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

A person-reported cumulative social risk measure does not show bias by income and education

BACKGROUND

Social risk such as housing instability, trouble affording medical care and food insecurity are a downstream effect of social determinants of health (SDOHs) and are frequently associated with worse health. SDOHs include experiences of racism, sexism and other discrimination as well as differences in income and education. The collective effects of each social risk a person reports are called cumulative social risk. Cumulative social risk has traditionally been measured through counts or sum scores that treat each social risk as equivalent. We have proposed to use item response theory (IRT) as an alternative measure of person-reported cumulative social risk as IRT accounts for the severity in each risk and allows for more efficient screening with computerized adaptive testing.

METHODS

We conducted a differential item functioning (DIF) analysis comparing IRT-based person-reported cumulative social risk scores by income and education in a population-based sample (n = 2122). Six social risk items were analyzed using the two-parameter logistic model and graded response model.

RESULTS

Analyses showed no DIF on an IRT-based cumulative social risk score by education level for the six items examined. Statistically significant DIF was found on three items by income level but the ultimate effect on the scores was negligible.

CONCLUSIONS

Results suggest an IRT-based cumulative social risk score is not biased by education and income level and can be used for comparisons between groups. An IRT-based cumulative social risk score will be useful for combining datasets to examine policy factors affecting social risk and for more efficient screening of patients for social risk using computerized adaptive testing.

Alienation from medical care policy, medical care avoidance, and the role of sex and risk perception

BACKGROUND

Medical care avoidance affects individuals' health status. Previous studies on medical care avoidance have mainly focused on medical costs and people's satisfaction with medical services. This study investigates whether an individual's sense of policy alienation toward medical care policy (SPA-M) affects behavioral intention of medical care avoidance, and to what extent an intermediary variable-medical financial risk perception-mediates the relationship between SPA-M and medical care avoidance.

METHODS

A cross-sectional survey was conducted involving 434 people aged 35-59 years from Wuhu, a city in China's Anhui province. A moderated mediation model was constructed to investigate the research question and sex (biological: male and female) was used as a moderating variable between SPA-M and medical financial risk perception.

RESULTS

We found that SPA-M significantly impacted medical care avoidance, and that medical financial risk perception played a complete mediating role in this relationship, while sex moderated the relationship between SPA-M and medical financial risk perception.

CONCLUSION

This study contributes to the literature by enhancing our understanding of the factors that influence behavioral intention regarding medical care avoidance, deepening our understanding of the role of SPA-M in medical care policy, and expanding the role of sex differences in the analysis of the relationship between SPA-M, medical financial risk perception, and medical care avoidance, offering implications for public and community health.

Expanding opportunities for chronic disease prevention for Hispanics: the Better Together REACH program in Pennsylvania

Background

Hispanics in Lebanon and Reading, Pennsylvania, experience high levels of socioeconomic and health disparities in risk factors for chronic disease. In 2018, our community-academic coalition "Better Together" received a Racial and Ethnic Approaches to Community Health (REACH) award to improve healthy lifestyles. This report describes our work-in-progress and lessons learned to date from our REACH-supported initiatives in Lebanon and Reading.

Methods

For the past 4 years, our coalition has leveraged strong community collaborations to implement and evaluate culturally-tailored practice- and evidence-based activities aimed at increasing physical activity, healthy nutrition, and community-clinical linkages. This community case report summarizes the context where our overall program was implemented, including the priority population, target geographical area, socioeconomic and health disparities data, community-academic coalition, conceptual model, and details the progress of the Better Together initiative in the two communities impacted.

Results

To improve physical activity, we are: (1) creating new and enhancing existing trails connecting everyday destinations through city redesigning and master planning, (2) promoting outdoor physical activity, (3) increasing awareness of community resources for chronic disease prevention, and (4) supporting access to bikes for youth and families. To improve nutrition, we are: (1) expanding access to locally-grown fresh fruit and vegetables in community and clinical settings, through the Farmers Market Nutrition Program to beneficiaries of the Women, Infants, and Children (WIC) program and the Veggie Rx to patients who are at risk for or have diabetes, and (2) providing bilingual breastfeeding education. To enhance community-clinical linkages, we are training bilingual community health workers to connect at-risk individuals with diabetes prevention programs.

Conclusions

Intervening in areas facing high chronic disease health disparities leads us to develop a community-collaborative blueprint that can be replicated across Hispanic communities in Pennsylvania and the United States.

