largely attributed to late stage at diagnosis (Chevarley and White, 1997). Increasing levels of participation in screening programs by groups at high risk of death from cancers can lead to earlier detection, greater treatment efficacy, and better survival rates.

Behavioral Risk Factor Surveillance: Existing Mechanisms

The purpose of the Behavioral Risk Factor Surveillance Survey (BRFSS) is to collect data regarding the prevalence of behavioral risk factors among U.S. adults to be used to establish and monitor progress toward public health objectives. The data are collected by telephone by using responses to surveys that are administered by the states in coordination with the CDC (Sugarman et al., 1992). Use of telephone responses limits the generalizability of the results of BRFSS, since many low-income households lack telephone service. For example, only approximately a third of all households on northern Arizona reservations (e.g., that of the Hopi tribe) have telephones (National Cancer Institute, 1994). Special studies with the results of BRFSS have been conducted among Native Americans in attempts to address some of these concerns. Oklahoma developed its own Native-American Supplement, which was administered in 1994 (Smith et al., 1995). Additionally, BRFSS data from 1,055 Native American respondents obtained from 1985 to 1988 were evaluated for their usefulness in monitoring the progress of this population toward achieving year 2000 national health objectives (Sugarman et al., 1992). The conclusion of that report was that BRFSS data may be useful in the surveillance of Native Americans if they are combined with community-specific household-based surveys. Similar conclusions may be appropriate for other distinct geographic, cultural, and ethnic groups. For example, in several counties of eastern Kentucky, 20 percent or more of the households do not have telephones (U.S. Bureau of Census, 1997b).

National Health and Nutrition Examination Survey

In 1967, the U.S. Congress mandated that appropriate federal and state officials conduct a comprehensive survey in response to concerns about hunger, malnutrition, and health. In 1969, the initial 10-state effort was expanded by President Richard Nixon to cover the entire United States. NCHS added a nutritional assessment component to health status measurements already being collected in the National Health Examination Survey, and the first National Health and Nutrition Examination Survey (NHANES) was conducted between 1971 and 1974.

The purpose of NHANES is to periodically assess the nutritional and



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