National weighting of data from the Behavioral Risk Factor Surveillance System (BRFSS)

Racial/Ethnic Disparities in HRQoL and Associated Risk Factors in Colorectal Cancer Survivors: With a Focus on Social Determinants of Health (SDOH)

PURPOSE

This study aimed to understand how health-related quality of life (HRQoL) differs by race/ethnicity in colorectal (CRC) survivors. We aimed to 1) examine racial/ethnic disparities in HRQoL, and 2) explore the roles of social determinants of health (SDOH) risk factors for HRQoL differ by racial/ethnic groups.

METHODS

In 2,492 adult CRC survivors using Behavioral Risk Factor Surveillance System (BRFSS) survey data (from 2014 to 2021, excluding 2015 due to the absence of CRC data), we used the Centers for Disease Control and Prevention (CDC) HRQoL measure, categorized into "better" and "poor." Multivariate logistic regressions with prevalence risk (PR) were employed for our primary analyses.

RESULTS

Compared with non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB) (PR = 0.61, p = .045) and Hispanics (PR = 0.32, p < .001) reported worse HRQoL in adjusted models. In adjusted models, unemployed/retired and low-income levels were common risk factors for worse HRQoL across all comparison groups (NHW, NHB, non-Hispanic other races, and Hispanics). Other SDOH associated with worse HRQoL include divorced/widowed/never married marital status (non-Hispanic other races and Hispanics), living in rural areas (NHW and NHB), and low education levels (NHB and Hispanics). Marital status, education, and employment status significantly interacted with race/ethnicity, with the strongest interaction between Hispanics and education (PR = 2.45, p = .045) in adjusted models.

CONCLUSION

These findings highlight the need for culturally tailored interventions targeting modifiable factors (e.g., social and financial supports, health literacy), specifically for socially vulnerable CRC survivors, to address the disparities in HRQoL among different racial/ethnic groups.

Is Subjective Cognitive Decline Associated with Behavioral Health Outcomes Among Mothers?

OBJECTIVES

Studies suggests that pregnancy can alter the maternal neurological function of the brain (i.e., result in cognitive decline) in a way that remains prevalent well into middle and older adulthood. However, little research has explored these changes and how they might affect behavioral health outcomes, such as substance use and depression.

METHODS

We merged data from the 2016, 2017, and 2018 Behavioral Risk Factor Surveillance System (BRFSS) surveys, with a final analytic sample of 1330 female participants (649 participants were mothers). Chi-square tests or t-tests were used to examine differences in demographic and health characteristics of the sample by subjective cognitive decline (SCD) status. To test the study hypotheses, three generalized linear mixed models were estimated with a logit link.

RESULTS

SCD was not associated with alcohol misuse among mothers (aOR = 0.27, p = 0.23). Mothers with SCD were more likely to smoke (aOR = 3.33, p = 0.01) and experience mental distress (aOR = 6.59, p < 0.001) than those without SCD.

CONCLUSION

Interventions aimed at supporting mothers should consider how existing mental health and tobacco cessation programs can be adapted to better serve this population and should aim to identify those that may have early signs of early signs of neurodegenerative conditions.

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.

Difference in the physical and mental health of informal caregivers pre- and post-COVID-19 National Emergency Declaration in the United States

Background

The burden of informal caregiving represents a chronic stressor for the informal caregivers (ICs). The study investigates differences in the physical and mental health of ICs and that of non-informal caregivers before and during COVID-19.

Methods

We used data from the 2019/2020 Behavioral Risk Factor Surveillance System (BRFSS) to investigate differences in the rates of days of poor physical and mental health among ICs compared to non-informal caregivers before and after the COVID-19 National Emergency Declaration (NED). A propensity score model simulated a pseudo experimental design, comparing ICs ("treated") with non-informal caregivers ("control"). A difference-in-difference regression model estimated the incidence rate ratios for days of poor physical and mental health as a function of IC status and time of care provision.

Results

A total of 44,583 respondents were identified with valid responses on informal caregiving status and key sociodemographic characteristics. Of those, 6.24% (n = 3073) were ICs, matched against 15,365 non-informal caregivers. In the matched sample (n = 18,848), the incidence rate for days of poor physical health among ICs was 17% (p = 0.003) higher compared to non-informal caregivers. The incidence rate for days of poor physical health was 23% (p < 0.001) lower in the post-NED compared to the pre-NED periods. The incidence rate for days of poor mental health was 44% (p < 0.001) higher among ICs compared to non-informal caregivers and 22% higher among respondents who took the survey post-NED compared to those who answered during the pre-NED period. No statistically significant differences were found between the two groups in their incidence rates for days of poor physical and mental health from the pre-to the post-NED period.

Conclusion

These findings suggest a need to balance between the benefits conferred by public health restrictions versus the mental health burden that may result among certain groups, including ICs, who experience higher negative mental health outcomes.

Self-reported condom use among Washington State residents prior to and during the COVID-19 pandemic: a cross-sectional analysis of BRFSS data

OBJECTIVES

COVID-19 significantly impacted healthcare access and sexual behaviour, but little is known about how COVID-19 affected condom use. This study aimed to investigate whether self-reported condom use and sex in Washington State changed during pandemic restrictions compared with prepandemic.

DESIGN

Cross-sectional survey data from the Behavioral Risk Factor Surveillance System.

SETTING

Washington State.

PARTICIPANTS

11 684 participants aged 18-65.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was changes in the prevalence of condom use by time of interview pre-COVID-19, before the Washington State lockdown (1 January 2019 to 23 March 2020, n=7708) and during COVID-19, after the first state lockdown (24 March 2020 to 31 December 2020, n=3976). The secondary outcome was changes in the prevalence of reported sex during the same periods. We assessed whether associations differed by rurality and HIV risk behaviour.

RESULTS

Condom use was similar during COVID-19 (37.3%) compared with pre-COVID-19 (37.8%) (adjusted prevalence ratio (PR): 0.98, 95% CI 0.89, 1.01). Associations did not differ by rurality or HIV risk behaviour. Compared with pre-COVID-19 (83.0%), a smaller proportion of respondents reported having sex in the last 12 months during COVID-19 (80.5%), a relative decrease of 3% (PR: 0.97, 95% CI 0.96, 0.99; p<0.001).

CONCLUSIONS

The prevalence of reported sex declined during COVID-19, but condom use remained steady in Washington. As our reproductive health system faces increased challenges, these results may inform future sexual health services.

Trends in U.S. self-reported health and self-care behaviors during the COVID-19 pandemic

IMPORTANCE

The COVID-19 pandemic represents a unique stressor in Americans' daily lives and access to health services. However, it remains unclear how the pandemic impacted perceived health status and engagement in health-related behaviors.

OBJECTIVE

To assess changes in self-reported health outcomes during the COVID-19 pandemic, and to explore trends in health-related behaviors that may underlie the observed health changes.

DESIGN

Interrupted time series stratified by age, gender, race/ethnicity, educational attainment, household income, and employment status.

SETTING

United States.

PARTICIPANTS

All adult respondents to the 2016-2020 Behavioral Risk Factor Surveillance System (N = 2,146,384).

EXPOSURE

Survey completion following the U.S. public health emergency declaration (March-December 2020). January 2019 to February 2020 served as our reference period.

MAIN OUTCOMES AND MEASURES

Self-reported health outcomes included the number of days per month that respondents spent in poor mental health, physical health, or when poor health prevented their usual activities of daily living. Self-reported health behaviors included the number of hours slept per day, number of days in the past month where alcohol was consumed, participation in any exercise, and current smoking status.

RESULTS

The national rate of days spent in poor physical health decreased overall (-1.00 days, 95% CI: -1.10 to -0.90) and for all analyzed subgroups. The rate of poor mental health days or days when poor health prevented usual activities did not change overall but exhibited substantial heterogeneity by subgroup. We also observed overall increases in mean sleep hours per day (+0.09, 95% CI 0.05 to 0.13), the percentage of adults who report any exercise activity (+3.28%, 95% CI 2.48 to 4.09), increased alcohol consumption days (0.27, 95% CI 0.18 to 0.37), and decreased smoking prevalence (-1.11%, 95% CI -1.39 to -0.83).

CONCLUSIONS AND RELEVANCE

The COVID-19 pandemic had deleterious but heterogeneous effects on mental health, days when poor health prevented usual activities, and alcohol consumption. In contrast, the pandemic's onset was associated with improvements in physical health, mean hours of sleep per day, exercise participation, and smoking status. These findings highlight the need for targeted outreach and interventions to improve mental health in individuals who may be disproportionately affected by the pandemic.

Risk Factors of Health-Related Quality of Life among Gastrointestinal Cancer Survivors in the U.S.: With a Focus on Social and Behavioral Determinants of Health (SBDH)

BACKGROUND

Increasing numbers of long-term gastrointestinal (GI) cancer survivors highlight the importance of understanding the factors contributing to their health-related quality of life (HRQoL). We investigated the risk factors of HRQoL, including demographics, clinical characteristics, and social and behavioral determinants of health (SBDH).

METHODS

Data on adult GI cancer survivors (n = 3201) from the Behavioral Risk Factors Surveillance System (BRFSS) surveys from 2014-2021 (except for 2015) were analyzed. Unadjusted/adjusted logistic regression was used.

RESULTS

The majority were women (54%) and white (78%), with a median age of 67. Survivors who were 65 years or older, diagnosed with colorectal cancer, or who had fewer comorbidities were more likely to report significantly better HRQoL. Significant social factors of poor HRQoL included unmarried, racial and ethnic minorities, poor socioeconomic status, and poor healthcare access. Significant behavioral factors of poor HRQoL were lack of physical activity, heavy alcohol consumption, and current smoking, with lack of physical activity being the most significant factor.

CONCLUSIONS

The SBDH has a critical role in HRQoL. Future studies are warranted to develop a tailored survivorship intervention, such as physical rehabilitation, and to explore machine learning/artificial intelligence-based predictive models to identify cancer survivors at a high risk of developing poor HRQoL.

