2023 NHIS - Description and Justification of Changes

Nonsubstantive Change Request

NATIONAL HEALTH INTERVIEW SURVEY

OMB No. 0920-0214, Expiration Date 12/31/2023

Contact Information:

Stephen Blumberg, PhD

Division of Health Interview Statistics

National Center for Health Statistics/CDC

3311 Toledo Road

Hyattsville, MD 20782

301.458.4107 (voice)

301.458.4035 (fax)

swb5@cdc.gov

October 13, 2022

Table of Contents

1. Circumstance Making the Collection of Information Necessary 5

2. Purpose and Use of Information Collection 6

12. Estimates of Annualized Burden Hours and Costs 7

15. Explanation for Program Changes or Adjustments 9

List of Attachments

Att 3b	NHIS Snapshot 3 Year-Cycle Questionnaire Content and Periodicity
Att 5a	2023 NHIS Proposed New Content – Concepts Measured
Att 5b	2023 NHIS Proposed New Content - Concepts Measured, Duplication, and Proposed Uses of Data
Att 7a	2021-2022 Adolescent Follow-back Survey (AFS) - Content Summary and Field Dates
Att 8	Precision Tables
Att 9a	2023 NHIS Roster Questionnaire
Att 9b	2023 NHIS Sample Adult Questionnaire
Att 9c	2023 NHIS Sample Child Questionnaire
Att 9d	Revised 2023 Reinterview Questionnaire
Att 10	Updated advance letter

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NCHS National Health Interview Survey

This is a request for approval of a nonsubstantive change to the National Health Interview Survey (NHIS) (OMB No. 0920-0214, Exp. Date 12/31/2023), conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). This nonsubstantive change requests two general changes: (1) continuation of the Adolescent Follow-back Survey (AFS) and (2) changes in content for the 2023 NHIS.

Continuation of the Adolescent Follow-back Survey (AFS)

The adolescent follow-back survey is a pilot test of whether online surveys can be successfully used to collect additional data from NHIS households. It is part of the CDC Public Health Data Modernization Initiative. NCHS is continuing the AFS through the end of 2023 with the same questionnaire that was submitted in the NHIS revision package and approved in December of 2020. No additional burden hours are requested from the revision package since the number of responses to the survey is lower than assumed in the revision package. Continuation of the AFS for an additional year will not exceed the total burden hours approved for the AFS in the revision package.

Changes in survey content

The NHIS has been conducted every year since 1957. The current design of the NHIS questionnaire, implemented in 2019, features a rotational schedule consisting of annual core, rotating core, emerging content and sponsored content modules. Summarized here are the proposed nonsubstantive changes from the 2022 NHIS to the 2023 NHIS.

The NHIS rotates core content onto the survey on a periodic basis such that all content will appear at least once in a three year cycle begun in 2019. As of the end of 2021, all NHIS rotating core content has been fielded at least once. There are no changes to the rotating content other than the usual rotation of sections on and off the NHIS.

Addition of questions planned to be rotated in as part of the NHIS rotating core schedule

1. Add 21 questions on preventive services including questions on aspirin use and preventive screening for adults

2. Add 10 questions on chronic pain for adults

3. Add 8 questions on repetitive strain injuries and 21 questions on acute injuries for adults

4. Add 6 questions on detailed employment for adults

5. Add 18 questions on injuries for children

Removal of questions planned to be rotated out as part of the NHIS rotating core schedule

1. Remove 15 questions on mental health for adults

2. Remove 35 questions on health related behaviors including questions about fatigue, cigarettes and e-cigarettes, alcohol use, physical activity, walking, content of care about physical activity, and sleep for adults

3. Remove 33 questions on mental health assessments for children

4. Remove 20 questions on health-related behaviors including height and weight, physical activity, neighborhood characteristics, sleep, and screen time for children

This submission also seeks approval to add and remove sponsored content in the 2023 NHIS:

Addition of sponsored content in 2023

1. Add 24 questions as part of annual cancer control content sponsored by the National Cancer Institute (NCI, NIH) and the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP, CDC) including questions on cancer screening, genetic testing for cancer, and family history of cancer for adults

2. Add 2 questions on Crohn’s disease and ulcerative colitis and 1 question on psoriasis for adults sponsored by NCCDPHP, CDC.

