Impact of COVID-19 Pandemic on Health Behaviors and Outcomes by Age Group and Race Ethnicity: Results From Behavioral Risk Factor Surveillance System Data

This study aimed to examine changes in health behaviors and outcomes during early-pandemic (2020) vs pre-pandemic (2019) years by age groups and race/ethnicity. Multivariable logistic regressions were conducted using Behavioral Risk Factor Surveillance System datasets from 2019 (n = 418 268) and 2020 (n = 401 958). All participants reported less likelihood to exercise (aOR, .78; 95% CI: .73-.83) and have poor physical health (aOR, .91; 95% CI: .86-.98) but more likelihood to have excellent general health (aOR, 1.33; 1.17-1.53) during 2020 vs 2019. Compared to 2019, during 2020 (i) Blacks were more likely to exercise (aOR, 1.24; 95% CI: 1.02-1.51) and have excellent general health (aOR, 1.69; 95% CI: 1.13-2.54); (ii) Hispanics were less likely to exercise (aOR, .80; 95% CI: .74-.88), but more likely to have excellent general health (aOR, 2.44; 95% CI: 1.79-3.33) and mental health (aOR, 1.41; 95% CI: 1.15-1.72); and (iii) Whites were less likely to exercise (aOR, .58; 95% CI: .50-.67) and have good physical health (aOR, 0.89; 95% CI: .82-.95). All age groups, except 18-24 years, were less likely to exercise by 18%-39% during 2020 vs 2019. Furthermore, the 55-64 years age-group was 36% more likely to report excellent general health but 14% less likely to have good physical health. Identifying the most vulnerable racial/ethnic and age groups is pivotal to prioritizing public health resources and interventions to mitigate the impact of health crises.

Engagement with Preventive Health Behaviors and Safe Firearm Storage Practices Using the 2017 Behavioral Risk Factor Surveillance System

PURPOSE

"Behavioral bundling" is a theory that explains how some health behaviors reinforce one another. This study aims to investigate the relationship between preventive health behaviors (PHBs) and safe firearm storage.

DESIGN

This study used a cross-sectional design using 2017 Behavioral Risk Factor Surveillance Survey data.

SETTING

Survey participants resided in California, Idaho, Kansas, Oregon, Texas, and Utah.

SUBJECTS

There were 12,817 people living in households with a firearm included in this study.

MEASURES

We classified individuals' engagement in 5 PHBs: cholesterol screening, influenza immunization, physical activity, primary care, and seatbelt use. We defined safe firearm storage as storing a firearm unloaded, or loaded but locked.

ANALYSIS

Using Poisson regression models, we calculated adjusted prevalence ratios (aPRs) to estimate the association between engagement in the five PHBs with safe firearm storage.

RESULTS

Most firearm owners reported safe firearm storage (80.3%). The prevalence of safe firearm storage was 3% higher for each additional PHB engaged in (aPR = 1.03 [1.01, 1.05]). There was a higher prevalence of safe firearm storage among those who always wore a seatbelt while driving or riding in a car compared to those who did not (aPR = 1.12 [1.05, 1.18]).

CONCLUSION

This study found preliminary evidence to suggest that engagement in seatbelt usage may be bundled with safe firearm storage, though we are not able to determine causality.

Role of Insulin Use and Social Determinants of Health on Non-melanoma Skin Cancer: Results From the Behavioral Risk Factor Surveillance System

BACKGROUND

Non-melanoma skin cancer (NMSC) is a frequent type of malignancy with a steadily increasing incidence rate worldwide. Although NMSC was shown to be associated with diabetes, no studies have addressed the extent to which insulin use influences the risk of NMSC in light of social determinants of health (SDOH). We conducted a quantitative study that examined the interplay between insulin use, SDOH, additional covariates, and NMSC among individuals with diabetes.

METHODS

We based our analysis on the 2020 Behavioral Risk Factor Surveillance System (BRFSS), a national survey conducted yearly in the US. We performed weighted chi-squared test, logistic regression, and survival analyses on 8685 eligible participants with diabetes enrolled in the BRFSS.

RESULTS

Kaplan Meier survival curves showed higher probability of NMSC event-free survival for participants with diabetes using insulin compared to participants with diabetes not using insulin (log-rank test P < .001). Significant associations were detected between insulin use and reduced odds of NMSC (OR .56; 95% CI: .38-.82), and decreased hazard (HR .36; 95% CI: .21-.62), along with indices of SDOH.

CONCLUSIONS

Our findings suggest that socioeconomic differences related to the healthcare system and behavioral patterns are linked to discrepancies in the use of insulin and the development of NMSC.

Health Care Access and Cardiovascular Risk Factor Management Among Working-Age US Adults During the Pandemic

BACKGROUND

Low-income working-age US adults disproportionately experienced health care disruptions at the onset of the coronavirus disease 2019 pandemic. Little is known about how health care access and cardiovascular risk factor management changed as the pandemic went on or if patterns differed by state Medicaid expansion status.

METHODS

Cross-sectional data from the behavioral risk factor surveillance system were used to compare self-reported measures of health care access and cardiovascular risk factor management among US adults aged 18 to 64 years in 2021 (pandemic) to 2019 (prepandemic) using multivariable Poisson regression models. We assessed differential changes between low-income (<138% federal poverty level) and high-income (>400% federal poverty level) working-age adults by including an interaction term for income group and year. We then evaluated changes among low-income adults in Medicaid expansion versus nonexpansion states using a similar approach.

RESULTS

The unweighted study population included 80 767 low-income and 184 136 high-income adults. Low-income adults experienced improvements in insurance coverage (relative risk [RR], 1.10 [95% CI, 1.08-1.12]), access to a provider (RR, 1.12 [95% CI, 1.09-1.14]), and ability to afford care (RR, 1.07 [95% CI, 1.05-1.09]) in 2021 compared with 2019. While these measures also improved for high-income adults, gains in coverage and ability to afford care were more pronounced among low-income adults. However, routine visits (RR, 0.96 [95% CI, 0.94-0.98]) and cholesterol testing (RR, 0.93 [95% CI, 0.91-0.96]) decreased for low-income adults, while diabetes screening (RR, 1.01 [95% CI, 0.95-1.08]) remained stable. Treatment for hypertension (RR, 1.05 [95% CI, 1.02-1.08]) increased, and diabetes-focused visits and insulin use remained stable. These patterns were similar for high-income adults. Across most outcomes, there were no differential changes between low-income adults residing in Medicaid expansion versus nonexpansion states.

CONCLUSIONS

In this national study of working-age adults in the United States, measures of health care access improved for low- and high-income adults in 2021. However, routine outpatient visits and cardiovascular risk factor screening did not return to prepandemic levels, while risk factor treatment remained stable. As many coronavirus disease-era safety net policies come to an end, targeted strategies are needed to protect health care access and improve cardiovascular risk factor screening for working-age adults.

Trends in colorectal cancer screening in the United States, 2012 to 2020

OBJECTIVES

Despite recommendations to increase the uptake of colorectal cancer (CRC) screening, trends in CRC screening vary with sociodemographic status. We aimed to evaluate trends in CRC screening in the US population and subpopulations.

