Process evaluation of an implementation intervention to facilitate the use of the Swedish Physical Activity on Prescription in primary healthcare.

BACKGROUND: The Swedish Physical Activity on Prescription (PAP-S) is a method for healthcare to promote physical activity for prevention and treatment of health disorders. Despite scientific support and education campaigns, the use has been low. The aim of this study was to perform a process evaluation of an implementation intervention targeting the use of the PAP-S method in primary healthcare (PHC). Specifically, we wanted to evaluate feasibility of the implementation intervention, and its effect on the implementation process and the outcome (number of PAP-S prescriptions). METHODS: This was a longitudinal study using the Medical Research Council guidance for process evaluation of a 9-month implementation intervention among healthcare staff at three PHC centres in Sweden. Data was collected by: participatory observations of the implementation process; questionnaires to the staff before, after and 6 months after the implementation intervention; interviews after the implementation intervention; and number of PAP-S prescriptions. RESULTS: During the implementation intervention, the workplaces' readiness-to-change and the healthcare staff's confidence in using the PAP-S method were favourably influenced, as was the number of PAP-S prescriptions. After the implementation intervention, the number of PAP-S prescriptions decreased to about the same number as before the implementation intervention, at two out of three PHC centres. Four of the six implementation strategies appeared to impact on the implementation process: external facilitation; leadership engagement by a committed workplace management; local PAP-S coordinator taking a leading role and acting as local champion; educational outreach concerning how to use the PAP-S method. CONCLUSION: The implementation intervention was not sufficient to produce sustained change of the healthcare staff's behaviour, nor did it achieve favourable long-term outcome on the number of PAP-S prescriptions. The healthcare staffs' sparse knowledge of the PAP-S method prior to the implementation intervention hampered the implementation. More hands-on education in how to use the PAP-S method introduced early in the implementation process is imperative for successful implementation of the PAP-S method. The findings also suggest that committed workplace management and local PAP-S coordinators, taking leading roles and acting as local champions, need to be firmly established at the PHC centres before the external facilitator withdraws. TRIAL REGISTRATION: Registered in the ISRCTN registry with study registration number: ISRCTN15551042 (Registration date: 12/01/2016).

Quality of life of type 2 diabetes mellitus patients in Ramallah and al-Bireh Governorate-Palestine: a part of the Palestinian diabetes complications and control study (PDCCS).

PURPOSE: Type 2 diabetes mellitus (T2DM) is a considerable impact on physical health as well as on emotional and social wellbeing. This study aimed to investigate the quality of life and its associated factors among Palestinians with T2DM. METHODS: A cross-sectional study including 517 patients (68% female) was conducted in eleven primary health care clinics located in Ramallah and al-Bireh governorate of the West Bank. To assess socio-demographic data, risk factors and diabetes control, interviews, physical examinations, anthropometric measurements, and blood and urine tests were performed. The validated Arabic version of the Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire was carried out on all patients to measure Quality of Life (QoL). A multivariable regression analysis was performed. RESULTS: The average weighted impact (AWI) score was -3.38 (95% CI: -3.55 to -3.21, range: -9.00 to 0.12). This indicates that diabetes was perceived as having a considerable negative impact on the quality of life. The life domains 'freedom to eat', 'physical activities', and 'work-life' were the most negatively impacted. Males and individuals living with diabetes for a prolonged time were associated with a more significant negative impact on quality of life. CONCLUSION: The study showed that diabetes generally had a negative impact on QoL and identified the demand for diabetes management programs tailored to patient needs and different patient groups, as well as health policies that put patients in the center of diabetes care.

Playing the complex game of social status in school - a qualitative study.

BACKGROUND: Research suggests that social status in school plays an important role in the social lives of adolescents and that their social status is associated with their health. Additional knowledge about adolescents' understanding of social hierarchies could help to explain inequalities in adolescents' health and guide public health interventions. OBJECTIVE: The study aimed to explore what contributes to subjective social status in school and the strategies used for social positioning. METHODS: A qualitative research design with think-aloud interviews was used. The study included 57 adolescents in lower (7th grade) and upper secondary school (12th grade) in Sweden. Subjective social status was explored using a slightly modified version of the MacArthur Scale of Subjective Social Status in school. Data were analyzed using thematic network analysis. RESULTS: The participants were highly aware of their social status in school. Elements tied to gender, age, ethnicity and parental economy influenced their preconditions in the positioning. In addition, expectations on how to look, act and interact, influenced the pursue for social desirability. The way these different factors intersected and had to be balanced suggests that social positioning in school is complex and multifaceted. CONCLUSIONS: Because the norms that guided social positioning left little room for diversity, the possible negative impact of status hierarchies on adolescents' health needs to be considered. In school interventions, we suggest that norms on e.g. gender and ethnicity need to be addressed and problematized from an intersectional approach.

Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: A nationwide register-based cohort study.

AIMS: To examine if personnel resources and organisational features in Swedish primary health-care centres (PHCCs) are associated to all-cause mortality (ACM) in people with type 2 diabetes mellitus (T2DM). METHODS: A total of 187,570 people with T2DM registered in the Swedish National Diabetes Register (NDR) during 2013 were included in this nationwide cohort study. Individual NDR data were linked to data from a questionnaire addressing personnel resources and organisational features for 787 (68%) PHCCs as well as to individual data on socio-economic status and comorbidities. Furthermore, data on ACM were obtained and followed up until 30 January 2018. Hierarchical Cox regression analyses were applied. RESULTS: After a median follow-up of 4.2 years, 27,136 (14.5%) participants had died. An association was found between number of whole-time-equivalent (WTE) general practitioner's (GP's) devoted to diabetes care/500 people with T2DM and lower risk of early death (hazard ratio 0.919 [95% confidence interval 0.895-0.945] per additional WTE GP; p = 0.002). No other personnel resources or organisational features were significantly associated with ACM. CONCLUSIONS: This nationwide register-based cohort study suggests that the number of WTE GPs devoted to diabetes care have an impact on the risk of early death in people with T2DM.

Written Examinations in Swedish Medical Schools: Minds Molded to Medicate?

Lifestyle medicine (LM) is part of official educational goals in Swedish medical schools. We studied questions concerning 5 noncommunicable diseases: diabetes, hypertension, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and stroke from 124 written examinations conducted between 2012 and 2015. LM knowledge yielded between 2% and 10%, whereas pharmacology-related knowledge yielded between 24% and 50%, of total points. The multiples at which pharmacology-related knowledge was valued higher than LM knowledge were 2.4 for COPD (P < .056), 4.3 for diabetes (P < .0001), 4.8 for hypertension (P < .0001), 5.2 for CHD (P < .0001), and 31.5 for stroke (P < .0001). Our results indicate that lifestyle-related knowledge, though covered by official teaching goals, is currently underrated in Swedish medical education.

Health-Care Administrator Perspectives on Prevention Guidelines and Healthy Lifestyle Counseling in a Primary Care Setting in New York State.

INTRODUCTION: The incidence of chronic disease and treatment costs have been steadily increasing in the United States over the past few decades. Primary prevention and healthy lifestyle counseling have been identified as important strategies for reducing health-care costs and chronic disease prevalence. This article seeks to examine decision-makers' experiences and self-perceived roles in guideline and lifestyle counseling implementation in a primary care setting in the United States. METHODS: Qualitative interviews were conducted with administrators at a health-care network in Upstate New York and with state-level administrators, such as insurers. Decision-makers were asked to discuss prevention guidelines and healthy lifestyle counseling, as well as how they support implementation of these initiatives. Interviews were analyzed using a thematic analysis framework and relevant sections of text were sorted using a priori codes. RESULTS: Interviews identified numerous barriers to guideline implementation. These included the complexity and profusion of guidelines, the highly politicized nature of health-care provision, and resistance from providers who sometimes prefer to make decisions autonomously. Barriers to supporting prevention counseling included relatively time-limited patient encounters, the lack of reimbursement mechanisms for counseling, lack of patient resources, and regulatory complexities. CONCLUSIONS: Our research indicates that administrators and administrative structures face barriers to supporting prevention activities such as guideline implementation and healthy lifestyle counseling in primary care settings. They also identified several solutions for addressing existing primary prevention barriers, such as relying on nurses to provide healthy lifestyle support to patients. This article provides an important assessment of institutional readiness to support primary prevention efforts.

Self-rated health, subjective social status in school and socioeconomic status in adolescents: a cross-sectional study.

