UHR Volume 16 (2011)_OCR

UTAH'S HEALTH: AN ANNUAL REVIEW JUNE 2011 | VOLUME 16 www.matheson.utah.edu/UHReview UH REVIEW 2011 Utah's Health: An Annual Review Original Research Articles 10 Racial and Ethnic Disparities in Seasonal Influenza Vaccination Among Utah Adults, 2000-2008 Andrew E. Burger, BA; EricN. Reither, PhD; David W. Ramos, BS; & Sun Young Jeon, BS 21 Sexual Activity and Contraceptive Use: A survey of University of Utah Undergraduate Students Aged 18-20 Janet C. Jacobson, MD; Sara E. Simonsen, CNM, MSPH; Katherine Morgan Ward DNP, WHNP; Ashley Lena Havlicak; & David K. Turok, MD/MPH 30 Protocol Use in Disease Outbreak Investigations: Applying a Technical Systems Solution to a Natural System Problem Heidi S. Kramer, MS; LaverneA. Snow, MPH; Matthew Samore, MD; and FrankA. Drews, PhD 35 May We Speak to the Lady of the House? Are Women Really the Ones Who Look for Health Information? Kathleen Digre, MD, Sally Patrick, MLS, Sara Simonsen, CNM, MSPH, Brenda Ralls, PhD, Michael Varner, MD, and Patricia Murphy, PhD 40 Preliminary Findings from a Pilot Integrative Obesity and Eating Disorder Intervention Justine J. Reel, PhD, LPC, CC-AASP; Sonya S00H00, PhD; Carlie Ashcraft, MS; & Rachel Lacy, MS 47 Cancer Survival in LTtah: Female Breast, Prostate, Colorectal, Lung and Bronchus, and Melanoma of the Skin, 1995-2006 Antoinette M. Stroup, PhD; C Janna Harrell, MS; Kimberly A. Herget, BA; Rosemary Dibble, CTR Perspectives 58 Awareness of Radon-Associated Health Risks in LTtah Wallace Aker ley, Chris Keyser, Sandie Edwards, Rob Wilson, Terry Van Du-ren, Dylan Akerley, Sarah Tranter, Susan Sharry 61 Community Readiness to Prevent Intimate Partner Violence: A LTniversity Needs Assessment to Health Education Practice Jacqueline R. Barco, MS & Justine J. Reel, PhD, LPC, CC-AASP 70 Working with Individuals with Intellectual Disabilities in Healthcare Settings: Body Image and Eating Disorder Concerns Justine J. Reel, PhD, LPC, CC-A4SP & Robert A. Bucciere, MSW, LCSW T7 2011 Utah Legislative Review 89 2011 Utah Health Data Review UTHE UNIVERSITY OF UTAH® Utah's Health: An Annual Review Executive Editors JB Flinders, MPH, MBA Editor-in-Chief Articles Editor Michelle Everill-Flinders Managing Editor Priti Shah Data Editor Sarah Watts-Justice, MHA, MPA Production Editor Jason Fox, MPA Legislative Editor Editorial Board Members Kyle Burningham Breanna Johnson Ryan Vanderwerff Anthony Tran Caroline Harris Zane Partridge Kimberly Judd Gregg Jones Acknowledgement We would like to thank Dr. Richard Sperry for his continued support and guidance, Sue Dean for her timely and unwavering assistance, the University of Utah Publications Council, ASUU, and the Governor Scott M. Matheson Center for Healthcare Studies for their financial support. Faculty Advisor Richard Sperry, MD, PhD Governor Scott M. Matheson Presidential Endowed Chair in Health Policy Management Advisory Board Members Marlene Egger, PhD Professor, Family & Preventive Medicine, University of Utah Leslie Francis, PhD Dean, College of Humanities, Alfred C. Emery Professor of Law Robert Paul Huefner, PhD Professor Emeritus, Political Science, University of Utah Pamela S. Perlich, PhD Senior Research Economist, Bureau of Economic and Business Research, University of Utah Debra Scammon, PhD Emma Eccles Jones Professor of Marketing, David Eccles School of Business, University of Utah Tawna Skousen, PhD Executive Vice President, Sawyer Technologies Natalie Stillman-Webb, PhD Assistant Professor (Lecturer), English & the University Writing Program, University of Utah Julia Summerhays, PhD Assistant Professor, Health Promotion and Education, University of Utah Norman J. Waitzman, PhD Professor, Department of Economics, University of Utah Utah's Health: An Annual Review 2011 Volume 16 www.uhreview.com A Publication of The University of Utah Utah's Health: An Annual Review | The University of Utah Governor Scott M. Matheson Center for Healthcare Studies 175 North Medical Drive East, Salt Lake City, Utah 84132 © 2011 The University of Utah. All Rights Reserved Introduction and Editor's Note It is with great pleasure that I, on behalf of the 2010-2011 Editorial Board, present the sixteenth volume of Utah's Health: An Annual Review. Utah's Health is dedicated to publishing original and timely health-related research relating to the State of Utah, and providing an analysis of important health-related data. It is a vehicle for health policy dialogue at both state and national levels and is designed to aid students, researchers, legislators, and health-related professionals in the continual pursuit of health-related knowledge and practice. Utah's Health also serves as a health education resource to the general public, and is available online at www.matheson.utah.edu. As in previous years, Utah's Health is comprised of four main sections: Original Research Articles, Perspectives, a Legislative Review, and a Data Review. The Original Research Articles submitted this year are of the utmost qual-ity and demonstrate a high caliber of peer-reviewed scientific research that relates to the health of Utahns. I am most grateful for all of the wonderful submissions that were received. Journals are a complicated and time-consuming process. They involve perseverance, patience, and sacrifice on the part of numerous individuals and organizations. Appreciation is due to many individuals, not only those involved in the journal directly, but those that continue to engage in research, data collection, and the practice of health itself. First and foremost, I would like to thank the diligent group of authors, contributors, and volunteers that have sac-rificed their time and effort to make this journal possible. Their commitment to the research and analysis of health related issues in Utah is the impetus behind the quality of this edition. I am extraordinarily fortunate to have, and extremely thankful for, the guidance of a fantastic group of advisory board members. Their insight and expertise in providing expert reviews and revisions to the numerous articles and data pages is invaluable. I would also like to ex-tend my deepest gratitude to Dr. Richard Sperry for his unwavering support and direction as our faculty advisor. I greatly appreciate the contributions of a remarkable group of fellow students and editorial board members who excelled in the creation of this work. As the Editor-in-Chief, I extend to each one of them a sincere and heartfelt thank you for their hard work and commitment to the success of this publication. My extra special thanks to Mrs. Sarah Watts-Justice for her diligence and guidance throughout the revision and publication process. In her hands, the jour-nal truly becomes an outstanding blend of art and science. As a final note, I continue to be surprised at the vast information we have regarding our health and health behaviors, and how little of it we truly take to heart. We as practitioners, researchers, and educators should always remember that in order to truly create and maintain healthy behaviors in our families, communities, and organizations, we must first do so in our own lives. Again this year, this volume is dedicated to the friends, colleagues, relatives, and loved ones we have lost over the past year. May we continue to use our gifts of knowledge, research, and practice for the health, safety, and ever-improving quality of life in our communities, our families, and within ourselves. JB Flinders, MPH, MBA Editor-in-Chief Utah's Health: An Annual Review-Volume XVI, 2011 UTAH'SHEALTH: ANANNUAL REVIEW2011 Authors and Contributors Wallace Akerley, MD, is Director of Community Oncology Research, Medical Director of the Clinical Trials Office, co-director o f the Thoracic Cancer Program at Huntsman Cancer Institute (HCI) and Professor o f Medicine at the University of Utah, both in Salt Lake City, Utah. Dr. Akerley earned his medical degree from the Brown University School of Medicine in Providence, Rhode Island. He held his residency in internal medicine at the LAC-USC Medical Center in Los Angeles, California. He is Chairman of the Data and Safety Monitoring Committee at the Huntsman Cancer Center and Director of the SEER Utah Cancer Registry as part of the Department o f Health in the State of Utah. Dr. Akerley is a member o f the American Society of Clinical Oncology, the International Association for the Study of Lung Cancer, and the Society of Utah Medical Oncologists, as well as nu-merous cancer management committees. Carlie Ashcraft is a graduate student in the Department o f Health Promotion and Education. She works at the Salt Lake Valley Health Department. Jacqueline R. Barco, MS, is a doctoral candidate in Counseling Psy-chology at the University o f Utah. She is a researcher and advocate in the field of mental health and gender studies, particularly as they relate to the social etiology of gender-based violence and its effects on women. Robert A. Bucciere, MSW, LCSW, is the Lead Licensed Clinical Social Worker for the University Health Care: Neurobehavior HOME Program at the University of Utah that serves clients with intellectual disabilities. He treats youth and adults with disabilities and is a member o f ATSA for the specialization in sexual offender treatment. Rosemary Dibble, CTR, is the Director o f Operations at the Utah Cancer Registry. During her more than 20-year tenure as Director of Operations, the Utah Cancer Registry has consistently been one of the top ranked SEER Reg-istries in the nation and has received numerous awards. Frank Drews, PhD - Associate Professor, Department of Psychology, University o f Utah. C. Janna Harrell has a Master o f Sci-ence in Family Ecology from the Univer-sity of Utah with an emphasis in Demog-raphy. She is the Senior Research Analyst at the Utah Cancer Registry. Kim Herget has a Bachelor's of Arts in Psychology and is a Masters of Statistics student in the Sociology department at the University of Utah. She is a Biostatis-tician at the Utah Cancer Registry. Heidi S. Kramer, MS - Gradu-ate Student, Department of Psychology, University o f Utah. Rachel Lacy is a graduate student in the Department o f Health Promotion and Education. She works at the Salt Lake Valley Health Department. Justine J. Reel, PhD, LPC, CC-AASP, is an Assistant Professor in the Department o f Health Promotion and Education at the University of Utah. She directs the eating disorder and obesity prevention graduate track and is the Founder and Faculty Advisor o f Students Promoting Eating disorder Awareness and Knowledge (SPEAK). Matthew Samore, MD - Professor of Medicine, Adjunct Professor of Bio-medical Informatics. Dr. Samore is the Director of the Salt Lake IDEAS Center and Chief of the Division o f Epidemiology at the University of Utah. Laverne A. Snow, MPH - Graduate Student, Biomedical Informatics Depart-ment, University of Utah. Sonya SooHoo, PhD, is a Research Associate at the Center for Health Care Evaluation, VA Palo Alto Health Care System located in Menlo Park, CA. She received her doctoral degree from Uni-versity o f Utah. Antoinette M. Stroup, PhD, has a Master of Science in Family Ecology from the University of Utah and a PhD in Epidemiology from the University of California. She is the Director of the Utah Cancer Registry and is a Research Assis-tant Professor in the Division of Epidemi-ology, Department of Internal Medicine, School o f Medicine at the University of Utah. UTAH'SHEALTH: ANANNUAL REVIEW2011 Contents Original Research Articles Racial and Ethnic Disparities in Seasonal Influenza Vaccination Among Utah Adults, 2000-2008 Andrew E. Burger, BA; Eric N. Reither, PhD; David W. Ramos, BS; & Sun Young Jeon, BS Sexual Activity and Contraceptive Use: A survey of University of Utah Undergraduate Students Aged 18-20 Janet C. Jacobson, MD; Sara E. Simonsen, CNM, MSPH; Katherine Morgan Ward DNP, WHNP; Ashley Lena Havlicak; & David K. Turok, MD/MPH Protocol Use in Disease Outbreak Investigations: Applying a Technical Systems Solution to a Natural System Problem Heidi S. Kramer, MS; Laverne A. Snow, MPH; Matthew Samore, MD; and Frank A. Drews, PhD May We Speak to the Lady of the House? Are Women Really the Ones Who Look for Health Information? Kathleen Digre, MD, Sally Patrick, MLS, Sara Simonsen, CNM, MSPH, Brenda Ralls, PhD, Michael Varner, MD, and Patricia Murphy, PhD Preliminary Findings from a Pilot Integrative Obesity and Eating Disorder Intervention Justine J. Reel, PhD, LPC, CC-AASP; Sonya SooHoo, PhD; Carlie Ashcraft, MS; & Rachel Lacy, MS Cancer Survival in Utah: Female Breast, Prostate, Colorectal, Lung and Bronchus, and Melanoma of the Skin, 1995-2006 Antoinette M. Stroup, PhD; C Janna Harrell, MS; Kimberly A. Herget, BA; Rosemary Dibble, CTR Perspectives Awareness of Radon-Associated Health Risks in Utah Wallace Akerley, Chris Keyser, Sandie Edwards, Rob Wilson, Terry Van Duren, Dylan Akerley, Sarah Tranter, Susan Sharry Community Readiness to Prevent Intimate Partner Violence: A University Needs Assessment to Health Education Practice Jacqueline R. Barco, MS & Justine J. Reel, PhD, LPC, CC-AASP Working with Individuals with Intellectual Disabilities in Healthcare Settings: Body Image and Eating Disorder Concerns Justine J. Reel, PhD, LPC, CC-AASP & Robert A. Bucciere, MSW, LCSW 2011 Utah Legislative Review 2011 Utah Health Data Review 10 21 30 35 40 47 58 61 70 77 89 UTAH'SHEALTH: ANANNUAL REVIEW2011 Original Research Articles 2011 Utah's Health: An Annual Review 2011 UTAH'S HEALTH: AN ANNUAL REVIEW CORRESPONDENCE Andrew E. Burger sociology Graduate student Utah state University department of ssw&A 0730 old Main Hill Logan, UT 84322-0730 phone [phone] cell [phone] fax [phone] email [e-mail]. edu k e yw o r d s influenza, vaccination, health disparities, race/ethnicity, socioeconomic status (s e s ) Racial and Ethnic Disparities in Seasonal Influenza Vaccination among Utah Adults, 2000-2008 Andrew E. Burger, BA; Eric N. Reither, phD; David w. Ramos, Bs; & sun Young Jeon, Bs a b s t r a c t Health inequalities have long been observed among racial/ethnic groups in the United States. Despite initiatives to address health disparities, substantial differences remain. One important area o f concern is racial/ethnic disparities in vaccination for the seasonal flu. The seasonal flu is responsible for thousands o f deaths each year in the United States, and even more hospitalizations, with billions o f dollars drained from the economy due to illness and lost productivity. Seasonal vaccination remains the most simple and effective means of preventing the flu, but millions go unvaccinated every year with notable differ-ences across racial/ethnic groups. Using the Behavioral Risk Factor Surveillance System (BRFSS), we examine vaccination rates among adults from various racial/ethnic groups in Utah during the 2000-2008 influenza seasons. Our analyses demonstrate that flu vaccina-tions increased significantly for non-Hispanic Whites over this period, but appear to have declined somewhat among Hispanics. Through a series o f logistic regression models, we discovered that lower odds of vaccination among Hispanics disappeared after controlling for healthcare coverage and other socioeconomic characteristics. These findings suggest that seasonal influenza vaccination rates can be improved among racial/ethnic minorities in Utah by addressing structural barriers to receiving the seasonal flu vaccination, espe-cially access to healthcare coverage. 