North Carolina Behavioral Risk Factor Surveillance System: Data Dissemination and Use in Planning and Evaluation

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• North Carolina Behavioral Risk Factor
  Surveillance System Data Dissemination and Use
  in Planning and Evaluation

Ziya Gizlice, Ph. D. BRFSS Project Director and
Coordinator State Center for Health Statistics
Division of Public Health North Carolina
Department of Health and Human Services
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Todays Presentation

• North Carolina BRFSS
• Establishing Partnerships (Funding)
• Data Dissemination
• Data Use
• State Programs
• Local Levels

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North Carolina BRFSS

• NC-BRFSS was funded by the Centers for Disease
  Control and Prevention (CDC) in 1984
• to monitor adult health-risk behaviors and health
  practices
• to collect state and regional estimates for
  targeting high-risk groups.
• Collects 1,250 interviews/month
• NC-BRFSS has its own survey laboratory with 20
  work stations
• 30 part time interviewers 2 part-time
  supervisors.

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• 22 largest counties alone
• 13 regions from remaining 78 counties
• 2 Native American Census Tracks

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NC BRFSS 2004 and Beyond

• In 2004, the sample size was increased to 15,000
  and 22 counties, 13 regions and census tracks
  with large American Indians have been over
  sampled.
• 3,000 African Americans
• 600 Hispanics (300 Spanish Speaking)
• 400 American Indians
• 200 Asian Americans
• Produce Race, Sex, and Race X Sex Specific
  Estimates for whites and African Americans

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Funding the BRFSS
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Funding the BRFSS

• Federal BRFSS Grant
• State Public Health Programs
• County Health Departments
• Special Surveys
• CDC Programs
• Health Associations (March of Dimes, ACS etc).

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Funding the BRFSS

• UNC School of Public Health
• NC Blue Cross Blue Shield
• NC Medicaid
• Glaxo Smith Kline?
• State Appropriations- 23,000/year
• Public Health Task Force 2004 Recommendation

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Interim Report North Carolina Public Health Task
Force 2004

• Essential Public Health Services1) Monitor
  health status to identify and solve community
  health problems
• Planning Outcomes Committee Improve the data
  and epidemiology for state and local
  decision-making and allocation of resources.
• Establish a common set of core health indicators.
• Build capacity to conduct the Behavioral Risk
  Factor Surveillance Survey (BRFSS) to provide
  county-specific or multi-county data (300,000)

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Data Dissemination
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Data Dissemination

• Internet
• Data posting (close 10,000 data tables)
• Annual Statewide and Local Summary PowerPoint
  Presentations (5,000 slides)
• Reports
• Total Requests between July1, 2003-May31, 2004
  152,662
• 31.4 megabyte/day
• Printed Reports
• Electronic Distribution of Annual Survey Results
• Data Requests (300)
• Community Level Summary Reports (besides BRFSS
  includes other mortality, hospitalization, cancer
  data, and other statistics).

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Data Users Sites July 1, 2003-May 31, 2004
Number of Requests
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Reports by the BRFSS
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Data Use in Planning and Evaluation by State
Programs

• Tobacco Prevention and Control
• Heart Disease and Stroke Prevention
• Diabetes
• Physical Activity and Nutrition
• Cancer Control Program

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Tobacco Prevention and ControlBRFSS Tracked
Tobacco Measures

• Current Smoking
• Quit Smoking
• Worksite and Home Smoking Policy
• Visiting Doctor in the Past Year
• Doctor Advice to Quit Smoking
• Smokeless Tobacco Use
• Other Tobacco Products
• Tobacco Tax
• Total Cigarette Consumption
• Age at Smoking

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Tobacco Prevention and ControlBRFSS Related
Program Goals and Objectives

• Ultimate Outcome Reducing morbidity and
  mortality related to tobacco use
• Goal Prevent initiation of tobacco among young
  people
• Maintain public support greater than 50 for
  increase of cigarette tax (2006)
• Increase number of people who never smoked (2006)
• Goal Eliminate exposure to secondhand smoke
  (SHS)
• Increase of workers covered by work-site
  smoke-free policies from 74.8 to 80 (2010)
• Increase of adults and youth who do not
  currently smoke from 74.3 to 77 of adults and
  from 73.2 to 80 of high school students (2010)
• Goal Promote smoking cessation among adults and
  young people
• Increase the of adults who have stopped smoking
  for a day or longer during the last 12 months
  from 55.8 to 60 (2010)
• Increase percent of adults asked and advised to
  quit by provider from 73.1 to 77 and assessed,
  assisted and arranged follow-up services from 0
  to 25 (2006)
• Goal Identify and eliminate tobacco-related
  disparities in specific population groups
• Decrease tobacco use prevalence rates among
  priority populations (2010)
• Increase cessation attempts among priority
  populations from 51 to 70 (2010)

