Centers for Disease Control & Prevention YRBSS Methodology Report 2013

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This report, prepared by the Centers for Disease Control and Prevention (CDC), provides a comprehensive overview of the methodology used in the Youth Risk Behavior Surveillance System (YRBSS) in 2013. The YRBSS is a critical surveillance system established in 1991 to monitor six categories of priority health-risk behaviors among youths and young adults, including behaviors contributing to unintentional injuries and violence, sexual behaviors, tobacco use, alcohol and other drug use, unhealthy dietary behaviors, and physical inactivity. The report details the system's evolution, including questionnaire content, operational procedures, sampling, weighting, data-collection protocols, data-processing procedures, and data quality. It also includes results of methods studies and highlights changes and improvements made since 2004. The YRBSS aims to provide data for public health professionals, educators, and policymakers to describe prevalence, assess trends, and evaluate health-related policies and programs. The data are collected through national, state, territorial, tribal, and large urban school district surveys, providing comparable data across different populations and monitoring progress towards national health objectives. The report emphasizes the importance of the YRBSS in informing and evaluating school health programs and addressing the leading causes of morbidity and mortality among U.S. youths and adults. This document is available on Desklib for student use.
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Centers for Disease Control & Prevention (CDC)
Methodology of the Youth Risk Behavior Surveillance System — 2013
Author(s): Nancy D. Brener, Laura Kann, Shari Shanklin, Steve Kinchen, Danice K. Eaton,
Joseph Hawkins and Katherine H. Flint
Source: Morbidity and Mortality Weekly Report: Recommendations and Reports, Vol. 62,
No. 1 (March 1, 2013), pp. 1-20
Published by: Centers for Disease Control & Prevention (CDC)
Stable URL: https://www.jstor.org/stable/10.2307/24832543
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Recommendations and Reports
Methodology of the
Youth Risk Behavior Surveillance System — 2013
Prepared by
Nancy D. Brener, PhD1
Laura Kann, PhD1
Shari Shanklin, MS1
Steve Kinchen1
Danice K. Eaton, PhD2
Joseph Hawkins, MA3
Katherine H. Flint, MS4
1Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, C
2Division of Human Development and Disability, National Center for Birth Defects and Developmental Disabilities
3Westat, Rockville, Maryland
4ICF International, Calverton, Maryland
Summary
Priority health-risk behaviors (i.e., interrelated and preventable behaviors that contribute to the lead
and mortality among youths and adults) often are established during childhood and adolescence and
Youth Risk Behavior Surveillance System (YRBSS), established in 1991, monitors six categories of prio
among youths and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2
contribute to human immunodeficiency virus (HIV) infection, other sexually transmitted diseases, and
3) tobacco use; 4) alcohol and other drug use; 5) unhealthy dietary behaviors; and 6) physical inactivi
monitors the prevalence of obesity and asthma among this population.
YRBSS data are obtained from multiple sources including a national school-based survey conducted
based state, territorial, tribal, and large urban school district surveys conducted by education and hea
have been conducted biennially since 1991 and include representative samples of students in grades
of the YRBSS methodology was published (CDC. Methodology of the Youth Risk Behavior Surveillance
[No RR-12]). Since 2004, improvements have been made to YRBSS, including increases in coverage a
This report describes these changes and updates earlier descriptions of the system, including questio
procedures; sampling, weighting, and response rates; data-collection protocols; data-processing proce
and data quality. This report also includes results of methods studies that systematically examined ho
affect prevalence estimates. YRBSS continues to evolve to meet the needs of CDC and other data use
of the questionnaire, the addition of new populations, and the development of innovative methods for
had been ongoing since 1975 (1). This study measureBackground and Rationale use and related determinants in a national sample of
Data from surveillance systems are critical for planning andin grade 12; it has since been expanded to include st
evaluating public health programs. During the late 1980s,in grades 8 and 10 and a broader health-risk behavio
when CDC began funding education agencies to implementIn 1987, the one-time National Adolescent Student He
school-based programs to prevent human immunodeficiencySurvey was administered to a nationally representativ
virus (HIV), only a limited number of health-related school-of students in grades 8 and 10; this survey measured
based surveys existed in the United States to inform programskills (e.g., reading food and drug labels), alcohol and
planning and evaluation. The Monitoring the Future studydrug use, injury prevention, nutrition, knowledge and
The material in this report originated in the National Center for HIV/
AIDS, Viral Hepatitis, STD, and TB Prevention, Rima F. Khabbaz,
MD, Acting Director; and the Division of Adolescent and School
Health, Howell Wechsler, EdD, Director.
Corresponding preparer: Nancy D. Brener, PhD, National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 4770 Buford
Highway NE, MS K-33, Atlanta, GA 30341; Telephone: 770-488-6184;
Fax: 770-488-6156; E-mail: nad1@cdc.gov.
about sexually transmitted diseases (STDs) and a
immunodeficiency syndrome (AIDS), attempted suicid
violence-related behaviors (2). In addition, in 198
conducted a national survey to measure knowledge, b
and behaviors concerning HIV among high school stu
(3). However, surveys conducted only on a national le
time surveys, and surveys addressing only certain ca
of health-risk behaviors could not meet the need
MMWR / March 1, 2013/ Vol. 62/ No. 1 1
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Recommendations and Reports
territorial, and local education and health agencies that had
begun receiving funding to implement school health programs.
More specifically, in 1987, CDC began providing financial
and technical assistance to state, territorial, and local education
agencies to implement effective HIV prevention programs
for youths. Since 1992, CDC also has provided financial and
technical assistance to state education agencies to implement
additional broad-based programs, often referred to as
coordinated school health programs,” which focus on obesity
and tobacco use prevention. Since 2008, CDC also has funded
tribal governments for HIV prevention and coordinated school
health programs.
