# Presentation: 659933

## Kathleen M. Turczyn, MPH
Kenneth Keppel, PhD

National Center for Health Statistics

- Kathleen M. Turczyn, MPH
- Kenneth Keppel, PhD
- National Center for Health Statistics

- Measuring Disparity in Healthy People 2010 Physical Activity and Fitness Objectives

- APHA 131st Annual Meeting
- Monday, November 17, 2003

## Healthy People 2010 goals

- 1.  Increase quality and years of healthy life

- 2.  Eliminate health disparities

-    “... among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.”

## Definition of disparity

- Disparity is the quantity that separates a group from a reference point expressed in terms of a rate, percent, mean, or other quantifiable measure.

## Physical Activity and FitnessGoal: Improve health, fitness, and quality of life through daily physical activity

**Physical Activity and Fitness**Goal:** **Improve health, fitness, and quality of life through daily physical activity

**Physical Activity in Adults**
- 22-1 No leisure-time physical activity
- 22-2 Moderate physical activity
- 22-3 Vigorous physical activity
**Muscular Strength/Endurance and Flexibility**
- 22-4 Muscular strength and endurance
- 22-5 Flexibility

**Physical Activity in Children and Adolescents**
- 22-6 Moderate physical activity in adolescents
- 22-7 Vigorous physical activity in adolescents
- 22-8 Physical education requirement in schools
- 22-9 Daily physical education in schools
- 22-10 Physical activity in physical education class
- 22-11 Television viewing
**Access**
- 22-12 School physical activity facilities
- 22-13 Worksite physical activity and fitness
- 22-14 Community walking
- 22-15 Community bicycling

## Race and ethnicity
Gender
Education level (ages 25 years and over)
Geographic location (adults)
Disability status (adults)
Select populations
Age groups (adults)
Persons with/without arthritis symptoms (adults)
Grade level (adolescents)

- Gender
- Education level (ages 25 years and over)
- Geographic location (adults)
- Disability status (adults)
- Select populations
- Age groups (adults)
- Persons with/without arthritis symptoms (adults)
- Grade level (adolescents)

- HP2010 data template for population-based PAF objectives

## Disparity measured primarily in relative terms
Disparity measure made on negative outcomes - objectives transposed, as necessary, to rates/percents of adverse events
More favorable (“best” group) rate used as reference point
“Percent difference” used between one or more individual groups and a common reference point
“Index of disparity” used as a summary measure for a domain of several groups

- Disparity measure made on negative outcomes - objectives transposed, as necessary, to rates/percents of _adverse events_
- More favorable (“best” group) rate used as reference point
- “Percent difference” used between one or more individual groups and a common reference point
- “Index of disparity” used as a summary measure for a domain of several groups

- Summary of attributes of Healthy People 2010 measure of disparity

## Absolute vs. relative measures: Adults participating in vigorous physical activity, 2001

- Source:  National Health Interview Survey, NCHS, CDC.

- |80-73| = 7

- |20-27| =7

- |80-73/73| = 10%

- |20-27/27| = 26%

- 80

- 20

- No vigorous activity

- Do vigorous activity

- 73

- 27

- No vigorous activity

- Do vigorous activity

- Percent

- Female

- Male

## Absolute vs. relative measures: Adults participating in vigorous physical activity, 2001

- Source:  National Health Interview Survey, NCHS, CDC.

- |80-73| = 7

- |20-27| =7

- |80-73/73| = 10%

- |20-27/27| = 26%

- 80

- 20

- No vigorous activity

- Do vigorous activity

- 73

- 27

- No vigorous activity

- Do vigorous activity

- Percent

- Female

- Male

- Relative

- Relative

## Choice of reference point

- Target – fixed; no variability; BUT can’t distinguish between progress toward target and progress toward eliminating disparity
- Total population rate (weighted average of subgroup rates) – reflects average experience of all groups in the population;  BUT influenced by change in distribution of the population among groups over time
- Mean of group rates (unweighted average of subgroup rates) – not affected by changes in population distribution over time; BUT more affected by outlying group rates than other measures
- Largest group rate – reliable; BUT singles out one group as the standard of comparison for all objectives
- “Best” group rate – implicit is idea that all differences are inequitable (fits with goal of elimination of disparity); BUT differs from one domain to the next; may change over time; best group might be the least reliable

## Different disparity measures for number of groups in a domain

- Between 2 groups (one is “best” rate):
- Use the percent difference
- Among several groups (one is “best” rate):
- Use a summary measure: the average of percent differences
- Index of disparity

