A Swedish version of the SCREEN II for malnutrition assessment among community-dwelling elderly

Abstract

Background: The Seniors in the Community: Risk Evaluation for Eating and Nutrition II (SCREEN II) Questionnaire assesses nutritional risk among elderly people living at home. Our aim was to produce a Swedish language version of the SCREEN II and to examine response patterns, data completeness and the relationship between malnutrition and general health. Methods: The SCREEN II was translated into Swedish using dual panel methodology, and then followed up with field test interviews of 24 seniors (median age, 83 years). We used the survey data (n = 565) to assess item and score distribution, missing responses, and the relationship to the subject’s general and nutritional health. Results: The Swedish SCREEN II was considered easy to understand, respond to, and relevant (n = 21; 88% of subjects found it so in all three respects) and its median completion time was 5 minutes. The level of survey item data completeness was 94–99%, and 82% of surveys had computable total scores. Of those subjects with completed forms, 35% had no nutritional risk; 35% had moderate risk; and 30% were at high risk. The malnutrition risk increased with poorer perceived health. Conclusions: Our study results are similar to those using previous SCREEN II versions, indicating that the scale adaptation was successful and providing initial support for use of the Swedish SCREEN II Questionnaire.

Keywords

SCREEN II malnutrition home-dwelling

Background

Malnutrition does not only include undernutrition, but also overweight/obesity and nutrient deficiencies. For example, the prevalence of undernutrition in the elderly home-dwelling population was estimated to be 14.5%, according to the Mini Nutritional Assessment (MNA) [1]; while another study, using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN) Questionnaire among home-dwelling seniors, found that 24% had moderate and 33% had high malnutrition risk [2]. In addition, malnutrition risk increased with poorer health [3]. The MNA was developed to assess undernutrition risk among geriatric patients and was originally not intended for self-assessment [1] . The SCREEN II was developed to identify any nutrition problems, also at an early stage, among home-dwelling elderly persons and can either be self- or interviewer administered [2 –4] From a public health perspective, it is important to detect malnutrition risk and take actions against it, because malnutrition can have serious health consequences [5 –12]. SCREEN II seems more optimal to use among home-dwelling elderly persons than the MNA due to facilitating early detection of risk, that it is specifically developed for this population, and can be either self- or interviewer administered [2 -4]. However, the availability of scientifically documented non-English versions appears limited.

This study describes the translation into Swedish and subsequent application of the SCREEN II Questionnaire, to assess response patterns, data completeness and the relationship between malnutrition and general health.

Methods

Screen II Questionnaire

SCREEN II is a 14-item rating scale (with sub-questions regarding weight change and meal preparation) to assess the risk of malnutrition in ordinary housing, based on subjects’ self-reports [3]. Items have different ranges (typically 0–4) and it yields a total score ranging from 0 to 64 (higher scores are better). It has been suggested that total scores of 50–53 indicate moderate nutritional risk and scores < 50, a high nutritional risk. For individual items, scores ⩽ 2 have been suggested as indicating risk [3].

Translation of the SCREEN II into Swedish and a field-test evaluation

The SCREEN II Questionnaire was translated using the dual-panel methodology [13,14], emphasising conceptual, rather than linguistic equivalence. The instrument was first translated from English into Swedish by a bilingual panel, comprised of seven individuals fluent in both languages. The panel worked together to agree on the most appropriate translations. The translated version was then reviewed by a second panel of six lay people, to ensure clarity and acceptability of language.

Following this translation, the Swedish SCREEN II was field tested with a convenience sample of 24 community-dwelling seniors (age mean of 78.5 (SD 11.8) years and median of 83 (q1 to q3 of 65.7–88.7) years), of whom nine received ‘meals on wheels’. Three participants were healthy and the others suffered from disease (e.g. Parkinson’s disease, multiple sclerosis, cardiovascular disease and diabetes mellitus). Participants completed the SCREEN II (self-administered) in the presence of an interviewer, whom noted the time taken to complete the questionnaire (as an indicator of respondent burden: It should be ⩽ 10 minutes [15,16]), and whether any problems were experienced by the interviewees. Participants were then interviewed regarding the understandability and relevance of the Swedish SCREEN II, and were asked to suggest potential improvements [14]. Any ambiguities and potential revisions during the translation process were discussed with the developer of the SCREEN II (Heather Keller).

