Increasing health examination survey participation rates by SMS reminders and flexible examination times

HBM4EU feasibility studies: Lessons learned in combining health and human biomonitoring studies

BACKGROUND

The European Human Biomonitoring Initiative (HBM4EU) is a joint program evaluating humans' exposure to several environmental substances and their potential health effects. One of the main objectives of HBM4EU is to make use of human biomonitoring (HBM) to assess human exposure to chemicals in Europe to better understand the associated health impacts and to improve chemical risk assessment. In parallel to HBM studies, health examination surveys (HESs), nutrition/dietary surveys, and disease specific health surveys are conducted in many European countries. In HESs, information collected by questionnaire(s) is supplemented with physical examinations and analysis of clinical and biological biomarkers in biological samples. HBM and health examination survey (HES) use similar data collection methods and infrastructures hence the feasibility of combining these two is explored in this paper.

METHODS

Within HBM4EU, three feasibility studies (in Finland, Germany, and UK/England) were conducted to evaluate opportunities and obstacles of combining HBM and health studies. In this paper we report lessons learned from these feasibility studies.

RESULTS

The Finnish feasibility study called KouBio-KUOPIO study was a new initiative without links to existing studies. The German feasibility study added a HBM module to the first follow-up examination of the LIFE-Adult-Study, a population-based cohort study. The UK feasibility integrates a sustainable HBM module into the Health Survey for England (HSfE), an annual health examination survey. Benefits of combining HBM and HESs include the use of shared infrastructures. Furthermore, participants can receive additional health information from HES, and participation rates tend to be higher due to the potential to obtain personal health information. Preparatory phases including obtaining ethical approval can be time-consuming and complicated. Recruitment of participants and low participation rates are common concerns in survey research and therefore designing user-friendly questionnaires with low participant burden is important. Unexpected events such as the COVID-19 pandemic can cause substantial challenges and delays for such studies. Furthermore, experiences from several countries demonstrated that long-term funding for combined studies can be difficult to obtain.

CONCLUSIONS

In the future, incorporating HBM modules into existing HESs can provide a feasible and cost-effective method to conduct HBM studies and obtain a wide range of relevant data to support public health policies and research.

Automated Text Messaging During COVID-19: Patient Feedback to Increase Adoption

Automated text messaging interventions can effectively improve self-care and were used to support the U.S. Veterans Health Administration's (VHA) public health outreach during the COVID pandemic. Currently, significant gaps exist in knowledge about VHA patients' texting protocol preferences that may impact user receptivity, engagement, and effectiveness. This study qualitatively evaluated patient suggestions to improve two VHA Covid-related texting interventions and preferences for future text message protocols. We reviewed cross-sectional type-written survey responses from patients receiving either the "Coronavirus Precautions" or the "Coping During COVID" multi-week text protocols. Two team members independently and inductively coded all responses allowing for an upward abstraction of qualitative data. Nine hundred five patients (72.8% male) responded to the open-response item questions targeted by this research. An item that sought feedback to improve protocol acceptability generated thirteen distinct descriptive categories (inter-rater reliability 83.5%). Codable feedback showed, for example, that patients desired to manipulate message frequency and to have a more sophisticated interaction with messages. Patients' suggestions for future automated text messaging protocols yielded nine distinct topic areas. Patients offered suggestions that may impact receptivity and engagement of future automated text message protocols, particularly as they relate to outreach during a public health crisis. In addition, patients offered specific topics they would like to see in future text message protocols. We discuss how the findings can be used to increase engagement in current and post-pandemic public health interventions.

Developing and Piloting a Standardized European Protocol for Hepatitis C Prevalence Surveys in the General Population (2016-2019)

Background: A robust estimate of the number of people with chronic hepatitis C virus (HCV) infection is essential for an appropriate public health response and for monitoring progress toward the WHO goal of eliminating viral hepatitis. Existing HCV prevalence studies in the European Union (EU)/European Economic Area (EEA) countries are heterogeneous and often of poor quality due to non-probability based sampling methods, small sample sizes and lack of standardization, leading to poor national representativeness. This project aimed to develop and pilot standardized protocols for undertaking nationally representative HCV prevalence surveys in the general adult population. Methods: From 2016 to 2019 a team from the Robert Koch-Institute contracted by the European Centre for Disease Prevention and Control synthesized evidence on existing HCV prevalence surveys and survey methodology and drafted a protocol. The methodological elements of the protocol were piloted and evaluated in Bulgaria, Finland and Italy, and lessons learnt from the pilots were integrated in the final protocol. An international multidisciplinary expert group was consulted regularly. Results: The protocol includes three alternative study approaches: a stand-alone survey; a "nested" survey within an existing health survey; and a retrospective testing survey approach. A decision algorithm advising which approach to use was developed. The protocol was piloted and finalized covering minimum and gold standards for all steps to be implemented from sampling, data protection and ethical issues, recruitment, specimen collection and laboratory testing options, staff training, data management and analysis and budget considerations. Through piloting, the survey approaches were effectively implemented to produce HCV prevalence estimates and the pilots highlighted the strengths and limitations of each approach and key lessons learnt were used to improve the protocol. Conclusions: An evidence-based protocol for undertaking HCV prevalence serosurveys in the general population reflecting the different needs, resources and epidemiological situations has been developed, effectively implemented and refined through piloting. This technical guidance supports EU/EEA countries in their efforts to estimate their national hepatitis C burden as part of monitoring progress toward the elimination targets.

