Previous Use and Development

Attachment 2: Previous Use and Development

Cognitive decline:

Recognizing the importance of cognitive decline as a public health issue, the National Center for Chronic Disease Prevention & Health Promotion’s Alzheimer’s Disease and Healthy Aging Program, in collaboration with national experts, developed and implemented an optional module of questions on self-assessed cognitive decline, for states to use on the Behavioral Risk Factor Surveillance System (BRFSS).¹ The original 6-question version of the BRFSS Cognitive Decline Optional Module was available to states in 2015-2022 to estimate the prevalence of subjective cognitive decline and related measures. A revised 5-question version of the module was made available to states in 2023. Data from the revised BRFSS module will first be available for public use in the Fall of 2024. Due to the revisions, CDC’s Alzheimer’s Disease Science Team anticipates that the prevalence of subjective cognitive decline and other measures will change. A quantitative split sample study conducted during 2022-2023 supports this assumption. This study showed notable differences in results between the original version of the module and the revised version, but without explanation. NCHS/CCQDER are evaluating these questions using cognitive interviewing prior to their fielding on RANDS 11 to inform a mixed-methods study and explain how changes to the module affected the resulting measures used for disease surveillance.

One of the key differences between the original and the revised module was the use of an introduction, priming respondents as to what to consider when answering the module of questions. The introduction and its impact on how respondents may answer subsequent questions will form the focus of the web probing on RANDS 11.

Two potential additional questions, intended to give an indication of self-assessed severity and anxiety caused by any self-perceived cognitive decline, are also included for evaluation in this study. These two questions are currently being cognitively tested by NCHS/CCQDER.

Additional information about the original module:

Behavioral Risk Factor Surveillance System (BRFSS) Cognitive Decline Module | Healthy Aging Data | CDCBRFSS Statistical Brief: Cognitive Decline Optional Module, October 2019Cannabis use and experiences:

The cannabis questions were compiled and developed by CDC’s Cannabis Strategy Unit, state and federal agencies contributing to the Behavioral Health Coordinating Committee (BHCC) report on the state of cannabis surveillance in the U.S., and the Council for State and Territorial Epidemiologists (CSTE) Cannabis Subcommittee. They were revised following initial evaluation by NCHS/CCQDER in 2021-2022. The methodological experiment using triads was developed by NCHS/CCQDER to assess the prevalence of different categorizations of cannabis products.

Findings from the initial evaluation by NCHS/CCQDER can be found in Smith, Z., Cibelli Hibben K., Massey, M. Cognitive Evaluation of Questions on Cannabis Product Use. National Center for Health Statistics – CCQDER. Q-Bank. 2024. Available from: https://wwwn.cdc.gov/ QBank/Report.aspx?1251.

The origin and rationale for each of the questions are described below:

MARIJUANA (versions 1 and 2): These questions were modified from the Youth Risk Behavioral Surveillance System (YRBSS) introductory language, which was cognitively tested in Spring 2020. The question was revised after two rounds of evaluation by NCHS/CCQDER and includes a split-ballot experiment to assess the impact of different response options on response rate and burden. It is accompanied by several probes to assess the types of products included and whether respondents who use medical marijuana are including such use in responding to this item.

MJBUY: This question was modified from NSDUH and developed for the BHCC report in conjunction with SAMHSA colleagues. It was cognitively tested for NSDUH. The question goal is to assess whether point of access/purchase could be used as a proxy to understand if people are reporting hemp/CBD-only use. The question was revised after an initial round of evaluation by NCHS/CCQDER. It is accompanied by a probe to determine the extent to which respondents may report the same activity using multiple response options.

COUSE: This question was developed with state and federal agency input for the BHCC report. The question goal is to understand polysubstance use and substances that may be co-administered or used in close proximity to marijuana. The question was revised after an initial round of evaluation by NCHS/CCQDER.

REPLACE: This question was developed with state and federal agency input for the BHCC report. The goal is to assess potential substitution across substances. The question was revised after two rounds of evaluation by NCHS/CCQDER.

DRIVING (versions _HIGH and _IMPAIRED): This question was modified from the Oregon BRFSS and includes modifications in probes from questions asked by other states in their BRFSS modules. The goal is to assess impaired driving. The question was revised after an initial round of evaluation by NCHS/CCQDER. The question includes a split-ballot experiment to assess the impact of question wording.

