Clinical Section Gerontology 25: 345-349 (1979)
Use of a Self-Administered Postal Questionnaire when Screening for Health Problems in the Elderly G.K. Wilcock Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford
Key Words. Health screening programmes ■Postal questionnaire • Immobility problems ■Joints Abstract. The feasibility and value of conducting health screening programmes for elderly
It is widely recognised that elderly people often attribute symptoms of disease to the relentless progression of normal senescence. Many studies have revealed the great value of screening procedures in older people and the extent to which pathology exists unreported by elderly patients ( Williamson et al., 1964; Akhtar, 1972; Currie et al., 1974; Wilcock, 1977). The detection of unreported disease should continue and possible expand to play a major part in health care, but it is essential, particular ly at a time of economic restraint, to limit screening procedures to the detection of condi tions which occur frequently enough to be important, and to utilize the most effective and least expensive methods available. Most screen ing procedures have employed the use of trained personnel, especially nurses, health visi tors and doctors. It has been suggested that health visitors in particular could have an im
portant role in screening the elderly for physi cal disabilities ( Williamson et al., 1964). How ever, although the situation has improved since Donald (1971) emphasised the paucity of health visitors in relation to the number of General Practitioners in Britain, they are still few in number compared to the number of elderly persons, and many of them concentrate on the paediatric end of the spectrum of health care. It therefore seems appropriate to empha sise the advantages of self-administered postal screening procedures as an adjunct to the sur vey of disease in the older age group. These procedures obviate the necessity for trained interviewers, and have been shown to be at least comparable and often superior to interviewer administered questionnaires (Stouffer et al., 1950; Metzner and Mann, 1952; Young, 1972). They are also inexpensive. There are, however, disadvantages in their use, e.g., it is necessary to
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
people using self-administered postal questionnaires is discussed in relation to the outcome of a community study of mobility problems in the elderly. It is argued that this procedure minimizes the work and expense involved in organising and carrying out such programmes.
Wilcock
346
Method This is described below in outline only, since it is reported in detail elsewhere (Wilcock, 1977). 536 persons identified from a computer list of patients aged 65 years or over in a single general practice in Oxfordshire were sent a postal questionnaire asking for information concerning certain common, treatable, conditions which interfere with mobility (fig. 1). The main purpose of this was to enquire about arthritis of the hip and knee, but the opportunity was also taken to ask about other conditions. The letter printed above the questionnaire included reference to the recipient’s general practitioner, and also bore the practice address, in the hope that this would make the questionnaire seem less unfamiliar.
Table I. Response to postal questionnaire
n
%
Replies to First questionnaire Second questionnaire Neither questionnaire
454 50 32
85 9 6
Total
536
100
The number of questions was kept to a minimum (six), and each only required a ring placed around the answer. A second questionnaire with a covering letter was sent to everybody who had not replied to the first after a month. Arrangements were made at the health centre for the collection of replies, and a stamped addressed envelope was included with the question naire.
Results
Of the 536 questionnaires sent out at the beginning of the study, 454 (85%) were re turned within the first 4 weeks (table I). The second questionnaire, sent to all those who had not returned the first, brought a further 50 replies (9%). The overall response to the two mailings was therefore 94%, leaving only 6% of persons (32 people) from whom neither ques tionnaire was returned. The writer visited the homes of all persons who had failed to return either questionnaire. It was found that of these 32 ‘non-responders’, 20 had died or left the area before the study began (and together with 58 other persons already known from returned questionnaires to be in this category, they totalled 78 persons incor rectly included on the general practice list). 3 people out of the remaining 12 refused to participate, and 8 did not have any symptoms and were fully mobile. Finally, 1 person was found to have arthritic symptoms but neverthe less still refused to be examined. In summary, therefore, the true size of the population surveyed was 458, of whom only four refused to participate. In addition, one other person was excluded because she was too confused to answer questions. This gives a lapse rate for the study of approximately 1%. The medical conditions discovered during the screening programme are reported in detail elsewhere ( Wilcock, 1977).
