SHORT REPORT

Feasibility and yield of a self-administeredquestionnaire for health risk appraisalin older people in three EuropeancountriesANDREAS E. STUCK1, P. ELKUCH1, U. DAPP

2, J. ANDERS2, S. ILIFFE3, CAMERON G. SWIFT

4

FOR THE PRO-AGE PILOT STUDY GROUP�

1Department of Geriatrics and Rehabilitation, Spital Bern Ziegler, Morillonstr. 75, 3001 Bern, Switzerland2Albertinen-Haus Geriatrics Centre Hamburg, Sellhopsweg 18–22, D-22459 Hamburg, Germany3Department of Primary Care and Population Sciences, Royal Free and University College Medical School,Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK

4Department of Health Care of the Elderly, GKT School of Medicine, East Dulwich Grove, London SE22 8PT, UK

Address correspondence to: A. E. Stuck. Fax: (q41) 31 970 7767. Email: Andreas.Stuck@spitalbern.ch

Abstract

Objective: to test the feasibility of a self-administered questionnaire for health risk appraisal in older people.Methods: a scientifically updated and culturally adapted English and German language version of the Health RiskAppraisal for Older Persons self-administered questionnaire identifying risk factors for functional impairment in olderpeople was administered to three samples of older people (UK: Urban-based general practitioner list, n=348;Switzerland: Community-based lists in rural/suburban area, n=213; Germany: Occupants of residential care facilities,n=149).Results: the majority of people judged the questionnaire as easy to comprehend (UK 81.4%; Switzerland 97.2%;Germany 93.1%) and to complete (83.2%, 95.8%, 91.4%). Prevalence of risk factors was higher than 10% at each sitefor excessive fat intake (25–54%), lack of social activity (15–47%), low physical activity (28–46%), impaired vision(17–38%), impaired hearing (23–25%), and urinary incontinence (13–37%). Uptake of recommended preventive healthmeasures, including screening and vaccination was below 50% in more than half of recommended items, with largevariations between sites.Discussion: acceptance of the adapted Health Risk Appraisal for Older Persons questionnaire was high and itsfeasibility supported. The findings identified a high prevalence of potentially modifiable risk factors for ill health anddisability in older people with large variations in prevalence rates and awareness between sites. The yield supports thefurther development and evaluation of the approach.

Keywords: aged, prevention, health promotion, health risk appraisal, risk factor

Introduction

Health and social care services required by older peopleare a growing burden and a major societal challenge for

this century. Developing methods for cost-effectiveprevention of disability among older people has there-fore a high priority [1–4]. There is promising evidenceof the effects of health risk appraisal in older people.

�Members of the PRO-AGE (PRevention in Older people – Assessment in

GEneralists’ practices) pilot study group are: H. P. Meier-Baumgartner,

U. Dapp, J. Anders, N. Lubke (Albertinen-Haus Geriatrics Centre Hamburg,

Sellhopsweg, Hamburg, Germany); C. Swift, D. Harari (Department of Health

Care of the Elderly, GKT School of Medicine, East Dulwich Grove, London,

UK); S. Iliffe, K. Kharicha (Primary Care and Population Sciences, London,

UK); A. E. Stuck, P. Elkuch, S. Born, T. Munzer, M. Bachmann, Th. Conzett,

R. Ludwig (Department of Geriatrics and Rehabilitation, Spital Bern Ziegler,

Bern, Switzerland); S. Goetz (Inselspital, Bern, Switzerland); C.E. Minder,

G. Gillmann (Biostatistical Division, Department of Social and Preventive

Medicine, University of Bern, Switzerland); J. C. Beck (UCLA School of

Medicine, University of California, Los Angeles, USA)

Age and Ageing 2002; 31: 463–467 # 2002, British Geriatrics Society

463

A longitudinal cohort study revealed a beneficial impactof a mailed health risk appraisal programme onself-reported health risk behaviour in older people, over30 months [5]. A randomized study revealed favourableeffects on health behaviour in older people and adecrease of health care costs with an interventionprogramme consisting of health habit questionnaires,personal recommendation letters and self-managementmaterial over a one-year follow-up period [6]. Further-more, none of the previous studies was conducted inEurope, [5–8], and little is known about the feasibilityof conducting health risk appraisal in a Europeancontext.

