Overview of the 2019 National Health Interview Survey Questionnaire Redesign.

Data System. Federal health surveys, like the National Health Interview Survey (NHIS), represent important surveillance mechanisms for collecting timely, representative data that can be used to monitor the health and health care of the US population. Data Collection/Processing. Conducted by the National Center for Health Statistics (NCHS), NHIS uses an address-based, complex clustered sample of housing units, yielding data representative of the civilian noninstitutionalized US population. Survey redesigns that reduce survey length and eliminate proxy reporting may reduce respondent burden and increase participation. Such were goals in 2019, when NCHS implemented a redesigned NHIS questionnaire that also focused on topics most relevant and appropriate for surveillance of child and adult health. Data Analysis/Dissemination. Public-use microdata files and selected health estimates and detailed documentation are released online annually. Public Health Implications. Declining response rates may lead to biased estimates and weaken users' ability to make valid conclusions from the data, hindering public health efforts. The 2019 NHIS questionnaire redesign was associated with improvements in the survey's response rate, declines in respondent burden, and increases in data quality and survey relevancy. (Am J Public Health. 2023;113(4):408-415. https://doi.org/10.2105/AJPH.2022.307197).

National Center for Health Statistics Guidelines for Analysis of Trends.

Many reports present analyses of trends over time based on multiple years of data from National Center for Health Statistics (NCHS) surveys and the National Vital Statistics System (NVSS). Trend analyses of NCHS data involve analytic choices that can lead to different conclusions about the trends. This report discusses issues that should be considered when conducting a time trend analysis using NCHS data and presents guidelines for making trend analysis choices. Trend analysis issues discussed include: choosing the observed time points to include in the analysis, considerations for survey data and vital records data (record level and aggregated), a general approach for conducting trend analyses, assorted other analytic issues, and joinpoint regression. This report provides 12 guidelines for trend analyses, examples of analyses using NCHS survey and vital records data, statistical details for some analysis issues, and SAS and SUDAAN code for specification of joinpoint regression models. Several an lytic choices must be made during the course of a trend analysis, and the choices made can affect the results. This report highlights the strengths and limitations of different choices and presents guidelines for making some of these choices. While this report focuses on time trend analyses, the issues discussed and guidelines presented are applicable to trend analyses involving other ordinal and interval variables.

Comparison of in-home collection of physical measurements and biospecimens with collection in a standardized setting: the health measures at home study.

OBJECTIVES: Collection of physical measurements and biospecimens in the home may be an efficient way to obtain objective health measurements. This study assesses differences between collection in the home and a standardized setting. METHODS: Participants had physical measurements and biospecimens taken in the National Health and Nutrition Examination Survey mobile examination center (MEC). Then, they had height and weight measured in the MEC using portable equipment. In the home, participants had height, weight, and blood pressure measured and dried blood spots collected using portable equipment. Two complete examinations were done in the home: one by a health technician and one by a field interviewer. RESULTS: Home environments were less standardized and presented more challenges to examiners. Correlations between all four height measurements and all four weight measurements were higher than 99%. Mean differences in height (0.3 cm) and weight (0.4 kg) were small but statistically significant. The home measurements perfectly or near-perfectly classified participants as obese relative to the standardized MEC examination. CONCLUSIONS: The selected physical measurements can be collected in the home by field interviewers using portable equipment. Before adding home collection of physical measurements to household interview surveys, further research should be done to examine the impact of these changes on interviewer training, participant recruitment, and participant response rates.

The geography of heterosexual partnerships in Baltimore city adults.