Prevalence of hepatitis C in the adult population of Bulgaria: a pilot study

Objective

This study piloted a European technical protocol for conducting chronic hepatitis C prevalence surveys in the general population. The pilot study took place in the Bulgarian city of Stara Zagora in 2018, and results of setting up, conducting and evaluating the survey are presented.

Results

A probability-based sample of the general adult population was drawn from the local population registry, stratified by age and sex. A sample size of 999 was calculated, and accounting for 50% non-response, 1998 registered invitation letters were sent. Venous blood samples and questionnaire data were collected by the Regional Health Inspectorate in Stara Zagora. Blood samples were tested for anti-HCV, and if reactive for RNA. 252 (21.6%) of the participants were included in the study. Mean age and sex distribution differed between the participants (55.9 years, 60.3% females) and the total sample (48.9 years, 53.4%). The weighted chronic HCV prevalence among participants was 0.9% [95% CI 0.2–4.2%]. The approach of only sending registered letters contributed to a low response rate, and more efforts are needed to reduce non-response, especially among men and younger age groups. Results of the evaluation were integrated in the final technical protocol.

Recommendations for design and analysis of health examination surveys under selective non-participation

Background

The decreasing participation rates and selective non-participation peril the representativeness of health examination surveys (HESs).

Methods

Finnish HESs conducted in 1972-2012 are used to demonstrate that survey participation rates can be enhanced with well-planned recruitment procedures and auxiliary information about survey non-participants can be used to reduce selection bias.

Results

Experiments incorporated to pilot surveys and experience from previously conducted surveys lead to practical improvements. For example, SMS reminders were taken as a routine procedure to the Finnish HESs after testing their effect on a pilot study and finding them as a cost-effective way to increase participation rate especially among younger age groups. Auxiliary information about survey non-participants can be obtained from many sources: sampling frames, previous measurements in longitudinal setting, re-contacts and non-response questionnaires, and record linkage to administrative data sources. These data can be used in statistical modelling to adjust the population level estimates for the selection bias. Information on the characteristics of non-participants also helps to improve targeting the recruitment in the future.

Conclusion

All methods discussed and recommended are relatively easy to incorporate to any national HES in Europe except the record linkage of survey data from administrative data sources. This is not feasible in all European countries because of non-existence of registries, lack of an identifier needed for record linkage, or national data protection legislation which restricts the data use.

Field Testing of the Use of Intake24-An Online 24-Hour Dietary Recall System

Dietary assessment is important for monitoring and evaluating population intakes. Online tools can reduce the level of participant burden and the time taken to complete records, compared with other methods. The study aimed to field test an online dietary recall tool (Intake24) to test the suitability for collecting dietary information in Scottish national surveys and to develop the system based on feedback and emerging issues. Previous Scottish Health Survey participants, aged 11+ years, were invited to complete Intake24 and provide feedback about it. Of those who agreed to take part, 60% completed at least one recall. Intake24 was found to be user-friendly, enjoyable to use, and easy to follow and understand. Users agreed they would like to use Intake24 often, (44% compared with 15% who disagreed) and >75% felt the system accurately captured their dietary intakes. The main challenge reported was finding foods within the database. Of those completing fewer recalls than requested, the majority reported that they believed they had completed the required number or reported not receiving emails requesting they complete a further recall. Intake24 was found to be a user-friendly tool allowing dietary assessment without interviewer presence. Feedback indicated the method for recall reminders needs to be refined and tailored.

Using text message reminders in health care services: A narrative literature review

INTRODUCTION

Despite the extensive use of mHealth behavior change interventions, questions remain about the use of technology-based reminders in delivering health care services. Text messaging, or short message service (SMS), is one reminder method that has been extensively researched. Most SMS-reminder research is distributed across a range of health care outcomes. The aim of this article is to systematically review the aggregate impact of these reminders on overall health care outcomes.

METHODS

A systematic literature review was conducted and yielded 2316 articles. Studies were included if they used SMS reminders to support patient health care outcomes. Study methodology was aligned with the PRISMA guidelines for systematic reviews.

RESULTS

Following screening, 162 articles met inclusion criteria. Of these studies, 93 investigated medical compliance reminders and 56 investigated appointment reminders. The review found that nearly all the SMS-reminder studies helped improve patient medical compliance and appointment reminders. Additionally, researchers reported numerous benefits from using SMS reminders, including ease of use, relative inexpensiveness, and rapid and automated message delivery. Minimal risks were reported and most participants found the reminders to be acceptable.

