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HSE - Methodology and Documentation

Appendix B

Measurement protocols

1 Height, weight and infant length measurement

1.1 Eligibility

You should be able to measure the height and weight of most of the informants. However, in some cases it may not be possible or appropriate to do so. Do not force the informant to be measured if it is clear that the measurement will be far from reliable but whenever you think a reasonable measurement can be taken, do so. Examples of people who should not be measured are:

• Chairbound informants.

• If after discussion with an informant it becomes clear that they are too unsteady on their feet for these measurements
• If the informant finds it painful to stand or stand straight, do not attempt to measure height.
• If an elderly informant is too stooped to obtain a reliable measurement.
• Pregnant women are not eligible for weight as this is clearly affected by their condition.
• Children under the age of 2 years do not have their height measurement taken.
• For small children, there is an option to weight them held by an adult. In this case, you weigh the adult on his/her own first and then the adult and the child. The computer will calculate the child's weight.

1.2 Site

It is strongly preferable to measure height and weight on a floor which is level and not carpeted. If the entire household is carpeted, choose a floor with the thinnest and hardest carpet (usually the kitchen or bathroom).

1.3 Height measurements

The equipment

Portable stadiometer - collapsible device with a sliding head plate, a base plate and three connecting rods marked with a measuring scale.

Frankfort plane card

The protocol - adults (aged 16 and over)

1. Ask the informant to remove their shoes in order to obtain a measurement that is as accurate as possible.

2. Assemble the stadiometer and raise the headplate to allow sufficient room for the informant to stand underneath it. Double check that you have assembled the stadiometer correctly.

3. The informant should stand with their feet flat on the centre of the base plate, feet together and heels against the rod. The informant's back should be as straight as possible, preferably against the rod but NOT leaning on it. They should have their arms hanging loosely by their sides. They should be facing forwards.

4. Move the informant's head so that the Frankfort Plane is in a horizontal position (i.e. parallel to the floor). The Frankfort Plane is an imaginary line passing through the external ear canal and across the top of the lower bone of the eye socket, immediately under the eye (see diagram). This position is important if an accurate reading is to be obtained. An additional check is to ensure that the measuring arm rests on the crown of the head, i.e. the top back half.

To make sure that the Frankfort Plane is horizontal, you can use the Frankfort Plane Card to line up the bottom of the eye socket with the flap of skin on the ear. The Frankfort Plane is horizontal when the card is parallel to the stadiometer arm.

5. Instruct the informant to keep their eyes focused on a point straight ahead, to breathe in deeply and to stretch to their fullest height. If after stretching up the informant's head is no longer horizontal, repeat the procedure. It can be difficult to determine whether the stadiometer headplate is resting on the informant's head. If so, ask the informant to tell you when s/he feels it touching their head.

6. Ask the informant to step forwards. If the measurement has been done correctly the informant will be able to step off the stadiometer without ducking their head. Make sure that the head plate does not move when the informant does this.

7. Look at the bottom edge of the head plate cuff. There is a green arrowhead pointing to the measuring scale. Take the reading from this point and record the informant's height in centimetres and millimetres, that is in the form 123.4, at the question Height. You may at this time record the informant's height onto their Measurement Record Card and at the question MbookHt you will be asked to check that you have done so. At that point the computer will display the recorded height in both centimetres and in feet and inches. At RelHiteB you will be asked to code whether the measurement you obtained was reliable or unreliable.

8. Height must be recorded in centimetres and millimetres, e.g. 176.5 cms. If a measurement falls between two millimetres, it should be recorded to the nearest even millimetre. For example, if informant's height is between 176.4 and 176.5 cms, you should round it down to 176.4. Likewise, if an informant's height is between 176.5 and 176.6 cms, you should round it up to 176.6 cms.

9. Push the head plate high enough to avoid any member of the household hitting their head against it when getting ready to be measured.

The protocol - children (aged 2-15)

The protocol for measuring children differs slightly to that for adults. You must get the co-operation of an adult household member. You will need their assistance in order to carry out the protocol, and children are much more likely to be co-operative themselves if another household member is involved in the measurement. If possible measure children last so that they can see what is going on before they are measured themselves.

Children's bodies are much more elastic than those of adults. Unlike adults they will need your help in order to stretch to their fullest height. This is done by stretching them. This is essential in order to get an accurate measurement. It causes no pain and simply helps support the child while they stretch to their tallest height.

It is important that you practice these measurement techniques on any young children among your family or friends. The more practice you get before going into the field the better your technique will be.

1. In addition to removing their shoes, children should remove their socks as well. This is not because the socks affect the measurement. It is so that you can make sure that children don't lift their heels off of the base plate. (See point 3 below).

2. Assemble the stadiometer and raise the head plate to allow sufficient room for the child to stand underneath it.

3. The child should stand with their feet flat on the centre of the base plate, feet together and heels against the rod. The child's back should be as straight as possible, preferably against the rod, and their arms hanging loosely by their sides. They should be facing forwards.

4. Place the measuring arm just above the child's head.

5. Move the child's head so that the Frankfort Plane is in a horizontal position. This position is as important when measuring children as it is when measuring adults if the measurements are to be accurate. To make sure that the Frankfort Plane is horizontal, you can use the Frankfort Plane Card to line up the bottom of the eye socket with the flap of skin on the ear. The Frankfort Plane is horizontal when the card is parallel to the stadiometer arm.

6. Cup the child's head in you hands, placing the heals of your palms either side of the chin. Your fingers should come to rest just under the ears.

7. Firmly but gently, apply upward pressure lifting the child's head upwards towards the stadiometer headplate and thus stretching the child to their maximum height. Avoid jerky movements, perform the procedure smoothly and take care not to tilt the head at an angle: you must keep it in the Frankfort plane. Explain what you are doing and tell the child that you want them to stand up straight and tall but not to move their head or stand on their tip-toes.

