Part A:
General Data Issues

1. Target Setting and Assessing Progress for Measurable Objectives

Target-Setting Methods

One of the three overarching goals for the Healthy People 2000 prevention initiative was to reduce health disparities among Americans.1 The framework of Healthy People 2010 has taken this a step further by proposing to “eliminate health disparities” as one of the two primary goals for the next decade.

To support this goal of eliminating health disparities, a single national target that is applicable to all select populations has been set for each measurable, population-based objective. Three guiding principles were used in setting targets for the measurable, population-based objectives:

Beyond this general guidance, the exact target levels were determined by the lead agency workgroups that developed the objectives. The workgroups used various methods for arriving at the target levels, including retention of the year 2000 target, computation of a statistical regression using current rates to project a target, knowledge of the programs currently in place and expected change, and expert judgment.

The following target-setting methods have been used:

The specific method for developing the target is described under each objective in Healthy People 2010.2

Assessing Progress

Most objectives are tracked by a single measure. For these objectives, progress will be assessed by the change from the baseline measure toward the target. Some objectives seek to increase positive behaviors or outcomes while others are stated in terms of decreasing negative behaviors or outcomes.

A number of objectives contain multiple measures. Progress will be assessed separately for each measure. For these objectives, therefore, the progress may be mixed if some measures are progressing toward the target and others are regressing. Whenever possible, assessment of progress should consider the standard errors associated with the data (see section 9. Variability of Estimates).

For some objectives, precise measures that match the objective are not available. In these cases, similar proxy measures may be used to track progress. The tracking data and methods for assessing progress will be reviewed during the midcourse review in 2005, and a determination will be made at that time whether any changes will be made.

References

1. U.S. Department of Health and Human Services (HHS). Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: HHS, Public Health Service (PHS), 1991.

2. HHS. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

2. Developmental Objectives

Developmental objectives are those that currently do not have national baseline data (see Reader’s Guide section in Healthy People 20101) and, therefore, currently have no operational definitions. Some objectives that contain several measures may have parts that are developmental. Developmental objectives indicate areas that need to be placed on the national agenda for data collection. They address subjects of sufficient national importance that investments should be made over the next decade to measure their change.

A potential data source has been identified for all developmental objectives or subobjective measures. These sources, along with other information, will be discussed in the operational definitions under “Comments.” As data are developed and become available for these objectives, operational definitions will be disseminated on the Internet and/or in Healthy Peoplepublications. No targets have been set for developmental objectives; targets will be proposed at the midcourse review for those developmental objectives that have baseline data.

Reference

1. HHS. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

3. Population Estimates

Healthy People 2010 uses population estimates from the U.S. Census Bureau to calculate morbidity and mortality rates for many of the objectives. Every 10 years, the Census Bureau conducts a full census of the resident population of the United States, Puerto Rico, and U.S. territories and collects data on gender, race, age, and marital status; the estimates produced represent the U.S. population as of April 1 of the census year. More detailed data on education, housing, occupation, income, and other information are also collected from a representative sample of the population (about 17 percent of the total population).1

The increasing diversity of the population has necessitated modification of the way race data are collected. In both the 1980 and 1990 censuses, a substantial number of persons did not specify a racial group that could be classified as any of the categories on the census form (white, black, American Indian, Eskimo, Aleut, Asian, or Pacific Islander).2 In 1980, the number of persons of “other” race was nearly 7 million; in 1990 it was almost 10 million. In both censuses, the majority of these persons were of Hispanic origin (based on response to a separate question on the form), and many wrote in their Hispanic origin, or Hispanic origin type (for example, Mexican, Puerto Rican) as their race.

The Census Bureau presents population data by race in two different ways. In decennial census publications, persons of unspecified race are maintained in the single category of “other.” For the purpose of providing comparable denominator data to other Federal and non-Federal data users, in both 1980 and 1990, the Census Bureau produced another set of population estimates for census years; in these population estimates, persons of unspecified race were allocated to one of the four tabulated racial groups (white, black, American Indian or Alaska Native, Asian or Pacific Islander), based on their response to the Hispanic question. These four race categories conform with Office of Management and Budget (OMB) Directive 153 and are more consistent with the race categories used in most major data systems, including vital statistics.4 The postcensal and intercensal population estimates described below are based on these “OMB-consistent” populations.

