Structural equation modeling using complex survey data: Evaluating quasi-maximum likelihood estimation with Satorra-Bentler correction and multiple imputation

As a theory-guided approach, SEM can estimate directional pathways in complex models using longitudinal or cross-sectional data where randomized control trials would either be unethical or cost prohibitive, thereby providing researchers with an alternative approach for delineating causal relationships. As SEM is a technique requiring large sample size, federal and state level surveys are often used, which are designed with complex sampling strategies. As many of the variables and in turn, weighted-ness, may be subject to non-normality, it is important to adjust the SEM model fit statistics to more closely match the reference distribution (Satorra-Bentler, 1994). Further, missing data is a regular issue in nearly all surveys, especially those with large-scale, complex designs. The purpose of the study is to provide a comparison of estimations, modification indices, and goodness-of-fit tests for SEM between standard maximum likelihood estimation and quasi-maximum likelihood using Satorra-Bentler correction using a complex survey data and multiple imputation. Using non-simulated data with missingness can provide guidance on how to incorporate both SEM and multiple imputation in future research. This study found that coefficients were the same regardless of estimator; however, standard errors increased under QML. Model fit statistics were better under QML, and Lagrange multiplier values from the modification indices were on average lower under QML, however, only with structural model components

Cardiac Drift in Response to Rowing on an Ergometer

In rowing, there are many physiological strains imposed upon the body unlike those in any other sport. The process of rowing powerfully contracts and expands the entire body at a controlled rate between 18 to 40 strokes per minute. Unique characteristics of the rowing stroke may influence heart rate variability over time. Cardiovascular drift is a gradual increase of HR during steady-state exercise at moderate intensity; research shows that this phenomenon occurs after approximately 15 minutes of exertion during running and cycling. Measuring HR variability and the occurrence of cardiac drift has yet to be analyzed during rowing on an ergometer. Methods. Two groups of 10 male collegiate rowers (n = 20) performed a 60-minute session on an ergometer wearing HR monitors. During the bout, perceived rate of exertion was also measured at three-minute intervals. Demographic variables, post-workout dehydration, and ambient room temperature were measured. Descriptive statistics, dependent and independent samples t-tests, Pearson's correlation coefficients, and linear regression were conducted to analyze variables. Results. Cardiovascular drift occurred without a stabilization period as seen in other endurance exercise. The gradual increase in HR began after the early onset of the acclimation phase, approximately three minutes into the session, unlike that observed during running and cycling. A significant positive association between mean RPE and mean HR was observed (r = .989, p < .01). Ambient room temperature and additional weekly minutes of aerobic exercise apart from team practice affected RPE at the 60 minute mark. A colder room temperature and increasing minutes of aerobic exercise were associated with a higher 60-minute RPE (R2 = .409). Conclusion. These findings may alter the current approach to adapting cycling and running HR training regimens to the sport of rowing and may even necessitate that rowing coaches develop their own training regimens when using HR as a monitoring mechanism. The early onset of cardiac drift suggests that target heart rate training zones may be unique for the sport of rowing.Education (all programs

Disparities in diabetic foot examinations: A cross-sectional analysis of the Behavioral Risk Factor Surveillance System

