Assignment: Analyzing Changing Data and Definitions

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Assignment: Analyzing Changing Data and Definitions

Data collection and dissemination may present challenges to those working in the field. However, knowledge derived from its analysis and interpretation will provide the basis for crucial events at the management level, such as planning and program evaluation, policy development and advancement, and the overall advancement of the public health agenda at every level.

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For this Assignment, you will analyze how public health data and definitions have changed over the past decade, and you will evaluate the consistency and reliability of this data. Assignment: Analyzing Changing Data and Definitions

To prepare for Assignment: Analyzing Changing Data and Definitions:

  • Review the article: Why Do Americans Have Shorter Life Expectancy and Worse Health Than Do People in Other High-Income Countries? By Mauricio Avendano and Ichiro Kawachi (2014) at

By Day 7 of Assignment: Analyzing Changing Data and Definitions

Submit a 2- to 3-page analysis and your critique of the paper (not including title page, references, or tables). Include the following:

  • What data sources were used in this study?
  • Did the authors use secondary data or collected primary data?
  • What variables (dependent, independent, and covariates) were included?
  • What specific trend is being examined?
  • Did the authors find any specific trend? and if yes, what you can say about the future of this condition based on their trend analysis?
  • Define validity and reliability and explain if you have any concern about the reliability and validity of data used in this study. Assignment: Analyzing Changing Data and Definitions

Support your suggestions with additional scholarly resources. Use APA formatting for your paper and to cite your resources. Assignment: Analyzing Changing Data and Definitions

