final report final druckversion - europa · 2012-01-06 · 1 contributors to the project...

Eurostat Grant 10501.2009.007‐2009.890

Improvement of the European Health Interview

Survey (EHIS) modules on alcohol consumption,

physical activity and mental health

Final Report

Berlin, 26.09.2011

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Contributors to the project (alphabetical order)

Coordinator of the project: 1 Robert Koch Institute (RKI) – Germany

Markus Busch, Jonas Finger, Ulfert Hapke, Carmen Koschollek, Anna Lena Kratz, Cornelia Lange,

Sigward von Laue, Elena von der Lippe, Benjamin Mildner, Stephan Müters, Claudia Santos‐Hövener

Project coordinator: Cornelia Lange

Co‐partners: 2 Scientific Institute of Public Health (IPH) – Belgium

Lydia Gisle, Hélène Mimilidis, Jean Tafforeau

Co‐partner coordinator: Lydia Gisle

3 National Institute for Health Development (NIHD) – Estonia

Urve Heiter, Kati Karelson, Elin‐Külliki Kruusmaa, Helle‐Mai Loit, Ardo Matsi, Leila Oja, Angela

Poolakese, Mare Ruuge, Ingrid Valdmaa

Co‐partner coordinator: Elin‐Külliki Kruusmaa

Sub‐contractor:

National Centre for Social Research (NatCen) – United Kingdom

Meera Balarajan, Michelle Gray

Authors of the final report:

Jonas Finger1, Lydia Gisle2, Hélène Mimilidis2, Elin‐Külliki Kruusmaa3, Ardo Matsi3, Leila Oja3, Mare

Ruuge3, Anna Lena Kratz1, Cornelia Lange1

Proofreader:

R. W. Culverhouse

The project is financially supported by:

The European Commission (Eurostat) Grant agreement n° 10501.2099.007‐2009.890

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Acknowledgements:

We are grateful to the following institutions, working groups and experts for contributing at the

revision process of the EHIS modules:

Eurostat – Unit F‐5 “Health and Food Safety, Crime”

EHIS Core Group members

EHIS Technical Group members

Mental health

Maris Taube, MD (Department of Public Health, Latvia), Dr Carlos G. Forero (Institut Municipal

d'Investigació Mèdica, Spain)

Physical activity

Prof. Michael Sjöström (Karolinska Institute, Sweden), Dr Minna Aittasalo (UKK, Finnland)

Alcohol consumption

Jacek Moskalewicz (Institute of Psychiatry and Neurology, Poland), Paul Lemmens (University of

Maastricht, Netherlands), Gerhard Gmel (Swiss Institute for the Prevention of Alcohol and Drug

Problems –SFA‐ISPA, Switzerland), Silvia Ghirini (Istituto superiore di sanita – ISS, Italy), Peter

Allebeck (Karolinska Institutet, Sweden), Kersti Pärna (University of Tartu, Estonia), Dr Pamela

Campanelli (“The Survey Coach: Survey Research, Training, and Consultancy”)

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List of contents:

1 INTRODUCTION.......................................................................................................................... 13

2 DESCRIPTION OF THE PROCESS FOLLOWED FOR IMPROVING SELECTED EHIS QUESTIONS .......... 17

2.1 Mental health........................................................................................................... 17 2.1.1 Definition of concepts ...................................................................................... 17 2.1.2 Review of experience ....................................................................................... 17 2.1.3 International projects....................................................................................... 18 2.1.4 Review of scientific literature .......................................................................... 19 2.1.5 Consultation of experts .................................................................................... 20 2.1.6 Results of the EHIS workshop .......................................................................... 21 2.1.7 Justification and final instrument for cognitive testing ................................... 22

2.2 Physical activity ........................................................................................................ 25 2.2.1 Definition of the concepts................................................................................ 25 2.2.2 Review of experience ....................................................................................... 26 2.2.3 International projects....................................................................................... 27 2.2.4 Review of scientific literature .......................................................................... 28 2.2.5 Consultation of experts .................................................................................... 29 2.2.6 Results of the EHIS workshop .......................................................................... 30 2.2.7 Justification and final instrument for cognitive testing ................................... 30

2.3 Alcohol consumption ............................................................................................... 32 2.3.1 Definition of concepts ...................................................................................... 32 2.3.2 Review of experience ....................................................................................... 34 2.3.3 International projects....................................................................................... 36 2.3.4 Review of scientific literature .......................................................................... 37 2.3.5 Consultation of experts .................................................................................... 41 2.3.6 Results of the EHIS workshop .......................................................................... 44 2.3.7 Justification and final instrument for cognitive testing ................................... 44

3 INTERNATIONALISATION THROUGH TRANSLATION.................................................................... 49

3.1 Introduction (protocol used).................................................................................... 49 3.2 Mental health........................................................................................................... 52 3.2.1 Translation cards, minutes and problems encountered.................................. 52

3.3 Physical activity ........................................................................................................ 61 3.3.1 Translation cards, minutes and problems encountered.................................. 61

3.4 Alcohol consumption ............................................................................................... 80 3.4.1 Translation cards, minutes and problems encountered.................................. 80

4 PARALLEL COGNITIVE TESTING, ROUND I ................................................................................... 97

4.1 Introduction cognitive testing................................................................................ 101 4.1.1 Background..................................................................................................... 101 4.1.2 Objectives....................................................................................................... 101 4.1.3 Methods ......................................................................................................... 102

4.2 Overall analysis....................................................................................................... 104 4.2.1 Mental health module.................................................................................... 104

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4.2.2 Physical activity module................................................................................. 112 4.2.3 Alcohol consumption module ........................................................................ 117

4.3 Recommendations ................................................................................................. 119 4.3.1 Mental health................................................................................................. 119 4.3.2 Physical activity .............................................................................................. 120 4.3.3 Alcohol consumption ..................................................................................... 121 4.3.4 Overall recommendations.............................................................................. 122

4.4 Overall conclusion .................................................................................................. 122

5 PARALLEL COGNITIVE TESTING, ROUND II ................................................................................ 125

5.1 Development of a new physical activity proposal after cognitive testing............. 127 5.1.1 Background..................................................................................................... 127 5.1.2 Presentation of instrument............................................................................ 128 5.1.3 Description of the process ............................................................................. 130 5.1.4 Justification of instrument ............................................................................. 133

5.2 Introduction to cognitive testing round II .............................................................. 137 5.2.1 Background..................................................................................................... 137 5.2.2 Objectives....................................................................................................... 138 5.2.3 Methods ......................................................................................................... 138 5.2.4 Overall analysis............................................................................................... 141 5.2.5 Recommendations ......................................................................................... 145 5.2.6 Conclusions..................................................................................................... 146

6 ADAPTATION OF INSTRUMENTS AFTER COGNITIVE TESTING AND TRANSLATION PROTOCOLS OF REVISED INSTRUMENTS........................................................................................... 147