DISCUSSION

Text messages appear to be an effective reminder mechanism to promote improved patient appointment and medical compliance. Reminders should continue to be evaluated and improved to determine the most effective timing and frequency of messages for improving outcomes.

Asthma management practices in adults--findings from the German Health Update (GEDA) 2010 and the German National Health Interview and Examination Survey (DEGS1) 2008-2011

OBJECTIVES

In Germany, population-wide data on adherence to national asthma management guidelines are lacking, and performance measures (PM) for quality assurance in asthma care are systematically monitored for patients with German national asthma disease management program (DMP) enrollment only. We used national health survey data to assess variation in asthma care PM with respect to patient characteristics and care context, including DMP enrollment.

METHODS

Among adults 18-79 years with self-reported physician-diagnosed asthma in the past 12 months identified from a recent German National Health Interview Survey (GEDA 2010: N = 1096) and the German National Health interview and Examination Survey 2008-2011 (DEGS1: N = 333), variation in asthma care PM was analyzed using logistic regression analysis.

RESULTS

Overall, 38.4% (95% confidence interval: 32.5-44.6%) of adults with asthma were on current inhaled corticosteroid therapy. Regarding non-drug asthma management, low coverage was observed for inhaler technique monitoring (35.2%; 31.2-39.3%) and for provision of an asthma management plan (27.3%; 24.2-30.7%), particularly among those with low education. Specific PM were more complete among persons with than without asthma DMP enrollment (adjusted odds ratios ranging up to 10.19; 5.23-19.86), even if asthma patients were regularly followed in a different care context.

CONCLUSIONS

Guideline adherence appears to be suboptimal, particularly with respect to PM related to patient counseling. Barriers to the translation of recommendations into practice need to be identified and continuous monitoring of asthma care PM at the population level needs to be established.

Sample selection, recruitment and participation rates in health examination surveys in Europe--experience from seven national surveys

Background

Health examination surveys (HESs), carried out in Europe since the 1950’s, provide valuable information about the general population’s health for health monitoring, policy making, and research. Survey participation rates, important for representativeness, have been falling. International comparisons are hampered by differing exclusion criteria and definitions for non-response.

Method

Information was collected about seven national HESs in Europe conducted in 2007–2012. These surveys can be classified into household and individual-based surveys, depending on the sampling frames used. Participation rates of randomly selected adult samples were calculated for four survey modules using standardised definitions and compared by sex, age-group, geographical areas within countries, and over time, where possible.

Results

All surveys covered residents not just citizens; three countries excluded those in institutions. In two surveys, physical examinations and blood sample collection were conducted at the participants’ home; the others occurred at examination clinics. Recruitment processes varied considerably between surveys. Monetary incentives were used in four surveys. Initial participation rates aged 35–64 were 45 % in the Netherlands (phase II), 54 % in Germany (new and previous participants combined), 55 % in Italy, and 65 % in Finland. In Ireland, England and Scotland, household participation rates were 66 %, 66 % and 63 % respectively. Participation rates were generally higher in women and increased with age. Almost all participants attending an examination centre agreed to all modules but surveys conducted in the participants’ home had falling responses to each stage. Participation rates in most primate cities were substantially lower than the national average. Age-standardized response rates to blood pressure measurement among those aged 35–64 in Finland, Germany and England fell by 0.7-1.5 percentage points p.a. between 1998–2002 and 2010–2012. Longer trends in some countries show a more marked fall.

Conclusions

The coverage of the general population in these seven national HESs was good, based on the sampling frames used and the sample sizes. Pre-notification and reminders were used effectively in those with highest participation rates. Participation rates varied by age, sex, geographical area, and survey design. They have fallen in most countries; the Netherlands data shows that they can be maintained at higher levels but at much higher cost.

Differences in participation rates and lessons learned about recruitment of participants--the European Health Examination Survey Pilot Project

AIMS

In the 1980s, participation rates in health interview and health examination surveys were around 80% while now they are around 50-60%. There is also evidence that non-participation is selective. Low participation rates and selective non-participation may cause bias to our survey results based on participants alone. We aim to increase knowledge on cultural differences in acceptance and feasibility of different recruitment methods.

METHODS

The European Health Examination Survey Pilot Project, conducted in 2009-2012, included pilot surveys in 12 countries among people aged 25-64 years. Information about recruitment methods and participation rates in these surveys was collected.

RESULTS

Participation rates ranged from 16% to 57% for men and from 31% to 74% for women, where in most surveys women had higher participation rates than men. A variety of recruitment and promotion methods were used to obtain as high participation rates as possible. Combinations of phone calls, invitation letter and home visits were used to recruit invitees. Obtaining valid phone numbers for survey invitees was difficult in several countries. Incentives, websites and promotion in local media were used to promote the surveys.

CONCLUSIONS

The European Health Examination Survey Pilot surveys showed that obtaining a participation rate above 50% for a representative population sample is possible but it requires hard work and a well-planned recruitment strategy. Recruitment methods used in one country may not be possible to use in another country due to cultural norms and national regulations.