National Committee on Vital & Health Statistics
December 7, 1998
David Satcher, M.D.
Assistant Secretary for Health and Surgeon General
200 Independence Avenue SW
Washington, DC 20201
Dear Dr. Satcher:
The National Committee on Vital and Health Statistics appreciates the efforts that led to the production of the draft Healthy People: 2010 Objectives. We strongly endorse the decision to strengthen the Healthy People 2000 goal of reducing disparities and the proposed Healthy People 2010 goal of eliminating disparities. Our review and comments, therefore, have primarily focused on how this goal is reflected in the stated objectives, targets and accompanying text, and the following are our recommendations and rationale.
Recommendation #1: Baseline and monitoring data should be provided by race/ethnicity and income (or where not possible, by education and/or occupational status) for ALL objectives, including those that focus on program or governmental activities. If these data are not available for a particular objective, it should become a developmental objective. Each developmental objective should be accompanied by plans to obtain data by race/ethnicity and income. For race/ethnicity, the racial/ethnicity categories specified in OMB Directive No. 15 or its revision should be used as a minimum. Consistency across chapters in the reporting of baseline data, or plans to obtain it where not available, should be attempted.
Rationale: There are large differences across the 26 areas in the extent to which specific objectives address reductions in disparities. There are approximately 534 objectives (not including the sub-objectives denoted by lowercase letters); about 225 are developmental. Of the approximately 227 non-developmental, non-program/state objectives, only 40 (18%) provide baseline data by both race/ethnicity and income, 102 (46%) provide baseline data by race/ethnicity but NOT income. Of the additional nine objectives in Goal 1 (Increase Quality and Years of Healthy Life), six provide baseline data on race and three by race (from death data) and income (from the Behavioral Risk Factor Surveillance Survey).
Some topic areas make no mention of baseline data on either race/ethnicity or income:
- -Food safety
- -Occupational Health (although an argument could be made that this area inherently addresses socioeconomic disparities)
- -Medical Product Safety
- -Public Health Infrastructure
- -Health Communication
- -Disability and Secondary Conditions
Others mention only race/ethnicity data but no income data:
- -Education and Community-based programs
- -Prevention and Reduction of Diseases and Disorders
- -Mental Health
- -Substance Abuse
Topic areas where there is a well-known relationship between race/ethnicity and/or income yet a low proportion of objectives mentioning baseline data on either race/ethnicity or income include:
- -Mental Health
- -Immunizations and Infectious Diseases
- -Maternal and Child Health
- -Physical Activity
- -Environmental Health
- -Arthritis and Back Problems
- -Educational and Community-based programs
In addition to baseline data for each specific objective, introductions to each topic area sometimes (but not always) address disparities across population subgroups. There is little consistency in the completeness with which this is done. Introductions to only three chapters (3- Tobacco, 9-Oral Health, 22-Immunizations and Infectious Diseases) address disparities in health by both race/ethnicity and income as a separate section. The Disparities section in three chapters (18-Diabetes, 21-HIV, 25-STDs) addresses race/ethnicity only. Other explicit Disparities sections address other characteristics, e.g., age and pregnancy (6-Food Safety) The other chapters are lacking a separate discussion of disparities issues. Some chapters address disparities in their introductory remarks: 1-Physical Activity (gender, income, education); 2-Nutrition (race/ethnicity only); 5-Environmental Health (children only); 10-Access (race/ethnicity and low income); 11-Family Planning (race/ethnicity and poverty); 12-Maternal and Child Health (race/ethnicity and poverty); 15-Health Communication (mention of the need to be sensitive to race, culture, education, language, disability); 17-Cancer (race/ethnicity only); 19-Disability (age only); 20-Heart Disease and Stroke (gender and race/ethnicity only); 23-Mental Health (race/ethnicity and SES), 24-Respiratory Diseases (race/ethnicity, SES). One chapter (8- Occupational Health) is inherently related to SES. Thus, the vast majority of chapters do not address disparities as a specific general issue. These chapters include: Total Mortality (1), Education and Community-based programs (4), Injury and Violence prevention (7), Medical Product Safety (13), Public Health Infrastructure (14), Prevent and Reduce Diseases and Disorders (except for mention of race and income in the preview to Arthritis) (16), Respiratory Diseases (except for mention of race/ethnicity and SES in the Asthma overview) (24), Substance Abuse (26).