Postcensal Population Estimates

National population estimates for the years after the decennial census (postcensal estimates) are calculated using the decennial census as the base population and adjusting those counts using the following measures of population change: births and deaths (provided by the National Center for Health Statistics), immigration data (provided by the U.S. Immigration and Naturalization Service), data on the movement of Armed Forces personnel (from the U.S. Department of Defense [DoD]), movement between Puerto Rico and the U.S. mainland (from Puerto Rico Planning Board), and movement of Federal employees abroad (from the Office of Personnel Management and DoD). These estimates reflect the U.S. population as of July 1 of each year (see figure 1). Postcensal estimates for State and county populations are also calculated using these data, as well as data from the Internal Revenue Service and State departments of education. Postcensal estimates become less accurate as the date of the estimates moves farther from the date of the census.5

Intercensal Estimates

After the decennial population census, intercensal estimates for the preceding decade are calculated to replace postcensal estimates. These estimates reflect the population as of July 1. Intercensal estimates are more accurate than postcensal estimates because they incorporate data from the enumerations at the beginning and end of the decade. The intercensal estimates for the 1980s were used to revise some of the baselines for mortality objectives in Healthy People 2000; these were published in the Healthy People 2000 Midcourse Review and 1995 Revisions.6 The method that will be used to calculate intercensal estimates for the decade between 1990 and 2000 has not been developed because of the change in race and ethnicity data that will be collected in the year 2000 census (see section 4: Population Template). However, when the intercensal estimates for the decade become available, they will be used to recalculate some of the morbidity and mortality data for Healthy People 2010 baselines and tracking data for data years prior to the year 2000.

Population Undercounts

Some subgroups of the population (including some racial, ethnic, and age groups) are less likely than other groups to be completely enumerated in the decennial census. The undercounts of these groups lower the denominators and result in higher morbidity and mortality rates for these populations.7, 8 The Census Bureau makes estimates of net census undercount for the total, white, and black or African American populations by age. These estimates are then used to weight the populations used by most of the national health surveys, including National Health Interview Survey (NHIS), National Health and Nutrition Examination Survey (NHANES), the National Survey of Family Growth, and the National Health Care Surveys. The National Vital Statistics System (NVSS) (mortality and natality) use population denominators that are not adjusted for net census undercount.

Target Populations

Several types of target populations are used for Healthy People 2010objectives:

Resident Population

The resident population includes all persons whose usual place of residence is in one of the 50 States or the District of Columbia, including Armed Forces personnel stationed in the United States. The resident population is usually the denominator when calculating birth and death rates from the NVSS and incidence of disease rates from a number of data systems. The resident population is also the denominator for selected population-based rates that use numerator data from the National Nursing Home Survey.

Civilian Population

The civilian population is the resident population, excluding members of the Armed Forces (although their family members are included). The civilian population is the denominator for other Healthy People 2010 data sources, such as the National Hospital Discharge Survey.

Civilian, Noninstitutionalized Population

The civilian, noninstitutionalized population is the civilian population not residing in institutions (for example, correctional facilities, psychiatric hospitals, and nursing homes). This population is the denominator for rates from Healthy People data sources such as the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey. This population is also used in the weighting procedure to produce national estimates from health surveys such as NHIS, NHANES, and the National Household Survey on Drug Abuse.

Details on the specific populations targeted for each major Healthy People 2010data system can be found in the data source tables included in Part C: Major Data Sources. The objective operational definitions shown in Part B indicate the population covered by each objective, if applicable.

References

1. Detailed information on the methodology used to collect census data is available from the U.S. Bureau of the Census Web site: http://www.census.gov.

2. U.S. Bureau of the Census. U.S. population estimates, by age, gender, race and Hispanic origin, 1980–91. Current Population Reports. Series P-25, No. 1095. Washington, DC: U.S. Department of Commerce, 1992.

3. Office of Management and Budget (OMB). Directive No. 15. Race and ethnic standards for Federal statistics and administrative reporting. Statistical Policy Handbook. Washington, DC: OMB, 1978.

4. National Center for Health Statistics (NCHS). Vital Statistics of the United States, 1992, Vol. I Natality. Technical appendix. Hyattsville, MD: U.S. Department of Health and Human Services (HHS), Public Health Service (PHS), 1996.

5. Byerly, E. R., and Deardorff, K. National and State Population Estimates: 1990 to 1994. U.S. Bureau of the Census, Current Population Reports, P25-1127. Washington, DC: U.S. Government Printing Office, 1995.

6. PHS. Healthy People 2000 Midcourse Review and 1995 Revisions. Washington, DC: HHS, 1995.

7. NCHS. Vital Statistics of the United States, 1992, Vol. II Mortality, Part A. Technical appendix. Hyattsville, MD: HHS, PHS, 1996.

8. Rosenberg, H.M.; Maurer, J.D.; Sorlie, P.D.; et al. Quality of death rates by race and Hispanic origin: A summary of current research, 1999. NCHS. Vital and Health Statistics 2(128), 1999.

4. Population Template

Minimum Template

During the review of the September 1998 Healthy People 2010 Draft for Public Comment,1 the need for greater consistency in tracking population groups became apparent. To address this issue, a minimum template for all Healthy People 2010 population-based objectives was adopted. Population-based objectives may show more detailed and additional breakouts if appropriate.

This minimum select population template applies to most currently measurable population-based objectives and will be applied to developmental population-based objectives (see section 2. Developmental Objectives) when data become available. The template does not apply to non-population-based objectives such as those that measure schools, worksites, or States. Because of problems in interpreting risk, the template is also not shown for population-based measurable objectives that are tracked using counts of events rather than rates or percents.

