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National Center for Health Statistics (US) . Health, United States, 2008: With Special Feature on the Health of Young Adults. Hyattsville (MD): National Center for Health Statistics (US); 2009 Mar.

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Health, United States, 2008: With Special Feature on the Health of Young Adults.

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Population

Age

The population age 65 and over is increasing at a faster rate than the total population.

From 1950 to 2006, the total resident population of the United States increased from 151 to 299 million persons, representing an average annual growth rate of 1.2% (Figure 1). During the same period, the population 65–74 years of age grew, on average, 1.5% per year, increasing from 8 to 19 million persons. The population 75 years of age and over grew the fastest (on average, 2.8% per year), increasing from 4 to 18 million persons.

Figure 1

Figure 1

Total population and older population: United States, 1950–2050 Click here for spreadsheet version

By 2029, all of the baby boomers (those born in the post World War II period 1946–1964) will be age 65 years and over (1). As a result, the population age 65–74 years will increase from 6% to 10% of the total population between 2006 and 2030 (data table for Figure 1). As the baby boomers age, the population 75 years of age and over will rise from 6% in 2006 to 9% of the population by 2030 and continue to grow to 12% in 2050. By 2040, the population age 75 years and over will exceed the population 65–74 years of age.

Reference

1.
Day JC. National population projections. U.S. Census Bureau; 2001. Available from: http://www​.census.gov​/population/www/pop-profile/natproj​.html.

Race and Ethnicity

The percentage of Americans who identify themselves as Hispanic or Asian continues to increase.

Changes in the racial and ethnic composition of the population have important consequences for the United States’ health because many measures of disease and disability differ significantly by race and ethnicity. One of the overarching goals of U.S. public health policy is elimination of racial and ethnic disparities in health.

Diversity has long been a characteristic of the U.S. population, but the racial and ethnic composition of the United States has changed over time. In 2007, about 30% of adults and over 40% of children were members of racial or ethnic minority populations (data table for Figure 2). The percentage of the population that is of Hispanic origin or Asian has more than doubled in recent decades (data table for Figure 2).

In the 1980 and 1990 decennial censuses, Americans could choose only one racial category to describe their race (1). Beginning with the 2000 census, the question on race was modified to allow the choice of more than one racial category. Although, overall, a small percentage of persons of non-Hispanic origin selected two or more races in 2007, the percentage of children described as being of more than one race was more than twice as high as the percentage of adults (Figure 2). The number of American adults identifying themselves or their children as multiracial is expected to increase in the future (2).

Figure 2

Figure 2

Population in selected race and Hispanic origin groups, by age: United States, 1980–2007 Click here for spreadsheet version

The percentage of persons reporting two or more races varies considerably among racial groups. For example, the percentage of persons reporting a specified race in combination with one or more additional racial groups was 1.4% for white persons and 38.0% for American Indian or Alaska Native persons in 2007 (3).

References

1.
Grieco EM, Cassidy RC. Census 2000 brief . U.S. Census Bureau; Mar, 2001. Overview of race and Hispanic origin.
2.
Waters MC. Immigration, intermarriage, and the challenges of measuring racial/ethnic identities. Am J Public Health. 2000;90(11):1735–7. [PMC free article: PMC1446407] [PubMed: 11076242]
3.
U.S. Census Bureau. Monthly postcensal resident population, by single year of age, sex, race, and Hispanic origin. Available from: http://www​.census.gov​/popest/national/asrh/2006_nat_res.html [data for July 1, 2007]. Unpublished analysis.

Children Living with a Single Parent

The percentage of children living with a single parent more than doubled between 1970 and 2006, increasing from 12% to 28%.

Children living in single parent households, particularly when the single parent is the mother, tend to be more financially disadvantaged and to have poorer physical and mental health than children living with two biological parents (1). Even when children are born to married couples, many will spend part of their childhood living with a single parent because of parental divorce, separation, or death (2).

In 2006, 28% of children under 18 years of age were living with a single parent, an increase from 12% in 1970. Mothers account for the vast majority of single parents. In 2006, there were 17.2 million children living with their mother only, compared with 3.5 million children living with their father only (3).

Increases in the percentage of children under 18 years of age living with single parents have moderated in recent years. The percentage of children living with single parents increased, on average, 5.0% per year in the 1970s and 2.4% per year during the 1980s. The percentage of children living with single parents has stayed fairly stable at around 27%–28% from 1992 through 2006 (data table for Figure 3).

The percentage of children living with single parents varies by race and ethnicity (Figure 3). In 2006, black children (56%) were more likely than white (23%) or Hispanic children (29%) to live with a single parent. Between 1970 and 2006, the percentage of children living with single parents increased 159% among white children and increased 76% among black children. Among Hispanic children, the percentage living with single parents increased 38% since 1980 when data on Hispanic ethnicity became available.

Figure 3

Figure 3

Children under 18 years of age living with a single parent, by race and Hispanic origin: United States, 1970–2006 Click here for spreadsheet version

References

1.
Bramlett MD, Blumberg SJ. Family structure and children’s physical and mental health. Health Affairs. 2007;26(2):549–58. [PubMed: 17339685]
2.
Amato PR, Maynard RA. Decreasing nonmarital births and strengthening marriage to reduce poverty. The Future of Children. 2007;17(2):117–41. [PubMed: 17902263]
3.
U.S. Census Bureau. Current Population Survey, March and Annual Social and Economic Supplements, 2006 and earlier. Available from: http://www​.census.gov​/population/www/socdemo/hh-fam.html.

Poverty and Low Income

In 2006, Hispanic and black Americans in all age groups were more likely to live in poverty than white and Asian Americans.

Children and adults in families with income below or near the federal poverty level have worse health than those with higher income (see Appendix II, Poverty, for a definition of the federal poverty level). Although in some cases illness can lead to poverty, more often poverty causes poor health by its connection with inadequate nutrition, substandard housing, exposure to environmental hazards, unhealthy lifestyles, and decreased access to and use of health care services (1).

In 2006, the overall percentage of the U.S. population living in poverty declined to 12.3%. This was the first decline in the poverty rate since 2000 (2). The poverty rate decreased for all age groups from 2005 to 2006 with the largest decline among people 65 years of age and over (data table for Figure 4).

Starting in 1974, children have been more likely than either working-age or older adults to be living in poverty (Figure 4). In 2006, 13 million children (17.4%) lived in poverty and another 16 million children (21.6%) were classified as near-poor with family income of 100% to less than 200% of the poverty level (data table for Figure 5). In 2006, children represented 35% of people living in poverty but only 25% of the total population (2).

Figure 4

Figure 4

Poverty by age: United States, 1966–2006 Click here for spreadsheet version

Prior to 1974, persons 65 years of age and over were more likely to live in poverty than people of other ages. With the increased benefits provided by government social insurance programs such as Social Security, the poverty rate of older adults declined rapidly until 1974 and from then continued a gradual decline through 1999 (3). Between 1999 and 2005, rates fluctuated but increased overall compared with the poverty rate in 1999. In 2006, the poverty rate among older adults was the lowest since 1959, the first year for which poverty estimates were available, with 9.4% or 3.4 million persons age 65 years and over living in poverty. An additional 26.2% or 9.4 million older persons were near-poor (data table for Figure 5).

At all ages, a higher percentage of Hispanic and black persons than non-Hispanic white persons were poor (Figure 5). In 2006, 27%–33% of Hispanic and black children were poor compared with 10%–12% of non-Hispanic white and Asian children. Similarly, among persons 65 years of age and over, almost one-fifth of Hispanic and one-quarter of black persons were poor, compared with 7% of non-Hispanic white persons and 12% of Asians. In 2004–2006, 27% of American Indian or Alaska Native persons lived in poverty (estimate based on 3 years of data) (4).

Figure 5

Figure 5

Low income by age, race and Hispanic origin: United States, 2006 Click here for spreadsheet version

References

1.
Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Health, United States, 1998. Hyattsville, MD: NCHS; 1998. Socioeconomic Status and Health Chartbook.
2.
DeNavas-Walt C, Proctor BD, Smith J. Current population reports, series P–60, no 233 . Washington, DC: U.S. Government Printing Office; 2007. Income, poverty, and health insurance coverage in the United States: 2006. Available from: http://www​.census.gov​/prod/2007pubs/p60-233.pdf.
3.
Clark RL, Quinn JF. The economic status of the elderly. Medicare Brief. 1999;4:1–12. [PubMed: 10915459]
4.
U.S. Census Bureau. Current Population Survey, Annual Social and Economic Supplement, 2005 and 2007 data. Table generator available from: http://www​.census.gov​/hhes/www/cpstc/cps_table_creator.html.

Health Risk Factors

Tobacco Use

Nearly one-fifth of women and high school students and one-quarter of men still are current cigarette smokers, as are almost 11% of pregnant women.

Smoking is associated with a significantly increased risk of heart disease, stroke, lung and other types of cancer, and chronic lung diseases (1). Decreasing cigarette smoking among adolescents and adults is a major public health objective for the United States. Preventing smoking among teenagers and young adults is critical because smoking usually begins in adolescence (2). Smoking during pregnancy contributes to elevated risk of miscarriage, premature delivery, and having a low birthweight infant (3).

Following the first Surgeon General’s Report on smoking in 1964, cigarette smoking declined sharply for men and at a slower pace for women (Figure 6). The percentage of men and women who smoke declined more slowly starting in 1990, reaching the lowest level for men in 2004 (23%). The proportion of men and women who smoke has not changed significantly since 2004, suggesting a stall in the decline in cigarette smoking among adults (4). In 2006, 24% of men and 18% of women were smokers. Cigarette smoking by adults continues to be strongly associated with educational attainment. Adults with less than a high school education were three times as likely to smoke as those with a bachelor’s degree or more education (Table 64).

Figure 6

Figure 6

Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2007 Click here for spreadsheet version

In 2007, 20% of high school students in grades 9–12 had smoked cigarettes in the past month. Cigarette smoking rates among high school students peaked in 1997 and then decreased and leveled off. In 2007, 14% of high school students had smoked cigars and 8% had used smokeless tobacco in the past month (5).

Among mothers with a live birth, the percentage reporting on the birth certificate that they smoked cigarettes during pregnancy declined from 20% in 1989 to 11% in 2002. The rate remained at 11% during the period 2004–2005, when 36 states, D.C., and New York City continued to use the 1989 revision of the U.S. Standard Certificate of Live Birth (see Appendix II, Cigarette smoking). Maternal smoking has declined for all racial and ethnic groups, but differences among these groups persist (Table 11).

References

1.
US Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health; 2004. Available from: http://www​.cdc.gov/tobacco​/data_statistics​/sgr/sgr_2004/index.htm.
2.
US Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General . Atlanta, GA: U.S. Department of Health and Human Services, CDC Office on Smoking and Health; 1994. Available from: http://www​.cdc.gov/tobacco/sgr/sgr_1994/
3.
Mathews TJ. National vital statistics reports. Hyattsville, MD: NCHS; 2001. Smoking during pregnancy in the 1990s. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr49/nvsr49_07.pdf. [PubMed: 11561426]
4.
CDC. Cigarette smoking among adults—United States, 2006. MMWR. 2007. pp. 1157–61. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5644a2.htm. [PubMed: 17989644]
5.
CDC. Youth Risk Behavior Surveillance—United States, 2007. MMWR. 2008. pp. 1–131. Available from: http://www​.cdc.gov/HealthyYouth​/yrbs/pdf/yrbss07_mmwr.pdf. [PubMed: 18528314]

Overweight and Obesity

The proportion of American adults who are obese has doubled over the past three decades to about one-third of all American adults.

Excess body weight is associated with excess morbidity and mortality (1), but the magnitude of excess weight appears to matter. Obesity is correlated with excess mortality. In addition, obesity is associated with increased risk of heart disease, diabetes, osteoarthritis, and disability (2,3,4,5,6). The health implications of being overweight and not obese, however, are mixed and complex (7). Research has found that persons who are overweight but not obese do not have excess mortality compared with persons of normal weight (8,9). Diet, physical inactivity, genetic factors, environment, and health conditions all contribute to overweight and obesity. The potential health benefits from reducing the prevalence of obesity are of significant public health importance.

Findings from the National Health and Nutrition Examination Survey show that the proportion of adults who are obese has more than doubled from 15% in 1971–1974 to 34% in 2003–2006 for adults 20–74 years (age-adjusted) (Table 75). In contrast, the proportion of American adults who are overweight but not obese has been steady during that time period, at about one-third from 1971–1974 through 2003–2006 (Table 75).

Evidence suggests that the morbidity associated with obesity may increase with longer duration of obesity (7,8,10). Therefore overweight and obesity trends among young adults and children may signal future morbidity. Although young adults (18–29 years, and the topic of this year’s Special Feature) have lower prevalence of obesity (24%) compared with persons 30 years and over (31%–41%), it is noteworthy that the proportion of young adults who are obese has more than tripled from 8% in 1971–1974 to 24% in 2005–2006 (Figure 7), while in most other adult age groups the prevalence doubled during that time period.

Figure 7

Figure 7

Overweight and obese, by age: United States, 1971–1974 through 2005–2006 Click here for spreadsheet version

The increasing prevalence of obesity among adults has been accompanied by an increase of overweight among children (defined as a body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cut points from the 2000 CDC Growth Charts). The percentage of children (6–11 years of age) and adolescents (12–17 years of age) who are overweight has risen since 1976–1980. The percentage of preschool-age children (2–5 years of age) who are overweight doubled from 1976–1980 (5%) to 2005–2006 (11%) (11; data table for Figure 7; see related Table 76). In 2005–2006, 15%–18% of children and adolescents were overweight (data table for Figure 7). Between 1999–2000 and 2005–2006, the percentage of children and adolescents who were overweight has been steady (12).

References

1.
National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. 1998. NIH pub. no. 98—4083. Available from: http://www​.nhlbi.nih​.gov/guidelines/obesity/ob_gdlns.htm. [PubMed: 9813653]
2.
Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States—No statistically significant change since 2003—2004. Hyattsville, MD: NCHS; 2007. NCHS data brief no. 1. [PubMed: 19389313]
3.
U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services; 2001. Available from: http://www​.surgeongeneral​.gov/topics/obesity/
4.
Gregg EW, Guralnik JM. Is disability obesity’s price of longevity? JAMA. 2007;298(17):2066–7. [PubMed: 17986703]
5.
Alley DE, Chang VW. The changing relationship of obesity and disability, 1988–2004. JAMA. 2007;298(17):2020–7. [PubMed: 17986695]
6.
Visscher TLS, Rissanen A, Seidell JC, Heliöra M, Knekt P, Reunanen A, et al. Obesity and unhealthy life-years in adult Finns. Arch Intern Med. 2004;164:1413–20. [PubMed: 15249350]
7.
Gregg EW, Cheng YJ, Cadwell BL, Imperatore G, Williams DE, Flegal KM, et al. Secular trends in cardiovascular disease risk factors according to body mass index in U.S. adults. JAMA. 2005;293(15):1868–74. [PubMed: 15840861]
8.
Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA. 2007;298(17):2028–37. [PubMed: 17986696]
9.
Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861–7. [PubMed: 15840860]
10.
Lakdawalla DN, Bhattacharya J, Goldman DP. Are the young becoming more disabled? Health Aff. 2004;23(1):168–76. [PubMed: 15002639]
11.
CDC/NCHS. Prevalence of Overweight Among Children and Adolescents: United States, 2003—2004. Health E-Stats. Hyattsville, MD: NCHS; 2006.
12.
Ogden CL, Carroll MD, Flegal KM. High body mass index for age among U.S. children and adolescents, 2003–2006. JAMA. 2008;299(20):2401–5. [PubMed: 18505949]

Leisure-time Physical Activity and Strength Training

In recent years, American adults have made no substantial progress towards achieving recommended levels of physical activity or strength training.

Benefits of regular physical activity include a reduced risk of premature mortality and reduced risks of coronary heart disease, diabetes, colon cancer, hypertension, and osteoporosis (1). Regular physical activity also improves symptoms associated with musculoskeletal conditions and mental health conditions such as depression and anxiety. Physical activity, along with a healthy diet, plays an important role in the prevention of overweight and obesity (Figure 7, Tables 75 and 76). Benefits of strength training include a lessening of loss of muscle mass, functional decline, and fall-related injuries (2).

In 1995, the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) issued a public health recommendation that every U.S. adult should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week. In 2007, the ACSM and the American Heart Association issued updated recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health. They recommended moderate-intensity aerobic physical activity for a minimum of 30 minutes on five days per week or vigorous-intensity aerobic activity for a minimum of 20 minutes on three days per week. They also added a recommendation that adults should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week (3). In October 2008, the U.S. Department of Health and Human Services released guidance to help Americans age 6 and older improve their health through appropriate physical activity (4).

Between 1999–2000 and 2005–2006, about one-third of adults reported regular leisure-time physical activity (see Technical Notes for definition). During this period, the trend in the percentage of Americans who engaged in regular leisure-time physical activity remained relatively stable for adults in all age groups (Figure 8). In 2005–2006, the percentage of Americans engaged in regular leisure-time physical activity declined with increasing age from 36% among young adults 18–29 years of age to 22% among older adults. Regular leisure-time physical activity levels were higher among men than women in the youngest and oldest age groups (data table for Figure 8).

Figure 8

Figure 8

Regular leisure-time physical activity and strength training at least twice a week among adults 18 years of age and over, by age: United States, 1999–2006 Click here for spreadsheet version

The proportion of Americans who engaged in regular leisure-time physical activity varied by sociodemographic factors (Table 74). Participation in regular leisure-time physical activity was more common among those with higher levels of education and family income.

