Context Monitoring trends is essential for evaluating past activities and guiding
current preventive health program and policy efforts. Although tracking progress
toward national health goals is helpful, use of national estimates is limited
because most preventive health care activities, policies, and other efforts
occur at the state or community level. There may be important state trends
that are obscured by national data.
Objective To estimate state-specific trends for 5 health risk factors and 6 clinical
preventive services.
Design Telephone surveys were conducted from 1991 through 2000 as part of the
Behavioral Risk Factor Surveillance System.
Setting and Participants Randomly selected adults aged 18 years or older from 49 US states. Annual
state sample sizes ranged from 1188 to 7543.
Main Outcome Measures Statistically significant changes (P<.01)
in state prevalences of cigarette smoking, binge alcohol use, physical inactivity,
obesity, safety belt use, and mammography; screening for cervical cancer,
colorectal cancer, and cholesterol levels; and receipt of influenza and pneumococcal
disease vaccination.
Results There were statistically significant increases in safety belt use for
39 of 47 states and receipt of mammography in the past 2 years for women aged
40 years or older for 43 of 47 states. For persons aged 65 years or older,
there were increases in receipt of influenza vaccination for 44 of 49 states
and ever receiving pneumococcal vaccination for 48 of 49 states. State trends
were mixed for binge alcohol use (increasing in 19 of 47 states and declining
in 3), physical inactivity (increasing in 3 of 48 states and declining in
11), and cholesterol screening (increasing in 13 of 47 states and decreasing
in 5). Obesity increased in all states and smoking increased in 14 of 47 states
(declining only in Minnesota). Cervical cancer screening increased in 8 of
48 states and colorectal cancer screening increased in 13 of 49 states. New
York experienced improvements for 8 of 11 measures, while 7 of 11 measures
improved in Delaware, Kentucky, and Maryland; in contrast, Alaska experienced
improvements for no measures and at least 4 of 11 measures worsened in Iowa,
North Dakota, and South Dakota.
Conclusions Most states experienced increases in safety belt use, mammography, and
adult vaccinations. Trends for smoking and binge alcohol use are disturbing,
and obesity data support previous findings. Trend data are useful for targeting
state preventive health efforts.
It is well established that premature mortality can be reduced through
changes in health risk factors and timely receipt of clinical preventive services.
For instance, there is a strong scientific consensus that tobacco use, excessive
alcohol use, physical inactivity, obesity, and failure to use safety belts
increase mortality risk1-6
and that timely receipt of adult immunizations, screening for breast and cervical
cancer, and screening for high blood cholesterol levels can reduce the risk
of premature death.7-11
Population-based monitoring of progress toward health goals is a critical
part of the assessment function of public health and a key role for health
agencies.12 At the national level, monitoring
of health trends is well established through the Healthy People initiative
that began in 1980.13-15
Such information is essential for guiding current and future efforts to improve
health. State improvements in preventive health depend on many factors, including
socioeconomic status and other variables (eg, employment status, income level,
and insurance status), state and local programs and policies, clinical standards
of care, and the presence of consumers who are informed about prevention and
health care services.
Although tracking progress toward national health goals is helpful,
the use of national estimates is limited because most preventive health care
activities, policies, and other efforts occur at the state or community level.
Important state trends may exist that are obscured by national data.16,17 State mortality rates vary widely,18 as do the prevalence of health risk factors and receipt
of clinical preventive services19; state mortality
rates are known to correlate strongly with state risk factor estimates for
certain measures, such as coronary heart disease20
and lung cancer (Suzanne Proctor, MSPH, written communication, National Center
for Health Statistics, June 25, 2001).
A few studies have examined state-specific trends for health risk factors
and receipt of clinical preventive services during part of the 1990s,17,21-26
but they focused on trends for specific measures (eg, obesity and mammography
screening) rather than on a more comprehensive examination of multiple measures.