Examination of the demographic representativeness of a cross-sectional mobile phone survey in collecting health data in Colombia using random digit dialling

OBJECTIVES

As mobile phone ownership becomes more widespread in low-income and middle-income countries, mobile phone surveys (MPSs) present an opportunity to collect data on health more cost-effectively. However, selectivity and coverage biases in MPS are concerns, and there is limited information about the population-level representativeness of these surveys compared with household surveys. This study aims at comparing the sociodemographic characteristics of the respondents of an MPS on non-communicable disease risk factors to a household survey in Colombia.

DESIGN

Cross-sectional study. We used a random digit dialling method to select the samples for calling mobile phone numbers. The survey was conducted using two modalities: computer-assisted telephone interviews (CATIs) and interactive voice response (IVR). The participants were assigned randomly to one of the survey modalities based on a targeted sampling quota stratified by age and sex. The Quality-of-Life Survey (ECV), a nationally representative survey conducted in the same year of the MPS, was used as a reference to compare the sample distributions by sociodemographic characteristics of the MPS data. Univariate and bivariate analyses were performed to evaluate the population representativeness between the ECV and the MPSs.

SETTING

The study was conducted in Colombia in 2021.

PARTICIPANTS

Population at least 18 years old with a mobile phone.

RESULTS

We completed 1926 and 2983 interviews for CATI and IVR, respectively. We found that the MPS data have a similar (within 10% points) age-sex data distribution compared with the ECV dataset for some subpopulations, mainly for young populations, people with none/primary and secondary education levels, and people who live in urban and rural areas.

CONCLUSIONS

This study shows that MPS could collect similar data to household surveys in terms of age, sex, high school education level and geographical area for some population categories. Strategies are needed to improve representativeness of the under-represented groups.

Breast, cervical, and colorectal cancer screening test use in the US territories of Guam, Puerto Rico, and the US Virgin Islands

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer screening among eligible adults, but information on screening use in the US territories is limited.

METHODS

To estimate the proportion of adults up-to-date with breast, cervical, and colorectal cancer screening based on USPSTF recommendations, we analyzed Behavioral Risk Factor Surveillance System data from 2016, 2018, and 2020 for the 50 US states and DC (US) and US territories of Guam and Puerto Rico and from 2016 for the US Virgin Islands. Age-standardized weighted proportions for up-to-date cancer screening were examined overall and by select characteristics for each jurisdiction.

RESULTS

Overall, 67.2% (95% CI: 60.6-73.3) of women aged 50-74 years in the US Virgin Islands, 74.8% (70.9-78.3) in Guam, 83.4% (81.7-84.9) in Puerto Rico, and 78.3% (77.9-78.6) in the US were up-to-date with breast cancer screening. For cervical cancer screening, 71.1% (67.6-74.3) of women aged 21-65 years in Guam, 81.3% (74.6-86.5) in the US Virgin Islands, 83.0% (81.7-84.3) in Puerto Rico, and 84.5% (84.3-84.8) in the US were up-to-date. For colorectal cancer screening, 45.2% (40.0-50.5) of adults aged 50-75 years in the US Virgin Islands, 47.3% (43.6-51.0) in Guam, 61.2% (59.5-62.8) in Puerto Rico, and 69.0% (68.7-69.3) in the US were up-to-date. Adults without health care coverage reported low test use for all three cancers in all jurisdictions. In most jurisdictions, test use was lower among adults with less than a high school degree and an annual household income of < $25,000.

CONCLUSION

Cancer screening test use varied between the US territories, highlighting the importance of understanding and addressing territory-specific barriers. Test use was lower among groups without health care coverage and with lower income and education levels, suggesting the need for targeted evidence-based interventions.

Trends and Factors Associated with Fecal Occult Blood Test Utilization among Hispanic Adults in Puerto Rico and the United States: BRFSS 2012-2020

Identifying factors associated with colorectal cancer screening utilization is important to guide colorectal cancer prevention and control programs. We evaluated trends and factors associated with previous-year fecal occult blood test (FOBT) use among Hispanic adults living in Puerto Rico and the U.S. mainland. Using data from the Behavioral Risk Factor Surveillance System (2012-2020), trends in FOBT use were analyzed using joinpoint regression to estimate annual percentage change (APC). Logistic regression stratified by location identified factors associated with FOBT use. FOBT was more common among Hispanic adults ages 50 to 75 years living in Puerto Rico than in the U.S. mainland [Puerto Rico: 20.5%[2012] to 45.6%[2020], APC = 11.4%; U.S. mainland: 9.9%[2012] to 16.7%[2020], APC = 5.9%]. Factors inversely associated with FOBT use were similar in Puerto Rico and the U.S. mainland, including lack of health insurance, not having a personal doctor, having a checkup >12 months ago, and not being able to see a doctor due to cost, as were factors associated with higher FOBT use, including older age, retirement, or having two or more chronic diseases. Among Hispanics living in the U.S. mainland, lack of exercise and less education were inversely associated with FOBT. Factors related to poor access to healthcare were associated with lower use of FOBT among Hispanics. Efforts to improve colorectal cancer screening in Hispanics are necessary to address health disparities across the colorectal cancer care continuum.

PREVENTION RELEVANCE

Colorectal cancer screening reduces cancer incidence and mortality. All screening modalities, including less invasive FOBT tests, are underutilized, especially in non-White and low-income populations. Evaluation of trends and factors associated with the increase in the use of colorectal cancer screening can inform programs to address the lack of screening among racial minorities.

The Association of Multimorbidity With Whole Health Activities Among Adults in the United States: Evidence From the NHIS and BRFSS

Background

Whole health is a holistic approach encompassing integrative medicine, emotional, and spiritual health and is critical to improving health outcomes among individuals with multimorbidity.

Objective

To examine the prevalence of Whole Health activities and the association of multimorbidity and Whole Health activities using nationally representative datasets.

Methods

As no single dataset has information on Whole Health self-care activities, data from the 2017 National Health Interview Survey (n = 25 134) was used to measure participants' mind-body therapy usage, sleep, mental health, and physical activity. We used the 2017 Behavioral Risk Factor Surveillance System (n = 347 029) to assess regular vegetable and/or fruit consumption.

Results

A significantly lower percentage of adults with multimorbidity had adequate sleep (58.2%vs.67.1%), no psychological distress (71.8%vs.82.1%), adequate physical activity (48.2%vs.62.1%), and regular vegetable and/or fruit consumption (54.2%vs.56.6%) compared to those without multimorbidity. Although lower percentages of adults with multimorbidity utilized mind-body therapies (22.9%vs.25.2%), the association was reversed when adjusted for socioeconomic factors. In the fully adjusted models, adults with multimorbidity were more likely to use mind-body therapies (AOR = 1.19, 95%CI = 1.09, 1.31). Furthermore, when adjusting for other independent variables, the associations of multimorbidity with sleep, psychological distress, and diet were exacerbated, and the association of multimorbidity with physical activity was attenuated.

Conclusion

Adults with multimorbidity were less likely to engage in most of the Whole Health activities except mind-body therapies compared to the no multimorbidity group. Findings suggest that adjustment for other factors such as age and socioeconomic status changed the magnitude and direction of the association of multimorbidity with Whole Health activities.

Cross-Sectional Associations of Self-Reported Social/Emotional Support and Life Satisfaction with Smoking and Vaping Status in Adults

This study aimed to examine the cross-sectional association of self-reported social/emotional support and life satisfaction with smoking/vaping status in US adults. The study included 47,163 adult participants who self-reported social/emotional support, life satisfaction, and smoking/vaping status in the 2016 and 2017 BRFSS national survey data. We used multivariable weighted logistic regression models to measure the cross-sectional association of self-reported social/emotional support and life satisfaction with smoking/vaping status. Compared to never users, dual users and exclusive smokers were more likely to have low life satisfaction, with an adjusted odds ratio (aOR) = 1.770 (95% confidence interval [CI]: 1.135, 2.760) and an aOR = 1.452 (95% CI: 1.121, 1.880) respectively, especially for the age group 18-34. Exclusive cigarette smokers were more likely to have low life satisfaction compared to ex-smokers (aOR = 1.416, 95% CI: 1.095, 1.831). Exclusive cigarette smokers were more likely to have low social/emotional support (aOR = 1.193, 95% CI: 1.030, 1.381) than never users, especially those aged 65 and above. In addition, exclusive cigarette smokers were more likely to have low social/emotional support than ex-smokers, with an aOR = 1.279 (95% CI: 1.097, 1.492), which is more pronounced among the age group 18-34, as well as 65 and above. Our results suggest that life satisfaction and social/emotional support may play important roles in smoking and vaping, which should be incorporated into behavioral interventions to reduce tobacco use.

Rural Residence and Antihypertensive Medication Use in US Stroke Survivors

Background Relatively greater increases in hypertension prevalence among US rural residents may contribute to geographic disparities in recurrent stroke. There is limited US information on poststroke antihypertensive medication use by rural/urban residence. We assessed antihypertensive use and lifestyle characteristics for US rural compared with urban stroke survivors and residence-based trends in use between 2005 and 2019. Methods and Results US stroke survivors with hypertension were identified in the 2005 to 2019 national Behavioral Risk Factor Surveillance System surveys. We ascertained the survey-weighted prevalence of reported antihypertensive use and lifestyle characteristics (ie, physical activity, diabetes, cholesterol, body mass index, and smoking) among respondents with hypertension in odd years over this period by rural/urban residence. Separate trend analyses were used to detect changes in use over time. Survey-weighted logistic regression was used to calculate unadjusted and adjusted (sociodemographic and lifestyle factors) odds ratios for antihypertensive use by year. Our study included 82 175 individuals (36.4% rural residents). Lifestyle characteristics were similar between rural and urban residents except for higher smoking prevalence among rural residents. Antihypertensive use was similar between rural and urban stroke survivors in unadjusted and adjusted analyses (>90% in both populations). Trend analyses showed a small but significant increase in antihypertensive use over time among urban (P=0.033) but not rural stroke survivors (P=0.587). Conclusions Our findings indicate that poststroke antihypertensive use is comparable in rural and urban residents with a reported history of hypertension, but additional work is merited to identify reasons for a trend for increased use of these drugs among urban residents.