BACKGROUND: Human immunodeficiency virus/sexually transmitted disease (HIV/STD) risk is determined in part by sexual network characteristics, which include spatial parameters. Geography and proximity of partner selection are important factors, which may explain neighborhood-level differences in HIV/STD morbidity. To study the effects of neighborhood factors on HIV/STD transmission in high-density urban areas, the geography of partner selection must be understood. METHODS: The Baltimore site of the National HIV Behavioral Surveillance system surveyed adults reporting one or more heterosexual partnerships. Spatial assortativity was defined as both partners residing in the same or adjacent census tracts and based on participant report. HIV core areas were defined as the census tracts in the top quartile for standardized HIV/AIDS case rates. RESULTS: Participants (n = 307) provided data on 776 recent sexual partnerships, and geographic information were obtained for 510 partnerships (66%). Almost half (47%) reported choosing spatially assortative partners. Participants who lived in high HIV-prevalence areas were more likely to choose spatially assortative partners than residents of lower prevalence areas after adjusting for partnership type, gender, and number of partners. Although this population exhibited assortative mixing in all types of partnerships, racial and age assortativities were not associated with choosing spatially assortative partners. CONCLUSIONS: Over 15 years ago, STD clinic patients in Baltimore were found to seek partners within close proximity. We confirm these results in a non-STD clinic population, indicating a continuing need for neighborhood approaches to intervention programs in urban areas.

Sexually transmitted infection prevalence and behavioral risk factors among Latino and non-Latino patients attending the Baltimore City STD clinics.

BACKGROUND: Many studies have evaluated factors influencing sexually transmitted diseases (STD)/HIV disparities between black and white populations, but fewer have explicitly included Latinos for comparison. METHODS: We analyzed demographic and behavioral data captured in electronic medical records of patients first seen by a clinician in 1 of 2 Baltimore City public STD clinics between 2004 and 2007. Records from white, black, and Latino patients were included in the analysis. RESULTS: There were significant differences between Latinos and other racial/ethnic groups for several behavioral risk factors studied, with Latino patients reporting fewer behavioral risk factors than other patients. Latinos were more likely to have syphilis, but less likely to have gonorrhea than other racial/ethnic groups. English-proficient Latina (female) patients reported higher rates of infection and behavioral risk factors than Spanish-speaking Latina patients. After adjustment for gender and behavioral risk factors, Spanish-speaking Latinas also had significantly less risk of sexually transmitted infections than did English-speaking Latinas. CONCLUSIONS: These results are consistent with other studies showing that acculturation (as measured by language proficiency) is associated with increases in reported sexual risk behaviors among Latinos. Future studies on sexual risk behavior among specific Latino populations, characterized by country of origin, level of acculturation, and years in the United States, may identify further risk factors and protective factors to guide development of culturally appropriate STD/HIV interventions.

Cigar smoking prevalence and morbidity among US adults, 2000-2015.

Cigar smoking causes many of the same health conditions as cigarettes, but less information is available on prevalence of use trends and the disease burden of cigar smoking in the US. To examine these issues, we analyzed cigar use and health condition data from the National Health Interview Survey from 2000, 2005, 2010, and 2015, estimating prevalence of use by year and over time. We also estimated the number of, and adjusted disease prevalence ratios for, US adults aged ≥35 years with self-reported history of heart disease, stroke, or cancer attributable to cigar smoking. We found that prevalence of current cigar smoking has remained generally stable at around 2.3% among US adults aged ≥18 years between 2000 and 2015 but has increased among female and non-Hispanic black adults. Former exclusive cigar smokers were more likely to report having had heart conditions (aPR = 1.33, 95% CI = 1.03-1.72), stroke (aPR = 2.42, 95% CI = 1.57-3.75), and cancer (aPR = 1.44, 95% CI = 1.09-1.88) than never cigar smokers. It is estimated that nearly 200,000 cardiovascular conditions and cancer cases among US adults are attributable to former exclusive cigar smoking. This analysis shows that prevalence of current cigar smoking has remained stable among US adults but has increased among certain demographic groups. Former exclusive cigar use is associated with increased prevalence of heart disease, stroke, and cancer, which may result in part from smoking cessation following disease onset.

Association of Birthplace and Coronary Heart Disease and Stroke Among US Adults: National Health Interview Survey, 2006 to 2014.