8. Ask the household member who is helping you to lower the headplate down gently onto the child's head. Make sure that the plate touches the skull and that it is not pressing down too hard.

9. Still holding the child's head, relieve traction and allow the child to stand relaxed. If the measurement has been done properly the child should be able to step off the stadiometer without ducking their head. Make sure that the child does not knock the head plate as they step off.

10. Read the height value in metric units to the nearest millimetre and enter the reading into the computer at the question Height. At the question MbookHt you will be asked to check that you have entered the child's height onto their Measurement Record Card. At that point the computer will display the recorded height in both centimetres and in feet and inches.

11. Push the head plate high enough to avoid any member of the household hitting their head against it when getting ready to be measured.

Additional points - all informants

1. If the informant cannot stand upright with their back against the stadiometer and have their heels against the rod (e.g. those with protruding bottoms) then give priority to standing upright.

2. If the informant has a hair style which stands well above the top of their head, (or is wearing a turban), bring the headplate down until it touches the hair/turban. With some hairstyles you can compress the hair to touch the head. If you can not lower the headplate to touch the head, and think that this will lead to an unreliable measure, record this at question RelHite. If it is a hairstyle that can be altered, e.g. a bun, if possible ask the informant to change/undo it.

3. If the informant is tall, it can be difficult to line up the Frankfort Plane in the way described. When you think that the plane is horizontal, take one step back to check from a short distance that this is the case.

1.4 Weight measurements

The equipment

Soehnle, Seca or Tanita electronic bathroom scales, calibrated for the Health Survey.

The reading is shown in metric units, but as for height, the computer provides a conversion. If the informant would like to know their weight in stones and pounds you will be able to tell them when the computer has done the calculation. You also have a conversion chart on the back of the coding booklet.

The scales have an inbuilt memory which stores the weight for 10 minutes. If during this time you weigh another object that differs in weight by less than 500 grams (about 1lb), the stored weight will be displayed and not the weight that is being measured. This means that if you weigh someone else during this time, you could be given the wrong reading for the second person.

So if you get an identical reading for a second person, make sure that the memory has been cleared. Clear the memory from the last reading by weighing an object that is more than 500 grams lighter (i.e. a pile of books, your briefcase or even the stadiometer). You will then get the correct weight when you weigh the second informant.

You will only need to clear the memory in this way if:

a) You have to have a second or subsequent attempt at measuring the same person

b) Two informants appear to be of a very similar weight

c) Your reading for an informant in a household is identical to the reading for another informant in the household whom you have just weighed.

The protocol

1. Turn the display on by using the appropriate method for the scales. In most cases, this will involve pressing firmly with your hand or foot on top of the scales (the scales will automatically turn off after a short time). The readout should display 888.8 (1888 for the Seca 870) momentarily. If this is not displayed check the batteries, if this is not the cause you will need to report the problem to the National Centre at Brentwood. While the scales read 888.8 do not attempt to weigh anyone.

2. Ask the informant to remove shoes, heavy outer garments such as jackets and cardigans, heavy jewellery, loose change and keys.

3. Turn the scales on with your foot again. Wait for a display of 0.0 before the informant stands on the scales.

4. Ask the informant to stand with their feet together in the centre and their heels against the back edge of the scales. Arms should be hanging loosely at their sides and head facing forward. Ensure that they keep looking ahead - it may be tempting for the informant to look down at their weight reading. Ask them not to do this and assure them that you will tell them their weight afterwards if they want to know.

The posture of the informant is important. If they stand to one side, look down, or do not otherwise have their weight evenly spread, it can affect the reading.

5. The scales will take a short while to stabilise and will read 'C' until they have done so. (The Seca 870 displays alternate flashing lines in the display window. With the Tanita scales the weight will flash on and off when stabilised). If the informant moves excessively while the scales are stabilising you may get a false reading. If you think this is the case reweigh, but first ensure that you have erased the memory.

6. The scales have been calibrated in kilograms and 100 gram units (0.1 kg). Record the reading into the computer at the question Weight before the informant steps off the scales. At question MBookWt you will be asked to check that you have entered the informant's weight onto their Measurement Record Card. At that point the computer will display the measured weight in both kilos and in stones and pounds.

WARNING

The maximum weight registering accurately on the scales is 130kg (201/2 stone). If you think the informant exceeds this limit code them as 'Weight not attempted' at RespWts. The computer will display a question asking them for an estimate. Do not attempt to weigh them.

You must get the co-operation of an adult household member. This will help the child to relax and children, especially small children are much more likely to be co-operative themselves if an adult known to them is involved in the procedure.

Children wearing nappies should be wearing a dry disposable. If the nappy is wet, please ask the parent to change it for a dry one and explain that the wetness of the nappy will affect the weight measurement.

In most cases it will be possible to measure children's weight following the protocol set out for adults. However, if accurate readings are to be obtained, it is very important that informants stand still. Ask the child to stand perfectly still - 'Be a statue'. For very young children who are unable to stand unaided or small children who find this difficult you will need to alter the protocol and first weigh an adult then weigh that adult holding the child as follows:-

a) Code as 'Weight obtained (child held by adult)' at RespWts

b) Weigh the adult as normal following the protocol as set out above. Enter this weight into the computer at WtAdult.

c) Weigh the adult and child together and enter this into the computer at WtChAd.

The computer will then calculate the weight of the child and you will be asked to check that you have recorded the weight onto the child's Measurement Record Card at MBookWt. Again the computer will give the weight in both kilos and in stones and pounds.

1.5 Infant length measurement

Eligibility

This measurement is for infants aged under 2 years but at least 6 weeks old.

Equipment

Rollameter Baby Measure Mat
Frankfort Plane Card
Kitchen roll

Procedure

Infants (children under the age of 2) should be measured lying down (supinely). Two people are required for the task, yourself and the child's parent.