The aims of the present study, as part of a longer-term investigation, were (i) to test the feasibility of aself-administered health risk appraisal questionnaire forolder people in Europe and (ii) to determine whether theprevalence of the selected risk factors for functionalimpairment is sufficiently high to justify inclusion of themultiple domains.

Methods

Health Risk Appraisal for Older Peoplequestionnaire

The Health Risk Appraisal for Older People (HRA-O)instrument used in this study is an updated and regionallyadapted version of an instrument that was initiallydeveloped by University of California researchers [9]. Insummary, the original development was based on a sys-tematic literature search, focus group sessions, and pilottesting of several prototype versions. Criteria for selec-tion of risk factor domains in the questionnaire included:(1) magnitude of effect and potential impact on func-tional impairment; (2) validity and generalizability ofresults; (3) potential for risk reduction; and (4) feasibi-lity of assessment. For each selected risk factor, aself-administered instrument was selected based on thefollowing instrument criteria: (1) reliability; (2) validity;(3) feasibility; and (4) use of the instrument in other largedatabases. The HRA-O instrument consists of threecomponents: (i) a 32-page self-administered question-naire; (ii) a personalised feedback report to the olderperson; and (iii) a personal summary report for thehealth care provider of the older person. For generatingthe feedback reports, a software system was developedthat provides individual feedback statements.

The HRA-O questionnaire contains the followingsections: administrative information (name, address,date of birth, date of completion, duration for comple-tion); self-reported chronic conditions, preventive careuse [9], medication use, signs and symptoms [10, 11], self-perceived health [9], physical activity [12], nutrition [13],injury prevention [14], tobacco use [9], alcohol use[15], eyesight [16], hearing [17], depressive symptoms

[18], self-reported memory [19], social network [20],social support [21], basic and instrumental activities ofdaily living [22, 23], socio-economic information (educa-tion, professional activity), health measurements (weight,height, blood pressure, cholesterol), and feed-backquestions to the HRA-O questionnaire.

Update, translation, and adaptation ofquestionnaire

The update and cultural adaptation was conducted in foursteps. In Step 1, the questionnaire and feedback reportswere updated to correspond to the most recent evidence,and the software programme was modified to facilitatehandling multiple languages. In Step 2, the questionnaireand the feedback statements were translated intothe German language by a professional translator, thentranslated back to the English language by a secondtranslator who was blinded for the original version. Theback-translation was compared with the original version,and discrepancies were resolved by a third independenttranslator. In Step 3, for each region, the questions andstatements were regionally adapted by focus groups ofprofessionals and older people. In the final Step 4, theresulting prototype version of HRA-O was pilot testedin 20 people in each site and again discussed in focusgroup meetings.

Recruitment of the three study samples

The study was approved by the local institutional ethicalcommittees. To assess feasibility in different subgroupsof older people, each site chose a different sourcepopulation to administer the field test. The primarypurpose of the study was to evaluate the acceptanceand yield of the instrument in a broad range of olderpeople rather than to collect representative samples fromthree countries for cross-national comparison. In theUK, the sample was drawn from urban-based generalpractitioner list; in Switzerland, from community-basedlists in a mixed rural and suburban area; and in Germanyfrom a list of occupants of residential care facilities.The proportion of subjects agreeing to complete theHRA-O questionnaire was 58% in London, UK, 51%in Switzerland, and 57% in Germany. Details ofthe recruitment process are available on the Website(www.ageing.oupjournals.org).

Data collection and analysis

Participants were asked to complete the self-administeredHRA-O questionnaire and to return it to the regionalstudy centre. They were advised that they could ask afamily member or another proxy for help to fill out thequestionnaire, if needed. All participants received anindividualized health report from the study centre. Datawere analysed using the SAS programme [24].

