The prevalence of childhood asthma: interpreting falling rates in the context of shifting measurement and the COVID-19 pandemic

PURPOSE OF REVIEW

The estimated prevalence of childhood asthma in the United States, as measured by the National Health Information Survey (NHIS), has decreased by 30% since 2017. This review provides context for observed changes in asthma rates by describing recent shifts in NHIS data collection and analysis, and considers whether the COVID-19 pandemic might impact asthma prevalence in years to come.

RECENT FINDINGS

The NHIS underwent a planned redesign in 2019 with updated sampling weights to better match the U.S. population. In early 2020, the COVID-19 pandemic resulted in unplanned modifications to NHIS implementation, which may have included fewer children from populations at a heightened risk for asthma. Decreasing prevalence estimates in recent years are likely at least in part due to these survey changes rather than true epidemiologic shift. However, pandemic-related changes to risk factors for childhood asthma (including exposure to rhinovirus infections and allergic sensitization) may also influence prevalence in the future.

SUMMARY

Recent changes in estimated rates of childhood asthma in the USA are likely driven by changes to survey methods and implementation, both before and during the COVID-19 pandemic. Additional years of data are needed to determine whether a true shift in disease prevalence is occurring.

Trends in Collection of Disaggregated Asian American, Native Hawaiian, and Pacific Islander Data: Opportunities in Federal Health Surveys

Collection of data for Asian American, Native Hawaiian, and Pacific Islander (AANHPI) persons that is disaggregated by ethnic subgroup may identify disparities that are not apparent in aggregated data. Using content analysis, we identified national population surveys administered by the US Department of Health and Human Services (HHS) and evaluated trends in the collection of disaggregated AANHPI data between 2011 and 2021. In 2011, 4 of 15 surveys (27%) collected disaggregated data for Asian American, 2 of 15 surveys (13%) collected data on Native Hawaiian, and 2 of 15 surveys (13%) collected disaggregated data for Pacific Islander people. By 2019, 14 of 21 HHS-administered surveys (67%) collected disaggregated data for Asian American (6 subgroups), 67% collected data on Native Hawaiian, and 67% collected disaggregated data on Pacific Islander (3 subgroups) people. Collection of disaggregated AANHPI data in HHS-administered surveys increased from 2011 to 2021, but opportunities to expand collection and reporting remain. Strategies include outreach with community organizations, increased language assistance, and oversampling approaches. Increased availability and reporting of these data can inform health policies and mitigate disparities. (Am J Public Health. 2022;112(10):1429-1435. https://doi.org/10.2105/AJPH.2022.306969).

Long-Term Evolution of Functional Limitations in Stroke Survivors Compared With Stroke-Free Controls: Findings From 15 Years of Follow-Up Across 3 International Surveys of Aging

BACKGROUND AND PURPOSE

In the chronic phase 2 to 5 years poststroke, limitations in activities of daily living (ADL) and instrumental ADL (IADL) initially plateau before steady increasing. However, the impact of age and differences in initial levels of disability on the evolution of these limitations remains unclear. As such, this study aims to evaluate differences in long-term evolution of ADL/IADL limitations between stroke survivors and stroke-free population, and how limitations differ by initial level of disability for stroke survivors.

METHODS

Thirty-three thousand six hundred sixty participants (5610 first-ever stroke cases with no recurrence during follow-up and 28 050 stroke-free controls) aged ≥50 from the Health and Retirement Study, Survey of Health, Ageing and Retirement in Europe, and English Longitudinal Study of Ageing were assessed for number of ADL/IADL limitations during the poststroke chronic phase (for cases) and over follow-up years 1996 to 2018 (for controls). Three thousand seven hundred eighteen stroke cases were additionally categorized by disability level using the modified Rankin Scale score of 1 to 2 years poststroke. Evolution of ADL/IADL limitations was assessed in stroke cases and controls and by modified Rankin Scale score (0-1, 2-3, 4-5) using linear mixed models. Models were stratified by age group (50-74 and ≥75 years) and adjusted for baseline characteristics, health behaviors, BMI, and comorbidities.

RESULTS

Findings showed relative stability of ADL/IADL limitations during 3 to 6 years poststroke followed by an increase for both populations, which was faster for younger stroke cases, suggesting a differential age-effect (P<0.001). Disability level at 1 to 2 years poststroke influenced the evolution of limitations over time, especially for severe disability (modified Rankin Scale score, 4-5) associated with a reduction in limitations at 5 to 6 years poststroke.

CONCLUSIONS

Our findings showed that during the poststroke chronic phase functional limitations first plateau and then increase and the evolution differs by disability severity. These results highlight the importance of adaptive long-term health and social care measures for stroke survivors.

Predicting the risk of future depression among school-attending adolescents in Nigeria using a model developed in Brazil

Depression commonly emerges in adolescence and is a major public health issue in low- and middle-income countries where 90% of the world's adolescents live. Thus efforts to prevent depression onset are crucial in countries like Nigeria, where two-thirds of the population are aged under 24. Therefore, we tested the ability of a prediction model developed in Brazil to predict future depression in a Nigerian adolescent sample. Data were obtained from school students aged 14-16 years in Lagos, who were assessed in 2016 and 2019 for depression using a self-completed version of the Mini International Neuropsychiatric Interview for Children and Adolescents. Only the 1,928 students free of depression at baseline were included. Penalized logistic regression was used to predict individualized risk of developing depression at follow-up for each adolescent based on the 7 matching baseline sociodemographic predictors from the Brazilian model. Discrimination between adolescents who did and did not develop depression was better than chance (area under the curve = 0.62 (bootstrap-corrected 95% CI: 0.58-0.66). However, the model was not well-calibrated even after adjustment of the intercept, indicating poorer overall performance compared to the original Brazilian cohort. Updating the model with context-specific factors may improve prediction of depression in this setting.

Trends in smoking rates among individuals with serious psychological distress: Analysis of data from a Japanese national survey, 2007-2016

To determine whether the downward trend in the smoking rate over time in Japan differs between individuals with and without serious psychological distress (SPD), we used nationally representative data sets from the 2007, 2010, 2013, and 2016 Comprehensive Survey of Living Conditions of Japan. SPD was defined as a score ≥ 13 on the six-item Kessler Psychological Distress Scale. We conducted multivariate logistic regression analyses including the interaction terms between SPD and survey year. A total 187,685 participants were included. The interaction terms between SPD and survey year among men were significant for 2010 and 2016 but not for 2013. Among women, the interaction terms between SPD and survey year were not significant for any year. In conclusion, we confirmed that the gap in the rate of smoking between men with SPD and those without SPD decreased from 2007 to 2016. Among women, the gap in the smoking rate between those with SPD and those without SPD remained unchanged. Our findings suggest a need for specific support strategies including pharmacological interventions, especially for women smokers with SPD. Further studies are warranted to identify factors contributing to these sex differences.

Adult correlates of adverse childhood experiences in Ukraine

BACKGROUND

The impact of adverse childhood experiences (ACEs) on adult life outcomes is well-documented by a considerable body of research. This study investigates the relationship between ACEs and both physical and mental health outcomes in a nationally representative sample of Ukrainian adults.

OBJECTIVE

The aim of this study was to analyze whether ACEs are associated with lifetime physical and mental health outcomes in a nationally representative sample of Ukrainian adults. Participants and Setting In 2002, the World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was administered to a national probability sample of Ukrainian adults (n = 4725).

METHODS

Associations between ACEs and later life physical and mental health outcomes are examined using logistic regression models.

RESULTS

ACEs were significantly correlated with poor later life mental and physical health. Participants with three or more ACEs were most likely to have chronic pain, cardiovascular disease, other disease, depressive disorders, anxiety disorders, substance abuse disorders, and all disability metrics analyzed. Adjusted odds ratios for these models ranged from 1.80 to 3.81. Additionally, we found a large association between the number of ACES and later negative health outcomes.

CONCLUSIONS

Our results indicate that in Ukraine, ACEs have a strong negative effect on later life mental and physical health. Further research is needed to explore specific ACEs and examine potential mediators such as social support in the relationship between ACEs and health outcomes.

Changes in adolescent smoking with implementation of local smoke-free policies in Indonesia: Quasi-experimental repeat cross-sectional analysis of national surveys of 2007 and 2013

BACKGROUND

Banning smoking from public places may prevent adolescent smoking, but there is little evidence on impact of smoke-free policies (SFPs) from low and middle-income countries. This study assessed to what extent the adoption of local SPFs in Indonesia between 2007 and 2013 associated with adolescent smoking.

METHODS

Data on 239,170 adolescents (12-17 years old) were derived from the 2007 and 2013 national health surveys in 497 districts and 33 provinces. This study compared 2013 survey respondents living in districts/provinces that adopted SFPs between 2007 and 2013, with 2007 respondents and 2013 respondents in districts/provinces that did not adopt policies. Multilevel logistic regression analysis assessed whether SFP was associated with daily and non-daily smoking. We controlled for survey year, SFP in 2007, socio-demographics, and district characteristics.

