Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic - United States, August 2020-February 2021.

The spread of disease and increase in deaths during large outbreaks of transmissible diseases is often associated with fear and grief (1). Social restrictions, limits on operating nonessential businesses, and other measures to reduce pandemic-related mortality and morbidity can lead to isolation and unemployment or underemployment, further increasing the risk for mental health problems (2). To rapidly monitor changes in mental health status and access to care during the COVID-19 pandemic, CDC partnered with the U.S. Census Bureau to conduct the Household Pulse Survey (HPS). This report describes trends in the percentage of adults with symptoms of an anxiety disorder or a depressive disorder and those who sought mental health services. During August 19, 2020-February 1, 2021, the percentage of adults with symptoms of an anxiety or a depressive disorder during the past 7 days increased significantly (from 36.4% to 41.5%), as did the percentage reporting that they needed but did not receive mental health counseling or therapy during the past 4 weeks (from 9.2% to 11.7%). Increases were largest among adults aged 18-29 years and among those with less than a high school education. HPS data can be used in near real time to evaluate the impact of strategies that address mental health status and care of adults during the COVID-19 pandemic and to guide interventions for groups that are disproportionately affected.

Multiple chronic conditions among US adults: a 2012 update.

The objective of this research was to update earlier estimates of prevalence rates of single chronic conditions and multiple (>2) chronic conditions (MCC) among the noninstitutionalized, civilian US adult population. Data from the 2012 National Health Interview Survey (NHIS) were used to generate estimates of MCC for US adults and by select demographic characteristics. Approximately half (117 million) of US adults have at least one of the 10 chronic conditions examined (ie, hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, current asthma, or chronic obstructive pulmonary disease [COPD]). Furthermore, 1 in 4 adults has MCC.

Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010.

Preventing and ameliorating chronic conditions has long been a priority in the United States; however, the increasing recognition that people often have multiple chronic conditions (MCC) has added a layer of complexity with which to contend. The objective of this study was to present the prevalence of MCC and the most common MCC dyads/triads by selected demographic characteristics. We used respondent-reported data from the 2010 National Health Interview Survey (NHIS) to study the US adult civilian noninstitutionalized population aged 18 years or older (n = 27,157). We categorized adults as having 0 to 1, 2 to 3, or 4 or more of the following chronic conditions: hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, chronic obstructive pulmonary disease, or current asthma. We then generated descriptive estimates and tested for significant differences. Twenty-six percent of adults have MCC; the prevalence of MCC has increased from 21.8% in 2001 to 26.0% in 2010. The prevalence of MCC significantly increased with age, was significantly higher among women than men and among non-Hispanic white and non-Hispanic black adults than Hispanic adults. The most common dyad identified was arthritis and hypertension, and the combination of arthritis, hypertension, and diabetes was the most common triad. The findings of this study contribute information to the field of MCC research. The NHIS can be used to identify population subgroups most likely to have MCC and potentially lead to clinical guidelines for people with more common MCC combinations.

Summary health statistics for u.s. Adults: national health interview survey, 2011.

Objectives-This report presents health statistics from the 2011 National Health Interview Survey (NHIS) for the civilian noninstitutionalized adult population, classified by sex, age, race and Hispanic origin, education, family income, poverty status, health insurance coverage, marital status, and place and region of residence. Estimates (frequencies and percentages) are presented for selected chronic conditions and mental health characteristics, functional limitations, health status, health behaviors, health care access and utilization, and human immunodeficiency virus testing. Percentages and percent distributions are presented in both age-adjusted and unadjusted versions. Data Source-NHIS is a household, multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics. In 2011, data were collected on 33,014 adults in the Sample Adult questionnaire. The conditional response rate was 81.6%, and the final response rate was 66.3%. The health information for adults in this report was obtained from one randomly selected adult per family. In very rare instances where the sample adult was not able to respond for himself or herself, a proxy was used. Highlights-In 2011, 61% of adults aged 18 and over had excellent or very good health. Eleven percent of adults had been told by a doctor or other health professional that they had heart disease, 24% had been told on two or more visits that they had hypertension, 9% had been told that they had diabetes, and 22% had been told that they had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia. Nineteen percent of adults were current smokers, and 21% were former smokers. Based on estimates of body mass index, 34% of adults were overweight and 28% were obese.

