Defense Presentation Notes Version 1 Flashcards
What is the definition of ACEs?
Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance use problems. Toxic stress from ACEs can change brain development and affect how the body responds to stress.
Quick Notes:
- 1 in 6 adults experience four or more types of ACEs
- At least 5 of the top 10 leading causes of death are associated with ACEs
- Preventing ACEs could reduce the number of adults with depression by as much as 44%.
What is the ACE score?
The ACE score is a measure of cumulative exposure to particular adverse childhood conditions. Exposure to any single ACE condition is counted as one point. If a person experience none of the conditions in childhood, the ACE score is zero. Points are then totaled for a final ACE score. It is important to note that the ACE score does not capture the frequency or severity of any given ACE in a person’s life, focusing instead on the number of ACE conditions experienced. In addition, the ACE conditions used in the ACE study reflect only a select list of experiences.
Definitions of ACE experiences - abuse and household dysfunction.
Abuse:
Physical - Parent or adult in home ever hit, beat, kick, or physically hurt you in any way once or more than once (Does not include spanking).
Sexual - Anyone at least 5 years older than you or an adult, ever touch you sexually, try to make you touch them sexually, or force you to have sex once or more than once.
Emotional - Parent or adult in home ever swear at you, insult you, or put you down more than once.
Household Dysfunction:
Mental Illness - Lived with anyone who was depressed, mentally ill, or suicidal.
Substance Abuse - Alcohol, lived with anyone who was a problem drinker or alcoholic. Drugs, lived with anyone who used illegal drugs or abused prescription medication.
Divorce or Separation - Parents separated or divorced.
Domestic Violence - Parents or adults in your home ever slap, hit, kick, punch or beat each other up once or more than once.
Incarceration - Lived with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility.
Information about the original ACE study
The Adverse Childhood Experiences Study was conducted between 1995-1997 by Drs. Robert Anda and Vincent Felitti. The study was based on the compiled data of over 17,000 adult patients who were enrolled in the Kaiser-Permanent insurance program. Study participants, who were primarily middle-class and well-educated, were mailed a detailed questionnaire two weeks after going through a health-screening examination. The survey contained questions about early childhood experiences, physical and mental health history, and adult health behaviors. These results were then matched with the clinical record from the recent visit. While enrollment in the study was closed at the end of 1997, the study participants continue to be monitored for health outcomes. More than 100 scientific articles have now been published about the ACE study or subsequent related studies done to add understanding and clarity to these relationships.
Info about the BRFSS
In 1984, the Centers for Disease Control and Prevention developed the Behavioral Risk Factor Surveillance System (BRFSS), a survey to be used by individuals states to determine the status of their residents’ health based on behavioral risk factors. In all BRFSS surveys, there is a set of core questions that participating states must use and optional modules states can use.
What was the data source?
The 2019 BRFSS, which included 418,268 respondents overall.
What are the three components of the BRFSS Questionnaire?
1) Established core questions utilized by all states.
2) Optional modules that states can request to be included.
3) State added questions, which allows states to add their own specific areas of interest.
The 2019 questionnaire included 14 core sections and 31 optional modules.
How was the study sample created?
The study sample was taken from 2 specific parts of the BRFSS. First, the respondent’s answers to Question 2 of Module 29 (Sexual Orientation and Gender Identity) which asks, Do you consider yourself to be transgender? - were utilized to provide a sample for transgender women, transgender men, and transgender gender nonconforming. Respondents who answered “No” to Question 2 of Module 29 were utilized to provide a sample for cisgender people. Introduction question, Sex of Respondent, which is a question that is asked by all 50 states to every single respondent, was utilized to break the overall cisgender population for Question 2 of Module 29, into cisgender men and cisgender women populations.
What are the standard 11 ACE questionnaire questions?
1) Did you live with anyone who was depressed, mentally ill, or suicidal?
2) Did you live with anyone who was a problem drinker or alcoholic?
3) Did you live with anyone who used illegal street drugs or who abused prescription medications?
4) Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
5) Were your parents, separated, or divorced?
6) How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?
7) Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking.
8) How often did a parent or adult in your home ever swear at you, insult you, or put you down?
9) How often did anyone at least 5 years older than you or an adult ever touch you sexually?
10) How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually?
11) How often did anyone at least 5 years old than you or an adult, force you to have sex?
What optional BRFSS modules to Colorado participate in for 2019?
Colorado participated in two optional modules in 2019: Healthcare Access (Optional Module 14) and Sexual Orientation and Gender Identity (Optional Module 29).
