5
Measurement Tools for a Community Health Improvement Process

Chapter 4 has outlined a community health improvement process (CHIP) through which communities can assess health needs and priorities, formulate a health improvement strategy, and use performance indicators as part of a continuing and accountable process. This chapter reviews in more detail the two kinds of indicators and indicator sets proposed for use in a CHIP. Discussed first is the community health profile , with component indicators proposed by the committee, which can provide a broad overview of a community's characteristics and its health status and resources. The second part of the chapter focuses on the development of indicator sets for performance monitoring, which are intended for use with health improvement strategies for specific health issues. The committee presents some examples that illustrate how communities might approach selecting such performance indicators.

ROLE FOR A COMMUNITY HEALTH PROFILE

A community health profile is an integral component of the problem identification and prioritization cycle of the community health improvement process described in Chapter 4. The health profile is intended to be a set of indicators of basic demographic and socioeconomic characteristics, health status, health risk fac-



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Improving Health in the Community: A Role for Performance Monitoring 5 Measurement Tools for a Community Health Improvement Process Chapter 4 has outlined a community health improvement process (CHIP) through which communities can assess health needs and priorities, formulate a health improvement strategy, and use performance indicators as part of a continuing and accountable process. This chapter reviews in more detail the two kinds of indicators and indicator sets proposed for use in a CHIP. Discussed first is the community health profile , with component indicators proposed by the committee, which can provide a broad overview of a community's characteristics and its health status and resources. The second part of the chapter focuses on the development of indicator sets for performance monitoring, which are intended for use with health improvement strategies for specific health issues. The committee presents some examples that illustrate how communities might approach selecting such performance indicators. ROLE FOR A COMMUNITY HEALTH PROFILE A community health profile is an integral component of the problem identification and prioritization cycle of the community health improvement process described in Chapter 4. The health profile is intended to be a set of indicators of basic demographic and socioeconomic characteristics, health status, health risk fac-

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Improving Health in the Community: A Role for Performance Monitoring tors, and health resource use, which are relevant to most communities. The committee's proposal is consistent with the efforts of others over the past several years to identify small sets of indicators for key issues. One source of interest has been health promotion and Healthy Cities/Healthy Communities activities by the World Health Organization (WHO, 1986) and others (e.g., Canadian Healthy Communities Project, 1988; National Civic League, 1993). In the United States in particular, the inclusion of 300 indicators in Healthy People 2000 (USDHHS, 1991) led to interest in also selecting a smaller set of indicators that could be used to monitor health status (e.g., CDC, 1991; Stoto, 1992). In other work, a small set of indicators was proposed for monitoring access to health care (IOM, 1993). The health profile can help a community maintain a broad strategic view of its population's health status and factors that influence health in the community. It is not expected to be a comprehensive survey of all aspects of community health and well-being, but it should be able to help a community identify and focus attention on specific high-priority health issues. The background information provided by a health profile can help a community interpret data on those issues. A community health profile is made up of indicators of sociodemographic characteristics, health status and quality of life, health risk factors, and health resources that are relevant for most communities; these indicators provide basic descriptive information that can inform priority setting and interpretation of data on specific health issues. Health profile data can help motivate communities to address health issues. For example, evidence of underimmunization among children or the elderly might encourage various sectors of the community to respond, through ''official" actions (e.g., more systematic provider assessments of patients' immunization status) and through community action (e.g., volunteer groups offering transportation to immunization clinics). Even as raw numbers, these data may be an important signal to a community, especially when small numbers of cases make it difficult to construct meaningful rates. For example, any work-related deaths, births to teenagers, or cases of measles might be a source of

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Improving Health in the Community: A Role for Performance Monitoring concern. Working with small numbers of cases raises potential problems of privacy and confidentiality, which communities must consider. Further discussion of privacy and confidentiality considerations appears later in this chapter. Care should also be taken that evidence of health problems not be used as a basis for negative labels for particular population groups or neighborhoods in a community. Comparisons based on health profile data may be another source of motivation and may help communities in assessing health priorities as well. These comparisons can be based on measurements over time within an individual community, comparisons with other communities or with state or national measurements, or comparisons with a benchmark or target value such as an objective from Healthy People 2000 (USDHHS, 1991). A variety of specialized compilations of data may provide additional reference points (e.g., Andrulis et al., 1995; Annie E. Casey Foundation, 1996; Wennberg, 1996). The opportunity for such comparisons will be increased if there is widespread agreement across communities on a basic set of standard health profile indicators and their operational definitions. In making comparisons, however, communities must consider underlying factors that might contribute to observed differences. Some factors, if recognized, can be captured in quantitative form. For example, there might be a greater number of hospitalizations in an older population than in a younger population even though the age-specific rates are the same in both groups. Less easily addressed is the effect on the validity of comparisons among communities of different physical, social, political, and cultural contexts and different local needs and priorities, all of which may influence community profile indicators and, for some, argue against standard indicator sets (Hayes and Willms, 1990). (See Appendix B for further discussion of methodological issues in selecting and using health profile and performance indicators.) The committee emphasizes that communities should update their health profile data on a regular basis to maintain an accurate picture of community circumstances, including identifying positive or negative changes that might influence health improvement priorities. The health profile is not, however, intended to be a tool specifically to monitor changes in stakeholder performance or to establish responsibility and accountability for health outcomes. Some of the indicators that are included in a profile might, however, serve as performance indicators if they are applied to other CHIP activities. Immunization rates, for example, are a