BACKGROUND: Social position, traditionally measured by objective data on socioeconomic status (SES), is linked to health status in adults. In adolescents, the association is more uncertain and there are some studies suggesting that subjective social status (SSS) might be more adequate in relation to health. This study aimed to examine associations between SSS in school, SES and self-rated health (SRH) in adolescent boys and girls. METHODS: A descriptive cross-sectional research design with quantitative survey data was used. The study involved 705 Swedish adolescents in upper secondary school (17-18-year-olds). SRH was measured with a single-item question and SSS by a question where adolescents were asked to assess their social position within their school. Formal education level of the parents was used as a proxy for objective SES. Univariable and multivariable ordinal regression analyses were conducted to assess the associations between SRH and SSS in school and SES. RESULTS: In the multivariable analysis, SSS in school was positively associated with SRH, whereas no significant association between SES and SRH was found. The proportion of adolescents with high SRH increased with higher steps on the SSS ladder. Significant gender differences were found in that boys rated their SRH and SSS in school higher than girls did. CONCLUSIONS: The study shows that self-rated health in adolescents is related to perceived social position in school. Subjective social status in school seems to be a useful health-related measure of social position in adolescents.

[Updated Swedish National Guidelines on prevention and lifestyle habits: physicians' role]. / Läkaren har en nyckelroll i vårdarbetet med levnadsvanor - Socialstyrelsens nya Nationella riktlinjer betonar det rådgivande patientsamtalet.

The recently updated Swedish National Guidelines on prevention and lifestyle habits (tobacco use, hazardous use of alcohol, insufficient physical activity and unhealthy eating habits) emphasize the importance of supporting lifestyle changes among risk individuals, such as already affected by disease, carriers of risk factors that increase the risk of disease, and people with social vulnerability. More measures targeting youth are included, as well as measures to avoid smoking and alcohol use prior to surgery. Physicians have a key role in implementation of the new guidelines, as a great majority of patients who attend healthcare and discuss lifestyle habits do so with a physician.

Associations between quality of work features in primary health care and glycaemic control in people with Type 2 diabetes mellitus: A nationwide survey.

AIMS: To describe and analyse the associations between primary health care centres' (PHCCs') quality of work (QOW) and individual HbA1c levels in people with Type 2 diabetes mellitus (T2DM). METHODS: This cross-sectional study invited all 1152 Swedish PHCCs to answer a questionnaire addressing QOW conditions. Clinical, socio-economic and comorbidity data for 230,958 people with T2DM were linked to data on QOW conditions for 846 (73.4%) PHCCs. RESULTS: Of the participants, 56% had controlled (≤52mmol/mol), 31.9% intermediate (53-69mmol/mol), and 12.1% uncontrolled (≥70mmol/mol) HbA1c. An explanatory factor analysis identified seven QOW features. The features having a call-recall system, having individualized treatment plans, PHCCs' results always on the agenda, and having a follow-up strategy combined with taking responsibility of outcomes/results were associated with lower HbA1c levels in the controlled group (all p<0.05). For people with intermediate or uncontrolled HbA1c, having individualized treatment plans was the only QOW feature that was significantly associated with a lower HbA1c level (p<0.05). CONCLUSIONS: This nationwide study adds important knowledge regarding associations between QOW in real life clinical practice and HbA1c levels. PHCCs' QOW may mainly only benefit people with controlled HbA1c and more effective QOW strategies are needed to support people with uncontrolled HbA1c.

Complications of type 2 diabetes mellitus in Ramallah and al-Bireh: The Palestinian Diabetes Complications and Control Study (PDCCS).

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a growing pandemic that will lead, if not managed and controlled, to frequent complications, poor quality of life, and high rates of disability and death. Little is known about T2DM complications in Palestine. The aim of this study is to estimate the prevalence of T2DM complications in Ramallah and al-Bireh governorate of Palestine. METHODS: The study was conducted in eleven primary healthcare clinics offering services for persons with T2DM. Macrovascular complications were assessed using the Diabetes complication index. Microvascular complications were measured by physical examinations and laboratory tests. Questionnaires, laboratory tests, and physical examinations were used to assess socio-demographic characteristics, co-morbidities and other risk factors. RESULTS: 517 adult men and nonpregnant women participated in the study (166 men, 351 women). The response rate was 84%. Mean age and mean duration of diabetes were 58.1 and 9.4 years respectively. Prevalence of diagnosed microvascular and macrovascular complications was 67.2% and 28.6% respectively. 78.2% of the participants had poor glycemic control (HbA1c≥7.0%). CONCLUSION: Significant proportions of persons with T2DM had macro- and microvascular complications and poor metabolic control. These findings are important for policy development and the planning of health services.

