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Voluntary module in EHIS wave 3:HEALTH OF CHILDREN

2 versions of questionnaires for pre-testing

Table of Contents

1 Introduction...........................................................................................................................3

1.1 Questions proposed in version A: Focus on disability.......................................................................3

1.2 Questions proposed in version B: Focus on prevention.....................................................................3

1.3 Questions developed by Eurostat contractor but not proposed for pre-testing..............................4

2 Pre-testing version A: Focus on disability.............................................................................5

2.1 Height and weight of children (CBM).................................................................................................5

1) CBM1: Height of child without shoes....................................................................................................5

2) CBM2: Weight of child without shoes or clothes...................................................................................6

2.2 Minimum European Health Module (MEHM) for children.............................................................7

3) CHS1: Perceived general health of child: how the respondent perceives the child's health in general. .8

4) CHS2: Child longstanding health problem: Child suffering from any illness or health problem of duration of at least six months..........................................................................................................................8

5) CHS3: Child general activity limitation: Child limitation in activities children usually do because of a health problem for at least the past six months................................................................................................9

2.3 Physical and sensory functional limitations of children (CPL)......................................................11

6) CPL1: Child wearing glasses or contact lenses.....................................................................................13

7) CPL2: Difficulty of child in seeing even when wearing glasses or contact lenses...............................13

8) CPL3: Child using hearing aid..............................................................................................................14

9) CPL4: Difficulty of child in hearing even when using hearing aid......................................................15

10) CPL5: Child using equipment or receiving assistance for walking......................................................16

11) CPL6: Difficulty of child in walking without any aid or support.........................................................17

2.4 Cognitive limitations of children (CCL)...........................................................................................18

12) CCL1: Difficulty of child in learning new things.................................................................................19

13) CCL2: Difficulty of child in remembering things.................................................................................20

2.5 Social and mental health difficulties of children (CSM)..................................................................20

14) CSM1: Behavioural difficulty of child.................................................................................................21

15) CSM2: Mental health difficulty of child...............................................................................................22

2.6 Mobility and participation restrictions of children in major life domains....................................23

16) CMR1A: Difficulty of child in leaving [his/ her] home because of a longstanding health problem....25

17) CMR1B: Difficulty of child in accessing buildings [he/ she] wants to use because of a longstanding health problem................................................................................................................................................25

18) CMR1C: Difficulty of child in moving about in buildings [he/ she] wants to use, once inside because of a longstanding health problem...................................................................................................................25

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2.7 Participation of children in compulsory education..........................................................................26

19) CPR1: Difficulty of child participating in compulsory education because of a longstanding health problem..........................................................................................................................................................26

2.8 Participation of children in pursuing leisure activities....................................................................27

20) CPR3: Difficulty of child in pursuing leisure activities because of a longstanding health problem....27

3 Pre-testing version B: Focus on prevention........................................................................30

3.1 Height and weight of children (CBM)...............................................................................................30

1) CBM1: Height of child without shoes..................................................................................................30

2) CBM2: Weight of child without shoes or clothes.................................................................................31

3.2 Minimum European Health Module (MEHM) for children...........................................................32

3) CHS1: Perceived general health of child: how the respondent perceives the child's health in general33

4) CHS2: Child longstanding health problem: Child suffering from any illness or health problem of duration of at least six months........................................................................................................................33

5) CHS3: Child general activity limitation: Child limitation in activities children usually do because of a health problem for at least the past six months..............................................................................................34

3.3 Physical and sensory functional limitations of children (CPL)......................................................36

6) CPL1: Child wearing glasses or contact lenses.....................................................................................38

7) CPL2: Difficulty of child in seeing even when wearing glasses or contact lenses...............................38

8) CPL3: Child using hearing aid..............................................................................................................39

9) CPL4: Difficulty of child in hearing even when using hearing aid......................................................40

10) CPL5: Child using equipment or receiving assistance for walking......................................................41

11) CPL6: Difficulty of child in walking without any aid or support.........................................................42

3.4 Cognitive limitations of children (CCL)...........................................................................................43

12) CCL1: Difficulty of child in learning new things.................................................................................43

13) CCL2: Difficulty of child in remembering things.................................................................................44

3.5 Social and mental health difficulties of children (CSM)..................................................................45

14) CSM1: Behavioural difficulty of child.................................................................................................46

15) CSM2: Mental health difficulty of child...............................................................................................47

3.6 Physical activity/ exercise of children (CPE)....................................................................................47

16) CPE1: Number of days in a typical week carrying out sports, fitness, or recreational (leisure) physical activities that cause child to get out of breath or sweat..................................................................................48

17) CPE2: Time spent on doing sports, fitness, or recreational (leisure) physical activities that cause child to get out of breath or sweat...........................................................................................................................49

3.7 Child consumption of fruit and vegetables (CFV)...........................................................................50

18) CFV1: Frequency of child eating fruit, excluding juices......................................................................51

19) CFV3: Frequency of child eating vegetables or salad, excluding potatoes and juices.........................52

3.8 Child consumption of sugar-sweetened beverages (CSB)...............................................................53

20) CSB1: Frequency of child drinking sugar-sweetened soft drinks a week............................................53

4 Annex: List of questions not-proposed to TF EHIS for pre-testing......................................55

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1 IntroductionEurostat Unit F4 has been mandated by the European Directors of Social Statistics (DSS) to check – in collaboration with the countries participating in the European Statistical System (ESS) – whether an introduction of a sub-module on children's health in EHIS wave 3 could be realistic and feasible. In order to realise this task, the following two versions of questionnaires are proposed to countries for pre-testing:

1.1 Questions proposed in version A: Focus on disabilityThe set of 20 questions proposed for pre-testing called 'Version A' (focus on disability) is almost identical with the 'short module' (16 questions) of the Eurostat contractor. The following adaptions were proposed by Eurostat and discussed by the TF EHIS, though:

1) Two questions on the height, i.e. 1) CBM1 and weight, i.e., 2) CBM2 of the children are added (from the 'long module' of the contractor);

2) The three questions of the Minimum European Health Module (MEHM, adapted for children), i.e. 3) CHS1, 4) CHS2 and 5) CHS31 are added (from the 'long module' of the contractor);

3) Question CPL62 in the contractor proposal is removed; question CPL7 in the contractors proposal is renamed to 11) CPL6 (in versions A and B);

4) In order to reduce the number of questions, variable 20) CPR33 is proposed to be asked in a simplified version (see question 20) CPR3 in this document).

1.2 Questions proposed in version B: Focus on preventionThe set of 20 questions proposed for pre-testing and called 'Version B' (focus on prevention) reduces the focus on disability and adds more prevention related questions to the children's questionnaire. In detail:

1) The first 15 variables proposed for pre-testing in version B are identical with the first 15 questions in version A. Consequently, remarks 1) to 3) in paragraph 1.1 above are valid as well for version B.

2) However, in version B questions 16) to 18) were replaced (compared to version A) by two questions on physical exercise and two questions on the consumption of fruit and vegetables. The corresponding three 'new' questions 16) CPE1, 17) CPE2, 18) CFV1 and 19) CFV34 of version B were added from the 'long module' of the contractor.

3) Moreover, question 20) of version B was replaced (compared to version A) by a question on children's consumption of sugar-sweetened soft drinks. This 'new' question 20) CSB15 (identical with question DH6 in the EHIS wave 3 adult-persons questionnaire, except for a few adaptions of the particular wording for children) is taken from the 'long module' of the Eurostat contractor.

1 CHS1: Perceived general health of child; CHS2: Child longstanding health problem; CHS3: Child general activity limitation.

2 CPL6: Difficulty of child in walking even when using equipment or receiving assistance.3 CPR3: Difficulty of child in pursuing leisure activities because of a longstanding health problem. In the contractor's

proposal the variable consists of three questions: the level of difficulties is asked separately for three different kinds of activities: 1. Leisure activity; 2. Pursuing hobbies or interests, or playing with other children; 3. Attending cultural events.

4 CPE1: Number of days in a typical week carrying out sports, fitness, or recreational (leisure) physical activities that cause child to get out of breath or sweat; CPE2: Time spent on doing sports, fitness, or recreational (leisure) physical activities that cause child to get out of breath or sweat; CFV1: Frequency of child eating fruit, excluding juices; CFV3: Frequency of child eating vegetables or salad, excluding potatoes and juices.

5 The question 'CSB1: Frequency of child drinking sugar-sweetened soft drinks a week' could not be 'copied 1:1' from the 'long module' of the contractor because it actually contained eight questions. It is asked there individually for the frequency of drinking of the following beverages: A 100% fruit juice; B 100% vegetable juice; C Sweetened juices; D Soft drinks, regular; E Soft drinks, diet; F Sweetened tea; G Meal replacement shakes/ protein drinks; H Energy/ Sports drinks.

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1.3 Questions developed by Eurostat contractor but not proposed for pre-testing

Questions not proposed for pre-testing:The Annex (Section 4) shows the list of questions that were developed by Eurostat contractor, but are not proposed to the ESS countries for pre-testing.

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2 Pre-testing version A: Focus on disability2.1 Height and weight of children (CBM)

Rationale: According to the European Heart Network, data from several studies suggest that childhood obesity has increased steadily in Europe over the past two to three decades. In fact, it is estimated that almost 20% of children in Europe are overweight or obese, with some of these obese children already having multiple risk factors for type II diabetes, heart disease and a variety of other co-morbidities.

Policy priority: Medium

Calculation: Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. For children, however, age needs to be taken into consideration.

According to WHO, for children aged between two and 19:

- overweight is BMI-for-age greater than one standard deviation above the WHO Growth Reference median; and

- obesity is greater than two standard deviations above the WHO Growth Reference median.

The upper age limit was adjusted to cover up to the age after which EHIS picks up from, which is 15 years old. Thus, the question concerns two (WHO lower barrier)6 up to 14 years of age (in completed years).

An alternative source for the calculation of child overweight and obesity (and underweight) – used by Statistics Netherlands, for example – can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27365/pdf/1240.pdf.

According to the CHILD project, BMI of children at primary school entry should be used as the core indicator, while for the ages of 10 and 15 BMI should only be used if adequate measurement and recording systems at these additional ages can be provided.

Given that in a general health interview survey, sample size needs to be large enough, and since only a small part of the proxy respondents will have children at the ages of five/ six, 10, and 15, it is recommended that BMI is estimated for all children, regardless of age.

Introduction CBMI would now like to talk to you about the child's height and weight.

1) CBM1:Height of child without shoes

FILTERINTERVIEWER: NEXT QUESTION (CBM1) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD.

1) Question

How tall is [child's name] without shoes?1. _ _ _ [cm]

6 See http://www.who.int/mediacentre/factsheets/fs311/en/ 5

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27365/pdf/1240.pdf

http://www.who.int/mediacentre/factsheets/fs311/en/

2) Guidelines

General concept: Body height of child, aged two to 14 years old

Policy relevance: Close link to ECHI 42

Definitions and examples: How tall is the child without shoes: body length measured without wearing shoes.

Note (1): Other measurement units are allowed, but the data has to be converted into cm.

Note (2): An estimate should only be asked when the proxy respondent indicates that they do not know the exact answer.

2) CBM2:Weight of child without shoes or clothes


1) Question

How much does [child's name] weigh without clothes or shoes?1. _ _ _ [kg]

2) Guidelines

General concept: Body weight of child aged two to 14 years old


Definitions and examples: How much the child weighs without clothes or shoes: weight measured without clothes or shoes in kilograms or stones and pounds.