RESULTS

Strong district SFPs was significantly associated with lower odds of daily smoking (OR:0.81, 95 %CI:0.69-0.97), but non-significantly with non-daily smoking (OR:0.89, 95 %CI:0.76-1.05). Strong provincial SFPs was not associated with daily smoking (OR:1.02, 95 %CI:0.84-1.25), but was associated with higher odds of non-daily smoking (OR:1.22, 95 %CI:0.99-1.51). Moderately strong SFPs did not consistently show associations in the same direction. For example, moderately strong provincial SFP was associated with higher odds of daily smoking (OR:1.27, 95 %CI:1.11-1.46) and lower odds of non-daily smoking (OR:0.82, 95 %CI:0.72-0.93).

CONCLUSION

We did not detect a consistent short-term effect of district and province-level smoke-free policies on adolescent smoking in Indonesia. Weak implementation and poor compliance may compromise effectiveness, which would call for improvement of SFP implementation in Indonesia.

Cannabis use and physical activity among 89,777 adolescents aged 12-15 years from 21 low- and middle-income countries

BACKGROUND

Cannabis legalization and use are increasing globally, however, little is known about associations between cannabis use and other health behaviors, such as physical activity (PA). Importantly, the extent to which cannabis use is associated with PA in adolescents is yet to be explored in low- and middle-income countries (LMICs), where there may be unique sociodemographic and environmental characteristics compared with high-income countries. Therefore, this study examined the association between PA and cannabis use among adolescents in 21 LMICs using data from the 2010-2016 Global School-based Student Health Survey.

METHODS

A multivariable logistic regression analysis was performed among a final sample of 89,777 adolescents (49.2% females) aged 12-15 years with a mean (SD) age of 13.7 (0.9) years.

RESULTS

The overall prevalence of past (i.e., in lifetime but not in past 30 days) and current (in past 30 days) cannabis use were 1.0% and 2.9% respectively, while the prevalence of adequate PA in the past week (7 days/week of 60 min of PA) was 16.6%. The prevalence of adequate levels of PA in past and current cannabis use was 7.3% and 6.9%, respectively. Current and past cannabis use (vs. never) were associated with a significant 0.62 (95% CI = 0.41-0.94) and 0.43 (95%CI = 0.30-0.63) times lower odds for achieving adequate levels of PA, respectively.

CONCLUSION

The results underscore the high prevalence of low PA among adolescents in LMICs, and emphasize the need to understand behavioral factors that may affect PA levels, such as cannabis use, when designing interventions to improve health.

Addressing alcohol in routine healthcare in Sweden-population-based surveys in 2010 and 2017

BACKGROUND

The aim of the study was to compare how alcohol was addressed in routine healthcare practice in Sweden in 2010 and 2017, following the 2011 implementation of national drinking guidelines.

METHODS

Population-based cross-sectional surveys were conducted in 2010 and in 2017. Subjects were 3200 respondents in 2010 (response rate 54%) and 3000 respondents in 2017 (response rate 51%) in Sweden. Both the 2010 and 2017 surveys collected data on: socio-demographics; alcohol consumption; healthcare visits in the past 12 months and characteristics of alcohol conversations in healthcare (duration, contents, experience and effects).

RESULTS

It was significantly more likely that respondents had a conversation about alcohol in healthcare in 2017 than in 2010 (OR = 1.49; 95% CI = 1.27-1.75; P<0.001). Conversations about alcohol in the healthcare were mostly short (<4 min), both in 2010 and 2017. The alcohol conversations in 2017 included less information about alcohol's influence on health (P = 0.002) compared with 2010. The experience of the conversation about alcohol was perceived as less dramatic in 2017 than in 2010 (P = 0.038).

CONCLUSIONS

The results suggest that conversations about alcohol were more embedded in routine healthcare practice in Sweden in 2017 than in 2010. This development has occurred since the 2011 publication of the national guidelines. Alcohol conversations targeted also specific groups of drinkers as recommended by the guidelines. However, our study design does not allow for conclusions about the relationship between the guidelines and the changes in healthcare practice.

Trends in binge drinking and alcohol abstention among adolescents in the US, 2002-2016

BACKGROUND

Binge drinking accounts for several adverse health, social, legal, and academic outcomes among adolescents. Understanding trends and correlates of binge drinking and alcohol abstention has important implications for policy and programs and was the aim of this study. The current study examined trends in adolescent binge drinking and alcohol abstention by age, gender, and race/ethnicity over a 15-year period.

METHODS

Respondents between the ages of 12 and 17 years who participated in the National Survey on Drug Use and Health (NSDUH) between 2002 and 2016 were included in the sample of 258,309. Measures included binge drinking, alcohol abstention, and co-morbid factors (e.g., marijuana, other illicit drugs), and demographic factors.

RESULTS

Logistic regression analyses were conducted to examine the significance of trend changes by sub-groups while controlling for co-morbid and demographic factors. Findings indicated that binge drinking decreased substantially among adolescents in the US over the last 15 years. This decrease was shown among all age, gender, and racial/ethnic groups. In 2002, Year 1 of the study, 26% of 17-year-olds reported past-month binge drinking; in 2016, past-month binge drinking dropped to 12%. Findings also indicated comparable increases in the proportion of youth reporting abstention from alcohol consumption across all subgroups. Black youth reported substantially lower levels of binge alcohol use and higher levels of abstention, although the gap between Black, Hispanic and White youth narrowed substantially between 2002 and 2016.

CONCLUSION

Study findings are consistent with those of other research showing declines in problem alcohol- use behavior among youth.

Factors associated with alcohol consumption and prescribed drugs with addiction potential among older women and men - the Nord-Trøndelag health study (HUNT2 and HUNT3), Norway, a population-based longitudinal study

BACKGROUND

Little is known about factors associated with alcohol consumption and use of drugs with addiction potential in older adults. The aim of this study was to explore the association between socio-demographic variables, physical and mental health and the later (11 years) use of frequent drinking, prescribed drugs with addiction potential and the possible combination of frequent drinking and being prescribed drugs with addiction potential in older adults (≥ 65 years).

METHODS

In this longitudinal study, we used data from two surveys of the Nord-Trøndelag Health Study (HUNT2 1995-1997 and HUNT3 2006-2008), a population based study in Norway. We totally included 10,656 individuals (5683 women) aged 54 years and older when they participated in HUNT2. Frequent drinking was defined as drinking alcohol 4 days or more per week. Data on prescribed drugs with addiction potential were drawn from the Norwegian Prescription Database. Drugs with addiction potential were defined as at least one prescription of benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years between 2005 and 2009.

RESULTS

The typical frequent drinker in HUNT3 was younger, more educated, lived in urban areas, and reported smoking and drinking frequently in HUNT2 compared to the non-frequent drinker in HUNT3. The typical user of prescribed drugs with addiction potential in HUNT3 was an older woman who smoked and was in poor health, suffered from anxiety, had been hospitalized in the last 5 years and used anxiety or sleep medication every week or more often in HUNT2. The typical individual in HUNT3 with the possible combination of frequent drinking and being prescribed drugs with addiction potential had more education, smoked, drank frequently and used anxiety or sleep medication in HUNT2.

CONCLUSION

Individuals who were identified as frequent drinkers in HUNT2 were more likely to be frequent drinkers in HUNT3, and to have the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3. Health care professionals need to be aware of use of alcohol among older adults using drugs with addiction potential.

Serious psychological distress and daily cannabis use, 2008 to 2016: Potential implications for mental health?

BACKGROUND

Daily cannabis use is increasing in the United States (US). Yet, it is not known whether daily cannabis use is disproportionately common, or whether it has increased differentially over time, by mental health status. This study estimated the prevalence of daily cannabis use among adults in the US with and without past-month serious psychological distress (SPD; measured by the Kessler Psychological Distress Scale (K6)) in 2016 and estimated trends in daily cannabis use by past-30-day SPD status from 2008 to 2016.

METHODS

Data were drawn from adults age 18 and older in the 2008-2016 National Survey on Drug Use and Health (combined total analytic sample n = 356,413). Linear time trends of daily cannabis use, stratified by SPD status, were assessed using logistic regression models with continuous year as the predictor.

RESULTS

In 2016, past-month daily cannabis use was significantly more common among those with past-month SPD (8.07%), compared to those without past-month SPD (2.66%). Daily cannabis use increased significantly from 2008 to 2016 among those both with and without SPD although use among those with SPD was persistently higher than use among those without SPD over the time period studied.

CONCLUSIONS

Daily cannabis use is significantly more common among persons with serious psychological distress and is increasing in this group, as well as among those without. Given this increase and the high prevalence of cannabis use among those with SPD, it may be important to consider potential consequences of this increased use for those with mental health vulnerabilities.

Changes in the Prevalence of Child and Youth Mental Disorders and Perceived Need for Professional Help between 1983 and 2014: Evidence from the Ontario Child Health Study

OBJECTIVES

To examine: 1) changes in the prevalence of mental disorders and perceived need for professional help among children (ages 4 to 11) and youth (ages 12 to 16) between 1983 and 2014 in Ontario and 2) whether these changes vary by age and sex, urban-rural residency, poverty, lone-parent status, and immigrant background.

