Complex Survey Design Research Articles

Serum Cholesterol Differences Between Statin Users Who Take Dietary Supplements and Those Who Do Not: NHANES 2013–2018

BackgroundCardiovascular disease (CVD) is the leading cause of mortality in the United States and statins are the most commonly prescribed medication. It is important to understand the potential impact supplements may have when taken in combination with statins on serum lipid outcomes. ObjectivesTo evaluate the differences in the concentrations of cholesterol, triacylglycerol (TAG), and HbA1c between adults who use statins alone and those who combine statins and dietary supplements. MethodsA cross-sectional analysis using data from US adults aged ≥20 years who participated in the NHANES (2013–2018). The serum concentrations of lipids and the HbA1c levels were compared using independent sample t-tests. All analyses were adjusted for the complex survey design and used appropriate sample weights. ResultsOf 16,327 participants included in this analysis, 13% reported the use of statins alone, and 8.8% used statins and dietary supplements. Statin users who used dietary supplements tended to be women (50.5%), aged 65.8 ± 0.4 years, and were more likely to be White (77.4%). Participants who used statins in combination with dietary supplements were less likely to have higher levels of total cholesterol (5.1% ± 1.4% vs. 15.6% ± 2.7%, P < 0.001), HbA1c (6.0% ± 0.1% vs. 6.3% ± 0.1%, P < 0.05), and HDL cholesterol (50 ± 1.3 vs. 47 ± 0.8 mg/dL, P < 0.05) than those who used statins alone. No significant differences were identified between the two groups for LDL cholesterol and TAG concentrations. ConclusionsStatin users who coingested dietary supplements were less likely to have high levels of total cholesterol and HbA1c and greater HDL levels than statin users who did not take dietary supplements. Dietary intake, lifestyle choices, and other confounders may have influenced the observed outcome differences for those who took dietary supplements with statins and those who did not.

Assessment of Vitamin D status and association with inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

BackgroundIt is unclear whether 25(OH)D concentrations in children and female adults may be influenced by inflammation and thus require adjustment when estimating the population prevalence of vitamin D deficiency. ObjectivesWe examined correlations between inflammation biomarkers, CRP or alpha-1-acid glycoprotein (AGP), and serum 25(OH)D concentrations among preschool children (PSC; 6–59 mo) and nonpregnant females of reproductive age (FRA; 15–49 y). MethodsWe analyzed cross-sectional data from 6 nationally representative nutrition surveys (Afghanistan, Cambodia, Pakistan, UK, USA, and Vietnam) conducted among PSC (n = 9880) and FRA (n = 14,749) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project. Rank correlations between CRP or AGP and 25(OH)D concentrations were examined while taking into account complex survey design effects. ResultsAmong both PSC and FRA, correlations between inflammation and vitamin D biomarkers were weak and inconsistent across surveys. For PSC, correlation coefficients between CRP and 25(OH)D concentrations ranged from −0.04 to 0.08, and correlations between AGP and 25(OH)D ranged from 0.01 to 0.05. Correlation coefficients between CRP and 25(OH)D for FRA ranged from −0.11 to 0.14, and correlations between AGP and 25(OH)D concentrations ranged from −0.05 to 0.01. ConclusionsBased on the weak and inconsistent correlations between CRP or AGP and 25(OH)D, there is no rationale to adjust for these inflammation biomarkers when estimating population prevalence of vitamin D deficiency in PSC or FRA.

HIV Incidence, Recent HIV Infection, and Associated Factors, Kenya, 2007-2018.

