Vaccination Inequality in India, 2002-2013.

INTRODUCTION: India's childhood vaccination coverage has increased amid the implementation of national health policies intended to improve immunization levels. However, there is a dearth of contemporary studies comparing state-level childhood vaccination rates across India's highly diverse states and territories. This study assesses SES-based inequalities in childhood vaccination by state for 2002-2013. METHODS: National surveys from 2002 to 2004, 2007 to 2008, and 2012 to 2013 were used for analyses. Household SES was assessed using an asset index created through principal component analysis. Full vaccination comprised 1 dose bacille Calmette-Guerin, 3 doses diphtheria-pertussis-tetanus vaccine, 3 doses oral polio vaccine, and 1 dose measles-containing vaccine at age 12-60 months. Inequality analyses were stratified by 3 time periods and by government-designated high focus group versus non-high focus group states. RESULTS: Childhood vaccination steadily increased between 2002 and 2013 in high focus group states but fell in some non-high focus group states, whereas SES-based vaccination inequalities generally decreased in both. In 2012-2013, rural areas had lower vaccination rates than urban areas in high focus group states but similar vaccination rates as urban areas in non-high focus group states. Increases in vaccination rates were not consistently accompanied by improvements in SES-based inequalities in vaccination. CONCLUSIONS: Childhood vaccination in India has improved overall, although increases are more pronounced in high focus group states than in non-high focus group states over the study period. The gap in coverage between these states decreased over time owing in part to the latter experiencing reductions in full vaccination rates during 2007-2013. SES-based vaccination disparities persist in India, highlighting the need to improve vaccination rates for all children, especially those from disadvantaged and underserved groups. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Perceptions of alcohol-impaired driving and the blood alcohol concentration standard in the United States.

INTRODUCTION: Although the number of alcohol-impaired driving (AID) fatalities has declined over the past several years, AID continues to be a serious public health problem. The purpose of this effort was to gain a better understanding of the U.S. driving population's perceptions and thoughts about the impacts of lowering the blood alcohol concentration (BAC) driving standard below.08% on AID, health, and other outcomes. METHODS: A questionnaire was administered to a nationally representative sample of licensed drivers in the U.S. (n=1011) who were of age 21 or older on driving habits, alcohol consumption habits, drinking and driving habits, attitudes about drinking and driving, experiences with and opinions of drinking and driving laws, opinions about strategies to reduce drinking and driving, general concerns about traffic safety issues, and demographics. RESULTS: One-third of participants supported lowering the legal BAC standard, and participants rated a BAC standard of .05% to be moderately acceptable on average. 63.9% indicated that lowering 30 the BAC to .05% would have no effect on their decisions to drink and drive. Nearly 60% of respondents lacked accurate knowledge of their state's BAC standard. CONCLUSIONS: Public support for lowering the BAC standard was moderate and was partially tied to beliefs about the impacts of a change in the BAC standard. The results suggest that an opportunity for better educating the driving population about existing AID policy and the implications for lowering the BAC level on traffic injury prevention. PRACTICAL APPLICATIONS: The study results are useful for state traffic safety professionals and policy makers to have a better understanding of the public's perceptions of and thoughts about BAC standards. There is a clear need for more research into the effects of lowering the BAC standard on crashes, arrests, AID behavior, and alcohol-related behaviors.

Percentage and severity of periodontal diseases in Turkish adults aged 35+ years, 2009-10.

OBJECTIVE: This article presents data on the burden of periodontal diseases in Turkish adults aged 35 years or older. METHODS: Within each region of Turkey, a rural and an urban area or city were selected in 2009-10 using a probability proportional to size method. In the selected towns, local officials who were familiar with their communities assisted in recruiting subjects. Loss of Attachment (LOA) was measured at six sites around each tooth present in the mouth, excluding third molars. Additionally, the Community Periodontal Index was used to assess the severity of periodontal diseases around 12 index teeth. Self-reported data on key risk factors were also collected. Weights were computed using a raking ratio adjustment procedure and used in all analyses. RESULTS: Almost all examined adults had some loss of periodontal attachment. The proportion of those with more than 3 mm LOA ranged from 43 percent in 35-44 year olds to 91 percent in those aged 65+ years. Among females, older age, low education status, smoking 11-40+ cigarettes a day, being employed, and presence of high number of missing tooth surfaces were associated with LOA > 3 mm. Among males LOA >3 mm was associated with older age, use of alcohol, and unemployment. The CPI data did not yield the same associations with periodontal diseases and risk factors. CONCLUSIONS: Periodontal diseases in Turkish adults are highly prevalent. A tailored common risk factor health promotion program is recommended to reduce the burden of periodontal infection in Turkey.

