Justification for changes to the 2017 BRFSS Questionnaire

Change Request

2017 Behavioral Risk Factor Surveillance System (BRFSS)

(OMB No. 0920-1061 Exp. Date 3/31/2018)

September 13, 2016

Summary

Information collection for the Behavioral Risk Factor Surveillance System (BRFSS) consists of landline and cell phone interviews in each of the 50 states, Washington DC and several US territories. Personal interviews are conducted in one territory where phone lines are unavailable. The survey consists of a standardized core questionnaire, optional modules with set questions and state added questions (which are not overseen by the CDC and are not included in this document). Each state designs its own sample with technical assistance from the CDC.

We request the following:

OMB approval of modifications of the (rotating) core questionnaire including minor interviewer instruction changes and transition statements; Approval of a different set of previously reviewed modules for use in 2017 and inclusion of some new modules; Approval of minor updates in calling protocol (see Attachment 10a-2017 Calling Protocols and Dispositions) for data collection to clarify and standardize procedures.

Background and Justification

BRFSS is a unique collaboration between the federal government and states. It is highly responsive to diverse needs and priorities for states, the federal government, and non-governmental agencies. The core questionnaire has an even and odd numbered year version, so some of the changes in the 2017 are reflective of the move to the odd numbered year questionnaire (previously approved in 2015). These changes include fruit and vegetable consumption, physical activity, hypertension awareness, cholesterol awareness, arthritis burden. Deleted (even year) sections included oral health, falls, breast and cervical cancer, prostate cancer, colorectal cancer and drinking and driving. (Note that these sections are available to states as optional modules in off-years). All of these sections were previously reviewed by OMB in the full review in 2015 (the most recent odd-year version of the questionnaire), with the exception of changes in the wording of the fruit and vegetable section. One question in the immunization section (on whether the respondent has had a shingles vaccine) is rotated in as part of a three-year cycle, but question wording remains the same as previous administrations. The table below summarizes the changes requested.

Table 1. Summary of Changes in 2017 BRFSS Questionnaire (compared to 2016 BRFSS Questionnaire)
Action		Sections/ Modules Affected	Comment on Change
DELETE FROM CORE (these modules remain available as optional modules)	Oral Health Breast/ Cervical Cancer Screening Prostate Cancer Screening Falls Colorectal Cancer Screening Drinking and Driving		This is a regular deletion for odd-numbered year questionnaires.
ADD TO CORE	Fruit and Vegetable Consumption1 Hypertension Awareness Physical Activity Cholesterol Awareness Arthritis Burden Shingles question within Immunization Section		This is a regular addition for even-numbered year questionnaires. The shingles question appears once every three years.
ADD TO MODULES	Actions to Control High Blood Pressure Fire Arm Safety Lung Cancer Screening Preconception Health and Panning Respiratory Health Social Determinants of Health		These modules were proposed by CDC programs to the states, and were voting on for adoption as optional modules. The questions were included in the 2016 Field Test.
MODIFY	Fruit and Vegetable Consumption1 Transition statement from core to modules Introduction to e-cigarette questions		The fruit and vegetable questions have been modified for ease of administration and to reduce recall error. The transition statement to the modules has been revised so that respondents are not told that the survey is close to being over, as in some cases the modules represent a sizable portion of the entire questionnaire. The introduction to the e-cigarettes section has been revised so that respondents do not report marijuana use in this section.
CONTINUE WITH NO CHANGES	Health Status Core Section Healthy Days Core Section Health Care Access Core Section Chronic Health Conditions Core Section Demographics Core Section Tobacco Use Core Section E-cigarettes Core Section Alcohol Consumption Core Section Seatbelt Use Core Section HIV/AIDS Core Section Pre-diabetes Module Diabetes Module Cardiovascular Health Module Arthritis Management Module Adult Asthma History Module Healthy Days (Symptoms) Module Sleep Disorder Module Visual Impairment and Access to Eye Care Module Alcohol Screening and Brief Intervention Module Cancer Survivorship Module Sugar Sweetened Beverages Module Sodium or Salt-Related Behavior Module Marijuana Module Influenza Module Adult Human Papillomavirus Module Tetanus, Diphtheria and Acellular Pertussis (Adults) Module Caregiver Module Cognitive Decline Module Emotional Support and Life Satisfaction Module Industry and Occupation Module Sexual Orientation and Gender Identity Module Random Child Selection Module Childhood Asthma Prevalence Module
1 The Fruit and Vegetable Consumption Section is part of the odd-year rotating core. Therefore it appears in 2017 but was not included in 2016. Questions in this section have been updated, so wording compared to the 2015 administration of the questionnaire has also changed.