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
devise simple straightforward questions, and one can never be certain that the reply is the unaided work of the intended respondent. The advantages and disadvantages are discussed in detail by Bennett and Ritchie ( 1975). The self-administered postal screening ques tionnaire technique was used in a survey of some mobility problems in the elderly ( Wil cock, 1977). Mobility was chosen as a subject of this particular study since it is one of the major bastions of independence, and nowhere is this more so than in the elderly, where it often assists an individual to cope with the increasing pathologies which accumulate with age.
Use of Self-Administered Postal Questionnaire
Ref:
347
The Health Centre Coker Close Bicester, Oxon
Dear Your family doctor and I are trying to find out which of his patients have difficulty in walking, on account of some medical condition which might be treatable. Please would you answer the questions below concerning pain and stiffness in your legs and discomfort in your feet. This is being sent to most people aged 65 or over, so please excuse us, and fill it in anyway, even if it asks you some things your doctor already knows about. Please will you fill it in, even if there is nothing wrong, and return it in the enclosed envelope, which does not need a stamp. Please put a ring round your answers: Does pain or stiffness in either of your hips or groins make walking difficult? Does pain in either of your thighs make walking difficult? Does pain or stiffness in either of your knees make walking difficult? Does pain or stiffness in either of your legs (below your knees) make walking difficult? Do ulcers, bunions, corns or sore places on your feet make walking difficult? Does swelling of your ankles or feet make it difficult for you to get your shoes on?
YES YES YES
NO NO NO
YES YES
NO NO
YES
NO
Thank you very much for filling this in. Yours sincerely
¿LDr G.K. Wilcock
Discussion
The overall lapse rate in the survey is less than that reported for most other surveys of this nature. Variable results have been obtained in response to general surveys into the health
and welfare of the elderly. Evans et al. (1970) obtained an acceptance rate of only 55%, and Pike (1969) of 43%. Williamson (1970) initially found that only 50% accepted when he sur veyed three general practices, although this gradually rose to approximately 80% during the
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
Fig. 1
study. Two other authors also experienced re sponse rates of approximately 80% (Milne et al., 1971; Akhtar, 1972). Currie et al. (1974) on the other hand obtained a response rate of 95% from their population of elderly patients aged 7 0 -7 2 years, and Williams et al. (1972) found that 87% of 297 patients aged over 75 years in Bolton, Lancashire, participated in their study (Currie et al., 1974; Williams et al., 1972). Considering the response to the postal survey alone, it was of interest that similar results have been reported from other workers conducting such surveys among the elderly (Meyrick and Cox, 1969). It is possible that the attempts to identify the survey with the general practice setting may have made an important contribution to the high level of response. This could indicate that surveys of this type should be included as part of the general practice screening of the elderly, in conjunction with age/sex registers. At a time when it is becoming common for family doctors to visit even their elderly patients less frequently than in the past, postal screening, followed up by the health vis itor attached to the practice, and supervised over all by the general practitioner, could make a valu able contribution to the care of the elderly. Although some authors have suggested that the health of elderly people who decline to participate in medical screening surveys differs little from those who take part, this is not generally accepted, especially for the popula tion as a whole (Milne et al., 1971; Akhtar, 1972; Burgess and Tierney, 1970). However, if a survey is being conducted for health rather than research purposes, it is important to iden tify those persons who fail to respond but who nevertheless have symptoms of disease. Postal screening, if carefully planned, will result in few people failing to respond. It is difficult to be certain how frequently old people should be screened, and at what age
Wilcock
screening should be started, although the major ity of studies have concentrated on persons of at least 70 years of age. Since morbidity in creases with advancing years, it would be sen sible to screen more elderly people more fre quently. There will, however, be regional varia tions in the number and fitness of elderly persons. The ideal interval between successive screening procedures in different geographical areas would best be determined by a process of trial and error, initially for instance screening the 70-79 year olds yearly, and those aged 80 years and over every 6 months. This could then be adjusted in the light of local requirements. Interpreting the results of prevalence surveys requires caution. Whilst many persons will be found to have symptoms which need treatment, there will be others in whom the symptoms are minimal. In a community study of elderly people with arthritis, it was found that 74% of persons with previously undiagnosed and un treated symptoms had minimal, if any, disabil ity (Wilcock, 1977). The numbers were small, however, only 43 out of a population of 631 people over 65 years old had untreated arthritic symptoms. The majority of these people prob ably required observation rather than therapy, but it was at times difficult to resist recom mending treatment, especially when it was re quested. Prevalence surveys may also be of value when planning the provision of health service resources, but it is important not to base estimates of future need on the absolute preva lence of the condition discovered, but upon the number of people requiring intervention. The submerged bulk of the ‘ice-berg’ of disease is probably in part a reservoir of patients in whom symptoms unknown to their doctor and un treated, may progress until the sufferer decides to seek medical advice for a complaint which up until then really did not need treatment.
