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Leading Health Indicators for Healthy People 2020: Letter Report Howard Koh, M.D. Assistant Secretary for Health 200 Independence Avenue SW Hubert H. Humphrey Building, 7-716G Washington, DC 20201 Dear Dr. Koh: In response to a request from the Department of Health and Human Services (HHS), the Institute of Medicine (IOM) established the Committee on Leading Health Indicators for Healthy People 2020 to develop and recommend 12 indicators and 24 objectives for consideration by HHS for guiding a national health agenda and for consideration for inclusion in Healthy People 2020. It was anticipated that the work of the committee would build upon the 1999 IOM report, Leading Health Indicators for Healthy People 2010, and on the work of the Committee on the State of the USA Health Indicators. The product of the committee was to be a consensus letter report. In conducting its work, the committee was asked to Review current and past health indicators sets, including Healthy People 2010 Leading Health Indicators, the State of the USA (SUSA) indicators, and the Community Health Status Indicators; Give consideration to provisions of the Patient Protection and Affordable Care Act that mandate the establishment of key national indicators and prevention-related measures, goals, and objectives; Define basic principles or purposes for Healthy People 2020 Leading Health Indicators; Develop criteria for selecting Healthy People 2020 Leading Health Indicators. Such criteria should be actionable and reflect the importance of science, evidence, and public health concerns. Development of such criteria should involve consideration of Healthy People 2010 Leading Health Indicators and reflect the Healthy People 2020 framework that includes new issues and topics (e.g., health communication and health information technology); Choose indicators that, to the extent possible, have annual data sources, with comparable data available at the state and county level; and Identify 24 objectives drawn from Healthy People 2020 and 12 topics under which the selected objectives will be organized. During the HHS presentation of the charge to the committee on November 8, 2010, the committee was informed that since only 39 of
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Leading Health Indicators for Healthy People 2020: Letter Report the 42 Healthy People 2020 topics had written objectives, the committee could propose objectives for the three topics under development. Those topics are: social determinants of health; health-related quality of life and well-being; and lesbian, gay, bisexual, and transgender health. The committee also received clarification from HHS that the 12 topics selected by the committee did not need to be drawn from the list of 42 topics listed in Healthy People 2020. The following pages make up the letter report and provide the committee’s recommendations regarding that task described above. The report is organized as follows. First is a brief discussion of Healthy People 2020, its mission, goals, and foundation health measures, all of which served as background information for the committee in completing its task. Next is the presentation of the committee’s recommendations concerning topics, indicators, and objectives. This is followed by a discussion of the committee process, the framework and the process used to select objectives, and a discussion of the selection of topics and indicators. A detailed discussion of each of the selected objectives is then presented as well as suggestions for measures that could be used in the three Healthy People topic areas for which no objectives exist: social determinants of health; health-related quality of life and well being; and lesbian, gay, bisexual, and transgender health. HEALTHY PEOPLE 2020 Healthy People has evolved during the three decades in which it has existed. In 1990, Healthy People 2000 had two overarching goals, 15 topic areas, and 226 objectives. Today Healthy People 2020 has four overarching goals, 42 topics areas (of which 39 contain objectives), and nearly 600 objectives. The mission of Healthy People 2020 is to Identify nationwide health improvement priorities; Increase public awareness and understanding of determinants of health, disease, disability, and opportunities for progress; Provide measureable objectives and goals applicable at national, state, and local levels; Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; and Identify critical research evaluation and data collection needs. The following are the overarching goals of Healthy People 2020:
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Leading Health Indicators for Healthy People 2020: Letter Report Attain high-quality, longer lives free of preventable disease. Achieve health equity; eliminate disparities. Create social and physical environments that promote good health. Promote quality of life, healthy development, and healthy behaviors across life stages. Additionally, Healthy People 2020 has developed four “foundation health measures.” According to the Healthy People 2020 website1: Over the course of the decade, the four foundation health measures will be used to monitor progress toward promoting health, preventing disease and disability, eliminating disparities, and improving quality of life. The four classes of foundation health measures are general health status, health-related quality of life and well-being, determinants of health, and disparities. The foundation health measures were published by HHS after the charge to the committee was developed and the work of the committee begun. The committee was not required in the charge to take this set of measures into account in developing its recommendations. RECOMMENDATIONS As instructed in the statement of task, the committee has developed and recommends 12 indicators and 12 topics, and selected 24 objectives from the Healthy People 2020 objectives that relate to the identified indicators and topics. A list of the objectives with accompanying subobjectives, quantitative goals, and data sources can be found in Appendix B. Recommendation 1: The committee recommends that the following indicators be used by HHS as the Healthy People 2020 Leading Health Indicators. These indicators are: Proportion of the population with access to health care services Proportion of the population engaged in healthy behaviors Prevalence and mortality of chronic disease Proportion of the population experiencing a healthy physical environment Proportion of the population experiencing a healthy social environment 1 See http://www.healthypeople.gov/2020/about/tracking.aspx (accessed November 18, 2010).
