Gillmann, Gerhard

Goodman, Claire

Harari, Danielle

Iliffe, Steve

Kharicha, Kalpa

Manthorpe, Jill

Stuck, Andreas E.

Swift, Cameron G.

RERO DOC Digital Library

glucose lowering in type 2 diabetes. N Engl J Med 2008;358: 2545–59.27. Bathum L, Christiansen L, Jeune B, Vaupel J, McGue M,Christensen K. Apolipoprotein e genotypes: relationship tocognitive functioning, cognitive decline, and survival in nona-genarians. J Am Geriatr Soc 2006; 54: 654–8.28. Bergman A, Atzmon G, Ye K, MacCarthy T, Barzilai N.Buffering mechanisms in aging: a systems approach towarduncovering the genetic component of aging. PLoS ComputBiol 2007; 3: e170.29. Silverman JM, Smith CJ, Marin DB et al. Identifying familieswith likely genetic protective factors against Alzheimerdisease. Am J Hum Genet 1999; 64: 832–8.30. Silverman JM, Schnaider-Beeri M, Grossman HT, SchmeidlerJ, Wang JY, Lally RC. A phenotype for genetic studies of suc-cessful cognitive aging. Am J Med Genet B NeuropsyciatrGenet 2008; 147B: 167–73.doi: 10.1093/ageing/afr124Published electronically 18 September 2011© The Author 2011. Published by Oxford University Press on behalfof the British Geriatrics Society. All rights reserved. For Permissions,please email: journals.permissions@oup.comFeasibility of repeated use of the HealthRisk Appraisal for Older people systemas a health promotion tool in community-dwelling older people: retrospectivecohort study 2001–05SIR—Promotion of health and prevention of disability inlater life continue to be major health policy priorities inEngland [1, 2]. A system of NHS self-completion on-line‘Life Checks’ has been developed [3] which could potentiallycontribute to health gain in those who use it [4]. However, aweb-based health assessment tool may not be the most ef-fective way to reach the older population; an alternativemethod would be to use general practitioners’ lists.The Health Risk Appraisal for Older people (HRA-O)system is the most extensively evaluated approach for pro-moting health and well-being in later life. A self-completion, multidimensional postal questionnaire collectsinformation on health, functional status, health behaviours,preventive care and psychosocial factors. Based on a com-puter expert system’s analysis of questionnaire responses, itproﬁles individuals’ health and lifestyle and gives tailoredadvice in the form of a printed report on maximisinghealth, lifestyle changes and preventive care and suggestsuseful local sources of help.The acceptability and feasibility of the HRA-O in Britishprimary care has been reported [5] but its performance whenused repeatedly by a cohort of older people has yet to bestudied. Using data from the London arm of a EuropeanUnion funded RCT (Pro-Age) [6] and an EnglishDepartment of Health funded follow-up study (SWISH) [7,8], this paper explores the feasibility of repeated HRA-O useby reporting response rates to HRA-O use on three occa-sions over 4 years and by describing characteristics of non-responders within this retrospective cohort of older people.MethodsThree general practices in London were recruited and ran-domised to a multi-centre, multi-national RCT investigatingthe effect of the HRA-O on health behaviours and status[9]. A full account of the trial methodology is available else-where [10].General practitioners identiﬁed their eligible patientsaged 65 and over who were living at home, without (i) evi-dence of need for human assistance in basic activities ofdaily living, (ii) high dependency due to major physical orpsychiatric illness, or cognitive impairment or (iii) a terminalillness, and with a sufﬁcient level of English to completethe questionnaires. HRAO questionnaires were posted atbaseline (2001) and 1-year follow-up (2002). Full details ofthe trial outcomes are available in an earlier publication inthis journal [6]. The SWISH study allowed us to follow-upthis population and invite them to complete the HRA-Oagain in 2005.At each data collection point questionnaires were postedwith a study information sheet and covering letter from thepatient’s GP. All participants received personalised feedbackon each completion of the HRA-O. Eligibility was checkedprior to each contact to ensure that paperwork was notsent to people who had moved, died or developed severemental illness, or who were receiving palliative care.Reasons for exclusion were recorded.One of the three original practices discontinued involve-ment in 2005. Therefore