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2. Questionnaires

This section deals with risk factors and their awareness that can be determined through questionnaires. The recommended questionnaires for smoking, socio-economic status, awareness and treatment of hypertension, awareness and treatment of high cholesterol, use of acetylsalicylic acid and use of hormone replacement therapy are provided. They collect all the information required for expressing the indicators listed in Part I

Each questionnaire is accompanied by explanation or rationale for some of the questions. Items are emphasized that need special attention when adapting the questionnaires to local situations.

As a general rule, readability of the questionnaire should not require an education of more than about eight years (Flesch-Kincaid Grade Level score of 8). The versions of the questions presented here meet this requirement with a readability score of about 8. Versions that are translated into another language should also try to meet this criterion.

2.1 Guidelines for administration of questionnaires

Survey questionnaires can be completed either by the respondent or by an interviewer. Both alternatives have their advantages and disadvantages. 

Self-administration of the questionnaire is cost effective but assumes that respondents are not visually impaired and have a good literacy level. It also requires that all questions are completely self-explanatory. Self-administration eliminates the interviewer effect but may result in missing data as a result of uncertainty about the question. A slight modification to the self-administration process deals with the problem of missing data by having the respondent complete the questionnaire at an examination centre where assistance is available, if required, and immediate review can take place. Self-administration provides more privacy for the respondent and is particularly suitable for sensitive questions.

Interviews are time consuming and carry additional labor costs, but they eliminate the issues of literacy level and visual impairment and they provide an opportunity for clarification, if questions are not well understood. However, the protocol for such clarifications has to be precisely prescribed to avoid biased responses. Interviews can be conducted either by telephone or face-to-face. Telephone interviews are less expensive but provide no control over the environment in which the interview is conducted. There is a risk that interviewers introduce bias by asking leading questions or incorrect prompting. This risk can be reduced, but not eliminated, by proper training.  

2.2 Smoking questionnaire

The recommended smoking questionnaire has two parts. The first part asks about the personal smoking history (SMK1-SMK7) and the second part about the exposure to environmental tobacco smoke (SMK8, SMK9).

The first four questions (SMK1-SMK4) provide the information for the primary indicators for smoking listed in Part I. SMK 6 enables the separate reporting of cigarette smoking, which may be desirable for compatibility with previous questionnaires that focused primarily on cigarette smoking. Question SMK4 does not directly address any of the listed indicators but gives important supplementary information for question SMK3. With question SMK4 the non-daily smokers who have stopped smoking just a few days before can be defined.

Questions SMK1-SMK7 should be kept together even if the smoking questionnaire is expanded for local purposes. An alternative place for the questions on exposure to environmental tobacco smoke (SMK8, SMK9) is in the beginning of the smoking questionnaire. The recommended place for adding possible additional questions is either after SMK7 if more questions about personal smoking history is asked or otherwise after SMK9.

In its main parts, the questionnaire is similar to the questionnaire recommended by the WHO (World Health Organization. Guidelines for controlling and monitoring the tobacco epidemic. World Health Organization, 1998.)

SMK1

Have you smoked at least 100 cigarettes, cigars or pipefuls in your lifetime?
1 = Yes
2 = No (Go to question SMK8)
3 = Uncertain (Go to question SMK8)

|__|
SMK2 Have you ever smoked daily (= almost every day for at least one year)?
1 = Yes 
2 = No (Go to question SMK8)
3 = Uncertain (Go to question SMK8)
|__|
SMK3 Do you now smoke?
1 = Yes, daily (Go to question SMK5)
2 = Yes, occasionally 
3 = Not at all 
|__|
SMK4 When did you stop smoking daily? (If you have quit smoking several times, give the time when you last stopped smoking daily?)
1 = Today or yesterday
2 = 2 days - 6 days ago
3 = 1 week - less than 1 month ago
4 = 1 month - less than 1 year ago
5 = 1 - 5 years ago
6 = More than 5 years ago 

Go to question SMK7

|__|
SMK5 On average, how many times do you smoke per day (= number of cigarettes, cigars, pipefuls of tobacco etc.)? |__||__||__|
SMK6 Which of the products do you frequently smoke? 
Manufactured cigarettes (1=yes, 2=no)
Self-rolled cigarettes (1=yes, 2=no)
Pipe (1=yes, 2=no)
Cigars (1=yes, 2=no)

|__|
|__|
|__|
|__|
SMK7 Have you during the past year (12 months) been advised by a health professional to stop smoking?
1 = Yes
2 = No
3 = I have not smoked during the past 12 months
|__|
SMK8 Are you exposed to indoor tobacco smoke at home?
1 = Yes
2 = No
|__|
SMK9 About how many hours per day are you exposed to indoor tobacco smoke at your workplace?
1 = I do not work outside the home
2 = Almost never
3 = Less than one hour a day
4 = 1-5 hours a day
5 = More than 5 hours a day
|__|

In question SMK1 the limit of 100 smokes in a lifetime is designed to identify those individuals that never progressed beyond being an experimental smoker.

