The rising prevalence of chronic conditions among

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1 JOURNAL OF WOMEN S HEALTH Volume 25, Number 6, 2016 ª Mary A Liebert, Ic. DOI: /jwh Report from the CDC Behavioral Risk Factor Surveillace System State-Added Questios: Leveragig a Existig Surveillace System to Improve Kowledge of Wome s Reproductive Health Sheree L. Boulet, DrPH, 1 Lee Warer, PhD, 1 Alys Adamski, PhD, 1 Rube A. Smith, PhD, 1 Kim Burley, BS, 1 ad Violada Grigorescu, MD 2 ; for the BRFSS Wome s Health Workig Group* Abstract As the prevalece of chroic coditios amog wome of reproductive age cotiues to rise, studies assessig the itersectio of chroic disease ad wome s reproductive health status are icreasigly eeded. However, may data systems collect oly limited iformatio o wome s reproductive health, thereby hamperig the appraisal of risk ad protective factors across the life spa. Oe way to expad the study of wome s health with miimal ivestmet i time ad resources is to itegrate questios o reproductive health ito existig surveillace systems. I 2013, previously validated questios o wome s self-reported reproductive history, use of cotraceptio, ad ifertility were added to the Behavioral Risk Factor Surveillace System (BRFSS) by seve states (Coecticut, Ketucky, Massachusetts, Mississippi, Ohio, Texas, ad Utah); all female respodets aged years were icluded i the pool of respodets for these state-added questios. Of 8691 wome who completed the questios, 13.2% reported ever experiecig ifertility ad 59.8% of those at risk for uiteded pregacy reported usig cotraceptio at last itercourse. The iformatio garered from the stateadded reproductive health questios ca be augmeted with the BRFSS core questios o health-related risk behaviors, chroic coditios, ad use of prevetive services. Expadig existig data collectio systems with supplemetal questios o wome s reproductive health ca provide importat iformatio o risk factors ad outcomes that may ot be available from other sources. Itroductio The risig prevalece of chroic coditios amog wome of reproductive age uderscores the eed for a life course perspective to reduce morbidity ad mortality i both curret ad future geeratios. 1,2 Estimates from the Ceters for Disease Cotrol ad Prevetio s (CDC s) Pregacy Risk Assessmet Moitorig System (PRAMS) ad Behavioral Risk Factor Surveillace System (BRFSS) idicate that early oe quarter of U.S. wome years of age were obese ad approximately half participated i recommeded levels of physical activity. 3 I additio, *3% of wome reported beig diagosed with diabetes ad 10% reported beig diagosed with hypertesio. 3 Although the health status of reproductive-aged wome i the Uited States has improved over the past four decades, the burde of chroic disease is icreasig with cosequet effects o the physical ad metal health status of wome. 4 I additio, cosiderable health disparities remai ad may be exacerbated by barriers to healthcare access ad socioecoomic 1 Divisio of Reproductive Health, Natioal Ceter for Chroic Disease Prevetio ad Health Promotio, Ceters for Disease Cotrol ad Prevetio, Atlata, Georgia. 2 Divisio of Health Iformatics ad Surveillace, Ceter for Surveillace, Epidemiology ad Laboratory Services, Office of Public Health Scietific Services, Ceters for Disease Cotrol ad Prevetio, Atlata, Georgia. *BRFSS Wome s Health Workig Group cosists of the followig members: Carol Stoe (Coecticut Departmet of Public Health); Sarojii Kaotra (Ketucky Departmet of Public Health); Daa Berso (Massachusetts Departmet of Public Health); Charlee Collier, Ro McAally, ad Lei Zhag (Mississippi State Departmet of Health); Jillia Garratt ad Tyler Paye (Ohio Departmet of Health); Mihaela Johso, Divya Patel, ad Ella Puga (Texas Departmet of State Health Services); Rachel Allred (Utah Departmet of Health); Alys Adamski, Daielle Barradas, Deise Bradford, Sheree Boulet, Kim Burley, Sara Crawford, William Garvi, Violada Grigorescu, Sachiko Kuwabara, Rube Smith, Teecia Smith, Machell Tow, Lee Warer, ad Guixiag Zhao (Ceters for Disease Cotrol ad Prevetio). 565

