A compendium of public health data sources

This paper is a compendium of sources that contain quantitative data on the health of the US population. These data are useful for epidemiology, public health research, and surveillance activities. The data are from vital records, health surveys, surveillance systems, and the US Census. In this compendium, there are 107 sources of data on mortality, morbidity, natality, maternal and child health, health and health care, the Census, and nutrition surveillance. The telephone numbers and contact offices within the federal agencies responsible for these data bases are provided as guides to help researchers obtain this information. These data sources are useful for examining the relations between diet, behavior, exposure, and health, trends in mortality and morbidity for specific diseases, and patterns in food consumption and composition.     

Water quality laws and waterborne diseases: Cryptosporidium and other emerging pathogens

Waterborne diseases, such as cryptosporidiosis, cause many cases of serious illness in the United States annually. Water quality is regulated by a complex system of federal and state legal provisions and agencies, which has been poorly studied. The authors surveyed state and territorial agencies responsible for water quality about their laws, regulations, policies, and practices related to water quality and surveillance of cryptosporidiosis related to drinking water. In this commentary they review the development and current status of federal drinking water regulations, identify conflicts or gaps in legal authority between federal agencies and state and territorial agencies, and describe court-imposed limitations on federal authority with regard to regulation of water quality. Recommendations are made for government actions that would increase the efficiency of efforts to ensure water quality; protect watersheds; strengthen waterborne disease surveillance; and protect the health of vulnerable populations.     

Federal regulations and the future of research in human and medical genetics.

Recent events in genetics research have generated questions about the efficacy of federal regulations that govern the conduct of biomedical research, particularly genetics research. The regulatory definitions of "human subject" and "private information" that have governed the conduct of research for two decades are presently under scrutiny because of ambiguities created by the methods of family studies in human and medical genetics. Geneticists customarily collect family history information for the purposes of tracking and characterizing genes in large families. Amassing family history information usually entails asking human subjects about the health status of collateral relatives. Whether these relatives should be regarded as human subjects for the purposes of giving informed consent is the issue that has triggered wide debate and an exhaustive re-examination of federal regulations and guidelines. The purpose of this article is threefold. First, a review of the development of current federal regulations provides a foundation and a point of departure for resolving current issues in genetics research. Second, a review of customary practices in genetics research furthers thought regarding regulations or guidelines to address specific issues in genetics. Third, it asserts that any new regulations or guidelines must provide appropriate protections for human subjects and their families while simultaneously supporting appropriate activities in genetics research.     

加强国民营养监测,采取有效干预策略,减少营养性疾病的发生

国民营养事关国民健康素质的提高和社会经济的发展,营养与健康状况监测信息,是公共卫生及疾病预防控制工作不可缺少的基础信息,为全民营养健康状况改善、食物生产及慢性病防控策略的制定提供技术支持。近年来,我国营养供给能力显著增强,国民营养健康状况明显改善。本期“营养健康监测”栏目发表的论文来自中国居民营养与健康监测及省（市）级自主开展的营养监测报告,这些数据为制定全国或地方性营养与健康策略提供了科学的参考。当前,我国营养工作面临多重挑战,党中央、国务院始终把人民群众的营养与健康摆在十分重要的位置,为促进全民健康,我国政府已实施多项营养促进政策或策略,营养监测又将进一步评估这些措施实施的效果。     

Intersectoral action to improve nutrition: the roles of the state and the private sector. A case study from Australia

Much has been written about the desirability of ‘intersectoral’policies to promote health. However, little concrete analysisof the most appropriate roles for various governmental, non-governmentaland private-sector agencies in the intersectoral mix is availablefor specific health issues. This paper examines the case ofimproving community nutrition in Australia through intersectoraldivision of effort. It focuses on the respective roles of governmentalefforts and the designs of sections of the food industry tomeet market demand for ‘healthy’ foods. After describingthe nature and extent of the private sector's interests in promotingfoods compatible with the Australian Dietary Guidelines, eightroles for public sector workers nutrition promotion are described.These are:

• development and use of cost-efficient mass-reach strategiesin nutrition education;
• administration of, and advocacy for,regulation of food standards,nutrient labelling and advertising;
• formation of intersectoral mechanisms between government departments,NGOs and the private sector to promote nutritional concernsin policy making (e.g. primary industry), to coordinate efforts/avoid duplication and to advocate desired changes;
• subsidisingprimary food industries to encourage product developmentconsistentwith dietary guidelines (e.g. leaner meat; improvedfishingmethods etc);
• development of policy and guidelines for dietarypractice ingovernment institutions serving and selling food(schools, hospitals,prisons, office canteens, interstate trainsetc);
• ‘honest brokerage’ of information: opposingmisinformation;
• development of and participation in a nationalresearch strategyin nutrition; and
• training of health personnelin minimum standards of nutritionalknowledge and skills.

