575339 research-article2015
SJP0010.1177/1403494815575339A. Westergren et al.Malnutrition Screening using SCREEN II
Scandinavian Journal of Public Health, 2015; 43: 667–671
Short Communication
A Swedish version of the SCREEN II for malnutrition assessment among community-dwelling elderly
Albert Westergren, Atika Khalaf & Peter Hagell PRO-CARE Group, School of Health and Society, Kristianstad University, Kristianstad, Sweden
Abstract Background: The Seniors in the Community: Risk Evaluation for Eating and Nutrition II (SCREEN II) Questionnaire assesses nutritional risk among elderly people living at home. Our aim was to produce a Swedish language version of the SCREEN II and to examine response patterns, data completeness and the relationship between malnutrition and general health. Methods: The SCREEN II was translated into Swedish using dual panel methodology, and then followed up with field test interviews of 24 seniors (median age, 83 years). We used the survey data (n = 565) to assess item and score distribution, missing responses, and the relationship to the subject’s general and nutritional health. Results: The Swedish SCREEN II was considered easy to understand, respond to, and relevant (n = 21; 88% of subjects found it so in all three respects) and its median completion time was 5 minutes. The level of survey item data completeness was 94–99%, and 82% of surveys had computable total scores. Of those subjects with completed forms, 35% had no nutritional risk; 35% had moderate risk; and 30% were at high risk. The malnutrition risk increased with poorer perceived health. Conclusions: Our study results are similar to those using previous SCREEN II versions, indicating that the scale adaptation was successful and providing initial support for use of the Swedish SCREEN II Questionnaire. Key Words: SCREEN II, malnutrition, home-dwelling
Background Malnutrition does not only include undernutrition, but also overweight/obesity and nutrient deficiencies. For example, the prevalence of undernutrition in the elderly home-dwelling population was estimated to be 14.5%, according to the Mini Nutritional Assessment (MNA) [1]; while another study, using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN) Questionnaire among homedwelling seniors, found that 24% had moderate and 33% had high malnutrition risk [2]. In addition, malnutrition risk increased with poorer health [3]. The MNA was developed to assess undernutrition risk among geriatric patients and was originally not intended for self-assessment [1] . The SCREEN II was developed to identify any nutrition problems, also at an early stage, among home-dwelling elderly persons and
can either be self- or interviewer administered [2–4] From a public health perspective, it is important to detect malnutrition risk and take actions against it, because malnutrition can have serious health consequences [5–12]. SCREEN II seems more optimal to use among home-dwelling elderly persons than the MNA due to facilitating early detection of risk, that it is specifically developed for this population, and can be either self- or interviewer administered [2-4]. However, the availability of scientifically documented non-English versions appears limited. This study describes the translation into Swedish and subsequent application of the SCREEN II Questionnaire, to assess response patterns, data completeness and the relationship between malnutrition and general health.
