Monitoring HIV testing and pre-exposure prophylaxis information seeking by combining digital and traditional data.

BACKGROUND: Public health is increasingly turning to non-traditional digital data to inform HIV prevention and control strategies. We demonstrate a parsimonious method using both traditional survey and internet search histories to provide new insights into HIV testing and pre-exposure prophylaxis (PrEP) information seeking that can be easily extended to other settings. METHOD: We modeled how US internet search volumes from 2019 for HIV testing and PrEP compared against expected search volumes for HIV testing and PrEP using state HIV prevalence and socioeconomic characteristics as predictors. States with search volumes outside the upper and lower bound confidence interval were labeled as either over or under performing. State performance was evaluated by (a) Centers for Disease Control and Prevention designation as a hotspot for new HIV diagnoses (b) expanding Medicaid coverage. RESULTS: Ten states over-performed in models assessing information seeking for HIV testing, while eleven states under-performed. Thirteen states over-performed in models assessing internet searches for PrEP information, while thirteen states under-performed. States that expanded Medicaid coverage were more likely to over perform in PrEP models than states that did not expand Medicaid coverage. While states that were hotspots for new HIV diagnoses were more likely to over perform on HIV testing searches. CONCLUSION: Our study derived a method of measuring HIV and PrEP information seeking that is comparable across states. Several states exhibited information seeking for PrEP and HIV testing that deviated from model assessments. Statewide search volume for PrEP information was affected by a state's decision to expand Medicaid coverage. Our research provides health officials with an innovative way to monitor statewide interest in PrEP and HIV testing using a metric for information-seeking that is comparable across states.

"Repeal and replace": increased demand for intrauterine devices following the 2016 presidential election.

OBJECTIVE: To evaluate public's interest in contraceptive options following heightened focus on a repeal of the Affordable Care Act (ACA) since the 2016 United States presidential election. STUDY DESIGN: We monitored the fraction of Google searches emerging from the United States for the three most popular reversible contraceptive methods - oral contraceptives, intrauterine devices (IUDs) and condoms - from January 1, 2004, through October 31, 2017 (1 year after the presidential election). RESULTS: IUD searches were cumulatively 15% (95% CI: 10 to 20) higher than expected the year following the 2016 election, reflecting 10 to 21 million excess searches. IUD searches were statistically significantly higher in all states, except NV, and were consistent across states won by Trump or Clinton (Welch t test=0.60, p=.548). Conversely, searches for oral contraceptives and condoms remained stable (0%; 95% CI: -2 to 1) or declined (-4%; 95% CI: -5 to -2), respectively, following the election. CONCLUSIONS: The etiology of increased searches for IUDs is likely multifaceted. However, it may largely be because IUDs will confer continued protection even after an ACA repeal, thereby providing a medical hedge against a possible repeal. Regardless, these data suggest the heightened focus on an ACA repeal is a concern to the record number of Americans seeking out information about IUDs.

Revisiting the Rise of Electronic Nicotine Delivery Systems Using Search Query Surveillance.

INTRODUCTION: Public perceptions of electronic nicotine delivery systems (ENDS) remain poorly understood because surveys are too costly to regularly implement and, when implemented, there are long delays between data collection and dissemination. Search query surveillance has bridged some of these gaps. Herein, ENDS' popularity in the U.S. is reassessed using Google searches. METHODS: ENDS searches originating in the U.S. from January 2009 through January 2015 were disaggregated by terms focused on e-cigarette (e.g., e-cig) versus vaping (e.g., vapers); their geolocation (e.g., state); the aggregate tobacco control measures corresponding to their geolocation (e.g., clean indoor air laws); and by terms that indicated the searcher's potential interest (e.g., buy e-cigs likely indicates shopping)-all analyzed in 2015. RESULTS: ENDS searches are rapidly increasing in the U.S., with 8,498,000 searches during 2014 alone. Increasingly, searches are shifting from e-cigarette- to vaping-focused terms, especially in coastal states and states where anti-smoking norms are stronger. For example, nationally, e-cigarette searches declined 9% (95% CI=1%, 16%) during 2014 compared with 2013, whereas vaping searches increased 136% (95% CI=97%, 186%), even surpassing e-cigarette searches. Additionally, the percentage of ENDS searches related to shopping (e.g., vape shop) nearly doubled in 2014, whereas searches related to health concerns (e.g., vaping risks) or cessation (e.g., quit smoking with e-cigs) were rare and declined in 2014. CONCLUSIONS: ENDS popularity is rapidly growing and evolving. These findings could inform survey questionnaire development for follow-up investigation and immediately guide policy debates about how the public perceives the health risks or cessation benefits of ENDS.