METHODS

A total of 1,082,924 participants aged 50 to 75 from five cycles (2012, 2014, 2016, 2018, and 2020) of the Behavioral Risk Factor Surveillance System were involved. Multivariable logistic regression models were performed to evaluate linear trends in CRC screening utilization from 2012 to 2018. Rao-Scott chi-square tests were used to assess the differences in CRC screening utilization between 2018 and 2020.

RESULTS

The estimated percentage reporting up-to-date with CRC screening increased significantly (P for trend <0.001), from 62.8% (95% CI, 62.4%-63.2%) in 2012 to 66.7% (95% CI, 66.3%-67.2%) in 2018 and 70.4% (95% CI, 69.8%-71.0%) in 2020, in accordance with 2008 US Preventive Services Task Force recommendations. Trends followed similar patterns in most subgroups, although with different magnitudes in several subgroups, primarily those underweight showed a stable percentage over time (P for trend  =  0.170). In 2020, 72.4% of participants reported they were up to date with CRC screening, including the utilization of stool DNA tests and virtual colonoscopy. Colonoscopy was the most commonly used test in 2020 (64.5%), followed by FOBT (12.6%), stool DNA test (5.8%), sigmoidoscopy (3.8%), and virtual colonoscopy (2.7%).

CONCLUSIONS

In this nationally representative survey of the US population from 2012 through 2020, the percentage reporting up to date with CRC screening has increased, but not equally among all subgroups.

Social and racial inequalities in diabetes and cancer in the United States

Background

Cancer and diabetes are among the leading causes of morbidity and mortality worldwide. Several studies have reported diabetes as a risk factor for developing cancer, a relationship that may be explained by associated factors shared with both diseases such as age, sex, body weight, smoking, and alcohol consumption. Social factors referred to as social determinants of health (SDOH) were shown to be associated with the risk of developing cancer and diabetes. Despite that diabetes and social factors were identified as significant determinants of cancer, no studies examined their combined effect on the risk of developing cancer. In this study, we aim at filling this gap in the literature by triangulating the association between diabetes, indices of SDOH, and the risk of developing cancer.

Methods

We have conducted a quantitative study using data from the Behavioral Risk Factor Surveillance System (BRFSS), whereby information was collected nationally from residents in the United States (US) with respect to their health-related risk behaviors, chronic health conditions, and the use of preventive services. Data analysis using weighted regressions was conducted on 389,158 study participants.

Results

Our findings indicated that diabetes is a risk factor that increases the likelihood of cancer by 13% (OR 1.13; 95%CI: 1.05-1.21). People of White race had higher odds for cancer compared to African Americans (OR 0.44; 95%CI: 0.39-0.49), Asians (OR 0.27; 95%CI: 0.20-0.38), and other races (OR 0.56; 95%CI: 0.46-0.69). The indices of SDOH that were positively associated with having cancer encompassed unemployment (OR 1.78; 95%CI: 1.59-1.99), retirement (OR 1.54; 95%CI: 1.43-1.67), higher income levels with ORs ranging between 1.16-1.38, college education (OR 1.10; 95%CI: 1.02-1.18), college graduates (OR 1.31; 95%CI: 1.21-1.40), and healthcare coverage (OR 1.44; 95%CI: 1.22-1.71). On the other hand, the indices of SDOH that were protective against having cancer were comprised of renting a home (OR 0.86; 95%CI: 0.79-0.93) and never married (OR 0.73; 95%CI: 0.65-0.81).

Conclusion

This study offers a novel social dimension for the association between diabetes and cancer that could guide setting strategies for addressing social inequities in disease prevention and access to healthcare.

Small-area models to assess the geographical distribution of tobacco consumption by sex and age in Spain

INTRODUCTION

Complete and accurate data on smoking prevalence at a local level would enable health authorities to plan context-dependent smoking interventions. However, national health surveys do not generally provide direct estimates of smoking prevalence by sex and age groups at the subnational level. This study uses a small-area model-based methodology to obtain precise estimations of smoking prevalence by sex, age group and region, from a population-based survey.

METHODS

The areas targeted for analysis consisted of 180 groups based on a combination of sex, age group (15-34, 35-54, 55-64, 65-74, and ≥75 years), and Autonomous Region. Data on tobacco use came from the 2017 Spanish National Health Survey (2017 SNHS). In each of the 180 groups, we estimated the prevalence of smokers (S), ex-smokers (ExS) and never smokers (NS), as well as their coefficients of variation (CV), using a weighted ratio estimator (direct estimator) and a multinomial logistic model with random area effects.

RESULTS

When smoking prevalence was estimated using the small-area model, the precision of direct estimates improved; the CV of S and ExS decreased on average by 26%, and those of NS by 25%. The range of S prevalence was 11-46% in men and 4-37% in women, excluding the group aged ≥75 years.

CONCLUSIONS

This study proposes a methodology for obtaining reliable estimates of smoking prevalence in groups or areas not covered in the survey design. The model applied is a good alternative for enhancing the precision of estimates at a detailed level, at a much lower cost than that involved in conducting large-scale surveys. This method could be easily integrated into routine data processing of population health surveys. Having such estimates directly after completing a health survey would help characterize the tobacco epidemic and/or any other risk factor more precisely.

Prevalence of Self-Reported Kidney Disease in Older Adults by Sexual Orientation: Behavioral Risk Factor Surveillance System Analysis (2014-2019)

SIGNIFICANCE STATEMENT

Studies discusses CKD disparities by age, race and ethnicity, and socioeconomics. However, despite well-documented disparities in CKD risk factors in LGBT+ adults, limited literature addresses CKD prevalence in this population. This analysis uses Behavioral Risk Factor Surveillance System (2014-2019) data to compare self-reported kidney disease prevalence in LGBT+ older adults (older than 50 years) with their heterosexual peers. Our findings indicate that LGBT+ older adults have higher rates of self-reported kidney disease and a higher incidence of CKD risks including smoking, activity limitations, adverse health outcomes, and limited access to health care, housing, and employment. These results support increasing access to screening for CKD risk factors, providing culturally responsive health care, and addressing societal drivers of vulnerability in older LGBT+ adults.

BACKGROUND

Existing research documents disparities in CKD by age, race and ethnicity, and access to health care. However, research on CKD in lesbian, gay, bisexual, and trans (LGBT+) older adults, despite their higher rates of diabetes, heart disease, smoking, and alcohol use, is limited.

METHODS

Pooled data from the Behavioral Risk Factor Surveillance System (2014-2019) for 22,114 LGBT+ adults and 748,963 heterosexuals aged 50 and older were used to estimate the prevalence of self-reported kidney disease. Logistic regressions were used to compare older adults by sexual orientation.