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348
Use of Self-Administered Postal Questionnaire
References Akhtar, A.J.: Refusal to participate in a survey of the elderly. Geront. Clin. 14: 205-211 (1972). Bennett, A.E. and Ritchie, K.: Questionnaires in medi cine (Nuffield Provincial Hospitals Trust, London 1975). Burgess, A.M. and Tierney, J.T.: Bias due to non response in a male survey of Rhode Island physi cian smoking habits. New Engl. J. Med. 282: 908 (1970). Currie, G.; MacNcill, R.M.; Walker, J.G.; Barnie, E., and Mudie, E.W.: Medical and social screening of patients aged 70 72 by an urban general practice health team. Br. med. J. ii: 108-111 (1974). Donald, A.G.: Health visitor attachment. Update 1: 305-307 (1971). Evans, S.M.; Wilkes, E., and Dairymple-Smith, D.: Growing old. A country practice survey. J. R. Coll, gen. Pract. 20: 278-284 (1970). Metzner, H. and Mann, F.: A limited comparison of two methods of data collection. The fixed alterna tive questionnaire and the open-ended interview. Am. soc. Rev. 17: 486 492(1952). Meyrick, R.L. and Cox, A.: A geriatric survey repeat ed. Lancet i: 1146-1149(1969).
Milne, J.S.; Maule, M.M., and Williamson, J.: Method of sampling in a study of older people with a comparison of respondents and non-respondents. Br. J. prev. soc. Med. 25: 37- 41 (1971). Pike, L.A.: A screening programme for the elderly in a general practice. Practitioner 203: 805-812 (1969). Stouffer, S.A.; Guttman, L.; Suchman, E.A.; Lazarsfeld, P.F.; Star, S.A., and Clausen, J.A.: in Mea surement and prediction, p. 718 (Princeton Uni versity Press, Princeton 1950). Wilcock, G.K.: The prevalence of severe osteoarthrosis of the hip in the elderly and an assessment of the benefits of total hip replacement to the older patient and the community; thesis Oxford (1977). Williams, E.I.; Bennett, E.M.; Nixon, J.V.; Nicholson, M.R., and Gabert, J.: Sociomedical study of pa tients over 75 in general practice. Br. med. J. ii: 445-448 (1972). Williamson, J.; Stokoe, I.H.; Gray, S.; Fisher, M.; Smith, A.; McGee, A., and Stephenson, E.: Old people at home —their unreported needs. Lancet i; 1117-1120(1964). Williamson, J.: Preventive aspects of geriatric medi cine. Mod. Geriat. 1: 24 28 (1970). Young, D.W.: Comparison of information collected by a questionnaire with that in the patient’s hospital record. Meth. inform. Med. 11: 20-22 (1972).
Received: December 7, 1978 Accepted: January 4, 1979 G.K. Wilcock, Consultant Physician, Cowley Road Hospital, Oxford OX4 1XB (England)
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In conclusion, it would appear that the self-administered postal questionnaire as a means of detecting previously undiagnosed dis ease in the elderly is worthwhile despite reports to the contrary (Bennett and Ritchie, 1975), and with a minimum of follow-up by trained medical or para-medical staff the great majority of an elderly population can be effectively and reliably screened with the minimum of expense.
