# Part A: General Data Issues

#  {#section .unnumbered}

##  {#section-1 .unnumbered}

## 1. Target Setting and Assessing Progress for Measurable Objectives

### Target-Setting Methods

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

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

-   For objectives that address health services and protection (for
    example, access to prenatal care, health insurance coverage, etc.)
    the targets have been set so that there is an improvement for all
    racial/ethnic segments of the population (that is, the targets are
    set "better than the best" racial/ethnic subgroup shown for the
    objective). Data points for at least two population groups under the
    race and ethnicity category are needed to use "better than the best"
    as the target-setting method.

-   For objectives that can be influenced in the short term by policy
    decisions, lifestyle choices, and behaviors (for example, physical
    activity, diet, smoking, suicide, alcohol-related motor vehicle
    deaths, etc.), the target setting method is also "better than the
    best" group.

-   For objectives that are unlikely to achieve an equal health outcome
    in the next decade, regardless of the level of investment (for
    example, occupational exposure and resultant lung cancer), the
    target represents an improvement for a substantial proportion of the
    population and is regarded as a minimum acceptable level. Implicit
    in setting targets for these objectives is the recognition that
    population groups with baseline rates already better than the
    identified target should continue to improve.

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

The following target-setting methods have been used:

-   Better than the best.

-   \_\_ percent improvement.

-   "Total coverage" or "Total elimination" (for targets like 100
    percent,\
    0 percent, all States, etc.).

-   Consistent with \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(another
    national program, for example, national education goals).

-   Retain year 2000 target (the Healthy People 2000 target has been
    retained).

The specific method for developing the target is described under each
objective in *Healthy People 2010*.**^2^**

### Assessing Progress

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

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

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

## References

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

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

## 2. Developmental Objectives

Developmental objectives are those that currently do not have national
baseline data (see Reader's Guide section in *Healthy People
2010***^1^**) and, therefore, currently have no operational definitions.
Some objectives that contain several measures may have parts that are
developmental. Developmental objectives indicate areas that need to be
placed on the national agenda for data collection. They address subjects
of sufficient national importance that investments should be made over
the next decade to measure their change.

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

## Reference

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

## 3. Population Estimates

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

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

The Census Bureau presents population data by race in two different
ways. In decennial census publications, persons of unspecified race are
maintained in the single category of "other." For the purpose of
providing comparable denominator data to other Federal and non-Federal
data users, in both 1980 and 1990, the Census Bureau produced another
set of population estimates for census years; in these population
estimates, persons of unspecified race were allocated to one of the four
tabulated racial groups (white, black, American Indian or Alaska Native,
Asian or Pacific Islander), based on their response to the Hispanic
question. These four race categories conform with Office of Management
and Budget (OMB) Directive 15**^3^** and are more consistent with the
race categories used in most major data systems, including vital
statistics.**^4^** The postcensal and intercensal population estimates
described below are based on these "OMB-consistent" populations.

### Postcensal Population Estimates

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

### Intercensal Estimates

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

### Population Undercounts

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

### Target Populations

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

#### Resident Population {#resident-population .unnumbered}

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

#### Civilian Population {#civilian-population .unnumbered}

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

#### Civilian, Noninstitutionalized Population {#civilian-noninstitutionalized-population .unnumbered}

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

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

## References

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

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

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

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

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

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

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

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

## 4. Population Template

### Minimum Template

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

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

The minimum template for all population-based objectives is:

Race:

American Indian or Alaska Native

Asian or Pacific Islander

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

Hispanic origin and race:

Hispanic or Latino

Not Hispanic or Latino

Black or African American

White

Gender:

Female

Male

Socioeconomic status:

Family income level- or Education level-

Poor Less than high school

Near poor High school graduate

Middle/high income At least some college

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

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

### Race and Hispanic Origin

#### OMB Classification 

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

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

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

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

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

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

-   **American Indian or Alaska Native**. A person having origins in any
    of the original peoples of North and South America (including
    Central America), and who maintains tribal affiliation or community
    attachment.

-   **Asian**. A person having origins in any of the original peoples of
    the Far East, Southeast Asia, or the Indian subcontinent including,
    for example, Cambodia, China, India, Japan, Korea, Malaysia,
    Pakistan, the Philippine Islands, Thailand, and Vietnam.

-   **Black or African American**. A person having origins in any of the
    black racial groups of Africa. Terms such as "Haitian" or "Negro"
    can be used in addition to "Black or African American."

-   **Native Hawaiian or Other Pacific Islander**. A person having
    origins in any of the original peoples of Hawaii, Guam, Samoa, or
    other Pacific Islands.

-   **White**. A person having origins in any of the original peoples of
    Europe, the Middle East, or North Africa.

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

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

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

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

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

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

#### Misreporting Racial and Ethnic Data 

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

##### National Vital Statistics System (Mortality) {#national-vital-statistics-system-mortality .Heading5THP}

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

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

##### Patient Care Data {#patient-care-data .Heading5THP}

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

#### Missing Data

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

##### National Hospital Discharge Survey {#national-hospital-discharge-survey .Heading5THP}

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

##### National Ambulatory Medical Care Surveys  {#national-ambulatory-medical-care-surveys .Heading5THP}

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

##### National Notifiable Disease Surveillance System {#national-notifiable-disease-surveillance-system .Heading5THP}

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

### Socioeconomic Status

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

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

#### Income

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

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

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

##### Family Income Level {#family-income-level .Heading5THP}

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

-   Poor (below the Federal poverty level),

-   Near poor (100-199% of the Federal poverty level), and

-   Middle and high income (200% or more of the Federal poverty level).