Between 1999–2000 and 2005–2006, about one-fifth of adults reported participating in strength training at least twice a week (see Technical Notes for definition). During this period, the trend in the percentage of Americans who engaged in strength training remained fairly constant (Figure 8). The percentage of Americans who participated in strength training was even lower than the percentage of Americans who participated in regular leisure-time physical activity. Participation in strengthening activities decreased sharply with increasing age. The level among older adults was less than half that of adults 18–29 years of age. Men 18–44 years of age were more likely to participate in strength training than women of the same age (data table for Figure 8).

References

1.
U.S. Department of Health and Human Services. Physical activity and health: A report of the Surgeon General. Atlanta, GA: CDC; 1996. Available from: http://www​.cdc.gov/nccdphp/sgr/sgr.htm.
2.
CDC. Trends in strength training—United States, 1998–2004. MMWR . 2006. pp. 769–72. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5528a1.htm. [PubMed: 16855525]
3.
Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity and public health: Updated recommendation for adults from the American College of Sports Medicine and the American Health Association. Med Sci Sports Exerc. 2007;39(8):1423–34. [PubMed: 17762377]
4.
U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans. Washington, DC: DHHS ; 2008. Available from: http://www​.health.gov​/paguidelines/guidelines/default.aspx.

Morbidity and Limitation of Activity

Acute Viral Hepatitis

In 2006, incidence of acute viral hepatitis types A, B, and C was at or near record-low levels.

Acute viral hepatitis, an acute illness characterized by nausea, abdominal pain, and jaundice, is most frequently caused by infection with one of three, unrelated viruses: hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV) (1). In addition to acute illness, HBV and HCV can cause chronic infection associated with increased risk of chronic liver disease and liver cancer. In 2005, viral hepatitis was listed as the cause of death on approximately 5,500 U.S. death certificates (2).

HAV is usually spread when a person ingests fecal matter, even in microscopic amounts, from contact with objects, food, or drinks contaminated by the feces of an infected person. In 2006, the most commonly identified risk factor for hepatitis A was international travel (1). HBV is transmitted though exposure to the blood or body fluids of an infected person. Transmission occurs through exposures such as sexual contact with an infected person, injection-drug use, and from an infected mother to her infant during delivery (1). The most commonly identified risk factors for HBV infection in 2006 were sexual-risk factors such as sexual contact with an infected person and having multiple sex partners. HCV is also transmitted though exposure to the blood or body fluids of an infected person; the most common risk factor identified for HCV infection in 2006 was injection drug use (1).

Periodic outbreaks of hepatitis A have occurred in the United States every decade, with the last outbreak in 1995 (Figure 9). Since 1995, when vaccine to prevent HAV infection was introduced, the incidence rate of acute hepatitis A has declined steadily from 12 cases per 100,000 population to 1.2 cases per 100,000 population in 2006 (data table for Figure 9), the lowest rate since surveillance began in 1966. The 2006 rate represents about 3,600 acute symptomatic cases and an estimated 32,000 new infections, because reported cases represent only a portion of hepatitis virus infections that occur (1). Historically, hepatitis A rates were highest among children 5–14 years and were higher in the western region of the country, but routine immunization of children living in the states that have consistently had the highest rates of hepatitis A has resulted in significant declines in rates (1).

Figure 9

Figure 9

Incidence of acute viral hepatitis, by type and year: United States, 1966–2006 Click here for spreadsheet version

Vaccine to prevent HBV infection has been available since 1982 and is now part of the routine childhood immunization schedule (3). Since 1985, the incidence rate of hepatitis B has declined from 11.5 to 1.6 cases per 100,000 population in 2006 (Figure 9). This represents about 4,700 reported cases and an estimated 46,000 new infections in 2006 (1). In 2006, few cases of hepatitis B occurred among dialysis patients and health-care workers, populations previously considered at high risk, due to improvements in infection control and high vaccination rates (1). The greatest decrease in rates of hepatitis B occurred among the cohort of children who received routine immunization (1). It is estimated that about 1.3 million people in the United States were chronically infected with HBV in 2006 (4).

The incidence rate of acute hepatitis C has been declining since 1992, even though there is currently no vaccine to prevent infection (Figure 9). This decline is attributed to risk reduction practices among injection drug users, such as reduced needle-sharing (1). In 2006, the incidence rate of acute hepatitis C was 0.3 cases per 100,000 population compared with 2.4 per 100,000 population in 1992 (data table for Figure 9). However, approximately 3.2 million people in the United States remain chronically infected with HCV in 2006, making it the most prevalent blood-borne infection in the United States (1).

References

1.
CDC. Surveillance for acute viral hepatitis—United States, 2006. MMWR. 2008. pp. 1–24. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/ss5702a1.htm.
2.
Kung H-C, Hoyert DL, Xu J, Murphy SL. National vital statistics reports. 10. Vol. 56. Hyattsville, MD: NCHS; 2008. Deaths: Final data for 2005. [PubMed: 18512336]
3.
CDC. Achievements in public health: Hepatitis B vaccination—United States, 1982–2002. MMWR . 2002. pp. 549–552.pp. 563 Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5125a3.htm. [PubMed: 12118536]
4.
CDC. Viral hepatitis surveillance: Estimates of disease burden from viral hepatitis. Atlanta, GA: CDC; 2006. Available from: http://www​.cdc.gov/ncidod​/diseases/hepatitis​/resource/dz_burden.htm.

Asthma Among Adults

Current asthma prevalence is higher for adult women than for men, and varies by income and race and ethnicity.

Asthma is a chronic inflammatory disorder of the airways that is characterized by airway hyperresponsiveness and reversible episodes of airflow obstruction (1). These acute episodes or attacks are characterized by wheezing, chest tightness, and shortness of breath. While some industrial agents have been shown to cause asthma in adult workers, there is little definitive information on what causes individuals to develop asthma (2). In people who have asthma, attacks can be caused by triggers such as environmental tobacco smoke, dust, mites, and cold air. Although asthma cannot be cured, symptoms can be controlled by appropriate medical care and limiting trigger exposure (1).

People with asthma require frequent interaction with the health care system to effectively manage their asthma. It is recommended that patients see their physicians every 1 to 6 months depending on the severity of their disease (3). Although most emergency department visits and inpatient hospitalizations resulting from asthma exacerbations are preventable, these episodes commonly occur. In 2006, among adults there were about 1 million emergency department visits and 290,000 hospital discharges with asthma as the first-listed diagnosis (4).

Although asthma is often thought of as a childhood disease, it also affects adults. Boys are more likely to have current asthma than girls; but among adults, women have a higher prevalence than men (1). In 2004–2006, 9% of women age 18 years and over and 5% of adult men reported having current asthma (data table for Figure 10). Women have higher rates than men in all racial and ethnic groups, and regardless of income level (Figure 10).

Figure 10

Figure 10

Current asthma prevalence among adults 18 years of age and over, by sex, race and Hispanic origin, and percent of poverty level: United States, 2004–2006 Click here for spreadsheet version

Prevalence of asthma varies by poverty status. Almost 11% of adults with family income below the poverty level reported having current asthma in 2004–2006 compared with 6% of adults with an income of 200% or more of the poverty level (data table for Figure 10).

Current asthma prevalence differs by race and ethnicity, independent of poverty status and sex. Non-Hispanic black and white adults report higher asthma prevalence rates (7%–8%) than Hispanic and Asian adults (5%) (data table for Figure 10). When examining specific Hispanic populations, however, Hispanic persons of Puerto Rican ancestry had the highest prevalence of any group, with about 18% of women and 8% of men reporting current asthma (data table for Figure 10).

References

1.
CDC. National surveillance for asthma—United States, 1980–2004. MMWR. 2007;6(SS-8):1–54.
2.
Redd SC. Asthma in the United States: Burden and current theories. Environ Health Perspect. 2002;110(Supplement 4):557–60. [PMC free article: PMC1241205] [PubMed: 12194886]
3.
National Heart, Lung and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. 2007. Available from: http://www​.nhlbi.nih​.gov/guidelines/asthma/asthsumm.htm.
4.
CDC/NCHS. National Hospital Ambulatory Medical Care Survey (ED component). National Hospital Discharge Survey. unpublished analysis.

Limitation of Activity Due to Chronic Conditions: Children

Conditions associated with learning, emotional, behavioral, and developmental problems are leading causes of activity limitation among children.

Limitation of activity due to chronic physical, mental, or emotional conditions is a broad measure of health and functioning that gauges a child’s ability to engage in major age-appropriate activities. This measure of health is also related to a child’s need for special educational and medical services. The National Health Interview Survey identifies children with activity limitation through questions about specific limitations in activities such as play, self-care, walking, memory, and other activities, and the current use of special education or early intervention services. Estimates of the number of children with an activity limitation may differ depending on the type of limitations included and the methods used to identify them (1).

Between 1997 and 2006, the percentage of children with activity limitation was 7% (Table 58). In 2005–2006, the percentage of school-age children with activity limitation (8%) was double the percentage of preschoolers with activity limitation (4%). Most school-age children with activity limitation were identified as limited solely by their participation in special education (2).

In 2005–2006, chronic health conditions causing activity limitation in children varied by age (Figure 11). A speech problem, mental retardation, and asthma were identified by parents as the leading causes of activity limitation among preschool children. Learning disability and attention‐deficit/hyperactivity disorder (ADHD or ADD) were mentioned as important causes of activity limitation among all school-age children. Among younger school-age children, a speech problem was also reported as an important condition causing activity limitation. Among older school-age children, a mental, emotional, or behavioral problem (other than ADHD, mental retardation, or another developmental problem) was reported as an important condition causing activity limitation.

Figure 11

Figure 11

Limitation of activity caused by selected chronic health conditions among children, by age: United States, 2005–2006 Click here for spreadsheet version

References

1.
Newacheck PW, Strickland B, Shonkoff JP, et al. An epidemiologic profile of children with special health care needs. Pediatrics. 1998;102(1):117–23. [PubMed: 9651423]
2.
Federal Interagency Forum on Child and Family Statistics. America’s Children: Key National Indicators of Well-Being, 2007. Washington, DC: U.S. Government Printing Office; 2007. Available from: http://www​.childstats.gov/

Limitation of Activity Due to Chronic Conditions: Working-age and Older Adults

Arthritis and other musculoskeletal conditions are the most frequently reported cause of activity limitation among both working-age and older adults.

Chronic physical, mental, and emotional conditions can limit the ability of adults to perform important activities such as working and doing everyday household chores. With advancing age, an increasing percentage of adults experience limitation of activity. Estimates of the number of working-age and older adults with limitation of activity are important for determining current and future health care needs and associated costs (1).

Between 1997 and 2006, the percentage of non-institutionalized working-age adults 18–64 years of age reporting an activity limitation caused by a chronic health condition remained relatively stable (Table 58). In 2005–2006, the percentage of working-age adults who reported limitations ranged from 6% at age 18–44 years to 20% at age 55–64 years (2). Arthritis and other musculoskeletal conditions were the most frequently mentioned conditions causing limitation among working-age adults of all ages in 2005–2006 (Figure 12). Among adults 18–44 years of age, mental illness was the second leading cause of activity limitation. Among adults 45–64 years of age, heart and circulatory conditions were the second leading cause of limitation. Other frequently mentioned conditions included mental illness and diabetes.

Figure 12

Figure 12

Limitation of activity caused by selected chronic health conditions among working-age adults, by age: United States, 2005–2006 Click here for spreadsheet version

Between 1997 and 1999, the percentage of non-institutionalized adults 65 years and over with limitation of activity decreased. Between 2000 and 2006, the percentage was relatively stable (Table 58). In 2005–2006, the percentage of older adults with limitation of activity ranged from 25% of 65–74 year olds to 60% of adults 85 years old and over (2). Arthritis and other musculoskeletal conditions were the most frequently mentioned chronic conditions causing limitation of activity (Figure 13). Heart and circulatory conditions were the second leading cause of activity limitation. Among noninstitutionalized adults 85 years and over, senility or dementia, vision conditions, and hearing problems were frequently mentioned causes of activity limitation.

Figure 13

Figure 13

Limitation of activity caused by selected chronic health conditions among older adults, by age: United States, 2005–2006 Click here for spreadsheet version

References

1.
Kramarow E, Lubitz J, Lentzner H, Gorina Y. Trends in the health of older Americans, 1970–2005. Health Affairs. 2007;26:1417–25. [PubMed: 17848453]
2.
CDC/NCHS. National Health Interview Survey. unpublished analysis.

Mortality

Life Expectancy

The gap in life expectancy at birth between white persons and black persons persists, but has narrowed since 1990.

Life expectancy is a measure often used to gauge the overall health of a population. As a summary measure of mortality, life expectancy represents the average number of years of life that could be expected if current death rates were to remain constant. Shifts in life expectancy are often used to describe trends in mortality. Life expectancy at birth is strongly influenced by infant and child mortality. Life expectancy later in life reflects death rates at or above a given age and is independent of the effect of mortality at younger ages (1).

From 1900 through 2005, life expectancy at birth increased from 46 to 75 years for men and from 48 to 80 years for women (Table 26). Life expectancy at age 65 also increased during this period (2). Among men, life expectancy at age 65 rose from 12 to 17 years and among women from 12 to 20 years from 1900 through 2005. In contrast to life expectancy at birth, which increased sharply early in the 20th century, life expectancy at age 65 improved primarily after midcentury. Improved access to health care, advances in medicine, healthier lifestyles, and better health before age 65 are factors underlying decreased death rates among older Americans.

In 2005, life expectancy at birth was 76 years for white males compared with 70 years for black males and 81 years for white females compared with 77 years for black females (data table for Figure 14). Life expectancy at birth increased more for the black than for the white population between 1990 and 2005 (Figure 14). During this period, the gap in life expectancy between white males and black males narrowed from 8 years to 6 years (data table for Figure 14). During the same period, the gap in life expectancy between white females and black females decreased from 6 years to 4 years.

Figure 14

Figure 14

Life expectancy at birth and at 65 years of age, by race and sex: United States, 1970–2005 Click here for spreadsheet version

The gap in life expectancy between white and black people at age 65 is narrower than at birth. Between 1990 and 2005, the difference in life expectancy at age 65 between white males and black males remained stable at 2 years. In 2005, life expectancy at age 65 was 17 years for white males and 15 years for black males. The difference in life expectancy between white and black females has also been stable in recent years; in 2005, at age 65, white females and black females could expect to live an additional 20 and 19 years, respectively.

References

1.
Arriaga EE. Measuring and explaining the change in life expectancies. Demography. 1984;21(1):83–96. [PubMed: 6714492]
2.
Fried LP. Epidemiology of aging. Epidemiol Rev. 2000;22(1):95–106. [PubMed: 10939013]

Infant Mortality

After declining substantially between 1950 and 2000, infant, neonatal, and postneonatal mortality rates have remained constant in recent years.

The infant mortality rate, the risk of death during the first year of life, is related to the underlying health of the mother, public health practices, socioeconomic conditions, and availability and use of appropriate health care for infants and pregnant women. Disorders related to short gestation and low birthweight and congenital malformations are the leading causes of death during the neonatal period (less than 28 days of life). Sudden Infant Death Syndrome (SIDS) and congenital malformations rank as the leading causes of infant deaths during the postneonatal period (28 days through 11 months of life) (1). Results from a new analysis of preterm-related causes of death show that 37% of infant deaths in 2004 were due to preterm-related causes (2).

There has been little progress in lowering the U.S. infant mortality rate from 2000–2005. In 2005, the infant mortality rate was 6.87 infant deaths per 1,000 live births—which is not statistically different than the rate in 2004 (6.79) (Figure 15) (3). The 2005 infant mortality rate was 76% lower than in 1950, due to annual declines in the infant mortality rate from 1960–2000.

Figure 15

Figure 15

Infant, neonatal, and postneonatal mortality rates: United States, 1950–2005 Click here for spreadsheet version

Infant mortality rates have declined for most racial and ethnic groups, but large disparities among the groups remain. During 1995–2004, the infant mortality rate was consistently highest for infants of non-Hispanic black mothers. Infant mortality rates were also high among infants of American Indian or Alaska Native mothers and Puerto Rican mothers. Infants of mothers of Cuban origin had the lowest infant mortality rates (2).

References

1.
Heron M. National vital statistics reports. Hyattsville, MD: NCHS; 2007. Deaths: Leading causes for 2004. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr56/nvsr56_05.pdf. [PubMed: 18092547]
2.
Mathews TJ, MacDorman MF. National vital statistics reports. Hyattsville, MD: NCHS; 2007. Infant mortality statistics from the 2004 period linked birth/infant death data set. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr55/nvsr55_14.pdf. [PubMed: 17569269]
3.
Kung HC, Hoyert DL, Xu JQ, Murphy SL. National vital statistics reports. Hyattsville, MD: NCHS; 2008. Deaths: Final data for 2005. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr56/nvsr56_10.pdf.

Leading Causes of Death for All Ages

Mortality from heart disease, stroke, and unintentional injuries is substantially lower than in 1950.

In 2005, a total of 2.4 million deaths were reported in the United States (Table 30). The overall age-adjusted death rate was 45% lower in 2005 than in 1950. The reduction in overall mortality since 1950 was driven mostly by declines in mortality for such leading causes of death as heart disease, stroke, and unintentional injuries (Figure 16).

Figure 16

Figure 16

Death rates for leading causes of death for all ages: United States, 1950–2005 Click here for spreadsheet version

In 2005, the age-adjusted death rate for heart disease, the leading cause of death, was 64% lower than the rate in 1950 (Table 35). The age-adjusted death rate for stroke, the third leading cause of death, declined 74% since 1950 (Table 36). Heart disease and stroke mortality are associated with risk factors such as high cholesterol, high blood pressure, smoking, and dietary factors. Other important factors include socioeconomic status, obesity, and physical inactivity. Factors contributing to the decline in heart disease and stroke mortality include better control of risk factors, improved access to early detection, and better treatment and care, including new drugs and expanded uses for existing drugs (1).

