Effectiveness of various mailing strategies among nonrespondents in a prospective cohort study. Increasing response rates in physicians' mail surveys: an experimental study. Controlled trial of the effect of length, incentives, and follow-up techniques on response to a mailed questionnaire. A randomized trial of the impact of telephone and recorded delivery reminders on the response rate to research questionnaires. Effects of mailing strategies on response rate, response time, and cost in a questionnaire study among nurses. Increasing response to mailed questionnaires by including a pencil/pen. No increase in response rate by adding a web response option to a postal population survey: a randomized trial. Primer postcard improves postal survey response rates. Initial nonresponders had an increased response rate after repeated questionnaire mailings. [Mail questionnaires. A useful strategy for the follow-up of patients with a cerebrovascular stroke?]. Labour-saving strategies to maintain survey response rates: a randomised trial. A study of mail survey method. Possible factors affecting response to postal questionnaires: findings from a study of general practitioner services. Increasing the response rate to a mailed questionnaire by including more stamps on the return envelope: a cotwin control study. Enclosing a pen with a postal questionnaire can significantly increase the response rate. Physician participation in research surveys. A randomized study of inducements to return mailed research questionnaires. Short report: encouraging GPs to complete postal questionnaires--one big prize or many small prizes? A randomized controlled trial. Survey response rates to a professional association mail questionnaire. Randomized trial of use of a monetary incentive and a reminder card to increase the response rate to a mailed health survey. Response rate to mailed epidemiologic questionnaires: a population-based randomized trial of variations in design and mailing routines. A randomised controlled trial to assess the effectiveness of offering study results as an incentive to increase response rates to postal questionnaires [ISRCTN26118436]. Timing payments to subjects of mail surveys: cost-effectiveness and bias. Increasing response rates to postal questionnaires: a randomised trial of variations in design. Telephone reminders are a cost effective way to improve responses in postal health surveys. Randomized trial of 5 dollars versus 10 dollars monetary incentives, envelope size, and candy to increase physician response rates to mailed questionnaires. Effects of characteristics of the survey instrument on response rates to a mail survey of community hospitals. Questionnaire order significantly increased response to a postal survey sent to primary care physicians. Maximising response rates in a survey of general practitioners. Lessons from a Victorian survey on sexually transmissible diseases. Does anonymity increase response rate in postal questionnaire surveys about sensitive subjects? A randomised trial. Questionnaire color and response rates to mailed surveys. A randomized trial and a meta-analysis. Mailed survey follow-ups--are postcard reminders more cost-effective than second questionnaires? A comparison of response rate, data quality, and cost in the collection of data on sexual history and personal behaviors. Mail survey approaches and in-person interview. Response to mail surveys: effect of a request to explain refusal to participate. The ARIC Study Investigators. Provision of pen along with questionnaire does not increase the response rate to a postal survey: a randomised controlled trial. Day-of-the-week effect on doctors' response to a postal questionnaire. [Response rates and non-response bias in a health-related mailed survey]. A randomised controlled trial to determine the effect on response of including a lottery incentive in health surveys [ISRCTN32203485]. Differential effectiveness of telephone prompts by medical and nonmedical staff in increasing survey response rates: a randomised trial. Prepayment was superior to postpayment cash incentives in a randomized postal survey among physicians. Effect of mailed reminders on the response rate in surveys among patients in general practice. Increasing response to a postal survey of sedentary patients - a randomised controlled trial [ISRCTN45665423]. Evaluation of general practice computer templates. Lessons from a pilot randomised controlled trial. Does a deadline improve men's participation in self-administered health surveys? A randomized controlled trial in general practice. No difference in response rate to a mailed survey among prostate cancer survivors using conditional versus unconditional incentives. Impact of a postcard versus a questionnaire as a first reminder in a postal lifestyle survey. A randomized trial of the impact of certified mail on response rate to a physician survey, and a cost-effectiveness analysis. Does questionnaire structure influence response in postal surveys? The impact of different response alternatives on responders' reporting of health-related behaviour in a postal survey. Effect of a triage-based E-mail system on clinic resource use and patient and physician satisfaction in primary care: a randomized controlled trial. An informational versus monetary incentive in increasing physicians' response rates. Response rate according to title and length of questionnaire. The effect of cash and other financial inducements on the response rate of general practitioners in a national postal study. Do postage-stamps increase response rates to postal surveys? A randomized controlled trial. A randomised trial of telephone versus postcard prompts to enhance response rate in a phased population-based study about community preferences. The effects of variations in mode of delivery and monetary incentive on physicians' responses to a mailed survey assessing STD practice patterns. Effects of a mail and telephone intervention on breast health behaviors. Effects of different monetary incentives on the return rate of a national mail survey of physicians. The effect of two mailing strategies on the response to a survey of physicians. Telephone reminders are effective in recruiting nonresponding patients to randomized controlled trials. Factors impacting questionnaire response in a Dutch retrospective cohort study. Use of a coded postcard to maintain anonymity in a highly sensitive mail survey: cost, response rates, and bias. Effect of paper quality on the response rate to a postal survey: a randomised controlled trial. ISRCTN 32032031. Do postage stamps versus pre-paid envelopes increase responses to patient mail surveys? A randomised controlled trial. Do income questions and seeking consent to link medical records reduce survey response rates? A randomised controlled trial among older people. The effect of a monetary incentive on return of a postal health and development questionnaire: a randomised trial [ISRCTN53994660]. Conducting physician mail surveys on a limited budget. A randomized trial comparing $2 bill versus $5 bill incentives. Selected questionnaire size and color combinations were significantly related to mailed survey response rates. The effect on response rates of offering a small incentive with a mailed questionnaire. Physician response rates to a mail survey by specialty and timing of incentive. Improving response rates through incentive and follow-up: the effect on a survey of physicians' knowledge of genetics. The end-of-study patient survey: methods influencing response rate in the AVID Trial. Response rates and representativeness: a lottery incentive improves physician survey return rates. Screening optometric patients by questionnaire: methods of improving response. Effects on subject response of information brochures and small cash incentives in a mail-based case-control study. The effectiveness of tailored feedback and action plans in an intervention addressing multiple health behaviors. [Evaluation of inpatient satisfaction. Comparison of different survey methods]. Use and impact of an automated telephone outreach system for asthma in a managed care setting. What can you ask about? The effect on response to a postal screen of asking about two potentially sensitive questions. Crossing the digital divide: evaluating online communication between patients and their providers. Effectiveness of personalized written feedback through a mail intervention for smoking cessation: a randomized-controlled trial in Spanish smokers. A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies. Effect of prize draw incentive on the response rate to a postal survey of obstetricians and gynaecologists: a randomised controlled trial. [ISRCTN32823119]. Some experiments with factors that might affect the response of mothers to a postal questionnaire. Randomised controlled trial of routine individual feedback to improve rationality and reduce numbers of test requests. A monetary incentive increases postal survey response rates for pharmacists. Collecting saliva samples by mail. A mail survey of United States hematologists and oncologists: a comparison of business reply versus stamped return envelopes. Encouraging patient question-asking: a clinical trial. Comparison of open and closed questionnaire formats in obtaining demographic information from Canadian general internists. Maintaining mammography adherence through telephone counseling in a church-based trial. A randomized trial of incentives to improve response rates to a mailed women's health questionnaire. Response rates to a mailed survey targeting childhood cancer survivors: a comparison of conditional versus unconditional incentives. Effectiveness and efficiency of a literature search strategy to answer questions on the etiology of occupational diseases: a controlled trial. Dentists' response to financial incentives in a mail survey of malpractice liability experience. Preparing and updating systematic reviews of randomized controlled trials of health care. Effect on survey response rate of hand written versus printed signature on a covering letter: randomised controlled trial [ISRCTN67566265]. Longer response scales improved the acceptability and performance of the Nottingham Health Profile. Does requesting sensitive information on postal questionnaires have an impact on response rates? A randomised controlled trial in the south west of England. Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial. Effects of incentive size and timing on response rates to a follow-up wave of a longitudinal mailed survey.
Measures of association in prospective studies can be distorted by incomplete follow-up. Various mailing strategies were used to contact 12,233 cohort members of the Health Professionals Follow-up Study who had not responded to three successive bulk-rate mailings. Response rates were highest, 79.5% overall, from participants who were sent a certified mailing in phase 1 (63.2%), followed by a repeat certified mailing to nonrespondents (44.3%). Although altering the physical appearance of the envelope and using other postal rates were tested, certified mail was the most effective approach for reaching study members who were nonrespondents to a mailed questionnaire. It is becoming increasingly difficult to obtain high response rates in physicians' mail surveys. In 1983-84, we tested the effectiveness of two techniques among 604 Quebec physicians who had not responded to an initial letter. A handwritten thank you note at the bottom of the letter accompanying the questionnaire and a more personalized mailout package increased response rates by 40.7 per cent and 53.1 per cent, respectively, compared to control groups. Mailed questionnaires are an economical method of data collection for epidemiologic studies, but response tends to be lower than for telephone or personal interviews. As part of a follow-up study of volunteers who provided a brief health history and blood sample for a blood specimen bank in 1989, the authors conducted a controlled trial of the effect of length, incentives, and follow-up techniques on response to a mailed questionnaire. Interventions tested included variations on length of the questionnaire, effect of a monetary incentive, and effect of a postcard reminder versus a letter accompanied by a second questionnaire. Response was similar for the short (16-item, 4-page) and long (76-item, 16-page) questionnaire groups. The non-monetary [corrected] incentive did not improve the frequency of response. The second mailing of a questionnaire was significantly better than a postcard reminder in improving responses (23% vs. 10%). It is important to systematically test marketing principles to determine which techniques are effective in increasing response to mailed questionnaires for epidemiologic studies. A range of factors have been shown to affect the response rate to mailed questionnaires, but particular strategies to improve patients' response in trials conducted in general practice require further study.
                Non-responders in a larger trial were randomized to receive a telephone or recorded delivery reminder on the third contact. The cost of administration of each method was estimated.
                Significantly more patients returned completed questionnaires when sent questionnaires by recorded delivery, although the cost per patient contacted was nearly three times more than for contact by telephone.
                Our study indicates that sending reminders by recorded delivery, although more expensive, is more effective than telephone reminders for recruiting patients to a study in general practice using research questionnaires. We conducted a pilot study to determine the most efficient mailing strategy for a postal questionnaire study among nurses in Ontario, Canada. Five mailing strategies involving types of stamps on the return envelopes were considered: no stamp, business-reply stamp, metered stamp, small regular stamp, and large commemorative stamp. We found that paper stamps, especially large commemorative stamps, on return envelopes increased the response rate and reduced the response time, as compared with other mailing strategies. Business-reply stamps had the lowest cost per response received and a low total cost. Nonmonetary incentives lead to small increases in response rates to mailed questionnaires. However, inclusion of a pen or pencil, which may be a facilitating factor as well as a reward, has not been shown to improve response to health surveys in prior trials. In 2001 and 2002, the authors conducted two US trials in which a study-logo pen or pencil was randomly included in a second questionnaire mailed to nonresponders to a first mailing. In the first study, of 10,686 nonresponders to a cohort recruitment mailing, response to the second mailing was 55% with inclusion of a pen versus 40% without one (p < 0.001). In the second study, of 141 nonresponders to a pilot follow-up survey conducted 2 years after entry into a cohort, response was 43% with inclusion of a pencil versus 24% without one (p = 0.02). This 15-19 percentage point increase for mailing 2 translated to a 5-6 percentage point increase after the two mailings combined. In a simulated study of three mailings based on these studies, the overall response rate increased by 4 percentage points at no added cost through inclusion of a pencil in the second mailing. The additional cost of the pencil was compensated for by the reduced number of nonrespondents sent packets at the third mailing. This study supports including a study-logo pen or pencil in a second questionnaire mailing to nonrespondents as a cost-effective method of increasing response rates. There is substantial interest in use of the Internet for surveys, but there have been few health-oriented, large, randomized trials of general population surveys on the Internet. It is unclear whether providing the option to respond via Internet increases the response rate, and to what degree the results will differ.
                The aim of the study was to evaluate changes in response rate and outcomes in a postal respiratory health survey by adding an optional Web response alternative.
