County-Level Geographic Disparities in Disabilities Among US Adults, 2018.

INTRODUCTION: Local data are increasingly needed for public health practice. County-level data on disabilities can be a valuable complement to existing estimates of disabilities. The objective of this study was to describe the county-level prevalence of disabilities among US adults and identify geographic clusters of counties with a higher or lower prevalence of disabilities. METHODS: We applied a multilevel logistic regression and poststratification approach to geocoded 2018 Behavioral Risk Factor Surveillance System data, Census 2018 county-level population estimates, and American Community Survey 2014-2018 poverty estimates to generate county-level estimates for 6 functional disabilities and any disability type. We used cluster-outlier spatial statistical methods to identify clustered counties. RESULTS: Among 3,142 counties, median estimated prevalence was 29.5% for any disability and differed by type: hearing (8.0%), vision (4.9%), cognition (11.5%), mobility (14.9%), self-care (3.7%), and independent living (7.2%). The spatial autocorrelation statistic, Moran's I, was 0.70 for any disability and 0.60 or greater for all 6 types of disability, indicating that disabilities were highly clustered at the county level. We observed similar spatial cluster patterns in all disability types except hearing disability. CONCLUSION: The results suggest substantial differences in disability prevalence across US counties. These data, heretofore unavailable from a health survey, may help with planning programs at the county level to improve the quality of life for people with disabilities.

Health Care Access and Use Among Adults With and Without Vision Impairment: Behavioral Risk Factor Surveillance System, 2018.

INTRODUCTION: Adults with vision impairment may have unique needs when accessing health care to maintain good health. Our study examined the relationship between vision status and access to and use of health care. METHODS: We analyzed data on adults aged 18 years or older who participated in the 2018 Behavioral Risk Factor Surveillance System. Vision impairment was identified by a yes response to the question "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" Survey questions assessed health care access over the past year (having health insurance coverage, a usual health care provider, or unmet health care needs because of cost) and use of health care during that period (routine checkup and dental visit). We estimated age-adjusted prevalence of our outcomes of interest and used bivariate analyses to compare estimates of the outcomes by vision impairment status. RESULTS: The prevalence of self-reported vision impairment was 5.3%. Compared with adults without impaired vision, adults with vision impairment had a lower prevalence of having health insurance coverage (80.6% vs 87.6%), a usual health care provider (71.9% vs 75.7%), or a dental visit in the past year (52.9% vs 67.2%) and a higher prevalence of having an unmet health care need in the past year because of cost (29.2% vs 12.6%). CONCLUSION: Adults with vision impairment reported lower access to and use of health care than those without. Further research can better identify and understand barriers to care to improve access to and use of health care among this population.

Association Between Self-Reported Disability and Lifetime History of Traumatic Brain Injury With Loss of Consciousness Among Veterans and Nonveterans in North Carolina.

BACKGROUND: Compared with civilians, service members and veterans who have a history of traumatic brain injury (TBI) are more likely to experience poorer physical and mental health. To investigate this further, this article examines the association between self-reported history of TBI with loss of consciousness and living with 1 or more current disabilities (ie, serious difficulty with hearing, vision, cognition, or mobility; any difficulty with self-care or independent living) for both veterans and nonveterans. METHODS: A cross-sectional study using data from the North Carolina Behavioral Risk Factor Surveillance System for 4733 veterans and nonveterans aged 18 years and older. RESULTS: Approximately 34.7% of veterans residing in North Carolina reported having a lifetime history of TBI compared with 23.6% of nonveterans. Veterans reporting a lifetime history of TBI had a 1.4 times greater risk of also reporting living with a current disability (adjusted prevalence ratio = 1.4; 95% confidence interval, 1.2-1.8) compared with nonveterans. The most common types of disabilities reported were mobility, cognitive, and hearing. CONCLUSIONS: Compared with nonveterans, veterans who reported a lifetime history of TBI had an increased risk of reporting a current disability. Future studies, such as longitudinal studies, may further explore this to inform the development of interventions.

Prevalence of Arthritis and Arthritis-Attributable Activity Limitation - United States, 2016-2018.

