Advertisement

Practical Guidance for Using Behavioral Risk Factor Surveillance System Data: Merging States and Scoring Adverse Childhood Experiences

  • Paige K. Lombard
    Correspondence
    Address correspondence to: Paige K. Lombard, MPH, Netter Center for Community Partnerships, University of Pennsylvania, 3819-33 Chestnut Street, Suite 120, Philadelphia PA 19104.
    Affiliations
    Master of Public Health Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    Barbara and Edward Netter Center for Community Partnerships, University of Pennsylvania, Philadelphia, Pennsylvania
    Search for articles by this author
  • Peter F. Cronholm
    Affiliations
    The Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania

    Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
    Search for articles by this author
  • Christine M. Forke
    Affiliations
    Master of Public Health Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    The Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania

    Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania

    Center for Violence Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

    Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    Search for articles by this author
Published:February 01, 2022DOI:https://doi.org/10.1016/j.amepre.2021.11.012

      Introduction

      The Behavioral Risk Factor Surveillance System is a national health-related survey with an optional adverse childhood experience (ACE) module. States use varying methodologies, question formats, and sampling frames, and little guidance exists for conducting multistate explorations of adverse childhood experiences. In this study, 6 adverse childhood experience scoring approaches are compared, and practical recommendations are offered for when and how each approach can be utilized most effectively.

      Methods

      This study used 2015 Behavioral Risk Factor Surveillance System data from the adverse childhood experience module administered by 6 states. Data were merged and analyzed between 2018 and 2021. To understand how adverse childhood experience scoring may impact estimates of association, concordance/discordance among 6 approaches (continuous versus categorical, states that collected all adverse childhood experiences versus those that collected any adverse childhood experiences, and normalized versus standard scores) was evaluated. Using separate weighted multivariable logistic regression models controlling for confounders, the relationship between adverse childhood experiences using each approach and the presence of 10 chronic health conditions was also assessed.

      Results

      Comparisons revealed discordance for categorical versus continuous approaches (30%) and all-ACEs versus any-ACEs (20%) but full concordance for standard versus normalized approaches. Discordance occurred more frequently with low-prevalence outcomes (≤7.0%) and lower-exposure samples (any-ACEs).

      Conclusions

      Results revealed general concordance across adverse childhood experience scoring approaches when outcomes commonly occurred and when the sample was limited to just states that asked the full array of adverse childhood experiences. However, on a deeper exploration of discordant findings, specific nuances were uncovered that may help guide researchers when deciding on which approach to use on the basis of the research question and conceptual model driving study objectives.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

      1. Boullier M, Blair M. Adverse childhood experiences. Paediatr Child Health. 2018;28(3):132‒137. https://doi.org/10.1016/j.paed.2017.12.008.

      2. Sacks V, Murphey D. The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicity, Child Trends; Bethesda, MD 2018. https://www.childtrends.org/publications/prevalence-adverse-childhood-experiences-nationally-state-race-ethnicity. Published February 12Accessed April 14, 2019.

      3. Giano Z, Wheeler DL, Hubach RD. The frequencies and disparities of adverse childhood experiences in the U.S. BMC Public Health. 2020;20(1):1327. https://doi.org/10.1186/s12889-020-09411-z.

        • Bucci M
        • Marques SS
        • Oh D
        • Harris NB.
        Toxic stress in children and adolescents.
        Adv Pediatr. 2016; 63: 403-428https://doi.org/10.1016/j.yapd.2016.04.002
      4. About BRFSS. Centers for Disease Control and Prevention. https://www.cdc.gov/brfss/about/index.htm. Updated May 16, 2014. Accessed November 19, 2018.

