Appendix B
National and Community Health Data Sets

NATIONAL DATA SETS

The most readily available health-outcomes data for the United States are mortality data, which are derived from death certificates and population health surveys and contain self-reported health and functional status. The national surveys most often used are the Behavioral Risk Factors Surveillance System (BRFSS) and the National Health Interview Survey (NHIS), which provide data annually, and the National Health and Nutrition Examination Survey (NHANES), which provides data every 2 years (CDC, 2008, 2009a, 2009b).

The Behavioral Risk Factors Surveillance System

BRFSS is a cross-sectional telephone-based survey that collects information on changes in health conditions and risk factors (Mokdad, 2009). State health departments conduct BRFSS with support and design from the Centers for Disease Control and Prevention (CDC). Most states use BRFSS as their primary source of chronic-disease data for evaluating health behaviors in the population. BRFSS is the world’s largest telephone survey and has 413,000 adult participants each year (Balluz, 2010); it is offered in English and Spanish (CDC, 2008). The goals of BRFSS are to assess public health status, define public health priorities, evaluate programs, stimulate research, and monitor trends (Balluz, 2010). BRFSS provides state-level estimates and estimates for selected metropolitan statistical areas that have 500 or more respondents. It collects demographic variables on race, sex, age, income categories, education level, and number of children in the household



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Appendix B National and Community Health Data Sets NATIONAL DATA SETS The most readily available health-outcomes data for the United States are mortality data, which are derived from death certificates and population health surveys and contain self-reported health and functional status. The national surveys most often used are the Behavioral Risk Factors Surveil- lance System (BRFSS) and the National Health Interview Survey (NHIS), which provide data annually, and the National Health and Nutrition Ex- amination Survey (NHANES), which provides data every 2 years (CDC, 2008, 2009a, 2009b). The Behavioral Risk Factors Surveillance System BRFSS is a cross-sectional telephone-based survey that collects infor- mation on changes in health conditions and risk factors (Mokdad, 2009). State health departments conduct BRFSS with support and design from the Centers for Disease Control and Prevention (CDC). Most states use BRFSS as their primary source of chronic-disease data for evaluating health behaviors in the population. BRFSS is the world’s largest telephone survey and has 413,000 adult participants each year (Balluz, 2010); it is offered in English and Spanish (CDC, 2008). The goals of BRFSS are to assess public health status, define public health priorities, evaluate programs, stimulate research, and monitor trends (Balluz, 2010). BRFSS provides state-level estimates and estimates for selected metropolitan statistical areas that have 500 or more respondents. It collects demographic variables on race, sex, age, income categories, education level, and number of children in the household 147

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148 FOR THE PUBLIC’S HEALTH: MEASUREMENT (Mokdad, 2009). The BRFSS questionnaire is organized by core and option- al modules and includes individual-level risk factors associated with causes of premature death (Mokdad, 2009). More detailed information on chronic conditions—including diabetes, cardiovascular health, high blood pressure, and adult asthma—are included in optional modules (Balluz, 2010). The National Health Information Survey NHIS, supported by the CDC’s National Center for Health Statistics (NCHS), is a large-scale cross-sectional household interview survey. The survey includes information on population disease prevalence, extent of dis- ability, and use of health care services and is offered in English, Spanish, and other languages. NHIS describes disease prevalence from self-reports of di- agnoses received from clinicians (Burrows et al., 2007). The expected NHIS sample includes about 35,000–40,000 households with 75,000–100,000 persons of all ages. To provide state or local estimates of health outcomes and determinants of health, a few states and local areas, such as Wisconsin and New York City, conduct their own surveys based on the NHIS (and NHANES) method (CDC, 2009a; Parrish, 2010). The National Health and Nutrition Examination Survey NHANES is a “program of studies designed to assess the health and nutritional status of adults and children in the United States.” It combines interviews with physical examinations and is conducted by NCHS (CDC, 2009a). A nationally representative sample of about 5,000 people are inter- viewed each year. NHANES includes demographic, socioeconomic, dietary, and health-related questions offered in English and Spanish. The examina- tion component consists of medical, dental, and physiologic measurements, including laboratory tests. The data from the survey are used to determine the prevalence of major diseases and risk factors for diseases (CDC, 2009a). Limitations of the Behavioral Risk Factors Surveillance System, the National Health Information Survey, and the National Health and Nutrition Examination Survey BRFSS, NHIS, and NHANES all have limitations and challenges. BRFSS has a declining and low response rate (for example, 18 percent in California and a national median of 34 percent—a lower response rate than NHIS and NHANES) and inadequate time available for questions, responses are self- reported, data are available only at the state level (and some large jurisdic- tions), and the survey contains no biometric measurements. BRFSS includes

