Introduction to NHANES and NAMCS
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1 Introduction to NHANES and NAMCS CMU Summer Institute 2002 NHANES: National Health and Nutrition Examination Survey Home Page: Goal: To provide national estimates of the health and nutritional status of the United States civilian, noninstitutionalized population aged two months and older. NHANES is unique in that it combines a home interview with health tests that are done in a Mobile Examination Center (MEC). History: NHANES I ( ), NHANES II ( ), HHANES ( ), NHANES III ( ). Data files: Household Adult, Household Youth, Examination Data File, Laboratory Data File NHANES III Dietary Recall Data Files Questionnaires, and Examination and Laboratory Components: Questionnaires are administered to NHANES participants both at home and in the trailers Screener Modules Screener Module 1. This is administered on the doorstep. This set of questions determines if anyone in the household is eligible to be in the sample. Screener Module 2. This establishes the relationship of everyone in the household to everyone else in the household. Family Questionnaire Household and family level information is collected here. The sections are labeled to reflect content. Demographic Background/Occupation Food Security Health Insurance Housing Characteristics Income Pesticide Use 1
2 Smoking Tracking and Tracing Sample Person Questionnaire Individual level information on participants is collected here. Acculturation Audiometry Balance Blood Pressure Cardiovascular Disease Demographics Information Dermatology Diabetes Dietary Supplements and Prescription Medication Diet Behavior and Nutrition Digital Symbol Substitution Exercise Early Childhood Hospital Utilization and Access to Care Immunization Introduction and Verification Kidney Conditions Medical Conditions Miscellaneous Pain Physical Activity and Physical Fitness Physical Functioning Occupation Oral Health Osteoporosis Respiratory Health and Disease Smoking and Tobacco Use Social Support Tuberculosis 2
3 Vision Weight History Audio computer Assisted Personal Self Interview (MEC-ACASI) Alcohol (12-19) DISC Predictive Scale - Youth Conduct Disorder Drugs (12-59) Sexual Behavior (14-59) Tobacco Computer Assisted Personal Interview (MEC-CAPI) Alcohol (20+) Current Health Status Kidney Physical Activity Reproductive Health Respondent Information Tobacco (20+) Examination and Laboratory (MEC) Dietary Recall Examination Components consist of the following: Audiometry Balance and Vestibular Testing Body Composition Body Measurements Cardiovascular Fitness Dermatology Lower Extremity Disease Muscular Strength Oral Health Physician s Exam Vision 3
4 Laboratory Components consist of the following: Blood & Urine Venipuncture Urine Collection Bone Markers Diabetes Profile Infectious Disease Profile Markers of Immunization Status Miscellaneous Laboratory Assays Kidney Disease Profile Hormone Profile Nutritional Biochemistries and Hematologies Sexually Transmitted Disease Profile Tobacco Use Blood lipids Environmental Health Profile Special Studies: Hg, Pb, TB, VOC HW: 1) Pick 2 sections that no one else has picked and report on what is asked, any limitations or problems you see, and what you would like to see added or changed. 2) Pick two variables and carry out appropriate EDA. Access to data: Data are located in hseltman/nhames/adult.dat, etc. Documentation is in hseltman/nhames/adult.doc, etc. which are plain text files (not Word files). Much of the rest of the description of the dataset is taken from these doc files. Copy hseltman/nhames/adult.sas etc. to your file space and modify it to load the data you are interested in. Be sure to add a keep line to drop all but the pertinent variables. Be sure to look at Location of the interview and examination components in the five NHANES III public release data files and NHANES III Household Adult Data File Index in the adult and youth doc files to aid in finding and interpreting the variables in which you are interested. 4
5 Some descriptions of the data collection process NHANES III was conducted from October 1988 through October 1994 in two phases, each of which comprised a national probability sample. The first phase was conducted from October 18, 1988, through October 24, 1991, at 44 locations. The second phase was conducted from September 20, 1991, through October 15, 1994, at 45 different locations. In NHANES III, 39,695 persons were selected over the six years; of those, 33,994 (86%) were interviewed in their homes. All interviewed persons were invited to the MEC for a medical examination. Seventyeight percent (30,818) of the selected persons were examined in the MEC, and an additional 493 persons were given a special, limited examination in their homes. Data collection began with a household interview. Several questionnaires were administered in the household: Household Screener