US consumer interest in non-cigarette tobacco products spikes around the 2009 federal tobacco tax increase.

OBJECTIVES: This quasi-experimental longitudinal study monitored aggregate Google search queries as a proxy for consumer interest in non-cigarette tobacco products (NTP) around the time of the 2009 US federal tobacco tax increase. METHODS: Query trends for searches mentioning common NTP were downloaded from Google's public archives. The mean relative increase was estimated by comparing the observed with expected query volume for the 16 weeks around the tax. RESULTS: After the tax was announced, queries spiked for chewing tobacco, cigarillos, electronic cigarettes ('e-cigarettes'), roll-your-own (RYO) tobacco, snuff, and snus. E-cigarette queries were 75% (95% CI 70% to 80%) higher than expected 8 weeks before and after the tax, followed by RYO 59% (95% CI 53% to 65%), snus 34% (95% CI 31% to 37%), chewing tobacco 17% (95% CI 15% to 20%), cigarillos 14% (95% CI 11% to 17%), and snuff 13% (95% CI 10% to 14%). Unique queries increasing the most were 'ryo cigarettes' 427% (95% CI 308% to 534%), 'ryo tobacco' 348% (95% CI 300% to 391%), 'best electronic cigarette' 221% (95% CI 185% to 257%), and 'e-cigarette' 205% (95% CI 163% to 245%). CONCLUSIONS: The 2009 tobacco tax increase triggered large increases in consumer interest for some NTP, particularly e-cigarettes and RYO tobacco.

The environment modifies the relationship between social networks and secondhand smoke exposure among Korean nonsmokers in Seoul and California.

This study compared risks of secondhand smoke exposure (SHSe) among Korean nonsmokers in Seoul, South Korea and California, United States. Social networks were hypothesized to contain more smokers in Seoul than in California, and smokers were hypothesized to produce more secondhand smoke in Seoul than California, as Seoul's policies and norms are less restrictive. Telephone interviews were conducted with Korean adults in Seoul (N = 500) and California (N = 2830). In all, 69% (95% confidence interval [CI] = 64-74) of Koreans and 31% (95% CI = 29-33) of Korean Americans reported any SHSe. A total of 44% (95% CI = 40-47) of Korean family members smoked versus 29% (95% CI = 28-30) of Korean American family members (t = 7.84, P < .01). A 25% to 75% increase in the proportion of family members that smoked corresponded with a 13% (95% CI = 5-21) higher probability of any SHSe among Koreans compared with 6% (95% CI = 2-10) among Korean Americans. Network interventions in combination with policies and/or health campaigns may help reduce SHSe globally.

Population health concerns during the United States' Great Recession.

BACKGROUND: Associations between economic conditions and health are usually derived from cost-intensive surveys that are intermittently collected with nonspecific measures (i.e., self-rated health). PURPOSE: This study identified how precise health concerns changed during the U.S. Great Recession analyzing Google search queries to identify the concern by the query content and their prevalence by the query volume. METHODS: Excess health concerns were estimated during the Great Recession (December 2008 through 2011) by comparing the cumulative difference between observed and expected (based on linear projections from pre-existing trends) query volume for hundreds of individual terms. As performed in 2013, the 100 queries with the greatest excess were ranked and then clustered into themes based on query content. RESULTS: The specific queries with the greatest relative excess were stomach ulcer symptoms and headache symptoms, respectively, 228% (95% CI=35, 363) and 193% (95% CI=60, 275) greater than expected. Queries typically involved symptomology (i.e., gas symptoms) and diagnostics (i.e., heart monitor) naturally coalescing into themes. Among top themes, headache queries were 41% (95% CI=3, 148); hernia 37% (95% CI=16, 142); chest pain 35% (95% CI=6, 313); and arrhythmia 32% (95% CI=3, 149) greater than expected. Pain was common with back, gastric, joint, and tooth foci, with the latter 19% (95% CI=4, 46) higher. Among just the top 100, there were roughly 205 million excess health concern queries during the Great Recession. CONCLUSIONS: Google queries indicate that the Great Recession coincided with substantial increases in health concerns, hinting at how population health specifically changed during that time.