Overall age-adjusted death rates for cancer, the second leading cause of death, rose between 1960 and 1990 and then reversed direction (Table 37). Between 1990 and 2005, overall death rates for cancer declined 15%. The trend in the overall cancer death rate reflects the trend in the death rate for lung cancer (Table 38). Since 1970, the death rate for lung cancer for the total population has been higher than the death rate for any other cancer site.

Chronic lower respiratory diseases (CLRD) were the fourth leading cause of death in 2005. The age-adjusted death rate for CLRD in 2005 was 53% higher than the rate in 1980 (Table 40).

The fifth leading cause of death in 2005 was unintentional injuries. Age-adjusted death rates for unintentional injuries declined during the period 1950–1992 (Table 28). Since 1992, the unintentional injury mortality rate has gradually increased. Despite recent increases, the death rate for unintentional injuries in 2005 was still 50% lower than the rate in 1950.

Reference

1.
CDC. Achievements in public health 1990–1999: Decline in deaths from heart disease and stroke—United States, 1990–1999. MMWR . 1999. pp. 649–56. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm4830a1.htm. [PubMed: 10488780]

Health Insurance and Expenditures

Health Insurance Coverage at the Time of Interview

Between 1999 and 2006, the percentage of people under age 65 with private health insurance declined while enrollment in public coverage programs expanded, leaving the uninsured rate unchanged.

Health insurance coverage is an important determinant of access to health care (1). Uninsured children and adults under 65 years of age are substantially less likely to have a usual source of health care or a recent health care visit than their insured counterparts (Tables 78, 79 and 83). Uninsured people are more likely to forego needed health care because they cannot afford it (Table 80). The major source of coverage for persons under 65 years of age is private employer-sponsored group health insurance. Private health insurance may also be purchased on an individual basis, but is generally more costly and tends to provide less adequate coverage than group health insurance. Public programs such as Medicaid and the State Children’s Health Insurance Program (SCHIP) provide coverage for many low-income children and adults. Almost all adults age 65 and over are covered by the Medicare program, resulting in very few older adults without health insurance. Medicare enrollees may obtain additional private or public coverage to supplement their Medicare benefit package.

Between 1984 and 1994, private coverage declined among people under 65 years of age while Medicaid enrollment and the percentage with no health insurance increased (Figure 17, Appendix II, Health insurance coverage). After rising to 73% in 1999, the percentage with private health insurance has declined each year, reaching 66% in 2006. This decrease has been offset by an increase in the percentage with Medicaid or SCHIP, resulting in little change in the percentage of persons under age 65 who were uninsured.

Figure 17

Figure 17

Health insurance coverage at the time of interview among persons under 65 years of age: United States, 1984–2006 Click here for spreadsheet version

In recent years, 16%–17% of people under 65 years had no health insurance at the time of their interview. In 2006, cost was cited by more than one-half of these uninsured as the reason for their lack of coverage (2). Other reasons given were having lost a job or a change in employment (23%), Medicaid benefits stopped (11%), and ineligibility for family insurance coverage due to age or leaving school (9%).

References

1.
Institute of Medicine. Series of reports: Coverage matters: Insurance and health care; Care without coverage; Health insurance is a family matter; A shared destiny: Community effects of uninsurance; Hidden costs, value lost: Uninsurance in America. Washington, DC: National Academy Press; Committee on the consequences of uninsurance; pp. 2001–2003.
2.
Adams PF, Lucas JW, Barnes PM. Summary health statistics for the U.S. population: National Health Interview Survey, 2006. NCHS. Vital health stat. 2007. Available from: http://www​.cdc.gov/nchs​/data/series/sr_10/sr10_236.pdf. [PubMed: 18624012]

Length of Time Without Health Insurance Coverage

People of Mexican origin are more likely than those in other racial or ethnic groups to be uninsured for more than 12 months.

Many people under age 65, particularly those with low income, do not have health insurance coverage consistently throughout the year. Reasons for discontinuities in coverage may include loss or change of employment and financial reversals, divorce, births and other changes in life circumstances, and migration between states. To estimate the percentage of people without coverage at a point-in-time, respondents to the National Health Interview Survey (NHIS) were asked whether they had health insurance at the time of their interview (Figure 17) (see Appendix II, Health insurance coverage). To estimate the percentage without coverage for different lengths of time those covered by health insurance at the time of interview were asked whether there was any time during the 12 months prior to the interview when they did not have health insurance and those who were uninsured at the time of interview were asked how long it had been since they last had health coverage (Figure 18).

Figure 18

Figure 18

Uninsured for at least part of the 12 months prior to interview among persons under 65 years of age, by length of time uninsured and selected characteristics: United States, 2006 Click here for spreadsheet version

In 2006, 21% of people under 65 years of age reported being uninsured for at least part of the 12 months prior to interview. Among those who reported any time without insurance coverage during the 12 months prior to interview, the majority reported being uninsured for more than 12 months. About 12% of people under 65 years reported being uninsured for more than 12 months, 8% reported being uninsured for any period up to 12 months, and 1% reported being uninsured and had missing data for the length of time they were uninsured (data table for Figure 18).

Children under 18 years of age were less likely to be uninsured than were adults because low income children are eligible for public programs such as SCHIP designed specifically for them. The percentage of adults under 65 years of age without health insurance coverage decreased with age (Figure 18). In 2006, adults 18–34 years of age were more likely than adults age 55–64 years to lack coverage for at least part of the 12 months prior to interview (34%–36% compared with 13%). About 20% of persons 18–34 years of age lacked coverage for more than 12 months.

More than one-third of people with low family income (less than twice the poverty level) had no health insurance coverage for at least part of the 12 months prior to interview compared with 14% of those with higher family income. More than one-fifth of people in these lower income families were uninsured for more than 12 months, compared with 7% of people in higher income families. People of Mexican origin were more likely than those in any other racial or ethnic group to be uninsured for at least part of the 12 months prior to interview. In 2006, 42% of Mexican-origin people lacked coverage for at least part of the 12 months prior to interview with 32% lacking coverage for more than 12 months.

Health Care Expenditures

In 2006, the largest shares of personal health care expenditures were paid by private health insurance and the federal government.

In 2006, the United States spent 16% (up from 14% in 2000) of its Gross Domestic Product (GDP) on health care, a greater share than any other developed country for which data are collected by the Organisation for Economic Co-operation and Development (Tables 123 and 124).

In 2006, the United States spent $2.1 trillion on health care, an average of $7,026 per person (Table 124). Personal health care expenditures, a component of national health expenditures that includes spending for hospital care, physician services, prescription drugs, nursing home care, dental care, and other types of medical care, accounted for 84% of national health expenditures in 2006. The remaining 16% was spent on administration, government public health activities, research, and structures and equipment (Table 127) (1).

Private health insurance paid for 36% of total personal health expenditures in 2006, the federal government 35%, state and local government 10%, and out-of-pocket payments 15% (Figure 19). The share of personal health care expenditures paid out-of-pocket decreased from 27% in 1980 to 15% in 2006 (Table 128). This decrease resulted from an expansion of benefits in both private health insurance plans and government programs. Despite the decrease in the share of health care expenditures paid out-of-pocket, the growth in health care costs over recent years means that consumers may still have significant out-of-pocket expenditures for their health care.

Figure 19

Figure 19

Personal health care expenditures, by source of funds and type of expenditures: United States, 2006 Click here for spreadsheet version

In 2006, 37% of personal health care expenditures were for hospital care, 25% for physician services, 12% for prescription drugs, 7% for nursing home care, and the remaining 18% for other personal health care, including visits to nonphysician medical providers, medical supplies, and other health services (Figure 19). Prescription drug spending increased by 9% in 2006, partly as a result of the implementation of Medicare Part D, a Medicare expansion that partially finances prescription drugs for the elderly and disabled. The share of total personal health care expenditures devoted to hospital care decreased from 47% in 1980 to 37% in 2006 and the prescription drug expenditures share more than doubled from 6% to 12% over the same period, reflecting the shift in health care from inpatient to ambulatory care settings and the increasing contribution of prescription drugs to health care services and spending (calculated from Table 127).

Reference

1.
Catlin A, Cowan C, Hartman M, Heffler S. the National Health Expenditure Accounts team. National health spending in 2006: A year of change for prescription drugs. Health Aff (Millwood). 2008;27(1):14–29. [PubMed: 18180476]

Per Capita Personal Health Care Expenditures by State of Residence

In 2004, per capita personal health care expenditures varied by state from a high of $6,700 per Massachusetts resident to a low of $4,000 per Utah resident.

Personal health care expenditures, a component of national health expenditures, includes spending for hospital care, physician services, prescription drugs, nursing home care, dental care, medical products and devices, and other types of health care that are used directly by patients (see Appendix II, Health expenditures, national). State health expenditure data provide state-specific personal health care spending trends by service, using consistent definitions and methodologies that allow for comparisons across time and across states (1). These expenditures have been assigned to the state of residence of the patient rather than the state where the expenditures occurred. Many medical facilities are used by out-of-state residents attracted by the services offered and specialist availability, as well as travel convenience, so significant border-crossing to obtain medical care exists.

In 2004, per capita personal health care expenditures averaged $5,300 for each U.S. resident. There was, however, a wide range of expenditures by state from $4,000 for each Utah resident to $6,700 for each Massachusetts resident (data table for Figure 20). The states with the highest spending per resident were concentrated in the New England region ($6,400 on average) and the Mideast region ($6,200) (Figure 20). These two regions contained eight of the ten states and the District of Columbia with the highest per capita spending on health care. The states with the lowest levels of spending were concentrated in the Southwest, Rocky Mountains, and Far West regions of the country. Alaska was an exception to the low spending prevalent in the Far West region.

Figure 20

Figure 20

Per capita personal health care expenditures, by state of residence: United States, 2004 Click here for spreadsheet version

Suggested reasons underlying state per capita differences in health care expenditures are varied. They include the age, health, and income distribution of the state population; the supply of health facilities and health care providers; differences in utilization patterns; differential prices of health care services; the distance necessary to travel to obtain medical care that may reduce access to medical care in rural states and cause residents to receive less medical care; and differences in Medicaid spending (2). Variations in the level of expenditures in Medicaid publicly-funded health care programs may contribute to these state differences. Medicaid is a joint federal and state program for the poor, and within certain guidelines states determine their own eligibility rules and services covered for Medicaid as well as their payment rates to medical care providers. Consequently, Medicaid expenditures vary widely by state (Table 150). The pattern of lower expenditures in the Southwest, Rocky Mountains, and Far West regions of the United States is similar to that observed for health insurance coverage with lower rates of health insurance coverage in these regions (Table 140). People with no health insurance have lower health care expenditures than those who are covered by insurance (Table 151), adding to state spending differences.

References

1.
Centers for Medicare & Medicaid Services. State health expenditure accounts, by state of residence: Data sources & methods. Available from: http://www​.cms.hhs.gov​/NationalHealthExpendData​/downloads/res-methodology.pdf.
2.
Martin AB, Whittle L, Heffler S, Barron MC, Sisko A, Washington B. Health spending by state of residence, 1991–2004. Health Affairs web exclusive. 2007 18 Sep;

Utilization of and Access to Health Care

Attention-Deficit/Hyperactivity Disorder

Physician office and hospital outpatient department visit rates for attention-deficit/hyperactivity disorder (ADHD) were about three times higher for boys than for girls age 4–17, and visit rates for both boys and girls increased about 70% between 1996–1998 and 2004–2006.

Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder characterized by pervasive inattention and hyperactivity-impulsivity that is usually diagnosed in childhood (1). Symptoms often occur with other conditions, such as learning disabilities, anxiety disorders, and oppositional defiant disorder (2). Children with ADHD often have trouble in school and with peer and family relationships (3). ADHD can persist into adulthood, and adolescents and adults with ADHD have a higher prevalence of substance abuse disorders, risky sexual behavior, and a history of accidents (2). Although the causes of ADHD are not fully understood, there appears to be a strong genetic component to development of the disorder (3).

In 2003, one study found that 8% of U.S. children age 4–17 years had ever been diagnosed with ADHD, with boys having more than twice the rate of girls (11% versus 4%) (1). Prevalence estimates of ADHD in the United States vary widely though the pattern of increased prevalence among boys is consistently found (2).

Management of ADHD includes psychosocial interventions— such as parent and school-based interventions—and pharmaceutical management (3). The most commonly used medications are stimulants (3). About 4% of U.S. children age 4–17 years or 56% of those ever diagnosed with ADHD were taking medication to treat ADHD in 2003 (1). High prescription medication use and the need for behavioral interventions among children with ADHD lead to frequent interaction with the health care system.

From 1996–1998 to 2004–2006, visits to physician offices and hospital outpatient departments for which ADHD was the primary diagnosis at the visit increased from 5.4 visits to 9.2 visits per 100 children age 4–17 years (data table for Figure 21). Over this same period, among boys, ADHD visits increased from 8.0 to 13.9 visits per 100 children and among girls, from 2.6 to 4.4 visits per 100 children (Figure 21).

Figure 21

Figure 21

Visits to physician offices and hospital outpatient departments for attention-deficit/hyperactivity disorder (ADHD) among children 4–17 years of age, by sex and age: United States, 1996–2006 Click here for spreadsheet version

The highest rates of ADHD visits were among children 9–12 years of age (Figure 21). Visits in this age group increased from 8.4 to 13.8 visits per 100 children from 1996–1998 to 2004–2006 (Figure 21). Increases were seen in all children age 4–17 years over this time period (Figure 21). The reasons for these increases are not well understood, although increased availability and acceptability of pharmaceuticals to treat ADHD, as well as access to special education services due to coverage of ADHD under the Individual Disability Education Act of 1990 (ADHD was not included in the list of covered services until 1991), may have led to heightened awareness and acceptability of the diagnosis (4).

References

1.
CDC. Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder—United States, 2003. MMWR. 2005;54(34):842–7. [PubMed: 16138075]
2.
Rowland AS, Lesene CA, Abramowitz AJ. The epidemiology of attention-deficit/hyperactivity disorder (ADHD): A public health view. Mental retardation and developmental disabilities research reviews. 2002;8:162–70. [PubMed: 12216060]
3.
Katragadda S, Schubiner H. ADHD in children, adolescents and adults. Prim Care Clinic Office Prac. 2007;34:317–41. [PubMed: 17666230]
4.
Olfson M, Gameroff MJ, Marcus SC, Jensen PS. National trends in the treatment of attention deficit hyperactivity disorder. Am J Psychiatry. 2003;160:1071–7. [PubMed: 12777264]

Principal Reasons for Emergency Department Visits

The most frequently reported principal reasons given by adults for visiting the emergency department (ED) in 2006 were stomach and abdominal pain, chest pain, headache, and cough.

Hospital emergency departments (EDs) provide unscheduled care for a wide variety of reasons that range from life-threatening conditions to nonurgent problems that could be treated in a primary care setting. Over the past two decades, there has been an increasing demand for emergency services, resulting in ED overcrowding and ambulance diversions (1,2). In 2006, 119.2 million visits (40.5 visits per 100 persons) were made to emergency departments, a 24% increase over the 96.5 million visits made in 1995 (Table 94). Between 1995 and 2006, the overall ED utilization rate increased by 10%, from 36.9 to 40.5 visits per 100 persons. During the same period, the number of hospital emergency departments decreased about 9% (1).

The National Hospital Ambulatory Medical Care Survey (NHAMCS) collects data on the utilization and provision of ambulatory care services in hospital emergency departments. The patient’s main complaint, symptom, or other reason for visiting the ED was coded according to A Reason for Visit Classification for Ambulatory Care (RVC) coding typology (3). In 2006, the most frequently reported principal reasons given by adults 18 years of age and over for visiting the ED were stomach and abdominal pain, chest pain, headache, and cough. Together these four principal reasons for ED visits accounted for almost one-fifth of all ED visits by adults in 2006 (4).

Among adults, the principal reasons for visiting the ED varied by age (Figure 22). Chest pain was the most frequently reported reason by adults 65 years of age and over. For young adults 18–29 years of age, abdominal pain was the most frequently reported principal reason for visiting the ED. Younger adults came into the ED for headaches more frequently than older adults. In contrast, fever, which was not a common reason for visit among adults, was the most common reason among children (data table for Figure 22).

Figure 22

Figure 22

Selected principal reasons for emergency department visits among adults 18 years of age and over, by age: United States, 2006 Click here for spreadsheet version

References

1.
Nawar EW, Niska RW, Xu J. Advance data from vital and health statistics. Hyattsville, MD: NCHS; 2007. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. no. 386. [PubMed: 17703794]
2.
American Academy of Pediatrics: Committee on Pediatric Emergency Medicine. Overcrowding crisis in our nation’s emergency departments: Is our safety net unraveling? Pediatrics . Sep, 2004. pp. 878–88. Available from: http://pediatrics​.aappublications​.org/cgi​/content/full/114/3/878#SEC1. [PubMed: 15342870]
3.
Schneider D, Appleton L, McLemore T. Vital health stat. 78. Vol. 2. Hyattsville, MD: NCHS; 1979. A reason for visit classification for ambulatory care. [PubMed: 433160]
4.
CDC/NCHS. National Hospital Ambulatory Medical Care Survey. unpublished analysis.

Dental Visits for Teeth Cleaning

In 2003–2004, 61% of people 2 years of age and over reported having their teeth cleaned by a dentist or dental hygienist within the past year.

