Formatvorlage Annex BM 20110920 · Comments on and suggestions for specific ... Im Folgenden werde...

Eurostat Grant 10501.2009.007‐2009.890

Improvement of the European Health

Interview Survey (EHIS) modules on alcohol

consumption, physical activity and mental

health

Final Report Annex

2

Contents

1. Annex Chapter 3 – Translated Instruments ..................................................... 5

1.1. German version of PA and AL ........................................................................ 5

1.2. Estonian version of MH, PA and AL.............................................................. 16

1.3. French version of MH, PA and AL ................................................................ 27

2. Annex Chapter 4 – Country Reports of parallel Cognitive Testing, Round 1 .....39

2.1. Report UK (NatCen) ..................................................................................... 39 2.1.1. Background............................................................................................................. 41 2.1.2. Mental Health......................................................................................................... 45 2.1.3. Physical Activity...................................................................................................... 59 2.1.4. Alcohol Consumption ............................................................................................. 67 2.1.5. Technical Appendix ................................................................................................ 83 2.1.6. The Tested Physical Health Questions ................................................................... 88 2.1.7. HSE The Alcohol Consumption Module 2006 ........................................................ 93

2.2. Report BE (IPH) ............................................................................................ 99 2.2.1. Methods ............................................................................................................... 101 2.2.2. Mental Health....................................................................................................... 102 2.2.3. Alcohol Consumption ........................................................................................... 120 2.2.4. Physical Activity.................................................................................................... 136

2.3. Report EE (NHID) ....................................................................................... 145 2.3.1. Methods ............................................................................................................... 147 2.3.2. Physical Activity.................................................................................................... 148 2.3.3. Mental Health....................................................................................................... 153 2.3.4. Alcohol Consumption ........................................................................................... 159

2.4. Report DE (RKI) .......................................................................................... 163 2.4.1. Methods ............................................................................................................... 165 2.4.2. Results .................................................................................................................. 166 2.4.3. Mental Health....................................................................................................... 167 2.4.4. Physical Activity.................................................................................................... 178 2.4.5. Alcohol Consumption ........................................................................................... 183

2.5. Test Questions & Probe Sheet for Round 1 ............................................... 197

3. Annex Chapter 5 – Country Reports of Parallel Cognitive Testing, Round 2 ...217

3.1. Germany .................................................................................................... 217 3.1.1. Methods ............................................................................................................... 218 3.1.2. Results .................................................................................................................. 220

3.2. Estonia ....................................................................................................... 237 3.2.1. Methods ............................................................................................................... 239 3.2.2. Conclusions........................................................................................................... 260

3.3. Test Questions & Probe Sheet for Round 2 ............................................... 261

4. Review of CT Results AL Questionnaire ........................................................269

4.1. Background................................................................................................ 270

4.2. General Issues............................................................................................ 271

3

4.2.1. Mode of data collection ....................................................................................... 271 4.3. Comments on and suggestions for specific questions ............................... 281

5. Annex chapter 6 – Translated instruments ...................................................295

5.1. German version of PA and AL .................................................................... 295

5.2. Estonian version of PA and AL ................................................................... 305

5.3. French version of PA and AL ...................................................................... 315

6. Annex Chapter 7 – Field‐Testing Questionnaire ............................................327

4

List of Tables

Table 1: Characteristics of respondents in the cognitive interview sample ..................................44 Table 2: Perception of an overlap between Q1 and Q2 & the implication of this understanding46 Table 3: The implication of incomplete answer scale on how Q1 was answered .........................51 Table 4: How individual items in Q1 were understood..................................................................53 Table 5: Understanding of items in Q2 & implication on how they worked .................................57 Table 6: Module Preference by physical activity level...................................................................60 Table 7: How Vigorous and Moderate was understood by respondents ......................................62 Table 8: The mix between men and women we wanted to achieve in this study ........................86 Table 9: Characteristics of respondents participating in the cognitive testing study..................101 Table 10: Two mental health questions tested, Q1 (PHQ‐9) and Q2 (MHI‐5/EVI) ......................102 Table 11: Two principle aims in testing........................................................................................102 Table 12: Overview of some reasons put forward for an expressed preference ........................105 Table 13: Perceived overlap between Q1 and Q2 .......................................................................107 Table 14: The use of the reference period...................................................................................109 Table 15: Face‐to‐face interviews, perceived pros and cons.......................................................111 Table 16: PHQ‐9 answer categories and MHI‐5/EVI answer categories......................................112 Table 17: Summary results PHQ9.................................................................................................118 Table 18: Characteristics of respondents participating in the cognitive testing study ...............147 Table 19: Results of cognitive testing for Leisure‐time PA and Total PA questions ....................150 Table 20: Comments for NHIS and IPAQ by the respondents of different age groups ...............151 Table 21: Comparison of Q1 (PHQ‐9) and Q2 (MHI‐5/EVI) ..........................................................155 Table 22: Characteristics of respondents participating in the cognitive testing study ...............166 Table 23: Comparison Similarity/Simplicity of PHQ‐9 (Q1) and MHI‐5/EVI (Q2).........................168 Table 24: Understanding and overall findings for Q1 (PHQ‐9) ....................................................173 Table 25: Understanding and overall findings for Q2 (MHI‐5/EVI)..............................................176 Table 26: Preference for NHIS or IPAQ in relation to PA‐level ....................................................179 Table 27: Weekly alcohol consumption and preferences of respondents ..................................186 Table 28: Characteristics of respondents participating in cognitive testing round 2 ..................218 Table 29: Overview of respondents’ thought process when answering Q1................................223 Table 30: Examples of the definitions of bicycling given by the respondents.............................229 Table 31: Specific opinions about question .................................................................................233 Table 32: Characteristics of respondents participating in the cognitive testing study ...............239 Table 33: Overview of the Estonian respondents’ thought process when answering Q1...........252 Table 34: Overview of Estonian respondents’ thought process for Q3.1 and Q3.1A..................258

5

1. Annex Chapter 3 – Translated Instruments 1.1. German version of PA and AL

FRAGEN ZUR KÖRPERLICHEN AKTIVITÄT

BITTE ERST ALLE FRAGEN STELLEN UND ANSCHLIEßEND KOGNITIV TESTEN

In den nächsten Fragen geht es um Ihre körperliche Bewegung in der Freizeit (gemeint sind z.B. körperliches Training, sportliche Aktivitäten oder Hobbies, bei denen Sie körperlich aktiv sind). Q3:Wie oft üben Sie in Ihrer Freizeit SEHR ANSTRENGENDE körperliche Aktivitäten von MINDESTENS 10 MINUTEN Dauer aus, die zu STARKEM Schwitzen oder einem STARKEN Anstieg der Herz‐ oder Atemfrequenz führen?

*wenn nötig vorlesen: Wie viele Male am Tag, in der Woche, im Monat, oder im Jahr üben Sie diese Aktivitäten aus? *Anzahl Einheiten der sehr anstrengender Freizeitaktivität eintragen.

Nie

1 – 995 Mal ____

Nicht in der Lage diese Art von Aktivität auszuführen

keine Angabe

Weiß nicht

*Tragen Sie die gewählte Zeiteinheit für sehr anstrengende Freizeitaktivitäten ein.

Nie Go to Q4

am Tag ASK Q3a

in der Woche ASK Q3a

im Monat ASK Q3a

im Jahr ASK Q3a

Nicht in der Lage solche Aktivitäten auszuüben Go to Q4

keine Angabe Go to Q4

Weiß nicht Go to Q4

Notes:

6

Q3a: Wie lange etwa üben Sie jeweils in Ihrer Freizeit diese sehr anstrengenden körperlichen Aktivitäten aus? * Tragen Sie die Dauer sehr anstrengender Aktivitäten in der Freizeit ein.

1‐995 ____



* Tragen Sie die gewählte Zeiteinheit der Dauer sehr anstrengender Aktivitäten in der Freizeit ein.

Minuten Go to Q4

Stunden Go to Q4



Notes:

Q4: Wie oft üben Sie in Ihrer Freizeit LEICHT ODER MÄßIG ANSTRENGENDE körperliche Aktivitäten von MINDESTENS 10 MINUTEN Dauer aus, die zu LEICHTEM Schwitzen oder einem LEICHTEN bis MITTLEREN Anstieg der Herz‐ oder Atemfrequenz führen.

*Wenn nötig vorlesen: Wie viele Male am Tag, in der Woche, im Monat, oder im Jahr üben Sie diese Aktivitäten aus? *Anzahl Einheiten der leicht oder mäßig anstrengenden Aktivitäten in der Freizeit eintragen.

Nie

1‐995 Mal ____

Nicht in der Lage diese Art von Aktivität auszuüben

keine Angabe

Weiß nicht

*Tragen Sie die gewählte Zeiteinheit für die leicht oder mäßig anstrengenden Aktivitäten in der Freizeit ein.

7

Nie Go to Q4

am Tag ASK Q3a


im Monat ASK Q3a

im Jahr ASK Q3a




Notes:

Q4a: Wie lange etwa üben Sie jeweils in Ihrer Freizeit diese leicht oder mäßig anstrengenden körperlichen Aktivitäten aus?

* Tragen Sie die Dauer der leicht oder mäßig anstrengenden Aktivitäten in der Freizeit ein.

1‐995 ____

Keine Angabe Go to Q4


* Tragen Sie die gewählte Zeiteinheit der Dauer der leicht oder mäßig anstrengenden Aktivitäten in der Freizeit ein.

Minuten Go to Q4

Stunden Go to Q4



Notes:

8

Q5: Wie oft üben Sie in Ihrer Freizeit körperliche Aktivitäten aus, die speziell für den Aufbau oder die Kräftigung der Muskulatur gedacht sind wie beispielsweise Krafttraining oder Kräftigungsübungen? (Geben Sie hier alle Aktivitäten dieser Art an, selbst wenn Sie Sie vorher bereits mit einbezogen haben)

*Falls nötig vorlesen: Wie viele Male am Tag, in der Woche, im Monat, oder im Jahr üben Sie diese Aktivitäten aus? *Anzahl der Einheiten der Muskelkräftigung eintragen.

Nie

1‐995 Mal ____

Nicht in der Lage diese Art von Aktivität auszuüben

keine Angabe

Weiß nicht

*Tragen Sie die angegebene Zeiteinheit für die Muskelkräftigungsaktivitäten ein.

Nie Go to Q4

am Tag ASK Q3a


im Monat ASK Q3a

im Jahr ASK Q3a




Notes:

9

Wir haben jetzt den ersten Teil der Fragen zur körperlichen Aktivität abgeschlossen und gehen jetzt zum nächsten Teil über… Im Folgenden werde ich Sie fragen, wie viel Zeit Sie in den letzten 7 Tagen mit körperlicher Bewegung verbracht haben. Bitte beantworten Sie jede Frage, selbst wenn Sie sich selbst nicht für eine aktive Person halten. Denken Sie dabei an die körperliche Bewegung, die Sie auf der Arbeit, als Teil Ihrer Haus‐ und Gartenarbeit oder um von einem Ort zum Anderen zu gelangen ausgeübt haben sowie an körperliches Training oder sportliche Aktivität in Ihrer Freizeit.

Q6: Denken Sie zuerst an alle sehr anstrengenden Aktivitäten, die Sie in den letzten 7 Tagen ausgeübt haben und die eine schwere körperliche Leistung erforderten. Sehr anstrengende Aktivitäten führen zu einer sehr viel schnelleren und heftigeren Atmung und umfassen beispielsweise schweres Heben, Wettkampfsport sowie Fahrradfahren, Laufen oder Schwimmen mit hoher Geschwindigkeit. Denken Sie nur an körperliche Aktivitäten, die Sie für eine Dauer von mindestens 10 Minuten ausgeübt haben. An wie vielen der letzten 7 Tage haben Sie sehr anstrengende körperliche Aktivität ausgeübt?

Tage die Woche __ bei Null weiter mit Frage Q7, ansonsten weiter mit Frage Q6a

Weiß nicht weiter mit Frage Q7

Keine Angabe weiter mit Frage Q7

[Hinweis vorlesen: Denken Sie nur an körperliche Aktivitäten, die Sie für eine Dauer von mindestens 10 Minuten ausgeübt haben.]

Q6a: Wie lange üben Sie üblicherweise an einem solchen Tag sehr anstrengende körperliche Aktivitäten aus?

Stunden am Tag __ __ weiter mit Frage Q7

Minuten am Tag __ __ __ weiter mit Frage Q7




Notes:

10

Q7: Denken Sie nun an Aktivitäten, die Sie in den letzten 7 Tagen ausgeübt haben und die eine mäßige körperliche Leistung erforderten. Mäßig anstrengende Aktivitäten führen zu einer etwas schnelleren Atmung und umfassen beispielsweise das Tragen von leichten Lasten sowie Fahrradfahren, Laufen oder Schwimmen mit mäßiger Geschwindigkeit. Schließen Sie hier Spazieren bzw. zu Fuß gehen nicht

mit ein. An wie vielen der letzten 7 Tage haben Sie mäßig anstrengende körperliche Aktivitäten ausgeübt?

Tage die Woche __ Bei Null weiter mit Frage Q8, ansonsten weiter mit Frage Q7a

Weiß nicht Weiter mit Frage Q8

Keine Angabe Weiter mit Frage Q8

[Hinweis vorlesen: Denken Sie nur an körperliche Aktivitäten, die Sie für eine Dauer von mindestens 10 Minuten ausgeübt haben.] Q7a: Wie lange üben Sie üblicherweise mäßig anstrengende körperliche Aktivitäten an einem solchen Tag aus?






Notes:

Q8: Denken Sie nun an Wegstrecken, die Sie in den letzten 7 Tagen zu Fuß gegangen sind. Gemeint ist das zu Fuß gehen bei der Arbeit, zu Hause und um von einem Ort zum Anderen zu gelangen. Schließen Sie auch alle anderen Fußstrecken mit ein, wie beispielsweise Spaziergänge oder Wanderungen in der Freizeit. An wie vielen der letzten 7 Tage sind Sie für mindestens 10 Minuten ohne Unterbrechung zu Fuß gegangen?

Tage die Woche __ Bei Null weiter mit Frage Q9 ansonsten weiter mit Frage Q8a

Weiß nicht Weiter mit Frage Q9

Keine Angabe Weiter mit Frage Q9

[Hinweis vorlesen: Denken Sie nur an Gelegenheiten, bei denen Sie mindestens 10 Minuten zu Fuß gegangen sind.]

11

Q8a: Wie lange sind Sie üblicherweise an einem solchen Tag zu Fuß gegangen?





Notes:

Q9: Denken Sie nun an die Zeit, die Sie während der letzten 7 Tage werktags im Sitzen verbracht haben. Gemeint ist das Sitzen während der Arbeit, zu Hause, während des Schulunterrichts oder der Vorlesung, sowie in der Freizeit. Schließen Sie beispielsweise das Sitzen am Schreibtisch, beim Besuchen von Freunden, beim Lesen, sowie das Sitzen oder Liegen beim Fernsehgucken mit ein.

Wie viel Zeit haben Sie üblicherweise während der letzten 7 Tage im Sitzen verbracht?

Stunden am Tag __ __ weiter mit der nächsten Frage

Minuten am Tag __ __ __ weiter mit der nächsten Frage

Weiß nicht weiter mit der nächsten Frage

Keine Angabe weiter mit der nächsten Frage

[Hinweis vorlesen: Schließen Sie zusätzlich zum Sitzen auch den Zeiträume mit ein, den Sie im Wachzustand im Liegen verbringen.]

Notes:

12

FRAGEN ZUM ALKOHOLKONSUM

Bitte füllen Sie jetzt diesen Fragebogen aus. Aber zunächst bitte nur die ersten beiden Fragen, danach werde ich Ihnen ein paar Fragen stellen. SHOW CARD 3: Beispiele für Standardgetränke vorlegen! AL.1. Wie oft haben sie in den letzten 12 Monaten ein alkoholisches Getränk zu sich genommen?

Jeden Tag oder fast jeden Tag 1

5 ‐ 6 Tage die Woche 2



2 ‐ 3 Tage im Monat 5

Einmal im Monat 6

Einmal alle zwei Monate 7

Ein‐ oder zweimal in den letzten 12 Monaten 8

Ich habe früher Alkohol getrunken, aber nicht in den letzten 12 Monaten

9

Ende des Interviews

In meinem ganzen Leben nur kleine Mengen ausschließlich zum Probieren

10

Ende des Interviews

AL.1a. Wenn Sie Alkohol trinken, wie viele alkoholische Getränke trinken Sie dann üblicherweise an einem Tag? Bitte beziehen Sie sich auf die Abbildung. Gemeint sind die Standardgetränke.

24 oder mehr alkoholische Getränke 1

17 ‐ 23 alkoholische Getränke 2



6 alkoholische Getränke 5




1 alkoholisches Getränk 9

13

AL.2. An wie vielen Tagen unter der Woche (von Montag ‐ Donnerstag) trinken Sie üblicherweise Alkohol?

An allen vier Tagen 1

An drei Tagen 2

An zwei Tagen 3

An einem Tag 4

Gar nicht unter der Woche 5

weiter mit Frage AL.4

AL.3. Wenn Sie unter der Woche (Montag – Donnerstag) Alkohol trinken, wie viele alkoholische Getränke trinken Sie dann üblicherweise an einem Tag? Bitte beziehen Sie sich auf die Abbildung. Gemeint sind die Standardgetränke.


17‐23 alkoholische Getränke 2








AL.4. An wie vielen Tagen trinken Sie üblicherweise am Wochenende (Freitag – Sonntag) Alkohol?

An allen drei Tagen 1

An zwei Tagen 2

An einem Tag 3

Nicht am Wochenende 4

weiter mit Frage AL.6

14

AL.5. Wenn Sie am Wochenende (Freitag – Sonntag) Alkohol trinken, wie viele alkoholische Getränke trinken Sie dann üblicherweise an einem Tag? Bitte beziehen Sie sich auf die Abbildung. Gemeint sind die Standardgetränke.










AL.6. Wie oft haben Sie in den letzten 12 Monaten sechs oder mehr alkoholische Getränke bei einer Gelegenheit getrunken?


5 – 6 Tage die Woche 2




Einmal im Monat 6

Einmal alle zwei Monate 7

Ein oder zweimal in den letzten 12 Monaten 8

Gar nicht in den letzten 12 Monaten 9

Noch nie 10

15

Showcard Alkohol

16

1.2. Estonian version of MH, PA and AL

VAIMNE TERVIS

SISSEJUHATUS: Järgnevalt esitan mõned küsimused teie vaimse heaolu kohta. ABIKAART 1 Q 1: Kui tihti on teil viimase 2 nädala jooksul esinenud järgmisi probleeme...

PHQ‐9 Üldse mitte

Mõnel päeval

Rohkem kui

pooltel päevadel

Peaaegu iga päev

EOÖ Keeldumine

Q1.1 Tundsite, et miski ei huvita teid ega paku rõõmu

1 2 3 4 99 97

Q1.2 Tundsite rusutuse, masenduse või lootusetuse tunnet

1 2 3 4 99 97

Q1.3 Teil olid uinumisraskused, katkendlik uni või liigne unevajadus

1 2 3 4 99 97

Q1.4 Teil oli väsimustunne või liiga vähe energiat

1 2 3 4 99 97

Q1.5 Teil oli vähene söögiisu või kaldusite liigsöömisele

1 2 3 4 99 97

Q1.6 Tundsite end halvasti, väärtusetuna või et olete iseenda või perekonna lootusi petnud

1 2 3 4 99 97

Q1.7 Teil olid keskendumisraskused, näiteks ajalehe lugemisel või televiisori vaatamisel

1 2 3 4 99 97

Q1.8 Liikusite või rääkisite nii aeglaselt, et teised seda märkasid. Või vastupidi – olite nii püsimatu või rahutu, et liikusite tunduvalt rohkem kui tavaliselt

1 2 3 4 99 97

Q1.9 Mõtlesite, et parem oleks olla surnud või oli enesevigastamise mõtteid

1 2 3 4 99 97

ABIKAART 1 1. Üldse mitte

2. Mõnel päeval

3. Rohkem kui pooltel päevadel

4. Peaaegu iga päev

17

VAIMNE TERVIS

ABIKAART 2 Q2: Kui suure osa ajast viimase 4 nädala jooksul …

MHI‐5, EVI

Kogu aeg

Suurema osa ajast

Aeg‐ajalt

Harva Üldse mitte EOÖ Keeldumine

Q2.1 Tundsite end elujõulise ja teotahtelisena?

1 2 3 4 5 99 97

Q2.2 Olite väga närviline? 1 2 3 4 5 99 97

Q2.3 Tundsite end nii nukrameelsena, et miski ei suutnud tuju parandada?

1 2 3 4 5 99 97

Q2.4 Tundsite end rahuliku ja leplikuna?

1 2 3 4 5 99 97

Q2.5 Tundsite end väga energilisena?

1 2 3 4 5 99 97

Q2.6 Tundsite end rusutult ja masendununa?

1 2 3 4 5 99 97

Q2.7 Tundsite end kurnatuna? 1 2 3 4 5 99 97

Q2.8 Olite õnnelik? 1 2 3 4 5 99 97

Q2.9 Tundsite end väsinuna? 1 2 3 4 5 99 97

ABIKAART 2

1. Kogu aeg

2. Suurema osa ajast

3. Aeg‐ajalt

4. Harva

5. Üldse mitte

18

KEHALINE AKTIIVSUS/TEGEVUS

Järgnevad küsimused käsitlevad tervisespordi harrastamist, kõndimist, jooksmist, rattasõitu, jõuharjutusi, kehalist pingutust nõudvaid hobisid jmt millega tegelete VABAL AJAL. Q1: Kui tihti Te tegelete vabal ajal INTENSIIVSE kehalise tegevusega vähemalt 10 MINUTIT järjest, mis põhjustab TUGEVAT higistamist või hingeldamist või OLULIST südametegevuse kiirenemist? KÜSITLEJA: VASTUSEID VÕIB ANDA KÜSITLETAVA POOLT VALITUD AJAÜHIKU KOHTA (KORDADE ARV PÄEVAS, NÄDALAS, KUUS VÕI AASTAS) {LUGEDA ETTE, KUI VAJALIK} Mitu korda päevas, nädalas, kuus või aastas te neid tegevusi teete?

Mitte kunagi → Q4 1‐995 korda ____ Ei saa olla intensiivselt aktiivne → Q4 Keeldumine → Q4 EOÖ → Q4

KÜSITLEJA: MÄRKIGE JUURDE VASTAMISEL KASUTATUD AJAÜHIK.

1 Päevas

2 Nädalas

3 Kuus

4 Aastas

Q1a: Mitu minutit (või tundi) järjest Te igal korral neid intensiivseid tegevusi vabal ajal sooritate?

KÜSITLEJA: MÄRKIGE VABA AJA INTENSIIVSE KEHALISE AKTIIVSUSE KESTVUS.

1‐995 ____

Keeldumine → Q4

Ei tea → Q4

KÜSITLEJA: MÄRKIGE JUURDE VASTAMISEL KASUTATUD AJAÜHIK MÄRKIGE KÜSITLETAVA VASTUS KAS TUNDIDES VÕI MINUTITES

Tundi

Minutit

19

Q2: Kui tihti Te vabal ajal teete KERGET või MÕÕDUKAT kehalist PINGUTUST nõudvaid tegevusi vähemalt 10 MINUTIT järjest, mis põhjustab KERGET higistamist või paneb PISUT hingeldama või kiirendab VEIDI südametegevust? {LUGEDA ETTE, KUI VAJALIK} Mitu korda päevas, nädalas, kuus või aastas te neid tegevusi teete?

Mitte kunagi → Q5 1‐995 korda ____ Ei saa olla kehaliselt aktiivne → Q5 Keeldumine → Q5 Ei tea → Q5

KÜSITLEJA: MÄRKIGE JUURDE VASTAMISEL KASUTATUD AJAÜHIK

1 Päevas

2 Nädalas

3 Kuus

4 Aastas

Q2a: Mitu minutit (või tundi) järjest Te igal korral neid kergeid või mõõdukaid tegevusi vabal ajal sooritate?

KÜSITLEJA: MÄRKIGE VABA AJA KERGE VÕI MÕÕDUKA INTENSIIVSUSEGA KEHALISE AKTIIVSUSE KESTVUS

1‐995 ____

Keeldumine → Q5

Ei tea → Q5

KÜSITLEJA: MÄRKIGE JUURDE VASTAMISEL KASUTATUD AJAÜHIK MÄRKIGE KÜSITLETAVA VASTUS KAS TUNDIDES VÕI MINUTITES

Tundi

Minutit

20

Q3: Kui tihti te teete VABAL ajal jõuharjutusi, mis on spetsiaalselt mõeldud LIHASTE TUGEVDAMISEKS – näiteks jõutõstmine või spetsiaalsed jõuharjutused? (Arvake sisse kõik jõuharjutustega tegevused, ka need, mida te eelmiste küsimuste puhul juba sisse arvestasite.) {LUGEDA ETTE, KUI VAJALIK} Mitu korda päevas, nädalas, kuus või aastas te neid tegevusi teete?

Mitte kunagi → Q6 1‐995 korda ____ Ei saa olla kehaliselt aktiivne → Q6 Keeldumine → Q6 Ei tea → Q6

KÜSITLEJA: MÄRKIGE JUURDE VASTAMISEL KASUTATUD AJAÜHIK.

1 Päevas

2 Nädalas

3 Kuus

4 Aastas

KEHALINE AKTIIVSUS/TEGEVUS

Järgnevalt küsin Teie käest viimase 7 päeva kehalise aktiivsuse kohta.

Palun vastake igale küsimusele, isegi kui te ei ole enda meelest kehaliselt aktiivne inimene. Mõelge kehalistele tegevustele tööl, majapidamis‐ ja aiatöödel, ühest kohast teise liikumisel ning vabal ajal sportides või liikudes.

Mõelge nüüd kõigile INTENSIIVSETELE (JÕULISTELE) kehalistele tegevustele, mis nõuavad tugevat füüsilist pingutust ja mida te sooritasite viimase 7 päeva jooksul. Intensiivsed kehalised tegevused panevad teid tugevalt hingeldama, näiteks raskuste tõstmine, kaevamine, jooksmine, aeroobika või kiire jalgrattasõit. Mõelge ainult nendele tegevustele, mis kestsid vähemalt 10 minutit järjest. Q1: Mitmel päeval viimase 7 päeva jooksul tegelesite te intensiivse kehalise tegevusega?

Päeva nädalas __ Kui vastati 0, siis → Q7 Ei tea/Ei ole kindel → Q7 Keeldumine → Q7

[KÜSITLEJA TÄPSUSTUS: . Mõelge ainult nendele tegevustele, mis kestsid vähemalt 10 minutit järjest.]

21

Q1a: Kui palju aega kulus ühel neist päevadest intensiivsele kehalisele tegevusele?

Tundi päevas __ __ Minutit päevas __ __ __ Ei tea/Ei ole kindel Keeldumine [KÜSITLEJA TÄPSUSTUS: Mõelge ainult nendele tegevustele, mis kestsid vähemalt 10 minutit järjest.]

Mõelge nüüd kõigile MÕÕDUKATELE kehalistele tegevustele viimase 7 päeva jooksul. Mõõdukas kehaline tegevus paneb veidi hingeldama. Näiteks kergemate asjade kandmine, kepikõnd, aknapesu, rahulik rattasõit või tantsimine. Ärge arvake sisse kõndimist. Jällegi mõelge ainult neile tegevustele, mis kestsid vähemalt 10 minutit järjest. Q2: Mitmel päeval viimase 7 päeva jooksul tegelesite te mõõduka kehalise aktiivsusega?


[KÜSITLEJA TÄPSUSTUS: Mõelge ainult nendele tegevustele, mis kestsid vähemalt 10 minutit järjest.] Q2a: Kui palju aega kulus ühel neist päevadest mõõdukale kehalisele tegevusele?

Tundi päevas __ __ Minutit päevas __ __ __ Ei tea/Ei ole kindel Keeldumine

[KÜSITLEJA TÄPSUSTUS: Mõelge ainult nendele tegevustele, mis kestsid vähemalt 10 minutit järjest.] Mõelge nüüd sellele, kui palju aega te kulutasite viimase 7 päeva jooksul KÕNDIMISELE. See hõlmab kõndimist tööl ja kodus, kõndimist ühest kohast teise jõudmiseks ja muud kõndimist, mida te tegite aktiivse puhkuse või kehaliste harjutuste pärast (ärge arvestage kepikõndi). Arvestage ka jalutamist.

22

Q3: Mitmel päeval viimase 7 päeva jooksul te kõndisite korraga vähemalt 10 minutit järjest?


[KÜSITLEJA TÄPSUSTUS: Mõelge ainult kõndimisele, mis kestis vähemalt 10 minutit järjest.] Q3a: Kui palju aega kulus ühel neist päevadest tavaliselt kõndimisele?

Tundi päevas __ __ Minutit päevas __ __ __ Nüüd mõelge ajale, mille te viimase 7 päeva jooksul veetsite ISTUDES. Arvestage istumist tööl, kodus, õppides ja vabal ajal ‐ näiteks istumist koos sõpradega, lugedes, samuti lamades või istudes televiisori vaatamist.

Q4: Kui palju aega ühel päeval viimase 7 päeva jooksul te tavaliselt veetsite istudes?

Tundi päevas __ __ Jätkake järgmise osaga Minutit päevas __ __ __ Jätkake järgmise osaga

Ei tea/Ei ole kindel Jätkake järgmise osaga

Keeldumine Jätkake järgmise osaga [KÜSITLEJA TÄPSUSTUS: Arvestage nii istudes kui ka ärkvel olles lamades kulunud aega]

23

ALKOHOLI TARBIMINE

Ankeedi number ________

Järgnevad küsimused käsitlevad igasuguste alkohoolsete jookide tarbimist. Näiteks: õlu, vein, kokteilid, kange alkohol, liköörid, isevalmistatud alkohoolsed joogid (koduõlu, koduvein) jne. Palun tõmmake teile sobivale vastusevariandile ring ümber.

AL.1. Kui tihti Te viimase 12 kuu jooksul olete alkohoolseid jooke tarbinud?

Iga päev või peaaegu iga päev .............................................. 1

5 ‐ 6 päeval nädalas ............................................................... 2

3 ‐ 4 päeval nädalas ............................................................... 3

1 ‐ 2 päeval nädalas ............................................................... 4

2 ‐ 3 päeval kuus.................................................................... 5

1 kord kuus ............................................................................ 6

1 kord 2 kuu jooksul .............................................................. 7

Kord või kaks viimase 12 kuu jooksul ....................................

8

Viimasel 12 kuul ei ole tarvitanud, kuid enne tarbisin .......... 9 Küsitluse lõpp

Ei ole kunagi alkoholi tarbinud .............................................. 10 Küsitluse lõpp

AL.1a. Mitu annust alkoholi Te ühel sellisel päeval tavaliselt tarbite?

Vaadake abikaarti

24 alkoholiannust või rohkem.............................................. 1

17‐23 alkoholiannust............................................................ 2

10‐16 alkoholiannust............................................................ 3

7‐9 alkoholiannust................................................................ 4

6 alkoholiannust ................................................................... 5

4 ‐ 5 alkoholiannust .............................................................. 6

3 alkoholiannust ................................................................... 7

2 alkoholiannust ................................................................... 8

1 alkoholiannuse .................................................................. 9

24

AL.2. Mitmel päeval Te esmaspäevast neljapäevani (4 päeva) tavaliselt alkohoolseid jooke tarbite?

4 päeval ......................................................... 1

3 päeval ......................................................... 2

2 päeval ......................................................... 3

1 päeval ......................................................... 4

Ei tarbi neil päevadel ..................................... 5 jätkake AL.4

AL.3. Mitu alkoholiannust Te tavaliselt ühel nendest päevadest (esmaspäevast eljapäevani) tarbite?

Vaadake abikaarti

24 alkoholiannust või rohkem....................... 1

17‐23 alkoholiannust..................................... 2

10‐16 alkoholiannust..................................... 3

7‐9 alkoholiannust......................................... 4

6 alkoholiannust ............................................ 5

4 ‐ 5 alkoholiannust ....................................... 6

3 alkoholiannust ............................................ 7

2 alkoholiannust ............................................ 8

1 alkoholiannuse ........................................... 9

AL.4. Mitmel päeval Te reedest pühapäevani (3 päeva) tavaliselt alkohoolseid jooke tarbite?

3 päeval ......................................................... 1

2 päeval ......................................................... 2

1 päeval ......................................................... 3

Ei tarbi neil päevadel ..................................... 4 jätkake AL.6

25

AL.5. Mitu alkoholiannust Te tavaliselt ühel nendest päevadest (reedest pühapäevani) tarbite?

Vaadake abikaarti

24 alkoholiannust või rohkem............................ 1

17‐23 alkoholiannust.......................................... 2

10‐16 alkoholiannust.......................................... 3

7‐9 alkoholiannust.............................................. 4

6 alkoholiannust ................................................. 5

4‐5 alkoholiannust.............................................. 6

3 alkoholiannust ................................................. 7

2 alkoholiannust ................................................. 8

1 alkoholiannuse ................................................ 9

AL.6. Kui tihti Te viimase 12 kuu jooksul olete tarbinud korraga üle 6 annuse alkoholi?

Vaadake abikaarti

Iga päev või peaaegu iga päev .............................................. 1

5 ‐ 6 päeval nädalas ............................................................... 2

3 ‐ 4 päeval nädalas ............................................................... 3

1 ‐ 2 päeval nädalas ............................................................... 4

2 ‐ 3 päeval kuus.................................................................... 5

1 kord kuus ............................................................................ 6

1 kord 2 kuu jooksul .............................................................. 7

Kord või kaks viimase 12 kuu jooksul .................................... 8

Ei ole viimase 12 kuu jooksul tarbinud............... 9

Ei ole kunagi tarbinud......................................... 10

26

LAHJA ALKOHOL (õlu, siider, long drink, lahjad alkoholikokteilid, jm. kuni 6% alkoholisisaldusega) 0,5 l pudel, kann = 2 annust 0,3 l pudel, purk = 1 annus 1,5 l pudel = 6 annust 2 l pudel = 8 annust

VEIN, ka VAHUVEIN (9% ‐ 12% alkoholisisaldusega) 1 pokaal (125 ml) = 1 annus 0,5 l pudel = 5 annust 0,7 l pudel = 6,5 annust 1 l pudel = 10 annust

KANGE ÕLLE TEISENDUSED (üle 6% alkoholisisaldusega) 0,5 l pudel, kann = 2,5 annust 0,3 l pudel, purk = 1,5 annust 1,5 l pudel = 7,5 annust 2 l pudel = 10 annust

KANGE ALKOHOL (viin, konjak, brändi, džinn, viski, liköör*** jm. 40% alkoholisisaldusega) 1 pits (30ml) = 1 annus 0,35 l pudel = 11 annust 0,5 l pudel = 15 annust 0,7 l pudel = 22 annust 1 l pudel = 32 annust *** Lahjema likööri ja kangete viina‐, džinni‐, jms. kokteilide puhul (~20% alkoholisisaldusega) jagage annuste arv kahega.

27

1.3. French version of MH, PA and AL

QUESTIONS RELATIVES A LA SANTE MENTALE

INTERVIEWER: TOUT LIRE A VOIX HAUTE POSEZ D'ABORD TOUTES LES QUESTIONS DE SANTE MENTALE PUIS PROCEDEZ AU SONDAGE Intro: Nous allons maintenant aborder les questions sur le bien‐être psychologique, et cette partie se fera entièrement par interview… Voici une carte de réponses pour vous aider à choisir celle qui vous convient le mieux. INTERVIEWER: Donnez la SHOWCARD 1

Q 1: Au cours des deux dernières semaines, dans quelle mesure avez‐vous été perturbé(e) par les difficultés suivantes?

PHQ Jamais Plusieurs jours

Plus de la moitié du

tps

Presque ts les jours

NSP Refus

Q1.1 Avoir peu d’intérêt ou de plaisir à faire les choses

Q1.2 Se sentir triste, déprimé(e) ou désespéré(e)

Q1.3 Avoir des difficultés à s’endormir ou à rester endormi(e), ou alors dormir trop

Q1.4 Se sentir fatigué(e)ou sans énergie

Q1.5 Avoir peu d'appétit, ou au contraire manger de trop

Q1.6 Avoir une mauvaise opinion de soi‐même, ou avoir le sentiment d'être nul(le), d'avoir déçu sa famille ou de s'être déçu(e) soi‐même

Q1.7 Avoir du mal à se concentrer, par exemple, pour lire le journal ou regarder la télévision

Q1.8

Bouger ou parler si lentement que les autres auraient pu le remarquer. Ou au contraire, être si agité(e) que vous avez eu du mal à tenir en place par rapport à d’habitude

Q1.9 Penser qu’il vaudrait mieux mourir ou envisager de se faire du mal d’une certaine façon

28

INTERVIEWER: Donnez la SHOWCARD 2 {TOUT DEMANDER} Q2: Au cours des 4 dernières semaines, y a‐t‐il eu des moments où vous vous sentiez...

MHI, EVI

En perma‐nence

Sou‐vent

Quelque fois

Rare‐ment

Jamais Don't know

Refusal

Q2.1 Dynamique, plein(e) de vie?

Q2.2 Très nerveux(se)?

Q2.3 Si découragé(e) que rien ne pouvait vous remonter le moral?

Q2.4 Calme et détendu(e)?

Q2.5 Débordant(e) d’énergie?

Q2.6 Triste et abattu(e)?

Q2.7 Epuisé(e)?

Q2.8 Heureux(se)??

Q2.9 Fatigué(e)?

{FIN DE L'INTERVIEW SANTE MENTALE}

QUESTIONS CONCERNANT L'ACTIVITE PHYSIQUE

POSEZ D'ABORD TOUTES LES QUESTIONS DE CETTE SECTION PUIS PROCEDEZ AU SONDAGE Nous nous intéressons aux activités physiques. Dans ce qui suit, on distingue deux types d'activités physiques: l'un concerne les activités physiques durant les loisirs et l'autre a trait aux activités physiques dans leur totalité. Un des objectifs de cette interview est de voir pour lequel de ces deux types d'activités les questions sont les mieux adaptées. Les questions vous parraîtront dès lors un peu répétitives. Nous commencerons avec la série A qui concerne les activités physiques durant les loisirs, et je vous ferai savoir quand nous passerons à la série B.

29

Ainsi, les questions suivantes concernent les activités physiques (exercices, sports, hobbies actifs...) que vous pourriez faire durant vos loisirs.

Q3: Pendant vos loisirs, à quelle fréquence pratiquez‐vous des activités physiques INTENSES qui durent au moins 10 minutes et qui vous font beaucoup transpirer ou qui augmentent fortement votre respiration ou votre rythme cardiaque?

INTERVIEWER: Les réponses peuvent être rapportées dans l'unité de référence choisie par le répondant (nombre de fois par jour, par semaine, par mois, ou par an) {LIRE SI NECESSAIRE}

Combien de fois par jour, par semaine, par mois ou par année pratiquez‐vous ce type d’activité?

Jamais 1‐995 fois ____ Incapable de faire ce type d'activité Refus Ne sait pas

INTERVIEWER: Précisez la période de référence pour les activités physiques intense de loisirs.

Jamais Passez à Q4

Par jour Posez Q3a

Par semaine Posez Q3a

Par mois Posez Q3a

Par an Posez Q3a

Incapable de faire ce type d'activité Passez à Q4

Refus Passez à Q4

Ne sait pas Passez à Q4

Q3a: Combien de temps consacrez‐vous à chaque fois pour ces activités physiques intenses durant vos loisirs?

INTERVIEWER: Introduisez le chiffre correspondant à la durée des activités physiques intenses.

1‐995 ____

Refus Passez à Q4


30

INTERVIEWER: Précisez l'unité de temps se rapportant à la durée des activités physiques intenses. RAPPORTEZ LES REPONSES DONNEES SOIT EN HEURES OU EN MINUTES

Minutes � Passez à Q4

Heures � Passez à Q4

Refus � Passez à Q4

Ne sait pas � Passez à Q4

{A TOUS}

Q4: Pendant vos loisirs, à quelle fréquence pratiquez‐vous des activités physiques LEGERES à MODEREES qui durent au moins 10 minutes et qui vous font transpirer faiblement ou qui augmentent légèrement votre respiration ou votre rythme cardiaque?

{LIRE SI NECESSAIRE}



INTERVIEWER: Précisez la période de référence pour les activités physiques légères à modérées.

Jamais Passez à Q5

Par jour Posez Q4a

Par semaine Posez Q4a

Par mois Posez Q4a

Par an Posez Q4a


Refus Passez à Q5


31

Q4a: Combien de temps consacrez‐vous à chaque fois pour ces activités physiques légères à modérées durant vos loisirs?

INTERVIEWER: Introduisez le chiffre correspondant à la durée des activités physiques légères à modérées.

1‐995 ____

Refus Passez à Q5


INTERVIEWER: Précisez l'unité de temps se rapportant à la durée des activités physiques légères à modérées ‐ RAPPORTEZ LES REPONSES DONNEES SOIT EN HEURES OU EN MINUTES

Minutes Passez à Q5

Heures Passez à Q5

Refus Passez à Q5


{A TOUS}

Q5: Pendant vos loisirs, à quelle fréquence pratiquez‐vous des activités physiques spécialement destinées à renforcer vos muscles, comme soulever des poids ou faire du fitness? Considérez l’ensemble de ces activités, même si vous les avez déjà mentionnées en réponse aux questions précédentes.

{LIRE SI NECESSAIRE}



INTERVIEWER: Cochez l'unité temporelle de référence pour les activités physiques destinées à renforcer les muscles.

Jamais Passez à Q6

Par jour Passez à Q6

Par semaine Passez à Q6

Par mois Passez à Q6

Par an Passez à Q6


Refus Passez à Q6


32

{LIRE A TOUS} Nous avons terminé la setion A sur les activités physiques de loisir et nous passons maintenant à la section B sur l'ensemble des activités physiques, pendant mais aussi en dehors des loisirs.

{LIRE A TOUS}

Les questions qui suivent portent sur le temps que vous avez passé à être actif physiquement au cours des 7 derniers jours. Merci de répondre à chaque question même si vous ne vous considérez pas comme une personne physiquement active.

Pensez aux activités physiques que vous faites au travail, mais aussi à la maison ou au jardin, pour vos déplacements et pendant votre temps libre pour le loisir, l’exercice ou le sport...

Tout d’abord, pensez aux activités intenses qui vous ont demandé un gros effort physique au cours des 7 derniers jours.

Les activités intenses sont celles qui demandent un effort physique important et vous font respirer beaucoup plus vite que d’habitude. Il peut s’agir d’activités comme porter des charges lourdes, creuser, faire du fitness ou faire du vélo à un rythme rapide.

Q6: Ces 7 derniers jours, combien de jours avez‐vous fait des activités physiques intenses?

Jours par semaine __ Passez à Q7 si zéro AUTREMENT posez Q6a Ne sait pas/Pas sûr Passez à Q7 Refus Passez à Q7

[Clarification de l'interviewer: Pensez seulement aux activités physiques intenses qui ont duré au moins dix minutes d’affilée.]

Q6a: Au cours d’une de ces journées, combien de temps avez‐vous généralement consacré à des activités physiques intenses?

Heures par jour __ __ Passez à Q7 Minutes par jour __ __ __ Passez à Q7 Ne sait pas/Pas sûr Passez à Q7 Refus Passez à Q7

33

{LIRE A TOUS}

Maintenant pensez aux activités qui vous ont demandé un effort physique modéré au cours des 7 derniers jours.

Les activités physiques modérées sont celles qui vous font respirer un peu plus rapidement que d’habitude. Il peut s’agir d’activités comme soulever des charges légères, rouler à vélo à un rythme modéré ou faire du tennis en double… Ne tenez pas compte ici de la marche à pied.

Q7. Ces 7 derniers jours, combien de jours avez‐vous fait des activités physiques modérées?


[Clarification de l'interviewer: Pensez seulement aux activités physiques modérées qui ont duré au moins dix minutes d’affilée.]

Q7a: Au cours d’une de ces journées, combien de temps avez‐vous généralement consacré à des activités physiques modérées?


{LIRE A TOUS}

Pensez à présent au temps que vous avez passé à marcher au cours des 7 derniers jours, que ce soit au travail, à la maison, pour vous rendre d’un endroit à un autre, ou tout autre type de marche que vous auriez pu pratiquer pour la détente, le sport, l’exercice ou les loisirs.

Q8: Ces 7 derniers jours, combien de jours avez‐vous marché pendant au moins 10 minutes d’affilée?


[Clarification de l'interviewer: Pensez seulement à la marche que vous avez pratiqué pendant minimum 10 minutes d'affilée]

34

Q8a: Au cours d’une de ces journées, combien de temps avez‐vous marché généralement?


{LIRE A TOUS}

La dernière question porte sur le temps que vous avez passé assis pendant un jour de la semaine au cours des 7 derniers jours. Considérez les moments où vous étiez assis au travail, à la maison, au cours, ainsi que pendant vos loisirs. Cela peut comprendre le temps passé assis à votre bureau, chez des amis, à lire ou à regarder la télévision, que vous soyez assis ou allongé.

Q9: Ces 7 derniers jours, combien de temps aviez‐vous généralement passé assis au cours d’un jour de la semaine?

Heures par jour __ __ Passez au module suivant Minutes par jour __ __ __ Passez au module suivant Ne sait pas/Pas sûr Passez au module suivant Refus Passez au module suivant [Clarification de l'interviewer: Inclure le temps passé couché (éveillé) de même qu'assis]

35

Consommation d'alcool

Les questions suivantes portent sur votre consommation de boissons alcoolisées de tous

types: bière, vin, apéritif, cocktail, alcopop, cidre, alcool fort, spiritueux, liqueur, alcool fait

maison…

Veuillez cocher la case qui correspond le mieux à votre réponse

AL.1. Au cours des 12 derniers mois, à quelle fréquence avez‐vous consommé des boissons

alcoolisées, quelles qu'elles soient?

Tous les jours ou presque ..................................................... 1

5 ‐ 6 jours par semaine.......................................................... 2



Question AL.1a

2 ‐ 3 jours par mois................................................................ 5

Une fois par mois................................................................... 6

Une fois tous les deux mois................................................... 7

Une ou deux fois au cours des 12 derniers mois................... 8

Pas au cours des 12 derniers mois, mais j'en ai bu auparavant 9 fin du questionnaire

Jamais ou pas plus que quelques gorgées ou essais de toute ma vie ..........................................................................................

10

fin du questionnaire

AL.1a. Combien de verres de boissons alcoolisées buvez‐vous au cours d'une journée ordinaire où

vous consommez de l'alcool? Référez‐vous à la carte des verres standards

24 verres ou plus.............................................................. 1

17‐23 verres ..................................................................... 2

10‐16 verres ..................................................................... 3

7‐9 verres ......................................................................... 4

6 verres ............................................................................ 5

4 ‐ 5 verres ....................................................................... 6

3 verres ............................................................................ 7

2 verres ............................................................................ 8

1 verre.............................................................................. 9

36

AL.2. En semaine, au cours de combien de ces 4 jours (du lundi au jeudi) buvez‐vous généralement des boissons alcoolisées?

Les 4 jours de semaine .................................. 1

3 jours de semaine ........................................ 2

2 jours de semaine ........................................ 3

1 jour de semaine.......................................... 4

Pas les jours de semaine ............................... 5 passez à AL.4

AL.3. En général, combien de verres buvez‐vous au cours d'un de ces jours de semaine (lundi à jeudi) où vous consommez de l'alcool?

Référez‐vous à la carte des verres standards

24 verres ou plus .................................................................. 1

17‐23 verres.......................................................................... 2

10‐16 verres.......................................................................... 3

7‐9 verres.............................................................................. 4

6 verres................................................................................. 5

4 ‐ 5 verres............................................................................ 6

3 verres................................................................................. 7

2 verres................................................................................. 8

1 verre .................................................................................. 9

AL.4. Le weekend, au cours de combien de ces 3 jours (du vendredi au dimanche) buvez‐vous

généralement des boissons alcoolisées?

Les 3 jours du weekend................................. 1

2 jours de weekend ....................................... 2

1 jour de weekend......................................... 3

Pas les weekends........................................... 4 passez à AL.6

37

AL.5. En général, combien de verres buvez‐vous au cours d'un de ces jours du weekend (vendredi à dimanche) où vous consommez de l'alcool?

Référez‐vous à la carte des verres standards

24 verres ou plus .................................................................. 1

17‐23 verres.......................................................................... 2

10‐16 verres.......................................................................... 3

7‐9 verres.............................................................................. 4

6 verres................................................................................. 5

4 ‐ 5 verres............................................................................ 6

3 verres................................................................................. 7

2 verres................................................................................. 8

1 verre .................................................................................. 9

AL.6. Au cours des 12 derniers mois, à quelle fréquence avez‐vous consommé 6 verres ou plus de

boissons alcoolisées (éventuellement différentes) en une même occasion?

Tous les jours ou presque ..................................................... 1




2 ‐ 3 jours par mois................................................................ 5

Une fois par mois................................................................... 6

Une fois tous les deux mois................................................... 7

Une ou deux fois au cours des 12 derniers mois............. 8

Pas au cours des 12 derniers mois ........................................ 9

Jamais de toute ma vie.......................................................... 10

38

39

2. Annex Chapter 4 – Country Reports of parallel Cognitive Testing, Round 1 2.1. Report UK (NatCen)

Improvement of the European Health Interview

Survey (EHIS)

Cognitive testing of Questions in England

Authors: Meera Balarajan and Michelle Gray

Date: February 2011

Prepared for: Robert Koch Institute

40

Acknowledgements

At the Robert Koch Institut we would like to thank Claudia Santos‐Hövener and Jonas Finger for their

guidance and support throughout the project. We would also like to thank our colleagues on this project

at the Scientific Institute of Public Health, Belgium (IPH) and the National Institute for Health

Development, Estonia (NIHD).

We would also like to thank the interviewers who worked on this project: Oxana Metiuk, Sue Archer and

Amanda Maltby.

Most importantly, we are grateful to all those people who took part in this study, as without their help,

this research would not have been possible.

We would like to acknowledge the financial support of Grant Agreement No. 10501.2009.007‐2009.890;

and that the development of the study protocol was conducted in corporation with RKI for the cross

national cognitive testing of questions in the European Health Study.

41

2.1.1. Background

The Questionnaire Development and Testing (QDT) Hub at the National Centre for Social Research

(NatCen) has been commissioned by the Robert Koch Institute to test questions in the European Health

Interview Survey (EHIS) on mental health, physical activity and alcohol consumption in England. The

study is funded by the EHIS Improvement Project. The EHIS is a general health survey conducted

amongst the general adult population (16 and over). The aim of the survey is to collect harmonised

general health data across EU member and candidate countries. The survey is uni‐modal although the

preferred method for most sections is Computer Assisted Personal Interviewing (CAPI). The exception is

the alcohol consumption question module, which is designed to be used in a paper self‐completion

format (ideally). It is anticipated that the second wave of the survey will be conducted in participating

countries in 2014.

The aim of this study is to improve the questions on mental health, physical activity and alcohol

consumption, which were found to be problematic during wave one of the EHIS before their

implementation in the second wave. In order to achieve this, the Robert Koch Institute is coordinating a

cross‐national project to test questions in these three areas in four European countries. Our

collaborating partners on this study are Robert Koch Institute, Germany (coordinator), the Scientific

Institute of Public Health, Belgium (IPH) and the National Institute for Health Development, Estonia

(NIHD). Each collaborating partner is in charge of improving one section of the instrument, which was

identified as problematic in wave one. Questions on mental health are the responsibility of our German

partner, the physical activity questions the responsibility of our Estonian partner and the alcohol

consumption questions the responsibility of our Belgium partner. A revised set of questions in each of

the three areas, physical activity, alcohol consumption and mental health, were provided to us for

cognitive testing. In addition, we were also provided with the probe sheet to use in testing (appendix D).

The primary objective of the cognitive testing was to test how the questions worked with different

segments of the survey population. As part of this, the testing protocols were designed to explore:

• Respondents’ understanding of the questions;

• Respondents’ ability to answer the questions;

• Issues of sensitivity; and,

• How the questions work when administered.

The main aim of cognitive testing was to look at the cognitive answer process to explore how the

questions are understood and examine the judgement, recall and response processes respondents used

in formulating their answers in England. This is important because the questions will be asked of the

general population in different countries and need to work in a consistent way with respondents so that

the data can be considered comparable. Testing allows us to evaluate how the questions work and to

42

suggest revisions informed by evidence collected in the cognitive interviews. Where appropriate,

revisions were suggested to improve how the questions work.

Close collaboration between the research partners established a standard protocol for the cognitive

interviews, analysis and reporting. This report is focused on presenting the key finding from testing the

questions in England.

2.1.1.1. Project Design

This section gives a brief overview of the project design in England. Full details on the cognitive

interviewing methodology and analysis are contained in Appendix A.

The new survey questions were tested via cognitive interviewing. An interview protocol was developed

which included all the test questions and cognitive probes. The probes were used to explore how

respondents understood key concepts and terms; and whether any of the questions were sensitive.

A full copy of the interview protocol (i.e. the interview Question and Probe Sheet) is provided in

Appendix D.

2.1.1.2. Sample Recruited

A purposive sample was designed to ensure that the questions were fully tested with a range of

respondents in England. It was felt important to test the new questions with:

a mix of men and women;

a mix of respondents in different age groups;

respondents with and those without long standing illnesses;

respondents with different regular exercise behaviours (none, light, moderate and vigorous); and

Respondents with different alcoholic drinking behaviours (non‐drinker, light, moderate and heavy).

In total 15 respondents were interviewed in England. Five Interviews took place in the following three

areas in England:

Lancashire (North West England);

Nottinghamshire (Midlands); and

Greater London area.

The sample frame for the English arm of the cognitive testing was NatCen’s own Omnibus Survey.

Suitable respondents (who had agreed to be re‐contacted about future research at the time of their

Omnibus interview) were identified in the sample. An opt out exercise was conducted which involved all

suitable prospective respondents being sent an advance letter which explained the study and asked

43

them to contact the research team if they did not want to take part in the research. Respondents who

did not opt out were then contacted by NatCen’s own specialist Telephone Unit, who explained the

study, requested informed consent to recruit the respondent and then screen the individual in. All

recruits were sent a confirmation letter which provided further information about the study, including

the named interviewer who would be in touch if a definite respondent and may be in touch if a reserve.

Interviewers then contacted the recruit, and arranged a time and place convenient for them to take part

in the research. A summary of key respondent characteristics of who took part in the interviews is

provided in the table 1.1 (on page 9).

2.1.1.3. Report structure

We present the cognitive findings from the cognitive interviews in England in bullet points. The findings

for the three subject areas are discussed in dedicated chapters. The findings for the mental health

questions are presented in chapter 2, physical activity questions in chapter 3, and the alcohol

consumption questions in chapter 4. Each chapter begins with a summary of the key findings of how the

questions worked overall in that area and this is followed by the question by question findings and

recommendations. Each chapter is structured and focussed around its key area to be explored in testing,

and as such is structured slightly differently, so for:

Chapter 2 (Mental Health) this is whether both the PHQ‐9 and the MHI‐5/EVI could both be

asked in the main stage;

Chapter 3 (Physical activity) this is whether the NHIS or the IPAQ module should be asked;

and,

Chapter 4 (Alcohol consumption) how the module worked overall and its individual questions,

Each of the chapters detailing findings can be read as a standalone section of the report, although we

would advise that it is read with the methodology and appendix A. Each cognitively tested question is

presented with a brief description of the measurement aims, summary of the key findings that include

any problems and the probable causes. Recommendations are presented boxed and wording changes

shown in red font. The full report, would give the reader a full overview of how the questions in the

three subject area worked in the cognitive testing in England, bearing in mind that each chapter is

structured around a specific aim.

It should be noted that the findings and recommendations are based on evidence from the cognitive

interviews and we are unable to guarantee that the problems we highlight are the only ones that exist

with the questions nor are we able to guarantee that these problems would exist in the survey, and are

not just artefacts of cognitive interviewing. We have provided evidence of the problems we think are

worth worrying about and in doing so, we have identified our assessment of their causes and the

possible solutions. Additionally, without another round of cognitive interviews, we are not able to

guarantee that the revisions we suggest shall bring about improvements and therefore we would always

recommend that revisions are re‐tested. If further testing is not possible, we would advise that the new

44

questions are included in a pilot study, which we believe will be conducted following all the cognitive

interviews. If possible, our country partners may want to consider using respondent de‐briefing

questions to check that the questions appear to be working as intended. We would happy to make

suggestions on possible de‐brief questions.

For the remainder of this report, questions are mainly referred to using the numbering used in the

cognitive 'test’ questionnaire (which can be found in appendix D). Except when we discuss which module

to use in the physical health section, and here we refer to the original name, NHIS and IPAQ to prevent

any confusion of which module is being discussed. The headings for each section refer to both the

numbering used in the test questionnaire and the original name to help sign post the reader through the

report.

Table 1: Characteristics of respondents in the cognitive interview sample

Characteristic of respondent No. with characteristic

Male 10

Female 5

Gender

Total 15

18‐30 3

31‐59 6

60+ 6

Age of Respondent

Total 15

Doesn’t do exercise 3

Light 4

Moderate 6

Vigorous 2

Exercise behaviour

Total 15

Non drinker 4

Light 8

Moderate 2

Heavy 1

Drinking Alcohol

Total 15

Semi routine and routine occupation 4

Intermediate occupation 2

Lower supervisory and technical occupations 1

Managerial and professional occupation 7

Occupation type

Not classifiable 1

Total 15

Interviewer Area Lancashire (North West England); 5

Nottinghamshire (Midlands); and 5

Greater London area. 5

Total 15

45

2.1.2. Mental Health

Two mental health questions were tested (shown below).

Question 1 (PHQ‐9) and 2 (MHI‐5, EVI)

Q 1: Over the last 2 weeks, how often have you been bothered by any of the following problems….

Q2: How much of the time, during the past 4 weeks…

There were two principle aims in testing, which were:

1. To find out if it would be possible for both questions to used in the main stage survey, or if they

overlapped, to an extent which would prevent the two questions to be used; and

2. To find out if the individual items in Q1 and Q2 worked as intended.

In this section, we look at the first principle aim. The next two sections address the second aim, so in

section 2.2. We present how Q1 and its individual items worked in testing in England and present the

findings for Q2 in section 2.3. For both these questions, we only present additional findings not

remarked on in section 2.1.

The aspiration is that both Q1 and Q2 should be asked in the main stage as they explore different areas

of mental well being. The intention is that Q1, which is an exact copy of the Patient Health

Questionnaire (PHQ‐9), will be asked followed by Q2, which is based on the Mental Health Index‐5 and

the Energy and Vitality Index (MHI‐5/EVI). Q1 (PHQ‐9) is made up of nine items, which can be tentatively

used to diagnosis depression. Q2 (MHI‐5/EVI) is used to measure anxiety, energy and vitality all of which

are used are mental health measures. Q2 is composed of nine items, which are drawn from SF‐36.

2.1.2.1. Overall findings for Q1 (PHQ‐9) and Q2 (MHI‐5/ EVI)

Testing revealed there was a mixed reaction towards Q1 and Q2 and there was not one question

which was clearly preferred over the other. Reasons why Q1 was preferred over Q2 was that it

was more descriptive. The reasons why Q2 were preferred over Q1 were that it was:

o easier to think of a month than 2 weeks;

o not as intrusive as Q1;

o more positive in tone than Q1; and

o easier to select an answer because the options were more evenly spaced and it was felt

that option 1 was a missing an answer option between ‘not at all’ and ‘several days’

(described further in Q1 findings).

Respondents, who found both questions easy to answer overall, did not find the items sensitive,

either because they had not suffered from any aspect of Mental Health illness being measured at

Q1 or if they had, this was in the past and they were comfortable to answer these questions.

46

In testing, it was found that respondents could either see that the two questions clearly

overlapped, overlapped somewhat or did not overlap at all. Analysis by age, gender, and

occupation did not reveal a clear picture of the types of respondents who saw the questions

clearly or somewhat overlapped. There is limited evidence to suggest that respondents who had

had ‘low periods’ may be more inclined to feel that the two questions overlapped in contrast to

respondents who felt they had a ‘happy go lucky’ attitude or never experienced feeling ‘low’

seriously. Those who had experience of seriously feeling down for long periods of time (so for at

least a few days) could still answer the questions even if they felt the questions overlapped. The

findings are presented in the table below.

Table 2: Perception of an overlap between Q1 and Q2 & the implication of this understanding

Q1 and Q2 clearly overlapped Some overlap

Items overlapping between Q1

and Q2

No overlap at all

Item 4 in Q1 (feeling tired

and little energy) and item 9 in Q2

(Did you feel tired);

Item 2 in Q1 (feeling down,

depressed or hopeless) and item 6

in Q2 (Have you felt down hearted

and depressed).

There was no overlap, with

Q1 being about depression and Q2

was much calmer

Took more time over Q1

and or thought about each item

separately because it is looking at

something different.

Q1 looks at frequency and

Q2 looks at amount.

Clear overlap, and did not

like being asked again in Q2.

Felt Q2 was a trick question

or being used to check the answers

to Q1, and did not like it but did

answer the question.

Q2 is a positive version or a

calmer version of Q1

Q2 was just the inverse of

Q1

Implications

In the survey context, there will be respondents who would be willing and able to answer the second question

thinking about their answer and not being affected by the question order i.e. the first question. However, there

will be a group of respondents who will react negatively. In testing, respondents fell in the first group, but

cautioned this that they did not like answering a repetitive question.

On an occasion, it made Q2 harder to answer because the respondent tried to recall how they had answered Q1.

A concern that was expressed by respondents and the interviewers is that asking both questions

and/or Q1 (especially item nine) is inappropriate if respondents are vulnerable; unless

supportive measures are available, (we discuss this in the recommendations).

o Testing showed that there was a sense that the questions are ‘clinical type’ of questions

used to measure mental health. Respondents either just ‘felt this’ or articulated that

they had experience of these types of questions being used in a clinical setting. Included

in the first group, i.e. those who ‘just felt this’, was an ex nurse and a youth worker who

had strong concerns about Q1.9 being asked and questioned what follow‐up care would

be provided to respondents who were feeling such thoughts frequently.

47

In testing, respondents were able to answer all the items in Q1 and Q2, even if they were a bit

surprised by one of the items such as Q1.9. Respondents on the whole did not mind being asked

any of the items in Q1 and Q2 because they were better now and that episode was behind them,

or they understood the reason for the questions. Interesting, respondents who could relate to

having had the feelings identified at Q1.9 did not mind being asked this question. The sensitivity

expressed in testing generally arose due to concern about how others, who are vulnerable, could

feel about such a question.

On a rare occasion when an item was sensitive to the respondent, the respondent could still

answer the question although uncomfortable to explore the reasons during the probing. This

occurred at item Q1.5 (about eating).

Time period

Q1 and Q2 refer to two different time periods, Q1 asks respondents to think back over the last 2

weeks and Q2 the past 4 weeks. The time period at Q1 worked as intended with respondents

thinking about the last two weeks and not telescoping nor thinking generally because there is no

difference from week to week and this did not affect their answer (this answer strategy was seen

amongst retirees only who had not experienced the feelings identified in Q1).