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149 APPENDIX B few or no measures of newer constructs of community health, such as social cohesion, resilience, and literacy. Data in national data sets can sometimes be stratified for a state, or state data may be available from a state’s own efforts (for example, a state- based Health and Nutrition Examination Survey), but local leaders who seek statistics for their county, city, or census tract face challenges in obtain- ing geocodable data. The obstacles are sometimes methodologic—as when sample sizes or survey techniques are problematic in sparsely populated rural communities—but often the difficulty is that source agencies have done little either to collect the data or, when the data are available, to make the information readily available to the typical decision-maker. Procedures used by researchers to extract geocodable microdata from agency data warehouses or to file paperwork for agency approvals to in- tegrate such data often pose a formidable barrier for busy policy-makers or staff of public health agencies. Making such data accessible to those important users requires efforts at a high level to develop a front end that enables users to obtain available statistics easily and to cross government agency silos (such as planning, zoning, transportation, and education) to gather and report relevant local data from multiple sources in a useful way. NHIS does provide health status information on a representative sample of Americans, but it does not provide state or local estimates. BRFSS pro- vides state estimates, but it does not provide local data, and it provides minimal data on children. To complement what they obtain from BRFSS, 16 states provide funding to enhance their BRFSS samples with substate sam- pling strata to generate their own representative local data sets, and others add their own modules on other topics of interest to them. Eleven states have established separate comprehensive surveys independent of BRFSS, such as the California Health Interview Survey (CHIS), to meet their needs for local and state data not being served by BRFSS (UCLA Center for Health Policy Research, 2008), and 10 states conduct independent surveys to assess the health of children (UCLA Center for Healthier Children, 2010). Several states conduct city or county surveys on the basis of BRFSS and have been able to use the data to monitor trends and risks (CDC, 2009b), but overall the data are not adequate for use at the local level (and cannot measure inequalities in health that occur at the community level and among population subgroups), because samples are too small for calculating reli- able estimates (Parrish, 2010). NHIS and NHANES provide only national and some large regional estimates because of their sampling schemes and relatively small samples. Because a premium is placed on statistical rigor and because securing financing for the surveys and supplements is complex, these sources do not adapt rapidly to and maximize opportunities afforded by available communication technologies. In addition, data are not available

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150 FOR THE PUBLIC’S HEALTH: MEASUREMENT as rapidly as needed, and some content reflects the needs of funders rather than the overall needs of public health. COMMUNITY DATA SETS One early effort in population health measurement and reporting is America’s Health Rankings (AHR), which was begun in 1990 and provides a scorecard of health determinants and health-outcome measures and an overall ranking for each state (America’s Health Rankings, 2009). In 2009, a county analogue to AHR, the County Health Rankings, was released; it ranks counties in each state on specific health measures (County Health Rankings, 2010a). The Community Health Status Indicators (CHSI) activ- ity was initiated in 2000 and relaunched in 2006 by a collaborative group of federal, state, and local public health representation and nonprofit and academic partners (County Health Rankings, 2009).1 CHSI provides detailed health (and related) measures by county and allows users to com- pare peer counties (for example, counties with similar sociodemographic characteristics). The interest in and proliferation of health indicators is linked to a na- tional concern about health-related costs and health-system effectiveness and to a federal initiative on key national indicators (for example, related to population, economy, environment, health, education, and commerce) that began early in the 21st century. In 2003, the General Accounting Office (GAO), now the Government Accountability Office, held a forum on key national indicators in collaboration with the National Academies (GAO, 2003). In 2003 and 2004, GAO prepared several reports on the key indicators initiative; in 2004, the Organisation for Economic Co-operation and Development reported on this subject in its World Forum on Key In- dicators (GAO, 2004). The Academies continue to serve as the secretariat for the effort, supporting several activities that include a recent Institute of Medicine committee convened to identify 20 health indicators in three domains (health outcomes, health-related behaviors, and medical care de- livery systems) to track progress in health and health care (IOM, 2009). These will be incorporated into the State of the USA (SUSA) project, which is likely to be the repository for the Key National Indicators required by the Affordable Care Act in subjects including health and managed by the 1 Partners include the Centers for Disease Control and Prevention, the National Institutes of Health National Library of Medicine, the Health Resources Services Administration, the Public Health Foundation, the Association of State and Territorial Health Officials, the Na- tional Association of County and City Health Officials, the National Association of Local Boards of Health, and the Johns Hopkins University School of Public Health (County Health Rankings, 2010b).

