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The Center for Women’s Health Research (CWHR) released our tenth edition of the North Carolina Women’s Health Report Card May 14, 2018. This document is a progress report on the health and health care needs of North Carolina’s 5+ million women. Research efforts that require the most attention are identified through the collection and analysis of data for the report card. Current areas of research targeted by the Center include prevention, cancers affecting women, chronic disease (including cardiovascular health, diabetes, and obesity), women’s mental health, and substance abuse. It is the only health report of its kind in North Carolina.

Previous editions have been released biennially and tracked the state’s female health statistics in two year increments. The 2018 edition presents data primarily from 2016. Previous editions of the report card are also available for comparison. While each section below has key observations from the report card’s advisory board, there is also a summary of key findings available. Readers will also note that Healthy People 2020 is often cited as a benchmark to determine how North Carolina is hitting targets set by a consortium of agencies.

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State Demographics

Observations

  • The state’s female population is steadily growing and women are projected to outnumber men through 2020.
  • Overall, the median age is increasing, particularly among Caucasian women, who have an average age of 43.1. Asian and Hispanic women in NC have an average age of 34.5 and 27 respectively, and represent the youngest segments of the population.

The following data represents that reported by NC women in 2016:

Number of Women (all ages) 5,214,589
Life Expectancy at Birth 80.4
Age (Average all NC Women) 39.8
Caucasian 43.1
African American 38
Asian 34.5
Other 24
Hispanic 27
Age (% by Years of Age)
Under 18 21%
18 to 29 16%
30 to 44 19%
45 to 59 20%
60 and older 23%
Race & Ethnicity %
Caucasian 63%
African American 22%
Asian 3%
Other 3%
Hispanic 9%
% Veteran (18+) 1.7%

Source: Carolina Demography analysis of American Community Survey Data (1-year samples from IPUMS-USA). Life expectancy at birth from NC SCHS. County projections from North Carolina Office of State Budget and Management (OSBM). Download 2008-2016 Data


Family Structure

Observations

  • The number of married women has slowly decreased, and been replaced with higher numbers of women who report their marital status as single, widowed, divorced, or separated.

The following data represents that reported by NC women in 2016:

Average family size
All Women 2.72
Caucasian 2.58
African American 2.73
Asian 3.33
American Indian/Alaska Native 3.06
Other 2.93
Hispanic 3.68
% with own children in home (regardless of child age)
All Women 37%
Caucasian 34%
African 41%
Asian 49%
American Indian/Alaska Native 42%
Other 32%
Hispanic 56%
Among those with children in the home:
Number of children (average)
All Women 1.74
Caucasian 1.68
African American 1.68
Asian 1.69
American Indian/Alaska Native 1.81
Other 1.87
Hispanic 2.14
Number of children <5 (average)
All Women 0.33
Caucasian (non-Hispanic) 0.33
African American (non-Hispanic) 0.27
Asian (non-Hispanic) 0.34
American Indian/Alaska Native 0.39
Other (non-Hispanic) 0.47
Hispanic 0.46
% giving birth in past year (ages 15-50)
All Women 5%
Caucasian (non-Hispanic) 5%
African American (non-Hispanic) 5%
Asian (non-Hispanic) 5%
American Indian/Alaska Native 4%
Other (non-Hispanic) 6%
Hispanic 6%
Marital Status (15+)
Married 47%
Divorced/Separated 15%
Widowed 9%
Never Married/Single 29%

Source: Carolina Demography analysis of American Community Survey Data (1-year samples from IPUMS-USA). Download 2008-2016 Data

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Household Structure

The following data represents that reported by NC women in 2016:

Among women 18+
% Living in Group Quarters (all types) 2%
% Living in Households 98%
If living in Households
% Living in Single-Female Headed Household
All NC Women 19%
All NC female children (age 0-17) 24%
All NC women age 18+ 18%
Share of ALL NC households that are Single-female households 13%
% of 65+ living alone 33.8%
Caucasian 34%
African American 35%
Asian 14%
American Indian/Alaska Native 39%
Hispanic 20%
% 18+ Living in HH receiving food stamps 15.9%
Caucasian 10%
African American 31%
Asian 10%
American Indian/Alaska Native 29%
Hispanic 20%
Homelessness (2015)
Total Number of Homeless Women 4,183
with adults and children 2,201
w/o any children 1,940
child-only homeless 42
% of NC Female Population 0.08%

Source: Homelessness counts from NC Coalition to End Homelessness Point-in-Time County Data for 2015 (retrieved from www.ncceh.org/pitdata). All other data from Carolina Demography analysis of American Community Survey Data (1-year samples from IPUMS-USA). Download 2008-2016 Data


Health Access and Insurance Status

Observations

  • Only three states (Texas, Alaska, and Nevada) have higher percentages of uninsured women than NC.

The following data represents that reported by NC women in 2016:

% with ANY health insurance (18-64) 87%
Caucasian 90%
African American 87%
Asian 88%
American Indian/Alaska Native 79%
Hispanic 59%
% Women 18-64 with Private Health Insurance 73%
If receiving private health insurance
% with insurance from employer/union 79%
% who purchased insurance directly 20%
% with insurance through TRICARE 6%
% Women 18-64 with Public health insurance coverage 17%
If receiving public health insurance:
% with insurance through Medicaid 78%
% with insurance through Medicare 30%
% with insurance through VA 7%
% with insurance through Indian Health Services 0.1%
Note: Individuals can receive health insurance coverage from multiple sources

Source: Carolina Demography analysis of American Community Survey Data (1-year samples from IPUMS-USA) and 2016 Behavioral Risk Factor Surveillance System (BRFSS). Download Data

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Barriers to Care

Observations

  • It is disheartening that 30% of NC women live in poverty with an additional 10% near poverty – a trend that has remained relatively constant over the past 10 years. Consistent with national data, NC women of color are more likely to live in poverty, particularly African American women, who have nearly twice the poverty rate (27%) of Caucasian women (15%). In contrast, Caucasian women are 1.5 times more likely to have experienced 3 or more adverse childhood experiences (28%) than African American women (18%). Although the nature of adversity may differ by race, these data underscore that about 1 in 4 women residing in North Carolina experience significant stress at some point in their life.
  • Almost 1 in 5 women did not see a physician in the past 12 months due to cost. African American women were 1.5 times as likely to have not seen a doctor as Caucasian women. Despite this, African American women also report higher rates of medical debt than any other group.

The following data represents that reported by NC women in 2016:

% in the labor force (among women 18-64) 71%
% unemployed (among women 18-64 and in the civilian labor force) 6.4%
Poverty Status among women 18+
% In Poverty 19%
% Extreme Poverty (<50% FPL) 11%
% Near Poverty (100-150% FPL) 10%
% Poverty by Race/Ethnicity
Caucasian 15%
African American 27%
Asian 16%
American Indian/Alaska Native 23%
Hispanic 30%
Earned Income
% with any earned income (18+) 60%
Median earned income (if have earned income) $25,800
% with earned income (18-64) 72%
Median earned income (18-64) (if have earnings) $26,700
Any Disability (Ages 18+) 17.5%
Disability by Age (18+)
18 to 29 6%
30 to 44 8%
45 to 59 16%
60 and older 34%
Disability by Race/Ethnicity (18+)
Caucasian 18%
African American 20%
Asian 7%
American Indian/Alaska Native 22%
Hispanic 9%
Speak English Less than “Very Well” (18+) 5%
Caucasian 1%
African American 1%
Asian 36%
American Indian/Alaska Native 0%
Hispanic 45%

Source: Carolina Demography analysis of American Community Survey Data (1-year samples from IPUMS-USA). Download

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Education

The following data represents that reported by NC women in 2016:

Educational Attainment (25+)
Less than HS 11%
HS/GED 25%
Some College 33%
BA+ 31%
Caucasian Educational Attainment (25+)
Less than HS 8%
HS/GED 24%
Some College 33%
BA+ 34%
African American Educational Attainment (25+)
Less than HS 14%
HS/GED 26%
Some College 37%
BA+ 23%
Asian Educational Attainment (25+)
Less than HS 15%
HS/GED 16%
Some College 17%
BA+ 53%
American Indian/Alaska Native Educational Attainment (25+)
Less than HS 19%
HS/GED 33%
Some College 33%
BA+ 15%
Hispanic Educational Attainment (25+)
Less than HS 37%
HS/GED 25%
Some College 21%
BA+ 17%
% Currently enrolled in school (18-29) 38.8%
Caucasian 39%
African American 39%
Asian 49%
American Indian/Alaska Native 29%
Hispanic 33%

Source: Carolina Demography analysis of American Community Survey Data (1-year samples from IPUMS-USA). Download 2008-2016 Data


Preventative Health

Observations

  • The number of African American women in NC aged 50-74 who reported receiving a mammogram in the past two years (84%) exceeds the Healthy People 2020 target of 81.1%. Caucasian women are almost at that target at 79%. BRFSS sample size for 2016 was too small for information on other minority groups.
  • North Carolina women are exceeding Healthy People 2020 targets for colorectal screenings.
  • Dental care is a weakness for all women, but particularly African American women.
  • 75% of women participated in physical activity outside of their work but we do not know if that is once a month or five times a week.
  • Healthy People 2020’s target for seasonal influenza (flu) vaccinations is 70%. Only 47% of NC women received a flu shot in 2016.
  • The Healthy People 2020 goal for sleep is that 70.8% of women get 7+ hours a night. NC women fall just short of that target at 68%, with only 60% of African American women reporting 7+ hours of sleep a night. Sleep loss and untreated sleep disorders influence basic patterns of behavior that negatively affect family health and interpersonal relationships. Fatigue and sleepiness can reduce productivity and increase the chance for mishaps such as medical errors and motor vehicle or industrial accidents.
  • On the whole, Caucasian women are more likely to be diagnosed with a range of illnesses, such as chronic disease, cardiovascular disease, and depression. They are also more likely to report cancer, and less likely to die from cancer. This suggests a racial health disparity in doctor willingness to diagnose or a lack of doctor access.
  • Although data is often unavailable, Hispanic and Asian women appear to have very low health screening rates.

The following data represents that reported by NC women in 2016:

All NC Females Caucasian Females African Americans Females
Women 50+ who have ever had a sigmoidoscopy or colonoscopy 76% 78% 79%
Women age 50-75 who received one or more of the recommended colorectal cancer screening tests within the recommended time interval. 74% 75% 78%
Women 50-74 who have mammogram in last 2 years 79% 79% 84%
Women who have visited the dentist/dental clinic in the past year 67% 71% 57%
Women 18+ who have had pap test w/in past 3 years 77% 77% 80%
Women 65+ who have ever had a pneumonia vaccination 74%  ***  ***
Women 65+ who have had a flu shot within past year 65%  *** ***
Women 18+ who have had a flu shot in the past year 47% 50% 40%
Women who participated in physical activities in past month 75% 76% 71%
Women who had a routine checkup in the past year 80% 79% 86%
Women who sleep, on average, 7 or more hours in a 24-hour period 68% 70% 60%

Source: Carolina Demography analysis of 2016 Behavioral Risk Factor Surveillance System (BRFSS). Download

