Estimating health needs: the impact of a checklist of conditions and quality of life measurement on health information derived from community surveys

BACKGROUND: Prevalence estimates of chronic disease vary according to the technique used. Questionnaire surveys may be susceptible to inaccuracies, which may be overcome by addition of a checklist of conditions. This paper presents SF-36 scores and NHS consultation rates for people reporting individual chronic diseases or disabilities in two questionnaire surveys, one of which employed a checklist and one of which did not. We aimed to document differences in estimates of disease prevalence, and to determine whether or not subjective impact on quality of life is the same in people recruited by a checklist as in those who volunteer that they have a chronic disease or disability without the prompt of a checklist. We use these data to estimate the contribution that different chronic diseases and disabilities make to the burden of disease in the community. METHODS: Data were collected in two postal questionnaire surveys conducted in 1991 and 1997 with response rates of 72 per cent and 64 per cent. Both questionnaires included a question on long-standing illness, disability or infirmity, together with the SF-36 health status measure. Respondents to the 1991 survey were asked to specify their illness in a free text response, whereas the 1997 survey offered a checklist of conditions. Prevalence rates of each condition were calculated, together with an 'escalation factor' representing the increase in reporting of specific diseases between the surveys. SF-36 domain and component summary scores were calculated overall and for the groups reporting individual chronic diseases or disabilities. Disease-specific NHS consultation rates were calculated for both surveys. RESULTS: The overall reported rate of chronic disease and disability increased from 28 per cent in 1991 to 42 per cent in 1997. Reported levels of mental health problems and of conditions with a perceived psychosomatic element increased substantially, whereas rates of well-defined conditions were similar. The pattern of SF-36 scores for those reporting chronic disease or disability was similar in the two surveys in spite of very different prevalence rates, and respondents reporting chronic disease had similar levels of health service use. This suggests that they were reporting conditions with similar levels of impact on quality of life. Heart disease, arthritis and mental health problems had the greatest impact on quality of life, and asthma and hypertension the least. CONCLUSIONS: Evidence from SF-36 scores and NHS consultation rates suggests that addition of a checklist of conditions to this community health survey encouraged reporting of illnesses by the genuinely ill and not merely by those who are less severely affected by their disease. This method appears to give a more accurate reflection of health needs than information derived from routine data sources. The combination of prevalence data combined with subjective assessment of quality of life allows an alternative perspective of health needs. This approach highlights the relative importance of musculo-skeletal problems, particularly back pain, and mental health problems to the burden of disease, and the relative lack of importance of conditions such as asthma. It presents a contrast to studies based on other methods of health needs assessment.     

Health status of people using complementary and alternative medical practitioner services in 4 English counties

OBJECTIVES: This study was undertaken to establish the health status of users of complementary and alternative medicine (CAM) services in England. METHODS: A postal questionnaire (response rate: 64%) covering long-standing illness, use of conventional medical and CAM services, and the United Kingdom Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) was sent to more than 14 000 adults in 4 counties. RESULTS: Sixty percent of CAM users reported having a chronic illness or disability; back pain and bowel problems were the conditions most commonly reported. Regardless of whether chronic illness was reported, CAM users reported poorer health than nonusers, particularly in the dimensions of pain and physical disability, and made more visits to general practitioners. CONCLUSIONS: In England, users of CAM services have poorer physical health than nonusers and make more frequent use of conventional medical services.     

The causes and consequences of injury in students at UK institutes of higher education

BACKGROUND: Injuries are the leading cause of mortality and also an important cause of permanent disability in young people living in developed countries. This study aimed to inform injury prevention programmes by assessing the incidence of injury and disabling injury, and identifying factors predicting injury in students at institutes of higher education, an under-researched group with regard to injury studies. METHODS: Secondary analysis of data obtained from a postal questionnaire survey of 1208 students at three institutions in the UK. RESULTS: Eighteen percent (222/1208) of students reported at least one injury requiring medical attention in the last year. Males and younger students were at greater risk, as were those who reported 'seeking out risky activities because they enjoyed potential danger'. Seventy-nine percent of reported injuries caused some degree of, at least temporary, disability. Four percent of students reported an injury in the last year that interfered with studies, work or other regular daily activities for at least 1 month. Team sports increased the risk of injury by a factor of 2.5 independently of age, gender and risk-taking attitudes. Sport/physical activity injuries were much more likely to be disabling than injuries attributable to other causes. CONCLUSIONS: There is a need for injury prevention programmes among students at institutes of higher education. Programmes need to disseminate the risk of disabling injury, particularly that attributable to participation in sport/physical activity. There is an urgent need for those working on injury prevention to collaborate with those working on other aspects of health promotion to define the net health gain from participation in sport/physical activity and to develop coherent public health messages.     