10 r a c ia l a n d e t h n ic d is p a r i t ie s i n s e a s o n a l i n f l u e n z a v a c c in a t io n UTAH'S HEALTH: AN ANNUAL REVIEW 2011 Every year influenza infections and related comorbidities account for thousands of deaths in the United States. Effective and safe vaccines for seasonal influenza have been developed and promise to substantially reduce the mortali-ty and morbidity burden of influenza viruses. However, millions go unvaccinated every year in the United States. Past research has identified the existence o f disparities in seasonal influenza vaccination, with racial/ethnic minorities experiencing lower vaccination rates than non-Hispanic Whites (Egede and Zheng 2003; Fiscella 2005; Fiscella et al. 2007; Fiscella et al. 2002; Linn, Guralnik, and Patel 2010; Logan 2009; Zimmerman et al. 2003). While inequalities in vaccination have been observed in the past, they are typically based on single year observations. To better understand racial/ethnic disparities and trends in those disparities, this study will examine nine consecutive flu seasons beginning in the year 2000 in the state o f Utah. Given the increasingly diverse population in Utah - particularly with a rapidly growing Hispanic population - it is important to under-stand recent trends and disparities in flu vaccination, which will help identify opportunities to improve public health in the state. DISEASE BURDEN OF SEASONAL INFLUENZA Mortality In a recent publication issued by the Centers for Disease Con-trol and Prevention (CDC), mortality estimates were provided for the 1976-2007 influenza seasons in the United States (CDC 2010a). Deaths resulting from seasonal influenza were estimat-ed to have ranged from a low of 3,349 during the 1986-1987 flu season to a high of 48,614 deaths during the 2003-2004 season. The average level o f mortality from influenza during 1976-2007 was around 23,607 deaths per flu season. Using public data available for analysis online from the CDC (2003), we found that the mortality burden of the seasonal flu and pneumonia, which are often associated (see Klugman, Chien, and Madhi 2009), is so great that it was listed as the eighth leading cause of death in the United States from 1999-2007, with an estimated total of 553,629 deaths during that time period. This places influenza and pneumonia above suicide, homicide, liver disease, hypertension, and AIDS in terms of the estimated total number of deaths in the United States during that time period (CDC 2003). Molinari et al. (2007) estimate that 610,660 life-years are lost per annum in the U.S. due to the seasonal flu. Morbidity While the mortality burden associated with the seasonal flu has been well characterized in the scientific literature, the morbidity burden, while likely to be great, is harder to estimate. Hospitalizations due to influenza during each flu season may help in estimating the virulence of various flu strains. From 1979 to 2000, an average o f nearly 200,000 people was hospi-talized each year due to influenza-related illnesses (Thompson et al. 2004). However, because of the varying severity of the sea-sonal flu, estimates o f hospitalizations ranged anywhere from 157,911 during the 1990-1991 flu season to 430,960 during the 1997-1998 flu season. While hospitalization rates were found to be highest among the elderly, young children under the age o f 5 also experienced high hospitalization rates - similar, in fact, to those experienced by 50-64 year olds. Economic Burden The total economic burden o f the seasonal flu is estimated to be nearly $87 billion annually in the United States (Molinari et al. 2007). An estimated $6 billion is spent on influenza related hospitalizations, $6.8 billion on outpatient care, and more than $16 billion in lost earnings due to illness and loss of life. With an estimated annual 44 million days lost from work due to influ-enza, the impact of the seasonal flu in terms o f lost productivity, absenteeism, and related costs for employers is also substantial (Akazawa, Sindelar, and Paltiel 2003). Although these figures are striking, the actual disease burden of the seasonal flu is likely to be larger than previously esti-mated. Several reporting issues contribute to the underreport-ing of influenza related illnesses and deaths. One reason for the underreporting of deaths from influenza is that "states are not required to report individual seasonal flu cases or deaths of people older than 18 years o f age" to the CDC (CDC, 2010d, p. 1). Furthermore, influenza is rarely listed on death certificates of individuals who die from flu related complications, such as pneumonia. Additionally, even when the International Classifi-cation of Disease (ICD) codes are implemented to track mortal-ity, research has shown that many deaths caused by influenza tend to be missed, such as cardiovascular or circulatory deaths caused by influenza-related complications (Monto 2008). e f f e c t iv e n e s s o f i n f l u e n z a v a c c in a t io n The high mortality, morbidity, and economic costs associated with seasonal influenza could be reduced through vaccination, which is an effective way to prevent infection (Nichol 2008, CDC 2010b). The CDC recommends that obtaining a flu vac-cination should be the first step in preventing the seasonal flu (CDC 2010d). Vaccination against the seasonal flu provides substantial benefits for mothers and young infants (Zaman et al. 2008), as well as healthy children (Jefferson et al. 2005, Man-zoli et al. 2007). Among working U.S. adults, vaccination also has substantial health benefits, decreasing upper respiratory ill-ness by 25% and reducing absenteeism due to upper respiratory illness by 43% (Nichol et al. 1995). Vaccination also provides significant benefits for the elderly populations which are par-r a c ia l a n d e t h n ic d is p a r i t ie s i n s e a s o n a l i n f l u e n z a v a c c in a t io n 11 2011 U tah's h e a l th : an a n n u a l re v iew ticularly vulnerable to influenza (Nichol et al. 2007, Gross et al. 1995). Even during years where the influenza vaccine (which is prepared before the onset of each flu season) is a poor antigenic match for that season's particular flu strain, health benefits can still be gained through vaccination (Herrera et al. 2007, CDC 2010b). Given the substantial health benefits provided by influ-enza vaccination, the CDC revised its guidelines in 2010-2011 to recommend that all individuals 6 months o f age and older receive an influenza vaccination (CDC 2010b). Reaching this ambitious new standard will be difficult. Prior goals set by the CDC for vaccinating recommended age groups have been hard to attain (Nichol 2008). Before the 2010-2011 change in protocol, the CDC recommended influenza vaccina-tion only for select groups of the population, such as the elderly or those at particular risk of complications due to the flu (Nichol 2007). However, Lu et al. (2008) found that from 1989-2005, when the CDC focused on these high-risk populations, vaccina-tion attainment goals were rarely met. Indeed, only 69.5% of persons aged 65 and older received the flu vaccine in the United States during the 2007 flu season (Linn, Guralnik, and Patel 2010), demonstrating that considerable gains need to be made in order to achieve the new 2010-2011 standard of universal vaccination o f the entire population age six months and older. Important in understanding the barriers to attainment of the CDC goals is an examination o f the substantial differences in influenza vaccination rates by race/ethnicity. b a r r ie r s t o v a c c in a t io n Consistently, race and ethnicity prove to be strongly associated with seasonal influenza vaccination (Egede and Zheng 2003, Chen et al. 2007). Fiscella (2005) estimates that if racial/eth-nic disparities were eliminated, an additional 1 million elderly minority persons in the U.S. would receive an influenza vaccina-tion each year. Eliminating vaccination disparities could yield remarkable improvements in population health. To illustrate, eliminating vaccination disparities could save an estimated 33,000 years o f life per annum among racial/ethnic minorities in the U.S. (Fiscella 2007) Preventive healthcare services such as flu vaccination are often underutilized by racial/ethnic minorities (Logan 2009). Chen et al. (2007) found that Hispanics tend to cite structural barriers that prevent receipt of the seasonal flu vaccination, in-cluding insufficient access to preventive services, lack of trans-portation, not knowing where to go, and economic costs. These researchers also found that health insurance was a significant predictor o f vaccination among Hispanics. In addition to structural barriers, racial/ethnic minorities may be less informed regarding the severity of the seasonal flu and the benefits of vaccination. According to Chen et al. (2007), one o f the most common explanations among racial/ethnic minorities for not receiving the flu vaccine was a lack o f concern about contracting the flu. This suggests that some racial/eth-nic minorities may be less likely to go to a health care facility with the intent o f receiving just an influenza vaccine (Link et al. 2006). Misinformation and inadequate education about the seasonal flu among some racial/ethnic minorities may contrib-ute to lower rates of vaccination. Language barriers can also deter vaccination, especially among Hispanics and other racial/ethnic groups with large numbers of recent migrants. Fiscella et al. (2002) presents evidence showing that English-speaking Hispanics with health insurance did not differ significantly from their non-Hispanic White counterparts in terms o f receiving an influenza vaccina-tion. However, Spanish-speaking Hispanics with health insur-ance received flu vaccinations at lower rates than non-Hispanic Whites with insurance. m e t h o d s a n d p r o c e d u r e DATA sOURCE To identify racial/ethnic disparities in flu vaccination in Utah, this study will utilize the Behavioral Risk Factor Surveillance System (BRFSS), which is an annual health survey sponsored by the CDC. The BRFSS is the largest ongoing telephone based survey tracking health-related information of non-institution-alized U.S. adults over the age o f 18 (CDC 2008). The BRFSS is administered in Utah by the Department of Health; data are collected monthly on a range of different health topics (Utah Department o f Health). d e pe n d e n t v a r ia bl e The BRFSS measures influenza vaccination by asking respon-dents if they have received a flu shot during the past 12 months. The respondents' responses were coded as "Yes", "No", "Don't Know", or "Refused." Beginning in 2004, the BRFSS additional-ly asked respondents if they had received an influenza vaccina-tion through a nasal spray. Since the principal interest o f this research is vaccination, not the mode of vaccination, the two variables were combined so that if the respondent responded "Yes" to either or both, they were coded as having been vacci-nated during the last 12 months. Flu Seasons in the BRFSS The BRFSS presents some unique challenges in accurately linking reports of seasonal flu vaccination to the appropriate flu season. Given the seasonal timing of flu epidemics and the retrospective wording of the flu vaccine question in the BRFSS, 12 RACIAL AND ETHNIC DIs p ARITIEs IN sEAsONAL INFLUENzA vACCINATION UTAH'S HEALTH: AN ANNUAL REviEw 2011 it becomes difficult to identify which flu season the respondent is referring to in his or her responses about vaccinations. Previous studies o f BRFSS data have addressed this issue in a variety of ways. For example, Linn et al. (2010) include all responses from the 2008 BRFSS in their analysis o f flu vaccina-tion rates during the 2007 flu season. While this method likely does primarily capture individuals from the 2007 flu season, it certainly also includes respondents who were referring to either the 2006 or the 2008 flu seasons. Furthermore, using any given year of the BRFSS to estimate the previous year's flu season may prove inaccurate since vaccination rates may vary across flu sea-sons in response to the virulence of flu strains, economic condi-tions, and other factors. For instance, enhanced media coverage during a given flu season could increase vaccination rates as a larger segment of the population becomes aware o f the flu (Ma et al. 2006). Other factors, such as the influenza vaccine short-age of 2004 - in which there was a nearly 50% reduction in the supply o f flu vaccine - could also play a role in seasonal differ-ences in vaccination (Zimmerman et al. 2006). Until the 2009 BRFSS, respondents were only asked whether they had received a flu vaccination in the previous 12 months. Beginning with the 2009 BRFSS, however, information was gathered regarding the month and year of the respondent's last reported flu vaccination. With that information we can ac-curately determine