The PhenX Toolkit: Measurement Protocols for Assessment of Social Determinants of Health

INTRODUCTION

Social determinants are structures and conditions in the biological, physical, built, and social environments that affect health, social and physical functioning, health risk, quality of life, and health outcomes. The adoption of recommended, standard measurement protocols for social determinants of health will advance the science of minority health and health disparities research and provide standard social determinants of health protocols for inclusion in all studies with human participants.

METHODS

A PhenX (consensus measures for Phenotypes and eXposures) Working Group of social determinants of health experts was convened from October 2018 to May 2020 and followed a well-established consensus process to identify and recommend social determinants of health measurement protocols. The PhenX Toolkit contains data collection protocols suitable for inclusion in a wide range of research studies. The recommended social determinants of health protocols were shared with the broader scientific community to invite review and feedback before being added to the Toolkit.

RESULTS

Nineteen social determinants of health protocols were released in the PhenX Toolkit (https://www.phenxtoolkit.org) in May 2020 to provide measures at the individual and structural levels for built and natural environments, structural racism, economic resources, employment status, occupational health and safety, education, environmental exposures, food environment, health and health care, and sociocultural community context.

CONCLUSIONS

Promoting the adoption of well-established social determinants of health protocols can enable consistent data collection and facilitate comparing and combining studies, with the potential to increase their scientific impact.

Mountain Bike Injury Incidence and Risk Factors Among Members of a Wisconsin Mountain Bike Club

BACKGROUND

This study aimed to assess the incidence of and risk factors for mountain bike injuries among users of a local mountain bike trail system.

METHODS

An email survey was sent to 1,800 member households, and 410 (23%) responded. Exact Poisson test was used to calculate rate ratios, and a generalized linear model was used for multivariate analysis.

RESULTS

The injury incidence rate was 3.6 injuries per 1,000 person-hours of riding, with beginners at a significantly higher risk compared to advanced riders (rate ratio = 2.6, 95% CI, 1.4-4.4). However, only 0.4% of beginners required medical attention, compared to 3% of advanced riders.

CONCLUSIONS

More injuries occur among beginning riders, but the injuries are more severe with experienced riders, suggesting higher risk-taking or less attention to safety measures.

Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews

INTRODUCTION

Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening.

METHODS

Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community.

RESULTS

The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status.

DISCUSSION

Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

Behaviors and attitudes of college students during an academic semester at two Wisconsin universities during the COVID-19 pandemic

OBJECTIVE

Characterize college student COVID-19 behaviors and attitudes during the early pandemic. Participants: Students on two university campuses in Wisconsin.

METHODS

Surveys administered in September and November 2020.

RESULTS

Few students (3-19%) participated in most in-person activities during the semester, with eating at restaurants as the exception (72-80%) and attending work (35%) and parties (33%) also reported more frequently. The majority wore masks in public (94-99%), but comparatively fewer (42%) did so at parties. Mask-wearing at parties decreased from September to November (p < 0.05). Students attending parties, or consuming more alcohol, were less concerned and more likely to take COVID-19-associated risks.

CONCLUSIONS

Students were motivated to adhere to COVID-19 prevention measures but gathered socially. Though there was frequent public masking, mask-wearing at parties declined in November and may represent pandemic fatigue. High-yield strategies for decreasing viral spread may include changing masking social norms and engaging with students about creative risk-reduction strategies.

Alcohol Use During Chemotherapy: A Pilot Study

INTRODUCTION

Alcohol use increases the risk for some cancers and can cause complications during treatment. The prevalence of alcohol use during chemotherapy has not been well documented in current literature. This pilot study aimed to examine self-reported alcohol use during chemotherapy among cancer survivors as a basis for future research and interventions.

METHODS

We surveyed Wisconsin cancer survivors (N=69) who participated in the ongoing population-based research study, Survey of the Health of Wisconsin (SHOW), on alcohol use during chemotherapy.

RESULTS

Of the cancer survivors who reported receiving chemotherapy, 30.4% (N=21) reported consuming alcohol while receiving chemotherapy, and 38.1% (N=8) of those who drank reported complications. Alcohol use during chemotherapy was higher among older adults (age 65+, rate ratio [RR], 1.9; 95% CI, 0.7-4.9), men (RR, 2.7; 95% CI, 1.3-5.4), former and current smokers (former: RR, 1.6; 95% CI, 0.7-3.8, current: RR, 2.5; 95% CI, 1.1-5.8), and those with non-alcohol-related cancers (RR, 2.0; 95% CI, 0.9-4.2.).

CONCLUSION

Alcohol use during chemotherapy is common and may increase the risk of complications. More research is needed to better understand this problem and to design effective interventions.

Permanent Supportive Housing With Housing First: Findings From a Community Guide Systematic Economic Review

INTRODUCTION

The annual economic burden of chronic homelessness in the U.S. is estimated to be as high as $3.4 billion. The Permanent Supportive Housing with Housing First (Housing First) program, implemented to address the problem, has been shown to be effective. This paper examines the economic cost and benefit of Housing First Programs.

METHODS

The search of peer-reviewed and gray literature from inception of databases through November 2019 yielded 20 evaluation studies of Housing First Programs, 17 from the U.S. and 3 from Canada. All analyses were conducted from March 2019 through July 2020. Monetary values are reported in 2019 U.S. dollars.

RESULTS

Evidence from studies conducted in the U.S. was separated from those conducted in Canada. The median intervention cost per person per year for U.S. studies was $16,479, and for all studies, including those from Canada, it was $16,336. The median total benefit for the U.S. studies was $18,247 per person per year, and it was $17,751 for all studies, including those from Canada. The benefit-to-cost ratio for U.S. studies was 1.80:1, and for all studies, including those from Canada, it was 1.06:1.

DISCUSSION

The evidence from this review shows that economic benefits exceed the cost of Housing First Programs in the U.S. There were too few studies to determine cost-benefit in the Canadian context.

