on 23 October, 2007, to develop the EU Health Strategy for the period 2008-2013. In the
accompanying this White Paper, strategic objectives are selected with the aim of tackling areas in which strong European added value can be achieved. One of these actions is to improve the collection and compatibility of health data. Current work on developing a European system of health indicators needs to be continued, based on common mechanisms for collecting comparable health data (for example, the
including a European Health Examination Survey).
establishing a second programme of Community action in the field of health (2008-2013). One of the priorities of this programme is to further develop a sustainable health monitoring system with mechanisms for the collection of comparable data and information.
. The EHSS was agreed by the Directors of Social Statistics (DSS) in 2002 and supported by the Network of Competent Authorities on Health Information (NCA) as a framework for a regular collection of harmonised data – allowing inter-country comparisons – by means of surveys and/or survey modules on health. The aim of the EHSS is to set up a system for health data collection via population surveys in order to respond to the information needs of Europeans on the topics of health and health determinants.
DG SANCO considers the development of these actions under the EHSS a high priority as it is a highly valuable tool for providing the comparable data needed to construct indicators to target and evaluate health policies both at the EU and national level. This is particularly significant for the
list, as defined in the Community Public Health Programme.
The European Health Survey System is a comprehensive and coordinated set of surveys that are implemented in a flexible and modular manner. The main components are:
A Health Examination Survey is a survey that collects health information from both face-to-face interviews and medical examinations. It's a population-based survey specifically designed to investigate health issues; data is collected using survey questionnaires and by means of physical examinations and/or biological testing. In addition, diseases not previously diagnosed can be detected. This will provide more comprehensive results about the health of population than administrative registers, screenings or health interview surveys.
There is a need to develop core modules for a Health Examination Survey in Europe, which could include an interview with a few measurements and/or blood samples, or a comprehensive health examination taking several hours to complete (e.g. cardiovascular diseases, respiratory diseases, diabetes). Mental and dental health issues were often the subject of separate surveys and therefore rarely included in national general health surveys. Some risk factors can only be identified by clinical measurements such as blood pressure, blood lipids, height and weight, or blood glucose. These measurements can be combined with a home health interview. Other HES-specific measurements are ECG, bone density, spirometry or measurements of function. Some mental health measurements based on relatively long questionnaires can be equated with clinical measurements, and further clinical information can be obtained by clinical examinations carried out by dentists and doctors. This would enable the actual prevalence of many diseases to be assessed.
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The FEHES (Feasibility of a European Health Examination Survey) Project
In 2006, the European Commission selected the FEHES (Feasibility of a European Health Examination Survey) Project
for funding. This project is lead by the National Public Health Institute of Finland (KTL) with the aim of examining and analysing the feasibility of carrying out a European Health Examination Survey (HES), or repeated national HES, in the EU Member States. The project will support the exchange of information between the Member States that have experience of HES implementation with those that do not.
The specific objectives of the projects are:
- To create a network of experts and institutes for implementing HES in all the EU-Member States,
- To describe and analyze the feasibility of HES models with different intensities and costs,
- To collect and assess information on factors affecting feasibility of HES in all the EU-MS,
- To make proposals and recommendations for the future of HES in the EU and all MS, and
- To prepare a proposal for a European HES pilot to be carried out both in MS with previous national HES experience and also in MS without any such national surveys.
The main outputs of the project include reported recommendations and establishment of expert networks. The project is based on previous experience and collaboration of each member of the study team and associated partner allowing each to focus their expertise on the topics. The foundation of the work will be established through regular meetings of the study group members and by meetings with national and international experts, and with Commission representatives. This will be used to enhance EU and national-level planning, collection of information, and the discussion of the findings leading to a revision of the texts and their practical implications.
Each associated partner will lead and take the main responsibility for the tasks under one or more Work Packages. The collaborating partners, and the network of experts that will be identified during the project, will collect information in their country and be invited to the meetings to be consulted on the assessment of the draft recommendations. They will also distribute the results in each MS to build a basis for HES within the context of the EHSS.
See web site of the Feasibility of a European Health Examination Survey Group
See National Public Health Institute (KTL), Finland, How to improve international comparability of health surveys: the role of health examinations
Some previous Projects of the European Commission in this field
See the EU's project on Health Examination Survey (HES). Review of literature and inventory of surveys in the EU/EFTA Member States(2 MB)
, National Public Health Institute (KTL), Finland
See the EU's Phase 2 of the ‘Health Surveys in the EU: HIS and HIS/HES Evaluations and Models’ project
Recommendations for a European Health Examination Survey in the European Union
Health surveys are needed to provide data on health status, diseases, and their determinants on population basis. The main advantage of surveys is that they can be better controlled in order to provide valid health statistics at population level and that the data are obtained to analyse health and lifestyle according to socio-economic characteristics. This is particularly needed in order to monitor health inequalities with respect to different population groups.