during which flu season respondents were vaccinated. Flu seasons typically begin in late October or No-vember and can last until the next year's summer (CDC 2010c). Since public influenza vaccinations typically begin before the flu season starts, we will consider respondents who received their vaccine from September o f any given year through August of the next year as being vaccinated for that particular flu season. For example, in Table 1 approximately 78% (n = 3486) of those who reported receiving a flu vaccine in Utah did so during the 2008 flu season (sometime between September 2008 and August 2009). Approximately 20% (n = 902) reported having received their flu vaccine during the 2009 influenza season, and a little more than 1% (n = 56) reported having received their flu vaccine during the 2007 influenza season. Taken together, roughly 22% of respondents referred to flu seasons other than 2008, mean-ing that they would be misclassified using the methodology adopted by Linn et al. (2010). Clearly, it is necessary to exercise caution when making as-sumptions about the ability of a single wave o f the BRFSS to accurately depict vaccination rates for a particular flu season. However, dramatic gains in accuracy can be made when re-stricting the sample by interview month. Among respondents who were interviewed from January to September o f the 2009 Utah BRFSS, nearly 98% reported receiving their vaccination during the 2008 flu season. By excluding individuals who were interviewed from October to the end of the 2009 BRFSS, we greatly reduce the number of vaccinations reported for the 2009 flu season, which increases our ability to portray seasonal vac-cination rates accurately. Because vaccination dates are not available in the BRFSS prior to 2009, we propose an alternate method of measuring seasonal vaccination rates based on the respondents' month of interview. Our analyses suggest that by restricting the sample to those interviewed from January to September of each survey year, we will estimate the previous year's seasonal flu vac-cination rates with greater precision. To illustrate, we will use responses from individuals interviewed during the months o f January through September of the 2001 BRFSS to estimate vaccination rates during the 2000 flu season. Subsequent flu seasons will be coded in a like manner. This is an imperfect solution, as restricting the sample by in-terview month will result in the exclusion o f about a quarter of the respondents in each survey year. However, those individuals who are excluded are likely to be reporting a flu vaccine for a different flu season and their inclusion would produce error and significantly reduce our ability to evaluate specific flu seasons. TABLE 1. Influenza seasons in which vaccination was reported, 2009 Utah BRFSS. Entire Sample Interview Month 01/09 to 01/10 Restricting Vaccination by Interview Month 01/09 to 09/09 Restricting Vaccination by Interview Month 10/09 to 01/10 Flu Season n % Flu Season n % Flu Season n % 2007a 56 1 .2% 2007a 56 1 .6% 2007a 0 0.0% 2008b 3486 78.4% 2008b 3341 97.9% 2008b 145 14.0% 2009c 902 20.3% 2009c 14 0.4% 2009c 888 85.9% Total 4444 100% Total 3411 100% Total 1033 100% a. Received influenza vaccination from 01/08-08/08. b. Received influenza vaccination from 09/08-08/09. c. Received influenza vaccination from 09/09-12/09. r a c ia l a n d e t h n ic d is p a r i t ie s i n s e a s o n a l i n f l u e n z a v a c c in a t io n 13 2011 U tah's h e a l th : an a n n u a l re v iew Moreover, exploratory analyses indicate that the data are not biased in any particular fashion by eliminating respondents who were interviewed later in the year. Like previous research (Lu, Euler, and Callahan 2009), our study selects respondents by time of interview. However, whereas the methodology outlined by Lu et al. (2009) includes respondents interviewed from February to August, we include respondents over a wider interval o f time - January through September. This decision is rooted in our analyses of 2009 BRFSS data for Utah, which reveal that our technique retains fully 95.8% of respondents reporting vaccination for the 2008 flu season, compared to 89.3% using the previous standard. We retain these additional BRFSS participants without compromis-ing our ability to categorize them into the correct flu season; 97.9% o f the respondents in our sample report receiving their vaccination for the 2008 flu season, which results in a low rate of error that is comparable to the alternative approach. To en-sure that this finding is not anomalous, we compared our results against national BRFSS data. The benefits o f using interview months January through September are even more pronounced in national data, corroborating our findings for Utah. i n d e pe n d e n t v a r ia bl e s Our chief independent variable is race/ethnicity. Within the BRFSS, racial/ethnic background is coded as White non-His-panic, Black non-Hispanic, other race non-Hispanic, multiracial non-Hispanic, and Hispanic. However, due to the low num-ber of respondents in the Black non-Hispanic and multiracial non-Hispanic categories during our period of study, we com-bine them with the other race non-Hispanic category to create three exhaustive and mutually exclusive racial/ethnic catego-ries: White non-Hispanic, Hispanic, and other non-Hispanic. Although it is difficult to identify precisely which racial/ethnic groups comprise the other non-Hispanic category, we retain them in our analyses for comparative purposes and also to maximize statistical power for some analyses. Other independent variables of interest include age, sex, level of education, household income, and healthcare coverage. Age is collapsed into six categories including: 18-24, 25-34, 35-44, 4 5-5 4, 55-6 4 , and 65+. Educational attainment is recoded into five categories including: "Less than High School", "High School Graduate", "Some College or Technical School", and "College Graduate." To create the "Less than High School" category we combined three different responses: "Never Attended School or Only Kindergarten", "Elementary School (Grades 1-8)" and "Some High School (grades 9-11)." Household income is collapsed into seven different categories. Whether or not the respondent participated in some sort of healthcare plan was assessed through the question, "Do you have any kind o f health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?" to which the FIGURE 1. Directed acyclic graph (DAG) showing mediated effects of race/ethnicity on the odds of seasonal influenza vaccination. 14 RACIAL AND ETHNIC DIs p ARITIEs IN sEAsONAL INFLUENzA vACCINATION U ta h 's h e a l t h : a n a n n u a l r e v ie w 2011 respondent replied "Yes", "No", "Don't Know", or "Refused." ANALYsIs To illustrate plausible mechanisms through which race/eth-nicity influences the odds of receiving an influenza vaccination, we have constructed a directed acyclic diagram (Greenland, Pearl, and Robins 1999; Shrier and Platt 2008). As shown in Figure 1, we propose that the race effect is mediated primarily through healthcare coverage and indicators o f socioeconomic status (specifically household income and education); the "direct" influence o f race/ethnicity is therefore expected to at-tenuate substantially after controlling for these three mediators. Note that we also include a handful of demographic measures as control variables, to account for potential differences between racial/ethnic groups. For instance, Hispanic respondents tend to be younger than their non-Hispanic White counterparts, which could partially account for gross differences in influenza vaccination rates observed between these groups. All analyses were performed using SPSS 18 and Microsoft Excel 2007. Additionally, the SPSS Complex Samples Module was used to generate point estimates and produce variance estimates. Vaccination rates were estimated for the 2000- 2008 influenza seasons for various sociodemographic groups. Difference o f proportions tests were subsequently conducted to determine if the differences observed between racial/ethnic groups were statistically significant for each sociodemographic subgroup (e.g., females). Linear regression was also used to summarize trends in vaccination rates over this period of observation for non-Hispanic Whites and Hispanics. Trends in seasonal vaccination rates among other non-Hispanics were generally similar to Whites and are not shown in the results. Finally, a series of logistic regression models were estimated to assess potential mechanisms through which race/ethnic-ity affects the odds o f influenza vaccination. Model 1 includes demographic control variables, which likely account for some of the raw differences in the odds o f influenza vaccination ob-served between racial/ethnic groups. Model 2 includes presence of healthcare coverage, which potentially represents the single most important structural barrier to influenza vaccination for disadvantaged racial/ethnic groups. Model 3 includes socioeco-nomic factors (household income and education), which may represent additional mechanisms through which race/ethnicity influences the odds o f influenza vaccination. r e su l t s Influenza vaccination percentages are presented in Table 2 for the 2000-2008 flu seasons by race/ethnicity and sociode-mographic subgroups. For most Hispanic sociodemographic subgroups, vaccination rates were significantly lower than their non-Hispanic White counterparts. To illustrate, Hispanic males experienced substantially lower influenza vaccination rates than White males (23.1% vs. 34.6%). A similar disparity was observed for Hispanic females (31.9% vs. 39.5%). Significant differences between Hispanics and Whites were also observed across all income levels, with Hispanics experiencing lower vac-cination rates except for the $50,000-$74,999 category where Hispanic vaccination rates were higher. Noteworthy differences 2000 2001 2002 2003 2004 2005 2006 2007 2008 RACIAL AND ETHNIC DIs pARITIEs IN sEAsONAL INFLUENzA vACCINATION 15 2011 UTAH'S HEALTH: AN ANNUAL REviEw Table 2. Influenza vaccination coverage in sociodemographic subgroups by race: Utah, 2000-2008. Total Sample White, non-Hispanic Hispanic Other, non-Hispanic Characteristics ------ 1------ n % 95% CI n % 95% CI n % 95% CI n % 95% CI Age 18-24 2,682 24.5 22.4-26.7 2,278 25 22.8-27.5 267 19.9 14.1-27.3 137 25.8 17.2-36.7 25-34 6,353 25.8 24.5-27.1 5,509 25.9 24.6-27.3 567 23.2 19.2-27.7 277 29.1 22.5-36.8 35-44 6,554 27.3 25.9-28.7 5,749 27.4 26.0-28.9 492 24.5 19.8-29.8 313 30.3 24.3-37.0 45-54 6,646 35.9 34.4-37.5 6,070 36.2 34.6-37.8 339 33.7 27.7-40.2 237 34.7 27.4-42.8 55-64 5,541 48.4 46.6-50.1 5,148 49 47.1-50.8 214 39.2*** 30.9-48.1 179 44.6 35.2-54.4 65+ 7,245 74.2 72.8-75.6 6,857 74.1 72.7-75.5 218 0.749 66.9-81.5 170 78.2 69.9-84.8 Sex Male 15,188 33.5 32.5-34.5 13,699 34.6 33.5-35.7 877 23.1*** 19.6-27.0 612 32.1 27.5-37.1 Female 19,987 38.8 37.9-39.7 18,043 39.5 38.5-40.5 1228 31 9* * * 28.3-35.7 716 36.4 31.4-41.7 Household Income <$14,999 2,435 31.4 28.8-34.1 1,984 33.5 30.5-36.7 295 24.4** 18.6-31.4 156 23.8* 16.7-32.7 $15,000-$24,999 4,593 35 32.9-37.1 3,853 37.5 35.2-39.8 531 25 5* * * 20.4-31.3 209 28.5* 21.6-36.7 $25,000-$34,999 3,860 36.9 34.8-39.0 3,400 38.9 36.7-41.1 292 21.6* * * 16.2-28.3 168 37.3 26.8-49.1 $35,000-$49,999 5,915 34.5 32.9-36.2 5,376 35.3 33.6-36.9 311 28.5* 21.4-36.8 228 31.5 24.5-39.4 $50,000-$74,999 6,466 34.7 33.2-36.3 6,085 34.4 32.9-36.0 212 43.4** 35.2-52.0 169 33.1 23.7-44.0 >$75,000 8,311 39.1 37.7-40.5 7,894 39.3 37.8-40.7 184 30.4* 23.0-39.0 233 42.2 33.6-51.3 Education Less than HS 2,162 28.3 25.6-31.1 1,436 32.5 29.0-36.1 603 21 8* * * 17.4-26.8 123 26.8 17.7-38.4 High School 9,983 34.1 32.8-35.4 8,912 35.2 33.8-36.6 695 25.2*** 21.2-29.6 376 31.6 25.3-38.7 1-3 Years College 11,702 35.4 34.3-36.6 10,795 35.5 34.3-36.8 476 34.9 28.9-41.4 431 34.2 28.4-40.6 4+ Years College 11,280 41 39.8-42.1 10,559 41.3 40.1-42.5 324 34.8* 28.7-41.4 397 38.7 32.4-45.5 Healthcare Coverage Yes 30,903 39.4 38.7-40.1 28,508 39.7 38.9-40.5 1338 35.9* * 32.2-39.8 1057 37.2 33.3-41.3 No 4,168 17.8 16.3-19.5 3,147 18.4 16.6-20.5 763 15.8 12.8-19.5 258 18.6 13.4-25.1 t = unweighted sample size. CI = confidence interval. % and CI are calculated from weighted values. p values from difference of proportion test (White, non-Hispanic vs. Hispanic/White, non-Hispanic vs. Other, non-Hispanic). *p<0.05; **p<0.01; ***p<0.001. between Hispanics and Whites were also observed by education level. For instance, Hispanics with a High School degree or less had vaccination rates that were roughly 10% lower than Whites with similar education. Significant differences were also ob-served between Hispanics and Whites with four or more years of education, with Hispanics experiencing significantly lower rates of vaccination than their White counterparts. Age appears to play a very important role in vaccination across all racial/ethnic groups, with younger groups experienc-ing substantially lower vaccination rates than older respon-dents. Across all racial/ethnic groups, vaccination rates jump more than 25% from the 55-64 to the 65+ categories. From ages 18-54, estimated vaccination rates were similar among racial/ ethnic groups. Across all races/ethnicities, vaccination rates increased with rising age, household income, education, and membership in some form o f healthcare coverage plan. Figure 2 shows flu vaccination trends in Utah for non-His-panic Whites and Hispanics during the 2000-2008 flu seasons. In general, non-Hispanic Whites tend to exhibit higher annual vaccination rates than Hispanics. Over this period of obser-vation, non-Hispanic Whites also experienced a statistically significant increase in vaccination rates (p < 0.05). Somewhat disconcerting is the negative linear trend observed among His-panics (p > 0.05), which shows that disparities have widened over the past decade. Hispanic vaccination rates generally declined from their high of 35.4% during the 2000 flu season to their lowest point of 21.8% during the 2006 flu season, after which it rebounded. In Table 3, we present results from a series o f logistic re-gression