These studies used different methods and years and did not account for the
role of changes in demographics, thus limiting their usefulness. The purpose
of this study was to provide a comprehensive overview of state trends during
the 1990s, using a standard statistical approach, for 5 adult health risk
factors and 6 clinical preventive services that are known to have a substantial
impact on preventable morbidity and mortality in the United States. The trends
we examined include cigarette smoking, binge alcohol use, physical inactivity,
obesity, and safety belt use, as well as receipt of mammography, cervical
cancer screening, colorectal cancer screening, cholesterol screening, and
vaccination for influenza and for pneumococcal disease.
Data used in this study came from the Behavioral Risk Factor Surveillance
System (BRFSS) from 1991 through 2000. Details of the BRFSS have been published
elsewhere.27-29
The BRFSS is a state-based system of health surveys coordinated by the Centers
for Disease Control and Prevention. Begun in 15 states in 1984, by 1994 all
states were participating in the BRFSS. Data are obtained monthly by state
health departments through telephone surveys of randomly selected persons
aged 18 years or older.
The system obtains self-reported information primarily on health risk
factors related to chronic disease and injury, including health risk behaviors,
receipt of clinical preventive services, and health care access. In most states,
the BRFSS is the sole source for these data. Results from 30 methodological
studies suggest that most measures included in the BRFSS are both reliable
and valid.30
For the study period from 1991 through 2000, the total sample size increased
from 87 846 to 182 444 and the median state sample size increased
from 1790 to 3338. Annual state sample sizes ranged from 1188 to 7543. Median
annual response rates, based on persons actually reached by telephone, ranged
from 84.1% in 1991 to 59.6% in 2000.
A change in the survey design in 1993 resulted in data collection at
different intervals for certain topics. In all years, questions were asked
on cigarette smoking, obesity, mammography, and cervical cancer screening
(Papanicolaou test); in odd-numbered years for alcohol use, safety belt use,
colorectal cancer screening, cholesterol screening, pneumococcal vaccination,
and influenza vaccination; and in even-numbered years for physical inactivity
(Table 1). Because of variation
in the year in which states began to participate in the BRFSS and because
of missing data for certain years, trend data are only available for selected
measures for Arizona, Arkansas, Kansas, and Nevada and are not available for
the District of Columbia and Wyoming.
To provide stable estimates of state trends, analyses were restricted
to topics that were included on the survey by 1993 and for which data were
collected for 4 or more years. Data on safety belt use were collected only
through 1997. The questions used to define receipt of a Papanicolaou test
changed in 1992; thus, analyses for these questions were restricted to 1992
through 2000.
Definitions for the 5 health risk factors and the 6 clinical preventive
services are listed in Table 1.
We used definitions that are consistent with those used to measure national
Healthy People 2000 objectives14,15,31,32
or that are commonly used within the respective subject areas.
Except for cigarette smoking, mammography, and colorectal cancer screening,
the wording of survey questions was highly consistent across all years for
all measures. In 1996, a question that was used to define current cigarette
smoking was changed to make BRFSS questions comparable with other major national
surveys (Table 1). Based on data
from the National Health Interview Survey, this change increased the estimate
of smoking prevalence by about 1 percentage point.33
Because of this question's change, we adjusted model-based prevalence estimates
downward by 1 percentage point for the year 2000.
The introductory sentence to the mammography screening question was
altered slightly in 1992 to describe a mammogram as a radiograph that involves
pressing the breast between 2 plastic plates. This change resulted in a slight
decrease in the prevalence of mammography use,34
but we did not adjust our data because the wording change occurred only in
1 year and the overall effects were minor. Because of changes in screening
recommendations, the colorectal cancer screening question referred to proctoscopy
in 1993 and 1995, proctoscopy or sigmoidoscopy in 1997, and sigmoidoscopy
or colonoscopy in 1999. We were unable to examine trends for fecal occult
blood testing, another method used for colorectal cancer screening, because
these questions were not included until 1997.