Before 1991, school-based HIV prevention programs and
coordinated school health programs frequently were developed
without empiric information on the prevalence of key behaviors
that most influence health and on how those behaviors varied
over time and across subgroups of students. To plan and
help determine the effectiveness of school health programs,
public health and education officials need to understand how
programs influence the health-risk behaviors associated with
the leading causes of morbidity and mortality among youths
and adults in the United States.
In 1991, to address the need for data on the health-risk
behaviors that contribute substantially to the leading causes of
morbidity and mortality among U.S. youths and young adults,
CDC developed the Youth Risk Behavior Surveillance System
(YRBSS), which monitors six categories of priority health-risk
behaviors among youths and young adults: 1) behaviors that
contribute to unintentional injuries and violence; 2) sexual
behaviors that contribute to HIV infection, other STDs, and
unintended pregnancy; 3) tobacco use; 4) alcohol and other drug
use; 5) unhealthy dietary behaviors; and 6) physical inactivity.
In addition, the surveillance system monitors the prevalence of
obesity and asthma among this population. The system includes
a national school-based survey conducted by CDC as well as
school-based state, territorial, tribal, and large urban school
district surveys conducted by education and health agencies. In
these surveys, conducted biennially since 1991, representative
samples of students typically in grades 9–12 are drawn. In 2004,
a description of the YRBSS methodology was published (4).
This updated report discusses changes that have been made to
YRBSS since 2004 and provides an updated, detailed description
of the features of the system, including questionnaire content;
operational procedures; sampling, weighting, and response rates;
data-collection protocols; data-processing procedures; reports
and publications; and data quality. This report also includes
results of new methods studies on the use of computer-based data
collection and describes enhancements made to the technical
assistance system that supports state, territorial, tribal, and large
urban school district surveys.
Purposes of YRBSS
YRBSS has multiple purposes. The system was desig
enable public health professionals, educators, policy m
and researchers to 1) describe the prevalence of hea
behaviors among youths, 2) assess trends in hea
behaviors over time, and 3) evaluate and improv
related policies and programs. YRBSS also was de
to provide comparable national, state, territorial,
urban school district data as well as comparable data
subpopulations of youths (e.g., racial/ethnic subgroup
monitor progress toward achieving national health ob
(5–7) (Table 1) and other program indicators (e.g., CD
performance on selected Government Performance a
Act measures) (8). Although YRBSS is designed to pro
information to help assess the effect of broad nationa
territorial, tribal, and local policies and programs, it w
designed to evaluate the effectiveness of specific inte
(e.g., a professional development program, school cu
or media campaign).
As YRBSS was being developed, CDC decided that t
system should focus almost exclusively on health-risk
rather than on the determinants of these behavio
knowledge, attitudes, beliefs, and skills), because
more direct connection between specific health-risk b
and specific health outcomes than between determin
behaviors and health outcomes. Many behaviors (e.g.
and other drug use and sexual behaviors) measured b
also are associated with educational and social o
including absenteeism, poor academic achievemen
dropping out of school (9).
Data Sources
YRBSS data sources include ongoing surveys as
one-time national surveys, special-population surve
methods studies. The ongoing surveys include school
national, state, tribal, and large urban school district
of representative samples of high school students
certain sites, representative state, territorial, and larg
school district surveys of middle school students. The
surveys are conducted biennially; each cycle beg
of the preceding even-numbered year (e.g., in 2010 f
2011 cycle) when the questionnaire for the upcoming
released and continues until the data are published in
the following even-numbered year (e.g., in 2012 for t
cycle). This section describes the ongoing surveys, on
national surveys, and special-population surveys.
studies are described elsewhere in this report (see Da
MMWR / March 1, 2013/ Vol. 62/ No. 12
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Recommendations and Reports
TABLE 1. National health objectives and a leading health indicator measured by the national Youth Risk Behavior
Topic area/Objective no. Objective
Cancer
C-20.3 Reduce the proportion of adolescents in grades 9–12 who report using artificial sources of ultraviolet light for tanning
C-20.5 Increase the proportion of adolescents in grades 9–12 who follow protective measures that may reduce the risk of skin c
Injury and violence prevention
IVP-34 Reduce physical fighting among adolescents
IVP-35 Reduce bullying among adolescents
IVP-36 Reduce weapon carrying by adolescents on school property
Mental health and mental disorders
MHMD-2 Reduce suicide attempts by adolescents
MHMD-3 Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to control their weight
Physical activity
PA-3.1 Increase the proportion of adolescents who meet current Federal physical activity guidelines for aerobic physical activit
PA-3.2 Increase the proportion of adolescents who meet current Federal physical activity guidelines for muscle-strengthening a
PA-3.3 Increase the proportion of adolescents who meet current Federal physical activity guidelines for aerobic physical activit
muscle-strengthening activity
PA-5 Increase the proportion of adolescents who participate in daily school physical education
PA-8.2.3 Increase the proportion of adolescents in grades 9–12 who view television, videos, or play video games for no more tha
PA-8.3.3 Increase the proportion of adolescents in grades 9–12 who use a computer or play computer games outside of school (f
work) for no more than 2 hours a day
Sleep health
SH-3 Increase the proportion of students in grades 9–12 who get sufficient sleep
Substance abuse
SA-1 Reduce the proportion of adolescents who report that they rode, during the previous 30 days, with a driver who had bee
Tobacco use
TU-2.1 Reduce the use of tobacco products by adolescents (past month)
TU-2.2 Reduce the use of cigarettes by adolescents (past month)
TU-2.3 Reduce the use of smokeless tobacco products by adolescents (past month)
TU-2.4 Reduce the use of cigars by adolescents (past month)
TU-7 Increase smoking cessation attempts by adolescent smokers
* Source: National health objectives and leading health indicators are determined by the US Department of Health and Human Services. Adap
of Health and Human Services. Healthy People 2020. Available at http://www.healthypeople.gov/2020/default.aspx.