A scoping review of semantic integration of health data and information

OBJECTIVE

We summarized a decade of new research focusing on semantic data integration (SDI) since 2009, and we aim to: (1) summarize the state-of-art approaches on integrating health data and information; and (2) identify the main gaps and challenges of integrating health data and information from multiple levels and domains.

MATERIALS AND METHODS

We used PubMed as our focus is applications of SDI in biomedical domains and followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) to search and report for relevant studies published between January 1, 2009 and December 31, 2021. We used Covidence-a systematic review management system-to carry out this scoping review.

RESULTS

The initial search from PubMed resulted in 5,326 articles using the two sets of keywords. We then removed 44 duplicates and 5,282 articles were retained for abstract screening. After abstract screening, we included 246 articles for full-text screening, among which 87 articles were deemed eligible for full-text extraction. We summarized the 87 articles from four aspects: (1) methods for the global schema; (2) data integration strategies (i.e., federated system vs. data warehousing); (3) the sources of the data; and (4) downstream applications.

CONCLUSION

SDI approach can effectively resolve the semantic heterogeneities across different data sources. We identified two key gaps and challenges in existing SDI studies that (1) many of the existing SDI studies used data from only single-level data sources (e.g., integrating individual-level patient records from different hospital systems), and (2) documentation of the data integration processes is sparse, threatening the reproducibility of SDI studies.

An update on ACEs domain frequencies across race/ethnicity and sex in a nationally representative sample

BACKGROUND

Adverse childhood experiences (ACEs) research has yielded important information regarding ACEs prevalence and impacts; however, few studies have included American Indian/Alaska Native (AI/AN) populations.

OBJECTIVE

We aimed to update and expand the ACEs literature by using recent data (2009-2018; over 50% from 2015 to 2017); using a large, nationally representative sample (total N = 166,606) and AI/AN sub-sample (N = 3369); and including additional covariates (i.e., sex, age, income, education) to provide a comprehensive understanding of ACEs across diverse populations.

PARTICIPANTS AND SETTING

Data were from the CDC's BRFSS, a standardized scale used in most ACEs literature, to improve generalizability of study findings, which may contribute to investigating future ACEs trends.

METHODS

Descriptive statistics and negative binomial regression analyses were conducted to examine the frequency of ACEs and the eight ACEs domains across racial/ethnic and sex groups.

RESULTS

AI/ANs had the highest ACEs compared to all racial/ethnic groups. Females had higher mean ACEs compared to males of the same racial/ethnic group; significant differences were identified between non-Hispanic White (NHW) females and NHW males, and between Hispanic females and Hispanic males. Across all 10 stratified subgroups, AI/AN females had the highest average ACEs followed by AI/AN males. Emotional abuse was the most reported ACEs domain across all individuals, and family incarceration was the lowest. AI/AN females and males had the highest ACEs frequencies in family substance use, witnessing intimate partner violence, and sexual and emotional abuse.

CONCLUSIONS

Findings have important implications for public health intervention and prevention efforts that may mitigate the impact of ACEs across racial/ethnic groups, particularly for AI/AN populations.

Practical Guidance for Using Behavioral Risk Factor Surveillance System Data: Merging States and Scoring Adverse Childhood Experiences

INTRODUCTION

The Behavioral Risk Factor Surveillance System is a national health-related survey with an optional adverse childhood experience (ACE) module. States use varying methodologies, question formats, and sampling frames, and little guidance exists for conducting multistate explorations of adverse childhood experiences. In this study, 6 adverse childhood experience scoring approaches are compared, and practical recommendations are offered for when and how each approach can be utilized most effectively.

METHODS

This study used 2015 Behavioral Risk Factor Surveillance System data from the adverse childhood experience module administered by 6 states. Data were merged and analyzed between 2018 and 2021. To understand how adverse childhood experience scoring may impact estimates of association, concordance/discordance among 6 approaches (continuous versus categorical, states that collected all adverse childhood experiences versus those that collected any adverse childhood experiences, and normalized versus standard scores) was evaluated. Using separate weighted multivariable logistic regression models controlling for confounders, the relationship between adverse childhood experiences using each approach and the presence of 10 chronic health conditions was also assessed.

RESULTS

Comparisons revealed discordance for categorical versus continuous approaches (30%) and all-ACEs versus any-ACEs (20%) but full concordance for standard versus normalized approaches. Discordance occurred more frequently with low-prevalence outcomes (≤7.0%) and lower-exposure samples (any-ACEs).

CONCLUSIONS

Results revealed general concordance across adverse childhood experience scoring approaches when outcomes commonly occurred and when the sample was limited to just states that asked the full array of adverse childhood experiences. However, on a deeper exploration of discordant findings, specific nuances were uncovered that may help guide researchers when deciding on which approach to use on the basis of the research question and conceptual model driving study objectives.

Association Between Body Mass Index and Cancer Screening Adherence Among Latinas in the United States and Puerto Rico

Background

Research on the role of body size on cancer screening is mixed with few studies among Latinas in the United States. We evaluated the association between body size and cancer screening adherence among Latinas living in Puerto Rico and the rest of the United States.

Methods

We conducted a cross-sectional study using 2012-2018 Behavioral Risk Factor Surveillance System data among Latinas 50-64 years of age (n = 16,410). Breast, cervical, and colorectal cancer screening (guideline adherent: yes/no), height and weight were self-reported. Prevalence ratios (PRs) derived from Poisson models were estimated for each cancer screening utilization for Puerto Rico versus rest of the United States by body mass index (BMI) category.

Results

Nearly a quarter of women lacked adherence with breast and cervical cancer screening and 43.6% were nonadherent to colorectal cancer screening. Latinas with BMI ≥40.0 kg/m² in both groups were more likely to lack adherence to cervical cancer screening than women with BMI 18.5-24.9 kg/m². For those with BMI ≥40.0 kg/m², Latinas in Puerto Rico were more likely to lack adherence to colorectal cancer screening recommendations than Latinas living in the rest of the United States (adjusted PR: 1.38; 95% confidence interval = 1.12-1.70).

Conclusions

The role of body size in cancer screening utilization among Latinas differs in women living in Puerto Rico versus in the rest of the United States and varies by cancer type. Understanding Latinas' experience can inform culturally adapted interventions to promote cancer screening.

State and regional estimates using seven cycles of pooled nationally representative HINTS data

BACKGROUND

The Health Information National Trends Survey (HINTS) is a probability-based, nationally representative survey conducted routinely to gather information about the American public's cancer-related beliefs and behaviors, including the use of cancer-related information. HINTS was created to produce national estimates and has lacked the ability to create accurate and precise state and regional estimates. The motivation for this current work was to create state- and regional-level estimates using a national sample (HINTS) through standard calibration methods. Health estimates at a local level can inform policy decisions that better target the cancer needs within a community. Local-level data allow researchers an opportunity to examine local populations in finer detail without additional costly data collection.

METHODS

By combining seven cycles of HINTS data from 2012 to 2018 and then raking the previously created person-level weights, we were able to create tables and maps of HINTS subnational survey estimates for key outcomes that have small variances and little potential bias.

RESULTS AND CONCLUSION

This paper describes the methods used to harmonize and aggregate data across cycles, create state- and regional-level estimates from the pooled data, and produce survey weights for the pooled datasets. It demonstrates both the opportunities and the challenges of pooled data analysis.

The Use of Multimode Data Collection in Random Digit Dialing Cell Phone Surveys for Young Adults: Feasibility Study

Background

Young adults’ early adoption of new cell phone technologies have created challenges to survey recruitment but offer opportunities to combine random digit dialing (RDD) sampling with web mode data collection. The National Young Adult Health Survey was designed to test the feasibility of this methodology.

Objective

In this study, we compared response rates across the telephone mode and web mode, assessed sample representativeness, examined design effects (DEFFs), and compared cigarette smoking prevalence to a gold standard national survey.

Methods

We conducted a survey experiment where the sampling frame was randomized to single-mode telephone interviews, telephone-to-web sequential mixed mode, and single-mode web survey. A total of 831 respondents aged 18 to 34 years were recruited via RDD at baseline. A soft launch was conducted prior to main launch. We compared the web mode to the telephone modes (ie, single-mode and mixed mode) at wave 1 based on the American Association for Public Opinion Research response rate 3 for screening and extended surveys. Base-weighted demographic distributions were compared to the American Community Survey. The sample was calibrated to the US Census Bureau's American Community Survey to calculate DEFFs and to compare cigarette smoking prevalence to the National Health Interview Survey. Prevalence estimates are estimated with sampling weights and are presented with unweighted sample sizes. Consistency of estimates was judged by 95% CI.

