Objective To examine the prevalence of lack of health insurance and its changes over time among adult residents (aged 18–64 years) in 50 states and the District of Columbia (DC). Study design Cross-sectional surveys. Methods We aggregated annual state-based Behavioral Risk Factor Surveillance System (BRFSS) data from 1993 through 2014 to provide nationwide and state-based prevalence estimates for lack of insurance among adults aged 18–64 years. The adjusted prevalence was estimated using log-linear regression analyses with a robust variance estimator after controlling for demographic variables. The trend was assessed separately for the periods 1993–2010 and 2011–2014 due to methodologic changes in the BRFSS. Results From 1993 through 2010, the adjusted prevalence of lack of health insurance increased by 0.54% (P < 0.0001) annually (range: 16.3% in 1995 to 19.1% in 2005); this prevalence decreased significantly in 2014 (15.1%). In 2014, Georgia, Mississippi, and Texas had the highest adjusted prevalences (range: 23.0–24.6%) of lack of health insurance, and DC, Massachusetts, and Rhode Island had the lowest (range: 6.2–10.1%). The changes in the prevalence of lack of insurance over time varied significantly by state. Conclusions The nationwide prevalence of lack of health insurance decreased significantly in the past few years, especially in 2014 when about one-seventh of Americans aged 18–64 years reported lack of health insurance coverage. The huge variations in the prevalence of lack of health insurance and its changes over time among states suggest continuing efforts to ensure healthcare access for all Americans are needed to improve the overall health of the population.

INTRODUCTION: The objective of this study was to estimate the prevalence of lack of health insurance among adults aged 18 to 64 years for each state and the United States and to describe populations without insurance. METHODS: We used 2013 Behavioral Risk Factor Surveillance System data to categorize states into 3 groups on the basis of the prevalence of lack of health insurance in each state compared with the national average (21.5%; 95% confidence interval, 21.1%-21.8%): high-insured states (states with an estimated prevalence of lack of health insurance below the national average), average-insured states (states with an estimated prevalence of lack of health insurance equivalent to the national average), and low-insured states (states with an estimated prevalence of lack of health insurance higher than the national average). We used bivariate analyses to compare the sociodemographic characteristics of these 3 groups after age adjustment to the 2000 US standard population. We examined the distribution of Medicaid expansion among the 3 groups. RESULTS: Compared with the national age-adjusted prevalence of lack of health insurance, 24 states had lower rates of uninsured residents, 12 states had equivalent rates of uninsured, and 15 states had higher rates of uninsured. Compared with adults in the high-insured and average-insured state groups, adults in the low-insured state group were more likely to be non-Hispanic black or Hispanic, to have less than a high school education, to be previously married (divorced, widowed, or separated), and to have an annual household income at or below $35,000. Seventy-one percent of high-insured states were expanding Medicaid eligibility compared with 67% of average-insured states and 40% of low-insured states. CONCLUSION: Large variations exist among states in the estimated prevalence of health insurance. Many uninsured Americans reside in states that have opted out of Medicaid expansion.

BACKGROUND: Investigation into personal health has become focused on conditions at an increasingly local level, while response rates have declined and complicated the process of collecting data at an individual level. Simultaneously, social media data have exploded in availability and have been shown to correlate with the prevalence of certain health conditions. OBJECTIVE: Facebook likes may be a source of digital data that can complement traditional public health surveillance systems and provide data at a local level. We explored the use of Facebook likes as potential predictors of health outcomes and their behavioral determinants. METHODS: We performed principal components and regression analyses to examine the predictive qualities of Facebook likes with regard to mortality, diseases, and lifestyle behaviors in 214 counties across the United States and 61 of 67 counties in Florida. These results were compared with those obtainable from a demographic model. Health data were obtained from both the 2010 and 2011 Behavioral Risk Factor Surveillance System (BRFSS) and mortality data were obtained from the National Vital Statistics System. RESULTS: Facebook likes added significant value in predicting most examined health outcomes and behaviors even when controlling for age, race, and socioeconomic status, with model fit improvements (adjusted R(2)) of an average of 58% across models for 13 different health-related metrics over basic sociodemographic models. Small area data were not available in sufficient abundance to test the accuracy of the model in estimating health conditions in less populated markets, but initial analysis using data from Florida showed a strong model fit for obesity data (adjusted R(2)=.77). CONCLUSIONS: Facebook likes provide estimates for examined health outcomes and health behaviors that are comparable to those obtained from the BRFSS. Online sources may provide more reliable, timely, and cost-effective county-level data than that obtainable from traditional public health surveillance systems as well as serve as an adjunct to those systems.