Introduction: Diabetes Mellitus (DM) is a growing problem in the US and causes serious health complications such as cardiovascular disease, end-stage renal disease, peripheral neuropathy, foot ulcers, and amputations. There are guidelines in place for prevention of foot ulcers in individuals with diabetes; however, adherence to these guidelines appears to be poor due to financial barriers, time and resource constraints among physicians, and lack of education among patients. Poor mental health and poor physical health often arise from DM and also contribute to development of other complications. Thus, our objective was to identify how frequent poor mental health days, a depressive disorder diagnosis, frequent poor physical health days, or physical inactivity affect annual foot examinations in individuals with diabetes.Methods: We performed a cross-sectional analysis of the 2021 Behavioral Risk Factor Surveillance System (BRFSS) datasets to determine the relationship between annual foot examinations and frequent poor mental health days, a depressive disorder diagnosis, frequent poor physical health days, or physical inactivity. We used a bivariate logistic regression model to determine these associations using odds ratios (OR). The regression model was controlled for age, sex, race/ethnicity, health insurance, level of education, current smoking status, and BMI category.Results: Our results showed 72.06% of individuals with frequent poor mental health days received a foot check, compared with 76.38% of those without poor mental health days—a statistically significant association (AOR: 1.25; 95%CI: 1.09-1.43). Of those reporting a sedentary lifestyle with no physical activity, 73.15% received a foot check, compared with 77.07% of those who were physically active which was also statistically significant (AOR: 1.31; 95%CI: 1.14-1.49). Although having a depressive disorder diagnosis and reporting frequent poor physical health days had lower rates of annual foot examinations, these results were not statistically significant. Rates of foot checks were also lower among individuals who were female (X2 = 6.22, .013), Hispanic (X2 = 7.91, < .0001), lacked insurance (X2 = 51.24, < .0001), were currently smoking cigarettes (X2 = 12.24, <.001), did not complete high school (X2 = 12.24, <.001), had a BMI < 25 (X2 = 8.90, .003), or were less than 35 years of age (X2 = 14.97, < .0001).Conclusions: Individuals reporting frequent poor mental health days or a sedentary lifestyle were statistically less likely to obtain an annual foot examination. These results are likely explained by a decrease in motivation to partake in self-care among those with poor mental health or sedentary lifestyles. The critical nature of foot ulcer prevention highlights the need to identify groups that do not utilize preventive care so further complications may be avoided. Interventions such as increased mental health screening, counseling or support groups, exercise classes, and educational materials may increase utilization of preventive services among individuals with diabetes, and thus increase the rates of annual foot examinations and prevent foot ulcer development and amputations

HPV and meningococcal vaccine uptake among teens: A cross-sectional examination from the National Immunization Survey - Teen 2020

Background: Vaccination against both Human papillomavirus (HPV) and meningococcal disease is recommended for all adolescents aged 11-12 years; however, many teens have not received these vaccinations.Aim: This study aims to assess trends in dual vaccination against HPV and meningococcal disease among teens in the United States.Methods: We analyzed data on 31,083 adolescents aged 13-17 years from the 2020 National Immunization Survey - Teen. Bivariate and multivariate logistic regression models were constructed to determine dual vaccination rates and associations between vaccination status and sociodemographic characteristics.Results: Teens were 2.03 (95%CI: 1.98-2.09) times more likely to be vaccinated against meningococcal disease compared to HPV. Additionally, teens vaccinated against HPV were 1.21 (1.15-1.27) times more likely to be dually vaccinated than teens who were vaccinated against meningococcal disease. Among teens living in the South relative to the Northeast, the likelihood for being vaccinated against only HPV increased by a factor of 1.30 (1.07-1.58) and against only meningococcal disease increased by a factor of 1.17 (1.03-1.33). Relative to those living in the Northeast, the risk for being unvaccinated rather than dually vaccinated increased by a factor of 1.51 (1.25-1.83) for those living in the Midwest, 1.62 (1.30- 2.03) for those living in the West, and 1.80 (1.50-2.15) for those living in the South. Although less significant, we also found association between sex, race/ethnicity and income-to-poverty ratio.Conclusion: Dual vaccination against HPV and meningococcal disease among adolescents in the United States is associated with many factors including state legislation, physician recommendation, sex and census region. Although administration of both vaccines is recommended by the Advisory Committee on Immunization Practices (ACIP) to all adolescents aged 11-12 years, meningococcal vaccination is two times more likely than HPV vaccination. Given the trends in immunization and vaccine efficacy, we recommend that physicians advise patients in this age range to receive both vaccines during a single appointment. Increased vaccination at a societal level will increase protection against preventable diseases that cause significant burden to adolescents and young adults

Cross sectional analysis of the impact of a language barrier in the osteoarthritic Latina population