Implementation of clinical practice guidelines on lifestyle interventions in Swedish primary healthcare - a two-year follow up.

BACKGROUND: Implementation of interventions concerning prevention and health promotion in health care has faced particular challenges resulting in a low frequency and quality of these services. In November 2011, the Swedish National Board of Health and Welfare released national clinical practice guidelines to counteract patients' unhealthy lifestyle habits. Drawing on the results of a previous study as a point of departure, the aim of this two-year follow up was to assess the progress of work with lifestyle interventions in primary healthcare as well as the uptake and usage of the new guidelines on lifestyle interventions in clinical practice. METHODS: Longitudinal study among health professionals with survey at baseline and 2 years later. Development over time and differences between professional groups were calculated with Pearson chi-square test. RESULTS: Eighteen percent of the physicians reported to use the clinical practice guidelines, compared to 58% of the nurses. Nurses were also more likely to consider them as a support in their work than physicians did. Over time, health professionals usage of methods to change patients' tobacco habits and hazardous use of alcohol had increased, and the nurses worked to a higher extent than before with all four lifestyles. Knowledge on methods for lifestyle change was generally high; however, there was room for improvement concerning methods on alcohol, unhealthy eating and counselling. Forty-one percent reported to possess thorough knowledge of counselling skills. CONCLUSIONS: Even if the uptake and usage of the CPGs on lifestyle interventions so far is low, the participants reported more frequent counselling on patients' lifestyle changes concerning use of tobacco and hazardous use of alcohol. However, these findings should be evaluated acknowledging the possibility of selection bias in favour of health promotion and lifestyle guidance, and the loss of one study site in the follow up. Furthermore, this study indicates important differences in physicians and nurses' attitudes to and use of the guidelines, where the nurses reported working to a higher extent with all four lifestyles compared to the first study. These findings suggest further investigations on the implementation process in clinical practice, and the physicians' uptake and use of the CPGs.

Lifestyle counseling in primary care in the United States and Sweden: a comparison of patients' expectations and experiences.

BACKGROUND: Despite various guidelines, shortcomings in lifestyle counseling in primary care have been demonstrated. Comparisons between countries may provide insight on how to improve such counseling. To the best of our knowledge, studies comparing patients' views of lifestyle counseling beween the United States (US) and European countries have not been reported. OBJECTIVES: To quantify and compare patients' perspectives in the US and Sweden on primary care providers' counseling on weight, eating habits, physical activity, smoking, and alcohol consumption. METHODS: In a cross-sectional study, 629 patients from Sweden and the US completed a telephone interview about their experiences after a visit to a physician in primary care. The survey focused on patients' perception of the importance of healthy lifestyle habits, their need to change, their desire to receive support from primary care, and the support they had actually received. Data were analyzed using chi-square or Fisher's exact test. RESULTS: For three of the four lifestyle habits, the proportion saying they needed to change was higher in the US. The exception was for alcohol, where Swedish subjects indicated a greater need to change. Among those stating a need to change, the proportion saying that they would like to have support from primary care was generally above 80% in both countries. The proportion of US patients reporting that their primary care provider had initiated a discussion of lifestyle modification was, with the exception of alcohol, roughly double the level reported by the Swedish patients. CONCLUSIONS: This study demonstrates high and quite similar patient expectations concerning lifestyle counseling in both countries, but more frequent initiation of discussions of most lifestyle issues in US primary care. Further studies, e.g. qualitative interviews with physicians, and medical record reviews, are required to better understand what can explain the differences between countries indicated by the study.

What is required to facilitate implementation of Swedish physical activity on prescription? - interview study with primary healthcare staff and management.

