Summary and Justification of Proposed Changes for the 2023 BRFSS

Change Request

Proposed Changes to the 2023 Behavioral Risk Factor Surveillance System (BRFSS)

(OMB No. 0920-1061 Exp. Date 3/31/2024)

November 18, 2022

Summary

We request the following: OMB approval of revisions to the 2023 BRFSS Questionnaire and Data Collectors’ Protocol for use in the 2023 BRFSS. Specifically, we request the following:

1. Approval for minor changes in the 2023 Core Questionnaire. Including changes in wording (Landline Introduction, Cell Phone Introduction, Health Care Access), changes in response options, (Landline Introduction, Cell Phone Introduction, Demographics) and new questions (Long-term COVID Effects)

2. Approval for modifications to questions in optional modules including (Cognitive Decline, COVID Vaccination).

3. Approval of changes to the 2023 Calling Protocol and Dispositions.

Attachments

Attachment 5a-2023 BRFSS Questionnaire

Attachment 10a-2023 Calling Protocol and Dispositions

Background and Justification

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 (“states” or “BRFSS partners”). In addition, personal interviews are conducted in one territory where phone lines are unavailable. The currently approved survey instrument is based on modular design principles, consisting of a standardized core questionnaire administered by all states, and topic-specific optional modules that may be appended to the standardized core, at each state’s discretion. The modular design allows each state to customize the BRFSS questionnaire to address state-specific needs. To ensure that BRFSS content is relevant to the current needs of BRFSS partners, CDC updates selected items in the core questionnaire and/or the optional modules on an annual basis. Information collection needs and priorities for 2023 were discussed internally in the various state health departments as well as during the annual questionnaire meeting in 2022. The 2023 questionnaire includes 16 core sections (including one emerging core section, Long-term COVID Effects) and 32 optional modules. The number of optional modules has increased from 2022 (there were 28 offered in 2022). The number of core sections has reduced by one (there were 17 offered in 2022). This is due in part to a continued effort to reduce the length of the core over time thereby reducing respondent burden and decreasing break off interviews. There are only a few minor changes to the questionnaire to be approved in this change request. The table below lists all sections of the 2023 BRFSS core sections and optional modules where questionnaire changes have been made. All other items on the questionnaire have been previously reviewed and approved.