Quantitative survey

The Swedish SCREEN II Questionnaire was then used in a cross-sectional survey, conducted within an established structure for preventive home visits (PHV) [17 –19] targeting all elderly people without home-help service, in a Swedish municipality with approximately 12,500 inhabitants [20,21]. Two experienced nurses collected the data during a single home visit. Each PHV lasted for about 1 hour. Inclusion criteria were being 70 years or older and without home-help service. Exclusion criteria were: cognitive deficits, enteral and parenteral nutrition. Besides SCREEN II, four single items were used: general health (very good, quite good, quite poor and very poor); tiredness/fatigue (almost never, sometimes, often and always); and low-spiritedness (almost never, sometimes, often and always). The questions were interviewer-administered to 565 cognitively intact (clinical judgement of experienced nurses) persons.

Analyses

Data were assessed regarding underpinning assumptions, and were described and analysed accordingly, using the t-, Chi-square, Kruskal-Wallis and Mann-Whitney U-tests. Significance was set at p < 0.05. Percentages of missing item responses were calculated as an additional indicator of respondent acceptability (should be ⩽ 10% [22]). All analyses were conducted using Stata MP, version 13.1.

Results

Translation of the SCREEN II into Swedish and field-test evaluation

The translation process resulted in a few cultural adjustments, following discussions with the questionnaire developer. For example, peanut butter (seldom used in Sweden, particularly among the elderly) was replaced with ‘other meat alternatives’, and the estimation of beverage intake was changed to ‘glass’ instead of ‘cup’. Additional minor clarifications and changes in the order of the questions (to not start with the weight question) were made as a result of feedback from the first eight field test participants; no further needs for modification were identified among the subsequent 16 field test interviews. All questions were considered easy to understand, easy to respond to and relevant by 21 subjects (88%). The SCREEN II was completed in a median of 5 minutes (q1–q3 in 3.5–17.5; min–max 3–40).

Quantitative survey

Out of 565 respondents, 465 (82%) had complete SCREEN II forms, allowing for the calculation of total scores. Those with incomplete SCREEN II forms were slightly older than those with complete forms, and they reported significantly more tiredness/fatigue and low-spiritedness than those with complete forms (Table I). The share of respondents with missing data in individual items varied between < 1–6%; and having a score of ⩽ 2 in individual items varied between 1–86% (Table II).

Table I.

Demographic characteristics of elderly persons living at home without home help service. Comparisons between those with and without complete SCREEN II responses.

	Complete (n = 465)	Incomplete (n = 100)	p-value
Age			0.021^a
Mean (SD)	78.5 (3.7)	79.7 (4.8)
95% CI	78.2–78.8	78.8–80.7
Female gender, n (%)	249 (54)	54 (54)	0.935^b
Living alone, n (%)	201 (43)	47 (47)	0.490^b
General health, n (%)^d			0.159^c
Median (q1–q3)	1 (0–1)	1 (1–1)
Mean (95% CI)	0.9 (0.8–0.9)	1.0 (0.8–1.1)
Tiredness/fatigue, n (%)^e			0.038^c
Median (q1–q3)	1 (0–1)	1 (0–2)
Mean (95% CI)	0.9 (0.8–0.9)	1.1 (0.9–1.2)
Low-spiritedness, n (%)^e			0.038^c
Median (q1–q3)	0 (0–1)	0 (0–1)
Mean (95% CI)	0.3 (0.3–0.4)	0.4 (0.3–0.6)

t-test.

Chi-Square test.

Mann-Whitney U-test.

Response categories: 0=very good, 1=quite good, 2=quite poor, and 3=very poor, missing data n=15.