BACKGROUND: The method, Swedish Physical Activity on Prescription (SPAP), has been launched in Swedish healthcare to promote physical activity for prevention and treatment of lifestyle related health disorders. Despite scientific support for the method, and education campaigns, it is used to a limited extent by health professionals. The aim of the study was to describe the views of health professionals on perceived facilitators, barriers and requirements for successful implementation of SPAP in primary healthcare. METHODS: Eighteen semi-structured interviews with stakeholders in SPAP, i.e. ten people working in local or central management and eight primary healthcare professionals in two regional healthcare organisations, were analysed using qualitative content analysis. RESULTS: We identified an overarching theme regarding requirements for successful implementation of SPAP: Need for knowledge and organisational support, comprising four main categories: Need for increased knowledge and affirmative attitude among health professionals; Need for clear and supportive management; Need for central supporting structures; Need for local supporting structures. Knowledge of the SPAP method content and core components was limited. Confidence in the method varied among health professionals. There was a discrepancy between the central organisation policy documents declaring that disease preventive methods were prioritised and a mandatory assignment, while the health professionals asked for increased interest, support and resources from management, primarily time and supporting structures. There were somewhat conflicting views between primary healthcare professionals and managers concerning perceived barriers and requirements. In contrast to some of the management's beliefs, all primary healthcare professionals undisputedly acknowledged the importance of promoting physical activity, but they lacked time, written routines and in some cases competence for SPAP counselling. CONCLUSION: The study provides knowledge regarding requirements to facilitate the implementation of SPAP in healthcare. There was limited knowledge among health professionals regarding core components of SPAP and how to practise the method, which speaks for in-depth training in the SPAP method. The findings highlight the importance of forming policies and guidelines and establishing organisational supporting structures, and ensuring that these are well known and approved in all parts of the healthcare organisation.

Kunskap om levnadsvanor värderas olika på läkarutbildningarna - En genomgång av 124 skriftliga examinationer.

Substantial differences in valuation of lifestyle-related knowledge at Swedish medical schools Lifestyle factors are crucial for prevention and management of many non-communicable diseases such as hypertension, stroke, diabetes, coronary heart disease and chronic obstructive pulmonary disease. Lifestyle medicine is included in national learning outcomes for undergraduate medical education in Sweden. Since assessment drives learning, we reviewed questions from 124 written examinations from all 7 medical schools in Sweden, conducted between 2012 and 2015. There is up to a 5-fold difference between different universities in the weight attached to lifestyle-related knowledge compared to knowledge related to pharmacological treatments.

Resources and organisation in primary health care are associated with HbA1c level: A nationwide study of 230958 people with Type 2 diabetes mellitus.

AIMS: To examine the association between personnel resources and organisational features of primary health care centres (PHCCs) and individual HbA1c level in people with Type 2 diabetes mellitus (T2DM). METHODS: People with T2DM attending 846 PHCCs (n=230958) were included in this cross-sectional study based on PHCC-level data from a questionnaire sent to PHCCs in 2013 and individual-level clinical data from 2013 for people with T2DM reported in the Swedish National Diabetes Register, linked to individual-level data on socio-economic status and comorbidities. Data were analysed using a generalized estimating equations linear regression models. RESULTS: After adjusting for PHCC- and individual-level confounding factors, personnel resources associated with lower individual HbA1c level were mean credits of diabetes-specific education among registered nurses (RNs) (-0.02mmol/mol for each additional credit; P<0.001) and length of regular visits to RNs (-0.19mmol/mol for each additional 15min; P<0.001). Organisational features associated with HbA1c level were having a diabetes team (-0.18mmol/mol; P<0.01) and providing group education (-0.20mmol/mol; P<0.01). CONCLUSIONS: In this large sample, PHCC personnel resources and organisational features were associated with lower HbA1c level in people with T2DM.

Pride, shame and health among adolescents - a cross-sectional survey.

Background Pride and shame are important emotions known to influence identity development and psychological well-being in adolescence. Research evidence indicates that self-rated health (SRH) is a strong predictor of future health. This cross-sectional study, conducted during 2008-2009, aimed to investigate the associations between pride, shame and SRH among adolescent boys and girls. Methods The study sample comprised 705 adolescents in Sweden aged 17-18 years (318 boys and 387 girls) who completed a questionnaire that included items on SRH, shame and pride (participation rate 67%). Logistic regression analyses (univariable and multivariable) were used to investigate the associations between pride and shame as separate and combined constructs on SRH, adjusting for potential confounders (country of birth, parental educational level, school experience, having enough friends, mood in family and being active in associations). Results Pride and shame separately were significantly associated with SRH in both genders. Logistic regression analysis of the pride-shame model showed that the odds of having lower SRH were highest in boys and girls with lower pride-higher shame. In a multivariable logistic regression analysis of the pride-shame model the odds of having lower SRH remained significant in boys and girls with lower pride-higher shame [boys: odds ratio (OR) 3.51, confidence interval (CI) 1.40-8.81; girls: OR 2.70, CI 1.22-5.96] and in girls with lower pride-lower shame (OR 2.16, CI 1.02-4.56). Conclusion The emotions of shame and pride are associated with SRH in adolescence. Experiencing pride seems to serve as a protective mechanism in SRH in adolescents exposed to shame. We believe that this knowledge should be useful in adolescent health promotion.

Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013.

AIMS: To compare the resource allocation and organisational features in Swedish primary diabetes care for patients with type 2 diabetes mellitus (T2DM) between 2006 and 2013. METHODS: Using a repeated cross-sectional study design, questionnaires covering personnel resources and organisational features for patients with T2DM in 2006 and 2013 were sent to all Swedish primary health care centres (PHCCs) during the following year. In total, 684 (74.3%) PHCCs responded in 2006 and 880 (76.4%) in 2013. RESULTS: Compared with 2006, the median list size had decreased in 2013 (p<0.001), whereas the median number of listed patients with T2DM had increased (p<0.001). Time devoted to patients with T2DM and diabetes-specific education levels for registered nurses (RNs) had increased, and more PHCCs had in-house psychologists (all p<0.001). The use of follow-up systems and medical check-ups had increased (all p<0.05). Individual counselling was more often based on patients' needs, while arrangement of group-based education remained low. Patient participation in setting treatment targets mainly remained low. CONCLUSIONS: Even though the diabetes-specific educational level among RNs increased, the arrangement of group-based education and patient participation in setting treatment targets remained low. These results are of concern and should be prioritised as key features in the care of patients with T2DM.

What is Health and What is Important for its Achievement? A Qualitative Study on Adolescent Boys' Perceptions and Experiences of Health.

UNLABELLED: Few qualitative studies have explored adolescent boys' perceptions of health. AIM: The aim of this study was therefore to explore how adolescent boys understand the concept of health and what they find important for its achievement. METHODS: Grounded theory was used as a method to analyse interviews with 33 adolescent boys aged 16 to 17 years attending three upper secondary schools in a relatively small town in Sweden. RESULTS: There was a complexity in how health was perceived, experienced, dealt with, and valued. Although health on a conceptual level was described as 'holistic', health was experienced and dealt with in a more dualistic manner, one in which the boys were prone to differentiate between mind and body. Health was experienced as mainly emotional and relational, whereas the body had a subordinate value. The presence of positive emotions, experiencing self-esteem, balance in life, trustful relationships, and having a sense of belonging were important factors for health while the body was experienced as a tool to achieve health, as energy, and as a condition. CONCLUSION: Our findings indicate that young, masculine health is largely experienced through emotions and relationships and thus support theories on health as a social construction of interconnected processes.

Exploring self-rated health among adolescents: a think-aloud study.

BACKGROUND: Despite extensive use of self-rated health questions in youth studies, little is known about what such questions capture among adolescents. Hence, the aim of this study was to explore how adolescents interpret and reason when answering a question about self-rated health. METHODS: A qualitative study using think-aloud interviews explored the question, "How do you feel most of the time?", using five response options ("Very good", "Rather good", "Neither good, nor bad", "Rather bad", and "Very bad"). The study involved 58 adolescents (29 boys and 29 girls) in lower secondary school (7th grade) and upper secondary school (12th grade) in Sweden. RESULTS: Respondents' interpretations of the question about how they felt included social, mental, and physical aspects. Gender differences were found primarily in that girls emphasized stressors, while age differences were reflected mainly in the older respondents' inclusion of a wider variety of influences on their assessments. The five response options all demonstrated differences in self-rated health, and the respondents' understanding of the middle option, "Neither good, nor bad", varied widely. In the answering of potential sensitive survey questions, rationales for providing honest or biased answers were described. CONCLUSIONS: The use of a self-rated health question including the word 'feel' captured a holistic view of health among adolescents. Differences amongst response options should be acknowledged when analyzing self-rated health questions. If anonymity is not feasible when answering questions on self-rated health, a high level of privacy is recommended to increase the likelihood of reliability.