BACKGROUND: The proportion of foreign-born US adults has almost tripled since 1970. However, less is known about the cardiovascular morbidity by birthplace among adults residing in the United States. This study's objective was to compare the prevalence of coronary heart disease (CHD) and stroke among US adults by birthplace. METHODS AND RESULTS: We used data from the 2006 to 2014 National Health Interview Survey. Birthplace was categorized as United States or foreign born. Foreign born was then grouped into 6 birthplace regions. We defined CHD and stroke as ever being told by a physician that she or he had CHD or stroke. We adjusted for select demographic and health characteristics in the analysis. Of US adults, 16% were classified as foreign born. Age-standardized prevalence of both CHD and stroke were higher among US- than foreign-born adults (CHD: 8.2% versus 5.5% for men and 4.8% versus 4.1% for women; stroke: 2.7% versus 2.1% for men and 2.7% versus 1.9% for women; all P<0.05). Comparing individual regions with those of US- born adults, CHD prevalence was lower among foreign-born adults from Asia and Mexico, Central America, or the Caribbean. For stroke, although men from South America or Africa had the lowest prevalence, women from Europe had the lowest prevalence. Years of living in the United States was not related to risk of CHD or stroke after adjustment with demographic and health characteristics. CONCLUSIONS: Overall, foreign-born adults residing in the United States had a lower prevalence of CHD and stroke than US-born adults. However, considerable heterogeneity of CHD and stroke risk was found by region of birth.

Reasons for Emergency Room Use Among U.S. Adults Aged 18-64: National Health Interview Survey, 2013 and 2014.

OBJECTIVE: This report examines the percentage of adults aged 18­64 who had an emergency room (ER) visit and their reasons for the most recent visit. METHODS: Using the 2013 and 2014 National Health Interview Survey, estimates of use in the past year and reasons for most recent ER visit are presented. A hierarchy was created to classify respondents' reasons for their last ER visit into three mutually exclusive categories: seriousness of the medical problem, doctor's office or clinic was not open, and lack of access to other providers. RESULTS: In 2014, 18% of adults visited the ER one or more times. Seriousness of the medical problem was the reason for the most recent ER visit for 77% of adults aged 18­64, 12% because their doctor's office was not open, and 7% because of a lack of access to other providers (4% did not select any reason). Percentages were similar in 2013. Controlling for other variables, adults with Medicaid were most likely to report that seriousness of the medical problem was the reason for the most recent ER visit. Adults with private coverage were most likely to have used the ER because the doctor's office was not open. Uninsured adults were more likely than adults with private coverage to have visited the ER because they lacked access to other providers. Differences in reasons for use between demographic groups were also identified. CONCLUSIONS: Few changes in ER use were noted between 2013 and 2014. Differences persist in ER use and reasons for ER use at most recent visit by insurance type as well as sociodemographic characteristics.

Comparison of blood pressure measurements obtained in the home setting: analysis of the Health Measures at Home Study.

BACKGROUND: Automated blood pressure (BP) devices have been used in the home for self-management purposes and are increasingly being used in population-based research. Although these devices are convenient and affordable and may be used by inexperienced lay personnel, the potential impact of an examiner's skill level on the results needs to be evaluated quantitatively. The aim of this study was to compare BP measurements obtained in a home setting by personnel with healthcare experience with those obtained by personnel without healthcare experience. In addition, the percent agreement in high blood pressure (HBP) classification between the home BP measurement by the field interviewer (FI) and measurements obtained in a standardized environment was examined. METHODS: The Health Measures at Home Study was a pilot study carried out among 128 adult participants recruited from the National Health and Nutrition Examination Survey. The Health Measures at Home Study provided the opportunity to compare the BP values obtained with an automated device in a home setting by both experienced health technicians (HTs) with those obtained by FIs who had no healthcare experience. Differences between measurements obtained by the HT and measurements obtained by the FI were assessed using paired t-tests, Pearson's correlations, and Bland-Altman plots. Percent agreement and κ-statistics were used to assess agreement in HBP classification between examiners in the home. Measurements obtained by the FI were also compared with those obtained in the National Health and Nutrition Examination Survey mobile exam center (MEC) by a physician using percent agreement and κ-statistics. RESULTS: There was a high correlation in both systolic blood pressure (SBP; r=0.903) and diastolic blood pressure (DBP; r=0.894) between measurements obtained by HTs and those obtained by FIs. The mean SBP and DBP obtained by the FIs (SBP, 119.0±14.4 mmHg; DBP, 71.9±9.8 mmHg) were significantly higher than the HT measurements (SBP, 117.0±12.7 mmHg; DBP, 69.9.9±9.2 mmHg). In the home, the FI classified 11.7% as having HBP, whereas the HT classified 7.0%. The percent of individuals classified as having HBP by the physician in the MEC was 10.2% of the participants. CONCLUSION: Operationally, FIs could take BP measurements in the home; however, there were some differences between measurements obtained by the FI and HT. The absolute difference between measurements obtained by the FI and those obtained by the HT in the home showed that measurements obtained by the FI tended to be higher than the HT, but the magnitude of these differences was less than 5 mmHg. The HT classified 7.0% of HBP whereas the FI classified 11.7% of HBP. Similarly, the FI and the MEC physician classified a different percent of individuals with HBP. Further investigation is warranted to determine the cause of these small but significant absolute differences between measurements obtained by the FI and HT.