Health Interview Surveys (HIS – questionnaire to individuals) deliver information on, for example self-perceived health, demographic and socioeconomic factors, health behaviour, lifestyle factors, and the use of health services. However, on several key health determinants and chronic diseases, reliable data is best obtained using clinical measurements. This is achieved through health examinations, carried out in a standardised way by experienced and trained health professionals. Thus, well-designed Health Examination Surveys (HES) are needed to complete health information on areas where registers and interviews cannot be used. A comprehensive set of reliable and representative data on population health and its determinants can ideally be achieved by using both health interviewd and health examination surveys, although these instruments might well require extra resources.
Health Examination Surveys (HES) were developed mainly to provide epidemiological information on chronic diseases, but also to monitor their prevalence. A couple of decades later, the development of laboratory automation has made HES less labour intensive and decreased the time required to deliver results. Nowadays, HES address a full range of health issues, including chronic and infectious diseases, chronic non-communicable diseases, nutritional status, functional capacity, disabilities etc. and can involve physical examinations, clinical tests, blood samples, and various other measurements. To date, several HES have been and are carried out in disease specific surveys in certain regions as well as in international studies, but nationwide population based HES are an exception.
The intensity and extent of HES can vary a lot. The most restricted HES, like the Health Survey of England, comprises only a few measurements, for example blood pressure, height, weight and blood sample. More comprehensive HES consist of multiple measurements, e.g. blood pressure, height, weight and other anthropometric measurements, blood samples, resting ECG, some semi-diagnostic symptom questionnaires, and measurements of function such as walking speed and hand grip. The most comprehensive surveys involve a very large scale of tests and measurements. For example, the Finnish Health 2000 Survey included anthropometric measurements (e.g. height, weight, hip and abdominal circumference), physiological measurements (e.g. blood pressure, spirometry, bioimpedance, resting ECG, blood samples for serum and DNA), dental examination and oral X-ray, measurements of physical and cognitive functioning, psychiatric interview and clinical examination. All HES also include a HIS data collection component.
Conclusions of the 1st Workshop on Health Examination Surveys in the European Union
In order to implement the European Health Examination Survey, the FEHES (Feasibility of a European Health Examination Survey) Project and the European Commission organised a Workshop on Health Examination Surveys in the European Union (Luxembourg, 9-11 April 2008).
The purpose of this Workshop was to make recommendations concerning the structures that would be required in order to carry out standardised national HESs in the participating European countries, and to propose the standards for such surveys. Recommendations have been made by the FEHES (Feasibity of a European Health Examination Survey) Project and endorsed by the European Commission and the participants in the Workshop. These recommendations and review should also serve as basis for a future European Health Examination Survey.
See Review of Health Examination Surveys in Europe
See Recommendations for the Health Examination Surveys in Europe
See Recommendations for Organizing a Standardized European Health Examination Survey
Pilot Health Examination Survey in the European Union
A Call for Tender to implement a Pilot Health Examination Survey in the European Union to test these recommendations has been launched, as scheduled in the Commission Decision of 27 February 2008 on the adoption of the work plan for 2008 for the implementation of the second programme of Community action in the field of health (2008-2013)
, with the following content:
See Contract notice 2008/S 163-219619 from 23.08.2008: L-Luxembourg: the development and planning of a pilot European Health Examination Survey in European Union and EFTA Member States in preparation to test examination modules and field procedures for this survey
Health Examination Surveys and Biomonitoring activities
In the framework of Action 3 of the European Environment and Health Action Plan 2004-2010, adopted by the European Commission on 9 June, 2004 (COM (2004) 416 final, volume I, COM (2004) 416 final, volume II)
, the European Commission committed to develop, in close cooperation with the Member States, a coherent approach to Human Biomonitoring in Europe.
Human Biomonitoring (HBM) has been defined in the preparation of the Action Plan as "monitoring activities in human beings, using biomarkers, that focus on environmental exposures, diseases and/or disorders and genetic susceptibility, and their potential relationships".
The ultimate aim is to support environmental policy, as well as public health policy, by better data comparability and accessibility within and between countries. It also promotes effective use of resources through shared development of scientific tools and appropriate strategies.
The close methodology and compatibility of objectives between human biomonitoring testing and the blood and genetic testing in Health Examination Surveys should be supported by the European Commission.
See European Human Biomonitoring
See ESBIO (Expert Team to Support Biomonitoring in Europe)
The French Presidency of the Council organised in November 2008 the 'European Conference on Human Biomonitoring' in Paris. The integration of human biomonitoring activities and the future European Health Examination Survey is under discussion.
See European Conference on Human Biomonitoring - Institut de Veille Sanitaire (France)
Existing Health Examination Surveys in Europe and internationally
Within the last ten years, national HESs have been carried out in ten European countries (Croatia, Czech Republic, Finland, France, Germany, Ireland, Netherlands, Poland, Romania, United Kingdom) and in most of them at quite irregular and long intervals. In 2008 there a new ongoing national survey in three countries without previous national HESs (Denmark, Luxembourg, Spain).