HPASK (versions 1 and 2) and HPADVICE: These questions were modified with input from states and CSTE from tobacco control questions. The goal is to assess health professional engagements related to marijuana. The questions were revised after two rounds of evaluation by NCHS/CCQDER and include a split-ballot experiment to identify the necessity of including language explicitly referencing office intake forms as out of scope.

CUTDOWN: This question resulted from the combination of two questions assessing behaviors related to reducing or stopping marijuana use evaluated by NCHS/CCQDER in an initial round of testing. The original questions were developed with input from states and CSTE from tobacco control questions. The question was revised after an initial round of evaluation by NCHS/CCQDER. It is accompanied by a web probe seeking to identify the reasons for cutting back on marijuana use.

MJLIVESWITH: This question was modified from a tobacco control question that was cognitively tested in youth in 2018-2019. The goal is to assess household exposure to marijuana. The question was revised after an initial round of evaluation by NCHS/CCQDER.

ADVERTISING: This question was modified from the Oregon BRFSS. The goal of the question is to assess exposure to industry advertising and marketing. The question was revised after an initial round of evaluation by NCHS/CCQDER.

PREVENTION: This question was developed in conjunction with CSTE and state agencies. The goal is to assess exposure to prevention messaging. The question was revised after an initial round of evaluation by NCHS/CCQDER.

MJEFFECTS and MJEFFECTSLOCATION: This question set was developed for the International Cannabis Policy Study funded by the Canadian Institutes of Health Research and modified by NCIPC/DOP/CSU and NCHS/DRM/CCQDER.

CBD (versions 1 and 2): This question was modified from the Behavioral Risk Factor Surveillance System (BRFSS) and National Survey on Drug Use and Health (NSDUH) questions on past 30-day marijuana use, which have been cognitively tested previously. The goal of the question is to ascertain possible ways to segment hemp data from marijuana data and to collect basic data on hemp/CBD utilization. The question was revised after two rounds of evaluation by NCHS/CCQDER and includes a split-ballot experiment to assess the impact of different response options on response rate and burden. It is accompanied by a probe to assess the types of products included.

CBDUSE: This question was modified from the BRFSS marijuana mode of use question, which has been cognitively tested previously. The goal of the question is to understand the different ways that people use marijuana and CBD and if modes of use differ by product type. The question was revised after an initial round of evaluation by NCHS/CCQDER.

CBDBUY: This question was modified from NSDUH. The question was revised after an initial round of evaluation by NCHS/CCQDER. It is accompanied by a probe to determine the extent to which respondents may report the same activity using multiple response options.

COMPOSITION: This question was developed for the International Cannabis Policy Study funded by the Canadian Institutes of Health Research. The goal of this question is to ascertain consumer knowledge of their product consumption, particularly CBD ratio. The question was revised after an initial round of evaluation by NCHS/CCQDER.

Whole Person Health:

The Whole Person Health items to be evaluated were developed by the National Institutes of Health (NIH), National Center for Complementary and Integrated Health (NCCIH) for potential inclusion in federal and private surveys. NCCIH hosted a workshop to explore theoretical and methodological approaches to measuring Whole Person Health (https://www.nccih.nih.gov/news/events/methodological-approaches-for-whole-person-research) and followed this with a public request for information and extensive discussions with subject matter experts. [1] [2]

The response scale for the Whole Person Health concepts—quality of life, social and family connections, diet, physical activity, stress, sleep, ability to manage health, and spirituality—mirrors the typical unbalanced approach used to measure self-rated health (Excellent, Very Good, Good, Fair, and Poor). These questions were previously cognitively evaluated by CCQDER and tested on RANDS 10. Inclusion on RANDS 11 is intended to further evaluate revisions to the questions and understand performance. Similar items about diet, exercise, sleep, and ability to manage health conditions were previously approved by OMB for inclusion in RANDS 3 and RANDS 8 (https://www.cdc.gov/nchs/rands/data.htm).

In addition to the above items under evaluation, RANDS 11 will include:

1. Health-related items that will be used in NCHS’ typical approach to calibrate the panel weights to the National Health Interview Survey (NHIS).

2. Health-related and demographic items that will be used as covariates in analysis and benchmarks for evaluation of RANDS to other surveys.

3. Other items included for question evaluation and methodological research, including web probes.

Many of these items are the same that OMB has previously approved for inclusion in RANDS 10 and earlier. Table A1 displays the planned RANDS 11 items, whether OMB has previously approved the item for inclusion in previous rounds of RANDS, and the source (if appropriate).

