Adverse Childhood Events Significantly Impact Depression and Mental Distress in Adults with a History of Cancer

Objectives: Adverse childhood experiences (ACEs) are linked to a heightened risk of depression. We explored the relationship between ACEs and both depression and mental distress among cancer survivors. Methods: This was a cross-sectional analysis using the 2022 Behavioral Risk Factor Surveillance System database of cancer survivors aged ≥18 (n = 14,132). The primary outcome was self-reported history of depression, and the secondary outcome was mental distress. The exposure variable was the number of ACEs, classified as 0, 1-2, and ≥3. Weighted multivariable logistic regression models assessed the association between the number of ACEs and depression and mental distress while adjusting for covariates. Results: Approximately 22% of respondents reported experiencing ≥3 ACEs. The prevalence of depression was 21.8%, and mental distress was 15.4%. Compared with cancer survivors who had experienced 0 ACEs, those who had experienced ≥3 (aOR = 3.94; 95% CI, 3.04-5.10) or 1-2 (aOR = 1.85; 95% CI, 1.47-2.32) ACEs had a higher likelihood of reporting depression. Compared with cancer survivors who had experienced 0 ACEs, those who had experienced ≥3 (aOR = 0.67; 95% CI, 0.48-0.93) had a lower likelihood of reporting mental distress. Conclusions: This study highlights the impact of ACEs on depression in adulthood among cancer survivors.

The Together for Health - Virginia Research Program: A Multi-Modal Approach for Population Health Assessment

Background

The Together for Health-Virginia (T4H-VA) Research Program aimed to advance cancer prevention, education, and outreach in Virginia. Creating a representative and inclusive cohort is critical to the program's mission and quality of outcomes. The T4H-VA Research Program utilized a multi-modal sampling approach to improve population health assessment. The current study describes the technology-based, non-probability platform developed for this purpose and compares differences between the probability-based (mail-based) and non-probability-based (e-cohort) methods with respect to participant demographics, health characteristics, and health information and technology use.

Methods

T4H-VA is a research registry focusing on 54 counties within the Massey Comprehensive Cancer Center (MCCC) catchment area in Richmond, VA. Adult residents proficient in English were eligible. For the probability-based sampling, surveys were mailed to residents within the catchment area. For the non-probability sampling, an online study platform was developed and surveys were completed through the web/mobile app.

Results

Both cohorts fell short of recruitment goals. The study yielded 1158 participants (M=57, SD=16 years; 55.0% female; 72.1% White); 899 (77.6%) were sampled through the probability, mail-based approach. Participants who identified as "other" race were significantly less likely to be sampled by the non-probability method. Significant differences emerged, including health protective (greater moderate and high physical activity) and risk factors (greater alcohol consumption and personal history of cancer) in the non-probability, e-cohort relative to the probability sample. E-Cohort participants were significantly more likely to report using electronic health records.

Discussion

Overall difficulties in recruiting were caused, at least in part, by the onset of the COVID-19 pandemic and related factors. The e-cohort, which used exclusively digital recruitment strategies, fell significantly short of recruitment goals. This suggests in-person and mail-based strategies remain important for recruitment. Moreover, instead of favoring a singular approach, a combined approach to survey sampling may capitalize on the strengths of each sampling mode to increase diversity in sociodemographic and health risk characteristics.

Associations Among Family Caregivers' Perceptions of Loneliness, Choice, and Purpose: a Comparative Analysis Between Non-Hispanic Black Caregivers and Non-Hispanic White Caregivers in a Population-Based Sample

BACKGROUND

Loneliness is a frequent experience among family members engaging in caregiving responsibilities and may vary across racial and ethnic groups. This study aimed to examine (a) the difference in loneliness between non-Hispanic Black and non-Hispanic White caregivers, (b) the associations between loneliness and perceptions of choice and purpose in caregiving, and (c) whether those associations with loneliness differ by caregivers' race.

METHOD

Descriptive statistics and ordinal logistic regression were conducted in a population-based sample of 1000 caregivers (Black caregivers, n = 199; White caregivers, n = 801) from the 2020 Caregiving in the U.S.

STUDY

The survey design was properly addressed. Key variables included loneliness (level of feeling alone about being a caregiver), choice (whether or not reporting a choice in taking on the caregiver responsibility), sense of purpose (level of purpose/meaning in life from caregiving), and race (Black/White). Models adjusted for caregiving characteristics (e.g., hour of caregiving) and sociodemographic characteristics (e.g., age and education).

RESULTS

Black caregivers had lower odds of reporting a higher level vs. a lower level of loneliness than White caregivers (aOR = 0.67, 95%CI = 0.47, 0.96). Reporting having no choice was associated with higher odds of a higher level of loneliness (aOR, 0.77, 95%CI = 0.67, 0.88). Higher sense of purpose scores were associated with lower odds of a higher level of loneliness (aOR = 0.81, 95%CI = 0.71, 0.93). No significant moderation effects of race were found.

CONCLUSION

Black caregivers reported lower loneliness scores than White caregivers. Reporting no choice and lower sense of purpose were associated with higher loneliness in both racial groups.

Association Between Subjective Cognitive Decline and Twice-Weekly Muscle-Strengthening Activities in Middle-Aged and Older US Adults: An Analysis of the 2019 Behavioral Risk Factor Surveillance System

PURPOSE

Adults with subjective cognitive decline (SCD), the self-reported concern of reduced cognitive function, are recommended to do physical activity for its brain health benefits. US adults aged ≥45 with SCD are less likely to meet the American College of Sports Medicine (ACSM) aerobic activity recommendations. Their engagement in muscle-strengthening activities is unknown. We aimed to identify if US adults aged ≥45 with SCD are less likely to do twice-weekly muscle-strengthening activities compared to those without SCD.

DESIGN

Secondary analysis of the 2019 Behavioral Risk Factor Surveillance System (BRFSS) data.

SAMPLE

114 164 respondents, representing approximately 59 million US adults aged ≥45.

MEASURES

SCD was indicated if the respondent reported confusion or memory loss during the past 12 months (yes/no). Respondents reported the frequency of muscle-strengthening activities, which we categorized as meeting the ACSM's recommendations (2+ times per week) or not (<2 times per week).

ANALYSIS

Crude and adjusted logistic regression models controlling for variables associated with SCD and muscle-strengthening activities. The models used sample weights to represent US adults in the included 31 states and Washington D.C.

RESULTS

US adults aged ≥45 with SCD were less likely to do twice-weekly muscle-strengthening activities than those without SCD (28.6% [SE: .8%] vs 33.5% [SE: .3%], adjusted OR, .9; 95% CI: .9-1.0).

CONCLUSION

Primary care providers should encourage middle-aged and older patients to engage in muscle-strengthening and aerobic activities.

Engaging Antiracist And Decolonial Praxis To Advance Equity In Oregon Public Health Surveillance Practices

Public health surveillance and data systems in the US remain an unnamed facet of structural racism. What gets measured, which data get collected and analyzed, and how and by whom are not matters of happenstance. Rather, surveillance and data systems are productions and reproductions of political priority, epistemic privilege, and racialized state power. This has consequences for how communities of color are represented or misrepresented, viewed, and valued and for what is prioritized and viewed as legitimate cause for action. Surveillance and data systems accordingly must be understood as both an instrument of structural racism and an opportunity to dismantle it. Here, we outline a critique of standard surveillance systems and practice, drawing from the social epidemiology, critical theory, and decolonial theory literatures to illuminate matters of power germane to epistemic and procedural justice in the surveillance of communities of color. We then summarize how community partners, academics, and state health department data scientists collaborated to reimagine survey practices in Oregon, engaging public health critical race praxis and decolonial theory to reorient toward antiracist surveillance systems. We close with a brief discussion of implications for practice and areas for continued consideration and reflection.

Prevalence of menthol cigarette use among adults who smoke from the United States by census division and demographic subgroup, 2002-2020: findings from the International Tobacco Control (ITC) project

BACKGROUND

Targeted marketing of menthol cigarettes in the US influences disparities in the prevalence of menthol smoking. There has been no analysis of sub-national data documenting differences in use across demographic subgroups. This study estimated trends in the prevalence of menthol use among adults who smoke in the nine US census divisions by sex, age, and race/ethnicity from 2002 to 2020.

