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WP 4 - Preparation of protocols for data collection, design and piloting of appropriate instruments

Work Package 4 was led by the University of Liverpool and focused on preparing the protocols for the data collection, design and piloting of appropriate instruments.

The starting point was the set of urban health indicators recommended following EURO-URHIS. The EURO-URHIS study indicated which UAs were to be investigated. It also informed which parts of the proposed dataset were suited to collection by interrogation of health departments etc., and which parts require survey work using a random sample of relevant urban populations.

Additional items were included in the survey for completion of WP6 and 7. The University of Liverpool, together with the University of Manchester co-ordinated all partners to ensure all ethical issues and approval (where necessary) was sought. All ethical issues were overseen by the project management group and the University of Liverpool liaised with the steering group and expert advisory group to ensure the instruments were sufficient to answer all research questions, items were appropriately phrased/translated and optimum length for a high response rate.

The European Health Survey System (EHSS) and EUROSTAT officials were contacted at commencement of the project to help with design and translation of the instruments. Study design and methodology guidelines are available through the EHSS for development of instruments.

Definition of “urban area”

Prior to the a workshop in Maribor (19-22 January 2010), all partners were surveyed by the University of Manchester team so as to establish the most suitable definition of “urban area” to use in each location, with a view to providing the most suitable match with data availability, organisation of services, etc. Where possible, Urban Audit definitions were preferred, but where an urban area was beyond the scope of Urban Audit, or where there was a serious mismatch between an Urban Audit area and the equivalent public health administrative area, the public health administration area was chosen instead, as indicated in the table below:

Urban Audit `city` definition selected

Urban Audit `wider urban area` definition selected

Public Health administration area selected


Greater Manchester:










Ho Chi Minh
























Halton & St Helens









Routinely Available Data Collection Instrument (1A)

The process for indicator selection began in Duesseldorf, February 2009. A proposed long list of EURO-URHIS 2 Urban Health Indicators (UHIs) containing indicators from the first EURO-URHIS Study, supplemented by some further indicators sourced from ECHI and from EHIS, was discussed by all partners; in addition, the data requirements of WPs 6 and 7 were also taken into consideration. UHIs considered most important for the purposes of monitoring urban health, and those required for the later WPs were identified; these were separated into those which could collected from existing data sources (in most cases as demonstrated in the first EURO-URHIS Study), and those which could be collected more successfully in the context of the planned population surveys.

This process in Duesseldorf resulted in a long list of UHIs which could be collected from routine data sources.

UHIs were automatically retained for inclusion in the main study if, on the basis of the pilot, the following inclusion criteria were satisfied:

  • either ten or more urban areas reported that they could collect the UHI in question as according to the EURO-URHIS 2 definition, or
  • ten or more urban areas reported that they could collect data appropriate for a particular UHI using either the EURO-URHIS 2 definition or an alternative definition, provided that this alternate could be identified as comparable to the EURO-URHIS 2 definition.

However, any UHI which could be collected in only fewer than ten of the EURO-URHIS 2 urban areas was automatically excluded.

The final list of UHIs to be included was agreed, using the principles outlined above. For each UHI, the following were to be collected:

  • year and source of data (with the year to be the latest for which the relevant data is available),
  • sources, stated in the national language of the urban area concerned, with an English translation wherever possible, and
  • type of data that has been collected (e.g. registry statistics)

Adult Survey Instrument (1C)

The adult survey instrument was initially proposed in the Final Report or the first EURO-URHIS project. Subjects to be considered for inclusion in any such a future population survey instrument were identified in this Report, as was a further list of areas where it was recommended that considerable development work to develop new indicators was also needed.

Selection of indicators for inclusion

Soon after the Duesseldorf meeting, five leading individuals drawn from different project partners were invited to head up five working groups on different domains of the adult survey; Nigel Bruce was the lead for health-related lifestyle indicators, Dan Pope the lead for indicators of health status, Heidi Lyshol the lead for demographic-related indicators, Frank de Vocht the lead for indicators in the areas of the environment and occupation relevant to health, and Ioan Bocsan the lead for indicators relating to access to and use of health services. The domain for lifestyle data was, as recognised in the first EURO-URHIS Study, identified as the most important domain, and this domain was seen as the main justification for carrying out the adult survey. All group leaders were asked to identify indicators for possible inclusion in priority areas and to suggest suitable questions (wherever possible validated in previous studies) for use in these areas.

