National Health and Nutrition
Examination Survey – Oral Health
Components
Laurie Barker, MSPH
Mathematical Statistician
Surveillance, Investigation and Research Team
Division of Oral Health
National Center for Chronic Disease Prevention and Health Promotion
Office of Noncommunicable Diseases, Injury and Environmental Health
lub2@cdc.gov
Workshop Overview
• Lecture
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IV.
Introduction
NHANES Overview
NHANES Data Resources
Future Developments in NHANES
• Hands-on Workshop
V. Orientation to NCHS NHANES Web site
VI. Orientation to DRC tutorial materials
VII. Practice Examples (in SAS and SUDAAN)
I. Introduction
– CDC’s organization (oral health, NHANES) and
relationship to NIDCR and other Federal agencies,
and to universities and state governments
– Surveillance vs. Research
I. Introduction: CDC organization
– Within CDC
• DOH
– located within the National Center for Chronic Disease
Prevention and Health Promotion
– Funds 19 states to build oral health infrastructure
– Funds part of NHANES, along with NIDCR
• Division of HANES
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located within the National Center for Health Statistics
Designs, manages contract to operate NHANES
produces public and restricted data sets
Collaborates with other NCHS divisions to link NHANES to
other data sets
– Publishes a wide variety of reports on NHANES
I. Introduction: CDC organization
– Outside of CDC
• Department of Health and Human Services
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NIH/NIDCR
CDC
CMS
HRSA
IHS
SAMSHA
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I. Introduction
– Surveillance vs. Research
• Main purpose of surveillance is to monitor trends in
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known public health problems and related risk factors
Identify emerging problems
Broad picture of trends in national populations
Sentinel surveillance
» monitors rarer problems in higher risk populations
» Or problems in populations representative of a smaller
area (county, city or specific population)
• Survey-based Surveillance at the national level is
constrained by costs and burden to participants
I. Introduction
– Surveillance vs. Research
• Changes in trends or new problems identified through
surveillance ideally trigger focused research to explain
the observed change
• Surveillance data sets are often cross-sectional
– Few truly longitudinal surveys
– Limitations in the types of research that can be conducted
with surveillance data
– New developments
• linkage among surveys, linkage with external data
(CMS, environmental) may support more research
• Match rate could be a limiting issue
II. NHANES overview
– History of NHANES
– NHANES compared to other national surveys
– NHANES Oral Health Components
• 2009-2010
• Previous NHANES and precursor National Health
Examination Survey
– Survey design and analysis considerations
• Statistical methods
• Software
II. NHANES Overview: History of NHANES
• National Health Examination Surveys
– 1959-62, 1963-65, 1966-1970
• National Health and Nutrition Examination
Surveys
– 1971-1974, 1988-1995
– 1999+ Continuous NHANES
• Hispanic HANES 1986-1987
National Health Survey
NHES I 1959-1962 – 18-79y
NHES II 1963-1965 – 6-11y
NHES III 1966-1970 – 12-17y
NHANES I 1971-1974 – 1-74y
NIDR/OHSC I 1979-1980 5-17y
HHANES 1982-1984 6m-74y
NIDR/OHSC II 1986-1987 5-17y
State-based Health Survey
BSS - 3rd grade, K,1,2, HeadStart, older adults
BRFSS 1999, 2002, 2004, 2006, 2008, 2010 – 18y+
Some states in other years from 1995
NHANES III 1988-1994 2m+
NHANES 1999-2004 2y+
NHANES 2005-2008 5y+
NHANES 2009-2010 3-19y, 30y+
NHIS 1963-2010
NHAMCS 1992-2007
MEPS 1996-2008
PRAMS 1990-1995, 1996-1999, 2000-2003, 20042008, 2009+
NSCH 2003, 2007, 2011 – 0-17y
NSCSHCN 2001, 2005-2006, 2009-2010 – 0-17y
YRBSS 1991-2009, odd years
II. NHANES Overview: NHANES compared to other national surveys
• NHANES
– National Household - questionnaire, exam, lab
• NHIS
– National Household – questionnaire
• MEPS
– National Household – questionnaire focused on costs
• BRFSS
– State Telephone (multimodal now) – questionnaire
– National estimates from combined states
• YRBSS
– Paper survey
– Separate National and State samples
II. NHANES Overview: NHANES Oral Health Components
– 2009-2010 – dental hygienist raters
• Caries – tooth surface level, limited age range
• Periodontal disease – full mouth
– 2005-2008 – medical technician raters
• Caries – person level, limited age range
– 1999-2004 – dentist raters
• Caries and sealants - Tooth surface level
• Root caries, Fluorosis - Tooth level
• Periodontal disease – 2 quadrants, facial/buccal sites
– Previous NHANES and precursor National Health
Examination Survey – dentist raters
• Caries, other measures of oral health, some out-of-date
II. NHANES Overview:Survey design and analysis considerations
• Statistical methods
• Software
II. NHANES Overview:Survey design and analysis considerations
• Statistical methods
– Complex sample survey design requires methods that
account for clustering due to survey design, in
addition to any other clustering
• Typically, design-based analyses have been recommended –
parameter estimation limited by PSUs (~15 per 2 years)
• NCHS (and others) exploring other methods to account for
clustering, increase yield of information from survey data
– Sampling fraction, oversampling, non-response
• NCHS provides weights that should be used
• Little information to construct special weights due to
disclosure protections
II. NHANES Overview:Survey design and analysis considerations
• Software
– SUDAAN (or WESVAR), historically the
recommended software due to limited procedures
for complex samples in other software
– SAS, Stata, SPSS, R
• All now have procedures to account for survey design
• Point estimates should be the same from all packages
• Variance estimates may differ due to choices each
package has made in methods to account for clustering
– Differences probably less than 0.01?