METHODS

Data from 12 waves of the US ITC Survey were used to estimate the prevalence of menthol cigarette use across census divisions and demographic subgroups using multilevel regression and post-stratification (n = 12,020). Multilevel logistic regression was used to predict the prevalence of menthol cigarette use in 72 cross-classified groups of adults who smoke defined by sex, age, race/ethnicity, and socioeconomic status; division-level effects were fit with a random intercept. Predicted prevalence was weighted by the total number of adults who smoke in each cross-classified group and aggregated to divisions within demographic subgroup. Estimates were validated against the Tobacco Use Supplement to the Current Population Survey (TUS-CPS).

RESULTS

Overall modeled prevalence of menthol cigarette use was similar to TUS-CPS estimates. Prevalence among adults who smoke increased in each division from 2002 to 2020. By 2020, prevalence was highest in the Middle (46.3%) and South Atlantic (42.7%) and lowest in the Pacific (25.9%) and Mountain (24.2%) divisions. Prevalence was higher among adults aged 18-29 (vs. 50+) and females (vs. males). Prevalence among non-Hispanic Black people exceeded 80% in the Middle Atlantic, East North Central, West North Central, and South Atlantic in all years and varied most among Hispanic people in 2020 (Pacific: 26.5%, New England: 55.1%).

CONCLUSIONS

Significant geographic variation in the prevalence of menthol cigarette use among adults who smoke suggests the proposed US Food and Drug Administration (FDA) menthol cigarette ban will exert differential public health benefits and challenges across geographic and demographic subgroups.

Association between number of Adverse Childhood Experiences and depression among older adults is moderated by race

OBJECTIVE

This study aimed to assess the association between number of Adverse Childhood Experiences (ACE) and history of depression among older adults and to explore the interaction by race.

METHODS

This study was a cross-sectional analysis of the 2020 Behavioral Risk Factor Surveillance System (BRFSS) data among 60,122 older respondents (≥ 60 years old). The ACE score (zero, one, two-three, ≥four) included questions assessing exposure to eight types of ACEs before age 18. The outcome was the respondent's self-report depression diagnosed (yes/no). Multivariable logistic regression models examined the association between ACEs and depression stratified by race. Each model adjusted for age, smoking status, income, education, marital status, and body mass index.

RESULTS

In this sample of older adults, 47%, 23%, 19% and 10% reported having experienced zero, one, two-three, and four or more types of ACEs, respectively. Depression was reported by 16% of survey respondents. There was a significant interaction between ACE score and race and depression (p = 0.038). Respondents who experienced ≥4 ACEs had higher likelihood of reporting depression for all race/ethnicity groups: non-Hispanic Whites (aOR = 3.83; 95% CI: 3.07, 4.79), non-Hispanic Blacks (aOR = 3.39, 95% CI: 1.71, 6.71), or Hispanics (aOR = 12.61; 95% CI: 4.75, 33.43). This translated to a large effect size for non-Hispanic Whites and Hispanics although the magnitude was bigger for Hispanics.

CONCLUSION

The association between number of ACEs and depression was strongest for older adults who identify as Hispanic, but weaker and less consistent for adults who identify as White and Black.

U.S. dementia care spending by state: 2010-2019

INTRODUCTION

Dementia is the fourth largest cause of death for individuals 70 years of age and older in the United States, and it is tremendously costly. Existing estimates of the indirect costs of dementia are dated and do not report on differences across the United States.

METHODS

We used data from multiple surveys to create cost estimates and projections for informal dementia caregiving at the U.S. state level from 2010 through 2050.

RESULTS

In 2019, the annual replacement cost of informal caregiving was $42,422 per prevalent case, and the forgone wage cost was $10,677 per prevalent case. In 2019, it would have cost $230 billion to hire home health aides to provide all this care. If past trends persist, this cost is expected to grow to $404 billion per year in 2050.

DISCUSSION

The cost of informal care varied substantially by state and is expected to grow through at least 2050.

HIGHLIGHTS

In the United States in 2019, foregone wages due to informal dementia care was $58 billion. Replacing informal dementia care with health aides would have cost $230 billion. These costs vary dramatically by state, even when assessed per prevalent case. These costs are expected to nearly double by 2050.

Centering Communities of Color in the Modernization of a Public Health Survey System: Lessons from Oregon

Context

Public health survey systems are tools for informing public health programming and policy at the national, state, and local levels. Among the challenges states face with these kinds of surveys include concerns about the representativeness of communities of color and lack of community engagement in survey design, analysis, and interpretation of results or dissemination, which raises questions about their integrity and relevance.

Approach

Using a data equity framework (rooted in antiracism and intersectionality), the purpose of this project was to describe a formative participatory assessment approach to address challenges in Oregon Behavioral Risk Factor Surveillance System (BRFSS) and Student Health Survey (SHS) data system by centering community partnership and leadership in (1) understanding and interpreting data; (2) identifying strengths, gaps, and limitations of data and methodologies; (3) facilitating community-led data collection on community-identified gaps in the data; and (4) developing recommendations.

Results

Project team members' concerns, observations, and critiques are organized into six themes. Throughout this engagement process, community partners, including members of the project teams, shared a common concern: that these surveys reproduced the assumptions, norms, and methodologies of the dominant (White, individual centered) scientific approach and, in so doing, created further harm by excluding community knowledges and misrepresenting communities of color.

Conclusions

Meaningful community leadership is needed for public health survey systems to provide more actionable pathways toward improving population health outcomes. A data equity approach means centering communities of color throughout survey cycles, which can strengthen the scientific integrity and relevance of these data to inform community health efforts.

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.

Lifestyle Related Cancer Risk and Protective Behaviors Vary among a Convenient Sample of Physically Active, Young-to-Middle-Aged Adults 18-49

It is an assumption that physically active adults lead an overall healthy lifestyle. To examine this assumption, we administered a cross-sectional, web-based survey to a sample of young-to-middle-aged US adults between 18 and 49 who self-reported participation in at least one recreational sporting event in the past month. Logistic regressions were conducted to examine demographic characteristics associated with cancer risk and protective behaviors. Gender was represented equally (N = 938), and the average age was 32 years (SD: 8.4). Most participants reported >three days of moderate- to high-intensity physical activity (79%), but not meeting fruit and vegetable consumption guidelines (78%). Many reported current tobacco use (32%), binge drinking at least once in the past 30 days (62%), and suboptimal sun protection use (67%). Participation in lifestyle-related cancer risk and protective behaviors varied based on age, sex, education, routine doctor visits, perceived overall health, health-information-seeking behavior (how participants obtained health information), or team-based sport participation in regression models. Future interventions should be tailored to address varied cancer risk profiles among even physically active adults to encourage multiple healthy behavior changes.

Public Awareness of Diet-Related Diseases and Dietary Risk Factors: A 2022 Nationwide Cross-Sectional Survey among Adults in Poland

A suboptimal diet is a risk factor for numerous non-communicable diseases. This study aimed to assess the level of knowledge on diet-related diseases and dietary risk factors among adults in Poland as well as to identify factors associated with awareness of diet-related diseases and dietary risk factors. This cross-sectional survey was carried out in July 2022 on a representative sample of adults in Poland. Data were received from 1070 individuals (53.3% females) aged 18−89 years. Out of eight diet-related diseases included in this study, overweight/obesity was the most recognized diet-related disease (85.0%). Stroke (26.2%) and osteoporosis (17.9%) were the least recognized diet-related diseases. Out of eight dietary risk factors included in this study, excessive consumption of sugar and salt (73.4%) was the most recognized dietary risk factor. Less than half of the respondents were aware that (1) too little vitamin intake, (2) too little intake of calcium and magnesium, (3) too little consumption of fish and oils, and (4) too little dietary fiber intake can lead to the development of the diseases. Having higher education and the presence of chronic diseases were the most important factors associated with a higher level of awareness of diet-related diseases and dietary risk factors (p < 0.05).

Examining the Association of Food Insecurity and Being Up-to-Date for Breast and Colorectal Cancer Screenings

BACKGROUND

Food insecurity (FI) has been associated with poor access to health care. It is unclear whether this association is beyond that predicted by income, education, and health insurance. FI may serve as a target for intervention given the many programs designed to ameliorate FI. We examined the association of FI with being up-to-date to colorectal cancer and breast cancer screening guidelines.