Variable Name	Question Wording	Previously Approved for RANDS	Primary Purpose for Inclusion	Source
LAN_OTHERLAN	Do you speak a language other than English at home?	Yes	Calibration	NHIS
LAN_MEDIA	When you watch television, read news online or in print, or listen to the radio, which language do you use most often?	Yes	Calibration	NHIS
LAN_DOCTOR	When you see a doctor or other health care professional, which language do you use most often?	Yes	Calibration	NHIS
LAN_SOCIAL	When you participate in social activities, such as visiting friends, attending clubs, or going to parties, which language do you use most often?	Yes	Calibration	NHIS
PHSTAT	Would you say your health in general is excellent, very good, good, fair, or poor?	Yes	Benchmark	NHIS
PROBE_SRH	When you said your health in general was [INSERT RESPONSE FROM PHSTAT ; MAKE FIRST LETTER LOWERCASE], which of the following, if any, were you thinking about?	Yes	Methodological	CCQDER-Developed
THINKMEMINCR	During the past 12 months, have you experienced difficulties with thinking or memory that are happening more often or are getting worse?	No	Cognitive decline	NCCDPHP
PROBE_THINKMEMINCR	When answering the previous question, what difficulties were you thinking about?	No	Methodological	CCQDER-Developed
THINKMEMWORRY	Are you worried about these difficulties with thinking or memory?	No	Cognitive decline	NCCDPHP
THINKMEMDISCUSS	Have you or anyone else discussed your difficulties with thinking or memory with a health care provider?	No	Cognitive decline	NCCDPHP
PROBE_THINKMEMDISCUSS	Which of the following health care providers did you or anyone else discuss your difficulties with thinking or memory with?	No	Methodological	CCQDER-Developed
THINKMEMACTIVITY	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?	No	Cognitive decline	NCCDPHP
THINKMEMWORK	During the past 12 months, have your difficulties with thinking or memory interfered with your ability to work or volunteer?	No	Cognitive decline	NCCDPHP
THINKMEMCOMPARE	Over the past 12 months, how have your memory and thinking abilities compared with that of your peers (i.e., friends or acquaintances of a similar age)? [CATI: Would you say better than, the same, or worse than?]	No	Cognitive decline	NCCDPHP
THINKMEMCONCERN	During the past 12 months, have you become concerned about your memory loss and thinking?	No	Cognitive decline	NCCDPHP
HICOV	Are you covered by any kind of health insurance or some other kind of health care plan?	Yes	Covariate	NHIS
HIKIND	What kinds of health insurance or health care coverage do you have?	Yes	Covariate	NHIS
USUALPL	Is there a place that you usually go to if you are sick and need health care?	Yes	Covariate	NHIS
HYPEV	Have you ever been told by a doctor or other health professional that you had hypertension	Yes	Calibration	NHIS
CHLEV	Have you ever been told by a doctor or other health professional that you had high cholesterol	Yes	Calibration	NHIS
CHDEV	Have you ever been told by a doctor or other health professional that you had coronary heart disease	Yes	Calibration	NHIS
ASEV	Have you ever been told by a doctor or other health professional that you had asthma	Yes	Calibration	NHIS
COPDEV	Have you ever been told by a doctor or other health professional that you had Chronic Obstructive Pulmonary Disease (C.O.P.D.), emphysema, or chronic bronchitis	Yes	Calibration	NHIS
CANEV	Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind	Yes	Calibration	NHIS
ARTHEV	Have you ever been told by a doctor or other health professional that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia	Yes	Calibration	NHIS
CHL12M	During the past 12 months, have you had high cholesterol?	Yes	Benchmark	NHIS
ASTILL	Do you still have asthma?	Yes	Benchmark	NHIS
ANGEV	Have you ever been told by a doctor or other health professional that you had angina, also called angina pectoris?	Yes	Calibration	NHIS
MIEV	Have you ever been told by a doctor or other health professional that you had a heart attack, also called myocardial infarction?	Yes	Calibration	NHIS
STREV	Have you ever been told by a doctor or other health professional that you had a stroke?	Yes	Calibration	NHIS
PREDIB	Has a doctor or other health professional eve told you that you had prediabetes or borderline diabetes?	Yes	Calibration	NHIS
GESDIB	Has a doctor or other health professional ever told you that you had gestational diabetes, a type of diabetes that occurs <u>only</u> during pregnancy?	Yes	Calibration	NHIS
