Tools
Behavioral Risk Factor Surveillance System
Definition/Introduction
The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based national system of telephone surveys in the United States that collects data on health-related risk behaviors, chronic health conditions, and the use of preventive services for adults aged 18 or older (CDC. Behavioral Risk Factor Surveillance System).[1] A collaborative effort between the United States Centers for Disease Control and Prevention (CDC) and each state health department, it is the world's largest and the nation's leading ongoing health-related telephone survey.
The BRFSS was established in 1984 to serve individual states, especially for chronic disease prevention and health promotion programs.[2] In 2011, it was modified to accommodate the growing number of households with a cellular telephone but no landline telephone and to implement new weighting methods to address declining response rates.[3] All 50 states, including the District of Columbia, Puerto Rico, the United States Virgin Islands, and Guam, participate in the BRFSS. The success of this system led to the creation of the Pregnancy Risk Assessment Monitoring System in 1987 and the Youth Risk Behavior Surveillance System a few years later.[2]
Each year's survey questionnaire is designed by each state's survey coordinator from its state health department and designated CDC staff.[4] Over 400,000 telephone surveys are conducted yearly with noninstitutionalized United States adult residents to collect data on health status indicators, preventive practices, health risk behaviors, and chronic conditions. Health risk behaviors assessed include current cigarette smoking, binge drinking, lack of leisure-time physical activity, and fruit and vegetable consumption. Chronic conditions assessed include obesity, diabetes mellitus, arthritis, depressive disorder, high blood pressure, high blood cholesterol, coronary heart disease, and stroke.[5][6] Other modules include cognitive decline, emotional support, e-cigarette and marijuana use, and intimate partner violence.[2] This system is one of the few systems that collects data on individual-level racism.[7]
Many BRFSS questions are derived from other national surveys that collect information through face-to-face interviews, telephone interviews, and physical examinations. These surveys include the National Center for Health Statistics, National Health and Nutrition Interview Survey, National Survey of Family Growth, Current Population Survey, and National Survey on Drug Use and Health. Therefore, BRFSS prevalence estimates can be compared with other national surveys to assess their validity and accuracy. A comprehensive review of numerous published scholarly studies confirms its validity and reliability.[8]
There are 3 parts to the survey questionnaire—core, optional, and state-added questions. All states use the core component questions. The annual core questions are asked yearly. Rotating core questions are 2 sets of questions used in alternating years. The emerging core consists of 5 questions that address current or emerging issues such as vaccine shortage and influenza-like illness. Optional modules include rotating core questions that states may elect to use. Each state selects state-added questions based on its specific needs.[5][9] The questionnaire is designed to benefit individual states while also generating valuable national data.[2]
Each state's health department conducts survey interviews using the same core questionnaire, standardized sampling methods, and methodology. The data are then submitted to the CDC monthly for further processing and analysis. In 2011, the BRFSS adopted iterative proportional fitting, a new method incorporating additional demographic variables, enhancing representativeness and reducing potential bias.
The new methodology also incorporates the variable of telephone ownership. Survey data are published online by the CDC on an annual basis. Each year's questionnaire, background, design data, survey results from 1984 to the present, and analytical and statistical tools for further dissemination and processing are available on the CDC's BRFSS website, as is the BRFSS Maps application, which graphically displays the prevalence of behavioral risk factors using geographical information systems mapping technology.[5][6] According to the BRFSS website, the CDC's website is undergoing modifications to comply with the President's Executive Orders, though the impact on data validity remains uncertain.
