Module Components

• Overview
• Assignments

Topics

• Assessing Health Status
• Addressing the Challenge
• Modifiable Lifestyle Risk Factors
  • Smoking
  • High Blood Pressure
  • Elevated Serum Cholesterol
  • Diet, Overweight, Obesity and Physical Inactivity
  • Impact of Multiple Risk Factors

NRSG 780 - Health Promotion and Population Health

Module 2: Determinants of Health

Assessing Health Status of the Population

The health status of a population is most commonly measured by indicators that reflect disease and mortality, rather than health. Despite the inherent problems with using mortality as a proxy for health, mortality data are often available and used throughout the world to describe the health status of populations. Data on morbidity are not as readily available but are also essential when assessing the health status of a population.

Measures of Mortality

Life expectancy is the average number of years people born in a given year are expected to live based on a set of age-specific death rates. When life expectancy in the U.S. is compared to other nations in the world, we are not at the top, where we expect to be, but trailing behind many other countries for both men and women. During the past two decades life expectancy in the U.S. has fallen to 46th, 78.11 years, as compared to other nations, (Hong Kong ranks first with a life expectancy of 85.29) and is expected to fall further behind in the next several years  Click here to see  the most recent data from the United Nations Population Division that shows the rankings for 196 countries and the 45 that rank above the US. 

The leading causes of death in the U.S. are heart disease, cancer, COVID-19, accidents (unintentional injuries), stroke, and chronic lower respiratory diseases, followed by Alzheimer’s disease and diabetes. These are all heavily influenced by lifestyle risk factors.

Provisional* number of leading underlying causes of death†— National Vital Statistics System, United States, 2021

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9098238/

When assessing mortality, it is also important to consider the leading causes of death by age group in the U.S. as noted in the CDC table below.

• From 1 year to the age of 45, unintentional injuries are the leading cause of death.
• From 45 to 65, cancer is the leading cause of death. 
• After age 65, heart disease is the leading cause of death. 

 

10 Leading Causes of Death, United States
2021, All Races, Both Sexes

 

We can also measure mortality in the U.S. by examining rates the leading causes of death in comparison with peer countries.

Source: https://www.ncbi.nlm.nih.gov/books/NBK571929/table/tab2-1/?report=objectonly

Another way of looking at mortality in the U.S. is to consider the toll of premature mortality on our society. Death before the age of 75 is generally considered premature. Families, work, and the society as a whole lose the valuable contributions of each member who dies prematurely. When we consider premature mortality in relation to the leading causes of death, we see a different profile of the tolls of the leading causes of death.

The top five causes of premature mortality are unintended injury, malignant neoplasms, heart disease, COVID-19, and suicide.

Years of potential life lost (YPLL) is a measure of the years of potential life lost due to premature death. It is an estimate of the average years a person would have lived if he or she had not died prematurely. Here is an example of a calculation of YPLL before the age of 75 for males & females of ethnic groups in the U.S. Note the differences in years of potential life lost by category if the calculation is based on the age of 65 as shown in the chart below.

Source: https://wisqars.cdc.gov/cgi-bin/broker.exe

Source: https://wisqars.cdc.gov/cgi-bin/broker.exe

For more information on how YPLL is calculated, watch this video.

 

Measures of Morbidity

National Health and Nutrition Examination Surveys

To address the limitations of focusing on mortality data and existing utilization databases that only include information on those who access services, in 1956 the National Health Survey Act was passed. This federal legislation authorized a continuing national survey to provide measures of morbidity in terms of current statistical information on the amount, distribution and effects of illness and disability in the U.S. Now called the National Health and Nutrition ExaminationSurveys or NHANES, the U.S. has a continuous stratified sampling system in place to gather the data that provides an overview of the health status of the population. Watch the video, CDC’s former director Dr. Frieden discusses Public Health Data and the NHANES Program for a better understanding of public health data and the role of NHANES.

NHANES gathers household and family level information:

1. Demographic background/occupation
2. Food security
3. Health insurance
4. Housing characteristics
5. Income
6. Pesticide use
7. Smoking
8. Tracking and tracing

NHANES includes comprehensive self-reported information on all individuals in the household:

Acculturation	Medical conditions
Audiometry	Miscellaneous pain
Balance	Physical activity and physical fitness
Blood Pressure	Physical functioning
Cardiovascular Disease	Occupation
Dermatology	Oral health
Diabetes	Osteoporosis
Dietary supplements and prescription medication	Respiratory health and disease
Diet behavior and nutrition	Smoking and tobacco use
Digital symbol substitution exercise	Social support
Early childhood	Tuberculosis
Hospital utilization and access to care	Vision
Immunization	Weight history
Introduction and Verification	Dietary recall
Kidney conditions	Medical conditions

NHANES augments its data with a series of laboratory tests on all individuals in the household which confirm or question much or the self-reported information:

1. Blood and urine
2. Venipuncture
3. Urine collection
4. Bone markers
5. Diabetes profile
6. Infectious disease profile
7. Markers of immunization status
8. Miscellaneous laboratory assays
9. Kidney disease profile
10. Hormone profile
11. Nutrition biochemistries and hematologies
12. Sexually transmitted disease profile
13. Tobacco use
14. Blood lipids
15. Environmental health profile

NHANES conducts examinations on all members as well. 

1. Audiometry
2. Balance and vestibular testing
3. Body composition
4. Body Measurement
5. Cardiovascular Fitness
6. Dermatology
7. Lower extremity disease
8. Muscular strength
9. Oral health
10. Physician’s exam
11. Vision

Using these data, we are able to profile the health status of the nation as a whole.

Behavioral Risk Factor Surveillance System

In the late 1970s and early 1980s, states begin to ask the federal government for data that were specific to their population rather than the nation as a whole. Resources to replicate the NHANES laboratory and examination data would have been prohibitive on a state-by-state basis. However, telephone surveys were beginning to show the capacity to gain the requested data in a cost-effective format.

In the 1980s the Behavioral Risk Factor Surveillance System (BRFSS) was piloted by the CDC through state health departments and ultimately expanded to provide unique data for each state. The BRFSS uses telephone surveys which take about a half hour to complete. The BRFSS is conducted on an annual basis. In most states the samples are designed to also provide county specific data.

All states gather the same core data including:

1. Health Status
2. Health Care Access
3. Asthma
4. Diabetes
5. Care Giving
6. Exercise
7. Tobacco Use
8. Fruits and Vegetables
9. Weight Control
10. Demographics
11. Women Health
12. HIV/AIDS

States can add optional modules that include:

Diabetes	Injury Control
Sexual Behavior	Alcohol Consumption
Family Planning	Cardiovascular Disease
Health Care Coverage and Utilization	Arthritis
Health Care Satisfaction	Quality of Life and Caregiving
Oral health	Folic Acid
Hypertension Awareness	Skin Cancer
Cholesterol Awareness	Tobacco Use Prevention
Immunization	Smokeless Tobacco

BRFSS data can be analyzed by a variety of demographic variables:

• Age
• Sex
• Education
• Income
• Occupation
• Racial and Ethnic backgrounds

Exercise:

• Go to the BRFSS website and determine how data have been used recently in your state.
• Take a few moments to use the BRFSS maps to visualize the states with the highest reported rates of obesity by clicking on the link  https://www.cdc.gov/obesity/data/prevalence-maps.html and the highest rates of smoking by clicking on the link http://www.cdc.gov/statesystem/cigaretteuseadult.html . How does your state compare?