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© Copyright the Finnish National Public Health Institute 2002. All rights reserved.
The workshop received funding from the European Commission. The document reflects the views of the participants of the Workshop and the European Commission is not liable for any use that may be made of the information contained in the document.
In 1997 the European Commission established the Health Monitoring Programme (HMP) for the five year period from 1997 to 2001, but in 2001 it was extended until the end of 2002. The objective of the HMP was to establish a Community health monitoring system which would make it possible to:
55 projects were financed by the HMP to help achieve these objectives (see http://europa.eu.int/comm/health/index_en.html). The average grant was € 330.000. The main areas covered were:
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Health status reports were also financed:
A new Public Health (PH) Programme has been agreed on by the Conciliation Committee of the European Parliament and the Council on 8 May 2002. The Programme will replace the existing eight programmes and will run for six years starting on 1 January 2003 (till end of 2008) with a budget of € 312 million. EU actions will be refocused along three strands:
The activities in the three areas will be inter-linked and mutually reinforcing, embodying an integrated approach to ensure better health policies.
European Health Risk Monitoring (EHRM) and Health Surveys in the EU: HIS and HIS/HES Evaluations and Models are two of the projects of the current HMP. Both of these projects work on issues related to health surveys.
At earlier EHRM meetings, the participants of the project expressed the need for a wider range surveys than covered by EHRM, including also nutrition, physical activity etc. As these areas were covered by other HMP projects the idea of a joint meeting with all HMP projects working on health survey issues started to develop. The workshop on "Health Surveys in Europe - Role of Surveys in Monitoring" was organized jointly by EHRM project, Health Surveys in the EU: HIS and HIS/HES Evaluation and Models -project and the European Commission to bring together experts from all areas of health surveys.
The objectives of the Workshop were:
About 70 participants from different HMP projects and the European Commission (DG Sanco and Eustat) representing 19 countries (EU Member States and applicant countries) were present in the Workshop (Appendix 1).
In the HMP, several projects are/have been working on issues related to health surveys. Eleven of these introduced their recommendations and/or plans in the Workshop.
The first phase of ECHI is an attempt to construct a framework for a comprehensive list of EU health indicators. The system should be flexible so that indicators can be changed with changing policy and scientific interests. User windows i.e. different views or filters are intended to provide easy access to subsets of the data. The selection of indicators was guided by epidemiological and quality criteria. The list is based on existing comparable data but it also points to data and development needs. The main categories of ECHI are:
The indicators should cover Member States’ health policy interests. ECHI also identified currently unmet data and information needs such as disease-specific morbidity, mental health, health expectancies, personal factors, social determinants of health, quality of health care, health inequalities and emerging health threats. The data sources required range from registers to interview and health examination surveys and to special studies. ECHI 1 is followed by ECHI 2 which is intended to co-ordinate the efforts of various Health Monitoring Programme projects. In the longer term it is essential to create a central co-ordinating structure and appropriate networks for the development and running of the EU health monitoring system including health reporting.
The project has been doing an inventory of health interview and/or health examination surveys in 18 Western European countries, Canada, Australia and the USA. Data collected through this inventory have been recorded in the database called "European Health Surveys Database", which at the moment is on CD-ROM in Access2000 format. It is hoped that the database can shortly (by the end of 2002) be transferred to the Internet. Meanwhile, the CD-ROM can be requested from Dr. Claudine Vermeire (claudine.vermeire@iph.fgov.be).
The database includes information about the methods and questions used in the surveys. All questions are both in the original language and English.
At this stage the project will not propose specific health indicators or recommendations for measurements. However, it will assimilate recommendations of other HMP projects and other international recommendations and also include them in the database. The project also evaluates implementation of surveys and makes recommendations. It also evaluates in detail some current methods used in European surveys.
The project has prepared a list of indicators for chronic disease risk factors. The risk factors were selected on the basis that they are known to be predictive for at least one chronic disease, modifiable, measurable in the population, and relevant for the age range 35-74 years. The project has also made a recommendation for mechanisms for coordinating risk factor surveys, measurement protocols and manual of operations for chosen risk factors and international collaboration. The recommendation for international collaboration includes a proposal for a centralized facility for training, quality control and quality assessment.
The health indicators considered by the project cover:
The recommendations are available at http://www.ktl.fi/ehrm/ under "Documents".