Note (1): Other measurement units are allowed but the data has to be converted into kg.


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2.2 Minimum European Health Module (MEHM) for children

Rationale: SELF-PERCEIVED HEALTH: 'Subjective health measurement is contributing to the evaluation of health problems, the burden of diseases and health needs at the population level. Perceived health status is not a substitute for more objective indicators, but rather complements these measures. Studies have shown perceived health to be a good predictor of subsequent mortality.'

SELF-REPORTED CHRONIC MORBIDITY: 'Widely used measure of general health, contributing to the evaluation of health problems, the burden of diseases and health needs at the population level.'

LONG-TERM ACTIVITY LIMITATIONS: 'Widely used measure of general health, contributing to the evaluation of health problems, the burden of diseases and health needs at the population level.'

The proposed questions CHS1 and CHS3 are based on the 2017 EU-SILC questions of the ad-hoc module on children’s health. While question CHS2 was adjusted to children from the corresponding EHIS question HS2 addressed to adults, regarding longstanding health problems.

It is worth noting that USA’s National Survey of Children's Health (NSCH) contains an identical question to CHS1: In general, how would you describe [child’s name]’s health?, as well as a similar question to CHS3: Is [child’s name] limited or prevented in any way in [his/ her] ability to do things most children of the same age can do?

At this point it should be noted that relevant literature suggests that general questions on longstanding illnesses and activity limitations may collect information that is inaccurate. They can be overwhelming in scope or seem illogical to respondents, who should they have problems with only one activity, a positive response may feel like it is conveying the wrong overall picture of their limitations. Furthermore, asking about the status of specific health domains separately may impose artificial restrictions on respondents’ health-related cognitive space, limiting their interpretation of health and retrieval of related information.

In view of the above, some additional examples of longstanding illnesses and activity limitations have been included in their respective sections of 'Definitions and examples'. This approach serves two purposes, as the additional information on both concepts will facilitate the response formation process of the proxy respondents, while at the same time, leave the questions – which are used in a number of other EU surveys – unchanged, to ensure harmonisation among surveys.

Calculation: Proportion of children whose health is assessed to be 'very good' or 'good'. Number of people assessing the/ their child's health as either 'very good' or 'good' should be added and divided by the total number of people who were interviewed.

Proportion of children reported to have a longstanding illness or health problem. 'Longstanding' are illnesses or health problems which have lasted or are expected to last for at least six months.

Proportion of children reported to be 'severely limited' or 'limited but not severely', for at least the past six months.


General guidelines: The following three general questions on perceived health, chronic conditions, and activity limitations constitute an adaptation of the Minimum European Health Module (MEHM). They have been adjusted for proxy-reporting, with children being the target respondents.

You are asked to follow the order of the questions presented.

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3) CHS1: Perceived general health of child: how the respondent perceives the child's health in general

1) Question

How would you describe [child's name]'s health in general?1. Very good2. Good3. Fair4. Bad5. Very bad

2) Guidelines

General concept: perceived general health of child, aged one week to 14 years old

Policy relevance : close link to ECHI 33; child health (including young adults)

Definitions and examples: The concept of the variable refers to the perceived general/ overall health of a child. The assessment coming from an adult person about health of a child who lives in the same household might be influenced by impressions or opinions from others and by general social and cultural background of the respondent.

The reference is to health in general, rather than the present state of health, as the question is not intended to measure temporary health problems. It is expected to include the different dimensions of health, i.e. physical, social, and emotional functioning, mental health (covering psychological well-being and mental disorders) and biomedical signs and symptoms. It omits any reference to age as respondents are not specifically asked to compare the child’s health with others’ of the same age or with their own previous or future health state.

Fair: This intermediate category should be translated into an appropriately neutral term (neither good, nor bad), keeping in mind, as far as possible, cultural interpretations.

Note: The question should not be filtered by any preceding question.

Justification: It should be noted that an identical question included in NSCH, does not use age filters.

4) CHS2: Child longstanding health problem: Child suffering from any illness or health problem of duration of at least six months

1) Question

Does [child's name] have any longstanding illness or [longstanding] health problem?

INSTRUCTIONS/ CLARIFICATION: Prompt: 'By longstanding I mean illnesses or health problems which have lasted, or are expected to last, for 6 months or more'.

1. Yes2. No

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2) Guidelines

General concept: Proxy-reported longstanding illness/es and longstanding health problem/s of child, aged one week to 14 years old

Policy relevance: Close link to ECHI 34; child health (including young adults)

Definitions and examples: It is necessary to keep in mind that the recommended wording contains 'alternatives'. For instance:- Chronic or longstanding should be chosen according to what is best understood in a country/ language.- It is intended to ask if people have a chronic condition, not if they really suffer from it. But it seems that

in some countries/languages it would be strange to use the word 'have' and that the verb 'suffer' means the same as 'have'.

- 'Health problem' may not to be understood in some countries/ languages and therefore 'illness or condition' is the alternative.

In this question the words 'disability, handicap, impairment' should not be used as synonyms for 'illness or health problem'.

The main characteristics of a longstanding illness or health problem are that it is permanent and may be expected to require a long period of supervision, observation, or care.

Longstanding illnesses or health problems should have lasted or are expected to last six months or more; therefore, ignore any temporary problems, such as chicken pox or influenza. However, problems that are seasonal or intermittent, even if they 'flare up' for four to six months at a time are included (for instance allergies).

Illnesses or health problems include problems related to ill-health or diseases, regardless the cause. Examples of causes that are covered include injuries/ accidents, congenital conditions, birth defects, and others.

The nature of the condition, whether physical or mental, is irrelevant. Examples range from arthrosis and diabetes to depression, agoraphobia, claustrophobia, and others.

It is irrelevant whether the health problem is diagnosed by a doctor or not. Symptoms such as pain or breathlessness or fatigue should also be included.

Note (1): Even if the child has/ had a longstanding disease that does/ did not bother them or it is/ was kept under control with medication, the answer is also 'Yes'.

Note (2): It should not be used as a filter for CHS3.

5) CHS3: Child general activity limitation: Child limitation in activities children usually do because of a health problem for at least the past six months

FILTERINTERVIEWER: NEXT QUESTION [CHS3 (I)] IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD.

1) Question (i)

Is [child’s name] limited because of a health problem in activities most children of the same age usually do? Would you say he/ she is…?

1. Severely limited2. Limited, but not severely, or3. Not limited at all?

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FILTERINTERVIEWER: NEXT QUESTION [CHS3 (II)] IS TO BE ASKED ONLY FOR CHILDREN WHO ARE LIMITED [CODES 1 OR 2 IN CHS3 (I)].

1) Question (ii)

Has [he/ she] been limited for at least the past six months?1. Yes2. No

2) Guidelines

General concept: Proxy-reported general activity limitation(s) of child, aged six months to 14 years old, in activities children of the same age usually do due to health problem(s)


Definitions and examples: The concept of the variable refers to the participation restriction through long-standing limitation (and its severity) in activities of a child of certain age (six months to 14 years old) because of health problem(s).

Its purpose is to measure presence of longstanding limitations in children, as their consequences can have a large impact on a child’s life (e.g. care, dependency).

Excluded: Temporary or short-term limitations.

The variable measures the proxy respondent’s subjective assessment of whether the child is hampered in 'activities children usually do', by any on-going physical, mental, or emotional health problem, including disease or impairment compared with children of the same age. Similarly to CHS2, the cause is irrelevant. Examples of causes that are covered include injuries/ accidents, congenital conditions, birth defects, and others.

An activity is defined as 'the performance of a task or action by a child' and thus activity limitations are defined as 'the difficulties the child experiences in performing an activity'.

In activities children usually do: The question should clearly show that the reference is to the activities children usually do and not to the child’s own activities.

Children of the same age: To identify existing limitations, a reference is necessary, thus, activity limitations are assessed against a generally accepted population standard, relative to cultural and social expectations in reference only to activities children of the same age usually do.

'Limitations in activities children usually do' refers to difficulties with activities that are usually expected of children of the same age, covering all spectrums of activities: self-care and transportation, school, home and leisure activities.

For at least the past six months: The time period strictly refers to the duration of the activity limitation and not to the duration of the health problem. The limitations must have started at least six months ago and still exist at the moment of the interview. This means that codes 1 or 2 should be recorded only if the child is currently limited and has been limited in activities for at least the past six months.

Excluded: New limitations which have not yet lasted six months, even if usual medical knowledge would suggest that the health problem behind a new limitation is very likely to continue for a long time or for the rest of the life of the respondent (such as for type I diabetes).

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One reason is that in terms of activity limitation it may be possible to counteract at some point negative consequences for activity limitations by using assisting devices or personal assistance. Additionally, the activity limitations of the same health problem may also depend on the individual person and circumstances, and only past experience can provide a safe answer.

Because of a health problem: Only the limitations directly caused by one or more health problems are considered, regardless the type of the problem.

Excluded are limitations due to financial, cultural, or other non-health-related causes.

The response categories include three levels to better differentiate severity of activity limitations: severely limited (severe limitations), limited but not severely (moderate limitations), not limited at all (no limitations).

Severely limited means that performing or accomplishing an activity, which can normally be done by a child of the same age, cannot be done or only done with extreme difficulty. Children in this category, usually, cannot do the activity alone and (would) need help.

Limited, but not severely means that performing or accomplishing an activity, which can normally be done by a child of the same age, can be done, but only with some difficulties. Children in this category usually do not need help from other persons.

Note CHS3 should not be used as a filter for sub-module CPL.

Justification: According to the guiding principles of the Module on Child Functioning and Disability developed by the Washington Group on Disability Statistics (WG) and UNICEF, it may not be feasible to capture disabilities among children younger than two years old through population surveys due to the nature of the development process for children of this age. Thus, the selected starting age range of CHS3 was chosen to be the one employed by WG and UNICEF, namely two years old.

2.3 Physical and sensory functional limitations of children (CPL)

Rationale: Children with disabilities may face significant barriers to enjoying their fundamental rights. They might often be excluded from society, denied access to basic services, such as health care and education, and endure stigma and discrimination. Due to the lack of relevant data and for the purpose of employing internationally comparable indicators that will enable the formulation and implementation of policies that give effect to the Convention on the Rights of Persons with Disabilities (Article 31), the Washington Group on Disability Statistics (WG) and UNICEF developed a short set of disability measures, titled 'Module on Child Functioning and Disability' (hereinafter WG/ UNICEF Module).

The module went through a validation process, through cognitive and field testing, between 2012 and 2016. It covers 13 different sub-topics and addresses the functional limitations of children two to four and five to 17 years old. However, due to the large number of topics covered and questions included in the WG/ UNICEF Module, a selection process was followed on the basis of:

- UN recommendations in determining disability status using a census

- Questionnaire alignment to the existing structure of EHIS

According to the Principles and Recommendations for Population and Housing Censuses of the UN’s Department of Economic and Social Affairs, '[a] census can provide valuable information on disability and human functioning in a country. […] It is recommended that the following four domains be considered essential in determining disability status in a way that can be reasonably measured using a census and that would be appropriate for international comparison:

- walking

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- seeing

- hearing

- cognition

[..]. Two other domains, self-care and communication, have been identified for inclusion, if possible.'

Thus, in view of the above, 'Physical and sensory functional limitations of children' (CPL) focus on the first three domains, based on the questions developed for the Module on Child Functioning and Disability.

'Cognition' and particularly the aspect of 'learning' is examined separately due to the fact that it does not fall under the category of physical and sensory functional limitations (see CCL1 and CCL2).

