The United States public health services failure to control the coronavirus epidemic.

The unprecedented COVID-19 epidemic in the United States (US) and worldwide, caused by a new type of coronavirus (SARS-CoV-2), occurred mostly because of higher-than-expected transmission speed and degree of virulence compared with previous respiratory virus outbreaks, especially earlier Coronaviruses with person-to-person transmission (e.g., MERS, SARS). The epidemic's size and duration, however, are mostly a function of failure of public health systems to prevent/control the epidemic. In the US, this failure was due to historical disinvestment in public health services, key players equivocating on decisions, and political interference in public health actions. In this communication, we present a summary of these failures, discuss root causes, and make recommendations for improvement with focus on public health decisions.

Predicting coronavirus disease (COVID-19) outcomes in the United States early in the epidemic.

By 21 October 2020, the coronavirus disease (COVID-19) epidemic in the United States (US) had infected 8.3 million people, resulting in 61,364 laboratory-confirmed hospitalizations and 222,157 deaths. Currently, policymakers are trying to better understand this epidemic, especially the human-to-human transmissibility of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in relation to social, populational, air travel related and environmental exposure factors. Our study used 50 US states' public health surveillance datasets (January 1-April 1, 2020) to measure associations of confirmed COVID-19 cases, hospitalizations and deaths with these variables. Using the resulting associations and multivariate regression (Negative Binomial and Poisson), predicted cases, hospitalizations and deaths were generated for each US state early in the epidemic. Factors associated with a significantly increased risk of COVID-19 disease, hospitalization and death included: population density, enplanement, Black race and increased sun exposure; in addition, COVID-19 disease and hospitalization were also associated with morning humidity. Although predictions of the number of cases, hospitalizations and deaths due to COVID-19 were not accurate for every state, those states with a combination of large number of enplanements, high population density, high proportion of Black residents, high humidity or low sun exposure may expect more rapid than expected growth in the number of COVID-19 events early in the epidemic.

Comorbidities and the risk of cardiovascular disease mortality among racially diverse patients with breast cancer.

BACKGROUND: Women who have coexisting comorbidities at the time of breast cancer diagnosis have an increased risk of breast cancer and overall mortality. However, the associations between newly diagnosed comorbidities and the risk of cardiovascular disease (CVD) mortality among these patients have not been examined. METHODS: The authors compared the associations between coexisting and newly diagnosed CVD, type 2 diabetes, and hypertension and the risk of CVD mortality among patients with breast cancer identified in the Missouri Cancer Registry. In total, 33,099 women who had incident invasive breast cancer with inpatient and outpatient hospital discharge data within 2 years after breast cancer diagnosis were included: 9.3% were Black. Subdistribution hazard ratios (sdHRs) and 95% CIs were calculated for the risk of CVD-related mortality using adjusted Cox proportional hazards regression models, accounting for a competing risk of breast cancer deaths. RESULTS: Within the first 2 years after breast cancer, the most reported newly diagnosed comorbidity was hypertension (9%), followed by CVD (4%), and type 2 diabetes (2%). CVD mortality was increased in women who had newly diagnosed CVD (sdHR, 2.49; 95% CI, 2.09-2.99), diabetes (sdHR, 2.16; 95% CI, 1.68-2.77), or hypertension (sdHR, 2.06; 95% CI, 1.71-2.48) compared with women who did not have these conditions. Associations were similar by race. The strongest association was among women who received chemotherapy and then developed CVD (sdHR, 3.82; 95% CI, 2.69-5.43). CONCLUSIONS: Monitoring for diabetes, hypertension, and CVD from the time of breast diagnosis may reduce CVD mortality.

Usability Assessment of the Missouri Cancer Registry's Published Interactive Mapping Reports: Round Two.

BACKGROUND: Health-related data's users have trouble understanding and interpreting combined statistical and mapping information. This is the second round of a usability study conducted after we modified and simplified our tested maps based on the first round's results. OBJECTIVE: To explore if the tested maps' usability improved by modifying the maps according to the first round's results. METHODS: We recruited 13 cancer professionals from National American Central Cancer registries (NACCR) 2016 conference. The study involved three phases per participant: A pretest questionnaire, the multi-task usability test, and the System Usability Scale (SUS). Software was used to record the computer screen during the trial and the users' spoken comments. We measured several qualitative and quantitative usability metrics. The study's data was analyzed using spreadsheet software. RESULTS: In the current study, unlike the previous round, there was no significant statistical relationship between the subjects' performance on the study test and the experience in GIS tools (P = .17 previously was .03). Three out of the four (75%) of our subjects with a bachelor's degree or less accomplished the given tasks effectively and efficiently. This study developed a comparable satisfaction results to the first round study, despite that the previous round's participants were highly educated and more experienced with GIS. CONCLUSION: By considering the round one's results and by updating our maps, we made the tested maps simpler to be used by subjects who have little experience in using GIS technology, and have little spatial and statistical knowledge.

