PODCAST: Healthy People Initiative

April 9, 2021


HOST:  David Huang is the chief of the health promotion statistics branch at NCHS, and serves as the center’s primary statistical advisor on the Healthy People initiative. Healthy People for decades now has been identifying science-based objectives with targets to monitor progress and motivate and focus action aimed at improving the health of the nation.

David joined us to discuss the history of the program, what is going on presently, and what the future directions are.

HOST: David can you start by telling us a little bit about the history of the Healthy People program?

DAVID HUANG:  Sure.  Established in 1979, Healthy People is a science-based 10-year national initiative for improving the health of all Americans based on the latest available scientific evidence.  And at its core Healthy People provides a strategic framework for a national prevention agenda that communicates a vision for improving health and achieving health equity but at the heart of the initiative are the science-based measurable objectives with targets to be achieved by the end of each decade.  With the recent release of Healthy People 2030 last August, we’re actually now in our fifth decade of the initiative and while the Department of Health and Human Services or HHS leads the initiative through the Office of the Assistant Secretary for Health Office of Disease Prevention and Health Promotion or ODPHP, NCHS has served as the statistical advisor to the initiative since the first iteration of Healthy People.

HOST:  This program has been going on for quite a while – now how important is it in public health to have specific goals to work towards?

DAVID HUANG:  Well there are many federal health indicator projects, but the inclusion of a quantifiable target for each objective is a unique feature that distinguishes Healthy People from other broad federal prevention initiatives.  The use of targets was inspired by the “Management by Objectives” movement which emphasize setting of organizational goals and objectives and was outlined by Peter Drucker in his 1954 book called “The Practice of Management.”  Targets have been an integral part of Healthy People since its inception in 1979.  The examination of data relative to targets is considered critical to the usefulness of Healthy People as targets do communicate policy expectations and expert or evidence based recommendations to a wide range of stakeholders.  Moreover, targets offer a marker for assessing progress for each objective and for the initiative as a whole.

HOST:  How do you decide what the target is – is there any way of gauging whether it might be too lofty of a goal or too easy of a goal.  How is that process?

DAVID HUANG:  Targets are actually set by subject matter experts that are on topic area work groups and these are folks from across the Department.  Some from actually outside of HHS who provide subject matter expertise and at the end of the day these are the folks who are responsible for determining targets.  As policy constructs, NCHS does not advise one way or the other but we do provide statistical support as needed because there are certainly many cases where statistical methods are used to calculate targets.

HOST:  So there’s a lot of folks involved in this, is that correct?

DAVID HUANG:  Yes I would say probably hundreds from across the Department and certainly if you look at the stakeholder base of Healthy People, there are folks outside of government at the sub-national level, nonprofits… and really the intention is for Healthy People to reach the individual level.  In an ideal world that’s how I think the Department would like to see it.

HOST:  I wanted to then ask you what generally happens when you achieve one of these goals?  What happens to that health issue or condition as far as Healthy People goes?

DAVID HUANG:  Sure that’s definitely an interesting question and certainly one that has come up historically, particularly when targets are met or exceeded early in the decade.  In the last decade, for example, there was an objective in the Immunization and Infectious Diseases topic area.  They reached out to us in 2014 and actually asked to increase the Healthy People 2020 target for a specific objective IID 14 – that was one that tracked that percentage of adults 60 years and older who are vaccinated against zoster or shingles.  Ultimately, we decided for consistency and simplicity not to officially set new in Healthy People when targets are met, but to continue tracking and reporting data throughout the decade.  The work groups that as I mentioned manage Healthy People objectives have also been given the option to set unofficial secondary targets if desired.  Sometimes targets are adjusted for other reasons.  For example, some targets are set to be aligned with national policies, programs or laws and if there is some sort of change to that underlying policy program or law we do have the flexibility to make the same change to the corresponding Healthy People target.  Another example is if an objective baseline changes due to a change in science or data collection.  In those cases, targets are generally adjusted using the same target-setting method if possible.  And finally I’ll just note that there are certainly opportunities for further progress even after targets have been met.  So for example we continued to track the further reduction in overall cancer death rates, which is objective C1 for Healthy People 2020, even though the target for that objective was met in the year 2014.   Moreover, most population-based objectives continue to have underlying health disparities by various sociodemographic factors such as race, ethnicity or family income whether they have met their targets or not.  One of the overarching goals for Healthy People is actually to eliminate health disparities and achieve health equity.  And of course this is a topic that has been further highlighted by COVID-19.

HOST:  So you’re saying the official policy is not to make any adjustments if you’ve already met an objective.  Is that also true on the flip side – if there’s no progress being made and it might become apparent that maybe the goal is a little too ambitious?  Is it the same sort of approach on that side?