                This was a randomized trial of a random sample of 4213 permanent residents of Norway, aged 20-40 years. Participants were randomized into a traditional survey arm, where they were asked to return the survey by mail, and an arm where they were also offered the option to respond via a Web form.
                A total of 1928/4213 subjects responded, a response rate of 45.8% across both arms. The total response rate was 44.8% (944/2105) in the postal plus optional Internet response arm and 46.7% (984/2108) in the usual postal survey arm, with no statistically significant difference between the randomized groups (P = .24). In the optional Internet arm, 8.3% (175/2105) of the sample responded using the Internet and 36.5% (769/2105) responded by post. Thus, Internet response was chosen by 18.5% (175/944) of those who replied in the optional Internet arm. In the multivariate analysis, Internet response was associated with being male, frequency and type of Internet access (home users more likely to respond by Internet than work users), and smoking habit, with current smokers being more likely to be Internet responders. 57% preferred postal response (1102/1928), 38% preferred Internet response (733/1928), and 3% preferred telephone interview (54/1928), with no difference between randomization arms (P = .56). But among those who indicated that they preferred the Internet response and who were randomized to the optional Internet arm, only 47% actually chose the Internet response. Asthma prevalence was higher among participants choosing the Internet response mode (16.7% vs 12.4%).
                We failed to increase survey response rates by adding an optional Internet response. Asthma diagnosis was higher in the Internet response group, suggesting nonresponse bias. Method comparison studies should be carried out before Internet studies are accepted in new populations or new subject matters. This study measures the effect of an intervention to improve mailed survey response rates.
                A randomised controlled trial of a 'primer' postcard was performed as part of a large survey in Victoria in 1997. Prior to the survey mailout, half the sample of 800 general practitioners supplied by the Health Insurance Commission was sent, at random, a primer card to request prompt return of the survey.
                The intervention resulted in a more rapid return of the survey and improved overall response rates from 60% to 66%. The increased cost per returned survey (40 cents) was largely offset by fewer non-responders requiring follow-up.
                A primer postcard is a time and cost-efficient method to increase response rates in general practitioner surveys.
                Public health researchers should consider implementing this intervention to improve response rates to postal surveys. Reports of other response maximising strategies should report the cost per returned survey to allow better comparison. There is a growing evidence base on methods to improve response rates in surveys among patients. This study aimed to determine the additional effect of two intensive follow-up procedures compared to a simple follow-up procedure.
                Randomized controlled trial that compared repeated mailing of the questionnaire and a request to explain nonparticipation with a simple reminder card. The study population comprised 955 elderly adults registered with 26 general practitioners in The Netherlands.
                A total of 530 adults (56%) returned the questionnaire within 3 weeks and a total of 640 (67%) after follow-up. Repeated mailing of the questionnaire had additional effect compared to the simple reminder card in the group of initial nonresponders (relative risk=1.60, 95% confidence interval: 1.11-2.31), but not regarding the overall response rate. A request to explain nonparticipation did not have additional effect.
                Repeated mailing of the questionnaire increased the effectiveness of follow-up among initial nonresponders. Although not frequently used in Portugal, postal questionnaires allow the collection of information on patient's follow-up. In this study we assessed the rate of response and the usefulness of a postal questionnaire in a sample of patients with acute stroke. A prospective study was designed and analysed as a case-control: postal questionnaires were sent to 138 patients together with a randomly assigned stamped or post-free return envelope. The percentage of responders was 60% (n=78) and we found no significant differences in response rates according to the mailing strategy (58% for stamped and 62% for post-free return envelopes, p = 0.786). The time gap between hospital discharge and sending of the questionnaire had no significant influence in the response rate. Elder patients and women tend to respond more frequently, but these characteristics also do not change the response rate. Analysing socio-demographic variables reported at the acute phase, we only found differences in response rate for the smoking status: smoking was associated with a lower participation. In conclusion, the present study showed that a postal questionnaire is a useful method for the follow-up of stroke cases and that we must pay special attention to smokers for whom alternative strategies of contact or information should be used to increase compliance with postal questionnaire follow-up. To evaluate response-aiding strategies feasible in large surveys, we randomly allocated general practitioners (GPs) to one of four intervention groups: Group 1 received 'exhaustive' telephone prompts by a medical peer in advance of a questionnaire; Group 2, inclusion of an embossed pen with the questionnaire; Group 3, an advance letter prompt; and Group 4, a 'single attempt' advance telephone prompt by a non-medical research assistant. Follow-up procedures were identical. Response rates by group were not significantly different overall (chi 2 = 4.59, df = 3, p = 0.20) although advance prompts by a medical peer were significantly more effective than other strategies for male GPs. The difference in overall response rates between males (63%) and females (74%) was significant (chi 2 = 15.40, df = 1, p < 0.01). No other response bias was evident. Our demonstration of a significant interaction between respondent sex and response-aiding strategy invites further research. A major disadvantage of the mail survey in medical research is non-response, which may introduce bias. This study measured the effect of two simple factors on the response rate to a questionnaire concerning headache and migraine in a survey of 2,508 electors. The two factors were the class of postage and the colour of envelopes used; neither was found to have a significant effect. It was concluded that cheaper mailing methods are not likely to jeopardise response. Poor response rates affect the validity of results from postal questionnaires. The effect of three controllable factors upon response rates was examined in a recent study of patients' experiences and views of general practitioner services. The factors studied were the institution from which questionnaires were dispatched, the length of the questionnaire and the inclusion of a potentially sensitive question about ethnic origin. Questionnaires sent out by local Family Practitioner Committees were more likely to be returned than those sent out by a London-based independent research unit, but there were no differences in the nature of replies obtained. Neither the length of the questionnaire nor the inclusion of the potentially sensitive question affected response rates. The results of the study indicate that Family Practitioner Committees wishing to carry out postal surveys of users of general practitioner services can obtain satisfactory response rates. Twins taking part in two unrelated studies were sent a questionnaire together with a self-addressed envelope that either carried one or multiple (up to 5) stamps to the same value. The unprompted proportion of questionnaires returned (before commencement of telephone reminder calls) was increased from 62% to 71% in one study, and from 43% to 52% in the other study (test for common odds ratio in studies, p = 0.04). It is important to maximize response rates to postal questionnaires. We compared the impact of three low-cost interventions on response rates.
                A 2 x 2 x 2 factorial trial was conducted, nested within TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears). Three interventions were evaluated: (1) enclosing a TOMBOLA-branded pen with the questionnaire (as opposed to no pen); (2) sending the questionnaires by first class post (as opposed to second class); and (3) enclosing a preaddressed return envelope on which there was a second class postage stamp (rather than a freepost business-reply envelope). Nine hundred thirty women, aged 20-59 years, due to receive a TOMBOLA psychosocial questionnaire by post during June-August 2003 were randomized.
                Enclosing a pen resulted in a statistically significant 7.0% increase in the cumulative proportion of questionnaires returned (from 61.5 to 68.5%; P = .002). The adjusted odds of response was significantly raised (odds ratio [OR] = 1.38, 95% confidence interval [CI] 1.04-1.82). Neither first class post nor providing a stamped envelope had a significant impact on response. There were no interactions between the interventions.
                Enclosing a pen with a questionnaire can significantly increase response. This low-cost strategy was effective against a background of "good practice" with regard to the administration of postal questionnaires. The authors randomly selected 400 physicians from a population of 1,545 practicing physicians providing follow-up care to patients who received bone marrow or blood stem cell transplants at the Fred Hutchinson Cancer Research Center to determine interest in receiving Internet-based transplant information. In a two-factor completely randomized factorial design, the 400 physicians were assigned to receive mailed surveys with either no compensation or a $5 check and either no follow-up call or a follow-up call 3 weeks after mailing. Overall, 51.5% of the physicians returned the mailed surveys. Comparison of logit models showed that inclusion of a $5 check in the mailer significantly (p = .016) increased the probability of returning the surveys (57.5% vs. 45.5%). In contrast, the telephone follow-up had no overall effect. The authors concluded a modest financial reward can significantly improve physician response rates to research surveys but a telephone follow-up may be inefficient and even ineffective. Low response rates to surveys are a problem in general practice. There is evidence that offering GPs incentives improves response rates to postal questionnaires. However, there is less evidence about the most effective form of incentive.
                Our trial aimed to maximize response to a postal questionnaire and to test the most effective form of incentive.
                The study involved a randomized controlled trial of a postal survey
                The incentive of a lottery for six bottles of champagne generated a response rate of 79%. Furthermore, one chance of six bottles generated 9% more responses than six chances of one bottle.
                This study has established that, among incentives for postal questionnaires, one big prize improves the yield more than many small prizes despite the lower odds of winning. It has also confirmed that offering a modest incentive to GPs generates good response rates for postal questionnaires. The purpose of this research was to study the effect of various direct mail techniques on professional nurses' response rates to questionnaires. A random sample of 700 registered professional nurses consisting of five groups who were members of New York State Nurses Association (NYSNA) were mailed a questionnaire with 22 items. The study demonstrated that the response rates were directly attributable to techniques used. Providing information about the association was related to significantly decreased response rates and monetary incentives with significantly increased response rates. A combined direct mailing for questionnaire completion and membership solicitation was not effective for either purpose. Insufficient response rates are a frequent problem in mailed epidemiologic health surveys. As part of a health survey of 1,235 young adults conducted from November 1992 through January 1993 in Geneva, Switzerland, a randomized factorial trial was carried out to assess the contributions of two tactics to increase response rates. The first incentive was the promise of sending 10 Swiss francs (7 US dollars) to respondents; the second was a red postcard, mailed 2 days after the questionnaire, which reminded potential participants to complete the questionnaire. The most effective strategy according to interim analysis was to be selected for follow-up mailings. Two weeks after the first mailing, response rates were 65% for those who had received both incentives, 57% for those who had been offered the money reward only, 54% for recipients of the reminder card, and 48% for those who had received neither incentive (p based on chi 2 (3 df) test < 0.001). The relative hazards of responding were 1.34 (95% confidence interval 1.15-1.55) for the money reward and 1.22 (95% confidence interval 1.05-1.41) for the reminder card. Follow-up mailings to all nonrespondents included both incentives. At the end of data collection, 1,007 persons (82%) had returned the questionnaire. The final response rates were 83, 84, 82, and 78% in the four groups, respectively (p = 0.29). Both the promise of a monetary reward and a reminder postcard considerably improved early response rates. The use of both incentives in follow-up mailings brought final response rates above 80%, except for those who had received no initial incentive. Testing various combinations of incentives in the early stages of a mailed health survey may be a generally useful strategy. Although self-administered questionnaires are major sources of information in epidemiology, comparatively little has been done to study practical aspects of design and mailing. The objective of this study was to evaluate various measures taken to increase the response rate. A questionnaire was mailed in July 1995 to a random sample (n = 2,000) of the Swedish population aged 20-79 years. Using a randomized factorial study design, the questionnaire and mailing procedures were changed in three ways: preliminary notification, length of the questionnaire, and mention of telephone contact. The overall questionnaire retrieval rate was 49%. Preliminary notification (adjusted odds ratio of receiving a completed questionnaire = 1.30, 95% confidence interval (CI) 1.08-1.56 relative to the absence of preliminary notification) and short length of the questionnaire (odds ratio = 1.24, 95% CI 1.04-1.48 relative to a long questionnaire) were both independently associated with a higher retrieval rate. Of eight possible combinations, the one comprising preliminary notification, a short questionnaire, and no mention of telephone contact gave the highest retrieval rate, 56%. The lowest retrieval rate, 40%, was observed for the combination of no preliminary notification, a long questionnaire, and mention of telephone contact. Young age, male sex, and urban residence significantly lowered the retrieval rate. Although there was a positive association between the questionnaire retrieval rate and partial nonresponse (missing answers in retrieved questionnaires), the marginal losses due to the latter did not cancel the gains by optimized mailing routines. Old age was the strongest determinant of partial nonresponse. The data provide evidence that design and mailing strategies, as well as demographic characteristics, may greatly influence the response rate of mailed epidemiologic questionnaires. Postal questionnaires are widely used to collect outcome data on participants. However, a poor response to questionnaires will reduce the statistical power of the study and may introduce bias. A meta analysis of ten trials offering study results, largely in the fields of education and marketing, was shown to be ineffective, with the odds ratio for response with offering research findings is 0.92 (95% CI 0.75 to 1.11). However uncertainty still exists as it is uncertain whether results from such trials can be extrapolated to that of a health care setting. The aim of this study was to assess whether offering participants study results increases the response rates to postal questionnaires.