To estimate alcohol use, we examined state trends in binge drinking,
which was defined as consumption of 5 or more alcoholic beverages on 1 or
more occasions in the past 30 days. Binge drinking is strongly associated
with many health risk behaviors and adverse outcomes, including alcohol-impaired
driving, unprotected sexual activity, and acute alcohol poisoning.2,35
There is no consensus on the most appropriate survey questions for assessing
moderate or vigorous physical activity.36 Because
of this lack of consensus, we chose to examine trends in physical inactivity,
which we defined as participating in no leisure-time physical activity in
the past 30 days. Using guidelines from the World Health Organization,37 we defined obesity as having a body mass index of
at least 30 kg/m2. Safety belt use was defined as always using
a safety belt because this definition produces estimates similar to those
obtained from observational surveys.38,39
Recommendations differ on the optimal age for beginning routine breast
cancer screening.40 In this study, we examined
trends in receipt of mammography in the past 2 years for women aged 40 years
or older. For receipt of cervical cancer screening within the past 3 years,
analyses were restricted to women aged 18 years or older with an intact uterus.
Cholesterol screening was defined as receipt of a blood cholesterol test within
the past 5 years among persons aged 18 years or older.32
For receipt of influenza vaccination in the past year and ever receiving a
pneumococcal vaccination, analyses were restricted to persons aged 65 years
or older.31,32
Because all 11 of the outcomes we modeled were prevalences, we used
logit models to evaluate state trends. Using logit models allowed us to evaluate
trends while controlling for the effects age, sex, race/ethnicity, and education
level have on the various outcomes. Thus, the unit of analysis in all models
was the individual survey respondent. Respondents' answers were used to define
dichotomous outcome variables. The independent variables in the models were
year, age, sex, race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic,
or other), and education level (less than high school graduate, high school
graduate, and some college/college graduate). SUDAAN was used to take into
account the complex survey design in the modeling.41
To determine the appropriateness of a linear trend,
we added year2 (a quadratic term) to the models and examined its P value, setting the significance level at P<.01
because of the large sample sizes and the number of states. If the P value for the quadratic term was not less than .01, we assumed the
trend was linear. Of the 525 total state trends examined, a total of 458 (87%)
met our assumption of linearity. For these models, we removed the quadratic
term, refit the models, and used the estimated β coefficients for year
to calculate odds ratios (ORs). These ORs reflect the average annual change
per year (or per 2 years) in overall state odds estimates for each outcome,
controlling for the effects of demographic changes on each outcome. Odds ratios
with 99% confidence intervals (CIs) that excluded the null value of 1 were
considered statistically significant. β Coefficients with P<.01 were considered statistically significant.
For the 67 trends (13%) that violated the linearity assumption, we treated
year as a categorical variable and used the contrast between the estimate
available from the last year of the decade with the estimate from the first
year of the decade. The β value for the contrast was used to calculate
an OR that compared the overall odds estimate from the last year with the
overall odds estimate from the first year of the decade. These ORs represent
the average change across the entire decade using the first and last data
points available, controlling for the effects of demographic changes on each
outcome. β Coefficients with P<.01 were considered
statistically significant.
Finally, we used our models to determine the predicted prevalence at
the start and end of the decade for each measure in each state. Estimates
were indirectly standardized to the age, sex, race/ethnicity, and education
level of a typical person based on the pooled annual BRFSS sample population
from all states.41,42 Although
these model-based values are not the actual prevalence estimates, they allow
for appropriate comparisons across states over time and are similar to published
state estimates.30
State trends during the 1990s for the 5 health risk factor measures
are summarized in Table 2. Median
state estimates showed a substantial increase in both obesity and safety belt
use and a slight increase in binge alcohol use, and were essentially unchanged
for physical inactivity and cigarette smoking.