'Communication' and 'self-care' are not examined, as they are not considered essential in determining disability status in a census.

Moreover, building on the work already done for the development of the WG/ UNICEF Module, there are no questions addressed to children younger than two years old. Accordingly, due to the nature of the development process for children younger than two years old, it may not be feasible to capture disabilities through population surveys.

Calculation: Prevalence of physical and sensory functional limitations to be measured by questions CPL1 to CPL5

In the calculation of the indicator, questions on children’s use of glasses/ contact lenses (CPL1) and of a hearing aid (CPL3), of equipment or assistance in walking (CPL5) are not considered. Children are considered as:

- not limited, if the response for all remaining questions is always 'No difficulty';

- moderately limited, in case the response of at least one question is 'Some difficulty' (and for none of the questions the response is 'A lot of difficulty' or 'Cannot do at all/ unable to do'); and

- severely limited, if the response of at least one question is 'A lot of difficulty' or 'Cannot do at all/ unable to do'.

Policy priority: High

Introduction CPLNow I am going to ask you some further questions about the child's general physical health. These questions deal with the child's ability to do different basic activities. Please ignore any temporary problems.

General guidelines: Think about situations. A physical or sensory functional limitation can be measured through reference to many actions/ situations. The action/ situation is there only to help the proxy respondent assess the child’s level of functioning. For this reason distances (e.g. 500 metres) should not be taken literally, but as a reference to the scale we are interested in.

Ignore any temporary problems: The aim is to measure long-term (chronic) limitations. This wording is used so that a time limit is not required.

The aim of the questions that follow is to assess:

- how the child functions in its current environment using a performance qualifier: 'Does [child’s name] have difficulty…even when using equipment or receiving assistance', and

- in certain cases (walking), its ability to execute a task or an action using a capacity qualifier: 'Does [child’s name] have difficulty in walking…without any aid or support'.

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6) CPL1: Child wearing glasses or contact lenses

FILTERINTERVIEWER: NEXT QUESTION (CPL1) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD.

1) Question

Does [child's name] wear glasses or contact lenses?1. Yes2. No3. Child is blind, cannot see at all

2) Guidelines

General concept: Whether child, aged two to 14 years old, uses or not, glasses or contact lenses for improving their ability to see

Policy relevance: Close link to ECHI 36; child health (including young adults); EU Disability Strategy; UN Convention on the Rights of Persons with Disabilities

Justification: The original question of the WG/ UNICEF Module inquires about glasses only. The phrase 'or contact lenses' was added for consistency with the corresponding question in EHIS (PL1), addressed to adults.

7) CPL2: Difficulty of child in seeing even when wearing glasses or contact lenses

FILTERINTERVIEWER: NEXT QUESTION (CPL2) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD, WHO ARE NOT BLIND (CODES 1 OR 2 IN CPL1).

Introduction CPL2 (a)Please answer the following question according to [child’s name]’s normal use of [his/ her] glasses or contact lenses.

INSTRUCTIONS/ CLARIFICATIONS: Phrasing if CPL1 = 1:

1) Question (a)

When wearing [his/ her] glasses or contact lenses, does [child's name] have difficulty seeing? Would you say…?

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1) Question (b)

Does [child's name] have difficulty seeing? Would you say…?1. No difficulty2. Some difficulty3. A lot of difficulty4. Cannot do at all/ unable to do

2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in seeing, even when wearing glasses or contact lenses


Definitions and examples: When wearing [his/ her] glasses or contact lenses: The aim of the question is to assess the child’s performance, rather than capacity and, therefore, the use of technical devices/ aids is taken into account. Additionally, both, long- and short-distance seeing should be taken into account.

Eyesight problems should not be reported if glasses or contact lenses are sufficiently effective. For a child with seeing impairment, who does not have glasses (for instance, due to financial reasons), the respondent should answer without considering these aids.

If asked, the interviewer should mention that good lightening conditions are foreseen.

8) CPL3: Child using hearing aid


1) Question

Does [child's name] use a hearing aid?1. Yes2. No3. Child is deaf, cannot hear at all

2) Guidelines

General concept: Whether child, aged two to 14 years old, uses or not, a hearing aid


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Definitions and examples: Other hearing aids habitually worn and considered as 'within-the-skin' can be taken into account if it is relevant and important in a particular country. Implants are considered as 'within-the-skin' aids.

9) CPL4: Difficulty of child in hearing even when using hearing aid

FILTERINTERVIEWER: NEXT QUESTION (CPL4) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD, WHO ARE NOT DEAF (CODES 1 OR 2 IN CPL3).

Introduction CPL4 (a)Please answer the following question according to [child’s name]’s normal use of [his/ her] hearing aid[s].


1) Question (a)

When using [his/ her] hearing aid[s], does [child's name] have difficulty hearing sounds like peoples’ voices or music? Would you say…?


1) Question (b)

Does [child's name] have difficulty hearing sounds like peoples’ voices or music? Would you say…?

1. No difficulty2. Some difficulty3. A lot of difficulty4. Cannot do at all/ unable to do

2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in hearing sounds like peoples’ voices or music, even when using hearing aid


Definitions and examples: When using [his/ her] hearing aid[s]: The aim of the question is to assess the child’s performance, rather than capacity and, therefore, the use of technical devices/ aids is taken into account.

The situation is there, only to help the proxy respondent and interviewer assess the level of functioning. Hearing problems should not be reported if hearing aids are sufficiently effective. For a child with hearing impairment who does not have hearing aid (for instance, due to financial reasons), the respondent should answer without considering these aids.

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The question implies a normal situation where there is no background noise or at a very low level, so that there is no background noise that could make difficult to hear what another person says.

In case a child is deaf in one ear, the respondent’s answer should reflect an average situation.

Hearing difficulties include a range of problems that deal with some specific aspects of the hearing function: the perception of loudness and pitch, the discrimination of speech versus background noise, and the localisation of sounds. Background noise is a detractor for hearing and this distraction becomes worse with increasing levels of hearing loss.

10) CPL5: Child using equipment or receiving assistance for walking


1) Question

Does [child's name] use any equipment or receive assistance for walking?1. Yes2. No3. Child is on wheelchair, cannot walk at all

2) Guidelines

General concept: Whether child, aged two to 14 years old, uses or not, any equipment or assistance for walking


Definitions and examples: Walking aids include surgical footwear, canes or walking sticks, zimmer frames, callipers, splints, crutches, wheelchair, artificial limb (leg/ foot), prostheses, someone's assistance. Holding someone’s arm is considered as receiving assistance, as well.

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11) CPL6: Difficulty of child in walking without any aid or support

FILTERINTERVIEWER: NEXT QUESTION (CPL6) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD, WHO ARE NOT ON A WHEELCHAIR, BUT USE EQUIPMENT OR RECEIVE ASSISTANCE FOR WALKING (CODE 1 IN CPL5).

INSTRUCTIONS/ CLARIFICATIONS: Phrasing if CPL5 = 1 and child is aged 2-4 years old:

1) Question (a)

Without using [his/ her] equipment or assistance, does [child's name] have difficulty walking? Would you say…?


1) Question (b)

Without using [his/ her] equipment or assistance, does [child's name] have difficulty walking 500 meters on level ground? That would be [...]. Would you say…?


2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in walking, without any aid or support


Definitions and examples: Without using [his/ her] equipment or assistance: The aim of the question is to assess the child’s capacity and, therefore, the use of technical devices/ aids or assistance is not considered when evaluating the extent of difficulty.

The situation is there, only to help the proxy respondent and interviewer assess the level of functioning.

The question investigates for limitations in the physical act of walking, and not for limitations in walking due to other functioning problems. For example, for a blind child, the guide dog or the use of a stick or other walking aid or assistance, if the reason for using it is only limited seeing, should not be seen as an aid; in this case, a child (even if using a walking stick or having a guide dog) should not be seen as having walking difficulties.

Note (CPL6b): National equivalents for 500 metres are allowed to be used in the wording of the question.

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2.4 Cognitive limitations of children (CCL)

Rationale: 'Cognitive disability entails a substantial limitation in one’s capacity to think, including conceptualizing, planning and sequencing thoughts and actions, remembering, and interpreting the meaning of social and emotional cues, and of numbers and symbols.' Therefore, by definition, the ability to learn and remember are central in cognition, which is one of the four domains considered as essential in determining disability status in general population surveys.

The questions have been based on those provided by the WG/ UNICEF Module.


Calculation:

- Prevalence of cognitive limitations in children aged two to four measured by question CCL1

- Prevalence of cognitive limitations in children aged five to 14 measured by questions CCL1 and CCL2

Children, in terms of cognitive abilities, are considered as:

- not limited, if the response for all questions is always 'No difficulty';



Note: In accordance to the 'Principles and Recommendations for Population and Housing Censuses' of the UN’s Department of Economic and Social Affairs, the calculation of the indicator for prevalence of cognitive limitations should be at least combined with that of physical and sensory functional limitations (namely walking, seeing, and hearing) to determine disability status through general population surveys.

Temporary problems should be ignored: The problems (cognitive limitations) should have lasted or are expected to last four weeks or more.

Introduction CCLThe next question(s) concern(s) the child’s ability to learn [and – for children aged five and above – remember things]. Please ignore any temporary problems.

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12) CCL1: Difficulty of child in learning new things

FILTERINTERVIEWER: NEXT QUESTION (CCL1) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD.

1) Question

Compared with children of the same age, does [child’s name] have difficulty learning things due to a longstanding health problem? Would you say...?


2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in learning new things, compared to children of the same age

Policy relevance: (Planning of) health care resources and health care cost; child health (including young adults); EU Disability Strategy; UN Convention on the Rights of Persons with Disabilities

Definitions and examples: The aim of the question is to assess the child’s ability to learn and solve problems by gathering information and developing new skills, including thinking skills.

A discrepancy between the child's potential and actual achievement is usually called a specific learning difficulty or disability. Learning difficulties may fall into two categories: 1) Slow learners will always be behind their chronological peers what doesn't mean they can't be expected to improve; 2) Children with a specific learning disability can, with the right help, be expected to attain chronologically appropriate academic levels in time. Symptoms that may show learning disabilities or difficulties can be observed for reading, spelling, mathematics, physical aspects, psychological aspects and for social, emotional and behavioural aspects7.

Compared with children of the same age: For reference and to focus the respondent on the functioning of their own child in reference to that child’s cohort.

7 See http://www.kidspot.com.au/school/primary/learning-and-behaviour/learning-difficulties/ 19

http://www.kidspot.com.au/school/primary/learning-and-behaviour/learning-difficulties/

13) CCL2: Difficulty of child in remembering things


1) Question

Compared with children of the same age, does [child’s name] have difficulty remembering things due to a longstanding health problem? Would you say…?


2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged five to 14 years old, has in remembering things, compared to children of the same age


Definitions and examples: The aim of the question is to assess the child’s demonstrated ability to remember, namely their ability to recall a piece of information already provided to or acquired by the child.


2.5 Social and mental health difficulties of children (CSM)

Rationale: Social and mental health is an integral part of health and well-being, as reflected in WHO’s definition of health, which states that 'health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity'.

For the purposes of the present report, the term 'mental health' is used to incorporate a range of states, from excellent mental health to severe mental health problems. 'Mental well-being' constitutes the positive state of mental health, whereas 'mental illness' the negative aspect that comes at a fairly large cost to society and the economy.

