# Presentation: 187365

## Leading Health Indicators:Comparability of State and National Data

**Richard J. Klein, MPH; Kathleen M. Turczyn, MPH;**
**John Aberle-Grasse, MPH**
**National Center for Health Statistics**
**Centers for Disease Control and Prevention**

## Leading Health Indicators and Measures

**Leading Health Indicators and Measures**

**Notes:**
22 original measures
Currently, 4 supp measures; the number varies depending on available data.
15 measures use the same survey or system for national and state data.

## Purpose of LHI

** ****Define national health priorities**
** ****Target the general public**
** ****Serve as a link to the 467 Healthy ****	****People 2010 objectives **
** ****Give a “snapshot” of the health of ****	****the Nation**
** ****Track at various geographic levels **

**Notes:**
Established as part of Healthy People 2010 in January 2000

## Data sources for comparable state and national data 

** **** ****NVSS (4)**
**  ****NHSDA (4)**
**  ****YRBSS (2)**
**  ****AIRS (1)**
**  ****HCUP (1)**
**  ****NIS (1)**
**  ****STDSS (1)**

**Notes:**
14 sources are the same for state and national data.

## Different sources for state and national data

**Remaining LHI measures use:**
** ****BRFSS for state data for adults**
** ****YRBSS for state data for 1 LHI (overweight) in adolescents**
** ****Another source for national data**

## LHI measures that use the BRFSS for state data

**Moderate physical activity **
**Obesity in adults**
**Cigarette smoking**
**Condom use**
**Exposure to second-hand smoke ( 1 of 2 measures)**

**Influenza immunization**
**Pneumococcal immunization**
**Health care coverage**
**Specific source of ongoing care**

**Notes:**
10 remaining measures for adults; BRFSS measures 9 of them.
The official measure for exposure to second-hand smoke is serum cotinine, measured using the National Health and Nutrition Examination Survey.  This measure does not have a corresponding state measure. The supplemental measure is measured by the BRFSS.

## Features of the BRFSS

**Individual state surveys**
**Telephone interview**
**Core of questions (some rotating biennially) and optional modules**
**Adults 18 years and over**
**Length of interview averages 25 minutes**

**Notes:**
Behavioral Risk Factor Surveillance System

## Surveys providing national data for LHIs that use BRFSS state data

**National Health Interview Survey (NHIS), CDC, NCHS**
**National Health Nutrition and Examination Survey (NHANES), CDC, NCHS**
**National Survey of Family Growth (NSFG), CDC, NCHS**

## LHI BRFSS measures using the NHIS for national data

**Moderate physical activity**
**Cigarette smoking**
**Exposure to second-hand smoke**
**Influenza immunization**
**Pneumococcal immunization**
**Health care coverage**
**Specific source of ongoing care**

**Notes:**
7 of the 9 BRFSS LHI measures use NHIS for National data.

## Features of the NHIS

**In-home personal interview**
**Core questions with special supplements**
**LHI measures are in the core**
**All household members (all ages)**
**1 hour or more in length**
**Annual**

## Physical Activity

## Survey question comparison: moderate physical activity

**BRFSS (Rotating core)**
- (After an opening phrase including “other than your regular job duties”)
- During the past month, did you participate in any physical activities such as (examples)?
- What type of physical activity did you spend the most time doing?
- Frequency/duration
- Was there another physical activity or exercise that you participated in during the last month?

**NHIS (Core)**
- How often do you do vigorous activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?
- How often do you do light or moderate activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate?
- Frequency/duration

**Notes:**
Questions are very different.
1998 and 2000: BRFSS Core   1999 (11 States): Module
NHIS – 2 basic questions (moderate/vigorous) – physiological changes, no examples – open time frame, frequency/duration per each exercise session
BRFSS – list of example activities - choose 2 activities most done – time frame in past month, freq/dur per day/wk/month as defined by respondent

BRFSS (Rotating core starting in 2001)
(After an opening question on type of physical activity at work and a description of vigorous and moderate activity)
Reference period changes to: In a usual week
Moderate physical activity asked first, then vigorous
Use of many examples
Frequency/duration per day

## Moderate physical activity18 years and over

- Note:  Data are age adjusted to the 2000 standard population.
- Sources:  Behavioral Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS), CDC, NCHS.