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151 APPENDIX B National Academies (more information is available on the SUSA website2; see Public Law 111-148). Tables B-1 (national indicator sets) and B-2 (community indicator sets) present samples of the numerous indicator sets in existence. Those repre- sented in the table were chosen because they are the best known and are representative sets regarding the types of indications used currently in the United States. To view more exhaustive reviews of the existing data sets, see Public Health Institute (2010) and Wold (2008). REFERENCES Alameda County Public Health Department. 2008. Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County. Oakland, CA: Alameda County Public Health Department. America’s Health Rankings. 2009. A Call to Action for Individuals and Their Communities. Minnetonka, MN: United Health Foundation. America’s Health Rankings. 2010. Definitions of Components: Core Measures and Supple- mental Measures. http://www.americashealthrankings.org/2009/component.aspx (June 4, 2010). Balluz, L. 2010. (January 21, 2010). Behavioral Risk Factor Surveillance System (BRFSS). Presentation to the IOM Committee on Public Health Strategies to Improve Health. Washington, DC: IOM. Burrows, N. R., S. Parekh, Y. Li, L. S. Geiss, and CDC. 2007. Prevalence of self-reported cardiovascular disease among persons aged >35 years with diabetes—United States, 1997–2005. Morbidity and Mortality Weekly Report 56(43):1129-1132. CDC (Centers for Disease Control and Prevention). 2008. Behavioral Risk Factor Surveillance System: About the BRFSS. http://www.cdc.gov/brfss/about.htm (January 1, 2010). CDC. 2009a. About the National Health Interview Survey. http://www.cdc.gov/nchs/nhis/ about_nhis.htm (January 6, 2010). CDC. 2009b. Overview: BRFSS 2008. http://www.cdc.gov/brfss/technical_infodata/survey- data/2008/overview_08.rtf (January 6, 2010). Community Health Status Indicators. 2009. Community Health Status Indicators Project Fact Sheet. Washington, DC: HHS. Community Health Status Indicators Project Working Group. 2009. Data Sources, Definitions, and Notes for CHSI 2009. Washington, DC.: Department of Health and Human Services. County Health Rankings. 2009. About the Community Health Status Indicators Project. http://www.countyhealthrankings.org/latest-news/how-washington-county-residents- stay-healthy (January 6, 2010). County Health Rankings. 2010a. Data Collection Process. http://www.countyhealthrankings. org/about-project/data-collection-process (February 17, 2010). County Health Rankings. 2010b. How Healthy Is Your County? New County Health Rankings Give First County-by-county Snapshot of Health in Each State. http://www. countyhealthrankings.org/latest-news/healthday-county-county-report-sizes-americans- health (February 17, 2010). GAO (Government Accountability Office). 2003. Forum on Key National Indicators. Wash- ington, DC: GAO. 2 See http://www.stateoftheusa.org/.