A. E. Stuck et al.

464

Results

In each sample, more than 80% rated the questionnaire assomewhat easy or very easy to comprehend and tocomplete. In the UK practice-based sample, 27.3% statedthey completed the questionnaire with the assistanceof another person, compared to 9.4% in Switzerlandor 8.4% in Germany. The mean self-reported time tocomplete the questionnaire was longest in Switzerland(75.5"34.1 minutes) and shortest in the UK sample(50.6"33.0 minutes).

Table 1 shows the prevalence of risk factors relatedto health behaviour, social network, social support,

and functional impairment. The prevalence for each ofthe listed risk factors was higher than 5% in at leastone sample. In the UK sample the prevalence rate wasgreater than 20% for ten risk factors, 10–20% for five riskfactors and 5–10% for three risk factors. The Table alsoshows the large differences in prevalence rates betweensamples.

Table 2 summarizes the self-reported informationon use of recommended preventive care services. Therewas a low prevalence of use for most screening orvaccination recommendations. There were large differ-ences in uptake of preventive care in the three samples.For example, in the UK sample, 94.1% reported they

Table 1. Prevalence of possible risk factors for functional impairment in three samples of persons aged 65 years andolder (in order of risk factor prevalence in the UK sample)a

Questionnaire or instrument

Definition of risk factor

Urban primary care

practice registry Community-based registry Residential care

[Reference]

(London, UK)

(n=348)(Thal/Muri, Switzerland)

(n=213)(Hamburg, Germany)

(n=149). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cholesterol Reduction in

Seniors Program Fat Food

Screening Questionnaire [13]

Consumption of foods

with high fat contentb54.0% 45.1% 25.2%

Lubben Social Network Scale [20] Not engaged in social

activities (groups/

organizations)

47.0% 18.9% 15.3%

Physical Activity Scale for

the Elderly [12]

Low physical activityc 37.7% 27.7% 46.3%

Visual Functioning Questionnaire [16] Impaired visiond 32.3% 17.0% 37.8%

5-item Mental Health Inventory

Screening Test [18]

Depressive mood 31.2% 8.6% 28.0%

Health Risk Appraisal for

the Elderly [9]

Self-reported limitation

of activities due to

fear of falling

29.4% 22.2% 45.3%

Cholesterol Reduction in

Seniors Program Plant

Food Screening Questionnaire [13]

Low fibre diete 26.5% 6.6% 30.1%

Lubben Social Network Scale [20] High risk of social isolation 26.1% 2.9% 27.2%

Health Risk Appraisal for

the Elderly [9]

Driving without seat belt 25.8% 10.8% 4.6%

Hearing Handicap Inventory

for the Elderly [17]

Impaired hearing 23.1% 24.1% 25.4%

Memory Self Report [19] Memory problems 19.5% 3.8% 10.4%

The WHO Alcohol Use Disorders

Identification Test [15]

Possible hazardous

alcohol usef17.3% 9.4% 4.0%

Study of Osteoporotic Fractures

Research Group Survey [14]

History of repeated falls

in previous 12 months

15.0% 5.7% 14.9%

Partners in Prevention Tobacco

Use Questionnaire [9]

Current tobacco use 14.6% 10.8% 6.4%

Medical, Epidemiological and

Social Aspects of Aging

Project Questionnaire [11]

Urinary incontinence

on )5 days

during the last year

12.6% 25.8% 37.1%

Medical Outcomes Study Social

Support Survey [21]

Low level of emotional

support

9.2% 5.2% 9.9%

aDenominators vary due to missing values (London 295–335; Switzerland 210–213; Hamburg 124–148).bDefined as average consumption of more than 2 high-fat food items a day.cDefined as PASE-score (70 [12].dDefined as a problem in 01 subdomain of the Visual Functioning Questionnaire.eDefined as average consumption of less than 3 high-fibre food items a day.fBased on age- and gender-specific limits of quantity and frequency of self-reported alcohol use [15].

Feasibility and yield of health risk appraisal

465

had not had colon cancer screening (blood stool testwithin past year or colonoscopy or sigmoidoscopyover past 5 years), compared with 47.6% in Hamburg.In the German and Swiss samples, more than 90% ofsubjects reported they had no pneumococcal vaccinationcoverage.