Nationally representative surveys provide an opportunity to assess trends in recent human immunodeficiency virus (HIV) infection based on assays for recent HIV infection. We assessed HIV incidence in Kenya in 2018 and trends in recent HIV infection among adolescents and adults in Kenya using nationally representative household surveys conducted in 2007, 2012, and 2018. To assess trends, we defined a recent HIV infection testing algorithm (RITA) that classified as recently infected (<12 months) those HIV-positive participants that were recent on the HIV-1 limiting antigen (LAg)-avidity assay without evidence of antiretroviral use. We assessed factors associated with recent and long-term (≥12 months) HIV infection versus no infection using a multinomial logit model while accounting for complex survey design. Of 1,523 HIV-positive participants in 2018, 11 were classified as recent. Annual HIV incidence was 0.14% in 2018 [95% confidence interval (CI) 0.057-0.23], representing 35,900 (95% CI 16,300-55,600) new infections per year in Kenya among persons aged 15-64 years. The percentage of HIV infections that were determined to be recent was similar in 2007 and 2012 but fell significantly from 2012 to 2018 [adjusted odds ratio (aOR) = 0.31, p < .001]. Compared to no HIV infection, being aged 25-34 versus 35-64 years (aOR = 4.2, 95% CI 1.4-13), having more lifetime sex partners (aOR = 5.2, 95% CI 1.6-17 for 2-3 partners and aOR = 8.6, 95% CI 2.8-26 for ≥4 partners vs. 0-1 partners), and never having tested for HIV (aOR = 4.1, 95% CI 1.5-11) were independently associated with recent HIV infection. Although HIV remains a public health priority in Kenya, HIV incidence estimates and trends in recent HIV infection support a significant decrease in new HIV infections from 2012 to 2018, a period of rapid expansion in HIV diagnosis, prevention, and treatment.

RACE AND ETHNIC DIFFERENCES IN PHYSICAL ACTIVITY, OSTEOPENIA, AND OSTEOPOROSIS: RESULTS FROM NHANES

Abstract Introduction Osteopenia and osteoporosis are common age-related disorders with enormous health and economic consequences to older adults and society. Physical activity (PA) is an important modifiable risk factor for bone mineral density (BMD). This study aims to determine whether current physical activity is related to osteopenia and osteoporosis (based on BMD) in a racial/ethnically diverse sample of older adults. Methods Femoral bone BMD data from the National Health and Nutrition Examination Survey (NHANES 2009-2010, 2013-2014, 2017-2018) was obtained for 3,331 adults 60-80 years old. Self-reported PA was categorized into high, moderate, and low. Linear regression models that accounted for the complex survey design of NHANES examined the association between PA and BMD for each race/ethnic group. Results Non-Latino blacks (blacks) and Latinos reported low levels of PA when compared to Non-Latino whites (whites) (40.7%, 38.2% and 32.4% respectively; p&amp;lt; 0.0001). Further, blacks and Latinos had a lower prevalence of osteoporosis (5.6%, 6.4% and 9.0% respectively; p&amp;lt; 0.0001), but have similar prevalence of normal BMD and osteopenia categories when compared to whites. There was a 0.03 g/cm2 difference in BMD between those in the high PA versus the low PA (p&amp;lt; 0.0001). Conclusion Our findings indicate that despite lower levels of activity, black and Latino older adults were less likely to have osteoporosis. High levels of activity were significantly associated with higher BMD after controlling for confounders. Considering the prevalence and burden of osteopenia and osteoporosis and projected increases of the older population we need more research evidence supporting the role of PA.

Trends and socio-demographic components of modern contraceptive use among sexually active women in Rwanda: a multivariate decomposition analysis

BackgroundThe attainment of targets set for modern contraceptive use remains a challenge in sub-Saharan Africa. Rwanda, in its new Family Planning and Adolescent Sexual Reproductive Health/Family Planning (FP/ASRH) Strategic Plan 2018–2024 has set the attainment of a contraceptive prevalence rate (CPR) of 60% by 2024. To achieve this, identifying factors that enhance modern contraceptive use among sexually active women is critical.MethodsWe used three Rwanda Demographic Health Surveys (RDHS) datasets collected in 2010, 2015, and 2019/2020 in a multivariable decomposition analysis technique to describe trends and identify factors influencing change in modern contraceptive use among sexually active women aged 15–49 years. Results presented as coefficients and percentages took into consideration the complex survey design weighted using StataSE 17.ResultsModern contraceptive use increased from 40% in 2010 to 52.4% in 2020 among sexually active women. About 23.7% of the overall percentage change in modern contraceptive use was attributable to women’s characteristics which included women’s education levels, number of living children, and being told about family planning at health facilities. Coefficients contributed 76.26% to the change in modern contraceptive use. This change was attributed to modern contraceptive use among young women between the age of 20–24 years, women’s education level, the number of living children, changes in family size, and being visited by community health workers.ConclusionRwanda remains on course to archive its 2024 family planning targets. However, there is a need to enhance programs that target sexually active adolescents and young adults, and women from rural areas to sustain the gains made. Furthermore, continuous support of community health workers will be key in exceeding the set targets of modern contraceptive use among sexually active women in Rwanda.

