Research Proposal on "U.S. Residents Want a Society"

Research Proposal 15 pages (4592 words) Sources: 10

[EXCERPT] . . . .

During this period, the U.S. median household income fluctuated but experienced an overall increasing trend. A Gini index of 0.46 in 2007 is half of the average relative difference (0.92) in average income between any two U.S. households chosen at random. The relative difference in average income is the absolute difference in average income ($64,590) between any two households divided by the average income for all households ($70,207) (28).

HALex. HALex provides one individual-level measure of HRQL that can be used to monitor health status as well as examine inequalities in morbidity across time and groups. HALex provides a numerical measure that combines information on self-rated health and activity limitation reported in nationally representative surveys (29,30). HALex scores can theoretically range from 1.00 for persons who have no activity limitation and are in excellent health to 0.10 for persons who are limited in activities of daily living (ADL) and are in poor health. HALex scores are based on assumptions and are described elsewhere (29,30). For example, a person in excellent health with activities of daily living disabilities is considered as healthy, with an assigned HALex score of 0.47, as a person in poor health with no disabilities.

The average HALex and inequality for HALex among U.S. adults for 1997 -- 2007 is estimated and presented. Although U.S. residents are living longer, the average HRQL among adults (ages 18 -- 65 years), measured by using HALex, demonstrated a declining trend from 0.8766 in 1997 to 0.8662 in 2007. During the same period, health inequality among individual persons, as measured by the Gini index for HALex, fluctuated, varying from 0.084 to 0.093, and experienced an overall declining trend from 0.093 in 1997 to 0.087 in 2007.

Group-Level Measures of Inequality

Income inequality. The Gini index measuring inequality between states in average household income increased slightly from 0.063 in 1997 to 0.075 in 2007. Inequality between states is lower than inequality between individual persons across the nation as a whole because the former is based on average values within states; averaging attenuates some of the variability between individual persons. Nonetheless, this trend indicates that income inequality between states is increasing with time.

Premature mortality. YPLL before age 75 years is a common measure of premature mortality. Although the rate of premature mortality in the United States has been declining in recent years, considerable variation in rates still exists across states, with the inequality in YPLL between states, as measured by the Gini index, increasing from 0.076 in 1997 to 0.096 in 2007. A Gini index of inequality of YPLL of 0.096 in 2007 is related directly to the average difference in YPLL/100,000 population between any two states chosen at random (average difference = 0.19 YPLL/100,000 population).

Healthy days. The number of healthy days is an HRQL measure routinely reported by CDC and considered particularly useful in identifying health disparities among population groups (31). Healthy days are measured as the overall number of days during the previous 30 days during which a person reported good (or better) physical and mental health. The average number of healthy days and the inequality in healthy days among adults (ages ?18 years) by states is estimated by using data from the 2007 Behavioral Risk Factor Surveillance System. Certain states (e.g., Utah, Connecticut, and North Dakota) that have the highest mean healthy days have the lowest health inequality, and vice versa.

This examination of inequalities indicates that inequalities in income, YPLL, HALex, and healthy days measured across individual persons and among states were present in 2007. The magnitude of inequality or trends in inequality during 1997 -- 2007 varies on the basis of measures used and depending on whether individual- or group-level data are analyzed. The healthy days analysis indicates that states that have lower average health also have higher health inequality. At each level (low, medium, high) of the U.S. income distribution, higher health inequality is associated with lower average number of healthy days (p<.001, t-test of slope coefficient of linear regression line). Using YPLL, HALex, and healthy days to illustrate the potential value of health inequality measures in this report does not resolve all controversies surrounding the choice of appropriate measures of premature mortality and HRQL for monitoring population health status in the United States (17,32). Research into the attributes and psychometric properties of alternative measures of premature mortality and HRQL is ongoing. Emerging consensus on the best available measures for monitoring health disparities and inequalities in premature mortality and HRQL should be reflected in future editions of this report.

Gaps in the National Data

Efforts to monitor and report periodically on health disparities are confronted by data gaps in two critical disparity domains defined in the Healthy People series of national planning objectives (1,13): 1) disability status and 2) sexual orientation and identity. In CHDIR 2011, data gaps in disability status are evident. Only eight of the 22 topics include health disparities by disability status. Federal interagency working groups are discussing strategies for expanding the collection of data by disability status. Data gaps in sexual orientation are even more severe in that only one topic (human immunodeficiency virus diagnosis) contains information on disparities in a health outcome by a sexual behavior (i.e., men who have sex with men) that is related but not identical to sexual orientation, identity, or attraction. Similar discussions are under way regarding strategies to expand the collection of data by dimensions of sexual orientation (identity or attraction) and disability status.

Gaps in Disability Data

Regularly published health reports that include information on health disparities typically do not include disability status as a dimension for comparison. For example, of the 27 chapters in Healthy People 2010, a total of 10 included no objectives for disability,* and of 108 related objectives from other focus areas in the Disability and Secondary Conditions focus area, 71 had no source for disability data (17). However, recent publications have indicated the need for standard reporting of comparative health status between persons with and without disabilities (33,34). Disability includes impairments or limitations in activities or social participation as a result of an interaction between a person's environment and his or her health condition (35) that might be permanent and variable in severity. In surveys, disability is measured or determined to exist in multiple ways, depending on the purpose of the data and the mechanism used for data collection. In nationwide data systems, the level of detail that can be obtained (i.e., type of disability, severity, underlying cause, or duration) is defined operationally within the context of the particular survey employed. For example, in the National Health Interview Survey, which is administered in a face-to-face interview that permits extensive questioning, 32 questions are used to provide a detailed description of a person's disability (36). In the Behavioral Risk Factor Surveillance System, which places a premium on brevity, a binary indicator of disability is determined as a positive response to either of two questions having to do with a limitation in any activity related to physical, mental, or emotional problems, or use of assistive equipment (e.g., a cane, wheelchair, special bed, or special telephone). Both Healthy People 2010 and Healthy People 2020 have an objective to include a standard set of disability questions in the core of all relevant data systems to address this lack of consistency. Future CHDIR reports will contain more data on disability and be of better quality and greater salience to the reduction of health disparities adversely affecting persons with disabilities.

Gaps in Data Regarding Sexual Orientation

Data collection and analysis gaps in health disparities by sexual orientation are even more severe. Although Healthy People 2010 specifies that health disparities include "differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation," only a limited number of regularly published national- or state-level health reports include information on sexual orientation (lesbian, gay, bisexual, transsexual, or heterosexual identity) as a demographic variable for comparison. Research studies have identified health disparities among sexual minority populations and explored concepts of sexual identity and one's perception of one's emotional, romantic, and sexual attraction (37). Standard reporting of sexual identity/orientation or sexual behavior on national health surveys is necessary if these health inequities are to be observed and attenuated among population groups. Data on sexual orientation or sexual behavior from the National Survey of Family Growth (NSFG) have been published (38,39). More recent NSFG data will be released soon and improve on the ascertainment of sexual identity. At the state level, Massachusetts has collected sexual orientation data through its Youth Risk Behavior Survey and Washington has done so recently on its Behavioral Risk Factor Surveillance System survey (40). Information on sexual behavior, a concept that describes behavior instead of identity or attraction, also can be used to investigate health and health-care characteristics across population groups. However, it is not collected in most national- and state-level surveys. In addition to consistent and routine collection of sexual orientation or behavior as demographic… READ MORE

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