Surveillance for Certain Health Behaviors, Chronic Diseases, and Conditions, Access to Health Care, and Use of Preventive Health Services Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2012

Lifetime prevalence and correlates of colorectal cancer screening among low-income U.S. Veterans

PURPOSE

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the U.S. While preventive healthcare services are high priority in the VHA, low-income U.S. Veterans experience adverse life circumstances that may negatively impact their access to these services. This study examined lifetime prevalence as well as demographic, socioeconomic, military-specific, and clinical correlates of colorectal cancer (CRC) screening among low-income U.S. Veterans ≥ 50 years of age.

METHODS

Cross-sectional data on 862 participants were analyzed from the 2021-2022 National Veteran Homeless and Other Poverty Experiences study.

RESULTS

Overall, 55.3% (95% confidence interval [CI] 51.3-59.3%) reported ever-receiving CRC-screening services. In a multivariable logistic regression model, never-receivers of CRC screening were twice as likely to reside outside of the Northeast, and more likely to be married (odds ratio [OR] = 1.86, 95% CI 1.02, 3.37), have BMI < 25 kg/m2 [vs. 25- < 30 kg/m2] (OR = 1.75, 95% CI 1.19, 2.58), or ≥ 1 chronic condition (OR = 1.46, 95% CI 1.06, 2.02). Never-receivers of CRC screening were less likely to be female (OR = 0.53, 95% CI 0.29, 0.96), aged 65-79y [vs. ≥ 80y] (OR = 0.61, 95% CI 0.40, 0.92), live in 5 + member households (OR = 0.33, 95% CI 0.13, 0.86), disabled (OR = 0.45, 0.22, 0.92), with purchased health insurance (OR = 0.56, 95% CI 0.33, 0.98), or report alcohol-use disorder (OR = 0.10, 95% CI 0.02, 0.49) and/or HIV/AIDS (OR = 0.28, 95% CI 0.12, 0.68).

CONCLUSION

Nearly 55% of low-income U.S. Veterans reported ever screening for CRC. Variations in CRC-screening behaviors according to veteran characteristics highlight potential disparities as well as opportunities for targeted behavioral interventions.

State-Level Hypertension Prevalence and Control Among Adults in the U.S

INTRODUCTION

Improving hypertension control is a national priority. Electronic health record data have the potential to augment traditional surveillance systems. This study aimed to assess hypertension prevalence and control at the state level using a previously established electronic health record-based phenotype for hypertension.

METHODS

Adult patients (N=11,031,368) were included from the IQVIA ambulatory electronic medical record-U.S. 2019 data set. IQVIA ambulatory electronic medical record comprises electronic health records from >100,000 providers and includes patients from every U.S. state and Washington DC. Authors compared hypertension prevalence and control estimates against those from the Behavioral Risk Factor Surveillance System 2019. Results were age-standardized and stratified by state and sociodemographic characteristics. Statistical analyses were conducted in 2022-2023.

RESULTS

IQVIA ambulatory electronic medical record-U.S. patients had a median age of 55 years, and 56.7% were women. Overall age-standardized hypertension prevalence was higher in IQVIA ambulatory electronic medical record-U.S. (35.0%) than in the Behavioral Risk Factor Surveillance System (29.7%), however, state-level geographic patterns were similar, with the highest burden in the South and Appalachia. Similar patterns were also observed by sociodemographic characteristics in both data sets: hypertension prevalence was higher in older age groups (than younger), men (than women), and Black patients (than other races). Hypertension control varied widely across states: among states with >1% data coverage, control rates were lowest in Nevada (51.1%), Washington DC (52.0%), and Mississippi (55.2%); highest in Kansas (73.4%), New Jersey (72.3%), and Iowa (71.9%).

CONCLUSIONS

This study provided the first-ever estimates of hypertension control for all states and Washington DC. Electronic health record-based surveillance could support hypertension prevention and control efforts at the state level.

Identification of Hypertension in Electronic Health Records Through Computable Phenotype Development and Validation for Use in Public Health Surveillance: Retrospective Study

BACKGROUND

Electronic health record (EHR) systems are widely used in the United States to document care delivery and outcomes. Health information exchange (HIE) networks, which integrate EHR data from the various health care providers treating patients, are increasingly used to analyze population-level data. Existing methods for population health surveillance of essential hypertension by public health authorities may be complemented using EHR data from HIE networks to characterize disease burden at the community level.

OBJECTIVE

We aimed to derive and validate computable phenotypes (CPs) to estimate hypertension prevalence for population-based surveillance using an HIE network.

METHODS

Using existing data available from an HIE network, we developed 6 candidate CPs for essential (primary) hypertension in an adult population from a medium-sized Midwestern metropolitan area in the United States. A total of 2 independent clinician reviewers validated the phenotypes through a manual chart review of 150 randomly selected patient records. We assessed the precision of CPs by calculating sensitivity, specificity, positive predictive value (PPV), F1-score, and validity of chart reviews using prevalence-adjusted bias-adjusted κ. We further used the most balanced CP to estimate the prevalence of hypertension in the population.

RESULTS

Among a cohort of 548,232 adults, 6 CPs produced PPVs ranging from 71% (95% CI 64.3%-76.9%) to 95.7% (95% CI 84.9%-98.9%). The F1-score ranged from 0.40 to 0.91. The prevalence-adjusted bias-adjusted κ revealed a high percentage agreement of 0.88 for hypertension. Similarly, interrater agreement for individual phenotype determination demonstrated substantial agreement (range 0.70-0.88) for all 6 phenotypes examined. A phenotype based solely on diagnostic codes possessed reasonable performance (F1-score=0.63; PPV=95.1%) but was imbalanced with low sensitivity (47.6%). The most balanced phenotype (F1-score=0.91; PPV=83.5%) included diagnosis, blood pressure measurements, and medications and identified 210,764 (38.4%) individuals with hypertension during the study period (2014-2015).

CONCLUSIONS

We identified several high-performing phenotypes to identify essential hypertension prevalence for local public health surveillance using EHR data. Given the increasing availability of EHR systems in the United States and other nations, leveraging EHR data has the potential to enhance surveillance of chronic disease in health systems and communities. Yet given variability in performance, public health authorities will need to decide whether to seek optimal balance or declare a preference for algorithms that lean toward sensitivity or specificity to estimate population prevalence of disease.

Is tooth loss associated with multiple chronic conditions?

OBJECTIVES

To examine the relationship between tooth loss and co-occurrence of multiple chronic conditions (MCC) among American adults at working age.

MATERIALS AND METHODS

Data was from the Behavioural Risk Factor Surveillance System 2018, a cross-sectional telephone-based, nationally representative survey of American adults. We included participants aged 25-64 years. The survey included sociodemographic data, reported diagnosis of chronic conditions, the number of missing teeth and health behaviours. An aggregate variable of chronic conditions was created which included heart attack, angina, stroke, cancer, chronic pulmonary disease, diabetes, asthma, arthritis, depression, and kidney diseases. The association between the number of missing teeth and the aggregate of chronic conditions was assessed adjusting for confounders.

