Part 2: MEHM
The Minimum European Health Module
Introduction
The Minimum European Health Module
The
increasing needs for information and the
progress made in the domains of health, health related and social
indicators (Commission Health Monitoring Programme of the European Statistical System (ESS).), have made necessary to establish a proposal for a EU programme
for the coherent development of
consistant disability statistics.
During a meeting of experts from the MS, held in
Brussels on 31 January and 1 February 2002, the following aim was formulated: “
the program of the ESS should aim at a minimum set of items with reference
questions and data to be available in the EU (all MS and Eurostat) by 2006, at
least for supporting in a regular way disability and disability related
programmes and public health programmes of the Community.”
The emphasis is on
population based surveys as the backbone of a statistical information system
for disability and related matters.
Therefore the disability
items and questions/instruments have been proposed to fit into a census or general nation wide surveys; this is the first priority of the
Washington Group.
It is proposed to accept
for the EU the 3 general disability/health items and questions from the “Survey
on Income and Living Conditions”(SILC)
questionnaire, which is called the
Minimum European Health Module (MEHM).
The set of three MEHM questions should be used as one entity and not as
separate questions.
The MEHM (reference
instrument) is:
How is your health in general? Very good, good, fair, bad, very bad.
Do you have any long-standing illness or health
problem? Yes/no.
For at least the past 6 months, have you been limited
in activities people usually do because of a health problem? Yes, strongly limited; yes, limited; no, not limited.
The
SILC questionnaires have been accepted by the appropriate Working group of
Eurostat and as such is a formally accepted reference instrument at EU level
for use in the European Statistical System (ESS).
This means also that MS
should justify possible adaptations of national (operational) instruments.
It was stressed that due
to differences in culture and language the emphasis should not be on common
instruments but rather on common items and agreed related reference questions
or instruments, leaving the operationalization of the reference questions and
/or instruments at national level.
The MEHM is based upon Euro-REVES
recommendation and it takes into account the results of
several research projects particularly on the development of common
instruments, e.g. EuroHis of WHO-Euro (financed by BIOMEDII programme), REVES etc.
First question of MEHM: Perceived Health: general
question
|
* “How is your health in general? Very
good, good, fair, bad, very bad” *
This instrument is recommended by the World Health Organization (WHO-Europe,
1996). |
Self Perceived Health (PH) is a global measure that
includes the different dimensions of health, i.e. physical, social and emotional
function and biomedical signs and symptoms. Whereas with many health indicators
we get only a partial indication of health, SPH appears to be an effective
summary of health.
Its “holistic” approach and its generalizability of
the health concept, as well as the comprehensiveness of the population
responses, allows it to be used when comparing different populations
(Euro-REVES, 2002)
The
instrument is based on the existing recommendations; the question chosen is
that already recommended by the World Health
Organization (WHO-Europe,1996). Its importance has been also acknowledged by Euro-REVES project on “Setting up of a coherent set of health
expectancies for the European Union", carried out under the European Health Monitoring
Programme .
A systematically review
research on the self-perceived health measurement instrument (with particular
reference to the essential characteristics and quality assessment when
measurement of perceived health are used cross nationally) has been presented
in the Final Report of the Euro-REVES project (Coherent Set of Health
Indicators for the European Union, Chapter 6, (Euro-REVES, 2002).
Context/Brief Summary
In recognition of the need
to elicit an individual’s own assessment of their health and of the
considerable advantages of measuring overall health through the use of a simple
question, the notion of ‘self-perceived health’ (SPH) has become popular.
SPH
is considered to be one of the best health indicators at both, the individual
and population level. Several cross-sectional and longitudinal studies have
demonstrated its relationship with other health status variables, thus
reinforcing its validity as a global indicator of health.
SPH
has consistently been shown to be a good predictor of general and specific mortality,
by selected causes, over both the short and long term, as well as of the future
functional capacity of individuals. This characteristic has stimulated the
increased use of SPH in clinical and public health surveys as a key indicator
of individual health status. It has become a commonly used indicator available
in many countries. Furthermore, the association between SPH and physical
symptoms, limitations on daily activities and the use of health services has
also been well documented. The level of perception of bad health in the
population is a clear indication on the needs, services and health care
requirements of a community.
Question
characteristics
Domain:
The reference
domain is a general state of health
Format: The
proposed indicator is an absolute, single-item measure of SPH.
Age reference: The
question is not age related.
Time reference: The
question is not time limited. The exact wording of the question is absolute in
that it omits any reference to either an age or time comparison. WHO argues
that the inclusion of such comparisons would prevent the monitoring of progress
in the average health of a population.
General wording: The
reference is to ‘health in general’ rather than ‘present state of
health’. The question is not intended to measure temporary health problems.
Short-term disturbances should ideally not influence answers to the question (WHO-Europe,1996).