Vaccination Timeliness in Children Under India's Universal Immunization Program.

BACKGROUND: India has the highest number of deaths among children younger than 5 years of age globally; the majority are from vaccine preventable diseases. Untimely vaccination unnecessarily prolongs susceptibility to disease and contributes to the burden of childhood morbidity and mortality, yet there is scarce literature on vaccination delays. The aim of this study is to characterize the timeliness of childhood vaccinations administered under India's routine immunization program using a novel application of an existing statistical methodology. METHODS: This study utilized the district level household and facility survey data, 2008 from India using vaccination data from children with and without immunization cards. Turnbull estimator of the cumulative distribution function was used to estimate the probability of vaccination at each age. Timeliness of Bacille Calmette-Guerin (BCG), all 3 doses of diphtheria, pertussis and tetanus vaccine (DPT) and measles-containing vaccine (MCV) were considered for this analysis. RESULTS: Vaccination data on 268,553 children who were 0-60 months of age were analyzed; timely administration of BCG, DPT3 and MCV occurred in 31%, 19% and 34% of children, respectively. The estimated vaccination probability plateaued for DPT and BCG around the age of 24 months, whereas MCV uptake increased another 5% after 24 months of age. The 5-year coverage of BCG, DPT3 and MCV in Indian children was 87%, 63% and 76%, respectively. CONCLUSIONS: Lack of timely administration of key childhood vaccines, especially DPT3 and MCV, remains a major challenge in India and likely contributes to the significant burden of vaccine preventable disease-related morbidity and mortality in children.

Predictors of vaccination in India for children aged 12-36 months.

INTRODUCTION: India has one of the lowest immunization rates worldwide despite a longstanding Universal Immunization Program (UIP) that provides free childhood vaccines. This study characterizes the predictors for under- and non-vaccination among Indian children aged 12-36 months. METHODS: This study utilized District Level Household and Facility Survey Data, 2008 (DLHS3), from India. DLHS3 is a nationally representative sample collected from December 2007 through December 2008; this analysis was conducted during 2014. Children's vaccination status was categorized as fully, under-, and non-vaccinated based on whether children received all, some, or none of the UIP-recommended vaccines (one dose each of bacillus Calmette-Guérin and measles, and three doses of diphtheria-pertussis-tetanus). A multinomial logistic regression model estimated the odds of undervaccination compared with full vaccination, and odds of non-vaccination compared with full vaccination. Analytic predictors included socioeconomic, cultural, household, maternal, and childhood characteristics. RESULTS: The analysis included 108,057 children; the estimated proportions of fully, under-, and non-vaccinated children were 57%, 31%, and 12%, respectively. After adjusting for state of residence, age, gender, household wealth, and maternal education, additional significant predictors of children's vaccination status were religion, caste, place of delivery, number of antenatal care visits, and maternal tetanus vaccination, all of which demonstrated large effect sizes. CONCLUSIONS: India's immunization coverage remained low in 2008, with just slightly more than half of all children aged 12-36 months fully vaccinated with UIP-recommended vaccines. A better understanding of the predictors for vaccination can help shape interventions to reduce disparities in full vaccination among children of differing demographic/cultural groups.

Predictors of Vaccination in India for Children Aged 12-36 Months.

