Summary
INTRODUCTION: According to the UN Special High
Level meeting on global non-communicable diseases, high fat diet, inactivity
and substance abuse are risk factors. These exacerbate events for
cardio-vascular (CV) diseases, lung diseases, hormonal deficiencies, obesity
and cancer. Medical check-ups make it possible for earlier diagnosis of CV risk
factors. Physical exercises help reduce CV risks. Early, timely and regular
medical check-ups, active lifestyle, moderate use of alcohol and non-smoking
help in timely diagnosis and management of metabolic-syndromes. This study
sought to gauge these levels of activity, risk-factors and attendances for
medical check-ups among ‘Ugandan-in-America’. By ‘Ugandan-in-America’ is meant,
a person of Ugandan descent who has stayed in USA for 6 months to 20 years or
beyond.
METHOD:
Using key informant interview and
observation guides, 3 categories of Ugandans in America were followed for 7
months from August 2012- Feb 2013. The
breakdown is as follows: 70 were above 50 (32 females: 38 males); 100 were
between 30-40 years (52 females: 48 males) and; 20 who were between 15-22 years
(15 males: 5 females). The states visited were Illinois, Massachusetts,
California and Texas.
FINDINGS: In the past 12 months, 30 (thirty) respondents had
gone once for a medical check-up: 12 were above 50 years; 7 were between 30-40
years; 10 were between 15-22 years. 22 (22-30 years) had accessed
ante/post-natal services. 12 (3 males: 9 females) chronic care and for
anti-hypertensive medications. 2 males (19 & 23 years) accessed cancer
treatment services regularly. 22 (2 were above 50 years and 20 were below 36
years) had engaged in a regularized physical fitness activity. 65 continued
taking OTC pain relievers. All 190 had attended a Ugandan-led social gathering.
12 deaths related to end-stage heart disease and 2 from sickle-cell-anemia were
noted.
“I do play soccer
and am on the school soccer team. We are 4 children and our parents have bought
membership for us at the local YWCA. My father and mother are members too but
they never come to exercise. I do attend social gatherings organized by
Ugandan-Americans” [Key Informant, 15
year old teenager.]
Conclusion: Efforts to encourage
‘Ugandans-in-America’ to adopt lifestyles that promote quality life in USA are
possible through their peer networks. These act as primary mobilization
platforms for population health services.
Introduction:
Two factors; ‘low activity’ and ‘risky nutrition’ used in this paper are based on experiential
initiatives by respondents. They, however, are not the only factors hindering
access to health services and adoption of practices that help prevent
endocrine-related illnesses in Ugandan-American. When it comes to
non-communicable diseases, integration of prevention initiatives should be
combined to target endocrine, tobacco[i]
and alcohol-related morbidity and mortality. The term ‘activity’ in this paper covers: personal initiative to seek out a
health care provider; engaging in exercise; to ensure foods or ingested substances
are healthy and; joining health clubs or support initiatives. As a new comer
demography, Ugandan-Americans can use their households (see table 2) or
community meetings to promote a culture of scheduled weight control. This can
be an entry point into encouraging various forms of positive adherence. Uganda
is one of the countries in Africa. It is on the eastern side in an
economical-geopolitical zone called East-Africa. Ugandans are ‘new-comers’ in
USA (In this paper the terms used interchangeably are: Ugandans-in -America or Ugandan-Americans.
The terms are not in the same sense as that of the United States Citizenship
and immigration services. They are used to provide insight into real-time
physical address). Being new, Ugandan-Americans need support and empowerment to
access or afford social services such as, health. This calls for adopting
behavior, dedication and re-education to understand the USA targeted health
objectives. The conceptual approaches of family medicine[ii]
that promote a beneficial relation between doctor-patient should be explored as
an entry point for many Ugandan-Americans who may not be familiar with
demanding, access and utilization of US health services. Medicine in the 21st Century has
been, and continues to be a life preserving influence. Life preserving
practices are prescriptive and self-executed based on informed choices,
affordability, proximity or peerage. The US has high quality medical services
with a variety of choices. These choices include: accessing screenings,
vaccinations and counseling with/without co-payment, co-insurance or deductible.