The project dealt with pre- and post-harmonization of food consumption data. The project recommends that post-harmonization should start with four food groups: vegetables, fruits, bread and fish. This is the best that can be done with existing data.
For pre-harmonization of future surveys, the project has prepared recommendations for:
For more information, see European Journal of Clinical Nutrition 2002; 56 (Supplement 2): S1-S94.
The project deals with nutrition in a broad perspective including seven primary categories:
The project is preparing a list of indicators in these areas and also operational instructions.
The DAta Food NEtworking (DAFNE) is an already existing databank on food availability, comprising 50 household budget surveys in 13 European countries (Belgium, France, Germany, Greece, Hungary, Ireland, Italy, Luxembourg, Norway, Poland, Portugal, Spain and the United Kingdom) covering the last 20 years. Data from Austria, Finland and Sweden are planned to be included in the databank in the future.
The DAFNE team aims at structuring a proposal on the methodology to collect data on meals taken outside the household as this is one of the limitations of household budget surveys.
More information about the DAFNE can be found from:
The project aims to:
More information about the ECAS II (and ECAS I) and recommendations can be found from:
The project was set up to:
The project has prepared recommendations for a list of core indicators to be used in future surveillance and a set of additional indicators which focus on psycho-social, contextual dimensions of physical activity. The project is also supporting on-going research activities to improve the validity and reliability of internationally comparable physical activity indicators (e.g. IPAQ, EUROHIS, EUPASS).
The IPAQ questionnaire (long and short versions) are available at http://www.ipaq.ki.se/.
The project:
The project recommended 36 indicators for mental health. Fourteen of these indicators require surveys and they include several measures:
References:
The project is to establish and recommend a convenient set of European diabetes indicators to:
The project is recommending 41 possible indicators, which can be divided into 5 groups:
The project aims to identify existing indicators of musculoskeletal disorders in the population, and primary and secondary care. This includes information on prevalence, trends, determinants and consequences at a national and community level.
The project will recommend indicators, which can be used to monitor musculoskeletal disorders at the national and community level. The project is giving priority to poorly described conditions, missing from the existing international classifications and to establishing means of distinguishing minor transient episodes from the more significant conditions.
The project is focusing on child health indicators by reviewing literature and projects and subsequently will prepare a recommendations for indicators for monitoring the health of children. The topics covered are:
Other sources on child health are:
Several interview surveys, which also include health components, already exist at the European level.
The European Community Household Panel (ECHP) was conducted in 1994-2001 in all EU Member States except Sweden: 60 0000 households, 120 000 persons aged 16 years or older were included. The health topics covered were:
For more information about ECHP see http://forum.europa.eu.int/Public/irc/dsis/echpanel. (Access to this web site will require username and password to CIRCA.)
Statistics on Income and Living Conditions (SILC) is a successor to ECHP and will start in 2003/2004/2005. SILC will also include some health 'modules'.
European Labour Force Surveys (LFS) comprises harmonised national surveys. It dates from 1973 and in 2002 it will include a module with:
Eurobarometer (http://europa.eu.int/comm/public_opinion/) is an European survey on public opinions, conducted annually. There are health related 'modules' in Eurobarometer on smoking, drugs, prevention, satisfaction with health systems, blood transfusion, alcohol and in 2002 also questions about organ/blood donation, mental health, diet/nutrition and physical activity.
In addition to these European level international health surveys, in almost all European countries some national health survey activities are ongoing. Information about these national surveys is collected on database coordinated by Health Surveys in the EU: HIS and HIS/HES Evaluation and Models -project.
Good quality and comparable data are needed for research as well as for health monitoring purposes. Health policy, based on poor quality data, may lead to over or under investment and to a waste of public resources.
Good quality data do not necessarily mean comparable data. For comparability, harmonization, standardization and common protocols are needed as well as collaboration between academic and government departments.
The validity and reliability of the measurements chosen can be achieved by using standardized and well proven instruments, common training of interviewers and measurers, and well organized communication with field staff during the survey and feed back to them. For the analysis of biochemical markers, a centralised reference laboratory is needed to ensure comparability between laboratories.
The organization of a comprehensive European wide health survey is currently not feasible. The necessary health information can be collected through regional and national health surveys if a common set of health indicators is defined and their measurement methods are standardized throughout the Member States. This will also require centralized coordination and quality control.