6.1 Adaptation of instruments after cognitive testing ................................................ 147 6.1.1 Mental health................................................................................................. 147 6.1.2 Physical activity .............................................................................................. 148 6.1.3 Alcohol consumption ..................................................................................... 152

6.2 Internationalisation through translation of revised instruments .......................... 158 6.2.1 Physical activity .............................................................................................. 159 6.2.2 Alcohol consumption ..................................................................................... 168

7 PARALLEL FIELD TESTING.......................................................................................................... 175

7.1 Field test standard operating procedures.............................................................. 181 7.1.1 Introduction.................................................................................................... 181 7.1.2 Objective ........................................................................................................ 182 7.1.3 Methods ......................................................................................................... 182 7.1.4 Sampling ......................................................................................................... 183 7.1.5 Data‐collection procedures............................................................................ 186 7.1.6 Data flow and management........................................................................... 191 7.1.7 Results and reporting ..................................................................................... 192

7.2 Results: Sample description and country reports.................................................. 193 7.2.1 Description of the pooled sample characteristics.......................................... 193 7.2.2 Mental health report ‐ RKI, Germany............................................................. 195 7.2.3 Physical activity report – RKI, Germany in coorperation with NIHD, Estonia 202 7.2.4 Alcohol consumption report – IPH, Belgium.................................................. 216

7.3 Analysis of the Debriefing Questions by Country .................................................. 230

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7.3.1 Analysis of the debriefing questions – RKI, Germany .................................... 230 7.3.2 Analysis of debriefing questions – NIHD, Estonia .......................................... 240 7.3.3 Analysis of debriefing questions: IPH, Belgium.............................................. 255

8 ADAPTATION OF INSTRUMENTS AFTER FIELD TESTING AND TRANSLATION PROTOCOLS OF REVISED INSTRUMENTS.................................................................................................................... 294

8.1 Adaptation of instruments after field testing ........................................................ 294 8.1.1 Mental health................................................................................................. 294 8.1.2 Physical activity .............................................................................................. 294 8.1.3 Alcohol consumption ..................................................................................... 301

8.2 Internationalisation through translation of revised instruments .......................... 304 8.2.1 Physical activity .............................................................................................. 304 8.2.2 Alcohol consumption ..................................................................................... 315

9 INSTRUMENT MANUALS .......................................................................................................... 322

9.1 Mental health......................................................................................................... 322 9.1.1 Background..................................................................................................... 322 9.1.2 Patient Health Questionnaire ‐ 8‐item depression screener (PHQ‐8) ........... 323 9.1.3 PHQ‐8 questionnaire (English version) .......................................................... 323 9.1.4 Conceptual card and interviewer’s instructions ............................................ 325 9.1.5 Data processing .............................................................................................. 326 9.1.6 Linguistic versions including show cards........................................................ 331 9.1.7 List of outcome indicators.............................................................................. 337 9.1.8 Mental Health Index and Energy and Vitality Index (MHI‐5/EVI) .................. 338 9.1.9 Oslo‐3 Social Support Scale (OSS‐3) ............................................................... 338

9.2 Physical activity ...................................................................................................... 342 9.2.1 Background..................................................................................................... 342 9.2.2 Questionnaire (English version) ..................................................................... 343 9.2.3 Show cards ..................................................................................................... 345 9.2.4 Conceptual cards and explanations for the interviewers .............................. 346 9.2.5 Data processing .............................................................................................. 354 9.2.6 List of corresponding indicators..................................................................... 362 9.2.7 Linguistic versions including show cards........................................................ 363

9.3 Alcohol consumption ............................................................................................. 376 9.3.1 Linguistic versions including show cards........................................................ 381 9.3.2 Guidelines and instructions to investigators.................................................. 392 9.3.3 Conceptual cards............................................................................................ 400 9.3.4 Data processing .............................................................................................. 404 9.3.5 List of corresponding indicators..................................................................... 412

10 EXECUTIVE SUMMARY ............................................................................................................. 414

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List of tables:

Table 1: Percentages of expert ratings of the SF‐36v2 scales (review of experience: EHIS round 1) .................................................................................................................................... 18 Table 2: Qualitative analysis of comments on mental health.................................................. 18 Table 3: List of instruments with pros and cons ...................................................................... 19 Table 4: Revised recommendation on the mental health module of EHIS.............................. 23 Table 5: Comparison of IPAQ‐SF and GPAQ............................................................................. 28 Table 6: Compilation of a specific physical activity proposal................................................... 30 Table 7: Alcohol use and misuse, potential concepts for investigation discussed during the meeting and outcomes in terms of indicators to be used....................................................... 41 Table 8: Alcohol consumption, approaches to measurement (Greenfield & Kerr, 2008; Sobell & Sobell, 2004; Rehm 1998).......................................................................................................... 43 Table 9: Problems encountered in the translation process and corresponding solutions for PHQ‐9, Estonia.......................................................................................................................... 55 Table 10: Problems encountered in the translation process and corresponding solutions for MHI‐5/EVI, Estonia ................................................................................................................... 56 Table 11: Problems encountered in the translation process and corresponding solutions for PHQ‐9 and MHI‐5/EVI, Belgium ............................................................................................... 58 Table 12: Problems encountered in the translation process and accordant solutions for IPAQ, German..................................................................................................................................... 68 Table 13: Problems encountered in the translation process and accordant solutions for NHIS, Germany................................................................................................................................... 70 Table 14: Problems encountered in the translation process and corresponding solutions for IPAQ, Estonia ............................................................................................................................ 71 Table 15: Problems encountered in the translation process and corresponding solutions for NHIS, Estonia ............................................................................................................................ 73 Table 16: Problems encountered in the translation process and corresponding solutions for NHIS and IPAQ, Belgium........................................................................................................... 74 Table 17: Problems encountered in the translation process and corresponding solutions for AL, Germany ............................................................................................................................. 88 Table 18: Problems encountered in the translation process and corresponding solutions for AL, Estonia ................................................................................................................................ 89 Table 19: Problems encountered in the translation process and corresponding solutions for AL, Belgium............................................................................................................................... 91 Table 20: Sampling frame Cognitive testing (BE, EE, DE)....................................................... 102 Table 21: Cognitive testing results: Preference for NHIS and IPAQ....................................... 113 Table 22: Similarity, simplicity and conclusions of cognitive testing of Physical Activity (BE, EE, DE, UK).............................................................................................................................. 115 Table 23: Characteristics of Estonian respondents participating in the cognitive testing (round 2) study....................................................................................................................... 139 Table 24: Characteristics of German respondents participating in the cognitive testing (round 2) study................................................................................................................................... 139 Table 25: Problems encountered in the translation process and corresponding solutions for PA after CT, Germany............................................................................................................. 159 Table 26: Problems encountered in the translation process and corresponding solutions for PA after CT, Estonia ................................................................................................................ 162 Table 27: Problems encountered in the translation process and corresponding solutions for PA after CT, Belgium............................................................................................................... 165