The emphasis in question SMK6 is on frequent use of the various products, i.e. only those that are used at least several times per week should be indicated. Every daily smoker has to indicate at least one product. 

Local versions of the questionnaire should replace in SMK7 the term "health professional" with a list of professionals that are responsible for  advising people about health risk relating to smoking.

The term "indoor tobacco smoke" should be replaced by the commonly used local equivalent (e.g. second-hand smoke, passive smoke etc.).

2.3 Questionnaire about socio-economic status

For the assessment of socio-economic status three different sets of questions are used, one set for educational level, one for employment status and one for income.

For the educational level two questions are used. The categorized question SES2 was recommended by the EU Health Monitoring project "Socio-economic Inequalities in Health".

SES1 How many years in total have you spent in school or in full time study? |__||__|
SES2 What is your highest level of education?
1 = Primary education, or first stage of basic education, or less
2 = Lower secondary education, or second stage of basic education
3 = (Upper) secondary education
4 = Post-secondary non-tertiary education
5 = First stage of tertiary education
6 = Second stage of tertiary education
|__|
SES3 What is your current employment status?
1 = Employed
2 = Doing housework at home
3 = Student
4 = Retired/long-term disabled
5 = Unemployed
|__|
SES4a What is your net annual income?
1 = less than ??? €
2 = ???-??? €
3 = ???-??? €
4 = more than ??? €
|__|
SES4b What is your net monthly income?
1 =  less than ??? €
2 = ???-??? €
3 = ???-??? €
4 = more than ??? €
|__|
SES5 How many persons older than 18 years, including yourself, live in your household? |__||__|

In SES2 the categories should be named according to the educational system of the country. Typical characteristics of the listed levels are

Code  1 Primary education, or first stage of basic education, or less (level 1)
  • entry at the start of compulsory education (where it exists)
  • beginning of systematic study of reading, writing and mathematics
  • corresponds to first 6 years of 'basic education' (where it exists)
  • also includes literacy programs for those too old to enter elementary school
Code  2 Lower secondary education, or second stage of basic education  (level 2)
  • entry after some 6 years of primary education
  • full implementation of basic skills, and foundation for lifelong learning
  • several teachers conduct classes in their field of specialisation
  • end corresponds to the end of compulsory education (where it exists)
  • also includes remedial, special or adult education similar in content
Code  3 (Upper) secondary education (level 3)
  • minimum entrance requirements (usually completion of level 2)
  • includes both programmes designed to provide access to tertiary education and programmes designed to lead directly to labour market
  • more specialisation than at level 2
  • teachers need to be more qualified or specialised than at level 2
  • also includes special or adult education similar in contents
Code 4 Post-secondary non-tertiary education (level 4 )
  • admittance requires as a rule completion of level 3
  • typically, programmes aim to prepare students for studies at level 5, by broadening the knowledge of those who completed level 3
  • more specialisation and more complex applications than at level 3
  • a typical full-time duration of between 6 months and 2 years
  • also includes adult education such as a courses during professional life
Code 5 First stage of tertiary education (level 5)
  • admittance requires as a rule completion of level 3 or 4
  • programmes have a cumulative theoretical duration of at least 2 years
  • prorammes are theoretically based, research preparatory or give access to professions with high skill requirements
  • completion corresponds to Bachelor's degree (English speaking countries), 'Diplom' (German) or the Licence (French)
  • also includes adult education similar in content
Code 6 Second stage of tertiary education (level 6)
  • leads to the award of an advanced research qualification
  • programmes require the submission of the thesis or other product of original research

In SES4, monthly and annual income formats are presented. The version that is most common in a country should be used. If the monthly income format is used, instructions should be provided on how to document seasonally variable incomes. The quartiles  should be selected as quartiles of the national distribution of net personal incomes.  The reason for using personal vs. household income was that often not all members are sufficiently aware of the actual income of all other household members. Also, according to A. Kunst, plausible arguments can be made to justify personal income as one of the socio-economic markers.

2.4 Questionnaire about awareness and treatment of hypertension

Four questions are recommended for capture of awareness and treatment of hypertension. The purpose of the questions is to provide information on the prevalence of blood pressure measurements, the awareness of elevated blood pressure, and the treatment of hypertension in the population.

The increasingly important non-pharmacological treatment of hypertension is captured by HBP4, without attempting to establish the details of intervention.

HBP1 When was your blood pressure last measured by a health professional?
1 = Within the past 12 months
2 = 1-5 years ago
3 = Not within the past 5 years
|__|
HBP2 Have you been told by a health professional in the past year (12 months) that you have elevated blood pressure or hypertension?
1 = Yes 
2 = No 
3 = Uncertain
|__|
HBP3 Are you currently taking medication prescribed by a doctor to lower your blood pressure?
1 = Yes
2 = No
3 = Uncertain
|__|
HBP4 Has a doctor in the past year ordered you to change your way of life, in order to lower your blood pressure?
1 = Yes
2 = No
3 = Uncertain
|__|

Local versions of the questionnaire should replace in HBP1 and HBP2  the term "health professional" with the name of professions that are qualified to medically assess blood pressure level and that are in a position to initiate a link to further investigation and treatment. In most situations such a list will include doctors and nurses but may not be limited to these two professions.