Response categories: Five: Very
good, good, fair, bad, very bad.
The following criteria have been used in the analysis
process and in filling out the related table (see also Appendix 7)
Absolute
format: It refers to questions that do not
specially asked the respondents to compare their health with others of the same
age or with their own previous or future health state. Answers categories: Yes,
No (when comparison is asked)
Age
reference: When
the respondent are specifically asked to compare their health with others of
the same age. Answers categories: Yes, No
Time
reference: When the wording includes a reference
time. Answers categories: Yes (it is specified the time reference), No
Verbs
used (What the respondent have to do): What
respondent are asked to do with respect to self-perceived-health. It is
reported the verb used.
What
the respondent must analyse: It is related with
the object of the analysis. The different expression used referring to “health”
are reported.
In
general: It
is reported if a generalizing word is used. Answers categories: Yes, No
Response
categories: The
response categories are reported. (nominal or numerical)
A total of 42 European surveys, out of 53 surveys
analyzed contain questions on
SPH were identified, however two surveys (I04 and N01) included more than one
SPH question. As result, 44 questions have been examined.
If we take into consideration the instrument as whole
(wording-question and answer categories) only 5 surveys (B02, B03, Bc02, I01,
I04 -in both questions) out of 42 surveys have identical wording proposed by
MEHM.
It must be
underline that, among the others surveys, in some case difference are minimum
such as for example in F09 “How is your general state of health?”, or in P01 “What is your general state of health?”
or in S01 and S02 “In your opinion, how is your state of health?” or in UK02
“How is your health in general? Would you say it was…?”, or in H01 “What do you
think about your health in general?”.
In other cases the wording is quite different (such as
for example in E02 “In the last twelve months, i.e. since February 2000, would
you consider your health as being very good, good, normal, bad or very bad?”,
in F03 “Can you indicate, between 0 and 10, your
state of health?” or in IS02 “In
general, how do you evaluate your physical health? Do you find it very good, good, fair or poor?” or in
IS03 “Are you generally in good or poor health? Do you find it very
good, good, fair or poor?”).
If
we take into consideration only the answer categories the number of surveys
using exactly MEHM answer categories is higher (13 surveys, plus at least other
3 in which the difference seems to be related with English translation).
Differences in
wording among the selected ones appear according to:
Only two surveys use a not absolute format -as describe above, in fact
F08 and F12 (same survey carried out in two different years: 1999 and 2001 ask
“Compared with other people your age, would you describe your state of health
as…”. They use an age-related format
to measure SPH.
§
Time
reference
28 out of 42 surveys do not refer to any
time and use the verb in present tense.
14 surveys out of
42 use a time limited format, as they include a reference to time in their
question to measure SPH. In particular, in the majority of these surveys (11
out of 14), respondents are asked about their ‘present’ or ‘current’
state of health using the follows expressions: “Now” (CH01, CH02), “Present” (D02,
Dk02, FIN01, FIN06, FIN09), “At present” (F05, F07, F11), “Nowdays” (FIN03).
While the others 3 surveys refer to the past: “In the last 12 months” (E02),
“Over 12 months” (UK11, UK15).
§
Verbs used (What respondents are asked to do with respect to
SPH).
In fact several
verbs were present in the wordings as follows:
To be (“…how is your ….”): 11 surveys B02,
B03, Bc02, F09, FIN03, I01, I04 (in both questions)
NL03, P01, S01, S02;
To say 10
surveys D05, EL02, IRL01, IRL02, IRL03,
IRL04, N01 (in only
one
question), UK02, UK11, UK15;
To assess/to
evaluate: 5 surveys A01, FIN01,
FIN06, FIN09, IS02
Verbs such as To
describe and To consider were used both in 4 surveys respectively in D02,
F08, F12, N01 -in only one
question; and in E02, F05, F07, F11. While CH01, CH02, L01 surveys use To feel
and DK02, E04 use To rate.
The each of the
following verbs was used in 1 survey: To Find (FIN07), To indicate (F03), To
think about ( H01).
Anyway, in several wording more than one verb is used.
The most common combination is To say and To be in a wording such as “In general, would you say your health is…”
(D05, IRL01, IRL03, N01) or “Would you say that your health, during the last 12
months was..” (EL02) or “In general, how good would you say your health is?
Would you say it is…” (IRL02, IRL04), or
"How is your health in general? Would you
say it was” (UK02), "Over the last twelve months would you say your health has on the whole been good, fairly
good, or No good?” (UK11), "Over
the last twelve months would you say your health has on the whole been?”
(UK15).
§
What the
respondent must “analyze”.
This refers to
different expressions used for concept of health.