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Table 28: Problems encountered in the translation process and corresponding solutions for AL after CT, Germany ............................................................................................................. 168 Table 29: Problems encountered in the translation process and corresponding solutions for AL after CT, Estonia ................................................................................................................ 170 Table 30: Problems encountered in the translation process and accordant solutions for AL after CT, Belgium.................................................................................................................... 172 Table 31: Sample roster for field testing ‐ Belgium............................................................... 183 Table 32: Sample roster for field testing per country/mode................................................. 183 Table 33: Sections of the 'health status' and 'health determinants' modules included in the PAPI field test questionnaires ................................................................................................ 187 Table 34: Characteristics of the field test sample by country (mode)................................... 194 Table 35: Depression prevalence according to PHQ‐8........................................................... 196 Table 36: Depression severity according to PHQ‐8................................................................ 199 Table 37: Consistency between PHQ‐8 mental health score and self‐perceived health....... 200 Table 38: Descriptive results of work‐related physical activity according to key variables .. 203 Table 39: Descriptive results of transportation physical activity according to selected key variables ................................................................................................................................. 205 Table 40: Quintile boundaries of walking minutes per week according by country ............. 206 Table 41: Quintile boundaries of bicycling minutes per week according by country............ 207 Table 42: Quintile boundaries of overall transportation MET minutes per week according by country ................................................................................................................................... 207 Table 43: Descriptive results of leisure‐time physical activity according to selected key variables ................................................................................................................................. 208 Table 44: Quintile boundaries of health‐enhancing physical activity minutes per week according by country.............................................................................................................. 210 Table 45: Compliance with WHO physical activity recommendation according to selected key variables ................................................................................................................................. 210 Table 46: Conversion table for number of drinks: variable values into amount of drinks .... 217 Table 47: Distribution of respondents according to frequency of drinking alcohol by selected characteristics – pooled analysis Belgium, Germany, Estonia ............................................... 220 Table 48: Mean quantity of alcohol (in no. of glasses) consumed on weekdays and on weekend days, mean total consumption over the whole week and hazardous consumption according to ECHI standards (> 2 drinks/day in women or > 4 drinks/day in men) among weekly drinkers by selected characteristics ‐ pooled analysis Belgium, Germany, Estonia .. 221 Table 49: Distribution of respondents according to frequency of risky single‐occasion drinking by selected characteristics – pooled analysis Belgium, Germany, Estonia.............. 222 Table 50: Distribution of respondents according to their drinking frequency, pooled samples................................................................................................................................................ 223 Table 51: Distribution of respondents according to their RSOD frequency, pooled samples226 Table 52: Distribution of respondents according to the number of drinks consumed on a weekday, pooled samples ...................................................................................................... 228 Table 53: Distribution of respondents according to the number of drinks consumed on a weekend day, pooled samples............................................................................................... 228 Table 54: Quantitative analysis of the feedback question ‘simplicity in wording’ for the alcohol module....................................................................................................................... 230 Table 55: Quantitative analysis of the feedback question ‘simplicity of estimating alcohol consumption’ in the alcohol module ..................................................................................... 231 Table 56: Quantitative analysis of the feedback question ‘representative answer categories’ in the alcohol module............................................................................................................. 232

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Table 57: Quantitative analysis of the feedback question ‘use of show card alcoholic standard drink’’ in the alcohol module .................................................................................. 233 Table 58: Quantitative analysis of the feedback question ‘simplicity of wording’ in the PHQ‐8 module ................................................................................................................................... 234 Table 59: Quantitative analysis of the feedback question ‘simplicity of keeping the reference period in mind’ in the PHQ‐8 module .................................................................................... 235 Table 60: Quantitative analysis of the feedback question ‘representativeness of answer categories’ in the PHQ‐8 module ........................................................................................... 235 Table 61: Quantitative analysis of the feedback question ‘simplicity of wording’ in the physical activity module......................................................................................................... 236 Table 62: Quantitative analysis of the feedback question ‘simplicity of calculating the time spent on physical activities’ ................................................................................................... 237 Table 63: Quantitative analysis of the feedback question ‘representativeness of answer categories’ in the physical activity module ............................................................................ 237 Table 64: Quantitative analysis of the feedback question ‘simplicity of use of the show cards’ in the physical activity module............................................................................................... 238 Table 65: Summary table: Recommendations for further improvements in the modules under revision after field testing............................................................................................ 239 Table 66: Problems encountered in the translation process and corresponding solutions for PA after FT, Germany ............................................................................................................. 304 Table 67: Problems encountered in the translation process and corresponding solutions for PA after FT, Estonia ................................................................................................................ 305 Table 68: Problems encountered in the translation process and corresponding solutions for PA after FT, Belgium............................................................................................................... 308 Table 69: Problems encountered in the translation process and corresponding solutions for AL after FT, Germany.............................................................................................................. 315 Table 70: Problems encountered in the translation process and corresponding solutions for AL after FT, Estonia................................................................................................................. 316 Table 71: Problems encountered in the translation process and corresponding solutions for AL after FT, Belgium ............................................................................................................... 317 Table 72: Recommendations on the mental health module of EHIS..................................... 322 Table 73: Instrument presentation: PHQ‐8............................................................................ 324 Table 74: Showcard: PHQ‐8.................................................................................................... 324 Table 75: Instrument presentation: MHI‐5/EVI ..................................................................... 338 Table 76: Instrument presentation: OSS‐3............................................................................. 339 Table 78: Example of correct and incorrect layout and instructions pertaining to the answer categories ............................................................................................................................... 392 Table 79: Recommendations for the telephone survey mode… ........................................... 394

List of figures:

Figure 1: Model of Alcohol Consumption, Intermediates Outcomes, and Long‐Term Consequences ‐

(Rehm et al, 2006) ................................................................................................................................. 32 Figure 2: CDC data for PHQ‐8 based on a sample of 235,067 US individuals ..................................... 197 Figure 3: Prevalence of past 12 months' drinkers by country............................................................. 216 Figure 4: Distribution of respondents (%) according to the frequency of risky single occasion drinking,

by country‐mode. ................................................................................................................................ 219

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List of countries and abbreviations:

AL Alcohol consumption LT Lithuania

AT Austria LU Luxemburg

BE Belgium LV Latvia

BG Bulgaria MH Mental health

CATI Computer‐assisted telephone interview MS Member State(s)

CC Candidate country1 MT Malta

CH Switzerland NIHD National Institute for Health

Development, Tallinn

CY Republic of Cyprus NL Netherland

CZ Czech Republic NO Norway

DE Germany PA Physical activity

DK Denmark PAPI Paper‐and‐pencil interview

EE Estonia PL Poland

EFTA European Free Trade Association2 PT Portugal

EHIS European Health Interview Survey QF Quantity – frequency (approach for

measuring alcohol consumption)

EL Greece RKI Robert Koch Institute, Berlin

ES Spain RO Romania

EU European Union RSOD Risky single occasion drinking

FI Finland SE Sweden

FR France SI Slovenia

HR Croatia SK Slovak Republic

HU Hungary SOP Standard operating procedures

IE Ireland TR Turkey

ImpEHIS Improvement of the EHIS

questionnaire project (for round 2)

UK United Kingdom

IPH (Scientific) Institute of Public Health,

Brussels

WD Weekday

IS Iceland WE Weekend day

IT Italy

1 Candidate countries: Croatia, Iceland, Macedonia and Turkey. 2 EFTA countries: Iceland, Liechtenstein, Norway, Switzerland and Liechtenstein.