Internet Published Policies Regarding Liver Transplant Eligibility and Substance Use in United States Transplant Centers

Liver transplant centers in the United States retain great autonomy in determining eligibility criteria for a liver transplant. This study aims to define the availability and content of liver transplant centers' publicly available Internet policies regarding eligibility criteria for liver transplant. Three trained undergraduate students performed a structured pilot‐tested assessment of official websites of the United Network for Organ Sharing‐registered liver transplant centers. All 141 liver transplant centers had an accessible website. Some account of eligibility criteria was provided by 53% of centers, while 32% of centers discussed substance use. Only 17% discussed their policy regarding alcohol use in candidates with underlying alcohol use disorder, and only 2% stipulated that 6 months of abstinence was required. While exclusion based on substance use or age was discussed infrequently, insurance coverage requirements, the need for social support, and the need for adherence to medical care were mentioned in 21%, 37%, and 23% of centers, respectively. Conclusion: In 2018, half of liver transplant centers provided some information on their official websites regarding eligibility criteria for liver transplant. Detailed information regarding substance use disorders and social health requirements was rare. The Internet is infrequently used by liver transplant centers as a means to publicly share information regarding selection criteria.

The Race to the Bottom: Wisconsin's Long-Term Trends in Health Rankings

BACKGROUND

Wisconsin's health ranking dropped from 7th healthiest in 1990 to 23rd in 2018. The purpose of this paper is to identify the contributory factors to this decline.

METHODS

Trends in Wisconsin's health rank for 1990 to 2018 were compared overall and for only identical measures used in both years.

RESULTS

Of the identical measures used in both years (n=10), the median rank declined from 8.5 (range 6-21) in 1990 to 19 (range 9-43) in 2018, with the greatest declines for infectious diseases, infant mortality, and smoking. The ranks were lower in 2018 for the similar measures used and for measures used only in 2018 compared to measures used only in 1990.

DISCUSSION

Wisconsin's drop in health ranking is real and calls for action to address the root causes.

Trends in Smoking During Pregnancy in Wisconsin, 2011-2016

BACKGROUND

Smoking during pregnancy remains a significant public health concern with widespread social, economic, and health effects.

OBJECTIVE

To describe the epidemiology of maternal smoking in Wisconsin over time and by county, age, race/ethnicity, education, and other characteristics.

METHODS

Cigarette smoking during pregnancy in 2011-2016 was evaluated using Wisconsin Interactive Statistics on Health data.

RESULTS

Maternal smoking rates declined from 14.4% in 2011 to 11.4% in 2016. Rates are highest among women aged 20-24 and those with less education. American Indians had the highest rates of smoking during pregnancy at all education levels.

CONCLUSION

Despite continued declines in the rates of smoking during pregnancy in Wisconsin, disparities exist for American Indians, young, and less-educated women. Physicians should continue to encourage cessation throughout pregnancy and support evidence-based community programs and policies.

Using a Community Preventive Services Task Force Recommendation to Prevent and Reduce Intimate Partner Violence and Sexual Violence

Intimate partner violence (IPV) and sexual violence (SV) are preventable public health problems affecting millions in the United States. The Community Preventive Services Task Force (CPSTF), an independent panel of experts that develops evidence-based recommendations based on rigorous systematic reviews, recommends interventions that aim to prevent or reduce IPV and SV among youth aged 12-24 years. Decision makers can use these findings to select interventions appropriate for their populations, identify additional areas for research, and justify funding requests.

The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999-2015

OBJECTIVES

To evaluate trends in premature death rates by cause of death, age, race, and urbanization level in the United States.

METHODS

We calculated cause-specific death rates using the Compressed Mortality File, National Center for Health Statistics data for adults aged 25 to 64 years in 2 time periods: 1999 to 2001 and 2013 to 2015. We defined 48 subpopulations by 10-year age groups, race/ethnicity, and county urbanization level (large urban, suburban, small or medium metropolitan, and rural).

RESULTS

The age-adjusted premature death rates for all adults declined by 8% between 1999 to 2001 and 2013 to 2015, with decreases in 39 of the 48 subpopulations. Most decreases in death rates were attributable to HIV, cardiovascular disease, and cancer. All 9 subpopulations with increased death rates were non-Hispanic Whites, largely outside large urban areas. Most increases in death rates were attributable to suicide, poisoning, and liver disease.

CONCLUSIONS

The unfavorable recent trends in premature death rate among non-Hispanic Whites outside large urban areas were primarily caused by self-destructive health behaviors likely related to underlying social and economic factors in these communities.

A Community Health Assessment Curriculum to Develop Population Health Competencies

Introduction

The Institute of Medicine, Association of American Medical Colleges, and Centers for Disease Control and Prevention recommend population health training for medical students. Medical schools struggle to teach and evaluate population health curricula. We developed, implemented, and evaluated a community health assessment exercise (CHA) within a required clinical rotation to address this need.

Methods

Descriptive statistics and t-test comparison of means were used to analyze student scores on curricular assignments and responses to pretest and posttest items assessing student-rated skill and likelihood of conducting a CHA in practice, and in finding evidence to support public health programs and policies.

Results

Student-rated skill in conducting a CHA increased from 3.3 ± 1.2 on the pretest to 4.8 ± 0.9 on the posttest (P < 0.01). Student-rated skill in finding evidence that supports public health programs and policies increased from 4.0 ± 1.1 to 5.1 ± 0.9 (P < 0.01). There was no difference between pretest and posttest in the likelihood of participating in a CHA organized by others (4.7 ± 1.3 vs 4.9 ± 1.3, p = 0.4), or in initiating a CHA as a practicing physician (4.2 ± 1.4 vs 4.3 ± 1.4, P = 0.8). Asked if the CHA improved their educational experience, 56% of students agreed and 25% disagreed. Asked if the CHA improved their ability to provide patient care, 40% of students agreed and 37% disagreed.

Conclusions

The addition of a CHA to a clinical rotation is feasible and develops key medical student public health competencies.