RESULTS

The analysis included 202,809 participants. The mean number of MCC was 0.86 (95% Confidence Interval 'CI':0.85,0.87). Tooth loss was significantly associated with MCC with rate ratio 1.18 (95% CI:1.15,1.21), 1.53 (95% CI:1.48,1.59) and 1.62 (95% CI:1.55,1.69) for those reporting losing 1-5 teeth, 6 or more but not all, and all teeth, respectively after adjusting for demographic, socioeconomic, and behavioural factors.

CONCLUSION

Tooth loss could be an early marker for the co-occurrence of multiple chronic conditions among adults of working age. The association could be attributed to common risk factors for oral and general health.

Sexually Transmitted Infections in Older Adults: Increasing Tide and How to Stem It

Sexually transmitted infections (STIs) have been increasing in older adults. Sexual health remains an important part of overall health care at any age. There are several barriers and facilitators to addressing sexual health in this population. Changes attributable to normal physiologic aging as well as sexual dysfunction can affect sexuality in older adults. When it comes to preventing STIs, combination prevention strategies remain applicable in older adults. Addressing sexual health using a tailored approach is critical to stem the tide of increasing STIs rates in older adults.

All Types Obesity and Physical Inactivity Associated with the Risk of Activity of Daily Living Limitations Among People with Asthma

Purpose

To examine the association between all types of obesity, physical inactivity, and the risk of activity of daily living limitations in people with asthma.

Patients and Methods

In this cross-sectional study, data from 2555 people aged between 25 and 74 years were acquired from the National Survey of Midlife Development in the United States Refresher conducted between 2011 and 2014. Self-reported questions were used to specify the presence or absence of asthma and physical inactivity. All participants were categorized as having no asthma or asthma. Obesity was defined based on three distinctive indicators: body mass index, waist circumference, and waist-to-hip ratio.

Results

Logistic regression analysis showed that people with asthma who had all types of obesity alone or both all types of obesity and physical inactivity were significantly (P <0.0001) almost more than three times more likely to have limitations in the activity of daily living than those without this condition, even after adjusting for all covariates. Moreover, the odds of activity of daily living limitations were 1.69 times increased in asthma patients with physical inactivity alone, but this increase in risk was not significant (P =0.465). In addition, the odds of activity of daily living limitations were significantly (P <0.0001) more than twice independently in people with asthma aged between 60 and 74 years, female, undergraduate level of education, smoking, and having joint/bone underlying diseases.

Conclusion

The results demonstrated that the presence of all types of obesity is related to a higher risk of activity of daily living limitations in people with asthma than in those without asthma. Having both all types of obesity and physical inactivity are also linked to a greater risk of activity of daily living limitations in these patients.

Understanding how psychosocial factors relate to seeking medical care among older adults using a new model of care seeking

RATIONALE

Research has identified psychosocial factors related to the use of health services among the older population; however, the specific roles by which these factors drive behavior have not been identified and empirically tested.

OBJECTIVE

This study tested whether previously identified psychosocial factors decrease or increase the motivational potential to seek care, the motivational sensitivity to perceived access, or the motivational sensitivity to perceived need.

METHODS

The 2014 U.S. Health and Retirement Study was used. Analysis was based on 2589 older noninstitutionalized respondents (age greater than 64). The dependent variable was the number of healthcare provider visits in the preceding two years. Psychosocial factors included were life satisfaction, social network indicators, optimism, pessimism, positive social support, hopelessness, loneliness, self-efficacy, health efficacy, positive affect, negative affect, and purpose in life. Covariates included age and sex. Maximum likelihood estimation of an interpretable structural model was used.

RESULTS

Results of the study provide evidence that psychosocial variables are related to health care seeking through both motivational potential and sensitivity parameters. Some psychosocial variables are related to multiple roles. For example, pessimism is related to a lower motivational potential and is more sensitive to access at higher levels of access, whereas hopelessness is related to a higher motivational potential and more sensitive to need and access at lower levels of each.

CONCLUSIONS

Findings imply psychosocial characteristics are related to health care seeking and utilization of older adults via different roles that can countervail each other, and therefore the influence of interventions can be complex. To address this, complex interventions may be required.

Evaluating Screening Participation, Follow-up, and Outcomes for Breast, Cervical, and Colorectal Cancer in the PROSPR Consortium

BACKGROUND

Cancer screening is a complex process encompassing risk assessment, the initial screening examination, diagnostic evaluation, and treatment of cancer precursors or early cancers. Metrics that enable comparisons across different screening targets are needed. We present population-based screening metrics for breast, cervical, and colorectal cancers for nine sites participating in the Population-based Research Optimizing Screening through Personalized Regimens consortium.

METHODS

We describe how selected metrics map to a trans-organ conceptual model of the screening process. For each cancer type, we calculated calendar year 2013 metrics for the screen-eligible target population (breast: ages 40-74 years; cervical: ages 21-64 years; colorectal: ages 50-75 years). Metrics for screening participation, timely diagnostic evaluation, and diagnosed cancers in the screened and total populations are presented for the total eligible population and stratified by age group and cancer type.

RESULTS

The overall screening-eligible populations in 2013 were 305 568 participants for breast, 3 160 128 for cervical, and 2 363 922 for colorectal cancer screening. Being up-to-date for testing was common for all three cancer types: breast (63.5%), cervical (84.6%), and colorectal (77.5%). The percentage of abnormal screens ranged from 10.7% for breast, 4.4% for cervical, and 4.5% for colorectal cancer screening. Abnormal breast screens were followed up diagnostically in almost all (96.8%) cases, and cervical and colorectal were similar (76.2% and 76.3%, respectively). Cancer rates per 1000 screens were 5.66, 0.17, and 1.46 for breast, cervical, and colorectal cancer, respectively.

CONCLUSIONS

Comprehensive assessment of metrics by the Population-based Research Optimizing Screening through Personalized Regimens consortium enabled systematic identification of screening process steps in need of improvement. We encourage widespread use of common metrics to allow interventions to be tested across cancer types and health-care settings.

Health and Wellness Coaching in Serving the Needs of Today's Patients: A Primer for Healthcare Professionals

The past six decades have been marked by leaps and bounds in medical advances, while concurrently clinical outcomes and the quality of life continued to lag or decline. There is a need for more comprehensive approaches to delivering healthcare to patients that address illness and wellness within and outside healthcare settings. Mounting evidence shows that making sustainable changes in healthcare requires approaching patients'/individuals' care as a continuum-within and outside healthcare settings-while addressing their capacity (ie ability) and workload (ie demands) and incorporating their values and preferences. Health and Wellness Coaching (HWC) has been proposed as a solution to create partnerships to empower individuals to take ownership, leadership, and accountability of their well-being, using nondirective, empathic, and mindful conversations that employ motivational-interviewing and evidence-based approaches. Insufficient clarity exists among healthcare professionals in understanding the definition, roles, and types of HWC. This primer summarizes HWC concepts and history and compares HWC types and its potential role in promoting, supporting, and improving the well-being, clinical outcomes, and quality of life of the pertinent stakeholders. This primer also highlights current and potential areas of application of HWC within different subpopulations and healthcare-related settings.

