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2019 Questionnaire Redesign
Overview
The content and structure of the NHIS were updated in 2019 to better meet the needs of data users. Aims of the questionnaire redesign were to improve the measurement of covered health topics, reduce respondent burden by shortening the length of the questionnaire, harmonize overlapping content with other federal health surveys, establish a long-term structure of ongoing and periodic topics, and incorporate advances in survey methodology and measurement.
Redesigned Questionnaire Structure
One “sample adult” aged 18 years or older and one “sample child” aged 17 years or younger (if any children live in the household) are randomly selected from each household following a brief screener that identifies the age, sex, race, and ethnicity of everyone who usually lives or stays in the household. Information about the sample adult is collected from the sample adult him/herself unless s/he is physically or mentally unable to do so, in which case a knowledgeable proxy can answer for the sample adult. Information about the sample child is collected from a parent or adult who is knowledgeable about and responsible for the health care of the sample child. This respondent may or may not also be the sample adult.
In the 1997-2018 NHIS, questions from the family questionnaire were asked about the family as a whole and about each member of the family. The NHIS has consistently defined a family as an individual or a group of two or more people residing together who are related by birth, marriage, or adoption. A family additionally includes any unrelated children who are cared for by the family (such as foster children) and any unmarried cohabiting partners and their children. In the redesigned NHIS, the definition of family will remain the same.
In the redesigned survey, family-level content is collected in the sample adult and/or sample child questionnaire. Much of the content that was collected in the family section is now collected directly within the sample adult and sample child questionnaires. There is some loss of the content that has previously been collected in the family questionnaire, including: detailed relationships of all family members to household and family respondent, country of birth (if not US), some employment and earnings information, active duty military time periods, instrumental activities of daily living (IADLs), disability-associated conditions, receipt of medical advice by phone, and amount of money that the family spent out of pocket for medical care.
An estimated 30,000 sample adult and 9,000 sample child interviews are expected to be available annually for analysis in the redesigned NHIS. The redesign allows for data users to pool two or more years of sample if needed to produce reliable estimates for population subgroups.
The redesigned sample adult and sample child questionnaire structures consist of four components: the annual core, rotating core, sponsored content (sustaining and periodic), and emerging topics.
Annual Core
The annual core questionnaire contains the same questions from year to year. These questions focus on demographic characteristics, health insurance, health care access and use, health conditions, tobacco use, and functioning and disability.
Rotating Core
The rotating core questionnaire consists of questions that will be included in the interview on some years with fixed periodicity. The core questions (both the annual and rotating) are sponsored by NCHS and reflect the prioritized content areas. Efforts have been made to ensure that rotating content on the sample adult and sample child interviews is consistent, so that similar topics are addressed in both the sample adult and sample child interviews in a given year. These questions focus on service utilization, preventive services, chronic pain, injuries, sleep and fatigue, physical activity, psychological distress, and allergies.
Sponsored Content
Some questions on the NHIS are funded by other federal agencies. In the past, sponsored content has included questions on food security, cancer screening, complementary and alternative medicine, and heart disease, among others. Sustaining sponsors are agencies that will sponsor content every year over multiple years; this content does not necessarily include the same questions from year to year. Periodic sponsored content is included in the interview in one or more years, but not every year.
Emerging Content
Emerging content includes new topics of growing interest that may be added by NCHS, generally for one year. In 2019, information on opioid use and pain management was collected in the sample adult interview. In 2020 and 2021, information on concussions is collected in the sample child interview.
Content Order
The images below summarize the topics that will be included in NHIS each year from 2019 through 2027:
In households with children, the order of the sample adult and sample child interviews will vary by household. The relationship between the sample adult and sample child will be obtained. When the sample adult and sample child are in the same family, content areas that refer to the family will be captured only once, in whichever interview comes first. When they are not, questions about the family will be asked in both the sample adult and the sample child interview.
The proposed schedule of rotating content for sponsored content on cancer is available on the National Cancer Institute’s website.
Questionnaires
The specific wording of the survey questions and the order in which they appear can be found with the NHIS data files and annual documentation.
The annual survey questionnaires are nearly 1,000 pages long. Bookmarks are included in the pdf files to help with navigation.
Rationale for Redesign and Criteria for Prioritizing Content
In general, the following criteria were used for prioritizing content included in the redesigned questionnaire:
- Strong link to public health
- Relevant to HHS agency goals, strategic plans, or initiatives
- Long-term monitoring of the topic area is needed
- Topic area can be measured well in household interviews
- Measure is used by other federal surveys for calibration
- Measure does not duplicate the detail collected by federal surveys with more targeted purposes
- Topic area can be estimated reliably with only one or two years of data
Content areas with a strong link to public health include:
- Leading causes of morbidity/mortality
- Intermediate health outcomes for leading causes of morbidity/mortality
- Targets of major federal health promotion initiatives
- Health insurance coverage
- Health care access and utilization
- Individual behavioral risk or protective factors for the content areas listed above
- Other factors that identify priority populations at elevated risk of poorer health or receiving poorer health care
Public Outreach Activities
In October 2015, February 2016, and June 2016, NCHS requested input on the proposed NHIS questionnaire redesign. Many suggestions were received; the most frequent areas of input were requests to retain detailed questions about disability, health behaviors, health care access and utilization, mental health, specific chronic conditions, health insurance, and the health of other family members. In October 2016, NCHS requested public comments through the Federal Register. The most frequent requests were for additional questions on dental and oral health, behavior of children aged 0-1 years, adult disability, and allergies.
Some comments were incorporated into the redesigned core questionnaire. The redesigned NHIS continues to identify people with functional limitations and difficulties. A battery of mental health questions to assess depression and anxiety is part of the new rotating core. Chronic conditions with sufficient prevalence were considered for inclusion. Some data on family relationships continue to be collected, including marital status of sample adults and parents of sample children. Several family context variables are also retained, including race/ethnicity, education, and employment status of all adults in the family.
Comments were also received that have not been incorporated into the core questionnaire. Topics such as caregiving burden and social isolation may be incorporated occasionally (i.e., without a set periodicity) or as supplemental content sponsored by another federal agency rather than added to the NHIS core. Other topics may be more appropriate for other federal surveys. For example, nutritional inventories (including details on common allergens) and health expenditure amounts are collected in detail in other surveys.