Leading health indicator.
This report focuses predominantly on the ongoing school-
based national, state, territorial, tribal, and large urban school
district surveys. The national Youth Risk Behavior Survey
(YRBS) provides data representative of students in grades 9–12
attending U.S. high schools. State, territorial, tribal, and large
urban school district surveys provide data representative of high
school students or middle school students in states, territories,
tribal governments, and large urban school districts that receive
funding from CDC through cooperative agreements. Starting
in 2013, education or health agencies in all 50 states, seven
territorial education agencies, and 31 local education agencies
are eligible to receive funding to conduct a YRBS.
One-Time National Surveys
Several one-time national surveys have been conducted as
part of YRBSS. These one-time surveys include a Youth Risk
Behavior Supplement, which was added to the 1992 National
Health Interview Survey to provide information regarding
persons aged 12–21 years, including youths attending school
as well as those not attending school (10); a National College
Health Risk Behavior Survey, which was conducted in
to measure the prevalence of health-risk behavior
undergraduate students enrolled in public and private
4-year colleges and universities (11); and a National A
High School Youth Risk Behavior Survey, which was c
in 1998 to measure selected health-risk behaviors am
nationally representative sample of students in grade
attending alternative high schools (12).
In 2010, also as part of YRBSS, CDC conducted
National Youth Physical Activity and Nutrition Stud
(NYPANS), which was designed to 1) provide nati
representative data on behaviors and behavioral dete
related to nutrition and physical activity among high
students, 2) provide data to help improve the clarity a
the performance of questions on the YRBSS questionn
and 3) enhance understanding of the associations
behaviors and behavioral determinants related to
activity and nutrition and their association with body
index (BMI) (weight[kg]/height[m]2). The study included a
paper-and-pencil questionnaire administered to a nat
representative sample of 11,429 students attendin
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and private schools in grades 9–12, a standardized protocol to
measure height and weight among all students completing the
questionnaire, and telephone interviews to measure 24-hour
dietary recalls among a subsample of 909 students (8% of those
who completed questionnaires).
Special-Population Surveys
Special-population surveys related to short-term federal
initiatives have been conducted periodically as part of
YRBSS. In 2005, 2007, and 2009, a total of 40 communities
participating in the Steps to a HealthierUS program (13)
conducted at least one school-based survey of students in grades
9–12 in their program intervention areas. These communities
used a modified YRBSS questionnaire that measured dietary
behaviors, physical activity, and tobacco use and the prevalence
of obesity and asthma (13). In 2010 and 2011, a total of
44 communities participating in the Communities Putting
Prevention to Work (CPPW) program conducted school-
based surveys of students in grades 9–12 in their program
intervention areas. Six communities used the standard YRBSS
questionnaire, and 38 used a modified questionnaire that
measured dietary behaviors, physical activity, and tobacco use
and the prevalence of obesity. In 2012 and 2013, a total of 17
CPPW communities will conduct a second YRBS.
In addition to the fiscal and technical support provided
through cooperative agreements to tribal governments to
conduct a YRBS, CDC also provides technical assistance for
other surveys of American Indian youths. Since 1994, the
Bureau of Indian Education (BIE) has conducted a YRBS
periodically among American Indian youths attending middle
and high schools funded by BIE. Since 1997, the Navajo
Nation has conducted a YRBS periodically in schools on
Navajo reservations and in border town schools having high
Navajo enrollment. In 2011, CDC also provided technical
assistance to the Nez Perce Tribe to conduct a YRBS.
Questionnaire
Initial Questionnaire Development
To determine which health-risk behaviors YRBSS would
assess initially, CDC first reviewed the leading causes of
morbidity and mortality among youths and adults. In
1988, four causes accounted for 68% of all deaths among
persons aged 1–24 years: motor-vehicle crashes (31%), other
unintentional injuries (14%), homicide (13%), and suicide
(10%) (14). In 2008, of all deaths among persons aged 10–24
years, 72% were attributed to these four causes: 26% resulted
from motor-vehicle crashes, 17% from other unintentional
injuries, 16% from homicide, and 13% from suicide (1
1988, substantial morbidity also resulted from approx
1 million pregnancies occurring among adolescents (1
the estimated 12 million cases of STDs among person
15–29 years (17). Although rates of pregnancy an
among adolescents have decreased during 1991–200
pregnancy and STDs, including HIV infection, remain
public health problems among youths. In 1988, appro
two thirds of all deaths among adults aged >25 years
from cardiovascular disease (41%) and cancer (23%)
2008, the percentage of deaths among persons in thi
resulting from cardiovascular disease had decreased
the percentage resulting from cancer remained at 23
These serial reviews indicate that virtually all b
contributing to the leading causes of morbidity and m
can be placed into six priority health-risk behavior ca
1) behaviors that contribute to unintentional injur
violence; 2) sexual behaviors that contribute to HIV in
other STDs, and unintended pregnancy; 3) tobacc
4) alcohol and other drug use; 5) unhealthy dietary be
and 6) physical inactivity. These behaviors frequen
interrelated and often are established during childhoo
adolescence and extend into adulthood.