Arthritis has been the most frequently reported main cause of disability among U.S. adults for >15 years (1), was responsible for >$300 billion in arthritis-attributable direct and indirect annual costs in the U.S. during 2013 (2), is linked to disproportionately high levels of anxiety and depression (3), and is projected to increase 49% in prevalence from 2010-2012 to 2040 (4). To update national prevalence estimates for arthritis and arthritis-attributable activity limitation (AAAL) among U.S. adults, CDC analyzed combined National Health Interview Survey (NHIS) data from 2016-2018. An estimated 58.5 million adults aged ≥18 years (23.7%) reported arthritis; 25.7 million (10.4% overall; 43.9% among those with arthritis) reported AAAL. Prevalence of both arthritis and AAAL was highest among adults with physical limitations, few economic opportunities, and poor overall health. Arthritis was reported by more than one half of respondents aged ≥65 years (50.4%), adults who were unable to work or disabled* (52.3%), or adults with fair/poor self-rated health (51.2%), joint symptoms in the past 30 days (52.2%), activities of daily living (ADL)† disability (54.8%), or instrumental activities of daily living (IADL)§ disability (55.9%). More widespread dissemination of existing, evidence-based, community-delivered interventions, along with clinical coordination and attention to social determinants of health (e.g., improved social, economic, and mental health opportunities), can help reduce widespread arthritis prevalence and its adverse effects.

Indicators of poor mental health and stressors during the COVID-19 pandemic, by disability status: A cross-sectional analysis.

BACKGROUND: Evidence from previous public health emergencies indicates that adults with disabilities have higher risk for morbidity (physical and mental) and mortality than adults without disabilities. OBJECTIVE: To provide estimates of mental health indicators and stressors for US adults by disability status during April and May 2020, shortly following the emergence of the COVID-19 pandemic. METHODS: We analyzed data from Porter Novelli View 360 opt-in Internet panel survey conducted during the weeks of April 20th and May 18th, 2020 among 1004 English-speaking adults aged ≥18 years without and with disabilities (serious difficulty with hearing, vision, cognition, or mobility; any difficulty with self-care or independent living). Weighted logistic regression was used to test for significant differences between calculated prevalence estimates at the P ≤ .05 level. RESULTS: One in four adults reported any disability. Adults with any disability were significantly more likely than adults without disability to report current depressive symptoms, frequent mental distress, suicidal ideation, and COVID-19-related initiated or increased substance use (all p values < .0001). Adults with disabilities also reported significantly higher levels of stressors, such as access to health care services (p < .0001), difficulty caring for their own (or another's) chronic condition (p < .0001), emotional or physical abuse from others (p < .001), and not having enough food (p < .01). CONCLUSIONS: The disproportionately high levels of poor mental health indicators among adults with disabilities as compared to those without highlight the importance of delivering timely mental health screening and treatment/intervention during and after the COVID-19 pandemic to persons with disabilities.

Racial and Ethnic Disparities in the Prevalence of Stress and Worry, Mental Health Conditions, and Increased Substance Use Among Adults During the COVID-19 Pandemic - United States, April and May 2020.

In 2019, approximately 51 million U.S. adults aged ≥18 years reported any mental illness,* and 7.7% reported a past-year substance use disorder† (1). Although reported prevalence estimates of certain mental disorders, substance use, or substance use disorders are not generally higher among racial and ethnic minority groups, persons in these groups are often less likely to receive treatment services (1). Persistent systemic social inequities and discrimination related to living conditions and work environments, which contribute to disparities in underlying medical conditions, can further compound health problems faced by members of racial and ethnic minority groups during the coronavirus disease 2019 (COVID-19) pandemic and worsen stress and associated mental health concerns (2,3). In April and May 2020, opt-in Internet panel surveys of English-speaking U.S. adults aged ≥18 years were conducted to assess the prevalence of self-reported mental health conditions and initiation of or increases in substance use to cope with stress, psychosocial stressors, and social determinants of health. Combined prevalence estimates of current depression, initiating or increasing substance use, and suicidal thoughts/ideation were 28.6%, 18.2%, and 8.4%, respectively. Hispanic/Latino (Hispanic) adults reported a higher prevalence of psychosocial stress related to not having enough food or stable housing than did adults in other racial and ethnic groups. These estimates highlight the importance of population-level and tailored interventions for mental health promotion and mental illness prevention, substance use prevention, screening and treatment services, and increased provision of resources to address social determinants of health. How Right Now (Qué Hacer Ahora) is an evidence-based and culturally appropriate communications campaign designed to promote and strengthen the emotional well-being and resiliency of populations adversely affected by COVID-19-related stress, grief, and loss (4).

