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State-Specific Prevalence of Walking Among Adults with Arthritis — United States, 2011

Walking contributes to total physical activity and is an appropriate activity to increase overall physical activity levels among adults with arthritis. Walking also is the most preferred exercise among arthritis patients (1,2) and has been shown to improve arthritis symptoms, physical function, gait speed, and quality of life (3–5). To estimate the distribution of average weekly minutes of walking among adults with arthritis by state and map the prevalence of low amounts of walking (<90 minutes per week) among adults with arthritis, CDC analyzed data from the 2011 Behavioral Risk Factor Surveillance System (BRFSS). This report describes the results of that analysis, which indicated that among adults with arthritis in the 50 states and the District of Columbia (DC), the median prevalence of walking was 53% (range: 44.3%–66.2%) for 0 minutes per week, 13.1% (range: 9.3%–16.2%) for 1–89 minutes per week, 5.3% (range: 3.2%–6.8%) for 90–119 minutes per week, 5.6% (range: 2.6%–8.3%) for 120–149 minutes per week, and 23.2% (range: 16.0%–30.6%) for ≥150 minutes per week. A state median of 66% of adults with arthritis walked <90 minutes per week, ranging from a low of 58.0% in California to a high of 76.2% in Tennessee. The large number of persons with arthritis who are not getting the full benefit of regular walking might benefit from community interventions aimed at increasing access to walking as well as specific programs that offer social support.

BRFSS is a random-digit–dialed telephone survey conducted annually in all 50 states, DC, and U.S. territories. Data collected in 2011 from 50 states and DC (497,967 respondents; 166,417 with arthritis) were used to assess the distribution of average weekly minutes of walking and the prevalence of walking <90 minutes per week among adults with self-reported, doctor-diagnosed arthritis. After excluding responses from respondents with missing data on key variables (e.g., arthritis status and physical activity), the analytic sample size was 153,688 respondents with arthritis. Response rates for BRFSS are calculated using standards set by the American Association of Public Opinion Research response rate formula no. 4.* The response rate is the number of respondents who completed the survey as a proportion of all eligible and likely eligible persons. The 2011 median survey response rate for all states and DC was 53.0%; response rates ranged from 37.4% in California to 66.5% in South Dakota.

Respondents were classified as having arthritis if they answered "yes" to the question, "Have you ever been told by a doctor or other health professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" Respondents who reported they had participated in physical activities or exercise (excluding occupational and transportation activities) in the past month were subsequently asked to recall the frequency, duration, and type of activity for the two activities they did most often. Walking was one of approximately 60 activities listed, and the most common activity reported. For adults who reported walking, the time spent walking per week was calculated by multiplying the frequency (times per week) by duration (minutes per session). Based on the 2008 Physical Activity Guidelines for Americans, time spent in vigorous-intensity walking (walking is a vigorous-intensity activity for some older adults) was multiplied by two.§

The average number of minutes walked per week was grouped into five categories: 0, 1–89, 90–119, 120–149, and ≥150 minutes per week. Walking minutes were dichotomized to <90 minutes per week and ≥90 minutes per week to assess the state-specific prevalence of low amounts of walking. The 90-minute threshold was based on the minimum amount of weekly walking shown in a randomized controlled trial to lower pain (27% decrease) and improve function (39% increase) among adults with arthritis (5) and the typical amount of walking achieved in the Arthritis Foundation's Walk With Ease (WWE) program, which is 3 days per week with approximately 30 minutes of total walking time per session (3). Unadjusted prevalence estimates, 95% confidence intervals, medians, and ranges for all 50 states and DC were calculated (Table). Age-adjusted prevalence estimates, categorized by tertiles, also were calculated (Figure). All estimates use sampling weights (raking methodology) to account for the complex sample design, nonresponse, noncoverage, and cellphone-only households; this method of weighting sample BRFSS data is new in 2011; therefore, 2011 estimates should not be compared to estimates from previous years.

