The 1999 Iowa Health Fact Book is produced for use by care providers, health policy makers, and public health practitioners in the state of Iowa. The information provided within the Fact Book is designed to address the needs of these individuals and others who are concerned with outcomes, health behaviors, resources, and descriptions of the state demographically. Most tables and graphs in the text focus on the county as the principal unit of observation. This should facilitate the use of the demographic and health outcome data by those individuals who wish to make county-to-county comparisons or who wish to contrast an individual county to the state as a whole.

The 1999 Iowa Health Fact Book is similar to the 1997 Iowa Health Fact Book in a number of important ways. First, the information presented in the Fact Books is comparable, including major summaries of demographics, health behaviors, reproductive health, infectious disease incidence, cancer incidence and mortality, injury mortality, youth injury mortality, other major mortality, health resources, and health care facilities. In addition to this organizational similarity, this edition, like the 1997 version, makes no attempt to conduct sophisticated statistical analyses of the data presented. The data presented are intended to be descriptive in nature, and any formal comparisons need to be done with the usual care associated with technical concerns such as sample size, validity, and the reliability of statistics based on relatively small numbers. These limitations notwithstanding, the Fact Book should provide a rich source of information for describing the health and demographics of the state of Iowa.

In the 1999 Iowa Health Fact Book, many of the mortality and incidence figures presented are grouped into three non-overlapping three-year time windows: 1988-1990, 1991-1993, and 1994-1996. Throughout, the estimated Year 2000 US population has been utilized when calculating age-adjusted rates. The presentations of rates include both crude rates within each of the three-year time windows and rates age-adjusted to the estimated Year 2000 US population. To facilitate meaningful and valid comparisons of county groups, counties have been grouped into population groups based on mean county population size between 1988-1996. The graphs have been prepared by grouping counties into four major population groupings: counties with a mean population (between 1988 and 1996) less than 10,000, those between 10,000 and 20,000, those greater than 20,000, and those as Metropolitan Statistical Areas. For each county, the charts display the three three-year time intervals contiguously, enabling trends to be gleaned from the graphs. In addition to the graphical presentations, a table is presented which identifies the counties included within the population size groupings. These tables show the observed number of events for the tabulated health outcome, the crude rate, and the adjusted rate. The tables combined with the graphs provide a rather thorough comparison base for each county. For example, each county can be compared to others within the same population grouping by examination of the table.

Even with three-year groupings of events, and in some cases nine-year groupings, the number of observed events is often quite small. Throughout we have chosen the convention of not reporting the number of events in the table if the number is less than three. It is merely noted that the count is less than three. These actual numbers, of course, are used in the graphical presentations of the crude and adjusted rates found in the figures.

In the early part of the book, demographic information is presented on a county-by-county basis. Population tables show the average county population as well as the percent average population by specific age groups. Comparisons in these percent distributions may be useful to individuals as they compare the health outcomes of their county to others. Since the estimated Year 2000 US standard population is used for the age adjustment calculations, these figures are also displayed in the demographic section.

There are additional distinctions between the 1999 version of the Iowa Health Fact Book and the 1997 version. In the 1997 version, county-specific rankings were generated for each health outcome. The 1997 edition noted that county-to-county comparisons of these rankings could be misleading due to the small numbers of events. The same is true for this year’s version of the Fact Book; for this reason the rankings and quintile classifications have not been generated. It is still possible to examine a county’s rate in comparison to rates of other counties. For estimation and comparison purposes, small county counts/rates for certain health outcomes are generally unreliable.

In using the 1999 Iowa Health Fact Book, there are several additional statistical considerations the reader should note. First, as stated earlier, the projected Year 2000 US population has been used for adjustment purposes. This US Census Bureau population projection is the standard generally used in most contemporary national health reports, and for this reason we have chosen to use it here.

The second statistical issue concerns the calculation and presentation of rates. Both crude and direct age-adjusted rates have been calculated. Crude rates for an entity, e.g. county, are the number of events of a health outcome divided by the overall population size in the county. Age-adjusted rates, however, take the estimated Year 2000 US population shown on page 7 and apply it to the comparable age-specific rates in a county, therefore adjusting the county’s rates to the hypothetical standard within the estimated Year 2000 US population. If a county has a greater proportion of elderly in contrast to the estimated Year 2000 US population, then the age-adjusted rates will tend to be lower than its crude rate. Conversely, a county with a lower fraction of elderly would have a higher adjusted rate compared to its crude rate.

