Although the health of all Americans has continued to improve over the more than two decades since the 1985 Task Force Report on Black and Minority Health was issued, racial and ethnic health disparities persist and, in some cases, are increasing. The persistence of such disparities suggests that current approaches and strategies are not producing the kinds of results needed to ensure that all Americans are able to achieve the same quality and years of healthy life, regardless of race/ethnicity, gender and other variables (as reflected in the two overarching goals of Healthy People 2010).
The mission of the HHS Office of Minority Health (OMH) is to improve the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate disparities. OMH has a unique leadership and coordination role to play within the Department and across the nation, relative to this mission. However, such a mission cannot be accomplished by OMH alone. We need the active engagement and sustained efforts of all stakeholders working together with us and each other to effect the necessary changes at every level and across all sectors over time. These stakeholders include racial and ethnic minority communities and those who serve them, other HHS and Federal entities, academic and research institutions, State and Tribal governments, faith- and community-based organizations, private industry, philanthropies and many others. We also need to examine what we are doing, identify what must be done differently and determine how best to work together - within and across our respective disciplines, areas of interest, organizational/institutional or geographic boundaries and spheres of influence - to enhance our individual and collective effectiveness and impacts.
The Strategic Framework for Improving Racial and Ethnic Minority Health and Eliminating Racial and Ethnic Health Disparities (Framework) presented here is intended to help guide, organize and coordinate the systematic planning, implementation and evaluation of efforts within OMH, HHS and across the nation to achieve better results relative to minority health improvements and health disparities reductions. The Framework reflects current knowledge and understanding of the nature and extent of health disparities, their causes or contributing factors, effective solutions and desired outcomes and impacts. It reinforces the importance of having and using science and knowledge as the basis for planning and implementing our program-, research-, or policy-oriented actions and activities. The Framework also suggests the need to adequately evaluate our efforts so that new knowledge can be used for continuous improvement. In addition, the Framework infers the need to fund our efforts accordingly, and to explore ways to enhance efficient use of programmatic and research funds as well as other resources and assets at our disposal.
Several aspects of this framework are worth highlighting:
We believe that the structure and approach outlined in the Framework offers a rational and systematic, yet broad and flexible, way of viewing and informing our efforts to achieve the OMH and, in reality, the national mission. We hope that the Framework will provide context for the actions needed by OMH and its partners across HHS and the nation to better leverage resources, establish priorities for ensuring effectiveness of programs and activities funded and conducted, enable identification and promotion of best practices and concrete solutions at all levels and serve as the foundation for a national results-oriented culture on racial and ethnic minority health improvement and the elimination of racial and ethnic health disparities.
The Challenge. - The United States is a diverse nation. According to 2000 Census data (U.S. Census Bureau, 2000), the population of the United States grew by 13 percent over the last decade, and has increased in diversity at an even greater rate. Racial and ethnic minorities are among the fastest growing of all communities in the country, and today comprise approximately 34 percent of the total U.S. population (U.S. Census Bureau, 2006a, 2). It is projected that, by 2030, 40 percent of the population will be non-White (U.S. Census Bureau, 2004) .
Data on health status point to the fact that there is significant evidence of poor health outcomes among racial/ethnic minority populations with respect to premature death and preventable disease. These poor health outcomes for racial/ethnic minorities are reflected in the pervasiveness of health disparities (Note: This paper will often use the term "health disparities" to refer to the more precise, but longer term, "disparities in health care and health status.") that exist. For example:
These health issues have been key public health concerns at the Federal level since the 1985 Secretary's Task Force Report on Black and Minority Health (HHS, 1985) under then Secretary of Health and Human Services Margaret Heckler. However, data demonstrate that these disparities remain formidable challenges today. Reports of progress on the "reducing health disparities" goal of Healthy People 2000 (HHS, 1990) showed that, in many respects, racial/ethnic minority populations have remained in relatively poor health, and continue to be underserved by the health care system. In many cases, the health gaps identified in the 1985 Task Force Report have grown (NCHS, 2001, 8). The need to address racial and ethnic minority health status and health disparities was reinforced in the two overarching goals of Healthy People 2010: to increase the quality and years of healthy life for all U.S. populations, and to eliminate health disparities, including those that affect racial and ethnic minorities (HHS, 2000a). The challenge for the U.S. is to adequately address poor racial/ethnic minority health status and persistent racial/ethnic health disparities at a time of rapidly increasing racial and ethnic diversity. Successfully meeting this challenge will promote the continued strength and vitality of the Nation.