Regular dental visits are important for early diagnosis, prevention, and treatment of oral diseases, as well as assessment of self-care practices. The American Academy of Pediatric Dentistry emphasizes the importance of initiating professional oral health intervention in infancy and continuing through adolescence and beyond (1,2). People who have their teeth cleaned by a dental professional at least once a year are less likely to have plaque, gingivitis, and calculus than people reporting less frequent visits (3). The recommended frequency of professional teeth cleaning depends on the health of an individual’s teeth and gums. Healthy children and adults should have their teeth cleaned at least once every 12–24 months (4).

In the 2003–2004 National Health and Nutrition Examination Survey (NHANES), respondents were asked how long it has been since they had their teeth cleaned by a dentist or dental hygienist. This analysis includes those with at least one natural tooth.

Sixty-one percent of persons 2 years of age and over reported having a dental cleaning in the past year (Figure 23). Females were more likely than males to have had their teeth cleaned in the past year (65% compared with 57%). Children 2–17 years of age were more likely than adults to have their teeth cleaned in the past year (79% compared with 51%–65%). Older adults 65 years of age and over were more likely to have their teeth cleaned than younger adults 18–44 years old. One-third of persons 75 years of age and over and one-fourth of persons 65–74 years old were edentulous (without any teeth); they were excluded from the denominators of percentages.

Figure 23

Figure 23

Dental visits for teeth cleaning by a dentist or dental hygienist in the past year among persons 2 years of age and over, by selected characteristics: United States, 2003–2004 Click here for spreadsheet version

Professional teeth cleaning varied substantially by family income and race and ethnicity. Non-Hispanic white people were more likely to see a dental professional for a cleaning in the past year than non-Hispanic black or Mexican-origin people (Figure 23). People with a family income of at least 200% of poverty were more likely to have had a dental visit for cleaning in the past year than people living below 200% of poverty (68% compared with 47%–50%). People 2 years of age and over living in families with family income below 200% of poverty were more than twice as likely to report delaying visits to dentists due to cost (16%–17% for people living in families with family income below 200% of poverty compared with 7% for family income of 200% of poverty or more) (5).

References

1.
U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institute of Health; 2000.
2.
Lewis DW, Ismail AI. Periodic health examination, 1995 Update: 2. Prevention of dental caries. Canadian Task Force on the Periodic Health Examination. Can Med Assoc J. 1995;152:836–46. [PMC free article: PMC1337757] [PubMed: 7697577]
3.
Lang WP, Ronis DL, Farghaly MM. Preventive behaviors as correlates of periodontal health status. Journal of Public Health Dentistry. 1995;55(1):10–7. [PubMed: 7776285]
4.
CDC/NCHS. National Oral Health Surveillance System: Frequently Asked Questions. Available from: http://www​.cdc.gov/nohss/index.htm.
5.
CDC/NCHS. National Health Interview Survey. unpublished analysis.

Influenza and Pneumococcal Vaccination Among Middle-age and Older Adults

Between 1989 and 2006, influenza and pneumococcal vaccination levels increased substantially but differences by age remain.

Vaccination of persons at risk for complications from influenza is a key public health strategy for preventing morbidity and mortality in the United States. In the United States, annual epidemics of influenza occur typically during the winter season (1). It is estimated that during 1990–1999, approximately 36,000 of the respiratory and circulatory deaths that occurred each year were associated with influenza (1). During 1979–2001, an estimated 226,000 of the primary respiratory and circulatory hospitalizations that occurred each year on average were associated with influenza (2).

In April 2000, the Advisory Committee on Immunization Practices (ACIP) recommended that all adults 50 years of age and over receive an annual influenza vaccination (3). In response to the unexpected shortfall in the 2000–2001 and 2004–2005 influenza vaccine supply, the ACIP and the Centers for Disease Control and Prevention modified the universal recommendation for influenza vaccination among adults 50 years of age and over, and established vaccine priority groups. These groups included persons 65 years of age and over, and children and adults with chronic underlying health conditions (4,5).

Between 1989 and 1997, influenza vaccine coverage among persons living in the community tripled for adults 50–64 years of age and approximately doubled for adults 65 years of age and over (Figure 24). Between 1997 and 2004, influenza vaccine coverage remained essentially stable. As a result of the 2004–2005 influenza vaccine shortage, 2005 estimates of vaccine coverage decreased among adults 50–64 years, 65–74 years, and 75–84 years of age and were unchanged among adults 85 years of age and over. In 2006, influenza vaccine coverage generally returned to the 2004 level. Influenza vaccine coverage increases with older age; persons 85 years of age and over were twice as likely as those 50–64 years of age to have had a vaccination in the past 12 months in 2006.

Figure 24

Figure 24

Influenza and pneumococcal vaccination among middle-age and older adults, by age: United States, 1989–2006 Click here for spreadsheet version

Pneumococcal infection is a serious disease that kills more people in the United States each year than any other vaccine-preventable bacterial disease (6). Each year in the United States, pneumococcal infection causes an estimated 40,000 deaths with the highest mortality rates among older persons and those with underlying medical conditions. A one-time pneumococcal polysaccharide vaccine has been recommended by the ACIP for all adults 65 years of age and over since 1997.

Between 1989 and 2002 the percentage of non-institutionalized adults 65 years of age and over who reported ever having received a pneumococcal vaccination increased from 14% to 56% and then remained level through 2006 (Figure 24). Pneumococcal vaccination coverage has remained consistently below that of influenza vaccination coverage. Pneumococcal vaccination rates were lower among adults 65–74 years of age than for older adults, and at a similar level among adults 75–84 years and 85 years of age and over.

References

1.
Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003;289:179–86. [PubMed: 12517228]
2.
Thompson WW, Shay DK, Weintraub E, Brammer L, Bridges CB, Cox NJ, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333–40. [PubMed: 15367555]
3.
CDC. Prevention and control of influenza: Recommendations of the advisory committee on immunization practices (ACIP). MMWR. 2007. pp. 1–60. Available from: http://www​.cdc.gov/mmwr/PDF/rr/rr5606​.pdf. [PubMed: 17625497]
4.
CDC. Notice to readers: Updated recommendations from the advisory committee on immunization practices in response to delays in supply of influenza vaccine for the 2000–01 season. MMWR. 2000. pp. 888–92. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm4939a4.htm. [PubMed: 11055742]
5.
CDC. Interim influenza vaccination recommendations, 2004–05 influenza season. MMWR. 2004. pp. 923–4. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5339a6.htm. [PubMed: 15614237]
6.
CDC. Prevention of pneumococcal disease: Recommendations of the advisory committee on immunization practices (ACIP). MMWR. 1997. pp. 1–24. Available from: http://www​.cdc.gov/mmwr/PDF/rr/rr4608​.pdf. [PubMed: 9132580]

Pneumonia Hospitalizations Among Older Adults

Between 1979–1980 and 2005–2006, rates of hospitalizations with any-listed pneumonia diagnosis nearly doubled among persons 65 years of age and over.

Pneumonia deaths among older adults have declined markedly in the United States during the 20th century, but pneumonia remains an important cause of morbidity and mortality (1). In 2005, there were 54,000 pneumonia deaths among adults 65 years of age and over (2). Because pneumonia is one of the serious complications of influenza, annual influenza vaccination of adults age 50 and over is an important component of pneumonia prevention efforts (3, Figure 24, Table 87). Research also suggests that efforts to prevent pneumonia include controlling preventable comorbid health conditions such as chronic cardiac or pulmonary disease and diabetes (4).

Any-listed pneumonia hospitalizations are defined as those for which pneumonia was listed as any of the seven possible discharge diagnoses collected in the National Hospital Discharge Survey (see Appendix II, Table X for ICD–9–CM codes). This includes hospitalizations to treat community-acquired pneumonia in addition to hospitalizations during which pneumonia developed (nosocomial or hospital-acquired pneumonia). Any-listed pneumonia discharge rates measure the overall burden of pneumonia diagnosis and treatment during hospitalization.

Between 1979–1980 and 2005–2006, any-listed pneumonia discharge rates per 10,000 population nearly doubled among persons 65–74 years and increased more than 70% among persons 75–84 years and 85 years of age and over (Figure 25). By contrast, hospitalization rates for all causes among persons 65–84 years of age increased between 1979–1980 and 1983–1984, when Medicare initiated prospective payment for inpatient hospital services based on diagnosis-related groups (DRGs), and then declined and leveled off (data table for Figure 25). Among persons 85 years of age and over, hospitalization rates for all causes also increased from 1979–1980 until 1983–1984 and then declined only briefly before increasing to approximately pre-DRG levels.

Figure 25

Figure 25

Any-listed pneumonia discharges from nonfederal short-stay hospitals among persons 65 years of age and over, by age: United States, 1979–2006 Click here for spreadsheet version

Hospital discharge rates for any-listed pneumonia diagnosis increase with age among older persons (Figure 25). In 2005–2006, the any-listed pneumonia hospitalization rate among persons 85 years of age and over was more than three times that among persons 65–74 years of age.

Between 1979–1980 and 2005–2006, the share of all hospitalizations among persons age 65 years and over with an any-listed pneumonia diagnosis doubled (data table for Figure 25). In 2005–2006, pneumonia was listed as one of the seven possible discharge diagnoses for 9% of all hospital discharges among persons 65–74 years, 10% among persons 75–84 years, and 14% among persons 85 years of age and over.

References

1.
CDC. Achievements in public health, 1900–1999: Control of infectious diseases. MMWR. 1999;48(29):621–9. [PubMed: 10458535]
2.
Kung HC, Hoyert DL, Xu J, Murphy SL. National vital statistics reports. Hyattsville, MD: NCHS; 2008. Deaths: Final data for 2005. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr56/nvsr56_10.pdf. [PubMed: 18512336]
3.
CDC. Prevention and control of influenza: Recommendations of the advisory committee on immunization practices (ACIP). MMWR. 2000. pp. 1–38. Available from: http://www​.cdc.gov/mmwr/PDF/rr/rr4903​.pdf. [PubMed: 15580733]
4.
Fry AM, Shay DK, Holman RC, Curns AT, Anderson LJ. Trends in hospitalizations for pneumonia among persons aged 65 years or older in the United States, 1988–2002. JAMA. 2005;294(21):2712–9. [PubMed: 16333006]

Cesarean Delivery

Cesarean delivery rates increased by 45% between 1996 and 2005 among young women 18–29 years of age, the age group that accounts for the largest proportion of births in the United States.

The rate of cesarean delivery (c-section) has reached the highest point ever recorded in the United States. In 2006, the (preliminary) cesarean rate increased to 31.1 per 100 live births (1). After declining somewhat in the early and mid-1990s among women under 45 years of age, cesarean delivery rates have increased steadily since 1997. Among women 45 years of age and over, although c-section rates were consistently much higher than rates for younger women, rates fluctuated from 1990–1998, rose sharply from 1998–2002 and again fluctuated slightly during 2002–2005. By 2005, the c-section rate among women 45 years of age and over was nearly double the rate in 1990.

Cesarean delivery rates increased with increasing maternal age. Among women ages 45 years and older, the rate was more than twice that of women 18–29 years of age in 2005 (Figure 26). The higher cesarean delivery rates for older mothers in more recent years may be related to increased rates of multiple births in part due to the use of assisted reproductive technologies, their higher rates of complications during labor, and patient or practitioner concerns (2,3). Researchers have found that cesarean delivery for the diagnoses of failure to progress and fetal distress was more frequent in older women (2).

Figure 26

Figure 26

Cesarean delivery rates by maternal age: United States, 1990–2005 Click here for spreadsheet version

In 2005, 59% of all births and 68% of first births in the United States occurred among young women 18–29 years of age (4). With the recent steep rise in the cesarean rate among this age group (from 18.5 per 100 live births in 1996 to 26.8 in 2005), total cesarean rates are likely to rise further, as the overwhelming majority of women who have a first cesarean go on to have repeat cesareans with subsequent births (4).

Cesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Some cesarean deliveries are elective (no medical indication). The risks, benefits, and long-term consequences of cesarean delivery, especially for cesarean delivery with no medical or obstetrical indication are the subject of intense debate (5). A National Institutes of Health expert panel recently acknowledged a lack of national data or other studies on mothers’ preferences and recommended against cesareans that are not medically indicated for women desiring several children, and for pregnancies of less than 39 weeks of gestation (3).

References

1.
Hamilton BE, Martin JA, Ventura SJ. National vital statistics reports. 7. Vol. 56. Hyattsville, MD: NCHS; 2007. Births: Preliminary Data for 2006.
2.
Ecker JL, Chen KT, Cohen AP, et al. Increased risk of cesarean delivery with advancing maternal age: Indications and associated factors in nulliparous women. Am J Obstet Gynecol. 2001;185(4):883–7. [PubMed: 11641671]
3.
NIH. State-of-the Science Conference Statement on Cesarean Delivery on Maternal Request. NIH Consens Sci Statements ; Mar 27–29; 2006. pp. 1–29. [PubMed: 17308552]
4.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, et al. National vital statistics reports. 6. Vol. 56. Hyattsville, MD: NCHS; 2007. Births: Final data for 2005.
5.
Minkoff H, Powderly KR, Chervenak F, McCullough LB. Ethical dimensions of elective primary cesarean delivery. Obstet Gynecol. 2004;103(2):387–92. [PubMed: 14754712]

Special Feature: Young Adults Age 18–29 Years

Introduction

The period from age 18–29 years is a transitional period in terms of education, marital status, family structure, and employment; and a critical time when many behaviors and risk factors are established that will affect health status later in life.

The period from age 18–29 years is a period of transitions. Age 18 is often considered the advent of legal “adulthood.” Upon reaching age 18, young people can, with a few exceptions, vote, drive an automobile, marry without parental consent, be employed for pay, and in almost all but a few states enter into binding contracts. They can join the military and obtain credit (and debt) in their own names. They are tried and sentenced in criminal cases as adults. They can consent to medical procedures without parental consent or legal interference. At age 18 young adults can legally have consensual sex. By age 19 they can buy cigarettes and by age 21, young adults can legally buy and consume alcohol.

Yet the period starting with age 18 and spanning into the late twenties is also often considered just the beginning of a transition to adulthood, when young people seek to obtain financial and emotional independence (1,2). Financial and other support services previously provided to children by government-sponsored social programs, such as food assistance, Medicaid, State Children’s Health Insurance Programs (SCHIP), or school programs are reduced or terminated, often abruptly, as they age out of the programs. In addition, during this period young adults often transition from financial and other support, such as health insurance coverage, previously provided by parents. As parental and other adult oversight decreases, young people assume increasing responsibility for their own decisions. This includes decisions that will either directly affect their current and future health status—such as alcohol, cigarette, and illicit drug use or nonuse; sexual activity; childbearing; exercise; and eating habits—as well as decisions that will indirectly affect their future health. These decisions include whether to pursue higher education, which helps to determine future income; whether to work and type of employment, which is highly correlated with having health insurance coverage; whether to marry and/or to have children; and other decisions that help determine future income and lifestyle as well as affect the well-being of their families.

In 2007, the estimated 51 million people age 18–29 years, defined in this report as young adults, made up about 17% of the total resident population (3). About 49 million were in the civilian, noninstitutionalized population with the remainder in the group quarter population, including those living in college dormitories, military barracks, and prisons and jails (4, Table 2).

Like the rest of the United States population, the population age 18–29 is becoming more racially and ethnically diverse (5, Figure 2). The racial and ethnic composition of a population group has important consequences for health because many risk factors and diseases differ by race and ethnicity. Almost 19% of young adults are of Hispanic origin, compared with about 15% of the entire population (data table for Figure 27; Figure 2). The percentage of young adults who were not born in the United States is also increasing. A large number of foreign-born young adults are not naturalized citizens. Noncitizen foreign-born persons are disproportionately low income and uninsured (6). Additionally, noncitizen status affects access to government-sponsored social and health insurance programs. In 2007, 12% of young adults, 42% of Hispanic young adults, and 39% of Asian young adults were not citizens (7).

Young adults of both sexes are increasingly postponing marriage. In 1980, the median age at first marriage was 24.7 for men and 22.0 for women; by 2006 the median age had increased to 27.5 years for men and 25.5 years for women (8). In 2007, less than 3% of young adults age 18–19 were married and living with their spouse, increasing to 15% at age 20–24 years (Figure 27). By age 25–29 years, 41% were married (36% of men and 47% of women) (data table for Figure 27). This represents a substantial decline from 1980 when 62% of men and 70% of women age 25–29 years were married (9). Marriage rates also vary by race and ethnicity. In 2007, 9% of non-Hispanic black men 18–29 years of age were married compared with 21% of non-Hispanic white men, and 24% of Hispanic men. Differences by race and ethnicity are even larger for young adult women—in 2007, 12% of non-Hispanic black women, 30% of non-Hispanic white women, and 37% of Hispanic women age 18–29 years were married (data table for Figure 27).

Figure 27

Figure 27

Selected characteristics of young adults 18–29 years of age, by age: United States, 2007 Click here for spreadsheet version

Investment in postsecondary (past high school) education and training programs has been shown to be correlated with increased future income and more stable employment patterns (10). Decisions about postsecondary education— particularly college enrollment—are usually made between the ages of 18–24. Family income, and race and ethnicity can be influential in decisions about life course, particularly education and employment. College enrollment for all races, ethnicities, and income groups has increased over time (Figure 28). Young women are more likely to be enrolled in college than young men, and this gender enrollment gap has widened over time (11). College enrollment rates (immediately following high school graduation) also vary by family income. High school graduates from wealthier families are considerably more likely to be enrolled than poorer graduates, although college attendance for all income groups has increased over time (12). Among high school graduates in the bottom 20% of family income, college enrollment rates increased from 33% in 1980 to 54% in 2005; and for high school graduates in the highest 20% of family income college enrollment rates increased from 65% to 81% over the same time period.