Depending on one’s age, and at no cost, it is possible to access: blood
pressure, diabetes, cholesterol, various cancer screenings, mammograms,
colonoscopies consequential counselling according to age and lifestyles, life
planning skills, nutrition counselling, weight control, well-baby, well
child-visits from birth to 21 years of age, routine vaccinations, ensuring
healthy pregnancies, pneumonia and flu shots. In order to enjoy the health
benefits it engenders adherence to efforts such as, routine visits to a
health-care provider. By taking an initiative to talk to one’s health care
provider, one not only receives healing, hope and compassion but information on
covered preventive services[iii].
In this case, one would expect universal, timely and regular health-seeking
behavior. However, this is not the case for Ugandan-Americans as this paper
attempts to show. Medicine as a service is now packaged and quantified in means
that make it user-friendly. The risks and benefits are now communicated with
the patient or client in mind. It makes it easier for a potential patient or
client to engage in negotiations for critical and prospective choices[iv].
In this paper, we show that for the average Ugandan-American, translating
health benefits into life preserving practices is still elusive. This paper was prompted by the 12 deaths
related to end-stage heart disease and 2 from sickle-cell anemia that occurred
during the same period of study. Medical intervention was sought in all cases
but, it was sought at a late stage. There was an expressed opinion that the ‘costs’
are exorbitant. Costs can be higher if one waits longer to see a doctor; in
such a situation a visit to the outpatient department may end up into
hospitalization. Efforts will be taken to quantify the influencing factors,
deterrents and enablers for Ugandan-Americans to prevent and control metabolic
syndromes. Risk factors for alcohol and tobacco-related morbidity and mortality
will be highlighted. Knowledge that alcohol, tobacco and endocrine-related
diseases are ‘silent killers’ has not been translated into Ugandan-American
life preserving lifestyles. The ‘silence’ means it is unseen, is not clear and
of no threat. This being the case there was no need to plan for it. These silent killers are in form of: cardio-vascular
(CV) diseases, lung diseases, hormonal deficiencies, obesity and cancer. Ugandans-in-American
need to establish community structures to address health issues. They need to
understand that non-communicable diseases are common causes of illnesses and
death. This can be in adults and children. The various aspects of US Health
policy and school health system are helping in ensuring school-age children
access health care services. The immunizations and routine check-ups were
adhered to. The housing, education, education
and social protection for families point towards lowered rates of child deaths.
There were cases of congenital anomalies receiving adequate treatment. It was
not possible to check out a large number of children to know extent of causes
of morbidity and mortality in children.
Child morbidity and mortality data list: injuries and poisonings;
neoplasms; circulatory diseases; digestive diseases; respiratory diseases;
infectious diseases; neurological disorders and; congenital anomalies[v].
If opportunity allows health aspects of children born to Ugandan-Americans will
be investigated in future. Marked characteristics among adult Ugandan-Americans
who formed the bulk of respondents for this study were observed between: the recent comers (below 2 years’ stay in
USA) and; those who have stayed here more than 2 years. Ugandan-Americans who
had stayed longer in US negotiated health better. There were those who were
formally employed and had insurance cover and; others whose jobs or work schedule
did not allow them time and space to seek medical check-ups. It is in the
latter group that the more risky practices such as: low or no annual medical
checkups, high fat diet, high salt ingestion, self medication, use of
pain-reliever OTCs, low morale for sports and marked substance use were found.
These are risk factors for non-communicable diseases[vi].
Medical checkups are an opportunity to initiate interventions in case any form
of infection, illness, anomaly or malignancy is detected. It reduces on missed
opportunities to break a cycle that would lead to debilitation, acute or
chronic situations. There are opportunities for mobilization of Ugandan-American
community members to embrace cultural tools engendering change towards quality
life in USA. According to the Ugandan-North American Association (UNAA), there
are over 100,000 adult Ugandans in USA who have interacted or attended UNAA
sponsored meetings since its inception. This is one medium of mobilization that
needs tapping into.
Methods:
This is a qualitative
study using an observational checklist and a key Informant Interview
guide. It was possible to get structured
answers to posed questions from identified respondents. Children helped in
corroborating information around nutrition and exercising as this statement
from a 15 year old teenager shows: “I do
play soccer and am on the school soccer team. We are 4 children and our parents
have bought membership for us at the local YWCA. My father and mother are
members too but they never come to exercise. I do attend social gatherings
organized by Ugandan-Americans.”