METHODS

Nine NCI-designated cancer centers surveyed adults in their catchment areas using demographic items and a two-item FI questionnaire. For the colorectal cancer screening sample (n = 4,816), adults ages 50-75 years who reported having a stool test in the past year or a colonoscopy in the past 10 years were considered up-to-date. For the breast cancer screening sample (n = 2,449), female participants ages 50-74 years who reported having a mammogram in the past 2 years were up-to-date. We used logistic regression to examine the association between colorectal cancer or breast cancer screening status and FI, adjusting for race/ethnicity, income, education, health insurance, and other sociodemographic covariates.

RESULTS

The prevalence of FI was 18.2% and 21.6% among colorectal cancer and breast cancer screening participants, respectively. For screenings, 25.6% of colorectal cancer and 34.1% of breast cancer participants were not up-to-date. In two separate adjusted models, FI was significantly associated with lower odds of being up-to-date with colorectal cancer screening [OR, 0.7; 95% confidence interval (CI), 0.5-0.99)] and breast cancer screening (OR, 0.6; 95% CI, 0.4-0.96).

CONCLUSIONS

FI was inversely associated with being up-to-date for colorectal cancer and breast cancer screening.

IMPACT

Future studies should combine FI and cancer screening interventions to improve screening rates.

Overall and sex-specific risk factors for subjective cognitive decline: findings from the 2015-2018 Behavioral Risk Factor Surveillance System Survey

BACKGROUND

Prior research indicates that at least 35% of Alzheimer's disease and related dementia risk may be amenable to prevention. Subjective cognitive decline is often the first indication of preclinical dementia, with the risk of subsequent Alzheimer's disease in such individuals being greater in women than men. We wished to understand how modifiable factors are associated with subjective cognitive decline, and whether differences exist by sex.

METHODS

Data were collected from men and women (45 years and older) who completed the U.S. Behavioral Risk Factor Surveillance System Cognitive Decline Module (2015-2018), n = 216,838. We calculated population-attributable fractions for subjective cognitive decline, stratified by sex, of the following factors: limited education, deafness, social isolation, depression, smoking, physical inactivity, obesity, hypertension, and diabetes. Our models were adjusted for age, race, income, employment, marital and Veteran status, and accounted for communality among risk factors.

RESULTS

The final study sample included more women (53.7%) than men, but both had a similar prevalence of subjective cognitive decline (10.6% of women versus 11.2% of men). Women and men had nearly equivalent overall population-attributable fractions to explain subjective cognitive decline (39.7% for women versus 41.3% for men). The top three contributing risk factors were social isolation, depression, and hypertension, which explained three-quarters of the overall population-attributable fraction.

CONCLUSIONS

While we did not identify any differences in modifiable factors between men and women contributing to subjective cognitive decline, other factors including reproductive or endocrinological health history or biological factors that interact with sex to modify risk warrant further research.

Gender differences in the association between unmet support service needs and mental health among American cancer caregivers

PURPOSE

Cancer caregiving can be distressing, and many caregivers have support service needs. Given the role gender has played in shaping norms around caring, gender may influence caregiving experiences. Using Behavioral Risk Factor Surveillance System data, 2015-2018, we aimed to examine gender as an effect modifier of the unmet support service needs and mental health association among cancer caregivers.

METHODS

Our n = 5814 sample represented approximately 4.8 million caregivers. Mental health was operationalized as number of mentally unhealthy days over the past 30 (MUDs) and Frequent Mental Distress (FMD, MUDs ± 14 days). Unmet supportive care needs included endorsement of needing but not receiving caregiving classes, help accessing services, support groups, counseling, and respite care. We conducted zero-inflated negative binomial (ZINB) and logistic regression analyses to examine the associations between unmet needs with MUDs and FMD and then tested gender as an effect modifier.

RESULTS

Cancer caregivers reported an average of 6 MUDs. Approximately 20% of caregivers reported FMD, and 17% reported having any unmet needs. Gender moderated the unmet needs and FMD association. Among female caregivers, those with unmet needs were more likely to report FMD (aOR: 2.167; 95%CI: 1.447, 3.243); among male caregivers, no association was found (aOR: 0.970; 95%CI: 0.471, 2.001). In the ZINB model of MUDs, no significant moderation effect of gender was found.

CONCLUSION

Though distress does not appear to vary by gender, having unmet support needs may negatively affect mental health in female cancer caregivers. Studies on gendered experiences can inform strategies to meet caregiver needs.

Examining Health Behaviors of Chronic Disease Caregivers in the U.S

INTRODUCTION

Many informal caregivers experience a significant caregiving burden, which may interfere with their health behaviors. Caregiver health behaviors may vary by disease context, but this has rarely been studied. This study compares the health behaviors of prevalent groups of chronic illness caregivers (i.e., dementia, cancer, chronic obstructive pulmonary disease/emphysema, diabetes) with those of noncaregivers and examines whether caregiving intensity is associated with these behaviors.

METHODS

In 2021, using pooled cross-sectional 2015-2019 Behavioral Risk Factor Surveillance System data, health behaviors (i.e., physical activity, diet, alcohol use, smoking, sleep, and influenza immunization) of caregivers of patients with dementia (n=5,525), cancer (n=4,246), chronic obstructive pulmonary disease/emphysema (n=1,959), and diabetes (n=2,853) and noncaregivers (n=203,848) were compared. Relationships between caregiving intensity (e.g., hours, type of tasks) and caregiver health behaviors were examined. Regression analyses were used to compare groups.

RESULTS

Compared with noncaregivers, caregiver groups were more likely to report engaging in both risky (i.e., smoking, shorter sleep duration) and health-promoting (i.e., physical activity, vegetable consumption, abstaining from heavy drinking) behaviors, whereas nonsignificant differences were observed for influenza immunization. Longer caregiving hours and providing help with personal care were associated with poorer health behaviors (e.g., shorter sleep duration). Few differences in health behaviors were observed between caregivers of patients with dementia and other caregiver groups.

CONCLUSIONS

Results suggest that caregivers are more likely to engage in both risky and health-promoting behaviors than noncaregivers. Furthermore, findings suggest that greater caregiving responsibilities are associated with certain risky health behaviors. Findings support the development and implementation of strategies to improve caregivers' health behaviors across disease contexts.

Trends and patterns of disparities in diabetes and chronic kidney disease mortality among US counties, 1980-2014

Introduction

Diabetes and chronic kidney diseases are associated with a large health burden in the USA and globally.

Objective

To estimate age-standardized mortality rates by county from diabetes mellitus and chronic kidney disease.

Design and setting

Validated small area estimation models were applied to de-identified death records from the National Center for Health Statistics (NCHS) and population counts from the census bureau, NCHS, and the Human Mortality Database to estimate county-level mortality rates from 1980 to 2014 from diabetes mellitus and chronic kidney disease (CKD).

Exposures

County of residence.

Main outcomes and measures

Age-standardized mortality rates by county, year, sex, and cause.

Results

Between 1980 and 2014, 2,067,805 deaths due to diabetes were recorded in the USA. The mortality rate due to diabetes increased by 33.6% (95% UI: 26.5%–41.3%) between 1980 and 2000 and then declined by 26.4% (95% UI: 22.8%–30.0%) between 2000 and 2014. Counties with very high mortality rates were found along the southern half of the Mississippi river and in parts of South and North Dakota, while very low rates were observed in central Colorado, and select counties in the Midwest, California, and southern Florida. A total of 1,659,045 deaths due to CKD were recorded between 1980 and 2014 (477,332 due to diabetes mellitus, 1,056,150 due to hypertension, 122,795 due to glomerulonephritis, and 2,768 due to other causes). CKD mortality varied among counties with very low mortality rates observed in central Colorado as well as some counties in southern Florida, California, and Great Plains states. High mortality rates from CKD were observed in counties throughout much of the Deep South, and a cluster of counties with particularly high rates was observed around the Mississippi river.

Conclusions and relevance

This study found large inequalities in diabetes and CKD mortality among US counties. The findings provide insights into the root causes of this variation and call for improvements in risk factors, access to medical care, and quality of medical care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-022-00285-4.

