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Effective COVID-19 prevention in kindergarten through grade 12 (K-12) schools requires multicomponent prevention strategies in school buildings and school-based transportation, including improving ventilation (1). Improved ventilation can reduce the concentration of infectious aerosols and duration of potential exposures (2,3), is linked to lower COVID-19 incidence (4), and can offer other health-related benefits (e.g., better measures of respiratory health, such as reduced allergy symptoms) (5). Whereas ambient wind currents effectively dissipate SARS-CoV-2 (the virus that causes COVID-19) outdoors,* ventilation systems provide protective airflow and filtration indoors (6). CDC examined reported ventilation improvement strategies among a nationally representative sample of K-12 public schools in the United States using wave 4 (February 14-March 27, 2022) data from the National School COVID-19 Prevention Study (NSCPS) (420 schools), a web-based survey administered to school-level administrators beginning in summer 2021.

Respondent-driven sampling (RDS) is an approach commonly used to recruit nonprobability samples of rare and hard-to-find populations. The purpose of this study was to explore the utility of phone- and web-based RDS methodology to sample sexual minority women (SMW) for participation in a telephone survey. Key features included (i) utilizing a national probability survey sample to select seeds; (ii) web-based recruitment with emailed coupons; and (iii) virtual processes for orienting, screening, and scheduling potential participants for computer-assisted telephone interviews. Rather than resulting in a large diverse sample of SMW, only a small group of randomly selected women completed the survey and agreed to recruit their peers, and very few women recruited even one participant. Only seeds from the most recent of two waves of the probability study generated new SMW recruits. Three RDS attempts to recruit SMW over several years and findings from brief qualitative interviews revealed four key challenges to successful phone- and web-based RDS with this population. First, population-based sampling precludes sampling based on participant characteristics that are often used in RDS. Second, methods that distance prospective participants from the research team may impede development of relationships, investment in the study, and motivation to participate. Third, recruitment for telephone surveys may be impeded by multiple burdens on seeds and recruits (e.g., survey length, understanding the study and RDS process). Finally, many seeds from a population-based sample may be needed, which is not generally feasible when working with a limited pool of potential seeds. This method may yield short recruitment chains, which would not meet key RDS assumptions for approximation of a probability sample. In conclusion, potential challenges to using RDS in studies with SMW, particularly those using virtual approaches, should be considered.

Background Trends in estimates of US pediatric SARS-CoV-2 infection-induced seroprevalence from commercial laboratory specimens may overrepresent children with frequent health care needs. We examined seroprevalence trends and compared seroprevalence estimates by testing type and diagnostic coding. Methods Cross-sectional convenience samples of residual sera September 2021-February 2022 from 52 US jurisdictions were assayed for infection-induced SARS-CoV-2 antibodies; monthly seroprevalence estimates were calculated by age group. Multivariate logistic analyses compared seroprevalence estimates for specimens associated with International Classification of Diseases-Tenth Revision (ICD-10) codes and laboratory orders indicating well-child care with estimates for other pediatric specimens. Results Infection-induced SARS-CoV-2 seroprevalence increased in each age group, from 30% to 68% (1–4 years), 38% to 77% (5–11 years), and 40% to 74% (12–17 years). On multivariate analysis, patients with well-child ICD-10 codes were seropositive more often than other patients aged 1–17 years (adjusted prevalence ratio [aPR] 1.04; 95% confidence interval [CI], 1.02–1.07); children aged 9–11 years receiving standard lipid screening were seropositive more often than those receiving other laboratory tests (aPR, 1.05; 95% CI, 1.02–1.08). Conclusions Infection-induced seroprevalence more than doubled among children younger than 12 years between September 2021 and February 2022, and increased 85% in adolescents. Differences in seroprevalence by care type did not substantially impact US pediatric seroprevalence estimates.

Students with special education needs or underlying health conditions have been disproportionately impacted (e.g., by reduced access to services) throughout the COVID-19 pandemic.This study describes challenges reported by schools in providing services and supports to students with special education needs or underlying health conditions and describes schools' use of accessible communication strategies for COVID-19 prevention.This study analyzes survey data from a nationally representative sample of U.S. K-12 public schools (n = 420, February-March 2022). Weighted prevalence estimates of challenges in serving students with special education needs or underlying health conditions and use of accessible communication strategies are presented. Differences by school locale (city/suburb vs. town/rural) are examined using chi-square tests.The two most frequently reported school-based challenges were staff shortages (51.3%) and student compliance with prevention strategies (32.4%), and the two most frequently reported home-based challenges were the lack of learning partners at home (25.5%) and lack of digital literacy among students' families (21.4%). A minority of schools reported using accessible communications strategies for COVID-19 prevention efforts, such as low-literacy materials (7.3%) and transcripts that accompany podcasts or videos (6.7%). Town/rural schools were more likely to report non-existent or insufficient access to the internet at home and less likely to report use of certain accessible communication than city/suburb schools.Schools might need additional supports to address challenges in serving students with special education needs or with underlying health conditions and improve use of accessible communication strategies for COVID-19 and other infectious disease prevention.

