Empirical evidence of recall bias for primary health care visits

BACKGROUND: While it is common for an economic evaluation of health care to rely on trial participants for self-reported health service utilisation, there is variability in the accuracy of this data due to potential recall bias. The aim of this study was to quantify the level of recall bias in self-reported primary health care general practitioner (GP) visits following inpatient rehabilitation over a 12 month period.

METHODS: This report is a secondary analysis from a larger randomised control trial of an economic evaluation of additional Saturday inpatient rehabilitation. Participants were adults who had been discharged into the community following admission to an acute general rehabilitation hospital. Participants were asked to recall primary health care visits, including community GP visits, via a telephone questionnaire which was administered at 6 and 12 months following discharge from inpatient rehabilitation. Participants were asked to recall health service utilisation over each preceding 6 month period. The self-reported data were compared to equivalent claims data from the national insurer, over the same period.

RESULTS: 751 participants (75% of the full trial) with a mean age of 74 years (SD 13) were included in this analysis. Over the 12 month period following discharge from rehabilitation there was an under-reporting of 14% in self-reported health service utilisation for GP visits compared to national insurer claims data over the same period. From 0 to 6 months following discharge from rehabilitation, there was an over-reporting of self-reported GP visits of 35% and from 7 to 12 months there was an under-reporting of self-reported GP visits of 36%, compared to national insurer claims data over the same period. 46% of patients reported the same or one number difference in self-reported GP visits between the 0 to 6 and the 7 to 12 month periods.

CONCLUSION: Based on these findings we recommend that an economic evaluation alongside a clinical trial for an elderly adult rehabilitation population include a sensitivity analysis that inflates self-reported GP visits by 16% over 12 months. However caution is required when utilising self-reported GP visits as the data may contain periods of both over and under reporting. Where general practitioner visits are expected to vary significantly between intervention and control groups we recommend that administrative data be included in the trial to accurately capture resources for an economic evaluation.

Tests of measurement invariance failed to support the application of the "then-test"

Objective
The use of then-test (retrospective pre-test) scores has frequently been proposed as a solution to potential confounding of change scores because of response shift, as it is assumed that then-test and post-test responses are provided from the same perspective. However, this assumption has not been formally tested using robust quantitative methods. The aim of this study was to compare the psychometric performance of then-test/post-test with traditional pre-test/post-test data and assessing whether the resulting data structures support the application of the then-test for evaluations of chronic disease self-management interventions.

Study Design and Setting
Pre-test, post-test, and then-test data were collected from 314 participants of self-management courses using the Health Education Impact Questionnaire (heiQ). The derived change scores (pre-test/post-test; then-test/post-test) were examined for their psychometric performance using tests of measurement invariance.

Results
Few questionnaire items were noninvariant across pre-test/post-test, with four items identified and requiring removal to enable an unbiased comparison of factor means. In contrast, 12 items were identified and required removal in then-test/post-test data to avoid biased change score estimates.

Conclusion
Traditional pre-test/post-test data appear to be robust with little indication of response shift. In contrast, the weaker psychometric performance of then-test/post-test data suggests psychometric flaws that may be the result of implicit theory of change, social desirability, and recall bias.

Leptin in depressed women : Cross-sectional and longitudinal data from an epidemiologic study

Background There is conflicting evidence regarding levels of leptin in depression. In this study we aimed to investigate the relationship between serum leptin level and depression in a community sample of women using both cross-sectional and longitudinal data.

Methods From among 510 women aged 20–78 yr, 83 were identified with a lifetime history of major depressive disorder or dysthymia, ascertained using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID-I/NP). Serum leptin levels were measured by radioimmunoassay. Medication use and lifestyle were self-reported and body mass index (BMI) determined from measures of height and weight.

Results Using multiple linear regression, serum leptin levels were greater among women with a lifetime history of depression compared to women without any history of depression, independent of BMI. Adjusted geometric mean values of serum leptin were 16.37 (95%CI 14.70–18.23) ng/mL for depressed and 14.46 (95%CI 13.79–15.16) ng/mL for non-depressed women (P = 0.039). The hazard ratio (HR) for a de novo depressive disorder over five years increased 2.56-fold for each standard deviation increase in log-transformed serum leptin among non-smokers and this was not explained by differences in BMI, medications or other lifestyle factors (HR = 2.56, 95%CI 1.52-4.30). No association was observed for smokers.

Limitations There is potential for unrecognised confounding, recall bias and transient changes in body composition.