METHODS

The 1983 ( n = 2836) and 2014 ( n = 5785) Ontario Child Health Studies are provincially representative cross-sectional surveys with identical self-report checklist measures of conduct disorder, hyperactivity, and emotional disorder, as well as perceived need for professional help, assessed by integrating parent and teacher responses (ages 4 to 11) and parent and youth responses (ages 12 to 16).

RESULTS

The overall prevalence of perceived need for professional help increased from 6.8% to 18.9% among 4- to 16-year-olds. An increase in any disorder among children (15.4% to 19.6%) was attributable to increases in hyperactivity among males (8.9% to 15.7%). Although the prevalence of any disorder did not change among youth, conduct disorder decreased (7.2% to 2.5%) while emotional disorder increased (9.2% to 13.2%). The prevalence of any disorder increased more in rural and small to medium urban areas versus large urban areas. The prevalence of any disorder decreased for children and youth in immigrant but not nonimmigrant families.

CONCLUSIONS

Although there have been decreases in the prevalence of conduct disorder, increases in other mental disorders and perceived need for professional help underscore the continued need for effective prevention and intervention programs.

Quantifying heterogeneous contact patterns in Japan: a social contact survey

BACKGROUND

Social contact surveys can greatly help in quantifying the heterogeneous patterns of infectious disease transmission. The present study aimed to conduct a contact survey in Japan, offering estimates of contact by age and location and validating a social contact matrix using a seroepidemiological dataset of influenza.

METHODS

An internet-based questionnaire survey was conducted, covering all 47 prefectures in Japan and including a total of 1476 households. The social contact matrix was quantified assuming reciprocity and using the maximum likelihood method. By imposing several parametric assumptions for the next-generation matrix, the empirical seroepidemiological data of influenza A (H1N1) 2009 was analysed and we estimated the basic reproduction number, R0.

RESULTS

In total, the reported number of contacts on weekdays was 10,682 whereas that on weekend days was 8867. Strong age-dependent assortativity was identified. Forty percent of weekday contacts took place at schools or workplaces, but that declined to 14% on weekends. Accounting for the age-dependent heterogeneity with the known social contact matrix, the minimum value of the Akaike information criterion was obtained and R0 was estimated at 1.45 (95% confidence interval: 1.42, 1.49).

CONCLUSIONS

Survey datasets will be useful for parameterizing the heterogeneous transmission model of various directly transmitted infectious diseases in Japan. Age-dependent assortativity, especially among children, along with numerous contacts in school settings on weekdays implies the potential effectiveness of school closure.

Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study

BACKGROUND

Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates.

METHODS AND FINDINGS

Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries.

CONCLUSIONS

To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.

Patterns in Reduction or Cessation of Drinking in Australia (2001-2013) and Motivation for Change

AIMS

This paper examines: (a) change over time (2001-2013) in recently reducing or ceasing drinking in the Australian population and (b) the reasons given for reducing or ceasing drinking in the most recent survey (2013); stratified by sex and age group.

SHORT SUMMARY

Rates of reducing and ceasing drinking increased between 2001 and 2013 in Australia. Young people were more likely to modify drinking due to lifestyle and enjoyment reasons; older groups were more likely to report health reasons. These trends contribute to the broader context of declining alcohol consumption in Australia.

METHODS

Data are from five waves of the National Drug Strategy Household Survey (N = 119,397). Logistic regression models with interaction terms were used to identify a shift in sex or age over time in predicting reduction or cessation of drinking and to predict motivations for reducing or ceasing drinking by sex and age.

RESULTS

Reports of recently reducing the quantity or frequency of drinking increased from 2001 to 2007 and remained stable between 2007 and 2013. There was a steady increase in the number of Australians reporting recently ceasing drinking from 2001 to 2013, with a significant effect for age (younger groups more likely than older groups to cease drinking in the past two waves). Reasons for reducing or ceasing drinking varied by age, with older people more likely to report health reasons and younger people more likely to report lifestyle reasons or enjoyment.

CONCLUSION

Increases over time in reports of reduction or cessation of drinking due to health, lifestyle, social and enjoyment reasons suggest that the social position of alcohol in Australia may be shifting, particularly among young people.

Association between random glucose and all-cause mortality: findings from the mortality follow-up of the German National Health Interview and Examination Survey 1998

BACKGROUND

Random glucose is widely measured in epidemiological studies and in the clinical setting when standardized fasting protocols and oral glucose tolerance testing or HbA_1c measuring are not feasible. The relationship between random glucose and all-cause mortality has hardly been studied so far and was examined in the present study.

METHODS

We ascertained mortality status among 5955 persons aged 18-79 years and free of known diabetes when participating in the German National Health Interview and Examination Survey 1998 (mean observation time 11.7 years, 458 deaths). Cox regression was applied to analyze the association of random serum glucose with all-cause mortality taken potential confounders into account. Relative mortality risks were estimated as hazard ratios (HRs) with 95% confidence intervals (CIs) modeling random glucose as categorical or continuous variable.

RESULTS

Compared to random glucose levels of 4.3 - < 5.3 mmol/L, HRs (95% CIs) were 1.94 (0.85-4.45) for levels < 4.3 mmol/L and 1.16 (0.89-1.50), 1.20 (0.91-1.58), 1.42 (0.88-2.29), 2.02 (1.26-3.25) and 4.71 (2.20-10.10) for levels 5.3 - < 5.8, 5.8 - < 6.8, 6.8 - < 7.8, 7.8 - < 11.1 and ≥ 11.1 mmol/L, adjusted for age, sex, lifestyle, anthropometry and chronic diseases. An additional adjustment for fasting time or HbA_1c yielded similar estimates. Modeling continuous random glucose by restricted cubic spline functions revealed comparable findings.

CONCLUSIONS

In the present epidemiological study drawn from the general population, random glucose showed a significant association with all-cause mortality, independent of main potential confounders. Thus, random glucose measures are highly relevant to health risk assessment among people without known diabetes when fasting glucose or HbA_1c are difficult to obtain.

Tracking Declines in Mercury Exposure in the New York City Adult Population, 2004-2014

Mercury is a toxic metal that can be measured in human blood and urine. Population-based biomonitoring from 2004 guided New York City (NYC) Department of Health and Mental Hygiene (DOHMH) efforts to reduce exposures by educating the public about risks and benefits of fish consumption-a predominant source of exposure in the general population-and removing mercury-containing skin-lightening creams and other consumer products from the marketplace. We describe changes in exposures over the past decade in relation to these local public health actions and in the context of national changes by comparing mercury concentrations measured in blood (1201 specimens) and urine (1408 specimens) from the NYC Health and Nutrition Examination Survey (NYC HANES) 2013-2014 with measurements from NYC HANES 2004 and National Health and Nutrition Examination Surveys (NHANES) 2003-2004 and 2013-2014. We found that NYC adult blood and urine geometric mean mercury concentrations decreased 46% and 45%, respectively. Adult New Yorkers with blood mercury concentration ≥ 5 μg/L (the New York State reportable level) declined from 24.8% (95% CL = 22.2%, 27.7%) to 12.0% (95% CL = 10.1%, 14.3%). The decline in blood mercury in NYC was greater than the national decline, while the decline in urine mercury was similar. As in 2004, Asian New Yorkers had higher blood mercury concentrations than other racial/ethnic groups. Foreign-born adults of East or Southeast Asian origin had the highest prevalence of reportable levels (29.7%; 95% CL = 21.0%, 40.1%) across sociodemographic groups, and Asians generally were the most frequent fish consumers, eating on average 11 fish meals in the past month compared with 7 among other groups (p < 0.001). Fish consumption patterns were similar over time, and fish continues to be consumed more frequently in NYC than nationwide (24.7% of NYC adults ate fish ten or more times in the past 30 days vs. 14.7% nationally, p < 0.001). The findings are consistent with the hypothesis that blood mercury levels have declined in part because of local and national efforts to promote consumption of lower mercury fish. Local NYC efforts may have accelerated the reduction in exposure. Having "silver-colored fillings" on five or more teeth was associated with the highest 95th percentile for urine mercury (4.06 μg/L; 95% CL = 3.1, 5.9). An estimated 5.5% of the adult population (95% CL = 4.3%, 7.0%) reported using a skin-lightening cream in the past 30 days, but there was little evidence that use was associated with elevated urine mercury in 2013-14.

Change in Obesity Prevalence among New York City Adults: the NYC Health and Nutrition Examination Survey, 2004 and 2013-2014

The objective of this study was to measure change in obesity prevalence among New York City (NYC) adults from 2004 to 2013-2014 and assess variation across sociodemographic subgroups. We used objectively measured height and weight data from the NYC Health and Nutrition Examination Survey to calculate relative percent change in obesity (≥ 30 kg/m2) between 2004 (n = 1987) and 2013-2014 (n = 1489) among all NYC adults and sociodemographic subgroups. We also examined changes in self-reported proxies for energy imbalance. Estimates were age-standardized and statistical significance was evaluated using two-tailed T tests and multivariable regression (p < 0.05). Between 2004 and 2013-2014, obesity increased from 27.5 to 32.4% (p = 0.01). Prevalence remained stable and high among women (31.2 to 32.8%, p = 0.53), but increased among men (23.4 to 32.0%, p = 0.002), especially among non-Latino White men and men age ≥ 65 years. Black adults had the highest prevalence in 2013-2014 (37.1%) and Asian adults experienced the largest increase (20.1 to 29.2%, p = 0.06), especially Asian women. Foreign-born participants and participants lacking health insurance also had large increases in obesity. We observed increases in eating out and screen time over time and no improvements in physical activity. Our findings show increases in obesity in NYC in the past decade, with important sociodemographic differences.