Patient perspectives on cervical cancer screening interventions among underscreened women

BACKGROUND

Cervical cancer is highly preventable with regular screening, yet over 4,000 women die from it annually in the United States. Over half of new cervical cancer cases in the U.S. are attributable to insufficient screening.

METHODS

Participants were 23 low-income, uninsured or Medicaid-insured women in North Carolina who were overdue for cervical cancer screening according to national guidelines. Semi-structured interviews examined perspectives on barriers to cervical cancer screening and on interventions to reduce these barriers. We also elicited feedback on three proposed evidence-based interventions: one-on-one education, coupons to reduce out-of-pocket costs, and self-collection of samples for detection of high-risk human papillomavirus (HPV) infection, the primary cause of cervical cancer.

RESULTS

Reported barriers included high cost, inconvenient clinic hours, lack of provider recommendation, poor transportation, difficulty finding a provider, fear of pain, and low perceived need. Participants suggested interventions including reducing cost, improving convenience through community-based screening or extended clinic hours, strengthening provider recommendations, and providing one-on-one counseling and education outreach. HPV self-collection was most frequently selected as the "most helpful" of 3 proposed interventions (n = 11), followed by reducing out-of-pocket costs (n = 7) and one-on-one education (n = 5).

CONCLUSION

Cost was the most reported barrier to cervical cancer screening, although women experience multiple simultaneous barriers. Novel interventions such as HPV self-collection promise to reduce some, but not all, barriers to primary screening. Interventions that work on reducing multiple barriers, including obstacles to receiving follow-up care, may be most effective to prevent cervical cancer among these high-risk women.

Environmental Exposure to Cyanobacteria Hepatotoxins in a Pacific Island Community: A Cross-Sectional Assessment

(1) Background: Cyanobacteria produce a wide range of secondary metabolites, including tumor-promoting hepatotoxins. We recently reported evidence of an independent association between oral cyanobacteria and hepatocellular carcinoma in a U.S. population. We sought to characterize the nature, sources, and health correlates of cyanotoxin exposure in the U.S. Pacific Island territory of Guam, which has a high incidence of liver cancer. (2) Methods: Seventy-four adult males and females were enrolled in a cross-sectional study to quantify cyanotoxins in saliva, urine, and blood and their correlation with health behaviors, medical history, and environmental exposures. Plant samples were collected from locations throughout the island. Microcystin/nodularin (MC/NOD), cylindrospermopsin (CYN), and anabaenopeptin (AB) were measured in biospecimens and in plant extracts by ELISA. (3) Results: Overall, among study participants MC/NOD were detected in 53.9% of saliva, 7.5% of urine, and 100% of serum.; CYN in 40.0% of saliva, 100.0% of urine, and 70.4% of serum; AB in 30.8% of saliva, 85% of urine, and 92.6% of serum. Salivary MC/NOD levels were significantly higher in individuals using municipal tap water as their primary source of drinking water; both salivary and urinary MC/NOD levels were higher in those not using store-bought/commercial water. Urine MC/NOD levels were highest among individuals consuming fruits and vegetables exclusively from local sources. Urine MC/NOD levels were elevated in individuals with hypertension and hyperlipidemia and salivary MC/NOD in those with recent alcohol consumption. Cyanotoxins were prevalent in plant samples including MC/NOD (46.6%), CYN (35.1%), and AB (51.7%). (4) Conclusions: Our study provides evidence that exposure to cyanobacterial hepatotoxins, including tumor promoters, may be prevalent in Guam and may originate from environmental sources. Population-based epidemiologic studies are needed to investigate the role of cyanotoxins in liver cancer development.

Handling, task complexity, time-of-day, and sleep deprivation as dynamic modulators of recognition memory in mice

Sleep is essential for optimal cognitive functioning. Although we lack a complete understanding of the role of sleep in memory consolidation, we know that various factors that disturb sleep or sleep quality have consequences for cognitive performance. Such factors can be unintended components of behavioral experiments on rodents and other experimental animals that generate differing results from different labs. These experimental variables include habituation to handling, intended or unintended sleep deprivation, task complexity, time of testing, and environmental features. We have examined how these variables impact recognition memory in C57BL/6 mice. Handled mice outperformed their non-handled counterparts across different combinations of delay phase duration and lighting conditions. Results also suggest that simple task recall is more resistant to diurnal variation and the impairing effects of sleep deprivation than is complex task recall. This study underscores the role of protocol and environmental factors in recognition memory and in conflicting results from different laboratories.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Lifestyle Modification Using a Wearable Biometric Ring and Guided Feedback Improve Sleep and Exercise Behaviors: A 12-Month Randomized, Placebo-Controlled Study