The relationship between linkage refusal and selected health conditions of survey respondents.

To maximize limited resources and reduce respondent burden, there is an increased interest in linking population health surveys with other sources of data, such as administrative records. Health differences between adults who consent to and refuse linkage could bias study results with linked data. National Health Interview Survey (NHIS) data are routinely linked to administrative records from the Social Security Administration and the Centers for Medicare and Medicaid Services. Using the NHIS 2010-2013, we examined the association between selected health conditions and respondents' linkage refusal. Linkage refusal was significantly lower for adults with serious psychological distress, chronic obstructive pulmonary disease, diabetes, heart disease, stroke, hypertension, and cancer compared to those without these conditions. Linkage refusal decreased as the number of conditions increased and health status decreased. Our finding that linkage consent was associated with respondents' health characteristics suggests that researchers should try to address potential linkage bias in their analyses.

Electronic Cigarette Use Among Adults: United States, 2014.

The National Health Interview Survey (NHIS) first began collecting data about e-cigarette use in 2014. The estimates presented in this report provide a foundation for understanding who is using e-cigarettes and for monitoring changes in e-cigarette use among U.S. adults over time. In 2014, men were more likely than women to have ever tried e-cigarettes but were not more likely to be current users. Younger adults were more likely than older adults to have tried e-cigarettes and to currently use e-cigarettes. Both non-Hispanic AIAN and non-Hispanic white adults were more likely than non-Hispanic black, non-Hispanic Asian, and Hispanic adults to have ever tried e-cigarettes and to be current e-cigarette users. When examined in the context of conventional cigarette smoking, use of e-cigarettes was highest among current and recent former cigarette smokers, and among current smokers who had made a quit attempt in the past year. Although fewer than 4% of adults who had never smoked conventional cigarettes had ever tried an e-cigarette, nearly 1 in 10 never-smokers aged 18­24 had tried an e-cigarette at least once.

Use of low-dose aspirin as secondary prevention of atherosclerotic cardiovascular disease in US adults (from the National Health Interview Survey, 2012).

Current guidelines recommend that adults with atherosclerotic cardiovascular disease take low-dose aspirin or other antiplatelet medications as secondary prevention of recurrent cardiovascular events. Yet, no national level assessment of low-dose aspirin use for secondary prevention of cardiovascular disease has been reported in a community-based population. Using data from the 2012 National Health Interview Survey, we assessed low-dose aspirin use in those with atherosclerotic cardiovascular disease. We estimated the prevalence ratios of low-dose aspirin use, adjusting for sociodemographic status, health insurance, and cardiovascular risk factors. In those with atherosclerotic cardiovascular disease (n = 3,068), 76% had been instructed to take aspirin and 88% of those were following this advice. Of those not advised, 11% took aspirin on their own. Overall, 70% were taking aspirin (including those who followed their health care provider's advice and those who were not advised but took aspirin on their own). Logistic regression models showed that women, non-Hispanic blacks and Hispanics, those aged 40 to 64 years, with a high school education or with some college, or with fewer cardiovascular disease risk factors were less likely to take aspirin than men, non-Hispanic whites, those aged ≥65 years, with a college education or higher, or with all 4 selected cardiovascular disease risk factors, respectively. Additional analyses conducted in those with coronary heart disease only (n = 2,007) showed similar patterns. In conclusion, use of low-dose aspirin for secondary prevention was 70%, with high reported adherence to health care providers' advice to take low-dose aspirin (88%) and significant variability within subgroups.

Collection and laboratory methods for dried blood spots for hemoglobin A1c and total and high-density lipoprotein cholesterol in population-based surveys.