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152 FOR THE PUBLIC’S HEALTH: MEASUREMENT GAO. 2004. Informing Our Nation: Improving How to Understand and Assess the USA’s Position and Progress. Washington, DC: GAO. HHS (Department of Health and Human Services). 2009a. Healthy People 2020 Framework. http://www.healthypeople.gov/hp2020/objectives/framework.aspx (April 28, 2010). HHS. 2009b. Healthy People 2020 Public Meetings—2009 Draft Objectives. Washington, DC: Department of Health and Human Services. IOM (Institute of Medicine). 2009. State of the USA Health Indicators: Letter Report. Wash- ington, DC: The National Academies Press. Mokdad, A. H. 2009. The Behavioral Risk Factors Surveillance System: Past, present, and future. Annual Review of Public Health 30:43-54. Parrish, R. G. 2010. Measuring population health outcomes. Preventing Chronic Disease Public Health Research, Practice and Policy 7(4). http://www.cdc.gov/pcd/issues/2010/ jul/10_0005.htm. (July 4, 2010). Public Health Institute. 2010. Data Sets, Data Platforms, Data Utility: Resource Compendium. Oakland, CA: Public Health Institute. Saskatoon Regional Health Authority. 2007. 2006-2007 Annual Report to the Minister of Health and the Minister of Healthy Living Services. Saskatoon, Canada: Saskatoon Regional Health Authority. Seattle and King County Public Health. 2010. King County Community Health Indicators. http://www.kingcounty.gov/healthservices/health/data/chi.aspx (January 6, 2010). Summers, C., L. Cohen, A. Havusha, F. Sliger, and T. Farley. 2009. Take Care New York 2012: A Policy for a Healthier New York City. New York: New York City Department of Health and Mental Hygiene. SUSA (State of the USA). 2010a. Mission. http://www.stateoftheusa.org/about/mission (June 11, 2010). SUSA. 2010b. The State of the USA. http://www.stateoftheusa.org (September 1, 2010). Trust for America’s Health. 2010. State Data. http://healthyamericans.org/states (October 15, 2010). UCLA (University of California, Los Angeles) Center for Health Policy Research. 2008. About CHIS. http://www.askchis.com/about.html (September 1, 2010). UCLA Center for Healthier Children. 2010. Framework for System Transformation. http:// healthychild.ucla.edu/Transformation.asp (June 16, 2010). Wold, C. 2008. Health Indicators: A Review of Reports Currently in Use. Conducted for The State of the USA. Wold and Associates.

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153 APPENDIX B TABLES B-1 AND B-2 START ON THE FOLLOWING PAGE

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154 FOR THE PUBLIC’S HEALTH: MEASUREMENT TABLE B-1 National Indicator Sets Community America’s Health County Health Health Status Rankings Rankings Indicators (AHR) (CHR) (CHSI) Total number of 39 26 200 indicators Purpose The purpose of The purpose The purpose of AHR is to have a of CHR is to CHSI is to provide comparable and illustrate how health providers comprehensive factors in the and community national and environment members with state measure of affect health local community health and health outcomes, such as health indicators outcomes. a person’s health and encourage and longevity. action in CHR is a “call to improving the action” for state community’s and local health health. departments and community leaders outside the public health sector to improve community health. Primary data Public, federal Public, federal sources sectora sector,b local-area data Population- Mortality Mortality Mortality · remature death · remature · ll causes of health outcome P P A measures Morbidity death death Morbidity Quality of life Health-related · oor–physical- P Health-related quality of life · verage life health days A quality of life · oor–mental- · oor or fair P P expectancy · elf-rated health days health S · oor or fair · oor–physical- P P health status · nhealthy days health health days U · oor–mental- P Poor birth outcomes · ow birth L health days weight Birth outcomes · ow birth L weight

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155 APPENDIX B Healthy People 2020 State of the USA Trust for America’s Health (HP2020) (SUSA) (TFAH) 38 (objectives) 20 32 The purpose of HP2020 The purpose of SUSA is to The purpose of TFAH’s state is to provide the nation assist people in tracking data is to rank states on with science-based, progress in health and various public health issues 10-year objectives for health care in the United and health outcomes to promoting health and States by using high-quality prevent communicable and preventing disease and in statistical data and to chronic diseases and to hold doing so to increase the compare the United States officials accountable for their population’s quality of with other countries. performance on public health life and eliminate health issues and activities. disparities. Public, federal sector Public, federal sector, Public, federal sector, nonprofit sectord nonprofit sector, internationalc Morbidity Mortality Mortality · ental health and · nfant mortality · nfant mortality M I I · njury-related mortality mental disorder I Health-related quality of Health-related quality life of life · uality of life and · ife expectancy at birth Q L · ife expectancy at 65 well-being L years old · elf-reported health S status · nhealthy days, U physical and mental · erious psychological S distress Continued