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Improving Health in the Community: A Role for Performance Monitoring useful community health descriptor but could also be monitored as an outcome measure for targeted efforts to reduce the risk of vaccine-preventable disease. PROPOSED INDICATORS FOR A COMMUNITY HEALTH PROFILE To promote community use of health profiles, the committee is proposing a basic set of 25 indicators (see Table 5-1). They provide descriptive information on a community's demographic and socioeconomic characteristics and highlight important aspects of health status and various health determinants, including behavior, factors in the social and physical environments, and health care. Some the indicators include multiple measures within a broader category (e.g., causes of death and incidence of infectious diseases). Appendix 5A reviews each indicator individually. TABLE 5-1 Proposed Indicators for a Community Health Profile Sociodemographic Characteristics 1. Distribution of the population by age and race/ethnicity 2. Number and proportion of persons in groups such as migrants, homeless, or the non-English speaking, for whom access to community services and resources may be a concern 3. Number and proportion of persons aged 25 and older with less than a high school education 4. Ratio of the number of students graduating from high school to the number of students who entered 9th grade three years previously 5. Median household income 6. Proportion of children less than 15 years of age living in families at or below the poverty level 7. Unemployment rate 8. Number and proportion of single-parent families 9. Number and proportion of persons without health insurance Health Status 10. Infant mortality rate by race/ethnicity 11. Numbers of deaths or age-adjusted death rates for motor vehicle crashes, work-related injuries, suicide, homicide, lung cancer, breast cancer, cardiovascular diseases, and all causes, by age, race, and gender as appropriate 12. Reported incidence of AIDS, measles, tuberculosis, and primary and secondary syphilis, by age, race, and gender as appropriate 13. Births to adolescents (ages 10–17) as a proportion of total live births 14. Number and rate of confirmed abuse and neglect cases among children

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Improving Health in the Community: A Role for Performance Monitoring Health Risk Factors 15. Proportion of 2-year-old children who have received all age-appropriate vaccines, as recommended by the Advisory Committee on Immunization Practices 16. Proportion of adults aged 65 and older who have ever been immunized for pneumococcal pneumonia; proportion who have been immunized in the past 12 months for influenza 17. Proportion of the population who smoke, by age, race, and gender as appropriate 18. Proportion of the population aged 18 and older who are obese 19. Number and type of U.S. Environmental Protection Agency air quality standards not met 20. Proportion of assessed rivers, lakes, and estuaries that support beneficial uses (e.g., fishing and swimming approved) Health Care Resource Consumption 21. Per capita health care spending for Medicare beneficiaries (the Medicare adjusted average per capita cost [AAPCC]) Functional Status 22. Proportion of adults reporting that their general health is good to excellent 23. During the past 30 days, average number of days for which adults report that their physical or mental health was not good Quality of Life 24. Proportion of adults satisfied with the health care system in the community 25. Proportion of persons satisfied with the quality of life in the community NOTE: See Appendix 5A for additional information on each indicator. Selection of Community Health Profile Indicators The committee's selection of indicators reflects consideration of several factors. Measures were sought that would be relevant across a broad range of communities. Recognizing the diversity among communities in health needs, priorities, and resources, the committee selected a limited number of indicators that could be expected to be widely applicable. The list draws extensively from the "consensus set" of indicators for assessing community health status (CDC, 1991) that was developed in response to Healthy People 2000 Objective 22.1. This objective calls for developing a set of health status indicators appropriate for use by federal, state, and local health agencies and implementing them in at least 40 states by the year 2000 (USDHHS, 1991). The committee gave these indicators a high priority because they and Healthy People 2000 have had an important influence on commu-

