked second among
white females (4.2/100,000).
22
Figure 14: Leading causes of death, 25- to 44-years-old
Selected mortality categories by race and and gender, 25 to 44 years old,
Tennessee 2001-2003
160
deaths per 100,000 population
140
Black female
Black male
120
White female
White male
100
80
60
40
20
Genitourinary system
Digestive diseases
(K00-K93)
Respiratory diseases
(J00-J99)
Endocrine,
nutritional, metabolic
diseases (E00-E90)
Infectious disease
(A00-B99)
Accidents and
injuries (V01- Y98)
Cancer (C00-D48)
Cardiovascular
disease (I00-I99)
0
The 25 to 44 age group has a higher overall mortality rate than younger age groups (Figure 14). In
addition to accidents and injuries, which includes violent deaths, members of this age group now
have cardiovascular disease, cancer and infectious disease as causes of death which begin to be
major causes of mortality. Accidents and injuries continue to be the leading cause of mortality for
African-American males (135.7/100,000), white males (112.1/100,000) and white females
(46.6/100,000). African-American females suffer from cardiovascular causes of death as their
primary cause of death (53.1/100,000). Cardiovascular disease is the second leading cause of death
among African-American males (83.9/100,000) and white males (47.1/100,000), whereas cancer is
second among white females (30.2/100,000) and African-American females (44.1/100,000).
Infectious diseases are a close third place on the list of mortality categories among AfricanAmerican males (77.9/100,000), whereas cancer is third among white males (25.5/100,000).
Accidents are third among African-American females (37.6/100,000) and cardiovascular disease is
third among white females (23.3/100,000).
23
Figure 15: Leading causes of death, 45- to 64-years-old
Selected mortality categories by race and and gender, 45 to 64 years old,
Tennessee 2001-2003
deaths per 100,000 population
700
Black female
600
Black male
White female
500
White male
400
300
200
100
Genitourinary
system
Digestive diseases
(K00-K93)
Respiratory
diseases (J00-J99)
Endocrine,
nutritional,
metabolic diseases
(E00-E90)
Infectious disease
(A00-B99)
Accidents and
injuries (V01- Y98)
Cancer (C00-D48)
Cardiovascular
disease (I00-I99)
0
In the next age group of 45- to 64-years-old, the leading causes of death are similar across races and
genders. Cardiovascular disease is the leading cause of death, followed by cancer. This age group
settles into a pattern that will continue for the rest of the age groups, with cardiovascular disease and
cancer as major sources of mortality. White females are the exception, with cancer as the leading
cause of death. Cardiovascular disease shows up as the leading cause of death in this age group and
continues to be the biggest threat to life for the rest of the age groups. As is nearly always the case,
African-American males have the highest mortality rate. Deaths from cardiovascular disease are top
killer among African-American males (584.4/100,000), white males (318.4/100,000) and AfricanAmerican females (337.7/100,000). However, cardiovascular disease is the second killer among
white females (147.4/100,000). Cancer is the leading cause of death for white females
(211.5/100,000) and the second leading cause of death for African-American males (388.2/100,000),
white males (293.2/100,000) and African-American females (264.6/100,000). By the 45- to 64-yearold age group, deaths from accidents constitute a much smaller portion of the total deaths compared
to the younger age groups; however, they are the third leading cause of death for African-American
males (118.8/100,000) and white males (101.4/100,000). White women, on the other hand, suffer
from respiratory disease as their third leading cause of death (54.4/100,000), while AfricanAmerican women are more likely to die from endocrine disorders (i.e., diabetes) as their third
leading cause of death (77.4/100,000).
24
Figure 16: Leading causes of death, 65- to 79-years-old
Selected mortality categories by race and and gender, 65 to 79 years old,
Tennessee 2001-2003
deaths per 100,000 population
2500
2000
Black female
Black male
White female
1500
White male
1000
500
Genitourinary
system
Digestive diseases
(K00-K93)
Respiratory
diseases (J00-J99)
Endocrine,
nutritional,
metabolic diseases
(E00-E90)
Infectious disease
(A00-B99)
Accidents and
injuries (V01- Y98)
Cancer (C00-D48)
Cardiovascular
disease (I00-I99)
0
A large increase in mortality rates occurs in the age group of 65- to 79-years-old. In this age group
the overall mortality spikes upward considerably with cardiovascular disease and cancer as leading
causes of mortality, while respiratory disease follows in third place. African-American males have
the highest mortality rate from cardiovascular disease (2,281.4/100,000), followed by AfricanAmerican females (1,542.1/100,000), white males (1,454.7/100,000) and then white females
(919.4/1,000). The second highest cause of mortality for all groups is cancer. African-American
males (1,715.6/100,000) lead in cancer-related mortality once again, followed by white males
(1,261.6/100,000), African-American females (899.0/100,000) and white females (759.7/100,000).
Respiratory disease is another primary killer of white males (506.0/1,000), African-American males
(451.5/100,000) and white females (343.6/100,000). African-American females suffer from
endocrine disorders as their third leading cause of mortality (301/100,000).
Although other causes of death in this group are proportionally less that the aforementioned causes
of death, even relatively “minor” causes of death, such as accidents, occur at a rate that exceeds the
accident fatality rate of even the 15- to 24-year-old age group, in which accidents are the leading
cause of death.
25
Figure 17: Leading causes of death, 80+ years-old
Selected mortality categories by race and and gender, 80+ years old, Tennessee 2001-2003
6000
Black female
Black male
White female
White male
5000
4000
3000
2000
Nervous system
G enitourinary system
Diges tive diseases
(K00-K93)
Respiratory diseases
(J00-J99)
Endocrine, nutritional,
metabolic diseases
(E00-E90)
Infectious disease
(A00-B99)
Accidents and injuries
(V01- Y98)
0
Cancer (C00-D48)
1000
Cardiovascular
disease (I00-I99)
deaths per 100,000 population
7000
In this final age group of 80-years-old and above, cardiovascular disease, cancer and respiratory
diseases are the three leading causes of mortality in that order (Figure 17). Cardiovascular disease
takes a heavy toll on Tennesseans living past 79 years: African-American males (6,622.8/100,000),
white males (6,089.5/100,000), African-American females (5,817.3/100,000) and white females
(5,535.5/100,000). Cancer is the second leading cause of death, highest among African-American
males (2,948/100,000) followed by white males (2,520.8/100,000), African-American females
(1,633.2/100,000) and white females (1,299.3/100,000). Respiratory disease is the third leading
cause of death for this age group, affecting white males the most (1,960.1/100,000), followed by
African-American males (1,569.2/100,000), white females (1,253.2/100,000) and African-American
females (746.7/100,000).
26
Injury and violence
Among 15- to 34-year-old African-American males, homicide is the leading cause of death,
responsible for 34 percent of deaths in this age group. Unintentional injuries were responsible for an
additional 21.4 percent of deaths. For white males aged 15 to 34, unintentional injuries were
responsible for nearly 50 percent of the deaths, while suicide was the second leading cause of death,
causing approximately 16 percent of deaths.
Homicide is a serious issue for African-American males in Tennessee (Table 3). Based on 20012003 data, African-American males aged 15 to 24 years die from homicide at a rate that is more than
31 times that of white females. In the 25 to 44 age group, the homicide-related death rate for
African-Americans drops to 62.2 per 100,000, but this is still much higher than the rates for white
males (9.4/100,000), white females (4/100,000) or African-American females (12.9/100,000). It
should be noted that African-American females also suffer from homicide-related mortality at a rate
that is higher than either white males or females.
Table 3: Race and homicide-related mortality rate, Tennessee 2001-2003
Race/Sex
White males
African-American males
White females
African-American females
Aged 15-24 years
6.6
90.2
2.9
14.3
Aged 25-44 years
9.4
62.2
4
12.9
Inversely, white males aged 15 to 24 years die from suicide at a rate that is 23 times that of AfricanAmerican females. (The rate is 0.8/100,000 for African-American females and 18.5/100,000 for
white males. For African-American males the rate is 13.9 per 100,000 and for white females,
2.9/100,000.) Everyone aged 25- to 44-years-old has even higher suicide rates, lead by white males
(30.1/100,000), followed by African-American males (19.9/100,000), white females (9.5/100,000)
and African-American females (2.6/100,000). In the 45- to 64-year-old category, the suicide and
homicide rates drop. (The homicide-related mortality rate is 25.4 for African-American males,
slightly over a quarter of the rate among the 15- to 24-year-olds.)
Guns play a central role in violent deaths. Among African-American males, death from assault
involving a gun is much higher than for whites. However, self-inflicted gunshot deaths are higher
among whites (Figure 18).
27
Figure 18: Guns and death.
Premature death and years of potential life lost /age-adjusted mortality rates by race and
ethnicity
Years of potential life lost (YPLL) are an important tool with which public health professionals
measure relative impacts of various diseases and conditions on a specific population. The YPLL
measure calculates the number of years of life lost due to a specific condition before 65 years of age.
This allows analysis of the impact on the population. For example, a condition like AIDS causes
sufferers to lose many decades of life because they are typically younger and may have lived many
years longer. On the other hand, conditions which typically affect elderly people such as
Alzheimer’s disease cause less years of potential life lost because those impacted are typically closer
to completing their life expectancy.
Tennessee attributed 5,146 years of life lost per 100,000 inhabitants in 2000. These lost years of life
were attributable to a variety of causes of which injuries were the primary cause of lost years of life.
Approximately 32 percent of years of life lost were lost because of injuries, including accidents,
homicide and suicide. Cancer contributed to 15 percent of the years of life lost and heart disease
contributed to 14 percent of lost years of life. YPLL rates in Tennessee demonstrate the racial
disparity. African-American males lose many more years of life prematurely compared to whites
and females of both races. African-American males have the highest rate of years of potential life
lost at 11,688/100,000 population. This is nearly double the rate for white males and AfricanAmerican females. It is nearly four times the rate of years of potential life lost of white women.
28
Figure 19: Years of potential life lost by race and gender
Years of Life Lost per 100,000 Population, Tennessee 2001-2002
14,000
12,000
11,688
Years of Life Lost
10,000
8,000
6,000
6,155
6,108
4,000
3,148
2,000
0
Black males
Black females
29
White males
White females
Chapter III: Birth-related indicators
Fertility Rate
The general fertility rate varies by race (Figures 20, 21 and 22). In 2003, African-American women
had a general fertility rate of 68.2/1,000 compared to the general fertility rate of 61.6/1,000 among
white women. In the Sullivan, Northeast, East, Upper Cumberland and Southeast regions over 92
percent of the babies born are white. The western regions of Tennessee have a high percentage of
birth among African-Americans, with Shelby County having the most. Currently, Davidson County
has the highest percentage of births to Hispanic mothers.
Figure 20: Distribution of white infant births
Figure 21: Distribution of African-American infant births
30
Figure 22: Distribution of Hispanic infant births
31
Adolescent pregnancy
In Tennessee, adolescent pregnancy rates are an area of considerable disparity between whites and
African-Americans. Adolescent pregnancies occur at a higher rate among African-American
teenage girls, with the greatest disparity among the very youngest teenage mothers. Stewart and
Perry Counties have the highest adolescent pregnancy rates for African-Americans in Tennessee
(Figure 25). The adolescent pregnancy rate among whites varies considerably between Tennessee
counties, with Williamson County experiencing the lowest adolescent pregnancy rate among whites
(Figure 24). Higher rates among whites are found scattered across the state.
Figure 23: Teenage mothers and race
Adolescent Pregnancy, Tennessee 2003
Pregnancies per 1,000 females
160
140
120
100
White
80
Black
60
40
20
0
10 to 14
15 to 17
Age of mother
32
18 to 19
Figure 24: Adolescent pregnancies among whites
Figure 25: Adolescent pregnancies among African-Americans
33
Prenatal care
Although prenatal care rates for whites are higher than for African-Americans in Tennessee, counties
such as Stewart and Montgomery have low utilization of prenatal care by whites (Figure 26).
African-Americans with inadequate or no prenatal care are found across Tennessee and receive
inadequate or no prenatal care at much higher rates than whites (Figure 27).
Figure 26: Prenatal care rates for whites
Figure 27: African-Americans with inadequate or no prenatal care
34
Prematurity and low birthweight
Both prematurity and low birthweight are major risk factors for infant mortality and morbidity.
Therefore understanding the racial disparities that exist pertaining to these two important indicators
of infant health is vital. Figure 28 demonstrates two important trends: one, African-Americans
consistently have higher rates of low birthweight babies and two, mothers from their mid twenties to
early thirties have the best birth outcomes.
Figure 28: Low birthweight by age and race
Low Birth We ight
Age and Race
Te nne sse e , 1994-2003
40
35
30
25
20
15
10
Black
5
Whit e
0
12 14 16 18 2 0 2 2 2 4 2 6 2 8 3 0 3 2 3 4 3 6 3 8 4 0 4 2 4 4 4 6
Mo t h e r s A g e
Infant mortality
Infant mortality is a health indicator that is of particular importance. In addition to the tragic
dimension that the death of an infant represents for the family, infant mortality demonstrates a
breakdown in system of health care delivery and public health in many cases. Several figures
(Figure 29, 30, 32, 33, 34 and 35) and Table 4 depict the infant mortality situation in Tennessee.