                1038 women aged over 70 years were remotely randomised by computer in a 3:1 ratio. 250 participants did not receive the offer of knowing the results of the trial and 788 participants were offered the results of the trial in a postal questionnaire. The main outcome measure was response rate. Chi square test was used to evaluate the overall differences in response rate between the two groups. An adjusted analysis, adjusting for whether the participant was taking calcium and age was also undertaken.
                The response rates were not significantly different Odds Ratio 0.88 (95% confidence intervals 0.48 to 1.63) p = 0.69.
                Offering study results to women living in the community aged over 70 does not increase response rates to postal questionnaires. Although researchers have an ethical obligation to offer participants study results, since 10% of women did not wish to receive the results, investigators should give participants the option to opt out of receiving the study's results. Although mailed surveys are an important component of epidemiological research, results from mailed surveys are often suspect because of poor response rates and the potential for nonresponse bias. Previous work has demonstrated that paying subjects to complete questionnaires increases response rates, but this work has not well addressed the impact of the timing of incentives on total cost, cost effectiveness, and response bias. We surveyed 400 university employees about health benefits. By random allocation, half received a check for $5 along with the mailed survey, and the other half received the promise of $5 on return of a completed survey. The response rates for both groups were about the same (64 and 59%, respectively), but prepayment was less expensive in aggregate and less expensive per response. In addition, we found that subjects with lower salaries were more likely to respond when paid in advance. We conclude that prepayment may actually be less expensive and more cost effective than payment on completion, but that the timing of payment may influence the profile of respondents. Low response rates to postal questionnaires can threaten the validity of studies by reducing the effective sample size and introducing bias. The identification of methods with which to optimise response rates could, therefore, improve the quality of studies. In an attempt to identify such methods, we undertook a randomised trial of two simple variations in questionnaire design.
                Using a 2 x 2 factorial design, we conducted a randomised trial to test two variations in questionnaire design; the questionnaires were printed on either single-sided or double-sided paper and had either a single- or multiple-booklet layout. Using equal random allocation, 3836 women were randomised to receive one of these questionnaires as part of a study investigating risk factors for osteoporotic fractures.
                One thousand eight hundred and seventy questionnaires were returned, giving an overall response rate of 48.7%. There were no significant differences in the overall response to each of the four questionnaire designs. When the number of responders who completed at least 50% of each of the three sections was identified, it was found that single-booklet questionnaires had a better response than the multiple-booklet questionnaires and that single-sided questionnaires had a better response than double-sided questionnaires. However, these results were not significant at the 5% level. There were no significant differences in the response to questions on the odd (left-hand side) pages for the single- compared with the double-sided questionnaires.
                As the most cost-effective use of resources, we would advocate the use of double- rather than single-sided questionnaires, and use of a single- rather than multiple-booklet design. To assess the effectiveness of a telephone reminder in increasing responses to postal surveys and to calculate the differential costs per completed questionnaire.
                Randomised controlled trial.
                Australian university and rehabilitation medicine practice.
                The trial was conducted in 1999 among the 143 non-respondents to a questionnaire about work related neck and upper body disorders. The questionnaire was sent to two Australian female samples: 200 office workers (Sample A) and 92 former rehabilitation medicine patients (Sample B). A reminder letter, another copy of the questionnaire and a final letter were sent at two week intervals. Half of the non-respondents within each sample were randomly selected to receive a telephone reminder just after the second mailout of the questionnaire. All direct costs were calculated.
                Responses were significantly higher among those who received the telephone reminder intervention (relative risk 2.54, 95% confidence intervals 1.43 to 4.52). Analysed by intention to phone, 47% of non-respondents in Sample A and 38% in Sample B returned a complete questionnaire after the intervention, compared with 21% and 10%, respectively, in the control groups. For the 112 women (combined samples) who returned completed questionnaires before randomisation, the average cost per respondent was AUD14. There was a higher total cost for the intervention groups (AUD851 versus AUD386 for controls), but the significantly higher number of additional completed responses (31 versus 12) resulted in a 15% lower marginal cost per completed questionnaire in those groups.
                Telephone reminders are cost effective in improving responses to postal surveys. The validity of the results of mailed surveys is often threatened by nonresponse bias, which is made more likely when response rates are low. However, the effectiveness and cost-effectiveness of several strategies to increase response rates are uncertain.
                To assess three strategies to increase response rates to mailed physician surveys: including a 10 dollars versus a 5 dollars cash incentive in the initial mailing, including a mint candy or not, and using a large versus small outgoing envelope.
                Using a 2 x 2 x 2 factorial design, a randomized trial of these strategies was conducted in a survey of 1200 physicians randomly selected from the American Medical Association's Master File.
                Including a 10 dollars incentive yielded a significantly higher response rate (60.5% vs. 52.8%) (P = 0.009). The mailing and incentive costs per completed response were 12.24 dollars (95% CI, 11.75 dollars, 13.64 dollars) in the 5 dollars group and 18.48 dollars (95% CI, 17.77 dollars, 20.69 dollars) in the 10 dollars group. Each additional response obtained in the 10 dollars group came at an incremental cost of 61.26 dollars (95% CI, 36.98 dollars, 200.80 dollars). Neither inclusion of a mint nor use of a large envelope influenced the response rate.
                Investigators may increase response rates by including more money in the initial questionnaire packet, but there may be diminishing returns to serial increments in incentives greater than 5 dollars. Including smaller incentives in more questionnaires may maximize total responses. A 4-factor, 16-cell experimental design was used to investigate the relationship between response rates of community hospitals to a survey conducted by the American Hospital Association (AHA) and 4 characteristics of the survey instrument, each varied dichotomously: the perceived length of the questionnaire, the order of questions, the orientation of the appeal made in the cover letter, and the presence or absence of a promise to share the results of the study with respondents. Response rate variations between the various cells were examined and multiple logistic regression was used to analyze the significance of the association between response rates and each of the four survey instrument variables while controlling for the effect of the others. At the same time, control was also maintained for the effects of five institutional characteristics of hospitals which a previous study had shown to have a significant relationship to response: bed size, location within or outside a standard metropolitan statistical area, AHA membership status, type of ownership, and form of control. The perceived length of the questionnaire and the order of questions were found to have a significant effect on response rates, but the orientation of the cover letter and a promise to share the results of the study with the respondents were found to be insignificant. Primary care physicians are increasingly being asked to participate in postal surveys. Difficulties in achieving adequate response rates among physicians have been reported. We investigated the effect of two low-cost interventions on response to a primary care physician postal questionnaire.
                A 2x2 factorial trial was developed within the context of a national survey assessing views and practices of physicians regarding prostate-specific antigen testing. We evaluated questionnaire order (version 1: demographics first, version 2: topic-specific questions first) and written precontact. A national database of primary care physicians was compiled. One thousand five hundred ninety-nine physicians were randomly selected, stratified by health board, and randomized.
                47.9% of eligible physicians completed a questionnaire. There was a statistically significant 5.1% higher response rate among physicians receiving version 1 of the questionnaire than those receiving version 2 (50.6% vs. 45.4%, P=0.05); the adjusted odds of response were significantly raised (odds ratio=1.24; 95% confidence interval=1.01-1.54). Precontact resulted in a nonsignificant 3.6% increase in response (49.8% vs. 46.2%; P=0.16). The interventions did not interact.
                Ordering questionnaires with general questions first can significantly increase response rates, whereas precontact can achieve a modest increase. These strategies may enhance response while adding little to the cost of a physician survey. To describe factors that influence participation by general practitioners (GPs) in survey research, and in particular to examine the effectiveness of telephone prompts made by a GP researcher compared with non-medical researchers in a survey of GPs on sexually transmissible diseases (STDs).
                A questionnaire survey of knowledge, attitudes, behaviour and practice (KABP) in relation to STDs was distributed to 520 Victorian GPs randomly selected from the Australian Medical Publishing Company's (AMPCo) database of Australian medical practitioners.
                Number of GPs able to be contacted by telephone and cumulative and overall response rates to the questionnaire.
                The overall response rate was 85%. Although the GP researcher was able to make contact by telephone in a higher proportion of cases (80%) than the non-GP researchers combined (69%, p < 0.01) response rates were not significantly different (83% versus 87%).
                Telephone prompts to encourage GP response in survey research need not be made by a medical practitioner. Other important factors in relation to response rate that should be considered by researchers are GP involvement in the developing and piloting of the survey instrument, incentives and provision of detailed feedback of the results of the survey. The aim of the study was to determine whether complete anonymity improves the response rates to a postal questionnaire.
                The study derived from a series of postal surveys on AIDS knowledge conducted on six different dates in 1986 and 1987. The sample was randomly divided into two, each group being sent the same questionnaire. One group was informed that the replies were anonymous, the other that they were not. The latter were sent reminders.
                Recipients of the questionnaires were drawn from the Southampton electoral rolls.
                300 people in each survey (total 1800) were sent questionnaires, representing on each occasion a different 1:500 systematic sample.
                Response rate was 49% for the anonymous questionnaires and 51% for the numbered questionnaires. Reminders boosted the response in the numbered group to 72%.
                There is no evidence that anonymity improves response to postal questionnaires, but the use of reminders may do so. The authors conducted a randomized trial in Geneva, Switzerland, to assess whether response rates to a mailed survey could be increased by printing the questionnaire on green paper. The authors also conducted a meta-analysis of 10 experimental studies that tested the effect of colored questionnaires on response rates. The randomized trial showed no effect (relative risk of responding [RR] = 1.00). The meta-analysis showed that mailing questionnaires on pink paper increased response rates by 12% (RR = 1.12, 95% confidence interval = 1.01 to 1.25, p = 0.04). Other colors had no statistically significant effect (blue: RR = 1.03, p = 0.49; green: RR = 1.02, p = 0.23; yellow: RR = 0.96, p = 0.30). Overall, using colored instead of white paper had no effect (RR = 1.02, p = 0.17). Thus, printing questionnaires on colored paper does not substantially increase response rates in surveys, except for pink paper. Finding cost-effective ways to increase response to mailed surveys is a concern for many nurse researchers. This study compared two follow-up methods: sending a second questionnaire packet versus sending a reminder postcard to those who did not respond to an initial mailing. Although the second questionnaire yielded a higher response than did the postcard, the cost per additional response was approximately 2 1/2 times higher for the questionnaire than for the postcard when the differential cost of the two mailings is considered. The authors examined differences in rate of response, data quality, and cost between mail approaches and in-person interview in the collection of data on sexual history and personal behaviors. A sample of women from a midwestern United States university (n = 342) was identified from health service medical records as having been seen for a sexually transmitted disease (cases) or a contraceptive visit (controls) during the latter half of 1985. The women were randomly assigned to one of three data collection strategies. A total of 268 subjects (78%) participated. Results indicated no differences in validity by method of data collection or by case-control status but there were significant differences in completeness, cost, and response rates. In-person interviews resulted in more complete data than mail approaches, although all instruments had low proportions of missing data (0.001-0.006). Response rate differences were not found when data collection methodologies were compared (75-82%) but were found in case-control analyses. Cases were consistently less likely to participate and significantly less likely to respond by mail (p less than 0.05). The cost of the in-person interview was approximately four times that of the mail survey for the data collection. Implications of the case-control response rate difference suggest that mail methodologies, although low in cost, may introduce sampling bias in studies of sexually transmitted diseases. As part of a mailed health survey, we investigated the effect on the response rate of a request to explain refusal to participate. Subjects (N = 1,240) were randomized either to receive or not to receive, with the first mailing, a letter requesting an explanation of their decision not to fill out the questionnaire, if they chose that option. There was a slightly higher cumulative response during most of the study from subjects who had been sent the request, but little difference between the two study groups in the ultimate response rate [80% from the intervention group vs 83% from the control group; response rate difference = -3%; 95% confidence limits (CL) = -7%, 1%]. Of 209 individuals who were sent the request and did not return the questionnaire, only 15 (7%) sent back an explanation. A request to explain a refusal to participate in a mail survey neither jeopardized the response rate nor enhanced it. nan To test a possible day-of-the-week effect on doctors' response rate to a postal questionnaire.