Finally, there is the issue of which rate, the crude or age-adjusted, is more meaningful to a specific county. While general rules are difficult to specify, some guidelines are possible. A crude rate for a county reflects the disease or mortality burden for a county and may be useful to the health policy makers in the county. The age-adjusted rate is more useful as a county comparison index, as counties being compared have had these rates adjusted to the same population. Hence, both are useful descriptive indices of diseases, but with differences in interpretation.

To facilitate use of the 1999 Iowa Health Fact Book, it is being presented in printed book form as well as being published on the World Wide Web. The Internet address is www.pmeh.uiowa.edu/factbook or you may link to this site from the Iowa Department of Public Health’s website at www.idph.state.ia.us. This permits users to review and download individual sections of the book, or the entire book.

The 1999 Iowa Health Fact Book is a collaborative product of the Iowa Department of Public Health and the University of Iowa. The University’s Colleges of Medicine and Public Health faculty and staff interacted with staff of the Iowa Department of Public Health in producing the Fact Book. It is expected that the Fact Book will be maintained by the Center for Public Health Statistics of the newly-formed College of Public Health at The University of Iowa. This maintenance will be a collaborative effort with the Iowa Department of Public Health. If there are questions in accessing the Internet site or if additional copies of the text of the book are needed, requests can be made directly to the Deputy Director, Center for Public Health Statistics, College of Public Health, 2215 Westlawn, The University of Iowa, Iowa City, IA 52242.

We are pleased to make this important health information available to the public. The data included in this book were obtained from a number of statewide databases maintained by the Iowa Department of Public Health and The University of Iowa. Appended to the book are lists of many additional Iowa health information resources and a glossary of terms used throughout the text. Primary sources have been used for generation of many tables and graphs; in these cases citations are indicated. We hope the 1999 edition of the Iowa Health Fact Book will be useful to public health practitioners and policy makers within the state of Iowa.

The demographics of Iowa are changing with the population increasing in age, becoming more urban, and increasing percentages of ethnic populations. These components characterize the state and its counties. This book details the occurrence of health indicators by the population of the county and state. Rates of these health indicators will be presented by stratification of the counties into population subgroups. This not only contrasts the rural and urban aspects of the state but also includes trends in age and ethnic distribution of the population. These rates also look to the future by using the estimated Year 2000 US standard population age distribution for calculating age-adjusted rates.

Information on marriage dissolutions, crime statistics, and per capita sales of liquor are included in this section because they characterize and contrast the dynamics of the population that can affect health of the population.

Population estimates have been obtained from the US Census. Estimates are used for each year and year groupings where appropriate. The US population distribution has been used to age-adjust the county and state rates to the population in the year 2000.

Information on dissolutions, crime rates and sales of liquor have been obtained through the Iowa Department of Public Health. The crime data may be incomplete due to selective reporting by counties and jurisdictions.

Using the average annual population from 1988-1996 there were 18 counties with less than 10,000 population, 47 counties with 10,000 to 20,000 residents, 24 counties with 20,000 to 50,000 residents, and 10 Metropolitan Statistical Area (MSA) counties. The distribution of the population by age is different between the county groupings. The larger size counties have a greater percentage of their population as young adults (15-44 years) compared to the small counties. The small counties have a larger percentage of persons 65 years of age or older. These differences in age distribution are standardized through age-adjustment so risk factors other than age can be compared. As shown, the population of the state is also becoming older and the percentage is increasing in the larger counties.

As for the characteristics of the population, marriage dissolutions in 1994-1996 were 3.7 per 1,000 population with more in urban counties but a decline in dissolutions in all county strata over 1994 to 1996. OMVI arrests (operating a motor vehicle while intoxicated) were 4.8 per 1,000 with rates higher in urban counties and different trends in the county strata. Narcotic arrests were 2.6 per 1,000 with an increasing trend across population sizes and across time. Juvenile vandalism arrests were low in many counties but 10 counties exceeded 1 arrest per 1,000 population. Juvenile arrests were increasing in all of the county groupings and for the state. The sale of liquor increased by population size with little observed change from 1995 to 1996. Cases of domestic abuse occurred more frequently in the large counties with a decline observed in 1996 compared to 1995.

The Behavioral Risk Factor Surveillance System (BRFSS) survey is conducted each year in Iowa, and in every other state, the District of Columbia, and Puerto Rico.