Background: Food insecurity (FI) has been associated with poor access to health care. It is unclear whether this association is beyond that predicted by income, education, and health insurance. FI may serve as a target for intervention given the many programs designed to ameliorate FI. We examined the association of FI with being up-to-date to colorectal cancer and breast cancer screening guidelines. Methods: Nine NCI-designated cancer centers surveyed adults in their catchment areas using demographic items and a two-item FI questionnaire. For the colorectal cancer screening sample (n = 4,816), adults ages 50–75 years who reported having a stool test in the past year or a colonoscopy in the past 10 years were considered up-to-date. For the breast cancer screening sample (n = 2,449), female participants ages 50–74 years who reported having a mammogram in the past 2 years were up-to-date. We used logistic regression to examine the association between colorectal cancer or breast cancer screening status and FI, adjusting for race/ethnicity, income, education, health insurance, and other sociodemographic covariates. Results: The prevalence of FI was 18.2% and 21.6% among colorectal cancer and breast cancer screening participants, respectively. For screenings, 25.6% of colorectal cancer and 34.1% of breast cancer participants were not up-to-date. In two separate adjusted models, FI was significantly associated with lower odds of being up-to-date with colorectal cancer screening [OR, 0.7; 95% confidence interval (CI), 0.5–0.99)] and breast cancer screening (OR, 0.6; 95% CI, 0.4–0.96). Conclusions: FI was inversely associated with being up-to-date for colorectal cancer and breast cancer screening. Impact: Future studies should combine FI and cancer screening interventions to improve screening rates.

In December 2021, the B.1.1.529 (Omicron) variant of SARS-CoV-2, the virus that causes COVID-19, became predominant in the United States. Subsequently, national COVID-19 case rates peaked at their highest recorded levels.* Traditional methods of disease surveillance do not capture all COVID-19 cases because some are asymptomatic, not diagnosed, or not reported; therefore, the proportion of the population with SARS-CoV-2 antibodies (i.e., seroprevalence) can improve understanding of population-level incidence of COVID-19. This report uses data from CDC's national commercial laboratory seroprevalence study and the 2018 American Community Survey to examine U.S. trends in infection-induced SARS-CoV-2 seroprevalence during September 2021-February 2022, by age group.

Published surveys in the United States provide much evidence that COVID-19 vaccination is influenced by disease and vaccine-related risk perceptions. However, there has been little examination of whether individual’s general beliefs about vaccines are also related to COVID-19 vaccination, especially among unvaccinated adults. This study used an August 2021 national survey of 1000 U.S. adults to examine whether general beliefs about vaccines were associated with COVID-19 vaccination status. In addition, it used multivariate analyses to assess the relative contribution of individual vaccine beliefs to current vaccine status independently of COVID-19-specific attitudes and experiences, and demographics. The findings indicated that, collectively, general vaccine beliefs mattered more than demographics, COVID-19-specific risk perceptions, confidence in government, or trust in public health agencies in COVID-19 vaccination status. Overall, the findings affirm the importance of vaccine education and communication efforts that help people understand why vaccines are needed, how vaccine safety is established and monitored, and how vaccines provide protection from infectious diseases. To achieve success among vaccine-hesitant individuals, communication strategies should target vaccine beliefs that most influence vaccination outcomes.

Background: Rural populations experience a disproportionate cancer burden relative to urban populations. One possibility is that rural populations are more likely to hold counterproductive cancer beliefs such as fatalism and information overload that undermine prevention and screening behaviors. Methods: Between 2016 and 2020, 12 U.S. cancer centers surveyed adults in their service areas using online and in-person survey instruments. Participants (N = 10,362) were designated as rural (n = 3,821) or urban (n = 6,541). All participants were 18 and older (M = 56.97, SD = 16.55), predominately non-Hispanic White (81%), and female (57%). Participants completed three items measuring cancer fatalism (“It seems like everything causes cancer,” “There's not much you can do to lower your chances of getting cancer,” and “When I think about cancer, I automatically think about death”) and one item measuring cancer information overload (“There are so many different recommendations about preventing cancer, it's hard to know which ones to follow”). Results: Compared with urban residents, rural residents were more likely to believe that (i) everything causes cancer (OR = 1.29; 95% CI, 1.17–1.43); (ii) prevention is not possible (OR = 1.34; 95% CI, 1.19–1.51); and (iii) there are too many different recommendations about cancer prevention (OR = 1.26; 95% CI, 1.13–1.41), and cancer is always fatal (OR = 1.21; 95% CI, 1.11–1.33). Conclusions: Compared with their urban counterparts, rural populations exhibited higher levels of cancer fatalism and cancer information overload. Impact: Future interventions targeting rural populations should account for higher levels of fatalism and information overload.

Background: The Population Health Assessment initiative by NCI sought to enhance cancer centers’ capacity to acquire, aggregate, and integrate data from multiple sources, as well as to plan, coordinate, and enhance catchment area analysis activities. Methods: Key objectives of this initiative are pooling data and comparing local data with national data. A novel aspect of analyzing data from this initiative is the methodology used to weight datasets from sites that collected both probability and nonprobability samples. This article describes the methods developed to weight data, which cancer centers collected with combinations of probability, and nonprobability sampling designs. Results: We compare alternative weighting methods in particular for the hybrid probability and nonprobability sampling designs employed by different cancer centers. We also include comparisons of local center data with national survey data from large probability samples. Conclusions: This hybrid approach to calculating statistical weights can be implemented both within cancer centers that collect both probability and nonprobability samples with common measures. Aggregation can also apply to cancer centers that share common data elements, and target similar populations, but differ in survey sampling designs. Impact: Researchers interested in local versus national comparisons for cancer surveillance and control outcomes should consider various weighting approaches, including hybrid approaches, when analyzing their data.