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

###### Table 1. Poverty thresholds in 1998, by size of family and number of related children under 18 years.

<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<thead>
<tr class="header">
<th rowspan="2"><p id="size-of-family-unit" class="heading">Size of
Family Unit</p></th>
<th colspan="9"><p id="related-children-under-18-years"
class="heading">Related Children Under 18 Years</p></th>
</tr>
<tr class="odd">
<th><p id="none" class="heading"> None</p></th>
<th><strong>1</strong></th>
<th><strong>2</strong></th>
<th><strong>3</strong></th>
<th><strong>4</strong></th>
<th><strong>5</strong></th>
<th><strong>6</strong></th>
<th><strong>7</strong></th>
<th><strong>8</strong></th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td>One person</td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Under 65 years</p>
</blockquote></td>
<td>8,480</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>65 years and older</p>
</blockquote></td>
<td>7,818</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Two persons</td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Householder under 65 years</p>
</blockquote></td>
<td>10,915</td>
<td>11,235</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Householder 65 years and older</p>
</blockquote></td>
<td>9,853</td>
<td>11,193</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Three persons</td>
<td>12,750</td>
<td>13,120</td>
<td>13,133</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Four persons</td>
<td>16,813</td>
<td>17,088</td>
<td>16,530</td>
<td>16,588</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Five persons</td>
<td>20,275</td>
<td>20,570</td>
<td>19,940</td>
<td>19,453</td>
<td>19,155</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Six persons</td>
<td>23,320</td>
<td>23,413</td>
<td>22,930</td>
<td>22,468</td>
<td>21,780</td>
<td>21,373</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Seven persons</td>
<td>26,833</td>
<td>27,000</td>
<td>26,423</td>
<td>26,020</td>
<td>25,270</td>
<td>24,395</td>
<td>23,435</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Eight persons</td>
<td>30,010</td>
<td>30,275</td>
<td>29,730</td>
<td>29,253</td>
<td>28,575</td>
<td>27,715</td>
<td>26,820</td>
<td>26,593</td>
<td></td>
</tr>
<tr class="odd">
<td>Nine persons or more</td>
<td>36,100</td>
<td>36,275</td>
<td>35,793</td>
<td>35,388</td>
<td>34,723</td>
<td>33,808</td>
<td>32,980</td>
<td>32,775</td>
<td>31,513</td>
</tr>
</tbody>
</table>

Note: Numbers represent income in U.S. dollars.

Source: U.S. Bureau of the Census.

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

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

#### Education 

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

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

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

-   Less than high school (persons with less than 12 years of schooling
    or no high school diploma),

-   High school graduate (persons with either 12 years of schooling, a
    high school diploma, or general equivalency diploma \[GED\], and

-   At least some college (persons with a high school diploma or GED and
    13 or more years of schooling).

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

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

###### Table 2. Healthy People 2010 data systems and ages used to report educational attainment.

+----------------------------------------------+-----------------------+
| ####### Data System                          | Ages Used To Report   |
|                                              | Educational           |
|                                              | Attainment            |
+----------------------------------------------+-----------------------+
| Behavioral Risk Factor Surveillance System   | 25 years and older    |
| (BRFSS)                                      |                       |
+----------------------------------------------+-----------------------+
| National Health and Nutrition Examination    | 25 years and older\   |
| Survey (NHANES)                              | (unless otherwise     |
|                                              | noted)                |
+----------------------------------------------+-----------------------+
| National Health Interview Survey (NHIS)      | 25 years and older    |
+----------------------------------------------+-----------------------+
| National Survey of Family Growth (NSFG)      | 22--44 years          |
+----------------------------------------------+-----------------------+
| National Vital Statistics System---Mortality | 25--64 years          |
| (NVSS-M)                                     |                       |
+----------------------------------------------+-----------------------+
| National Vital Statistics System---Natality  | 20 years and older    |
| and Linked (NVSS-N and NVSS-L)               |                       |
+----------------------------------------------+-----------------------+
| National Household Survey on Drug Abuse      | 18 years and older    |
| (NHSDA)                                      |                       |
+----------------------------------------------+-----------------------+

### Other Population Groups

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

#### Urbanization

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

##### Urban {#urban .Heading5THP}

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

##### Metropolitan Statistical Areas (MSA's) {#metropolitan-statistical-areas-msas .Heading5THP}

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

#### Health Insurance Status

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

#### Disability

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

According to ICIDH-2, components of disability include:

-   losses or abnormalities of bodily function and structure
    (impairments),

-   limitations of activities,

-   restrictions in participation (formerly called handicaps),

-   barriers and facilitators which make up the physical, social and
    attitudinal environment (environmental factors).

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

-   Decennial Census

-   Survey of Income and Program Participation (SIPP)

-   National Health Interview Survey (NHIS)

-   National Health and Nutrition Examination Survey (NHANES)

-   Medical Expenditure Panel Survey (MEPS)

-   Current Population Survey (CPS)

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

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

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

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

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

-   Are you limited in any way in any activities because of any
    impairment or health problem?

-   If you use special equipment or help from others to get around, what
    type do you use?

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

-   Are you limited in the kind or amount of [work]{.underline} you can
    do because of any impairment or health problem?

-   Are you limited in the kind or amount of [housework]{.underline} you
    can do because of any impairment or health problem?

-   Are you limited in any way in any [activities]{.underline} because
    of any impairment or health problem?

-   Do you usually use any device to help you get around such as a cane,
    wheelchair, crutches or walker?

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

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

#### Age {#age .unnumbered}

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

## References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

17\. NCHS. Current estimates from the National Health Interview Survey,
1995. *Vital and Health Statistics* 10(199), 1998.

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

## 5. Age Adjustment

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

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

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

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

Age-adjusted baseline data are noted in *Healthy People 2010***^2^** and
in Part B: Operational Definitions. Any data not specifically denoted as
age adjusted, should be considered crude (unadjusted) data.

### Mortality

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

-   Numbers of deaths

-   Age-specific death rates

-   Maternal/infant rates, which use births as the denominator, or

-   Crude death rates from other systems such as the Fatality Analysis
    Reporting System or the Census of Fatal Occupational Injuries

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

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

> AADR = ∑ *w~si~ ⋅ R~i~*

where *R~i~* is the age-specific death rate for age interval *i* and
*w~si~* denotes the standard weight for age interval *i* such that

> *P~si~*
>
> *w~si\ ~*=
>
> ∑ *P~si~*

where *P~si~* denotes the population in age interval *i* in the standard
population, 0\<*w~si~*\<1, and the *w~si~* sum to 1.

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

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

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

Changing standards will affect comparisons between race and Hispanic
groups. In particular, ratios of African American to white age-adjusted
death rates are reduced from those based on the 1940 standard
population, reducing the disparity between these two groups**^6^** (see
figure 8 above). This is due to the older age structure among the white
population compared to the African-American population and greater
weight given to death rates at the older ages. Comparisons between white
and other minority groups may also be affected.

Comparisons should not be made between age-adjusted death rates based on
different standards since the numerical value of the age-adjusted rate
depends on the standard used; thus, age-adjusted death rates calculated
before the implementation of the 2000 standard will not be comparable
with rates based on the 2000 standard. Comparability requires
recalculating the time series predating the new standard. For more
detailed information regarding age adjustment and the implications of
implementing the 2000 standard, refer to the National Center for Health
Statistics (NCHS) publication "Age standardization of death rates:
implementation of the 2000 standard,"**^6^** which can be obtained at
the following Internet address:

http://www.cdc.gov/nchs/products/pubs/pubd/nvsr/

> The 2000 standard age distribution for mortality data along with
> corresponding values for *w~si~* are shown in Table 3.