The Iowa BRFSS is an ongoing monthly telephone survey which is financially and technically supported by the Centers for Disease Control and Prevention (CDC). The statewide survey is a scientifically designed and validated method of collecting information from 3,600 household telephone surveys, and is designed to collect information on health risk behaviors of Iowa residents age 18 and over on nationally agreed upon topics and on additional areas of special interest to Iowa, and to monitor prevalence of these behaviors over time. The risk behaviors surveyed are major contributors to illness, disability, and premature death.

The goal of the Iowa BRFSS is to provide data to initiate and guide health promotion and disease prevention programs. The BRFSS program achieves this goal by 1) determining state specific prevalence of personal health behaviors related to the leading causes of premature death, 2) developing the capacity of the state health department to conduct credible telephone surveys, and 3) advancing the understanding that health-related behaviors are critical indices of health. The BRFSS results tell health professionals what is really going on, and can be used as a measure of the effectiveness of various public health strategies.

The key areas of emphasis are:

Health Care Coverage Health Status

Smoking Alcohol Consumption

Injury Control Women’s Health

Adult Immunizations Colorectal Cancer Screening

HIV/AIDS Diabetes

Physical Inactivity

Each year more than 4 million families in the United States bring home a healthy baby who has all the potential for a full and productive life. But one family in 100 will suffer the loss of their child soon after birth. Why are some 40,000 babies dying each year, and even more suffering from conditions of morbidity? Babies being born too small or too early cause more than three-quarters of infant deaths. The occurrence of this mortality and morbidity is highly correlated with size at birth and length of gestation.

Low birth weight results in significant loss of life; surviving infants often sustain residual injuries that involve the central nervous system, and there is a substantial financial cost involved in caring for these infants. Certain factors have proven to increase the likelihood of delivering a low birth weight infant:

Birth defects rank as the leading cause of mortality in full-term newborn babies in the US. Iowa’s overall birth defect rate is approximately 5%. Currently, Iowa is one of only seven states with an active surveillance program. The Iowa Birth Defects Registry monitors the types and frequency of birth defects within the state of Iowa. Information is collected directly from medical records in hospitals and clinics as compared to passive surveillance where information is collected only from birth and death certificates. The state of Iowa has taken a leadership role in birth defects surveillance and has served as a model to other states as they establish similar programs.

Interventions need to focus on providing perinatal health care to at-risk women. This involves preconceptual counseling, early and consistent prenatal care, and substance abuse treatment that keeps the family unit intact.

Some 46 diseases are reportable by Iowa code 641 Chapter 1. The Center for Acute Disease Epidemiology does disease surveillance and follow-up on these diseases as necessary. The county public health nurses individually interview the case or parent of every case of salmonella, shigella, E. coli, and hepatitis A, giving information on prevention of spread and watching for common sources. Clusters of giardia, cryptosporidium, and campylobacter are investigated as indicated.

Syphilis, gonorrhea, and chlamydia have been combined into the group "Sexually Transmitted Diseases" and presented by county. The incidence of the other infectious diseases was not sufficient to present data at the county level. For these diseases, the number and crude rates for each year 1994-1996 have been presented. In general, rates for all infectious diseases have remained constant over the three-year period, with the exception of an increase in 1995 for chlamydia.

Cancer is the second leading cause of death in Iowa. From 1988 through 1996, 56,965 Iowans died from cancer. Cancer accounted for about one out of every four deaths in Iowa. During this same period, 130,488 cancers were newly diagnosed among residents of Iowa. Cancer affects Iowans in every county. Although it occurs in people of all ages, more than 65 percent of new cancers occur in those 65 years of age and older.

There are four primary types of cancer that affect Iowans: lung & bronchus, colorectum, prostate, and female breast. From 1988 through 1996, these four types accounted for 58 percent of all incident cancers and 55 percent of all cancer deaths. Breast cancer was the most common female cancer; prostate cancer was the most common male cancer. Lung & bronchial cancer was the leading cause of cancer death and was responsible for 13 percent of all cancer deaths.