The Obesity Prevention Initiative: A Statewide Effort to Improve Child Health in Wisconsin

BACKGROUND/SIGNIFICANCE

Obesity rates have increased dramatically, especially among children and disadvantaged populations. Obesity is a complex issue, creating a compelling need for prevention efforts in communities to move from single isolated programs to comprehensive multisystem interventions. To address these issues, we have established a childhood Obesity Prevention Initiative (Initiative) for Wisconsin. This Initiative seeks to test community change frameworks that can support multisystem interventions and provide data for local action as a means for influencing policies, systems, and environments that support individuals’ healthy eating and physical activity.

APPROACHES/AIMS

The Initiative is comprised of three components: (1) infrastructure to support a statewide obesity prevention and health promotion network with state- and local-level public messaging and dissemination of evidence-based solutions (healthTIDE); (2) piloting a local, multisetting community-led intervention study in 2 Wisconsin counties; and (3) developing a geocoded statewide childhood obesity and fitness surveillance system.

RELEVANCE

This Initiative is using a new model that involves both coalition action and community organizing to align resources to achieve health improvement at local and state levels. We expect that it will help lead to the implementation of cohesive and sustainable policy, system, and environment health promotion and obesity prevention strategies in communities statewide, and it has the potential to help Wisconsin become a national model for multisetting community interventions to address obesity. Addressing individual-level health through population-level changes ultimately will result in reductions in the prevalence of childhood obesity, current and future health care costs, and chronic disease mortality.

Obesity Prevalence and Health Consequences: Findings From the Survey of the Health of Wisconsin, 2008-2013

IMPORTANCE

Although the trends in obesity in Wisconsin overall are well described, less is known about characteristics and health consequences of different degrees of obesity. The Survey of the Health of Wisconsin is a novel population-based health examination survey that provides reliable and valid objective measurements of body mass index.

OBJECTIVE

Data from the Survey of the Health of Wisconsin is used to characterize the prevalence and consequences of different levels of obesity and track trends over time.

METHODS

A total of 3,384 participants age 21-74 years and living in Wisconsin at the time of data collection were surveyed in 2008-2013. Participants completed computer-assisted interviews and physical exams. Predictors and comorbidities of different levels of obesity were measured as prevalence, odds ratios, and population-attributable prevalence.

RESULTS

Of Wisconsin adults, 1.2% (CI, 0.7-1.7) are underweight, 26.1% (CI, 23.8-28.4) are normal weight, 33.4% (CI, 31.0-35.7) are overweight, and 39.4% (CI, 35.0-43.7) are obese—with 20.1 % (CI, 18.4-21.9), 10.3% (CI, 9.0-11.7), and 8.9% (CI, 7.6-10.2) in Class I, Class II, and Class III obesity categories, respectively. Obesity rates are higher in people who are older, poor, less educated, minorities, or who live in a community with high economic hardship. There is a dose response relationship between level of obesity and prevalence of all 9 comorbidities that were examined.

CONCLUSIONS AND RELEVANCE

Measured rates of obesity in Wisconsin adults are higher than previously reported for the state, and obesity accounts for a significant proportion of chronic diseases.

Development of an Obesity Prevention Dashboard for Wisconsin

IMPORTANCE

A comprehensive obesity surveillance system monitors obesity rates along with causes and related health policies, which are valuable for tracking and identifying problems needing intervention.

METHODS

A statewide obesity dashboard was created using the County Health Rankings model. Indicators were obtained through publicly available secondary data sources and used to rank Wisconsin amongst other states on obesity rates, health factors, and policies.

RESULTS

Wisconsin consistently ranks in the middle of states for a majority of indicators and has not implemented any of the evidence-based health policies.

CONCLUSIONS AND RELEVANCE

This state of obesity report shows Wisconsin has marked room for improvement regarding obesity prevention, especially with obesity-related health policies. Physicians and health care systems can play a pivotal role in making progress on obesity prevention.

Prevalence of Pre-pregnancy Obesity, 2011-2014

IMPORTANCE

Obesity before and during pregnancy increases risk among mothers for poor health outcomes, such as diabetes, high blood pressure, and cardiovascular disease.

OBJECTIVE

To describe trends in pre-pregnancy obesity rates among women in Wisconsin.

METHODS

Cross-sectional data from Wisconsin birth certificates were analyzed. Prevalence of pre-pregnancy obesity (defined as body mass index ≥ 30) among Wisconsin women who gave birth from 2011 through 2014 was compared across demographic and geographic dimensions.

RESULTS

Overall, 27.8% of Wisconsin women who gave birth during 2011-2014 were obese. Obesity rates were highest among 40- to 44-year-old women (31.8%), women with a high school/ GED diploma (32.8 %), American Indian/Alaska Native women (43.9%), and women with 5 or more pregnancies (35.4%). Obesity rates varied by county of residence (highest in Forest County, 45.2%) and city of residence (highest in the city of Racine, 34.8%).

CONCLUSIONS

There are significant socioeconomic, racial, and geographic disparities in pre-pregnancy obesity among women who give birth in Wisconsin.

A Qualitative Pilot Study of Pediatricians' Approach to Childhood Obesity

IMPORTANCE

Over the past 3 decades, rates of childhood obesity have tripled. Given the gravity of this health concern, it is important that physicians intervene early. However, physicians continue to underdiagnose and undertreat childhood overweight and obesity.

OBJECTIVE

The aim of this pilot study was to identify current tools and strategies used by pediatricians in regard to childhood obesity, as well as to reassess barriers to success, and to uncover areas for improvement.

DESIGN

One-on-one interviews were conducted with pediatricians during the summer of 2013. Seven of the interviews occurred in person, and 10 occurred via telephone. Each interview lasted 30 to 60 minutes. All interviewees (n = 17, 13.2% response rate) were Wisconsin pediatricians, representing 7 different health systems.

MAIN OUTCOMES

Themes relating to pediatrician's experiences in addressing and managing childhood obesity.

RESULTS

Pediatricians interviewed in this survey are comfortable identifying and diagnosing pediatric obesity with the widespread use of electronic health records. They have several tools and strategies at their disposal for the treatment and management of obesity, but do not often achieve the desired outcome of achieving healthy body weight. Most of them lack connections to community resources and the ability to effectively communicate with referral systems outside of their clinic, such as with dietitians.

