Washington Global Health Alliance Discovery Series Ali Mokdad June 2, 2008 'Surveillance in a Changing Environment'

1. Surveillance in a Changing Environment Ali H. Mokdad, Ph.D. Centers for Disease Control and Prevention Atlanta, GA, USA

5. What problems are we trying to address?

10. Establish and Track Health Objectives

11. Prevalence of Obesity* Among U.S. Adults Prevalence of Diabetes* Among U.S. Adults (*Includes gestational diabetes) 1990 1990 1996 1996 2004 2004 No Data < 4% 4%-6% 6-8% 8-10% No Data < 10% 10%–14% 15%–19% 20%-24%  25% >10% (*BMI  30, or about 30 lbs overweight for 5’4” person)

12. Prevalence of Women Who Never Had a Mammogram, Ages 40 and Older BRFSS 1990–2004

13. Support Policies and Legislation: Mandatory Insurance Coverage for Screening Mammography 1981 1990 2004 No mandatory insurance coverage for screening mammography. Mandatory insurance coverage for screening mammography. Source: National Cancer Institute — State Cancer Legislative Database Program, Bethesda, MD, 2004.

14. Support Policies and Legislation: Prevalence of Safety Belt Use, 2002 Areas with primary safety belt laws Prevalence > 80% of always using a safety belt among persons aged > 18 years. Prevalence < 80% of always using a safety belt among persons aged > 18 years. Source: CDC. Impact of primary laws on adult use of safety belts – United States, 2002. MMWR 2004;53:257-260.

16. Healthy People in Healthy Places

17. People Prepared for Emerging Health Threats

27. WEAT Startup Screen

28. WEAT Crosstabs Application Select Age by General Health

29. WEAT Crosstabs Application Age by General Health Control Race

30. WEAT Logistic Application Select Independent Variable

31. WEAT Logistic Application Output for ‘Overweight’ Dependent, ‘Exercise’ Independent Reference = ‘yes’

33. Response rate trends: Behavioral Risk Factor Surveillance System (BRFSS)

36. Percent Distribution of Household Telephone Status for Adults, July-December 2007 Wireless Only: 14.5% Landline with Some Wireless: 49.2% Landline Only: 19.1% Unknown: 1.3% Phoneless: 1.9% Wireless Mostly: 14.0%

43. Goal: Optimize survey design to decrease total survey error for a given cost Costs Measurement Nonresponse Coverage Sampling

45. Assessing Data Validity

48. Monitoring the Data Collection Process

54. Refining post-survey adjustments

59. Does It Represent an Improvement?

60. Changes in estimate of health status Percentage with Fair or Poor Health Status 19.0 20.0 21.0 22.0 23.0 24.0 25.0 BRFSS Final Weight Add Race Add Education Add Marital Status Add Age by Educ Add Age by Race % At Risk

63. Benchmarking to external standards

68. Ever smoke cigarettes 42.4% 44.0% 48.0%

69. Ever told had diabetes 8.1% 8.0% 6.1%

70. Body Mass Index 27.0 27.0 27.6

71. Percentage of 18–34 year olds 31.2% 31.5% 41.5%

72. Percentage of Males 48.4% 48.4% 50.9%

73. Percentage of whites 71.7% 70.4% 74.9%

75. Finding new ways of collecting data: Cell phones & Address-based sampling

76. The Plague of Cell Phones!!!

79. Response rates 14.8% 29.7% 14.1%

80. Landline and Cell phone populations and frames CELL PHONE LANDLINE A B C

81. Percent male 46.6 51.1 38.2 37.9 Landline survey Cell phone survey State equalized design weight applied

82. Percent 18–34 years 24.0 51.4 19.6 14.5 Landline survey Cell phone survey State equalized design weight applied

83. Percent Hispanic 15.2 21.4 12.2 16.8 Landline survey Cell phone survey State equalized design weight applied

84. Percent high school or less education 39.8 48.5 33.6 60.3 Landline survey Cell phone survey State equalized design weight applied

85. Comparison of key survey estimates

86. Percent any kind of health care coverage 86.0 70.1* 89.0 78.7 Landline survey Cell phone survey State equalized design weight applied

87. Percent currently smoke cigarettes 19.7 31.1* 17.3 24.8 Landline survey Cell phone survey State equalized design weight applied

88. Percent ever tested for HIV 43.6 54.2* 36.6 37.5 Landline survey Cell phone survey State equalized design weight applied

89. Percent binge drink past 30 days 13.0 23.5 21.1 11.0 Landline survey Cell phone survey State equalized design weight applied

91. Address-based sampling

93. Response rates by mode: 2003 BRFSS mode pilot (address-matched sample)

96. Item Nonresponse: Telephone vs Mail (Percent DK / RF / Blank) Note: Percentages are unweighted. Significance: * p<.05, ** p<.01, *** p < .001 1 Questions not asked of respondents age 65 years or older Health condition / risk factor Telephone (%) Mail (%) Asthma 0.2 2.4 *** Diabetes 0.1 0.9 *** High blood pressure 0.2 1.7 *** Obese (BMI > 30) 8.2 3.0*** Current smoker 0.4 1.9 *** Binge drinking 2.3 2.1 Tested for HIV 1 5.6 2.8*** HIV risk behaviors 1 3.7 3.4

