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Behavioral Risk Factor Surveillance, 1988

Robert F. Anda, M.D., M.S. Michael N. Waller Karen G. Wooten Eric E. Mast, M.D., M.P.H. Luis G. Escobedo, M.D., M.P.H. Lee M. Sanderson, Ph.D. State BRFSS Coordinators* Behavioral Risk Factor Surveillance Branch Office of Surveillance and Analysis Center for Chronic Disease Prevention and Health Promotion Summary

In 1988, 36 states (including the District of Columbia) participated in the Behavioral Risk Factor Surveillance System (BRFSS). This report provides state-specific estimates of the prevalence of certain health-risk behaviors and of the delivery of clinical preventive services as measured by the BRFSS during 1988. Because estimates vary considerably from state to state, national estimates are not always suitable for states to use in planning local programs. Therefore, the BRFSS will continue to provide state-specific data about health behaviors and the use of preventive health services. These data can be used to monitor trends in health behaviors that affect the burden of chronic diseases in the United States and to assess progress toward the year 2000 objectives for the nation. INTRODUCTION

In 1981, CDC, in collaboration with state health departments, began to conduct a system of telephone surveys about health behaviors to provide state-level data to track the progress of programs intended to affect health behavior and to support major public health initiatives, such as legislation concerning mandatory use of seatbelts, drinking and driving, and cigarette taxation. Between 1981 and 1983, 25 state health departments conducted telephone surveys using CDC's training, coordination, and standard methods. In 1984, these surveys evolved into the Behavioral Risk Factor Surveillance System (BRFSS) (1).

By 1988, when the BRFSS completed its fifth year, 36 states and the District of Columbia were collecting data on health behaviors and the delivery of clinical preventive services. Currently, 45 states and the District of Columbia are conducting these surveys for the 1990 cycle of BRFSS data collection (Appendix 2). This report summarizes data for 1988. METHODS Sampling

With the use of the multistage-cluster-design procedure, based on the Waksberg method of random-digit dialing (2), adult respondents were randomly selected from noninstitutionalized residents who had telephones. Telephone numbers were randomly generated by using the first eight digits of the 10-digit telephone numbers. A cluster of 100 numbers was randomly generated by using the last two digits of the telephone numbers. Clusters were then screened by calling the first randomly selected telephone number. If the number was for a private residence, the entire cluster of 100 numbers was accepted. If the number was not for a private residence or was not working, the entire cluster was rejected. This screening procedure improved the efficiency of the surveys by accepting clusters with a higher probability of having residential numbers.

After a cluster was accepted, numbers were sequentially dialed from the randomly ordered list until three interviews were completed for each cluster. Interviewers made up to 20 attempts to contact a respondent at a given number before replacing it with the next telephone number. After contacting a household, the interviewer randomly selected a resident greater than or equal to 18 years of age. If the person selected was not available at the time of the initial call, subsequent calls were made according to a specified protocol until the interview was completed. Interviews were conducted during a 7- to 10-day period every month. Questionnaire

The questionnaire had three components: 1) a core of questions asked by all states, 2) standardized modules of questions developed by CDC that are added after the core questions at each state's discretion, and 3) questions developed by individual states to meet specific needs. When possible, questions were adopted from national surveys, such as the National Health and Nutrition Examination Surveys and the National Health Interview Surveys, to allow states to make comparisons with national estimates. Data Processing and Analysis

When the interview cycle was completed each month, the data were sent to CDC for editing. Twenty states used computer-assisted telephone interviewing (CATI), which permitted direct entry of data into a computer file. CATI facilitated interviewer monitoring, data coding and entry, and quality-control procedures. After being edited, the data were weighted to the age-, race-, and sex-specific population counts from the most current census in each state, as well as for the respondent's probability of selection (3). The prevalence estimates for this report were computed by using these sampling weights. SESUDAAN (4), a procedure for analyzing complex sample-survey data, was used to calculate the standard errors for the prevalence estimates. Definitions of Risk Factors

Overweight was defined as a body mass index (BMI=weight(kg)/height(m2)) greater than or equal to 27.8 for men and greater than or equal to 27.3 for women. These values represent the sex-specific 85th percentile of BMI for U.S. 20- to 29-year-olds, estimated from the Second National Health and Nutrition Examination Survey.