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Improving Health in the Community: A Role for Performance Monitoring nity health assessment activities since 1991. The committee agreed, however, that the consensus indicators per se were not sufficient to constitute an adequate community health profile. The committee considered four other factors in selecting indicators: consistency with the field model framework for the determinants of health; attention to the health needs of specific populations; existence of a measure with an operational definition; and availability of data. The mix of indicators was also examined to ensure relevance across the age spectrum (Stoto, 1992). Table 5-2 summarizes the filed model domains and current or potential sources of data for each proposed health profile indicator. The broad perspective on health embodied in the field model (Evans and Stoddart, 1994) is a fundamental component of the committee's approach to health improvement and performance monitoring. For the community health profile, proposed indicators were mapped to the domains of the field model (social and physical environment, genetic endowment, behavior, disease, health care, health and function, prosperity, and well-being) to identify potential gaps and to assess the distribution of indicators across domains. Only the domain of genetic endowment is not represented directly; its contribution can be seen, however, in indicators such as infant mortality, cardiovascular disease mortality, and obesity. In its selections, the committee favored measures that are in use and have a recognized operational definition or lend themselves to the construction of such a definition. Being able to specify clearly how an indicator is measured will help communities determine what data they need and will help them identify points of comparison with other communities and at state and national levels. For some of the selected indicators, generally recognized measures have not been established. This applies in particular to the indicators on satisfaction with the quality of life in the community and with the health care system in the community. The committee felt, however, that these indicators were of sufficient importance for understanding health in the broadest sense that they should be proposed for inclusion in a community health profile to encourage the development of suitable measures. The Centers for Disease Control and Prevention (CDC) has developed survey questions on the influence of personal health on quality of life that are now in use in the Behavioral Risk Factor Surveillance System (BRFSS) and is attempting to identify community-level indicators of health-related quality of life (Hennessy

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Improving Health in the Community: A Role for Performance Monitoring TABLE 5-2 Features of Proposed Community Profile Indicators Indicator Topic Field Model Domain Data Sources Sociodemographic Characteristics 1. Age and race/ethnicity Social environment (behavior, genetics) Census; intercensal estimates 2. Groups whose access to community services or resources may be limited Social environment (behavior, physical environment, prosperity) Census; intercensal estimates 3. Educational attainment (high school graduation) Social environment (behavior, physical environment, prosperity, well-being) Census; intercensal estimates 4. High school dropouts Social environment (disease, behavior, physical environment, prosperity) Local school districts 5. Household income Prosperity (behavior, social environment, physical environment, health care, health and function) Census; intercensal estimates 6. Children in poverty Social environment, prosperity (behavior, physical environment, health care, health and function) Census; intercensal estimates 7. Unemployment rate Social environment, prosperity (behavior, physical environment, health care, health and function, well-being) State employment security office 8. Single-parent families Social environment (behavior, physical environment, health care, prosperity, well-being) Census; intercensal estimates 9. Persons without health insurance Social environment, health care (disease, health and function, prosperity) Behavioral Risk Factor Surveillance System (special sampling)

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Improving Health in the Community: A Role for Performance Monitoring Health Status 10. Infant mortality Disease, genetics, social environment, behavior, physical environment, health care, prosperity State vital records 11. Death rates, overall and for selected causes Disease, genetics, behavior, social environment, physical environment, health care, prosperity State vital records 12. Incidence of AIDS, measles, tuberculosis, syphilis Disease, behavior, social environment, health care (prosperity, health and function, well-being) State communicable disease records 13. Births to adolescents Behavior, social environment (prosperity, well-being) State vital records 14. Child abuse and neglect Behavior, social environment (disease, physical environment, health care, well-being) State or local child protection agency records Health Risk Factors 15. Preschool immunization Behavior, health care (social environment, prosperity) Community survey; retrospective estimates from school entry records; immunization registry 16. Older adult immunization Behavior, health care (social environment, prosperity) Medicare claims files; health plan records 17. Prevalence of smoking Disease, behavior, social environment, physical environment, health and function (health care, prosperity) Behavioral Risk Factor Surveillance System (special sampling) 18. Prevalence of obesity Behavior, health and function (genetics, social environment, health care, well-being) Behavioral Risk Factor Surveillance System (special sampling) 19. Air quality Disease, physical environment (social environment, well-being) State environmental quality agency; local air quality management agency 20. Water quality (for recreational uses) Physical environment (behavior, social environment, well-being) State environmental quality agency

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Improving Health in the Community: A Role for Performance Monitoring Indicator Topic Field Model Domain Data Sources Health Care Resource Consumption 21. Per capita Medicare spending Health care, prosperity Health Care Financing Administration Functional Status 22. Self-reported health status Health and function, well-being Behavioral Risk Factor Surveillance System (special sampling) 23. Recent poor health Health and function, well-being Behavioral Risk Factor Surveillance System (special sampling) Quality of Life 24. Satisfaction with health care system Health care, well-being (social environment, prosperity, health and function) Community survey 25. Satisfaction with quality of life Well-being (behavior, social environment, physical environment, health care, prosperity, health and function) Community survey NOTE: Secondary field model domains are listed in parentheses; some indicators could be addressed by questions developed for the state-based surveys of the Behavioral Risk Factor Surveillance System (CDC, 1993), but special sampling methods would have to be adopted to obtain community-specific estimates.