The
majority of the surveys (21 out of 42) use
only the word “Health” (B02, B03, Bc02, D05, E02, E04, EL02, I01, I04
(in both questions), IRL01, IRL02, IRL03, IRL04, IS03, L01, N01 (in both
questions), NL03, UK02, Uk11, UK15, H01)
Followed by 14
surveys (A01, D02, Dk02, F03, F05, F07, F08, F09, F11, F12, FIN01, P01, S01,
S02) using “State of health”.
Only 4 surveys
(FIN03, FIN06, FIN07, FIN09) use the expression “Health status”.
Survey IS01
specified to what kind of health it interesting on (Physical health) while
surveys Ch01 and Ch02 do not introduces directly the concept of health, in fact
the wording is “How do you feel now?”
§
Use of
generalizing words
Referring to this
aspect there are 19 surveys (CH01, CH02, D02, E02, EL02, F03, F05, F07, F08,
F11, F12, FIN01, FIN03, FIN06, FIN07, FIN09, L01, S01, S02) that do no not
use any of this kind of word, while 23 surveys do it (A01, B02, B03, Bc02,
D05, DK02, E04, F09, I01, I04 (in both questions), IRL01, IRL02, IRL03, IRL04,
IS02, IS03, N01 (in both questions),
NL03, P01, UK02, UK11, UK15, H01).
§
Response
categories
In addition to the specific wording of the questions, major differences
also appear in the response categories.
Five answer categories have been used in 33 surveys out of 42 (A01, B02,
B03, Bc02, CH01, CH02, D02, D05, DK02, E02, E04, F05, F09, FIN01, FIN03, FIN06,
FIN07, FIN09, I01, I04 (in only one question), IRL01, IRL02, IRL03, IRL04,
IS03, L01, N01 (in both questions), NL03, P01, S01,S02, UK02, H01). It must be
underline that among these 13 surveys use exactly the five MEHM response
categories recommended (very good,
good, fair, bad, very bad).
These surveys are: B02, B03, Bc02, Ch01,
Ch02, E04, I01, I04 (in only one question), IRL02, IRL04, S01, S02, UK02.
Different seems to be related with the translation in the following
cases DK02 (very good = really good), H01 (very bad = very poor), P01 (fair =
reasonable).
The other 17 surveys also include five response categories but the
wording of these categories does not correspond to the MEHM recommendation.
There are variations in the distribution of positive, neutral and negative
response categories. So, although a number of surveys include the same number
of response categories, slight deviations in the wording of the responses makes
it impossible to compare results. (A01, D02, D05, E02, F05, F09, FIN01, FIN03,
FIN06, FIN07, FIN09, IRL01, IRL03,
IS03, L01, N01 (in both questions),
NL03).
A different number of categories is used in 8 surveys as follows:
3 categories (UK11, UK15)
4 categories (EL02, F08, F12, IS02)
6 categories (F07, F11)
2 surveys use rating scales ranging from 1 to 10 (F03) or from 1 to 5
(104, only for one questions). These differences of course have a strong
implications on the score systems and on the possibility to make international
comparisons.
Second question of MEHM:
Chronic morbidity
|
“Do
you have any long-standing illness or health problems? Yes No” |
The second global instrument of the MEHM is an open-ended question used
to measure the global indicator on chronic morbidity.
Chronic diseases represent, as well known, one of the most
relevant problem for the health-related quality of life, especially for the
elderly, and one of the main cause of utilisation of health services. Often,
the chronic diseases play a key role, altering an individual's ability to be
self-sufficient and affecting his psychic and motor skills for long periods of
time or indefinitely. These reasons allow acknowledging the diffusion of
chronic diseases in a population.
The instrument has been developed by ISTAT for Euro-HIS and also
accepted by Euro-REVES.
The exact wording of the question depends on the cross-cultural
applicability and validity, for this reason the instrument proposed by
Euroreves was a conceptual translation of the Chronic Disease question
developed by ISTAT for EuroHIS
Context/Brief Summary:
According
to the functional approach, that was developed, in the last twenty years,
mainly to assess the consequences of the emerging poor health status on daily
life activities, chronic morbidity is strongly related to the disability
indicators since many impairments or disorders, which are usually parts of the
“diseases process” can result in long term disability; more exactly, the
consequences of the diseases can conduct an individual to suffer from
functional limitations and activity restrictions as a result of interaction
between physical conditions and social environment.
Chronic
morbidity indicators have been officially adopted as relevant to policy by the
Member States of the WHO for evaluation of national health policies, and they
have been included as a field of actions in the EuroHIS project (WHO-Euro, granted by the Union, BIOMED 2).
The Euro-HIS project.
The
project aims at selecting the common
instruments and methodology to be used in the European Region by all the Member
States in the context of health interview surveys.
Common instruments proposed for chronic conditions are the result of a
two year work on this topic by the Euro-HIS project. The stages undertaken were:
Concept
exploration
What do we mean as chronic condition?
Analysis
of some important methodological aspects
What is the right methodological approach for the
surveying of chronic conditions?