Figure 28

Figure 28

School enrollment of young adults 18–29 years of age, by age: United States, 1980–2005 Click here for spreadsheet version

In 2005, two-thirds of young adults 18–19 years of age, one-half of 20–21 year-olds, more than one-quarter of 22–24 year-olds, and 12% of 25–29 year-olds were enrolled in school (of any type) (data table for Figure 28). Many more young adults under age 25 are enrolled in school than in past years, but the percentage of those 25–29 years of age enrolled in school has not increased substantially since 1980. Asian young adults are more likely than young adults in other racial and ethnic subgroups to be enrolled in school, especially those 20 years of age and over (data table for Figure 28).

As college enrollment rates have increased, there has been a corresponding decrease in high school status dropout rates (the percentage of 16–24 year olds who were not enrolled in high school and who lack a high school credential), from 14% in 1980 to 9% in 2005 (13). High school dropouts have lower earning potential and are more likely to be unemployed, or incarcerated, than high school graduates. In 2005, 22% of Hispanic youth age 16–24 years were considered dropouts compared with 10% of non-Hispanic black youth and 6% of non-Hispanic white youth.

Most young adults 18–29 years of age are employed for pay (about 66%) but only 42% are employed full-time, year round (data table for Figure 27). Full-time employment is a major source of private employer-sponsored health insurance coverage, although health insurance offerings vary widely by industry and firm size, and firms with a larger share of younger workers are less likely to offer health insurance than firms with a smaller share of younger workers (14). Young adults are less likely to be employed in firms that offer such insurance than are older adults. Hispanic males are the most likely young adult group to be employed full-time for a full year (58%), and young women of all races are less likely than young men of all races to be employed full-time (data table for Figure 27).

Young people who are neither working nor in school are considered to be at risk for future lower earnings and poverty, because they are neither investing in their education nor gaining work experience. In 2006, 13% of youth age 18–19 were disengaged (15). Non-Hispanic black and Hispanic youth age 16–19 are more likely to not be working and not in school than non-Hispanic white or Asian youth, and youth from poor and near poor families are more likely to be neither working nor in school than those from wealthier families.

Residents of prisons or jails are considered part of the civilian institutionalized population and thus not part of the labor force. Prisons are disproportionately, and increasingly, populated by young adults age 18–29 years. Between 1999 and 2006 there was a 15% increase in the number of young adult men, and a 25% increase in the number of young adult women in jail or prison (Table 2). Black young adults are particularly likely to be incarcerated. In 2006, about 5% of non-Hispanic black men age 18–19 years, 11% age 20–24 years, and 12% age 25–29 years were in prison or jail, compared with less than 2% of non-Hispanic white men and about 4% of Hispanic men in those age groups (Table 2).

Young adults take many paths to independence. The paths they take are strongly influenced both by their environment and their families’ income. Young adults today have more choices (or more perceived choices) about what course to pursue after age 17 than in past generations. They increasingly postpone marriage, and are more likely to experience a nonmarital birth. Today, young adults take many different, and often nonlinear, routes to adulthood and financial independence, with alternating periods of school and employment (or both school and employment, or neither), and moving in and out of their childhood homes and other living arrangements. As young adults become more independent, schools and family members become increasingly less influential in young adults’ decision-making.

The remainder of this Special Feature focuses on the health of young adults and the factors that influence it, and on their access to and utilization of health services. Poverty and nonmarital childbearing can delay education and delay or precipitate employment, and rates vary by age and race/ethnicity. Smoking and heavy drinking, use of illicit drugs, sexually transmitted diseases, and forced sexual activity are common risk factors during this life period and may have lasting effects on health. Although they are healthier than older adults, young adults are still subject to chronic diseases, activity limitations, and death, and need health care for various reasons. However, they are the age group least likely to have health insurance, and when they do need health care, they experience problems accessing the health care system. In addition to the data provided in the Special Feature, data on young adults age 18–29 are included along with data for other age groups in the first section of the Health, United States Chartbook, including data on overweight and obesity, leisure-time physical activity, principal reason for emergency department visits, dental cleanings, and cesarean section hospitalization rates.

The period between ages 18 and 29 sets the foundation for future health behaviors and health status, and may be the time in life when health education and preventive care may arguably have their greatest impact. Finding ways to target health education programs among this diverse group, however, is challenging.

References

1.
Arnett JJ. Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist. 2000;55(5):469–80. [PubMed: 10842426]
2.
Furstenberg FF Jr, Kennedy S, Mcloyd V, Rumbaut RG, Settersten RA Jr. Growing up is harder to do. Contexts. 2004;3(3):33–41.
3.
U.S. Census Bureau. Monthly postcensal resident population, by single year of age, sex, race, and Hispanic origin. July 1, 2007. Available from: http://www​.census.gov​/popest/national/asrh/2006_nat_res.html.
4.
U.S. Census Bureau. Census 2000 PHC-T-26. Population in group quarters by type, sex and age, for the United States, 2000. 2003. Available from http://www​.census.gov​/population/cen2000/phc-t26/tab01.xls.
5.
KewalRamani A, Gilbertson L, Fox M, Provasnik S. Status and trends in the education of racial and ethnic minorities (NCES 2007–039). Washington, DC: National Center for Education Statistics, Institute of Education Sciences, U.S. Department of Education; 2007. Available from: http://nces​.ed.gov/pubsearch/pubsinfo​.asp?pubid=2007039.
6.
Kaiser Commission on Medicaid and the Uninsured. Immigrant’s health care coverage and access. Washington, DC: Kaiser Family Foundation; Aug, 2003.
7.
U.S. Census Bureau. Current population survey table generator. Available from: http://www​.census.gov​/hhes/www/cpstc/cps_table_creator.html.
8.
U.S. Census Bureau. Current population survey, March and Annual social and economic supplements, 2006 and earlier. Estimated median age at first marriage, by sex: 1890 to the present. Available from: http://www​.census.gov​/population/socdemo/hh-fam/ms2.csv.
9.
U.S. Census Bureau. Statistical Abstract of the United States: 1981. 102d. Washington, DC: U.S Census Bureau; 1981.
10.
Day JC, Newburger EC. The big payoff: Educational attainment and synthetic estimates of work-life earnings. Current Population Reports . 2002. pp. P23–210. Available from: http://www​.census.gov​/prod/2002pubs/p23-210.pdf.
11.
Mather M, Adams D. The crossover in female-male college enrollment rates . Washington, DC: Population Reference Bureau; 2007. Available from: http://www​.prb.org/Articles​/2007/CrossoverinFemaleMaleCollegeEnrollmentRates​.aspx.
12.
U.S. Department of Education, National Center for Education Statistics. Condition of Education 2007. Table 25–1. Percentage of high school completers who were enrolled in college the October immediately following high school completion, by family income and race/ethnicity. 1972–2005. Available from: http://nces​.ed.gov/programs​/coe/2007/section3/table​.asp?tableID=702.
13.
Laird J, DeBell M, Kienzl G, Chapman C. Dropout rates in the United States: 2005. U.S. Department of Education, National Center for Education Statistics; 2007. Available from: http://nces​.ed.gov/pubsearch/pubsinfo​.asp?pubid=2007059.
14.
Claxton G, DiJulio B, Finder B, Becker E. The Kaiser Family Foundation and Health Research and Educational Trust. Employer health benefits 2007 annual survey. Available from: http://www​.kff.org/insurance​/7672/upload/76723.pdf.
15.
U.S. Department of Education, National Center for Education Statistics. Condition of Education 2007. Indicator 19: Percentage of youth ages 16–19 who were neither enrolled in school nor working, by selected characteristics: Selected years 1986–2006. Available from: http://nces​.ed.gov/programs​/coe/2007/section2/table​.asp?tableID=694.

Poverty and Low Income

One-half of black and Hispanic young adults live below 200% of the poverty line, compared with less than one-third of white and Asian young adults.

Most 18-year olds are starting on their path to independent living with few skills and little job experience. They often start out with low (or no) income, with the hope that their education—for those who receive postsecondary education— will enable them to obtain better paying jobs, or that employment experience will increase their earnings over time. Young adults age 18–24 years are most likely of all people age 18 and over to have family income that classifies them as below the poverty threshold, or to be near poor (defined as 100%–less than 200% of the poverty threshold) (1). More than one-third of young adults 18–29 years (36%) were poor or near poor in 2004–2006 (data table for Figure 29). The group age 18–24 years is more likely to be poor or near poor (38%) than those age 25–29 years (33%).

The distribution of family income for young adults by race and ethnicity mirrors the distribution of income for the whole population by race and ethnicity (Figure 5). There is also evidence that children’s subsequent economic position is heavily influenced by the economic position of their parents (2). About 12% of all Americans live below the poverty threshold and 18% are near poor, compared with 16% of young adults who are poor and 20% who are near poor (data tables for Figures 5 and 29). Even if young adults are not living with parents, their families often provide financial assistance, with wealthier families providing more economic support than less wealthy families (3).

Education is a major path out of poverty and near poverty status (4). Simulations of lifetime earnings estimate that people with no high school degree earn an average of $18,900 per year over their lifespan, $25,900 for those with a high school diploma, $45,400 for those with bachelor’s degrees, and $99,300 for those with professional degrees (earnings are in constant 1999 dollars). Men of all ages, however, earn more than women at each education level. Average earnings also vary by race and ethnicity, with non-Hispanic white adults earning more than non-Hispanic black or Hispanic adults at almost every educational attainment level (4).

With the exception of young Asian adults, young adult women are more likely to live in poverty than are young adult men in each racial and ethnic group (Figure 29). This relationship holds even though young women are more likely to graduate from high school and to attend college (5). Among racial and ethnic groups examined, non-Hispanic black women (31%) were the most likely of the young adult groups to be poor, followed by Hispanic women (25%). Non-Hispanic white and non-Hispanic Asian women were significantly less likely to be poor (15%) (Figure 29).

Figure 29

Figure 29

Low income among young adults 18–29 years of age, by sex, race and Hispanic origin: United States, 2004–2006 Click here for spreadsheet version

High school dropouts are disproportionately represented in the prison population and prison stays may also impact future employment and income opportunities (6–8). Forty percent of state prison inmates and one-quarter of federal inmates did not have a high school degree or its equivalent (7).

Differentials in wages by race and ethnicity also contribute to higher poverty rates among black and Hispanic young adults, compared with non-Hispanic white and Asian young adults (9). A gap in earnings by gender across racial and ethnic group persists, but has been narrowing (10). In addition, nonmarital childbearing is associated with lower earnings (11). These three factors combined help to explain higher poverty rates among non-Hispanic black and Hispanic young adult women (Figure 30).

Figure 30

Figure 30

Live birth rates for unmarried women 18–29 years of age, by age, race and Hispanic origin: United States, 1990–2005 Click here for spreadsheet version

References

1.
Current Population Survey. Data table: People in families by relationship to householder, age of householder, number of related children present, and family structure: 2006, Below 100% of poverty—All races. Available from: http://pubdb3​.census​.gov/macro/032007/pov/new05_100_01.htm.
2.
Isaacs J. Economic mobility of families across generations. Economic mobility project, Executive summary. Available from: http://www​.economicmobility​.org/assets/pdfs​/EMP_Across_Generations_ES.pdf.
3.
National Poverty Center (NPC). Family support during the transition to adulthood. Ann Arbor, MI: NPC Policy Brief #3; 2004. Available from: http://www​.npc.umich​.edu/publications/policy_briefs​/brief3/brief3.pdf.
4.
Day JC, Newburger EC. The big payoff: Educational attainment and synthetic estimates of work-life earnings. Current Population Reports . 2002. pp. P23–210. Available from: http://www​.census.gov​/prod/2002pubs/p23-210.pdf.
5.
Snyder TD, Dillow SA, Hoffman CM. Digest of education statistics 2007. Washington, DC: National Center for Education Statistics, Institute of Education Sciences, U.S. Department of Education (NCES 2008–022); 2008.
6.
Sweeten G, Apel R. Incarceration and the transition to adulthood. National Poverty Center Working Paper Series #07. 2007. Available from: http://www​.npc.umich​.edu/publications/u/working_paper07-23​.pdf.
7.
Harlow CW. Bureau of Justice Statistics. Special Report. Washington, DC: U.S. Department of Justice; 2003. Education and correctional populations. Available from: http://www​.ojp.usdoj​.gov/bjs/pub/pdf/ecp.pdf.
8.
Western B. The impact of incarceration on wage mobility and inequality. American Sociological Review. 2002;67(4):477–98.
9.
Lerman RI. Meritocracy without rising inequality? Wage rate differences are widening by education and narrowing by gender and race Washington, DC: The Urban Institute; Brief #2. 1997Available from: http://www​.urban.org​/publications/307563.html.
10.
The Council of Economic Advisors. Explaining trends in the gender wage gap. The White House. 1998. Available from: http://clinton4​.nara​.gov/WH/EOP/CEA/html/gendergap.html#exec.
11.
Driscoll AK, Hearn GK, Evans VJ, Moore KA, Sugland BW, Call V. Nonmarital childbearing among adult women. Journal of Marriage and Family. 1999;61(1):178–87.

Births to Unmarried Women

Young adult non-Hispanic white women have considerably lower nonmarital birth rates than black or Hispanic young adult women.

Unmarried mothers and their children are more likely to be disadvantaged and have a generally less favorable health status than married mothers and children, even when differences in age and education are taken into account. Women who have nonmarital births have lower educational attainment and lower income, are less likely to work full-time, and are more likely to receive public assistance (1–3). They are twice as likely to smoke while pregnant and, among mothers age 20 years and over, about twice as likely to have a low birthweight baby (3). Low birthweight is a major correlate of infant illness and mortality.

Between 1990 and 2005, the proportion of births that are to unmarried women was highest for women under age 20. Between 1990 and 2005, the proportion of births to unmarried women rose from 66% to 84% for women age 18 years, from 58% to 77% for women age 19, from 37% to 56% for women age 20–24, and from 18% to 29% for women age 25–29. Proportionally, the increase in the share of births to unmarried women was greater for women 25–29 (63%) and women 20–24 (52%) than for women age 19 (33%) and women age 18 (26%). The proportion of births that are to unmarried women is a function both of decreasing birth rates among married women and of increasing birth rates among unmarried Hispanic women of all age groups and unmarried non-Hispanic white women in their twenties.

Birth rates for unmarried women varied considerably by age as well as by race and ethnicity. In 2005, the highest birth rate for unmarried women was among women 20–24 years of age (74.9 per 1,000 women) and the second highest was among women age 25–29 years (71.1 per 1,000 women). The lowest nonmarital birth rate among young adults was among teenagers, 18–19 years (58.4 per 1,000 women). Rates for nonmarital births among all other age groups were lower (5).

Among young adult women, nonmarital birth rates and patterns differ markedly by race and Hispanic origin (Figure 30). Non-Hispanic white women have considerably lower nonmarital birth rates than black or Hispanic women in all three age groups (18–19, 20–24, and 25–29 years). In 2005, Hispanic women had higher nonmarital birth rates than black or non-Hispanic white young women in all three age groups, although the difference between black and Hispanic young women age 18–19 years was relatively small.

Trends in nonmarital birth rates for young non-Hispanic white women have been relatively stable since 1990. Among unmarried Hispanic women, birth rates have fluctuated somewhat but have been increasing since the late 1990s. For black women, 18–19 years of age, nonmarital birth rates declined by 29% between 1990 and 2005. They had higher nonmarital birth rates than their Hispanic counterparts until 2002, when the ongoing decline resulted in the rate dropping below that of Hispanic women age 18–19 years.

References

1.
Driscoll AK, Hearn GK, Evans VJ, Moore KA, Sugland BW, Call V. Nonmarital childbearing among adult women. Journal of Marriage and the Family. 1999;61(1):178–87.
2.
Department of Health and Human Services. Report to Congress on out-of-wedlock childbearing. Hyattsville, MD: NCHS. ; 1995.
3.
Ventura SJ. Vital health stat. 53. Vol. 21. Hyattsville, MD: NCHS.; 1995. Births to unmarried mothers: United States, 1980–92. [PubMed: 7654859]
4.
Ventura SJ, Bachrach CA. National vital statistics reports. 16. Vol. 48. Hyattsville, MD: NCHS; 2000. Nonmarital childbearing in the United States, 1940–99. [PubMed: 11060989]
5.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, et al. National vital statistics reports. 6. Vol. 56. Hyattsville, MD: NCHS; 2007. Births: Final data for 2005.

Cigarette Smoking and Alcohol Use

Between 1997 and 2006, the prevalence of cigarette smoking and alcohol consumption among young adults 18–29 years of age remained unchanged.

By age 19, young adults can legally purchase tobacco in all 50 states, and by age 21 they can legally purchase alcohol, although under-age use of both of these products is apparent (Tables 66 and 67). Since 1964, the Surgeon General’s reports on smoking and health have concluded that tobacco use is a major cause of disease, disability, and death (1). Alcohol use contributes to increased mortality from alcohol-related unintentional injuries, including motor-vehicle crashes while under the influence of alcohol (2). Some drinking patterns—particularly regular heavy alcohol consumption and drinking 5 or more drinks in one day—can have both acute and chronic detrimental effects on health (3).

Smoking among young adults continues to be a public health concern. In 2006, young adult men were 37% more likely to smoke cigarettes than young adult women (29% compared with 21%) (Figure 31). Between 1997 and 2006, the current smoking rate declined nearly 20% among young adult women but did not decline significantly among young adult men (Figure 31). Among young adult women, the decline was primarily among women 18–24 years of age (data table for Figure 31).