Testing showed that there were four different ways in which the time period at Q2 appeared to

be influenced by the one used in Q1, which we report on below. There were cases where the

respondent:

1. realised the change in time period when the question was read out and correctly re‐

adjusted to the new time period, even it was difficult to start with;

2. realised only half through Q2 that they should be thinking of the past 4 weeks and not

the last 2 weeks (as with Q1) but made the conscious decision to carry on thinking about

the last 2 weeks as it would not make much difference to their answers;

3. started answering Q2 with the correct time period in mind (4 weeks) but then half way

through Q2, reverted to Q1’s time frame; or,

4. did not provide evidence that there was an affect on their answer, because the

respondent’s experience was the same whether it was the last 2 weeks or the last 4

weeks.

The affect of the second and third way in which Q1’s reference period impacted upon how Q2

was answered is that the measurement aim of Q2 could be damaged, as respondents could

under or over report, if they had experienced different behaviours/feelings over the last four

weeks compared to the last two weeks.

48

Recommendation for asking both PHQ‐9 and MHI‐5, EVI

Asking both questions

It is possible to ask both questions however, we would suggest:

1. That a clear introduction is provided to the section, so the context is set. We note in

the main stage that mental health is not the first set of questions asked, which again, will help

settle the respondent.

2. The time period is made consistent between the two questions (so choose either 2

weeks or 4 weeks depending on whether the intention is focused or broad).

3. Ideally, a five‐point scale should be asked at both questions, for example the answer

scale used at Q2.

4. The order they were asked (Q1 followed by Q2) seemed to be appropriate as far as

interviewers were concerned as Q2 was more positive so ended on a high note.

As these questions could reveal that a respondent is vulnerable, there is a need for a dialogue

on the ethics which will be observed on this study. Obviously, this discussion is needed prior

to the implementation of this survey to ensure all participating countries observe the same

consistent high standards of good research. For example, to decide what information is

conveyed to respondents about the topics, which will be covered in the survey, e.g. there will

be questions on mental health. It also needs to be made clear under which situations, if at

all, potential disclosure to authorities needs to be considered, i.e. if the responses the

respondent gives indicate that they have a severe form of depression (which appears to be

untreated) or if a respondent is having thoughts of hurting themselves nearly every day. A

protocol is needed to state under which circumstances the interviewer should raise the alarm

– and how this should be done. Also we would advise that the circumstances in which

disclosure may be necessary should be made aware to prospective respondents prior to

informed consent being requested to recruit them, to ensure all respondents are fully

informed.

We make a few specific wording suggestions to the stems of Q1 and Q2 in the following

sections after presenting how these two questions worked individually.

49

2.1.2.2. Question 1 and 2: To measure common mental health illnesses

Overall findings for Q1 (PHQ‐9): To measure depression and anxiety

“Generally these Qs were about how you see life, how you feel about things that affect you” (Female 55

with bad health and a limiting long standing illness) (OM05)

Question 1 (PHQ‐9)

{READ OUT TO ALL}

Mental Health Intro: In the following, I will be asking you some questions about your psychological well‐

being.

SHOW CARD 1

{ASK ALL}


PHQ‐9 Not at all

Several

Days

More than

half the days

Nearly every day

Don’t know

Refusal

Q1.1 Little interest or pleasure in doing things

Q1.2 Feeling down, depressed or hopeless

Q1.3 Trouble falling or staying asleep, or sleeping too much

Q1.4 Feeling tired or having little energy

Q1.5 Poor appetite or overeating

Q1.6 Feeling bad about yourself‐or that you are a failure or have let yourself or your family down.

Q1.7 Trouble concentrating on things, such as reading the newspaper or watching television

Q1.8 Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

Q1.9 Thoughts that you would be better off dead or of hurting yourself.

50

Overall findings

Generally, this question has worked as intended but there were occasions when respondents have

understood ‘bothered’ more literally than the question intended. In addition, the four‐point scale used

at this question was considered to be missing an important dimension: a category between ‘not at all’

and ‘several days’. We report on both of these below, followed by how well the time period worked and

understandings of the nine items.

Being ‘bothered’ by the problem

• Testing revealed that this question could be understood literally, with respondents recognising

that they are affected by one of the problems identified in the question but because they had

learnt to live with it, or take medication to manage it, they are not bothered by the condition. If

the intention of this question is to measure experience of mental health and depression, and the

severity of each of the different symptoms, there is a risk that (at present) there will be under‐

reporting of problems in the survey data.

• This said and there was conflicting evidence which suggests that respondents could also over‐

emphasise problem and report more trivial feelings which would not, in a clinical setting, be

associated with serious symptoms of depression. This tended to happen at the items which

could be interpreted by people with no experience of mental ill‐health as problematic in their

life: for example sleeping too much as a result of being tired due to the pressures of every day

life (and not as a result of depression).

There were two strategies adopted by respondents who took medication to address a problem

identified at Q1. Either to answer the question thinking about:

1. how they would have felt if they had not taken their medication, and,

2. those who considered whether they were troubled by the problem after taking their

medication.

This inconsistency indicates further direction is needed to ensure the question achieves its

measurement aims consistently.

Use of the answer scale

Testing revealed that respondents felt that there was a missing option between not at all and

several days (the first two points on the scale). Testing of Q2 showed that respondents liked the

five‐point scale compared to the four‐point scale at this question, because this questions’ scale

leapt from never to several days, and fails to provide a way to identify the occasional incidents.

The figure below illustrates how the scale was understood and used.

51

Table 3: The implication of incomplete answer scale on how Q1 was answered

NOT AT ALL MISSING OPTION SEVERAL DAYS MORE THAN HALF

A DAY

NEARLY EVERY DAY

Understood as….

Never; or,

Not applicable

some days, a few

days and occasionally

three to four times

per week or

7 times in 14 days

8 days or more or

less than 14 days.

IMPLICATION

Respondents who fell

in this group either

selected not at all or

several days

Although there were respondents who saw

these two options as distinct, there was a

group who felt they sounded the same i.e.

measuring the same thing.

Respondents who felt an option was missing between ‘not at all’ and ‘several days’, almost

universally selected ‘several days’ because ‘not at all’ was not true although ‘several days’

indicated something more serious or that happened more frequently than it did (which felt

hesitant and uncomfortable to choose), but felt this was ‘truer’ than saying not at all.

There was an overlap in understanding between ‘several days’ and ‘more than half a day’, which

resulted in respondents with the similar levels of experience selecting either option, which

reduces the measurement ‘precision’ of the these two points on the scale.

Time period

Although overall respondents thought about the last 2 weeks, there were respondents who just

answered the question thinking generally. Universally, this group of respondents articulated that

it made no difference because their experience was always the same.

Testing revealed that the timing of the survey could affect how respondents answer this question. A

respondent described how she felt more bothered during the winter season than in the summer,

when she would have answered this question more positively. As the aim of the EHIS is to collect

harmonised data on health it will be important that the administration of the survey is harmonised,

including when the survey is administered. Though in a cross national sense, it is likely to be

impossible to control fieldwork timing so the ‘seasonal’ effect is just something to be aware of.

Understanding of items

Overall, the items were understood as intended. In the next table we illustrate how individual

items in Q1 were understood and under a blue heading, how the statements were

misunderstood.

52

Recommendation for Q1 (PHQ‐9)

Consider adding an answer option such as ‘occasionally’ between point 1 and 2, to provide more

discrimination in the answer options

We believe the PHQ‐9 works in primary care as an indicator of the major mental health

illnesses if a respondent answers Q1.1 or Q.1.2 and five or more of Q1.1‐Q1.9 are at least

‘More than half the days’. How the respondent understands ‘More than half a days’ is

therefore key element in this subjective question working as intended. We do not believe

there will be scope to change the wording, since this question is based on a standard

question. However, testing in England has revealed that there could be respondents who do

not see the differentiation between ‘several days’ and ‘most of the days’. If the analysis from

this question will be used to run a similar scoring used in a ‘clinical setting’ to provide a

indicator of mental illness in the general population this is likely to be over‐recorded in

England. When this question is used by health practitioners, this does not matter, as it would

be safer to refer patients to specialists who many have less severe mental health illness.

However, for a survey context, this could result in over‐estimation of serve mental health

illness, especially as it is being used in a general population survey. If there is scope to change

the wording, we would suggest that the answer scale at Q2 is used at this question; if it can

we scored in the same way as the current scale and thereby inform the PHQ‐9 indicator. We

would strongly suggest that further research is conducted to see if PHQ‐9 can work as

intended using the MHI‐5/EVI answer scale and that any changes are cognitively tested.

Consider placing in bold the last 2 weeks to help interviewers to stress this or if used in a self‐

completion this is visually pronounced.

Consider rewording the question slightly to ‐ Over the last two weeks, how often have you

been troubled by any of the following problems.

At the moment there is inconsistency in the inclusion of thinking about the affect of the

problem with and without taking medication. To help the question achieve its measurement

aims, we would suggest that direction is provided in the question wording whether to include

or exclude this, depending on the measurement aim of the question.

We would question whether item nine should be included in a general population health

survey, for ethical reasons, and would advise this is not asked.

53

Table 4: How individual items in Q1 were understood Capitals highlighting how the term was understood (misunderstanding shown under the blue heading) and bullet points provide examples

UNDERSTANDING and OTHER FINDNGS FOR ITEMS COGNITIVELY TESTED

Q1.1 Little interest or

pleasure in doing things

Q1.2 Feeling down,

depressed or hopeless

Q1.3 Trouble falling

asleep or sleeping too

much

Q1.6 Feeling bad about

yourself …let yourself or your

family down

Q1.8 Moving or speaking

slowly…fidgety or restless

Q1.9 …..better off dead or hurting yourself

BROAD INTEREST IN LIFE OVERALL SLEEPING TOO MUCH LETTING SELF/FAMILY DOWN FIDGETY/RESTLESS OVERALL

Sleeping through alarm

more than usual

About suicide;

Abusing oneself

TROUBLE FALLING

ASLEEP

No longer interested in

hobbies

“It doesn’t bother me at

all because I’m always

interested in everything

that goes on around me

whether it’s work, home

life, children. You know,

so I’m always interested

in something.” R adds

that he tries to find

pleasure in life.”

Likes cooking but cannot

stand for long because

of medication so has no

interest now.

General feeling of

dissatisfaction with

oneself.

Feeling miserable

“Somebody who

can’t motivate

themselves to do

anything …quite a

state of despair e.g.

people being a

couch potato with

no desire to do

anything” (26 years

old Female in good

health)

Taking longer to fall

asleep than the

usual practice

Waking up in the

night and not being

able to fall back to

sleep

Tried and failed at

something/depends on

the situation for example

raising a child who goes of

the rails, losing a job and

thinking if you had worked

a bit harder (SA03) (SA05)

Not paying interest in life

“That seemed to

me…generally directed at

asking perceptions of ones

own self worth” (Female

67 with a non limiting long

standing illness)

Not calm

“not being able to sit

still, constantly having to

do something with your

hands” (29 years old

Male in good health)

Jumpy, feeling that

something is not right,

nervous about

something.

CORRECTLY NOT INCLUDED FEELING DOWN WRONGLY EXCLUDED BEING A FAILURE WRONGLY INCLUDED

Tasks/activities that the

respondents does not

like doing e.g. going

shopping when engaged

in a good book

Outlook on life is to

Tired

Not bothered

Felt a bit fed up for

a day

Trouble failing

asleep which is

being treated by

medication

Severe trouble with

sleep but ‘not

Failure in terms of

relationships. So it would

be about letting people

down, not living up to

their expectations,

disappointing them in

Moving slowly due to old

aged compared to how

they moved when they

were young.

OTHER FINDINGS

Testing found that

there were three

reactions to this

question, either to

think it was OK or

to think this

question need to

be asked with care

or thirdly felt this

question should not

be asked at all.

Respondents in the

first group, either

had never had any

thoughts like this or

their feelings of

suicide and self

harm where in the

past. When the

third view was held

54

have little interest and is

not bothered by it

bothered’ by it

because after

several years learnt

just to manage.

some way, umm, not

being a good friend.”

“You have made a mess of

your life” (SA04)

DEPRESSION

“Life isn’t going as you want it to at the moment and you are struggling.

INCORRECTLY INCLUDED

HOPELESS

Misunderstood question as: doing anything interesting. (This occurred on an occasion and the respondent has recently become fluent in English.

Lost all ones hopes

UNCERTAINTY IN

UNDERSTANDING SHOWN BY

R cautioning correct understanding with a I’m not sure

Misunderstood question as: doing anything interesting. (This occurred on an occasion and the respondent has recently become fluent in English.

Lost all ones hopes

it was because

respondents had

experience of

working in the

health or social

care sector and

strongly felt this

question should

only be asked in a

clinical setting.

There was concern

that asking a

question like this to

a vulnerable person

could put the idea

in their head and or

what the

interviewer would

do if they answered

yes.

55

2.1.2.3. Question Q2: To measure energy and vitality as an indication of mental illness

Question 2 (MHI‐5/EVI)

SHOW CARD 2

{ASK ALL}


MHI‐5,

EVI

All of

the time

Most of

the time

Some of

the time

A little

of the

time

None of

the time Don't

know Refusal

Q2.1 Did you feel full of life?

Q2.2 Have you been very nervous?

Q2.3 Have you felt so down in the

dumps that nothing could cheer

you up?

Q2.4 Have you felt calm and

peaceful?

Q2.5 Did you have a lot of energy?

Q2.6 Have you felt down‐hearted and

depressed?

Q2.7 Did you feel worn out?

Q2.8 Have you been happy?

Q2.9 Did you feel tired?

Overall Findings

This question worked well generally, as respondents found the items more positive, calmer, and

less precise so less intrusive than Q1 and found the question easy to answer, even after

following Q1.

The question was understood as ‘How do you feel about yourself’.

The answer options were easier to use because there was not a missing option, like at Q1. One

respondent questioned why it was not possible to use Q1s answer scale at this question.

There was inconsistency in the time period thought about at this question, which we have

already reported in section 2.1.

It was felt on occasions that there were statements within Q2 which overlapped, for example

Q2.3 (Have you felt so down in the dumps that nothing could cheer you up?) and Q.2.6 (Have

you felt down‐hearted and depressed?) were felt to be similar. This was reflected generally with

the same answer being provided at both questions:

56

“I’m struggling to differentiate between the two” (29 Male Managerial/Professional)

The items were well understood by respondents. These items are subjective, although

respondents understood the items, the level of severity did vary but this was reflected in the

answer options selected, reinforcing the evidence that this question has worked as intended. In

the table on the next page we present how items 2.1,2.3, 2.6, 2.7 and 2.8 which we are asked to

probe on specifically were understood.

Recommendations for Q2 (MHI‐5/EVI)

To assist Q2.7 and Q2.9 achieve their measurement aims consider providing further direction to one

or both items. If it is not possible to change the actual composition of the items, we would strongly

advise that an introductory statement is added to precede this question (with something similar

before Q1 too) which directs the respondent to think about episodes (of say being ‘worn out’ for

example) which were felt to be a result of poor mental health, and not those associated with the

tires of everyday life. If this question remains as it is, we fear that there will be both respondents

who report episodes of ‘feeling tired’ or ‘being worn out’ as results of their poor mental health, as

well as respondents who report the same periods but for reasons which are not associated with

poor mental health (just being tired because life can be tiring at times!)

As Q2.3 and Q2.6 seem very similar, consider whether both are necessary and if they are felt

to be needed, we suggest distancing them from one another (so placing them further apart in

the list which is read out).

As the data collected at Q1 and Q2 inform two different indicators, we presume there is no

scope to remove the overlaps between the two questions, especially as the answer scales are

different. However, in testing, it was found the answer scale at Q2 was found to be easier

than the answer scale used at Q1. If it is possible for the answer scale at Q2 to be used at Q1,

this would ease the question and answer process for both questions, and provide scope to

address the perceived overlap between items such as Q1.2 and Q2.3 and Q2.6

Even if the suggestions above are not possible to implement, it is possible for this question to

work as intended.

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Table 5: Understanding of items in Q2 & implication on how they worked The different understandings are shown in capitals and bullet points provide examples

UNDERSTANDING and OTHER FINDNGS FOR ITEMS COGNITIVELY TESTED Q2.1 Did you feel full of life? Q2.3 … Felt so down in the

dumps that nothing could cheer you up

Q2.6 Felt down‐hearted and depressed

Q2.7 Did you feel worn out Q.2.8 Have you been happy

Was well understood as.... Was understood as Was understood as.. Was understood as.. Was understood universally as

GENERAL CONTENTMENT COPING/ UNCERTAINITY SAME AS Q2.3 PHYSICALLY AND PSYCHOLOGICALLY

GENERAL HAPPINESS

Down in the dumps

Cannot energise oneself

Depressed

NOT HAVING GENERAL CONTENTMENT

Unable to Cope “Whether

you felt like giving up on

life really...you’ve got the

will to carry on” (Male 43

Lower supervisory and

technical occupation)

“Being unsure of yourself

and miserable”. (Female 67

Intermediate Occupation) LONELY

Exhausted by family

“Tired is quite a normal day to day thing....worn out is a more extreme version of that where you are so tired you can’t do what you need to do” (Female 56 long standing illness not working)

“It’s a state of being”

(Male 70

professional/Manage

rial)

“Just feeling joyful” Male 43 Lower supervisory and technical occupations)

“A feeling of having a warm

glow and feeling good about

yourself and various aspects

of our life. But not just

feeling neutral or passive

about it but feeling actively

good” (Male 29

Professional/Managerial)

Enjoying it, life” (Male 70

Managerial/Professional) LONG TERM DEPRESSION PHYSICALLY ONLY

ENERGY/READY FOR THE DAY

JUST HAVING A BAD DAY

Exhausted after working 70

hour week

Feel tired to do things

because of a lack of sleep

“Getting up in the mornings,

getting on with things; not

bothered by things (Male 75

Semi routine)

OPPOSITE OF 2.1, FULL OF LIFE

MORE EXHAUSTED THAN tired (2.9)

IMPLICATION

This item has been well understood in the context of respondents’ life e.g. working or retired.

If respondents understand this item the third way this could result in over‐reporting of severity of this element of

In testing, respondents who understood this item identically or similarly to 2.3 provided the same answer at

Although respondents did

differentiate between 2.7

and 2.9, this item or 2.9

This item has been well understood in the context of respondents’ life e.g.

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mental health, which is being measured by this item.

Q2.1 showing consistency in their answer strategy. In the main stage, respondents may adopt short cuts if questions start to feel repetitive, although this was not seen during the cognitive interviews. Examples of short cuts that could be adopted are to select the first option on a show card/self completion (primacy effect) or the last option they hear in a CAPI/CATI interview (recency).

could benefit from further

clarification or explanation

to ensure they measure

different aspects of mental

health.

working or retired.

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2.1.3. Physical Activity

Two modules of questions were tested, the National Health Interview Survey (NHIS) and the

International Physical Activity Questionnaire (IPAQ). The NHIS questions were questions Q3 – Q5

inclusive in the test instrument, and the IPAQ were from Q6 – Q9 inclusive. The NHIS measures leisure

time physical activities and the IPAQ measures total physical activity.

Overall respondents understood what the questions were asking in both modules. The one exception

was Q4, when a respondent thought she was being asked how long she has done the activity. This

respondent, although fairly fluent in English, had only recently learnt English.

We firstly present the evidence of how the two modules worked overall, identifying which module

worked better in the cognitive testing in England, as the key aim of cognitive testing of this section was

to identify which of the two modules should go forward to the pilot.

Additional findings not already presented in section 3.1 will be presented in the question‐by‐question

findings in section 3.2. The questions tested on physical activity can be found in Appendix B.

How the NHIS (measuring leisure‐time physical activities) and the IPAQ (measuring total physical

activities) compared to each other in testing

Respondents’ Preference

There was not one clearly preferred module which came from testing. The reasons why

respondents preferred the NHIS module, ranged from:

o it involved less thinking about than the IPAQ questions;

o it was quicker to answer especially for respondents who did no exercise; to

o a dislike for Q9 (how long did you spend sitting on a week day) which resulted in a

preference for the entire NHIS module.

Reasons for preferring the IPAQ were that it was easier to identify activities, allowed for more

precise reflection of the respondents’ physical activities and it provided a question to include

walking, which was felt to be missing in the NHIS module.

IPAQ measured respondents’ physical activity better than NHIS

The table 3.1 presents how the level of regular physical activity (Vigorous, moderate, light or no

exercise) affected preference of module. Analysis by level of regular activity did reveal that the IPAQ

module although harder than the NHIS questions, is still easy to answer and it provides a more

accurate measurement of respondents’ activity levels. An exception is the sitting question (Q9) in the

IPAQ module, which is discussed later. Analysis of the question and answer process suggests that the

IPAQ module measured physical activity more accurately indicating that in the UK context at least,

this module would be the one we would advise is adopted for the next wave of EHIS. For example in

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testing, there were respondents who, answered the NHIS indicating that they never do vigorous or

moderate/light exercise but identified in the IPAQ questions that they regularly walk for exercise.

Below we present further evidence of how the two modules worked and why we advise the

adoption of the IPAQ in the EHIS.

Table 6: Module Preference by physical activity level

Reasons for preference Physical

Activity

level 1

A preference for NHIS (Q3‐

Q5)

No preference or the same feeling

about the 2 modules

A preference for IPAQ

(Q6‐Q9)

Vigorous Easier to answer for example because this

module did not require

respondents to recall back

over the last 7 days.

Both equally good Easy to answer

Moderate ‘Easy for me because it is

something I actually do”

(Male 43 lower supervisory

role and technical

occupation)

Easier because it is more

specific being just about

leisure activities.

Both equally good and easy for regular moderate exercisers.

Did not like either module of

questions “If you are trying to identify

the types of exercise I do, there surely

is a simpler way of finding‐out what

and how regularly I exercise…seemed

like I had to slot them into the

descriptions, which wasn’t easy to do.

I wasn’t sure I was answering them

correctly, even though I was sure of

the activity I was doing. I don’t know if

I was answering them appropriately

or accurately” (Female 26 managerial/

professional)

This was easier for example because :

o it identified

activities;

o helpful descriptions.

Preferred this module

because it provided a

more accurate picture,

although the NHIS

questions were easier

to answer.

Light Quicker and or easier to answer compared to IPAQ,

because NHIS only asks did

they do an activity or not;

but IPAQ asks for times.

Respondents in this group

nevertheless found IPAQ

easy to answer on the

IPAQ was preferred because it allowed non‐

vigorous exercise or

‘normal activities’ to be

identified in contrast to

NHIS.

Allowed more detail to

be captured like

1 A screening in exercise was conducted to be able to test the questions with a range of people. One of the sample

characteristics that we recruited was physical activity level. During recruitment a screening questionnaire was

administered and respondents were asked if they do exercise, and if they answered yes, whether this was light,

moderate or vigorous. It is this screening variable which is listed in the table.

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Reasons for preference Physical

Activity

level 1

A preference for NHIS (Q3‐

Q5)

No preference or the same feeling

about the 2 modules

A preference for IPAQ

(Q6‐Q9)

whole.

walking. There was

clear direction where to

include and exclude

walking.

Easier to think about the last 7 days.

No

exercise

Much better because

enraged by Q9 (IPAQ) which

the respondent could not

answer/was not willing to

try to calculate an answer.

Both equally easy except Q9 (sitting down)

Ambiguity and inconstancies in the inclusion of activities and time periods

Difficulty coding different exercise patterns in the NHIS module

Interviewers found it difficult to impossible to code respondents answers for the NHIS questions

if:

o respondents’ regular pattern involved different time spent on different physical

activities (e.g. goes to the gym three times the week, and jogs daily for 45 around 45

minutes), or

o Respondents had irregular activity patterns.

In testing, although respondents who exhibited these two exercise patterns mentioned above

found the NHIS question easy to answer because they just provided an ‘open’ answer, it was not

possible for the interviewer to code the answer, which in a survey context would result in item

non response for respondents who have either of these exercise patterns. Interviewers were

able to code the answers in the NHIS questions for respondents who did one physical activity

regularly. The NHIS questions would benefit from adopting another approach to ensure the

questions accurately measure all leisure activities.

What to include under the different activity levels

In table 3.2 we illustrate how respondents understood vigorous and moderate exercise.

Although respondents included different exercises under vigorous and moderate depending on

the description used at with in the NHIS module and in the IPAQ module they defined them as

meaning the same thing at both questions, when probed specifically on the meaning of the

terms.

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NHIS module required respondents to make a judgement of what exercise to include under

vigorous, moderate and light. Respondents found the examples in the IPAQ removed the

ambiguity of what to include, making the questions easier to answer. For example, a respondent

was not sure whether to include walking when they sweat because of the weather and not

because of doing the exercise. This difficulty was not observed at the walking question, Q8 and

Q8a in the IPAQ module. These questions just ask on how many days in the last week the

respondent has spent walking and how much time is usually spent walking on one of these days.

Table 7: How Vigorous and Moderate was understood by respondents

Understanding of terms in both NHIS and IPAQ module

Vigorous Moderate

Defined by impact on the body

Takes it out of you

When you push your body to the limits

Defined by what exercises are carried out

Playing tennis Dancing

Heavy muscular activities Light work out

Brisk walking Light walking

Hard competitive sports Slow biking

Digging in the garden Doing things around the house

Climbing (only thought about at Q6)

In testing respondents included walking under vigorous if it was brisk, and as light or moderate if

it was their usual walk and it made them sweat or breathe a bit harder in the NHIS questions.

Respondents found it easier to think about this at Q8 as they included all their walks.

Judgement of what to include under which activity at both questions

Leisure activity was well understood. Nearly universally, respondents only thought about non‐

work related activities done in ones own time. However, one respondent did include work and

leisure activities when answering the NHIS questions and excluded this when she answered the

IPAQ questions. This respondent although quite fluent in English, had only recently learnt

English. This finding nevertheless highlights that irrespective of which module goes forward, it is

important that the module is introduced with a clear simple introduction which clearly tells

respondents what to think about when answering the questions. Retirees viewed all of their time

as leisure time. There was an inconsistency on whether to include housework when answering

the NHIS questions, which we discuss below.

Housework

In testing, respondents adopted two strategies in relation to housework, they either

1. included it, if it was not considered a chore; or

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2. they excluded it because one has to do it and therefore is not a leisure activity.

Housework was usually understood as cleaning and vacuuming but also on a rare occasion house

renovations were included. The respondent who understood housework to include house

renovation, did not include this vigorous exercise when he answered the NHIS questions,

because he observed the second answer strategy, but he did include it when he answer the

IPAQ. If the question is solely measuring activities done in leisure time, as defined by the

respondent, than this module does achieve this however if the module is trying to measure non‐

work physical activities then this question would benefit from clarifying whether housework

should be included.

Thinking about the usual practice or the last 7 days

Overall, respondents thought about their usual or typical practice when answering the NHIS

questions and the last 7 days when answering the IPAQ questions. The exception was when one

respondent when answering the IPAQ questions decided not to think about the last 7 days

because it was atypical and thought of the preceding week only as this was reflective of their

usual exercise behaviour. There is no evidence that respondents telescoped when answering the

questions.

Testing revealed that when respondents have different exercise patterns, they could either:

o Provide an average answer;

o Think about the day they do the least exercise so not to be seen as doing more exercise

than they do; or,

o Think about the day that they do the most exercise to be seen in good light.

These answer strategies were observed when Q4 (NHIS) and Q8a (IPAQ) were answered.

Sensitivity of asking about how long you spend sitting down in a day

Respondents felt that respondents may under‐report how much time they spend sitting as they

would feel bad to been seen as a sedentary person or a ‘couch potato’ which socially is looked

down upon these days; the younger adults especially held this view.

Reflecting on how individual questions in the two modules have worked, we would recommend the

IPAQ module goes forward to the pilot stage.

Additional Question by Question findings for the physical health section

In the rest of this chapter we present additional findings on how the IPAQ questions have worked,

as we have suggested in the previous section that this module is taken forward.

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2.1.3.1. Question 5 (PAQ3) To measure frequency of doing strengthening exercises

Findings

In testing respondents universally, irrespective of age or how much exercise or level of activity

they did, universally understood this as exercise to build up muscles. Overall respondents

associated this form of exercise involving lifting weights, which included dumb bells, bricks and

people. When lifting people was included, it was because the respondent answered this

question thinking about her work as a carer, which involved lifting people to move them.

Universally calisthenics was not understood at all.

2.1.3.2. Question 8 (IPAQ‐5) and Q8a (IPAQ‐6) To measure frequency of doing at least 10 minutes of

walking in a week and much time usually is spent walking in a usual day

Findings

This question worked well generally, with respondents finding both questions easy question to

answer and the descriptions useful. Respondents correctly included walks outside the home and

inside the home too, in cases when this was their form of exercise as they could not/did not go

outside. However, during probing on occasions respondents realised that they had missed some

days when they had taken walks outside the house. This suggests that Q8 could be vulnerable to

under‐reporting. In addition, testing showed that Q8a could be vulnerable to under and over‐

reporting, as respondents who have two or more walking patterns in a week either:

o Selected the day they did the least to ensure they did not indicate they did more than

they did;

o Calculated what the average walk would be; or,

o Selected the day they did their ‘long’ walk, to show them in a good light or what they

could do.

There is evidence that respondents did think about the last 7 days for both questions and did not

telescope, so for example did not include a walk they did on the 8th day.

On rare occasions, respondents asked for clarification at Q8a if they should provide the total

time spent walking in a week or how much on one of these occasions. Respondents universally

did answer the question correctly but this finding suggests that this question could benefit from

a clarification in the wording.

There was one occasion when a respondent could not answer Q8a because he is retired and free

to walk for as long as he likes and he does not know for how long he walks. He could answer Q8.

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2.1.3.3. Question 9 (IPAQ‐7): To measure how sedentary the respondent is on a weekday

Findings

Nearly universally respondents were surprised by the question. On occasions respondents were

also concerned by their answer which revealed how long they spent sitting during a week day.

Testing revealed that respondents could either answer this quickly by providing an average

answer based on the assumption they are sitting down for the entire working day or a general

day and some time in the evening; or, took time actually calculating how much time are sitting

on a usual day. Respondents who adopted the first strategy found the question relatively easy

to answer but the figure they produced is a rough figure as it is unlikely that the respondent is

sitting down for the full working day i.e. for 7 hours flat although this may work it’s self out, as

respondents added only an hour or two for the evenings. Respondents who calculated an

answer did struggle and this was shown either by the time it took to answer the question (taking

as long as 8 minutes), articulating that they were finding it difficult, or taking out a pen and some

paper to help them to calculate their answer. Respondents in this group painstakingly thought

about over the whole day, e.g. thinking about sitting down while having their meals, watching

the television, doing the cross word etc.

In testing, a respondent who uses a mobility aid, like a wheel chair, also thought about this when

answering the question. One respondent missed including the time he spent sitting in his car.

Both these respondents adopted the first strategy mentioned in the previous bullet point ‘of

thinking of their work day/general day’ when they answered this question.

There were cases where the question was not answered and this tended to be for one of two

reasons, either because:

o The respondent was angry by the question. Unfortunately, we do not have the evidence

to know if it was the subject matter or the computation that this question required

which made the respondent angry;

o It was too hard to answer because the respondent is retired and is free to do what he

likes when he likes and he found it hard to think of a regular practice in the last 7 days.

This respondent for the same reason could not answer Q8a.

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Recommendation of which module to use/wording changes to individual questions within each module

Consider using the IPAQ module rather than the NHIS module of questions as this module of

question has worked better overall. There was no evidence of ‘cultural’ factors impacting on

either module rather the quality of information provided and coded by interviewers is much

improved in the IPAQ.

If an exact figure is necessary, this level of computation is too difficult to expect respondents

to observe in a survey context, in which case we would advise not asking the sitting question

(IPAQ‐7). If an approximate figure is acceptable and this can feed into a physical activity and

inactivity indicator, then this can be asked, and we would advise slightly rewording the

question so respondents know they do not need to provide an exact answer. A suggestion for

rewording is:

During the last 7 days, how much time do you think you usually spend sitting on a weekday? A

rough estimate is fine.

We would also suggest that the wording at Q8a is slightly amended to help respondents to

think about a total figure and not just one of the walks they may have done on the day. A

suggestion for rewording is:

How much time in total do you usually spend walking on one of those days? If you do not have

a regular pattern please answer thinking about the day you last walked.

Interviewers made a suggestion to improve the administration of the questions in the IPAQ

module and this is shown below.

Q6a: Change the wording to: How much time did you spend doing vigorous physical activities

on any one of those days?

We would recommend that any question rewordings are tested again.

Consider dropping the example of callisthenics at Q5 (IPAQ‐3) because this was poorly

understood and respondents understood what to think about without this example.

If the intention, following the experience of how the questions have worked in other European

countries, is to opt for the NHIS questions, we would suggest the following steps are

considered:

That appropriate examples are added to the questions as respondents found this helpful to

understand what to include under vigorous and moderate/light exercise; to

Consider slightly amending Q3 and Q4. Currently it is difficult for respondents who have a

variety of exercise patterns for their answers to be easily and accurately coded by

interviewers. One option would be if the question is administered in a CAPI or CATI to give the

option for the interviewer to add the information for each exercise.

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2.1.4. Alcohol Consumption

Overall Findings

The alcohol consumption section in the questionnaire covers the basic health related elements of

drinking: overall prevalence, volume of consumption and frequency of consumption. Alcohol

consumption is included as a health determinant within the questionnaire as it is a known

contributory factor to overall health status. The alcohol consumption section is comprised of seven

questions; these will be discussed in turn.

The key finding from testing is that respondents did not understand the show card and on the

whole respondents just answered all the questions in the module thinking about how many

glasses of drinks they had had. If respondents understood the show card, either at the start or

later started to get an understanding, they did not like the feeling it brought about, indicating to

them that they were drinking more (as ‘units’ do not correspond with ‘drinks’).

Although using units on the show card may have improved the show card, there is evidence to

indicate that this would not have worked consistently well because respondents said they did

not understand units and also this does not get round the problem that respondent do not feel

comfortable, even on a self‐completion, identifying how many units/drinks (as understood in this

module) they have. Respondents on the whole, are comfortable to truthfully identify how many

glasses of drinks they had, though converting these into units is both:

o Unfamiliar and illogical (i.e. one drink=two units?). and,

o Disconcerting, as it highlights a reality which would rather be ignored (i.e. drinking more

than you like to think you are).

We discuss in detail below how the show card has worked. We begin by discussing the group of

people who are either not accommodated in the current module. This group struggled with the

questions because their type of drinking behaviour is not really considered.

Missing very light drinkers and those who have never drank alcohol

Testing revealed that the current module does not cater for respondents who never drank

alcohol in their entire life or saw themselves in this group (non drinkers) or hardly drink alcohol

i.e. less than one drink in a year (very light drinkers). We report on below how different drinking

patterns affected the performance of individual questions, under the relevant question in the

following sections (section 4.2‐4.8).

Show card did not work for cultural reasons

The show card did not work well in testing in England. Universally respondents who were not in

managerial/professional occupations did not understand the show card and or could not see the

point of it.

Universally respondents instinctive understanding of a ‘drink’ on reading the question was what

they actually drank, so one glass of wine of one drink (regardless of what size it was). Similarly,

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one pint was considered one drink, in the same way half a pint was one drink but at no point

were drinks converted into units (as the question intends). One respondent described buying a

round of drinks, and that contains whatever drinks people are having.

“a glassful …that could be a glass of wine or a pint of beer, and they may have

varying units, varying alcohol content etc. I still took them to be one particular

drink.” (Managerial and professional response after been asked about the show

card (Male, 29))

Respondents who retained this understanding (non managerial/professional respondents) on

the whole found the questions in this section relatively easy to answer unless they fell in the

group of a non drinker a very light drinker, and it was the lack of appropriate answer options

rather than their understanding, which was the problem because for them their understanding

of drink happened to coincide with units, being such a small amount of alcohol consumed in the

year or nothing consumed.

Among the managerial and professional respondents, there was a group who did understand the

show card; even though it took some time to make the connections.

However, not all the managerial and professional respondents referred to the show card when

answering the question, because they did not read the instruction.

There were three reactions to the card when it was understood. These were those who:

1. didn’t mind it, because they could understand it;

2. did not like it because it doubles how much the respondent was drinking; and,

3. those who felt that it made AL.1 more difficult.

“There is a lot of information…..this is complicated now” (26 Female

Managerial/Professional who answered AL 1.a correctly using the card).

The implication of the second reaction (listed above) was that testing found that respondents

may not be quite truthful, including rounding answers down even if they would answer truthfully

if simply asked how many drinks they drank.

There were respondents who spontaneously referred to units when referring to the show card,

but not all felt knowledgeable about units. So although changing drinks to units on the show

card may help the measurement aims of the questions in this section working as intended, it will

only go so far because there will be a group of respondents who will not understand the

connection between drinks and units on the show card and also a group who will not like to

answer that they drink more in unit terms (which feels less when thinking in terms of drinks) and

then deciding to under‐report.

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In testing, a respondent used the show card but could not see small glass of wine so only

reported the medium glass of wine. There is always the risk that respondents rather than

understanding the show card use it literally, like focusing on the examples. This answer strategy

would result in under‐recording of alcohol consumption.

In the UK context, this approach of linking drink to unit has not worked well. Although

understood by managers/professional the question needs to work for the population as a whole

to prevent measurement bias. This suggests that another approach is needed in the UK to

measure alcohol consumption, because for English respondents this approach is challenging

their cultural understanding of what a drink is.

Impact of not understanding the show card

We would recommend that an approach such as the approach taken by the Health Survey and

Social Care Survey for England (HSE) could be adopted, as it could work in all cultural/nation

contexts. This survey starts by identifying if the respondent drinks at all, what alcoholic drinks

the respondent drinks, and then systematically asks about each type of drink over the last 7

days, covering overall prevalence, volume of consumption and frequency of consumption. This

approach elicits units consumed however the respondent is not responsible for converting the

alcoholic drinks into units (this is done as part of the post‐data coding). This is the only approach

we can suggest which will prevent the systematic measurement bias in asking these current

questions in the UK and whilst the approach is lengthily, as it walks respondents through all kinds

of drinks and collects the necessary detail, it has been used on the HSE for some years now and

feedback suggests that it is successful. The current questions will result in serious under‐

estimation of alcoholic consumption in the UK especially amongst non‐managerial professional

class – who are a vulnerable population for health related problems associated with alcohol

consumption in the UK. If the questions remain unchanged, it would be incorrect to report on

units consumed as we know (from this testing) that respondents don’t think it terms of number

of units when being asked about the number of drinks they have consumed.

For transparency, we provide question‐by‐question findings on how the question has worked.

We also provide in appendix C the HSE questions used in 2006.

Recommendation

The inherent difficulty that respondents need to transpose how much they drink into units is

not working well, so we would recommend HSE’s approach of asking about alcohol

consumption. We provide in Appendix C a copy of the questions used in this survey.

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2.1.4.1. QAL.1 To measure how frequently alcoholic drinks have been consumed in the last 12 months

AL.1. During the past 12 months, how often have you had an alcoholic drink of any kind?

Every day or almost every day ............................................. 1

5 ‐ 6 days a week ................................................................... 2

3 ‐ 4 days a week ................................................................... 3

1 ‐ 2 days a week ................................................................... 4

2 ‐ 3 days in a month ............................................................. 5

Once a month........................................................................ 6

Once every 2 months ............................................................ 7

Once or twice in the past 12 months .................................... 8

Not in the past 12 months, but I drank formerly .................. 9

end of interview

Never more than a few sips or trials in my whole life........... 10

end of interview

Findings

Generally, respondents said this question was easy to answer for those who drank some amount

of alcohol in the last 12 months. Respondents had an answer in mind, and read down until they

matched their answer. On the face of it, it appears that this question has worked well, however

on the whole respondents answered this question just thinking about how many glasses of

alcohol beverage they drank. And it is with this understanding that respondents found this

question easy to answer.

“Don’t have to think too much for that…. That was easy” (Female, 75, light drinker)

So, if the intention of AL.1 is to simply differentiate those who have consumed any alcohol

(regardless of number of units) in the last 12 months from those who have not, it worked as

intended.

Never drank alcohol and gave up alcohol

However, respondents who had never drunk alcohol in their entire life or viewed themselves as

someone who abstains from alcohol re‐read the question several times and/or read the next

question(s) to find out how to answer the question. This current question does not provide an

option for respondents who have never touched any alcohol, not even a few sips (as option 10

‘Never more than a few sips or trials in my whole life’ infers that the person has had a few sips).

There is a cultural assumption in the wording that everyone would have tried alcohol. In testing,

we had one respondent who had never drunk any amount of alcohol in her life, and she was

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proud of this, but felt the best option for her was to select code 10. The question would benefit

from amending the wording of code 10 to accommodate respondents with this drinking pattern

or providing an additional code for never drank alcohol if there is an interest to measuring

specifically those who have had a few sips or tried it but did not continue drinking alcohol

thereafter. In the UK, which is very multicultural, this amendment would be advisable as there

faiths/religious/cultural beliefs that discourage drinking alcohol all together.

In testing, code 9 was not considered satisfactory for respondents who have given up drinking

and have not taken alcohol for a number of years, although they did universally answer this

question correctly, albeit hesitantly. If the purpose of this item is to route these respondents

away from the rest of the alcohol consumptions questions, then a code could be developed

which would cater for respondents who never drank alcohol and have given up such as Not

Applicable – I don’t drink alcohol at all. Interviewers raised an important point that the word

‘formerly’, in code 9, could be misunderstood to be ‘formally’, i.e. about drinking on formal

occasions (and not as it was intended to be about the past / previous / former times).

Recommendation

Consider changing code 9 to “Not in the last 12 months as I no longer drink alcohol.“

Consider adding a code 11: “I have never drunk alcohol in my whole life.”

Or if it is not necessary to captured separate data on a former drinkers and non drinkers then

consider replacing code 9 and 10 with „Not Applicable – I don’t drink alcohol at all”

72

2.1.4.2. QAL.1a: To measure how many alcoholic drinks are drunk on a typical day

AL.1a. How many drinks containing alcohol do you have on a typical day when you are drinking?

Refer to the show card

24 or more drinks ................................................................. 1

17‐23 drinks.......................................................................... 2

10‐16 drinks.......................................................................... 3

7‐9 drinks.............................................................................. 4

6 drinks ................................................................................. 5

4 ‐ 5 drinks ............................................................................ 6

3 drinks ................................................................................. 7

2 drinks ................................................................................. 8

1 drink................................................................................... 9

Findings

Overall respondents said they found this question easy to answer. However, as reported earlier

apart from managerial/professionals they all answered the question wrongly because they were

not thinking of drinks in the intended way (i.e. reporting units consumed). Even respondents

within the managerial/ professional group answered the question incorrectly because they did

not see the instruction to refer to the show card or on an occasion were adamant that they had x

pints which is x drinks even after referring to the show card. (See overall findings for further

discussion). We report on additional findings below.

Answering honestly

Testing revealed that offering 24 or more drinks actually assisted respondents who were not

heavy drinkers to be honest because they were surprised by this amount even if they felt a bit

sensitive initially by the question. However, respondents were thinking of 24 glasses of an

alcohol beverage and not 24 units of alcohol.

Testing showed that heavy drinkers could find this question sensitive to answer. This was shown

by joking if one had to answer the question or talking in the third person that people would be

uncomfortable answering this question. This sensitivity was based on an understanding of 24

glasses of an alcoholic drink and not units (which would incidentally could be less units than

glasses).

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“People never give the correct answer; they know that they are drinking more than

they’re supposed to be, so they tend to count‐down a bit.“ (Male, 60+, Heavy

drinker, managerial and professional).

Understanding of a typical day

Respondents generally answered the question thinking about their usual day.

Findings revealed that respondents could have a number of typical drinking patterns, for

example, a regular pattern on holiday, or on a night out compared to a night in. In addition,

respondents can have different patterns at different times of the year, for example they might

have one drink on Christmas day or drink more during the five colder and darker months in

England. There could be seasonality effect on the data collected, with less drinks being recorded

in summer for example. There was one occasion in testing, when a respondent decided to

answer thinking about a night out, although she felt this could be a false representation. This

variation would affect the accuracy of the data collected because it would not be possible to

know which ‘typical day’ was thought about. The Health Survey for England gets around this

difficulty by asking respondents to think about the last seven days, although of course the last

seven days may not be typical.

Less than one drink

Respondents who have less than one glass of an alcohol drink in a year struggled throughout the

questionnaire, either writing in none at AL.3 and AL.5 or selecting one because that was the

closest to their answer, which was available. A filter needs to be put into place so that very

occasional drinkers are not inappropriately asked about number of drinks they have ‘on a typical

day when they are drinking’. See suggestions below in recommendations box.

74

Recommendation

It makes little sense to ask very occasional drinkers (i.e. those who have had one or two alcoholic

drinks on one occasion in the past 12 months) this and the following questions as the questions

refer to ‘typical days’ ‘when drinking’ and ask about drinking patterns on weekdays and on

weekends. We recognise that there are options at AL.2 and AL.4 which could be chosen by a very

occasional drinker; however AL.1a seems like a strange question to ask someone who drinks very

rarely (i.e. someone who might have had a glass of champagne to celebrate something that

occurred in the last year but otherwise avoids alcohol). Consideration needs to be given to this,

and whether very occasional drinkers (that could be identified if they choose option 8 at AL.1)

should even be asked any of the subsequent questions in this module.

Consider adding another option at AL.1a 'less than one drink and the route these respondents to

the next section in the questionnaire, this approach is adopted in HSE.

Below we have pasted the relevant CAPI copy of the 2006 HSE instrument.

Drink I am now going to ask you a few questions about what you drink ‐ that is if you drink. Do you ever drink alcohol nowadays including drinks you brew or make at home? 1 Yes 2 No IF Drink = No THEN DrinkAny Could I just check, does that mean you never have an alcoholic drink nowadays, or do you have an alcoholic drink very occasionally, perhaps for medicinal purposes or on special occasions like Christmas and New Year? 1 Very occasionally 2 Never ENDIF IF (Drink = Yes) OR (DrinkAny = very occasionally) THEN DrinkOft SHOW CARD Y Thinking now about all kinds of drinks, how often have you had an alcoholic drink of any kind during the last 12 months? 1 Almost every day 2 Five or six days a week 3 Three or four days a week 4 Once or twice a week 5 Once or twice a month 6 Once every couple of months 7 Once or twice a year 8 Not at all in the last 12 months IF DrinkOft <> Not at all in the last 12 months THEN DrinkL7 You have told me what you have drunk over the last 12 months, but we know that what people drink can vary a lot from week to week, so I'd like to ask you a few questions about last week. Did you have an alcoholic drink in the seven days ending yesterday? 1 Yes 2 No

If Drink L7 – End

Source:http://surveynet.ac.uk/index/_search1099%5cHse%5c5089_2006_quest_capi_indiv.pdf#search="survey

(title:health survey england)"

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2.1.4.3. QAL.2 To measure on how many weekdays the respondent drinks alcohol.

AL.2. During the weekdays (Monday through Thursday), on how many of these 4 days do you usually

drink alcohol?

On the 4 week days ....................................... 1

On 3 week days ............................................. 2

On 2 week days ............................................. 3

On 1 week day............................................... 4

Not on week days.......................................... 5

go to AL.4

Findings

Overall, this question worked as intended, although occasionally respondents did not see the routing

instructions (go to AL.4)

Understanding of weekdays as Monday to Thursday

Testing showed that respondents either accepted that they should think about weekdays as

Monday to Thursday or read the question and still answered including Friday. The latter

situation was observed on an occasion and the respondent was 85 years old. This respondent

did not include Fridays when he answered AL.4 or AL.5. So on the whole, defining weekdays as

‘Monday through Thursday’ in a question about drinking behaviour seemed quite logical to

respondents.

One of the interviewers pointed out that ‘Monday through Thursday’ was an American way of

stating a period of time. Instead, this interviewer thought the question could benefit from simply

stating ‘Monday to Thursday’, incidentally AL.3 does this though AL.4 refers to ‘from Friday to

Sunday’. It should be noted here however that the so called American language caused no

difficulties for respondents, none of whom commented on this.

Thought the question was asking how many drinks on any one weekday

There was one respondent who selected ‘on 1 week day’ to indicate she has one drink on every

weekday, and the respondent corrected her misunderstanding at AL.4 which is a similar

question.

Variations in patterns each week

This question was considered difficult if patterns varied as the respondent had to consider what

a usual pattern would be.

In addition, it was pointed out that working weeks can vary so Friday night may not mark the

start of the weekend.

76

Recommendation

This question worked well on the whole, so if the module is being retained consider keeping this

without modification.

If the question is asked in a self‐completion, consider applying visual design principles to help

respondents navigate through the questionnaire2.

The words use to state the periods of time (from when to when) should be consistently referred

to in all questions. For example, either use:

1. (Monday to Thursday) / (Friday to Sunday),

2. (Monday through Thursday) / (Friday through Sunday), or

3. (from Monday to Thursday) / (From Friday to Sunday).

Our preference would probably be the first option above.

2 Christian Lea., Don A Dillman and Jolene Symth (2007) Helping Respondents Get it Right the First Time: The

Influence of Words, Symbols, and Graphics in Web Surveys in Public Opinion Quarterly Vol. 7 No 1 Spring 2007

p113‐125 http://poq.oxfordjournals.org/cgi/reprint/nfl039v3

77

2.1.4.4. QAL.3 To measure how much alcohol the respondent drinks on one week day.

AL.3. How many drinks containing alcohol do you usually have on one of those weekdays (Monday to

Thursday) when you drink alcohol?


24 or more drinks .......................................... 1

17‐23 drinks................................................... 2

10‐16 drinks................................................... 3

7‐9 drinks....................................................... 4

6 drinks .......................................................... 5

4 ‐ 5 drinks ..................................................... 6

3 drinks .......................................................... 7

2 drinks .......................................................... 8

1 drink............................................................ 9

Findings

Testing revealed that respondents found this question easy to answer however on the whole

respondents did not answer this question correctly because they understood drinks as a

‘glassful’ and not in terms of unit (the exception being the mangers/professionals who

understood the show card correctly at AL.1a). Therefore, there would be a systematic bias in the

data collected if this question is used in the UK.

On the whole, respondents did not see the routing instruction at AL.2 so went to AL.3. When

this happened respondents either:

o Wrote none or NA on the self completion; or

o Thought it was odd to be asked but then thought if someone came round they may have

a pint so answered one.

If the second strategy occurs this would result in over‐reporting at this question.

Recommendation

The inherent difficulty that respondents need to transpose how much they drink into units is not

working well, hence our suggestion in section 4.1 to adopt HSE’s approach of asking about alcohol

consumption questions.

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2.1.4.5. QAL.4 To measure on how many weekend days the respondent drinks alcohol.

AL.4. During the weekends (from Friday to Sunday), on how many of these 3 days do you usually drink

alcohol?

On the 3 weekend days................................. 1

On 2 weekend days ....................................... 2

On 1 weekend day......................................... 3

Not on weekends .......................................... 4 Go to AL.6

Findings

Respondents found this question easy to answer. On the whole, respondents did think about a

three‐day weekend when they answered the question, because they could see the logic that

Friday was the start of the weekend. The very light drinkers, less than one drink in a year,

answered ‘not on weekends’. The same respondent who included Friday at AL.3 excluded it at

this question.

Recommendation

This question worked well overall, so if the module is being retained consider keeping this

question without modification.

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2.1.4.6. QAL.5 To measure how much alcohol the respondent drinks on one weekend day

AL.5. How many drinks containing alcohol do you usually have on one of those weekend days (Friday

to Sunday) when you drink alcohol?


24 or more drinks ............................................... 1

17‐23 drinks........................................................ 2

10‐16 drinks........................................................ 3

7‐9 drinks............................................................ 4

6 drinks ............................................................... 5

4‐5 drinks............................................................ 6

3 drinks ............................................................... 7

2 drinks ............................................................... 8

1 drink................................................................. 9

Findings

This question suffered from the same problem reported in section 4.1 ‘Show card did not work for

cultural reasons and seen at AL.3, so respondents retained their wrong but consistent practice of

reporting how many glasses of drinks they drink rather than units, apart from the select group of

managerial/professional respondents who understood the show card. There was one respondent who by

this stage was starting to understand the show card but did not like to think of himself drinking four

drinks (or four units), which would take him into the 4‐5 category so decided to stick with reporting the

two pints he had had. So there is not only lack of understanding, there is also the sensitivity around the

realisation of how much they drink which will result in under‐reporting. The HSE approach takes a gentle

approach of collecting the necessary information to calculate the units without leaving this cognitive

process to the respondents. We present addition findings found from cognitively testing this question

below.

Very light drinkers and Heavy Drinkers

Respondents who hardly drink wrote on the self‐completion none and one respondent articulated that

“it is so hard to answer these questions” (Female, 67, intermediate occupation) reiterating the need to

identify these respondents at AL.1 and route them to the next section in the EHIS.

The heavy drinker under‐reported how much he drank so it would look better. There is a risk of social

desirability effects affecting answers, and more so in an interviewer administered instrument. Even if

the alcohol module is asked as a self‐completion to moderate this effect, the interviewer could still be in

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the room as the other modules will be administered in CAPI (ideally) so this will only go some way from

removing this sensitivity. Although HSE is designed to be asked in CAPI, its indirect approach does

address to some extent the social desirability effect that we have found in testing.

Difficulty of recording how much alcohol is consumed on the weekends

It was clear to respondents why the questions asked about week days and weekend days. It was well

recognised that peoples’ drinking patterns vary between these two time periods, even amongst very

light drinkers. Testing this question revealed that this question is harder than AL.3 because respondents

patterns vary on the weekend depending on what they are doing. This lead respondents to make

judgement, with respondents on the whole thinking about how much they drink on average.

Respondents thought about the different occasions and averaged it.

Recommendation

The inherent difficulty that respondents need to transpose how much they drink into the

‘drinks’ on the show card (i.e. units) is not working well, hence our suggestion in section 4.1 to

adopt HSE’s approach.

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2.1.4.7. QAL.6 To measure how frequently the respondent exceeded 6 or more drinks on an occasion.

AL.6. During the past 12 months, how often did you have 6 or more drinks on one occasion?

Every day or almost every day .......................... 1

5 ‐ 6 days a week ................................................ 2

3 ‐ 4 days a week ................................................ 3

1 ‐ 2 days a week ................................................ 4

2 ‐ 3 days in a month .......................................... 5

Once a month..................................................... 6

Once every 2 months ......................................... 7

Once or twice in the past 12 months ................. 8

Not in the past 12 months.................................. 9

Never in my whole life........................................ 10

Findings

On the whole respondents did not understand this question correctly. They understood 6 or

more drinks to mean six glasses of an alcoholic beverage of any kind. With this understanding,

respondents were able to answer the question quickly and easily generally. We present below

the two difficulties, which were revealed in testing.

An interviewer pointed out that the question wording misses the word ‘alcohol’ and does not

make any reference to ‘alcoholic drinks’ in the answer categories either. Although none of the

respondents in our sample picked up on this, and this was probably a result of being primed into

thinking about alcohol consumption from the previous questions, there is still a risk that it could

be answered with any drink (including exclusively soft drinks) _in mind.

Two drinking patterns

A respondent in testing was confused how to answer the question because he had two different

drinking patters. This confused him because on holiday his pattern is to drink more than 6 drinks

every day (based on the understanding of 6 glasses of some alcoholic beverage). However, his

regular pattern for the rest of the year is not to drink alcohol on weekdays (Monday‐Thursday)

and to have two drinks on the weekend. He did not want to select code 1 because it is not what

he does on 365 days (implied by the words ‘every day or almost every day’). The respondent

could not find a suitable answer option, so decided not to answer the question. This highlights

that this question could be vulnerable to unit non‐responses.

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Heavy drinkers

Testing found that heavy drinkers could find this question repetitive, although answerable.

Although not found in this testing, this question could be sensitive for heavy drinkers who are

uncomfortable about how much they drink, which could result in them under‐reporting at this

question.

Occasions

There was one respondent who selected code 8 because he understood the question on first

reading as ‘during the past 12 months how often have you had an occasion where you had an

alcoholic drink’. The respondent thought of his great grandchildren naming ceremony. During

the probing, the respondent realised his error.

Recommendation

The inherent difficulty that respondents need to transpose how much they drink into drinks

(units) is not working well, hence our suggestion in section 4.1 to adopt HSE’s approach of

asking about alcohol consumption questions.

The answer options at this question do not match the question. The question asks for the

frequency of 6 or more drinks being consumed on one occasion over the past 12 months,

however the answer options imply regularity of such behaviour (e.g. generally).

We suspect that the problems experienced by respondents in the UK sample were, in part,

caused by the confusing nature of this question. The respondent who drank more than 6

drinks everyday for a fortnight, on his summer holiday, for example found this impossible to

answer as the options he had to choose from did not present him with a means of answering.

If this question is retained, we suggest that the answer categories fit with the question or that

a different question (which still manages to capture the frequency of when 6 or more drinks

are consumed) is instead asked.

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2.1.5. Technical Appendix

This appendix describes in further detail the design and conduct of the cognitive testing.

The Questionnaire Development and Testing (QDT) Hub at the National Centre for Social Research

(NatCen) has been commissioned by the Robert Koch Institut to test questions in the European Health

Interview Survey (EHIS) on mental health, physical activity and alcohol consumption in England. The

study is funded by the EHIS Improvement Project. The EHIS is a general health survey conducted

amongst the general adult population (16 and over). The aim of the survey is to collect harmonised

general health data across EU member and candidate countries. The survey is uni‐modal although the

preferred method for most sections is computer assisted personal interview survey (CAPI). The

exception is the alcohol consumption questions, which are designed to be used in a self‐completion

questionnaire (ideally). It is anticipated that the second wave of the survey will be conducted in

participating countries in 2014.

The aim of this study is to improve the questions on mental health, physical activity and alcohol

consumption in the European Health Interview Survey, which were found to be problematic during the

first EHIS wave before their implementation in the second wave. In order to achieve this, the Robert

Koch Institut is coordinating a cross‐national project to test questions in these three areas in four

European countries. Our collaborating partners on this study are Robert Koch Institute, Germany

(coordinator), the Scientific Institute of Public Health, Belgium (IPH) and the National Institute for Health

Development, Estonia (NIHD). Each collaborating partner is in charge of improving one section of the

instrument, which was identified as problematic in wave one. Questions on mental health are the

responsibility of our German partner, the physical activity questions the responsibility of our Estonian

partner and the alcohol consumption questions the responsibility of our Belgium partner. A revised set

of questions in each of the three areas, physical activity, alcohol consumption and mental health, were

provided to us for cognitive testing. In addition, we were also provided with the probe sheet to use in

testing (in appendix D).

The primary objective of the cognitive testing was to test how the questions, worked with different

segments of the survey population. As part of this, the testing protocols were designed to explore:

• Respondents’ understanding of the questions;

• Respondents’ ability to answer the questions;

• Issues of sensitivity; and,

• How the questions work when administered.

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The main aim of cognitive testing was to look at the cognitive answer process to explore how the

questions are understood and examine the judgement, recall and response processes respondents used

in formulating their answers in England. This is important because the questions will be asked of the

general population in different countries and need to work in a consistent way with respondents taking

into consideration country specific and cultural variations. Testing allows us to evaluate how the

questions work and to suggest revisions informed by evidence collected in the cognitive interviews.

Were appropriate revisions were suggested to improve how the questions work. Revisions were

suggested to improve how the questions could work in the cross‐national survey as a whole as well as

well as in the English context. Suggestions were made in the context that the data collected should be

comparable in all survey participating countries.

2.1.5.1. Cognitive Methods

The cognitive interviews used methods derived from cognitive psychology that enable researchers to

examine (in detail) the question and answer process. This form of testing helps to identify problems with

questions and illuminate possible solutions to these issues. Cognitive interviewing techniques focus on

four main processes:

how respondents understand and interpret questions;

how respondents recall the information required to answer questions;

the judgements respondents make as to what information to use when formulating their

answers; and

How respondents respond to the questions.

The two most frequently used cognitive interviewing techniques are think aloud and probing. In this

study, both techniques were used. In the think aloud technique, respondents are asked to say aloud

what they are thinking as they go about completing the task of answering the question. For example,

respondents are encouraged to articulate what information they are drawing on to complete the task,

what decisions they are making about what information to draw on and how they are deciding their

answer to the question. In the probing technique, the interviewer asks specific questions, which provide

information on how respondents interpret question wording and what processes they go through when

deciding how to answer. These ‘probes’ were scripted to provide a consistency between interviewers

and between partners to ensure the key areas were explored. As cognitive interviews are qualitative in

nature, interviewers also had the freedom to probe on aspects that they considered were unique to the

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respondent and to explore issues that had not been foreseen in advance. A copy of the test

questionnaire and probes used can be found in Appendix D.

2.1.5.2. Study Design

The survey aims to measure different aspects of general health. The aim of this testing, was to test

questions specifically on mental health, physical health and alcohol consumption in England. The QDT

Hub was asked to test cognitively the questions. The mental health and physical health questions we

were given to test were designed to be administered in a CAPI interview. The alcohol questions were

tested as a self‐completion instrument. The interview was designed so that the mental health and

physical health questions were tested first. Respondents were then asked to fill in the self‐completion

and think aloud while doing so. Interviewers used probing techniques to explore how the questions in

the three sections worked.

2.1.5.3. Sample and Recruitment

Cognitive interviews are qualitative in nature so the samples are purposive and designed to reflect the

range and diversity of the population of interest, rather than to be statistically representative. As this

survey is a general population survey, the sample was designed to include a range of adults to test fully

the questions.

To identify people with particular characteristics to take part in the cognitive interviews former

respondents from the 2010 NatCen Omnibus Survey (known to respondents as the NatCen Topical Issues

study) were re‐contacted. All respondents recruited had previously stated that they would be happy to

be contacted again by NatCen for further research. The advantages of using this approach were the

survey data could be used to identify eligible respondents in the interviewer areas. An opt out exercise

was then conducted. This involved prospective respondents being sent an advance letter, which

explained the study and which also, asked them to contact the research team if they did not want to take

part in the research. This was important because respondents who had previously agreed may not have

been in a position to take part now and may not have wanted to take part in a cognitive interview

exploring general health questions. Potential respondents who did not opt out were contacted by

NatCen’s own specialist Telephone Unit (TU), who explained the study, requested informed consent to

recruit the individual, and then screen the individual in and confirmed their contact details. All recruits

were sent a confirmation letter which provided further information about the study including the named

86

interviewer who would be in touch, if a definite respondent, and may be in touch, if a reserve. All

respondents were provided with contact details of a researcher whom they could contact if they had any

queries or concerns about the study. Interviewers then contacted the respondent, arranged a time, and

place convenient for them to take part in the research.

Fifteen face‐to‐face interviews were conducted in England. To ensure we recruited a range of people to

test the questions on, we provided the TU with a screening in questionnaire and quotas. The screening

in exercise only took place once the respondent had been told about the study and they had consented

to take part in the study. Suitable respondents were those who fitted our quotas to reflect the range

and diversity of the population of interest in the interviewer areas.