Correspondence: Albert Westergren, PRO-CARE Group, School of Health and Society, Kristianstad University, Elmetorpsvägen 15, SE-291 88 Kristianstad, Sweden. E-mail: [email protected] (Accepted 9 February 2015) © 2015 the Nordic Societies of Public Health DOI: 10.1177/1403494815575339
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668 A. Westergren et al. Methods Screen II Questionnaire SCREEN II is a 14-item rating scale (with sub-questions regarding weight change and meal preparation) to assess the risk of malnutrition in ordinary housing, based on subjects’ self-reports [3]. Items have different ranges (typically 0–4) and it yields a total score ranging from 0 to 64 (higher scores are better). It has been suggested that total scores of 50–53 indicate moderate nutritional risk and scores < 50, a high nutritional risk. For individual items, scores ⩽ 2 have been suggested as indicating risk [3]. Translation of the SCREEN II into Swedish and a field-test evaluation The SCREEN II Questionnaire was translated using the dual-panel methodology [13,14], emphasising conceptual, rather than linguistic equivalence. The instrument was first translated from English into Swedish by a bilingual panel, comprised of seven individuals fluent in both languages. The panel worked together to agree on the most appropriate translations. The translated version was then reviewed by a second panel of six lay people, to ensure clarity and acceptability of language. Following this translation, the Swedish SCREEN II was field tested with a convenience sample of 24 community-dwelling seniors (age mean of 78.5 (SD 11.8) years and median of 83 (q1 to q3 of 65.7–88.7) years), of whom nine received ‘meals on wheels’. Three participants were healthy and the others suffered from disease (e.g. Parkinson’s disease, multiple sclerosis, cardiovascular disease and diabetes mellitus). Participants completed the SCREEN II (selfadministered) in the presence of an interviewer, whom noted the time taken to complete the questionnaire (as an indicator of respondent burden: It should be ⩽ 10 minutes [15,16]), and whether any problems were experienced by the interviewees. Participants were then interviewed regarding the understandability and relevance of the Swedish SCREEN II, and were asked to suggest potential improvements [14]. Any ambiguities and potential revisions during the translation process were discussed with the developer of the SCREEN II (Heather Keller). Quantitative survey. The Swedish SCREEN II Questionnaire was then used in a cross-sectional survey, conducted within an established structure for preventive home visits (PHV) [17–19] targeting all elderly people without home-help service, in a Swedish municipality with approximately 12,500 inhabitants [20,21]. Two experienced nurses collected the data during a single home visit. Each PHV lasted for
about 1 hour. Inclusion criteria were being 70 years or older and without home-help service. Exclusion criteria were: cognitive deficits, enteral and parenteral nutrition. Besides SCREEN II, four single items were used: general health (very good, quite good, quite poor and very poor); tiredness/fatigue (almost never, sometimes, often and always); and lowspiritedness (almost never, sometimes, often and always). The questions were interviewer-administered to 565 cognitively intact (clinical judgement of experienced nurses) persons. Analyses. Data were assessed regarding underpinning assumptions, and were described and analysed accordingly, using the t-, Chi-square, KruskalWallis and Mann-Whitney U-tests. Significance was set at p < 0.05. Percentages of missing item responses were calculated as an additional indicator of respondent acceptability (should be ⩽ 10% [22]). All analyses were conducted using Stata MP, version 13.1. Results Translation of the SCREEN II into Swedish and field-test evaluation The translation process resulted in a few cultural adjustments, following discussions with the questionnaire developer. For example, peanut butter (seldom used in Sweden, particularly among the elderly) was replaced with ‘other meat alternatives’, and the estimation of beverage intake was changed to ‘glass’ instead of ‘cup’. Additional minor clarifications and changes in the order of the questions (to not start with the weight question) were made as a result of feedback from the first eight field test participants; no further needs for modification were identified among the subsequent 16 field test interviews. All questions were considered easy to understand, easy to respond to and relevant by 21 subjects (88%). The SCREEN II was completed in a median of 5 minutes (q1–q3 in 3.5–17.5; min–max 3–40). Quantitative survey Out of 565 respondents, 465 (82%) had complete SCREEN II forms, allowing for the calculation of total scores. Those with incomplete SCREEN II forms were slightly older than those with complete forms, and they reported significantly more tiredness/fatigue and low-spiritedness than those with complete forms (Table I). The share of respondents with missing data in individual items varied between < 1–6%; and having a score of ⩽ 2 in individual items varied between 1–86% (Table II).
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Malnutrition Screening using SCREEN II 669 Table I. Demographic characteristics of elderly persons living at home without home help service. Comparisons between those with and without complete SCREEN II responses.
