1

EVALUATION OF HEALTH INTERVIEW SURVEYS AND

HEALTH EXAMINATION SURVEYS IN THE EUROPEAN UNION

Arpo Aromaa, Professor (1)

Päivikki Koponen, PhD, Senior researcher (1)

Jean Tafforeau, MD, MPH, Head of research (2)

Claudine Vermeire, MD, MPH, Researcher (2)

and the HIS/HES Core Group (see Annex 1)

1 National Public Health Institute, Helsinki Finland

2 Scientific Institute of Public Health, Brussels Belgium

Contact/Correspondence: paivikki.koponen@ktl.fi

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ABSTRACT

The project on Health Surveys in the EU supports health monitoring by developing a

computerised health survey database, by reviewing and evaluating surveys, their

methods and comparability, by recommending designs and methods, and by

disseminating this information. It also assesses the coverage of specific health and

health related areas in national and international surveys. At present, Health

Interview Surveys (HIS) and Health Examination Surveys (HES) are included from

18 Western European countries as well as Canada, Australia and USA.

National HISs are carried out regularly in almost all Western European countries.

National HESs with a comprehensive focus are conducted at regular or irregular

intervals in five countries. The HIS may consist of short health sections or modules

within multi-purpose surveys or lengthy health interviews with several questionnaires.

The HES (or HIS/HES) may comprise an interview with a few measurements or a

comprehensive health examination. There are important differences in sampling

frames, in fieldwork, and in quality control procedures. The response rates vary

greatly. Differences in instruments used, in the wordings and in survey protocols

reduce the comparability of many topics.

The interactive Internet based HIS/HES database allows for a quick reference and

comparison of methods and instruments used in national health surveys. It also

illustrates the great variety in instruments and protocols, and the need for

harmonisation. Collaboration and co-ordination is needed to promote comprehensive

health monitoring at the European level.

Keywords: Health surveys, health interview, health examination, survey methodology

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Introduction

Health Interview Surveys (HIS) and combinations of Health Interviews and Health

Examinations (HIS/HES) are central components of a comprehensive health

monitoring system. HISs deliver valuable information on health status, illnesses,

functional capacity and use of health care services. By definition, interviews and

questionnaires are the only way to obtain data on perceived health, symptoms and

health related behaviour. However, clinical measurement is needed to obtain valid

information on many chronic conditions, functional limitations and disabilities, and

on several key health determinants.

Examples of conditions, which cannot be adequately assessed by typical health

interviews are musculoskeletal diseases, mental health problems, functional

limitations, and many risk and protective factors. Chronic diseases are often under

reported or over reported in HISs (1, 2, 3, 4). Non-symptomatic persons may suffer

from some conditions (e.g. hypertension) requiring treatment, the symptoms or

findings (e.g. visual or auditory acuity) may not be specific enough or there is a

considerable recall bias (e.g. infections and immunisations). The results of physical

examination and subjective reporting of pain and disability can differ (5). A well-

documented example of differences in self-reports compared to actual measurements

is under-reporting weight and over- or under-reporting height (6).

Both HISs and HESs may, when well applied yield excellent results. However, to

obtain comprehensive and comparable information on Community Health Indicators

(7) in a reliable and valid manner both HIS and HES methods should be used.

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HES is more expensive and logistically more demanding than HIS, as it requires a

variety of highly qualified personnel, and careful training and quality control.

Safeguarding the confidentiality of personal information is even more important than

in HIS and liaison with local health service personnel at the examination sites is

needed. In practice, an integral part of every HES is a HIS, and sometimes the HES is

carried out on a sub-sample due to the special demands in the design and procedures.

(2, 8)

It is often overlooked that the HIS/HES combination brings about the advantages of

both methods, although at a cost. In particular, many measurements and examinations

of a typical HES are closer to clinical practice and some have better validity than HIS

methods), which is not to say that physical examinations are not prone to error (9).

The major advantage of the HIS/HES combination is obvious in measurement of time

trends and differences between population groups. Also, interpretation of the findings

is much facilitated by the different types of measures.

