Recruitment: Who will participate? Presentation on workshop in Luxembourg 10. April 2008 Sidsel Graff-Iversen

A challenge: Participation rates in HES and HIS have declined during the last decades Rates: 25-85% in European HES Not at random: Those interested in their own health are the easiest to recruit Substitution of selected persons with neighbours etc is not accepted

Low participation: a critical point Non-participants’ mortality is elevated Health related habits, substance use and health differ by participation. Low participation does not necessarily bias the results, based on control for relevant factors from registers. But register information has limitations. Some HES variables are more vulnerable for selection bias than others In conclusion, at least 70% of selected persons should participate.

A survey within the FEHES network: We sent an e-request on sampling and recruitment to national experts in Answers for 26 of 32 countries: 17 countries answered for a recent HES and 9 countries for a recent HIS

Results of the request Answers could be grouped in 3 categories: Repeated contact (by letter, phone or visit) Participant service and information Appeal to public gain

Repeated contact Re-contacts done in all 17 countries with HES And re-contacts was considered the most effective recruitment method in 8 of these 17 countries.

Repeated contact Phone for re-contact in 13/17 countries. Cell phone/SMS not specified, but we know it was used. Up to 25 contact attempts. Who called? Could be junior staff, senior staff, physician or head of project. Home visit was part of the strategy in 10/17 countries.

Participant service Mentioned by most experts and ranked as the best method for 5/17 countries Gain for own health (“Include an ethically approved test that really attracts people”) High quality, user-friendly written materials in relevant languages Flexible opening hours Possibility of examination by home visit

Participant service Local partners (like work-sites, hospitals, universities) Skilled, polite and interested field personell Mass communication Internet site Reimbursement of travel expenses Small gift (pen, lottery ticket, voucher - if considered effective)

Appeal to public gain ”Invitation signed by Health Director General”. “Used the authority of the National Institute of Public Health”. “A physician made the first (or last) phone call to non-participants”. General appeal to public gain.

Conclusion of the request Countries with recent HES recognise the need for several recruitment strategies - which have to comply with cultural norms.

Recommendations Prior to invitation: Inform health authorities and other relevant actors Mass media, survey website, a free contact telephone, ways to change appointment time Written materials: appealing and easy to understand. Training of field personnel for service If possible, plan to collect some information from non-participants Prepare for record keeping about each invitee

Recommendations In any information, public or personal: Explain why it is so important that each selected person joins the HES. – None of them can be replaced. Appeal to personal and public gain by joining the national HES. Consider who should front the information and who should sign the invitation letter.

Recommendations Flexibility and tailored appointments: Flexible opening hours, including evenings and week-ends. Possible for invitees to “drop in”? Examination by mobile survey teams and home visits? Other solutions, such as transporting the participant to the survey clinic?

Recommendations After the first invitation: At least one re-invitation in all countries At least two re-invitations if participation is lower than 70 % after the first invitation