Five Fruit and Vegetable a Day Does Not Reflect the Upward Trend of Obesity in the U.S.

OBJECTIVE: After almost three decades of U.S. surveillance in fruit and vegetable (F&V) intake and obesity, it is important to evaluate their usefulness for monitoring prevention and health promotion efforts in public health. We used U.S. surveillance data to evaluate whether the 16-year trends of F&V intake, measured by the prevalence of eating five or more servings of fruits and vegetables a day (FV5/day) is related to obesity trend as measured by its prevalence in the same period. We also evaluated whether trends in the prevalence of FV5/day by important sociodemographic factors (age, race/ethnicity, etc.) could explain the findings. STUDY DESIGN: A secondary analysis of U.S. adults (≥ 18 years) from the Behavioral Risk Factor Surveillance System (BRFSS) (1994-2009). METHODS: We categorized survey subjects for their F&V intake derived from the BRFSS six-question food frequency questionnaire into two groups: < FV5/day vs. ≥ FV5/day. Obesity was defined as BMI ≥ 30. We used logistic regressions to compute predicted prevalence of FV5/day and obesity, and to estimate the odds ratio of FV5/day by obesity and levels of sociodemographic, stratified by year. RESULTS: Between 1994 and 2009, the prevalence of FV5/day hovered around 25% among U.S. adults, while the obesity prevalence steadily increased from 14.8% to 27.4%. As measured through odds ratio, an inverse association between FV5/day and obesity was only observed in 55+, but not in other age, racial/ethnic or education groups. CONCLUSIONS: Between 1994 and 2009, we could not confirm a decrease in the prevalence of FV5/day associated with an increase in obesity prevalence, except for age 55+ group. Known disparities in FV5/day and obesity across sociodemographic factors persisted over the study period. FV5/day may be an inappropriate measure of total calories derived from eating fruits and vegetables. Its use to measure impact of public health strategies to improve nutrition and prevent obesity may be questionable.

The effect of metabolic risk factors on cancer mortality among blacks and whites.

BACKGROUND: Previous data showed that metabolic syndrome (MS) and its components are associated with cancer mortality. However, whether the association varies by race is unclear. To examine the association between metabolic risk factors and cancer death in non-Hispanic whites (whites) and non-Hispanic blacks (blacks) in the US. METHODS: We used data from National Health and Nutrition Examination Survey III (NHANES III) [1988-1994], a nationwide survey conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention in the US. We included a total of 18,001 participants aged ≥20 years in the study. We ascertained cancer death from NHANES III mortality follow-up study, which linked with the National Death Index and provides follow-up from the date of baseline NHANES III [1988-1994] through December 2006. MS was defined as the presence of at least three of five risk factors [i.e., elevated triglycerides (TG) (≥150 mg/dL), impaired fasting blood glucose (≥100 mg/dL), increased waist circumference (≥88 cm for women and ≥102 cm for men), elevated blood pressure (BP) (≥130 mmHg systolic BP or ≥85 mmHg diastolic BP) and, reduced high density lipoprotein (HDL) cholesterol (<50 mg/dL)]. The interaction between race and MS and its components against total cancer mortality was first tested. Cox proportional hazards regression was then used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for total cancer mortality in relation to each MS individual component, and a MS composite score in whites and blacks, separately. RESULTS: We found a statistically significant interaction between MS and race as well as MS components and race in their effect on cancer death. In adjusted models, elevated BP was significantly associated with a 41% increased risk of total cancer death in blacks (HR 1.41; 95% CI, 1.10-1.80) while in whites, the risk of cancer death increased 29% with central obesity (HR 1.29; 95% CI, 1.05-1.59), 26% with low HDL (HR 1.26; 95% CI, 1.04-1.52), and 45% with impaired fasting glucose (HR 1.45; 95% CI, 1.19-1.76). CONCLUSIONS: The relationship between metabolic risk factors and total cancer mortality differed by race in the US. In blacks, high BP was associated with an increased risk for cancer death while in whites, central obesity, low HDL, and especially impaired fasting glucose were positively associated with cancer death.