The minimum template for all population-based objectives is:

Race:

               American Indian or Alaska Native

               Asian or Pacific Islander

                   Asian

                   Native Hawaiian or Other Pacific Islander

               Black or African American

               White

Hispanic origin and race:

               Hispanic or Latino

               Not Hispanic or Latino

                   Black or African American

                   White

Gender:

               Female

               Male

Socioeconomic status:

               Family income level-   or         Education level-

                   Poor                                                   Less than high school

                   Near poor                                           High school graduate

                   Middle/high income                             At least some college

The groups listed under most headings (race, Hispanic origin, gender, and income) in the minimum template are comprehensive; that is, they are intended to sum to the population (excluding “unknowns”) tracked by the objective. For example, the three groups under income equal the total population tracked by the objective. The exception is the education category, which is limited to people of a minimum age or, in some cases, a maximum age (see Socioeconomic Status discussion below). The groups listed under the subheading “Not Hispanic or Latino” are not inclusive.

If data are not provided for a group, this is indicated by one of four statements: data have been collected but have not yet been analyzed (DNA), data are not collected by the data system used to track the objective (DNC), data are statistically unreliable (DSU), or the specific breakout is not applicable (NA). In cases where data for the entire template are not collected by the data system tracking the objective, a note to this effect will replace the template. For more information on statistical reliability, see section 9: Variability of Estimates.

Race and Hispanic Origin

OMB Classification

On October 30, 1997, the Office of Management and Budget (OMB) published “Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity” (Federal Register, 62 FR 58781- 58790).2 The new standards revise OMB Directive No. 15, adopted on May 12, 1977,3 and modify the data collection policy, making it possible for Federal agencies to collect information that reflects the increasing diversity of our Nation’s population stemming from growth in interracial marriages and immigration. As a result, the ways that data on race are tabulated and analyzed also will become more complex. Draft provisional tabulation guidelines, posted on the Internet at http://www.whitehouse.gov/
WH/EOP/OMB/html/misc-doc.html, provide options for tabulating and for bridging between data collected under the old and new standards.4

The new standards are being used by the U.S. Census Bureau in the 2000 decennial census. Other Federal programs are adopting the standards as soon as possible, but not later than January 1, 2003, for use in household surveys, administrative forms and records, and other data collections.

OMB Directive No. 15, still in effect as tracking of the Healthy People 2010 objectives begins, defined the basic racial and Hispanic origin categories for Federal statistics and program administrative reporting as American Indian or Alaska Native, Asian or Pacific Islander, Black, White, and Hispanic.3 The distribution of the U.S. population in 1998 by race and Hispanic origin is shown in figures 2 and 3, respectively, using the OMB Directive No. 15 categories. Although baselines and the first few years of tracking are guided by OMB 15, sometime during the decade the race and Hispanic origin classifications for objectives will change. Change in the categories is not expected to happen all at once, but will be implemented incrementally as data systems adopt the new standards and, if applicable, denominator data from the Census Bureau for rates and percentages become available.

The major changes to the reporting of data on race and Hispanic origin under the new guidelines are (1) the instruction to “mark one or more” racial categories, and (2) the dividing of the “Asian or Pacific Islander” category into two separate categories— “Asian” and “Native Hawaiian or Other Pacific Islander.” The new OMB standards also call for tabulating data for multiple races. Because these guidelines have generally not yet been implemented by most major health data systems, data for more than one race are not shown. When data are available for more than one race for most of the major Healthy People 2010data systems, they will be included in the tracking data. Also, most data systems currently do not produce data separately for the Asian and Native Hawaiian or Other Pacific Islander populations. Until data are tabulated for these groups, they will be shown as not collected.

Other changes include (1) “Hispanic” origin has been replaced by “Hispanic or Latino” (the preference remains for collecting these data in a separate question, the way it is presently being done on most Federal data collection forms), (2) Central and South American Indians, formerly not included in the “American Indian” category, are now included, and (3) the former “Black” category is replaced by “Black or African American.” Race and Hispanic origin may be reported in more detail for some objectives, subject to satisfying agency criteria for statistical reliability and confidentiality. For example, “Puerto Rican,” “Mexican,” and “Cuban” may be reported separately within the “Hispanic or Latino” group.

Under the new policy, agencies are required to offer respondents the option of selecting one or more of the following five racial categories included in the updated standards:

These five categories are the minimum set for data on race for Federal statistics, program administrative reporting, and civil rights compliance reporting. The new standards explicitly do not include an “other race” category for data collection; an “other” category may be used for tabulating and data reporting.3 Issues related to an “other” race category for census population data are discussed in section 3: Population Estimates. For Healthy People 2010, the designation “African American” will be used interchangeably with “Black or African American.”

The standards require that at a minimum, the total number of persons identifying with more than one race be reported when data are available. It is stressed that this is a minimum; the presentation of detailed information on specific racial combinations subject to constraints of data reliability and confidentiality standards is preferred. Based on preliminary research, it is estimated that less than 2 percent of the Nation’s total population is likely to identify with more than one race.3 Over time, this percentage may increase as those who identify with more than one race become aware of the opportunity to report more than one race group.