DAVID HUANG:  Yeah it is a similar approach for… consistency and simplicity, not to change targets. I think in those situations where an objective is moving in the wrong direction… these certainly highlight opportunities for further work in disease prevention and health promotion.  In addition, this could be a consideration for the target-setting for the following decade if that objective happens to be carried over from one 10-year iteration to the next.

HOST:  Our thanks to David Huang for joining us on this edition of “Statcast.”

QuickStats: Age-Adjusted Percentage of Adults Aged ≥18 Years Who Had an Influenza Vaccination in the Past 12 Months, by Sex and Race/Ethnicity

April 9, 2021


In 2019, women aged 18 years or older were more likely than were men (48.9% versus 41.7%) to have had an influenza vaccination in the past 12 months.

This pattern was found for non-Hispanic White adults (50.8% versus 42.9%), Hispanic adults (44.6% versus 35.7%), and non-Hispanic Asian adults (57.7% versus 50.7%), but there was no statistically significant difference by sex among non-Hispanic Black adults (41.1% versus 37.9%).

For both men and women, non-Hispanic Black and Hispanic adults were less likely to have had an influenza vaccination in the past 12 months than were non-Hispanic White and non-Hispanic Asian adults.

Source: National Center for Health Statistics, National Health Interview Survey, 2019. https://www.cdc.gov/nchs/nhis.htm


PODCAST: Death Certificate Data & COVID-19, Part 4

April 6, 2021



HOST:  In our final segment with Dr. Robert Anderson, we discussed the importance of listing the correct underlying cause of death on the death certificate, along with examples of when COVID-19 and other causes of death should be cited in this manner.

HOST:  There have been a lot of reported cases where somebody with COVID-19 recovers but still has a lot of symptoms and complications lingering, perhaps weeks or months, and then in a hypothetical situation if a person then eventually died even though they had recovered from COVID-19, would COVID-19 still be listed as the underlying cause of death or should that be the case?

ROBERT ANDERSON:  Generally it should be – it’s not unusual actually for somebody to get COVID-19 and develop these complications, particularly the breathing problems.  And they may linger on a ventilator for weeks.  But in the meantime, the virus has run its course but the damage is done.  And so some of these people die.  And when that happens the certifier is supposed to think to themselves,  “OK, what started the chain of events leading to death?  What started that sequence?”  And in a case like what you described, it would be the COVID-19 that started the sequence because that’s what resulted in the damage to the lungs that caused them to have to be put on a ventilator and ultimately killed them.  So regardless of whether the virus is still active, COVID-19 can be reported as the underlying cause of death.  It’s still the disease that initiated the sequence of events leading to death even if it’s not active. 

HOST:  Now would that be the case as well in a non-COVID-19 situation?  Let’s just say somebody was in a car crash and had severe after-effects, health issues and what not, and then eventually at some point down the road they died from those complications.  Would that also still be appropriate for ‘motor vehicle crash’ to be the underlying cause of death in that situation?

ROBERT ANDERSON:  Yeah this is true regardless of the cause. I mean, to give another example that is not uncommon:  Suppose a person is shot by another person but survives with serious complications from the bullet wound.  If those complications result in death, even if it occurs years later, then the underlying cause would be homicide.  And actually these sorts of cases would be investigated as a homicide as well.

HOST:  And that’s assuming that in that hypothetical, the person who shot them, it wasn’t an unintentional shooting of course.

ROBERT ANDERSON:  Well yes this would mean that they were shot on purpose, yes.  So if any disease or injury results in long term complications that eventually cause death, it’s that disease or injury that caused the fatal complications, that started the sequence this should be reported as the underlying cause.

HOST:   OK so a lot of people, in the media in particular, have been anxious to see where COVID-19 ranks as a leading cause of death.  But I’m curious about another potential issue looming down the road as far as the categorization of COVID-19, particularly with pneumonia because for years now pneumonia and influenza have been listed as one category.  And that’s due to the fact that influenza, like COVID-19, causes these complications like pneumonia that can lead to death. So what about all these deaths – I guess there’s nearly half of COVID-19 deaths where pneumonia was involved.  Is it something where we may likely see at some point a category called “COVID-19 and pneumonia” or how do you plan to sort of separate those?