Table 8: The mix between men and women we wanted to achieve in this study

Men

(Total 8)

Women

(Total 7)

18‐30 31‐59 60+ 18‐30 31‐59 60+

2 2 4 2 2 3

There were also several other respondent characteristics that we wanted to include in our 15 interviews,

which were not mutually exclusive. These were:

At least one respondent who does light exercise regularly,

At least one respondent who does moderate exercise regularly,

At least one respondent who does vigorous exercise regularly,

At least two respondents who do not drink alcohol,

At least two respondents who are light drinkers,

At least two respondents who are moderate drinkers,

At least two respondents who are heavy drinkers,

At least three respondents who have a long standing illnesses, and

A mix of respondents in different occupations high and low levels of education.

The areas in which interviews took place in England were:

Lancashire (North West England);

Nottinghamshire (Midlands); and

Greater London area.

Table 1 on page 44 shows the characteristics of respondents interviewed as part of this study.

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All the interviews were conducted face‐to‐face and each interview lasted approximately one hour.

Interviews were digitally recorded with respondents’ consent. Respondents were given a thank you

letter and a £20 high street voucher as a token of our appreciation for taking part in the interview.

Recruitment took place in December 2010 and in January 2011 and interviews took place in January and

February 2011.

2.1.5.4. Analysis

After each interview, the cognitive interviewers made detailed notes on their cognitive interview using a

notes template, with reference to the recording of the interview. These interviewer notes, recordings of

the interviews and the completed test questionnaires were reviewed as part of the analytical process.

To provide consistency between the country partners in their analytical approach all the interviewers

used the same notes template, which was translated into their respective languages.

Notes were analysed using a content analysis approach in Excel. The framework set up in Excel was

based on Framework, an analytic tool developed by the former Qualitative Research Unit at NatCen. The

same analytical Excel framework was used by all the research partners to allow for ease in drawing out

conclusions. A matrix was set up, which listed the respective areas of the questionnaire we tested across

the page and cases down the page. The matrix included a summary of the characteristics of respondents:

such as their gender, age, exercise behaviour and drinking behaviour. Under each question, a summary

was made of each respondent’s understanding of the question, recall strategies used, judgements made

in formulating an answer and the answer provided. Any other problems were also recorded. Thus, data

could be read horizontally as a complete case record for an individual, or vertically by question, looking

across all cases. Once the matrix was completed, the data was reviewed. In reviewing the matrix, the full

range of problems with the each test question was explored.

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2.1.6. The Tested Physical Health Questions

NHIS questions which were tested

{READ TO ALL} In the following, there are two sections on physical activity, one on leisure‐time physical activity and one on total physical activity. One of the aims of this interview is to find out which section works better. Therefore, some of the questions might seem repetitive. We are now starting with section A about your physical activities in your leisure time and I will let you know when we move to section B. {READ OUT TO ALL} The next questions are about physical activities (exercise, sports, physically active hobbies...) that you may do in your LEISURE time. {ASK ALL} Q3: How often do you do VIGOROUS leisure‐time physical activities for AT LEAST 10 MINUTES that cause HEAVY sweating or LARGE increases in breathing or heart rate? INTERVIEWER: Responses can be offered in terms of any time unit the respondent volunteers (times per day, per week, per month, or per year) {READ IF NECESSARY} How many times per day, per week, per month, or per year do you do these activities?

Never

1‐995 time(s) ____

Unable to do this type activity

Refused

Don't know

INTERVIEWER: Enter time period for vigorous leisure‐time physical activities.

Never Go to Q4

Per day ASK Q3a

Per week ASK Q3a

Per month ASK Q3a

Per year ASK Q3a

Unable to do this activity Go to Q4

Refused Go to Q4

Don't know Go to Q4

{ASK ALL} Q3a: About how long do you do these vigorous leisure‐time physical activities each time?

INTERVIEWER: Enter number for length of vigorous leisure‐time physical activities.

1‐995

Refused Go to Q4

Don't know Go to Q4

89

INTERVIEWER: Enter time period for length of vigorous leisure‐time physical activities. RECORD RESPONDENT'S ANSWER IN EITHER HOURS OR MINUTES

Minutes Go to Q4

Hours Go to Q4

Refused Go to Q4

Don't know Go to Q4

{ASK ALL} Q4: How often do you do LIGHT OR MODERATE LEISURE‐TIME physical activities for AT LEAST 10 MINUTES that cause ONLY LIGHT sweating or a SLIGHT to MODERATE increase in breathing or heart rate? {READ IF NECESSARY} How many times per day, per week, per month, or per year do you do these activities?

Never

1‐995 time(s) ____


Refused

Don't know

INTERVIEWER: Enter time period for light or moderate leisure‐time physical activities.

Never Go to Q5

Per day ASK Q4a

Per week ASK Q4a

Per month ASK Q4a

Per year ASK Q4a


Refused Go to Q5

Don't know Go to Q5

{ASK ALL} Q4a: About how long do you do these light or moderate leisure‐time physical activities each time?


1‐995 ____

Refused Go to Q5

Don't know Go to Q5

INTERVIEWER: Enter time period for length of vigorous leisure‐time physical activities. RECORD RESPONDENT'S ANSWER IN EITHER HOURS OR MINUTES

Minutes Go to Q5

Hours Go to Q5

Refused Go to Q5

Don't know Go to Q5

{ASK ALL} Q5: How often do you do LEISURE‐TIME physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.)

90

{READ IF NECESSARY} How many times per day, per week, per month, or per year do you do these activities?

Never

1‐995 time(s) ____


Refused

Don't know

INTERVIEWER: Enter time period for leisure‐time spent on muscle STRENGHENING physical activities.

Never Go to Q6

Per day Go to Q6

Per week Go to Q6

Per month Go to Q6

Per year Go to Q6


Refused Go to Q6

Don't know Go to Q6

IPAQ questions which were tested

{READ TO ALL} We have now finished the section A on leisure time physical activity and will move to section B on total physical activity. {READ OUT TO ALL}

I am going to ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.

Now, think about all the vigorous activities which take hard physical effort that you did in the last 7 days. Vigorous activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics, or fast bicycling. Think only about those physical activities that you did for at least 10 minutes at a time. Q6: During the last 7 days, on how many days did you do vigorous physical activities?

Days per week __ Go to Q7 if zero OTHERWISE ASK Q6a

Don't Know/Not Sure Go to Q7

Refused Go to Q7

[Interviewer clarification: Think only about those physical activities that you do for at least 10 minutes at a time.]

Q6a: How much time did you usually spend doing vigorous physical activities on one of those days?

Hours per day __ __ Go to Q7

Minutes per day __ __ __ Go to Q7


Refused Go to Q7

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[Interviewer clarification: Think only about those physical activities you do for at least 10 minutes at a time.]

{READ OUT TO ALL} Now think about activities which take moderate physical effort that you did in the last 7 days.

Moderate physical activities make you breathe somewhat harder than normal and may include

carrying light loads, bicycling at a regular pace, or doubles tennis. Do not include walking. Again,

think about only those physical activities that you did for at least 10 minutes at a time.

Q7: During the last 7 days, on how many days did you do moderate physical activities?



Refused Go to Q8

[Interviewer clarification: Think only about those physical activities that you do for at least 10 minutes at a time]

Q7a: How much time did you usually spend doing moderate physical activities on one of those days?




Refused Go to Q8

[Interviewer clarification: Think only about those physical activities that you do for at least 10 minutes at a time.]

{READ OUT TO ALL} Now think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

Q8: During the last 7 days, on how many days did you walk for at least 10 minutes at a time?



Refused Go to Q9

[Interviewer clarification: Think only about the walking that you do for at least 10 minutes at a time.]

Q8a: How much time did you usually spend walking on one of those days?




Refused Go to Q9

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{READ OUT TO ALL} Now think about the time you spent sitting on week days during the last 7 days. Include time spent at work, at home, while doing course work, and during leisure time. This may include time spent sitting at a desk, visiting friends, reading or sitting or lying down to watch television.

Q9: During the last 7 days, how much time did you usually spend sitting on a week day?

Hours per day __ __ Go to next part

Minutes per day __ __ __ Go to next part

Don't Know/Not Sure Go to next part

Refused Go to next part

[Interviewer clarification: Include time spent lying down (awake) as well as sitting]

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2.1.7. HSE The Alcohol Consumption Module 2006

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2.2. Report BE (IPH)

WORKPACKAGE 5: COGNITIVE TESTING

GRANT 10501.2009.007– 2009.890

ImpEHIS MII: Evaluation of the Modules for the

European Health Interview Survey (EHIS)

Scientific Institute of Public Health Public Health & Surveillance Surveys, Life styles & Chronic diseases Rue Juliette Wytsmanstraat 14 | 1050 Brussels www.wiv-isp.be

June 2011

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Authors of this report: Lydia Gisle and Hélène Mimilidis Operational Directorate: Surveys, Life styles & Chronic diseases Institute of Public Health, Belgium June 2011 The project is financially supported by: EUROSTAT – 5 Rue Alphonse Weicker L-2721 – Luxembourg

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2.2.1. Methods

This qualitative study comprised a set of 16 face‐to‐face interviews which were carried out in

Belgium among the French speaking community in February 2011, using the methodology of

cognitive testing.

The study was performed as part of the four‐country cross‐national cognitive interview study in the

context of the “Improvement of the EHIS modules project” (ImpEHIS).

The interviews were conducted in Belgium using a translated French version of the standardized

probe document elaborated in January 2011 in coordination with the different partners of the

project (RKI, Germany, and NIHD, Estonia) and the National Center for Social Research (UK).

The sample population was a non‐probability sample of people, all residents of the country and for

which the mother tong is French. The respondents were recruited according to some criteria (gender

and age categories) defined in cooperation with the partners of the project during a coordination

meeting that was held in Berlin in January 2011. Prior to the interview, respondents received

information about the study by telephone. All contacted persons gave their informed consent to

participate during this telephone call. They received a random serial number, starting with the letters

BE (for Belgium) and followed by specification of their gender and age (gender: age, see table

beneath)

Table 9: Characteristics of respondents participating in the cognitive testing study

Age Male Female Total

15 – 20 BE‐05 (M:18)

BE‐16 (M:16)

BE‐06 (F:15) 3

20 – 39 BE‐13 (M:29)

BE‐02 (M:23)

BE‐01 (F:24)

BE‐07 (F:38)

4

(2 males/2 females)

40 – 59 BE‐08 (M:40)

BE‐11 (M:40)

BE‐09 (F:47)

BE‐12 (F:42)

4

(2 males/2 females)

60+

BE‐10 (M:80)

BE‐14 (M:63)

BE‐15 (F:60)

BE‐03 (F:70)

BE‐04 (F:61)

5

(2 males/3 females)

Total 8 males 8 females 16

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Table 10: Two mental health questions tested, Q1 (PHQ‐9) and Q2 (MHI‐5/EVI)

Mental Health:

In the following I will be asking you some questions about your psychological well‐being.

Q 1: Over the last 2 weeks, how often have you been bothered by any of the following problems?


Considering that a particular aim of the EHIS is to explore specific areas of mental health, the

suggestion is to use, in the main stage survey, two sets of questions, simultaneously:

The Patient Health Questionnaire (PHQ‐9), a tool specific to “depression” that simply scores each

of the 9 DSM‐IV criteria3, with a four‐point answer scale, referring to a two‐week reference

period.

Another set made up of the Mental Health Index‐5 measuring “psychological distress”, and the

Energy and Vitality Index, focused on “positive mental health” (MHI‐5/EVI). This set is thus also

composed of nine items, all of which are drawn from the Short Form 36 (SF‐36), with a five‐point

Likert response scale, asking for a four‐week reference period.

In this frame, the aims of cognitive testing as for the mental health section were established as

followed (main questions):

Did the respondent feel that the questions were overlapping? Is there an overlap of the

statements within one question?

Do respondents understand the wording of specific questions?

Was there any question that made respondents feel uncomfortable?

How did respondents use the answer scale? Did they find it easy to place themselves on it, and

differentiate between points?

How do respondents decide on their answer?

Table 11: Two principle aims in testing (M. Balarajan & M. Gray, National Center for Social Research, 2011)

To find out if it would be possible for both questions to be used in the main stage of the survey,

or if they overlapped, to an extent which would prevent the two questions to be used; and

To find out if the individual items in Q1 and Q2 worked as intended.

In section 2.1 we explore the first principle aim (see Table 2). That is, to ascertain whether the two

questionnaires are not overlapping to such a degree that would prevent their simultaneous use in

the main stage survey. A series of other findings are also pointed out (the use of specific time

periods, or the use of particular answer scales…). These “items” are presented in the same section,

under various subheadings, considering the impact they had on the way both questionnaires were

dealt with and answered.

3 http://www.phqscreeners.com/overview.aspx?Screener=02_PHQ-9

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Section 2.3 and 2.4 examine more closely the second principle aim. That is, to establish, respectively,

whether the individual items in Q1 (PHQ‐9) and Q2 (MHI‐5/EVI) worked as intended in the Belgian

context (for the French‐speaking). More attention is paid here to respondents’ understanding of the

questions, than to respondents’ ability to answer the questions (retrieval, judgment, and answer

strategies), or to issues of sensitivity (see section 2.1).

2.2.2.1. Overall Findings for Q1 (PHQ‐9) and Q2 (MHI‐5/EVI)

How were these questions for respondents?

Overall, a great majority of respondents found the questions (for both sets) easy to answer.

Nevertheless, to the question of “which set was easier to answer than the other”, either respondents

could not position themselves in favour of one or the other alternative (both questions were seen as

easy to answer) or they simply argued that Q2 was globally easier to answer. The reasons put

forward are various and refer to the pitfalls discussed later:

Less ambiguity: there is only one concept per question in Q2.

In Q1, the internal structure of the different items was perceived as being quite complex,

especially because of opposite statements (“poor appetite or overeating”) or lists of statements

(“feeling down, depressed or hopeless”). In other words, testing revealed that the “syntax” in

Q2 is clear and less disturbing for respondents.

Also, the concepts in Q2 are seen as more straightforward. Indeed, it was difficult for some

respondents to grasp the meaning of some items in Q1 such as “moving or speaking so slowly

that other people could have noticed” or having “little interest or pleasure in doing things”.

Overall, respondents had “to think more” for Q1.

Better answer categories: the answer options proposed in Q2 were globally perceived as more

exhaustive, straightforward, and were thus easier to use.

Answer categories in Q2 are more exhaustive than the ones displayed in Q1. Indeed, many

respondents expressed the concern that one category is missing for Q1, more specifically

between “not at all” and “several days”, the result being that respondents were not quite

satisfied of their answers (answers were not seen as “correct”).

Besides, the labels given to the answer categories for Q2 were globally described as being easier

to grasp in terms of “meaning” (esp. “more than half the days” in Q1).

Finally, the response options provided in Q2 allowed respondents to vary their answers (positive

feature for respondents), also because the questions were alternating between negative and

positive statements: “Personally, I found the second one [Q2] more interesting. Because the

questions are presented in alternate way, between positive and negative statements... So, you

don't have always to answer "never" or "several days". You can choose. And the spread was

more interesting ("fine tuned")... Anyway I found this questionnaire more interesting, more

pleasant” (BE‐08, M: 40).

Less sensitivity issue: Q2 is definitely seen as “less embarrassing” or “less personal” and was also

described as being “friendlier” or as “having a less discouraging content”. Indeed, for Q1, the

questions were perceived as having on the whole a truly negative tone.

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Completion is faster: respondents shared that for Q2 there was no need “to think a lot” in order

to provide an answer. Indeed, less concentration and less thinking was necessary to complete

the task, either because:

The concepts in Q2 are more “global”, expressing “general states of mind”, and are not really

ambivalent. On the contrary, concepts in Q1 are more complex to interpret because of the

way items are structured, and worded; respondents had the impression that they were more

subtle and specific: “There were less possibilities for me to make a mistake [respondent found

Q2 easier], because being “full of life”, “nervous”, “tired”, “peaceful”, I think it's easier to

answer than "having less appetite or eating more", which is already more subtle. Q1 is more

subtle, overall, and Q2 is more general" (BE‐15, F: 60). "The second one was easier, the one

that appears to me as being more "physical". Because there, you know directly how you feel, if

you're in shape. It's quite easy to answer. [On the contrary for Q1]..."Here, you have to think,

to search in your memory for specific moments. The other [Q2] is more about a general

state..." (BE‐07, F: 38).

The answer categories in Q2 are not as sharply contrasted as for Q1. Actually, the sharp

distinction between “not at all” and “several days” forced some respondents to stay really

cautious in the sense that they were actually afraid “to make a mistake” while answering to

Q1: “Q2 is more "simple" and you are not afraid of making a mistake while answering, if

you tick the box that is next to the answer you want to provide, it make no difference, it

doesn't matter” (BE‐10, M: 80).

Also, testing revealed that the use of a 4 weeks timeframe in Q2 may have eased the task

for respondents who did not experience “sudden turns” (positive or negative) in their

professional or sentimental life over the past 4 weeks. For some respondents, the

timeframe (4 weeks) was in that case perceived as referring to respondents’ “general

state”, thus asking for less complex and thorough retrieval strategies (than for the two

weeks period stated in Q1).

Only two respondents stated that Q1 was easier to answer. Using respondents’ words: because “the

first series of questions were quite easy and clear” (BE‐02, M: 23) or because these questions were

“straightforward” in relation to respondent’s experience (BE‐11, M: 40).

Testing revealed that Q2 was clearly preferred over Q1. Indeed, a majority of respondents expressed

a positive inclination towards Q2 (see Table 3).

When the case, the reasons put forward to explain why Q1 was preferred over Q2 were that Q1 asks

about “concrete life problems” (not purely “states of mind” or “medical symptoms”). Also, the

questions in Q1 were seen as more “precise”, describing events/states that are easier to remember,

also because these events/states are mainly “negative” ones (facilitating recollection in comparison

with more positive events/states that are less striking in daily life).

On the other hand, the reasons put forward to explain why Q2 was preferred over Q1 were that:

Q2 is “clear”, needs less thinking, less concentration, and is thus easier to answer than Q1;

Q2 is more positive in tone than Q1 (and has also less sensitive questions: Q1.9);

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Also, the fact that Q2 alternates between positive and negative statements, allowed respondents

to vary the way they were answering the questions (not monotonous task as in Q1 where

respondents were constantly answering “not at all” or “several days”);

Q2 has better answer categories. Indeed, according to respondents, answer options have not

only a better “spread/distribution” (answers are exhaustive in the sense that Q1 was missing an

answer option between “not at all” and “several days”) but their label is also more user‐friendly

(you can more easily grasp the meaning of the answers provided).

Table 12: Overview of some reasons put forward for an expressed preference

Preferred Q1 Preferred Q2 No opinion "It describes society in a better way". Q1 is focused on "life problems" (“concrete problems that may be encountered through life”) – BE‐10 (M:80)

Q1 is more “precise”, events are easier to remember (also, it’s easier to remember negative states than positive ones) – BE‐16 (M:16)

Easier to answer – BE‐15 (F:60) Q2 needs less concentration, less thinking than Q1, & Q2 is more clear – BE‐01 (F:24) & BE‐11 (M:40)

Better response categories – BE‐13 (M:29)

“Questions are less detailed, but you have more choice” (more exhaustive categories) – BE‐05 (M:18)

“You can choose” (more exhaustive categories, and you don’t have always to select the same categories, as in Q1) – BE‐08 (M:40)

More interesting and agreeable (not always negative in tone) – BE‐08 (M:40)

Q1 is “longer” and “more discouraging” (in tone) – BE‐09 (F:47)

Questions are presented in a better way (the set alternates between positive and negative statements) – BE‐08 (M:40)

Q2 is “really easy” but Q1 is “interesting” (“you have to think about the questions) – BE‐07 (F:38)

Both sets can be in the questionnaire, “it’s not too burdensome” – BE‐03 (F:70)

“None of them bothered me” – BE‐12 (F:42)

“Both equal” – BE‐15 (M:63)

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Overlap between Q1 and Q2

Testing revealed that there was mixed reaction towards overlapping of Q1 and Q2. Either

respondents argued that the two questions clearly overlapped, overlapped somewhat or did not

overlap at all (see Table 4).

Analysis by gender and age did not reveal a clear picture of the type of respondents who felt these

questions overlapped (either partially or totally). There is nevertheless some evidence to suggest that

respondents who declared experiencing “low periods” (self‐perception of feeling down) may be

more prone to qualify the two questions as overlapping (either partially or totally) in comparison

with respondents who stated experiencing “a good period” or those who said never having

experienced a “depressive state”.

In any case, respondents who felt these questions overlapped (either partially or totally) could still

answer the questions (even if some tried to recall how they had answered before, that is, either to

the set before, or to the precedent items in one specific set).

Moreover, a majority of respondents stated that even though the questions are interrelated (totally

or partially), their feeling – to some extent – was that the questions were not too repetitive (that is

also burdensome), either because:

The answer categories were different between Q1 and Q2:

“[Is that repetitive or bothering?]... No, not at all, no because…I was answering in another

manner” (BE‐09, F: 47);

The wording (or the scope/focus) of the questions was dissimilar:

Q1 "is more detailed than the other one [Q2] where it's more in general, global... It's less precise,

over one moment or one fact, than [in Q1 where it] is more precisely asked..." (BE‐05, M: 18);

The reference period was different (2 weeks vs. 4 weeks):

"Between the two questions there was some repetition, but the fact that there was two distinct

reference periods made a difference! Q2 seemed more complete, had more items and was more

focused on topics, while Q1 was vaguer” (BE‐01, F: 24);

Or simply because the questions being read aloud (respondents did not have to read the

questions) they had a general impression of “free‐flowing”.

Actually, some respondents did not realize, at first, that Q1 and Q2 were in fact two different

questions, or they did not realize immediately that the different items of each question was

“interconnected”, organized and interrelated (between Q1 and Q2).

Evidence thus suggests that these idiosyncratic characteristics of the two sets coupled with a specific

administration mode (personal interviewing) contributed to ease the procedure of administering two

different sets of questions focusing on related topics, offering to respondents some variation in the

task they were asked to complete.

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Table 13: Perceived overlap between Q1 and Q2

Clear overlap Some overlap No overlap

"Yes. I have an impression it overlaps. But concerning the 2nd questionnaire, we have answer categories with a better spread ("avec une granularité intéressante"). BE‐08 (M: 40)

“They were more or less talking about the same thing. It's always on the feelings, how do you feel...[difference] Q1: "it's more detailed than the other one [Q2] where it's more in general, global,...It's less precise, over one moment or one fact, than [Q1] is more precisely asked...". BE‐05 (M:18)

"Yes…yes, in fact...questions are expressed [in Q1] are practically similar to the ones here [Q2] except that they are presented differently, the wording of the question is different and the answers we have to provide are put in a different manner […] So, the way the questions are done is different, but for me, it's the same thing [repetitiveness, bothering?]...No, not at all, no because…I was answering in another manner”. BE‐09 (F:47)

They "follow the same line" [...] Q1 is more about "the consequences of what you've been put through" and Q2 is more about "a general state of being" ("un état d'être en général") […] For her, everything is related ("tout découle de tout"). But she admitted that while answering she did not make these links: "I just answered". She did not found the Q1 and Q2 repetitive. BE‐15 (F: 60)

"There is certainly something. But for me these questions are still clearly different. There are things that are related such as "having little interest" and "feeling down‐hearted and depressed"; "feeling down" or "feeling happy"...I felt that one was more "physical" [Q2] and the other one more "mental" [Q1]. BE‐07 (F: 38)

"Between the 2 Q there was some repetition, but the fact that there was 2 distinct reference periods made a difference! Q2 seemed more complete, had more items and was more focused on topics, while Q1 was vaguer” BE‐01 (F: 24)

"The repetition was mainly inside the second questionnaire. The 2 questionnaires intertwine, but I didn't have the impression of repetition, because the Q1 was more concrete (sleep, tiredness), whereas Q2 is more vague and abstract".BE‐02 (M: 23)

"A bit different" [Interviewer: what differences?]: "euh..." (She couldn't put it in words).BE‐06 (F: 15)

"Inside a series of questions, there are things that intertwine” For R, Q2 was more general whereas Q1 referred more to symptoms. BE‐12 (F:42)

"I have the feeling that they are totally different because they are not at the same level…and they are not complementary […] Q1 is focused on "life problems" (concrete problems that may be encountered through life ‐ "des problèmes de société"). Q2 is "easier", more "simple" and focused on "symptoms" ("medical state")”. BE‐10 (M: 80)

"As the questions were asked one after the other. For me, they were part of the same section. I did not see a distinction between the two […] The type of questions were different: one was over 2 weeks, the other 4 weeks, Q1 was more "completed questions" and Q2 more "adjectives" […] For me, it was a logical succession. I did not see a difference. It was free‐flowing. BE‐13 (M:29)

"No, no. As the answers that I had to give were different [different scales] I had the feeling the questions were different..." BE‐16 (M:16)

R thinks there is a difference: "The first is more psychological ‐ more physical even... it didn't seem repetitive. The problems are so subtle, it's normal to go around". BE‐03 (F: 70)

"No not really" ‐ but R didn't explain what would be the difference. BE‐04 (F: 61)

"They are distinct if you really listen to the questions". It was not too repetitive. BE‐11 (M:40)

"No, not really". R agrees that both can be in the final questionnaire. BE‐14 (M: 63)

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Timeframe: the past 2 weeks (PHQ‐9) and the past 4 weeks (MHI‐5/EVI)

Q1 and Q2 refer to two distinct timeframes, respectively “the past two weeks” (PHQ‐9) and “the past

4 weeks” (MHI‐5/EVI). Overall, the timeframe for both sets worked more or less as intended

(especially for Q1). The problems, when they appear, tended to focus either on Q2, or in the fact that

some respondents did not take the reference period into consideration while answering to the

questions (see Table 5).

In fact, the different time periods worked especially well for respondents experiencing “sudden

turns” (positive or negative) in their professional or sentimental life. For them, the timeframe was

clearly seen as crucial in order to assess their personal situation and to provide an adequate answer

(in the sense that if they were asked these questions 2 weeks or 4 weeks ago, their answers would

have been different). These respondents were thus clearly attentive to the change brought between

Q1 and Q2.

Another interesting finding concerns a respondent experiencing a long‐lasting state of depression.

Actually, this respondent used the “last week” or a “close past” as reference, and did not pay

attention to the timeframe stated in the questions. Indeed, “I thought about these last months. The

last two months, because two weeks, it's so short to realize that something has changed, except for

more physical problems, illnesses (the flue). But here, we are talking about states of mind, so it's

difficult to tell...” (BE‐15, F: 60). For this respondent, the time periods were thus not appropriate in

order to evaluate her current state (the experience of the disease induce a more extended sense of

temporality, because the disease itself and its different stages towards recovery are spread over a

longer period).

Some respondents also did not pay attention to the timeframe, but this time, considering that it

would not make much difference to their answers. Indeed, according to them, their experience was

the same whether it concerned the last 2 weeks or the last 4 weeks.

Concerning the respondents who did not apply the correct time period for Q2, the strategies used

were quite diverse: some applied a “general context” instead of the 4 weeks timeframe (“general

state”, “how I am in general”), others kept a two weeks time frame for reasons of ease (simpler in

terms of retrieval strategy), one respondent experiencing a “sudden turn” took the two first weeks

out of the four as a reference in order to provide an answer corresponding to how he is usually, thus

considering the last two weeks as a temporary state not representative of how he is in general. As

mentioned by our UK partners (M. Balarajan & M. Gray, National Center for Social Research): “the

measurement aim of Q2 could be damaged, as respondents could under or over report, if they had

experienced different behaviours/feelings over the last four weeks compared to the last two weeks”

or if they had experienced different behaviours over these 4 weeks compared to “how they feel in

general”.

Finally, respondents shared that, in general, it was not easy to remember their feelings and behaviours over

the last 4 weeks. Indeed, four weeks is often perceived as a too long period to recollect their experience

with some degree of precision. Considering the last comment, respondents’ task was thus rendered even

more complicated by “averaging procedures” they had sometimes to apply (leading sometimes to a more

“global” assessment, less complex and thorough retrieval strategies).

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Table 14: The use of the reference period

Used the correct timeframe Did not use the correct

timeframe for Q2 Did not care about the

timeframe

“You easily keep it in mind […] Then, I remember well this period because the pressure is raising at work....I really looked at me during the last 4 or 2 weeks according to the question". BE‐13 (M:29)

“I was able to make the distinction [Q1 and Q2] It was clearly stated in the questions... 2 weeks I can still clearly see what happened, but 4 weeks... you need to think a little bit more. It's not that fresh anymore". BE‐07 (F: 38)

"Two weeks was easy...for 4 weeks I worked more on “averages”…I can remember that, globally, everything went fine”.BE‐08 (M:40)

"I had to think back as to how far ago went the 4 last weeks ‐ but I kept the difference in mind" […] as the questions are quite general, we don't have to think too deeply... In fact, 2 weeks, 4 weeks or more, the replies wouldn't have been any different!" BE‐01 (F:24)

"The past 2 weeks, I was in a very positive state, so answers were very clear, while in past 4 weeks, it's more ambivalent, I had to average ‐ but for some states like depressed, down hearted etc., it's also clear, I'm never like that, it's not in my temperament". BE‐11(M: 40)

R says he kept the 2 different reference periods in mind when answering. There was no problem. BE‐14 (M: 63)

The timeframe had to be repeated several times (with or without the main question). R kept the two weeks’ timeframe easily in mind but applied a "general context" for the four weeks timeframe. BE‐10 (M: 80)

For the two weeks it was OK. But for the 4 weeks I thought about the 2 first weeks, as I'm usually, and I answered like that. I took the two first weeks out of the four, as a reference. Because, for the moment, I'm feeling a bit blue, but it will pass”. BE‐05 (M:18)

"I kept the two weeks...I didn't use the 4 weeks, I kept 2 weeks...It's easier 2 weeks that 4 weeks”.BE‐16 (M:16)

"I didn't understand why we pass from 2 weeks to 4 weeks." (...) "The last 2 weeks is easier ‐ past 1 month is more difficult to remember back..." BE‐04 (F:61)

For R, the 2 past weeks are OK, but it's more difficult for the past 4 weeks. BE‐06 (F:15)

For Q1, R says she kept in mind the past 2 weeks, while for Q2, she based her replies on her general state. She did not focus on the past 4 weeks. R says she responded "spontaneously, like that, because that's how I am in general". Later she adds: "If you answer spontaneously, it's easy to answer". BE‐12 (F:42)

"I did not pay attention to that. I thought about these last months. The last two months, because two weeks, it's so short to realize that something changed. Except for more physical problems, illnesses (the flue, two weeks later, it's finished). But here, we are talking about states of mind, so it's difficult to tell... If you tell me 2 or 4 weeks, I'm thinking of "the last weeks" ("les semaines passées"), I will not go one year ago, but a "close past". BE‐15(F:60)

"I even didn't think about that, not at all... Either 4 or 2. For me it could have been 6 weeks, it's the same thing”. BE‐09 (F:47)

"I heard you said 2 weeks/4 weeks but it made no difference in my replies, so I didn't focus on that". BE‐02 (M:23)

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Sensitivity

Two aspects were investigated at this stage: on the one hand, we tried to explore whether

respondents would have preferred answering to this module using a self‐administered form or if they

didn’t mind being placed in a face‐to‐face setting, and on the other hand we explored whether the

questions, in general, and perhaps some items more specifically, were felt as too personal, or even

hurting or shocking.

Investigating whether respondents would have preferred answering to this module using a self‐

administered form, we found that for a great majority of them, being placed in a face‐to‐face setting

was not really a problem (see Table 6). Nevertheless, a non‐negligible amount of respondents

expressed some concerns about asking these specific questions – especially Q1 (Q1.9) – to more

vulnerable persons. Also, some respondents felt that Q1 was displaying perhaps too personal items.

Only three respondents clearly expressed not being inclined to answer these questions in a face to

face setting. Either because the respondent felt that otherwise he would have had more time to

think well about the questions, also because he/she felt the answer process would be facilitated, or

because people would not be embarrassed “to answer more” on these questions: "You will target

more people who will answer more, for these questionnaires, for all the categories, for all ages, when

using a paper like that, than during an interview. Because... First, you have more time. You read the

question. Sometimes, understanding, for some, is not easy. But you will have more time for the

answer. On the contrary, when you speak, it doesn't follow immediately. So, I think it will be easier for

people with the paper, yes. More persons will understand". (BE‐09, F: 47).

Concerning the second aspect exploring whether the questions, in general, and perhaps some items

more specifically, were felt as too personal, or even hurting or shocking, it was found that

respondents were able and willing to provide an answer for all the items in Q1 and Q2, even if they

were a bit surprised, and sometimes shocked, by one of the items such as Q1.9. Hereafter some

comments collected about the aforementioned item (Q1.9):

[Q1.9] "It's the question the most…whaouuu... I think a person that would have thought about suicide

over the last 15 days, would not have said anything. That's the first thing that I thought...I find this

question really strong, harsh... What can you answer in any case, apart from "never"...? I cannot

imagine a person answering something different than "never"... Even someone that has considered

suicide...” (BE‐08, M: 40).

"If someone gives you a positive answer here, you should give him the telephone number of "SOS‐

Suicide" [association]…The Q was asking "do I want to die, do I have ideas about suicide, am I so

depressed to a level that…”. For me this question is inappropriate, embarrassing, there is no point of

asking that. You shouldn't ask that...I find it really indelicate, clumsy, heavy‐handed this

question…There is no meaning in asking that because the person that thinks about dying will not

accept to participate answering to the questionnaire anyway [...] I don't think a lot of people will

answer to that" (BE‐13, M:29).

"Answering to that, it's really difficult [Q1.9]. I found it difficult, I think that if you're not feeling good,

it's difficult to answer to that question, because sometimes this comes into your mind. It's not

something that you want to talk about, to share. Six month ago, I would have been embarrassed to

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say that, yes, it came into my mind. Even to my physicist I would be embarrassed to say that. I would

have been ashamed to say that I thought about suicide... These are very personal questions. I don't

know perhaps some people will tell you the truth" (BE‐15, F: 60 – respondent with a long‐lasting state

of depression).

Table 15: Face‐to‐face interviews, perceived pros and cons

Pros Cons

It's funny, (BE‐07, F: 38)

It’s good to alternate [the mode] because you don't have

to read all the questions, you go less fast (BE‐07, F: 38)

"You have to be more concentrated in a F to F setting.

Interview is better if you need complete and valid

answers, because in the interview you have a more in

depth thinking, while on paper, I have to fill in a cross, I’ll

do it, even if I hesitate on my answer". (BE‐11, M: 40)

Being read the questions offers at least the advantage of

spontaneity... If I had read them to answer I think that I

will have "thought" a bit more in the sense of

"interpreted". (BE‐08, M:40)

I would perhaps have lied... because, usually, I'm never

sad or depressed; I would have answered "never"...

Perhaps also for "sleeping". Apart from that...

Spontaneously, I could not lie; I had to say directly what

was coming into my mind..." (BE‐05, M:18)

R thinks it wouldn't be a problem in interview setting

because "we don't have to justify our answers". (BE‐01,

F:24)

I prefer by interview because alone, you can tick a

response and might not have understood the question

correctly, while in interview, you can guide us if we don't

understand. (BE‐04, F: 61)

Questions can be asked by interview. For him, they're not

too private (alcohol is a more sensitive subject according

to him)... "There aren't really 'intimate' questions here".

(BE‐14, M: 63)

You don’t have the opportunity to read the

question again (BE‐07, F: 38)

You don’t have time to think a little bit

more (BE‐07, F: 38)

If I had to read the questions myself, it

would perhaps have been different for

some questions [answers provided],

because I would have taken more time...

BE‐05 (M:18)

"I would have preferred answering the

questionnaire "manually" [self‐

administration] because I'm more visual

and you can read the general question

again. Here, you have to ask to repeat the

question [especially for Q2]... It would have

been easier on paper" (BE‐13, M:29)

It's always in case of problems, if the person

is willing to open herself or not.

(BE‐07, F: 38 and BE‐01, F:24)

R prefers in F to F. But she said it would be

more embarrassing for the first series (Q1)

that is more personal. (BE‐06, F: 15)

Q2 is adequate in F to F interview, because

it's not too invasive… Well, Q1 is OK also, in

the end, except maybe for Q1.9 that is

more shocking, both are OK in F to F. (BE‐

12, F: 42)

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Understanding of the questions (general frame)

Overall, testing revealed that there were mixed reactions towards the questions, in the sense that

not all respondents showed a clear understanding of the questions (and their different items) as

being specifically designed to measure “depression” or “psychological distress”. Some respondents

interpreted some or several items composing the two sets in the light of their daily experience and

habits (for instance a young respondent answered “several days” for “feeling tired or having little

energy” arguing that it is his “personality” to be like that, also for having “poor appetite or

overeating" many respondents answered, considering that usually they eat a lot, etc.) trying to make

sense out of these questions, to find some coherence in the task they were asked to complete, even

though these respondents were far from exhibiting the slightest symptom of any “disorder”. Actually,

it’s not really known to which extent such a tendency could affect the validity of the results obtained.

Answer categories

Table 16: PHQ‐9 answer categories and MHI‐5/EVI answer categories

PHQ‐9 answer categories MHI‐5/EVI answer categories

Not at all

Several Days

More than half the days

Nearly every day

All of the time

Most of the time

Some of the time

A little of the time

None of the time

Testing revealed that a majority of respondents expressed some reluctance towards the use of Q1 answer

categories. The answer options proposed in Q2 were globally perceived as more exhaustive or more

refined, straightforward, and were thus qualified – almost unanimously – as easier to use, also because

they gave respondents the opportunity to state a precise answer.

First, answer categories in Q2 were seen as more exhaustive, or more refined than the ones displayed in Q1.

Indeed, many respondents expressed the concern that one category is missing for Q1, more specifically

between “not at all” and “several days”, the result being that respondents were not quite satisfied of their

answers (answers were not totally seen as “correct”):

"I thought that the response categories were very annoying. A category is really missing

between “Never” and “Several days”. Several days makes a lot on 2 weeks, so I choose "never"

(BE‐01, F: 24).

“I said “never” but in fact it's “sometimes”. Oh, but this category doesn't exist! Several days are

too much, because I perk up quite fast. So... In fact a response category is lacking between

“never” and “several days” (BE‐03, F: 70).

“For Q2 "it is well done". For Q1 there was a problem for Q1.7 (“trouble concentrating on

things”) were a category could have been added "sometimes”, something like that, between

"never" and "several days" BE‐10 (M: 80).

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“Despite the fact that the questions are less detailed, I had more choice [in Q2]. [For Q1]

Everything that I placed under "several days" was only "from time to time", it happened let say

2 or 3 times... and "several days" for me, it's more [4‐5 days over the last two weeks]...It was

not "never", but " several days" it was too much...The second was better because I had more

answers..." (BE‐05, M: 18).

“Several days, it's more than a couple of days; it's nearly half of the time...". Respondent said

something is missing between never and several days: "I would have preferred "1‐2 days", "in

certain circumstances" ("dans certains cas"). Then, "several days", "3‐4 days" or "3‐7 days"...

Something was missing between "never" and "several days"... I hesitated there, it's not enough

refined… I would have said 1‐2 days if there was the possibility to do so... On the contrary "more

than half the time" and "almost every day" it's similar ("cela revient au même [...] c'est le même

paquet"…)” (BE‐13, M: 29).

Second, some respondents shared that the labels of the answer categories for Q2 were globally easier to

grasp in terms of “meaning”. Some worries were also expressed about the fact that the response options

in Q1 were not clearly distinguished from one another, perhaps because of the vagueness of the wording

in use” (the options are not evenly spread).

For Q1, the problems specifically settled around the meaning of “several days“, and “more than half the

days” versus “nearly every day”:

"What does several days mean. Is it 2 days (or more)? Then, 1 day, where is it!" (BE‐12, F: 42);

“On the contrary "more than half the time" and "almost every day", it's similar ("cela revient au

même [...] c'est le même paquet”…)” (BE‐13, M: 29);

"Several days, or more than half the time, these are notions that I cannot really grasp… It's

difficult to evaluate something like "more than half of the time", and "several days" also…

Feeling down [respondent answered several days], it happened some days ("quelques fois, pas

une fois, pas deux fois, quelques fois)... I cannot tell how many times, but I know it happened

some days"). For me, "some days" equals to "several days" (BE‐15, F: 60).

On the contrary, response options in Q2 were mainly qualified as “well distinguished, in a certain order, with

a rhythm” (BE‐15, F: 60). Also, the labels were easier to grasp in terms of “meaning”, perhaps because these

options refer to the ones respondents use naturally (at least in French):

"Here I had no problem [in comparison with Q1]...These are “customarily” options. It really

did not bother me… Here I had no problem in comparison with "never" and "several days"

were "1‐2 days" was missing..." (BE‐13, M: 29)

"I prefer them [to those of Q1] because I find them more "precise", I would say...because

"more than half the time", "several days"...I find it more clear "rarely", "sometimes" (5

days), “most of the time (two weeks), “all of the time” (4 weeks). I preferred these answers

over the others” (BE‐16, M: 16)

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Nevertheless, some problems were also reported about Q2 response options. Difficulties mainly targeted

“some of the time” and/versus “a little of the time”:

“It’s just the "rarely" [a little of the time]. It's difficult to use, it's more a "formulation",

an “expression” than a proper "answer"...Nevertheless, the choice is better than this

one [Q1]. For me it's more clear. It's easier. For me "more than half the time" it's vague,

“nearly every day” also... You cannot evaluate that...it's difficult to distinguish” (BE‐09,

F: 47).

"Both questions were easy, I mean if I understood correctly… Sometime I had difficulties

to find the right answer, I didn't quite know which category to choose" (between “some

of the time” and “a little of the time)” (BE‐04, F: 61).

“For the respondents, it’s not that easy: are frequencies about averages over “days” or are

we talking about specific “moments"? She explains "because at certain moments of the

day, yes, you're tired. You see, tired, I don't feel tired in the sense that I'm tired the whole

day and want to send things to hell, but there are certain moments during the day or

during the week when I'm tired" (...) a normal tiredness after a working day or after a lot of

excitement about something” (BE‐12, F: 42).

Besides, the response options provided in Q2 allowed respondents to vary their answers (positive

feature for respondents), also because the questions were alternating between negative and positive

statements: “Personally, I found the second one [Q2] more interesting. Because the questions are

presented in an alternate way, between positive and negative statement... So, you don't have always

to answer "never" or "several days". You can choose. And the spread was more interesting ("la

granularité")... Anyway I found this questionnaire more interesting, more pleasant” (BE‐08, M: 40).

Finally, a respondent was totally confused when the interviewer passed from Q1 and Q2 because the

direction of the scale (as presented in the show card) changed. Indeed, response options were

presented in Q2 in descending order, while for Q1 options were presented in ascending order. Also,

one should consider the possibility that some respondents (not having experienced any particular

problem) having answered consistently and repeatedly “never” to Q1 may be somewhat “disturbed”

or somehow “influenced” in providing specific answers for Q2:

Notes: “when the interviewer passed from Q1 to Q2, the respondent was very confused because the

direction of the scale changed: the first category "never" in Q1 became "All of the time" in Q2... The

respondent said: "So as I always replied "never" in Q1, now (for Q2) I am inclined to answer "all of the

time"... I can't even concentrate on your questions, it’ really disturbing!" Respondent had perhaps

been influenced by the first scale; he got confused because options were presented in the reversed

order" (BE‐12, F: 42).

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Recommendation for asking both PHQ‐9 and MHI‐5/EVI

Both sets can be used simultaneously during the main stage. Even thought mixed results were

reported on the overlapping of Q1 and Q2, a majority of respondents felt the questions not

being too repetitive or burdensome. Therefore there is presently no objection drawn from the

testing which could prevent the simultaneous use of these two sets.

Administering the module in a face‐to‐face setting did not seem to bother or embarrass

respondents. Testing did not provide real strong evidence preventing the use of this type of

administration mode in order to collect information on “mental health” topics.

Concerning sensitivity issues, perhaps the PHQ‐8 could be used instead of the PHQ‐9. The

PHQ‐8 includes “all items of PHQ‐9 except the 9th item on self‐harm, and is mainly used in

non‐depression research studies”4 (see annex 2).

If it is planned to use PHQ‐9, an introductory statement on the “sensitivity of certain

questions” should be added (respondents need to be informed prior to answering). Also, the

possibility of offering a series of supportive measures needs to be reflected upon (these

procedures need definitely to be discussed, especially as when these are to be launched; a

common strategy tackling these issues needs to be set up).

Possibly, harmonize the answer categories and adapt the show card. Maybe think of another

semantic anchoring of the 5 point Likert scale on question Q1 (PHQ9) and change the order of

the response categories (in the show card) in one of the 2 scales so that they are adjusted to

each other (all in ascending order, or all in descending order).

Possibly, harmonize the timeframe between questions. Nevertheless, if the timeframe or the

answer categories have to be harmonized, this needs to be done in a very careful manner

because the task may therefore become monotonous and repetitive for respondents (variety

in the tasks offered to respondents remains an important asset if we want them to stay

interested and focused).

The order in which the questions appear (PHQ‐9, and then MHI‐5/EVI) seems adequate.

Questions from the PHQ‐9 being less positively worded, it is perhaps more appropriate to end

the mental health module by asking the MHI‐5/EVI (the positive tone may help respondents to

feel more comfortable). Nevertheless, one should also consider the possibility of “order

effects” in the sense that positive/negative answers (in the second questionnaire) may be

somewhat reinforced after respondents having to answer to a succession of negative

statements (in the first questionnaire).

4 http://www.phqscreeners.com/instructions/instructions.pdf

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Cognitive Testing: Detailed Results (question by question)

Section 3.3 and 3.4 is focused on the specific items composing the different sets placed

under scrutiny (understanding of the different items). Nevertheless, recommendations

presented at the end of each section include more general comments which were also

highlighted in the previous sections.

2.2.2.2. Overall findings for Q1 (PHQ‐9) to measure depression

Understanding of items (see also annex 1)

Respondents expressed some trouble in trying to understand and interpret a series of items.

Namely, having “little interest or pleasure in doing things” (Q1.1), “sleeping too much” (Q1.3),

“moving or speaking so slowly that other people could have noticed” (Q1.8), and “Feeling bad

about yourself‐or that you are a failure or have let yourself or your family down (Q1.6)

Some respondents experienced difficulties in providing an answer, or used specific answer

strategies to cope with items listing a series of states (actually, these states were seen as really

distinct and not interrelated). Other respondents focused on the less harmful state, or on the

strongest state, in order to provide an answer (in either case, these respondents only focused on

one item of the list). This happened for “feeling down, depressed or hopeless” (Q1.2), “feeling

bad about yourself‐or that you are a failure or have let yourself or your family down” (Q1.6) and

“thoughts that you would be better off dead or of hurting yourself in some way” (Q1.9).

Some respondents did not really understand why the expression “you have let your family

down” (Q1.6) needed to be included in the question, and asked why, then, the question was not

mentioning “friends”.

Some respondents misunderstood the meaning of certain items such as having “trouble falling or

staying asleep, or sleeping too much” (Q1.3), having “poor appetite or overeating” (Q1.5), having

“trouble concentrating on things, such as reading the newspaper or watching television” (Q1.7), or

“feeling tired or having little energy (Q1.4), and “being so fidgety or restless that you have been

moving around a lot more than usual” (Q1.8)

A young respondent (16 years old) was totally confused by the use of opposite statements. This

respondent asked why it was asked “two questions in one question”. He was clearly disturbed.

One respondent faced difficulties with Q1.3 on having “trouble falling or staying asleep or

sleeping too much”. This respondent was using medication (sleeping pills) and she did not know

how to answer (because currently she is fine, but without medication it will be totally different).

Finally, she could not provide an answer.

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Recommendation

Consider adding one response option between “not at all” and “several days”;

Consider adapting the label (but this not necessarily possible) for “more than half the days”

considering that some confusion exists as concerning, on the one hand the correct interpretation

to give to this specific options, and on the other hand to what distinguish this option from “nearly

every day”. If not possible, try to put some emphasis on the timeframe (2 weeks), because “more

than half the days” can make more sense to respondents if they can clearly refer themselves to

this time period;

Consider dropping item Q1.9 on self‐harm (sensitivity): possible use of PHQ‐8

Consider providing some indication to respondents on whether they should consider the impact

of a certain trouble or problem (a respondent was taking sleeping pills and did not know how to

answer to Q1.3), with or without them taking medication.

2.2.2.3. Overall findings for Q2 (MHI‐5/EVI) to measure well‐being and vitality

Understanding of items

Some respondents felt that these items were overlapping, either because some were “similar”,

or because others were “opposite” (one question is therefore necessary). Nevertheless,

respondents completed the task without sharing any comment on that, prior to the probing.

Some respondents had difficulties in providing an answer for Q2.2 because they did not know

how to interpret “have you been very nervous”. According to them, “being nervous” (at least in

French) has a lot of different connotations: “There are different ways of being nervous... worried,

excited, and irritated. These are small differences” (BE‐07, F: 38).

Some respondents shared that they interpreted Q2.7 on “did you feel worn out” as simply

“being tired”. Thus, the answer they provided was to a certain extent referring to “being tired”,

and not to “being worn out”. This also happened because the question on “being tired” (Q2.9)

was asked after the one on “being worn out”. Some respondents were quite surprised, having

therefore the impression that they had already answered this questions (feeling of overlapping).

Recommendation

Consider placing item Q2.9 (tired) before Q2.7 (worn out), so to avoid a misinterpret‐tation of

what the question Q2.7 is intended to measure; or provide more guidance to respondent in

order for them to establish a clear frame on what is exactly meant by “being worn out” (that is

not being tired in because of sport, or activities of daily life).

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Table 17: Summary results PHQ9 “Over the last 2 weeks, how often have you been bothered by any of the following problems?”

Little

interest Down,

depressed... Troubles sleeping

Tired, little energy

Troubles eating

Feeling bad, failure

Troubles concentrating

Slow/fidgety Self harm/ suicide

BE‐10 (M:80) Not at all Not at all extr

Not at all (habit – wake up late)

Several days Not at all Not at all (frame)

Several days Not at all Not at all extr – hurting

BE‐15 (F:60) under medication

Not at all Several days Several days Several days

Nearly every day (Eat too much: habit)

Not at all (family)

Several days Not at all Not at all (sensitivity)

BE‐13 (M:29) “bad time”

Several days Not at all extr

Several days Several days Several days Not at all (family) extr – failure

Not at all Several days (slowly “part”)

Not at all (sensitivity)

BE‐07 (F:38) Not at all Not at all Not at all Not at all Not at all (Eat too much: habit)

Not at all min (it happened once)

Not at all Not at all Not at all

BE‐08 (M:40) Several days Not at all extr

Several days Several days Several days Not at all extr Several days Not at all Not at all (sensitivity)

BE‐05 (M:18) “bad time”

Not at all Several days min

Several days Nearly every day (personality)

Several days Not at all extr – failure (frame)

Not at all Several days (excited, with friends)

Not at all

BE‐16 (M:16) Not at all Not at all Several days (problems to wake up)

Several days

Not at all min (poor appetite) (Eat too much: habit)

Not at all (frame)

Not at all (journal & television, why not school)

Not at all (excited, with friends)


BE‐09 (F:47) Not at all Not at all Several days Several days Not at all Not at all Not at all Not at all (wording)

Not at all

BE‐01, (F:24) Not at all Not at all extr

Not at all Not at all/ Several days

Not at all Not at all Not at all (judgment: fidgety)


BE‐02 (M:23) Several days Not at all/ Several days


Not at all/ Several days

Several days Not at all (esp. slowly “part”)


119

Little interest Down,

depressed... Troubles sleeping

Tired, little energy

Troubles eating

Feeling bad, failure

Troubles concentrating

Slow/fidgety Self harm/ suicide

BE‐03 (F:70) Not at all Not at all/ Several days

Could not give an answer

(Eat too much: habit)

Not at all (frame)

Not at all Not at all

BE‐04, (F:61) Not at all Not at all Not at all Not at all Not at all Not at all

BE‐06, (F:15) Several days Several days More than half the days

Several days Not at all Not at all (sensitivity)

BE‐11 (M:40) Not at all Not at all Not at all Not at all Not at all Not at all (sensitivity)

BE‐12 (F:42) Not at all Not at all Not at all/ Several days

Not at all Not at all Not at all sensitivity)

BE‐14 (M:63) Not at all Not at all Not at all Not at all Not at all (esp. slowly “part”)


Understanding and Retrieval: problem with the meaning of the question: “what do you mean by this?”

Answer strategy: Extreme items as “reference” Answer strategy: Less strong item as reference Problem with listing of items: several states per question

Problem with “opposite concepts” in the same question Item understood as something usual Misunderstanding of the question

: Response categories; hesitation between “Not at all “and “Several days”, or choose “several days” but R meant less than that (1 or 2 days) : Retrieval and Judgement: R is under medication (“sleeping pills” or antidepressant). Don’t know how to answer

highlighted

highlighted

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Introduction

The alcohol consumption section in the EHIS wave 2 questionnaire is placed in the self‐

completion form for sensitivity reasons. This section is meant to deliver information on basic

dimensions, such as:

Drinking status: overall prevalence of lifetime abstainers, former drinkers and current (past

12 months) drinkers.

Volume of consumption: overall frequency of consumption, usual daily quantity and average

daily volume (that is, quantity multiplied by frequency on a weekly basis, divided by seven).

Data should also allow the calculation of "hazardous drinking" defined as more than 20 g

pure alcohol daily for women, and more than 40 g pure alcohol daily for men.

Risky single occasion drinking (RSOD): overall frequency of having 60 g or more pure alcohol

in one occasion. Also referred to as "binge drinking".

The alcohol consumption section proposed for EHIS wave 2 is comprised of six questions (full

questionnaire in probe sheet, annex 4.5), of which:

AL1: frequency question, but also filter (non‐drinkers are routed to next section);

AL2‐AL5: extended quantity frequency (EQF) questions for week vs. weekend days;

AL6: a frequency question for RSOD.

As it is generally required to keep to a minimum set of questions in surveys, we wanted to test an

alternative quantity question (AL1a) which could replace the four EQF ones (AL2 to AL5) if needed.

This question (AL1a) is thus not part of the original set of questions proposed in the framework of the

“ImpEHIS” project. It was inserted in the present study at the second place of the cognitive testing

questionnaire, after the global frequency question (AL1). This implied that the original routing of the

questions could no longer be respected: normally, less‐than‐weekly drinkers (measured on question

AL1) skip the EQF questions (AL2 to AL5) and are directed to question AL6. Having AL1a in the

questionnaire broke this flow, because infrequent drinkers were invited to report their usual drinking

quantity (AL1a). From there, they continued with AL2 to AL5, originally designed for frequent or

weekly drinkers.

In the report on cognitive testing from UK, this was not properly comprehended, so the conclusions

in this respect should be considered with caution.

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Questions AL1, AL1a, AL6 are more or less the basic questions from the AUDIT‐C questionnaire,

except for the 12 months reference period (that came from the EHIS wave‐1) and the response

categories. Indeed, as the AUDIT mainly serves screening purposes, the response scales were

modified (refined) for the improved EHIS wave‐2 questionnaire in order to calculate volume of

consumption with more accuracy than the broad categories originally allowed.

In the EHIS questionnaire, just as for the AUDIT, the questions on the quantity of alcohol consumed

and RSOD are based on the presumption that people report "standard drinks", that is, drinks

equivalent to a 10 g ethanol content (whatever the beverage). This presumption is challenged by the

fact that people do not all have the same servings of the same beverages and that the standard

servings also vary from one country to another. One way to come around this problem is to have

people report their consumption in terms of standard drinks or standard units, and a show card is

handed to them with pictures to refer to. People have to convert their actual drinks in order to

match those standard ones presented on the show cards. It is assumed, though, that this might not

be ideal from a cognitive perspective.

Each country was asked to produce its own show card according to its specific national beverages

and standard servings. For instance, in Italy, standard drinks usually contain 12 g ethanol. In UK, it is

reckoned that standard drinks represent 8 g ethanol, but in fact, they vary widely because of a range

of different containers. This means that each country should ask the questions having in mind the

ethanol content in their “standard drinks”. When reporting the data, the number of drinks should be

converted into grams of ethanol for comparison reasons. Show cards are thus country‐specific.

Unfortunately, when the UK started the study on cognitive testing, no show card was available

representing country‐specific drinks, containers and units, and the Belgian team had to produce one

in a short time span, based on what could be gathered from other British surveys. It came out that

this show card did not perform as intended, but this was not really surprising! The Belgian show card

was simpler and seemed to work better; at least for the few people that used it. Here drinks

(translated into "glasses" in French) were not converted in units of alcohol content, but it was shown

for instance that one strong Belgian beer equals two ordinary beers and that a can of 50 cl beer

should also count for two. Other pictograms on that card indicated that a bottle of wine counts 6

glasses of wine, a bottle of spirits holds 23 glasses, etc. It was thus simpler than the UK show card

that considered all types of containers and sort alcohol and gave their conversion into “units”.

The results of the cognitive testing are presented hereafter. Section 3.2 presents the overall findings

regarding the questionnaire: instructions, use of the show card, sensitivity issue, preference for a

specific set of questions, etc. Sections 3.3 to 3.9 present detailed results regarding the specific

questions of the instrument. A conclusion is drawn in section 3.10.

2.2.3.1. Overall findings concerning the alcohol module

Instructions

The instructions at the beginning of the questionnaire were globally ignored. This was the case for

the introductory examples of what the concept of "alcoholic beverage" referred to in the section, as

well as for the instructions to tick the boxes corresponding to the respondents' answer and to use

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the show card to report the number of drinks. Besides, few respondents followed the skip

instructions when they applied. To conclude, careful attention should be put into integrating the

instructions in the questions and drawing attention to skip patterns.

Show card

Most respondents did not refer to the show card. Some had a glance at it, spotted their type of

beverage and reckoned their own glasses (of wine or beer) were similar to the ones represented on

the show card, so they went on with the questions. Others said that they always had normal servings

("12 cl wine glasses") or knew what a glass was, so they didn't need to refer to the card. Some didn't

pay attention because they didn't bother trying to understand it. Two respondents thought it just

represented the different types of alcoholic beverages (considered as mnemotechnic or probe

purpose).

On the other hand, amongst the three respondents that drank strong Belgian beers, two used the

card correctly (doubling their consumption for these beverages), but one refused to consider that

strong beer counted as 2 drinks. He stated: "a drink is a drink, whatever the strength, whatever the

serving" (M: 40), and refused to count double for strong beer.

Sensitivity ‐ confidentiality

Respondents thought the questions on quantity of alcohol consumed (but not the one on frequency

alone) could be embarrassing for some people, more specifically for those who drink excessively or

for those that are not at ease with their drinking. This was the impression a majority of respondents

reported. It was generally believed that excessive drinkers might lie on their consumption (under‐

reporting) because they do not want to be judged.

Beside this, a young respondent (M: 16) said that it might be embarrassing for youngsters to report

their drinking behaviour because they don't like to talk about it. On the opposite, another young

respondent (F: 15) said the questions would be embarrassing for the young people who don't drink

(note: this young girl constantly over‐reported her consumption, as if it were shameful not to be

familiarised with drinking!). Most respondents claimed that they were not themselves bothered by

these questions.

When asked, most respondents said it was preferable to keep this section in a self‐completed form

rather than in a face‐to‐face interview setting, as this way it might lead to more honest replies. One

respondent suggested giving a good briefing on the aim of the questions beforehand in order to help

people feel more comfortable.

Week day – weekend day distinction

Questions AL1 and AL1a refer to the simple quantity‐frequency approach, whereas AL2‐AL5

distinguish quantity and frequency over week days and weekend days.

When asking whether it was USEFUL or not to question on week days and weekend days separately,

almost all respondents recognized that it was worthwhile, because there is a difference between

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consuming alcohol on working (or school) days and days off. Even the retired thought so. It was

stressed that going out with friends or inviting friends over, going to parties and attending special

events, “where people tend to drink more”, usually takes place on weekends. Respondents added

that the split reflected better their real consumption, stuck better to reality. But this aspect disturbed

some respondents, in the sense that it made them realize they were drinking too much! Finally, three

respondents said splitting into week days and weekend days made no difference, so it was not seen

as useful, but rather burdensome.

The three respondents that said the split was not useful also replied it was more complicated to

answer. This was the case because they had a fairly low consumption (maximum 2 glasses per

occasion) on an irregular basis. They were "circumstantial drinkers", having a drink only “once in a

while when they felt like it”, or “with a good meal”, or when “friends pop in”… ‐ and this doesn't

depend on the day of the week but rather on random circumstances!

The question about the PREFERENCE for one or the other approach revealed a less clear‐cut picture.

If most respondents said it was useful to distinguish, five of them preferred replying to AL1a: either

because this usual quantity question "is less shocking, it lowers my consumption, makes me feel more

at ease", or because respondents find it "easier, less complicated" (than thinking over weekday and

weekend consumption). Two other respondents, on the contrary, found it easier to calculate their

week day and weekend day consumption separately than referring to "usual" consumption or to an

"ordinary day", because of the great variability between those two periods of the week.

General remarks from respondents

The following spontaneous remarks from respondents revealed interesting to consider:

Questions need to be reformulated, structured, cut (at least in the French version). As they are,

they threaten accurate understanding, especially question AL6.

Both series of questions are found to be easy (for regular, steady drinkers), or equivalent, or bear

the same problems (for irregular drinkers).

AL2 is seen as being more demanding, because people drink more occasionally on week days, so

it's difficult to report X drinking days for every week (variability).

General considerations over the section

A quantitative comparison between volume of consumption obtained from AL1‐AL1a on the one

hand and AL2‐AL5 on the other hand seems biased. It appeared that while answering the two

sets of questions, some respondents were clearly trying to provide coherent answers from the

first (AL1‐AL1a) to the second series (AL2‐AL5) of questions. There was most probably a

contamination of replies. It thus doesn’t make sense to compare quantitative replies (volume) on

the basis of these two questionnaires.

The recall of consumption over past 12 months did not seem to apply to overall measures of

"usual" consumption. Rather, these measures of usual consumption are meant to grasp the

general idea of consumption in terms of frequency and quantity – it is not based on an exact

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recall of all drinking occasions and all drinking amounts during those 12 months. The cognitive

operation at stake here is probably some kind of telescoping where responses are based on more

recent drinking behavior, rather than taking into consideration what might have been happening

the previous year at the same period.

Recommendation

Regarding the fact that the preliminary instructions were passed out, we recommend

placing the introduction part on alcoholic beverages under or in the question AL1

(instead of above), like it was the case in the EHIS wave‐1 version of the question. The

instructions and routing should generally be made more visible.

The show card could be made more clear and professional.

As alcohol consumption is a sensitive topic, it would be advised to avoid asking about it

in a face‐to‐face setting, but rather in a self‐administered format.

The weekday – weekend split ought to be kept, as it fits better the consumption of most

respondents and is also seen as useful by the majority. The circumstantial light drinkers

are the losers regarding this approach, but they represent a minority.

The translation of the questions should be revised – sentences are cumbersome.