The standards regarding Hispanic origin provide for the collection of data on whether or not a person is of “Hispanic or Latino” culture or origin. This category is defined as follows:

Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or  Latino.” Persons of Hispanic origin may be of any race and persons in the various race groups may be of any origin.

To provide flexibility and to assure data quality, the new OMB guidelines recommend that a two-question format (separate race and Hispanic ethnicity questions) be used, especially when self-identification is used. When race and ethnicity are collected separately, ethnicity should be collected first. Most Healthy People data systems that use self-identification, such as the National Health Interview Survey and the National Health and Nutrition Examination Survey, use the two-question format.

When self-identification is not feasible (for example, the National Notifiable Disease Surveillance System) or when there are overriding data collection considerations (for example, the Youth Risk Behavior Surveillance System), a combined race and ethnicity question can be used which includes a separate Hispanic category co-equal with the other (racial) categories. When a combined question is used, more than one entry (race and ethnicity or multiple races) is also possible.

Misreporting Racial and Ethnic Data

Most health survey and census population data use the self-reported race of the respondent, which is considered the most accurate representation of a person’s racial or ethnic background. However, some data systems, such as the National Vital Statistics System (mortality), do not collect self-reported race or ethnicity of the decedent. In other systems, such as those derived from hospital/patient care records, it is often unclear whether the information is self-reported. In these cases, race and ethnicity may be entered by someone else (clerical staff, hospital personnel, etc.) based on the report of proxy respondents or by observation. Several of these data systems are discussed below.

National Vital Statistics System (Mortality)

Death rates by race and Hispanic origin may be biased from misreporting of race and Hispanic origin in the numerator of the rates and misreporting and undercoverage in the denominator of the rates.5 Numerator information is from the death certificate as reported by the funeral director based on information from an informant, usually a family member;6 while denominator information, from surveys or the Census of Population, is either self-reported or is reported by a member of the household. Based on comparisons of death certificate information with that from independent sources such as the Current Population Survey, the quality of reporting of race and Hispanic origin on the death certificate is good for the white and African American populations; however, reporting of other groups may be seriously under-reported.7 Additional reporting problems, such as net census undercount (see section 3: Population Estimates), affect population counts and estimates.8 As a consequence of the combined effect of numerator and denominator biases, it has been estimated that death rates for the white population are overestimated by about 1 percent and for the African American population by about 5 percent; and are underestimated for the American Indian or Alaska Native population by approximately 21 percent; Asian or Pacific Islanders, 11 percent; and Hispanics, 2 percent.5 These estimates are approximations; they do not take into account differential misreporting by age and sex among the race/ethnic origin groups.

For Healthy People 2010, infant mortality rates for races and ethnic populations are based on linked files of infant deaths and live births.9 These rates use the race of mother as self-reported on the birth certificate and, therefore, are not affected by the misreporting of race on the death certificate.

Patient Care Data

Data from systems that use patient records such as the National Hospital Discharge Survey (NHDS), the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, the National Notifiable Disease Surveillance System, the HIV/AIDS Surveillance System, also may misreport the race of individuals. It is often unclear how race and ethnicity are reported in these systems. The race and ethnicity of the patient may be reported by hospital or other medical care personnel by observation, by proxy report, or by the patient. Therefore, one must use information on race and ethnicity from these systems with caution.

Missing Data

In addition to the problems of misreporting race and ethnicity, the information on race reported by some data systems are often missing or incomplete. Some of these systems are described below. Specific information on the quality and completeness of reporting of race and ethnicity for the major Healthy People 2010data systems is included, where available, in the data source description in Part C: Major Data Sources.

National Hospital Discharge Survey

Race is not reported in about 18 percent of NHDS records since data on race are not reported by many hospitals due to the omission of a race field on hospital discharge reporting forms.10 More hospitals have automated their discharge systems in recent years and are currently using form UB-92 which does not require race reporting. A comparison of NHDS data with data on persons who reported being hospitalized in the National Health Interview Survey (NHIS) (NHIS data were adjusted to exclude hospitalizations of 1 day or less) indicated that underreporting for the white patients was about 22 percent in 1991; the difference for African Americans was negligible.10 Hispanic origin is not reported for 85 percent of the NHDS records.

National Ambulatory Medical Care Surveys

For the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey, race is not reported for about 11 percent of records.

National Notifiable Disease Surveillance System

Although staff in State health departments and CDC attempt to obtain complete demographic information associated with nationally notifiable cases of disease, some data (particularly for the variables of race and ethnicity) are not available for some cases of disease. Laws, regulations, and mandates for public health reporting (including specific data items that are reported) fall under the authority of individual States, and in some States, race and ethnicity may not be approved for reporting to the national level. Race and ethnicity data may also be unknown when cases are reported from a laboratory or when cases are reported as aggregate disease totals.