Among adults with arthritis in the 50 states and the District of Columbia (DC), the median prevalence of walking was 53% (range: 44.3%–66.2%) for 0 minutes per week, 13.1% (range: 9.3%–16.2%) for 1–89 minutes per week, 5.3% (range: 3.2%–6.8%) for 90–119 minutes per week, 5.6% (range: 2.6%–8.3%) for 120–149 minutes per week, and 23.2% (range: 16.0%–30.6%) for ≥150 minutes per week. A median of 66% adults with arthritis walked <90 minutes per week, ranging from a low of 58.0% in California to a high of 76.2% in Tennessee (Table). Among adults with arthritis, eight states had age-adjusted prevalences of walking <90 minutes per week of ≥71.8%, 25 states had prevalences ranging from 65.3 to <71.8% and 18 states had prevalences of <65.3% (Figure).

Reported by

Jennifer M. Hootman PhD, Kamil E. Barbour PhD, Div of Population Health; Kathleen B. Watson, PhD, Janet E. Fulton, PhD, Div of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Jennifer M. Hootman, jhootman@cdc.gov, 770-488-6038.

Editorial Note

Walking is a low-impact, acceptable, convenient, inexpensive, feasible, and proven physical activity intervention that can help reduce arthritis pain, improve function (3,6), and move persons with arthritis along the continuum of physical activity, getting them closer to meeting the 2008 Physical Activity Guidelines for Americans. In this study, more than half of adults with arthritis in all 50 states and DC reported no or low (<90 minutes) walking per week. Better access to evidence-based physical activity programs for adults with arthritis will provide increased reach of these programs, which might improve physical activity levels and provide associated health benefits to this population.

The Guide to Community Preventive Services recommends both behavioral and social approaches and environmental and policy approaches to increase physical activity.** Individually adapted behavior-change programs that incorporate skills such as goal setting, building social support, and problem solving have been shown to increase time spent in physical activity as well as increase aerobic capacity and energy expenditure. Such programs include the Arthritis Foundation Exercise Program, Senior Services' EnhanceFitness program, and the Arthritis Foundation's WWE program.†† Pairing individual, evidence-based physical activity programs with environmental/policy approaches that increase access to physical activity is a feasible way to increase walking among adults with arthritis. For example, worksites that build walking trails or provide walking maps as an environmental approach to increasing employee physical activity might augment their worksite wellness programs by offering an evidence-based program, such as WWE, to employees who desire to increase their walking in a group-lead or self-directed program.

WWE, a 6-week walking program, has been shown to reduce pain and fatigue and increase function, ability, strength, balance, and walking pace among adults with arthritis (3). WWE has two formats, a traditional group-lead version using a trained leader, and a self-directed version where persons can go through the program at their own pace. Typically, WWE groups meet 3 days a week for about an hour, with a maximum walking time of 30–40 minutes per session. Persons with arthritis who walk <90 minutes per week might find that the structure and social support of WWE reduces barriers to walking. The social support of a group walking program also might help improve adherence to a walking program and promote a feeling of safety (6). Currently, CDC funds 12 states to implement evidenced-based physical activity programs in local communities. In the first year of the current 5-year grant cycle, all 12 states offered WWE by partnering with various delivery systems, such as county extension offices, health-care systems and health plans, parks and recreation departments, and organizations serving aging adults.

The findings in this report are subject to at least six limitations. First, all data in BRFSS is based on self-report; therefore, arthritis status and the weekly amount of walking might be misreported. However, the case-finding question used in BRFSS to assess arthritis status has been shown to be sufficiently sensitive and specific for public health surveillance purposes (7). Second, among adults with arthritis, rates of meeting physical activity recommendations via self-reported measures (approximately 30%) are much higher than when activity is objectively measured using motion sensors (13% among men and 8% among women); however, the prevalence of physical inactivity (the low end of the activity spectrum) is similar using both methods (8,9). Third, BRFSS questions do not include transportation or occupational activities that involve walking. Fourth, BRFSS does not assess the severity, location, or type of arthritis, which might affect walking differently. Fifth, because of the sample size, categories (e.g., 1–89 minutes per week) were collapsed so respondents in this category range from being practically inactive to walking an amount that might have important health effects. However, these respondents still are on the low end of the continuum and are good targets for marketing evidenced-based programs. Finally, the 2011 median survey response rate for all states and DC was 53.0% and ranged as low as 37.4% in California; lower response rates can result in response bias.