Non-communicable diseases still remain the largest health problem throughout Europe because they are common, costly and disabling. Because of that, there should be a core set of standardized indicators of the determinants of health and disease to be monitored through regular health surveys. These determinants should be modifiable and based on public health evidence, and the indicators should be amenable to quality control and limited to certain age ranges. Survey questions planned for the adult population are often inapplicable to children and adolescents, who need survey instruments developed specifically for these age groups.
For young people (age < 20 years) the set of indicators should include perceived health, smoking, BMI, waist and hip, physical activity, parity, violence, alcohol use, substance abuse and perceived health. Several other indicators are important like blood pressure, mental health, educational attainment, sense of mastery, LDL cholesterol, glucose, nutritional status etc. Chronic ill-health in childhood may persist into old age.
Among working age people (20-65 years), the indicator set should include perceived health, smoking, BMI, waist and hip, blood pressure, physical activity, employment type, educational attainment, alcohol use, LDL cholesterol, glucose and mental health. Also sense of mastery, functional limitations, social support, mental and physical work place exposure, nutritional status, quality of life etc. are important and should be monitored.
Among elderly people (age > 65 years), functional limitations, perceived health, blood pressure, physical activity, social support, alcohol use, smoking, quality of life and educational attainment are important health indicators. Also sense of mastery, mental health, cognitive status, medications, dietary intake, LDL cholesterol, glucose, BMI, waist and hip and violence and accidents should be considered for monitoring.
Both for people of working age and the elderly, and interview survey could cover some major infections and vaccinations. The priorities on these may vary by country.
Surveys can be either interview or examination surveys. Interview surveys can be conducted by mail (self-completion), telephone or face-to-face interview. The selection of survey type depends on the topic to be surveyed and availability of funding. However, part of the information can only be obtained by health examination surveys.
From the ECHI list, socio-economic status (SES), general health status, prevention and health promotion and health care utilization indicators can be collected by interview when personal and biological factors and health behaviours (e.g. food frequency questionnaire, 24-hour recall) often also require examination survey.
Available resources limit the frequency at which different types of surveys can be conducted. Health interview surveys can be conducted every few years depending on surveyed topic and resources, where as for health examination surveys this may not be feasible. Basic risk factor surveys with a limited number of physiological examinations at the 5-year interval is often enough. For more comprehensive health examination surveys, 10-15 years intervals are advisable.
In general, the target population for surveys should be the whole population living in the country (resident population) or region if health provision is at this level. If institutionalized persons are excluded the consequences should be carefully assessed and reported. Some surveys may need to look more closely at special population groups.
The response rate in surveys should be relatively high (above 70%) and there should always be some information about the non-respondents. It is important to invest on getting high response rates by motivating respondents as well as survey personnel. Large well-planned quality surveys, well spaced in time, are infinitely preferable to frequent, small, poor quality ones.
There is a clear need for relevant, valid and comparable health survey information at the European level. The existing information suffers from poor coverage of the most important health items, poor quality and comparability as well as from lack of coverage and accessibility.
To improve the situation, collaboration between counties, organizations and experts is needed. Improving national health interview and health examination surveys should be the main approach. Through EU supported collaboration, a core set of health indicators should be defined which would form the minimum set of information to be collected in each country. As well as this core set, a stepwise approach could be adopted to include more indicators if available. These sets of indicators should be flexible and adapt to changes over time if new health issues arise (e.g. biochemical indicators, genetic determinants). Countries are encouraged to extend their health surveys to other health indicators of interest. The EU level collaboration should involve MS experts, DG Sanco, Eurostat and the forthcoming EU structure for health monitoring.
To get reliable and comparable information from selected health indicators, standardized measurement protocols and questionnaires need to be developed and validated. Special attention is needed for laboratory measurement standardization through establishment of European reference laboratories (for biochemical measurements such as blood lipids, biomarkers urinary tests, etc.).
Centralized training and quality control during and after the surveys is needed to support country survey organizers to achieve reliable and comparable health information. This support is especially important for countries without previous experience of health interview and examination surveys.
The agreed core set of data should be reported to a common European database accessible to the European health monitoring system and experts in the member countries. The forthcoming EU health monitoring structure should play a central role in compiling , analysing and distributing the data and information.
In the longer term, the feasibility of a European health survey/surveys should be examined taking into account the experiences gained from this collaboration involving national survey experts and health authorities.