Correction Notice: An Erratum for this article was reported in Vol 5(2) of Psychology of Violence (see record 2015-04307-001). Data in Table 2 were incorrectly reported in the "Obtain needed support" column for the country-level predictors unemployment rate and median income. No corrections to the text were needed. The correct data are presented in the erratum.] Objective: This study determined whether county-level social determinants of health and adverse childhood experiences (ACE) were associated with emotional support and health-related quality of life (HRQOL) in adulthood. This study represents the largest population-based investigation on ACE to include county-level indicators of the social ecology. Method: We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) survey (29,212 adults from 5 states) and the American Community Survey (2010; 304 counties). Multilevel structural equation models were employed to test direct and indirect associations between county-level social determinants of health, ACEs and indicators of adult HRQOL. Results: At the individual level, ACEs were associated with lower emotional support, and lower emotional support was associated with worse physical and mental HRQOL. Parental divorce was associated with better mental HRQOL for individuals who reported =2 forms of childhood maltreatment and/or negative household environments during childhood. At the county-level, low median income and high county-level unemployment were associated with low emotional support, and high median income and high unemployment were directly associated with poor physical and mental HRQOL. Conclusion: Findings from this study suggest that intervention efforts designed to promote positive emotional supports for adults who have experienced ACEs, particularly for those living in disadvantaged counties, may ameliorate potential health consequences during adulthood.

The aim of this study is to examine psychological distress and its individual symptoms between adults with and without disabilities, and among adults with disabilities, to examine whether an association exists between severity of distress and health-related factors. Cross-sectional data from the 2007 Behavioral Risk Factor Surveillance System were used for this study. Severity of psychological distress was assessed using the Kessler 6 scale of nonspecific psychological distress. Logistic regression analyses were performed to estimate predicted marginals and prevalence ratios. Nine percent of adults had mild to moderate psychological distress and 3.9% had serious psychological distress. The adjusted mean Kessler 6 total scores and individual item scores were higher for adults with disabilities, as was the average number of days that a mental health condition interfered with activities in the past 30 days. Among adults with disabilities, mild to moderate and serious psychological distress were particularly high among those who were unemployed or unable to work. Those who had either mild to moderate or serious psychological distress were significantly more likely than those with no psychological distress to be physically inactive, to smoke, and to report fair or poor health, life dissatisfaction, and inadequate social support. A dose-response relationship exists between categorical severity of psychological distress and examined health-related factors. These findings may inform the design of targeted public health strategies that aim to eliminate health disparities between people with and without disabilities.

BACKGROUND: Adverse childhood experiences (ACEs), including child abuse and family dysfunction, are linked to leading causes of adult morbidity and mortality. Most prior ACE studies were based on a nonrepresentative patient sample from one Southern California HMO. PURPOSE: To determine if ACE exposure increases the risk of chronic disease and disability using a larger, more representative sample of adults than prior studies. METHODS: Ten states and the District of Columbia included an optional ACE module in the 2010 Behavioral Risk Factor Surveillance Survey, a national cross-sectional, random-digit-dial telephone survey of adults. Analysis was conducted in November 2012. Respondents were asked about nine ACEs, including physical, sexual, and emotional abuse and household member mental illness, alcoholism, drug abuse, imprisonment, divorce, and intimate partner violence. An ACE score was calculated for each subject by summing the endorsed ACE items. After controlling for sociodemographic variables, weighted AORs were calculated for self-reported health conditions given exposure to zero, one to three, four to six, or seven to nine ACEs. RESULTS: Compared to those who reported no ACE exposure, the adjusted odds of reporting myocardial infarction, asthma, fair/poor health, frequent mental distress, and disability were higher for those reporting one to three, four to six, or seven to nine ACEs. Odds of reporting coronary heart disease and stroke were higher for those who reported four to six and seven to nine ACEs; odds of diabetes were higher for those reporting one to three and four to six ACEs. CONCLUSIONS: These findings underscore the importance of child maltreatment prevention as a means to mitigate adult morbidity and mortality.