INTRODUCTION: India has one of the lowest immunization rates worldwide despite a longstanding Universal Immunization Program (UIP) that provides free childhood vaccines. This study characterizes the predictors for under- and non-vaccination among Indian children aged 12-36 months. METHODS: This study utilized District Level Household and Facility Survey Data, 2008 (DLHS3), from India. DLHS3 is a nationally representative sample collected from December 2007 through December 2008; this analysis was conducted during 2014. Children's vaccination status was categorized as fully, under-, and non-vaccinated based on whether children received all, some, or none of the UIP-recommended vaccines (one dose each of bacillus Calmette-Guérin and measles, and three doses of diphtheria-pertussis-tetanus). A multinomial logistic regression model estimated the odds of under-vaccination compared with full vaccination, and odds of non-vaccination compared with full vaccination. Analytic predictors included socioeconomic, cultural, household, maternal, and childhood characteristics. RESULTS: The analysis included 108,057 children; the estimated proportions of fully, under-, and non-vaccinated children were 57%, 31%, and 12%, respectively. After adjusting for state of residence, age, gender, household wealth, and maternal education, additional significant predictors of children's vaccination status were religion, caste, place of delivery, number of antenatal care visits, and maternal tetanus vaccination, all of which demonstrated large effect sizes. CONCLUSIONS: India's immunization coverage remained low in 2008, with just slightly more than half of all children aged 12-36 months fully vaccinated with UIP-recommended vaccines. A better understanding of the predictors for vaccination can help shape interventions to reduce disparities in full vaccination among children of differing demographic/cultural groups.

Development of a psychosocial distress measure for Ugandan adolescents living with HIV.

Psychological distress among adolescents living with HIV (ALH) has been associated with risky behaviors including non-adherence to anti-retroviral therapy, leading to increased risk for AIDS morbidity and mortality. Efforts to establish the nature, prevalence, and impact of psychological distress among ALH in Uganda are hindered by the lack of culturally relevant assessment tools. The purpose of this study was to develop and test a measure for psychological distress for Ugandan ALH aged 12-19 years (N = 508; 53.1 % female). Using a mixed method approach, we developed and tested a 25-item checklist with six subscales-anhedonia, depressive-anxiety, isolation, suicidal ideation, sleep problems, and somatization. We found adequate reliability for the scale (α = 0.89), and a satisfactory measurement structure in our confirmatory factor analyses (RMSEA <1.0, and CFI and TLI >0.90). We discuss the potential use of this culturally sensitive scale to examine psychological distress among ALH in Uganda.

Estimation of age- and sex-specific background human serum concentrations of PCDDs, PCDFs, and PCBs in the UMDES and NHANES populations.

Age- and sex-specific estimates of serum dioxin concentrations are important for comparisons among populations. However, such comparisons are problematic because populations have different age and sex structures and values are typically reported only in broad age ranges that are not comparable across studies. There are few studies that report congener-specific serum concentrations, and none that provide these by sex for age as a continuous function. We combined the NHANES 2003-2004 data with the University of Michigan Dioxin Exposure Study (UMDES) referent population 2005 data to achieve stable and accurate estimates of mean and quantiles of serum dioxins by sex over ages 18-85. Survey-weighted linear and quantile regression models were fitted on the combined data with the log-transformed congener concentration as outcome and age, sex, and data source as covariates. Formulas are provided to allow calculations of age- and sex-specific mean and quantile estimates over ages 18-85. For instance, the geometric mean, median, 75th percentile, and 95th percentile of serum TEQ for men aged 50 can be estimated, respectively, from the formulas as 18.33, 19.02, 22.60, and 30.37 pg g(-1) lipids among the Michigan general population, and as 15.71, 15.89, 22.60, and 29.90 pg g(-1) lipids among US non-Hispanic whites. These methods and results are useful for comparing the congener-specific human serum dioxin concentrations in any individual to the general population mean, median, 75th percentile, and 95th percentile, and for comparing the serum dioxin concentration in any group of interest to the US and the Michigan general populations.

Responsive Design, Weighting, andVariance Estimation in the 2006-2010 National Survey of Family Growth.

