Clustering of behavioral and chronic health risk factors and their association with self-reported health and cardiovascular disease outcome among adults in North Carolina

Childhood trauma, including sexual assault (CSA), is a known risk factor for adverse mental health outcomes. This study quantifies the impact of CSA on the likelihood of being diagnosed with depression in adulthood, as well as its influence on poor mental and physical health days. We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) (2016-2023), comprising 321,106 respondents. The primary exposure was self-reported CSA, while the main outcomes were depression diagnosis, poor mental health days, and poor physical health days. Covariates included race, gender, marital status, employment, age, education, state, year, language spoken at home, metropolitan status, and urban residence. We employed Inverse Probability Weighting (IPW) to estimate the Average Treatment Effect (ATE), controlling for confounders and incorporating state and year fixed effects. Sampling weights ensured national representativeness, and robust standard errors accounted for clustering by state. In a matched cohort of 15,150 individuals with CSA and 15,150 controls, the CSA group had an average age of 50.3 ± 16.3 years, with most being White (69.3%) and female (76.7%). CSA was significantly associated with an increased risk of depression diagnosis, with a 22.1 percentage-point increase for those with one CSA experience (ATE = 0.221, 95% CI: 0.192-0.250, p < 0.001) and a 24.4 percentage-point increase for those with multiple CSA experiences (ATE = 0.244, 95% CI: 0.222-0.266, p < 0.001). CSA also impacted mental health. Those with a single CSA exposure reported 2.8 more days of poor mental health per month (ATE = 2.829, 95% CI: 2.096-3.398, p < 0.001), while those with multiple exposures reported 4.2 more days (ATE = 4.175, 95% CI: 3.609-4.740, p < 0.001) compared to controls. Regarding physical health, individuals with one CSA exposure reported 1.5 additional poor physical health days (ATE = 1.538, 95% CI: 0.788-2.289), while those with multiple exposures experienced 2.6 additional days (ATE = 2.587, 95% CI: 1.941-3.232). This study provides robust evidence that CSA significantly increases the likelihood of depression in adulthood and leads to more poor mental and physical health days. The findings underscore the cumulative impact of multiple CSA exposures on health outcomes and emphasize the need for trauma-informed healthcare, early intervention, and public health strategies to mitigate the long-term consequences of CSA.