**Notes:**
2-group domains: gender, geographic location, disability status, with-or-without arthritis, with-or-without diabetes, etc.
3+-group domains: race/ethnicity, education, income

## Measuring disparity betweentwo groups

- Percent Difference = Ri-Rr / Rr * 100

- Ri: Rate or percent of specific group
- Rr: Rate or percent of reference population
-      with “best” rate or percent

## Gender disparity for PAF objectives for adults 18 years and over

- *

- 70.4

- 70.3

-        Male

- 0.0

***68.5***

- 0.0

***69.7***

-        Female

** **

** **

** **

**Objective 22-05 (T)   1998 baseline**

- 0.0

***76.6***

- 0.0

***78.8***

-        Male

- *

- 82.8

- *

- 85.6

-        Female

* *

* *

**Objective 22-04 (T)   1997 baseline**

- 0.0

***73.0***

- 0.0

***73.4***

-        Male

- *

- 80.4

- *

- 80.1

-        Female

** **

** **

** **

**Objective 22-03 (T)   1997 baseline**

- 0.0

***64.6***

- 0.0

***64.7***

-        Male

- *

- *

- 71.2

- *

- 81.3

-        Female

* *

* *

**Objective 22-02 (T)   1997 baseline**

- 0.0

***34.7***

- 0.0

***36.2***

-        Male

- *

- 40.1

- *

- 43.0

-        Female

** **

** **

** **

**Objective 22-01   1997 baseline**

- % dif.     from "best"

- Rate or percent

- % dif. from "best"

- Rate or percent

**Objectives and Gender**

- Most recent
-    2001

- Baseline                    1997/98

- Change in disparity from baseline to most recent (percentage points)

- Prevalence

**Gender disparity for PAF objectives for adults 18 years and over**

## Measures of disparity between males and females for selected PAF objectives, 2001

- 0

- 5

- 10

- Percent difference from “the best” group

- 15

- 20

- 55

- Adults

- Adolescents

- *Statistically significant at P<0.05.
- Data for adults are for ages 18 years and over; data for adolescents are for grades 9-12.
- Sources: For adults - CDC, NCHS, National Health Interview Survey; for adolescents – CDC, NCCDPHP, Youth Risk Behavior Surveillance System.

- 60

- Ri-Rr / Rr*100

## Adults
No leisure-time physical activity 
 Male
No moderate physical activity
 Male 
No vigorous physical activity
 Male
No strength/endurance exercises
 Male
No stretching exercises for flexibility
 Female

- No leisure-time physical activity
-  Male
- No moderate physical activity
-  Male
- No vigorous physical activity
-  Male
- No strength/endurance exercises
-  Male
- No stretching exercises for flexibility
-  Female

- Genders with best rates for PAF objectives: 2001

- Adolescents
- No moderate physical activity
- Male
- No vigorous physical activity
- Male
- No daily school PE
- Male
- Less than 50% active PE class time
- Male
- TV over 2 hours school days
- Female

## Changes in disparity for males and females, selected PAF objectives: Baseline to most recent update (2001)

- -10

- -5

- 0

- *Statistically significant at P<0.05.
- Data for adults are for ages 18 years and over; data for adolescents are for grades 9-12.
- Sources: Adults - CDC, NCHS, National Health Interview Survey (1997/98-2001);
-                Adolescents – CDC, NCCDPHP, Youth Risk Behavior Surveillance System (1999-2001).

- Percentage point change in disparity

- 5

- 10

- 15

- 20

- More disparity over time

- Less disparity over time

- -20

- -15

**Adults**

**Adolescents**

## Measuring disparity among several groups

- Index of Disparity = (n-1i=1 PDi) / (n-1)

- PDi: Percent difference from “best” rate
- 	for each group rate of interest
- n: 	Total number of groups

## Race/ethnicity disparity for adults with no leisure-time physical activity

-  46.0

- 40.0

*** ***

- Index of disparity (percent)

- -3.9

- 5.2

- 32.8

-  9.2

- 35.4

-      White only

- -1.2

- *

- 57.2

- 49.1

- *

- 58.5

- 51.4

-      Black only

- -2.5

- 13.2

- 35.3

- *

- 15.7

- 37.5

- Not Hispanic or Latino

- 6.3

- *

- 78.1

- 55.6

- *

- 71.8

- 55.7

- Hispanic or Latino

- 0.0

- 0.0

***31.2***

-  0.0

***32.4***

- 2 or more races

- -2.2

- 13.4

- 35.4

- *

- 15.6

- 37.5

- White only

- -1.2

- *

- 57.2

- 49.1

- *

- 58.4

- 51.4

- Black only

- 11.0

- *

- 29.8

- 40.5

- 18.8

- 38.5

- Asian only

- 18.0

- *

- 59.8

- 49.9

- *

- 41.9

- 46.0

- American Indian or Alaska Native only

** **

** **

** **

**Adults with no leisure-time physical activity**

**Objective 22-01**

- % dif.     from "best"