In 1989, CDC asked each of the federal agencies res
for improving or monitoring the incidence and prevale
behavioral risks in each of the six categories to appoi
to serve on a YRBSS steering committee. In August 19
and steering committee members convened a 2-day
to identify priority behaviors and devise questions to
those behaviors. For each of the six priority health-ris
categories, a panel was established that included
experts from other federal agencies, including the
Department of Education, the National Institutes of H
the Health Resources and Services Administration, an
Office of the Assistant Secretary for Health as well as
from academic institutions, survey research specialis
CDC’s National Center for Health Statistics (NCHS), an
staff from CDC’s Division of Adolescent and School He
Because YRBSS was to be implemented primarily
school-based surveys, a representative of the Society
Directors of Health, Physical Education, and Recreatio
organization of state leaders of school-based health p
also was included on each panel. Because students w
a single class period of approximately 45 minutes to c
the YRBSS questionnaire covering all six priority healt
behavior categories, each panel was asked to identify
highest priority behaviors and to recommend a limite
of questions to measure the prevalence of those
In October 1989, the first draft of the YRBSS question
was completed and was reviewed by representatives
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education agency of each state, the District of Columbia,
four U.S. territories, and 16 local education agencies then
funded by CDC. Survey research specialists from NCHS
also provided comments and suggestions. A second version
of the YRBSS questionnaire was administered during spring
1990 to a national sample of students in grades 9–12 as well
as to samples of students in 25 states and nine large urban
school districts. In addition, the second version was sent to
the Questionnaire Design Research Laboratory at NCHS
for laboratory and field testing with high school students.
NCHS staff examined student responses to the questionnaire
and recommended ways to improve reliability and validity by
clarifying the wording of questions, setting recall periods, and
identifying response options.
In October 1990, a third version of the YRBSS questionnaire
was completed. The questionnaire was similar to that used
during spring 1990 but revised to take into account data
collected by CDC and state and local education agencies
during spring 1990, information from NCHS’s laboratory
and field tests, and input from YRBSS steering committee
members and representatives of each state and the 16 local
education agencies. It also included questions for measuring
national health objectives for 2000 (5). During spring 1991,
this questionnaire was used by 26 states and 11 large urban
school districts to conduct a YRBS and by CDC to conduct
a national YRBS.
In 1991, CDC determined that biennial surveys would be
sufficient to measure health-risk behaviors among students
because behavior changes typically occur gradually. Since 1991,
YRBSs have been conducted every odd year at the national,
state, territorial, and large urban school district levels.
Questionnaire Characteristics and
Revisions
All YRBSS questionnaires are self-administered, and students
record their responses on a computer-scannable questionnaire
booklet or answer sheet. Skip patterns* are not included in any
YRBSS questionnaire to help ensure that similar amounts of
time are required to complete the questionnaire, regardless of
each student’s health-risk behavior status. This technique also
prevents students from detecting on other answer sheets and
questionnaire booklets a pattern of blank responses that might
identify the specific health-risk behaviors of other students.
In each even-numbered year between 1991 and 1997, in
consultation with the sites (states, territories, and large urban
school districts) conducting a survey, CDC revised the YRBSS
questionnaire to be used in the subsequent cycle. These revisions
* Skip patterns occur when a particular response to one question indicates to the
respondents that they should not answer one or more subsequent questions.
reflected site and national priorities. For example, in
added 10 questions to the 1993 questionnaire to mea
National Education Goal for safe, disciplined, and drug
schools (21) and to address reporting requirements fo
Department of Education’s Safe and Drug-Free Schoo
(http://www2.ed.gov/about/offices/list/osdfs/index.htm
In 1997, CDC undertook an in-depth, systematic rev
the YRBSS questionnaire. The review was motivated b
factors, including a goal for YRBSS to measure Health
2010 national health objectives, which were being de
at that time. The purpose of the review and the subse
revision process was to ensure that the questionnaire
provide the most effective assessment of the most cr
risk behaviors among youths. To guide the decision-m
process, CDC solicited input from content experts fro
and academia as well as from representatives from o
agencies; state, territorial, and local education agenc
health departments; and national organizations, foun
and institutes. On the basis of input from approximate
persons, CDC developed a proposed set of questi
revisions that were sent to all state, territorial, and lo
agencies for further input. In addition to consider
amount of support from sites for the proposed revisio
considered multiple factors in making final decisions
questionnaire, including 1) input from the original rev
2) whether the question measured a health-risk b
practiced by youths, 3) whether data on the topic wer
from other sources, 4) the relation of the behavior to
causes of morbidity and mortality among youths and
5) whether effective interventions existed that could
modify the behavior. As a result of this process, CDC
1999 YRBSS questionnaire by adding 16 new question
11 questions, and making substantial wording change
questions. For example, two questions that assessed
height and weight were added in recognition of i
concerns regarding obesity. As a result, YRBSS now g
national, state, territorial, tribal, and large urban scho
estimates of BMI calculated from self-reported data.
The 2013 YRBSS questionnaire reflects minor ch
that CDC has made to the questionnaire since 1999. D
each even-numbered year since 1999, CDC has soug
from experts both inside and outside of CDC reg
what questions should be changed, added, or deleted
changes, additions, and deletions were then placed o
sent to the YRBS coordinators at all sites, and each si
for or against each proposed change, addition, and de
CDC considered the results of this balloting process w
finalizing each questionnaire. Each cycle, CDC de
standard questionnaire that sites can use as is or mod
meet their needs. The 2013 standard YRBSS question
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includes five questions that assess demographic information;
23 questions related to unintentional injuries and violence; 10
on tobacco use; 18 on alcohol and other drug use; seven on
sexual behaviors; 16 on body weight and dietary behaviors,
including height and weight; five on physical activity; and
two on other health-related topics (i.e., asthma and sleep). The
2013 standard questionnaire and the rationale for the inclusion
of each question are available at http://www.cdc.gov/yrbss.
For the national YRBS, five to 11 additional questions are
added to the standard questionnaire each cycle. These questions
typically cover health-related topics that do not fit in the six
priority health-risk behavior categories (e.g., sun protection).
The 2013 national YRBS questionnaire also is available at
http://www.cdc.gov/yrbss.