Sedentary life-style was defined as less than three 20-minute sessions of leisure-time physical activity per week.

Persons who had smoked at least 100 cigarettes were defined as "ever smokers." Current smokers were defined as persons who had smoked at least 100 cigarettes and who currently smoked. The quit ratio was defined as the percentage of ever smokers who did not smoke at the time of the interview.

Binge drinking was defined as having consumed five or more alcoholic beverages on a single occasion at least once during the past month. Heavier drinking was defined as having consumed 60 or more drinks in the past month. Drinking and driving was defined as having driven after drinking too much at least once in the last month.

Seatbelt nonusers were defined as persons who reported that they sometimes, seldom, or never wore seatbelts. Definitions of Preventive Services

All persons were asked if they had ever had their cholesterol level measured. Those who responded yes were defined as ever having their cholesterol checked. Persons who have had their cholesterol checked were asked if they had ever been told their cholesterol level in numbers. Persons who were able to report a number were defined as knowing their cholesterol level.

Women were asked if they had ever had a mammogram. Those who responded yes were defined as ever having a mammogram. RESULTS Behavioral Risk Factors Overweight

The prevalence of being overweight varied nearly twofold, from 14.7% in New Mexico to 28.0% in Wisconsin (median = 20.9%) (Table 1). The prevalence increased with increasing age until age 64 and then declined (median prevalences: 18-34 years = 13.7%, 35-49 years = 23.8%, 50-64 years = 29.8%, and greater than or equal to 65 years = 23.4%). In most states, the median prevalence of being overweight was similar for men and for women. Sedentary life-style

The prevalence of sedentary life-style ranged from a low of 45.3% in Washington to a high of 73.6% in New York (median = 58.0%) (Table 2). On the basis of median prevalences, the majority of persons in all age groups were sedentary (median prevalences: 18-34 years = 53.3%, 35-49 years = 58.2%, 50-64 years = 62.2%, and greater than or equal to 65 years = 67.1%). In most states, the median prevalences of sedentary life-style were similar for men and for women. Cigarette smoking

The prevalence of current cigarette smoking varied more than twofold, from 14.7% in Utah to 34.4% in Kentucky (median = 24.7%) (Table 3). The median prevalence of current smoking declined substantially after age 65 years (median prevalences: 18-34 years = 26.2%, 35-49 years = 29.6%, 50-64 years = 24.8%, and greater than or equal to 65 years = 12.9%). The median prevalences of current smoking for men and women were 25.7% and 23.5%, respectively.

The prevalence of ever smoking varied widely by state, from 33.9% in Utah to 57.9% in New Hampshire (median = 48.7%) (Table 4). The median prevalence of ever smoking increased with increasing age until age 64 and then declined (median prevalences: 18-34 years = 41.1%, 35-49 years = 56.2%, 50-64 years = 60.0%, and greater than or equal to 65 years = 47.2%). The median prevalence of ever smoking was substantially higher for men than for women (median prevalences: men = 56.8%, women = 43.1%).

The quit ratio ranged from a low of 37.8% in Kentucky to a high of 58.6% in Montana (median = 50.5%) (Table 5). The quit ratio increased with increasing age (median ratios: 18-34 years = 37.2%, 35-49 years = 47.0%, 50-64 years = 57.5%, and greater than or equal to 65 years = 71.1%). The median quit ratio was substantially higher for men than for women (median ratios: men = 54.2%, women = 44.6%). Alcohol use

The prevalence of binge drinking varied more than threefold, from 7.1% in the District of Columbia to 25.3% in Wisconsin (median = 15.3%) (Table 6). The median prevalence of binge drinking decreased substantially with increasing age (median prevalences: 18-34 years = 25.1%, 35-49 years = 14.0%, 50-64 years = 8.1%, and greater than or equal to 65 years = 2.5%). Men were more than three times more likely to be heavier drinkers than were women (median prevalences: men = 24.6%, women = 7.2%).

Heavier drinking varied nearly threefold, from 3.3% in North Dakota to 10.8% in New Hampshire (median = 5.8%) (Table 7). The median prevalence of heavier drinking decreased with increasing age (median prevalences: 18-34 years = 7.6%, 35-49 years = 5.7%, 50-64 years = 4.8%, and greater than or equal to 65 years = 2.3%). Men were more than six times more likely to be heavier drinkers than women (median prevalences: men = 10.2%, women = 1.6%).

