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Goal 2: Eliminate Health Disparities
The second goal of Healthy People 2010 stems from the observation
that there are substantial disparities among populations in specific
measures of health, life expectancy, and quality of life. The second
goal is to eliminate health disparities that occur by race and
ethnicity, gender, education, income, geographic location, disability
status, or sexual orientation.1 As discussed in the section on Healthy
People objectives and as shown in Figure 5 and
Table 3, there has been
widespread improvement in objectives for nearly all of the populations
associated with these characteristics. However, progress toward the
target for individual populations and progress toward the goal to
eliminate disparities are independent of each other.10 Improvements for
individual populations—even improvements for all of the populations for
a characteristic—do not necessarily ensure the elimination of
disparities. This section focuses specifically on relative disparities
between populations and changes in these relative disparities over time,
regardless of whether the rates for specific populations are moving
toward or away from the targets for each objective (see the Technical
Appendix for further discussion of the measurement of disparities and
changes in disparities).
Disparities between populations and the persistence of disparities
over time have been well documented.1,
11, 12,
13, 14,
15, 16,
17, 18
Unlike previous Healthy People initiatives, Healthy People 2010 calls
for monitoring objectives for an extensive array of specific population
characteristics. All population-based objectives and subobjectives were
monitored by race and ethnicity, by income or education, and by gender
(if applicable). Monitoring for other characteristics (that is,
geographic location and disability status) was optional. Healthy People
2010, therefore, provides the basis for a broad examination of
disparities among populations and changes in disparities over time.
Findings for specific objectives and populations are presented in 27 of
the 28 focus area chapters. None of the objectives in
Public Health Infrastructure (Focus Area 23) call for data according to population
characteristics. The findings concerning disparities among populations
are summarized below. The following conclusions are based on this
summary:
- Substantial disparities between populations were evident for
many Healthy People 2010 objectives.
- Both increases and decreases in relative disparities were
evident for individual populations for specific objectives and
subobjectives; however, there was no change in disparity for most of
the objectives and subobjectives with data for any group.
For specific population characteristics:
- Among 195 objectives and subobjectives with trend data for
racial and ethnic groups, disparities decreased for 24 and
increased for 14.
- Among 238 objectives and subobjectives with trend data for
males and females, disparities decreased for 25 and increased
for 15. Females more often had the best group rate, and
reductions in disparity were more frequent among males.
- Among education groups, disparities decreased for 3
objectives and subobjectives and increased for 14.
- Among income groups, among geographic groups, and between
persons with disabilities and persons without disabilities,
there were few changes in disparities.
Measuring Disparities
There are 498 population-based objectives and subobjectives for
which disparities among populations could be measured. The second
figure in each focus area chapter provides detailed information
about disparities among populations for the objectives and
subobjectives in that focus area. These figures provide information
about the availability of data for each population, the size of
relative disparities between populations for each characteristic,
and the size of changes in these disparities between the Healthy
People 2010 baseline and the most recent data point for each
objective and subobjective. Data are not available for all
populations for each objective and subobjective, and tracking data
are not always available to assess changes in disparity from the
baseline. Data are not available by sexual orientation for any of
the Healthy People 2010 objectives.
In this midcourse review,
disparities are measured using the “best” or most favorable group
rate as the reference point.10 Best is used to identify the group
with the most favorable rate among the groups associated with a
particular characteristic. Best does not imply that no further
improvement is called for. Disparities by race and ethnicity, for
example, are measured using the rate for the racial and ethnic population
with the best rate as the reference point. Disparities are measured
in relative terms as the percent difference between the rate for
each of the other populations and the rate for the best group for
each characteristic. In the measurement of disparities, objectives
are generally expressed in terms of adverse events, such as death
rates, to facilitate comparisons among them (except for a small
number of objectives that cannot be expressed in adverse terms).
Changes in disparity are measured by subtracting the percent
difference from the best group rate at the baseline from the percent
difference from the best group rate at the most recent data point.
As a result, changes in disparity are measured in percentage points.