Key questions prompted conversation around
health, diet, work, sleeping patterns, diet, exercise, visits to health
facility and recreation. Participation and immersion in various Ugandan-American
communities at different locations in four (4) states of America with large
populations of Ugandans increased on representativeness.
Study
Population:
There are social patterns unique to Ugandan-Americans. Some include:
showers, social meetings, entrepreneur conferences and faith-based meetings.
These meeting spaces provided the bulk of respondents and subsequent focused
discussion was possible from these first time encounters. This study was done
in 7 months from August 2012- Feb 2013. 190 respondents were followed: 70 were
above 50 (32 females: 38 males); 100 were between 30-40 years (52 females: 48
males) and; 20 who were between 15-22 years (15 males: 5 females). The states
visited were Illinois, Massachusetts, California and Texas.
State
|
Illinois
Responses
|
Massachusetts
Responses
|
California
Responses
|
Texas
Responses
|
Aspect
(Out of 190 respondents or 45 H/holds)
|
Annual medical checkups (10)
|
Annual medical checkups (10)
|
Annual medical checkups (06)
|
Annual medical checkups (06)
|
Based
on 45 H/holds
|
High
Fat diet (07)
|
High
Fat diet (08)
|
High
Fat diet (11)
|
High
Fat diet (05)
|
Based
on 45 H/holds
|
High-salt ingestion (10)
|
High-salt ingestion (10)
|
High-salt ingestion (20)
|
High-salt ingestion (05)
|
Based
on 45 H/holds
|
Planned fresh fruits, vegetables, lean protein and
fiber as part of H/Hold meals (04)
|
Planned fresh fruits, vegetables, lean protein and
fiber as part of H/Hold meals (08)
|
Planned fresh fruits, vegetables, lean protein and
fiber as part of H/Hold meals (07)
|
Planned fresh fruits, vegetables, lean protein and
fiber as part of H/Hold meals (06)
|
Based
on 45 H/holds
|
Ensure green vegetables or salads as part of the
planned household nutrition; a chart recording weight or blood pressure
readings and regular visits to a health facility (02)
|
Ensure green vegetables or salads as part of the
planned household nutrition; a chart recording weight or blood pressure
readings and regular visits to a health facility (04)
|
Ensure green vegetables or salads as part of the
planned household nutrition; a chart recording weight or blood pressure
readings and regular visits to a health facility (05)
|
Ensure green vegetables or salads as part of the
planned household nutrition; a chart recording weight or blood pressure
readings and regular visits to a health facility (04)
|
Based
on 45 H/holds
|
Relate co-payment, coverage policy and US
Preventive services (04)
|
Relate co-payment, coverage policy and US
Preventive services (09)
|
Relate co-payment, coverage policy and US
Preventive services (08)
|
Relate co-payment, coverage policy and US
Preventive services (07)
|
Out of
190 respondents
|
Tobacco Use (05)
|
Tobacco Use (38)
|
Tobacco Use (24)
|
Tobacco Use (08)
|
Out of
190 respondents
|
Alcohol Use (07)
|
Alcohol Use (58)
|
Alcohol Use (34)
|
Alcohol Use (08)
|
Out of
190 respondents
|
Use of pain-relievers/Self medication OTC’s (10)
|
Use of pain-relievers/Self medication OTC’s (40)
|
Use of pain-relievers/Self medication OTC’s (38)
|
Use of pain-relievers/Self medication OTC’s (10)
|
Out of
190 respondents
|
Substance Use/Herbal Therapeutics (03)
|
Substance Use/ Herbal Therapeutics (10)
|
Substance Use/Herbal Therapeutics (08)
|
Substance Use/Herbal Therapeutics (04)
|
Based
on 45 H/holds
|
Physical exercise/ form of sports (05)
|
Physical exercise/ form of sports (05)
|
Physical exercise / form of sports (06)
|
Physical exercise/ form of sports (05)
|
Table
1 Aspects per states visited
State
|
Illinois
|
Massachusetts
|
California
|
Texas
|
Weight Control at H/hold level (Based on
05 H/holds)/month
|
Physical
exercise/form of Sport (05)
|
Physical
exercise/form of Sport (05)
|
Physical
exercise/form of Sport (06)
|
Physical
exercise/form of Sport (05)
|
Bicycling
|
02
|
02
|
02
|
02
|
Aerobics
|
03
|
02
|
01
|
01
|
Tennis
|
02
|
02
|
04
|
04
|
Jogging
|
02
|
02
|
02
|
02
|
Brisk walk
|
02
|
02
|
02
|
03
|
Stair-walk
|
01
|
01
|
01
|
01
|
Leisure-walk
|
03
|
03
|
03
|
02
|
Dancing/Clubs
|
03
|
04
|
03
|
03
|
Swimming
|
04
|
04
|
04
|
02
|
In-door Treadmill/Elliptical
|
02
|
03
|
04
|
02
|
Sauna
|
02
|
02
|
02
|
02
|
Table 2 Weight
Control-related behavior and practices
Study
definitions and determinants:
Key determinants: sex;
