Using 3 Health Surveys to Compare Multilevel Models for Small Area Estimation for Chronic Diseases and Health Behaviors

Background We used a multilevel regression and poststratification approach to generate estimates of health-related outcomes using Behavioral Risk Factor Surveillance System 2013 (BRFSS) data for the 500 US cities. We conducted an empirical study to investigate whether the approach is robust using different health surveys. Methods We constructed a multilevel logistic model with individual-level age, sex, and race/ethnicity as predictors (Model I), and sequentially added educational attainment (Model II) and area-level poverty (Model III) for 5 health-related outcomes using the nationwide BRFSS, the Massachusetts BRFSS 2013 (a state subset of nationwide BRFSS), and the Boston BRFSS 2010/2013 (an independent survey), respectively. We applied each model to the Boston population (2010 Census) to predict each outcome in Boston and compared each with corresponding Boston BRFSS direct estimates. Results Using Model I for the nationwide BRFSS, estimates of diabetes, high blood pressure, physical inactivity, and binge drinking fell within the 95% confidence interval of corresponding Boston BRFSS direct estimates. Adding educational attainment and county-level poverty (Models II and III) further improved their accuracy, particularly for current smoking (the model-based estimate was 15.2% by Model I and 18.1% by Model II). The estimates based on state BRFSS and Boston BRFSS models were similar to those based on the nationwide BRFSS, but area-level poverty did not improve the estimates significantly. Conclusion The estimates of health-related outcomes were similar using different health surveys. Model specification could vary by surveys with different geographic coverage.