In addition, when more than two groups are associated with a
characteristic (race and ethnicity, education, or income), a
summary index is used to describe the average percent difference
from the best group rate for all of the other group
rates.10,
18 The
summary index provides a basis for conclusions about changes in the
size of the disparities associated with these characteristics. A
detailed description of the methods used to measure and evaluate
disparities is provided in the Technical Appendix.
Finding
Concerning Disparities
Information about disparities among racial and ethnic populations at the
most recent data point based on the disparity tables for each focus area
is summarized in Figure 9. The measurement of disparities depends on the
availability of data for each group. The number of objectives and
subobjectives with the data needed to measure disparities varies from 43
for the Native Hawaiian or other Pacific Islander population to 356 for
the black non-Hispanic population.
Figure 9.
Percent Distribution of Healthy People 2010 Objectives and Subobjectives
by Size of Disparity for Racial and Ethnic Groups at the Most Recent
Data Point
View text version of Figure 9.
The data needed to assess disparities for the American Indian or Alaska
Native population are available for 155 objectives and subobjectives
(Figure 9). This group had the best rate for 13 percent of these
objectives and subobjectives, including the least exposure to ozone
(8-1a), the lowest stroke death rate (12-7), and the lowest case rate
for hepatitis A (14-6). The American Indian or Alaska Native population
had a larger proportion of disparities in the greater than or equal to
100 percent category than any of the other racial and ethnic populations.
The American Indian or Alaska Native population had rates at least 100 percent worse than (or at least twice
as high as) the best group rate for 24 percent of these objectives and
subobjectives, including health insurance coverage among persons under
age 65 (1-1), new AIDS cases (13-1), infant deaths (16-1c), and deaths
of persons aged 15 to 24 years (16-3b and c). Disparities increased for
the American Indian or Alaska Native population for 13 objectives and
subobjectives, including increases of 100 percentage points or more for
hepatitis B among persons aged 40 years and older (14-3c) and women
smoking during pregnancy (16-17c). Disparities from the best group rate
decreased for 12 objectives and subobjectives, including reductions of
100 percentage points or more for end-stage renal disease due to
diabetes (4-7), HIV testing of tuberculosis patients aged 25 to 44 years
(13-11), new cases of hepatitis A (14-6), physical assault (15-37),
gonorrhea among females aged 15 to 24 years (25-2b), and primary and
secondary syphilis (25-3). Reductions of 100 percentage points do not
mean that the disparity has been eliminated. For example, the percent
difference from the best group rate for the American Indian or Alaska
Native population for the physical assault objective (15-37) declined by
254 percentage points, from 626 percent at baseline in 1998 to 372
percent in 2001.
The data needed to assess disparities for the Asian population
(excluding the Native Hawaiian or other Pacific Islander population) are
available for 107 objectives and subobjectives (Figure 9). The Asian
population had the best group rate for 36 percent of these objectives
and subobjectives, including preterm birth (16-11a, b, and c) and fetal
and infant mortality (16-1a through f). This population had rates at
least 100 percent worse than the best group rate for 7 percent of the
objectives and subobjectives with data for this population, including
source of ongoing care for persons aged 18 years and under (1-4b), Pap
test ever received (3-11a), and tuberculosis cases (14-11). For the
Asian population, disparities increased for four objectives and
subobjectives, and there were none for which disparities decreased.
Data for the Native Hawaiian or other Pacific Islander population are
available for 43 objectives and subobjectives (Figure 9). This population had
a smaller percentage of best group rates (16 percent) and a greater
percentage of large disparities (21 percent) than the Asian population.