Background: Osteoarthritis (OA) is a very prominent musculoskeletal disorder that affects approximately 303 million people worldwide. Numerous studies have shown language barriers interfere with the ability of Spanish speakers to communicate their pain symptoms to non-Spanish speaking physicians. The challenge that language barriers present to the Latina population in regard to the diagnosis and treatment of osteoarthritis remain largely unknown.Hypothesis: We hypothesize that the presence of a language barrier will negatively affect the diagnosis and treatment of osteoarthritis, leading to worse health outcomes for the Latina population.Methods: We analyzed data from the CDC’s Behavioral Risk Screening and Surveillance System, combining the 2017-2020 cycles using sampling weights provided by BRFSS, adjusted for multiple cycles. Determination of English- or Spanish-speaking groups was based on the language of the survey submitted with 20,659 and 18,559 in each group respectively (n=39,218). We calculated population estimates for arthritis diagnosis, physical limitations, and mean joint pain among language groups and by age (40+ and 65+), and determined associations via odds ratios.Results: Rates of arthritis diagnosis between groups were similar for both age groups; however, we found that Spanish speaking Latinas 65+ were statistically more likely to report being limited by pain. Further, Spanish speaking Latinas in both age groups reported higher pain scores than the English speaking group (p < .001).Conclusions: Results from this study show that while there were no significant differences in rates of diagnosis, Spanish-speaking Latinas were more likely to be limited by joint pain and report higher pain scores. Given potential language barriers and potentially later diagnosis, emphasizing the holistic nature of osteopathic medicine should strive to provide equitable treatment and support for Spanish-speaking women. When language barriers exist, incorporating translators in medical settings may improve outcome

Native American student perspectives on tribally affiliated osteopathic medical school education

Background: As the first tribally affiliated medical school, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation (OSUCOM-CN) presents a landmark opportunity for Native American (NA) students. Little research has been conducted regarding NA students’ sense of belonging in university settings and no research investigates this in the medical school environment. Students’ sense of belonging is linked to positive academic outcomes, including higher grades, higher engagement, self- confidence, and acceptance. In addition to sense of belonging, documenting NA medical students’ perspective of culture, relationships, or closeness with their own tribe, and what it means to them to be medical students in the inaugural class of a tribally affiliated college of medicine is important. Thus, our objective is to evaluate NA students’ sense of belonging at OSUCOM-CN through a sense of belonging survey, interviews, and essay responses through this mixed-methods study.Methods: A social constructivist approach using qualitative methods was adopted to gain an understanding of medical students’ perspectives on sense of belonging in the inaugural class at OSUCOM-CN. Data were gathered via mixed methods using a sense of belonging survey, semi-structured interviews, and essay prompts. Participants were recruited from a sampling of all medical students in the inaugural class at OSUCOM-CN identifying as tribally enrolled or of tribal descendancy alone or in combination with other race(s). Sense of belonging surveys and short-answer essays were collected via electronic and paper-copy. Interviews were audio-recorded and transcribed. (Rev, Austin, TX) Thematic analysis was conducted using Braun and Clarke’s six-phase framework. MAXQDA software was used for data categorization and management. MH generated inductive codes with themes identified from the coded data. AG and RT reviewed transcripts individually and coded the data; after which, dissolving discrepancies until 100% inter-reviewer reliability was met.Results: Seven medical students meeting eligibility for participation criteria enrolled in this study. Data were categorized into four main themes: 1.) Psychosocial and Personal Identity: identity, personality, affiliation, or mental or physical health that affect students’ learning, engagement, and attainment, particularly stereotyping, stigma, and historical trauma. 2.) Native Culture and Heritage: family origin, heritage, participation in tribal ceremonies, oppression, stigma with specific notation of past, present, or historical oppression against engagement. 3.) Community Perception: tribe or community's change in pride or stigma over time in general or related to medicine. 4.) Tribal Affiliation: affiliation with first tribally affiliated college of medicine (TA-COM) related to the campus, faculty, other medical students, community, and the importance of being tribally affiliated.Conclusion: This is the first study exploring NA medical students’ perspectives on sense of belonging in a tribally affiliated medical school. NA medical students in this study reported a sense of belonging related to their NA heritage, expressed the importance of bridging past and present cultural involvement, and discussed positive changes in personal and community perception of NA culture and medicine. All students placed personal and community-level importance on tribal affiliation for their sense of belonging and ability for success in becoming NA osteopathic physicians

Associations between social determinants of health and frequency of poor mental health days: A cross-sectional analysis of 2017 BRFSS