Accuracy of Linking VR-12 and PROMIS Global Health Scores in Clinical Practice

OBJECTIVES

To examine the accuracy of general health cross-walk tables in a clinical sample of patients with spine disorders. Published tables (Schalet BD, Rothrock NE, Hays RD, et al. Linking physical and mental health summary scores from the Veterans RAND 12-Item Health Survey (VR-12) to the PROMIS(®) Global Health Scale. J Gen Intern Med 2015;30:1524-30) link scores from the Veterans RAND 12-Item Health Survey (VR-12) to the 10-Item Patient-Reported Outcome Measurement Information System (PROMIS), a global health scale metric for both mental (GMH) and physical (GPH) summary scores.

METHODS

We assessed the accuracy of administered PROMIS and VR-12 scores with scores predicted by cross-walks in 4606 adult patients seen in a spine clinic from October 2015 to 2016. Accuracy of linking scores was evaluated using Pearson correlation, intraclass correlation coefficients, and mean and SD of score differences. Bland-Altman plots were used to graphically assess the levels of agreement. The consistency in scores' discrimination across levels of pain severity, depression, and other patient characteristics was assessed. Bootstrap methods estimated linking precision across varying sample sizes.

RESULTS

Actual and cross-walked PROMIS scores showed moderate correlation (ICC(3,1): GMH 0.73; GPH 0.81), with Bland-Altman plots suggesting smaller differences between scores in patients with lower and higher general health. Significant discrimination between patient subgroups was demonstrated reliably by both actual and estimated scores. Bootstrapped resamples indicated adequate precision for 200 patients (95% confidence interval for mean difference: GMH -1.38 to 0.60; GPH 0.39 to 1.93).

CONCLUSIONS

VR-12 and PROMIS global health scores can be accurately linked within a sample of patients with spine disorders; nevertheless, bias is high and precision is low for linking on the patient level. Linked scores at the group level for more than 200 patients can be used in comparative effectiveness research and for comparing results across studies.

Among whom is cigarette smoking declining in the United States? The impact of cannabis use status, 2002-2015

OBJECTIVES

To 1) estimate changes in the prevalence of daily and non-daily cigarette smoking among current (past 30-day) daily, non-daily, and non-cannabis users in the United States (U.S.) population; 2) examine time trends in current (past 30-day) cigarette smoking in daily, non-daily, and non-cannabis users ages 12+ from 2002 to 2015.

METHODS

Data collected annually from the 2002 to 2015 National Survey on Drug Use and Health (NSDUH) were employed. Linear time trends of daily and non-daily cigarette smoking were assessed using logistic regression with year as the predictor.

RESULTS

In 2015, the prevalence of current (past 30-day) cigarette smoking was highest among daily (54.57%), followed by non-daily (40.17%) and non-cannabis users (15.06%). The prevalence of non-daily cigarette smoking increased among daily cannabis users from 2002 to 2015, whereas non-daily cigarette smoking declined among non-daily cannabis users and non-cannabis users from 2002 to 2015. Daily cigarette smoking declined among both cannabis users and non-users; the most rapid decline was observed among daily cannabis users, followed by non-daily and then by non-cannabis users. However, the relative magnitude of the change in prevalence of daily cigarette smoking was similar across the three cannabis groups.

CONCLUSIONS

Despite ongoing declines in cigarette smoking in the U.S., non-daily cigarette smoking is increasing among current cannabis users, a growing proportion of the U.S.

POPULATION

Daily and non-daily cigarette smoking continue to decline among those who do not use cannabis. Efforts to further tobacco control should consider novel co-use-oriented intervention strategies and outreach for the increasing population of cannabis users.

Estimating a Dutch Value Set for the Pediatric Preference-Based CHU9D Using a Discrete Choice Experiment with Duration

OBJECTIVE

This article presents the development of the Dutch value set for the Child Health Utility 9D, a pediatric preference-based measure of quality of life that can be used to generate quality-adjusted life-years.

METHODS

A large online survey was conducted using a discrete choice experiment including a duration attribute with adult members of the Netherlands general population (N = 1276) who were representative in terms of age, gender, marital status, employment, education, and region. Respondents were asked which of two health states they prefer, where each health state was described using the nine dimensions of the Child Health Utility 9D (worried, sad, pain, tired, annoyed, school work/homework, sleep, daily routine, able to join in activities) and duration. The data were modeled using conditional logit with robust standard errors to produce utility values for every health state described by the Child Health Utility 9D.

RESULTS

The majority of the dimension level coefficients were monotonic, leading to a decrease in utility as severity increases. There was, however, evidence of some logical inconsistencies, particularly for the school work/homework dimension. The value set produced was based on the ordered model and ranges from -0.568 for the worst state to 1 for the best state.

CONCLUSION

The valuation of the Child Health Utility 9D using online discrete choice experiment with duration with adult members of the Dutch general population was feasible and produced a valid model for use in cost utility analysis. Normative questions are raised around the valuation of pediatric preference-based measures, including the appropriate perspective for imagining hypothetical pediatric health states.

Does social participation reduce the risk of functional disability among older adults in China? A survival analysis using the 2005-2011 waves of the CLHLS data

BACKGROUND

Existing studies in developed countries show that social participation has beneficial effects on the functional ability of older adults, but research on Chinese older people is limited. This study examined the effects of participating in different types of social activities on the onset of functional disability and the underlying behavioral and psychosocial mechanisms among older adults aged 65 and older in China.

METHODS

The 2005, 2008, and 2011 waves of the Chinese Longitudinal Health Longevity Study were used. Life table analysis and discrete time hazard models were adopted to examine the relationship between social participation and functional disability. Social participation was defined as the frequencies of engaging in group leisure-time activities (i.e., playing cards/mahjong) and organized social activities, involving in informal social interactions (i.e., number of siblings frequently visited), and participating in paid jobs. Extensive social participation was measured by a composite index by adding up the four types of social activities that an older person was engaged in.

RESULTS

After controlling for the effect of socio-demographic characteristics, health status, and health behavioral factors, extensive social participation is associated with a significant reduced risk for the onset of functional disability (hazard ratio [HR] = 0.92, p < 0.001). Different types of social participation affect the risk of functional decline through different mechanisms. Frequent playing of cards/mahjong is a protective factor for functional decline (HR = 0.78, p < 0.001), and the relationship is partially mediated by cognitive ability and positive emotions (accounting for 18.9% and 7.0% of the association, respectively). Frequent participation in organized social activities is significantly related to a reduced risk of functional decline (HR = 0.78, p < 0.001), and the association is mediated by physical exercises and cognitive ability (accounting for 25.7% and 17.7% of the association, respectively). Frequent visits from siblings has a strong inverse relationship with functional decline (HR = 0.75, p < 0.001). However, no significant association between paid job and functional decline is observed.

CONCLUSION

Extensive social participation, regular engagement in group leisure-time activities, organized social activities, and informal social interactions in particular may have beneficial effects on the functional health of older adults through behavioral and psychosocial pathways. The findings shed light for the importance of promoting social participation among older adults.

The associated risk factors for underweight and overweight high school students in Cambodia

PURPOSE

Overweight and underweight are one of the leading risk factors for non-communicable diseases (NCDs), but little research on this area has been undertaken in Cambodia. Therefore, this study aimed to measure underweight and overweight and their associated risk behaviors among Cambodian high school students.

METHODS

3806 students (mean ag = 15.65 years, SD = 1.80, age range = 11-18 years) from the 2013 Cambodia-Global School-based Student Health Survey were used to yield representative samples of the Cambodian students. Body Mass Index (BMI) was assessed by students' self-reported height and weight. The substance use, depression, eating behaviors, suicidal ideation, and violence were examined as risk factors. The Chi-square and multinomial regressions were performed to assess the relationships between risk factors and BMI.

RESULTS

The prevalence of underweight was 47.4% (N = 1805, Male = 23.3%vs.24.1%) and overweight was 2.3% (N = 89, Male = 1.0%vs.1.3%). The BMI was significantly controlled by age, gender, and body height. Both underweight and overweight students were significantly vulnerable to substance use, feeling depressed, and violent behaviors. Of the risk factors, shortest sleep was prevalent for underweight students while feeling lonely and suicide attempts were the critical risks for overweight students. The daily fruit/vegetable consumption and physical activity were good preventive factors of both underweight and overweight epidemics.

CONCLUSIONS

The risk behaviors of students appear to be strongly associated with underweight and overweight. Interventions targeting these risk behaviors may have the potential to reduce risks. Meanwhile, the preventive strategies should focus on vulnerable students who have poor academic performance, mental health issues and a history of violent experiences.