3. Add 15 questions for adults and 4 questions for children on vision sponsored by the National Eye Institute (NEI, NIH)

4. Add 1 question on long-term COVID-19 symptoms reducing one’s ability to carry out day-to-day activities for adults and children National Center for Immunization and Respiratory Diseases (NCIRD, CDC)

5. Add 2 questions on A1C screening for adults sponsored by NCCDPHP, CDC

6. Add 4 questions on hepatitis vaccination for adults sponsored by NCIRD, CDC

7. Add 5 questions on traumatic brain injuries in the past 12 months for adults and children sponsored by the National Center for Injury Prevention and Control (NCIPC, CDC)

8. Add 5 questions on arthritis for adults sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS, NIH) and the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP, CDC)

9. Add 28 questions for adults and children on balance and hearing sponsored by the National Institute on Deafness and Other Communication Disorders (NIDCD, NIH) and the National Institute for Occupational Safety and Health (NIOSH, CDC)

10. Add 3 questions for adults on workplace exposure to ototoxic substances sponsored by the National Institute for Occupational Safety and Health (NIOSH, CDC)

Removal of sponsored content from 2022

1. Remove 6 questions on COVID-19, tetanus and HPV immunizations for adults and 4 questions on COVID-19 and HPV immunizations for children

2. Remove 13 questions on smoking cessation for adults

3. Remove 14 questions on diet and nutrition for adults

4. Remove 25 questions on complementary and integrative health for adults and children

5. Remove 17 questions on voice, swallowing, speech, and language problems for adults and children

6. Remove 1 question on life satisfaction for children

In addition, this submission seeks to add and remove emerging content to address issues of growing interest to the Department of Health and Human Services.

Addition of emerging content in 2023

1. Add 9 questions on discrimination including 5 questions from the Everyday Discrimination Scale and 4 questions from the Heightened Vigilance Scale for adults

2. Add 1 question on housing insecurity

Removal of emerging content from 2022

1. Remove 5 questions on access barriers to care for adults

2. Remove 3 questions on health care utilization and access for children

3. Remove 1 question on social support for children

4. Remove 1 question on stressful life events for children

5. Remove 3 questions on bullying for children

6. Removed 5 questions on lifetime concussions for children

Modifications were also made to existing questions for the 2023 NHIS. Questions on about being told by a doctor or health professional and testing positive for COVID-19 were combined into one question asking whether the respondent ever had COVID-19. Modifications to sex and gender identity questions are described in Section A.2.

Finally, some questions on the reinterview questionnaire were replaced to reflect new content for the 2023 NHIS. Two questions for adults about whether respondents remembered being asked about yoga and whether respondents remembered being asked about receiving vaccination for COVID-19 are being replaced by a question about whether the respondent remembered being asked about exposure to loud sounds and a question about whether respondents remembered being asked about being treated with less courtesy and respect than others.

1. Justification

1. Circumstance Making the Collection of Information Necessary

The NHIS is conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC) to collect, on an annual basis, statistically valid data on the amount, distribution, and effects of illness and disability in the population and on the utilization of health care services for such conditions. The NHIS has been conducted every year since 1957, and the questionnaire has been periodically redesigned (most recently in 2019) to reflect the latest state of the science and maintain the survey’s topical relevance toward its critical public health mission.

The current design of the NHIS questionnaire implemented in 2019, features a rotational schedule consisting of annual core, rotating core, emerging content and sponsored content modules. Attachment 3b provides a visual depiction of the content and module structure. The NHIS sample adult and sample child questionnaires include annual core content that is scheduled to be fielded every year, rotating content that is fielded periodically, emerging content to address new topics of growing interest to NHCS, CDC, and DHHS, and sponsored content that is fielded when external funding is available.

2. Purpose and Use of Information Collection

All rotating content for the 2023 NHIS has previously been included in the NHIS after the redesign in 2019. For each of the new questions added – sponsored, and emerging - attachment 5a lists the concepts and Attachment 5b expands list of concepts to describe efforts to locate duplication with other surveys and proposed uses of the data. This includes the following content:

Sponsored content: New sponsored content for sample adults only includes questions on conditions (Crohn’s disease, ulcerative colitis, psoriasis, arthritis), conditions specific to vision (diabetic retinopathy, glaucoma, macular degeneration), preventive screening (breast and colorectal cancer screening), family history of cancer, genetic cancer screening, and workplace exposure to ototoxic substances (e.g., solvents and tobacco smoke).

