Postal Completion Research Articles

A multi-centre, UK-based, non-inferiority randomised controlled trial of 4 follow-up assessment methods in stroke survivors

BackgroundRecovery following a stroke is a long and ongoing process. Post-stroke follow-up after leaving the hospital is recommended. Methods for follow-up patients include face-to-face, via the telephone, post or online (internet). However, there is a debate which method is preferred by patients. This study aimed to determine whether telephone interview, online questionnaire and postal questionnaire were as acceptable as face-to-face follow-up.MethodsIn a blinded, UK-wide, multi-centre, Zelen’s designed, 4-arm (postal, online, telephone, compared to face-to-face), pragmatic non-inferiority randomised controlled trial of the mode of administration, stroke survivors were randomised to postal, online, telephone and face-to-face assessment, in an equal ratio (1:1:1:1). The primary outcome was the proportion of participants that responded to the three allocation groups, compared to the face-to-face group. Subgroup analyses for age, aphasia and type and severity of stroke were carried out. A non-inferiority margin of 0.025 was used, and Holm-Bonferroni multiplicity adjustment was made.ResultsOf the 2074 eligible patients randomised, 55% were male (1142/2074), with an average age of 73.0 years old (SD = 13.2). Of those randomised, 22% (116/525), 9% (47/515) and 20% (101/513) responded in postal, online and telephone, respectively, compared to 17% (89/521) in the face-to-face group. The reduction in the online response rate compared to face-to-face was found to be both inferior and not non-inferior and estimated as an 8% reduction (95% CI 3.9 to 12.0%; p < 0.001). The association with lower online completion was present regardless of age, stroke type (haemorrhage or infarct) and stroke severity. In haemorrhagic stroke, the reduction in response online, compared to face-to-face, was 21% (95% CI 10 to 32%; p value = 0.002). A secondary analysis found non-aphasic stroke survivors preferred postal completion adjusted odds ratio of 1.43 (95% CI 1.04 to 1.95; p = 0.026).ConclusionsThe study found that fewer stroke survivors completed follow-up assessment using an online method, compared to face-to-face. This finding was present in all age groups. Caution should be employed when considering online follow-up methods in stroke survivors, particularly in those who have experienced a cerebrovascular haemorrhage.Trials registrationClinicalTrials.gov, NCT03177161. Registered on 6 June 2017.

Measure of activity performance of the hand (MAP-Hand) questionnaire: linguistic validation, cultural adaptation and psychometric testing in people with rheumatoid arthritis in the UK

BackgroundDeveloped in the Norway, the Measure of Activity Performance of the Hand (MAP-Hand) assesses 18 activities performed using the hands. It was developed for people with rheumatoid arthritis (RA) using patient generated items, which are scored on a 0–3 scale and summarised into a total score range (0 to 54). This study reports the development and psychometric testing of the British English MAP-Hand in a UK population of people with RA.MethodsRecruitment took place in the National Health Service (NHS) through 17 Rheumatology outpatient clinics. Phase 1 (cross-cultural adaptation) involved: forward translation to British English; synthesis; expert panel review and cognitive debriefing interviews with people with RA. Phase 2 (psychometric testing) involved postal completion of the MAP-Hand, Health Assessment Questionnaire (HAQ), Upper Limb HAQ (ULHAQ), Short-Form 36 (SF-36v2) and Disabilities of the Arm Shoulder Hand (DASH) to measure internal consistency (Cronbach’s alpha); concurrent validity (Spearman’s correlations) and Minimal Detectable Difference (MDC95). The MAP-Hand was repeated three-weeks later to assess test-retest reliability (linear weighted kappa and Intra-Class Correlations (ICC (2,1)). Unidimensionality (internal construct validity) was assessed using (i) Confirmatory Factor Analysis (CFA) (ii) Mokken scaling and (iii) Rasch model. The RUMM2030 software was used, applying the Rasch partial credit model.ResultsIn Phase 1, 31 participants considered all items relevant. In Phase 2, 340 people completed Test-1 and 273 (80%) completed Test-2 questionnaires. Internal consistency was excellent (α = 0.96). Test-retest reliability was good (ICC (2,1) = 0.96 (95% CI 0.94, 0.97)). The MAP-Hand correlated strongly with HAQ20 (rs = .88), ULHAQ (rs = .91), SF-36v2 Physical Functioning (PF) Score (rs = −.80) and DASH (rs = .93), indicating strong concurrent validity. CFA failed to support unidimensionality (Chi-Square 236.0 (df 120; p < 0.001)). However, Mokken scaling suggested a probabilistic ordering. There was differential item functioning (DIF) for gender. Four testlets were formed, resulting in much improved fit and unidimensionality. Following this, testlets were further merged in pairs where opposite bias existed. This resulted in perfect fit to the model.ConclusionsThe British English version of the MAP-Hand has good validity and reliability in people with RA and can be used in both research and clinical practice.