349
Use of a Self-Administered Postal Questionnaire when Screening for Health Problems in the Elderly G.K. Wilcock Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford
Key Words. Health screening programmes ■Postal questionnaire • Immobility problems ■Joints Abstract. The feasibility and value of conducting health screening programmes for elderly
It is widely recognised that elderly people often attribute symptoms of disease to the relentless progression of normal senescence. Many studies have revealed the great value of screening procedures in older people and the extent to which pathology exists unreported by elderly patients ( Williamson et al., 1964; Akhtar, 1972; Currie et al., 1974; Wilcock, 1977). The detection of unreported disease should continue and possible expand to play a major part in health care, but it is essential, particular ly at a time of economic restraint, to limit screening procedures to the detection of condi tions which occur frequently enough to be important, and to utilize the most effective and least expensive methods available. Most screen ing procedures have employed the use of trained personnel, especially nurses, health visi tors and doctors. It has been suggested that health visitors in particular could have an im
portant role in screening the elderly for physi cal disabilities ( Williamson et al., 1964). How ever, although the situation has improved since Donald (1971) emphasised the paucity of health visitors in relation to the number of General Practitioners in Britain, they are still few in number compared to the number of elderly persons, and many of them concentrate on the paediatric end of the spectrum of health care. It therefore seems appropriate to empha sise the advantages of self-administered postal screening procedures as an adjunct to the sur vey of disease in the older age group. These procedures obviate the necessity for trained interviewers, and have been shown to be at least comparable and often superior to interviewer administered questionnaires (Stouffer et al., 1950; Metzner and Mann, 1952; Young, 1972). They are also inexpensive. There are, however, disadvantages in their use, e.g., it is necessary to
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
people using self-administered postal questionnaires is discussed in relation to the outcome of a community study of mobility problems in the elderly. It is argued that this procedure minimizes the work and expense involved in organising and carrying out such programmes.
Wilcock
346
Method This is described below in outline only, since it is reported in detail elsewhere (Wilcock, 1977). 536 persons identified from a computer list of patients aged 65 years or over in a single general practice in Oxfordshire were sent a postal questionnaire asking for information concerning certain common, treatable, conditions which interfere with mobility (fig. 1). The main purpose of this was to enquire about arthritis of the hip and knee, but the opportunity was also taken to ask about other conditions. The letter printed above the questionnaire included reference to the recipient’s general practitioner, and also bore the practice address, in the hope that this would make the questionnaire seem less unfamiliar.
Table I. Response to postal questionnaire
n
%
Replies to First questionnaire Second questionnaire Neither questionnaire
454 50 32
85 9 6
Total
536
100
The number of questions was kept to a minimum (six), and each only required a ring placed around the answer. A second questionnaire with a covering letter was sent to everybody who had not replied to the first after a month. Arrangements were made at the health centre for the collection of replies, and a stamped addressed envelope was included with the question naire.
Results
Of the 536 questionnaires sent out at the beginning of the study, 454 (85%) were re turned within the first 4 weeks (table I). The second questionnaire, sent to all those who had not returned the first, brought a further 50 replies (9%). The overall response to the two mailings was therefore 94%, leaving only 6% of persons (32 people) from whom neither ques tionnaire was returned. The writer visited the homes of all persons who had failed to return either questionnaire. It was found that of these 32 ‘non-responders’, 20 had died or left the area before the study began (and together with 58 other persons already known from returned questionnaires to be in this category, they totalled 78 persons incor rectly included on the general practice list). 3 people out of the remaining 12 refused to participate, and 8 did not have any symptoms and were fully mobile. Finally, 1 person was found to have arthritic symptoms but neverthe less still refused to be examined. In summary, therefore, the true size of the population surveyed was 458, of whom only four refused to participate. In addition, one other person was excluded because she was too confused to answer questions. This gives a lapse rate for the study of approximately 1%. The medical conditions discovered during the screening programme are reported in detail elsewhere ( Wilcock, 1977).
