New modules for EHIS wave 2 (Physical activity, mental health)

1. New modules for EHIS wave 2(Physical activity, mental health)

2. Recommendations of the Core Group concerning an instrument on physical activity (March 1st, 2011) • The HIS Core group decided to go for simple validated behavioural questions, to look more at behaviour than potential health effects. Focus will be given to three areas: commuting (cycle, walk), work and sport. The aim is to identify groups of population that are active and prevalence of those activities

3. Purposes of the new proposed instrument • It‘s not on total physical activity -> it‘s focus is on health-enhancing PA • It‘s not designed to calculate MET equivalents • 3 separate indicators can be calculated : * work-related activities (for paid work and anpaid work related activities; * transportation related acitivities; * sports related activities • It enables to calculate whether the new WHO recommendations are met (algorithms are already developed)

4. WHO recommendations on PA 2010 (age group 18-64) WHO (2010) Global recommendations on physical activity for health. World Health Organization 2010

5. What does it mean “this is a ‘validated’ instrument” in the field of physical activity assessment? • It means that there was a validity study conducted but this does not mean that the validity of the instrument is good • In contrast, looking in detail on results of validity studies of PA questionnaires there is no single established instrument available which show good validity against the gold standard measurement accelerometer • IPAQ-short form showed ‘poor to fair’ validity and also GPAQ showed no better validity than IPAQ (both questionnaire use the concepts of distinguishes between “moderate” and “vigorous” activities) • IPAQ and GPAQ are the most established PA questionnaires in a international health survey context which use similar concepts

6. Criterion-related validity of the last 7-day, short form of the IPAQ in Sweden (Ekelund et al. 2006) Ekelund, U., Sepp, H., Brage, S., Becker, W., Jakes, R., Hennings, M., Wareham, N.J., 2006. Criterion-related validity of the last 7-day, short form of the International Physical Activity Questionnaire in Swedish adults. Public Health Nutrition 9, 258-265.

7. Discussing the validity of the IPAQ-SF/GPAQ questionnaire • Correlation coefficients ranged from 0.16 to 0.35, indicating “poor to fair” criterion validity of the IPAQ short form instrument • These correlation coefficients are similar to those obtained in the 12-country reliability and validity study of IPAQ (Craig et al. 2003) • Validity particularly low for walking and sitting as such daily activities are performed unconscious (are not controlled, planned or structured) and are therefore hard to remember • CT revealed that Rs did not manage to provide an exact estimate (in hours and minutes) for such activities (walking and sitting) which resulted in item non response for those questions • The Correlation Coefficients for vigorous activities were higher because such activities can be better controlled, planned and structured and are therefore easier to remember • The differentiation between vigorous and moderate activity might be reasonable from an analyzing point of view, however, Rs did not understand the underlying concepts - and even if they understood - they were not able to ‘squeeze’ their activities into such categories (Craig, C.L., Marshall, A.L., Sjöström, M., Bauman, A.E., Booth, M.L., Ainsworth, B.E., Pratt, M., Ekelund, U., Yngve, A., Sallis, J.F., 2003. International physical activity questionnaire: 12-country reliability and validity. Medicine & Science in Sports & Exercise 35, 1381.)

8. Lesson learned for the construction of the EHIS-PAQ • We used the “validated” instrument GPAQ as a basis for the new questionnaire in terms of benefitting from the development work done to define the PA domains and developing the wording of the questions • We removed the main disadvantages the CT and other studies revealed and made the questions more simple: • We removed the distinction between ”vigorous” and “moderate” activity and asking now for activities which are by definition AT LEAST moderate-intensity activities • We removed the requirement to indicate exact figures of average duration for daily activities which are difficult to recall such as walking or bicycling for transportation and provide categorical answer options instead • We kept the requirement to indicate exact figures for the sports and exercise section as such activities are controlled, planned and structured and Rs can therefore easier remember such activities. But we ask for the total time spend per week and not for the time spent on a typical day • We added a question of muscle-strengthening in order to be able to measure the new WHO PA recommendation compliance which distinguished for the first time between aerobic activity and muscle-strengthening activity

9. Overview of advantages of the EHIS-PAQ • It uses simple questions which are easy to answer (use of categorical answers scales, no distinction between “vigorous” and “moderate”) • It provides three stand-alone indicators for the most important physical activity dimension “work-related PA”, “transportation PA” and “sports, exercise and recreational activities” • It enables us to determine whether the new WHO PA recommendation are met (including the distinction between aerobic PA and muscle-strengthening activities) • Our hypothesis is that the validity of the EHIS-PAQ might be improved in comparison to the GPAQ and IPAQ questionnaires as we removed major disadvantages reported to explain low criterion validity of such instruments • However, the validity of the EHIS-PAQ must now be tested in validation studies

10. Proposal for the new EHIS-PAQ Activity at work

11. Proposal for the new EHIS-PAQ Travel to an from places (commuting activities)

12. Proposal for the new EHIS-PAQ Sports, fitness and recreational activities

13. Mental health (depression)

14. Instrument on mental health – depressive SymptomsPHQ 9

15. PHQ-9 (8-item-version)

16. PHQ-9question 9 (skipped)

17. Additional questions on depression in EHIS wave 2 • HS 4 – Prevalence of depression (self-reported) • HC 16 – Visit of a psychologist or psychotherapist • MD 2(N) – Use of medicine for depression • MD 4 (F) – Use of medicine (not prescribed) for mental health problems (i.e. emotional distress)

18. Criteria for major depressive episode (DSM-IV-TR 2000)

19. Advantages of PHQ9 – PHQ8 • Based on DSM- IV criteria • Translations are available for nearly all European languages • Validated among different cultures, ethnicities, population groups • Can be used as diagnostic instrument as well as screening instrument in population-based studies • „The PHQ8 is a useful depression measure for population-based studies, and either ist diagnostic algorithm or a cutpoint >= 10 can be used for defining current depression“ (Kroenke et al. 2007) • http://www.nri-inc.org/projects/SDICC/WorkGroups/Kroenke_phq8.pdf

20. Comparability across racially and ethnically diverse primary care patients Huang FY et al (2006) Using the Patient Health Questionnaire-9 to Measure Depression among Racially and Ethnically Diverse Primary Care Patients. Journal of General Internal Medicine 21:547-552

21. Comparability across racially and ethnically diverse primary care patients Huang FY et al (2006) Using the Patient Health Questionnaire-9 to Measure Depression among Racially and Ethnically Diverse Primary Care Patients. Journal of General Internal Medicine 21:547-552