Impact of a diet and activity health promotion intervention on regional patterns of DNA methylation

BACKGROUND

Studies demonstrate the impact of diet and physical activity on epigenetic biomarkers, specifically DNA methylation. However, no intervention studies have examined the combined impact of dietary and activity changes on the blood epigenome. The objective of this study was to examine the impact of the Make Better Choices 2 (MBC2) healthy diet and activity intervention on patterns of epigenome-wide DNA methylation. The MBC2 study was a 9-month randomized controlled trial among adults aged 18-65 with non-optimal levels of health behaviors. The study compared three 12-week interventions to (1) simultaneously increase exercise and fruit/vegetable intake, while decreasing sedentary leisure screen time; (2) sequentially increase fruit/vegetable intake and decrease leisure screen time first, then increase exercise; (3) increase sleep and decrease stress (control). We collected blood samples at baseline, 3 and 9 months, and measured DNA methylation using the Illumina EPIC (850 k) BeadChip. We examined region-based differential methylation patterns using linear regression models with the false discovery rate of 0.05. We also conducted pathway analysis using gene ontology (GO), KEGG, and IPA canonical pathway databases.

RESULTS

We found no differences between the MBC2 population (n = 340) and the subsample with DNA methylation measured (n = 68) on baseline characteristics or the impact of the intervention on behavior change. We identified no differentially methylated regions at baseline between the control versus intervention groups. At 3 versus 9 months, we identified 154 and 298 differentially methylated regions, respectively, between controls compared to pooled samples from sequential and simultaneous groups. In the GO database, we identified two gene ontology terms related to hemophilic cell adhesion and cell-cell adhesion. In IPA analysis, we found pathways related to carcinogenesis including PI3K/AKT, Wnt/β-catenin, sonic hedgehog, and p53 signaling. We observed an overlap between 3 and 9 months, including the GDP-L-fucose biosynthesis I, methylmalonyl metabolism, and estrogen-mediated cell cycle regulation pathways.

CONCLUSIONS

The results demonstrate that the MBC2 diet and physical activity intervention impacts patterns of DNA methylation in gene regions related to cell cycle regulation and carcinogenesis. Future studies will examine DNA methylation as a biomarker to identify populations that may particularly benefit from incorporating health behavior change into plans for precision prevention.

Association between the food and physical activity environment, obesity, and cardiovascular health across Maine counties

BACKGROUND

Accounting for nearly one-third of all deaths, cardiovascular disease is the leading cause of mortality and morbidity in the United States. Adverse health behaviors are major determinants of this high incidence of disease. Examining local food and physical activity environments and population characteristics in a poor, rural state may highlight underlying drivers of these behaviors. We aimed to identify demographic and environmental factors associated with both obesity and overall poor cardiovascular health (CVH) behaviors in Maine counties.

METHODS

Our cross-sectional study analyzed 40,398 Behavioral Risk Factor Surveillance System (BRFSS) 2011-2014 respondents alongside county-level United States Department of Agriculture (USDA) Food Environment Atlas 2010-2012 measures of the built environment (i.e., density of restaurants, convenience stores, grocery stores, and fitness facilities; food store access; and county income). Poor CVH score was defined as exhibiting greater than 5 out of the 7 risk factors defined by the American Heart Association (current smoking, physical inactivity, obesity, poor diet, hypertension, diabetes, and high cholesterol). Multivariable logistic regression models described the contributions of built environment variables to obesity and overall poor CVH score after adjustment for demographic controls.

RESULTS

Both demographic and environmental factors were associated with obesity and overall poor CVH. After adjustment for demographics (age, sex, personal income, and education), environmental characteristics most strongly associated with obesity included low full-service restaurant density (OR 1.34; 95% CI 1.24-1.45), low county median household income (OR 1.31; 95% CI 1.21-1.42) and high convenience store density (OR 1.21; 95% CI 1.12-1.32). The strongest predictors of overall poor CVH behaviors were low county median household income (OR 1.30; 95% CI 1.13-1.51), low full-service restaurant density (OR 1.38; 95% CI 1.19-1.59), and low fitness facility density (OR 1.27; 95% CI 1.11-1.46).

CONCLUSIONS

In a rural state, both demographic and environmental factors predict overall poor CVH. These findings may help inform communities and policymakers of the impact of both social determinants of health and local environments on health outcomes.

Estimating State-Level Health Burden of Diabetes: Diabetes-Attributable Fractions for Diabetes Complications

INTRODUCTION

Limited information is available on the health burden of diabetes at the state level. This study estimated state-specific attributable fractions and the number of cases attributable to diabetes for diabetes-related complications.

METHODS

For each state, diabetes-attributable fractions for nine diabetes complications were estimated: three self-reported complications from the 2013 Behavioral Risk Factor Surveillance System, hospitalizations with three complications from 2011 to 2014 State Inpatient Databases, and three complications from 2013 Medicare data. Attributable fractions were calculated using RR and diabetes prevalence and the total number of cases using attributable fractions and total number of complications. Adjusted RR of each complication for people with and without diabetes by age and sex was estimated using a generalized linear model. Analyses were conducted in 2015-2016.

RESULTS

Median state-level diabetes-attributable fractions for self-reported complications were 0.14 (range, 0.10-0.19) for mobility limitations; 0.13 (range, 0.04-0.21) for limitations in instrumental activities of daily living; and 0.12 (range, 0.06-0.20) for severe visual impairment or blindness. Median state-level diabetes-attributable fractions for diabetes-associated hospitalizations were 0.19 (range, 0.08-0.24) for congestive heart failure; 0.08 (range, 0.02-0.16) for myocardial infarction; and 0.62 (range, 0.46-0.73) for lower extremity amputations. Median state-level diabetes-attributable fractions for complications among Medicare beneficiaries were 0.17 (range, 0.14-0.23) for coronary heart disease; 0.28 (range, 0.24-0.33) for chronic kidney disease; and 0.22 (range, 0.08-0.32) for peripheral vascular disease.

CONCLUSIONS

Diabetes carries a significant health burden, and results vary across states. Efforts to prevent or delay diabetes or to improve diabetes management could reduce the health burden because of diabetes.

The role of centrality to self-concept in moderating the associations between injury perceptions and outcomes

OBJECTIVES

To test the centrality of injury to self-concept as a moderator of the associations between injury perceptions and outcomes.

METHODS

Two concurrent studies on samples of injured individuals.

MEASURES

The centrality of injury to one's self concept was measured by the degree of self-injury separation (PRISM); injury perceptions were measured by the injury perception questionnaire; and outcomes by standard scales of self-assessed health, physical, emotional and social functioning, vitality, depression, anxiety and somatisation. Regression analyses examined the significance of adding the interactions between injury centrality and injury perceptions to explained outcome variance, beyond their separate contributions.

RESULTS

Both injury centrality and injury perceptions significantly explained variance in patients' functioning and well-being. Injury centrality moderated the associations between various injury perceptions and outcomes, especially pronounced for emotional representations of the injury. As hypothesised, the effects of injury perceptions on outcomes were stronger among patients for whom the injury was central to their self-concept compared to patients who perceived the injury as peripheral to their self-concept.

CONCLUSIONS

'Centrality to the self' is a moderator of the impact of perceptions on outcomes of injuries. The findings suggest ways to tailor interventions to sub-groups of injured patients based on injury centrality to their self-concept.