Response categories: 0=almost never, 1=sometimes, 2=often, and 3=always, missing data n=5.

CI: confidence interval; q1–q3: quartile 1 and 3; SCREEN II: Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire, version II; SD: standard deviation.

Table II.

Risk (item score ⩽ 2), response patterns, and missing responses for SCREEN II items among elderly persons living at home without home help service.^a)

Item (number in Swedish version)	Item score ⩽ 2(n = 465)^a)	n = 465(%)					Missing (n=565)^b)
Response categories		0	2	3	4
Fair/poor appetite (1)	29 (6)	7 (1)	22 (5)	176 (38)	260 (56)	–	2 (<1)
Response categories		0	1	2	4
Often/always skip meals (2)	51 (11)	3 (< 1)	6 (1)	42 (9)	414 (89)	–	9 (2)
Weight change (4a1–a3)	69 (15)	22 (5)	28 (6)	19 (4)	396 (85)	–	16 (3)
Often/always difficulty with shopping groceries (13)	10 (2)	4 (1)	2 (<1)	4 (1)	455 (98)	–	11 (2)
Response categories		0	2	4
Limits food (3)	68 (15)	1 (<1)	67 (14)	397 (85)	–	–	15 (3)
Sometimes/often use meal replacements (11)	7 (1)	4 (1)	3 (<1)	458 (98)	–	–	17 (3)
Cooking is a chore/dissatisfied with others cooking (14a–b)	83 (18)	24 (5)	59 (13)	382 (82)	–	–	21 (4)
Response categories		0	4
Have you tried to achieve weight change (4b)	16 (3)	16 (3)	449 (97)	–	–	–	35 (6)
Think excess weight/less than should be (4c)	189 (41)	189 (41)	276 (59)	–	–	–	34 (6)
Response categories		0	1	2	3	4
⩽ 3 Fruits and vegetables per day (5)	398 (86)	100 (21)	166 (36)	132 (28)	40 (9)	27 (6)	17 (3)
⩽ 2 Milk products per day (7)	241 (52)	12 (3)	48 (10)	181 (39)	190 (41)	34 (7)	14 (2)
⩽ 4–6 glasses per day (8)	204 (44)	0	2 (<1)	202 (43)	219 (47)	42 (9)	7 (1)
Response categories		0	1	3	4
⩽ 1 Meat and alternatives per day (6)	144 (31)	6 (1)	138 (30)	165 (36)	156 (33)	–	14 (2)
Sometimes/often swallow difficulty (9)	75 (16)	8 (2)	67 (14)	48 (10)	342 (74)	–	10 (2)
Sometimes/often chewing difficulty (10)	18 (4)	5 (1)	13 (3)	9 (2)	438 (94)	–	9 (2)
Response categories		0	2	3	4
Sometimes/never eat with others (12)	157 (34)	96 (20)	61 (13)	17 (4)	291 (63)	–	7 (1)

Scores ⩽2 indicate risk (includes only those with complete forms).

Includes both those with complete as well as with incomplete SCEEN II forms.

The mean SCREEN II score was 51.4 (SD 5.1). There were no floor nor ceiling effects, as no respondents had the lowest nor highest possible scores. No malnutrition risk was found among 35% of respondents, 35% had a moderate risk and 30% had a high risk (Table III). Malnutrition risk increased with poorer perceived health (p < 0.001).

Table III.

SCREEN II scores in relation to general health among elderly persons living at home, without home help service.