97. Potential mode affects on response: Unadjusted estimates ‡ Questions not asked of respondents age 65 years or older Health condition / risk factor Unadjusted prevalence estimates CATI % (95% CI) Mail Survey % (95% CI) Web survey % (95%CI) Asthma 11.7 (10.3-13.1) 12.0 (9.8-14.2) 11.9 (10.0-13.8) Diabetes 9.5 (8.2-10.8) 11.9 (9.7-14.1) 10.2 (8.4-12.0) High blood pressure 31.1 (29.1-33.1) 38.1 (34.8-41.4) 33.2 (30.5-35.9) Obese (BMI > 30) 21.6 (19.8-23.4) 26.5 (23.5-29.5) 25.6 (23.0-28.2) Current smoker 22.8 (21.0-24.6) 16.9 (14.4-19.4) 17.3 (15.1-19.5) Binge drinking 14.4 (12.9-15.9) 12.3 (10.1-14.5) 21.6 (9.0-24.2) STD prevention 1 8.2 (6.8 - 9.6) 4.3 (2.6 - 6.0) 3.3 (2.2 - 4.4) Tested for HIV 1 38.8 (36.3-41.3) 30.8 (27.0-34.6) 32.1 (29.1-35.1)

98. Potential mode affects on response: Adjusted estimates * Models are adjusted for respondents’ state of residence, sex, race, age, education, and number of adults in the household. 1 Questions not asked of respondents age 65 years or older Health condition / risk factor Adjusted odds ratios * CATI Mail survey AOR (95%CI) Web survey AOR (95%CI) Asthma 1.0 1.07 (0.84-1.34) 1.06 (0.83-1.38) Diabetes 1.0 1.16 (0.89-1.51) 1.30 (1.01-1.67) High blood pressure 1.0 1.22 (1.01-1.46) 1.30 (1.09-1.54) Obese (BMI > 30) 1.0 1.37 (1.12-1.66) 1.31 (1.10-1.57) Current smoker 1.0 0.83 (0.67-1.03) 0.77 (0.63-0.93) Binge drinking 1.0 1.17 (0.90-1.52) 1.87 (1.50-2.34) STD prevention 1 1.0 0.69 (0.43-1.12) 0.51 (0.33-0.78) Tested for HIV 1 1.0 0.81 (0.65-1.01) 0.85 (0.71-1.03)

102. Response rates

103. RDD telephone and ABS multimode survey AAPOR #4 response rates State RDD telephone survey ABS multimode Survey Mail survey (only) Telephone follow-up (only) CA 25.4 36.1*** 33.1 3.0 FL 32.8 37.4*** 33.4 4.0 MA 26.3 42.4*** 36.5 5.9 MN 48.5 54.1*** 48.5 5.6 SC 49.1 41.8*** 37.3 4.5 TX 28.7 35.3*** 30.8 4.5 Mean 35.1 41.2 36.6 4.6

104. Comparison of respondent demographics

105. Percent male 48.6 39.3 40.9 41.3 38.5 RDD and ABS data weighted by state equalized design weight only.

106. Percent 18-34 years old 31.1 19.0 17.6 16.8 22.7 RDD and ABS data weighted by state equalized design weight only.

107. Percent 65 year old and older 16.9 22.7 23.9 24.8 18.2 RDD and ABS data weighted by state equalized design weight only.

108. Percent some college or more 55.7 55.7 69.2 55.0 67.2 RDD and ABS data weighted by state equalized design weight only. 60.8

109. Percent Hispanic 16.2 14.9 8.9 7.9 14.9 RDD and ABS data weighted by state equalized design weight only.

110. Percent one adult households 18.6 16.8 17.0 15.7 RDD and ABS data weighted by state equalized design weight only. 21.6

111. Percent live in non-metropolitan area 15.0 14.9 15.6 13.8 16.1 RDD and ABS data weighted by state equalized design weight only.

112. Type of household telephone access 1 SJ.Blumberg and JV Luke (2007). “Wireless substitution: Early release of estimates based on data from the National Health Interview Survey, July – December 2006.” National Center for Health Statistics E-States. Household Telephone access National Health Interview Survey 1 (%) BRFSS ABS mixed-mode survey (%) Land line 85.0 88.4 -- Landline only --- 14.5 -- Landline and cellular phone --- 73.9 Cellular phone only 12.8 10.5 No telephone 2.2 1.1

113. Comparison of Survey Estimates

114. Comparison of Survey Estimates Significance: * p<.05, ** p<.01, *** p < .001 Note: Data weighted for sample design and post-stratified to sex, age, and race totals for each state. Final weights were ratio adjusted to equalize the number of cases across states. Health condition / risk factor RDD telephone survey ABS multimode survey Total Mail survey (only) Telephone survey (only) Health care coverage 81.9 81.3 82.4 75.5** Asthma 12.4 13.4 13.6 12.6 Diabetes 9.3 10.8 10.3 13.8 Cardiovascular disease 8.3 8.7 8.9 8.0 Obese (BMI > 30) 22.9 26.7*** 26.7 26.6 Current smoker 20.1 19.9 18.1 29.5*** Binge drinking 15.1 18.1*** 18.9 13.7* Tested for HIV 36.7 36.1 35.3 40.2 [n] [21,743] [4,871] [4,327] [544]

115. 18-34 year olds: Binge drinking & HIV test by household phone access Note: Data weighted for sample design and post-stratified to sex, age, and race totals for each state. Final weights were ratio adjusted to equalize the number of cases across states.

119. Operational considerations

126. ASSESSING MODE EFFECTS

127. ASSESSING MODE EFFECTS KEY ENABLER IS “OVERLAP” MODE 1 MODE 2

132. Contact: Ali Mokdad [email_address] For more information on BRFSS: www.cdc.gov/brfss