1. Ask the parent to remove any bulky clothing that the infant is wearing. It is not necessary for them to remove the infant's nappy.

2. Unroll the Rollameter and lay it flat on any suitable flat, firm surface (e.g. table, floor). It is essential that the Rollameter is fully unrolled and as flat as possible, therefore doing the measurement on a deep pile carpet or rug would not be appropriate. Lay one layer of kitchen roll on the mat (just in case there are any accidents!!)

If taking the measurement on a table, take extra care and ensure that somebody is with the infant at all times to prevent them rolling/falling off the table.

3. Place the child onto the foam bed with his/her head touching the headpiece on which the name Rollameter is printed.

4. Move the child's head so that Frankfort Plane is in a position at right angles to the floor/table (see diagram below). Ask the parent to hold the child in this position and make sure their head is in contact with the headpiece.

6. With your free hand, move the foot rest on which the measuring tape is mounted to touch the child's heals by depressing the red button on the tape measure.

7. The measurement is read from the red cursor in the tape window. The measurement is recorded in centimetres and millimetres to the nearest millimetre. If the measurement lies between two millimetres then you should round to the nearest even millimetre. For example, if the measurement is halfway between 68.3 and 68.4, then round up to 68.4. If the measurement is halfway between 68.8 and 68.9 then round down to 68.8.

2 Recording ambient air temperature

2.1 The thermometer

You have been provided with a digital thermometer and probe. This instrument is very sensitive to minor changes in temperature. It is therefore important that you record temperature at the appropriate time in your routine. It can also take a few minutes to settle down to a final reading if it is experiencing a large change in temperature (e.g. coming into a warm house from a cold outside).

Immediately after you have settled the informant down to rest for five minutes prior to taking their blood pressure set up the thermometer to take a reading. Just prior to recording the blood pressure note the temperature and record it when the computer prompts you do to so. Always switch it off after taking a reading, to avoid battery problems. The thermometer automatically switches off if you have left it on for more than 7 minutes. You will also need to enter the temperature before the lung function reading.

Place the thermometer on a surface near the Omron. Do not let the probe touch anything - you can for example let it hang over the edge of a table. Do not put it on top of the Omron as it will be warm.

Please note that you must enter the temperature to one decimal place - do not round it to the nearest degree. For example, enter '21.2', not just '21'. If you do not enter a decimal point, the computer will give you a warning. If the temperature is exactly, say, 21 degrees, then all you need to do is suppress the warning and it will automatically fill in the '.0' for you. Otherwise, you must go back and amend your answer. As a further check, it will also ask you to confirm that a temperature ending in '.0' is correct.

2.2 Instructions for using the thermometer

1. The probe plug fits into the socket at the top of the instrument.

2. Press the completely white circle to turn the instrument on. To turn off, press the white ring.

3. Before taking a reading off the display, ensure that the reading has stabilised.

4. Be careful of the probe - it is quite fragile.

5. When 'LO BAT' is shown on the display the battery needs replacing, take no further readings.

6. The battery in your thermometer is a long-life battery and should last at least one year. However, should it run low please purchase a new battery. Take the old one with you to ensure it is the same type. Claim in the usual way.

7. To remove old battery and insert a new one, unscrew the screw on the back of the thermometer.

3 Blood pressure measurement

3.1 Eligibility

High blood pressure is an important risk factor for cardiovascular disease. It is important that we look at the blood pressure of everyone in the survey using a standard method so we can see the distribution of blood pressure across the population. This is vital for monitoring change over time, and monitoring progress towards lower blood pressure targets set in the Health of the Nation.

The only people not eligible for blood pressure measurement are those who are pregnant or aged less than 5 years old. However, if a pregnant woman wishes to have her blood pressure measured, you may do so, but do not record the readings on the computer.

3.2 Protocol for blood pressure recording: Omron HEM-907

This section describes the protocol for measuring blood pressure using the Omron HEM 907. More detailed information may be obtained from the instructions booklet inside the box.

Protocol
Equipment
Omron HEM 907 blood pressure monitor
Small cuff (17-22 cm)
Standard adult cuff (22-32 cm)
Large adult cuff (32-42 cm)
AC adapter

The Omron HEM-907 blood pressure monitor is an automated machine. It is designed to measure systolic blood pressure, diastolic blood pressure and pulse rate automatically at pre-selected time intervals. On this study three readings are collected at one-minute intervals.

The Omron 907 is equipped with a rechargeable battery, which is usable for approximately 300 measurements when fully charged. To recharge the battery, connect the monitor to the mains. A battery symbol will appear in the CHARGING display when the battery is charging. When ready to use the symbol will disappear. A dark battery symbol in the BATTERY display indicates that the battery is charged and the machine is usable. The battery can be charged in approx. 12 hours. When the battery symbol in the BATTERY display starts to flash there are 20-30 measurements left, you need to charge the battery soon. When a light battery symbol appears in the BATTERY display the battery needs to be put on charge immediately. The Omron 907 is NOT designed to work off the mains adaptor; it should be run off the battery power pack. The mains adaptor should ONLY be used to charge the battery pack.

PLEASE REMEMBER TO CHARGE THE BATTERY!

The picture below shows the main features of the Omron HEM-907.

The informant should not have eaten, smoked, drunk alcohol or taken vigorous exercise in the 30 minutes preceding the blood pressure measurement as blood pressure can be higher than normal immediately after any of these activities.

Ask the informant to remove outer garments (e.g. jumper, cardigan, jacket) and expose the right upper arm. The sleeve should be rolled or slid up to allow sufficient room to place the cuff. If the sleeve constricts the arm, restricting the circulation of blood, ask the informant if they would mind taking their arm out of the sleeve for the measurement.

3.4 Selecting the correct cuff

Adults aged 16 and over: Do not measure the upper arm circumference. Instead, choose the correct cuff size based on the acceptable range which is marked on the inside of the cuff. You will note that there is some overlap between the cuffs. If the informant falls within this overlap range then use the standard cuff where possible.