Results

The American Association for Public Opinion Research response rate 3 was higher in the telephone mode than in the web mode (24% and 30% vs 6.1% and 12.5%, for soft launch and main launch, respectively), which was reflected in response rate 3 for screening and extended surveys. During the soft launch, the extended survey and eligibility rate were low for respondents pushed to the web mode. To boost productivity and survey completes for the web condition, the main launch used cell phone numbers from the sampling frame where the sample vendor matched the number to auxiliary data, which suggested that the number likely belonged to an adult in the target age range. This increased the eligibility rate, but the screener response rate was lower. Compared to population distribution from the US Census Bureau, the telephone mode overrepresented men (57.1% [unweighted n=412] vs 50.9%) and those enrolled in college (40.3% [unweighted n=269] vs 23.8%); it also underrepresented those with a Bachelor of Arts or Science (34.4% [unweighted n=239] vs 55%). The web mode overrepresented White, non-Latinos (70.7% [unweighted n=90] vs 54.4%) and those with some college education (30.4% [unweighted n=40] vs 7.6%); it also underrepresented Latinos (13.6% [unweighted n=20] vs 20.7%) and those with a high school or General Education Development diploma (15.3% [unweighted n=20] vs 29.3%). The DEFF measure was 1.28 (subpopulation range 0.96-1.93). The National Young Adult Health Survey cigarette smoking prevalence was consistent with the National Health Interview Survey overall (15%, CI 12.4%-18% [unweighted 149/831] vs 13.5%, CI 12.3%-14.7% [unweighted 823/5552]), with notable deviation among 18- to 24-year-olds (15.6%, CI 11.3%-22.2% [unweighted 51/337] vs 8.7%, CI 7.1%-10.6% [unweighted 167/1647]), and those with education levels lower than Bachelor of Arts or Science (24%, CI 19.3%-29.4% [unweighted 123/524] vs 17.1%, CI 15.6%-18.7% [unweighted 690/3493]).

Conclusions

RDD sampling for a web survey is not feasible for young adults due to its low response rate. However, combining this methodology with RDD telephone surveys may have a great potential for including media and collecting autophotographic data in population surveys.

Cannabis vaping among adults in the United States: Prevalence, trends, and association with high-risk behaviors and adverse respiratory conditions

The e-cigarette or vaping product-use-associated lung injury outbreak in the United States has raised concerns about the potential health effects of cannabis vaping, a method of cannabis use that is becoming increasingly popular. We used 2017-2019 Behavioral Risk Factor Surveillance System data to estimate yearly prevalence and trends of past-30-day cannabis use and vaping among US adults. We used multivariable logistic regression to evaluate the associations of cannabis vaping with high-risk behaviors, asthma, and other respiratory symptoms. Our sample size was 160,209 (53,945-2017; 55,475-2018; and 50,789-2019). Past-30-day cannabis use prevalence increased from 10.0% (95% CI, 9.4%-10.7%) in 2017 to 13.4% (12.8%-12.0%) in 2019. Similarly, past-30-day cannabis vaping prevalence increased from 1.0% (0.8%-1.2%) to 2.0% (1.7%-2.2%) over the same period, with the greatest increase, 1.2% to 3.9%, observed among young adults (18-24 years). Individuals who vaped cannabis were more likely to concurrently vape nicotine. Cannabis vaping was associated with increased odds of heavy alcohol use (aOR, 1.95; 95% CI, 1.45-2.63), binge drinking (aOR, 2.82; 95% CI, 2.25-3.54), and other high-risk behaviors (aOR, 2.47; 95% CI, 1.89-3.24). In analyses adjusting for sociodemographic characteristics and body mass index, cannabis vaping was not associated with asthma (aOR, 1.03; 95% CI, 0.64-1.64) or other respiratory symptoms (aOR, 1.08; 95% CI, 0.44-2.63). Adjusting for nicotine vaping did not substantively alter these associations. The prevalence of past-30-day cannabis vaping has increased, particularly among young adults, and was associated with high-risk behaviors. Although there was no association between cannabis vaping and asthma or other respiratory symptoms, the increasing trends of cannabis vaping, particularly among young adults, raise concern and underscore the need for continued surveillance.

Population Health Surveillance Using Mobile Phone Surveys in Low- and Middle-Income Countries: Methodology and Sample Representativeness of a Cross-sectional Survey of Live Poultry Exposure in Bangladesh

Background

Population-based health surveys are typically conducted using face-to-face household interviews in low- and middle-income countries (LMICs). However, telephone-based surveys are cheaper, faster, and can provide greater access to hard-to-reach or remote populations. The rapid growth in mobile phone ownership in LMICs provides a unique opportunity to implement novel data collection methods for population health surveys.

Objective

This study aims to describe the development and population representativeness of a mobile phone survey measuring live poultry exposure in urban Bangladesh.

Methods

A population-based, cross-sectional, mobile phone survey was conducted between September and November 2019 in North and South Dhaka City Corporations (DCC), Bangladesh, to measure live poultry exposure using a stratified probability sampling design. Data were collected using a computer-assisted telephone interview platform. The call operational data were summarized, and the participant data were weighted by age, sex, and education to the 2011 census. The demographic distribution of the weighted sample was compared with external sources to assess population representativeness.

Results

A total of 5486 unique mobile phone numbers were dialed, with 1047 respondents completing the survey. The survey had an overall response rate of 52.2% (1047/2006) and a co-operation rate of 89.0% (1047/1176). Initial results comparing the sociodemographic profile of the survey sample to the census population showed that mobile phone sampling slightly underrepresented older individuals and overrepresented those with higher secondary education. After weighting, the demographic profile of the sample population matched well with the latest DCC census population profile.

Conclusions

Probability-based mobile phone survey sampling and data collection methods produced a population-representative sample with minimal adjustment in DCC, Bangladesh. Mobile phone–based surveys can offer an efficient, economic, and robust way to conduct surveillance for population health outcomes, which has important implications for improving population health surveillance in LMICs.

Examining Predictors of Myocardial Infarction

Cardiovascular diseases are the leading cause of death in the United States. This study analyzed predictors of myocardial infarction (MI) for those aged 35 and older based on demographic, socioeconomic, geographic, behavioral, and risk factors, as well as access to healthcare variables using the Center for Disease (CDC) Control Behavioral Risk Factor Surveillance System (BRFSS) survey for the year 2019. Multiple quasibinomial models were generated on an 80% training set hierarchically and then used to forecast the 20% test set. The final training model proved somewhat capable of prediction with a weighted F1-Score = 0.898. A complete model based on statistically significant variables using the entirety of the dataset was compared to the same model built on the training set. Models demonstrated coefficient stability. Similar to previous studies, age, gender, marital status, veteran status, income, home ownership, employment status, and education level were important demographic and socioeconomic predictors. The only geographic variable that remained in the model was associated with the West North Central Census Division (in-creased risk). Statistically important behavioral and risk factors as well as comorbidities included health status, smoking, alcohol consumption frequency, cholesterol, blood pressure, diabetes, stroke, chronic obstructive pulmonary disorder (COPD), kidney disease, and arthritis. Three access to healthcare variables proved statistically significant: lack of a primary care provider (Odds Ratio, OR = 0.853, p < 0.001), cost considerations prevented some care (OR = 1.232, p < 0.001), and lack of an annual checkup (OR = 0.807, p < 0.001). The directionality of these odds ratios is congruent with a marginal effects model and implies that those without MI are more likely not to have a primary provider or annual checkup, but those with MI are more likely to have missed care due to the cost of that care. Cost of healthcare for MI patients is associated with not receiving care after accounting for all other variables.

Recent cannabis use and myocardial infarction in young adults: a cross-sectional study

BACKGROUND

Cannabis use is increasing among young adults, but its effects on cardiovascular health are poorly understood. We aimed to assess the association between recent cannabis use and history of myocardial infarction (MI) in young adults (aged 18-44 yr).

METHODS

We performed a cross-sectional study using pooled data from the 2017 and 2018 cohorts of the American Behavioral Risk Factor Surveillance System survey of US adults. We analyzed the association between any recent cannabis use and history of MI using a weighted logistic regression model that adjusted for demographic factors, socioeconomic factors, health-related behaviours, concomitant substance use and other comorbidities. We also assessed this association after stratifying by frequency of use and by primary method of consumption.

RESULTS

Among 33 173 young adults (18.5 million weighted), 4610 respondents (3.2 million weighted) reported recent cannabis use (17.5%, 95% confidence interval [CI] 16.8%-18.2%). A history of MI was more frequent among recent cannabis users (n = 61 of 4610, 1.3%) relative to nonusers (n = 240 of 28 563 [0.8%], adjusted odds ratio [OR] 2.07, 95% CI 1.12-3.82). A history of MI was associated with cannabis use of more than 4 times per month (adjusted OR 2.31, 95% CI 1.18-4.50), and with smoking as a primary method of consumption (adjusted OR 2.01, 95% CI 1.02-3.98).

INTERPRETATION

Our study provides evidence supporting an association between recent cannabis use and history of MI in young adults. Increasing cannabis use in an at-risk population could have negative implications for cardiovascular health.

When American Adults Do Move, How Do They Do So? Trends in Physical Activity Intensity, Type, and Modality: 1988-2017

BACKGROUND

Few Americans accumulate enough physical activity (PA) to realize its benefits. Understanding how and why individuals use their discretionary time for different forms of PA could help identify and rectify issues that drive individuals away from certain physical activities, and leverage successful strategies to increase participation in others.

METHODS

The authors analyzed approximately 30 years of changes in PA behavior by intensity, type, and mode, using data from the Behavioral Risk Factor Surveillance System.

RESULTS

Since 1988, the proportions of adults most frequently engaging in exercise, sport, or lifestyle physical activity have changed noticeably. The most apparent changes from 1988 to 2017 were the proportions most frequently engaging in Exercise and Sport. In addition, the proportion of time reportedly spent in vigorous-intensity PA decreased over time, particularly among male respondents. Moreover, the proportion of Americans reporting an "Other" PA mode increased substantially, suggesting a growing need for a greater variety of easily accessible options for adult PA.

CONCLUSIONS

Over time, a smaller proportion of American adults reported participating in sport and exercise modalities and reported engaging more frequently in low-intensity physical activities.