Table 1 List of Changes to the BRFSS Questionnaire for 2023
Section	Previously Approved Text	New Text	Changes in skip pattens or interviewer notes	Reason For Change
Cell Phone Introduction	Are you male or female? Response: 1 Male 2 Female 3 Nonbinary 7 Don’t know/Not sure 9 Refused	Are you? Response: 1 Male 2 Female 3 Unspecified or another gender identity Do not read: 7 Don’t know/Not sure 9 Refused		Wording revised: The question has been taken from a presentation by the Federal Committee on Statistical Methodology Interest Group, entitled Collecting SOGI Data: Principles and Practices (Slide 11).
	What was your sex at birth? Was it male or female? 1 Male 2 Female 7 Don’t know/Not sure 9 Refused	N/A		This question is new to the Cell Phone Introduction, but has been used previously in the Sex at Birth optional module. The question is only asked if the respondent does not respond to previous question. This additional probe was taken from the 2022 NHIS Questionnaire.
Health Care Access	What is the current primary source of your health insurance?	What is the current source of your primary health insurance?		The question will be used to replace the previous health care coverage question in the 2022 BRFSS. The phrase “health care coverage” was changed to “health insurance” to improve understanding of the term by respondents, and the word ‘primary’ was moved after feedback from the 2022 Field Test. Results from the 2022 field test including both the health care coverage question asked through 2020 and the health insurance question used since 2021 had produced similar percentages of respondents with coverage. About 2% of respondents which indicated no health care coverage on the first question selected a type of coverage with the second question. About 1% of respondents indicating they had health care coverage on the first question, did not select a type of coverage with the second question.
Exercise (Physical Activity)	Question was last asked in 2019 using previous list of 77 physical activity codes.	What type of physical activity or exercise did you spend the most time doing during the past month? Specify from Physical Activity Coding List 1. Walking 2. Running or jogging 3. Gardening or yard work 4. Bicycling or bicycling machine exercise 5. Aerobics video or class 6. Calisthenics 7. Elliptical/EFX machine exercise 8. Household activities 9. Weightlifting 10. Yoga, Pilates, or Tai Chi 11. Other		List of physical activities has been reduced to reduce time needed for coding a response.
Demographics	Current 2022 Question and Responses Which one or more of the following would you say is your race? Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 88 No choices 77 Don’t know / Not sure 99 Refused	Question Proposed 2023 Responses Which one or more of the following would you say is your race? Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No Additional choices 77 Don’t know / Not sure 99 Refused		Subcategories are only read if response 40 (Asian) or 50 (Pacific Islander) is selected. Response 60 (Other) was added, but will not be read by the interviewer, and the word “Additional” was added in response 88. Note, we have set the definition for partial complete at CDEM.11 for both landline and cell phone.
Long-term COVID Effects	Has a doctor, nurse, or other health professional ever told you that you tested positive for COVID 19?	Have you ever tested positive for COVID-19 (using a rapid point-of-care test, self-test, or laboratory test) or been told by a doctor or other health care provider that you have or had COVID-19?		Wording revised: With the increased use of home tests over the past year, a health care provider might not have been involved in delivering positive test result.
	Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?	Do you currently have symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?		Wording revised: The 2022 question assessed period prevalence (from start of pandemic to survey date). Point prevalence will be more useful in 2023 for assessing health care needs because it will more closely reflect ongoing the burden of long-term symptoms as transmission wanes.
		Do these long-term symptoms reduce your ability to carry out day-to-day activities compared with the time before you had COVID-19? 1. Yes, a lot 2. Yes, a little 3. Not at all.		New question: Assessment of functional impairment is necessary to describe the impact of long-term COVID effects and inform and inform the public health response. In 2023, assessing the impact of symptoms on daily activity is now a higher priority (has more information value), as frequencies of various symptoms following COVID will have been well-studied by then.
Cognitive Decline Optional Module	Introduction: The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.	Introduction: The next few questions ask about difficulties in thinking or memory that can make a big difference in everyday activities. We want to know how these difficulties may have impacted you.		Introduction was shortened to: Reduce time needed to administer. Remove mention of specific activities from the current introduction (i.e., “forgetting how to do things you’ve always done”). These activities were removed to avoid priming respondents to answer one way or another.
	During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?	During the past 12 months, have you experienced difficulties with thinking or memory that are happening more often or are getting worse?		Wording revised: Removed “confusion.” Current research on subjective cognitive decline (SCD) does not suggest confusion is a major component of SCD. “Difficulties with thinking or memory” was a specific suggestion for phrasing by the individuals living with early-stage dementia and reflected how they would have first described their subjective symptoms with cognition.
		Are you worried about these difficulties with thinking or memory?		New question. Current research on subjective cognitive decline (SCD) suggests a strong correlation between those who express worry about their difficulties with thinking or memory and future risk of developing dementia. This data will further identify population burden of cognitive impairment.
	Have you or anyone else discussed your confusion or memory loss with a health care professional?	Have you or anyone else discussed your difficulties with thinking or memory with a health care provider?		Wording revised: The change to “provider” is to align with other questions on the BRFSS. The proposed change of order — to move the question to third rather than last — is to improve the flow of questions and place similar/cascading questions next to one another.
	During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? Would you say it is…	During the past 12 months, have your difficulties with thinking or memory interfered with day-to-day activities, such as managing medications, paying bills, or keeping track of appointments?		Wording revised: Based on current research on subjective cognitive decline (SCD), the proposed activities listed align well with difficulties first noted by those experiencing SCD. Clinical researchers on the advisory group noted that the cognitive effort required for “paying bills” was different than the effort required to “clean.” Further, the input from those living with early-stage dementia cited “managing medications” and “paying bills” as two of the activities when they first noticed cognitive issues in themselves. “keeping track of appointments” was added as another example that required similar cognitive load. The decision to change “given up” to “interfered with” was to resolve the ambiguity around what “given up” meant. The advisory group noted that “interfered with” would be easier for respondents to answer.
	During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home? Would you say it is…	During the past 12 months, have your difficulties with thinking or memory interfered with your ability to work or volunteer?		Wording revised: Question was simplified to ascertain additional burden among those experiencing subjective cognitive decline (SCD). “engage in social activities” was removed due to mild confusion over what the phrase meant. “outside the home” was removed since respondents may work or volunteer from home.
COVID Vaccination Optional Module	Current 2022 question and responses: How many COVID-19 vaccinations have you received? 1 One 2 Two 3 Three 4 Four or more	2023 question and additional response How many COVID-19 vaccinations have you received? 1 One 2 Two 3 Three 4 Four 5 Five or more
Social Determinants and Health Equity	How often do you feel socially isolated from others?	How often do you feel lonely?		After discussions with NCHS about the use of the term “socially isolated” to address loneliness the question has been change to “lonely”

Effect of Proposed Changes on the Burden Estimate

No increases are anticipated in burden estimate, as provided in the 2022 OMB review, and presented below in Table 2. Given the reduced number of core questions and questions from optional modules provided for state use, it is likely that respondent burden will be lower than anticipated by preapproved estimates.

Table 2 Estimated Annual Burden to Respondents
Type of Respondents	Form Name	No. of Respondents	No. of Responses per Respondent	Avg. Burden per Response (in hr)	Total Burden (in hr)
U.S. General Population	Landline Screener	375,000	1	1/60	6,250
	Cell Phone Screener	292,682	1	1/60	4,879
	Field Test Screener	900	1	1/60	15
Annual Survey Respondents (Adults >18 Years)	BRFSS Core Survey	480,000	1	15/60	120,000
	BRFSS Optional Modules	440,000	1	15/60	110,000
Field Test Respondents (Adults >18 Years)	2022 Field Test Survey	500	1	45/60	375
Total					241,519

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 questions or screener language of the BRFSS. All updates are provided in red text in each attachment.

Previous Attachment Title	Change Request Attachment Title
5a 2022 BRFSS Questionnaire	5a 2023 BRFSS Questionnaire
10a- 2022 Calling Protocol and Dispositions	10a- 2023 Calling Protocol and Dispositions

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