A long list of possible questions resulted. These were derived from the following European Studies:

  • Amsterdamse Gezondheidsmonitor 2008,
  • ECRHS II- European Community Respiratory Health Survey,
  • EHIS- European Health Interview Survey,
  • EPIFUND- Epidemiological Study of Functional Disorders,
  • FINBALT- NATIONAL PUBLIC HEALTH INSTITUTE (KTL) Department of Epidemiology and Health Promotion Finland, in collaboration with centres in Estonia, Latvia and Lithuania,
  • GHS SILC 2006- General Household Survey,
  • HAPIEE - Health, Alcohol and Psychosocial factors in Eastern Europe,
  • HEPRO- Health and Social Well-being in the Baltic Sea Region,
  • LSCQM - Lifestyle Surveys Core Questions and Methods, North West Public Health Observatory,
  • NWPHO- North West Public Health Observatory, and
  • WHO-EURO survey- World Health Organization Regional Office for Europe.

After a meeting in Oslo (11 - 13 May, 2009), the WP 4 leader selected questions from the long list to produce a more manageable list, using the following criteria:

  1. Inclusion of questions from all five domains: demographic variables, health-related lifestyle factors, health status indicators, environmental indicators, indicators of access to health services.
  2. Selection from the long list as according to priority as advised by domain leaders.
  3. Maintenance as one whole (wherever possible) each series of questions previously validated as one complete related group.
  4. Inclusion of questions necessary to provide the data requirements (with the other data collection instruments) of all relevant later Euro-Urhis 2 work packages.
  5. Limitation of the length of the whole instrument to one taking not more than 20-25 minutes to complete.

This methodology worked well, and accordingly an instrument was produced taking into account not only the above criteria, but also recommendations in the Report of the first EURO-URHIS project, discussions at Dusseldorf, the choices of questions indicated at Oslo, and also the extent to which previously used validated questions had been used in more than one country. Where indicators related to significant European public health priorities, this was also taken into account.

Youth Survey Instrument (1D)

The decision to carry out a separate survey using a questionnaire targeted at “children” was taken at the Duesseldorf meeting of the Steering Group in February 2009. Contemporaneously with the setting up of five working groups to consider the five domains planned for the adult survey, a similar working group was established to carry out a similar function for this “children`s” survey; Zuzana Katreniakova was invited to lead this group, especially on account of her experience of and involvement in the Health Behaviour in School Children (HBSC) surveys.

Scope of survey and question selection

At a meeting in Utrecht (March 2009) it was recommended that for the youth survey (as it was now called), HBSC was to be regarded as the principal source for selection of validated questions for relevant UHIs, and that the total length of the questionnaire was not to exceed 40 minutes completion time (this being approximately the length of one lesson period in many schools in most urban areas). The criteria for selection of questions were to be based upon:

  • validity,
  • same interpretation / meaning across different cultures / countries,
  • sensitivity,
  • availability of reference data at national level,
  • public health importance / significance,
  • importance to school health policy, and
  • their being as comparable as possible with questions to be used in the adult survey.

At Oslo, in May 2009, Olivera Stanojevic (on behalf of Zuzana Katreniakova) presented the working group`s recommendations for the youth survey; the following domains and subject areas for the EURO-URHIS 2 youth survey were proposed:

  1. demographic variables,
  2. indicators of health status,
  3. health-related lifestyle indicators,
  4. indicators of the social environment,
  5. indicators of financial and material background,
  6. indicators of the physical environment, and
  7. indicators of access to and use of health care services.

Several previous studies and questionnaires were suggested as suitable sources of validated questions in these domains; the list of sources drawn upon for the youth survey questions were as follows:

  • Health Behaviour in School Aged Children (HBSC, 2005/2006)
  • International Study of Asthma and Allergies in Childhood (ISAAC)
  • European Health Interview Survey Questionnaire (EHIS)
  • Health Related Behaviour Questionnaire (HRBQ, version 21)
  • European School Survey Project on Alcohol and Other Drugs (ESPAD)
  • Survey on Income and Living Conditions Questionnaire (SILC, 2008)
  • European Community Respiratory Health Survey (ECRHS)

Translation and back-translation of instruments, local piloting and ethical approval

These processes were carried out mainly by all partners for themselves, although coordinated from the UK. This proved to be an extremely valuable process, ensuring that all translated versions of the relevant instruments, and their English originals, were as close to being identical in meaning as possible. Translations were carried out initially by the relevant partners themselves; in most cases they then arranged an independent native English speaker to carry out translations back into English (in a few cases this latter process was arranged by the Liverpool team). The Liverpool team checked the translations and back translations, identifying any anomalies or ambiguities. These were discussed with the partners involved, and appropriate alterations made, until final translated versions were agreed between partners and the Liverpool team. Partners then carried out local piloting, using the finally agreed translated versions of the questionnaires. They also applied for and were granted local research ethics committee approval, where this was necessary.

In respect of certain questions in the adult survey instrument, some local variation to questions was permitted; this applies to the questions on ethnicity and to level of education experienced. Although in some cases these issues were discussed in general terms prior to translation, details were agreed finally as part of the translation / back-translation processes.