Each cycle, CDC makes the standard questionnaire available
to sites as a computer-scannable booklet. In 2011, nine states,
one tribe, and six large urban school districts used the standard
questionnaire computer-scannable booklets. CDC sends sites
that wish to modify the standard questionnaire a print-ready
copy of their questionnaire and scannable answer sheets.
Sites can modify the standard questionnaire within certain
parameters: 1) two thirds of the questions from the standard
YRBSS questionnaire must remain unchanged; 2) additional
questions are limited to eight mutually exclusive response
options; and 3) skip patterns, grid formats, and fill-in-the
blank formats cannot be used. Furthermore, sites that modify
the standard YRBSS questionnaire and use the scannable
answer sheets must retain the height and weight questions
as questions six and seven and cannot have more than 99
questions. This numerical limit is set so the questionnaire can
be completed during a single class period by all students, even
those who might read slowly.
For sites that want to modify the standard questionnaire, CDC
also provides a list of optional questions for consideration. This
list has been available to sites since 1999 and is updated when the
standard YRBSS questionnaire is updated. It includes questions on
the current version of the national YRBS questionnaire; questions
that have been included in a previous national, state, territorial,
tribal, or large urban school district YRBS questionnaire; and
questions designed to address topics of key interest to CDC or
the sites. By using these optional questions, sites can obtain data
comparable to those from the national YRBS or from other sites
that use these questions and be assured they are adding questions
that already have been reviewed and approved by CDC. A site also
can choose to develop its own questions if none of the optional
questions addresses a topic that the site wants to measure. CDC
reviews site-developed questions to ensure that their complexity,
reading level, and formatting are appropriate for a YRBS. In 2011,
a total of 38 states, five territories, 16 large urban school districts,
and three tribes modified the standard questionnaire.
Questionnaire Reliability and Valid
CDC has conducted two test-retest reliability studie
national YRBS questionnaire, one in 1992 and one in
In the first study, the 1991 version of the questionnai
administered to a convenience sample of 1,679 stude
grades 7–12. The questionnaire was administered
occasions, 14 days apart (22). Approximately three fo
of the questions were rated as having a substantial o
reliability (kappa = 61%–100%), and no statistically s
differences were observed between the prevalence e
for the first and second times that the questionn
administered. The responses of students in grade 7 w
consistent than those of students in grades 9–12, indi
that the questionnaire is best suited for students in th
In the second study, the 1999 questionnaire was ad
to a convenience sample of 4,619 high school st
The questionnaire was administered on two occas
approximately 2 weeks apart (23). Approximately
five questions (22%) had significantly different pr
estimates for the first and second times that the ques
was administered. Ten questions (14%) had both
<61% and significantly different time-1 and time-2 pr
estimates, indicating that the reliability of these ques
questionable (23). These problematic questions were
or deleted from later versions of the questionnaire.
No study has been conducted to assess the validity
self-reported behaviors that are included on the Y
questionnaire. However, in 2003, CDC reviewed e
empiric literature to assess cognitive and situational
might affect the validity of adolescent self-reporting o
measured by the YRBSS questionnaire (24). In this re
CDC determined that, although self-reports of these t
behaviors are affected by both cognitive and situation
these factors do not threaten the validity of self-repor
type of behavior equally. In addition, each type of beh
differs in the extent to which its self-report can be va
an objective measure. For example, reports of tobacc
influenced by both cognitive and situational factors a
be validated by biochemical measures (e.g., cotinine)
of sexual behavior also can be influenced by both cog
and situational factors, but no standard exists to valid
behavior. In contrast, reports of physical activity are i
substantially by cognitive factors and to a lesser
situational ones. Such reports can be validated by me
electronic monitors (e.g., heart rate monitors). Under
the differences in factors that compromise the validit
reporting of different types of behavior can assist pol
in interpreting data and researchers in designing mea
do not compromise validity.
MMWR / March 1, 2013/ Vol. 62/ No. 16
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In 2000, CDC conducted a study to assess the validity of
the two YRBS questions on self-reported height and weight
(25). In that study, 2,965 high school students completed
the 1999 version of the YRBSS questionnaire on two
occasions approximately 2 weeks apart. After completing
the questionnaire, the students were weighed and had their
height measured. Self-reported height, weight, and BMI
calculated from these values were substantially reliable, but on
average, students in the study overreported their height by 2.7
inches and underreported their weight by 3.5 pounds, which
indicates that YRBSS probably underestimates the prevalence
of overweight and obesity in adolescent populations.
Operational Procedures
The national YRBS is conducted during February–May of
each odd-numbered year. All except a few sites also conduct
their survey during this period; certain sites conduct their
YRBS during the fall of odd-numbered years or during even-
numbered years. Separate samples and operational procedures
are used in the national survey and in the state, territorial,
tribal, and large urban school district surveys. The national
sample is not an aggregation of the state and large urban
school district surveys, and state or large urban school district
estimates cannot be obtained from the national survey.
In certain instances, a school is selected as part of the national
sample as well as a state or large urban school district sample.
Similarly, a school might be selected as part of both a state and a
large urban school district sample or a state and a tribal sample.
When a school is selected as part of two or more samples, the
field work is conducted only once to minimize the burden on
the school and eliminate duplication of efforts. The school’s
data then are incorporated into both datasets during data
processing. The coordination of these overlapping samples
is critical to the successful operation of YRBSS, and weekly
meetings are required to ensure that overlapping schools are
identified, responsibilities for recruitment and data collection
are documented, and methods for sharing data are agreed upon.
National Survey
Since 1990, the national school-based YRBS has been
conducted under contract with ICF Macro, Inc., an ICF
International Company. With CDC oversight, the contractor
is responsible for sample design and sample selection. After the
schools have been selected, the contractor also is responsible
for obtaining the appropriate state-, district-, and school-
level clearances to conduct the survey in those schools. The
contractor works with sampled schools to select classes,
schedule data collection, and obtain parental permission. In
addition, the contractor hires and trains data coll
follow a common protocol to administer the questionn
in the schools, coordinates data collection, weights th
and prepares the data for analysis.