BACKGROUND: The Health Information National Trends Survey (HINTS) is a probability-based, nationally representative survey conducted routinely to gather information about the American public’s cancer-related beliefs and behaviors, including the use of cancer-related information. HINTS was created to produce national estimates and has lacked the ability to create accurate and precise state and regional estimates. The motivation for this current work was to create state- and regional-level estimates using a national sample (HINTS) through standard calibration methods. Health estimates at a local level can inform policy decisions that better target the cancer needs within a community. Local-level data allow researchers an opportunity to examine local populations in finer detail without additional costly data collection. METHODS: By combining seven cycles of HINTS data from 2012–2018 and then raking the previously created person-level weights, we were able to create tables and maps of HINTS subnational survey estimates for key outcomes that have small variances and little potential bias. RESULTS AND CONCLUSION: This paper describes the methods used to harmonize and aggregate data across cycles, create state- and regional-level estimates from the pooled data, and produce survey weights for the pooled datasets. It demonstrates both the opportunities and the challenges of pooled data analysis.

Key Points Question What proportion of persons across 52 US jurisdictions had detectable antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from July to September 2020? Findings In this repeated, cross-sectional study of 177 919 residual clinical specimens, the estimated percentage of persons in a jurisdiction with detectable SARS-CoV-2 antibodies ranged from fewer than 1% to 23%. Over 4 sampling periods in 42 of 49 jurisdictions with calculated estimates, fewer than 10% of people had detectable SARS-CoV-2 antibodies. Meaning While SARS-CoV-2 antibody prevalence estimates varied widely across jurisdictions, most people in the US did not have evidence of previous SARS-CoV-2 infection., Importance Case-based surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely underestimates the true prevalence of infections. Large-scale seroprevalence surveys can better estimate infection across many geographic regions. Objective To estimate the prevalence of persons with SARS-CoV-2 antibodies using residual sera from commercial laboratories across the US and assess changes over time. Design, Setting, and Participants This repeated, cross-sectional study conducted across all 50 states, the District of Columbia, and Puerto Rico used a convenience sample of residual serum specimens provided by persons of all ages that were originally submitted for routine screening or clinical management from 2 private clinical commercial laboratories. Samples were obtained during 4 collection periods: July 27 to August 13, August 10 to August 27, August 24 to September 10, and September 7 to September 24, 2020. Exposures Infection with SARS-CoV-2. Main Outcomes and Measures The proportion of persons previously infected with SARS-CoV-2 as measured by the presence of antibodies to SARS-CoV-2 by 1 of 3 chemiluminescent immunoassays. Iterative poststratification was used to adjust seroprevalence estimates to the demographic profile and urbanicity of each jurisdiction. Seroprevalence was estimated by jurisdiction, sex, age group (0-17, 18-49, 50-64, and ≥65 years), and metropolitan/nonmetropolitan status. Results Of 177 919 serum samples tested, 103 771 (58.3%) were from women, 26 716 (15.0%) from persons 17 years or younger, 47 513 (26.7%) from persons 65 years or older, and 26 290 (14.8%) from individuals living in nonmetropolitan areas. Jurisdiction-level seroprevalence over 4 collection periods ranged from less than 1% to 23%. In 42 of 49 jurisdictions with sufficient samples to estimate seroprevalence across all periods, fewer than 10% of people had detectable SARS-CoV-2 antibodies. Seroprevalence estimates varied between sexes, across age groups, and between metropolitan/nonmetropolitan areas. Changes from period 1 to 4 were less than 7 percentage points in all jurisdictions and varied across sites. Conclusions and Relevance This cross-sectional study found that as of September 2020, most persons in the US did not have serologic evidence of previous SARS-CoV-2 infection, although prevalence varied widely by jurisdiction. Biweekly nationwide testing of commercial clinical laboratory sera can play an important role in helping track the spread of SARS-CoV-2 in the US., This cross-sectional study examines the prevalence of persons with SARS-CoV-2 antibodies across the US and changes from July to September 2020.

Population-based surveys have long been a key tool for health researchers, policy makers and program managers. The addition of bio-measures, including physical measures and specimen collection, to self-reported health and health behaviors can increase the value of the research for health sciences. At the same time, these bio-measures are likely to increase the perceived burden and intrusiveness to the respondent. Relatively little research has been reported on respondent willingness to participate in surveys that involve physical measures and specimen collection and whether there is any associated non-response bias. This paper explores the willingness of respondents to participate in surveys that involve physical measures and biomarkers. A Census-balanced sample of nearly 2000 adults from a national mobile panel of persons residing in the U.S. were interviewed. Willingness to participate in six specific bio-measures was assessed. The survey finds a high correlation in the willingness of respondents to participate among these specific bio-measures. This suggests there is a general propensity towards (and against) bio-measures among potential respondents, despite some differences in willingness to participate in the more sensitive, intrusive or burdensome biomarkers. This study finds the general propensity to participate in bio-measures is correlated with a number of key measures of health and illness. This suggests that the inclusion of biomarkers in health surveys may introduce some bias in key measures that need to be balanced against the value of the additional information.