RESULTS

Older LGBT+ men (adjusted odds ratio=1.3; 95% confidence interval [CI], 1.09-1.54) were more likely than their heterosexual counterparts to report kidney disease, after controlling for sociodemographic factors, health behaviors, access to health care, and self-reported coronary heart disease, HIV, and diabetes; LGBT+ men and women also reported higher incidences of known risk factors for CKD. For example, both LGBT+ men (odds ratio [OR]=1.39; [95% CI], 1.26-1.54) and LGBT+ women (OR=1.39; [95% CI], 1.25-1.55) were more likely to be smokers and have a higher incidence of activity limitations, adverse health outcomes, and limited access to health care, housing, and employment.

CONCLUSION

These results support increasing access to screenings for CKD risk factors, providing preventative education and culturally responsive and affirming care, and addressing other societal drivers of vulnerability in older LGBT+ adults. The findings also support the value of interventions that address the interaction between CKD risk factors and the social marginalization that older LGBT+ adults experience.

Sex Differences in Cardiac Risk Factors in Young Adults: A Secondary Analysis and Surveillance Study

BACKGROUND

Coronary artery disease (CAD) is increasing in young adults, and greater understanding of their cardiac risk factors is essential to ensure effective prevention. Given the sex differences in CAD observed in older adults, understanding sex differences in risk factors for this younger group of adults is important. Having insight of cardiac risk factors and sex differences in the young adult population is essential to creating personalized strategies for prevention in nursing care and in this age group.

OBJECTIVES

The aims of this study were to determine the differences in CAD risk factors for young adult men and women and examine which factors are related to CAD early in life, ultimately to guide approaches for CAD prevention in primary care.

METHODS

In this secondary analysis, 125 017 community-dwelling young adults were evaluated for health behaviors considered as risk factors for CAD. The 2017 Behavior Risk Factor Surveillance System database from the Center for Disease Control was utilized. This database contains questions asked of young adults that would help with risk management for chronic diseases like CAD. Young adults in this article were defined as being between 18 and 44 years of age.

RESULTS

Men reported more cardiovascular risk factors than women and developed risk factors at an earlier age. Women had greater percentages of obesity and low activity levels. In this population, those with hypertension had the highest odds ratio for developing CAD.

CONCLUSIONS

Differences between men and women in CAD risk factors included lifestyle and other chronic conditions. Greater prevention efforts should focus on these differences in young men and women to reduce risk factors and prevent the development of CAD.

Disparate Cardiovascular Hospitalization Trends Among Young and Middle-Aged Adults Within and Across Race and Ethnicity Groups in Four States in the United States

Background Inpatient hospitalizations for cardiovascular disease (CVD) decreased nationally in the past decade. However, data are lacking on whether national declines represent trends within and across race and ethnicity populations from different US regions. Methods and Results Using State Inpatient Databases, Census Bureau and Behavioral Risk Factor Surveillance System data for Florida, Kentucky, New Jersey, and North Carolina, we identified all CVD hospitalizations and population characteristics for adults aged 18 to 64 years between January 1, 2009 and December 31, 2018. We calculated yearly CVD hospitalization rates for each state for the overall population, by sex, race, and ethnicity. We modeled yearly trends in age-adjusted CVD hospitalization rate in each state using negative binomial regression. State base populations were similar by age (mean age: 40-42 years) and sex (50%-51% female) throughout the study period. There were 314 973 and 288 843 total CVD hospitalizations among the 4 states in 2009 and 2018, respectively. Crude hospitalization rates declined in all states (age 18-44 years NJ: -33.4%; KY: -17.0%; FL: -11.9%; NC: -11.2%; age 45-64 years NJ: -29.8%; KY: -20.3%; FL: -12.2%; NC: -11.6%) over the study period. In age-adjusted models, overall hospitalization rates declined significantly in NJ -2.5%/y (95% CI, -2.9 to -2.1) and in KY -1.6%/y (-1.9 to -1.2) with no significant declining trend in FL and NC. Similar findings were present by sex. Among non-Hispanic White populations, mean yearly decline in hospitalization rate was significant in all states except FL, with the greatest declines in NJ (-3.8%/y [-4.4 to -3.2], P values for state-year interaction <0.0001). By contrast, a significant declining trend was present for non-Hispanic Black and Hispanic populations only in NJ (P values for state-year interaction <0.001). We found similar differences in trend between states in sensitivity analyses incorporating additional demographic and comorbid characteristics. Conclusions Decreases in CVD hospitalization rates in the past decade among nonelderly adults varied considerably by state and appeared largely driven by declines among non-Hispanic White populations. Overall declines did not represent divergent trends between states within non-Hispanic Black and Hispanic populations. Recognition of differences not just between but also within race and ethnicity populations should inform national and local policy initiatives aimed at reducing disparities in CVD outcomes.

Cervical cancer screening among women with comorbidities: a cross-sectional examination of disparities from the behavioral risk factor surveillance system

CONTEXT

Implementation of guideline-based Papanicolaou (Pap) smear screening, human papillomavirus (HPV) testing, and HPV vaccination has reduced cervical cancer (CC) rates up to 80%, yet prevention disparities continue to exist.

OBJECTIVES

This study aims to analyze whether CC screening rates differ among women with comorbidities-body mass index (BMI) ≥30 kg/m², diabetes mellitus, hypertension, cardiovascular disease, chronic obstructive pulmonary disease (COPD), arthritis, kidney disease, depression, or skin cancer-compared to women without these comorbidities.

METHODS

Combined 2018 and 2019 Behavioral Risk Factor Surveillance System (BRFSS) datasets were evaluated utilizing multivariate logistic regression models to determine the adjusted odds ratios (AORs) of persons having completed CC screening without comorbidities compared to those with individual diagnoses, as well as in those with multiple comorbidities (1, 2-4, 5+). Confidence intervals (CIs) were reported at 95%.

RESULTS

Among the 127,057 individuals meeting inclusion criteria, 78.3% (n = 83,242; n = 27,875,328) met CC screening guidelines. Multivariable regression showed that women who had a BMI ≥30 kg/m² were significantly less likely to have completed a CC screening (AOR: 0.90; CI: 0.83-0.97) as were those with COPD (AOR: 0.77; CI: 0.67-0.87) and kidney disease (AOR: 0.81; CI: 0.67-0.99). Conversely, women with skin cancer were significantly more likely to report CC screening (AOR: 1.22; CI: 1.05-1.43). We found no significant differences in CC screening completion rates by diagnosis of diabetes, hypertension, cardiovascular disease, arthritis, or depression nor between women lacking comorbidities compared to women with multiple comorbidities.

CONCLUSIONS

Women with BMI ≥30 kg/m², COPD, and kidney disease were less likely to complete CC screening, whereas women with skin cancer were more likely to complete CC screening. Additionally, diabetes mellitus, hypertension, cardiovascular disease, arthritis, and depression diagnoses did not significantly impact rates of CC screening. Physicians should be aware of the deviations in CC screening completion among patients with diagnoses to know when there may be an increased need for Pap tests and pelvic examinations. CC screening is critical to reduce mortality through early detection and prevention measures.