Disparities increased for this population for five objectives and subobjectives, including increases of 100 percentage points or more for
cigarette smoking during pregnancy (16-17c), and disparities decreased
for three objectives and subobjectives. Data are available for the
combined Asian or Pacific Islander population for 76 objectives and
subobjectives (Figure 9). This combined population had the best group
rate for 55 percent of these objectives and subobjectives, including
many causes of death in Cancer (Focus Area 3); Injury and Violence
Prevention (Focus Area 15); and Maternal, Infant, and Child Health
(Focus Area 16). The Asian or Pacific Islander population had rates at
least 100 percent worse than the best group rate for two objectives—HIV
testing among tuberculosis patients aged 25 to 44 years (13-11) and
congenital syphilis (25-9). Disparities increased for the Asian or
Pacific Islander population for six objectives, including an increase of
100 percentage points or more for congenital syphilis (25-9).
Disparities decreased for this population for six objectives and
subobjectives, including decreases of 100 percentage points or more for
cases of hepatitis B (14-3a, b, and c). The data needed to assess disparities for the Hispanic
population are available for 330 objectives and subobjectives (Figure 9). The Hispanic population had the best group rate for 18 percent of
these objectives and subobjectives, including objectives and
subobjectives related to injury and violence (Focus Area 15), nutrition
(Focus Area 19), and tobacco use (Focus Area 27). This population had
rates at least 100 percent worse than (or at least twice as high as) the
best group rate for 12 percent of these objectives and subobjectives,
including health insurance coverage among persons under age 65 years (1-1),
source of ongoing care (1-4a, b, and c), new AIDS cases and HIV
infection deaths (13-1 and 13-14), and objectives related to violence
(Focus Area 15). Between the baseline and the most recent data point,
disparities increased for 22 objectives and subobjectives, including
increases of 100 percentage points or more for exposure to particulate
matter (8-1b), new cases of tuberculosis (14-11), physical assault
(15-37), and congenital syphilis (25-9), and decreased for 25 objectives
and subobjectives, including decreases of 100 percentage points or more
for new AIDS cases (13-1), hepatitis A and B (14-6 and 14-3c), nonfatal
firearm-related injuries (15-5), and primary and secondary syphilis
(25-3). Data needed to assess disparities for the black non-Hispanic
population (or, in some cases, for blacks, including persons of Hispanic
origin) are available for 356 objectives and subobjectives (Figure 9).
This population had the best rate for 21 percent of these objectives and subobjectives, including counseling about health risks (Focus Areas 1
and 2) and quality of their health providers’ communication skills
(Focus Area 11). This population had rates at least 100 percent worse
than the best group for 20 percent of these objectives and subobjectives,
including most causes of death in many focus areas. Between the baseline
and the most recent data point, disparities increased for 32 objectives
and subobjectives, including increases of 100 percentage points or more
for prostate cancer deaths (3-7), invasive early onset group B
streptococcal disease (14-16), firearm-related deaths (15-3), smoking
during pregnancy (16-17c), and genital herpes in persons aged 20 to 29
years (25-4). Disparities decreased for 26 objectives and subobjectives,
including decreases of 100 percentage points or more for new AIDS cases
(13-1), invasive pneumococcal infections in persons aged 5 years and
under (14-5a), residential fire deaths (15-25), asthma deaths among
persons aged 15 to 34 years (24-1c), new cases of gonorrhea (25-2a),
total cases of gonorrhea in women aged 15 to 44 years (25-2b), total
cases of primary and secondary syphilis (25-3), and cases of congenital
syphilis (25-9). To reiterate, reductions of 100 percentage points do
not mean that the disparity has been eliminated.
Data needed to assess disparities for the white non-Hispanic
population (or, in some cases, for whites, including persons of Hispanic
origin) are available for 355 objectives and subobjectives (Figure 9).
