3.1 Overview

This chapter includes a literature review of previous studies that have used national health surveys to answer public health and health services research questions. The background literature provided lays the groundwork for the case studies used in Chapters 6-10 in this textbook. However, the literature reviews are not comprehensive. The reader is encouraged to conduct their own literature reviews in PubMed, Ovid MEDLINE, Google Scholar, and other library sources to gain a deeper understanding of the existing evidence for each topic.

3.2 National Health Interview Survey (NHIS) Case Study

 The objective of the NHIS survey case study is to determine associations between a combined measure of race, ethnicity, and nativity status and seasonal influenza vaccine uptake among foreign-born Arab Americans compared to other racial/ethnic groups. Data from the 2018 NHIS person and sample adult files will be used to fulfil this objective.

3.2.1 Why examine differences in influenza vaccine uptake among foreign-born Arab Americans compared to other US- groups?

During the 2018-2019 season, it was estimated that there were 38,000,000 cases of symptomatic illness, 18,000,000 medical visits, and 22,000 deaths in the US.¹ Seasonal influenza vaccination is recommended among all individuals ages 6 months and older to prevent morbidity and mortality from influenza and other health conditions.² Despite established benefits, disparities exist in vaccination coverage by race, ethnicity, and nativity status. Using 2010-2016 NHIS data, Lu and colleagues found that Hispanic and non-Hispanic Black adults were less likely to receive annual influenza vaccines compared to non-Hispanic Whites.³ Using 2012 data, Lu and colleagues found foreign-born adults were less likely to receive an influenza vaccination than their US-born counterparts.⁴ Results were similar among other studies.⁵ Research on influenza vaccination coverage among Arab Americans is limited despite evidence showing that morbidity and mortality estimates for several health conditions are higher than other groups. For example, Dallo and colleagues evaluated administrative hospital data and found that Arab American women were more likely to have influenza or pneumonia than non-Hispanic White women in Michigan.⁶ Furthermore, other research has demonstrated that Arab American males have higher mortality rates from influenza or pneumonia than other non-Hispanic White males.⁷ In 2015, Dallo and Kindratt used NHIS data to determine the prevalence of not receiving influenza vaccinations among Arab American men and women compared to US- and foreign-born non-Hispanic White adults from Europe using NHIS person level and sample adult data.^8,9 A foreign-born Arab American ethnic group was created using restricted country of birth data collected from the NHIS. Results indicated that foreign-born Arab American men had 62% lower odds (OR=0.38; 95% CI=0.21-0.67) and foreign-born Arab American women had 66% lower odds (OR=0.34; 95% CI=0.21-0.58) of receiving an influenza vaccine compared to their US-born non-Hispanic White counterparts.^8,9 The NHIS case study will extend this previous research by using 2018 public-use person and sample adult data.

3.3 Medical Expenditure Panel Survey (MEPS) Case Study

The objective of the MEPS case study is to determine associations between adults’ perceptions of patient-provider communication quality and seasonal influenza vaccination uptake. Data from the 2015 and 2016 MEPS household level in-person and self-administered questionnaire data will be used to fulfil this objective.

3.3.1 Why determine how adults’ perceptions of patient-provider communication quality are associated with influenza vaccination?

 Efforts are needed to address barriers to influenza vaccination uptake among underrepresented racial, ethnic, and immigrant minority groups. Previous research suggests that effective communication between health care providers and patients during in-person and between visits may contribute to more adults receiving recommended preventive services, including cancer screenings and influenza vaccinations.^10-13 Kindratt and colleagues previous research using 2011-2015 MEPS data examined associations between adults’ perceptions of specific qualities of patient-provider communication and their likelihood of receiving cancer screenings by racial and ethnic subgroups.¹⁰ Results demonstrated that Hispanic and non-Hispanic Black adults who reported their health care providers gave them specific instructions had higher odds of receiving breast and colorectal cancer screenings. Non-Hispanic Asian women who reported their health care providers asked them to describe how they were going to follow the instructions given to them had higher odds of receiving cervical cancer screenings.¹⁰ Research examining the role of patient-provider communication on influenza vaccine uptake using nationally representative samples is limited. Villani and Mortensen (2013) examined the influence of patient-provider communication qualities on preventive services uptake, including recommended cancer screenings and vaccinations, using 2009 MEPS data.¹⁴ They did not find a statistically significant association between adults’ (ages 50+ years) perceptions of patient-provider communication and influenza vaccine uptake. However, to my knowledge, no other studies have examined the role of patient-provider communication during face-to-face visits on influenza vaccine uptake using nationally representative MEPS data. The MEPS case study will extend this previous research by using 2015-2016 household data.