Summary health statistics for U.S. adults: National Health Interview Survey, 2010.

OBJECTIVES: This report presents health statistics from the 2010 National Health Interview Survey (NHIS) for the civilian noninstitutionalized adult population, classified by sex, age, race and Hispanic origin, education, family income, poverty status, health insurance coverage, marital status, and place and region of residence. Estimates are presented for selected chronic conditions and mental health characteristics, functional limitations, health status, health behaviors, health care access and utilization, and human immunodeficiency virus testing. Percentages and percent distributions are presented in both age-adjusted and unadjusted versions. DATA SOURCE: NHIS is a household, multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics. In 2010, data were collected on 27,157 adults in the Sample Adult questionnaire. The conditional response rate was 77.3%, and the final response rate was 60.8%. The health information for adults in this report was obtained from one randomly selected adult per family. In very rare instances where the sample adult was not able to respond for himself or herself, a proxy was used. HIGHLIGHTS: In 2010, 61% of adults aged 18 years and over had excellent or very good health. Twelve percent of adults had been told by a doctor or health professional that they had heart disease, 25% had been told on two or more visits that they had hypertension, 9% had been told they had diabetes, and 22% had been told they had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia. Twenty-one percent of adults were current smokers, and 21% were former smokers. Based on estimates of body mass index, 35% of adults were overweight and 27% were obese.

Mental Health Treatment Among Adults Aged 18-44: United States, 2019-2021.

In 2020, the percentage of adults who had received any mental health treatment in the past 12 months was significantly higher than in 2019 (1,2). Previous research has found that symptoms of an anxiety disorder or a depressive disorder increased from 2020 through the beginning of 2021, especially among younger adults (3). This report describes trends in the percentage of adults aged 18-44 who had received any mental health treatment, defined as having either taken medication for mental health, received counseling or therapy, or both in the past 12 months by selected characteristics based on data from the 2019-2021 National Health Interview Survey (NHIS). Estimates for adults aged 45-64 and 65 and over are presented for comparison.

Fall injury episodes among noninstitutionalized older adults: United States, 2001-2003.

OBJECTIVE: This report presents national estimates of fall injury episodes for noninstitutionalized U.S. adults aged 65 years and over, by selected characteristics. Circumstances surrounding the fall injury and activity limitations and utilization of health care resulting from the fall injury are also presented. METHODS: Combined data from the 2001-2003 National Health Interview Surveys (NHIS), conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS), were analyzed to produce estimates for the U.S. civilian noninstitutionalized population. Data on nonfatal medically attended fall injuries occurring within the 3 months preceding the interview were obtained from an adult family member. RESULTS: The annualized rate of fall injury episodes for noninstitutionalized adults aged 65 years and over in 2001-2003 was 51 episodes per 1,000 population. Rates of fall injuries increased with age, and were higher for women compared with men. Non-Hispanic white older adults had higher rates of fall injuries compared with non-Hispanic black older adults. Older adults with certain chronic conditions and activity limitations had higher rates of fall injuries compared with older adults without these conditions. The most common cause of fall injuries among older adults was slipping, tripping, or stumbling, and most fall injuries occurred inside or around the outside of the home. Nearly 60 percent of older adults who experienced a fall injury visited an emergency room for treatment or advice. Nearly one-third of older adults experiencing a fall injury needed help with activities of daily living as a result, and over one-half of these persons expected to need this help for at least 6 months. A similar percentage experienced limitation in instrumental activities of daily living as a result of fall injuries. CONCLUSION: Fall injuries remain very prevalent among older adults and result in high health care utilization and activity limitations. Rates of fall injuries vary by demographic and health characteristics of older noninstitutionalized adults.