Although some infant deaths are beyond the control of current preventive measures, there are many
deaths that could be prevented and it is these deaths which are particularly tragic. The infant
mortality rate among African-Americans is over two and a half times that of white infants. Hispanics
often have lower infant mortality rates than whites. Although there has been a considerable decrease
in the last century in infant mortality rates, the disparity remains and in recent years has grown
proportionally larger as gains in health care have disproportionately benefited whites. Since 1999,
the infant mortality rate among African-Americans has increased. The exact reason why this has
occurred is not fully known. Hispanic infant mortality is typically lower than that of the white
population, especially among recent immigrants. Not only is there African-American/white infant
mortality disparity within Tennessee, but Tennessee as a whole has a higher infant mortality rate
than the rest of the U.S. In the years since 1999, the infant mortality disparity between Tennessee
and the rest of the U.S. has increased. Higher infant mortality among the African-American
population has been an issue of focus of the Tennessee Department of Health and continues to be an
area of concern.
35
Figure 29: Infant mortality disparity
Infant Mortality Disparity- Tennessee 1995-2003
20
18
16
Infant Deaths per 1,000 Live Births
14
White
Black
12
Hispanic
BHIAT Target 2010
10
8
6
4
2
0
1995
1996
1997
1998
36
1999
2000
2001
2002
2010
Figure 30: Infant mortality, Tennessee and U.S. compared
Infant Mortality Trends: Tennessee and the U.S. (1994-2003)
10
I n f a n t D e a t h s p e r 1 , 0 0 0 L iv e B irt h s
9.5
9
8.5
8
7.5
7
TN
US
6.5
BHIAT 2010 Objective
6
1994
1995
1996
1997
1998
1999
2000
2001
2002
Figure 31: Infant mortality disparity between African-Americans and whites
Infant Mortality Rate per 1,000 Live Births
Infant Mortality Rate by Race and Ethnicity
Tennessee- 2003
20
18
16
14
12
10
8
6
4
2
0
Black
White
37
Hispanic
2003
…
2010
The leading causes of infant mortality among African-Americans are related to short gestation and
low birthweight, whereas congenital problems are the leading cause of death among whites.
Table 4: Leading causes of death for infants
Infant mortality leading causes of death by race. Tennessee 1999-2002
AfricanAmerican
ICD-10 Labels:
1
P07 Short Gestation, low birthweight
2
Q00-Q99 Congenital, malformations, chromo abnormalities
3
R95 SIDS
4
P29 Cardiovascular disorders originating in the perinatal period
5
P22 Respiratory distress
6
V01-X59, Y85-86 Accidents
7
P36 Bacterial Sepsis
8
P01 Maternal complications of pregnancy
9
P02 Complications of placenta, cord and membranes
9
P77 Necrotizing enterocolitis of newborn
10
P28 Other respiratory conditions originating in the perinatal period
10
P50-P52, 54 Neonatal hemorrhage
11
P21 Birth asphyxia
12
A41 Other septicemia
13
P83 Other conditions of integument specific to newborn
White
3
1
2
9
4
5
6
6
7
14
8
10
11
13
12
At nearly every age, African-American women have higher rates of infant mortality than white
women (Figure 32). Racial health disparities in infant mortality rates are not limited to Tennessee
alone. However, the magnitude of the disparity in Tennessee is larger than the surrounding southern
states. An African-American baby born in Tennessee has a greater chance of dying than if that baby
were born in any other state in the South. Tennessee has a lower overall infant mortality rate than
some other states, but this means little because of the differing racial compositions of the comparison
states. Tennessee is the most dangerous state in the South for an infant to be born, in terms of infant
mortality (Figure 33).
38
Infant Deaths per 1,000 Live Births
Figure 32: Infant mortality and age of mother
Infant Mortality and Age of Mother
Tennessee 1995-2002
25
White
Black
20
Total
15
10
5
0
<15
15-17
18-22
23-26
27-33
34-38
39+
Figure 33: Infant mortality in the South
Infant Mortality in Region IV States by Race, 2002
Infant Deaths per 1,000 Live Births
20.0
White
Black
18.0
All Races
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
United States
Region IV
(The South)
Tennessee
South
Carolina
North
Carolina
Mississippi
Kentucky
Georgia
Florida
Alabama
0.0
In order to better understand the issue of health disparities, we turn our attention to the geographic
distribution of infant mortality. The following two maps show the considerable difference in infant
mortality that exists throughout the state. Infant mortality among African-Americans can clearly be
seen as higher in the areas where sufficient data is available to allow comparisons.
39
Figure 34: Infant mortality rates for whites
Figure 35: Infant mortality rates for African-Americans
40
Fetal death
Fetal death is another measure of health disparities and is significant because it measures the relative
health of the fetus within the womb. Fetal death disparities parallel other health disparities between
African-Americans and whites in Tennessee.
Figure 36: Fetal death and race
Fetal Death Rate: Race
Tennessee (1996-2003)
10
Fetal Deaths per 1,000 Live Births + Fetal Deaths
9
8
7
White
Black
Total
6
5
4
3
2
1996
1997
1998
1999
2000
2001
2002
2003
Special focus: Memphis/Shelby County
Shelby County has become an area of special focus in Tennessee because of the large number of
infants dying before reaching their first birthday. Recently the renewed focus on infant mortality has
led to a closer scrutiny of the conditions in Shelby County which may be contributors to the
unusually high mortality rate among infants in this area.
Although Shelby County appears to have very high infant mortality rates, the problem upon further
investigation appears to be less related to geography and more closely related to conditions within
Shelby County, such as the racial composition of the population of Shelby County. In fact, 60
percent of the births are to African-American women in Shelby County, but nearly 80 percent of the
infant deaths are among African-Americans. Although there are some counties in Tennessee with
higher infant mortality rates among African-Americans, an African-American baby born in Shelby
County does have a relatively disadvantaged first year of life.
41
There is a “perfect storm” of infant mortality in Shelby County in which there is a large underserved African-American population, an urban setting and high levels of reported extremely low
birthweight infants.
There are multiple factors contributing to infant mortality, but short gestation/low birthweight and
SIDS are two major causes of death among infants in Shelby County. Short gestation/low
birthweight in Shelby County account for 27 percent of infant deaths (compared to 14 percent for the
rest of the state), and SIDS accounts for 11 percent of the infant deaths (compared to 10 percent for
the rest of the state).
There does seem to be an elevated proportion of extremely low birthweight (ELBW <500 grams)
babies born to African-American women in Shelby County compared to African-American women
in the rest of the state. African-Americans born in Shelby are nearly three times as likely to die
within the first year of life as their white counterparts.
As mentioned previously, low birthweight is one major risk factor for infant mortality in general.
African-Americans as a group experience both higher rates of low birthweight infants and higher
mortality rates of those low birthweight infants. An African-American mother is over four times as
likely to give birth to an ELBW infant compared to a non-African-American in Shelby County.
Finally, African-American women in Shelby County are twice as likely to give birth to a low birth
weight baby (LBW<2500 grams) as non African-Americans, and infants in this weight category are
nearly one and a half times as likely to fail to reach their first birthday.
There are a number of factors that separate African-American women from other women, which
may contribute to higher rates of infant mortality. The rate of teenage pregnancy is higher among
African-American women in general and in Shelby County. Teenage motherhood places the infant
at a higher risk for infant mortality. Mothers under 19 years of age are approximately 32 percent
more likely to lose their babies in the first year of life. Lack of prenatal care, a more common issue
among African-Americans, is associated with a risk of infant death that is much greater than among
infants whose mothers receive prenatal care. Although it is difficult to quantify, African-American
women report a number of risk factors which affect general health and possibly infant health. For
example, African-American women are more likely to be diabetic and to suffer from hypertension.
In addition, they are less likely to report “excellent” or “very good” health than white women, less
likely to see a doctor (because of prohibitive cost) and less likely to have exercised in the past
month.
Interventions may target the underlying causes of low birthweight; guaranteeing healthcare access,
educating mothers regarding SIDS prevention and addressing seriously underserved women in
Shelby County and their specific needs.
42
Chapter IV: Economics of health
Introduction
Economics is defined as “the scientific study of the choices made by individuals and societies in
regard to the alternative uses of scarce resources which are employed to satisfy wants.” This
definition stresses that there simply are not enough basic resources (such as clean water, land, labor,
capital equipment and vaccines) in the world to produce everything that the people want. Thus,
specific populations devise systems to share scarce resources. The way resources are allocated is
determined by the economic actions of individuals in the population.
The Tennessee Department of Health’s Office of Disparity Elimination, Office of Planning, Policy
and Assessment, and Office of Minority Health have targeted the health disparities among the
different minority populations in Tennessee, specifically the African-American population.
In regard to the level of health quality, a population is strongly constrained by certain economic
indicators: income, poverty level, employment, education attainment and housing status. As a
county develops economically, the health of its population improves. This improvement in health is
direct evidence that people are leading better lives. However, health also has a productive side:
Healthier people can work harder and longer; they can also think more clearly. Healthier students
can learn better. Thus, health and socioeconomic status impact each other mutually. It is this
productive aspect of health, health as a form of human capital, which will be explored in this section
in regards to the African-American population. This section explains the large health gap between
the African-American population and white population and also the consequences that the AfricanAmerican population faces due to their poor health.
Real per capita and median household income
Income varies considerably by race and is indicative of the broader racial disparities present. The
median household income is lowest for the African-American population. Income is highly
correlated with health status. It is still not certain whether the direction of causation goes from high
income leading to good health or good health leading to high income, but it is likely that the
causation works both ways. Improvement in health and nutrition raises output in two ways: first, it
brings people into the labor force who would otherwise have been unable to work, and second, good
health status improves the productivity of those who are already working. As a result of increased
health and nutrition, these workers are able to work more and, in turn, increase their income.
43
There are clear racial disparities in household income in Tennessee. African-Americans have an
income level that is only 60 percent of the Asian income level and 71 percent of the income of
whites.
Figure 37: Household income and race
Median Household Income by Race
Tennessee, 2000
50,000
$45,497
45,000
Median Household Income
40,000
$38,189
$33,764
35,000
30,000
$27,166
25,000
20,000
15,000
10,000
5,000
0
White
Black
Native American
Asian
Unemployment rate
The unemployment rates are highest (10 percent or higher) in the southeast counties of Tennessee.
In economic terms, members of the workforce in these counties are not working to their full
capacity; thus, output is not at its optimal level.
African-Americans in Tennessee experience a rate of unemployment that is several times higher than
whites and Asians. The lowest unemployment rate in Tennessee is to be found among white males,
contrasted with the highest rate found among African-American males. In addition to income, a
measure of wealth should also be considered. Wealth, the sum of all assets or total net worth, is an
indicator of the ability to weather hard times and seek care. Whites typically have considerably
more wealth than African-Americans which may potentially further explain the health disparity.
44
Figure 38: Unemployment and race
Unemployment Disparities by Race and Sex- Tennessee 2000
12
10
8
Male
6
Female
4
2
0
White
African-American Native American
Asian
Wealth
According to the U.S. Census Bureau Survey of Income and Program Participation, there is a very
large difference in actual wealth levels among racial groups. This reduces the safety net for AfricanAmericans. It is important to not simply consider income, but overall wealth. Merely considering
income misses the very important factor of total wealth, which is typically much lower for AfricanAmericans. In addition, minorities typically own a smaller market share of businesses. Therefore,
their labor provides profits for someone else, profits which do not remain in their communities as
investment income, but rather accumulate as wealth for non-African-Americans.
Wealth is very different between whites and African-Americans at all quintiles. The richest whites
are several times richer than the richest African-Americans. These extremely large differences in
wealth account for lifestyle differences which are not explained by income alone.
45
Figure 39: Net worth and race
Median Net Worth by Race and Household Income
140000
White
Black
120000
Value in Dollars
100000
80000
60000
40000
20000
0
Overall
Poorest 20%
2nd Quintile
3rd Quintile
4th Quintile
Richest 20%
Home ownership
Levels of home ownership are another area of disparity among racial groups. Among whites, 77
percent own their own home compared to only 54 percent of African-Americans. This is one more
measure of disparity and demonstrates one way in which wealth is poorly distributed among
African-Americans. Wealth is often accumulated through gains in equity and appreciation of real
estate. With lower levels of home ownership, African-Americans are less likely to accumulate
capital and total overall wealth. This cycle of poverty and lack of ability to accumulate wealth,
credit and opportunity is seen in the African-American community and diminishes the amount of
wealth inherited by the next generation. Lack of home ownership represents a missed opportunity to
break the intergenerational cycle of poverty.
A larger portion of African-Americans’ income is spent on rent than whites. Whites are more likely
to invest in home ownership which brings future gains from equity and real estate appreciation.
46
Figure 40: Home ownership and race
Home Ow nership by Race
Tennessee, 2000
90
80
Ow ner occupied
70
Renter occupied
60
50
40
30
20
10
0
W hite
African-American
Education
The impact of education on income is apparent. Individuals with higher levels of education typically
have higher income levels. However, education alone does not entirely erase the economic disparity
that exists between African-Americans and whites. While education is directly correlated with
higher income, African-Americans with equivalent education levels have lower incomes than their
white counterparts.