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Improving Health in the Community: A Role for Performance Monitoring et al., 1994; Moriarty, 1996). Once valid and reliable measures are available, issues of data collection can be addressed. Availability of and Access to Data The availability of data is a special concern at the community level. For most of the health profile indicators proposed by the committee, data are already being collected at the state or national level, but not necessarily by communities themselves or in a form that can produce community-level information or as frequently as might be desired. Few communities have the financial resources or expertise to collect such data on a routine basis or to perform the additional analysis that may be needed to make available data meaningful at the community level. In some cases, however, opportunities may exist to develop sources of data for communities. In selecting indicators for the community profile, the committee frequently chose to suggest such potential sources of data rather than limit its list of indicators to only those for which community-level data are typically available now. As noted in Chapter 4, the committee believes that states have an obligation to ensure that communities have access to the data needed to construct health profiles. Some states have already assumed this responsibility, and an Assessment Initiative managed by the National Center for Health Statistics (NCHS, 1995a) is assisting other states in developing the capacity to provide such data. Information is often produced in printed reports, but some states such as Illinois and Massachusetts are also developing data systems that give local health departments online access to data. In Massachusetts, the MassCHIP (Massachusetts Community Health Information Profile) data system makes community-level health profile data available to the public as well as to the state's community health network areas (see Box 5-1 for additional information on MassCHIP). Minnesota is providing electronic access to county data from its Substance Abuse Monitoring System (Minnesota Department of Human Services, 1995). Evolving computer and communications technologies can be expected to facilitate access to information not only within states but across the country. Some states, federal agencies, and private companies are already making data available through the Internet. One promising source of community-level data on adults may be the BRFSS, through which the states and CDC collaborate to produce state estimates for a variety of health status, health behavior, and health risk topics (CDC, 1993). Modifications to the

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Improving Health in the Community: A Role for Performance Monitoring BOX 5-1 Massachusetts Community Health Information Profile The Massachusetts Department of Public Health (MDPH) has established as a priority improving the availability of health status data for community-based health promotion and prevention. In 1996, MDPH implemented the Massachusetts Community Health Information Profile—MassCHIP—an information service to provide dial-up access to community-level data for assessing community health needs, monitoring health status indicator, and evaluating programs. In the initial phase, data on health status, health outcome, program utilization, and sociodemographic characteristics are available from 18 separate data sets. The system is designed to be used by anyone with modem access, which could include local governments, health plans, individual health care providers, researchers, community agencies and organizations, and the general public. Mass CHIP has the ability to create standard or customized reports for several different levels of geographic detail: 351 cities and towns; neighborhoods in Boston, Springfield, and Lowell; standard regional units (counties, MDPH regions, and Community health Network Areas [CHNAs]); or user-defined combinations of cities, towns, and regions. Depending on the original data, variables such as age, sex, race or ethnicity, education, or income can be used to restrict reporting to groups of interest. All data elements are cross-linked to relevant Healthy People 2000 objectives. Reports can be based on observed counts, crude or age-adjusted rates, age-specific rates, and standardized ratios. The system includes guidelines for suppressing small numbers as needed to ensure confidentiality. Among the standard reports are sets of health status indicators for CHNAs. SOURCE: Massachusetts Department of Public Health (1995); D.K. Walker, personal communication (1996). sampling methods and inclusion of additional questions could make it possible to generate county or other substate estimates. Illinois, for example, is adopting a program to produce periodic county-level estimates by oversampling different groups of counties for each BRFSS round. In Massachusetts, similar arrangements are being made for cities and regions of the state. The school-based Youth Risk Behavior Surveillance System (YRBSS)—a collaborative effort involving states, cities, and the CDC (1995)—may lend itself to similar approaches to generating community data for adolescents. Neither the BRFSS nor the YRBSS as they are currently designed will provide information on children. To