Furthermore, according to WG and UNICEF, the prevalent types of disability differ between adults and children. More specifically, accordingly, studies at both national and international levels suggest that in adults major problems are mobility, sensory functions, and personal care – especially with advancing years. While in children disabilities tend to relate to intellectual functioning, affect, and behaviour.

The questions presented below have been based on those provided by the WG/ UNICEF Module.

Different questions covering the same sub-domains – namely, psychological distress and ability to control one’s behaviour – identified in other surveys include the following:

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- NSCH: I am going to read a list of items that sometimes describe children. For each item, please tell me how often this was true for [CHILD’S NAME] during the past month.

- [He/ She] is unhappy, sad, or depressed

- [He/ She] stays calm and in control when faced with a challenge

- HBSC: In the last 6 months: how often have you had the following…?

- Feeling

- Irritability or bad temper

- Feeling nervous


Calculation: Prevalence of behavioural (social) difficulty in children, aged two to four, to be measured by question CSM1

Prevalence of behavioural (social) and mental health difficulty in children, aged five to 14, to be measured by questions CSM1 and CSM2

Children, in terms of social and mental health, are considered as:

- not limited, if the response for question CSM1 is 'Not at all' or 'The same or less' and for CSM2 is 'Never'

- moderately, if the response for question CSM1 is 'More' or for CSM2 is 'A few times a year' or 'Monthly'

- severely limited, if the response for question CSM1 is or 'A lot more' or for CSM2 is 'Weekly' or 'Daily'

Note: The calculation of the indicator for social and mental health difficulties may be combined with those of physical and sensory functional limitations (namely walking, seeing, and hearing) and cognitive limitations to determine disability status through general population surveys.

Temporary problems should be ignored: The problems (social and mental health difficulties) should have lasted or are expected to last four weeks or more.

Introduction CSMThe next question[s] is [are] about the child’s behaviour [and – for children aged five and above – feelings]. Please ignore any temporary problems.

14) CSM1: Behavioural difficulty of child

FILTERINTERVIEWER: NEXT QUESTION (CSM1) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD.

INSTRUCTIONS/ CLARIFICATIONS: Phrasing if child is aged 2-4 years old:

1) Question (a)

Compared with children of the same age, how much does [child’s name] kick, bite or hit other children or adults? Would you say…?

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1) Question (b)

Compared with children of the same age, how much difficulty does [child’s name] have controlling his/ her behaviour? Would you say…?

1. Not at all2. The same or less3. More (often / difficulty)4. A lot more (often / difficulty)

2) Guidelines

General concept: Assessment of the extent of behavioural difficulties which a child, aged two to 14 years old, has compared to children of the same age.

Policy relevance: Close link to ECHI 38; (Planning of) health care resources and health care cost; child health (including young adults)

Definitions and examples:

Controlling behaviour: All children have moments when they do not behave properly. They can go through different phases as they develop and become more independent. Toddlers and adolescents can have their challenging moments and this might mean they push limits from time to time. Occasionally, a child will have a temper tantrum, or an outburst of aggressive or destructive behaviour.

Behavioural difficulties: Behavioural problems can happen in children of all ages. The signs are: 1) The child continues to behave badly for several months or longer, is repeatedly being disobedient, cheeky and aggressive;2) The child's behaviour is out of the ordinary, and seriously breaks the rules accepted in their home and school. This is much more than ordinary childish mischief or adolescent rebelliousness8.

Compared with children of the same age: For reference and to focus the respondent on the functioning of their own child in reference to that child’s age cohort.

15) CSM2: Mental health difficulty of child


8 Source: http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/behaviouralproblems.aspx. 23

http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/behaviouralproblems.aspx

1) Question

How often does [child’s name] seem very anxious, nervous, or worried? Would you say..?1. Daily2. Weekly3. Monthly4. A few times a year5. Never

2) Guidelines

General concept: Assessment of the extent of the mental ill-health of child aged five to 14 years old


Justification: The question was rephrased from the original 'how much' to 'how often', as the answer categories provided concern frequency, rather than quantity.

2.6 Mobility and participation restrictions of children in major life domains

Rationale: According to the European Disability Strategy 2010-2020: A Renewed Commitment to a Barrier-Free Europe (hereinafter European Disability Strategy), one in six people in the EU has a disability, ranging from mild to severe. As a result,

- around 80 million people are often prevented from taking part fully in society and the economy because of environmental and attitudinal barriers;

- the rate of poverty for people with disabilities is 70% higher than the average, partly, due to limited access to employment; and

- more than 33% of people aged over 75 have disabilities that restrict them to some extent, and more than 20% are considerably restricted.

Given the refocus from a reactive to a proactive health care system, measuring these aspects from an early age will provide essential insight regarding future health needs that will support relevant EU strategy and policy decision-making.

On the basis of the eight main areas identified in the European Disability Strategy for action, the European health and social integration survey EHSIS collects information on the experience of barriers in ten life domains. For the purpose of keeping the questionnaire length to a minimum (about 20 questions), participation restrictions of children focus on three key areas of a child’s life. These include:

- Mobility and environmental accessibility

- Education

- Leisure and play

The three domains were selected on the basis of their – comparatively – greater applicability across different ages, as well as by negation of the other life domains. More specifically, social contact and support, economic life, employment, internet use and attitudes and behaviour of others were excluded; the latter also on the premise

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that parents are likely not to possess the relevant information, necessary to answer the corresponding questions meaningfully


Calculation: Absolute number and percentage of children, aged five to 14 years old, facing participation restrictions in major key areas of a child’s life due to longstanding health problem(s), to be measured by questions CMR1, CPR1, and CPR3. Children are considered as:

- not limited, if the responses for all questions is always 'No difficulty';

- moderately limited, in case the response for at least one question is 'Some difficulty' (and for none of the questions the response is 'A lot of difficulty' or 'Cannot do at all/ unable to do'); and

- severely limited, if the response for at least one question is 'A lot of difficulty' or 'Cannot do at all/ unable to do'.

Introduction: This section concerns the opportunities that all children have in their lives to participate in society as much as they want to. It examines the three main life activities that all children could take part in if they were made available to them. The section explores the level of difficulty that some children may experience due to health problems or impairments.

General guidelines: The phrase 'because of a longstanding health problem' has been included in the relevant questions to ensure that reported difficulty is health-related. Therefore, respondents are asked to assess the level of difficulty that is a result of longstanding health problem. Difficulties experienced due to other reasons, such as financial ones are not of interest. The difference must be stressed to respondents.

Longstanding health problems should have lasted or are expected to last six months or more; therefore, ignore any temporary problems, such as chicken pox or influenza. However, problems that are seasonal or intermittent, even if they 'flare up' for four to six months at a time are included (for instance allergies). Moreover, longstanding health problems may be expected to require a long period of supervision, observation or care.

Health problems include health conditions, illnesses, diseases, or limitations in basic activities (such as seeing, hearing, concentrating, moving around, or using hands) regardless of the cause. Examples include injuries/ accidents, congenital conditions, birth defects, and others.

The nature of the health problem, whether physical or mental, is irrelevant. Examples range from asthma and diabetes to depression, agoraphobia, claustrophobia, and others.

It is irrelevant whether the health problem is diagnosed by a doctor or not. Symptoms such as pain, breathlessness, or fatigue should also be included.

Excluded are temporary problems, such as those caused by a broken arm or leg, or a sprained ankle.

Note (1): If the child has/ had a longstanding disease that does/ did not bother them or it is/ was kept under control with medication, the answer is 'No difficulty'.

Note (2): We are interested in the child’s current situation at the time of interview.

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16) CMR1A: Difficulty of child in leaving [his/ her] home because of a longstanding health problem

17) CMR1B: Difficulty of child in accessing buildings [he/ she] wants to use because of a longstanding health problem

18) CMR1C: Difficulty of child in moving about in buildings [he/ she] wants to use, once inside because of a longstanding health problem

FILTERINTERVIEWER: NEXT QUESTION (CMR1) IS TO BE ASKED ONLY FOR CHILDREN 5-14 YEARS OLD.

1) Question

Compared with children of the same age, does [child’s name] have difficulty in performing any of these actions related to [his/ her] mobility because of a longstanding health problem?

INSTRUCTIONS/ CLARIFICATIONS: Tick an answer for each aspect of mobility.

Mobility aspecta. Leaving [his/ her] homeb. Accessing buildings [he/ she] wants to usec. Moving about in buildings [he/ she] wants to use, once inside

1. No difficulty2. Some difficulty3. A lot of difficulty4. Cannot do at all/ unable to do5. Not applicable

2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged five to 14 years old, has, in aspect(s) of mobility due to longstanding health problem(s), compared to children of the same age

Policy relevance: (Planning of) health care resources and health care cost; child health (including young adults); health inequalities (including accessibility of care); EU Disability Strategy; UN Convention on the Rights of Persons with Disabilities

Definitions and examples: 'Leaving home' refers going beyond the boundary of one’s property. It would not include going out to the garden shed, for example, but being able to get out and about in the local neighbourhood. Difficulties may be experienced because of too many hills, slopes or steps, footpath design, uneven or slippery surfaces, no resting places or toilets, no ramps or handrails, or no audio crossings, around the area where the respondent lives.

It does not matter whether the person leaves home on foot (or in a wheelchair) or by transport, with or without assistance, or with or without assistive devices.

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'Buildings [he/ she] wants to use' refers to school, shops, restaurants, cafes, leisure facilities and other people’s homes.

'Accessing buildings [he/ she] wants to use' refers to getting into (or out of) buildings. The focus is on the design of the building or the immediate surrounding area. Difficulties may be experienced due to, for example, poor signage, the footpath design, narrow door frames, or lack of ramps. It excludes getting to and from buildings.

'Moving about in buildings [he/ she] wants to use, once inside' refers to getting around the building once inside, for example, going through a department store or getting from one floor to another. It also includes using the facilities in the building, for example, seating, using toilets, purchasing items over the counter, accessing the cooler, using lifts etc. Difficulties may be experienced due to, for example, poor signage, poor floor surfaces, poor ventilation, lack of ramps or a building being too crowded are also included.


'Some difficulty', 'A lot of difficulty', or 'Cannot do at all/ unable to do' should be coded when respondents believe that a medical condition contributes to the difficulties the child experiences in the different mobility aspects.

Excluded: Difficulties experienced due to financial reasons, such as transport costs, and other non-health-related reasons in general, such as lack of knowledge about what is available or being too busy.

Not applicable should be coded when the child has no longstanding health problem(s) or cannot do so for reasons other than (a) longstanding health problem(s).

Use of showcard: A showcard of the different actions related to mobility can be used.

2.7 Participation of children in compulsory education

19) CPR1: Difficulty of child participating in compulsory education because of a longstanding health problem

FILTERINTERVIEWER: NEXT QUESTION (CPR1) IS TO BE ASKED ONLY FOR CHILDREN 5-14 YEARS OLD.

1) Question

Compared with children of the same age, does [child’s name] have difficulty in attending primary or secondary school because of a longstanding health problem?


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2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged five to 14 years old, has, in participating in compulsory education due to longstanding health problem(s)

Policy relevance: (Planning of) health care resources and health care cost; health inequalities (including accessibility of care); child health (including young adults); EU Disability Strategy; UN Convention on the Rights of Persons with Disabilities

Definitions and examples: Attending primary or secondary school at the moment: This question covers primary and secondary education at a school or academy/ college or technical institute. In all EU countries there is a period of educational attendance required of all students, often determined by law, known as compulsory education. Depending on the country, this education may take place at a registered school (schooling), at home (home-schooling), or any other formal educational establishment.