Purpose: Wearable biometric monitoring devices (WBMD) show promise as a cutting edge means to improve health and prevent disease through increasing accountability. By regularly providing real-time quantitative data regarding activity, sleep quality, and recovery, users may become more aware of the impact that their lifestyle has on their health. The purpose of this study was to examine the efficacy of a biometric tracking ring on improving sleep quality and increasing physical fitness over a one-year period. Methods: Fifty-six participants received a biometric tracking ring and were placed in one of two groups. One group received a 3-month interactive behavioral modification intervention (INT) that was delivered virtually via a smartphone app with guided text message feedback (GTF). The other received a 3-month non-directive wellness education control (CON). After three months, the INT group was divided into a long-term feedback group (LT-GTF) that continued to receive GTF for another nine months or short-term feedback group (ST-GTF) that stopped receiving GTF. Weight, body composition, and VO2max were assessed at baseline, 3months, and 12months for all participants and additionally at 6 and 9months for the ST-GTF and LT-GTF groups. To establish baseline measurements, sleep and physical activity data were collected daily over a 30-day period. Daily measurements were also conducted throughout the 12-month duration of the study. Results: Over the first 3months, the INT group had significant (p<0.001) improvements in sleep onset latency, daily step count, % time jogging, VO2max, body fat percentage, and heart rate variability (rMSSD HRV) compared to the CON group. Over the next 9months, the LT-GTF group continued to improve significantly (p<0.001) in sleep onset latency, daily step count, % time jogging, VO2max, and rMSSD HRV. The ST-GTF group neither improved nor regressed over the latter 9months except for a small increase in sleep latency. Conclusion: Using a WBMD concomitantly with personalized education, encouragement, and feedback, elicits greater change than using a WBMD alone. Additionally, the improvements achieved from a short duration of personalized coaching are largely maintained with the continued use of a WBMD.

How sleep can help maximize human potential: The role of leaders

OBJECTIVE

During multi-domain operations (MDO), soldiers need the physical supremacy, cognitive dominance, and emotional resilience to help defend and win our nation's wars. Optimal sleep has been shown to boost physical performance and cognitive processing. This manuscript will discuss how recent advances in sleep science strongly argue for the integration of sleep planning into military operations.

DESIGN

Review article.

METHODS

We reviewed the current understanding of how sleep affects Soldier readiness, how sleep and pain are interrelated, and unique challenges to obtaining adequate sleep in military training environments. We then address solutions that can be implemented by leaders and individuals to manage warfighter fatigue and optimize unit performance.

RESULTS

Since sleep is foundational to soldier health and readiness, improving warfighter fatigue management is a priority for leaders.

CONCLUSION

To succeed in MDO, military personnel require physical supremacy, cognitive dominance, and emotional resilience to fight and win. Sleep science is a rapidly emerging field, and the clear implications for maximizing human performance argue strongly for more deliberate integration into military training and operations. Leaders that incorporate sleep and fatigue management into the planning and execution phases of operations will help facilitate mission priorities and prove a powerful force multiplier.

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.

Smoke at night and sleep worse? The associations between cigarette smoking with insomnia severity and sleep duration

OBJECTIVE

Insomnia is a clinically verified nicotine withdrawal symptom. As nicotine is a stimulant, it is plausible that smoking at night could disturb sleep more than smoking at earlier times of the day, but this remains empirically unclear. This study examined smoking status and its associations with insomnia severity and sleep duration while considering the potential role of smoking time.

METHODS

Data were derived from the Sleep and Healthy Activity Diet Environment and Socialization study, a community-based study of 1007 adults (nnonsmokers = 818; nsmokers = 189) aged 22-60 from the Philadelphia area. Smoking status and time of smoking were self-reported. Insomnia was assessed with the Insomnia Severity Index and categorized as none, mild, and moderate-to-severe. Sleep duration was assessed with one item from the National Health and Nutrition Examination Survey and categorized as very short, short, normal, and long. Ordinal and multinomial logistic regressions were used to determine the association of smoking status including smoking time with insomnia severity and sleep duration controlling for sociodemographic covariates.