1 Introduction The overall aim of the project was to reinforce the “infrastructure for the basic system on public

health statistics” (at MS and EU level), to harmonise and improve of the comparability of existing

data, and to ensure that basic concepts, definitions and classifications on health statistics will be

used for the whole area of health information. In particular, the emphasis is on the further

implementation of the European Health Interview Survey (EHIS).”

In order to prepare the second wave of the European Health Interview Survey (EHIS) (planned for

2014) and to “produce comparable data that can be achieved only by means of surveys that make

use of common instruments”, it was decided that the EHIS questionnaire was in need of a revision

process. It was suggested to that selected parts of the EHIS questionnaire should be improved which

were identified as being problematic during the first EHIS round. In order to do so and to address and

facilitate the improvement of the instrument, an 18‐month project (ImpEHIS II) was launched at the

beginning of 2010, starting on February 1, 2010. The aim was to improve the current EHIS

questionnaire, bearing in mind that sensitive questions, such as psychological well‐being or alcohol

consumption, could be interpreted and decoded differently in different member states (MSs) and

cultures. The resulting improved Health Interview Survey (HIS) is expected to become a widely

accepted instrument, able to provide comparable data on health topics in relation to the personal

characteristics of the population. The expectation is that this will better reflect the differences

between population groups in relation to certain health topics.

The main tasks to be accomplished were:

To identify problems that MSs encountered when implementing the EHIS with the different sections of the EHIS instrument;

To organise an EHIS workshop with representatives of MSs. To improve of three modules that were previously noted as being problematic, namely the

sections on mental health, physical activity and alcohol consumption; this would include the

proposal of new questions or instruments and the cognitive and pre‐testing of these;

Three research institutes participated in the ImpEHIS II project: the Scientific Institute of Public

Health (IPH) in Belgium worked on improving of the alcohol module (AL) of the EHIS, while the

National Institute for Health Development (NIHD) in Estonia focused on enhancing the physical

activity section (PA) of the EHIS. The main project coordinator was the Robert Koch Institute (RKI) in

Germany, which was in charge of improving of the mental health module (MH) of the EHIS and

reviewing of experience and the organisation of the EHIS workshop.

The present report refers in detail to the ImpEHIS work packages were not covered by the interim

report submitted to Eurostat in November 2011; i.e. work packages no. 3 (development of a revised

set of questions or choice of instrument), 4 (internationalisation through translation), 5 (parallel

cognitive testing), 6 (parallel field testing) and 7 (preparation of a final report).

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The report is correspondingly structured in several parts:

Chapter 2 is a summary of the work results from February 2010 up until November 2010 and

basically describes the steps that where undertaken in the run‐up to the EHIS workshop and the

results of the latter. For a complete description of the process followed to improve the selected EHIS

questions before the EHIS workshop, please see the interim report and corresponding annex.

Chapter 3 documents the translation process of all three modules (MH, PA and AL) from English into

three European languages according to a fixed translation protocol and based on conceptual

translation cards. Each partner institution was responsible for translation in its language, i.e. RKI into

German, IPH into French and NIHD into Estonian.

Chapter 4 describes the first round of parallel cognitive testing that was conducted in Estonia,

Belgium, Germany and the UK in order to test the three modules in four different language settings

(Estonian, French, German and English). Each partner institution was responsible for conducting the

cognitive testing in its country. The cognitive testing of the English version was carried out by a

subcontracter (NatCen) who in addition, supported the RKI in developing the standard operating

procedure. The National Institute for Health Development (NIHD) was responsible for the report on

the overall results of the four‐country cognitive testing study (chapter 4). The chapter gives an

overview on the standardised methodology (which was developed at the cordination meeting in

Berlin in January 2011) and the overall results; it also contains the conclusions and overall

recommendations. The four country reports can be found in the annex.

Chapter 5 describes of the second round of parallel cognitive testing that was conducted in Estonia

and Germany in order to test a newly‐designed setting‐specific physical activity questionnaire. The

chapter contains the presentation of the new instrument and a justification of why it was nessesary

to develop a new instrument after the cognitive testing round 1. Morever, the chapter contains

information on the standardised methodology, as well as the overall qualitative analysis of the

cognitive testing data collected in the two countries. NIHD was responsible for the overall analysis of

round 2 of the cognitive testing results. The two respective country reports can be found in the

annex.

Chapter 6 on the one hand documents the adaptations resulting from the outcomes of the two

cognitive testing rounds, i.e. changes in wording of the questions and response categories, etc. and

on the other hand it describes the translation process when adapting the linguistic country versions

according to the revised instrument versions into German, Estonian and French.

Chapter 7 is about the parallel field testing conducted in Estonia, Belgium and Germany. It describes

the aims, the standard and country‐specific pretesting procedures (design, sampling, data‐collection

instruments, planned analysis), the quantitative results obtained for each question module (AL, PA,

MH), the country reports analysing the debriefing questions of the respective module and the

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interviewer feedback, and finally, the recommendations on the final set of questions to be produced.

The Scientific Institute of Public Health (IPH) was responsible for the coordination of the

multinational field test and the composition of the overall report.

Chapter 8 on the one hand describes the adaptations conducted based on the outcomes of the field

testing, i.e. changes in the wording of the questions and response catgories, etc. On the other hand it

describes the translation process when adapting the linguistic country versions into German,

Estonian and French according to the revised instrument versions.

Chapter 9 comprises the final instrument manuals recommended for the Wave 2 EHIS Core

questionnaire. This chapter presents, the final linguistic versions of the respective instruments (AL,

PA, MH) including show cards, conceptual cards, interviewer’s instructions, guidelines for data

cleaning and algorithms for indicator construction. The chapter is structured in modules.

Chapter 10 contains an overall executive summary of the ImpEHIS II project.

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2 Description of the process followed for improving selected EHIS questions

2.1 Mental health 2.1.1 Definition of concepts

The term mental health is defined as a broad concept encompassing a positive mental health

dimension of psychological well‐being and a negative mental health dimension of psychological

distress as generic components of the mental health concept (1, 2). The negative mental health

dimension, moreover, includes a specific component on mental health problems and disorders.