###### Table 3. 2000 standard million age distribution.

+-------------------+----------------+----------------+----------------+
| ####### Age       | **Population\  | ####### St     | ####### *Propo |
|                   | ***(in         | andard Million | rtion Distribu |
|                   | thousands)*    |                | tions* (w~si~) |
+-------------------+----------------+----------------+----------------+
| All ages          | 274,634        | 1,000,000      | 1.000000       |
+-------------------+----------------+----------------+----------------+
| Under 1 year      | 3,795          | 13,818         | 0.013818       |
+-------------------+----------------+----------------+----------------+
| 1-4 years         | 15,192         | 55,317         | 0.055317       |
+-------------------+----------------+----------------+----------------+
| 5-14 years        | 39,977         | 145,565        | 0.145565       |
+-------------------+----------------+----------------+----------------+
| 15-24 years       | 38,077         | 138,646        | 0.138646       |
+-------------------+----------------+----------------+----------------+
| 25-34 years       | 37,233         | 135,573        | 0.135573       |
+-------------------+----------------+----------------+----------------+
| 35-44 years       | 44,659         | 162,613        | 0.162613       |
+-------------------+----------------+----------------+----------------+
| 45-54 years       | 37,030         | 134,834        | 0.134834       |
+-------------------+----------------+----------------+----------------+
| 55-64 years       | 23,961         | 87,247         | 0.087247       |
+-------------------+----------------+----------------+----------------+
| 65-74 years       | 18,136         | 66,037         | 0.066037       |
+-------------------+----------------+----------------+----------------+
| 75-84 years       | 12,315         | 44,842         | 0.044842       |
+-------------------+----------------+----------------+----------------+
| 85 years and      | 4,259          | 15,508         | 0.015508       |
| older             |                |                |                |
+-------------------+----------------+----------------+----------------+

Source: U.S. Census Bureau, Population Estimates Program.

### Health Surveys

A number of other Healthy People 2010 objectives use data from national
health surveys that are also age adjusted. These are specified in
Healthy People 2010**^2^** and in the operational definition for each
objective. These include objectives tracked by the National Health
Interview Survey (NHIS), the Medical Expenditure Panel Survey (MEPS),
the National Hospital Discharge Survey (NHDS), the National Ambulatory
Medical Care Survey (NAMCS), the National Hospital Ambulatory Medical
Care Survey (NHAMCS), the Behavioral Risk Factor Surveillance System
(BRFSS), the Continuing Survey of Food Intakes by Individuals (CSFII),
and the National Health and Nutrition Examination Survey (NHANES). Data
for these objectives are also age adjusted to the 2000 standard
population, using the equations previously shown where R~i~ is the
age-specific rate for the health status, health behavior, or health care
utilization variable, as appropriate.

However, the age groups used to adjust the survey data may be somewhat
different from those used to adjust mortality data. In general, to
maximize the stability of the rates, fewer age groups are used.
Differences resulting from the specific age groups used should be
relatively small. In some cases, the applicable age range for the
objective may not be the total population. For example, an objective may
refer to persons aged 18 years and older, females aged 40 years and
older, or persons aged 45-74 years, etc. In these cases, the weights are
recomputed for applicable age groups so that they total to 1 (or
1,000,000).

The following age groups were used for the major data systems shown in
Table 4. The specific grouping used depends on the age group targeted by
the objective.

+-----------+----------+----------+----------+----------+----------+
| ###### Ta |          |          |          |          |          |
| ble 4. Ag |          |          |          |          |          |
| e groups  |          |          |          |          |          |
| used to a |          |          |          |          |          |
| ge adjust |          |          |          |          |          |
|  from sel |          |          |          |          |          |
| ected maj |          |          |          |          |          |
| or Health |          |          |          |          |          |
| y People  |          |          |          |          |          |
| 2010 data |          |          |          |          |          |
|  systems. |          |          |          |          |          |
+===========+==========+==========+==========+==========+==========+
| #         | ####     |          |          |          |          |
| ###### Da | ### Age  |          |          |          |          |
| ta System | Grouping |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| NHIS      | (All     | (Ages    | (Ages    | (Ages    | (Ages    |
|           | Ages)    | 2+)      | 18+)     | 18+)     | 25+)     |
+-----------+----------+----------+----------+----------+----------+
| BRFSS     | 0-17     | 2-17     | 18-24    | 18-24    | 25-34    |
+-----------+----------+----------+----------+----------+----------+
| MEPS      | 18-44    | 18-44    | 25-34    | 25-44    | 35-44    |
+-----------+----------+----------+----------+----------+----------+
|           | 45-54    | 45-54    | 35-44    | 45-64    | 45-64    |
+-----------+----------+----------+----------+----------+----------+
|           | 55-64    | 55-64    | 45-64    | 65+      | 65+      |
+-----------+----------+----------+----------+----------+----------+
|           | 65-74    | 65-74    | 65+      |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 75+      | 75+      |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | (Ages    | (Ages    | (Ages    | (Ages    | (Ages    |
|           | 40+)     | 45+)     | 50+)     | 65+)     | 0-17)    |
+-----------+----------+----------+----------+----------+----------+
|           | 40-49    | 45-49    | 50-64    | 65-74    | 0-4      |
+-----------+----------+----------+----------+----------+----------+
|           | 50-64    | 50-64    | 65+      | 75+      | 5-11     |
+-----------+----------+----------+----------+----------+----------+
|           | 65+      | 65+      |          |          | 12-17    |
+-----------+----------+----------+----------+----------+----------+
|           |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | (Ages    |          |          |          |          |
|           | 18-64)   |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 18-24    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 25-34    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 35-44    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 45-64    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| NHANES    | (All     | (Ages    | (Ages    | (Ages    | (Ages    |
|           | Ages)    | 2+)      | 18+)     | 18+)     | 25+)     |
+-----------+----------+----------+----------+----------+----------+
| CSFII     | 0-12     | 2-5      | 12-19    | 18-29    | 20-29    |
+-----------+----------+----------+----------+----------+----------+
|           | 12-19    | 6-11     | 20-29    | 30-39    | 30-39    |
+-----------+----------+----------+----------+----------+----------+
|           | 20-29    | 12-19    | 30-39    | 40-49    | 40-49    |
+-----------+----------+----------+----------+----------+----------+
|           | 30-39    | 20-29    | 40-49    | 50-59    | 50-59    |
+-----------+----------+----------+----------+----------+----------+
|           | 40-49    | 30-39    | 50-59    | 60-69    | 60-69    |
+-----------+----------+----------+----------+----------+----------+
|           | 50-59    | 40-49    | 60-69    | 70-79    | 70-79    |
+-----------+----------+----------+----------+----------+----------+
|           | 60-69    | 50-59    | 70-9     | 80+      | 80+      |
+-----------+----------+----------+----------+----------+----------+
|           | 70-79    | 60-69    | 80+      |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 80+      | 70-79    |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          | 80+      |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | (Ages    |          |          |          |          |
|           | 20+)     |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 20-39    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 40-59    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 60+      |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          |          |          |          | C        |
|           |          |          |          |          | ontinued |
+-----------+----------+----------+----------+----------+----------+
| NAMCS     | (All     | (Ages    |          |          |          |
|           | Ages)    | 20+)     |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| NHAMCS    | 0-18     | 20-44    |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 18-44    | 45-64    |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 45-64    | 65+      |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 65-74    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 75+      |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| NHDS      | (All     | (Ages    | (Age     | (Ages    |          |
|           | Ages)    | 65+)     | 0-64)    | 5-64)    |          |
+-----------+----------+----------+----------+----------+----------+
|           | 0-18     | 65-74    | 0-17     | 5-17     |          |
+-----------+----------+----------+----------+----------+----------+
|           | 18-44    | 75+      | 18-44    | 18-44    |          |
+-----------+----------+----------+----------+----------+----------+
|           | 45-64    |          | 45-64    | 45-64    |          |
+-----------+----------+----------+----------+----------+----------+
|           | 65-74    |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | 75+      |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+