3.4 Health Information National Trends Survey (HINTS) Case Study

The objective of the HINTS case study is to explore associations between e-mail communication and breast cancer screening uptake. Data from the HINTS 5, Cycle 3 data collected in 2019 will be used to fulfil this objective.

3.4.1 Why determine how the use of e-mail communication is associated with breast cancer screening uptake?

Advances in health information technology and the use of the internet as a mode of communication have allowed for greater interaction between health care providers and their patients between visits. In addition to traditional telephone communications, patients can communicate with their health care providers by e-mail, text messaging, patient portals, and mobile applications. Previous studies have examined patients’ perceptions of the benefits of electronic patient-provider communication, specifically using e-mail communication. Patients identified some benefits to using e-mail communication, including convenient access at any time, increased level of comfort asking questions, and the ability to save and keep track of conversations.¹⁶ Studies have shown that using e-mail patient-provider communication may lead to improved health outcomes. Research examining associations between e-mail patient-provider communication and adults’ use of preventive services are limited. Using 2011-2015 NHIS data, Kindratt and colleagues demonstrated that adults who used e-mail to communicate with their health care providers had 1.51 times greater odds (95% CI=1.44-1.59) of receiving a seasonal influenza vaccine compared to those who do not use e-mail to communicate with their health care providers.¹² Using HINTS 4, Cycles 1-4 data, Kindratt and colleagues also looked at associations between e-mail patient-provider communication and cancer screenings using HINTS data. Results demonstrated that there was not a significant association between e-mail patient-provider communication and breast, cervical or colorectal cancer screenings.¹¹ No other studies have evaluated the influence of e-mail patient-provider communication practices on cancer screenings using national representative HINTS data. The HINTS case study will extend this previous research by using HINTS 5, Cycle 3 data.

3.5 Behavior Risk Factor Surveillance System (BRFSS) Case Study

 The objective of the BRFSS case study is to explore whether differences in Alzheimer’s disease and related dementia (ADRD) caregiving experiences among urban and rural adults in Texas are moderated by race and ethnicity. The differences obtained among urban and rural adults will be evaluated as a whole, and stratified by racial and ethnic groups. Data from the 2019 BRFSS will be used to fulfil this objective.

3.5.1 Why explore how differences in ADRD caregiving experiences among urban and rural adults in Texas are moderated by race and ethnicity?

In 2020, the National Alliance for Caregiving and American Association of Retired Persons estimated that 21% of adults in the US are informal caregivers, which has increased by 9.5 million since 2015.¹⁷ Over 11 million unpaid individuals, family or friends, are caregivers for persons living with ADRD.¹⁷ While most older adults with ADRD are currently non-Hispanic White, the racial and ethnic diversity of older adults living with ADRD is increasing.¹⁸

Previous studies on ADRD caregiving experiences across geographic contexts highlight unmet resource needs and support the lack of dementia-specific¹⁹ and respite services²⁰ in non-metro or rural areas. Urban/rural comparisons of ADRD caregiving experiences have been limited to descriptive analyses due to research studies only being conducted with small non-representative samples. Few studies have examined differences in caregiving experiences among racial and ethnic caregivers living in urban and rural areas.²¹

A recent study was conducted using data from the National Study of Caregiving (NSOC), which includes a sample of caregivers linked to the National Health and Aging Trends Survey (NHATS).²² The aims of the study were to determine whether: 1) caregiver experiences and health differed across urban and rural areas and 2) the links between caregiving experiences and health were moderated by caregiver race/ethnicity. Results indicated non-metro ADRD caregivers were less racially/ethnically diverse (82.7% White), and more were spouses/partners (20.2%).²² Among racial/ethnic minority ADRD caregivers, non-metro context was associated with having more chronic conditions, providing less care, and not co-residing with care recipients. Amid White ADRD caregivers, non-metro context was associated with not reporting caregiving was more than they could handle and finding financial assistance for caregiving. Non-metro minority ADRD caregivers had 3.09 times higher odds (95% CI=1.02-9.36) of reporting anxiety in comparison to metro minority ADRD caregivers.²² While this study lays the groundwork for national research on ADRD caregiving by geographic context, large differences may exist by state. The BRFSS case study will extend this previous research by using BRFSS data from Texas. 

