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4/14/09 1
Community Health Assessment Part I: Measuring Health
Community Health Assessment Part I: Measuring Health
NMDOH Community Health Assessment Program (CHAP)
New Mexico Department of Health4/14/09 2
OverviewOverview
Community Health Assessment– What is it?– Measurement basics– Common public health measures
New Mexico Department of Health4/14/09 3
Public Health AssessmentPublic Health Assessment
The core functions of government in public health:– to develop policy that supports the health of
populations, – to assure access to health care and the
quality of that care, and – to assess the health status of the population.
Institute of Medicine; Committee for the Study of the Future of Public Health; Division of Health Care Services (1988) The Future of Public Health. Washington, D.C.: National Academies Press.
New Mexico Department of Health4/14/09 4
Assessment Function of Public Health
Assessment Function of Public Health
Assessment is the regular and systematic
collection,
assembly,
analysis, and
dissemination
of information about the health of a community.
Institute of Medicine (1988) The Future of Public Health, National Academies Press.
New Mexico Department of Health4/14/09 5
AssessmentAssessment“An understanding of the determinants of health and of the nature and extent of community need is a fundamental prerequisite to sound decision-making about health. Accurate information serves the interests both of justice and the efficient use of available resources. Assessment is therefore a core governmental obligation in public health.” (emphasis mine)
Institute of Medicine (1988) The Future of Public Health, National Academies Press.
New Mexico Department of Health4/14/09 6
HealthHealth
World Health Organization definition of health:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
WHO Definition of Health, downloaded from http://www.who.int/about/definition /en/print.html on 7/6/09.
4/14/09 7
Fundamental Considerations in Measuring Community
Health Status
Fundamental Considerations in Measuring Community
Health Status
New Mexico Department of Health4/14/09 8
Measuring Community Health
Measuring Community Health
Health Conditions: Medical, social, and economic– Not all “Health-related Conditions” are medical
(e.g., poverty, education, environment)
Population at Risk– Include demographic measures to help
identify at-risk populations within the community. (e.g., age, sex, language)
New Mexico Department of Health4/14/09 9
Measuring Community Health
Measuring Community Health
Clinical prevention, early detection– Certain conditions are interesting primarily
because they may be prevented or detected early, before complications arise (e.g., vaccine-preventable diseases, dental caries, breast cancer)
Mooney, A. and Rives, N.W. (1978). Measures of community health status for health planning. Hospital Research and Educational Trust, (Summer), pp 129-145.
New Mexico Department of Health4/14/09 10
Types of PreventionTypes of Prevention
Primary Prevention– Reducing the incidence of a condition (e.g., vaccine)
Secondary Prevention– Reducing the complications of an illness (e.g., treating
high blood pressure)
Tertiary Prevention– Reducing levels of residual disability or other long-
term effects, given that an illness has already occurred (e.g., managing diabetes)
New Mexico Department of Health4/14/09 11
Morbidity versus MortalityMorbidity versus Mortality
– Morbidity is another term for illness. Morbidities are not deaths, and occur among the population of living persons. Examples of morbidities include Alzheimer's disease, diabetes, and traumatic brain injury.
– Mortality is another term for death. A mortality rate is the number of deaths due to a disease divided by the number of persons in the population. A mortality rate is typically multiplied by a factor of ten (e.g, 100,000) so that the rate may be expressed as a whole number.
New Mexico Department of Health4/14/09 12
Incidence Versus PrevalenceIncidence Versus Prevalence
– Incidence is the number of new cases (of disease) in a given period of time. (e.g., cancer incidence is the number of new cases of cancer during the time period)
– Prevalence is the number of existing cases (e.g., of a disease or risk factor) in a given period of time. (e.g., prevalence of high blood pressure, prevalence of obesity)
New Mexico Department of Health4/14/09 13
Measurement BasicsMeasurement Basics
Example: Age Distribution of This Class.1. On a blank sheet of paper, write your age. (If you
don’t want to divulge your age, you can write a different age.)