Frequent Mental Distress Among Adults, by Disability Status, Disability Type, and Selected Characteristics - United States, 2018.

Frequent mental distress, defined as 14 or more self-reported mentally unhealthy days in the past 30 days,* is associated with adverse health behaviors, increased use of health services, mental disorders (e.g., diagnosis of major depressive disorder), chronic diseases, and functional limitations (1). Adults with disabilities more often report depression and anxiety (2), reduced health care access (3), and health-related risk behaviors (4) than do adults without disabilities. CDC analyzed 2018 Behavioral Risk Factor Surveillance System (BRFSS) data to compare the prevalence of frequent mental distress among adults with disabilities with that among adults without disabilities and to identify factors associated with mental distress among those with disabilities. Nationwide, an estimated 17.4 million adults with disabilities reported frequent mental distress; the prevalence of reported mental distress among those with disabilities (32.9%) was 4.6 times that of those without disabilities (7.2%). Among adults with disabilities, those with both cognitive and mobility disabilities most frequently reported mental distress (55.6%). Adults with disabilities who reported adverse health-related characteristics (e.g., cigarette smoking, physical inactivity, insufficient sleep, obesity, or depressive disorders) or an unmet health care need because of cost also reported experiencing more mental distress than did those with disabilities who did not have these characteristics. Adults living below the federal poverty level reported mental distress 70% more often than did adults in higher income households. Among states, age-adjusted prevalence of mental distress among adults with disabilities ranged from 25.2% (Alaska) to 42.9% (New Hampshire). Understanding the prevalence of mental distress among adults with disabilities could help health care providers, public health professionals, and policy makers target interventions and inform programs and policies to ensure receipt of mental health screening, care, and support services to reduce mental distress among adults with disabilities.

Comparisons of Estimates From the Behavioral Risk Factor Surveillance System and Other National Health Surveys, 2011-2016.

INTRODUCTION: The Behavioral Risk Factor Surveillance System (BRFSS) is composed of telephone surveys that collect state data from non-institutionalized U.S. adults regarding health-related risk behaviors and chronic health conditions. A new design was implemented in 2011 to include participants on cellular telephones. It is important to validate estimates since 2011. METHODS: A total of 10 key and widely used variables between BRFSS and the National Health and Nutrition Examination Survey (NHANES) or National Health Interview Survey (NHIS) in 2011-2016 were compared. Data analysis was conducted in 2018. RESULTS: Between BRFSS and NHANES, similar linear time trends of prevalences or means were found for 8 of 9 studied variables. There were no significant differences in the prevalences of the following variables: self-reported fair/poor health, ever told have diabetes, and ever told to have hypertension. In trend comparison of BRFSS versus NHIS, interactions of prevalence between survey and time period were not found for 5 variables: current smoking, self-reported fair/poor health, ever told have diabetes, and self-reported height and weight. Although there were significant differences in many estimates between BRFSS and either NHANES or NHIS, the absolute differences across years were rather small. CONCLUSIONS: Comparing BRFSS time trends with those of 2 national benchmark surveys in 10 key and widely used variables suggests that the trends of prevalences (or means) from BRFSS, NHANES, and NHIS are mostly similar. For many variables, despite statistically significant differences in the prevalences (or means) between surveys, absolute differences in most cases were small and not meaningful from a public health surveillance perspective.

Screening for Alcohol Use and Brief Counseling of Adults - 13 States and the District of Columbia, 2017.