RESULTS

Compared to nonsmoking, smoking was associated with experiencing increased insomnia (odds ratio = 2.5, 95% confidence interval [CI] 1.9, 3.4, P < .001) as well as very short (relative risk ratio = 1.9, 95% CI 1.1, 3.3) and short (relative risk ratio = 1.5, 95% CI 1.0, 2.3) sleep (vs normal sleep duration). Night-time smoking was significantly associated with greater insomnia and shorter sleep duration.

CONCLUSIONS

Findings provide evidence that smoking is associated with increased insomnia severity and shorter sleep duration, particularly nightly smoking. Sleep health should be considered in smoking cessation efforts.

Financial Anxiety is Associated With Cancer Screening Adherence in Women at High Risk of Breast Cancer

BACKGROUND

Previous studies have examined the impact of material financial hardship on cancer screening but without focusing on the psychological aspects of financial hardship.

PURPOSE

This study examined the effects of different types of financial anxiety on adherence to breast cancer screening in women at high risk of breast cancer. Adherence to cervical cancer screening was also examined to determine whether associations between financial anxiety and screening adherence were unique to breast cancer screening or more general.

METHODS

Women (n = 324) aged 30-50 and at high risk for inherited breast cancer completed a survey on general financial anxiety, worry about affording healthcare, financial stigma due to cancer risk, and adherence to cancer screening. Multivariate analyses controlled for poverty, age, and race.

RESULTS

More financial anxiety was associated with lower odds of mammogram adherence (odds ratio [OR] = 0.97, confidence interval [CI] = 0.94, 0.99), Pap smear adherence (OR = 0.98, CI = 0.96, 0.996), and clinical breast examination adherence (OR = 0.98, CI = 0.96, 0.995). More worry about affording healthcare was associated with lower odds of clinical breast examination adherence (OR = 0.95, CI = 0.91, 0.9992) but not mammogram or Pap smear adherence (p > .05). Financial stigma due to cancer risk was associated with lower odds of Pap smear adherence (OR = 0.87, CI = 0.77, 0.97) but no other cancer screenings (p > .07).

CONCLUSIONS

Financial anxiety may impede cancer screening, even for high-risk women aware of their risk status. Clinical interventions focused on social determinants of health may also need to address financial anxiety for women at high risk of breast cancer.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

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.

Medicaid expansion, health insurance coverage, and cost barriers to care among low-income adults with asthma: the Adult Asthma Call-Back Survey

OBJECTIVE

To examine Medicaid expansion (ME) effects on health insurance coverage (HIC) and cost barriers to medical care among people with asthma.

METHOD

We analyzed 2012-2013 and 2015-2016 data from low-income adults with current asthma aged 18-64 years in the Behavioral Risk Factor Surveillance System Asthma Call-Back Survey (state-level telephone survey). We calculated weighted percentages and 95% confidence intervals from ME and non-ME jurisdictions (according to 2014 ME status). Outcomes were HIC and cost barriers to buying asthma medication (MED), seeing a health care provider for asthma (HCP), or any asthma care (AAC). Using SUDAAN, we performed survey-weighted difference-in-differences analyses, adjusting for demographics. Subgroup analyses were stratified by demographics.

RESULTS

Our study population included 6445 participants from 25 states plus Puerto Rico. In 2015-2016 compared to 2012-2013, HIC was more common in ME jurisdictions (P < 0.001) but unchanged in non-ME jurisdictions. Adjusted difference-in-differences analyses showed ME was associated with a statistically significant 13.36 percentage-point increase in HIC (standard error = 0.053). Cost barriers to MED, HCP, and AAC did not change significantly for either group in descriptive and difference-in-differences analyses. In subgroup analyses, we noted variation in outcomes by demographics and 2014 ME status.

CONCLUSIONS

We found ME significantly affected HIC among low-income adults with asthma, but not cost barriers to asthma-related health care. Strategies to reduce cost barriers to asthma care could further improve health care access among low-income adults with asthma in ME jurisdictions.