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2.2.3.2. Detailed Results (question by question)

Frequency of drinking in the last 12 months

Question AL.1. During the past 12 months, how often have you had an alcoholic drink of any kind?

Every day or almost every day ....................................................... 1

5 ‐ 6 days a week............................................................................. 2

3 ‐ 4 days a week............................................................................. 3

1 ‐ 2 days a week............................................................................. 4

2 ‐ 3 days in a month....................................................................... 5

Once a month.................................................................................. 6

Once every 2 months ...................................................................... 7

Once or twice in the past 12 months .............................................. 8

Not in the past 12 months, but I drank formerly ............................ 9

end of interview

Never more than a few sips or trials in my whole life .................... 10

end of interview

Findings

SIMPLICITY

This question was easy to answer for almost all respondents. It was difficult for one irregular

drinker to find an average frequency and for another that changed consumption behaviour

(drastic reduction) in the course of the past 12 months. Others had a clear vision of their habits

or found it easy to average over time.

REFERENCE PERIOD

Many respondents found that a 12 months' time period was too long. Especially because over

that time, drinking pattern is more prone to variation (holidays, ups and downs). It was

sometimes difficult to think of alcohol consumption that far back in time.

RESPONSE SCALE

Respondents had an answer in mind, and read down the response scale until they matched their

answer. Some read 'week' (cat. 2 – 5) and directly jumped to 'month' to cut short. The scale was

easily understood and generally presented no problem. A few respondents said they did not see

the interest of having such detailed options at the top of the scale – but a few others thought it

was too detailed at the bottom of the scale! This evidently depended on their own consumption

and on their own vision of what information was important to gather. Others thought it was nice

to have such a diversity of replies – drinking being diverse across the population. All found a

category that matched their reply.

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Recommendation

This question on simple frequency is common to many surveys and is a basis for frequency

calculations as well as for filtering out and distinguishing infrequent drinkers, abstainers and

former drinkers.

This question was found to be easy to answer – even though some people wondered why it

was so precise / diverse. The lengthy scale did not affect their reply, though, as they read

through the graduated options quite fast.

Hence, we recommend keeping this question with few changes: following the

recommendation from UK, response categories 9 (former drinker) and 10 (never drinker)

should be reworded.

Simple quantity: how many drinks on a typical day.

Question AL.1a. How many drinks containing alcohol do you have on a typical day when you are

drinking?


24 or more drinks........................................................................... 1

17‐23 drinks ................................................................................... 2

10‐16 drinks ................................................................................... 3

7‐9 drinks ....................................................................................... 4

6 drinks........................................................................................... 5

4 ‐ 5 drinks...................................................................................... 6

3 drinks........................................................................................... 7

2 drinks........................................................................................... 8

1 drink ............................................................................................ 9

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Findings

SIMPLICITY

1. Many respondents said they found this question easy to answer. When so, they explained it was

easy to average their consumption, or that they always drank the same amount, or that they

never drank more than a certain amount, so in all cases, they knew perfectly well how much to

report!

However, it was more difficult to answer this question when the number of drinks varied from

one occasion or day to another. In this case, most respondents fell back on the question, which

in French is translated by "an ordinary day when you drink". Here, many respondents thought of

'ordinary' as opposed to 'exceptional' (instead of referring to the meaning of ‘ordinary’ as

'common, typical, characteristic'), so they based their estimation on weekdays only, excluding

weekends (when they usually drink) or at least, excluding parties or events when they drink

more, because these are just not "ordinary" days, even though they seem quite common

(frequent). This question leads to underestimating the true consumption of the respondents,

because "typical" or "ordinary" days are those when irregular drinkers drink the less.

UNDERSTANDING OF A TYPICAL (ORDINARY) DAY

The way people understood this question depended on whether they read the whole statement

("an ordinary day when you drink") or whether they focused on the first part ("an ordinary

day"). This influenced their reply. One respondent stated clearly:

"Days when I drink are not ordinary days… I don't drink on ordinary days"

Examples of opposite understanding are reflected in the following conceptions of "ordinary

days": For one person, they are "days of the week when I don't receive visitors", while for

another, "an ordinary day when I drink is a day when friends come over for dinner".

Or, one respondent said "an ordinary day when I drink is a day when I relax with friends, it's

farniente!", while for others, it refers to "classical working days".

This divergence in views probably affects the accuracy of the data collected because it is not

possible to know in which sense an 'ordinary day' is thought about.

The more common understanding of an "ordinary day" amongst respondents was any

traditional day when there is neither partying nor special/exceptional event going on. Put simply,

it's the days when people drink without any particular 'reason'. This way, weekends are often

excluded from the estimations. This, of course, is due to produce underestimates of true

consumption.

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RESPONSE CATEGORIES

Testing revealed that many respondents were surprised by the amount of 24 or more drinks.

One respondent said he looked back at the question to make sure he had correctly understood

"on one day". Another thought it was too much for an "ordinary day", no one would tick this

category. Others found the amount impressive but admitted that some people might drink as

much. Again others said that those who drink that much wouldn't admit it. Finally, the majority

had no problem with this scale, as they just didn't feel concerned with those categories that

didn't match their reply!

Respondents that did not drink on an ordinary day felt a category of "zero drink" was missing.

Respondents that had inconsistent drinking patterns would have preferred to have broader

quantity categories on the bottom of the scale (i.e. 1‐2 drinks or 2‐3 drinks), because they

hesitated on those very precise quantities ("the distinctions are too farfetched").

Some respondents stated there were too many categories. Others on the contrary found it easy

because of the large choice of categories ("everything is in there!").

On the whole, all respondents found a match to their answer.

Recommendation

o This question seems to work rather well, as many respondents claimed it was easy for them to

answer. In reality, respondents were referring to very different situations, some including and

some excluding specific drinking moments. Hence, this question is problematic from a

psychometric point of view, leading to unreliable results and to a clear underestimation of true

consumption due to a misinterpretation of the question.

o We recommend not to use this simple quantity question (from Audit‐C), unless the

questionnaire on alcohol consumption must imperatively be reduced to 3 questions. In this

case, we would propose to change the wording in the French version, removing the term

"ordinary". Nevertheless, the presumption of stability in the amount of alcohol consumed on a

typical day remains unresolved!

Week day frequency

Question AL.2. During the weekdays (Monday through Thursday), on how many of these 4 days do

you usually drink alcohol?

On the 4 week days.............................................. 1

On 3 week days .................................................... 2

On 2 week days .................................................... 3

On 1 week day...................................................... 4

Not on week days................................................. 5

go to AL.4

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Findings

Overall, this question worked as intended; The French translation of this question should be

made more fluid, though, as some respondents had to read the question over before fully

understanding what was asked, because the sentence is complicated.

UNDERSTANDING OF WEEKDAYS AS MONDAY TO THURSDAY

Most respondents accepted to think about weekdays as Monday to Thursday, as they were told

so in the question. They made sense of this split referring to people who work or study. This

weekday definition in a question about drinking seemed logical to them, even preferable. A

minority of respondents denied the split: one answered still including Friday (because it made

no difference), while another considered the whole 7‐days week (because his drinking does not

depend on the day of the week).

VARIATIONS IN DRINKING PATTERNS

This question was considered difficult if patterns varied over large periods (i.e. abstinence for

some periods, then uneven drinking over other periods) or if weekly drinking was occasional and

light (respondents drink 'when they feel like it' or 'according to circumstances'). In these cases,

the respondents try to consider what a usual pattern would be. Most make an average

estimation.

If drinking during the week is very exceptional, respondents do not mention that as 'usual'

weekday drinking, but then they feel they are underrating their consumption.

Recommendation

This question worked well for people who have regularity, habits or rules (ex. 'never during

the weekdays') in their drinking behavior.

Some respondents were bothered that the 'weekdays' stopped on Thursday. This could be

avoided if the question refers simply to the days at stake (i.e., Monday to Thursday) without

specifying "on weekdays" (see results from the Estonian translation and testing, as this

approach was applied).

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Week day quantity

Question AL.3. How many drinks containing alcohol do you usually have on one of those weekdays

(Monday to Thursday) when you drink alcohol?


24 or more drinks................................................. 1

17‐23 drinks ......................................................... 2

10‐16 drinks ......................................................... 3

7‐9 drinks ............................................................. 4

6 drinks................................................................. 5

4 ‐ 5 drinks............................................................ 6

3 drinks................................................................. 7

2 drinks................................................................. 8

1 drink .................................................................. 9

Findings

SIMPLICITY

Testing revealed that respondents found this question easy to answer. It was easier than Q1a

(usual quantity) for people who have a drinking pattern that varies from weekdays to weekend

days. Respondents gave an average consumption on a day. Those who report that they 'never

drink more than…' found it very easy to estimate, because they reported their maximum

(which turns around one to two glasses).

RESPONSE CATEGORIES

People generally found the category corresponding to their consumption. Testing revealed

that some thought the categories were too to fine‐grained for reporting average estimations,

while others found the upper categories could be cut down.

SKIP AND ROUTING

Most respondents did not see the routing instruction at AL.2 so went to AL.3. When this

happened, respondents either:

o Thought it was odd to be asked, but then remembered those exceptional occasions

where they drink during the week, so answered one or two drinks.

o Thought that the category "0 drink" was missing.

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If the first strategy occurs, it should not constitute a problem because the algorithm to

calculate the volume consumed takes into account both AL2 and AL3 (AL2 x AL3). If one of the

two values equals zero, weekday consumption equals zero as well. So for instance, AL2 = 0 (not

on weekdays) times 'X' drink(s) = 0.

Recommendation

Globally, there is no problem with this question and response categories (other than that

stated for AL1a). Some respondents find it exaggerated to have so many over‐consumption

categories. Hence, even if it is known that alcohol abusers exceed this amount of daily

drinking, it might be relevant to lower the top category of 24+ drinks.

Weekend day frequency

Question AL.4. During the weekends (from Friday to Sunday), on how many of these 3 days do you

usually drink alcohol?

On the 3 weekend days........................................ 1

On 2 weekend days.............................................. 2

On 1 weekend day ............................................... 3

Not on weekends ................................................. 4 Go to AL.6

Findings

SIMPLICITY

Respondents found this question easy to answer.

UNDERSTANDING ‘WEEKEND’

On the whole, respondents did think about a three‐day weekend when they answered the

question, because they could see the logic that Friday evening was the start of the weekend.

They did not omit Sunday either when producing their frequency estimations.

Recommendation

This question worked well overall, so it can be kept without modification.

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Weekend day quantity

Question AL.5. How many drinks containing alcohol do you usually have on one of those weekend

days (Friday to Sunday) when you drink alcohol?


24 or more drinks...................................................... 1

17‐23 drinks .............................................................. 2

10‐16 drinks .............................................................. 3

7‐9 drinks .................................................................. 4

6 drinks...................................................................... 5

4‐5 drinks .................................................................. 6

3 drinks...................................................................... 7

2 drinks...................................................................... 8

1 drink ....................................................................... 9

Findings

SIMPLICITY

Overall, this question was easy to answer. It was easier for those who had drinking habits

(rituals) and those who knew they never drank more than 'X'. The latter report 'X', meaning that

they usually have their maximum, but some mentioned this was not always the case! … So here,

the estimation is slightly pushed up.

It was more complicated to answer when drinking fluctuated from WE to WE according to

circumstances, or over the 3 WE days… In these cases, the average is supposedly pulled down.

Thus, there is some variation on the manner people reply to this question. Those with a variable

pattern tend to average their consumption and focus on "usual" situations, those who drink

little tend to give their maximum, and those who drink steadily give an exact account.

There is also the sensitivity around the awareness of how much they drink on WE which may

result in under‐reporting. Example: "during usual (as opposed to "big") parties, I drink 4‐5‐6

beers of 50 cl, so (R converts to) 8‐9 of 33 cl… Therefore the category 7‐9 drinks". A more correct

estimation would have been to convert into 8‐10‐12 beers of 25 cl, so category 10‐16 drinks

would best apply, especially because there are some "big" parties where the respondent drinks

more. But this might not have seemed acceptable to report!

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VERY LIGHT DRINKERS AND HEAVY DRINKERS

Contrary to what is mentioned in the UK report, infrequent drinkers are in fact filtered out at

AL1 (in the real questionnaire, where AL1a is not included) and routed to AL6 (verifying for

RSOD), so they are not supposed to answer AL2‐AL5 which refers to weekly drinking.

Heavy drinkers might have the tendency to under‐report how much they drink so it would look

better. There is a risk of social desirability effects affecting answers, and more so in an

interviewer administered instrument than self‐administered.

Recommendation

Globally, there is no major problem with this question and response categories (other than

that stated for AL1a and AL3).

Frequency of having 6 drinks or more on one single occasion

Question AL.6. During the past 12 months, how often did you have 6 or more drinks on one

occasion?

Every day or almost every day ................................. 1

5 ‐ 6 days a week....................................................... 2

3 ‐ 4 days a week....................................................... 3

1 ‐ 2 days a week....................................................... 4

2 ‐ 3 days in a month................................................. 5

Once a month............................................................ 6

Once every 2 months ................................................ 7

Once or twice in the past 12 months ........................ 8

Not in the past 12 months ........................................ 9

Never in my whole life .............................................. 10

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Findings

SIMPLICITY

Respondents had difficulties to understand this question, having to read it over again a few

times. This could be due to translation matters.

Once the question was properly understood, most respondents found it easy to answer and

were confident about their reply.

The French version of this question (from Audit‐C) explicitly mentions "6 or more glasses of

alcoholic beverages (possibly different)…" in the question. The concern in UK about "drinks"

being misinterpreted by including soft drinks is thus not at stake in Belgium.

Regarding the scale, reactions were globally favorable. Most respondents found an adequate

response category, though someone mentioned a gap between 'once every two months' and

'once or twice in the past 12 months'. A few respondents found it too detailed, whereas others

thought it gave the opportunity to each person to find the accurate answer. In general, people

didn't spend much time finding the right category.

OCCASIONS

In French, "occasion" has different meanings: "circumstance, event, opportunity, event's time,

special occasion"… When answering this question, respondents either thought about a special

(lengthy) occasion (an event like a marriage ceremonial, birthday party, family reunion,

summertime barbecue, New Year's Eve) because they cannot imagine drinking 6+ glasses

otherwise than throughout an extended period of time. On the other hand, those who are prone

to have such quantities (6+), defined "occasion" as the same evening, same day, same party,

going out, having a meal with friends, going to the pub..;

Some people thought changing settings made two different occasions, while others considered

an occasion as continuing through several settings. Someone defined it as being "the period of

time between the first drink and going to bed", however extended this might be. Someone else

stated that when a nap took place between two events where a person drank, this counted for

two different occasions.

Recommendation

The question formulation should be revised in French to make it simpler.

The answer options imply regularity of drinking 6+ alcoholic beverages on one occasion in past

12 months. Though this was a problem in UK, respondents in Belgium did not encounter any

difficulty in this respect.

The diversity of comprehension of the statement "on the same occasion" might need

clarification, though people thinking about a special event are usually not the binge drinkers

and report having had this amount less than monthly. While heavy drinkers think about those

times they have six or more drinks, and this is not necessarily on special occasions – and this is

captured with the frequency dimension (they reply at least once a month, usually more).

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Conclusions for the alcohol consumption section

Overall, the questions on alcohol consumption worked rather well, even if the instructions and show

card were rarely taken into account. Nonetheless, some people had difficulties with the principle of

the “usual drinking” approach, because there is no “usual drinking” for them – it depends on their

life circumstances. Splitting the reporting of consumption between week days (where alcohol

consumption is supposed to be lesser) and weekend days (where it is probably higher) allowed to

overcome part of the difficulty due to variability in drinking habits. Still, irregular light drinkers who,

for instance, never have more than 2 glasses when they drink alcohol, found this distinction

inappropriate because they drink indistinctively regarding the days of the week (including

weekends)! These respondents felt more comfortable with the simple questions on frequency on a

whole week and quantity on a usual drinking day (AUDIT questions). However, these sporadic light

drinkers constituted a marginal group.

On the other hand, the cognitive testing enlightened some problems regarding the length and the

wording of the questions, their understanding, the reference period, the response scale categories

and the routing. For these matters, the Belgian Institute of Public Health, in charge of improving the

alcohol section of the EHIS, requested the assistance of an external native English speaking expert in

survey methodology and questionnaire design (Dr. P. Campanelli5) to overcome these problems.

In order to inform Dr. Campanelli on the ongoing improvement process, a series of documents

concerning the alcohol consumption module were provided: the original EHIS questionnaire wave‐1,

the first EHIS‐2 questionnaire and theoretical document presented at the workshop in Berlin

(01/10/2010), the subsequent modifications of questionnaire after feedback from the member

states, the conceptual guidelines of the questionnaire and the translation cards, the probe sheet for

the cognitive testing as well as the country reports on cognitive testing from UK, Germany and

Belgium. Dr. Campanelli’s recommendations for changes and their justification are presented in an

annexed report (4.6).

A new questionnaire on alcohol consumption was produced on the basis of her proposal (see report

in annex 4.6), but also taking into account some suggestions of the country reports on cognitive

testing (annex 4.1 to 4.4) as well as requirement of the EHIS Core Group and Technical Group

members. The suggestion to take up other approaches like the AUDIT questionnaire or the UK

method for measuring alcohol consumption (see UK report in annex 4.1 and DE report in annex 4.4)

was not followed.

The new questionnaire based on the cognitive test results was checked in the next step of the

project, namely during the pilot field test (work package 6). It is included in the field test

questionnaire, annexed to the field test report.

5 http://www.thesurveycoach.com/campanelli_surveycoach.html

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Introduction

Two batteries of questions on physical activity were tested:

The National Health Interview Survey NHIS‐PAQ (Section A: Q3 ‐ Q5), referring to leisure time

physical activities;

The International Physical Activity Questionnaire IPAQ‐SF (Section B: Q6 – Q9), on total

physical activities during the past 7 days.

The aims of testing the physical activity questions were to find out which one of those sets of

questions – NHIS‐PAQ vs. IPAQ‐SF – worked better in terms of ease to answer, wording of the

questions and certainty of responses given (i.e., recall and social desirability issues). It was also

examined how the respondents calculated the frequency and the duration of the physical activities

reported, as well as what decision process was used to classify activities as ‘light/moderate’ or

‘vigorous’.

The probes relative to the cognitive testing process (see probe sheet in appendix) were designed in

order to find out which questionnaire produced the more accurate results.

2.2.4.1. Overall findings: Which set of questions is better, IPAQ or NHIS?

Preference and ease to answer

In the Belgian sample, the overall impression from the whole physical activity section was

that people were struggling with both questionnaires. Probing on this matter revealed that 6

respondents out of 11 found that the questions of both sections were “HARD” to remember

and/or to answer. When asking specifically for each section, 9/14 respondents found that

Section A (NHIS‐leisure) was difficult and 10/15 respondents found that Section B (IPAQ‐

total) was difficult. IPAQ questions are specifically too long and complicated to understand.

However, a higher number of respondents (9/15) PREFERRED answering the IPAQ because it

refers to everyday life activities, so they could report more activities and felt better about it!

They also preferred the short time frame (7 days) for recalling, though some people felt

frustrated when the last seven days were not representative of their usual pattern of

activities.

On the other hand, others were irritated answering the leisure‐time activity questionnaire

(NHIS) because it made them look inactive, while they considered that they actually

performed activities, like bicycling to work, walking to go shopping or cleaning the house.

o One must keep in mind that a contamination between questionnaires might be operating:

having answered the first set of questions makes it easier to answer the second.

137

For some people though, it was DIFFICULT to add up the time spent in total time activities in

IPAQ because they don’t consciously think about what they are doing, so they felt they were

missing out activities that they couldn’t really recall.

Those who preferred the NHIS set regarding leisure time activities argued that the questions

(activities) were more focused, straightforward and specific, requiring less calculation. This

section was EASIER for the people that didn’t do any sports at all or, on the opposite, for

those that had regular (weekly fixed) sport activities… but it became more DIFFICULT to

answer if leisure time exercises were irregular, punctual or seasonal (skiing, hiking,

opportunistic activities…)

Understanding the concepts

Considering the conceptual coverage of the questionnaires, it appeared that the notions were

understood and were considered differently in the sample:

LEISURE TIME PHYSICAL ACTIVITIES

For some people, leisure time physical activities strictly referred to activities you do “for fun”,

because you like them. For others, activities done “to stay fit” should also count, even if they are

disliked. One person (F: 42) just couldn’t consider the concept of “physical activities” otherwise

than as being leisure activities (or else they would be called “labor activities” instead of “physical

activities”!). A student (F: 15) reported school‐time activities such as gym and dancing (8

hours/week training) as leisure time activities because she liked them, whereas other students

didn’t take these types of activities into account because they were during school.

In the same vein, some people considered that “leisure time activities” cover everything outside

working hours, including housework like cleaning and working in the garden, even if bearing

some kind of “obligation”. Finally, all kind of activities on spare time were sometimes taken into

account (i.e., commuting by foot or by bike, having sexual intercourse, painting, playing a music

instrument), while not all respondents thought of including them..

INTENSITY OF PHYSICAL ACTIVITIES

Variability was also found when “vigorous ‐ vs. ‐ moderate” activities were defined. What was

seen as “intense” physical activities for some people was considered as “moderate” for others.

Besides, respondents tended to count all their activities as “vigorous” because they were keen to

report them (social desirability!), and were not aware that a question on “moderate” activities

was coming after… This “primacy” bias could be avoided by an extra introduction statement (“we

will first consider vigorous activities, then less intense ones”) or, as respondents suggested, by

having the questions in a self‐completion form so that they can come back to a reply and change

it.

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Some people didn’t grasp the distinction that was made between the two levels of intensity, not

knowing in which category their activities fitted best.

The term “vigorous activity” is translated as “intense activity” in French. This leaded to some

confusion in a student (F: 15) who referred to intensive training in dancing (several full days for

preparing a show), though she was not actually dancing during the whole days…

Sensitivity issue

o Only a few respondents wondered why the questions on physical activity might prove

embarrassing for some people. Someone (F, 61) said she wasn’t ashamed not to practice sports

because she did many other things instead. But most respondents reckoned that for some

people it could be difficult for them to admit not doing any physical activities.

o Respondents generally suspected that people would give an overestimation of the frequency and

time spent on leisure time activities. Social desirability was seen as an issue in this respect.

Recommendation

Both questionnaires are complex, cognitively demanding and require much attention,

especially if the respondent doesn’t have the questions in sight. If these instruments are to

be kept – which wouldn’t be advisable in a full EHIS survey – they should be delivered in a

self‐completion format.

NHIS questions (Q3‐Q5) proved to be difficult to account for, especially in people that do

not have regular sport activities. A clear definition of “leisure time activities” should be

given beforehand, as well as an introductory statement specifying that questions will first

enquire about “vigorous” activities (provoking a large increase in heart rate and breathing)

and then will ask about “moderate to light” activities (inducing a slight increase in heart

rate and breathing).

IPAQ questions (Q6‐Q9) were less frustrating for people who considered themselves as

physically active despite that they didn’t have regular sport activities, and for the

retired/elderly people. A question on activities outside leisure time should definitely be

kept, even if not considered as “health enhancing” in the public health arena.

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2.2.4.2. Detailed results: NHIS questions on leisure time activities

Questions

The next questions are about physical activities (exercise, sports, physically active hobbies...) that you may do in your LEISURE time.

Q3: How often do you do VIGOROUS leisure‐time physical activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?

Q3a: About how long do you do these vigorous leisure‐time physical activities each time?

Q4: How often do you do light or moderate leisure‐time physical activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate?

Q4a: About how long do you do these light or moderate leisure‐time physical activities each time?

Q5: How often do you do leisure‐time physical activities specifically designed to strengthen your muscles such as lifting weights or doing calisthenics?

Understanding the concepts

VIGOROUS

Under the concept of “vigorous” activities, respondents gave examples such as sports’ club

(general), running, playing tennis and badminton, doing fitness exercises, brisk bicycling,

intense sexual activity, etc.

For most, “vigorous” meant there was a lot of sweating involved, aching muscles, heavy

breathing… It implies making an effort, going beyond your strength and will. A person said

‘vigorous’ is when one comes out really exhausted from doing these activities. Though not all

respondents referred to such a definition when answering Q3‐Q3a, they just focused on

“leisure time” physical activities – not on “vigorous”.

Confusion in concepts came later for some respondents, when the question on moderate

activities was asked. They were not sure anymore whether the activities they reported as

“vigorous” were properly classified. All of a sudden, vigorous activities sounded to them like

training for competition‐level sports, whereas moderate activity was more what they were

actually doing. This was confusing for them; some even changed their answer on Q3‐Q3a and

shifted it to Q4‐Q4a.

MODERATE OR LIGHT

The examples for “moderate or light” activities was leisurely walking, swimming and bicycling

(not brisk!), gardening, painting or playing an instrument (effort for the arms), less intense

sexual activities, or the warm up period just before the sports get more intense. Fitness was

also mentioned here because, the respondent (M: 80) said: “you exercise at your own pace,

10 minutes abdominals, 10 minutes cycling – you stop when your muscles hurt”.

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One person (F: 38) said “ironing, cleaning, shopping, walking for short itineraries, otherwise I

don't see clearly, to park the car perhaps? ...I thought about that when answering... small

efforts in daily life activities...".

People practicing yoga had difficulties to place it somewhere: on the one hand, it is physically

demanding and some exercise really put strain on the body, but on the other hand, yoga is

also about learning to control the breathing and lower the hart rate, making it more regular…

so it doesn’t correspond to the definition in the question “increase in heart rate and

breathing”.

MUSCLE STRENGTHENING

Confusion on this question is well described by this respondent (F: 24): "Muscle

strengthening is an objective, and it's not especially mine! But all sports reinforce muscles..;

so when I run, I don't know whether this enters the category because it's not my objective to

reinforce my muscles. So it's not very clear…”.

For some respondents, it was very clear and straightforward: “it is bodybuilding, nothing

else”.

One respondent was thinking about the need to strengthen muscles to relieve back pain (F:

60): “For [some people] it will be lifting weights in order to look better, but for me it's working

on my abdominal muscles to strengthen my back".

Another respondent declared (F: 42): “Working the muscles, not necessarily abdominals.

Yoga and Pilates exercises reinforce the muscles, but “smoothly” (“en douceur”). Probably

people don't think of reporting them here!”

And still others included heavy labor, forgetting the idea of “leisure time” activities: “it also

implies hard work in the construction industry like masonry, building and all that…” (F: 61).

Conclusion

All in all, these questions were difficult for the respondents. Some respondent could

clearly grasp the difference between vigorous – vs. – light and moderate activities, but

others got really confused. Confusion also came from the fact that leisure time covered

different meanings, so for some, only pleasant activities were taken into account, while

for others, daily activities like ironing, cleaning and shopping were included, because

outside the paid work time. It was also difficult for some respondents to keep in mind the

reference to leisure time activities when thinking about the intensity of activities

(example: masonry for strengthening the muscles). Muscle strengthening was also

understood in various ways and people were not sure what to report or not.

We recommend to simplify these questions or to better define them

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2.2.4.3. Detailed results: IPAQ questions on total physical activities

Questions

I am going to ask you about the time you spent being physically active in the last 7 days. Please answer

each question even if you do not consider yourself to be an active person. Think about the activities you

do at work, as part of your house and yard work, to get from place to place, and in your spare time for

recreation, exercise or sport.

Q6: Now, think about all the vigorous activities which take hard physical effort that you did in the last 7

days. Vigorous activities make you breathe much harder than normal and may include heavy lifting,

digging, aerobics, or fast bicycling. Think only about those physical activities that you did for at least

10 minutes at a time.

During the last 7 days, on how many days did you do vigorous physical activities?


Q7: Now think about activities which take moderate physical effort that you did in the last 7 days.




During the last 7 days, on how many days did you do moderate physical activities?


Q8: Now think about the time you spent walking in the last 7 days. This includes at work and at home,

walking to travel from place to place, and any other walking that you might do solely for recreation,

sport, exercise, or leisure.

During the last 7 days, on how many days did you walk for at least 10 minutes at a time?



Reporting past 7 days activities and time doing them

In some cases, there was contamination of the two sets of questions (NHIS > IPAQ). People

based their reply on leisure time activities – if regular – then added extras (like moving or

carrying furniture or working in the garden) if these activities took place in the past 7 days.

Differentiation was usually easy for these people.

But a few respondents couldn’t make the difference with regard to the leisure time activities.

Example: “The questions were difficult...For me, a vigorous activity can only be "sport",

otherwise I don't see what it could be...[...]..." (F: 38).

Someone (F: 42) also mentioned that “the questions are difficult: they are too long and the

distinctions that have to be made are difficult because everything is linked”.

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As one respondent pointed out: "Everything is relative. What can we call "vigorous"? [...] "If

you consider that I have to vacuum and clean the house in laps of one hour, for me, I call that

a vigorous activity. And I've done that 4 times this week” (F: 60). Of course, for others,

vacuum cleaning is reported as a “moderate” activity!

The same kind of thought was brought up for “moderate” activities, as in the following

example: “I looked at what've done more or less… I find this a bit complicated... the others

questions [modules] were easier. If the questions [on physical activities] were only about

sport, it would have been easier...here, it's more difficult, less precise because in your daily

life, you do what you have to do... I don't look at how many hours I spend cleaning, or when

I'm ironing, or when I have to move to go here or there... I don't know how much time it

takes... So you try to estimate the time spent... And all these questions are relative [from one

person to the other things are experienced differently, what is a vigorous activity for an old

women, it's nothing for a sportive young man]..." (F: 38).

When calculating the time spent on one of those days the activity took place, either

respondents had a precise reference in mind and reported it, or they average the activities

(tennis for 1h on one day, moving a friend for 2 hours on another day, so report 1:30) or still

they choose the maximum activity day on the past 7 days. One respondent honestly stated

when asking how she came to her reply: “I can't remember what I answered and I can't even

tell how I calculated!” (F: 42).

Generally, respondents had the 7‐day time frame in mind. Some just reported usual

activities, though, because they said it made no difference. Nevertheless, one can question

the accuracy of their answer if they didn’t make the effort to try to actively recall activities of

the past 7 days. But do people really think back in detail about the past 7 days? Not really,

considering the following statement: “I remembered the last 7 days, but not in details,

analyzing what I've done exactly… I thought "for the moment I do that…" (F: 38).

Reporting about walking

The question concerning walking was often difficult for respondents to answer, because this

activity is perceived as being “automatic”, without conscious recognition.

Retrieval over the past 7 days was a cognitive challenge for some respondents. For instance,

10 minutes in a row for the elderly is a limit they have to think about: “when I walk the dog…

no, it’s not more than 10 minutes… when I go shopping? Yes, it's possible, shopping in the

supermarket with all these long corridors, then I have to go there and come back, 3 or 4 times

per week, it's more than 10 minutes in a row!” (M: 80).

For most individuals, though, it was easy because: “When I go to work and back […] it's

always more than 10 minutes in a raw" (M: 29). Or “When I walk, I try to walk at least 30

minutes” (F: 61).

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Estimating the time spent on walking was done in different manners: some calculate what

they usually walk on a typical day (going here or there and adding up). Most find it difficult to

estimate: Ex. “it was complicated... It's only if a person has specific activities planned in a

determined schedule, then it's easy. But me... Apart from my yoga, I walk perhaps a bit more

during the weekend, less during the week" (F: 60). Still others found it impossible: “It’s very

variable – I couldn't answer! What does "usually" mean when we refer to the past 7 days??

Should Ii report that day I walked the most? It's weird! "Usually" should be removed from the

question!” (M: 40).

Reporting about sitting

People that have a current job generally referred to an ordinary work day and didn’t consider

the weekends. They thought of a typical day – how much time they spend behind their office,

then they add time at home eating, watching television or reading… For instance: “I counted

when I was in my car, at the computer, when eating, all times when I sit. I averaged, did not

think of particular days… I was focused on working days though” (M: 40).

The others have variable techniques to estimate sitting time without a clear reference. Some

tried to recollect what they were doing during "a normal day", in general, during the week.

Ex.: “Morning ‐ breakfast, noon ‐ lunch, evening/night ‐ dinner + reading or watching TV +

reading in bed… In general, it's like that" [R though about a "general week". She left out

exceptional events such as going to the movie theater, visiting a friend... because it was not

recurrent] (F: 60). But beware: some respondents did report going to the movies or the

theatre!

Some respondents included the time spent eating or sitting in transportation (car, train, etc.),

others didn’t, because it was not considered as relaxing: “Well I thought about the time I

spend relaxing or when I'm tired, after I've finished my activities. Everybody sits to eat, so why

count that? I didn't count being in my car either! That's not relaxing” (F: 60).

Conclusion

The IPAQ questionnaire gave people trouble:

1. to understand the questions (too long) and the concepts (too vague, too difficult to

distinguish);

2. to retrieve the required information (not conscious, not regular);

3. to estimate the time spent on it (add up? Average? Pick one day or ‘usual’? What activities

to include in calculation? Etc.).

4. This led to the impression of uncertainty in their answers. It also leads to questioning the

reliability and validity of this instrument in the framework of a face‐to‐face health

interview survey.

144

145

2.3. Report EE (NHID)

Improvement of the European Health

Interview Survey (EHIS)

Eurostat grant no 10501.2009.007‐2009.890

Cognitive testing of three modules in Estonia

Report

Tallinn 2011

146

The report is prepared by

Leila Oja, Researcher, Chronic diseases department

Elin‐Külliki Kruusmaa, Analyst, Department of health statistics

Ardo Matsi, Analyst, Chronic diseases department

National Institute for Health Development

Hiiu 42, 11619 Tallinn, Estonia

www.tai.ee

147

2.3.1. Methods

This qualitative study comprised a set of 15 face‐to‐face interviews which were carried out in Estonia

during February 2011 and using the methodology of cognitive testing. The study was performed as

part of the four‐country cross‐national cognitive interview study in the context of the ‘Improvement

of the EHIS modules project’.

The interviews were conducted in Estonia using a translated Estonian version of the standardized

probe document elaborated in January 2011 in coordination with the partners of the project –

Robert Koch Institut (RKI), Germany; Scientific Institute of Public Health (IPH), Belgium and National

Institute for Health Development (NIHD), Estonia as well as the subcontractor of the main partner

RKI, the National Centre for Social Research (NatCen), UK.

The sample population was a non‐probability sample of people with residence mainly in Tallinn but

as well in some smaller towns in Estonia. The mother tongue of the respondents was Estonian.

The respondents were recruited according to the criteria (gender and age category) defined in

cooperation with the partners of the project during the coordination meeting that was held in Berlin

in January 2011.

The interviews took place in the localities of the National Institute for Health Development in Tallinn

or interviewers visited the respondents at home. The interviews were conducted by six trained

interviewers. The interviewer training was based on the standardized training material and the

training was conducted from 14th to 15th of December 2010 by the trainer Mrs Merle Paats licensed

by NatCen, UK.


Age group Male Female Total

15−20 EE‐51 (M:15) EE‐21 (F:20) 2

(1 male/1 female)

21−39 EE‐61 (M:33)

EE‐63 (M:30)

EE‐13 (F:33)

EE‐62 (F:29)

4

(2 males/2 females)

40−59 EE‐24 (M:45)

EE‐52 (M:46)

EE‐12 (F:54)

EE‐22 (F:54)

4

(2 males/2 females)

60+ EE‐11 (M:61)

EE‐23 (M:79)

EE‐31 (F:66)

EE‐32 (F:60)

EE‐71 (F:81)

5

(2 males/3 females)

Total 7 8 15

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Two sets of questions on physical activity were tested: the National Health Interview Survey

NHIS‐PAQ (Q3−Q5) and the International Physical Activity Questionnaire IPAQ‐SF (Q6−Q9).

Both sets of questions were assessed by means of face‐to‐face interviews. The physical activity

module did not include show cards.

For output of the cognitive testing were formulated questions to help identify which of the

questionnaires works better. The questions were divided into three sections: General probes (both

sections), General probes for the leisure‐time physical activity questions (section A) and General

probes for the total physical activity questions (section B).

The following questions were asked:

General probes (both sections)

P: Which set of questions was easier to answer?

P: Which set of questions did Rs prefer answering?

1. Set A: Leisure‐time physical activity

2. Set B: Total physical activity

3. Or do you not have a preference

P: In general was it easy or hard to remember physical activities for Rs?

General probes for the leisure‐time physical activity questions (section A)

P: How were these questions for Rs?

P: Was it easy or hard to answer these questions?

P: What came to mind when R answered these questions?

P: Was there a particularly difficult statement for Rs?

P: How did Rs remember that?

General probes for the total physical activity questions (section B)

P: How were these questions for Rs? Was it easy or hard to answer these questions?

P: What came to mind when R answered these questions?

P: Was there a particularly difficult statement for Rs?

P: How did Rs remember that?

2.3.3. Overall findings: Which set of question worked better: NHIS or IPAQ‐SF?

Detailed results of the above questions are shown in the table below. First, some general

conclusions:

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NHIS

Pro: (1) NHIS was easy to answer (2/15)

(2) The questionnaire is appropriate assessment of leisure time PA, and is suitable to

physically active people.

Con: (1) hard to define leisure time, what is if there is an obligation (gardening, chopping wood)

(2) was easier if respondents have some weekly training plan.

IPAQ‐SF

Pro: (1) IPAQ was easy to answer (9/15)

(2) The questionnaire is an appropriate tool to evaluate total PA and collect information

about sedentary behaviour.

Con: (1) If ‘the last 7 days’ were different than their ‘usual week’, respondents felt answers did not

represent correctly their activity level.

(2) If respondents have no weekly training plan, then they can include all of their activities,

especially if their job includes activities (majority of cases).

Preference NHIS vs. IPAQ

Altogether, there were 15 respondents who participated in cognitive testing. 2 respondents

preferred NHIS questionnaire and 9 respondents preferred IPAQ questionnaire. There was no

preference between the questionnaires for 4 respondents.

150

Table 19: Results of cognitive testing for Leisure‐time PA and Total PA questions

Probes Answers General probes (both sections)

Which set of questions was easier to answer? Set 1: Leisure‐time PA (NHIS‐PAQ)

Set 2: Total PA (IPAQ‐SF) Don’t know/refusal

Quantitative results N (%) 2 (13,3) 9 (60,0) 4 (26,7)

Qualitative results (Reasons)

It depends, if respondent has some fixed schedule. Then it is easy to answer.

If respondents have no fixed schedule, then they can include all of their activities, especially if their job includes physical activities.

Which set of questions did R prefer answering?

Set 1: Leisure‐time PA (NHIS‐PAQ)

Set 2: Total PA (IPAQ‐SF) No preference


In general was it easy or hard to remember physical activities for Rs?

Easy Hard Don’t know/Refusal

Quantitative results N (%) 8 (53,3) 7 (46,7)


If respondent has certain routine, then it is easy, otherwise the activities vary.

* Difficult to compute average number – weekdays and weekends are completely different. * Days include a lot and different kind of activities, hard to remember and estimate the intensity.

General probes (section A versus section B) Set 1: Leisure‐time PA (NHIS‐PAQ)

Set 2: Total PA (IPAQ‐SF)

Was it easy or hard to answer these questions?

Easy Hard Easy Hard Don’t know/Refusal

Quantitative results N (%) 8 (53,3) 7 (46,7) 10 (66,7) 2 (13,3) 3(20,0)* IPAQ don’t know


Hard to define “leisure time”. If there is an obligation, then it is not leisure time activity (gardening, chopping wood).

* If “last 7 days” were different than their “usual week” (because of illness), then respondents felt, that their answer did not indicate their usual activities. * In IPAQ introduction there should be mentioned, that there are separate questions about vigorous and moderate activities, it gives respondent a better clue.

151

Comparison of the results of cognitive testing in the age groups

How to understand the PA concepts and definitions at different ages? The table below lists the

various comments on the issues by the respondents at different age.

Table 20: Comments for NHIS and IPAQ by the respondents of different age groups

Age

group

Comments for NHIS

Comments for IPAQ

15−20 Unpleasantly specific questions (M:15). Difficult to answer, mostly because there is

no need for such things to remember (F:20).

21−39 Who is not active during leisure time cannot

answer (F:29). Confusion about what to

consider and what not. In some question it is

necessary to take walking into account, and

in another, not. Is sports walking included to

walking or not? All depends on the intensity,

after all (F:33).

Difficult to answer (M:33).

Intensive vs. moderate, the time was also

difficult to calculate. For example, if there is

a training plan, it is easier to answer (M:30).

40−59 Questions are understandable; however it is

difficult to answer (F:54). The concept of free

time does not work (M:46). If you do not go

to the gym on a regular basis it is difficult to

answer (F:54).

Vague questions. It is easier to answer a

direct question, as “how many times a week

do you do sports?” (M:46). “Lying down” in

the question caused confusion (M:45).

60+ Free time is hard to distinguish from the rest

of the time (M:61).

As for a pensioner free time equals to his/her

total time, so for retired persons, this

question does not fit (F:81). The wording in

questions is complicated, difficult to

understand (M:79).

The total physical activity questionnaire has

been more specific (M:61). Difficult to give

a clear and short answer (F:81).

If you go in for sports or have trainings

somewhere, i.e. fitness centre, then it

would be easier to remember and easier to

define the time (F:66). Without individual

training plan it is difficult to answer these

questions (M:61).

In each age group there were representatives to whom both questionnaires were ambiguous. In each

age group there were problems of understanding the concept of leisure time (NHIS) and calculating

the time that was spent in a physically active state (IPAQ).

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Respondents in each age group felt that it would be easier to answer if there is a regular training

plan. With increasing age the attention to details decreased in both questionnaires. When the

younger respondents (21−39 year old) found that it is difficult to distinguish between the moderate

and the vigorous activity (IPAQ), or considered walking to be part of leisure time activities (HNIS),

then the older respondents (60+) felt that the whole questionnaire is difficult to understand.

Specific findings

Similarity

Generally the respondents understood the questions in both modules. Still, both the questionnaires

were difficult to respond because of the different physical activity levels: moderate and vigorous.

There was also a problem with evaluating the given timeframe (10 min) spent in activity.

Simplicity

During cognitive testing it was noticed that respondents had difficulties remembering the time they

had spent walking or sitting. For calculating the total amount, they did not include irregular walks, for

example.

Sensitivity

Questions were not representative of daily activities. The question about sitting caused

embarrassment. If a persons’ main job is sedentary, a big amount of time is shown.

Recommendation for this: It is necessary to distinguish between work‐related PA and sedentary

activity outside working hours.

Reference period

It was remarked that the last 7 days (IPAQ) may not be representative for regular days. One of the

respondents said that for the last 7 days, he had not lived his normal life and the answer is not

representative for his usual daily actions. It may be used if the respondent has to consider only the

usual 7 days. It should be fixed in the interview’s manual whether the 7‐day reference period is

counted from Monday till Sunday or is it counted backwards 7 days from the day of the interview.

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Recommendation

Consider using the IPAQ rather than the NHIS module although both questionnaires have their

weaknesses.

• IPAQ questionnaire covers all aspects of physical activity and gives therefore a more

objective view of the person’s activities while NHIS gives only a limited view of the

respondent’s activities.

• Respondents preferred IPAQ, because they had no certain leisure‐time activities and they

are more active in summer, but now (in winter) it is hard to remember these activities.

• IPAQ has some limitations too – as weekends and weekdays have different intensity, it is

hard to calculate the average.

• If respondents have a certain exercise schedule, NHIS would be easier to fill in.

• If one of the questionnaires will be used the strong recommendation is to improve the

wording and shorten sentences according to the findings of the cognitive testing.

Especially, clear definitions of “vigorous” and “moderate” should be given as well as

distinction between the degrees should be underlined.


During cognitive testing two mental health questionnaires were tested ‐ Q1 (Patient Health

Questionnaire ‐ HQ‐9) and Q2 (Mental Health Index‐5 ‐ MHI‐5/EVI).

Technical characteristics of Question set 1 (PHQ‐9):

composed of 9 items

gives a four‐point answer scale

two‐week reference period

specifically measures depression

Technical characteristics of Questions set 2 (MHI‐5/EVI – drawn from SF‐36):

composed of 9 items

gives a five‐point answer scale

four‐week reference period

specifically measures psychological distress

Both question sets were assessed by means of face‐to‐face interviews. Interviewers handed out

show cards on which the answer categories for the respective question were to be depicted.

The general aim of cognitive testing of the mental health questions was to find out whether one of

the questionnaires PHQ‐9 (Q1) or MHI‐5/EVI (Q2) better describes the demand of EHIS2.

The following questions were asked:

Do the two sets of questions overlap?

Is there an overlap of the statements within one question?

Do Rs understand the wording of specific questions?

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Was there any question that made Rs feel uncomfortable?

How did Rs use the answer scale? Did they find it easy to place themselves on it & differentiate

between points?

How did Rs decide on their answer? (I.e. is it compared to others, compared to their

needs/wants, etc?)

2.3.5. Overall Findings for Q1 (PHQ‐9) and Q2 (MHI‐5/EVI)

The following table describes the similarities and differences between PHQ‐9 (Q1) and MHI‐5/EVI

(Q2): are the questionnaires overlapping or not; is one set of questions easier to respond than the

other and how the different reference periods work for respondents.

155

Table 21: Comparison of Q1 (PHQ‐9) and Q2 (MHI‐5/EVI)

Probes Answers

Overlap between Q1 and Q2

Overlap No overlap Don’t know/Refusal

Quantitative results N (%)

11 (73,3) 2 (13,3) 2 (13,3)

* There is an overlap of emotions between the two sets, but Q1 has more negative and Q2 has more positive nature (F:20)

* One questionnaire is the opposite of another (M:33)

* It seemed like cross‐examination, that later the results will be checked (M:61)

* Negative vs. positive approach (M:30)

* Meaning of the questions was the same (F:33) * No difference at all (M:79)

Qualitative results (important citations)

* Did not notice any difference except different reference periods (M:46; M:45)

Was one of the questions easier to answer than the other?

Q1 was easier to answer Q2 was easier to answer No difference/Don’t know or refusal


2 (13,3) 3 (20,0) 9 (60,0) / 1 (6,7)

* Q1 has less answer categories so it was easier to choose (M:61)

* Q2 was easier (F:54) * Some Rs expressed unwillingness to response in the beginning of the interview (M:45; F:54)

* Q2 had some difficult terms – like what “happy” means? (F:54)

* Q2 seems more positive, so it is more comfortable to answer (F:20)

* Quite similar because feelings and emotions have been stable for a long time (M:33)

* Both were very hard to respond. Why you are asking so confusing questions? (M:79)

* It is hard to acknowledge your weaknesses (M:45)

Qualitative results (reasons)

* Lately there have been less worries and therefore it was simple to respond (F:66)

How did the different reference periods work for you?

Worked well Did not work well Don’t know/Refusal

Quantitative results N 13(86,7) 2(13,3)

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(%)

Qualitative results * No difference, feelings/mood have been the same (M:33)

(important citations) * For a longer period it may be even better to generalize the mood or emotional condition (F:66)

* At first I recognized my present mood and then thought back for some time (F:60)

* Feelings were almost the same for both periods. I suggest to ask better “during” some period rather strictly about last 2 or 4 weeks (M:61)

Was it easy or difficult to keep the different reference periods in mind (two weeks vs. four weeks)

It was easy It was difficult Don’t know/Refusal


12 (80,0) 3(20,0)

Qualitative results * Feelings have been stable for the last half of a year, so there are no difficulties. (F:54)

(important citations)

* 2 weeks is a more concrete period and 4 weeks more like “last time” (F:33)

* Hard to express feelings during a certain time‐period (M:61)

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2.3.6. Specific findings

Similarity

In general, a great majority of respondents found the questions in sets overlapping. Concerning the

simplicity of the questions most of them responded that both sets are similarly easy (or similarly

difficult) to answer and they could not position themselves in favour of one or the other alternative.

The main reason to prefer Q2 was because this set has a more positive attitude. At the same time

few respondents noted that the response categories in the Q1 and Q2 are placed in the opposite

order (the first response choice in Q1 is „not at all“ vs. in Q2 ‐ „all the time“), and that is confusing.

Simplicity

Regarding the simplicity of two sets of questions we cannot bring out one clearly polarized

preference.

Some of the respondents stressed that it is easy to respond when you do not have problems with

depression (i.e. you are composed and content with yourself) and very difficult when you have

corresponding problems. Quite a few told that the feelings/ emotional states described in the

questions were very familiar to them in the past but do not correspond to them at present.

Regarding the simplicity of the wording of questions some respondents pointed out problems

concerning difficulties to bind up the different aspects of the question with the concrete response

category. In contrast to Q2 where there is only one concept per question there are two (“poor

appetite or overeating”; „speaking so slowly or being so fidgety or restless“) or even three („trouble

falling or staying asleep, or sleeping too much“) opposite statements in Q1. Many respondents

argued that they would prefer to respond to every separate description of a physiological or

psychological condition separately because there is no general response to every aspect in the

question.

Concerning translation of MH (mental health) questions most respondents confirmed good

understanding of wording. No one refused to response due to misunderstanding of wording of the

sentences.

Sensitivity

Regarding the sensitivity we have asked the respondents whether they prefer answering “face‐to‐

face” or in a “self‐administered” mode of interview. The respondents who had or have had problems

with mental health or more sensible persons expressed clearly that they reckon most of the MH

questions too personal and would prefer to respond in self‐administered form. Most of the other

respondents agreed that for many people the MH questions could be too private and it could be

more difficult to respond in “face‐to‐face” mode.

Concerning Q1 one respondent recognized it as psychiatric questionnaire for measuring depression.

Some persons told that the last question in Q1 is very depressive and inconvenient to reply, they felt

it too personal.

158

Reference periods

One aim of the testing was to find out whether the different reference periods (two weeks in Q1 and

four weeks in Q2) cause confusion for the respondents. Results of testing showed that most of the

respondents found it easy to keep the two different reference periods in mind and they did not

prefer one reference period to the other. The main finding concerning different reference periods

was that shorter period could describe more the short‐term emotions (sometimes episodic and not

fundamental) and the longer one corresponds more to the common mood of the respondent.

Answer categories

Most respondents found the response categories suitable for them but they noticed that Q2 (5

categories) gave more choices than Q1 (4 categories). Some respondents argued that in Q1 there is

missing a response category between “not at all” and “several days”, they would prefer that the

additional category “in few days” or “sometimes” would be added.

It was also pointed out that there is an opposite categorization of response choices in the question

sets, and that was a little confusing – one of them is starting with minimum frequency and another

with the greatest one.

So we suggest that when both sets of questions will be used in the survey then the order of response

categories should be the same irrespectively of which category of regularity („not at all/none of the

time“ or „nearly every day/all of the time“) would be put to the first position of responses.

Show card

For simplification of choosing the suitable response category and to avoid the need to repeat the

answer categories the corresponding show cards were given to the respondents in the beginning of

both testing. Most of the respondents found the show cards useful except a few older people who

had bad eyesight or had forgotten to take along their glasses.

We have noticed that those respondents who felt uncomfortable at the time of testing preferred to

give their responses in numbers not in sentences. So, in order to minimize inconveniences and

increase confidentiality of respondents’ answer we suggest allow the respondents to respond in

numbers instead of sentences.

Recommendations

1. As the sets of questions overlap each other only one set of questions can be used in next

stages of the survey. Regarding the excessive sensitivity of Q1, Q2 should be preferred.

2. Even if administering the module in a face‐to‐face interview did not seem to disturb or

frustrate many of our respondents, there was a clear preference to respond in self‐

administered form among those persons who felt the questions too personal. Most of the

respondents didn’t have any mental problems and for them orally answered questions

were well acceptable.

3. Concerning sensitivity the last question of PHQ‐9 could be excluded.

4. If both sets of questions would be used then there is a definite need to harmonize the

response categories and the timeframe as well.

159


The alcohol consumption module consists of 7 questions: First two questions AL.1 and AL.1a ask

about last 12 months, AL.2−AL.5 ask about average drinking habits on weekdays and weekends

separately and the last question AL.6 asks about consuming 6 drinks or more alcohol on one

occasion.

The first questions of the module AL.1 and AL.1a were self‐administered and questions AL.2−AL.6

were carried out as face‐to‐face interview. For questions asking the quantities of consumed alcohol

(AL.1a, AL.3, AL.5, AL.6) the respondents were asked to use show card.

The objectives of the cognitive testing were to find out:

Were the questions understandable?

Was it easy to answer all the questions?

How did the show cards work?

How did the skips work?

How do the terms “drink” and “occasion” work?

Were the terms “weekend” and “week days” clear to all of the respondents?

Did social norms affect the given answers in desirable direction?

2.3.8. Overall findings

Simplicity/understanding

Most of the respondents found it easy to answer the questions, but respondents who drink very

rarely did not find the categories they needed (F:54; M:45). There was also a problem with irregular

drinkers (F:66), who consumed irregular amounts of alcohol – so, for them it was difficult to compute

the “average”. In the questionnaire we did not use the terms “weekends” and “weekdays”, but “from

Friday to Sunday” and “from Monday to Thursday”. We added the terms in the cognitive test

questions to get respondents’ opinion about these terms.

Sensitivity of questions

Most of the respondents said, that indicating their drinking‐behaviour is delicate and people would

definitely lessen their quantities to acceptable level. People with alcohol‐problems would definitely

deny their problem (F:20). Some respondents said that they did not include “heavy parties”, where

they drink a lot, but which do not take place every week (F:29; M:30).

160

Certainty about answers

Most of the respondents said, that they have certain drinking‐patterns and there is no problem

remembering quantities or frequencies.

Show card

The Estonian show card was constructed according to the most common drinks and quantities. After

the explanations all the respondents found that it was easy to use. Some of the respondents said,

that they had seen such cards before, so there was no problem (F:33).

Answer categories

Answer categories in AL.1 worked fine for most of the respondents, but some of them said, that

there should be “once in a quarter” included (M:79) and “2−3 days a week” (M:45). One respondent

(F:33) said that she has different intensity of consumption through the year – she does not drink for

2−3 months and then drinks more frequently, so it is difficult to find the right category.

2.3.9. Specific findings question by question

AL.1. During the past 12 months, how often have you had an alcoholic drink of any kind?


There was no problem of understanding the essence of the question ‐ duration and the term

“alcoholic drink of any kind” were interpreted in the same way.

Answer categories

This area had three problems as indicated before: there was no suitable variable for people who

drink rarely but more frequently than 1−2 times during 12 months; also, it is hard for respondents

with irregular drinking‐pattern to find a suitable category for themselves and “2−3 days a week”

would have been more suitable for one respondent (M:45).

AL.1a. How many drinks containing alcohol do you have on a typical day when you are drinking?


One respondent did not include “parties”, so she underestimated her quantity (F:33). Everybody

understood the concept of “drink containing alcohol” as an alcoholic beverage, but there was a

discussion with one respondent about the medicine “Doppelherz” which contains alcohol, but is not

considered as an alcoholic drink (F:66).

“Typical drinking day” was understandable for all respondents, but there is a difference between

“drinking day” and “drinking episode”, as “episode lasts as long as you are going to get sober” (M:42;

M:30). “Typical drinking day” did not mean birthdays or other occasions where usually more than the

average amount of alcohol is consumed (F:33; M:30).

161

Answer categories

As the Estonian show card was different (the quantities had fractions – 0.7 l bottle of wine, for

example), there were difficulties in finding the correct category.


drink alcohol?


A respondent who had had contacts with alcoholics did not like it (F:66). Hard to answer, if you drink

rarely (F:54). Others found this question easy to answer, one respondent (M:45) mentioned, that if

he would work on weekends, then the questions would be confusing due to the wording in Estonian.

Skips

Skips were understood correctly by most of the respondents, but some did not find them easy and

needed more explanations (F:54; F:20). Majority of the respondents had no need to use skips.



Answer categories

The categories should be in reversed order (F:32).

AL.4. During the weekends (from Friday to Sunday), on how many of these 3 days do you usually

drink alcohol?


Some of the people indicated, that they usually do not drink on Sunday (F:21; M:45) or if they do, it

completely differs from Friday or Saturday ‐ they drink maybe 1 beer (M:30; M:33).

One respondent said, that there is no need to distinguish between week days and weekends – if a

person has problems with alcohol, he/she will drink anyway (F:66).




Some of the respondents thought about the whole weekend (F:33; F:20; M:15; F:29), others more

about Saturday (M:61; M:30; M:33) or about Friday and Saturday (M:45).

People preferred more general questions as they were shorter (M:33) and 12 months gives more

information about drinking‐habits (F:60).

162



Respondents were remembering it by thinking about parties they have had (M:46).

“One occasion” meant drinking in one evening/night (F:60; F:20), not getting sober between drinks

(M:30; F:29), “it could be one day or one‐time gathering of people” (F:54), in about 3 hours (M:15),

drinking occasion without longer pauses in between.

Answer categories

Most of the respondents found the answer categories satisfying and had no problems finding the one

they wanted; one had no opinion (F:81).

Recommendations

1. Generally, there was no major problem with the AL questions and response categories. The questions were not very sensitive and the use of the self‐completed format is not definitely necessary.

2. The skips should be more highlighted and made visible. 3. Consider to improve the wording of “drink” or add some explanation.

163

2.4. Report DE (RKI)

Improvement of the EHIS

Report cognitive testing DE (RKI)

Berlin, 21.03.2011

164

List of tables

Table 22: Characteristics of respondents participating in the cognitive testing study ......... 166 Table 23: Comparison Similarity/Simplicity of PHQ‐9 (Q1) and MHI‐5/EVI (Q2)................... 168 Table 24: Understanding and overall findings for Q1 (PHQ‐9) .............................................. 173 Table 25: Understanding and overall findings for Q2 (MHI‐5/EVI)........................................ 176 Table 26: Preference for NHIS or IPAQ in relation to PA‐level .............................................. 179

165

2.4.1. Methods

This qualitative study comprised 16 face‐to‐face interviews which were carried out in Germany using

the methodology of cognitive testing. The study was performed as part of the four‐country cross‐

national cognitive interview study in the context of the ‘Improvement of the EHIS modules project’.

The interviews were conducted in Germany using a translated German version of the standardised

probe document. The sample population was a non‐probability sample of people with residence in

Berlin, who had previously participated in the pre‐test of the German Health Interview and

Examination Survey for Adults (DEGS) in 2008. The respondents were recruited by telephone and

received information material about the study by mail. All test persons gave their informed consent.

The study sample was selected using a parallelisation approach, filling up the required subgroup

sample sizes of a standardised age‐sex roster which was described in detail in the method section. All

respondents received an incentive of 20 Euros after completing the interview. The interviews took

place in the localities of the Robert Koch Institute in Berlin or, if requested, interviewers visited the

respondents at home. The interviews were conducted by three trained interviewers. The interviewer

training was based on the standardised training material.

In order to contextualise the respondents’ answers to the probes according to their physical activity

level, mental health state and level of alcohol consumption, we used the information obtained

through the revised questions for the respective modules in order to calculate the respondents’

condition. We assumed that the respondents answered the questions truthfully even though the

questions they were raised under the conditions of a cognitive interview.

The mental health state was determined using the SF‐scales MHI‐5 and EVI. In a first step, we

calculated the 0‐100 vitality score (based on EVI) and the 0‐100 mental health score (based on MHI‐

5) according to the SF‐manual (Ware, et al., 2001). In a second step we computed with STATA 11.0

tertiles for each of the 0‐100 scores in order to group respondents into three groups of ‘low’,

‘moderate’ and ‘high’ vitality and mental health, respectively. In the last step, we arranged the

respondents into three groups of mental well‐being: low (if both ‘vitality’ and ‘mental health’ were

low), high (if both ‘vitality’ and ‘mental health’ were high) and moderate (for all other combinations).

The physical activity level was calculated using the NHIS‐PAQ questions. Respondents were

categorised into three groups: no = no aerobic physical activity, low = some aerobic physical activity,

high = meeting the WHO aerobic physical activity recommendations for 18‐64 aged adults of 75

minutes ‘vigorous’ or 150 minutes ‘moderate’ or an adequate combination of ‘vigorous’ and

‘moderate’ aerobic physical activity (World Health Organisation, 2010).

The level of alcohol consumption was calculated using questions AL.1 and AL.1a. We arranged the

respondents in three groups: non to light = less than 1 drink per week, moderate = 1‐5 drinks per

week and heavy = more than 5 drinks per week. The particular subgroup boundaries were selected in

order to achieve an equal distribution of respondents over three categories of alcohol consumption.

166

2.4.2. Results

The following table gives an overview of general characteristics of participants included in the study

sample.


Characteristic of respondent No. with characteristic

Male 8

Female 8

Gender

Total 16

U20 2 (1 female/1 male)

20‐39 4 (2 female/2 male)

40‐59 4 (2 female/2 male)

60+ 6 (3 female/3 male)

Age of respondent

Total 16

No 3

Low 5

High 8

Physical activity

Total 16

Non to light 3

Moderate 6

Heavy 7

Alcohol consumption

Total 16

Low 2

Moderate 9

High 5

Mental well‐being

Total 16

167


During cognitive testing, two mental health questions were tested. Question 1 (PHQ‐9) is composed

of 9 items with a four‐point answer scale, referring to a two‐week reference period. The instrument

produces categorical outcomes and can be used as a major depression episode screener based on

DSM‐IV and ICD‐10 criteria. Question 2 (MHI‐5/EVI – drawn from SF‐36) is also made up of 9 items

but includes a Likert (five‐point) scale, asking for a four‐week reference period. The instrument

produced numerical outcomes and can be used to measure mental health and vitality (psychological

distress/well‐being). Both questions were assessed by means of face‐to‐face interviews. Interviewers

would hand out show cards on which the answer categories for the respective question were

depicted.

The general aim of testing the mental health questions was to find out whether PHQ‐9 (Q1) and MHI‐

5/EVI (Q2) could both be asked in the main stage?

More specifically:

Did the respondent feel that the questions were overlapping?

Was it easy or hard to answer the two questions?

Was one question easier to answer than the other?

Was it easy or difficult to keep the different reference periods in mind?

Which concept of answer categories worked better (Q1 versus Q2)?

Did the respondents make use of the show cards? Where they easy to use?

In addition, we looked at Q1 and Q2 separately in order to find out whether…

respondents understood the wording and concepts of the statements.

there was any question which made the respondents feel uncomfortable.

the answer categories were appropriate.

2.4.4. Overall findings: Could PHQ‐9 and MHI‐5/EVI both be asked in the main stage?

In the following section, we focused on the similarities and differences between PHQ‐9 (Q1) and

MHI‐5/EVI (Q2). Furthermore, we compared the simplicity of the two questions regarding wording

and concepts, reference periods and response categories.

The following table illustrates whether respondents perceived an overlap between Q1 and Q2, if the

questions were easy or difficult to answer and which set of question was easier to answer and why.

We stratified the respondents’ answers according to their mental well‐being assessed on the basis of

their answers given to the MHI‐5/EVI question (described in the method part).