Antibiotics Use and Its Knowledge in the Community: A Mobile Phone Survey during the COVID-19 Pandemic in Bangladesh

The general population has been excessively using antibiotics during the COVID-19 pandemic. Therefore, the use of antibiotics for any reported illnesses in the preceding four weeks and knowledge of antibiotics among the general population in the community were assessed for possible interventions. A mobile phone survey among a general population across eight administrative divisions of Bangladesh was conducted during January-March 2021. Reported illness episodes irrespective of COVID-19 in the preceding four weeks of the interview, use of antibiotics for the illnesses, and knowledge on antibiotics among the general population were recorded. Descriptive analyses were performed. We randomly interviewed 1854 participants, with a mean age of 28.5 years (range: 18-75 years); 60.6% were male. Among all participants, 86.3% (95% CI: 84.7-87.8) heard names of antibiotics, but only 12.1% reported unspecified harmful effects, and 3.5% reported antimicrobial resistance when antibiotics were taken without a physician's prescription. Among 257 (13.9%) participants, who consumed medicines for their recent illness episode, 32.7% (95% CI: 27.2-38.6) reported using antibiotics. Of those who could recall the names of antibiotics prescribed (n = 36), the most frequently used was azithromycin (22.2%) followed by cefixime (11.1%) and ciprofloxacin (5.6%). Our findings show an increased antibiotic use for illnesses reported in the preceding four weeks and an elevated knowledge at the community level during the COVID-19 pandemic compared with the pre-pandemic period.

Self-assessment of health status among lesbian, gay, and bisexual cancer survivors in the United States

BACKGROUND

Research is lacking for understanding the health disparities in cancer survivorship in the lesbian, gay, and bisexual (LGB) population in the United States. Self-reported health status is used as a predictor of health disparities.

METHODS

This secondary data analysis study used 2018 Behavioral Risk Factor Surveillance System data to analyze cancer survivorship characteristics by sexual orientation and sex through the use of logistic regressions.

RESULTS

Overall, 17,656,329 US cancer survivors were included in this study after weighting, with percentage estimates of 1.52% for gays/lesbians and 1.41% for bisexuals. LGB participants were younger and more ethnically diverse. Significantly, bisexuals had current smoking (32.3% vs 13.6%) and binge drinking rates (17.1% vs 9.1%) twice those of heterosexuals; 16.6% of bisexuals versus 4.1% of heterosexuals reported no health insurance coverage (P < .0001). After adjustments for socioeconomic, health-related behavioral risk, and health care access factors, bisexual females reported poorer general health (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.31-1.36) as well as mental health (OR, 2.43; 95% CI, 2.39-2.46) than their heterosexual peers (P < .0001). Bisexual males were 5.14 times more likely to be told that they had depressive disorders than their heterosexual counterparts (95% CI, 5.05-5.23), whereas bisexual females were 3.23 times more likely for the same outcome (95% CI, 3.18-3.28). All LGB groups reported significantly more inadequate sleep than their heterosexual counterparts (especially lesbians: OR, 2.14; 95% CI, 2.10-2.18).

CONCLUSIONS

This study indicates that LGB cancer survivors have worse survivorship than their heterosexual peers with heterogeneity in subgroups. Future studies should use larger sample sizes, further investigate disparities, and promote survivorship in LGB populations.

LAY SUMMARY

It has been observed that lesbian, gay, and bisexual (LGB) cancer survivors may face challenges in cancer survivorship that are not as prevalent in the heterosexual community. This cross-sectional study has found that LGB cancer survivors, especially bisexuals, have overall poorer physical and mental health, are more likely to be told that they have depressive disorders, and have worse sleep quality in comparison with their heterosexual counterparts. These results also differ by sex, and this can provide rationales for future studies and guide interventions to relocate resources to better promote equality.

Sources of Missing Sexual Orientation and Gender Identity Data in the Behavioral Risk Factor Surveillance System

INTRODUCTION

This paper describes the sources, magnitude, and correlates of missing data in the Behavioral Risk Factor Surveillance System Sexual Orientation and Gender Identity module.

METHODS

Missing data from the Behavioral Risk Factor Surveillance System Sexual Orientation and Gender Identity module fielded from 2014 to 2019 were ascribed to 4 sources: the optional nature of the Sexual Orientation and Gender Identity module, out-of-state cell phone respondents, interview termination, and item nonresponse. The prevalence of missingness from these 4 sources was examined in relation to sociodemographic factors and survey process factors. Data were analyzed in 2018-2020.

RESULTS

From 2014 to 2019, of 2,698,738 Behavioral Risk Factor Surveillance System respondents, 1,330,025 (44.8%, weighted) were in states that did not administer the Sexual Orientation and Gender Identity module. Among 723,301 cell phone interviews in states administering the module, 12.5% (weighted) were out of state. Among 1,316,174 otherwise potential respondents, 9.4% (weighted) terminated the interview before Sexual Orientation and Gender Identity module administration. Among 1,205,177 administered the module, item-level missingness was 3.4% for sexual orientation and 1.3% for gender identity. Correlates of missingness varied considerably at each stage.

CONCLUSIONS

Missing the Behavioral Risk Factor Surveillance System Sexual Orientation and Gender Identity data is much more prevalent than item nonresponse alone would suggest. Analytic techniques that consider only item nonresponse, such as complete case analysis, risk producing biased findings. Including the Sexual Orientation and Gender Identity module in the required core demographics section is the only feasible method to reduce the amount and complexity of missing data.

Subjective cognitive decline higher among sexual and gender minorities in the United States, 2015-2018

INTRODUCTION

Subjective cognitive decline (SCD) represents self-reported problems with memory, a possible early sign of dementia. Little is known about SCD among sexual and gender minority (SGM) adults who identify as lesbian, gay, bisexual, and/or transgender or gender non-binary.

METHODS

Data were weighted to represent population estimates from 25 states' 2015-2018 Behavioral Risk Factor Surveillance System to describe SCD in adults ≥45 years by SGM status. Logistic regression tested associations between demographic and health conditions.

RESULTS

SCD prevalence was higher in SGM (15.7%; 95% confidence interval [CI]:13.1-18.2) than in non-SGM adults (10.5%; 95% CI:10.1-10.9; P < .0001). SGM adults with SCD were also more likely to report functional limitations due to SCD than non-SGM adults with SCD, 60.8% versus 47.8%, P = .0048. Differences in SCD by SGM status were attenuated after accounting for depression.

DISCUSSION

Higher prevalence of SCD in SGM adults highlights the importance of ensuring inclusive screenings, interventions, care services, and resources for SGM adults.

Determinants of Diabetes Disease Management, 2011-2019

This study estimated the effects of Medicaid Expansion, demographics, socioeconomic status (SES), and health status on disease management of diabetes over time. The hypothesis was that the introduction of the ACA and particularly Medicaid Expansion would increase the following dependent variables (all proportions): (1) provider checks of HbA1c, (2) provider checks of feet, (3) provider checks of eyes, (4) patient education, (5) annual physician checks for diabetes, (6) patient self-checks of blood sugar. Data were available from the Behavioral Risk Factor Surveillance System for 2011 to 2019. We filtered the data to include only patients with diagnosed non-gestational diabetes of age 45 or older (n = 510,991 cases prior to weighting). Linear splines modeled Medicaid Expansion based on state of residence as well as implementation status. Descriptive time series plots showed no major changes in proportions of the dependent variables over time. Quasibinomial analysis showed that implementation of Medicaid Expansion had a statistically negative effect on patient self-checks of blood sugar (odds ratio = 0.971, p < 0.001), a statistically positive effect on physician checks of HbA1c (odds ratio = 1.048, p < 0.001), a statistically positive effect on feet checks (odds ratio = 1.021, p < 0.001), and no other significant effects. Evidence of demographic, SES, and health status disparities existed for most of the dependent variables. This finding was especially significant for HbA1c checks by providers. Barriers to achieving better diabetic care remain and require innovative policy interventions.

Barriers to Dissemination of Local Health Data Faced by US State Agencies: Survey Study of Behavioral Risk Factor Surveillance System Coordinators

Background

Advances in information technology have paved the way to facilitate accessibility to population-level health data through web-based data query systems (WDQSs). Despite these advances in technology, US state agencies face many challenges related to the dissemination of their local health data. It is essential for the public to have access to high-quality data that are easy to interpret, reliable, and trusted. These challenges have been at the forefront throughout the COVID-19 pandemic.

Objective

The purpose of this study is to identify the most significant challenges faced by state agencies, from the perspective of the Behavioral Risk Factor Surveillance System (BRFSS) coordinator from each state, and to assess if the coordinators from states with a WDQS perceive these challenges differently.

Methods

We surveyed BRFSS coordinators (N=43) across all 50 US states and the District of Columbia. We surveyed the participants about contextual factors and asked them to rate system aspects and challenges they faced with their health data system on a Likert scale. We used two-sample t tests to compare the means of the ratings by participants from states with and without a WDQS.

Results

Overall, 41/43 states (95%) make health data available over the internet, while 65% (28/43) employ a WDQS. States with a WDQS reported greater challenges (P=.01) related to the cost of hardware and software (mean score 3.44/4, 95% CI 3.09-3.78) than states without a WDQS (mean score 2.63/4, 95% CI 2.25-3.00). The system aspect of standardization of vocabulary scored more favorably (P=.01) in states with a WDQS (mean score 3.32/5, 95% CI 2.94-3.69) than in states without a WDQS (mean score 2.85/5, 95% CI 2.47-3.22).

Conclusions

Securing of adequate resources and commitment to standardization are vital in the dissemination of local-level health data. Factors such as receiving data in a timely manner, privacy, and political opposition are less significant barriers than anticipated.