Socioeconomic Status

One of the three overarching goals for the Healthy People 2000 prevention initiative was to reduce health disparities among Americans.11 The proposed framework of Healthy People 2010has taken this a step further by proposing to “eliminate health disparities” as one of the two primary goals for the next decade. While disparities among racial and ethnic groups—especially between whites and African Americans—have received considerable attention over the last decade, differential health outcomes and access to social and health care resources often reflect differences in education, occupation, income, and wealth. Monitoring progress toward eliminating social and economic disparities in health over the next decade will require improved collection and use of standardized data on the socioeconomic status of individuals.

Socioeconomic status (SES) may be represented by income, level of education, or type of occupation. Healthy People 2010 primarily uses education and income-related measures. The following discussion presents data issues for income and education measures.

Income

Income is the most common measure of socioeconomic status, and is probably the most relevant to health policy formulation. Current income provides a direct measure of the quality of food, housing, leisure-time amenities, and health care an individual is able to acquire, as well as reflecting the relative position in society. However, income may fluctuate over time so that income received in a given year may not accurately reflect one’s lifetime income stream or total wealth, the measures of resources more relevant to health. For example, elderly persons who have low incomes may also have accumulated assets that offset their need for a high annual income. Of particular importance in considering the relationship between income and health is the fact that income may be low because illness has limited the amount of income earned or prevented earning income entirely. The use of income as a measure of SES also involves more practical difficulties. In many heath surveys a substantial number of persons either do not know or refuse to report their incomes.12

For most objectives, income reflects total family income for a given reference period, usually the previous 12 months or last calendar year. However, some data systems, such as the Continuing Survey of Food Intakes by Individuals (CSFII), use the income of the household (which includes income of unrelated household members). These systems generally require household income for program purposes. When household income is used instead of family income this is noted in the template for the objective.

When income is selected for the template, poor, near poor, and middle/high income categories are used unless overridden by programmatic or data considerations (for example, Women, Infants, and Children (WIC) eligibility). In these special cases, the poverty categories appropriate for the program or system are used. For most health surveys, income is defined as money income before taxes and does not include the value of non-cash benefits such as food stamps, Medicare, Medicaid, public housing, and employer-provided fringe benefits.

Family Income Level

Converting income to poverty status adjusts for family size and inflation, facilitating comparisons among groups and over time. Poverty status measures family income relative to family size using the poverty thresholds developed by the U.S. Census Bureau, based on definitions originally developed by the Social Security Administration. These thresholds vary by family size and composition and are updated annually to reflect changes in the Consumer Price Index for all urban consumers. Families or individuals with income below their appropriate thresholds are classified as below the poverty level. Focusing simply on the dichotomy of “above” versus “below” poverty, however, obscures the full gradient of inequalities in income distribution and in health. Understanding burden across the income gradient provides information useful for potential eligibility expansions or other programmatic modifications. ForHealthy People 2010, the three categories of family level income that are primarily used (see figure 4 for the distribution of population by poverty status) are:

For a family of four, the average Federal poverty level weighted for family composition was $16,813 in 1998. Table 1 shows the 1998 poverty thresholds by size of family and number of related children under 18 years.

In addition to the limitations discussed for income, converting income to poverty status introduces other issues that need to be considered. If income data are collected by selecting an appropriate income category, rather than giving the actual dollar amount, then the conversion to poverty status must be performed using category means or medians and will thus result in some misclassification.

The process of setting the official poverty definitions is currently being reevaluated. In 1990, a committee of the U.S. Congress requested that the National Academy of Science/National Research Council (NRC) conduct a study of the official poverty measure. In the final report issued in 1995, the NRC’s Panel on Poverty and Family Assistance proposed a new approach for developing an operational definition of poverty. The proposed poverty measure would incorporate more broadly defined thresholds and a new definition of family resources (income) that includes the value of non-cash benefits such as food stamps, Medicare, Medicaid, public housing, and employer-provided fringe benefits and deducts work-related and medical expenses. The Census Bureau is currently conducting an extensive examination of the Panel’s recommendations and alternative procedures. Revising the official U.S. poverty measure could have implications for data collection and trend analysis in Healthy People 2010.

Education

Education is frequently used as the measure of SES in presentations of health data. There are several reasons for this preference. Education is generally more completely reported than income; usually 95 percent or more of respondents report their attained level of education. Unlike occupation, all adults may be characterized by their education level. Education, unlike income or occupation, remains fixed for most people after the age of 25 and usually is not influenced by health. In addition, education is highly related to both income and occupation.