Cigarette smoking and smoking cessation among persons with chronic obstructive pulmonary disease.

PURPOSE: To identify factors predictive of smoking cessation among adults with chronic obstructive pulmonary disease (COPD). Data from the 1997 to 2002 National Health Interview Surveys were analyzed for adults at least 25 years of age with COPD using logistic regression. RESULTS: Of the adults with COPD, 36.2% were current smokers. Of the current smokers and former smokers who had quit smoking during the past year, 22.9% reported not receiving cessation advice from a health care professional during the past year Although half of smokers with COPD had attempted to quit during the past year, only 14.6% were successful. Attempting to quit was negatively associated with heavy drinking but positively associated with being younger and having cardiovascular diseases, lung cancer, and activity limitation due to lung problems. Factors predictive of successful cessation included being at least 65 years old, not being poor, and activity limitation due to lung problems. CONCLUSION: This study underscores the importance of continuing to develop smoking cessation strategies for COPD patients and implementing clinical guidelines on smoking cessation among health care providers.

State Variation in Health Care Service Utilization: United States, 2014.

KEY FINDINGS: Data from the National Health Interview Survey, 2014 •The percentage of adults without a usual place of medical care ranged from 2.8% in Vermont to 26.7% in Nevada. •The percentage of adults who did not have a general doctor visit in the past 12 months ranged from 15.9% in Vermont to 48.1% in Montana. •The percentage of adults without a usual place of medical care was lower in states that expanded Medicaid compared with nonexpansion states. •The percentage of adults without a usual place of medical care or who did not see a general doctor in the past 12 months was lower in states with partnership marketplaces compared with Federally Facilitated Marketplace states. State-level differences in the percentage of uninsured Americans, along with other factors, may affect health care access and utilization (1-4). This report examines the prevalence of two health care utilization measures among adults aged 18-64 by state. Additionally, differences by Medicaid expansion status and state Health Insurance Marketplace type are examined. Estimates are based on the 2014 National Health Interview Survey, a nationally representative sample of the noninstitutionalized U.S.

Summary health statistics for the U.S. population: National Health Interview Survey, 2003.

OBJECTIVES: This report presents both age-adjusted and unadjusted health statistics from the 2003 National Health Interview Survey (NHIS) for the civilian noninstitutionalized population of the United States, classified by age, sex, race and Hispanic or Latino origin, family income, poverty status, education, place of residence, region of residence, and where appropriate, health insurance coverage. The topics covered are health status and limitations in activities, special education or early intervention services, injuries and poisonings, health care access and utilization, and health insurance coverage. SOURCE OF DATA: The NHIS is a household, multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics. In 2003, household interviews were completed for 92,148 persons living in 35,921 households, reflecting a household response rate of 89.2%. SELECTED HIGHLIGHTS: Nearly 7 in 10 persons were in excellent or very good health in 2003. About 34 million persons (12%) were limited in their usual activities due to one or more chronic health conditions, and about 4 million persons (2%) required the help of another person with activities of daily living. About 6% of children received special education or early intervention services. Among persons under age 65 years, about 41 million (17%) did not have any health insurance coverage. The most common reason for lacking health insurance was cost, followed by a change in employment.

Summary health statistics for the U.S. population: National Health Interview Survey, 2002.

OBJECTIVES: This report presents both age-adjusted and unadjusted health statistics from the 2002 National Health Interview Survey (NHIS) for the civilian noninstitutionalized population of the United States, classified by age, sex, race and Hispanic or Latino origin, family income, poverty status, education, place of residence, region of residence, and, where appropriate, health insurance coverage. The topics covered are health status and limitations in activities, special education or early intervention services, injuries and poisonings, health care access and utilization, and health insurance coverage. SOURCE OF DATA: The NHIS is a household, multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics. In 2002, household interviews were completed for 93,386 persons living in 36,161 households, reflecting a household response rate of 89.6%. SELECTED HIGHLIGHTS: Nearly 7 in 10 persons were in excellent or very good health in 2002. About 34 million persons (12%) were limited in their usual activities due to one or more chronic health conditions, and about 4 million persons (2%) required the help of another person with activities of daily living. About 6% of children received special education or early intervention services. Among persons under age 65 years, about 40 million (17%) did not have any health insurance coverage. The most common reason for lacking health insurance was cost, followed by a change in employment.