OBJECTIVE: The purpose of the current investigation is to assess and validate the factor structure of the Behavioral Risk Factor Surveillance System's (BRFSS) Adverse Childhood Experience (ACE) module. METHOD: ACE data available from the 2009 BRFSS survey were fit using exploratory factor analysis (EFA) to estimate an initial factorial structure. The exploratory solution was then validated using confirmatory factor analysis (CFA) with data from the 2010 BRFSS survey. Lastly, ACE factors were tested for measurement invariance using multiple group factor analysis. RESULTS: EFA results suggested that a 3-factor solution adequately fit the data. Examination of factor loadings and item content suggested the factors represented the following construct areas: Household Dysfunction, Emotional/Physical Abuse, and Sexual Abuse. Subsequent CFA results confirmed the 3-factor solution and provided preliminary support for estimation of an overall latent ACE score summarizing the responses to all available items. Measurement invariance was supported across both gender and age. CONCLUSIONS: Results of this study provides support for the use of the current ACE module scoring algorithm, which uses the sum of the number of items endorsed to estimate exposure. However, the results also suggest potential benefits to estimating 3 separate composite scores to estimate the specific effects of exposure to Household Dysfunction, Emotional/Physical Abuse, and Sexual Abuse.

PURPOSE: Among adults with disabilities, we examined whether increasing levels of psychological distress were associated with higher estimated prevalences of chronic conditions, obesity, health care access, and use of preventive services. METHODS: We analyzed data from the 2007 Behavioral Risk Factor Surveillance System. The Kessler-6 scale was used to assess psychological distress. RESULTS: Increasing levels of psychological distress were associated with an increased prevalence of chronic diseases and conditions, and decreased access to health care and utilization of preventive services in keeping with what has been established for non-disabled populations. Among adults with disabilities, aged 18-64 years and 65 years or older, increasing levels of distress were also associated with increased receipt of mental health treatment. However, compared to adults aged 18-64 years, larger proportions of older adults reported non-receipt of mental health treatment (mild to moderate psychological distress: 58.0% versus 70.6%; serious psychological distress: 40.5% versus 54.5%). CONCLUSIONS: While adults with disabilities who had increased levels of psychological distress were more likely to receive mental health services, they also had higher estimated prevalences of chronic conditions, barriers to health care, and non-receipt of preventive cancer screenings.

BACKGROUND: Expansion of health insurance coverage, and hence clinical preventive services (CPS), provides an opportunity for improvements in the health of adults. The degree to which expansion of health insurance coverage affects the use of CPS is unknown. OBJECTIVE: To assess whether Massachusetts health reform was associated with changes in healthcare access and use of CPS. DESIGN: We used a difference-in-differences framework to examine change in healthcare access and use of CPS among working-aged adults pre-reform (2002-2005) and post-reform (2007-2010) in Massachusetts compared with change in other New England states (ONES). SETTING: Population-based, cross-sectional Behavioral Risk Factor Surveillance System surveys. PARTICIPANTS: A total of 208,831 survey participants aged 18 to 64 years. INTERVENTION: Massachusetts health reform enacted in 2006. MEASUREMENTS: Four healthcare access measures outcomes and five CPS. KEY RESULTS: The proportions of adults who had health insurance coverage, a healthcare provider, no cost barrier to healthcare, an annual routine checkup, and a colorectal cancer screening increased significantly more in Massachusetts than those in the ONES. In Massachusetts, the prevalence of cervical cancer screening in pre-reform and post-reform periods was about the same; however, the ONES had a decrease of -1.6 percentage points (95 % confidence interval [CI] -2.5, -0.7; p <0.001). As a result, the prevalence of cervical cancer screening in Massachusetts was increased relative to the ONES (1.7, 95 % CI 0.2, 3.2; p = 0.02). Cholesterol screening, influenza immunization, and breast cancer screening did not improve more in Massachusetts than in the ONES. LIMITATIONS: Data are self-reported. CONCLUSIONS: Health reform may increase healthcare access and improve use of CPS. However, the effects of health reform on CPS use may vary by type of service and by state.