What is the right reference period?
What are the criteria for reporting?
Analysis
of the instruments adopted by the European countries
Based on the
main results from the survey on surveys.
Development of preliminary common instrument to
survey chronic physical conditions
On the base of
an international review on chronic diseases, comparability of questions and
methodological aspects in different surveys have been analysed.
Pre-test and Field-test
To assess the
applicability of the instrument, the quality of transfer into national
environment, the comprehension of the questions proposed.
Draft proposal of common instrument to survey
chronic physical conditions,
Based on the Italian
pre-test and field-test experience and on the pre-testing results of other
European countries.
Very
few countries have indicated an explicit criteria for defining chronic
conditions, usually these criteria refer to the nature of the disease and to
its duration. Most of the countries have reported the question (open ended
and/or specific disease) used by them to survey chronic conditions.
There
is a general agreement on the following characteristics of chronic condition:
are permanent and may be expected to require a long period of supervision,
observation or care.
In surveying chronic conditions, two types
of questions can be used: open-ended questions and disease-specific questions.
The open-ended question inquires whether respondents have a chronic condition
and, eventually, which one. The disease-specific question includes a checklist
of condition or diseases (or a card that has to be shown) and respondents are
questioned whether or not they are affected from one or more of them.
Open-ended questions used by different countries rarely
refer explicitly to physical and/or mental conditions, generally they refer to
"any chronic conditions, defect or injury". In most cases open-ended
questions include explicitly handicaps and/or disabilities.
Similar problems are found in the disease-specific
questions. The checklist includes different type of conditions: physical and/or
mental and/or disabilities.
The prevalence of chronic diseases resulting from the
global question is generally underestimated if compared with the prevalence
coming from the specific questions. The
higher prevalence for female and the increasing trend with age are consistent
with the knowledge of the phenomenon.
Question
characteristics
ICF domain: BS- BF
Duration (long term/short term):
Long standing
Dichotomous/Multiple response categories:
Dichotomous (Yes/No)
Terminology:
Neutral
Reference/Norm/:
NO
Complexity: NO
Age-oriented: NO
How the question address mental
functioning: Not directly, it is included in
“illness/health problem”.
Main Results
A
total of 39 out of 53 European Surveys have questions related on long standing
illness or health problems. Survey B02
has two questions.
As
already pointed out, two types of
questions are used in surveys: open-ended questions and disease-specific
questions.
Following the criteria of these two approaches the 39 surveys can be divided
in two groups:
- 24 Surveys with global approach: B02 in both questions, B03,
Bc02, CH01, CH02, DK02, EL01, EL02, F08, F09, F12, FIN03, FIN06, IRL02, IRL04,
IrlC02, N01, NL03, S01, S02, UK02, UK11,UK15, H01.
-
15 Surveys with specific approach: A01, D02, D05, E02, E04, F03, FIN07,
FIN09, I01, I04,IRL01, IRL03, IS02, NL02, H01.
Out of the 24 surveys using a global approach question, 7 surveys (B02,
Ch01, Ch02, EL02, FIN03, FIN06, NL03) have also a question with specific approach using a list.
Only the “global approach” questions were analyzed
following these criteria (see also Appendix 8)
Global
approach: it is considered as global approach
when the question simply asks if the person is suffering/has a chronic disease.
Answer categories: Yes, No.
Specific
approach: it
is considered as specific approach when the question asks which is disease
(with or without reference list). Answer categories: Yes, No. If yes, it is
also specified if the answer categories is open or has a list.
Time
reference: It
is related with reference time given in the wording. Answer categories:
present, past, future.
.
Other
concepts: It
refers to other concepts specific included in the wording. Here are reported
the words used.
Use
of neutral terminology: It is related with the
use of word neutral connotation. Answer categories: Yes, No.
Response categories: Dichotomous,
Multiple.
In some cases
difference are related with the introduction of others concepts such as cause of the health problems
or typologies of health or to underline that this/these illness limits the
respondent in carrying out activities.
Differences in
wording among the selected ones appear according to:
§
Time
Reference
No
time reference
in 17 surveys (B02 – in both questions, B03, Bc02, DK02, EL01, EL02, F09,
FIN03, FIN06, IRL02, IRL04, IrlC02, NL03, S01, S02, UK15, H01).
Time
reference is
given in 7 surveys as follows:
-
Future: F08 and F12 “that will
continue to affect you in the future?”
-
Past
and Future:
N01 “it has lasted or is expected to last for 6 months or more”; UK02 and UK11
“has trouble you over a period of time or that is likely to affect you over a
period of time”
-
Past: Ch01 e CH02 “you have had for more than one year”
§
Long
standing/chronic
Only
4 surveys (CH01, Ch02, EL02, Fin06, H01) do not refer in the wording
directly to long standing/chronic
illness but Ch01 and Ch02 specified that the problem or illness should have
“more than one year” duration.
