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Behavioral Risk Factor Surveillance System

OVERVIEW: BRFSS 2019

July 26, 2019

Background The Behavioral Risk Factor Surveillance System (BRFSS) is a collaborative project between all of the states in

the United States (US) and participating US territories and the Centers for Disease Control and Prevention (CDC).

The BRFSS is administered and supported by CDC's Population Health Surveillance Branch, under the Division

of Population Health at the National Center for Chronic Disease Prevention and Health Promotion. The BRFSS

is a system of ongoing health-related telephone surveys designed to collect data on health-related risk behaviors,

chronic health conditions, and use of preventive services from the noninstitutionalized adult population (≥ 18

years) residing in the United States.

The BRFSS was initiated in 1984, with 15 states collecting surveillance data on risk behaviors through monthly

telephone interviews. Over time, the number of states participating in the survey increased; BRFSS now collects

data in all 50 states as well as the District of Columbia and participating US territories. During 2019, All 50

states, the District of Columbia, Guam, and Puerto Rico collected BRFSS data. In this document, the term

“state” is used to refer to all areas participating in the BRFSS, including the District of Columbia, Guam, and

the Commonwealth of Puerto Rico. New Jersey was unable to collect enough BRFSS data in 2019 to meet the

minimum requirements for inclusion in the 2019 annual aggregate data set.

BRFSS’s objective is to collect uniform state-specific data on health risk behaviors, chronic diseases and

conditions, access to health care, and use of preventive health services related to the leading causes of

death and disability in the United States. Factors assessed by the BRFSS in 2019 included health status,

healthy days/health-related quality of life, health care access, exercise, inadequate sleep, chronic health

conditions, oral health, tobacco use, e-cigarettes, alcohol consumption, immunization, falls, seat belt use,

drinking and driving, breast- and cervical cancer screening, prostate cancer screening, colorectal cancer

screening, and HIV/AIDS knowledge. Since 2011, the BRFSS has been conducting both landline telephone-

and cellular telephone-based surveys. All the responses were self-reported; proxy interviews are not conducted

by the BRFSS. In conducting the landline telephone survey, interviewers collect data from a randomly selected

adult in a household. In conducting the cellular telephone survey, interviewers collect data from adults

answering the cellular telephones residing in a private residence or college housing. Beginning in 2014, all

adults contacted through their cellular telephone were eligible, regardless of their landline phone use (i.e.,

complete overlap).

The BRFSS field operations are managed by state health departments that follow protocols adopted by the

states, with technical assistance provided by CDC. State health departments collaborate during survey

development and conduct the interviews themselves or use contractors. The data are transmitted to CDC for

editing, processing, weighting, and analysis. An edited and weighted data file is provided to each participating

state health department for each year of data collection, and summary reports of state-specific data are prepared

by CDC. State health departments use the BRFSS data for a variety of purposes, including identifying

demographic variations in health-related behaviors; designing, implementing, and evaluating public health

programs; addressing emergent and critical health issues; proposing legislation for health initiatives; and

measuring progress toward state health objectives.1 For specific examples of how state officials use the finalized

BRFSS data sets, please refer to the appropriate state information on the BRFSS website.

Health characteristics estimated from the BRFSS pertain to the noninstitutionalized adult population—aged 18

years or older—who reside in the United States. In 2019, an optional module was included to provide a measure

for several childhood health and wellness indicators, including asthma prevalence for people aged 17 years or

younger. BRFSS respondents are identified through telephone-based methods. According to the 2018 American

Community Survey (ACS), 98.5% of all occupied housing units in the United States had telephone service

available and telephone non-coverage ranged from less than 1.0% in Delaware to 2.5% in Montana.2 It is

estimated that 4.0% of occupied households in Puerto Rico did not have telephone service.2 The increasing

percentage of households that are abandoning their landline telephones for cellular telephones has significantly

eroded the population coverage provided by landline telephone-based surveys to pre-1970s levels. The

preliminary results (January to June 2019) from the National Health Interview Survey (NHIS) indicate that

58.4% of adults were wireless-only.3 Using a dual-frame survey including landline and cellular telephones

improved the validity, data quality, and representativeness of BRFSS data.

In 2011, a new weighting methodology called iterative proportional fitting (or “raking”) 4 replaced the post-

stratification method to weight BRFSS data. Raking allows incorporation of cellular telephone survey data and

permits the introduction of additional demographic characteristics (e.g., education level, marital status, home

renter/owner) in addition to age-race/ethnicity-gender that improves the degree and extent to which the BRFSS

sample properly reflects the socio-demographic make-up of individual state. The 2019 BRFSS raking method

includes categories of age by gender, detailed race and ethnicity groups, education levels, marital status, regions

within states, gender by race and ethnicity, telephone source, renter or owner status, and age groups by race and

ethnicity. In 2019, 50 states, the District of Columbia, Guam, and Puerto Rico collected samples of interviews

conducted by landline and cellular telephone.