DIBEV	Not including prediabetes or gestational diabetes, has a doctor or other health professional ever told you that you had diabetes?	Yes	Calibration	NHIS
SMKEV	Have you smoked at least 100 cigarettes in your entire life?	Yes	Covariate	NHIS
ACCSSINT	Do you have access to the Internet?	Yes	Calibration	NHIS
ACCSSHOM	Do you have access to the Internet from your home?	Yes	Calibration	NHIS
HIT_GRID	During the past 12 months, have you used the Internet for any of the following reasons?	Yes	Calibration	NHIS
EMPLASTWK	Last week, did you work for pay at a job or business?	Yes	Covariate	NHIS
CEVOLUN1	During the past 12 months, did you spend any time volunteering for any organization or association?	Yes	Calibration	NHIS
CEVOLUN2	Some people don’t think of activities they do infrequently or for children’s schools or youth organizations as volunteer activities. During the past 12 months, have you done any of these types of activities?	Yes	Calibration	NHIS
CEMMETNG	During the past 12 months, did you attend a public meeting, such as a zoning or school board meeting, that discussed a local issue?	Yes	Calibration	NHIS
CEVOTELC	Did you vote in the last local elections, such as for mayor, councilmembers, or school board?	Yes	Calibration	NHIS
ALCDAY5	During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?	Yes	Covariate	NHIS
AVEDRNK3	During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?	Yes	Covariate	NHIS
DRNK3GE5	Considering all types of alcoholic beverages, how many times during the past 30 days did you have [4/5] or more drinks on an occasion?	Yes	Covariate	NHIS
MAXDRNKS	During the past 30 days, what is the largest number of drinks you had on any occasion?	Yes	Covariate	NHIS
TRIAD_1	Which one of these is not like the other two? Your best guess is fine.	No	Methodological	CCQDER-developed
TRIAD_2	Which one of these is not like the other two? Your best guess is fine.	No	Methodological	CCQDER-developed
TRIAD_3	Which one of these is not like the other two? Your best guess is fine.	No	Methodological	CCQDER-developed
MARIJUANA_1	During the past 30 days, on how many days did you use marijuana?	No	Cannabis	NCIPC
MARIJUANA_2	During the past 30 days, on how many days did you use marijuana?	No	Cannabis	NCIPC
PROBE_MARIJUANA	What marijuana products were you thinking of when you answered the previous question?	No	Methodological	CCQDER-developed
PROBE_MEDMAR	Do you use marijuana for medical purposes?	No	Methodological	CCQDER-developed
PROBE_MEDMARINCLUDE	When you answered [fill: MARIJUANA] days, did you include marijuana used for medical purposes?	No	Methodological	CCQDER-developed
PROBE_MEDMARCARD	Do you have a medical marijuana card?	No	Methodological	CCQDER-developed
MJBUY	In the past 30 days, how did you get the marijuana you use?	No	Cannabis	NCIPC
PROBE_MJBUY	Do you get marijuana products delivered from the same dispensary you go to in person or from a different business?	No	Methodological	CCQDER-developed
COUSE	When you used marijuana in the past 30 days, did you use any of the following substances at the same time or within a few hours?	No	Cannabis	NCIPC
REPLACE	When you used marijuana in the past 30 days, did you use it to cut down on or stop using [CAWI: …?] [CATI: any of the following? You can say yes or no to each one.]	No	Cannabis	NCIPC
DRIVING_HIGH	During the past 30 days, have you driven a vehicle while high from marijuana use?	No	Cannabis	NCIPC
DRIVING_IMPAIRED	During the past 30 days, have you driven a vehicle while impaired from marijuana use?	No	Methodological	CCQDER-developed
HPASK_1	In the past 12 months, has a health professional, such as a doctor, nurse, or mental health professional, asked you about your marijuana use?	No	Cannabis	NCIPC
HPASK_2	For the next question, do not include office intake forms completed prior to an appointment. In the past 12 months, has a health professional, such as a doctor, nurse, or mental health professional, asked you about your marijuana use?	No	Cannabis	NCIPC
HPADVICE	In the past 12 months, has a health professional, such as a doctor, nurse, or therapist, done any of the following?	No	Cannabis	NCIPC
CUTDOWN	During the past 12 months, were you able to cut down on or stop using marijuana every time you wanted to or tried to?	No	Cannabis	NCIPC
