(Mokdad, 2009). The BRFSS questionnaire is organized by core and optional modules and includes individual-level risk factors associated with causes of premature death (Mokdad, 2009). More detailed information on chronic conditions—including diabetes, cardiovascular health, high blood pressure, and adult asthma—are included in optional modules (Balluz, 2010).

The National Health Information Survey

NHIS, supported by the CDC’s National Center for Health Statistics (NCHS), is a large-scale cross-sectional household interview survey. The survey includes information on population disease prevalence, extent of disability, and use of health care services and is offered in English, Spanish, and other languages. NHIS describes disease prevalence from self-reports of diagnoses received from clinicians (Burrows et al., 2007). The expected NHIS sample includes about 35,000–40,000 households with 75,000–100,000 persons of all ages. To provide state or local estimates of health outcomes and determinants of health, a few states and local areas, such as Wisconsin and New York City, conduct their own surveys based on the NHIS (and NHANES) method (CDC, 2009a; Parrish, 2010).

The National Health and Nutrition Examination Survey

NHANES is a “program of studies designed to assess the health and nutritional status of adults and children in the United States.” It combines interviews with physical examinations and is conducted by NCHS (CDC, 2009a). A nationally representative sample of about 5,000 people are interviewed each year. NHANES includes demographic, socioeconomic, dietary, and health-related questions offered in English and Spanish. The examination component consists of medical, dental, and physiologic measurements, including laboratory tests. The data from the survey are used to determine the prevalence of major diseases and risk factors for diseases (CDC, 2009a).

Limitations of the Behavioral Risk Factors Surveillance System, the National Health Information Survey, and the National Health and Nutrition Examination Survey

BRFSS, NHIS, and NHANES all have limitations and challenges. BRFSS has a declining and low response rate (for example, 18 percent in California and a national median of 34 percent—a lower response rate than NHIS and NHANES) and inadequate time available for questions, responses are self-reported, data are available only at the state level (and some large jurisdictions), and the survey contains no biometric measurements. BRFSS includes



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