2077. Assessing the Association Between Parent-Child Relationships and HIV Testing in the Asian American Population: A Longitudinal Study

Abstract Background Asian Americans (AAs) make up approximately 2% of new HIV diagnoses, 1.5% of all diagnoses, and are the only ethnic group noted to have a continuous increase in infection rate from 2011 to 2016. AAs also report the lowest rates of HIV testing (33.5%). Barriers to HIV testing in Asian Americans continue to exist; however, the predictors of HIV testing among Asians in the United States are not well studied. Prior studies have shown that the parent-child relationship may play a role in increasing the likelihood of HIV testing. One study found that father-child communication in the Black population was positively associated with HIV testing. No such study has been performed in the AA population. This study examined the association between parent-child relationships and HIV testing in AAs to understand what factors can contribute to increased HIV testing uptake. Methods We used data from Waves I and III of the National Longitudinal Study of Adolescent Health, a nationally representative, longitudinal study. Parent-child relationships were categorized as authoritarian (low warmth, high control), permissive (high warmth, low control), neglectful (low warmth, low control) and compared to an authoritative reference group (high warmth, high control. Based on prior studies as well as theory, age, gender, and parental education were included as covariates. Analyses were performed using Stata 17.0. We used multivariate logistic regression, controlling for covariates. Analyses were weighted to account for the complex survey design. Results 302 respondents self-reported as Asian. 147 (48.68%) identified as female. 42 respondents (13.91%) reported having been tested for HIV, while 259 (85.76%) did not. Compared to the authoritative reference group, both authoritarian and neglectful parenting were significantly associated with having a lower likelihood of obtaining an HIV test (authoritarian OR 0.27, p=0.026; neglectful OR 0.08, p=0.026), after adjusting for covariates. Conclusion Authoritative parenting style is most supportive of HIV testing in Asian American adolescents and young adults, while authoritarian and neglectful parenting predicted decreased HIV testing. Parenting style likely plays a role in HIV testing uptake in the Asian American population. Disclosures All Authors: No reported disclosures.

Ecological analysis of demographic-, nutritional- and housing-related factors associated with anaemia among women of reproductive age group in Nigeria

Anaemia remains a major public health concern, particularly, in sub-Saharan Africa (SSA), where it is one of the causes of maternal death. The most common cause of maternal anaemia is iron deficiency or malnutrition. This study examined the prevalence of and risk factors for anaemia among women that participated in the Nigerian Demographic Health Survey. We used data of 14,454 women that participated in the 2018 Nigeria Demographic and Health Survey (NDHS). We extracted information such as demographic, social and housing, dietary characteristics and haemoglobin concentration. The descriptive statistic results, prevalence and 95% confidence interval (CIs) of anaemia with the selected respondents background characteristics were presented. The Poisson regression model with robust variance was used to assess the risk of anaemia among women of reproductive age. All analyses were weighted and adjusted for the complex survey design. Statistical significance was interpreted at p value < 0.05. Maternal status, body mass index, education, residence, religion, ethnicity, region and type of cooking fuel were all important determinants of anaemia. The prevalence of anaemia was high among pregnant women (61.8%; 95% CI: 58.5-65.0), adolescents (60.4%; 95% CI: 58.1-62.6), underweight women (62.6%; 95% CI: 59.5-65.5), women who had no formal education (64.1%; 95% CI: 62.2-66.0) and those who belonged to the poorest wealth quintile (65.8%; 95% CI: 63.1-68.4). Similarly, anaemia was high among women residing in rural areas (61.5%; 95% CI: 60.0-63.0), Muslims (59.9%; 95% CI: 58.1-61.6) and women with six or more children (62.1%; 95% CI: 60.0-64.1). The risk of anaemia were 2% less likely among women who took minimum adequate diet compared to those who do not. To date, this is the largest data on maternal anaemia in Nigeria. The study highlighted the high burden of maternal anaemia in the country and different risk factors (medical and social) that are associated with this medical condition among women of reproductive age. We recommend future longitudinal studies to test hypothesis in order to assess whether there is any causal relationship between identified risk factors and anaemia in this group of women.