Are the U.S. territories lagging behind in diabetes care practices?

AIMS

Although U.S. territories fall within the mandate outlined by Healthy People 2020, they remain neglected in diabetes care research. We compared the prevalence and secular trends of four recommended diabetes care practices in the U.S. territories of Guam, Puerto Rico, and the U.S. Virgin Islands to the 50 United States and D.C. ("U.S. States") in 2001-2015.

METHODS

Data were from 390,268 adult participants with self-reported physician diagnosed diabetes in the Behavioral Risk Factor Surveillance System. Diabetes care practices included biannual HbA1c tests, attendance of diabetes education classes, daily self-monitoring of blood glucose, and receipt of annual foot examination. Practices were compared by U.S. territory and between territories and U.S. states. Multivariable models accounted for age, sex, education, and year.

RESULTS

Of adults with diagnosed diabetes, 7% to 11% in the U.S. territories engaged in all four recommended diabetes care practices compared with 25% for those, on average, in U.S. states. Relative to the U.S. states, on average, the proportion achieving biannual HbA1c testing was lower in Guam and the U.S. Virgin Islands (45.6% and 44.9% vs. 62.2%), while annual foot examinations were lower in Puerto Rico (45.9% vs 66.1% in the U.S. states). Diabetes education and daily glucose self-monitoring were lower in all three territories.

CONCLUSIONS

U.S. territories lag behind U.S. states in diabetes care practices. Policies aimed at improving diabetes care practices are needed in the U.S. territories to achieve Healthy People 2020 goals and attain parity with U.S. states.

Comparison between buprenorphine provider availability and opioid deaths among US counties

BACKGROUND

Buprenorphine is an effective medication for the treatment of opioid addiction, but current barriers to buprenorphine access limit treatment availability for many patients. We identify and characterize regions within the United States (US) with poor buprenorphine access relative to the observed burden of overdose deaths.

METHODS

This cross sectional study includes US county-level data on the number of available buprenorphine providers (Substance Abuse and Mental Health Services Administration Buprenorphine Treatment Practitioner Locator) and the number of opioid-related overdose deaths between 2013 and 2015 (Centers for Disease Control and Prevention WONDER Database). Counties with fewer than 10 deaths during this time period were excluded to maintain patient privacy. Population-adjusted county death rates and provider availability were compared to identify locations with high disease burdens and limited buprenorphine access. The presence of significant clustering across the dataset was evaluated using Global Moran's I and zones of significant spatial clusters and anomalies were identified using Local Indicator of Spatial Autocorrelation.

RESULTS

County data were available for 846 counties from 49 states and the District of Columbia, comprising 83% of the US population. The median number of opioid overdose deaths per county was 20.0 deaths per 100,000 residents (interquartile range 13.4-29.9, range 2.9 to 108.8). The number of buprenorphine providers per 100,000 county residents ranged from 0 to 45, with a median of 5.9 (interquartile range 3.2 to 9.5). Global Moran's I analysis yielded significant clustering in the distribution of both providers and deaths, with notable significant clusters of higher than average providers and deaths in the Northeast, and scattered mismatched regions of lower-than-average providers and higher-than-average deaths across the Southern, Midwestern, and Western US. Graphical analysis of buprenorphine provider availability and overdose burden reveals limited treatment access relative to overdose deaths throughout much of the Midwestern and Southern US.

CONCLUSIONS

Substantial county-level imbalances between the availability of buprenorphine providers and the burden of opioid overdose deaths are present within the US.

Assessing Colorectal Cancer Screening Barriers by Two Methods

Colorectal cancer (CRC) is commonly diagnosed in the USA despite screening tests that have decreased CRC incidence and mortality. Finding the best method to identify patient-level screening barriers is important to improve CRC screening rates. A group-randomized trial was conducted among ten primary-care clinics. Clinics were randomized to a multi-level (clinic, provider, patient) CRC screening intervention or usual care (2007-2013). Subsequent to clinic- and provider-level interventions, a three-step, patient-level intervention was conducted. One step of the patient-level intervention was a CRC screening barriers counseling call conducted by a lay health advisor (LHA). During the call, two methods were used to identify CRC screening barriers. An open-ended question was used first to determine why participants had not completed screening (without probes). Subsequently, the LHA read a list of additional potential screening barriers and asked participants whether each barrier was applicable (with probes). A generalized estimating equation approach was used to compare the two methods. Participants (n = 109) were female (59%), had a mean age of 57.2 years, and were white (67%) or black (31%). Most participants had some college education or a college degree (79%), annual household income $30,000+ (60%), and health insurance (80%). The number of CRC screening barriers increased with probing compared to the open-ended question format (OR 2.10, 95% CI 1.92-2.31; p < 0.01). The ranking of reported CRC screening barriers did not vary by assessment method. However, the methodology used to document CRC screening barriers may influence the content of patient-directed interventions.

Health conditions and lifestyle risk factors of adults living in Puerto Rico: a cross-sectional study

Background

Puerto Rico is experiencing an economic and healthcare crisis, yet there are scarce recent and comprehensive reports on the population’s health profile. We aimed to describe prevalent risk factors and health conditions of adults living in Puerto Rico and assess their interrelationship.

Methods

Participants (n = 380) aged 30-75y recruited from a 2015 convenience sample in primary care clinics in the San Juan, Puerto Rico metropolitan area answered cross-sectional interviewer-administered questionnaires on sociodemographic characteristics, lifestyle behaviors, self-reported medically-diagnosed diseases, health services, and psychosocial factors. Anthropometric measures were obtained. Logistic regression models assessed factors associated with having ≥2 cardiometabolic conditions or ≥ 2 chronic diseases.

Results

Most participants had completed ≥college education (57%), had household income <$10,000/y (60%), received government-assisted food benefits (51%), and had health insurance (93%). Nearly 20% reported smoking, 27% alcohol use, 74% light/sedentary physical activity, 51% sleeping difficulties, and 36% self-rated fair/poor diet. Social support was moderate, and 53% screened positive for depressive symptomatology. Abdominal obesity was observed in 33% of men and 76% of women (p < 0.0001). Self-reported medically-diagnosed conditions included hypertension (39%), anxiety (30%), obesity (28%), arthritis (26%), hypercholesterolemia (24%), depression (22%), respiratory problems (21%), and diabetes (21%). Higher odds of having ≥2 cardiometabolic conditions (37%) was observed among participants aged ≥50y, with sedentary physical activity, and self-rated fair/poor diet. Odds of having ≥2 chronic diseases (62%) were higher among ≥50y, sleeping difficulties, > 2 h/day television, and self-rated fair/poor diet. Participants obtained (79%) and trusted (92%) health information from physicians. While most participants with a cardiometabolic condition reported receiving medical recommendations on diet (> 73%) and physical activity (> 67%), fewer followed them (< 67% and < 53%, respectively), yet most adhered to medication treatments (> 73%). Participants following medical recommendations were more likely to report healthy vs. poor behaviors (90% vs. 75%, self-rated diet); (73% vs. 56%, physical activity).