CONCLUSIONS

Building stronger connections between physicians and dietitians, as well as between physicians and the local community, may allow physicians to feel more empowered when it comes to managing childhood obesity.

The Development of a Summary Measure to Estimate the Relative Burden of Smoking in Wisconsin Counties

BACKGROUND

The rate of cigarette smoking among US adults has declined over the past 50 years. Yet smoking remains the leading cause of preventable death and marked disparities now exist in smoking rates based on education level, socioeconomic status, race/ethnicity, and geographic location. In order to target resources to reduce these disparities, a summary measure comparing the relative burden of smoking among smaller populations is needed.

OBJECTIVE

To create a single summary measure that assesses the relative health burden from smoking in Wisconsin counties using age-adjusted mortality rates for smoking-attributable diseases, current adult smoking prevalence, and the current rate of mothers who smoked during pregnancy.

RESULTS

Rates varied significantly between counties for smoking-attributable deaths (2-fold), adult smoking prevalence (5-fold), and smoking in pregnancy (5-fold). The summary measure of relative smoking burden was highest in rural counties and in counties with less education, higher rates of poverty, and more veterans. The ranking of a county's smoking burden was highly correlated with its overall health ranking from the County Health Rankings.

DISCUSSION

The burden from smoking varied markedly across Wisconsin and was highest in the least advantaged counties in the state. Additional public health efforts must be directed toward the counties with the greater relative smoking burden in order to reduce these disparities.

Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force

BACKGROUND

Trials have shown efficacy of rigorous diet and physical activity promotion programs to reduce diabetes incidence and improve glycemic measures in adults at increased risk for type 2 diabetes.

PURPOSE

To evaluate diet and physical activity promotion programs for persons at increased risk for type 2 diabetes, primarily to reduce diabetes risk and decrease body weight and glycemia.

DATA SOURCES

MEDLINE, the Cochrane Central Register of Controlled Trials, CAB Abstracts, Global Health, and Ovid HealthSTAR from 1991 through 27 February 2015, with no language restriction.

STUDY SELECTION

8 researchers screened articles for single-group or comparative studies of combined diet and physical activity promotion programs with at least 2 sessions over at least 3 months in participants at increased risk for type 2 diabetes.

DATA EXTRACTION

7 researchers extracted data on study design; participant, intervention, and outcome descriptions; and results and assessed study quality.

DATA SYNTHESIS

53 studies (30 of diet and physical activity promotion programs vs. usual care, 13 of more intensive vs. less intensive programs, and 13 of single programs) evaluated 66 programs. Compared with usual care, diet and physical activity promotion programs reduced type 2 diabetes incidence (risk ratio [RR], 0.59 [95% CI, 0.52 to 0.66]) (16 studies), decreased body weight (net change, -2.2% [CI, -2.9% to -1.4%]) (24 studies) and fasting blood glucose level (net change, -0.12 mmol/L [-2.2 mg/dL] [CI, -0.20 to -0.05 mmol/L {-3.6 to -0.9 mg/dL}]) (17 studies), and improved other cardiometabolic risk factors. Evidence for clinical events was limited. More intensive programs were more effective.

LIMITATIONS

Wide variation in diet and physical activity promotion programs limited identification of features most relevant to effectiveness. Evidence on clinical outcomes and in children was sparse.

CONCLUSION

Combined diet and physical activity promotion programs are effective at decreasing diabetes incidence and improving cardiometabolic risk factors in persons at increased risk. More intensive programs are more effective.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention Community Preventive Services Task Force.

Combined Diet and Physical Activity Promotion Programs for Prevention of Diabetes: Community Preventive Services Task Force Recommendation Statement

DESCRIPTION

Community Preventive Services Task Force recommendation on the use of combined diet and physical activity promotion programs to reduce progression to type 2 diabetes in persons at increased risk.

METHODS

The Task Force commissioned an evidence review that assessed the benefits and harms of programs to promote and support individual improvements in diet, exercise, and weight and supervised a review on the economic efficiency of these programs in clinical trial, primary care, and primary care-referable settings.

POPULATION

Adolescents and adults at increased risk for progression to type 2 diabetes.

RECOMMENDATION

The Task Force recommends the use of combined diet and physical activity promotion programs by health care systems, communities, and other implementers to provide counseling and support to clients identified as being at increased risk for type 2 diabetes. Economic evidence indicates that these programs are cost-effective.

Variation in Breast Cancer-Risk Factor Associations by Method of Detection: Results From a Series of Case-Control Studies

Concerns about breast cancer overdiagnosis have increased the need to understand how cancers detected through screening mammography differ from those first detected by a woman or her clinician. We investigated risk factor associations for invasive breast cancer by method of detection within a series of case-control studies (1992-2007) carried out in Wisconsin, Massachusetts, and New Hampshire (n=15,648 invasive breast cancer patients and 17,602 controls aged 40-79 years). Approximately half of case women reported that their cancer had been detected by mammographic screening and half that they or their clinician had detected it. In polytomous logistic regression models, parity and age at first birth were more strongly associated with risk of mammography-detected breast cancer than with risk of woman/clinician-detected breast cancer (P≤0.01; adjusted for mammography utilization). Among postmenopausal women, estrogen-progestin hormone use was predominantly associated with risk of woman/clinician-detected breast cancer (odds ratio (OR)=1.49, 95% confidence interval (CI): 1.29, 1.72), whereas obesity was predominantly associated with risk of mammography-detected breast cancer (OR=1.72, 95% CI: 1.54, 1.92). Among regularly screened premenopausal women, obesity was not associated with increased risk of mammography-detected breast cancer (OR=0.99, 95% CI: 0.83, 1.18), but it was associated with reduced risk of woman/clinician-detected breast cancer (OR=0.53, 95% CI: 0.43, 0.64). These findings indicate important differences in breast cancer risk factors according to method of detection.