Children aged 5 to 15: It is important to select the correct cuff size. The appropriate cuff is the largest cuff which fits between the axilla (underarm) and the antecubital fossa (front of elbow) without obscuring the brachial pulse and so that the index line is within the range marked on the inside of the cuff. You will be provided with a child's cuff as well as the other adult cuffs. Many children will not need the children's cuff and instead will require a small adult cuff or a standard adult cuff. You should choose the cuff that is appropriate to the circumference of the arm.

Adults and Children: The appropriate cuff should be connected via the grey air tube to right end side of the monitor.

3.5 Procedure

Wrap the correct sized cuff round the upper right arm and check that the index line falls within the range lines. Use the left arm only if it is impossible to use the right. If the left arm is used, record this on the schedule. Locate the brachial pulse just medial to the biceps tendon and position the arrow on the cuff over the brachial artery. The lower edge should be about 1-2 cm above the cubital fossa (elbow crease).

Do not put the cuff on too tightly as bruising may occur on inflation. Ideally, it should be possible to insert two fingers between cuff and arm. However, the cuff should not be applied too loosely, as this will result in an inaccurate measurement.

The informant should be sitting in a comfortable chair with a suitable support so that the right arm will be resting at a level to bring the antecubital fossa (elbow) to approximately heart level. They should be seated in a comfortable position with cuff applied, legs uncrossed and feet flat on the floor.

Explain that before the blood pressure measurement we need them to sit quietly for five minutes to rest. They should not smoke, eat, drink or during this time. Explain that during the measurement the cuff will inflate three times and they will feel some pressure on their arm during the procedure.

It is important that children as well as adults rest for five minutes before the measurement is taken. However, making children sit still for five minutes can be unrealistic. They may move around a little, but they should not be running or taking vigorous exercise. As with adults, they should not eat or drink during this time.

After five minutes explain you are starting the measurement. Ask the informant to relax and not to speak until the measurement is completed as this may affect their reading.

3.6 How to operate the monitor

See Picture of Omron HEM-907 monitor on previous page.

1. Switch the monitor on by pushing the ON/OFF button. Wait for the READY TO MEASURE symbol to light, indicating the machine is ready to start the measurement (approx 2 sec).

2. Check that the MODE Selector is set to AVG and the P-SET (pressure setting) Volume is set to AUTO.

3. Press the START button to start the measurement. The cuff will now start to inflate and take the first measurement. When the first measurement is complete the LCD displays show systolic pressure, diastolic pressure, and pulse rate. Record the readings on the interview schedule.

4. Blood pressure will then be recorded at one-minute intervals thereafter. After each interval record the reading from the LCD displays on the interview schedule.

5. After the three measurements are complete press the ON/OFF button to turn off the power and remove the cuff.

If there are any problems during the blood pressure measurements or the measurement is disturbed for any reason, press the STOP button and start the procedure again. If the informant has to get up to do something, then ask them to sit and rest for five minutes again.

3.7 Error readings

They appear on the LCD display:

Er1, Er2. Check that the tube connecting the cuff to the monitor is properly inserted and it is not bent. Check that the cuff is properly wrapped around the arm. Repeat the measurement.

Er3. Check that the tube connecting the cuff to the monitor is not bent. Repeat the measurement.

Er4. This could be because of a motion artefact. Ask the informant to sit as still as possible and take the measurement again. If you still get another Er4 error reading, it could be because the informant has a very high blood pressure. Set the P-SET Volume to 260 and repeat the measurement.

Er5, Er6. Check that the cuff is properly wrapper around the arm. Repeat the measurement.

If any of these errors readings persist record that it wasn't possible to get a reading and explain to the informant that this sometimes happens. Then contact Brentwood and inform them that there is a problem with the monitor.

Er7, Er8. Check that the informant does not move, ask the informant to sit as still as possible and take the measurement again. If you still get an error reading the pulse may be irregular. Do NOT palpate the pulse. Record that it wasn't possible to get a reading and explain to the informant that this sometimes happens.

Er9. Technical fault. Contact Brentwood immediately and inform them that there is a problem with the monitor.

3.8 Feedback to informants

If the informant/parent wishes, you should record details of their readings on their Measurement Record Card.

a) Child informants (age 5 to 15)
We do not wish you to comment on the child's blood pressure readings to the parents. If they seek comment, reiterate what you have already said about not being able to interpret a single blood pressure measurement without checking to see whether it is normal for the child's age and height. Reassure them that if it is found to be abnormal, the Survey Doctor will get in touch and advice them as to what steps they should take. This rule applies for all readings you obtain.

b) Adult informants (aged 16+)
In answering queries about an adults blood pressure it is very IMPORTANT to remember that it is not the purpose of the survey to provide informants with medical advice, nor are you in a position to do so as you do not have the informant's full medical history. But you will need to say something. What you say in each situation has been agreed with the Department of Health, and you have been given a sheet with these comments to read out. It is very important that you make all the points relevant to the particular situation and that you do not provide a more detailed interpretation as this could be misleading. Read the instructions below very carefully and make sure you always follow these guidelines.

Your comments should be based on the last two of the first three readings you take from the Omron HEM-907. Base your advice on the higher of the last two readings. If the first reading is higher than the other two, explain that the first reading can be high because people are nervous of having their pressure taken.

Definitions of raised blood pressure differ slightly. The Department of Health has decided to adopt the ones given below for this survey. It is important that you adhere to these definitions, so that all informants are treated in an identical manner. These are shown on the next page.