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Improving Health in the Community: A Role for Performance Monitoring FAcct. 1996. In Practice—Diabetes. Accountability! (Fall):1–29. Gostin, L.O. 1995. Health Information Privacy. Cornell Law Review 80(3):451–528. Gostin, L.O., Lazzarini, Z., Neslund, V.S., and Osterholm, M.T. 1996. The Public Health Information Infrastructure: A National Review of the Law on Health Information Privacy. Journal of the American Medical Association 275:1921–1927. Hayes, M.V., and Willms, S.M. 1990. Healthy Community Indicators: The Perils of the Search and the Paucity of the Find. Health Promotion International 5(2):161–166. Hennessy, C.H., Moriarty, D.G., Zack, M.M., Scherr, P.A., and Brackbill, R. 1994. Measuring Health-Related Quality of Life for Public Health Surveillance. Public Health Reports 109:665–672. IOM (Institute of Medicine). 1992. Guidelines for Clinical Practice: From Development to Use. M.J. Field and K.N. Lohr, eds. Washington, D.C.: National Academy Press. IOM. 1993. Access to Health Care in America. M. Millman, ed. Washington, D.C.: National Academy Press. IOM. 1994. Health Data in the Information Age: Use, Disclosure, and Privacy. M.S. Donaldson and K.N. Lohr, eds. Washington, D.C.: National Academy Press. Massachusetts Department of Public Health. 1995. Massachusetts Community Health Information Profile. Boston: Massachusetts Department of Public Health. (brochure) MCHB (Maternal and Child Health Bureau). 1995. Annual Report Guidance for the Maternal and Child Health Services Block Grant Program. OMB No. 0915-0172. Rockville, Md.: U.S. Department of Health and Human Services. Minnesota Department of Human Services. 1995. The Substance Abuse Monitoring System. research NEWS (January). St. Paul: Minnesota Department of Human Services, Chemical Dependency Division. Moriarty, D. 1996. CDC Studies Community Quality of Life. NACCHO News 12(3):10, 13. NACHO (National Association of County Health Officials). 1991. APEXPH: Assessment Protocol for Excellence in Public Health. Washington, D.C.: NACHO. National Civic League. 1993. The Healthy Communities Handbook. Denver: National Civic League. NCHS (National Center for Health Statistics). 1995a. The CDC Assessment Initiative: A Summary of State Activities. Healthy People 2000: Statistics and Surveillance. No. 7 (October). Hyattsville, Md.: U.S. Department of Health and Human Services. NCHS. 1995b. Pilot Test of Community Survey. Healthy People 2000: Activity Update. (Brock, B.M. A Telephone Survey Methodology for Local Health Departments' Community Health Status and Risk Factor Assessments Related to Healthy People 2000. DHHS/PHS/CDC Contract #200-94-7064.) Hyattsville, Md.: U.S. Department of Health and Human Services. NCQA (National Committee for Quality Assurance). 1993. Health Plan Employer Data and Information Set and User's Manual, Version 2.0 (HEDIS 2.0). Washington, D.C.: NCQA. NCQA. 1996. HEDIS 3.0 Draft for Public Comment. Washington, D.C.: NCQA. NRC (National Research Council). 1996. Assessment of Performance Measures in Public Health. Phase 1 Report. Draft for Comment. Washington, D.C.: National Academy Press.

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Improving Health in the Community: A Role for Performance Monitoring Patrick, D.L., and Wickizer, T.M. 1995. Community and Health. In Society and Health. B.C. Amick, s. Levine, A.R. Tarlov, and D.C. Walsh, eds. New York: Oxford University Press. Perrin, E.B. 1995. SAC Instrument Review Process. Medical Outcomes Trust Bulletin 3(4):1, I–IV. Regional Municipality of Hamilton-Wentworth. 1996. Signposts on the Trail to Vision 2020: Hamilton-Wentworth Sustainable Indicators, 1996. Hamilton. Ont.: Regional Municipality of Hamilton-Wentworth Environment Department. Sofaer, S. 1995. Performance Indicators: A Commentary from the Perspective of an Expanded View of Health. Washington, D.C.: Center for the Advancement of Health. Stoto, M.A. 1992. Public Health Assessment in the 1990s. Annual Review of Public Health 13:59–78. U.S. Congress, House of Representatives. 1996. H.R. 3482: Medical Privacy in the Age of New Technologies Act of 1996. 104th Congress, 2nd Session, May 16. U.S. Congress, Senate. 1995. S. 1360: Medical Records Confidentiality Act of 1995. 104th Congress, 1st Session, October 24. USDHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . DHHS Pub. No. (PHS) 91-50212. Washington, D.C.: Office of the Assistant Secretary for Health. USDHHS. No date. Performance Measurement in Selected Public Health Programs: 1995–1996 Regional Meetings. Washington, D.C.: Office of the Assistant Secretary for Health. U.S. Preventive Services Task Force. 1996. Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams and Wilkins. Wennberg, J., ed. 1996. The Dartmouth Atlas of Health Care. Chicago: American Hospital Press. Westin, A.F. 1967. Privacy and Freedom. New York: Atheneum. WHO (World Health Organization). 1986. A Discussion Document on the Concept and Principles of Health Promotion. Health Promotion 1(1):73–76. APPENDIX 5A PROPOSED COMMUNITY HEALTH PROFILE INDICATORS Distribution of the population by age and race or ethnicity. Data on the basic demographic characteristics of a community are important for understanding current or potential health concerns. For example, a community that has a significant percentage of young families may have a special interest in health issues related to children, pregnancy, teenagers, and injuries, whereas an older community may need to address health issues related to health care resources and utilization, and chronic disease associated with aging. The demographic composition of the population should be understood because significant disparities in health status between minority and nonminority populations may be due to factors including economic resources, health care access, discrimination, and genetic susceptibility to disease. Field

