Transcript Working Paper No.3 Add.2 21 November 2005 STATISTICAL COMMISSION and UN ECONOMIC COMMISSION FOR EUROPE STATISTICAL OFFICE OF THE EUROPEAN COMMUNITIES (EUROSTAT) CONFERENCE OF EUROPEAN STATISTICIANS WORLD HEALTH ORGANIZATION (WHO) Joint UNECE/WHO/Eurostat.

Working Paper No.3 Add.2
21 November 2005
STATISTICAL COMMISSION and
UN ECONOMIC COMMISSION FOR
EUROPE
STATISTICAL OFFICE OF THE
EUROPEAN COMMUNITIES
(EUROSTAT)
CONFERENCE OF EUROPEAN
STATISTICIANS
WORLD HEALTH
ORGANIZATION (WHO)
Joint UNECE/WHO/Eurostat Meeting
on the Measurement of Health Status
(Budapest, Hungary, 14-16 November 2005)
Session 3 – Invited paper
Proposed items for the
measurement of Dexterity, Vitality,
Affect, Vision
Lidia Gargiulo, Gabriella Sebastiani, Alessandra
Tinto & Elena DePalma – ISTAT, Italy
The domains
 Dexterity
(domain 2)
 Vitality/fatigue
(domain 3)
 Affect
(domain 4)
 Vision
(domain 6)
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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Development of the proposed
items
The HIS/HES* database was used as a
reference
1.
Overview of questions items used in the population health
surveys and of established health status measurement
instruments;
2.
Selection of questions should be able to measure the concepts
underlying each specific domain;
3.
Analysis of the main characteristics of each question (wording,
reference period, answer categories ...), similarities and
difference among selected questions.
* www.iph.fgov.be/hishes/
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dexterity
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definition
ICF :
fine hand use (d440) 
performing the coordinated actions of
handling objects, picking up, manipulating
and releasing them using one’s hand, fingers,
and thumb, such as required to lift coins off a
table or turn a dial or knob.
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dexterity
two main
aspects:
manipulating
and grasping
Carrying, moving and
handling objects
(ICF)
Mobility
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Health Status", Budapest, November 2005
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how it is measured
Manipulating:
Using fingers to grasp or handle
a small object like a pen
Grasping:
Turning a tap or unscrew a lid
Both dimensions are covered in the proposed
items.
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Health Status", Budapest, November 2005
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first proposal and reviews

The first proposal was selected from
the European Health Status Module.

After a discussion within the TF, the
answer categories were modified to
include the level of difficulty.
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Health Status", Budapest, November 2005
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proposed items (1)
DEX-1. Can you use your fingers to grasp or handle a small
object like a pen without any aids?
Yes, with no difficulties
Yes, with some difficulties
No
If no:
DEX-2. Can you use your fingers to grasp or handle a small
object like a pen with aids?
Yes
No
Has no aids
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Health Status", Budapest, November 2005
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proposed items (2)
DEX-3. Can you turn on a tap or unscrew the lid of a jar of
coffee without any aids?
Yes, with no difficulties
Yes, with some difficulties
No
If no:
DEX-4. Can you turn on a tap or unscrew the lid of a jar of
coffee with aids?
Yes
No
Has no aids

By using different examples in each country, it would be clearer
what is intended with the term aids.
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Health Status", Budapest, November 2005
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issues of the proposed items
 Uni-dimensional items;
 Distinguishing dexterity with and without the use of
aids allows to identify capacity;
 Simplicity and clarity of wording.
 Answer categories ?
 Reference period ?
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Health Status", Budapest, November 2005
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vitality / fatigue
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Health Status", Budapest, November 2005
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Definition
ICF :
Body Functions
Global Mental functions
 Energy and drive functions
energy level (b1300):
mental functions that
produce vigor and stamina
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vitality /
fatigue
two main aspects:
tiredness
vs refreshed
Energy and drive
functions
Mental functions
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Health Status", Budapest, November 2005
(ICF)
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tools used
 various National Health Interview surveys
 European Health Status Module
 World Health Survey
main outcomes
 used from 1 up to 4 questions
 4 questions  SF-36 adapted
 time reference:
 “the past 4 weeks/last 30 days/past month”.
 response categories: measure the frequency in time
spent being in a certain health state.
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how it is measured
rested
 full of pep
refreshed  have a lot of energy
positive
tiredness
lack of energy
negative
 feel tired
 feel worn out
From SF - 36
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Health Status", Budapest, November 2005
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First proposal and reviews

