Progress Toward Healthy People 2010 Targets

The following discussion highlights objectives that met or exceeded their 2010 targets; moved toward the targets, demonstrated no change, or moved away from the targets; and those that lacked data to assess progress. Progress is illustrated in the Progress Quotient bar chart (see Figure 15-1), which displays the percent of targeted change achieved for objectives and subobjectives with sufficient data to assess progress.

Each of the measurable objectives and subobjectives demonstrated change toward or away from the target in the first half of the decade.

Objectives that met or exceeded their targets. Physical assaults by intimate partners of persons aged 12 years and older (15-34) decreased from the baseline, exceeding the target. This decrease occurred in the context of declining rates for intimate partner physical assaults over the past two decades. The improvement during the first half of the decade may be attributable to some of the same reasons identified over the past 20 years, including increased economic opportunities for women, which give women greater freedom to exit abusive relationships,³ and age at first marriage (younger women are more at risk for intimate partner violence than older women).⁴ In addition, the availability of domestic violence services has increased as a result of the efforts of many State, local, and private entities.⁵ All of these initiatives have been linked to a decrease in intimate partner homicides and may also be linked to the reduction in physical assaults by intimate partners.

Reduction of rape or attempted rape of persons aged 12 years and older (15-35) also met its target. Despite the reduction in the rate, rape and attempted rape remain significant public health problems. In 2001, an estimated 146,000 people were victims of rape or attempted rape.⁶ Given individuals' reluctance to disclose sexual violence victimization and the limitations of available data, it is likely that the true rates of rape and attempted rape are likely higher than what the data indicate.

Objectives that moved toward their targets. The objectives and subobjectives in the focus area's three topical sections—injury prevention, unintentional injury prevention, and violence and abuse prevention—demonstrated progress.

Two injury prevention objectives moved toward their targets: nonfatal spinal cord injuries (15-2) and nonfatal firearm-related injuries (15-5).

Nine unintentional injury prevention objectives made progress toward their targets. Emergency department visits for nonfatal unintentional injuries (15-14) achieved 55 percent of the targeted change. The rate decreased from a baseline of 9,764 injuries per 100,000 population in 2000 to 9,343 injuries per 100,000 population in 2003. This decline may be related to the progress that many of the topic-specific unintentional injury objectives were making.¹ For example, the rate for nonfatal motor vehicle injuries (15-17) achieved 47 percent of the targeted change. The decreased rate for this objective was related to increased use of occupant restraints.⁷ One way the Centers for Disease Control and Prevention (CDC) worked to reduce this rate was implementing and evaluating a community-based intervention project designed to increase booster seat use in children aged 4 to 8 years.^{8, 9}

The pedestrian death rate (15-16) achieved 22 percent of its targeted change, declining from 1.9 deaths per 100,000 population in 1998 to 1.7 deaths per 100,000 persons in 2001. The target is 1.0 pedestrian death per 100,000 population.

Use of safety belts (15-19) achieved 26 percent of the targeted change. Safety belt use increased from 69 percent in 1998 to 75 percent in 2002, moving toward its target of 92 percent. Contributing to this positive movement were projects such as the National Highway Traffic Safety Administration's "Click It or Ticket" campaign.^{10, 11} Primary enforcement safety belt laws, which allow a police officer to stop a motorist solely for not wearing a safety belt, and enhanced enforcement, which includes increased police presence, safety belt citations, and safety belt checkpoints, can contribute to increased safety belt use and decreased injuries and fatalities.^{11, 12, 13} However, it may be difficult to affect groups like teens and truck drivers, who, despite State and local efforts, continue to lag behind the rest of the Nation in their use of safety belts.^{7, 10, 14} Another safety belt initiative is an enhanced enforcement campaign to increase use of safety belts in rural areas.¹⁵