age; legal status; length of stay in USA; living conditions (whether living in
apartments/suites or houses); checking use of medicines (whether they are OTCs
or prescribed medicines), social activities and; kind of food eaten including
medication. 45 house-holds (15 apartment/suites and 30 bungalow homes) in all were
visited (see table 1.) and the following were on the observation checklist;
observing for tell-tale sports shoes in the shoe racks; presence of an exercise
machine (e.g. elliptical or treadmill); inquiry into membership with a sports’
club and insurance plan and; sleeping patterns of house-hold members. A respondent was someone who had stayed in USA
for 6 months and above. Lifestyles observed to increase risks for CV included:
Inability to translate information about health objectives into life preserving
activities and poor or no linkage of weight to diet or vice versa. High fatty
foods, added sugar drinks in form of ‘quick foods’ and use of saturated fats were
noted variables (see table 1). Baseline variables included: ensuring green
vegetables or salads as part of the planned household nutrition; engaging in
sports/exercise; a chart recording weight or blood pressure readings and
regular visits to a health facility. A knowledgeable respondent was one who had
received counselling, knew their recent weight and blood pressure from a health
worker in USA, could relate co-payment, coverage policy and US Preventive
services to a minimum health seeking package and was ready to plan for a
healthy life. A compliant respondent attended
a medical check up health service in the past 12 months leading to up to the
study and engaged in a form of sport. Most house-hold settings provided
opportunities to engage in light house-chores, taking up a flight of more than
ten steps every day, running or a form of physical exercise that caused
sweating and any form of recreation. Ugandan-Americans have all the contexts
that define a beneficiary of the Affordable Care Act (ACA)[vii].
The ACA in offering first-dollar coverage for various preventive services
enables patients overcome a major deterrent from obtaining needed services[viii].
Analysis:
In carrying out this study socioeconomic status and health indicators
(SES) were used to link morbidity, mortality, health care utilization, health
risk factors, prevention, health insurance and personal health care. 32
households had members who had attended annual medical check-ups: respondents
here knew their recent weight and blood pressure from a health worker in USA In
all 45 households visited, high salt and fat ingestion was in form of ‘quick
foods’. When asked why, 110 respondents said ‘quick foods’ saved time. 45
respondents could not recall when they had last had fresh fruits, vegetables,
lean protein and fiber planned as part of the foods taken on a regular basis.
They cited job pressures left no spare time for shopping. They also did not
know their recent weight and blood pressure from a health worker in USA. Planned
fresh fruit, vegetables, lean protein and fiber as part of H/hold nutrition
plans occurred in 25 households. 15 households ensured green vegetables or
salads as part of the planned household nutrition had a chart recording weight
or blood pressure readings and a culture of regular visits to health facility
was established. 28 households had members who could relate co-payment,
coverage policy to US preventive services. They had plans outlined to visit
their health-care provider. They knew which health facilities their health care
providers belonged to. 75 respondents smoked. 99 respondents used alcoholic
drinks in above allowable measures. 108 respondents self-medicated using OTCs
regularly and did not their recent weight and blood pressure from a health
worker in USA. 138 respondents did not have health insurance cover or health
safety net provisions. 55 respondents used energy drinks and enhancement
supplements. 21 households had members engaged in regular sports/exercises (see
tables 1 & 2). The recorded sports were: tennis, bicycling, weight lifting,
aerobics, jogging and swimming. All the children under 19 years had completed
all immunizations and those with ailments were receiving medical care. This was
possible because they were beneficiaries of various insurance plans targeting
children. 43 adults were fully insured and it was possible for them to access
regular health care services including regular check-ups.