Background Engaging diverse populations in biomedical research, including biospecimen donation, remains a national challenge. This study examined factors associated with an invitation to participate in biomedical research, intent to participate in biomedical research in the future, and participation in biomedical research and biospecimen donation among a diverse, multilingual, community-based sample across 3 distinct geographic areas. Methods Three National Cancer Institute-designated cancer centers engaged in community partnerships to develop and implement population health assessments, reaching a convenience sample of 4343 participants spanning their respective catchment areas. Data harmonization, multiple imputation, and multivariable logistic modeling were used. Results African Americans, Hispanic/Latinos, and other racial minority groups were more likely to be offered opportunities to participate in biomedical research compared to whites. Access to care, history of cancer, educational level, survey language, nativity, and rural residence also influenced opportunity, intent, and actual participation in biomedical research. Conclusions Traditionally underserved racial and ethnic groups reported heightened opportunity and interest in participating in biomedical research. Well-established community partnerships and long-standing community engagement around biomedical research led to a diverse sample being reached at each site and may in part explain the current study findings. However, this study illustrates an ongoing need to establish trust and diversify biomedical research participation through innovative and tailored approaches. National Cancer Institute-designated cancer centers have the potential to increase opportunities for diverse participation in biomedical research through community partnerships and engagement. Additional work remains to identify and address system-level and individual-level barriers to participation in both clinical trials and biospecimen donation for research.

Objectives The Medical Monitoring Project (MMP) is a public health surveillance system that provides representative estimates of the experiences and behaviors of adults with diagnosed HIV in the United States. In 2015, the sample design and frame of MMP changed from a system that only included HIV patients to one that captures the experiences of persons receiving and not receiving HIV care. We describe methods investigated for calculating survey weights, the approach chosen, and the benefits of using a dynamic surveillance registry as a sampling frame. Methods MMP samples adults with diagnosed HIV from the National HIV Surveillance System, the HIV case surveillance registry for the United States. In the methodological study presented in this manuscript, we compared methods that account for sample design and nonresponse, including weighting class adjustment vs. propensity weighting and a single-stage nonresponse adjustment vs. sequential adjustments for noncontact and nonresponse. We investigated how best to adjust for non-coverage using surveillance data to post-stratify estimates. Results After assessing these methods, we chose as our preferred procedure weighting class adjustments and a single-stage nonresponse adjustment. Classes were constructed using variables associated with respondents’ characteristics and important survey outcomes, chief among them laboratory results available from surveillance that served as a proxy for medical care. Conclusions MMPs weighting procedures reduced sample bias by leveraging auxiliary information on medical care available from the surveillance registry sampling frame. Expanding MMPs population of focus provides important information on characteristics of persons with diagnosed HIV that complement the information provided by the surveillance registry. MMP methods can be applied to other disease registries or population-monitoring systems when more detailed information is needed for a population, with the detailed information obtained efficiently from a representative sample of the population covered by the registry.

Key Points Question Could the amenability index be extended to account for differences in breast and colorectal cancer screening adherence among women residing in urban vs rural communities in the United States? Findings In a cross-sectional study of 2897 women from 11 US states, lower colorectal cancer screening adherence was found among rural-dwelling women compared with urban-dwelling women, but the prevalence of screening adherence for breast cancer was similar among women residing in urban and rural communities. Meaning Rural colorectal cancer screening disparities could be explained by slower diffusion of colorectal cancer screening and present significant preventable public health challenges, which could be attenuated through effective interventions to increase diffusion of screening modalities., This cross-sectional study compares the prevalence of breast and colorectal cancer screening adherence and identifies factors associated with screening adherence among women residing in rural vs urban areas., Importance Screening for breast and colorectal cancer has resulted in reductions in mortality; however, questions remain regarding how these interventions are being diffused to all segments of the population. If an intervention is less amenable to diffusion, it could be associated with disparities in mortality rates, especially in rural vs urban areas. Objectives To compare the prevalence of breast and colorectal cancer screening adherence and to identify factors associated with screening adherence among women residing in rural vs urban areas in the United States. Design, Setting, and Participants This population-based cross-sectional study of women aged 50 to 75 years in 11 states was conducted from 2017 to 2020. Main Outcomes and Measures Adherence to cancer screening based on the US Preventative Services Task Force guidelines. For breast cancer screening, women who had mammograms in the past 2 years were considered adherent. For colorectal cancer screening, women who had (1) a stool test in the past year, (2) a colonoscopy in the past 10 years, or (3) a sigmoidoscopy in the past 5 years were considered adherent. Rural status was coded using Rural Urban Continuum Codes, and other variables were assessed to identify factors associated with screening. Results The overall sample of 2897 women included 1090 (38.4%) rural residents; 2393 (83.5%) non-Hispanic White women; 263 (9.2%) non-Hispanic Black women; 68 (2.4%) Hispanic women; 1629 women (56.2%) aged 50 to 64 years; and 712 women (24.8%) with a high school education or less. Women residing in urban areas were significantly more likely to be adherent to colorectal cancer screening compared with women residing in rural areas (1429 [82%] vs 848 [78%]; P = .01), whereas the groups were equally likely to be adherent to breast cancer screening (1347 [81%] vs 830 [81%]; P = .78). Multivariable mixed-effects logistic regression analyses confirmed that rural residence was associated with lower odds of being adherent to colorectal cancer screening (odds ratio [OR], 0.81; 95% CI, 0.66-0.99, P = .047). Non-Hispanic Black race was associated with adherence to breast cancer screening guidelines (OR, 2.85; 95% CI, 1.78-4.56; P