Objective-The National Survey of Family Growth (NSFG) collects data on pregnancy, childbearing, men's and women's health, and parenting from a national sample of men and women aged 15-44 in the United States. The 2006-2010 NSFG design was a significant departure from the previous periodic design, used in 1973-2002. This report shows fieldwork results and weighting, imputation, and variance estimation procedures. The report should be useful to users of the 2006-2010 public-use data file and to survey methodologists wishing to learn how the NSFG was conducted. Methods-NSFG's new design is based on an independent national probability sample of men and women aged 15-44. The University of Michigan's Institute for Social Research conducted fieldwork under a contract with the National Center for Health Statistics. Professional female interviewers conducted in-person, face-to-face interviews using laptop computers. A responsive design approach was used in planning and managing the fieldwork for NSFG to control costs and reduce nonresponse bias. Results-The 2006-2010 NSFG is based on 22,682 completed interviews-10,403 interviews with men and 12,279 with women. Interviews with men lasted an average of 52 minutes, and for women, 71 minutes. Weighted response rates were 75% among men, 78% among women, and 77% overall. Analysis of NSFG data requires the use of sampling weights and estimation of sampling errors that account for the complex sample design and estimation features of the survey. Sampling weights are provided on the data files. The rate of missing data in the survey is generally low.

Attitudes of pregnant women towards collection of biological specimens during pregnancy and at birth.

Epidemiological investigations of maternal and child health may involve the collection of biological specimens, including cord blood and the placenta; however, the attitudes of pregnant women towards participation in the collection of biological specimens have been studied rarely. We evaluated attitudes towards collection and storage of biological specimens, and determined whether attitudes differed by maternal characteristics, in a cross-sectional study of pregnant women residing in Kent County, Michigan. Women were interviewed at their first visit for prenatal care between April and October 2006 (n = 311). Willingness to participate was highest for maternal blood collection (72%), followed by storage of biological specimens (68%), placenta collection (64%), and cord blood collection (63%). About one-quarter of women (25-28% by procedure) would not participate even if compensated. Hispanic ethnicity was associated with unwillingness to participate in maternal blood collection (OR = 2.16 [95% CI 1.15, 4.04]). Primiparity was associated with unwillingness to participate in cord blood collection (OR = 1.72 [95% CI 1.23, 2.42]). Among women willing to participate, Hispanic women were less likely to require compensation; while higher educated, married and primiparous women were more likely to require compensation. In conclusion, while many pregnant women were willing to participate in biological specimen collection, some women were more resistant, in particular Hispanic and primiparous women. Targeting these groups of women for enhanced recruitment efforts may improve overall participation rates and the representativeness of participants in future studies of maternal and child health.

Evaluation of a brief tailored motivational intervention to prevent early childhood caries.

OBJECTIVES: This pragmatic randomized trial evaluated the effectiveness of a tailored educational intervention on oral health behaviors and new untreated carious lesions in low-income African-American children in Detroit, Michigan. METHODS: Participating families were recruited in a longitudinal study of the determinants of dental caries in 1021 randomly selected children (0-5 years) and their caregivers. The families were examined at baseline in 2002-2004 (Wave I), 2004-2005 (Wave II) and 2007 (Wave III). Prior to Wave II, the families were randomized into two educational groups. An interviewer trained in applying motivational interviewing principles (MI) reviewed the dental examination findings with caregivers assigned to the intervention group (MI + DVD) and engaged the caregiver in a dialogue on the importance of and potential actions for improving the child's oral health. The interviewer and caregiver watched a special 15-minute DVD developed specifically for this project based on data collected at Wave I and focused on how the caregivers can 'keep their children free from tooth decay'. After the MI session, the caregivers developed their own preventive goals. Some families in this group chose not to develop goals and were offered the project-developed goals. The goals, if defined, were printed on glossy paper that included the child's photograph. Families in the second group (DVD-only) were met by an interviewer, shown the DVD, and provided with the project's recommended goals. Both groups of families received a copy of the DVD. Families in the MI + DVD group received booster calls within 6 months of the intervention. Both caregivers and the children were interviewed and examined after approximately 2 years (Wave III: 2007). RESULTS: After 6-month of follow-up, caregivers receiving MI + DVD were more likely to report checking the child for 'precavities' and making sure the child brushes at bedtime. Evaluation of the final outcomes approximately 2 years later found that caregivers receiving the MI + DVD were still more likely to report making sure the child brushed at bedtime, yet were no more likely to make sure the child brushed twice per day. Despite differences in one of the reported behaviors, children whose caregivers received the motivational intervention did not have fewer new untreated lesions at the final evaluation. CONCLUSIONS: This study found that a single motivational interviewing intervention may change some reported oral health behaviors, it failed to reduce the number of new untreated carious lesions.