A
total of 20 surveys out of 24 use long-standing or chronic in the wording.
§
Other
concepts:
Some
surveys add other concepts to indicate cause of the health problems or
typologies of health or to underline that this/these illness limited the
respondent in carrying out activities.
For
example, Dk02, FIN03, N01,
S01 and S02 refer respectively to “after effect from injury”, “Some
defect, trouble or injury”, “disorder congenital, disease or effect of an
injury”, “after effect from an
accident”, while EL02,
F08 and F12, IRL02 and IRL04 refer respectively to “physical disease”, “physical
infirmity”, “Physical and mental problem”. IrlC02 refers to
specific type of disabilities such as
“blindness, deafness, or a severe vision or hearing impairment”.
Furthermore, 5 surveys (FIN03, FIN06 IrlC02, UK15, H01) include
reference to the concept that the respondent can be affected by this/these illness
in working capacity, in functional ability or can be limited in usual
activities.
The introduction of other concepts quite often include also the use or
not neutral terminology.
§
Neutral Terminology
18
surveys out of 24 do not use neutral terminology. The word “disability” is used
by 10 Surveys: DK02, FIN06, IRL02, IRL04, IrlC02, S01, S02, UK02, UK11, UK15.
The word “handicap” is used by 8 surveys: B02 – in only one questions, B03, Bc02, EL01, EL02, F08, F12, NL03.
§
Response
categories:
All
24 surveys with global approach use a dichotomous as answer category. Only B02,
B03, Bc02, F08, F09, F12 add also “Doesn’t Know”.
Third question of MEHM: Limitation in usual
activities[1]
|
“For
at least the past 6 months or more have you been limited in activities people
usually do because of a health problem? Yes,
strongly limited Yes,
limited No,
not limited” |
A
Global Activity Limitation Indicator (GALI, previously referred to as Global
Disability Indicator (Verbrugge, 1997) is defined as an instrument that is able
to identify subjects, in both general and/or specific populations, who perceive
themselves to have long-standing, health-related limitations (restrictions) in
the usual activities.
There
are two main reasons to develop a GALI for public health policy.
First,
due to the ageing of populations and the change in the morbidity-profile to
chronic health conditions, simple information on health has to be extended with
a concise instrument which provides policy makers with easily obtainable
information on the perception of activity limitations that could result
in a need for support. Further activity limitations may lead to disadvantages
in social participation.
Instruments
to measure limitations in usual activities are normally complex (multi-item)
instruments. The output of these instruments depends on the specific activities
included. In different countries or surveys different instruments are used,
making comparisons almost impossible.
Secondly,
similar to the concept of perceived health, there is a search for developing a
global single question instrument to measure these activity limitations,
independently of the type of activity, the specific life situations, the kind
of health problem causing the activity limitation, specific age groups, sexes
or other subgroups.
A
single question instrument should make it more acceptable for countries and
researchers to include it in their different surveys, making comparison between
countries and subgroups possible.
The
proposed instrument is a global single item instrument.
The
following steps were taken in developing the proposal for a GALI:
·
the conceptual framework of the ICF, and
previous work in the framework of REVES was used to develop a set of criteria
for evaluation of candidate GALI instruments;
·
instruments were collected for evaluation
by a Medline search, over the time period 1990-1999 and using key words
disability/measurement/activity limitations, and by an extensive E-mail survey
among experts in the field of disability research;
·
instruments were qualitatively screened
for a set of criteria;
·
selection of existing or the creation of
a new instrument to be proposed.
A standard
procedure was set up to develop the GALI-instrument in the different languages
of the European Member States (MS). In a first step a translation procedure was
developed with focus on the concept rather than the technical translation. The
formulation into an other language was done by both a linguist and a public
health scientist independently; another linguist and public health scientist
were then responsible for a back translation. All were provided with technical
information explaining the concept of the GALI. After the control through
back-translation the proposed version was evaluated against the major concept
within the instrument:
Activity
limitations or restriction
• Caused by a
health problem or condition
• Duration of the
limitation: at least 6 months before the interview
• Population norm
: activities people usual do
The
GALI-instrument is currently translated in 10 languages.
Purpose
The
instrument will allow estimation of the number of persons in a population that
perceive themselves to have limitations in their activities, estimating the
prevalence of the perceived activity limitations of that population.
Depending
on the type or the objectives of the survey and the need for more information,
the GALI instrument can be extended by additional questions providing
information on the life situations in which the activities are limited, on the
causes of the activity limitation and on the use of personal assistance and/or
devices.
Question
characteristics
ICF
domain: Activities
Capacity/Performance:
The measure address Performance.
Duration
(long term/short term): 6 months but it is
related with activity limitation and not with health problems/disability.
Dichotomous/Multiple
response categories: Nominal Scale
responses (Yes strongly limited,/ Yes, limited/ No, not limited).