Drinking and driving varied more than fourfold, from 1.4% in Kentucky to 6.2% in Wisconsin (median = 3.2%) (Table 8). The median prevalence of drinking and driving decreased with increasing age (median prevalences: 18-34 years = 5.9%, 35-49 years = 2.4%, 50-64 years = 0.8%, and greater than or equal to 65 years = 0.0%). Men were more than four times more likely to drink and drive than were women (median prevalences: men = 5.3%, women = 1.2%). Seatbelt nonuse

Seatbelt nonuse showed the most extreme variation (tenfold), from 6.5% in Hawaii to 67.4% in South Dakota (median 30.1%) (Table 9). The median prevalence of seatbelt nonuse decreased with increasing age (median prevalences: 18-34 years = 33.3%, 35-49 years = 31.0%, 50-64 years = 27.1%, and greater than or equal to 65 years = 23.1%). The median prevalences of seatbelt nonuse for men and women were 36.7% and 24.7%, respectively. Clinical Preventive Services Cholesterol screening

The percentage of adults who reported ever having their cholesterol checked ranged from 41.3% in New Mexico to 58.2% in Maine (median = 49.8%) (Table 10). The median percentage increased with increasing age (median prevalences: 18-34 years = 30.3%, 35-49 years = 53.6%, 50-64 years = 68.9%, and greater than or equal to 65 years = 70.4%). The median percentage was similar for men and for women.

The percentage of adults who had ever been told their cholesterol level varied more than twofold, from 17.8% in South Carolina to 39.6% in Wisconsin (median = 28.7%) (Table 11). The median percentage was lowest among young adults (median prevalences: 18-34 years = 14.7%, 35-49 years = 33.7%, 50-64 years = 41.9%, and greater than or equal to 65 years = 37.2%). The median percentage was similar for men and for women.

The percentage of adults who reported knowing their cholesterol level varied threefold, from 6.8% in the District of Columbia to 22.7% in Michigan (median = 13.2%) (Table 12). The median percentage was lowest among young adults (median prevalences: 18-34 years = 5.5%, 35-49 years = 15.9%, 50-64 years = 21.7%, and greater than or equal to 65 years = 20.4%). The median percentage was similar for men and for women. Mammography

Seventeen states used the standard module of questions about mammography. Among women 40-49 years of age, the percentage who reported ever having a mammogram ranged from 41.5% in Nebraska to 67.5% in Maine (median 53.3%) (Table 13). Among women 50-64 years of age, the percentage who reported ever having a mammogram ranged from 46.6% in Indiana to 79.5% in New Hampshire (median 59.8%). Among women greater than or equal to 65 years, the percentage who reported ever having a mammogram ranged from 30.6% in South Carolina to 64.5% in California (median = 48.5%). Among all women greater than or equal to 40 years, the percentage who reported ever having a mammogram ranged from 42.0% in South Carolina to 67.5% in New Hampshire (median = 54.0%). DISCUSSION

Data from the BRFSS have consistently shown that self-reported behavioral risk factors vary widely among reporting states (5-6). Because of this variation, state-specific data are useful in setting appropriate health objectives at the state level. For example, in 1988 the prevalence of smoking in Utah (14.7%) was well below the 1990 objective for the nation (25%) (7), whereas the prevalence in Kentucky (34.4%) was well above the 1990 objective.

Self-reported alcohol consumption has been shown to be related to other measures of alcohol use and to rates of alcohol-related disease. Per capita alcohol consumption based on BRFSS data correlates well with estimates of per capita consumption based on sales data (8). Self-reported alcohol consumption has been shown to be related to the risk of fatal injury (9), and estimates of the prevalences of drinking and driving and of binge drinking based on the BRFSS estimates have been positively correlated with rates of alcohol-related motor vehicle crashes (10).

Analysis of the changes in the BRFSS estimates of drinking and driving and of binge drinking between 1982 and 1985 in 10 states suggested that some progress had been made in reducing these health risk behaviors (11). Analyses are planned in which BRFSS data will be used to examine trends in high-risk alcohol use through the year 1989.