Age and Sex-Related Associations between Marital Status, Physical Activity and TV Time

Marital status mediates an association between physical activity (PA) and TV time with health outcomes. However, population-based studies have revealed that the health effect of marriage or divorce is age-dependent and differs between women and men. The study aimed to identify the age and sex-related associations between marital status with PA and TV time. We used data from Vigitel, an annual telephone survey started in 2006 in Brazil. We applied a complex sample logistic regression model to estimate the odds for PA and TV time comparing marital statuses according to age and sex subgroups, independent of obesity, hypertension, diabetes, self-assessed poor health, and smoking. Our sample included 561,837 individuals from 18 to 99 years, with a TV time > 3 h/day (prevalence = 25.2%) and PA > 150 min/week (prevalence = 35%). Later, we divided our sample in seven age groups by marital status and sex. Compared to single individuals, married men and women were less likely to watch TV more than 3 h/day in participants >30 years old. When compared to single, married participants were less likely to do more than 150 min of PA/week at younger age groups. Married women older than 40 years were more likely to do more than 150 min of PA/week than the single ones, while there were no differences among married men by age group. In conclusion, our study suggests that the investments in public policies to encourage the practice of PA and reduction of TV time could be based on the marital status, sex, and age, prioritizing less active groups.

Using a Social Determinants of Health Summary Measure to Predict General Health Status in the BRFSS

PURPOSE

This study aims to assess the relationship between social determinants of health (SDoH) burden and overall health.

DESIGN

Three years of Behavioral Risk Factor Surveillance System (BRFSS) data (2017-2019) were combined for this cross-sectional study.

SETTING

Massachusetts.

SUBJECTS

Out of a possible 21,312 respondents, 16,929 (79%) were eligible for inclusion.

MEASURES

To create the SDoH summary measure, items assessing social risk experiences including financial instability (1 item), housing instability (2 items), perceptions of neighborhood crime (1 item), and food insecurity (2 items) were summed to create a count of risk experiences. Outcome measures included self-rated general health, days of poor physical health, and days of poor mental health.

ANALYSIS

Multivariable logistic regression was used to evaluate the association between each outcome and the SDoH summary measure, adjusting for demographic confounders.

RESULTS

In adjusted analyses, respondents who reported experiencing 1, 2, 3, or 4+ SDoH had a 1.6 (95% CI: 1.3-2.0), 2.9 (95% CI: 2.3-3.7), 3.2 (95% CI: 2.4-4.3), or 5.3 (95% CI: 4.0-7.0) increased odds (respectively) of self-rated fair/poor health, compared to those who reported zero SDoH. The adjusted relationship between the SDoH summary measure and physical health and mental health was similar in magnitude and statistically significant.

CONCLUSIONS

These results demonstrate that the overall burden of risk due to SDoH is an important predictor of health.

An association between electronic nicotine delivery systems use and a history of stroke using the 2016 behavioral risk factor surveillance system

Electronic nicotine delivery systems (ENDS) are growing in use and many of the health implications with these devices remain unknown. This study aims to assess, using a survey representative of the USA general population, if an association exists between a history of ENDS use and a history of stroke.This cross-sectional study was a secondary data analysis using the 2016 behavioral risk factor surveillance system survey. The main exposure variable of the study was a self-reported history of ENDS use. The main outcome was a self-reported history of stroke. Covariates included sex, race, traditional cigarette use, smokeless tobacco use, chronic kidney disease, diabetes, myocardial infarction, and coronary artery disease. Unadjusted and adjusted logistic regression analyses were done. Adjusted odds ratios (AOR) and their corresponding 95% confidence intervals (CI) were calculated.Of the 486,303 total behavioral risk factor surveillance system survey participants, 465,594 met the inclusion criteria for this study of ENDS use and stroke. This study shows that current ENDS use was positively associated with a history of stroke. AOR of some daily ENDS use with stroke was 1.28 (95% CI: 1.02-1.61) and AOR of current daily ENDS use with stroke was 1.62 (95% CI: 1.18-2.31). The majority (55.9%) of current daily ENDS users reported former traditional cigarette smoking. Female sex, non-white ethnicity, elderly age, chronic kidney disease, coronary artery disease, diabetes, and traditional cigarette use characteristics were all also associated with increased odds of reporting a stroke.This study found a statistically significant and positive association between ENDS use and a history of stroke. Further research is warranted to investigate the reproducibility and temporality of this association. Nevertheless, this study contributes to the growing body of knowledge about the potential cardiovascular concerns related to ENDS use and the need for large cohort studies.

Factors Associated with E-Cigarette Use in U.S. Young Adult Never Smokers of Conventional Cigarettes: A Machine Learning Approach

E-cigarette use is increasing among young adult never smokers of conventional cigarettes, but the awareness of the factors associated with e-cigarette use in this population is limited. The goal of this work was to use machine learning (ML) algorithms to determine the factors associated with current e-cigarette use among US young adult never cigarette smokers. Young adult (18-34 years) never cigarette smokers from the 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) who reported current or never e-cigarette use were used for the analysis (n = 79,539). Variables associated with current e-cigarette use were selected by two ML algorithms (Boruta and Least absolute shrinkage and selection operator (LASSO)). Odds ratios were calculated to determine the association between e-cigarette use and the variables selected by the ML algorithms, after adjusting for age, gender and race/ethnicity and incorporating the BRFSS complex design. The prevalence of e-cigarette use varied across states. Factors previously reported in the literature, such as age, race/ethnicity, alcohol use, depression, as well as novel factors associated with e-cigarette use, such as disabilities, obesity, history of diabetes and history of arthritis were identified. These results can be used to generate further hypotheses for research, increase public awareness and help provide targeted e-cigarette education.

Physical Activity Guidelines Compliance and Its Relationship With Preventative Health Behaviors and Risky Health Behaviors

BACKGROUND

People who are physically active enjoy a multitude of health benefits across their lifespan compared with people who are not physically active. However, little research has sought to determine whether those who meet the physical activity (PA) guidelines also engage in other healthy behaviors. The purpose of this study was to compare healthy behaviors of people who met the PA guidelines set forth by the U.S. Department of Health and Human Services to those who did not meet the guidelines.

METHODS

This was a cross-sectional study using data from the Behavioral Risk Factor Surveillance System survey conducted in 2017. Descriptive statistical analyses were performed using chi-square tests. Odds and adjusted odds ratios were calculated using multiple logistic regressions.

RESULTS

Those who met the PA guidelines were more likely to get a flu shot, have a medical checkup, take human immunodeficiency virus tests, wear seatbelts, and binge drink more frequently, compared with those who did not meet the guidelines. This group is also less likely to be smokers and be overweight or obese in comparison to their inactive counterparts.

CONCLUSION

The positive association between PA and other healthy behaviors represents synergistic health activities, with healthy behaviors supporting others.

Factors associated with mammography use: A side-by-side comparison of results from two national surveys

BACKGROUND

Mammography use is affected by multiple factors that may change as public health interventions are implemented. We examined two nationally representative, population-based surveys to seek consensus and identify inconsistencies in factors associated with mammography use in the entirety of the US population, and by black and white subgroups.