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Leading Health Indicators for Healthy People 2020: Letter Report Proportion of the population that experiences injury Proportion of the population experiencing positive mental health Proportion of healthy births Proportion of the population engaged in responsible sexual behavior Proportion of the population engaged in substance abuse Proportion of the population using tobacco Proportion of the population receiving quality health care services Recommendation 2: The committee recommends the following 24 objectives,2 selected from the Healthy People 2020 objectives, as important objectives related to these indicators. AH 5: Increase educational achievement of adolescents and young adults. AHS 1: Increase the proportion of persons with health insurance. AHS 3: Increase proportion of persons with a usual primary care provider. AHS 7: (Developmental) Increase the proportion of persons who receive appropriate evidence-based clinical preventive services. C 1: Reduce the overall cancer death rate. EH 1: Reduce the number of days the Air Quality Index (AQI) exceeds 100. EMC 1: (Developmental) Increase the proportion of children who are ready for school in all five domains of healthy development: physical development, social-emotional development, approaches to learning, language, and cognitive development. FP 8: Reduce pregnancy rates among adolescent females. HA 1: Reduce central line-associated bloodstream infections (CLABSI). HC/HIT 1: (Developmental) Improve the health literacy of the population. HDS 2: Reduce coronary heart disease deaths. HDS 5: Reduce the proportion of persons in the population with hypertension. 2 The numbers are those used in Healthy People 2020 to identify the objectives.
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Leading Health Indicators for Healthy People 2020: Letter Report HIV 17: Increase the proportion of sexually active persons who use condoms. IVP 1: Reduce fatal and nonfatal injuries. MHMD 4: Reduce the proportion of persons who experience major depressive episodes (MDE). MICH 8: Reduce low birth weight (LBW) and very low birth weight (VLBW). NWS 10: Reduce the proportion of children and adolescents who are considered obese. NWS 17: Reduce consumption of calories from solid fats and added sugars in the population aged 2 years and older. PA 2: Increase the proportion of adults who meet current federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity. SA 13: Reduce past-month use of illicit substances. SA 14: Reduce the proportion of persons engaging in binge drinking of alcoholic beverages. SH 4: Increase the proportion of adults who get sufficient sleep. TU 1: Reduce tobacco use by adults. TU 3: Reduce the initiation of tobacco use among children, adolescents, and young adults. Table 1 displays the relationship among the recommended objectives, indicators, and topics. The following section of the report describes the process the committee used to complete its work. COMMITTEE PROCESS The committee met three times over the course of this 6-month study. The first meeting was held in conjunction with an information gathering session during which HHS staff delivered the charge to the committee and provided background information on the evolution of Healthy People since 1990. The remaining two meetings were held in closed session during which the committee reviewed, analyzed, and synthesized different approaches to indicator development, among which were Leading Health Indicators for Healthy People 2010 (IOM, 1999), the State of the USA Health Indicators (IOM, 2009b), the Community Health Status Indicators program of HHS, and the County Health Rankings (Mobilizing Action Toward Community Health, 2010). The committee also reviewed provisions of the Patient Protection and Affordable Care Act (ACA) related to the key national indicator system, and various quality provisions including the
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Leading Health Indicators for Healthy People 2020: Letter Report TABLE 1 Topics, Indicators, and Objectives Topic Indicator Objectivea Access to Care Proportion of the population with access to health care services 1. AHS 1: Increase the proportion of persons with health insurance. 2. AHS 3: Increase proportion of persons with a usual primary care provider. 3. AHS 7: (Developmental) Increase the proportion of persons who receive appropriate evidence-based clinical preventive services. Healthy Behaviors Proportion of the population engaged in healthy behaviors 4. PA 2: Increase the proportion of adults who meet current federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity. 5. NWS 10: Reduce the proportion of children and adolescents who are considered obese. 6. NWS 17: Reduce consumption of calories from solid fats and added sugars in the population aged 2 years and older. 7. SH 4: Increase the proportion of adults who get sufficient sleep. Chronic Disease Prevalence and mortality of chronic disease 8. HDS 2: Reduce coronary heart disease deaths. 9. HDS 5: Reduce the proportion of persons in the population with hypertension. 10. C 1: Reduce the overall cancer death rate. Environmental Determinants Proportion of the population experiencing a healthy physical environment 11. EH 1: Reduce the number of days the Air Quality Index (AQI) exceeds 100. Social Determinants Proportion of the population experiencing a healthy social environment 12. HC/HIT 1: (Developmental) Improve the health literacy of the population. 13. EMC 1: (Developmental) Increase the proportion of children who are ready for school in all five domains of healthy development: physical development, social-emotional development, approaches to learning, language, and cognitive development. 14. AH 5: Increase educational achievement of adolescents and young adults.