At the moment: Proxy respondents are asked to think about the difficulty the child may be experiencing in taking up education, currently. This is important because we are interested in existing barriers to education.


'Some difficulty', 'A lot of difficulty', or 'Cannot do at all/ unable to do' should be coded when respondents believe that a medical condition contributes to the child’s difficulty in participating in education.

Excluded are difficulties experienced due to financial reasons, such as transport costs, and other non-health-related reasons in general, such as lack of knowledge about what is available.

Not applicable should be coded when the child is attending school or is being home-schooled or cannot do so for reasons other than (a) longstanding health problem(s). It should also be coded when the child has no longstanding health problem(s).

2.8 Participation of children in pursuing leisure activities

20) CPR3: Difficulty of child in pursuing leisure activities because of a longstanding health problem

FILTERINTERVIEWER: NEXT QUESTION (CPR3) IS TO BE ASKED ONLY FOR CHILDREN 5-14 YEARS OLD.

1) Question

Compared with children of the same age, does [child’s name] have difficulty pursuing leisure activities or playing because of a longstanding health problem?


28

2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged five to 14 years old, has, in pursuing leisure activities due to longstanding health problem(s)

Policy relevance: (Planning of) health care resources and health care cost; health inequalities (including accessibility of care); child health (including young adults); EU Disability Strategy; UN Convention on the Rights of Persons with Disabilities

Definitions and examples: 'Pursuing leisure activities or playing with other children' both fall under the category of leisure pursuits, namely activities children usually do for leisure during the time they are not studying, looking after siblings, or babysitting, doing household chores, etc. Attending cultural events are also included in the definition.

These questions examine the difficulty that children with a health problem may be experiencing in pursing leisure activities that involve social interaction with others, namely not lone pursuits. The interest is in the activities children do in the physical company of other people, therefore, talking to them only on the telephone or the internet is not considered. The key point is meeting like-minded people.

Hobbies or interests can be split into two main themes:

- Recreation and leisure activities includes taking part in sports such a member of a football team. Watching sports is also included if the activity is carried out with other children or adults. Attending a football match as a spectator is included because it involves being with other people. Watching a football match on television with friends is also included if the respondent considers the child to be doing this activity as a hobby or interest. Watching a football match on television at home alone would not be included. Belonging to a cycling club is included, if the child cycles with others. Cycling alone is not included.

Attending a dancing or aerobics class, or going to the gym is included again, because the activity is carried out in the company of other people. Drawing, painting, or arts crafts making are not included, unless the child attended classes or events with others sharing the same interest. Reading books is not included, unless the child was, for example, a member of a book club and met face-to-face with the other book club members. Shopping is not usually considered a hobby or interest, unless the child collects car toys or dolls/ stuffed animals, for example, and considers it a hobby or interest. Playing in a band or orchestra is included.

- Note (1): When pursuing hobbies or interests the contact may involve telephone or email correspondence, but the activity must sometimes involve meeting with or being with other people.

- Note (2): Pursuing leisure activities in one’s own home are included, only if it involves meeting with others. Therefore, children that are housebound may still do this activity if others come to their home.

- Note (3): Studying for pleasure that is simply for interest, is included, only if the study does not lead to a formal qualification, but involves attending classes/ lectures with other people. For example attending drawing or dancing classes.

- Note (4): Pursuing hobbies can cover a wide range of activities. Therefore, the examples presented above are not exhaustive, but are rather there to facilitate the proxy respondent and interviewer.

- Community life includes being a Boy or Girl Scout, or a volunteer, etc., if it involves meeting with other people. Also includes helping out at a school fair or charity event. Belonging to a social club associated with a child’s faith or religion is also included but the act of praying or attending a church service is not included.

Attending cultural events may be something children do with their parents or other relatives, peers or, less often, they may do it on their own; but there are other people around. Examples: going to the cinema, the theatre, fetes or carnivals, music concerts, museums or places of special interests.

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'Some difficulty', 'A lot of difficulty', or 'Cannot do at all/ unable to do' should be coded when respondents believe that a medical condition contributes to the child’s difficulty in pursuing leisure pursuits or playing with other children.

Excluded are difficulties experienced due to financial reasons, such as transport costs, and other non-health-related reasons in general, such as lack of knowledge about what is available.

Not applicable should be coded when the child never tried to pursue the leisure activity in question or cannot do so for reasons other than (a) longstanding health problem(s). It should also be coded when the child has no longstanding health problem(s).

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3 Pre-testing version B: Focus on prevention3.1 Height and weight of children (CBM)

Rationale: According to the European Heart Network, data from several studies suggest that childhood obesity has increased steadily in Europe over the past two to three decades. In fact, it is estimated that almost 20% of children in Europe are overweight or obese, with some of these obese children already having multiple risk factors for type II diabetes, heart disease and a variety of other co-morbidities.


Calculation: Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. For children, however, age needs to be taken into consideration.

According to WHO, for children aged between two and 19:

- overweight is BMI-for-age greater than one standard deviation above the WHO Growth Reference median; and

- obesity is greater than two standard deviations above the WHO Growth Reference median.

The upper age limit was adjusted to cover up to the age after which EHIS picks up from, which is 15 years old. Thus, the question concerns two (WHO lower barrier)9 up to 14 years of age (in completed years).

An alternative source for the calculation of child overweight and obesity (and underweight) – used by used by Statistics Netherlands, for example – can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27365/pdf/1240.pdf.

According to the CHILD project, BMI of children at primary school entry should be used as the core indicator, while for the ages of 10 and 15 BMI should only be used if adequate measurement and recording systems at these additional ages can be provided.

Given that in a general health interview survey, sample size needs to be large enough, and since only a small part of the proxy respondents will have children at the ages of five/ six, 10, and 15, it is recommended that BMI is estimated for all children, regardless of age.

Introduction CBMI would now like to talk to you about the child's height and weight.

1) CBM1:Height of child without shoes


1) Question

How tall is [child's name] without shoes?1. _ _ _ [cm]

9 See http://www.who.int/mediacentre/factsheets/fs311/en/ 31

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27365/pdf/1240.pdf

http://www.who.int/mediacentre/factsheets/fs311/en/

2) Guidelines

General concept: Body height of child, aged two to 14 years old


Definitions and examples: How tall is the child without shoes: body length measured without wearing shoes.

Note (1): Other measurement units are allowed, but the data has to be converted into cm.


2) CBM2:Weight of child without shoes or clothes


1) Question

How much does [child's name] weigh without clothes or shoes?1. _ _ _ [kg]

2) Guidelines

General concept: Body weight of child aged two to 14 years old


Definitions and examples: How much the child weighs without clothes or shoes: weight measured without clothes or shoes in kilograms or stones and pounds.

Note (1): Other measurement units are allowed but the data has to be converted into kg.


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3.2 Minimum European Health Module (MEHM) for children

Rationale: SELF-PERCEIVED HEALTH: 'Subjective health measurement is contributing to the evaluation of health problems, the burden of diseases and health needs at the population level. Perceived health status is not a substitute for more objective indicators, but rather complements these measures. Studies have shown perceived health to be a good predictor of subsequent mortality.'

SELF-REPORTED CHRONIC MORBIDITY: 'Widely used measure of general health, contributing to the evaluation of health problems, the burden of diseases and health needs at the population level.'

LONG-TERM ACTIVITY LIMITATIONS: 'Widely used measure of general health, contributing to the evaluation of health problems, the burden of diseases and health needs at the population level.'

The proposed questions CHS1 and CHS3 are based on the 2017 EU-SILC questions of the ad-hoc module on children’s health. While question CHS2 was adjusted to children from the corresponding EHIS question HS2 addressed to adults, regarding longstanding health problems.

It is worth noting that USA’s National Survey of Children's Health (NSCH) contains an identical question to CHS1: In general, how would you describe [child’s name]’s health?, as well as a similar question to CHS3: Is [child’s name] limited or prevented in any way in [his/ her] ability to do things most children of the same age can do?

At this point it should be noted that relevant literature suggests that general questions on longstanding illnesses and activity limitations may collect information that is inaccurate. They can be overwhelming in scope or seem illogical to respondents, who should they have problems with only one activity, a positive response may feel like it is conveying the wrong overall picture of their limitations. Furthermore, asking about the status of specific health domains separately may impose artificial restrictions on respondents’ health-related cognitive space, limiting their interpretation of health and retrieval of related information.

In view of the above, some additional examples of longstanding illnesses and activity limitations have been included in their respective sections of 'Definitions and examples'. This approach serves two purposes, as the additional information on both concepts will facilitate the response formation process of the proxy respondents, while at the same time, leave the variables – which are used in a number of other EU surveys – unchanged, to ensure harmonisation among surveys.

Calculation: Proportion of children whose health is assessed to be 'very good' or 'good'. Number of people assessing the/ their child's health as either 'very good' or 'good' should be added and divided by the total number of people who were interviewed.

Proportion of children reported to have a longstanding illness or health problem. 'Longstanding' are illnesses or health problems which have lasted or are expected to last for at least six months.

Proportion of children reported to be 'severely limited' or 'limited but not severely', for at least the past six months.


General guidelines: The following three general questions on perceived health, chronic conditions, and activity limitations constitute an adaptation of the Minimum European Health Module (MEHM). They have been adjusted for proxy-reporting, with children being the target respondents.

You are asked to follow the order of the questions presented.

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3) CHS1: Perceived general health of child: how the respondent perceives the child's health in general

1) Question

How would you describe [child's name]'s health in general?1. Very good2. Good3. Fair4. Bad5. Very bad

2) Guidelines

General concept: perceived general health of child, aged one week to 14 years old

Policy relevance : close link to ECHI 33; child health (including young adults)

Definitions and examples: The concept of the variable refers to the perceived general/ overall health of a child. The assessment coming from an adult person about health of a child who lives in the same household might be influenced by impressions or opinions from others and by general social and cultural background of the respondent.

The reference is to health in general, rather than the present state of health, as the question is not intended to measure temporary health problems. It is expected to include the different dimensions of health, i.e. physical, social, and emotional functioning, mental health (covering psychological well-being and mental disorders) and biomedical signs and symptoms. It omits any reference to age as respondents are not specifically asked to compare the child’s health with others’ of the same age or with their own previous or future health state.

Fair: This intermediate category should be translated into an appropriately neutral term (neither good, nor bad), keeping in mind, as far as possible, cultural interpretations.

Note: The question should not be filtered by any preceding question.

Justification: It should be noted that an identical question included in NSCH, does not use age filters.

4) CHS2: Child longstanding health problem: Child suffering from any illness or health problem of duration of at least six months

1) Question

Does [child's name] have any longstanding illness or [longstanding] health problem?

INSTRUCTIONS/ CLARIFICATION: Prompt: 'By longstanding I mean illnesses or health problems which have lasted, or are expected to last, for 6 months or more'.

1. Yes2. No

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2) Guidelines

General concept: Proxy-reported longstanding illness(es) and longstanding health problem(s) of child, aged one week to 14 years old


Definitions and examples: It is necessary to keep in mind that the recommended wording contains 'alternatives'. For instance:- Chronic or longstanding should be chosen according to what is best understood in a country/ language.- It is intended to ask if people have a chronic condition, not if they really suffer from it. But it seems that

in some countries/languages it would be strange to use the word 'have' and that the verb 'suffer' means the same as 'have'.

- 'Health problem' may not to be understood in some countries/ languages and therefore 'illness or condition' is the alternative.

In this question the words 'disability, handicap, impairment' should not be used as synonyms for 'illness or health problem'.