Are Gyms a Feasible Setting for Exercise Training Interventions in Patients with Cardiovascular Risk Factors? An Italian 10-Years Cross-Sectional Survey Comparison

Background: Exercise training is a known important prevention and treatment modality in patients with cardiovascular (CV) diseases. However, the CV risk factors in gym users have been poorly studied. The aim of this study was to monitor CV risk factors of gym users over 10 years in order to investigate whether gyms are used settings for secondary disease prevention. Methods: In 2007 and 2017, a cross-sectional research survey was adopted to determine CV risk factors and habits in gym users (18–69 years) of the Veneto region. These data were analyzed and compared with those of PASSI, a national surveillance system of the Italian population. Results: During the last decade, there has been an increase in gym users over 50 years of age and in people with arterial hypertension and hypercholesterolemia. People attending the gym on medical referral are increasing, but they are still few (<10%). When comparing the collected data with PASSI surveillance, most of the CV risk factors are strongly underrepresented in gym users. Conclusion: The prevalence of gym users with CV risk factors is rather low, regardless of age. Physicians still need to encourage and prescribe physical exercise for secondary prevention and treatment of chronic diseases.

Large-scale diet tracking data reveal disparate associations between food environment and diet

An unhealthy diet is a major risk factor for chronic diseases including cardiovascular disease, type 2 diabetes, and cancer1-4. Limited access to healthy food options may contribute to unhealthy diets5,6. Studying diets is challenging, typically restricted to small sample sizes, single locations, and non-uniform design across studies, and has led to mixed results on the impact of the food environment7-23. Here we leverage smartphones to track diet health, operationalized through the self-reported consumption of fresh fruits and vegetables, fast food and soda, as well as body-mass index status in a country-wide observational study of 1,164,926 U.S. participants (MyFitnessPal app users) and 2.3 billion food entries to study the independent contributions of fast food and grocery store access, income and education to diet health outcomes. This study constitutes the largest nationwide study examining the relationship between the food environment and diet to date. We find that higher access to grocery stores, lower access to fast food, higher income and college education are independently associated with higher consumption of fresh fruits and vegetables, lower consumption of fast food and soda, and lower likelihood of being affected by overweight and obesity. However, these associations vary significantly across zip codes with predominantly Black, Hispanic or white populations. For instance, high grocery store access has a significantly larger association with higher fruit and vegetable consumption in zip codes with predominantly Hispanic populations (7.4% difference) and Black populations (10.2% difference) in contrast to zip codes with predominantly white populations (1.7% difference). Policy targeted at improving food access, income and education may increase healthy eating, but intervention allocation may need to be optimized for specific subpopulations and locations.

Behavioral medicine, cancer control, and NCI: reflections on a fruitful past and auspicious future

Cancer prevention and control has benefited substantially from behavioral medicine research over the last several decades. The National Cancer Institute's (NCI) Division of Cancer Control and Population Sciences, ably led by Barbara Rimer and then Bob Croyle since being established in 1997, has been a primary supporter of this research. NCI has made significant investments in many of the topics featured in this special section and will continue to do so. These include research on basic behavioral processes such as affect as well as optimal approaches to health communication. A key and enduring focus has been the support of behavioral interventions, particularly for tobacco, diet, physical activity, and sun exposure. The success of such interventions will be amplified to the extent that they leverage novel research designs, emerging digital technologies, evidence gleaned from the burgeoning field of implementation science, and lessons learned from greater attention to the impact of health disparities and inequities. Moreover, as the cancer survivor population continues to grow given the rapid development of diagnostic and therapeutic science, it will be even more essential to devote attention to understanding and addressing the health care and other needs of survivors such as cognitive dysfunction and financial toxicity. The field of behavioral medicine should be both applauded for its many contributions to reducing the cancer burden and encouraged to continue developing new research ideas in these critical areas.

Health-Related Quality of Life: A Comparative Analysis of Caregivers of People With Dementia, Cancer, COPD/Emphysema, and Diabetes and Noncaregivers, 2015-2018 BRFSS

BACKGROUND

Many informal caregivers experience significant caregiving burden and report worsening health-related quality of life (HRQoL). Caregiver HRQoL may vary by disease context, but this has rarely been studied.

PURPOSE

Informed by the Model of Carer Stress and Burden, we compared HRQoL outcomes of prevalent groups of caregivers of people with chronic illness (i.e., dementia, cancer, chronic obstructive pulmonary disease [COPD]/emphysema, and diabetes) and noncaregivers and examined whether caregiving intensity (e.g., duration and hours) was associated with caregiver HRQoL.

METHODS

Using 2015-2018 Behavioral Risk Factor Surveillance System data, we identified caregivers of people with dementia (n = 4,513), cancer (n = 3,701), COPD/emphysema (n = 1,718), and diabetes (n = 2,504) and noncaregivers (n = 176,749). Regression analyses were used to compare groups.

RESULTS

Caregiver groups showed small, nonsignificant differences in HRQoL outcomes. Consistent with theory, all caregiver groups reported more mentally unhealthy days than noncaregivers (RRs = 1.29-1.61, ps < .001). Caregivers of people with cancer and COPD/emphysema reported more physically unhealthy days than noncaregivers (RRs = 1.17-1.24, ps < .01), and caregivers of people with diabetes reported a similar pattern (RR = 1.24, p = .01). However, general health and days of interference of poor health did not differ between caregivers and noncaregivers. Across caregiver groups, most caregiving intensity variables were unrelated to HRQoL outcomes; only greater caregiving hours were associated with more mentally unhealthy days (RR = 1.13, p < .001).

CONCLUSIONS

Results suggest that HRQoL decrements associated with caregiving do not vary substantially across chronic illness contexts and are largely unrelated to the perceived intensity of the caregiving. Findings support the development and implementation of strategies to optimize caregiver health across illness contexts.

THE ROLE OF HEALTH LITERACY IN PROSTATE CANCER SCREENING

OBJECTIVE

To determine if there is an association between self-reported health literacy and rates of prostate cancer screening through PSA testing.

METHODS

This secondary data analysis utilized information from the 2016 Behavioral Risk Factor Surveillance System (BRFSS). The primary exposure was self-reported health literacy, and the primary outcome was whether patients underwent prior PSA testing. Males 55-69 years old from 13 states were included in the study and were excluded if they had any missing data. Participants were categorized into low, moderate, or high level of health literacy. Confounders were adjusted for using binary logistic regression. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

A total of 12,149 participants were included. Five percent of participants reported low health literacy, 54% moderate health literacy, and 41% high health literacy. Compared with study participants who self-reported high levels of health literacy, the odds of undergoing PSA testing were 59% lower in those with low health literacy (OR 0.41; 95% CI 0.28-0.64) and 30% lower in those with moderate health literacy (OR 0.70; 95% CI 0.60-0.83).

CONCLUSIONS

Our research demonstrates a positive association between self-reported health literacy and the likelihood of PSA screening. While PSA screening can be controversial, health literacy may serve as a window into which patients are more likely to be proactive in their urologic care. Future studies examining how health literacy effects other urologic conditions is necessary.

Unmet needs for assistance related to subjective cognitive decline among community-dwelling middle-aged and older adults in the US: prevalence and impact on health-related quality of life

OBJECTIVES

To estimate the prevalence of unmet needs for assistance among middle-aged and older adults with subjective cognitive decline (SCD) in the US and to evaluate whether unmet needs were associated with health-related quality of life (HRQOL).

DESIGN

Cross-sectional.

SETTING

US - 50 states, District of Columbia, and Puerto Rico.

PARTICIPANTS

Community-dwelling adults aged 45 years and older who completed the Cognitive Decline module on the 2015--2018 Behavioral Risk Factor Surveillance System reported experiencing SCD and always, usually, or sometimes needed assistance with day-to-day activities because of SCD (n = 6,568).

MEASUREMENTS

We defined SCD as confusion or memory loss that was happening more often or getting worse over the past 12 months. Respondents with SCD were considered to have an unmet need for assistance if they sometimes, rarely, or never got the help they needed with day-to-day activities. We measured three domains of HRQOL: (1) mental (frequent mental distress, ≥14 days of poor mental health in the past 30 days), (2) physical (frequent physical distress, ≥14 days of poor physical health in the past 30 days), and (3) social (SCD always, usually, or sometimes interfered with the ability to work, volunteer, or engage in social activities outside the home). We used log-binomial regression models to estimate prevalence ratios (PRs). All estimates were weighted.

RESULTS

In total, 40.2% of people who needed SCD-related assistance reported an unmet need. Among respondents without depression, an unmet need was associated with a higher prevalence of frequent mental distress (PR = 1.55, 95% CI: 1.12-2.13, p = 0.007). Frequent physical distress and social limitations did not differ between people with met and unmet needs.

CONCLUSIONS

Middle-aged and older adults with SCD-related needs for assistance frequently did not have those needs met, which could negatively impact their mental health. Interventions to identify and meet the unmet needs among people with SCD may improve HRQOL.