They knew their recent weight and
blood pressure from a health worker in USA. 53 (30 adults and23 children below
21 years) respondents had ever done a dental check up. As with other works there are observations
around health conditions for children below 18 years by family incomes among
Ugandan-Americans that reflect national percent of poverty level data and
insurance coverage[ix].
Reported cases of: asthma, attention deficit hyperactivity disorder, emotional
or behavioral difficulties, food allergy, skin allergy, respiratory allergy and
forms of infections were noted. In the past 12 months, 30 (thirty) adult respondents
had gone once for a medical check-up following unexplained headache and joint
pains.103 respondents had no voluntary plans to visit a health clinic. All 190
respondents could relate; no physical sports; use of tobacco; indiscriminate
sodium in-take; prolonged use of alcohol beyond allowable measures and; self
medication, e.g., decongestants, pain relievers, steroids, diet pills and some
antidepressants as risk factors for endocrine-related illnesses. 60 had
translated their knowledge into initiatives to prevent endocrine-related
illnesses. There is need to provide
information about practices that lower blood pressure. One such decision is to
switch to DASH-Dietary Approaches to Stop
Hypertension-diet. It involves eating more fruits, vegetables, whole-grain
foods, low-fat dairy, poultry and nuts. It is advisable to eat less red meat,
saturated fats and sweets as well as reducing sodium on one’s diet. Use of
medicines, exercise and forms of therapies that promote relaxation are other
ways to manage hypertension or control weight was noted on a low scale. Regular
exercise helps lower one’s blood pressure. It is advisable for adults to get
150 minutes of moderate-intensity exercise every week. This can include,
bicycling, aerobics, walking briskly, gardening. Muscle-strengthening
activities are recommended at least two days a week and should work all major
muscle groups[x]. 129
respondents had two or more jobs and none of the jobs provided health insurance
cover. In 17 households members pooled together funds for utilities and many
had two or more jobs. Having more than one jobs made it difficult to find spare
time for personal health care. All 190 had attended a Ugandan-led social
gathering. 12 deaths related to end-stage heart disease and 2 from
sickle-cell-anemia were noted. 20 households had 22 female respondents above 55
years. 08 had physician diagnosed diabetes and managed their diabetes with
medication, 06 were hypertensive and 04 engaged in physical exercises on a
weekly basis as a result of a health workers’ advice. Of the 38 males above 55,
19 were diabetic and had no recollections of where their charts and home
testing kits were. They were not engaged in strict glycemic control
procedures. 06 of the 38 males above 55 years said they
were aware of high blood pressure signs and engaged in physical exercise. Respondents
from 17 households had heard about cancer, diabetes and causes of hypertension.
Diabetes and hypertension are silent killers. Primary diagnosis of diabetes,
hypertension, glomerulonephritis, cystic kidney and urologic conditions should
not go untreated or poorly controlled because they end fatally as end-stage
renal disease[xi].
At national level there is a reported poor glycemic control among persons with
diagnosed diabetes with hemoglobin A1c of 9% and above in adults above 20[xii].
70 respondents had a form of health insurance, 90 had a life insurance “that in case of death would cover for
interning remains back in Uganda[xiii].”
The forms of social gatherings popular among Ugandan-Americans include:
showers, cultural galas, membership to organizations (Ugandan-North American
Association, Ugandan-Californian Community, and Ugandans at Heart,
Ugandan-Diaspora Boston Meetings, Ugandan-Catholic Associations,
Ugandan-Islamic associations, Ugandan-Protestant Association, Buganda Chapters
and other gatherings). All respondents had attended one or two gatherings in
which Ugandans in America meet. If Ugandan-Americans are motivated to attend
social-gatherings, it is possible to use these spaces for health outreach
services.
Discussion:
Understanding and
navigating the preventive services stands out highly for many Ugandan-Americans.
It is a skill that will give them confidence to access and plan for health.
There are a whole range of activities on a personal level Ugandan-Americans can
engage in to promote quality health. Sports, recreation, social meetings and support
clubs could be some. Ugandan-Americans need to set aside time to visit a
health-care provider to get to know issues around health status needs,
interventions and coverage.[xiv]
Ugandan-Americans need to establish community-led health care initiatives.