Figure 41: Income and education
Median Income in 2000 by Education for Full-Time Workers 25+ Years of Age
100000
90000
Black Males
70000
White Males
60000
50000
40000
30000
20000
47
Professional
Doctorate
Master
Bachelor
AS degree
Some College
0
HS Grad
10000
Not finish HS
Income in Dollars
80000
Poverty Line
One measure of the overall economic health and well-being of a population is the percentage of
individuals that fall below the poverty line (Figure 42). The population of Tennessee is generally
poorer than the rest of the U.S. population. The percentage of Tennesseans that are below the
poverty line is somewhat greater than the national average. Furthermore, in Tennessee 11.5 percent
of whites are in poverty, compared with 27.9 percent of African-Americans. Approximately 22.6
percent of Hispanics in Tennessee live in poverty. African-American women are particularly at risk
for poverty. In fact, according to the BRFSS survey, 15 percent of African-American women report
an annual household income of less than $10,000 (Figure 43).
Figure 42: Poverty and race, U.S. Census
Percent of Individuals Below Poverty Level: Tennessee 2004
30
25
%
20
15
10
5
0
White
African-American
48
Hispanic
Figure 43: BRFSS reported annual household income
Race, Sex and Income:
BRFSS- Tennessee, 2004
30
25
White Male
Black Male
White Female
20
15
10
5
49
<$75,000
<$50,000
<$35,000
<$25,000
<$20,000
<$15,000
0
<$10,000
%
Black Female
Chapter V: Risks and disease disparity
Behavioral Risk Factor Surveillance System
BRFSS identifies a number of lifestyle factors that differ between whites and African-Americans.
Whites are at a slightly higher risk for asthma, heavy drinking and smoking than African-Americans.
However, African-Americans are more likely to have never checked their blood cholesterol levels,
much more likely to be obese, more likely not to have exercised in the past month, less likely to
consume five servings of fruits and/or vegetables per day, more likely to have no type of health
coverage, more likely to suffer from hypertension and more likely to report insufficient moderate
exercise. African-American women are much more likely to be obese than white women. Being
unaware of high cholesterol places those with this health risk factor in danger because the first
indication may be a serious health condition. Lack of exercise and poor dietary choices further
exacerbate the problem of obesity and, as risk factors themselves, potentially contribute to a variety
of health problems including heart disease, cancer and diabetes, and a host of other lifestyle
correlated health conditions. Lower levels of health coverage may contribute to African-Americans
seeking health care later when a particular disease condition has advanced further than it would have
in their white counterparts. In addition, this may contribute to African-Americans presenting with
more advanced illness and multiple morbidity factors.
Tennessee in general has higher levels of poor health and poor health behavior. Tennesseans on the
whole report a poorer diet, less leisure activity, higher blood pressure, more smokers, higher obesity
rates and more diabetes than the national averages.
Table 5: Prevalence of selected health risks based on BRFSS data Tennessee, 2003
White
Asthma –at risk
Cholesterol- never checked
Heavy drinking- at risk
Obese
No exercise in past month
Consume less than 5 servings of fruits/vegetables per day
No type of health coverage
Told they have hypertension
Insufficient moderate exercise
Daily smoker
50
7.8
18.7
2.3
23.2
28.8
77.1
11.9
29.9
61.4
22.1
AfricanAmerican
10
27
1.9
36.8
37.6
82
13.1
33.6
68.2
15.9
Figure 44: Self-reported general health
Self-Reported General Health:
BRFSS- Tennessee, 2004
45
40
White Male
Black Male
35
White Female
30
Black Female
%
25
20
15
10
5
0
Excellent
Very Good
Good
Fair
Poor
Figure 45: Race and flu vaccine
Proportion of Recommended Individuals Reporting
Receiving a Flu Vaccine in the Previous 12 Months: BRFSSTennessee, 2004
45
40
35
30
%
25
20
15
10
5
0
White Male
Black Male
51
White Female
Black Female
Risky sexual behavior is defined in BRFSS as that which places the individual at risk for HIV and
includes using intravenous drugs in the past year, having acquired a sexually transmitted disease in
the past year, having given or received money or drugs in exchange for sex in the past year and/or
having anal sex without a condom in the past year. Women of both races report approximately the
same levels of risky behavior; 3 percent engage in one or more of the risky behaviors in the past 12
months. White males report slightly higher levels of risky sexual behavior than women of both
races. African-American males in report much higher levels of risky sexual behavior than even
white males. This places them at elevated risk for sexually transmitted diseases.
Figure 46: Self-reported risky sexual behavior
Proportion of the Population Reporting Engaging in Sexually
Risky Behavior in Past 12 Months: BRFSS- Tennessee, 2004
10
9
8
%
7
6
5
4
3
2
1
0
White Male
Black Male
White Female
Black Female
Access to health care is one area of reported disparity. African-Americans are more likely to report
being unable to see a physician because of cost, with African-American males reporting the highest
barriers to health care access. In addition, African-American males are less likely to receive the
prostate cancer screening test which tests PSA (Prostate Specific Antigen) levels.
52
Figure 47: Healthcare economic barriers
Figure 48: PSA testing
Proportion of Males Reporting PSA Testing:
BRFSS- Tennessee, 2004
70
60
50
%
40
30
20
10
0
White
53
Black
Propensity to exercise varies among subpopulations. African-American females report the lowest
levels of exercise in the past 30 days and also report the highest levels of obesity. White males
reported the highest likelihood of exercising during the previous 30 days.
Figure 49: Exercise and race
80
Proportion of Individuals Reporting Exercising in Past
30 Days: BRFSS- Tennessee, 2004
70
60
%
50
40
30
20
10
0
White Male
Black Male
White Female
Black Female
Excessive body weight is a problem that is growing worse each year. African-American women
report the highest levels of obesity. African-American males report the lowest level of normal
weight. African-American males and white males are similar in their reported BMI levels.
54
Figure 50: BMI, race and sex
BMI Status Based on Self-Reported
Height and Weight, Tennessee 2004
(Source: BRFSS 2004)
50
45
40
White Male
Black Male
White Female
Black Female
35
30
25
20
15
10
5
0
Normal
Overweight
Obese
Chronic diseases
According to morbidity data pertaining to inpatient hospitalization rates, African-Americans fare
worse than whites in the three major LifeStyle diseases that are the focus of the Department of
Health’s current “Better Health: It’s About Time” initiative: diabetes, heart disease and stroke.
African-Americans are hospitalized at nearly three times the rate of whites for diabetes-related
morbidity. There are numerous health conditions that are caused directly or indirectly by diabetes.
Heart disease related mortality in Tennessee is greater than the national average. Heart disease
hospitalization occurs at a rate that is approximately 25 percent higher among African-Americans
than whites. However, white males actually have a higher lifetime prevalence of heart attacks than
African-Americans. Per capita inpatient charges for heart disease are highest among males, with
African-American males accruing higher inpatient charges than white males. The higher per capita
charges for African-Americans are likely because of the higher percentage of African-Americans
who are admitted through emergency rooms (approximately 74 percent for African-Americans and
approximately 55 percent for whites). From 1997 to 2002, age-adjusted hospitalization rates for
heart disease among whites and African-American females remained essentially unchanged, whereas
among African-American males the hospitalization rate has actually declined. Mortality rates from
heart disease have decreased for all races and both genders.
55
Regardless of the disparity issues, cardiovascular disease continues to be an issue of concern for the
State of Tennessee. In addition to human suffering, the economic costs associated with disease
totaled over $1.2 billion in 2002 in total outpatient charges. From 1997 to 2002, hospitalization
charges increased 73 percent.
Stroke-related hospitalization occurs at an approximately 50 percent higher rate among AfricanAmericans than whites. African-American males have a life-time stroke prevalence of 9.1 percent,
compared to 3.9 percent for white males, 2.7 percent for white females and 2.8 percent for AfricanAmerican females. Per capita age-adjusted stroke inpatient charges remained relatively steady for
whites but increased for African-Americans. African-Americans have higher per capita charges than
whites. A greater proportion of African-Americans are admitted for treatment of stroke-related
conditions through emergency rooms than whites. As is the case with other chronic conditions, the
age- adjusted mortality rate for stroke in Tennessee is higher than the national average, implying
systematic lifestyle factors. However, there has been a decrease in stroke-related mortality in
Tennessee for all races, both male and female, from 1997 to 2002.
On a positive note, diabetes, heart disease and stroke are all lifestyle-related diseases so it may be
possible to lower the incidence of morbidity attributed to these diseases through lifestyle changes.
However, it is important that populations at risk be specifically targeted with effective and pertinent
lifestyle change approaches and messages.
Figure 51: Rates of hospitalization related to diabetes, heart disease and stroke
Age-adjusted Inpatient Hospitalization Rates, Tennessee 2002
1600
1,375
1400
1,191
1,097
1000
800
600
476
400
200
347
328
149
311
117
Diabetes
Heart Disease
56
Stroke
White
African
American
State
Overall
White
African
American
State
Overall
White
African
American
0
State
Overall
Rate per 100,000
1200
Cancer
Cancer impacts the lives of nearly every Tennessean and is the second leading cause of death in the
country. Compared to other states, Tennessee has a cancer mortality rate that is one of the highest,
ranked 46th for all cancers and races aggregated. The overall age-adjusted cancer mortality rate is
215.4 per 100,000 Tennessean compared to 197.8 per 100,000 U.S. residents. There are racial
disparities in cancer mortality both nationwide and in Tennessee. For example, African-Americans
in Tennessee exhibited a mortality rate of 274.4 per 100,000 from cancer, while the mortality rate
among whites was 208.4 per 100,000 during the 1998-2002 period. Although there is a racial
disparity in cancer mortality rates on the national level, the disparity is even greater in Tennessee.
Nationally, the mortality rate is 27 percent higher among African-Americans than whites, whereas in
Tennessee it is 32 percent higher. Males of both races have a higher cancer mortality rate than
females (Figure 52).
Figure 52: Cancer, race and sex
450
Cancer Mortality Rate, 1998-2002 Tennessee
African-American Males
400
Deaths per 100,000
350
African-American Females
White Males
382.2
White Females
300
250
274.1
200
209.8
150
166.2
100
50
0
African-American Males
African-American
Females
White Males
White Females
Specific cancers exhibit varying degrees of racial disparity (Figure 53). Colorectal cancer
mortalities occurred at a rate of 33.6 per 100,000 African-Americans compared to 19.5 per 100,000
whites. This is contrasted to the national rates of 27.9/100,000 and 20/100,000 respectively. Breast
cancer occurs at a 12 percent higher incidence among white women; however the mortality rate from
breast cancer is 48 percent higher for African-American women. In other words, proportionally
many more African-American women die from breast cancer than do white women, even though
white women actually have a higher risk of developing the cancer. Cervical cancer also impacts
African-American women in a disparate manner.
57
Unlike breast cancer, both cervical cancer incidence and mortality rates are higher among AfricanAmerican women. During the period from 1998-2002, the respective cervical cancer mortality rates
were three per 100,000 white women and 6.8 per 100,000 African-American women. The mortality
rate for cervical cancer in African-American women is higher than the national average, as the case
with in many types of cancer. Ovarian cancer is an exception to the trend, with both a lower
incidence and mortality rate among African-American women than white women. The mortality
rates are 7.6 per 100,000 African-American women versus 9.2 per 100,000 white women.
Lung cancer mortality rates are higher among males than females. African-American and white
women in Tennessee have nearly the same mortality rate from lung cancer: 44.4 per 100,000
African-American women versus 44 per 100,000 white women. African-American males have
higher lung cancer mortality rates: 121.9 per 100,000. This is higher than both the national average
for African-American male lung cancer mortality (101.3 per 100,000 nationally) and the lung cancer
rate for white males in Tennessee (102.3 per 100,000 white males). In turn, white males in
Tennessee have a lung cancer mortality rate that is higher than the national average for white males
(75.2 per 100,000). Tennessee ranks as nearly the worst state in lung cancer mortality rates - 48th in
2002. Tennessee also ranks as nearly the worst in brain and central nervous system cancer with only
one state having a mortality rate that is higher than the rate in Tennessee. The rate is actually higher
among whites than African-Americans at 3.1 per 100,000 African-Americans in Tennessee versus
5.6 per 100,000 whites. Non-Hodgkin lymphoma, for which Tennessee is ranked 41st in the U.S, is
another cancer which for which African-Americans has a lower mortality rate 5.8 per 100,000
African-Americans compared to 8.9 per 100,000 whites. The largest disparate advantage AfricanAmericans exhibit is in the mortality associated with melanoma of the skin, which occurs a rate of
only 0.5 per 100,000 African-Americans compared to 3.2 per 100,000 among whites, nearly a
sevenfold difference. Prostate cancer is one of the greatest causes of mortality among AfricanAmerican males and is more than two and a half times as frequent among white males: 72.6 prostate
cancer deaths per 100,000 African-American males versus 28.6 deaths per 100,000 white males.
Tennessee is 40th in liver cancer mortality at a rate of 6.3 per 100,000 African-Americans and 4.1 per
100,000 whites. Tennessee also ranks 40th in pancreatic cancer mortality rates: 16.7 per 100,000
African-Americans and 10.3 per 100,000 whites. For oropharyngeal cancers Tennessee also ranks
poorly at 43rd in the nation: 5.4 per 100,000 African-Americans and 2.9 per 100,000 whites.
While, esophageal cancer mortality rates are low in Tennessee compared to the rest of the country Tennessee is 9th nationwide, with the rate among African-Americans of seven per 100,000 is nearly
double the rate among whites which is 3.6 per 100,000.