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Leading Health Indicators for Healthy People 2020: Letter Report Topic Indicator Objectivea Injury Proportion of the population that experiences injury 15. IVP 1: Reduce fatal and nonfatal injuries. Mental Health Proportion of the population experiencing positive mental health 16. MHMD 4: Reduce the proportion of persons who experience major depressive episodes (MDE). Maternal and Infant Health Proportion of healthy births 17. MICH 8: Reduce low birth weight (LBW) and very low birth weight (VLBW). Responsible Sexual Behavior Proportion of the population engaged in responsible sexual behavior 18. FP 8: Reduce pregnancy rates among adolescent females. 19. HIV 17: Increase the proportion of sexually active persons who use condoms. Substance Abuse Proportion of the population engaged in substance abuse 20. SA 13: Reduce past-month use of illicit substances. 21. SA 14: Reduce the proportion of persons engaging in binge drinking of alcoholic beverages. Tobacco Proportion of the population using tobacco 22. TU 1: Reduce tobacco use by adults. 23. TU 3: Reduce the initiation of tobacco use among children, adolescents, and young adults. Quality of Care Proportion of the population receiving quality health care services 24. HA 1: Reduce central line-associated bloodstream infections (CLABSI). a The numbering of the objectives is directly from Healthy People 2020. National Strategy to Improve Health Care Quality, Quality Measure Development, and quality in wellness programs. (Appendix A provides a table that summarizes provisions of the ACA as they relate to the 12 indicators and 24 identified objectives.) In the document Leading Health Indicators for Healthy People 2010: Final Report (IOM, 1999), the committee found the use of the terms topic, indicator, and objective confusing. The committee determined that it was necessary to define these three terms because it was directed to identify
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Leading Health Indicators for Healthy People 2020: Letter Report 12 indicators, 24 objectives and 12 topics (number six above in the list of issues to consider). For purposes of this report, therefore, a topic is defined as a general category relevant to health, for example, chronic illness. An indicator is defined as a measurement, for example, prevalence of cardiovascular disease. An indicator could relate to multiple topics, for example, the indicator percentage of adults with a body mass index (BMI) equal to or greater than 30 could relate to the topics of chronic disease and health behaviors. Leading health indicators are quantitative expressions of health-related concepts that reflect major public health concerns. By major public health concern, the committee means a major component of overall morbidity, mortality, or limited functional health status or health-related quality of life, or a major determinant of morbidity, mortality, or functional health status or health-related quality of life. An objective is a statement of movement in an indicator toward a quantitative target, for example, reduce the prevalence of cardiovascular disease by 10 percent. PRINCIPLES AND PURPOSES The committee was asked to define basic principles or purposes for Healthy People 2020 Leading Health Indicators. The committee confined its discussion to the scope of the charge that it was given and tried to address each of the bullet points as well as the overall statement of task. In identifying topics, indicators, and objectives, the committee sought to use the available base of scientific knowledge to identify important domains of health in terms of statistics on mortality, morbidity, functional health status, and the extent to which a current health state also represented a risk for future health concerns. Within these broad principles, the committee chose specific objectives using the criteria listed in Table 2, which were similar to those used to select the Healthy People 2010 Leading Health Indicators. Since a larger set of topics and objectives already exists in the full-length Healthy People 2020 document, and HHS has also identified a set of foundation health measures for special focus, the committee worked with the idea that the topics, indicators, and objectives it put forward could be used to create an even sharper focus on health domains of special significance. Leading Health Indicators for Healthy People 2010 (IOM, 1999) recommended that indicators be used as follows: To elicit interest and awareness among the general population; To motivate diverse population groups to engage in activities that will exert a positive impact on specific indicators and, in turn, improve the overall health of the nation; and