The County Health Rankings: rationale and methods

Background

Annually since 2010, the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation have produced the County Health Rankings—a “population health checkup” for the nation’s over 3,000 counties. The purpose of this paper is to review the background and rationale for the Rankings, explain in detail the methods we use to create the health rankings in each state, and discuss the strengths and limitations associated with ranking the health of communities.

Methods

We base the Rankings on a conceptual model of population health that includes both health outcomes (mortality and morbidity) and health factors (health behaviors, clinical care, social and economic factors, and the physical environment). Data for over 30 measures available at the county level are assembled from a number of national sources. Z-scores are calculated for each measure, multiplied by their assigned weights, and summed to create composite measure scores. Composite scores are then ordered and counties are ranked from best to worst health within each state.

Results

Health outcomes and related health factors vary significantly within states, with over two-fold differences between the least healthy counties versus the healthiest counties for measures such as premature mortality, teen birth rates, and percent of children living in poverty. Ranking within each state depicts disparities that are not apparent when counties are ranked across the entire nation.

Discussion

The County Health Rankings can be used to clearly demonstrate differences in health by place, raise awareness of the many factors that influence health, and stimulate community health improvement efforts. The Rankings draws upon the human instinct to compete by facilitating comparisons between neighboring or peer counties within states. Since no population health model, or rankings based off such models, will ever perfectly describe the health of its population, we encourage users to look to local sources of data to understand more about the health of their community.

Predicting in-hospital death among patients injured in traffic crashes in Saudi Arabia

INTRODUCTION

Traffic-related injuries are a major cause of premature death in developing countries. Saudi Arabia has struggled with high rates of traffic-related deaths for decades, yet little is known about health outcomes of motor vehicle victims seeking medical care. This study aims to develop and validate a model to predict in-hospital death among patients admitted to a large-urban trauma centre in Saudi Arabia for treatment following traffic-related crashes.

METHODS

The analysis used data from King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. During the study period 2001-2010, 5325 patients met the inclusion criteria of being injured in traffic crashes and seen in the Emergency Department (ED) and/or admitted to the hospital. Backward stepwise logistic regression, with in-hospital death as the outcome, was performed. Variables with p<0.05 were included in the final model. The Bayesian Information Criterion (BIC) was employed to identify the most parsimonious model. Model discrimination was evaluated by the C-statistic and calibration by the Hosmer-Lemeshow Goodness of Fit statistic. Bootstrapping was used to assess overestimation of model performance and obtain a corrected C-statistic.

RESULTS

457 (8.5%) patients died at some time during their treatment in the ED or hospital. Older age, the Triage-Revised Trauma Scale (T-RTS), and Injury Severity Score were independent risk factors for in-hospital death: T-RTS was best modelled with linear and quadratic terms to capture a flattening of the relationship to death in the more severe range. The model showed excellent discrimination (C-statistic=0.96) and calibration (H-L statistic 4.29 [p>0.05]). Internal bootstrap validation gave similar results (C-statistic=0.96).

CONCLUSIONS

The proposed model can predict in-hospital death accurately. It can facilitate the triage process among injured patients, and identify unexpected deaths in order to address potential pitfalls in the care process. Conversely, by identifying high-risk patients, strategies can be developed to improve trauma care for these patients and reduce case-fatality. This is the first study to develop and validate a model to predict traffic-related mortality in a developing country. Future studies from developing countries can use this study as a reference for case fatality achievable for different risk profiles at a well-equipped trauma centre.

In-hospital mortality among patients injured in motor vehicle crashes in a Saudi Arabian hospital relative to large U.S. trauma centers

Background

Traffic-related fatalities are a leading cause of premature death worldwide. According to the 2012 report the Global Burden of Disease 2010, traffic injuries ranked 8th as a cause of death in 2010, compared to 10th in 1990. Saudi Arabia is estimated to have an overall traffic fatality rate more than double that of the U.S., but it is unknown whether mortality differences also exist for injured patients seeking medical care. We aim to compare in-hospital mortality between Saudi Arabia and the United States, adjusting for severity and demographic variables.

Methods

The analysis included 485,611 patients from the U.S. National Trauma Data Bank (NTDB) and 5,290 patients from a trauma registry at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. For comparability, we restricted our sample to NTDB data from level-I public trauma centers (≥400 beds) in the U.S. Multiple logistic regression analyses were performed to evaluate the effect of setting (KAMC vs. NTDB) on in-hospital mortality after adjusting for age, sex, Triage-Revised Scale (T-RTS), Injury Severity Score (ISS), mechanism of injury, hypotension, surgery and head injuries. Interactions between setting and ISS, and predictors were also evaluated.

Results

Injured patients in the Saudi registry were more likely to be males, and younger than those from the NTDB. Patients at the Saudi hospital were at higher risk of in-hospital death than their U.S. counterparts. In the highest severity group (ISSs, 25–75), the odds ratio of in-hospital death in KAMC versus NTDB was 5.0 (95% CI 4.3-5.8). There were no differences in mortality between KAMC and NTDB among patients from lower ISS groups (ISSs, 1–8, 9–15, and 16–24).

Conclusions

Patients who are severely injured following traffic crash injuries in Saudi Arabia are significantly more likely to die in the hospital than comparable patients admitted to large U.S. trauma centers. Further research is needed to identify reasons for this disparity and strategies for improving the care of patients severely injured in traffic crashes in Saudi Arabia.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-014-0021-4) contains supplementary material, which is available to authorized users.