Mental health problems are defined as disease outcomes such as mood disorders (depression),

anxiety, substance abuse or impulse control disorders (3, 4).

Psychological well‐being describes a sense of positive mental mood. A state of mental well‐being as a

related concept is part of the triangular definition of health according to the World Health

Organisation (1946): “Health is a state of complete physical, mental and social well‐being and not

merely the absence of disease or infirmity” (5). Since then, the concept of psychological well‐being

has grown over time with various attempts to describe mental health in a positive way (6).

Psychological distress is a subset of the negative mental health dimension and the counterpart to

psychological well‐being. Psychological distress is a non‐specific dimension of psychopathology in

terms of a perceived sense of negative mental mood. It indicates that something is wrong but has not

yet necessarily led to a diagnostic assessment: it does not necessary involve a mental illness or

require services from the mental health system.

Mental health problems, as a subset of negative mental health, comprises specifically defined

concepts of mental disorders which can be diagnosed according to diagnostic guidelines such as the

“Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV‐TR)” of the American Psychiatric

Association (7) or according to the ICD‐10 Classification of Mental and Behavioural Disorders of the

World Health Organisation (8) and assessment methods developed on the basis of these guidelines,

such as the World Health Organisation (WHO) Composite International Diagnostic Interview (CIDI)

(9).

2.1.2 Review of experience In the first EHIS round, assessing mental health with the SF‐36 subscales five‐item Mental Health

Index (MHI‐5) and Energy and Vitality Index (EVI) only in the European health status module was

generally perceived as problematic. For this reason, the Core Group members and Eurostat agreed

that the EHIS mental health module needed improvement.

When conducting the EHIS expert survey, we collected information and comments on the mental

health module of the EHIS. In the following we briefly summarise the problems and issues that

experts described. The table below shows that 43% of all respondents indicated that the current

mental health module required improvement.

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Table 1: Percentages of expert ratings of the SF‐36v2 scales (review of experience: EHIS round 1)

Item

Should be removed Should be totally changed

Should be kept with some adaptation

Total (should be removed, changed or

adapted) MHI‐5 / EVI from SF‐36v2

4% 13% 26% 43%

Member State

LT BE, MT, ES, LV

CY, GR, IE, TR, DE

The table below summarises the comments of respondents on the mental health module. The table

is divided into main categories and supporting sub‐themes.

Table 2: Qualitative analysis of comments on mental health Categories Sub-themes Inadequate coverage of MH

Insufficient coverage of anxiety (SE) Lack of depth and not multi‐dimensional (AT, NL, CH, GR, BE) Questionable construct validity (BE) Produces only two indicators (BE) Difficult to analyse and interpret (LV) Used different instrument for EHIS (BE, EE)

Caused problems for respondents

Questions repetitive and "boring " (CY) Confusion and misunderstandings(TR, CY, ES, DE) Response categories (BG, LT, CY)

Cultural issues

Issues for specific subgroups Expressing emotions Conceptual understanding

Response categories

Interpretation difficult (LT) Too many categories, difficult to distinguish (BG, TR) No control for inconsistencies (CY)

Alternative instruments

GHQ‐12 + Energy and Vitality Index (BE) Centre for Epidemiological Studies Depression Scale CES‐D (FR) Euro‐D scale (SHARE) (FR) Oslo Social Support Scale (BE) The Affect Balance Scale (Bradburn)(LV)

Problems included the insufficient coverage of mental health, issues with response categories, and

confusion and misunderstandings among respondents. In addtion, varying cultural experiences with

expressing emotions were listed as concerns.

2.1.3 International projects Many projects have been carried out in an international context to improve information on mental

health in Europe. The following list gives an overview about what has been done so far in the

European context (for more in‐depth information, see EHIS interim report, chapter 3.3.2).

The European Commission Health Monitoring Programme (1995 – 2010) The European Health Survey Information Database (EUSHID) The pilot EU survey The European Study of the Epidemiology of Mental Disorders (ESEMeD) The Eurobarometer Surveys

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The Mental health information and determinants for the European level project (MINDFUL) The MGEN Foundation cross‐national validation project The European Community Health Indicator (ECHI) project: minimum data set of European mental

health indicators

The European Health Interview Survey (EHIS) project Other projects ("Improving the Mental Health of the Population"; "Mental health promotion and

mental disorder prevention across European Member States: a collection of country stories";

"Mental health in the EU: key facts, figures, and activities"; "Imhpa Project"; "Mental well‐being

impact assessment: a toolkit")

2.1.4 Review of scientific literature The first step in the progress of improving the mental health section of the EHIS Wave was to

conduct a systematic literature review on selected instruments. For more in‐depth information see

the EHIS interim report, chapter 3.3.3). The following table gives an overview of the advantages and

disadvantages of selected instruments.

Table 3: List of instruments with pros and cons

Instrument Underlying concept

Advantages Disadvantages

Generic measures Mental Health Inventory (MHI‐5)(10)

Psychological distress

Energy and Vitality Index (EVI) (10)

Psychological well‐being

Short Validated Comparability (time‐line EHIS 1) Results were consistent across different EU countries Covers distress AND well‐being

Only covers general psychological distress and vitality Lack of depth Cultural variations in experiencing and expressing the inner feelings and emotions Caused problems for some respondents

General Health Questionnaire GHQ 12 (11)

Psychological distress

Validated for numerous languages and cultural settings. Has been used as a screening tool for depression

Produces higher scores for some populations Unclear and misleading response options for items on negative mood states

Well‐being Index (WHO‐5) (12)

Positive psychological well‐being

Short Has been validated for a lot of languages

Does not cover distress

Lifetime review section (screening section) CIDI version 3.0 (9)

Life‐time prevalence of selected mental disorders

Developed by WHO for CIDI‐interview Has been used in various cultural settings Validated for specific disorders

Life‐time prevalence only Limitations of screening instrument No matrix for data analysis

The Affect Balance Scale (Bradburn) (13)

Positive and negative affect

Has been used in large‐scale studies in the 198’0s (US, UK) Composite scale estimator for “perceived quality of life” Positive and negative are independent factors

Concept of scale is not up‐to‐date (from 1969) Unspecific recall period “in the past few weeks” Rarely used in large‐scale studies nowadays

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Instrument Underlying concept

Advantages Disadvantages

Specific measures Brief Patient Health Questionnaire depression module (PHQ‐9) (14)

Depressive symptoms (differentiates betweem major depression and other forms of depression)

High validity in screening major depression and in assessing severity of depression according to ICD‐10 High internal reliability and construct validity Validated in several countries and cultural settings

No life‐time prevalence Overlapping of primary and secondary depressive symptoms

Brief Patient Health Questionnaire anxiety 5‐item panic module (14)

Panic Attacks High validity in screening panic disorder according to ICD‐10 High internal reliability and construct validity Validated in several countries and cultural settings

Only life‐time prevalence Does not cover other anxiety disorders

Memory impairment screen (15)