this secondary analysis focuses onthe sub-sample of patients from the two general practiceswho received the HRA-O questionnaire on three occasionsover 4 years.Independent variables were socio-demographic (age,gender, income, education), health risk behaviours and lackof preventive care uptake as collected in the HRA-O. Thefull list of independent variables is available asSupplementary data in Age and Ageing online, Appendix 1.Binary logistic regression analyses were used to calculateunadjusted and adjusted odds ratios and 95% conﬁdenceintervals for non-response in 2002 and 2005.Two binary logistic regression models were constructed:ﬁrst including all signiﬁcant associations from the bivariateanalyses at both P < 0.01 and P < 0.05 levels (plus ageand gender) and second including only those signiﬁcant atthe P < 0.01 level. Signiﬁcant variables were entered in asingle step, to determine variables that remained independ-ently associated with non-response.ResultsBaseline characteristics of participants in the trial have beenreported in earlier publications [10]. In 2001, 812 older128Research letterspeople were posted the HRA-O questionnaire. Initial re-sponse rates were very high (n = 716, 88.2%) and remainedhigh 1 year later in 2002, when all 716 respondents from2001 were sent the HRA-O questionnaire again, and 582completed it (81.3%). Before the third mailing in 2005 aneligibility check of the 582 responders excluded 141(24.2%) (see Figure 1). Response rates in 2005 from theremaining 441 participants fell to 65.1% (n = 287).Table 1 reports the characteristics of non-responders atthe second (2002) and third (2005) mailings of the ques-tionnaire, as well as age and gender, using unadjusted andadjusted odds ratios.In 2002, non-responders were signiﬁcantly (P < 0.01)more likely to be dependent on state pension alone (i.e. wereless well off ), more likely to have been using tobacco in2001 and signiﬁcantly less likely to have had a dental checkin the 12 months preceding 2001. Low uptake of dental careis likely to be linked to being on a lower income. No add-itional variables were signiﬁcant at P < 0.05 level.After adjusting for age, gender and the above three sig-niﬁcant associations, tobacco use and income remained in-dependently associated with non-response. Non-responderswere 2.18 times more likely to be tobacco users and 1.72times more likely to be dependent on state pension alone.Non-response to the third mailing of the HRA-O wassigniﬁcantly associated with being less well off ﬁnanciallyand less educated. In terms of health risk behaviour, thosethat were at risk of depression, rated their health as fair orpoor, reported low levels of physical activity and had lowlevels of fruit and ﬁbre in their diet in 2002 were less likelyto respond. Non-responders in 2005 were also less likely tohave had a dental check or ﬂu vaccination in the 12months before the 2002 HRA-O completion.Regression models, using ﬁrst the variables signiﬁcant atboth P < 0.05 and P < 0.01 and then those signiﬁcant just atthe P < 0.01 level (as well as age and gender), identiﬁed thesame variables independently associated with non-response.Non-responders were 1.99 times as likely to be less well off ﬁ-nancially, 2.49 times likely to be at risk of depression, 1.80times likely to report low physical activity and 1.82 timeslikely not to have had a dental check in the last 12 months.DiscussionThe best approach to health promotion for older people isstill widely debated [11], particularly following the negativeﬁndings of the large MRC trial. Our study, using a postalself-completion HRA-O system showed that the HRA-O isfeasible (in terms of response rates) in a heterogeneousolder population with sequential use over 4 years.The MRC trial reported response rates of 83.5% fromsingle-use of a postal screening questionnaire in the olderpopulation [12]. The use of an accompanying coveringletter from the GP, stamped address return envelope andassociation with a university are factors identiﬁed in a sys-tematic review on increasing response rates to postal ques-tionnaires and were used in this study [13].Figure 1. Attrition in responders to HRA-O over time—known causes.129Research lettersOlder people who did not engage with HRA-O ques-tionnaire completion after 1 year were more likely to be ona lower income and use tobacco. After 4 years non-response was associated with low income, fair/poor self-rated health, depression