2. Arrange yourselves in the back and sides of the classroom, from youngest to oldest.
3. Where there is more than one person of the same age, stand in front of one another.
4. Where there are gaps, with no person of a certain age, leave a space for that age.
New Mexico Department of Health4/14/09 14
Age Distribution HistogramAge Distribution Histogram
Age Distribution of Community Health Assessment Class (This is a special type of bar chart, called a HISTOGRAM)
0
1
2
3
4
5
24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68
Age
Nu
mb
er o
f P
erso
ns Mean: 48.8Median: 41.5
Mode: 37
New Mexico Department of Health4/14/09 15
Age Distribution HistogramAge Distribution Histogram
Age Distribution of Community Health Assessment Class (This is a special type of bar chart, called a HISTOGRAM)
0
1
2
3
4
5
24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68
Age
Nu
mb
er o
f P
erso
ns
New Mexico Department of Health4/14/09 16
Distribution “Curve”Distribution “Curve”Age Distribution of Community Health Assessment Class
0
1
2
3
4
5
24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68
Age
Nu
mb
er o
f P
erso
ns
New Mexico Department of Health4/14/09 17
Age Distribution of Community Health Assessment Class
0
1
2
3
4
5
24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68
Age
Nu
mb
er o
f P
erso
ns
Distribution “Curve”Distribution “Curve”
New Mexico Department of Health4/14/09 19
Measurement and “True Scores”
Measurement and “True Scores”
Why do we look at data?
– Sometimes we just use the number at face value.
“If one obstetrician can serve 100 pregnant women and the births of their babies in a given year, and our community has had 883 births, on average, in the last 5 years, then we will need to ensure availability of 9 O.B.s for the women of this community.”
New Mexico Department of Health4/14/09 20
Measurement and “True Scores”
Measurement and “True Scores”
– More often, we use the data to tell us something about RISK.
– Which of these communities has the higher diabetes death risk?
Community
2004-2006 Diabetes Deaths
2004-2006 Population
Size
2004-2006 Diabetes
Death Rate (Age-adjusted)
A 96 234,932 59.8
B 62 213,156 31.9
New Mexico Department of Health4/14/09 21
Measurement and “True Scores”
Measurement and “True Scores”
– Which of these communities has the higher diabetes death risk?
Community
2004-2006 Diabetes Deaths
2004-2006 Population
Size
2004-2006 Diabetes
Death Rate (Age-adjusted)
A 96 234,932 59.8
C 96 430,479 22.3
New Mexico Department of Health4/14/09 22
Measurement and True Scores
Measurement and True Scores
What has this got to do with measurement and true risk?– Each of the three communities in the previous
examples has an underlying risk for diabetes death.
– The 3 communities have different RISK levels because of a variety of factors, including lifestyle (diet and exercise), medical care (diagnosis and disease management), and other factors.
New Mexico Department of Health4/14/09 23
Measurement and True Scores
Measurement and True Scores
What has this got to do with measurement and true risk?– The OBSERVED number of diabetes deaths,
and the diabetes death rates are a MEASURE of the diabetes death RISK.
– The TRUE RISK is the actual risk level. It can not be measured directly. We use death data to estimate, or INFER the diabetes death risk.
New Mexico Department of Health4/14/09 24
Measurement and True Scores
Measurement and True Scores
What has this got to do with measurement and true risk?– While the actual risk changes slowly, in
response to changes in the contributing factors, the measure (observed diabetes deaths) can very considerably from year to year, especially in a small population.
New Mexico Department of Health4/14/09 25
Trend Lines for Two Communities
Trend Lines for Two Communities
Diabetes Deaths per 100,000 Population by Year
0
10
20
30
40
50
60
70
1999 2000 2001 2002 2003 2004 2005 2006
Year
Dea
ths
per
100
,000
Community X
Community Y
New Mexico Department of Health4/14/09 26
Calculating Some StatisticsCalculating Some Statistics
Counts– Incidence is the number of new cases (e.g., of
disease) in a given period of time. – Prevalence is the number of existing cases
(e.g., of a disease or risk factor) in a given period of time.
New Mexico Department of Health4/14/09 28
CountCount
1. Get a count of the prevalence of green M&Ms in your sample. (Count the green M&Ms.)
New Mexico Department of Health4/14/09 29
Calculating Some StatisticsCalculating Some Statistics
Rate– A rate is a fraction, in which the numerator is
the number of people (or M&Ms) among whom an event occurred during a certain period of time, and the denominator is the total number of people (or M&Ms) in the population at risk for the same period of time. Rates are typically multiplied by some factor of ten so that the result is a whole number.
New Mexico Department of Health4/14/09 30
RateRate
1. Count the green M&Ms.
2. Count the total number of M&Ms.
3. Divide the number of green M&Ms by the total number of M&Ms.
# Green M&Ms
Total # M&Ms in the package
Formula
8
25= 0.32
Example
New Mexico Department of Health4/14/09 31
Calculating Some StatisticsCalculating Some Statistics
Percentage– A percentage is a rate in which the quotient
is multiplied by 100.