How did you calculate ACE scores?
We utilized the calculated ACE from Ford et al. (2014) for this study. Each question was collapsed into 1 of 8 ACE categories: physical abuse, emotional abuse, sexual abuse, household mental illness, household substance use, incarcerated household member, parental separation or divorce, and household domestic violence. The responses were dichotomized to indicate exposure and were summed to create an ACE score (range 1.00-8.00, with higher scores indicating greater exposure). Ford et al. (2014) provides a full description of the BRFSS ACE module and calculated ACE score. This methodology was used in several studies (Ford et al., 2014; Merrick et al., 2017; Merrick et al., 2018).
How was alcohol consumption measured?
Using Core Section 10 of the BRFSS Questionnaire - participants in the study were assessed for heavy drinking and binge drinking. Current drinkers were defined as those who reported consumption of alcohol in the past 30 days. To assess how many drinks participants had when they drank, participants were asked “One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.” During the past 30 days, on days when you drank, about how many drinks did you drink on the average? Consistent with previous studies and BRFSS guidelines, past month binge drinking was defined as five or more drinks in one sitting for men and four or more drinks in one setting for women, and heavy drinking was defined as consuming fourteen or more drinks per week for men and seven or more drinks per week for women. These two drinking behaviors were not mutually exclusive. Binge and heavy drinking served as the primary dependent variable.
What were the sociodemographic control variables?
Age group: 18-24, 25-34, 35-44, 45-54, 55-64, 65 and older
Race/Ethnicity: While only non-Hispanic, Black only non-Hispanic, Other race only non-Hispanic, Multiracial non-Hispanic, Hispanic
Marital Status: Married, Divorced, Separated or Widowed, Never Married/Member Unmarried Couple
Educational Level: Less than high school, high school graduate/GED, attended college or technical school, college graduate, or technical school
Annual Household Income: Less that $15,000, $15,000 to less than $25,000, $25,000 to less than $35,000, $35,000 to less than $50,000, or $50,000 or more.
How representative is the sample to the population under study?
Since we used the BRFSS - which is probability sampling, we know that technically the data is highly representative of the greater population. However, in terms of the implications of this study and understanding the data for specifically the transgender population – it is a big “if” on whether this data is truly representative of the transgender population because they were not able to completely capture that subset - and that’s clear from how small of a sample the transgender population was in our study.
That’s due to a couple of reasons – first because of the nature of the optional modules, they are missing people because not all states asked the questions related to gender identity. Second, the survey is only administered in two languages right now, English and Spanish. Third, you can’t assess gender identity of just one question given that identity is a complex and nuanced variable.
The BRFSS is weighted based on race, age, and by sex (male or female). So that’s a challenge with the transgender population because there isn’t current concrete data on how many transgender individuals are living in the U.S, which is a big issue. The SO/GI module in the BRFSS had approximately a quarter of a million people, and the sample size for transgender was really, really small. And that’s because the BRFSS as a measurement tool - is not able to detect the number of transgender people properly.
They are not currently collecting that data in the U.S. Census and therefore it does create challenges on whether this data can be considered highly representative of the transgender population.
What was the sampling method that was used in the study?
Probability Sampling. Probability sampling is defined as a sampling technique in which the researcher chooses samples from a larger population using a method based on the theory of probability. For a participant to be considered as a probability sample, an individual must be selected using a random selection.
How can you strengthen representation in your study?
If the BRFSS were to make Module 22 (ACEs) and Module 29 (Sexual Orientation and Gender Identity) a core section module offered by all states, it would likely strengthen the representation in the study. If that were not able to occur a study comparing a multitude of years would increase representation. Also, adding additional modules or screens to capture the transgender population and changing the logic of the way the weighting in the survey works could really support capturing this population
How did you determine the reliability of your sample?
Pierannunzi et al. (2013) preformed a review of literature surrounding reliability and validity of the BRFSS that other researchers had done when examining their area of interest in their own research. Additionally, validity and reliability of the BRFSS was also compared with that of other national health surveys such as the National Health Interview Study, the National Health and Nutrition Examination Survey, the National Survey on Drug Use and Health, the Current Population Survey and the National Survey of Family Growth.