This population had the best rate for 49 percent of these objectives and subobjectives and disparities greater than or equal to 100 percent for 5
percent. The large disparities included deaths from lung cancer (3-2),
female breast cancer (3-3), prostate cancer (3-7), melanoma (3-8),
firearms (15-3), poisoning (15-8), unintentional injury (15-13), suicide
(18-1), and chronic obstructive pulmonary disease (24-10). Between the
baseline and the most recent data point, disparities increased for 25
objectives and subobjectives, including increases of 100 percentage
points or more for poisoning deaths (15-8), smoking during pregnancy
(16-17c), and drug-induced deaths (26-3). Between the baseline and the
most recent data point, disparities declined for 16 objectives and
subobjectives. All decreases in disparity were less than 50 percentage
points. Data for individuals who identified with more than one race
are available for 82 objectives and subobjectives (Figure 9). This
population had the best rate for 23 percent of these objectives and subobjectives, including physical activities that enhance muscular
strength (22-4) and flexibility (22-5). This population had rates 100
percent worse than the best group rate for 10 percent of these
objectives and subobjectives, including activity limitations due to
chronic lung disease (24-9), activity limitations due to chronic back
conditions (2-11), and delay or difficulty in getting emergency care
(1-10). Disparities increased for this group for two air pollution
subobjectives: exposure to particulate matter and carbon monoxide (8-1b
and c, respectively). In addition to the findings for individual racial and ethnic
groups, a summary index allows the evaluation of changes in disparity
over time among all racial and ethnic populations. There was no change
in disparities among racial and ethnic populations for 157 objectives
and subobjectives or 81 percent of the 195 objectives and subobjectives
with the data needed to calculate the index and assess change over time.
The average percent difference from the best group rate decreased for 24
objectives and subobjectives and increased for 14 objectives and
subobjectives (Figure 10). Disparity increased by at least 100
percentage points for smoking during pregnancy (16-17c). Disparities
decreased by at least 100 percentage points for new AIDS cases (13-1),
hepatitis A (14-6), nonfatal firearm-related injuries (15-5), gonorrhea
(25-2a and b), primary and secondary syphilis (25-3), and congenital
syphilis (25-9).
Figure 10. Number of Objectives
and Subojectives With Changes in Disparity
From the Healthy People 2010 Baseline to the Most Recent Data Point for
Each Population Characteristic
View text version of Figure 10.
Data by gender are available for 304 objectives and
subobjectives (Figure 11). For some objectives and subobjectives only
baseline data are available. As noted below, trends in disparity can
only be measured for 238 objectives and subobjectives. Disparities by
gender are not relevant to objectives and subobjectives that apply only
to females or males, including those in Family Planning (Focus Area 9)
and a number of objectives and subobjectives in other focus areas.
Results by gender are summarized in Figure 11.
Figure 11. Percent Distribution of Healthy People 2010 Objectives
and Subojectives
by Size of Disparity for Females and Males at the Most Recent Data Point
View text version of Figure 11.
Females had the better group rate for 64 percent of these objectives and
subobjectives, compared with 40 percent for males. There were a number of
cases in which males and females had the same rate; therefore, both were
counted as the better rate. Females had a smaller percentage of objectives
and subobjectives that were greater than or equal to 100 percent worse
than males. Cases of genital herpes (25-4) and physical assault by an
intimate partner (15-34) were more than twice as common among females.
Males had the better group rate for 40 percent of these objectives and
subobjectives. Males had a larger percentage of objectives that were
greater than or equal to 100 percent worse than females, including less
favorable rates for oropharyngeal cancer deaths (3-6), melanoma deaths
(3-8), and lower extremity amputations in persons with diabetes (5-10)
and nine objectives related to injury and violence (Focus Area 15).
The data needed to evaluate changes in gender disparities over time are
available for 238 objectives and subobjectives. There was no change in
disparity for 198 objectives and subobjectives, or 83 percent of the
total with data. Disparity decreased for 25 objectives and subobjectives
and increased for 15 (Figure 10). The number of
objectives and subobjectives with decreases in disparity, therefore,
outnumbered those with increases. Changes in disparity were more common
among males, in part because females more often had the better group rate.
Among males, disparities decreased for 21 objectives and subobjectives
and increased for 13. In a few instances, reductions in the difference
between males and females were associated with increases in death
rates—deaths from poisoning (15-8), falls (15-27), and drugs (26-3)
(data not shown)—of both males and females.