The BRFSS Design

The BRFSS Questionnaire

Each year, the states—represented by their BRFSS coordinators and CDC—agree on the content of the

questionnaire. The BRFSS questionnaire consists of a core component, optional modules, and state-added

questions. Many questions are taken from established national surveys, such as the National Health Interview

Survey or the National Health and Nutrition Examination Survey. This practice allows the BRFSS to take

advantage of questions that have been tested and allows states to compare their data with those from other

surveys. Any new questions that states, federal agencies, or other entities propose as additions to the BRFSS

must go through cognitive testing and field testing before they can become part of the BRFSS questionnaire. In

addition, a majority vote of all state representatives is required before questions are adopted. The BRFSS

guidelines—agreed upon by the state representatives and CDC—specify that all states ask the core component

questions without modification. They may choose to add any, all, or none of the optional modules and may add

questions of their choosing as state-added questions.

The questionnaire has three parts:

1. Core component: A standard set of questions that all states use. Core content includes queries about current

health-related perceptions, conditions, and behaviors (e.g., health status, health care access, alcohol

consumption, tobacco use, fruits and vegetable consumptions, HIV/AIDS risks), as well as demographic

questions. The core component includes the annual core comprising questions asked each year and rotating core

questions that are included in even- and odd–numbered years.

2. Optional BRFSS modules: These are sets of questions on specific topics (e.g., pre-diabetes, diabetes, sugar-

sweetened beverages, excess sun exposure, caregiving, shingles, cancer survivorship) that states elect to use on

their questionnaires. Generally, CDC programs submit module questions and the states vote to adopt final

questions that can be included as optional modules. For more information, please see the questionnaire section

of the BRFSS website.

3. State-added questions: Individual states develop or acquire these questions and add them to their BRFSS

questionnaires. CDC does not edit, evaluate, or track or report responses from these questions.

The BRFSS supported 23 modules in 2019, but states limited modules and state-added questions to only the

most useful for their state program purposes, in order to keep surveys at a reasonable length. Because different

states have different needs, there is wide variation between states in terms of question totals each year. The

BRFSS implements a new questionnaire in January and usually does not change it significantly for the rest of

the year. The flexibility of state-added questions, however, does permit additions, changes, and deletions at any

time during the year.

The 2019 list of optional modules used on both the landline telephone and cellular telephone surveys is

available on the BRFSS website. In order to allow for a wider range of questions in optional modules, combined

landline telephone and cellular telephone data for 2019 include up to three split versions of the questionnaire. A

split version is used when a subset of telephone numbers for data collection still followed the state sample

design, and administrators used it as the state’s BRFSS sample, but the optional modules and state-added

questions may have been different from other split-version questionnaires. For additional information on split

version questionnaires, see the 2019 module data appendix table, published with this yearly release.

Annual Questionnaire Development

The governance of the BRFSS includes a representative body of state health officials, elected by region. During

the year, the State BRFSS Coordinators Working Group meets with CDC’s BRFSS program management.

Before the beginning of the calendar year, CDC provides states with the text of the core component and the

optional modules that the BRFSS will support in the coming year. States select their optional modules and ready

any state-added questions they plan to use. Each state then constructs its own questionnaire. The order of the

questioning is always the same—interviewers ask questions from the core component first, then they ask any

questions from the optional modules, and the state-added questions. This content order ensures comparability

across states and follows the BRFSS guidelines. Generally, the only changes that the standard protocol allows

are limited insertions of state-added questions on topics related to core questions. CDC and state partners must

agree to these exceptions. In some cases, however, states have not been able to follow all set guidelines. Users

should refer to the yearly Comparability of Data document, which lists the known deviations.

Once each state finalizes its questionnaire content—consisting of the core questionnaire, optional modules, and

state-added questions—the state prepares a hard copy or electronic version of the instrument and sends it to

CDC. States use the questionnaire without changes for one calendar year, and CDC archives a copy on the

BRFSS website. If a significant portion of any state’s population does not speak English, states have the option

of translating the questionnaire into other languages. Currently, CDC provides a Spanish version of the core

questionnaire and optional modules. Specific wording of the Spanish version of the questionnaire may be

adapted by the states to fit the needs of their Hispanic populations.

Sample Description

In a telephone survey such as the BRFSS, a sample record is one telephone number in the list of all telephone

numbers the system randomly selects for dialing. To meet the BRFSS standard for the participating states'

sample designs, one must be able to justify sample records as a probability sample of all households with

telephones in the state. All participating areas met this criterion in 2018. Fifty-one projects used a

disproportionate stratified sample (DSS) design for their landline samples. Guam and Puerto Rico used a simple

random-sample design.

In the type of DSS design that states most commonly used in the BRFSS landline telephone sampling, the

BRFSS divides telephone numbers into two groups, or strata, which are sampled separately. The high-density

and medium-density strata contain telephone numbers that are expected to belong mostly to households.

Whether a telephone number goes into the high-density or medium-density stratum is determined by the number

of listed household numbers in its hundred block, or set of 100 telephone num