A reference list based on the projected 2000 population from which
weights can be computed to age-adjust data for virtually all Healthy
People 2010 objectives is shown below in Table 5:

###### Table 5. 2000 population projections by age *(in thousands).*

+------------------+--------------+---------------------+-------------+
| ####### Age      | ######       | ####### Age         | #######     |
|                  | # Population |                     |  Population |
+------------------+--------------+---------------------+-------------+
| > Total          | > 274,634    |                     |             |
+------------------+--------------+---------------------+-------------+
| > Under 1 year   | > 3,795      | > 30-34 years       | > 19,511    |
+------------------+--------------+---------------------+-------------+
| > 1 year         | > 3,759      | > 35-39 years       | > 22,180    |
+------------------+--------------+---------------------+-------------+
| > 2-4 years      | > 11,433     | > 40-44 years       | > 22,479    |
+------------------+--------------+---------------------+-------------+
| > 5 years        | > 3,896      | > 45-49 years       | > 19,806    |
+------------------+--------------+---------------------+-------------+
| > 6-8 years      | > 11,800     | > 50-54 years       | > 17,224    |
+------------------+--------------+---------------------+-------------+
| > 9 years        | > 4,224      | > 55-59 years       | > 13,307    |
+------------------+--------------+---------------------+-------------+
| > 10-11 years    | > 8,258      | > 60-64 years       | > 10,654    |
+------------------+--------------+---------------------+-------------+
| > 12-14 years    | > 11,799     | > 65-69 years       | > 9,410     |
+------------------+--------------+---------------------+-------------+
| > 15-17 years    | > 11,819     | > 70-74 years       | > 8,726     |
+------------------+--------------+---------------------+-------------+
| > 18-19 years    | > 8,001      | > 75-79 years       | > 7,415     |
+------------------+--------------+---------------------+-------------+
| > 20-24 years    | > 18,257     | > 80-84 years       | > 4,900     |
+------------------+--------------+---------------------+-------------+
| > 25-29 years    | > 17,722     | > 85 years and      | > 4,259     |
|                  |              | > older             |             |
+------------------+--------------+---------------------+-------------+

> Source: U.S. Bureau of the Census, Population Estimates Program.

More information on the age groups used to adjust and the weights used
for specific data systems can be found in *Health, United
States*.**^8^**

## References

1\. Shryock, H.S., and Siegel, J.S. *The Methods and Materials of
Demography*. San Diego, CA: Academic Press, 1976.

2\. U.S. Department of Health and Human Services (HHS). *Healthy People
2010*. 2nd ed. With Understanding and Improving Health and Objectives
for Improving Health. 2 vols. Washington, DC: U.S. Government Printing
Office, November 2000.

3\. Feinleib, M., and Zarate, A.O., eds. Reconsidering Age Adjustment
Procedures: Workshop Proceedings. *Vital and Health Statistics* 4(29),
1992.

4\. Curtin, L.R.; Maurer, J.; and Rosenberg, H.M. On the selection of
alternative standards for the age-adjusted death rate. *Proceedings of
the Social Statistics Sections, American Statistical Association*
218-223, 1980.

5\. Anderson, R.N., and Rosenberg, H.M. Report of the Second Workshop on
Age Adjustment. *Vital and Health Statistics* 4(30), 1998.

6\. Anderson, R.N., and Rosenberg, H.M. *Age Standardization of Death
Rates: Implementation of the Year 2000 Standard.* National Vital
Statistics Reports. Vol. 47, No. 3. Hyattsville, MD: NCHS, 1998.

7\. Curtin. L.R., and Klein, R.J. *Direct Standardization (Age-Adjusted
Death Rates).* Statistical Notes No. 6 revised. Hyattsville, MD: NCHS,
1995.

8\. NCHS. *Health, United States, 2000 With Adolescent Health Chart
Book*. Hyattsville, MD: NCHS, 2000.

## 6. Mortality and Morbidity Classification

### Mortality Data 

Baseline data for mortality objectives for specific causes of death in
this report are classified and coded according to the World Health
Organization's (WHO) Ninth Revision of the International Classification
of Diseases (ICD-9)**^1^** that was implemented in the United States
effective with deaths occurring in 1979. The specific ICD-9 codes used
are included in the operational definition for each mortality objective.
Beginning with deaths occurring in January 1999, the Tenth Revision of
the ICD will be used (ICD-10).^**2**^

Since the beginning of the century, the ICD for mortality has been
modified about once every 10 years, except for the 20-year interval
between the last two revisions, ICD-9 and ICD-10. The purpose of the
revisions is to stay abreast with medical advances in terms of disease
nomenclature and etiology.

The ICD is a classification system for causes of death, which includes
(1) coding rules for causes of death that allow a medical coder to
identify the underlying cause of death on the death certificate that is
considered most informative from a public health point of view; (2)
definitions for concepts like "underlying cause of death;" (3)
tabulation lists that indicate the cause-of-death groupings that
countries should use to present mortality data that can be compared with
other countries; and (4) the prescribed format of the medical
certification section of the death certificate. Use of the ICD for
classification and coding of mortality is required under an agreement
between the United States and WHO.

Data for most Healthy People 2010 mortality objectives are based on the
underlying cause of death. The underlying cause of death is defined by
WHO as the disease or injury that initiated the sequence of events
leading directly to death or as the circumstances of the violence or
accident that produced the fatal injury.**^1^** It is selected from the
conditions entered by the physician in the cause of death section on the
death certificate. When more than one cause is entered by the physician,
the underlying cause is determined by the sequence of conditions on the
certificate, provisions of the ICD, and associated selection rules and
modifications.**^3^** Generally, more information is reported on the
death certificate than is directly reflected in the underlying cause of
death. This is captured in the multiple cause-of-death statistics.
Several objectives use all mentions of a cause (or "multiple" cause) on
the death certificate. Details on the ICD-9 codes used for the baseline
for the Healthy People 2010 objective and whether the data used are
underlying or multiple cause will be found in the operational definition
for each mortality objective and also summarized in Appendix D.

