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About the Behavioral Risk Factor Surveillance System (BRFSS)

Key Points about the BRFSS	Limitations
Topics	Results from BRFSS
Collecting Data

Key Points about the BRFSS

The BRFSS collects information from adults on health behaviors and preventive practices related to several leading causes of death.

The BRFSS is used by all states, the District of Columbia, and three territories, through funds disbursed by CDC and supplemented by state program funds.

The BRFSS provides data for many purposes:

Assessing risk for chronic diseases.
Identifying demographic differences and trends in health-related behaviors.
Designing and monitoring health interventions and services.
Addressing emergent and critical health issues.
Formulating policy and proposing legislation for health initiatives.
Measuring progress toward achieving state and national health objectives.

The BRFSS can be adapted to meet state-specific needs, while still allowing for state-to-state and regional comparisons.
The BRFSS can be used to assess special populations, such as military personnel and members of health maintenance organizations. In Washington, many local health jurisdictions and several tribal authorities have also implemented local BRFSS surveys modeled on the national and state surveys.

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Topics

The BRFSS questionnaire is designed to include a core set of questions used by all states and an additional set sponsored by each state that may be derived from optional modules developed by CDC or other appropriate sources. Below is a general list of topics in either the core or the state-added portions of the annual BRFSS surveys; topics may vary somewhat from year to year.

Health status, including general, physical, and mental heath, as well as activity lost because of health conditions.
Access to health care, as measured by having health insurance, being able to see a doctor because of cost, and time since last routine checkup.
Awareness of selected medical conditions: hypertension, diabetes, and high cholesterol.
Nutrition and weight control, including eating of fruits and vegetables and experiencing hunger.
Injury control, including use of seatbelts by respondents and children in their household.
Tobacco use and alcohol consumption.
Women's health concerns, including screening for breast and cervical cancer, pregnancy, and prevalence of hysterectomy.
Use of other preventive services, such as immunization for influenza and pneumonia, screening for colorectal cancer, and testing for HIV infection.
Knowledge, attitudes, beliefs, and behaviors regarding sexually transmitted diseases, particularly AIDS.
Interpersonal violence, including abuse as a child and domestic violence.
Attitudes and behaviors pertaining to environmental issues, including perceived air quality problems, waste disposal methods, heating source, and discomfort due to air quality.
Social and demographic characteristics, including gender, age, race/ethnicity, marital status, education attainment, employment, household income, weight and height.

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Collecting Data

Sampling Method

First, a sample of telephone numbers is drawn from all possible area codes and three digit prefixes assigned to a state. In Washington State, a disproportionate stratified random sampling (DSS) method is used. For DSS, information obtained from previous surveys is used to classify 100-number blocks of telephone numbers into strata that are either "likely" or "unlikely" to yield residential numbers. Telephone numbers in the "likely" strata that are sampled at a higher rate than numbers in the "unlikely" strata.

Once a household is selected, one adult (aged 18 or older) is randomly selected to be interviewed from each selected household. To facilitate the random selection process, the interviewer asks questions in order to construct a list of the adults from the oldest to the youngest male and then oldest to youngest female. A respondent is randomly selected from the ordered list of adults.

Beginning in 2008, the land-line sample has been supplemented by a smaller cell phone only sample. Telephone numbers are sampled from the set of cell phone numbers assigned to Washington State and activated. Unlike the land-line sample, cell phone sample cannot be tested for working numbers and business numbers, so yield from a bank of 100 numbers is much smaller for the cell phone only sample.

The questionnaire for the cell phone only sample includes questions to screen for adults who do not have a land line phone in their residence.

Telephone Method

The BRFSS uses telephone surveys to collect data. Adults (people aged 18 years or older) who live in households having a telephone are randomly selected for an interview. The survey is conducted in each state; calls are made seven days a week during both the daytime and the evening. Each state completes between 100 and 400 interviews each month. In Washington State in 2009, approximately 1,500 interviews are completed monthly.

Like most states, Washington uses a computer-assisted telephone interviewing (CATI) software program. When a CATI program is used, a questionnaire is displayed on a computer screen during each interview, and the interviewer enters the responses directly into a computer. A CATI program offers several advantages:

Data entry errors are minimized since responses need not be entered into a computer as a second step.
Questions not applicable to the current respondent (for example, age- or sex-specific questions) are automatically skipped.
Responses are immediately checked for acceptability, and those that are found unacceptable (such as impossible body weight) are immediately brought to the interviewer's attention so that they can be corrected.

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Limitations

The BRFSS relies on information reported directly by the respondent. As such, this self-reported data may be subject to a number of sources of possible error. How questions are worded my elicit responses in a certain way and can result in what is called "measurement error." Similarly, the ability of individuals to accurately recall details is subject to "response error."

Because the questionnaire is asked in English and Spanish in Washington State, adults who are not able to be interviewed in English or Spanish are not included in the sample. Also, individuals without telephones are not contacted. As a result, BRFSS findings can only be generalized to English and Spanish speaking adults living in households with telephones. (Unlisted telephone numbers are included in the sample through the random dialing method that is used.)

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Results from the BRFSS

BRFSS information has been used to track changes in behavior and to measure progress toward achieving national, state, and local public health objectives. For example, the document, Healthy People 2010: National Health Promotion and Disease Prevention Objectives, outlines the U.S. Department of Health and Human Services' strategy for improving the health of the nation. The more than 300 objectives stated in this publication are aimed at reducing risk factors for diseases and injury and at improving the use of health services. Many of these risk factors can be examined using information from BRFSS.

State and local health assessment reports have relied extensively on BRFSS data to examine the attitudes and behaviors that reflect the underlying health risks and access to care for the population of Washington.

The Health of Washington State is the Department of Health's periodic review of Washington's well-being. It asks three general questions: How healthy is Washington State as a place to live? How healthy are we as a community of people sharing that place? And, are some of us better off than others? Now published on the web (http://www.doh.wa.gov/HWS), it relies on substantial number of BRFSS measures.
The Local Public Health Indicators website is a new on-line data resource to help measure the health of Washington communities and inform the programs and policies of state and local public health agencies. (http://www.doh.wa.gov/phip/intiative/phi.htm)
The Public Health Improvement Plan (PHIP) works to guide the development of Washington» s public health system, based on a shared vision of the public health system we would like to bring about (http://www.doh.wa.gov/phip). The PHIP partnership has used BRFSS data in developing The Report Card for Health (http://www.doh.wa.gov/phip/doc/phi/card.pdf).

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