State, Territorial, Tribal, and Large U
School District Surveys
Before 2003, CDC funded state and local education
for HIV prevention or coordinated school health progr
sites could use a portion of these cooperative agreem
to conduct a YRBS. Since the 2003 cycle, separate co
agreement funds have been made available to sites t
a survey, and since 2008, both state education and st
agencies have been eligible to apply for these fu
state must determine which agency will take respons
conducting its survey. In 2011, five state health depa
directly received separate YRBSS cooperative agreem
and health departments in an additional eight states
urban school district received funds from the educatio
to lead administration of their survey (Box 1). The rem
surveys were conducted by education agencies. Since
governments also have been eligible to apply for fund
a YRBS. Certain state and local education agencies co
YRBS with the assistance of survey contractors. In 20
of 24 state education agencies and five local educatio
hired contractors to assist with survey administration
State, territorial, and local agencies and tribal gover
funded by CDC to conduct a YRBS do so among samp
of high school students. In addition, certain sites
a separate survey among middle school students by u
modified YRBSS questionnaire designed specifically fo
reading and comprehension skills of students in this a
In 2011, a total of 16 states, three territories, one trib
large urban school districts conducted a middle schoo
(Box 1). In addition, in 2011, one state (Alaska)
large urban school districts (Memphis and San Bernar
conducted a YRBS among alternative school students
Certain states coordinate their YRBS sample with sa
for other surveys (e.g., the Youth Tobacco Survey
(http://www.cdc.gov/tobacco/data_statistics/surveys/y
htm) to reduce the burden on schools and students a
save resources. States use one of two methods of coo
sampling: multiple-school sampling and multiple-cl
sampling. In multiple-school sampling, the number of
needed for one survey is multiplied by the number of
being coordinated. This method produces nonoverl
samples of schools. The separate samples can be use
the same or separate semesters, and schools can be
that they will be asked to participate in only one
MMWR / March 1, 2013/ Vol. 62/ No. 1 7
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Recommendations and Reports
BOX 1. Sites that conducted a Youth Risk Behavior Survey (YRBS), 2011
State surveys
Alabama* Illinois Montana Rhode Island
Alaska Indiana Nebraska South Carolina§,¶
Arizona Iowa Nevada§,†† South Dakota
Arkansas Kansas New Hampshire Tennessee
California**,†† Kentucky§ New Jersey Texas
Colorado§ Louisiana New Mexico§ Utah**
Connecticut Maine§ New York Vermont
Delaware§ Maryland North Carolina§,¶ Virginia¶,**
Florida Massachusetts North Dakota§,¶ West Virginia§,¶
Georgia§,¶,** Michigan Ohio** Wisconsin
Hawaii§,¶ Mississippi§,¶ Oklahoma Wyoming§
Idaho Missouri¶,†† Pennsylvania¶,††
Territorial surveys
American Samoa
Guam§,¶
Marshall Islands
Northern Mariana Islands§
Palau§
Puerto Rico
Tribal government surveys
Cherokee Nation
Winnebago Tribe§
Large urban school district surveys
Baltimore, Maryland†† Duval County, Florida§ Orange County, Florida§
Boston, Massachusetts Houston, Texas§ Palm Beach County, Florida§
Broward County, Florida Los Angeles, California* Philadelphia, Pennsylvania*
Charlotte-Mecklenburg, North Carolina§ Memphis, Tennessee§ San Bernardino, California§
Chicago, Illinois§ Miami-Dade County, Florida§ San Diego, California
Dallas, Texas§ Milwaukee, Wisconsin§ San Francisco, California§
Detroit, Michigan New York City, New York Seattle, Washington
District of Columbia§
* Site used coordinated samples to conduct its YRBS and a Communities Putting Prevention to Work survey.
Health department received funds from the education agency to administer YRBS.
§ Site conducted a middle school YRBS.
Site used coordinated samples to conduct its YRBS and Youth Tobacco Survey.
** Health department received YRBS-specific funds directly from CDC.
†† Site did not obtain weighted survey data.
This approach is most useful in sites that have at least 50
high schools, in sites that administer the surveys in different
semesters, and in sites in which at least one of the surveys
has been considered controversial or has not been conducted
successfully. This method ensures that the success of one survey
does not depend on the success of the others. In multiple-class
sampling, multiple surveys are conducted simultaneously in
separate classes in the same sample of schools. The number
of classes needed for one survey is multiplied by the number
of surveys, and then the classes are assigned randomly to each
survey. This approach is useful in states with few high
in states where each survey has been conducted succ
in states where the coordinators of each survey are w
work together closely. Regardless of the type of coord
CDC and the sponsoring agencies work together to pl
implement the coordination. In 2011, a total of 17 sta
territory, and one tribe used coordinated samples to c
their YRBS and YTS. In addition, one state and two lar
urban school districts coordinated their YRBS sample
CPPW sample (Box 1).
MMWR / March 1, 2013/ Vol. 62/ No. 18
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Technical Assistance
Technical assistance for state, territorial, and local agencies
and tribal governments is provided by both CDC and Westat,
which has served as CDC’s technical assistance contractor since
the inception of YRBSS. CDC staff include scientists and project
officers who oversee the cooperative agreement for the sites. In
addition, each site is assigned a survey operations specialist and
a statistician from Westat.