Test of episodic memory delayed free and cued recall

Brief (approx. 2 min.) screening instrument In‐person and telephone administration Published cut‐off for screening for cognitive impairment

Requires training Scoring slightly more complicated than simple word list Has not yet been used in large‐scale surveys

Associated measures SF‐36 subscale: Role‐emotional functioning (RE01, RE02, RE03) (10)

Impairment in daily activities due to emotional problems

Short Validated Measures the subjective perception of how emotional problems limit daily activities

Not useful as a stand‐alone measure

Only useful in combination with other MH measures

Oslo Social Support Scale (16)

Social support Brief Widely used

No psychological validation

2.1.5 Consultation of experts At the same time as the systematic literature review, colleagues with mental health expertise at the

RKI were asked for advice: Dr Ulfert Hapke, a psychologist with an expertise in mental health

assessment and Dr Markus Busch, an MD who has worked on various mental health projects in

Germany and the European Union. Furthermore, the RKI working group held a mental health

meeting of experts to discuss the mental health module with the above‐mentioned and the following

experts: Dr Maris Taube (Centre of Health Economics, Director Public Health, Riga, Latvia) and Dr

Carlos Garcia Forero (Health Services Research Unit, Barcelona, Spain). The external experts were

selected, since they were mental health experts doing research in different cultural setting in Europe,

Dr Maris Taube works in a ‘new’ European Union member state in northern Europe (Latvia) and Dr

Carlos Garcia Forero works in an ‘old’ European Union member state in southern Europe (Spain). The

meetings with these experts served to identify and discuss of appropriate instruments for mental

health assessment in Europe and regular follow up on the process.

The experts and the RKI working group on MH agreed on the following instruments to be presented

as preliminary recommendations at the EHIS workshop in Berlin:

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Generic measures:

Psychological distress, Mental Health Inventory (MHI‐5) from SF‐36

Psychological well‐being, Energy and Vitality Index (EVI) from SF‐36

Specific measures:

Brief Patient Health Questionnaire, Depression Module (PHQ‐9)

Brief Patient Health Questionnaire, five‐item Anxiety Panic Module

Memory Impairment Screen

Associated measures:

Social Support (Oslo) 3‐item scale

2.1.6 Results of the EHIS workshop Regarding the MHI‐5 and the EVI, the delegates did not criticise the choice of instruments

fundamentally, because the importance of covering the concepts of psychological distress and well‐

being was not doubted. Even participants who had been sceptical about the instruments commented

that the SF‐subscales were the instruments of choice in the absence of another appropriate short

instrument for capturing this information. However, some cultural differences relating to the scales

were pointed out, and most participants agreed that there was generally a need to develop a

new/modified instrument to address the need for a short, culturally appropriate measure. The

development of a new psychometric instrument, however, is beyond the scope of EHIS and should

be addressed in a separate study.

Regarding the PHQ‐9, participants agreed that depression was a major public‐health issue with a very

high prevalence in the population. However, there was concern that the questions of the PHQ‐9 and

the SF‐subscales might overlap and questions might therefore be repetitive. However, such overlaps

cannot be completely avoided when measures on psychological distress and well‐being are included,

because the symptoms of depression include distress (e.g. persons with depression might have a low

feeling of well‐being and higher levels of distress). It was also recommended that the Budapest

Initiative questions on depression should be considered as an alternative to the PHQ‐9.

In their discussions on the PHQ‐9, the delegates also considered editing the wording of the question

on depression in the 'EHIS list of diseases' (HS.6) and changing it from 'chronic depression' to merely

'depression'.

Concerning the Oslo Social Support Scale there was agreement that all three items should be

included in EHIS 2 (as opposed to the previous EHIS version where only one question was used). The

discussion focused on where to place the Oslo Social Support Scale within the survey and whether it

should stay in the environmental health section or be moved to the mental health part.

With regard to the Memory Impairment Screen, the general consensus was that it should not be in

the mandatory part of the EHIS. The concept of memory impairment in an ageing society was seen as

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important, and some delegates favoured the inclusion of the section. Most participants ruled against

it, however, because of the need to train the interviewers.

The inclusion of the PHQ‐5 panic module was dismissed by most workshop participants due to the

low prevalence of panic attacks and because the instrument only covers one dimension of anxiety

disorders. Anxiety in general was seen as an important aspect of mental health, but in the absence of

a short validated instrument that covers anxiety disorders comprehensively, this issue will not be

addressed in the EHIS.

2.1.7 Justification and final instrument for cognitive testing The table below gives an overview of the revised recommendation for the mental health section of

the EHIS. Considering the feedback from the workshop we are dividing our proposal into two

sections, containing a 'mandatory' part that will be part of the EHIS core and a 'voluntary' section

that member states can add if they wish.

The mental health group at RKI decided to propose the MHI‐5 and the EVI as instruments covering

the dimensions of psychological distress and well‐being. Although there were some issues with the

scales, they cover these dimensions adequately. Most other generic mental health measures such as

the GHQ‐12, only cover the dimension of psychological distress and are also longer than the two SF‐

subscales. As mentioned before, the scales have been validated in epidemiological studies in various

cultural settings.

We are also recommending the PHQ‐9 in order to obtain more information on the prevalence of

depressive syndromes in the population, an aspect that was found to be important at the EHIS

workshop. This particular instrument is suggested because of its proven validity in different

populations (17‐19) and cultural settings (20‐23), and because it measures current depressive

syndromes based on established diagnostic classifications (DSM‐IV & ICD10). As requested at the

EHIS workshop, we compared the PHQ‐9 to the Budapest Initiative’s questions on depression, finding

that these questions are not properly validated for use in an epidemiological study. Also, while the

PHQ‐9 is a screening tool, the questions on depression in the Budapest Initiative are self‐reported;

responses are thus based on the individual’s definition of depression that responses might be

strongly shaped by cultural and social issues and norms.

With regard to the potential overlap (for the respondent) between the SF‐subscales and the PHQ‐9,

this cannot be completely avoided when including measures on both psychological distress and well‐

being, because the symptoms of depression include distress and impact on well‐being. Due to the

repeated request for a brief measure, there was a lack of alternatives, because other validated

instruments for screening depression are longer than the PHQ‐9.

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Since social support is an important associated measure of mental health, all three items should be

included in EHIS 2. Discussions at the EHIS workshop showed that the delegates from the member

states agreed that the questions should stay in the environmental health section of EHIS, because

they address the support provided in social and professional life.

In our initial suggestion for the EHIS mental health module, we had included both the memory‐

impairment screen and the PHQ‐5 panic module. After considering the feedback during the EHIS

workshop, we have decided to include these two measures as voluntary scales that can be added to

the EHIS core by member states.