The data needed to assess disparities among populations by
education level are available for 158 to 161 objectives and
subobjectives in 23 focus areas (Figure 12). Education level was not
included as a characteristic in all focus areas. The population with at
least some college education had the best rate for 82 percent of the
objectives and subobjectives with data by education. The population with
less than a high school education and high school graduates had the best
group rate for 9 percent and 11 percent of the objectives and
subobjectives with data by education, respectively. For example, the
least educated population had the best or most favorable rates for three
subobjectives concerning communication with health care providers
(11-6a, c, and d). There were no objectives or subobjectives for which
the difference between the population with at least some college
education and the best group differed by at least 100 percent. The
population that completed high school had rates at least 100 percent
higher than the best group rate for 17 percent of these objectives and
subobjectives, and the population with less than a high school education
had rates at least 100 percent higher than the best group rate for 25
percent of these objectives. Among persons with less than a high school
education, disparity increased for nine objectives and subobjectives and
decreased for nine. Among persons with a high school education,
disparity increased for 24 objectives and subobjectives and decreased
for 2. Among persons with at least some college, there was one objective with an increase
in disparity. There were no increases or decreases in disparity of 100
percentage points or more for any of the three populations by education
level.
Figure 12. Percent Distribution of Healthy People 2010 Objectives
and Subobjectives
by Size of Disparity for Education Groups at the Most Recent Data Point
View text version of Figure 12.
In addition to the findings for individual populations by education
level, the summary index permits the evaluation of changes in
disparities over time among all three populations by level of education.
There was no change in disparity among populations by education level for
92 objectives and subobjectives or 84 percent of the 109 objectives and
subobjectives with the data needed to calculate the index and assess
change over time. The average percent difference from the best group
rate decreased for 3 objectives and subobjectives and increased for 14;
therefore, increases in disparity by level of education outnumbered
decreases in disparity (Figure 10). There were no increases or decreases
of 100 percentage points or more.
Income level was not included as a characteristic in all focus areas.
All of the objectives and subobjectives in Nutrition and Overweight
(Focus Area 19) and six subobjectives in Immunization and Infectious
Diseases (Focus Area 14) are excluded from this summary because data by
income were available for only two populations. This summary is based on
99 to 104 objectives and subobjectives with data for populations by
income level (Figure 13). The population with middle/high income had the
best rate for 76 percent of the objectives and subobjectives with data
by income level. The poor and near-poor income populations each had the
best rate for 16 percent of their objectives and subobjectives. The poor
population had the most favorable rates for counseling about diet and
nutrition (1-3b) and counseling about reduced alcohol consumption
(1-3d) and for eight objectives and subobjectives in Substance Abuse (Focus
Area 26). In almost all cases, disparities for the other populations by
income level were less than 10 percent.
Figure 13. Percent Distribution of Healthy People 2010 Objectives
and Subobjectives
by Size of Disparity for Income Groups
at the Most Recent Data Point
View text version of Figure 13.
There were no objectives or subobjectives for which the difference
between persons with middle/high income and the best group differed by
100 percent or more. The near-poor income population had rates at least
100 percent higher than the best group rate for 6 percent of the
objectives and subobjectives with data for this population. The poor or lowest
income population had rates at least 100 percent higher than the best
group rate for 12 percent of the objectives and subobjectives with data.
The summary index enables the evaluation of changes in
disparity over time among populations by income level. The data needed
to evaluate changes in disparity among the populations by income level
are available for 53 objectives and subobjectives (Figure 10). There was
little evidence of any change in disparity among populations by income
level. The average percent difference from the best group rate did not
increase for any objectives or subobjectives and decreased for one
objective related to births within 24 months of a previous birth (9-2).
Geographic location is defined in different ways in Healthy
People 2010. For some objectives, the distinction is between urban and
rural areas, while for others, the distinction is between metropolitan
and nonmetropolitan areas. Findings for disparities by geographic
location for 52 objectives and subobjectives in 13 focus areas are
summarized in Figure 14.
Figure 14. Percent Distribution of Healthy People 2010 Objectives
and Subobjectives
by Size of Disparity for Geographic Groups
at the Most Recent Data Point
View text version of Figure 14.