Figure 31

Figure 31

Cigarette smoking and alcohol use among young adults 18–29 years of age, by sex: United States, 1997–2006 Click here for spreadsheet version

Although recent research has shown a consistently higher rate of at-risk drinking behaviors, including heavy drinking and binge drinking, among college students than among their nonstudent counterparts, the differences in rates between these two groups are not large (4). Trends in heavy drinking remained constant for both men and women during the period, with about 6%–8% of young men and 3%–5% of young women reporting heavy drinking (Figure 31). Heavy drinking is defined as more than 14 drinks per week for men and more than seven drinks per week for women, on average.

Having 5 or more drinks in a day on at least 12 days in the past year typically peaks during young adulthood (Table 69). Between 1997 and 2006, about one-quarter of young men 18–29 years of age reported having 5 or more drinks in a day on at least 12 days in the past year (Figure 31). During the period, the percentage of young women reporting this level of drinking (7%–9%) was substantially lower than that reported by young men.

References

1.
DHHS. The Health Consequences of Smoking: What it means to you. US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion Office of Smoking and Health; 2004.
2.
Hingson RW, Heeren T, Zakocs RC, Kopstein A, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18–24. J Stud Alcohol. 2002;63:136–44. [PubMed: 12033690]
3.
Rehm J, Gmel G, Sempos CT, Trevisan M. Alcohol-related morbidity and mortality. Alcohol Research & Health. 2003;27(1):39–51. [PubMed: 15301399]
4.
Bingham CR, Shope JT, Tang X. Drinking behavior from high school to young adulthood: Differences by college education. Alcohol Clin Exp Res. 2005;29(12):2170–80. [PMC free article: PMC1397708] [PubMed: 16385187]

Illicit Drug Use

Almost 40% of young adults 18–20 years of age, about one-third of 21–25 year- olds, and one-quarter of 26–29 year-olds reported using an illicit drug in the past year.

Use of illicit drugs, such as heroin, marijuana, cocaine, and methamphetamine, or nonmedical use of prescription drugs such as pain relievers, tranquilizers, stimulants, and sedatives, can be associated with serious consequences. These include injury, illness, disability, and death as well as crime, domestic violence, and lost school or workplace productivity (1,2). Long-term consequences, such as chronic depression, sexual dysfunction, and psychosis as well as drug use disorders may also result from drug use (2,3).

The National Survey on Drug Use & Health asks noninstitutionalized civilians age 12 and over about their use of illicit drugs, alcohol, tobacco, and other substances. Illicit drug use includes marijuana or hashish, cocaine including crack cocaine, heroin, inhalants, other illegal drugs used recreationally, and nonmedical use of prescription medications, whether obtained legally or illegally.

Recent use of illicit drugs (in the month prior to interview) among young adults 18–29 years of age decreases sharply with age (Figure 32). In 2006, nearly one-quarter (22%) of 18–20 year-olds compared with 18% of 21–25 year-olds, and 14% of 26–29 year-olds reported illicit drug use in the past month. Recent use of illegal drugs was at its highest level among persons 18–20 years of age. Levels among this age group were higher than among teenagers under age 18 or persons age 30 and over (3).

Figure 32

Figure 32

Illicit drug use among young adults 18–29 years of age, by age: United States, 2006 Click here for spreadsheet version

Illicit drug use in the past year followed a similar pattern by age to use in the past month. In 2006, almost 40% of young people age 18–20, about one-third of 21–25 year-olds, and one-quarter of 26–29 year-olds reported using an illicit drug in the past year.

Marijuana or hashish was the most commonly reported illicit drug. Almost one-third of 18–20 year olds reported marijuana use in the past year, and nearly one-fifth in the past month. Fifteen percent of 21–25 year-olds and 10% of 26–29 year-olds also reported marijuana use in the past month (Figure 32). Recent use of marijuana among persons 26–29 years of age was about half that of 18–20 year-olds.

Nonmedical use of prescription drugs was the next most commonly reported illicit drug; this includes pain relievers, tranquilizers, stimulants, and sedatives but not over-the‐counter drugs. Eleven to seventeen percent of young adults 18–29 years of age reported using prescription drugs for nonmedical reasons in the past year, as did 5%–7% during the past month (Figure 32).

References

1.
Office of National Drug Control Policy. The National Drug Control Strategy 2000 Annual Report. Available from: http://www​.ncjrs.gov​/ondcppubs/publications​/policy/ndcs00/chap2_10.html.
2.
U.S. Department of Health and Human Services. With Understanding and Improving Health and Objectives for Improving Health. 2. Washington, DC: U.S. Government Printing Office; Nov, 2000. Healthy People 2010. Chapter 26: Substance abuse. Available from: http://www​.healthypeople​.gov/document/html​/volume2/26substance.htm#_Toc489757833.
3.
Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use & Health: National Findings. Rockville, MD: DHHS; 2007. (Office of Applied Studies, NSDUH Series H–32, DHHS Publication No. SMA 07–4293) Available from: http://oas​.samhsa.gov​/nsduh/2k6nsduh/2k6Results.cfm#2.3.

Prevalence of Human Papillomavirus Infection

Among young women age 20–24 years in the United States, 45% were infected with human papillomavirus in 2003–2004.

Human papillomavirus (HPV) refers to a group of viruses that includes over 100 different strains or types (1). More than 40 of these viruses are sexually transmitted, and can infect the anogenital area (2). These viruses are classified according to their risk of causing cervical cancer. “High-risk” types, including HPV 16 and HPV 18, are detected in 99% of cervical cancers and can also cause anal and other genital cancers (3). Other strains of HPV, such as HPV 6 and HPV 11, are classified as “low-risk” types and can cause mild Pap test abnormalities and genital warts (4). About 1% of sexually active adolescents and adults had clinically apparent genital warts in 2003 (3).

Approximately 6.2 million people are newly infected with HPV annually (5). It is estimated that by age 50, at least 80% of women will have acquired HPV (1). The majority of infections are transient—70% of new HPV infections clear within 1 year and approximately 90% clear within 2 years (3). Persistent infection with the high-risk types of HPV affects only a small proportion of women but is the main risk factor for cervical cancer (1). In 2003, cervical cancer incidence in the United States was 8.1 per 100,000 women representing approximately 11,820 new cases (3).

Most cases of HPV infection are asymptomatic and cause no disease. A subset of infections result in subclinical disease, detected by either an abnormal Pap test or by visual discovery of anogenital warts (1). A DNA test to detect infection with any of 13 high risk types of HPV is approved by the FDA for women with mild Pap test abnormalities, or women older than 30 years, but currently, no test exists for HPV detection in men (1).

The prevalence of HPV infection is higher among young women, with the highest prevalence in women age 20–24 years (6). Using data from the laboratory component of the 2003–2004 National Health and Nutrition Examination Survey, 45% of women age 20–24 years tested positive for HPV infection (Figure 33). Women age 25–29 years had a prevalence of 27% (Figure 33). Non-Hispanic black women age 20–29 years had a prevalence of HPV infection of 47% compared with 30%–33% among Mexican and non-Hispanic white women (Figure 33). Women with family income below 100% of poverty had a higher prevalence compared with higher income groups (46% compared with 31%–38%) (Figure 33).

Figure 33

Figure 33

Prevalence of human papillomavirus (HPV) infection among women 20–29 years of age, by selected characteristics: United States, 2003–2004 Click here for spreadsheet version

Because HPV is spread by sexual contact, the number of sexual partners is the most consistent risk factor for HPV infection (3). In 2003–2004, 62% of women age 20–29 years who had three or more sexual partners in the past year were positive for HPV compared with 32% of women who had one partner in the past year (Figure 33).

In June, 2006, a vaccine to protect against four different strains of HPV (6,11,16, and 18) was approved by the U.S. Food and Drug Administration for females age 9–26 years (3). The Advisory Committee on Immunization Practices recommends routine vaccination of females age 11–12 years, and catch-up vaccination for females age 13–26 years who have not been previously vaccinated (3). Routine cervical screening continues to be recommended among sexually active young women because the vaccine does not prevent all types of HPV that are associated with cervical cancer (3).

References

1.
CDC. Genital HPV infection—CDC Fact Sheet. 2004. Available from: http://www​.cdc.gov/std/hpv/#fact.
2.
Baseman JG, Koutsky LA. The epidemiology of human papillomavirus infections. Journal of Clinical Virology. 2005;32S:S16–S24. [PubMed: 15753008]
3.
CDC. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices. 2007;56(RR02):1–23. [PubMed: 17380109]
4.
Ault KA. Epidemiology and natural history of human papillomavirus infections in the female genital tract. Infect Dis Obstet Gynecol. 2006;26:1–5. [PMC free article: PMC1581465] [PubMed: 16967912]
5.
Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health. 2004;36(1):6–10. [PubMed: 14982671]
6.
Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan DC, Patel SS, et al. Prevalence of HPV infection among females in the United States. JAMA. 2007;297:813–9. [PubMed: 17327523]

Forced Sexual Intercourse

About one-fifth of women 18–44 years of age reported forced sexual intercourse before the age of 30.

Forced sexual intercourse may have lasting physical, psychological, and social consequences for its victims. Potential physical effects include gynecological and other injury, infection with a sexually transmitted disease, and unwanted pregnancy. The psychological consequences may include depression, suicidal thoughts, and the adoption of unhealthy behaviors including poor diet, substance abuse, and high-risk sexual behaviors (1–4).

The 2002 National Survey of Family Growth (NSFG) asked women and men age 18–44 if they had ever been forced to have sexual intercourse, and if so, the type of force experienced. Classifying an encounter as forced and identifying the types of force used are subjective, based on the respondent’s perception of force. The force may have been from intimidation (due to the perpetrator’s size or words), from the use of alcohol or drugs, or due to physical threat, injury, or restraint.

Twenty-three percent of women and about 8% of men 18–44 years of age reported forced intercourse at some time in their lives (5,6). The first incident of forced sexual intercourse for women generally occurs before age 30. Twenty-one percent of women reported forced sexual intercourse before age 30. This may have consequences that affect the young adult years and possibly beyond (7).

Non-Hispanic white or black women 18–44 years of age were more likely than Latinas to report forced sexual intercourse under age 30 (22%–23% compared with 17%). Women with family income below 200% of poverty were more likely than higher income women to report forced sexual intercourse before age 30 (24%–25% compared with 19%).

To better understand the nature of forced sexual intercourse, the NSFG included questions designed to capture the nature and degree of force. For the exact wording of the questions, see the Technical Notes. Types of force were grouped into two mutually exclusive categories for Figure 34: physical threat or force (if threats of physical harm, physical harm, or being physically held down were reported) and nonphysical force (only nonphysical types of force or unknown type of force). Fifteen percent of women reported being physically threatened or forced before age 30 (Figure 34). Non-Hispanic white or black women were more likely than Hispanic women to report being physically threatened or forced (15%–16% compared with 11%). Women with family income below 200% of poverty were more likely than higher income women to report being physically threatened or forced before age 30 (17%–18% compared with 13%).

Figure 34

Figure 34

Any report of forced sexual intercourse before age 30 among women 18–44 years of age at interview, by type of force, race and Hispanic origin, and percent of poverty level: United States, 2002 Click here for spreadsheet version

References

1.
World Health Organization. World report on violence and health. Geneva: WHO. ; 2002. Available from: http://www​.who.int/violence​_injury_prevention​/violence/global_campaign/en/chap6​.pdf.
2.
Schafran LH. Topics for our time: Rape is a major public health issue. AJPH. 1996;86(1):15–7. [PMC free article: PMC1380353] [PubMed: 8561235]
3.
Welch J, Mason F. Rape and sexual assault. BMJ. 2007;334:1154–8. [PMC free article: PMC1885326] [PubMed: 17540944]
4.
Cantu M, Coppola M, Lindner AJ. Evaluation and management of the sexually assaulted woman. Emerg Med Clin N Am. 2003;21(3):737–50. [PubMed: 12962356]
5.
Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Vital health stat. 25. Vol. 23. Hyattsville, MD: NCHS; 2005. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. [PubMed: 16532609]
6.
Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Vital health stat. 26. Vol. 23. Hyattsville, MD: NCHS; 2006. Fertility, contraception, and fatherhood: Data on men and women from Cycle 6 (2002) of the National Survey of Family Growth. [PubMed: 16900800]
7.
Zweig JM. A longitudinal examination of the consequences of sexual victimization for rural young adult women. Journal of Sex Research. 1999;36(4):396–409.

Selected Health Indicators

Eighteen percent of young women and 12% of young men reported at least one of six selected serious health conditions in 2004–2006, and 4%–5% of young women and young men reported overall fair or poor health or an activity limitation due to a chronic health condition.

The young adult years can be challenged by the presence of chronic health conditions, poor overall health, or limitations in usual activity due to the presence of chronic health conditions. The presence of serious physical and mental health conditions among young adults, coupled with the high prevalence of risk factors and unhealthy behaviors, has health and economic implications for successful transition into adulthood (1,2).

Obesity and lack of exercise are risk factors for developing chronic conditions as are unhealthy behaviors such as cigarette smoking, heavy or binge alcohol use, and illicit drug use. The proportion of young adults 18–29 years of age who were obese more than tripled from 8% in 1971–1974 to 24% in 2003–2004 (Figure 7). Nearly two-thirds of young adults did not have regular leisure-time physical activity and three-quarters did not report strength-training at least twice a week (Figure 8). Nearly 30% of young adults were current cigarette smokers, one-fifth reported 5 or more drinks in a day on at least 12 days in the past year, and between one-quarter and one-third of young adults reported using an illicit drug in the past year (Figures 31 and 32).

The health of this age group was assessed in several different ways using data from the National Health Interview Survey. Young adults were asked if they have ever been told by a physician or other health provider that they had any of six specific health conditions (arthritis, current asthma, cancer, diabetes, heart disease, or hypertension. See Technical Notes for survey questions). Their overall health status was assessed by respondent-report using a scale ranging from excellent to poor. Another series of questions asked the survey respondents about limitations in their ability to perform activities usual for their age group due to a chronic physical, mental, or emotional condition.

Four percent of young adults assessed their current overall health status as fair or poor and five percent reported activity limitation due to a chronic condition (data table for Figure 35). Fifteen percent of young adults reported being told by a physician that they had at least one of six specified health conditions with a higher prevalence among young adult women compared with young adult men (18% compared with 12%) (Figure 35).

Figure 35

Figure 35

Selected physician-diagnosed health conditions, respondent-assessed fair or poor health, or activity limitation due to a chronic condition among young adults 18–29 years of age, by sex: United States, 2004–2006 Click here for spreadsheet (more...)

Current asthma was the most commonly reported of the six conditions and was more common among young women than young men (9% compared with 5%) (Figure 35). The second most common condition was arthritis, also more common among young women than men (5% compared with 3%). Hypertension was the third most commonly reported condition, reported by about 3% of young women and young men. About 1%–2% of young women and young men reported cancer, diabetes, or heart disease.

References

1.
Arnett JJ. Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist. 2000 May;55(5):469–80. [PubMed: 10842426]
2.
Furstenberg FF Jr, Kennedy S, Mcloyd VC, Rumbaut RG, Settersten RA Jr. Growing up is harder to do. Contexts. 2004. Available from: http://www2​.asanet.org​/media/furstenberg_adulthood.pdf.

Selected Mental Disorders

In 1999–2004, almost 9% of young adults 20–29 years of age had major depression, generalized anxiety disorder, or panic disorder in the past 12 months.

The young adult years represent a critical period for identifying mental health problems, because three-quarters of all lifetime cases of diagnosable mental disorders begin by age 24 (1). The range of mental health problems that young adults encounter is generally similar to those of older adults, and includes major depression, panic disorder, and anxiety disorders. These mental health problems can lead to suicide attempts, substance abuse, self-harm, eating disorders, and other behavioral difficulties (2).

Mental health disorders such as major depression rank among the top 10 causes of disability worldwide (3). The category of “selected mental disorders” presented in Figure 36 includes major depressive episode (referred to here as major depression), generalized anxiety disorder, or panic disorder. Major depression is the largest component of this category and is characterized by many different physical and psychological symptoms, including profound sadness, loss of interest or pleasure in activities normally enjoyed, and other symptoms that impair a person’s ability to function. Episodes of major depression may occur suddenly or gradually and usually last several months. It is common for depression to recur and it can take an enormous toll on functional status, productivity, quality of life, and physical health—depression is associated with elevated risk of heart disease and suicide (4). The total economic burden of depression in the United States (including direct care, mortality, and workplace costs) has been estimated at $83 billion in 2000, with over 60% of the costs resulting from lowered productivity and absenteeism in the workplace (5).

Figure 36

Figure 36

Selected mental disorders in the past 12 months among young adults 20–29 years of age, by sex and age: United States, 1999–2004 Click here for spreadsheet version

From 1999–2004, trained lay interviewers from National Health and Nutrition Examination Survey (NHANES) administered three diagnostic modules—major depression, generalized anxiety disorder, and panic disorder from the World Health Organization’s Composite International Diagnostic Interview (CIDI). The CIDI modules are computer-based comprehensive and structured interviews that assess mental disorders using definitions and criteria from the International Classification of Diseases, Tenth Revision and the Diagnostic and Statistical Manual of Mental Diseases (DSM IV). Each module obtains information about symptoms and persistence of symptoms over the past 12 months and uses a computer algorithm to define each diagnosis (6). Almost 9% of young adults 20–29 years of age had one or more of these three illnesses in the past 12 months (Figure 36). An estimated 7% of young adults 20–29 years of age had a diagnosis of major depression in the past 12 months. Young women (11%) were almost twice as likely as young men (6%) to have major depression, generalized anxiety disorder, or a panic disorder in the past 12 months.