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Leading Health Indicators for Healthy People 2020: Letter Report To provide ongoing feedback concerning progress toward improving the status of specific indicators. The committee believes that the indicators for Healthy People 2020 also should serve these purposes. The specific number 12 for indicators suggests that an indicator and related objectives could be selected for special attention each month during a calendar year, although the recommended indicators and objectives are clearly important enough to be worthy of attention at all times. HHS may wish to use the recommended indicators and objectives in a variety of other ways, including highlighting them in communications to state and local health departments, using them as a guide to funding priorities in a variety of HHS programs, and using them as priority guides for ongoing departmental public health data collection and reporting activities. HHS may also wish to invest analytic resources into the development of aggregate indices for any of the 12 recommended topics for which such indices do not already exist. The committee’s discussion of health-related quality of life and the Economic Hardship Index offers an example of aggregate indices in topics other than the 12 recommended here for special attention. While each of the 24 recommended objectives has at least one clearly defined measure and data source, many of the broader topics and indicators are not easily reflected or monitored by a single number. Development and validation of aggregate indices in these areas would be a valuable part of the Healthy People 2020 effort that could then carry into future 10-year Healthy People cycles. FRAMEWORK FOR SELECTING INDICATORS AND OBJECTIVES Once the committee agreed on the definitions of terms to be used in its task, it turned to defining the framework for health within which the topics, indicators, and objectives would be developed or selected. The committee agreed that developing the framework would have been facilitated if Healthy People 2020 had included a definition of health. However, absent that definition, the committee proceeded by reviewing several existing frameworks. The framework used in the report Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention highlighted preventive health services, health protection, and health promotion as important determinants of disease and disability (HEW, 1979). Evans and Stoddart (1990) proposed a framework of health determinants that included disease, health functioning, well-being, and behavioral and biological responses to social and physical environments. A population health framework for setting national and state health goals proposed by Kindig and colleagues (2008) included health outcomes, health determi-
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Leading Health Indicators for Healthy People 2020: Letter Report nants (health care, health behaviors, socioeconomic factors, and physical environment), and health policies and interventions. A similar framework is used in the County Health Rankings (Mobilizing Action Toward Community Health, 2010) and includes health outcomes (morbidity and mortality), health factors (health behaviors, clinical care, social and economic factors, and physical environment), and programs and policies. The conceptual framework the committee developed for organizing and displaying the 24 objectives selected for Healthy People 2020 (Figure 1) consists of the intersection of two conceptual models: the life course model or perspective and the health determinants and health outcomes model. These two models represent two of the three conceptual frameworks recommended by the IOM Leading Health Indicator Committee for Healthy People 2010, which the committee was asked to consider in its work (IOM, 1999). The life course perspective also forms the implicit basis for one of the four overarching goals of Healthy People 2020: “Promote quality of life, healthy development, and healthy behaviors across all life stages.” Health determinants are one of the four foundational health measures of Healthy People 2020. The life course approach is based on two concepts: first, the impact of specific risk factors and determinants of health varies during the life FIGURE 1 Framework for objectives for leading health indicators.