METHODS

Self-reported mammography use in the past year was extracted for 12 639 and 169 116 women aged 40-74 years from the 2016 National Health Interview Survey (NHIS) and the 2016 Behavioral Risk Factor Surveillance System (BRFSS), respectively. We applied a random forest algorithm to identify the risk factors of mammography use and used a subset of them in multivariable survey logistic regressions to examine their associations with mammography use, reporting predictive margins and effect sizes.

RESULTS

The weighted prevalence of past year mammography use was comparable across surveys: 54.31% overall, 54.50% in white, and 61.57% in black in NHIS and 53.24% overall, 56.97% in white, and 62.11% in black in BRFSS. Overall, mammography use was positively associated with black race, older age, higher income, and having health insurance, while negatively associated with having three or more children at home and residing in the Western region of the US. Overweight and moderate obesity were significantly associated with increased mammography use among black women (NHIS), while severe obesity was significantly associated with decreased mammography use among white women (BRFSS).

CONCLUSION

We found higher mammography use among black women than white women, a change in the historical trend. We also identified high parity as a risk factor for mammography use, which suggests a potential subpopulation to target with interventions aimed at increasing mammography use.

A Cross-Sectional Analysis of Differences in Physical Activity Levels between Stroke Belt and Non-Stroke Belt US Adults

BACKGROUND

The Stroke Belt is a region of the United States with elevated stroke incidence and prevalence of stroke risk factors. Physical inactivity is an important stroke risk factor, but little is known about whether current physical activity levels differ between Stroke Belt and non-Stroke Belt states. In this nationally representative study, we determined whether unadjusted and adjusted physical activity levels differ between the Stroke Belt region and the rest of the United States.

METHODS

Using 2017 Behavioral Risk Factor Surveillance System data, we conducted bivariate analyses to obtain unadjusted physical activity levels in Stroke Belt and non-Stroke Belt states. Logistic regressions that controlled for sociodemographic and stroke risk factors were created to estimate adjusted associations between Stroke Belt residence and physical activity.

RESULTS

A higher percentage of Stroke Belt residents were inactive (Stroke Belt: 35.3%, non-Stroke Belt: 29.4%) and failed to meet physical activity guidelines (Stroke Belt: 53.7%, non-Stroke Belt: 47.8%) compared to non-Stroke Belt residents. Stroke Belt residence was significantly associated with lower odds of meeting physical activity guidelines in a model that adjusted for sociodemographic factors only (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.78-0.91) and one that adjusted for both sociodemographic and stroke risk factors (OR: 0.87, 95% CI: 0.81-0.93).

CONCLUSIONS

The considerably lower physical activity levels and likelihood of meeting physical activity guidelines in Stroke Belt residents compared to their non-Stroke Belt counterparts demonstrates a need for clinician attention and public health interventions to increase regular physical activity as part of a stroke reduction strategy in this region.

Clustering of esophageal cancer among white men in the United States

Studies of the geographic distribution of esophageal cancer in the United States have been limited. We aimed to examine geographic clustering of esophageal cancer in the United States and assess whether that clustering is explained by the distribution of known risk factors for esophageal cancer. We conducted cluster analyses derived from county mortality rates of esophageal cancer, using publicly available datasets. State incidence rates of esophageal adenocarcinoma were from the National Program of Cancer Registries, and county esophageal-cancer mortality rates were from the Vital Statistics Cooperative Program. County prevalences of cigarette use, alcohol use, obesity, education, and income were published estimates derived from the Behavioral Risk Factor Surveillance System and the American Community Survey. The primary outcomes were clusters of high and low esophageal-cancer mortality rates among non-Hispanic white men, both unadjusted and adjusted for risk factors. Age-standardized county rates of esophageal-cancer mortality among non-Hispanic white men ranged from 4.8 to 21.2 per 100,000/year. There was a cluster of high mortality in the Great Lakes states and New England and a cluster of low mortality in the Southeastern United States. State incidence rates of esophageal adenocarcinoma were consistent with this pattern. Adjusting for risk factors did little to change the pattern of observed rates or the clusters derived from them. Among non-Hispanic white men, there are clusters of high and low mortality rates with esophageal cancer within the United States, likely representing esophageal adenocarcinoma; but those clusters were not explained by several known risk factors. Focusing future efforts in the high-cluster areas might improve the efficiency of cancer screening and control.

Obesity, Diabetes, and the Risk of Invasive Group B Streptococcal Disease in Nonpregnant Adults in the United States

Background

Rates of invasive group B Streptococcus (GBS) disease, obesity, and diabetes have increased in US adults. We hypothesized that obesity would be independently associated with an increased risk of invasive GBS disease.

Methods

We identified adults with invasive GBS disease within Active Bacterial Core surveillance during 2010–2012 and used population estimates from the Behavioral Risk Factor Surveillance System to calculate invasive GBS incidence rates. We estimated relative risks (RRs) of invasive GBS using Poisson analysis with offset denominators, with obesity categorized as class I/II (body mass index [BMI] = 30–39.9 kg/m²) and class III (BMI ≥ 40.0 kg/m²).

Results

In multivariable analysis of 4281 cases, the adjusted RRs of invasive GBS disease were increased for obesity (class I/II: RR, 1.52; 95% confidence interval [CI], 1.14–2.02; and class III: RR, 4.87; 95% CI, 3.50–6.77; reference overweight) and diabetes (RR, 6.04; 95% CI, 4.77–7.65). The adjusted RR associated with class III obesity was 3-fold among persons with diabetes (95% CI, 1.38–6.61) and nearly 9-fold among persons without diabetes (95% CI, 6.41–12.46), compared with overweight. The adjusted RRs associated with diabetes varied by age and BMI, with the highest RR in young populations without obesity. Population attributable risks of invasive GBS disease were 27.2% for obesity and 40.1% for diabetes.

Conclusions

Obesity and diabetes were associated with substantially increased risk of infection from invasive GBS. Given the population attributable risks of obesity and diabetes, interventions that reduce the prevalence of these conditions would likely reduce the burden of invasive GBS infection.

Ecological Momentary Assessment of Physical Activity: Validation Study

Background

Ecological momentary assessment (EMA) may elicit physical activity (PA) estimates that are less prone to bias than traditional self-report measures while providing context.

Objectives

The objective of this study was to examine the convergent validity of EMA-assessed PA compared with accelerometry.

Methods

The participants self-reported their PA using International Physical Activity Questionnaire (IPAQ) and Behavioral Risk Factor Surveillance System (BRFSS) and wore an accelerometer while completing daily EMAs (delivered through the mobile phone) for 7 days. Weekly summary estimates included sedentary time and moderate-, vigorous-, and moderate-to vigorous-intensity physical activity (MVPA). Spearman coefficients and Lin’s concordance correlation coefficients (LCC) examined the linear association and agreement for EMA and the questionnaires as compared with accelerometry.