African-Americans have much higher mortality rates among the cancers that are the biggest killers:
colorectal, lung, prostate and breast. Although a few cancers have been mentioned which impact
whites more than African-Americans, the cancers which are responsible for the majority of cancer
deaths occur with startling disparity among African-Americans.
58
The causes of unusually high cancer mortality and racial disparity in mortality rates among
Tennesseans are likely varied. Women in Tennessee report some of the lowest rates of physical
activity (ranked 48th in the nation) and highest rates of obesity (41st nationwide). Both sexes report
some of the highest smoking levels in the nation, with Tennessee ranked 44th worst. These are
perhaps some of the risk factors which lead to the unusually high cancer mortality rates in
Tennessee.
Figure 53: Cancer mortality, race and sex
Age-Adjusted Cancer Mortality: 1998-2002, Tennessee
140
African-American Males
120
African-American Females
White Males
White Females
Deaths per 100,000
100
80
60
40
Uterus
Stomach
Prostate
Pancreas
Ovary
Oral/ Pharyngeal
Non-Hodgkin Lymphoma
Lung
Liver
Leukemia
Kidney
Esophagus
Colon / Rectum
Cervix
Breast
Brain/ONS
0
Bladder
20
Infectious diseases
HIV/AIDS
There is a tremendous racial and ethnic disparity between the rates of AIDS cases in Tennessee.
AIDS is a disease that has struck the African-American community with devastating impact. The
number of AIDS cases per 100,000 among African-American adults and adolescents in Tennessee is
more than eight times the relative rate among whites (Figure 54). Hispanics in Tennessee have a
slighter higher AIDS rate than whites, but it is still far below the rate found in African-Americans.
This is a devastating disease for many reasons.
59
AIDS disproportionately impacts people in younger age groups and contributes to too many YPLL.
In addition to the human costs, AIDS is an expensive disease both directly, due to the high cost of
medications and treatments over a period of many years, as well as indirectly, because of the loss of
productive members of society in their prime years of life.
Figure 54: AIDS and race
Adult/Adolescent AIDS Cases Rate by Race/Ethnicity, Tennessee 2003
70
66.3
Cases per 100,000 Population
60
Black
White
Hispanic
50
40
30
20
7.9
10
11.8
0
Black
White
60
Hispanic
Tuberculosis
The overall tuberculosis (TB) case rate in Tennessee is 4.7 per 100,000. This is lower than the U.S.
average of 4.9 cases per 100,000 individuals. Males comprise more than two-thirds of the TB cases
(67.4 percent). TB strikes African-Americans at a disproportionately high level. Although 16.3
percent of Tennesseans are African-Americans, over 43 percent of the TB cases are among AfricanAmericans. Foreign-born individuals also comprise a disproportionately larger percentage of cases
than native-born residents of Tennessee with 17.6 percent of TB cases in Tennessee occurring
among foreign-born individuals. One in ten TB cases occur among homeless individuals, and over
one in five TB cases occur among individuals who report excessive alcohol use. A history of
incarceration is also a risk factor for acquiring TB, with 3.9 percent of cases identified while the
individuals were in a correctional facility. In addition, there is a high level of co-morbidity between
HIV and TB, with 8.2 percent of TB also infected with HIV.
Figure 55: Tuberculosis infection distribution in Tennessee
Distribution of Reported TB Cases- Tennessee, 2004
50
43.4
45
40
39.4
35
Cases
30
25
20
15
10.4
10
5.7
5
0
Non-Hispanic White
Non-Hispanic AfricanAmerican
61
Hispanic
Asian
Chlamydia
Chlamydia infection rates in Tennessee exhibit racial disparity. Although African-Americans
comprise approximately 16 percent of the population of Tennessee, 42 percent of the reported
Chlamydia cases in 2003 were among African-Americans. Chlamydia, the most commonly
diagnosed bacterial sexually transmitted disease in the U.S., can cause Pelvic Inflammatory Disease
(PID) and may increase the risk of acquiring HIV by fivefold among infected women.
Figure 56: Chlamydia infection distribution in Tennessee
Chlamydia Morbidity- Tennessee, 2003
45
42
40
35
34
% of Cases
30
25
20
20
15
10
3
5
0
Non-Hispanic White
Non-Hispanic AfricanAmerican
62
Hispanic
Unknown
Gonorrhea
Gonorrhea is another sexually transmitted disease that is found disproportionately among AfricanAmericans. Sixty percent of Gonorrhea infections in 2003 were among African-Americans.
Gonorrhea, like other STDs can cause Pelvic Inflammatory Disease (PID), and increase the risk of
ectopic pregnancy for infected women.
Figure 57: Gonorrhea infection distribution in Tennessee
Gonorrhea Morbidity- Tennessee, 2003
70
60
60
% of Cases
50
40
30
20
19
20
10
1
0
Non-Hispanic White
Non-Hispanic AfricanAmerican
63
Hispanic
Unknown
Syphilis
African-Americans suffer from Syphilis at levels that are disproportionately much higher than other
racial groups. Primary and secondary syphilis are the early stages of this disease and are
characterized by a chancre (small painless sore) followed by a rash, fever and sore throat, as well as
other possible symptoms. If untreated, a latent syphilis infection occurs, which is characterized by
an absence of symptoms with damage potentially beginning to affect internal organs such as brain,
nerves, eyes, heart, blood vessels, liver and even bones and joints. Sixty-seven percent of the
primary/secondary syphilis cases in Tennessee occur among African-Americans while 82 percent of
early latent cases are found in African-Americans. Both of these figures far exceed the proportion of
the general population which African-Americans comprise and are indicative of a serious Syphilis
infection disparity.
Figure 58: Syphilis morbidity in Tennessee
Syphilis Morbidity- Tennessee, 2003
90
82
80
67
70
Primary/Secondary
% Cases
60
Early Latent
50
40
30
30
20
17
10
3
1
0
Non-Hispanic White
Non-Hispanic African-American
64
Hispanic
Mental health
Mental health is a vital component of the overall well-being of an individual. Based on TennCare
data, African-Americans and white people vary somewhat in the types of behavioral health
medications they receive. In Tennessee, whites are more likely to fill prescriptions for anti-anxiety
medication, whereas African-Americans are more likely to receive anti-psychotic medication (Figure
59). African-Americans in the U.S. are more likely suffer from mental disorders, less likely to see
treatment, and when treatment is sought, they are more likely to seek health care at an emergency
room and receive inpatient care. African-Americans on TennCare seek mental health services less
frequently than do their white counterparts.
Figure 59: Psychiatric medication prescriptions (adults)
Proportion of Prescription Recipients by Race and
Medication Therapeutic Class: Tennessee 2003
Note: individual patients may receive prescriptions of more than one class of medication
45
%
40
35
White
30
African-American
25
20
15
10
5
0
Anti-Anxiety
Antidepressant
Anti-Mania
Anti-Psychotic
Other
African-Americans on TennCare seek mental health services less frequently than do their white
counterparts. The rate for unique individuals served with mental health services for AfricanAmericans is 105 per 1,000 TennCare eligible adults and 51 per 1,000 for children. Among white
people, the rates are 142 per 1,000 for adults and 79 per 1,000 among children. Hispanics receive
the least services with a rate of mental health services of 49 per 1,000 eligible adult TennCare
recipients and 14 per 1,000 among children (Figure 60).
65
Figure 60: Unique TennCare recipients’ rate of mental health services received.
Rate of Persons Served per 1,000 TennCare Eligibles: Tennessee, 2003
160
Adults, 142
Rate per 1,000 Eligibles
140
120
Adults, 105
100
Children, 79
80
60
Children, 51
Adults, 49
40
Children, 14
20
0
African American
White
Hispanic
Suicide is one area that does not exhibit health disparities between African-Americans and whites.
As mentioned previously, white males are more likely to commit suicide than African-American
males. However, among African-American males ages 15-34, the suicide rate doubles from
10.4/1,000 to 18.7/1,000. African-American women have a suicide rate less than a fourth the rate of
white women.
Table 6: Race and suicide all ages, Tennessee 2001-2003
Race/Sex
White males
African-American males
White females
African-American females
Suicide Rate
23.3
10.4
6
1.4
Hospital admissions throughout Tennessee show a difference in both quantity of services sought and
the types of diagnoses between African-Americans and whites. Based on the number of hospital
admissions, whites have higher rates of admissions for most mental health conditions. However,
African-Americans have higher admission rates for alcoholic psychosis and schizophrenic
conditions. In 2003, the admission rate for alcoholic psychosis was 20 percent greater among
African-Americans than for whites. The admission rate for schizophrenic conditions was nearly
double among African-Americans compared to whites during the same period. Research studies
have found that African-Americans may be overdiagnosed for schizophrenia and under-diagnosed
for a number of other conditions.
66
It is important to note that statistical-based hospital admissions may be inherently biased
because of lack of access to services experienced by many African-Americans. This lack of
access could result in an underestimation of certain conditions, as many affected individuals
may not be counted. The National Mental Health Association has identified a number of
factors that may contribute to African-Americans being hesitant to seek mental health
treatment, which often results in their misdiagnosis. Some of these factors are cultural barriers,
reliance on religious organizations and faith traditions rather than on health professionals, a
tendency to talk comfortably about physical symptoms rather than mental symptoms, lower
socioeconomic status and stigma regarding mental illness. Although whites receive higher rates
of mental health services per admission, African-Americans self reported slightly higher rates
of poor mental health in the previous 30 days to prior to admission. For example, 27.8 percent
of African-Americans report at least one day of poor mental health compared to 26.5 percent of
whites (Figure 61). Overall, the self-reported mental health status for white people and
African-Americans is very similar, although whites do receive more services.
Figure 61: Mental health status in the past months
Self-Reported Number of Mental Health Days Not Good in Past Month:
BRFSS, Tennessee- 2004
80
70
60
White
%
50
African-American
40
30
20
10
0
1 to 2 days
3 to 7 days
2 weeks
67
3 weeks
4 weeks
None
Chapter VI: Office of Minority Health Town Hall Meetings - Concerns and
recommendations
The Tennessee Department of Health, Office of Minority Health, in collaboration with the
Tennessee Department of Mental Health and Developmental Disabilities and the Tennessee
Minority Health Community Development Coalition, Inc., hosted town hall meetings across the
state of Tennessee to discuss the Populations of Color Health in Tennessee: Health Status
Report. The purpose of these town hall meetings was to present community members and
stakeholders with region-specific data pertaining to health issues that disproportionately impact
communities of color in Tennessee and also provide an avenue for attendees to voice their
concerns and offer recommendations for addressing the issues.
Community-based and faith-based organizations, health professionals and individuals within
each of the six metropolitan regions (Memphis, Jackson, Nashville, Knoxville, Johnson City
and Chattanooga) were invited to attend the town hall meeting in their community. Town hall
meetings, generally lasting two hours, were held at different venues (e.g. high schools, colleges,
hospitals). The information presented at each meeting was derived from the draft Populations
of Color in Tennessee: Health Status Report and focused on local data including infant
mortality, chronic diseases (e.g. stroke, heart disease, diabetes, cancer), sexuality transmitted
diseases (e.g. HIV/AIDS, Chlamydia, Gonorrhea, Syphilis), teen pregnancy, mental health,
violence and economics. Major themes and recommendations for reducing and eliminating
health disparities were captured from dialogue generated at each event and included in this
report.
The Populations of Color in Tennessee: Health Status Report is the second major report
produced by the Office of Minority Health that addresses health disparities in Tennessee’s
minority communities. Although several of the attendees were familiar with the health
inequalities that exist among Tennessee’s minorities, the region-specific data examined these
health issues in a more defined context. Many of the attendees, including health professionals
working daily in these communities, were shocked by the information presented.
In an effort to respond to the challenge of reducing and eliminating health disparities by raising
awareness and coordinating activities towards improving the health status among minority
populations in Tennessee, the Tennessee Department of Health, Office of Minority Health
offers this report of concerns and recommendations.
The reader’s feedback is encouraged as the Department collectively moves forward in
developing strategies, building and strengthening partnerships towards these endeavors.
68
The state of health in Tennessee’s communities – Overview
In 2006, the overall health of Tennesseans ranked 48th in the nation, down from a ranking of
46th in 2003. The state’s strengths are a low rate of uninsured population at 13.2 percent and
moderate access to prenatal care, with 77.1 percent of pregnant women receiving adequate
prenatal care. Challenges include a high infant mortality rate at 9.2 deaths per 1,000 live births
and a low high school graduation rate with only 56.7 percent of incoming ninth graders
graduating within four years. The state also ranks in the bottom 10 states on seven of the other
health indicators, including a high prevalence of smoking, a high prevalence of obesity, a high
violent crime rate, a high rate of deaths from cardiovascular disease, a high rate of cancer
deaths, a high total mortality rate and a high premature death rate.
Tennessee is ranked 44th in the country for the combined measures of risk factors and 46th for
the combined measures of outcomes, suggesting that the state's health status is likely to remain
at the same relative healthiness in the near future. Health disparity is present within the state, as
illustrated by differences in premature death rates between black, non-Hispanic individuals
(14,538 years of potential life lost before age 75 per 100,000 population) and white, nonHispanic individuals (8,395 years lost).