Summary health statistics for U.S. adults: National Health Interview Survey, 2000.

OBJECTIVES: This report presents health statistics from the 2000 National Health Interview Survey for the civilian noninstitutionalized adult population, classified by sex, age, race and Hispanic origin, poverty status, and region of residence for chronic condition prevalence, health status and limitations in activity, health care access and utilization, health behaviors, and human immunodeficiency virus (HIV) testing. Also, health statistics by education, income, health insurance coverage, marital status, and place of residence are presented for health status and limitations in activity, health care access and utilization, health behaviors, and knowledge and attitudes toward HIV. SOURCE OF DATA: The NHIS is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the National Center for Health Statistics, Centers for Disease Control and Prevention, and is representative of the civilian noninstitutionalized U.S. population. Sociodemographic data are collected for everyone in the family during face-to-face interviews with adults present at the time of the interview. The health information for adults in this report was obtained from one randomly selected adult per family. HIGHLIGHTS: In 2000, 64% of adults 18 years of age and over reported excellent or very good health. Eighteen percent of adults under 65 years of age had no health insurance coverage, and 14% of adults did not have a usual place of health care. Eleven percent of adults had ever been told by a doctor or health professional that they had heart disease, and 20% had been told on two or more visits that they had hypertension. Nearly a quarter of adults were current smokers, and 22% were former smokers. Sixty percent did not engage in any leisure-time vigorous physical activity, and, based on estimates of body mass index, 35% were overweight and 21% were obese.

Summary health statistics for U.S. adults: National Health Interview Survey, 2001.

OBJECTIVES: This report presents health statistics from the 2001 National Health Interview Survey for the civilian noninstitutionalized adult population classified by sex, age, race and Hispanic origin, poverty status, and region of residence for chronic condition prevalence, health status and functional limitations, health care access and utilization, health behaviors, and human immunodeficiency virus (HIV) testing. Also, health statistics by education, income, health insurance coverage, marital status, and place of residence are presented for health status and limitations in activity, health care access and utilization, health behaviors, and knowledge and attitudes toward HIV. SOURCE OF DATA: The National Health Interview Survey is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics and is representative of the civilian noninstitutionalized U.S. population. Sociodemographic data are collected for everyone in the family during face-to-face interviews with adults present at the time of the interview. The health information for adults in this report was obtained from one randomly selected adult per family. HIGHLIGHTS: In 2001, 64% of adults 18 years of age and over reported excellent or very good health. Fifty-eight percent of adults never participated in any type of vigorous leisure-time physical activity, and 13% of adults did not have a usual place of health care. Twelve percent of adults had been told by a doctor or health professional that they had heart disease, and 21% had been told on two or more visits that they had hypertension. Nearly a quarter of all adults were current smokers, and 22% were former smokers. Based on estimates of body mass index, 36% of adults were overweight and 23% were obese.

Summary health statistics for U.S. adults: National Health Interview Survey, 2002.

OBJECTIVES: This report presents health statistics from the 2002 National Health Interview Survey (NHIS) for the civilian noninstitutionalized adult population, classified by sex, age, race and Hispanic origin, education, income, poverty status, health insurance coverage, marital status, place of residence, and region of residence for chronic condition prevalence, health status, functional limitations, health care access and utilization, health behaviors, and human immunodeficiency virus testing. The presentation of percentages and percent distributions in both age-adjusted and unadjusted versions is new this year. SOURCE OF DATA: The NHIS is a household, multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics. In 2002, data were collected for 31,044 adults for the Sample Adult questionnaire. The conditional response rate was 84.4%, and the final response rate was 74.4%. The health information for adults in this report was obtained from one randomly selected adult per family. HIGHLIGHTS: In 2002, 62% of adults 18 years of age or over reported excellent or very good health. Fifty-nine percent of adults never participated in any type of vigorous leisure-time physical activity, and 14% of adults did not have a usual place of health care. Eleven percent of adults had been told by a doctor or health professional that they had heart disease, and 21% had been told on two or more visits that they had hypertension. Twenty-two percent of all adults were current smokers, and 23% were former smokers. Based on their body mass index, 35% of adults were overweight, and 23% were obese.