The only substantive wording change of existing questions was in the Fruit and Vegetable Section of the rotating core. The BRFSS reviewed questions on other surveys and used questions that are modeled after the Youth Risk Behavior Survey. The National Survey on Drug Use and Health includes a question on fried potatoes which has wording that is comparable to the new BRFSS question on that topic. State BRFSS coordinators and members of the CDC staff who are subject matter expert in nutrition created a taskforce to propose new wording for the section. Cognitive testing was conducted and a set of questions was set for field testing. Following the field test, minor changes were made. The state coordinators were then presented with the new questions for approval. The CDC Division of Nutrition, Physical Activity and Obesity was part of the taskforce and had direct input into field test wording and subsequent fine tuning of the questions. The table below illustrates the fruit and vegetable questions that were asked in 2015 and those that are proposed for 2017.

Table 2. Comparison of 2015 and 2017 Fruit and Vegetable Questions
2015	2017	Reasons for Change
1. During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.	1. Not including juices, how often did you eat fruit? You can tell me times per day, per week or per month.	The old fruit and vegetable questions were complicated and required extensive recall on the part of the respondents. Respondents often were confused by listening to long questions and there were a high number of respondent break-offs during this section. The new questions do not ask respondents to recall food intake over the previous 30 days, but allow respondents to provide information on regular food consumption behaviors. Overall the new questions are easier to administer, as evidenced by a reduction in the length of time the fruit and vegetable questions take to administer. The new questions will also be useful in determining whether respondents meet nutrition standards, without the confusion of the wording of previous questions.
2. During the past month, not counting juice, how many times per day, week, or month did you eat fruit? Count fresh, frozen, or canned fruit.	2. Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?
3. During the past month, how many times per day, week, or month did you eat cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.
4. During the past month, how many times per day, week, or month did you eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?	3. How often did you eat a green leafy or lettuce salad, with or without other vegetables? You can tell me times per day, per week or per month.
5. During the past month, how many times per day, week, or month did you eat orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?	4. How often did you eat any kind of fried potatoes, including French fries, home fries, or hash browns? 5. How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?
6. Not counting what you just told me about, during the past month, about how many times per day, week, or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes.	6. Not including lettuce salads and potatoes, how often did you eat other vegetables?

Other minor changes were also made in the 2017 BRFSS Questionnaire (See Attachment 5a-2017). As was noted and approved in the original approval, the 2017 questionnaire will include the odd-year rotating sections (fruit and vegetable consumption, hypertension awareness, cholesterol awareness, arthritis burden and physical activity) in the core. Even-year rotating sections (Breast/cervical cancer screening, prostate cancer screening, colorectal cancer screening, oral health, falls, drinking and driving) have been cut and will be available as optional modules for the states. Minor changes in interviewer instructions and transitions from one section to the next are also included and highlighted in red text on the full questionnaire (Attachment 5a-2017). New optional modules (actions to control high blood pressure, fire arm safety, lung cancer screening, preconception health/family planning, respiratory health and social determinants of health) are also included (see Attachment 4a-2017: Approved Optional Modules). These were in response to changing requirements or needs of programs within CDC, and were voted on by the states at the annual BRFSS meeting last spring. All changes in the 2017 questionnaire are highlighted in red text in Attachment 5a-2017: BRFSS Questionnaire and/or in Attachment 4b-2017: Approved Questions by Optional Module.

Effect of Proposed Changes on the Burden Estimate

None. The number of interviews declined in 2015 from previous years and was approximately 441,456. This number is over 53,000 short of the anticipated and previously approved annual total. The total number of interviews in 2016 and 2017 will also be under the estimated, approved total. States are also careful to ensure that total survey length does not exceed 27 minutes, inclusive of household enumeration on landline interviews and optional modules.

Effect of Proposed Changes on Currently Approved Instruments and Attachments

The following table describes those attachments which have been updated as a result of changes in the BRFSS. All updates are provided in red text in each attachment.

Previous Attachment Title	Change Request Attachment Title
4a-2016 Approved Optional Modules	4a-2017 Approved Optional Modules
4b-2016 Approved Questions by Optional Module	4b-2017 Approved Questions by Optional Module
5a-2016 BRFSS Questionnaire	5a-2017 BRFSS Questionnaire
10a-2016 Calling Protocol and Dispositions	10a-2017 Calling Protocol and Dispositions

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