Results

Participants were aged 43.3 (SD 13.1) years, 51.7% (123/238) were African American, 74.8% (178/238) were overweight or obese, and 63.0% (150/238) were low income. The linear associations of EMA and traditional self-reports with accelerometer estimates were statistically significant (P<.05) for sedentary time (EMA: ρ=.16), moderate-intensity PA (EMA: ρ=.29; BRFSS: ρ=.17; IPAQ: ρ=.24), and MVPA (EMA: ρ=.31; BRFSS: ρ=.17; IPAQ: ρ=.20). Only EMA estimates of PA were statistically significant compared with accelerometer for agreement.

Conclusions

The mobile EMA showed better correlation and agreement to accelerometer estimates than traditional self-report methods. These findings suggest that mobile EMA may be a practical alternative to accelerometers to assess PA in free-living settings.

Obesity Epidemic: Is Its Impact on Total Joint Arthroplasty Underestimated? An Analysis of National Trends

BACKGROUND

Obesity is a well-established risk factor for total joint arthroplasty (TJA) and a number of complications including prosthetic joint infection. The annual changes in the prevalence of obesity among primary, revision, and infected TJA has not been studied at a national level. Given the higher costs of complications of TJA, it is important to understand the association of obesity with the annual trends of revision and infected TJA.

QUESTIONS/PURPOSES

(1) Is the prevalence of obesity increasing among patients undergoing THA/TKA? (2) Is the prevalence of obesity increasing among patients undergoing revision THA/TKA? (3) Is the prevalence of obesity increasing among patients with infected THA/TKA?

METHODS

Annual volumes of primary, revision, and infected THA and TKA from 1998 to 2011 were obtained from the Nationwide Inpatient Sample. Using mathematical equations, the prevalence of obesity was estimated from relative risks and national obesity prevalence. National obesity prevalence was obtained from public health sources and the relative risk estimates were obtained from previously published meta-analyses and population-based studies. Annual prevalence of obesity was obtained by dividing the number of obese primary/revision/infected procedures in each year by the total number of corresponding procedures in that year. Annual changes in the prevalence of obesity were analyzed using linear regression.

RESULTS

The prevalence of obesity is increasing among patients undergoing THA (1998: 60,264 of 154,337 [39%], 2011: 160,241 of 305,755 [52%], increase of 1.05%/year [confidence interval {CI}, 0.95%-1.15%], p < 0.001) and TKA (1998: 143,681 of 251,309 [57%], 2011: 448,712 of 644,243 [70%], increase of 0.97%/year [CI, 0.87%-1.07%], p < 0.001). There was an increasing prevalence of obesity with THA revisions (1998: 16,322 of 34,139 [48%], 2011: 33,304 of 54,453 [61%], increase of 1.04%/year [CI, 0.94%-1.15%], p < 0.001) and in TKA revisions (1998: 16,837 of 26,539 [63%], 2011: 52,151 of 69,632 [75%], increase of 0.89%/year [CI, 0.79%-0.99%], p < 0.001). There was an increasing prevalence of obesity with THA infections (1998: 2068 of 3018 [69%], 2011: 6856 of 8687 [79%], increase of 0.80%/year [CI, 0.71%-0.89%], p < 0.001) and in TKA infections (1998: 3563 of 4684 [76%], 2011: 14,178 of 16,774 [85%], increase of 0.65%/year [CI, 0.57%-0.73%], p < 0.001).

CONCLUSIONS

The prevalence of obesity has increased in patients undergoing primary, revision, and infected TJA in United States. The obesity epidemic appears to be related to the growing trends of revision and infection after TJA. With the obesity rates expected to grow further, the revision and infection burden associated with obesity may increase in the future.

LEVEL OF EVIDENCE

Level II, prognostic study.

A Modified Behavior Risk Factor Surveillance System to Assess Diabetes Self-management Behaviors and Diabetes Care in Monterrey Mexico: A Cross-sectional Study

Type 2 diabetes mellitus (T2DM) is one of the leading causes of death from worldwide non-communicable diseases. The prevalence of diabetes in the Mexico (MX)–United States border states exceeds the national rate in both countries. The economic burden of diabetes, due to decreased productivity, disability, and medical costs, is staggering and increases significantly when T2DM-related complications occur. The purpose of this study was to use a modified behavioral risk factor surveillance system (BRFSS) to describe the T2DM self-management behaviors, diabetes care, and health perception of a convenience sample of adults with T2DM in Monterrey, MX. This cross-sectional study design, with convenience sampling, was conducted with a convenience sample (n = 351) of adults in the metropolitan area of Monterrey, MX who self-reported a diagnosis of T2DM. Potential participants were recruited from local supermarkets. Twenty-six diabetes and health-related items were selected from the BRFSS and administered in face-to-face interviews by trained data collectors. Data analysis was conducted using descriptive statistics. The mean age was 47 years, and the mean length of time with T2DM was 12 years. The majority was taking oral medication and 34% required insulin. Daily self-monitoring of feet was performed by 56% of the participants; however, only 8.8% engaged in blood glucose self-monitoring. The mean number of health-care provider visits was 9.09 per year, and glycated hemoglobin level (HbA1c) was assessed 2.6 times per year. Finally, only 40.5% of the participants recalled having a dilated eye exam. We conclude the modified BRFSS survey administered in a face-to-face interview format is an appropriate tool for assessing engagement in T2DM self-management behaviors, diabetes care, and health perception. Extension of the use of this survey in a more rigorous design with a larger scale survey is encouraged.

Permanent tooth loss and sugar-sweetened beverage intake in U.S. young adults

OBJECTIVE

In young adults, sugar-sweetened beverage (SSB) intake is associated with dental caries, which in turn is a major contributor to tooth loss. The independent role of SSB intake on tooth loss, however, has not been well-described. This cross-sectional study examined associations between tooth loss and SSB intake among U.S. young adults.

METHODS

The outcome was number of permanent teeth lost because of dental caries or periodontal disease (0, 1-5, ≥6 teeth). Data from the 2012 Behavioral Risk Factor Surveillance System were used. The 22,526 adults aged 18-39 years completed the Sugar Drink Module. The exposure variable was daily frequency of SSB intake. We used multinomial logistic regression to examine the adjusted associations between tooth loss and daily SSB consumption (0, >0 to <1, 1-2, >2 times/day).

RESULTS

Approximately, 26% of young adults reported losing at least one permanent tooth. Tooth loss was positively associated with SSB intake frequency; the odds of losing 1-5 teeth were higher among adults drinking SSBs >0-<1 times/day (OR = 1.44, 95%CI = 1.16-1.79), 1-2 times/day (OR = 1.58, 95%CI = 1.25-1.99), and >2 times/day (OR = 1.97, 95%CI = 1.51-2.58) than non-SSB consumers. The odds of losing ≥6 teeth were higher among adults drinking SSBs 1-2 times/day (OR = 2.20, 95%CI = 1.15-4.22) and >2 times/day (OR = 2.81, 95%CI = 1.37-5.76) than non-SSB consumers.

CONCLUSIONS

Frequency of SSB consumption was positively associated with tooth loss among young adults even when the average SSB intake was less than one time per day. This study suggests that efforts to reduce SSB intake among young adults may help to decrease the risk of tooth loss.