Use of child restraints (15-20) moved toward the target of 100 percent, increasing from 92 percent in 1998 to 95 percent in 2002, achieving 38 percent of the targeted change. This progress can be linked to increased enforcement, public education, child safety seat distribution programs, and laws mandating the use of child safety seats. The first child passenger protection law was enacted in Tennessee in 1977. Since then, all 50 States have enacted child passenger protection laws, many of which have subsequently been strengthened. Initiatives in this area range from a systematic review of literature about community efforts to increase the use of child safety seats and identification of the most effective interventions¹⁶ to the implementation and evaluation of a booster seat promotion program combining education with booster seat distribution and incentives.¹³

Residential fire death rates (15-25) achieved 10 percent of its targeted change, declining from 1.2 deaths per 100,000 population in 1999 to 1.1 per 100,000 population in 2002. The use of smoke alarms has been shown to be an effective,¹⁷ reliable, and inexpensive method of providing early warning in residential fires. If a fire occurs in a home with a smoke alarm, the risk of death is decreased by 40 percent to 50 percent.¹⁸ Since 1998, the U.S. Department of Health and Human Services (HHS) has worked through CDC to promote smoke alarm installation and fire safety education programs in high-risk communities, including communities with fire death rates higher than State and national averages and median household incomes below the poverty level.¹⁹ In addition to these programs, progress toward reaching the target may be the result of fire prevention partnerships and collaborations between Federal and nongovernmental organizations, including HHS and the U.S. Department of Homeland Security, the National Fire Protection Association, and the public-private Fire Safety Council, a partnership of public agencies and private-sector organizations.²⁰

Hip fracture rates for men and women aged 65 years and older (15-28a and b), drownings (15-29), and rates for emergency department visits for nonfatal dog bites (15-30) also demonstrated progress toward their targets. Initiatives in the area of hip fracture prevention include the development and dissemination of the Tool Kit to Prevent Senior Falls.²¹ The kit contains fact sheets and health education materials designed to help reduce falls and related injuries among older adults. The decreasing trend in hip fracture rates among females suggests that osteoporosis screening, combined with pharmaceutical treatment, is an effective approach to reducing this serious fall injury.²² A major obstacle to preventing hip fractures is the efficacy, acceptability, and use of hip protectors among community-dwelling persons over 65 years of age. The majority of older adults will not use hip protectors, citing discomfort, cost, appearance, and denial of risk, while industry barriers include lack of product specifications and cost reimbursement policies. However, partially due to decreasing mortality from chronic conditions (such as heart disease and stroke), a growing number of people are living past age 65 years. This trend illustrates the challenge of meeting this fall and hip fracture objective in an active and aging population.²³

In HHS's efforts to reduce the rate for drownings, CDC collaborates in research and programs to disseminate messages about drowning risks and effective prevention strategies, including supervision of children, fencing around pools, development of swimming skills, and utilization of lifeguards.²⁴ Also, CDC has published a report of the evidence for the effectiveness of strategies to prevent drowning, including personal flotation devices, environmental restrictions to unsafe swim areas, behavioral approaches such as improved parental supervision, awareness and safety education, pool fence requirements, alcohol limits while boating, and drowning prevention campaigns.²⁵ However, the added expense of safety devices, such as pool covers and fences, may serve as a deterrent to implementing some of these strategies.

Emergency department visits for nonfatal dog bites (15-30) decreased from 152 visits per 100,000 population in 1997 to 116 visits per 100,000 population in 2002, achieving 94 percent of the targeted change toward the target of 114 visits per 100,000 population. An important strategy to reduce emergency department visits for nonfatal dog bites is to educate the public about how to interact safely with dogs.^{26, 27} This prevention education should include how to interact appropriately with all dogs and how to select, train, socialize, and care for a dog.²⁸ Since there is no accurate way to determine which breeds are more likely to bite or kill, policies and programs to prevent dog bites should include all dogs, regardless of breed.