Each YRBS site has a survey coordinator who works for a
state, territorial, or local education or health agency or tribal
government. These coordinators have variable expertise and
experience in conducting surveys. To help ensure the quality
of YRBSS, since the first cycle, CDC has provided technical
assistance to the agencies conducting the surveys. This assistance
has become increasingly comprehensive. During the first cycle,
such assistance was limited and consisted primarily of answering
questions posed by site coordinators. Since that time, technical
assistance has been expanded to cover the entire survey process
and is a continual and proactive system. CDC and its technical
assistance contractor provide technical assistance on survey
planning, sample selection, questionnaire modification, survey
administration, obtaining parental permission, data processing,
weighting, report generation, and dissemination of results. Sites
are responsible for administering the surveys; the role of CDC
and its technical assistance contractor is to help ensure that survey
administration runs smoothly and yields sufficient response rates
and high-quality data.
Technical Assistance Tools
Westat has worked with CDC to develop tools for providing
technical assistance. These tools include instructional materials,
communication tools, and specialized software.
Instructional Materials
CDC publishes the Handbook for Conducting Youth Risk
Behavior Surveys (26), a comprehensive guide that is revised
each cycle on the basis of feedback from sites and questions
that arose during the preceding cycle. The 2013 version of the
Handbook contains 107 pages spanning eight chapters and
also includes nine appendices (Box 2). As a supplement to the
Handbook, in 2008 and 2010, CDC and Westat developed
two short instructional videos for sites. One video focuses on
scientifically selecting classes, and the other describes how to
prepare the data and documentation for processing. Each video
has step-by-step instructions for routine tasks. These videos use
animation to make the information engaging. The videos are
designed to provide an overview of these tasks at the beginning
of a cycle and to serve as a resource for survey coordinators to
use as they prepare to carry out each task.
Communication Tools
A monthly electronic newsletter is sent to all su
coordinators via e-mail. Each one-page newsletter
on a part of the survey process (e.g., sampling, quest
modification, or follow-up). Topics are selected to coin
the typical survey timeline. The brief newsletters prov
or reminders designed to help sites conduct successf
The password-protected Survey Technical Assista
Website, which CDC and Westat launched in 1999, is
by survey coordinators to request materials (e.g., que
booklets and answer sheets), download references
supporting documents (e.g., the Handbook and sa
parental permission forms), and check the status of t
(e.g., what processing steps already have been c
Survey coordinators also can use the website to acce
information for CDC and technical assistance contrac
and send e-mail messages to request further assistan
the 2011 cycle, the website received 812 visits from
survey sites. The website also provides reports to sup
management. For example, CDC and Westat use the
to track when questionnaires are received from each
to check the status of data processing.
Survey coordinators can access peer-to-peer tec
assistance through a YRBSS listserv that was establis
2009 by the South Carolina Department of Education
listserv has 79 members, including survey coordinato
staff from CDC, Westat, and ICF Macro. CDC staff mon
the listserv to provide clarifications when needed. On
15 messages are posted to the listserv each month. T
common topics discussed are survey administratio
techniques for obtaining parental permission), questio
modification, dissemination of results, and the use
incentives. Members also have used the listserv to co
meetings or with others in their region.
Specialized Software
To provide technical assistance with sample sele
1989, CDC and Westat developed PCSample, a specia
software program that draws two-stage cluster sa
schools and classes within sampled schools for e
CDC and Westat use PCSample to select YRBS sam
efficiently. Schools are selected with probability propo
to school enrollment size, and classes are selected ra
When PCSample was developed, no commercially ava
software program was available for this purpose, and
remains the only example of this type of program. Alt
PCSample was developed specifically for YRBSS, it
used for other school-based surveys (e.g., YTS, Globa
and Global YRBS).
MMWR / March 1, 2013/ Vol. 62/ No. 1 9
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BOX 2. Handbook for Conducting Youth Risk Behavior Surveys
(YRBS) table of contents
Chapters
Planning your YRBS
Modifying questionnaires
Obtaining clearance
Sampling schools and classes
Obtaining parental permission
Administering surveys
Preparing data for analysis
Reporting survey results
Appendices
2013 YRBS questionnaires
Item rationale
Bibliography
Letters of support
Questions and answers
Clearance strategies
Selecting classes
Parental permission
Survey TA users’ guide
PCSample requires an updated sampling frame, which is a list
of schools in the site’s jurisdiction that also includes the number
of students in each school enrolled in grades 9–12. If the state,
territorial, or local agency or tribal government cannot provide
the sampling frame, the technical assistance contractor provides
the frame used previously or one created using the Common Core
of Data from the National Center for Education Statistics (27).
The survey coordinator then must update the sampling frame
by deleting closed schools, adding newly opened schools, and
providing updated enrollment numbers. PCSample also requires
information on sampling parameters (e.g., expected school and
student response rates, attendance rates, and desired sample size).
This information is provided by the survey coordinator, with
assistance from CDC and its technical assistance contractor, via
a sampling parameter worksheet. The sampling parameters are
used to balance the need to select a sample that is large enough
to generate precise estimates but small enough so that the site’s
resources are not overtaxed and schools and students are not
burdened unnecessarily.
PCSample generates two types of forms: school-level forms
for each school in the sample and a classroom-level form for
each school that is reproduced later for each sampled classroom
in that school. The school-level form contains unique random
numbers calculated by using a sampling interval based on
the size of the school and the desired sample size; the survey
coordinator uses these numbers to select classes randomly in
participating schools. The survey coordinator comp
school-level form for each sampled school and a class
level form for each sampled classroom. The informati
these forms provides a record of the sampling an
administration process and is used to weight the data
To help monitor site progress, the technical ass
contractor provides each site with a Microsoft Excel (
tracking form for recording information on scheduling
and school and student participation. Before developm
the tracking form in 2011, CDC and Westat contacted
regularly during data collection to check whether sch
been cleared and scheduled for survey administration
sites used paper tracking forms or created electronic
help them monitor their progress, but this recordkeep
not done in a systematic or consistent fashion. The tr
form now in use in all sites is a spreadsheet that cont
of the schools selected for the survey, along with colu
documenting the date the school agrees to participat
for survey administration, the date the survey is confi
as completed, and student participation informatio
spreadsheet is programmed to calculate the school, s
and overall response rates automatically as new infor
is added. Sites are required to send the tracking form
technical assistance contractor regularly to aid troubl
and technical assistance.