OMH's Role and Responsibilities. - The Office of Minority Health (OMH) resides within the Office of Public Health and Science (OPHS), in the Office of the Secretary of the U.S. Department of Health and Human Services (HHS). Its creation was one of the most significant outcomes of the 1985 Task Force Report (HHS, 1985). OMH is a key player in the Federal effort to improve racial/ethnic minority health and to reduce and, ultimately, eliminate racial/ethnic disparities in health care and health status. The OMH mission is "to improve the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate disparities". (Note: Racial and ethnic minorities encompassed in OMH?s mission include Black or African Americans, Asians, Native Hawaiians or Other Pacific Islanders, American Indians and Alaska Natives and Hispanics.) This mission statement points to the two key action areas?policies and programs?through which OMH serves as the focal point within HHS for efforts to improve racial/ethnic minority health and eliminate racial/ethnic health disparities.
While OMH is the focal point within HHS for racial/ethnic minority health and health disparities efforts, it is not the only Federal agency involved in efforts to address racial/ethnic minority health and health disparities. Within HHS, a number of agencies and operating divisions engage in extensive activities to improve racial/ethnic minority health and reduce racial/ethnic health disparities. They fund a range of racial/ethnic minority health- and health disparities-related efforts, including health services to underserved (often racial/ethnic minority) communities, community-based health education and health communication campaigns and programs, biomedical, behavioral and social science research and health services and community-based prevention research. Such efforts also extend outside of HHS to other public- and private-sector organizations that have a stake in improving the health of racial/ethnic minorities and addressing racial and ethnic health disparities. In spite of these efforts, there is still much room for improvement.
Purpose of the Strategic Framework - The purpose of this strategic framework is to guide and organize the systematic planning, implementation, and evaluation of OMH and other efforts aimed at improving racial/ethnic minority health?and reducing and, ultimately, eliminating racial/ethnic health disparities. Efforts include those aimed directly at racial/ethnic minority health problems, but also those that support a "systems approach" to addressing such problems across the country. This systems approach has not been previously available in efforts targeted to racial/ethnic minority health and health disparities issues.
OMH, through the application of a strategic framework, can sharpen the focus, coordination and dissemination of its work, as well as that of its partners inside and outside of HHS. The ultimate goal, for all stakeholders, is that individual and collective efforts on behalf of racial/ethnic minority health will be more evidence-based and will use available resources effectively and efficiently. The strategic framework provides:
Approach to Developing the Strategic Framework - To maximize clarity, a logic model approach is employed for developing the strategic framework. Logic models originate from the evaluation field as a way to plan, implement and evaluate programmatic efforts, and to provide the theory or rationale, undergirding what is being done (HHS, 1999; Taylor-Powell, Jones, and Henert, 2002). Similarly, the Framework presents the rational basis for efforts related to racial/ethnic minority health and health disparities by tying together the following components typically found in logic models (Note: Numerous sources exist for information on the use of logic models to enhance program performance. Examples include, but are not limited to, the following sources identified in OMH's evaluation planning guidelines: The Centers for Disease Control and Prevention at http://www.cdc.gov/eval/resources.htm#logic%20model; the University of Wisconsin Cooperative Extention at http://www1.uwex.edu/ces/lmcourse ; and the W.K. Kellogg Foundation at http://www.wkkf.org/Pubs/Tools/Evaluation/Pub3669.pdf [PDF, 1.4MB].):
Figure 1 is a graphic depiction of the general structure of the strategic framework, which builds upon each of these five components.
Figure 1. A graphic depiction of the general structure of the strategic framework
Developing a strategic framework using a logic model development process emphasizes five steps, which correspond to each of the components in Figure 1: (1) examination of the long-term problems that OMH and others are trying to address, (2) review of the major factors known to contribute to or cause the long-term problems, (3) identification of promising, best and/or evidence-based strategies and practices known to impact the causal or contributing factors, (4) presentation of measurable outcomes and impacts that might be expected from the strategies and practices and (5) assessment of the extent to which long-term objectives and goals have been achieved.