Four objectives related to violence and abuse prevention progressed toward their targets. Sexual assault other than rape in persons aged 12 years and older (15-36) achieved 50 percent of its targeted change, physical assault on persons aged 12 years and older (15-37) achieved 53 percent of the targeted change, physical fighting by students in grades 9 through 12 (15-38) achieved 75 percent of the targeted change, and weapon carrying by students in grades 9 through 12 on school property (15-39) achieved 40 percent of the targeted change.

Objectives that demonstrated mixed movement toward or away from their targets. Two objectives showed mixed movement toward their targets: motor vehicle crash death rates (15-15) and maltreatment and maltreatment fatalities of children (15-33).

The rate for deaths from motor vehicle crashes per 100,000 population (15-15a) increased from 14.7 deaths in 1999 per 100,000 population to 15.2 deaths per 100,000 population in 2002, moving away from the target of 8 deaths per 100,000 population. The increase in the number of motor vehicle crash deaths per 100,000 population is related to the changing demographics of drivers in the United States.¹⁴ The number of older drivers is increasing, and although they drive less, they are more likely to crash and to die in a crash.^{29, 30} In addition, changes in the culture of driving, changes in the vehicle mix on the road, and new sources of driver distraction (for example, cell phone use) may be reducing the impact of safety gains in other areas, such as increased restraint use and reductions in alcohol-impaired driving.³¹

In contrast, motor vehicle crash deaths per 100 million miles traveled (15-15b) moved toward the target of 0.8 deaths per million miles traveled. The rate decreased from 1.6 deaths per 100 million miles traveled in 1998 to 1.5 deaths per 100 million miles traveled in 2001, achieving 13 percent of the targeted change.

Despite increased exposure to risk and motorization, vehicle deaths per million miles traveled are declining. This progress can be attributed to the reduced rates for alcohol-impaired driving and increased use of driver and passenger restraints.¹⁴ HHS initiatives in this area include the Task Force on Community Preventive Services publication of systematic literature reviews for five community-based interventions to reduce alcohol-impaired driving. The reviews revealed strong evidence of effectiveness for 0.08 percent blood alcohol concentration (BAC) laws, minimum legal drinking age laws, and sobriety checkpoints.³² The systematic review of the effectiveness of 0.08 percent BAC laws for drivers was helpful in establishing a 0.08 percent standard nationwide.³³

Although a reduction occurred in the overall rate for maltreatment of children under 18 years of age (15-33a), an increase was noted in maltreatment fatalities (15-33b). This increase may be related to how maltreatment is determined as the cause of death. Child death review teams (CDRTs) have played a large part in this determination. States and localities now review many child fatalities that were not reviewed in the past. They are discovering that some deaths labeled as "undetermined" or labeled with a specific cause of death actually appear to be the result of caregiver maltreatment.³⁴ Increases in reported child maltreatment deaths are based on State child maltreatment mortality surveillance. These CDRTs are also initiating public awareness campaigns and other prevention programs to prevent child deaths.^{35, 36} One such prevention program, called the Positive Parenting Program (Triple P), provides parent training to reduce the risk of child mistreatment. It reaches out to more than 25,000 parents and works with about 500 practitioners in a variety of fields, including counselors, therapists, parent educators, social workers, and nurses.³⁷

Objectives that moved away from their targets. Eleven objectives moved away from their targets.

Six injury prevention objectives moved away from their targets: nonfatal head injuries (15-1), firearm-related deaths (15-3), nonfatal poisonings (15-7), poisoning deaths (15-8), deaths from suffocation (15-9), and injury-related emergency department visits (15-12).