Women’s empowerment indicators and short- and long-acting contraceptive method use: evidence from DHS from 11 countries

BackgroundWith a population of about 1.1 billion, sub-Saharan Africa is projected to overtake Eastern, Southern and Central Asia to become the most populous region by 2060. One effective approach for slowing this rapid population growth is the use of modern contraception and this may be short-acting or long acting. Previous studies have explored the association between women empowerment indicators contraception use, however, there is limited evidence on how women empowerment indicators associate with type of contraception. Hence the present study investigated the association between women empowerment indicators and type of contraception used by women in 11 sub-Saharan African countries.MethodsWe utilised Demographic and Health Survey data of 22,637 women from 11 countries, collected between 2018 and 2021. The outcome variable was type of contraception used. Descriptive and inferential analyses were executed. The descriptive analysis reflected women empowerment indicators and the proportion of women using contraceptives. Multinomial logistic regression was considered for the inferential analysis. The results for the multinomial logistic regression were presented as adjusted odds ratios (aORs) along with the respective 95% confidence intervals (CIs) signifying precision. The sample weight (wt) was used to account for the complex survey (svy) design. All the analyses were done with Stata version 13 and SPSS version 25.ResultsThe study showed that on the average, 15.95% of the women do not use modern contraceptives, whilst 30.67% and 53.38% use long-acting and short-acting contraceptives respectively. The adjusted models showed that women who were working had higher odds of using long-acting (aOR = 1.44, CI 1.28–1.62) and short-acting (aOR = 2.00, CI 1.79–2.24) methods compared with those who were not working. The analysis revealed higher likelihood of long-acting method use among women with high decision-making capacity (aOR = 1.27, CI 1.09–1.47) compared with women with low decision-making capacity. Women with medium knowledge level had a higher likelihood (aOR = 1.54, 1.09–2.17) of using long-acting methods than their counterparts with low knowledge level.ConclusionOur findings show that most women in the 11 countries use modern contraceptives, however, different empowerment indicators align with different contraceptive type. It therefore behoves governments of the studied countries to review current interventions and embrace new ones that are more responsive to the peculiar contraception needs of empowered and non-empowered women.

E-Cigarettes Used by Adolescents to Try to Quit Smoking Are Associated With Less Quitting: A Cross-Sectional Analysis of the National Youth Tobacco Survey

PurposeThis paper determines the association between youth e-cigarette use “to try to quit using other tobacco products, such as cigarettes” and having stopped smoking cigarettes (defined as an ever cigarette smoker who did not smoke in the past 30 days). MethodsThis study uses data from the NYTS from 2015 through 2021, focusing on youth who started smoking cigarettes before they started using e-cigarettes. Associations between using e-cigarettes to quit and having stopped smoking were computed using logistic regression accounting for the complex survey design and adjusting for level of nicotine dependence, year, age, gender, and race/ethnicity. Sensitivity analyses allowed for having started cigarettes and e-cigarettes in the same year and without regard for starting sequence. ResultsThe primary analytic subsample included 6435 United States middle and high school students (mean age 15.9 years, 55.4% male). Using e-cigarettes to quit was associated with significantly lower odds of having stopped smoking cigarettes (odds ratio, 0.62; 95% confidence interval, 0.45–0.85), controlling for nicotine dependence and demographics. Youth with higher levels of nicotine dependence also had lower odds of having stopped smoking. The results were stable over time. Sensitivity analyses produced similar results. DiscussionEver-smoking youth who used e-cigarettes “to try to quit using other tobacco products, such as cigarettes” had lower odds of having stopped smoking cigarettes than those who did not use e-cigarettes as to try to quit. Physicians, regulators, and educators should discourage youth from attempting to use e-cigarettes as a way to stop smoking cigarettes.