Urban or metropolitan areas had the better rate for 65 percent of the
objectives and subobjectives with data. Urban or metropolitan areas also
had more objectives and subobjectives with larger disparities than rural
or nonmetropolitan areas. There was at least a 100 percent difference
from nonmetropolitan areas for four of the six air pollution
subobjectives (8-1a, b, c, and e).
Rural or nonmetropolitan areas had the best rate for 42 percent of these
objectives and subobjectives. Urban and rural areas had the same
rate—therefore also the better rate—for four objectives. There were no
objectives or subobjectives for which rural or nonmetropolitan areas had
rates at least twice as high as rates in urban or metropolitan areas.
The data needed to evaluate changes in disparities between geographic
areas are available for 38 objectives and subobjectives. Disparities
from the best geographic group rate declined for three subobjectives,
and there were no increases (Figure 10). Between
the baseline in 1997 and the data point in 2001, disparities declined by
at least 100 percentage points for two air pollution subobjectives—exposure
to particulate matter and carbon monoxide (8-1b and 8-1c)—and declined
by a smaller margin for exposure to ozone (8-1a). Reductions of 100
percentage points do not mean that the disparity has been eliminated.
Data for persons with disabilities and persons without
disabilities for 63 objectives and subobjectives in 17 focus areas are
summarized in Figure 15. Persons with disabilities had the better group
rate for 46 percent of these objectives and subobjectives, and persons
without disabilities had the better group rate for 54 percent. The
similarity in the percentage with the better group rate between persons
with disabilities and persons without disabilities may be a reflection
of more frequent contacts with health care providers among persons with
disabilities. Persons with disabilities had rates at least 100 percent
higher than persons without disabilities for 6 percent of these
objectives and subobjectives, including delay or difficulty getting
emergency care (1-10), new cases of diabetes (5-2), overall cases of
diabetes (5-3), and blindness and visual impairment (28-4).
Figure 15. Percent Distribution of Healthy People 2010 Objectives
and Subobjectives
by Size of Disparity for Persons With Disabilities and Persons Without
Disabilities
at the Most Recent Data Point
View text version of Figure 15.
The data needed to evaluate changes in disparities between
disability groups are available for 48 objectives and subobjectives
(Figure 10). There were few changes in disparity by disability status.
Disparities between these populations declined for one objective and one subobjective. Between the baseline in 1997 and the data point in 2003,
disparity declined by at least 100 percentage points for blindness and
visual impairment (28-4). Between 2000 and 2003, the disparity declined
by a smaller margin for sun exposure (3-9b). Disparity from the
population with the better rate (persons with disabilities) increased
for persons without disabilities for source of ongoing care (1-4a).
Several factors limit the number of objectives
for which changes in disparity can be assessed. First, the number of
years on which this assessment is based varies greatly. Among 328
population-based objectives with trend data, 16 percent are based on an
interval of 2 years or less between the baseline and the most recent
data point. Second, this assessment is limited by a lack of data for
specific populations. There are no racial and ethnic data for about 15
percent of the population-based objectives, with larger proportions
without data among American Indian or Alaska Native, Asian, Hispanic, and Native Hawaiian or other Pacific
Islander populations. Data by
gender are not available for about 15 percent of the relevant
population-based objectives. Data by education level and income level
are not available for about 30 percent and 55 percent, respectively, of
the population-based objectives and subobjectives for which education
level and income level were selected as characteristics to be tracked.
These findings are also subject to the limitations of the data on which
they are based. This assessment is based only on data at the baseline
and at the most recent data point; intervening data values are not
considered. The findings presented here are also limited by the
reliability and validity of information about the persons on which the
data are based. The reporting of race and income from some data systems
is particularly problematic.2,
19 Assessments of the
probability that disparities or changes in disparity are due to random
fluctuations in the data are limited by the lack of estimates of
variability (that is, standard errors) for some of the data on which
Healthy People 2010 objectives are based (see the Technical Appendix).
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