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156 FOR THE PUBLIC’S HEALTH: MEASUREMENT TABLE B-1 Continued Community America’s Health County Health Health Status Rankings Rankings Indicators (AHR) (CHR) (CHSI) · mployment Domain (or Mortality Education E · nfant mortality · igh-school equivalent) I status H · ommunity- · ardiovascular · isabled C C D graduation · ollege degrees · omicide health deaths H C · ancer deaths · otor-vehicle measures Employment C M · hronic · remature · nemployment C P injury U · nfant health Income deaths I · ccupational · hildren in conditions mortalitye O C · ocial factors · nintentional S fatalities U poverty · conomic · ncome E Morbidity injury I · nfectious · ersons living factors I P inequality Family and social below povertyf disease Chronic disease support Chronic diseases, · troke · nadequate health problems S I · igh cholesterol · iabetes H D social support · ypertension · ingle-parent · igh blood H H S · eart attack H pressure households · oronary heart · besity C Community safety O · iolent-crime · oronary heart disease C V · iabetes D disease rate · troke Environmental, Physical S · ancerg community environment C · ir pollution · ir pollution: Environmental A A · hildren in health C particulate- · nfectious poverty I matter days · iolent crime · ir pollution: diseasesh V A · oxic Economic T ozone days · ersonal Income Built Environment P chemicals · nder- · ccess to U released A employment rate annually health foods · nemployment · iquor-store · ational U N L rate air-quality density · edian standards meti M household income

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157 APPENDIX B Healthy People 2020 State of the USA Trust for America’s Health (HP2020) (SUSA) (TFAH) · aternal, infant, M Alzheimer’s disease Chronic diseases, health child health · ral health problems O · ocial determinants of · ancer S C · sthma: adult, percentage health A Chronic disease, health of high-school students · besity: adult, high-school problems O · rthritis, A students, children 10–17 osteoporosis, chronic years old · ypertension back pain H · lood disorders, · iabetes B D Communicable, infectious blood safety · ancer diseases C · idney disease · est Nile virus K W · iabetes · uberculosis D T · isability, secondary Sexually transmitted diseases D · IDS: 13 years old and conditions A · earing, other H older, less than 13 years sensory or old · hlamydia infection communication C · yphilis disorders S · eart disease, stroke Community H · IV · iving in poverty H L · mmunization, · edian family Income I M infectious diseases · espiratory diseases R · exually transmitted S diseases · ision V Environmental, community · ducational, E community-based programs · nvironmental health E · amily planning F · ood safety F · lobal health G · njury, violence I prevention · ccupational safety, O health Continued

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160 FOR THE PUBLIC’S HEALTH: MEASUREMENT TABLE B-1 Continued Community America’s Health County Health Health Status Rankings Rankings Indicators (AHR) (CHR) (CHSI) Other domains Public health or Birth measures · irth weighto other policies B · ack of health · umber of L N birthsp insurance · mmunization · remature I P coverage birth · ublic health Access to care P · ninsured funding U · edicare M · Medicaid a Data sources include BRFSS; National Center for Education Statistics; Census of Fatal Occupational Injuries, Bureau of Labor Statistics; Department of Labor, Crime in the United States: 2008 Federal Bureau of Investigation; Population Survey, Mortality and Morbidity Weekly Reports, CDC; Environmental Protection Agency; Census Bureau; Trust for America’s Health; National Immunization Program at CDC; American Medical Association, Physician Characteristics and Distribution in the United States; The Dartmouth Atlas of Health Care; National Heart, Lung and Blood Institute; Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion. b Data sources include National Vital Statistics System, NCHS; BRFSS (2000–2006); Census Bureau; Healthy People 2010; Notifiable Infectious Diseases; Toxic Release Inventory Data, Environmental Protection Agency Air Quality Standards; Medicare Enrollment County Data at the Centers for Medicaid and Medicare Services; Area Resource File, Health Resources and Services Administration; American Medical Association Physician Master File; American Dental Association; State and County Demographics Report, Health Resources and Services Administration Geospatial Data Warehouse. c Data sources include BRFSS; NHANES; NCHS; World Health Organization: Statistical Information System and Report on Global Tobacco Epidemic; National Survey on Drug Use and Health; Global Database on Body Mass Index; Centers for Medicaid and Medicare Services; National Health Expenditure Account, Organisation for Economic Co-operation and Development; Medical Expenditure Panel Survey; Census Bureau Current Population Survey; American Community Survey, Agency for Healthcare Research and Quality. d Data sources include Census Bureau; CDC HIV/AIDS Surveillance Report; Alzheimer’s Association Report; BRFSS; National Immunization Survey at CDC; American Cancer Society, HHS; CDC Division of Vector-Borne Infectious Diseases; CDC STI Disease Surveillance; NCHS; Health Resources Services Administration Geospatial Data Warehouse.