models that examine the effect of race/ethnicity on vaccination, while controlling for various sociodemographic characteristics. In Model 1 we examined the effect of race/eth-nicity while controlling for sex, age, and period of observation. This model indicates that the odds o f receiving a flu vaccine were about 18% lower among Hispanics than non-Hispanic Whites (p < 0.01). Statistically significant differences by sex were also observed; the odds o f flu vaccination were about 17% lower among men (p < 0.001). Age was also significantly associ-ated with flu vaccination, with odds of vaccination dramatically increasing with age. Relative to the oldest age group (65+), the odds o f vaccination among those in the 55-64 age group were nearly 70% lower (p < 0.001). Finally, consistent with our find- 16 r a c ia l a n d e t h n ic d is p a r i t ie s i n s e a s o n a l i n f l u e n z a v a c c in a t io n U ta h 's h e a l t h : a n a n n u a l r e v ie w 2011 Table 3. Logistic regression estimates of the effect of race/ethnicity and sociodemographic factors on influenza vaccinations for Utah adults, 2000-2008. Sociodemographic Factors Model 1 Model 2 Model 3 AORt 95% CIt AOR 95% CI AOR 95% CI Race/ethnicity White 1.000 1.000 1.000 Hispanic 0.819** 0.708 0.947 0.999 0.859 1.161 1.131 0.959 1.333 Other 1.082 0.909 1.288 1.089 0.916 1.293 1.067 0.890 1.279 Sex Female 1.000 1.000 1.000 Male 0.824*** 0.772 0.879 0.843*** 0.789 0.900 0.810*** 0.755 0.869 Age 65+ 1.000 1.000 1.000 55-64 0.323*** 0.292 0.358 0.338*** 0.305 0.374 0.301*** 0.269 0.338 45-54 0.195*** 0.177 0.215 0.204*** 0.185 0.226 0.180*** 0.161 0.202 35-44 0.132*** 0.119 0.146 0.140*** 0.127 0.155 0.124*** 0.110 0.139 25-34 0.120* * * 0.109 0.133 0.132*** 0.120 0.146 0.119*** 0.106 0.133 18-24 0.114*** 0.099 0.130 0.130*** 0.113 0.149 0.128*** 0.110 0.150 Healthcare Coverage No 1.000 1.000 Yes 2.182*** 1.927 2.471 1.911*** 1.662 2.197 Education Less than HS 1.000 High School 1.254* 1.034 1.520 1-3 Years College 1.338** 1.106 1.619 4+ Years College 1.593*** 1.316 1.928 Household Income <$14,000 1.000 $15,000-$24,999 1.083 0.909 1.290 $25,000-$34,999 1.213* 1.020 1.442 $35,000-$49,999 1.139 0.964 1.345 $50,000-$74,999 1.180 0.999 1.395 >$75,000 1.324** 1.119 1.567 Period 2000-2008 1.065*** 1.052 1.079 1.069*** 1.055 1.082 1.066*** 1.051 1.080 Valid n.f 35,021 34,920 31,437 * p <0.05; **p <0.01; * **p <0.001. t AOR, adjusted odds ratio; CI, confidence interval. t Unweighted sample size. RACIAL AND ETHNIC DIspARITIEs IN sEAsONAL INFLUENzA vACCINATION 17 2011 U tah's h e a l th : an a n n u a l re v iew ings for non-Hispanic Whites in Figure 2, the overall trend in flu vaccination over this period of observation was positive and statistically significant (p < 0.001). In Model 2, we extend the previous model by controlling for healthcare coverage. Most interesting is the disappearance of any statistically significant effect of Hispanic ethnicity on the odds of vaccination (p = 0.99) when controlling for healthcare coverage. Among respondents with some form of healthcare, the odds o f receiving an influenza vaccination were over two times greater than respondents without healthcare coverage (p < 0.001). Model 3 includes all variables in Models 1 and 2 and also adds education and household income. In this model, the non-significant impact of race/ethnicity is maintained. However, it is interesting to note that controlling for healthcare coverage, education and household income causes the odds o f vaccina-tion among Hispanics to reverse relative to Model 1. That is, in Model 3 the odds of vaccination are about 13% higher among Hispanics than non-Hispanic Whites - and this effect ap-proaches a marginal level o f statistical significance (p = 0.14). d i s c u s s i o n As shown through these analyses, there were significant dif-ferences in flu vaccination rates across racial/ethnic groups in Utah during the 2000-2008 flu seasons. The main finding to emerge from our study is that Hispanics in Utah were generally vaccinated at lower rates than non-Hispanic Whites. Unfortu-nately, over the past decade disparities between non-Hispanic Whites and Hispanics in seasonal influenza vaccination have in-creased. While Hispanic ethnicity appears to play an important role in determining influenza vaccination, its effect is driven primarily by access to some form of healthcare coverage, as well socioeconomic factors. This is promising news, as it suggests that policies and programs designed to address basic structural barriers like health insurance and education can potentially overcome certain racial/ethnic health disparities, including widening gaps in influenza vaccine coverage in the state o f Utah. Another key finding in our study is the jump in vaccina-tion rates for each racial/ethnic group that occurs at the age of 65. Aside from being more susceptible to influenza related complications (which could motivate individuals to seek im-munization), a likely explanation for the large increase in flu vaccination rates for individuals ages 65 and older is Medicare coverage, which starts at the age o f 65 and usually covers the cost o f influenza vaccinations. Additionally, since the target age populations for the influenza and pneumococcal vaccination overlap, the CDC strongly recommends that health-care officials administer the vaccines concurrently which may also increase vaccination rates among those 65 and older (CDC 2002). We think it is important to note that the sharp drop in vac-cination coverage for non-Hispanic Whites during the 2004 season was expected, since that season experienced a serious shortage in flu vaccination supplies (Zimmerman et al. 2006). It is interesting to note however, that the 2004 vaccine short-age did not drive Hispanic vaccination rates any lower - in fact, our estimates suggest that they rose somewhat and the disparity between Hispanics and non-Hispanic Whites narrowed. One ex-planation for relatively stable vaccination rates among Hispan-ics during the vaccine shortage could be greater efforts to reach vulnerable populations during this period of time. That is, 2004 could be interpreted as a public health success story. Unfortu-nately, during subsequent years vaccination rates continued to decline for Hispanics. It wasn't until the 2007 influenza season, when vaccinations supplies had fully recovered, that vaccination rates among Hispanics improved noticeably. Between non-Hispanic Whites and Hispanics, one o f the most important gaps in coverage appears in the 55-64 age group. In this age category, about 39% o f Hispanics reported receiv-ing a flu vaccine, as opposed to 49% o f non-Hispanic Whites. Addressing this particular racial/ethnic disparity is important given the increased susceptibility of older individuals to flu complications (Nichol 2007). Men of Hispanic descent were also substantially less likely than other groups to receive the flu vaccine, which may point to a need for outreach programs targeted at Hispanic males. Similarly, persons with low income, little education, and no form of healthcare coverage are gener-ally less likely to receive influenza vaccination. Public health stakeholders should take note o f these high-risk groups. c o n c l u s io n Reduced disease burden and improved population health can be achieved through routine vaccination for seasonal influenza. Unfortunately, this study demonstrates that there are signifi-cant racial/ethnic and sociodemographic disparities in vaccina-tion rates in the state of Utah. Moreover, estimated disparities between non-Hispanic Whites and Hispanics have widened substantially over the past decade. Importantly however, the impact of Hispanic ethnicity on the odds o f vaccination ap-pears to be a function of healthcare coverage, education and household income. This lends support to the findings o f Chen et al. (2006) which found that structural barriers (such as lack of health insurance) were the greatest impediment to Hispanics in obtaining a seasonal flu vaccine. With only 58% of Utah Hispanics reporting some form of 18 RACIAL AND ETHNIC DIspARITIEs IN sEAsONAL INFLUENzA vACCINATION UTAH'S HEALTH: AN ANNUAL REviEw 2011 healthcare coverage as opposed to 88% of non-Hispanic Whites during the period of observation in this study, it is clear that important gains in influenza vaccination coverage can be made by increasing healthcare coverage among Hispanics. Further-more, continued efforts to better inform Hispanic males about the benefits o f vaccination would be worthwhile. Across all race/ethnicities vaccination rates were very high for the 65+ age group during the 2000-2008 flu seasons. While Utah has done remarkably well in vaccinating this vulnerable age group regardless of race/ethnicity, it has fared less well in terms of reducing racial/ethnic health disparities, which is a primary public health objective outlined in Healthy People 2020 (U.S. Department o f Health and Human Services 2010). The seasonal flu is a serious disease that carries substantial mortality, morbidity, and economic burdens for the state of Utah. Addressing racial/ethnic disparities in influenza vaccina-tion, especially among Hispanics, will reduce these burdens while simultaneously helping achieve nationally prominent public health objectives. By focusing on initiatives that improve access to healthcare and health insurance and that increase the overall socioeconomic condition of the Utah Hispanic popula-tion, the disparity between Hispanics and non-Hispanic Whites in terms o f seasonal influenza vaccination could be greatly diminished. r e f e r e n c e s 1. 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Katherine Morgan ward is the program Director for the Nurse-Midwifery and Women's Health Nurse Practitioner program at the University of Utah college o f Nursing. Ashley Lena Havlicak is an undergraduate pre-medical student majoring in psychology. David Turok is a co-Director of the University of Utah's Family planning Fellowship in the Department of obstetrics and Gynecology. k e yw o r d s survey, college student, sexuality, contraception Sexual Activity and Contraceptive Use: A survey of University of Utah Undergraduate Students Aged 18-20 Janet c. Jacobson, MD; Sara E. Simonsen, cNM, MSp H; Katherine Morgan Ward DNP, WHNP; Ashley Lena Havlicak; & David K. Turok, MD/MPH a b s t r a c t b a c k g r o u n d The majority of undergraduate college students <20 years old are sexually active and nearly all wish to protect themselves against the risks o f unplanned pregnancy and sexu-ally transmitted infections (STI). This study investigates levels o f sexual activity among University of Utah undergraduates as well as use of contraception and STI protection. m e t h o d s A convenience sample o f University of Utah students age 18-20 was surveyed using an anonymous web-based questionnaire. RESULTS Of 6,176 eligible students 23.3% completed the survey (n=1,441). Among survey respon-dents, 57.6% reported ever being sexually active and 46.3% reported being currently sexual active. Of those who reported current sexual activity 93.2% were using a method of contraception. However, only 3.7% o f those were using a highly effective method and 4.0% reported using no method. Over half of sexually active students report current use o f two or more methods of contraception and 38.0% report having used emergency contraception (EC). Of sexually active students 5.5% have been (or had a partner who was) pregnant and 4.8% report having had an STI. Over one-fourth (350, 26.8%) of respondents report hav-ing used oral sex in place of vaginal sex and 65 (5.0%) had used anal sex in place of vaginal sex as a method of pregnancy prevention. c o n c l u s io n Sexual activity and associated risks are common among University of Utah undergradu-ates surveyed. Sexually active students report high use o f contraception, multiple methods of contraception, and EC use. There are opportunities for expanding use o f highly effective methods o f contraception, EC and STI education and testing. s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e 21 2011 U tah's h e a l th : an a n n u a l re v iew Like all adolescents, teens in Utah mature in a sexu-ally complex society where they are exposed to highly sexualized images in the mainstream media. In the last decade, information for youth on healthy sexuality has become more limited with the expansion o f abstinence-only sexuality education which avoids discussions of healthy sexual relation-ships and pregnancy prevention [1]. Statistics on adolescent sexual practices and outcomes have been reported for decades, but in the current social environment they have generated greater interest. Recent publications on adolescent sexual behavior have expanded to include data on oral sex [2], anal intercourse [3] and masturbation [4]. Data on the sexual behavior o f U.S. adolescents has been generated for decades by large national samples including the Youth Risk Behavior Survey (YRBS) [5], the National Survey of Family Growth (NSFG) [6], and the National Longitudi-nal Study on Adolescent Health [7]. In 1991 54.1% of high-school students reported ever having sexual intercourse with a decrease to 46.0% in 2009. During this time, there was an increase in self-reported condom use at the time o f last inter-course from 46.2% in 1991 to 61.1% in 2009 [5]. Data on U.S. adolescent pregnancies have shown a consistent decline for the last 3 decades [8] but reached a nadir in 2005 with 2006 showing an increase in the U.S. rate [1] and further increases in Utah teen pregnancy rates from 2006-2008 [9]. Information on sexually transmitted infections (STIs) show that nationally and in Utah, rates o f Chlamydia infection have risen sharply over the last decade, and in Utah, nearly two-thirds of new cases are diagnosed in 15-24 year olds [9]. Data on the sexual behavior o f Utah's adolescents and young adults are not available. While the Utah State Department of Health thoroughly reports reproductive health outcomes for ad-olescents and young adults, it does not report on sexual behav-iors for these groups, such as levels of sexual activity, contracep-tive use or