Modification of breast cancer risk according to age and menopausal status: a combined analysis of five population-based case-control studies

While several risk factors for breast cancer have been identified, studies have not consistently shown whether these factors operate more strongly at certain ages or for just pre- or postmenopausal women. We evaluated whether risk factors for breast cancer differ according to age or menopausal status. Data from five population-based case-control studies conducted during 1988-2008 were combined and analyzed. Cases (N = 23,959) and population controls (N = 28,304) completed telephone interviews. Logistic regression was used to estimate adjusted odds ratios and 95 % confidence intervals and tests for interaction by age and menopausal status. Odds ratios for first-degree family history of breast cancer were strongest for younger women-reaching twofold elevations-but were still statistically significantly elevated by 58-69 % among older women. Obesity was inversely associated with breast cancer among younger women and positively associated with risk for older women (interaction P < 0.0001). Recent alcohol intake was more strongly related to breast cancer risk among older women, although consumption of 3 or more drinks/day among younger women also was associated with elevated odd ratios (P < 0.0001). Associations with benign breast disease and most reproductive/menstrual factors did not vary by age. Repeating analysis stratifying by menopausal status produced similar results. With few exceptions, menstrual and lifestyle factors are associated with breast cancer risk regardless of age or menopausal status. Variation in the association of family history, obesity, and alcohol use with breast cancer risk by age and menopausal status may need to be considered when determining individual risk for breast cancer.

Evaluating the implementation of a primary care weight management toolkit

OBJECTIVE

With over one-third of adults in the United States classified as obese, new recommendations call for screening all adults for obesity at outpatient visits. The UW Health Fox Valley Clinic does not actively screen for obesity. The objective of this project was to test the feasibility of an obesity screening and brief intervention protocol.

PROCESS

A modified version of the Promoting Healthier Weight in Primary Care toolkit was implemented into a family medicine practice for 6 weeks. Patients (N = 88) were asked about visit satisfaction and acceptability of weight-focused conversation. Providers (N = 22) were asked about acceptability and feasibility of use.

OUTCOME

Almost all patients (97.7%) found the conversation acceptable. Providers found the toolkit helpful, not confusing for their patients, and easy to use. Time was the greatest barrier.

Monitoring progress in population health: trends in premature death rates

Introduction

Trends in population health outcomes can be monitored to evaluate the performance of population health systems at the national, state, and local levels. The objective of this study was to compare and contrast 4 measures for assessing progress in population health improvement by using age-adjusted premature death rates as a summary measure of the overall health outcomes in the United States and in all 50 states.

Methods

To evaluate the performance of statewide population health systems during the past 20 years, we used 4 measures of age-adjusted premature (<75 years of age) death rates: current rates (2009), baseline trends (1990s), follow-up trends (2000s), and changes in trends from baseline to the follow-up periods (ie, “bending the curve”).

Results

Current premature death rates varied by approximately twofold, with the lowest rate in Minnesota (268 deaths per 100,000) and the highest rate in Mississippi (482 deaths per 100,000). Rates improved the most in New York during the baseline period (−3.05% per year) and in New Jersey during the follow-up period (−2.87% per year), whereas Oklahoma ranked last in trends during both periods (−0.30%/y, baseline; +0.18%/y, follow-up). Trends improved the most in Connecticut, bending the curve downward by −1.03%; trends worsened the most in New Mexico, bending the curve upward by 1.21%.

Discussion

Current premature death rates, recent trends, and changes in trends vary by state in the United States. Policy makers can use these measures to evaluate the long-term population health impact of broad health care, behavioral, social, and economic investments in population health.

Look local: the value of cancer surveillance and reporting by American Indian clinics

Introduction

Cancer incidence and mortality rates for American Indians in the Northern Plains region of the United States are among the highest in the nation. Reliable cancer surveillance data are essential to help reduce this burden; however, racial data in state cancer registries are often misclassified, and cases are often underreported.

Methods

We used a community-based participatory research approach to conduct a retrospective ascertainment of cancer cases in clinic medical records over a 9-year period (1995–2003) and compared the results with the state cancer registry to evaluate missing or racially misclassified cases. Six tribal and/or urban Indian clinics participated in the study. The project team consisted of participating clinics, a state cancer registry, a comprehensive cancer center, an American Indian/Alaska Native Leadership Initiative on Cancer, and a set of diverse organizational partners. Clinic personnel were trained by project staff to accurately identify cancer cases in clinic records. These records were then matched with the state cancer registry to assess misclassification and underreporting.

Results

Forty American Indian cases were identified that were either missing or misclassified in the state registry. Adding these cases to the registry increased the number of American Indian cases by 21.3% during the study period (P = .05).

Conclusions

Our results indicate that direct reporting of cancer cases by tribal and urban Indian health clinics to a state cancer registry improved the quality of the data available for cancer surveillance. Higher-quality data can advance the efforts of cancer prevention and control stakeholders to address disparities in Native communities.

Progress in reducing premature deaths in Wisconsin counties, 2000-2010

BACKGROUND

Measuring trends in a county's premature death rate is a straightforward method that can be used to assess a county's progress in improving the health of the population.

METHODS

Age-adjusted premature death rate data from Wisconsin Interactive Statistics on Health for persons less than 75 years of age were collected for the years 2000-2010. Overall 10-year percent change was calculated, compared, and ranked for all Wisconsin counties during this time period. Progress was assessed as excellent (25.0% or greater decline), very good (20.0%-24.9% decline), good (10.0%-19.9% decline), fair (0.0%-9.9% decline), or poor (any increase).

RESULTS

Overall, premature death rates in counties declined by 16.8% over the 10-year period 2000-2010 in Wisconsin. Trends varied by county, with 8, 15, 37, 9, and 3 counties having excellent, very good, good, fair, and poor progress, respectively. The most improvement was seen in Kewaunee County (decreasing 38.3%) and the least progress in Lafayette County (increasing 4.8%). Trends in premature death rates were not related to the county's initial death rate, population, rurality, or income.

CONCLUSIONS

Although premature death rates declined overall in Wisconsin during the 2000s, this progress varied across counties and was not related to baseline mortality rates or other county characteristics.

Using empirical Bayes methods to rank counties on population health measures

The University of Wisconsin Population Health Institute has published County Health Rankings (The Rankings) since 2010. These rankings use population-based data to highlight variation in health and encourage health assessment for all US counties. However, the uncertainty of estimates remains a limitation. We sought to quantify the precision of TheRankings for selected measures. We developed hierarchical models for 5 health outcome measures and applied empirical Bayes methods to obtain county rank estimates for a composite health outcome measure. We compared results using models with and without demographic fixed effects to determine whether covariates improved rank precision. Counties whose rank had wide confidence intervals had smaller populations or ranked in the middle of all counties for health outcomes. Incorporating covariates in the models produced narrower intervals, but rank estimates remained imprecise for many counties. Local health officials, especially in smaller population and mid-performing communities, should consider these limitations when interpreting the results of TheRankings.