Data for health monitoring can also be obtained from other sources, most importantly

from registers and routine statistics. It is generally acknowledged that morbidity and

mortality statistics can only indicate where the main problems of chronic disease lie

and suggest hypotheses for further investigation (10). Regular statistical sources and

registers, e.g. hospital discharge registers and general practice registers, can provide

an overview of morbidity and their data are valuable for the evaluation of health care

services. However, such data is not sufficiently comprehensive for population health

monitoring purposes (11). Population surveys overcome much of this selection bias of

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health service users compared to the total population. However, this presupposes that

participation is good in all population groups.

Within the framework of the EC Health Monitoring Programme (1995-2002), the

project “Health Surveys in the EU: HIS and HIS/HES evaluations and models”

represents European collaboration with the aim of producing an inventory of health

interview and/or health examination surveys in 18 Western European countries as

well as Canada, Australia and the USA. The project’s main objective focuses on

standardisation and improvement of health survey instruments, methods and the

implementation of surveys. The project has been carried out in two phases, the first

phase in 1999-2001 and the second, ongoing phase in 2001-2003. A final third phase

is planned.

Aims

The HIS/HES project aims to support Health Monitoring by producing a computerised

up to date overview of methods and contents of existing and planned HIS,

combinations of HIS/HES, and other national population surveys with a significant

health component in the Member States and EFTA/EEA countries. The project also

aims to provide insight into the coverage of health and health related topics that are

relevant for Health Monitoring by national and international surveys

The specific aims of the current second phase of the project are

1) to review, evaluate and recommend methods for use in HIS and HIS/HES surveys

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2) to maintain and develop the health survey database created during the first phase of

the project, to add new data on new surveys, to gather information on existing

recommendations and standards, and to develop the database for dissemination.

Several recent projects under the auspices of the EU Health Monitoring Programme

(12, 13, 14) and international organisations (15) have proposed instruments for use in

health surveys and made recommendations to enhance international comparability.

Data collection for health monitoring is developed under several organisations (11). In

the HIS/HES project existing survey instruments and recommendations have been

gathered. The usefulness and feasibility of various methods and instruments is being

assessed and the international comparability of the findings will be evaluated.

Project execution

The first phase of the project consisted of two related parts. One concerned Health

Interview Surveys (HIS) and the other Health Examination Surveys (HES). A core

group of experts in the field of health survey research was established and comprises

partners from eight countries (see Appendix 1). A European network for development

and testing of proposed methodologies was initiated.

Inventories of national HIS and HIS/HES in EU Member States and EFTA countries

were carried out and updated during the project (16, 17, 18). Collection of information

about previous, ongoing and planned surveys as well as on methods used was based

on literature reviews, personal communication, a systematic postal survey covering all

EU/EFTA Member States, and methodological questionnaires sent to contact persons

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of identified surveys. Only one institute (one HIS) did not return the methodological

questionnaire.

Information on the methods and contents of these HISs and HIS/HESs have been

entered into a specially designed health survey database. Also, recommended

instruments and protocols of e.g. WHO/EURO (15) and the EHRM -project (14) are

included. Apart from methodological items, the database covers all interview

questions, both in the original language and in English, and HES examination

protocols. Users of the database can search for specific information: on particular

survey methodology, interview or examination designs of a full survey, or on

particular health topics covered in all or a limited number of surveys.

Subprojects

Five subprojects were launched during phase 2 to address specific health topics,

survey instruments and methodological questions. The joint aim of all subprojects is

to make recommendations concerning survey methodology, instruments and protocols

in order to improve comparability at the European level.

1) The SF-36 project, led by Paola Primatesta at the University College of

London, UK.

The aim of this subproject is to compare HIS and HES survey results and compare

results from three countries as far as cardiovascular risk factors, subjective health and

quality of life (measured by SF-36) are concerned. This subproject serves as an

example of merging/pooling and joint analysis of data from national health surveys.