The 2006-2010 National Survey of Family Growth: sample design and analysis of a continuous survey.

OBJECTIVE: The National Survey of Family Growth (NSFG) collects data on pregnancy, childbearing, men's and women's health, and parenting from a national sample of women and men 15-44 years of age in the United States. This report describes the sample design for the NSFG's new continuous design and the effects of that design on weighting and variance estimation procedures. A working knowledge of this information is important for researchers who wish to use the data. Two data files are being released--the first covering 2.5 years (30 months) of data collection and the second after all data have been collected. This report is being released with the first data file. A later report in this Series will include specific results of the weighting, imputation, and variance estimation. METHODS: The NSFG's new design is based on an independent, national probability sample of women and men 15-44 years of age. Fieldwork was carried out by the University of Michigan's Institute for Social Research (ISR) under a contract with the National Center for Health Statistics (NCHS). In-person, face-to-face interviews were conducted by professional female interviewers using laptop computers. RESULTS: Analysis of NSFG data requires the use of sampling weights and estimation of sampling errors that account for the complex sample design and estimation features of the survey. Sampling weights are provided on the data files. The rate of missing data in the survey is generally low. However, missing data were imputed for about 600 key variables (called "recodes") that are used for most analyses of the survey. Imputation was accomplished using a multiple regression procedure with software called IVEware, available from the University of Michigan website.

Healthy aging in neighborhoods of diversity across the life span (HANDLS): overcoming barriers to implementing a longitudinal, epidemiologic, urban study of health, race, and socioeconomic status.

OBJECTIVE: Examine the influences of race, socioeconomic status, sex, and age on barriers to participation in a study of cross-sectional differences and longitudinal changes in health-related outcomes. METHODS: We designed a multidisciplinary, community-based, prospective longitudinal epidemiologic study among socioeconomically diverse African Americans and Whites. We recruited 3722 participants from Baltimore, Md. with a mean age of 47.7 (range 30-64) years, 45% males; 2200 African Americans (59%) and 1522 whites (41%); 41% reported household incomes below the 125% poverty delimiter. RESULTS: There were no significant age differences associated with sex or race. Participants below the 125% poverty delimiter were slightly younger than those above the delimiter. Age, race, and sex, but not poverty status, were associated with the likelihood of a physical examination. Older participants, women, and Whites were more likely to complete their examinations. Among those who completed their examinations, there were no age differences associated with sex and poverty status, but African Americans were negligibly younger than Whites. CONCLUSIONS: Although some literature suggests that minorities and low-income people are less willing to participate in clinical research, these baseline data suggest that African Americans individuals and individuals from households with incomes below 125% of the poverty level are at least as willing to participate in observational clinical studies as Whites and higher income individuals of similar age and sex.

Estimation of background serum 2,3,7,8-TCDD concentrations by using quantile regression in the UMDES and NHANES populations.

