The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based random digit dial (RDD) telephone survey that is conducted annually in all states, the District of Columbia, and U.S. territories. Data obtained from the BRFSS are representative of each state's total non-institutionalized population over 18 years of age and has included more than 400,000 annual respondents with landline telephones or cellphones since 2011. Data are weighted using iterative proportional fitting (also called "raking") methods to reflect population distributions. For the County Health Rankings, data from the BRFSS are used to measure various health behaviors and health-related quality of life (HRQoL) indicators. HRQoL measures are age-adjusted to the 2000 U.S. standard population.

Prior to the 2018 County Health Rankings, up to seven survey years of landline only BRFSS data were aggregated to produce county estimates. However, even with multiple years of data, these did not provide reliable estimates for all counties, particularly those with smaller respondent samples.

For the 2018 County Health Rankings, the CDC produced 2014 county estimates using single-year 2014 BRFSS data and a multilevel modeling approach based on respondent answers and their age, sex and race/ethnicity, combined with county-level poverty and county and state level contextual effects (1).

To produce estimates for those counties where there was no or limited data, the modeling approach borrowed information from the entire BRFSS sample as well as Census Vintage 2014 population estimates. CDC used a parametric bootstrapping method to produce standard errors and confidence intervals for those point estimates. This estimation methodology was validated for all U.S. counties, including those with no or small (<50 respondents) samples (2).

One limitation of the BRFSS is that all measures are based on self-reported information, which cannot be validated with medical records. Another limitation is that these model-based estimates were created by borrowing information from the entire BRFSS, which may or may not accurately reflect those counties’ local intervention experiences. Additionally, the confidence intervals constructed from these methods appear much smaller than confidence intervals reported for direct survey methods in previous years.

1. Zhang X, Holt JB, Lu H, Wheaton AG, Ford ES, Greenlund K, Croft JB. Multilevel regression and poststratification for small-area estimation of population health outcomes: a case study of chronic obstructive pulmonary disease prevalence using the Behavioral Risk Factor Surveillance System. American Journal of Epidemiology 2014;179(8):1025-1033.
2. Zhang X, Holt JB, Yun, S, Lu H, Greenlund K, Croft JB. Validation of multilevel regression and poststratification methodology for small area estimation of health outcomes. American Journal of Epidemiology 2015;182(2):127-137.