Table 4: Revised recommendation on the mental health module of EHIS Instrument Revised recommendation after EHIS Workshop

Mandatory mental Health Section for EHIS Wave 2 (EHIS Core) MIH‐5 and EVI Captures important dimensions of psychological distress and well‐being

Possibility of comparison with EHIS‐1 data PHQ‐9 Screening Instrument for Depression

Validated in the general population and clinical settings and in various cultural settings based on DSM‐IV & ICD10 classifications. Questions in the Budapest Initiative are comparable to the “list of diseases in EHIS” and do not have screening abilities

Oslo Social Support Scale Important associated measure of mental health Should be kept in the section on environmental health

Change in Health Status Module HS.6 question on “chronic depression”

Change wording from “chronic depression” to merely “depression

Optional for Member States Memory Impairment Screen

Important for the elderly (age filter) Specific interviewer training required

PHQ‐5 item panic module Covers merely panic attacks as part of anxiety disorders Prevalence might be higher in specific subgroups (potential filter)

The Core Group members and RKI agreed to test the mandatory instruments of the RKI proposal

using the methodology of cognitive testing as the next working step in the EHIS‐improvement

project. However, the Oslo Social Support Scale was not integrated into the cognitive testing

proposal, since the experts did not questioned the practicability of using the instrument in the next

EHIS Wave. As a result, the final cognitive testing proposal for mental health comprised the following

instruments:

MHI‐5 and EVI

PHQ‐9

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Literature

1. Kovess V, Brugha T, Carta M, Lehtinen V. The state of mental health in the European Union. European Commission. 2006.

2. Lavikainen J, Fryers T, Lehtinen V, Eds. Improving mental health information in Europe: proposal of the MINDFUL project. Helsinki2006.

3. Lavikainen J, Lahtinen E, Lehtinen V. Public health approach on mental health in Europe: STAKES; 2000.

4. Kessler R, Ustun T. The World Mental Health (WMH) survey initiative version of the world health organisation (WHO) Composite international diagnostic interview (CIDI). International journal of methods in psychiatric research. 2004;13(2):93‐121.

5. World Health Organisation. Preamble to the Constitution of the World Health Organisation. International Health Conference, New York 19‐22 June (Official Records of the World Health Organisation, no 2, p 100)1946.

6. Pilgrim D. Key concepts in mental health: Sage Publications Ltd; 2009. 7. American Psychiatric Association. Diagnostic and statistical Manual of Mental Disorders: DSM‐IV‐

TR 4th edition ed: American Psychiatric Publishing, Inc.; 2000. 8. World Health Organisation. The ICD‐10 classification of mental and behavioural disorders: clinical

descriptions and diagnostic guidelines: World Health Organization; 1992. 9. World Health Organisation. WHO‐CIDI instruments. 2004 [cited 2010 1th June]; Available from:

http://www.hcp.med.harvard.edu/wmhcidi/instruments.php. 10. Ware J, Kosinski M, Dewey J. How to score version 2 of the SF‐36 health survey (standard & acute

forms). Lincoln, RI: Quality Metric Incorporated 2001. 11. Goldberg D. General Health Questionnaire (GHQ)‐12. NFER‐Nelson. Windsor, UK. 1992. 12. Bech P, Lindberg L, Refsgaard E, Lunde M, Søndergaard S, Andreasson K. WHO‐5 Questionnaires.

2003 [cited 6 June 2010]; available from: http://www.who‐5.org/. 13. Bradburn N, Noll C. The structure of psychological well‐being: Aldine Chicago; 1969. 14. Spitzer R, Kroenke K, Williams J. Validation and utility of a self‐report version of PRIME‐MD: the

PHQ primary care study. Jama. 1999;282(18):1737. 15. Buschke H, Kuslansky G, Katz M, Stewart W, Sliwinski M, Eckholdt H, et al Screening for dementia

with the memory impairment screen. Neurology. 1999;52(2):231. 16. Dalgard OS. Explanation of OSS‐3. Bilthoven2008 [cited 26 May 2008]; EUphact\ Determinants of

health\ Environment\ Social support]. Available from: http://www.euphix.org. 17. Wittkampf K, van Ravesteijn H, Baas K, van de Hoogen H, Schene A, Bindels P, et al The accuracy

of Patient Health Questionnaire‐9 in detecting depression and measuring depression severity in high‐risk groups in primary care. Gen Hosp Psychiatry. [Research Support, Non‐U.S. Gov Validation Studies]. 2009 Sep‐Oct;31(5):451‐9. Epub 2009 Jul 10.

18. Martin A, Rief W, Klaiberg A, Braehler E. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ‐9) in the general population. Gen Hosp Psychiatry. 2006 Jan‐Feb;28(1):71‐7.

19. Cameron I, Crawford J, Lawton K, Reid I. Psychometric comparison of PHQ‐9 and HADS for measuring depression severity in primary care. The British Journal of General Practice. 2008;58(546):32.

20. Chen S, Chiu H, Xu B, Ma Y, Jin T, Wu M, et al Reliability and validity of the PHQ‐9 for screening late‐life depression in Chinese primary care. International Journal of Geriatric Psychiatry. 2009.

21. Frederick Y Huang HC, Kurt Kroenke, Kevin L Delucchi, Robert L Spitzer,. Using the Patient Health Questionnaire‐9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med. 2006;21(6):547–52.

22. Monahan P, Shacham E, Reece M, Kroenke K, Ong’or W, Omollo O, et al Validity/Reliability of PHQ‐9 and PHQ‐2 Depression Scales Among Adults Living with HIV/AIDS in western Kenya. Journal of General Internal Medicine. 2009;24(2):189‐97.

23. Lawson Wulsin ES, Jeffery Heck. The feasibility of using the Spanish PHQ‐9 to screen for depression in primary care in Honduras. Prim Care Companion J Clin Psychiatry. 2002;4(5):191‐5.

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2.2 Physical activity 2.2.1 Definition of the concepts Physical activity per definition is “any bodily movement produced by the contraction of skeletal

muscles which increases energy expenditure above the basal level” (1).

The frequency, intensity and duration of ‐ and the amount of muscles involved in ‐ a certain activity

are commonly recognised characteristics used to describe patterns of physical activity (2). Recently,

the definition of two ideal types of health‐enhancing physical activity has increasingly been attracting

the attention notice of the scientific community:

Aerobic activity – also called endurance activity or cardio activity – involves the rhythmic work of more than one sixth of the skeletal muscles for at least 10 minutes at a moderate to

vigorous intensity level. Aerobic activity involves the utilisation of the cardiovascular and

metabolic system and leads to a significant increase in the heart rate and breathing. Regular

aerobic activity leads to physiological adaptations within the cardiovascular and metabolic

system and to an increase in aerobic physical work capacity (endurance capacity). Hence,

regular aerobic activity is health‐enhancing with regard to cardiovascular and metabolic

health and protective against diseases such as heart attack, stroke, diabetes and certain

types of cancer and related morbidity and mortality (3, 4).