ICD-10 differs from ICD-9 in a number of respects: (1) ICD-10 is far
more detailed than ICD-9, about 8,000 categories compared with 4,000
categories,

mainly to provide more clinical detail for morbidity (illness)
applications; (2) ICD-10 uses 4-digit alpha-numeric codes compared with
4-digit numeric codes in ICD-9; (3) three additional chapters have been
added, some chapters rearranged, cause of death titles have been
changed, and conditions have been regrouped; and (4) some coding rules
have been changed.

The ICD-10 cause-of-death categories are reflected in ICD-10 tabulation
lists created by the National Center for Health Statistics (NCHS) in
collaboration with other Federal agencies and the States. A total of
eight tabulation lists were developed for ICD-10, the most detailed of
which includes each of the 4-digit categories that are valid for
underlying cause of death. Replacing the widely used ICD-9 list of 72
selected causes of death plus HIV and Alzheimer's is the ICD-10
tabulation list of 113 Selected Causes of Death. This list, which will
be used to identify and rank the leading causes of death, will also be
used, wherever possible, to track the Healthy People 2010 mortality
objectives.

The lists are published in the NCHS Instruction Manual, Part 9.**^4^**
They can be accessed through the NCHS mortality Web site at the
following address:

http://www.cdc.gov/nchs/about/major/dvs/im.htm

Introduction of a new revision of the ICD creates discontinuities---some
serious---in time series trends for causes of death, because of the
reclassification of diseases and changes in the coding rules. Therefore,
the causes of death used for the 1997 and 1998 baselines in the initial
Healthy People 2010 report will not be strictly comparable with the
tracking data for 1999 and subsequent years.

When graphically displaying mortality data across revisions of the ICD,
it is helpful if trend lines be broken at the point in time that the new
ICD revision was introduced to emphasize the discontinuities resulting
from the change in revision.**^3^** The extent of the discontinuity is
measured using a "comparability ratio," which results from double-coding
a large sample of the national mortality file, once by the old revision
(ICD-9), and again by the new revision (ICD-10), and expressing the
results of the comparison as a ratio of deaths for a cause of death by
the later revision divided by the number of that cause of death coded
and classified by the earlier revision.**^5^** Preliminary comparability
ratios for causes of death between ICD-9 and ICD-10 will be published by
NCHS in the year 2000. In subsequent Healthy People 2010 reports,
information will be provided on the comparability of the ICD-9 baseline
data and the ICD-10 tracking data for Healthy People 2010 objectives
that are affected.

The NCHS Web site for ICD-10 for mortality is as follows:

http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

Data for the Healthy People 2000 mortality objectives were also coded
according to ICD-9, although in a few cases, the specific codes used for
the 2010 objectives are different from those used for the comparable
Healthy People 2000 objective. These differences are noted in the
operational definition for the objective in Part B: Operational
Definitions.

### Morbidity Data

Baseline data for morbidity objectives from sources such as the National
Hospital Discharge Survey, National Ambulatory Medical Care Survey, and
the National Hospital Ambulatory Care Survey are coded to International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM).**^6^** The specific ICD-9-CM codes used will be included in
the operational definition for each morbidity objective.

ICD-9-CM is a clinical modification of the WHO's International
Classification of Diseases, 9th Revision (ICD-9). The term "clinical" is
used to emphasize the modification's intent to serve as a useful tool in
the area of classification of morbidity data for indexing of hospital
medical records, medical care review, and ambulatory and other medical
care programs, as well as for basic health statistics. ICD-9-CM provides
greater specificity at the fifth digit level of detail, which goes
beyond the three and four digit level of ICD-9.

ICD-9-CM is used to code and classify morbidity data from inpatient and
outpatient records, physicians' offices, long term care facilities and
most health surveys. ICD-9-CM is compatible with its parent
classification (ICD-9), thus meeting the need for comparability of
morbidity and mortality statistics.

Additional codes and code changes were made to the ICD-9-CM beginning in
1986. A conversion table for diagnosis and procedure code changes
between 1986 and 1998 is available to assist users in data retrieval.
The table shows the date the new code became effective and its
previously assigned code equivalent. The latest additions to the
classification appear in bold print. The conversion table may be found
on the NCHS Web site at the following address:

http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#conv

Code assignment using ICD-9-CM is based on official national coding
guidelines. The guidelines for selecting the "first-listed" or principal
diagnosis for morbidity records differ from those used in coding death
records to select the underlying cause of death. Under morbidity coding
rules, the first listed or principal diagnosis is that condition
established after study to be chiefly responsible for occasioning the
admission to the hospital or the encounter with the health care provider
for care. In some instances the principal diagnosis may be a
manifestation of the disease rather than the underlying cause. For
example, if a patient with a primary malignant neoplasm with metastasis
is admitted to receive treatment directed toward a secondary site, the
secondary site would be designated on the hospital discharge form as the
principal diagnosis.

For Healthy People 2010, the principal ("first-listed") diagnosis is
generally used to track the morbidity objectives. However, in some cases
"all-listed" diagnoses, which include the principal and all other
diagnoses appearing on the medical record, are used (as many as 7 to 10
diagnoses may appear in some records). Details on the specific ICD-9-CM
diagnoses used are noted in the operational definition for each
applicable objective and are summarized in Appendix E.

The official coding guidelines are available on the NCHS morbidity Web
site at the following address:

http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guide

A clinical modification of ICD-10 (ICD-10-CM) has been developed as a
replacement for ICD-9-CM, however, as of this writing, an implementation
date had not been designated. Once implemented, revised coding
guidelines, training materials and crosswalks between ICD-9-CM and
ICD-10-CM will be made available on the NCHS Web site.

Data for the Healthy People 2000 morbidity objectives from the sources
listed above were also coded according to ICD-9-CM, although in a few
cases, the specific codes used for the 2010 objectives are different
from those used for the comparable Healthy People 2000 objective. These
differences are noted in the operational definition for the objective in
Part B: Operational Definitions.

## References

1\. World Health Organization (WHO). *Manual of the International
Statistical Classification of Diseases, Injuries, and Causes of Death,
Based on the Recommendations of the Ninth Revision Conference*. Geneva,
Switzerland: WHO, 1977.

2\. WHO*. International Statistical Classification of Diseases and
Related Health Problems, Tenth Revision*. Geneva, Switzerland: WHO,
1992.

3\. Hoyert, D.L.; Kochanek, K.D.; and Murphy, S.L. *Deaths: Final Data
for 1997.* National Vital Statistics Reports. Vol. 47 No.19, figure 4.
Hyattsville, MD: National Center for Health Statistics (NCHS), 1999.