Burden of Illness in Type 2 Diabetes Mellitus

An estimated 30.2 million Americans have diabetes, and this number is expected to increase based on trends over recent decades and compounded by an aging U.S.

POPULATION

As reviewed in this article, type 2 diabetes mellitus (T2DM) is associated with impaired health-related quality of life (HRQoL) and with a substantial socioeconomic burden. Compared with individuals without T2DM, those with T2DM have worse HRQoL, greater decrements in HRQoL over time, and possibly greater depressive symptomology. Diabetes-related complications and comorbidities (e.g., obesity and cardiovascular disease) are associated with worse HRQoL. Hypoglycemic episodes are associated with reduced HRQoL and greater levels of depression; they can also interfere with social and occupational activities. In turn, low HRQoL can be a driver for poor glycemic control. In 2012, the total estimated cost associated with diagnosed diabetes in the United States was $245 billion. Factors contributing to increased health care resource utilization and costs in patients with T2DM include medical comorbidities, diabetes-related complications, inadequate glycemic control, and hypoglycemic episodes. Readmission is a key driver of hospital-related costs and is more common among elderly patients with T2DM. Elderly patients with T2DM represent a particularly vulnerable population given that these patients may have varying degrees of physical and mental comorbidities that can increase their risk of hypoglycemia, falls, and depression. This review demonstrates that T2DM imposes a considerable burden on both the individual and society. Treatment strategies should consider the effects of treatment on HRQoL and on outcomes (e.g., complications and hypoglycemia) that affect both HRQoL and costs. Management strategies that maximize HRQoL while minimizing the risk of hypoglycemia and other treatment-related complications are particularly critical in the elderly.

DISCLOSURES

This supplement was funded by Novo Nordisk. Cannon reports speaker fees and owns stock in Novo Nordisk. Handelsman reports research grants from Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Grifols, Janssen, Lexicon, Merck, Novo Nordisk, Regeneron, and Sanofi; speaker fees from Amarin, Amgen, AstraZeneca, Boehringer Ingelheim-Lilly, Janssen, Merck, Novo Nordisk, Regeneron, and Sanofi; and has served in advisory capacity to Amarin, Amgen, AstraZeneca, Boehringer Ingelheim, Eisai, Intarcia, Janssen, Lilly, Merck, Merck-Pfizer, Novo Nordisk, Regeneron, and Sanofi. Heile reports speaker fees from and has served as advisor to Novo Nordisk. Shannon reports consultant and speaker fees from Novo Nordisk and Boehringer Ingelheim-Lilly Alliance.

Trend analysis for national surveys: Application to all variables from the Canadian Health Measures Survey cycle 1 to 4

BACKGROUND

Trend analysis summarizes patterns over time in the data to show the direction of change and can be used to investigate uncertainties in different time points and associations with other factors. However, this approach is not widely applied to national surveys and only selected outcomes are investigated. This study demonstrates a research framework to conduct trend analysis for all variables in a national survey, the Canadian Health Measures Survey (CHMS).

DATA AND METHODS

The CHMS cycle 1 to 4 was implemented between 2007 and 2015. The characteristics of all variables were screened and associated to the weight variables. Missing values were identified and cleaned according to the User Guide. The characteristics of all variables were extracted and used to guide data cleaning. Trend analysis examined the statistical significance of candidate predictors: the cycles, age, sex, education, household income and body mass index (BMI). R (v3.2) and RStudio (v0.98.113) were used to develop the framework.

RESULTS

There were 26557 variables in 79 data files from four cycles. There were 1055 variables significantly associated with the CHMS cycles and 2154 associated with the BMI after controlling for other predictors. The trend of blood pressure was similar to those published.

CONCLUSION

Trend analysis for all variables in the CHMS is feasible and is a systematic approach to understand the data. Because of trend analysis, we have detected data errors and identified several environmental biomarkers with extreme rates of change across cycles. The impact of these biomarkers has not been well studied by Statistics Canada or others. This framework can be extended to other surveys, especially the Canadian Community Health Survey.

Potential Effect Modifiers of the Association Between Physical Activity Patterns and Joint Symptoms in Middle-Aged Women

OBJECTIVE

To examine whether body mass index (BMI), menopausal status, and hormone therapy (HT) use modify the association between physical activity (PA) patterns throughout middle age and the incidence and prevalence of joint symptoms in women in later middle age.

METHODS

Data were from 6,661 participants (born 1946-1951) in the Australian Longitudinal Study on Women's Health. Surveys, with questions on joint pain and stiffness, PA, height and weight, menopausal symptoms, and HT use, were completed every 3 years from 1998 to 2010. PA patterns were defined as none or low, low or meeting guidelines, fluctuating, or meeting guidelines at all times (reference pattern). Logistic regression was used to examine the association between PA patterns and prevalent (in 2010) and cumulative incident (1998-2010) joint symptoms and effect modification by patterns in BMI, menopausal status, and HT.

RESULTS

The groups representing fluctuating PA (odds ratio [OR] 1.34 [99% confidence interval (99% CI) 1.04-1.72]) and no or low PA (OR 1.60 [99% CI 1.08-2.35]) had higher odds of incident joint symptoms than those described as meeting guidelines at all times. Stratification by BMI showed that this association was statistically significant in the obese group only. No evidence for effect modification by menopausal status or HT use was found. The findings were similar for prevalent joint symptoms.

CONCLUSION

Maintaining at least low levels of PA throughout middle age was associated with a lower prevalence and incidence of joint symptoms later in life. This apparent protective effect of PA on joint symptoms was stronger in obese women than in under- or normal-weight women, and not related to menopause or HT status.

Insomnia and risk of chronic musculoskeletal complaints: longitudinal data from the HUNT study, Norway

BACKGROUND

The aim of this study was to investigate the prospective association between insomnia and risk of chronic musculoskeletal complaints (CMSC) and chronic widespread musculoskeletal complaints (CWMSC). A second aim was to evaluate the association between insomnia and number of body regions with CMSC at follow-up.

METHODS

We used data from the second (HUNT2, 1995-1997) and third (HUNT3, 2006-2008) wave of the Nord-Trøndelag Health Study (the HUNT Study). The population-at-risk included 13,429 people aged 20-70 years who reported no CMSC at baseline in HUNT2 and who answered the questionnaires on insomnia in HUNT2 and CMSC in HUNT3. Insomnia was defined according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) with minor modification, whereas CMSC was assessed for nine different body regions. CWMSC was defined according to the 1990 criteria by the American College of Rheumatology. We used Poisson regression to estimate adjusted risk ratios (RRs) for CMSC and CWMSC at 11 years follow-up. Precision of the estimates was assessed by a 95% confidence interval (CIs).

RESULTS

Insomnia at baseline was associated with increased risk of any CMSC (RR 1.16, 95% CI 1.03-1.32) and CWMSC (RR 1.58, 95% CI 1.26-1.98) at follow-up. RR for CMSC for specific body regions ranged from 1.34 (95% CI 1.05-1.73) for the knees and 1.34 (1.10-1.63) for the neck to 1.60 (95% CI 1.19-2.14) for the ankles/ft. Further, insomnia was associated with increased risk of CMSC in 3-4 regions (RR 1.36, 95% CI 1.05-1.77), and 5 or more regions (RR 1.93, 95% CI 1.40-2.66), but not 1-2 regions (RR 0.99, 95% CI 0.80-1.24).

CONCLUSIONS

Insomnia is associated with increased risk of CMSC, CWMSC, and CMSC located in 3 or more body regions.

Decline in the perceived risk of cigarette smoking between 2006 and 2015: Findings from a U.S. nationally representative sample

INTRODUCTION

Perceived risk of smoking is associated with smoking status, interest in quitting, quit attempts, and sustained quitting. Tracking and reporting of risk perceptions is integral to inform regulation and education. However, no research describes temporal changes in perceived great risk of smoking in the U.S. using nationally representative data.

METHODS

Data came from the 2006-2015 National Survey on Drug Use and Health (NSDUH). Time trends were assessed for the population overall, stratified by smoking status and by sociodemographic characteristics. Linear time trends of perceived great risk (versus other risk) were assessed using logistic regression, with survey year as the predictor.

RESULTS

Perceived great risk of smoking declined significantly among the entire population between 2006 and 2015 (73.89% versus 72.89%). Perceived great risk also decreased among all smoking statuses: daily (51.16% versus 48.19%), non-daily (64.12% versus 58.44%, former (79.57% versus 77.12%), and non-smokers (79.32% versus 77.10%). The prevalence of perceived great risk declined between 2006 and 2015 among both males and females; the rate of decline was more rapid among females (aOR = 0.98, 95% CI = 0.97, 0.98 versus aOR = 0.99, 95% CI = 0.98, 0.99). Older age, African American and Hispanic race/ethnicity, educational attainment, and non-daily, former, and never smoking statuses were positively associated with perceived great risk of smoking.

DISCUSSION

Perceived risk of smoking has declined over a 10-year period in the U.S. Declines in perceived risk indicate the need for innovative interventions to reinforce the harms associated with smoking. Differential rates of decline among males and females indicate the need for sex-specific interventions.