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Improving Health in the Community: A Role for Performance Monitoring model domains: individual behavior, genetics, and social environment. Data sources: decennial census; states may also develop intercensal estimates for communities. Number and proportion of persons in groups such as migrants, the homeless, or the non-English speaking, for whom access to community services and resources may be a concern. Subpopulations such as migrants, the homeless, or those who do not speak English are at greater risk for more significant health problems than the general population, may have greater difficulty gaining access to community services and resources, and may benefit from a variety of specialized responses. If a community has a large population of this type, then an attempt should be made to collect health indicator data for that group. In most cases, however, special populations are small, which necessitates special care in the analysis of group-specific data. The size and composition of these populations may change more rapidly than the rest of the population, so care should also be exercised in using data that are not current. Field model domains: individual behavior, social environment, physical environment, and prosperity. Data sources: decennial census; local agencies that serve special populations. Caution may also be needed in using census data if there is reason to believe that a group may have been undercounted relative to others in the community. Number and proportion of persons aged 25 and older with less than a high school education. Adults with less than a high school education can be at increased risk of health problems because of illiteracy, low-paying jobs that do not provide health insurance, lack of health information, and poor living conditions. There is also evidence that children living with parents whose educational attainment is low have more health problems than other children, even after other socio-economic factors have been taken into account (Zill, 1996). These problems can begin even before birth because low educational attainment is associated with poor maternal health. Field model domains: individual behavior, social environment, physical environment, prosperity, and well-being. Data sources: decennial census; intercensal data may be available from state or community data systems or estimates.

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Improving Health in the Community: A Role for Performance Monitoring Ratio of the number of students graduating from high school to the number of students who entered 9th grade three years previously. Teenagers who drop out of high school may be at increased risk of unwanted pregnancy, sexually transmitted diseases, substance abuse, low-paying jobs without health insurance, and violence. This indicator is a measure of cumulative dropouts from the beginning of the high school period. Adjustments will be needed to account for students who transfer to or from other schools. Field model domains: disease, individual behavior, social environment, physical environment, and prosperity. Data sources: local school districts; data should be collected by individual districts and for all districts combined. Median household income. Median household income in the community provides information on family economic resources and the distribution of income in the community. Household income can affect a family's ability to obtain suitable housing, nutrition, or health insurance and may be related to behaviors that affect health. Comparisons over time within a community, among population groups within a community, or with other communities may be helpful in gauging the possible relationship between income and health status or other factors. Field model domains: individual behavior, social environment, physical environment, prosperity, health care, and health and function. Data sources: decennial census; may be available from state surveys. Proportion of children less than 15 years of age living in families at or below the poverty level. This indicator is included in the consensus set recommended by the Centers for Disease Control and Prevention (CDC, 1991) for use by all states and communities. It is similar to median household income but focuses specifically on children in low-income households, whose risk for health problems is high and whose ability to address health risks is limited. Many of these children will be enrolled in Medicaid or qualify for other health-related programs such as WIC (Special Supplemental Food Program for Women, Infants, and Children). Field model domains: individual behavior, social environment, physical environment, prosperity, health care, and health and function. Data sources: decennial census; may be available from state or local surveys.

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Improving Health in the Community: A Role for Performance Monitoring Unemployment rate. For individuals, unemployment reduces household income, can limit access to health insurance, and can contribute to psychological stress. For a community, an increase in the unemployment rate can increase demands on social services and might signal broader economic problems. The unemployment rate can fluctuate considerably from month to month; therefore rates should be obtained by month or quarter for one to two years to determine the underlying trend. Field model domains: individual behavior, social environment, physical environment, prosperity, health care, and health and function. Data sources: state employment security office. Number and proportion of single-parent families. Single-parent families may experience many economic and social stresses that affect the health status of adults and children. Field model domains: individual behavior, social environment, physical environment, prosperity, health care, and well-being. Data sources: decennial census; data on divorce and births to unmarried mothers can be obtained from the state vital records office to monitor changes in family structure. Number and proportion of persons without health insurance. Having health insurance can be key for access to health care services. Without insurance, individuals often do not receive timely treatment or preventive care, which can compound adverse health conditions. Field model domains: disease, social environment, health care, health and function, and well-being. Data sources: no uniform community-level data collection tool is available; state assistance may be necessary to obtain data through community surveys. Oversampling in a state-level survey for the Behavioral Risk Factor Surveillance System (BRFSS) might be a source of information on adults; modifications would be required to obtain information on children. Infant mortality rate by race or ethnicity. This indicator is included in the consensus set recommended by the CDC (1991) for use by all states and communities. It is widely used as an indicator of child health. Because there are many reasons why infants die, infant mortality reflects the effectiveness of health departments, personal health care providers,

