This chapter provides a general overview of the United States (US) national health surveys covered in this textbook. Summaries are provided describing the National Health Interview Survey (NHIS), Medical Expenditure Panel Survey (MEPS), Health Information National Trends Survey (HINTS), Behavioral Risk Factor Surveillance System (BRFSS), and National Health and Nutrition Examination Survey (NHANES). The corresponding chapters for each survey (Chapters 6-10) provide case studies using public-use data from each national health survey to answer research questions pertaining to how predisposing and enabling factors of individuals are associated with health behaviors and preventive services use.
2.2 History of National Health Surveys
National health surveys have been used in the US since the 1920s. One of the first efforts to systematically collect health information from the US population came from the Committee on the Cost of Medical Care Studies (CMCS) who collected data from 1928 to 1933.1 The CMCS received funding from private organizations to collect information on health care delivery and payments from 8,758 families in 17 states and Washington, DC. This monumental study documented the large disparity in health care costs, with 40% of the costs being incurred by only 10% of the families surveyed. A major limitation of this national data collection effort was that it did not include underrepresented minority groups, specifically Black or African American families.1 From 1935-1936, the Public Health Service implemented the National Health Survey (NHS) to measure the incidence of illness and use of medical services. This survey was the first to use multistage area sampling across 21 states. The CMCS and NHS provided national health data until the early 1950s. In 1953, the Health Information Foundation in New York and National Opinion Research Center in Chicago collaborated to develop the first survey using a nation-wide probability sample, which laid the groundwork for national surveillance systems such as the NHIS to be conducted annually. More details of the history, design and context of national health surveys are provided elsewhere.1
2.3 National Health Interview Survey (NHIS)
Since 1957, the NHIS has been collected annually on a national scale by the National Center for Health Statistics (NCHS). The purpose of the NHIS is to monitor and explore trends in the health status and health care utilization among adults and children in the US.2 Secondary analyses of NHIS data use cross-sectional study designs. Self-reported data are collected annually using a computer-assisted personal interviewing (CAPI) system during in-person interviews in households across the US. The NHIS has one of the largest annual sample sizes among national surveys. Data are collected from roughly 35,000 households and 87,500 individuals each year. From 2014-2018, the annual household response rates slightly decreased from 73.8% in 2014 to 64.2% in 2018.2 Further details on the design, questionnaires, public-use data, and reports are available on the NHIS website.
2.4 Medical Expenditure Panel Survey (MEPS)
Since 1996, the MEPS has been collected on a national scale by the Agency for Healthcare Research and Quality (AHRQ). The purpose of the MEPS is to gather information on health services used by adults and children in the US, including cost, frequency, and payment structures.3 The MEPS uses a survey panel design that consists of five rounds of interviews over a two-year period. Therefore, the secondary analysis of MEPS data can use both longitudinal or cross-sectional study designs. Households recruited for each panel are selected based on a subsample of households who participated in the previous year’s NHIS. Similar to the NHIS, data are collected in-person using a CAPI system. Self-administered paper questionnaires are also completed by participants. Medical providers are contacted by telephone to provide additional details on medical visit summaries, diagnostic codes and billing. The MEPS annual sample size is roughly 15,000 individuals. From 2014-2018, the annual combined (all five rounds completed) response rates slightly decreased from 48.5% in 2014 to 42.7% in 2018.3 Further details on the design, questionnaires, public-use data, and reports are available on the MEPS website.
2.5 Health Information National Trends Survey (HINTS)
Since 2003, the HINTS has been collected on a national scale by the National Cancer Institute (NCI). The purpose of the HINTS is to evaluate how patterns of health information technology and health communication are related to health-related knowledge, attitudes and behaviors among the noninstitutionalized US adult civilian population.4 After the first 3 iterations (HINTS 1 collected in 2003, HINTS 2 collected in 2005, HINT 3 collected in 2008), each iteration was separated into four cycles. HINTS 4 cycles were collected annually beginning in 2011 (HINTS 4, Cycle 1 in 2011; HINTS 4, Cycle 2 in 2012; HINTS 4, Cycle 3 in 2013; HINTS 4, Cycle 4 in 2014). HINTS 5 cycles were collected annually beginning in 2017 (HINTS 5, Cycle 1 in 2017; HINTS 5, Cycle 2 in 2018; HINTS 5, Cycle 3 in 2019; HINTS 5, Cycle 4 in 2020). Secondary analyses of HINTS data use cross-sectional study designs. Self-reported data have been collected using random digit dialing, mailings and web-based data collection options. The HINTS sample size is roughly 3,500-6,000 individuals for each iteration. Response rates are calculated for each data collection method. Total response rates are roughly 30% for each iteration.4 Further details on the design, questionnaires, public-use data, and reports are available on the HINTS website.