These are peer networks which in turn create a critical number that demands
health services and engages in health preserving practices. It makes it
possible to train health-care mobilisers from among Ugandan-Americans who in
turn conduct follow up services and continuum care adherence support. This was
echoed by two cervical cancer survivors receiving chemotherapy. These two were
of the view that there should be health education sessions targeting
Ugandan-Americans. This they hoped would be an empowerment in embracing
preventive practices such as vaccination. There was need to provide information
on benefits of inoculations of say, Human papilloma virus (HPV). There are
strains of cancer causing HPV which can be prevented by vaccines. The virus,
transmitted during sex, causes cervical cancer as well as vaginal, vulvar, anal
and oral cancers[xv].
The health education sessions, it was suggested should show advances in medical
fields but at the same time make it possible for one to make decisions to
access medical check-ups and the follow up continuum. Information as that found
in the Surveillance, Epidemiology and End Result (SEER) and Population-based
cancer registries should be made available in forms that promote informed
decisions. Ugandan-Americans need to be
made aware of morbidity, mortality, health care utilization, health risk
factors, prevention, personal health and insurance coverage. This model could
be replicated and should prepare them to adopt practices that promote health
lifestyles. It could contribute to lessening morbidity and mortality[xvi].
The number of new cancer cases per
100,000 population range from 7.5 in the case of Cervix uteri to 148.4 for
prostate cancer[xvii].
Ugandan-Americans need to relate this kind of information to their own lives. This
includes personal initiative to engage in life preserving practices. It is
possible to plan for health for a Ugandan-American community estimated at 60,000. The primary mobilization platforms can be through their peer networks.
This paper was written to inform that kind of mobilization.
Acknowledgements:
In
making this study as less intrusive as possible, the Ugandan-American community
leaders (with titles of ‘Mukulu’, ‘Kojja’or ‘Ssenga’ are the chosen elders) in
all states where Ugandans are found helped provide a soft landing spot. The
Ugandan-North American Association (UNAA) and various social spaces in which
Ugandan-Americans mix acted as insightful contexts.
[i]
American Lung Association, state of tobacco control 2013
report. Washington: American Lung Association, 2013.
[ii] Lucy M. Candib: Medicine and Family; A
feminist Perspective. New York: BasicBooks. 1995.
[iii] www.healthcare.gov/news/factsheets/2007/07/preventive-services-list.html
[iv]
Mol Annemarie: The Logic of Care: health and the problem of patient choice.
London: Routledge, 2008
[v] WHO Mortality Database, 2012
[vi] UN Special High Level meeting on Non-Communicable
diseases, 2012
[vii] Solanki G. Schauffer HH: Cost sharing and the
utilization of clinical prevention services. Am J Prev Med. 1999: 17 (2):
127-133.
[viii] Hinman AR: National Vaccine Advisory Committee.
Financing Vaccines in the 21st Century: recommendations from
National Vaccine Advisory Committee. Am J Prev Med 2005; 29 (1): 71-75.
[ix] Table 46 (pages
1-5). Health conditions among children under 18 years of age by selected
characteristics: United States, Average Annual, selected years 1997-1999
through 2008-2010; Health, United States 2011. Page 180.
[x]www.webmd.com/hypertension-high-blood-pressure/ss/slideshow-hypertension-overview?ecd=wnl_men_050713&ctr=wnl-men-050713_ld-stry&mb=
[xi] Tables 51(pages
1 & 2): End-stage renal disease
patients, by selected characteristics: United States, selected years 1980-2008:
Health, United States, 2011.
[xii] Tables 50
(pages 1 and 2): Diabetes Prevalence and glycemic Control among adults 20 years
of age and over by sex, age and race and Hispanic origin: United States,
selected years 1988-1994 through 2003-206: Health, United States, 2011; Pages 188-189.
[xiii]
A statement made by 62 year old diabetic and
hypertensive Ugandan-American female respondent from California, USA.
[xiv] www.healthcare.gov/law/features/rights/preventive-care/index.html
[xv] Telegram
& Gazette Friday, May 10, 2013, Page A 3.
[xvi] National
Center for health statistics: Health, United States 2011; with special feature
on Socioeconomic status and Health. Hyattsville, MD 2012.
[xvii] Tables 47
(pages 1-3): Age-adjusted cancer incidence rates for selected cancer sites,
selected geographic areas, selected years 1990-2008; Health, United States
2011; Trend Tables pages 181-184.
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