For both adults and children, new sponsored content includes questions about vision services. For adults, questions on time of last eye exam, use of vision rehabilitation devices, use of vision assistive devices, health professional recommend services, need for eyeglasses/contact to read up close, need for eyeglasses/contacts to see in a distance are proposed. For children questions on ever having vision tested, time of last eye exam and need for eyeglasses/contact to read up close, need for eyeglasses/contacts to see in a distance are proposed. Questions about balance and hearing such as hearing ability and testing, ear infections, balance, dizziness problems or falls, head injuries, tinnitus, exposure to loud noises and efforts to protect hearing, and consultation with health care providers for hearing problems are also new for both adults and children. Finally, new sponsored content includes questions on traumatic brain injuries in the past 12 months for both adults and children.

Emerging content: New emerging content includes sample adult questions about housing insecurity and discrimination (everyday discrimination scale and heightened vigilance scale).

The revision package for the NHIS that was approved on 12-23-2020 included most of the general topic areas for the sponsored and emerging content that is being added to the 2023 NHIS. This includes hearing, balance, vision, family cancer history, genetic cancer screening, and arthritis. All rotating content that has been added in 2023 has previously been on the NHIS. Other content including Crohn’s disease, ulcerative colitis, psoriasis, cancer screening, long-term COVID, A1C screening, hepatitis B vaccination, and concussions are topics that have been included on the NHIS in previous years.

The sample adult gender identity questions help NCHS inform “Executive Order 13988 on Preventing and Combating Discrimination on the Basis of Gender Identity and Sexual Orientation”. Different versions of sex and gender identity questions were experimentally tested in the 2022 NHIS. Preliminary results of the experiment; consultation with the NCHS Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER); and a review of the National Academies of Science, Engineering , and Medicine report on “Measuring Sex, Gender Identity, and Sexual Orientation” informed the wording of the sex and gender questions in the 2023 NHIS. NCHS is also adding an other specify for those who answer “something else” or “I don’t know” to the sexual orientation question to better understand the terminology used by sexual minorities.

The questions on discrimination from the everyday discrimination scale and heightened vigilance scale help NCHS provide better data to address “Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.” The EDS questions have been previously tested using both qualitative and quantitative evaluation methods. The Collaborating Center for Question Design and Evaluation Research (CCQDER) at NCHS is also currently conducting cognitive testing on both scales to understand how respondents answer the questions.

Reinterview

The Census Bureau conducts a short quality control reinterview with a small subsample (<5%) of NHIS respondents. Questions are updated each year to reflect the change in NHIS content. The reinterview instrument can be found as Attachment 9d.

12. Estimates of Annualized Burden Hours and Costs

1. Time Estimates

This nonsubstantive change request seeks approval of changes to the OMB revision package that was approved on 12/31/2020 (OMB# 0920-0214, expires 12/31/2023). The average burden for each survey component for one complete survey cycle is shown in the table below. The estimated total average annual burden for all components in the NHIS OMB package was revised to 37,595 hours in 2022. The total average annualized burden hours are increasing by 500 hours. The updated total burden hours are 38,095 hours as a result of this nonsubstantive change request.

The increase in total average annual burden is primarily the result of the net effect of changes to the adult questionnaire. There is an increase in burden hours due to planned increases in rotating core content and additional sponsored content for 2023. The average annualized burden per response across the years 2021-2023 will increase from 44 to 45 minutes. The changes result in an increase of 500 total burden hours for the Adult Questionnaire. There is a reduction in content included on the child questionnaire due to planned reductions in rotating core content and sponsored content; however, this did not have any impact on average annualized burden. Continuation of the Adolescent Follow-back Survey for an additional year will not exceed the total burden hours approved for the AFS in the revision package.

Any future modification that might impact the instruments and/or burden estimates will be submitted as a nonsubstantive change request for OMB review, as applicable.