Multivariate Mixture Model for Small Area Estimation of Poverty Indicators

Abstract When disaggregation of national estimates in several domains or areas is required, direct survey estimators, which use only the domain-specific survey data, are usually design-unbiased even under complex survey designs (at least approximately) and require no model assumptions. Nevertheless, they are appropriate only for domains or areas with sufficiently large sample size. For example, when estimating poverty in a domain with a small sample size (small area), the volatility of a direct estimator might make that area seems like very poor in one period and very rich in the next one. Small area (or indirect) estimators have been developed in order to avoid such undesired instability. Small area estimators borrow strength from the other areas so as to improve the precision and therefore obtain much more stable estimators. However, the usual model-based assumptions, which include some kind of area homogeneity, may not hold in real applications. A more flexible model based on multivariate mixtures of normal distributions that generalises the usual nested error linear regression model is proposed for estimation of general parameters in small areas. This flexibility makes the model adaptable to more general situations, where there may be areas with a different behaviour from the other ones, making the model less restrictive (hence, more close to nonparametric) and more robust to outlying areas. An expectation-maximisation (E-M) method is designed for fitting the proposed mixture model. Under the proposed mixture model, two different new predictors of general small area indicators are proposed. A parametric bootstrap method is used to estimate the mean squared errors of the proposed predictors. Small sample properties of the new predictors and of the bootstrap procedure are analysed by simulation studies and the new methodology is illustrated with an application to poverty mapping in Palestine.

Associations between Diet Quality and Allostatic Load in US Adults: Findings from the National Health and Nutrition Examination Survey, 2015-2018.

Allostatic load (AL), the concept of cumulative biological risk from chronic stressful exposures, may provide a framework with which to examine the links between diet, physiological stress, and disease. This study examined the associations between diet quality and AL. This cross-sectional study was conducted using the 2015 through 2018 cycles of the National Health and Nutrition Examination Survey. Dietary intake was assessed using two 24-hour diet recalls. Diet quality was measured using the Healthy Eating Index 2015. AL was measured by a composite score of nine biochemical markers, with three or more dysregulated values signaling elevated AL. All markers were collected during a physical examination. This study was conducted in a nationally representative population of 5,343 US adults aged 19 years or older who had no prior diagnosis of diabetes (except gestational diabetes), cancer (except skin cancer), or cardiovascular disease; were not pregnant; and had complete dietary intake and AL biomarker data. The outcome was odds of elevated AL. Accounting for the complex survey design of the National Health and Nutrition Examination Survey, multivariable logistic regression was used to examine the associations between Healthy Eating Index 2015 score and elevated AL, adjusting for sociodemographic variables. A significant inverse association between AL and diet quality was observed among adults aged 31 years and older but not among those aged 19 to 30 years. Among adults aged 31 years and older, those in higher quintiles of Healthy Eating Index 2015 score had significantly lower odds of elevated AL compared with the lowest quintile (P for trend < 0.05). These results suggest that, in adults older than age 30 years, consuming a more healthful diet is inversely associated with AL.

Prenatal Perception of WIC Breastfeeding Recommendations Predicts Breastfeeding Exclusivity and Duration in the Infants’ First Year

Pregnant participants who perceived that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) recommends breastfeeding only were more likely to have better early breastfeeding outcomes. Our objective was to examine the association between prenatal perception of WIC's breastfeeding recommendations and breastfeeding duration through the first year of infant life. This observational study used a national longitudinal sample of 1594 pregnant participants in the WIC Infant and Toddler Feeding Practices Study-2 in 2013. Four measures of breastfeeding duration were used: 1) a discrete measure of exclusive breastfeeding through 5 mo; 2) a continuous measure of exclusive breastfeeding (in days up to 7 mo); 3) a discrete measure of any breastfeeding through 11 mo; and 4) a continuous measure of any breastfeeding (in days up to 13 mo). The primary explanatory variable was the participant's prenatal perception of whether WIC recommended breastfeeding only. The univariate analyses of time to breastfeeding cessation were performed using Kaplan-Meier curves. The Cox regression model was adopted to estimate the likelihood of breastfeeding outcomes over time. All analyses accounted for complex survey design effects. Compared with their peers who perceived WIC to recommend formula only or both breastfeeding and formula equally, participants who perceived WIC as recommending breastfeeding only were less likely to stop exclusive breastfeeding through 5 mo (HR = 0.83; 95% CI: 0.69, 0.99) or to stop any breastfeeding through 11 mo (HR = 0.80; 95% CI: 0.69, 0.92), without controlling for prenatal infant feeding intentions. Similar patterns were observed in the 2 continuous measures, as they were also less likely to stop exclusive breastfeeding by 7 mo (HR = 0.78; 95% CI: 0.69, 0.90) or to stop any breastfeeding by 13 mo (HR = 0.82; 95% CI: 0.71, 0.95). Prenatal perception of WIC's breastfeeding recommendation can be a useful predictor of breastfeeding duration in WIC participants.