Conclusion Women with a lifetime history of depression have elevated levels of serum leptin, and elevated serum leptin predicts subsequent development of a depressive disorder.

Does reverse causality explain the relationship between diet and depression?

BACKGROUND: Observational studies have repeatedly demonstrated relationships between habitual diet quality and depression. However, whilst reverse causality has not been the identified mechanism for these associations in prospective studies, the relationship between diet and depression is likely complex and bidirectional. Thus explicit investigation of the reverse causality hypothesis is warranted. METHODS: Data were drawn from the Personality and Total Health (PATH) Through Life Study, a longitudinal community survey following three age cohorts from Australia. Analyses evaluated the relationships between past depression and treatment, current depressive symptoms and dietary patterns. RESULTS: Individuals with current depression had lower scores on a healthy dietary pattern; however, those who had been previously depressed and sought treatment had higher scores on the healthy dietary pattern at the later baseline assessment. Moreover, those who had reported prior, but not current, depression also had lower scores on the western dietary pattern than those without prior depression, regardless of whether they had been previously treated for their symptoms. LIMITATIONS: Self-report data and possible recall bias limit our conclusions. CONCLUSIONS: In this study, prior depression was associated with better quality diets at the later time point. Thus, while current depression is associated with poorer dietary habits, a history of depression may prompt healthier dietary behaviours in the long term. Given the demonstrated relationships between diet quality and depressive illness, clinicians should advocate dietary improvement for their patients with depression and should not be pessimistic about the likelihood of adherence to such recommendations.

Depression as a risk factor for fracture in women: a 10 year longitudinal study

BACKGROUND: Previous research has demonstrated deficits in bone mineral density (BMD) among individuals with depression. While reduced BMD is a known risk for fracture, a direct link between depression and fracture risk is yet to be confirmed. METHODS: A population-based sample of women participating in the Geelong Osteoporosis Study was studied using both nested case-control and retrospective cohort study designs. A lifetime history of depression was identified using a semi-structured clinical interview (SCID-I/NP). Incident fractures were identified from radiological reports and BMD was measured at the femoral neck using dual energy absorptiometry. Anthropometry was measured and information on medication use and lifestyle factors was obtained via questionnaire. RESULTS: Among 179 cases with incident fracture and 914 controls, depression was associated with increased odds of fracture (adjusted odds ratio (OR) 1.57, 95%CI 1.04-2.38); further adjustment for psychotropic medication use appeared to attenuate this association (adjusted OR 1.52, 95%CI 0.98-2.36). Among 165 women with a history of depression at baseline and 693 who had no history of depression, depression was associated with a 68% increased risk of incident fracture (adjusted hazard ratio (HR) 1.68, 95%CI 1.02-2.76), with further adjustment for psychotropic medication use also appearing to attenuate this association (adjusted HR 1.58, 95%CI 0.95-2.61). LIMITATIONS: Potential limitations include recall bias, unrecognised confounding and generalizability. CONCLUSIONS: This study provides both cross-sectional and longitudinal evidence to suggest that clinical depression is a risk factor for radiologically-confirmed incident fracture, independent of a number of known risk factors. If there is indeed a clinically meaningful co-morbidity between mental and bone health, potentially worsened by psychotropic medications, the issue of screening at-risk populations needs to become a priority.

Street characteristics preferred for transportation walking among older adults: a choice-based conjoint analysis with manipulated photographs

BACKGROUND: Knowledge about the relationships between micro-scale environmental factors and older adults' walking for transport is limited and inconsistent. This is probably due to methodological limitations, such as absence of an accurate neighborhood definition, lack of environmental heterogeneity, environmental co-variation, and recall bias. Furthermore, most previous studies are observational in nature. We aimed to address these limitations by investigating the effects of manipulating photographs on micro-scale environmental factors on the appeal of a street for older adults' transportation walking. Secondly, we used latent class analysis to examine whether subgroups could be identified that have different environmental preferences for transportation walking. Thirdly, we investigated whether these subgroups differed in socio-demographic, functional and psychosocial characteristics, current level of walking and environmental perceptions of their own street.

METHODS: Data were collected among 1131 Flemish older adults through an online (n = 940) or an interview version of the questionnaire (n = 191). This questionnaire included a choice-based conjoint exercise with manipulated photographs of a street. These manipulated photographs originated from one panoramic photograph of an existing street that was manipulated on nine environmental attributes. Participants chose which of two presented streets they would prefer to walk for transport.