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Chronic Disease

Observations

  • After age 65, over half of North Carolina women are living with two or more chronic diseases. Chronic disease has a negative impact on the overall physical, mental, and financial well-being of women. Those with one chronic disease are at a higher risk of developing other chronic diseases.
  • Arthritis, rheumatoid arthritis, gout, lupus, and fibromyalgia are common and experienced by 29% of the state’s women. After age 55, over half of women reported arthritis or a related disease. By age 75+, this was the most common chronic disease reported. Older women need to be especially careful about arthritis pain as it can lead to falls.
  • 62% of women are overweight or obese. Obesity plays an important role in the risk factors for chronic diseases such as diabetes, cardiovascular disease, arthritis, and stroke. Particular attention to lifestyle factors such as diet and physical activity have been shown to have a positive impact on weight data.
  • African American women are nearly twice as likely as Caucasian women to meet criteria for obesity. This is undoubtedly a major contributor to the finding that 47% of the state’s African American women have been diagnosed with high blood pressure. It also reflects their increased risk for metabolic disorders such as diabetes. Importantly, 71% of African American women are being appropriately screened for diabetes.
  • Many women with diabetes are unaware that they have it and discovery may not occur until after damage to the heart, eyes, kidneys, and other organs has occurred. Risk increases rapidly from ages 35 to 64. Women should talk with their doctor about diabetes prevention and whether they need to be tested for diabetes.
  • Heart disease is the number one killer of women. While it is a serious concern for women of all ages, rates of heart disease increase dramatically between age groups 55-64, 65-74, and 75+. Women should strive to maintain a healthy weight and diet while engaging in exercise to decrease their risk of heart disease.

The following data represents that reported by NC women in 2016, unless otherwise noted:

All NC Females Caucasian Females African American Females 18 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+
Women with no chronic diseases 44% 39% 47% 66% 53% 46% 31% 18% 16%
Women with 1 chronic disease 28% 29% 25% 25% 27% 25% 30% 33% 30%
Women with 2 or more chronic diseases 29% 31% 28% 9% 20% 30% 40% 49% 54%
Chronic disease summary index is comprised of 9 indicators
History of any cardiovascular disease (heart attack/stroke/angina). Consists of yes to any of the following: 9% 9% 11% *** 2% 7% 12% 18% 25%
Ever been told you had a heart attack (also called myocardial infarction)? 3% 3% 4% *** *** *** 4% 6% 11%
Ever been told you have angina or coronary heart disease? 4% 5% 3% *** *** 3% 5% 10% 13%
Ever been told you had a stroke? 4% 4% 7% *** *** 4% 7% 8% 11%
Women currently with asthma 11% 9% 14% 10% 12% 10% 12% 12% 7%
Women ever told they had skin cancer 7% 10% *** *** 2% 7% 11% 14% 22%
Women ever told they had other cancer 8% 9% 5% *** 4% 7% 8% 16% 20%
Women ever told they had COPD, emphysema, or chronic bronchitis 8% 8% 9% 3% 5% 7% 13% 16% 12%
Women ever told they had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia 29% 33% 28% 7% 17% 28% 44% 55% 57%
Women ever told they had a depressive disorder, including depression, major depression, dysthymia, or minor depression 24% 27% 19% 22% 26% 25% 29% 25% 14%
Women ever told they had kidney disease 4% 3% 4% 2% *** 3% 6% 6% 5%
Women ever told they had diabetes 12% 11% 174% 1% 7% 13% 17% 25% 21%
Other Diabetes
Women ever told by a health professional they have pre-or borderline diabetes 1.9% 1.4% 3.5%  ***  *** *** 3.6% 2.8% ***
(2015 BRFSS) Women ever been tested for high blood sugar or diabetes in the past 3 years 65% 65% 71% 52% 66% 65% 76% 78% 73%
Weight range (at recommended, overweight, obese, underweight or unknown) by Race/Ethnicity
Underweight 2% 2% 2% 3% 1% 1% 2% 2% 2%
Recommended Range 36% 40% 22% 42% 34% 31% 32% 28% 47%
Overweight 29% 29% 27% 25% 25% 30% 31% 36% 30%
Obese 33% 29% 50% 29% 40% 39% 35% 34% 22%
Other (from 2015 BRFSS)
% of women who have ever told by health professional they have high blood pressure 35% 34% 47% 9% 20% 35% 55% 67% 67%
% of women who have ever told by health professional they have high cholesterol 37% 39% 39% 8% 25% 38% 53% 57% 57%

Source: Carolina Demography analysis of 2016 Behavioral Risk Factor Surveillance System (BRFSS). Download