Geographic Variation in Human Papillomavirus Vaccination Initiation and Completion Among Young Adults in the U.S

INTRODUCTION

This study explores how human papillomavirus vaccination initiation and completion among men and women aged 18-34 years varies by geographic region.

METHODS

Data from the 2015-2017 Behavioral Risk Factor Surveillance System were analyzed. Geographic regions for the selected states were defined as South, Northeast, and Midwest/West. Human papillomavirus vaccination initiation was defined as receipt of ≥1 dose, and completion was defined as receipt of ≥3 doses. Weighted, multivariable logistic regression models estimated the association between geographic region and vaccine uptake, adjusting for sociodemographic, health, and healthcare factors. Analyses were performed in November 2019.

RESULTS

A total of 18,078 adults were included in the study, 80% of whom resided in the South. The overall vaccination initiation rate was 23.4%, and the completion rate was 11.0%. Initiation was higher among those who resided in the Northeast (38.6%), followed by Midwest/West (23.8%), and lowest for those in the South (21.8%) (p<0.0001). Completion rates followed the same trend as initiation. In the adjusted models, compared with the adults residing in the Northeast, those living in the South were less likely to initiate (AOR=0.47, 95% CI=0.40, 0.55) and complete (AOR=0.56, 95% CI=0.46, 0.68) human papillomavirus vaccination.

CONCLUSIONS

Human papillomavirus vaccine uptake was low for all regions, but vaccine uptake was significantly lower in the South region. This demonstrates the need to identify barriers specifically associated with the Southern population, which may include differing levels of education and insurance. Such work is especially pertinent because many Southern states face increased risk of human papillomavirus-associated cancers such as cervix and oral cavity and pharynx cancers.

Population measures of subjective cognitive decline: A means of advancing public health policy to address cognitive health

Subjective cognitive decline (SCD) is receiving increasing attention as studies have suggested that SCD status is associated with risk of future cognitive decline and dementia. Population-based measures of SCD can be extremely useful to the public health community, health-care providers, researchers, and policymakers. A large population-based SCD measure now exists through the state-based Behavioral Risk Factor Surveillance System (BRFSS). All 50 states have included the cognitive decline module, which asks about SCD, to their BRFSS survey one or more times. Population measures of SCD can aid researchers in designing clinical studies by better estimating the populations that may be at risk for more severe cognitive decline based on their SCD status to ensure that the optimal groups are targeted. Population-level estimates of SCD can also help to inform health-care providers' decisions about initiating cognitive assessments, managing other conditions among those with memory problems, and identifying the needs of caregivers.

COVID-19 Information-Seeking and Prevention Behaviors in Florida, April 2020

Introduction

Coronavirus disease 2019 (COVID-19) surveillance can be enhanced by collecting population-level data on individual prevention measures. We described the use of a state-based, population-level surveillance system on COVID-19 prevention and information-seeking behaviors in Florida during the first month of survey administration.

Methods

Beginning in April 2020, respondents of the Florida Behavioral Risk Factor Surveillance System were asked a series of 8 questions about sources of COVID-19 information and prevention behaviors. We analyzed the prevalence of information-seeking and prevention behaviors among respondents who answered at least 1 of the 8 questions (N = 1,004) overall, by demographic characteristics, and by the presence of chronic conditions.

Results

Most respondents reported engaging in prevention behaviors, including handwashing (98.2%), reducing or avoiding travel (96.6%), avoiding crowds and public events (96.5%), and keeping household members at home (87.5%); however, the prevalence of prevention behaviors varied significantly by age, sex, and education. The most frequently reported source of COVID-19 information was the Centers for Disease Control and Prevention’s website (40.8%) followed by the Florida Department of Health’s website (32.9%). We found significant differences in information sources across all demographic and chronic condition subgroups. A larger proportion of respondents with chronic conditions (vs without chronic conditions) reported consulting their personal doctor for COVID-19 information.

Conclusion

Understanding the uptake and characteristics associated with individual prevention and information-seeking behaviors at the population level facilitates COVID-19 response efforts. The rapid implementation of COVID-19–related questions in the Florida BRFSS provides a useful model for other population-based surveillance systems.

Adverse Childhood Experiences among Adults in North Carolina, USA: Influences on Risk Factors for Poor Health across the Lifespan and Intergenerational Implications

Adverse childhood experiences (ACEs) are a critical determinant and predictor of health across the lifespan. The Appalachian region of the United States, particularly the central and southern portions, experiences worse health outcomes when compared to the rest of the nation. The current research sought to understand the cross-sectional relationships between ACEs, social determinants of health and other health risk factors in one southcentral Appalachian state. Researchers used the 2012 and 2014 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) for analyses. An indicator variable of Appalachian county (n = 29) was used to make comparisons against non-Appalachian counties (n = 71). Analyses further examined the prevalence of ACEs in households with and without children across Appalachian and non-Appalachian regions, and the effects of experiencing four or more ACEs on health risk factors. There were no statistically significant differences between Appalachian and non-Appalachian counties in the prevalence of ACEs. However, compared with adults in households without children, those with children reported a higher percentage of ACEs. Reporting four or more ACEs was associated with higher prevalence of smoking (prevalence ratio [PR] = 1.56), heavy alcohol consumption (PR = 1.69), overweight/obesity (PR = 1.07), frequent mental distress (PR = 2.45), and food insecurity (PR = 1.58) in adjusted models and with fair or poor health only outside Appalachia (PR = 1.65). Residence in an Appalachian county was independently associated with higher prevalence of food insecurity (PR = 1.13). Developing programs and implementing policies aimed at reducing the impact of ACEs could improve social determinants of health, thereby helping to reduce health disparities.

Prevalence and Factors Associated with Electronic Cigarette Use Among Young Adult Cancer Survivors Using Behavioral Risk Factor Surveillance System, 2016-2018

Purpose: This study describes the prevalence trends of electronic cigarette (e-cigarette) use in young adult cancer survivors and compares these to the prevalence among young adults without a cancer history. It also examines the association between conventional cigarette use, binge drinking, depression, and other sociodemographic factors, and e-cigarette use in young adult cancer survivors. Methods: Cross-sectional analyses, using the Behavioral Risk Factor Surveillance System, 2016-2018, were done. Multivariable logistic regression was used to examine the associations between conventional cigarette use, binge drinking, and depression as well as other factors associated with e-cigarette use in young adult cancer survivors. Results: Lifetime e-cigarette use increased from 40.1% in 2016 to 47.4% in 2018. Former smokers were 5.47 times (95% confidence interval [CI]: 3.48-8.61) more likely to be lifetime e-cigarette users and 1.9 times (95% CI: 1.12-3.23) more likely to be current e-cigarette users compared to never smokers. Current smokers were over sixteen folds more likely (adjusted odds ratio: 16.50, 95% CI: 11.59-23.57) to be lifetime e-cigarette users and 2.1 times (95% CI: 1.24-3.57) more likely to be current e-cigarette users relative to never smokers. Furthermore, binge drinking and depression were associated with higher odds of lifetime e-cigarette use, while increasing age was associated with lower odds of e-cigarette use. Compared to females, males were significantly more likely to be current users of e-cigarettes relative to former users. Conclusion: Conventional cigarette use, binge drinking, depression, age, and gender were found to be associated with e-cigarette use among young adult cancer survivors. Policies targeted at e-cigarette control among young adult cancer survivors need to be multipronged, simultaneously addressing other harmful practices such as binge drinking and the use of conventional cigarettes.

Assessing county-level determinants of diabetes in the United States (2003-2012)

Using data from the United States Behavioral Risk Factor Surveillance System (2003-2012; N = 3,397,124 adults), we estimated associations between prevalent diabetes and four county-level exposures (fast food restaurant density, convenience store density, unemployment, active commuting). All associations confirmed our a priori hypotheses in conventional multilevel analyses that pooled across years. In contrast, using a random-effects within-between model, we found weak, ambiguous evidence that within-county changes in exposures were associated with within-county change in odds of diabetes. Decomposition revealed that the pooled associations were largely driven by time-invariant, between-county factors that may be more susceptible to confounding versus within-county associations.

Prevalence and domains of disability within and outside Appalachian North Carolina: 2013-2016 Behavioral Risk Factor Surveillance System

BACKGROUND

The health and social conditions of the Appalachian region generally are poorer than in the US overall, and this gap is widening, suggesting disability may be higher in Appalachia.