Poisoning deaths (15-8) increased from 7.1 deaths per 100,000 population in 1999 to 9.2 deaths per 100,000 population in 2002, moving away from the target of 1.5 deaths per 100,000 population. This increase is primarily attributable to increasing numbers of prescription painkiller overdoses.³⁸ Challenges include a lack of recognition of the extent of the problem and difficulty in preventing abusers from acquiring readily available drugs. Research is being done in this area to document the problem and identify solutions.³⁸

Injury-related emergency department visits (15-12) increased from 131 visits per 1,000 population in 1997 to 139 visits per 1,000 population in 2002, moving away from the target of 126 visits per 1,000 population. This movement away from the target may be a reflection of improved surveillance, medical services, trauma systems, and care rather than a true change in the rate. For example, through CDC, HHS has implemented traumatic brain injury surveillance in 30 States. The increased use of emergency departments as sources of primary care for some populations may be contributing to this movement away from the target. Minor injuries once relegated to a general practitioner's office are being seen by emergency physicians, increasing the overall numbers of persons under surveillance via emergency department visits nationwide.³⁹

Four unintentional injury objectives moved away from their targets. Unintentional injury deaths (15-13) climbed from 35.3 deaths per 100,000 population in 1999 to 36.9 deaths per 100,000 population in 2002, moving away from the target of 17.1 deaths per 100,000 population. The rates for nonfatal pedestrian injuries (15-18), motorcycle helmet use (15-21), and deaths from falls (15-27) also moved away from their targets. Nonfatal pedestrian injuries on public roads (15-18) increased from 26 injuries per 100,000 population in 1998 to 28 injuries per 100,000 population in 2001, moving away from the target of 19 injuries per 100,000 population. An increasingly hazardous urban environment⁴⁰ and alcohol use by pedestrians and drivers⁴¹ contribute toward this rising rate. Research suggests the design of new communities in the Sunbelt States, which approximately include the States in the southern third of the Nation, contributes to the increased injury risk to pedestrians.⁴² Also, there are more larger vehicles on the road, and, due to their size, they are associated with greater risk of injury to pedestrians.⁴³

Deaths from falls among adults aged 65 years and older (15-27) moved away from the target of 3.3 deaths from falls per 100,000 people, with the rate increasing from 4.8 deaths per 100,000 population in 1999 to 5.6 deaths per 100,000 population in 2002. A number of factors may explain the increase in the rate for older adult fall deaths. Death rates from cardiovascular and other chronic diseases have decreased, and the average life expectancy has increased—from 76.7 years in 1999 to 77.3 years in 2002.⁴⁴ Although the fatality rates were adjusted for age, additional age-related factors may explain the increasing rate. Advancing age is associated with physiologic changes, including decreased muscle strength and endurance, delayed reaction times, slowed reflexes, and loss of visual acuity. These changes may interact with use of psychoactive medications and chronic conditions, such as osteoporosis, arthritis, and diabetes, which put older adults at high risk of sustaining fatal fall injuries.^{45, 46} Efforts are under way to decrease deaths from falls among older adults. For example, within HHS, CDC is collaborating with the States to provide custom exercise classes designed to improve strength, balance, and mobility; education about how to reduce fall risk factors; assistance to improve the home environment; and medical referrals as appropriate. The program is being implemented in senior centers, senior housing, and a community hospital.

One violence and abuse prevention objective appeared to have moved away from its target. Between 1999 and 2002, the homicide rate (15-32) increased from 6.0 deaths per 100,000 population to 6.1 deaths per 100,000 population, moving away from the target of 2.8 deaths per 100,000 population. This change may not be statistically significant, but efforts to understand these trends in homicide rates are under way.

The National Violent Death Reporting System (NVDRS)⁴⁷ seeks to provide a more detailed description of the circumstances around homicides through enhanced data collection so that prevention programs can be targeted appropriately. NVDRS operates in 17 States by gathering, sharing, and linking State-level data about violent deaths. These data will then inform violence prevention efforts and provide a better understanding of what strategies are effective at saving lives.

Objectives that could not be assessed. Nine objectives did not have data to assess progress toward the targets: proper firearm storage in homes (15-4), child fatality review (15-6), emergency department and hospital discharge surveillance systems (15-10 and 15-11), graduated driver licensing (15-22), bicycle helmet use (15-23), bicycle helmet laws (15-24), functioning smoke alarms in residences (15-26), and injury protection in school sports (15-31). Trend data are anticipated for these nine objectives by the end of the decade.

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