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Behavioral Risk Factor Surveillance System

Editor: Eric Robbins Updated: 2/13/2023 7:55:55 PM


Behavior risk factor surveillance system or BRFSS is a United States national self-report telephone survey that provides prevalence data concerning behavioral risk factors associated with the nation's most common health conditions.[1] A collaborative effort between the CDC and each state health department, it is the world's largest and nation's leading ongoing telephone survey. Established in 1984, today, all 50 states and 3 U.S. territories participate in this survey. Each year's survey questionnaire is designed by each state's survey coordinator from its state health department and designated CDC staff.[2] Every year over 400 thousand noninstitutionalized U.S. resident adult telephone survey interviews are conducted to collect data about chronic health conditions and risk behaviors associated with the nation's leading causes of morbidity and mortality, including blood pressure, seat belt usage, smoking, drug use, cholesterol, cancer (breast, cervical, colorectal, prostate), immunization, sleep practices, health care access, alcohol use, drinking and driving, sex practices, HIV, and oral health.[3][4]

Many of the BRFSS questions come from other national surveys that collect information via face-to-face interviews, telephone interviews, and physical examination. These surveys include the National Center for Health Statistics (NHANES), National Health and Nutrition Interview Survey (NHIS), National Survey of Family Growth (NSFG), Current Population Survey (CPS), and National Survey on Drug Use and Health (NSUH). 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.[5]

There are three parts to the survey questionnaire- core, optional, and state-added questions. The core contains three sections. Core questions are a standardized set of questions used by all states. The annual core consists of questions that are asked yearly. Rotating core questions are two sets of questions used in alternating years. The emerging core consists of 5 questions that address current or emerging issues and are usually apart of the core for one year. Optional modules include rotating core questions that are not in use that year. State-added questions are questions each state chooses to add based on its individual needs.[6][3] 

Throughout the year, survey interviews are conducted by each state's health department using the same core questionnaire, standardized sampling methods, and methodology. This data is then submitted to the CDC monthly for further processing and analysis. Weighting and adding calculated variables are statistical and analytical methods that decrease potential bias and ensure that the data collected is representative of the population from which it is derived. Survey data is published online by the CDC on an annual basis. Each year's questionnaire, background, design data, survey results from 1984 to the present, as well as analytical and statistical tools for further disseminating and processing are available on the CDC's BRFSS website.[4][3]

Issues of Concern

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Issues of Concern

The significant challenges faced by BRFSS include low response rates, adapting to change in modes of communication, and reaching a multi-language diverse population. The rate of response has dropped significantly since 1993. Currently, surveys are conducted using cell phones and landlines in both English and Spanish. The addition of multi-language versions and new outreach strategies aimed at accessing hard-to-reach respondents is necessary to increase the participation of a diverse and expanding U.S. resident population.[2][7]

Clinical Significance

BRFSS prevalence data concerning chronic diseases, health risk behaviors, and preventive practices are used by all 50 states and 3 U.S. territories to track and monitor the health of U.S. residents. Policymakers, scientists, governmental municipalities, and agencies use this data to implement public health policies, research, programs, and resources to target the leading causes of morbidity and mortality. It helps to support public health planning and policies such as legislation concerning drinking and driving, air pollution, and the usage of seat belts.[1][4] Data from the BRFSS H1N1 outbreak was used to plan for subsequent influenza pandemic outbreaks. Additionally, data from previous years' flu season served to monitor the influenza vaccination shortage.[8] BRFSS prevalence data is published yearly 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.[1]

Nursing, Allied Health, and Interprofessional Team Interventions

Cardiovascular disease, cancer, diabetes, suicide, kidney disease, chronic respiratory disease, etc., are among the nation's leading causes of morbidity and mortality.[4] A recent study of male veterans using BRFSS data revealed physical health status and activity were directly related to mental health.[9] Furthermore, patients with mental health issues have demonstrated an increased risk of suicide, as well as risk factors related to cardiovascular diseases like smoking and obesity.[10][11] State and federal agencies like the CDC provide much-needed resources and public health data about the prevalence of these chronic diseases. However, the collaborative effort of nurses, physicians, pharmacists, psychologists, etc., at the clinical level is vital to addressing this cyclical pattern of morbidity and mortality. A review of 22 random control trials and nine systematic reviews involving the interprofessional team approach for the management of diabetes demonstrated statistically and clinically significant improvement in both hemoglobin A1c and systolic blood pressure compared to usual care that does not involve the interprofessional team approach.[12]



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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;     [PubMed PMID: 18558030]

Level 3 (low-level) evidence


Iachan 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;     [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;     [PubMed PMID: 29953431]


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;     [PubMed PMID: 23522349]

Level 1 (high-level) evidence


Laflamme DM,Vanderslice JA, Using the Behavioral Risk Factor Surveillance System (BRFSS) for exposure tracking: experiences from Washington State. Environmental health perspectives. 2004 Oct;     [PubMed PMID: 15471738]

Level 3 (low-level) evidence


Cunningham 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;     [PubMed PMID: 30114006]


Dotis J,Roilides E, H1N1 influenza A infection. Hippokratia. 2009 Jul;     [PubMed PMID: 19918299]


Shaffer SE,Shaffer KJ,Perryman KD,Patterson JK,Hartos JL, Does Mental Health Differ by Alcohol Use in Elderly Male Veterans? Gerontology     [PubMed PMID: 30993150]


Stellefson M,Paige SR,Barry AE,Wang MQ,Apperson A, Risk factors associated with physical and mental distress in people who report a COPD diagnosis: latent class analysis of 2016 behavioral risk factor surveillance system data. International journal of chronic obstructive pulmonary disease. 2019;     [PubMed PMID: 31040659]


Miyakado-Steger H,Seidel S, Using the Behavioral Risk Factor Surveillance System to Assess Mental Health, Travis County, Texas, 2011-2016. Preventing chronic disease. 2019 Mar 14;     [PubMed PMID: 30873939]


Community-based care for the management of type 2 diabetes: an evidence-based analysis. Ontario health technology assessment series. 2009;     [PubMed PMID: 23074528]