The proportion of the U.S. population with Internet access has risen dramatically from one in five households (18%) in 1997 to nearly four out of five households (78.5%) in 2013. Consequently, the majority of market research and public opinion surveys are now conducted by Internet. Non-probability panels of volunteer respondents who agree to receive invitations to conduct surveys account for the largest share of online research. Despite the major role of non-probability online panels in surveys, we know little about the size and characteristics of their panelists. This paper investigates the potential coverage of Internet panels among American adults. Since online panels frequently partner with other panel organizations in order to generate samples that are larger or more diverse than their own panel, the population who participate in any online panels is more critical to evaluating potential coverage error and bias in this type of survey than the population of individual panels. The size and characteristics of the population of online panelists is estimated from a national dual frame random digit dialing survey conducted in spring 2015. We believe this is the first published estimate of the size of the total population engaged in online panels based upon a national probability survey. The total sample size for the survey was approximately 500, which is adequate to estimate that size of the population. We have also presented the characteristics of the online panelists in the sample since this is the first survey of that population. However, due to the small size of the subsample of online panelists, these findings should be treated as preliminary.

Obesity and lack of physical activity among children and adolescents are public health problems in the United States. This Presidential Youth Fitness Program (PYFP) evaluation measured program implementation in 13 middle schools and its effect on physical education practices, student fitness knowledge, and student physical activity and fitness levels. PYFP, a free program with the potential to positively affect student health and fitness outcomes, was designed to improve fitness education practices that are easily integrated into existing physical education programs. We used a 2-group (13 PYFP and 13 comparison schools) quasi-experimental design to collect FitnessGram assessments, accelerometry data, and surveys of students, physical education teachers, and administrators. Although the program was positively associated with student cardiovascular endurance and physical activity gains during the semester, schools underused professional development courses and fitness recognition resources.

Introduction It is important to quickly identify parent beliefs, intentions, and behaviors toward childhood vaccination, especially parents of children 19 to 35 months. This paper describes parental immunization beliefs, intentions, and behaviors; assesses the relationships between beliefs and intentions regarding child immunization and actual behaviors; and assesses whether beliefs, intentions, and/or behaviors varied across demographic subgroups. Methods A sample of parents, ages 18 and older, from a mobile panel with people residing in the U.S. were invited to answer immunization behavior, intention, and belief questions using a smartphone app that was not vaccine specific. 10,000 panel members with a child under 18 were sent invitations. 1029 surveys were completed by a respondent with a child 19 to 35 months. The survey instrument replicated many NIS questions and had similar sequencing. Findings Respondents reported that most children received all recommended vaccines, except flu vaccine, suggesting some may not understand the immunization schedule. Demographics closely associated with immunization behaviors were respondents’ education and household income. There is strong agreement that vaccines are effective, important to community health, and the child’s health. There is concern about the number of shots received, disease prevention, and ingredient safety. Some belief remains about vaccines causing learning disabilities. Positive beliefs about the benefits of childhood vaccines and concomitant risks vary with demographics. Conclusions This survey provided insights into beliefs and behaviors of parents regarding childhood vaccination. It found evidence of differences in beliefs, particularly related to delaying or declining recommended childhood vaccinations. The survey was conducted in a few days and at lower cost than traditional methods. This serves as a model for health agencies where rapid results or inexpensive approaches are needed.

Background Appalachians experience increased rates of cancer incidence and mortality compared to non-Appalachians. Many factors may contribute to the elevated cancer burden, including lack of knowledge and negative beliefs about the disease. Methods Three National Cancer Institute (NCI)-designated cancer centers with Appalachian counties in their respective population-based geographic service areas-Kentucky, Ohio, and Pennsylvania-surveyed their communities to better understand their health profiles, including 5 items assessing cancer beliefs. Weighted univariate and bivariate statistics were calculated for each of the 3 state's Appalachian population and for a combined Appalachian sample. Weighted multiple linear regression was used to identify factors associated with a cancer beliefs composite score. Data from the combined Appalachian sample were compared to NCI's Health Information National Trends Survey (HINTS). Results Data from 1,891 Appalachian respondents were included in the analysis (Kentucky = 798, Ohio = 112, Pennsylvania = 981). Significant differences were observed across the 3 Appalachian populations related to income, education, marital status, rurality, perceptions of present income, and body mass index (BMI). Four of 5 cancer beliefs were significantly different across the 3 states. Education, BMI, perceptions of financial security, and Kentucky residence were significantly associated with a lower composite score of cancer beliefs. When comparing the combined Appalachian population to HINTS, 3 of 5 cancer belief measures were significantly different. Conclusions Variations in cancer beliefs were observed across the 3 states' Appalachian populations. Interventions should be tailored to specific communities to improve cancer knowledge and beliefs and, ultimately, prevention and screening behaviors.