Improving Visualization of Female Breast Cancer Survival Estimates: Analysis Using Interactive Mapping Reports.

BACKGROUND: The Missouri Cancer Registry collects population-based cancer incidence data on Missouri residents diagnosed with reportable malignant neoplasms. The Missouri Cancer Registry wanted to produce data that would be of interest to lawmakers as well as public health officials at the legislative district level on breast cancer, the most common non-skin cancer among females. OBJECTIVE: The aim was to measure and interactively visualize survival data of female breast cancer cases in the Missouri Cancer Registry. METHODS: Female breast cancer data were linked to Missouri death records and the Social Security Death Index. Unlinked female breast cancer cases were crossmatched to the National Death Index. Female breast cancer cases in subcounty senate districts were geocoded using TIGER/Line shapefiles to identify their district. A database was created and analyzed in SEER*Stat. Senatorial district maps were created using US Census Bureau's cartographic boundary files. The results were loaded with the cartographic data into InstantAtlas software to produce interactive mapping reports. RESULTS: Female breast cancer survival profiles of 5-year cause-specific survival percentages and 95% confidence intervals, displayed in tables and interactive maps, were created for all 34 senatorial districts. The maps visualized survival data by age, race, stage, and grade at diagnosis for the period from 2004 through 2010. CONCLUSIONS: Linking cancer registry data to the National Death Index database improved accuracy of female breast cancer survival data in Missouri and this could positively impact cancer research and policy. The created survival mapping report could be very informative and usable by public health professionals, policy makers, at-risk women, and the public.

Geographic Information Systems: Usability, Perception, and Preferences of Public Health Professionals.

BACKGROUND: Analyzing and visualizing health-related databases using Geographic Information Systems (GISs) becomes essential in controlling many public health problems. OBJECTIVES: To explore the perception and preferences of public health professionals (PHPs) about the usability of GISs in public health field. METHODS: For this scoping review, the investigators searched Medline Ovid, PubMed, IEEE, Scopus, and GeoBase databases. A total of 105 articles were identified. Nine articles met the inclusion criteria. RESULTS: Iterative evaluations, training, and involvement of GIS end users are productive in GIS usability. More methodologies are needed to support the validity of GIS usability studies. The exchange of GIS technology impacts public health policy and research positively. DISCUSSION: PHPs are aware of the use of GISs in the public health field, and the exchange of visualized health data in determining inequalities and inaccessibility issues. CONCLUSION: GISs are essential to control public health problems, if the related health datasets are analyzed carefully and if the mapping reports are extensively evaluated and interpreted.

Usability Assessment of the Missouri Cancer Registry's Published Interactive Mapping Reports: Round One.

BACKGROUND:  Many users of spatial data have difficulty interpreting information in health-related spatial reports. The Missouri Cancer Registry and Research Center (MCR-ARC) has produced interactive reports for several years. These reports have never been tested for usability. OBJECTIVE:  The aims of this study were to: (1) conduct a multi-approach usability testing study to understand ease of use (user friendliness) and user satisfaction; and (2) evaluate the usability of MCR-ARC's published InstantAtlas reports. METHODS:   An institutional review board (IRB) approved mixed methodology usability testing study using a convenience sample of health professionals. A recruiting email was sent to faculty in the Master of Public Health program and to faculty and staff in the Department of Health Management and Informatics at the University of Missouri-Columbia. The study included 7 participants. The test included a pretest questionnaire, a multi-task usability test, and the System Usability Scale (SUS). Also, the researchers collected participants' comments about the tested maps immediately after every trial. Software was used to record the computer screen during the trial and the participants' spoken comments. Several performance and usability metrics were measured to evaluate the usability of MCR-ARC's published mapping reports. RESULTS: Of the 10 assigned tasks, 6 reached a 100% completion success rate, and this outcome was relative to the complexity of the tasks. The simple tasks were handled more efficiently than the complicated tasks. The SUS score ranged between 20-100 points, with an average of 62.7 points and a median of 50.5 points. The tested maps' effectiveness outcomes were better than the efficiency and satisfaction outcomes. There was a statistically significant relationship between the subjects' performance on the study test and the users' previous experience with geographic information system (GIS) tools (P=.03). There were no statistically significant relationships between users' performance and satisfaction and their education level, work type, or previous experience in health care (P>.05). There were strong positive correlations between the three measured usability elements. CONCLUSIONS: The tested maps should undergo an extensive refining and updating to overcome all the discovered usability issues and meet the perspectives and needs of the tested maps' potential users. The study results might convey the perspectives of academic health professionals toward GIS health data. We need to conduct a second-round usability study with public health practitioners and cancer professionals who use GIS tools on a routine basis. Usability testing should be conducted before and after releasing MCR-ARC's maps in the future.