4\. NCHS. *Vital Statistics, ICD-10 Cause-of-Death Lists for Tabulating
Mortality Statistics, Effective 1999.* NCHS Instruction Manual, Part 9.
Hyattsville, MD: Public Health Service (PHS), NCHS. 1997.

5\. NCHS. *Vital Statistics of the United States, Vol. II, Mortality,
Part A, Technical Appendix.* Washington, DC: U.S. Department of Health
and Human Services (HHS), PHS, annual.

6\. HHS. *International Classification of Diseases, Ninth Revision,
Clinical Modifications.* 6th ed. Washington, DC: HHS Publication No.
96-1260. Washington, DC: HHS, PHS, Health Care Financing Administration,
1997.

## 7. National Data

Data used to track the Healthy People 2010 objectives are based on
events occurring in the 50 States and the District of Columbia, where
available. Unless specifically noted, all objectives exclude data for
U.S. territories. The data used to track most population-based Healthy
People 2010 objectives are derived from either a national census of
events (for example, National Vital Statistics System, National
Notifiable Disease Surveillance System, Fatality Analysis Reporting
System) or from nationally representative sample surveys (for example,
National Health Interview Survey, National Household Survey on Drug
Abuse, School Health Policies and Programs Study).

For some objectives, however, complete national data are not available
and data for selected States and/or areas are used to monitor the
objectives. In these cases, the coverage area is described with the data
for the objective and in the operational definitions. Examples of these
data systems include the Metropolitan Atlanta Developmental Disabilities
Surveillance Program (MADDSP), the Adult Spectrum of Disease Project
(ASD), the Health Care Cost and Utilization Project (HCUP), and the
Toxic Exposure Surveillance System (TESS). Data for these objectives may
not be representative of the United States as a whole. If during the
decade national data become available, they will be used to track the
objectives.

For some national data systems that cover the entire United States, such
as the Behavioral Risk Factor Surveillance System and the National Vital
Statistics System, data are not available for some variables for all
States. This is either because data for a specific variable are not
collected by some States or because the quality of data for some States
is not sufficient to produce reliable estimates for some variables. Some
examples are shown in Table 6, with the number of States reporting in
the baseline data year. The number of reporting States can vary from
year to year. This information is also shown in the operational
definitions for selected objectives.

###### Table 6. Variables in major data systems for which data are not available from all States.

  ------------------------ ------------------------ ----------------------
  **Data System**          **Variable**             **Number of States
                                                    With Data Available**

  National Vital           Education                46 States + District
  Statistics System                                 of Columbia (1998)
  (Mortality)                                       

  National Vital           Maternal smoking         46 States + District
  Statistics System                                 of Columbia and New
  (Natality)                                        York City (1998)

  Behavioral Risk Factor   Diabetes variables       39 States (1998)
  Surveillance System                               

  Behavioral Risk Factor   Disability               11 States + District
  Surveillance System                               of Columbia (1998)
  ------------------------ ------------------------ ----------------------

##  8. State and Local Data

Healthy People has provided a framework for national, State, and local
health agencies and non-governmental organizations to assess health
status, health behaviors, and services and to plan and evaluate health
promotion programs.**^1,\ 2^** The national Healthy People initiatives
have served as a "menu" for identifying State and local priorities and
selecting objectives that are most relevant to specific States,
communities, and specific settings (schools, worksites, etc.), and
health care delivery systems.**^3,\ 4^** By using the national Healthy
People initiative as a common point of departure, agencies and
organizations have tailored programs targeted toward their customers,
yet retained a common basis for evaluating performance in relation to
both the nation, other States, or populations.**^5^**

This focus on performance has prompted State and local health agencies
to shift from their emphasis of primarily providing services to one that
conducts needs assessment and quality assurance.**^6,\ 7^** This shift
has required increased collection and analysis of data. Health care
delivery organizations have also experienced this shift and have
increased efforts to collect standardized data on patients, services,
and outcomes.**^8^** The increased emphasis on data collection and
analysis for purposes of assessment and evaluation has increased the
need to address the associated issues of data availability,
validity/reliability, comparability, and utilization. These issues also
affect the relevance of the national Healthy People objectives at the
State and local level. The large number and diversity of State and local
health agency structures and resources amplify the impact of these data
issues when trying to compare Healthy People plans, objectives, and
progress among States or between a State and the nation. States also
vary considerably in their capacity to monitor the objectives they
identify as most relevant to their constituents.**^9^** Some key areas
where these issues need to be examined at State and local levels are
discussed below.

### Objective Wording/Operational Definition 

The Healthy People "menu" provides a useful way for States and
localities to focus on serious health issues, but many agencies and
organizations have tailored the objectives to better focus on specific
concerns of their constituents. These modifications may more effectively
address the health concerns of the State or local population, but they
also reduce comparability when evaluating objective progress relative to
the nation, other States, or localities.^**10**^

### Population Data/Race and Ethnicity Reporting 

Many Healthy People objectives are population based and are expressed in
terms of mortality or morbidity rates (for example, lung cancer deaths
per 100,000), where the denominator is a population estimate. National,
State, and local health agencies primarily rely on population estimates
produced by the U.S. Census Bureau. The Bureau produces estimates for
the nation, States, counties, and large municipalities during the
decennial census and has provided annual post-censal estimates since
1990 (see section 3: Population Estimates). These estimates are provided
by gender, age, and race and ethnicity (see section 4: Population
Template). However, the sizes of some racial groups (American Indian or
Alaska Native and Asian or Pacific Islander) are relatively small, even
at the national level, and are distributed unevenly across State and
local areas. This precludes many jurisdictions from producing reliable
rates for objectives that focus on these populations.

### "Rare" Events/Confidentiality 

Some Healthy People objectives (for example, suicide or HIV deaths)
address important, sensitive health issues which are, fortunately,
relatively rare events. Reporting small numbers of suicides or HIV
deaths in a county or municipality with a small population may produce
unreliable, nonrepresentative rates. Reporting these rates by certain
characteristics, including geocoding and displaying maps of the
distribution of sensitive or rate events, also may jeopardize
confidentiality. It may be necessary to aggregate data over geographic
areas, personal characteristics, and/or data years to address both of
these problems.

### Age Adjustment

In general, States and localities age-adjust mortality data to the same
standard population used for the national data (see section 5: Age
Adjustment). However, because Healthy People 2010 is implementing the
2000 standard population ahead of the recommended schedule (see section
5, Age Adjustment), there may be a period of time when the State
mortality data do not match the Healthy People 2010 data.