The Prevalence of Chronic Health Conditions Impacting on Daily Functioning and the Association With Emotional Well-Being Among a National Sample of High School Students

PurposeThis study aims to describe the prevalence of self-reported chronic health conditions among high school students in New Zealand, the extent to which the condition impacts on their activities and socialization, and to explore the association between the level of impact of the illness or disability and the emotional well-being of students with chronic health conditions.MethodsA two-stage cluster sample of 9,107 students (Years 9–13) from 96 New Zealand high schools participated in a 2007 health survey using internet tablets. Students were asked about any chronic illness or disabilities lasting more than 6 months, the impact of the illness or disabilities on their daily activities and socialization, and their depressive symptoms (RADS-SF) and emotional well-being (WHO-5).ResultsAlmost one in five students (18%) reported a chronic health condition. Among them, 28% reported an impact of their illness or disability on their activities, and 8% reported an impact on their ability to socialize. High levels of depressive symptoms were found among students with chronic health conditions reporting that their illness or disability impacts their activities (18%) or their ability to socialize (40%), and this was significantly higher than among students without chronic health conditions (10%).ConclusionsOur findings suggest that there is a large group of adolescents with chronic health conditions for whom their illness or disability has an impact on their daily activities and ability to socialize with their peers. These students are more likely to experience emotional distress and require support and opportunities for healthy youth development.     

Injury morbidity in 18-64-year-olds: impact and risk factors

BACKGROUND: Non-fatal injury is an important public health problem but is thought to be difficult to quantify. This study aimed to estimate the extent of disability attributable to injury in the working age population, and its impact on quality of life, as well as identifying factors associated with an increased risk of disabling and non-disabling injury. METHODS: Secondary analysis was carried out of data obtained from a postal questionnaire survey of 8889 18-64-year-olds randomly selected from computerized general practitioner records in Oxfordshire, Buckinghamshire, Berkshire and Northamptonshire. RESULTS: Sixteen per cent of survey respondents reported an injury requiring medical attention in the previous 12 months, 5 per cent reported an injury that had disabled them for more than 1 month, and a further 5 per cent a longstanding disability as a result of injury. The point prevalence of disability as a result of injury was estimated to be 6.4 per cent. SF-36 scores suggest that the quality of life of people reporting injury-related disability was markedly reduced. Social class is associated less with injury morbidity than with injury mortality. Sport was the commonest cause of all injuries, and of disabling injuries. There was a dose-response relationship between vigorous exercise and injury. CONCLUSIONS: Injury is a significant cause of disability in the working age population. It is potentially feasible to monitor injury-related disability in postal questionnaire surveys. Estimates of health gain to be achieved from participation in sport should take account of injury-related disability.     

Interlocking oppressions: the effect of a comorbid physical disability on perceived stigma and discrimination among mental health consumers in Canada

People living with mental health problems often face stigma and discrimination; however, there is a lack of research that examines how comorbid conditions affect this perceived stigma. This study sought to determine whether people who have a comorbid physical and psychiatric disability experience more stigma than those with only a psychiatric disability. It also looked at how perceived stigma and discrimination affect physical and mental health. A secondary analysis on data from interviews with 336 former and current clients of the mental health system in a mid-size Canadian city in 2005 was performed. Of these, 203 (60.4%) reported they had a psychiatric disability, 112 (33.0%) reported that they had a physical disability, with 74 reporting both a psychiatric and a physical disability. People with a self-reported psychiatric disability and a self-reported comorbid physical disability faced more overall perceived discrimination/stigma ( P  = 0.04), than those with a psychiatric disability alone. Perceived discrimination/stigma was positively correlated with psychiatric problem severity ( P  = 0.02), and negatively correlated with self-rated general health ( P  < 0.001), physical condition ( P  < 0.001), emotional well-being ( P  < 0.001) and life satisfaction ( P  < 0.001). These results bring to light the aggravating effect of a physical disability on the perceived stigma for those living with a mental illness, and also strengthen the knowledge that stigma and discrimination have a negative impact on health. Healthcare providers should recognise this negative impact and screen for these comorbid conditions. Policy-makers should take measures such as improving access to housing and employment services to help reduce stigma and discrimination against this particularly vulnerable group.     