Questionnaire, Family Questionnaire, Household Adult Questionnaire, and Household Youth Questionnaire. At the MEC, an examination was performed, and five automated questionnaires or interviews were administered: MEC Adult Questionnaire, MEC Youth Questionnaire, MEC Proxy Questionnaire, 24-Hour Dietary Recall, and Dietary Food Frequency (ages years). The health examination component included a variety of tests and procedures. The examinee s age at the time of the interview and other factors determined which procedures were administered. Blood and urine specimens were obtained, and a number of tests and measurements were performed including body measurements, spirometry, fundus photography, x-rays, electrocardiography, allergy and glucose tolerance tests, and ultrasonography. Measurements were taken of bone density, hearing, and physical, cognitive, and central nervous system functions. A physician performed a limited standardized medical examination and a dentist performed a standardized dental examination. While some of the blood and urine analyses were performed in the MEC laboratory, most analyses were conducted elsewhere by contract laboratories. A home examination was conducted for those sample persons aged 2-11 months and aged 20 years or older who were unable to visit the mobile examination center. The home examination consisted of an abbreviated version of the tests and interviews performed in the MEC. Depending on age of the sample person, the components included body measurements, blood pressure, spirometry, venipuncture, physical function evaluation, and a questionnaire to inquire about infant feeding, selected health conditions, cognitive function, tobacco use, and reproductive history. 5
6 Sampling design Subgroups of the population of special interest for nutritional assessment should include pre-school children, the aged, and the poor. These groups should be oversampled to improve the reliability of the statistics for the subgroups. Examinations should be conducted in three mobile examination centers. At any time during the survey period (except holidays) two of the centers should be operating in different locations while the third is being serviced or relocated. The average length of an individual examination should be between 2 and 3 hours, but it should vary depending on the age of the examinee. The time required to examine a preschooler should be less than 1 hour, while the time for an adult should not exceed 2.5 to 3 hours. The NHANES III sample represented the total civilian, noninstitutionalized population, two months of age or over, in the 50 states and the District of Columbia of the United States. The first stage of the design consisted of selecting a sample of 81 PSU s (out of a total of 2812). These were mostly individual counties. In a few cases, adjacent counties were combined to keep PSU s above a minimum population size. The PSU s were stratified and selected with probability proportional to size (PPS). Thirteen large counties (strata) were chosen with certainty (probability of one). For operational reasons, these 13 certainty PSU s were divided into 21 survey locations. After the 13 certainty strata were designated, the remaining PSU s in the United States were grouped into 34 strata, and two PSU s were selected per stratum (68 survey locations). The selection was done with PPS and without replacement. The NHANES III sample therefore consists of 81 PSU s or 89 locations. The 89 locations were randomly divided into two groups, one for each phase. The first group consisted of 44 and the other of 45 locations. One set of PSU s was allocated to the first three-year survey period ( ) and the other set to the second three-year period ( ). Therefore, unbiased estimates (from the point of view of sample selection) of health and nutrition characteristics can be independently produced for both Phase 1 and Phase 2 as well as for both phases combined. The second stage of the design consisted of area segments composed of city or suburban blocks, combinations of blocks, or other area segments in places where block statistics were not produced in the 1980 Census. In the first phase of NHANES III ( ), new building permits supplemented 1980 census data. 6