Age Mean (SD) 95% CI Female gender, n (%) Living alone, n (%) General health, n (%)d Median (q1–q3) Mean (95% CI) Tiredness/fatigue, n (%)e Median (q1–q3) Mean (95% CI) Low-spiritedness, n (%)e Median (q1–q3) Mean (95% CI)
Complete (n = 465)
Incomplete (n = 100)
78.5 (3.7) 78.2–78.8 249 (54) 201 (43)
79.7 (4.8) 78.8–80.7 54 (54) 47 (47)
1 (0–1) 0.9 (0.8–0.9)
1 (1–1) 1.0 (0.8–1.1)
1 (0–1) 0.9 (0.8–0.9)
1 (0–2) 1.1 (0.9–1.2)
0 (0–1) 0.3 (0.3–0.4)
0 (0–1) 0.4 (0.3–0.6)
p-value 0.021a 0.935b 0.490b 0.159c 0.038c 0.038c
at-test. bChi-Square
test. U-test. dResponse categories: 0=very good, 1=quite good, 2=quite poor, and 3=very poor, missing data n=15. eResponse categories: 0=almost never, 1=sometimes, 2=often, and 3=always, missing data n=5. CI: confidence interval; q1–q3: quartile 1 and 3; SCREEN II: Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire, version II; SD: standard deviation. cMann-Whitney
Table II. Risk (item score ⩽ 2), response patterns, and missing responses for SCREEN II items among elderly persons living at home without home help service.a) Item score ⩽ 2 (n = 465)a)
Item (number in Swedish version) Response categories Fair/poor appetite (1) Response categories Often/always skip meals (2) Weight change (4a1–a3) Often/always difficulty with shopping groceries (13) Response categories Limits food (3) Sometimes/often use meal replacements (11) Cooking is a chore/dissatisfied with others cooking (14a–b) Response categories Have you tried to achieve weight change (4b) Think excess weight/less than should be (4c) Response categories
29 (6) 51 (11) 69 (15) 10 (2) 68 (15) 7 (1) 83 (18) 16 (3) 189 (41)
n = 465(%) 0 7 (1) 0 3 (< 1) 22 (5) 4 (1) 0 1 (
SJP0010.1177/1403494815575339A. Westergren et al.Malnutrition Screening using SCREEN II
Scandinavian Journal of Public Health, 2015; 43: 667–671
Short Communication
A Swedish version of the SCREEN II for malnutrition assessment among community-dwelling elderly
Albert Westergren, Atika Khalaf & Peter Hagell PRO-CARE Group, School of Health and Society, Kristianstad University, Kristianstad, Sweden
Abstract Background: The Seniors in the Community: Risk Evaluation for Eating and Nutrition II (SCREEN II) Questionnaire assesses nutritional risk among elderly people living at home. Our aim was to produce a Swedish language version of the SCREEN II and to examine response patterns, data completeness and the relationship between malnutrition and general health. Methods: The SCREEN II was translated into Swedish using dual panel methodology, and then followed up with field test interviews of 24 seniors (median age, 83 years). We used the survey data (n = 565) to assess item and score distribution, missing responses, and the relationship to the subject’s general and nutritional health. Results: The Swedish SCREEN II was considered easy to understand, respond to, and relevant (n = 21; 88% of subjects found it so in all three respects) and its median completion time was 5 minutes. The level of survey item data completeness was 94–99%, and 82% of surveys had computable total scores. Of those subjects with completed forms, 35% had no nutritional risk; 35% had moderate risk; and 30% were at high risk. The malnutrition risk increased with poorer perceived health. Conclusions: Our study results are similar to those using previous SCREEN II versions, indicating that the scale adaptation was successful and providing initial support for use of the Swedish SCREEN II Questionnaire. Key Words: SCREEN II, malnutrition, home-dwelling
Background Malnutrition does not only include undernutrition, but also overweight/obesity and nutrient deficiencies. For example, the prevalence of undernutrition in the elderly home-dwelling population was estimated to be 14.5%, according to the Mini Nutritional Assessment (MNA) [1]; while another study, using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN) Questionnaire among homedwelling seniors, found that 24% had moderate and 33% had high malnutrition risk [2]. In addition, malnutrition risk increased with poorer health [3]. The MNA was developed to assess undernutrition risk among geriatric patients and was originally not intended for self-assessment [1] . The SCREEN II was developed to identify any nutrition problems, also at an early stage, among home-dwelling elderly persons and
can either be self- or interviewer administered [2–4] From a public health perspective, it is important to detect malnutrition risk and take actions against it, because malnutrition can have serious health consequences [5–12]. SCREEN II seems more optimal to use among home-dwelling elderly persons than the MNA due to facilitating early detection of risk, that it is specifically developed for this population, and can be either self- or interviewer administered [2-4]. However, the availability of scientifically documented non-English versions appears limited. This study describes the translation into Swedish and subsequent application of the SCREEN II Questionnaire, to assess response patterns, data completeness and the relationship between malnutrition and general health.