Conclusions

Adults living in Puerto Rico have multiple lifestyles risk factors and high prevalence of chronic diseases, namely cardiometabolic and psychological conditions. Comprehensive epidemiological studies are needed to identify contributors to chronic disease, including lifestyle behaviors. Concerted multi-level public health and clinical programs should be prioritized to help this population improve their health.

Family Coaching as a delivery modality for evidence-based prevention programs

Family Coaching is proposed as a new delivery format for evidence-based prevention programs (EBPPs). Three recent developments in health promotion support the potential efficacy of Family Coaching: (1) renewed interest in integrated prevention programs for multiple risk factors and behavior changes, (2) broad and long-term impacts of family-based interventions, and (3) popular acceptance of "coaching" as a nonstigmatizing, goal-focused intervention strategy. Family coaches are community members and paraprofessionals trained in common elements of EBPP. Family Coaching has specific goals, is short term, and has definable outcomes. Coaches frame the program's goals to be consistent with the family's values, normalize the family's experience, assess their strengths, and help the family set goals and develop skills and routines to problem solve challenging situations. Broad dissemination of EBPP will be facilitated with delivery formats that are flexible to meet families' priorities and providers' desires and capacities to tailor programs to local contexts.

Perceptions of Important Characteristics of Physical Activity Facilities: Implications for Engagement in Walking, Moderate and Vigorous Physical Activity

Background

Although few United States adults meet physical activity recommendations, those that do are more likely to access to physical activity facilities. Additionally, vigorous exercisers may be more likely to utilize a nearby physical activity facility, while light-to-moderate exercisers are less likely to do so. However, it is unclear what characteristics of those facilities are most important as well as how those characteristics are related to activity intensity.

Purpose

This study examined relationships between self-reported leisure-time physical activities and the use of and perceived characteristics of physical activity facilities.

Methods

Data were from a cross-sectional study in a major metropolitan area. Participants (N = 582; ages 18–74, mean age = 45 ± 14.7 years) were more likely to be female (69.9%), Caucasian (65.6%), married (51.7%), and have some college education (72.8%). Household surveys queried leisure-time physical activity, regular physical activity facility use, and importance ratings for key facility characteristics.

Results

Leisure-time physical activity recommendations were met by 41.0% of participants and 50.9% regularly used a physical activity facility. Regular facility use was positively associated with meeting walking (p = 0.036), moderate (p < 0.001), and vigorous (p < 0.001) recommendations. Vigorous exercisers were more likely to use a gym/fitness center (p = 0.006) and to place higher importance on facility quality (p = 0.022), variety of physical activity options offered (p = 0.003), and availability of special equipment and resources (p = 0.01). The facility characteristics of low or free cost (p = 0.02) and offering childcare (p = 0.028) were barriers for walking, and being where friends and family like to go were barriers for moderate leisure-time physical activity (p = 0.013).

Conclusion

Findings offer insights for structuring interventions using the social ecological model as well as for improving existing physical activity facilities.

Development of the Injury Perceptions Questionnaire (InjPQ)

OBJECTIVES

Injuries are major causes of morbidity and mortality in the population. Given the central role of perceptions in self-regulation of health conditions, it is important to investigate how they are perceived. This article describes the development of the Injury Perceptions Questionnaire (InjPQ).

METHODS

A concurrent study in a diverse sample of injured individuals (n = 333). The internal structure and the reliability (Cronbach's α) of InjPQ sub-scales were explored by factor analyses. Relationships between injury perception dimensions and equivalent illness perception scales and outcome measures (self-assessed health; physical, emotional and social functioning; depression, anxiety and somatisation; satisfaction with life) were investigated.

RESULTS

The InjPQ was found to represent the following perception scales: injury identity composed of social and body part components, PTSD symptoms, Injury event, Injury specific emotions, Injured self-image, Positive consequences, Responsibility/guilt, Coping, Time distance, Dependency, Healthy self, External attributions and Injury risk factors. The reliability and construct validity of the scales were found adequate.

CONCLUSIONS

Injury perceptions can be reliably measured. While partly overlapping with equivalent illness perception scales, the InjPQ depicts cognitive dimensions unique to injury that add significantly to explaining variance in outcomes. The InjPQ is recommended for research and clinical use as a measure of injury perceptions.

Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2013 and 2014

PROBLEM

Chronic diseases and conditions (e.g., heart diseases, stroke, arthritis, and diabetes) are the leading causes of morbidity and mortality in the United States. These conditions are costly to the U.S. economy, yet they are often preventable or controllable. Behavioral risk factors (e.g., excessive alcohol consumption, tobacco use, poor diet, frequent mental distress, and insufficient sleep) are linked to the leading causes of morbidity and mortality. Adopting positive health behaviors (e.g., staying physically active, quitting tobacco use, obtaining routine physical checkups, and checking blood pressure and cholesterol levels) can reduce morbidity and mortality from chronic diseases and conditions. Monitoring the health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services at multilevel public health points (states, territories, and metropolitan and micropolitan statistical areas [MMSA]) can provide important information for development and evaluation of health intervention programs.

REPORTING PERIOD

2013 and 2014.

DESCRIPTION OF THE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services and practices related to the leading causes of death and disability in the United States and participating territories. This is the first BRFSS report to include age-adjusted prevalence estimates. For 2013 and 2014, these age-adjusted prevalence estimates are presented for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, and selected MMSA.

RESULTS

Age-adjusted prevalence estimates of health status indicators, health care access and preventive practices, health risk behaviors, chronic diseases and conditions, and cardiovascular conditions vary by state, territory, and MMSA. Each set of proportions presented refers to the range of age-adjusted prevalence estimates of selected BRFSS measures as reported by survey respondents. The following are estimates for 2013. Adults reporting frequent mental distress: 7.7%-15.2% in states and territories and 6.3%-19.4% in MMSA. Adults with inadequate sleep: 27.6%-49.2% in states and territories and 26.5%-44.4% in MMSA. Adults aged 18-64 years having health care coverage: 66.9%-92.4% in states and territories and 60.5%-97.6% in MMSA. Adults identifying as current cigarette smokers: 10.1%-28.8% in states and territories and 6.1%-33.6% in MMSA. Adults reporting binge drinking during the past month: 10.5%-25.2% in states and territories and 7.2%-25.3% in MMSA. Adults with obesity: 21.0%-35.2% in states and territories and 12.1%-37.1% in MMSA. Adults aged ≥45 years with some form of arthritis: 30.6%-51.0% in states and territories and 27.6%-52.4% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 7.4%-17.5% in states and territories and 6.2%-20.9% in MMSA. Adults aged ≥45 years who have had a stroke: 3.1%-7.5% in states and territories and 2.3%-9.4% in MMSA. Adults with high blood pressure: 25.2%-40.1% in states and territories and 22.2%-42.2% in MMSA. Adults with high blood cholesterol: 28.8%-38.4% in states and territories and 26.3%-39.6% in MMSA. The following are estimates for 2014. Adults reporting frequent physical distress: 7.8%-16.0% in states and territories and 6.2%-18.5% in MMSA. Women aged 21-65 years who had a Papanicolaou test during the past 3 years: 67.7%-87.8% in states and territories and 68.0%-94.3% in MMSA. Adults aged 50-75 years who received colorectal cancer screening on the basis of the 2008 U.S. Preventive Services Task Force recommendation: 42.8%-76.7% in states and territories and 49.1%-79.6% in MMSA. Adults with inadequate sleep: 28.4%-48.6% in states and territories and 25.4%-45.3% in MMSA. Adults reporting binge drinking during the past month: 10.7%-25.1% in states and territories and 6.7%-26.3% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 8.0%-17.1% in states and territories and 7.6%-19.2% in MMSA. Adults aged ≥45 years with some form of arthritis: 31.2%-54.7% in states and territories and 28.4%-54.7% in MMSA. Adults with obesity: 21.0%-35.9% in states and territories and 19.7%-42.5% in MMSA.