69
Chattanooga
An Overview
According to the 2000 Census, there is a total population of 155,554 people, 65,499 households and
39,626 families residing in the city of Chattanooga. The population density is 444.2/km²
(1,150.5/mi²). The racial makeup of the city is 59.71 percent white, 36.06 percent Black or AfricanAmerican, 2.11 percent Hispanic or Latino, 0.29 percent Native American, 1.54 percent Asian, 0.11
percent Pacific Islander, 1.01 percent from other races and 1.30 percent from two or more additional
races.
There are 65,499 households out of which 25.3 percent have children under the age of 18 living with
them, 39.2 percent are married couples living together, 17.3 percent have a single female as head of
household and 39.5 percent are non-families. Single family households make up 33.5 percent of all
households and 11.6 percent have someone living alone who is 65 years of age or older. The average
household size is 2.29 people and the average family size is 2.92 people.
In the city, the age of the population is spread out with 22.4 percent under the age of 18, 10.8 percent
from ages 18 to 24, 28.8 percent from ages 25 to 44, 22.8 percent from ages 45 to 64 and 15.2 percent
is 65 years of age or older. The median age is 37-years-old. For every 100 females of all ages, there
are 89.3 males. For every 100 females age 18 and over, there are 85.2 males.
The median income for a household in the city was $32,006 and the median income for a family was
$41,318. Males have a median income of $31,375 versus $23,267 for females. The per capita
income for the city is $19,689. Approximately 17.9 percent of the population and 14 percent of
families are below the poverty line. Of the total population, 27 percent of those are under the age of
18 and 13.8 percent of those 65 and older are living below the poverty line.
70
Recommendations for Improving Health Outcomes for Minority Communities
The following concerns and recommendations were captured according to concerns voiced during the
Town Hall Meetings held on January 27, and February 3, 2006, in Chattanooga.
ƒ
Teen pregnancy seems to be a problem. Are they going for prenatal care? Can schools
follow-up with pregnant teen mothers?
ƒ
Get the local chapters of nursing association involved in dissemination of disparity
information and training.
ƒ
African-Americans don’t get mammograms. African-Americans don’t know the health
statistics. Community-based organizations should share information more.
ƒ
Keep repeating healthy lifestyle information.
ƒ
Take health professionals to the children. Increase the number of health professionals.
ƒ
Change some cultural norms of the community.
ƒ
Take news and information to the schools and churches.
ƒ
Medical doctors should give more information to their patients and community.
ƒ
We need lots of compassion with non-compliant patients from the health care providers.
ƒ
Have people tell their stories about overcoming health obstacles.
ƒ
Work with community groups.
ƒ
Training the trainers to provide lay health training in the community.
ƒ
Shared chronic disease data for Hamilton County with the community.
ƒ
Does health care consider lifestyle risk?
ƒ
Teen pregnancy medical care is not sought after by African-American mothers. Health
departments and schools are primary provider in this instance and should follow up with
mothers.
ƒ
Most African-American women don’t get mammograms. Start teaching younger girls
earlier.
ƒ
Utilize Project Access’ database of doctors to expand clinics to work with the public to
provide health care for low income individuals. Educate physicians and nurses on
disparities.
ƒ
Make material more personal to incorporate health, media, small churches or other
communication avenues. Train the trainers who meet periodically.
71
Jackson
An Overview
The 2000 Census reveals that there are 59,643 people living in the city of Jackson, 23,503
households and 15,135 families residing in Jackson. The population density is 465.3/km2
(1,205.2mi2). There are 25,501 housing units at an average density of 198.9/km2 (515.3/mi2). The
racial make up of the city is 55.13 percent white, 42.07 percent African-American, 2.16 percent
Hispanic or Latino, 0.15 percent Native American, 0.79 percent Asian, 0.01 percent pacific Islander,
0.88 percent from other races and 0.97 percent from two or more races, 2.16 percent of the
population are Hispanic or Latino for any race.
There are 23,503 households out of which 32.1 percent have children under the age of 18 living
with them, 41.5 percent are married couples living together, 19.4 percent have a female as the head
of household with no husband present and 35.6 percent are non-families. Approximately 30.3
percent of all households are made up of individuals and 10.4 percent have someone living alone
who is 65 years of age or older. The average household size is 2.40 and the average family size is
2.99 people.
In Jackson, the age of the population is spread out with 25.9 percent under the age of 18, 12.8
percent from ages 18 to 24, 28.7 percent from ages 25 to 44, 19.5 percent from ages 45 to 64, and
13.2 percent who are 65 years of age or older. The median age is 33 years. For every 100 females
there are 87.4 males and for every 100 females age 18 and over there are a total of 81.7 males.
The median income for a household in Jackson is $33,194 and the median income for a family is
$40,922. Males have a median income of $32,777 versus $23,229 for females. The per capita
income for the city is $18,495. Approximately 17.1 percent of the population and 14 percent of
families are below the poverty line. Of the total population, 23 percent of those are under the age of
18 and 11.5 percent of those 65 and older are living below the poverty line.
72
Recommendations for Improving Health Outcomes for Minority Communities
The following concerns and recommendations were compiled according to concerns voiced during the
Town Hall Meeting held on February 3, 2006, in Jackson.
ƒ
The state and local health departments need to go to the community.
ƒ
Collaborate with community organizations.
ƒ
Train people on the college campuses.
ƒ
Organize in small communities.
ƒ
Public schools and churches need to be involved.
ƒ
Health care systems focus on the sick community, and not on prevention.
ƒ
Health promotion should addresses prevention.
ƒ
Encourage the media to focus on health disparities in talk shows and articles.
ƒ
Make policy makers aware of the problem.
ƒ
Policy workers should make findings of health disparity elimination a priority.
73
Knoxville
An Overview
The 2000 census indicates that there are 173,890 people, 76,650 households, and 40,164 families
residing in the city, and greater Knoxville area has a population of 687,249. The population density is
724.6/km² (1,876.7/mi²). There are 84,981 housing units at an average density of 354.1/km²
(917.1/mi²). The racial makeup of the city is 79.7 percent white, 16.2 percent African-American, 0.31
percent Native American, 1.45 percent Asian, 0.03 percent Pacific Islander, 1.58 percent Hispanic or
Latino, 0.72 percent from other races and 1.57 percent from two or more races.
There were 76,650 households out of which 22.8 percent had children under the age of 18 living with
them, 35.3 percent were married couples living together, 13.7 percent had a female householder with
no husband present, and 47.6 percent were non-families. More than 38 percent of all households were
made up of individuals and 11.4 percent had someone living alone who was 65 years of age or older.
The average household size was 2.12 and the average family size was 2.84 people.
In the city, the age of the population was spread out with 19.7 percent under the age of 18, 16.8
percent from 18 to 24, 29.5 percent from 25 to 44, 19.6 percent from 45 to 64, and 14.4 percent who
were 65 years of age or older. The median age was 33 years. For every 100 females there were 90
males. For every 100 females age 18 and over, there were 86.3 males.
The median income for a household in the city is $27,492, and the median income for a family is
$37,708. Males had a median income of $29,070 versus $22,593 for females. The per capita income
for the city is $18,171. More than 20 percent of the population and 14.4 percent of families were
below the poverty line. Approximately 26 percent of those under the age of 18 and 12 percent of
those 65 and older were living below the poverty line.
74
Recommendations for Improving Health Outcomes for Minority Communities
The following concerns and recommendations were compiled according to concerns voiced during the
Town Hall Meeting held on February 8, 2006, in Knoxville.
ƒ
City leaders should receive a full report of the health conditions of the city’s minority
community members.
ƒ
Involve the National Association of Mental Health in getting the community interested and
aware of mental illness and the negative stigma associated with mental illness that is rampant
in the minority community.
ƒ
More health educators should be employed to better educate the community about seeking
treatment for those who are mentally ill.
ƒ
Discourage separation of mental illness and HIV when addressing general health disparities.
ƒ
Increase awareness of mental health issues in the community, as well as ways to recognize it
if there is a problem.
ƒ
Improve TennCare’s behavioral health services to include a more holistic approach that
serves the mental and the physical concerns.
ƒ
Plan and create initiatives to work for the elimination of stigmas in regards to mental health.
ƒ
Educate religious leaders to speak knowledgeably and openly about health issues affecting
their congregations and the community at large.
ƒ
Increase educational resources in the minority community regarding health knowledge.
ƒ
Increase awareness of the uninsured populations and find ways to assist these persons to get
affordable or free health care.
75
Tri-Cities
An Overview
KINGSPORT
The 2000 Census for Kingsport indicates that there are 44,905 people, 19,662 households and
12,642 families residing in the city. The population density is 393.4/km² (1,018.9/mi²). There are
21,796 housing units at an average density of 191/km² (494.6/mi²). The racial makeup of the city is
93.32 percent white, 4.22 percent African-American, 1.05 percent Hispanic or Latino, 0.24 percent
Native American, 0.79 percent Asian, 0.02 percent Pacific Islander, 0.34 percent from other races
and 1.06 percent from two or more races.
There are 19,662 households out of which 26.5 percent have children under the age of 18 living
with them, 48.5 percent are married couples living together, 12.7 percent have a female as head of
household with no husband present and 35.7 percent are non-families. Approximately 32.5 percent
of all households are made up of individuals and 14.7 percent have someone living alone who is 65
years of age or older. The average household size is 2.22 and the average family size is 2.80
people.
In Kingsport, the age of the population is spread out with 21.7 percent under the age of 18, 6.5
percent from ages 18 to 24, 26.2 percent from ages 25 to 44, 25.3 percent from ages 45 to 64, and
20.3 percent who are 65 years of age or older. The median age is 42 years and for every 100
females there are 84.1 males. For every 100 females age 18 and over there are 79.6 males.
The median income for a household in Kingsport is $30,524, and the median income for a family is
$40,183. Males have a median income of $33,075 versus $23,217 for females. The per capita
income for the city is $20,549. Approximately 17 percent of the population and 14.2 percent of
families are below the poverty line. Of the total population, 24.9 percent of those are under the age
of 18 and 13 percent of those are 65 and older and are living below the poverty line.
76
JOHNSON CITY
According to the 2000 Census there are 55,469 people, 23,720 households and 14,018 families
residing in the city. The population density is 545.4/km² (1,412.4/mi²). There are 25,730 housing
units at an average density of 253/km² (655.1/mi²). The racial makeup of the city is 90.09 percent
white, 6.40 percent African-American, 1.89 percent Hispanic or Latino, 0.26 percent Native
American, 1.22 percent Asian, 0.02 percent Pacific Islander, 0.69 percent from other races and 1.32
percent from two or more races.
There are 23,720 households out of which 25 percent have children under the age of 18 living with
them, 44.1 percent are married couples living together, 11.6 percent have a female who is head of
household with no husband present and 40.9 percent are non-families. Approximately 33.9 percent
of all households are made up of individuals and 11.5 percent have someone living alone who is 65
years of age or older. The average household size is 2.20 and the average family size is 2.82
people.
In Johnson City, the age of the population is spread out with 19.8 percent under the age of 18, 13.7
percent from ages 18 to 24, 28.1 percent from ages 25 to 44, 22.5 percent from ages 45 to 64, and
15.9 percent who are 65 years of age or older. The median age is 37 years and for every 100
females there are 91.1 males. For every 100 females age 18 and over there are 88 males.
The median income for a household in the city is $30,835 and the median income for a family is
$40,977. Males have a median income of $31,326 versus $22,150 for females. The per capita
income for the city is $20,364. 15.9 percent of the population and 11.4 percent of families are
below the poverty line. Of the total population, 18.9 percent of those are under the age of 18 and
12.7 percent of those 65 and older are living below the poverty line.
77
BRISTOL
There are 24,821 people, 10,648 households and 6,825 families according to the 2000 census that
reside in the city of Bristol. The population density is 326.5/km² (845.8/mi²). There are 11,511
housing units at an average density of 151.4/km² (392.2/mi²). The racial makeup of the city is
95.15 percent white, 2.97 percent African-American, 0.31 percent Native American, 0.68 percent
either Hispanic or Latino, 0.64 percent Asian, 0.01 percent Pacific Islander, 0.23 percent from other
races and 0.70 percent from two or more races.
There are 10,648 households out of which 26.2 percent have children under the age of 18 living
with them, 49 percent are married couples living together, 11.4 percent have a female as head of
household with no husband present and 35.9 percent are non-families. Approximately 32.1 percent
of all households are made up of individuals and 14.1 percent have someone living alone who is 65
years of age or older. The average household size is 2.26 and the average family size is 2.84
people.
In Bristol, the age of the population is spread out with 21.1 percent under the age of 18, 9.1 percent
from ages 18 to 24, 27.2 percent from ages 25 to 44, 24.7 percent from ages 45 to 64, and 17.9
percent who are 65 years of age or older. The median age is 40 years. For every 100 females of all
ages there are 90.6 males and for every 100 females age 18 and over there are 87.3 males.
The median income for a household in the city was $32,006 and the median income for a family
was $41,318. Males have a median income of $31,375 versus $23,267 for females. The per capita
income for the city is $19,689. Nearly 18 percent of the population and 14 percent of families are
below the poverty line. Of the total population, 27 percent of those are under the age of 18 and
13.8 percent of those 65 and older are living below the poverty line.
78
Recommendations for Improving Health Outcomes for Minority Communities
The following concerns and recommendations were captured according to concerns voiced during Town
Hall Meeting held on February 6, 2006, in Tri-Cities.