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Improving Health in the Community: A Role for Performance Monitoring outreach services, and preventive services for the mother before and during pregnancy and for the child during the first year of life. The number of deaths will be small in most communities so caution is required in analyzing these data. Usually, data will have to be aggregated for multiple years to produce a stable rate. Field model domains: disease, genetics, individual behavior, social environment, physical environment, health care, and prosperity. Data sources: state or local vital records. Numbers of deaths or age-adjusted death rates for motor vehicle crashes (ICD-9 codes: E810–E8251), work-related injuries, suicide (E950–E959), homicide (E970–E978), lung cancer (162), breast cancer (174), cardiovascular diseases (390–448), and all causes, by age, race, and gender as appropriate. This indicator is included in the consensus set recommended by CDC (1991) for use by all states and communities. These leading causes of death provide a basic understanding of the health status of the community. Data should be analyzed by age, race, and gender if possible to target preventive efforts. Although in some communities the numbers of deaths will always be too small to develop a stable rate, it is important to know the number of events. For example, although there may not be a large number of teenage suicides, any number is unacceptable. At the community level, the number of deaths for any specific cause will be small, and data will need to be aggregated for multiple years to produce stable rates. Field model domains: disease, genetics, individual behavior, social environment, physical environment, health care, and prosperity. Data sources: state or local vital records. Reported incidence of AIDS, measles, tuberculosis, and primary and secondary syphilis, by age, race, and gender as appropriate. This indicator is included in the consensus set recommended by CDC (1991) for use by all states and communities. Communicable diseases such as these affect the individuals who are infected and also place the entire community at risk. For some conditions, the numbers of cases may be too small to develop stable rates, but establishing the number of persons with the disease is important since nearly all cases are potentially prevent- 1   Diagnostic codes assigned under the International Classification of Diseases, 9th Revision (USDHHS, 1995).

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Improving Health in the Community: A Role for Performance Monitoring able. Field model domains: disease, genetics, individual behavior, social environment, health care, health and function, well-being, and prosperity. Data sources: state or local disease surveillance systems. Births to adolescents (ages 10–17) as a proportion of total live births. This indicator is included in the consensus set recommended by CDC (1991) for use by all states and communities. Births to young women of school age are usually unplanned and often unwanted. The pregnancy can have a negative impact on the health and well-being of the mother, father, grandparents, and child. Lack of economic and social support can manifest in various diseases and health conditions. Field model domains: individual behavior, social environment, well-being, and prosperity. Data sources: state or local vital records. Number and rate of confirmed abuse and neglect cases among children. This indicator is included among the priority data needs to augment the consensus indicators recommended by CDC (1991) for use by all states and communities. Children are the most vulnerable population in a community. Most abuse and neglect cases involve young children who cannot defend or choose for themselves; thus, a community response is required. Child abuse and neglect are thought to be underreported, and inconsistencies in reporting and confirmation practices make it difficult to assess changes in incidence (NRC, 1993). Field model domains: disease, individual behavior, social environment, physical environment, health care, and well-being. Data sources: state or local child protection agency. Proportion of 2-year-old children who have received all age-appropriate vaccines, as recommended by the Advisory Committee on Immunization Practices. This indicator is included among the priority data needs to augment the consensus indicators recommended by CDC (1991) for use by all states and communities. The immunization rate reflects the effectiveness of the public health system and personal health care providers in delivering immunization services. It also reflects the impact of family decisions, which can be influenced by personal circumstances, economic factors, and factors affecting access to services. The current series of immunizations recom-

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Improving Health in the Community: A Role for Performance Monitoring mended for completion by 2 years of age is four doses of diphtheria-tetanus-pertussis (DTP) vaccine; three doses of polio vaccine (oral or inactivated); three doses of Haemophilus influenzae type b (Hib) vaccine; three doses of hepatitis B vaccine; one dose of measles-mumps-rubella (MMR) vaccine; and one dose of varicella vaccine (CDC, 1996). Field model domains: individual behavior, social environment, prosperity, and health care. Data sources: retrospective school records surveys; community immunization register; community surveys; health plan records; reviews of patient records. Except where an immunization registry has been established, there is no routine reporting on immunizations. Proportion of adults aged 65 and older who have ever been immunized for pneumococcal pneumonia; proportion who have been immunized in the past 12 months for influenza. This indicator is included among the priority data needs to augment the consensus indicators recommended by CDC (1991) for use by all states and communities. The immunization rate reflects the effectiveness of the public health system and personal health care providers, as well as decisions of the elderly or their caretakers. Field model domains: individual behavior, social environment, prosperity, and health care. Data sources: Medicare claims files; health plan records; community surveys (questions have been developed for the BRFSS). Proportion of the population who smoke by age, race, and gender as appropriate. This indicator is included among the priority data needs to augment the consensus indicators recommended by CDC (1991) for use by all states and communities. Smoking is the greatest risk factor associated with the leading causes of death. It has been estimated that 19 percent of all deaths are related to smoking (McGinnis and Foege, 1993). It also contributes to morbidity from chronic lung disease and respiratory infections. Smoking adversely affects the health of smokers and also other persons who breathe secondhand smoke. The fetus of a pregnant woman can be adversely affected as well. Estimates of the prevalence of smoking among adolescents (ages 10–14 and 15–19) might serve as a proxy for more direct measures of smoking initiation. Field model domains: disease, individual behavior, social environment, physical environment, prosperity, health care, and health and function. Data sources: community surveys (e.g., oversampling