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
devise simple straightforward questions, and one can never be certain that the reply is the unaided work of the intended respondent. The advantages and disadvantages are discussed in detail by Bennett and Ritchie ( 1975). The self-administered postal screening ques tionnaire technique was used in a survey of some mobility problems in the elderly ( Wil cock, 1977). Mobility was chosen as a subject of this particular study since it is one of the major bastions of independence, and nowhere is this more so than in the elderly, where it often assists an individual to cope with the increasing pathologies which accumulate with age.
Use of Self-Administered Postal Questionnaire
Ref:
347
The Health Centre Coker Close Bicester, Oxon
Dear Your family doctor and I are trying to find out which of his patients have difficulty in walking, on account of some medical condition which might be treatable. Please would you answer the questions below concerning pain and stiffness in your legs and discomfort in your feet. This is being sent to most people aged 65 or over, so please excuse us, and fill it in anyway, even if it asks you some things your doctor already knows about. Please will you fill it in, even if there is nothing wrong, and return it in the enclosed envelope, which does not need a stamp. Please put a ring round your answers: Does pain or stiffness in either of your hips or groins make walking difficult? Does pain in either of your thighs make walking difficult? Does pain or stiffness in either of your knees make walking difficult? Does pain or stiffness in either of your legs (below your knees) make walking difficult? Do ulcers, bunions, corns or sore places on your feet make walking difficult? Does swelling of your ankles or feet make it difficult for you to get your shoes on?
YES YES YES
NO NO NO
YES YES
NO NO
YES
NO
Thank you very much for filling this in. Yours sincerely
¿LDr G.K. Wilcock
Discussion
The overall lapse rate in the survey is less than that reported for most other surveys of this nature. Variable results have been obtained in response to general surveys into the health
and welfare of the elderly. Evans et al. (1970) obtained an acceptance rate of only 55%, and Pike (1969) of 43%. Williamson (1970) initially found that only 50% accepted when he sur veyed three general practices, although this gradually rose to approximately 80% during the
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
Fig. 1
study. Two other authors also experienced re sponse rates of approximately 80% (Milne et al., 1971; Akhtar, 1972). Currie et al. (1974) on the other hand obtained a response rate of 95% from their population of elderly patients aged 7 0 -7 2 years, and Williams et al. (1972) found that 87% of 297 patients aged over 75 years in Bolton, Lancashire, participated in their study (Currie et al., 1974; Williams et al., 1972). Considering the response to the postal survey alone, it was of interest that similar results have been reported from other workers conducting such surveys among the elderly (Meyrick and Cox, 1969). It is possible that the attempts to identify the survey with the general practice setting may have made an important contribution to the high level of response. This could indicate that surveys of this type should be included as part of the general practice screening of the elderly, in conjunction with age/sex registers. At a time when it is becoming common for family doctors to visit even their elderly patients less frequently than in the past, postal screening, followed up by the health vis itor attached to the practice, and supervised over all by the general practitioner, could make a valu able contribution to the care of the elderly. Although some authors have suggested that the health of elderly people who decline to participate in medical screening surveys differs little from those who take part, this is not generally accepted, especially for the popula tion as a whole (Milne et al., 1971; Akhtar, 1972; Burgess and Tierney, 1970). However, if a survey is being conducted for health rather than research purposes, it is important to iden tify those persons who fail to respond but who nevertheless have symptoms of disease. Postal screening, if carefully planned, will result in few people failing to respond. It is difficult to be certain how frequently old people should be screened, and at what age
Wilcock
screening should be started, although the major ity of studies have concentrated on persons of at least 70 years of age. Since morbidity in creases with advancing years, it would be sen sible to screen more elderly people more fre quently. There will, however, be regional varia tions in the number and fitness of elderly persons. The ideal interval between successive screening procedures in different geographical areas would best be determined by a process of trial and error, initially for instance screening the 70-79 year olds yearly, and those aged 80 years and over every 6 months. This could then be adjusted in the light of local requirements. Interpreting the results of prevalence surveys requires caution. Whilst many persons will be found to have symptoms which need treatment, there will be others in whom the symptoms are minimal. In a community study of elderly people with arthritis, it was found that 74% of persons with previously undiagnosed and un treated symptoms had minimal, if any, disabil ity (Wilcock, 1977). The numbers were small, however, only 43 out of a population of 631 people over 65 years old had untreated arthritic symptoms. The majority of these people prob ably required observation rather than therapy, but it was at times difficult to resist recom mending treatment, especially when it was re quested. Prevalence surveys may also be of value when planning the provision of health service resources, but it is important not to base estimates of future need on the absolute preva lence of the condition discovered, but upon the number of people requiring intervention. The submerged bulk of the ‘ice-berg’ of disease is probably in part a reservoir of patients in whom symptoms unknown to their doctor and un treated, may progress until the sufferer decides to seek medical advice for a complaint which up until then really did not need treatment.