Adults only
Survey definition of blood pressure ratings
Rating	Systolic		Diastolic
For men aged
less than 50 and
all women
Normal	<140	and	<85
Mildly raised	140-159	or	85-99
Moderately raised	160-179	or	100-114
Considerably raised	180 or more	or	115 or more
Men aged 50 or over
Normal	<160	and	<95
Mildly raised	160-169	or	96-104
Moderately raised	170-179	or	105-114
Considerably raised	180 or more	or	115 or more

NB: < less than

Normal:

'Your blood pressure is normal'

Mildly raised:

'Your blood pressure is a bit high today.'

'Blood pressure can vary from day to day and throughout the day so that one high reading does not necessarily mean that you suffer from high blood pressure.'

'You are advised to visit your GP within 3 months to have a further blood pressure reading to see whether this is a once-off finding or not.'

Moderately raised:

'Your blood pressure is a bit high today.'

'Blood pressure can vary from day to day and throughout the day so that one high reading does not necessarily mean that you suffer from high blood pressure.'

'You are advised to visit your GP within 2-3 weeks to have a further blood pressure reading to see whether this is a once-off finding or not.'

Considerably raised:

'Your blood pressure is high today.'

'Blood pressure can vary from day to day and throughout the day so that one high reading does not necessarily mean that you suffer from high blood pressure.'

'You are strongly advised to visit your GP within 5 days to have a further blood pressure reading to see whether this is a once-off finding or not.'

Note: If the informant is elderly and has severely raised blood pressure, amend your advice so that they are advised to contact their GP within the next week or so about this reading. This is because in many cases the GP will be well aware of their high blood pressure and we do not want to worry the informant unduly. It is however important that they do contact their GP about the reading within 7 to 10 days. In the meantime, we will have informed the GP of their result (providing the informant has given their permission).

3.9 Action to be taken by the nurse after the visit

If you need to contact the Survey Doctor, do not do this from the informant's home - you will cause unnecessary distress.

Pulse - for all informants the survey doctor routinely checks fast and slow pulse rates so no further action is necessary.

a) Children
No further action is required after taking blood pressure readings on children. All high readings are viewed routinely by the Survey Doctor. However, in the rare event that you encounter a child with a very high blood pressure, i.e. systolic 160 or above or diastolic 100 or above please call the Survey Doctor.

b) Adults
The chart on the next page summarises what action you should take as a result of the knowledge you have gained from taking an adult's blood pressure readings. For this purpose you should only take into account the last two of the three readings you take. We do not want you to use the first reading as it is prone to error for the reason stated above.

Blood pressure	Action
Normal/mild/moderate bp	No further action necessary
Systolic < 180 mmHg and Diastolic < 115 mmHg	If you feel that the circumstances demand further action, inform the Survey Doctor who will then inform the informant's GP immediately if she deems it necessary.b
Considerably raised bp	Contact the Survey Doctor at the earliest opportunity and she will inform the informant's GP.b
Systolic > 180 mmHg and Diastolic > 115 mmHg	If the informant has any symptoms of a hypertensive crisisa contact the survey doctor immediately or call an ambulance. The Survey Doctor must be informed as soon as possible. If the informant has any symptoms of a hypertensive crisisb contact the survey doctor immediately or call an ambulance. The Survey Doctor must be informed as soon as possible.

NB. < less than; > greater than or equal to.

^a A hypertensive crisis is an extremely rare complication of high blood pressure. Its signs and symptoms include diastolic bp > 135 mmHg, headache, confusion, sleepiness, stupor, visual loss, seizures, coma, cardiac failure, oliguria, nausea & vomiting.

^b You must still contact the Survey Doctor even if informants tell you that their GP knows about their raised BP.

All high or unusual readings will be looked at by the Survey Doctor when they reach the office. If the reading is high, then the Survey Doctor will contact the informant GP. If the informant is not registered with a GP, or has refused consent for us to contact their GP, the informant will be contacted directly.

Measurement of waist and hip circumferences

4.1 Purpose

There has been increasing interest in the distribution of body fat as an important indicator of increased risk of cardiovascular disease. The waist-to-hip ratio is a measure of distribution of body fat (both subcutaneous and intra-abdominal). Analyses suggest that this ratio is a predictor of health risk like the body mass index (weight relative to height).

4.2 Equipment

Insertion tape calibrated in mm, with a metal buckle at one end.

The tape is passed around the circumference and the end of the tape is inserted through the metal buckle at the other end of the tape.

4.3 Eligibility

Waist and hip measurements will only be carried out on informants aged 16 and over.

The informant is ineligible for the waist and hip measurement if:

a) Chairbound.

b) Has a colostomy/ileostomy.

If (a) and/or (b) apply, record this on the computer (question WHPNABM). If there are any other reasons why the measurement was not taken, record this on the computer and type in the reason.

4.4 Preparing the informant

The interviewer will have asked the informant to wear light clothing for your visit. Explain to the informant the importance of this measurement and that clothing can substantially affect the reading.

If possible, without embarrassing you or the informant, ensure that the following items of clothing are removed:

• All outer layers of clothing, such as jackets, heavy or baggy jumpers, cardigans and waistcoats.

• Shoes with heels.

• Tight garments intended to alter the shape of the body, such as corsets, lycra body suits and support tights.

Pockets should be emptied.

If the informant is not willing to remove bulky outer garments or tight garments and you are of the opinion that this will significantly affect the measurement, record this on the Schedule at questions WJRel and/or HJRel.

If possible, ask the informant to empty their bladder before taking the measurement. If the person is in over 16 and in a sample II household they will be eligible to provide a urine sample - this may be collected earlier in the interview if the person needs to empty their bladder.

4.5 Using the insertion tape

All measurements should be taken to the nearest millimetre. If the length lies half-way between two millimetres, then round to the nearest even millimetre. For example, if the measurement is halfway between 68.3 and 68.4, round up to 68.4. And if the measurement is halfway between 68.8 and 68.9, round down to 68.8. Please note that you must enter the measurement to one decimal place - do not round it to the nearest centimetre. For example, enter '78.2', not just '78'. If you do not enter a decimal point, the computer will give you a warning. If the measurement is exactly, say, 78cm, then all you need to do is suppress the warning and it will automatically fill in the '.0' for you. Otherwise, you must go back and amend your answer. As a further check, the computer will also ask you to confirm that a measurement ending in '.0' is correct.