Causal effects of smoking on depressive symptoms: the 8th Korea national health and nutrition examination survey

Several studies have been conducted on the relationship between smoking and depressive symptoms using observational study data. This manuscript examines if smoking has a causal effect on depressive symptoms using the 8th Korea national health and nutrition examination survey data. We conduct propensity score matching to reduce the self-selection bias of the observational study through balancing covariates to estimate the average treatment effect for the treatment group. In the propensity score matching process, this paper focuses on two major cautions. First, if the outcome variable is binary, the marginal effect may not coincide with the conditional effect. Thus, we use G-computation to estimate the marginal effect, robustly. Second, in the complex survey sampling data, we consider complex survey design when the target population is entire, not the group of respondents. The result shows that smoking can lead to an increase in depressive symptoms based on the causal inference approach, and it is the same between the entire population and the group of survey respondents.

Prevalence and factors associated with visual impairment in middle-aged and older Chinese population.

This study aimed to estimate the prevalence of visual impairment and to identify the factors associated with it in China. Data for this cross-sectional study were retrieved from the China Health and Retirement Longitudinal Study (CHARLS) for a total of 16,480 subjects who completed the questionnaire between June 2011 and March 2012. The prevalence of visual impairment was estimated considering the complex survey design and response rate. Associated factors were identified using the weighted logistic regression analysis. The overall prevalence of visual impairment among middle-aged and older Chinese adults was 6.22%. Regionally, Qinghai and Gansu provinces showed the highest prevalence of visual impairment, whereas Shanghai showed the lowest prevalence of visual impairment in China. Older age (OR = 1.888; 95% CI: 1.537-2.467) was correlated with a higher likelihood of visual impairment, whereas a non-alcohol intake (OR = 0.072; 95% CI: 0.018-0.246) was correlated with a lower likelihood of visual impairment. Hypertension (OR = 1.299; 95% CI: 1.189-1.467), diabetes (OR = 2.000; 95% CI: 1.163-3.765), lung diseases (OR = 1.795; 95% CI: 1.067-3.019), liver diseases (OR = 1.270; 95% CI: 1.221-2.876), stroke (OR = 1.135; 95% CI: 1.107-3.528), and heart disease (OR = 1.350; 95% CI: 1.104-1.708) were significantly associated with visual impairment. Geographical variations in the prevalence of visual impairment in China were defined, indicating that such variations do exist in China. Age, alcohol intake, hypertension, diabetes, lung diseases, liver diseases, stroke, and heart disease were factors associated with visual impairment.

Associations between sleep and overweight/obesity in adolescents vary by race/ethnicity and socioeconomic status.

To examine the interaction between sleep and social determinants of health (SDOH) [race/ethnicity and socioeconomic status (SES)] on overweight/obesity in adolescents. Cross-sectional. We conducted a secondary analysis using the 2017-2018 National Survey of Children's Health data. We included adolescents (10-17 years old) who had sleep and body mass index (BMI) data available (n=24,337) in analyses (samples with BMI <5th percentile excluded). Parents reported children's sleep duration and regularity. High BMI (≥85th percentile) for age defines overweight/obesity. We selected SDOH (race/ethnicity, family income, primary caregiver education and neighbourhood condition) and covariates (age, sex, smoking, exercise and depression) using a hierarchical model-building approach. Accounting for complex survey design, logistic regression estimated the interaction between sleep and SDOH. There were significant interactions between sleep duration and SDOH. The association between increasing sleep and decreasing odds of overweight/obesity only showed in the following subgroups: White, family income ≥400% federal poverty level (FPL) or primary caregiver' education ≥ high school. Compared with these subgroups, Hispanic adolescents and adolescents whose family income was below 100% FPL and whose caregiver education was below high school had weakened and reversed associations. Sleep regularity was not associated with overweight/obesity. Increasing sleep duration was associated with a decreased risk of overweight/obesity, but the association was not present in adolescents from racial/ethnic minority groups (i.e. Hispanic) and those with low SES. The study findings suggest that associations between sleep and overweight/obesity vary by race and SES. Identification of additional mechanisms for obesity is needed for racial/ethnic minority groups and those from families with low SES. Also, the complexity of these relationships underscores the importance of community-based needs assessment in the design of targeted and meaningful interventions to address complex health conditions such as poor sleep and obesity.