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Mental Health and Substance Abuse

 Observations

  • One in four NC women has been diagnosed with a depressive disorder and, unlike other chronic conditions, the rate of depression does not increase with age. So, even among young women, almost a quarter have suffered from some form of depression. Stressful life events contribute to both mental and physical illness. Assessing current stressful events as part of a clinical history may improve the clinical care and outcomes for women in NC and beyond.
  • A quarter of North Carolina women reported three or more adverse childhood experiences. This rate is higher than national averages and should be an area to highlight for intervention efforts. The data underscore not only the prevalence and problem of childhood adversity, but that it cuts across all socioeconomic and racial divides. Depression in later life is a common consequence of childhood adversity.
  • Depression is common and must be part of regular health screening for women, both in the perinatal period and at all other times. There are effective treatments and women should not hesitate to discuss their concerns with their primary care doctor.
  • Caucasian women in North Carolina are 1.5 times as likely to have been diagnosed with a depressive disorder as African American women. Research suggests this may be due to the heavily rural makeup of the state, however the racial difference in childhood adversity is also a likely causal factor.
  • North Carolina substance use data among women is slightly lower than national data and is generally in line with other states’ data. However, the need for effective prevention and treatment still exists.

The following data represents that reported by NC women in 2016:

All NC Females Caucasian Females African American Females
Percent of women ever diagnosed with depressive disorder 24% 27% 19%
Percent of women reporting 3+ adverse childhood experiences 27% 28% 18%
Percent of women who currently smoke 15% 16% 16%
Percent of women who participate in binge drinking 11% 11% 10%
Percent of women who participate in heavy drinking 7% 8% 6%

Source: Carolina Demography analysis of 2016 Behavioral Risk Factor Surveillance System (BRFSS). Download

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Infectious Disease

Observations

  • North Carolina continues to be well below the Healthy People 2020 goal of having 73.6% of all adolescents and adults tested for HIV. African American women are nearly twice as likely to have been tested (57%) as Caucasian women (33%).

The following data represents that reported by NC women in 2016:

All NC Females Caucasian Females African American Females American Indian/Alaska Native Asian/Pacific Islander Hispanic
Percent ever tested for HIV 42% 32% 57% ***  *** ***
Incidence of newly diagnosed cases per 100,000 women (2016)
HIV infections 6.0 1.6 18.5 1.9 8.4 5.1
AIDS 4.2 0.9 14.0 3.8 3.0 2.9
Primary and secondary syphilis 2.1 0.6 6.6 1.6 0.6 0.2
Early latent syphilis 3.0 0.9 9.4 3.2 0.6 1.6
Gonorrhea 183.2 41.9 382.4 240.3 13.1 61.2
Chlamydia 788.8 229.3 1,196.2 977.2 144.9 637.6

Source: NC 2016 HIV/STD Surveillance Report. Download

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Cancer

Observations

  • Effective strategies exist to combat the four most prevalent cancers amongst the state’s women, including education on lifestyle, activities, HPV vaccination, and screenings for breast, colorectal, and cervical cancer.
  • Although the incidence rates are nearly identical, minority women are 1.5 times as likely to die of breast cancer as Caucasian women and twice as likely to die of cervical or uterine cancer.

The following data represents that reported by NC women in 2015 (per 100,000):