ƒ
While collecting data on the state of health for minorities in Northeast Tennessee the first thing
that became apparent was the lack of accurate information available for populations of color in
the area. The majority of data provided figures per 100,000 of the total population. The 29,000
minority residents deserve an accurate, easily obtainable picture of their health status as a
beginning place for community and governmental action.
o Compile and disseminate health statistics in an easily obtainable format for populations
group with congressional districts (at a minimum).
ƒ
Partnerships between African-Americans, Hispanic communities and higher education
institutions are available across the state. The details and structure of these partnerships vary in
content and approach. The state should provide specific resources to demonstrate these
partnerships on a project basis including a strong process and outcomes evaluation to describe
and demonstrate change.
o The state should identify model health partnerships between the African-American and the
Hispanic communities in Tennessee that will include higher education institutions. This
information should be shared across the state.
o The state should help promote these partnerships by creating a statewide funding program
that ensures demonstration in all public, university service areas across the state.
o Successful projects and their counts should be featured on the Tennessee Department of
Health Web site.
ƒ
ҏHealth literature and experience show that community member/minority advocates feel that lay
health workers could effectively help address health issues. A conceptual model should be
framed that uses health behavior theory to explain the values of these programs. If this is done in
conjunction with a business model, recommendations should be made to demonstrate such a
program in the First Congressional District with small populations. This might include two
separate, three-year demonstrations: one, TennCare reimbursement for specific lay health
worker services and two, the creation of a job title and employment of lay health workers should
address special needs, diseases and populations.
o The lay health worker model including training and payment for time is already being
used in certain state health programs but not in others. This should be expanded to include
focus on illnesses, prevention and treatment for high priority areas, such as diabetes and
heart disease. Lay workers in these programs should be paid for services rendered.
o The state should promote expansion through considering three potential sources of
payment for lay health workers: one, inclusion of a special lay health worker in a minority
health program to be included in the state budget similar to the Patient Navigator Program
in Kentucky; and two, special demonstration program through TennCare for
reimbursement for specified lay health worker services and (3) identifying use of lay
health workers as a priority for funding in state categorical health program grants.
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ƒ
The Tennessee Department of Health should sponsor an awards program that focuses on best
practices for program effectiveness in reaching African-American and Hispanic populations.
Each health services program sponsored by the state should be considered in a separate category
(e.g. immunizations program, breast and cervical cancer program, diabetes program). At a
minimum, each application should include a description and statement of the problems for the
population community goals and strategies used to reach the targeted populations.
o A statewide awards program should be established to recognize the most effective models
in reaching populations, such as people of color within each state health department
categorical health programs.
o Requests for nominations process which would include identification of the target
population, statements of problems, goals, effective strategies and documentation of
outcomes.
o Final selections would be made and recognition presented at the Annual Minority Health
Conference that is usually scheduled in August. All recognized programs would then
compete for prestigious, statewide award to be given at the Tennessee Public Health
Association Conference that is usually scheduled in November.
ƒ
A body of literature and personal experiences for people of color confirms that lack of cultural
sensitivity and outright discrimination by health professionals and in the health care system that
contribute to health disparities. Personal stories of African-American and Hispanic residents of
Northeast Tennessee sadly confirm these findings. Quality of care, access to care and equal care
are essential to address in all aspects of seeking health care.
o Tennessee should significantly increase its efforts to recruit young people of color towards
health professions, especially nursing, physical therapy, pharmacy counseling and
medicine, in particular. An aggressive, targeted recruitment and support campaign should
be launched through a partnership between the Department of Education and the
Department of Health.
o Training institutions for health professionals should enhance both their cultural curriculum
and cross-cultural experiences for students, documenting their activities and continual
improvement in this area.
o We support the Office of Minority Health’s idea of developing an organizational
certification for cultural competence. We encourage the state to assure that certification is
translated into a daily practice commitment and not become just a certificate or just “paper
on the wall”. To accomplish this objective, yearly recertification based on well-defined
and articulated outcome measures should be at the center of any certification program.
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Memphis - Shelby County
Overview
There are 650,100 people, 250,721 households and 158,455 families residing in Memphis as shown in
the 2000 Census. The population density is 898.6/km² (2, 327.4/mi²). There are 271,552 housing units
at an average density of 375.4/km² (972.2/mi²). The racial makeup of Memphis is 61.41 percent
African-American, 34.41 percent white, 2.97 percent Hispanic or Latino, 1.46 percent Asian, 0.19
percent Native American, 0.04 percent Pacific Islander, 1.45 percent from other races and 1.04 percent
from two or more races.
There are 250,721 households of which 31.3 percent have children under the age of 18 living with
them, 34.1 percent are married couples living together, 23.8 percent have a female who is the head of
household with no husband present and 36.8 percent are non-families. Approximately 30.5 percent of
all households are made up of individuals and 8.9 percent have someone living alone who is 65 years
of age or older. The average household size is 2.52 and the average family size is 3.18 people.
In Memphis, the age of the population is spread out with 27.9 percent under the age of 18, 10.8 percent
from ages 18 to 24, 30.7 percent from ages 25 to 44, 19.7 percent from 45 to 64, and 10.9 percent who
are 65 years of age or older. The median age is 32 years. For every 100 females of all ages there are
89.8 males and for every 100 females age 18 and over there are 84.9 males.
The median income for a household in the city is $32,285 and the median income for a family is
$37,767. Males have a median income of $31,236 versus $25,183 for females. The per capita income
for Memphis is $17,838. Approximately 20.6 percent of the population and 17.2 percent of families
are below the poverty line. Of the total population, 30.1 percent are under the age of 18 and 15.4
percent are 65 and older and are living below the poverty line.
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Recommendations for Improving Health Outcomes for Minority Communities
The following concerns and recommendations were captured according to responses voiced during the Town
Hall Meeting held February 30, 2006, in Memphis-Shelby County.
ƒ
We need to honor people for what they are currently doing to help those in their communities.
ƒ
Involve faith communities in public health care.
ƒ
Get the majority media involved in education campaigns to reach out to the minority
communities.
ƒ
The message has to be developed so that we can get their [African-Americans’] attention.
ƒ
Increase corporate sponsors to assist health care agencies to help sustain the agencies.
ƒ
The way the Medicaid/TennCare dollars are distributed in the Shelby County area; there is
serious distribution problem in Shelby County compared to the other regions.
ƒ
The fee for service model does not work in Shelby County. We need to come up with a creative
way to address the problem in Shelby County.
ƒ
Mental health professionals should collaborate with pastors in local churches
ƒ
Look at the churches as a resource.
ƒ
Look at the research to validate and support our recommendations.
ƒ
Partner with universities.
ƒ
Methodist Hospital is looking at leading causes of life; this is a good model.
ƒ
To give honor, hope and give back to the community.
ƒ
Cultural sensitivity training.
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Nashville - Davidson County
Overview
The 2000 Census reveals that there are 569,891 people, 237,405 households, and 138,169 families
residing in Nashville. The population density is 438.1/km² (1,134.6/mi²). There are 252,977 housing
units at an average density of 194.5/km² (503.7/mi²). The racial makeup of Nashville is 66.99 percent
white, 25.92 percent African-American, 4.58 percent Hispanic or Latino, 0.29 percent Native
American, 2.33 percent Asian, 0.07 percent Pacific Islander, 2.42 percent from other races and 1.97
percent from two or more races.
There are 237,405 households of which 26.7 percent have children under the age of 18 living with
them, 39.9 percent are married couples living together, 14.3 percent have a female as head of
household with no husband present and 41.8 percent are non-families. More than 33 percent of all
households are made up of individuals and 8.2 percent have someone living alone who is 65 years of
age or older. The average household size is 2.30 and the average family size is 2.96 people.
In Nashville, the age of the population is spread out with 22.2 percent under the age of 18, 11.6 percent
from ages 18 to 24, 34 percent from ages 25 to 44, 21.1 percent from ages 45 to 64 and 11.1 percent
who are 65 years of age or older. The median age is 34 years. For every 100 females of all ages there
are 93.8 males and for every 100 females age 18 and over there are 90.8 males.
The median income for a household in the city of Nashville is $39,797 and the median income for a
family is $49,317. Males have a median income of $33,844 versus $27,770 for females. The per
capita income for Nashville is $23,069. Thirteen percent of the population and 10 percent of families
are below the poverty line. Of the total population, 19.1 percent of those are under the age of 18 and
10.5 percent of those are 65 and older are living below the poverty line.
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Recommendations for Improving Health Outcomes for Minority Communities
The following concerns and recommendations were compiled according to concerns voiced during the Town
Hall Meeting held on February 1, 2006, in Nashville-Davidson County.
Question 1:
Provide an overall critique of the information presented on health disparities.
Response #1:
The information presented based on health disparities among minority populations focused on the
determinants of health and their implications among minorities. To my understanding, it seems that a
large number of persons are well informed about the issues of health disparities facing people of color
in American society. However, the presenters didn’t talk about the possible solutions to these ongoing
concerns. For instance, the causes were exhaustively discussed but the fact that these causes have
solutions to them has not been acknowledged.
Response #2:
The overall information presented on health disparities was very informative. The information was
based on African-Americans and whites and it determined how many were faced with diseases such as
strokes, heart diseases, cancer, diabetes, transmitted diseases, HIV/AIDS and chronic diseases. The
overall results indicated that African-Americans’ percentages were higher than whites in every
category. After reviewing the statistics of the African-Americans and whites, there is a need for
improvement in each population. According to crime rates, African-American statistics showed that it
was three times greater than whites. The income, education and working rates were available for
individuals to know and maybe get individuals to think and change the statistics provided. The
information provided should be given to as many people possible. Many people need to know how the
community is standing with facts about African-Americans and health disparities.
Response #3:
The response that I have to offer is an overall critique for the information that was presented on health
disparities I am questioning the ways in which data was collected. I’d like to know about the subjects
that data has been collected on. I’d also like to have data about the subjects that data has been collected
on. The percentages of minorities’ data somehow appear to be at times biased.
For example, how can you say to me that African-Americans’ pre-admission rate with diagnosed
schizophrenia was nearly doubled compared to that of the Caucasians? I find that most difficult to
comprehend. It is a fact that African-Americans may endure a lot of stress and they have been the most
disadvantaged race for many years from the Caucasian race.
Response #4:
This information was truly awakening. Although some of the facts were a reminder, it is definitely
important to keep these statistics in mind while continuing my preparation to practice in my field of
study because it affects us all. The fact that all ages of African-Americans have a shorter life
expectancy than whites is outrageous. Perhaps changes could be made if these types of presentations
were to continue. The presenters were very knowledgeable and open minded. I like that they were so
open to suggestions and criticism. Hopefully, these dedicated professional presenters will continue to
inform people of these shocking and overwhelming data such as the infant mortality so we can improve
upon them. In addition to improving the future result, groups such as the BHIAT will get no exposure
resulting in more funds to make a difference.
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Response #5:
“The Population of Color” presentation was very informative about the different health disparities
within the State of Tennessee. It covered all the disparities and who was more accessible compared
between the whites and African-Americans. What I found that was very disturbing is that the AfricanAmericans are more prone than anybody else to die from serious diseases. Now some of the
information that was given made me wonder a little if the information was totally correct. I think there
are a lot of people that have not been surveyed on their disparities or keep their health status private
because they don’t want people to know their business. If we conducted research at private doctor’s
offices, I think the percentages between blacks and whites would be a whole lot closer than what they
are now.
With the violence information, I find the percentages to be a little over exaggerated because whites
commit a lot of crime but just get away with it. I also found it amazing that the Tennessee had almost
the highest infant mortality rate but that just goes along with the fact that Tennessee is number 48
among the healthiest states. So if the parent isn’t healthy, what makes you think the child will be too?
Overall, the presentation was great but I think we just can’t look at the public facilities and get
numbers, the most disparities that are being reported are happening in the private practice doctors’
offices as well.
Response #6:
I found the information presented on health disparities in Tennessee was insightful, yet some areas
were ambiguous. Personally, the power point data reinforced the need for health promotion throughout
the State of Tennessee. However, no suggestions or course of action were presented on how to address
these issues.
In reading through the handouts, I was not too surprised to see that leading cause of death for
Caucasians and African-Americans is heart disease. Nor was I shocked to see that the fourth ranking
disease differs between the ethnic groups. Diabetes mellitus is prevalent among African-Americans as
a killer, while among Caucasians, the fourth leading disease is chronic lower respiratory problems.
There were other disparities that alarmed as well. For instance, the State of Tennessee has one of the
worst infant mortality rates in the United States along with the west region of Tennessee suffering the
most from all disparities. I feel the presenter focused more on the infant mortality rates and the fact the
areas of concentration for this disparity and maybe all disparities are in West Tennessee where there is
31 percent to 52.9 percent African-American representation. Again, the data reiterates the need for
focused health promotion in that region of Tennessee.
Regarding the vagueness of the information and the overall visual value of the power point
presentation, I feel if the presenter could have researched more in depth the leading causes for the gaps
between the ethnic group disparities, the audience would have enjoyed the information more. Also,
some of the slides were difficult to understand.
Overall the information presented was again helpful in understanding the need for African-Americans
and people of color to receive adequate health care and the need for health promotion throughout the
State of Tennessee. I feel with better visual aids and more concise data, the presentation would have
been excellent.