Recommendation #2: A separate chapter on Information Systems and Data Needs should be added; we recommend that the HHS Data Council be directed to do this. This chapter should address obtaining data on disparities by race/ethnicity and income (or where not possible, by education and/or occupational status).
Rationale: The current chapter on Public Health Infrastructure contains three objectives (14-7, 14-8, 14-9, the last of which is developmental) relating to data; 14-7 relates specifically to data for select populations. However, responsibility for these objectives is not clear and baseline data for them is not provided. Since the need for data crosses many agencies, the HHS Data Council would appear to be in the best position to define and coordinate these as well as other possible objectives by collaborating with the Healthy People Steering Committee to expand on the data- related objectives and the development of plans to obtain baseline and monitoring data by race/ethnicity and income in a systematic way in each of the chapters. Consideration should also be given to the extent to which objectives can be tracked at state and local levels.
Recommendation #3: The most likely primary source of data should be given for each objective.
Rationale: In the Draft, some secondary sources are provided for baseline data, e.g., Objective 20.2 on page 20-9, line 13. As these sources are unlikely to be ongoing, they do not indicate the source of ongoing data for monitoring.
Recommendation #4: Geocoding should be used when individual data on race/ethnicity and income are not available with appropriate consideration of the need to assure privacy and confidentiality.
Rationale: The National Committee on Vital and Health Statistics supports developmental objective 14.9 on page 14-9 regarding the development of the capacity for increased geocoding. Draft Healthy People 2010 objectives take little advantage of the potential of geocoding and linkage with census files or other geographic files, for the purpose of getting information for monitoring disparities in health. Many objectives, including those related to program or governmental efforts as well as individual data, lend themselves to using geocoding for the purpose of examining disparities in the absence of information at the individual level including, but not limited to, those objectives that represent program or governmental efforts. Data should be obtained at the lowest possible geographic level (the block level) and be aggregatable to larger areas.
Recommendation #5: There should be a separate section, perhaps an appendix, for each major data source, including information on its periodicity; inclusion of data on race/ethnicity, socioeconomic status and gender, and, where relevant, disability; and the quality of data with regard to representativeness, reliability and validity. We understand that there are current plans for a separate volume to accomplish this purpose and we endorse this effort.
Rationale: In the Draft, it is not possible to determine whether the specific data source supports the characterization by race/ethnicity and income. For example, for some objectives (e.g., Objectives 6-8 in Goal 1) the Behavioral Risk Factor Surveillance Survey is indicated as the source of data for baseline data but other specific objectives using this data source indicate lack of availability of baseline data for income.
Recommendation #6: The objectives relating to primary care should be revised to reflect current knowledge. This includes objectives for access, continuity, comprehensiveness, and coordination of services.
Rationale: Systematic disparities by race/ethnicity and income exist in the receipt of primary care services. Access to, and continuity of care from, an identifiable primary care practitioner differ by race/ethnicity and income, and these differences are associated with differences in various outcomes of care. Mental health services are an important aspect of comprehensiveness of services and objectives for their provision in primary care in the population and subpopulations should be developed. The NCVHS offers its services in identifying possible measures for the assessment of these goals.
The National Committee on Vital and Health Statistics recognizes that monitoring of changes in Healthy People 2010 objectives, targets, and baseline and monitoring data will have to be take into account changes in ICD-10, ICD-10-CM, racial and ethnicity categories, and age-adjustment procedures. The NCVHS offers its assistance as the Department engages in discussions regarding how to respond to these changes.
Don E. Detmer, M.D.
John Eisenberg, Ph. D., Data Council Co-chair
Margaret Hamburg, M.D., Data Council Co-chair
Linda Meyers, Ph.D., Acting Director, ODPHP