Most persons with arthritis do no or little walking per week. Effective and safe interventions are available in the community and can assist persons with arthritis to start and maintain a walking program. By coupling environmental and policy strategies to increase access to walking, it might be possible to expand the reach of these effective programs for adults with arthritis.

References

  1. Henchoz Y, Zufferey P, So A. Stages of change, barriers, benefits, and preferences for exercise in RA patients: a cross sectional study. Scand J Rheumatol. 2013;42:136–45.
  2. Manning VL, Hurley MV, Scott DL, Bearne LM. Are patients meeting the updated physical activity guidelines? Physical activity participation, recommendations, and preferences among inner-city adults with rheumatic diseases. J Clin Rheumatol 2012;18:399–404.
  3. Callahan LF, Shreffler JH, Altpeter M, et al. Evaluation of group and self-directed formats of the Arthritis Foundation's Walk with Ease program. Arthritis Care Res (Hoboken) 2011;63:1098–107.
  4. Leow L, Brosseau L, Wells GA, et al. Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis. Arch Phys Med Rehabil 2012;93:1269–85.
  5. Kovar PA, Allegrante JP, MacKenzie CR, Peterson MG, Gutin B, Charlson ME. Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 1992;116:529–34.
  6. C3 Collaborating for Health. The benefits of regular walking for health, well-being and the environment. London, United Kingdom: C3 Collaborating for Health; 2012. Available at http://www.c3health.org/wp-content/uploads/2009/09/C3-report-on-walking-v-1-20120911.pdf.
  7. Sacks JJ, Harrold LR, Helmick CG, Gurwitz JH, Emani S, Yood RA. Validation of a surveillance case definition for arthritis. J Rheumatol 2005;32:340–7.
  8. Shih M, Hootman JM, Kruger J, Helmick CG. Physical activity in men and women with arthritis National Health Interview Survey, 2002. Am J Prev Med 2006;30:385–93.
  9. Dunlop DD, Song J, Semanik PA, et al. Objective physical activity measurement in the osteoarthritis initiative: are guidelines being met? Arthritis Rheum 2011;63:3372–82.

* Response rate definitions http://www.aapor.org/standard_definitions2.htm.

2011 Behavioral Risk Factor Surveillance Survey Summary Data Quality Report available at http://www.cdc.gov/brfss/pdf/2011_summary_data_quality_report.pdf.

§ 2008 Physical Activity Guidelines for Americans available at http://www.health.gov/paguidelines.

2011 BRFSS overview available at http://www.cdc.gov/brfss/annual_data/annual_2011.htm.

** Guide to Community Preventive Services available at http://www.thecommunityguide.org/pa/index.html.

†† Arthritis Appropriate Physical Activity and Self-Management Education Interventions: A Compendium of Implementation Information available at http://www.cdc.gov/arthritis/interventions/marketing-support/compendium/docs/pdf/compendium-2012.pdf.


What is already known on this topic?

Walking has been shown to reduce arthritis symptoms and improve physical function, strength, balance, and quality-of-life. Walking is a low-impact, acceptable, convenient, inexpensive, and preferred activity for adults with arthritis and is an appropriate activity to increase overall physical activity.

What is added by this report?

In every state, more than half of adults with arthritis do no or little (<90 minutes) walking per week. Prevalence of walking <90 minutes per week ranged from 58.0% in California to 76.2% in Tennessee. The age-adjusted prevalence of walking <90 minutes per week was ≥71.8% in eight states.

What are the implications for public health practice?

The large number of persons with arthritis who are not getting the full benefit of regular walking might benefit from community interventions aimed at increasing access to walking as well as specific programs that offer social support.