Mortality Rate Incidence Rate
All Females Caucasian Female Minority Female All Females Caucasian Female Minority Female
Oral Cavity 1.2 1.2 1.1 6.5 7.1 4.6
Esophagus 1.1 0.9 1.4 1.2 1 2
Stomach 2.2 1.8 3.5 4 3.3 6.4
Colon & Rectum 11.8 11 14.3 30.9 29.7 33.6
Liver 4 3.8 4.1 3.9 3.4 5.7
Gallbladder 0.7 .6 1.1 1.2 1 2
Pancreas 9.7 8.8 12.7 9.7 8.9 12.5
Larynx 0.4 0.4 0.4 0.6 0.7 0.6
Lungh & Bronchus 35.5 37.5 26.7 51.2 53.5 42
Bone 0.4 0.4 0.4 0.6 0.7 0.6
Soft Tissue 1.1 1 1.4 2.3 2.2 2.5
Melanoma (skin) 1.6 2 0.2 19.2 24.8 0.8
Female Breast 21.7 19.1 28.2 150.7 149.6 148.2
Cervix Uteri 1.9 1.7 2.7 6.6 6.3 7.3
Corpus Uteri 4.1 3.4 6.4 24.3 24.1 24.6
Ovary 6.1 6.1 6.3 9.9 10.6 7.6
Bladder 2.1 2 2.3 7.5 7.9 5.5
Kidney 1.9 1.8 2.1 10.3 9.5 13.1
Endocrine 0.8 0.5 1.6 17.8 18.7 15
Multiple Myeloma 3.4 2.8 5.3 5.2 3.7 9.7
Leukemia 4.4 4.3 4.3 7.3 7.1 7.1
Brain & Other CNS (includes benign brain) 3.2 3.5 2.1 17.4 17.6 15.7
Hodgkin Disease 0.3 0.2 0.5 1.8 1.7 2.1
Non-Hodgkins Lymphoma 4.2 4.4 3.4 13.4 14.2 10.1
Other Cancer 13.3 13.5 12.2 26.3 26 26.4
All Cancers 137.0 132.6 144.6 418.1 421.6 393.4

Source: NC Central Cancer Registry. Download

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Perinatal Health

Observations

  • PRAMS 2015 response rate fell short of the 55% rate that PRAMS has regarded as the epidemiologically valid threshold.
  • More NC babies are born with a low birth weight (9.2%) than the Healthy People 2020 target of 7.8%. African American women are more likely than other ethnicities to experience premature birth and have babies with a lower birth weight. Preterm birth and low birth weight can have lifelong implications for the health and well-being of families.

The following data is from 2016 NC Live Births:

Total Caucasian African American
Other Hispanic
Low Birth Weight (<=2500 grams) 9.2% 7.6% 14.1% 9.9% 7.4%
Normal Birth Weight 90.8% 92.4% 85.9% 90.1% 92.6%
Premature Birth (<37 weeks) 10.4% 9.4% 13.8% 9.7% 9.0%

Source: Carolina Demography analysis of 2016 NC Live Births. Download

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Intimate Partner Violence

Observations

  • Data on intimate partner violence (IPV) is challenging to quantify. Measurement tools vary in their definitions of IPV, making comparisons difficult. Almost all measures rely on self-report, which depends upon accurate recall and willingness to report the violence.
  • No amount of IPV is acceptable. IPV during pregnancy increases the risk of adverse birth outcomes with short and long-term complications for women.
  • Studies demonstrate that children exposed to violence may be at risk for repeating those patterns in their adult years.
Total
Percent pushed, hit, slapped, kicked, choked, or physically hurt in 12 months prior to pregnancy 1.3%
Percent pushed, hit, slapped, kicked, choked, or physically hurt during pregnancy 2.1%

Source: Carolina Demography analysis of 2015 Pregnancy Risk Assessment Monitoring System (PRAMS)

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The following UNC Chapel Hill faculty and staff were integral to the completion of this report card: Rebecca Tippet, Carolina Population Center; Dr. Leigh Callahan, Thurston Arthritis Research Center; Dr. Rebecca Fry, Dr. Penny Gordon-Larsen, Dr. Hazel Nichols, and Dr. Heather Wasser, Gillings School of Global Public Health; Dr. Victoria Bae-Jump, Dr. Kim Boggess, Dr. Giselle Corbie-Smith, Dr. Susan Girdler, Dr. Margaret Gourlay, Dr. Hendree Jones, Dr. Samantha Meltzer-Brody, Dr. Paula Miller, Dr. Wanda Nicholson, and Dr. Alison Stuebe, School of Medicine; Dr. Wendy Brewster, Michael Kerr, and Molly Smith, Center for Women’s Health Research.