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2) The Mental Health project carried out by Ulla-Sisko Lehto-Järnstedt at KTL,

Finland.

The aim of this subproject is to describe the use of and to evaluate the quality and

comparability of the measurement of mental health issues in national comprehensive

HIS and HES surveys.

3) The project on participation and representation in HIS and in HIS/HES

carried out by Päivikki Koponen at KTL, Finland and Carlos Matias Dias at INSA

(National Institute of Health), Portugal.

The aims of this subproject are to compare sampling frames, recruitment methods,

response rates and methods used to follow up non-responders, and to evaluate efficacy

of design and fieldwork procedures from the point of view of representation. Methods

of data collection from persons living in institutions are compared to identify

adaptations made to the survey protocols of non-institutionalised persons.

4) The project on the measurement of physical functioning in national health

surveys carried out by Sanna Räty at KTL, Finland.

The aim of this subproject is to describe methodological aspects of measurement of

physical functioning in national HIS and HIS/HES, and to evaluate these from the

viewpoint of international comparability and development of measurement. The final

aim is to evaluate how the currently used instruments of physical functioning can be

linked to the International Classification of Functioning, Disability and Health (the

ICF codes, 19).

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The development of the HIS/HES Database

The aim of the database is to:

• Inform about the implementation and methods used in each survey

• Provide an overview of the topics covered in each survey

• Act as a consultation forum on recommended questions and examination protocols

• Allow searches on specific questions or examinations

• Enable comparisons of health surveys in different countries

• Strengthen the development of questions and examinations in future health

surveys leading to comparable data and European Community Health Indicators

• Identify institutions and contact persons responsible for each health survey and

maintain an operational European network.

The inclusion criteria for HISs and HIS/HESs have been the following. The surveys

must be based on nationally representative population samples, they must be repeated

at more or less regular intervals, and the surveys are comprehensive (not disease/topic

specific or restricted to a narrow age group, e.g. only children or the elderly). The

current (January 2003) version of the database includes 90 HIS (with a total of 13809

questions) and 16 HESs (with a total of 221 test/examination protocols) in EU/EFTA

Member States, and in Australia, Canada and USA. Seven international (WHO,

European Community) HISs are also included as well as internationally recommended

instruments and protocols.

The HIS/HES database was first developed in Microsoft Access®. The CD-Rom of

the Access version has been distributed to more than 150 institutions, national

governmental services (statistical and health) and some international organisations

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playing a key role in health monitoring (EC, WHO, OECD). The newly developed

Internet compatible version (the HIS/HES web site) will be finalised during spring

2003. It will greatly improve accessibility and dissemination of data to all interested

users.

Preliminary analysis of the health survey questions and examination protocols, and

use of the European Community Health Indicators (7) led to the design of a

classification of health and health related areas and health topics. Corresponding

health survey questions and examination protocols were then linked to these topics,

which are used to search for questions and methods of interest.

The list of HIS topics has been divided into seven areas: demographic and socio-

economic factors, health status, personal factors, life style factors, living and working

conditions, prevention, health protection and health promotion, and health and social

services. The list of HES topics is partly based on the ICF- classification (19), it is

divided into 17 areas: e.g. risk factors, cardiovascular function and diseases, diabetes

mellitus and other metabolic diseases, kidney, urinary tract and thyroid function and

disease, infections and inflammations, and sensory function, physical function and

physical fitness.

Current and planned national HISs and HIS/HESs in Europe

The inventory of national HISs in EU and EFTA Member States showed that HISs are

being regularly executed in most countries (Table 1). Especially in Finland, France

and the UK many health surveys are repeated regularly. In most countries one or two

national HISs have been recorded, namely in Belgium, Denmark, Germany, Iceland,

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Ireland, Italy, Norway, Portugal, Spain, Sweden, Switzerland and The Netherlands.

These national interview surveys vary from "health modules/sections" within living

condition surveys to disability surveys, lifestyle and health education surveys, surveys

on use of health services and comprehensive/general health surveys. In the future

there are plans for about 20 national HISs per year in EU and EFTA countries.