Estimated and Interactively Visualized Female Breast Cancer Incidence Rates in Missouri Senate Districts: 2008-2012.

OBJECTIVES: To measure and interactively visualize female breast cancer (FBC) incidence rates in Missouri by age, race, stage and grade, and senate district of residence at diagnosis from 2008 to 2012. METHODS: An observational epidemiological study. The FBC cases in counties split by senate districts were geocoded. Population database was created. A database was created within SEER*Stat. The incidence rates and the 95% Confidence Interval (CI) were age standardized using US 2000 Standard Population. The Census Bureau's Cartographic Boundary Files were used to create maps showing Missouri senate districts. Incidence results were loaded along with the maps into InstantAtlas™ software to produce interactive reports. RESULTS: Cancer profiles were created for all 34 Missouri senate districts. An area profile and a double map that included interactive maps, graphs, and tables for the 34 Missouri senate districts were built. CONCLUSION: The results may provide an estimation of social inequality within the state and could provide clues about the impact of level of coverage and accessibility to screening and health care services on disease prevention and early diagnosis.

Increased risk for colorectal cancer under age 50 in racial and ethnic minorities living in the United States.

Colorectal cancer (CRC) is the second most common cause of cancer death in USA. We analyzed CRC disparities in African Americans, Hispanics, Asians/Pacific Islanders, and American Indians/Alaska Natives compared to non-Hispanic Whites. Current guidelines recommend screening for CRC beginning at age 50. Using SEER (Surveillance, Epidemiology, and End Results) database 1973-2009 and North American Association of Central Cancer Registries (NAACCR) 1995-2009 dataset, we performed frequency and rate analysis on colorectal cancer demographics and incidence based on race/ethnicity. We also used the SEER database to analyze stage, grade, and survival based on race/ethnicity. Utilizing SEER database, the median age of CRC diagnosis is significantly less in Hispanics (66 years), Asians/Pacific Islanders (68 years), American Indians/Alaska Natives (64 years), and African Americans (64 years) compared to non-Hispanic whites (72 years). Twelve percent of Asians/Pacific Islanders, 15.4% Hispanics, 16.5% American Indians/Alaska Natives, and 11.9% African Americans with CRC are diagnosed at age <50 years compared to only 6.7% in non-Hispanic Whites (P < 0.0001). Minority groups have more advanced stages at diagnosis compared to non-Hispanic Whites. Trend analysis showed age-adjusted incidence rates of CRC diagnosed under the age of 50 years have significantly increased in all racial and ethnic groups but are stable in African Americans. These results were confirmed through analysis of NAACCR 1995-2009 dataset covering nearly the entire USA. A significantly higher proportion of minority groups in USA with CRC are diagnosed before age 50 compared to non-Hispanic Whites, documenting that these minority groups are at higher risk for early CRC. Further studies are needed to identify the causes and risk factors responsible for young onset CRC among minority groups and to develop intervention strategies including earlier CRC screening, among others.

Information Management in Cancer Registries: Evaluating the Needs for Cancer Data Collection and Cancer Research.

Cancer registry data collection involves, at a minimum, collecting data on demographics, tumor characteristics, and treatment. A common, identified, and standardized set of data elements is needed to share data quickly and efficiently with consumers of this data. This project highlights the fact that, there is a need to develop common data elements; Surveys were developed for central cancer registries (CCRs) and cancer researchers (CRs) at NCI-designated Cancer Centers, in order to understand data needs. Survey questions were developed based on the project focus, an evaluation of the research registries and database responses, and systematic review of the literature. Questions covered the following topics: 1) Research, 2) Data collection, 3) Database/ repository, 4) Use of data, 5) Additional data items, 6) Data requests, 7) New data fields, and 8) Cancer registry data set. A review of the surveys indicates that all cancer registries' data are used for public health surveillance, and 96% of the registries indicate the data are also used for research. Data are available online in interactive tables from over 50% of CRs and 87% of CCRs. Some other survey responses indicate that CCR treatment data are not complete for example treatment data, however cancer researchers are interested in treatment variables from CCRs. Cancer registries have many data available for review, but need to examine what data are needed and used by different entities. Cancer Registries can further enhance usage through collaborations and partnerships to connect common interests in the data by making registries visible and accessible.