OBJECTIVE

To describe the prevalence of disability overall and by domain in Appalachian and non-Appalachian regions in North Carolina (NC) and describe the characteristics of people with and without disability in each region.

METHODS

We conducted a cross-sectional study using data from the NC Behavioral Risk Factor Surveillance System from 2013 to 2016 which assessed disability in five domains: vision, cognitive, mobility, self-care, and independent living. We calculated weighted proportions and age- and sex-adjusted prevalence using direct standardization to the 2010 Census.

RESULTS

The prevalence of disability in Appalachian NC was significantly higher than in non-Appalachian NC after standardizing by age and sex (26.6% in Appalachia, 24.1% outside Appalachia, p < 0.001). In both regions, mobility disability was most common and self-care disability was least common. People within Appalachia more frequently reported disability in all domains compared to people outside Appalachia.

CONCLUSIONS

More than one in four adults in Appalachian North Carolina experience disability in at least one domain and one in eight experiences disability in multiple domains. The high prevalence of disability should be considered when planning programs and services across the spectrum of public health. Understanding common disability domains present in populations can inform public health agencies and service providers and help them develop programs and messaging that meet the needs of residents in Appalachia and are accessible to people with disabilities.

Medicaid Expansion and Breast Cancer Screening in Appalachia and Non-Appalachia, United States, BRFSS 2003 to 2015

Background:

Prior data suggests that breast cancer screening rates are lower among women in the Appalachian region of the United States. This study examined the changes in breast cancer screening before and after the implementation of the Affordable Care Act Medicaid expansion, in Appalachia and non-Appalachia states.

Methods:

Data from the Behavioral Risk Factor Surveillance System between 2003 and 2015 were analyzed to evaluate changes in breast cancer screening in the past 2 years among US women aged 50-74 years. Multivariable adjusted logistic regression and generalized estimating equation models were utilized, adjusting for sociodemographic, socioeconomic, and health-care characteristics. Data were analyzed for 2 periods: 2003 to 2009 (pre-expansion) and 2011 to 2015 (post-expansion) comparing Appalachia and non-Appalachia states.

Results:

The prevalence for of self-reported breast cancer screening in Appalachia and non-Appalachia states were 83% and 82% (P < .001), respectively. In Appalachian states, breast cancer screening was marginally higher in non-expanded versus expanded states in both the pre-expansion (relative risk [RR]: 1.002, 95% confidence interval [CI]: 1.002-1.003) and post-expansion period (RR: 1.001, 95% CI: 1.001-1.002). In non-Appalachian states, screening was lower in non-expanded states versus expanded states in both the pre-expansion (RR: 0.98, 95% CI: 0.97-0.98) and post-expansion period (RR: 0.95, 95% CI: 0.95-0.96). There were modest 3% to 4% declines in breast cancer screening rates in the pos-texpansion period regardless of expansion and Appalachia status.

Conclusions:

Breast cancer screening rates were higher in Appalachia versus non-Appalachia US states and higher in expanded versus nonexpanded non-Appalachia states. There were modest declines in breast cancer screening rates in the post-expansion period regardless of expansion and Appalachia status, suggesting that more work may be needed to reduce administrative, logistical, and structural barriers to breast cancer screening services.

Inclusion of electronic nicotine delivery systems in indoor smoke-free air policies and associated vaping behavior

INTRODUCTION

Despite an ongoing debate over regulations of use of electronic nicotine delivery systems (ENDS) in public places, fourteen U.S. states or territories banned use of ENDS in indoor areas such as workplaces, restaurants, or bars (aerosol-free policies), as of March 31 ,2018. However, there is a paucity of studies on state-level aerosol-free policies. This study aimed to investigate the relationship between statewide aerosol-free policies and U.S. adults' ENDS use.

METHODS

We analyzed data from the 2016 Behavioral Risk Factor Surveillance System, a nationally representative sample of U.S. adults (N = 240,849, ages 18-59 years), using multilevel logistic regressions, taking into account clustering of individuals within a state. We conducted stratified analyses by age groups to examine if the association between aerosol-free policy and ENDS use would be different between different age groups of adults.

RESULTS

Adults living in the states with an aerosol-free policy were less likely to use ENDS compared with those living in the states without an aerosol-free policy, controlling for individual- and state-level covariates (adjusted odds ratio = 0.79, 95% confidence interval = 0.64, 0.97). Stratified analyses showed that the association varied by age group; the statewide aerosol-free policies was associated with lower odds of ENDS use only in adults aged 25-59 but not young adults (aged 18-24).

CONCLUSIONS

The results supported enforcement of prohibiting ENDS as well as traditional tobacco product indoor areas as a means of ENDS use prevention. Our findings also confirmed that young adults should be a priority target population for ENDS use prevention policies and programming efforts.

Health outcomes, utility and costs of returning incidental results from genomic sequencing in a Canadian cancer population: protocol for a mixed-methods randomised controlled trial

INTRODUCTION

Genomic sequencing has rapidly transitioned into clinical practice, improving diagnosis and treatment options for patients with hereditary disorders. However, large-scale implementation of genomic sequencing faces challenges, especially with regard to the return of incidental results, which refer to genetic variants uncovered during testing that are unrelated to the primary disease under investigation, but of potential clinical significance. High-quality evidence evaluating health outcomes and costs of receiving incidental results is critical for the adoption of genomic sequencing into clinical care and to understand the unintended consequences of adoption of genomic sequencing. We aim to evaluate the health outcomes and costs of receiving incidental results for patients undergoing genomic sequencing.

METHODS AND ANALYSIS

We will compare health outcomes and costs of receiving, versus not receiving, incidental results for adult patients with cancer undergoing genomic sequencing in a mixed-methods randomised controlled trial. Two hundred and sixty patients who have previously undergone first or second-tier genetic testing for cancer and received uninformative results will be recruited from familial cancer clinics in Toronto, Ontario. Participants in both arms will receive cancer-related results. Participants in the intervention arm have the option to receive incidental results. Our primary outcome is psychological distress at 2 weeks following return of results. Secondary outcomes include behavioural consequences, clinical and personal utility assessed over the 12 months after results are returned and health service use and costs at 12 months and 5 years. A subset of participants and providers will complete qualitative interviews about utility of incidental results.

ETHICS AND DISSEMINATION

This study has been approved by Clinical Trials Ontario Streamlined Research Ethics Review System that provides ethical review and oversight for multiple sites participating in the same clinical trial in Ontario.Results from the trial will be shared through stakeholder workshops, national and international conferences, and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03597165.

Evaluation of a Mobile Device Survey System for Behavioral Risk Factors (SHAPE): App Development and Usability Study

Background

Risk factors, including limited exercise, poor sleep, smoking, and alcohol and drug use, if mitigated early, can improve long-term health. Risk prevalence has traditionally been measured using methods that now have diminished participation rates. With >75% of American citizens owning smartphones, new data collection methods using mobile apps can be evaluated.

Objective

The objective of our study was to describe the development, implementation, and evaluation of a mobile device–based survey system for behavioral risk assessment. Specifically, we evaluated its feasibility, usability, acceptability, and validity.

Methods

We enrolled 536 students from 3 Vermont State Colleges. Iterative mobile app development incorporated focus groups, extensive testing, and the following 4 app versions: iOS standard, iOS gamified, Android standard, and Android gamified. We aimed to capture survey data, paradata, and ambient data such as geolocation. Using 3 separate surveys, we asked a total of 27 questions that included demographic characteristics, behavioral health, and questions regarding the app’s usability and survey process.

Results

Planned enrollment was exceeded in just a few days. There were 1392 “hits” to the landing page where the app could be downloaded. Excluding known project testers and others not part of the study population, 670 participants downloadeded the SHAPE app. Of those, 94.9% of participants (636/670) agreed to participate by providing in-app consent. Of the 636 who provided consent, 84.3% (536/636) were deemed eligible for the study. The majority of eligible respondents completed the initial survey (459/536, 85.6%), whereas 29.9% (160/536) completed the second survey and 28.5% (153/536) completed the third survey. The SHAPE survey obtained 414 participants on the behavioral risk items in survey 1, which is nearly double the 209 participants who completed the traditional Vermont College Health Survey in 2014. SHAPE survey responses were consistent with the traditionally collected Vermont College Health Survey data.