Education cannot be used to characterize the socioeconomic position of children (except through the educational level of parents or head of household), and the average education level of the U.S. population has increased steadily over time, complicating comparisons across age groups. Between 1971 and 1997, the educational attainment of persons aged 25 to 29 years completing high school rose from 78 to 87 percent; the percentage with some college rose from 44 to 65 percent; and the percentage with 4 or more years of college rose from 22 to 32 percent.13 

Educational attainment is typically measured either by the number of years of education the individual has completed or by the highest credential received (see figure 5). The categories for educational attainment that are primarily used in Healthy People 2010 are:

In general, data on educational attainment are presented for ages beginning with 25 years, consistent with guidance given by the U.S. Census Bureau. However, objectives using different data systems may have different age groups for the education variable. The actual ages that are used to calculate educational attainment for some of the major Healthy People 2010 data systemsare shown in Table 2. Because of the requirements of the different data systems, the age groups used to calculate educational attainment for an objective may differ from the age groups used to report the data for other select populations and the overall measure of the same objective. For clarity, each objective in Healthy People 2010 states the age groups used to measure the levels in the educational attainment category and caution must be used in comparing the data by educational attainment with data for the main objective and other select populations.

Healthy People 2010 baseline education data for the mortality objectives are based on reports from 46 States and the District of Columbia. Mortality statistics do not report data by education for the elderly population (65 years and older) because the percentage with “education not stated” is higher for this group and because of possible bias due to misreporting of education on the death certificate. Misreporting of education on the death certificate tends to overstate the death rate for high school graduates (12 years of education) because there is a tendency for some people who did not graduate from high school to be reported as high school graduates on the death certificate; by extension, the death rate for the group with less than 12 years of education tends to be understated.14 

Other Population Groups

Several other groups were considered for inclusion in the minimum set of select populations but were left to the discretion of the workgroups to include under specific objectives where appropriate. These groups included urban/rural residence, health insurance status, disability status, age, sexual orientation, the institutionalized population, and immigrant status, some of which are discussed in greater detail below. Some objectives also include select populations of persons with specific conditions—such as persons with diabetes, persons with hypertension, and persons with arthritis.

Urbanization

Urban residence in Healthy People 2010is specified as either residing within or outside a metropolitan statistical area (MSA) or residing within or outside an urbanized area (UA) or urban place (called “urban” in the template) as designated by the U.S. Census Bureau (see figure 6 for a distribution of population by metropolitan and non-metropolitan residence).

Urban

Urban residence is defined as people living within the boundaries of an UA and the urban portion of places outside an UA that have a decennial census population of 2,500 or more. An UA is an area consisting of a central place(s) and adjacent urban fringe that together have a minimum residential population of at least 50,000 people and generally an overall population density of at least 1,000 people per square mile of land area. The U.S. Census Bureau uses published criteria to determine the qualification and boundaries of UA’s. For more information see the Census Bureau Web site at http://www.census.gov/geo/www/tiger/glossary.htm.

Metropolitan Statistical Areas (MSA’s)

Metropolitan statistical areas (MSA’s) are established by the U.S. Office of Management and Budget (see figure 6). The MSA standards are revised before each decennial census. When census data become available, the standards are applied to define the actual MSA’s. An MSA is a county or group of contiguous counties that contains at least one city with a population of 50,000 or more or includes a U.S. Census Bureau-defined urbanized area of at least 50,000 with a metropolitan population of at least 100,000. In addition to the county containing the main city or urbanized area, an MSA may contain other counties that are metropolitan in character and are economically and socially integrated with the central counties. In New England, cities and towns, rather than counties, are used to define MSA’s. A rural residence, using the MSA standard, is defined as residing outside of an MSA. For further information on MSA’s, see U.S. Department of Commerce, U.S. Census Bureau, State and Metropolitan Area Data Book.15

Health Insurance Status

Health insurance information applies only to persons aged under 65 years. Those 65 years and older are considered to be covered by Medicare. Respondents are considered to have health insurance if they are covered by either private or public health plans. Private insurance includes fee-for-service plans, single service hospital plans, and coverage by health maintenance organizations (HMO’s). Public insurance includes Medicaid or other public assistance, Aid for Families with Dependent Children (AFDC), Supplementary Security Income (SSI), Medicare, or military health plan coverage.

Disability

In 1980, the World Health Organization (WHO) published the first version of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) as a classification of the “consequences of disease.” The new version, ICIDH-2, a classification of functioning and disability, is currently undergoing field testing worldwide with a May 2001 target date for implementation.16

According to ICIDH-2, components of disability include:

The major sources of national data on people with disabilities include:

For Healthy People 2010, the major sources of disability data are the NHIS and NHANES for national data and the Behavioral Risk Factor Surveillance System (BRFSS) for State-level data. The NHIS has several variables that can be used to operationally define disability status, including limitation of activity, restriction of participation (bed days, work-loss days, school-loss days), and assessed health status.17 The NHIS was redesigned in 1997 and many of the variables, especially limitation of activity, may be somewhat different than those collected by the survey before 1997. The BRFSS also collects information on health-related quality of life, limitation of activity, and self-assessed health status.

Disability is operationally defined in a number of different ways for program purposes and for analytic and research purposes, depending on the data collected by the data systems. In Healthy People 2010, disability is primarily defined using information on activity limitation or the use of special equipment. The following are the definitions used for NHIS, BRFSS, and NHANES measures.