     

The public and private sectors in health: economic issues

Major changes in the public/private mix of health services are occurring in many countries. These changes may be analysed by examining the financing and provision of services and subsidization of the purchase of the factors of production. The public sector and not-for-profit and for-profit elements of the private sector must be viewed as separate entities in such analyses due to their differing objectives, motives and form of operation. The issues to be dealt with by countries in finding the public/private mix which is appropriate for their health system and achieves their objectives include efficiency, quality, regulation, equity and consumer choice and satisfaction. The recommendations for action for countries include: promoting collaboration between private and public sectors; testing different public/private mix models; identifying appropriate expansion paths for private sector services; improving information for policy and planning decisions; enhancing management capacity; and, reviewing programme and project support. International agencies also have a role in this process by supporting countries through the provision of technical assistance, financial aid, promoting policy reviews, and facilitating the sharing of information and experiences among countries concerning these public/private mix issues.     

Meeting the Need for State-Level Estimates of Health Insurance Coverage: Use of State and Federal Survey Data

Objective. Critically review estimates of health insurance coverage available from different sources, including the federal government, state survey initiatives, and foundation-sponsored surveys for use in state policy research.
Study Setting and Design. We review the surveys in an attempt to flesh out the current weaknesses of survey data for state policy uses. The main data sources assessed in this analysis are federal government surveys (such as the Current Population Survey's Annual Social and Economic Supplement, and the National Health Interview Survey), foundation-supported surveys (National Survey of America's Families, and the Community Tracking Survey), and state-sponsored surveys.
Principal Findings. Despite information on estimates of health insurance coverage from six federal surveys, states find the data lacking for state policy purposes. We document the need for state representative data on the uninsured and the recent history of state data collection efforts spurred in part by the Health Resources Services Administration State Planning Grant program. We assess the state estimates of uninsurance from the Current Population Survey and make recommendations for a new consolidated federal survey with better state representative data.
Conclusions. We think there are several options to consider for coordinating a federal and state data collection strategy to inform state and national policy on coverage and access.     

Financing nutrition services in a competitive market

Budget deficits and inflationary medical care costs threaten nutrition services, which until recently have been funded largely by federal, state, and local revenues. Nutritionists and dietitians responding to demands in the marketplace should develop innovative programs and pursue new sources for financing through the private sector, third-party payers, business/industry health promotion, and consumer fees for their services, as well as targeted federal, state, and locally funded food assistance, nutrition education, and health care programs. Trail-blazing dietitians are successfully offering their services in health maintenance organizations (HMOs), hospital or industry fitness programs, private practice, voluntary health agencies, and official agency programs. With the new federalism, nutritionists must articulate their role in comprehensive health care and market their services at the state and local levels in addition to the federal level. Nutrition services are defined to include assessment, planning, counseling, education, and referral to supportive agencies. Data management, managerial, and marketing skills must be developed for dietitians to compete effectively. Basic educational preparation and continuing education for practicing professionals must develop these competencies.     

Nutritional surveillance in Australia: a case of groping in the dark?

Nutritional surveillance means to watch over nutrition in order to make decisions and take actions to improve nutrition in populations. The information obtained through the surveillance system can be used in at least four areas--policy analysis, planning, program management and research. However, in Australia the information currently available is less than adequate for many key questions in these areas. The present state of infrequent and irregular data collection and analysis handicaps our efforts to understand the nutrition situation and to implement effective strategies to improve the nutritional health of Australians.     

Status of nutrition surveillance activities in 24 State and metropolitan health departments

A study was undertaken to examine nutrition surveillance activities and their usefulness in managing programs of nutrition intervention. Questionnaires were returned by 24 of 26 directors of nutrition units in State or metropolitan health departments participating in 1981 in the coordinated nutrition surveillance system of the Centers for Disease Control, which monitors high risk pediatric patients and pregnant women. The mean years of experience in surveillance activities among the agencies was 4. Only 25 percent of the responding departments reported a self-sufficient computerized surveillance system. Personnel most involved in the coordinating, analyzing, and interpreting of the data were nutritionists who spent an average of 17 hours per month. Major uses of surveillance data reported for purposes of the nutrition programs were to (a) identify collection sites with problems such as errors in measuring heights and weights and hematocrits warranting checks for quality control, (b) define the extent of nutrition-related disorders in the target populations, (c) provide objective local data to assist in decision-making and program planning, (d) enhance followup of specific clients, and (e) provide feedback to clinic staffs about the quality and relative impact of their services. The survey results yielded evidence that nutrition surveillance activities have important consequences for the planning, implementation, and evaluation of programs of nutritional intervention.     