INTERPRETATION

Prevalence of certain chronic diseases and conditions, health risk behaviors, and use of preventive health services varies among states, territories, and MMSA. The findings of this report highlight the need for continued monitoring of health status, health care access, health behaviors, and chronic diseases and conditions at state and local levels.

PUBLIC HEALTH ACTION

State and local health departments and agencies can continue to use BRFSS data to identify populations at risk for certain unhealthy behaviors and chronic diseases and conditions. Data also can be used to design, monitor, and evaluate public health programs at state and local levels.

Nativity, Chronic Health Conditions, and Health Behaviors in Filipino Americans

INTRODUCTION

Nearly half of Americans have a chronic health condition related to unhealthful behavior. One in four Americans is an immigrant; yet immigrants' health has been studied little, particularly among Asian American subpopulations.

METHODOLOGY

Years lived in United States, hypertension, diabetes, smoking, walking, adiposity, and fruit/vegetable variables in the 2011-2012 California Health Interview Survey were analyzed to examine the influence of nativity on chronic health conditions and health behaviors in 555 adult Filipinos, the second largest Asian American immigrant subpopulation.

RESULTS

Recent and long-term immigrant Filipinos had higher odds of having hypertension and diabetes, but lower odds of smoking and overweight/obesity compared with second-generation Filipinos.

DISCUSSION

Being born in the United States may be protective against chronic health conditions, but not for healthful behaviors among Filipinos. Chronic disease prevention and health promotion strategies should consider nativity/length of residence, which may be a more consequential health determinant than other immigration and acculturation characteristics.

State and Local Chronic Disease Surveillance Using Electronic Health Record Systems

OBJECTIVES

To assess the feasibility of chronic disease surveillance using distributed analysis of electronic health records and to compare results with Behavioral Risk Factor Surveillance System (BRFSS) state and small-area estimates.

METHODS

We queried the electronic health records of 3 independent Massachusetts-based practice groups using a distributed analysis tool called MDPHnet to measure the prevalence of diabetes, asthma, smoking, hypertension, and obesity in adults for the state and 13 cities. We adjusted observed rates for age, gender, and race/ethnicity relative to census data and compared them with BRFSS state and small-area estimates.

RESULTS

The MDPHnet population under surveillance included 1 073 545 adults (21.8% of the state adult population). MDPHnet and BRFSS state-level estimates were similar: 9.4% versus 9.7% for diabetes, 10.0% versus 12.0% for asthma, 13.5% versus 14.7% for smoking, 26.3% versus 29.6% for hypertension, and 22.8% versus 23.8% for obesity. Correlation coefficients for MDPHnet versus BRFSS small-area estimates ranged from 0.890 for diabetes to 0.646 for obesity.

CONCLUSIONS

Chronic disease surveillance using electronic health record data is feasible and generates estimates comparable with BRFSS state and small-area estimates.

Depression and health behaviors in Brazilian adults - PNS 2013

OBJECTIVE

To evaluate the prevalence of health-related behaviors according to presence and type of depression in Brazilian adults.

METHODS

Based on a sample of 49,025 adults (18 to 59 years) from the National Survey on Health 2013 (PNS 2013), we estimated the prevalence of health-related behaviors (smoking; passive smoking; frequent or risky alcohol consumption; leisure time physical activity; time watching TV; and eating pattern indicators), according to the presence of depression (minor and major), evaluated by the Patient Health Questionnaire – 9 (PHQ-9), and the report of depressive mood (in up to seven days or more than seven days) over a two-week period. Prevalence ratios were estimated by Poisson regression.

RESULTS

Evaluated by the PHQ-9 scale, 9.7% of the Brazilian adults had depression and 3.9% presented major depression. About 21.0% reported depressive mood and, in 34.9% of them, that feeling has been present for more than seven days. In individuals with major depression (PHQ-9), higher prevalence was found in almost all unhealthy behaviors analyzed, in particular, smoking (PR = 1.65), passive smoking (PR = 1.55), risk alcohol consumption (PR = 1.72), TV for ≥ 5 hours/day (PR = 2.13), consumption of fat meat (PR = 1.43) and soft drink (PR = 1.42). The prevalence ratios tended to be lower in those with minor depression. Similar results were observed in adults with depressive mood.

CONCLUSIONS

This study detected relevant association between depression and health behaviors, in particular for smoking and physical activity. The associations found with the PHQ were similar to those observed with the application of a single question about depressive mood. Our results indicate the importance of assessing the presence of depression and the frequency and severity of symptoms when implementing actions for the promotion of healthy behaviors.

Incidence of Multiple Sclerosis in Puerto Rico, 2014: A Population-Based Study

BACKGROUND

Multiple sclerosis (MS) affects millions of people worldwide. The estimates for MS incidence are difficult to obtain but are important for understanding MS etiology, developing prevention strategies, and service planning. This study is aimed at estimating the 2014 incidence of MS in Puerto Rico (PR).

METHODS

The PR MS Foundation's registry was used as the data source. Neurologists, specialty pharmacies, MRI centers, health insurance companies, and the PR Department of Health identified MS cases missed by the registry. MS patients were 18 years and older and met the 2010 revised McDonald criteria. Age-standardized MS incidence rates and their corresponding 95% CIs were computed.

RESULTS

A total of 144 new MS cases were diagnosed in 2014. The age-standardized MS incidence rate was 5.1/100,000 (95% CI 4.3-5.9). The incidence rate was 7.1/100,000 (95% CI 5.7-8.5) for females and 2.9/100,000 (95% CI 2.0-3.8) for males. MS cases were mostly females (72.9%) with a mean age of 41.0 years (±1.0).

CONCLUSION

According to the country estimates, PR has a higher MS incidence than other Caribbean and Latin American countries, but a lower incidence compared to countries at higher latitudes. Our findings provide insights into the MS etiology in the Hispanic population that require additional research.

Healthcare utilization and associated barriers experienced by wheelchair users: A pilot study

BACKGROUND

More than twenty-five years after passage of the ADA, little remains known about the experiences of wheelchair users when attempting to access health care and how accessibility may influence health care utilization.

OBJECTIVE/HYPOTHESIS

To describe health care utilization among wheelchair users and characterize barriers encountered when attempting to obtain access to health care.

METHODS

An internet-based survey of wheelchair users was conducted. Measures included demographics, condition, socioeconomic status, health care utilization and receipt of preventive services within the past year, physical barriers encountered at outpatient facilities, and satisfaction with care.