7 Table 1: Variables used for stratification in NHANES II, by region Stratification variables Number Races other than Rate of growth Region and type of super- white plus or % below of stratum strata Income Hispanics poverty level Northeastern 16 Self-representing strata 12 Highly urban-new England 1 Other urban-new England 1 Large counties (by population) 6 high, medium, low high, low (poverty) Small counties (by population) 4 high, low high, low (poverty) Nonself-representing strata 4 New England places 1 Other 3 high, medium, low Midwestern 16 Self-representing strata 8 Certainty 1 Large counties (by population) 3 high, low high, low (growth) Small counties (by population) 4 high, medium, low Nonself-representing strata 8 Large strata (by, population) 4 high, low high, low (growth) Small strata (by population) 4 high, low high, low (growth) Southern 16 Self-representing strata 6 Large counties (by population) 3 high, medium, low Small counties (by population) 3 high, medium, low Nonself-representing strata 10 Large strata (by population) 6 high, medium, low high, low Small strata (by population) 4 high, low high, low Western 16 Self-representing strata 9 Certainty 2 Large counties (by population) 4 high, low high, low Small counties (by population) 3 high, medium, low Nonself-representing strata 7 Large strata (by population) 4 high, low high, low Small strata (by population) 3 high, medium, low New England is subdivided into townships rather than counties. Cook County in the Midwestern Region and Los Angeles County (2 stands) in the Western Region were selected into the sample with-a probability of 1. 7
8 In the second phase, ( ) 1990 census data and maps alone were used to define the area segments. The third stage of sample selection consisted of households and certain types of group quarters, such as dormitories. All households and eligible group quarters in the sample segments were listed, and a subsample was designated for screening to identify potential sample persons. The subsampling rates enabled production of a national, approximately equal-probability sample of households in most of the United States with higher rates for the geographic strata with high Mexican- American populations. Within each geographic stratum, there was a nearly equalprobability sample of households across all 89 stands. Persons within the sample of households or group quarters were the fourth stage of sample selection. All eligible members within a household were listed, and a subsample of individuals was selected based on sex, age, and race or ethnicity. Below is a summary of the sample sizes for the full six-year NHANES III at each stage of selection: Number of PSU s 81 Number of stands (survey locations) 89 Number of segments 2,144 Number of households screened 93,653 Number of households with sample persons 19,528 Number of designated sample persons 39,695 Number of interviewed sample persons 33,994 Number of MEC-examined sample persons 30,818 Number of home-examined sample persons 493 8
9 National Ambulatory Medical Care Survey (NAMCS) The basic sampling unit for the NAMCS is the physician-patient encounter or visit. Only visits to the offices of nonfederally employed physicians classified by the AMA or the American Osteopathic Association as office-based, patient care are included in the physician universe. Physicians in the specialties of anesthesiology, pathology, and radiology are excluded. Types of contacts not included are those made by telephone, those made outside the physician s office (for example, house calls), visits made in hospital settings (unless the physician has a private office in a hospital), visits made in institutional settings by patients for whom the institution has primary responsibility over time (e.g., nursing homes), and visits to doctors offices that are made for administrative purposes only (e.g., to leave a specimen, pay a bill, or pick up insurance forms). The NAMCS utilizes a multistage probability design that involves probability samples of primary sampling units (PSUs), physician practices within PSUs, and patient visits within practices. The first-stage sample includes 112 PSUs. PSUs are geographic segments composed of counties, groups of counties, county equivalents (such as parishes or independent cities) or towns and townships (for some PSUs in New England) within the 50 States and the District of Columbia. The second stage consists of a probability sample of practicing physicians selected from the master files maintained by the American Medical Association and the American Osteopathic Association. Within each PSU, all eligible physicians were stratified by 15 groups: general and family practice, osteopathy, internal medicine, pediatrics, general surgery, obstetrics and gynecology, orthopedic surgery, cardiovascular diseases, dermatology, urology, psychiatry, neurology, ophthalmology, otolaryngology, and a residual category of all other specialties. The final stage is the selection of patient visits within the annual practices of sample physicians. This involves two steps. First, the total physician sample is divided into 52 random subsamples of approximately equal size, and each subsample is randomly assigned to 1 of the 52 weeks in the survey year. Second, a systematic random sample of visits is selected by the physician during the reporting week. The sampling rate varies for this final step from a 100 percent sample for very small practices, to a 20 percent sample for very large practices as determined in a presurvey interview. 9
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