Data Source

"The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based random digit dial (RDD) telephone survey conducted annually in all states, the District of Columbia, and U.S. territories. Data obtained from the BRFSS are representative of each state’s total non-institutionalized population over 18 years of age and have included more than 400,000 annual respondents with landline telephones or cellphones since 2011. Data are weighted using iterative proportional fitting (also called "raking") methods to reflect population distributions. For the County Health Rankings, data from the BRFSS are used to measure various health behaviors and health-related quality of life (HRQoL) indicators. HRQoL measures are age-adjusted to the 2000 U.S. standard population."

Measure Methods

• "Poor Mental Health Days is an average: Poor Mental Health Days measures the average number of mentally unhealthy days reported in past 30 days."

• "Poor Mental Health Days estimates are age-adjusted: Age is a non-modifiable risk factor, and poor health outcomes are more likely as age increases. We report an age-adjusted rate to compare counties with differing age structures fairly."

• "The method for calculating Poor Mental Health Days has changed: Before the 2016 County Health Rankings, the CDC’s BRFSS provided the Rankings with county-level estimates constructed from seven years of responses from participants who used a landline phone. Beginning with the 2016 Rankings, the CDC provided single-year modeled county-level estimates that included landline and cell phone users. Beginning with the 2021 Rankings, the CDC has updated its modeling procedure for producing small-area estimates. All of these changes were implemented to provide users with the most accurate estimates of health in their community."

• "Poor Mental Health Days estimates are created using statistical modeling: Statistical modeling is used to obtain more informed and reliable estimates than survey data alone can provide. Modeling generates more stable estimates for places with small numbers of residents or survey responses. The Poor Mental Health Days estimates are produced from one year of survey data and are created using complex statistical modeling. Please see their methodology for more technical information on PLACES modeling using BRFSS data. There are also drawbacks to using modeled data. The smaller the county population or sample size, the more the estimates are derived from the model and the less they are based on survey responses. Models make assumptions about statistical relationships that may not hold in all cases. Finally, there is no perfect model, and each model generally has limitations specific to their methods."

• "Numerator: The numerator is the number of days respondents reported to the question "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?"

• "Denominator: The denominator is the county's total number of adult respondents."

• "Can This Measure Be Used to Track Progress?  This measure could only be used to track progress after considering its substantial limitations. Methodological changes in the Behavioral Risk Factor Surveillance System, discussed above and implemented in the 2016 Rankings, make comparisons with estimates difficult before that release year. Additional changes to the methodology to create the estimates were implemented in the 2021 Rankings, making comparisons with estimates before that release year difficult. Finally, current estimates are produced using sophisticated modeling techniques, making them difficult to track progress, especially in small geographic areas. Modeled estimates have specific drawbacks about their usefulness in tracking progress in communities. Modeled data are not particularly good at incorporating the effects of local conditions, such as health promotion policies or unique population characteristics, into their estimates. Counties measuring the effects of programs and policies on the data should use great caution when using modeled estimates. To better understand and validate modeled estimates, confirming this data with additional data sources at the local level is particularly valuable."

Source: Poor Mental Health Days | County Health Rankings & Roadmaps

References

• Andresen EM, Catlin TK, Wyrwich KW, Jackson-Thompson J. Retest reliability of surveillance questions on health related quality of life. Journal of Epidemiology & Community Health. 2003; 57:339-343.

• Jia H, Muennig P, Lubetkin EI, Gold MR. Predicting geographical variations in behavioural risk factors: An analysis of physical and mental healthy days. Journal of Epidemiology & Community Health. 2004; 58:150-155.

• Bombak AE. Self-rated health and public health: a critical perspective. Frontiers in Public Health. 2013; 1:15. 

• PLACES Project. Centers for Disease Control and Prevention. Accessed March 9, 2021. https://www.cdc.gov/places.