168

Table 23: Comparison Similarity/Simplicity of PHQ‐9 (Q1) and MHI‐5/EVI (Q2)

Comparison PHQ‐9 (Q1) and MHI‐5/EVI (Q2) Mental

well

being

Overlap/Similar No Overlap/Different Simplicity

High Questions are similar

Similar, because all questions are personal ones; only difference is time period (female, 40 ‐ 59)

Questions are a little bit different (female, 60+)

Not too similar

Both easy to answer Q2 was easier, didn’t like

‘polarities’ in Q1 (male, U20)

Middle Questions are similar, but also different because of the different reference periods (male, 40 ‐ 59)

Just remembered different time periods, thinks both questionnaires are too general (male, 40 ‐ 59)

No big differences Questions are similar but

Q2 was more emotional (female, 20 ‐ 39)

Questions are not overlapping

Q1 was more about motivation, Q2 about mood (male, 20 ‐ 39)

Q1 more personal, Q2 more general (male, 60+)

Different answer categories, topics differing slightly

Q1 was more "medical", more about physical situation, Q2 more about mental state (female, 20 ‐ 39)

Q1 was more about motivation, Q2 about mood (male, 20 ‐ 39)

Both easy to answer Both not that easy Both easy but answer

categories of the Q1 are better, i.e. Q1 easier

Q2 was phrased a bit unclear and generally more difficult to answer, since statements like "full of life" had to be defined before being answered (female, 20 ‐ 39)

Difficulties in Q2 with concepts of "müde (tired)" and "erschöpft (worn out)" (male, 60+)

Low Similar in their statements, but since the response categories and the time spans were different, they didn't really appear that similar (male, 20 ‐ 39)

Not too similar Q1 was easier, because of the response categories, which were more concrete and graduated more thoroughly (male, 20 ‐ 39)

Q1 was easy, Q2 more difficult (female, 40 ‐ 59)

Similarity

Regarding similarity of the two questions, the testing revealed that there was a mixed perception

among the respondents: Some said that the two questions were similar, both sets being personal.

Some respondents indicated that the questions were similar, but also different, that they were

similar by the statements but different regarding the answer categories and reference periods, that

they were similar but that the Q2 was more emotional. Some respondents said that the two

questions were different. They said that the first set of question was more about motivation and the

second about the mood; that Q1 was more "medical" and more about the physical situation,

whereas Q2 was more about the mental state.

169

Simplicity

In testing the mental health questions, we asked for differences regarding the simplicity of the two

questions. Many respondents stated that both questions were equally easy to answer. Others found

that Q1 was easier to answer, some of them due to the response categories being more concrete and

graduated more thoroughly. Some respondents found Q2 difficult to answer because they had

problems with the concepts ‘full of life’, ‘tired’ and ‘worn out’. Some respondents said that Q2 was

easier to answer because of the contradictory statements in Q1.

Reference periods

As Q1 and Q2 refer to two different reference periods – Q1 asks for the last two weeks, Q2 for the

last four weeks – one aim of the testing was to find out whether the different time periods worked as

intended. The testing in Germany revealed that most of the respondents found it easy to keep the

two different reference periods in mind. One respondent (male, 60+, moderate mental well‐being)

said it was easy because the answers are based on general mental health and two weeks make no big

difference. Some said that the reference period of two weeks was easier to recapitulate and that two

weeks were more situational. One respondent (male, 40 ‐ 59, moderate mental well‐being) said that

a reference period of two weeks was too short (due to the ‘phases of the moon’). Answering half

through the first set of questions, one respondent (female, 20 – 39, moderate mental well‐being) had

to affirm the time period.

Answer categories

Most respondents were able to identify with the answer categories and found a category that

matched their response. One respondent (male, 60+, moderate mental well‐being) commented that

for Q1, the answer category 'every day' was missing and that he had problems with 'half the days',

asking 'which half?’ Another respondent (male, U20, high mental well‐being) did not like the fact that

the answer categories of Q1 referred to whole days, while the statements could also apply to parts of

a day rather than whole days; he preferred the answer categories of Q2 as they were not that

binding. One respondent (male, 40 ‐ 59, moderate mental well‐being) said that there was not much

space to differentiate between answers.

Show card

In order to simplify and shorten the interview, we prepared show cards displaying the answer

categories of Q1 and Q2. Instead of repeating the answer options after each statement, the

interviewers explained the categories once and then asked the respondent to use the respective

show card when answering the question. Most of the respondents found the show cards helpful.

Some used other wordings, even if they had the possible answers in front of them. One respondent

(male, 40 – 59, moderate mental well‐being) indicated that he had trouble with the answer

categories and instead preferred some graphic chart or diagram.

170

Recommendations for asking both PHQ‐9 and MHI‐5/EVI

It is possible to ask both question (PHQ‐9 and EVI/MHI‐5) in the EHIS core questionnaire

Separate the two questions from each other within the health status section

Develop clear instructions as to how interviewers should handle the show cards

2.4.5. Specific findings for PHQ‐9

{READ OUT TO ALL} Mental Health Intro: In the following I will be asking you some questions about

your psychological well‐being.

INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 1

{ASK ALL} Q 1: Over the last 2 weeks, how often have you been bothered by any of the following

problems?

PHQ‐9 Not at

all

Several

Days

More

than half

the days

Nearly

every day

Don’t

know

Refusal



Q1.3 Trouble falling or staying asleep, or sleeping

too much



Q1.6 Feeling bad about yourself‐or that you are

a failure or have let yourself or your family

down

Q1.7 Trouble concentrating on things, such as

reading the newspaper or watching

television

Q1.8 Moving or speaking so slowly that other

people could have noticed. Or the

opposite—being so fidgety or restless that

you have been moving around a lot more

than usual

Q1.9 Thoughts that you would be better off dead

or of hurting yourself in some way

171

Simplicity

In general, the respondents understood the question Q1 as intended and were able to identify with

the respective statements (female, 60+, high: “I never thought about those things, but it was OK to

answer this question, since it is about daily life and life in general”). One respondent found the

question very general (male, 40 ‐ 59, middle: “I could not identify myself (personally) with the

statements, more in a general way”).

Statements asking opposite concepts

Most respondents had no difficulties responding to statements that asked for two opposite concepts

(i.e. poor appetite or overeating). However, some respondents stated that it was difficult for them to

consider contrary concepts in one statement and that it would be easier to split them. Other

respondents seemed to refer only to one of the concepts when answering those questions with

opposite concepts (female, 20 ‐ 39, middle: “Since the question asks about two different concepts, I

thought I can choose which one to refer to”).

Sensitivity

In the testing, most respondents were very reluctant to answer statement Q1.9. Some seemed to be

even shocked by the straightforwardness of the question. Besides, in terms of honesty and

confidentiality, some respondents stated that they might not give a true answer. One respondent

stated that people would answer in a way that they would not leave a bad impression. Another

respondent (male, 20 ‐ 39, moderate mental well‐being) said that people might not answer honestly

since the question is very personal and that some might feel taken by surprise by the sudden and

direct nature of the question. Another respondent (male, 40 ‐ 59, moderate mental well‐being)

stated that he had in fact once been in that situation, and would then not have told the truth. Seen

retrospectively, he said, he would have denied it completely. Another respondent (male, 20 ‐ 39, low

mental well‐being) thought that the problem was that a lot of people were suicidal but wouldn't

admit as suicidal thoughts are culturally frowned upon.

Reference period

Generally, the respondents had no difficulties remembering their feelings and behaviour of the last 2

weeks. Most respondents stated that they did not refer to the reference period but thought about

their feelings in general. Others respondents said that they roughly estimated their mental

constitution of the last weeks. One respondent (male, 20 ‐ 39, low mental well‐being) said: “I thought

about what exactly had happened in the last 2 weeks and if I, since the last 2 weeks were quite

unusual, should consider the two weeks before them to produce a more "regular" situation. I didn't

do that, though. In the end I just recapitulated it all in all intuitively”). One respondent (male, 60+,

moderate mental well‐being) tried to think of any serious events in the given time period, that might

have effected his mental state. One respondent (male, 60+, moderate mental well‐being) stated that

he thought only about the last three days as a longer period would be speculation.

172

Answer categories

Testing revealed that most of the respondents were able to identify with the answer categories of

Q1. One respondent (male, 60+, moderate mental well‐being) noted that the category 'every day' is

missing and that he had problems with 'half the days', asking “which half?” Another respondent

(male, U20, high mental well‐being) did not like the fact that the answer categories were referring to

whole days. He said that statements might fit for parts of days, but not for whole days. Others

preferred the answer categories of Q1 because they were more concrete.

Recommendations for Q1 (PHQ‐9)

Do not ask individual statement 9 for sensitivity reasons (include PHQ‐8)

Include PHQ‐8 after HS.6

Provide a short introduction before asking the questions

PHQ‐8 should be mandatory

173

Understanding (comprehension) of individual statements

Table 24: Understanding and overall findings for Q1 (PHQ‐9)



Q1.3 Trouble falling asleep or sleeping too much

Q1.6 Feeling bad about yourself … or your family down

Q1.8 Moving or speaking slowly…fidgety or restless

Q1.9 …..better off dead or hurting yourself

OVERALL UNDER‐STANDING

FEELING DOWN TROUBLE FALLING/ STAYING ASLEEP


FIDGETY/ RESTLESS


It means inactivity, lack of motivation. When I have to do something that I don't look forward to. (male, 20 ‐ 39, low mental well‐being)"

Little interest or pleasure one can have concerning work. (male, 60+, moderate mental well‐being)

Misunderstood the question: Thought the question first asks for "little interest" and secondly "pleasure in doing things"(male, 60+, moderate mental well‐being)

It means feeling sorrow (female, 60+, high mental well‐being)

It means being unmotivated, tired (male, 20 ‐ 39, moderate mental well‐being)

I feel down when someone disappoints me (male, 60+, moderate mental well‐being)

It means if something is coming up and I cannot handle or cannot control (male, 60+, moderate mental well‐being)

Means that I have difficulties falling asleep, e.g. brood over something, even unconsciously or when I have pain in my body or when my wife snores, i.e. can depend on emotional state/mood or surroundings (male, 60+, moderate mental well‐being)

To be driven by thoughts, by any worries, (…) and therefore cannot fall asleep (male, 40 ‐ 59, moderate mental well‐being)

Trouble falling asleep I have quite often, it means that my rhythm of life is messed up (female, 20 ‐ 39, moderate mental well‐being)

This question is about having a bad opinion about yourself, i.e. when you did something wrong (female, 60+, high mental well‐being)

When others expect something of me that I do not fulfill and vice versa (male, 60+, moderate mental well‐being)

This question is about self‐esteem (male, 40 ‐ 59, moderate mental well‐being)

“Being fidgety or restless” means to me if you don't want or can’t take time to do something calmly or in ease. If you are nervous (female, 60+, high mental well‐being)

I thought in fear of failure and lack of prospects which can also lead to an artificial push, you want to bring something forward but you can't and then you are fidgety or restless (male, 40 ‐ 59, moderate mental well‐being)

“Being fidgety or restless" means not to be able to find peace, being squirrely, etc. (female, 20 ‐ 39, moderate mental well‐being)

It means that people are very sad, that they can not cope with their life, so that they would prefer to do something to themselves instead of living on (female, 60+, moderate mental well‐being)

In principle, it's about self‐destruction, you want to know whether I have suicidal tendencies (male, 40 ‐ 59, moderate mental well‐being)

174

DEPRESSION SLEEPING TOO MUCH LETTING SELF/FAMILY

DOWN OVERALL

UNDER‐STANDING CONFIDENTIALITY

I can imagine that people who suffer from such syndromes might not want to answer this question (male, 60+, moderate mental well‐being)

Definitely too personal! (male, U20, high mental well‐being)

I was in that situation. If I had answered the question then, I would not have told the truth (male, 40 ‐ 59, moderate mental well‐being)

OBSERVATIONS

Feeling down means a form of a little depression (male, 40 ‐ 59, moderate mental well‐being)

Not one respondent referred to it

Letting your family down means to me not having the power to keep the family together (female, 60+, high mental well‐being)

“Having let your family down" can happen when the family expects to much or does not respect small achievements (female, 20 ‐ 39, moderate mental well‐being)

This question is addressing people with nervous illness (female, 60+, high mental well‐being)

This question is addressing old age, dementia and such things (female, 60+, high mental well‐being)

Question seems to be about depression (female, 20 ‐ 39, moderate mental well‐being)

Didn't get that question. Fidgety or restless you can only be for a short moment, not a whole day, or it is a question of personality (female, 20 ‐ 39, moderate mental well‐being)

This is the first question that is about physical aspects. I suppose it aims at the point when the psyche has effects on the body (male, 20 ‐ 39, low mental well‐being)

Some respondents did not want to go into detail.

Some felt clearly uncomfortable, almost shocked

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2.4.6. Specific findings for MHI‐5/EVI

INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 2

{ASK ALL} Q2: How much of the time, during the past 4 weeks…

MHI‐5,

EVI

All of the

time

Most of

the time

Some of

the time

A little

of the

time

None of

the time Don't

know Refusal




dumps that nothing could cheer

you up?

Q2.4 Have you felt calm and peaceful?


Q2.6 Have you felt down‐hearted and

depressed?




Simplicity

In general, most respondents found the question and the individual statements “normal” and easy to

answer. Many respondents had difficulties with the concepts of "tired" and "worn out", as they were

wondering whether the mental or physical concept was being asked. The concept of “full of life” was

also quite difficult for most respondents (female, n20 ‐ 39, middle: “’Full of life’ was a bit difficult to

answer, especially comparing it to ‘having a lot of energy’”) and they asked for a definition.

Sensitivity

Whereas most of the respondents did not say anything concerning the sensitivity of Q2, one

respondent (female, 40 ‐ 59, low mental well‐being) stated that the question was very special and

touching sensitive issues. Another respondent found the questions quite personal.

Reference period

Most respondents stated that it was easy to remember their mental state in the last four weeks. One

respondent said that it was more difficult to remember the last four weeks than the last two weeks;

one said that it was difficult to remember, since four weeks were a long time. Another respondent

stated that he thought about his mental state in general, not in the last four weeks.

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Answer categories

One respondent said that he did not like the response categories of Q2 but could not specify why.

Another respondent (male, 20 ‐ 39, low mental well‐being) said that for negative statements, one

tends to answer “sometimes” as the reference period was quite long and “mostly” was quite harsh,

i.e. “sometimes” was the easy way out. “Between those two answer categories there needs to be

another category.” One respondent had difficulties deciding between “never” and “sometimes.” Two

respondents answered in the answer categories of Q1 before correcting themselves.

Recommendations for Q2 (MHI‐5/EVI)

Ask MHI‐5/EVI at the end of the health status section

Keep introduction of EHIS core wave 1

MHI‐5/EVI might be optional

Understanding (comprehension) of individual statements of Q2 (MHI‐5/EVI)

Table 25: Understanding and overall findings for Q2 (MHI‐5/EVI)

Q2.1 Do you feel full of life?

Q2.3 .Felt so down in the dumps that nothing could cheer you up

Q2.6 Felt down‐hearted and depressed

Q2.7 Did you feel worn out

Q.2.8 Have you been happy

OVERALL UNDERSTANDING

OVERALL UNDERSTANDING

DIFFERENCE DOWN‐HEARTED AND DEPRESSED

CONCEPT HAPPINESS

It means to me that I feel completely comfortable (male, 60+, moderate mental well‐being)

It means lust for life, having pleasure or the need to partake in life (female, 20 ‐ 39, moderate mental well‐being)

Happy or something (female, 40 ‐ 59, high mental well‐being)

This question is about strokes of fate and such things (male, 60+, moderate mental well‐being)

Depressive tendencies (female, 20 ‐ 39, moderate mental well‐being)

There is a difference between being down‐hearted and depressed. One can be downhearted about many different things, but depressed is something different. Then you loose courage to do certain things, if one has false pretences not to do something. Downheartedness passes by (male, 60+, moderate mental well‐being)

Two different concepts: physically worn out OR mentally worn out? (male, 60+, moderate mental well‐being)

One can be physically exhausted, which is after heavy work or effort, or worn out, if one does not know, how to go on in life, if one tries to find a solution (male, 60+, moderate mental well‐being)

COMPREHENSION COMPREHENSION COMPREHENSION COMPREHENSION

Question is about being content with oneself

Moments of uncertainty which can also

It's about my mental status, to see whether it is

Weak, without energy, general exhaustion

One is "happy" when everything works out fine; work, relation, whatever (male, 20 ‐ 39, moderate mental well‐being)

One is "happy" when he/she is optimistic and nothing bad happens (female, 20 ‐ 39, moderate mental well‐being)

I am happy when I am more then content. Happy when something succeeds, can be a work result or a holiday (male, 40 ‐ 59, moderate mental well‐being)

Due to my self‐reflections these

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(male, 20 ‐ 39, moderate mental well‐being)

I don't know what this question is about (female, 20 ‐ 39, moderate mental well‐being)

I think the question is about my emotional state (male, 60+, moderate mental well‐being)

drift into depression, when you can't sleep. It is about a mental state that you want to fathom (male, 40 ‐ 59, moderate mental well‐being)

About short‐term mental lows (female, U20, high mental well‐being)

longstanding, then it would do something with me. It is about to fathom how deep it is, is it stress due to work or a bereavement in the family, that would go deeper (male, 40 ‐ 59, moderate mental well‐being)

It is about serious diseases, death and so on (female, 60+, high mental well‐being)

Question is about decreasing strength/energy (female, 20 ‐ 39, moderate mental well‐being)

(female, 60+, high mental well‐being)

Without impulse, unmotivated. Could also be regarding the physical condition (male, 20 ‐ 39, moderate mental well‐being)

Could be rephrased as ‘exhausted, knackered’ (female, 20 ‐ 39, moderate mental well‐being)

are just very short moments, or moments that just come. It is something about satisfaction, about fulfilment, it is a moment, so to say, when these things occur in their purest form (male, 40 ‐ 59, moderate mental well‐being)

OBSERVATIONS OBSERVATIONS OBSERVATIONS OBSERVATIONS OBSERVATIONS

Some respondents asked for definition

Underlined that questions touch very sensitive issues (female, 40 ‐ 59, low mental well‐being)

This on is a bit hard, since there are two different things to be considered. That is too much for one question, these two concepts could be split into two questions (male, 20 ‐ 39, moderate mental well‐being)

The question was not easy to answer since it is not clear which of the two concepts is asked. I was unsure. Should be better defined (male, 40 ‐ 59, moderate mental well‐being)

Can't really decide between two response categories (male, 20 ‐ 39, low mental well‐being)

Some found it easy, moderate or ‘normal’ to answer

Happy means being full of life, enjoying doing one's tasks (female, U20, high mental well‐being)

There is a clear difference between ‘happy’ and ‘full of life’ (full of life is happiness gone mad). Happiness is really being content, without having to be very active to achieve it (male, 20 ‐ 39, low mental well‐being)

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Two batteries of questions on physical activity were tested: the National Health Interview Survey

NHIS‐PAQ (Q3 ‐ Q5) and the International Physical Activity Questionnaire IPAQ‐SF (Q6 – Q9). The

aims of testing the physical activity questions were to find out:

Which set of questions – IPAQ‐SF vs. NHIS‐PAQ – worked better?

Which set was easier to answer?

Which set did the respondents prefer to answer?

Which set was better in regards to the wording of questions?

How certain were the respondents about their answers?

How easy was it to remember the physical activity behaviour?

Were there any differences between the two sets of questions regarding certainty about the

answers?

How truthfully did the respondents answer the questions?

Was there any bias due to social desirability?

Was there a difference regarding the truthfulness of the answers between the two sets of

questions?

How did respondents come up with their answers (thought process)?

How did the respondents calculate the frequency of activities?

How did the respondents calculate the duration of activities?

How did the respondents decide whether an activity is ‘light/moderate’ or ‘vigorous’?

With these points in mind, the probes were designed in order to find out which questionnaire

produced the more accurate and scientifically, as well as politically significant results.

Overall findings: Which set of question worked better: IPAQ‐SF or NHIS‐PAQ?

Respondents tended to like the NHIS questionnaire better, although the fact that almost all of them

also found it easier compared to the IPAQ has to be borne in mind. At least one respondent on every

level of physical activity said that they preferred the NHIS due to its simplicity compared to the IPAQ,

like one respondent who said she liked NHIS better since she didn’t have to think or to calculate

(female, 20‐39, low PA). For scientific purposes, this shouldn’t be a criterion; although the IPAQ

might be harder to answer and demand a more elaborate thinking process, it might also provide the

more accurate picture of the status of physical activity.

Nevertheless, it has to be acknowledged that most people actually found the NHIS questionnaire

easier to answer than the IPAQ and might therefore also give more accurate answers and be more

concentrated and focussed on the questionnaire; the IPAQ’s questions about the time spent walking

and sitting caused insecurity and confusion in some of the respondents and tended to result in very

roughly estimated answers.

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Another problem with NHIS is that it doesn’t capture other aspects of life, which means that

someone who is physically inactive during leisure time is recorded as an inactive person, regardless

of the physical strain at work that might lead to the inactivity in the spare time. One respondent in

particular pointed out that the IPAQ is more suitable for him and therefore preferred it, although he

found it more difficult (male, 60+, no PA). The NHIS therefore has a high specificity, giving fewer

people the possibility to give an account of their physical activity.

Table 26: Preference for NHIS or IPAQ in relation to PA‐level

Certainty with answers

Generally, the respondents stated that it wasn’t too hard for them to recall their physical activity,

whether regular leisure time activity (NHIS) or general activity in the previous 7 days (IPAQ).

Cognitive testing showed that in NHIS, respondents could often easily say what kind of activity they

usually do as part of their leisure time, because it is more often than not quite woven into their

weekly schedule and planned in advance; or, as one respondent phrased it, one has more control

over activities in the leisure time (male, 20‐39, high PA). Therefore, their physical activity can be

measured more precisely and thoroughly, resulting in a more accurate finding.

It was sometimes remarked that the respondent felt that the last 7 days, that the IPAQ asked about,

weren’t representative for his/her regular life, because of, for example, a recent illness, bad weather

or a holiday trip. Then again, with a cross‐national and cross‐seasonal survey, questioning hundreds

of thousands of respondents, that aspect shouldn’t be of great consequence. It might be of use,

though, to significantly point out that the respondent should only consider the last 7 days, regardless

of any irregularities.

PA Level

Preference for NHIS Preference for IPAQ

None

IPAQ was more detailed, R had to think more (male, 40 ‐ 59)

IPAQ's questions and explanations were too long (female, 40 ‐ 59)

IPAQ is more complicated due to whole‐day reference (male, 60+)

R prefers IPAQ, because it is more suitable for him; although he finds it more difficult (male, 60+)

Low

IPAQ more difficult, as you can not control the physical behaviour (e.g. at work) (female, 60+)

The first set was easier for R to answer since nothing applies to her (female, 20 ‐ 39)

R preferred NHIS, since it is easier to answer because of the more direct questions and the lesser necessity to calculate (several Rs)

High

IPAQ was problematic due to the concepts of 'last seven days' and 'usually' (male, U20)

NHIS has 'better wording' (male, U20)

NHIS was easier to answer, but only because IPAQ was too similar (female, U20)

Rs preferred NHIS due to its relative simplicity and the controllability of leisure time PA (several Rs)

IPAQ was more global, not that differentiated (male, 40 ‐ 59)

In IPAQ, the expected performance is clearly defined and not differentiating between work and leisure time suits R better (male, 40 ‐ 59)

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During cognitive testing, we observed that some respondents had difficulties recalling the time they

had spent walking and sitting (IPAQ); the problem was that these activities are usually not done

consciously and don’t have limited time slots in the respondents’ daily schedules. One respondent

stated that she didn’t know whether her answer was correct or not, since the activities that were

asked for were ones that she couldn’t control and therefore couldn’t indicate either (female, 60+,

low PA). Especially sitting was therefore often, if at all, only very roughly calculated, with some

respondents just subtracting the time they usually sleep and the time they engage in any physical

activity from a day’s 24 hours.

Social desirability

The biggest advantage of the IPAQ is certainly its extensiveness and high sensitivity, measuring all the

physical activity that a respondent might engage in. Therefore, the aspect of social desirability is less

likely to affect the result, since even very inactive respondents don’t have to give only negative

answers.

The IPAQ’s question about the time spent sitting on a usual day was on a few occasions perceived as

being a bit uncomfortable for the respondent, as the amount of time that an average person spends

sitting is often more than five or six hours a day, which might in fact not be a lot, providing that the

respondent is also physically active in some way, but for the respondent it can seem like very much

or even too much. One elderly participant, for example, hesitated and laughed a bit when he realised

that he was seated during a normal day for about eight hours (male, 60+, high PA). The fact that the

answer to that question was often quite hard to calculate could lead to the respondent more easily

giving a “brightened” answer.

Thought process

The concept of asking what the respondent “usually” does (NHIS‐PAQ) was sometimes perceived as

too ambiguous and unclear, making it difficult to calculate an average amount of physical activity and

to give a single, accurate answer. This was a problem for respondents, who, for example, did one

activity once a month and another once a week; or respondents, who did one activity every day but

not in winter. One participant thought about her answer to question Q4 for a long time, since she

rides the bike regularly for nine months a year, but cannot do so during the winter, so that she had to

calculate quite complicatedly (female, 20‐39, high PA).

Some respondents found it difficult to decide whether they had done an activity for more than ten

minutes or less, especially with less consciously done activities like walking and sitting.

Also, it could be observed that, whereas in NHIS, respondents could often more clearly decide what

they had done in their leisure time, recalling total activity in IPAQ posed a bigger problem. Then

again, we could assume that while in IPAQ, the respondents felt that any activity they had done at all

had to be included, they might have only included “concrete” leisure time activities, not total activity

performed in their leisure time. We could reckon that it wasn’t directly understood what the

questions in NHIS are asking for, i.e. making it seem easier compared to the IPAQ.

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The concept of “light”, “moderate” and “vigorous” activity that is used in both NHIS and IPAQ was

often not understood intuitively. Whereas in IPAQ, there are examples given to illustrate what is

meant by the respective activity, in NHIS, respondents had to define them for themselves. This

sometimes led to confusion and the outcome that apparently activities were included in a category

that would actually have belonged in another. One elderly respondent, for example, had difficulties

differentiating between vigorous and moderate activity and ended up counting gymnastics as

vigorous activity (female, 60+, low PA).

In conclusion, comparing NHIS‐PAQ and IPAQ‐SF, we can say that the IPAQ, used and understood

correctly, appears to be more accurate in finding out how active a person is in general, asking about

aspects of physical activity that every respondent can adapt to. If a respondent has to be very

physically active at work, the fact that he/she hardly exercises in his/her leisure time is thereby put

into perspective. It has to be realised, though, that the IPAQ is more difficult to use and respondents

tend to give slightly contradictory and imprecise answers, which could diminish its formerly

mentioned advantages.

Recommendations PA overall

IPAQ and NHIS are both no satisfactory instruments

IPAQ should be used if the research interest is…

‐ to conduct information on total energy expenditure

‐ to conduct physical activity information also on inactive persons

NHIS should be used if the research interest is…

‐ to conduct information about health‐enhancing physical activity

‐ to determine whether the WHO’s physical activity recommendations are met

2.4.8. Specific findings NHIS‐PAQ

Categorisation “light or moderate” and “vigorous”

Generally, the concept of dividing physical activity into “light or moderate” and “vigorous” activity

was not grasped thoroughly by at least some respondents. This differentiation might be reasonable

from a scientific and analytical point of view; cognitive testing, however, showed its flaws in practical

experience. Examples for the different types of physical activity, like the ones given in the IPAQ

questionnaire, could help to understand these concepts. Some respondents explicitly pointed out to

have referred to the examples provided in the IPAQ (e.g. female, 40‐59, low PA)

Concept

Asking about what the respondent “usually” does turned out to be difficult, since some respondents

seemed to be uncertain about what to include (e.g. male, U20, high PA). Also, and possibly to a

greater extent, it was perceived as being quite challenging to calculate an average amount of time

that represented a plausible average rather than a rough guess. Thus, especially for one respondent

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who exercised certain activities in irregular intervals and for irregular amounts of time, it took longer

or was even impossible to come up with a satisfying answer (female, 20‐39, high PA).

Ignoring other activity

Focussing only on leisure time physical activity automatically neglects all other activity that a

respondent might engage in, as e.g. the physical strain at work or transportational activity such as

walking or cycling to and from places. People who do not exercise regularly or are completely

“inactive” (according to NHIS‐PAQ) don’t get the opportunity to state any other activity that might be

of interest from a medical viewpoint (i.e. affecting cardiac health issues, etc.). One respondent

preferred the IPAQ (even though being more difficult to answer) due to the fact that it applies more

to him and gives a better account of his actual physical activity (male, 60+, no PA). A PA module that

is based upon the NHIS approach should therefore also include similar questions concerning work

related and transportational activity in order to cover the different aspects of physical activity to the

greatest extent possible.

Recommendations NHIS

Remove the distinction between ‘light to moderate’ and ‘vigorous’ activities

Consider to complement the NHIS questions with other questions covering other important

domains of PA apart from leisure‐time PA such as work‐related or transportation PA

2.4.9. Specific findings IPAQ‐SF

Categorisation “moderate” and “vigorous”

Similarly to the NHIS‐PAQ, the differentiation in the IPAQ‐SF between “moderate” and “vigorous”

activity has not been understood intuitively in cognitive testing, with the IPAQ even lacking the

inclusion of “light” physical activity, thereby making it on the one hand incomplete and on the other

hard for respondents to decide upon whether or not to include certain types of physical activity. The

fact that examples for the different categories of activity were provided in the IPAQ, did seem to

reduce the problem, but these examples could be modified in order to resemble more the activities

the respondents intuitively associated with these categories.

Less conscious activities walking and sitting

The questions concerning walking and sitting were often difficult for respondents to understand and

to answer, since these kinds of activities are often perceived as being “subconscious”, i.e. done

automatically, without being recognised as specific activities. For example, one respondent felt the

question about the time he spent sitting was “paradox…, I am sitting all day long” (male, 40‐59, no

PA). Requesting exact data about the time spent on these activities might be logic from a theoretical

angle, but turned out to be impractical, as respondents usually can’t say, for example, how many

hours and minutes they usually spend sitting on a regular day. This problem could be minimised by

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offering a restricted number of response categories that indicate different levels of more “passive”

activeness. The result would then not be an imprecise average, but a more precise tendency.

Recommendations IPAQ

Remove the distinction between ‘moderate’ and ‘vigorous’ activities

Replace the concept of open answer options (asking for exact duration in hours and minutes)

with categorical answer options for the daily activities ‘walking’ and ‘sitting’


The alcohol section comprises 7 questions: AL.1 and AL.1a focus on frequency and quantity of alcohol

consumption based on a 12 month reference period, AL.2 ‐ 5 focus on frequency and quantity of

alcohol consumption on a weekly basis distinguishing between weekdays and weekends, AL.6 has a

focus on the issue of whether 6 or more drinks were consumed on one occasion (binge drinking).

The aims of testing the alcohol questions were to find out:

Did the respondents understand the questions?

Was the wording of the questions clear?

Was the terminology of the questions clear?

Did the respondents feel that the questions were sensitive?

Did the respondents feel uncomfortable answering the questions?

Did respondents give truthful answers?

Were there any issues of social desirability?

Were the respondents certain about their answers?

Was it easy for respondents to remember their drinking patterns?

Were there any concerns about the reference periods?

How did the respondents come up with their answers (thought process)?

Did the show card work as intended?

Did the filters (skips) work as intended?

Was it easy or difficult to use the answer categories?

Which question worked better (AL1/AL1a (AUDIT‐C) vs. AL2 ‐ 5 (distinction weekend/weekdays))?

Was the concept of weekend and weekdays understood by respondents?

What were the results of the different questions?

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2.4.11. Overall findings for AL1 – AL6: General vs. distinguishing


The majority of respondents indicated that it was rather easy to answer the questions in the section

on alcohol consumption. Nevertheless, respondents reported that answering the questions required

careful reading and a high degree of concentration. One respondent stated that the questions were

difficult to understand (female, 60+, moderate drinker). Respondents which had the most difficulties

in answering the questions said that it was because of recall problems, as the reference period of 12

months (questions AL.1 and AL.1a) was too long. The distinction between weekend and weekdays

was problematic for drinkers with irregular drinking patterns. They reported that difficulties arose

from trying to fit their answers into the answer categories, rather than from unclear wording of the

questions or unclearness regarding the underlying terminology of the questions.

Sensitivity (confidentiality) of questions

The opinion that drinking behaviour is a delicate issue, in particular for heavy drinkers, was shared by

the majority of respondents. Some respondents also reported that they could imagine that heavy

drinkers feel uncomfortable when answering the questions, since they have to reflect upon an issue

that they know is not considered a desirable behaviour. On the other hand, some respondents

reported that they think that there is no such problem of confidentiality with the questions

concerning alcohol consumption. One respondent pointed out that the confidentiality is not a

problem since the questions are raised in a self‐completion mode which might lead to more truthful

answers (female, 20 – 39, heavy drinker). The differentiation between weekdays and weekend

enables the analysts to identify alcohol‐addicted respondents who drink during the week – this

differentiation is too personal and can lead to receiving a false answer, as another respondent noted

(female, 40 – 59, non‐drinker). The category of ‘24 or more drinks’, according to one respondent

(female, 20 – 39, heavy drinker), improves the truthfulness of answers. Finally, one respondent

admitted that she did not give a truthful answer in terms that she underreported her alcohol

consumption (female, 40 – 59, moderate drinker).

Certainty about answers

Many respondents reported that they were not certain about their answers. They had difficulties in

general to remember their alcohol consumption. However, some also found the 12 month reference

period too long (AL.1), some had problems distinguishing between weekend and weekdays and

others had difficulties to fit their drinking patterns into answer categories due to irregular alcohol

consumption.

Show card

We observed quite mixed ways of respondents working with the show card and referring their

alcohol consumption to the concept of standard‐drink units. Many respondents reported that they

did use the standard‐drink unit and that it was easy to use. Some respondents, however, did not

refer their answers to the show card and indicated that it was difficult to break down their

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consumption into standard units. In contrast to that one respondent (male, U20, moderate drinker)

found it very logical to calculate that 1 litre beer equals 3 standard drinks, therefore the explanation

takes too much space for him. Another respondent remarked that the show card depicts a large beer

as 1 ½ units, although such a response category was not provided, which she feels is incoherent

(female, 20 – 39, heavy drinker). Other participants reported that they had not used the show card

since they already know how much they usually drink; one could assume that they had seen the

show card as more of a help to remember the respondent’s drinking behaviour rather than a guide as

to how the drinking behaviour should be converted into an answer category.

Skips

The skips in the questionnaire did not work as intended for many respondents. More specifically,

some respondents answered questions which they were not supposed to answer which lead to some

confusion as a consequence. For those respondents who noticed the skips and to whom they

applied, they worked as intended.

In addition, one of the interviewers noticed that for strict non‐drinkers, i.e. teetotallers, there was no

adequate answer option provided in AL.1. When such a response category was included, there would

need to be a skip forwarding the respondent directly to the end of the section on alcohol

consumption.

Answer categories

As it was mentioned, within question AL.1, a category for teetotallers is missing. All suggested

answer categories imply that at least once in the whole life one had had an alcoholic drink. Another

point mentioned was that the gap between the answer categories ‘Once every 2 months’ and ‘Once

or twice in the last 12 months’ (as in AL..1 and AL.6) is too big (male, U20, moderate drinker).

Furthermore, he criticized that a category ‘3 – 4 drinks’ is missing in e.g. AL.1a. In contrast to that,

another respondent (male, 20 – 39, heavy drinker) would have liked it if the three categories ‘1

drink’, ‘2 drinks’ and ‘3 drinks’ were summed up to ‘1 – 3 drinks’. In addition, he said that if 6 drinks is

the limit beyond which drinking problematic, this should not be expressed through the categories.

Furthermore, it can be said that with regard to the answer categories, respondents reacted to

reading ’24 or more drinks’ with quite a shock or at least astonishment. In contrast to that, still two

respondents saw this as being a ‘good psychological trick’ (female, 20 – 39, heavy drinker and male,

40 – 59, heavy drinker) to make respondents feel more comfortable with their answers.

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AL1/AL1a (AUDIT‐C) versus AL2‐5 (distinction weekend/weekdays)

The following table shows the amount of standard drinks consumed on a weekly basis, which is put

into context of general characteristics of the respondents.

Table 27: Weekly alcohol consumption and preferences of respondents (general vs. distinguishing)

General

(AL.1 – AL.1a) Distinction (AL.2 – AL.5)

ID Gender Age category Category of drinking behaviourStandard drinks

per week Standard drinks

per week Distinction is useful

1 w 60 + moderate 1,88 9,00 no

2 m 60 + moderate 1,25 2,00 no

3 m 60 + heavy 7,00 3,00 yes

4 w 40 ‐ 59 moderate 3,00 (2)* no

5 w 60 + moderate 1,25 (1)* no

6 w 60 + moderate 1,50 (1)* yes

7 m 60 + heavy 24,75 31,50 ‐ **

8 m U20 moderate 2,81 4,50 yes

9 m 40 ‐ 59 light 0,06 0,00 ‐ **

10 w 20 ‐ 39 heavy 10,50 9,00 yes

11 m 40 ‐ 59 heavy 11,00 8,00 ‐ **

12 w U20 light 0,13 1,00 yes

13 w 20 ‐ 39 heavy 5,50 9,00 yes

14 m 20 ‐ 39 heavy 15,75 15,00 yes

15 w 40 ‐ 59 non‐drinker 0,00 0,00 ‐ **

16 m 20 ‐ 39 heavy 19,50 22,50 yes

(* no exact calculation possible due to skips missed or similar; ** no clear preference articulated)

We observed that the results for the weekly consumption assessed on the basis of the two different

approaches (general questions AL.1 and AL.1a vs. specific questions AL.2 – AL.5) differed but with no

clear tendency in any direction of higher sensitivity of either instrument.

Many respondents indicated that it is clear why AL2‐5 distinguishes between weekdays and weekend

when estimating alcohol consumption and the majority of those respondents indicated that the

distinction is useful. However, some respondents such as retired persons and those who reported to

do shift work noted that this distinction does not make sense for them and that it is rather confusing.

Some respondents liked questions AL2‐5 better because their reference period was shorter and

easier to recall than it was for AL1/AL1a, the latter referring to the last 12 months.

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Recommendations alcohol module

Consider using AL1/AL1A instead of AL2‐5 to measure frequency and quantity of alcohol

consumption

Adjust wording of questions (AL1,AL1a/AL6) to original AUDIT‐C wording

(http://www.thenationalcouncil.org/galleries/business‐practice%20files/tool_auditc.pdf)

Consider to use a shorter reference period (AUDIT‐C does not require the 12 month

reference period), for example ‘last four weeks’

Use a simpler show card, for example:

(http://www.gadesurgery.co.uk/AuditCQuestionnaire.pdf)

2.4.12. Specific findings for AL.1 – AL.6

Q AL.1 To measure how frequently alcoholic drinks have been consumed in the last 12 months AL.1. During the past 12 months, how often have you had an alcoholic drink of any kind?

Every day or almost every day ............................................. 1

5 ‐ 6 days a week ................................................................... 2

3 ‐ 4 days a week ................................................................... 3

1 ‐ 2 days a week ................................................................... 4

2 ‐ 3 days in a month ............................................................. 5

Once a month........................................................................ 6

Once every 2 months ............................................................ 7

Once or twice in the past 12 months .................................... 8

Not in the past 12 months, but I drank formerly .................. 9 end of interview

Never more than a few sips or trials in my whole life........... 10 end of interview

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Simplicity

Overall, most respondents found it easy or rather easy to answer this question. Most of the

respondents who found it easy were heavy drinkers, but also moderate and light/non drinkers stated

this. More than half of those who found it difficult to answer were moderate drinkers.

The wording in question AL.1 was problematic for one respondent, probably due to the translation of

‘an alcoholic drink’, which, in the German version, came out as ‘one alcoholic drink’. He (male, 60+,

moderate drinker) therefore thought about how often he actually had ONE drink during the last

twelve months.

Another respondent mentioned that there is a seasonal bias (male, U20, moderate drinker). He

reported that he drank more in summer than in winter. In consequence, he would prefer a more

general question like: “How often do you drink approximately?”

What might be another point for biases is the fact that some respondents ticked a maximum

amount, while others answered with an average.

Main problem

The main problem concerning this question was the time period, which was too long for some

respondents and therefore caused difficulties to recall the drinking behaviour. Also, it appeared

problematic for some to convert their drinking behaviour into one of the given categories. Those

respondents were confused because the question asked about a whole year while the answer

categories indicated e.g. ‘per week’ or ‘per month’. The recall problem occurred in all three groups of

drinkers (light, moderate and heavy drinkers), while the difficulty of converting was reported only by

moderate and heavy drinkers.

Answer categories

For some respondents it was difficult to convert their answers into the given categories, while others

reported that „every possible answer was covered” (female, 20‐39, heavy drinker). So, most of the

respondents liked the answer categories, stating that they were reasonable, comprehensive and

detailed.

One respondent (female, 20‐39, heavy drinker) was unsure what answer to tick, because she did not

know whether to put in a number for weekdays or for the weekend.

Even the one non‐drinking respondent (female, 40‐59) found a satisfactory answer category. She

ticked answer 10 (“Never more than a few sips or trials in my whole life”), because there were

birthdays or events in the past, where she also had had a drink.

One respondent raised the concern that the category ‘5‐6 days a week’ is almost the same as ‘every

day or almost every day’ (male, 20‐39, heavy drinker):

“If you drink 6 days a week you can choose either answer. Also, it is suggestive, since one would not

answer ‘almost every day’ because it sounds like an accusation.”

189

Q AL.1a To measure how many alcoholic drinks are drunk on a typical day. AL.1a. How many drinks containing alcohol do you have on a typical day when you are drinking? Refer to the show card

24 or more drinks ................................................................. 1

17‐23 drinks.......................................................................... 2

10‐16 drinks.......................................................................... 3

7‐9 drinks.............................................................................. 4

6 drinks ................................................................................. 5

4 ‐ 5 drinks ............................................................................ 6

3 drinks ................................................................................. 7

2 drinks ................................................................................. 8

1 drink................................................................................... 9

Simplicity

Most of the respondents found it easy or rather easy to answer this question. Most of them thought

about how often they drink alcohol and if they do, how much they drink. Thus, they indicated their

usual behaviour.

Two respondents (male, 60+, moderate drinker and female, 60+, moderate drinker) had serious

problems understanding the term ‘drinks containing alcohol’. They thought about sorts of alcoholic

beverages (e.g. beer, wine), but not about amounts of drinks (e.g. glasses of wine, bottles of beer).

After explaining of the show card, one respondent said “this is not well‐defined here… the question.”.

The other respondent described her thought process like this: “For me, an alcoholic drink is wine or

sparkling wine (…). And if I have a guest and drink a glass or two [glasses], then for me, this is one

alcoholic drink”. After asking her more thoroughly, she revealed that for her, two glasses of wine are

one alcoholic drink.

Answer categories

The answer categories were ‘reasonable’, ‘suitable’ or simply ‘made sense’ to most respondents.

Some raised concerns that ’24 or more drinks’ are ‘far too much’ or just seemed shocked when

reading this response category. One respondent (male, 20 ‐ 39, heavy drinker) stated: “’24 or more’ is

stupid, putting that at the top has a daunting effect” and another (male, 40‐59, light drinker) said:

“’24 or more drinks’ is not reasonable, you cannot take that much! Even as an alcoholic, that is not

possible.”

Another point mentioned twice during cognitive testing was about how the categories were split up.

At the lowermost level they were much differentiated but at the uppermost level numbers were

summed up. One respondent (male, 20‐39, heavy drinker) proposed to sum up the first three

categories to ‘1 – 3 drinks’. In contrast to that, another respondent (male, U20, moderate drinker)

190

stated that for him the category ‘3 – 4 drinks’ is missing, for him 3 is too little, but 4 ‐ 5 is a bit too

much.

Another important point that was highlighted by a respondent (female, 20‐39, heavy drinker) is that

the show card indicates on the one hand that 0,5 l of beer correspond to 1,5 standard drinks, but on

the other hand, there is no matching answer category for such an amount.

Understanding

A ‘typical drinking day’, for the respondents, was on the one hand more of a regular day (most of

them heavy drinkers, also moderate drinkers), on the other hand respondents described such a day

as including events like birthdays, when someone comes over or if they go out. One respondent

(male, 40‐59, light drinker) answered that such a day is “for me an exception, normally I do not

drink”. In contrast to that, one respondent (female, 20‐39, heavy drinker) said: “When you drink one

glass of wine in the evening and not till you drop.”

“Drinks containing alcohol”, for most respondents, are made up of e.g. beer, wine, hard liquor or just

“anything from a beer ‘upwards’ “, (female, U20, light drinker). Some of the respondents, when

asked this question, just referred to the show card and read out the given examples.

Confidentiality

All respondents thought that this question might be too personal for some people; i.e. for those who

have drinking problems or former alcoholics. Also, there might be people who would not want to

reveal drinking every day; those people might be embarrassed. One respondent (female, 20‐39,

heavy drinker) pinpointed: “This part of the questionnaire is ‘predestined’ to give untrue answers.”

Q AL.2 To measure on how many weekdays the respondent drinks alcohol.


drink alcohol?

On the 4 weekdays ........................................ 1

On 3 weekdays .............................................. 2

On 2 weekdays .............................................. 3

On 1 weekday................................................ 4

Not on weekdays........................................... 5 go to AL.4

Simplicity

Most respondents found it easy to answer that question. One respondent (female, 60+, moderate

drinker) had trouble regarding the word ‘usually’, since drinking is not ‘usual’ in her case but rare.

This point was raised by another respondent (female, 40‐59, moderate drinker), too. For her, this

wording excludes exceptional cases, which she dislikes.

191

One respondent (male, 20‐39, heavy drinker) proposed to ask this question before the general

question that refers to the whole year, because he thinks it is easier to think about the weekly

consumption first and then to project the yearly amount.

Reference period (week days)

For most respondents, it was not difficult to understand the concept of weekdays ranging from

Monday to Thursday. This can be underlined by the statement “Friday in the evening is a potential

nominee for drinking” (male, U20, moderate drinker), after which he explained that he understands

the question like this: it is about “evenings before work”. Therefore, he would prefer it if it was

phrased that way.

One respondent (female, 40‐59, moderate drinker) mentioned that this was a little difficult for her

since she was doing shift work in her last job. This was underlined by another respondent who was

formerly working at a theatre (male, 40‐59, heavy drinker) and is now unemployed. There was

another respondent (female, 20‐39, heavy drinker) who did not like the differentiation, because she

thinks that there are not that many people who have such a structured life.

Furthermore, for retired respondents the differentiation was not that important. But they

nevertheless liked it, thinking of people working. One respondent (male, 60+, heavy drinker) stated:

“If people need to go to work, sometimes there is only the weekend left ‘to kick over the traces’.”

Q AL.3 To measure how much alcohol the respondent drinks on one week day.




24 or more drinks .......................................... 1

17‐23 drinks................................................... 2

10‐16 drinks................................................... 3

7‐9 drinks....................................................... 4

6 drinks .......................................................... 5

4 ‐ 5 drinks ..................................................... 6

3 drinks .......................................................... 7

2 drinks .......................................................... 8

1 drink............................................................ 9

192

Simplicity

The majority of respondents found it easy to answer this question, or at least not difficult. This might

be due to the fact that those who answered this question were moderate or heavy drinkers with a

rather constant drinking behaviour.

Thought process

Most of the respondents thought about their usual behaviour, not referring to particular days.

Others tried to remember certain occasions like dinners or when they had had guests. One

respondent just thought about how often he goes for buying beer and how much he is buying then

(male, 40‐59, heavy drinker).

Answer categories

On the one hand, the response categories were well received by one part of the respondents. They

evaluated them as being “explicit” (male, 60+, heavy drinker), good, suitable, sufficient and making

sense. One respondent underlined again that he feels the category ’24 or more drinks’ is a good trick

to loosen up respondents (male, 40‐59, heavy drinker).

But on the other hand, there were respondents who did not like the categories. One respondent

(female, 40‐59, moderate drinker) said she needed to read very thoroughly and concentrate on what

was asked. Another respondent (female, 60+, moderate drinker) stated: “I can’t tell anything about

that, I have an idea of what 6 alcoholic drinks are but 18 or 24 or even more I can’t imagine.”

Another statement raised was: “If 6 is the limit beyond which drinking is problematic, it shouldn’t be

made that obvious through the categories” (male, 20‐39, heavy drinker).

Q AL.4 To measure on how many weekend days the respondent drinks alcohol.

AL.4. During the weekends (from Friday to Sunday), on how many of these 3 days do you usually

drink alcohol?

On the 3 weekend days................................. 1

On 2 weekend days ....................................... 2

On 1 weekend day......................................... 3

Not on weekends .......................................... 4 Go to AL.6

Thought process

The majority of respondents recalled drinking behaviour on weekends referring to Saturday. Friday

was also included quite frequently; in addition, some respondents also included Sunday. In contrast

to that, some respondents referred to Sunday as a day “on which one doesn’t drink” (male, 20‐39,

heavy drinker).

Two respondents criticised the question with regard to the corresponding response categories (male,

U20, moderate drinker and female, U20, light drinker). The implication of both combined is that one

193

needs to be a regular drinker for being able to give a true answer. For those who drink little (e.g. not

on every weekend), finding an answer category is difficult. Irregular drinkers will therefore tick the

”lesser evil” option of ‘on 1 weekend day’, which then results in an overestimation.

Distinguishing weekend and weekdays

Half of the respondents clearly indicated that they prefer such a distinction, since parties or other

occasions for drinking are mostly on the weekends. Moreover, the fact of being able to sleep in the

next day played a role for one respondent (male, 20‐39, heavy drinker).

In addition, other respondents liked the distinction with regard to working people, although they

themselves were retired. Consequently, for them the distinction was not of importance, but still they

would not have changed the questions.

Only a minority stated that the distinction was not important. One respondent was rather worried

about it (male, 40‐59, heavy drinker) due to the decreasing number of regular jobs nowadays.

Another respondent (female, 20‐39, heavy drinker) made the proposal to differentiate between

workdays and leisure time in the questions.

Q AL.5 To measure how much alcohol the respondent drinks on one weekend day




24 or more drinks ............................................... 1

17‐23 drinks........................................................ 2

10‐16 drinks........................................................ 3

7‐9 drinks............................................................ 4

6 drinks ............................................................... 5

4‐5 drinks............................................................ 6

3 drinks ............................................................... 7

2 drinks ............................................................... 8

1 drink................................................................. 9

Simplicity

About half of the respondents found it easy to answer this question, even though some of them

would prefer a more general question instead of the distinction of weekdays and weekend. In fact,

some respondents found it easier to answer a general question rather than one that differentiates.

But still no respondent complained that it was too difficult to answer that question.

194

Thought process

The majority of the respondents recalled their usual drinking behaviour of late. Some of them

estimated or averaged their consumption; in contrast to that, some respondents said they would

know the exact number.

A minority of respondents recalled their drinking behaviour by thinking about certain events like

birthdays or when they had guests.

One respondent (female, 60+, moderate drinker) still thought of kinds of drinks and not units,

although this was explained to her during the interview. It might be necessary to improve the

wording or to add a hint in the questions reminding the respondent to think of units.

Preference of general question or distinction

The distinction between alcohol consumption on weekdays and weekends was preferred by half of

the respondents. However, they had different reasons for that opinion. One respondent (male, 60+,

heavy drinker) stated: “For concrete questions, there are concrete answers.” In contrast to that,

another respondent (male, U20, moderate drinker) pointed out that the distinction is useful in order

to inquire about the attitude of the respondents towards drinking. This idea was underlined by the

statement of another respondent (female, U20, light drinker) who said that this distinction surely

makes a difference.

Another opinion towards this distinction was that the distinction itself is useful, but needs to be

improved in order to be “more universally valid” (female, 20‐39, heavy drinker).

Those respondents who preferred a general question without distinction justified their opinion by

saying that such a general question was easier for them to answer.

One respondent did not state any preference (male, 40‐59, heavy drinker). He said that the questions

were not useful to him at all. He would prefer questions that dealt with the regular total

consumption of alcohol.

Q AL.6 To measure how frequently the respondent exceeded 6 or more drinks on an occasion.


Every day or almost every day .......................... 1

5 ‐ 6 days a week ................................................ 2

3 ‐ 4 days a week ................................................ 3

1 ‐ 2 days a week ................................................ 4

2 ‐ 3 days in a month .......................................... 5

Once a month..................................................... 6

Once every 2 months ......................................... 7

Once or twice in the past 12 months ................. 8

Not in the past 12 months.................................. 9

Never in my whole life........................................ 10

195

Simplicity

The majority of respondents answered this question by thinking about whether there had been a

celebration or a party of late. One respondent (male, U20, moderate drinker) rephrased the question

and asked himself: “How often was I rather drunk?”. He acknowledged, however, that he cannot say

for sure whether he had six or more drinks in such cases or ‘just’ 5 drinks. But other respondents also

indicated not to be sure of their answers.

Also, there were respondents who were not sure if such a case (having had 6 or more drinks) had

ever occurred in their lives.

The respondent (female, 60+, moderate drinker) who thought of kinds of drinks instead of amounts

was confused by the question and had to think a while about how to answer it.

Another respondent (male, 20‐39, heavy drinker) explicitly mentioned that he only thought about

the last month and if he had then drunk more than usual. Furthermore, he noted that 12 months are

quite a long time and therefore one needed to think about it carefully.

Understanding of ‘one occasion’

‘One occasion’ for the majority of respondents meant a party or a birthday, having guests around or

other celebrations, going out to meet friends or to dance. Altogether, one occasion for the majority

of respondents was linked to going out and not just sitting at home, watching TV, etc. One

respondent (female, 60+, moderate drinker) also referred to pleasant incidents, having a drink when

a particular athlete won a sports competition. One respondent (male, 40‐59, heavy drinker) explicitly

mentioned that for him, a dinner is not an occasion to have 6 or more drinks. For him, occasions are

rather social gatherings, when there is a lot to drink around. In addition, it was referred to ‘one

evening’ or ‘one part of the day’ by younger respondents (male, 20‐39, heavy drinker and male, U20,

moderate drinker) when thinking about what an occasion means to them.

Answer categories

The answer categories were positively received by most respondents. They are “clear” and

“suitable”. One respondent (male, U20, moderate drinker) stated that for him, the gap between

‘once every two months’ and ‘once or twice in the last 12 months’ is too big. Therefore, he thinks that

some people might have problems answering that question. Furthermore, some respondents were

again astonished or even ‘shocked’ by the frequencies indicated by the answer categories.

196

197

2.5. Test Questions & Probe Sheet for Round 1

Cognitive Testing

P3064 Questions from the European Health Interview Survey

Name of Interviewer: ___________________________________

Date of Interview: _____________________________________

Serial ID Number: ___________________________________ (e.g. Serial Number)

Sex of Respondent: _________________

Age of Respondent: ____________________________

The Main Objectives for the interview

To examine respondent’s understanding of the questions

To examine whether respondents are able to answer the new survey questions (i.e. whether

they can recall all the information required).

To explore whether the new survey questions capture full information (i.e. answer categories

are adequate).

To examine issues of potential sensitivity in the survey context.

To explore whether respondents understand the instructions and routing of the paper

instrument.

To explore whether there are any concerns about length.

198

Stage One: Introduction

Introduce yourself, NatCen, and the study

In order to prepare the second wave of the European Health Interview Survey (EHIS) it was

decided that the EHIS questionnaire was in need of a revision process. To address and

facilitate the improvement of the instrument, this research was launched

One of the objectives of the project was the improvement of the sections on mental health,

physical activity and alcohol consumption.

Explain that you will be asking them questions on these topics to find out how the questions

work. After they have finished answering the questions you will ask them some questions

about how they found the new questions. You will therefore be performing two roles: the

survey interviewer, where you need to ask the questions as worded and elicit a response,

and the cognitive interviewer: where you will be exploring the question and answer process.

Explain we are not so much interested in the answers they give but how they understand

the questions and the process by which they arrive at their answers.

Stress there are no right or wrong answers and this isn’t a test. We are just trying to explore

if the questions work as the researchers intend. Explain if they have any difficulty answering

the questions it shows the questions need to be improved. Explain they do not have to

answer any question they don’t want to.

Stress the confidentiality of the process; all the findings will be reported anonymously. The

respondents name will not be on the questionnaire or any of the notes you write up. Please

make sure they understand this.

Remind them that the interview will last up to one hour.

Explain that you will be recording the interview so that you don't have to make lots of notes

during the interview. Check this is OK with the respondent. If they ask who will have access

to the recording, tell them that only the small research team at the institute and yourself

will, and that recordings are stored securely i.e. they are password protected.

Ask whether they have any questions before you start.

199

Stage Two: Specific Question to Question Probing

QUESTIONS ON MENTAL HEALTH

PLEASE ASK ALL QUESTIONS IN THE SECTION FIRST AND THEN PROCEED WITH PROBING.

{READ OUT TO ALL}

Mental Health Intro: In the following I will be asking you some questions about your psychological

well‐being.

SHOW CARD 1

{ASK ALL}


PHQ‐9 Not at

all

Several

Days

More

than

half the

days

Nearly

every

day

Don’t

know

Refusal

Q1.1 Little interest or pleasure in doing

things


Q1.3 Trouble falling or staying asleep, or

sleeping too much



Q1.6 Feeling bad about yourself‐or that you

are a failure or have let yourself or your

family down.

Q1.7 Trouble concentrating on things, such

as reading the newspaper or watching

television

Q1.8 Moving or speaking so slowly that

other people could have noticed. Or the

opposite—being so fidgety or restless

that you have been moving around a lot

more than usual

Q1.9 Thoughts that you would be better off

dead or of hurting yourself.

SHOW CARD 2

200

{ASK ALL}


MHI‐5,

EVI

All of

the

time

Most of

the

time

Some of

the time

A little

of the

time

None of

the time Don't

know Refusal




dumps that nothing could

cheer you up?

Q2.4 Have you felt calm and

peaceful?


Q2.6 Have you felt down‐hearted

and depressed?




Mental health section

Aims:

Do the two set of questions overlap?

Is there an overlap of the statements within one question?




between points?

How do Rs decide on their answer? (I.e. is it compared to others, compared to their needs/wants,

etc?)

201

Mental health section: Probes

General Probes

How were these questions for you?

Did you feel that the first question (Q1) overlapped with the second question (Q2)? (Probe for

examples)

(If there were differences observed) Can you explain what you see as being the main differences

between the two questions (Q1 versus Q2)?

Was it easy or hard to answer the two questions?

Was one of the questions easier to answer than the other? (Probe for reasons)

Was it easy or difficult to keep the different reference periods in mind (two weeks vs. four weeks)?

Specific Probes for question Q1 (PHQ‐9)

Now, I would like to get your feedback on the first question (remind respondent of the question):

In general how did the different statements work for you?

What came to mind when you were answering these questions?

From the top of your head do you remember any statement that was difficult for you to answer?

Examples

Was it easy or hard to remember your feelings and behaviours over the past 2 weeks?

How did you remember that? Examples

How did the response categories work for you?

Some statements were asking for two opposite concepts (i.e. “poor appetite or overeating”. How

was that to answer these kind of questions?

Individual statements question Q1 (PHQ‐9)

Please let respondent know that you will be asking them know about the individual statements of the

first question. Read out the statement first and then continue with the probes.

Statement Q1.1: Little interest or pleasure in doing things

What did the term ‘little interest or pleasure in doing things’ mean to you?

What kinds of things were you thinking about when you answered this part of the question?

Examples

How did you decide on a response?

Was it easy or hard to answer?

Statement Q1.2: Feeling down, depressed or hopeless

What does ‘feeling down’ mean to you? Examples

What did you think this question was asking of you?

202

Statement Q1.3: Trouble falling or staying asleep, or sleeping too much

What did you understand by ’trouble falling or staying asleep’? Examples

How easy or hard is it to answer that question?

Statement Q1.6: Feeling bad about yourself‐or that you are a failure or have let yourself or your

family down

What would you say that question was asking of you?

How easy or difficult did you find it to decide on your answer to this question? Why?

What does ‘being a failure” mean to you? Examples

How do you understand ‘letting yourself or your family down’? Examples

Statement Q1.8: Moving or speaking so slowly that other people could have noticed. Or the

opposite—being so fidgety or restless that you have been moving around a lot more than usual

What did you understand by ‘being fidgety or restless’ in this question? Examples

What did you think this question was asking of you? Examples

How easy or difficult did you find it to decide on your answer to this question? Why? Probe for

examples

Statement Q1.9: Thoughts that you would be better off dead or of hurting yourself.

How did you understand this question and why?

How would you express the question in your own words? Examples

Do you think some people might find the question too personal?

Do you think some people might not give a true answer to this question?

General Probes on question Q2 (MHI‐5, EVI)

In general how did these questions work for you?


From the top of your head to you remember any statement that was difficult for you to answer?

Examples

Was it easy or hard to remember your feelings over the past 4 weeks?

How well did you remember that? Examples

Did you find the statements repetitive or could you see the differences? Reasons and examples

203

Probes on individual statements question Q2 (MHI‐5, EVI)

Statement Q2.1: Did you feel full of life?

What do you understand by ‘feeling full of life’?


How did you remember how you felt over the last 4 weeks?

What did you think of when you tried to remember?

How well to you remember that?

How sure are you of your answer?

Statement Q2.3: Have you felt so down in the dumps that nothing could cheer you up?


What brought that to mind?

How sure are you of your answer?

Statement Q2.6: Have you felt down‐hearted and depressed?

What did you think this question is asking of you? Examples

Was it easy or hard to answer?

Statement Q2.7: Did you feel worn out?

Can your repeat that statement in your own words?

Was it easy to answer?

Statement Q2.8: Have you been happy?

What did ‘happy’ mean to you? Examples

How did you arrive at your answer?

204

QUESTIONS ON PHYSICAL ACTIVITY

PLEASE ASK ALL QUESTIONS OF THIS SECTION FIRST AND THEN PROCEED WITH PROBING

{READ TO ALL}

In the following there are two sections on physical activity, one on leisure‐time physical activity and

one on total physical activity. One of the aims of this interview is to find out which section works

better. Therefore, some of the questions might seem repetitive.

We are now starting with section A about your physical activities in your leisure time and I will let

you know when we move to section B.

{READ OUT TO ALL}

The next questions are about physical activities (exercise, sports, physically active hobbies...) that you

may do in your LEISURE time.

{ASK ALL}

Q3: How often do you do VIGOROUS leisure‐time physical activities for AT LEAST 10 MINUTES that

cause HEAVY sweating or LARGE increases in breathing or heart rate?

INTERVIEWER: Responses can be offered in terms of any time unit the respondent volunteers (times

per day, per week, per month, or per year)

{READ IF NECESSARY}

How many times per day, per week, per month, or per year do you do these activities?

Never 1‐995 time(s) ____ Unable to do this type activity Refused Don't know

INTERVIEWER: Enter time period for vigorous leisure‐time physical activities.

Never Go to Q4

Per day ASK Q3a

Per week ASK Q3a

Per month ASK Q3a

Per year ASK Q3a


205

Refused Go to Q4

Don't know Go to Q4

{ASK ALL}

Q3a: About how long do you do these vigorous leisure‐time physical activities each time?


1‐995 ____

Refused Go to Q4

Don't know Go to Q4

INTERVIEWER: Enter time period for length of vigorous leisure‐time physical activities.