Issues of Concern
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Issues of Concern
The significant challenges faced by BRFSS include low response rates, adapting to changes in modes of communication, and reaching a multilingual, diverse population. Response rates have dropped significantly since 1993. Currently, surveys are conducted through cell phones and landlines in both English and Spanish. Creating multi-language versions and new outreach strategies aimed at accessing hard-to-reach respondents are necessary to increase the participation of a diverse and expanding United States resident population.[4][10]
Clinical Significance
BRFSS prevalence data on chronic diseases, health risk behaviors, and preventive practices are used by all 50 states and 3 United States territories to track and monitor the health of United States residents. Policymakers, scientists, governmental municipalities, and agencies use these data to implement public health policies, research studies, programs, and resources to reduce morbidity and mortality. BRFSS data support public health planning and policies, such as legislation concerning drinking and driving, air pollution, and the usage of seat belts.[11] Data from the BRFSS during the H1N1 outbreak were used to prepare for subsequent influenza pandemic outbreaks. In addition, data from the previous year's flu season served to monitor the influenza vaccination shortage.[12]
BRFSS prevalence data are published annually in the CDC's Morbidity and Mortality Weekly Report, an epidemiological report used to disseminate recommendations and various public health information reported to the CDC by each state health department.[11]
The BFRSS has recently been used to study the following:
Nursing, Allied Health, and Interprofessional Team Interventions
State and federal agencies, such as the CDC, provide essential resources and public health data on the prevalence of chronic diseases. However, collaboration among healthcare professionals, including clinicians, pharmacists, psychologists, and other healthcare providers, is essential for addressing cyclical morbidity and mortality patterns. A review of 22 random control trials and 9 systematic reviews involving the interprofessional team approach for managing diabetes mellitus demonstrated statistically and clinically significant improvement in hemoglobin A1c and systolic blood pressure compared to usual care that does not involve the interprofessional team approach.[20]
References
Hsia J, Zhao G, Town M, Ren J, Okoro CA, Pierannunzi C, Garvin W. Comparisons of Estimates From the Behavioral Risk Factor Surveillance System and Other National Health Surveys, 2011-2016. American journal of preventive medicine. 2020 Jun:58(6):e181-e190. doi: 10.1016/j.amepre.2020.01.025. Epub [PubMed PMID: 32444008]
Level 3 (low-level) evidenceMarks JS, Mokdad AH, Town M. The Behavioral Risk Factor Surveillance System: Information, Relationships, and Influence. American journal of preventive medicine. 2020 Dec:59(6):773-775. doi: 10.1016/j.amepre.2020.09.001. Epub 2020 Nov 18 [PubMed PMID: 33220750]
Centers for Disease Control and Prevention (CDC). Methodologic changes in the Behavioral Risk Factor Surveillance System in 2011 and potential effects on prevalence estimates. MMWR. Morbidity and mortality weekly report. 2012 Jun 8:61(22):410-3 [PubMed PMID: 22672976]
Fahimi M, Link M, Mokdad A, Schwartz DA, Levy P. Tracking chronic disease and risk behavior prevalence as survey participation declines: statistics from the behavioral risk factor surveillance system and other national surveys. Preventing chronic disease. 2008 Jul:5(3):A80 [PubMed PMID: 18558030]
Level 3 (low-level) evidenceIachan R, Pierannunzi C, Healey K, Greenlund KJ, Town M. National weighting of data from the Behavioral Risk Factor Surveillance System (BRFSS). BMC medical research methodology. 2016 Nov 15:16(1):155 [PubMed PMID: 27842500]
Pickens CM, Pierannunzi C, Garvin W, Town M. Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2015. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002). 2018 Jun 29:67(9):1-90. doi: 10.15585/mmwr.ss6709a1. Epub 2018 Jun 29 [PubMed PMID: 29953431]