Discussion

The results support the feasibility of this approach inthree European countries and indicate a substantial yieldin terms of risk appraisal. First, a high acceptance rate ofthis multidimensional health risk appraisal questionnairewas found in three diverse samples of older people ofdifferent nationalities. Second, prevalence rates for riskfactors included in the HRA-O questionnaire were high.

The limitations of the data in size and scope areacknowledged. The three samples are in no way repre-sentative of each of the three regions. Therefore, theobserved differences in prevalence rates of risk factorsare less likely to reflect regional variability than differentsubgroup variables at the three sites. Furthermore,given the selected subgroups of the population and theresponse rates between 50 and 60%, the figures mightnot be generalizable across the whole of the population.

Compared to several other HRA tools for olderpeople, the questionnaire used in this study was relativelylong [25]. A key concern, therefore, was the feasibilityof using a questionnaire of this size in older people.Although the majority of older people had no difficultycompleting the questionnaire, a minority of persons

reported some level of difficulty. Part of the develop-ment agenda for this and similar approaches, therefore,is to explore ways in which this group might be betterenabled to complete their responses. The use of self-administered questionnaires is also supported by findingsof the UK MRC trial of the assessment and managementof older people in the community [26]. Based on datafrom 32,990 people aged 75 years and older it was foundthat postal questionnaires produced a higher responserate than interviews by nurses or lay interviewers.

This study does not address additional factors thatare relevant for feasibility and impact of a health riskappraisal based programme. Other aspects include theacceptance of the HRA-O based feed-back system byolder persons and physicians, the proportion of olderpersons willing to participate in a preventive programmeof this type, and effects and costs of a HRA-O basedintervention. The prevalence findings support the rele-vance of further developing and implementing riskfactor modification programmes in Europe, with furtherdevelopment and testing of the health risk assessmentmethod.

Key points. Health risk appraisal combined with reinforcement of

recommendations has been shown to reduce riskfactors for functional decline in older people.

. This article describes an updated and regionallyadapted version of a multidimensional health riskappraisal instrument consisting of self-administered

Table 2. Self-reported use of preventive care in three samples of persons aged 65 years and oldera

Urban primary care practice registry Community-based registry Sheltered housing

(London, UK)

(n=348)(Thal/Muri, Switzerland)

(n=213)(Hamburg, Germany)

(n=149). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No blood pressure measurement

within the past year

16.4% 6.1% 6.7%

No cholesterol measurement

within the past 5 years

56.1% 19.7% 15.8%

No colon cancer screening 94.1% 65.7% 47.6%

No mammography within the

past 2 years (women only)b81.7% 82.3% N/A

No cervical smear within

past 3 years (women only)b68.7%c 52.8% 50.8%

No dental checkup within

the past year

45.4% 23.9% 27.9%

No vision checkup within

the past year

43.8% 34.7% 16.3%

No hearing checkup within

the past year

86.6% 68.5% 57.8%

No influenza vaccination within

the past year

40.5% 51.6% 38.4%

No pneumococcal vaccination ever 70.6% 95.3% 93.1%

aMissing information for -5% of respondents.bDenominator includes women only (UK, n=205; Switzerland, n=125; Germany, n=124).cIn London, women were asked for Pap smear within the past 5 years.

N/A - denotes not available (question not included in Hamburg version of questionnaire).

A. E. Stuck et al.

466

questionnaire and computer-generated reports forolder people and their general practitioners.

. Acceptance of this instrument was high among olderpeople, and it identified a high number of potentiallymodifiable risk factors for functional status decline.

. The effects of this approach are being evaluated inan ongoing multi-site randomized controlled study(PRO-AGE) in Hamburg, London, and Switzerland.

Acknowledgements

The present study was supported by grants of theEuropean Union (QLKK6-CT-1999–02205), the FederalEducation and Science Ministry (Berne, Switzerland,BBW 990311.1), the Swiss National Science Founda-tion (32.-52804.97), the Swiss Foundation for HealthPromotion (Project No. 398), and the Velux Foundation.The authors would like to thank Jim Gabriel and JerilynHiga for their contributions.

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Received 20 November 2001; accepted in revised form 25June 2002

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