For the 1997 NHIS, a person is classified as having a disability if a “yes” response was obtained to any of the age-appropriate limitation questions or to the use of special equipment. (See the operational definition for the denominators used for objectives 6-2 (children) and 6-3 (adults) in Part B for the specific questions used from the 1997 NHIS.)

For NHIS data prior to 1997, the special equipment questions were not asked, so persons are categorized in the templates as “with activity limitation” rather than “with disabilities.”

State data are available from the BRFSS telephone surveys. For Healthy People 2010, using 1998 BRFSS data, people answering “yes” to any of the following questions define adults 18 years and older with disabilities:

Disability data from the NHANES are limited to the second phase of NHANES III (1991–94) and are calculated only for people 20 years and older. People are classified as having a disability if a “yes” response was obtained to any of the following questions:

The Centers for Disease Control and Prevention (CDC) has proposed that a standardized set of questions on disability status be developed. As standard questions are adopted by the data systems, the data produced from them will be incorporated into the Healthy People 2010 objectives that specifically identify people with disabilities. This presents the opportunity in the future to have a standard definition of people with disabilities that can be used across data systems and geographic levels. Objective 6-1 of Healthy People 2010 will track the incorporation of a standard definition in data systems used to monitor the Healthy People 2010 objectives.

To a large extent, disability measures are related to the generation of many summary measures discussed in the goals section of Healthy People 2010: Understanding and Improving Health.18 Summary measures of health generally combine information on mortality and health into a single measure. Many of these summary measures use variables that directly relate to disability status to generate the health component (often referred to as health-related quality of life) of the measure. Because of this, disability measures have importance beyond the assessment of the disability status of a population.

Age

Age is not included in the minimum template because to show inclusive age categories would add considerable complexity to the minimum set. Furthermore, age is often stated in the objective (for example, mammograms for females 40 years and older) and many objectives are relevant only for a subset of age groups. Age-specific select populations are added to objectives where needed and may not be inclusive of the total population. For example, data lines for the elderly, adolescents, or children have been added to some objectives without adding other groups, although showing inclusive age breakouts, if relevant, is preferred.

References

1. U.S. Department of Health and Human Services (HHS). Healthy People 2010 Objectives: Draft for Public Comment. Washington, DC: HHS, Office of Public Health and Science, 1998.

2. Office of Management and Budget (OMB). Standards for maintaining, collecting, and presenting Federal data on race and ethnicity. Federal Register, 62 FR 58781-58790, 1997.

3. OMB. Directive No. 15. Race and Ethnic Standards for Federal Statistics and Administrative Reporting. Statistical Policy Handbook. Washington, DC: OMB, 1978.

4. OMB. Tabulation Working Group of the Interagency Committee for the Review of Standards for Data on Race and Ethnicity. Draft Provisional Guidance on the Implementation of the 1997 Standards for the Collection of Federal Data on Race and Ethnicity. <http://www.whitehouse.gov/WH/EOP/OMB/html/misc-doc.html>February 17, 1999.

5. Rosenberg, H.M.; Maurer, J.D.; Sorlie, P.D.; et al. Quality of death rates by race and Hispanic origin: A summary of current research, 1999. National Center for Health Statistics (NCHS). Vital and Health Statistics 2(128), 1999.

6. NCHS. Vital Statistics of the United States, 1992, Vol. II, Mortality, Part A. Technical appendix. Hyattsville, MD: HHS, Public Health Service (PHS), 1996.

7. Sorlie, P.D.; Rogot, E.; and Johnson, N.J. Validity of demographic characteristics on the death certificate. Epidemiology 3(2):181-184, 1992.

8. Hogan, H. The 1990 Post-enumeration survey: Operations and results. Journal of the American Statistical Association 88(423):1047-1060, 1993.

9. MacDorman, M.F., and Atkinson, J.O. Infant Mortality Statistics from the 1996 Period Linked Birth/Infant Death Data Set.Monthly Vital Statistics Report. Vol. 46. No. 12. Hyattsville, MD: NCHS, 1998.

10. Kozak, L.J. Underreporting of Race in the National Hospital Discharge Survey.Advance Data from Vital and Health Statistics No. 265. Hyattsville, MD; NCHS, 1995.

11. HHS. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: HHS, PHS, 1991.

12. NCHS. Health United States, 1998, With Socioeconomic Status and Health Chartbook. Hyattsville, MD: HHS, 1998.

13. U.S. Department of Education. The Condition of Education 1998: Indicator 22: Educational Attainment. Jessup, MD: National Center for Education Statistics, 1998.

14. Sorlie, P.D., and Johnson, N.J: Validity of education information on the death certificate. Epidemiology 7(4):437-439, 1996.

15. U.S. Department of Commerce (DOC), Bureau of the Census. State and Metropolitan Area Data Book 1997–98. Washington, DC: DOC, 1999.