Introduction: In 2020, over 50 million adults in the US had a diagnosed mental illness. While the overall burden of illness among mental health disorders is great, studies continue to show increased mental health needs among US adults. Frequency of poor mental health days (FPMHD) has shown to be related to individual factors such as SES, race, and rural versus urban environments. Additionally, social determinants of health (SDOH) have been found to directly influence factors related to premature death. Assessing the disparities in mental health outcomes regionally and among sociodemographic variables may highlight predictors of mental health outcomes. Therefore, our objective was to examine the relationship between frequent (14+) poor mental health days and SDOH, and which states had the highest rates of FPMHD.Methods: We conducted a cross-sectional analysis of the 2017 Behavioral Risk Factor Surveillance System (BRFSS) to extract data regarding poor mental health days and the SDOH module. We extracted sociodemographic variables to use as controls and constructed bivariate and multivariable logistic regression models to determine associations, via odds ratios, between SDOH and FPMHD. We visualized overall state-levels of FPMHD via a heatmap.Results: We found statistically significant associations between all SDOH variables in both the binary and multivariable regression models. The average number of poor mental health days per month was the highest in West Virginia (14.11 days), Oklahoma (12.94 days), and Mississippi (12.87 days). However, individuals in states that reported experiencing zero poor mental health days were the lowest in Oregon (58.7%), Utah (59.65%), and Arkansas (59.84%).Conclusion: Our study found that frequency of poor mental health days was significantly associated with all domains of SDOH. Providing expanded mental health care resources through the use of evidence based programs could improve average numbers of poor mental health days among US adults. Additionally, further investigation to identify the specific variables of each SDOH domain and their association with FPMHD is warranted to improve the efficacy and reach of available mental health resources

Disparities in season flu vaccine uptake among Spanish and English-speaking Hispanic Americans: a cross-sectional analysis of Behavioral Risk Factor Surveillance Systems (BRFSS) from 2017-2020

Introduction: Research has shown that vaccination for Seasonal Influenza (flu) is associated with a nearly ⅓ reduction in flu-related mortality and a ¼ reduction in likelihood of ICU admission.1 From 2009-2019, Hispanic residents of the United States had the third highest rate of flu-related hospitalization with more severe outcomes including intensive care and mortality than non-Hispanic Whites.2 Thus, the purpose of this study is to analyze Behavioral Risk Factor Surveillance System (BRFSS) data in order to compare rates between Spanish- and English-speaking Hispanics aged 18-64 and among those 65 and older from 2017-2020 with a secondary objective to investigate trends among age groups by sex.Methods: For this cross-sectional study we extracted data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2017-2020. The BRFSS uses raking weights to produce population estimates that adjust for survey non-coverage, non-response, and the probability of being sampled given geographic location, age, race, and sex.9 Respondents were included if they identified as being Hispanic and responding to a question regarding flu vaccination (either via shot or nasal spray). Other variables extracted included the language of survey used (to identify Spanish and English speaking participants), age (18-64 and 65+), and sex. We then estimated the prevalence of flu vaccination among easy BRFSS cycle overall and among each sub-group (language, sex, and age-group) and used X2 tests of independence to determine associations among groupings.Results: Trends of the data showed that flu vaccine uptake among all Hispanics was lowest in 2018 (25.29%) while 2020 was the highest (34.83%). Each year, the 65 and older age grouping had higher rates of flu vaccine uptake compared to the 18-64 age group. Significant differences among English- and Spanish-speaking groups occurred each year, most often occurring among the 18-64+ group of both sexes. Hispanic US adults ages 65 and over had the highest percentage of flu shots received in 2017 (57.75%) while 2018 had the lowest (50.11%). Spanish-speaking men, age 18-64, had the lowest uptake of flu vaccination throughout the time span.Conclusion: From 2018 through 2020 there was a statistically significant difference in uptake of English speaking women when compared to Spanish speaking women ages 18-64. Predominantly English speaking women aged 18-64 had higher vaccination rates in 2019 and 2020 while Spanish speaking women had higher rates in 2017. Pearson et al., found that Spanish-speaking Hispanics, aged 65 or older, were significantly less likely to have received the influenza vaccine compared to English-speaking Hispanices from 2005-2007.3 Our study reveals that this trend changed in 2018 when more Spanish speaking women received vaccination than the English speaking women aged 65+. Spanish speaking men aged 18-64 were also less likely to receive vaccination than Spanish speaking women aged 18-64 across the board when comparing statistically significant data