Background: Health surveys of the general US population are inadequate for monitoring human immunodeficiency virus (HIV) infection because the relatively low prevalence of the disease ( Objective: To collect a nationally and locally representative probability sample of HIV-infected adults receiving medical care to monitor clinical and behavioral outcomes, supplementing the data in the National HIV Surveillance System. This paper describes the sample design and weighting methods for the Medical Monitoring Project (MMP) and provides estimates of the size and characteristics of this population. Methods: To develop a method for obtaining valid, representative estimates of the in-care population, we implemented a cross-sectional, three-stage design that sampled 23 jurisdictions, then 691 facilities, then 9,344 HIV patients receiving medical care, using probability-proportional-to-size methods. The data weighting process followed standard methods, accounting for the probabilities of selection at each stage and adjusting for nonresponse and multiplicity. Nonresponse adjustments accounted for differing response at both facility and patient levels. Multiplicity adjustments accounted for visits to more than one HIV care facility. Results: MMP used a multistage stratified probability sampling design that was approximately self-weighting in each of the 23 project areas and nationally. The probability sample represents the estimated 421,186 HIV-infected adults receiving medical care during January through April 2009. Methods were efficient (i.e., induced small, unequal weighting effects and small standard errors for a range of weighted estimates). Conclusion: The information collected through MMP allows monitoring trends in clinical and behavioral outcomes and informs resource allocation for treatment and prevention activities.

A global priority for the behavioural sciences is to develop cost-effective, scalable interventions that could improve the academic outcomes of adolescents at a population level, but no such interventions have so far been evaluated in a population-generalizable sample. Here we show that a short (less than one hour), online growth mindset intervention-which teaches that intellectual abilities can be developed-improved grades among lower-achieving students and increased overall enrolment to advanced mathematics courses in a nationally representative sample of students in secondary education in the United States. Notably, the study identified school contexts that sustained the effects of the growth mindset intervention: the intervention changed grades when peer norms aligned with the messages of the intervention. Confidence in the conclusions of this study comes from independent data collection and processing, pre-registration of analyses, and corroboration of results by a blinded Bayesian analysis.

Large-scale health surveys are major data sources for health policy research, and telephone survey is the major mode for national or state health surveys. With the dramatic increase of cell phone use over the past decade, large telephone surveys need to employ the dual-frame design, which greatly improves the representativeness of the sample. From a practical perspective, it is not clear how to optimally implement the dual-frame sampling design. This article studies the impact of different design and analytical strategies of dual-frame surveys on the estimation of population quantities via both simulation studies and using data from the Ohio Family Health Survey (OFHS). Results imply that cell-only design is less biased than the cell-any design with no or poor post-stratification. If accurate post-stratification information is available for different phone use patterns, all estimation techniques provide similar results and the cell-any supplemental sampling is more cost efficient. Practical recommendations for health policy researchers are provided based on applying different analytical methods to the OFHS data.

Background Gaps in the understanding of how different types of violent behavior are linked have limited the ability to design violence prevention efforts that can address multiple types of violence. The objective of this study was to quantify the associations among suicide attempts, and date and peer violence victimization and perpetration and to determine any differences in these associations by gender. Methods Analyses, computed in 2006 and 2007, used data from the Youth Violence Survey conducted in 2004. This survey was administered to over 80% of public school students in grades 7, 9, 11, and 12 (N=4131) in a high-risk, urban school district. Analyses were restricted to adolescents who dated in the past year ( n =2888). Five forms of violent behaviors (i.e., dating violence perpetration, dating violence victimization, peer violence perpetration, peer violence victimization, and suicide attempts) were examined. Results Peer violence victimization was the most common type of violence reported (33.0%), followed by date violence victimization (30.7%), peer violence perpetration (29.9%), date violence perpetration (24.8%), and suicide attempts (11.2%). Among all students, 9.8% reported involvement in at least four of the five violent behaviors examined. All five forms of violent behaviors were associated. The highest ORs were observed for victimization and perpetration within either the dating or peer context. However, associations across contexts were also observed. Conclusions There is a substantial overlap among different forms of violent behavior, suggesting that additional research is needed to better understand the factors that contribute to involvement in multiple forms of violence.

School connectedness includes liking school and positive relations with teachers and peers. School connectedness is associated with a variety of positive health outcomes. The goal of this study was to identify characteristics of students, schools, and school neighborhoods that are related to school connectedness. In the Health Behavior in School-Aged Children (HBSC) Study, school connectedness was reported by 13,207 students (grades 6-10) in 340 schools. HBSC measured a variety of student characteristics. Characteristics of schools were culled from data maintained by Quality Education Data, and school neighborhood characteristics were derived from the 2000 decennial census. Associations between connectedness and student, school, and school neighborhood characteristics were estimated using hierarchical linear models. Characteristics of students, schools, and school neighborhoods were associated with school connectedness. Connectedness was greater among younger students, females, students with better academic performance and greater extracurricular involvement, students with greater self-rated physical attractiveness, students with more friends, students from 2-parent families, and students whose parents were more involved with school. Connectedness was greater in smaller schools, more racially homogeneous schools, and schools with more students from relatively wealthy households. School connectedness was higher in neighborhoods with a greater percentage of non-US citizens. As the percent of renters in the neighborhood increased beyond 20%, school connectedness tended to decrease. The findings point to possible strategies for fostering school connectedness.