methods employed to prevent STIs. Unfortunately, the CDC's YRBS is not a source o f data on sexual activity among Utah's youth. While Utah is one of 44 states participating in the YRBS program, it is one o f four states that does not collect data on sexual behaviors [5]. The majority of studies on adolescent sexual practices have focused on younger ages (15-19 year olds) in part be-cause they are easily accessible in high school classrooms. However, information on the practices o f older adoles-cents is important as they have the highest rates o f STIs and unplanned pregnancy and may provide some insight into the practices o f those transitioning into mature sexual relationships in young adulthood. In addition, the majority of college students are sexually active, not seek-ing to become pregnant, with to avoid STI exposure and largely living for the first time with far less adult supervision and great-er possibilities for sexual exploration. These factors make early college students a suitable population to study sexual practices at time o f transition from adolescence to young adulthood. The sexual behaviors o f Utah's adolescents may differ in important ways from other states and the United States as a whole. As a state with extremely low rates of teen pregnancy and STIs, these differences may provide important information on improving outcomes. If we are to have some impact improv-ing reproductive health outcomes for our State's youth, we need to gather current information on the sexual practices that drive these outcomes. In order to collect such data, we designed an anonymous web-based survey to collect information on rates of sexual activity, contraceptive use and STI protection from a sample o f college students in Utah. m e t h o d s This research project was a component of an internet based, convenience sample survey of University of Utah undergradu-ate students, 18-20 years old, who attended high school in the United States. These college students were used to assess young adult and older adolescent sexuality behaviors because of the difficulty in accessing a large group o f young adults and adolescents under the age o f 18 in this conservative state. The survey was developed by a multidisciplinary group of experts. Questions were developed to address sexuality education, sexual behaviors, contraceptive use, and demographic data. Survey questions regarding contraceptive use were adapted from prior studies by this group of investigators [10]. The survey was initially beta tested with small groups o f uni-versity students to assess clarity and comprehension. A draft of the survey was piloted in university classroom settings and revi-sions were made accordingly. The survey participants received a series of three email messages containing a link to a web-based anonymous internet questionnaire via www.surveymonkey.com and were offered entry into a drawing for one of five $100 gift cards for completion of the survey. Respondent demographics Table 1. Methods of contraception grouped by typical use failure rates Highly Effective Effective Less Effective (<2% failure) (3-8% failure) ( > 8% failure) Implants Oral Contraceptive Pills Condoms (male or female) IUD Contraceptive Patch withdrawal Sterilization vaginal Ring Barriers Depo-provera spermicide Contraceptive Sponge Fertility Awareness Methods Emergency Contraception 22 s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e UTAH'S HEALTH: AN ANNUAL REviEw 2011 were evaluated midway through data collec-tion and because more females than males had responded, males were oversampled during the mailing o f the final invita-tion to participate in the study. The online survey was conducted between September and December 2008. All study materi-als and procedures were approved by the Institu-tional Review Board at the University o f Utah (IRB# 000 2 7 5 4 7 ). To collect information about participant's sexual activity, the following questions were included in the survey: "Do you consider yourself to be sexually active?", "Have you EVER had sex with males, females, or both?", "Are you CURRENTLY having sex with males, females, both, or neither?" , and "Have you had vaginal intercourse within the last 3 months?". To determine which con-traceptives were being used, two questions were asked. These included, "Which methods of birth control have you EVER used (or has a partner EVER used with you)? (Check ALL that apply)" and "What method(s) of contraception are you / your partner(s) CURRENTLY using? (Check ALL that apply)." The questions about contraceptive use were only asked to respon-dents who reported having a current or previous sex partner. Contraceptives were categorized according to levels o f efficacy based on typical use failure rates reported as the percent of women experiencing unintended pregnancy in the first year of use and are presented in Table 1 [11]. Highly effective methods are those with a pregnancy rate less than or equal to 2% and in-clude etonorgestrel contraceptive implants, intrauterine devices (IUDs), and sterilization. Effective methods were defined as having a pregnancy rate o f 3-8% and include oral contraceptive Table 2. Demographic characteristics of survey participants (University of Utah Undergraduate Students Aged 18-20) Demographics of Respondents Who Completed Survey (N =1441) Composition of Student Population Surveyed Variable No. (%) (%) Gender Male 542 (37.6) (42.0) Female 889 (61.7) (56.0) Race Native American or Alaska Native 12 (0.8) (0.7) Asian 92 (6.4) (9.3) Black or African-American 7 (0.5) (1.5) Native Hawaiian or Pacific Islander 9 (0.6) (1.7) w h ite or caucasian 1147 (79.6) (82.2) Other/Not Specified/Unknown 107 (7.4) (4.9) Ethnicity Hispanic or Latino 99 (6.9) (6.6) Marital Status Married 51 (3.5) * Divorced 2 (0.1 ) * Single 1286 (89.2) * Living w ith partner or sig other 90 (6.3) * Religion LDS (Mormon) 491 (34.4) * catholic 148 (10.4) * Protestant 63 (4.4) * other 105 (18.2) * Unaffiliated 415 (29.0) * Place of Birth Utah 845 (62.3) * outside o f Utah 498 (37.1) * State of High School Attendance pills, the combined hormonal contraceptive patch, the vaginal ring and Depo-Provera. Less effective methods have failure rates greater than 8% and include male or female condoms, emergency contraception (EC), withdrawal, cervical barrier methods (the cervical cap or diaphragm), spermicide, the con-traceptive sponge and fertility awareness methods. No method of contraception and abstinence were considered separate categories. Students reporting use of more than one method of contra-ception were placed in the category consistent with the most effective method in use. For example, someone using oral contraceptive pills and condoms was placed in the effective methods group. While use o f both methods simultaneously and consistently may be consistent with the failure rates in the high-ly effective range this has not been well studied. In addition, we were unable to ascertain when more than one method was s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e 23 2011 U tah's h e a l th : an a n n u a l re v iew Utah 1145 (80.6) * Outside o f Utah 275 (19.4) * Highest Education Level of Parents Did Not Finish Hs 19 (1.3) * Hs Graduate or GED 150 (10.4) * some College 370 (25.7) * College Graduate 476 (33.0) * Attended Graduate School 417 (28.9) * Childhood Household 2 parents living together 1073 (74.5) * parents Divorced 253 (17.6) * single parent 66 (4.6) * same sex parents 2 (0.1 ) * Childhood Community Type Rural 215 (14.9) * suburban 972 (67.5) * Urban 198 (13.7) * Annual Income of Childhood Household < $25,000 53 (3.7) * $25,001 - $50,000 216 (15.0) * $50, 001 - $75,000 240 (16.7) * $75,001 - $100,000 263 (18.3) * > $ 100,000 243 (16.9) * Number of Childhood Household Members 2 or less 84 (5.9) * 3 192 (13.5) * 4 387 (27.3) * 5 309 (21.8) * 6 210 (14.8) * 7 or more 236 (16.6) * * Data not available for the UU student population reported if use was simultaneous with each act of intercourse or had been used recently but not simultaneously. Statistical analyses were conducted using STATA 11 statistical software (College Station, Texas). Respondents were given the response option "I prefer not to answer this question" for each question in the survey. Answers in this category were coded as missing for analysis. Analyses about use of contraceptives were stratified into 3 groups: history of contraceptive use among all respondents who reported having had sex, current use of contraceptives among all respondents who reported having had sex and current use o f contraceptives among respondents with a current sex partner. Raw numbers and percentages are reported for demographics and health behaviors. In addition, we report raw numbers, percentages, means, and standard deviations for information on sexual behaviors and pregnancy history among respondents. r e su l t s There were 6,176 students who met inclusion criteria and received an email inviting them to partici-pate in the survey. Twenty six percent o f eligible stu-dents (n=1,587) initiated the survey, and 23.3% completed it (n=1,441). A demographic description of the respondents can be found in Table 2. The majority o f respondents were single, Non-Hispanic Caucasians who reported being born and graduating from high school in Utah. More females than males completed the survey. Just over 1/3 o f respondents (34.4%) reported belong-ing to the predominant religion in Utah-the Church o f Jesus Christ of Latter Day Saints (LDS). The demographic pro-file o f study participants was representative o f the greater University of Utah population (see Table 2). Information on the number and percentage of respondents who report being sexually active varies depending upon the question analyzed. Overall, 46.3% o f respondents (n=560) reported being sexually active, while 57.6% (n=700) reported having had a sex partner either in the past or present. This includes 44.0% o f respon-dents (n=534) who reported that they were currently having sex with one or more partners o f either sex and 13.7% (n=166) who reported having had sex in the past but who did not have a cur-rent partner at the time o f the survey. Among all respondents who reported being sexually active at the time of the survey (n=560), 93.2% reported using at least one method of contraception. Overall, the most common meth-ods of contraception used by sexually active respondents, either alone or in combination with other methods, included condoms 24 s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e U ta h 's h e a l t h : a n a n n u a l r e v ie w 2011 Table 3. Abstinence & Methods of Birth Control by Level of Efficacy Reported by University of Utah Undergraduate Students Aged 18-20 Efficacy Level o f Birth Control Method Ever Used Contraception Among Respondents who Have Had sex (N = 696) Current Contraception Use Among Respondents who Have Had sex (N = 667) Current Contraception Use Among Respondents w ith a Current sex partner (N = 521) N (%) N (%) N (%) Highly Effective 25 (3.6) 20 (3.0) 19 (3.7) Effective 490 (70.4) 362 (54.3) 331 (63.5) Less Effective 155 (22.3) 162 (24.3) 142 (27.3) Abstinence 5 (0.7) 54 (8.1) 8 (1.5) None 21 (3.0) 69 (10.3) 21 (4.0) Table 4: Sexual Activity Status & Current Number of Birth Control Methods Reported by University of Utah Undergraduate Students Aged 18-20 Number of Current Birth Control Methods Respondents Who Have Had Sex (N =667) Respondents With A Sex Partner at the Time of Survey (N = 521) Frequency percent Frequency percent One Method 290 (43.5) 213 (40.9) Two Methods 220 (33.0) 203 (39.0) Three Methods 79 (11.8) 75 (14.4) Four Methods 9 (1.4) 9 (1.7) None 69 (10.3) 21 (4.0) (61.3%), oral contraceptives (52.6%), withdrawal (28.1%), and abstinence (5.5%). Table 3 shows that of the 667 University of Utah students ages 18 to 20 who reported having had sex and who answered the questions on current contraceptive use, only 3.0% were using a type of birth control that was highly effective. Most students (54.3%) were using effective forms of birth control, 24.3% were using less effective forms of birth control, 8.1% were abstaining and 10.3% were not using any form of birth control. When comparing the results among all individuals who report-ed having had sex with those of individuals who reported having a sexual partner at the time of the survey, the latter group had slightly greater use of very effective (3.7%) and effective (63.5%) methods (see Figure 1). Use of multiple methods o f contracep-tion was common (Table 4). Among college students who report having had sex, only 4.8% reported having been diagnosed with an STI and only 5.5% reported ever being pregnant or getting a woman pregnant (see Table 5). The most common STIs were human papilloma virus, chlamydia, and herpes. When asked about sexual behavior, 350 (28.4%) of respondents answered they had used oral sex in place of vaginal sex and 65 (5.2%) had used anal sex in place of vaginal sex as a method of pregnancy prevention. For sexually active respondents 92.2% had opposite sex partners, 5.9% had same sex partners and 1.9% had both opposite sex and same sex partners. Of students with same sex partners, 78.1% were male and 22.0% were female (Table 5). Current sexual activ-ity (Table 6) was reported more frequently by fe-males (48.8%) than males (41.8%), non-LDS affiliated college students (56.8%) than LDS affiliated college students (26.6%) and students who attended high school outside o f Utah (54.7%) vs those who attended high school in Utah (44.3%). Current contraceptive use (Table 6) was re-ported more frequently by females (93.0%) than males (82.7%), similarly among non- LDS and LDS affiliated college students (89.7% and 88.4% respectively) and more frequently among students who attended high school outside of Utah (94.5%) vs (88.0%). The non-response rates for survey questions ranged from 0.1% (Are you male or female?) to 53.4% (What method(s) of contraception are you / your partner(s) currently using?). d i s c u s s i o n This survey of college students in Utah establishes a baseline to begin understanding sexual and contraceptive practices among those transitioning to young