2 566 BOULET ET AL. ad cultural iequities. 4,5 Furthermore, our uderstadig of wome s health risks is ofte icomplete with limited iformatio o risk ad protective factors across the life spa. As such, there is a cotiued eed for ew ad iovative studies of wome s reproductive health, especially those assessig the joit effects of chroic diseases ad their associated risk factors. Oe way to rapidly ad iexpesively expad the surveillace of wome s reproductive health with miimal resources is to leverage existig public health surveillace systems. This process capitalizes o a established ifrastructure by augmetig existig data collectio systems with supplemetal iformatio o other factors that impact wome s health. I additio to providig a feasible ad efficiet mechaism for collectig iformatio, this approach allows research ad program staff to evaluate associatios betwee risk behaviors ad reproductive outcomes that otherwise may ot be ivestigated. The purpose of this report is to highlight the implemetatio of a set of state-added questios o wome s reproductive health withi CDC s BRFSS i The twelve questio set icluded a series of questios o pregacy history ad itetios, use of cotraceptio, ad ifertility diagosis ad treatmet. These questios, whe combied with BRFSS core questios o health-related risk behaviors, chroic coditios, ad use of prevetive services, 6 provide a uique opportuity to evaluate the reproductive health for wome betwee 18 ad 50 years of age. History of the BRFSS ad Wome s Reproductive Health State-Added Questios Established i 1984, the BRFSS is the logest cotiuously coducted health-related telephoe survey i the world ad collects state-specific data o risk behaviors ad prevetive health practices for all 50 states, Washigto DC, Puerto Rico, Guam, ad U.S. Virgi Islads. 6 Ladlie ad cellular telephoe surveys have bee icluded sice A radomly selected adult livig i the household is iterviewed for the ladlie survey; the cellular telephoe survey collects iformatio from a adult who resides i a private residece or college housig ad does ot have a alterate ladlie. The BRFSS questioaire has three parts: (1) the core compoet that cosists of a stadard set of questios used by all states, (2) optioal modules, which are CDCsupported sets of questios o specific topics that states ca elect to use o their questioaires, ad (3) state-added questios, which are questios developed or acquired by idividual states ad added to their questioaires. Call back surveys ca be also added to BRFSS depedig o public health priorities ad availability of fudig. The wome s reproductive health questios were developed to support the goals of the Precoceptio Health ad Healthcare (PCHHC) Iitiative, a public private partership composed of federal agecies ad private sector orgaizatios established i 2006 to implemet actio steps as outlied i CDC s Natioal Recommedatios to Improve Precoceptio Health ad Healthcare. 7,8 A key objective of the Actio Pla was to reduce chroic disease ad improve health before ad betwee pregacies amog wome of reproductive age. To iform the developmet of effective itervetio ad prevetio strategies, recommedatios were made to explore multiple data sources for a better uderstadig of wome s health eeds ad risk exposures, icludig access to healthcare ad persoal behaviors. I March 2012, a roud table was coveed at the 29th aual BRFSS meetig i Atlata, Georgia. Sevetee states expressed a iterest i implemetig the reproductive health questios. CDC s Divisio of Reproductive Heath provided fudig for the project, eablig seve states (Coecticut, Ketucky, Massachusetts, Mississippi, Ohio, Texas, ad Utah) to admiister the reproductive health questios with the 2013 survey. Give the itetio to cover key aspects of reproductive health, the questios were categorized i three sectios (four questios each): reproductive history, family plaig ad cotraceptio, ad ifertility. To be icluded i the reproductive health module, the questios had to be already field tested or implemeted i other surveys. Existig surveys such as PRAMS 9 ad the Natioal Health ad Nutritio Examiatio Survey (NHANES) 10 served as the source for the eight questios o reproductive history ad family plaig ad cotraceptio. Four state field-tested questios developed for aother project 11 were used to assess ifertility. I total, the reproductive health questios icluded self-reported gravidity, parity, method of delivery, pregacy itetios, use ad type of