RECORD RESPONDENT'S ANSWER IN EITHER HOURS OR MINUTES

Minutes Go to Q4

Hours Go to Q4

Refused Go to Q4

Don't know Go to Q4

{ASK ALL}

Q4: How often do you do LIGHT OR MODERATE LEISURE‐TIME physical activities for AT LEAST 10

MINUTES that cause ONLY LIGHT sweating or a SLIGHT to MODERATE increase in breathing or heart

rate?

{READ IF NECESSARY}



INTERVIEWER: Enter time period for light or moderate leisure‐time physical activities.

206

Never Go to Q5

Per day ASK Q4a

Per week ASK Q4a

Per month ASK Q4a

Per year ASK Q4a


Refused Go to Q5

Don't know Go to Q5

{ASK ALL}

Q4a: About how long do you do these light or moderate leisure‐time physical activities each time?


1‐995 ____

Refused Go to Q5

Don't know Go to Q5

INTERVIEWER: Enter time period for length of vigorous leisure‐time physical activities.

RECORD RESPONDENT'S ANSWER IN EITHER HOURS OR MINUTES

Minutes Go to Q5

Hours Go to Q5

Refused Go to Q5

Don't know Go to Q5

{ASK ALL}

207

Q5: How often do you do LEISURE‐TIME physical activities specifically designed to STRENGTHEN your

muscles such as lifting weights or doing calisthenics?

(Include all such activities even if you have mentioned them before.)

{READ IF NECESSARY}



INTERVIEWER: Enter time period for leisure‐time spent on muscle STRENGHENING physical

activities.

Never Go to Q6

Per day Go to Q6

Per week Go to Q6

Per month Go to Q6

Per year Go to Q6


Refused Go to Q6

Don't know Go to Q6

208

{READ TO ALL}

We have now finished the section A on leisure time physical activity and will move to section B on

total physical activity.

{READ OUT TO ALL}

I am going to ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.

Now, think about all the vigorous activities which take hard physical effort that you did in the last 7

days. Vigorous activities make you breathe much harder than normal and may include heavy lifting,

digging, aerobics, or fast bicycling. Think only about those physical activities that you did for at least

10 minutes at a time.

Q6: During the last 7 days, on how many days did you do vigorous physical activities?


Don't Know/Not Sure Go to Q7 Refused Go to Q7

[Interviewer clarification: Think only about those physical activities that you do for at least

10 minutes at a time.]


Hours per day __ __ Go to Q7 Minutes per day __ __ __ Go to Q7 Don't Know/Not Sure Go to Q7 Refused Go to Q7

[Interviewer clarification: Think only about those physical activities you do for at least 10

minutes at a time.]

209

{READ OUT TO ALL}

Now think about activities which take moderate physical effort that you did in the last 7 days.




Q7: During the last 7 days, on how many days did you do moderate physical activities?

Days per week __ Go to Q8 if zero OTHERWISE ASK Q7a Don't Know/Not Sure Go to Q8 Refused Go to Q8

[Interviewer clarification: Think only about those physical activities that you do for at least

10 minutes at a time]



[Interviewer clarification: Think only about those physical activities that you do for at least 10

minutes at a time.]

{READ OUT TO ALL}

Now think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.


Days per week __ Go to Q9 if zero OTHERWISE ASK Q8a Don't Know/Not Sure Go to Q9 Refused Go to Q9 [Interviewer clarification: Think only about the walking that you do for at least 10 minutes at a time.]

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{READ OUT TO ALL}

Now think about the time you spent sitting on week days during the last 7 days. Include time spent at work, at home, while doing course work, and during leisure time. This may include time spent sitting at a desk, visiting friends, reading or sitting or lying down to watch television.


Hours per day __ __ Go to next part Minutes per day __ __ __ Go to next part Don't Know/Not Sure Go to next part Refused Go to next part

[Interviewer clarification: Include time spent lying down (awake) as well as sitting]

Physical Activity Section

Aims:

What set of questions was easier to answer?

Do respondents understand the underlying concepts of the questions?

How do Rs remember their physical activity level?

Do Rs understand the wording of respective questions?



etc?)

Are Rs answering in a truthful way?

211

1. General probes

If you think of the two different sections (leisure‐time versus total activity), which set of questions

was easier for you to answer and why? Examples

Which set of questions did you prefer answering? Read out…

1. Set A: Leisure‐time physical activity

2. Set B: Total physical activity

3. Or do you not have a preference?

INTERVIEWER: EXPLORE THE REASONS FOR THE PREFERRED SET OF QUESTIONS.

In general was it easy or hard to remember your physical activities?

2. General probes for the leisure‐time physical activity questions (section A)


Was it easy or hard to answer the questions?



Examples


2. a Probes on specific questions of leisure‐time physical activity section (A)

Q3: How often do you do VIGOROUS leisure‐time physical activities for AT LEAST 10 MINUTES that

cause HEAVY sweating or LARGE increases in breathing or heart rate?

How do you understand the term ‘vigorous activity’? Examples

Was it easy or hard to answer this question?

What did ‘leisure time activity’ mean to you, in your own words?

How did you go an answering this question?

What came to mind when you were thinking of an answer? Examples

Q4: How often do you do LIGHT OR MODERATE LEISURE‐TIME physical activities for AT LEAST 10

MINUTES that cause ONLY LIGHT sweating or a SLIGHT to MODERATE increase in breathing or

heart rate?

How did you come to your answer?

What is light and what is moderate physical activity for you? Examples

How do you remember this? Examples

How did you decide what activities to include and exclude?

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Q5: How often do you do LEISURE‐TIME physical activities specifically designed to STRENGTHEN

your muscles such as lifting weights or doing calisthenics?

What does ‘muscle strengthening’ mean to you? Examples

How would you say that in your own words?

How did you go about answering this question? Examples

Do you think that some people might not give a true answer to this question? Why?

3. General probes for the total physical activity questions (section B)


Was it easy or hard to answer questions?



Examples


3. a Probes on specific questions of total physical activity section (B)

Q6: During the last 7 days, on how many days did you do vigorous physical activities? (like heavy

lifting, digging, aerobics, or fast bicycling)

How was your understanding of “vigorous activity”? Examples


Did you have a particular time period on mind?

Did you think about “a usual week” or “the last 7 days”?

What activities did you think of when answering this question? Did you think about vigorous activity

in general or did you focus on the examples?

Do you think that some people might not give a true answer to this question? Why?


How did you go about calculating your answer? Examples

How did you decide on the one day to think about?



How did you decide on which walks to include? How did you decide that a walk lasted 10 minutes?

How sure were you of your answer?

Did you think about regular walks you do or did you also include irregular walks?

213


How did you go on answering this question? Examples

How is your understanding of ‘usually spend walking’?

How did you decide on what to include and exclude when thinking about ‘usually spend walking’?

And how did you calculate an overall figure?


What does the term 'sitting’ in this context mean to you?

How did you decide on what to include and exclude?

And how did you calculate an overall figure?

Was it easy or hard to decide what occasions to include or exclude? Examples

What days were you thinking of when answering this question?

Overall probe: Overall probe: Interviewer please explore the kinds of physical activity the respondent usually

does, or has done in the last month. Then explore if there were any activities that they did not include, or were

unsure about where they should include these, and why this was

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QUESTIONS ON ALCOHOL CONSUMPTION

Information for Interviewer: Respondents will fill out a self‐completion form. Let them fill out the

first two questions and ask the first probes. Then they will fill out the rest of the questionnaire and

you will proceed with probing afterwards.

{READ TO ALL}

Please fill out the questionnaire yourself. Start with filling out the first two questions (1 and 1a)

and pause afterwards. I will then ask you a few questions.

INTERVIEWER INSTRUCTION: PLEASE GIVE THE ALCOHOL SHOW CARD AFTER THE R ANSWER Q1A.

Question AL.1: During the past 12 months, how often have you had an alcoholic drink of any kind?

Was it easy or hard to come up with an answer? Why?

Were the response categories suitable?

Was it easy or difficult to match your answer to the response options given?

QuestionAL.1a: How many drinks containing alcohol do you have on a typical day when you are

drinking?


Was it easy or hard to come up with an answer? Why?

How did you estimate the number of drinks?

Were the response categories suitable?

Was it easy or difficult to match your answer to the response options given?

What is a typical drinking day for you?

What to you are ‘drinks containing alcohol’? Examples

Do you think some people might find this question embarrassing?

INTERVIEWER INSTRUCTIONS: After asking the probes on the first two questions, ask respondent

to fill out the remaining questions on alcohol consumption. Continue with probing afterwards.

Alcohol Consumption Section

Aims:

Do respondents understand the questions?




between points?


etc?)

How easy was it for Rs to remember their drinking behaviour?

215

Are the answers truthful?

Clarification of terminology e.g. weekdays vs. week end days

1. General Probes


Was it easy or hard to answer the questions?


From the top of your head do you remember any questions that were more difficult for you to

answer? Examples

Was it easy or hard to remember details of your drinking behaviour?


2. Specific Probes

Question AL.2: During the week days (from Monday to Thursday), on how many of these 4 days do

you usually drink alcohol?

How did you go about answering this question?

Was it easy or hard to understand the question?

Was it clear or confusing that we referred to a weekday ranging from Monday through Thursday?

Was it easy or hard to estimate your USUAL consumption?

(Ask if necessary: Was there a particular week you were thinking of?)

Question AL.3: How many drinks containing alcohol do you usually have on one of those week days

when you drink alcohol (Monday to Thursday)?


What went on in your mind when you answered that question? Examples

Was there a particular day you were you thinking about and why?

Was it easy or difficult to answer this question? Examples

What did you think of the answer categories?

Did you find a category that matched your drinking patterns?

Question AL.4: During the weekends (from Friday to Sunday), on how many of these 3 days do you

usually drink alcohol?

When you answered this question, about the ‘weekend’, what days were you thinking about?

How did you arrive at your answer?

What days did you include in your estimation?

(Probe if necessary: How about Sunday?)

Was it useful or not to distinguish between weekend and weekday to estimate your consumption?

How so?

216

Question AL.5: How many drinks containing alcohol do you usually have on one of those weekend

days when you drink alcohol (Friday to Sunday)?

How did you go about answering that question?

When responding, did you think of one day or did you think of the whole weekend?

How easy was it to answer this question? Examples

How did you remember that?

If you had to choose between tow alternatives, would you prefer a more general question like 1a) or

the question that differentiate between weekdays and weekends consumption?

Question Al.6: During the past 12 months, how often did you have 6 or more drinks on one

occasion?

How did you arrive at your answer? Examples

How did you remember that?

What does “one occasion” mean to you?

Was it easy or hard to provide an answer?

(Probe if necessary: Was it easy or difficult to recall when you had six or more drinks?)

What did you think of the answer categories?

Did you find a category that matched your drinking patterns?

Some other general probes on use of show card, skips and sensitivity:

Did you refer to the show card when reporting your consumption?

(If no: Why?)

(If yes: Was it easy or difficult to use?)

What did you think about the skips in the questions?

Questions sometimes have different kinds of effects on people. We would like your opinion on these

questions. Please tell me whether you think the questions would make people uneasy or not?

STAGE THREE: CONCLUSION

Ask Rs if they have any questions about the project

Remind them that the data will be treated confidentially

Tell them once more that they are helping us to improve the new survey and that their input it truly

appreciated.

Thank them for their effort

217

3. Annex Chapter 5 – Country Reports of Parallel Cognitive Testing, Round 2 3.1. Germany

Improvement of the EHIS

Report cognitive testing (round 2, RKI). Testing the new physical activity questions in Germany

Berlin, 7 May 2011

218

3.1.1. Methods

In round 2 of cognitive testing, we followed the same methodology as reported for the first round.

The non‐probability sample of German speaking adults 18+ years of age who lived at baseline in

Berlin showed the following parallelisation.

Table 28: Characteristics of respondents participating in cognitive testing round 2

Age in years Men Women < 20 1 1

20‐39 2 2

40‐59 1 2

60 + 3 2

Total 7 7

Instrument to be tested

Physical Activity

Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions even if you do not consider yourself to be a physically active person.

Activity at work

Q1

Think first about the time you spend doing work. Think of work as the things that you have to do such as paid and unpaid work, work around your home, taking care of family, studying or training. [Insert other examples if needed]. When you are WORKING, which of the following best describes what you do? Would you say— INTERVIEWER INSTRUCTION: If respondent does multiple tasks, include all tasks. Please hand out SHOW CARD 1.

1 Mostly sitting or standing

2 Mostly walking

3 Mostly heavy labour or physically demanding work

Do not read:

8 Don’t know / Not sure

9 Refused

Travel to and from places (commuting activities)

Q2

The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way you TRAVEL TO AND FROM PLACES. For example to work, to school, for shopping, or to market. [insert other examples if needed]

Q2.1

In a typical week, on how many days do you WALK for at least 10 minutes continuously to get to and from places? INTERVIEWER INSTRUCTION: If respondent does brisk walking for travel that causes AT LEAST a small increase in breathing or heart rate include such activities in the next section (Sports, fitness and recreational activities).

Number of days: ___ If zero go to question 2.2

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10 ‐ 29 minutes per day


1 ‐ 2 hours per day


Q2.1A How much time do you spend walking for travel on a typical day?

3 hours or more per day

Q2.2

In a typical week, on how many days do you BICYCLE for at least 10 minutes continuously to get to and from places? Interviewer instruction: Include here also the use of other non motor‐driven means of active transportation such as scooter, roller or skates etc.

Number of days: ___ If zero go to question 3





Q2.2A How much time do you spend bicycling for travel on a typical day?


Sports, fitness and recreational activities

Q3

The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about SPORTS, FITNESS and RECREATIONAL ACTIVITIES (leisure) that causes AT LEAST a small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling, or swimming. [insert other examples if needed] INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 2.

Q3.1

In a typical week, on how many days do you do sports, fitness or recreational (leisure) activities for at least 10 minutes continuously?

Number of days: ___ If zero go to the next section

Q3.1A

How much time do you spend in total doing sports, fitness or recreational activities in a typical week?

___ ___ : ___ ___ per week hrs mins

Muscle‐strengthening activities

Q4

In a typical week, on how many days do you do physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.) INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 3.

Number of days: ___

In regards to the work‐related physical activity question ‐ in order to test whether the interviewer

instruction work as intended ‐ we decided that the interviewer should always read the instruction “If

you do multiple tasks, include all tasks” even if in the original question this information should only

be given if the respondent explicitly asks whether to include multiple working tasks if applicable.

220

Please find the standardized probe document in the annex

3.1.2. Results 3.1.3. Overall findings

Simplicity:

Most of the respondents indicated that the questions were easy to answer (10/14) and that they

found it easy to remember their physical activity behaviour. One reason why respondents found it

difficult to answer the questions was that they had difficulties to estimate an average duration in the

case when activities were performed irregularly. In addition, two women (ID 24, f, 20‐39/ID 27, f, 40‐

59) indicated that it was difficult to combine work and other activities at home in the work‐related

physical activity section. Two respondents indicated that the muscle‐strengthening question was the

easiest question (ID24, 27), two respondents reported that the leisure‐time physical activity question

was the easiest to answer (ID 21, 27), whereas one respondent felt that the work‐related physical

activity question was the easiest (ID19).

Conclusions: In general, the questions were perceived as being clear and easy to answer. The work‐

related physical activity question seemed to be easy to answer if respondents did homogeneous

work‐related tasks which were covered by the answer categories. If respondents did multiple tasks

such as paid work and domestic work, this question was more difficult to answer. This seemed to be

the case especially among women who work and also fulfil domestic tasks.

Reference period: ‘typical week’ versus ‘in the last seven days’:

Most of the respondents preferred the ‘typical week’ reference period (8/11). The reasons for that

were that it is more truthful and representative, while ‘in the last seven days’ would be especially

problematic if those last seven days differed from a usual week. Three respondents preferred the

‘last 7 days’ concept because of irregular activity schedules, especially for bicycling, as they think that

there is no such thing as a typical week also for the reason that such behaviour varies between

summer and winter. Two respondents were not sure which option would be better and indicated

that the last seven days are easier to recall but it might differ from a usual week (ID 26, m, 25).

Conclusions: Most respondent felt that the ‘typical week’ reference period is more appropriate and

represents what they do in a better way. However, in case of irregular activity behaviour and

seasonal differences, ‘the last 7 days’ concept might be a better solution.

Reference unit to indicate physical activity duration: ‘daily’ versus ‘weekly’ basis:

Asking the respondents whether it makes sense to ask for the duration of travel activities on a daily

basis while asking about the duration of leisure‐time activities on a weekly basis, all respondents

indicated that it makes sense to ask the questions using different reference units. They indicated that

they rather walk and bicycle for travel daily, whereas they plan their exercise and sports schedule on

a weekly basis. Consequently, asking whether they found it difficult to switch from the daily basis

(active transportation) to a weekly basis (sports, fitness, recreational activity), all 14 respondents

221

indicated that it was easy to obtain this switch. One respondent indicated that she did not even

notice the shift (ID27, f, 40‐59).

Conclusions: Asking for the duration of transportation activity on a daily basis and for sports, fitness

and recreational activity on a weekly basis was plausible for all respondents, as activities for

transport are usually daily activities, whereas sports, exercise and recreational activities are usually

planned on a weekly basis. No one found shifting from the daily to the weekly basis difficult.

Issues around the show cards:

Only two respondents indicated that they used the show cards for all questions. Many respondents

(6/14) indicated that they partly used them, some of those respondents reporting that they

particularly used the show card on work‐related physical activity, while others reported that they

used the show card on muscle‐strengthening activity question. Four respondents indicated that they

did not use the show cards since the concepts were clear and easy to understand, with or without

the show cards. The majority of respondents indicated that it was easy to use the show cards (9/11),

whereas two respondents found them a bit difficult to use. One reason was that they found that not

all relevant activities were depicted. One respondent did not like the categorisation of the work‐

related physical activity show card and claimed that in the leisure‐time question, the focus was too

much on sports activities (ID20, f, 40‐59).

3.1.4. Findings on specific questions

Q1: work‐related physical activity

Work‐related physical activity

1

Think first about the time you spend doing work. Think of work as the things that you have to do such as paid and unpaid work, work around your home, taking care of family, studying or training. [Insert other examples if needed]. When you are WORKING, which of the following best describes what you do? Would you say— Interviewer instructions: Please hand out show card 1. If respondent does multiple tasks, include all tasks.


2 Mostly walking


Do not read:


9 Refused

Simplicity:

The majority of respondents indicated that Q1 was easy to answer (9/12). One reason why some

respondents found it difficult to answer was that apart from paid work, also unpaid work such as

household chores should be included additionally.

222

Show card:

Many respondents indicated that they did not use the show card for question Q1. The main reason

for that was that they didn’t have any problems finding the correct answer category which

represents their profile straight away. Most respondents who used the show card found the

underlying concepts clear and the show card easy to use. One respondent (ID20, m, 40‐59) indicated

that he did not like the representation of the ‘mostly walking’ category on the show card, since,

according to him, ‘electrical work’ and ‘plumbing’ does not include ‘mostly walking’. He suggested

calling the category “light work”.

Thought process:

The following table gives an overview of the respondents’ thought process on how they came to their

answer, what they had in mind when answering the question, and whether it was easy or difficult for

them to refer their answers to what they ‘mostly’ do when they are working.

223

Table 29: Overview of respondents’ thought process when answering Q1

Respondent Definition in mind when

answering the question Respondents answer

Which working tasks were

included

Easy or difficult to define

what “R” 'mostly' does

ID17, f, 60+ ‘Being physically active, vacuum cleaning, or physical household work’

‘Mostly walking or tasks of light to moderate effort’

Mainly household work, in other "fields" R is not active anymore

Easy, R is not involved in many activities anymore

ID18, m, 0+ ‘A targeted activity, which normally leads to a certain achievement. In terms of university, this may not be applicable. (...) Non‐paid work should be included as well, such as household work’

‘Mostly sitting or standing’ studying, several times a week ‐Easy to find adequate option ‐Concept clear, studying also implies walking, but it is predominantly sitting

ID19, f, 0‐59 ‘I didn’t refer "working" to my occupational activity to e.g. gardening’

‘Mostly sitting or standing’ ‐ I initially thought that the first category suits me, but I carefully considered the other options as well and looked at the show card; then I came to the category which suits me best by excluding the other options.

Not difficult

ID20, m, 40‐59 ‘Work, for me, means paid work (…)’

‘Mostly sitting or standing’ ‐ sitting: 4 ‐ 5 hrs per day ‐ physically active at building site: 1 hr ‐ rest of the time: standing, talking & solving problems

Not difficult

ID21, m, 60+ ‘Mental‐physical work, or work which is physically demanding’

‘Mostly sitting or standing’ ‐ Referred answer to former occupational activities

Easy

224

Respondent Definition in mind when

answering the question Respondents answer

Which working tasks were

included

Easy or difficult to define

'mostly'

ID22, f, 60+ ‘Gardening, weeding pest plants, digging, chopping something, to trundle, watering the flowers, to mow the lawn, or household chores, such as (vacuum‐) cleaning, and cleaning the windows’


‐Thinks of activities she does when helping relatives ‐ Describes the work at brother‐in‐law’s house and the work R has done in terms of chopping and stacking wood

‐ Not difficult ‐ She does mostly household and gardening work.

ID23, f, 20‐39 ‘Certainly not household activities, only in case of unemployment’. Thinks mainly of activities related to her university/studies.

‘Mostly sitting or standing’ ‐Less standing, mainly sitting, explains the time R spends sitting during tutorials, lunch and learning at home ‐Rather difficult to remember time, does differ from day to day, but recalls 6hours/day

‐ Predominantly university studies

ID24, f, 0‐39 Thought of part‐time jobs, in which is mostly sitting and standing. Housework is not included in R’s definition.

‘Mostly sitting or standing’ Thinking of most common/ predominant work, namely (paid) part‐time work

‐ Not difficult as only (paid) part‐time jobs were included (…) hours of work could be recalled easily

ID25, m, 20‐39 ‘Work is the occupation of employment’. R didn't really think much about the definition because it was clear to him that the main part of it is done "sitting or standing"

‘Mostly sitting or standing’ ‐ I thought mainly of my paid work since it clearly predominates

‐ Easy to define

225

Respondent Definition in mind when answering the question

Respondents answer Which working tasks were included

Easy or difficult to define 'mostly'

ID26, m, 20‐39 ‘First of all I thought about what I am earning money with, after the explanation within the question, I included unpaid studying’

‘Mostly sitting or standing’ ‐ Mostly sitting at the desk, when studying or working, 8 ‐ 10 hrs per day at the moment.

‐ Not difficult, studying and working include same tasks

ID27, f, 40 – 59 ‐ ‘I thought about paid work only’

‐ ‘Mostly sitting or standing’ or ‘mostly walking or tasks of light to moderate effort’ (R was not sure which category fits better)

‐ My paid work, predominantly counselling interviews and other activities of my work and work around my home.

‐ Difficult, that's why I couldn't decide between two answer categories.

ID28, m, 60+ ‘For me, work means paid work. Considering unpaid work was not that easy’

‘Mostly sitting or standing’ ‐ ‘I thought about all my activities and tried to calculate a time average’

‐ ‘Quite hard, since I do a lot of different activities. So it was difficult to indicate what I do but not that I mostly sit’

ID29, f, U20 ‐ First of all, thought of school, as this is the place where she spends most time. Furthermore, R thought of cleaning and doing the dishes.

‐ ‘Mostly sitting or standing’ ‐ R stated that she thought mainly of school. Doing the dishes and cleaning up was not mentioned anymore.

‐ Easy ‐ Thinking of most predominant work such as going to school

ID30, m, U20 ‘I thought about paid work. Work at home is not a physical activity to me’.

‘Mostly sitting or standing’ ‐ ‘I thought about my studying activities. At present, I study 2‐3 hours per day’.

‐ Easy

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Discussion:

Most respondents found it easy to indicate their physical activity level at work. Analysing the thought

process table, the question worked as intended in most cases. Some respondents had difficulties

with the instruction “if you do multiple tasks include all tasks” which was always read by the

interviewer in the context of cognitive testing, since they had to add the activities at their workplace

and the activities they did at home, and then decide what they did ‘mostly’. This mental exercise

caused problems for some respondents. During the interview situation, this explanation should only

be given if a respondent explicitly asks whether he/she should include multiple jobs/tasks. With

regards to the show card, the second category, combining ‘mostly walking’ with ‘tasks of light to

moderate effort’ such as plumbing or electrical work, confused one respondent. It might be an

improvement to clarify the phrasing of the second answer category of the first question, explaining

that not only walking is to be included, but also tasks of light to moderate physical effort, such as

domestic work, plumbing, electrical work etc. As a result, the second answer category of Q1 might be

phrased as ‘Mostly walking or tasks of light to moderate physical effort’. Moreover, we noticed that

there is no option to indicate that this question is not applicable, e.g. in case that a test person is

unemployed or does not work for other reasons.

Recommendations:

Add the answer category “not applicable’.

Consider to call the second answer category ‘mostly walking or tasks of light to moderate

physical effort’ instead of ‘mostly walking’.

In the interviewer instruction, define that respondents should refer their answer to the work

they “mainly” do. Only if respondents do multiple tasks (work) should they include all tasks.

Q2: Physical activity to travel to and from places (commuting activity)

Q2.1 Walking for transportation


2


2.1

In a typical week, on how many days do you WALK for at least 10 minutes continuously to get to and from places?






2.1A How much time do you spend walking for travel on a typical day?


227

Which walks did the respondents include?

All respondents understood the underlying concept of the question that only ‘walking for travelling

to and from places’ should be included when answering the question. Two respondents indicated

that they do not walk at all for at least 10 minutes continuously for travel (ID27, f, 40‐59/ID28, m,

60+). Respondents included the following walks tram or bus, to the market, for shopping, to friends,

and from one village to another. All examples mentioned by the respondents met the intended

underlying concept of the question.

How certain were the respondents on whether the walks they included were performed for at least

10 minutes continuously?

Most of the respondents (7 out of 12) indicated that they were sure that the walks they included

took at least 10 minutes continuously. However, some of those respondents reported that they

roughly estimated whether a walk took at least 10 minutes. Others were very sure about their

answer because they performed the indicated walks regularly and indicated that they know the

duration of such walks. Five respondents indicated that they were not sure whether the walks they

included were performed for at least 10 minutes continuously.

Did the respondent only include regular walks or also irregular walks?

Many respondents (7 out of 12) indicated that they included mainly regular walks, whereas the other

respondents said that they also included irregular walks, mostly by roughly estimating how

frequently they perform irregular walks and then providing an average.

How did respondents calculate the duration of walks for travel and how certain were they about

their answers?

When answering question Q2.1A, many respondents reported that they were thinking about their

daily walking routine in terms of specific walks of which they know how long they take, and then

calculating an approximation in terms of an average duration on a daily basis. In regards to certainty

with the answer, 6 out of 7 respondents who gave a clear answer on this question indicated that they

were certain about the estimated duration they indicated. Those respondents mostly reported that

they had a regular daily walking routine.

Did respondents prefer to indicate the duration of walking using closed or open answer categories?

8 out of 10 respondents who provided a clear answer on this question preferred closed answer

categories instead of giving an exact figure. The main reasons for this choice were that it is easier to

answer the question with closed answer options, since they could only provide a rough estimation on

the daily walking routine, which means closed answer options are better instead of providing an

exact figure; also, it is less mentally burdening to choose between answer categories instead of

providing an exact figure. The two respondents (ID30, m, 19/ ID22, f, 60+) who preferred to provide

an exact figure had a very regular walking routine and were very sure about the duration they walk

daily and indicated therefore, that they could easily provide an exact figure.

228

Did Rs prefer to indicate the duration of walking on a daily or weekly basis?

9 out of 11 respondents indicated that they preferred answering question Q2.1A on a daily basis. The

main reason for that was that under the premise of having a daily walking routine, they would have

to sum up all the daily walks to give an estimation on a weekly basis, which would be an additional

effort. One respondent (ID19, f, 40‐59) who preferred to indicate the duration on a weekly basis

reported that her walking behaviour differs between weekdays and weekends.

Discussion:

The underlying concept of the questions on “walking for travel” was well understood by all

respondents. About half of the respondents were sure about including only walks which were

performed for at least 10 minutes continuously. Moreover, about half of the respondents indicated

that they mainly included regular walks ‐ the other half also included irregular walks. The vast

majority of respondents preferred categorical answer options on a daily basis to indicate the

duration of walks. The main reasons for this decision were that walking is performed in a daily

routine and that it is easier to tick a closed answer option; since the calculated walking duration is

based on an approximate estimation, one cannot be sure enough to indicate an exact figure.

Recommendations:

Keep closed answer categories

Keep asking for the walking duration on a daily basis

Q2.2 Bicycling for transportation

2.2







2.2A How much time do you spend bicycling for travel on a typical day?


229

Definition of bicycling applied:

10 out of 14 interviewees indicated that they do perform bicycling to get to and from places. Asking

about the definition they had in mind when answering the questions, nine out of ten respondents

understood the question the way it is intended, only including bicycling for transportation. One

respondent (ID21, m, 60+) also included bicycling tours in his leisure time. The following table shows

examples of the definitions respondents had in mind when answering the questions.

Table 30: Examples of the definitions of bicycling given by the respondents

Respondent Definition of bicycling applied

ID24, f, 20‐39 “Cycling is a mean to travel from one place to another”

ID27, f, 40‐59 “I get on my bike to get to a certain location”

ID28, m, 60+ “Like walking, but instead of putting one foot in front of the other I get on my bike to

reach a destination”

Which bicycling routes did the respondents include?

The following examples were given by the respondents when asking which routes they were thinking

of when answering the question: Routes to work, to school, to university, to the city, to friends, to go

working out, when going out, to go from village to village, bicycling tours (concept was falsely

understood by one respondent (ID21, m, 60+)).

Decision on length of routes; inclusion of regular and/or irregular routes; certainty about answers:

Most of the respondents who did perform bicycling for transportation indicated that they know the

regular routes they bicycle very well and that they know the distances and how long such routes

take. Six out of nine respondents indicated that they only included regular routes, three respondents

said that they also included irregular routes. Nine out of ten respondents who used their bicycle for

transportation indicated that they were certain about their answers. Those respondents indicated

that they use their bicycles regularly and know the distances of their regular routes.

Inclusion of other means of physically active transportation:

The majority of respondents indicated that to them, it makes sense to also include other means of

active transportation in this question, even if it did not apply to anyone in our sample. One

respondent (ID30, m, U20) felt that scooters might be used as a mean of transportation but not

skateboards or skates. Using skateboards and skates would be considered leisure‐time activity rather

than active transportation.

Did respondents prefer to indicate the duration of bicycling on a daily or weekly basis?

Seven out of ten respondents who use their bicycle for transportation reported that they prefer to

indicate the time they spend bicycling on a daily basis, those respondents were more likely to use the

bicycle regularly and every day. One respondent reported that his bicycling behaviour differs

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between weekdays and weekends and that he applied a weekday when answering the question

(ID25, m, 20‐39). Three respondents preferred to indicate the duration of bicycling on a weekly basis

(ID18, 19, 20‐39). One of those respondents indicated that it might be easier to indicate the duration

on a daily basis as one does not have to add up the duration of the single days. However, first of all a

typical day would have to be defined and this is difficult as the duration of bicycling varies strongly

from day to day (ID18, m, 60+).

Discussion:

Overall, the question worked as intended. The results of the cognitive interview showed that

respondents who regularly use their bicycle for transportation know the frequency and duration of

their regular routes well, are able to recall the routes they cycle easily and were therefore certain

about their answers. Those people mostly preferred to state the duration of bicycling on a daily basis.

However, there will always be a few people who do not regularly use their bicycle. Those people

might have more difficulties to recall their bicycling behaviour and might be more likely to prefer

stating the time they cycle on a weekly basis. As health‐enhancing effects of physical activity mainly

become relevant when activities are performed regularly, we think that the focus of bicycling for

transportation assessment should be on regular bicycling. For this reason, we propose to assess the

duration of activities on a daily basis. Another reason why we think that it would be better to ask

about bicycling on a daily basis is that walking is also strongly recommended to be asked for on a

daily basis, as it is a daily activity; it would be better to maintain the same reference period for the

bicycling section. In this case, respondents do not have to switch to another reference period when

answering the succeeding questions on walking and bicycling.

Recommendations:

Keep closed answer categories

Keep asking for the bicycling duration on a daily basis

Q3 Sports fitness and recreational activities

3

The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about SPORTS, FITNESS and RECREATIONAL ACTIVITIES (leisure) that causes AT LEAST a small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling or swimming. [insert other examples if needed] Interviewer instruction: Please hand out show card 2.

3.1



3.1A



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Possibility to include all leisure‐time physical activities performed:

11 out of 14 respondents reported that they do sports, fitness or recreational activity. All of those 11

respondents reported that they were able to include all physical activities they do in their leisure

time, with the exception of one respondent (ID20, m, 40‐59) who remarked that he did not include

gardening in his leisure time.

Issues around the show card; understanding of the underlying concepts:

The vast majority of the respondents reported that the underlying concept of Q3 was clear. Many

respondents indicated that they did not use the show card for question Q3. The main reason for that

was again that they found the concept of the question clear without using the show card. Most of

the respondents who used the show card reported that it was easy to understand. One respondent

(ID27, f, 40‐59) suggested including dancing as an image on the show card, while another respondent

(ID30, m, U20) did not find ‘sailing’ on the show card, however he did include his sailing activities

when he answered the question. One respondent (ID26, m, 20‐39) was not sure whether he should

include fitness training – although, after looking at the show card he was sure about including it.

Social desirability bias:

All respondents could imagine that people might over‐report their leisure‐time activity level, most of

them thinking that this would be done unconsciously. One respondent, who indicated that he feels

bad when realizing that he is not that active anymore, referred his answer to sports activities (table

tennis) of the past which he does not perform any longer (ID21, m, 60+). When we asked him for

social desirability bias in the context of physical activity, he indicated that “people might include

activities which they actually do not perform”.

Preference indicating duration of activities on a weekly versus daily basis:

All 11 respondents who reported being physically active in their leisure time reported that they

prefer to state the duration of their activities on a weekly basis instead of a daily basis. They justified

their choice saying that leisure‐time activity is planned on a weekly basis and is usually not

performed every day.

Simplicity to provide exact figure about duration of activities:

7 out of 8 respondents who provided a clear answer on the question whether it is feasible to ask for

leisure‐time activity duration with an open answer category indicated that it was easy to provide an

exact figure. One respondent indicated that it was a bit difficult.

Thought process:

The following table gives an overview about the thought processes of respondents when answering

the questions Q3.1 and Q3.1A.

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Discussion:

Looking on the cognitive testing results of the leisure‐time physical activity section, we conclude that

the questions worked as intended. All active respondents were able to include all activities they do,

the underlying concepts of the questions were clear for the vast majority of respondents, for those

who used the show card it was easy to use, to indicate an exact figure about the time spend doing

leisure‐time activities was perceived being feasible by most respondents, and all active respondents

preferred to indicate the performed activity duration on a weekly basis. In compliance with the

respondents answers we believe that it is feasible to ask for an exact figure regarding the leisure‐

time physical activity duration. In contrast to walking or bicycling for transportation which are more

diffuse and non‐conscious behaviour, leisure‐time activity is a behaviour which is planned, structured

and controlled by the individual. As a result, leisure‐time activity behaviour is performed consciously,

consequently, it is easier to recall and the indication of an exact figure of activity duration seems to

be feasible. To indicate the activity duration on a weekly basis makes more sense than indicating it

on a daily basis, since leisure‐time activity is planned and structured on a weekly basis and rarely

performed daily.

Recommendations:

Keep open answer categories to estimate duration of activities

Keep asking for activity duration on a weekly basis

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Table 31: Specific opinions about question

Respondent Understanding of concept Respondents answer Which activities were included

Certainty about answer

ID17, f, 60+ Concept clear, knows how body reacts on physical activity

2 times a week, 30 minutes per week

2 x gymnastics, knows that breath and heart rate is increasing, no information about duration

Rather sure

ID18, m, 60+ Concept clear Once a week, 60 minutes per week

Once a week R goes to sports lesson for one hour

Sure

ID19, f,40‐59 Concept clear 4 times a week, 210 minutes per week

Yoga, bicycling, other activities, no information about duration

ID20, m, 40‐59 Thought that only sports‐related activities should be included

No activities named He does gardening for 4‐5 hours per week but did not include it here

ID21, m, 60+ Thought about movement (to move the body)

2 time a week, 240 minutes per week

Calisthenics once a day for 10 minutes. Describes the frequency and duration of the table tennis training he did in the past

Certain (R referred his answer to sports activities he did in the past but not anymore)

ID22, f, 60+ Thought about fast running or bicycling

3 times a week, 180 minutes a week

Bicycling three times a week, three hours all in all

sure

ID23, f, 20‐39 ‐ Physical activity which is done intentionally ‐less than 10 minutes is, regarding to R, not a sports activity

2 times, 180 minutes per week Gym 2x/week for approx. 1.5 hours

Sure

ID24, f, 20‐39 Concept was clear No activities named Not engaged in any physical activity

Sure

ID25, m, 20‐39 Concept was clear Once a week, 300 minutes per week

Gym and other irregular activities such as inline‐skating, jogging, swimming

Reasonably certain, but had to calculate average because of irregular activities.

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Respondent Understanding of concept Respondents answer Which activities were included

Certainty about answer

ID26, m, 20‐39 Thought about which sports he does consciously


Fitness‐sports, 2 time a week, 1.5 hours each time

Sure

ID27, f, 40 – 59 Concept was clear 2 times a week, 150 minutes Twice a week swimming plus crawl‐swimming, 2.5 hours altogether

Certain

ID28, m, 60+ Concept was clear No activities named Certain

ID29, f, U20 Sure about the concept 3 times a week, 420 minutes per week

‐ Only regular activities ‐ hockey training 2‐3 times a week, with a duration of 2.5 hours ‐ Sports lessons in school ‐ Acrobatics in school, 2 hours per week

Sure

ID30, m, U20 Concept was clear 5 times a week, 900 minutes per week

‐ bicycling for transport not included ‐ Gym 3 times a week for two hours each ‐ Sailing on the weekends with average duration of 8 hours per weekend

Certain

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Q4 Muscle‐strengthening activity

4

In a typical week, on how many days do you do physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.) Interviewer instruction: Please hand out show card 3.

Number of days: ___

About half of the respondents indicated that they did perform muscle‐strengthening physical activity.

The following findings are mainly based on the feedback of those respondents.

Understanding:

Regularly, muscle strengthening activities were defined more or less according to the concepts

presented on the respective show card, i.e. working out in the gym, lifting weights, but also yoga,

Pilates and aerobics. It was regularly understood as repeating certain movements and holding certain

positions to the extent of training muscles and thereby strengthening them. Also, some interviewees

included ‘active’ swimming and bicycling (ID20, m, 40‐59/ID21, m, 60+) and even chopping wood

(ID22, f, 60+).

Thought process:

For most respondents who performed activities which they defined as muscle strengthening,

calculating their frequency wasn’t very complicated. This was due to the fact that most of them did

those activities quite regularly. However, the given definition sometimes posed a bit of a problem;

one respondent thought of activities such as yoga as to some extent aimed at muscle strengthening,

to another extent targeted otherwise (ID19, f, 40‐59). She then had to calculate a certain percentage

of the time she spends on her regular yoga exercises to answer this question. Once this split had

been done, it wasn’t too difficult to come up with an answer.

Certainty:

Most respondents felt certain about their answer, with some remarks about the need to think a bit

longer about the question before answering (ID19, f, 40‐59). The main reason for that was that some

activities had different aims, muscle strengthening being only one of them. Thus, the respondents

weren’t sure whether to calculate a certain percentage of those activities or find another way of

including them. One respondent said that he wasn’t really sure about whether the activities he

included were meant for that category or not (ID28, m, 60+).

Use of show cards:

Those respondents who said that they performed activities of that sort generally understood the

concepts of the show card and mostly found them easy to use and to understand, sometimes also

helpful for answering the question. Some even said that they took a look at it, only to reassure

themselves that the concepts they had already had in mind were the ones we were asking about

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(ID25, m, 20‐39/ID26, m, 20‐39). Some concerns were expressed at the relatively small range of

activities depicted on the show card, with one respondent being unable to find his respective

exercise (ID28, m, 60+). Two interviewees admitted that they hadn’t used the show card at all. (ID21,

m, 60+/ID22, f, 60+)

Discussion:

In principal the question worked as intended. The vast majority of the respondents did refer their

answers to activities which were intended to be included. However, two respondents included

aerobic activities such as swimming and bicycling, which should not be included. It should be

considered to define muscle‐strengthening activity more clear to avoid misclassification bias.

Recommendations:

Consider to find a clearer definition for muscle‐strengthening activities to avoid

misclassification bias

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3.2. Estonia

Improvement of the European Health Interview Survey (EHIS) Eurostat grant no 10501.2009.007‐2009.890

Cognitive testing of the physical activity module in Estonia

Report

Tallinn 2011

238

The report is prepared by Leila Oja, Researcher, Chronic diseases department Elin‐Külliki Kruusmaa, Analyst, Department of health statistics Ardo Matsi, Analyst, Chronic diseases department National Institute for Health Development Hiiu 42, 11619 Tallinn, Estonia www.tai.ee

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3.2.1. Methods

This qualitative study comprised a set of 15 face‐to‐face interviews which were carried out in Estonia

during the second half of April 2011 using the methodology of cognitive testing. The study was

performed as part of the two‐country cognitive interview study in the context of the ‘Improvement

of the EHIS modules project’.

The interviews were conducted in Estonia using the translated Estonian version of the standardized

probe document elaborated in April 2011 by the Robert Koch Institute (RKI), Germany and adapted

by National Institute for Health Development (NIHD), Estonia.

The sample was a non‐probability sample of people with residence mainly in Tallinn but as well in

some smaller towns in Estonia. The native language of the respondents was Estonian.

The respondents were recruited according to the criteria (gender and age category) defined in

cooperation with the partners of the project during the coordination meeting that was held in Berlin

in January 2011.

The interviews took place in the National Institute for Health Development in Tallinn or interviewers

visited the respondents at home. The interviews were conducted by three trained interviewers. The

interviewer training was based on the standardized training material and the training was conducted

from 14th to 15th of December 2010 by the trainer Mrs Merle Paats licensed by NatCen, UK.


Age group Male Female Total

15−20 EE‐32 (M:15) EE‐28 (F:20) 2 (1 male/1 female)

21−39 EE‐61 (M:30)

EE‐63 (M:33)

EE‐62 (F:27)

EE‐64 (F:35)

4 (2 males/2 females)

40−59 EE‐25 (M:40)

EE‐31 (M:45)

EE‐21 (F:55)

EE‐23 (F:59)


60+ EE‐26 (M:60)

EE‐27 (M:60)

EE‐22 (F:74)

EE‐24 (F:69)

EE‐33 (F:74)


Total 7 8 15

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Updated set of questions on physical activity compiled by researchers of Robert Koch Institute was

tested.

Physical Activity


Activity at work

Q1 Think first about the time you spend doing work. Think of work as the things that you have to do such as paid and unpaid work, work around your home, taking care of family, studying or training. [Insert other examples if needed]. When you are WORKING, which of the following best describes what you do? Would you say— INTERVIEWER INSTRUCTION: If respondent does multiple tasks, include all tasks. Please hand out SHOW CARD 1.


2 Mostly walking


Do not read:

7 Not applicable 8 Don’t know / Not sure

9 Refused


Q2 The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way you TRAVEL TO AND FROM PLACES. For example to work, to school, for shopping, or to market. [insert other examples if needed]

Q2.1









Q2.2 In a typical week, on how many days do you BICYCLE for at least 10 minutes continuously to get to and from places? Interviewer instruction: Include here also the use of other non motor‐driven means of active transportation such as scooter, roller or skates etc.








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Q3 The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about SPORTS, FITNESS and RECREATIONAL ACTIVITIES (leisure) that cause AT LEAST a small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling, or swimming. [insert other examples if needed] INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 2.

Q3.1 In a typical week, on how many days do you do sports, fitness or recreational (leisure) activities for at least 10 minutes continuously?


Q3.1A How much time do you spend in total doing sports, fitness or recreational activities in a typical week?



Q4 In a typical week, on how many days do you do physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.) INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 3.

Number of days: ___

In regards to the work‐related physical activity question ‐ in order to test whether the interviewer

instruction works as intended – it was decided that the interviewer should always read the

instruction: “If you do multiple tasks, include all tasks”, even if in the original question this

information was only to be given if the respondent would explicitly ask whether to include multiple

working tasks if applicable.

The set of questions was assessed by means of face‐to‐face interviews. The physical activity module

included three show cards – the first for work‐related activities, the second for sports, fitness and

recreational activities and the third for muscle‐strengthening activities.

As an output of the cognitive testing questions were formulated to help identify how well the

questionnaire works. The questions were divided into five sections: General probes (about all

sections), Specific probes for the work‐related physical activity question, Specific probes for the

commuting activities questions, Specific probes for the sports, fitness and recreational activities

question and Specific probes for the muscle‐strengthening activities question.

3.2.2. Overall findings

Detailed results of the probes are shown in the table below. The table follows the order of the

questions.

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Table 3: Results of cognitive testing for PA questions Probes Answers

General probes

Was it easy or hard to answer the questions? In general was it easy or hard to remember your physical activities? (If “hard”: why?)

Easy Hard/difficult Don’t know/refusal

Quantitative results N (%) 14 (93,3) 1 (6,7) 0


For most of the respondents it was easy to respond and to remember their physical activities, while few people argued concerning the first part of the questionnaire.


Easy /no preference More complicated ‐ work‐related PA More complicated ‐ recreational PA

Quantitative results N 6 (46,2) 2 (15,4) 5 (38,5)


When respondents have concrete work at the same activity level and a certain schedule then it is easy to answer.

When respondents have various work‐tasks with different activity level then it is much more difficult to find the suitable response category (M40; M60; M15).

When respondents don’t have any specific schedule then it is more difficult to decide what kind of activities to include.

We requested that you refer your answers to a “usual week”. Do you think that it would be better to refer your answers to “the last 7 days”?

“Usual week” “The last 7 days” No difference



Most respondents told that “usual week” describes better their everyday activities even though for some persons with very various work tasks it was difficult to describe their “usual week”. If respondent has a certain everyday routine, then it is easy to respond, but when the activities vary more calculation is needed.

It would be better to answer about last 7 days. This gives more accurate responses because it is easier to remember (M30;M33). One respondent added a suggestion that about walking it should be asked separately about weekends and weekdays because the intensity of walking on those days is completely different (N27).

These respondents didn’t point out any preferences.

We asked for the time you spent on walking Same reference period Different reference periods No preference

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Probes Answers and bicycling for travel on a day basis, whereas we asked the time you spent doing sports, fitness, recreational activity on a weekly basis. Do you think that it was reasonable to ask the questions this way? Explain why? Do you feel that it is easy or hard to switch from a daily (Q2) to a weekly (Q3) reference period? Explain why?

Quantitative results N (%) 5 (33,3) 7 (46,7) 3 (20)


Minority of the respondents said that all the questions should have the same reference‐period, otherwise it’s confusing (M30; N20).

Respondents noticed that when you have trainings per week, then it’s easier to give a response on weekly basis even if it needs more attention and interviewer must stress it (N55; M33) but walking should be assessed on daily basis (N35).

Some respondents didn't notice any difference and for them it wasn’t significant to have one reference period (N74).

Did you use the show cards? Were the show cards difficult or easy to use? (If “difficult”: why?)

Easy to use Difficult to use Don’t know/Refusal

Quantitative results N (%) 12 (80) 3 (20) 0


All respondents used show cards. Show cards were useful for the identification which response category suits the best; especially for those persons whose work tasks or other activities were varying a lot.

Few respondents pointed out that the cards include too much information, are repetitive or even confusing, because their duties vary from one category to another and they couldn’t choose a suitable category (M15; M45; M60).

Q1 Probes on specific questions ‐ work‐related physical activity

How would you define the term “WORKING” in your own words that you had in mind when answering this question? How would you repeat this question with your own words?

Well defined Not well defined Don’t know/refusal



Most of the respondents confirmed good understanding of the question. The reason could be that except one pupil other respondents (incl. retired persons) have full or part‐time paid work or their own

Some respondents pointed out that paid work and unpaid work (work at home) should be separated (M15; M45; N74). And if the aim of the survey is to find out what kind of work the respondents do 8 hours per

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Probes Answers business and they assessed PA at paid work, not other household‐activities.

day, then the duration as criteria should be more clearly brought out in the question (N27; N35).

How did you go on answering this question? Was it easy or difficult to indicate what you “mostly” do? (If “hard” explain why?)

Easy Difficult Don’t know/refusal



Mainly the respondents thought about their paid work and corresponding activities and when their work was comparable at the same activity level then it was easy to answer. Some respondents told that when they noticed computer in the first picture then they promptly decided that this category suits for them (N59; M60).

When respondents had various work tasks with different activity level then it was much more difficult to find the suitable response category (M40; M60).

How easy or difficult was it to choose an answer category that “best describes” what you do? How well did the response categories suit the answer you wanted to provide? (If it suit not well, explain why?)

Easy/suitable Difficult/not suitable Don’t know/refusal



When respondents have concrete paid full‐time work at the same activity level then it is easy to answer.

Respondents who have various work tasks on different activity level or who have part‐time work or they are not engaged with similar activities the whole day, didn’t find a suitable response category. They stressed that one response category covering the activity level between sitting/standing and walking is missing (M40; N74; N69).

How easy or difficult was it to use the show card? Were the underlying concepts of the show card clear or unclear? If unclear, what was unclear?

Easy /clear Difficult/ not clear Don’t know/refusal


Qualitative results Most respondents stressed that show card One respondent mentioned that show card

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Probes Answers (Reasons) was easy to use and conceptually clear. was unclear (M45) and another told that

even if the concept of show card was clear, it didn't give him any suitable response category (M60).

Q2.1 Probes on specific questions – activities to travel to and from places on foot

How did you come to your answer? How did you decide upon which walks to include? How do you remember this? Examples

Easy Difficult Don’t know/refusal



All respondents remembered their purposeful walking or not having such walks well. Mainly their walks where connected with travelling to and from work/school or shopping.

Some respondents argued about separation between purposeful travel and simple walking (N74; M60; N27). Dog‐owners wanted to include those quite long walks to their response because they do not walk so actively that it is possible to describe it under recreational activities where increase in breathing is expected (N20; N27; N74).

How did you decide which walks lasted 10 minutes??

Exact duration Estimation Don’t know/refusal

Quantitative results N (%) 11 (73,3) 3 (20) 1 (6,7)


Most of the respondents told that they have certain destinations and they know quite exactly the duration of their walks.

Some respondents assumed or just intuitively gave an estimation of the duration of their travel (N20; N55; M30).

One respondent said that he travels to and from places by car only and has a walk without any purpose (M60).

Did you think about regular walks only or did you also include irregular walks?

Both Regular Irregular



Only few respondents acknowledged that they included all their travelling (M30; M33).

Mainly respondents considered only their regular travelling. Some of them pointed out that they have only few irregular walks and it is difficult to broaden those to weekly basis (N69).

One respondent told that she included only irregular walks because she mainly drives by car (N55).

Q2.1A Probes on specific questions – activities to travel to and from places on foot

Please define walking to get to and from places? Give examples.

Exact calculation Estimation Don’t know/refusal

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Probes Answers How did you calculate the amount of time spent walking for travel? Please describe your thought process on how you arrived at your answer?



All respondents thought that the question was well formulated and understandable. Most of them knew very well how long it takes for them to travel from place to place because they had to be on time at a certain place (at school, at work, in the bus/train stop) (N59, M40, M15).

Some respondents gave just estimation. Their travel from place to place was more connected with shopping or some other activities which do not need to be very exactly estimated (N74; N20; N55).

Two respondents do not walk for purpose (M60; M45)

Do you think that it is helpful providing closed answer options indicating the time you spent walking for travel? Or do you think it would be better asking for the exact figure of time you spent on walking for travel? Please explain why?

Exact duration Closed answer categories Don’t know/refusal



Some respondents knew well how long their travelling takes and therefore they preferred to give exact figure to be correct (N69; M40; M30; M15).

Mainly respondents preferred closed answer categories because it helped them to give response and they didn’t waste time for calculations (N20; N59; N74). At the same time they preferred to see the list of categories for making a decision.

Two respondents didn’t give their preference, they accepted both possibilities (N55; M60) and two respondents didn’t have such walks (M60; M45)).

We asked you to indicate the time you spent walking for travel on a daily basis. Do you think it would be better to ask this question on a weekly basis? Please explain why?

Daily Weekly No difference/ Don’t know

Quantitative results N (%) 9 (60) 2 (13,3) 4 (26,7)


Most of the respondents preferred to give response on daily basis because their daily travels do not differ much and it avoids additional calculations (N59; N74; N69; M30; N35).

Some respondents preferred weekly reference due to different pattern in the weekend (M33) or while their days are not similar (N55).

Two respondents told that they have no preference (N20; N27) and two respondents didn’t answer (M60; M45)).

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Probes Answers Q2.2 and Q2.2A Probes on specific questions – activities to travel to and from places by bike

Questions Yes No Don’t know/refusal

Quantitative results N (%) 0 15 (100) 0


No‐one from our respondents travel by bike. The main reason is that there are not enough special biking roads and biking is season‐sensitive in Estonia. Even these respondents who travel by bike sometimes in summer told that this does not describe their typical week.

Q3.1 Probes on specific questions – sports, fitness and recreational activities

Was the concept of ‘sports, fitness and recreational activities (leisure) that causes AT LEAST a small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling or swimming’ for you clear or unclear? Please tell me why?

Clear Unclear Don’t know/refusal

Quantitative results N (%) 15 (100) 0(0) 0


Fishing should be added (M40‐59). Sentence “...causes at least a small increase in breathing...” was a little confusing, otherwise wording was clear (M15‐39).

How did you decide upon which activities to include and to exclude?

Has a certain training‐schedule Has no such activities other

Quantitative results N (%) 5(33,3) 4(26,7) 6(40)


“according to the list of activities mentioned in the previous question”(W60+); “I do not have so many different trainings that I couldn't remember”(M39‐60); “What is the difference when I walk to cinema for half an hour or just have a walk of the same duration?”(M60+)

Were the underlying concepts of the show card Clear Unclear Don’t know/Refusal

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Probes Answers clear or unclear? If unclear, what was unclear?



Would include dancing, skiing(W40‐59); include fishing and gardening(M40‐59); include hunting(M60+); Include aerobics, dancing, Nordic walk(W15‐39)

Unclear, because not a single concept, all actions are taken together

Was it easy or difficult to define what a typical week is like, if yes, indicate why?

Easy Difficult Don’t know/Refusal



The only problem is when you are sick, then you cannot go in for sports(M60+)

Typical week is not a good choice ‐ there are several times a year, when respondent is very active, but it is hard to give the average of a typical week(M21‐39)

Do you think that someone might not give a truthful answer on this question? And if yes, indicate why?

Yes No Don’t know/Refusal



Yes, when one wants to seem better than he/she really is (N60+); of course, very many prefer to show that they are more active and sporty (M60+); Yes, those who are ashamed that they are not active (M21‐39)

Q3.1A Probes on specific questions – sports, fitness and recreational activities

How did you calculate the amount of time spent doing sports, fitness and recreational activities? Please describe your thought process on how you arrived at your answer.

Has a training‐schedule Thought about walks, activities Don’t know/refusal



Was it easy or hard to provide an exact figure on the time you spent doing sports, fitness or recreational activities in a typical week? Explain

Easy Hard

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Probes Answers why?

Quantitative results N (%) 8 (88,9) 1 (11,1)


Easy when there is a schedule or a routine for a week

Sometimes more and sometimes less, but the average should be correct(M60+ )

We asked you about the time you spend doing sports, fitness and recreational activities on a weekly basis. Do you think it would be better to ask this question on a daily basis? Explain why?

Weekly Daily

No difference



Weekly basis is better as days have different intensity(M15‐39)

If there is a schedule, there is no difference (W15‐39)

Q4 Probes on specific questions – muscle‐strengthening activities

What does ‘muscle strengthening’ mean to you? Examples.

For me ‐ yoga maybe, but generally muscle training and fitness (W15‐39); At first I thought only about training in the fitness clubs, but from the show card I noticed that stretching or morning exercises are included (W40‐59); for me it is water aerobics (W60+); physical weight training (M15‐39); push ups (M15‐39)

Were the underlying concepts of the show card clear or unclear? If unclear, what was unclear?

Clear Unclear Don’t know/refusal



Understandable, maybe the picture of sit‐ups was not very clear (W40‐59)

Are there specific exercises also included as push‐ups, or is it general strength‐training? (W15‐39)

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General

Respondents in each age group felt that it would be easier to answer if there is a regular work and

concrete training plan.

Simplicity

Most of the respondents indicated that the questions were easy to answer (14/15) and that they

found it easy to remember their physical activity behaviour.

Some reasons why respondents found it difficult to answer the questions:

Duration ‐ Many people had difficulties to estimate an average duration when activities were

performed irregularly.

Work‐related activities – Some respondents, mainly women (F 74), indicated that it was difficult to

combine work and other activities at home in the work‐related physical activity section. Some men

(M 40; M 60; M 15) argued that they have various working tasks on different activity level (computer

work mixed with transportation or training or carrying boxes or work supervision), which made it

difficult to choose the suitable response category.

Leisure time activities – 6 of15 respondents reported that they had no preference concerning

answering the questions, 2 persons indicated that the work‐related part was more complicated, 5

respondents said that the recreational physical activity part was more difficult to respond and 2

respondents didn’t specify their answers.

Sensitivity

The questions were not found to be sensitive even if some respondents felt a little embarrassed that

they were not very active and wanted to do more sports than they do.

Reference periods

Most of the respondents preferred the ‘usual week’ reference period (8/15) for the reason that it is

more representative, while ‘the last seven days’ would be especially problematic if those days

differed from a usual week (people were sick or on holidays). Two respondents preferred the ‘last 7

days’ concept because of irregular activity schedules (e.g. freelancers or trainers). It was especially

mentioned about bicycling, as they think that there is no such thing as a typical week because cycling

is season‐sensitive and the intensity can also be completely different during weekdays and

weekends. Five respondents were not sure which option would be better and indicated that the last

seven days are easier to recall but it might differ from a usual week (M 30; M 33).

Concerning the different reference periods for travel from place to place and for recreational

activities we suggest to keep them different ‐ daily basis for travel from place to place and weekly

basis for recreational activities.

Answer categories

2/3 of respondents agreed with the proposed answer categories because they have concrete paid

full‐time work at the same activity level. But respondents who have various work tasks on different

activity level or who have part‐time work or do not perform similar activities the whole day, didn’t

251

find a suitable response category. They stressed that one response category covering the activity

level between sitting/standing and walking is missing (M40; N74; N69).

Show card

All respondents indicated that they used show card to some extent, some of those respondents

reported that they particularly used the show card on work‐related physical activity, while others

said that they used the show card on muscle‐strengthening activity question. The majority of

respondents (80 %) indicated that it was easy to use the show cards (12/15), whereas three

respondents found them a bit difficult to use. One reason was that they didn’t find all relevant

activities represented. Some respondents did not like the categorisation of the work‐related physical

activity show card (M 60+).

3.2.3. Specific findings

Q1: work‐related physical activity

Simplicity

The majority of respondents (66,7 %) indicated that Q1 was easy to answer (10/15). One reason why

some respondents found it difficult to answer was that apart from paid work, also unpaid work such

as household chores (also activities at school versus at home) should be included additionally (M 15;

M 45; F 74). Also, respondent’s work‐related activities can vary a lot and therefore fall under

different response categories (F 27; F 35).

Show card:

Most of the Estonian respondents used the show card either to be sure that their decision was

correct or just to check for interest how it is compiled, even if they didn’t have problems with answer

categories; and they didn't go deeply into the pictures because they realised that one of them

represented their main activity. Most respondents who used the show card found the underlying

concepts clear and the show card easy to use. One respondent (M 60) expressed dissatisfaction that

this card does not describe his work and is therefore useless.

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Table 33: Overview of the Estonian respondents’ thought process when answering Q1

Respondent Definition in mind when answering

the question Respondents answer

Which working tasks were included

Easy or difficult to define what “R” 'mostly' does

ID21, f, 55 I am working in office most of the day ‘Mostly sitting or standing’ I concentrated on the working tasks – computer work

Easy

ID22, f, 74 I thought about the contents of my everyday life ‐ there are 2 components: housekeeping and computer work


It consists of 1,5‐5 hours computer work and some hours for housekeeping

Easy

ID23, f, 59 Work is what I do every day in the office

‘Mostly sitting or standing’ Computer work, scanning, calling, sending mails etc

Not difficult

ID24, f, 69 Housekeeping, gardening, handicraft work

‘Mostly sitting or standing’ Housekeeping, gardening, work of a self‐employer

In the beginning – yes – it was difficult because half of my everyday tasks are connected with some walking (gardening etc) and half of them are not, but due to my leg injury I try to avoid longer walks at the moment

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Respondent Definition in mind when answering the question

Respondents answer Which working tasks were

included Easy or difficult to define what “R” 'mostly' does

ID25, m, 40 When I think of my whole day, then I realise that I walk a lot from place to place


I thought of my different tasks – 3‐4 hours computer work, some meetings, organisational work, trainings, some hours in garden etc

For me it was difficult to decide because my different jobs require different activity levels

ID26, m, 60 My duties are very different but mainly I do computer work or have a phone conversation

‘Mostly sitting or standing’ I have a lot of various tasks but mainly my work is connected with computer, e‐mailing, communication by ordinary or mobile phone

Quite easy

ID27, m, 60 Work, for me, means paid work even if those categories do not represent my work at all

‘Mostly sitting or standing’ 3 days per week I sit and do computer work and 2 days I drive around between different construction sites; what should I respond then? My work is varying a lot

I know very well what I mostly do, but it is difficult to place it under one of those categories, because no‐one describes my work

ID28, f, 20 I thought of every task I do every day ‐ I drive around, carry books to customers, so it is not so easy as office work, but it doesn't give such physical load than builders or plumbers have

‘Mostly sitting or standing’ Calling by phone, driving by car, carrying books

Easy, because I do every day the same activities, even if the tasks themselves are very different

ID31, m, 45 Daily paid work ‘Mostly walking or tasks of light to moderate effort’

Participation in meetings and computer work

Usually I’m doing paid work, so it was easy to decide

ID32, m, 15 For my these are daily activities at school

‘Mostly sitting or standing’ I sit every day at school Easy

ID33, f, 74 Activities at work and at home ‘Mostly sitting or standing’ Paid work is mostly sedentary, but chores at home are more active

Very hard, because the question is broader than the answer variables

ID61, m, 30 Mostly paid job ‘Mostly sitting or standing’ All my tasks are mostly sitting Easy

ID62, f, 27 Mostly paid job ‘Mostly sitting or standing’ Daily tasks, because at home my work is of different intensity, so it is difficult to measure it

About job – easy, about home tasks – not easy

ID63, m, 33 Paid job only ‘Mostly walking or tasks of light to moderate effort’

All tasks on warehouse Easy

ID64, f, 35 Paid job only ‘Mostly sitting or standing’ All tasks are mainly sitting Easy

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Recommendations

Consider expanding the second answer category ‘mostly walking or tasks of light to

moderate physical effort’ instead of ‘mostly walking’.