Summary health statistics for the U.S. population: National Health Interview Survey, 2000.

OBJECTIVES: This report presents health statistics from the 2000 National Health Interview Survey for the civilian noninstitutionalized population of the United States, classified by age, sex, race and Hispanic or Latino origin, family income, poverty status, education, place of residence, region of residence, and, where appropriate, health insurance coverage. The topics covered are health status and limitations in activities, special education or early intervention services, injuries and poisonings, health care access and utilization, and health insurance coverage. SOURCE OF DATA: The NHIS is a household, multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention, National Center for Health Statistics. Household interviews were completed for 100,618 persons living in 38,633 households, reflecting a household response rate of 89%. SELECTED HIGHLIGHTS: Nearly 7 in 10 persons were in excellent or very good health in 2000, and fewer than 1 in 10 were in fair or poor health. About 31 million people (11%) were limited in their usual activities due to one or more chronic health conditions, and about 3 million people (2%) required the help of another person with activities of daily living such as bathing and dressing. Persons with the least education and the lowest incomes were the most likely to be limited in their ability to work. About 5% of children received special education or early intervention services. The three leading causes of medically attended injury and poisoning episodes were falls, being struck by a person or an object, and transportation. Among people under age 65 years, about 40 million (17%) did not have any health insurance coverage.

Summary health statistics for the U.S. population: National Health Interview Survey, 2001.

OBJECTIVES: This report presents health statistics from the 2001 National Health Interview Survey for the civilian noninstitutionalized population of the United States, classified by age, sex, race and Hispanic or Latino origin, family income, poverty status, education, place of residence, region of residence, and, where appropriate, health insurance coverage. The topics covered are health status and limitations in activities, special education or early intervention services, injuries and poisonings, health care access and utilization, and health insurance coverage. SOURCE OF DATA: The NHIS is a household, multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control's National Center for Health Statistics. Household interviews were completed for 100,760 persons living in 38,932 households, reflecting a household response rate of 89%. SELECTED HIGHLIGHTS: Nearly 7 in 10 persons were in excellent or very good health in 2001. About 33 million persons (12%) were limited in their usual activities due to one or more chronic health conditions, and about 4 million persons (2%) required the help of another person with activities of daily living. Persons with the least education and the lowest incomes were the most likely to be limited in their ability to work. About 6% of children received special education or early intervention services. The three leading causes of medically attended injury and poisoning episodes were falls, transportation, and overexertion. Among persons under age 65 years, about 39 million (16%) did not have any health insurance coverage. The most common reason for lacking health insurance was cost, followed by a change in employment.

Summary health statistics for U.S. children: National Health Interview Survey, 2002.

OBJECTIVES: This report presents both age-adjusted and unadjusted statistics from the 2002 National Health Interview Survey on selected health measures for children under 18 years of age, classified by sex, age, race, Hispanic origin, family structure, parent's education, family income, poverty status, health insurance coverage, place of residence, region, and current health status. The topics covered are asthma, allergies, learning disability, Attention Deficit Hyperactivity Disorder (ADHD), use of prescription medication, respondent-assessed health status, school-loss days, usual place of health care, time since last contact with a health care professional, unmet dental needs, time since last dental contact, and selected measures of health care access. SOURCE OF DATA: The NHIS is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics and is representative of the civilian noninstitutionalized population of the United States. Data are collected during face-to-face interviews with adults present at the time of interview. Information about children is collected for one randomly selected child per family in face-to-face interviews with an adult proxy respondent familiar with the child's health. SELECTED HIGHLIGHTS: In 2002, most U.S. children under 18 years of age had excellent or very good health (84%). However, 10% of children had no health insurance coverage, and 5% of children had no usual place of health care. Twelve percent of children had ever been diagnosed with asthma. An estimated 8% of children 3-17 years of age had a learning disability, and an estimated 7% of children had ADHD.