ProblemChronic conditions and disorders (e.g., diabetes, cardiovascular diseases, arthritis, and depression) are leading causes of morbidity and mortality in the United States. Healthy behaviors (e.g., physical activity, avoiding cigarette use, and refraining from binge drinking) and preventive practices (e.g., visiting a doctor for a routine check-up, tracking blood pressure, and monitoring blood cholesterol) might help prevent or successfully manage these chronic conditions. Monitoring chronic diseases, health-risk behaviors, and access to and use of health care are fundamental to the development of effective public health programs and policies at the state and local levels.Reporting PeriodJanuary–December 2015.Description of the SystemThe Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit–dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to and use of health care, and use of preventive health services related to the leading causes of death and disability. This report presents results for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico (Puerto Rico), and Guam and for 130 metropolitan and micropolitan statistical areas (MMSAs) (N = 441,456 respondents) for 2015.ResultsThe age-adjusted prevalence estimates of health-risk behaviors, self-reported chronic health conditions, access to and use of health care, and use of preventive health services varied substantially by state, territory, and MMSA in 2015. Results are summarized for selected BRFSS measures. Each set of proportions refers to the median (range) of age-adjusted prevalence estimates for health-risk behaviors, self-reported chronic diseases or conditions, or use of preventive health care services by geographic jurisdiction, as reported by survey respondents. Adults with good or better health: 84.6% (65.9%–88.8%) for states and territories and 85.2% (66.9%–91.3%) for MMSAs. Adults with ≥14 days of poor physical health in the past 30 days: 10.9% (8.2%–17.2%) for states and territories and 10.9% (6.6%–19.1%) for MMSAs. Adults with ≥14 days of poor mental health in the past 30 days: 11.3% (7.3%–15.8%) for states and territories and 11.4% (5.6%–20.5%) for MMSAs. Adults aged 18–64 years with health care coverage: 86.8% (72.0%–93.8%) for states and territories and 86.8% (63.2%–95.7%) for MMSAs. Adults who received a routine physical checkup during the preceding 12 months: 69.0% (58.1%–79.8%) for states and territories and 69.4% (57.1%–81.1%) for MMSAs. Adults who ever had their blood cholesterol checked: 79.1% (73.3%–86.7%) for states and territories and 79.5% (65.1%–87.3%) for MMSAs. Current cigarette smoking among adults: 17.7% (9.0%–27.2%) for states and territories and 17.3% (4.5%–29.5%) for MMSAs. Binge drinking among adults during the preceding 30 days: 17.2% (11.2%–26.0%) for states and territories and 17.4% (5.5%–24.5%) for MMSAs. Adults who reported no leisure-time physical activity during the preceding month: 25.5% (17.6%–47.1%) for states and territories and 24.5% (16.1%–47.3%) for MMSAs. Adults who reported consuming fruit less than once per day during the preceding month: 40.5% (33.3%–55.5%) for states and territories and 40.3% (30.1%–57.3%) for MMSAs. Adults who reported consuming vegetables less than once per day during the preceding month: 22.4% (16.6%–31.3%) for states and territories and 22.3% (13.6%–32.0%) for MMSAs. Adults who have obesity: 29.5% (19.9%–36.0%) for states and territories and 28.5% (17.8%–41.6%) for MMSAs. Adults aged ≥45 years with diagnosed diabetes: 15.9% (11.2%–26.8%) for states and territories and 15.7% (10.5%–27.6%) for MMSAs. Adults aged ≥18 years with a form of arthritis: 22.7% (17.2%–33.6%) for states and territories and 23.2% (12.3%–33.9%) for MMSAs. Adults having had a depressive disorder: 19.0% (9.6%–27.0%) for states and territories and 19.2% (9.9%–27.2%) for MMSAs. Adults with high blood pressure: 29.1% (24.2%–39.9%) for states and territories and 29.0% (19.7%–41.0%) for MMSAs. Adults with high blood cholesterol: 31.8% (27.1%–37.3%) for states and territories and 31.4% (23.2%–42.0%) for MMSAs. Adults aged ≥45 years who have had coronary heart disease: 10.3% (7.2%–16.8%) for states and territories and 10.1% (4.7%–17.8%) for MMSAs. Adults aged ≥45 years who have had a stroke: 4.9% (2.5%–7.5%) for states and territories and 4.7% (2.1%–8.4%) for MMSAs.InterpretationThe prevalence of health care access and use, health-risk behaviors, and chronic health conditions varied by state, territory, and MMSA. The data in this report underline the importance of continuing to monitor chronic diseases, health-risk behaviors, and access to and use of health care in order to assist in the planning and evaluation of public health programs and policies at the state, territory, and MMSA level.Public Health ActionState and local health departments and agencies and others interested in health and health care can continue to use BRFSS data to identify groups with or at high risk for chronic conditions, unhealthy behaviors, and limited health care access and use. BRFSS data also can be used to help design, implement, monitor, and evaluate health-related programs and policies.

BackgroundInformal caregiving, a common form of social support, can be a chronic stressor with health consequences for caregivers. It is unclear how varying restrictions during the COVID-19 pandemic affected caregivers’ physical and mental health. This study explores pre-post March 2020 differences in reported days of poor physical and mental health among informal caregivers.MethodsData from the 2019/2020 Behavioral Risk Factor Surveillance System survey were used to match, via propensity scores, informal caregivers who provided care during COVID-19 restrictions to those who provided care before the pandemic. Negative binomial weighted regression models estimated incidence rate ratios (IRRs) and differences by demographics of reporting days of poor physical and mental health. A sensitivity analysis including multiple imputation was also performed.ResultsThe sample included 9,240 informal caregivers, of whom 861 provided care during the COVID-19 pandemic. The incidence rate for days of poor physical health was 26% lower (p = 0.001) for those who provided care during the COVID-19 pandemic, though the incidence rates for days of poor mental health were not statistically different between groups. Informal caregivers with low educational attainment experienced significantly higher IRRs for days of poor physical and mental health. Younger informal caregivers had a significantly lower IRR for days of poor physical health, but higher IRR for days of poor mental health.ConclusionsThis study contends that the physical and mental health burden associated with informal caregiving in a period of great uncertainty may be heightened among certain populations. Policymakers should consider expanding access to resources through institutional mechanisms for informal caregivers, who may be likely to incur a higher physical and mental health burden during public health emergencies, especially those identified as higher risk.

Difference in the physical and mental health of informal caregivers pre- and post-COVID-19 National Emergency Declaration in the United States.