Smoking prevalence decreased significantly only in Minnesota; in contrast,
it was unchanged in 32 states and increased in 14 states primarily located
in the Midwest (7 states) and South (4 states). Binge alcohol use declined
in Arizona, Minnesota, and Pennsylvania, remained unchanged in 25 states,
and increased in 19 states. Increases were concentrated primarily in the South
(8 states) and Midwest (6 states), although baseline prevalence estimates
were generally low in southern states. The prevalence of physical inactivity
decreased in 11 states, increased in 3 states (Arizona, Minnesota, and Montana),
and was unchanged in 34 states; about half the states registering declines
were in the South. The prevalence of obesity increased in all states, and
safety belt use increased in 39 of 47 states.
The pattern for receipt of clinical preventive services was different
from that for health risk factors (Table
3). Median state estimates increased substantially for mammography,
influenza immunization, and pneumococcal immunization, as most states experienced
increases for these measures. In contrast, median estimates increased only
slightly for colorectal cancer, cervical cancer, and cholesterol screening.
Receipt of mammography for women aged 40 years or older in the prior 2 years
increased significantly in 43 of 47 states (all except Alaska, Colorado, Minnesota,
and Washington). Receipt of cervical cancer screening increased in 8 of 48
states, all of which were in the Northeast or South (Connecticut, Delaware,
Kentucky, Maryland, Massachusetts, New York, Pennsylvania, and Rhode Island).
The use of colorectal cancer screening increased in 13 of 49 states,
with 11 of these states in the Northeast or South. Trends in the receipt of
cholesterol screening demonstrated a mixed picture, as increases occurred
in 13 of 47 states (11 of which were in the South), but declines in screening
occurred in Iowa, Minnesota, North Dakota, South Dakota, and Washington state.
The trend in the increased use of vaccinations among persons aged 65 years
or older was almost nationwide. Increases in the receipt of influenza vaccination
in the past year occurred in 44 of 49 states, and the percentage of the older
population who had ever received pneumococcal vaccination increased in 48
of 49 states.
With the exception of Minnesota, state trends in cigarette smoking during
the 1990s were discouraging. After adjusting for changes in demographics,
nearly 30% of states experienced an increase in smoking during this period,
with half of these states located in the Midwest. Only Utah achieved the Healthy
People 2000 goal for adult smoking prevalence of 15%,14
but this state had already attained this goal before the start of the decade.
Reasons for the decline in smoking in Minnesota are unclear from these data,
and there were few state or local tobacco control policies implemented in
this state during the 1990s.43,44
The lack of a reduction in smoking in nearly all states indicates the continued
need for major tobacco prevention and control efforts, such as increasing
excise taxes and smoking cessation activities,45
because cigarette smoking remains the leading cause of preventable death in
the United States.6
State trends in binge alcohol use during the 1990s were disturbing.
Although per capita consumption of alcohol-containing beverages decreased
from 1991 through 1998 in most states,46 national
alcohol survey data suggest that binge alcohol use leveled off between 1990
and 1995 after decreasing in earlier years.47
Reasons for the increase in binge drinking in 19 states, and for the decline
of such drinking in Arizona and Pennsylvania,48
are unknown. Minnesota's decrease in binge drinking during the 1990s may have
resulted from that state's extensive educational and policy efforts directed
toward reducing drinking and driving, fetal alcohol exposure, and adolescent
drinking.49-51
Physical inactivity decreased in 11 states. The reasons for this improvement
are unclear but may have resulted from state and local health promotion programs
designed to improve cardiovascular health. In contrast, physical inactivity
prevalence increased or was unchanged in 37 states. For obesity, all states
experienced a significant increase from 1991 through 2000, confirming findings
from previous studies on the growing nationwide epidemic of obesity.24,52-55
Multiple approaches for increasing physical activity and reducing obesity
are needed, including educational programs, policies, and environmental interventions
to increase physical activity and improve dietary patterns.3,24
Although data were available only through 1997, adult safety belt use
increased in most states. Even among some states that showed no improvement
(ie, Hawaii, Maryland, New Jersey, and Virginia), safety belt use was already
high in 1991 and remained so during the study period. By the end of 1997,
California, Hawaii, North Carolina, New Mexico, and Oregon had achieved the
Healthy People 2000 goal of 85% for safety belt use.14
The extensive enactment of safety belt laws during the 1980s and 1990s and
changing societal norms about safety belt use have probably been the major
contributors to the increase in safety belt use.56
Despite the increases, enhanced efforts to improve safety belt use are still
warranted in most states.