3.6 National Health and Nutrition Examination Survey (NHANES) Case Study

The NHANES case study will focus on movement behaviors among US adults. The objective of the NHANES case study is to evaluate adherence to 24-hour movement guidelines (sleep, sedentary behavior, and physical activity) among US adults and determine differences by race, ethnicity, and nativity status. Sedentary behavior will be used as the outcome of interest. Specifically, data from the 2017-2020 in-person interviews and examination data will be used to fulfil this objective.

3.6.1. Why Evaluate 24-hour movement guideline adherence among racial and ethnic groups in the US?

The recently published 24-hour movement guidelines include recommendations for sedentary behavior, physical activity, and sleep among adults ages 18-64 years and 65 years and older.²³ The guidelines integrate recommendations for sleep, physical activity, and sedentary behavior with the acknowledgement that combination of these behaviors throughout the day is associated with health outcomes.²³ There are slight differences between recommendations for younger and older adults. For example, it is recommended that adults ages 18-64 years get 7 to 9 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times. It is recommended that adults perform a variety of intensities and types of physical activity, including 1) moderate to vigorous aerobic physical activities that accumulate up to 150 minutes per week, 2) muscle strengthening activities using major muscle groups at least twice a week, and 30 several hours of light physical activities, including standing. Finally, it is recommended that adults limit sedentary behavior to 8 hours or less (~480 minutes), including no more than 3 hours of recreational screen time and breaking up long periods of sitting as often as possible.²⁴ Little is known about how adherence to these guidelines differs among US adults, particularly among different racial and ethnic groups. The NHANES case study will explore racial and ethnic differences in sedentary behavior among US- and foreign-born Hispanics, non-Hispanic Whites, non-Hispanic Blacks, and non-Hispanic Asians using 2017-2020 pre-pandemic data.

3.7 Summary

In summary, this chapter provided a brief background to support the case studies used in Chapters 6-10. The topics of the case studies are broad and encompass the wide range of research being conducted using national health surveys by the primary author of this textbook. The reader is encouraged to conduct their own literature reviews using electronic databases to gain a deeper understanding of the content areas for each case study.