The first proposal was the European
Health Status Module that include
questions on vitality of SF-36.

After a discussion within the TF, aiming
to introduce a measure of intensity, just
2 questions out of 4 were selected.
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Health Status", Budapest, November 2005
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proposed items (1)
VIT-1
How much, during the past 4 weeks, did you have a lot of
energy?
All the time
Most of the time
Some of the time
A little of the time
None of the time
VIT-2
How much, during the past 4 weeks, did you feel tired?
All the time
Most of the time
Some of the time
A little of the time
None of the time
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Health Status", Budapest, November 2005
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proposed items (2)
VIT-3
Thinking about the past 4 weeks, on a scale from 1-100
how intense was the level of energy on average: 0 is lowest
level and 100 is the highest level imaginable.
no energy at all
highest level of energy imaginable
|__________________________________________________ |
|
|
0
100
VIT-4
Thinking about the past 4 weeks, on a scale from 1-100
how intense was the level of tiredness on average: 0 is
lowest level and 100 is the highest level imaginable.
no tiredness at all
highest level of tiredness imaginable
|__________________________________________________ |
|
|
0
100
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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issues of the proposed items






Include both positive and negative aspects
Measure the frequency of refreshed and tiredness
Measure the intensity of refreshed and tiredness
Uni-dimensional items
Simplicity and clarity of wording
Number of countries using the question (translated into
many languages and wide knowledge of instrument);
 use of medicines?
 reference period?
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Health Status", Budapest, November 2005
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affect
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Health Status", Budapest, November 2005
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definition
ICF :
Body Functions 
specific mental functions
Emotional functions (b152): related to the feeling and
affective components of
the process of the mind
Inclusions:
functions of appropriate emotions and range of
emotion, affect, sadness, happiness, love, fear,
anger, tension, anxiety, joy, sorrow, ability of
emotion, flattening of affect.
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Health Status", Budapest, November 2005
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two main aspects:
happiness
and depression
affect
Emotional functions
Mental functions
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Health Status", Budapest, November 2005
(ICF)
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tools used




various National Health Interview surveys
European Health Status Module (SF-36 MH module)
CIDI – short form
World Health Survey
main outcomes
 reference period: “the past 4 weeks/ 2 weeks in the
last 12 months /last 30 days”.
 response categories: mainly measure the frequency
in time spent being in a certain emotional state.
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Health Status", Budapest, November 2005
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Selection of the instrument
Comparing the instruments, the MH module of SF-36 was
selected for following reasons:

WHS and CIDI Short Form are mainly oriented to the
measure of negative emotional states

CIDI Short Form seems to be of difficult comprehension
for the respondents due to the double time reference
period (2 weeks in a raw within the last 12 months)

SF 36 Mental Health is oriented to measure positive and
negative emotional states; it is widely used in HIS and it is
easy to administer with different data collection techniques
in population surveys.
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how it is measured in SF 36
 Positive emotional state
 Calm and peaceful
 Feel happy
 Negative emotional state
 Feel down in dumps
 Feel down hearted
 Feel nervous
From SF - 36
A lot of specific aspects from both emotional states are excluded. To
analyze depression, for example, several other items are considered in
measurement scales used in psychiatry but including them the
parsimonious criteria couldn’t be respected.
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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first proposal and reviews

The initial proposal was the European
Health Status Module that includes the
Mental Health scale of SF-36 (except the
quest of feeling nervous).