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161 APPENDIX B Healthy People 2020 State of the USA Trust for America’s Health (HP2020) (SUSA) (TFAH) · edical-product · edical cost of obesity M M · ublic health preparedness safety P · lder adults O Birth Measures · ublic health · ow birth weight P L · remature births infrastructure P e Infant-mortality indicators also broken down into white non-Hispanic, black non-Hispanic, Hispanic, neonatal, postneonatal. f This information is broken down into age distributions (under 19 years, 19–64 years, 65–84 years, and 85+ years), race and ethnicity (white, black, American Indian, Asian/Pacific Islander, and Hispanic). g Cancer of lung, colon, or breast. h Cases of Escherichia coli, Salmonella, Shigella infection reported, expected per county. i Particles of CO, NO , SO , O , particulate matter, lead measured. 2 2 3 j Cases of syphilis, congenital rubella syndrome, pertussis, measles, hepatitis A, hepatitis B, tuberculosis, influenza, AIDS reported, expected. k Such indicators as immunizations, dental caries, prevalence of lead screening are not collected at national level and must be obtained locally. l Percentage of population within county who had Pap smear, mammography, sigmoidoscopy, pneumonia vaccine, influenza vaccine. m Age-appropriate services recommended by US Preventive Services Task Force and influenza vaccination. n Diabetes, cardiovascular disease, chronic obstructive pulmonary disease, chronic bronchitis and emphysema, asthma, cancer, arthritis. o Low birth weight, very low birth weight. p Under 18 years old, 40–54 years old, unmarried. SOURCES: America’s Health Rankings, 2009, 2010; Community Health Status Indicators, 2009; Community Health Status Indicators Project Working Group, 2009; HHS, 2009a,b; SUSA, 2010a; Trust for America’s Health, 2010.

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162 FOR THE PUBLIC’S HEALTH: MEASUREMENT TABLE B-2 Community Health Data Sets Alameda County Total number of indicators 60 Purpose The purpose of the Alameda County Public Health Department’s report is to provide a detailed description of inequities in the economic, social, physical, and service environments affecting health and leading to death from “unnatural causes.” Data and policy analysis can be used by residents to identify and advocate for policies that can reduce social and health inequalities, evaluate progress, and propose polices that affect inequities. Primary data sources Public sector, governmenta · Population health outcome measures Mortality Rate (census tract) · All causes of mortality · Self-reported health status · Life expectancy at birth

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163 APPENDIX B Seattle–King County City of Saskatoon New York City 67 31 33 (10 core) The purpose of King The purpose of Saskatoon’s The purpose of NYC Policy County Community community analysis is for a healthier New York Indicators is to to describe the extent of is to improve the health provide a broad array health disparity, determine of New Yorkers; having of comprehensive, the causes of the health policy-makers, residents, population-based data disparity, explain that communities, businesses, to community-based most health disparity is organizations by developing organizations, community preventable, and suggest policies, laws, regulations that health centers, public that evidence-based policy will improve environmental, agencies, policy-makers, options with sufficient economic, social conditions and the general public. public support should affecting health; emphasizing proceed into action. preventive health care, improving quality of care, expanding access to care; health promotion to inform, educate, engage residents to improve their health, health of their communities. Public sectorb Public sectorc Public sector · Life expectancy at birth · Infant mortality Mortality · Life expectancy at age · · Deaths from smoking- All causes of mortality · 65 years Life expectancy at birth related illnesses · · Premature deaths from Mortality Life expectancy at age · Leading causes of death 65 years major cardiovascular · Infant mortality · Self-rated health statusd disease · · HIV/AIDS–related deaths Overweight or obesee Health outcomes, overall · · Drug overdose death Physical activityf health · Fair or poor health · Diabetesg (unintentional) · Years of healthy life · · Colorectal-cancer death Injury hospitalization · · Infant mortalityh Cardiovascular-disease death Continued