Countries with the longest traditions of organising national HESs in Europe are:
In contrast to the few national HESs, several national HISs have been carried out within the last 5-10 years and with regular intervals in most European countries.
There have been major regional surveys repeated at regular intervals and/or covering several regions in ten countries which did not previously have any nationally representative surveys (Cyprus, Denmark, Iceland, Italy, Lithuania, Norway, Slovakia, Slovenia, Spain, Sweden). Most of these were cardiovascular risk factor surveys that were initiated in the WHO MONICA Project and/or carried out in CINDI demonstration areas. Local, regional, or topic specific surveys have been carried out in almost all countries.
Health Examination Surveys outside Europe
Experiences in the USA, Canada, and Australia have provided some important examples of success and difficulties in organising national HESs.
The US National Health and Nutrition Examination Survey (NHANES)
is the best-known model for national HES. Over a 30-year history, the US National Center for Health Statistics (NCHS) has developed a model comprising a multipurpose, national, cross-sectional, prevalence survey of major diseases, conditions, and risk factors.
The fieldwork for a new Canadian Health Measures Survey (CHMS)
was started in 2007 to address previous limitations within Canada’s health surveillance system.
In Australia, a pilot test of a proposed new national Australian Health Measurement Survey (AHMS) was carried out in 2003.
International Multicentre Health Examination Surveys
The CINDI Programme (Countrywide Integrated Non-Communicable Disease Intervention)
is a WHO coordinated programme for the prevention of major non-communicable diseases and for the promotion of health by co-ordinated and comprehensive action. The aim is to reduce common, established risk factors and to favourably influence related lifestyles in the population. The CINDI programme was established in 1985. Standardised periodical risk factor surveys have been carried out as part of the outcome evaluation of the CINDI programme in 23 countries in Europe.
The European Commission Respiratory Health Survey (ECRHS)
was initiated in 1990 under the European Community’s Concerted Action on Asthma Prevalence and Risk Factors. The European Community Respiratory Health Survey (ECRHS) II funded by the European Commission analysed risk factors for the development of allergic disease, atopy and rapid loss of lung function in middle-aged adults living in Europe. From 1991 to 1993, more than 18,000 individuals took part in ECRHS I and provided information on symptoms and exposure to known or suspected risk factors for asthma. Blood samples for assessment of immunoglobulin E specific to environmental allergens were taken, and lung function and bronchial responsiveness to methacholine were assessed. From 1999 to 2001, study participants were re-contacted to determine symptom status and exposure to a variety of factors, including tobacco smoke, animals, occupational agents, and air pollutants (including particulate matter). In a subsample of responders, exposure to house dust-mite allergen was assessed by analysis of dust samples taken from participants' mattresses. In addition, blood samples suitable for DNA extraction were collected and stored.
The European Prospective Investigation into Cancer and Nutrition (EPIC)
investigates the relation between diet, nutritional and metabolic characteristics, various lifestyle factors, and the risk of cancer. An additional component, EPIC-Heart, extends the study to cardiovascular disease. EPIC was designed to investigate the relationships between diet, nutritional status, lifestyle and environmental factors, and the incidence of cancer and other chronic diseases. EPIC is the largest study of diet and health ever undertaken, having recruited over half a million (520,000) people in ten European countries. Recruitment into the study, which was initiated in 1992, was principally from the general population aged 20 years or over, and took place between 1993 and 1999. Detailed information on diet and lifestyle was obtained by questionnaire, anthropometric measurements, and blood samples taken at recruitment.
The Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA)
project is a multicentre international collaborative project coordinated by the WHO. It was initiated in the early 1980s. The project had common standardised survey methods for data collection, and centralised data analysis and quality control. The MONICA methods have been utilised by several other projects in addition to the MONICA centres. All MONICA surveys included a common core, but additional methods and health status components were used in several countries/study areas. In some countries the surveys were carried out in just one area (e.g. one city), but other surveys also had national significance with several nationally representative study areas in different parts of the country.
Ongoing HES Projects under the Community Public Health Programme
The EU Project IMCA II - Indicators for Monitoring COPD and Asthma in the EU
is developing a module of COPD and asthma to be incorporated in the health examination surveys. Feasibility and pilot performance is being tested in a selection of four small and one large samples of geographical areas of Spain, Italy, Sweden, and Germany. The project will explore the use of a group of essential measurements of respiratory health and morbidity to be introduced in future HES. This will involve using innovative technological methods (sensors) to carry out measurements, validation and transmission of the data (fieldwork online), and the use of a Telemedicine Network (GBT-UPM) to provide online training and support to the fieldworkers. The project will explore the feasibility of taking a blood sample at home in the context of a HES to measure the relevant indicators on allergy (IgE and specific IgE) obtain DNA samples, and other ad hoc determinants.