The main characteristics of a longstanding illness or health problem are that it is permanent and may be expected to require a long period of supervision, observation, or care.

Longstanding illnesses or health problems should have lasted or are expected to last six months or more; therefore, ignore any temporary problems, such as chicken pox or influenza. However, problems that are seasonal or intermittent, even if they 'flare up' for four to six months at a time are included (for instance allergies).

Illnesses or health problems include problems related to ill-health or diseases, regardless the cause. Examples of causes that are covered include injuries/ accidents, congenital conditions, birth defects, and others.

The nature of the condition, whether physical or mental, is irrelevant. Examples range from arthrosis and diabetes to depression, agoraphobia, claustrophobia, and others.

It is irrelevant whether the health problem is diagnosed by a doctor or not. Symptoms such as pain or breathlessness or fatigue should also be included.

Note (1): Even if the child has/ had a longstanding disease that does/ did not bother them or it is/ was kept under control with medication, the answer is also 'Yes'.

Note (2): It should not be used as a filter for CHS3.

5) CHS3: Child general activity limitation: Child limitation in activities children usually do because of a health problem for at least the past six months

FILTERINTERVIEWER: NEXT QUESTION [CHS3 (I)] IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD.

1) Question (i)

Is [child’s name] limited because of a health problem in activities most children of the same age usually do? Would you say he/ she is…?

1. Severely limited2. Limited, but not severely, or3. Not limited at all?

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FILTERINTERVIEWER: NEXT QUESTION [CHS3 (II)] IS TO BE ASKED ONLY FOR CHILDREN WHO ARE LIMITED [CODES 1 OR 2 IN CHS3 (I)].

1) Question (ii)

Has [he/ she] been limited for at least the past six months?1. Yes2. No

2) Guidelines

General concept: Proxy-reported general activity limitation(s) of child, aged six months to 14 years old, in activities children of the same age usually do due to health problem(s)


Definitions and examples: The concept of the variable refers to the participation restriction through long-standing limitation (and its severity) in activities of a child of certain age (six months to 14 years old) because of health problem(s).

Its purpose is to measure presence of longstanding limitations in children, as their consequences can have a large impact on a child’s life (e.g. care, dependency).

Excluded: Temporary or short-term limitations.

The variable measures the proxy respondent’s subjective assessment of whether the child is hampered in 'activities children usually do', by any on-going physical, mental, or emotional health problem, including disease or impairment compared with children of the same age. Similarly to CHS2, the cause is irrelevant. Examples of causes that are covered include injuries/ accidents, congenital conditions, birth defects, and others.

An activity is defined as 'the performance of a task or action by a child' and thus activity limitations are defined as 'the difficulties the child experiences in performing an activity'.

In activities children usually do: The question should clearly show that the reference is to the activities children usually do and not to the child’s own activities.

Children of the same age: To identify existing limitations, a reference is necessary, thus, activity limitations are assessed against a generally accepted population standard, relative to cultural and social expectations in reference only to activities children of the same age usually do.

'Limitations in activities children usually do' refers to difficulties with activities that are usually expected of children of the same age, covering all spectrums of activities: self-care and transportation, school, home and leisure activities.

For at least the past six months: The time period strictly refers to the duration of the activity limitation and not to the duration of the health problem. The limitations must have started at least six months ago and still exist at the moment of the interview. This means that codes 1 or 2 should be recorded only if the child is currently limited and has been limited in activities for at least the past six months.

Excluded: New limitations which have not yet lasted six months, even if usual medical knowledge would suggest that the health problem behind a new limitation is very likely to continue for a long time or for the rest of the life of the respondent (such as for type I diabetes).

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One reason is that in terms of activity limitation it may be possible to counteract at some point negative consequences for activity limitations by using assisting devices or personal assistance. Additionally, the activity limitations of the same health problem may also depend on the individual person and circumstances, and only past experience can provide a safe answer.

Because of a health problem: Only the limitations directly caused by one or more health problems are considered, regardless the type of the problem.

Excluded are limitations due to financial, cultural, or other non-health-related causes.

The response categories include three levels to better differentiate severity of activity limitations: severely limited (severe limitations), limited but not severely (moderate limitations), not limited at all (no limitations).

Severely limited means that performing or accomplishing an activity, which can normally be done by a child of the same age, cannot be done or only done with extreme difficulty. Children in this category, usually, cannot do the activity alone and (would) need help.

Limited, but not severely means that performing or accomplishing an activity, which can normally be done by a child of the same age, can be done, but only with some difficulties. Children in this category usually do not need help from other persons.

Note CHS3 should not be used as a filter for sub-module CPL.

Justification: According to the guiding principles of the Module on Child Functioning and Disability developed by the Washington Group on Disability Statistics (WG) and UNICEF, it may not be feasible to capture disabilities among children younger than two years old through population surveys due to the nature of the development process for children of this age. Thus, the selected starting age range of CHS3 was chosen to be the one employed by WG and UNICEF, namely two years old.

3.3 Physical and sensory functional limitations of children (CPL)

Rationale: Children with disabilities may face significant barriers to enjoying their fundamental rights. They might often be excluded from society, denied access to basic services, such as health care and education, and endure stigma and discrimination. Due to the lack of relevant data and for the purpose of employing internationally comparable indicators that will enable the formulation and implementation of policies that give effect to the Convention on the Rights of Persons with Disabilities (Article 31), the Washington Group on Disability Statistics (WG) and UNICEF developed a short set of disability measures, titled 'Module on Child Functioning and Disability' (hereinafter WG/ UNICEF Module).

The module went through a validation process, through cognitive and field testing, between 2012 and 2016. It covers 13 different sub-topics and addresses the functional limitations of children two to four and five to 17 years old. However, due to the large number of topics covered and questions included in the WG/ UNICEF Module, a selection process was followed on the basis of UN recommendations in determining disability status using a census and questionnaire alignment to the existing structure of EHIS.

According to the Principles and Recommendations for Population and Housing Censuses of the UN’s Department of Economic and Social Affairs, '[a] census can provide valuable information on disability and human functioning in a country. […] It is recommended that the following four domains be considered essential in determining disability status in a way that can be reasonably measured using a census and that would be appropriate for international comparison:

- walking- seeing- hearing- cognition

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[..]. Two other domains, self-care and communication, have been identified for inclusion, if possible.'

Thus, in view of the above, 'Physical and sensory functional limitations of children' (CPL) focus on the first three domains, based on the questions developed for the Module on Child Functioning and Disability.

'Cognition' and particularly the aspect of 'learning' is examined separately due to the fact that it does not fall under the category of physical and sensory functional limitations (see CCL1 and CCL2).

'Communication' and 'self-care' are not examined, as they are not considered essential in determining disability status in a census.

Moreover, building on the work already done for the development of the WG/ UNICEF Module, there are no questions addressed to children younger than two years old. Accordingly, due to the nature of the development process for children younger than two years old, it may not be feasible to capture disabilities through population surveys.

Calculation: Prevalence of physical and sensory functional limitations to be measured by questions CPL1 to CPL6

In the calculation of the indicator, questions on children’s use of glasses/ contact lenses (CPL1), of a hearing aid (CPL3), and of equipment or assistance in walking (CPL5) are not considered. Children are considered as:

- not limited, if the response for all remaining questions is always 'No difficulty';




Introduction CPLNow I am going to ask you some further questions about the child's general physical health. These questions deal with the child's ability to do different basic activities. Please ignore any temporary problems.

General guidelines: Think about situations. A physical or sensory functional limitation can be measured through reference to many actions/ situations. The action/ situation is there only to help the proxy respondent assess the child’s level of functioning. For this reason distances (e.g. 500 metres) should not be taken literally, but as a reference to the scale we are interested in.

Ignore any temporary problems: The aim is to measure long-term (chronic) limitations. This wording is used so that a time limit is not required.

The aim of the questions that follow is to assess:

- how the child functions in its current environment using a performance qualifier: 'Does [child’s name] have difficulty…even when using equipment or receiving assistance', and

- in certain cases (walking), its ability to execute a task or an action using a capacity qualifier: 'Does [child’s name] have difficulty in walking…without any aid or support'.

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6) CPL1: Child wearing glasses or contact lenses


1) Question

Does [child's name] wear glasses or contact lenses?1. Yes2. No3. Child is blind, cannot see at all

2) Guidelines

General concept: Whether child, aged two to 14 years old, uses or not, glasses or contact lenses for improving their ability to see


Justification: The original question of the WG/ UNICEF Module inquires about glasses only. The phrase 'or contact lenses' was added for consistency with the corresponding question in EHIS (PL1), addressed to adults.

7) CPL2: Difficulty of child in seeing even when wearing glasses or contact lenses

FILTERINTERVIEWER: NEXT QUESTION (CPL2) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD, WHO ARE NOT BLIND (CODES 1 OR 2 IN CPL1).

Introduction CPL2 (a)Please answer the following question according to [child’s name]’s normal use of [his/ her] glasses or contact lenses.


1) Question (a)

When wearing [his/ her] glasses or contact lenses, does [child's name] have difficulty seeing? Would you say…?

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1) Question (b)

Does [child's name] have difficulty seeing? Would you say…?1. No difficulty2. Some difficulty3. A lot of difficulty4. Cannot do at all/ unable to do

2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in seeing, even when wearing glasses or contact lenses


Definitions and examples: When wearing [his/ her] glasses or contact lenses: The aim of the question is to assess the child’s performance, rather than capacity and, therefore, the use of technical devices/ aids is taken into account. Additionally, both, long- and short-distance seeing should be taken into account.

Eyesight problems should not be reported if glasses or contact lenses are sufficiently effective. For a child with seeing impairment, who does not have glasses (for instance, due to financial reasons), the respondent should answer without considering these aids.

If asked, the interviewer should mention that good lightening conditions are foreseen.

8) CPL3: Child using hearing aid


1) Question

Does [child's name] use a hearing aid?1. Yes2. No3. Child is deaf, cannot hear at all

2) Guidelines

General concept: Whether child, aged two to 14 years old, uses or not, a hearing aid


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Definitions and examples: Other hearing aids habitually worn and considered as 'within-the-skin' can be taken into account if it is relevant and important in a particular country. Implants are considered as 'within-the-skin' aids.

9) CPL4: Difficulty of child in hearing even when using hearing aid

FILTERINTERVIEWER: NEXT QUESTION (CPL4) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD, WHO ARE NOT DEAF (CODES 1 OR 2 IN CPL3).

Introduction CPL4 (a)Please answer the following question according to [child’s name]’s normal use of [his/ her] hearing aid[s].


1) Question (a)

When using [his/ her] hearing aid[s], does [child's name] have difficulty hearing sounds like peoples’ voices or music? Would you say…?


1) Question (b)

Does [child's name] have difficulty hearing sounds like peoples’ voices or music? Would you say…?


2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in hearing sounds like peoples’ voices or music, even when using hearing aid


Definitions and examples: When using [his/ her] hearing aid[s]: The aim of the question is to assess the child’s performance, rather than capacity and, therefore, the use of technical devices/ aids is taken into account.

The situation is there, only to help the proxy respondent and interviewer assess the level of functioning. Hearing problems should not be reported if hearing aids are sufficiently effective. For a child with hearing impairment who does not have hearing aid (for instance, due to financial reasons), the respondent should answer without considering these aids.

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The question implies a normal situation where there is no background noise or at a very low level, so that there is no background noise that could make difficult to hear what another person says.

In case a child is deaf in one ear, the respondent’s answer should reflect an average situation.