RESULTS: In the total sample, sidewalk evenness had by far the greatest appeal for transportation walking. The other environmental attributes were less important. Four subgroups that differed in their environmental preferences for transportation walking were identified. In the two largest subgroups (representing 86% of the sample) sidewalk evenness was the most important environmental attribute. In the two smaller subgroups (each comprising 7% of the sample), traffic volume and speed limit were the most important environmental attributes for one, and the presence of vegetation and a bench were the most important environmental attributes for the other. This latter subgroup included a higher percentage of service flat residents than the other subgroups.

CONCLUSIONS: Our results suggest that the provision of even sidewalks should be considered a priority when developing environmental interventions aiming to stimulate older adults' transportation walking. Natural experiments are needed to confirm whether our findings can be translated to real environments and actual transportation walking behavior.

Do logbooks influence recall of physical activity in validation studies?

Purpose: To examine whether physical activity logbooks influence estimates of validity of 7-d recall physical activity questionnaires. Methods: A  convenience sample of 551 adults aged 18–75 yr wore an MTI  accelerometer for seven consecutive days and were then randomly administered two of four 7-d recall physical activity questionnaires that varied in length and format (Active Australia Survey (AAS), long and short  International Physical Activity Questionnaires (IPAQ-L and IPAQ-S), and Behavioral Risk Factor Surveillance System (BRFSS)). A subsample of 75% concurrently completed a physical activity logbook. Results: Correlations (rho) between self-reported and measured duration of moderate- and vigorous-intensity activity and total activity were similar among participants who received a logbook and those who did not for each of the four instruments. There was also no interaction between assessment method (survey, accelerometer) and the assignment of a logbook. For the IPAQ-L, however, variability in the difference between accelerometer data and responses to the vigorous items was smaller among those assigned a logbook (F = 4.128, df = 260, P = 0.043). Overall, there were no differences in percent agreement or kappa for participation in sufficient levels of physical activity according to receipt of a logbook for any of the surveys. Conclusion: The process of self-monitoring through completion of a logbook does not appear to influence estimates of validity for brief or long questionnaires with global questions. Whereas the magnitude of error in accuracy of recall of particular types of activity may be reduced by completion of a logbook that is similar in structure to the survey being validated, this does not appear to influence overall estimates of validity.

Is optimistic bias influenced by control or delay?

Optimistic bias is a commonly observed but poorly explained phenomenon. Our aim was to determine whether optimistic bias varied according to the nature of the event. Two event characteristics were explored: control and delay. A sample of 100 participants aged 18–30 years was randomly selected from the local residential telephone directory. Respondents were interviewed over the telephone. The highly structured interview schedule assessed respondents' perceptions of their own risk, and the risk of an average person of their age and sex for experiencing four negative life events: developing skin cancer, being involved in a serious car accident as the driver, being involved in a serious car accident as a passenger and having to wear a hearing aid. It also assessed respondents' perceptions of control and delay for each event. Data analysis using a repeated-measures MANOVA showed that optimistic bias occurred for all four events. Optimistic bias was significantly greater for the two events high in control (skin cancer and accident as the driver) than for those low in control (accident as a passenger and hearing aid). Delay was not related to the magnitude of optimistic bias. These findings have implications for health promotion campaigns and self-protective behaviors.

Optimistic bias for negative and positive events.

Presents results of an investigation into the occurrence of optimistic bias in relation to both positive and negative events, using absolute judgements to assess perceived risk for each of six events. Participants were asked why they offered different ratings for themselves and for others. The results showed that optimistic bias is a pervasive phenomenon that occurs for both positive and negative events. It occurred for all six events when comparisons were made with an unspecified person of the same age and sex, and occurred for three of six events when comparisons were made with the same-sex best friend. Participants could provide information about their own behaviour that they felt justified their positive outlook; however, they implicitly assumed that the comparison target did not engage in the same behaviour. Concludes that risk-reduction education needs to be made personally relevant to the target audience.

Eliciting children's recall of events: how do computers compare with humans?

This study investigated the usefulness of an interactive computer program in eliciting children's reports about an event. Fifty-four 5–6- and fifty-nine  7–8-year old children participated in an event with their regular class teacher which involved several activities and a mildly negative secret. Four days and again 14 days later, the children were interviewed individually by computer (alone) or by a human interviewer. The computer program incorporated animation and audio whereby an animated figure asked the questions and the children were required to provide a verbal response. The accuracy and detail of the children’s reports was similar across the interview conditions. The children were more willing to review their answers with the computer than the adult interviewer. However, responses to the computer were less consistent across the interviews, and the children were less willing to disclose the secret in the second interview to the computer compared with the human interviewer. Overall, the computer revealed little benefit in eliciting children’s recall of the event over the standard face-to-face interview.