As the components of the Framework - using this five-step logic model approach?were developed, extensive literature reviews and environmental scans were conducted to identify what is known?and not known - about the long-term problems, contributing or causal factors, effective strategies and practices to address the factors and identification and measurement of expected outcomes and impacts. As necessary, targeted reviews of the literature from fields other than public health and medicine (e.g., systems research) were also carried out to inform OMH's understanding of the content needed in the Framework. In this way, the components and subcomponents of the Framework build on existing science and knowledge.
Considerations and Limitations in Developing the Framework - The five-step process outlined above results in a strategic framework for addressing racial and ethnic minority health improvements and reducing and, ultimately, eliminating racial and ethnic health disparities. However, several points must be made regarding the task of identifying "best" or evidence-based strategies and practices:
Given these limitations and the certainty that any framework will be used within a complex, public policy and decision-making environment, this framework should be viewed as a dynamic, evolving document that provides guidelines for action rather than as a linear, predictable model for problem-solving and decision-making.
In addition, the utility of this framework does not end with the achievement of some objectives and goals. Rather, results can and should be used to inform OMH and its partners on their level of success in improving racial/ethnic minority health and tackling health disparities. Thus, any knowledge gained can be incorporated into the continuing efforts of all stakeholders. This process will help OMH, its grantees and other partners consistently monitor and adjust program and policy efforts in ways that will result in greater effectiveness, efficiency and success. The logic model approach used in the Framework and its general structure can, thus, also serve as a guide for action in a number of ways, and for a variety of public and private entities.
The Framework is presented in five sections, organized sequentially into the components presented in the graphic depiction of its general structure shown in Figure 1. Each component of the Framework, and the corresponding step toward its development, is discussed separately. The major elements within each of these sections are drawn from the literature and briefly outlined and discussed below.
Step 1: Begin with Long-Term Problems
There are two sets of long-term problems that OMH and its partners must continue to address: (1) racial and ethnic minority health problems and (2) systems issues that inhibit the ability to effectively impact racial/ethnic minority health problems. These long-term problems are depicted graphically in Figure 2.
Figure 2. Long Term Problems.
The two racial/ethnic minority health issues?health status and health disparities?parallel and link to the two principal goals of Healthy People 2010 . (HHS, 2000b) Thus, success in addressing racial/ethnic minority health issues will contribute to the achievement of the two central goals of Healthy People 2010 .
Step 2: Address Contributing Factors
Since the factors contributing to poor racial/ethnic minority health?and to racial/ethnic health disparities?are many and complex, they have been organized into three categories or levels : individual-level factors, environmental-/community-level factors and systems-level factors.
Figure 3. Contributing factors.
These three levels, or sets, of factors interact to form the context for considering health outcomes in general (see Evans and Stoddart, 1990; Green and Kreuter, 1999; Green, Potvin, and Richard, 1996), including those specific to racial/ethnic minority health improvement and health disparities reduction. A good example of an interacting factors model that is organized into levels or categories is the Determinants of Health Model in Healthy People 2010 (HHS, 2000c). In this model, key categories or factors include biology, behavior, social environment, physical environment, policies and interventions and access to quality health care. The determinants, or factors, approach to health is used herein to synthesize some of what the literature, research and expert opinion have identified as the key factors that contribute to racial/ethnic minority health problems and disparities in health status and health care. (Note: Approaches to population health that describe relationships and interactions between multiple determinants of health at the individual and environmental/community levels and how they affect health or illness are sometimes referred to as "ecological models" of health.)