ROBERT ANDERSON:  Well you know the pneumonia and influenza category has been useful to us as an indicator for influenza mortality surveillance for decades.  The emergence of COVID-19 has certainly complicated the situation from a surveillance standpoint. That said, with regard to standard cause of death tabulation and leading causes, those cases where COVID-19 is the cause of pneumonia will be reported as COVID-19 deaths.  Leading causes are based on the underlying cause and so in this case COVID-19 would be the underlying cause.  And the pneumonia and influenza category will only include those deaths where either pneumonia or influenza was the underlying cause. We couldn’t combine pneumonia with both COVID-19 and influenza, otherwise we’re going to be double counting deaths.  So I don’t see this for purposes of the leading causes being a big issue.  It does complicate things from a surveillance standpoint but for leading causes of death, those cases where COVID-19 causes pneumonia will be in the COVID-19 category and the pneumonia and influenza will include those where pneumonia was the underlying cause or influenza was the underlying cause.

HOST:  Now there are other strains of the virus out there now.  Will it be possible via the death certificate to determine which strain of COVID-19 is responsible for the deaths moving forward?

ROBERT ANDERSON:  It’s really unlikely that we’ll be able to distinguish between the strains of the virus in any meaningful way. Variants or strains of specific organisms such as viruses or bacteria are rarely reported on death certificates, so in most cases we would only have COVID-19 reported with no mention of the variant.  And even if we did get the variant in some instances, because so much of it is likely to be more generally reported without mentioning the variant, we wouldn’t really be able to say anything about how many deaths are due to B117 or South African variant or what have you.


HOST:  This week in the March 31st edition of CDC’s Morbidity and Mortality Weekly Report, NCHS published two articles which cover many of these topics discussed in our Statcasts with Dr. Robert Anderson.  The articles also documented that COVID-19 was the 3rd leading cause of death in the United States in 2020, according to provisional data.  Out of the estimated 357,000 COVID-19 death certificates with at least one other condition listed, 97% had a co-occurring diagnosis of a plausible chain of event condition, or a significant contributing condition, or both.  These findings support the accuracy of COVID-19 mortality surveillance in the U.S. using official death certificates.

NCHS was busy with other topics this week as well.  A new report on osteoporosis among older Americans age 50 and up showed that this condition has increased by more than a third, from 9.4% in 2007-2008 to 12.6% in 2017-2018.  NCHS also released the latest data on maternal mortality in the U.S., showing that nearly 100 more women died from maternal causes in 2019 than the year before.  The rate of maternal deaths in 2019 was also significantly higher than in 2018.  Finally, NCHS released a new report examining drug overdose deaths involving opioids and cocaine and other psychostimulants.  The report showed over half of all psychostimulant deaths also involved an opioid, and that 3 out of 4 cocaine deaths involved an opioid as well. 

Co-involvement of Opioids in Drug Overdose Deaths Involving Cocaine and Psychostimulants

April 2, 2021

DB406_Cover1New NCHS report provides additional information on drug overdose deaths involving cocaine and other psychostimulants (drugs such as methamphetamine, amphetamine, and methylphenidate) by examining the concurrent involvement of opioids. Trends from 2009 through 2019 and differences by census region in 2019 are presented.


  • From 2009 through 2019, the rate of overdose deaths involving both cocaine and opioids increased at a faster pace than the rate of overdose deaths with cocaine but no opioids.
  • In 2019, 76% of overdose deaths involving cocaine also involved an opioid; the percentage varied by region, from 83% in the Northeast to 63% in the West.
  • From 2009 through 2016, the rate of overdose deaths involving psychostimulants but no opioids was higher than the rate for deaths involving both drugs; from 2017 through 2019, the pattern reversed with a higher rate for deaths involving both psychostimulants and opioids.
  • In 2019, 54% of overdose deaths involving psychostimulants also involved an opioid; the percentage varied by region, from 80% in the Northeast to 44% in the West.

QuickStats: Percentage of Adults with Fair or Poor Health, by Home Ownership Status and Age Group — National Health Interview Survey, United States, 2019

April 2, 2021


In 2019, 18.0% of renters assessed their health as fair or poor, compared with 13.3% of homeowners.

For each age group, renters were more likely than homeowners to report fair or poor health: 9.0% versus 6.0% among adults aged 18–39 years, 26.6% versus 13.2% among those aged 40–64 years, and 37.1% versus 21.6% among those aged 65 years or older.

For both renters and homeowners, the percentage of adults with fair or poor health increased with increasing age.

Source: National Health Interview Survey, 2019. https://www.cdc.gov/nchs/nhis.htm


Maternal Mortality Rates in the United States, 2019

April 1, 2021

A new NCHS report presents maternal mortality rates for 2019 based on data from the National Vital Statistics System. A maternal death is defined by the World Health Organization as, “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Maternal mortality rates, which are the number of maternal deaths per 100,000 live births, are shown in this report by age group and race and Hispanic origin.