Conclusions

This study provides data highlighting the potential for mobile apps to improve population-based health, including an assessment of recruitment methods, burden and response rapidity, and future adaptations. Although gamification and monetary rewards were relatively unimportant to this study population, item response theory may be technologically feasible to reduce individual survey burden. Additional data collected by smartphones, such as geolocation, could be important in additional analysis, such as neighborhood characteristics and their impact on behavioral risk factors. Mobile tools that offer rapid adaptation for specific populations may improve research data collection for primary prevention and could be used to improve engagement and health outcomes.

Population-Based Profile of Mental Health and Support Service Need Among Family Caregivers of Adults With Cancer

PURPOSE

We examined associations between caregiving intensity and mental health among cancer caregivers at the population level and potential moderation by an actionable intervention target, support service needs.

METHODS

Behavioral Risk Factors Surveillance System survey data (2015) from caregivers of adult patients with cancer was analyzed. Caregiving intensity included hours per week caregiving (high, > 20; low, ≤ 20) and caregiving duration (long, > 2 years; short, ≤ 2 years). Mental health was reported as number of mentally unhealthy days (MUDs) in the past 30. Support service needs comprised caregiving classes, service access, support groups, counseling, and respite care. Multivariable linear regression models were performed adjusting for sociodemographics and sampling weights.

RESULTS

A total of 1,831 caregivers were included in the study, representing approximately 1.1 million cancer caregivers in the 18 US states, distributed with the following intensity: 122 (8.3%) caregivers reported care at high hours/long duration, 213 (13.1%) high hours/short duration, 329 (18.4%) low hours/long duration, and 910 (60.2%) low hours/short duration. Mean MUDs was 6 (SE, 0.5). The highest reported unmet service need was help with service access (48.4%). Higher caregiving intensity and support service need were associated with more MUDs ( P < .05), with a significant interaction ( P = .02) between caregiving intensity and unmet support service needs. High hour/long duration caregivers reporting any unmet needs had a mean of 15 versus 8 MUDs for those with no unmet needs.

CONCLUSION

High-intensity cancer caregiving was associated with poor mental health, especially for those reporting support service needs. Developing strategies to optimize support service provision for high-intensity cancer caregivers is warranted.

Self-Reported Physical and Mental Health of Gender Nonconforming Transgender Adults in the United States

PURPOSE

This study compares the health status of gender nonconforming transgender adults with gender-binary transgender peers (i.e., transgender men and transgender women).

METHODS

We performed a retrospective analysis of the 2014-2016 Behavioral Risk Factor Surveillance System.

RESULTS

After adjustment for sociodemographic characteristics, proxies for healthcare access, health conditions, and health behaviors, gender nonconforming transgender adults were at increased odds, compared with gender-binary transgender peers, of self-reported poor or fair health and self-reported limitation in any way in any activities because of physical, mental, or emotional problems.

CONCLUSIONS

Gender nonconforming transgender adults experienced worse self-reported health disparities than gender-binary transgender peers.

The Economic Value of Informal Caregiving for Persons With Dementia: Results From 38 States, the District of Columbia, and Puerto Rico, 2015 and 2016 BRFSS

OBJECTIVES

To estimate the economic value from a societal perspective of informal caregiving of persons with dementia in 38 states, the District of Columbia, and Puerto Rico.

METHODS

Using a cost replacement method and data from the 2015 and 2016 Behavioral Risk Factor Surveillance System caregiver module, the US Bureau of Labor Statistics May 2016 Occupation Profiles, and the US Department of Labor, we estimated the number and economic direct cost of caregiving hours.

RESULTS

An estimated 3.2 million dementia caregivers provided more than 4.1 billion hours of care, with an average of 1278 hours per caregiver. The median hourly value of dementia caregiving was $10.28. Overall, we valued these caregiving hours at $41.5 billion, with an average of $13 069 per caregiver.

CONCLUSIONS

Caregivers of persons with dementia provide care that has important economic implications. Without these efforts, many people would either not receive needed care or have to pay for that support. Surveillance data can be used to estimate the contributions of informal caregivers and the economic value of the care they provide.

Identifying Barriers to Access and Utilization of Preventive Health-Care Services by Young Adults in Vermont

PURPOSE

The objective of this study was to examine barriers to accessing and utilizing routine preventive health-care checkups for Vermont young adults.

METHODS

A population-based analysis was conducted using aggregated data from the 2011-2014 Behavioral Risk Factor Surveillance System (BRFSS) surveys of Vermont young adults aged 18-25 years (N = 1,329). Predictors analyzed as barriers were classified county of residence, health-care coverage, and annual household income level, as well as covariates, with the outcome of the length of time since the last routine checkup.

RESULTS

A total of 81.1% of Vermont young adults reported having a routine checkup in the past 2 years. Health-care coverage was a predictor of undergoing routine checkups within the past 2 years, with 85.2% of insured respondents undergoing checkups compared with 56.3% of uninsured respondents (p < .001). Additionally, 81.9% of respondents from Vermont counties classified as mostly rural reported undergoing a checkup within the past 2 years (p < .05). A total of 80.8% of respondents from the middle level (p < .05) and 89.0% of respondents from the highest level (p < .001) of annual household incomes reported undergoing a checkup in the past 2 years. Finally, age (p < .001) and sex (p < .01) were shown to indicate receipt of routine preventive checkups more often.

CONCLUSIONS

For Vermont young adults, health-care coverage, classified county of residence, and household income level were shown to be indicators of undergoing routine preventive health care more often. Further investigation is needed to examine how these barriers may impede preventive screenings, thereby contributing to the ongoing development of health-care guidelines and policies for young adults in rural settings.

The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States

Introduction

Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state.

Objective

To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016.

Design and Setting

A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year.

Main Outcomes and Measures

Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed.

Results

Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states).

Conclusions and Relevance

There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.

Annual Total Binge Drinks Consumed by U.S. Adults, 2015

INTRODUCTION

Binge drinking (four or more drinks for women, five or more drinks for men on an occasion) accounts for more than half of the 88,000 U.S. deaths resulting from excessive drinking annually. Adult binge drinkers do so frequently and at high intensity; however, there are known disparities in binge drinking that are not well characterized by any single binge-drinking measure. A new measure of total annual binge drinks was used to assess these disparities at the state and national levels.

METHODS

Behavioral Risk Factor Surveillance System 2015 data (analyzed in 2016) were used to estimate the prevalence, frequency, intensity, and total binge drinks among U.S. adults. Total annual binge drinks was calculated by multiplying annual binge-drinking episodes by binge-drinking intensity.

RESULTS

In 2015, a total of 17.1% of U.S. adults (37.4 million) reported an annual average of 53.1 binge-drinking episodes per binge drinker, at an average intensity of 7.0 drinks per binge episode, resulting in 17.5 billion total binge drinks, or 467.0 binge drinks per binge drinker. Although binge drinking was more common among young adults (aged 18-34 years), half of the total binge drinks were consumed by adults aged ≥35 years. Total binge drinks per binge drinker were substantially higher among those with lower educational levels and household incomes than among those with higher educational levels and household incomes.

CONCLUSIONS

U.S. adult binge drinkers consume about 17.5 billion total binge drinks annually, or about 470 binge drinks/binge drinker. Monitoring total binge drinks can help characterize disparities in binge drinking and help plan and evaluate effective prevention strategies.

Toward optimal implementation of cancer prevention and control programs in public health: a study protocol on mis-implementation

BACKGROUND

Much of the cancer burden in the USA is preventable, through application of existing knowledge. State-level funders and public health practitioners are in ideal positions to affect programs and policies related to cancer control. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones. Greater attention to mis-implementation should lead to use of effective interventions and more efficient expenditure of resources, which in the long term, will lead to more positive cancer outcomes.

METHODS

This is a three-phase study that takes a comprehensive approach, leading to the elucidation of tactics for addressing mis-implementation. Phase 1: We assess the extent to which mis-implementation is occurring among state cancer control programs in public health. This initial phase will involve a survey of 800 practitioners representing all states. The programs represented will span the full continuum of cancer control, from primary prevention to survivorship. Phase 2: Using data from phase 1 to identify organizations in which mis-implementation is particularly high or low, the team will conduct eight comparative case studies to get a richer understanding of mis-implementation and to understand contextual differences. These case studies will highlight lessons learned about mis-implementation and identify hypothesized drivers. Phase 3: Agent-based modeling will be used to identify dynamic interactions between individual capacity, organizational capacity, use of evidence, funding, and external factors driving mis-implementation. The team will then translate and disseminate findings from phases 1 to 3 to practitioners and practice-related stakeholders to support the reduction of mis-implementation.