BACKGROUND: The Health Measures at Home Study was a study designed to evaluate the feasibility of incorporating dried blood spots (DBS) collection into the National Health Interview Survey and to compare the proficiencies between field interviewers and health technicians in obtaining DBS. METHODS: DBS collection and venipuncture were attempted on 125 participants. The DBS were collected in the participant's home and venous blood was collected in the National Health and Nutrition Examination Survey (NHANES) mobile examination center. The DBS results were compared to venous results in the NHANES for the measurements of hemoglobin A1c (HbA1c) and total and high-density lipoprotein (HDL) cholesterol. RESULTS: Field interviewers and health technicians were able to collect the DBS for greater than 95% of participants. For DBS, health technicians and field interviewers were highly correlated for HbA1c (r=0.92) and total cholesterol (r=0.89), but not for HDL cholesterol (r=0.72). The DBS results of interviewers and health technicians compared to the venous method for HbA1c (r=0.90), but did not compare well for HDL cholesterol (r=0.64-0.66) and total cholesterol (r=0.65-0.67). CONCLUSION: DBS was comparable to venous HbA1c, but not for total and HDL cholesterol. Health technicians and field interviewers had similar performance for DBS methods, except HDL cholesterol.

Consequences of a restrictive syringe exchange policy on utilisation patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk.

INTRODUCTION AND AIMS: Syringe distribution policies continue to be debated in many jurisdictions throughout the USA. The Baltimore Needle and Syringe Exchange Program (NSP) operated under a 1-for-1 syringe exchange policy from its inception in 1994 through 1999, when it implemented a restrictive policy (2000-2004) that dictated less than 1-for-1 exchange for non-program syringes. DESIGN AND METHODS: Data were derived from the Baltimore NSP, which prospectively collected data on all client visits. We examined the impact of this restrictive policy on program-level output measures (i.e. distributed : returned syringe ratio, client volume) before, during and after the restrictive exchange policy. Through multiple logistic regression, we examined correlates of less than 1-for-1 exchange ratios at the client level before and during the restrictive exchange policy periods. RESULTS: During the restrictive policy period, the average annual program-level ratio of total syringes distributed : returned dropped from 0.99 to 0.88, with a low point of 0.85 in 2000. There were substantial decreases in the average number of syringes distributed, syringes returned, the total number of clients and new clients enrolling during the restrictive compared to the preceding period. During the restrictive period, 33 508 more syringes were returned to the needle exchange than were distributed. In the presence of other variables, correlates of less than 1-for-1 exchange ratio were being white, female and less than 30 years old. DISCUSSION AND CONCLUSIONS: With fewer clean syringes in circulation, restrictive policies could increase the risk of exposure to HIV among Injection Drug Users (IDUs) and the broader community. The study provides evidence to the potentially harmful effects of such policies.

Reasons for emergency room use among U.S. children: National Health Interview Survey, 2012.

KEY FINDINGS: Data from the National Health Interview Survey, 2012. In 2012, children with Medicaid coverage were more likely than uninsured children and those with private coverage to have visited the emergency room (ER) at least once in the past year. About 75% of children's most recent visits to an ER in the past 12 months took place at night or on a weekend, regardless of health insurance coverage status. The seriousness of the medical problem was less likely to be the reason that children with Medicaid visited the ER at their most recent visit compared with children with private insurance. Among children whose most recent visit to the ER was for reasons other than the seriousness of the medical problem, the majority visited the ER because the doctor's office was not open. Emergency rooms (ERs) are intended to provide care for acute and life-threatening medical conditions for people of all ages, but use is highest among older adults and young children (1). In 2012, 18% of children aged 0-17 years visited the ER at least once in the past year (2). Rising health care costs make it important to understand the reasons that families with children seek ER care, rather than less expensive office-based or outpatient care (3). Families visiting the ER at night or on weekends may have different characteristics or reasons for using the ER than those who visit during the day (4). Previous research among adults found that the majority visited the ER because "only a hospital could help," or the "doctor's office [was] not open" (5). This report provides comparable statistics on reasons for children's ER use.

Trends in insurance coverage and source of private coverage among young adults aged 19-25: United States, 2008-2012.