References

1.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593–602. [PubMed: 15939837]
2.
U.S. Department of Health and Human Services. Mental Health: A report of the surgeon general. Atlanta, GA: USDHHS; 1999. Available from: http://www​.surgeongeneral​.gov/library/mentalhealth/home.html.
3.
Lopez AD, Murray C. The global burden of disease, 1990–2020. Nature Medicine. 1998;4(11):1241–3. [PubMed: 9809543]
4.
National Institute of Health . National Institute of Mental Health. Depression. Available from: http://www​.nimh.nih.gov​/health/publications​/depression/complete-publication​.shtml#pub1.
5.
Greenberg PE, Kessler RC, Birnbaum HG, Leong SA, Lowe SW, Berglund PA, et al. The economic burden of depression in the United States: How did it change between 1990 and 2000? J Clin Psychiatry. 2003;64(12):1465–75. [PubMed: 14728109]
6.
CDC/NCHS. National Health and Nutrition Examination Survey 2003–2004 Documentation, Codebook, Questionnaires, and Frequencies. 2006. Available from: http://www​.cdc.gov/nchs​/data/nhanes/mecintv.pdf and http://www​.cdc.gov/nchs​/data/nhanes/cidi_quex.pdf.

Mortality

Between 1980 and 2005, death rates for all causes declined 30% among young men and 22% among young women.

The vast majority of deaths among young adults 18–29 years of age are injury-related with unintentional injury (“accidents”), homicide, and suicide being the three leading causes of death among this age group. Together, the three injury-related causes accounted for 70% of the 47,000 deaths that occurred among young adults 18–29 years of age in 2005. Deaths from motor vehicle-related injuries accounted for 26% of all deaths in this age group. Public health efforts to reduce deaths from motor vehicle-related injuries include campaigns on safe driving such as initiatives against drinking and driving. Alcohol plays a significant role in fatal motor-vehicle crashes among young adults (1). In 2006, 51% of motor-vehicle fatalities among young adults 18–29 years of age were alcohol-related, down from 72% in 1982 (2). Public health efforts towards reducing deaths from violence include strategies to raise awareness about suicide as a preventable public health problem, and primary prevention programs designed to reduce risk for suicidal behavior and perpetration of violence through integrated use of complementary strategies (e.g., monitoring risk behaviors, promoting help-seeking, improving social problem solving skills, and enhancing availability of health and social support services) (3).

Deaths among young adults varied substantially by sex, with three-quarters of deaths among this age group occurring among young adult men. In 2005, the all cause death rate among young adult men was nearly three times the rate among young adult women, over three times for unintentional injuries, over six times for homicide, and nearly five times for suicide (data table for Figure 37).

Between 1980 and 2005, death rates for all causes among young adult men 18–29 years of age declined by 30% (Figure 37). Unintentional injuries, which were the leading cause of death for young adult men throughout the period, declined 39%. Homicide and suicide were the second and third leading causes of death among young adult men during the period. Homicide rates rose between 1980 and the early 1990s, declined sharply in the later part of the 1990s, and then stabilized. Suicide rates declined by one-quarter between 1980 and 2005. Death rates for cancer and heart disease, the fourth and fifth leading causes of death among young adult men, were much lower than for the other leading causes. Between 1980 and 2005, cancer death rates among young adult men declined by over one-third while heart disease death rates remained fairly constant.

Figure 37

Figure 37

Death rates for leading causes of death among young adults 18–29 years of age, by sex: United States, 1980–2005 Click here for spreadsheet version

The mechanism of injury provides information on the events that preceded the injury death (4). In 2005, motor vehicle-related injuries accounted for 27%, firearm-related injuries for 24%, and poisoning for 12% of all deaths among young adult men in 2005 (data table for Figure 37). Death rates from poisoning (which includes drug overdoses) among young adult men have nearly doubled in the past 7 years.

All cause mortality rates among young adult women 18–29 years of age declined by 22% between 1980 and 2005 (Figure 37). As with young men, unintentional injuries were the leading cause of death among young adult women with a 19% decline during the period. During this period, homicide rates declined by nearly one-half, and suicide and cancer death rates by nearly one-third, while heart disease death rates remained fairly constant. Cancer has been the second leading cause of death for young women but the fourth leading cause for men since 1996.

In 2005, motor vehicle-related injuries accounted for 25%, poisoning for 12%, and firearm-related injuries for 7% of all deaths among young adult women in 2005 (data table for Figure 37). As with young adult men, poisoning death rates among young adult women have doubled in the past 7 years.

References

1.
National Highway Traffic Safety Administration. Traffic safety facts: Crash stats. Alcohol-related fatalities and alcohol involvement among drivers and motorcycle operators in 2005. August , 2006. DOT HS 810 644. Available from: http://www​.nhtsa.gov.
2.
National Highway Traffic Safety Administration. Fatality Analysis Reporting System (FARS) data from the National Center for Statistics & Analysis. unpublished analysis.
3.
Doll L, Bonzo S, Sleet D, Mercy J, Hass E, editors. Handbook of injury and violence prevention. New York (NY): Springer; 2007.
4.
Bergen G, Chen LH, Warner M, Fingerhut LA. Injury in the United States: 2007 Chartbook. Hyattsville, MD: NCHS; 2008.

Health Insurance Coverage at the Time of Interview

One-third of young adults age 20–24 are uninsured—the highest percentage of any age group.

Most young adults are healthy, but when they do become ill or need medical services, lacking health insurance can be a barrier to receiving health care. Lack of insurance is of particular importance to this age group because a large percentage of young adults are poor or have low income (1,2, Figure 29). During the period between age 18 and 29, young adults typically transition from their parents’ health insurance to their own. When they reach age 19 they generally lose coverage under their parents’ plans, although private plans often give an exception to full-time students with dependent status ending at graduation or a specified age. Age 19 is also almost always the end of eligibility for federal and state programs such as State Children’s Health Insurance Program (SCHIP) and Medicaid. This is a particular problem for adolescents with special health care needs, who age out of supportive public assistance and health care coverage programs (3).

Young adults age 20–24 years are the most likely age group to be uninsured in the United States (34% in 2006). In 2006, 30% of young adults age 18–29 years were uninsured, compared with 9.5% of children under 18 years of age, and 19% of adults 35–44 years of age (data table for Figure 38 and Table 140). Young adult men were more likely than young adult women, especially among those 20–24 years of age, to be uninsured (Figure 38).

Figure 38

Figure 38

Health insurance coverage at the time of interview among young adults 18–29 years of age, by age: United States, 2006 Click here for spreadsheet version

Whereas the majority of young adults had private health insurance coverage in 2006 (58%), they are less likely to have this type of insurance than other adult age groups (Table 137). Private coverage is obtained in three possible ways: through a family health insurance policy carried by a parent of the young adult; as a single person (working or in college); or as the health insurance policy holder or spouse in a new family (more likely among 24–29 year-olds). Young men and young women have similar rates of private health insurance (Figure 38). Rates of private health insurance among young adults are lowest among those 20–24 years of age. Young adults age 18–24 are also the age group least likely to have employer-sponsored private insurance (Table 138). In recent years, employers have been less likely to offer health coverage, which has led to an overall decline in private health insurance coverage. This is particularly true among young adults, who have less job tenure, less attachment to the labor force, and are least likely to be grandfathered under existing employer-sponsored benefits (4,5). Two other major sources of health care coverage for adolescents and young adults are Medicaid and SCHIP. Medicaid is a health program for the poor, and among young adults it has traditionally targeted poor single mothers with children. SCHIP targets near poor children. States coordinate their SCHIP and Medicaid programs; some do not have a separate SCHIP program but instead have expanded their Medicaid program to cover low income children, and some states have enacted SCHIP expansions to allow buy-ins to the program for some poor families, further blurring the distinction between the two programs. Because of some National Health Interview respondents’ inability to distinguish Medicaid from SCHIP programs, Medicaid and SCHIP participation rates have been combined in Figure 38. In 2006, young women were more likely than young men to be covered by Medicaid or SCHIP (15% compared with 6%), primarily because of their eligibility status through childbearing and because they are more likely to live in poverty or have low income (Figure 28).

In an attempt to address directly the high rates of uninsurance among young adults, state lawmakers are proposing and enacting legislation that extends dependent benefits to older children. Some states and insurers have addressed additional populations within this age group, ensuring that students who take a leave of absence from school due to illness, injury, or service in the armed forces do not lose their health insurance (6).

References

1.
Callahan ST, Cooper WO. Uninsurance and health care access among young adults in the United States. Pediatrics. 2005;116(1):88–95. [PubMed: 15995037]
2.
Adams SH, Newacheck PW, Park MJ, Brindis CD, Irwin CE. Health insurance across vulnerable ages: Patterns and disparities from adolescence to the early 30s. Pediatrics. 2007;119(5):e1033–e1039. [PubMed: 17473076]
3.
Callahan ST, Cooper WO. Continuity of health insurance coverage among adults with disabilities. Pediatrics. 2007;119(6):1175–80. [PubMed: 17545386]
4.
Levy H. Health insurance and the transition to adulthood. In: Sheldon Danziger, Cecilia Rouse , editors. The Price of Independence: The Economics of Early Adulthood. New York: Russell Sage Foundation; 2008.
5.
Holahan J, Cook A. Changes in economic conditions and health insurance coverage, 2000–2004. Health Affairs. 2005 November; Web exclusive. [PubMed: 16263774]
6.
National Conference of State Legislatures. The changing definition of ‘dependent’: Who is insured and for how long?; Available from: http://www​.ncsl.org/programs​/health/dependentstatus.htm.

Unmet Need for Health-related Services Due to Cost

In 2004–2006, 28% of uninsured young adult men and 40% of uninsured young adult women reported they did not receive at least one of the following needed health-related services in the past 12 months— prescription medicines, medical care, eyeglasses, or mental health care—because they could not afford them.

Although young adults 18–29 years of age are generally thought of as “healthy,” significant percentages of them have health conditions or other reasons for accessing the health care system (see related Figure 40). All young adults have a need for preventive care such as routine dental examinations and cleanings and periodic eye examinations (1,2). Young adult women need recommended gynecological screening and other services (3). Although many chronic conditions are more common with advancing age (Tables 54, 71, and 72), the young adult years can be complicated by the presence of, or a history of, serious health conditions such as arthritis, asthma, hypertension, cancer, heart disease, or diabetes (Figure 35). Nine percent of young adults had major depression, generalized anxiety disorder, or panic disorder in the past 12 months (Figure 36). Young adults may have difficulty affording needed health care because substantial numbers of them are low income (Figure 29) and uninsured (Figure 38).

Figure 40

Figure 40

Selected types of health care utilization among young adults 18–29 years of age, by sex: United States, 1999–2004 and 2006 Click here for spreadsheet version

Dental care was the most commonly reported individual health-related service not received due to cost. In 2004–2006, 15% of young adults reported they did not receive dental care in the past 12 months due to cost. Dental care is associated with higher out-of-pocket costs because fewer people have dental insurance than general medical insurance coverage, and for those who do have dental insurance, coverage is generally less comprehensive than medical insurance (4,5).

Seventeen percent of young adults reported they did not receive at least one of the following needed services in the past 12 months because they could not afford them— prescription medicines, medical care, eyeglasses, or mental health care (data table for Figure 39). About 9%–10% of young adults reported not receiving needed prescription medicines and medical care, 7% did not receive needed eyeglasses, and 3% did not receive needed mental health care in the past 12 months due to cost. Young adults were about as likely as other adults 18–64 years of age to report not receiving needed medical care due to cost (Table 80).

Not receiving needed health-related services due to cost varied by sex and health insurance status (Figure 39). Forty percent of uninsured young adult women, compared with 28% of uninsured young adult men, did not receive at least one needed health service in the past 12 months due to cost. Almost twice as many insured young women (14%) as insured young men (8%) reported they did not receive at least one needed health service in the past 12 months due to cost.

Figure 39

Figure 39

Young adults 18–29 years of age reporting they did not receive needed health-related services in the past 12 months because they could not afford them, by sex and health insurance status: United States, 2004–2006 Click here for spreadsheet (more...)

Prescription medicines and medical care were the most common health services (other than dental care) not received in the past 12 months due to cost for both young adult men and women. Fifteen to sixteen percent of uninsured men compared with 3%–4% of insured men, and about one-quarter of uninsured women compared with 5%–8% of insured women reported not receiving needed prescription medicines or medical care in the past 12 months because they could not afford it.

References

1.
U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available from: http://www​.surgeongeneral​.gov/library/oralhealth/
2.
American Optometric Association. The importance of regular eye exams. Available from: http://www​.aoa.org/eye-exams.xml.
3.
U.S. Preventive Services Task Force. Screening for cervical cancer: Recommendations and rationale. 2003. Available from: http://ahrq​.gov/clinic​/3rduspstf/cervcan/cervcanrr.pdf.
4.
Dental, Oral and Craniofacial Data Research Center. Bethesda, MD: Oral health U.S; 2002. Available from: http://drc​.hhs.gov/report/inside_cover​.htm.
5.
Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. Center for Financing, Access, and Cost Trends. Dental services expenditures table 2. 2003. Available from: http://www​.meps.ahrq​.gov/mepsweb/data_stats​/summ_tables/hc/state_expend​/2003/table2.htm.

Health Care Utilization

Seventy percent of young adults had a doctor visit in the past 12 months, 24% reported an emergency department visit, and 7% had a visit to a mental health care provider in 2006.

Although young adults age 18–29 years are generally considered to be healthy, they may use health care to control, ameliorate, or prevent medical conditions. In 2004–2006, about 15% reported having at least one of these chronic medical conditions: arthritis, asthma, cancer, diabetes, heart disease, or hypertension (see Figure 35 for more information). Chronic conditions and poorer health status were more commonly reported by young women than young men. In addition to chronic conditions, young adults have the highest rate of injury-related emergency department visits among all age groups (Figure 41 and Table 93). Besides seeking health care to treat medical conditions or injuries, young adults use health care for preventive services and reproductive care. About one-third of young women reported using a prescribed contraceptive method of birth control—such as the pill, contraceptive patch, or an injectable contraceptive—in the month prior to interview (1,2).

Figure 41

Figure 41

Injury-related visits to hospital emergency departments among young adults 18–29 years of age, by sex and mechanism of injury: United States, 2005–2006 Click here for spreadsheet version

Two surveys that collect data from respondents on their health and health care utilization are the National Health Interview Survey (NHIS) and the National Health and Nutrition Examination Survey (NHANES). The NHIS asks respondents about their health care utilization, including medical visits and hospital stays during the 12 months prior to interview. NHANES collects a variety of information on health status and utilization, including information on prescription drugs used in the month prior to the interview.

Young women were substantially more likely to report all types of health care utilization than young men (Figure 40). In 2006, 84% of young women reported a doctor visit in the past 12 months, compared with 57% of young men (Figure 40); and 63% of young women and 54% of young men reported a dental visit. Young women (28%) were more likely to visit an emergency room in the past 12 months than young men (20%), although young men have a higher visit rate to emergency rooms for injuries (Figure 41). Nine percent of young women and 5% of young men reported a visit to a mental health provider in the past 12 months. Young women were almost four times as likely to report a hospital stay in the past year (11%) as young men (3%) and twice as likely to report taking a prescription drugs in the past month (39% compared with 19%). Women of reproductive age use more health care than men, in part due to the need for contraceptive services, gynecological checkups, and visits and hospitalizations associated with childbearing (3).

References

1.
CDC/NCHS. National Survey of Family Growth. 2002. unpublished analysis.
2.
Mosher WD, Martinez GM, Chandra A, Abma JC, Wilson SJ. Use of contraception and use of family planning services in the United States: 1982–2002. NCHS. 2004 Advance data 350. [PubMed: 15633582]
3.
Mustard CA, Kaufert P, Kozyrskyj A, Mayer T. Sex differences in the use of health care services. N Engl J Med. 1998;338(23):1678–83. [PubMed: 9614260]

Injury-related Emergency Department Visits

Young adults have the highest rate of injury-related emergency department visits of all age groups; being struck was the leading mechanism of injury for young men with emergency department visits, and motor vehicle traffic accidents were the leading mechanism of injury among young women.

Injuries cost society directly—in medical costs—but also indirectly in lost productivity from premature death due to fatal injuries and lost work time due to nonfatal injuries (1). It is estimated that in 2000, medical expenditures related to injuries for all ages accounted for about 10% of all U.S. medical expenditures (1). In 2004, injuries accounted for approximately 167,000 deaths (2), nearly 2 million hospitalizations (3), and 31 million emergency department visits (3). Nonfatal injuries are a leading reason for health care utilization among young adults. Young adults have among the highest rate of emergency department visits (4,5) and the highest rate of injury-related emergency department visits (see related Table 93) among all age groups. Whereas the majority of ambulatory care visits for nonfatal injuries were in physician offices, injuries resulting in an emergency department visit are often more serious (6).

The National Hospital Ambulatory Medical Care Survey (NHAMCS) collects data on visits to hospital emergency departments (ED). In this analysis, an emergency department visit was classified as an injury-related visit if there was a valid injury diagnosis code or a valid external cause of injury code and if it was the initial visit for that injury (7). In 2005–2006, there were an average of 7 million injury-related ED visits per year by young adults, age 18–29 years (8). Young men had higher rates of emergency department visits for injuries (1,615 ED visits per 10,000 civilian population) than young women (1,286 visits per 10,000 civilian population) (data table for Figure 41).