Objective Church Environment Audits and Attendee Perceptions of Healthy Eating and Physical Activity Supports within the Church Setting

Interventions in faith-based settings are increasingly popular, due to their effectiveness for improving attendee health outcomes and behaviors. Little past research has examined the important role of the church environment in individual-level outcomes using objective environmental audits. This study examined associations between the objectively measured physical church environment and attendees' perceptions of physical activity (PA) and healthy eating (HE) supports within the church environment, self-efficacy for PA and HE, and self-reported PA and HE behaviors. Data were collected via church audits and church attendee surveys in 54 churches in a rural, medically underserved county in South Carolina. Multi-level regression was used to analyze associations between the church environment and outcomes. Physical elements of churches were positively related to attendees' perceptions of church environment supports for PA (B = 0.03, 95% CI = 0.01, 0.05) and HE (B = 0.05, 95% CI = 0.01, 0.09) and there was a significant interaction between perceptions of HE supports and HE church environment. Self-efficacy and behaviors for PA and HE did not show an association with the church environment. Future research should establish a temporal relationship between the church environment and these important constructs for improving health. Future faith-based interventions should apply infrastructure changes to the church environment to influence important mediating constructs to health behavior.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Impact of human papillomavirus (HPV) self-collection on subsequent cervical cancer screening completion among under-screened US women: MyBodyMyTest-3 protocol for a randomized controlled trial

Background

Screening substantially reduces cervical cancer incidence and mortality. More than half of invasive cervical cancers are attributable to infrequent screening or not screening at all. The current study, My Body My Test (MBMT), evaluates the impact of mailed kits for self-collection of samples for human papillomavirus (HPV) testing on completion of cervical cancer screening in low-income, North Carolina women overdue for cervical cancer screening.

Methods/design

The study will enroll at least 510 US women aged 25–64 years who report no Pap test in the last 4 years and no HPV test in the last 6 years. We will randomize participants to an intervention or control arm. The intervention arm will receive kits to self-collect a sample at home and mail it for HPV testing. In both the intervention and control arms, participants will receive assistance in scheduling an appointment for screening in clinic. Study staff will deliver HPV self-collection results by phone and assist in scheduling participants for screening in clinic. The primary outcome is completion of cervical cancer screening. Specifically, completion of screening will be defined as screening in clinic or receipt of negative HPV self-collection results. Women with HPV-negative self-collection results will be considered screening-complete. All other participants will be considered screening-complete if they obtain co-testing or Pap test screening at a study-affiliated institution or other clinic. We will assess whether the self-collection intervention influences participants’ perceived risk of cervical cancer and whether perceived risk mediates the relationship between HPV self-collection results and subsequent screening in clinic. We also will estimate the incremental cost per woman screened of offering at-home HPV self-collection kits with scheduling assistance as compared to offering scheduling assistance alone.

Discussion

If mailed self-collection of samples for HPV testing is an effective strategy for increasing cervical cancer screening among women overdue for screening, this method has the potential to reduce cervical cancer incidence and mortality in medically underserved women at higher risk of developing cervical cancer.

Trial registration

ClinicalTrials.gov NCT02651883, Registered on 11 January 2016.

Home Self-Collection by Mail to Test for Human Papillomavirus and Sexually Transmitted Infections

OBJECTIVE

To evaluate the validity and acceptability of at-home self-collection to test for high-risk human papillomavirus (HPV) and sexually transmitted infections among women overdue for cervical cancer screening by national guidelines.

METHODS

Low-income, infrequently screened women were recruited from the general population in North Carolina to participate in an observational study. Participants provided two self-collected cervicovaginal samples (one at home and one in the clinic) and a clinician-collected cervical sample. Samples were tested for high-risk HPV, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium. Cervical samples were also tested by liquid-based cytology.

RESULTS

Overall, 193 women had conclusive high-risk HPV results for all three samples and cytology results. Prevalence of high-risk HPV within self-home samples (12.4%) was not different from that within clinician samples (11.4%; P=.79) and from that within self clinic samples (15.5%; P=.21). Positivity for high-risk HPV in all sample types increased with increasing grades of cervical abnormality (P<.001). Self-home samples detected high-risk HPV in all identified cases of high-grade squamous intraepithelial lesions and of cervical intraepithelial neoplasia 2 or worse. Detection was comparable across sample types for T vaginalis (range 10.2-10.8%), M genitalium (3.3-5.5%), C trachomatis (1.1-2.1%), and N gonorrhoeae (0-0.5%). Kappa values between sample types ranged from 0.56 to 0.66 for high-risk HPV, 0.86-0.91 for T vaginalis, and 0.65-0.83 for M genitalium. Most participants reported no difficulty understanding self-collection instructions (93.6%) and were willing to use self-collection in the future (96.3%).