Technical Assistance Modes
In addition to the tools developed to help sites
successful surveys, a key part of technical assista
one-on-one guidance provided to sites. This individua
technical assistance is provided most commonly t
toll-free telephone number and e-mail. CDC and its te
assistance contractor also meet with survey coordina
person. Coordinators often attend national conferenc
other meetings during which appointments can be sc
with CDC or contractor staff also in attendance. Site v
by project officers also provide opportunities for prov
site-specific technical assistance. Every conversation
any personnel at a site and CDC or its technical assist
contractor, whether in person, through e-mail, or
telephone, is logged into the Survey Technical As
Website. This enables all technical assistance staff m
working with the site to see in real time what questio
been asked and what information has been shared. D
2011 cycle (July 2010–July 2012), 5,279 contacts wer
between sites and Westat or CDC. The number of con
site during this period ranged from three to 125 (med
Approximately 36% of these requests were of a gene
(e.g., how to obtain YRBSS-related materials), 22%
related to sampling, 16% to questionnaire admini
MMWR / March 1, 2013/ Vol. 62/ No. 110
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Recommendations and Reports
7% each to clearance and questionnaire modification, 6%
to weighting, 3% to reports, and 3% to other concerns (e.g.,
scanning and data processing).
A critical aspect of technical assistance is the 2-day in-person
training sessions that CDC and Westat have provided for sites
since 1992. These sessions are conducted during August of every
even-numbered year in preparation for YRBSS data collection in
the odd-numbered year. CDC invites survey coordinators and
contractors who either are new or are from sites that have not
conducted a YRBS successfully to attend the training. The content
of the training is based on the YRBS Handbook (26) and covers
all aspects of the survey process, including planning the survey,
modifying questionnaires, obtaining clearance, selecting schools
and classes, obtaining parental permission, administering surveys,
and preparing data for analysis. The training comprises both
lectures and hands-on skill-building activities and is designed by
persons with expertise in adult learning principles. In addition to
the Handbook, participants receive a training manual containing
practice exercises and supplemental resources to help them
conduct successful surveys. In addition, intensive, one-on-one
technical assistance meetings are available at the training for sites
that want to discuss detailed questionnaire or sampling issues.
In 2012, YRBS coordinators and contractors from 29 sites
participated in the training.
Sampling, Weighting, and
Response Rates
State, Territorial, Tribal, and Large Urban
School District Surveys
Each state, territorial, tribal, and large urban school district
YRBS employs a two-stage, cluster sample design to produce
a representative sample of students in grades 9–12 in its
jurisdiction. Samples are selected using PCSample. In 2011,
Ohio and South Dakota included both public and private
schools in their sampling frames; all other states included
only public schools. Each large urban school district sample
included only schools in the funded school district (e.g., San
Diego Unified School District) rather than in the entire area
(e.g., greater San Diego County). In the first sampling stage,
in all except a few sites, schools are selected with probability
proportional to school enrollment size. In the second sampling
stage, intact classes of a required subject or intact classes during
a required period (e.g., second period) are selected randomly. All
students in sampled classes are eligible to participate. In certain
sites, these procedures are modified to meet the individual needs
of the sites. For example, in a given site, all schools, rather than
a sample of schools, might be selected to participate.
Those surveys that have a sample selected acc
the protocol described above, appropriate documenta
school and classroom selection, and an overall respon
of ≥60% are weighted. These three criteria are used
that the data are representative of students in grades
that jurisdiction. The overall response rate is calcu
multiplying the school response rate by the student r
rate. A weight is applied to each student record to ad
student nonresponse and the distribution of students
sex, and race/ethnicity in each jurisdiction. Therefore
estimates are representative of all students in grades
each jurisdiction.
Surveys that do not have an overall response rate o
appropriate documentation are not weighted. Unweig
represent only the students participating in the surve
1991, both the number of participating sites and the
and percentage of weighted sites have increased (Ta
2011, a total of 43 states, five territories, 21 large urb
districts, and two tribal governments had weighted da
states and one large urban school district had un
data (Box 1). In 2011, in sites with weighted data, the
sample sizes ranged from 1,147 to 13,201 (median: 2
the state surveys, from 1,013 to 11,570 (median: 1,7
the large urban school district surveys, and from 476
(median: 1,634) for the territorial surveys. Studen
sizes were 91 and 1,480 for the two tribal surveys. Am
the state surveys, school response rates ranged from
100%, student response rates ranged from 60% to 88
overall response rates ranged from 60% to 84%. Amo
large urban school district surveys, school response r
from 84% to 100%, student response rates ranged fro
to 86%, and overall response rates ranged from 61%
Among the territorial surveys, school response rates r
from 97% to 100%, student response rates ranged fro
to 85%, and overall response rates ranged from 75%
Among the tribal surveys, school response rates were
100%, student response rates were 77% and 83%, an
response rates were 65% and 77%.
National Survey
The national YRBS uses a three-stage, cluster samp
to obtain a nationally representative sample of U.S. s
grades 9–12. The target population comprises all pub
private school students in grades 9–12 in the 50 state
the District of Columbia. U.S. territories are not includ
the sampling frame. The national YRBS sample is des
to produce estimates that are accurate within ±5% a
confidence level. Overall estimates as well as est
sex, grade, race/ethnicity, grade by sex, and race
MMWR / March 1, 2013/ Vol. 62/ No. 1 11
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