COVID-19 Vaccine Hesitancy Among Medicare Beneficiaries with and Without Cancer History: A US Population-based Study.

Understanding COVID-19 vaccine hesitancy among Medicare beneficiaries is critical for increasing COVID-19 vaccine uptake in the US. This study aimed to estimate and compare the vaccine hesitancy rate among community-dwelling Medicare beneficiaries with and without cancer history, also to investigate factors associated with vaccine hesitancy during the first four months after COVID-19 vaccine became available. We used population-based, cross-sectional data on 3,034 community-living Medicare beneficiaries from the Medicare Current Beneficiary Survey COVID-19 Winter 2021 Supplement. Sample weights were applied to account for the complex survey design with results generalizable to 16.4million Medicare beneficiaries. Weighted multivariable logistic regression model was conducted to investigate the association between cancer history and vaccine hesitancy adjusting for covariates. A total of 39.6% were hesitant about getting COVID-19 vaccine. Those with cancer history were significantly less likely to be hesitant to get vaccinated than those without cancer history (adjusted odds ratio = 0.80, 95% confidence interval: 0.64, 0.99, p = .050). The most common reason for being hesitant to get COVID-19 vaccine was that the vaccine could have side effects or was viewed as not safe (19.2%), followed by not trusting what government says about vaccine (11.4%). Those with cancer history were more likely to report ongoing health conditions, lack of recommendation from a doctor, and doctor recommending against COVID-19 vaccination as reasons for not getting the vaccine compared to participants without cancer history. Increasing the confidence and knowledge about vaccine benefits among high-risk and more hesitant individuals are urgently needed to increase the vaccine uptake.

A national household survey on HIV prevalence and clinical cascade among children aged ≤15 years in Kenya (2018).

We analyzed data from the 2018 Kenya Population-Based HIV Impact Assessment (KENPHIA), a cross-sectional, nationally representative survey, to estimate the burden and prevalence of pediatric HIV infection, identify associated factors, and describe the clinical cascade among children aged < 15 years in Kenya. Interviewers collected information from caregivers or guardians on child's demographics, HIV testing, and treatment history. Blood specimens were collected for HIV serology and if HIV-positive, the samples were tested for viral load and antiretrovirals (ARV). For participants <18 months TNA PCR is performed. We computed weighted proportions with 95% confidence intervals (CI), accounting for the complex survey design. We used bivariable and multivariable logistic regression to assess factors associated with HIV prevalence. Separate survey weights were developed for interview responses and for biomarker testing to account for the survey design and non-response. HIV burden was estimated by multiplying HIV prevalence by the national population projection by age for 2018. Of 9072 survey participants (< 15 years), 87% (7865) had blood drawn with valid HIV test results. KENPHIA identified 57 HIV-positive children, translating to an HIV prevalence of 0.7%, (95% CI: 0.4%-1.0%) and an estimated 138,900 (95% CI: 84,000-193,800) of HIV among children in Kenya. Specifically, children who were orphaned had about 2 times higher odds of HIV-infection compared to those not orphaned, adjusted Odds Ratio (aOR) 2.2 (95% CI:1.0-4.8). Additionally, children whose caregivers had no knowledge of their HIV status also had 2 times higher odds of HIV-infection compared to whose caregivers had knowledge of their HIV status, aOR 2.4 (95% CI: 1.1-5.4)". From the unconditional analysis; population level estimates, 78.9% of HIV-positive children had known HIV status (95% CI: 67.1%-90.2%), 73.6% (95% CI: 60.9%-86.2%) were receiving ART, and 49% (95% CI: 32.1%-66.7%) were virally suppressed. However, in the clinical cascade for HIV infected children, 92% (95% CI: 84.4%-100%) were receiving ART, and of these, 67.1% (95% CI: 45.1%-89.2%) were virally suppressed. The KENPHIA survey confirms a substantial HIV burden among children in Kenya, especially among orphans.

Joint Association of Diabetes and Physical Activity With Falls Among Midlife and Older Adults: 2018 Behavioral Risk Factor Surveillance System.