Binge drinking* is a leading preventable public health problem. From 2006 to 2010, binge drinking contributed to approximately 49,000 annual deaths resulting from acute conditions (e.g., injuries and violence) (1). Binge drinking also increases the risk for adverse health conditions, including some chronic diseases (e.g., breast cancer) and fetal alcohol spectrum disorders (2). In 2004, 2013, and again in 2018, for all U.S. adults aged ≥18 years in primary care, the U.S. Preventive Services Task Force (USPSTF) recommended alcohol screening and brief intervention (alcohol SBI) or counseling for persons whose screening indicated drinking in excess of recommended limits or in ways that increase risk for poor health outcomes (3-5). However, previous CDC surveillance data indicate that patients report rarely talking to their provider about alcohol use,† and alcohol SBI is traditionally delivered through conversation. CDC recently analyzed 2017 data from the Behavioral Risk Factor Surveillance System (BRFSS) survey's five-question module, which asked adults in 13 states§ and the District of Columbia (DC) about the delivery of alcohol SBI during their most recent checkup in the past 2 years. Overall, 81.4% of adults (age-standardized estimate) reported being asked about alcohol use by a health professional in person or on a form during a checkup in the past 2 years, but only 37.8% reported being asked a question about binge-level alcohol consumption, which is included on USPSTF recommended instruments (3). Among module respondents who were asked about alcohol use at a checkup in the past 2 years and reported current binge drinking (past 30 days) at time of survey, only 41.7% were advised about the harms of drinking too much at a checkup in the past 2 years, and only 20.1% were advised to reduce or quit drinking at a checkup in the past 2 years. These findings suggest that missed opportunities remain for health care providers to intervene with patients who report binge drinking. Working to implement alcohol SBI at a systems level, including the provision of the new Healthcare Effectiveness Data Information Set (HEDIS) measure, Unhealthy Alcohol Use Screening and Follow-Up, can improve alcohol SBI's use and benefit in primary care.

Self-reported short sleep duration among US adults by disability status and functional disability type: Results from the 2016 Behavioral Risk Factor Surveillance System.

BACKGROUND: Short sleep duration is associated with an increased risk of chronic disease and all-cause death. A better understanding of sleep disparities between people with and without disabilities can help inform interventions designed to improve sleep duration among people with disabilities. OBJECTIVE: To examine population-based prevalence estimates of short sleep duration by disability status and disability type among noninstitutionalized adults aged ≥18 years. METHODS: Data from the 2016 Behavioral Risk Factor Surveillance System were used to assess prevalence of short sleep duration among adults without and with disabilities (serious difficulty with cognition, hearing, mobility, or vision; any difficulty with self-care or independent living). Short sleep duration was defined as <7 h per 24-h period. We used log-binomial regression to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) while adjusting for socioeconomic and health-related characteristics. RESULTS: Adults with any disability had a higher prevalence of short sleep duration than those without disability (43.8% vs. 31.6%; p < .001). After controlling for selected covariates, short sleep was most prevalent among adults with multiple disabilities (PR 1.40, 95% CI: 1.36-1.43), followed by adults with a single disability type (range: PR 1.13, 95% CI: 1.03-1.24 [for independent living disability] to PR 1.25, 95% CI: 1.21-1.30 [for mobility disability]) compared to adults without disability. CONCLUSIONS: People with disabilities had a higher likelihood of reporting short sleep duration than those without disabilities. Assessment of sleep duration may be an important component in the provision of medical care to people with disabilities.

Prevalence of Disability and Disability Types by Urban-Rural County Classification-U.S., 2016.

INTRODUCTION: In the U.S., disability affects approximately 61.4 million (25.7%) adults, with mobility disability being the most prevalent type, affecting about 1 in 7 U.S. adults. However, little is known about the prevalence of disability and functional disability types by urbanization level. METHODS: Data from the 2016 Behavioral Risk Factor Surveillance System were analyzed. The prevalences of disability, overall and by functional disability type, were estimated among U.S. adults across 6 levels of urban-rural county categories based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. Adjusted prevalence ratios with 95% CIs were estimated by conducting log-linear regression analyses with robust variance estimator while adjusting for study covariates. Data analyses were conducted in 2018. RESULTS: The prevalences of having any disability, functional disability type, or multiple disabilities were lowest in large metropolitan centers and fringe metropolitan counties and highest in noncore (rural) counties. After controlling for age, sex, race/ethnicity, education, and federal poverty level, adults living in noncore counties were 9% more likely to report having any disability, 24% more likely to report having 3 or more disabilities, and 7% (cognition) to 35% (hearing) more likely to report specific disability types than the adults living in large metropolitan centers. CONCLUSIONS: Results of this study suggest that significant disparities in the prevalence of disability exist by level of urbanization, with rural U.S. residents having the highest prevalence of disability. Public health interventions to reduce health disparities could include people with disabilities, particularly in rural counties.

Prevalence of Disabilities and Health Care Access by Disability Status and Type Among Adults - United States, 2016.