Associations of Smoking, Physical Inactivity, Heavy Drinking, and Obesity with Quality-Adjusted Life Expectancy among US Adults with Depression

OBJECTIVES

To examine associations between four health behaviors (smoking, physical inactivity, heavy alcohol drinking, and obesity) and three health indices (health-related quality of life, life expectancy, and quality-adjusted life expectancy (QALE)) among US adults with depression.

METHODS

Data were obtained from the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System data. The EuroQol five-dimensional questionnaire (EQ-5D) health preference scores were estimated on the basis of extrapolations from the Centers for Disease Control and Prevention's healthy days measures. Depression scores were estimated using the eight-item Patient Health Questionnaire. Life expectancy estimates were obtained from US life tables, and QALE was estimated from a weighted combination of the EQ-5D scores and the life expectancy estimates. Outcomes were summarized by depression status for the four health behaviors (smoking, physical inactivity, heavy alcohol drinking, and obesity).

RESULTS

For depressed adults, current smokers and the physically inactive had significantly lower EQ-5D scores (0.040 and 0.171, respectively), shorter life expectancy (12.9 and 10.8 years, respectively), and substantially less QALE (8.6 and 10.9 years, respectively). For nondepressed adults, estimated effects were similar but smaller. Heavy alcohol drinking among depressed adults, paradoxically, was associated with higher EQ-5D scores but shorter life expectancy. Obesity was strongly associated with lower EQ-5D scores but only weakly associated with shorter life expectancy.

CONCLUSIONS

Among depressed adults, physical inactivity and smoking were strongly associated with lower EQ-5D scores, life expectancy, and QALE, whereas obesity and heavy drinking were only weakly associated with these indices. These results suggest that reducing physical inactivity and smoking would improve health more among depressed adults.

Time Trends in Smoking Onset by Sex and Race/Ethnicity Among Adolescents and Young Adults: Findings From the 2006-2013 National Survey on Drug Use and Health

Introduction

During the 2000s the number of adolescents who became new smokers in the United States declined while the number of young adults who did so increased. However, we do not know among which demographic groups these changes occurred.

Methods

We analyzed data from the 2006 to 2013 National Survey of Drug Use and Health (n = 180 079). Multivariate linear regression models were used to assess annual trends in smoking onset and log-binomial regression models to assess changes over time in the risk of smoking onset among young adults (18- to 25-years-old) relative adolescents (12- to 17-years-old).

Results

From 2006 to 2013, the rate of onset among young adults (6.3%) was greater than among adolescents (1.9%). Time trends demonstrated that annual declines in smoking onset occurred among white young adult males and females. Rates of smoking onset increased among black and Hispanic young adult males with a lower rate of decline among black and Hispanic young adult females. There was a greater risk of smoking onset among young adults relative to adolescents that did not change over time.

Conclusions

Smoking onset is becoming more concentrated in the young adult than adolescent years. Despite this trend, there were annual declines in young adult smoking onset but not uniformly across racial/ethnic groups. More effective strategies to prevent young adult smoking onset may contribute to a further decline in adult smoking and a reduction in tobacco-related health disparities.

Implications

Smoking onset is becoming more concentrated in the young adult years across sex and racial/ethnic groups. The United States may be experiencing a period of increasing age of smoking onset and must develop tobacco control policies and practices informed by these changes.

The burden of headache disorders in Ethiopia: national estimates from a population-based door-to-door survey

BACKGROUND

Headache disorders are the third-highest cause of disability worldwide, with migraine and medication-overuse headache (MOH) the major contributors. In Ethiopia we have shown these disorders to be highly prevalent: migraine 17.7%, TTH 20.6%, probable MOH (pMOH) 0.7%, any headache yesterday (HY) 6.4%. To inform local health policy, we now estimate disability and other burdens attributable to headache in this country.

METHODS

In a cross-sectional survey using cluster-randomized sampling, we visited households unannounced in four diverse regions (urban and rural) of Ethiopia. We interviewed one member (18-65 years old) of each household using the HARDSHIP structured questionnaire. Screening and diagnostic questions based on ICHD-II were followed by burden enquiry in multiple domains. We estimated disability using disability weights (DWs) from the Global Burden of Disease 2013 study.

RESULTS

We interviewed 2385 participants (1064 [44.7%] male, 596 [25.0%] urban; participating proportion 99.8%). Reported mean intensity of migraine was 2.6 (scale 1-3). People with migraine spent 11.7% of their time in the ictal state (DW: 0.441); they were therefore 5.2% disabled overall. Pain and disability from TTH were much lower. Mean intensity of pMOH was 2.95. People with pMOH spent 60.2% of time with headache (DW: 0.223), and were 13.4% disabled. Average proportions of per-person lost productive time were, for migraine, 4.5% from paid work, 5.3% from household work; for pMOH they were 29.2% and 16.0%. There were highly-disabled minorities, and large gender differences, males losing more paid workdays, females more household workdays. All headache types were associated with impairments in quality of life. Across the population aged 18-65 years (effectively the working population), disability from headache was 1.4%, with 1.6% of workdays lost (half from migraine). Estimates from HY, eliminating recall error, were highly compatible.

CONCLUSIONS

Ethiopia is a low-income country, and cannot afford these losses - including, perhaps, 1.6% of GDP. Political action is necessary, aimed at mitigating both the economic burden and the associated ill health. WHO has recommended structured headache services with their basis in primary care as the most efficient, effective, affordable and equitable solution, potentially cost-saving. We believe they can be implemented within Ethiopia's existing health-care infrastructure.

Cancer mortality disparities among New York City's Upper Manhattan neighborhoods

The East Harlem (EH), Central Harlem (CH), and Upper East Side (UES) neighborhoods of New York City are geographically contiguous to tertiary medical care, but are characterized by cancer mortality rate disparities. This ecological study aims to disentangle the effects of race and neighborhood on cancer deaths. Mortality-to-incidence ratios were determined using neighborhood-specific data from the New York State Cancer Registry and Vital Records Office (2007-2011). Ecological data on modifiable cancer risk factors from the New York City Community Health Survey (2002-2006) were stratified by sex, age group, race/ethnicity, and neighborhood and modeled against stratified mortality rates to disentangle race/ethnicity and neighborhood using logistic regression. Significant gaps in mortality rates were observed between the UES and both CH and EH across all cancers, favoring UES. Mortality-to-incidence ratios of both CH and EH were similarly elevated in the range of 0.41-0.44 compared with UES (0.26-0.30). After covariate and multivariable adjustment, black race (odds ratio=1.68; 95% confidence interval: 1.46-1.93) and EH residence (odds ratio=1.20; 95% confidence interval: 1.07-1.35) remained significant risk factors in all cancers' combined mortality. Mortality disparities remain among EH, CH, and UES neighborhoods. Both neighborhood and race are significantly associated with cancer mortality, independent of each other. Multivariable adjusted models that include Community Health Survey risk factors show that this mortality gap may be avoidable through community-based public health interventions.

Trends in obesity and diabetes across Africa from 1980 to 2014: an analysis of pooled population-based studies

Background

The 2016 Dar Es Salaam Call to Action on Diabetes and Other non-communicable diseases (NCDs) advocates national multi-sectoral NCD strategies and action plans based on available data and information from countries of sub-Saharan Africa and beyond. We estimated trends from 1980 to 2014 in age-standardized mean body mass index (BMI) and diabetes prevalence in these countries, in order to assess the co-progression and assist policy formulation.

Methods

We pooled data from African and worldwide population-based studies which measured height, weight and biomarkers to assess diabetes status in adults aged ≥ 18 years. A Bayesian hierarchical model was used to estimate trends by sex for 200 countries and territories including 53 countries across five African regions (central, eastern, northern, southern and western), in mean BMI and diabetes prevalence (defined as either fasting plasma glucose of ≥ 7.0 mmol/l, history of diabetes diagnosis, or use of insulin or oral glucose control agents).

Results

African data came from 245 population-based surveys (1.2 million participants) for BMI and 76 surveys (182 000 participants) for diabetes prevalence estimates. Countries with the highest number of data sources for BMI were South Africa (n = 17), Nigeria (n = 15) and Egypt (n = 13); and for diabetes estimates, Tanzania (n = 8), Tunisia (n = 7), and Cameroon, Egypt and South Africa (all n = 6). The age-standardized mean BMI increased from 21.0 kg/m2 (95% credible interval: 20.3-21.7) to 23.0 kg/m2 (22.7-23.3) in men, and from 21.9 kg/m2 (21.3-22.5) to 24.9 kg/m2 (24.6-25.1) in women. The age-standardized prevalence of diabetes increased from 3.4% (1.5-6.3) to 8.5% (6.5-10.8) in men, and from 4.1% (2.0-7.5) to 8.9% (6.9-11.2) in women. Estimates in northern and southern regions were mostly higher than the global average; those in central, eastern and western regions were lower than global averages. A positive association (correlation coefficient ≃ 0.9) was observed between mean BMI and diabetes prevalence in both sexes in 1980 and 2014.

Conclusions

These estimates, based on limited data sources, confirm the rapidly increasing burden of diabetes in Africa. This rise is being driven, at least in part, by increasing adiposity, with regional variations in observed trends. African countries' efforts to prevent and control diabetes and obesity should integrate the setting up of reliable monitoring systems, consistent with the World Health Organization's Global Monitoring System Framework.