NIH Public Access Author Manuscript Annu Rev Public Health. Author manuscript; available in PMC 2015 January 09. NIH-PA Author Manuscript Published in final edited form as: Annu Rev Public Health. 2014 ; 35: 307–325. doi:10.1146/annurev-publhealth-032013-182411. Why do Americans have shorter life expectancy and worse health than people in other high-income countries? Mauricio Avendano1,2 and Ichiro Kawachi2 Mauricio Avendano: [email protected]; Ichiro Kawachi: [email protected] 1London School of Economics and Political Science, Department of Social Policy, LSE Health and Social Care, London, United Kingdom 2Harvard School of Public Health, Department of Social and Behavioral Sciences, Boston, USA Abstract NIH-PA Author Manuscript Americans lead shorter and less healthy lives than people in other high-income countries. We review the evidence and explanations for these variations in longevity and health. Our overview suggests that the US health disadvantage applies to multiple mortality and morbidity outcomes. The American health disadvantage begins at birth and extends across the life-course, and it is particularly marked for American women and for regions in the US South and Midwest. Proposed explanations include differences in health care, individual behaviors, socioeconomic inequalities, and the physical and built environment. While these factors may contribute to poorer health in America, a focus on proximal causes fails to adequately account for the ubiquity of the US health disadvantage across the life-course. We discuss the role of specific public policies and conclude that while multiple causes are implicated, crucial differences in social policy might underlie an important part of the US health disadvantage. Keywords United States; mortality; morbidity; Internationality; public policy NIH-PA Author Manuscript Introduction During the last several decades, life expectancy gains in the US have not kept pace with gains in other high-income countries. In 2012, life expectancy in the US ranked 32 worldwide, below most other industrialized nations. Recent reports(5, 10, 12, 60, 64–66, 94) suggest that Americans also experience higher rates of disease, injury and health-damaging behaviors than men and women in other high-income countries. Initial reports noted a US health disadvantage for ages 50 and above(5, 10, 12, 94), but recent reports suggest that American men and women from all ages up to 75 have worse health and higher mortality Address for correspondence: Mauricio Avendano, Cowdray House, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, Tel.: +44 20 7955 7203, [email protected] Disclosure statement The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review Avendano and Kawachi Page 2 NIH-PA Author Manuscript compared to their counterparts in 13 other wealthy nations in Western Europe, Japan, Australia and Canada(38, 60, 66). Life expectancy among European countries has also diverged and converged at several points, partly coinciding with major wars and economic hardship episodes in European history(57). In contrast, the US health disadvantage emerged during the second half of the 20th century and has steadily grown, which is remarkable given that this coincided with a period of unprecedented economic growth and stability in the US. This raises questions about specific aspects of post-war America which may be responsible for the US health disadvantage. In this paper, we review current evidence and theories for the US lag in health and life expectancy. After characterizing the US health disadvantage, we critically discuss common explanations in light of recent studies. Proposed theories so far provide a partial account, falling short of explaining why the US health disadvantage is pervasive across the lifecourse. We discuss alternative hypotheses and propose a programme of future research on the role of public policies. The US Health disadvantage NIH-PA Author Manuscript Earlier reports have summarized differences in health and life expectancy between the US and other high-income countries (13, 64–66). This section draws on this literature to illustrate four key features of the US health disadvantage: First, Americans have both higher mortality and morbidity than men and women in other high-income countries. Second, the US health disadvantage begins at birth and extends across the life-course. Third, the lag in US life expectancy is particularly large for American women. Finally, the US health disadvantage is most pronounced for the Midwest and Southeast regions of the US. Mortality and Life expectancy NIH-PA Author Manuscript Figure 1 shows that the last 50 years have witness remarkable gains in life expectancy in the US and 16 other country members of the Organization for Economic Cooperation and Development (OECD). However, improvements have occurred at different pace across nations(39, 64–66, 70). Between 1960 and 2008, total gains in life expectancy at birth ranged from 15.9 years in Japan to only 6.6 years in Denmark among women; and from 15.1 years in Portugal to 6.1 years in Denmark among men. US gains in life expectancy (7.5 years for women and 9 years for men) have been substantial but only about half of those in the best performing country. Next to the US, Denmark, the Netherlands and Norway have had comparatively modest gains in life expectancy, while women in Japan and Southern Europe (Portugal, Spain and Italy) have enjoyed the largest gains. As a result, in 2008, the US had the shortest life expectancy for both women (80.6) and men (75.6), while life expectancy was longest for Japan (86.1) among women and for Switzerland (79.8) among men. Cross-national variations in life expectancy at ages 40, 60 and 80 years are smaller than differences in life expectancy at birth (Supplemental Figure 1, see the Supplemental Material link in the online version of this article or at, suggesting that excess deaths before age 40 substantially contribute to life expectancy variations between the US and other countries. Nevertheless, with the exception of Annu Rev Public Health. Author manuscript; available in PMC 2015 January 09. Avendano and Kawachi Page 3 NIH-PA Author Manuscript Denmark, female life expectancy at ages 40 and 60 is lowest in the US compared to any other high-income country. Among men, life expectancy at ages 40 and 60 is similar or better in the US than in Portugal, Denmark and Finland, but shorter than in other highincome countries. Beyond age 80, life expectancy in the US is around average or better than in other