2.6 Behavioral Risk Factor Surveillance System (BRFSS)
Since 1984, the BRFSS has been collected on the state level by the Centers for Disease Control and Prevention (CDC). The purpose of the BRFSS is collect data on health behaviors, physical activity, diet, hypertension and preventive safety measures (e.g. seat-belt use) among US adults.5 In 1988, the system was expanded to include optional modules, including chronic disease, health care access, and preventive services uptake. Some optional modules include data collection among children. In 1993, the BRFSS was expanded to become an annual national surveillance system. Secondary analyses of BRFSS data use cross-sectional study designs. Self-reported data are collected annually using random-digit-dialing methods. Data are collected using a computer-assisted telephone interview (CATI) system. Prior to 2008, data were only collected from landline telephones. In 2008, the methodology was revised to conduct interviews using cell phones. The BRFSS is one of the largest health surveys collected worldwide with over 400,000 responses collected each year.6 Response rates are calculated for landline, cell phone, and combined responses. In 2019, the overall response rate was 49.4%. In 2018, the landline response rate was 53.3% and the cell phone response rate was 43.4%.5 Further details on the design, questionnaires, public-use data, and reports are available on the BRFSS website.
2.7 National Health and Nutrition Examination Survey (NHANES)
Since 1960, national data on the health and diet of individuals in the US has been collected by the NCHS. Starting in 1999, NHANES data have been collected from adults and children on a consistent basis.7 Topics have been expanded to include chronic diseases and other health indicators over the years. Secondary analyses of NHANES data use cross-sectional study designs. The NHANES differs from other national health surveys because it collects self-reported data using in-person household interviews while also collecting objective measurements by physical examinations and laboratory tests of participants at mobile examination centers.7,8 The inclusion of both objective and subjective measurements allows for reliability comparisons. For example, participants self-report whether or not they have ever been diagnosed with diabetes during the household interviews and will have their glucose tested for verification at the mobile examination center. The sample size includes approximately 5,000 individuals every year and data are compiled across two-year data collection periods (e.g. 2015-2016, 2017-2018). Response rates are calculated for interviewed and examined samples. During 2017-2018, the interviewed response rate was 51.9% and the examination response rate was 48.8%.8 Further details on the design, questionnaires, public-use data, and reports are available on the NHANES website.
2.8 Restricted Data
Although most data collected by national health surveys are made available to the public in a deidentified format, any data that may compromise the confidentiality of its participants are restricted and require special procedures and approvals to access. Among the national health surveys discussed in this textbook, the NHANES and NHIS have restricted data accessible by the NCHS and Federal Statistical Research Data Centers. The NHANES restricts data on geography (Census 2010 Block ID), genetics (e.g. BRCA1 associated protein), and the exact dates of participants’ interviews and examinations.9 The NHIS restricts data on geography.10 Among individuals born in the US, data on participants’ state of birth (variable: USBRTHPL) and whether they live in an urban or rural residence (variable: URB_RRL) are restricted. Among foreign-born participants, data on the year that participants came to the US (variable: USYR) and their country of birth (variable: COUNTRY) are restricted.10 The primary author of this textbook (Kindratt) and colleagues have analyzed restricted NHIS data to determine chronic disease prevalence,11 preventive cancer screenings and vaccinations among men12 and women,13 and smoking status14 among Arab American immigrants. The NHIS collects data on country of birth and categorizes each country into 10 worldwide geographic regions (US, Mexico, Central America and Caribbean Islands, South American, Europe, Russia, Middle East, India subcontinent, Southeast Asia, and Asia). The Middle East region includes individuals who were born in 25 countries. However, some countries, such as Iran, are located in the Middle East but not part of the Arab League of Nations. Therefore, previous research by Kindratt and others used responses to the country of birth question to create a variable limited to individuals born in 15 countries that were part of the Arab League of Nations and geographically located in the Middle East region to ensure the findings were representative of the Arab ethnicity.11-14 Using restricted data from the NHIS allowed the authors to disaggregate Arab American immigrants from other ethnicities and exclude non-Arab countries (e.g. Iran) from the grouping.
2.9 Linked Data
National health survey data can also be linked to each other and to other sources. The NHANES and NHIS can be linked to data from the National Death Index to determine mortality rates. For example, Borrell and colleagues linked NHANES III data collected from 1988-1994 with 2015 mortality data to examine associations between allostatic load and all-cause/cardiovascular disease specific mortality among US adults.15 Because the MEPS collects data from the previous year’s NHIS sample, ID numbers from each survey can be linked to expand the variables for each survey.16 Kindratt and colleagues have used linked NHIS and MEPS data to answer several research questions on Middle Eastern and North African cognitive health17 and parents’ perceptions of patient- and family-centered care practices among those whose children have developmental and chronic health conditions.18 Additional studies using linked NHIS and MEPS data are underway.