TABLE. State-specific prevalence of walking among adults with arthritis, by average minutes walked per week — United States, Behavioral Risk Factor Surveillance System, 2011

State

Average minutes walked per week

0

1–89

90–119

120–149

≥150

<90

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

Alabama

59.7

(57.2–62.2)

14.5

(12.8–16.3)

4.8

( 3.8– 6.1)

4.2

( 3.2– 5.5)

16.8

(15.0–18.6)

74.2

(71.9–76.4)

Alaska

49.8

(45.1–54.5)

10.9

( 8.3–14.2)

4.4

( 2.9– 6.5)

5.5

( 3.5– 8.6)

29.4

(25.2–34.0)

60.7

(56.0–65.3)

Arizona

50.1

(46.2–54.0)

12.8

(10.5–15.7)

5.6

( 4.1– 7.5)

5.1

( 3.7– 7.0)

26.4

(23.1–29.9)

63.0

(59.2–66.6)

Arkansas

59.6

(56.0–63.1)

13.7

(11.3–16.4)

4.2

( 3.0– 6.0)

4.7

( 3.5– 6.2)

17.8

(15.2–20.8)

73.2

(69.9–76.3)

California

44.3

(42.3–46.4)

13.7

(12.3–15.2)

6.6

( 5.5– 7.9)

7.7

( 6.6– 8.9)

27.7

(26.0–29.6)

58.0

(55.9–60.0)

Colorado

46.6

(44.3–48.9)

13.5

(12.0–15.1)

6.6

( 5.6– 7.8)

7.0

( 5.9– 8.4)

26.3

(24.4–28.3)

60.1

(57.8–62.3)

Connecticut

53.3

(50.1–56.4)

12.7

(10.8–14.8)

4.5

( 3.4– 5.9)

5.5

( 4.3– 6.9)

24.1

(21.5–26.9)

65.9

(62.9–68.8)

Delaware

62.5

(58.9–65.9)

10.6

( 8.5–13.1)

4.7

( 3.4– 6.5)

4.1

( 2.9– 5.7)

18.1

(15.5–21.1)

73.1

(69.8–76.1)

District of Columbia

49.4

(45.2–53.7)

9.3

( 7.6–11.3)

4.8

( 3.2– 7.2)

5.8

( 4.4– 7.7)

30.6

(26.9–34.6)

58.7

(54.5–62.8)

Florida

54.1

(51.6–56.5)

11.2

( 9.8–12.8)

4.4

( 3.5– 5.6)

5.7

( 4.5– 7.1)

24.7

(22.6–26.8)

65.2

(62.8–67.6)

Georgia

55.0

(52.3–57.6)

12.3

(10.7–14.0)

5.9

( 4.8– 7.4)

5.8

( 4.7– 7.2)

21.0

(18.9–23.3)

67.3

(64.7–69.7)

Hawaii

50.5

(47.0–54.1)

12.0

( 9.9–14.6)

4.8

( 3.5– 6.4)

6.8

( 5.2– 8.9)

25.9

(22.9–29.1)

62.5

(59.1–65.9)

Idaho

49.7

(46.3–53.2)

14.2

(12.1–16.7)

5.8

( 4.4– 7.7)

8.3

( 6.4–10.6)

22.0

(19.5–24.7)

63.9

(60.6–67.1)

Illinois

50.7

(47.3–54.2)

13.8

(11.6–16.3)

5.3

( 4.1– 6.9)

5.1

( 3.8– 6.7)

25.1

(22.0–28.5)

64.5

(61.0–67.8)

Indiana

55.3

(52.7–57.9)

14.7

(13.0–16.6)

5.6

( 4.5– 7.0)

4.4

( 3.5– 5.4)

20.1

(18.1–22.2)

70.0

(67.5–72.3)

Iowa

51.6

(48.9–54.3)

15.8

(14.0–17.9)

5.4

( 4.3– 6.8)

5.5

( 4.4– 6.8)

21.7

(19.5–24.0)

67.4

(64.9–69.9)

Kansas

56.2

(54.6–57.8)

15.5

(14.4–16.7)

5.0

( 4.4– 5.7)

5.0

( 4.4– 5.7)

18.3

(17.1–19.5)

71.7

(70.3–73.1)

Kentucky

54.7

(52.1–57.2)

14.6

(13.0–16.4)

5.9

( 4.7– 7.3)

5.4

( 4.3– 6.6)

19.5

(17.5–21.6)

69.3

(66.8–71.6)

Louisiana

63.5

(60.9–66.0)

12.2

(10.7–14.0)

3.7

( 2.9– 4.8)

4.6

( 3.6– 5.9)

16.0

(14.1–18.0)

75.7

(73.4–77.9)

Maine

47.5

(45.5–49.4)

12.8

(11.6–14.1)

6.7

( 5.8– 7.8)