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Leading Health Indicators for Healthy People 2020: Letter Report course; and second, health and disease result from the accumulation of the effects of risk factors and determinants over the life course. The combination of these two components produces a life course health “trajectory” that represents the cumulative effect of risk factors and determinants at each point in the life course. Typically, the health trajectory “rises” during childhood, adolescence, and early adulthood, plateaus during middle age, and then declines with advancing age. This trajectory can be improved through the reduction of risk factors and the promotion of health through individual and population level (i.e., societal) actions, applied at specific points or during specific stages of the life course, especially during the early years of life (Ben-Shlomo and Kuh, 2002; Halfon, 2009; Halfon and Horchstein, 2002; IOM, 1999; Wise, 2009). There is also evidence to suggest that the impact of factors during early life and at other points in the life course is not immutable but can be influenced by other factors later in the life course (Ben-Shlomo and Kuh, 2002; Wise, 2009). The committee believes that the life course approach provides a useful framework for viewing health determinants and their relative importance at different stages of life, and for guiding the development of targeted health policies, programs, and actions to improve health (Guyer et al., 2009). OBJECTIVES In addition to the framework, the committee also developed criteria for selecting objectives from among the almost 600 objectives in Healthy People 2020. In the 1999 IOM report Leading Health Indicators for Healthy People 2010, the criteria listed were identified as criteria for selecting leading health indicators. To reflect its definitions of topics, indicators, and objectives, the committee modified the criteria used in Healthy People 2010, for its use in selecting objectives. These criteria are displayed in Table 2. Despite a conceptual framework and explicit criteria for selection contained in Table 2, the task of choosing 24 objectives from the hundreds of objectives proposed for Healthy People 2020 was very challenging. Each of the objectives included in Healthy People 2020 has relevance and is important to a particular population. Yet, the committee was charged with selecting only 24. Some objectives were eliminated from consideration because they represented health determinants with relatively small effects on overall health in a population or because they were not clearly “actionable” (i.e., responsive to policies or initiatives by public or private health agencies) or because great progress has already been made in the specific area addressed by the objective. The committee also sought to have a balance in the selected objectives so they were not all focused, for example, on individual health behaviors or on measures of health for children. A
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Leading Health Indicators for Healthy People 2020: Letter Report The committee reviewed the 24 objectives it selected for inclusion in the Healthy People 2020 Leading Health Indicators and noted that, while these objectives are relevant to all, there are particular disparities in many of the underlying indicators that are related to LGBT populations. As discussed earlier in this report, educational achievement is related to improved health which may be of particular importance in LGBT populations, many of whom face high rates of special and complex health problems (e.g., HIV/AIDs) and difficulties in dealing with the health care system more generally. Therefore, the committee offers the following modifications of the selected objectives for use in tracking LBGT health. For ease of comparison with the original Healthy People 2020 objective, the number of the objective has been modified by placing an L immediately after the number to indicate its use with LGBT populations: AH 5L: Increase the educational achievement of lesbians, gay men, and bisexual and transgender adolescents and young adults. AHS 1L: Increase the proportion of lesbians, gay men, and bisexual and transgender persons with health insurance. AHS 5L: Increase the proportion of lesbians and transgender persons with a usual primary care provider. HIV 17L: Increase the proportion of condom use among gay or bisexual males aged 15 and above who are sexually active with other men or women. MHMD 4L.1: Reduce the proportion of gay, bisexual or questioning males and females aged 12 to 17 years who experience major depressive episodes (MDEs). MHMD 4L.2: Reduce the proportion of lesbian, gay men, bisexual, and transgender persons aged 18 years and older who experience major depressive episodes (MDEs). NWS 10L: Reduce the proportion of lesbian and bisexual female adolescents who are considered obese. SA 13L: Reduce the proportion of lesbians’, gay males’, bisexuals’, and transgender persons’ past-month use of illicit drugs. SA 14L: Reduce the proportion of lesbian, gay males, and bisexual persons engaging in binge drinking of alcoholic beverages. TU 1L: Reduce tobacco use by lesbian, gay men, and transgender adults. The committee believes that by including objectives that address issues of disparities in health for the LGBT populations, there will be a focus for implementing actions to lesson disparities and improve the health of LGBT populations. A major difficulty in examining LGBT health relates to the availability
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Leading Health Indicators for Healthy People 2020: Letter Report of data for analysis. According to the Healthy People website,11 “Sexual orientation and gender identity questions are not asked on most national or state surveys, making it difficult to estimate the number of LGBT individuals and their health needs.” Therefore, the committee believes HHS should focus on improving and developing datasets that will facilitate analysis of disparities in LGBT health, thereby leading to action that can improve the quality of life and well-being of LGBT populations. CONCLUSION Based on a framework that integrates the life course model with a model of health determinants and health outcomes, the committee selected 24 objectives and grouped them into two sets of topics and indicators. The first set is the approach recommended by the committee. This thematic approach categorizes the objectives into 12 health-related themes. The second set, the framework approach, places the objectives into each of the categories of the overarching framework. Either or both of these two approaches can be used by HHS to focus on health domains of particular interest or to identify priority areas for collecting and reporting information. The committee also suggested that HHS consider several ideas for populating the three Healthy People 2020 topic areas that do not currently have objectives. These include Social Determinants of Health Explore the use of the Hardship Index for use in monitoring socioeconomic aspects of the social determinants of health. Health-Related Quality of Life and Well-Being Use health-adjusted life expectancy as an indicator for health-related quality of life. Focus particular attention on measures that are capable of producing summary measures of health in the form of a 0–1 health utility score. Review measures and datasets related to the concepts of happiness and well-being as a basis for defining specific objectives. Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Modify objectives identified by the committee to focus specifically on lesbian, gay, bisexual and transgender populations. 11 See http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25 (accessed January 9, 2011).