1. Using your green M&M prevalence rate, multiply it by 100 to get the percentage of green M&Ms in your sample.
New Mexico Department of Health4/14/09 32
Confidence IntervalConfidence Interval
A confidence interval is a range around a measurement that conveys how precise the measurement is.– the possible range around the estimate– how stable the estimate is
• A stable estimate is one that would be close to the same value if the measurement were repeated.
• An unstable estimate is one that would vary from one measurement to another.
New Mexico Department of Health4/14/09 33
Trend Lines for Two Communities
Trend Lines for Two Communities
Diabetes Deaths per 100,000 Population by Year
0
20
40
60
80
100
120
140
1999 2000 2001 2002 2003 2004 2005 2006
Year
Dea
ths
per
100
,000
Community X
Community Y
New Mexico Department of Health4/14/09 34
Trend Lines for Two Communities
Trend Lines for Two Communities
Diabetes Deaths per 100,000 Population by Year
0
20
40
60
80
100
120
140
1999 2000 2001 2002 2003 2004 2005 2006
Year
Dea
ths
per
100
,000
Community X
Community Y
New Mexico Department of Health4/14/09 35
Trend Lines for Two Communities
Trend Lines for Two Communities
Diabetes Deaths per 100,000 Population by Year
0
20
40
60
80
100
120
140
1999 2000 2001 2002 2003 2004 2005 2006
Year
Dea
ths
per
100
,000
Community X
Community Y
4/14/09 36
Community Health Assessment Part 2:
Documenting Health Status
Community Health Assessment Part 2:
Documenting Health Status
NMDOH Community Health Assessment Program (CHAP)
4/14/09 37
Assembling Data to Communicate for Community
Health Status
Assembling Data to Communicate for Community
Health Status
New Mexico Department of Health4/14/09 38
Population-BasedPopulation-Based
Population-based: Covers the entire population.– Population-based:
• Residents of New Mexico• Children in Mora County
– Why are these NOT Population-based?• Clinic patients• WIC recipients
New Mexico Department of Health4/14/09 39
Mortality Risk Inferred from Mortality Data
Mortality Risk Inferred from Mortality Data
Life expectancy
Death Rates
Years of Potential Life Lost– YPLL stands for "Years of Potential Life Lost," and is
a measure of premature mortality. It is calculated as the difference, across all persons in a population, between the actual age at death and age 65. It can also be calculated as the sum of the remaining years of life expectancy for all decedents in a population.
New Mexico Department of Health4/14/09 40
Morbidity Risk Inferred from Mortality Data
Morbidity Risk Inferred from Mortality Data
Cause-specific deaths– Diabetes-related deaths– Alcohol-related motor vehicle crash deaths– Heart disease deaths– Chronic liver disease and cirrhosis– Suicide deaths– Chronic obstructive pulmonary disease
(emphysema)
New Mexico Department of Health4/14/09 42
Calculating a Death RateCalculating a Death Rate
A rate has four components:– A specified time period.– The numerator, the number of people in whom an
event occurred during a given period of time, and– The denominator, the total number of people in the
population at risk for the same period of time. This is also referred to as the "person-years at risk."
– A constant. The result of the fraction is usually multiplied by some factor of 10 (such as 100,000), so that the rate may be expressed as a whole number.
New Mexico Department of Health4/14/09 43
The Numerator: Causes of Death
The Numerator: Causes of Death
National Center for Health Statistics, 50 Leading Causes of Death– In order to provide a consistent ranking
standard the NCHS (National Center for Health Statistics, part of the CDC) prepared a list of 113 selected causes of death. The NCHS 50 leading causes of death are taken from the list of 113. For more information about the NCHS rankings, see Cause of Death Ranking on the NCHS website.
New Mexico Department of Health4/14/09 44
The Numerator: Causes of Death
The Numerator: Causes of Death
New Mexico Department of Health4/14/09 45
The Numerator: Causes of Death
The Numerator: Causes of Death
New Mexico Department of Health4/14/09 46
The Numerator: Causes of Death
The Numerator: Causes of Death
New Mexico Department of Health4/14/09 47
International Classification of Disease, Version 10 (ICD-10)International Classification of Disease, Version 10 (ICD-10)
New Mexico Department of Health4/14/09 48
The Numerator: Causes of Death
The Numerator: Causes of Death
New Mexico Department of Health4/14/09 50
Calculating a Death RateCalculating a Death Rate
The calculation for the death rate for Heart Disease in Region 1 looks like this:
1. Do the division:
2. Multiply by the ‘constant’:
New Mexico Department of Health4/14/09 52
Age-Specific RatesAge-Specific Rates
Calculation of an age-specific rate is the same as for a crude rate. The only difference is that the count in both the numerator and the denominator is limited to a specific age group.