- Percent

- % dif. from "best"

- Percent

**Objectives and Race/Ethnicity**

- Most recent          2001

- Baseline for Race/Ethnic Groups                    1999

- Summary
- change in disparity from baseline to most recent (percentage points)

- Prevalence

**Race/ethnicity disparity for adults with no leisure-time physical activity**

- 6.0

- Data are for adults ages 18 and over.  Source: CDC, NCHS, National Health Interview Survey.

## Measures of disparity for race/ethnicity for selected PAF objectives, 2001

- 0

- 10

- Index of disparity from “the best” group

- 20

- 50

- Adults
- (6 groups)

- Adolescents
- (3 groups)

- Data for adults are for ages 18 years and over; data for adolescents are for grades 9-12.
- Sources: For adults - CDC, NCHS, National Health Interview Survey; for adolescents – CDC, NCCDPHP, Youth Risk Behavior Surveillance System.

- 90

- Σn-1i=1 PDi / n-1

- 30

- 40

## Ri-Rr / Rr*100

- 0

- 40

- Percent difference from “the best” group

- 60

- 20

- Asian only

- Hispanic or Latino

- Black, not Hispanic only

- American Indian/ Alaska Native only

- White, not Hispanic only

- Data for adults are for ages 18 years and over.
- Source: CDC, NCHS, National Health Interview Survey.

- 80

- Ri-Rr / Rr*100

- Percent difference from best group rate for race/ethnicity groups for no leisure-time physical activity, adults: 2001

- Best group: Two or more races

- Index of disparity: 46.0%

## Ri-Rr / Rr*100

- 0

- 40

- Percent difference from “the best” group

- 60

- 20

- Hispanic or Latino

- Black, not Hispanic only

- Data for adolescents are for grades 9-12.
- Source: CDC, NCCDPHP, Youth Risk Behavior Surveillance System.

- 80

- Ri-Rr / Rr*100

- Percent difference from best group rate for race/ethnicity groups for watching TV over 2 hours on school days, adolescents: 2001

- Best group: White, not Hispanic only

- Index of disparity: 88.2%

- 120

- 140

- 100

## Adults
No leisure-time physical activity 
Two or more races
No moderate physical activity
White, not Hispanic only
No vigorous physical activity
American Indian/Alaska Native
No strength/endurance exercises
Two or more races
No stretching exercises for flexibility
Asian only

- No leisure-time physical activity
- Two or more races
- No moderate physical activity
- White, not Hispanic only
- No vigorous physical activity
- American Indian/Alaska Native
- No strength/endurance exercises
- Two or more races
- No stretching exercises for flexibility
- Asian only

- Race/ethnicity groups with the best rates for PAF objectives: 2001

- Adolescents
- No moderate physical activity
- White, not Hispanic only
- No vigorous physical activity
- White, not Hispanic only
- No daily school PE
- Hispanic or Latino
- Less than 50% active PE class time
- Hispanic or Latino
- TV over 2 hours school days
- White, not Hispanic only

## Changes in disparity among race/ethnic groups, selected PAF objectives: 1999-2001

- Data for adults are for ages 18 years and over; data for adolescents are for grades 9-12.
- Sources: Adults - CDC, NCHS, National Health Interview Survey;  Adolescents – CDC, NCCDPHP, Youth Risk Behavior Surveillance System.

- Percentage point change in disparity

- More disparity over time

- Less disparity over time

- Adults
- (6 groups)

- Adolescents
- (3 groups)

## Measures of educational attainment disparity for selected PAF objectives, 2001

- 0

- 10

- 20

- Index of disparity from “the best” group

- 30

- 40

- Adults
- (5 groups§)

- Adolescents
- (4 grades)

- §Index of disparity for flexibility is based on 3 education groups; other objectives for adults use an index of disparity based on 5 education groups.
- Data for adults are for ages 25 years and over; data for adolescents are for grades 9-12.
- Sources: Adults - CDC, NCHS, National Health Interview Survey; Adolescents – CDC, NCCDPHP, Youth Risk Behavior Surveillance System.