Development and Psychometric Validation of the Veterinary Service Satisfaction Questionnaire (VSSQ)

In the absence of a widely available, psychometrically tested questionnaire for measuring satisfaction with UK veterinary services, the Veterinary Service Satisfaction Questionnaire (VSSQ) was developed. Items in the first draft were derived from a literature review, guidelines from professional bodies and interviews with pet owners and veterinarians. The questionnaire includes 72 satisfaction items, each with a five-option response format. A total of 183 domestic pet owners from three small animal practices (60% response rate) completed it by mail. Pilot testing and postal completion rates indicate the acceptability and relevance of the VSSQ. Principal components analyses of respondent ratings suggested that the VSSQ can be scored as five scales: general services, staff communication, vet communication, death of pet and vet technical abilities. Six further items are scored separately. Descriptive statistics are provided for individual items and scales. Subgroup differences are explored according to owners' demographic variables. The VSSQ demonstrates preliminary face and content validity, excellent internal consistency reliability in each of the five scales (Cronbach's alpha 0.93-0.97) and good construct validity: those who had recommended the practice to others had significantly higher scores. Scoring guidelines are provided for the VSSQ, which is now ready for use.

Evaluation of an intervention to improve successful completion of the Mini-AQLQ: comparison of postal and supervised completion

Previous postal administration of Mini Asthma-related Quality of Life Questionnaire (Mini-AQLQ) (validated for self-completion under supervision) resulted in 12.7% completion error rate. To administer the Mini-AQLQ by post with instructions, and to compare completion errors with our previous study and usable response rate with supervised self-completion. The Mini-AQLQ, with an instruction sheet, was posted to 96 participants from UK general practice, for completion 1 week before supervised self-completion in the surgery. 94/96 (98%) postal questionnaires were returned: the error rate of 10.6% was similar to our previous study (postal versus previous: 10/94 versus 23/181: P=0.62). 86/96 (90%) attended for supervised completion with no completion errors (supervised versus postal: 0/86 versus 10/94: P</=0.01) Overall usable response rates were similar. (supervised versus postal: 86/96 versus 84/96, P=0.65). Our instruction sheet did not significantly reduce postal completion errors, however the good postal return rate achieved comparable overall usable response rates to supervised administration.

Can Findings from Postal Questionnaires be Combined with Interview Results to Improve the Response Rate among Ethnic Minority Populations?

Study Objective. To maximise the response rate in a community survey among ethnic minorities by combining postal questionnaires and interviews and to evaluate the validity of combining results from these different methods. Design. A cross-sectional community survey of a local population using postal questionnaires with interview questionnaires for non-respondents. Postal questionnaires were in English and interview questionnaires were prepared in South Asian languages. A sub-sample completed both postal and interview questionnaires. Setting. Two general practices in Tameside, Greater Manchester, UK. Participants. Questionnaires were mailed to 1,267 people. People were included if they defined their ethnicity as Indian, Pakistani, Bangladeshi or a combination of these. Fifty-five people who returned postal questionnaires were also interviewed. Main Results. Overall response rate was 75%. Comparison of questionnaire and interview responses produced values of kappa ranging from marginally below zero to one. Equivalence was greater with a shorter time between postal completion and interview and where questions were more objective. Conclusions. It is possible to achieve a good response rate for an epidemiological study among ethnic minorities by using both postal questionnaires and interviews. Care should be taken when results from these two methods are combined, since equivalence is uncertain.

