MCHB/EPI Miami Conference — December 7 - 9, 2005

Watching Our Children Grow: Child Health Surveillance — Transcript

JODI DRISKO: Good morning everyone. It's a pleasure to be here. It's still freezing in Colorado so it is supposed to be nice and hot today here so that is great.

Also I had the opportunity two years ago at this same conference to present the methods and how we developed this survey so I'll kind of breeze over some of that. What I'm presenting this year is our full first year of data, which is 2004, and our survey is almost completed for 2005. We've already developed our 2006 and have our funding secured and all. So this is definitely an ongoing survey for us.

So I think you've probably heard this from Ziya but we have this vision of data across the lifespan. In Colorado we don't have any surveillance system for this age group which our Community Advisory Panel or our Child Health Survey group choose the age group of 1 to 14 year olds. It wasn't our decision but we let them drive the whole thing since they are funding the survey, they should get what they want.

So as you know PRAMS is really Perinatal Mom and Newborn Experiences Around Pregnancy. YRBS is high school. BRFSS is adults. We have birth and death data so this is just a huge gap in our state of this age group.

So like Ziya mentioned, ours is also a surveillance system to monitor the health and risk behaviors for children and we have core content areas and then some modules that different programs have added to the survey. Either specific questions that they have or the full kids with special health care needs screener questions. Those standard, I think, fourteen questions. That is on there as well.

So the benefits of the survey, I think a lot of these are pretty obvious. To monitor trends in child health and estimate prevalence of health conditions and the risk factors around those health conditions. We have the ability to analyze sub group analysis and to look at disparities and monitor progress for Healthy people 2010. We used a lot of this data in our latest MCH Block Grant application and needs assessment, which was great. For the first time we could actually report on this population instead of having a big old gap in our MCH needs assessment. We've used the data and are planning questions to be able to better evaluate our programs at the state level. We've done county over samples. We have one of the Steps to a Healthier U.S. Grant for a State, which covers four smaller counties in our state. So we've also conducted over samples of the child health survey for those four counties so they can also have data on this age group. Then we have been able to assist other states. We worked with North Carolina . We've fielded questions from a few other states so we are really open to that if anybody is interested. We are very happy to share our knowledge, our questionnaire; whatever we have that we can share we are willing to that.

So the survey was developed. This has been a pretty long process in Colorado . It probably took about a year to get the survey developed. We piloted and re-piloted. I did an in depth lit review on multiple questionnaires from this country. State specific ones, national surveys as well as looking at some questionnaires from other countries. In Australia , they do a fabulous survey in New South Wales . I think they do about 14,000 a year and it is a pretty small providence. I think that is what they are called in Australia . It is amazing the stuff they've done. There is also the health survey for England which they do a similar one with loads of numbers. So I grabbed some questions from there as well that were pretty unique and took some wording. Then I also looked at the AAP recommendations and of course AHRQ looking at their indicators and what is important to the pediatric population in general.

So on our survey, our core content area is our demographics, access to health and dental care. Health status and health behaviors, which are a lot of different types of health behaviors, that are not on the National Survey of Children's Health. It's part of the reason why we developed our own is because we can ask things about fruit and vegetable consumption and physical activity that they don't necessarily ask on that questionnaire. We purposefully design our survey so there is overlap between the National Survey of Children's Health and our survey so we can compare data, see what it looks like. Are we on target? Do these look the same or are they really different. Then we have some questions on mental health and behavioral health and identification of children with special health care needs.

So I probably don't need to mention this but we do the same thing. It is a follow back to the BRFSS. We call about 10 days to two weeks later so people can have a break. They just answered a 20-minute BRFSS questionnaire so we don't want to slam them with another 16-minute child health survey. We ask for the person most knowledgeable about the child's health and in the same case of North Carolina about 75 percent is the biological mother. About another 20 percent is the father, 5 percent is somebody else whether it is grandmother, older sibling, whoever is really taking care of the child. Then we specifically ask, at the end of the BRFSS after we have done the random selection of the child, we ask if we can link the data back to the BRFSS at some point in time. Then when we call them back since we may be talking to a different person we specifically ask that again so we are covered IRB wise and everything. We have the consent to do that.