Physical diability after retirement and occupational risk factors during working life: a cross sectional epidemiological study in the Paris area.

STUDY OBJECTIVE--The aim was to examine the relationship between exposure to occupational risk factors during working life and physical disability after retirement. DESIGN--The study was a cross sectional epidemiological survey of a representative sample of retired subjects belonging to a supplementary pension fund in the Paris area. SETTING--The study took place in the general community. PATIENTS--307 men and 320 women (63.1% of those approached) answered a questionnaire during home interviews. Their average age was 69 (SD4) years at the beginning of the survey. Whether or not subjects had been exposed to occupational risks was determined from their statements concerning the presence or absence of eight harmful environmental conditions while at work. Physical disability was defined as difficulty in carrying out seven basic activities of daily life. MAIN RESULTS--The results of univariate analyses showed significant relationships between exposure during working life to occupational risks including noise, heat, dust, carrying heavy loads, and awkward postures on the one hand, and the presence of a physical disability after retirement on the other. Multivariate analysis based on logistic regression models that took account of age, sex, and health impairments revealed a specific link between exposure to carrying heavy loads and physical disability after retirement. CONCLUSIONS--These results suggest that occupational risk factors might be important in determining such disability in retired people.     

When work and satisfaction with life do not go hand in hand: Health barriers and personal resources in the participation of people with chronic physical disabilities

People with chronic physical disabilities participate less in both paid and voluntary work and are less satisfied with their lives than people without health problems. Governments and scientists have suggested that participation in employment is the main road to well-being. We analysed national survey data on the participation in work and satisfaction with life, comparing people with a chronic illness and a physical disability (n = 603) to people with a chronic illness but without a physical disability (n = 1199) and the general population (n = 6128) in the Netherlands. The results show that the relationship between happiness and work is different for people with a chronic illness and a physical disability, as compared to the other two populations. Fewer people with a chronic illness and disability were categorized as ‘satisfied people with work’ (i.e. participating in work and satisfied with their life), while most people belonged to a group of ‘satisfied people without work’ and, surprisingly, not to the expected group of ‘dissatisfied people without work’. In order to explain this exceptional distribution we modelled satisfied participation in work as an outcome of a balance between personal resources and barriers. By means of discriminant regression analysis, we identified the severity of motor disability as the main barrier, and education level and age, as the main resource factors that distinguish between ‘satisfied people with work’ and others among the group of people with a chronic illness and a physical disability.     

The health of students in institutes of higher education: an important and neglected public health problem?

BACKGROUND: A survey of students in three UK higher education establishments was undertaken to obtain information about students' physical and emotional well-being, their attitudes to, and beliefs about health, and the prevalence of risk factors for future ill health. METHODS: Health was measured by the prevalence of longstanding illness and by the SF-36 health status measurement tool. Survey results were compared with equivalent data for 18- to 34-year-olds in the local population. The prevalence of long-standing illness was also compared with two national surveys. RESULTS: The survey achieved a 49 per cent response rate. More than one-third of respondents reported a long-standing illness, a higher prevalence than in all comparison surveys. Students scored significantly worse than their peers in the local population on all eight SF-36 dimensions. The greatest difference was for role limitations as a result of emotional problems. The main sources of emotional distress were study or work problems and money. CONCLUSION: The poor response rate in this survey dictates the need for caution in interpretation of the results. However, they suggest that the health of students is poor relative to that of their peers, and that their emotional health is more of a problem than their physical health. Public health practitioners might want to pay more attention to the health of this important and relatively neglected group. Worries about studies and money appear to be affecting students' academic work, and this should be of concern to higher education establishments.     