adulthood. University of Utah students aged 18-20 report relatively low rates o f sexual activity, unplanned pregnancy and STIs relative to comparative national samples. The 57.6% of our sample reporting ever having had sex and 46.3% who are currently sexually active are fewer than that reported by the YRBS for both 12th grade and college students in other states. For 12th graders, the portion o f the YRBS clos-est in age to our sample, the most current published data were collected in 2009. Sexually activity increases at each year when adolescents are surveyed, thus we would expect our sample (18-20 year olds) to report higher rates o f sexual activity than 12th graders. However, in 2009, 62.3% o f 12th graders reported ever having sexual intercourse and 49.1% reported being cur-rently sexually active (defined as sexual intercourse within the 3 months preceding the survey). Only one version of the YRBS s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e 25 2011 UTAH'S HEALTH: AN ANNUAL REviEw Table 5: Pregnancy and Sexual Practice Reported by University of Utah Undergraduate Students Aged 18-20, Who Report Having Had Sex p r e g n a n c y d at a Frequency Percent History o f Pregnancy 39 (5.5)* History o f Abortion 15 (2.1 )* History o f Miscarriage 15 (2.1 )* Respondents with children 9 (1.3)* Mean Standard Deviation Age at time o f Pregnancy 17.3 (4.3) s e x u a l a c t iv it y DATA Frequency Percent Sexually Active 560 (46.3) Has one or More current Sex Partner(s) 534 (44.0) Had vaginal Intercourse within Last 3 Months 549 (45.2) Ever Used oral Sex to Avoid Pregnancy 350 (28.4) Ever Used Anal Intercourse to Avoid Pregnancy 65 (5.2) Sex o f Partners opposite Sex Partner(s) 642 (92.2) Same Sex Partner(s) 41 (5.9) Partners o f Both Same and opposite Sex 13 (1.9) Mean Standard Deviation Age at Time o f First Intercourse 16.9 yrs (1.7 yrs) Number of Sexual Partners in Past 12 Months 2.1 (3.6) Number o f Sexual Partners in Lifetime 3.8 (4.3) *The denominator is all respondents who answered the question "Have you ever been pregnant before / gotten a woman pregnant?" (n=704) included college students and the data were collected in 1995. In this survey, 79.5% o f college students aged 18-24 reported ever having sexual intercourse and 62.1% reported current sexual activity (intercourse within the 3 months preceding survey) [12]. O f note, our sample may under represent males aged 19-20 because o f members o f this group who are participating in LDS missions. We did not attempt to contact members o f this group as they were not enrolled students at the time o f the survey. Due to the conservative sexual nature o f this under-represented group, we would expect even lower rates of reported sexual activity. This would likely have driven the overall percentage o f sexually activity reported down even further. While levels o f sexual activity are low among our sample compared to national norms, use of contraception among those who are sexually active is consistent with data from the YRBS. Though use o f the most effective methods among currently sex-ually active students is low (3.6%), the large majority of sexually active students are using reliable methods of contraception. Several practices might decrease the risk of unplanned pregnan-cy in this group. The use o f multiple methods of contraception is encouraging and the majority of sexually active students in our sample report this. In the National Survey o f Family Growth (NSFG) males aged 15-19 reported using dual methods 24% of the time at last sexual intercourse. University of Utah students who are currently sexually active compare favorably with this figure as 55.1% report using two methods or more. If these multiple methods are used consis-tently, this could significantly increase contraceptive efficacy and reduce unplanned pregnancies. In addition, use o f EC is high with 38.0% report-ing having used dedicated emergency contracep-tive pills or combined oral contraceptive pills for EC. This is more than twice the figure reported in a recent study of Pennsylvania college students [13]. The high use o f EC suggests the importance o f edu-cating students regarding use of EC within 12 hours of intercourse when it is most effective. Students should also know that EC is best used as a back-up method. Additionally, students should know that over time, the lowest rates of pregnancy are as-sociated with forgettable methods of contraception (methods with little possibility for user error once inserted including IUDs and the contraceptive im-plant). Unfortunately, use of no method of contra-ception appears to be consistent with NSFG data for this age group with approximately 10% of University of Utah students reporting this behavior. The use o f oral sex and anal intercourse to avoid vaginal intercourse is an effective strategy to prevent pregnancy; however, engaging in these behaviors carries the risk o f STIs. Young people are less likely to use a barrier method for STI protection during these behaviors [14], increasing the risk of STI transmission [15]. In addition, the currently sexually active Utah college students we sampled actually used condoms less frequently than 12th graders sampled in the YRBS (45.1% vs. 55.0%). These factors, especially when viewed from the perspec-tive of increasing STI rates in Utah, demonstrate the need for greater STI education for young people and the need to encour-age STI testing on campus. We do not have specific statistics on frequency of anal sex but 5% report using this activity to prevent pregnancy. The frequency of this behavior may be similar to the 10% reported among adolescents [16] and the 20% reported in a recent study o f college students [4]. This behavior along with the high use of EC may indicate that students' access to effective methods of contraception may be falling short o f the need and better access to contraception and especially the most effec-tive methods is desirable. There are few options for students to 26 s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e U ta h 's h e a l t h : a n a n n u a l r e v ie w 2011 receive the best methods of contracep-tion due to lack of insurance coverage. However, the use o f IUDs may be eas-ily expanded when financial obstacles are removed as demonstrated in a survey of EC users from Salt Lake City who were offered the copper IUD [17]. Based on the number of students who have enrolled in trials of IUDs at the University, increased availability may be warmly received by this group. Like any survey of sexual behav-ior, this study is subject to reporting bias. The potential underreporting of sexual activity and over reporting of contraception and STI protection are examples o f social desirability bias when study participants provide inac-curate information that will be viewed favorably by others [18]. A recent example of this came from a study that found that more than 10% of STIs con-firmed by urine PCR came from young adults who reported abstaining from Figure 1: Current Birth Control Use by Efficacy for Current Contraceptive Users and Currently Sexually Active Contraceptive Users Highly effective is less than or equal to a 2% pregnancy rate, effective is a 3-8% pregnancy rate and less effective is anything greater than an 8% pregnancy rate. Table 6: Current Sexual Activity and Contraceptive Use by Gender, Latter Day Saint Religious Affiliation, and High School Location Current Sexual Activity = Yes Current Sexual Activity = No P value Male (N = 435) 182 (41.8%) 253 (58.2%) 0.048 Female (N = 771) 376 (48.8%) 395 (51.2%) Latter Day Saint = Yes (N = 421) 112 (26.6%) 309 (73.4%) < 0.001 Latter Day Saint = No (N = 789) 448 (56.8%) 341 (43.2%) High school in Utah = Yes (N = 974) 431 (44.3%) 543 (55.7%) 0.004 High school In Utah = No (N = 236) 129 (54.7%) 107 (45.3%) Contraceptive Use = Yes Contraceptive Use = No Male (N = 225) 186 (82.7%) 39 (17.3%) < 0.001 Female (N = 443) 412 (93.0%) 31 (7.0%) Latter Day Saint = Yes (N = 146) 129 (88.4%) 17 (11.6%) 0.453 Latter Day Saint = No (N = 525) 471 (89.7%) 54 (10.3%) High school in Utah = Yes (N = 525) 462 (88.0%) 63 (12.0%) 0.152 High school In Utah = No (N = 146) 138 (94.5%) 8 (5.5%) s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e 27 2011 UTAH'S HEALTH: AN ANNUAL REviEw sexual activity during the previous 12 months and greater than 5% o f these positive STI samples came from participants who reported never having penile/vaginal sex [19]. Of note, students in our study were given the choice to participate in the survey, had no obligation to finish the survey, and were given the option "I prefer not to answer this question" for each query. Accord-ingly, this may have reduced reporting bias where students may not have answered questions rather than providing inaccurate information but may have increased selection bias where those less likely to be sexually active might have started the survey and not continued. Internet based surveys are also limited by relatively low response rates. While only 26% o f those who received the email invitation to the survey responded, this is considered an average response for an internet survey [20] and still yielded usable re-sponses from over 1,400 participants. In other studies utilizing convenience samples to assess university students' sexual prac-tices and beliefs the response rates are comparable to ours [21, 22]. A study o f sexual activity and contraception sampling in a Utah population invites concerns o f limited external validity. A common perception is that people in Utah are more reli-gious than the rest of the country and the majority of Utah resi-dents belong to a single religious group. However, the survey showed this in not the case as 66% o f respondents considered themselves to be part of an organized religion, and 29% had no religious affiliation. A national poll o f all adults shows that 83% practice some form of organized religion and only 16% are unaf-filiated. When breaking the groups down by age, the national data shows that one-quarter of all adults 18-29 are unaffiliated [23]. However, one must consider that the University popula-tion itself could potentially be less religious than the general adult population, and may pose a limitation when translating these results to the general young adult population. The influ-ence of abstinence only sex education is not addressed in this manuscript but will be addressed in a forthcoming one devoted to the specific relationship between sources of sexuality educa-tion and its relationship with sexual knowledge and practice. This data set provides novel information on the sexual and contraceptive practice of University o f Utah undergraduates transitioning to young adulthood. This sample is not represen-tative o f all University students or all State residents in this age group; however, it does provide some information to indicate that sexual activity is likely less frequent and contraceptive use overall is similar to other U.S. college students with greater use of EC and multiple contraceptive methods. Providing students with greater access to the most effective methods of contracep-tion and increasing knowledge of STI exposures may further reduce STIs and unplanned pregnancies in Utah's young adults. 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Journal ofAdolescentHealth, 2008. 43(3): p. 231-238. 17. Turok, G., Handley, Simonsen, Sok, North, Frost, Murphy, A survey of women obtaining emergency contraception: are they 28 s e x u a l a c t iv it y a n d c o n t r a c e p t iv e USE U ta h 's h e a l t h : a n a n n u a l r e v ie w 2011 interested in using the copper IUD? Contra-ception, 2010. 18. Stuart, G.S. and D.A. Grimes, Social desirability bias in family planning studies: a neglected problem. Contraception, 2009. 80(2): p. 108-112. 19. Diclemente, R.J., et al., Association Between Sexually Transmitted Diseases and Young Adults' Self-reported Abstinence. Pedi-atrics, 2011. 20. Creech, S. Instructional Assessment Re-sources. 2007 [cited 2010 December 6, 2010]; Available from: http://www.utexas.edu/aca-demic/ ctl/assessment/iar/teaching/gather/ method/survey-Response.php. 21. Davidson Sr, J.K., et al., Sexual attitudes and behavior at four universities: Do region, race, and/or religion matter? Adolescence, 2008. 43(170): p. 189-220. 22. Hans, J.D., M. Gillen, and K. Akande, Sex redefined: the reclassification of oral-genital contact. Perspect SexReprodHealth, 2010. 42(2): p. 74-8 . 23. (TPF), T.P.F.o.R.P.L., U.S. Religious Landscape Survey; Religious Affiliation: Diverse and Dynamic. 