In spite of increased gambling opportunities, risk factors associated with recreational gambling remain poorly understood. This study assessed behavioral risk factors associated with frequency of recreational gambling. Data were derived from the 2013 Massachusetts Behavioral Risk Factor Surveillance System. Gambling frequency was divided into two or more times per week, 1-4 times a month, less than 10 times in total, and not at all. Health risk behaviors included smoking, drinking, obesity, seat belt use, and sleep patterns. Multivariate logistic regression was used to assess relationships between overall gambling participation and gambling frequency and behavioral risk behaviors. Final analytical sample included 3,988 survey respondents. Statistical analyses were performed using STATA. Significant differences exist in the socio-demographic characteristics of recreational gamblers. Highest gambling frequency is associated with increased odds of alcohol consumption (ie, having at least one alcohol drink during the past 30 days) (OR 1.9; p < .05), binge drinking (ie, having five or more alcohol drinks at least once during the past 30 days) (OR 3.7; p < .001), and tobacco use (ie, having smoked at least 100 cigarettes in a lifetime) (OR 3.4; p < .001). The odds of having fourteen days of poor mental health are twofold for recreational gamblers who gamble two or more times per week (OR 2.2; p < .05). Differing behavioral and mental health risk factors emerge among recreational gamblers by gambling frequency. Gambling frequency may be a better proxy for assessing the risk of developing gambling related behavioral disorders than overall endorsement of gambling participation.

Insufficient research attention has been paid to the diversity of informal caregivers, including sexual and gender minority caregivers. This study examined health effects of caregiving separately from sexual orientation or gender identity status, while stratifying by gender among cisgender adults. We hypothesized that compared with heterosexual cisgender noncaregivers, heterosexual caregivers and lesbian/gay/bisexual (LGB), and transgender (T) noncaregivers would report poorer health outcomes (i.e., self-reported health, and poor mental health days and poor physical health days), and LGBT caregivers would report the worst health outcomes. This is a secondary data analysis of the 2015 and 2016 Behavioral Risk Factor Surveillance System data from 19 U.S. states. After adjusting for covariates and stratifying by gender among the cisgender sample, heterosexual caregivers, LGB noncaregivers and LGB caregivers had significantly higher odds of self-reported fair or poor health (adjusted odds ratios [aORs] 1.3-2.0 for women and 1.2 for men), poor physical health days (aORs 1.2-2.8 for women and 1.3-2.8 for men), and poor mental health days (aORs 1.4-4.7 for women and 1.5-5.6 for men) compared with heterosexual noncaregivers (reference group). By contrast, transgender caregivers did not have significantly poorer health than cisgender noncaregivers. LGB caregivers reported the worst health compared with other groups on multiple measures, signifying they are an at-risk population. These results suggest the necessity to develop LGB appropriate services and programs to prevent poor health in LGB caregivers. Existing policies should also be inclusive of LGBT individuals who are caregivers.

SummaryBackgroundInequality of opportunity, defined as differences in the prospects for upward social mobility, might have important consequences for health. Diminished opportunity can lower the motivation to invest in future health by reducing economic returns to health investments and undermining hope. We estimated the association between county-level economic opportunity and individual-level health in young adults in the general US population.MethodsIn this population-based cross-sectional study, we used individual-level data from the 2009–12 United States Behavioral Risk Factor Surveillance Surveys. Our primary outcomes were current self-reported overall health and the number of days of poor physical and mental health in the last month. Economic opportunity was measured by the county-averaged national income rank attained by individuals born to families in the lowest income quartile. We restricted our sample to adults aged 25–35 years old to match the data used to assign exposure. Multivariable ordinary least squares and probit models were used to estimate the association between the outcomes and economic opportunity. We adjusted for a range of demographic and socioeconomic characteristics, including age, sex, race, education, income, access to health care, area income inequality, segregation, and social capital.FindingsWe assessed nearly 147 000 individuals between the ages of 25 years and 35 years surveyed from 2009 to 2012. In models adjusting for individual-level demographics and county-level socioeconomic characteristics, increases in county-level economic opportunity were associated with greater self-reported overall health. An interdecile increase in economic opportunity was associated with 0·76 fewer days of poor mental health (95% CI −1·26 to −0·25) and 0·53 fewer days of poor physical health (−0·96 to −0·09) in the last month. The results were robust to sensitivity analyses.InterpretationEconomic opportunity is independently associated with self-reported health and health behaviours. Policies seeking to expand economic opportunities might have important spillover effects on health.FundingRobert Wood Johnson Foundation Health and Society Scholars Program.