Digital detection for tobacco control: online reactions to the 2009 U.S. cigarette excise tax increase.

INTRODUCTION: The Internet is revolutionizing tobacco control, but few have harnessed the Web for surveillance. We demonstrate for the first time an approach for analyzing aggregate Internet search queries that captures precise changes in population considerations about tobacco. METHODS: We compared tobacco-related Google queries originating in the United States during the week of the State Children's Health Insurance Program (SCHIP) 2009 cigarette excise tax increase with a historic baseline. Specific queries were then ranked according to their relative increases while also considering approximations of changes in absolute search volume. RESULTS: Individual queries with the largest relative increases the week of the SCHIP tax were "cigarettes Indian reservations" 640% (95% CI, 472-918), "free cigarettes online" 557% (95% CI, 432-756), and "Indian reservations cigarettes" 542% (95% CI, 414-733), amounting to about 7,500 excess searches. By themes, the largest relative increases were tribal cigarettes 246% (95% CI, 228-265), "free" cigarettes 215% (95% CI, 191-242), and cigarette stores 176% (95% CI, 160-193), accounting for 21,000, 27,000, and 90,000 excess queries. All avoidance queries, including those aforementioned themes, relatively increased 150% (95% CI, 144-155) or 550,000 from their baseline. All cessation queries increased 46% (95% CI, 44-48), or 175,000, around SCHIP; including themes for "cold turkey" 19% (95% CI, 11-27) or 2,600, cessation products 47% (95% CI, 44-50) or 78,000, and dubious cessation approaches (e.g., hypnosis) 40% (95% CI, 33-47) or 2,300. CONCLUSIONS: The SCHIP tax motivated specific changes in population considerations. Our strategy can support evaluations that temporally link tobacco control measures with instantaneous population reactions, as well as serve as a springboard for traditional studies, for example, including survey questionnaire design.

Smoking trajectories among Koreans in Seoul and California: exemplifying a common error in age parameterization.

Immigration to a nation with a stronger anti-smoking environment has been hypothesized to make smoking less common. However, little is known about how environments influence risk of smoking across the lifecourse. Research suggested a linear decline in smoking over the lifecourse but these associations, in fact, might not be linear. This study assessed the possible nonlinear associations between age and smoking and examined how these associations differed by environment through comparing Koreans in Seoul, South Korea and Korean Americans in California, United States. Data were drawn from population based telephone surveys of Korean adults in Seoul (N=500) and California (N=2,830) from 2001-2002. Locally weighted scatterplot smoothing (lowess) was used to approximate the association between age and smoking with multivariable spline logistic regressions, including adjustment for confounds used to draw population inferences. Smoking differed across the lifecourse between Korean and Korean American men. The association between age and smoking peaked around 35 years among Korean and Korean American men. From 18 to 35 the probability of smoking was 57% higher (95%CI, 40 to 71) among Korean men versus 8% (95%CI, 3 to 19) higher among Korean American men. A similar difference in age after 35, from 40 to 57 years of age, was associated with a 2% (95%CI, 0 to 10) and 20% (95%CI, 16 to 25) lower probability of smoking among Korean and Korean American men. A nonlinear pattern was also observed among Korean American women. Social role transitions provide plausible explanations for the decline in smoking after 35. Investigators should be mindful of nonlinearities in age when attempting to understand tobacco use.

Novel surveillance of psychological distress during the great recession.