Consider adding one response category to the work‐related activities list for people having

various work tasks.

Consider focusing on paid job only or adding a question about homework/other activities

In the interviewer instruction, explain that respondents should refer their answer to the

work they “mainly” do. Only if respondents do multiple tasks (work) should they include all

tasks and consider which one takes the most of time.

Q2: Physical activity to travel to and from places (commuting activity)

Q2.1 Walking for transportation

Understanding of concept

All respondents understood the underlying concept of the question that only ‘walking for travelling

to and from places’ should be included when answering the question. For one respondent (F 60+)

walking the dog is also purposed travelling. She explained that otherwise it would be like splitting

hairs to separate walking with the purpose to visit someone from walking a dog. Three respondents

indicated that they do not walk at all for at least 10 minutes continuously for travel (F 40‐59; M 60+;

M 40‐59), if they walk then during leisure time only.

Respondents included the following walks – to the tram/bus stops or train station, to the market, for

shopping, to friends, and from one village to another. Mainly the examples mentioned by the

respondents met the intended underlying concept of the question.

Certainty of the walk duration

Six out of 15 respondents were very sure about their answer because they perform the indicated

walks regularly and said that they know the duration of such walks. Other six respondents indicated

that they were sure that the walks they included took at least 10 minutes of continuous walking.

However, some of those respondents reported that they roughly estimated whether a walk took at

least 10 minutes. Three Estonian respondents told that they estimated the time of walking very

roughly according to the cognitive feeling.

Regularity of the walks

More than half of the respondents (9 out of 14) indicated that they included mainly regular walks,

whereas the other respondents said that they also included irregular walks, mostly by roughly

estimating how frequently they perform irregular walks and then providing an average. One

respondent did not have any regular nor irregular walks.

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Calculation of the duration of walks

When answering question Q2.1A, many respondents reported that they were thinking about their

daily walking routine in terms of specific walks of which they knew how long they take, and then

calculating an approximate average on a daily basis. In regards to certainty with the answer, all 9

Estonian respondents who gave a clear answer to this question indicated that they were certain

about the estimated duration they indicated. Those respondents mostly reported that they have a

regular daily walking routine and they know exactly how much time it takes to get to bus and tram

stops or train station.

Closed versus open answer categories

It was not possible to identify the corresponding correlation among the Estonian respondents. 6

interviewees preferred the closed answer categories, and the main reason was that it shows the

timeframe, is easier to respond and does not need much calculation.

Four respondents (F 60+; M 45; M 15‐20; M 30) who preferred to provide an exact figure had a very

regular walking routine and they were very sure about the duration they spend walking daily and

indicated therefore, that they could easily provide an exact figure.

Two Estonian respondents (F 55; M 60) told that they do not have a preference how to respond.

Daily versus weekly basis

9 out of 11 respondents indicated that they preferred answering question Q2.1A on a daily basis. The

main reason was that otherwise they would have to sum up all the daily walks to give estimation on a

weekly basis, which would be an additional effort. Some respondents (F 55; M 33), who preferred to

indicate the duration on a weekly basis, reported that their walking behaviour differs between

weekdays and weekends and even if it is more difficult to calculate it gives a more accurate result.

The rest of them did not have any preference.

Recommendations

If the purpose is to make it simple for respondents to give a reply then keep closed answer

categories.

If closed answer categories will be used then an additional show card for Q2.1A (and for

Q2.2A as well) is needed because remembering the intervals of closed answer options could

cause difficulties.

Keep asking for the walking duration on a daily basis

Special remark concerning irregular walks should be added

Q2.2 Bicycling for transportation

No one of the Estonian respondents confirmed that they perform daily or weekly bicycling to get to

and from places in a typical week. According to the Estonian sample, bicycling is mainly used in

leisure time and mainly in summer and therefore not applicable to describe it as ‘usual way to travel

to and from places’ but only as a seasonal activity.

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Recommendations

Exclude the question ‘bicycling for travel’ or leave it as optional because it is a

seasonally affected activity

Q3 Sports, fitness and recreational activities

Possibility to include all leisure‐time physical activities performed

47% (7 out of 15) Estonian respondents reported that they do sports, fitness or recreational

activities. All of them reported that they were able to include all physical activities they do in their

leisure time. One respondent (M 40) suggested adding gardening and fishing to the list of activities.

Some elderly people told (M 60; F 74) that they do not go in for sports any more but they have

regular long walks.

Understanding of the show card

All Estonian respondents used the show card even if the concept was for most of them clear and

understandable. Most of the respondents who used the show card reported that it was easy to

understand it. Some respondents (F55; M40) suggested including activities like skiing, gardening and

fishing. Only one respondent (M 45) was displeased because for him the underlying concept of the

show card was unclear and all actions were put together.

Social desirability bias

53 % (8 out of 15) of the Estonian respondents told that to their mind people might over‐report their

leisure‐time activity level. One respondent (M 60) said that very many people would prefer to show

that they are more active and sporty than they actually are, and he even suggested cutting from the

average result about 20% to get the real activity level.

Weekly versus daily basis

50 % (6 out of 12) of the Estonian respondents who reported being physically active in their leisure

time told that they prefer to state the duration of their activities on a weekly basis instead of a daily

basis. They indicated that their leisure‐time activities are planned mainly on a weekly basis. Some

respondents (F 69; F 27; F 35) did not have any preference and some (M 45; M 15; F 74) preferred to

have a daily basis.

Closed versus open answer categories

75 % (9 out of 12) Estonian respondents who provided a clear answer to the question whether it is

feasible to ask for the duration of leisure‐time activities with an open answer category, indicated that

it was easy to provide an exact figure. Two respondents indicated that it was a bit difficult.

257

Recommendations

Keep open answer categories to estimate duration of activities.

Keep asking for duration of activities on a weekly basis.

Supplement the list of activities with suitable activities for the elderly people or add to the

interviewer manual a special remark for elderly people about the activities not described on

the show card but fit for their age (e.g. longer walks).

Some additional examples of recreational activities (dancing, skiing, hunting) should be

added to the show card

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Table 34: Overview of Estonian respondents’ thought process for Q3.1 and Q3.1A

Respondent Understanding of concept Respondents answer Which activities were included Certainty about

answer ID21, f, 55 Understandable No activities named Not engaged in any physical activity I am sure

ID22, f, 74 Understandable Every morning, 7 days per week, about 10‐15 minutes and every day longer walks with the dog, 300 minutes per week

I thought to gymnastics and walking with the dog

I am sure

ID23, f, 59 Concept is clear No activities named I am not going in for any sports I am sure

ID24, f, 69 Sports is sports, there is nothing difficult 2 times a week, 120 minutes per week

Swimming, water aerobics Sure

ID25, m, 40 Quite clear, but I think gardening and fishing should be added because they are also recreational physical activities for me


Swimming Sure

ID26, m, 60 What could be unclear here? When an activity is sports for me then I include it to my response

3 times a week, 240 minutes a week

I play weekly football 1‐1,5 h, in winter I sometimes use an exercise machine and in summer I bike

More or less sure

ID27, m, 60 Very well described; I do not go in for sports now, but when someone had asked me this question 10 years ago I would have known exactly what it means

Once a week, 180 minutes per week

At the moment any intensive sports is out of question for me but I am going for longer walks on weekends

Sure

ID28, f, 20 Concept was clear, all kind of sports activities 3 times a week, 180 minutes a week

Volleyball, balance training and some yoga Sure

ID31, m, 45 Concept was clear Twice a week, 80 minutes per week

Calisthenics Very sure

ID32, m, 15 Concept was clear 4 times per week, 240 minutes per week

According to my training plan Very sure

ID33, f, 74 Concept was clear 2 times a week, 240 minutes per week

Some longer walks and gardening Very sure

ID61, m, 30 Concept is clear, but "causes at least a small increase in breathing" is a little confusing

No activities named No regular training in a typical week. For me the typical week is not a good choice ‐ there are several times a year, when I am very active, but it is hard to "average" it to the typical week

Sure

259

ID62, f, 27 Understandable 5 times per week, 300 minutes per week

Dancing, aerobics, Nordic walking Sure

ID63, m, 33 Understandable 6 times per week, 270 minutes per week

Exercise machine, lifting weights Sure

ID64, f, 35 Understandable 3 times per week, 270 minutes per week

Walking Sure

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Q4 Muscle‐strengthening activities

Understanding

About half of all the respondents indicated that they did perform muscle‐strengthening exercises.

Muscle strengthening activities were defined more or less according to the concepts presented on

the respective show card, even if at the first moment most respondents thought about bodybuilding

exercises only. Some interviewees included ‘active’ swimming, water aerobics and morning exercises

to their responses (F 69; F 55).

Certainty

Most respondents felt certain about their answer, especially after having consulted the show card,

even if they weren’t quite sure before.

Use of show card

Mostly respondents found the show card very helpful for answering the question because they found

that yoga and stretching were represented (F 55; F 20, EE).

Recommendations

Consider finding a clearer definition for muscle‐strengthening activities to avoid

misclassification bias

Consider keeping this question as optional only

3.2.4. Conclusions

The cognitive testing was successfully carried out despite of the limited time. Respondents had a

positive attitude towards the study, even though the cognitive questions seemed to bother them.

The wording of questions (=translation) was mainly declared as clear and understandable. The

concept of show cards was also mentioned as clear and well prepared, even if some activities were

recommended to be included.

Some problems occurred in finding a suitable response category when work‐related activities were

various or people did not have a full‐time job. The mixing of paid and unpaid work was also

problematic.

Unfortunately, biking as the usual activity to be engaged in is not very widespread in Estonia due to

the climatic limits. Therefore we could not succeed in cognitively testing of this part of the

questionnaire, and our suggestion is to exclude asking separately about biking as a means of

transportation, especially when the survey will be conducted in winter.

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3.3. Test Questions & Probe Sheet for Round 2

Cognitive Testing (round two) P3064 Physical activity questions from the European Health Interview Survey

Name of Interviewer: ___________________________________

Date of Interview: _____________________________________

Serial ID Number: ___________________________________ (e.g. Serial Number)

Sex of Respondent: _________________ Age of Respondent: ____________________________

The Main Objectives for the interview

To examine respondent’s understanding of the questions

To examine whether respondents are able to answer the new survey questions (i.e. whether they

can recall all the information required).

To explore whether the new survey questions capture full information (i.e. answer categories are

adequate).

To explore whether respondents/interviewers understand the instructions and routing of the

instrument

To examine whether the interviewer instructions worked as intended and improved the accuracy

of estimates

To examine whether the show cards worked as intended

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Stage One: Introduction

Introduce yourself, your institution, and the study

In order to prepare the second wave of the European Health Interview Survey (EHIS) it was

decided that the EHIS questionnaire was in need of a revision process. To address and

facilitate the improvement of the instrument, this research was launched

One of the objectives of the project was the improvement of the sections on physical

activity.

Explain that you will be asking them questions on this topic to find out how the questions

work. After they have finished answering the questions you will ask them some questions

about how they found the new questions. You will therefore be performing two roles: the

survey interviewer, where you need to ask the questions as worded and elicit a response,

and the cognitive interviewer, where you will be exploring the question and answer process.

Explain that we are not so much interested in the answers they give but how they

understand the questions and the process by which they arrive at their answers.

Stress there are no right or wrong answers and this isn’t a test. We are just trying to explore

if the questions work as the researchers intend. Explain if they have any difficulty answering

the questions it shows the questions need to be improved. Explain they do not have to

answer any question they don’t want to.

Stress the confidentiality of the process; all the findings will be reported anonymously. The

respondents name will not be on the questionnaire or any of the notes you write up. Please

make sure they understand this.

Remind them that the interview will last up to 30 minutes.

Explain that you will be recording the interview so that you don't have to make lots of notes

during the interview. Check this is OK with the respondent. If they ask who will have access

to the recording, tell them that only the small research team at the institute and yourself

will, and that recordings are stored securely i.e. they are password protected.

Ask whether they have any questions before you start.

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Stage Two: Specific Questions to Question Probing

QUESTIONS ON PHYSICAL ACTIVITY PLEASE ASK ALL QUESTIONS IN THE SECTION FIRST AND THEN PROCEED WITH PROBING.

Physical Activity


Activity at work

Q1

Think first about the time you spend doing work. Think of work as the things that you have to do such as paid and unpaid work, work around your home, taking care of family, studying or training. [Insert other examples if needed]. When you are WORKING, which of the following best describes what you do? Would you say— INTERVIEWER INSTRUCTION: If respondent does multiple tasks, include all tasks. Please hand out SHOW CARD 1.


2 Mostly walking


Do not read:


9 Refused


Q2


Q2.1









Q2.2







264




Q3

The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about SPORTS, FITNESS and RECREATIONAL ACTIVITIES (leisure) that causes AT LEAST a small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling, or swimming. [insert other examples if needed] INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 2.

Q3.1



Q3.1A




Q4

In a typical week, on how many days do you do physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.) INTERVIEWER INSTRUCTION: Please hand out SHOW CARD 3.

Number of days: ___

Stage Three: Question probing

Probing aims:

Do respondents understand the questions?



between points?


etc?)

How easy was it for Rs to remember their physical activity behaviour?

Are the answers truthful?

Clarification of terminology e.g. activity at work, activities to travel to and from places, sports,

fitness, recreational activities, muscle‐strengthening activities, typical week, etc.

265

1 General Probes

Was it easy or hard to answer the questions? (If “hard”: why?)

In general was it easy or hard to remember your physical activities? (If “hard”: why?)


We requested that you refer your answers to a “usual week”. Do you think that it would be

better to refer your answers to “the last 7 days”? Give reasons why do think is that so?

We asked for the time you spent on walking and bicycling for travel on a day basis, whereas

we asked the time you spent doing sports, fitness, recreational activity on a weekly basis. Do

you think that it was reasonable to ask the questions this way? Explain why?

Do you feel that it is easy or hard to switch from a daily (Q2) to a weekly (Q3) reference

period? Explain why?

Did you use the show cards?

Were the show cards difficult or easy to use? (If “difficult”: why?)

2 Probes on specific questions

Now, I would like to get your feedback on the questions of the different physical activity sections. We will start with the question on ‘activity at work’ and move on to the questions on ‘active transportation’, ‘Sports, Fitness and recreational activities’ and ‘muscle‐strengthening activity’. Activity at work (remind respondent of the question): Q1: When you are WORKING, which of the following best describes what you do? Would you say—


2 Mostly walking


How would you define the term “WORKING” in your own words that you had in mind when

answering this question?

Was it easy or hard for you to answer this question? (If “hard”: why?)

How did you go on answering this question?

Which working tasks did you include when answering this question and how long do you

carry them out?

Was it easy or difficult to indicate what you “mostly” do? (If “hard” explain why?)

How easy or difficult was it to use the show card?

Were the underlying concepts of the show card clear or unclear? If unclear, what was

unclear?

How easy or difficult was it to choose an answer category that “best describes” what you do?

How well did the response categories suit the answer you wanted to provide? (If it suit not

well, explain why?)

How would you repeat this question with your own words?

266

Activities to travel to and from places (commuting activities) (remind respondent of the questions): Q2.1: In a typical week, on how many days do you WALK for at least 10 minutes continuously to get to and from places?


How did you decide upon which walks to include?

How did you decide which walks lasted 10 minutes?

Did you think about regular walks only or did you also include irregular walks?

Did you include brisk walking that causes AT LEAST a small increase in breathing or heart rate?

Was it clear or confusing to exclude brisk walking when answering this question?

How do you remember this? Examples


Q2.1A: How much time do you spend walking for travel on a typical day?

Please define walking to get to and from places? Give examples.

How did you calculate the amount of time spent walking for travel? Please describe your

thought process on how you arrived at your answer?


Do you think that it is helpful providing closed answer options indicating the time you spent

walking for travel? Or do you think it would be better asking for the exact figure of time you

spent on walking for travel? Please explain why?

We asked you to indicate the time you spent walking for travel on a daily basis. Do you think

it would be better to ask this question on a weekly basis? Please explain why?

Q2.2: In a typical week, on how many days do you BICYCLE for at least 10 minutes continuously to get to and from places?

Please define bicycling to get to and from places? Give examples.


How did you decide upon which bicycling to include?

How did you decide on whether bicycling was performed for at least 10 minutes

continuously?

Did you think about regular bicycling only or did you also include irregular bicycling?

Were you aware that you should have included here also the use of other non motor‐driven

means of active transportation such as scooter, roller or skates etc.?

How do you remember your bicycling for travel behaviour? Examples


Q2.2A: How much time do you spend bicycling for travel on a typical day?

How did you calculate the amount of time spent bicycling for travel? Please describe your

thought process on how you arrived at your answer?


267

Do you think that it is helpful providing closed answer options indicating the time you spent

bicycling for travel? Or do you think it would be better asking for the exact figure of time you

spent on bicycling for travel? Please explain why?

We asked you to indicate the time you spent bicycling for travel on a daily basis. Do you think

it would be better to ask this question on a weekly basis? Please explain why?

Sports, Fitness and recreational activities (remind respondent of the questions): Q3.1: During In a typical week, on how many days do you do sports, fitness or recreational Activities (leisure) for at least 10 minutes continuously?

Was the concept of ‘sports, fitness and recreational activities (leisure) that causes AT LEAST a

small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling or

swimming’ for you clear or unclear? Please tell me why?

How did you decide upon which activities to include and to exclude?



unclear?

Were you able to indicate all sports, fitness, and recreational activities that you usually do? If

any, which activities you were not able to include and why?

Which activities did you include and how often and for how long do you carry them out?

Was it easy or difficult to define what a typical week is like, if yes, indicate why?


Do you think that someone might not give a truthful answer on this question? And if yes,

indicate why?

Q3.1A: How much time do you spend in total doing sports, fitness or recreational activities in a typical week?

How did you go on answering this question? Examples

How did you calculate the amount of time spend doing sports, fitness and recreational

activities? Please describe your thought process on how you arrived at your answer.

Was it easy or hard to provide an exact figure on the time you spend doing sports, fitness or

recreational activities in a typical week? Explain why?

We asked you about the time you spend doing sports, fitness and recreational activities on a

weekly basis. Do you think it would be better to ask this question on a daily basis? Explain

why?


268

Muscle‐strengthening activities (remind respondent of the questions): Q4: In a typical week, on how many days do you do physical activities specifically designed to

STRENGTHEN your muscles such as lifting weights or doing calisthenics?

What does ‘muscle strengthening’ mean to you? Examples

How did you decide on what to include and exclude?



unclear?

Which muscle‐strengthening activities do you do and how many times per week do you do

such activities?

Was it easy or hard to decide what occasions to include or exclude? Examples

What days were you thinking of when answering this question?


269

4. Review of CT Review AL Questionnaire

An Independent Review of

the Improvement of the

EHIS Wave 2 Questionnaire on

Alcohol Consumption

March 2011

Dr. Pamela Campanelli Survey Methodologist, Chartered Statistician and Chartered Scientist

270

4.1. Background

Measuring alcohol consumption is a very difficult task given issues of sensitivity, memory recall, and

wide variation in respondent behaviour. These issues are further complicated by multiple

assessment methods (such as a prospective diary, a retrospective diary, quantity and frequency

questions, adjusted and extended quantity and frequency questions, and graduated quantity and

frequency questions), the objectives of the study, the specified outcomes and level of accuracy, the

respondents studied, the mode of data collection and the number of questions allowed. And these

issues are made even more difficult by the need for comparability across countries.

Thus, perfecting the EHIS Wave 2 Alcohol Questions is no easy matter. This report makes comments

on and suggestions for the current questions. This report comes at the end of March, 2011, just after

the cognitive testing and before the field pilot. It is based on questionnaire design knowledge and

experience in combination with a review of the following documents:

EHIS Wave 1 alcohol questions

The proposal for the Berlin workshop (September 2010): including a critique of the Wave 1

questionnaire, a summary review of the literature with the advantages and disadvantages of

different measurement tools, and proposed questions for Wave 2.

Revisions after the Berlin workshop: including criticism raised at the workshop,

considerations and justifications for further changes, and revised questions for Wave 2.

Conceptual translation guidelines

Questionnaire used for cognitive testing

Showcards used for cognitive testing in UK and Belgium

Preliminary results of cognitive testing given at Feb 2011 Core group meeting

Cognitive testing reports from UK, Belgium, and Germany (The report from Estonia was not

yet available)

Current version of EHIS Wave 2 alcohol questions

What follows is a general section about issues and suggestions, followed by comments for each

question.

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4.2. General Issues

Given the difficulties presented in the task of refining the EHIS questions on alcohol consumption, I

think the core group have made good progress. The current version of the questions is a definite

improvement over the EHIS Wave 1 questions, particularly with the removal of the very difficult

typical week drinking grid (which had been broken down by day the week and type of drink.) But

several general issues need to be discussed.

4.2.1. Mode of data collection

As well established in the literature, sensitive questions such as these alcohol questions are best

administered in a self‐completion format. This can be in a postal or web survey. However, research

also suggests that an equally viable option is a self‐completion component in a face‐to‐face survey

(see Tourangeau, Rips and Rasinski, 2000, p. 298). Most problematic would be the telephone mode

due to interviewer presence, unless it was possible to post a separate self‐completion questionnaire

to the respondent. In addition to interviewer presence, telephone is typically different that postal or

web modes or a self‐completion component in a face‐to‐face survey as the former is based on aural

communication and the latter three are based on visual communication(see, for example, Christian,

Dillman and Smyth 2008). Use of the telephone mode therefore increases differences in

comparability.

RECOMMENDATIONS:

• The project team has already recommended self‐completion. This should be a strong

recommendation for self‐completion in a face‐to‐face survey, postal or web.

• If telephone has to be used, then optimal conceptual translation guidelines should be given

for AL.3, AL.5 and AL.6 in addition to AL.1.

Yet, self‐completion questionnaires are not without their challenges. Over the last 20 years the

critical importance of the ‘visual layout’ of the self‐completion questionnaire has become apparent.

The visual layout of the questionnaire page makes a large difference in the accuracy and

completeness of a respondents answers. According to Dillman (2000, p. 81), a ‘respondent friendly’

questionnaire reduces item nonresponse and improves data quality because “many respondents do

not read the entire content of questionnaires in a thoughtful way. Respondents take clues from the

layout about what must be read and what can safely be ignored, and some respondents skip many

words, with the frequent result that questions get misinterpreted” or missed. A well‐designed layout

prevents items or answer categories from being missed because of their location on the page.

The importance of visual layout is particularly pertinent for the EHIS alcohol question series for (a)

the placement of general instructions and (2) instructions for skips. (The later problem could be

avoided with a properly programmed web survey.)

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General Instructions:

Respondents don’t read instructions. In New Zealand, 65 percent of respondents completed a partial

ranking task, by using rating instead of ranking. This was because they did not read the instruction.

In experimenting with groupings of answer categories, Smyth, Dillman, Christian, and, Stern (2004),

found that respondents choose one from each group even with a large instruction only to pick one.

These finding tie in nicely with the results of the cognitive testing. This is best described in the

Belgium report (p, 30), “Instructions were globally ignored”.

In the EHIS alcohol questionnaire there is an introductory statement: “The following questions are

about your use of alcoholic beverages of any kind: that is, beer, wine, cocktails, premix, spirits,

liqueurs, home‐made alcohol”. Such an introductory statement is traditional for an interview survey,

but is problematic for a self‐completion survey. There is a suggestion from Dillman (2000, p.99) to

“place instructions exactly where that information is needed and not is a separate section at the

beginning of the questionnaire”.

RECOMMENDATIONS:

• For self‐completion, the text describing the different types of alcohol should be made part

of the question as it was in the Wave 1 EHIS questions.

• The showcard should be part of questionnaire rather than separate document as many

respondents won’t read the instruction to use the showcard.

Skip instructions:

“A consistent finding in the research on item nonresponse is that questionnaires or questions, with

branching instructions lead to greater item nonresponse than those without” (Redline and Dillman,

2002, p. 180). But errors of commission are more common than errors of omission. With their

control group, Redline and Dillman (2002) found that 20.3 percent of Washington State University

students failed to see the skip instruction and continued on to the next question and only 1.6 percent

incorrectly followed the skip instruction leading to item missing data. As part of a US Census test of

the general population, Redline and Dillman et al (2003), found a 19.7 percent commission error and

5.0 percent omission error. Commission errors are also confirmed by the cognitive testing of the

EHIS questionnaire. As well‐described in the German Cognitive Testing Report (p. 27), “The skips in

the questionnaire did not work as intended for many respondents. More specifically, some

respondents answered questions which they were not supposed to answer which lead to some

confusion as a consequence”. This was also noted in the UK report (p.43), “occasionally respondents

did not see the routing instructions (go to AL.4)”.6

Using an experimental ‘detection’ method (use of two arrows – one to the skip instruction and the

other to the next question and inclusion of ‘(If yes)’ in the subsequent question), Redline and Dillman

6 Remember that question AL.1 in the cognitive testing questionnaire did have the elaborate skip instruction pattern as in

the current questionnaire because AL.1a had been introduced for the purpose of a comparison to AL.2 to AL.5.

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(2002) found that commission errors could be reduced to 7.4 percent (omission errors increased

slightly to 3.7 percent) and Redline and Dillman et al (2003) found that commission errors could be

reduced to 13.5 percent (omission errors also were decreased down to 4.0 percent). Note that these

results were with simple ‘yes/no’ filter questions.

Even with the Redline and Dillman methods, not everyone will follow the skip patterns. It is

therefore very important to include a zero value on questions AL.3 and AL.5. This is nicely illustrated

from the UK Cognitive Testing Report (p.45): “On the whole, respondents did not see the routing

instruction at AL.2 so went to AL.3.” “When this happened respondents either wrote none or NA on

the self‐completion or thought it was odd to be asked but then thought if someone came round they

may have a pint so answered one. If the second strategy occurs this would result in over‐reporting at

this question.”

RECOMMENDATIONS:

• The skipping instructions in the alcohol questions, unfortunately, resemble those used by

Redline and Dillman for the “control” group which had the highest level of error. Make use

of Redline and Dillman’s ‘detection’ method where possible. (The skipping pattern in AL.1 is

very complex and not suitable for adaption to the detection method, but AL.2 and AL.4 are.

AL.2 and AL.4 are displayed with the double arrow part of the detection method in Section

3. )

• Add a zero category to AL.3 and AL.5 so that those respondents who fail to see the skip

instruction at AL.2 and AL.4 (and also AL.1) have a place to mark their answer. This will

lessen their frustration with the questionnaire.

Timeframe

The length of a reference period in a survey question should be appropriate to the type of

information collected. Longer reference periods are appropriate for infrequent but memorable

events whereas shorter time periods are more appropriate for mundane common events.

Unfortunately with a cross‐section of respondents from the general public, alcohol use can fall into

either or both of these categories.

AL.1: A 12 month reference period is challenging for respondents because (a) it is a long time to

remember and (b) respondents’ drinking patterns may be highly variable over that period of time

(e.g., changes of behaviour, seasonal patterns etc.). The German cognitive testing results are in line

with (a) as they suggest the reference period of a year is too long (p. 30) and that it should be

reduced to 4 weeks (p.29). The UK Cognitive Testing Report (p. 41) gives a good example of (b)

although this refers to AL1a. “Findings revealed that respondents could have a number of typical

drinking patterns, for example, a regular pattern on holiday, or on a night out compared to a night in.

In addition, respondents can have different patterns at different times of the year, for example they

might have one drink on Christmas day or drink more during the five colder and darker months in

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England. There could be seasonality effect on the data collected, with less drinks being recorded in

summer for example.” The Belgium report (p.31) also notes that “probing on a recall of consumption

over the past 12 months did not seem to apply to an overall measure of “usual” consumption . . .

What is probably operating though, is some kind of telescoping based on more recent drinking

behaviour”.

Some arguments against shortening the reference period are (a) that it would be less representative

(e.g., there may be something unusual about the last 4 weeks) and (b) that the purpose of question

AL.1 is to make a distinction between, current drinkers, former drinkers and lifetime abstainers. The

longer reference period is better equipped to identify true former drinkers.

AL.2 – AL.5. Here no reference period is given. Some respondents may still be thinking of the past 12

months, but more likely is that they are using just the most accessible memories. Using easily

accessible memories rather than doing a thorough search through memory is a common respondent

behaviour (see Tourangeau, Rips, and Rasinski, 2000, and Sudman, Bradburn and Schwarz, 1996). It

would have been useful to have a specific cognitive probe on this to determine exactly what EHIS

respondents were doing.

AL.6. The 12 month reference period may be the most appropriate here as the goal is to look at the

frequency of risky single occasion drinking.

RECOMMENDATION:

• If the most important part of the question is to create the 3‐way classification, lifetime

abstainers, former drinkers and current drinkers, keep the 12 month reference period. But

be aware that answers to the question for current drinkers probably does not reflect a full

memory scan over the past 12 months.

Influence of answer categories (particularly in frequency questions), range of answers, and option of

using an open question

Sudman, Bradburn and Schwarz (1996), point out the impact of the answer categories on frequency

questions. Across a wide range of content domains, respondents report higher frequencies on scales

with high rather than low frequency answer categories. This is because respondents assume the

range of answers reflects researchers’ knowledge of or expectations about the distribution of the

behaviour in the ‘real world’. The key is that this is dependent on “respondent’s knowledge about

the behaviour: the more respondents know about the frequency of the behaviour” the less they are

affected by the answer categories. Also “when the behaviour was an irregular one, respondents

relied on the range of the response alternatives in computing an estimate” (p. 220). Schwarz and

Hippler (1991) also point out that for mundane and frequent behaviours (which alcohol use is for

some people), events are not separately represented in memory. “Rather, individual episodes tend to

blend into one generic representations, thus making it difficult to determine their frequency . . .

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Accordingly, respondents have to rely on an estimation strategy, for which they will use any

information that seems helpful” such as the answer categories.

An older view point about the reason for the influence of answer categories on respondents is that it

is related to question sensitivity rather than memory issues and a ‘not knowingness’ (see, Bradburn

and Danis, 1984, and Fowler, 1995). Both of these type of effects may be present in hard to

remember but sensitive topics such as the lifetime number of sexual partners (see Tourangeau and

Smith, 1996). In questions where it is clear that sensitivity is an issue, having a high upper range

beyond what most respondents drink could be helpful to make respondents more comfortable to

answer truthfully. This could apply to questions AL1.a, AL.3 and AL.5. As described in the UK

Cognitive Testing Report (p. 40), “testing revealed that offering 24 or more drinks actually assisted

respondents who were not heavy drinkers to be honest because they were surprised by this amount

even if they felt a bit sensitive initially by the question.” This is similar to views expressed in the

German Cognitive Testing Report on pages 20 and 21.

But is this a good enough reason to keep the extreme of ‘24 drinks or more’. This is so extreme that

respondents wondered about it. For example in the German Cognitive Testing Report (p.34) a

respondent is quoted as saying, “I have an idea of what 6 alcoholic drinks are but 18 or 24 or even

more I can’t imagine”. Similarly, the Belgium report notes on page 38) that “some respondents find it

exaggerated to have so many over‐consumption categories”. Also a concern was raised by the core

group about these extreme categories, particularly in some countries. I do not know the background

justification for choosing ‘24 or more’ drinks as the top category. But if we want to benefit by making

most respondents feel comfortable about their drinking level, I would suspect 18 or more would

have the same effect and be less surprising to respondents.7

Should there be country specific decisions made on this extreme value? In general, country specific

tailoring is a good idea. But given that the answer categories can influence both respondents to who

are trying to estimate their answer because of not remembering or knowing the true answer and

those who find the question sensitive, it would be useful to keep the scale the same across countries.

An open question could be used to stop respondents from incorrectly using the answer categories as

a frame of reference, but this could potentially lead to more item nonresponse because (1) open

questions are more likely to be left blank in paper self‐completion (although less so with simple

numeric questions) and (2) answers may be given in un‐codable formats (although potentially less so

with simple numeric questions). It is too late now to make such a radical change in the question

format, but some tests on this could be done for the next wave of the EHIS.

7 There was also a concern raised by the core group about the use of the separate category for ‘6 drinks’. In some counties

this would be equivalent to a bottle of wine.

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RECOMMENDATION:

• Think about reducing the number of drinks category to something less than 24 (perhaps 18)

and keep this consistent across countries.

• Test the advantages and disadvantages of using an open question for the EHIS Wave 3. (An

experiment could be done with high frequency answer categories (1 to 24 drinks), low

frequency answer categories (perhaps 1 to 9 drinks) and an open question. A 4th group

could also be introduced (1 to 18 drinks) to double check the impact of this reduction.

Approximate ranges and the problem of irregular behaviour

The answer categories for AL.1 and AL.6 are “approximate ranges”. As suggested by Fowler (1995,

p.157), a “fundamental problem with a question oriented toward this response task is the assumption

of some kind of regularity. . . Moreover, even for activities that are done regularly by some people,

such as going to church or drinking alcohol, there are other people whose patterns are more erratic.”

Fowler (1995, p.157) suggests that frequency is better measured “by asking people to estimate the

number of times they have actually done something in an appropriate period of time.” This is in line

with the recommendations from the UK cognitive interview team. But the EHIS core team have

reviewed the literature to look at the ‘advantages’ and ‘disadvantages’ of a retrospective or weekly

recall diary, quantity‐frequency methods, adjusted quantity frequency methods and graduated

frequency methods. They decided to not to go with a retrospective recall method asking about the

last 7 days.

But the issue remains that not all respondents’ behaviour is regular. AL.2 and AL.4 suffer from this as

well. The current extended quantity‐frequency method seems the best of the option given the

constraints of the project.

RECOMMENDATION:

• Without changing the measurement method, the problems caused by no regular alcohol

consumption behaviour will have to be lived with.

Avoid forcing a definition on respondents if there is an easier way

Respondents often reject long cumbersome definitions and use their own definition (which is what

the researcher is trying to avoid ‐ see Beinart and Smith, 1997). But this can also happen in the case

of simple definitions. In questions AL.2 and AL.4, weekdays are defined as Monday to Thursday and

weekends as Friday to Sunday. This division is aligned with typical drinking behaviour.

The cognitive testing results suggest that this distinction is generally accepted, but there were

exceptions. For example in the UK Cognitive Testing Report (p.43) “testing showed that respondents

either accepted that they should think about weekdays as Monday to Thursday or read the question

and still answered including Friday.” An example from the German report (p.33) is of a respondent

who preferred the phrase “evenings before work” rather than the weekday / weekend distinction.

Although the exceptions are less frequent than the majority of opinion, as discussed in Section 2.7

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below, they should be given equal weight to the majority opinion as this is a small qualitative sample

and we don’t know the true prevalence of these behaviours and attitudes in the general population.

It is not always necessary to use both the original ambiguous word and the definition. Using both

can make a question more ‘wordy’ than it needs to be. For example, take the following question:

“Would you say that the office where you collected this questionnaire was your usual post office

which you use most often?” (From a UK Royal Mail survey). The word ‘usual’ is ambiguous and is

then defined as the one ‘which you use most often’. But the question could be simplified to, “Is the

office where you collected this questionnaire, the post office which you use most often?”. Similarly

we could drop the words weekday and weekend in AL.2 to AL.5 and just go with the actual days. This

would also make the question less awkwardly worded in English. See Section 3 for a suggested

revised wording.

RECOMMENDATION:

• Re‐word questions AL2 to AL.5. Suggested wording in Section 3.

Drinks versus units versus standard drinks derived from number of glasses

In an ideal questionnaire, respondents would be allowed to report their alcohol consumption in the

volumes they are used to using and then as part of post‐data collection coding, this would be

converted into units (and then into grams of pure ethanol). This would put minimum burden on the

respondent and potentially increase the accuracy of the estimates. Unfortunately such a

questionnaire would require a lot more than 6 questions (for example, the Health Survey for England

questions were suggested by the UK Cognitive Testing Report).

The alternative is that ‘drinks’ need to be converted into ‘units’ by the respondent. This is

particularly difficult in the case of the UK. Although UK health recommendations are based on

‘units’, average respondents don’t know the units connected with their drinks! This is well illustrated

by the UK cognitive testing: “Respondents said they did not understand units” (p. 35). Using units is

not only unfamiliar, but illogical for some respondents (i.e., that one drink equals two units). In

addition, the use of units makes the questions more sensitive as units highlight that respondents are

drinking more than they would like to think they are because the UK health recommendations are

based on ‘units’. Some issues about converting to units also came up in the German cognitive testing

as illustrated by this quote from a respondent on page 31, “Two glasses of wine are one alcoholic

drink”. Another illustrative quote is from the UK report (p.36), “. . . a glass of wine or a pint of beer,

and they may have varying units, varying alcohol content, etc. I still took them to be one particular

drink”. And here is one from the Belgium report (p.30), “a drink is a drink, whatever the strength,

whatever the serving”.

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There were also issues about the showcards (aside from failing to use them because they were a

separate document – see Section 2.1)). Answer categories need to be consistent with the showcards

used. In the German Cognitive Testing Report (p. 31), a respondent pointed out that the showcard

said that 0.5 litres of beer correspond to 1.5 standard drinks, but there was no answer category for

such an amount. Another important finding from the German Cognitive Testing Report is that some

respondents failed to use the showcard because they felt they didn’t need it.

But perhaps the issue of units would be far less contentious if the question asked about units rather

than drinks? This is a great idea proposed by the German Cognitive Testing Report (p. 35). Also the

same report suggests the use of a simplified showcard (p.29). Please see below.8

Another alternative is whether national initiatives can be created to compute the number of

standard drinks based on the declaration by the respondent (in number of glasses). I think this plan

would only work if more questions were used in the questionnaire because ideally questions would

need to be divided by glass used and type of alcohol consumed (e.g., large versus small glass and

beer versus wine). This is particularly true for the UK (e.g., pint and half pint for beer and 175 and

250 ml glasses for wine.)

RECOMMENDATIONS:

• Continue with the showcard approach for this wave of the EHIS. But this should be with

improved showcards and with showcards actually being part of the questionnaire.

• Consider rewording the questions to ask about ‘units’ rather than ‘drinks’ as this will make the

need for the showcards clearer to respondents.

Comments about the cognitive interviewing done using the ‘easy versus difficult’ probe

Basing questionnaire design decisions on how easy or difficult respondent find a question can be

problematic. Yes, we want to know if a question is difficult and why this is so and that is useful. But

in contrast if a respondent tells us a question is easy, it doesn’t really tell us very much. This is

because easy questions are not necessarily good questions. In the footnote below is an example of a

very poor question which as tested as part of a UK Mixed Modes and Measurement Error grant

8 Interestingly this is from the UK

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(report forthcoming).9 The question is problematic because it assumes that respondents like their

neighbourhood; that the given characteristic applies to their neighbourhood (i.e. the facilities exist);

and if it applies, that it is something respondents like about their neighbourhood. But nevertheless

respondents found the question easy: respondent comments suggested that the question was easy,

straightforward and about, as one respondent described, “everyday stuff”. Similarly, Hunt (1986)

made it very clear that the general public are not good judges of poor survey questions.

Respondents evaluating a survey questionnaire failed to notice loaded words, double‐barrelled

questions, ambiguous questions, etc.

Equally, just because respondents say that a question is easy, doesn’t mean that the wording of it

can’t be improved. This applies to questions AL.2 to AL.5. The Belgium Cognitive Testing Report (p.

31‐32) also notes that questions need to be reformulated (at least for the French version) as they are

cumbersome.

RECOMMENDATIONS:

• Be careful of interpreting cognitive results when respondent say a question is easy.

• Reword questions AL.2 to AL.5 as the current wording is awkward (see Section 3 for

suggested new wording for each of these questions).

Asking for respondent preferences

Similar to ease and difficulty, it can be useful to note questions which bring up negative feeling in

respondents. But in general, asking respondents for their preference for a question version is not

helpful. Sangster and Fox (2000), found that which version of the question respondents preferred

was poorly related to their accuracy in answering the questions. Respondents are not trained in

questionnaire design nor the research objectives of a study. It is much better to judge question

quality by how respondent come up with their answers and the difficulties that arise in this process

rather asking their opinion.

RECOMMENDATION:

• Be careful of interpreting cognitive results when respondent say they prefer a particular

question version.

9 What are the things that you like about your neighbourhood? MARK ALL THAT APPLY

Its community spirit....................... o It feels safe....................................... o The neighbours............................... o The character of its buildings........ o Its cleanliness.................................. o Its location...................................... o Its quietness .................................. o Its transport facilities.................... o

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Don’t quantify cognitive results

Cognitive interviewing is qualitative in nature and uses small quota samples rather than large

probability samples. Talking about a minority or majority of cognitive respondents did a particular

thing describes the quota sample, but cannot describe the frequency of respondents with that

behaviour in the main survey. In other words, a behaviour only shown by a few respondents is

equally important as a behaviour shown by the majority of respondents.

RECOMMENDATION:

• Remember that cognitive interview results only apply to a few cognitive subjects and

therefore both frequent and less frequent finding should both be considered as important

(unless there is good reason to believe that one pattern versus another will be more

prevalent in the general survey population).

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4.3. Comments on and suggestions for specific questions

AL.1

During the past 12 months, how often have you had an alcoholic drink of any kind?

Every day or almost every day 1 go to AL.2

5 ‐ 6 days a week 2 go to AL.2



2 ‐ 3 days in a month 5 go to AL.6

Once a month 6 go to AL.6

Once every 2 months 7 go to AL.6

Once or twice in the past 12 months 8 go to AL.6

Not in the past 12 months, but I drank formerly 9 go to (next section)

Never more than a few sips or trials in my whole life 10

go to (next section)

RECOMMENDATIONS ALREADY MADE IN SECTION 2:

• For postal, web and self‐completion in a face‐to‐face survey, remove introduction and

reword as, “During the past 12 months, how often have you had an alcoholic drink of any

kind (that is beer, wine, cocktails, premix, spirits, liqueurs, home‐made alcohol)?”

• Skip instructions are problematic in this question, but keep ‘as is’ because Redline and

Dillman’s ‘detection’ method would be too complicated for this question.

• Strongly discourage use of telephone interview. But if used include unfolding (branching)

method as is done in Conceptual Translations Guidelines document.

Other issues:

Is it needed to keep such detailed answer categories? This seems to have worked okay for

respondents. The UK Cognitive Interviewing Report (p.38) suggested that “respondents had an

answer in mind, and read down until they matched their answer.” Similarly as noted in the Belgium

Cognitive Testing Report (p.33), “all found a category that matched their reply”. This scale is also the

same scale as used by SMART.

As pointed out by a respondent in the German Cognitive Testing Report (p.30), “If you drink 6 days a

week you can choose either answer” (i.e., Category 1 or 2).

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As mentioned in both the UK and German cognitive testing reports, there is no category for ‘never’.

And in UK report there is a suggestion for rewording category 9.

A further problem was observed by the German cognitive team (see p. 3) in that “some respondents

ticked a maximum amount, while other answered with an average.

As discussed in Section 2.4, this question could be difficult for respondents whose behaviour is not

constant. An example of this is shown in the German Cognitive Interviewing Report (p 30), because a

respondent did not know whether to put in her weekday or weekend behaviour.

In a comment from the Berlin workshop, it was noted that this question presumes that the

respondent drinks. In interview surveys, it is good practice to have a separate filter question. But as

discussed in Section 2.1, respondents are very poor at following skip instructions in paper self‐

completion questionnaires.

OTHER RECOMMENDATIONS: • Keep the detailed scale, but use UK recommendation to change category 9 to “Not in the last

12 months as I no longer drink alcohol” and category 10 to “Never or only a few sips or trials in my whole life”.

• Consider changing the first category just to “everyday”. • The question may need to be modified to make it clear whether the maximum frequency or

the usual frequency should be given. • Problems due to irregular behaviour will have to be lived with.

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AL.1a. How many drinks containing alcohol do you have on a typical day when you are drinking? Refer to the show card

24 or more drinks ................................................................ 1

17‐23 drinks......................................................................... 2

10‐16 drinks......................................................................... 3

7‐9 drinks............................................................................. 4

6 drinks ................................................................................ 5

4 ‐ 5 drinks ........................................................................... 6

3 drinks ................................................................................ 7

2 drinks ................................................................................ 8

1 drink.................................................................................. 9


If this question is kept (see next section for recommendations on whether to keep this question or

not),

• Use a smaller maximum, 24 is too extreme.

• Keep same answer categories for all countries.

• Showcard needs to be part of the questionnaire, not a separate document.

• Consider rephrasing the question as: “How many units of alcohol do you have on a typical day

when you are drinking?” (with answer categories which are also phrased as units).

• Strongly discourage use of telephone interview. But if used, give clear recommendations in

the Conceptual Translations Guidelines document. The answer categories will need to be read

out. An open question should be avoided as this will not be comparable to the other modes!

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Other issues:

For some respondents there can be problems in identifying a ‘typical day’. Respondents generally

answered the question thinking about their usual day. As described in the UK Cognitive Testing

report (p.41), “findings revealed that respondents could have a number of typical drinking patterns,

for example, a regular pattern on holiday, or on a night out compared to a night in. In addition,

respondents can have different patterns at different times of the year, for example they might have

one drink on Christmas day or drink more during the five colder and darker months in England. There

could be seasonality effect on the data collected, with less drinks being recorded in summer for

example”. The Belgium Cognitive Testing Report (p. 34) noted that this question could

underestimate true consumption “because ‘typical’ or ‘ordinary’ days are those when irregular

drinkers drink less”.

Is it appropriate to start with the high end of the scale? Sudman and Bradburn (1982) suggested to

start with the end of the scale that is least socially desirable. This would argue to start with the high

end of the scale. But there is new evidence that breaking what the respondent considers the normal

order of a scale (in this case, from smallest to biggest with the most desirable items appearing at the

top) can be problematic (see Tourangeau, Couper and Conrad, 2004). But it is also useful to have

consistency across all questions. For AL.1 the phrasing of the approximate ranges is easiest when

one starts with the most frequent end of the scale. Using the high end of the scale in AL.1a, would

be consistent with this.

OTHER RECOMMENDATIONS:

• Respondents can have a number of typical drinking patterns, it is inherent is this question

format that these can result in measurement error.

• Continue to start with the high end of the scale.

• See recommendation for keeping AL.1a versus AL.2 to AL.5 below.

AL.1a versus AL.2 to AL.5

In the German cognitive testing there was a specific comparison between AL.1/AL.1a and AL.2 to

AL.5 with respect to weekly consumption but no clear differences were found (p.28). The cognitive

team pointed out that some respondents found the differentiation between weekday and weekends

confusing (e.g., shift workers), but for the retired it was more the case that the differentiation was

not that important (p.33). Preferences for the two sets of questions were mixed (p.34) – (Note

Section 2.7 of this report on the dangers of basing research decisions on respondent preferences).

But it is not clear why they recommend the AL.1/AL.1a question pair instead of the AL.2 to AL.5 set. 10

10 It is also not clear why the German cognitive team suggest to adjust the wording of AL1, AL1a and AL6 back to AUDIT‐C. .

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The differences between these two question sets were not specifically tested in the UK. But the

report does point out that answering question in general is difficult if drinking patterns varied. This

came out in the context of AL.2 because of the word ‘usual’ and respondents not knowing what their

usual pattern would be (p.43) and on AL.6 for a respondent who had two different drinking patterns

(p. 49) and most clearly on AL.1a with respect to a ‘typical’ day (as described in the Section on AL.1a).

The cognitive testing team found that “some respondents liked questions AL2‐5 better because their

reference period was shorter and easier to recall than it was for AL1/AL1a, the latter referring to the

last 12 months.”11

The Belgium Cognitive Testing Report (p.38) revealed that respondents who have “a drinking pattern

that varies from weekdays to weekends”, found this question easier than AL.1a.

On AL.2 to AL.5, the reason for splitting of the questions into Weekdays and Weekends was generally

well understood across all the cognitive testing. But more importantly AL.2 to AL.5 should provide

better estimation of true drinking because it provides more detail and fits the consumption pattern

of most respondents. Also as noted in the proposal document for the Berlin meeting, the weekday‐

weekend “breakdown was favoured by the expert panel as a valid compromise against the simple QF

questions (usual quantity on usual day) and the more thorough (but lengthier) beverage‐specific QF

or graduated frequency questions” (p.10).

RECOMMENDATION: • Although the cognitive interviewing evidence is mixed, continue to use AL.2 to AL.5 for EHIS

Wave 2 as it should give a more accurate picture of volume of consumption than AL.1/AL.1a.

11 In actuality the bigger reference period is missing, i.e., a usual week over what period of time? But adding this to these

questions would make them overly complicated. For example the German Cognitive Testing Report (p. 30) suggested that

some respondents were confused simply by the different time reference answer categories (per week, per month) within

the period of a year.

286

AL.2 During the week days (from Monday to Thursday), on how many of these 4 days do you usually drink alcohol?

On the 4 week days 1

On 3 week days 2

On 2 week days 3

On 1 week day 4

Not on week days 5 go to AL.4


A possible re‐phrasing of AL.2 and with use of Redline and Dillman ‘detection’ method arrows.

AL.2. Thinking of Monday to Thursday, on how many of these 4 days to you usually drink

alcohol?

AL.3. Still thinking about Monday to Thursday, when you drink alcohol, how many drinks do you

usually have on ONE of these days?

On all 4 days 1

On 3 of the 4

days 2

On 2 of the 4

days 3

On 1 of the 4

days 4

On none of the

4 days

5 Go to AL.4.

287

AL.3

How many drinks containing alcohol do you usually have on one of those week days when you

drink alcohol (Monday to Thursday)?

24 drinks or more 1

17‐23 drinks 2

10‐16 drinks 3

7‐9 drinks 4

6 drinks 5

4 ‐ 5 drinks 6

3 drinks 7

2 drinks 8

1 drink 9


Use a smaller maximum, 24 is too extreme.

Keep same answer categories for all countries.

Showcard needs to be part of the questionnaire, not a separate document.

Consider a possible re‐phrasing of AL.3: “Still thinking about Monday to Thursday, when you

drink alcohol, how many drinks do you usually have on ONE of these days?”

Strongly discourage use of telephone interview. But if used, give clear recommendations in

the Conceptual Translations Guidelines document. The answer categories will need to be read

out. An open question should be avoided as this will not be comparable to the other modes!

Be sure to add a ‘0 drinks’ category for those who miss the earlier skip instructions.

288

AL.4

During the weekends (from Friday to Sunday), on how many of these 3 days do you usually drink

alcohol?

On the 3 weekend days 1

On 2 weekend days 2

On 1 weekend day 3

Not on weekends 4 go to AL.6


A possible re‐phrasing of AL.4 and with use of Redline and Dillman ‘detection’ method arrows.

AL.4. Thinking of Friday to Sunday, on how many of these 3 days to you usually drink alcohol?

AL.5. Still thinking about Friday to Sunday, when you drink alcohol, how many drinks do you

usually have on ONE of these days?

On all 3

days 1

On 2 of

the 3 days 2

On 1 of

the 3 days 3

On none

of the 3

days

4

Other issues:

Problems for light and irregular drinks: “For those who drink little (e.g., not on every weekend),

finding an answer category is difficult. Irregular drinkers will therefore tick the ‘lesser evil’ option of

‘on 1 weekend day’, which then results in an overestimation” (from German Cognitive Testing

Report, p. 34.)

OTHER RECOMMENDATION:

• Problems with irregular behaviour remain and are inherent in this type of question.

Go to AL.6.

289

AL.5

How many drinks containing alcohol do you usually have on one of those weekend days when you

drink alcohol (Friday to Sunday)?

24 or more drinks 1

17‐23 drinks 2

10‐16 drinks 3

7‐9 drinks 4

6 drinks 5

4‐5 drinks 6

3 drinks 7

2 drinks 8

1 drink 9


• Use a smaller maximum, 24 is too extreme.

• Keep same answer categories for all countries.

• Showcard needs to be part of the questionnaire, not a separate document.

• A possible re‐phrasing of AL.5: “Still thinking about Friday to Sunday, when you drink alcohol,

how many drinks do you usually have on ONE of these days?

• Strongly discourage use of telephone interview. But if used, give clear recommendations in

the Conceptual Translations Guidelines document. The answer categories will need to be

read out. An open question should be avoided as this will not be comparable to the other

modes!

• Be sure to add a ‘0 drinks’ category for those who miss the earlier skip instructions.

Other issues:

“Testing this question revealed that this question is harder than AL.3 because respondents patterns

vary on the weekend depending on what they are doing. This lead respondents to make judgement,

with respondents on the whole thinking about how much they drink on average. Respondents

thought about the different occasions and averaged it.” From the UK Cognitive Testing report (p. 48).

Similarly as noted in the Belgium report (p. 40), “there is some variation on the manner people reply

to this question. Those with a variable pattern tend to average their consumption and focus on ‘usual’

situations, those who drink little tend to give their maximum, and those who drink steadily give an

exact account”.

OTHER RECOMMENDATION:

• Problems with irregular behaviour remain and are inherent in this type of question.

290

AL.6

During the past 12 months, how often did you have 6 or more drinks on one occasion?

Every day or almost every day 1

5 ‐ 6 days a week 2



2 ‐ 3 days in a month 5

Once a month 6

Once every 2 months 7

Once or twice in the past 12 months 8

Not in the past 12 months 9

Never in my whole life 10

Country information:

Here, 6 drinks are defined based on a "standard drink" equivalent to 10 g of ethanol. If standard

serve/container sizes or strength of beverage are higher in a given country, it is advised to

change the number of drinks in the question in order to meet the cut‐off of 60 g per occasion.

Hence, for instance, if a standard drink in a given country has 12 g ethanol, question AL.6 should

be adapted accordingly: "How often did you have 5 or more drinks on one occasion".


• Keep timeframe of 12 months

• Strongly discourage use of telephone interview. But if used include unfolding (branching)

method as is done in Conceptual Translations Guidelines document for AL.1.

Other issues:

The German Cognitive Testing Report (p. 36), suggests that some respondents had uncertainty about

whether they had had 6 or more drinks.

In the Belgium Cognitive Testing Report (pp.41‐42) it was noted that in French, ‘occasion’ has

different meanings such as, circumstance, event, opportunity, event's time, special occasion.

291

OTHER RECOMMENDATIONS:

• As this country information box is at the end of the questionnaire, it may not be clear at first

glance that it is only for question AL.6. Change ‘Country information’ to ‘Country information

for AL.6’.

• As noted in UK cognitive testing report, change “drinks” to “alcoholic drinks”. (Although this

could be inferred from the previous questions, good questionnaire design recommends that

each question is clear in and of itself – see Fowler, 1995).

• Perhaps add further clarification on what is an ‘occasion’ or use a different word.

Pilot test

Include respondent debriefing questions (see Belson, 1981; Campanelli et al, 1991) for those

questions which have changed since the cognitive testing. The standard field pilot test only picks up

on problems that are visible through respondent behaviour. Respondent debriefing (like the probes

from cognitive interviewing) provide a deeper understanding of how respondents are understanding

and processing the questions.

292

References

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Department for Education and Employment.

Belson, W.R. (1981), The Design and Understanding of Survey Questions, Aldershot, England: Gower.

Bradburn, NM and Danis, C. (1984). “Potential Contributions of Cognitive Research to Survey

Questionnaire Design,” in Cognitive Aspects of Survey Methodology: Building a Bridge Between

Disciplines, T.B. Jabine, M.L. Straf, J.M. Tanur, and R. Tourangeau (Eds.), Washington, DC:

National Academy Press, pp.101‐129.

Campanelli, P.C., Martin, E.A., and Rothgeb, J.M. (1991), The Use of Respondent and Interviewer

Debriefing Studies as a Way to Study Response Error in Survey Data, The Statistician, 40, 253‐

264.

Christian, L., Dillman, D., and Smyth, J. (2008), Effects of Mode and Format on Answers to Scalar

Questions in Telephone and Web Surveys, in Lepkowski et al (eds), Advances in Telephone

Survey Methodology, Hoboken, New Jersey: Wiley.

Dillman, D. (2000), Mail and Internet Surveys: The Tailored Design Method, New York: Wiley.

Fowler, F.J. Jr. (1995), Improving Survey Questions: Design and Evaluation, Thousand Oaks, CA: Sage.

Hunt, S.D. Sparkman, R.D. Jr., and Wilcox, J.B. (1982), The pretest in survey research: issues and

preliminary findings, Journal of Marketing Research, 19: 269‐273.

Redline, C. and Dillman, D. (2002), The Influence of Alternative Visual Designs on Respondents’

Performance with Branching Instructions in Self‐Administered Questionnaires, in R. Groves et

al (eds), Survey Nonresponse, New York, Wiley.

Redline, C., Dillman, D., Dajani, A., and Scaggs, M. (2003), Navigational Performance in Census 2000:

An Experiment of the Alteration of Visually Administered Languages, Journal of Official

Statistics,19: 403‐19.

Sangster, R. and Fox, J.E. (2000), Housing Rent Stability Bias Study, Washington, DC: U.S. Bureau of

Labor Statistics, Statistical Methods Div.

Schwarz, N. and Hippler, H. (1991), Response Alternatives: The Impact of Their Choice and

Presentation Order, in Biemer et al. (eds), Measurement Errors in Surveys, New York: Wiley.

Smyth, J., Dillman, D., Christian, L.M., Stern, M.J. (2004), How Visual Grouping Influences Answers to

Internet Surveys, Technical Report #04‐023, Pullman, Washington: Washington State University

Social and Economic Sciences Research Center:

Sudman, S. and Bradburn, N.M. (1982), Asking Questions: A Practical Guide to Questionnaire Design,

San Francisco: Jossey‐Bass, p. 149.

Sudman, S., Bradburn, N., and Schwarz, N. (1996), Thinking about Answers: The Application of

Cognitive Processes to Survey Methodology, San Francisco, CA: Jossey‐Bass.

293

Tourangeau, R., Couper, M., and Conrad, F. (2004), Spacing, Position, and Order: Interpretive Heuristics

for Visual Features of Survey Questions, Public Opinion Quarterly, 68(3): 368‐393.

Tourangeau, R., Rips, L.J., and Rasinski, K. (2000), The Psychology of Survey Response, Cambridge:

Cambridge University Press.

Tourangeau, R. and Smith, T.W. (1996), Asking sensitive questions: the impact of data collection mode,

question format, and question context, Public Opinion Quarterly, 60(2), 275‐304.

294

295

5. Annex chapter 6 – Translated instruments

5.1. German version of PA and AL

Einleitung 9 Ich werde Sie nun nach der Zeitdauer fragen, die Sie in einer typischen Woche mit der Ausübung verschiedener körperlicher Aktivitäten verbringen. Bitte beantworten Sie die Fragen auch, wenn Sie sich selbst nicht für eine körperlich aktive Person halten. PE.1 Denken Sie zuerst an die Zeit, in der Sie arbeiten. Denken Sie bei Arbeiten an Dinge, die Sie tun müssen, wie beispielsweise bezahlte und unbezahlte Arbeit, Arbeiten rund um Ihr zu Hause, Kinderbetreuung, Pflege von Angehörigen, Schule oder Studium. Wenn Sie arbeiten, welche der folgenden Antwortmöglichkeiten beschreibt am Besten was Sie tun? Würden Sie sagen—

INTERVIEWERINSTRUKTION: BITTE SHOW CARD 8 AUSHÄNDIGEN. DIE BEFRAGTEN SOLLEN IHRE ANGABE AUF DIE ‚HAUPTTÄTIGKEIT’ BEZIEHEN. FALLS BEFRAGTE MEHRERE TÄTIGKEITEN AUSÜBEN, SOLLEN SIE ALLE TÄTIGKEITEN EINSCHLIEßEN.

- Vorwiegend Sitzen oder Stehen 1

- Vorwiegend Gehen oder leichte bis mäßig anstrengende körperliche Tätigkeiten 2

- Vorwiegend schwere Arbeit oder körperlich beanspruchende Tätigkeiten 3

- Nicht zutreffend 97 - Weiß nicht 98

- Keine Angabe 99

PE.2 Die nächste Frage schließt die körperlichen Aktivitäten bei der Arbeit aus, die Sie bereits genannt haben. Ich würde Sie nun gerne dazu befragen, wie Sie sich üblicherweise von Ort zu Ort fortbewegen. Zum Beispiel zur Arbeit, zur Uni, zur Schule, zu Freunden oder zum Einkaufen. An wie vielen Tagen in einer typischen Woche gehen Sie für mindestens 10 Minuten ohne Unterbrechung zu Fuß, um von Ort zu Ort zu gelangen?

Anzahl der Tage: ___ → falls „Null“ weiter mit Frage PE.4

- Weiß nicht 98

- Keine Angabe 99

296

PE.3 Wie lange gehen Sie an einem typischen Tag zu Fuß, um von Ort zu Ort zu gelangen?

INTERVIEWER INSTRUKTION: BITTE SHOW CARD 9 AUSHÄNDIGEN.

- 10 ‐ 29 Minuten am Tag 1


- 1 ‐ 2 Stunden am Tag 3


- 3 Stunden am Tag oder mehr 5

- Weiß nicht 98 - Keine Angabe 99

PE.4 An wie vielen Tagen in einer typischen Woche fahren Sie für mindestens 10 Minuten ohne Unterbrechung mit dem Fahrrad, um von Ort zu Ort zu gelangen?

INTERVIEWERINSTRUKTION: HIER SOLL AUCH DIE NUTZUNG WEITERER NICHT MOTORISIERTER VERKEHRSMITTEL ZUR KÖRPERLICH AKTIVEN FORTBEWEGUNG EINGESCHLOSSEN WERDEN, WIE BEISPIELSWEISE ROLLER, SKATEBOARD ODER ROLLSCHUHE.

Anzahl der Tage: ___ → falls „Null“ weiter mit Frage PE.6

- Weiß nicht 98

- Keine Angabe 99

PE.5 Wie lange fahren Sie an einem typischen Tag mit dem Fahrrad, um von Ort zu Ort zu gelangen?

INTERVIEWERINSTRUKTION: BITTE AUF SHOW CARD 9 VERWEISEN.





- 3 Stunden am Tag und mehr 5

- Weiß nicht 98 - Keine Angabe �99

PE.6 Die nächste Frage schließt die körperlichen Aktivitäten bei der Arbeit und um von Ort zu Ort zu gelangen aus, die Sie bereits genannt haben. Ich würde Sie nun gerne nach SPORT, FITNESS

297

und KÖRPERLICHER AKTIVITÄT IN DER FREIZEIT befragen, welche MINDESTENS zu einem mäßigen Anstieg der Atem‐ oder Herzfrequenz führen, wie beispielsweise (Nordic‐) Walking, Ballsport, Joggen, Fahrradfahren oder Schwimmen. An wie vielen Tagen in einer typischen Woche üben Sie für mindestens 10 Minuten ohne Unterbrechung Sport, Fitness oder körperliche Aktivität in der Freizeit aus?


Anzahl der Tage: ___ → falls „Null“ weiter mit Frage Einleitung 10

- Weiß nicht 98

- Keine Angabe 99

PE.7 Wie viel Zeit verbringen Sie insgesamt in einer typischen Woche mit Sport, Fitness oder körperlicher Aktivität in der Freizeit?