RESULTS

Four hundred thirty-two wheelchair users responded to the survey. Nearly all respondents (97.2%) had a primary care appointment within the past year and most reported 3-5 visits to both primary and specialty care providers. Most encountered physical barriers when accessing care (73.8% primary, 68.5% specialty). Participants received most preventive interventions at rates similar to national averages with the exception of Pap tests. Most participants remained clothed for their primary care evaluation (76.1%), and were examined seated in their wheelchair (69.7%). More than half of participants (54.1%) felt they received incomplete care, and 57% believed their physician had no more than a moderate understanding of their disability-specific medical concerns.

CONCLUSIONS

Wheelchair users face persistent barriers to care, may receive less than thorough physical evaluations, receive fewer screenings for cervical cancer, and largely believe they receive incomplete care.

Associations between active living-oriented zoning and no adult leisure-time physical activity in the U.S

Nearly one-third of adults report no leisure-time physical activity (LTPA). Governmental and authoritative bodies recognize the role that community design through zoning code changes can play in enabling LTPA. This study examined the association between zoning and no adult LTPA in the U.S. This study was conducted between 2012 and 2016, with analyses occurring in 2015-2016. Zoning codes effective as of 2010 were compiled for jurisdictions located in the 495 most populous U.S. counties and were evaluated for pedestrian-oriented code reform zoning, 11 active living-oriented provisions (e.g., sidewalks, bike-pedestrian connectivity, mixed use, bike lanes) and a summated zoning scale (max=12). Individual-level LTPA data were obtained from the 2012 CDC Behavioral Risk Factor Surveillance System (BRFSS). County-aggregated, population-weighted zoning variables were constructed for linking to BRFSS. Log-log multivariate regressions (N=147,517 adults), controlling for individual and county characteristics and with robust standard errors clustered on county, were conducted to examine associations between zoning and no LTPA. Relative risks (RR) compared predicted lack of LTPA at 0% and 100% county-level population exposure to each zoning predictor. Zoning code reforms were associated with a 13% lower probability of no LTPA (RR: 0.87, 95% CI: 0.82-0.92). Except for crosswalks, all zoning provisions were associated with an 11-16% lower probability of no LTPA. Having all 12 zoning provisions was associated with a 22% lower probability of no LTPA (RR: 0.78, 95% CI: 0.72-0.83). The results suggest that active living-oriented zoning is a policy lever available to communities seeking to reduce rates of no LTPA.

Comparison of Side Effects of the 2015-2016 High-Dose, Inactivated, Trivalent Influenza Vaccine and Standard Dose, Inactivated, Trivalent Influenza Vaccine in Adults ≥65 Years

BACKGROUND

High-dose, inactivated, trivalent influenza vaccine (HD) is associated with higher rates of side effects than standard dose (SD) vaccine, which may represent a barrier to use.

METHODS

We surveyed subjects ≥65 years who received either HD or SD vaccine at the Minneapolis Veteran Affairs Health Care System clinics on October 27, 28, or 29, 2015. Research assistants conducted a 17-item telephone survey of influenza vaccine recipients to inquire about self-reported health and symptoms experienced the week after vaccination.

RESULTS

A total of 547 HD recipients and 541 SD recipients responded to the survey. The 2 groups were similar at baseline with respect to age, gender, and presence of high-risk medical conditions. At least ≥95% of individuals in both HD and SD groups reported that their overall health was the same or better than usual during the week after vaccination. Thirty-seven percent of HD recipients and 22% of SD recipients reported a local or systemic side effect (P < .001), most of which were mild to moderate. Only 7 of 547 (1.3%) HD recipients and 3 of 541 (0.6%) SD recipients reported a severe side effect (P = .34). There was no significant difference in healthcare visits between the groups.

CONCLUSIONS

Side effects were more common among subjects ≥65 years who received HD influenza vaccine compared with SD vaccine. These side effects were well tolerated and were not associated with impairment of general health status. These findings should reassure patients and their providers of the safety and tolerability of the HD influenza vaccine.

The relationships among physical activity, sedentary behaviour, obesity and quitting behaviours within a cohort of smokers in California

BACKGROUND

Smoking, insufficient physical activity (PA), sedentary behaviour (SB) and obesity are leading risk factors for morbidity and premature mortality. Few studies examining the relationship between these behavioural risk factors and quitting behaviours among cohorts of smokers have been published.

PURPOSE

The goals of this study are to examine the cross-sectional relationships among behavioural health risk factors (insufficient PA, SB and obesity) and past year quitting behaviours within a sample of smokers.

METHODS

The California Smokers Cohort, conducted from 2011 through 2013, is a population-based survey of adult smokers in California. Using follow-up data (n = 1050), participants' self-reported health behaviours and past year quitting behaviours were examined in univariate analyses and multivariate logistic regression analyses controlling for demographic covariates.

RESULTS

In univariate analyses examining health behaviours among smokers, all three health behaviours examined (PA, SB and obesity) were related, and significantly more obese smokers with high PA and low SB reported a ≥20% smoking rate reduction than smokers with other combinations of health behaviours (48.8%, Chi-squared = 4.765, P = 0.045). In multivariate models adjusted for sociodemographic characteristics, obese smokers (odds ratio [OR] = 1.450, 95% confidence interval [CI]: 1.088-1.932, P = 0.011) and smokers with higher levels of PA (OR = 1.448, 95% CI: 1.111-1.887, P = 0.006) were more likely to report a past year ≥24-hour quit attempt regardless of SB, and obese smokers (OR = 1.760, 95% CI: 1.095-2.828, P = 0.019) were more likely to report being quit for ≥30 days regardless of PA and SB.

CONCLUSIONS

Overall, the results demonstrated that more physically active and obese smokers were more likely to report positive strides towards quitting. These findings support the potential positive effect of addressing multiple health behaviours along with smoking.

Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors

CONTEXT

Medial tibial stress syndrome (MTSS) is a common condition in active individuals and presents as diffuse pain along the posteromedial border of the tibia.

OBJECTIVE

To use cross-sectional, case-control, and cohort studies to identify significant MTSS risk factors.

DATA SOURCES

Bibliographic databases (PubMed, Scopus, CINAHL, SPORTDiscus, EMBASE, EBM Reviews, PEDRo), grey literature, electronic search of full text of journals, manual review of reference lists, and automatically executed PubMed MTSS searches were utilized. All searches were conducted between 2011 and 2015.

STUDY SELECTION

Inclusion criteria were determined a priori and included original research with participants' pain diffuse, located in the posterior medial tibial region, and activity related.

STUDY DESIGN

Systematic review with meta-analysis.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Titles and abstracts were reviewed to eliminate citations that did not meet the criteria for inclusion. Study characteristics identified a priori were extracted for data analysis. Statistical heterogeneity was examined using the I2 index and Cochran Q test, and a random-effects model was used to calculate the meta-analysis when 2 or more studies examined a risk factor. Two authors independently assessed study quality.