This study examined the relationship between the presence of chronic disease conditions and mental and physical health among cancer survivors in the United States. We conducted a cross-sectional analysis utilizing survey data from the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) on 65,673 eligible cancer survivors. The primary outcomes of interest were self-rated metal/physical health in the past 30days. Descriptive statistics and multivariate logistic regression were used to examine the mentioned association. 15.3% and 24.8% of survivors reported having several days of poor mental and physical health (14-30days compared to 0-13days), and 42.4% of survivors reported having one to two chronic diseases. In multivariate analysis, survivors with one to two chronic diseases were more likely to report several days of poor mental (OR, 2.74; 95% CI, 2.22-3.38) and physical (OR, 1.95; 95% CI, 1.72-2.22) health. Survivors with 3+ chronic diseases had markedly higher odds of having several days of poor mental (OR, 6.41; 95% CI, 5.19-7.91) and physical health (OR, 4.71; 95% CI, 4.16-5.34). Among survivors with at least one chronic disease, older age, insured, and more perceived social/emotional support were negatively associated with mental health (p value <0.05). Similarly, older age was related to fewer days of poor physical health (p value <0.05) regardless of chronic disease conditions. Having chronic diseases was associated with more days of poor mental and physical health among cancer survivors. Integrated, extensive care should include mental/physical health components and chronic disease management in cancer survivorship care.

Health care access increased for low-income Americans under the Affordable Care Act (ACA). It is unknown whether these changes in access were associated with improved self-reported health. Determine changes in health care access, health behaviors, and self-reported health among low-income Americans over the first 4 years of the ACA, stratified by state Medicaid expansion status. Interrupted time series and difference-in-differences analysis. Noninstitutionalized US adults (18-64 y) in low income households (<138% federal poverty level) interviewed in the Behavioral Risk Factor Surveillance System 2011-2017 (N=505,824). Self-reported insurance coverage, access to a primary care physician, avoided care due to cost; self-reported general health, days of poor physical health, days of poor mental health days, and days when poor health limited usual activities; self-reported health behaviors, use of preventive services, and diagnoses. Despite increases in access, the ACA was not associated with improved physical or general health among low-income adults during the first 4 years of implementation. However, Medicaid expansion was associated with fewer days spent in poor mental health (-1.1 d/mo, 95% confidence interval: -2.1 to -0.5). There were significant changes in specific health behaviors, preventive service use, and diagnosis patterns during the same time period which may mediate the relationship between the ACA rollout and self-reported health. In nationally-representative survey data, we observed improvements in mental but not physical self-reported health among low-income Americans after 4 years of full ACA implementation.

Physical activity and exercise improve function, symptom control, and health-related quality of life (QoL) for many cancer survivors; however, the evidence is limited and inconsistent in lung cancer. We examined the relationship between leisure-time physical activity (LTPA) and health-related QoL in a national sample of US lung cancer survivors. We conducted a cross-sectional study using the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. We defined LTPA as a self-report of engaging in any physical activity or exercise such as running, calisthenics, golf, gardening, or walking for exercise in the past 30 days, health-related QoL as the number of days of having poor physical or mental health in the past 30 days, and general health status. We analyzed using multivariable logistic regressions with 95% confidence intervals (CIs). Among 614 lung cancer survivors, 316 (51.5%) reported engaging in LTPA. The counts (and proportions) of participants who engaged in LTPA vs no LTPA were, respectively, 135 (42.7%) vs 63 (21.1%) for 0 days of poor physical health, 222 (70.3%) vs 174 (58.4%) for 0 days of poor mental health, and 158 (50.0%) vs 77 (25.8%) for good to excellent general health. In multivariable analyses, participating in LTPA was associated with odds ratios of 2.64 (95% CI = 1.76 to 3.96) and 1.43 (95% CI = 0.97 to 2.10) for 0 days of poor physical and mental health, respectively, and 2.61 (95% CI = 1.74 to 3.91) for good to excellent general health. Participating in LTPA was associated with improved health-related QoL. Interventions to promote LTPA and/or exercise-based rehabilitation may improve QoL among lung cancer survivors.