6.0

( 5.1– 7.0)

27.0

(25.3–28.8)

60.3

(58.3–62.2)

Maryland

55.0

(52.2–57.8)

13.1

(11.4–15.0)

4.7

( 3.5– 6.1)

6.1

( 4.9– 7.6)

21.1

(19.0–23.5)

68.1

(65.4–70.6)

Massachusetts

53.1

(51.0–55.3)

10.8

( 9.5–12.2)

4.4

( 3.7– 5.2)

5.6

( 4.8– 6.5)

26.2

(24.3–28.1)

63.9

(61.9–65.9)

Michigan

52.1

(49.7–54.5)

14.2

(12.7–16.0)

5.2

( 4.3– 6.3)

6.1

( 5.0– 7.4)

22.4

(20.5–24.4)

66.3

(64.1–68.5)

Minnesota

49.2

(46.8–51.6)

14.8

(13.1–16.6)

5.6

( 4.5– 7.0)

5.2

( 4.3– 6.3)

25.2

(23.2–27.3)

64.0

(61.7–66.3)

Mississippi

59.6

(57.2–62.0)

13.5

(12.0–15.3)

5.9

( 4.9– 7.2)

4.4

( 3.6– 5.4)

16.5

(14.7–18.4)

73.2

(71.0–75.3)

Missouri

56.4

(53.2–59.5)

13.6

(11.5–16.1)

5.0

( 3.8– 6.6)

5.6

( 4.2– 7.3)

19.4

(17.1–22.0)

70.0

(67.0–72.8)

Montana

53.0

(50.3–55.7)

12.5

(10.9–14.3)

4.9

( 3.8– 6.4)

4.9

( 4.0– 6.1)

24.6

(22.4–27.0)

65.5

(62.9–68.1)

Nebraska

53.9

(52.2–55.6)

14.2

(13.1–15.4)

5.5

( 4.7– 6.4)

4.6

( 4.1– 5.3)

21.8

(20.5–23.2)

68.1

(66.5–69.6)

Nevada

54.0

(49.3–58.6)

10.5

( 8.4–13.1)

5.6

( 3.8– 8.1)

5.8

( 4.1– 8.1)

24.2

(20.5–28.3)

64.5

(59.9–68.8)

New Hampshire

51.9

(48.9–54.9)

13.5

(11.5–15.8)

5.2

( 4.1– 6.5)

5.6

( 4.4– 7.1)

23.8

(21.4–26.3)

65.4

(62.6–68.2)

New Jersey

55.0

(52.7–57.3)

10.1

( 8.8–11.6)

4.2

( 3.4– 5.2)

5.4

( 4.4– 6.5)

25.3

(23.4–27.3)

65.1

(62.9–67.3)

New Mexico

50.1

(47.6–52.6)

12.7

(11.2–14.4)

6.2

( 4.9– 7.7)

5.7

( 4.7– 6.9)

25.3

(23.2–27.6)

62.8

(60.3–65.2)

New York

50.6

(47.6–53.6)

13.2

(11.3–15.5)

5.0

( 3.8– 6.5)

6.2

( 4.9– 7.9)

24.9

(22.5–27.5)

63.8

(60.9–66.6)

North Carolina

54.5

(51.8–57.2)

14.6

(12.8–16.6)

6.0

( 4.7– 7.6)

6.5

( 5.4– 7.9)

18.4

(16.3–20.6)

69.1

(66.5–71.6)

North Dakota

53.0

(49.7–56.2)

12.2

(10.4–14.2)

5.9

( 4.7– 7.5)

5.5

( 4.2– 7.2)

23.4

(20.6–26.3)

65.2

(62.0–68.3)

Ohio

54.8

(52.3–57.3)

12.5

(11.0–14.2)

5.4

( 4.4– 6.6)

5.2

( 4.2– 6.3)

22.0

(19.9–24.3)

67.4

(64.9–69.7)

Oklahoma

57.7

(55.3–60.1)

14.7

(13.0–16.5)

4.6

( 3.7– 5.7)

4.7

( 3.8– 5.8)

18.4

(16.6–20.3)

72.4

(70.2–74.5)

Oregon

47.6

(44.7–50.5)

13.2

(11.3–15.4)