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Current Smoking 1990-2003
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Support for Tobacco Tax (any amount) by Sex,
Race, Age, Education Income (2003)

Maintain public support greater than 50 for
increase of cigarette tax
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Support for Amount of Tax on Pack of Cigarettes
by Smoking Status

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Worksites Prohibit Smoking in Both Public and
Work Areas (2002)
Percent
Target is 80, baseline was 74.8. In 2003 the
rate is 77.8
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Current Smoker (2002)
Percent
Increase of adults who do not currently smoke
from 74.3 to 77 of adults 2003 Rate 75.2
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Quit Smoking One Day or Longer in Past Year (2002)
Percent
Increase the of adults who have stopped
smoking for a day or longer during the last 12
months from 55.8 to 60. 2003 Rate is 52.6
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Advised by Health Professional to Quit Smoking in
Past Year (2002)
Percent
Increase percent of adults asked and advised
to quit by provider from 73.1 to 77 2003---76.1
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Tobacco Prevention and ControlPolicy Challenges

• NC Preemption Law - NCGS 143-595-601 Regulate
  smoking in public places and establishes
  standards for local governments electing to
  regulate smoking (1993).
• Prohibits smoking in some public places such as
  school buses and health departments and
  facilities and requires designated smoking areas
  (20) in state buildings
• Prohibits local governments to regulate smoking
  more stringent than this law.
• Possible BRFSS Questions to obtain public opinion
  data on this
• Do you favor or oppose letting local NC
  communities have the option of passing their own
  laws to restrict smoking in public places, even
  if those laws may be stronger than the state law?
• Do you feel that way strongly or not so strongly?
• Tobacco Tax (5 Cents) Increase to 75 Cents/pack
• House Bill 1313 to allow local governments to
  levy taxes on tobacco- Not Passed
• House Bill 254 to increase tax on tobacco at a
  rate of 30 of cost- Not Passed
• Success with Tobacco Free School

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Tobacco Prevention and ControlEducation and
Other Efforts

• A number of annually updated surveillance briefs
  featuring current smoking, worksite smoking
  policies, and quitting smoking.
• Annual Report for Great American Smokeout day
  every November
• One-pager fact sheets
• Numerous presentations and other educational
  materials
• Incorporate Adult Tobacco Survey into the BRFSS

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Tobacco Prevention and ControlEducation and
Other Efforts

• 2004 BRFSS includes a question
• Are you aware of Quit Now NC smoking cessation
  phone lines or Quit Now websites?

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Heart Disease Stroke Prevention Program
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HDSP Program Lead Counties
Surry
Nash
Wake
Pitt
Henderson Transylvania
Cabarrus
Craven
Robeson
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Heart Disease Stroke Prevention Program BRFSS
Tracked HDSP Measures

• Physical activity
• Fruit and vegetable consumption
• Overweight and Obesity
• Tobacco use
• Diabetes
• Hypertension
• High cholesterol
• Heart disease and stroke history
• Knowledge of heart attack and stroke symptoms
• Calling 911 for heart attack or stroke

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Heart Disease Stroke Prevention Program
Original Focus - 1998-2003

• Improve Physical Activity Healthy Eating
• support Tobacco Prevention Control Efforts
• Through Policy Environmental Change
• In 4 Settings
• Community
• Worksite
• Schools
• Healthcare

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No Leisure Time Physical Activity
Percent
Henderson/Transylvania, Pitt, Robeson, Wake
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Fruits Vegetables (5/Day-2002)
Percent

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Prevalence of Obesity (2002)
Percent

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Obesity Prevalence 1990-2003
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Heart Disease Stroke Prevention Program New
Focus Beginning 2003

• Improve Hypertension and Dyslipidemia Prevention
  Control, Emergency Response to Acute CVD
  Events, Secondary Prevention of CVD
• support work of Phys. Act/Nutrition, Obesity,
  Tobacco, Diabetes Programs
• Through Policy Environmental Change
• In the same 4 Settings
• Program is in transition

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Heart Disease Stroke Prevention Program
Program Goals
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Heart Disease Stroke Prevention Program BRFSS
Related Program Objectives by 2010

• Increase to at least 90 the proportion of adults
  who have had their blood cholesterol checked
  within the preceding 5 years.
• Maintain at 95 or more the proportion of adults
  who have had their blood pressure checked within
  the preceding 2 years.
• Increase the proportion of adults who are aware
  of the early warning signs and symptoms of a
  stroke (developmental).
• Increase the proportion of adults who are aware
  of the early warning signs and symptoms of a
  heart attack (developmental).
• Increase the proportion of adults who are aware
  of the importance of accessing rapid emergency
  care for heart attack and stroke by calling 911
  (developmental).
• Increase to at least 75 the proportion of adults
  with coronary heart disease or stroke history who
  have been counseled about diet and exercise.
• Increase to at least 95 the proportion of adults
  with a heart attack history (and with no
  contraindications to aspirin) who are taking
  aspirin daily or every other day.