### Data Sources 

The availability and comparability of data for national, State, and
local monitoring of Healthy People objectives vary considerably. Some
data, especially vital statistics, are readily available at national,
State, county, and some municipal levels. The standardization of vital
statistics data contributes to its comparability across jurisdictions.
Because they are readily accessible and generally comparable, mortality
and natality data were key parts of the 18 Health Status Indicators
(HSI) selected for widespread State and local use in Healthy People
2000.**^11^** However, vital statistics data provide only a limited
perspective on health status, risk behaviors, and access to health care.
Morbidity and risk factor data are required to monitor a very large
proportion of the current and proposed Healthy People objectives. Data
for these objectives come from a wide range of household surveys,
environmental hazard data, and other sources.

Many of the national Healthy People objectives are monitored using data
from the National Health Interview Survey (NHIS). Some of these
objectives are monitored at State and some local levels using data from
the Behavioral Risk Factor Surveillance System (BRFSS). Details of these
surveys (for example, design, sampling) are described in Part C: Major
Data Sources. In general, however, it should be noted that both
differences in the data collection methods (household interview versus
telephone interview) and wording of questions used to monitor the same
objectives can affect the comparability of the information collected.
Additionally, some objectives monitored with identical questions in both
the NHIS and the BRFSS (for example, firearm storage) are only included
periodically in a specific rotating module of the BRFSS or supplements
to the NHIS. Not all States use these modules or the year of the
"rotation" may not coincide with national data from the NHIS. This
limits comparability between national and State data.

Other national Healthy People objectives are monitored using composite
data sources (for example, General Estimates System, National Water
Quality Trends Report). The national data from these systems are
aggregated from data collected at State or local levels. Unlike the
vital statistics data (which include all births and deaths), several of
these systems are samples of events that use somewhat different data
collection and analysis methods between States or between
communities.**^12^** This affects the quality and comparability of
national, State, and local data.

For other Healthy People objectives, State and local jurisdictions were
unable to monitor progress. This prompted the development of Priority
Data Needs under Healthy People 2000,**^13^** which identified sources
of State and local data that could be used to track important health
issues, such as adult immunization and access to primary health care.
During the development of the Healthy People 2010 objectives,
participants proposed that a set of Leading Health Indicators be
selected to further improve national, State, and local agencies'
abilities to measure and evaluate health status and programmatic
activity.**^14^** The availability of data for the Leading Health
Indicators may be somewhat limited at the State level and it represents
a substantial challenge for measurement at the local level.

## References

1\. Public Health Foundation. *Measuring Health Objectives and
Indicators: 1997 State and Local Capacity Survey*. Washington, DC: the
Foundation, 1998.

2\. American Public Health Association. *Healthy Communities: Guidelines
for Community Attainment of the Year 2000 National Health Objectives*.
Washington, DC: the Association, 1991.

3\. Public Health Service (PHS). *Promoting Health/Preventing Disease:
Objectives for the Nation*, Washington, DC: U.S. Department of Health
and Human Services (HHS), 1980.

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

5\. Twenty-two percent of the objectives included in the HHS agency's
strategic plan (developed in accordance with the Government Performance
and Results Act of 1993) were adopted from Healthy People 2000 (see
Office of Disease Prevention and Health Promotion*. HHS Leading
Indicators for Healthy People 2010: A report from the HHS Working Group
on Sentinel Objectives*. Washington, DC: HHS, 1998).

6\. Institute of Medicine. *The Future of Public Health*. Washington,
DC: National Academy Press, 1988.

7\. National Center for Health Statistics (NCHS), Centers for Disease
Control and Prevention. *The CDC Assessment Initiative: A Summary of
State Activities*. Statistics and Surveillance Note*,* No. 7.
Hyattsville, MD: NCHS, 1995.

8\. Many health care organizations have adopted the use of the Health
Employer Data Information System (HEDIS) as a mechanism to standardize
the collection of data and to evaluate outcomes. (See National Committee
for Quality Assurance Web site: \<http://www.ncqa.org\>.)

9\. The Public Health Foundation reports that in 1997, States reported
an average ability to measure 39 percent of the Healthy People 2000
objectives. (See Public Health Foundation. *Measuring Health Objectives
and Indicators: 1997 State and Local Capacity Survey*, Washington, DC:
the Foundation, 1998.) To focus on the need to develop capacity for
tracking at the State and local level, Healthy People 2010 includes a
separate focus area aimed at improving infrastructure and surveillance
capability. (See Office of Public Health and Science. *Healthy People
2010: Objectives for Improving Health*. Washington, DC: HHS, 1998.)

10\. For example, there is a national objective calling for increased
testing and mitigation of homes for threats from radon. Some States have
adopted this objective verbatim, whereas others also have included
schools or day care centers within the same objective related to home
testing. Additionally, the operational definitions used for the same or
similar national and State/local objectives may vary considerably. The
national radon objective is monitored using self-report data from a
household survey, whereas some States use data based on actual
installation of radon monitors and picocurie information collected.

11\. Freedman, M.A. *Health Status Indicators for the Year 2000.*
Statistical Note No. 1. Hyattsville, MD: NCHS, 1991.

12\. For example, the National Water Quality data are compiled from
State data on "assessed" rivers, lakes, and estuaries. States vary in
the proportions and the specific bodies of waters they assess across
time. Hence, both State and national estimates may be subject to
considerable variation.

13\. Kim, I., and Keppel, K.K. *Priority Data Needs: Sources of
National, State, and Local-Level Data and Data Collection Systems.*
Statistical Note No.15. Hyattsville, MD: NCHS, 1997.

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

## 9. Variability of Estimates

For many health outcomes, assessing all individuals in a population may
be impossible, impractical, expensive, or inaccurate. Therefore, it is
usually advantageous to study a sample of the original
population.**^1^** Much of the data used to monitor the Healthy People
2010 objectives are derived from sample surveys (for example, National
Health Interview Survey, National Survey of Family Growth, National
Household Survey on Drug Abuse, National Health and Nutrition
Examination Survey, Youth Risk Behavior Surveillance System) that make
estimates for a population from a representative sample of respondents.
These estimates are subject to sampling variation or sampling error. The
standard error is a measure of sampling error and represents the
variations that can occur by chance since only a sample of the
population is surveyed rather than the entire population. Assuming a
normal distribution of events, the chances are about 68 in 100 that an
estimate from the sample would differ from a complete census by less
than the standard error. The chances are about 95 in 100 that the
difference would be less than twice the standard error. This is often
referred to as the 95 percent confidence interval, where the estimate is
expressed as a range of the observed rates, approximately +/- 1.96
standard errors.