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Improving Health in the Community: A Role for Performance Monitoring for a state survey for the BRFSS) and school-based surveys (e.g., for the Youth Risk Behavior Surveillance System) for data on adolescents; maternal smoking status is recorded on birth certificates, but the quality of the data needs to be evaluated. Proportion of the population age 18 and older who are obese. This indicator is included among the priority data needs to augment the consensus indicators recommended by CDC (1991) for use by all states and communities. Obesity is associated with increased risk for cardiovascular diseases, diabetes, some cancers, and conditions such as arthritis. It also generally reflects a combination of dietary factors and limited physical activity that are themselves associated with increased health risks. It has been estimated that 14 percent of all deaths in the United States are related to diet and activity patterns (McGinnis and Foege, 1993). Obesity can be measured in terms of the body mass index, which can be constructed from weight and height data (kg/m2). Field model domains: individual behavior, genetics, social environment, health care, health and function, and well-being. Data sources: community surveys (e.g., oversampling for a state survey for the BRFSS). Number and type of U.S. Environmental Protection Agency air quality standards not met. This indicator is included in the consensus set recommended by CDC (1991) for use by all states and communities. Air quality can have a significant impact on health, particularly for those who have chronic respiratory conditions. Field model domains: disease, social environment, physical environment, and well-being. Data sources: state environmental quality agency; local air quality management agency. Proportion of assessed rivers, lakes and estuaries that support beneficial uses (e.g., fishing and swimming approved). This indicator is included among the priority data needs to augment the consensus indicators recommended by CDC (1991) for use by all states and communities. Pollution in a community's rivers, lakes, and estuaries may directly cause disease and also affect the well-being of the community. Field model domains: disease, individual behavior, social environment, physical environment, and well-being. Data sources: state environmental quality agency.

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Improving Health in the Community: A Role for Performance Monitoring Per capita health care spending for Medicare beneficiaries (the Medicare adjusted average per capita cost [AAPCC]). Analysis shows considerable differences among communities in health care costs even after controlling for demographic factors (Wennberg, 1996). These analyses also indicate no discernible differences in mortality rates in communities that spend less money on health care. Communities should use this indicator in combination with other information (e.g., AAPCC and morbidity levels over time or across communities) in considering the appropriateness of resource use for health care. Because data do not exist on the total health care costs for most communities, the per capita health care spending for Medicare beneficiaries serves as a proxy for the community's total health care costs. Field model domains: health care and prosperity. Data sources: Health Care Financing Administration. Proportion of adults reporting that their general health is good to excellent. This indicator is a good overall indicator of the health status of persons in the community. Field model domains: health and function and well-being. Data sources: community surveys (e.g., oversampling for a state survey for the BRFSS). During the past 30 days, average number of days for which adults report that their physical or mental health was not good. This indicator is another approach to measuring the overall health of persons in the community. Field model domains: health and function and well-being. Data sources: community surveys (e.g., oversampling for a state survey for the BRFSS). Proportion of persons satisfied with the health care system in the community. Perceptions regarding the health care system can have an influence on perceived health status. This indicator is a broad measure of satisfaction, which could relate to many aspects of the health care system including access, cost, availability, quality, and options in health care. No standard measure of ''satisfaction" has been established, but the committee endorses efforts to do so. Field model domains: social environment, health care, health and function, well-being, and prosperity. Data sources: community survey.

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Improving Health in the Community: A Role for Performance Monitoring Proportion of persons satisfied with the quality of life in the community. As proposed by the committee, health is more than just the biological events occurring or not occurring in a person. The ideal of health is a sense of well-being in a person's life. Although quality of life is a difficult concept to measure, this indicator represents an effort to address this state. Standard measures of satisfaction and quality of life would have to be developed to use this indicator. Field model domains: individual behavior, social environment, physical environment, prosperity, health care, health and function, and well-being. Data sources: community survey; questions related to quality of life have been developed for the BRFSS. REFERENCES CDC (Centers for Disease Control and Prevention). 1991. Consensus Set of Health Status Indicators for the General Assessment of Community Health Status—United States. Morbidity and Mortality Weekly Report 40:449–451. CDC. 1996. Immunization Schedule—United States, January–June 1996. Morbidity and Mortality Weekly Report 44:940–943. McGinnis, J.M., and Foege, W.H. 1993. Actual Causes of Death in the United States. Journal of the American Medical Association 270:2207–2211. NRC (National Research Council). 1993. Understanding Child Abuse and Neglect. Washington, D.C.: National Academy Press. USDHHS. 1995. International Classification of Diseases, Ninth Revision, Clinical Modification. 5th ed. DHHS Pub. No. (PHS) 95-1260. Washington, D.C.: National Center for Health Statistics and Health Care Financing Administration. Wennberg, J., ed. 1996. The Dartmouth Atlas of Health Care. Chicago: American Hospital Press. Zill, N. 1996. Parental Schooling and Children's Health. Public Health Reports 111:34–43.