risk, low physical activity, lowfruit/ﬁbre consumption and no ﬂu vaccination or dentalcheck. The negative impact of another socio-demographicfactor, low educational level, on oral health-related qualityof life has also been reported [14]. It is, however, importantto note the lack of association with non-response at 4-yearfollow-up of age, gender, functional ability, pain, co-morbidity, memory, falls, lifestyle factors (tobacco andalcohol use) and preventive care uptake (blood pressuremeasurement and eyesight check).Engagement with the repeated use of a health promo-tion system which gives personalised feedback may beaffected by the content of the feedback. Those encouragedto make further changes to health behaviour and lifestylesmay be deterred from further participation, whereas thosepraised for healthier lifestyles may be more likely torespond.Although the characteristics of those less likely torespond over time make the HRA-O system unsuitable forreducing inequalities, non-response is itself potentially auseful marker for an emerging at-risk group. The systemelicits responses from an active and potentially socially im-portant section of the older population upon whom othersmay depend. Older people provide over a third of theso-called ‘informal care’ of ill and disabled people, are amajor source of childcare for the increasing number ofworking mothers, and are the backbone of the voluntarysector [15]. Preventive care interventions aimed at thisgroup may be particularly valuable.Those who completed the HRA-O questionnaire wereparticipating in a trial, not responding to a component ofroutine medical care, so their responses may differ fromthose of a population invited to take part in a health pro-motion programme. The practices involved were insuburban London, and this study population may not berepresentative of older populations elsewhere.To maximise engagement and further explore the feasi-bility of using the HRA-O system as a health promotiontool for the older population, further work is required totest the impact of HRA-O when embedded within an inter-vention programme designed to support repetitive assess-ments. This would allow comparison betweenconsumer-driven approaches to health promotion like ‘LifeChecks’ and approaches made through primary care.Key points• Multi-component interventions targeting several healthbehaviours can improve general health perception andself-efﬁcacy in old age.• HRA-O is the most extensively evaluated approach forpromoting health and well-being in later life, but little isknown about the impact of its repeated use.• Repeated use of the postal, self-completion HRA-O ques-tionnaire is feasible in a heterogeneous older population,with response rates remaining high with sequential useover 4 years.• Although characteristics of those less likely to respond re-peatedly over time make the HRA-O tool unsuitable forreducing inequalities, an economically active and sociallyimportant section of the older population upon whomothers may depend can be proﬁled, with a view to target-ing health promotion interventions.AcknowledgementsWe thank the practices who took part in the two studies,members of the older people’s and lay advisory group, andall the older people who completed the HRA-Oquestionnaire.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table 1. Characteristics of non-responders to the HRA-O on second (2002) and third (2005) mailings2002 2005Unadjusted odds ratios(95% CI)Adjusted odds ratios(95% CI)Unadjusted odds ratios(95% CI)Adjusted odds ratios(95% CI)Male 0.82 (0.56–0.19) 0.94 (0.63–1.39)Aged 75 and over 0.81 (0.55–1.18) 1.19 (0.80–1.77)Receives only state pension 1.77 (1.20–2.60)** 1.72 (1.13–2.62)* 1.91 (1.26–2.89)** 1.99 (1.26–3.14)*Basic education only 1.64 (1.09–2.46)*At risk of depression 2.19 (1.26–3.66)** 2.49 (1.33–4.64)*Fair or poor self-rated health 2.00 (1.20–3.35)**Current tobacco use 2.32 (1.39–3.87)** 2.18 (1.27–3.74)*Low physical activity 2.13 (1.32–3.42)** 1.80 (1.07–3.02)*Low fruit/fibre consumption 1.54 (1.00–2.35)*No dental check up in last 12 months 1.72 (1.15–2.56)** 1.87 (1.20–2.93)** 1.82 (1.12–2.96)*No flu vaccine in last 12 months 1.70 (1.01–2.88)**P< 0.05**P< 0.01130Research lettersConflicts of interestNone declared.Ethical approvalEthical approval for the Pro-Age study was sought fromBrent Medical Ethics Committee and King’s CollegeHospital Research Ethics Committee, and for the SWISHstudy from Guy’s