CONCLUSION

Mail-based, at-home self-collection for high-risk HPV and sexually transmitted infection detection was valid and well accepted among infrequently screened women in our study. These findings support the future use of high-risk HPV self-collection to increase cervical cancer screening rates among higher risk women in the United States.

Cancer Statistics for Hispanics/Latinos, 2018

Cancer is the leading cause of death among Hispanics/Latinos, who represent the largest racial/ethnic minority group in the United States, accounting for 17.8% (57.5 million) of the total population in the continental United States and Hawaii in 2016. In addition, more than 3 million Hispanic Americans live in the US territory of Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanics in the United States based on data from the National Cancer Institute, the North American Association of Central Cancer Registries, and the Centers for Disease Control and Prevention. For the first time, contemporary incidence and mortality rates for Puerto Rico, which has a 99% Hispanic population, are also presented. An estimated 149,100 new cancer cases and 42,700 cancer deaths will occur among Hispanics in the continental United States and Hawaii in 2018. For all cancers combined, Hispanics have 25% lower incidence and 30% lower mortality compared with non-Hispanic whites, although rates of infection-related cancers, such as liver, are up to twice as high in Hispanics. However, these aggregated data mask substantial heterogeneity within the Hispanic population because of variable cancer risk, as exemplified by the substantial differences in the cancer burden between island Puerto Ricans and other US Hispanics. For example, during 2011 to 2015, prostate cancer incidence rates in Puerto Rico (146.6 per 100,000) were 60% higher than those in other US Hispanics combined (91.6 per 100,000) and 44% higher than those in non-Hispanic whites (101.7 per 100,000). Prostate cancer is also the leading cause of cancer death among men in Puerto Rico, accounting for nearly 1 in 6 cancer deaths during 2011-2015, whereas lung cancer is the leading cause of cancer death among other US Hispanic men combined. Variations in cancer risk are driven by differences in exposure to cancer-causing infectious agents and behavioral risk factors as well as the prevalence of screening. Strategies for reducing cancer risk in Hispanic populations include targeted, culturally appropriate interventions for increasing the uptake of preventive services and reducing cancer risk factor prevalence, as well as additional funding for Puerto Rico-specific and subgroup-specific cancer research and surveillance.

Effects of an entertaining, culturally targeted narrative and an appealing expert interview on the colorectal screening intentions of African American women

Universal screening for colorectal cancer (CRC) is recommended for individuals 50-75 years of age, but screening uptake is suboptimal and African Americans have suffered persistent racial disparities in CRC incidence and deaths. We compared a culturally tailored fictional narrative and an engaging expert interview on the ability to increase intentions to be screened for CRC among African American women. In a post-only experiment, women (N = 442) in face-to-face listening groups in African American churches heard audio recordings of either a narrative or an expert interview. Questionnaires were completed immediately afterward and 30 days later. Women who heard narratives reported stronger intentions to be screened with a home stool blood test than women who heard the interview; the effect lasted at least 30 days. Culturally tailored, fictional narratives appear to be an effective persuasive strategy for reducing racial disparities in CRC outcomes.

Trends in Medical Use of Opioids in the U.S., 2006-2016

INTRODUCTION

The U.S. is experiencing an opioid epidemic which is at least partially iatrogenic and fueled by both prescription and illicit misuse. This study provides a nationwide examination of opioid distribution patterns during the last decade.

METHODS

Data were obtained from the U.S. Drug Enforcement Administration's Automation of Reports and Consolidated Orders System for 2006-2016. Analyses include quantities of ten opioids legally dispensed nationwide by weight and converted to Morphine Milligram Equivalents. Geospatial and state-level analyses were also completed in 2017.

RESULTS

The total for ten opioids peaked in 2011 (389.5 metric tons Morphine Milligram Equivalents) relative to both 2006 (286.1) and 2016 (364.6). Changes in the volume of opioids by weight over the decade were agent specific. Since 2011, there were decreases in hydrocodone (-28.4%); oxymorphone (-28.0%); fentanyl (-21.4%); morphine (-18.9%); oxycodone (-13.8%); and meperidine (-58.0%) and an increase in buprenorphine (75.2%) in 2016. There were substantial inter-state variations in rates with a fivefold difference between the highest Morphine Milligram Equivalents in 2016 (Rhode Island=2,623.7 mg/person) relative to the lowest (North Dakota=484.7 mg/person). An association was identified between state median age and per capita Morphine Milligram Equivalents (r =0.49, p<0.0005).