Other examples of “–specific” rates include ‘age- and sex-specific’ rates, ‘cause-specific’ death rates, ‘county-specific’ rates, etc.
New Mexico Department of Health4/14/09 54
Age-Adjusted RatesAge-Adjusted Rates
An age-adjusted rate is a measure that controls for the effects of age differences on health event rates. When comparing across geographic areas, years, or race/ethnic groups, some method of age-adjusting is typically used to control for the influence that different population age distributions might have on health event rates.
New Mexico Department of Health4/14/09 55
Morbidity Risk Inferred from Infectious Disease Data
Morbidity Risk Inferred from Infectious Disease Data
State law determines which diseases are reportable.
Examples include:– Sexually transmitted (Chlamydia, HIV)– Vector borne (West Nile, Hanta Virus)– Food borne (E. coli, Salmonella)– Other (Influenza, meningitis)
New Mexico Department of Health4/14/09 56
Morbidity Risk and Access to Care Inferred from Birth DataMorbidity Risk and Access to Care Inferred from Birth Data
Infant birth weight (high or low)
Teen births
Births to single mothers
Alcohol use during pregnancy
Late or no prenatal care
High-risk infants born at tertiary care facilities
New Mexico Department of Health4/14/09 57
Morbidity Risk Inferred from Health Surveys
Morbidity Risk Inferred from Health Surveys
Behavioral Risk Factor Surveillance System (BRFSS)– Smoking– Physical Activity, overweight
Pregnancy Risk Assessment and Monitoring System (PRAMS)– Intendedness of pregnancy– Health care coverage for prenatal care
Youth Risk and Resiliency Survey (YRRS)– Drug use, smoking– Suicidal thoughts
New Mexico Department of Health4/14/09 58
Morbidity Risk Inferred from Utilization and Treatment Data
Morbidity Risk Inferred from Utilization and Treatment Data Inpatient Hospital Discharges
– Diabetes– Influenza, pneumonia
Emergency Department Encounters– Injury and substance abuse– Mental health encounters
RPMS/IHS– Chronic conditions– Preventive clinical care
New Mexico Department of Health4/14/09 59
Disease RegistriesDisease Registries
Cancer Registry
Traumatic Brain Injury/ Spinal Cord Injury (TBI/SCI)
Chronic diseases (diabetes, asthma, hypertension)
Child blood lead
New Mexico Department of Health4/14/09 60
Other AgenciesOther Agencies
Public Education Department– HS dropout rates– free and reduced lunch (measure of poverty)
Children Youth and Families– Child abuse and neglect– Children in foster care
Department of Workforce Solutions– unemployment
New Mexico Department of Health4/14/09 61
Census BureauCensus Bureau
Age, Sex, Race composition of the population
Geographic distribution of the population
POPULATION DENOMINATORS
New Mexico Department of Health4/14/09 62
Getting IBIS to Calculate Your Rates
Getting IBIS to Calculate Your Rates
New Mexico’s Indicator-Based Information System for Public Health (NM-IBIS).
http://ibis.health.state.nm.ushttp://ibis.health.state.nm.us
New Mexico Department of Health4/14/09 63
Why “Indicator-Based?”Why “Indicator-Based?”
GAO found that comprehensive key indicator systems had positive effects in four areas:
– Enhanced collaboration to address public issues,
– Provided tools to encourage progress,
– Informed decision making and improved research,
– Increased public knowledge about key issues
Government Accountability Office (GAO). Informing Our Nation. Improving how to understand the USA’s position and Progress. November 2004. Accessed 1/5/2007 online at http://www.gao.gov/new.items/d051.pdf.
4/14/09 64
Community Health Assessment Part 3:
Prioritizing Needs and Planning Interventions
Community Health Assessment Part 3:
Prioritizing Needs and Planning Interventions
NMDOH Community Health Assessment Program (CHAP)
4/14/09 65
Thank You!Thank You!
Lois M. Haggard, PhD
Community Health Assessment Program
New Mexico Department of Health
505-827-5274