Persons with disabilities face greater barriers to health care than do those without disabilities (1). To identify characteristics of noninstitutionalized adults with six specific disability types (hearing, vision, cognition, mobility, self-care, and independent living),* and to assess disability-specific disparities in health care access, CDC analyzed 2016 Behavioral Risk Factor Surveillance System (BRFSS) data. The prevalences of disability overall and by disability type, and access to health care by disability type, were estimated. Analyses were stratified by three age groups: 18-44 years (young adults), 45-64 years (middle-aged adults), and ≥65 years (older adults). Among young adults, cognitive disability (10.6%) was the most prevalent type. Mobility disability was most prevalent among middle-aged (18.1%) and older adults (26.9%). Generally, disability prevalences were higher among women, American Indians/Alaska Natives (AI/AN), adults with income below the federal poverty level (FPL), and persons in the South U.S. Census region. Disability-specific disparities in health care access were prevalent, particularly among young and middle-aged adults. These data might inform public health programs of the sociodemographic characteristics and disparities in health care access associated with age and specific disability types and guide efforts to improve access to care for persons with disabilities.

Self-Perceived Poor/Fair Health, Frequent Mental Distress, and Health Insurance Status Among Working-Aged US Adults.

We examined associations of health insurance status with self-perceived poor/fair health and frequent mental distress (FMD) among working-aged US adults from 42 states and the District of Columbia using data from the 2014 Behavioral Risk Factor Surveillance System. After multiple-variable adjustment, compared with adequately insured adults, underinsured and never insured adults were 39% and 59% more likely to report poor/fair health, respectively, and 38% more likely to report FMD. Compared with working-aged adults with employer-based insurance, adults with Medicaid/Medicare or other public insurance coverage were 28% and 13% more likely to report poor/fair health, respectively, and 15% more likely to report FMD. Increasing insurance coverage and reducing cost barriers to care may improve general and mental health.

Linking Data From Health Surveys and Electronic Health Records: A Demonstration Project in Two Chicago Health Center Clinics.

INTRODUCTION: Monitoring and understanding population health requires conducting health-related surveys and surveillance. The objective of our study was to assess whether data from self-administered surveys could be collected electronically from patients in urban, primary-care, safety-net clinics and subsequently linked and compared with the same patients' electronic health records (EHRs). METHODS: Data from self-administered surveys were collected electronically from a convenience sample of 527 patients at 2 Chicago health centers from September through November, 2014. Survey data were linked to EHRs. RESULTS: A total of 251 (47.6%) patients who completed the survey consented to having their responses linked to their EHRs. Consenting participants were older, more likely to report fair or poor health, and took longer to complete the survey than those who did not consent. For 8 of 18 categorical variables, overall percentage of agreement between survey data and EHR data exceeded 80% (sex, race/ethnicity, pneumococcal vaccination, self-reported body mass index [BMI], diabetes, high blood pressure, medication for high blood pressure, and hyperlipidemia), and of these, the level of agreement was good or excellent (κ ≥0.64) except for pneumococcal vaccination (κ = 0.40) and hyperlipidemia (κ = 0.47). Of 7 continuous variables, agreement was substantial for age and weight (concordance coefficients ≥0.95); however, with the exception of calculated survey BMI and EHR-BMI (concordance coefficient = 0.88), all other continuous variables had poor agreement. CONCLUSIONS: Self-administered and web-based surveys can be completed in urban, primary-care, safety-net clinics and linked to EHRs. Linking survey and EHR data can enhance public health surveillance by validating self-reported data, completing gaps in patient data, and extending sample sizes obtained through current methods. This approach will require promoting and sustaining patient involvement.

Health Insurance Status and Clinical Cancer Screenings Among U.S. Adults.