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Response #7:
My opinion about the information presented on health disparities is that it was very discouraging to see
African-Americans as a whole doing so poorly. In some instances, you can see why, because lack of
education and being too stubborn, but in the same sense it’s startling. In addition, to compare blacks to
a race that is superior to all others, we fail to match up to them in any category in which as blacks we
have less people to compare since we only make up seven percent of the U.S. population. You feel as a
black citizen that somewhere along the lines that there has been a failure as a U.S. government to help
educate the blacks about the problem that they have found in the black communities. Instead of
stereotyping blacks, they should inform blacks of the problems that are constantly reoccurring. If the
Department of Health and we as future black leaders of tomorrow do not inform our friends and family
of these problems it will only get worse. I do not really feel that the government cares about the health
of the African-American race.
Response #8:
The information presented on health disparities was very in depth. The information gave a clear picture
that minority health disparities is a major problem in Davidson County. Despite the positive aspects of
the presentation, I felt that there were several ambiguous facts given during the presentation. Some of
the statistics seemed to be misleading and not fully telling of the truth. In order to fix that, they could
have been explained more. The visual aids used in the power point presentation were very helpful to
see the extent of the disparities. Overall, the presentation was a good attempt to shed light on this
ongoing problem.
Response #9:
The overall presentation was very informative. It really puts life into perspective. When the facts were
presented about the different diseases and crimes from a racial stand point, it made me look at life in a
whole different way. Yes some of the hereditary diseases can not always be controlled, but as far as
crime against each other and STDs, they can be controlled but are taking over our African-American
race. They way our society is going one might think that life is a joke, but it is not. Life is something
that should be cherished and never taken for granted. The presentation shows me that a lot of people do
not care about their own life or others. The presentation is a good way to get people educated on the
subject matter. A big problem is that a lot of people are not knowledgeable about the situation. As for
the overall presentation, it was very well presented
Question 2:
What ideas and/or suggestions do you have about resolving health disparities among
minorities?
Response #1:
The following bulleted items are my ideas and suggestions regarding these problems:
ƒ Free access or nationalized health care system.
ƒ Avoid income stratification.
ƒ Educate people to stop smoking.
ƒ Educate people about the significance of balanced diet, that is low intake of sugary or salty
foods.
Response #2:
The ideas and/or suggestions I have about resolving health disparities among minorities consist of
providing financial assistance to do research to identify the health disparities, provide health seminars
in each county of Tennessee to teach individuals about health, provide the different counties of
Tennessee with pamphlets and newsletters to show statistics on health disparities, provide affordable
cost for minorities that are uninsured and the underinsured to receive treatment from clinics and
86
hospitals, and provide better programs that have good finances to help treat individuals with different
diseases who cannot afford insurance.
Response #3:
The ideas and suggestions that I have about resolving health disparities among minorities are that
possibly some of the monies gained from the lottery tickets sold be placed in funding health care cost
for minorities. Supposedly, some of the money is being applied to the educational system. However, I
have yet to see that done. In fact, I have been reading and hearing about school closings and
restructuring in the minority areas and the claim that there is no funding to keep the schools opened for
that particular area. Yet, the next week, I learned that schools in prestigious areas have been given
funding for additions, equipment, or to benefit a school in the area for recreational purposes. Well,
what is wrong with that picture? Minorities should have some of the same funding opportunities for
health care. The reason why minorities do not get proper medical treatment is because they can not
afford it. I believe minorities should be educated about being disease free by exercising, and eating the
proper foods. Many are too concerned with health problems, unemployment and little compensation
while being overworked. If some of the lottery money could be used to assist the minorities, health
disparities can be minimized to some extent. It is a long process but it would really benefit a lot of the
disadvantaged.
Response #4:
I believe presenting the adolescent pregnancy portion of the presentation should be shown to middle
and high school students. I expect that would cause the numbers to change. The only reason I could
think that this may be a problem is that some parents may not want their children to know. My solution
to that would be to present it the parents first at PTA meetings for approval. These are just my
thoughts. I’m unsure, but I believe that it would cause a significant difference in the 23.6 percent
(African-Americans).
Response #5:
The ideas and suggestions I have about resolving health disparities among minorities consist of:
ƒ
ƒ
ƒ
ƒ
ƒ
Provide financial assistance to do research to identify the health disparities.
Provide health seminars in each county of Tennessee to teach individuals about health
disparities.
Provide the different counties of Tennessee with pamphlets and newsletters to show
statistics on health disparities.
Provide affordable cost health care for minorities that are uninsured and allow the
underinsured to receive treatment from clinics and hospitals.
Provide better programs that have good finances to help treat individuals with different
diseases who cannot afford insurance.
Response #6:
My suggestion for resolving health disparities among minorities is more public service announcements
which include television commercials, billboard ads and ads on buses. Also have more public officials
holding health forums in low-income and rural areas and building more public clinics in these
neighborhoods. Another suggestion is to give incentive to health care providers for servicing these
areas. For example, help pay off student loans or increase salaries.
There are ways we can change this chronic problem with people of color and deliver the message of
health promotion. It is a message that must be preached in churches, schools, health clinics, public park
facilities, billboards and television. It is our social responsibility.
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Response #7:
I think as future black professionals and leaders, we should conduct community awareness meetings in
our hometowns. We should inform our communities of the problems that exist and disseminate some
strategies to stop the problem from constantly occurring. In addition, we should pass out surveys to the
elderly and try to help them with their health problems because they are the fastest growing population
in the U.S.
Response #8:
In order to help in the fight against minority health disparities, there are many political and social
measures that need to take place. Unfortunately, many of these factors are virtually out of our control.
My biggest suggestion is to focus on the things that we can change. Poor diet and lack of exercise are
two controllable factors that lead to poor health. There should be more affordable ways that lowincome individuals in bad neighborhoods can get more affordable or free memberships to fitness
centers (e.g., YMCA). Next, when individuals qualify for food stamps or EBT, there should be more
literature offered that details proper nutrition. Beneficiaries should also have to visit a nutritionist. By
reaching out into the minority community and helping them to adopt healthier lifestyles, minority
health disparities can be reduced.
Response #9:
An idea or suggestion I have about resolving health disparities among minorities is becoming more
educated. There should be some class implemented into the school system to teach the young people
about what is going on as far as STDs and crime since it is affecting the young generation more than
the older generation. Some seminars opened to the public and broadcast on television and radio shows
to get more people involved. There can also be a play performed where minorities tell of some
disparities and ways to overcome them. A walk-a-thon is always good when trying to get the public
involved in what is going on in the society. Also, at the seminars, make sure that the presenters are
someone who can relate to the audience so that they will want to come out and listen to the
information.
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Based on data and community feedback, the following represent strategies
for further consideration by the Office of Minority Health:
ƒ
Monitor health status to identify and solve community health problems:
o Diagnose the community health status.
o Identify threats to health and assessment of health services needs.
o Collection, analysis and publication of information on access, utilization,
cost and outcome data.
o Review of vital statistics and health status of specific groups that are at
higher risk than the total population.
o Collaboration in the management of integrated information systems with
private providers and health benefit plans.
ƒ
Diagnose and investigate health problems and health hazards in the community:
o Identify epidemiological and emerging health threats.
o Utilize public health laboratory capabilities to conduct rapid screening and
high volume testing.
o Review epidemiological studies on active diseases.
o Enhance technical capacity for epidemiological review of disease
outbreaks and patterns of chronic disease and injury in minority
communities.
ƒ
Inform, educate and empower people about health issues:
o Integrate social marketing and targeted media public communication into
various special initiative and current programs.
o Collaborate with health care providers to reinforce health promotion
messages and programs.
o Conduct joint health education programs with schools, churches and
worksites.
ƒ
Mobilizing community partnerships and action to identify and solve health
problems:
o Participate in and/or convene and facilitate community groups and
associations involved in prevention, screening, rehabilitation and support
programs.
o Coalition development to enhance human and material resources
addressing community health needs.
ƒ
Develop policies and plans that support individual and community health efforts:
o Leadership development at all levels of public health.
o Health planning in all jurisdictions at the community and state level.
o Develop tracking system of measurable health issues for quality
improvement in prevention, intervention and treatment programs.
o Assessment of prevention and treatment services in the health care
delivery system to develop consistent policies regarding health and health
care disparities.
o Propose principles, regulations and legislation to guide best practice in
public health.
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Monitor and encourage the enforcement of laws and regulations that protect
health and ensure safety:
o Assist in the regulation and enforcement of sanitary codes, especially in
the food industry and clean air standards.
o Assist in providing protection of drinking water supply.
o Ensure timely follow-up of hazards, preventable injuries and exposurerelated diseases identified in occupational and community settings.
o Monitor quality of health care service delivery.
o Ensure timely review of new drug, biological and medical device
applications.
ƒ
Linking people to needed personal health services, and assuring the provision of
health care when otherwise not available:
o Assuring access to care through a coordinated system of appropriate
prevention, intervention and treatment.
o Develop and coordinate appropriate culturally and linguistically sensitive
materials and ensure health personnel will provide referral to services and
information for special population groups.
o Assure that ongoing care management is provided, transportation services
and targeted health information is available to high-risk populations.
o Provide technical assistance for effective worksite health promotion/
disease prevention programs.
ƒ
Assuring a competent public and personal health care workforce:
o Provide staff education and training for personnel to meet the needs of
public and personal health services.
o Assist in assuring the efficiency and effectiveness of the licensure process
of professionals, and certification of facilities, providing regular
verification and inspection follow-up.
o Advocate for lifelong learning and continuous quality improvement of all
licensure and certification programs.
o Develop and/or participate in management and leadership development
programs for individuals involved in administrative and executive
activities.
O Develop and/or enhance active partnership with professional training
programs to assure community-relevant learning experiences for all
students.
ƒ
Evaluating the effectiveness, accessibility, and quality of personal and populationbased services:
o Provide ongoing evaluation of health programs, based on analysis of
health status, service utilization data, and program effectiveness
assessment.
o Provide information necessary for allocating resources and reshaping
programs.
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Researching for new insights and innovative solutions to health problems:
o Provide continuous linkage with appropriate institutions of higher learning
and research.
o Enhance internal capacity for timely epidemiological and economic
analysis, and conduct health services research on health disparities.
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Observations from the Office of Minority Health:
This report explores numerous health indicators that examine racial disparities among
Tennessee populations. Most health indicators discussed in the report reveal that the
minority population is poorer and has worse health status than the white population. For
example, infant mortality rates are over two and a half times higher among black infants
than white infants. Mortality rates at all ages are higher among African-Americans, and
morbidity factors such as obesity also occur at higher rates in populations of color.
The disparities are most glaring and persistent in such areas as infant mortality and
firearm deaths. The question that was repeated during our meetings with community
groups across the state was far beyond the scope and substance of this basically
descriptive report: “What are the underlying causes for health disparities?” The answer is
complex. Issues such as access to healthcare, differing educational levels, cultural biases,
de facto segregation, proximity to environmental hazards, genetic predispositions,
different treatment approaches by healthcare professionals for people of color, higher
underemployment and unemployment, low income, low levels of wealth and lifestyle
choices are all cited as possible explanatory factors for differences in health outcomes.
Notably, the report reflects that minorities in Tennessee are less likely to engage in
certain positive health activities such as adequate intake of fruits and participation in
moderate exercise. Also, it has been demonstrated that black women breastfeed at lower
rates than white or Hispanic women which may negatively impact their babies’ health.
In addition, African-American mothers are less likely to receive adequate prenatal care.
A growing body of literature suggests that environmental factors exacerbate the health
disparities. Minorities are more likely to live in areas with environmental hazards such as
airborne pollutants. These environmental exposures have been associated with increased
morbidity. Particulate airborne pollutants are typically found in higher concentrations in
minority neighborhoods. Economic/racial disparities are correlated with the proximity of
housing and employment to hazardous waste and other environmental health issues.
Studies have demonstrated differences in health care based on racial groupings.
Decisions to perform certain potentially life-saving procedures are often made at different
rates for different racial groups. Another phenomenon is that of increased levels of comorbidity in minority populations. Often when minorities present in a clinical setting
they have multiple health problems. This co-morbidity unfortunately impacts their health
outcomes negatively.
Women are, although not technically a minority population, do have special health needs.
It has been estimated that two-thirds of health care dollars are spent on women. AfricanAmerican women in particular are at a high risk for morbidity and mortality, a problem
exacerbated because they often present with higher rates of obesity which complicates
their treatment and results in poorer health outcomes.
Although health indicators such as infant mortality have improved considerably for
people of all races over the last century, the disparity between black and white
populations has been persistent over time. For example, in 1950, the infant mortality rate
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for black babies in the U.S. was 1.6 time higher than white babies whereas now it is 2.5
times higher. Clearly health improvements have not impacted both races equally. In
fact, when premature deaths are calculated, in 1998 there were 265 deaths every day
among African-American that would not have occurred had health disparities not existed!
This is of concern because nearly 50 percent of health care dollars spent worldwide are
spent in the United States, yet this racial health disparity has not yet disappeared.
Another special population is children. Rates of obesity and overweight status are rising
rapidly among children, to unprecedented levels. Diseases such as type II diabetes and
gallbladder disease, which previously were a health issues mostly limited to adults, are
occurring among children. In addition to the human costs and suffering, the monetary
costs in Tennessee alone because of overweight youth and young adults (<24 years of
age) are $200 million annually. For the most part, children are at the mercy of their
environment and care providers. Parents and day care centers that provide unhealthy
food and sedentary entertainment contribute to a lifestyle that is potentially fatal.
