That succinct statement from Tennessee Department of Health Commissioner Susan R. Cooper, MSN, RN, sums up the sentiment of health professionals across the state reviewing data collected for the 2009 Tennessee Women's Health Report Card. "This report is consistent with other national reports on the state of women's health and can serve as a road map for charting our journey to better health," Cooper continued.

 

The report card was produced as a collaborative effort of Vanderbilt Institute for Medicine and Public Health (VIMPH), the Vanderbilt Institute for Clinical and Translational Research, Meharry Medical College, East Tennessee State University, the University of Tennessee Health Science Center and the Tennessee Department of Health.

 

"We benchmarked to the Healthy People 2010 goals, which are national goals," explained Katherine Hartmann, MD, PhD, deputy director for VIMPH and director of Women's Health Research at Vanderbilt. Data from 2002 and 2007 were evaluated against the national goals. If the trend for an indicator appeared to be worsening, the state lost a letter grade. For indicators that do not have a correlating Healthy People 2010 target, grading was based on the change in data from 2002 to 2007.

 

Not surprisingly, there were far more Ds and Fs than As and Bs. "I don't think we were blindsided in any way to find a number of indicators were bad," said Hartmann, "but I think it was good to take a step back and think about what that means in terms of individual women and the health system."

 

On the plus side, there was some good news. "I was actually pleasantly surprised at the number of women having some preventative screens like mammograms and Pap smears," noted Gloria Richard-Davis, MD, FACOG, professor and chair of the Department of OB/GYN at Meharry Medical College and the associate director of the Center for Women's Health Research.

 

In 2007, 75.8 percent of all Tennessee women age 40+ had a mammogram within a two-year window, earning the state an A in that category. African-American women actually had an even higher rate at 82.7 percent and Hispanic women followed at 81.7 percent. For women 18 and over, 87.6 percent had a Pap test within a three-year period, but that percentage earned a B for Tennessee. Caucasian women recorded a rate of 87 percent; African-American women came in at 93.9 percent; and Hispanic women lagged the group at 74.7 percent.

 

Cooper pointed out other good news included a decrease in death rates from diabetes, heart disease stroke and homicide between 2002 and 2007. She also highlighted improvements in several of the preventative health screening numbers including clinical breast exams. However, that category also pinpoints some of the frustrations in getting health messages out to culturally diverse populations. Caucasian (90.5 percent) and African-American (91.9 percent) both showed improvement in the number of women over age 18 having clinical breast exams, but Hispanic women fell sharply from 97.3 percent in 2002 to 80.6 percent in 2007.

 

"On the not-so-good side," Richard-Davis noted, "is the number of women who did not receive prenatal care." These figures continue to plague the state and have consequences that stretch far beyond the nine months of gestation. "Fewer women are entering prenatal care in the first trimester, and the percentage of women with no prenatal care is rising," said Cooper. "All of these factors impact infant mortality in this state. This is not acceptable."

 

Richard-Davis noted the state saw an increase among all women who received absolutely no prenatal care at all. "No care," she stressed, "literally dropping in and having a baby." She said in 2002, 1.1 percent of women in Tennessee fell into this category. In 2007, it increased to 4.7 percent. Caucasian women increased from 0.9 to 3.7 percent; African-American women jumped from 3.5 to 8.8 percent; and Hispanic women went from 5.3 to 11.1 percent in the five-year period.

 

"That's an increase that was very concerning for me … particularly when prenatal care is so important for that child getting off to a good start. Children are the base of our society. If they don't get a good start out the chute, their chances in life are diminished." She added that TennCare coverage makes it possible for all women to have access to care during pregnancy. "That is something we absolutely provide no matter what the normal insurance status is." She continued, "Are there real challenges or barriers to getting enrolled? I don't know, but those are questions we need to ask."

 

Hartmann found the clearest message to be the disconnect between behavioral choices and health outcomes.

 

"There are opportunities for people to invest in their own health by making modest and consistent changes that will really pay off and will pay off across many of the measures," she said. Hartmann added research has shown that even minimal increases in physical activity sustained over time could have a significant impact on important numbers like blood pressure within a window of just a few weeks. "Across the board, everything from diabetes to obesity, strokes, heart disease risk, hip fractures –– all of those are responsive to changes in physical activity and how we eat."

 

She added the benefits are staggering and include lower stress levels, better sleep, better bone health, more energy and better balance … which is particularly important for older women.

 

"One out of every three homes may have a person who gets no physical activity," Hartmann said. "Yet, the average number of hours television is watched in the United States is huge." In 2007, 33.4 percent of Caucasian women, 42.1 percent of African-American women and 27.5 percent of Hispanic women in Tennessee admitted to engaging in no physical activity in their leisure time. In addition to the impact on their own health, Hartmann worried about the example it sets for the rest of the family.

 

Richard-Davis also felt frustrated by the increases in obesity and lack of physical activity. She pointed out the increase in obesity as defined by a Body Mass Index of 30 or greater rose from 23.3 to 28.8 percent overall in Tennessee from 2002 to 2007. Nearly 40 percent of African-American women (38.7 percent) were categorized as obese in the latest data.

 

"It's one of those things we can control," she noted of diet and exercise. "It gets a lot of attention, but we're just not getting a lot of traction."

 

She and Hartmann both said every little bit helps. "Walking is good," pointed out Richard-Davis. "You don't have to run as long as you're moving in any way." Hartmann added, "I think people … especially women … have conflicting targets like 'pre-baby weight.' That's not to say don't chase your dreams, but we skip over the fact that the health benefits happen way before we get there."

 

Both physicians also recognize various barriers to better nutrition and exercise exist in both rural and urban areas –– from a lack of facilities to unsafe surroundings to food desserts. However, they also noted that simple steps could make a big difference … literally. Park farther away from the office, take the stairs instead of the elevator, and pack a healthy lunch.

 

Richard-Davis said pedometers are inexpensive and eye opening. "People have the concept, 'Oh, I'm always moving. I never sit down,'" she said. "If people wore them (pedometer), they'd realize how inactive they are."

 

Hartmann suggested physicians should take the lead in helping their patients connect the dots between small, manageable lifestyle changes and improvements in overall health. "Put it on the same part as, 'Take this medication.' I really am saying, 'What I want you to take each day is a few thousand more steps.'"

 

Commissioner Cooper concluded, "No one entity or department is singularly responsible for health. In fact, health is influenced by many factors, biological, socioeconomic, education, gender, and geography … as well as access to care and the healthcare visit.  Small changes in behaviors can contribute to better overall health.  Providers can help us share the messages: If you smoke. Quit. If you are not exercising every day, start today … five minutes soon becomes 30 minutes of regular physical activity. Urge your friends and family to incorporate more fruits, vegetables and whole grains into their diets. 

 

"From a policy perspective, this is the time to integrate health into all policies –– health, agriculture, education, urban design, economic development –– all policies at all levels. We need to ask ourselves the question, 'What health impact will this policy have on the health of Tennesseans?'"