                Dispatch of postal questionnaire randomized to Thursday or Saturday.
                A nationwide survey on doctors' attitudes.
                200 general practitioners and 260 practising specialists/consultants.
                Response rate and Kaplan-Meier survival curve for no-response.
                The probability of response was not influenced by receiving the questionnaire just before or just after a week-end.
                Response rates in postal surveys sent to doctors cannot be improved by their receiving the questionnaire just before a week-end. A health-related mailed survey was conducted to investigate the effect of follow-up mailings to response rates. In addition, the answer distributions among early and late respondents were compared to check non-response bias. Approximately 3,000 persons aged 40-64 were randomized into two groups; a questionnaire with four pages (twenty-two questions) was assigned to the first group, and a questionnaire with eight pages (thirty-five questions) to the second group. Both questionnaires contained questions of current health status, health-related practice, smoking status, etc. Follow-up mailings were sent twice to non-respondents. Response rates were increased from 38% to 62% by the first follow-up mail, and to 71% by the second follow-up mail. Although the length of the questionnaire did not affect response rates, response rates among the older subjects was higher than the younger subjects. Positive response to current smoking status was 10% lower among early respondents than late respondents, collected after the second follow-up mailing, and response to regular participation in physical/medical checkup was 15% higher among early respondents, whereas there were few differences for answers to other questions. Odds ratios between current health status and several health-related questions may not be biased by late response. However, increased response rates are needed to prevent non-response bias, because there were some differences in responses from follow-up mailings. Postal questionnaires are an economical and simple method of data collection for research purposes but are subject to non-response bias. Several studies have explored the effect of monetary and non-monetary incentives on response. Recent meta-analyses conclude that financial incentives are an effective way of increasing response rates. However, large surveys rarely have the resources to reward individual participants. Three previous papers report on the effectiveness of lottery incentives with contradictory results. This study aimed to determine the effect of including a lottery-style incentive on response rates to a postal health survey.
                Randomised controlled trial. Setting: North and West Birmingham. 8,645 patients aged 18 or over randomly selected from registers of eight general practices (family physician practices). Intervention: Inclusion of a flyer and letter with a health questionnaire informing patients that returned questionnaires would be entered into a lottery-style draw for pound 100 of gift vouchers. Control: Health questionnaire accompanied only by standard letter of explanation. Main outcome measures: Response rate and completion rate to questionnaire.
                5,209 individuals responded with identical rates in both groups (62.1%). Practice, patient age, sex and Townsend score (a postcode based deprivation measure) were identified as predictive of response, with higher response related to older age, being female and living in an area with a lower Townsend score (less deprived).
                This RCT, using a large community based sample, found that the offer of entry into a lottery style draw for pound 100 of High Street vouchers has no effect on response rates to a postal health questionnaire. We conducted a randomised trial to determine the differential effectiveness of a telephone prompt by a medical researcher compared with a nonmedical research assistant in improving response rates of general practitioners to a survey and to compare personnel costs. A national random sample of Australian general practitioners was allocated randomly to two intervention groups. In advance of a self-administered questionnaire, Group A (n = 184) received a telephone prompt by a medical researcher and Group B (n = 189) a prompt by an experienced nonmedical research assistant. Other aspects of survey administration were identical for both groups. The five-month cumulative response rate obtained by the medical researcher (81 per cent) was not significantly different from that of 72 percent obtained by the research assistant (chi 2 = 3.3, 1 df, P = 0.07). For Group A, 279 telephone calls, consuming 23 hours 15 minutes, were made. Group B required more calls (384) and more time (32 hours). Using the relevant award pay scales, the estimated personnel costs for each group were $631 and $601 respectively. We conclude that an experienced nonmedical research assistant is as effective as a medical practitioner in administering telephone prompts to enhance survey response rates, although savings are not necessarily made. Improving response rates, particularly among physicians, is important to minimize nonresponder bias and increase the effective sample size in epidemiologic research. We conducted a randomized trial to examine the impact of prepayment vs. postpayment incentives on response rates.
                Self-completion postal questionnaires were mailed to 949 physicians who were respondents to an earlier survey and representative of the general physician population in Hong Kong. These physicians were randomly allocated to receive a HK dollar 20 cash prepayment incentive that accompanied the survey (n=474) or a postpayment reward of the same amount on receipt of the completed questionnaire (n=475).
                The final prepayment response rate was 82.9%, compared with 72.5% in the postpayment arm (P < .001). Of the eight alternative incentive and follow-up strategies evaluated, three lie on the efficiency frontier (i.e., not dominated), including postpayment with three mailings at HK dollar 42.7, prepayment with three mailings at HK dollar 66.5 and prepayment with three mailings and telephone follow-up at HK dollar 112.1 per responder recruited (US dollar 1=HK dollar 7.8).
                The findings demonstrate that prepayment cash incentives are superior to postpayment of the equivalent amount in improving response rates among a representative sample of Hong Kong physicians. Further research should concentrate on confirming the generalizability of these findings in other health care occupation groups and settings. Randomized trials were performed in Denmark and The Netherlands to determine the effect of mailed reminders on the response rate in surveys among patients in general practice. In both countries, general practitioners handed out questionnaires to 200 adult patients who came to visit them. An intervention group of 100 patients received reminders at 3 weeks after the visit, whereas a control group of the remaining 100 patients did not receive reminders. The response rate was significantly higher in the intervention groups than in the control group in The Netherlands (86% versus 55%, respectively) but not in Denmark (87% versus 81%, respectively). Mailed reminders can improve the response rate in surveys related to a general practice, but they are not effective in all situations. A systematic review identified a range of methods, which can influence response rates. However, analysis specific to a healthcare setting, and in particular, involving people expected to be poor responders, was missing, We examined the effect of pre-warning letters on response rates to a postal survey of sedentary patients whom we expected a low rate of response.
                Participants were randomised to receive a pre-warning letter or no pre-warning letter, seven days before sending the main questionnaire. The main questionnaire included a covering letter and pre-paid return envelope. After seven days, non-responders were sent a reminder letter and seven days later, another reminder letter with a further copy of the questionnaire and return envelope.
                627 adults, with a mean age of 48 years (SD 13, range 18 to 78) of whom 69.2% (434/627) were women, were randomised. 49.0% (307/627) of patients were allocated to receive a pre-warning letter and 51.0% (320/627) no pre-warning letter, seven days in advance of posting the main questionnaire. The final response rate to the main questionnaire was 30.0% (92/307) amongst those sent a pre-warning letter and 20.9% (67/320) not sent a pre-warning letter, with an adjusted odds ratio of 1.60 (95% CI 1.1, 2.30).
                The relatively low cost method of sending a pre-warning letter had a modest impact on increasing response rates to a postal questionnaire sent to a group of patients for whom a low response rate was anticipated. Investigators should consider incorporating this simple intervention when conducting postal surveys, to reduce the potential for nonresponse bias and to increase the study power. Methods other than postal surveys may be needed however when a low response rate to postal surveys is likely. We conducted a pilot randomised trial of computerised templates for the management of asthma and diabetes in general practice in six general practices in North London. Uptake of the guidelines by general practitioners and practice nurses was assessed using qualitative (semi-structured interviews designed to assess the users' views) and quantitative (change in use of the template during the study period) outcome measures. The practice nurses used the templates frequently but general practitioners rarely used them. Several reasons were offered for non-use of the templates, such as the length of the template and non-involvement in the care of asthma or diabetes. Despite this, however, health professionals were favourably disposed to the use of templates for general clinical care. Pilot investigations of computerised templates are best achieved by observational or quasi-experimental methods rather than a randomised controlled trial. The use of both qualitative and quantitative methods in this study allowed exploration of the barriers to use of computers. Self-administered questionnaires are commonly used in experimental studies to elicit quality of life or other outcomes. Hence, achieving an acceptable level of follow-up from patients is critical to minimizing bias. Many methods for maximizing follow-up remain untested. It is also unclear what level of follow-up is required to prevent bias being introduced.
                We recruited 246 men from general practice surgeries in Sydney, Australia. These 246 men were randomized to receive a covering letter with their follow-up questionnaire either advising of a deadline to reply (Deadline, n = 126) or a standard letter without a deadline (No Deadline, n = 120). Four standardized reminder prompts subsequently were administered. We calculated interim response rates and the final proportion of follow-up questionnaires received according to group. We also compared scores on two main outcomes, namely, knowledge and decisional conflict at each time when reminder prompts were administered.
                One hundred and twelve (88.9%) men in the Deadline group returned their follow-up questionnaires compared with 102 (85.0%) men in the No Deadline group. This difference was not statistically significant [odds ratio = 1.41, 95% confidence interval (CI) = 0.67-2.99; p = 0.36]. Time to response also was not significantly affected by cover letter received (hazard ratio = 0.96; 95% CI = 0.73-1.25; p = 0.76). Results of the original RCT were similar in terms of direction and effect size at all times irrespective of when reminder prompts were administered.
                The addition of a deadline adds no further impact in improving response rates from male patients compared with an unspecified letter. Despite the accepted wisdom that higher response protects against bias, differences in outcomes were consistent throughout the post-test data collection period. Mailed surveys are widely used to collect epidemiological and health service data on cancer populations. Nonresponse can threaten the validity of surveys and various strategies, including the enclosure of modest incentives, are often used to increase response rates. A study was undertaken to determine whether response rate to a mailed survey differed with provision of immediate versus delayed incentives. A six-page mailed survey to ascertain dietary supplement use was sent to 1402 men who had been diagnosed with prostate cancer. Subjects were block randomized into two groups based on age (< or =65 years versus >65 years), race (white versus nonwhite), and disease status (locoregional versus distant). One group received a 30-min prepaid phone card concurrently with their blank survey (unconditional incentive), whereas the other group received the incentive only on receipt of their completed survey (conditional incentive). A 60% overall response rate was achieved, and no differences in response rates were noted between conditional and unconditional incentive groups (overall, as well as within defined age, race, and disease-defined strata). Nonwhites, however, were significantly less likely to respond than whites (P < 0.0001). In conclusion, acceptable response rates to a mailed survey can be achieved in a general population of cancer survivors using modest incentives. Given no differences in response rates using conditional versus unconditional incentives, the decision to provide immediate versus delayed incentives is one that should be considered on a study-specific basis, and a decision based primarily on cost. Other means, however, appear necessary to achieve acceptable response rates among minority group cancer survivors. The study aimed to consider the impact of two different types of reminder on response rates and costs in a postal survey.
                The study was a cross sectional survey. A self-completion lifestyle questionnaire was used. Those who did not respond after the initial mailing were randomly allocated to receive either a postcard or questionnaire as a first reminder. All outstanding non-responders received a questionnaire as a second reminder.
                A representative sample of 698 adults aged 16-70 was used, drawn from a family health services authority register.
                Postcard reminders were as effective as questionnaire reminders in increasing response whether one or two reminders are sent. The costs per response were calculated. Two questionnaires as reminders were found to be 1.7 times more expensive than a postcard plus questionnaire. Including the initial mailing, the cost per response using all questionnaires was 1.3 times the cost when a postcard was used for the first reminder.