Oral health among residents of publicly supported housing in Boston

Tooth loss in adults diminishes quality of daily life, affecting eating, speaking, appearance, and social interactions. Tooth loss is linked to severe periodontitis and caries; and to risk of stroke, cardiovascular disease, rheumatoid arthritis, and dementia. At the national (USA) level, poverty and African-American race have been linked to lower utilization of dental services, suggesting that the 7.5 million residents of publicly supported housing may be at risk of tooth loss and poor overall oral health. We assessed whether residence in publicly supported housing in Boston was associated with four oral health-related indicators. Compared to residents of nonpublicly supported housing, after adjusting for covariates residents of both public housing developments (PHDs) and rental assistance units (RAUs) had significantly lower odds of having had a dental cleaning in the past year (PHD, OR = 0.64 (95 % CI, 0.44-0.93); RAU, OR = 0.67 (95 % CI, 0.45-0.99))-despite parity in having had a past year dental visit. Further, residents of RAUs had double the odds of having had six or more teeth removed (OR = 2.20 (95 % CI, 1.39-3.50)). Associations of race/ethnicity and housing type with dental insurance were interrelated. Unadjusted results document a deficit in oral health-related indicators among public housing residents, taken as a group, giving a clear picture of an oral health care gap and identifying a defined real-world population that could benefit from services. Existing public housing infrastructure could provide both a venue and a foundation for interventions to reduce oral health disparities on a broad scale.

Housing instability among people who inject drugs: results from the Australian needle and syringe program survey

High rates of substance dependence are consistently documented among homeless people, and are associated with a broad range of negative outcomes among this population. Investigations of homelessness among drug users are less readily available. This study examined the prevalence and correlates of housing instability among clients of needle syringe programs (NSPs) via the Australian NSP Survey, annual cross-sectional seroprevalence studies among NSP attendees. Following self-completion of a brief, anonymous survey and provision of a capillary blood sample by 2,396 NSP clients, multivariate logistic regressions identified the variables independently associated with housing instability. Nineteen percent of ANSPS participants reported current unstable housing, with primary ('sleeping rough'; 5 %), secondary (staying with friends/relatives or in specialist homelessness services; 8 %), and tertiary (residential arrangements involving neither secure lease nor private facilities; 6 %) homelessness all evident. Extensive histories of housing instability were apparent among the sample: 66 % reported at least one period of sleeping rough, while 77 % had shifted between friends/relatives (73 %) and/or resided in crisis accommodation (52 %). Participants with a history of homelessness had cycled in and out of homelessness over an average of 10 years; and one third reported first being homeless before age 15. Compared to their stably housed counterparts, unstably housed participants were younger, more likely to be male, of Indigenous Australian descent, and to report previous incarceration; they also reported higher rates of key risk behaviors including public injecting and receptive sharing of injecting equipment. The high prevalence of both historical and current housing instability among this group, particularly when considered in the light of other research documenting the many adverse outcomes associated with this particular form of disadvantage, highlights the need for increased supply of secure, affordable public housing in locations removed from established drug markets and serviced by health, social, and welfare support agencies.

Preconception health indicators: a comparison between non-Appalachian and Appalachian women

To compare preconception health indicators (PCHIs) among non-pregnant women aged 18-44 years residing in Appalachian and non-Appalachian counties in 13 U.S. states. Data from the 1997-2005 Behavioral Risk Factor Surveillance System were used to estimate the prevalence of PCHIs among women in states with ≥1 Appalachian county. Counties were classified as Appalachian (n = 36,496 women) or non-Appalachian (n = 88,312 women) and Appalachian counties were categorized according to economic status. Bivariate and multivariable logistic regression models examined differences in PCHIs among women by (1) Appalachian residence, and (2) economic classification. Appalachian women were younger, lower income, and more often white and married compared to women in non-Appalachia. Appalachian women had significantly higher odds of reporting Collapse

Key Words

• preconception health
• appalachia
• disparities
• socioeconomic status
• behavioral risk factor surveillance system
• rural populations

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MESH Headings

• Adolescent
• Adult
• Age Factors
• Appalachian Region/epidemiology
• Behavioral Risk Factor Surveillance System
• Cross-Sectional Studies
• Female
• Health Behavior
• Health Status
• Health Status Indicators
• Healthcare Disparities
• Humans
• Insurance Coverage/statistics & numerical data
• Logistic Models
• Obesity/epidemiology
• Population Surveillance
• Preconception Care
• Prevalence
• Preventive Health Services/statistics & numerical data
• Risk Factors
• Rural Population
• Socioeconomic Factors
• United States/epidemiology
• Vaginal Smears/statistics & numerical data
• Young Adult

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Grants

• CC999999 Intramural CDC HHS
• U38 HM000414 NCHM CDC HHS
• 5U38HM000414 NCHM CDC HHS

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Social-emotional support, life satisfaction, and mental health on reproductive age women's health utilization, US, 2009

To examine the associations among social-emotional support, life satisfaction, and mental health with not having a routine checkup among women of reproductive age in the US, data from the 2009 Behavioral Risk Factor Surveillance System, a population-based telephone survey of health behaviors, were analyzed among reproductive aged (18-44 years) women in the US. Prevalence estimates were calculated for not having a routine checkup in the past year with measures of social-emotional support, life satisfaction, and mental distress. Independent multivariable logistic regressions for each measure assessed not having a routine checkup within the past year with adjustment for age, race/ethnicity, education level, and health care coverage. Among women of reproductive age, 33.7 % (95 % CI 33.0-34.4) did not have a routine checkup within the past year. Factors associated with not having a routine checkup included: having social-emotional support most of the time (AOR = 1.29, 95 % CI 1.20-1.38) or sometimes or less (AOR = 1.47, 95 % CI 1.34-1.61) compared to those who reported always having the social-emotional support they need; reporting life satisfaction as being satisfied (AOR = 1.27, 95 % CI 1.19-1.36) or dissatisfied (AOR = 1.65, 95 % CI 1.43-1.91) compared to being very satisfied; and frequent mental distress (AOR = 1.19, 95 % CI 1.09-1.30) compared to those without. Women who report lower levels of social-emotional support, less life satisfaction, and frequent mental distress are less likely to see a doctor for a routine checkup. Targeted outreach that provides appropriate support are needed so these women can access clinical services to increase exposure to preventive health opportunities and improve overall health.

Health-related quality of life and chronic obstructive pulmonary disease in North Carolina

Background:

Comparisons of health-related quality of life (HRQOL) between persons with chronic obstructive pulmonary disease (COPD) and adults in the general population are not well described.

Aims:

To examine associations between COPD and four measures of HRQOL in a population-based sample.

Patients & Methods:

These relationships were examined using data from 13,887 adults aged >18 years who participated in the 2007 Behavioral Risk Factor Surveillance System (BRFSS) conducted in North Carolina (NC). Logistic regression was used to obtain adjusted relative odds (aOR).

