In This Article Expand or collapse the "in this article" section Behavioral Risk Factor Surveillance

  • Introduction
  • General Overviews
  • Historical Aspects
  • Development and Examples by Country
  • Surveillance as an Information System
  • Surveillance and Social Determinants of Health

Public Health Behavioral Risk Factor Surveillance
Stefano Campostrini
  • LAST REVIEWED: 14 January 2022
  • LAST MODIFIED: 13 January 2014
  • DOI: 10.1093/obo/9780199756797-0065


Surveillance has long been a core issue for infectious diseases, and it is still one of the main focuses for those working in this field. In recent years, parallel to the rising importance of noncommunicable diseases (NCDs), a growing demand for information arose, particularly on the “causes” of NCDs, the risk factors and other determinants of NCDs and chronic diseases. Initially, it was thought that the usual health (cross-sectional) surveys were sufficient, but soon (although not obviously for many decision makers—and this partly explains why behavioral risk factor surveillance (BRFS) has been developed in only a few countries) it became clear that (a) some behaviors in the population can change much more rapidly than expected; (b) observing trends and change is not enough—there is a also need to understand why attitudes and behaviors are changing; and (c) there is an increasing need for answers related to changes that have happened because of secular trends or because of interventions. Most existing health survey systems (typically collecting data once yearly or even every three to five years) were not capable of explaining the dynamics of behavioral change in populations, which highlighted the need, for dynamic, more continuous data collections systems. The rise of the NCD burden exacerbated this need. In its short history (the first stable surveillance system started only in the 1980s), this dynamic type of behavioral surveillance focused initially on the modifiable risk factors (with the so-called “Big Four” always present: smoking, physical inactivity, diet, and alcohol), which led to this approach being called “behavioral risk factor surveillance” (BRFS). Soon, together with the main behavior risk factors, several other types of information have been collected, ranging from health service access to health insurance coverage. Also included were attitudinal aspects of behavior, with all variables chosen with a common denominator: that of being relevant to support public health decision-making. In addition to the characteristic of timely, near continuous data collection, this is perhaps the other fundamental pillar of what it still called BRFS: the link with public health action. Notably, and different from other health data sources, surveillance systems are often embedded into the bureaucratic health system, and rarely delegated to some external institution (such as national statistical institutes). This is a sign of the fundamental link with public health and the role of surveillance in it: far from being a research activity, BRFS serves as an information system to support health promotion and public health decision-making.

General Overviews

This section identifies some of the most important general aspects of behavioral risk factor surveillance (BRFS). To understand both the role of surveillance in public health and that peculiar to BRFS interventions, some of the works cited here concern general public health surveillance, and some are much more specific to BRFS. The first the main reference is Teutsch and Churchill 2000, now at its third edition (Lee, et al. 2010). McQueen and Puska 2003 was the first comprehensive reflection on the role of BRFS, addressing its fundaments and its main methodological aspects, based on experiences from around the country that pioneered the construction of BRFS systems. The salient work begun with this book has been reorganized by an international network called the World Alliance for Risk Factor Surveillance (WARFS), which is hosted by the International Union for Health Promotion and Education (IUHPE). This organization has produced a White Paper on Surveillance and Health Promotion (Campostrini, et al. 2011), which, although not a scientific paper, can be useful as a first general overview. Any reference list must include the first well-developed (and still running) BRFS system in the world, started by the Centers for Disease Control and Prevention (CDC) in the United States at the beginning of the 1980s The CDC’s Behavioral Risk Factor Surveillance System (BRFSS) has collected millions of interviews in the three decades of its life (Nelson, et al. 2001). A different, in some aspects, approach is that proposed by the World Health Organization (WHO) through its surveillance system, the STEPwise approach to Surveillance (STEPS). This system is less concerned about continuous observation and more focused on reliability aspects, putting at the top of the stairs of importance actual physical and biochemical measures. Noting that the WHO STEPS approach is a more general NCD surveillance system and not a specific BRFS system, the WHO proposal has been critiqued by some authors, though it is widely accepted by many health ministries throughout the world. A general definition of public health surveillance (PHS) can be found in the Dictionary of Epidemiology (Porta 2008), while the evolution of PHS in the United States is well presented in Thacker, et al. 2012. The foundational and some validity aspects of the most developed BRFS system, the CDC’s BRFSS, is presented in Nelson, et al. 2001.

  • Campostrini, Stefano, Dave McQueen, Anne Taylor, and Alison Daly. 2011. White paper on surveillance and health promotion. Paris: International Union for Health Promotion and Education.

    The World Alliance for Risk Factor Surveillance (WARFS) counts on members from many countries. Summarized in this white paper are the basic definitions of this particular surveillance and its characteristics, as well as its role in public health. Interesting examples from some countries surveillance systems are presented.

  • Lee, L. M., S. B. Thacker, and M. E. St. Louis. 2010. Principles and practice of public health surveillance. New York: Oxford Univ. Press.

    DOI: 10.1093/acprof:oso/9780195372922.001.0001

    A revised and updated version of Teutsch and Churchill 2000.

  • McQueen, D. V., and P. Puska, eds. 2003. Global behavioral risk factor surveillance. New York: Kluwer Academic/Plenum.

    DOI: 10.1007/978-1-4615-0071-1

    Published after the second meeting of an international network on behavioral risk factor surveillance (BRFS), this was the first attempt to condense several issues of interest for BRFS development, from theory to methods, including country examples.

  • Nelson, D. E., D. Holtzman, J. Bolen, C. A. Stanwyck, and K. A. Mack. 2001. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Sozial- und Praventivmedizin 46.1: 3–42.

    One could find several hundred scientific articles related to the US surveillance system BRFSS. In this article Nelson and colleagues present the system and its methodological issues, and they discuss the reliability and validity of the measures used. The article is particularly useful in laying out the limits and potentialities of self-related subject measures in a surveillance system.

  • Porta, M., ed. 2008. Dictionary of epidemiology. 5th ed. New York: Oxford Univ. Press.

    A well-known dictionary of epidemiology. Of course, it is useful for many other purposes, but it is cited here for its help in understanding the “basics” of (public health) surveillance and its role, from a broader perspective,

  • STEPwise approach to Surveillance (STEPS). World Health Organization.

    This WHO web page on STEPS presents its approach to surveillance, offering a practical approach for countries interested in running a surveillance system. It is a more general approach than the behavioral risk factor surveillance one, as it focuses also on morbidity and mortality measures and approaches risk factor through physical measures.

  • Teutsch, S. M., and R. E. Churchill, eds. 2000. Principles and practice of public health surveillance. 2d ed. New York: Oxford Univ. Press.

    Perhaps the most important and cited work on public health surveillance (PHS), first edited in 1994. The second edition of 2000 can be considered an exhaustive manual on PHS, from planning to communication. BRFS is described as a component of the PHS system. It is presented mainly from an American perspective, although a chapter is dedicated to low- and middle-income countries.

  • Thacker, S. B., J. R. Qualters, and L. M. Lee. 2012. Public health surveillance in the United States: Evolution and challenges. Morbidity and Mortality Weekly Report 61:3–9.

    An interesting work, and one certainly useful to understand the evolution of public health surveillance (PHS) in the United States. With the attention and the funding that PHS has gathered in the last year in the United States, what is discussed here can be paradigmatic for many other countries, particularly for understanding the challenges that could be faced.

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