                To increase the response to a postal survey effectively and economically, two reminders should be sent--first a postcard and then a questionnaire. This study's goals were to (a) determine whether sending a survey by certified mail results in a higher response rate from physicians compared to sending by first-class mail and (b) evaluate the cost-effectiveness of this method. The study sample was 409 physicians who were nonrespondents to two previous mailings of a medical specialty society survey. Eligible physicians were designated at random to receive a final mailing either by U.S. Postal Service certified mail including a return-receipt postcard or by first-class mail. There was a higher response rate from the certified mail group compared with the first-class mail group (41.3% versus 24.8%; relative risk = 1.66, 95% Confidence interval 1.25, 2.21). A cost-effectiveness analysis showed that the cost per respondent was higher using certified mail versus first-class mail in the third mailing ($2.77 versus $2.34). Thus, use of certified mail is effective in increasing survey response but more costly. This study tested the effect of questionnaire structure on response, speed of return, and content of answers in a postal survey. All 259 patients aged 30-59 years who consulted with back pain at four UK general practices from March to June 2001 were randomly allocated to receive either a traditionally or chronologically structured self-completion questionnaire. The response was higher and the returns quicker (P =.05) for the chronologic questionnaire. There were no statistically significant differences in completion rates or scores on the SF-36, Chronic Pain Grade, Hospital Anxiety and Depression Scale, or Roland-Morris Disability Questionnaire between the two types of questionnaire, and test-retest reliability was high for all scales. Changing questionnaire structure to make questions chronologic does not substantially affect the answers given, but may make a questionnaire more acceptable and easier to complete and speed up returns. Previous experimental research in other topic areas has shown that the choice of response alternatives can influence respondents' reporting of the frequency of vaguely defined events and that the set of response alternatives is treated as information in the interpretation of the question. The aim of this study was to examine whether such affects would occur in the context of respondents reporting of health-related events using high and medium frequency closed format response categories, which might be used interchangeably by researchers. The study consisted of a postal survey of n = 518 patients aged > or = 18 years randomly selected from the patient list of a diabetes centre and who were equally and randomly allocated to one of three conditions (Condition A: high frequency response alternatives/horizontal orientation; condition B: medium frequency response alternatives/horizontal orientations; condition C: high frequency response alternatives/vertical orientation). Testing for the effect of response alternatives for the combined responses of five vaguely defined questions between conditions A and B was chi 2 = 5.5, p = 0.019, for the difference in proportions, indicating that overall, those respondents presented with response alternatives discriminating at medium frequency, reported significantly fewer target events than those presented with high frequency response alternatives. Testing for the effect of orientation of the combined question responses between conditions A and C, differences in proportions between conditions, did not reach statistical significance (p > 0.05). Findings from this and previous studies indicate that response alternatives provide information on the interpretation of vaguely defined questionnaire items and that their choice should not be left to intuition alone when designing questionnaire items. E-mail communication between patients and their providers has diffused slowly in clinical practice. To address concerns about the use of this technology, we performed a randomized controlled trial of a triage-based e-mail system in primary care. DESIGN AND PATIENTS/PARTICIPANTS: Physicians in 2 university-affiliated primary care centers were randomized to a triage-based e-mail system promoted to their patients. E-mails from patients of intervention physicians were routed to a central account and parsed to the appropriate staff for response. Control group physicians and their patients did not have access to the system. We collected information on patient e-mail use, phone calls, and visit distribution by physician over the 10 months and performed physician and patient surveys to examine attitudes about communication.
                E-mail volume was greater for intervention versus control physicians (46 weekly e-mails per 100 scheduled visits vs 9 in the control group at the study midpoint; P <.01) but there were no between-group differences in phone volume (67 weekly phone calls per 100 scheduled visits vs 55 in the control group; P =.45) or rates of patient no-shows (5% in both groups; P =.77). Intervention physicians reported more favorable attitudes toward electronic communication than did control physicians but there were no differences in attitudes toward patient or staff communication in general. There were few between-group differences in patient attitudes toward electronic communication or communication in general.
                E-mail generated through a triage-based system did not appear to substitute for phone communication or to reduce visit no-shows in a primary care setting. Physicians' attitudes toward electronic communication were improved, but physicians' and patients' attitudes toward general communication did not change. Growth of e-mail communication in primary care settings may not improve the efficiency of clinical care. This study examined return rates for a cancer prevention survey by pediatricians in relation to an informational booklet versus a monetary incentive in the first of a three-wave mailing. Of the 300 surveys sent which included an informational booklet incentive, 189 (64%) were returned. Of the 300 surveys sent which included a $1.00 incentive 227 (79%) were returned, indicating the $1.00 incentive was more effective than the informational incentive in increasing return rates in this sample of physicians. The purpose of this study was to investigate how response rates to a postal questionnaire are affected by title and length of the survey instrument. Five questionnaires, which differed according to title and length, were designed. Each questionnaire was mailed to a random sample of one thousand Norwegian women aged, 35-49 years. A total of 3,106 questionnaires were returned (62.1%). The highest response rate (70.2%) was achieved by a two-page questionnaire entitled "Women and Cancer". An otherwise identical questionnaire entitled "Oral Contraceptives and Cancer" had a response rate of 60.7%. Questionnaires entitled "Women and Cancer" with a length of four and six pages had a response rate of 62.8% and 63.3%, respectively. The four page questionnaire entitled "Women, Lifestyle and Health" had the lowest response rate of 57.1%. This study shows that in a general population of Norwegian women the title of a postal questionnaire influences the response rate. The results indicate that although the shortest questionnaire had the highest response rate, the most extensive survey instrument did not have the lowest response rate. The distribution of risk factors for breast cancer did not vary according to response rate or design of questionnaire. The overall findings of this study suggest that the benefits from the increased information obtained from extensive postal questionnaires out-weighs a potential non-response bias due to a somewhat lower response rate. Low response rates are acknowledged as a potential source of bias in survey results. Response rates are a particular problem in surveys of GPs. Thus, the methods used to encourage response to mailed surveys and the influence of inducements in maximizing response rates are fundamental issues to be examined when addressing the problem of response bias.
                To increase the overall response rate to a national study of GPs and to explore the effects of financial and non-financial inducements on response rates.
                Two mailing waves of a postal questionnaire to a 20% random sample of all GPs in England and Wales had achieved a 33% response rate. For the third mailing wave, the non-responding GPs were then divided into a control group, a group who were offered a donation to charity to complete the questionnaire and a group who were offered cash. The charity and cash groups were further subdivided into 5 pounds and 10 pounds groups to assess the effect of the size of the inducement offered. For the control group, a fourth wave was sent the offer of a 5 pounds or 10 pounds incentive.
                Response was positively affected by the offer of an inducement. Cash, however, had a more substantial effect than the offer of a donation to charity. Older GPs were less likely to participate overall, whereas male GPs were more likely to respond to a cash inducement. Doctors who had seen more patients were less likely to reply earlier and were more likely to respond to the offer of cash.
                Primary care is going through many changes, some of which have increased the workload of the GP. It may now be that, to achieve the response rates needed to validate policy-related research, the offer of inducements will become a necessary part of the research process. nan nan High response rates from physicians are key to obtaining valid and generalizable data regarding their sexually transmitted disease (STD) diagnosis, treatment, and control practices. A factorial (3 x 2) study was designed using varying cash incentives ($0, $15, $25) and delivery modes (Federal Express, U.S. mail). Surveys, with three follow-up mailings, were sent to a national probability sample of 311 physicians in OB-GYN, family practice, internal and emergency medicine, and pediatrics specialties. Overall, 156 physicians returned completed surveys (56% overall response rate). Significant effects for incentive level (F = 28.2, df = 2, p < .01) and delivery mode (F = 4.1, df = 1, p < .05) existed. Highest response was among physicians in the $25-FedEx condition (81%). High response rates from busy practicing physicians can be achieved if surveys are relevant to clinical practice, sponsored by a reputable organization (the Centers for Disease Control and Prevention), include a monetary incentive, and are delivered by courier. This study evaluated a mail and telephone intervention to improve breast health behaviors while maintaining quality of life. Women recruited from the general public were randomized to a stepped-intensity intervention consisting of mailings, telephone calls, and counseling (if requested or appropriate given a woman's genetic risk for breast cancer) or to a delayed treatment control group. Outcomes (mammography screening and quality of life) were measured at baseline in a telephone survey and again at a 12-month follow-up period. Women in the intervention group significantly increased screening mammography uptake by 12% and quality of life by 5.3 scale points compared to control participants. Changes in knowledge of breast cancer, genetic testing, and cancer worry all significantly predicted intervention changes. This successful intervention can help women make better breast health choices without causing increased worry. Mail surveys of physicians have been characterized by lower response rates than general population surveys, raising concerns about nonresponse bias. Although monetary incentives have routinely been used to improve survey response among physicians, questions remain regarding how much of an incentive is most cost-effective. The present study seeks to further examine the effects of incentive size on response rates to a national mail survey of physicians.
                This study used a random sample of 873 physicians practicing in the United States; the response rate was 65% (n = 563). Respondents were randomly assigned to receive a $5, $10, or $20 cash incentive in the initial mailing. Except for the magnitude of the incentive, the procedures for each condition were identical, with each respondent receiving up to 3 follow-up mailings and 2 telephone calls.
                Overall response rates ranged from 60.3% for the $5 incentive category to 68.0% for the $10 incentive category. Differences in overall response rates across the incentive categories, however, were not significant. Higher levels of incentives also did not significantly reduce the number of mail and/or telephone interventions required to reach the target response rate of 60.0%. As expected, aggregate costs (excluding labor) were lowest for the $5 incentive group.
                Our findings suggest that changes in the magnitude of incentive do not automatically result in increases in survey response among physicians. Possible reasons for this lack of effect as well as alternatives to monetary incentives are addressed. In 1989, the authors tested the effectiveness of two response-enhancing techniques, a postage stamped or franked return envelope and a prenotification letter, in a survey of pregnancy among 10,047 resident physicians in the United States. The techniques were randomly assigned using a factorial design. No significant interactions were observed between the techniques. After two mailings, those who received a stamped return envelope had a response of 71.2%, compared with 68.2% for those who received a franked return envelope (95% confidence interval 1.3-4.9%). Men who received the stamped envelope had a 5.9% greater response than those who received the franked envelope (p less than 0.001), but the type of postage did not influence response among women (p = 0.84); this interaction was statistically significant (p = 0.006). Physicians who received a prenotification letter had a response of 69.0%, compared with 70.5% for those who did not receive the letter (95% confidence interval -3.3 to 0.2%). The authors conclude that seemingly minor changes in survey design could have saved from 12% to 19% of the total cost of the study. Studies investigating means of recruiting participants to randomized controlled trials (RCTs) are sparse. We investigated the effects of telephone reminders as a recruitment strategy.
                Sick-listed employees received a written invitation to participate in a study comparing standard treatments with a solution-focused follow-up and were randomly allocated to an intervention or control group (n=703). Those who did not respond within 2 weeks received either 'no reminder' (n=242) or 'attempted telephone reminder' (n=256). Outcome was enrollment to the RCT.
                An intention to recruit analysis revealed no significant differences between the groups (P=.229). An intention to phone analysis among nonresponders revealed significant differences between 'no reminder' (recruited 4.5%) and 'attempted telephone reminder' (recruited 12.1%) (P=.003, odds ratio 2.89, 95% confidence interval [CI] 1.42-5.90). An analysis of numbers needed to phone showed that to recruit one more person in this group of nonresponders, we needed to phone 13 persons (95% CI=8-33).
                Systematic use of telephone calls can increase the recruitment rate among nonresponders in RCTs. To study questionnaire length, type of consent, approach to recruitment, and subject characteristics on participation in epidemiologic studies.
                As part of a health survey among Dutch subjects treated for ear, nose, and throat disorders in childhood, we conducted a pilot study of 200 individuals who were randomly assigned to one of four categories, defined by length of questionnaire (long vs. short) and type of consent form (basic vs. multi-option). In addition, among 8402 subjects eligible to be in the main study (average age 41 years in 1997), we examined the effect of approach to recruitment and subject characteristics on participation rates.
                The pilot study showed a non-significant 10% increase in participation rate using the shorter questionnaire, but no differences by type of consent form. In the full survey, the participation rate was 49% after the first mailing. Response increased by 15% after a written reminder and by 10% after a telephone survey. The total participation rate was 74%. Attained age, sex, exposure status, age at exposure, and response to an earlier survey were determinants of participation rates. Among male non-participants, outright refusal was less frequent than non-response. The refusal rate, unlike the non-response rate, was positively associated with older age at time of survey.