        • Centers for Disease Control and Prevention
        BRFSS adverse childhood experience (ACE) module.
        Centers for Disease Control and Prevention, Atlanta, GA2021 (Accessed December 13)
        • Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
        A data users guide to the BRFSS physical activity questions: how to assess the 2008 physical activity guidelines for Americans.
        Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA2021 (Accessed December 13)
        • Iachan R
        • Pierannunzi C
        • Healey K
        • Greenlund KJ
        • Town M.
        National weighting of data from the Behavioral Risk Factor Surveillance System (BRFSS).
        BMC Med Res Methodol. 2016; 16: 155https://doi.org/10.1186/s12874-016-0255-7
        • ASTHO
        Data-driven primary prevention strategies for adverse childhood experiences.
        ASTHO, Arlington, VA2019 (Published JulyAccessed December 13, 2021)
        • Cheong EV
        • Sinnott C
        • Dahly D
        • Kearney PM.
        Adverse childhood experiences (ACEs) and later-life depression: perceived social support as a potential protective factor.
        BMJ Open. 2017; 7e013228https://doi.org/10.1136/bmjopen-2016-013228
        • Bhan N
        • Glymour MM
        • Kawachi I
        • Subramanian SV.
        Childhood adversity and asthma prevalence: evidence from 10 US states (2009-2011).
        BMJ Open Respir Res. 2014; 1e000016https://doi.org/10.1136/bmjresp-2013-000016
        • Ege MA
        • Messias E
        • Thapa PB
        • Krain LP.
        Adverse childhood experiences and geriatric depression: results from the 2010 BRFSS.
        Am J Geriatr Psychiatry. 2015; 23: 110-114https://doi.org/10.1016/j.jagp.2014.08.014
        • Chapman DP
        • Whitfield CL
        • Felitti VJ
        • Dube SR
        • Edwards VJ
        • Anda RF.
        Adverse childhood experiences and the risk of depressive disorders in adulthood.
        J Affect Disord. 2004; 82: 217-225https://doi.org/10.1016/j.jad.2003.12.013
        • Cronholm PF
        • Forke CM
        • Wade R
        • et al.
        Adverse childhood experiences: expanding the concept of adversity.
        Am J Prev Med. 2015; 49: 354-361https://doi.org/10.1016/j.amepre.2015.02.001
        • Merrick MT
        • Ford DC
        • Ports KA
        • Guinn AS.
        Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 states [published correction appears in JAMA Pediatr. 2018;172(11):1104].
        JAMA Pediatr. 2018; 172: 1038-1044https://doi.org/10.1001/jamapediatrics.2018.2537
        • Merrick MT
        • Ford DC
        • Ports KA
        • et al.
        Vital signs: estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention - 25 states, 2015-2017.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 999-1005https://doi.org/10.15585/mmwr.mm6844e1
        • Deschênes SS
        • Graham E
        • Kivimäki M
        • Schmitz N.
        Adverse childhood experiences and the risk of diabetes: examining the roles of depressive symptoms and cardiometabolic dysregulations in the Whitehall II cohort study.
        Diabetes Care. 2018; 41: 2120-2126https://doi.org/10.2337/dc18-0932
        • Felitti VJ
        • Anda RF
        • Nordenberg D
        • et al.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study.
        Am J Prev Med. 1998; 14: 245-258https://doi.org/10.1016/s0749-3797(98)00017-8
        • Krinner LM
        • Warren-Findlow J
        • Bowling J
        • Issel LM
        • Reeve CL.
        The dimensionality of adverse childhood experiences: a scoping review of ACE dimensions measurement.
        Child Abuse Negl. 2021; 121105270https://doi.org/10.1016/j.chiabu.2021.105270
        • Reidy DE
        • Niolon PH
        • Estefan LF
        • et al.
        Measurement of adverse childhood experiences: it matters.
        Am J Prev Med. 2021; 61: 821-830https://doi.org/10.1016/j.amepre.2021.05.043
      5. Behavioral Risk Factor Surveillance System comparability of data BRFSS 2015.
        Centers for Disease Control and Prevention, 2016 (Updated JuneAccessed December 13, 2021)
      6. Behavioral Risk Factor Surveillance System ACE data.
        Centers for Disease Control and Prevention, 2020 (Updated April 3Accessed July 13, 2020)
        • Lee RD
        • Chen J.
        Adverse childhood experiences, mental health, and excessive alcohol use: examination of race/ethnicity and sex differences.
        Child Abuse Negl. 2017; 69: 40-48https://doi.org/10.1016/j.chiabu.2017.04.004
        • Centers for Disease Control and Prevention
        Behavioral Risk Factor Surveillance System: weighting BRFSS data 2015.
        Centers for Disease Control and Prevention, Atlanta, GA2015 (PublishedAccessed December 13, 2021)
        • Andersen JP
        • Blosnich J.
        Disparities in adverse childhood experiences among sexual minority and heterosexual adults: results from a multi-state probability-based sample.
        PLoS One. 2013; 8: e54691https://doi.org/10.1371/journal.pone.0054691
        • Chang X
        • Jiang X
        • Mkandarwire T
        • Shen M.
        Associations between adverse childhood experiences and health outcomes in adults aged 18-59 years.
        PLoS One. 2019; 14e0211850https://doi.org/10.1371/journal.pone.0211850
        • Monnat SM
        • Chandler RF.
        Long term physical health consequences of adverse childhood experiences.
        Sociol Q. 2015; 56: 723-752https://doi.org/10.1111/tsq.12107
        • Altman DG.
        Practical Statistics for Medical Research.
        1st ed. Chapman & Hall, London, United Kingdom1990
        • Rothman KJ
        • Greenland S
        • Lash TL.
        Chapter 10. Precision and statistics in epidemiologic studies.
        Modern Epidemiology. Lippincott Williams & Wilkins, Philadelphia, PA2008