Ensure the informant is standing erect in a relaxed manner and breathing normally. Weight should be evenly balanced on both feet and the feet should be about 25-30cm (1 foot) apart. The arms should be hanging loosely at their sides.

If possible, kneel or sit on a chair to the side of the informant.

Pass the tape around the body of the informant and insert the plain end of the tape through the metal ring at the other end of the tape.

To check the tape is horizontal you have to position the tape on the right flank and peer round the informant's back from his/her left flank to check that it is level. This will be easier if you are kneeling or sitting on a chair to the side of the informant.

Hold the buckle flat against the body and flatten the end of the tape to read the measurement from the outer edge of the buckle. Do not pull the tape towards you, as this will lift away from the informant's body, affecting the measurement.

4.6 Measuring waist circumference

1. The waist is defined as the point midway between the iliac crest and the costal margin (lower rib). To locate the levels of the costal margin and the iliac crest use the fingers of the right hand held straight and pointing in front of the participant to slide upward over the iliac crest. Men's waists tend to be above the top of their trousers whereas women's waists are often under the waistband of their trousers or skirts.

2. Do not try to avoid the effects of waistbands by measuring the circumference at a different position or by lifting or lowering clothing items. For example, if the informant has a waistband at the correct level of the waist (midway between the lower rib margin and the iliac crest) measure the waist circumference over the waistband.

3. Ensure the tape is horizontal. Ask the participant to breathe out gently and to look straight ahead (to prevent the informant from contracting their muscles or holding their breath). Take the measurement at the end of a normal expiration. Measure to the nearest millimetre and record this on the schedule.

4. Repeat this measurement again.

5. If you are of the opinion that clothing, posture or any other factor is significantly affecting the waist measurement, record this on the schedule.

4.7 Measuring hip circumference

1. The hip circumference is defined as being the widest circumference over the buttocks and below the iliac crest. To obtain an accurate measurement you should measure the circumference at several positions and record the widest circumference.

2. Check the tape is horizontal and the informant is not contracting the gluteal muscles. Pull the tape, allowing it to maintain its position but not to cause indentation. Record the measurement on the schedule to the nearest millimetre, e.g. 95.3.

3. If clothing is significantly affecting the measurement, record this on the schedule.

4. Repeat this measurement again.

4.8 General points

The tape should be tight enough so that it doesn't slip but not tight enough to indent clothing. If clothing is baggy, it should be folded before the measure is taken.

If the informant is large, ask him/her to pass the tape around rather than having to 'hug' them. Remember though to check that the tape is correctly placed for the measurement being taken and that the tape is horizontal all the way around.

If your second waist or hip measurement differs by 3cm or more from the first, the computer will give you a warning. If you have made a mistake when entering the figures (e.g. typed 78.2 instead of 68.2), you should type over the mistake. If it was not a mistake, you should suppress the warning and take a third measurement.

If you have problems palpating the rib, ask the informant to breathe in very deeply. Locate the rib and as the informant breathes out, follow the rib as it moves down with your finger. If your informant has a bow at the back of her skirt, this should be untied as it may add a substantial amount to the waist circumference.

Female informants wearing jeans may present a problem if the waistband of the jeans is on the waist at the back but dips down at the front. It is essential that the waist measurement is taken midway between the iliac crest and the lower rib and that the tape is horizontal. Therefore in this circumstance the waist measurement would be taken on the waist band at the back and off the waist band at the front. Only if the waistband is over the waist all the way around can the measurement be taken on the waistband. If there are belt loops, the tape should be threaded through these so they don't add to the measurement.

4.9 Recording problems

We only want to record problems that will affect the measurement by more than would be expected when measuring over light clothing. As a rough guide only record a problem if you feel it affected the measurements by more than 0.5cm. We particularly want to know if waist and hip are affected differently.

5 Non fasting blood sample

5.1 Eligibility

All persons aged 16 and over, with the following exceptions, are eligible to give blood.

a) Pregnant women.

b) People with clotting or bleeding disorder (see note below).

c) People who have ever had a fit.

d) People who are not willing to give their consent in writing.

e) People who are currently on anticoagulant drugs, e.g. Warfarin therapy.

5.2 Purpose

A non-fasting blood sample will be collected from adults, aged 16 and over, who give consent for this. The blood will be analysed for total cholesterol, HDL cholesterol, glycated haemoglobin, fibrinogen and C-reactive protein.

Glycated haemoglobin is a measure of the informant's glycaemic status. High levels are indicative of diabetes.

Total cholesterol and fibrinogen are being measured because raised levels are associated with higher risks of heart attacks, while HDL cholesterol has a protective role.

The level of C-reactive protein in the blood gives information on inflammatory activity in the body, and it is also associated with risk of heart disease.

The blood will not be tested for any viruses, such as HIV (AIDS).

5.3 Equipment

Tourniquet	Vacutainer holder
Alcohol swabs	Vacutainer needles 21G (green)
Dental rolls	Vacutainer needles 22G (black)
Vinyl gloves	Butterfly needles 23G
Adhesive dressing	Needle disposal box
Plastic postal containers	Vacutainer plain red tubes
Padded envelopes	Vacutainer EDTA purple tubes
Sealable plastic bags	Vacutainer citrate blue tubes
Kitchen roll	Ametop gel
Micropore tape	Tegaderm dressings
Set of labels for blood sample tubes

5.4 The blood tubes

Three tubes need to be filled. They should be filled in the following order so that, if a situation arises where there will be insufficient blood to fill all the tubes, the analyses with the highest priority can still be undertaken.