Hearing difficulties include a range of problems that deal with some specific aspects of the hearing function: the perception of loudness and pitch, the discrimination of speech versus background noise, and the localisation of sounds. Background noise is a detractor for hearing and this distraction becomes worse with increasing levels of hearing loss.

10) CPL5: Child using equipment or receiving assistance for walking


1) Question

Does [child's name] use any equipment or receive assistance for walking?4. Yes5. No6. Child is on wheelchair, cannot walk at all

2) Guidelines

General concept: Whether child, aged two to 14 years old, uses or not, any equipment or assistance for walking


Definitions and examples: Walking aids include surgical footwear, canes or walking sticks, zimmer frames, callipers, splints, crutches, wheelchair, artificial limb (leg/ foot), prostheses, someone's assistance. Holding someone’s arm is considered as receiving assistance, as well.

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11) CPL6: Difficulty of child in walking without any aid or support

FILTERINTERVIEWER: NEXT QUESTION (CPL6) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD, WHO ARE NOT ON A WHEELCHAIR, BUT USE EQUIPMENT OR RECEIVE ASSISTANCE FOR WALKING (CODE 1 IN CPL5).


1) Question (a)

Without using [his/ her] equipment or assistance, does [child's name] have difficulty walking? Would you say…?


1) Question (b)

Without using [his/ her] equipment or assistance, does [child's name] have difficulty walking 500 meters on level ground? That would be [...]. Would you say…?


2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in walking, without any aid or support


Definitions and examples: Without using [his/ her] equipment or assistance: The aim of the question is to assess the child’s capacity and, therefore, the use of technical devices/ aids or assistance is not considered when evaluating the extent of difficulty.

The situation is there, only to help the proxy respondent and interviewer assess the level of functioning.

The question investigates for limitations in the physical act of walking, and not for limitations in walking due to other functioning problems. For example, for a blind child, the guide dog or the use of a stick or other walking aid or assistance, if the reason for using it is only limited seeing, should not be seen as an aid; in this case, a child (even if using a walking stick or having a guide dog) should not be seen as having walking difficulties.

Note (CPL6b): National equivalents for 500 metres are allowed to be used in the wording of the question.

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3.4 Cognitive limitations of children (CCL)

Rationale: 'Cognitive disability entails a substantial limitation in one’s capacity to think, including conceptualizing, planning and sequencing thoughts and actions, remembering, and interpreting the meaning of social and emotional cues, and of numbers and symbols.' Therefore, by definition, the ability to learn and remember are central in cognition, which is one of the four domains considered as essential in determining disability status in general population surveys.

The questions have been based on those provided by the WG/ UNICEF Module.


Calculation:

- Prevalence of cognitive limitations in children aged two to four measured by question CCL1

- Prevalence of cognitive limitations in children aged five to 14 measured by questions CCL1 and CCL2

Children, in terms of cognitive abilities, are considered as:

- not limited, if the response for all questions is always 'No difficulty';



Note: In accordance to the Principles and Recommendations for Population and Housing Censuses of the UN’s Department of Economic and Social Affairs, the calculation of the indicator for prevalence of cognitive limitations should be at least combined with that of physical and sensory functional limitations (namely walking, seeing, and hearing) to determine disability status through general population surveys.

Temporary problems should be ignored: The problems (cognitive limitations) should have lasted or are expected to last four weeks or more.

Introduction CCLThe next question(s) concern(s) the child’s ability to learn [and – for children aged five and above – remember things]. Please ignore any temporary problems.

12) CCL1: Difficulty of child in learning new things


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1) Question

Compared with children of the same age, does [child’s name] have difficulty learning things due to a longstanding health problem? Would you say...?


2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged two to 14 years old, has, in learning new things, compared to children of the same age


Definitions and examples: The aim of the question is to assess the child’s ability to learn and solve problems by gathering information and developing new skills, including thinking skills.

A discrepancy between the child's potential and actual achievement is usually called a specific learning difficulty or disability. Learning difficulties may fall into two categories: - Slow learners will always be behind their chronological peers, which doesn't mean they can't be expected to improve. - Children with a specific learning disability can, with the right help, be expected to attain chronologically appropriate academic levels in time. Symptoms that may show learning disabilities or difficulties can be observed for reading, spelling, mathematics, physical aspects, psychological aspects and for social, emotional and behavioural aspects10.


13) CCL2: Difficulty of child in remembering things


1) Question

Compared with children of the same age, does [child’s name] have difficulty remembering things due to a longstanding health problem? Would you say…?


10 See http://www.kidspot.com.au/school/primary/learning-and-behaviour/learning-difficulties/ 45

http://www.kidspot.com.au/school/primary/learning-and-behaviour/learning-difficulties/

2) Guidelines

General concept: Assessment of the extent of difficulty which a child, aged five to 14 years old, has in remembering things, compared to children of the same age


Definitions and examples: The aim of the question is to assess the child’s demonstrated ability to remember, namely their ability to recall a piece of information already provided to or acquired by the child.


3.5 Social and mental health difficulties of children (CSM)

Rationale: Social and mental health is an integral part of health and well-being, as reflected in WHO’s definition of health, which states that 'health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity'.

For the purposes of the present report, the term 'mental health' is used to incorporate a range of states, from excellent mental health to severe mental health problems. 'Mental well-being' constitutes the positive state of mental health, whereas 'mental illness' the negative aspect that comes at a fairly large cost to society and the economy.

Furthermore, according to WG and UNICEF, the prevalent types of disability differ between adults and children. More specifically, accordingly, studies at both national and international levels suggest that in adults major problems are mobility, sensory functions, and personal care – especially with advancing years. While in children disabilities tend to relate to intellectual functioning, affect, and behaviour.

The questions presented below have been based on those provided by the WG/ UNICEF Module.

Different questions covering the same sub-domains – namely, psychological distress and ability to control one’s behaviour – identified in other surveys include the following:

- NSCH: I am going to read a list of items that sometimes describe children. For each item, please tell me how often this was true for [CHILD’S NAME] during the past month.

- [He/ She] is unhappy, sad, or depressed

- [He/ She] stays calm and in control when faced with a challenge

- HBSC: In the last 6 months: how often have you had the following…?

- Feeling

- Irritability or bad temper

- Feeling nervous


Calculation: Prevalence of behavioural (social) difficulty in children, aged two to four, to be measured by question CSM1

Prevalence of behavioural (social) and mental health difficulty in children, aged five to 14, to be measured by questions CSM1 and CSM2

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Children, in terms of social and mental health, are considered as:

- not limited, if the response for question CSM1 is 'Not at all' or 'The same or less' and for CSM2 is 'Never'

- moderately, if the response for question CSM1 is 'More' or for CSM2 is 'A few times a year' or 'Monthly'

- severely limited, if the response for question CSM1 is or 'A lot more' or for CSM2 is 'Weekly' or 'Daily'

Note: The calculation of the indicator for social and mental health difficulties may be combined with those of physical and sensory functional limitations (namely walking, seeing, and hearing) and cognitive limitations to determine disability status through general population surveys.

Temporary problems should be ignored: The problems (social and mental health difficulties) should have lasted or are expected to last four weeks or more.

Introduction CSMThe next question[s] is [are] about the child’s behaviour [and – for children aged five and above – feelings]. Please ignore any temporary problems.

14) CSM1: Behavioural difficulty of child



1) Question (a)

Compared with children of the same age, how much does [child’s name] kick, bite or hit other children or adults? Would you say…?


1) Question (b)

Compared with children of the same age, how much difficulty does [child’s name] have controlling his/ her behaviour? Would you say…?

1. Not at all2. The same or less3. More4. A lot more

2) Guidelines

General concept: Assessment of the extent of behavioural difficulties which a child, aged two to 14 years old, has, compared to children of the same age

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Definitions and examples: Compared with children of the same age: For reference and to focus the respondent on the functioning of their own child in reference to that child’s cohort.

15) CSM2: Mental health difficulty of child


1) Question

How often does [child’s name] seem very anxious, nervous, or worried? Would you say..?1. Daily2. Weekly3. Monthly4. A few times a year5. Never

2) Guidelines

General concept: Assessment of the extent of the mental ill-health of child aged five to 14 years old

Policy relevance: Close link to ECHI 38; (Planning of) health care resources and health care cost ; child health (including young adults)

Justification: The question was rephrased from the original 'how much' to 'how often', as the answer categories provided concern frequency, rather than quantity.

3.6 Physical activity/ exercise of children (CPE)

Rationale: 'It has been largely recognised that physical activity has a substantial impact on health status and must be considered as one of the major behaviours to be promoted in the field of public health. Relative physical inactivity, usually together with unhealthy food habits, is associated with the development of many of the major non-communicable diseases in society, such as [cardiovascular disease] CVD, some cancers, obesity, and diabetes.'

Adding to that, accurate assessment of physical activity in children is necessary to identify current levels of activity and to assess the effectiveness of intervention programmes designed to increase physical activity.


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Calculation: Proportion of children performing vigorous physical activities (days and/ or hours per week), derived from questions CPE1 to CPE2: Days and time devoted to vigorous physical activities (doing sports, fitness, or recreational activities), in a typical week.

Introduction CPENext I am going to ask about the time [child's name] spends doing sports, fitness, or recreational (leisure) physical activities in a typical week OUTSIDE SCHOOL HOURS. Please answer these questions even if you do not consider [child's name] to be a physically active child.

16) CPE1: Number of days in a typical week carrying out sports, fitness, or recreational (leisure) physical activities that cause child to get out of breath or sweat

FILTERINTERVIEWER: NEXT QUESTION (CPE1) IS TO BE ASKED ONLY FOR CHILDREN 5-14 YEARS OLD.

1) Question

In a typical week, on how many days does [child's name] carry out sports, fitness, or recreational (leisure) physical activities outside school hours that cause [him/ her] to get out of breath or sweat?

1. Number of days: _2. 0. Never carries such physical activities

2) Guidelines

General concept: Number of days in a typical week doing sports, fitness, or recreational activities that cause the child, aged five to 14 years old, to get out breath or sweat


Definitions and examples: In this question, focus is on the leisure-time physical activities that the child engages in, during a typical week, which cause them to get out of breath or sweat. The two questions focus on the frequency and duration of sports, fitness and recreational activities in general.

Valid values: 0-7 days.

'Sports' refers to physical activity which is structured, repetitive and usually requires skills. Sports are often aerobe physical activities, competitive or performed as a game. Examples: ball games, athletics, competitive bicycling, running, swimming, etc.

'Fitness' refers to the act or process of retaining or improving physical fitness. Fitness often relates to physical exercise. Examples: endurance training, strength exercise, flexibility training, etc.

'Recreational activity' refers to the act or process of creating regeneration by performing physical activities that cause at least a small increase in breathing or heart rate. Recreational activities are physical activities performed in leisure time. Examples: Nordic walking, brisk walking, ball games, jogging, bicycling, swimming, aerobics, rowing, badminton, etc.

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'Cause the child to get out of breath or sweat' refers to moderate- or vigorous-intensity sports, fitness or recreational (leisure) activities which are physically demanding and lead at least to a small increase in breathing or heart rate.

Use of showcard: Showcard 3 of the European Health Interview Survey (EHIS wave 2 and 3) – Methodological manual can be used.

Justification: Given that similarly to the rest of the questionnaire CPE1 will be answered by parents, the question has been derived from EHIS wave 2 (PE6), adapted to children and aligned to a similar question from the study on Health Behavior in School-Aged Children (HBSC). More specifically, the phrase used in the EHIS questionnaire 'that cause at least a small increase in breathing or heart rate' was replaced with the one used in the HBSC study 'cause the child to get out of breath or sweat', as the latter can be more easily visible than the former by a proxy respondent.