Causes
of disability:
General health-related problems as cause of the limitations.
Terminology:
Neutral words
Reference/Norm/:
NO, In the definition of the GALI, the term “usual activities” refers to the
fact that the limitations in the execution of actions and tasks are assessed
against a generally accepted population standard, relative to cultural and
social expectations. This is consistent with the self-perceived health
instrument and gives no restrictions by culture, age, gender or the subjects
own ambition.
Complexity:
NO
Age-oriented:
NO, there is no reference to specific type of activities, the same instrument
can be used for subgroups in a population: age, gender, cultural. All these
specific subgroups have their own usual activities.
In order to provide good estimates of the
perceived activity limitations of a population, this instrument should be
administered to a general population of all ages or to special groups within a
population. The wording of the proposed instrument does not relate to any age
group in particular. The simple wording should also allow administration in
institutionalized populations and can be used in different survey methods.
How
the question address mental functioning: NO
directly. It is enclosed in the concept of health problems
Instructions:
It is defined long-standing as a time period of 6 months or more. The time
period refers to the duration of the activity limitation and not of the
health condition, as the focus of a GALI instrument is on the activity
limitations and not as much on the health problems.
The
GALI should refer to health-related problems as cause of the limitations. The
indicator is not meant to measure limitations due to financial, cultural
or other none health-related causes.
To
be general, specification of health concepts (e.g. physical and mental health)
should be avoided. Existing instruments sometimes refer only to physical health
problems, other instruments to physical and mental health problems and a few of
them to additional problems, mainly combined in one question, but often in up
to three specific questions. This makes comparison more difficult.
According
to the ICF an activity is defined as: ‘the execution of a task or action by
an individual’ and thus activity limitations are defined as ‘the
difficulties the individual experience in executing an activity’ (World
Health Organization, 2001) Within the framework of the ICF, limitations should
be due to a health condition.
In
the definition of the GALI, the term “usual activities” refers to the fact that
the limitations in the execution of actions and tasks are assessed against a
generally accepted population standard, relative to cultural and social
expectations.
Main
Results
A total of 26 European surveys
containing question on activities limitation (as global approach) were
identified. Surveys A01 and B02 have
two questions on the same topic both of them were included. The
total of question analyzed is 28.
It must be underline that several survey investigate “activities
limitation” with more than one or two questions and usually they refers to ADL,
IADL scale or similar. The surveys using such scale and without a global
approach to the topic were not taken into account.
Furthermore, several surveys adopt a global approach question followed
by more detailed question on type of activities limitation.
All questions selected
were analyzed (see Appendix 9)
using the following criteria:
Time reference for activities limitation: it is
related with time reference used in the question, if Yes, it is reported.
Norm reference: it
refers to if it is asked to compare with what people of the same age done.
Answers categories: Yes, No
Attribution to health: This
address the issue if the wording enclosed a reference to health problem as
caused of the limitation in activities and participation. Answer categories: Yes (words used are
reported), No
Limited in activities: It
refers to if the question does or doesn’t indicate specific activities. Answer
categories: Yes (if it is a specific reference to activities or environment),
words are reported), No.
Need of help: It refers to whether in the wording it is also asked
if the person needs assistance in doing activities. Answer categories: Yes, No
Use of neutral terminology: It is related with the use of word with neutral connotation. Answer
categories: Yes, No
Response categories: The
response categories are reported.
In same case
difference are related with the introduction of details on the type of
activities or context, or on the type of health conditions, or with the
introduction of other concepts such as “need of help”; in others difference are
related with the omission of the time reference for activities limitation.
Differences in
wording among the selected ones appear according to:
Almost all the surveys (23 out of 26
surveys) do not use expression to give a time reference related with activities
limitation.
Only B02 (“for the last past 6 months or
more”) and F09 (“during at least six months”)
give a time reference related with the past. H01 indicates “today” as
time reference.
Must be underline that B02 survey has two questions and only one gives
time reference.
§
Norm Reference
In the European surveys analysed, the
questions never use a norm reference.
§
Attribution to health conditions
22 surveys out of 26 in the wording
attribute the activities limitation to health conditions. (A01- in both
questions, B02 – in both questions, B03, Bc02, D02, DK02, E02, F02, F09, I01,
I03, I04, IRL01, IRL02, IRL03, IRL04, IrlC02, N01, NL02, NL03, UK02, UL11).
Only 4 surveys (F1999, FIN06, IS02, H01)
do not ask if the activities limitation is due to health conditions.
§
Activity restriction
8 surveys refer to activity with any
other specification in the wording/instruction (B02 – in both questions, B03,
Bc02, F09, IRL02, IRL04, UK02, UK11), while
17 surveys refer not only to “usual activities” or “everyday life” but also
to context or example of activities (A01- in both questions, D02, DK02, E02,
F1999, FIN06, I01, I03, I04, IRL01, IRL03 IrlC02, IS02, N01, NL02, NL03, H01).