Postpartum Treatment for Substance Use Disorder Among Mothers of Infants with Neonatal Abstinence Syndrome and Prenatal Substance Exposure

Background: Little is known about rates of substance use disorder (SUD) treatment for women in dyads affected by substance use in the immediate postpartum period. This study's objectives were to (1) identify characteristics of mothers of infants with neonatal abstinence syndrome (NAS) and/or prenatal substance exposure (PSE) who did or did not receive SUD treatment in the first 60 days postpartum and (2) describe timing of treatment receipt. Methods: This descriptive study examined linked mother-infant dyads using Medicaid data from Louisiana, Massachusetts, and Wisconsin for 2006-2009. Dyads were included if the infant had NAS and/or PSE. Descriptive statistics on sociodemographic characteristics, prenatal SUD, mental health conditions, Medicaid enrollment, and health care utilization were reported for women who did and did not receive SUD treatment in the first 60 days postpartum. The distribution of each variable was compared using chi-square tests. The timing of first postpartum treatment in weeks since delivery was examined. Results: Among Medicaid-insured women whose infants had in utero substance exposure, 15% received any postpartum SUD treatment. Fewer than half were diagnosed with SUD prenatally. Of those who received postpartum SUD treatment, 68% had received prenatal treatment. No association was observed between postpartum SUD treatment receipt and months of Medicaid enrollment in the year before delivery, prenatal visits, or postpartum visit attendance. Conclusions: Most women who likely need postpartum SUD treatment did not receive it and multipronged solutions are needed. These findings provide a useful baseline for evaluations of policies aimed at improving maternal health.

Association of premature atherosclerotic cardiovascular disease with higher risk of cancer: a behavioral risk factor surveillance system study

AIM 

The aim of this study was to investigate a possible association between atherosclerotic cardiovascular disease (ASCVD) and risk of cancer in young adults.

METHODS 

We utilized data from the Behavioral Risk Factor Surveillance System, a nationally representative US telephone-based survey to identify participants in the age group of 18-55 years who reported a history of ASCVD. These patients were defined as having premature ASCVD. Weighted multivariable logistic regression models were used to study the association between premature ASCVD and cancer including various cancer subtypes.

RESULTS 

Between 2016 and 2019, we identified 28 522 (3.3%) participants with a history of premature ASCVD. Compared with patients without premature ASCVD, individuals with premature ASCVD were more likely to be Black adults, have lower income, lower levels of education, reside in states without Medicaid expansion, have hypertension, diabetes mellitus, chronic kidney disease, obesity, and had delays in seeking medical care. Individuals with premature ASCVD were more likely to have been diagnosed with any form of cancer (13.7% vs 3.9%), and this association remained consistent in multivariable models (odds ratio, 95% confidence interval: 2.08 [1.72-2.50], P < 0.01); this association was significant for head and neck (21.08[4.86-91.43], P < 0.01), genitourinary (18.64 [3.69-94.24], P < 0.01), and breast cancer (3.96 [1.51-10.35], P < 0.01). Furthermore, this association was consistent when results were stratified based on gender and race, and in sensitivity analysis using propensity score matching.

CONCLUSION 

Premature ASCVD is associated with a higher risk of cancer. These data have important implications for the design of strategies to prevent ASCVD and cancer in young adults.

Association of Smokeless Tobacco Use With the Use of Other Illicit Drugs in the United States

BACKGROUND

There has been an increase in the use of smokeless tobacco recently. Whether smokeless tobacco use may predispose individuals to use other addictive substances is unknown. The use of multiple addictive substances may compound an individual's adverse health effects.

METHODS

In a cross-sectional analysis, we used the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) survey database to identify all individuals who reported the use of smokeless tobacco and extracted data regarding baseline and demographic patterns, as well as information regarding the use of other addictive substances. Weighted multivariable logistic regression models adjusting for age, gender, race/ethnicity, poverty level, education, employment status, and marital status were used to determine the odds ratios (ORs) for use of alcohol, cigarettes, e-cigarettes, and marijuana among smokeless tobacco users.

RESULTS

We identified 30,395 (3.38%) individuals in our study population who reported smokeless tobacco use. Compared with non-users, smokeless tobacco users were more likely to be unmarried, male, Caucasian, belonging to the lower socioeconomic strata, and did not have a formal college education (P <0.01). In multivariable analyses, smokeless tobacco use was associated with a higher likelihood of cigarettes use (OR: 1.76 [95% confidence interval {CI}: 1.66-1.86, P <0.01]), e-cigarette use (OR: 1.61 [95% CI: 1.52-1.71, P <0.01]), and heavy alcohol consumption (OR:2.36 [95% CI: 2.17-2.56, P <0.01]) but not marijuana use (OR: 1.11 [95% CI: 0.90-1.38, P = 0.33]).

CONCLUSION

In a large, nationally representative sample, smokeless tobacco use was associated with the increased use of cigarettes, e-cigarettes, and alcohol. Simultaneous use of these substances may compound the adverse health effects of smokeless tobacco use. Public health interventions addressing this concerning trend are warranted.

Use of Electronic Cigarettes and Self-Reported Chronic Obstructive Pulmonary Disease Diagnosis in Adults

INTRODUCTION

Electronic cigarette (e-cigarette) use (vaping) has increased in recent years. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death associated with smoking.

AIMS AND METHODS

Based on 2016 and 2017 Behavioral Risk Factor Surveillance System national survey data on 891 242 adult participants who indicated their smoking and vaping status, the cross-sectional association of vaping with self-reported COPD diagnosis was investigated, using univariable and multivariable weighted logistic regression models.

RESULTS

Compared to never users, while dual users showed the highest association with self-reported COPD diagnosis (adjusted odds ratio [aOR] = 4.39; 95% confidence interval [CI] = 3.98 to 4.85), current vapers who were either ex-smokers or never smoked showed significantly higher association with self-reported COPD diagnosis (aOR = 3.24; 95% CI = 2.78 to 3.78 and aOR = 1.47; 95% CI = 1.01 to 2.12, respectively). Current vapers who were ex-smokers showed higher association with self-reported COPD diagnosis than ex-smokers who do not vape (aOR = 1.27; 95% CI = 1.09 to 1.48). Dual users showed higher association with self-reported COPD diagnosis than current smokers who do not vape (aOR = 1.16; 95% CI = 1.05 to 1.27). Ex-smokers showed significantly less association with self-reported COPD diagnosis (aOR = 0.67; 95% CI = 0.64 to 0.71) than current smokers. Current vapers who were either ex-smokers or never smoked had less association with self-reported COPD diagnosis compared to current smokers, with aOR = 0.85 (95% CI = 0.73 to 0.99) and aOR = 0.39 (95% CI = 0.27 to 0.56).

CONCLUSIONS

Vaping is significantly associated with self-reported COPD diagnosis in adults, even among vapers who never smoked. Whether there is a benefit for COPD of switching from smoking to vaping requires study of the long-term effects of vaping.

IMPLICATIONS

With the increase of e-cigarette use in recent years, the health effects of e-cigarettes need to be investigated. While several studies have examined the association of vaping with respiratory symptoms among adolescents, little is known about the association of vaping with susceptibility to COPD among US adults. Using cross-sectional national survey data in adults, our study showed that vaping was significantly associated with self-reported COPD diagnosis. Although our data did not establish the causal relationship between vaping and self-reported COPD diagnosis, this study raises concerns about the observed association between vaping and self-reported COPD diagnosis.

Electronic cigarette use and subjective cognitive complaints in adults

INTRODUCTION

Electronic cigarette use (vaping) has become popular in recent years. The number of Americans with a variety of cognitive deficits has been increasing dramatically. This study aimed to examine the potential association of vaping with subjective cognitive complaints in US adults.

METHODS

A combined 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) national survey dataset yielded 886,603 adults who indicated their smoking and vaping status, as well as whether they had subjective cognitive complaints. With this dataset, the cross-sectional association of electronic cigarette use with subjective cognitive complaints was examined using multivariable weighted logistic regression models.

RESULTS

Both dual users (adjusted Odds Ratio [aOR] = 2.07; 95% Confidence Interval [CI] = 1.66 to 2.60) and current vapers who were either ex-smokers (aOR = 1.94; 95% CI = 1.40 to 2.71) or never smoked (aOR = 1.96; 95% CI = 1.16 to 3.30) showed a significantly higher association with subjective cognitive complaints than never users. Current smokers (aOR = 1.49; 95% CI = 1.32 to 1.69) and ex-smokers (aOR = 1.25; 95% CI = 1.11 to 1.41) had a significantly higher association with subjective cognitive complaints compared to never users. Compared to current smokers, the ex-smokers showed a lower association with subjective cognitive complaints (aOR = 0.84; 95% CI = 0.73 to 0.96). Finally, the association of vaping with subjective cognitive complaints was not statistically significant in individual age group.

CONCLUSION

Similar to smoking, vaping is associated with subjective cognitive complaints in US adults. These results provide preliminary evidence for a cross-sectional association of vaping with potential cognitive health effects in adults.

Community Gardening as a Way to Build Cross-Cultural Community Resilience in Intersectionally Diverse Gardeners: Community-Based Participatory Research and Campus-Community-Partnered Proposal

BACKGROUND

Community-based agriculture has been found to decrease food insecurity and alleviate health inequities. Furthermore, it provides a sense of ownership, resources to help integrate new communities, and a space to nurture existing cultural identities for intersectionally diverse gardeners. This sense of belonging in connection with access to growing plots has been linked to psychological well-being and resilience. However, little is known about how the psychosocial benefits of plot ownership affect resilience and which aspects of this resilience are salient.

OBJECTIVE

This community-based participatory research (CBPR) project will examine the role of community gardens in decreasing food insecurity and facilitating various forms of resilience in food-insecure groups in Rochester, Minnesota. Since participation in community gardens nurtures various forms of resilience along individual, group, and community dimensions, our research seeks to understand how dimensions of resilience vary along intersectional lines. In addition to mapping the psychosocial benefits linked to plot ownership, we find that examining which forms of resilience are fostered in community-based agricultural projects addresses an important gap in the academic literature. This can help us propose policy-level practices that reduce health inequities connected to food and nutrition at the local level.

METHODS

Using a mixed methods approach, this ongoing community-campus partnership will examine the experiences of current and new plot owners. As a CBPR project, our data collection plan, from design to dissemination, incorporates the intellectual and creative labor of the individuals representing members of the campus community (ie, college students and faculty members engaged in other citizen science projects hosted by the garden), community growers, individuals involved in the community garden's board, and representatives of various organizational bodies. Data collection activities will consist of surveys, in-depth interviews, and photovoice.