BACKGROUND: The goal of the present study was to quantify the population-based background serum concentrations of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) by using data from the reference population of the 2005 University of Michigan Dioxin Exposure Study (UMDES) and the 2003-2004 National Health and Nutrition Examination Survey (NHANES). METHODS: Multiple imputation was used to impute the serum TCDD concentrations below the limit of detection by combining the 2 data sources. The background mean, quartiles, and 95th percentile serum TCDD concentrations were estimated by age and sex by using linear and quantile regressions for complex survey data. RESULTS: Any age- and sex-specific mean, quartiles, and 95th percentiles of background serum TCDD concentrations of study participants between ages 18 and 85 years can be estimated from the regressions for the UMDES reference population and the NHANES non-Hispanic white population. For example, for a 50-year-old man in the reference population of UMDES, the mean, quartiles, and 95th percentile serum TCDD concentrations are estimated to be 1.1, 0.6, 1.1, 1.8, and 3.3 parts per trillion, respectively. The study also shows that the UMDES reference population is a valid reference population for serum TCDD concentrations for other predominantly white populations in Michigan. CONCLUSION: The serum TCDD concentrations increased with age and increased more over age in women than in men, and hence estimation of background concentrations must be adjusted for age and sex. The methods and results discussed in this article have wide application in studies of the concentrations of chemicals in human serum and in environmental samples.

Attitudes of pregnant women towards participation in perinatal epidemiological research.

We assessed attitudes of a multi-ethnic sample of pregnant women in regard to participation in five data collection procedures planned for use in the National Children's Study. A cross-sectional survey was conducted in nine prenatal clinics in Kent County, Michigan between April and October 2006. Women were approached in clinic waiting rooms at the time of their first prenatal visit and 311 (91.0%) participated. Women were asked about their willingness to participate, and the smallest amount of compensation required for participation in a 45-min in-person interview, a 15-min telephone interview, maternal and infant medical record abstraction, and an infant physical examination. Percentages for willingness to participate were highest for telephone interview (83%), followed by in-person interview (60%), infant examination (57%), and maternal (56%) and infant medical records (54%). About 34-48% of women reported that no compensation would be required for participation by data procedure. Some women reported unwillingness to participate in telephone (9%) or personal (17%) interview, record abstraction (34%) or infant examination (26%), even with compensation. Education greater than high school was associated with increased odds of refusal for infant physical examination, adjusted odds ratio 2.44 [95% confidence interval 1.41, 4.23]. In conclusion, 9-34% of pregnant women, depending on procedure, stated they would not participate in non-invasive research procedures such as medical record abstraction and infant examination, even with compensation. Resistance to these research procedures was especially noted among more highly educated women. Planning for the National Children's Study will have to address potential resistance to research among pregnant women.

Obesity and sugar-sweetened beverages in African-American preschool children: a longitudinal study.

A representative sample of 365 low-income African-American preschool children aged 3-5 years was studied to determine the association between sugar-sweetened beverage consumption (soda, fruit drinks, and both combined) and overweight and obesity. Children were examined at a dental clinic in 2002-2003 and again after 2 years. Dietary information was collected using the Block Kids Food Frequency Questionnaire. A BMI score was computed from recorded height and weight. Overweight and obesity were defined by national reference age-sex specific BMI: those with an age-sex specific BMI>or=85th, but <95th percentile as overweight and those with BMI>or=95th age-sex specific percentile as obese. The prevalence of overweight was 12.9% in baseline, and increased to 18.7% after 2 years. The prevalence of obesity increased from 10.3 to 20.4% during the same period. Baseline intake of soda and all sugar-sweetened beverages were positively associated with baseline BMI z-scores. After adjusting for covariates, additional intake of fruit drinks and all sugar-sweetened beverages at baseline showed significantly higher odds of incidence of overweight over 2 years. Among a longitudinal cohort of African-American preschool children, high consumption of sugar-sweetened beverages was significantly associated with an increased risk for obesity.

Planning and development of the continuous National Survey of Family Growth.

OBJECTIVES: This report describes how the continuous National Survey of Family Growth (NSFG) (begun in 2006) was designed, planned, and implemented. The NSFG is a continuous national survey of men and women 15-44 years of age designed to provide national estimates of factors affecting pregnancy and birth rates; men's and women's health; and parenting. METHODS: The survey used in-person, face-to-face interviews conducted by trained female interviewers. One person per household was interviewed from a national area probability sample. The data collection used computer-assisted personal interviewing (CAPI). Separate questionnaires were used for male and female respondents. The last section of the questionnaires used a self-administered technique called audio computer-assisted self-interviewing or ACASI. Each data collection period lasted 12 weeks-10 weeks for "Phase 1," the main data collection protocol, and 2 weeks for "Phase 2," an intensive attempt to locate and interview nonrespondents. RESULTS: Each year, about 5,000 persons were interviewed in about 33 areas, called primary sampling units (PSUs). Over a 4-year period, 110 PSUs will be used. This report gives an overview of the procedures used in the conduct of the continuous NSFG. A later report will describe response rates and other results of the data collection, but the early fieldwork has gone well.