Maintaining life satisfaction: the role of positive cognitive bias

Recent research into population standards of life satisfaction has revealed a remarkable level of uniformity, with the mean values for Western populations clustering at around three-quarters of the measurement scale maximum. While this seems to suggest the presence of a homeostatic mechanism for life satisfaction, the character of such a hypothetical device is uncertain. This paper proposes that well-being homeostasis is controlled by positive cognitive biases pertaining to the self. Most particular in this regard are the positive biases in relation to self-esteem, control and optimism. Past controversies in relation to this proposition are reviewed and resolved in favour of the proposed mechanism. The empirical data to support this hypothesis are discussed in the context of perceived well-being as an adaptive human attribute.

Validity and reliability of a physical activity recall instrument among overweight and non-overweight men and women

This study examined the validity and reliability of survey items measuring one-week recall of physical activity (PA) and examined differences by weight status. A sub-aim of the study was to objectively assess the intensity of activity that most closely matches self-report. A questionnaire was administered to adults twice, three days apart. It was again administered after subjects wore a MTI/CSA accelerometer for seven days (n = 118). Several metabolic equivalent (MET) thresholds were applied to the accelerometer data. Agreement between test and re- test estimates of sufficient physical activity for health benefits (150 min/week) was high (% agreement > 90%). Correlations (rho) between total reported PA (mins/day) and accelerometer data were 0.29 (p < 0.05) among men and 0.25 (p < 0.05) among women. Among men, self- reported duration of moderate PA (3-5.9 METS) and accelerometer data were significantly correlated (rho = 0.40, p < 0.01), with no differences by weight status. Among women, a significant relationship was found only for those who were not overweight (rho = 0.52, p < 0.001). A significant correlation between self-reported duration of vigorous PA (6+ METS) and accelerometer data was only found for overweight men (rho = 0.40, p < 0.05). When lower MET thresholds were applied to the accelerometer data, women's reported duration of moderate-intensity PA was most strongly correlated with moderate PA (accelerometer) defined as 2.0-5.9 METS (rho = 0.39, p < 0.01). The recall instrument provides a consistent measure of physical activity and validation coefficients were similar to those obtained for other physical activity recall questionnaires. However, the ability to measure PA by self-report may vary by weight status.

Improving children's recall of an occurrence of a repeated event: is it a matter of helping them to generate options?

Three experiments were conducted to explore whether children's recall of an occurrence of a repeated event could be improved by encouraging them to consider various details that occurred across a series of events prior to making a judgement about which details were included in the target (to-be-recalled) occurrence. Experiment 1 explored whether children's recall of the target occurrence was better after the interviewer presented all the items from the series prior to the child identifying the final item. Experiment 2 explored whether having the children generate all the items facilitated their subsequent recall of the target occurrence. Finally, Experiment 3 directly compared the effectiveness of the above 2 procedures. Regardless of the children's age, the retention interval, or the type of item, children's capacity to identify which details were included in a target occurrence was enhanced when they were initially provided with all the possible details from the series of events. However, without relying on the interviewer to generate the options, the benefit of the technique was directly contingent on the children's ability to generate content details; this was a distinct source of difficulty for the children. Indeed, having children generate options had no beneficial effect on decisions about the temporal position of items unless performance was made conditional on the children's ability to remember the relevant details in the first place. The implications of the findings for the legal setting and for future research are discussed.

The effect of intellectual disability on children's recall of an event across different question types

This research examined the performance of 80 children aged 9–12 years with either a mild and moderate intellectual disability when recalling an innocuous event that was staged in their school. The children actively participated in a 30-min magic show, which included 21 specific target items. The first interview (held 3 days after the magic show) provided false and true biasing information about these 21 items. The second interview (held the following day) was designed to elicit the children's recall of the target details using the least number of specific prompts possible. The children's performance was compared with that of 2 control groups; a group of mainstream children matched for mental age and a group of mainstream children matched for chronological age. Overall, this study showed that children with either a mild or moderate intellectual disability can provide accurate and highly specific event-related information. However, their recall is less complete and less clear in response to free-narrative prompts and less accurate in response to specific questions when compared to both the mainstream age-matched groups. The implications of the findings for legal professionals and researchers are discussed.