Young children, because of their immaturity and their rapid development compared to adults, are considered to be more susceptible to the health effects of environmental pollutants. They are also more likely to be exposed to these pollutants, because of their continual exploration of their environments with all their senses. Although there has been increased emphasis in recent years on exposure research aimed at this specific susceptible population, there are still large gaps in the available data, especially in the area of chronic, low-level exposures of children in their home and school environments. A research program on preschool children's exposures was established in 1996 at the USEPA National Exposure Research Laboratory. The emphasis of this program is on children's aggregate exposures to common contaminants in their everyday environments, from multiple media, through all routes of exposure. The current research project, "Children's Total Exposure to Persistent Pesticides and Other Persistent Organic Pollutants," (CTEPP), is a pilot-scale study of the exposures of 257 children, ages 1(1/2)-5 years, and their primary adult caregivers to contaminants in their everyday surroundings. The contaminants of interest include several pesticides, phenols, polychlorinated biphenyls, polycyclic aromatic hydrocarbons, and phthalate esters. Field recruitment and data collection began in February 2000 in North Carolina and were completed in November 2001 in Ohio. This paper describes the design strategy, survey sampling, recruiting, and field methods for the CTEPP study.

This article extends an index introduced in Iachan (1984) to measure agreement or congruence between a pair of three-letter codes. Three-letter codes are used in Holland's vocational theory to characterize occupations, work environments, job preferences, college majors, personality types, etc. The congruence index is extended to cover two situations: (a) when ties occur in the three-letter codes and (b) when only two top letters are recorded and/or used. This article suggests methodologies for breaking ties and for measuring agreement between two-letter codes. In addition, a computer algorithm for computing the index is included in an appendix.

Background Posttraumatic stress disorder (PTSD) has been studied largely among adults and in the context of intentional, collective experiences such as war and terrorism. Far less is known about PTSD among adolescents and resulting from massive industrial accidents. Such an accident in Toulouse, France, 10 days after the World Trade Center disaster, provided an opportunity to examine its effects among adolescents already sensitized by media coverage of the World Trade Center disaster. Objectives (1) To assess the presence of symptoms consistent with PTSD (SCW-PTSD) among adolescents in Toulouse after a massive industrial accident, (2) to determine the “excess” of SCW-PTSD among those directly exposed vs those nondirectly exposed, and (3) to examine dosage effects for exposure and the cumulative effect on PTSD of accident-related experiences. Design, Setting, and Participants A survey containing questions on exposure and SCW-PTSD was administered to students aged 11 years, 13 years, 15 years, and 17 years who were enrolled in randomly selected, grade-stratified classrooms from schools for directly exposed students (n = 577) in Toulouse and nondirectly exposed students (n = 900) in the region. Main Outcome Measure The prevalence of SCW-PTSD among directly exposed and nondirectly exposed students. Results Nine months after the industrial accident, 44.6% of 11- and 13-year-old directly exposed students and 28.5% of 15- and 17-year-old directly exposed students still showed SCW-PTSD, compared with 22.1% of 11- and 13-year-old nondirectly exposed students and 4.4% of 15-year-old nondirectly exposed students. Among 11- and 13-year-olds, the likelihood of having SCW-PTSD was higher for girls who were enrolled in elementary schools, were personally injured, and had severe damage at home, as opposed to boys who were high-school students without severe damage at home or personal injury. Among the 15- and 17-year-olds, being a girl, 17 years old, and personally injured increased the likelihood of having SCW-PTSD, as opposed to 15-year-old boys who were not injured. The effects of injuries were cumulative: students injured personally and with an injured family member were more likely to have SCW-PTSD than those experiencing either personal or family injury but not both. Excess of SCW-PTSD attributable to direct exposure was 50.5% for 11-year-olds, 49.3% for 13-year-olds, and 73.5% for 15-year-olds. Conclusions A substantial proportion of Toulouse adolescents still had SCW-PTSD 9 months after the accident. Directly exposed students were far more likely to show SCW-PTSD than those nondirectly exposed, but both groups had SCW-PTSD at rates that were higher than expected. The symptoms were associated with demographic characteristics and direct experiences of trauma. Higher rates applied to students who were personally injured with injured family members and severe damage at home. Students with these characteristics predictive of SCW-PTSD should be given prompt attention to avoid long-lasting effects.

Background: Violent behavior among adolescents is a significant problem worldwide, and a cross-national comparison of adolescent violent behaviors can provide information about the development and pattern of physical violence in young adolescents. Objectives: To determine and compare frequencies of adolescent violence-related behaviors in 5 countries and to examine associations between violence-related behaviors and potential explanatory characteristics. Design, Setting, and Participants: Cross-sectional, school-based nationally representative survey at ages 11.5, 13.5, and 15.5 years in 5 countries (Ireland, Israel, Portugal, Sweden, and the United States). Main Outcome Measures: Frequency of physical fighting, bullying, weapon carrying, and fighting injuries in relation to other risk behaviors and characteristics in home and school settings. Results: Fighting frequency among US youth was similar to that of all 5 countries (nonfighters: US, 60.2%; mean frequency of 5 countries, 60.2%), as were the frequencies of weapon carrying (noncarriers: US, 89.6%; mean frequency of 5 countries, 89.6%) and fighting injury (noninjured: US, 84.5%; mean frequency of 5 countries, 84.6%). Bullying frequency varied widely cross-nationally (nonbullies: from 57.0% for Israel to 85.2% for Sweden). Fighting was most highly associated with smoking, drinking, feeling irritable or bad tempered, and having been bullied. Conclusions: Adolescents in 5 countries behaved similarly in their expression of violence-related behaviors. Occasional fighting and bullying were common, whereas frequent fighting, frequent bullying, any weapon carrying, or any fighting injury were infrequent behaviors. These findings were consistent across countries, with little cross-national variation except for bullying rates. Traditional risk-taking behaviors (smoking and drinking) and being bullied were highly associated with the expression of violence-related behavior.