KEY FINDINGS: Data from the National Health Interview Survey, 2008-2012. The percentage of young adults with private health insurance coverage increased from the last 6 months of 2010 through the last 6 months of 2012 (52.0% to 57.9%). Except for an increase in the first 6 months of 2011, the percentage of privately insured young adults who had a gap in coverage during the past 12 months decreased from the first 6 months of 2008 through the last 6 months of 2012 (10.5% to 7.8%). The percentage of privately insured young adults with coverage in their own name decreased from 40.8% in the last 6 months of 2010 to 27.2% in the last 6 months of 2012. The percentage of privately insured young adults with employer-sponsored health insurance increased from the last 6 months of 2010 to the last 6 months of 2012 (85.6% to 92.5%). Young adults often experience instability with regard to work, school, residential status, and financial independence. This could contribute to a lack of or gaps in insurance coverage (1,2). In September 2010, the Affordable Care Act (ACA) extended dependent health coverage to young adults up to age 26. This provision was expected to lead to increases in private coverage for young adults aged 19-25 when they became eligible for coverage through their parents' employment (3,4). This report provides estimates describing the previous insurance status and sources of coverage among privately insured young adults aged 19-25, using data from the 2008-2012 National Health Interview Survey (NHIS). Comparisons are made with adults aged 26-34, the most similar age group that was not affected by the ACA provision.

Strategies used by adults to reduce their prescription drug costs.

In 2011, Americans spent $45 billion out-of-pocket on retail prescription drugs (1). Some adults reduce prescription drug costs by skipping doses and delaying filling prescriptions (2). Some cost-reduction strategies used by adults have been associated with negative health outcomes. For example, adults who do not take prescription medication as prescribed have been shown to have poorer health status and increased emergency room use, hospitalizations, and cardiovascular events (3,4). This report analyzes different strategies used by U.S. adults to reduce their prescription drug costs, by age, health insurance status, and poverty status, using data from the 2011 National Health Interview Survey (NHIS).

Health insurance coverage and adverse experiences with physician availability: United States, 2012.

KEY FINDINGS: Data from the National Health Interview Survey, 2012. In the 12 months prior to interview, 2.4% of people in the U.S. had problems finding a general doctor, 2.1% had been told that a doctor would not accept them as new patients, and 2.9% had been told that a doctor did not accept their health care coverage. People under age 65 who had public coverage only were more likely than those with private insurance to have these three types of adverse experiences with physician availability. Adults aged 18-64 who were uninsured were more likely than privately insured adults to have trouble finding a general doctor or be told that a doctor would not accept them as new patients. Adults aged 65 and over with Medicare only were as likely as those with both Medicare and private insurance to have these experiences with physician availability. Rates of private insurance and public coverage have been increasing (1,2). As coverage and utilization increase, a growing concern is the availability of health care providers to meet patient needs (3). Almost 90% of general physicians accept new patients with private insurance, but less than 75% accept new patients with public coverage (e.g., Medicare, Medicaid), and the proportion of specialists accepting new patients with Medicare or Medicaid is declining (4). While most studies approach access from a provider perspective, this report examines the percentage of people who had each of three adverse experiences with physician availability in the past 12 months. Estimates were produced by age group and health insurance status using data from the 2012 National Health Interview Survey (NHIS).

Assessing measurement error in Medicare coverage from the National Health Interview Survey.

OBJECTIVES: Using linked administrative data, to validate Medicare coverage estimates among adults aged 65 or older from the National Health Interview Survey (NHIS), and to assess the impact of a recently added Medicare probe question on the validity of these estimates. DATA SOURCES: Linked 2005 NHIS and Master Beneficiary Record and Payment History Update System files from the Social Security Administration (SSA). STUDY DESIGN: We compared Medicare coverage reported on NHIS with "benchmark" benefit records from SSA. PRINCIPAL FINDINGS: With the addition of the probe question, more reports of coverage were captured, and the agreement between the NHIS-reported coverage and SSA records increased from 88% to 95%. Few additional overreports were observed. CONCLUSIONS: Increased accuracy of the Medicare coverage status of NHIS participants was achieved with the Medicare probe question. Though some misclassification remains, data users interested in Medicare coverage as an outcome or correlate can use this survey measure with confidence.