___ ___ : ___ ___ in der Woche Std Min

- Weiß nicht 98

- Keine Angabe 99

PE.8 An wie vielen Tagen in einer typischen Woche üben Sie körperliche Aktivitäten aus, die speziell für den Aufbau oder die Kräftigung der Muskulatur gedacht sind wie beispielsweise Krafttraining oder Kräftigungsübungen? Geben Sie hier alle Aktivitäten dieser Art an, selbst wenn Sie Sie vorher bereits mit einbezogen haben.


Anzahl der Tage: ___

- Weiß nicht 98

- Keine Angabe 99

298

ALKOHOL Einleitung Die folgenden Fragen beziehen sich auf Ihren Alkoholkonsum in den letzten 12 Monaten. AL.1 Wie oft (falls überhaupt) haben Sie in den letzten zwölf Monaten alkoholische Getränke aller Art zu sich genommen, wie zum Beispiel Bier, Wein, Spirituosen, Cocktails, Mixgetränke, Alkopops, Liköre, hausgemachten oder selbstgebrannten Alkohol…? Bitte zutreffende Antwort ankreuzen

Jeden Tag oder fast jeden Tag................................................ 1

5 – 6 Tage die Woche ............................................................. 2

3 – 4 Tage die Woche ............................................................. 3

1 – 2 Tage die Woche ............................................................. 4

2 – 3 Tage im Monat............................................................... 5

Einmal im Monat .................................................................... 6

Seltener als einmal im Monat ............................................... 7

Ich habe früher Alkohol getrunken, aber nicht in den letzten zwölf Monaten 8

Nie oder im meinem ganzen Leben nur kleine Mengen ausschließlich zum Probieren................................................. 9

AL.2 Denken Sie an Montag bis Donnerstag, an wie vielen dieser vier Tage trinken Sie üblicherweise Alkohol?

An allen vier Tagen ................................................................... 1

An drei Tagen ........................................................................... 2

An zwei Tagen .......................................................................... 3

An einem Tag 4

An keinem dieser vier Tage ...................................................... 5

AL.3 Wenn Sie an den Tagen von Montag bis Donnerstag Alkohol trinken, wie viele alkoholische Getränke trinken Sie durchschnittlich an EINEM dieser Tage?

16 oder mehr alkoholische Getränke....................................... 1

10 ‐ 15 alkoholische Getränke.................................................. 2

6 – 9 alkoholische Getränke .................................................... 3

4 – 5 alkoholische Getränke ................................................... 4

3 alkoholische Getränke .......................................................... 5


1 alkoholisches Getränk .......................................................... 7


Weiter mit Frage AL.4



Weiter mit dem nächsten Abschnitt

299

AL.4 Denken Sie an Freitag bis Sonntag, an wie vielen dieser drei Tage trinken Sie üblicherweise Alkohol?

An allen drei Tagen................................................................... 1

An zwei Tagen .......................................................................... 2

An einem Tag............................................................................ 3

An keinem dieser drei Tage...................................................... 4

AL.5 Wenn Sie an den Tagen von Freitag bis Sonntag Alkohol trinken, wie viele alkoholische Getränke trinken Sie durchschnittlich an EINEM dieser Tage?

16 oder mehr alkoholische Getränke....................................... 1

10 ‐ 15 alkoholische Getränke.................................................. 2

6 – 9 alkoholische Getränke .................................................... 3

4 – 5 alkoholische Getränke ................................................... 4



1 alkoholisches Getränk .......................................................... 7


AL.6 Wie oft (wenn überhaupt) haben Sie in den letzten zwölf Monaten sechs oder mehr alkoholische Getränke aller Art bei einer Gelegenheit getrunken (z. B. während eines Abends, einer Feier, einer Veranstaltung oder alleine…?


5 – 6 Tage die Woche 2




Einmal im Monat 6

Seltener als einmal im Monat 7

Gar nicht in den letzten 12 Monaten 8

Noch nie im meinem ganzen Leben 9


300

SHOW CARD 8: Körperliche Aktivität bei der Arbeit

Vorwiegend sitzen oder stehen

Tätigkeiten ohne körperliche Anstrengung wie Büroarbeit, Lesen, Schreiben, Zeichnen, Sprechen oder Telefonieren, Unterrichten, Gitarre, Klavier oder Flöte üben oder am Computer arbeiten etc.

Vorwiegend gehen oder leichte bis mäßig anstrengende körperliche Tätigkeiten

Tätigkeiten von leichter bis mäßiger Anstrengung wie Elektriker‐ oder Klempnerarbeiten, Auto‐Reparaturarbeiten, Arbeiten an Werkzeugmaschinen, Putzen, Staubsaugen, Geschirrspülen, Einkaufen, mit Kindern spielen, Tragen von leichten Gegenständen, Rasen‐ und Gartenbewässern etc.

Vorwiegend schwere Arbeit oder körperlich beanspruchende Tätigkeiten

Sehr anstrengende Tätigkeiten wie das Bedienen von schweren angetriebenen Werkzeugen, Bauarbeiten, Bergbau, Tragen von schweren Gegenständen, Be‐ und Entladearbeiten, Holzhacken, Umgraben oder schwere Land‐ oder Gartenarbeit etc.

301

SHOW CARD 9

Antworten

10 ‐ 29 Minuten am Tag

30 ‐ 59 Minuten am Tag

1 ‐ 2 Stunden am Tag

2 ‐ 3 Stunden am Tag

3 Stunden am Tag oder mehr

302

SHOW CARD 10: Sport, Fitness und körperliche Aktivität in der Freizeit

Sport, Fitness und körperliche Aktivität in der Freizeit

Körperliche Aktivitäten in der Freizeit, welche MINDESTENS zu einem mäßigen Anstieg der Atem‐ und Herzfrequenz führen, wie beispielspielsweise (Nordic) Walking, Ballsport, Joggen, Fahrradfahren oder Schwimmen.

303

SHOW CARD 11: Aktivitäten zur Muskelkräftigung

Aktivitäten zur Muskelkräftigung

Körperliche Aktivitäten, die speziell für den Aufbau oder die Kräftigung der Muskulatur gedacht sind wie beispielsweise Krafttraining oder Kräftigungsübungen.

304

SHOW CARD 12

305

5.2. Estonian version of PA and AL

SISSEJUHATAV TEKST 9 Järgmised küsimused puudutavad tavalisel nädalal kehalistele tegevustele kuluvat aega. Palun vastake neile küsimustele ka siis, kui Te ei pea ennast kehaliselt aktiivseks inimeseks. Mõelge igapäevastele, tööga seotud tegevustele. Töötamise all mõelge nii tasustatud kui ka tasustamata tööd, õppimise või väljaõppega seotud tegevusi, samuti majapidamistöid nagu aiatööd, perekonna eest hoolitsemine jms. PE.1 Missugune järgnevatest kirjeldustest iseloomustab kõige paremini teie TÖÖTAMIST? Kas Teie töö on ...

KÜSITLEJA: ULATAGE ABIKAART 8. VASTAJA PEAKS LÄHTUMA OMA PÕHILISEST TÖÖALASEST TEGEVUSEST. KUI KÜSITLETAV TEEB MITMEID ERILAADSEID TÖID, ARVESTAGE NEID KÕIKI.

PE.1

- Peamiselt istumine või seismine 1 - Peamiselt kõndimine või on seotud tegevustega,

mis nõuavad kerget või mõõdukat kehalist pingutust

2

- Peamiselt füüsiliselt raske või füüsilist pingutust nõudev töö 3

KÜSITLEJALE: ÄRA LOE:

- Ei ole kohaldatav 7

- Ei oska öelda / Pole kindel 8

- Keeldumine 9 Järgmised küsimused ei hõlma tegevusi töötamisel, mida te juba kirjeldasite. Nüüd tahaksin Teilt küsida, kuidas Te tavaliselt ÜHEST KOHAST TEISE LIIGUTE, näiteks kui lähete tööle, kooli, poodi sisseoste tegema, sõpradele külla vms. PE.2 Mõeldes tavalisele nädalale, mitmel päeval nädalas Te KÕNNITE pidevalt vähemalt 10 minutit järjest ühest kohast teise jõudmiseks?

Päevade arv: ___

KUI NULL, SIIS JÄTKAKE KÜSIMUSEGA PE.4

306

PE.3 Kui palju aega Te ühel sellisel päeval kokku kõnnite?

KÜSITLEJA: ULATAGE ABIKAART 9.

PE.3

- 10 ‐ 29 minutit päevas 1


- 1 tund – 1 tund 59 minutit päevas 3

- 2 tundi – 2 tundi 59 minutit päevas 4

- 3 või rohkem tundi päevas 5 PE.4 Mõeldes tavalisele nädalale, mitmel päeval nädalas Te SÕIDATE JALGRATTAGA pidevalt vähemalt 10 minutit järjest ühest kohast teise jõudmiseks?

KÜSITLEJA: VÕTKE SIIN ARVESSE KA TEISTE MITTE MOOTORI JÕUL LIIKUVATE TRANSPORDIVAHENDITE KASUTAMINE NAGU TÕUKERATAS, RULLUISUD, RULA JNE.

Päevade arv: ___

KUI NULL, SIIS JÄTKAKE KÜSIMUSEGA PE.6

PE.5 Kui palju aega Te ühel sellisel päeval kokku jalgrattaga sõidate?


PE.5



- 1 tund – 1 tund 59 minutit päevas 3

- 2 tundi – 2 tundi 59 minutit päevas 4

- 3 või rohkem tundi päevas 5 PE.6 Järgmistele küsimustele vastates ärge arvestage juba eelnevalt kirjeldatud tegevusi nagu töötamine ja sihipärane liikumine. Nüüd tahaksin küsida Teilt TERVISESPORDI, TREENINGU ja VABA AJA TEGEVUSTE kohta, mis põhjustavad VÄHEMALT väikest hingamise või südametegevuse kiirenemist nagu kepikõnd, pallimängud, sörkjooks, jalgrattasõit, ujumine jms.


307

PE.6 Mõeldes tavalisele nädalale, kui mitmel päeval NÄDALAS Te tegelete tervisespordi, treeningu või aktiivse vaba aja veetmisega vähemalt 10 minutit järjest?

Päevade arv: ___

KUI NULL, SIIS JÄTKAKE KÜSIMUSEGA PE.8.

PE.7 Kui palju aega Te ühel tavalisel NÄDALAL sportimisele, tervisespordile või aktiivsele vaba aja veetmisele kokku kulutate?

___ ___ : ___ ___ nädalas tundi minutit

PE.8 Mõeldes tavalisele nädalale, kui mitmel päeval NÄDALAS Te sooritate kehalisi harjutusi, mis on spetsiaalselt mõeldud lihaste jõu treeninguks nagu jõuharjutused või raskuste tõstmine? Võtke arvesse ka tegevused, mida Te eespool juba arvestasite.


Päevade arv: ___

308

ALKOHOL Juhis Järgmisena küsime Teie alkoholitarbimise kohta viimase 12 kuu jooksul.


AL.1 Kui tihti (kui üldse) Te viimase 12 kuu jooksul olete alkohoolseid jooke tarbinud? Nt õlu, vein, siider, kokteilid, kange alkohol, liköörid, isevalmistatud alkohoolsed joogid (koduõlu, koduvein) jne. Märkige oma vastus

Iga päev või peaaegu iga päev................................................ 1

5 – 6 päeval nädalas .............................................................. 2

3 ‐ 4 päeval nädalas ................................................................ 3

1 ‐ 2 päeval nädalas ................................................................ 4

2 ‐ 3 päeval kuus..................................................................... 5

1 kord kuus ............................................................................. 6

Harvemini kui 1 kord kuus ..................................................... 7

Viimasel 12 kuul ei ole tarvitanud, sest ma olen alkoholi tarbimisest loobunud ............................................................. 8

Ei ole kunagi alkoholi tarbinud või võtnud kogu oma elu jooksul mõne sõõmu .............................................................. 9

AL.2 Mitmel päeval Te esmaspäevast neljapäevani (4 päeva) tavaliselt alkohoolseid jooke tarbite?

Kõigil 4 päeval........................................................................... 1

3 päeval neljast......................................................................... 2

2 päeval neljast......................................................................... 3

1 päeval neljast......................................................................... 4

Ei tarbi neil päevadel ................................................................ 5

AL.4

AL.6

AL.2

Liigu järelküsimuste juurde

309

AL.3 Mitu alkoholiannust Te tavaliselt ÜHEL nendest päevadest (esmaspäevast neljapäevani) tarbite? (Palun vaadake abikaarti)

16 alkoholiannust või rohkem.................................................. 1

10 ‐ 15 alkoholiannust .............................................................. 2

6 ‐ 9 alkoholiannust ................................................................. 3

4 ‐ 5 alkoholiannust ................................................................. 4

3 alkoholiannust ...................................................................... 5

2 alkoholiannust ...................................................................... 6

1 alkoholiannuse ..................................................................... 7

0 alkoholiannust ...................................................................... 8

AL.4 Mitmel päeval Te reedest pühapäevani (3 päeva) tavaliselt alkohoolseid jooke tarbite?

Kõigil 3 päeval........................................................................... 1

2 päeval kolmest ...................................................................... 2

1 päeval kolmest ...................................................................... 3

Ei tarbi neil päevadel ................................................................ 4

AL.5 Mitu alkoholiannust Te tavaliselt ÜHEL nendest päevadest (reedest pühapäevani) tarbite? (Palun vaadake abikaarti)

16 alkoholiannust või rohkem.................................................. 1

10 ‐ 15 alkoholiannust ............................................................. 2

6 ‐ 9 alkoholiannust ................................................................. 3

4 ‐ 5 alkoholiannust ................................................................. 4

3 alkoholiannust ...................................................................... 5

2 alkoholiannust ...................................................................... 6

1 alkoholiannuse ..................................................................... 7

0 alkoholiannust ...................................................................... 8

AL.6

310

AL.6 Kui tihti Te viimase 12 kuu jooksul olete tarbinud (kui üldse olete tarbinud) korraga 6 või rohkem annust (ka erinevat) alkoholi ühe sündmuse (milleks on õhtu, pidu, üritus, ka üksinda,…) käigus?

Iga päev või peaaegu iga päev.................................................. 1

5 ‐ 6 päeval nädalas ................................................................. 2

3 ‐ 4 päeval nädalas .................................................................. 3

1 ‐ 2 päeval nädalas .................................................................. 4

2 ‐ 3 päeval kuus....................................................................... 5

Kord kuus.................................................................................. 6

Harvemini kui kord kuus........................................................... 7

Ei ole tarbinud viimase 12 kuu jooksul..................................... 8

Ei ole kunagi tarbinud............................................................... 9

311

ABIKAART 8: TÖÖGA SEOTUD KEHALINE AKTIIVSUS

Peamiselt istumine või seismine

Kehalist pingutust vähenõudvad tööd nagu kontoritöö, lugemine, kirjutamine, joonistamine, kõnelemine või telefoniga rääkimine, õpetamine, muusikariista (nt kitarri, klaveri või flöödi) mängimine, arvutitöö jne.

Peamiselt kõndimine või liikumine või tegevused, mis nõuavad kerget või mõõdukat kehalist pingutust

Tööd, mis eeldavad liikumist ja/või kerget või mõõdukat pingutust nagu elektritööd, torutööd, autoremont, tööpingiga töötamine, koristamine/puhastusteenindus, tolmuimejaga töötamine, nõudepesemine, poeskäimine, lastega mängimine, kergemate asjade kandmine, muru või aia kastmine jne.

Peamiselt füüsiliselt raske või füüsilist pingutust nõudev töö

Suurt pingutust nõudvad tööd nagu raskete tööriistade kasutamine, suruõhuhaamri kasutamine, ehitustööd, kaevandamine, raskete asjade kandmine, laadimistööd, puude ladumine või lõhkumine, põllutööd, teetööd, maa kaevamine jne.

312

ABIKAART 9 ‐ 10

Vastused 10 ‐ 29 MINUTIT PÄEVAS 30 ‐ 59 MINUTIT PÄEVAS 1 TUND – 1 TUND 59 MINUTIT PÄEVAS 2 TUNDI – 2 TUNDI 59 MINUTIT PÄEVAS 3 VÕI ENAM TUNDI PÄEVAS

313

ABIKAART 11: SPORT, TERVISESPORT JA VABAAJA KEHALINE TEGEVUS

Sport, tervisesport ja vabaaja kehaline tegevus

Sport, tervisesport, treening ja vabaaja aktiivsed tegevused, mis põhjustavad VÄHEMALT kerget hingeldamist või südametegevuse kiirenemist nagu kepikõnd, pallimängud, sörkimine, rattasõit või ujumine, raskuste tõstmine ja jõu‐ või venitusharjutused

ABIKAART 12: LIHASTE TUGEVDAMINE

Lihaste tugevdamine

Kehalised tegevused, mis on spetsiaalselt mõeldud lihaste TUGEVDAMISEKS nagu raskuste tõstmine või jõuharjutused.

314

ABIKAART 13

LAHJA ALKOHOL (õlu, siider, long drink, lahjad alkoholikokteilid, jm. kuni 6% alkoholisisaldusega) 0,5 l pudel, kann = 2 annust 0,3 l pudel, purk = 1 annus 1,5 l pudel = 6 annust 2 l pudel = 8 annust

VEIN, ka VAHUVEIN (9% ‐ 12% alkoholisisaldusega) 1 pokaal (125 ml) = 1 annus 0,5 l pudel = 5 annust 0,7 l pudel = 6,5 annust 1 l pudel = 10 annust

KANGE ÕLLE TEISENDUSED (üle 6% alkoholisisaldusega) 0,5 l pudel, kann = 2,5 annust 0,3 l pudel, purk = 1,5 annust 1,5 l pudel = 7,5 annust 2 l pudel = 10 annust

KANGE ALKOHOL (viin, konjak, brändi, džinn, viski, liköör*** jm. 40% alkoholisisaldusega) 1 pits (30ml) = 1 annus 0,35 l pudel = 11 annust 0,5 l pudel = 15 annust 0,7 l pudel = 22 annust 1 l pudel = 32 annust *** Lahjema likööri ja kangete viina‐, džinni‐, jms. kokteilide puhul (~20% alkoholisisaldusega) jagage annuste arv kahega.

315

5.3. French version of PA and AL

ACTIVITES PHYSIQUES

Introduction Les questions suivantes concernent le temps que vous consacrez à différentes activités physiques au cours d'une semaine‐type. Veuillez répondre à chaque question, même si vous ne vous considérez pas comme étant une personne physiquement active.

ACTIVITÉS PHYSIQUES LIÉES AU TRAVAIL Pensez d'abord au temps que vous consacrez à votre travail. Considérez le travail comme une activité rémunérée ou non, le travail à la maison ou autour, le ménage, s'occuper de la famille, étudier, aller au cours…

ENQUETEUR: MONTREZ LA CARTE 8.

SI LE RÉPONDANT FAIT PLUSIEURS ACTIVITES, INCLUEZ‐LES TOUTES.

PE.1 Lorsque vous TRAVAILLEZ, laquelle de ces propositions décrit le mieux ce que vous faites? Etes‐

vous…

Principalement assis(e) ou debout 1

Principalement en train de marcher 2

Principalement occupé à un travail lourd ou

physiquement exigeant 3

Ne sait pas 8

Refus 9

ACTIVITÉS PHYSIQUES LIÉES AUX DEPLACEMENTS Les questions suivantes excluent toutes les activités liées au travail que vous avez déjà mentionnées. Ici, je vous demande de penser à la manière habituelle dont vous vous déplacez d'un endroit à un autre. Par exemple, pour vous rendre au travail, à l'école, au marché, pour faire du shopping, etc.

316

PE.2 Au cours d'une semaine type, combien de jours marchez‐vous au moins 10 minutes d'affiliée pour vous rendre d'un endroit à un autre?

Nombre de jours: ____ (SI ZÉRO PASSEZ À LA QUESTION PE.4)


PE.3 Combien de temps marchez‐vous pendant vos déplacements au cours d'une journée type?

10 ‐ 29 minutes par jour 1


1 ‐ 2 heures par jour 3


3 heures par jour ou plus 5

PE.4 Au cours d'une semaine type, combien de jours vous déplacez‐vous en vélo au moins 10

minutes d'affiliée pour vous rendre d'un endroit à un autre? ENQUETEUR: INCLUEZ ICI ÉGALEMENT D'AUTRES MOYENS ACTIFS DE TRANSPORT NON‐MOTORISÉS COMME LES

ROLLERS, PATINS À ROULETTES, SKATE BOARDS.

Nombre de jours: ____ (SI ZÉRO PASSEZ À LA QUESTION PE.6)


PE.5 Combien de temps roulez‐vous à vélo (ou autre) pendant vos déplacements au cours d'une journée type?





3 heures par jour ou plus 5

317

SPORTS, FITNESS ET ACTIVITÉS DE LOISIRS Les questions suivantes excluent toutes les activités liées au travail ou aux déplacements que vous avez déjà mentionnés ci‐dessus. Ici, on se réfère au sport, au fitness et aux activités que vous faites durant vos loisirs et qui provoquent AU MOINS une légère augmentation de la respiration ou du rythme cardiaque, comme la marche rapide, les jeux de ballon, le jogging, le vélo ou la natation…


PE.6 Au cours d'une semaine type, combien de jours pratiquez‐vous du sport, du fitness ou des

activités physiques de loisir au moins 10 minutes d'affiliée?

Nombre de jours: ____ (SI ZÉRO PASSEZ AU MODULE SUIVANT)

PE.7 Combien de temps consacrez‐vous au sport, au fitness ou à des activités physiques de loisir

au cours d'une semaine type?

___ ___ : ___ ___ par semaine

h. min.

ACTIVITÉS DE MUSCULATION PE.8 Au cours d'une semaine type, combien de jours pratiquez‐vous des activités physiques

spécialement destinées à renforcer les muscles, comme soulever des poids ou faire du bodybuilding? Incluez toutes les activités de ce type, même si elles ont déjà été mentionnées.


Nombre de jours: ____

318

AUTO QUESTIONNAIRE

Répondez vous‐même aux questions suivantes.

Avant de répondre, lisez attentivement la question et les possibilités de réponse. Faites un seul choix de réponse par question.

Pour indiquer votre choix de réponse, cochez d'une croix la case correspondante X ou écrivez un chiffre dans les encoches prévues, par exemple:��.

Des flèches vous indiquent alors le parcours à suivre au travers du questionnaire.

Les instruction qui apparaissent avec une flèche "→ Passez à …" à côté d'une case de réponse indique la question à laquelle vous devez vous rendre après avoir coché cette case. Sans cette indication de saut de question, suivez simplement l'ordre chronologique des questions.

Soyez assurés que vos réponses demeurent confidentielles et sont traitées de façon anonyme.

References:

Pictures for the Belgian show card were gathered on the Internet at the following URL addresses:

Alcohol equivalence: http://www.frar.asso.fr/IMG/jpg/quantites.jpg (Source: INPES ‐adapted)

Strong beers (adapted): http://www.allodeleau.com/photos/coffretbieres03P.jpg

Can 50cl (adapted) http://i01.i.aliimg.com/photo/108509225/JUPILER_BEER_v0.summ.jpg

Porto (adapted) http://media.telemarket.fr/imgnwprd/000/000380/00038091/00038091‐t0.jpg

Whisky (adapted) http://media.telemarket.fr/imgnwprd/000/000382/00038245/00038245‐t0.jpg

2 5

319

Dans ce questionnaire, il vous sera demandé de rapporter votre concommation éventuelle de boissons alcoolisées en termes de verres standard, c'est‐à‐dire ce qui est habituellement servi dans le secteur horeca. Veuillez vous référer à ces valeurs lorsque vous estimez le nombre de verres que vous consommez.

Un verre standard contient environ 10 grammes d'alcool, quelle que soit le type d'alcool:

On compte généralement 2 VERRES STANDARD pour:

Une bière forte à 7‐9° (33 cl) Une maxi cannette de pils (50 cl)

Voici le nombre de verres standard par bouteille selon le type de boisson considéré:

1 bouteille de vin 75 cl

= 6 verres standard

1 bouteille de Porto 75 cl

= 12 verres standard

1 bouteille de spiritueux 70 cl

= 23 verres standard

CONSOMMATION D'ALCOOL

320

AL.1 Au cours des 12 derniers mois, à quelle fréquence avez‐vous consommé des boissons alcoolisées, quelle qu'elles soient: bière, vin, apéritif, cidre, cocktail, breezers, spiritueux, liqueur, alcool fait maison…?

Tous les jours ou presque .............................................................. 1

5 ‐ 6 jours par semaine .................................................................. 2

3 ‐ 4 jours par semaine................................................................... 3

1 ‐ 2 jours par semaine................................................................... 4

2 ‐ 3 jours par mois......................................................................... 5

1 jour par mois ............................................................................... 6

Moins d'un jour par mois .............................................................. 7

Pas au cours des 12 derniers mois, car je ne bois plus d'alcool..... 8

Jamais de ma vie, ou pas plus de quelques gorgées...................... 9

AL.2 Pensez à la période de semaine du lundi au jeudi inclus. En général, au cours de combien de

ces 4 jours de la semaine buvez‐vous de l'alcool?

Les 4 jours.................................................................. 1

3 jours sur les 4 ......................................................... 2

2 jours sur les 4.......................................................... 3

1 jour sur les 4 ........................................................... 4

Aucun des ces 4 jours ................................................ 5

AL.3 Toujours du lundi au jeudi, lorsque vous consommez de l'alcool, combien de verres en buvez‐

vous en moyenne par jour?

16 verres ou plus ............................................................ 1

10 ‐ 15 verres.................................................................. 2

6 ‐ 9 verres..................................................................... 3

4 ‐ 5 verres..................................................................... 4

3 verres.......................................................................... 5

2 verres.......................................................................... 6

1 verre ........................................................................... 7

0 verre ........................................................................... 8

PASSEZ À AL.6

FIN

PASSEZ À AL.4

321

AL.4 Cette fois, pensez à la période de la semaine du vendredi au dimanche inclus. En général, au cours de combien de ces 3 jours buvez‐vous de l'alcool?

Les 3 jours ............................................................... 1

2 jours sur les 3 ...................................................... 2

1 jour sur les 3......................................................... 3

Aucun de ces 3 jours ............................................... 4

AL.5 Du vendredi au dimanche, lorsque vous consommez de l'alcool, combien de verres en buvez‐vous en moyenne par jour?

16 verres ou plus.......................................................... 1

10 ‐ 15 verres ............................................................... 2

6 ‐ 9 verres................................................................... 3

4 ‐ 5 verres................................................................... 4

3 verres........................................................................ 5

2 verres........................................................................ 6

1 verre ........................................................................ 7

0 verre ......................................................................... 8

AL.6 Au cours des 12 derniers mois, à quelle fréquence avez‐vous consommé 6 verres ou plus de boissons alcoolisées, éventuellement différentes, en une même occasion (par exemple, au cours d'une soirée, une fête, un événement, avec des amis ou seul(e) chez vous…)?

Tous les jours ou presque ............................................................... 1

5 ‐ 6 jours par semaine ................................................................... 2

3 ‐ 4 jours par semaine.................................................................... 3

1 ‐ 2 jours par semaine.................................................................... 4

2 ‐ 3 jours par mois.......................................................................... 5

1 jour par mois ................................................................................ 6

Moins d'un jour par mois ............................................................... 7

Pas au cours des 12 derniers mois.................................................. 8

Jamais de ma vie ............................................................................. 9

FIN DU QUESTIONNAIRE

PASSEZ À AL.6

322

CARTES DE REPONSES

CARTE 7

Santé mentale

Jamais

Plusieurs jours

Plus de la moitié du temps

Presque tous les jours

CARTE 9 ET CARTE 10

Activités physiques

10 ‐ 29 minutes par jour

30 ‐ 59 minutes par jour

1 ‐ 2 heures par jour

2 ‐ 3 heures par jour

3 heures ou plus par jour

323

CARTE 8: Activité physique liée au travail

Principalement assis(e) ou debout

Tâches sans activité physique, comme: Le travail de bureau, lire, écrire, dessiner, parler ou parler au téléphone, donner cours, jouer un instrument de musique, utiliser l'ordinateur, etc.…

Principalment de la marche

Ou tâches exigeant un effort physique léger à modéré: Travail de plomberie ou d'électricité, réparation de voitures, de machines, nettoyer, passer l'aspirateur, laver la vaisselle, faire les courses, jouer avec les enfants, porter des choses, arroser le jardin, etc.

Principalement un travail lourd ou physiquement exigeant

Tâches laborieuses ou ardues comme: Employer les machines‐outils lourdes, travail de construction, travail dans les mines, porter des charges lourdes, couper, charger ou empiler du bois, travaux de la terre et de jardin, déblayer ou creuser, etc.

324

CARTE 11: Sports, fitness, activité physique de loisir

Sports, fitness, activités de loisir

Activités de loisir qui provoquent AU MOINS une petite augmentation de la respiration ou la fréquence cardiaque telle que la marche rapide, les jeux de ballons, le jogging, le vélo ou la nage, la gymnastique ou soulever de poids…

325

CARTE 12: Renforcement des muscles

Renforcement des muscles

Activités physiques spécialement destinées à RENFORCER les muscles, comme soulever des poids ou faire de la gym.

326

327

6. Annex Chapter 7 – Field‐Testing Questionnaire

IMPROVEMENT OF THE EHIS FIELD TESTING

QUESTIONNAIRE – 1ST DRAFT

Figure 1: How to construct the identification number of the selected respondents?

Identification number of person selected: 5 digits. This identification number should be specified for each interview.

‐ ‐ ‐

Label Description

A Country Number

The country number is composed of 1 digit: - “1” for Belgium - “2“ for Germany (interview) - “3” for Germany (telephone) - “4” for Estonia

B Interviewer number The interviewer number is composed of 1 digit. Every interviewer should receive a unique number prior to the field test.

C Sex of respondent Gender is composed of 1 digit:

- “1” for male - “2” for female

D Age of respondent The age is encoded using two digits.

Identification number of person selected (5 digits):

‐ ‐ ‐

Starting time of interview: ___ ___ : ___ ___

hrs mins

D

X A

X B

XC

X X

328

End time of interview: ___ ___ : ___ ___

hrs mins

Date of interview: └─┴─┴─┴─┴─┴─┴─┴─┘ (ddmmyyyy)

329

BACKGROUND MODULE – CORE SOCIAL VARIABLES (CSV)

PART A: INTERVIEW PROTOCOL

IP.1 Country: └─┘

- Belgium (PAPI) 1

- Germany (PAPI) 2

- Germany (CATI) 3

- Estonia (PAPI) 4

IP.2 Sex of respondent:

- Male 1

- Female 2

IP.3 Age of respondent: └─┴─┘ (years old)

330

PART B: PERSONAL CHARACTERISTICS

INTERVIEWER: THIS PART WILL BE ASKED TO THE SELECTED PERSON [SAMPLE OF INDIVIDUALS]. INTERVIEWER: NEXT QUESTIONS ARE FOR PERSONS AGED 15 AND MORE.

Introduction First, I would like to ask you some questions about your household. HH.1 How many persons live in the household?

└─┴─┘persons HH.2 What is your legal marital status?

CODE THAT APPLIES FIRST

- never married and never in a registered partnership 1

- married or in a registered partnership 2

- widowed or with registered partnership that ended with death of partner (not remarried or in new registered partnership)

3

- divorced or with registered partnership that was legally dissolved (not remarried or in new registered partnership)

4

FILTER 1

INTERVIEWER: IF THE HOUSEHOLD HAS ONLY 1 MEMBER, SKIP QUESTION HH.3 AND ASK QUESTION HH.4. OTHERWISE, ASK QUESTION HH.3.

HH.3 May I just check, are you living with someone in this household as a couple?

ASK OR RECORD De facto marital status (consensual union): De facto marital status is defined as the marital status of each individual in terms of his or her actual living arrangements within the household.

- Person living in a consensual union 1

- Person not living in a consensual union 2

331

HH.4 What is the highest education leaving certificate, diploma or education degree you have obtained? Please include any vocational training.

- No formal education or below (ISCED 1) 1

- Primary education (ISCED 1) 2

- Lower secondary education (ISCED 2) 3

- Upper secondary education (ISCED 3) 4

- Post‐secondary but non‐tertiary education (ISCED 4) 5

- First stage of tertiary education (ISCED 5) 6

- Second stage of tertiary education (ISCED 6) 7

The response categories should be named according to the educational system of the country.

Introduction Now I'm going to ask you some questions about your current labour situation. HH.5 How would you define your current labour status?

- Carries out a job or profession, including unpaid work for a family business or holding, including an apprenticeship or paid traineeship, etc. (full‐time or part‐time)

1

- Unemployed 2

- Pupil, student, further training, unpaid work experience

3

- In retirement or early retirement or has given up business 4

- Permanently disabled 5 GO TO HS.1

- In compulsory military or community service 6

- Fulfilling domestic tasks 7

- Other inactive person 8

HH.6 Do you work full‐time or part‐time?

- Full time 1

- Part time 2

EUROPEAN HEALTH STATUS MODULE

332

HEALTH AND MORBIDITY Introduction 1 I would now like to talk to you about your health. HS.1 How is your health in general? Is it…

RUNNING PROMPT In all questions, answers such as "don't remember" and "not sure" are covered by the response category "don't know".

- Very good 1

- Good 2

- Fair 3

- Bad 4

- Very bad? 5

- Don't know 8

- Refusal 9

HS.2 Do you have any longstanding illness or [longstanding]12 health problem?

[By longstanding I mean illnesses or health problems which have lasted, or are expected to last, for 6 months or more]1.

- Yes 1

- No 2

- Don't know 8

- Refusal 9

12 This word / sentence is not part of the MEHM and shall not be considered as included in this question. However, according to the

remarks that were received, in some languages it may be necessary to include them. In these languages, it would be useful to test first

the effect of this addition to the question. Depending on results, the word / sentence may be added to the national question or only

included in the instructions for the interviewers, etc. However, this has to be done very soon, as the coordination with SILC shall be

ensured within a very short time.

333

HS.3 For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do? Would you say you have been …

RUNNING PROMPT

- Severely limited 1

- Limited but not severely, or 2

- Not limited at all? 3

- Don't know 8 - Refusal 9

Introduction 2 Here is a list of diseases or conditions. HS.4 Do you have or have you ever had any of the following diseases or conditions in the past 12 months?

- Yes 1

- No 2

- Don't know 8

- Refusal 9

INTERVIEWER: HAND SHOW CARD 1. RESPONDENT TO READ OUT ONLY THE CATEGORIES THAT APPLY TO HIM/HER, CODE ALL CATEGORIES AND FOR EACH DISEASE / HEALTH PROBLEM REPORTED ASK HS.5. IF NO DISEASE / HEALTH PROBLEM IS REPORTED (CODES 2, 8 OR 9) GO TO QUESTION HS.6.

HS.5 Was this disease/condition diagnosed by a medical doctor?

- Yes 1

- No 2

- Don't know 8

- Refusal 9

334

HS.4 HS.5

01 Asthma (allergic asthma included) └─┘ └─┘

02 Chronic bronchitis, chronic obstructive pulmonary disease, emphysema

└─┘ └─┘

03 Myocardial infarction └─┘ └─┘

04 Coronary heart disease (angina pectoris)

└─┘ └─┘

05 High blood pressure (hypertension)

└─┘ └─┘

06 Stroke (cerebral haemorrhage, cerebral thrombosis)

└─┘ └─┘

07 Osteoarthritis └─┘ └─┘

08 Low back disorder or other chronic back defect

└─┘ └─┘

09 Neck disorder or other chronic neck defect

└─┘ └─┘

10 Diabetes └─┘ └─┘

11 Allergy, such as rhinitis, eye inflammation, dermatitis, food allergy or other (allergic asthma excluded)

└─┘ └─┘

12 Cirrhosis of the liver, liver dysfunction

└─┘ └─┘

13 Urinary incontinence, problems in controlling the bladder

└─┘ └─┘

14 Depression └─┘ └─┘

Countries, which for national purposes, might be interested to add new diseases or conditions should include them at the end of the list above.

HS.6 In the past 12 months, have you had any of the following type of accidents resulting in injury?

335

INTERVIEWER: HAND SHOW CARD 2. RESPONDENT TO READ OUT ONLY THE CATEGORIES THAT APPLY TO HIM/HER, AND CODE ALL CATEGORIES. FOR EACH POSITIVE ANSWER, ASK HS.7. IF NO ACCIDENT IS REPORTED (CODES 2, 8 OR 9) THEN GO TO FILTER 1. INTERVIEWER CLARIFICATION: INJURIES RESULTING FROM POISONING AND WILFUL ACTS OF OTHER PERSONS ARE ALSO INCLUDED. HOME ACCIDENTS: ALL THOSE ACCIDENTS WHO OCCURRED IN HOME, WHATEVER THE ACTIVITY THE PERSON WAS DOING LEISURE ACCIDENTS: ALL THE ACCIDENTS OCCURRED DURING LEISURE EXCLUDING THOSE OCCURRED IN HOME

- Yes 1

- No 2

- Don't know 8

- Refusal 9

HS.7 Did you visit a doctor, a nurse or an emergency department of a hospital as a result of this accident?

IF THERE IS MORE THAN 1 ACCIDENT, THE QUESTION REFERS TO THE MOST SERIOUS. WHEN THERE IS MORE THAN 1 ACCIDENT, THE QUESTION SHOULD EXPLAIN TO WHICH ACCIDENT IT REFERS TO: THE CHOICE IS "THE MOST SERIOUS".

- Yes, I visited a doctor or nurse 1

- Yes, I went to an emergency department 2

- No consultation or intervention was necessary 3

- Don't know 8

- Refusal 9

INTERVIEWER: MULTIPLE ANSWERS ARE POSSIBLE.

Type of accident HS.6 HS.7

01 Road traffic accident └─┘ └─┘

02 Home accident └─┘ └─┘

03 Leisure accident └─┘ └─┘

FILTER 1

336

INTERVIEWER: NEXT QUESTION (HS.8) IS TO BE ASKED ONLY FOR RESPONDENTS CURRENTLY WORKING (CODE 1 IN HH.5 IN THE BACKGROUND MODULE).

HS.8 In the past 12 months, have you been absent from work for reasons of health problems? Take into account all kind of diseases, injuries and other health problems that you had and which resulted in your absence from work.

- Yes 1

- No 2 → GO TO INTRODUCTION 3

- Don't know 8 → GO TO INTRODUCTION 3

- Refusal 9 → GO TO INTRODUCTION 3

HS.9 In the past 12 months, how many days in total were you absent from work for reasons of health problems?

INTERVIEWER PROMPT ONLY IF NECESSARY "AN ESTIMATE IS ACCEPTABLE".

└─┴─┴─┘ days

- Don't know 998

- Refusal 999

337

FUNCTIONING/BODY FUNCTIONS, STRUCTURES AND ACTIVITIES Introduction 3 Now I would like you to think about situations you may face in everyday life. Please ignore any temporary problems. Interviewer read: "Now I am going to ask you some [further] questions about [your/his/her] general mental and physical health. These questions deal with [your/his/her] ability to do different daily activities, as well as with how [you have/he has/she has] been feeling. [Although some of these questions may seem similar to ones you have already answered, it is important that we ask them all.]"

INTERVIEWER: IF THE RESPONDENT IS BLIND MARK WITH CODE 3 IN VIS_1 AND THEN GO TO HEAR_1. FOR THE OTHERS, ASK VIS_1.

VIS_1 [Do/Does] [you/he/she] wear glasses or contact lenses?

- Yes 1

- No 2

- I am blind or can not see at all 3

- Don't know 8

- Refusal 9

Statement 1 Interviewer read: “Please answer the following questions according to your normal use of glasses or contact lenses”

INTERVIEWER: FOR QUESTIONS VIS_2 TO MOB_3 (EXCEPT HEAR_1) HAND SHOW CARD 3.

VIS_2 [Do/Does] [you/he/she] have difficulty seeing, [If VIS_1 = 1: even when wearing your glasses]? Would you say… [Read response categories]

- No difficulty 1

- Some difficulty 2

- A lot of difficulty 3

- Cannot do at all / Unable to do 4

- Don't know 8

- Refusal 9

338

INTERVIEWER: IF THE RESPONDENT IS DEAF MARK WITH CODE 3 IN HEAR_1 AND THEN GO TO MOB_1. FOR THE OTHERS, ASK HEAR_1.

HEAR_1 [Do/Does] [you/he/she] use a hearing aid?

- Yes 1

- No 2

- I am profoundly deaf 3 → GO TO MOB_1.

SKIP OTHER HEARING QUESTIONS.

- Don't know 8

- Refusal 9

Statement 2 Interviewer read: “Please answer the following question according to your normal use of your hearing aid” HEAR_2 [Do/Does] [you/he/she] have difficulty hearing what is said in a conversation with one other person in a quiet room [If HEAR_1 = 1: even when using your hearing aid(s)]? Would you say… [Read response categories]

- No difficulty 1

- Some difficulty 2


- Cannot do at all / Unable to do 4 → GO TO MOB_1.

SKIP TO NEXT SECTION.

- Don't know 8

- Refusal 9 HEAR_3 [Do/Does] [you/he/she] have difficulty hearing what is said in a conversation with one other person in a noisier room [If HEAR_1 = 1: even when using your hearing aid(s)]? Would you say… [Read response categories]

- No difficulty 1

- Some difficulty 2



- Don't know 8

- Refusal 9

339

MOB_1 [Do/Does] [you/he/she] have difficulty walking 100 meters on level ground, that would be about the length of one football field or one city block [without the use of your aid]? Would you say… [Read response categories]

- No difficulty 1

- Some difficulty 2



- Don't know 8

- Refusal 9

NOTE: ALLOW NATIONAL EQUIVALENTS FOR 100 METRES.

MOB_2 [Do/Does] [you/he/she] have difficulty walking half a km on level ground, that would be the length of five football fields or five city blocks [without the use of your aid]? Would you say… [Read response categories]

- No difficulty 1

- Some difficulty 2



- Don't know 8

- Refusal 9

NOTE: ALLOW NATIONAL EQUIVALENTS FOR 500 METRES.

MOB_3 [Do/Does] [you/he/she] have difficulty walking up or down 12 steps without a stick, other walking aid, assistance or using the banister? Would you say… [Read response categories]

- No difficulty 1

- Some difficulty 2



- Don't know 8

- Refusal 9

340

SELF CARE ACTIVITIES Introduction 4 "Now I would like you to think about everyday personal care. Again, please ignore temporary problems. Here is a list of activities"

INTERVIEWER: HAND SHOW CARD 4 AND CODE ALL ACTIVITIES.

PC.1 Do you usually have difficulty doing any of these activities by yourself?

- No difficulty 1

- Yes, some difficulty 2

- Yes, a lot of difficulty 3

- I can't achieve it by myself 4

- Don't know 8

- Refusal 9

Activities PC.1

01 Feeding yourself └─┘

02 Getting in and out of a bed or chair └─┘

03 Dressing and undressing └─┘

04 Using toilets └─┘

05 Bathing or showering └─┘

INTERVIEWER: ‐ IF PC.1 = 2, 3 OR 4 FOR AT LEAST ONE ACTIVITY THEN READ STATEMENT 3 AND ASK PC.2 AND PC.3, ‐ IF PC.1 = 1, 8 OR 9 FOR ALL ACTIVITIES THEN GO TO PC.4.

Statement 3 Interviewer read: "Thinking about all personal care activities where you have difficulty in doing them by yourself…” PC.2 Do you usually have help?

- Yes, at least for one activity 1

- No, I do all these activities by myself 2

- Don't know 8

- Refusal 9

341

PC.3 Would you need help?


- No 2

- Don't know 8

- Refusal 9

PC.4 Do you give at least once a week apart from your profession a help or cares to one or more persons having a disease, affection or sustainable disability?

- Yes 1 → GO TO PC.5

- No 2 → GO TO THE NEXT MODULE

- Don't know 8 → GO TO THE NEXT MODULE

- Refusal 9 → GO TO THE NEXT MODULE

PC.5 Is (are) this or these person(s):

- Member(s) of your household 1

- Member(s) of your family but not belonging to your household 2

- Neighbour(s) 3

- Friends, relationships, etc 4

PC.6 How much time do you dedicate to this help or cares?

- At least once a week (but not everyday) 1

- Everyday less than 30 minutes 2

- Everyday from 30 minutes to 2 hours 3

- Everyday from 2 to less than 4 hours 4

- Everyday 4 hours or more 5

342

DOMESTIC ACTIVITIES

FILTER: THE QUESTIONS ARE ONLY ADDRESSED TO OLDER AGED RESPONDENTS: 60 +.

Introduction 5 Now I would like you to think about some household activities. Please ignore any temporary problems. Here is a list of activities.

INTERVIEWER: HAND SHOW CARD 5 AND CODE ALL ACTIVITIES.

HA.1 Do you usually have difficulty doing any of these activities by yourself?

- No difficulty 1

- Yes, some difficulty 2

- Yes, a lot of difficulty 3

- I can't achieve it by myself 4

- Don't know 8

- Refusal 9

INTERVIEWER: FOR EACH ACTIVITY FOR WHICH A DEGREE OF DIFFICULTY IS REPORTED (HA.1 = 2, 3, 4 OR 8) ASK HA.2.IF NO DIFFCULTY IS REPORTED FOR ALL ACTIVITIES (HA.1 = 1 OR 9) THEN GO TO INTRODUCTION 6.

HA.2 Why?

- Mainly, because of health state, disability or old age 1

- Mainly, because of other reasons (never tried to do it, etc.) 2

- Don't know 8

- Refusal 9

Activities HA.1 HA.2

01 Preparing meals └─┘ └─┘

02 Using the telephone └─┘ └─┘

03 Shopping └─┘ └─┘

04 Light or occasional heavy housework └─┘ └─┘

05 Managing medication └─┘ └─┘

06 Taking care of finances and everyday administrative tasks └─┘ └─┘

343

INTERVIEWER: ‐ IF HA.2 = 1 FOR AT LEAST ONE ACTIVITY THEN READ STATEMENT 4 AND ASK HA.3 TO HA.4. ‐ IF HA.2 = 2, 8 OR 9 FOR ALL ACTIVITIES THEN GO TO INTRODUCTION 6.

Statement 4 Interviewer read: “Thinking about all household activities where you have difficulty in doing them by yourself”. HA.3 Do you usually have help?


- No, I do all these activities by myself 2 → GO TO HA.5

- Don't know 8 → GO TO HA.5

- Refusal 9 → GO TO HA.5

HA.4 Would you need help?


- No 2

- Don't know 8

- Refusal 9

344

PAIN Introduction 6 Next question is about any physical pain you have had during the past 4 weeks. SF.1 Overall during the past four weeks, how much physical pain or physical discomfort did you have?

INTERVIEWER: HAND SHOW CARD 6 WITH THE POSSIBLE RESPONSES.

- None 1

- Mild 2

- Moderate 3

- Severe 4

- Extreme 5

- Don't know 8

- Refusal 9

MENTAL WELL‐BEING Introduction 7 Next questions are about how you feel and how things have been with you during the past 2 weeks. For each question, please give the answer that come closest to the way you have been feeling.

INTERVIEWER: HAND SHOW CARD 7 WITH THE POSSIBLE RESPONSES AND CODE THEM.

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Not at all Several Days


Nearly every day

Don’t know

Refusal

PHQ.1 Little interest or pleasure in doing things

1 2 3 4 8 9

PHQ.2 Feeling down, depressed or hopeless

1 2 3 4 8 9

PHQ.3 Trouble falling or staying asleep, or sleeping too much

1 2 3 4 8 9

345

PHQ.4 Feeling tired or having little energy 1 2 3 4 8 9

PHQ.5 Poor appetite or overeating 1 2 3 4 8 9

PHQ.6 Feeling bad about yourself‐or that you are a failure or have let yourself or your family down

1 2 3 4 8 9

PHQ.7 Trouble concentrating on things, such as reading the newspaper or watching television

1 2 3 4 8 9

PHQ.8 Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

1 2 3 4 8 9

346

EUROPEAN HEALTH DETERMINANTS MODULE

Introduction 8

The following questions focus on certain aspects of the lifestyle that influence health.

Now I'm going to ask you about your height and weight. BMI.1 How tall are you without shoes?

└─┴─┴─┘ cm

- Don't know 998

- Refusal 999

BMI.2 How much do you weigh without clothes and shoes?

└─┴─┴─┘ kg

- Don't know 998

- Refusal 999

Introduction 9 Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions even if you do not consider yourself to be a physically active person. Think first about the time you spend doing work. Think of work as the things that you have to do such as paid and unpaid work, work around your home, taking care of family, studying or training. PE.1 When you are WORKING, which of the following best describes what you do? Would you say—

INTERVIEWER INSTRUCTIONS: PLEASE HAND OUT SHOW CARD 8. IF RESPONDENT DOES MULTIPLE TASKS, INCLUDE ALL TASKS.

- Mostly sitting or standing 1

- Mostly walking 2

- Mostly heavy labour or physically demanding work 3

- Don’t know / Not sure 8

- Refused 9

347

The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way you TRAVEL TO AND FROM PLACES. For example to work, to school, for shopping, or to market. PE.2 In a typical week, on how many days do you WALK for at least 10 minutes continuously to get to and from places?

Number of days: ___

IF ZERO GO TO QUESTION PE.4

PE.3 How much time do you spend walking for travel on a typical day?

INTERVIEWER INSTRUCTIONS: PLEASE HAND OUT SHOW CARD 9.

- 10 ‐ 29 minutes per day 1


- 1 ‐ 2 hours per day 3


- 3 hours or more per day 5

PE.4 In a typical week, on how many days do you BICYCLE for at least 10 minutes continuously to get to and from places?

INTERVIEWER INSTRUCTION: INCLUDE HERE ALSO THE USE OF OTHER NON MOTOR‐DRIVEN MEANS OF ACTIVE TRANSPORTATION SUCH AS SCOOTER, ROLLER OR SKATES ETC.

Number of days: ___

IF ZERO GO TO QUESTION PE.6

348

PE.5 How much time do you spend bicycling for travel on a typical day?

INTERVIEWER INSTRUCTIONS: PLEASE HAND OUT SHOW CARD 10.





- 3 hours or more per day 5

The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about SPORTS, FITNESS and RECREATIONAL ACTIVITIES (leisure) that causes AT LEAST a small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling or swimming.

INTERVIEWER INSTRUCTION: PLEASE HAND OUT SHOW CARD 11.

PE.6 In a typical week, on how many days do you do sports, fitness or recreational (leisure) activities for at least 10 minutes continuously?

Number of days: ___

IF ZERO GO TO THE NEXT SECTION.

PE.7 How much time do you spend in total doing sports, fitness or recreational activities in a typical week?


PE.8 In a typical week, on how many days do you do physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? Include all such activities even if you have mentioned them before.

INTERVIEWER INSTRUCTION: PLEASE HAND OUT SHOW CARD 12.

Number of days: ___

349

Introduction 10 Next questions concern the consumption of fruits and vegetables. FV.1 How often do you eat fruits (excluding juice)?

- Once or more a day 1 → GO TO FV.2

- Less than once a day but at least 4 times a week 2 → GO TO FV.3

- Less than 4 times a week, but at least once a week 3 → GO TO FV.3

- Less than once a week 4 → GO TO FV.3

- Never 5 → GO TO FV.3

- Don't know 8

- Refusal 9

FV.2 How many portions of fruit, of any sort, do you eat each day?

INTERVIEWER, PROBE (IF NECESSARY): A PORTION OF FRUIT CORRESPONDS TO :

- 1 APPLE, 1 BANANA, 1 ORANGE… OR - 2 PLUMS, 2 KIWIS, 7 STRAWBERRIES … OR - 1 SLICE OF PINEAPPLE OR MELON - ½ GRAPEFRUIT

A PORTION OF VEGETABLES CORRESPONDS TO A QUANTITY OF 200 GRAMMES OF PRODUCT.

Number └─┴─┘

FV.3 How often do you eat vegetables or salad (excluding juice and potatoes)?

- Once or more a day 1 → GO TO FV.4

- Less than once a day but at least 4 times a week 2 → END OF INTERVIEW

- Less than 4 times a week, but at least once a week 3 → END OF INTERVIEW

- Less than once a week 4 → END OF INTERVIEW

- Never 5 → END OF INTERVIEW

- Don't know 8

- Refusal 9

350

FV.4 How many portions of vegetables, excluding potatoes, do you eat each day?

Number └─┴─┘

END OF INTERVIEW

Starting time of questionnaire: ___ ___ : ___ ___

hrs mins

End time of questionnaire: ___ ___ : ___ ___

hrs mins

Date of interview: └─┴─┴─┴─┴─┴─┴─┴─┘ (ddmmyyyy)

351

SELF COMPLETION FORM

The questions have to be answered personally. Before giving an answer, read attentively the question and its response categories. Place an X in one box that best describes your answer to

each question or write figures in the open boxes ��.

Instructions following the sign "→" near a box indicate the question to which you should go after marking the answer into that box. In case that the marked box is not followed by the sign "→", you should go to the next question. Mark one box per question, unless suggested otherwise (i.e. „more answers are possible”). Your answers will remain confidential so please be honest.

QUESTIONS ON SMOKING SK.1 Do you smoke?

- Yes, daily 1

- Yes, occasionally 2

- Not at all 3

SK.3 On average, how many cigarettes do you smoke each day?

- Manufactured or hand‐rolled cigarettes └─┴─┘

- Doesn't smoke cigarettes 99

SK.6 How often are you exposed to tobacco smoke indoors at home?

- Never or almost never 1

- Less than 1 hour per day 2

- 1 hour or more a day 3

352

QUESTIONS ON DRINKING ALCOHOL Introduction The following questions are about your use of alcoholic beverages during the past 12 months. AL.1 During the past 12 months, how often (if ever) have you had an alcoholic drink of any kind, that is, beer, wine, cider, spirits, cocktails, premix, liqueurs, home made alcohol…? Cross your answer

Every day or almost ................................................................ 1

5 ‐ 6 days a week ................................................................... 2

3 ‐ 4 days a week .................................................................... 3

1 ‐ 2 days a week .................................................................... 4

2 ‐ 3 days in a month .............................................................. 5

Once a month......................................................................... 6

Less than once a month ......................................................... 7

Not in the past 12 months, as I no longer drink alcohol ........ 8

Never, or only a few sips or trials, in my whole life ............... 9

AL.2 Thinking of Monday to Thursday, on how many of these 4 days do you usually drink alcohol?

On all 4 days ............................................................................. 1

On 3 of the 4 days .................................................................... 2

On 2 of the 4 days .................................................................... 3

On 1 of the 4 days .................................................................... 4

On none of the 4 days .............................................................. 5

AL.3 Still thinking about Monday to Thursday, how many drinks do you have on average on ONE of these days when you drink alcohol?

16 or more drinks ..................................................................... 1

10 ‐ 15 drinks ............................................................................ 2

6 ‐ 9 drinks ............................................................................... 3

4 ‐ 5 drinks ............................................................................... 4

3 drinks .................................................................................... 5

2 drinks .................................................................................... 6

1 drink...................................................................................... 7

0 drink...................................................................................... 8

Go to AL.4

Go to AL.6

Go to AL.2

Go to next section

353

AL.4 Thinking of Friday to Sunday, on how many of these 3 days do you usually drink alcohol?

On all 3 days ............................................................................. 1

On 2 of the 3 days .................................................................... 2

On 1 of the 3 days .................................................................... 3

On none of the 3 days .............................................................. 4

AL.5 Still thinking about Friday to Sunday, how many drinks do you have on average on ONE of these days when you drink alcohol?

16 or more drinks ..................................................................... 1

10 ‐ 15 drinks ........................................................................... 2

6 ‐ 9 drinks ............................................................................... 3

4 ‐ 5 drinks ............................................................................... 4

3 drinks .................................................................................... 5

2 drinks .................................................................................... 6

1 drink ..................................................................................... 7

0 drink...................................................................................... 8

AL.6 During the past 12 months, how often (if ever) did you have 6 alcoholic drinks or more, even different, on one occasion (that is, during an evening, a party, a happening, alone, …)?

Every day or almost .................................................................. 1

5 ‐ 6 days a week ..................................................................... 2

3 ‐ 4 days a week ...................................................................... 3

1 ‐ 2 days a week ...................................................................... 4

2 ‐ 3 days in a month ................................................................ 5

Once a month........................................................................... 6

Less than once a month ........................................................... 7

Not in the past 12 months........................................................ 8

Never in my whole life.............................................................. 9

END OF QUESTIONNAIRE

Go to AL.6

354

DEBRIEFING QUESTIONNAIRE FOR RESPONDENTS “The questions we’ve been asking you are important for finding out about people’s health. We want to make these questions as clear and easy to answer as possible. We would like your help in making them better. In order to do this, I’d like to get some of your thoughts about a series of questions I asked you earlier”13.

INTERVIEWER: FOR THE DEBRIEFING QUESTIONNAIRE, DON’T FORGET TO PROVIDE FULL DETAILS/FINDINGS FROM THE PROBES.

QUESTIONS ON DRINKING ALCOHOL [SHOW CARD?]

1. In regards to the alcohol consumption section, what did you think about the wording of the questions?

very easy to grasp

easy to grasp neutral hard to grasp very hard to grasp

Notes: ___________________________________________________________________________

2. From the top of your head, was there any particular question you felt was more difficult to understand than others? Why? (More than one answer is possible)

_________________________________________________________________________________

3. In regards to the alcohol consumption section, was it easy or difficult to calculate the frequency and the amount of alcohol you usually drink?

very easy to calculate

easy to calculate neutral difficult to calculate

very difficult to calculate

13 This introduction was taken from Oksenberg, L., Cannell, C., Kalton, G. (1991) New Strategies for Pretesting

Survey Questions, Journal of Official Statistics, 7 (3), pp.349‐365.

355

Notes: ___________________________________________________________________________

4. From the top of your head, was there any particular question where you felt it was more difficult to provide an answer than others? Why? (More than one answer is possible)

__________________________________________________________________________________

__________________________________________________________________________________

5. In regards to the alcohol consumption section, were you able to choose answer categories that accurately represent your current drinking patterns?

they did fully represent my

state

they did almost represente my

state neutral

they did rather not represent my

state

they did not at all represent my state

Notes: ___________________________________________________________________________

6. Did you refer to the show card in order to estimate your consumption (the number of alcoholic drinks)?

Yes

No GO TO QUESTION 8

7. If yes, did it had an impact on the amount you reported? Why?

Yes No

Notes: ____________________________________________________________________________

356

QUESTIONS ON PSYCHOLOGICAL/MENTAL WELL‐BEING

8. In regards to the mental health section, what did you think about the wording of the questions?

very easy to grasp


Notes: ___________________________________________________________________________

9. From the top of your head, was there any particular statement you felt was more difficult [to understand, to answer, etc.] than others? Why? (More than one answer is possible)

_________________________________________________________________________________

10. In regards to the mental health section, was it easy or difficult to keep the reference period in mind (two weeks) while answering to the questions?

very easy easy neutral difficult very difficult

Notes: ___________________________________________________________________________

357

11. In regards to the mental health section, were you always able to choose an answer category that fully represents your current state? [If not always, ask for examples]

I was always able to choose an

answer that fully represent my

state

I was often able to choose an answer that fully represent

my state

I was sometimes able to choose an answer that fully represent

my state

I was rarely able to choose an

answer that fully represent my

state

I was never able to choose an answer

that fully represent my state

Notes:

Examples _______________________________________________________________________

358

PHYSICAL ACTIVITY SECTION [SHOW CARD?] 12. In regards to the physical activity section, what did you think about the wording of the

questions?

very easy to grasp


13. From the top of your head, was there any particular question you felt was more difficult [to understand, to answer, etc.] than others? Why? [More than one answer is possible]

_________________________________________________________________________________

14. Was it easy or difficult to use the different show cards? [If difficult, ask why/examples]

very easy to use easy to use neutral difficult to use very difficult to use

Notes: Examples________________________________________________________________________

15. In regards to the physical activity section, was it easy or difficult to calculate the number of days spent on physical activity in a typical week? [If difficult, ask why/examples]




Notes: Examples________________________________________________________________________

359

16. In regards to the physical activity section, was it easy or difficult to calculate the time spent on physical activity? [If difficult, ask why/examples]




Notes: Examples________________________________________________________________________

17. In regards to the entire section, were you able each time [when asked for] to choose an answer category that accurately describes what you do? [If not fully, ask for examples]

answers provided did fully correspond to

my state

answers provided did almost

correspond to my state

neutral

answers provided did rather not


answers provided did not at all


Notes: Examples_______________________________________________________________________

360

SHOW CARDS

SHOW CARD 1

Asthma (allergic asthma included)

Chronic bronchitis, chronic obstructive pulmonary disease, emphysema

Myocardial infarction

Coronary heart disease (angina pectoris)

High blood pressure (hypertension)

Stroke (cerebral haemorrhage, cerebral thrombosis)

Osteoarthritis

Low back disorder or other chronic back defect

Neck disorder or other chronic neck defect

Diabetes

Allergy, such as rhinitis, eye inflammation, dermatitis, food allergy or other (allergic asthma excluded)

Cirrhosis of the liver, liver dysfunction

Urinary incontinence, problems in controlling the bladder

Depression

SHOW CARD 2

Type of accident

Road traffic accident

Home accident

Leisure accident

361

SHOW CARD 3

Answers

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all / Unable to do

SHOW CARD 4

Activities

Feeding yourself

Getting in and out of a bed or chair

Dressing and undressing

Using toilets

Bathing or showering

362

SHOW CARD 5

Activities

Preparing meals

Using the telephone

Shopping

Light or occasional heavy housework

Managing medication

Taking care of finances and everyday administrative tasks

SHOW CARD 6

Answers

None

Mild

Moderate

Severe

Extreme

SHOW CARD 7

Answers

Not at all Several Days

More than half the days Nearly every day

363

SHOW CARD 8: WORK‐RELATED PHYSICAL ACTIVITY

Mostly sitting or standing

Physically inactive tasks such as desk work, reading, writing, drawing, talking or talking on phone, teaching, playing guitar, piano or flute, or using computer etc.

Mostly walking

OR tasks of light to moderate effort such as electrical work, plumbing, automobile repair, machine tooling, cleaning, vacuuming, washing dishes, shopping, playing with children, carrying light things, or watering lawn or garden etc.

Mostly heavy labour or physically demanding work

Strenuous tasks such as using heavy power tools, construction work, mining, carrying heavy things, loading, stacking or chopping wood, cleaning land, shovelling or digging, spading, or filling garden etc.

364

SHOW CARDS 9 ‐ 10

Answers

10 ‐ 29 MINUTES PER DAY

30 ‐ 59 MINUTES PER DAY

1 ‐ 2 HOURS PER DAY

2 ‐ 3 HOURS PER DAY

3 HOURS OR MORE PER DAY

365

SHOW CARD 11: SPORTS, FITNESS, RECREATIONAL PHYSICAL ACTIVITY

Sports, fitness, recreational activities

Leisure‐time activities that causes AT LEAST a small increase in breathing or heart rate such as brisk walking, ball games, jogging, cycling or swimming, lifting weights or doing calisthenics

SHOW CARD 12: MUSCLE‐STRENGTHENING ACTIVITIES


Physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics

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