Objective This study reports the prevalence and comorbidity of depression in two large samples of black and white young adult women. Method Clinical interviews of participants in a follow-up study of the National Heart, Lung, and Blood Institute Growth and Health Study (NGHS-Wave II; N = 378) were contrasted with a subsample of the National Comorbidity Survey (NCS; N = 3749) to examine the rates and comorbidity of lifetime major depressive disorder in black and white women using methodology described by Kraemer (1995). The sequencing of disorders was also examined to determine which disorder was primary. Comorbidity and sequencing were examined for alcohol and drug use disorder, panic disorder, specific phobia, social phobia, and post-traumatic stress disorder. Results Prevalence estimates for depression, alcohol use disorder, and drug use disorder were higher for white women than for black women in both NGHS-Wave II and NCS. Over half of depressed participants in both samples had at least one comorbid disorder and depression was associated with an increased probability of all the investigated disorders. Only one ethnic difference was found in comorbidity, indicating that black women were more likely to have comorbid panic disorder than white women were. Depression was primary to alcohol and substance use disorders, whereas it was secondary to specific phobia and PTSD. Conclusions High rates of comorbiclity were found for both black and white women, though few ethnic differences in comorbidity were found. Preventive and treatment interventions are needed to address multiple disorders in young adult women. (c) 2004 Elsevier Ltd. All rights reserved.

To determine the prevalence, risk factors, and risk behaviors associated with depressive symptoms in a nationally representative, cross-sectional sample of young adolescents.A school-based survey collected through self-administered questionnaires in grades 6, 8, and 10 in 1996.Schools in the United States.9863 students in grades 6, 8, and 10 (average ages, 11, 13, and 15).Depressive symptoms, substance use, somatic symptoms, scholastic behaviors, and involvement in bullying.Eighteen percent of youths reported symptoms of depression. A higher proportion of females (25%) reported depressive symptoms than males (10%). Prevalence of depressive symptoms increased by age for both males and females. Among American Indian youths, 29% reported depressive symptoms, as compared with 22% of Hispanic, 18% of white, 17% of Asian American, and 15% of African American youths. Youths who were frequently involved in bullying, either as perpetrators or as victims, were more than twice as likely to report depressive symptoms than those who were not involved in bullying. A significantly higher percentage of youths who reported using substances reported depressive symptoms as compared with other youths. Similarly, youths who reported experiencing somatic symptoms also reported significantly higher proportions of depressive symptoms than other youths.Depression is a substantial and largely unrecognized problem among young adolescents that warrants an increased need and opportunity for identification and intervention at the middle school level. Understanding differences in prevalence between males and females and among racial/ethnic groups may be important to the recognition and treatment of depression among youths.

ContextTobacco products continue to be widely accessible to minors. Between 1997 and 1999, the US Food and Drug Administration (FDA) conducted more than 150,000 tobacco sales age-restriction compliance checks. Data obtained from these checks provide important guidance for curbing illegal sales.ObjectiveTo determine which elements of the compliance checks were most highly associated with illegal sales and thereby inform best practices for conducting efficient compliance check programs.Design and SettingCross-sectional analysis of FDA compliance checks in 110,062 unique establishments in 36 US states and the District of Columbia.Main Outcome MeasureIllegal sales of tobacco to minors at compliance checks; association of illegal sales with variables such as age and sex of the minor.ResultsThe rate of illegal sales for all first compliance checks in unique stores was 26.6%. Clerk failure to request proof of age was strongly associated with illegal sales (uncorrected sales rate, 10.5% compared with 89.5% sales when proof was not requested; multivariate-adjusted odds ratio [OR], 0.03; 95% confidence interval [CI], 0.03-0.04). Other factors associated with increased illegal sales were employment of older minors to make the purchase attempt (adjusted ORs for 16- and 17-year-old minors compared with 15-year-olds were 1.52 [95% CI, 1.46-1.63] and 2.43 [95% CI, 2.31-2.59], respectively), attempt to purchase smokeless tobacco (adjusted OR, 2.16 [95% CI, 1.90-2.45] vs cigarette purchase attempts), and performing checks at or after 5 PM (adjusted OR, 1.28 [95% CI, 1.21-1.35] vs before 5 PM). Female sex of clerk and minor, Saturday checks, type of store (convenience store selling gas, gas station, drugstore, supermarket and general merchandise), and rural store locations also were associated with increased illegal sales.ConclusionsThis analysis found that a request for age verification strongly predicted compliance with the law. The results suggest several ways in which the process of compliance checks might be optimized.

Response errors have become extremely important in increasingly complex surveys and a review of the ever expanding literature on the subject was judged necessary. The emphasis here is on models for response and nonresponse errors the most recent ones incorporating the concept of response probabilities.

A measure of agreement for partially ordered data is suggested that makes use of the k categories with the highest ranks, the ranks of the remaining categories being disregarded. The proposed measure is applied to the Self-Directed Search in order to evaluate its agreement with occupational preference. Other forms of agreement in the Holland classification system can also be assessed by the proposed measure. Examples are congruence and husband-wife and counselor-client agreement.

Measures of agreement for ordinal scaled data are suggested that make use of the k categories with the highest ranks. The proposed measures are applied to the Self-Directed Search in order to evaluate its agreement with self-assessment (translation ability) or with the work environment (congruence).