Geographic and racial variation in teen pregnancy rates in Wisconsin

BACKGROUND

Despite recent declines in teen birth rates, teenage pregnancy remains an important public health problem in Wisconsin with significant social, economic, and health-related effects.

OBJECTIVE

Compare and contrast teen birth rate trends by race, ethnicity, and county in Wisconsin.

METHODS

Teen (ages 15-19 years) birth rates (per 1000 teenage females) in Wisconsin from 2001-2010 were compared by racelethnicity and county of residence using data from the Wisconsin Interactive Statistics on Health.

RESULTS

Teen birth rates in Wisconsin have declined by 20% over the past decade, from 35.5/1000 teens in 2001 to 28.3/1000 teens in 2010-a relative decline of 20.3%. However, trends vary by race, with declines among blacks (-33%) and whites (-26%) and increases among American Indians (+21%) and Hispanics (+30%). Minority teen birth rates continue to be 3 to 5 times greater than birth rates among whites. Rates varied even more by county, with an over 14-fold difference between Ozaukee County (7.8/1000) and Menominee County (114.2).

CONCLUSION

Despite recent declines, teen pregnancy continues to be an important public health problem in Wisconsin. Pregnancy prevention programs should be targeted toward the populations and counties with the highest rates.

The association between motor vehicle injuries and health-related quality of life: a longitudinal study of a population-based sample in the United States

PURPOSE

As many as 3 million US residents are injured in traffic-related incidents every year leaving many victims with disabling conditions. To date, limited numbers of studies have examined the effects of traffic-related injuries on self-reported health. This study aims to examine the association between health-related quality of life (HRQOL) and traffic-related injuries longitudinally in a nationally representative sample of US adult population.

METHODS/APPROACH

This is a longitudinal study of adult participants (age ≥18) from seven panels (2000-2007) of the Medical Expenditure Panel Survey. The dependent variables included the physical and mental components of the SF-12, a measure of self-reported health. The outcome was assessed twice during the follow-up period: round 2 (~4-5 months into the study) and round 4 (~18 months into the study) for 62,298 individuals. Two methods estimate the association between traffic-related injuries and HRQOL: a within person change using paired tests and a between person change using multivariable regression adjusting for age, sex, income and educational level.

RESULTS

Nine hundred and ninety-three participants reported traffic-related injuries during the follow-up period. Compared to their pre-crash HRQOL, these participants lost 2.7 of the physical component score while their mental component did not change. Adjusted results showed significant deficits in the physical component (-2.84, p value = <.001) but not the mental component (-0.07, p value = .83) of HRQOL after controlling for potential confounders.

CONCLUSION

Traffic injuries were significantly associated with the physical component of HRQOL. These findings highlight the individual and societal burden associated with motor vehicle crash-related disability in the United States.

Lessons Learned from a Community Based Lifestyle Intervention for Youth at Risk for Type 2 Diabetes

PURPOSE

This pilot study examined the feasibility and acceptability of a peer led diabetes prevention intervention for youth in an underserved community.

METHODS

Children and adolescents randomized to the intervention group participated in a one year program which included peer support, physical activity, and family nutrition, and behavior modification sessions. Participants were asked about their satisfaction with the study and possible benefits, what they learned, and whether they would recommend participation to a friend. Youth randomized to the control group received monthly healthy lifestyle educational materials through the mail.

RESULTS

Children and adolescents (n=67) with an average age of 12.5 years and BMI greater than or equal to 85 percentile for age and sex were enrolled in the study. The average monthly participation rate varied between 90 and 50 percent with a mean rate of 82 percent. Ninety four percent of parents reported being very satisfied with the program and all (100%) reported they would recommend the program to a friend. All the children and adolescents (100%) reported that they enjoyed working with the youth peer coaches and 94% felt their assigned coach was a good role model. The observed changes in BMI z-score trended towards improvement in the intervention group, but this study was underpowered to detect differences between groups.

CONCLUSION

The peer led diabetes prevention program was feasible and acceptable and demonstrated potential for improving health behaviors.

Health promotion data for state health departments: telephone versus in-person survey estimates of smoking and alcohol use

Abstract During 1988, more than 40 state health departments conducted telephone surveys to obtain state-specific population estimates of the prevalence of adult health behaviors and health practices. However, the comparability of estimates obtained from these telephone surveys with more expensive in-person surveys has not been assessed in an applied setting. This study compared the prevalence estimates of smoking and binge drinking obtained from a telephone survey (N = 1,492) with an in-person survey (N = 2,802) which were conducted by the state of Michigan during 1982-1983. Although the standard errors for the differences in the estimates for the two surveys were relatively large, the actual differences were consistently small within most age-, sex-, and education-specific groups. Despite certain limitations, telephone surveys provide a reasonable alternative to in-person surveys for estimating the prevalence of health behaviors. The data obtained from these surveys are being used to set state health objectives, to plan state-wide health promotion programs, and to support public health legislation.

Integrative cases for preclinical medical students: connecting clinical, basic science, and public health approaches

BACKGROUND

Healthcare and public health systems are each transforming, resulting in a need for better integration between clinical and population-based approaches to improve the health of populations. These changes also demand substantial transformations in the curriculum for medical students. Integrative Cases were designed for all first- and second-year medical students to provide them with more awareness, knowledge, and skills in integrating public health into clinical medicine. Each case examines basic science factors, clinical approaches, and public health determinants, including risk factors and direct and indirect contributing factors.

PURPOSE

This study was designed to evaluate the effectiveness of Integrative Cases in the medical student curriculum.