cotraceptio, reasos for ot usig cotraceptio, ifertility or difficulty stayig pregat, ad use of ifertility treatmets ad outcome of the treatmet (Table 1). To help esure adequate respose rates, the set of reproductive health questios was icluded as state-added questios rather tha a callback survey. The reproductive health stateadded questios were asked as part of the state s mothly BRFSS sample, but the rage of moths over which these questios were asked varied by state. The target populatio was wome years of age who were icluded i the BRFSS samplig; therefore, addig questios to the ed of the BRFSS did ot require additioal resources for further radomizatio or adjustmets to sample desig weights. All female respodets aged years withi a give moth were icluded i the pool of respodets for the additioal reproductive health questios. To make sure the data were represetative of all wome aged years i each state, wome with resposes to at least oe of the followig three state-added questios o reproductive health: How may times have you bee pregat?, How do you feel about havig a child ow or sometime i the future?, ad Have you or your spouse or parter ever experieced ifertility, icludig difficulty stayig pregat? were reweighted for each state usig iterative rakig procedures that icluded five variables: age, race/ethicity, marital status, educatio, ad telephoe source. If a woma did ot have a respose to at least oe of the above questios, she was excluded from the dataset. Prevalece of Selected Reproductive Health Idicators To examie the status of reproductive health amog wome i the seve states that implemeted the state-added questios o reproductive health, we estimated the prevalece of self-report of ever havig ifertility (uable to become pregat after a year of tryig) or difficulty stayig pregat (uable to stay pregat after a year of tryig), use of ay ifertility treatmets amog wome reportig ifertility or difficulty stayig pregat, desire for a child sometime i the future, ad use of ay cotraceptio at last itercourse amog wome at-risk of uiteded pregacy (wome who

3 BRFSS REPRODUCTIVE HEALTH QUESTIONS 567 Table 1. List of State-Added Questios Regardig Wome s Reproductive Health Added i the 2013 BRFSS Sectio Questio Respose optios Reproductive history Family plaig ad cotraceptio How may times have you bee pregat? How may vagial deliveries have you had? How may cesarea deliveries have you had? How may of your deliveries resulted i a live birth? How do you feel about havig a child ow or sometime i the future? Did you or your spouse or parter do aythig the LAST TIME YOU HAD SEX to keep you from gettig pregat? What did you or your spouse or parter do the LAST TIME YOU HAD SEX to keep you from gettig pregat? Some reasos for ot doig aythig to keep you from gettig pregat the LAST TIME YOU HAD SEX might iclude 1 = You do t wat to have oe 2 = You do wat to have oe, <12 moths from ow 3 = You do wat to have oe, betwee 12 moths to <2 years from ow 4 = You do wat to have oe, betwee 2 years to <5 years from ow 5 = You do wat to have oe, five or more years from ow 6 = You do wat to have oe, but ot sure whe or do t have a timelie 8 = Uable to have childre/hysterectomy 1 = Yes 2 = No 3 = No parter/ot sexually active 4 = I a same-sex relatioship 01 = Female sterilizatio (e.g., tubal ligatio, Essure, ad Adiaa) 02 = Male sterilizatio (vasectomy) 03 = Cotraceptive implat (e.g., Implao) 04 = Hormoal IUD (e.g., Mirea) 05 = Copper-bearig IUD (e.g., ParaGard) 06 = IUD, type ukow 07 = Shots/ijectios (e.g., Depo-Provera) 08 = Birth cotrol pills, ay kid 09 = Cotraceptive patch (e.g., Ortho Evra) 10 = Cotraceptive rig (e.g., NuvaRig) 11 = Male codoms 12 = Diaphragm, cervical cap, or spoge 13 = Female codoms 14 = Not havig sex at certai times (rhythm or atural family plaig) 15 = Withdrawal (or pullig out) 16 = Foam, jelly, film, or cream 17 = Emergecy cotraceptio (morig after pill) 18 = Other method, specify 01 = You did t thik you were goig to have sex/o regular parter 02 = You just did t thik about it/do t care if you get pregat (cotiued)