F02 do not ask about activities
limitation but to “physical, sensorial intellectual or mental difficulties”.
§
Need of help
The majority of the surveys (21
surveys out of 26) do not include this
concept in the question (B02 – in both questions, B03, Bc02, D02, DK02, F02,
F09, F1999, FIN06, IRL01, IRL02, IRL03, IRL04, IrlC02, IS02, N01, NL02, NL03,
UK02, UK11, H01), while
5 Surveys (A01 – in both questions, E02, I01, I03, I04) ask the respondent if
he/she needs help in doing everyday life activities.
As examples of wordings:
I01, I03, I04 “Are you affected by a
longstanding illness or a permanent disability that reduces your personal
freedom till requiring help from other people for daily needs inside and
outside the home?
NO
YES, intermittently, for some needs
YES, continuously, or for important needs”;
E02
“Does some of people of the household need some type of special dedication for
the fact of suffering a handicap or some limitation (not being able to be
alone at nights, to need help to go out in the street, personal hygiene, etc.)
to carry out with normality the activities of the family, social and labour
life?
Yes
No”
14 surveys use neutral terminology (A01 –
in both questions, D02, DK02, F02, F09, F1999, FIN06, I03, I04, IrlC02, IS02,
NL02, NL03, H01), while
11 surveys (B03, Bc02, E02, I01, IRL01,
IRL02, IRL03, IRL04, N01, UK02, UK11) use “handicap” or “disability2 that are
not considered as neutral words.
B02 survey uses neutral terminology in one
question and no neutral terminology in other where is added “handicaps”.
The total of 26 surveys can be divided in
two groups by following the response categories used:
-
multiple in
17 surveys
-
dichotomous in 7
surveys (E02, F02, F09, F1999, IrlC02, UK02, UK11). To this surveys should be
add IRL01 e IRL03 that use an unique type of answer categories “Yes
No, Do not have any of the above”.
The
17 surveys using multiple response categories can be also split in two groups
taking into account if the answer categories are based on “degree of restrictions/limitations/difficulties” or on
the “frequency” of the limitations:
-
10 surveys refer to the degree of the
limitations (D02, Dk02, FIN06, IRL02, IRL04, IS02, N01, NL02, NL03, H01)
-
6 surveys refer to the “time” dimension (
A01- for both questions, B03, Bc02,
I01, I03, I04)
B02
utilize both aspect of the limitation, one for each questions.
Examples of answer categories regarding to
“degree” of the limitations are as follows:
“Yes, strongly limited/Yes limited/No, not
limited” (B02 – in only one question)
“Not at all/ A little/ Considerably” (D02)
“Yes, very much/ Yes, a little/No” (DK02)
“ No difficulty coping/ Slight difficulty
coping/ A great deal of difficulty coping/ I cannot cope on my own” (Fin06)
“Yes, severely/ Yes to some extent/ No” (IRL02,
IRL04)
“Very difficult/ Rather difficult/ Slightly
difficult/ Not at all difficult” (IS02)
“Not possible / Extremely difficult / Somewhat
difficult / Not difficult” (N01)
“No difficulties/ Some difficulties / unable to
carry out” (NL02)
“Severely limited/ Moderate limited/ Not
limited” (NL03)
“I have no problems with performing my usual
activities/ I have some problems with performing my usual activities/ I am unable to perform my usual activities”
(H01).
Examples of answer categories regarding to “frequency”
of the limitations are as follows:
“Never/Sometimes/Frequently/Always” (A01);
“Continually/At intervals/ Not or seldom” (B02 – in only one
question, B03, Bc02);
“Yes, Intermittently or occasionally for some
needs/ Yes, continuously or for important needs/No” (I01, I03, I04).
Among the surveys using multiple answer
categories (19 out of 26 surveys) adopt 3 or 4 categories as follows:
-
3 answer categories are used in 14 surveys (B02-
in both questions, B03, Bc02, D02, Dk02, Fin06, I01, I03, I04, IRL02, IRL04,
NL02, NL03, H01);
-
4 answer are used in 3 surveys (A01 in both
questions, IS02, N01).
Final Remarks
From the review of the questions related to MEHM
used in European surveys the following conclusion can be drawn:
§
48 out of 53 surveys selected have at least one
question related to MEHM. It is important to underline that for some other
surveys the full questionnaire or the full wording were not available. Furthermore, for some of the surveys included
in the 48 more information and documents are needed to have a better complete
picture of the questions used.
§
Among the 48 surveys (see appendix 5a):
-
66% of 48 surveys cover all the three topics of
MEHM questions. Differences to the instruments proposed by MEHM are due to add
more specification on health condition or to activity restriction. The instruments used are generally quite similar
to the ones proposed; differences are also due to the translation in English.