The five leading mechanisms of injury for which young men and women (age 18–29 years) sought treatment in emergency departments were being struck by or against objects or persons, motor vehicle traffic accidents, falls, cut or pierce injuries, and overexertion (Figure 41). The emergency department visit rate for injuries due to being struck was twice as high for young men (289 visits per 10,000 population) compared with young women (139 visits per 10,000 population). ED visit rates per 10,000 population for injuries related to motor vehicle traffic accidents were similar among young women (272 visits) than young men (233 visits). Visit rates for falls were also similar for young women (206 visits) and young men (212 visits).

Efforts to reduce injuries include the promotion of injury prevention activities such as the reduction of drunk driving, the use of seat belts and air bags, increased availability of functioning smoke detectors in homes, the use of helmets for sporting activities, along with efforts to reduce the number of suicides and assaults (9).

References

1.
CDC. Medical expenditures attributable to injuries—United States, 2000. MMWR. 2004;53(01):1–4. [PubMed: 14724557]
2.
Minino AM, Heron MP, Murphy SL, Kochanek KD. Deaths: Final data for 2004. NCHS. National vital statistics reports . 2007;55(19) [PubMed: 17867520]
3.
Bergen G, Chen L, Warner M, Fingerhut LA. Chartbook. Hyattsville, MD: NCHS; 2008. Injury in the United States: 2007. Available from: http://www​.cdc.gov/nchs​/data/misc/injury2007.pdf.
4.
Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Hyattsville, MD: NCHS.; 2007. Advance data 386. [PubMed: 17703794]
5.
Park MJ, Mulye TP, Adams SH, Brindis CD, Irwin CE Jr. The health status of young adults in the United States. J Adolesc Health. 2006;39:305–17. [PubMed: 16919791]
6.
Burt CW, Fingerhut LA. Vital health stat. 131. Vol. 13. Hyattsville, MD: NCHS; 1998. Injury visits to hospital emergency departments: United States, 1992–95. [PubMed: 9604689]
7.
Fingerhut LA. Health E-Stats. Hyattsville, MD: NCHS; 2006. Recommended definition of initial injury visits to emergency departments for use with the NHAMCS-ED data. Available from: http://www​.cdc.gov/nchs​/products/pubs/pubd​/hestats/injury/injury.htm.
8.
CDC/NCHS. National Hospital Ambulatory Medical Care Survey. unpublished analysis.
9.
Heinen M, Hall MJ, Boudreault MA, Fingerhut LA. National trends in injury hospitalization, 1979–2001. Hyattsville, MD: NCHS; 2005.

Technical Notes

Data Sources and Comparability

Data for the Chartbook come from many surveys and data systems and cover a broad range of years. Detailed descriptions of data sources are in Appendix I.

Data Presentation

Many measures in the Chartbook section are shown for people in specific age groups because of the strong effect age has on most health outcomes. Some estimates are age-adjusted using the age distribution of the 2000 standard population, and this is noted in the data tables that accompany each figure (see Appendix II, Age adjustment). Age-adjusted rates are computed to eliminate differences in observed rates that result from age differences in population composition. For some figures, data years are combined to increase sample size and reliability of the estimates. Some charts present time trends and others focus on differences in estimates among population subgroups for the most recent time point available.

Graphic Presentation

Most trends are shown on a linear scale to emphasize absolute differences over time. The linear scale is the scale most frequently used and recognized, and it emphasizes the absolute changes between data points over time (1). The time trends for overall mortality measures are shown on a logarithmic (or log) scale to emphasize the rate of change and to enable measures with large differences in magnitude to be shown on the same chart. Log scales emphasize the relative or percentage change between data points. Readers are cautioned that one potential disadvantage to log scale is that the absolute magnitude of changes may appear smaller than the untransformed statistics would indicate (2). When interpreting data on a log scale, the following points should be kept in mind:

  1. A sloping straight line indicates a constant rate (not amount) of increase or decrease in the values,
  2. A horizontal line indicates no change,
  3. The slope of the line indicates the rate of increase or decrease,
  4. Parallel lines, regardless of their magnitude, depict similar rates of change (1).

Tabular Presentation

Following the Technical Notes are data tables that present the data points graphed in each figure. Some data tables contain additional data that were not graphed because of space considerations. Standard errors for data points are provided for many measures. Additional information clarifying and qualifying the data are included in table notes and Appendix I and II references.

Survey Questions and Coding:

Additional information on data used in the Chartbook and Special Feature, including exact wording of questions and coding schemes, is detailed below.

National Health Interview Survey (NHIS)

Figure 8: Persons who engaged in regular leisure-time physical activity reported five or more sessions per week of light or moderate activity lasting at least 30 minutes or three or more sessions per week of vigorous physical activity lasting at least 20 minutes. See Appendix II, Physical activity, leisure-time.

Strength training: To assess participation in strength training activities, adults were asked: “How often do you do leisure-time physical activities specifically designed to strengthen your muscles such as lifting weights or doing calisthenics?” (Include all such activities even if you have mentioned them before). This figure shows estimates for those who reported engaging in strength training at least twice a week.

Figure 22: Data are based on the patient’s main complaint, symptom, or other reason for visiting the emergency department and were coded according to A Reason for Visit Classification for Ambulatory Care (RVC). Up to three reasons could be coded per visit, and only the most important reason (principal reason) coded was used in this analysis. The following codes were used in this analysis:

Abdominal pain: 1545.0, 1545.1–1545.3

Chest pain: 1050.0, 1050.1, 1050.2, 1050.3

Fever: 1010.0

Headache: 1210.0

Cough: 1440.0

Figure 24: These questions were asked of respondents living in the community. “During the past 12 months, have you had a flu shot? A flu shot is usually given in the fall and protects against influenza for the flu season.” Estimates exclude persons who reported Flu Mist. Respondents were asked: “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot.”

Figure 31: See Appendix II, Alcohol consumption, Cigarette smoking.

Figure 35: Data are for the civilian noninstitutionalized population. Young adults who reported more than one condition were counted in each category. Conditions refer to response categories in the NHIS. Conditions, except for current asthma, were determined by asking “Have you ever been told by a doctor or other health professional that you had a specific condition?” Current asthma prevalence estimates are also based on the question, “Do you still have asthma?” Arthritis includes arthritis, rheumatoid arthritis, gout, lupus, and fibromyalgia. Diabetes includes all types with the exception of diabetic conditions related to pregnancy. Heart disease includes coronary heart disease, angina or angina pectoris, or heart attack or myocardial infarction. Cancer excludes nonmelanoma skin cancer or skin cancers of unknown types. Hypertension is told on two or more different visits. Condition questions were asked of the young adult during the sample adult questionnaire; and health status and activity limitation questions were asked of the survey respondent in the family questionnaire. See Appendix II, Health status, respondent-assessed; Limitation of activity.

Figure 39: This analysis is based on the following two questions: “The following questions were about the use of health care. Do not include dental care. DURING THE PAST 12 MONTHS, was there any time when [you/someone in the family] needed medical care, but did not get it because [you/the family] couldn’t afford it?” (In this analysis, results are presented for sample adults to be consistent with the rest of the chart. Therefore, estimates in this figure may differ slightly from those presented in Table 79.)

“DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn’t get it because you couldn’t afford it?” (asked of sample adults)

___ prescription medicines

___ mental health care or counseling

___ dental care (including checkups)

___ eyeglasses

Figure 40: This analysis uses the following five questions from NHIS, along with National Health and Nutrition Examination Survey data: “DURING THE PAST 12 MONTHS, HOW MANY TIMES have you seen a doctor or other health care professional about your own health at a DOCTOR’S OFFICE, A CLINIC, OR SOME OTHER PLACE?” DO NOT INCLUDE TIMES YOU WERE HOSPITALIZED OVERNIGHT, VISITS TO HOSPITAL EMERGENCY ROOMS, HOME VISITS, DENTAL VISITS, OR TELEPHONE CALLS.

“About how long has it been since you last saw a dentist?” Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

“DURING THE PAST 12 MONTHS, that is since {12 month ref. date}, have you seen or talked to any of the following health care providers about your own health? . . . A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker.”

“DURING THE PAST 12 MONTHS, HOW MANY TIMES have you gone to a HOSPITAL EMERGENCY ROOM about your own health?” (This includes emergency room visits that resulted in a hospital admission.)

“[Were you/has anyone in the family] been hospitalized OVERNIGHT in the past 12 months? Do not include an overnight stay in the emergency room.”

Data on doctor, dental, emergency room, and mental health professional visits are from the NHIS sample adult questionnaire and are weighted using the weight from that file. Data on hospital stays are from the NHIS family core questionnaire and are weighted using the weight from that file. For more information, see Appendix I, National Health Interview Survey (NHIS) and Appendix II, Dental visit; Emergency department or emergency room visit; Health care contact; Hospital utilization.

National Hospital Discharge Survey (NHDS)

Figure 25: See Appendix II, Table X for list of ICD–9–CM codes.

National Health and Nutrition Examination Survey (NHANES)

Figure 40: The questionnaire administered to all participants also included a question on whether they had taken a prescription drug in the past month. Those who answered “yes” were asked to show the interviewer the medication containers for all the prescriptions. For each drug reported, the interviewer entered the product’s complete name from the container. If no container was available, the interviewer asked the participant to verbally report the name of the drug. More information on prescription drug data collection and coding in NHANES is available from: http://www.cdc.gov/nchs/data/nhanes/frequency/rxq_rxdoc.pdf. Also see Appendix I, National Health and Nutrition Examination Survey.

National Survey of Family Growth (NSFG)

Figure 34: The National Survey of Family Growth (NSFG) provides national data on factors affecting birth and pregnancy rates, topics related to family formation, and reproductive health of men and women. In-person interviews were conducted with a sample of women and men age 15–44 years. Most of the survey was administered using computer-assisted personal interviewing, in which a trained female interviewer asks the questions and enters the answers into a computer. In the last portion of the survey, however, the respondent used the interviewer’s computer to answer the most sensitive items directly—including questions about forced sexual intercourse—by entering his or her own answers into the computer. The respondent could read the questions on the screen, as well as listen to them through headphones. The object of this interviewing technique is to give respondents a more private opportunity to report this sensitive information.

The questions about forced sexual intercourse were asked only of respondents 18–44 years of age. Both women and men were asked about forced sexual experiences. For Figure 34, data are presented only for women. Whether the respondent had ever been forced to have intercourse was ascertained with the following question: “At any time in your life, have you ever been forced by a male to have vaginal intercourse against your will?” This question is used in conjunction with the responses to two sets of questions. The first set of questions related to the respondent’s first vaginal intercourse. The second set related to sexual intercourse subsequent to the first time. For the first set of questions, respondents were asked: “Would you say then that this first vaginal intercourse was voluntary or not voluntary, that is, did you choose to have sex of your own free will or not?” Respondents who selected “not voluntary” in response to this question were classified as having been forced to have sexual intercourse. The second series of questions began with this question: “(Besides the time you already reported,) have you ever been forced by a male to have vaginal intercourse against your will?” Respondents who selected “yes” in response to this question were classified as having been forced to have sexual intercourse. In both series of questions, respondents indicating that they had been forced to have sexual intercourse were asked additional questions that elicited the age at which this first happened and the type of force that was used. Respondents were asked if each of seven different types of force was used and could indicate as many types of force as appropriate. The types of force asked about were:

  • ▪ Were you given alcohol or drugs?
  • ▪ Did you do what he said because he was bigger than you or a grownup, and you were young?
  • ▪ Were you told that the relationship would end if you didn’t have sex?
  • ▪ Were you pressured into it by his words or actions, but without threats of harm?
  • ▪ Were you threatened with physical hurt or injury?
  • ▪ Were you physically hurt or injured?
  • ▪ Were you physically held down?

For the purposes of Figure 34, women were classified as having been physically threatened or physically forced if they indicated that they were threatened with physical hurt or injury, physically hurt or injured, or physically held down. Women not reporting one of these types of force (but responding to at least one of the types of force questions), were classified as having been forced with nonphysical force. Women reporting forced sexual intercourse but not reporting the type of force used were included with nonphysical force.

The estimates presented in Figure 34 include both women who were forced on their first time of vaginal intercourse and those first forced at a subsequent time. If a respondent had been forced more than once, she is only counted once, because the data are at the person level. If a respondent reported that her first vaginal intercourse was not voluntary and also reported that she was subsequently forced to have sexual intercourse, the age at which she was first forced and the type of force used is based on her responses to the questions related to her first vaginal intercourse.

For more information on the survey, see Appendix I, National Survey of Family Growth (NSFG) and Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. Vital health stat 2005;23(25). Available from: http://www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf.

References

1.
Page RM, Cole GE, Timmreck TC. Basic epidemiological methods and biostatistics: A practical guidebook . Sudbury, MA: Jones and Bartlett Publishers; 1995.
2.
Jekel JF, Elmore JG, Katz DL. Epidemiology biostatistics and preventive medicine . Philadelphia, PA: W.B. Saunders Company; 1996.

Data Tables for Figures 1–41

Data table for Figure 1. Total population and older population: United States, 1950–2050

Data table for Figure 2. Population in selected race and Hispanic origin groups, by age: United States, 1980–2007

Data table for Figure 3. Children under 18 years of age living with a single parent, by race: United States, 1970–2006

Data table for Figure 4. Poverty by age: United States, 1966–2006

Data table for Figure 5. Low income by age, race and Hispanic origin: United States, 2006

Data table for Figure 6. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2007

Data table for Figure 7. Overweight and obese, by age: United States, 1971–1974 through 2005–2006

Data table for Figure 8. Regular leisure-time physical activity and strength training at least twice a week among adults 18 years of age and over, by sex and age: United States, 1999–2006

Data table for Figure 9. Incidence of acute viral hepatitis, by type: United States 1966–2006

Data table for Figure 10. Current asthma prevalence among adults 18 years of age and over, by sex, race and Hispanic origin, and percent of poverty level: United States, 2004–2006

Data table for Figure 11. Limitation of activity caused by selected chronic health conditions among children, by age: United States, 2005–2006

Data table for Figure 12. Limitation of activity caused by selected chronic health conditions among working-age adults, by age: United States, 2005–2006

Data table for Figure 13. Limitation of activity caused by selected chronic health conditions among older adults, by age: United States, 2005–2006

Data table for Figure 14. Life expectancy at birth and at 65 years of age, by race and sex: United States, 1970–2005

Data table for Figure 15. Infant, neonatal, and postneonatal mortality rates: United States, selected years 1950–2005

Data table for Figure 16. Death rates for leading causes of death for all ages: United States, 1950–2005

Data table for Figure 17. Health insurance coverage at the time of interview among persons under 65 years of age: United States, 1984–2006

Data table for Figure 18. Uninsured for at least part of the 12 months prior to interview among persons under 65 years of age, by length of time uninsured and selected characteristics: United States, 2006

Data table for Figure 19. Personal health care expenditures, by source of funds and type of expenditures: United States, 2006

Data table for Figure 20. Per capita personal health care expenditures, by state of residence: United States, 2004

Data table for Figure 21. Visits to physician offices and hospital outpatient departments for attention-deficit/hyperactivity disorder (ADHD) among children 4–17 years of age, by sex and age: United States, 1996–2006

Data table for Figure 22. Selected principal reasons for emergency department visits, by age and sex: United States, 2006

Data table for Figure 23. Dental visits for teeth cleaning by a dentist or dental hygienist in the past year among persons 2 years of age and over, by selected characteristics: United States, 2003–2004

Data table for Figure 24. Influenza and pneumococcal vaccination among middle-age and older adults, by age: United States, 1989–2006

Data table for Figure 25. Total discharges and any-listed pneumonia discharges from nonfederal short-stay hospitals among persons 65 years of age and over, by age: United States, 1979–2006

Data table for Figure 26. Cesarean delivery rates by maternal age: United States, 1990–2005

Data table for Figure 27. Selected characteristics of young adults 18–29 years of age, by age and race and Hispanic origin: United States, 2007

Data table for Figure 28. School enrollment of young adults 18–29 years of age, by age, sex, race, and Hispanic origin: United States, 1980–2005

Data table for Figure 29. Low income among young adults 18–29 years of age, by sex, race and Hispanic origin: United States, 2004–2006

Data table for Figure 30. Live births for unmarried women 18–29 years of age, by age, race and Hispanic origin: United States 1990–2005

Data table for Figure 31. Cigarette smoking and alcohol use among young adults 18–29 years of age, by sex and age: United States, 1997–2006

Data table for Figure 32. Illicit drug use among young adults 18–29 years of age, by age: United States, 2006

Data table for Figure 33. Prevalence of human papillomavirus (HPV) infection among women 20–29 years of age, by selected characteristics: United States, 2003–2004

Data table for Figure 34. Any report of forced sexual intercourse before age 30 among women 18–44 years of age at interview, by type of force, race and Hispanic origin, and percent of poverty level: United States, 2002

Data table for Figure 35. Selected physician-diagnosed health conditions, respondent-assessed fair or poor health, or activity limitation due to a chronic condition among young adults 18–29 years of age, by sex: United States, 2004–2006.

Data table for Figure 36. Selected mental disorders in the past 12 months among young adults 20–29 years of age, by sex and age: United States, 1999–2004

Data table for Figure 37. Death rates for leading causes of death among young adults 18–29 years of age, by sex: United States, 1980–2005

Data table for Figure 38. Health insurance coverage at the time of interview among young adults 18–29 years of age, by age: United States, 2006

Data table for Figure 39. Young adults 18–29 years of age reporting they did not receive needed health-related services in the past 12 months because they could not afford them, by sex and health insurance status: United States, 2004–2006

Data table for Figure 40. Selected types of health care utilization among young adults 18–29 years of age, by sex: United States, 1999–2004 and 2006

Data table for Figure 41. Injury-related visits to hospital emergency departments among young adults 18–29 years of age, by sex and mechanism of injury: United States, 2005–2006

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