Melanoma surveillance in the United States: overview of methods.

BACKGROUND: Skin cancer is the most common form of cancer in the United States. Melanoma skin cancer is particularly deadly; more than 8000 US residents die from it each year. Although recent reports suggest that melanoma incidence rates have been increasing, these apparent increases could be caused by an increase in reporting and/or screening, and by an actual increase in the occurrence of melanoma. OBJECTIVE: In this report, we describe methods used in this supplement to assess the current burden of melanoma in the United States using data from two federal cancer surveillance programs: the Centers for Disease Control and Prevention (CDC) National Program of Cancer Registries and the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results program. We also provide basic descriptive epidemiologic data about melanoma in the United States. METHODS: Cancer incidence data from population-based cancer registries that participate in the CDC National Program of Cancer Registries and/or the NCI Surveillance, Epidemiology, and End Results Program covering 78% of the US population for 2004 to 2006 were used. RESULTS: Over 45 thousand melanomas were diagnosed annually, with a rate of 19 cases per 100,000 persons. LIMITATIONS: Melanoma rates may vary because of differences in reporting, diagnosis, and screening. CONCLUSION: To our knowledge, the articles in this supplement constitute the first comprehensive examination of the overall burden of melanoma in the United States based on data from a majority of the US population.

Regional differences in colorectal cancer incidence, stage, and subsite among American Indians and Alaska Natives, 1999-2004.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality for American Indians and Alaska Natives (AI/ANs), but misclassification of race causes underestimates of disease burden. METHODS: The authors compared regional differences in CRC incidence, stage at diagnosis, and anatomic distribution between AI/ANs and non-Hispanic whites (NHWs). To reduce misclassification, data from the National Program of Cancer Registries; the Surveillance, Epidemiology, and End Results Program; and the Indian Health Service (IHS) were linked. The analysis was limited to the 56% of AI/AN who live in IHS Contract Health Service Delivery Areas. RESULTS: From 1999 to 2004, the overall incidence rate (per 100,000 persons per year) of CRC was 9% lower in the AI/AN population (46.3) than in the NHW population (50.8). However, AI/AN CRC incidence rates varied nearly 5-fold regionally, from 21 in the Southwest to 102.6 in Alaska. Compared with NHW rates, AI/AN rates were significantly higher in Alaska (rate ratio [RR], 2.03), the Northern Plains (RR, 1.39), and the Southern Plains (RR, 1.16) but were lower in the Pacific Coast (RR, 0.80), the East (RR, 0.65), and the Southwest (RR, 0.45). AI/ANs were diagnosed more often with advanced CRC than with localized CRC (RR, 1.92) compared with NHWs (RR, 1.48). Females more often had proximal CRC among both the AI/AN population (females, 40.1%; males, 33.5%) and the NHW population (females, 50.1%; males, 40.3%), although AI/ANs had a higher proportion of distal cancers overall. CONCLUSIONS: CRC incidence rates in AI/AN populations varied dramatically between regions. Efforts are needed to make CRC screening a priority, overcome barriers to endoscopic screening, and to engage AI/AN communities in culturally appropriate ways to participate in prevention and early detection programs.

Breast cancer incidence among American Indian and Alaska Native women: US, 1999-2004.

BACKGROUND: Breast cancer is a leading cause of cancer morbidity and mortality among American Indian and Alaska Native (AI/AN) women. Although published studies have suggested that breast cancer rates among AI/AN women are lower than those among other racial and ethnic populations, accurate determinations of the breast cancer burden have been hampered by misclassification of AI/AN race. METHODS: Cancer incidence data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program were combined to estimate age-adjusted rates for the diagnosis years 1999 through 2004. Several steps were taken to reduce the misclassification of AI/AN race: linking cases to Indian Health Service (IHS) patient services database, restricting analyses to Contract Health Service Delivery Area counties, and stratifying results by IHS region. RESULTS: Breast cancer incidence rates among AI/AN women varied nearly 3-fold across IHS regions. The highest rates were in Alaska (134.8) and the Plains (Northern, 115.9; Southern, 115.7), and the lowest rates were in the Southwest (50.8). The rate in Alaska was similar to the rate among non-Hispanic white (NHW) women in Alaska. Overall, AI/AN women had lower rates of breast cancer than NHW women, but AI/AN women were more likely to be diagnosed with late-stage disease. CONCLUSIONS: To the authors' knowledge, this report provides the most comprehensive breast cancer incidence data for AI/AN women to date. The wide regional variation indicates an important need for etiologic and health services research, and the large percentage of AI/AN women with late-stage disease demands innovative approaches for increasing access to screening.