4 568 BOULET ET AL. Table 1. (Cotiued) Sectio Questio Respose optios Ifertility watig a pregacy, ot beig able to pay for birth cotrol, or ot thikig that you ca get pregat. What was your mai reaso for ot doig aythig the LAST TIME YOU HAD SEX to keep you from gettig pregat? Have you or your spouse or parter ever experieced ifertility, icludig difficulty stayig pregat? Was it ifertility, difficulty stayig pregat, or both? Did you or your spouse or parter receive ay of the followig treatmets? Note: Up to six resposes are allowed. What was the result of the most recet treatmet? Did you. 03 = You wat a pregacy 04 = You or your parter do t wat to use birth cotrol 05 = You or your parter do t like birth cotrol/side effects 06 = You could t pay for birth cotrol 07 = You had a problem gettig birth cotrol whe you eeded it 08 = Religious reasos 09 = Lapse i use of a method 10 = Do t thik you ca get pregat (ifertile or too old) 11 = You had tubes tied (sterilizatio) 12 = You had a hysterectomy 13 = Your parter had a vasectomy (sterilizatio) 14 = You are curretly breast-feedig 15 = You just had a baby/postpartum 16 = You are pregat ow 17 = Same-sex parter 18 = Forced to have sex 19 = Uder the ifluece of alcohol or drugs 20 = Other reaso 1 = Yes, I have 2 = Yes, my spouse or parter has 3 = Yes, we both have 4 = Yes, but udetermied 5 = No 6 = Never tried to get pregat 1 = Ifertility 2 = Difficulty stayig pregat 3 = Both 01 = Drugs to improve or stimulate ovulatio such as Clomid Ò, Serophee Ò, or Pergoal Ò 02 = Artificial isemiatio or itrauterie isemiatio 03 = Assisted reproductive techology 04 = Aother type of surgical treatmet for ifertility 05 = A cosultatio with a ifertility specialist 06 = Somethig else [specify] 07 = Or, you have ot received medical cosultatio or treatmet for ifertility 1 = Become pregat ad are still pregat 2 = Become pregat ad had a baby 3 = Become pregat, but the pregacy was ot maitaied 4 = Did ot become pregat, but are still tryig 5 = Did ot become pregat ad have stopped tryig 6 = You are curretly receivig ifertility treatmet 7 = Do t kow/ot Sure BRFSS, Behavioral Risk Factor Surveillace System.

5 Table 2. Prevalece of Ever Havig Ifertility or Difficulty Stayig Pregat, Use of Fertility Treatmets, Pregacy Itetio, ad Cotraceptive Use at Last Itercourse Amog Wome Years, 2013 BRFSS Reproductive Health Data for Coecticut, Ketucky, Massachusetts, Mississippi, Ohio, Texas, ad Utah Ifertility or difficulty stayig pregat Received ay ifertility treatmet a Wat a child i the future Used ay cotraceptive at last itercourse b Uweighted Uweighted Uweighted Uweighted Overall ( ) ( ) ( ) ( ) Age ( ) < ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ( ) ( ) ( ) ( ) Race/ethicity No-Hispaic white ( ) ( ) ( ) ( ) No-Hispaic black ( ) ( ) ( ) ( ) Hispaic ( ) ( ) ( ) ( ) Other ( ) ( ) ( ) ( ) Educatio <High school ( ) < ( ) ( ) High school ( ) ( ) ( ) ( ) College ( ) ( ) ( ) ( ) a Amog those reportig ifertility or difficulty stayig pregat. b Amog wome at-risk for uiteded pregacy (wome who were ot curretly pregat, did ot have a hysterectomy, were sexually active, did ot report a same-sex parter, ad did ot wat to be pregat <12 moths from time of survey). Data ot show due to small sample size ( < 30). CI, cofidece iterval. 569

6 570 BOULET ET AL. were ot curretly pregat, did ot have a hysterectomy, were sexually active, did ot report a same-sex parter, ad did ot wat to be pregat <12 moths from time of survey). Overall, 8691 wome i the seve participatig states completed the state-added reproductive health questios for a weighted sample size of 13.1 millio wome years of age. A total of 13.2% of wome reported ever havig ifertility or difficulty stayig pregat; of those, 51.7% used some type of fertility treatmet, icludig ovulatio-iducig medicatios, itrauterie isemiatio, assisted reproductive techology, or other treatmet (Table 2). Nearly half (46.6%) of the wome who were ot pregat reported the desire to have a child sometime i the future, ad 59.8% of wome at-risk for uiteded pregacy reported the use of cotraceptio at last sexual itercourse. There was variatio by age, race/ethicity, ad educatio status for some idicators, idicatig potetial disparities that may require further exploratio. Future Directios The set of state-added questios o reproductive health developed for the 2013 BRFSS provides a uique opportuity to evaluate a broad array of factors associated with wome s reproductive