                Health survey participation is influenced by questionnaire length, frequency of contact, and subject characteristics. In a survey about euthanasia, 1,600 critical care nurses were randomly assigned to receive either three complete, anonymous mailings of the questionnaire or, with each mailing, a coded postcard to be returned separately from the questionnaire to reduce subsequent mailings to previous responders. The response rate in these two groups was 76.5% [95% confidence interval (CI) = 73.6-79.4%] and 69% (95% CI = 65.7-72.4%), respectively. The two strategies yielded similar responses, and costs were much lower for the postcard group. Using coded postcards to be returned separately from completed instruments appears to lower the response rate to anonymous mail surveys, but it also lowers cost and may not introduce additional bias. Response rates to surveys are declining and this threatens the validity and generalisability of their findings. We wanted to determine whether paper quality influences the response rate to postal surveys
                A postal questionnaire was sent to all members of the British Society of Gynaecological Endoscopy (BSGE). Recipients were randomised to receiving the questionnaire printed on standard quality paper or high quality paper.
                The response rate for the recipients of high quality paper was 43/195 (22%) and 57/194 (29%) for standard quality paper (relative rate of response 0.75, 95% CI 0.33-1.05, p = 0.1
                The use of high quality paper did not increase response rates to a questionnaire survey of gynaecologists affiliated to an endoscopic society. Studies largely from the market research field suggest that the inclusion of a stamped addressed envelope, rather than a pre-paid business reply, increases the response rate to mail surveys. The evidence that this is also the case regarding patient mail surveys is limited.
                The aim of this study is to investigate whether stamped addressed envelopes increase response rates to patient mail surveys compared to pre-paid business reply envelopes and compare the relative costs. A sample of 477 initial non-responders to a mail survey of patients attending breast clinics in Greater Manchester between 1/10/2002 - 31/7/2003 were entered into the trial: 239 were randomly allocated to receive a stamped envelope and 238 to receive a pre-paid envelope in with their reminder surveys. Overall cost and per item returned were calculated.
                The response to the stamped envelope group was 31.8% (95% CI: 25.9% - 37.7%) compared to 26.9% (21.3% - 32.5%) for the pre-paid group. The difference (4.9% 95% CI: -3.3% - 13.1%) is not significant at alpha = 0.05 (chi2 = 1.39; 2 tailed test, d.f. = 1; P = 0.239). The stamped envelopes were cheaper in terms of cost per returned item (1.20 pounds) than the pre-paid envelopes (1.67 pounds). However if the set up cost for the licence to use the pre-paid service is excluded, the cost of the stamped envelopes is more expensive than pre-paid returns (1.20 pounds versus 0.73 pounds).
                Compared with pre-paid business replies, stamped envelopes did not produce a statistically significant increase in response rate to this patient survey. However, the response gain of the stamped strategy (4.9%) is similar to that demonstrated in a Cochrane review (5.3%) of strategies to increase response to general mail surveys. Further studies and meta analyses of patient responses to mail surveys via stamped versus pre-paid envelopes are needed with sufficient power to detect response gains of this magnitude in a patient population. Traditional measures of socioeconomic status may not be reliable for older people and income may be a useful measure for research into inequalities in health. At the same time, researchers increasingly wish to link survey findings to individual data taken from medical records. For this, consent must be sought. To examine whether questions on household income and seeking consent for medical record linkage affected response rates, a postal health survey of patients aged 65 to 74 was undertaken in an inner London practice. The overall response rate was 62.8%. In this study, the inclusion of an income question or seeking consent to access medical records did not reduce response rates to a health survey among older people. Postal questionnaires are widely used to collect data in healthcare research but a poor response rate may reduce the validity and reliability of results. There was a lack of evidence available relating to use of a monetary incentive to improve the response rate in the healthcare setting.
                The MRC ORACLE Children Study is assessing the health and development of nearly 9000 seven year old children whose mothers' joined the MRC ORACLE Trial. We carried out a randomised controlled trial of inclusion of monetary incentive (five pound voucher redeemable at many high street stores) with the reminder questionnaire to parents. This trial took place between April 2002 and November 2003. When the parents were sent the reminder questionnaire about their child's health and development they were randomly assigned by concealed computer-generated allocation stratified by week of birthday to receive a five pound voucher or no incentive. The population were 722 non-responders to the initial mailing of a 12-page questionnaire. Main outcome measures: Difference in response rate between the two groups.
                Inclusion of the voucher with the reminder questionnaire resulted in a 11.7%(95% CI 4.7% to 18.6%) improvement in the response rate between the two groups.
                This improvement in response rate and hence the validity and reliability of results obtained appears to be justified ethically and financially. The effects of incentive size on physicians' response rates to a mail survey were determined.
                One thousand US primary care physicians were assigned randomly to receive a survey with either a $5 bill or a $2 bill as an incentive. For each of the two incentive groups, the overall response rate for three mailing waves, the total cost, and the total cost per usable response were measured.
                The response rate among those receiving the $5 bill (61%) was 32% higher than the response rate among those receiving the $2 bill (46%); overall costs were slightly higher in the $5 group, but the cost per response for each group was similar ($15.46 versus $14.93). For the same cost, a higher response rate could have been achieved in the $2 group if costs saved from foregoing the third mailing were instead used to increase the incentive for a portion of the subjects.
                A $5 bill incentive yielded a higher response rate among the physicians in this study than did a $2 bill incentive. Moreover, the powerful effect of the incentive size, combined with the consequent decline in the costs of subsequent mailing waves, suggests that resources in a fixed survey budget are allocated more efficiently to increasing the initial incentive rather than to providing a third wave to nonresponders. To determine the degree to which mailed survey response rates, response times, and nonresponse bias are affected by questionnaire size and color.
                Questionnaires were mailed to a random sample of 2,000 Mayo Clinic patients in one of four size/color "test" groups. One thousand three hundred nine surveys were completed, approximately two-thirds in each group.
                A small (6 (1/8) x 8 (1/4) in) questionnaire booklet on white paper had a higher response rate (68.4%) than a similarly sized questionnaire on blue paper (62.3%). A large (8 (1/4) x 11 in) questionnaire on white paper had a 62.7% rate, whereas a large, blue questionnaire had a response rate of 68.6%. Median response times did not differ by questionnaire size/color. No evidence of differential nonresponse bias was observed across the four test groups.
                This study supports the use of a small/white questionnaire format advocated by the Total Design Method advanced by Don Dillman at Washington State University. We observed a favorable response rate for a large questionnaire printed on blue paper; however, if time and resources are limited, use of a small/white questionnaire appears preferable. To determine whether response rates to a mailed questionnaire sent to population control subjects could be increased through offer of a small incentive, half of the control subjects (n = 477) in a case-control study of renal cell carcinoma were randomly selected to receive a contact letter offering a lottery ticket if a completed questionnaire was returned; the remaining subjects (n = 477) received the same letter but with no mention of a lottery ticket. Overall response rates did not differ between the two groups (72.6% versus 74.4%), although a higher percentage of those offered a lottery ticket responded without follow-up (24.4% versus 18.5%). Binomial regression modeling of the effect of the lottery ticket offer, sex, age, and percent of urban dwellers on response indicated a significant effect only for percent of urban dwellers, the rate of response increasing with a decreasing percentage of urban dwellers. The effect of sex was of borderline significance (P = 0.05), with females having the higher rate of response. Historically, achieving a high response rate on physician surveys has been a challenging task. Given such concerns, understanding research strategies that facilitate adequate response rates is important. Primary care physician responses to a mail survey on smoking cessation are summarized by physician specialty and timing of incentive.
                A stratified random-sample design, stratified by patient populations-adults, adolescents, and pregnant women-was used. The sampling frame included New Jersey internists, general practitioners, family physicians, pediatricians, and obstetrician-gynecologists. A total of 2100 physicians, 700 physicians from each patient strata, were sampled and mailed a smoking-cessation survey in summer 2002. The sample was randomized by incentive timing: Half received the incentive (i.e., 25 dollars gift card) with the first survey mailing, and half received the incentive on receipt of their completed survey.
                The promised-incentive group achieved a significantly lower response rate (56%) compared with the up-front-incentive group (71.5%). Response rates by medical specialty varied overall and within incentive groups. The difference between the incentive groups was greatest among obstetrician-gynecologists (i.e., 20.2 percentage points) and was least among pediatricians (i.e., 5.8 percentage points).
                Physician response rates to mail surveys are greatly improved, especially among certain medical specialties, by using up-front incentives. This study assessed efforts to increase response rates to a mailed physician survey and examined whether, as a result, nonresponse bias was reduced.
                Randomly selected physicians and geneticists were mailed a questionnaire concerning genetics knowledge and attitudes. In the final but not the pilot survey, a $25 incentive and intensive follow-up were used to increase the response rate.
                The response rate from physicians in the final survey was 64.8% (n = 1140), compared with 19.6% in the pilot test (n = 69). Sample representatives in sociodemographic and practice characteristics was improved by follow-up. Respondents recruited with more difficulty did not differ on the principal outcome variable, genetics knowledge, except on one subscore. Pilot study and final survey respondents did not differ in knowledge.
                Although the effect of increased response rates on the principal outcome variable in this study was minimal, this may not be the case for other studies. Every effort should be made to attain as high a response rate as is practical and to establish that respondents are representative of the population being sampled. Patient surveys are commonly distributed at the end of a multicenter clinical trial. This Antiarrhythmics Versus Implantable Defibrillators (AVID) substudy prospectively explored the relationship between methods used in distributing a survey and the quantity of responses received. AVID was a multicenter, randomized trial comparing survival in arrhythmia patients treated with antiarrhythmic drugs versus implantable defibrillators. At study termination, a patient satisfaction survey was mailed to the 664 surviving participants. Questions included reasons for study participation, study benefits and problems and quality of care. Survey mailings were stratified by four factors in a 2x2x2x2 factorial design: delivery mode (overnight vs. regular mail), certificate of appreciation, timing of administration ("early" vs. "late") and cover letter signed by a physician versus coordinator. Patients were randomly assigned to received one of 16 combinations of these four factors. Clinical characteristics and response rates were evaluated. Patients were more likely to return surveys delivered by overnight mail (75% vs. 68%, p=0.04), with no certificate of appreciation enclosed (75% vs. 68%, p=0.05) and administered close to the time of study closeout (79% vs. 72%, p=0.085). Compared to the 184 nonrespondents, the 456 (71%) respondents were older, Caucasian, lived with others, were high school graduates and less likely to have Medicare/Medicaid or HMO insurance (p<0.03). Physician recommendation was the most common reason cited for trial participation. Main benefits included increased knowledge of their medical condition and improved health. Reported problems included parking, transportation and excess clinic wait time. This randomized study demonstrated that methods of patient survey distribution affect the survey return rate. Additional studies should explore mechanisms for maximizing return rates.
                Copyright 2002 Elsevier Science Inc. To test the effect of a AU dollars 2 scratch lottery ticket on response rates to a national mailed questionnaire of Australian general practitioners (GPs) and medical specialists.
                A randomized controlled trial was conducted and the incentive sent to half of the participants with the first mailing. A single follow-up mailing without incentive was sent to all non-respondents. Survey respondents were then informed of the research question regarding incentives and allowed to withdraw their study data. Differences in response rates between doctors receiving and not receiving the incentive, and between respondents and non-respondents, were examined.
                The overall response rate was 47% (443 respondents). Twenty-two respondents (5%) withdrew their data after being informed of the research question. Of the remaining 421 respondents, 233 had received the incentive (response rate 49.7%) and 188 had not (40.1%, p=0.0032). The absolute increase in response rate with the incentive (9.6%, 95%CI 3.2, 15.9) was quantitatively similar in effect to the reminder mailing (11.8%). The incentive had a larger effect among the GP sample compared with specialists (13.4 vs. 5.9%), although the difference was not statistically significant (p=0.20). There were no systematic differences in demographic characteristics between respondents and non-respondents.
                Increased response rates associated with a small incentive may reduce the need for a second mailed reminder, but strong views about the use of incentives may negatively influence the participation of some practitioners. While the overall response rate was low, there was no evidence of bias in our sample.