Coping with a Second Disability: Implications of the Late Effects of Poliomyelitis for Occupational Therapists

The long term effects of many physical disabilities have only recently begun to be appreciated. For people who have lived for years with what they thought to be stable conditions, the onset of secondary disabilities may be associated with considerable problems and distress. A questionnaire survey of 324 people with poliomyelitis revealed the occurrence of late effects in 94% of respondents. The majority reported increased weakness, pain and fatigue, problems in carrying out daily living activities and difficulties in obtaining appropriate health care. Although occupational therapists were less likely to be consulted than other professionals, they received one of the highest satisfaction ratings from clients. Discussion of case studies indicates ways in which occupational therapists can provide symptom relief and enable clients to maintain valued roles. As the survival rates of people with disabilities increase there is a need for greater awareness of, and research into, the late effects of disability.     

New obstacles and widening gaps: A qualitative study of the effects of the COVID-19 pandemic on U.S. adults with disabilities

BackgroundPrior research has demonstrated that the needs of the disability community have not been met during public health emergencies. The COVID-19 pandemic has exacerbated existing inequities for many populations including people with disabilities, and data is needed to develop inclusive public health response policies.ObjectiveTo identify how COVID-19 has uniquely impacted the lives of adults with disabilities.Methods38 participants were recruited through disability advocacy groups and social media. Semi-structured virtual focus groups were conducted with adults (≥18 years) who self-identified as having a disability. Focus groups were conducted for each of six disability sub-groups: vision, hearing, mobility and physical, mental health, cognitive, intellectual, and developmental, and chronic illness. Using inductive coding, major themes were identified and compared across the disability sub-groups.ResultsThree major themes and thirteen sub-themes were identified from the focus groups. The three major themes comprised: new problems created by the pandemic, obstacles in daily life that were exacerbated by the pandemic, and broader changes to accessibility and disability identity. Sub-themes such as difficulty with COVID-19 testing and regular medical care were reported by participants of all disability sub-groups, while other sub-themes like direct care needs and medical rationing were reported by participants from a subset of the disability sub-groups.ConclusionsThese results indicate how the COVID-19 pandemic unequally impacts disabled people. The participants indicated that to fully address their needs, disability perspectives must be included in the public health pandemic response. As new research shows that COVID-19 can cause long-term disability, the urgency to ensure the disability community is part of public health policies will increase.     

Ethnicity,health and health services utilization in a British study

Despite the exponential growth in the number of studies addressing ethnicity and health, there is considerable debate about definitions of ethnicity, the appropriate use of ethnicity in health research and whether research focusing on ethnicity in the health field will ultimately result in reduced disadvantage or will simply contribute to the reification of ethnic origin as a cause of health problems. The authors present and discuss health outcomes among White (n = 227), African-Caribbean (n = 213) and Indian and Pakistani (n = 233) adults aged between 18 and 59 years living in Leeds as measured in a stratified population survey, with particular emphasis on the interaction between reports of health conditions and health status in relation to ethnicity and gender. The survey included both general and specific measures of health and impairment and was undertaken following extensive qualitative fieldwork. Overall the results of the study suggest that adults in both broad minority ethnic groups studied have a somewhat less favourable profile of physical and mental health and risk factors such as obesity and low birthweight. Despite an absence of ethnic differences in reporting of long-term conditions, minority groups had lower health status because those with long-term conditions were generally in worse health than their White counterparts. The study findings agree with previous research in suggesting that variation in health status was better explained by specific measures of actual limitations in daily activities than by general measures of limiting long-term illness. These data suggest that limiting long-term illness or disability questions may underestimate functional limitation relative to more specific measures and consequently their use in resource allocation may be problematic.     