1. Plain (red, large) tube.

2. EDTA (purple, small) tube.

3. Citrate (blue, small) tube.

5.5 Ametop gel

All informants aged 16 and 17 who consent to give a blood sample must be offered Ametop gel. Ametop gel may also be used with older informants who request it, but should not specifically be offered to older informants.

Informants who have had a reaction to any anaesthetic (local or general) are not eligible to have Ametop gel. This means that you may not take a blood sample from these informants, unless they consent to give a sample without using Ametop.

5.6 Procedure for taking blood sample

1. Pregnant women are not eligible to give a blood sample.

2. Ask the screening question to check whether the informant has a clotting or bleeding disorder, or is currently on anticoagulant therapy e.g. Warfarin.

3. Ask the screening question to find out whether the informant has ever had a fit.

Informants who have a clotting or bleeding disorder, or are currently on anticoagulant therapy, or who have ever had a fit, are NOT ELIGIBLE to give a blood sample.

4. Explain the purpose and procedures for taking blood.

In addition if the informant is aged 16 or 17:

• Explain that there is the option of using Ametop gel - but that a sample can be given
  without Ametop.
• Give parent/young person the information sheet about AMETOP GEL and allow them
  time to read it.
• Answer any questions about use of Ametop, advantages and disadvantages - side
  effects, time taken to work, etc.
.
• Explain that AMETOP GEL cannot be used if the young person has a known allergic
  reaction to any local or general anaesthetic.

5. Ask if informant is willing to give blood sample.

6. If yes and informant is aged 16-17
Ask if informant wishes Ametop gel to be used.

7. If informant is aged 16-17 and wishes Ametop gel to be used
Ask screening question to determine whether informant has ever had allergic reaction to anaesthetic. If they have had an allergic reaction, they are not eligible to use Ametop gel, so you cannot take a blood sample unless they are willing to give a sample without Ametop.

8. If informant wishes Ametop gel to be used
Decide with informant whether you will take blood sample now or arrange another time to return to take the sample. Remember you will need to allow 30 minutes for the Ametop gel to work before taking the blood sample.

NB. The concept of blood taking and use of AMETOP GEL must not be raised with the informant before the appropriate point in the CAPI schedule. Do not introduce blood taking before this, as this might risk affecting other measurements, e.g. blood pressure.

If blood sample will be taken NOW, follow 9. onwards. If you will be returning on a separate occasion, complete remainder of interview and arrange separate appointment to return to take blood sample.

9. WHEN YOU ARE SET TO COMMENCE BLOOD-TAKING PROCEDURE:
Obtain necessary written consents to give blood sample, notify GP of results, and storage of blood sample. Consent sheet BS(A) is for adults aged 18+ and BS(C) is for informants aged 16-17 years.

If informant is aged 16-17 you must make sure that you always obtain both the informant's own signature and the signature of their parent or the person who has parental responsibility. Remember that even if 16/17 year old informants are married and not living with their parent or person who has legal responsibility, you cannot take blood until you have their parent's consent. It is not sufficient to simply have one signature at items I-III on the BS (C) page of the Consent Booklet. You must make sure that you have all relevant signatures

There are tick boxes on the consent sheet BS(C) to indicate whether the informant/parent consented to give a blood sample with or without the use of Ametop gel. Please tick the appropriate box.

10. IF AMETOP GEL IS TO BE USED:
Apply Ametop gel following the instructions in Section 5.8.

11. Take blood sample following the instructions in Section 5.9.

5.7 General information about Ametop gel

Ametop gel is an effective local anaesthetic cream with minimal side-effects. Occasionally mild local skin reactions are experienced. You will need to explain the pros and cons of using AMETOP GEL to each informant and parent, in addition to giving them the written note to read. It is important that informants understand that you are not a doctor and cannot treat unexpected reactions.

Pros:

• Reduces sensation of needle prick
• l Easy to apply
• Generally safe

• Takes half an hour to work, and so may increase anxiety
• Risk of local reaction in people known to be allergic to similar drugs
• Other possible side effects:
  

itching

None of the local skin side-effects (if they occur) requires treatment. The whitening or reddening will disappear by itself over a period of hours. A local allergic reaction may involve itching, but is unlikely to required treatment.

AMETOP GEL contains an anaesthetic called amethocaine. It is important that you ask the question below (also within CAPI) to determine whether the informant has any known anaesthetic allergies.

Has the person giving this blood sample ever had a bad reaction to a local or general anaesthetic bought over the counter at a chemist, or given by a doctor, dentist or in hospital?

If the informant has ever had a bad reaction to an anaesthetic then Ametop gel MUST NOT be used. However the informant can still give a blood sample without AMETOP GEL if they are willing.

AMETOP GEL is a prescription medication, so it is very important that you account for all AMETOP GEL tubes used on the record sheet supplied. Any AMETOP GEL tubes you have left at the end of your assignment should be returned to the Brentwood office with the record sheet. For safety, AMETOP GEL must not be left lying around where young children could get at it.

5.8 Applying Ametop gel

Ametop gel must only be applied to healthy skin; therefore it must not be applied to sore or broken skin (e.g. eczema or cuts). Make sure the Ametop gel is kept away from eyes or ears.

If the young person requires AMETOP GEL to be applied prior to venepuncture, inspect the antecubital fossae and decide which arm you will use for blood-taking. If both arms are suitable, use the left arm.

Ametop gel must be applied to ONE arm only. This means that, if you encounter problems during blood-taking (e.g. collapsing vein), NO ATTEMPT can be made to take blood from the other arm.

Apply Ametop gel over the antecubital fossa. Cover with a Tegaderm dressing (a vapour permeable and self-sticking film dressing) to keep the AMETOP GEL in place. See details about how to apply AMETOP GEL below. Please note the illustration shows AMETOP GEL being used on the hand. National Centre policy is to only take blood samples from the arm.