The true impact of fatigue in primary biliary cirrhosis: A population study

Patient surveys suggest that fatigue is a common problem in primary biliary cirrhosis (PBC). The actual extent of the problems caused by fatigue in PBC has yet to be determined as previous studies addressing this question have tended to use selected patient subgroups and subjective or non-quantitative fatigue assessment tools. Here, we have attempted to more accurately assess the extent of fatigue in PBC, and the specificity of the symptom for this disease, by the application of an objective measure of fatigue impact (the fatigue impact score [FIS]) to a geographically based patient cohort, age- and sex-matched normal controls, and chronic liver disease controls. Postal completion of the FIS and linked symptom assessment tools. Median FIS was significantly higher in patients (n = 136) than community controls (40 [0-138] vs. 28 [0-156]; P < 0.0001) and chronic liver disease controls (n = 38) (20.5 [0-145]; P < 0.05). Fatigue scores in the 11 patients who had undergone liver transplantation (median 3.5 years previously) were the same as those in non-transplanted patients with advanced disease. Fatigue is a significant and specific problem in PBC. It is not, however, universal and affects fewer patients than has previously been thought to be the case based on data from selected patient cohorts. This definition of the "normal range" for fatigue in PBC will assist in future studies of etiology and therapy.

Development and validation of the Nottingham Leisure Questionnaire (NLQ).

To reduce the length of the Nottingham Leisure Questionnaire (NLQ) in order to make it more suitable for postal use, and to evaluate its test-retest reliability, sensitivity, stability and validity in relation to other measures of activities of daily living (ADL), mood and handicap. The NLQ was shortened and the response categories collapsed. Results from a previous trial which had used the NLQ were reanalysed to establish if significant group differences were maintained. The new version of the NLQ was subsequently tested for test-retest reliability on a new group of patients from the Nottingham stroke register who were asked to complete it twice. The new NLQ and other measures were sent to patients in a multicentre rehabilitation trial (TOTAL) six and twelve months after recruitment for postal completion. One hundred and thirty-seven consecutive patients from the Nottingham stroke register and 466 patients with a stroke in a multicentre rehabilitation trial. The original NLQ was reduced from 37 to 30 items and from five to three response categories. Data from an earlier study were reanalysed and differences between treatment groups remained. The results of a test-retest analysis using kappa showed that six items had excellent agreement, 15 good and nine fair, suggesting acceptable test-retest reliability. Results from the rehabilitation trial showed that the subjects performed all items and few additional activities were suggested. Higher NLQ scores were associated with higher subscores on the Nottingham Extended Activities of Daily Living Scale (NEADL) and lower NLQ scores with living alone and worse emotional health. The NLQ has been successfully modified for postal self-administration but there is potential for further development.

A study of the use of the Edinburgh postnatal depression scale with parent groups outside the postpartum period

The Edinburgh Postnatal Depression Scale (EPDS) was sent by post to 206 mothers and 201 fathers of toddlers (aged between 19 and 22 months). At the same time these parents also completed subscales of the Crown—Crisp Experiential Index (CCEI). The responses were used to assess the feasibility of postal completion of the EPDS and its acceptability to parents outside the postpartum year, particularly fathers for whom there have been no previous reports of its use. On a small sub-group, the sensitivity, specificity and predictive values of the measures were assessed using the Present. State Examination. Answers to the depression subscale of the CCEI to the EPDS and to the Present State Examination were compared to assess validity. Completion of the postally-administered EPDS was satisfactory, though some difficulties were experienced in a second postal administration to a subsample. The scale was completed without obvious error or omission and this, combined with positive comments from parents, suggests the acceptability of the scale to both mothers and fathers. The mean scores were higher for mothers than for fathers, but the pattern of distribution was similar with a marked positive skew and a distinct decline in scores above 10. Because the subsample of parents interviewed was small the calculation of sensitivity and specificity has to be treated with caution. However, the results for mothers suggest that the EPDS has satisfactory validity for this group and one superior to the depression subscale of the CCEI. Among the fathers interviewed there were insufficient cases to enable calculation of sensitivity and specificity. Other results were encouraging, however, and suggest the merit of further studies of the application and validity of the EPDS with fathers.