Receipt of Clinical Preventive Services
State trends of increasing mammography screening among women aged 40
years or older are very encouraging and confirm findings from earlier studies.22,57-59 Educational
campaigns directed toward health care practitioners and the general public,
state mandates for insurance coverage of mammograms, and programs for providing
mammography services to low-income women have all played a role in increasing
breast cancer screening in nearly all states.22
Efforts to increase mammography are needed in Alaska, Colorado, Minnesota,
and Washington.
State trends in cervical cancer screening are difficult to interpret.
Median estimates were high in 1991 and increased only slightly by 2000; however,
most states reached the Healthy People 2000 goal of 85% for receipt of a Papanicolaou
test in the prior 3 years.14 The situation
is further complicated because during the 1990s, various organizations issued
differing recommendations on frequency and age groups for cervical cancer
screening.22,60,61
More research is needed to delineate state-specific trends among subpopulations
of women to ascertain whether changes in screening are occurring among women
who are at different risks for developing cervical cancer.
Colorectal cancer screening, defined as receipt of proctoscopy, sigmoidoscopy,
or colonoscopy among persons aged 50 years or older, increased in 13 states
during the 1990s. Despite these improvements, fewer than half of persons in
this age group in all states received this type of screening in 1999. Unfortunately,
trend data on receipt of fecal occult blood testing, another means of screening
for colorectal cancer, are not available, as these questions were not included
on the BRFSS until 1997. Data from 1997 and 1999 indicate that about 20% of
adults aged 50 years or older reported undergoing fecal occult blood testing
in the past year.26,62 Because
colorectal cancer is the second leading cause of cancer-related deaths in
the United States,63 increased efforts directed
toward the public and health care practitioners are needed to increase the
use of colorectal cancer screening.
Cholesterol screening trends among states were variable. Although receipt
of screening increased in 13 states, the nationwide median for all states
increased only modestly. Decreases in the receipt of screening in Iowa, Minnesota,
North Dakota, South Dakota, and Washington are of special concern. Because
heart disease is the leading cause of death in the United States and because
high blood cholesterol levels increase the risk for this disease, major efforts
are needed to improve cholesterol screening and lower cholesterol levels.23
State trends in adult vaccination were highly encouraging. Forty-eight
of 49 states met the Healthy People 2000 goal of 60% for influenza vaccination,
although only 8 of 49 states reached the goal of 60% for pneumococcal vaccination.14 (Data are not available from the BRFSS to ascertain
influenza or pneumococcal disease vaccination among persons with selected
chronic conditions that warrant receipt of these vaccines.) Reasons for these
increases probably include a greater acceptance of using preventive medical
services by practitioners and consumers, increased delivery and administration
of vaccines from multiple sources, and Medicare reimbursement for vaccination.25
Summary of State Progress in Preventive Health
While examining state trends for specific health risk factors and clinical
preventive service measures is important, it is also useful to consider state
trends across the entire spectrum of measures. New York showed the greatest
positive change during the 1990s, with improvements in 8 measures. Delaware,
Kentucky, and Maryland improved in 7 measures, but these increases were tempered
somewhat by increases in binge alcohol use in Delaware and Maryland and in
smoking in Kentucky. In contrast, Alaska had statistically significant improvements
for no measures, North and South Dakota had 4 measures that improved and 4
that worsened, and Iowa had 5 measures that improved and 4 that worsened.
Reasons for the state-to-state differences in trends across all 11 measures
cannot be ascertained from these data. Contributing factors may include changes
and differences in states' economies, health or other policies, migration
patterns, socioeconomic status, educational or mass media efforts, social
norms, and health-related activities by voluntary, professional, and private
organizations.