OBJECTIVES: We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health. METHODS: We used 2003-2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform. RESULTS: The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states-from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs. CONCLUSIONS: On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need. (Am J Public Health. Published online ahead of print April 18, 2013: e1-e8. doi:10.2105/AJPH.2012.300997).

Obesity is associated with increased risks for mental disorders. This study examined associations of obesity indicators including body mass index (BMI), waist circumference, and waist-height ratio with suicidal ideation among U.S. women. We analyzed data from 3,732 nonpregnant women aged ≥20 years who participated in the 2005-2008 National Health and Nutrition Examination Survey. We used anthropometric measures of weight, height, and waist circumference to calculate BMI and waist-height ratio. Suicidal ideation was assessed using the Item 9 of the Patient Health Questionnaire-9. Odds ratios with 95% conference intervals were estimated using logistic regression analyses after controlling for potential confounders. The age-adjusted prevalence of suicidal ideation was 3.0%; the prevalence increased linearly across quartiles of BMI, waist circumference, and waist-height ratio (P for linear trend <0.01 for all). The positive associations of waist circumference and waist-height ratio with suicidal ideation remained significant (P < 0.05) after adjustment for sociodemographics, lifestyle-related behavioral factors, and having either chronic conditions or current depression. However, these associations were attenuated after both chronic conditions and depression were entered into the models. Thus, the previously reported association between obesity and suicidal ideation appears to be confounded by coexistence of chronic conditions and current depression among women of the United States.

OBJECTIVE: To investigate whether level of positive mental health complements mental illness in predicting students at risk for suicidal behavior and impaired academic performance. PARTICPANTS: A sample of 5,689 college students participated in the 2007 Healthy Minds Study and completed an Internet survey that included the Mental Health Continuum-Short Form and the Patient Health Questionnaire screening scales for depression and anxiety disorders, questions about suicide ideation, plans, and attempts, and academic impairment. RESULTS: Just under half (49.3%) of students were flourishing and did not screen positive for a mental disorder. Among students who did, and those who did not, screen for a mental disorder, suicidal behavior and impaired academic performance were lowest in those with flourishing, higher among those with moderate, and highest in those with languishing mental health. CONCLUSIONS: Positive mental health complements mental disorder screening in mental health surveillance and prediction of suicidal behavior and impairment of academic performance.

Mental illnesses account for a larger proportion of disability in developed countries than any other group of illnesses, including cancer and heart disease. In 2004, an estimated 25% of adults in the United States reported having a mental illness in the previous year. The economic cost of mental illness in the United States is substantial, approximately $300 billion in 2002. Population surveys and surveys of health-care use measure the occurrence of mental illness, associated risk behaviors (e.g., alcohol and drug abuse) and chronic conditions, and use of mental health-related care and clinical services. Population-based surveys and surveillance systems provide much of the evidence needed to guide effective mental health promotion, mental illness prevention, and treatment programs. This report summarizes data from selected CDC surveillance systems that measure the prevalence and impact of mental illness in the U.S. adult population. CDC surveillance systems provide several types of mental health information: estimates of the prevalence of diagnosed mental illness from self-report or recorded diagnosis, estimates of the prevalence of symptoms associated with mental illness, and estimates of the impact of mental illness on health and well-being. Data from the CDC 2005-2008 National Health and Nutrition Examination Survey indicate that 6.8% of adults had moderate to severe depression in the 2 weeks before completing the survey. State-specific data from the CDC 2006 Behavioral Risk Factor Surveillance System (BRFSS), the most recent BRFSS data available, indicate that the prevalence of moderate to severe depression was generally higher in southeastern states compared with other states. Two other CDC surveys on ambulatory care services, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, indicate that during 2007-2008, approximately 5% of ambulatory care visits involved patients with a diagnosis of a mental health disorder, and most of these were classified as depression, psychoses, or anxiety disorders. Future surveillance should pay particular attention to changes in the prevalence of depression both nationwide and at the state and county levels. In addition, national and state-level mental illness surveillance should measure a wider range of psychiatric conditions and should include anxiety disorders. Many mental illnesses can be managed successfully, and increasing access to and use of mental health treatment services could substantially reduce the associated morbidity.