INTRODUCTION: Health insurance coverage is linked to clinical preventive service use. This study examined cancer screenings among U.S. adults by health insurance status. METHODS: The Behavioral Risk Factor Surveillance System collected data on healthcare access and cancer screenings from 42 states and the District of Columbia in 2014. Data analyses were conducted in 2016. Participants' health insurance status during the preceding 12 months was categorized as adequately insured, underinsured, or never insured. Primary type of insurance coverage was categorized as employer-based or Medicare (aged ≥65 years), self-purchased plan, Medicaid/Medicare (aged <65 years), and other public insurance. Clinical cancer screenings were assessed following the U.S. Preventive Services Task Force recommendations. RESULTS: Compared with adequately insured adults, underinsured and never insured women were 6% (p<0.001) and 41% (p<0.001) less likely to receive breast cancer screening, respectively; 1% (p<0.05) and 19% (p<0.001) less likely to receive cervical cancer screening, respectively; and 3% (p<0.01) and 47% (p<0.001) less likely to receive colorectal cancer screening, respectively; underinsured and never insured men were 6% (p<0.001) and 52% (p<0.001) less likely to receive colorectal cancer screening, respectively. Compared with adults with employer-based insurance/Medicare (aged ≥65 years), women with all other types of insurance were less likely to receive breast and cervical cancer screenings; women and men with self-purchased plans were less likely to receive colorectal cancer screening; however, men with other public insurance were more likely to receive colorectal cancer screening. CONCLUSIONS: Disparities in cancer screenings by health insurance status and type of insurance exist among U.S. adults. Greater efforts to increase screening rates and to reduce disparities in cancer screenings are an important strategy to help improve overall population health.

Daily Sugar-Sweetened Beverage Consumption, by Disability Status, Among Adults in 23 States and the District of Columbia.

INTRODUCTION: Information on dietary intake, including sugar-sweetened beverages (SSBs), for adults with disabilities is limited. Such information can inform interventions to prevent chronic disease and promote health among adults with disabilities. The objective of this study was to describe the associations between SSB consumption and disability among adults. METHODS: We examined data on adults aged 18 years or older in 23 states and the District of Columbia who participated in the 2013 Behavioral Risk Factor Surveillance System (n = 150,760). Participants who reported a limitation in any activity caused by physical, mental, or emotional problems or who reported use of special equipment were considered to have a disability (n = 41,199). Participants were classified as daily SSB consumers (≥1 time/d) and non-daily SSB consumers (<1 time/d). Multivariable logistic regression was used to examine associations between daily SSB intake and disability after controlling for sociodemographic characteristics. An interaction effect between disability and obesity status was tested to consider obesity status as a potential effect modifier. RESULTS: The prevalence of drinking SSBs at least once daily was significantly higher among adults with disabilities (30.3%) than among adults without disabilities (28.6%) (P = .01). After controlling for sociodemographic characteristics, among nonobese adults, the odds of daily SSB intake were significantly higher among adults with disabilities than among adults without disabilities (adjusted odds ratio = 1.27, P < .001). Among obese adults, daily SSB intake was not associated with disability status (adjusted odds ratio = 0.97; P = .58). CONCLUSION: Our findings highlight the need for increased awareness of SSB consumption among adults with disabilities.

Screening for Excessive Alcohol Use and Brief Counseling of Adults - 17 States and the District of Columbia, 2014.

Excessive and/or risky alcohol use* resulted in $249 billion in economic costs in 2010 (1) and >88,000 deaths in the United States every year from 2006 to 2010 (2). It is associated with birth defects and disabilities (e.g., fetal alcohol spectrum disorders [FASDs]), increases in chronic diseases (e.g., heart disease and breast cancer), and injuries and violence (e.g., motor vehicle crashes, suicide, and homicide).† Since 2004, the U.S. Preventive Services Task Force (USPSTF) has recommended alcohol misuse screening and brief counseling (also known as alcohol screening and brief intervention or ASBI) for adults aged ≥18 years (3).§ Among adults, ASBI reduces episodes of binge-level consumption, reduces weekly alcohol consumption, and increases compliance with recommended drinking limits in those who have an intervention in comparison to those who do not (3). A recent study suggested that health care providers rarely talk with patients about alcohol use (4). To estimate the prevalence of U.S. adults who reported receiving elements of ASBI, CDC analyzed 2014 Behavioral Risk Factor Surveillance System (BRFSS) data from 17 states¶ and the District of Columbia (DC). Weighted crude and age-standardized overall and state-level prevalence estimates were calculated by selected drinking patterns and demographic characteristics. Overall, 77.7% of adults (age-standardized estimate) reported being asked about alcohol use by a health professional in person or on a form during a checkup, but only 32.9% reported being asked about binge-level alcohol consumption (3). Among binge drinkers, only 37.2% reported being asked about alcohol use and advised about the harms of drinking too much, and only 18.1% reported being asked about alcohol use and advised to reduce or quit drinking. Widespread implementation of ASBI and other evidence-based interventions could help reduce excessive alcohol use in adults and related harms.

Surveillance for Health Care Access and Health Services Use, Adults Aged 18-64 Years - Behavioral Risk Factor Surveillance System, United States, 2014.