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Ever Told by Health Professional that You Have
High Blood Pressure (2003)
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Have Had Blood Cholesterol Checked within 5 Years
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Told by a Doctor that Your Blood Cholesterol is
High
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Did Not Know All Heart Attack Symptoms -2003
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Percent Who Recognized Signs Symptoms of a
Heart Attack-2003
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Did Not Know All Stroke Symptoms -2003
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Percent Who Recognized Signs Symptoms of a
Stroke -2003
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Percent with History of CVD Counseled by Health
Professional to
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Call 911 as First Response, if Someone Was Having
a Heart Attack or Stroke
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Heart Disease Stroke Prevention ProgramPolicy
and Environmental Measures Obtained through BRFSS

• Environmental tobacco smoke policies
• worksite
• home
• Neighborhood environments relevant to physical
  activity (state-added)
• perceived safety from crime
• presence of sidewalks, trails, heavy traffic,
  unattended dogs
• Social marketing efforts include
• need to know stroke symptoms
• take appropriate action (call 911)

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Heart Disease Stroke Prevention Program Social
Marketing

• Current social marketing efforts include
• need to know and understand blood pressure
  numbers
• need to know stroke symptoms and take appropriate
  action (call 911)
• Social marketing efforts tied to policy
  environmental change efforts, e.g.
• provider policies and systems to improve
  hypertension detection treatment (working
  diabetes program)
• EMS and hospital policies and systems to treat
  acute stroke
• AED (Automatic External Defibrillators) placement
  and training (working with American Heart
  Association)

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Physical Activity and Nutrition (PAN) Program
Environmental Change Effort

• Winners Circle Program Sponsored by
• Mecklenburg County Health Department
• Charlotte REACH 2010 Program
• NC Prevention Partners
• Cardiovascular Health Program
• NC Department of Health and Human Services

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Diabetes Prevention Program BRFSS Tracked
Diabetes Measures

• Diabetes
• Diabetes Best Practice indicators
• Diabetes Screening
• Diabetes Counseling
• Overweight and Obesity
• Physical activity
• Fruit and vegetable consumption
• Hypertension
• High cholesterol

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Diabetes Prevalence
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The Prevalence of Diabetes by Sex Race

III. Chronic Diseases
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Diabetes Prevention Program BRFSS Related
Program Goals and Objectives

• Goals
• By March 2008, establish surveillance procedures
  to address the burden of diabetes in high risk
  populations not currently captured in the BRFSS
  as evidence by data collection, analysis and
  reporting.
• By 2005
• determine the the prevalence of diabetes
  screening test in the population at risk for
  diabetes
• monitor the trend of self-reported diabetes
  prevalence by race/ethnicity, socioeconomic
  status, insurance status, minorities, age and
  gender
• monitor the trend of diabetes prevalence quality
  of health care indicators by race, sex and age
• BRFSS 12 Questions of the Diabetes modules
  linked to the above objectives

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Ever Had a Blood Test for Diabetes
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Diabetes Management Indicators

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Diabetes Risk Indicators

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Diabetes Prevention Program Planning and
Evaluation

• BRFSS data allowed to plan, monitor and
  evaluate the main outcomes of the NC diabetes
  Plan
• By 2002 increase the percentage of person with
  diabetes in North Carolina who received the
  recommended foot and eye exams, influenza and
  pneumocoala vaccines, nephpathy assessment, and
  test for hemoglobin A1c and
• By 2002 establish at least ten useful community
  based programs for promotion of wellness,
  physical activity, weight and blood pressure
  control, smoking cessation for persons with and
  at risk for diabetes.
• By 2002 reduce health disparities for high risk
  populations with respect to diabetes prevention
  and control

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Prevalence of Selected Health Care Indicators in
People with Diabetes 1998-2003
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Diabetes Prevention Program Policy Changes

• NC Coverage for Diabetes Act in Health and
  Accident Insurance Policies in Hospitals or
  Medical Services and HMO Plans. Law - NCGS S.L
  1997-225, House Bill 5
• Regulate insurance coverage for medically and
  necessary services including diabetes outpatient
  self-management training and educational services
  , equipment, supplies, medications and laboratory
  procedures used to treat diabetes.
• Diabetes outpatient self-management training and
  educational services shall be provided by a
  physician or health care professional designated
  by the physician.
• BRFSS Questions to obtain prevalence estimates in
  people with diabetes
• Have you ever taken a course or class in how to
  manage your diabetes yourself?
• During the past 12 months, was there any time
  that you did not have testing supplies (strips
  lancet, meter) or diabetes medicine due to lack
  of money?