Analyses of the HIS questionnaires included in the database showed which health

topics are frequently included in HISs and which topics are rare (Table 2). Topics on

the health status of respondents were most common. Questions on disease specific

morbidity, perceived health, activities of daily living, and chronic conditions were

also included in many surveys. Life style, in particular smoking, was a common topic.

Other generally occurring themes relate to the use of health and social services, like

hospitalisation, contacts with the GP, and use of medicines.

The comparability of the questions in different national HISs has been studied e.g. in

regard of smoking prevalence and alcohol use. The comparability of almost all topics

appears quite limited across all countries. However, an evolution toward better

comparability and broadening the range of health topics is evident in the most recent

surveys. Findings to be presented in the final report of phase 2 reveal several topics

which already now can be compared between a number of European countries.

National population based HESs with a comprehensive focus have been conducted at

regular or irregular intervals in five countries (Finland, Germany, Ireland, the

Netherlands and UK) (Table 1). In these countries several local, regional and/or

focused surveys have been carried out in addition to the national HESs. All of the

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national HESs included a HIS component preceding or parallel to the HES. National

HESs in the planning or pilot stage were identified in two countries (France, Italy) and

there are some plans for a national survey in one more country (Portugal). In addition,

surveys focused on specific age-groups (e.g. the elderly in Sweden) or based on

regional rather than national samples (e.g. Norway) were identified. Surveys focused

on specific age-groups or diseases, and geographically limited HESs have been

carried out in almost all EU/EFTA countries. A well-known example are the WHO-

MONICA related surveys (20).

In replies to our questionnaire the main reason given for not carrying out national

HESs until now was the high expense or the difficulties in implementing fieldwork.

However, all respondents from countries without a national HES stated that such

national examination surveys are necessary. Most respondents also felt that there is a

need to develop a core module for HES in Europe.

There were important differences between sampling frames, especially concerning

age-range and the inclusion of institutionalised persons. No age limits were used in

nearly half of the surveys. When age limits were applied, the lower limit varied from

2 to 30 years, and the upper limit from 64 to 84 years. Institutionalised persons were

included in 15 surveys in 7 countries (11 HISs and 4 HIS/HESs, out of a total of 55

surveys carried out in 18 EU/EFTA countries between 1998-2002). Sample sizes

varied from fewer than 2000 individuals (Iceland) to 79 000 households (Spain) and

non-response rates from 5 % to 75 %.

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The HIS/HESs were carried out according to different models ranging from an

interview with single measurements and/or blood samples to a comprehensive health

examination taking several hours to complete per person. Differences in the

measurement protocols and other differences in the fieldwork phase limit

comparability of results of the surveys. In the examinations there was a clear

emphasis on cardiovascular diseases and their risk factors (Table 3), but other topics

were also covered, most often respiratory function, diabetes, liver function,

haematological system function, infections and allergy. Topics covered in only one

European examination survey, the Health 2000 survey in Finland, were examinations

of the locomotor system including bone density measurement, sensory function

(vision and hearing tests), and dental health (clinical dental examination). Mental and

dental health issues were often the subject of separate surveys. During the

examinations diagnostic interviews for mental health were part of the general

HIS/HESs in two countries, while specific national mental health surveys were carried

out in two other countries. Thus, detailed diagnostic information on mental disorders

is still scarce in national European surveys.

Plans for the future

Products available by April 2003 will be: Final report of phase 2, reports from the

sub-projects and the Internet version of the HIS/HES database. The inventory of

health surveys is being completed with information from 16 new EU member

states/candidate countries. This work will be finalised in 2004. Updating and further

development of the database is a major challenge for the anticipated third phase of the

HIS/HES project. Other central aims for the third phase will be further evaluation and

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development of recommendations on survey methodology, instruments and protocols,

as well as proposals for improving quality and comparability of national surveys. All

of this is expected to be carried out in the framework of the EU Public Health

Programme, taking into account other European survey work.