PROBE_CUTDOWN	During the past 12 months, why did you try to cut down on or stop using marijuana?	No	Methodological	CCQDER-developed
MJLIVESWITH	Does anyone who currently lives with you use marijuana?	No	Cannabis	NCIPC
ADVERTISING	During the past 30 days, how often have you seen or heard an advertisement for marijuana products or stores or seen a marijuana storefront?	No	Cannabis	NCIPC
PREVENTION	During the past 30 days, how often have you seen or heard an advertisement, message, or product label about preventing harmful marijuana use or avoiding marijuana use?	No	Cannabis	NCIPC
MJEFFECTS	In the past 12 months, did you seek help for adverse or negative health effects caused by marijuana?	No	Cannabis	NCIPC
MJEFFECTSLOCATION	Where did you seek help for adverse or negative health effects caused by marijuana?	No	Cannabis	NCIPC
CBD_1	During the past 30 days, on how many days did you use CBD products?	No	Cannabis	NCIPC
CBD_2	During the past 30 days, on how many days did you use CBD products?	No	Cannabis	NCIPC
PROBE_CBD	What CBD products were you thinking of when you answered the previous question?	No	Methodological	CCQDER-developed
CBDUSE	When you used a CBD product during the past 30 days, how did you use it?	No	Cannabis	NCIPC
CBDBUY	In the past 30 days, how did you get the CBD products you use?	No	Cannabis	NCIPC
PROBE_CBDBUY	Do you get CBD products delivered from the same [if CBDBUY=1: business; if CBDBUY=2: dispensary] you go to in person or from a different business?	No	Methodological	CCQDER-developed
COMPOSITION	When you use CBD or marijuana products, which of the following best describes the product you use most often? Your best guess is fine.	No	Cannabis	NCIPC
WPH_QOL	How would you rate your quality of life, focusing on what matters most to you?	Yes	Whole Person Health	WHO Quality of Life Scale [3]
PROBE_WPH_QOL	In the previous question, when you rated your quality of life as [FILL], which of the following were you thinking about?	No	Methodological	CCQDER-developed
WPH_SOC	How would you rate your social and family connections ?	No	Whole Person Health	NCCIH-developed
PRAPARE16	In a typical week, [FILL if HHSIZE >1: “and not including people you live with,” how many times do you see or talk to people that you care about and feel close to?	Yes	Whole Person Health	NHIS
SOCCON_TECH	In a typical week, how many times do you use email, text messages, or social media apps to chat with people that you care about and feel close to?	No	Methodological	NHIS
SOCCON_RELIG	In a typical year, how often do you attend religious services?	No	Methodological	NHIS, CCQDER-modified
PULSE_SOCIND4	In a typical year, how often do you attend meetings of clubs or organizations you belong to?	Yes	Methodological	Census Household Pulse Survey in coordination with the Office of the Surgeon General
WPH_DIET	In general, how healthy is your overall diet?	Yes	Whole Person Health	NHANES
WPH_PHYS	How would you rate your physical activity, compared with people in your age group?	No	Whole Person Health	NCCIH-developed and CCQDER-modifie
WPH_STRESS	How would you rate your ability to manage stress?	Yes	Whole Person Health	NCCIH-developed
WPH_SLEEP	How would you rate your sleep?	Yes	Whole Person Health	NCCIH-developed
WPH_SPIRIT	How would you rate your spirituality or spiritual life?	Yes	Whole Person Health	NCCIH-developed
PROBE_WPH_SPIRIT	Currently, how important is religion in your daily life?	Yes	Methodological	NSFG
WPH_HEALTH	How would you rate your ability to manage your health, focusing on aspects of your health that matter most to you?	No	Whole Person Health	NCCIH-developed and CCQDER-modified
PROBE_WPH_HEALTH	When you answered [FILL ] to the previous question about your ability to manage your health, which of the following aspects of your life were you thinking about, if any?	No	Methodological	CCQDER-developed
BURDEN1	How burdensome was it to complete this survey?	Yes	Methodological	CCQDER-Developed
BURDEN2	How difficult was it to answer the questions?	Yes	Methodological	CCQDER-Developed

Sources

[1] “Methodological Approaches for Whole Person Research Workshop.” https://www.nccih.nih.gov/news/events/methodological-approaches-for-whole-person-research.

[2] Langevin H.M. 2022. “Making Connections to Improve Health Outcomes.” Global Advances in Health and Medicine. 11. doi:10.1177/2164957X221079792

[3] “WHOQOL: Measuring Quality of Life.” https://www.who.int/tools/whoqol

1 CDC - BRFSS