high-income countries(39, 58). The fact that mortality at relatively young ages accounts for much of the US life expectancy disadvantage was highlighted in a recent analysis examining mortality under age 50 across countries(38, 66). Results from this study indicate that mortality differences below age 50 account for two thirds of the gap in life expectancy at birth between men in the US and an average of 17 other OECD countries, and 40% of this difference among women. These findings underscore the point that the US life expectancy disadvantage originates at early age and extends across the life-course. Causes of death NIH-PA Author Manuscript Age-standardized rates of mortality from selected causes occurring disproportionately at young and middle-age are presented in Figure 2 for women and in Supplemental Figure 2 (see the Supplemental Material link in the online version of this article or at http:// for men. Mortality rates from infectious diseases; complications of pregnancy, childbirth and the puerperium; and conditions originating in the perinatal period are higher in the US than in nearly all other OECD countries. Differences in some causes emerged around 1980; for example, the gap in transport accidents and accidental poisoning became stark in recent decades due to larger declines in other countries paired with increasing or stagnant trends in the US. In contrast, homicide mortality has consistently been higher in the US for several decades, which is consistent with prior evidence of substantially higher US rates of fire-arm related deaths (46). Recent evidence indicates that the major causes of death contributing to years of life lost below age 50 between the US and an average of 17 other OECD countries among women were non-communicable diseases, perinatal conditions, transport injuries and non-transport injuries(38, 66). Among men, homicide mortality was the largest contributor, followed by transport injuries, non-transport injuries and perinatal conditions(38, 66). NIH-PA Author Manuscript The contrast between the US and other high-income countries is less stark for mortality from non-communicable diseases that disproportionately affect older populations (Figure 3 for women and Supplemental Figure 3 for men, see the Supplemental Material link in the online version of this article or at However, mortality from ischemic heart disease (IHD), diabetes, nervous system diseases, and respiratory diseases (women only) is higher in the US than it is most other high-income countries(30, 38). Stroke mortality is lower in the US, although larger declines in other countries have led to a smaller US advantage in recent years(30). While mortality from these causes is driven by mortality at older ages, a recent study concluded that mortality from non-communicable diseases also contribute to excess premature mortality, explaining 29% of years of life lost below age 50 in the US compared to other OECD countries among women, and 18% among men(38). US cancer mortality is relatively low for males and around average for females. Annu Rev Public Health. Author manuscript; available in PMC 2015 January 09. Avendano and Kawachi Page 4 Differences in health and morbidity NIH-PA Author Manuscript The US health disadvantage is not limited to mortality but extends to many other non-fatal health outcomes beginning at birth and extending across youth, mid-life and old age(5, 7, 10, 32, 65, 66). Supplemental Figure 4 (see the Supplemental Material link in the online version of this article or at provides an example for selected morbidity outcomes. Compared to most other countries, Americans have higher prevalence of low birth weight, traffic injuries and HIV incidence. Paradoxically, Americans are more likely to rate their own health as good than men and women in other high-income countries, but this pattern appears to be driven by cross-national differences in the style of reporting(12, 19, 43). A recent review shows that Americans have also higher prevalence of preterm births and poor maternal health; adolescent pregnancy and sexually transmitted infections; and overweight, obesity and diabetes during childhood and mid-age(66). NIH-PA Author Manuscript Figure 4 shows that older Americans report a higher prevalence of heart disease, stroke, hypertension, diabetes, obesity, lung disease and limitations with basic instrumental activities of daily living (IADL) than their European counterparts at ages 50 and above. Similar patterns have been reported for ages 50–74(5, 10, 12, 19, 94). While US adults are also more likely to report a cancer diagnosis, this is likely to reflect more aggressive screening and possibly better cancer survival rates in the US (5, 10, 18, 19, 29, 78, 81). Differences between the US and Europe are also evident for biologically assessed outcomes such as blood pressure, blood cholesterol, fasting glucose levels and C-reactive protein(10, 19, 60). Some Americans are at greater health disadvantage In a series of studies, Murray and colleagues sub-divided the US into eight race-county combinations, referred to as the ‘Eight Americas’, and found large differences in life expectancy between these groups(62, 63). For example, life expectancy for black males living in high-risk urban environments is 21 years lower than life expectancy for female Asian Americans. For young and middle-aged males and females, mortality in the disadvantaged Americas is up to two times worse than that in the worst OECD country(62, 63). Disparities across US regions have grown since the 1980’s, a factor that has contributed to the overall US lag in life expectancy(47, 99). NIH-PA Author Manuscript Supplemental Figure 5 (see the Supplemental Material link in the online version of this article or at shows that American women in the five census divisions located in the south and Midwest regions have higher mortality than women in most other OECD countries, but even the best US divisions, the US Pacific and New England, have higher mortality than 11 other OECD countries. Earlier reports indicate that even in the healthiest US regions, female life expectancy lags behind that in the least healthy regions of countries such as Japan and France(99). Among men, most divisions in the south and Midwest perform poorly compared to most other OECD countries, while the Pacific and New England divisions have relatively low mortality. Both men and women in the East South Central US divisions have the highest rates. Annu Rev Public Health. Author manuscript; available in PMC 2015 January 09. Avendano