The final report of phase 2 is currently being written as a joint effort of the core group

members. It comprises a full review of current HIS and HIS/HES surveys, with

special emphasis on the possibilities to improve their validity and comparability. This

implies recommendations for design and implementation as well as evaluation of

current methods. Recommendations are also being reviewed. One section assesses co-

ordination, joint training, and quality assurance and control. The possibilities to use

data from national surveys in European reviews and comparisons are evaluated.

Finally, an overview is given of possible ways to organise future national surveys in

collaboration.

Conclusions and recommendations

The interactive HIS/HES database allows for a quick reference and comparison of

methods and instruments used in national health surveys in 18 Western European

countries as well as in Canada, Australia and USA. It illustrates the great variety in

instruments and the need for harmonisation through a network effort in order to serve

the ultimate goals of national health monitoring on an internationally comparable

basis.

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National HISs are a widely used tool of health policy and planning. Comprehensive

national HESs are still relatively rare but interest in them is increasing in many

countries. The most important reason is that accurate information on many major

public health problems and their risk factors cannot be obtained by any alternative

method. Also, the advantages of having access to different types of measurements are

clear for assessing time trends and differences between countries, regions and

population groups. Comprehensive local or regional HESs have been carried out

occasionally in several countries. Often their motivation is not a health monitoring

need but scientific research. Several regional and local/community level HIS/HESs

have been carried out in most countries and most countries have participated in major

international multi-centre HIS/HESs carried out since the 1950s.

We believe that by the questionnaires and consultations with contact persons from all

EU/EFTA Member States we have been able to identify all major surveys in these

countries. We welcome any information on remaining unidentified surveys.

The national HIS and HIS/HESs have been carried out using different designs and

models. The HIS may consist of short health sections/modules within multi-purpose

surveys or lengthy health interviews with several questionnaires. The HES may

consist of an interview with single measurements and/or blood samples or a

comprehensive health examination. There are also important differences in sampling

frames and participation. This may cause serious bias in the results, since those who

most likely have several chronic conditions and functional limitations may be

excluded from the sample or health problems are accumulated among the non-

participants (21, 22).

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Differences in the fieldwork phase limit comparability of results. There are

differences e.g. in the place of the examinations (home or clinic), in the data

collection methods (e.g. face to face or self-administered questionnaires), in the

professional background and number of survey personnel, and in their training before

and during fieldwork. Quality control procedures for interviews, laboratory tests and

some measurements (e.g. blood pressure) are well established and recommendations

for protocols and quality control are available, but for some measurements there are

no common standards. Even when recommendations and standards exist, their

application varies. One prerequisite of better comparability seems to be jointly

organised training and quality control.

The response rates in national and international health surveys vary greatly (23,24).

Recruitment remains one of the most challenging and underestimated phases in the

research process (22,25). The efforts made to enhance comparability of survey results

through the use of common standardised instruments should be complemented by

more attention paid to recruitment issues and potential bias from non-participation.

More understanding is needed on willingness and unwillingness to participate in

research (21).

Differences in instruments used (and versions of these instruments), in the choice of

wording of questions and in examination protocols restrict comparisons of many

health survey topics. The health survey database can be used to facilitate the needed

future harmonisation process. However, most recently developed and recommended

instruments require further testing and evaluation before they are matured enough to

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be released for wider application. Continuous international collaboration of experts

and co-ordination of the surveys is needed to promote comprehensive health

monitoring at the European level.

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Appendix 1 Participants and organisation

The Phase 1 of the project was coordinated by Jaap van den Berg at Statistics

Netherlands. The subcontractor was The National Public Health Institute (KTL, Prof.

Arpo Aromaa) in Finland.

The phase 2 of the project was coordinated by Prof. A. Aromaa at KTL in Finland. The

subcontractor was the Institute of Public Health (IPH) in Brussels (Dr. Jean Tafforeau).