16. World Health Organization (WHO). ICIDH-2: International Classification of Functioning and Disability: Beta-2 Draft,  Full version. 5-28, 185-212. Geneva, Switzerland: WHO, 1999. <http://.who.int/icidh>

17. NCHS. Current estimates from the National Health Interview Survey, 1995. Vital and Health Statistics10(199), 1998.

18. HHS. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

5. Age Adjustment

Because many objectives in Healthy People 2010 have outcomes that vary by age, data for a number of objectives are age adjusted to control for differences due only to differences in age composition. Age adjustment, using the direct method, is the application of age-specific rates in a population of interest to a standardized age distribution in order to eliminate differences in observed rates that result from age differences in the population composition. This adjustment is usually done when comparing two or more populations (such as race/ethnic groups) at one point in time or one population at two or more points in time.

Age-adjusted rates are useful for comparison purposes only, not to measure absolute magnitude. (To compare absolute magnitude, numbers or crude rates are used.)  The actual numerical value of an age-adjusted rate is dependent on the standard population used and, therefore, has no intrinsic meaning. Because age-adjusted rates are adjusted to a predetermined standard, they should be viewed as constructs or indexes rather than as direct or actual measures. It is important to note that in order to compare age-adjusted rates they must be adjusted to the same standard population.1 

For the Healthy People 2000 objectives, age adjustment was used for most of the mortality objectives and only for a very few selected other objectives. For Healthy People 2010, age adjustment is used again for most of the mortality objectives but also for many objectives that measure health outcomes and risk factors. Age-adjusted data may be shown for objectives that target either the total population or a groups with a large age range. Objectives or population subgroups that target groups with relatively small age ranges (generally less than 40 years) are not adjusted.

For some population groups, the age-adjusted rates are considerably different than crude rates. This happens because the population distribution of the group is quite different from the distribution of the standard population, which, for most objectives, is based on the projected year 2000 population for the entire United States. For example, for the Hispanic population (especially Mexican Americans) the age-adjusted rates for many outcomes and behaviors that are generally more frequent among the older population are considerably higher than the crude rates. This occurs because the Hispanic population has a much younger age distribution than the standard population.

Age-adjusted baseline data are noted in Healthy People 20102 and in Part B: Operational Definitions. Any data not specifically denoted as age adjusted, should be considered crude (unadjusted) data.

Mortality

There are about 40 Healthy People 2010 objectives that monitor mortality outcomes. Most of these objectives use data from the National Vital Statistics System (NVSS) of which 26 use death rates age adjusted by the direct method, to the 2000 standard population (see Appendix C). The other mortality objectives are measured using either:

The details of measurement will be specified in the operational definition for each objective.

The age-adjusted death rate (AADR) is a weighted average of the age-specific death rates where the age-specific weights represent the relative age distribution of a standard population. The AADR is calculated by the direct method using the following formula:2

AADR =  å w_si × R_i

where R_i is the age-specific death rate for age interval i and w_si denotes the standard weight for age interval i such that

               
where P_si denotes the population in age interval i in the standard population, 0< w_si<1,  and the w_si sum to 1.

Selection of the standard age distribution, or standard population, is to some extent arbitrary.3, 4 At least three different standards have been widely used over the years by Federal and State statistical agencies. Beginning with the analyses of data collected in 1999, all agencies of the U.S. Department of Health and Human Services (DHHS) will use a single standard based on a projection of the year 2000 U.S. population.5, 6 Use of a single and more contemporary population standard helps reduce perceptions that the previously used standards are outdated, as well as confusion and misunderstanding among data users and the media when multiple data standards were used by the Department of Health and Human Services.5 Moreover, reflecting the current population structure, the new standard results in death rates that more closely approximate the average risk of death reflected in crude death rates.

Age-adjusted death rates for 1997 and 1998 used for Healthy People 2010 baseline data are based on the 2000 population standard. Therefore, they differ from rates shown in previous Healthy People 2000 reports,7 which show rates based on the 1940 standard population. Healthy People 2010 is showing rates adjusted to the 2000 standard before implementation of the new standard by most other agencies and publications. Therefore, the Healthy People 2010baseline data will differ from those published in Health, United States, or the National Vital Statistics Report. To assist with the transition from the 1940 to the 2000 standard, the baseline 2010 rates adjusted to 1940 for the applicable mortality objectives are included in Appendix C.

Changing to the 2000 standard has implications for the interpretation of mortality trends and comparisons. Figure 7 shows the trend in mortality for the crude death rate and the age-adjusted death rates based on the 1940 and 2000 standard.6 The age-adjusted death rate based on the 2000 standard for recent years much more closely reflects the observed average risk of mortality (represented by the crude death rate) than the rate adjusted to 1940. The age-adjusted rate based on the 2000 standard population is larger because the 2000 population, which has an older age structure than the 1940 population, gives more weight than the 1940 standard to death rates at the older ages where mortality is higher. The trend lines for the age-adjusted total mortality rates are roughly parallel, showing decreases in age-adjusted rates that are similar for the period 1979 through 1995. However, trends for some causes of death may differ. For Healthy People this means that the rates computed for Healthy People 2000 cannot be used in trend comparisons with rates computed for Healthy People 2010.