Hospital Research Ethics Committee.FundingEuropean Commission project QLK6-CT-1999–02205 (thePro-Age study) and the English Department of HealthModernising Adult Social Care programme (the SWISH study).Supplementary dataSupplementary data mentioned in the text is available tosubscribers in Age and Ageing online.KALPA KHARICHA1,*, STEVE ILIFFE1, DANIELLE HARARI2,CAMERON G. SWIFT3, CLAIRE GOODMAN4, JILL MANTHORPE5,GERHARD GILLMANN6, ANDREAS E. STUCK71Research Department of Primary Care and Population Health,UCL, London, UKTel: +44 (0)20 7830 2392; Fax: +44 (0)20 7794 1224.Email: k.kharicha@ucl.ac.uk2Department of Ageing and Health, Guy’s and St Thomas’ NHSFoundation Trust, London, UK3Department of Health Care of the Elderly, King’s College London,London, UK4Centre for Research in Primary and Community Care, University ofHertfordshire, Hatfield, UK5Social Care Workforce Research Unit, King’s College London,150 Stamford Street, London SE1 9NN, UK6Swiss Federal Office of Statistics, Neuchâtel, Switzerland7Division of Geriatrics, Department of General Internal Medicine,Inselspital and University of Bern, Bern, Switzerland*To whom correspondence should be addressedReferences1. Department of Health. The National Service Framework forOlder People. London: The Stationery Ofﬁce, 2001.2. Department of Health. Equity and Excellence: Liberating theNHS, Cm 7881. London: The Stationary Ofﬁce, 2010.3. www.midlifecheck.co.uk (accessed 28 July 2010).4. Gill TM, Williams CS, Richardson ED, Tinetti ME.Impairments in physical performance and cognitive status aspredisposing factors for functional dependence among nondis-abled older persons. J Gerontol A Biol Sci Med 1996; 51:M283–8.5. Iliffe S, Kharicha K, Harari D, Swift C, Stuck A. Health riskappraisal for older people in general practice using an expertsystem: a pilot study. Health Soc Care Community 2005; 13:21–9.6. Harari D, Iliffe S, Kharicha K et al Promotion of health inolder people: a randomised controlled trial of health risk ap-praisal in British general practice. Age Ageing 2008; 37:565–71.7. Iliffe S, Kharicha K, Harari D, Swift C, Goodman C,Manthorpe J. User involvement in the development of ahealth promotion technology for older people: ﬁndings fromthe SWISH project. Health Soc Care Community 2009;August 25 [Epub ahead of print].8. Manthorpe J, Kharicha K, Goodman C, Harari D, Swift C,Iliffe S. Smarter working in social and health care: professionalperspectives on a new technology for risk appraisal with olderpeople. Br J Social Work 2010; 40: 1829–46.9. Stuck AE, Elkuch P, Dapp U, Anders J, Iliffe S, Swift C. forthe Pro-Age pilot study group. Feasibility and yield of a self-administered questionnaire for health risk appraisal in olderpeople in three European countries. Age Ageing 2002; 31:463–7.10. Stuck AE, Kharicha K, Dapp U et al The PRO-AGEstudy: an international randomized controlled study ofhealth risk appraisal for older persons based in generalpractice [ISRCTN28458424]. BMC Med Res Methodol2007; 7: 2.11. Stuck AE, Egger M, Beck JC. Preventing disability in elderlypeople. Lancet 2004; 364: 1641–2.12. Smeeth L, Fletcher AE, Stirling S et al Randomised compari-son of three methods of administering a screening question-naire to elderly people: ﬁndings from the MRC trial of theassessment and management of older people in the commu-nity. BMJ 2001; 323: 1403–7.13. Edwards P, Roberts A, Clarke M et al Increasing responserates to postal questionnaire: systematic review. BMJ 2002;324: 1183.14. Tsakos G, Sheiham A, Iliffe S et al The impact of educationallevel on oral health-related quality of life in older people inLondon. Eur J Oral Sci 2009; 117: 286–92.15. Audit Commission. Don’t Stop Me Now: Preparing for AnAgeing Population, London; Audit Commission, 2008.doi: 10.1093/ageing/afr126Published electronically 6 October 2011© The Author 2011. Published by Oxford University Press on behalfof the British Geriatrics Society. All rights reserved. For Permissions,please email: journals.permissions@oup.com131Research letters

Feasibility of repeated use of the Health Risk Appraisal for Older people system as a health promotion tool in community-dwelling older people: retrospective cohort study 2001-05

Feasibility of repeated use of the Health Risk Appraisal for Older people system as a health promotion tool in community-dwelling older people: retrospective cohort study 2001-05

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