Depression in primary care. A nationwide epidemiological survey

BACKGROUND: Most epidemiological studies on depression in primary care are conducted at single sites, and variations in reported prevalence may depend on characteristics of health care services and other local factors. OBJECTIVES: Our aim was to investigate the prevalence of depression in primary care in Italy and its association with physical illness, disability and health care utilization. METHODS: This nationwide epidemiological study involved 191 primary care physicians (PCPs) who assessed during one index week 1896 patients aged 14 and over attending their clinics. Screening was conducted by using the General Health Questionnaire-12. Probable cases were assessed by PCPs with the WHO ICD-10 Checklist for Depression and rated for severity of physical illness. RESULTS: The prevalence of current depression ranged between 7.8 and 9.0% in the three main Italian areas, with no significant variations. A linear increase from North to South was observed for psychological distress, disability and frequency of medical consultation. Depression was associated with severe, but not with mild or moderate physical illness. Depression was also associated with disability and accounted for an increased rate of consultation. CONCLUSION: Because of the disability associated with depression and of its impact on health care utilization, guidelines and intervention strategies are needed.     

Income and employment among homeless people: the role of mental health, health and substance abuse

BACKGROUND: The homeless population is among the poorest of the poor in the United States. Employment and government programs are potential sources of income, but many homeless people face potential barriers to work: many have serious mental and physical disabilities, and many more have alcohol and drug disorders. As a result, most homeless who work do so either for a few hours per day or only some days, which provides little income. General Assistance, a public program of last resort, also provides a low level of income support. More income might be gained through higher levels of work or participation in income support programs for people with disabilities. AIMS OF THE STUDY: To investigate the characteristics of homeless people that impede them in the labor market and in government program participation, paying particular attention to their mental and physical health, as well as their alcohol and drug problems. DATA: Data are from a survey of the homeless population in Alameda County, California, conducted from 1991 to 1993. Our sample is 471 homeless adults randomly selected from area shelters and meal providers, who were reinterviewed approximately 6 months later, regardless of domiciliary status. Mental health and substance use problems were assessed using the Diagnostic Interview Schedule, a structured, psychiatric interview that uses criteria based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 3rd edn (revised). Employment between the first and second interview is categorized as none, low level (less than 6 hours a day or fewer than half the days between interviews) or higher level (at least 6 hours a day for at least half the days). ANALYTICAL PROCEDURES: The models of employment status and program participation are recursive in that homelessness at the first wave of the survey is treated as given. Thus we explore whether, given their initial homelessness, persons can gain or maintain access to income between the two interviews, conditional on the sample member's homelessness, health and disability at the first interview. Using maximum-likelihood methods, we estimate a generalized ordered logit model of whether the person works not at all, at a low level or at a higher level. Participation in disability programs and GA are estimated as probit models over the subsamples of potentially eligible participants. RESULTS: While a surprisingly large number of homeless people work, few homeless persons are able to generate significant earnings from employment alone. Physical health problems that limit work or daily activities, in particular, are barriers to employment. Drug and alcohol abuse and dependence are positively associated with lower work level but are negatively related to higher work level. Program participation is quite low relative to eligibility. Those with physical health problems are substantially more likely than those with mental health problems to be in the more generous disability programs. Substance use disorders are also a barrier to participation in disability programs. DISCUSSION: Mental health, health and disability play a large role in the employment and program participation of the homeless and persons at risk for homelessness. Physical disabilities are a barrier to employment, and those with substance use disorders are most likely to work at lower levels that provide less income. Rates of participation in government programs are low, and people with major mental disorders have especially low participation rate in disability programs. The low rates of participation, particularly in the disability programs, suggest the need for continued research in improving access to income support programs among eligible homeless populations.     

Mobility Limitations Negatively Impact Work Outcomes among Medicaid Enrollees with Disabilities

INTRODUCTION: Fear of losing health insurance is believed to be a significant work barrier for people with disabilities in the US. We examined the relationship of different types of daily activity limitations to work outcomes among adults with a variety of disabling conditions for whom the risk of losing health insurance has been removed by enrolling in a Medicaid buy-in (MBI) program. METHODS: 1093 working-age adults with disabilities in the Massachusetts MBI program responded to the MassHealth Employment and Disability Survey, which provided data on the types of disabling conditions and activity limitations members experienced as well as three work outcomes--work status of members; annual earnings above substantial gainful activity of working members; and plans to work in the future of non-working members. RESULTS: Among different types of activity limitations, mobility limitations were generally associated with poorer work outcomes, regardless of disabling condition. Across members in three disability groups--psychiatric; physical; and co-occurring psychiatric and physical--those reporting mobility limitations were significantly less likely to be working or, if non-working, to be planning work than those reporting no or other types of limitations. There was an exception to this pattern with respect earnings among working members. Overall, work outcomes among members with co-occurring psychiatric and physical disabilities were most consistently negatively impacted by mobility limitations. CONCLUSIONS: Rehabilitation providers aiming to promote entry into the workforce need to be aware of the varied ways in which mobility limitations may create barriers for people with all types of disabilities.     