2.10 Other Surveys
There are several other national health surveys that provide surveillance data for public health professionals and researchers to utilize and examine trends. Inclusion criteria, sample sizes, and health-related content differs across surveys. Although not a comprehensive list, a selection of other common national health surveys are listed below:
- American Community Survey (ACS)
- Health and Retirement Study (HRS)
- National Death Index (NDI)
- National Health and Aging Trends Survey (NHATS)
- National Longitudinal Study of Adolescent to Adult Health (Add Health)
- National Study of Caregiving (NSOC)
- National Survey of Family Growth (NSFG)
- National Vital Statistics System (NVSS)
- Youth Risk Factor Surveillance System (YRFSS)
This chapter provided an overview of the national health surveys covered in this textbook> It also covers brief details of some expanded data analysis procedures and exposure to other health surveys to broaden students’ knowledge of other data sources. More specific details on each survey are provided in Chapters 6-10 (Chapter 6 NHIS, Chapter 7 MEPS, Chapter 8 HINTS, Chapter 9 BRFSS, Chapter 10 NHANES).
- Andersen RM. National health surveys and the behavioral model of health services use. Med Care. 2008;46(7):647-653. doi:10.1097/MLR.0b013e31817a835d
- National Center for Health Statistics. National Health Interview Survey, 2011-2015. Public-use data file and documentation. Published August 5, 2020. Accessed August 10, 2020. https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm
- Agency for Healthcare Research and Quality (AHRQ). Medical Expenditure Panel Survey Home. Accessed September 2, 2020. https://meps.ahrq.gov/mepsweb/
- National Cancer Institute. Health Information National Trends Survey (HINTS): Overview of the HINTS 5 Cycle 3 Survey and Data Analysis Recommendations, January 2020.
- Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: 2019 Summary Data Quality Report.; 2020. Accessed June 19, 2022. https://www.cdc.gov/brfss/annual_data/2019/pdf/2019-sdqr-508.pdf
- Centers for Disease Control and Prevention. About the Behavioral Risk Factor Surveillance System (BRFSS). Published February 9, 2019. Accessed December 10, 2020. https://www.cdc.gov/brfss/about/about_brfss.htm
- NHANES – About the National Health and Nutrition Examination Survey. Published January 8, 2020. Accessed November 3, 2021. https://www.cdc.gov/nchs/nhanes/about_nhanes.htm
- Chen TC, Parker JD, Clark J, Shin HC, Rammon JR, Burt VL. National Health and Nutrition Examination Survey: Estimation Procedures, 2011-2014. Vital Health Stat 2. 2018;(177):1-26.
- RDC – Restricted Data – NHANES. Published August 27, 2021. Accessed June 23, 2022. https://www.cdc.gov/rdc/b1datatype/Dt1222.htm
- RDC – Restricted Data – NHIS. Published March 17, 2022. Accessed June 23, 2022. https://www.cdc.gov/rdc/b1datatype/Dt1225.htm
- Dallo FJ, Kindratt TB. Disparities in Chronic Disease Prevalence Among Non-Hispanic Whites: Heterogeneity Among Foreign-Born Arab and European Americans. J Racial Ethn Health Disparities. 2016;3(4):590-598. doi:10.1007/s40615-015-0178-8
- Dallo FJ, Kindratt TB. Disparities in preventive health behaviors among non-Hispanic White men: heterogeneity among foreign-born Arab and European Americans. Am J Mens Health. 2015;9(2):124-131. doi:10.1177/1557988314532285
- Dallo FJ, Kindratt TB. Disparities in vaccinations and cancer screening among U.S.- and foreign-born Arab and European American non-Hispanic White women. Womens Health Issues. 2015;25(1):56-62. doi:10.1016/j.whi.2014.10.002
- Kindratt TB, Dallo FJ, Roddy J. Cigarette Smoking among US- and Foreign-Born European and Arab American Non-Hispanic White Men and Women. J Racial Ethn Health Disparities. 2018;5(6):1284-1292. doi:10.1007/s40615-018-0476-z
- Borrell LN, Rodríguez-Álvarez E, Dallo FJ. Racial/ethnic inequities in the associations of allostatic load with all-cause and cardiovascular-specific mortality risk in U.S. adults. PLoS One. 2020;15(2):e0228336. doi:10.1371/journal.pone.0228336
- NHIS – Medical Expenditure Panel Survey Linkage Files. Published May 10, 2019. Accessed June 23, 2022. https://www.cdc.gov/nchs/nhis/nhismep.htm
- Kindratt TB, Dallo FJ, Zahodne LB, Ajrouch KJ. Cognitive Limitations Among Middle Eastern and North African Immigrants. J Aging Health. Published online May 23, 2022:8982643221103712. doi:10.1177/08982643221103712
- Kindratt TB, Lark P, Ray M, Brannon GE. Disparities in Patient- and Family-Centered Care Among Children With Health Conditions. J Patient Exp. 2022;9:23743735221092496. doi:10.1177/23743735221092494