- 130

- Σn-1i=1 PDi / n-1

- 50

- 60

## Adults
No leisure-time physical activity 
College graduate or above
No moderate physical activity
College graduate or above
No vigorous physical activity
College graduate or above
No strength/endurance exercises
College graduate or above
No stretching exercises for flexibility
At least some college

- No leisure-time physical activity
- College graduate or above
- No moderate physical activity
- College graduate or above
- No vigorous physical activity
- College graduate or above
- No strength/endurance exercises
- College graduate or above
- No stretching exercises for flexibility
- At least some college

- Education groups with the best rates for PAF objectives: 2001

- Adolescents
- No moderate physical activity
- Grade 9
- No vigorous physical activity
- Grade 9
- No daily school PE
- Grade 9
- Less than 50% active PE class time
- Grade 9
- TV over 2 hours school days
- Grade 12

## Changes in disparity among education groups, selected PAF objectives: Baseline to most recent update (2001)

- -10

- -5

- 0

- *Significantly different at P<0.05.
- §Index of disparity for flexibility is based on 3 education groups; other objectives for adults use an index of disparity based on 5 education groups.
- Data for adults are for ages 25 years and over; data for adolescents are for grades 9-12.
- Sources: Adults - CDC, NCHS, National Health Interview Survey (1997/98-2001);  Adolescents – CDC, NCCDPHP, Youth Risk Behavior Surveillance System (1999-2001).

- Percentage point change in disparity

- 5

- 10

- 15

- More disparity over time

- Less disparity over time

- -15

- 25

- 20

- -25

- -20

- Adults
- (5 groups§)

- Adolescents
- (4 grades)

## Least disparity: 
Between genders - no flexibility exercises
Among race/ethnicity groups - no vigorous activity
Among education groups - no strength and endurance exercises
Most disparity:
Between genders - no leisure-time physical activity 
Among race/ethnicity groups - no leisure-time physical activity 
Among education groups - no leisure-time physical activity 

- Between genders - no flexibility exercises
- Among race/ethnicity groups - no vigorous activity
- Among education groups - no strength and endurance exercises
- Most disparity:
- Between genders - no leisure-time physical activity
- Among race/ethnicity groups - no leisure-time physical activity
- Among education groups - no leisure-time physical activity

- Summary of PAF disparity measures for adults: 2001

## Least disparity: 
 Between genders – no moderate physical activity
 Among race/ethnicity groups – no daily school PE
 Among grade levels – no moderate physical activity
Most disparity: 
Between genders – no vigorous physical activity
 Among race/ethnicity groups – TV watching
 Among grade levels – TV watching 

-  Between genders – no moderate physical activity
-  Among race/ethnicity groups – no daily school PE
-  Among grade levels – no moderate physical activity
- Most disparity:
- Between genders – no vigorous physical activity
-  Among race/ethnicity groups – TV watching
-  Among grade levels – TV watching

- Summary of PAF disparity measures for adolescents: 2001

## Lessening disparity
Adults: gender; race/ethnicity
Adolescents: race/ethnicity
Increasing disparity
Adults: education groups
Adolescents: gender; education groups

- Adults: gender; race/ethnicity
- Adolescents: race/ethnicity
- Increasing disparity
- Adults: education groups
- Adolescents: gender; education groups

- Summary of disparity for PAF objectives over time, baseline§ to 2001

- §Baseline varies from 1997 to 1999 by domain and by objective.

**Notes:**
What to make of all this?  The Midcourse Review for HP2010 will be in process during 2004-2005.  Measures of disparities and trends in disparities for objectives in each focus area will be published for the first time.  Perhaps this information will stimulate additional targeted resources toward the elimination of disparities.

## Resources

**NCHS Healthy People:**
_**www.**__[cdc.gov/nchs/hphome.htm](http://www.cdc.gov/nchs/hphome.htm)_
**DATA2010:**
_**wonder.cdc.gov/data2010**_
**DHHS Healthy People:**
- _[www.health.gov/healthypeople](http://www.health.gov/healthypeople)_

**Kathleen M. Turczyn, M.P.H.**
**Office of Analysis and Epidemiology**
**National Center for Health Statistics**
**Centers for Disease Control and Prevention**
**3311 Toledo Road, Room 6323**
**Hyattsville, Maryland 20782**
**PH: 301.458.4538**
**FX: 301.458.4036**
**EM: kturczyn@cdc.gov**