                Copyright (c) 2005 John Wiley & Sons, Ltd. Mailed questionnaires are a quick and cheap means of obtaining data, but they have two disadvantages. They often produce low response rates irrespective of the nature of the group sampled, and they may seem inappropriate for clinical samples with visual problems. High response rates are needed for reliable results and valid conclusions. This paper presents a set of techniques enabling high response rates to be obtained. It also reports research showing that such techniques are appropriate even for the partially sighted. To investigate the impact on subject response of an information brochure and cash incentives included with mailed questionnaires in case-control studies.
                A randomized trial was carried out within a case-control study investigating cancer in the Province of Ontario. Brochures were included with half of the mailed questionnaires sent to 7487 cases and 2561 controls. Controls were also sent cash incentives of $2, $5, or no money.
                With the brochure, response changed from 75.0% to 75.8% in cases, and from 70.3% to 71.1% in controls. Adjusting for differences in age, residence, sex, and cancer site/status, the change was 0.2% [95% confidence interval (CI) = -1.7-2.1] in cases, and 0.6% (95% CI = -3.1-4.3) in controls. The $2 and $5 incentives increased overall response in controls from 61.9% to 72.8% and 77.2%, respectively, i.e., by 10.9% (95% CI = 6.1-15.6) and 15.1% (95% CI = 10.4-19.7), after adjustment. This effect was largely confined to urban areas (for $2 and $5, respectively: 5.5% and 14.2% in Toronto, 15.3% and 20.4% in other urban areas vs. 2.7% and 1.0% in rural areas; p = 0.02). Response time showed little or no improvement when the brochure was included, but was markedly reduced for both the $2 and $5 incentives.
                Cash incentives can improve subject response in epidemiologic studies, whereas information brochures do not appear to have an effect. Examine the effects of three iterative tailored feedback letters addressing smoking; physical activity; and fruit, vegetable, and fat intake, and test the additional effects of providing feedback on action plans.
                A tailored, print-based intervention was developed and tested in a randomized control trial with a posttest after 9 months.
                A total of 2827 respondents agreed to participate. They were recruited from a random sample of 35,000 addresses obtained through the Dutch national telephone company.
                The mean age was 49 years, and 55% were female. Intervention. The experimental group received three printed tailored letters, and the control group received three printed generic letters. Respondents from the experimental group randomly received either a third letter with tailored information or tailored information and action-planning feedback. MEASURES; The questionnaire assessed physical activity; smoking; consumption of fruit, vegetables and fat; motivational determinants; action plans; and demographics.
                Tailored information resulted in more improvement over time than generic information for the intake of fruit, vegetables, and fat and for physical activity. No differences between the conditions were found for smoking because of high cessation rates in all conditions. Action-planning feedback did not increase the effects.
                Tailored lifestyle information can be effective for adults in changing nutrition behavior and physical activity. To assess the impact of patient satisfaction survey method on response rate, data quality and satisfaction.
                Four modes of data collection were assessed during a randomized trial that included 400 inpatients discharged from a teaching hospital.
                The response rate was 58% within the mail survey group (72% with follow-up letter) versus 73% and 81% within the home and telephone interview group (p < 0.01). 69% of the mailed questionnaires contained no missing values versus 94% and 96% for home and telephone interview modes (p < 0.01). The global satisfaction scale score was greater within the mail survey groups (8.1/10 without follow-up letter and 7.9 with follow-up letter) than within the telephone interview group (7.8) and the face to face interview group (7.3), (p < 0.05).
                Mail survey with follow-up letter constitutes an operational method despite lower data quality and overestimation of patients' satisfaction scores. To test the ability of an automated telephone outreach intervention to reduce acute healthcare utilization and improve quality of life among adult asthma patients in a large managed care organization.
                Randomized clinical trial.
                Patients with persistent asthma were randomly assigned to telephone outreach (automated = 3389, live caller = 192) or usual care (n = 3367). Intervention participants received 3 outreach calls over a 10-month period. The intervention provided brief, supportive information and flagged individuals with poor asthma control for follow-up by a provider. A survey was mailed to 792 intervention participants and 236 providers after the intervention. Additional feedback was obtained as part of the final intervention contact.
                The intent-to-treat analysis found no significant differences between the intervention and usual-care groups for medication use, healthcare utilization, asthma control, or quality of life. Post hoc analyses found that, compared with the control group, individuals who actually participated in the intervention were significantly more likely to use inhaled steroids and to have had a routine medical visit for asthma during the follow-up period and less likely to use short-acting beta-agonists. They also reported higher satisfaction with their asthma care and better asthma-specific quality of life. Of surveyed providers, 59% stated the program helped them to clinically manage their asthma patients and 70% thought the program should be continued.
                This study did not find improved health outcomes in the primary analyses. The intervention was well accepted by providers, however, and the individuals who participated in the calls appeared to have benefited from them. These findings suggest that further studies of automated telephone outreach interventions seem warranted. The purpose was to determine whether asking about ethnic origin and housing tenure in a postal survey affects the response rate.
                The study derived from a postal survey designed to determine eligibility for a study of outpatients. A two way factorial design was used to look at the two experimental factors, questionnaires being randomly divided into four groups with or without questions about ethnic origin and housing tenure.
                10,000 people (1000 from each of 10 areas) were systematically sampled from electoral registers, the areas being chosen to give a nationally representative sample.
                The response rate was 66% irrespective of whether ethnic origin was asked about, but was 65% and 67% respectively to questionnaires with and without questions about housing tenure.
                Asking about ethnic origin did not affect the overall response to this survey although it is possible that the response from some ethnic minority groups was lower. Asking about housing tenure slightly, but significantly, decreased response. To address provider, payer, and patient concerns about the use of online communication in healthcare settings by performing a randomized controlled trial of a Web-based patient-provider communication tool in primary care.
                Forty-one staff physicians and 91 residents in 4 primary care centers were randomized to a Web-based online communication system. Patients of intervention physicians were encouraged to communicate via the system about health issues, scheduling, prescription renewals, referrals, and billing. Data collected included patient Web use, e-mail use, telephone calls, visit distribution, and physician and patient attitudes toward and satisfaction with communication.
                One thousand thirty-eight patients sent 2238 messages during the 40-week study. Half of the messages were directly related to a patient's health; half were administrative. Patient Web use peaked at 8.5 weekly messages per 100 scheduled visits. Patient e-mail and telephone volume remained similar across groups. Intervention physicians reported more positive attitudes toward Web-based communication than control physicians (mean Web benefits scale score, 4.0 vs 1.1; P = .008), but there were no between-group differences in attitudes toward communication in general. Patients and physicians reported differential preferences for the use of online communication based on problem complexity and sensitivity.
                Web-based messaging was lower than expected because of patient-related factors and limitations of the technology. Patients, physicians, and staff had positive attitudes toward online communication. There was no detectable difference in communication volume between study groups, but more sensitive measures of work burden need to be developed and evaluated. This study evaluated the effects of written feedback adapted to a self-help mail intervention. The efficacy of the standard mail intervention treatment was 37% at the end of treatment, 22% at the 3-month follow-up, 19% at the 6-month follow-up, and 13% at the 12-month follow-up. In contrast, the standard mail program combined with personalized written feedback resulted in an efficacy of 51% at the end of treatment, 37% at the 3-month follow-up, 32% at the 6-month follow-up, and 27% at the 12-month follow-up. Both groups were significantly different from the control group at the end of treatment (0%), at the 3-month follow-up (1%), and at the 6-month follow-up (1%). There was a significant reduction in the number of cigarettes smoked daily among continuing smokers under both experimental conditions. The authors conclude that written feedback substantially increases abstinence rates when it is applied following similar guidelines to those used in clinical settings. Significant resources and time are invested in the production of research knowledge. The primary objective of this randomized controlled trial was to evaluate the effectiveness of three knowledge translation and exchange strategies in the incorporation of research evidence into public health policies and programs.
                This trial was conducted with a national sample of public health departments in Canada from 2004 to 2006. The three interventions, implemented over one year in 2005, included access to an online registry of research evidence; tailored messaging; and a knowledge broker. The primary outcome assessed the extent to which research evidence was used in a recent program decision, and the secondary outcome measured the change in the sum of evidence-informed healthy body weight promotion policies or programs being delivered at health departments. Mixed-effects models were used to test the hypotheses.
                One hundred and eight of 141 (77%) health departments participated in this study. No significant effect of the intervention was observed for primary outcome (p < 0.45). However, for public health policies and programs (HPPs), a significant effect of the intervention was observed only for tailored, targeted messages (p < 0.01). The treatment effect was moderated by organizational research culture (e.g., value placed on research evidence in decision making).
                The results of this study suggest that under certain conditions tailored, targeted messages are more effective than knowledge brokering and access to an online registry of research evidence. Greater emphasis on the identification of organizational factors is needed in order to implement strategies that best meet the needs of individual organizations.
                The trial registration number and title are as follows: ISRCTN35240937 -- Is a knowledge broker more effective than other strategies in promoting evidence-based physical activity and healthy body weight programming? Response rates to postal questionnaires are falling and this threatens the external validity of survey findings. We wanted to establish whether the incentive of being entered into a prize draw to win a personal digital assistant (PDA) would increase the response rate for a national survey of consultant obstetricians and gynaecologists.
                A randomised controlled trial was conducted. This involved sending a postal questionnaire to all Consultant Obstetricians and Gynaecologists in the United Kingdom. Recipients were randomised to receiving a questionnaire offering a prize draw incentive (on response) or no such incentive.
                The response rate for recipients offered the prize incentive was 64% (461/716) and 62% (429/694) in the no incentive group (relative rate of response 1.04, 95% CI 0.96 - 1.13)
                The offer of a prize draw incentive to win a PDA did not significantly increase response rates to a national questionnaire survey of consultant obstetricians and gynaecologists. The effects of a number of controllable factors on the response rate of mothers to a postal questionnaire were assessed by a series of experiments. In one a factorial design was used to look at seven factors with a random sample of 1600 mothers. The main findings were that the responses to questionnaires of 8, 16 or 24 pages were similar, but that rather more mothers replied when the questionnaires contained only factual questions than when they covered both facts and attitudes. Another experiment, based on a similar sample, compared the response rates when the questionnaires were sent out by a government organization or by the Institute for Social Studies in Medical Care, and found no difference. The final experiment looked at the effect of precoding the answers or asking respondents to tick boxes beside their replies and again found no difference in response rates. The overall response rate was 79 per cent, but this varied between 66 and 87 per cent in the ten randomly selected study areas--a much greater variation than that found with any of the experimental factors. Feedback can be described as a way to provide information on doctors' performance to enable changes in future behaviour. Feedback is used with the aim of changing test-ordering behaviour. It can lead to reductions in test usage and cost savings. It is not sufficiently clear, however, whether feedback leads to more appropriate test use. Since 1985, the Diagnostic Coordinating Center Maastricht has been giving feedback on diagnostic tests as a routine health care activity to all family doctors in its region. Both quantity and quality of requests are discussed. In a randomised, controlled trial over 2.5 years, discussion of tests not included previously was added to the existing routine feedback. One group of family doctors (n = 39) received feedback on test-group A (electrocardiography, endoscopy, cervical smears, and allergy tests), the other (n = 40) on test-group B (radiographic and ultrasonographic tests). Thus, each group of doctors acted as a control group for the other. Changes in volume and rationality of requests were analysed. The number of requests decreased during the trial (p = 0.036). Request numbers decreased particularly for test-group A (p = 0.04). The proportion of requests that were non-rational decreased more in the intervention than in the control groups (p = 0.009). Rationality improved predominantly for test-group B (p = 0.043). Thus, routine feedback can change the quantity and quality of requests. Achieving acceptable response rates from health care providers via postal questionnaires is an ongoing challenge. The use of monetary incentives is one of the most effective strategies for increasing response rates. However, the effect and cost of such an incentive on retail pharmacists' response rates has not been well studied.
                A sample of 700 pharmacies was selected at random from the electronic Yellow Pages in NSW Australia and mailed a brief survey regarding pharmacotherapies and advice for smoking cessation. Half of the sample was randomly allocated to receive an offer of an 14 US dollars gift voucher.
                The response rates were 65.9% for the voucher group and 53.5% for the no-voucher group. The odds of response from the voucher group was 1.68 (95%CI = 1.23, 2.30) times greater than for the no-voucher group. The cost per additional respondent was 67.95 US dollars. The incentive also reduced follow up costs by 10%.