Does a Crossover Age Effect Exist for African American and Hispanic Binge Drinkers? Findings from the 2010 to 2013 National Study on Drug Use and Health

BACKGROUND

Among general population studies, lower rates of binge drinking tend to be found among African Americans and Hispanics compared to Whites. However, among older adult populations, minority groups have been shown to be at higher risk for binge drinking, suggesting the presence of a crossover effect from low to high risk as a function of age. To date, limited research has examined the crossover effect among African American and Hispanic populations compared to non-Hispanic Whites across large developmental time frames or explored variation in risk based on income or gender. This study aimed to fill these gaps in the literature.

METHODS

Data were compiled from the 2010 to 2013 National Survey on Drug Use and Health surveys, which provide annual, nationally representative data on substance use behaviors among individuals aged 12 and older. Hispanic, non-Hispanic African American, and non-Hispanic White respondents were included (N = 205,198) in the analyses.

RESULTS

A crossover effect was found for African American males and females among the lowest income level (i.e., incomes less than $20,000). Specifically, after controlling for education and marital status, compared to Whites, risk for binge drinking was lower for African American males at ages 18 to 24 and for females at ages 18 to 34, but higher for both African American males and females at ages 50 to 64. No crossover effect was found for Hispanic respondents.

CONCLUSIONS

Although African Americans are generally at lower risk for binge drinking, risk appears to increase disproportionately with age among those who are impoverished. Explanatory factors, such as social determinants of health prevalent within low-income African American communities (e.g., lower education, violence exposure, housing insecurity) and potential areas for intervention programming are discussed.

The impact of residential status on cognitive decline among older adults in China: Results from a longitudinal study

BACKGROUND

Residential status has been linked to numerous determinants of health and well-being. However, the influence of residential status on cognitive decline remains unclear. The purpose of this research was to assess the changes of cognitive function among older adults with different residential status (urban residents, rural-to-urban residents, rural residents, and urban-to-rural residents), over a 12-year period.

METHODS

We used five waves of data (2002, 2005, 2008/2009, 2011/2012, and 2014) from the Chinese Longitudinal Healthy Longevity Survey with 17,333 older adults age 65 and over who were interviewed up to five times. Cognitive function was measured by the Mini Mental State Examination (MMSE). Multilevel models were used regarding the effects of residential status after adjusting for demographic characteristics, socioeconomic factors, family support, health behaviors, and health status.

RESULTS

After controlling for covariates, significant differences in cognitive function were found across the four groups: rural-to-urban and rural residents had a higher level of cognition than urban residents at baseline. On average, cognitive function decreased over the course of the study period. Rural-to-urban and rural residents demonstrated a faster decline in cognitive function than urban residents.

CONCLUSIONS

This study suggests that residential status has an impact on the rate of changes in cognition among older adults in China. Results from this study provide directions for future research that addresses health disparities, particularly in countries that are undergoing significant socioeconomic transitions.

The effect of alcohol consumption on household income in Ireland

This paper presents a study of the effects of alcohol consumption on household income in Ireland using the Slán National Health and Lifestyle Survey 2007 dataset, accounting for endogeneity and selection bias. Drinkers are categorised into one of four categories based on the recommended weekly drinking levels by the Irish Health Promotion Unit; those who never drank, non-drinkers, moderate and heavy drinkers. A multinomial logit OLS Two Step Estimate is used to explain individual's choice of drinking status and to correct for selection bias which would result in the selection into a particular category of drinking being endogenous. Endogeneity which may arise through the simultaneity of drinking status and income either due to the reverse causation between the two variables, income affecting alcohol consumption or alcohol consumption affecting income, or due to unobserved heterogeneity, is addressed. This paper finds that the household income of drinkers is higher than that of non-drinkers and of those who never drank. There is very little difference between the household income of moderate and heavy drinkers, with heavy drinkers earning slightly more. Weekly household income for those who never drank is €454.20, non-drinkers is €506.26, compared with €683.36 per week for moderate drinkers and €694.18 for heavy drinkers.

Trend in alcohol use in Australia over 13 years: has there been a trend reversal?

BACKGROUND

Skog's collectivity theory of alcohol consumption predicted that changes in alcohol consumption would synchronize across all types of drinkers in a population. The aim of this paper is examine this theory in the Australian context. We examined whether there was a collective change in alcohol use in Australia from 2001 to 2013, estimated alcohol consumption in non-high risk and high risk drinkers, and examined the trends in alcohol treatment episodes.

METHODS

Data from the 2001-2013 National Drug Strategy Household Surveys (N = 127,916) was used to estimate the prevalence and alcohol consumption of abstainers, high risk drinkers and frequent heavy episodic drinkers. Closed treatment episodes recorded in the Alcohol and Other Drug Treatment Services National Minimum Dataset (N = 608,367) from 2001 to 2013 were used to examine the trends of closed alcohol treatment episodes.

RESULTS

The prevalence of non-drinkers (abstainers) decreased to the lowest level in 2004 (15.3 %) and rebounded steadily thereafter (20.4 % in 2013; p < .001). Correspondingly, the per capita consumption of high risk drinkers (2 standard drinks or more on average per day) increased from 20.7 L in 2001 to peak in 2010 (21.5 L; p = .020). Non-high risk drinkers' consumption peaked in 2004 (2.9 L) and decreased to 2.8 L in 2013 (p < .05). There were decreases in alcohol treatment episodes across nearly all birth cohorts in recent years.

CONCLUSION

These findings are partially consistent with and support Skog's collectivity theory. There has been a turnaround in alcohol consumption after a decade-long uptrend, as evident in the collective decreases in alcohol consumption among nearly all types of drinkers. There was also a turnaround in rate of treatment seeking, which peaked at 2007 and then decreased steadily. The timing of this turnaround differs with level of drinking, with non-high risk drinkers reaching its peak consumption in 2004 and high risk drinkers reaching its peak consumption in 2010.

What Explains Cambodia's Success in Reducing Child Stunting-2000-2014?

In many developing countries, high levels of child undernutrition persist alongside rapid economic growth. There is considerable interest in the study of countries that have made rapid progress in child nutrition to uncover the driving forces behind these improvements. Cambodia is often cited as a success case having reduced the incidence of child stunting from 51% to 34% over the period 2000 to 2014. To what extent is this success driven by improvements in the underlying determinants of nutrition, such as wealth and education, ("covariate effects") and to what extent by changes in the strengths of association between these determinants and nutrition outcomes ("coefficient effects")? Using determinants derived from the widely-applied UNICEF framework for the analysis of child nutrition and data from four Demographic and Health Surveys datasets, we apply quantile regression based decomposition methods to quantify the covariate and coefficient effect contributions to this improvement in child nutrition. The method used in the study allows the covariate and coefficient effects to vary across the entire distribution of child nutrition outcomes. There are important differences in the drivers of improvements in child nutrition between severely stunted and moderately stunted children and between rural and urban areas. The translation of improvements in household endowments, characteristics and practices into improvements in child nutrition (the coefficient effects) may be influenced by macroeconomic shocks or other events such as natural calamities or civil disturbance and may vary substantially over different time periods. Our analysis also highlights the need to explicitly examine the contribution of targeted child health and nutrition interventions to improvements in child nutrition in developing countries.

Mental health care use in adolescents with and without mental disorders

The aim of the study was to estimate the proportion of adolescents with and without a psychiatric diagnosis receiving specialist mental health care and investigate their problem levels as well as utilization of other types of mental health care to detect possible over- and undertreatment. Care utilization data were linked to psychiatric diagnostic data of 2230 adolescents participating in the TRAILS cohort study, who were assessed biannually starting at age 11. Psychiatric diagnoses were established at the fourth wave by the Composite International Diagnostic Interview. Self-, parent- and teacher-reported emotional and behavioral problems and self-reported mental health care use were assessed at all four waves. Of all diagnosed adolescents, 35.3 % received specialist mental health care. This rate increased to 54.5 % when three or more disorders were diagnosed. Almost a third (28.5 %) of specialist care users had no psychiatric diagnosis; teachers gave them relatively high ratings on attention and impulsivity subscales. Diagnosed adolescents without specialist mental health care also reported low rates of other care use. We found no indication of overtreatment. Half of the adolescents with three or more disorders do not receive specialist mental health care nor any other type of care, which might indicate unmet needs.

The Effect of Leisure-Time Physical Activity on Obesity, Diabetes, High BP and Heart Disease Among Canadians: Evidence from 2000/2001 to 2005/2006

Although studies have looked at the effect of physical activity on obesity and other health outcomes, the causal nature of this relationship remains unclear. We fill this gap by investigating the impact of leisure-time physical activity (LTPA) and work-related physical activity (WRPA) on obesity and chronic conditions in Canadians aged 18-75 using instrumental variable and recursive bivariate probit approaches. Average local temperatures surrounding the respondents' interview month are used as a novel instrument to help identify the causal relationship between LTPA and health outcomes. We find that an active level of LTPA (i.e., walking ≥1 h/day) reduces the probability of obesity by five percentage points, which increases to 11 percentage points if also combined with some WRPA. WRPA exhibits a negative effect on the probability of obesity and chronic conditions.