OBJECTIVE: The purpose of this study is to examine the associations among depression, anxiety, use of oral health services, and tooth loss. MEYHODS: Data were analysed for 80 486 noninstitutionalized adults in 16 states who participated in the 2008 Behavioral Risk Factor Surveillance System. Binomial and multinomial logistic regression analyses were used to estimate predicted marginals, adjusted prevalence ratios, adjusted odds ratios (AOR) and their 95% confidence intervals (CI). RESULTS: The unadjusted prevalence for use of oral health services in the past year was 73.1% [standard error (SE), 0.3%]. The unadjusted prevalence by level of tooth loss was 56.1% (SE, 0.4%) for no tooth loss, 29.6% (SE, 0.3%) for 1-5 missing teeth, 9.7% (SE, 0.2%) for 6-31 missing teeth and 4.6% (SE, 0.1%) for total tooth loss. Adults with current depression had a significantly higher prevalence of nonuse of oral health services in the past year than those without this disorder (P < 0.001), after adjustment for age, sex, race/ethnicity, education, marital status, employment status, adverse health behaviours, chronic conditions, body mass index, assistive technology use and perceived social support. In logistic regression analyses employing tooth loss as a dichotomous outcome (0 versus ≥1) and as a nominal outcome (0 versus 1-5, 6-31, or all), adults with depression and anxiety were more likely to have tooth loss. Adults with current depression, lifetime diagnosed depression and lifetime diagnosed anxiety were significantly more likely to have had at least one tooth removed than those without each of these disorders (P < 0.001 for all), after fully adjusting for evaluated confounders (including use of oral health services). The adjusted odds of being in the 1-5 teeth removed, 6-31 teeth removed, or all teeth removed categories versus 0 teeth removed category were increased for adults with current depression versus those without (AOR = 1.35; 95% CI = 1.14-1.59; AOR = 1.83; 95% CI = 1.51-2.22; and AOR = 1.44; 95% CI = 1.11-1.86, respectively). The adjusted odds of being in the 1-5 teeth removed and 6-31 teeth removed categories versus 0 teeth removed category were also increased for adults with lifetime diagnosed depression or anxiety versus those without each of these disorders. CONCLUSIONS: Use of oral health services and tooth loss was associated with depression and anxiety after controlling for multiple confounders.

OBJECTIVE: Although effective mental health treatments exist, few population data are available on treatment receipt by persons with psychological distress. This study aimed to understand the association between symptoms and treatment receipt with data from the U.S Behavioral Risk Factor Surveillance System (BRFSS) survey. METHODS: In the 2007 survey, psychological distress was assessed with the Kessler-6 scale, and respondents were asked about receipt of mental health treatment. Data from 197,914 respondents were analyzed. RESULTS: In the overall population 87.5% of respondents reported no psychological distress, 8.5% mild to moderate psychological distress, and 3.9% serious psychological distress. Those with serious distress were nearly ten times as likely to receive treatment (adjusted odds ratio=9.58, 95% confidence interval=8.53-10.75) as those with no distress. One in ten persons (10.7%) in the study population reported receiving treatment. CONCLUSIONS: Distinct U.S. subpopulations exist by treatment and symptom status. Better understanding of all these groups is essential for improving population-based mental health care. (Psychiatric Services 62:396-403, 2011).