**Percent**

**BRFSS**

**NHIS**

**1998**

**1999**

**2000**

**25**

**29**

**25**

**30**

**26**

**31**

**Notes:**
NHIS significantly higher than BRFSS.  1999 only 11 States

BRFSS means:	1998:  25.3  SE:  0.2  CI:  24.9-25.7
	1999:  25.0  SE:  0.4  CI:  24.2-25.8
	2000:  26.2  SE:  0.2  CI:  25.8-26.6
NHIS prevalence:	1998:  29.3  SE:  0.3  CI:  28.7-29.9  signif diff
	1999:  29.8  SE:  0.4  CI:  29.0-30.6  signif diff
	2000:  31.4  SE:  0.4  CI:  30.6-32.2  signif diff

## Tobacco Use

## Survey question comparison:cigarette smoking

**NHIS (Core)**
- Have you smoked at least 100 cigarettes in your entire life?
- [If yes] Do you now smoke cigarettes everyday, some days, or not at all?

**BRFSS (Core)**
- Have you smoked at least 100 cigarettes in your entire life?
- [If yes] Do you now smoke cigarettes everyday, some days, or not at all?

**Notes:**
NHIS and BRFSS questions are identical.

## Cigarette smoking 18 years and over

- Note:  Data are age adjusted to the 2000 standard population.
- Source: Behavior Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS), CDC, NCHS.

**Percent**

**1998**

**1999**

**2000**

**BRFSS**

**NHIS**

**23**

**23**

**23**

**23**

**23**

**24**

**Notes:**
CI’s overlap: No statistical differences in the data.

BRFSS means:	1998:  23.1  SE:  0.2  CI:  22.7-23.5
	1999:  22.7  SE:  0.2  CI:  22.3-23.1
	2000:  22.5  SE:  0.2  CI:  22.1-22.9
NHIS prevalence:	1998:  24.0  SE:  0.3  CI:  23.4-24.6  no signif diff
	1999:  23.3  SE:  0.3  CI:  22.7-23.9  no signif diff
	2000:  23.1  SE:  0.3  CI:  22.5-23.7  no signif diff

## Environmental Quality

## Survey question comparison:Exposure to secondhand smoke

**NHIS (1998)**
- Does anyone who lives here smoke cigarettes, cigars, or pipes anywhere inside this home?
- On the average, about how many days per week do people who live here smoke anywhere inside this home?
- What is ____’s age and date of birth? Please give month, day, and year for the date of birth.

**BRFSS (1998,1999,2000)**
- In the past 30 days has anyone, including yourself, smoked cigarettes, cigars, or pipes anywhere inside your home?
- How many children live in your household who are less than 5 years old?

**Notes:**
This LHI is a supplemental indicator; the LHI is a serum cotinine measure from NHANES.
Questions differ in ages for children, people who smoke (residents vs anyone in the hh), times per week (NHIS 4+ days per week; BRFSS doesn’t specify)

NHIS definition: % children 6 years and under in households where a resident smoked at least 4 days per week inside the home among households with children 6 years and under.
BRFSS data are defined differently...BRFSS measures the percent of adults living in households with at least one child under 5...where someone smokes in the house.

NHIS requires a special supplement with outside funding; no data have been collected since 1998.

BRFSS: 1998 (14 States), 1999 (18 States), 2000 (20 States).  BRFSS has a time reference of 30 days. 
BRFSS definition:  children 4 years and under in households with children 4 years and under; asks about anyone who smoked inside home in past 30 days (these data are not specific to number of days in the past 30 days to measure this LHI well).

BRFSS 2001:  Does not ask for ages of children and has a different question for inside-home smoking. It still doesn’t measure the objective/LHI.
M Which statement best describes the rules about smoking inside your home?
1=Smoking is not allowed anywhere inside your home
2=Smoking is allowed in some places or at some times
3=Smoking is allowed anywhere inside the home
4=There are no rules about smoking inside the home

## Childhood exposure to second-hand smoke

- Note:  BRFSS data are for children 4 and under; NHIS data are for children 6 and under.
- *No NHIS data for 1999 and 2000.
- Sources: Behavior Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP;
-                 National Health Interview Survey (NHIS), CDC, NCHS.

**1998**

**1999**

**2000**

*****

*****

**BRFSS**

**NHIS**

**Percent**

**Supplemental**
**Measure**

**31**

**21**

**30**

**31**

**Notes:**
BRFSS estimates much higher than the more-restrictive NHIS.

BRFSS means:	1998:  30.8  SE:  3.0
	1999:  30.2  SE:  2.7
	2000:  31.0  SE:  1.6
NHIS prevalence:	1998:  20.3  SE:  0.7

## Immunization

**Immunization**

## Survey question comparison:influenza immunization

**NHIS (Core)**
- During the past 12 months, have you had a flu shot? A flu shot is usually given in the fall and protects against influenza for the flu season.