DISCUSSION

This study is innovative and significant because it will (1) be the first to refine and further develop reliable and valid measures of mis-implementation of public health programs; (2) bring together a strong, transdisciplinary team with significant expertise in practice-based research; (3) use agent-based modeling to address cancer control implementation; and (4) use a participatory, evidence-based, stakeholder-driven approach that will identify key leverage points for addressing mis-implementation among state public health programs. This research is expected to provide replicable computational simulation models that can identify leverage points and public health system dynamics to reduce mis-implementation in cancer control and may be of interest to other health areas.

When Should "Pre" Carry as Much Weight in the Diabetes Comorbidity Debate? Insights From a Population-Based Survey

INTRODUCTION

Estimates indicate that 86 million people in the United States fit the clinical definition of prediabetes, which contributes to the epidemic of nearly 2 million new diagnoses of type 2 diabetes mellitus each year. Effort has focused on preventing prediabetes from progressing to clinical diabetes. We investigated the sociodemographic, behavioral, and health factors in people diagnosed with diabetes or prediabetes and associated leading indicators and comorbidities.

METHODS

We used Behavioral Risk Factor Surveillance System data from 2011 through 2015 (N = 1,699,754). All respondents aged 18 years or older with complete covariate data were included, differentiating between self-reported diagnosis of diabetes or prediabetes. Weighted univariate and multivariable logistic regression analyses of 28 variables were developed, with adjusted odds of diagnosis, and standardized coefficients were calculated to rank predictors for diabetes and prediabetes.

RESULTS

Prevalence of prediabetes increased each year between 2011 and 2014. After adjusting for demographic, lifestyle, and health variables, the most significant predictors in magnitude of importance for prediabetes and diabetes were age and body mass index. Although adjusted odds for cardiovascular disease and kidney disease were higher in respondents with diabetes than in those with prediabetes, respondents with prediabetes had higher adjusted odds of arthritis, depressive disorder, cancer, and chronic obstructive pulmonary disease.

CONCLUSIONS

Concurrent chronic diseases occur in people with prediabetes even at normal and overweight classifications. By identifying the conditions that are concomitant with diabetes, people with prediabetes can be provided with more rigorous and individualized treatments that can lead to better population health.

The Efficacy of an American Indian Culturally-Based Risk Prevention Program for Upper Elementary School Youth Residing on the Northern Plains Reservations

Culturally-based risk behavior prevention programs for American Indian elementary school children are sparse. Thus a group of American Indian educators collaborated in the creation of a program that helps children make healthy decisions based on their cultural and traditional value system. In this paper the effectiveness of Lakota Circles of Hope (LCH), an elementary school culturally-based prevention program was studied and evaluated. Three cohorts of fourth and fifth graders participated in a mixed methods quasi-experimental evaluative research design that included focus groups and surveys prior to and following the intervention. Five research questions regarding the program's impact on students' self-esteem and self-efficacy, Lakota identity, communication, conflict resolution and risk behaviors were addressed in this study. Participants were compared to non-participants in three American Indian reservation school sites. Educators completed a survey to record their observations and feedback regarding the implementation of the program within their respective school sites. The study provides preliminary evidence that, when delivered with fidelity, LCH contributes to statistically significant changes in risk behaviors, Lakota identity, respect for others, and adult and parent communication. A two-way multivariate analysis of variance with post hoc analysis of data collected from the LCH participants (N = 1392) were used to substantiate a significant increase in respect for others and a decrease in risk behaviors which included alcohol, tobacco, and substance use at the 0.10 alpha level. Significant positive improvements in parent and adult communication and an increased Lakota identity at the 0.01 alpha level were obtained. There were no significant differences in self-esteem and conflict resolution from pre to post intervention and in comparison with non LCH participating students.

Alcohol-impaired driving in US counties, 2002-2012

Background

Excessive alcohol consumption and alcohol-impaired driving remain significant public health problems, leading to considerable morbidity and mortality, particularly among younger populations.

Methods

Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we employed a small areas modeling strategy to estimate the county-level annual prevalence of alcohol-impaired driving in every United States county for the years 2002 through 2012, the latest year in which county identifiers were publicly available.

Results

Alcohol-impaired driving episodes declined from 157.0 million in 2002 (prevalence 3.8%: 95% uncertainty interval [UI], 3.7%–4.0%) to 129.7 million in 2012 (prevalence 3.7%: 95% UI, 3.5%–3.8%), a 17.4% decline. There is considerable variation in the prevalence of alcohol-impaired driving at the county level, ranging from 2.0% in the Sitka City Borough of Alaska to 9.3% in Nance County, Nebraska. Clusters of increased alcohol-impaired driving were observed in Northern Wisconsin (Marinette, Florence, Forest, Vilas, Oneida, Iron counties), North Dakota (Cavalier, Pembina, Walsh, Ramsey, Nelson, Benson, Eddy counties) and Montana (Sheridan, Daniels, Roosevelt, Valley, Phillips, Petroleum, Garfield counties).

Conclusions

This study showed guarded progress with respect to the occurrence of alcohol-impaired driving episodes in the US from 2002 to 2012. Because these data rely on self-report, this likely represents an underestimate of the true prevalence of alcohol-impaired driving in the US. As the US continues to have several million episodes of alcohol-impaired driving each month, renewed efforts are needed to mitigate this high-risk health behavior.

Potential use of telephone-based survey for non-communicable disease surveillance in Sri Lanka

BACKGROUND

Telephone survey (TS) has been a popular tool for conducting health surveys, particularly in developed countries. However, the feasibility, and reliability of TS are not adequately explored in Sri Lanka. The main aim of this study is to assess the effectiveness of telephone-based survey in estimating the prevalence of common non-communicable diseases (NCDs) in Sri Lanka.

METHODS

We carried out an observational cross-sectional study using telephone interview method in Galle district, Sri Lanka. The study participants were selected randomly from the residents living in the households with fixed land telephone lines. The prevalence of the main NCDs was estimated using descriptive statistics.

RESULTS

Overall, 975 telephone numbers belonging to six main areas of Galle district were called, and 48% agreed to participate in the study. Of the non-respondents, 22% actively declined to participate. Data on NCDs were gathered from 1470 individuals. The most common self-reported NCD was hypertension (17.%), followed by diabetes (16.3%) and dyslipidaemia (15.6%). Smoking was exclusively seen in males (7.4%), and regular alcohol use was significantly more common in males (19.2%) than females (0.4%, P < .001).

CONCLUSIONS

Our study revealed average response rate for telephone based interview in Sri Lankan setting. Overall prevalence of main NCDs in this study showed a comparable prevalence to studies used face to face interview method. This study supports the potential use of telephone-based survey to assess heath related information in Sri Lanka.

Financial and Health Barriers and Caregiving-Related Difficulties Among Rural and Urban Caregivers

PURPOSE

To assess whether financial or health-related barriers were more common among rural caregivers and whether rural caregivers experienced more caregiving-related difficulties than their urban peers.

METHODS

We used data from 7,436 respondents to the Caregiver Module in 10 states from the 2011-2013 Behavioral Risk Factor Surveillance System. Respondents were classified as caregivers if they reported providing care to a family member or friend because of a long-term illness or disability. We classified respondents as living in a rural area if they lived outside of a Metropolitan Statistical Area (MSA). We defined a financial barrier as having an annual household income <$25,000 or not being able see a doctor when needed in the past year because of cost. We defined a health barrier as having multiple chronic health conditions, a disability, or fair or poor self-rated health.

FINDINGS

Rural caregivers more frequently had financial barriers than urban caregivers (38.1% vs 31.0%, P = .0001), but the prevalence of health barriers was similar (43.3% vs 40.6%, P = .18). After adjusting for demographic differences, financial barriers remained more common among rural caregivers. Rural caregivers were less likely than their urban peers to report that caregiving created any difficulty in both unadjusted and adjusted models (adjusted prevalence ratio = 0.90; P < .001).

CONCLUSIONS

Informal caregivers, particularly in rural areas, face financial barriers. Rural caregivers were less likely than urban caregivers to report caregiving-related difficulties. Rural caregivers' coping strategies or skills in identifying informal supports may explain this difference, but additional research is needed to explore this hypothesis.