Estimates of self-reported seatbelt use based on BRFSS data have been shown to correlate with observed use in 15 states studied (12). Analysis of the temporal trends in seatbelt use in relation to mandatory seatbelt legislation is under way.

Estimates of cholesterol screening from the BRFSS are similar to estimates from the cholesterol-awareness survey conducted jointly by the National Heart, Lung, and Blood Institute and the Food and Drug Administration during 1986. In the 1986 survey, an estimated 46% of adults had their cholesterol measured (13). Similarly, based on BRFSS data, the median percentage of adults who had their cholesterol measured was 46.6% in 1987 and 49.8% in 1988. A detailed analysis of changes in cholesterol screening and awareness between 1987 and 1988 based on BRFSS data has been published (14).

BRFSS data on mammography are useful for monitoring changes in the delivery of this preventive service. BRFSS data have shown that the percentage of women greater than or equal to 50 years of age who reported having a screening mammogram in the preceding 12 months increased substantially in 1987 (15). However, this upward trend in the use of screening mammograms was not uniform for all states (16), and the increase in the use of screening mammograms was lowest among women who were in low-income groups or who were elderly (17).

The BRFSS will continue to provide state-specific data about health behaviors and the use of preventive health services that can reduce the burden of chronic diseases in the United States. These data will be used to assess state-specific progress toward the 1990 and year 2000 objectives for the nation. If specific objectives for the nation have not been developed (e.g., drinking and driving), state health departments may wish to use BRFSS data to set appropriate objectives and to monitor trends in related behaviors.

References

  1. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM,

Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-1987. Public Health Rep 1988;103:366-75.

2. Waksberg JS. Methods for random digit dialing. J Am Stat Assoc 1978;73:40-6.

3. Gentry EM, Kalsbeek WD, Hogelin GC, Jones JT, et al. The Behavioral Risk Factor Surveys. Part II. Design, methods, and estimates from combined state data. Am J Prev Med 1985;1:19-4.

4. Shah BU. SESUDAAN: standard errors program for computing standardized rates from sample survey data. Triangle Park, NC: Research Triangle Institute, 1981.

5. CDC. Behavioral risk-factor surveillance in selected states--1985. MMWR 1986;35:441-4.

6. CDC. Behavioral risk factor surveillance--selected states, 1986. MMWR 1987;36:252-4.

7. Public Health Service. The 1990 health objectives for the nation: a midcourse review. Washington DC: Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 1986.

8. Smith PF, Remington PL, Williamson DF, Anda RF. Alcohol consumption and problem drinking: a comparison of sales data with surveys of self-reported alcohol use in 21 states. Am J Public Health 1990;80:309-12.

9. Anda RF, Williamson DF, Remington PL. Alcohol and fatal injuries among U.S. adults: findings from the NHANES I epidemiologic follow-up study. JAMA 1988;260:2529-32. 10. Anda RF, Remington PL, Dodson DL, DeGuire PJ, Forman MR, Gunn RA. Patterns of self-reported drinking and driving in Michigan. Am J Prev Med 1987;3:272-5. 11. CDC. Drinking and driving and binge drinking in selected states, 1982 and 1985--the behavioral risk factor surveys. MMWR 1987;35:788-91. 12. CDC. Comparison of observed and self-reported seat belt use rates--United States. MMWR 1988;37:549-51. 13. Schucker BS, Bailey K, Heimbach JT, et al. Change in public perspective on cholesterol and heart disease: results from two national surveys. JAMA 1987;258:3527-31. 14. CDC. State-specific changes in cholestrol screening and awareness--United States, 1987-1988. MMWR 1990;39:304-5,312-4. 15. CDC. Trends in screening mammograms for women 50 years of age and older--Behavioral Risk Factor Surveillance System, 1987. MMWR 1989;38:137-40. 16. CDC. State-to-state variation in screening mammograms for women 50 years of age--Behavioral Risk Factor Surveillance System, 1987. MMWR 1989;38:157-60. 17. Anda RF, Sienko DG, Remington PL, Gentry EM, Marks JS. Screening mammography for women 50 years and older: current practices and trends, 1987. Am J Prev Med (in press). *See Appendix 1.

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