We examined joint associations of diabetes and physical activity (PA) with falls. Complex survey (cross-sectional) design using the 2018 Behavioral Risk Factor Surveillance System (Response rate was 53% (landline phones) and 46% (cellular phones)). National survey in the U.S. Adults ≥45years who self-reported diabetes status, PA, and falls (n = 295,282; 98.5% of eligible samples; N = 130,103,093) were classified into 4 groups: no diabetes-PA, no diabetes-no PA, diabetes-PA, diabetes-no PA. Self-reported PA, diabetes, falls, and major health characteristics. Poisson regression models were used to estimate the association of groups with any (≥1 fall) falls. Compared to no diabetes-active groups, no diabetes-inactive (Relative Risk (RR) = 1.22; 95% CI: 1.18, 1.26), diabetes-active (RR = 1.25; 95% CI: 1.20, 1.30), and diabetes-inactive (RR = 1.46; 95% CI: 1.41, 1.51) groups were more likely to report falls, independent of tested covariates. Leisure-time PA may mitigate the likelihood of falls in adults with and without diabetes. Our findings could be useful for healthcare providers or clinicians to promote the importance of PA in midlife and older adults who are at risk of falls and/or diabetes. More detailed longitudinal information on objectively-estimated PA and a more frequent fall calendar are warranted to prevent recall bias and temporal ambiguity (causality between PA and falls).

Disparities in Cigarette, E-cigarette, Cigar, and Smokeless Tobacco Use at the Intersection of Multiple Social Identities in the US Adult Population. Results From the Tobacco Use Supplement to the Current Population Survey 2018-2019 Survey.

Sociodemographic disparities in tobacco use are prevalent and persistent in the United States. Nevertheless, few studies have examined disparities in tobacco use from an intersectionality perspective. We developed a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of multiple social identities. We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to estimate the prevalence of tobacco product use at the intersection of age (18-34, 35-54, ≥55 years), sex (male, female), race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other), and annual household income (<$50 000, $50 000-$99 999, and ≥$100 000). Estimates accounted for the complex survey design. For cigarettes, the most defining characteristic was income, with the highest prevalence among low-income NH White male adults aged 35-54 years (30.7%) and low-income NH White female adults aged 35-54 years (29.7%). For e-cigarettes, the most defining characteristic was age, with adults 18-34 years old having the highest prevalence. High prevalence groups for cigars included young- and middle-aged NH Black and NH White males, while NH White males had the highest prevalence of smokeless tobacco use. Our intersectionality visualization tool is helpful to uncover complex patterns of tobacco use, facilitating the identification of high-risk groups. We created a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of age, sex, race/ethnicity, and income. Our visualization tool helps uncover complex patterns of tobacco use, facilitating the identification of high-risk population groups that would otherwise be masked. These results can be used to implement tobacco control policies targeted at factors that promote or sustain tobacco use disparities.

Antenatal Care Services and Incidence of Low Birth Weight: A Comparison of Demographic and Health Surveys in 4 ASEAN Countries.

This study aimed to assess the effect of complete coverage and content of available antenatal care (ANC) on the incidence of low birth weight (LBW) in 4 countries belonging to the Association of Southeast Asian Nations (ASEAN). Measures of complete coverage and content of ANC services included the frequency of ANC visits and the seven service components (blood pressure measurement, iron supplementation, tetanus toxoid immunization, explanations of pregnancy complications, urine sample test, blood sample test, and weight measurement). The complete coverage and content of ANC services were assessed as high if more than 4 ANC visits and all seven components were delivered. Multivariable logistic regression with complex survey designs was conducted using Demographic Health Survey data from the 4 ASEAN countries in question from 2014 to 2017. The proportion of LBW infants was higher in the Philippines (13.8%) than in Indonesia (6.7%), Cambodia (6.7%), or Myanmar (7.5%). Poor ANC services were associated with a 1.30 times higher incidence of LBW than a high level of complete coverage and content of ANC services (adjusted odds ratio [aOR], 1.30; 95% confidence interval [CI], 1.11 to 1.52). In addition, the risk of LBW was higher in the Philippines than in other countries (aOR, 2.25; 95% CI, 2.01 to 2.51) after adjusting for mothers' demographic/socioeconomic factors, health behaviors, and other factors. In sum, complete coverage and content of ANC services were significantly associated with the incidence of LBW in Indonesia, Cambodia, and Myanmar. The Philippines did not show statistically significant results for this relationship, but had a higher risk of LBW with poor ANC.