and Kawachi Page 5 Explaining the US Health Disadvantage NIH-PA Author Manuscript Table 1 presents an overview of proposed explanations for the US health disadvantage, some of which have been empirically examined(64–66). The evidence reviewed here and elsewhere(13, 64–66) suggests that multiple factors are likely to be responsible for poorer health in the US compared to other high-income countries. In this section, we critically discuss the rationale and evidence for each of these explanations. Medical care and public health systems NIH-PA Author Manuscript The US spends more on healthcare than any other OECD country(70), yet medical care is often proposed as an explanation for the US health disadvantage (13, 64–66). A recent report reviewed evidence of differences in medical care and public health systems; the quality of health care; access to health care services and medical care; timing of care; and the prevalence of medical errors, among others(66). These and other comparisons provide a mixed picture and do not systematically point towards worst quality of care in the US compared to other OECD countries(66, 78, 101). Although whether insurance coverage is causally linked to health status has been debated(83), the lack of universal coverage may be an exacerbating factor (66). Nonetheless, both insured and uninsured Americans experience poorer health than their European counterparts, suggesting that health insurance might not be the only explanation(10, 66). Overall, health care provides at best a partial explanation. For example, excess deaths from violent causes (homicides, suicides, accidents) are hardly due to lack of health care; indeed, if it were not for advances in emergency medical care, it is estimated that thousands of more homicides would be recorded in the United States each year(34). In addition, US survival rates for several chronic conditions contributing to the US health disadvantage, such as heart disease, ischemic stroke and cancer, might be better in the US than in other high-income countries, suggesting that care for these conditions might not be worse in the US than in other OECD countries(18, 29, 66, 78). Macinko, Starfield and Shi(52) have linked the weaker primary health care system in the US to higher premature mortality(52). Nevertheless, regardless of cross-national differences in access to quality medical care, the fact remains that the overwhelming contributors to the incidence of disease (e.g. poor health behaviors) operate largely outside the influence of medical care. NIH-PA Author Manuscript Individual behaviors Differences in tobacco use, diet, physical inactivity, obesity, alcohol and other drug use, sexual practices and harmful behavior have been proposed as potential explanations of the US health disadvantage (Table 1). A recent report released by the National Academy of Sciences (NAS) concluded that smoking was likely the most important factor explaining the lag in US life expectancy at older age, particularly among women(64, 65). While the US enjoys currently lower smoking prevalence than most other high-income countries, the smoking epidemic started earlier and reached a higher pick in the US than in other countries, particularly among women(20, 64, 65, 77). Due to the long lag between smoking and lung cancer, current mortality reflects smoking trends two to three decades earlier. A recent study concluded that smoking explained two fifths of the difference in male life expectancy Annu Rev Public Health. Author manuscript; available in PMC 2015 January 09. Avendano and Kawachi Page 6 between the US and other high-income countries, and over three quarters of the difference in female life expectancy(65, 79). NIH-PA Author Manuscript Assessing the role of other individual behaviors has proved challenging given limited comparable data on risk factors across decades and countries. Yet, data suggest that the US has one of the highest total caloric intake and the highest sugar intake among all OECD countries(66, 71). The US also ranks high in total fat intake and total protein intake, while vegetable and fruit consumption in the US is similar to that in several other OECD countries(71). A poor diet, in combination with relatively low levels of physical activity(33, 91), may explain the high US obesity rates. Recent estimates based on macro-level data suggest that obesity might explain as much as two thirds of the US shortfall in male life expectancy and two fifths of the US female life expectancy disadvantage(80). However, this contrasts with another report showing that increasing trends in obesity are not specific to the US and might not explain current differences in life expectancy(2). In support of this view, cohort studies suggest that even after adjusting for obesity and other risk factors, differences in morbidity across countries remain(4, 5, 10, 60). NIH-PA Author Manuscript While it is likely that smoking and other unhealthy behaviors contribute to the poorer health of Americans, smoking does not explain why Americans have poorer health and worse trends in mortality below age 50(6, 38, 66). It is unlikely that parental smoking alone could account for the higher rate of infant mortality, poorer childbirth outcomes, injuries and homicide in the US compared to other high-income countries. Since mortality below age 50 from these and other causes explains two thirds of the difference in life expectancy at birth between the US and other countries among men, and two fifths among women(38, 66), smoking is at best only one among several factors explaining the US health disadvantage. While understanding the contribution of individual behaviors is crucial, an approach that focuses solely on behavioral differences is impoverished by its focus on “proximal” individual choices. The earlier adoption of smoking among US females, for example, may reflect features of the US environment that encouraged American women to smoke more than women in other countries. The fact that Americans behave poorly only raises the follow-up question of why Americans more often than adults in other countries make behavioral choices that are detrimental to their health. NIH-PA Author Manuscript Social and demographic explanations The US is characterized by pronounced racial, ethnic and socioeconomic disparities in health, which may contribute to the overall US health disadvantage. For example, although life expectancy for the United Sta … Assignment: Analyzing Changing Data and Definitions

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