Case completeness and data accuracy in the Centers for Disease Control and Prevention's National Program of Cancer Registries.

BACKGROUND: Issues of case completeness (CC) and data quality within the National Program of Cancer Registries (NPCR)-Cancer Surveillance System (NPCR-CSS) are assessed in part by the NPCR Technical Assistance and Audit Program (NPCR-TAA). In addition, the NPCR Annual Program Evaluation Instrument (NPCR-APEI) provides information about NPCR-supported central cancer registries (CCRs). The current report includes a unique, national-level analysis of NPCR-TAA results linked with NPCR-APEI data and other covariates. METHODS: NPCR-TAA results for 34 CCRs were aggregated across diagnosis years 1998 to 2001 for analysis of average CC rates and site-specific data accuracy (DA) rates by covariates obtained from the NPCR-APEI, United States Cancer Statistics (USCS) publications, and the North American Association of Central Cancer Registries (NAACCR) Web site. Site-specific DA rates were calculated for the 13 data elements examined in the audit program. Small-sample Student t tests were used to determine statistically significant differences in covariates (alpha = .05). RESULTS: Overall, the average CC and DA rates were 96.4% and 95%, respectively. Both site- and data element-specific DA issues were highlighted. Higher CC and DA rates were observed for CCRs that were staffed with more certified tumor registrars, had supplementary sources reporting, and met USCS publication standards and/or achieved NAACCR certification. CONCLUSIONS: Study findings underscored the importance of CCRs having adequate, well-trained staff, procuring supplemental reporting sources, and attaining compliance with national data standards. The study results also demonstrated the overall high completeness and quality of NPCR-CSS data and provided guidance to users of the data.

Evaluating the utility and accuracy of a reverse telephone directory to identify the location of survey respondents.

PURPOSE: To investigate the utility and positional accuracy of a reverse telephone directory to enhance geocoding using self-reported street addresses. METHODS: This cross-sectional study used 2001 self-reported survey data from 2636 participants in three Missouri areas. When available, street addresses were appended to participant telephone numbers using a reverse telephone directory. The odds of finding a telephone number in the reverse directory and the positional accuracy between self-reported addresses and those obtained from the reverse directory were calculated. We also determined the quality of self-reported address information and that obtained by means of the reverse telephone directory. RESULTS: Rural respondents, younger respondents, women, African Americans, and respondents with less than a high school education were less likely to have their telephone number present in the reverse directory. Using the reverse directory increased the overall percentage of respondents whose addresses were geocoded from 51.5% to 72.0%. Eighty-one percent of addresses were geocoded to the same US Census Block Group and 89% were geocoded to the same Census Tract as the self-reported addresses. CONCLUSIONS: The street address of survey participants obtained through the reverse directory can be used to augment the unknown location of telephone survey respondents but specific groups of people are less likely to be found in the directory.

The prevalence of arthritis and activity limitation and their predictors in Missouri.

Arthritis and other rheumatic conditions comprise the leading cause of disability in the United States. In 1990, an estimated 16.7% of Missourians had arthritis. By 2020, an estimated 20% of Missourians will have this condition. We examined Missouri's prevalence of self-reported physician-diagnosed arthritis, chronic joint symptoms, and activity limitation due to joint symptoms and their associations with selected predictors (i.e., socio-demographic, access to health care, risk factor, and comorbidity indicators) from Missouri's 1996 Behavioral Risk Factor Surveillance System. We conducted logistic regression analysis to generate Odds Ratios and 95% Confidence Intervals of arthritis and activity limitation across levels of predictors. Analysis indicates arthritis is under-diagnosed in younger individuals and that arthritis and activity limitation due to joint symptoms are significant contributors to functional limitation, enhancing dependency while decreasing the quality of life. As the population ages, arthritis, chronic joint symptoms, and activity limitation will become a larger public health problem.