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Cancer Control Program BRFSS Related Program
Goals and Objectives

• Prevention Related
• Goal 1 To promote and increase dietary
  consumption of foods and nutrients that are known
  to decrease cancer.
• Objectives
• Increase to 35 the proportion of North Carolina
  adults 18 and older who consume at least five
  servings
• of fruits and vegetables each day.
• Increase to 50 the proportion of North Carolina
  adults 18 and older with BMI below 25.0.
• Goal 2 Tobacco related and aligns with HP 2010
  Objectives
• Goal 3 To decrease ultraviolet radiation
  exposure by 2006.
• Goal 4 To promote and increase PA levels

http//www.nccancer.org/ccplan2006/prevention.pdf
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Cancer Control Program BRFSS Related Program
Goals and Objectives

• Early Detection
• To promote and increase the appropriate
  utilization of high-quality breast cancer
  screening and follow-up services.
• Breast Cancer Mammogram and CBE
• Cervical Cancer Pap smear
• Colorectal Cancer FOBT, Sigmoidoscopy/Colonoscopy
  
• Prostate Cancer
• educate men and their families about prostate
  cancer and issues related to screening and
  treatment.
• PSA and DRE but no target set.

http//www.nccancer.org/ccplan2006/prevention.pdf
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Cancer Control Program BRFSS Tracked Cancer
Control Measures

• Prostate Specific Antigen Test
• Digital Rectal Exam
• Blood Stool Test
• Colonoscopy/Sigmoidoscopy
• Mammogram CBE
• Pap Smear
• Skin Cancer Prevention
• Cancer Prevalence

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Ever Had a Colonoscopy Exam (2002)
Percent
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Not Had Mammogram and Breast Exam in the Last
Year (Age 50)
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Tried to Get a Tan from the Sun (2001)
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Sunburn in the Past Year (2001)
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Physical Activity and Nutrition (PAN) Program
BRFSS Tracked PAN Measures

• Reduce the proportion of adults who are obese.
• Target 16.8 percent.
• Increase the proportion of adults eating five or
  more servings of fruits and vegetables each day.
• Target 25.1 percent.
• Increase the proportion of adults (18 years and
  older) who engage in physical activity for at
  least 30 minutes on 5 or more days of the week.
• Reduce the proportion of adults (18 years and
  older) who engage in no leisure-time physical
  activity.
• Target 29 percent

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Obesity Prevalence -2003
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Recommended Level Of Physical Activity per
Week-2003
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No Leisure Time Activity
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Fruits and Vegetable Consumption (5/day) -2003
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Received Advise about Weight by Health
Professional in Past Year
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In Past Two Years, Taken Over-the-counter Weight
Loss Pills
77
In Past Two Years, Taken Weight Loss Pills
Prescribed by a Doctor
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Taking Over-the-counter Weight Loss Pills that
Contain Ephedra
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North Carolina Folic Acid Use Campaign

• The BRFSS data showed that Buncombe County had
  the highest percentage of folic acid knowledge
  among all individual counties surveyed.
• This result was corroborated by a separate
  independent telephone survey conducted by the
  Fullerton Genetics Center in Asheville.
• March of Dimes expanded that program to other
  areas of the state.

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Believe Folic Acid Helps Prevent Birth Defects
(2001)
Ages 18-44 included here
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Local Level BRFSS Data Use

• Community Health Assessment (CHA by Local Healthy
  Carolinian Coalitions)
• Orange County www.co.orange.nc.us/health/Charepo
  rt.pdf
• Guilford County www.co.guilford.nc.us/goverment/p
  ublichealth/HealthStatus2002.pdf
• Monitoring County Health Department Objectives
  mainly identified through CHA.

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Local Level BRFSS Data Use

• State Programs Set Objectives for Local Health
  Programs that are funded by the state.
• Heart Attack and Stroke Prevention Grants
• Health and Wellness Trust Fund Grants
• ASSIST (Tobacco Prevention Control)
• County Health Projects funded by sources other
  than state
• Stroke Elimination Grant
• STEPS to Healthier US Grants