The content of a low-income,uninsured primary care population: including the patient agenda

BACKGROUND: Poor and uninsured people have increased risk of medical and psychiatric illness, but they might be more reluctant to seek care than those with higher incomes. Little information exists about the biopsychosocial problems and concerns of this population in primary care. METHODS: We surveyed 500 consecutive patients (aged 18 to 64 years) in a primary care clinic serving only uninsured, low-income patients. We used self-report questions about why patients were coming to the clinic, a chronic illness questionnaire, the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, and items from the Childhood Trauma Questionnaire. Providers completed a questionnaire naming problems elicited from patients. RESULTS: Patients reported their most common chronic medical problems to be headaches, chronic back problems, and arthritis. The most common concerns patients wanted to discuss with providers and that providers elicited from patients were problems with mood. Compared with patients without current major mental illness, patients with a current major mental illness reported significantly (P <.001) more concerns, chronic illnesses, stressors, forms of maltreatment and physical symptoms. CONCLUSION: The illness content of this uninsured, low-income population is dominated by emotional distress and physical pain. These needs place a serious burden on providers and can complicate management of chronic medical illnesses. Recommendations for specialized interview training and integrating mental health services are discussed.     

Linking perceptions of neighbourhood to health in Hamilton, Canada

STUDY OBJECTIVE: To investigate the association between perceptions of neighbourhood physical and social characteristics and three health outcomes (self assessed health status, chronic conditions, and emotional distress). DESIGN: Cross sectional survey data analysed in small neighbourhoods. SETTING: Hamilton, Ontario, Canada, a medium sized industrial city, located at the western end of Lake Ontario (population at the time of the study about 380 000). PARTICIPANTS: Random sample of 1504 adults aged 18 years and older residing in four contrasting neighbourhoods. MAIN RESULTS: Significant differences across the four neighbourhoods are apparent in self assessed health status and emotional distress, but not in chronic conditions. Neighbourhoods with lower SES reported poorer health and more emotional distress. Perceptions of the physical environment dominated social concerns in all neighbourhoods. For all three health outcomes, individual risk factors followed expectations, with measures of poverty, age, and lifestyle all significantly associated with poor health outcomes. Physical environmental problems were positively and significantly associated with poor physical and emotional health. Specifically, people reporting they dislike aspects of their neighbourhood's physical environment are 1.5 times more likely to report chronic health conditions (OR 1.56, 95% CI 1.19 to 2.05), while those reporting physical likes with their neighbourhood are less likely to report fair/poor health (OR 0.50, 95% CI 0.28 to 0.90) or emotional distress (OR 0.45, 95% CI 0.26 to 0.80). CONCLUSIONS: These results demonstrate the importance of neighbourhood perceptions as a determinant of health, as well as conventional factors such as low income, lifestyle, and age. The dominance of physical environmental concerns may have arisen from the industrial nature of Hamilton, but this result merits further investigation.     

Physical ill health, disability, dependence and depression: results from the 2007 national survey of psychiatric morbidity among adults in England

BackgroundThe relationship between physical ill health, disability, and depression is not straightforward. Both cross-sectional and longitudinal studies have clearly shown that medical illness and physical disability are strongly associated with depression.ObjectiveTo test the hypothesis that disability is associated with an increased prevalence of depression irrespective of physical health problems and that this is proportionate to the severity of disability (measured in terms of the number of difficulties in daily activities and the degree of dependence on others).MethodsUsing a random probability sample design, 7460 respondents were interviewed for the third national survey of psychiatric morbidity of adults in the private household population in England. Fieldwork was carried out throughout 2007. The prevalence of depression was established by the administration of the revised Clinical Interview Schedule (CIS-R), while disability was measured by reported difficulties in activities of daily living (ADL) and instrumental activities of daily living (IADL).ResultsDisability was associated with depression even after adjustment for physical ill health. The number of ADL/IADL difficulties was directly related to the likelihood of respondents having depression. Dependence on others was not associated with depression once severity of disability had been accounted for.ConclusionAll ADL/IADL limitations are significantly associated with depression and there seems to be a cumulative effect irrespective of whether the limitation is in personal care or in instrumental activities such as mobility problems.     