Research Priorities Child and Maternal Nutrition: A USAID Perspective

This paper presents the views of the United States Agency for International Development, India (US-AID/India) on priorities for nutrition research in 2001-2005. Indices of nutrition status in India have been stagnant for 30 years. Although severe malnutrition has declined significantly, there has been little improvement since the 1970s in the percentage of children and/or mothers who are moderately undernourished. USAID views nutrition as a maternal and child survival intervention and focuses programmatic priorities on micronutrient nutrition (specifically vitamin A and iron/folate), integrated community nutrition (MinPak), and improved nutrition status through USAID's Title II program. Major areas of research interest for USAID include the prevalence and etiology of nutrition deficiencies, operations research to improve service delivery, the application of new tools and technologies to improve nutrition, and increasing the role of the private sector (including nongovernmental organizations) in nutrition service delivery. It is concluded that nutrition research must be prioritized to drive programmatic action; research must focus on the key questions; known tools must be widely applied; and elegance should be pursued in all research endeavors.     

Data requirements to measure progress on the objectives for the nation in health promotion and disease prevention

The Reagan Administration has adopted the policy guidelines developed over the previous few years in the disease prevention and health promotion initiative of the Carter Administration. Broad national consensus had been sought in the formulation of 226 measurable objectives for the decade. We classify the prevention objectives according to their position in an implied causal chain: 1) improved programs, 2) increased public and professional awareness, 3) reduced risk factors, and 4) improved health status. Prior to 1980, the data systems and periodic surveys sponsored by federal agencies and national organizations covered only four of the 42 objectives in the public and professional awareness category, whereas at least half of the objectives in each of the other three categories were covered by available national data sources, mostly federal. Sample surveys are needed to measure the majority of the currently unmeasured objectives in all four categories. Private and state health interview surveys are needed to supplement the federal capacity, especially in the face of federal cutbacks in survey capacity.     

Biologic and methodologic issues for nutritional biomarkers

Nutritional biomarkers are used for a variety of purposes in large-scale population surveys and epidemiologic studies as well as smaller clinical studies. The main reasons for using nutritional biomarkers are to provide measures of nutritional status that have less error than dietary data, nutrient status for nutrients with inadequate dietary data, to obtain a more proximal and integrated assessment of nutrient status that incorporates metabolism, to assess dietary change and compliance in intervention studies, and dietary intake for the validation of dietary questionnaires. However, often there is oversight by the investigators regarding biologic and laboratory issues, which have implications for the utility of nutritional biomarkers. This article reviews some of the physiologic issues that contribute to between-person variability in nutrient status and the utility and meaning of specimens from various body compartments. Issues related to the collection and storage of biologic specimens are addressed, although it is recommended that investigators contact laboratory colleagues at the beginning of any study for updated information. The necessity for blind quality surveillance of laboratory analyses beyond the normal procedures employed by collaborating laboratories also is addressed. The advantages and disadvantages of nutritional biomarkers are reviewed, especially in comparison with using dietary methodology.     

Methods of nutrition surveillance in low-income countries

Background

In 1974 a joint FAO/UNICEF/WHO Expert Committee met to develop methods for nutrition surveillance. There has been much interest and activity in this topic since then, however there is a lack of guidance for practitioners and confusion exists around the terminology of nutrition surveillance. In this paper we propose a classification of data collection activities, consider the technical issues for each category, and examine the potential applications and challenges related to information and communication technology.

Analysis

There are three major approaches used to collect primary data for nutrition surveillance: repeated cross-sectional surveys; community-based sentinel monitoring; and the collection of data in schools. There are three major sources of secondary data for surveillance: from feeding centres, health facilities, and community-based data collection, including mass screening for malnutrition in children. Surveillance systems involving repeated surveys are suitable for monitoring and comparing national trends and for planning and policy development. To plan at a local level, surveys at district level or in programme implementation areas are ideal, but given the usually high cost of primary data collection, data obtained from health systems are more appropriate provided they are interpreted with caution and with contextual information. For early warning, data from health systems and sentinel site assessments may be valuable, if consistent in their methods of collection and any systematic bias is deemed to be steady. For evaluation purposes, surveillance systems can only give plausible evidence of whether a programme is effective. However the implementation of programmes can be monitored as long as data are collected on process indicators such as access to, and use of, services. Surveillance systems also have an important role to provide information that can be used for advocacy and for promoting accountability for actions or lack of actions, including service delivery.