CONCLUSIONS

With the exception of buprenorphine, used to treat an opioid use disorder, prescription opioid use has been decreasing over the past 5 years in the U.S. Further efforts are needed to continue to optimize the balance between appropriate opioid access for acute pain while minimizing diversion and treating opioid addiction.

Geographic Variations in Arthritis Prevalence, Health-Related Characteristics, and Management - United States, 2015

Problem/Condition

Doctor-diagnosed arthritis is a common chronic condition affecting an estimated 23% (54 million) of adults in the United States, greatly influencing quality of life and costing approximately $300 billion annually. The geographic variations in arthritis prevalence, health-related characteristics, and management among states and territories are unknown. Therefore, public health professionals need to understand arthritis in their areas to target dissemination of evidence-based interventions that reduce arthritis morbidity.

Reporting Period

2015.

Description of System

The Behavioral Risk Factor Surveillance System is an annual, random-digit–dialed landline and cellular telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. Self-reported data are collected from the 50 states, the District of Columbia, Guam, and Puerto Rico. Unadjusted and age-standardized prevalences of arthritis, arthritis health-related characteristics, and arthritis management were calculated. County-level estimates were calculated using a validated statistical modeling method.

Results

In 2015, in the 50 states and the District of Columbia, median age-standardized prevalence of arthritis was 23.0% (range: 17.2%–33.6%). Modeled prevalence of arthritis varied considerably by county (range: 11.2%–42.7%). In 13 states that administered the arthritis management module, among adults with arthritis, the age-standardized median percentage of participation in a self-management education course was 14.5% (range: 9.1%–19.0%), being told by a health care provider to engage in physical activity or exercise was 58.5% (range: 52.3%–61.9%), and being told to lose weight to manage arthritis symptoms (if overweight or obese) was 44.5% (range: 35.1%–53.2%). Respondents with arthritis who lived in the quartile of states with the highest prevalences of arthritis had the highest percentages of negative health-related characteristics (i.e., arthritis-attributable activity limitations, arthritis-attributable severe joint pain, and arthritis-attributable social participation restriction; ≥14 physically unhealthy days during the past 30 days; ≥14 mentally unhealthy days during the past 30 days; obesity; and leisure-time physical inactivity) and the lowest percentage of leisure-time walking.

Interpretation

The prevalence, health-related characteristics, and management of arthritis varied substantially across states. The modeled prevalence of arthritis varied considerably by county.

Public Health Action

The findings highlight notable geographic variability in prevalence, health-related characteristics, and management of arthritis. Targeted use of evidence-based interventions that focus on physical activity and self-management education can reduce pain and improve function and quality of life for adults with arthritis and thus might reduce these geographic disparities.

Assessment of trends in cervical cancer screening rates using healthcare claims data: United States, 2003-2014

Improved understanding of the natural history of cervical cancer has led to changes in screening recommendations, including the addition of the human papillomavirus (HPV) testing as an option in routine screening. Most studies of screening trends have used national self-reported survey data. To better understand recent trends in cervical cancer screening, including cytology (Papanicolaou, or Pap, tests) and human papillomavirus co-tests (HPV + Pap test), we used healthcare claims data to examine screening practices and trends. We analyzed screening among commercially-insured females ages 18-65 during 2005-2014 who were continuously enrolled during three or more contiguous calendar years, to identify those who received cervical cancer screening with a Pap test or co-test. We examined screening prevalence by age group and year. During the latter years of our study period, screening prevalence (regardless of screening method) declined significantly for women in all age groups examined. Despite declines in overall screening, the prevalence of co-testing increased in all age groups except those aged 18-20. In 2014, women aged 30-39 had the highest overall screening uptake (77.5%) and the highest use of co-testing (44.4%); this group also had the lowest overall declines in screening over the time period (-4.5%). These screening measures from healthcare claims were lower than self-reported screening from national surveys of the general population. More research to explore the reasons for these differences is needed to ensure that women are receiving appropriate screening, and to better understand why screening prevalence is declining among this population of commercially insured women.