RESULTS

This project was funded in January 2020 and approved by the University of Minnesota's Institutional Review Board in March 2020. For the 2020 growing season, we will conduct evaluative interviews about the effect of COVID-19 on community gardeners, including their experiences during this growing season. For the 2021 growing season, data collection, via pre- and postsurveys, is projected to begin in March 2021 and end in November 2021. We will also conduct in-depth interviews from January to April 2021. Data analysis will commence in April 2021. Photovoice activities (ie, data collection, analysis, synthesis, and dissemination) are expected to take place during the spring and summer of 2021.

CONCLUSIONS

Findings emerging from this study will provide the preliminary data to foreground community gardening projects and initiatives to improve physical and mental health outcomes in food-insecure communities. Also, the data collected will highlight the role of CBPR methods in disseminating information about the organizational practices of the community garden; this will assist others in planning and implementing similar projects.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/21218.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring reasons for state-level variation in incidence of dialysis-requiring acute kidney injury (AKI-D) in the United States

BACKGROUND

There is considerable state-level variation in the incidence of dialysis-requiring acute kidney injury (AKI-D). However, little is known about reasons for this geographic variation.

METHODS

National cross-sectional state-level ecological study based on State Inpatient Databases (SID) and the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. We analyzed 18 states and six chronic health conditions (diabetes mellitus [diabetes], hypertension, chronic kidney disease [CKD], arteriosclerotic heart disease [ASHD], cancer (excluding skin cancer), and chronic obstructive pulmonary disease [COPD]). Associations between each of the chronic health conditions and AKI-D incidence was assessed using Pearson correlation and multiple regression adjusting for mean age, the proportion of males, and the proportion of non-Hispanic whites in each state.

RESULTS

The state-level AKI-D incidence ranged from 190 to 1139 per million population. State-level differences in rates of hospitalization with chronic health conditions (mostly < 3-fold difference in range) were larger than the state-level differences in prevalence for each chronic health condition (mostly < 2.5-fold difference in range). A significant correlation was shown between AKI-D incidence and prevalence of diabetes, ASHD, and COPD, as well as between AKI-D incidence and rate of hospitalization with hypertension. In regression models, after adjusting for age, sex, and race, AKI-D incidence was associated with prevalence of and rates of hospitalization with five chronic health conditions--diabetes, hypertension, CKD, ASHD and COPD--and rates of hospitalization with cancer.

CONCLUSIONS

Results from this ecological analysis suggest that state-level variation in AKI-D incidence may be influenced by state-level variations in prevalence of and rates of hospitalization with several chronic health conditions. For most of the explored chronic conditions, AKI-D correlated stronger with rates of hospitalizations with the health conditions rather than with their prevalences, suggesting that better disease management strategies that prevent hospitalizations may translate into lower incidence of AKI-D.

Hypertension among Mississippi Workers by Sociodemographic Characteristics and Occupation, Behavioral Risk Factor Surveillance System

In 2017, Mississippi had the third highest age-adjusted prevalence of hypertension in the United States. We estimated the prevalence of hypertension by sociodemographic characteristics and occupation and examined the association between hypertension with occupation and sociodemographic characteristics among Mississippi workers. We calculated adjusted prevalence and adjusted prevalence ratios (APRs) by sociodemographic characteristics and occupation among Mississippi adult workers. We analyzed combined 2013, 2015, and 2017 data from the Mississippi Behavioral Risk Factor Surveillance System for 6,965 workers in ten Standard Occupational Classification System major groups. Of the estimated 1.1 million Mississippi workers during the three survey years, 31.4% (95% confidence interval (CI), 30.0–32.8) had hypertension. The likelihood of having hypertension was significantly higher among workers aged 30–44 years, 45–64 years, blacks, and those classified as overweight and obese workers compared to their counterparts. The likelihood of having hypertension among workers in the fields of installation, repair and maintenance, and production were 26% higher (APR, 1.26; 95% CI, 1.03–1.55) and 33% higher (APR, 1.33; 95% CI, 1.11–1.58), respectively, than workers in all other occupational groups. Among Mississippi workers, hypertension prevalence varied by sociodemographic characteristics and occupational groups. Age, race, obesity status, installation, repair, maintenance, and production occupation groups are associated with an increased likelihood of hypertension. Novel and/or community-based or linked programs are needed that could target workers at risk of hypertension that are outside of a single-site workplace.

Changes in Health Care Access, Behaviors, and Self-reported Health Among Low-income US Adults Through the Fourth Year of the Affordable Care Act

BACKGROUND

Health care access increased for low-income Americans under the Affordable Care Act (ACA). It is unknown whether these changes in access were associated with improved self-reported health.

OBJECTIVE

Determine changes in health care access, health behaviors, and self-reported health among low-income Americans over the first 4 years of the ACA, stratified by state Medicaid expansion status.

DESIGN

Interrupted time series and difference-in-differences analysis.

SUBJECTS

Noninstitutionalized US adults (18-64 y) in low income households (<138% federal poverty level) interviewed in the Behavioral Risk Factor Surveillance System 2011-2017 (N=505,824).

MEASURES

Self-reported insurance coverage, access to a primary care physician, avoided care due to cost; self-reported general health, days of poor physical health, days of poor mental health days, and days when poor health limited usual activities; self-reported health behaviors, use of preventive services, and diagnoses.

RESULTS

Despite increases in access, the ACA was not associated with improved physical or general health among low-income adults during the first 4 years of implementation. However, Medicaid expansion was associated with fewer days spent in poor mental health (-1.1 d/mo, 95% confidence interval: -2.1 to -0.5). There were significant changes in specific health behaviors, preventive service use, and diagnosis patterns during the same time period which may mediate the relationship between the ACA rollout and self-reported health.

CONCLUSION

In nationally-representative survey data, we observed improvements in mental but not physical self-reported health among low-income Americans after 4 years of full ACA implementation.

Augmenting cancer registry data with health survey data with no cases in common: the relationship between pre-diagnosis health behaviour and post-diagnosis survival in oesophageal cancer

Background

For epidemiological research, cancer registry datasets often need to be augmented with additional data. Data linkage is not feasible when there are no cases in common between data sets. We present a novel approach to augmenting cancer registry data by imputing pre-diagnosis health behaviour and estimating its relationship with post-diagnosis survival time.

Methods

Six measures of pre-diagnosis health behaviours (focussing on tobacco smoking, ‘at risk’ alcohol consumption, overweight and exercise) were imputed for 28,000 cancer registry data records of US oesophageal cancers using cold deck imputation from an unrelated health behaviour dataset. Each data point was imputed twice. This calibration allowed us to estimate the misclassification rate. We applied statistical correction for the misclassification to estimate the relative risk of dying within 1 year of diagnosis for each of the imputed behaviour variables. Subgroup analyses were conducted for adenocarcinoma and squamous cell carcinoma separately.

Results

Simulated survival data confirmed that accurate estimates of true relative risks could be retrieved for health behaviours with greater than 5% prevalence, although confidence intervals were wide. Applied to real datasets, the estimated relative risks were largely consistent with current knowledge. For example, tobacco smoking status 5 years prior to diagnosis was associated with an increased age-adjusted risk of all cause death within 1 year of diagnosis for oesophageal squamous cell carcinoma (RR = 1.99 95% CI 1.24,3.12) but not oesophageal adenocarcinoma RR = 1.61, 95% CI 0.79,2.57).

Conclusions

We have demonstrated a novel imputation-based algorithm for augmenting cancer registry data for epidemiological research which can be used when there are no cases in common between data sets. The algorithm allows investigation of research questions which could not be addressed through direct data linkage.

Association of Electronic Cigarette Regulations With Electronic Cigarette Use Among Adults in the United States

IMPORTANCE

Millions of Americans use electronic cigarettes (e-cigarettes). A growing number of state and local governments have started to draft and implement laws regarding the sale, marketing, and use of e-cigarettes. The association of US state regulations regarding e-cigarettes with e-cigarette use remains unknown.

OBJECTIVE

To examine the association of US state regulations regarding e-cigarettes with current e-cigarette use among adults in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included adults aged 18 years or older from the 2016 and 2017 Behavioral Risk Factor Surveillance System, which is a nationwide, telephone-administered survey that collects state-representative data on health-related risk behaviors, chronic health conditions, and use of preventive services. Data analysis was performed from February 1, 2019, to April 31, 2019.

EXPOSURES

United States state laws regulating e-cigarette use, including prohibiting e-cigarette use in indoor areas of private workplaces, restaurants, and bars; requiring retailers to purchase a license to sell e-cigarettes; prohibiting self-service displays of e-cigarettes; prohibiting sales of tobacco products, including e-cigarettes, to persons younger than 21 years; and e-cigarette taxes.

MAIN OUTCOMES AND MEASURES

Current use of e-cigarettes.

RESULTS

Among 894 997 participants aged 18 years or older (503 688 women [51.3%], 679 443 non-Hispanic white [62.6%], 71 730 non-Hispanic black [16.3%], 69 823 Hispanic [11.4%], and 74 001 non-Hispanic other races [9.8%]), 28 907 (weighted prevalence, 4.4%) were currently using e-cigarettes. The age-standardized weighted prevalence of current e-cigarette use varied across US states and territories, from 1.0% in Puerto Rico to 6.2% in Guam. After adjustment for demographic, socioeconomic, and lifestyle factors, including conventional cigarette use, the odds ratios of current e-cigarette use were 0.90 (95% CI, 0.83-0.98) for state laws prohibiting e-cigarette use in indoor areas of private workplaces, restaurants, and bars; 0.90 (95% CI, 0.85-0.95) for state laws requiring retailers to purchase a license to sell e-cigarettes; 1.04 (95% CI, 0.99-1.09) for state laws prohibiting self-service displays of e-cigarettes; 0.86 (95% CI, 0.74-0.99) for state laws prohibiting sales of tobacco products, including e-cigarettes, to persons younger than 21 years; and 0.89 (95% CI, 0.83-0.96) for state laws applying taxes to e-cigarettes.