Public interest in supervised injection sites in the US following the opening of two clinics: an infodemiological study and time-series analysis of Google Trends

Purpose of Research: In Oklahoma, over 3,000 individuals died of overdose from 2014-2017. Supervised injection sites have reduced overdose deaths by 35% in surrounding neighborhoods and increase the participation in substance use treatment programs by more than 30%. By approaching substance use in a holistic manner and considering treatment options and disease prevention strategies currently outside of the norm in the United States, research supports initiation of SIS improve the lives and outcomes of persons using IV drugs.Research Question: Our objective for this study was to analyze the public interest in supervised injection sites and dispel misconceptions to reveal benefits of such strategies.Methods: Using Google trends, we searched for the topic “supervised injection sites” from 2019-2021 to collect relative search interest (0-100). An autoregressive integrated moving average model (ARIMA) was used to forecast the values of search interest if the court decision to legalize SIS in Philadelphia in February of 2020 through June did not occur. We then calculated the percent increase in search interest immediately (1 week) following the ruling.Results: Observational analysis of the plotted data, the largest peak occurred in February 2020 when a US district judge declared that the SIS could be legally opened in Philadelphia. The forecasted value the week after this ruling was 6.95 (95%CI: -2.86 - 16.76), compared to the peak (100) RSI. The difference in these values was 93.04 (83.24-102.86) representing a percent change of 1338.85%. A second peak occurred in November 2021, when New York City opened their first legal SIS. Given current interest in such programs, future peaks are likely as more SIS sites open in the United States.Conclusions: We found that following the court ruling, and opening of SIS, search interest in these facilities significantly increased. Given the novelty of the SIS within the US, their media coverage, and the stigma surrounding IV drugs and those who use them, it is necessary to provide information to the public that demonstrates the benefits of these facilities—reduced overdose deaths and related crime, improved quality of life, and increased uptake of treatment— especially in the midst of the current opioid crisi

Examining trends in the public’s awareness of exocrine pancreatic insufficiency in the United States using infodemiology metrics

Background: Exocrine Pancreatic Insufficiency (EPI) is a disorder caused by multiple etiologies leading to decreased pancreatic function. EPI presents with nonspecific symptoms and is largely unknown by the public, making EPI a difficult diagnosis. Awareness campaigns for EPI have been supported by AbbVie, a pharmaceutical company that manufactures the only available treatment for EPI (Creon), but it is unknown whether the campaigns have led to increased EPI awareness.Aims: We sought to assess changes in EPI awareness over time evidenced by internet searches in the United States. Findings from this study may reveal how awareness campaigns, such as radio ads, have influenced the public awareness of EPI.Methods: Google Trends is a popular and validated infodemiology tool. Using Google Trends allows for real-time data analysis that reflects public awareness over time, which is reported as relative search volume (RSV). RSV represents a relative percent change in Google searches for selected terms over a given time period. We observed trends for the term “Exocrine Pancreatic Insufficiency” over the date range January 1, 2011 to October 1, 2021 to capture search trends before and after AbbVie’s advertisement campaigns. We used an ARIMA model to forecast expected search volumes based on search data before Abbvie’s campaign for Creon.Results: We found many statistically significant increases in RSV since the launch of AbbVie’s campaign, with peak RSV occurring in August and September of 2021, together representing a 122.5% increase compared to expected values (P<.001). Similar peaks were observed in March 2019 and January 2020, though every year since the launch had multiple statistically significant increases in RSV for “Exocrine Pancreatic Insufficiency.”Conclusion: Results from our study suggest that the US public interest in EPI has increased steadily over the last 5 years compared to the 5 years prior, possibly reflecting the success of Abbvie advertisement campaigns. AbbVie has steadily increased advertisement spending since 2016, with reported net revenue for Creon following a similar trend. The success of AbbVie’s radio, TV, and internet advertisements may have served to educate patients on EPI, prompting them to search Google for more information or to find a physician who could evaluate them for EPI. Increasing awareness may support quicker and more accurate diagnosis of EPI