Ours has been a really big collaborative effort with multiple health department programs. I think a lot of them are kind of the usual suspects in this area. We've also worked with a couple of universities and the Prevention Research Center that we have in Colorado . The Department of Education has been a great partner and the Department of Alcohol and Drug Abuse. The Colorado Children's Campaign is a private foundation that really works advocacy around children's issues. Caring For Colorado foundation is a conversion foundation and Kaiser Permanente is one of the largest private insurers in Colorado .

So all of these people besides having input on what they wanted in the questionnaire, the way we funded is all these people paid for their questions. So we have about 125 questions about and we charge per question. So these people are really vested in their data. They feel a lot of ownership for the entire survey.

So to get to the more exciting part is our results. We have an overall response rate of 77 percent. This is a combined BRFSS response rate and the Child Health Survey Response rate. We found that about 95 percent of people agree to have us call them back and about 90 percent are actually then complete the questionnaire. We still can't get a hold of some people after many attempts. People love to talk about their kids and this has been a fabulous opportunity for us. We figured that out in the pilot because one of the pilots we did besides just to figure out are these the right questions is will anybody even do this after they've sat on the phone for 20 minutes with BRFSS. We just weren't even sure if people would be willing to sit through another big long phone call.

So we have, for 2004, a little over 1,000 completed interviews. We are a much smaller state than North Carolina . We do a lot fewer BRFSS every year. We do between 4,000 and 6,000 depending on the year. So this is a model that can work for a smaller state as well. If you don't happen to be one of the top 10 most populated states this could still be used. So we have a little under one thousand useable completed interviews after we cleaned up the data. Only nine people refused to have their data linked to BRFSS. We think it is important to ask them and get their consent for that. This is pretty private information and most people obviously didn't have a problem with that. We cleaned our data and we weighted it based on age and gender distribution in the state, which is the same methodology that the National Survey for Children's Health uses. So as you can see from this data there is about an equal distribution across the age ranges for each children, which is randomly selected. So if there is more than one child in the household we just randomly select one. Tell them, the same as North Carolina that we'll be calling back in about two weeks and could they weigh and measure their child that we'll be asking about those. So we have about half male, half female. These are actually right on with the Colorado estimates. A race ethnicity reflects our state for the most part. We are a little bit under in African American population. We have about five percent of children in this age group are African American so we are a little under there which is surprising because that year for BRFSS we did an African American over sample and we still ended up with a pretty small percentage.

So about almost 90 percent of children in this age group have health care coverage, about 87 percent have a regular doctor and 92 percent got the needed dental care in the past 12 months. I'm just going over some of the selected high points or as it may be low points for some of the questions. I'm not going over all of them. About 27 percent play or sports or physically active less than five hours a week. About 60 percent are on a sports team and 35 percent play video games one to two hours a day. So some of these kids are pretty sedentary and about 21 percent watch TV three or more hours a day.

Now these are the questions that aren't on the National Survey of Children's Health. Those previous questions I believe are all on the survey and looking at the estimates that they got and what we got, they are basically the same. About 36 percent eat two or more servings of fruit a day. The Healthy people 2010 goal I believe is 70 percent so we have quite a ways to go here. Only five percent have three or more vegetables a day and the Healthy people 2010 goal there is 50 percent. So that is probably even a little steeper curve. Fifty percent are consuming three or more servings of dairy and almost 25 percent eat fast food more than two times a week. Then this is just our one food insecurity question, about 28 percent either often or sometimes had to rely on low cost foods due to lack of money.

So our BMI percentiles we have about almost 15 percent in the 95th percentile and above which is considered overweight. The National Survey for Children's Health estimate about 9.9 percent so that is a little bit different. I think it is still within the confidence interval but I was surprised that their estimate was so low.