PROBLEM/CONDITION: As a result of the 2010 Patient Protection and Affordable Care Act, millions of U.S. adults attained health insurance coverage. However, millions of adults remain uninsured or underinsured. Compared with adults without barriers to health care, adults who lack health insurance coverage, have coverage gaps, or skip or delay care because of limited personal finances might face increased risk for poor physical and mental health and premature mortality. PERIOD COVERED: 2014. DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. Data are collected from states, the District of Columbia, and participating U.S. territories on health risk behaviors, chronic health conditions, health care access, and use of clinical preventive services (CPS). An optional Health Care Access module was included in the 2014 BRFSS. This report summarizes 2014 BRFSS data from all 50 states and the District of Columbia on health care access and use of selected CPS recommended by the U.S. Preventive Services Task Force or the Advisory Committee on Immunization Practices among working-aged adults (aged 18-64 years), by state, state Medicaid expansion status, expanded geographic region, and federal poverty level (FPL). This report also provides analysis of primary type of health insurance coverage at the time of interview, continuity of health insurance coverage during the preceding 12 months, and other health care access measures (i.e., unmet health care need because of cost, unmet prescription need because of cost, medical debt [medical bills being paid off over time], number of health care visits during the preceding year, and satisfaction with received health care) from 43 states that included questions from the optional BRFSS Health Care Access module. RESULTS: In 2014, health insurance coverage and other health care access measures varied substantially by state, state Medicaid expansion status, expanded geographic region (i.e., states categorized geographically into nine regions), and FPL category. The following proportions refer to the range of estimated prevalence for health insurance and other health care access measures by examined geographical unit (unless otherwise specified), as reported by respondents. Among adults with health insurance coverage, the range was 70.8%-94.5% for states, 78.8%-94.5% for Medicaid expansion states, 70.8%-89.1% for nonexpansion states, 73.3%-91.0% for expanded geographic regions, and 64.2%-95.8% for FPL categories. Among adults who had a usual source of health care, the range was 57.2%-86.6% for states, 57.2%-86.6% for Medicaid expansion states, 61.8%-83.9% for nonexpansion states, 64.4%-83.6% for expanded geographic regions, and 61.0%-81.6% for FPL categories. Among adults who received a routine checkup, the range was 52.1%-75.5% for states, 56.0%-75.5% for Medicaid expansion states, 52.1%-71.1% for nonexpansion states, 56.8%-70.2% for expanded geographic regions, and 59.9%-69.2% for FPL categories. Among adults who had unmet health care need because of cost, the range was 8.0%-23.1% for states, 8.0%-21.9% for Medicaid expansion states, 11.9%-23.1% for nonexpansion states, 11.6%-20.3% for expanded geographic regions, and 5.3%-32.9% for FPL categories. Estimated prevalence of cancer screenings, influenza vaccination, and having ever been tested for human immunodeficiency virus also varied by state, state Medicaid expansion status, expanded geographic region, and FPL category. The prevalence of insurance coverage varied by approximately 25 percentage points among racial/ethnic groups (range: 63.9% among Hispanics to 88.4% among non-Hispanic Asians) and by approximately 32 percentage points by FPL category (range: 64.2% among adults with household income <100% of FPL to 95.8% among adults with household income >400% of FPL). The prevalence of unmet health care need because of cost varied by nearly 14 percentage points among racial/ethnic groups (range: 11.3% among non-Hispanic Asians to 25.0% among Hispanics), by approximately 17 percentage points among adults with and without disabilities (30.8% versus 13.7%), and by approximately 28 percentage points by FPL category (range: 5.3% among adults with household income >400% of FPL to 32.9% among adults with household income <100% of FPL). Among the 43 states that included questions from the optional module, a majority of adults reported private health insurance coverage (63.4%), followed by public health plan coverage (19.4%) and no primary source of insurance (17.1%). Financial barriers to health care (unmet health care need because of cost, unmet prescribed medication need because of cost, and medical bills being paid off over time [medical debt]) were typically lower among adults in Medicaid expansion states than those in nonexpansion states regardless of source of insurance. Approximately 75.6% of adults reported being continuously insured during the preceding 12 months, 12.9% reported a gap in coverage, and 11.5% reported being uninsured during the preceding 12 months. The largest proportion of adults reported ≥3 visits to a health care professional during the preceding 12 months (47.3%), followed by 1-2 visits (37.1%), and no health care visits (15.6%). Adults in expansion and nonexpansion states reported similar levels of satisfaction with received health care by primary source of health insurance coverage and by continuity of health insurance coverage during the preceding 12 months. INTERPRETATION: This report presents for the first time estimates of population-based health care access and use of CPS among adults aged 18-64 years. The findings in this report indicate substantial variations in health insurance coverage; other health care access measures; and use of CPS by state, state Medicaid expansion status, expanded geographic region, and FPL category. In 2014, health insurance coverage, having a usual source of care, having a routine checkup, and not experiencing unmet health care need because of cost were higher among adults living below the poverty level (i.e., household income <100% of FPL) in states that expanded Medicaid than in states that did not. Similarly, estimates of breast and cervical cancer screening and influenza vaccination were higher among adults living below the poverty level in states that expanded Medicaid than in states that did not. These disparities might be due to larger differences to begin with, decreased disparities in Medicaid expansion states versus nonexpansion states, or increased disparities in nonexpansion states. PUBLIC HEALTH ACTION: BRFSS data from 2014 can be used as a baseline by which to assess and monitor changes that might occur after 2014 resulting from programs and policies designed to increase access to health care, reduce health disparities, and improve the health of the adult population. Post-2014 changes in health care access, such as source of health insurance coverage, attainment and continuity of coverage, financial barriers, preventive care services, and health outcomes, can be monitored using these baseline estimates.