The core group members and HIS centres are:

Jean Tafforeau/Claudine Vermeire, Institute of Public Health (IPH), Belgium

Jaap van den Berg/Christianne Hupkens, Statistics Netherlands (CBS)

J-M Robine/Emmanuelle Cambois, Equipe INSERM Démographie et Santé REVES

Network on Health Expectancy, France

V. Egidi/V. Buratta/L.Gargiulo, Instituto Nazionale di Statistica (ISTAT), Rome, Italy

C. Matias Dias, Observatorio Nacional de Saude Dr. Ricardo Jorge, Lisboa, Portugal

The core group members and HIS/HES centres are:

Arpo Aromaa/Päivikki Koponen, KTL, Finland

Jaap Seidell/Lucie Viet, RIVM, Bilthoven, The Netherlands

Bärbel-Maria Kurth, Robert Koch Institut, Berlin, Germany

Michael Marmot/Paola Primatesta, University College of London, United Kingdom

Gino Farchi/Susanna Conti, Instituto Superiore di Sanita, Rome, Italy

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Table 1. National HIS and HIS/HES surveys in EU/Efta countries (number of surveys

included in the HIS/HES database, and carried out 1998-2002)

HIS* HIS/HES**

Austria 1***

Belgium 2***

Denmark 1

Finland 3 2

France 8

Germany 2 1

Greece 1

Ireland 2 2

Iceland 2

Italy 3

Luxembourg 1

Netherlands 3 1

Norway 2

Portugal 2 ***

Spain 2

Sweden 2

Switzerland 1

UK 5 *** 6

Total 43*** 12

* General HIS, disability surveys, health education/lifestyle or living conditions

surveys etc. with a specific health module/section

** Combination of HIS and HES, Surveys including a health examination to all/some

participants of HIS

*** including health modules within a "Microcensus", General Census or a General

socio-economic survey to all citizens

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Table 2. Examples of health topics frequently covered in national/international HIS

(topics covered in interviews) in Europe (60 surveys carried out during 1998-

2002)

Topic Number of surveys

Demographic and socioeconomic factors:

education and/or employment status

34/60

Health status: self assessed/perceived health 49/60

Health status: long-standing illness/chronic

conditions/disabilities

49/60

Health status: Limitations of activities of daily

living, personal

23/60

Health status: general mental health 21/60

Personal factors: body height and weight 33/60

Life style factors: smoking 44/60

Life style factors: alcohol use and abuse 32/60

Life style factors: physical activity 33/60

Working conditions 27/60

Housing conditions 24/60

Prevention: contraception 12/60

Prevention: vaccinations 16/60

Health and social services: use of services, GP 32/60

Health and social services: medication 27/60

Health and social services: hospitalisation 27/60

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Table 3. Health topics covered in national HIS/HES (topics covered in clinical

examinations) in Europe (12 surveys carried out during 1998-2002)

Topic Number of surveys

Risk factors: Height and weight 12/12

Risk factors: Waist and Hip circumference 11/12

Risk Factors: Blood lipids 10/12

Cardiovascular function: Blood pressure 12/12

Cardiovascular function: Electrocardiogram 3/12

Respiratory function: Spirometry 5/12

Diabetes mellitus and other metabolic function:

Blood glucose

5/12

Kidney and urinary tract function: Blood and/or

urine tests (protein, albumin etc.)

4/12

Liver function: Gamma-GT and similar tests 6/12

Haematological system function: Blood count 5/12

Infections: Blood samples, general or specific

markers

5/12

Allergy: Blood samples, Immunoglobulins 5/12

Physical function: e.g. joint function 2/12

Mental disorders: Diagnostic measurement 2/12

Cognitive function: Memory testing 2/12

Nutritional status: Blood samples for vitamins,

and/or minerals and trace elements

5/12

This paper was produced for a meeting organized by Health & Consumer ProtectionDG and represents the views of its author on the subject. These views have not beenadopted or in any way approved by the Commission and should not be relied upon as astatement of the Commission's or Health & Consumer Protection DG's views. TheEuropean Commission does not guarantee the accuracy of the data included in thispaper, nor does it accept responsibility for any use made thereof.