Investigating the proxy effect and the saliency principle in household based postal questionnaires.

STUDY OBJECTIVE--The aim was to investigate two possible sources of bias inherent in using a household based postal questionnaire, the "proxy effect", inaccurate reporting about characteristics of others, and the "saliency principle", reporting of only the most salient features. This is of importance in surveys concerned with screening the population to identify individuals with certain characteristics, and so possibly relying on one member of the household to reply on behalf of all others. DESIGN AND SETTING--A two stage survey of disablement in the population was undertaken. A first phase postal questionnaire was sent to 25,168 households in Calderdale, West Yorkshire, England, to ascertain the prevalence of physical disability and of troubles with the joints. The second phase comprised in depth interviews with a sample of individuals identified in the first phase as being disabled. RESPONDENTS--A total of 21,889 postal questionnaires were returned (87%) representing households containing 42,826 people aged 16 years and over. A disproportionately stratified random sample of 950 respondents reporting disability was taken in the second phase. Of these 891 were still available, and 838 (94%) were interviewed. MEASUREMENTS AND MAIN RESULTS--The postal questionnaire found that almost 29% of those who lived "alone" (without another adult) reported some level of disability, compared to only 10% of those who lived with others. The difference remained significant after standardisation. This apparent underreporting or "proxy effect" was present for reporting about disability overall, but not for severe disability (dependence on help of others), which suggests the operation of the "saliency principle". Reporting on joint troubles appeared to be affected by the proxy effect both for any joint problems, and when more than five joints were affected. Analysis of a small set of postal questionnaires from respondents who reported joint problems only at interview and where we could identify who had completed the postal questionnaire supports the hypothesis of a proxy effect; two thirds of the original postal questionnaires had been completed by a proxy. The results were further complicated by an interaction between reporting of disability and joint troubles: the greater the level of disability, the less likely the reporting of joint troubles. CONCLUSIONS--The findings have general implications for studies involving postal household screening questionnaires, and raises additional concerns about those that are multitopic in content. In surveys of symptoms and minor disability, a proxy effect is likely to be operative. This effect is not apparent for obvious and long standing problems such as dependence on others for help. However the interaction between the reporting of disability and joint symptoms carries important implications for the development of multitopic postal screening questionnaires.     

Relevance and practical use of the Consultation and Relational Empathy (CARE) Measure in general practice

BACKGROUND: The Consultation and Relational Empathy (CARE) Measure has been developed as a tool for assessing the patients' perceptions of relational empathy in the consultation. OBJECTIVES: The present paper provides performance data on the CARE measure in a large sample of general practice consultations in areas of high and low deprivation. METHODS: The CARE Measure was included in a self-completed questionnaire study involving 3044 patients attending 26 GPs in 26 different practices (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). RESULTS: GPs and patients, in both high and low deprivation settings, endorsed the relevance of the CARE Measure. Overall, 76% of patients rated the measure as being 'very important' to their current consultation. Higher rating of importance were observed in older patients, patients consulting with psycho-social problems, patients with long-standing illness or disability, and patients with significant emotional distress. Few patients rated individual CARE Measure items as being 'not applicable' to their current consultation; only 3.1% of patients felt that more than 2 of the 10 items in the measure did not apply to their current consultation. Mean values were not influenced by deprivation, gender, reason for consulting, chronic illness, or emotional distress. Correlational analysis indicated that a sample size of 50 patients is sufficient to reliably estimate mean CARE score for an individual GP. CONCLUSIONS: These results indicate that the CARE Measure is considered by GPs and patients alike as being of direct relevance to everyday consultations in general practice, in both high and low deprivation settings. The measures is stable across patient groups and a reliable estimate of perceived GP empathy requires 50 completed questionnaires per doctor.