health. Plaed aalyses iclude assessig the characteristics of wome with ifertility or difficulty stayig pregat, health-related quality of life for wome with ifertility, the relatioship betwee pregacy itetio ad cotraceptive use, cotraceptive use amog sexually active wome with disabilities, ad cotraceptive use amog wome betwee ages 45 ad 50. States will also use the reproductive health data to prepare summary reports for state public health practitioers, policy makers, ad the geeral public. The reproductive health questios may be icluded as state-added questios i future BRFSS surveys to moitor chages i the idicators over time. I additio, questios related to me s reproductive health could be icluded, particularly as they relate to the areas of ifertility, 12 precoceptio health, 13 ad cotraceptive use. 14 Discussio Leveragig a existig surveillace system with previously tested questios is a efficiet way to ehace surveillace of wome s reproductive health. The advatage of implemetig such a module withi the BRFSS is the ability to assess other state-based health-related iformatio collected i the survey. The data ca also be used to assess the impact of state-based policies such as Medicaid Family Plaig Waivers. Factors such as healthcare access, chroic health coditios, ad other health behaviors directly or idirectly ifluece reproductive health ad warrat cosideratio i studies of wome s health. Eve periodic expasio of existig data collectio systems with supplemetal questios o wome s reproductive health provides valuable iformatio that may ot be available from other data sources. These data provide importat isight o factors that affect wome s health across the life spa ad ca be used to iform health promotio ad chroic disease prevetio strategies. Author Disclosure Statemet No competig fiacial iterests exist. Refereces 1. Barfield WD, Warer L. Prevetig chroic disease i wome of reproductive age: Opportuities for health promotio ad prevetive services. Prev Chroic Dis 2012; 9:E Collis JL, Lehherr J, Poser SF, Toomey KE. Ties that bid: Materal ad child health ad chroic disease prevetio at the Ceters for Disease Cotrol ad Prevetio. Prev Chroic Dis 2009;6:A Robbis CL, Zapata LB, Farr SL, et al. Core state precoceptio health idicators Pregacy risk assessmet moitorig system ad behavioral risk factor surveillace system, MMWR Surveill Summ 2014;63: Ebrahim SH, Aderso JE, Correa-de-Araujo R, Poser SF, Atrash HK. Overcomig social ad health iequalities amog U.S. wome of reproductive age Challeges to the atio s health i the 21st cetury. Health policy 2009; 90: AbouZahr C. Progress ad challeges i wome s health: A aalysis of levels ad patters of mortality ad morbidity. Cotraceptio 2014;90:S3 S Behavioral Risk Factor Surveillace System, Overview: BRFSS Available at: data/2013/pdf/overview_2013.pdf Accessed December 18, Floyd RL, Johso KA, Owes JR, Verbiest S, Moore CA, Boyle C. A atioal actio pla for promotig precoceptio health ad health care i the Uited States ( ). J Womes Health (Larchmt) 2013;22: Johso K, Poser SF, Bierma J, et al. Recommedatios to improve precoceptio health ad health care Uited States. A report of the CDC/ATSDR Precoceptio Care Work Group ad the Select Pael o Precoceptio Care. MMWR Recomm Rep 2006;55: Pregacy Risk Assessmet Moitorig System Available at: Accessed December 18, Natioal Health ad Nutritio Examiatio Survey Available at: Accessed December 18, Crawford S, Fussma C, Bailey M, et al. Estimates of lifetime ifertility from three states: The behavioral risk factor surveillace system. J Womes Health 2015;24: Ceters for Disease Cotrol ad Prevetio. Natioal Public Health Actio Pla for the Detectio, Prevetio, ad Maagemet of Ifertility. Atlata, GA: Ceters for Disease Cotrol ad Prevetio, Frey KA, Navarro SM, Kotelchuck M, Lu MC. The cliical cotet of precoceptio care: Precoceptio care for me. Am J Obstet Gyecol 2008;199:S389 S Ceters for Disease Cotrol ad Prevetio. Advacig Me s Reproductive Health i the Uited States: Curret Status ad Future Directios. Atlata, GA: Ceters for Disease Cotrol ad Prevetio, Address correspodece to: Sheree L. Boulet, DrPH Divisio of Reproductive Health Natioal Ceter for Chroic Disease Prevetio ad Health Promotio Ceters for Disease Cotrol ad Prevetio Atlata, GA sbu1@cdc.gov