2008, Pew Research Center: Washington, DC. 24. (WHO), W.H.O. Gender and Human Rights. Sexual and Reproductive Health 2002 [cited 2011 May 16, 2011]; Available from: http://www.who.int/reproductivehealth/top-ics/ gender_rights/sexual_health/en/. s e x u a l a c t iv it y a n d c o n t r a c e p t iv e u s e 29 2011 U tah's h e a l th : an a n n u a l re v iew k e yw o r d s public health, protocols, decision making a c k n o w l e d g e m e n t s This research is supported by the Utah Center of Excellence in public Health Informatics funded by the CDC. We express thanks to Juliana Grant for sharing her medical expertise, and to Jeffrey Norris for assistance in conducting interviews. In addition, we acknowledge and thank the Utah Local Health Officers' Association and the southern Nevada Health District for their support and participation; and the University of Utah physicians and professors who assisted in the creation and piloting of the interview. Protocol Use in Disease Outbreak Investigations: Applying a Technical Systems Solution to a Natural System Problem Heidi s. Kramer, Ms; Laverne A. snow, MpH; Matthew Samore, MD; and Frank A. Drews, PhD a b s t r a c t BACKGROUND Disease outbreaks affect millions of Americans every year and have potentially large health and financial costs. To manage the scope and diversity o f diseases public health agencies rely on the use o f protocols when conducting disease outbreak investigations. Protocols and checklists provide a good fit for dealing with situations in technical systems where there is little variation. However, disease outbreaks occur in natural systems that are characterized by their unpredictability. Understanding the effectiveness and limitations of protocol use in disease outbreak investigations is important to improving investigation outcomes. m e t h o d s We conducted a study that included semi-structured interviews with public health disease outbreak professionals to investigate the benefits and limitations related to the use of pro-tocols in managing disease outbreaks. r e su l t s Participants perceived significant benefits from the use of protocols; however, they were quick to note the limitations o f protocols. The perceived limitations can be classified into three groups based on root causes: 1) Protocols are underspecified, 2) Protocols become outdated and 3) Protocols are ambiguous. c o n c l u s io n s The issues of protocol use in the natural system of disease outbreak investigations can be addressed by a collaborative effort to improve disease outbreak investigations in at least three ways. Every year disease outbreaks affect millions o f Americans. A few of these disease outbreaks receive national attention. Examples include the 2010 and 2009 sal-monella outbreaks-the 2010 outbreak was linked to eggs and the 2009 outbreak 30 p r o t o c o l u s e i n d is e a s e o u t b r e a k i n v e s t i g a t i o n s UTAH'S HEALTH: AN ANNUAL REviEw 2011 was linked to peanuts and peanut butter. In addition to the risk of illness and possible death, huge financial costs can result from implicating food sources in enteric disease outbreaks-e.g., millions o f eggs were recalled [1] and more than 2000 products containing peanuts and peanut butter were recalled by over 50 manufacturers [2]. In the United States, large disease outbreaks are investigated and managed by state and local health departments in conjunc-tion with the U.S. Centers for Disease Control and Prevention (CDC). Aside from the larger outbreaks, many smaller, localized outbreaks are managed on a daily basis by local and state health departments. As a first step in outbreak detection the health departments must be informed. Utah has more than 70 diseases defined as "reportable." Due to the quantity and variability of these reportable diseases, the state and local public health agen-cies rely on protocols in the form of disease investigation plans and guidelines. Use o f checklists and protocols. Checklists are used in a wide range o f areas as cognitive aids to support a person in com-pleting a task. The use of checklists was pioneered in aviation to manage the growing complexity of modern aircraft and to produce reliable performance o f the human operator. Proto-cols have a similar function as checklists; disease investigation plans are protocols used in public health. Disease investigation plans are a procedural method that prescribes the design and implementation o f essential steps in the investigation. Disease investigation plans often include information describing the disease and epidemiology (e.g. clinical description, causative agent, laboratory identification, incubation period and period of communicability), public health control measures, and case investigation (e.g. reporting, outbreak definitions and case man-agement). As with guidelines in other aspects of health care, dis-ease investigation plans focus on assistance in making decisions and education [3]. Benefits o f protocols. There are multiple benefits to the use of protocols such as the disease investigation plans: Protocols serve as a repository o f background information and actions to be taken-thus simplifying the conceptualization and recall of information [4]. A well structured protocol often allows people who are not experts in a task to perform that task at a level that is similar to that o f an expert [5]. In addition protocols can be effective in error prevention and performance management [6-8] Limitations o f checklists and protocols in a natural system context. There are a number of limitations that potentially may be associated with the use o f checklists and protocols in public health. The domain and context of a protocol's application is an important aspect of protocol use that has not yet received suf-ficient attention. The use of checklists was pioneered in aviation which can be conceptualized as a technical system. However, when managing a disease outbreak, a public health investigator deals with a biological or natural system (disease) at the core. Disease outbreaks are characterized by their unpredictability. Protocols and checklists provide a good fit for dealing with situ-ations where there is little variation. For example, the displays in a cockpit of an aircraft, or the steps to manage an emergency in that cockpit do not change; therefore a checklist can be ap-plied consistently. However, in disease outbreaks many idiosyn-crasies have to be taken into account, including the context of the illness and the evolution of infectious diseases. As a conse-quence, one disease outbreak investigation will not be identical to another. Clearly there are differences between the technical system context o f aviation and natural system context o f public health disease investigations. Understanding the differences between natural and technical systems may cast some light on the effectiveness and limitations of protocol use. There are at least three distinguishing factors between natural and technical systems. The first is adaptability. A natural system adapts by evolving as the context and environ-ment changes. A technical system is created by a purposeful, intentional design process. The second distinguishing factor is the transparency o f the system. Natural systems are opaque and usually not very well understood, where technical systems are designed in such a way that they are transparent, (i.e., re-lationships between components are static and easy to under-stand). The third distinguishing factor applicable to technical and natural systems is predictability. A consistent, transparent technical system is designed to be easy to understand and main-tain, making prediction possible. Natural systems are difficult to understand because of their opaque and adaptive nature and consequently are difficult to predict. The investigation o f disease outbreaks happens in a dynamic and complex environment. In the context o f public health an outbreak investigator is dealing with a natural system that affects members in a community. A situation of opposing requirements is established: protocols should yield clear recom-mendations, yet protocols must also be sufficiently flexible to accommodate complex dynamic situations. We conducted a study to examine the tensions/issues that exist when applying the technical systems solution o f checklists and protocols to a natural system problem. Our overall goal is to find ways to improve disease outbreak investigations. The term protocol as used in the interviews could include state disease investigation plans or guidelines, CDC published guidelines or other formal or informal guidelines used in the course of an investigation. p r o t o c o l u s e i n d is e a s e o u t b r e a k in v e s t ig a t io n s 31 2011 U tah's h e a l th : an a n n u a l re v iew Table 1. Interview Questions What infectious communicable diseases do you investigate most often? Have you ever considered excluding someone from work o r school due to an infectious disease-related issue? (Depending on the participant's role, this question may be modified to ask if they have ever considered closing a restaurant or closing a pool.) Did protocols or guidelines exist? How did the protocols help you make decisions? Were there any problems in following the protocol? Was the protocol specific enough for the situation? What are the limitations o f the use of protocols or guidelines in the context o f your work? METHOD Participants. Study participants were employees of state and local health departments in urban and rural jurisdictions in Utah and Nevada. Participants included epidemiologists, microbi-ologists, environmental health scientists, nurses and physicians. All participants were involved in communicable disease prevention, surveillance, investigation, facility inspection and enforcement and/or case management. These professionals ranged from department directors to frontline staff. Procedures. Forty-one semi-structured interviews were conducted as part of a study approved by the University of Utah Institutional Review Board. Signed consent was obtained from each participant. The design of the interview process was refined by conducting a number of pilot interviews. The interview consisted of two parts. The first part focused on protocol use. (See Table 1 for a high level presentation o f inter-view questions.) In the second part o f the interview participants conducted a simulated outbreak investigation using an enteric disease scenario. The focus of this paper is protocol use, and the results o f the second part of the interview will be presented elsewhere. All interviews were digitally recorded, and profes-sionally transcribed. The first part of the interview was coded using qualitative research techniques. A coding schema was developed through iterative sessions to assure agreement based on identified categories. The inter-rater reliability was 80% agreement on the codes used across interviews. Coding was done by reading the interviews and marking sections with the defined codes. This paper is based on in-depth analysis of codes relating to protocol use and information resources. r e su l t s Thirty-eight of the 41 participants (93%) described a situa-tion where ambiguity or confusion was present in the context of using a protocol. Ninety-three percent of the participants mentioned issues with the availability, evaluation or reliability of information. These coded quotations were further analyzed for specific references to protocol use. From this analysis two categories emerged; 1) Perceived benefits of protocols; and 2) Perceived limitations o f protocols. The perceived limitations were further classified into three groups based on root causes: 1) Protocols are underspecified, 2) Protocols become outdated; and 3) Protocols are ambiguous. These classifications are dis-cussed in detail below. Perceived benefits o f protocols. Participants identified a num-ber o f benefits from using protocols: • Provide valuable information on the organism, incuba-tion period and transmission o f the diseases. • Define roles for disease investigation actions. • Provide a rationale for recommended action. • Save time by being a repository o f information (ques-tions to ask, priorities and case definitions). • Give the actions taken credibility and acts as a defense for actions taken. The benefits of protocols clearly involve accessibility of information needed for the investigation; protocols structure the investigation in terms of steps and roles taken and provide accountability, because they are based on scientific findings and knowledge o f diseases. Perceived limitations o f disease investigation protocols. Despite the fact that protocols have a number of benefits, par-ticipants also identified challenges and limitations o f protocol use. Three root causes o f these challenges and limitations are underspecification, obsolescence and ambiguity. These issues are outlined below. Underspecification. The first root cause of protocol limita-tions is that p ro to co ls a r e u n d e r sp e c if ied . Specifically, participants revealed the following issues: • Protocols may not define who is responsible for the ac-tions to be taken. • Rationale is not always given for recommended actions. • Timelines for recommended actions may be inconsistent or nonexistent. • "Unusual" illnesses are required to be reported and investigated; however, a specific protocol, laboratory test for confirmation, or agreed upon intervention may not exist for rare or new diseases. • Protocols lack guidelines on how to ensure patient com-pliance with recommend actions. • Protocols are based on individual diseases and do not provide guidelines for prioritizing investigation actions 32 p r o t o c o l u s e i n d is e a s e o u t b r e a k i n v e s t i g a t i o n s UTAH'S HEALTH: AN ANNUAL REviEw 2011 when there are simultaneous outbreaks. Implicit and inconsistent priorities are set for investigating diseases based on factors such as prevalence, transmission risk or illness severity. • Protocols may not include "bestpractice" as defined by experts. Underspecification in the protocols is a significant concern. A majority of features that were identified as making protocols beneficial are problematic when that information is missing. Specifically, it appears that information on roles, responsibili-ties for actions and adequate, consistent timelines along with providing rationale for intervention are both strengths and weaknesses o f protocols. Other important underspecification is-sues raised by participants related to the lack o f information on how to identify and respond to rare diseases, identify and stan-dardize use o f best practices and issues regarding compliance. Obsolescence. The second root cause o f protocol limitations is that p roto co ls can b ecom e outdated. The following were discussed by participants as contributing to protocol obsoles-cence: • Diseases may evolve. • New antibiotics, laboratory tests and vaccines are cre-ated. • New information is discovered or received on the ef-ficacy of vaccines and the sensitivity and specificity of confirmatory tests. • Treatment recommendations change. • Diseases listed as "reportable" change. • Political and social priorities change. Some o f the above factors reflect changes in technology and progress in medical science. These changes require modifying existing protocols and the development of new protocols. In addition, the biological changes of diseases as a result of adapta-tion creates a situation where protocols potentially lose their ap-plicability. Competition for time and resources may not permit protocols to be modified within an appropriate timeframe. Ambiguity. The third protocol limitation-p ro to co l am bi-g u ity-relates