-
Only 5
surveys (EL01, F02, F1999, IrlC02, NL02) seem not ask question on SPH. F08 and
F12 ask in not absolute format using “compared with other people your age”
and IS02 asks specifically on physical
health.
-
Only 9 surveys (F02, F05, F07, F11, F1999, FIN01, IS03, L01, P01) seem
do not have any kind of questions on long standing / chronic illness. 24
surveys use a global approach while 16 surveys prefer a specific approach.
-
In some cases
a question refer to both long standing illness/disability and activities
limitations (e.g. Ch01, Ch02, FIN03, FIN06, IrlC02, UK15, H01). Among these
surveys only 4 surveys (FIN06, IrlC02, UK15, H01) have another question with
global approach to activities limitations.
-
30 surveys have a global question on activity
limitation. 18 surveys (Ch01, Ch02, E04, EL01, EL02, F03, F05, F07, F08, F11, F12, FIN01, FIN07, FIN09, IS03, L01 S01,
S02) seem do not use a global approach on Activity Limitations issue.
-
All three questions with global approach in the
second question are included in 14 surveys (B02, B03, Bc02, Dk02, F09, FIN03,
FIN06, IRL02, IRL04, N01, NL03, UK02, UK11, H01)
-
All three questions with specific approach in
the second question are included in 18 surveys (A01, D02, D05, E02, I01, I03,
I04, IRL01, IRL03, IS02).
Appendix 5b (cfr Annex 5b)
“Overview of
the questions used in the European surveys”
Appendix 6
“Legend of criteria used for analyzing MEHM- related
questions”
Code: Database
His/Hes survey number code
Country:
Name
of the Country
Year: Year
of the survey
Title
Survey: Title
of the survey
Wording:
The exact wording is reported. Some
survey have is more than one question on this topic; each one was under
analysis.
Absolute
format: When the respondent are not
specifically asked to compare their health with others of the same age or with
their own previous or future health state. Answers categories: Yes, No
Age
reference: When
the respondent are specifically asked to compare their health with others of
the same age. Answers categories: Yes, No
Time
reference: When the wording includes a reference
time. Answers categories: Yes (it is specified the time reference), No
Verbs
used (What the respondent have to do):
What respondent are asked to do with respect to self-perceived-health. It is
reported the verb used.
What
the respondent must analyse: It is related to the
object of the analysis. The different expression used referring to “health” are
reported.
In
general: It
is reported if a generalizing word is used. Answers categories: Yes, No
Response
categories: The
response categories are reported. (nominal or numerical)
The
analysis is done only for the questions that are considered related with
“global approach”.
Code: Database
His/Hes survey number code
Country:
Name
of the Country
Year: Year
of the survey
Title
Survey: Title
of the survey
Wording:
The exact wording is reported. In
some case there is more than one, for each one analyse is done
Global
approach: it is considered as global approach
when the question simply asks if the person is suffering/has a chronic disease.
Answer categories: Yes, No.
Specific
approach: it
is considered as specific approach when the question asks which is disease
(with or without reference list). Completed analysis is done only for question
is not done for this type of question. Answer categories: Yes, No. If yes, it
is also specified if the answer categories is open or has a list.
Time reference: It is related to
reference time given. Answer categories: Yes (time is reported), No
.
Other
concepts: It
refers to other concepts specific included in the wording. Here are reported
the words used.
Use
of neutral terminology: It refers to using
words with neutral connotation. Answer categories: Yes, No
Response categories: Dichotomous,
Multiple.
Code: Database
His/Hes survey number code
Country:
Name
of the Country
Year: Year
of the survey
Title
Survey: Title
of the survey
Wording:
The exact wording is reported. In
some case there is more than one, for each one analyse is was made.
Need of help: It refers to whether in the wording it is also
asked if the person need assistance in doing activities. Answer categories:
Yes, No
Use
of neutral terminology: It refers to using
words with neutral connotation. Answer categories: Yes, No
Response
categories: The
response categories are reported.
Appendix
7 (cfr Annex 7 MEHM1 in Annex 7 8 9 MEHM analysed)
“Analysis
of questions related to MEHM 1”
Appendix
8 (cfr Annex 7 MEHM1 in Annex 7 8 9 MEHM analysed)
“Analysis
of questions related to MEHM 2”
Appendix
9 (cfr Annex 7 MEHM1 in Annex 7 8 9 MEHM analysed)
“Analysis
of questions related to MEHM 3”
[1]
(The following information is based on Cap. 5 “Limitation in usual
activities, a global approach” - Contributors: Rom Perenboom, Herman Van Oyen,
Loes van Herten-, enclosed in “Selection of a Coherent Set of Health Indicators
for the European Union. Phase II- Fianl Report, Edited by J-M Robine, C. Jagger
and I. Romieu)