Conclusion

This paper identifies issues that affect the collection of nutrition surveillance data, and proposes definitions of terms to differentiate between diverse sources of data of variable accuracy and validity. Increased interest in nutrition globally has resulted in high level commitments to reduce and prevent undernutrition. This review helps to address the need for accurate and regular data to convert these commitments into practice.

     

Nutritional surveillance

The concept of nutritional surveillance is derived from disease surveillance, and means “to watch over nutrition, in order to make decisions that lead to improvements in nutrition in populations”. Three distinct objectives have been defined for surveillance systems, primarily in relation to problems of malnutrition in developing countries: to aid long-term planning in health and development; to provide input for programme management and evaluation; and to give timely warning of the need for intervention to prevent critical deteriorations in food consumption. Decisions affecting nutrition are made at various administrative levels, and the uses of different types of nutritional surveillance information can be related to national policies, development programmes, public health and nutrition programmes, and timely warning and intervention programmes. The information should answer specific questions, for example concerning the nutritional status and trends of particular population groups.     

The role of the Medical Care Advisory Committee in the administration of state Medicaid programs. A twenty-year perspective

Every state Medicaid program has a Medical Care Advisory Committee (MCAC). MCACs are required by federal regulations to have representation from state human service agencies, health care providers, and Medicaid consumers. Survey data presented in this study show the make-up of MCACs by representative group. Other data presented show meeting frequencies, subcommittee structure, and information about MCAC activities. Comparisons are made from historical MCAC data showing long-term trends of their composition and structure. It is argued that MCACs can be useful to state Medicaid agencies in policy development but have not been structured to do so. Recommendations are given to make MCACs more useful.     

An Experimental Study Using Opt-in Internet Panel Surveys for Behavioral Health Surveillance

Objective

To present the design and preliminary results of a pilot study to investigate the use of opt-in Internet panel surveys for behavioral health surveillance.

Introduction

Today, surveyors in both the private and public sectors are facing considerable challenges with random digit dialed (RDD) landline telephone samples. The population coverage rates for landline telephone surveys are being eroded by wireless-only households, portable telephone numbers, telecommunication barriers (e.g., call forwarding, call blocking and pager connections), technological barriers (call-blocking, busy circuits) and increased refusal rates and privacy concerns. Addressing these issues increasingly drives up the costs associated with dual-frame telephone surveys designed to be representative of the target population as well as hinders their ability to be fully representative of the adult population of each state and territory in the United States.In an effort to continue to meet these challenges head on and assist state and territorial public health professionals in the continued collection of data that are representative of their respective populations, novel approaches to behavioral health surveillance need continued examination. Both private and public sector researchers are evaluating the use of Internet opt-in panels to augment dual-frame RDD survey methods. Compared to dual-frame RDD, opt-in Internet panels offer lower costs, quick data collection and dissemination, and the ability to gather additional data on panelists over time. However, as with dual-frame RDD, this mode has similar challenges with coverage error and non-response. Nevertheless, survey methodologists are moving forward and exploring ways to reduce or eliminate biases between the sample and the target population.

Methods

A collaborative pilot project was designed to assess the feasibility and accuracy of opt-in Internet panel surveys for behavioral health surveillance. This pilot project is a collaboration between the CDC, four state departments of health, opt-in Internet panel providers and the leads of several large surveys and systems such as the Patient-Reported Outcome Measures Information System (PROMIS) and the Cooperative Congressional Election Study (CCES). Pilot projects were conducted in four states (GA, IL, NY, and TX) and four Metropolitan Statistical Areas (Atlanta, Chicago, New York City, and Houston). Data were collected using three different opt-in Internet panels and sampling methods that differ with respect to recruitment strategy, sample selection and sample matching to the adult population of each geography. A question bank consisting of 80 questions was developed to benchmark with other existing surveys used to assess various public health surveillance measures (e.g., the Behavioral Risk Factor Surveillance System, the PROMIS, National Survey on Drug Use and Health, and the CCES).

Results

We present comparative analyses that assess the advantages and disadvantages of different opt-in Internet panels sampling methodologies across a range of parameters including cost, geography, timeliness, usability, and ease of use for technology transfer to states and local communities. Recommendations for future efforts in behavioral health surveillance are given based on these results.