CONCLUSIONS AND RELEVANCE

These findings suggest that several state regulations regarding e-cigarettes may be associated with reduced e-cigarette use among US adults.

Age Differences in Racial/Ethnic Disparities in Preventable Hospitalizations for Heart Failure in Connecticut, 2009-2015: A Population-Based Longitudinal Study

OBJECTIVE

Preventable hospitalizations for heart failure result in a large proportion of hospitalizations. The primary objective of this study was to describe longitudinal trends in the association of race/ethnicity with preventable hospitalizations for heart failure in Connecticut and differences in disparities by age.

METHODS

We analyzed data on hospitalizations in all civilian acute-care hospitals in Connecticut during a 7-year period, 2009 through 2015. We used raking methodology to weight the nonhospitalized population to create a reference population representative of the state's general population. Multivariate regression models examined racial/ethnic disparities among adults aged 35-64, controlling for age, sex, and type of health insurance. For adults aged ≥65, regression models controlled for age and sex.

RESULTS

After controlling for age and sex, the non-Hispanic black to non-Hispanic white odds ratio for preventable hospitalizations for heart failure ranged from 5.2-6.4 during the study period among adults aged 35-64. Among adults aged ≥65, non-Hispanic black adults had significantly higher odds (range, 1.2-1.8) of preventable hospitalizations than non-Hispanic white adults. Rates among Hispanic adults were significantly higher than rates among non-Hispanic adults after controlling for age and sex among adults aged ≥65 in 2014 and 2015.

CONCLUSIONS

This research provides information for clinical and population-based interventions targeting racial/ethnic gaps in heart failure hospitalizations. Demonstrating the persistent black-white disparity and age differences in racial/ethnic disparities, this study emphasizes the need for focused prevention among vulnerable populations. Raking methodology is an innovative approach to eliminating selection bias in hospital discharge data.

The association between e-cigarette use and asthma among never combustible cigarette smokers: behavioral risk factor surveillance system (BRFSS) 2016 & 2017

BACKGROUND

E-cigarette use prevalence has grown rapidly in the US. Despite the popularity of these products, few acute exposure toxicity studies exist, and studies on long-term pulmonary health effects are limited. E-cigarette users who are never combustible cigarette smokers (sole users) constitute a unique group of young adults that may be at increased risk of bronchial hyperreactivity and development of asthma. Given the public health concern about the potential pulmonary health effects of sole e-cigarette use, we aimed to examine the association between e-cigarette use and asthma among never combustible cigarette smokers.

METHODS

We pooled 2016 and 2017 data of the Behavioral Risk Factor Surveillance System (BRFSS), a large, cross-sectional telephone survey of adults aged 18 years and older in the U.S. We included 402,822 participants without any history of combustible cigarette smoking (defined as lifetime smoking < 100 cigarettes) and with complete self-reported information on key variables. Current e-cigarette use, further classified as daily or occasional use, was the primary exposure. The main outcome, asthma, was defined as self-reported history of asthma. We assess the relationship of sole e-cigarette use with asthma using multivariable logistic regression adjusting for age, sex, race, income, level of education and body mass index.

RESULTS

Of 402,822 never combustible cigarette smokers, there were 3103 (0.8%) current e-cigarette users and 34,074 (8.5%) with asthma. The median age group of current e-cigarette users was 18-24 years. Current e-cigarette use was associated with 39% higher odds of self-reported asthma compared to never e-cigarette users (Odds Ratio [OR], 1.39; 95% confidence interval: 1.15, 1.68). There was a graded increased odds of having asthma with increase of e-cigarette use intensity. The odds ratio of self-reported asthma increased from 1.31 (95% confidence interval: 1.05, 1.62) in occasional users to 1.73 (95% confidence interval: 1.21, 2.48) in daily e-cigarette users, compared to never e-cigarette users.

CONCLUSION

Our findings from a large, nationally representative survey suggest increased odds of asthma among never combustible smoking e-cigarette users. This may have potential public health implications, providing a strong rationale to support future longitudinal studies of pulmonary health in young e-cigarette-using adults.

Current smoking and quit-attempts among US adults following Medicaid expansion

The objective of this study was to estimate the influence of the Affordable Care Act (ACA) Medicaid Expansion on current smoking and quit attempts in expanded and non-expanded states. We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) between 2003 through 2015 to evaluate changes in current smoking and quit attempts using multivariable logistic regression and generalized estimating equations (GEE), adjusting for socioeconomic factors. Time periods evaluated were: 2003–2009 (pre-expansion) and 2011–2015 (post-expansion), and in supplemental analysis, also 2011–2017. Overall, smoking prevalence among adults in expanded and non-expanded states were 16% and 17% (p < 0.001), respectively, and quit attempt prevalence for expanded and non-expanded states were 56% and 57% (p = 0.05), respectively. In adjusted models comparing post- versus pre- expansion periods, current smoking declined by 6% in both expanded (RR: 0.94, 95% CI: 0.93–0.94) and non-expanded (RR: 0.94, 95% CI: 0.94–0.95) states. Quit attempts increased by 4% (RR: 1.04, 95% CI: 1.04–1.05) in expanded states, and by 3% (RR: 1.03, 95% CI: 1.02–1.03) in non-expanded states. States that imposed barriers to utilization of smoking cessation services e.g. prior authorization, saw only a 3% increase in quit attempts regardless of expansion status, while expanded states that did not impose barriers experienced a 6% (RR: 1.06, 95% CI: 1.05–1.06) increase in quit attempts. Reducing administrative barriers to smoking cessation programs may enhance further declines in smoking rates among US adults.

Dental care utilization: examining the associations between health services deficits and not having a dental visit in past 12 months

Background

A growing literature supports the contention that closing the divide between dental and medical care can improve access to and coordination of patient care. Health service deficits (HSDs) entail: no routine medical exam, no personal healthcare provider (HCP), no health insurance, and/or delaying medical care because of cost all within the last 12 months. Examining the associations between HSDs and dental care utilization could inform strategies and interventions aimed at narrowing the gap between the medical and dental professions. This study explored whether HSDs are associated with not having a dental care visit within the last 12 months. In addition, the study sought to provide an updated analysis of the characteristics and factors associated with dental care utilization.

Methods

Two thousand sixteen Behavioral Risk Factor Surveillance System survey data were analyzed using bivariate and multivariable techniques. The outcome variable for this study was: last dental visit was longer than 12 months ago.

Results

US adults without healthcare insurance, without a personal HCP, who had delayed medical care because of cost, and who had their last routine medical visit longer than 12 months ago had greater odds of not having a dental visit within the last 12 months. Further, this study identified disparities in dental care utilization among males, rural residents, those earning less than $50,000 per year, Non-Hispanic Blacks and Non-Hispanic other races. Individuals with six or more and/or all of their permanent teeth removed and current smokers also had greater odds of not having had a dental care visit in the past 12 months.

Conclusions

Findings suggest that a stronger integration of medical and dental care might increase dental care utilization. In addition, persistent disparities in dental care utilization remain for several demographic groups. Targeted interventions offer the promise of helping achieve HP 2020 goals for improved oral health.

Exploring the Relationship Between Lifestyle Behaviors and Health-Related Quality of Life Among Older Adults With Diabetes

Purpose

The purpose of the study was to examine the association between 3 lifestyle behaviors (smoking, physical activity, and fruit and vegetable consumption) and health-related quality of life (HRQOL) among older adults diagnosed with diabetes.

Methods

A sample of the US population 65 years and older who were diagnosed with diabetes from the 2015 Behavioral Risk factor Surveillance System (N = 11 503) was analyzed. The 4 HRQOL measures were self-rated health, physically unhealthy days, mentally unhealthy days, and impaired activity days in the past month. Multiple logistic regression analysis was conducted to predict HRQOL.

Results

The multiple logistic regression results showed that smoking and lack of physical activity were significant predictors for higher odds of fair or poor self-rated health, more physically unhealthy days, more mentally unhealthy days, and more impaired activity days during past 30 days. No significant relationship was found between fruit and vegetable consumption and any HRQOL measure.

Conclusions

Findings imply that diabetes education could continue and enhance efforts in smoking cessation and increase physical activity to promote the HRQOL among older adults diagnosed with diabetes. In addition, the measure of fruit and vegetable consumption should be further studied to reflect the needs of older adults with diabetes.

Can online self-reports assist in real-time identification of influenza vaccination uptake? A cross-sectional study of influenza vaccine-related tweets in the USA, 2013-2017

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) spend significant time and resources to track influenza vaccination coverage each influenza season using national surveys. Emerging data from social media provide an alternative solution to surveillance at both national and local levels of influenza vaccination coverage in near real time.

OBJECTIVES

This study aimed to characterise and analyse the vaccinated population from temporal, demographical and geographical perspectives using automatic classification of vaccination-related Twitter data.

METHODS

In this cross-sectional study, we continuously collected tweets containing both influenza-related terms and vaccine-related terms covering four consecutive influenza seasons from 2013 to 2017. We created a machine learning classifier to identify relevant tweets, then evaluated the approach by comparing to data from the CDC's FluVaxView. We limited our analysis to tweets geolocated within the USA.

RESULTS

We assessed 1 124 839 tweets. We found strong correlations of 0.799 between monthly Twitter estimates and CDC, with correlations as high as 0.950 in individual influenza seasons. We also found that our approach obtained geographical correlations of 0.387 at the US state level and 0.467 at the regional level. Finally, we found a higher level of influenza vaccine tweets among female users than male users, also consistent with the results of CDC surveys on vaccine uptake.

CONCLUSION

Significant correlations between Twitter data and CDC data show the potential of using social media for vaccination surveillance. Temporal variability is captured better than geographical and demographical variability. We discuss potential paths forward for leveraging this approach.