Pierannunzi et al. (2013) found high levels of reliability of the data in the BRFSS. Pierannunzi et al. (2013) concluded that the data represented in the BRFSS was reliable and valid, although they did point out that the data had some deficits. Nelson et al. (2001) also found that overall, the data contained in the BRFSS had high levels of validity and reliability, however the validity and reliability of the data fluctuated dependent upon the questions that were being asked. For example, Nelson et al. (2001) found that the data regarding alcohol consumption, cigarette use, and demographic information had a high level of validity and reliability. Moderate levels of validity and reliability were found regarding when medical procedures or interventions had last occurred, diet, and level of physical activity (Mucci et al., 2006). Nelson et al., (2001) failed to uncover any instances of low validity and reliability although they were able to isolate certain areas for further research as reliability and validity could not be tested.
An area of concern regarding the data within the BRFSS, is the progressively declining response rates over the years. For example, Fahimi et al. (2008) found that the BRFSS had a response rate of 72%. By 2006 the response rate had dipped to 51% (Fahimi et al., 2008). The BRFSS has traditionally been administered via landline telephone. As cell phones have proliferated and replaced landline telephones, response rate in the BRFSS has declined (Fahimi et al., 2008). In 2011, the BRFSS changed their methodology and included the use of cell phone numbers to gather data (Fahimi et al., 2008). In addition to bolstering their methodology with cell phone numbers, the BRFSS has also included the use of the Spanish language (Fahimi et al., 2008). This was done to allow for the collection of a data from a more diverse sample and attempt to keep up with the increasing diversification of the U.S. population (Rolle-Lake & Robbins, 2021).
Information about SO/GI Module and Sex at Birth Module from the BRFSS.
The BRFSS added the Sexual Orientation and Gender Identity (SO/GI) Module to the approved list of optional modules in 2014 and has been making this module available to the states and participating US territories since that time. In 2019, a single-question module on sex at birth was also added. Prior to the formal adoption of these modules, some states included questions on sex at birth, sexual orientation, and gender identity in the state-added section of their questionnaires; however, the state-added questions may have been asked in different formats and are not included in the pubic-use data sets. Researchers who want to obtain information for these questions could contact individual state health departments to access pre-2014 SO/GI data.
Because the Sex at Birth and SOGI modules are related to the traditional question on respondent sex, they may be placed in the core questionnaire within the demographic section of the core. An increasing number of states have adopted the SOGI Module since its introduction. In 2014, 19 states adopted the SOGI module; by 2019, the number had increased to 32. The Sex at Birth module was used by 7 states in 2019. Researchers should note that the question on sex may be asked of respondents in either the screening section of the questionnaire, the demographic section, or both.
Are there any considerations for the Spanish version of the SO/GI module?
Care should be taken when using the SOGI data for interviews conducted in Spanish. Translation of these questions may be modified by states to match the dialect of Spanish that is most common within any state. Interviewers have reported issues with some of the translations for some Spanish-speaking respondents. This experience was especially common prior to changes in the translation in the first two years of administration (2014-2015). The inclusion of language of interview in models to predict outcomes of the SOGI categories may be useful.
What is the landscape of gender identity being included in population-based surveys?
The BRFSS is one of the few population-based surveys to include questions on gender identity. Some researchers have noted that the number of response categories for gender identity is limited on the BRFSS. The inclusion of additional categories may be considered over time. The current number of responses, however, is very small, and the inclusion of additional categories would likely produced too few responses to analyze. The BRFSS will continue to monitor methods to include additional information on SOGI as more is known about measurement of this demographic.
What is Pearson’s chi-square test?
The chi-square test for independence, also called Pearson’s chi-square test or the chi-square test of association, is used to discover if there if a relationship between two categorical variables.
When you choose to analyze your data using a chi-square test for independence, you need to make sure that the data you want to analyze “passes” two assumptions. You need to do this because it is only appropriate to use a chi-square test for independence if your data passes these assumptions. If it does not, you cannot use a chi-square test for independence. These two assumptions are:
Assumption #1) Your two variables should be measured at an ordinal or nominal level (i.e. categorical data).
Assumption #2) Your two variables should consist of two or more categorical, independent groups. Example independent variables that meet this criterion include gender (2 groups: Males and Females), ethnicity (e.g. 3 groups: Caucasian, African American and Hispanic), physical activity level (e.g. 4 groups: sedentary, low, moderate, and high), profession (e.g., 5 groups: surgeon, doctor, nurse, dentist, therapist), and so forth.
What was your statistical analysis choice?
We chose to use Pearson’s Chi-Square test as our data was categorical.
What’s a bivariate analysis?
Bivariate analysis - analyzing two variables at once. Involves the analysis of two variables, for the purpose of determining the empirical relationship between them.