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164 FOR THE PUBLIC’S HEALTH: MEASUREMENT TABLE B-2 Continued Alameda County · Poverty rates Domain (or equivalent) · Community-health measures · Median household income · Chronic health conditions · Unemployment rates · Community measures · High-school dropout rate · Neighborhood high-school graduation · Crime rate · Education level Chronic diseases, health problems · Asthma (children emergency-room visits) Environmental, community · Neighborhood poverty rate · Fast-food and convenience-store density · Density of off-sale liquor licenses · Social cohesioni Transportation · Income dedicated to transportation cost · Transit-dependent household · Public subsidies · Air quality · Annual motor-vehicle–related pedestrian injuries or deaths Housing · Home median sales price · Fair-market rents · Renting households under severe cost burden · Homeless service users · Homeownership rates · Housing-opportunity index · Home-loan denial · Foreclosure rate Air quality · Proximity to toxic-air release facilitiesj Behavior domain Physical activity · Inactivity · Place near home to walk, exercise · Safe to exercise outdoors

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165 APPENDIX B Seattle–King County City of Saskatoon New York City · Suicidek · Preventable Unemployment rate · Frequent mental Income level hospitalizations · Teen pregnancies distress Education level · Level of educationl · Education-level disparity House prices · Living in poverty Chronic diseases, health Oral health Communicable disease Chronic diseases, health problems · Tuberculosis incidence · Cardiovascular disease problems · Chlamydial infections · Diabetes Environmental, community · Gonorrhea · Obstructive pulmonary · Housing qualityw · HIV/AIDSm · Neighborhood income disease · Coronary heart disease Chronic diseases disparity · Colorectal cancern · Cerebrovascular disease · Safety of walking, play · Breast cancero · Sexually transmitted spacesx · Heart-disease deaths · Presence of rodentsy infections/HIV · Stroke deaths · Overweight or obese · Diabetesp · Depression · Asthma (adult, · Anxiety · Communicable childhood)q Physical, environmental infectious diseasest · Asthma (adult, Environmental, community · Injuries, poisonings childhood)r · Air quality · Crime rate · Air quality · Water quality · Water quality · Food accessu · Active transportationv · Alcohol-induced deaths · Attempted suicide · Smokingbb · Drug-induced deaths · Level of physical · Adult sugar consumptioncc · Smokers (adults and · Condom use in male–male activityaa · Fruit, vegetable servings sexdd school age) · Overweight (adults and · Injection-drug use · Alcohol hospitalizationsee · Daily smoker · Fruit, vegetable servingsff school age) · Obese (adults and · Obesity (adults) · Alcohol consumption school age) · Physical activityz (teens)gg · Drinking Continued

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166 FOR THE PUBLIC’S HEALTH: MEASUREMENT TABLE B-2 Continued Alameda County · Health care access, use, services, other Uninsured (nonelderly adult) · Uninsured person · Usual source of care · Cancer screeninghh · Nativity, immigration status Other domains · Segregationpp · Employment health benefits · Employment by industry · Occupation · Median household income · Income level · Social supportqq School performance, condition · Reading and mathematics proficiency · English level · Reading scores · School conditions · Mealsrr · Student-reported well-beingss · Student-reported protective factorstt Criminal justice · Criminal rate · State-prison drug-offense admission rate · Incarceration rates under three-strikes law · County probation rate a Data sources include California Health Interview Survey 2003, 2005; FBI: Uniform Crime Report; Alameda County Sheriff’s Office; California Department of Finance; Alameda County Probation Department; Census Bureau 2000; California Center for Public Health Advocacy; California Department of Alcohol Beverage and Control; Environmental Protection Agency; California Department of Education; California Office of Statewide Health Planning and Development; California Highway Patrol, National Transit Database; Communities for a Better Environment; Labor Market Information System; State of cities Data System;

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167 APPENDIX B Seattle–King County City of Saskatoon New York City · Adults with no health · · Preventable Immunizationsii insurance hospitalizations · Children with no health · Medical care accessjj · Psychological distress—no insurance · Adults with unmet treatmentkk · Colonoscopyll medical need · Childhood · HPV vaccinationmm immunizations Screenings · Influenza vaccination · HIV-testednn · Chlamydia-testedoo (adults) · Pneumonia vaccination (adults) · Late or no prenatal care · Mammography · Dentist visit last year · Psychological Children 10–15 years old Nativityww · Self-reported health Overall health distress—interferencezz · Activity limitation · Adults with hypertension status · Unhealthy daysxx · Depressed needing medication and · Anxious Maternal, child health taking it · Birth weight ratesyy · Bully comparison · Adults with high · Preterm births · Suicidal thoughts cholesterol taking · Maternal smoking · Low self-esteem medication · Smoking · Breastfeedingaaa during pregnancy · Alcohol use Reproductive health · Adolescent birth rate · Marijuana use · Adolescent pregnancy rate Injury, violence · Homicide · Assault · Firearms-related deaths · Motor-vehicle injuries · Motor-vehicle deaths · Suicide hospitalizations · Suicides DataQuick: Foreclosures; National Association of Homebuilders, Federal Financial Institutions Examination; Department of Housing and Urban Development; American Community Survey; Department of Commerce, Bureau of Economic Analysis; Census 2000 Equal Employment Opportunity Data. b D ata sources include Births, deaths, abortions, hospitalizations: Washington State Department of Health, Center for Health Statistics; BRFSS, Department of Health and Continued