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
348
Use of Self-Administered Postal Questionnaire
References Akhtar, A.J.: Refusal to participate in a survey of the elderly. Geront. Clin. 14: 205-211 (1972). Bennett, A.E. and Ritchie, K.: Questionnaires in medi cine (Nuffield Provincial Hospitals Trust, London 1975). Burgess, A.M. and Tierney, J.T.: Bias due to non response in a male survey of Rhode Island physi cian smoking habits. New Engl. J. Med. 282: 908 (1970). Currie, G.; MacNcill, R.M.; Walker, J.G.; Barnie, E., and Mudie, E.W.: Medical and social screening of patients aged 70 72 by an urban general practice health team. Br. med. J. ii: 108-111 (1974). Donald, A.G.: Health visitor attachment. Update 1: 305-307 (1971). Evans, S.M.; Wilkes, E., and Dairymple-Smith, D.: Growing old. A country practice survey. J. R. Coll, gen. Pract. 20: 278-284 (1970). Metzner, H. and Mann, F.: A limited comparison of two methods of data collection. The fixed alterna tive questionnaire and the open-ended interview. Am. soc. Rev. 17: 486 492(1952). Meyrick, R.L. and Cox, A.: A geriatric survey repeat ed. Lancet i: 1146-1149(1969).
Milne, J.S.; Maule, M.M., and Williamson, J.: Method of sampling in a study of older people with a comparison of respondents and non-respondents. Br. J. prev. soc. Med. 25: 37- 41 (1971). Pike, L.A.: A screening programme for the elderly in a general practice. Practitioner 203: 805-812 (1969). Stouffer, S.A.; Guttman, L.; Suchman, E.A.; Lazarsfeld, P.F.; Star, S.A., and Clausen, J.A.: in Mea surement and prediction, p. 718 (Princeton Uni versity Press, Princeton 1950). Wilcock, G.K.: The prevalence of severe osteoarthrosis of the hip in the elderly and an assessment of the benefits of total hip replacement to the older patient and the community; thesis Oxford (1977). Williams, E.I.; Bennett, E.M.; Nixon, J.V.; Nicholson, M.R., and Gabert, J.: Sociomedical study of pa tients over 75 in general practice. Br. med. J. ii: 445-448 (1972). Williamson, J.; Stokoe, I.H.; Gray, S.; Fisher, M.; Smith, A.; McGee, A., and Stephenson, E.: Old people at home —their unreported needs. Lancet i; 1117-1120(1964). Williamson, J.: Preventive aspects of geriatric medi cine. Mod. Geriat. 1: 24 28 (1970). Young, D.W.: Comparison of information collected by a questionnaire with that in the patient’s hospital record. Meth. inform. Med. 11: 20-22 (1972).
Received: December 7, 1978 Accepted: January 4, 1979 G.K. Wilcock, Consultant Physician, Cowley Road Hospital, Oxford OX4 1XB (England)
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:32:29 AM
In conclusion, it would appear that the self-administered postal questionnaire as a means of detecting previously undiagnosed dis ease in the elderly is worthwhile despite reports to the contrary (Bennett and Ritchie, 1975), and with a minimum of follow-up by trained medical or para-medical staff the great majority of an elderly population can be effectively and reliably screened with the minimum of expense.
349