The Iowa Cancer Registry has been recording the occurrence of cancer in Iowa since 1973. It receives mortality data from the Iowa Department of Public Health. The Registry’s incidence and mortality databases have been used to generate the cancer incidence and cancer mortality statistics provided in this section of the 1999 Iowa Health Fact Book. Data are presented for 19 types of cancer as well as for all cancer sites. From 1988 through 1996, the rank order for frequency of occurrence of the 19 types was as follows: 1) prostate, 2) lung & bronchus, 3) female breast, 4) colorectum, 5) urinary bladder, 6) non-Hodgkin’s lymphoma, 7) leukemia, 8) uterine corpus, 9) skin melanoma, 10) kidney & renal pelvis, 11) pancreas, 12) ovary, 13) oral cavity (excluding lip), 14) stomach, 15) brain, 16) larynx, 17) uterine cervix, 18) esophagus, and 19) childhood cancers.

For all sites of cancer incidence and mortality (see pages 69 and 71), the age-adjusted rates by county grouping increased as the average population increased. However, the crude rates show the opposite trend, indicating that a larger proportion of older people reside in the more rural counties (see table and graph on page 6). Generally, these rates show a slight decline from 1994-96 compared with 1991-93. During the 1990s, declines in cancer incidence and mortality have been seen as well in the United States.

Tobacco use is the leading modifiable risk factor for cancer. Tobacco-associated cancers include the lung & bronchus, oral cavity (excluding lip), esophagus, larynx, pancreas, uterine cervix, urinary bladder, and kidney & renal pelvis. Alcohol consumption is also a known risk factor for cancers of the oral cavity (excluding lip), esophagus, and larynx. Ongoing research indicates that dietary factors may play an important role in the occurrence of cancers of the prostate and colorectum. Other important risk factors include obesity for cancer of the uterine corpus, excessive sunlight exposure for skin melanoma, and genetic predisposition (or positive family history) for breast cancer.

Widely accepted cancer screening guidelines exist for cancers of the female breast, uterine cervix, and colorectum. Recommended screening tests include mammography and clinical breast examination for female breast cancer, Papanicolaou (Pap) test for cancer of the uterine cervix, and fecal occult blood test and sigmoidoscopy for colorectal cancer. The primary objective of these screening tests is to reduce site-specific cancer mortality rates by increasing survival through detecting cancer at an earlier stage. Some of these tests, especially the Pap test and sigmoidoscopy, have the capability of detecting precancerous lesions. To the extent they accomplish this, these tests can also lead to a reduction in site-specific cancer incidence rates.

Today, less than half of the people in Iowa newly diagnosed with a cancer will die from it. However, survival rates vary considerably by cancer site. In this report, as the number of cancer deaths gets closer to the number of observed incident cancers, the survival rate for that cancer decreases. For example, from 1988 through 1996, there were 18,875 newly diagnosed lung & bronchial cancers and 15,112 lung & bronchial cancer deaths. Survival from lung & bronchial cancer is poor. On the other hand, during the same period, there were 18,713 newly diagnosed breast cancers and 4,855 breast cancer deaths. Survival from breast cancer is much better.

Injuries are the leading cause of death in persons 1-44 years of age. It is important to differentiate the etiology of the injury death to determine preventive strategies for injury control and also for resources for trauma response through a statewide trauma system. The state of Iowa is in the process of development of a statewide system to be implemented in 2001.

The source of this information is the cause of death data obtained from death certificates filed at the Iowa Department of Public Health. Analysis was done by the State Health Registry of Iowa at The University of Iowa. Age-adjusted rates were calculated using the estimated Year 2000 US population distribution.

Fires and burns cause 1.4 deaths per 100,000 population in the state of Iowa annually. Overall the rates of burn-related death have remained constant with some fluctuations in the smaller county strata. Drownings accounted for 111 deaths from 1994-1996 with a rate of 1.4 per 100,000. With the increasing age of the state’s population, deaths from falls increased to 7.7 per 100,000 in 1994-1996. Increases were observed in all but the MSA county groupings. Deaths from firearms remained constant over time, but the smallest county strata had the highest rates. Homicides were more likely in the larger counties and increased to 3.7 per 100,000 in the MSA counties in 1994-1996. Overall suicide rates remained constant. Poisonings also remained at a rate of nearly 1.4 per 100,000 population. Transportation related deaths were at 19.1 per 100,000 in 1994-1996 with motor vehicle crashes making up the majority (17.7 per 100,000). Rates were increasing in the smaller counties and decreasing in the larger county strata. Deaths from all other injuries were similar across time periods but were highest in the smaller counties.

Injuries remain the leading cause of death in persons age 1-44 years and contribute the most to years of life lost, particularly for those events of pre-adult ages. Deaths from unintentional injuries, homicides and suicides are the foremost public health problem in those 15-24 years of age with many of them preventable.