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168 FOR THE PUBLIC’S HEALTH: MEASUREMENT TABLE B-2 Continued Human Services, Centers for Disease Control and Prevention; Washington State Department of Health Center for Health Statistics; Seattle and King County; American Community Survey: Census Bureau; King County Community Health Survey: Public Health—Seattle and King County; State Population Survey: Washington State Office of Financial Management; Healthy Youth Survey: Washington State Department of Health; Puget Sound Clean Air Agency; Washington State Cancer Registry: Washington State Department of Health; National Immunization Survey: CDC; Population estimates: Washington State Department of Health, Vista Partnership, Krupski Consulting: Washington State Population Estimates for Public Health. c Canadian Institute for Health Information (CIHI), Student health survey. d Percentage of population (12+ years old) who reported their health as very good or excellent. e Percentage of population (18+ years old). f Percentage of population (12+ years old) who reported levels of active, moderately active, or inactive. g Age-adjusted prevalence. h Also have an infant-mortality disparity measure for injuries, sudden infant death syndrome. i People in neighborhood can be trusted, willing to help each other, get along, share values. j Broken down by demographic characteristics, population racial and ethnic composition, households living within 1 mile, public-school proximity. k Hospitalizations, deaths. l High-school education, bachelor’s degree. m Indicators for mortality, incidence, prevalence. n Incidence, death. o Incidence, death. p Prevalence, mortality, related mortality. q Prevalence, hospitalizations. r Prevalence, hospitalizations. s Average rental price, average vacancy rate. t Norovirus, tuberculosis, pneumococcal disease, methicillin-resistant staphylococcus, West Nile virus. u Food insecurity, cost of healthy eating. v Walking, cycling, public transit.

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169 APPENDIX B w Poor housing quality, by neighborhood. x Measured by pedestrian-injury hospitalizations of children. y Measured by properties with signs of rats. z CDC recommendation for adults and children, no physical activity. aa Active, moderate, inactive. bb Adults who currently smoke, high-school students who currently smoke. cc Adults who consume an average of one or more sugar-sweetened beverages per day. dd Men who have sex with men who report using a condom every time they have anal sex. ee Hospitalizations for problems attributable to alcohol. ff Adults eating no servings in the previous day. gg High-school students who drank alcohol in preceding 30 days. hh Prostatic, breast, cervical. ii Preschool, school, adult, influenza, high-risk. jj Adults who did not get needed medical care. kk Adults with serious psychological distress who did not receive treatment. ll Adults 50 years old and older who have had a colonoscopy in the last 10 years. mm Girls 13–17 years old who have received vaccination. nn Adults who have been tested for HIV. oo Sexually active women under 26 years old. pp Race or ethnicity, economic, schools. qq S omeone to get together with for relaxation, love and making you feel wanted, understanding problems, helping with daily chores when sick. rr School free or reduced-price meal-program enrollment. ss Physical fight at school, moved in last year, depression, skipped breakfast. tt High expectations, caring relationship, lacks meaningful participation. uu Not born in United States. vv Mean number, physical and mental. ww Low-birth weight singleton births, all births; very-low-birth weight singleton, all births. xx Adults who have serious psychological distress that interferes with their lives or activities. yy Mothers who breastfeed exclusively for at least 2 months. zz Adults who have serious psychological distress that interferes with their lives or activities. aaa Mothers who breastfeed exclusively for at least 2 months. SOURCES: Alameda County Public Health Department, 2008; Saskatoon Regional Health Authority, 2007; Seattle and King County Public Health, 2010; Summers et al., 2009.

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