Correspondence: Albert Westergren, PRO-CARE Group, School of Health and Society, Kristianstad University, Elmetorpsvägen 15, SE-291 88 Kristianstad, Sweden. E-mail: [email protected] (Accepted 9 February 2015) © 2015 the Nordic Societies of Public Health DOI: 10.1177/1403494815575339
Downloaded from sjp.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
668 A. Westergren et al. Methods Screen II Questionnaire SCREEN II is a 14-item rating scale (with sub-questions regarding weight change and meal preparation) to assess the risk of malnutrition in ordinary housing, based on subjects’ self-reports [3]. Items have different ranges (typically 0–4) and it yields a total score ranging from 0 to 64 (higher scores are better). It has been suggested that total scores of 50–53 indicate moderate nutritional risk and scores < 50, a high nutritional risk. For individual items, scores ⩽ 2 have been suggested as indicating risk [3]. Translation of the SCREEN II into Swedish and a field-test evaluation The SCREEN II Questionnaire was translated using the dual-panel methodology [13,14], emphasising conceptual, rather than linguistic equivalence. The instrument was first translated from English into Swedish by a bilingual panel, comprised of seven individuals fluent in both languages. The panel worked together to agree on the most appropriate translations. The translated version was then reviewed by a second panel of six lay people, to ensure clarity and acceptability of language. Following this translation, the Swedish SCREEN II was field tested with a convenience sample of 24 community-dwelling seniors (age mean of 78.5 (SD 11.8) years and median of 83 (q1 to q3 of 65.7–88.7) years), of whom nine received ‘meals on wheels’. Three participants were healthy and the others suffered from disease (e.g. Parkinson’s disease, multiple sclerosis, cardiovascular disease and diabetes mellitus). Participants completed the SCREEN II (selfadministered) in the presence of an interviewer, whom noted the time taken to complete the questionnaire (as an indicator of respondent burden: It should be ⩽ 10 minutes [15,16]), and whether any problems were experienced by the interviewees. Participants were then interviewed regarding the understandability and relevance of the Swedish SCREEN II, and were asked to suggest potential improvements [14]. Any ambiguities and potential revisions during the translation process were discussed with the developer of the SCREEN II (Heather Keller). Quantitative survey. The Swedish SCREEN II Questionnaire was then used in a cross-sectional survey, conducted within an established structure for preventive home visits (PHV) [17–19] targeting all elderly people without home-help service, in a Swedish municipality with approximately 12,500 inhabitants [20,21]. Two experienced nurses collected the data during a single home visit. Each PHV lasted for
about 1 hour. Inclusion criteria were being 70 years or older and without home-help service. Exclusion criteria were: cognitive deficits, enteral and parenteral nutrition. Besides SCREEN II, four single items were used: general health (very good, quite good, quite poor and very poor); tiredness/fatigue (almost never, sometimes, often and always); and lowspiritedness (almost never, sometimes, often and always). The questions were interviewer-administered to 565 cognitively intact (clinical judgement of experienced nurses) persons. Analyses. Data were assessed regarding underpinning assumptions, and were described and analysed accordingly, using the t-, Chi-square, KruskalWallis and Mann-Whitney