Prenatal care and delivery room staff attitudes toward research and the National Children's Study.

OBJECTIVES: The cooperation of healthcare personnel is essential for implementing clinical research, yet little is known about the willingness of staff to facilitate research. This study assessed attitudes of prenatal clinic and delivery room (DR) staff toward facilitation of research, with a particular focus on the National Children's Study (NCS). METHODS: Staff from seven sampled prenatal clinics (N=82) and all three DRs in Kent County, MI (N=169) completed anonymous surveys assessing willingness to recruit patients (clinic) or collect biological specimens (DR), desired incentives, and barriers to research in general and the NCS specifically. RESULTS: Clinic staff included 36 office workers, 29 nurses, 11 medical assistants and 6 physicians/physician assistants. DR staff included 127 nurses, 19 support staff, 11 physicians and 10 technicians. Clinic staff would hand out brochures (72%) and describe studies (65%), but only 44% wanted outside research staff to recruit patients. Non-White staff were 4.1 times more likely (95% CI. 1.2-14.1) to permit outside staff to recruit. DR staff would collect placentas (84%) and cord blood (77%), and preferred DR staff to perform the collections. In both settings, financial incentives were not required or were modest. Lack of time was the most reported research barrier, followed by patient flow and lack of space. A small fraction of healthcare workers reported refusal to facilitate research tasks. CONCLUSIONS: Careful planning of research with all clinic and DR staff will be necessary for successful execution of the NCS or other large-scale clinical research studies.

Estimation of the proportion of overweight individuals in small areas - a robust extension of the Fay-Herriot model.

Hierarchical model such as Fay-Herriot (FH) model is often used in small area estimation. The method might perform well overall but is vulnerable to outliers. We propose a robust extension of the FH model by assuming the area random effects follow a t distribution with an unknown degrees-of-freedom parameter. The inferences are constructed using a Bayesian framework. Monte Carlo Markov Chain (MCMC) such as Gibbs sampling and Metropolis-Hastings acceptance and rejection algorithms are used to obtain the joint posterior distribution of model parameters. The procedure is used to estimate the county-level proportion of overweight individuals from the 2003 public-use Behavioral Risk Factor Surveillance System (BRFSS) data. We also discuss two approaches for identifying outliers in the context of this application.

National Survey of Family Growth, Cycle 6: sample design, weighting, imputation, and variance estimation.

OBJECTIVES: Cycle 6 of the National Survey of Family Growth (NSFG) was conducted by the National Center for Health Statistics in 2002 and early 2003. This report describes how the sample was designed, shows response rates for various subgroups of men and women, describes how the sample weights were computed to make national estimates possible, shows how missing data were imputed for a limited set of key variables, and describes the proper ways to estimate sampling errors from the NSFG. The report includes both nontechnical summaries for readers who need only general information and more technical detail for readers who need an in-depth understanding of these topics. METHODS: The NSFG Cycle 6 was based on an independent, national probability sample of men and women 15-44 years of age. It was the first NSFG ever to include a national sample of men 15-44 as well as a sample of women. Fieldwork was carried out by the University of Michigan's Institute for Social Research (ISR) under a contract with NCHS. In-person, face-to-face interviews were conducted by professional female interviewers using laptop computers. In all, 12,571 women and men-7,643 females and 4,928 males-were interviewed, the largest NSFG ever done. RESULTS: Analysis of NSFG Cycle 6 data requires the use of sampling weights and estimation of sampling errors that accounts for the complex sample design and estimation features of the survey. Examples of how to use several available software packages that incorporate complex design features in estimation, such as SAS, SUDAAN, and STATA, are presented.