to the difficulty in predicting and defining the conditions where the protocols will be applied. The following factors were identified as contributing to ambiguity: • Protocols assume valid information and timely diag-nosis and reporting. Often the information reported to the health department is unreliable and the receipt of case reports often does not allow time for appropriate intervention. • The terms used in the protocols may be ambiguous or hard to define (e.g., exposure, contact, and enhanced surveillance). • Recommended actions may be based on information that is difficult to assess (e.g., vaccination levels and popula-tion immunity). • Recommended actions may be based on conditions that are subjective (e.g., anticipated patient compliance, pa-tient hygiene or patient comprehension). Ambiguity in protocol use appears to be a serious issue. The protocol may appear to clearly state the conditions under which actions should to be taken; however, the terminology, limita-tions in accessibility and reliability o f information, and subjec-tive assessment of conditions are problems that lead to ambigu-ity. This ambiguity undermines some o f the benefits of protocol use. d i s c u s s i o n The results o f this study indicate that participants have con-tradictory perceptions of disease investigation protocols. It is very clear that outbreak investigators appreciate the benefits of having resources that help in their investigations o f the dozens of reportable diseases; however, participants were also quick to point out the limitations o f the protocols. Note that topics listed as benefits are also noted as problems when they are underspec-ified (e.g. definition of roles, rationale, timelines and guidelines for investigation). This contradiction might be indicative of the fact that the level of development o f protocols varies, thus creating variability in the utility of individual protocols. One of the recommendations based on this result is to perform regular protocol audits that identify the potential problems individu-ally and to implement measures that remedy these weaknesses. However, to make these audits effective, in addition to subject matter experts, Human Factors experts should be involved to evaluate the cognitive limitations and implications o f protocols. One cognitive implication related to remediating under-specification is that in complex systems developers of protocols cannot foresee all the possible scenarios [9]. Even if it were possible to foresee all possible scenarios, the assimilation of the amount o f information necessary would likely result in cognitive overload and a rejection or potential misuse of such a compre-hensive protocol. The other limitations o f protocols in the context of public health are even more difficult to address; this difficulty is re-lated to the fact that public health deals with a natural system at its core. Many of the assumptions related to the use of protocols are carried over from their origins in technical systems. This is illustrated by the implicit assumption of disease investiga-tion protocols that disease characteristics can be defined and recommended actions will result in predictable and favorable outcomes. However, these assumptions do not take into account p r o t o c o l u s e i n d is e a s e o u t b r e a k in v e s t ig a t io n s 33 2011 U tah's h e a l th : an a n n u a l re v iew the level of uncertainty that is inherent to information in this context, the fact that the results of interventions differ in their efficacy and that often no clear evidence is available that would allow for a conclusive diagnosis. Protocol use in public health is also plagued by unreliable information, inappropriate timing, ambiguous terms, lack of access to information and the subjective interpretation of cues. Clearly, these issues cannot be resolved by creating an updated or more complete version of the protocol. These issues are inherent to the issue o f protocol use in a non-technical domain. Additionally, although protocols for both technical and natu-ral systems often require information to be updated, diseases adapting to changing conditions pose a serious challenge for maintaining outbreak investigation protocols. Varying levels o f investigators' expertise is another impor-tant aspect that affects the use of protocols. The incidence of diseases does not occur with equal prevalence. Consequentially, investigators may become very familiar with some diseases. When investigators have experience investigating a disease they may not reference the protocol. Therefore, any changes or details in the protocol may be missed and the protocol serves only a limited function. However, in the case of rare or "un-usual diseases," disease protocols have the potential to play a significant role as a substitute for expertise. Unfortunately these are the protocols that may not have been developed, or that do not get updated because of low prevalence of the disease. Thus, there is clearly a need for a rational, more structured approach that guides protocol development for rare outbreaks. Overall the results o f this study indicate that there are intrinsic challenges in the context o f protocol development for public health. Some o f these challenges can be addressed by public health professionals collaborating with human factors engineers, biomedical informaticists and software engineers. Human factors engineering can play a role the development of criteria for effective protocols and extend the focus of problem-solving beyond the content of protocols. In addition, human factors engineers can work with biomedical informaticists and software engineers to develop decision support software to facilitate investigators using what they know about the outbreak to move to resolving unknowns and explore options for ac-tion. By studying and gaining an understanding of the nature of ambiguities and other factors, such tools could be structured to present information that is filtered to apply to the current circumstances. By tailoring the presentation o f information to current circumstances the number of vague, non-specific rec-ommendations could be replaced by targeted, clear recommen-dations thus increasing compliance with protocol use [10]. In conclusion, the issues of protocol use in the natural system of disease outbreak investigations can be addressed by a col-laborative effort to improve disease outbreak investigations in at least three ways: 1) Perform protocol audits that identify the potential prob-lems of individual protocols and to implement measures that remedy these weaknesses. 2) Distinguish the differences (adaptability, transparency, and predictability) in the contexts o f natural and technical sys-tems. Leverage the benefits gained from the use of protocols in technical systems while addressing the limitations when applied to natural systems. 3) Apply an understanding o f the benefits and limitations o f protocol use to the creation of tools to support cognitive effort and decision making. r e f e r e n c e s 1. CDC. Investigation Update: Multistate Outbreak of Human Salmonella Enteritidis Infections Associated with Shell Eggs. 2010 December 2, 2010 [cited 2011 January 14, 2011]; Available from: http://www.cdc.gov/ salmonella/enteritidis/. 2. CDC. Multistate Outbreak of Salmonella Infections Associated with Peanut Butter and Peanut Butter--Containing Products - United States, 2008--2009. MMWR 2009; 58(early release):1-6. 2009 [cited 2009 February 16]; January 29, 2009:[Available from: http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm58e0129a1.htm. 3. Field, M.J. and K.N. Lohr, eds. Guidelines for Clinical Practice. 1992, National Academy Press: Washington, D.C. 426. 4. Morrow, D.G., et al., The Influence of List Format and Category Headers on Age Differ-ences in Understanding Medication Instruc-tions. Experimental Aging Research, 1998. 24(3): p. 231 - 256. 5. Drews, F.A., et al., Development and Evaluation of a Just-In-Time Support System. Human Factors: The Journal of the Human Factors and Ergonomics Society, 2007. 49(3): p. 543-551. 6. Wolff, A.M., S.A. Taylor, and J.F. McCabe, Using checklists and reminders in clinical pathways to improve hospital inpatient care. The Medical Journal of Australia (MJA), 2004. 181(8): p. 428-431. 7. Boorman, D., Today's electronic check-lists reduce likelihood o f crew errors and help prevent mishaps. ICAO Journal, 2001(1): p. 17-22. 8. Helmreich, R.L., On error management: Lessons from aviation. BMJ, 2000(320): p. 781-785. 9. Reason, J., Managing the risks of orga-nizational accidents. 1997, Burlington, VT: Ashgate Publishing Company. 252. 10. Grol, R., et al., Attributes o f clinical guidelines that influence use of guidelines in general practice: observational study. BMJ, 1998. 317(7162): p. 858-861. 34 p r o t o c o l u s e i n d is e a s e o u t b r e a k i n v e s t i g a t i o n s UTAH'S HEALTH: AN ANNUAL REviEw 2011 c o r r e spo n d e n c e Brenda Ralls Utah Diabetes Prevention & Control Program Po Box 142107 Salt Lake city, UT 84114-2107 Phone: [phone] Fax: [phone] email: [e-mail] k e yw o r d s health information, women, BRFSS a c k n o w l e d g e m e n t s Article written on behalf of the Utah Women's Health Information Network May We Speak to the Lady of the House? Are women really the ones who look for health information? Kathleen Digre, MD, Sally Patrick, MLS, Sara Simonsen, cNM, MSPH, Brenda Ralls, PhD, Michael varner, MD, and Patricia Murphy, PhD a b s t r a c t Health messages directed towards the woman in a household may have the greatest lever-age for influencing other household members. There is a widely held assumption that women, more than men, seek out health information that is used to make health-related decisions for others. However, little empirical documentation is available to confirm this idea. The Utah Women's Health Information Network (UWIN) added questions to a subsample of the 2009 statewide Behavioral Risk Factor Surveillance System (BRFSS) to test whether this assumption could be validated. Analyses were limited to respondents who reported either their husband or wife as the person who usually sought out health information (n=589). Findings showed that 74.0 percent of respondents reported that the primary health information seeker for the household was the wife. Proportions varied only slightly by the sex of the respondent, household income or the presence o f children in the household. This study supports the notion that health messages communicated to women may have a broad reach and can positively impact the health o f others in the household. Individuals are becoming increasingly proactive about taking charge of their health due, in large part, to the wealth o f readily accessible information that empowers them to make informed choices. Health topics are often featured in written media, particularly in women's magazines, and health issues are frequently discussed on radio and television programs. The Internet is an especially popular source o f health informa-tion (Baker, Wagner, Singer et al., 2003; Powell and Clarke, 2006). At least half of all w o m e n a n d h e a l t h i n f o r m a t i o n 35 2011 U tah's h e a l th : an a n n u a l re v iew Internet users report that they have looked for health informa-tion online (Cline and Haynes, 2001; Fox and Jones, 2009). An estimated 60 to 100 million people in the U.S. look for health information online at least monthly (Weaver, Mays, Weaver, Hopkins, Eroglu, & Bernhardt, 2010). Searches can be focused on finding information for one's own health, or they may reflect concerns for others in the household. Individuals are search-ing for information on illness or injury, or on preventive care topics such as school immunizations. Many health information seekers (about 70%) report they look for disease information so they can engage in more meaningful discussions with their physicians (Fox, Rainie, Horrigan, Lenhart, Spooner, Burke, Lewis, Carter, 2000). Almost half (47%) of seekers report the information they find on the Internet influences their treatment decisions (Fox and Jones, 2009; Fox et al., 2000). There is an assumption in the public health arena that women often take on the role of gathering health information for their families and use this information to influence decisions for the entire household. Thus, reaching the woman of the house-hold with health messages may have the greatest leverage by influencing not only her own health but also the health o f other household members. Despite this widely held belief that women are the gateway to household health, limited empirical docu-mentation is available to confirm this idea. A few studies have examined gender differences in searching for health information, and all support the notion that women, more than men, are likely to search for such information (Cline & Haynes, 2001; Fox & Jones, 2009; Hupfer & Detlor, 2006; National Cancer Institute, 2005; Powell & Clarke, 2006). This pattern persists whether information is sought online, through written media (such as books or magazines), through visits to the local library, or through dialogues with providers (Cour-tright, 2005; Gollop, 1997; Liu & Huang, 2008; National Cancer Institute, 2005). The same pattern is found whether the search is for health information in general or limited to looking for health information about a single disease. About 60 percent of women (but only 40 percent o f men) have sought information about cancer online (National Cancer Institute, 2005). Simi-larly, in a study of patients who had been diagnosed with an ischemic coronary event, women were much more likely than men to express the need for more information on managing their condition (Stewart, Abbey, Shnek, Grace, & Irvine, 2004). Not only are women more likely to seek information about their own health care, studies show they are more likely than men to search for health information regarding other family members. For example, in a study of men with prostate cancer, wives of the patients reported a greater need for information about the cancer than the patients themselves (Echlin & Rees, 2002; Krol va