The source of this information is the cause of death data obtained from death certificates filed at the Iowa Department of Public Health. Analysis was done by the State Health Registry of Iowa at The University of Iowa. Age-adjusted rates were calculated using the estimated Year 2000 US population distribution. Note that the crude rates and age-adjusted rates displayed in the graphs for ages 15-19 are identical to one another. This is because this represents only one age group in the age-adjustment analysis. The crude and age-adjusted rates for the 0-14 age group show slight differences as this represents three age groups (0-4, 5-9, and 10-14) in the age-adjustment analysis.

In 1988-1990 the age-adjusted rate was 4.9 deaths per 100,000 in those individuals less than 15 years of age, while in 1994-1996 the rate was 6.8 deaths per 100,000; a 40% increase. The increase was in all counties, with the greatest increase in smaller counties, but this was based on a small number of events. For those 15-19 years the rate was 35.2 per 100,000 with a slight decrease observed in the larger counties over time. All transportation-related deaths exhibited similar trends. For the state of Iowa homicides in youth increased but largely in the MSA counties. Suicides remained relatively constant at about 14 per 100,000 for those 15-19 years of age.

The top ten causes of death in Iowa are heart disease, cancer, stroke, respiratory disease, pneumonia and influenza, unintentional injuries, diabetes, arteriosclerosis, infectious and parasitic diseases and Alzheimer’s Disease. With the aging of the population, chronic disease becomes a major determinant of the health of Iowans and the need for health care services in the state.

The source of this information is the cause of death data obtained from death certificates filed at the Iowa Department of Public Health. Analysis was done by the State Health Registry of Iowa at The University of Iowa. Age-adjusted rates were calculated using the estimated Year 2000 US population distribution.

Heart disease is still the number one cause of death but between 1988 and 1996 the rates of heart disease death in Iowa decreased 7.6% to 326 deaths per 100,000 persons. After age-adjustment heart disease affects counties of different sizes similarly and the decreasing trend is observed across all strata. However for stroke there has been no decline and a similar trend is observed in all county groupings. For chronic obstructive pulmonary disease (COPD) the rates have been increasing across time with the larger counties having a higher mortality. In contrast death from pneumonia and influenza has been declining across all county levels. Diabetes has been increasing to nearly 22 per 100,000 with the smaller counties having increases. In general atherosclerosis as a primary cause of death has been declining. Infectious and parasitic diseases have been increasing as causes of mortality with the highest rates in the more urban counties. In general, chronic liver disease has been on the decline. Nephritis has only shown a decline in the 1994-1996 rates. For congenital anomalies the rates are similar except in the MSA counties where a decrease from 5.8 per 100,000 to 4.7 per 100,000 was observed. Deaths due to conditions originating in the perinatal period are approximately 4.1 per 100,000 with a decline observed in all county strata.

Health care provider data come from the Office of Statewide Clinical Education Programs (OSCEP) at The University of Iowa College of Medicine and from the Iowa Department of Public Health, Board of Nursing, and Bureau of Emergency Medical Services.

OSCEP provides an up-to-date inventory of physicians, physician assistants, nurse practitioners, pharmacists, and dentists to follow trends in health professionals practicing in the state and to provide the health science colleges information on progress of their programs.

The Board of Nursing enforces and regulates nursing education, nursing practice, and continuing education for nurses. The board sets standards, provides evaluation and licensing, and investigates complaints about licensed practical nurses, registered nurses, and advanced registered nurse practitioners. Its mission is "to protect the public health, safety and welfare of Iowans by ensuring that nursing is practiced by competent licensed individuals within their practice field."

The Bureau of Emergency Medical Services is a regulatory agency that establishes initial training, continuing education, and renewal requirements leading towards certification of emergency medical care providers including those presented in the 1999 Iowa Health Fact Book. The EMS Bureau is also responsible for the implementation of a statewide system of emergency care dealing with children and for the development of a statewide trauma system.

The information presented on health care facilities comes from the Division of Health Facilities in the Iowa Department of Inspections and Appeals (DIA). This state agency is responsible for inspection of all Chapter 135C licensed health care facilities in Iowa, including those presented in the 1999 Iowa Health Fact Book. This agency also conducts inspections of various Medicare/Medicaid entities (e.g., skilled nursing facilities, home health agencies, hospices, hospitals, CLIA labs, etc.) through contract with the Health Care Financing Administration (HCFA), and investigates complaints of substandard care or services in these entities.