RESULTS

Eighty-three articles met the inclusion criteria, and 22 articles included risk factor data. Of the 27 risk factors that were in 2 or more studies, 5 risk factors showed a significant pooled effect and low statistical heterogeneity, including female sex (odds ratio [OR], 2.35; CI, 1.58-3.50), increased weight (standardized mean difference [SMD], 0.24; CI, 0.03-0.45), higher navicular drop (SMD, 0.44; CI, 0.21-0.67), previous running injury (OR, 2.18; CI, 1.00-4.72), and greater hip external rotation with the hip in flexion (SMD, 0.44; CI, 0.23-0.65). The remaining risk factors had a nonsignificant pooled effect or significant pooled effect with high statistical heterogeneity.

CONCLUSION

Female sex, increased weight, higher navicular drop, previous running injury, and greater hip external rotation with the hip in flexion are risk factors for the development of MTSS.

Physical activity and obesity gap between black and white women in the southeastern U.S

BACKGROUND

Differences between black and white women in the associations of sedentary and active behaviors and obesity are mostly unknown.

PURPOSE

To examine associations of sedentary and active behaviors with BMI, a marker of overall obesity, in a large group of black and white women and to determine whether there are differences by race in these associations.

METHODS

Associations between time spent in sedentary and active behaviors and BMI were examined using cross-sectional data collected from 2002 to 2006 at enrollment into the Southern Community Cohort Study (SCCS) from 22,948 black and 7830 white women living in the southeastern U.S. These associations were examined using linear and polytomous logistic regression models controlling for age, race, income, education, occupational status, tobacco use, marital status, and comorbidities.

RESULTS

Time spent in sedentary behaviors was directly related to BMI whereas time spent in active behaviors such as moderate and vigorous physical activity was inversely related to BMI, with stronger associations for whites than blacks. White women in the highest quartile of sedentary behaviors were more likely to be moderately (BMI=30-39) or severely (BMI>40) obese than women in the lowest quartile (OR=2.3, 95% CI=1.8, 2.9 for moderate, and OR=4.0, 95% CI=3.1, 5.3 for severe obesity), whereas the ORs among similarly sedentary black women were modestly elevated (ORs of 1.4, 95% CI=1.2, 1.6; and 1.6, 95% CI=1.4, 1.8).

CONCLUSIONS

There are significant differences in the association of physical activity patterns and obesity between black and white women living in the southeastern U.S. Although most guidelines for prevention of obesity and maintaining weight promote increased time in moderate and vigorous physical activity, these results indicate that a reduction in sedentary behavior time may represent another useful strategy in this population.

Endometrial cancer in Puerto Rico: incidence, mortality and survival (1992-2003)

BACKGROUND

Endometrial cancer is the most common gynecologic malignancy in Puerto Rico and the United States (US).

METHODS

We compare the age-specific and age-adjusted incidence and mortality rates and the survival of endometrial cancer in Puerto Rico with that of non-Hispanic whites (NHW), non-Hispanic blacks (NHB) and Hispanics in the US. Data from the Puerto Rico Central Cancer Registry and the Surveillance, Epidemiology, and End Results program were analyzed from 1992-2003.

RESULTS

Age-standardized incidence rates of endometrial cancer increased significantly (p < 0.05) in Puerto Rico (APC = 2.8%) and among NHB (APC = 1.9%) and remained constant (p > 0.05) for NHW (APC = -0.1%) and Hispanics in the US (APC = 0.4%). Mortality trends remained constant in all racial/ethnic groups (p > 0.05). For 1999-2003, women in Puerto Rico had similar incidence of endometrial cancer as Hispanics (Standardized rate ratio [SRR] = 0.94, 95% CI = 0.87-1.01), although their risk was lower than that of NHW (SRR = 0.56, 95% CI = 0.53-0.59) and NHB (SRR = 0.91, 95% CI = 0.84-0.98). Meanwhile, women in Puerto Rico had 15% higher risk of death than Hispanic women (SRR = 1.15, 95% CI = 1.03-1.30) similar risk than NHW (SRR = 0.93, 95% CI = 0.83-1.03), and lower risk than NHB (SRR = 0.51, 95% CI = 0.46-0.57). Puerto Rico (63.1%) and NHB (56.8%) had a lower 5-year survival than NHW (78.4%) and Hispanics (79.5%). An age-adjusted Cox proportional hazards model showed that compared with women in Puerto Rico, Hispanic women in the United States had 37% lower mortality risk (HR = 0.63, 95% CI = 0.56-0.71) and NHW had 53% lower mortality risk (HR = 0.47, 95% CI = 0.43-0.52) after 5 years of diagnosis; NHB women had 22% higher mortality risk than women in Puerto Rico (HR = 1.22, 95% CI = 1.09-1.36).

CONCLUSIONS

The lower burden of endometrial cancer in Puerto Rico suggests the presence of protective factors or lower exposure to risk factors in this population, although increases in incidence suggest changes in the occurrence of lifestyles and environmental risk factors. Meanwhile, the lower five-year survival from endometrial cancer among Puerto Ricans suggests a health disparity for this group in areas such as quality of care and/or differences in terms of stage at diagnosis and associated comorbidities. Assessment of disease risk factors and characteristics, and access and response to treatment is required to further understand these results.

Factors associated with federal transportation funding for local pedestrian and bicycle programming and facilities

Providing safe, convenient places for walking and bicycling can reduce barriers to participating in regular physical activity. We examined bicycle- and pedestrian-related investments authorized by federal transportation legislation in 3,140 counties in the United States by region, population size and urbanization, social and economic characteristics, and indicators of travel-related walking and bicycling. From 1992 to 2004, states and counties implemented 10,012 bicycle- and pedestrian-related projects representing $3.17 billion in federal expenditures. We found disparities in implementation and system-building outcomes according to population size and location and social and economic indicators. Counties characterized by persistent poverty (odds ratio=0.69, 95% confidence interval 0.53-0.91) or low educational status (odds ratio=0.66, 95% confidence interval 0.52-0.84) were less likely to implement projects. Three key policy recommendations for improving public health outcomes are drawn from this research: Improved data tracking, more explicit linkages between transportation projects and public health, and improved planning assistance to underserved communities are all seen as essential steps.

Small-area estimation and prioritizing communities for tobacco control efforts in Massachusetts

OBJECTIVES

We developed a method to evaluate geographic and temporal variations in community-level risk factors and prevalence estimates, and used that method to identify communities in Massachusetts that should be considered high priority communities for smoking interventions.

METHODS

We integrated individual-level data from the Behavioral Risk Factor Surveillance System from 1999 to 2005 with community-level data in Massachusetts. We used small-area estimation models to assess the associations of adults' smoking status with both individual- and community-level characteristics and to estimate community-specific smoking prevalence in 398 communities. We classified communities into 8 groups according to their prevalence estimates, the precision of the estimates, and temporal trends.

RESULTS

Community-level prevalence of current cigarette smoking among adults ranged from 5% to 36% in 2005 and declined in all but 16 (4%) communities between 1999 and 2005. However, less than 15% of the communities met the national prevalence goal of 12% or less. High smoking prevalence remained in communities with lower income, higher percentage of blue-collar workers, and higher density of tobacco outlets.

CONCLUSIONS

Prioritizing communities for intervention can be accomplished through the use of small-area estimation models. In Massachusetts, socioeconomically disadvantaged communities have high smoking prevalence rates and should be of high priority to those working to control tobacco use.