This study has several limitations. First, we relied on self-reports.
Depending on the measure, self-reports can result in overestimates or underestimates
compared with other data sources, such as health care records, physiological
measures, or biochemical verification. Social desirability64
can lead to reporting of behavior in a more favorable light, probably resulting
in underestimates of obesity, binge drinking, and smoking. Social desirability,64 unfamiliarity with medical terms, and telescoping65 (recalling that events occurred more recently than
they actually occurred) can affect the validity of self-reported data on clinical
preventive services and probably result in overestimates.66,67
For example, self-reports overestimate prevalence of receipt of mammography67 and underestimate prevalence of obesity.68 The effects of social desirability, unfamiliarity
with medical terms, and telescoping on state trends during the 1990s is unknown.
As mentioned previously, there were wording changes to questions on
smoking, mammography, and colorectal cancer screening; adjustments were made
only for smoking. The impact of these wording changes on trends is unclear,
although any effect would be consistent across states. The effect of the 1992
wording change for mammography occurred only for 1 year and probably had little
effect.
The most substantial changes in question wording occurred for colorectal
cancer screening, and this question applied to different examinations across
the study period. How well the average adult can distinguish between terms
used to describe different medical instruments for examining the colon is
unknown. Thus, trends in receipt of colorectal cancer screening should be
interpreted cautiously, although as with other measures, the effects of wording
changes on trends should be consistent across states.
Households without telephones were excluded, which probably resulted
in slight underestimates of risk factors and overestimates of receipt of clinical
preventive services for most measures.69 Typical
of other telephone surveys conducted during the 1990s,70
response rates declined for nearly all states. Weighting procedures used in
the BRFSS partially adjust for nonresponse; however, the effect of declines
in response rates on trends is not known.
Because of different baseline values, states with high estimates early
in the decade were unlikely to experience increases to the same extent as
states with lower estimates (similarly, states with low estimates were unlikely
to experience declines to the same extent as those with higher initial estimates).
This finding was evident in states with high initial values for safety belt
use and receipt of cervical cancer screening. States had different sample
sizes, and some measures were applicable only to subpopulations with smaller
numbers of respondents (eg, vaccination among persons aged ≥65 years and
mammography among women aged ≥40 years). States with consistently larger
sample sizes in general were probably more likely to have statistically significant
differences compared with states with smaller sample sizes. This may, for
example, partially explain the lack of significant changes found for most
measures in Alaska, which was a state with smaller sample sizes in many years.
The numbers of years with data and, consequently, the number of data
points per measure differed (eg, 10 data points for mammography and 4 for
colorectal cancer screening). The effect of differing numbers of data points
on our results is not clear; however, for some measures, the assumption of
linearity was based on a limited number of data points. Finally, because of
the lack of linearity of data for 67 models, we used a different approach
for our regression analyses that relied only on data from the first and last
years. Thus, in these analyses, we were only able to compare estimates from
the beginning and end of the decade but could not examine trends over the
entire decade.
State monitoring of preventive health measures is an invaluable role
for public health,12 especially given the heterogeneity
of state trends. One of the most important purposes of the Healthy People
2000 and 2010 initiatives was to create health goals to be used throughout
the nation14,15 and not merely
as part of an exercise in federal data collection and reporting. The BRFSS
is, in turn, an invaluable data source for monitoring states' progress towards
reaching national objectives related to health risk factors and the receipt
of clinical preventive services.
This study demonstrates a mixed picture of state progress in adult preventive
health during the 1990s. With the exception of safety belt use, there was
limited progress in improving health risk factors. The trends in smoking,
obesity, and binge alcohol use are especially worrisome and will require strong
efforts to reduce the extent of these problems. Progress in increasing the
use of clinical preventive services has been substantial, especially for the
receipt of mammography and for influenza and pneumococcal vaccination. Our
findings suggest that increased efforts are especially needed to increase
the use of colorectal cancer and cholesterol screening.
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