One thing that we do on our survey that's a little different from either the National Survey of Children's Health or the North Carolina Survey is after we ask for the height of the child we ask how sure are you. Are you very sure, somewhat sure or not very sure? If they are anything but very sure we ask if we can call them back in a couple of days or they can call us after they have measured their child. We do the same thing with the weight. We've changed a lot of the data after we get the real measurement. A lot of parents aren't going to measure their child before the interview even though we may ask them to. I'm sure by the end of a 20-minute thing they are just like get me off the phone, I don't want to hear you anymore. So we built that in because in our pilot I think we ended up with about 35 percent overweight. I was like no way that can be true. Colorado if you didn't know is the least obese state in the country so we didn't think that over a third of children would be obese when the adults were about 16 percent obesity. So we built that in after I talked with a pediatrician who specializes in weight issues and we built in some checks and balances so we could try and get our data a little higher quality. But then 14 percent are at risk for overweight, which is another issue that we need to be aware of. Surprisingly enough 10 percent are under weight which is a different type of issue that I think a lot of people with so much focus on overweight and obesity, we often forget about these other kids that may be under nourished and aren't growing properly as well.

Our cancer program has sponsored these questions. About half of kids always or nearly always use sunscreen, although half of them have had sunburn in the past 12 months. So that is kind of an interesting phenomenon there. This last question here, parent thinks a tan makes a child look healthy. It is kind of a parent perception just about what do they think about this and does that impact their sunscreen behavior. I pulled that off the U.K. survey and about 25 percent believe a tan makes a child look healthy. So that will impact their decisions to use sunscreen or be really vigilant about it at least.

Our Department of Transportation and our Injury Program sponsored these questions. About 90 percent of kids always use a car seat, booster seat or seat belt. The response categories are different based on the age of the child. Forty-five percent always wear a bike helmet and 39 percent always wear a helmet while skating or scootering. We have different age--we don't ask the question of all ages obviously so we vary the questions based on age group.

About 12 percent of parents reported that their doctor told them their child had asthma at some point. Then the next question is do they still have asthma and that was 10 percent. All the pediatricians I've talked to have always told me that they don't believe that. Especially in children, you don't grow out of asthma so quickly. About 76 percent have a rescue inhaler which if a kid has asthma, they should all have a rescue inhaler so we have some work to do there. Thirty-six percent use a daily medication to prevent asthma. That is only appropriate for the set of kids that have persistent asthma. Then nine percent have been hospitalized one or more times for asthma and 27 percent have had to go to the emergency room or urgent care center for their asthma symptoms.

We have a couple of questions on the parent opinion, our Department of Education is using this data to try and sway the school board, legislature, any one who will listen. We have a pretty tough environment in Colorado around school issues. Our Department of Education is not a really strong department as far as being able to enact policy for all our districts. They all have local control so practices vary widely. So we wanted to give them a little fodder to help them be able to try and promote healthier items in school so they ask that changing contents of foods and snacks in vending, strong support of that issue as well as changing the contents of beverages in vending machines to water and 100 percent fruit juice. So we've had strong support for that. Parents thought it was very important for schools to limit the availability of high fat and sugar foods and also for schools to promote and encourage a healthy environment. And this we just thought was interesting, the Department of Ed wanted to know about parent support of specific health education topics in school. Since everyone hears about, well, I think the media really picks up on the negative pieces so interestingly enough 85 percent of parents really do support human sexuality education in school.

So in summary our survey has been a huge success. We get calls and data requests almost on a daily basis for this now. This is the first time we have ever had data for this. We are actually having to start to limit the number of questions on the survey because people are coming out of the woodwork. Now that we have data we have the data on our Web site as well. Bringing in new partners and we don't want the survey to get too long and out of control or nobody will want to answer it in the future. So we are going to convene a real advisory group that can make sure we are hitting all the important issues and we never dreamed that we would be in the position where we would actually have to limit the length of the survey. We were just happy that people were involved and wanted to support this effort in the first place. Thank you.