After a discussion within the TF, aiming
to introduce a measure of intensity, just two
questions out of five were selected.
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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proposed items (1)
 AFF-1. How much, during the past 4 weeks have you
been happy?
 All of the time
 Most of the time
 Some of the time
 A little of the time
 None of the time
 AFF-2. How much, during the past 4 weeks have you felt
down-hearted and depressed?
 All of the time
 Most of the time
 Some of the time
 A little of the time
 None of the time
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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Proposed items (2)
 AFF-3. Thinking about the past 4 weeks, on a scale from 1-100 how
intense was the level of happiness on average: 0 is lowest level and 100
is the highest level imaginable.
Not happy at all
As happy as I could ever imagine
|____________________________________________________________|
|
|
0
100
 AFF-4. Thinking about the past 4 weeks, on a scale from 1-100 how
intense was the level of depression on average: 0 is lowest level and
100 is the highest level imaginable.
Not depressed at all
The highest level of depression imaginable
|____________________________________________________________|
|
|
0
100
WHO-Eurostat-UNECE Meeting "Measurement of
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Health Status", Budapest, November 2005
issues of the proposed items
 Include both positive and negative aspects;
 Measure the frequency of the emotional state;
 Measure the intensity of the emotional state;
 Uni-dimensional items
 Simplicity and clarity of wording;
 Number of countries using the questions (translated
into many languages and wide knowledge of instrument);
 Limited number of questions make it very difficult to
detect this specific domain
 use of medicines?
 reference period?
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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vision
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Health Status", Budapest, November 2005
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Definition
ICF
Body Functions 
Sensory functions 
Seeing functions 
Visual acuity functions (b2100):
seeing functions of sensing form and
contour, both binocular and monocular,
for both distant and near vision.
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two main aspects:
 seeing from near
 seeing from far
vision
Seeing functions
Sensory functions
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
(ICF)
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How it is measured
 Seeing from near:
 arms length
 one meter distance
 newsprint letters.
 Seeing from far:
 across the street
 four meters distance
 20 meters distance
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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Tools used
 various National Health Interview surveys
 European Health Status Module
 World Health Survey.
Main outcomes
 time reference: mainly not included
 response categories: mainly focalized for the
individuation of the problem rather than measuring
severity
 visual aids: most of surveys clarify if included or not
WHO-Eurostat-UNECE Meeting "Measurement of
Health Status", Budapest, November 2005
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First proposal and reviews

The initial proposal was the adapted
European Health Status Module
integrated with a question of WHS on
the use of visual aids.

After a discussion within the TF, the
answering categories were changed in
order to measure the severity of
sight problem.
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Health Status", Budapest, November 2005
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Proposed items (1)
 VIS-1. Do [you/he/she] wear glasses, contact lenses or
other visual aids?
(If Respondent says YES to this question, preface the next 2
questions with "Please answer the following questions taking
into account your glasses, contact lenses or other visual
aids ".)
Yes
No
I am /he is /she is blind or I/he/she cannot see at all
section)
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Health Status", Budapest, November 2005
(next
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Proposed items (2)
 VIS-2. How clearly can [you/he/she] see newspaper
print?
Perfectly clearly
Very clearly
Somewhat clearly
Not very clearly
Not at all clearly
 VIS-3. How clearly can [you/he/she] see the face of
someone 4 metres away?
Perfectly clearly
Very clearly
Somewhat clearly
Not very clearly
WHO-Eurostat-UNECE Meeting "Measurement of
Not at all clearly
Health Status", Budapest, November 2005
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issues of the proposed items
 Identification of use of visual aids or being blind;
 Identification seeing difficulties considering use of visual
aids;
 Measure the level of severity of the problem;
 Number of countries using the questions;
 Simplicity and clarity of wording;
 Improving the cross-cultural comparability (standard
formulas i.e. distance in meters).
 Answer categories?
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