**BRFSS (Rotating Core)**
- During the past 12 months, have you had a flu shot?

**Notes:**
Questions generally comparable (same 12-month time frame; same words “flu shot”)

BRFSS:  
1998 module (14 States)
1999 core
2000 module (18 States)
2001 core

## Influenza immunization65 years and over

**Percent**

**1998**

**1999**

**2000**

- Note:  Data are age adjusted to the 2000 standard population.
- Source: Behavior Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS), CDC, NCHS.

**66**

**64**

**68**

**66**

**68**

**65**

**Notes:**
Data very close.  CI’s overlap in most years

BRFSS means:	1998:  66.3  SE:  0.8  CI:  64.7-67.9
	1999:  67.7  SE:  0.5  CI:  66.7-68.7
	2000:  68.4  SE:  0.8  CI:  66.8-70.0
NHIS prevalence:	1998:  63.6  SE:  0.7  CI:  62.2-65.0	no signif diff
	1999:  65.9  SE:  0.7  CI:  64.5-67.3	no signif diff
	2000:  64.5  SE:  0.7  CI:  63.1-65.9	yes signif diff

## Survey question comparison:pneumococcal immunization

**NHIS (Core)**
**Have you ever had a pneumonia vaccination? This shot is usually given only once in a person’s lifetime and is different from the flu shot.**

**BRFSS (Rotating Core)**
**1998-2000:**
**Have you ever had a pneumonia vaccination? **
**2001:**
**Have you ever had a pneumonia shot?  This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot.  It is also called the pneumococcal vaccine.**

**Notes:**
Questions generally comparable...virtually identical beginning in 2001

BRFSS:
1998 Module (14 States); 2000 Module (18 States)
1999 and 2001 Core

## Pneumococcal immunization 65 years and over

- Note:  Data are age adjusted to the 2000 standard population.
- Source: Behavior Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS), CDC, NCHS.

**Percent**

**1998**

**1999**

**2000**

**50**

**55**

**62**

**46**

**50**

**53**

**Notes:**
CI’s do not overlap...appear to be closer in earlier years

BRFSS means:	1998:  50.1  SE:  0.9  CI:  48.3-51.9
	1999:  55.1  SE:  0.5  CI:  54.1-56.1
	2000:  62.3  SE:  0.9  CI:  60.5-64.1
NHIS prevalence:	1998:  46.3  SE:  0.8  CI:  44.7-47.9  yes signif diff
	1999:  49.9  SE:  0.8  CI:  48.3-51.5  yes signif diff
	2000:  53.2  SE:  0.8  CI:  51.6-54.8  yes signif diff
Difference increasing over time

## Access to Care

**Notes:**
Two measures with different State and national sources.

## Survey question comparison:health care coverage

**NHIS (Core)**
**The next questions are about health insurance. Are you covered by any kind of health insurance or some other kind of health care plan? **
**What kind of health insurance coverage do you have? Exclude private plans that only provide extra cash while hospitalized or only pay for one type of service (nursing home care, accidents, or dental care).**

**BRFSS (Core)**
**Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?**
**What type of health care coverage do you use to pay for most of your medical care? Is it coverage through: [examples]?**

**Notes:**
Questions generally similar...different ages...NHIS asks more detail on types of insurance.

BRFSS Core:  1998, 2000
BRFSS Module:  1999 (5 States)
Ages 18-64
NHIS:  Ages 0-64 (and asks many more questions on specific types of insurance)

## Health care coverage

**1998**

**1999**

**2000**

**Percent**

- Note:  Data are age adjusted to the 2000 standard population. Data from NHIS are for ages under 65 years; BRFSS data are for ages18-64  years.
- Source: Behavior Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS), CDC, NCHS.