3.8 References 

1. Centers for Disease Control and Prevention (CDC). Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths in the United States — 2019–2020 Influenza Season | CDC. Published October 6, 2020. Accessed December 15, 2020. https://www.cdc.gov/flu/about/burden/2019-2020.html
2. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices – United States, 2020-21 Influenza Season. MMWR Recomm Rep. 2020;69(8):1-24. doi:10.15585/mmwr.rr6908a1
3. Lu PJ, Hung MC, O’Halloran AC, et al. Seasonal Influenza Vaccination Coverage Trends Among Adult Populations, U.S., 2010-2016. Am J Prev Med. 2019;57(4):458-469. doi:10.1016/j.amepre.2019.04.007
4. Lu PJ, Rodriguez-Lainz A, O’Halloran A, Greby S, Williams WW. Adult vaccination disparities among foreign-born populations in the U.S., 2012. Am J Prev Med. 2014;47(6):722-733. doi:10.1016/j.amepre.2014.08.009
5. Vlahov D, Bond KT, Jones KC, Ompad DC. Factors associated with differential uptake of seasonal influenza immunizations among underserved communities during the 2009-2010 influenza season. J Community Health. 2012;37(2):282-287. doi:10.1007/s10900-011-9443-x
6. Dallo FJ, Ruterbusch JJ, Kirma JD, Schwartz K, Fakhouri M. A Health Profile of Arab Americans in Michigan: A Novel Approach to Using a Hospital Administrative Database. J Immigr Minor Health. 2016;18(6):1449-1454. doi:10.1007/s10903-015-0296-8
7. Dallo FJ, Schwartz K, Ruterbusch JJ, Booza J, Williams DR. Mortality rates among Arab Americans in Michigan. J Immigr Minor Health. 2012;14(2):236-241. doi:10.1007/s10903-011-9441-1
8. Dallo FJ, Kindratt TB. Disparities in preventive health behaviors among non-Hispanic White men: heterogeneity among foreign-born Arab and European Americans. Am J Mens Health. 2015;9(2):124-131. doi:10.1177/1557988314532285
9. Dallo FJ, Kindratt TB. Disparities in vaccinations and cancer screening among U.S.- and foreign-born Arab and European American non-Hispanic White women. Womens Health Issues. 2015;25(1):56-62. doi:10.1016/j.whi.2014.10.002
10. Kindratt TB, Dallo FJ, Allicock M, Atem F, Balasubramanian BA. The influence of patient-provider communication on cancer screenings differs among racial and ethnic groups. Prev Med Rep. 2020;18:101086. doi:10.1016/j.pmedr.2020.101086
11. Kindratt TB, Atem F, Dallo FJ, Allicock M, Balasubramanian BA. The Influence of Patient–Provider Communication on Cancer Screening. Journal of Patient Experience. Published online May 11, 2020:2374373520924993. doi:10.1177/2374373520924993
12. Kindratt TB, Allicock M, Atem F, Dallo FJ, Balasubramanian BA. Email Patient-Provider Communication and Cancer Screenings Among US Adults: Cross-sectional Study. JMIR Cancer. 2021;7(3):e23790. doi:10.2196/23790
13. Kindratt T, Callender L, Cobbaert M, Wondrack J, Bandiera F, Salvo D. Health information technology use and influenza vaccine uptake among US adults. Int J Med Inform. 2019;129:37-42. doi:10.1016/j.ijmedinf.2019.05.025
14. Villani J, Mortensen K. Patient-provider communication and timely receipt of preventive services. Prev Med. 2013;57(5):658-663. doi:10.1016/j.ypmed.2013.08.034
15. Emily S. Lau MD, Sharonne N. Hayes MD, Annabelle Santos Volgman MD, et al. Does Patient-Physician Gender Concordance Influence Patient Perceptions or Outcomes? Journal of the American College of Cardiology. Published online March 2, 2021. Accessed November 15, 2021. https://www.jacc.org/doi/10.1016/j.jacc.2020.12.031
16. Ye J, Rust G, Fry-Johnson Y, Strothers H. E-mail in patient-provider communication: a systematic review. Patient Educ Couns. 2010;80(2):266-273. doi:10.1016/j.pec.2009.09.038
17. Jr SM. Caregiving in the US 2020 | The National Alliance for Caregiving. Published May 11, 2020. Accessed June 25, 2021. https://www.caregiving.org/caregiving-in-the-us-2020/
18. 2022 Alzheimer’s disease facts and figures. Alzheimers Dement. 2022;18(4):700-789. doi:10.1002/alz.12638
19. Gibson A, Holmes SD, Fields NL, Richardson VE. Providing Care for Persons with Dementia in Rural Communities: Informal Caregivers’ Perceptions of Supports and Services. J Gerontol Soc Work. 2019;62(6):630-648. doi:10.1080/01634372.2019.1636332
20. Kosloski K, Schaefer JP, Allwardt D, Montgomery RJV, Karner TX. The role of cultural factors on clients’ attitudes toward caregiving, perceptions of service delivery, and service utilization. Home Health Care Serv Q. 2002;21(3-4):65-88. doi:10.1300/J027v21n03_04
21. Dilworth-Anderson P, Moon H, Aranda MP. Dementia Caregiving Research: Expanding and Reframing the Lens of Diversity, Inclusivity, and Intersectionality. Bowers BJ, ed. The Gerontologist. 2020;60(5):797-805. doi:10.1093/geront/gnaa050
22. Kindratt T, Sylvers D, Yoshikawa A, Anuarbe ML, Webster N, Bouldin E. ADRD Caregiving Experiences and Health by Race, Ethnicity and Care Recipient Geographic Context. Innov Aging. 2021;5(Suppl 1):990. doi:10.1093/geroni/igab046.3557
23. Ross R, Tremblay M. Introduction to the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep. Appl Physiol Nutr Metab. 2020;45(10 (Suppl. 2)):v-xi. doi:10.1139/apnm-2020-0843
24. Ross R, Chaput JP, Giangregorio LM, et al. Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep. Appl Physiol Nutr Metab. 2020;45(10 (Suppl. 2)):S57-S102. doi:10.1139/apnm-2020-0467