Lines 1-3 of the burden table represent the different sections of the NHIS questionnaire. Line 4 covers the methodological projects such as web and/or mail-based methodological, cognitive testing activities, and pilot studies. Line 5 covers the adolescent follow-back survey. Line 6 covers a follow-up health exam. No follow-up health exams are being administered in 2023. Small quality control resurveys of participating households are represented on line 7.

Estimated Annualized Burden Hours

Type of Respondent	Form Name	Number of Respondents	Number of Responses per respondent	Average Burden per Response (in hours)	Total Burden Hours
Adult Household Member	Household Roster	36,000	1	4/60	2,400
Sample Adult	Adult Questionnaire	30,000	1	45/60	22,500
Adult Family Member	Child Questionnaire	10,000	1	22/60	3,667
Adult Family Member	Methodological Projects	15,000	1	20/60	5,000
Sample Child	Adolescent follow-back survey	1,200	1	16/60	320
Sample Adult	Health Exam	5,000	1	45/60	3,750
Adult Family Member	Reinterview Survey	5,500	1	5/60	458
Total					38,095

Not all questions apply to each person, and the questionnaire instrument automatically skips over questions that do not apply, based on earlier information given by the respondent. Thus, no respondent is ever asked all of the questions in the questionnaire.

The estimate of response burden above is based on an average length of interview per household. Variations occur in individual household interview times primarily because of differing numbers of persons in the household and variations in the number of health conditions reported in the household.

The burden on any single member of a sample family also varies according to who is designated respondent for each component. In some sample families the same adult could be the respondent for all of the major components: roster, adult, and child. In other families there could be a different respondent for each component. In the first case, the total average burden on the single respondent would be about one hour; in all other cases the burden on a single respondent would be less.

B. Cost to Respondents

At an average wage rate of $21.00 per hour, the estimated annualized cost for the 38,095 burden hours is

$799,995. This estimated cost does not represent an out of pocket expense but represents a monetary value attributed to the time spent doing the interview.

Estimated Annualized Burden Costs

Type of Respondent	Form Name	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Adult Household Member	Household Roster	2,400	$21.00	$50,400
Sample Adult	Adult Questionnaire	22,000	$21.00	$472,500
Adult Family Member	Child Questionnaire	3,667	$21.00	$77,000
Adult Family Member	Methodological Projects	5,000	$21.00	$105,000
Sample Child	Adolescent follow-back survey	320 267	$21.00	$6,720
Sample Adult	Health Exam	3,750	$21.00	$78,750
Adult Family Member	Reinterview Survey	458	$21.00	$9,625
Total	$799,995

15. Explanation for Program Changes or Adjustments

There is a slight increase in average annualized burden due to this nonsubstantive change. This increase is due to the net effect of changes to the sample adult questionnaire.

First, part of the net increase is due to planned changes to rotating core questions in the sample adult questionnaire. Rotating core content includes important topics that NCHS determined should be administered on a set schedule as part of the NHIS redesign.

Second, some of the net increase is due to changes in sponsored content on the survey in 2023. Each year the NHIS includes sponsored content from federal agencies. New sponsored content on the 2023 NHIS includes topics such as vision, hearing and balance, long-term COVID-19 symptoms, cancer screening, family history of cancer, genetic cancer testing and concussions. These topics are consistent with the guidance for sponsors adding questions for the NHIS. Much of the new sponsored content goes into more depth on subjects that are already included in the NHIS (e.g., vision, hearing, COVID-19, cancer screening, chronic conditions). Some of the sponsored content is also specifically evaluating nationwide health promotion initiaitives like Healthy People 2030. The questions are based on questions that were previously fielded on the NHIS or other surveys and are cognitively tested as needed. The estimates produced by the questions also meet requirements for statistical precision to be included on the NHIS.

Third, the NHIS includes new content on emerging topics. Emerging content addresses issues of growing interest to the Department of Health and Human Services. Emerging content for the 2023 NHIS related to discrimination, housing insecurity, and revised questions on gender identity address executive orders on advancing equity and combating discrimination.

Other updates made to the survey do not change the burden. The Adolescent Follow-back survey is being continued for an additional year to increase the sample size available for analysis. Updates were made to the child questionnaire that include planned changes to rotating core content and new sponsored content. The advance letter was also updated with new letterhead and updated language about the Federal Cybersecurity Enhancement Act of 2015.

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