Step 3: Support Effective Strategies and Practices
The contributing factors identified above form the basis for the targets to be addressed by a range of strategies and practices employed by OMH and its partners. The strategies and practices discussed in this document represent what current evidence and expert consensus suggest to be successful in impacting contributing factors. Those strategies and practices that address the contributing factors and fit into OMH's mission are emphasized. It is important to note that many of the strategies and practices may address several factors at the same time or in sequence, rather than only one factor. A number of strategies and practices are also often effectively combined with others, in more comprehensive approaches. In a number of cases, new strategies or practices need to be developed and tested, as guided by available science and practice. Figure 4 is a graphic depiction of the necessary relationship between the strategies and practices supported and the individual-, environmental-/community-, and/or systems-level factor(s) that cause or contribute to the problem(s) to be solved.
Step 4: Measure Intermediate Outcomes and Long-Term Impacts
This step identifies measurable outcomes and impacts that might be expected to take place following implementation of the indicated strategies and practices. Such outcomes and impacts relate to the contributing factors. Generally, outcomes refer to short-term results (e.g., increased awareness and knowledge about disease prevention or risk reduction) and impacts refer to long-term results (e.g., reduced morbidity or mortality). The outcomes and impacts include those for which there is actual research evidence as well as those based on expert judgment.
In many current efforts to address racial/ethnic minority health and health disparities problems, the strategies and practices have not been clearly tied to desired or intended outcomes and impacts. Nor have adequate and appropriate evaluations been performed to determine if, indeed, the strategies and practices produce meaningful results. This is a major shortcoming. It is necessary to structure future minority health and health disparity efforts so that they will be more health outcome- and impact-oriented. It is also important to determine the outcomes and impacts of systems-oriented strategies and practices on efforts to affect health outcomes and impacts. Identifying the outcomes and impacts expected from programmatic and policy-oriented minority health/health disparities efforts?as well as systems approaches to addressing minority health/health disparities issues?will inform, and be informed by, future research and evaluations. The Framework identifies and organizes a range of outcomes and impacts that might be expected, with reference to the contributing factors and the strategies and practices already discussed. These outcomes and impacts are organized into three categories, or levels, as depicted in Figure 5.
Figure 5. Outcomes and Impacts
A wide range of short-term, intermediate and longer-term outcomes and impacts are possible and desirable at the individual, environmental/community and systems levels to move OMH and other stakeholders toward long-term objectives and goals. The desired or expected results are dependent upon the kinds of strategies and practices being planned and implemented, the factors and problems to be affected, the populations being targeted and the settings in which interventions are taking place. Some examples of the general outcomes and impacts that might be produced by the strategies and practices are outlined below.
Individual-Level Outcomes and Impacts
Environmental- and Community-Level Outcomes and Impacts
Systems-Level Outcomes and Impacts
The identification of expected outcomes and impacts is an important part of the planning, implementation and evaluation processes needed in minority health- and health disparities-related efforts conducted or supported by OMH and its partners. Once desired or expected outcomes and impacts are identified, the process of determining performance measures or indicators of progress in achieving such outcomes and impacts can occur. With the identification and selection of performance measures or indicators of the expected outcomes or impacts, the effectiveness of the strategies and practices in producing the desired results can then be evaluated. Hence, the identification of outcomes and impacts within the strategic framework becomes the basis for identifying and developing performance measures as well as the kind of evaluation needed to promote an outcome or results orientation in the efforts being funded or otherwise supported by OMH and other stakeholders.
Step 5: Achieve Long-Term Objectives and Goals
An important part of the strategic framework is its focus on long-term objectives and goals, including those in Healthy People 2010. (Note: OMH encourages and supports efforts that contribute to the long-term objectives and goals specified in Healthy People 2010, especially those that are of particular relevance to racial/ethnic minority populations and systems-related priorities.) OMH, states, communities and other stakeholders can use this framework to guide the selection of problems, factors and strategies/practices that can be linked to short-term, intermediate- and long-term objectives and goals, based on identified outcomes and impacts. And, as shown in Figure 6, these objectives and goals can be set, if desired, for the individual, environment/community and/or systems level(s). With the collection of the appropriate output, outcome and impact data, stakeholder organizations can evaluate the extent to which the objectives and goals have been attained.
Figure 6. Long-Term Objectives and Goals.