Muscle‐strengthening (resistance) activity – which includes resistance training and lifting weights – comprises highly intensive movements of short duration of the major skeletal

muscles. The fraction of maximal force used for a contraction, the number of repetitions per

set, the number of sets performed and the duration of recovery intervals between sets are

influential factors for characterising types of muscle‐strengthening activity (5). Muscle‐

strengthening activity leads to an increase in muscular strength and improves the metabolic

processes in the passive structures of the musculoskeletal system (muscles, joints, tendons,

ligaments…). Muscle‐strengthening activity is protective against musculoskeletal disorders

such as back pain or arthritis, which are rarely a cause of death but severely limit the quality

of life (3, 4).

The differentiation between aerobic and muscle‐strengthening physical activity was taken into

account for the first time when designing the up‐to‐date physical activity guidelines for adults first

published by the US Department of Health and Human Service in 2008; they were incorporated by

the WHO in 2011:

“All adults should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits.

For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) a week of moderate‐intensity, or 75 minutes (1 hour and 15 minutes) a week of

vigorous‐intensity aerobic physical activity, or an equivalent combination of moderate‐ and

vigorous‐intensity aerobic activity. Aerobic activity should be performed in episodes of at

least 10 minutes, and should preferably be spread throughout the week.

For additional and more extensive health benefits, adults should increase their aerobic physical activity to 300 minutes (5 hours) a week of moderate‐intensity, or 150 minutes a

26

week of vigorous‐intensity aerobic physical activity, or an equivalent combination of

moderate‐ and vigorous‐intensity activity. Additional health benefits are gained by engaging

in physical activity beyond this amount.

Adults should also do muscle‐strengthening activities that are moderate or high intensity and involve all major muscle groups on 2 or more days a week, as these activities provide

additional health benefits” (3).

Due to past confusion over the difference between 'moderate‐intensity' and 'vigorous‐intensity'

physical activity, the Centre for Disease Control (CDC) came up with a new definition: moderate‐

intensity aerobic activity includes activities where "I can talk while I do them, but I can’t sing".

Vigorous‐intensity activity includes activities where "I can only say a few words without stopping to

catch my breath" (6).

Following the above‐mentioned definition of physical activity, various approaches have been

designed to measure overall physical activity or "any bodily movement which increases energy

expenditure" (1). Metabolic equivalent (MET) or physical activity level (PAL) serve as common

measuring units for estimating total energy expenditure or total physical activity level, respectively.

Many instruments use a setting‐specific approach to categorising physical activity according to

domains of physical activity. This makes it easier for the respondent to remember their physical

activity behaviour and can reduce recall bias. A common setting‐specific differentiation is to

distinguish occupational physical activity from leisure physical activity (7). Other domains of physical

activity which are applied in physical activity assessment research are transportation physical activity

and physical activity at home (around the house). Generally, physical activity settings are arranged in

such a way that they cover the total daily course of a person’s physical activity profile. The total

volume of physical activity in kilocalories, MET‐minutes or MET‐hours can be estimated by adding

together the sub‐domains together on a 24‐hour basis.

2.2.2 Review of experience In the context of the EHIS Wave 1, an adapted version of the International Physical Activity

Questionnaire – Short Form (IPAQ‐SF) was implemented to collect physical activity information for

Europe. The IPAQ‐SF was developed in 1997 as a result of various research projects. The IPAQ‐SF

applies an assessment approach that measures the dimension of 'total physical activity' in terms of

total energy expenditure on a metabolic‐equivalent (MET) basis using a generic assessment

approach. More specifically, it measures the number of days and the duration in the last 7 days of a)

vigorous‐intensity physical activity, b) moderate‐intensity physical activity, c) walking and d) sitting. It

assigns MET‐values to the respective intensity categories of physical activity in order to obtain a total

physical‐activity indicator. According to the head of the EHIS Core Group, the implementation of the

modified version of IPAQ‐SF in the first EHIS wave revealed problems such as incoherence in the

replies, the need to make a lot of corrections in the database due to these problems, and the

instability of the estimators, with the consequence that several member states indicated that they no

longer wanted to use the instrument for the next EHIS wave. As a result, the EHIS Core Group and

Eurostat decided that there was a need to improve the physical activity module for the next EHIS

Wave.

27

As a first step in the improvement process of the physical activity module, a review of experience

was conducted to examine which specific problems were encountered when implementing the

modified version of the IPAQ‐SF in the first EHIS round. Measuring physical activity with the modified

IPAQ‐SF instrument in the first EHIS Wave was reported to be problematic by half of the MSs (expert

feedback). Experts commented that the IPAQ‐SF was not suitable for a health interview survey (HIS),

and the physical activity module was rated as being the most problematic section of the EHIS core

questionnaire for various reasons. The questions were reported as being difficult to understand for

both the respondents and the interviewers, who tended to have problems fully grasping the essence

of the module (reported by PL, LV, FR, HR, AT, BE). In particular, some MSs noticed difficulties with

the definition of the terms 'vigorous' and 'moderate', which turned out not to be intuitive to many

respondents (reported by SK, RO, LT, FR, HR, BG). Other concerns that were raised related to the

repeatedly questioned validity and reliability of the IPAQ‐SF instrument (SE, DK, BE), the vagueness of

some of the questions, namely PE.1 – PE.4 (CH, LT), and the difficulty for respondents to calculate

their answer, since the amounts and numbers they were asked for were something they usually did

not keep track of (PL, BG, AT). Furthermore, the results produced by the instrument were considered

too difficult to analyse afterwards (LV, BE) and tended to ignore other, relevant PA dimensions, e.g.

leisure‐time physical activity (PL, AT). In fact, similar issues in regard to the IPAQ‐SF were also

reported after the EUROHIS pre‐testing process in 2000 (8).

In general, the evident result of EHIS Wave 1 was that the PA module worked poorly and caused

several problems for many member states.

2.2.3 International projects The second step in the improvement process was to review projects which have been carried out so

far in an international context with the aim of improving information on physical activity in Europe.

The following list gives an overview of important projects that have been carried out to collect

comparable physical‐activity data for Europe (for more in‐depth information see EHIS interim report,

chapter 3.1.1).

FINBALT Health Monitor Health Behaviour in School‐aged Children (HBSC) survey World Health Survey European food study EUPASS European Physical Activity Surveillance System Eurobarometer surveys European Health Interview Survey (since 2007 in all EU member states)

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2.2.4 Review of scientific literature The third step in the process of improving the physical activity module of the EHIS was to conduct a

systematic literature review on selected instruments. For more in‐depth information see the annex

of the EHIS interim report, chapter 3.1.2.

Physical activity questionnaires were identified which have shown sufficient content validity and/or

repeatability according to previous review studies (9‐11). In addition, the HIS/HES database was used

to identify additional physical activity questions which had been used in an HIS context in Europe to

date. As a next step, the number of questionnaires was restricted by applying selection criteria. The

main selection criteria were that the questions should be feasible for use in an international HIS

context, they should be short and ea

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