Response to prior terms of clearance and future testing

OMB Terms of clearance from field test of changes to 2023 BRFSS questionnaire (August 2022):

Approved consistent with BRFSS working with NCHS to test its questions about long COVID,

vaccinations, and gender identity screening

CDC Response:

The BRFSS field tested the questions proposed for 2023 on a sample of 304 people from a cellular telephone sample drawn from the state of Illinois. The response rate was 22.3%. No cognitive testing was performed pursuant to these prior terms of clearance. Instead, the BRFSS program commits to doing cognitive testing in parallel with data collection to inform how it interprets the data from these questions and additional development that is required for the 2024 administration of the survey.

Emerging Core section – Long-term COVID Effects

The three emerging core questions used in the 2023 field test were taken from 2022 Census Pulse Surveys. The BRFSS program shared the field tested questions with NCHS. There is not room for the fourth question used by NCHS. No cognitive testing has been completed on these questions yet, but BRFSS is committed to working with NCHS as they continue to test different version of the long Corvid questions.

COVID Vaccination Optional Module

The optional module was reduced from six questions to four questions for the field test. After testing the questions and suggestions from OMB the optional module has been reduced to three questions for 2023. Within the third question, another response category is included to allow for 5 or more vaccines. The fourth question on the COVID-19 vaccination status has been removed for 2023. The three remaining questions have been in use in the BRFSS as part of an optional module since July 2021, but had not been tested. The BRFSS program will work with NCHS to determine an optimal cognitive testing plan.

Landline and Cell Phone screener:

Screening questions on sex of respondent changed to use the example from a presentation by the Federal Committee on Statistical Methodology Interest Group, entitled Collecting SOGI Data: Principles and Practices (Slide 11) without further cognitively testing.

The second question in the screening section on respondent sex is taken from the Sex at Birth optional module and will asked of respondents which did not answer the previous question as “1. Male” or “2. Female”. The question has been modified to include an additional probe, consistent with a question included on the 2022 NHIS. The question on sex from NHIS was used in the 2023 field test with no respondents indicating ”Don’t know” or “Refused”. This question has been in use within the BRFSS since 2019.

NCHS has shared the question series they have developed for collection of gender identity and sex at birth in their 2023 questionnaire. These questions would be very difficult to require all states to collect in the screening section of the BRFSS questionnaire. We will work with the state coordinators in 2023 to find a common series of questions to address further detailed collection of gender identity and facilitate the sense of inclusion of additional respondents.

Remainder of changes in the 2023 BRFSS Questionnaire

Core section – Health Care Access

The question on health care coverage will include two modifications in 2023. The term “health insurance” will be used instead of “health care coverage”. This change was suggested to improve understanding of the term by respondents from discussions with BRFSS data collectors in February of 2022. The word “primary” was moved during the 2022 Field Test after feedback from interviewers and monitoring of the interviews. The field test included the health care coverage question used through 2020 and the modified version of the health care coverage question used in 2021 and 2022. The proposed question for 2023 resulted in about 1% more respondents indicating health insurance coverage versus the respondents to the health care coverage question used through 2020. We will cognitively test the 2023 question in parallel. On a side note, the granularity of the responses to the health care coverage question in use in the BRFSS since 2021 has been useful for programs to better identify where health care coverage disparities are occurring.

Core section – Exercise

The second and fifth questions in the section ask the respondent to identify the type of physical activity or exercise they spent the most time doing during the past month. This set of questions were last included in the BRFSS as a Core section in 2019. In previous years, this question had 77 types of exercise and the list of exercise types has been reduced to 11 for 2023. About 15% of the respondents in the 2023 field test indicating an exercise during the field test selected “11. Other”.

Core section – Demographics – Race

The race question was modified for the 2023 field test to include the response category “60. Other” available for coding. This response category will be included but not read as a category in the 2023 BRFSS questionnaire. The first race question will be the same as it was in the 2021 BRFSS questionnaire. The second race question for respondents indicating more than one race category to allow the respondent to indicate a single category for the race has been removed for 2023.

Cognitive Decline Optional Module

The optional module has been modified to reduce the time needed to administer. There are now five questions in the 2023 BRFSS optional module, in place of the six from 2022. These questions were included in the 2023 field test and tabular results along with comments from interviewers and monitoring by supervisors was shared with the BRFSS program. There were 160 respondents which received the first question of which 37 qualified to continue the remaining questions in the optional module. These questions were not cognitively tested in 2022. Cognitive testing will be conducted to understand the implications of the modifications to the optional module questions as proposed and further tested for potential inclusion in the 2024 BRFSS questionnaire.

Social Determinants and Health Equity

The optional module had one question modified to capture the respondents feeling of loneliness. After discussions with NCHS about the use of the term “socially isolated” to address loneliness the question has been changed to “lonely”. This modified question was not cognitively tested in 2022, but will be cognitively tested in 2023.

Random Child Selection Optional Module

The optional module was modified to reflect similar changes to the BRFSS screening for sex and race questions. The first question asking the sex of the child had a response of “3. Nonbinary” in 2022 and in 2023 this response category will be “3. Nonbinary/Other”. The second question asking the sex of the child at birth is only for those not answering the first sex of the child question as “1. Male” or “2. Female”, will use a modified question asking about sex on their original birth certificate.

Number of phone lines: The BRFSS program will cognitively test these questions for landline sample respondents in 2023.