To the extent that strategies and practices result directly or indirectly in impacts on the determinants of health, and achieve health outcomes, more progress will be made toward the long-term goals of improving racial/ethnic minority health and eliminating racial/ethnic health disparities. Such efforts will necessitate a systems approach and a concerted effort to build and deploy evidence-based practice in order to promote continuous improvement based on coordinated and strategic application of the most current science and knowledge and to mobilize the resources and talents of all stakeholders.
The Framework clearly identifies five steps that must be taken to ensure that strategies and practices aimed at improving racial/ethnic minority health and reducing racial/ethnic health disparities are effective. The five steps include: (1) identify the long-term problems, (2) identify the key factors that contribute to those long-term problems, (3) identify or develop strategies and practices that effectively address the contributing factors and the long-term problems, (4) identify expected outcomes and impacts and determine appropriate measures or indicators of such results, and (5) document progress in achieving agreed-upon objectives and goals. The Framework highlights many of the relationships between and among these five steps, and suggests a variety of ways in which the Framework can be used at a national, state, Tribal, regional or local level.
While health status is the ultimate measure of health disparities, the intermediate outcomes?representing key steps along the path toward greater equity in health care and health status?must be based on the kind of rationale and model presented in this document. This is a model that explicitly encompasses the full range of multiple and complex factors that contribute to poor health for many racial/ethnic minorities and high levels of racial/ethnic health disparities. This model is unique in that it includes the need for a "systems approach" to addressing racial/ethnic minority health problems (i.e., working together as an interconnected system) and the lack of systematic planning, implementation and evaluation of current efforts as a separate set of long-term problems that can have profound and persistent impacts on racial/ethnic minority health status and health disparities. Given their great importance, these systems issues must be addressed as problems in their own right, with attendant strategies and practices that are already proven or that need to be developed and rigorously evaluated. Improvements in systems that have population-wide scope can accelerate progress.
The strategic framework is simply structured, and its structure permits flexibility in its application by various stakeholders to different situations and for different purposes. First and foremost, the Framework can be used by OMH, other HHS entities and HHS partners to focus programmatic and policy-oriented actions that are based on existing science and knowledge about the problems and contributing factors to be addressed and about strategies and practices known to be effective in producing desired outcomes and impacts. Secondly, the Framework can also provide the basis for a protocol to systematically evaluate OMH-funded and other activities in a way that produces more consistent information on what grantees and others are actually doing to improve racial/ethnic minority health status and reduce racial/ethnic health disparities. (Note: As part of its Spring 2007 grant cycle, OMH issued its new Evaluation Planning Guidelines for Grant Applicants to strengthen evaluation within its grant programs. These guidelines were informed by the strategic framework and serve as the preliminary version of OMH?s evaluation protocol for its state-based and other funded efforts.)
In addition, through more systematic and rigorous research and evaluation, the Framework can facilitate more targeted and efficient methods for identifying and developing best or evidence-based practices, and can strengthen the justification for directing resources toward such efforts. Any effort to identify best practices, however, requires a set of criteria by which to make that judgment. The work of established, respected, scientific expert bodies within and outside of HHS?such as, the U.S. Preventive Services Task Force, the Task Force on Community Preventive Services, and the British-based Cochrane Collaboration?can inform this process. Both the Guide to Clinical Preventive Services (U.S. Preventive Services Task Force) and the Guide to Community Preventive Services (Task Force on Community Preventive Services) provide examples of how expert opinion?used as the basis for some strategies and practices where scientific evidence of their effectiveness is not adequate?and empirical evidence can be reconciled.
Thus, the Framework can promote use of existing science and knowledge while concurrently fostering the development of new evidence of effective strategies and practices for continuous improvement.
The Framework presented in this document is intended to help OMH, its partners and other stakeholders to use a more systems-oriented and strategic approach, based on existing science and knowledge, to attack the problems related to racial/ethnic minority health and health disparities. In the short run, this framework is being used by OMH to guide the development of a protocol for the evaluation of activities being funded in the states and elsewhere to improve racial/ethnic minority health and reduce racial/ethnic health disparities. In the longer run, this strategic framework can help in multiple ways:
Improving the health of racial and ethnic minorities and reducing and, ultimately, eliminating the burden of health disparities will require a multi-faceted process sustained over many years. This process must be guided by systems-oriented, strategic and systematic approaches.[D]
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