Note: Casual blood pressure measurements in shopping centres, drug stores, etc. do not qualify under HBP1.

2.5 Questionnaire about awareness and treatment of high cholesterol

Three questions are recommended for assessing the awareness and treatment of high cholesterol. The purpose of the questions is to provide information about the coverage of blood cholesterol measurements in the populations, the awareness of the high cholesterol in the populations and the prevalence of treatment of elevated cholesterol in the population.

HCL1 When was your blood cholesterol last measured?
1 = Within the past 12 months
2 = 1-5 years ago
3 = Not within the past 5 years
|__|
HCL2 Have you been told by a health professional in the past year (12 months) that you have raised (elevated) blood cholesterol?
1 = Yes 
2 = No 
3 = Uncertain 
|__|
HCL3 Are you currently taking medication prescribed by a doctor to lower your blood cholesterol level?
1 = Yes
2 = No
3 = Uncertain
|__|
HCL4 Has a doctor in the past year ordered you to change your way of life, in order to lower your total blood cholesterol?
1 = Yes
2 = No
3 = Uncertain
|__|

Local versions of the questionnaire should replace the term "health professional" in HCL2  with the name of professions that are qualified to medically assess cholesterol level and that are in a position to initiate a link to further investigation and treatment. In most situations such a list will include doctors and nurses but may not be limited to these two professions.

2.6 Questionnaire about awareness and treatment of diabetes mellitus

Diabetes mellitus is a major chronic disease in its own right, but it is also an important confounder of cardiovascular risk factors. Although the problem of diabetes mellitus is addressed by  the ongoing project of the Health Monitoring Programme on Establishment of Indicators Monitoring Diabetes Mellitus and its Morbidity, we propose here a set of two questions that might be used by risk factor surveys that do not incorporate the full slate of questions of the Establishment of Indicators Monitoring Diabetes Mellitus and its Morbidity project.

DIAB1 Have you ever been told by a doctor that you have diabetes?
1 = Yes
2 = No
3 = Uncertain
|__|
DIAB2 Are you currently taking insulin or pills to control diabetes?
1 = Yes 
2 = No 
3 = Uncertain 
|__|

Local adaptations of these two questions might expand the term "diabetes" by adding more colloquial terms for the disease (e.g. sugar diabetes, sugar disease, etc.)

2.7 Use of acetylsalicylic acid (Aspirin)

One question is recommended to determine the use of acetylsalicylic acid for treatment or prevention of heart disease or stroke. 

ASP1 Are you currently taking Aspirin or equivalent acetylsalicylic acid containing medication to prevent or treat heart disease or stroke?
1 = Yes
2 = No
3 = Uncertain
|__|

Local versions of this question should replace the term "equivalent acetylsalicylic acid containing medication" with brand names (as examples) of Aspirin- equivalent drugs that are commonly used for the prevention and treatment of heart disease. 

If prevailing treatment practices justify it, a second question might be added to capture the use of other platelet activation inhibitors.

2.8 Use of hormone replacement therapy

Two questions, together with applying an age limitation, are recommended to determine the proportion of post-menopausal women in the population who use hormone replacement therapy.

Note: A question about pregnancy should appear together with examinations where pregnancy might be considered an exclusion criterion (e.g.  anthropometric measurements or blood collection).

For women only: 

WOM1 Have you had any periods during the past six months?
1 = Yes 
2 =  No 
3 = Uncertain
|__|
WOM2 Are you currently using hormone replacement therapy? 
1 = Yes 
2 = No 
3 = Uncertain
|__|

2.9 Quality assurance

2.9.1 Training of the interviewers before the survey

In the training of the interviewers following points should be made:

  1. When reading the questions:
    1. Questions should be read exactly as they are written.
    2. Questions should be read in the normal speed (not too fast nor too slowly).
    3. Skip rules of the questions should be followed. Only questions relevant for the respondent should be asked.
  2. The exact answer of the respondent should be coded. Interviewer is not allowed to make his/her own interpretations about the responses.
  3. If the respondent has difficulty in understanding the questions:
    1. The questions or part of it should be re-read as written.
    2. Probing should be used according to general instructions that are given to all interviewers.
  4. General behavior of the interviewer.
    1. Appearance and behaviour should be professional
    2. Interviewer should not show his/her reactions to the respondent's answers. 

2.9.2 Monitoring the interviewers during the survey

During the survey, the procedures of questionnaire administration should be audited at regular intervals. This may be done by auditors playing the role of guest respondents. If the questionnaire is administered by an interviewer, criteria for evaluation should cover exact reading of the question, adequate probing, but avoidance of suggestive probing. Questionnaires should also be reviewed for completeness, preferably on a daily basis. 

Recalls of a percentage of survey participants (e.g. 10%) to check correctness of interviewer obtained data is recommended.

2.9.3 Evaluating the questionnaires after the survey

After the survey is completed and data collection is finished it is important to assess the quality of the collected data. In this retrospective quality assessment, the consistency and plausibility of the collected information can be evaluated.


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