BACKGROUND: Economic stressors have been retrospectively associated with net population increases in nonspecific psychological distress (PD). However, no sentinels exist to evaluate contemporaneous associations. Aggregate Internet search query surveillance was used to monitor population changes in PD around the United States' Great Recession. METHODS: Monthly PD query trends were compared with unemployment, underemployment, homes in delinquency and foreclosure, median home value or sale prices, and S&P 500 trends for 2004-2010. Time series analyses, where economic indicators predicted PD one to seven months into the future, were performed in 2011. RESULT: PD queries surpassed 1,000,000 per month, of which 300,000 may be attributable to the Great Recession. A one percentage point increase in mortgage delinquencies and foreclosures was associated with a 16% (95%CI, 9-24) increase in PD queries one-month, and 11% (95%CI, 3-18) four months later, in reference to a pre-Great Recession mean. Unemployment and underemployment had similar associations half and one-quarter the intensity. "Anxiety disorder", "what is depression", "signs of depression", "depression symptoms", and "symptoms of depression" were the queries exhibiting the strongest associations with mortgage delinquencies and foreclosures, unemployment or underemployment. Housing prices and S&P 500 trends were not associated with PD queries. LIMITATIONS: A non-traditional measure of PD was used. It is unclear if actual clinically significant depression or anxiety increased during the Great Recession. Alternative explanations for strong associations between the Great Recession and PD queries, such as media, were explored and rejected. CONCLUSIONS: Because the economy is constantly changing, this work not only provides a snapshot of recent associations between the economy and PD queries but also a framework and toolkit for real-time surveillance going forward. Health resources, clinician screening patterns, and policy debate may be informed by changes in PD query trends.

A novel evaluation of World No Tobacco day in Latin America.

BACKGROUND: World No Tobacco Day (WNTD), commemorated annually on May 31, aims to inform the public about tobacco harms. Because tobacco control surveillance is usually annualized, the effectiveness of WNTD remains unexplored into its 25th year. OBJECTIVE: To explore the potential of digital surveillance (infoveillance) to evaluate the impacts of WNTD on population awareness of and interest in cessation. METHODS: Health-related news stories and Internet search queries were aggregated to form a continuous and real-time data stream. We monitored daily news coverage of and Internet search queries for cessation in seven Latin American nations from 2006 to 2011. RESULTS: Cessation news coverage peaked around WNTD, typically increasing 71% (95% confidence interval [CI] 61-81), ranging from 61% in Mexico to 83% in Venezuela. Queries indicative of cessation interest peaked on WNTD, increasing 40% (95% CI 32-48), ranging from 24% in Colombia to 84% in Venezuela. A doubling in cessation news coverage was associated with approximately a 50% increase in cessation queries. To gain a practical perspective, we compared WNTD-related activity with New Year's Day and several cigarette excise tax increases in Mexico. Cessation queries around WNTD were typically greater than New Year's Day and approximated a 2.8% (95% CI -0.8 to 6.3) increase in cigarette excise taxes. CONCLUSIONS: This novel evaluation suggests WNTD had a significant impact on popular awareness (media trends) and individual interest (query trends) in smoking cessation. Because WNTD is constantly evolving, our work is also a model for real-time surveillance and potential improvement in WNTD and similar initiatives.

Using search query surveillance to monitor tax avoidance and smoking cessation following the United States' 2009 "SCHIP" cigarette tax increase.

Smokers can use the web to continue or quit their habit. Online vendors sell reduced or tax-free cigarettes lowering smoking costs, while health advocates use the web to promote cessation. We examined how smokers' tax avoidance and smoking cessation Internet search queries were motivated by the United States' (US) 2009 State Children's Health Insurance Program (SCHIP) federal cigarette excise tax increase and two other state specific tax increases. Google keyword searches among residents in a taxed geography (US or US state) were compared to an untaxed geography (Canada) for two years around each tax increase. Search data were normalized to a relative search volume (RSV) scale, where the highest search proportion was labeled 100 with lesser proportions scaled by how they relatively compared to the highest proportion. Changes in RSV were estimated by comparing means during and after the tax increase to means before the tax increase, across taxed and untaxed geographies. The SCHIP tax was associated with an 11.8% (95% confidence interval [95%CI], 5.7 to 17.9; p<.001) immediate increase in cessation searches; however, searches quickly abated and approximated differences from pre-tax levels in Canada during the months after the tax. Tax avoidance searches increased 27.9% (95%CI, 15.9 to 39.9; p<.001) and 5.3% (95%CI, 3.6 to 7.1; p<.001) during and in the months after the tax compared to Canada, respectively, suggesting avoidance is the more pronounced and durable response. Trends were similar for state-specific tax increases but suggest strong interactive processes across taxes. When the SCHIP tax followed Florida's tax, versus not, it promoted more cessation and avoidance searches. Efforts to combat tax avoidance and increase cessation may be enhanced by using interventions targeted and tailored to smokers' searches. Search query surveillance is a valuable real-time, free and public method, that may be generalized to other behavioral, biological, informational or psychological outcomes manifested online.