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Leading Health Indicators for Healthy People 2020: Letter Report Healthy People 2020 objectives are framed to drive action to improve health, and targets are set to allow for measuring progress over time. The committee believes that the selected objectives and indicators will help focus both national and local action aimed at achieving the Healthy People 2020 goals of attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death; achieving health equity, eliminating disparities, and improving the health of all groups; creating social and physical environments that promote good health for all; and promoting quality of life, healthy development, and healthy behaviors across all life stages. REFERENCES Abma, J. C., G. M. Martinez, W. D. Mosher, and B. S. Dawson. 2004. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002. Vital Health Stat 23(24):1-48. AHRQ (Agency for Healthcare Research and Quality). 2007. National healthcare disparities report. Rockville, MD: Agency for Healthcare Research Quality. AIRNow. 2010. Air Quality Index (AQI)—A guide to air quality and your health. http://www.airnow.gov/index.cfm?action=aqibasics.aqi (accessed December 14, 2010). American Academy of Pediatrics. 2000. Fetal alcohol syndrome and alcohol-related neuro-developmental disorders. Pediatrics 106(2 Pt 1):358-361. American Heart Association. 2010. Heart disease and stroke statistics: 2010 update at-a-glance. Dallas, TX: American Heart Association. American Lung Association. 2010. Trends in tobacco use. http://www.lungusa.org/finding-cures/our-research/trend-reports/Tobacco-Trend-Report.pdf (accessed February 4, 2011). Anderson, L. M., C. Shinn, M. T. Fullilove, S. C. Scrimshaw, J. E. Fielding, J. Normand, and V. G. Carande-Kulis. 2003. The effectiveness of early childhood development programs: A systematic review. American Journal of Preventive Medicine 24(3):32-46. Antonovsky, A. 1967. Social class, life expectancy and overall mortality. The Milbank Memorial Fund Quarterly 45(2):31-73. Barrett, D. C., L. M. Pollack, and M. L. Tilden. 2002. Teenage sexual orientation, adult openness, and status attainment in gay males. Sociological Perspectives 45(2):163-182. Behan, D., M. Eriksen, and Y. Lin. 2005. Economic effects of environmental tobacco smoke report. Schaumberg, IL: Society of Actuaries. Bell, M. L., A. McDermott, S. L. Zeger, J. M. Samet, and F. Dominici. 2004. Ozone and short-term mortality in 95 US urban communities, 1987-2000. Journal of the American Medical Association 292(19):2372-2378. Bell, M. L., F. Dominici, and J. M. Samet. 2005. A meta-analysis of time-series studies of ozone and mortality with comparison to the national morbidity, mortality, and air pollution study. Epidemiology 16(4):436-445. Ben-Shlomo, Y., and D. Kuh. 2002. A life course approach to chronic disease epidemiology: Conceptual models, empirical challenges and interdisciplinary perspectives. International Journal of Epidemiology 31(2):285-293. Bergen, G., L. Chen, M. Warner, and L. Fingerhut. 2008. Injury in the United States: 2007 charterbook. http://www.cdc.gov/nchs/data/misc/injury2007.pdf (accessed December 17, 2010).
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