White K, Beatty Moody DL, Lawrence JA. Integrating Racism as a Sentinel Indicator in Public Health Surveillance and Monitoring Systems. American journal of public health. 2023 Jan:113(S1):S80-S84. doi: 10.2105/AJPH.2022.307160. Epub [PubMed PMID: 36696616]
Pierannunzi C, Hu SS, Balluz L. A systematic review of publications assessing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS), 2004-2011. BMC medical research methodology. 2013 Mar 24:13():49. doi: 10.1186/1471-2288-13-49. Epub 2013 Mar 24 [PubMed PMID: 23522349]
Level 1 (high-level) evidenceLaflamme DM, Vanderslice JA. Using the Behavioral Risk Factor Surveillance System (BRFSS) for exposure tracking: experiences from Washington State. Environmental health perspectives. 2004 Oct:112(14):1428-33 [PubMed PMID: 15471738]
Level 3 (low-level) evidenceCunningham TJ, Xu F, Town M. Prevalence of Five Health-Related Behaviors for Chronic Disease Prevention Among Sexual and Gender Minority Adults - 25 U.S. States and Guam, 2016. MMWR. Morbidity and mortality weekly report. 2018 Aug 17:67(32):888-893. doi: 10.15585/mmwr.mm6732a4. Epub 2018 Aug 17 [PubMed PMID: 30114006]
Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public health reports (Washington, D.C. : 1974). 1988 Jul-Aug:103(4):366-75 [PubMed PMID: 2841712]
Dotis J, Roilides E. H1N1 influenza A infection. Hippokratia. 2009 Jul:13(3):135-8 [PubMed PMID: 19918299]
Al Rifai M, Mahtta D, Vaughan EM, Petersen LA, Virani SS. Letter to the Editor: Temporal Changes in Cost-Related Medication Nonadherence by Race/Ethnicity and Medicaid Expansion: The Behavioral Risk Factor Surveillance System Survey. Population health management. 2022 Feb:25(1):141-142. doi: 10.1089/pop.2021.0183. Epub 2021 Aug 9 [PubMed PMID: 34374582]
Level 3 (low-level) evidenceKherallah R, Al Rifai M, Kamat I, Krittanawong C, Mahtta D, Lee MT, Liu J, Nasir K, Valero-Elizondo J, Patel J, Al-Mallah MH, Petersen LA, Virani SS. Prevalence and predictors of cost-related medication nonadherence in individuals with cardiovascular disease: Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey. Preventive medicine. 2021 Dec:153():106715. doi: 10.1016/j.ypmed.2021.106715. Epub 2021 Jul 7 [PubMed PMID: 34242664]
Level 3 (low-level) evidenceDaher M, Al Rifai M, Kherallah RY, Rodriguez F, Mahtta D, Michos ED, Khan SU, Petersen LA, Virani SS. Gender disparities in difficulty accessing healthcare and cost-related medication non-adherence: The CDC behavioral risk factor surveillance system (BRFSS) survey. Preventive medicine. 2021 Dec:153():106779. doi: 10.1016/j.ypmed.2021.106779. Epub 2021 Sep 3 [PubMed PMID: 34487748]
Level 3 (low-level) evidenceEiden AL, Hartley L, Garbinsky D, Saande C, Russo J, Hufstader Gabriel M, Price M, Bhatti A. Adult vaccination coverage in the United States: A database analysis and literature review of improvement strategies. Human vaccines & immunotherapeutics. 2024 Dec 31:20(1):2381283. doi: 10.1080/21645515.2024.2381283. Epub 2024 Jul 30 [PubMed PMID: 39079694]
Lee BP, Dodge JL, Terrault NA. Medicaid expansion and variability in mortality in the USA: a national, observational cohort study. The Lancet. Public health. 2022 Jan:7(1):e48-e55. doi: 10.1016/S2468-2667(21)00252-8. Epub 2021 Dec 2 [PubMed PMID: 34863364]
Moskatel LS, Slusky DJG. The impact of COVID-19 on alcohol sales and consumption in the United States: A retrospective, observational analysis. Alcohol (Fayetteville, N.Y.). 2023 Sep:111():25-31. doi: 10.1016/j.alcohol.2023.05.003. Epub 2023 May 23 [PubMed PMID: 37230334]
Level 2 (mid-level) evidenceLundeen EA, Park S, Woo Baidal JA, Sharma AJ, Blanck HM. Sugar-Sweetened Beverage Intake Among Pregnant and Non-pregnant Women of Reproductive Age. Maternal and child health journal. 2020 Jun:24(6):709-717. doi: 10.1007/s10995-020-02918-2. Epub [PubMed PMID: 32303941]
Medical Advisory Secretariat. Community-based care for the management of type 2 diabetes: an evidence-based analysis. Ontario health technology assessment series. 2009:9(23):1-40 [PubMed PMID: 23074528]