**86**

**86**

**87**

**84**

**84**

**83**

**Notes:**
Estimates are very close. Tight CI’s do not overlap but are very close.

BRFSS:  Ages 18-64; NHIS:  Ages 0-64
BRFSS means:	1998:  85.9  SE:  0.2  CI:  85.6-86.2
	1999:  86.4  SE:  0.2  CI:  86.0-86.7
	2000:  86.5  SE:  0.2  CI:  86.2-86.8
NHIS prevalence:	1998:  83.5  SE:  0.3  CI:  82.9-84.1  yes signif diff
	1999:  83.6  SE:  0.3  CI:  83.0-84.2  yes signif diff
	2000:  83.2  SE:  0.2  CI:  82.8-83.6  yes signif diff

## Survey question comparison:specific source of care

**NHIS (Core)**
**Is there a place that you usually go when you are sick or need advice about your health?**
**What kind of place is it: a clinic, doctor’s office, emergency room or some other place?**

**BRFSS (Module)**
**Is there one particular clinic, health center, doctor’s office, or other place that you usually go to [go to most often when] if you are sick or need advice about your health?**
**What kind of place is it?**
**- - - - - - - - - - - - - - - - - - - - - - - **
**Do you have one person you think of as your personal doctor or health care provider? (added to the 2000 module; 2001 core)**

**Notes:**
Questions very similar
Different ages (all vs 18+)...few States select BRFSS optional module.

BRFSS Module:  1998 (4 States); 1999 (2 States); 2000 (4 States).  The last question about personal doctor was added in 2000 to the module, and then to the 2001 core.

NHIS: All ages
BRFSS: 18+

## Specific source of ongoing care

**1998**

**1999**

**2000**

**Percent**

- Note:  Data are age adjusted to the 2000 standard population. Data from BRFSS are for ages 18 years and over; NHIS data are for all ages.
- Source: Behavior Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS), CDC, NCHS.

**87**

**86**

**84**

**87**

**86**

**87**

**Notes:**
Despite different ages and the few states that selected the module...data virtually identical (except for 2000)

BRFSS data are for ages 18+
NHIS data are for all ages (as called for by the objective).
BRFSS means:	1998:  87.2  SE:  0.5  CI:  86.2-88.2
	1999:  85.9  SE:  0.7  CI:  84.1-87.3
	2000:  83.9  SE:  0.4  CI:  83.1-84.7
NHIS prevalence:	1998:  87.4  SE:  0.2  CI:  87.0-87.8  no signif diff
	1999:  85.9  SE:  0.2  CI:  85.5-86.3  no signif diff
	2000:  86.6  SE:  0.2  CI:  86.2-87.0  yes signif diff

## LHI measures using the NHANES for national data

**Obesity (adults)**
**Overweight (adolescents)**

## Features of the NHANES

**Standardized physical examinations**
**Personal interview**
**In home**
**In mobile examination center**
**4 hours or more in length**
**All ages**
**Annual beginning in 1999**

## Overweight and Obesity

## Survey question comparison:height and weight (adults)

**NHIS (Core)**
**About how tall are you without shoes?**
**About how much do you weigh without shoes?**

**BRFSS (Module)**
**About how much do you weigh without shoes?**
**About how tall are you without shoes?**

**     ****NHANES**
**Measured height**
**Measured weight**

**Notes:**
NHANES uses measured height and weight.
NHIS & BRFSS questions are identical, but reversed.

## Obesity in adults, 1999

**BRFSS**

**NHIS**

**NHANES***

- *NHANES data are for 1999-2000.
- I = 95% Confidence Interval.
- Notes:  Obesity is defined as Body Mass Index  (BMI) _>_ 30.  Data are for persons 20 years and over.  Data are age adjusted to the 2000 standard population.
- Sources: Behavioral Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS),CDC, NCHS; National Health and
-                Nutrition Examination Survey (NHANES),CDC, NCHS.

**Mode of administration affects estimate of obesity obtained from different surveys**
**Self-reported data underestimate the measured prevalence      of obesity**

**Telephone**
**interview**

**In-person**
**interview**

**In-person**
**examination**

**Percent**

**18.7**

**21.5**

**30.5**

**Notes:**
(Can’t make statement about telephone vs. in-person interview because the questions on height and weight are reversed.)

## LHI measure that uses the YRBSS for state data

**Overweight in adolescents**

**Notes:**
10 remaining measures for adults; BRFSS measures 9 of them.
The official measure for exposure to second-hand smoke is serum cotinine, measured using the National Health and Nutrition Examination Survey.  This measure does not have a corresponding state measure. The supplemental measure is measured by the BRFSS.

## Features of the YRBSS

**School-based anonymous self-administered written questionnaire**
**Grades 9-12**
**About 1/2 hour in length**
**National, State, and local**
**Conducted biennially (every odd year)**

## Survey question comparison:height and weight in adolescents

**NHANES**
**Measured height**
**Measured weight**

**YRBSS**
**How tall are you without your shoes on? **
**How much do you weigh without your shoes on?**** **

**Notes:**
Measures and questions are not comparable.  Age groups different for measure, also.

## Overweight in children and adolescents*

**2001**

**Percent**

- Note:  Data are age adjusted to the 2000 standard population.
- *Data from YRBSS are for grades 9-12; NHANES data are for ages 6-19.
- Overweight is defined as the 95th percentile of body mass index (BMI).
- Source: Youth Risk Behavior Surveillance System (YRBSS), CDC, NCCDPHP; National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.