                A moderately sized monetary incentive is able to achieve a significant increase in response rates for retail pharmacists, thereby reducing potential bias in the sample. Collecting saliva samples by mail can serve numerous purposes in epidemiologic research. The objectives of this study were to assess what proportion of participants in a mail survey would provide a saliva sample and whether incentives could improve participation. In 1995, 2,994 students, faculty, and staff members of Geneva University, Geneva, Switzerland, were randomized to receive, together with a mailed questionnaire about smoking, a saliva vial, a ballpoint pen, the offer of a lottery, or any combination of these. After one mailing and a reminder letter, response rates were 52% among those who had been requested to provide saliva and 63% among controls (p < 0.001). In the former group, most respondents (98%) provided a saliva sample. Incentives improved participation only among those who were asked to provide saliva (lottery: +11% response, p = 0.003; pen: +6% response, p = 0.1). The final participation, after up to three reminders, was 76% overall. The authors conclude that while the collection of saliva samples by mail is feasible it tends to decrease response rates. Mailed surveys are a popular means of obtaining data on large populations. In July 1999 a mail survey was conducted among 3000 randomly selected members of the American Society of Hematology to assess their approach to diagnosis and treatment of polycythemia vera. Because the researchers and the study population are members of the same professional organization with a vested interest in the results, we anticipated that the advantages of return stamped postage seen in previous studies would be less significant. The response rate for stamped return envelopes was 38% versus 32% for business reply envelopes. This statistically significant difference (P =.0005) of six percentage points is comparable to previous research. Excluding labor, the total cost per returned survey was $2.62 for business reply envelopes versus $1.82 for stamped return envelopes. We conclude that stamped return envelopes are a more effective and cost-efficient means of procuring data from physician specialists. Increases in patient participation in medical interactions have been achieved to date using structured waiting-room interviews. In this pilot study, a printed intervention was tested as an inexpensive alternative with potential for wider dissemination. Sixty-seven family medicine patients were assigned randomly to one to two educational conditions just prior to their medical visit: a treatment booklet stressing the importance of recognizing information needs and encouraging patients to ask questions; or a placebo education booklet similar in format but not in content. The patient-physician interactions were audiotaped to determine the number of questions patients asked, and a questionnaire was administered after each encounter to assess patient satisfaction with care. The mean numbers of questions asked in the experimental and control groups were 7.46 and 5.63, respectively; the mean difference of 1.83 questions was statistically non-significant (P greater than 0.05). Question-asking did not correlate with reported satisfaction. Suggestions for modification to this research approach are presented. The objective of this study was to compare the impact of closed- versus open-ended question formats on the completeness and accuracy of demographic data collected in a mailed survey questionnaire. We surveyed general internists in five Canadian provinces to determine their career satisfaction. We randomized respondents to receive versions of the questionnaire in which 16 demographic questions were presented in a closed-ended or open-ended format. Two questions required respondents to make a relatively simple computation (ensuring that three or four categories of response added to 100%). The response rate was 1007/1192 physicians (80.0%). The proportion of respondents with no missing data for all 16 questions was 44.7% for open-ended and 67.0% for closed-ended formats (P < 0.001). The odds of having missing items remained higher for open-ended response options after adjusting for a number of respondent characteristics (2.67, 95% confidence interval 2.01 to 3.55). For the two questions requiring computations focused on professional activity and income, there were more missing data (P = 0.02, 0.02, respectively) but fewer inaccurate responses (P = 0.009, 0.20, respectively) for the open-ended compared to the closed-ended format. Investigators can achieve higher response rates for demographic items using closed format response options, but at the risk of increasing inaccuracy in response to questions requiring computation. This study assessed the effectiveness of telephone counseling in a church-based mammography promotion intervention trial.
                Thirty churches were randomized to telephone counseling and control conditions; telephone interview data were used in assessing intervention effects on mammography adherence. Separate analyses were conducted for baseline-adherent participants (maintaining adherence) and baseline-nonadherent participants (conversion to adherence).
                Year 1 follow-up data indicated that the telephone counseling intervention maintained mammography adherence among baseline-adherent participants and reduced the nonadherence rate from 23% to 16%.
                Partnerships between the public health and faith communities are potentially effective conduits to promote maintenance of widely endorsed health behaviors such as regular cancer screening. Mailed questionnaires can be a convenient method for collecting data on women's health, although poor response rates are a concern.
                As part of a survey of women's health conducted in Maryland in 2001, a randomized trial was performed to assess the effects of two incentives (US dollars 1.00 or a lottery ticket) as well as precontact with an introductory postcard on response rates. Questionnaires were mailed to 3000 women aged 40-60 who were randomized to one of six incentive/precontact groups: lottery/postcard, money/postcard, postcard only, lottery only, money only, or no incentive/no postcard.
                The overall response rate was 37.6%. Each incentive/precontact group yielded a higher response rate than the no incentive/no postcard group, although only the response rates for the lottery/postcard group (41.3%) and the money only group (40.0%) were significantly higher than that of the no incentive/no postcard group (33.1%). Money was the only factor that had a significant independent effect on likelihood of response (hazards ratio [HR] compared to no incentive = 1.22, 95% confidence interval [CI] = 1.03, 1.43). Response rates were lower in minority ZIP codes, although the effects of the incentives were generally greater than in the nonminority ZIP codes.
                These results indicate that response rates to mailed women's health questionnaires may be improved with modest incentives, particularly cash incentives. Mailed surveys are widely used to collect epidemiologic and health service data. Given that nonresponse can threaten the validity of surveys, modest incentives are often used to increase response rates. A study was undertaken among childhood cancer survivors and their parents to determine if response rate to a mailed survey differed with provision of immediate versus delayed incentives.
                A self-administered survey designed to ascertain health behaviors was mailed to 397 childhood cancer survivors (and their parents if the survivor was <18 years of age). Subjects were randomized into two groups based on gender, age, race, and cancer type. One group received a 10 US dollars incentive with their blank survey (unconditional incentive), whereas the other group received the incentive upon receipt of their completed survey (conditional incentive). If children were minors, both the parent and the child received incentives.
                No significant differences in response rates were observed with respect to gender, age, race, or cancer type. However, significant differences in response rates were observed between incentive groups, with unconditional incentives yielding significantly higher response rates than conditional incentives for child survivors who were > or =18 years (64.4% versus 49.0%), as well as younger child survivors (62.5% versus 43.6%) and their parents (64.8% versus 41.5%; all P < 0.05).
                The provision of an immediate incentive generated significantly higher response rates to this mailed health survey among childhood cancer survivors and their parents. Given that survey studies are commonly conducted across various pediatric populations, these findings may help inform the design of future pediatric survey research. To evaluate the effectiveness and efficiency of a search strategy to find evidence-based answers to questions related to the possible occupational etiology of diseases.
                A controlled trial of 70 occupational health physicians and 55 insurance physicians who were asked to answer one out of four 'occupational disease case-vignettes' following the steps of evidence-based medicine (EBM). The intervention group were given the search strategy as a tool.
                The intervention group scored significantly better than the control group in answering the main question of the case-vignette correctly (57% versus 37%) using more adequate search terms. The intervention group scored significantly better regarding satisfaction with the applied search strategy (28% very satisfied versus 8%). We found no differences in time spent in solving the case or in the intention of future practice of EBM.
                The introduction and application of specific search strategies can have a positive effect on the effectiveness of searching literature. Future initiatives for developing and testing specific search strategies in the field of occupational health should be encouraged. This two-part methodologic research was designed to evaluate the effects of a financial incentive on questionnaire response rate and response bias for general dentists surveyed by mail. Subjects were 517 clinicians randomly selected from a two-state population of practitioners insured by a single malpractice liability carrier. Subjects received a check for either $5 or $10 in the original mailing. In Study 1, a single mailing and postcard follow-up resulted in a 57.8 percent (111/192) response rate. In Study 2, employing Dillman's Total Design Method, a 69.6 percent (208/299) response was obtained after a third mailing. Analysis of response rate by incentive level in each study revealed no significant differences. In contrast, early responders (first mailing and follow-up postcard) differed from late responders (second and third mailings) on age (41.4 vs 37.0 years; T = 2.17; P = .032), non-Caucasians (27.7% vs 63.9%; chi 2 = 17.3; df = 4; P < .002), females (13.9% vs 27.8%; chi 2 = 3.9; df = 1; P < .05), foreign-trained (7.0% vs 19.4%; chi 2 = 16.5; df = 2; P < .001), and dissatisfaction with practice (31% vs 51%; chi 2 = 7.8; df = 4; P = .10). Thus, the magnitude of the financial incentive in this experiment had no differential effect on response rate. But differences in responses from late responders (proxies for nonresponders) on demographic characteristics and key study variables suggest the persistence of response bias despite an acceptable response rate. Future dental health survey research should employ tests for response bias on both sets of variables. People providing health care tend to turn to review articles rather than reports of primary research when seeking information to guide their practices. For this reason, the process of reviewing the results of primary research must respect scientific principles. Reviews must be kept up to date and disseminated in appropriate ways to the people who make decisions about health care, including policy makers, practitioners, and users of the health services. This article describes the methods developed and used in an attempt to address these challenges for care during pregnancy and childbirth. It is important that response rates to postal surveys are as high as possible to ensure that the results are representative and to maximise statistical power. Previous research has suggested that any personalisation of approach helps to improve the response rate. This experiment tested whether personalising questionnaires by hand signing the covering letter improved the response rate compared with a non-personalised group where the investigator's signature on the covering letter was scanned into the document and printed.
                Randomised controlled trial. Questionnaires about surgical techniques of caesarean section were mailed to 3,799 Members and Fellows of the Royal College of Obstetricians and Gynaecologists resident in the UK. Individuals were randomly allocated to receive a covering letter with either a computer printed signature or a hand written signature. Two reminders were sent to non-respondents. The outcome measures were the proportion of questionnaires returned and their time to return.
                The response rate was 79.1% (1506/1905) in the hand-signed group and 78.4% (1484/1894) in the scanned and printed signature group. There was no detectable difference between the groups in response rate or time taken to respond.
                No advantage was detected to hand signing the covering letter accompanying a postal questionnaire to health professionals. To test alternative response formats for the Nottingham Health Profile (NHP), in terms of acceptability, score distributions, and measurement properties.
                Randomized trial of four response formats for the NHP: original "yes/no" format, a 3-point similarity format ("applies completely/in part/not at all"), a 5-point intensity format ("completely true" to "completely false"), and a 5-point frequency format ("all the time" to "never"). Respondents were patients discharged from a hospital. We compared scores distributions, reliability coefficients, correlations with dimension-specific numerical scales, and patient ratings of the instrument.
                Response rates were similar for the four versions. The original response format had the fewest fully completed questionnaires, and the largest ceiling effects. Internal consistency and test-retest coefficients were acceptable for all versions, but were higher for the two 5-point formats. Correlations reflecting convergent and discriminant validity were higher for the longer response formats than for the original version. The frequency format received the highest ratings from patients, particularly from the sicker and older subgroups.
                The psychometric performance and patient acceptability of the NHP can be improved by using a 5-point frequency response format instead of the original dichotomous response format. nan Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations.
                Inner-city academic general internal medicine practice.
                Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. DATA EXTRACTION/COLLECTION METHODS: Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires.
                During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed.
                Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease. Young adults who had previously participated in a longitudinal survey of youth were sent a questionnaire. They were randomly assigned to receive a $20 prepayment, a $20 postpayment, or a $25 postpayment for participation in the latest survey. Those in the large incentive condition were 7 percentage points more likely to return a survey than those in the smaller, postpayment group. Prepayment had a smaller, less reliable effect. Effects of incentive magnitude and timing were consistent at each month of the study period; only better high school grades distinguished early responders from late responders. Nonresponders had characteristics suggestive of low social conformity and were more likely than responders to be African American and male and have low SES. The discussion centers on motivations for participating in research and differences in the incentives likely to promote continued response versus initial study enrollment.
Health researchers using postal and electronic questionnaires can increase response using the strategies shown to be effective in this systematic review.