Furthermore, not excluding transport activities, will allow the relevant information collection through a single question (rather than two, as is done in the EHIS questionnaire), while at the same time enable the comparison between the data derived from the proposed questionnaire and that of HBSC.

Focusing the respondent on the physical exercise of the child outside school hours is also intended to facilitate the response formation process of the proxy, as parents or primary care givers are more likely to know where or what the child is doing when not at school.

Finally, it should be noted that the aforementioned considerations in phrasing the relevant question aim to minimise the proxy effect. Nonetheless, there is a risk that proxy respondents are actually misinformed by the child itself, especially as the latter gets older into adolescence, and in turn, report false information.

17) CPE2: Time spent on doing sports, fitness, or recreational (leisure) physical activities that cause child to get out of breath or sweat

FILTERINTERVIEWER: NEXT QUESTION (CPE2) IS TO BE ASKED ONLY FOR CHILDREN 5-14 YEARS OLD, WHO HAVE DONE SPORTS AT LEAST ONCE A WEEK (ANSWER DIFFERENT FROM 'CHILD NEVER CARRIES OUT SUCH PHYSICAL ACTIVITIES' IN CPE1).

1) Question

In a typical week, how many hours does [child's name] carry out sports, fitness, or recreational (leisure) physical activities?

1. _ _:_ _ per week (hours : minutes)

2) Guidelines

General concept: Total time in a typical week child, aged five to 14 years old, spends on doing sports, fitness, or recreational activities


Definitions and examples: The question asks about the total duration of carrying out sports, fitness, and recreational activities in a typical week performed by the child. Proxy respondents should add up all the sports,

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fitness and recreational activities the child performs in a typical week. They can choose the time unit of the weekly duration themselves. The duration can be minutes or hours, or a combination of hours and minutes. The interviewer should enter the duration in the same way, as the respondents answer the question.

Excluded are school activities or transport.

Respondents should refer only to the activities children perform in their leisure time.

Valid measuring units: Hours and/ or minutes.

Sports refer to physical activity which is structured, repetitive and usually requires skills. Sports are often aerobe physical activities, competitive or performed as a game. Examples: ball games, athletics, competitive bicycling, running, swimming, etc.

Fitness refers to the act or process of retaining or improving physical fitness. Fitness often relates to physical exercise.

Examples: endurance training, strength exercise, flexibility training, etc.

Recreational activity refers to the act or process of creating regeneration by performing physical activities that cause at least a small increase in breathing or heart rate. Recreational activities are physical activities performed in leisure time.

Examples: Nordic walking, brisk walking, ball games, jogging, bicycling, swimming, aerobics, rowing, badminton, etc.

3.7 Child consumption of fruit and vegetables (CFV)

Rationale: Healthy food intake is a key element for preventing numerous chronic diseases. The increasing scientific evidence shows that consumption of fruits and vegetables decreases the risk of several chronic diseases has created a firm basis for policy initiatives. In fact, fruits and vegetables are a dietary protective factor against several types of cancers, as well as for cardiovascular disease. Given that only selected aspects of food habits can be assessed via a general health survey, consumption of fruit and vegetables were selected as a proxy for a healthy diet.

It should be noted that, in contrast to the approach adopted in the EHIS wave 2 or 3 methodological manuals, there is no strict definition of what counts as a serving, which, in the questionnaire addressed to parents, is rather subjectively defined as 'the child’s regular portion of his/her food'.

In line with the Eurostat TF EHIS decision to exclude all kinds of juices (incl. 100% pure / fresh) from the questions of (adult) fruit and vegetable consumption, 100% pure / fresh are also excluded in the proposed questions on child consumption of fruit and vegetables.


Calculation: Percentage of children reported to eat fruits (excluding juice) at least once a day and percentage of children reported to eat vegetables (excluding potatoes and juice) at least once a day.

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Introduction CFVNext questions concern the child’s consumption of fruits and vegetables.

18) CFV1: Frequency of child eating fruit, excluding juices

FILTERINTERVIEWER: NEXT QUESTION (CFV1) IS TO BE ASKED ONLY FOR CHILDREN 6 MONTHS - 14 YEARS OLD.

1) Question

How often does [child’s name] eat fruits, excluding all kinds of juices?1. Once or more a day2. 4 to 6 times a week 3. 1 to 3 times a week4. Less than once a week5. Never

INSTRUCTIONS/ CLARIFICATIONS: Neither juices from fresh fruit nor juices prepared from concentrate nor processed fruits are included.

2) Guidelines

General concept: Frequency of child, aged six months to 14 years old, eating fruits (juices excluded)


Definitions and examples: How often refers to a typical week, including weekdays and weekend days in given season.

The fruits can be fresh or frozen. Also, they can be cut in small pieces or mashed (puréed). Canned or dried fruits should be included.

Excluded are all kinds of juices and smoothies.

Note: Each country can specify examples, some common, and some more specific to their country.

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19) CFV3: Frequency of child eating vegetables or salad, excluding potatoes and juices

FILTERINTERVIEWER: NEXT QUESTION (CFV3) IS TO BE ASKED ONLY FOR CHILDREN 6 MONTHS - 14 YEARS OLD.

1) Question

How often does [child’s name] eat vegetables or salad, excluding potatoes and all kinds of juices?

1. Once or more a day2. 4 to 6 times a week 3. 1 to 3 times a week4. Less than once a week5. Never

INSTRUCTIONS/ CLARIFICATIONS: Soups (warm and cold) are included. Excluded are all kinds of juices, either squeezed from fresh vegetables, or juices prepared from concentrate or processed vegetables, or artificially sweetened vegetable juices.

2) Guidelines

General concept: Frequency of child, aged six months to 14 years old, eating vegetables or salad (potatoes and vegetable juices excluded)


Definitions and examples: How often refers to a typical week, including weekdays and weekend days in a given season. Fresh or frozen vegetables are included. Vegetables may be cut in small pieces or mashed (puréed). Canned vegetables should be included. Legume (beans, lentils) and vegetable dishes, including soups (cooked as well as cold ones) should be included.

Excluded are all kinds of juices and smoothies; potatoes and similar starchy foods, such as yam, plantain, and cassava which are carbohydrate foods, and are included in the bread-and-cereals food group.

Note: Each country can specify examples, some common, and some more specific to their country.

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3.8 Child consumption of sugar-sweetened beverages (CSB)

Rationale: Excessive consumption of sugars has been linked with a variety of health conditions and diseases, including obesity and dental caries – two health outcomes identified as critical in relation to free sugars intake. According to WHO, 'there is increasing concern that intake of free sugars – particularly in the form of sugar-sweetened beverages – increases overall energy intake and may reduce the intake of foods containing more nutritionally adequate calories, leading to an unhealthy diet, weight gain, and increased risk of [Non-Communicable Diseases] NCDs', including dental diseases.


Calculation: Percentage of children reported to drink sugar-sweetened beverages at least once a day.

Introduction CSINext questions concern the child’s consumption of soft drinks that contain sugar.

20) CSB1: Frequency of child drinking sugar-sweetened soft drinks a week

FILTERINTERVIEWER: NEXT QUESTION (CSI1) IS TO BE ASKED ONLY FOR CHILDREN 2-14 YEARS OLD.

1) Question

How often does [child’s name] drink sugared soft drinks, for example lemonade or cola? Please, exclude light, diet or artificially sweetened soft drinks?

1. Once or more a day2. 4 to 6 times a week3. 1 to 3 times a week4. Less than once a week5. Never

INSTRUCTIONS/ CLARIFICATIONS: Light, diet or artificially sweetened soft drinks are excluded.

2) Guidelines

General concept: Frequency of child, aged two to 14 years old, drinking sugar-sweetened beverages

Policy relevance: Dietary habits; child health (including young adults); ECHI 21(A/B), ECHI 42.

Definitions and examples: Each country should specify some examples (maximum of three) of very common sugar-sweetened soft drinks in the country. Examples are carbonated soft drinks such as Coke, Fanta, Sprite, but diet coke/ Coca-Cola light, coke zero/ Coca-Cola zero, diet Fanta etc. are excluded.

How often refers to a typical week, including weekdays and weekend days in given season.

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Pre-testing (for the same question in the adult-persons questionnaire) of the Eurostat contractor revealed that respondents did often not exclude light, diet or artificially sweetened soft drinks. As consequence it is proposed to add 'Please, exclude light, diet or artificially sweetened soft drinks' to the question.

Pre-testing (for the same question in the adult-persons questionnaire) also revealed that no answers were provided for categories ‘Three times or more a day’ and ‘Twice of more a day’. The categories start with category ‘1. Once or more a day’.

Use of showcard: A showcard of examples of sugar-sweetened beverages can be used.

The starting age, was selected on the assumption that it is unlikely that children under the age of two will be consuming SSBs, and by extension are expected to be a very small percentage of the total population of children. Nonetheless, the appropriateness of the starting age may be further assessed on the basis of the feedback provided by Member States and other participating EU countries in EHIS.

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4 Annex: List of questions not-proposed to TF EHIS for pre-testing

Perceived oral health of child

COH1: Perceived condition of child's teeth: how the respondent perceives the child's oral health in general

COH2: Child occurrence of toothache, decayed teeth, and/ or unfilled cavities in the past 12 months

Physical and sensory functional limitations

CPL6: Difficulty of child in walking even when using equipment or receiving assistance

Mobility and participation of children in major life domains

CMR2A: Lack of special aids/equipment contributing to the level of difficulty experienced by child in [aspect of mobility]

CMR2B: Lack of personal help/assistance contributing to the level of difficulty experienced by child in [aspect of mobility]

Participation of children in compulsory education

CPR2A: Lack of special aids or equipment contributing to the level of difficulty experienced by child in participating in compulsory education

CPR2B: Lack of personal help or assistance contributing to the level of difficulty experienced by child in participating in compulsory education

Participation of children in pursuing leisure activities

CPR4A: Lack of special aids or equipment contributing to the level of difficulty experienced by child in pursuing leisure activities

CPR4B: Lack of personal help or assistance contributing to the level of difficulty experienced by child in pursuing leisure activities

Child consumption of fruit and vegetables (CFV)

CFV2: Number of portions of fruit a day consumed by child, excluding juice

CFV4: Number of portions of vegetables or salad a day consumed by child, excluding potatoes and juice

Child consumption of sugar-sweetened and artificially-sweetened beverages (CSB)

CSB1A: Frequency of child drinking 100% fruit juice

CSB1B: Frequency of child drinking 100% vegetable juice

CSB1C: Frequency of child drinking sweetened juices

CSB1D: Frequency of child drinking soft drinks, regular

CSB1E: Frequency of child drinking soft drinks, diet

CSB1F: Frequency of child drinking sweetened tea

CSB1G: Frequency of child drinking meal replacement shakes/ protein drinks

CSB1H: Frequency of child drinking energy/ sports drinks56

CSB2: Amount of 100% fruit juice child drinking each day

CSB1B: Amount of 100% vegetable juice child drinking each day

CSB1C: Amount of sweetened juices child drinking each day

CSB1D: Amount of soft drinks, regular child drinking each day

CSB1E: Amount of soft drinks, diet child drinking each day

CSB1F: Amount of sweetened tea child drinking each day

CSB1G: Amount of meal replacement shakes/ protein drinks child drinking each day

CSB1H: Amount of energy/ sports drinks child drinking each day

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