The World Health Organization (WHO) defines mental health as “not just the absence of mental disorder” but “as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”1(p2) Mental illness, on the other hand, is the “term that refers collectively to all diagnosable mental disorders” that are “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.”2(p5) | Further, WHO has long defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease, or infirmity.”3(p100) Given these definitions, it should be clear that there is no health without mental health.

OBJECTIVE: This study examined the prevalence and correlates of use of health professional services for the treatment of mental or emotional problems by using Andersen's Behavioral Model of Health Services Use. METHODS: In the 2007 Behavioral Risk Factor Surveillance System 169,546 community-dwelling respondents from 35 states, the District of Columbia, and Puerto Rico answered questions about their sociodemographic characteristics; perceived need; nonspecific psychological distress, as measured with the Kessler-6 scale; and use of professional treatment of mental or emotional problems. RESULTS: Evaluated need (psychological distress) was significantly associated with receipt of treatment for mental or emotional problems, as were predisposing factors (age, gender, race or ethnicity, marital status, and education), enabling and impeding factors (income, health insurance, and emotional support), and perceived need (number of mentally and physically unhealthy days and self-rated health). CONCLUSION: Constituents in the public mental health system should seriously consider that health services utilization is socially patterned and not just an individual behavior.

OBJECTIVES: To examine self-reported psychological distress (K-6 scale) and mental health treatment among persons with and without active duty U.S. military experience (ADME) currently residing in private residences in the U.S. METHODS: Analysis of 2007 Behavioral Risk Factor Surveillance System data from 35 states, District of Columbia, and Puerto Rico (n = 202,029 for those answering all K-6 questions, the treatment question, and the ADME question) RESULTS: Adjusting for age, sex, race/ethnicity, and education, overall mean K-6 scores of those with and without ADME were similar (p = 0.3223); however, more of those with, vs. without, ADME reported current mental health treatment (11.7 % vs. 9.6 %, p = 0.0001). Those with ADME receiving such treatment had a higher mean K-6 score (7.7) than those without ADME receiving such treatment (6.9) (p = 0.0032). CONCLUSIONS: Community-dwelling persons with ADME have similar demographically-adjusted mean K-6 psychological distress scores, but greater likelihood of recent mental health treatment, compared to those without ADME.

OBJECTIVE: To determine rates of access to and use of health services among adults with Serious Psychological Distress (SPD). METHODS: Adults > or = 18 years in the 2007 BRFSS were stratified based on the presence of SPD, assessed by scores > or = 13 using the Kessler-6 tool (N = 199,209). Access to and use of general and mental health services were compared for those with scores < 13 and those > or = 13 using Chi-square analyses and logistic regression models. RESULTS: Less than half of all adults with SPD indicated receiving mental health treatment. Persons < 65 years and having SPD were significantly less likely to have access to any type of health insurance (0.59 O.R., 0.51-0.68 95% C.I.) compared to persons <65 years without SPD. CONCLUSIONS: These results present a situation which could potentially lead to increased use of emergency departments for possible non-emergent services. Less than half of adults with SPD were receiving mental health treatment and most, regardless of their SPD score, were receiving routine health checkups; presenting an opportunity to identify and treat many mental health issues in the primary care setting.

OBJECTIVES: To examine the state-based prevalence of serious psychological distress (SPD) and its treatment using the Kessler-6 scale. METHODS: SPD and treatment data were obtained from 202,114 respondents in the 2007 Behavioral Risk Factor Surveillance System Mental Illness and Stigma Module in 35 states, the District of Columbia, and Puerto Rico. RESULTS: Approximately 4.0 % of persons in the 35 states, the District of Columbia, and Puerto Rico had SPD. The prevalence estimates ranged from 2.3 % in Iowa to 6.6 % in Mississippi. Among persons with SPD, 53.4 % were currently untreated, ranging from 33.3 % in Alaska to 67.0 % in Hawaii. CONCLUSIONS: Mental health parity and a multidimensional approach to healthcare with extensive referrals between mental and physical healthcare is warranted.