U-tests. Significance was set at p < 0.05. Percentages of missing item responses were calculated as an additional indicator of respondent acceptability (should be ⩽ 10% [22]). All analyses were conducted using Stata MP, version 13.1. Results Translation of the SCREEN II into Swedish and field-test evaluation The translation process resulted in a few cultural adjustments, following discussions with the questionnaire developer. For example, peanut butter (seldom used in Sweden, particularly among the elderly) was replaced with ‘other meat alternatives’, and the estimation of beverage intake was changed to ‘glass’ instead of ‘cup’. Additional minor clarifications and changes in the order of the questions (to not start with the weight question) were made as a result of feedback from the first eight field test participants; no further needs for modification were identified among the subsequent 16 field test interviews. All questions were considered easy to understand, easy to respond to and relevant by 21 subjects (88%). The SCREEN II was completed in a median of 5 minutes (q1–q3 in 3.5–17.5; min–max 3–40). Quantitative survey Out of 565 respondents, 465 (82%) had complete SCREEN II forms, allowing for the calculation of total scores. Those with incomplete SCREEN II forms were slightly older than those with complete forms, and they reported significantly more tiredness/fatigue and low-spiritedness than those with complete forms (Table I). The share of respondents with missing data in individual items varied between < 1–6%; and having a score of ⩽ 2 in individual items varied between 1–86% (Table II).
Downloaded from sjp.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
Malnutrition Screening using SCREEN II 669 Table I. Demographic characteristics of elderly persons living at home without home help service. Comparisons between those with and without complete SCREEN II responses.
Age Mean (SD) 95% CI Female gender, n (%) Living alone, n (%) General health, n (%)d Median (q1–q3) Mean (95% CI) Tiredness/fatigue, n (%)e Median (q1–q3) Mean (95% CI) Low-spiritedness, n (%)e Median (q1–q3) Mean (95% CI)
Complete (n = 465)
Incomplete (n = 100)
78.5 (3.7) 78.2–78.8 249 (54) 201 (43)
79.7 (4.8) 78.8–80.7 54 (54) 47 (47)
1 (0–1) 0.9 (0.8–0.9)
1 (1–1) 1.0 (0.8–1.1)
1 (0–1) 0.9 (0.8–0.9)
1 (0–2) 1.1 (0.9–1.2)
0 (0–1) 0.3 (0.3–0.4)
0 (0–1) 0.4 (0.3–0.6)
p-value 0.021a 0.935b 0.490b 0.159c 0.038c 0.038c
at-test. bChi-Square
test. U-test. dResponse categories: 0=very good, 1=quite good, 2=quite poor, and 3=very poor, missing data n=15. eResponse categories: 0=almost never, 1=sometimes, 2=often, and 3=always, missing data n=5. CI: confidence interval; q1–q3: quartile 1 and 3; SCREEN II: Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire, version II; SD: standard deviation. cMann-Whitney
Table II. Risk (item score ⩽ 2), response patterns, and missing responses for SCREEN II items among elderly persons living at home without home help service.a) Item score ⩽ 2 (n = 465)a)
Item (number in Swedish version) Response categories Fair/poor appetite (1) Response categories Often/always skip meals (2) Weight change (4a1–a3) Often/always difficulty with shopping groceries (13) Response categories Limits food (3) Sometimes/often use meal replacements (11) Cooking is a chore/dissatisfied with others cooking (14a–b) Response categories Have you tried to achieve weight change (4b) Think excess weight/less than should be (4c) Response categories
29 (6) 51 (11) 69 (15) 10 (2) 68 (15) 7 (1) 83 (18) 16 (3) 189 (41)
n = 465(%) 0 7 (1) 0 3 (< 1) 22 (5) 4 (1) 0 1 (