Smoking on both sides of the pacific: home smoking restrictions and secondhand smoke exposure among Korean adults and children in Seoul and California.

INTRODUCTION: This study, informed by ecological frameworks, compared the prevalence, predictors, and association of home smoking restrictions with secondhand smoke exposure (SHSe) between Koreans in Seoul, South Korea, and Korean Americans in California, United States. METHODS: A cross-sectional survey was drawn from telephone interviews with Korean adults in Seoul (N = 500) and California (N = 2,830) during 2001-02. Multivariable regressions were used for analyses. RESULTS: Koreans, compared with Korean Americans, had significantly fewer complete home smoking bans, 19% (95% CI: 16-23) versus 66% (95% CI: 64-68), and were more likely to not have a home smoking restriction, 64% (95% CI: 60-69) versus 5% (95% CI: 4-6). Home smoking restrictions were associated with lower home SHSe; however, the impact was consistently larger among Korean Americans. Households with more SHSe sources were less likely to have the strongest home smoking restrictions, where the difference in complete bans among Korean Americans versus Koreans was largely among those at low risk of SHSe, 82% (95% CI: 76-86) versus 36% (95% CI: 17-57), while high-risk Korean American and Koreans had similar low probabilities, 10% (95% CI: 7-13) versus 7% (95% CI: 3-13). CONCLUSIONS: Consistent with ecological frameworks, exposure to California's antismoking policy and culture was associated with stronger home smoking restrictions and improved effectiveness. Interventions tailored to Korean and Korean American SHSe profiles are needed. Behavioral interventions specifically for high-risk Korean Americans and stronger policy controls for Koreans may be effective at rapidly expanding home smoking restrictions.

Can religion help prevent obesity? Religious messages and the prevalence of being overweight or obese among Korean women in California.

This research examines the influence of messages from religious leaders and congregants on whether Korean women are overweight or obese. Data were drawn from telephone interviews with a probability sample (N = 591) of women of Korean descent living in California. Overweight or obese prevalence was measured using World Health Organization standards for Asians (BMI > 23). Respondents reported the frequency of messages discouraging "excessive eating" or encouraging "exercise" from religious leaders and congregants during a typical month. When conditioned on leaders' messages, the frequency of congregants' messages was associated with a significantly lower probability of being overweight or obese, although messages from either in the absence of the other were unassociated with being overweight or obese. At least for Korean women, religion may help prevent obesity via religious-based social mechanisms.

Sorting out the competing effects of acculturation, immigrant stress, and social support on depression: a report on Korean women in California.

This research identifies stressors that correlate with depression, focusing on acculturation, among female Korean immigrants in California. Telephone interviews were conducted with female adults of Korean descent (N = 592) from a probability sample from 2006 to 2007. Sixty-five percent of attempted interviews were completed, of which over 90% were conducted in Korean. Analyses include descriptive reports, bivariate correlations, and structural equation modeling. Findings suggest that acculturation did not have a direct impact on depression and was not associated with social support. However, acculturation was associated with reduced immigrant stress which, in turn, was related to decreased levels of depression. Immigrant stress and social support were the principal direct influences on depression, mediating the effect for most other predictors. Stressful experiences associated with immigration may induce depressive feelings. Interventions should facilitate acculturation thereby reducing immigrant stress and expand peer networks to increase social support to assuage depression.