Health behaviors of adults: United States, 1999-2001.

This report presents prevalence estimates for key indicators of alcohol use, cigarette smoking, leisure-time physical activity, and body weight status among U.S. adults, using data from the 1999-2001 National Health Interview Surveys (NHIS). The NHIS is conducted annually by the Centers for Disease Control and Prevention's National Center for Health Statistics. Estimates are shown for several sociodemographic subgroups for both sexes combined and for men and women separately. Subgroups are compared in terms of prevalence of healthy and unhealthy behaviors. Methods Data for the U.S. civilian noninstitutionalized population were collected using computer-assisted personal interviews (CAPI). Questions on health behaviors were asked in the Sample Adult component of the basic core questionnaire. All data were self-reported. This report is based on a total of 96,501 completed interviews with sample adults aged 18 years and over, representing an overall sample adult response rate of 71.8% for the 3 years combined. Statistics were age adjusted to the 2000 U.S. standard population. Results Overall, 6 in 10 U.S. adults were current drinkers in 1999-2001; about 1 in 4 adults (23.1%) were lifetime abstainers. About 1 in 4 adults (23.1%) were current smokers and over one-half of adults (54.3%) had never smoked cigarettes. About 6 in 10 adults engaged in at least some leisure-time physical activity with about 3 in 10 regularly engaging in such activities. About 6 in 10 adults were overweight or obese (BMI > or = 25), with 4 in 10 adults having a healthy weight.

Prevalence of complex activity limitations among racial/ethnic groups and Hispanic subgroups of adults: United States, 2003-2009.

This brief has shown that racial and ethnic differences exist in the prevalence of complex activity limitations among adults. Further, within the U.S. Hispanic adult population, a number of significant differences were found in complex activity limitations among Mexican, Puerto Rican, Cuban, Central or South American, and other Hispanic adults­differences that would likely go unnoticed if the Hispanic population were treated as a single group. These disparities in the prevalence of complex activity limitations are further influenced by sex and age.

Update on mammography trends: comparisons of rates in 2000, 2005, and 2008.

BACKGROUND: Mammography screening allows for the early detection of breast cancer, which helps reduce mortality from breast cancer, especially in women aged 50 to 69 years. For this report, the authors updated a previous analysis of trends in mammography using newly available data from the National Health Interview Survey (NHIS). METHODS: NHIS data from 2008 were used to update trends in rates of US women who had a mammogram within the 2 years before their interview, and 2 methods of calculating rates were compared. The authors focused particularly on the 2000, 2005, and 2008 mammography rates for women aged ≥ 40 years, 40 to 49 years, 50 to 64 years, and ≥ 65 years according to selected sociodemographic and healthcare access characteristics. RESULTS: For women aged 50 to 64 years and ≥ 65 years, the patterns were similar: Rates rose rapidly from 1987 to 2000, declined, or were stable and then declined, from 2000 to 2005, and increased from 2005 to 2008. Rates for women aged 40 to 49 years rose rapidly from 1987 to 1992 and were relatively stable through 2008. There were large increases in mammography rates among immigrants who had been in the United States for <10 years, non-Hispanic Asian women, and women aged ≥ 65 years who were without ambulatory care insurance. CONCLUSIONS: Overall, mammography rates did not continue to decline between 2005 and 2008. Even so, in 2008, the percentage of women aged ≥ 40 years who had a recent mammogram fell below the Healthy People 2010 objective of 70%, which was met in 2000. However, women aged 50 to 64 years exceeded the Healthy People objective in 2000, 2005, and 2008; and some groups with very low mammography rates currently are catching up. These are important public health achievements.