Elderly minorities also often fare worse than their white counterparts. As noted in this
report, minorities typically earn less during their years of employment and accumulate
less wealth. Financial hardships and less discretionary income may make maintaining a
high quality of life more difficult and may constitute a barrier to seeking health care.
Non-white individuals are more likely to be poor when they are elderly. Nationwide,
22.4 percent of elderly African-Americans live in poverty compared to 8.9 percent of
whites.
Contributing factors to health disparities include lack of accurate data to measure and
document progress, shortage of minority targeted health programs, limited technical
assistance to improve the quality of health care professionals, inadequate funding or lack
of funding priorities, cultural and language barriers, data collection limitations,
geographic isolation and patient/client apathy.
From lower quality health care, disproportionate incarceration rates, diminished
collective wealth, to inequities in education, minorities are faced with disparities on every
front. Although the circumstances are not the same for all minority communities, the
effects remain the same: lessened health and quality of life for people of color in the
United States.
It is important that any interventions designed to eliminate health disparities be chosen in
such a way that measurable benefits take place. Assessment of efforts and outcome
analysis are necessary to determine if any shifts in strategies are needed.
The concept of Culturally and Linguistically Appropriate Services (CLAS) is important
to keep in mind when planning and evaluating interventions. Communication, marketing
and interventions need to be tuned to the specific target culture in order to create
behavioral change. Health services provided to minorities should be appropriate and
should address needs. An increase in minority health care providers is one way to better
serve the needs of minority populations. Nationwide, minority health care providers
comprise a smaller proportion of the healthcare workforce than their corresponding
proportion in the general population.
93
The current approaches are clearly not working. Although minority groups such as
African-Americans have improved their overall health over time, the actual disparity
between populations of color and white population persists. Clearly, the challenge is to
find new, creative approaches that actually work, and not to accept anything less than the
reduction and ultimate elimination of racial and ethnic health disparities.
94
Appendix 1: Tennessee population estimates by county and region, 2005
Area
Tennessee
Anderson
Bedford
Benton
Bledsoe
Blount
Bradley
Campbell
Cannon
Carroll
Carter
Cheatham
Chester
Claiborne
Clay
Cocke
Coffee
Crockett
Cumberland
Davidson
Decatur
Dekalb
Dickson
Dyer
Fayette
Fentress
Franklin
Gibson
Giles
Grainger
Greene
Grundy
Hamblen
Hamilton
Hancock
Hardeman
Hardin
Hawkins
Haywood
Henderson
Henry
Hickman
Houston
Humphreys
Jackson
95
AfricanAmericans
Whites
1,006,566
3,099
3,427
358
495
3,310
4,020
148
198
3,134
647
566
1,629
245
135
762
1,931
2,110
80
161,191
435
283
2,188
5,220
10,297
16
2,322
9,703
3,628
73
1,471
20
2,676
64,327
40
12,623
991
884
10,306
2,171
2,874
1,047
298
578
20
4,847,027
67,842
37,140
16,354
12,279
107,348
87,678
40,419
13,155
26,739
56,424
37,864
14,672
30,497
7,899
34,035
47,899
12,891
49,726
407,631
11,334
17,951
43,170
32,637
20,805
17,221
38,070
38,670
26,289
21,687
63,018
14,651
57,055
241,887
6,776
16,768
25,367
54,632
9,545
24,291
28,672
22,947
7,875
17,771
11,353
Jefferson
Johnson
Knox
Lake
Lauderdale
Lawrence
Lewis
Lincoln
Loudon
McMinn
McNairy
Macon
Madison
Marion
Marshall
Maury
Meigs
Monroe
Montgomery
Moore
Morgan
Obion
Overton
Perry
Pickett
Polk
Putnam
Rhea
Roane
Robertson
Rutherford
Scott
Sequatchie
Sevier
Shelby
Smith
Stewart
Sullivan
Sumner
Tipton
Trousdale
Unicoi
Union
Van Buren
Warren
Washington
Wayne
Weakley
White
Williamson
Wilson
1,127
433
35,277
2,557
9,845
660
194
2,389
507
2,407
1,605
51
31,707
1,191
2,231
10,491
145
939
29,112
156
508
3,382
64
138
7
29
1,282
644
1,531
4,842
19,700
28
24
469
471,233
500
189
3,159
8,711
10,666
833
25
20
6
1,311
4,628
1,268
2,671
419
7,141
6,138
96
46,349
17,676
353,293
5,335
18,335
40,363
11,632
29,764
40,769
48,223
23,408
21,349
62,844
27,008
25,976
62,884
11,516
40,342
110,513
5,786
19,924
29,370
20,497
7,531
5,100
16,330
63,944
28,681
51,320
54,088
178,542
22,192
12,114
76,255
433,103
18,209
12,821
149,885
130,149
44,604
6,780
17,770
19,275
5,619
38,334
106,057
16,068
32,254
23,414
134,714
89,784
Northeast
East Tennessee
Upper-Cumberland
Southeast
Mid-Cumberland
South Central
Northwest
Southwest
Metro Regions
8,128
15,442
4,372
11,297
80,296
27,560
32,009
60,568
766,894
322,353
675,309
313,771
296,550
824,071
334,279
222,922
209,129
1,648,643
Non-Metro Regions
239,672
3,198,384
97
Appendix 2: LifeStart data county rankings. Three-year average, Tennessee 20012003
Counties
Anderson
Bedford
Benton
Bledsoe
Blount
Bradley
Campbell
Cannon
Carroll
Carter
Cheatham
Chester
Claiborne
Clay
Cocke
Coffee
Crockett
Cumberland
Davidson
Decatur
DeKalb
Dickson
Dyer
Fayette
Fentress
Franklin
Gibson
Giles
Grainger
Greene
Grundy
Hamblen
Hamilton
Hancock
Hardeman
Hardin
Hawkins
Haywood
Henderson
Henry
Hickman
Houston
Humphreys
Jackson
Jefferson
Johnson
Knox
McNairy
Macon
Madison
Marion
Marshall
Maury
Meigs
Monroe
Montgomery
Moore
Adolescent
(15 to 17) years
old
Pregnancy
29
86
14
36
35
52
60
6
45
40
44
25
18
22
76
58
62
48
91
30
87
39
74
85
10
82
83
53
42
77
38
88
75
9
81
46
28
94
84
49
90
20
26
7
54
16
55
66
50
80
68
33
59
32
79
56
1
Low
Birthweight
First
Trimester
Care
21
34
81
42
28
22
47
8
43
65
10
89
59
30
76
60
70
50
62
2
45
52
82
83
69
6
35
13
56
40
64
12
92
15
94
66
31
91
46
74
68
41
18
32
29
86
44
19
5
84
78
37
24
72
33
26
85
13
75
29
61
8
68
30
19
20
48
3
66
45
63
69
87
83
23
27
47
46
37
95
82
14
71
84
41
36
35
80
79
40
32
86
18
34
93
67
26
51
90
65
62
39
73
24
10
31
81
70
49
64
78
52
88
9
98
Inadequate
Care
15
65
46
63
11
62
28
18
57
30
8
76
33
67
73
78
88
12
42
51
34
53
91
89
43
74
82
32
36
44
83
86
38
47
84
14
71
90
70
50
45
85
77
55
49
59
37
35
39
80
60
24
41
27
40
92
4
Infant
Deaths
63
59
31
7
62
37
45
41
67
66
8
89
11
1
15
71
79
9
58
91
29
34
74
81
77
5
90
72
44
35
22
30
69
19
88
55
43
92
61
76
70
84
86
40
13
93
32
27
57
80
20
48
39
85
21
52
2
Counties
Morgan
Obion
Overton
Perry
Pickett
Polk
Putnam
Rhea
Roane
Robertson
Rutherford
Scott
Sequatchie
Sevier
Shelby
Smith
Stewart
Sullivan
Sumner
Tipton
Trousdale
Unicoi
Union
Van Buren
Warren
Washington
Wayne
Weakley
White
Williamson
Wilson
Adolescent
(15 to 17) years
old
Pregnancy
Low
Birthweight
First
Trimester
Care
Inadequate
Care
Infant
Deaths
15
43
8
13
3
61
21
72
17
69
23
78
63
51
93
34
73
31
27
65
89
11
67
4
70
24
41
37
64
2
19
58
77
1
9
93
71
27
63
57
11
51
38
80
36
90
25
88
49
17
87
16
20
79
73
23
55
7
54
75
3
48
11
59
44
85
16
89
58
38
12
22
6
28
21
7
92
56
91
50
4
15
42
53
33
43
77
17
57
2
25
1
5
5
75
22
87
29
48
64
21
10
54
9
2
17
20
93
66
95
58
3
72
31
23
52
6
56
7
13
24
25
1
16
28
75
16
10
82
95
33
53
54
23
36
60
56
46
87
18
94
47
38
78
3
14
51
73
24
65
4
49
42
12
25
County rankings are in ascending order.
99
Appendix 3: LifeStyle data county rankings. Three-year average, Tennessee 20012003
Counties
Anderson
Bedford
Benton
Bledsoe
Blount
Bradley
Campbell
Cannon
Carroll
Carter
Cheatham
Chester
Claiborne
Clay
Cocke
Coffee
Crockett
Cumberland
Davidson
Decatur
DeKalb
Dickson
Dyer
Fayette
Fentress
Franklin
Gibson
Giles
Grainger
Greene
Grundy
Hamblen
Hamilton
Hancock
Hardeman
Hardin
Hawkins
Haywood
Henderson
Henry
Hickman
Houston
Humphreys
Jackson
Jefferson
Johnson
Knox
Lake
Lauderdale
Lawrence
Lewis
Lincoln
Heart Disease Cerebrovascular
Deaths
Disease (Stroke)
Deaths
5
48
87
65
7
46
74
84
93
41
50
2
77
88
90
53
92
28
22
55
26
68
62
83
86
8
59
63
27
76
21
37
11
64
81
85
47
79
72
66
3
25
57
75
12
4
7
91
94
32
89
36
10
74
17
90
62
24
41
91
71
36
13
57
25
86
87
54
82
5
47
29
39
53
45
32
40
66
76
55
81
80
51
89
42
70
4
93
48
33
95
83
60
75
1
85
69
46
26
37
3
22
8
68
100
Diabetes
Mellitus
7
8
5
80
35
58
14
34
78
33
30
88
59
2
69
32
54
9
43
16
75
4
37
81
28
79
45
10
74
18
63
90
47
95
72
86
24
84
20
60
49
82
65
1
85
48
31
70
44
39
89
12
Counties
Heart Disease Cerebrovascular
Disease (Stroke)
Deaths
Loudon
McMinn
McNairy
Macon
Madison
Marion
Marshall
Maury
Meigs
Monroe
Montgomery
Moore
Morgan
Obion
Overton
Perry
Pickett
Polk
Putnam
Rhea
Roane
Robertson
Rutherford
Scott
Sequatchie
Sevier
Shelby
Smith
Stewart
Sullivan
Sumner
Tipton
Trousdale
Unicoi
Union
Warren
Washington
Wayne
Weakley
White
Williamson
Wilson
35
20
82
16
15
51
23
29
67
10
30
1
17
71
73
43
95
54
33
13
24
45
44
56
31
80
60
58
61
14
19
78
49
70
42
40
39
69
38
52
6
34
County rankings are in ascending order.
101
Deaths
Diabetes
Mellitus
Deaths
20
43
12
9
77
19
56
30
94
49
59
78
7
73
79
15
23
14
64
21
34
84
50
31
18
6
63
88
16
38
61
58
2
35
11
65
44
28
27
92
52
67
46
92
68
77
51
94
6
53
22
57
13
25
64
83
11
73
3
87
52
67
40
36
41
93
66
21
56
55
23
62
29
71
38
26
42
61
50
19
76
91
17
27
Sources used
Behavioral Risk Factor Surveillance System, CDC. 2003.
Better Health: It’s About Time, LifeStart/LifeStyle baseline data, 2002.
CDC: Office of Minority Health. Fact sheets. http://www.cdc.gov/omh/AMH/factsheets/mental.htm
Interim Projections of the Total Population for the United States and States: April 1, 2000 to July 1, 2030.
Source: U.S. Census Bureau, Population Division, Interim State Population Projections, 2005.
McDonough, J. E., et al. A state policy agenda to eliminate racial and ethnic health disparities. The
Commonwealth Fund. June 2004.
National Mental Health Association. Fact sheets.
http://www.nmha.org/infoctr/factsheets/BipolarDisorderAfricanAmericans.cfm
State Cancer Profiles. National Cancer Institute. 1998-2002 data.
TennCare Partners Progress Report. State of Tennessee Department of Mental Health. Fiscal Year 2003.
http://www.state.tn.us/mental/publications/TCPfy2003.pdf.
Tennessee Comprehensive Cancer Control Plan for 2005-2008. Tennessee Department of Health. 19972001 data.
Tennessee Department of Health HIT site. http://hit.state.tn.us/
Tennessee Health Status Report 2001-2002, Tennessee Department of Health and the Community Research
Group, The University of Tennessee, Knoxville, June 2003.
The burden of heart disease and stroke in Tennessee (Draft). Department of Health, 2005.
Tuberculosis Elimination Program, 2004 data.
Williams, David R. The State of Black America. Lee A. Daniels, Editor, New York, NY; National Urban
League, 2004.
102
Department of Health. Authorization No. 343829, No. of Copies 3,000
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