5.9

( 4.7– 7.5)

7.1

( 5.8– 8.6)

26.1

(23.8–28.6)

60.9

(58.1–63.6)

Pennsylvania

52.2

(49.9–54.5)

12.4

(10.9–14.0)

5.8

( 4.8– 7.1)

6.2

( 5.2– 7.3)

23.4

(21.6–25.3)

64.6

(62.4–66.7)

Rhode Island

52.6

(49.8–55.4)

12.9

(11.2–14.8)

4.5

( 3.6– 5.8)

6.2

( 5.0– 7.6)

23.8

(21.4–26.3)

65.5

(62.8–68.2)

South Carolina

52.9

(50.6–55.3)

14.5

(13.0–16.2)

5.4

( 4.5– 6.5)

6.2

( 5.0– 7.6)

20.9

(19.1–22.8)

67.5

(65.2–69.7)

South Dakota

52.1

(47.9–56.1)

16.2

(13.6–19.2)

5.7

( 3.9– 8.2)

5.7

( 4.1– 8.1)

20.3

(17.2–23.9)

68.3

(64.2–72.0)

Tennessee

66.2

(61.7–70.4)

10.0

( 8.0–12.5)

3.6

( 2.5– 5.1)

2.6

( 1.9– 3.6)

17.5

(14.1–21.6)

76.2

(72.0–79.9)

Texas

54.2

(51.3–56.9)

15.0

(12.9–17.2)

5.4

( 4.3– 6.7)

5.5

( 4.3– 7.0)

20.0

(18.0–22.1)

69.1

(66.5–71.6)

Utah

49.0

(46.6–51.4)

14.9

(13.3–16.7)

6.1

( 5.1– 7.4)

6.7

( 5.7– 8.0)

23.2

(21.3–25.2)

63.9

(61.7–66.2)

Vermont

49.5

(46.7–52.2)

12.2

(10.6–14.0)

6.1

( 5.0– 7.5)

6.3

( 5.1– 7.7)

26.0

(23.6–28.5)

61.6

(58.9–64.3)

Virginia

58.4

(55.2–61.5)

12.2

(10.3–14.4)

4.5

( 3.4– 6.0)

6.3

( 4.8– 8.1)

18.7

(16.4–21.1)

70.6

(67.7–73.4)

Washington

46.8

(44.3–49.3)

14.2

(12.6–15.9)

5.3

( 4.3– 6.6)

6.5

( 5.4– 7.8)

27.3

(25.1–29.5)

61.0

(58.5–63.3)

West Virginia

62.2

(59.6–64.7)

12.1

(10.5–13.9)

3.2

( 2.4– 4.2)

3.6

( 2.8– 4.6)

18.9

(16.9–21.1)

74.3

(72.0–76.6)

Wisconsin

47.1

(43.1–51.1)

12.2

( 9.9–14.9)

6.8

( 4.6– 9.9)

5.6

( 4.3– 7.3)

28.3

(24.9–32.0)

59.3

(55.3–63.2)

Wyoming

49.8

(46.2–53.3)

12.1

(10.1–14.5)

4.8

( 3.5– 6.6)

5.0

( 3.7– 6.6)

28.3

(25.1–31.8)

61.9

(58.3–65.4)

Median

53.0

(51.6–54.2)

13.1

(12.5–13.7)

5.3

(4.9–5.6)

5.6

(5.4–5.8)

23.2

(21.1–24.7)

65.5

(64.5–67.5)

Range

44.3–66.2

9.3–16.2

3.2–6.8

2.6–8.3

16.0–30.6

58.0–76.2

Abbreviation: CI = confidence interval.


FIGURE. Age-adjusted prevalence of walking <90 minutes per week among adults with arthritis, by state — United States, Behavioral Risk Factor Surveillance System, 2011

The figure shows age-adjusted prevalence of walking <90 minutes per week among adults with arthritis, by U.S. state, during 2011. Age-adjusted prevalence estimates, categorized by tertiles, also were calculated.

Alternate Text: The figure above shows age-adjusted prevalence of walking <90 minutes per week among adults with arthritis, by U.S. state, during 2011. Age-adjusted prevalence estimates, categorized by tertiles, also were calculated.


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