Creating a scientific solution: local problem solving in the Portuguese Health Examination Survey: a mixed method study

Heidi Lyshol, Ana Paula Gil, Hanna Tolonen, Sónia Namorado, Irina Kislaya, Marta Barreto, Liliana Antunes, Ana J. Santos, Ana P Rodrigues, Carlos M. Dias, Vania Gaio

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Background Participation rates in health surveys, recognized as an important quality dimension, have been declining over the years, which may affect representativeness and confidence in results. The Portuguese national health examination survey INSEF (2015) achieved a participation rate of 43.9%,
which is in line with participation rates from other similar health examination surveys. The objective of this article is to describe strategies used by the local teams to increase participation rates and to solve practical survey problems.
Methods After a literature search, informal interviews were conducted with 14 public health officials from local health examination teams, regional and central authorities. 41 of the local staff members also filled in a short questionnaire anonymously. The interviews and self-administered questionnaires were
analysed using mixed methods, informed by thematic analysis.
Results The local teams believed that the detailed manual, described as a "cookbook for making a health examination survey", made it possible to maintain high scientific standards while allowing for improvising solutions to problems in the local context. The quality of the manual, supported by a series
of training workshops with the central research and support team, gave the teams the confidence and knowledge to implement local solutions. Motivation and cohesion within the local teams were among the goals of the training process. Local teams felt empowered by being given large responsibilities and worked hard to incite people to attend the examination through a close and persuasive approach.
Local teams praised their INSA contacts for being available for assistance throughout the survey, and said they were inspired to try harder to reach participants to please their contacts for interpersonal reasons.
Conclusions The theory of organizational improvisation or bricolage, which means using limited resources to solve problems, was useful to discuss and understand what took place during INSEF.
A detailed manual covering standard procedures and face-to-face workshops, including role-play, were vital to assure high scientific standards and high participation rates in this health examination survey.
Close contacts between the central team and local focal points in all regions and all survey sites were key to accommodating unexpected challenges and innovative solutions.
Original languageEnglish
Pages (from-to)1-24
Number of pages24
JournalBMC Research Square
Publication statusPublished - May 2021


  • Procedure manual
  • Health examination survey
  • Participation rate
  • Organizational improvisation


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