	Total sample		General health^a
	(n = 465)	Very good (n = 120)	Quite good (n = 284)	Quite/very poor (n = 55)
Total score according to SCREEN II
Mean (SD)	51.4 (5.1)	53.6 (3.9)	51.3 (4.9)	47.4 (5.9)
95% CI (mean)	51.0–51.9	52.9–54.3	50.7–51.8	45.8–49.0
Median (q1–q3)	52 (48–55)	54 (51–57)	52 (48–55)	48 (45–51)
95% CI (median)	51–52	53–55	51–52	47–50
Min-max	29–62	44–62	34–62	29–59
Malnutrition risk according to SCREEN II^a
No risk, % (95% CI)	35 (31–40)	52 (43–61)	33 (27–38)	11 (5–22)
Moderate risk, % (95% CI)	35 (31–39)	31 (23–40)	37 (32–43)	31 (20–44)
High risk, % (95% CI)	30 (26–34)	17 (11–24)	30 (25–35)	58 (45–70)

Missing data n=15, bScores ⩾ 54 = no risk of malnutrition; < 54 = moderate risk for malnutrition; < 50 = high risk for malnutrition.

CI: confidence interval; max: maximum; min: minimum; SCREEN II: The Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire, version II.

Discussion

This paper presents a Swedish translation of the SCREEN II that is highly acceptable by respondents, has relatively low respondent burden and acceptable levels of missing item data. Despite this, a relatively large proportion of survey questionnaires could not be used to derive total SCREEN II scores, due to missing item responses. Although factors such as tiredness/fatigue, low-spiritedness and age in part may have contributed, measures to maximize the possibility of deriving total scores and risk group assignments should be considered. One such possibility may be to score the questionnaire according to the 8-item abbreviated SCREEN II, suggested by Keller et al. [3]. This does not include the two items with most missing data, i.e. the items about weight change (4b), and excess weight/less than should be (4c). Applying the abbreviated SCREEN II on the data in this study would result in 91% risk-assessed people, compared to 82% with the full version, with 37% and 31% falling into the moderate and high nutritional risk groups, respectively.

Some critique against SCREEN II can be put forward. A self-reported tool is not useful in people with cognitive deficits (a large and growing group with nutritional problems); a proxy SCREEN II assessment might then be an alternative but needs validation. High age, tiredness/fatigue and low-spiritedness are known risk factors for being malnourished [1, 21] and were associated with lower SCREEN II completion rates. These persons should be considered as having a risk until a fuller assessment of their nutritional status has been completed. Anyhow, for most home-dwelling elderly persons, the SCREEN II helps to identify reasons for malnutrition risk and to identify needs for nutritional interventions.

Our observations are in general agreement with those in the original SCREEN II study [3]. In that study, median SCREEN II scores were 49–52 and the lower scores were associated with poorer perceived health. This supports the validity of the Swedish SCREEN II: It appears that our sample is representative of elderly community-dwelling people without home-help service, but to a slightly less extent for the oldest old; however, the design of this study did not allow for assessment of aspects such as test-retest reliability and re-evaluation of the suggested cut-off scores, which will need to be addressed in additional samples.

Available nutritional screening tools focus on undernutrition, but disregard other aspects of malnutrition [23 –26]. The successful adaptation and usefulness of the SCREEN II for malnutrition screening in a Swedish context opens up an opportunity for more holistic nutritional screening. This is of significant value, from a primary care and public health perspective.

Footnotes

Acknowledgements

The authors wish to thank all participating respondents for their cooperation. We are grateful to Heather Keller for valuable discussions; Maria Nilsson for involvement in the translation process; Kerstin Ulander (deceased), Ellinor Edfors, Susanne Lindskov, Gun Oredsson and Inger Holmgren for help with the data collection. We also thank Johnny Kvarnhammar for his support and initiation of our collaboration, and Lina Axelsson and Gita Hedin for help with data management. Special thanks to the Swedish House in Kavalla, Greece.

Conflict of interest

The authors declare that there are no conflicts of interest.

Ethics

The study was conducted according to the Declaration of Helsinki [27] and is based on data collected as part of regular clinical praxis. The manager (medically responsible nurse) for the municipality care initiated the collaboration between the municipality and the research group, and provided fully de-identified data from the municipal registry. All participants provided informed consent before the PHV.

Funding statement

This study was supported by the Swedish Research Council, The Kamprad Family Foundation for Entrepreneurship and Charity, and the Vårdal Foundation.

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