With the proliferation of anti-transgender policies in some U.S. jurisdictions, this study examines the general, mental, and physical health of transgender and cisgender populations. Data from the 2020-2023 Behavioral Risk Factor Surveillance System were analyzed to examine associations between gender identity and health outcomes. Propensity score weighting was used to address potential imbalances among group characteristics. We conducted logistic regression for the binary outcome of self-rated health and quasi-Poisson regression for the number of days reporting poor mental and physical health. Results reveal significant disparities in health outcomes, with transgender individuals reporting lower proportions of good general health and more days of poor mental and physical health compared to cisgender individuals. In the adjusted analyses, transgender individuals were significantly less likely to report good general health compared to cisgender peers (OR = 0.60, 95% CI = 0.52-0.69). Gender nonconforming (GNC), male-to-female (MTF), and female-to-male (FTM) individuals had lower odds of reporting good general health compared to cisgender individuals (GNC, OR = 0.46, 95% CI = 0.35-0.61; MTF, OR = 0.67, 95% CI = 0.53-0.85; FTM, OR = 0.71, 95% CI = 0.57-0.87). GNC individuals had an 86% higher frequency of poor mental health days (IRR = 1.86, 95% CI = 1.57-2.21) and a 37% higher frequency of poor physical health days (IRR = 1.37, 95% CI = 1.15-1.63) compared to cisgender counterparts. Similarly, MTF and FTM individuals had significantly higher frequencies of poor mental and physical health days. The study highlights significant health disparities faced by transgender individuals, who report poorer general, mental, and physical health. These findings underscore the need to address the unique challenges and improve health outcomes within the transgender community.

PurposeThe passage of the Affordable Care Act in the US resulted in more Americans with health insurance coverage as well as expanded health benefits. However, barriers in accessing health care still exist in the US especially as it relates to some of the most vulnerable Americans including those with depressive disorders. The purpose of this cross-sectional secondary data analysis was to examine the differences in health-related quality of life for individuals with depressive disorders in early years of the implementation of the Affordable Care Act as compared to later years of implementation.MethodsThis study used a repeated cross-sectional design that pooled data from the 2011–2017 Behavioral Risk Factor Surveillance System which is a nationally representative survey of the non-institutionalized U.S. population. Logistic regression models were used to evaluate the before and after impact of the Affordable Care Act on health related quality of life for those with depressive disorders.ResultsThose with depressive disorders in early years of implementation of the Affordable Care Act were less likely to report 14 or more days of poor physical health (AOR = 0.96; 95% CI: 0.95, 0.98), were less likely to report 14 or more days of poor mental health (AOR = 0.93; 95% CI: 0.92, 0.94), and less likely to report 14 or more days of overall poor physical and mental health (AOR = 0.93; 95% CI: 0.90, 0.96) as opposed to later years of implementation.ConclusionsOur results indicate poorer health related quality of life for those with depressive disorders in later years of implementation of the Affordable Care Act. Despite expanded mental health benefits under the Affordable Care Act, those benefits do not always translate into improved access or improved patient-reported outcomes. The federal government needs to comprehensively address mental health services in order to improve patient-reported outcomes and mental health treatment for those with depression.

Aim:This study aimed to identify how frequent poor mental health days, a depressive disorder diagnosis, frequent poor physical health days, or physical inactivity affect annual foot examinations in individuals with diabetes.Background:Diabetes mellitus (DM), particularly type 2, is a growing problem in the United States and causes serious health complications such as cardiovascular disease, end-stage renal disease, peripheral neuropathy, foot ulcers, and amputations. There are guidelines in place for the prevention of foot ulcers in individuals with diabetes that are not often followed. Poor mental health and poor physical health often arise from DM and contribute to the development of other complications.Methods:We performed a cross-sectional analysis of the 2021 Behavioural Risk Factor Surveillance System dataset to determine the relationship between annual foot examinations and frequent poor mental health days, a depressive disorder diagnosis, frequent poor physical health days, or physical inactivity using a bivariate logistic regression model. The regression model was controlled for age, sex, race/ethnicity, health insurance, level of education, current smoking status, and Body Mass Index (BMI) category.Findings:Our results showed that 72.06% of individuals with frequent poor mental health days received a foot check, compared with 76.38% of those without poor mental health days – a statistically significant association (AOR: 1.25; 95% CI: 1.09–1.43). Of those reporting a sedentary lifestyle, 73.15% received a foot check, compared with 77.07% of those who were physically active, which was also statistically significant (AOR: 1.31; 95% CI: 1.14–1.49). Although individuals reporting depressive disorder diagnoses and frequent poor physical health days had lower rates of foot examinations, these results were not statistically significant. To reduce rates of foot ulcers and possible amputations, we recommend the implementation of counselling or support groups, increased mental health screening, educational materials, or exercise classes.

U.S. State-Level Social Capital and Health-Related Quality of Life: Multilevel Evidence of Main, Mediating, and Modifying Effects

Relationships of self-reported opioid and benzodiazepine use with health-related quality of life among adults with spinal cord injury