METHODS

Integrative Cases were formatively evaluated using standardized online post-event questionnaires emailed to students after each case. The questionnaires focused on goals specific to each case, ratings of particular sessions and facilitators, general impressions of the case, and student suggestions for improvement.

RESULTS

Student evaluations indicate that Integrative Cases achieved their goals, especially providing experiences that offer a more expansive view of medicine and public health, stimulating interest and questions that anticipate future learning and making connections across basic science, medicine, and health. Students also indicated that these cases added to their understanding of public health issues and how to apply what they had learned to patient care.

CONCLUSIONS

Integrative Cases demonstrate the effectiveness of a comprehensive approach that integrates clinical medicine with basic science and public health perspectives.

An observational study of the secondary effects of a local smoke-free ordinance

INTRODUCTION

The secondary, sometimes unintended effects of smoke-free ordinances have not been thoroughly evaluated. In this observational study, we evaluated the association of a local ordinance implemented in Madison, Wisconsin, with changes in public disturbances; smoking, drinking, and bar-going behaviors in the general population; and smoking and drinking behaviors among university students.

METHODS

We obtained data from 4 sources: police records, key informant interviews, a community survey, and an undergraduate survey. Except for interviews, which we conducted postenactment only, we compared measures before and after the ordinance was put into effect.

RESULTS

We found no evidence of association of the ordinance with public disturbances. We found that the ordinance was not associated with changes in smoking rates, drinking rates, or bar-going in the general population, although bar-going decreased among the 16% of the general adult population who smokes (from 84% in 2005 to 70% in 2007, P < .001). Student smoking rates also decreased (from 23% in 2005 to 16% in 2007, P < .001), but student binge drinking did not change.

CONCLUSION

The study adds unique information to the evidence base on the effect of smoke-free policies, finding little evidence of their secondary, unintended effects. With the addition of these results to existing evidence, we conclude that the potential health benefits of smoke-free ordinances outweigh the potential harms from unintended effects.

An analysis of lobbying activity on tobacco issues in the Wisconsin legislature

BACKGROUND

Although public and media attention has focused on the federal role in the regulation of tobacco products, state government remains an important arena for changing tobacco control policies. Lobbying state officials by public health and the tobacco industry is a commonly used mechanism to influence public policy.

METHODS

Major bills of the 2007-2008 and 2009-2010 Wisconsin legislative sessions related to tobacco use regulation were analyzed by the hours engaged in lobbying and the estimated expenditures by supporters and opponents of tobacco control legislation in reports submitted to the Government Accountability Board.

RESULTS

In the 2007-2008 legislative session, anti-tobacco control organizations reported lobbying expenditures of more than $2 million (2627 hours) while opposing bills to raise tobacco excise taxes and enact smoke-free legislation; pro-tobacco control organizations reported lobbying expenditures of $623,000 (3997 hours) while supporting these bills. In the first 6 months of the 2009 session, anti-tobacco control groups spent $1.25 million (1472 hours) and pro-tobacco control groups spent $172,000 (1727 hours).

CONCLUSION

In the 2007-2008 legislative session, the proposal to increase the tobacco tax by $1 per pack was passed. However, the smoke-free indoor air bill was defeated. Anti-tobacco control organizations outspent pro-tobacco control organizations by a margin of over 3:1. In 2009 anti-tobacco control groups outspent health groups by a ratio of 7:1. Legislation for smoke-free workplaces and an increase in the cigarette tax was enacted. However, funding for tobacco prevention and treatment programs was substantially reduced.

The contribution of postmenopausal hormone use cessation to the declining incidence of breast cancer

The striking decline in United States breast cancer incidence since 2002 has been widely attributed to a reduction in postmenopausal hormone use, yet very little analysis has been conducted to quantify the contribution of changes in hormone use to the declining trend. We used literature-based estimates of the relative risk and the changing prevalence of hormone use to estimate the impact of hormone use on the decline in breast cancer incidence between 2002 and 2003 among women aged 40-79. For the base case of a 44% decline in hormone use and a relative risk for current use of 1.5, we estimated that 43% of the decline in incidence was attributable to hormone use. By exploring a range of parameter values, we found that high, unlikely values of the relative risk (i.e., ≥ 2.25) and/or the percent decline in hormone use (i.e., ≥ 75%) would be required to account for 100% of the observed decline in breast cancer incidence. We conclude that hormone use is unlikely to account for more than half of the observed decline in breast cancer incidence between 2002 and 2003. Further efforts are needed to quantify the potential contributions of other factors, such as the plateau in screening mammography utilization.

Socioeconomic status and survival after an invasive breast cancer diagnosis

BACKGROUND

Women who live in geographic areas with high poverty rates and low levels of education experience poorer survival after a breast cancer diagnosis than women who live in communities with indicators of high socioeconomic status (SES). However, very few studies have examined individual-level SES in relation to breast cancer survival or have assessed the contextual role of community-level SES independent of individual-level SES.

METHODS

The authors of this report examined both individual-level and community-level SES in relation to breast cancer survival in a population-based cohort of women ages 20 to 69 years who were diagnosed with breast cancer in Wisconsin between 1995 and 2003 (N = 5820).

RESULTS

Compared with college graduates, women who had no education beyond high school were 1.39 times more likely (95% confidence interval [CI], 1.10-1.76) to die from breast cancer. Women who had household incomes <2.5 times the poverty level were 1.46 times more likely (95% CI, 1.10-1.92) to die from breast cancer than women who had household incomes ≥5 times the poverty level. Adjusting the analysis for use of screening mammography, disease stage at diagnosis, and lifestyle factors eliminated the disparity by income, but the disparity by education persisted (hazard ratio [HR], 1.27; 95% CI, 0.99-1.61). In multilevel analyses, low community-level education was associated with increased breast cancer mortality even after adjusting for individual-level SES (HR, 1.57; 95% CI, 1.09-2.27 for ≥20% vs <10% of adults without a high school degree).

CONCLUSIONS

The current results indicated that screening and early detection explain some of the disparity according to SES, but further research will be needed to understand the additional ways in which individual-level and community-level education are associated with survival.