Some of the data (for example, vital statistics, infectious disease
incidence) used to track the Healthy People 2010 objectives are based on
complete counts. As such, they are not subject to sampling error,
although they are subject to errors in the registration process.
However, when the estimates are used for analytical purposes, such as
the comparison of rates over a period of time or for different groups or
areas, the number of events that actually occurred may be considered as
one of a large series of possible results that could have arisen under
the same circumstances. This is generally known as random variation.
When the number of events is large, random variation is usually small.
However, when the number of events is small (fewer than 100) and the
probability of such an event is small, random variation can be
substantial and considerable caution must be used in interpreting the
change described by the estimates. In these cases, it is desirable to
compute the standard error of the estimates and use that computation in
the comparison of interest. More information on random variation and
small numbers can be found in the *Vital Statistics of the United
States*.**^2^**

To properly interpret differences between rates for different groups or
changes over time derived from sample surveys, it is important to
consider the sampling variation associated with each rate. Healthy
People 2010 specifies the use of a population template that includes
detailed racial, ethnic, and socioeconomic breakouts for all
population-based objectives (see section 4: Population Template).
Therefore, some objectives show data for relatively small populations
groups. These data may be associated with large standard errors and,
therefore, apparent differences between population groups or between a
population group in the template and the total population may be within
expected sampling or random error. Standard errors should be considered
when evaluating progress or comparing population groups for objectives
using survey data. For ease of presentation, the standard errors
associated with the estimates for the Healthy People 2010 objectives do
not appear in either *Healthy People 2010***^3^** or *Tracking Healthy
People 2010*. However, where available, they will be included in the
Healthy People 2010 database (see section 10: Healthy People 2010
Database). More information on the sample design and variance estimation
for some of the major data systems used to monitor the Healthy People
2010 objectives can be found in Part C: Major Data Systems and in other
publications.**^4,\ 5,\ 6,\ 7,\ 8,\ 9,\ 10,\ 11,\ 12,\ 13^**

If the data for any group are considered statistically unreliable, "DSU"
(data are statistically unreliable) is shown in the cell in place of the
data in *Healthy People 2010***^3^** and in the Healthy People 2010
database (see section 10, Healthy People 2010 Database). DSU is used to
address a number of situations that produce unreliable data that vary by
data system. For a number of Healthy People 2010 sample survey data
systems (for example, NHIS and NHANES), a figure is considered
unreliable if it has a relative standard error (RSE) of greater than 30
percent. For vital statistics data that are based on complete counts, a
figure is considered unreliable if it is based on fewer than 20 events.
Data may also be considered unreliable if there are a large number of
unknown entries or if the sampling frame cannot produce representative
estimates for a particular group.

For most objectives, the data are for single years. However, for some
objectives (or subgroups in the population template) that are based on
relatively few events, multiple years of data are used to produce more
stable estimates.

## References

1\. Kuzma, J.W. *Basic Statistics for the Health Sciences*. Loma Linda
University, CA: Mayfield Publishing Co., 1984.

2\. National Center for Health Statistics (NCHS). *Vital Statistics of
the United States. Vol. I, Natality and Vol. II, Mortality.* Washington,
DC: Public Health Service (PHS), annual.

3\. U.S. Department of Health and Human Services (HHS). *Healthy People
2010*. 2nd ed. With Understanding and Improving Health and Objectives
for Improving Health. 2 vols. Washington, DC: U.S. Government Printing
Office, November 2000.

4\. Maurer, K.R. Plan and operation of the Hispanic Health and Nutrition
Examination Survey, 1982--84. *Vital and Health Statistics* 1(19), 1985.

5\. NCHS. Plan and operation of the Third National Health and Nutrition
Examination Survey, 1988--94. *Vital and Health Statistics* 1(32), 1994.

6\. Ezzati, T.M. Sample design: Third National Health and Nutrition
Examination Survey. *Vital and Health Statistics* 2(113), 1992.

7\. Waksberg, J.; Sperry, S.; Judkins, D.; and Smith, V. National Survey
of Family Growth, Cycle IV, Evaluation of linked design. *Vital and
Health Statistics* 2(117), 1993.

8\. Judkins, D.R.; Mosher, W.D.; and Botman, S. National Survey of
Family Growth: Design, estimation, and inference. *Vital and Health
Statistics* 2(109), 1991.

9\. Massey, J.T.; Moore, T.F.; Parsons, V.L.; et al. Design and
estimation for the National Health Interview Survey, 1985--94. *Vital
and Health Statistics* 2(110), 1989.

10\. Kann, L.; Kolbe, L.J.; and Collins, J.L.; eds. Measuring the health
behavior of adolescents: The Youth Risk Behavior Surveillance System and
recent reports on high-risk adolescents. *Public Health Reports*
108(Suppl. 1):1-67, 1993.

11\. Errecart, M.T.; Ross, J.G.; and Robb, W.; et al. The School Health
Policies and Programs Study (SHPPS): Methodology. *Journal of School
Health* 8(65):295-301, 1995.

12\. Benson, V., and Marano, M.A.. Current estimates from the National
Health Interview Survey, 1995*.* *Vital and Health Statistics* 10(199),
1996.

13\. Haupt, B.J., and Kozak, L.J. Estimates from two survey designs:
National Hospital Discharge Survey*.* *Vital and Health Statistics*
13(111), 1992.

## 10. Healthy People 2010 Database

The Healthy People 2010 database, called "DATA2010," can be accessed
through the CDC/WONDER system found on the Internet at
[http://wonder.cdc.gov/\
data2010](http://wonder.cdc.gov/data2010) or through the NCHS Web site
at <http://www.cdc.gov/nchs>. Through DATA2010 the user can create
tables that contain the baseline and tracking data for each of the
Healthy People 2010 objectives and the Leading Health Indicators.

Tables can be constructed by selecting an entire Healthy People 2010
focus area (with or without related objectives in other focus areas), by
selecting an objective within a focus area, or by selecting an objective
from a keyword search that will search for all objectives containing a
specific word or phrase. Users can also select all data for population
subgroups such as race, ethnicity, gender, SES status, etc. Once tables
are generated they can be exported in either ASCII, comma-delimited, or
HTML format for use in common software applications such as Lotus 1-2-3
and SAS.

These Web sites also allow users to obtain other Healthy People 2010
information, such as full text of the objectives, lead agency contacts
for each focus area, and information on Healthy People 2010 progress
reviews.

### Database Description

DATA2010 is a SAS database that contains one record (or observation) for
each objective and subpart found in the 28 focus areas. The database
will also contain records for the measures used to track the goals and
the Leading Health Indicators.

Each record in the database contains the following information:

-   Objective number

-   Objective text (abbreviated)

-   Baseline year

-   Baseline data

-   Tracking data for subsequent years (future)

-   2010 Target

-   Comments (definitions, clarifications, and explanations)

-   Data source(s)

### Future Plans

In the future, DATA2010 will contain additional population groups, and
include options for chart and map generation. State data are expected to
be added to the database, and users will be able to select national
and/or State data. There also will be links to the operational
definitions in *Tracking Healthy People 2010* and to the Healthy People
2010 Web site <http://health.gov/healthypeople>. Where available,
standard errors of the estimates will be included in the database