Results:

The age-adjusted prevalence of COPD among NC adults was 5.4% (standard error 0.27). Nearly half of adults with COPD reported fair/poor health compared with 15% of those without the condition (age-aOR, 5.5; 95% confidence interval [ CI] , 4.4 to 6.8). On average, adults with COPD reported twice as many unhealthy days (physical/mental) as those without the condition. The age-adjusted prevalence of >14 unhealthy days during the prior 30 days was 45% for adults with COPD and 17% for those without. The aOR of >14 unhealthy days was 1.7 (95% CI, 1.4 to 2.2) times greater among adults with COPD compared with those without.

Conclusions:

These results suggest COPD is independently associated with lower levels of HRQOL and reinforce the importance of preventing COPD and its complications through health education messages stressing efforts to reduce total personal exposure to tobacco smoke, occupational dusts and chemicals, and other indoor and outdoor air pollutants linked to COPD and early disease recognition. Our findings represent one of the few statewide efforts in the US and provide guidance for disease management and policy decision making.

Cardiovascular knowledge among urban American Indians and Alaska Natives: first steps in addressing cardiovascular health

BACKGROUND

Cardiovascular disease (CVD) is common among American Indians/Alaska Natives (AI/ANs). Given limited access to health care, urban AI/ANs may be at particular risk. Lack of available data, however, limits our understanding of cardiovascular health in this population.

OBJECTIVES

We conducted a survey to characterize CVD-related knowledge, behavior, and risk of urban AI/ANs. Results related to knowledge are reported.

METHODS

In collaboration with the Indian clinics in two urban communities, we surveyed 298 AI/ANs.

RESULTS

Respondents recognized approximately half of the symptoms of heart attack and stroke, and were significantly less likely to recognize each symptom than reported in national studies using the same items. General CVD knowledge (e.g., risks of high blood pressure) was stronger, although areas for improvement were noted.

CONCLUSIONS

Urban AI/ANs would benefit from efforts to enhance CVD knowledge. These preliminary data are providing the foundation for community-based efforts to address CVD risk among urban AI/ANs.

Smoking prevalence among US veterans

BACKGROUND/OBJECTIVE

Cigarette smoking is a significant health problem within the US military. Data from the 2003-2007 Behavioral Risk Factor Surveillance System (BRFSS) were used to estimate and compare the prevalence of smoking among US veterans with that of adults who did not serve in the US armed forces.

METHODS

Data from the BRFSS, a state-based random-digit dialed telephone survey supported by the Centers for Disease Control and Prevention, were used to estimate the prevalence of current smoking among adults (aged >or=18 years) who reported ever serving on active duty in the United States Armed Forces. We compared, by birth cohort, age-adjusted smoking prevalence among veterans with that of adults who did not serve in the military.

RESULTS

A total of 224,169 US veterans participated during 2003-2007. The age-adjusted prevalence of smoking during the period was 27.0% (standard error, 0.36) among veterans and 21% (0.12) among non-veterans. For both groups, the prevalence decreased across years from 29% (0.79) in 2003 to 25% (0.82) in 2007 among veterans and from 23% (0.29) in 2003 to 20% (0.26) in 2007 among non-veterans. Among veterans, smoking prevalence was highest among men born between 1975-1984 (36%; 90%CI = 33.7-37.5) and those born between 1985-1989 (37%; 90%CI = 31.7-48.2) with lower prevalences among men born between 1945-1954 (26%; 90%CI = 25.1-26.3), 1955-1964 (33%; 90%CI = 32.3-34.3), and 1965-1974 (27%; 90%CI = 26.0-28.1). The prevalence of smoking was 43% (90%CI = 39.0-47.6) among veterans with self-reported coronary heart disease (CHD), greater than that for non-veterans with CHD (31%; 90%CI = 28.6-33.1).

CONCLUSIONS

Although the prevalence of smoking has declined among US adults, there are opportunities to further reduce smoking among US veterans, particularly young veterans for whom the prevalence of smoking is similar to that of the US adult population during the late 1960s/early 1970s. Continued work is necessary to target the high smoking prevalence among veterans with CHD, a group for which smoking cessation is especially important.

Perceived discrimination in health care and use of preventive health services

OBJECTIVE

To examine the relationship between perceived discrimination and preventive health care utilization.

DESIGN AND PARTICIPANTS

Cross-sectional analysis using the 2004 Behavioral Risk Factor Surveillance System "Reactions to Race" module (N = 28,839).

MEASUREMENTS

Outcomes were self-reported utilization of seven preventive health services. Predictors included perceived negative and positive racial discrimination (vs. none) while seeking health care in the past year. Multivariable models adjusted for additional patient characteristics.

MAIN RESULTS

In unadjusted models, negative discrimination was significantly associated with less utilization of mammogram, pap test, PSA test, blood stool test, and sigmoidoscopy/colonoscopy (ORs = 0.53-0.73, p < .05), but not flu or pneumococcal vaccines (ORs = 0.76 and 0.84). Positive discrimination was significantly associated with more utilization of all services (ORs = 1.29-1.58, p < .05) except pap test (OR = 0.94). In adjusted models, neither negative nor positive discrimination was predictive of utilization, except for PSA test (positive discrimination OR = 1.33, p < .05).

CONCLUSIONS

Perceived racial discrimination in health care does not independently predict preventive health care utilization.

Delivery of preventive services to adults aged 50-64: monitoring performance using a composite measure, 1997-2004

OBJECTIVE

Population-based rates for the delivery of adult vaccinations or screenings are typically tracked as individual services. The current approach is useful in monitoring progress toward national health goals but does not yield information regarding how many U.S. adults receive a combination of preventive services routinely recommended based on a person's age and gender. A composite measure is important for policymaking, for developing public health interventions, and for monitoring the quality of clinical care. During the period under study, influenza vaccination was newly recommended (2000) to be routinely delivered to adults in this age range. The objective of the study was to compare the delivery of routine clinical preventive services to U.S. adults aged 50-64 years between 1997 and 2004 using a composite measure that includes cancer screenings and vaccinations.

DESIGN

Data were collected via telephone surveys in 1997, 2002, and 2004 as part of the Behavioral Risk Factor Surveillance System.

PARTICIPANTS

The participants were randomly selected adults aged 50-64 years in the 50 states and the District of Columbia in the selected years. Sample sizes ranged from 24,917 to 77,244.

MEASUREMENTS AND MAIN RESULTS

The composite measure includes screening for colorectal cancer, cervical cancer, breast cancer, and vaccination against influenza (2002 and 2004 only). The composite measure quantifies the percentage of adults who are up-to-date with the complete set according to recommended schedules. With the inclusion of newly recommended influenza vaccination, the percentage of men and women aged 50-64 who were up-to-date on all selected measures in 2004 was 23.4% and 23.0%, respectively, compared with 37.6% and 30.5% in 1997. Without including influenza vaccination, the percentage of up-to-date adults aged 50-64 would have risen in 2004 to 50.5% (men) and to 44.7% (women). For both sexes, results varied by education, race/ethnicity, marriage status, insurance status, health status, and state.

CONCLUSION

In 2004, the percentage of adults aged 50-64 years receiving routinely recommended cancer screenings and influenza vaccination was low with fewer than 1 in 4 being up to date.