[Psychopathological problems and psychosocial impairment in children and adolescents aged 3-17 years in the German population: prevalence and time trends at two measurement points (2003-2006 and 2009-2012): results of the KiGGS study: first follow-up (KiGGS Wave 1)]

Child and adolescent mental health problems burden not only the individual, but also their families and their social environment and may, therefore, be regarded as a highly relevant public health issue. The data on mental health problems of children and adolescents from the KiGGS Wave 1 study (sample period 2009-2012) make it possible to report on both current prevalence rates and time trends over the 6-year period beginning with the KiGGS baseline survey (2003-2006). The assessment of emotional and behavioral problems in KiGGS Wave 1 was carried out with the symptoms questionnaire of the Strengths and Difficulties Questionnaire (SDQ) in a telephone interview with 10,353 guardians of children and adolescents aged 3-17 years. Moreover, using the SDQ impact supplement, the KIGGS Wave 1 data provide information on psychosocial impairment following child and adolescent mental health problems. Subjects with a borderline or abnormal SDQ score, according to German normative data, were considered at risk. A total of 20.2% (95% CI: 18.9-21.6%) of the study subjects were identified as being at risk for a mental health disorder, compared with 20.0% (19.1-20.9%) during the KiGGS baseline study (age-standardized based on population from 12 December 2010). Thus, no significant changes over time in the prevalence of mental health problems were detected. Also, there were no statistically significant differences in prevalence by sex, age group, or socioeconomic status between the KiGGS baseline survey and KiGGS Wave 1. The statistical comparison of the subscale mean values for both girls and boys showed higher values with respect to the subscales for emotional problems, behavioral problems, and prosocial behavior and lower mean values for the peer problems subscale in KiGGS Wave 1. These partly small temporal trends, however, may be due to possible mode effects (written questionnaire in the KiGGS baseline study versus telephone interview in KiGGS Wave 1). The hyperactivity subscale remained stable across the two sample periods. Regarding impairments following mental health problems at the second sample period, boys were more affected in the areas of chronicity, family burden, and impact score. The high and stable prevalence rates and magnitude of emotional and behavioral problems should prompt increased preventive efforts.

[Health-related quality of life in children and adolescents in Germany: results of the KiGGS study: first follow-up (KiGGS Wave 1)]

In recent years, there has been a change in the health and disease spectrum among children and adolescents, with an increase in mental health problems and a shift from acute to chronic illness. In this phase, the health-related quality of life (HRQoL) has increased in importance as a dimension of subjective health. The aim of this study is to describe the HRQoL of children and adolescents measured with the internationally standardized screening instrument KIDSCREEN-10. In the follow-up of the KiGGS study in 2009-2012 (KiGGS Wave 1), 2,567 parents of children aged 7-10 years and 4,878 adolescents aged 11 years or older completed the KIDSCREEN-10 questionnaire. In all, 94% of parents of 7- to 10-year-old girls and boys estimate the HRQoL of their children to be "very good" or "good." Of the 11- to 17-year-old adolescents, 96% report their HRQoL as "very good" or "good." Somatic diseases and pain as well as mental health problems and a low social status are included in the HRQoL in only a limited way. Potential differences in HRQoL by social status were not confirmed in multivariate models. The HRQoL of the examined children and adolescents is predominantly very good or good. Interventions to improve the HRQoL of children and adolescents with diseases and psychopathological problems are necessary, regardless of their social status.

IQ and level of alcohol consumption—findings from a national survey of Swedish conscripts

BACKGROUND

Studies of the association between IQ and alcohol consumption have shown conflicting results. The aim of this study was to investigate the association between IQ test results and alcohol consumption, measured as both total alcohol intake and pattern of alcohol use.

METHODS

The study population consists of 49,321 Swedish males born 1949 to 1951 who were conscripted for Swedish military service 1969 to 1970. IQ test results were available from tests performed at conscription. Questionnaires performed at conscription provided data on total alcohol intake (consumed grams of alcohol/wk) and pattern of drinking. Multinomial and binomial logistic regressions were performed on the cross-sectional data to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Adjustments were made for socioeconomic position as a child, psychiatric symptoms and emotional stability, and father's alcohol habits.

RESULTS

We found an increased OR of 1.20 (1.17 to 1.23) for every step decrease on the stanine scale to be a high consumer versus a light consumer of alcohol. For binge drinking, an increased OR of 1.09 (95% CI = 1.08 to 1.11) was estimated for every step decrease on the stanine scale. Adjustment for confounders attenuated the associations. Also, IQ in adolescence was found to be inversely associated with moderate/high alcohol consumption measured in middle age.

CONCLUSIONS

We found that lower results on IQ tests are associated with higher consumption of alcohol measured in terms of both total alcohol intake and binge drinking in Swedish adolescent men.

How do recovery definitions distinguish recovering individuals? Five typologies

BACKGROUND

Six percent of American adults say they are "in recovery" from an alcohol or drug problem yet only a scant emergent literature has begun to ask how they define "recovery" or explored whether there is heterogeneity among their definitions.

METHODS

Secondary analysis of the "What is Recovery?" online survey employed latent class analysis (LCA) to identify typologies of study participants based on their actual endorsement of 39 recovery elements and to compare the composition of these typologies in terms of distinguishing personal characteristics.

RESULTS

A five-class solution provided the best fit and conceptual representation for the recovery definitions. Classes were labeled 12-step traditionalist (n=4912); 12-step enthusiast (n=2014); secular (n=980); self-reliant (n=1040); and atypical (n=382) based on patterns of endorsement of the recovery elements. Abstinence, spiritual, and social interaction elements differentiated the classes most (as did age and recovery duration but to a lesser extent). Although levels and patterns of endorsement to the elements varied by class, a rank-ordering of the top 10 elements indicated that four elements were endorsed by all five classes: being honest with myself, handling negative feelings without using, being able to enjoy life, and process of growth and development.

CONCLUSIONS

The results of the LCA demonstrate the diversity of meanings, and varying degrees of identification with, specific elements of recovery. As others have found, multiple constituents are invested in how recovery is defined and this has ramifications for professional, personal, and cultural processes related to how strategies to promote recovery are implemented.

Estimating quality-adjusted life-year loss due to noncommunicable diseases in Korean adults through to the year 2040

OBJECTIVES

To estimate the loss in quality-adjusted life-years (QALYs) in Korean adults due to 13 noncommunicable diseases (NCDs) in 2010 and predict changes in QALY loss through to the year 2040.

METHODS

Thirteen NCDs (hypertension, diabetes mellitus, hyperlipidemia, stroke, myocardial infarction, angina, arthritis, osteoporosis, asthma, allergic rhinitis, atopic dermatitis, cataract, and depression) were selected from the Korean Community Health Survey 2010. The EuroQol five-dimensional questionnaire index from the Korean Community Health Survey 2010 and the Korean valuation set were used to estimate utility weights according to sex, age, and disease. Morbidity data were also obtained from the Korean Community Health Survey 2010. Mortality data according to disease and life expectancy were retrieved from the Korean Statistical Information Service. To predict future QALY loss, future population projection data from the Korean Statistical Information Service were used as substitutes for 2010 population size.

RESULTS

Among the assessed 13 NCDs, the largest total QALY loss was for hypertension (513,113 QALYs; units are omitted hereafter), followed by arthritis (509,317) and stroke (431,049). The largest QALY loss due to mortality was stroke (306,733), whereas the largest QALY loss due to morbidity was arthritis (502,513). By applying the middle estimate of future population, the largest increase in total QALY loss between 2010 and 2040 was for hypertension (840,582), followed by stroke (719,076) and diabetes mellitus (474,607).

CONCLUSIONS

Hypertension, arthritis, and stroke are important in terms of total QALY loss, which will continuous to increase because of aging. These results could be used to develop cost-effective interventions that reduce the burden of NCDs.

A brief report on Primary Care Service Area catchment geographies in New South Wales Australia

BACKGROUND

To develop a method to use survey data to establish catchment areas of primary care or Primary Care Service Areas. Primary Care Service Areas are small areas, the majority of patients resident in which obtain their primary care services from within the geography.

METHODS

The data are from a large health survey (n =267,153, year 2006-2009) linked to General Practitioner service use data (year 2002-2010) from New South Wales, Australia. Our methods broadly follow those used previously by researchers in the United States of America and Switzerland, with significant modifications to improve robustness. This algorithm allocates post code areas to Primary Care Service Areas that receive the plurality of patient visits from the post code area.

RESULTS

Consistent with international findings the median Localization Index or the median percentage of patients that obtain their primary care from within a Primary Care Service Area is 55% with localization increasing with rurality.

CONCLUSIONS

With the additional methodological refinements in this study, Australian Primary Care Service Areas have great potential to be of value to policymakers and researchers.

Monitoring and evaluating progress towards Universal Health Coverage in Bangladesh

This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Tanvir Mahmudul Huda and colleagues illustrate progress towards UHC and its monitoring and evaluation in Bangladesh. Please see later in the article for the Editors' Summary