II. NHANES Overview:Survey design and analysis considerations
• Key references
– Heeringa, Steven G, Brady T. West and Patricia
Berglund. 2010. Applied Survey Data Analysis.
Chapman & Hall, CRC, New York.
– Korn, Edward L. and Barry Graubard. 1999.
Analysis of Health Surveys. John Wiley, New York.
– Groves, Robert M., Floyd J. Fowler, Jr., Mick P.
Cooper, James M. Lepkowski, Eleanor Singer,
Roger Tourangeau. 2004. Survey Methodology, 2nd
edition. John Wiley, New York, 2009.
III. NHANES data resources
– NCHS NHANES Tutorial
– Dental, Oral and Craniofacial Data Resource
Center (CDC and NIDCR funded project)
• Current online resources
• Tutorial materials in development
– Restricted data, linked data and Research Data
Centers operated by NCHS or Census
III. NHANES data resources
– NCHS NHANES Tutorial
http://www.cdc.gov/nchs/tutorials/index.htm
• Excellent tutorial, materials being added regularly
• Not specific to oral health, but good resources for
– Dietary interview data
– Environmental chemical data
– Variable crosswalks
• Cross year variable table
http://www.cdc.gov/nchs/nhanes/variable_tables/cross_year_vari
ables_list.htm
• Not for oral health yet, but many others
– Demographics, dietary recall, C-reactive protein, smoking, reproductive
health
– Q-Bank – question evaluation reports
• http://wwwn.cdc.gov/qbank/Home.aspx
III. NHANES data resources
– Dental, Oral and Craniofacial Data Resource Center
(CDC and NIDCR funded project)
• Current online resources
– Data Query System, some publications, survey questions
inventory, Catalog of Surveys and Archive of Methods Related to
Oral Health (400+ surveys listed)
• Tutorial materials in development
– Will cover this in hands-on workshop
» Basic info on key data sets with oral health, linked to source
» Expanded documentation of oral health components
» Variable crosswalks
» Code for creating analytic data sets
» “clean” oral health data sets
III. NHANES data resources
– Restricted data, linked data and Research Data
Centers operated by NCHS or Census
– Research Data Centers http://www.cdc.gov/rdc/
– Linked data – national surveys linked to CMS,
mortality, air quality, Social Security Benefit
history
• http://www.cdc.gov/nchs/data_access/data_linkage_ac
tivities.htm
Hands-on workshop
V. Orientation to NCHS NHANES Web site
VI. Orientation to DRC tutorial materials
VII.Practice examples (in SAS and SUDAAN)
Hands-on Workshop
V. Orientation to NCHS NHANES Web site
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Locating and downloading files
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Demographics
Questionnaire
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Examination
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Oral health
Oral health referral and recommendations
Household and other files
Oral health examination
Dietary interview files
Laboratory
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Tobacco
C-Reactive Protein
Vitamin D
Hands-on workshop
VI. Orientation to DRC tutorial materials
Hands-on workshop
VII.Practice examples (in SAS and SUDAAN)
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Setting up an analytic data set with
questionnaire items
Preparing an analytic data set with oral health
examination items and dental indices
Preparing an analytic data set with laboratory
items
Producing national estimates for Healthy People
objectives
Hands-on workshop
VII.Practice examples (in SAS and SUDAAN)
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Setting up an analytic data set with
questionnaire items
Hands-on workshop
VII.Practice examples (in SAS and SUDAAN)
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Preparing an analytic data set with oral health
examination items and dental indices
Hands-on workshop
VII.Practice examples (in SAS and SUDAAN)
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Preparing an analytic data set with laboratory
items
Hands-on workshop
VII.Practice examples (in SAS and SUDAAN)
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Producing national estimates for Healthy People
objectives
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Tracking Healthy People 2010
CDC WONDER/Data2010