Comparison of 2 Disability Measures, Behavioral Risk Factor Surveillance System, 2013.

INTRODUCTION: Beginning in 2013, in addition to the 2-item disability question set asked since 2001, Behavioral Risk Factor Surveillance System (BRFSS) began using 5 of the 6 items from the US Department of Health and Human Services-recommended disability question set. We assess and compare disability prevalence using the 2-question and 5-question sets and describe characteristics of respondents who identified as having a disability using each question set. METHODS: We used data from the 2013 BRFSS to estimate the prevalence of disability for each question set and the 5 specific types of disability. Among respondents identified by each disability question set, we calculated the prevalence of selected demographic characteristics, health conditions, health behaviors, and health status. RESULTS: With the 2-question set, 21.6% of adults had a disability and with the 5-question set, 22.7% of adults had disability. A total of 51.2% of adults who identified as having a disability with either the 2-question or 5-question set reported having disabilities with both sets. Adults with different disability types differed by demographic and health characteristics. CONCLUSION: The inclusion of the 5 new disability questions in BRFSS provides a level of detail that can help develop targeted interventions and programs and can guide the adaptation of existing health promotion programs to be more inclusive of adults who experience specific types of disabilities.

A new source of data for public health surveillance: Facebook likes.

BACKGROUND: Investigation into personal health has become focused on conditions at an increasingly local level, while response rates have declined and complicated the process of collecting data at an individual level. Simultaneously, social media data have exploded in availability and have been shown to correlate with the prevalence of certain health conditions. OBJECTIVE: Facebook likes may be a source of digital data that can complement traditional public health surveillance systems and provide data at a local level. We explored the use of Facebook likes as potential predictors of health outcomes and their behavioral determinants. METHODS: We performed principal components and regression analyses to examine the predictive qualities of Facebook likes with regard to mortality, diseases, and lifestyle behaviors in 214 counties across the United States and 61 of 67 counties in Florida. These results were compared with those obtainable from a demographic model. Health data were obtained from both the 2010 and 2011 Behavioral Risk Factor Surveillance System (BRFSS) and mortality data were obtained from the National Vital Statistics System. RESULTS: Facebook likes added significant value in predicting most examined health outcomes and behaviors even when controlling for age, race, and socioeconomic status, with model fit improvements (adjusted R(2)) of an average of 58% across models for 13 different health-related metrics over basic sociodemographic models. Small area data were not available in sufficient abundance to test the accuracy of the model in estimating health conditions in less populated markets, but initial analysis using data from Florida showed a strong model fit for obesity data (adjusted R(2)=.77). CONCLUSIONS: Facebook likes provide estimates for examined health outcomes and health behaviors that are comparable to those obtained from the BRFSS. Online sources may provide more reliable, timely, and cost-effective county-level data than that obtainable from traditional public health surveillance systems as well as serve as an adjunct to those systems.