**1999-2000**

**11**

**15**

**Notes:**
95th BMI percentile = overweight
2001 YRBSS: SE= +-1.0 grades 9-12
1999-2000 NHANES:  SE= +-0.97   ages 6-19

## LHI measure using the NSFG for national data

**Condom use by adults**

## Features of the NSFG

**In-home personal interview**
**Men and women 15-44 years**
**1 hour or more in length**
**Conducted 5 times since 1973 (last one in 1995)**
**Has a self-administered section**
**2002 is the first time men are included in the sample**

## Responsible Sexual Behavior

## Survey question comparison:condom use by adults

**NSFG**
**The last time you had intercourse, did you or your partner use any method?  [list of birth control methods, including “condom”]**

**BRFSS (Optional module)**
**Was a condom used the last time you had sexual intercourse?  **

**Notes:**
Questions are not comparable.
Data are for unmarried adults only.
BRFSS:  
1998 module (8 States) both sets of questions (sexual behavior and family planning – sexual behavior questions are used for the data)
1999 optional module (12 States) – questions are in family planning and sexual behavior both types of questions
2000 optional module (4 States)  same as 1998-99
2001 optional module Sexual Behavior q’s only: “Was a condom used the last time you had sexual intercourse?  The last time you had sexual intercourse, was the condom used to prevent pregnancy, to prevent disease like syphilis, gonorrhea, and AIDS, for both of these reasons, or for some other reason?
2002 family planning questions are in core; no sexual behavior questions

## Condom use by adults

- Note:  Data are for unmarried, sexually active adults 18-44 years.
- I = 95% Confidence Interval.
- Sources: Behavior Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP; National Survey of Family Growth (NSFG), CDC, NCHS.

**1995**

**1998**

**2000**

**BRFSS**

**NSFG**

**Percent**

**23**

**39**

**37**

**1999**

**40**

**Notes:**
NSFG uses a list of birth control methods with condom use as one of them.  Use limited to birth control.
BRFSS asks a direct question and does not limit the respondent to birth control as the reason for using a condom.
BRFSS data much higher than NSFG data.

## Data comparability

**Comparable **
**Generally comparable, but use caution**
**Not comparable**

## NHIS
Moderate physical activity
Cigarette smoking
Exposure to secondhand smoke 
Influenza immunization
Pneumococcal immunization
Health care coverage
Source of ongoing care

**Moderate physical activity**
**Cigarette smoking**
**Exposure to secondhand smoke **
**Influenza immunization**
**Pneumococcal immunization**
**Health care coverage**
**Source of ongoing care**

_**NHANES**_
**Obesity**
_**NSFG**_
**Condom use**

**Summary of state and national comparability**

**Notes:**
Summary criteria:  Questions   Data         Summary
                             Green        Green       Green
                             Green        Green       If LT 1⁄2 States, Yellow
                             Green        Yellow      Yellow  
                             Whatever   Red          Red
                             Red           NE Red     Yellow  (NA)
                             Yellow       Green       Yellow

Conclusion – 5/9 the measures are generally ok.  The others would need explanation/interpretation of why State data are different from national.

## Leading Health Indicators and Measures

**Leading Health Indicators and Measures**

**Notes:**
NOTE:  In black/white, the colors of the measures do not show up.
Of 24 measures, 19 are quite comparable.  5 of 24 are not comparable.
Environmental tobacco smoke exposure and Ozone not measured this year.

## Slide 47

**Notes:**
Addition of State data began in 2001 with NVSS. 
BRFSS data were added this year (2002).

## Websites

- <date/time>

**Websites**

**DHHS Healthy People:**
- _[www.health.gov/healthypeople](http://www.health.gov/healthypeople)_
**NCHS Healthy People:**
- _[www.cdc.gov/nchs/](http://interdev2.nchs.cdc.gov/nchs/)__[healthypeople](http://interdev2.nchs.cdc.gov/nchs/)_
**DATA2010:**
- _[www.wonder.cdc.gov/data2010](http://interdev2.nchs.cdc.gov/nchs/)_

**Notes:**
Useful websites.