As you may well be aware, removing the Tegaderm is sometimes painful so take care on hairy arms!

It is very important that the used tubes of AMETOP GEL should not be left lying around. Make sure you have removed them from the household on completion of the phlebotomy.

Use the AMETOP GEL record sheet to record the informant's serial number and the date Ametop gel was used. Return this sheet with any unused tubes of Ametop gel to the Brentwood office.

5.9 Preparing the informant

Ask the informant if they have had any problems having blood taken before.

1. Explain the procedure to the informant (and parent if informant aged under 18). The informant should be seated comfortably in a chair, or if they wish, lying down on a bed or sofa.

2.IF NO AMETOP GEL HAS BEEN USED:Ask the informant to roll up their left sleeve and rest their arm on a suitable surface. Ask them to remove their jacket or any thick clothing, if it is difficult to roll up their sleeve.

The antecubital fossae may then be inspected. It may be necessary to inspect both arms for a suitable choice to be made, and the informant may have to be repositioned accordingly.

IF AMETOP GEL HAS BEEN USED: Remove the Tegaderm dressing and wipe away excess Ametop gel.

3. Do not ask the informant to clench his/her fist.

Select a suitable vein and apply the tourniquet around the informant's arm. However, it is desirable to use the tourniquet applying minimal pressure and for the shortest duration of time. Do not leave the tourniquet in place for longer than 2 minutes.

Ask the informant to keep his/her arm as still as possible during the procedure.

4. Put on your gloves at this point.

Clean the venepuncture site gently with an alcohol swab. Allow the area to dry completely before the sample is drawn.

5.10 Taking the sample

Venepuncture is performed with a green twenty one gauge vacutainer needle or butterfly.

For children you have the option of using a black 22 gauge Vacutainer needle if it is more appropriate.

Grasp the informant's arm firmly at the elbow to control the natural tendency for the informant to pull the arm away when the skin is punctured. Place your thumb an inch or two below the vein and pull gently to make the skin a little taut. This will anchor the vein and make it more visible. Ensure the needle is bevelled upwards, enter the vein in a smooth continuous motion.

Remember to take the tubes in the correct order. The first tube should always be the large plain tube with the red cap followed by the EDTA tube and then (if informant aged 16 or older) the blue citrate tube. The vacutainers should be filled to capacity in turn and inverted gently on removal to ensure complete mixing of blood and preservative.

Release the tourniquet (if not already loosened) as the blood starts to be drawn into the tube. Remove the needle and place a dental roll firmly over the venepuncture site. Ask the informant to hold the pad firmly for three minutes to prevent haematoma formation.

If venepuncture is unsuccessful on the first attempt, make a second attempt on the other arm. If a second attempt is unsuccessful, DO NOT attempt to try again. Record the number of attempts on the Schedule.

Record which arm the sample was drawn from (or both).

Remove the needle from the vacutainer holder by inserting it into the slot at the top of the needle disposal box. Push it towards the narrow end of the slot until the hub fins are engaged. Twist the holder anti-clockwise to unthread the needle. Then slide the holder towards the centre of the slot, allowing the needle to drop into the container.

IMPORTANT WARNING

Never re-sheath the needle after use.

Do not allow the disposal box to become overfull as this can present

a potential hazard.

Check on the venepuncture site and affix an adhesive dressing, if the informant is not allergic to them. If they are allergic, use a dental roll secured with micropore.

5.11 Fainting informants

If a informant looks or feels faint during the procedure, it should be discontinued. The informant should be asked to place their head between their knees. They should subsequently be asked to lie down.

If they are happy for the test to be continued after a suitable length of time, it should be done so with the informant supine and the circumstances should be recorded. They may wish to discontinue the procedure at this point, but willing to give the blood sample at a later time.

5.12 Disposal of needles and other materials

Place the used needles, the used cotton wool balls and the vacutainer holders in the sharps box and put gloves etc in the self-seal disposal bag. The needle disposable box should be taken to your local hospital or GP practice for incineration. Telephone them beforehand, if you are not sure where to go.

If you have difficulties with finding a hospital or practice, contact your local pharmacist. If you come across any problems with the disposal, contact the Survey Doctor or Brentwood. The sealed bag can be disposed of with household waste as long as it does not have any items in it that are contaminated by blood.

5.13 Needle stick injuries

Any nurse who sustains such an injury should seek immediate advice from their GP. The nurse should inform his/her nurse supervisor of the incident, and the nurse supervisor should inform the survey doctor.

5.14 Informants who are HIV or Hepatitis B positive

If an informant volunteers that they are HIV or Hepatitis B positive, do not take a blood sample. Record this as the reason on the Schedule. You should never, of course, seek this information.

6 Fasting blood sample

6.1 Eligibility

In sample II households, all persons aged 35 and over, with the following exceptions, are eligible to give blood.

a) Pregnant women.

b) People with clotting or bleeding disorder (see note below).

c) People who have ever had a fit.

d) People who are not willing to give their consent in writing.

e) People who are currently on anticoagulant drugs, e.g. Warfarin therapy.

f) People who have eaten or drunk something (except water) in the last eight hours.

6.2 Purpose

The analytes on the fasting blood sample are LDL cholesterol, triglycerides and glucose.

LDL cholesterol and triglycerides, together with total and HDL cholesterol, provide a lipid profile which can give information on the risk of cardiovascular disease.

The glucose is being measured on the fasting blood sample as an indicator of diabetes, which is characterised by chronic hyperglycemia.

6.3 Equipment

Blood sample equipment as in Section 5.3 plus Vacutainer plain red tubes and Vacutainer grey fluoride tubes.

Two tubes should be filled for eligible adults. They should be filled in the following order so that if a situation arises where there will insufficient blood to fill all the tubes, the analyses with the highest priority can still be undertaken.

1. Plain (red, large) tube.
2. Fluoride (grey, small) tube.

If the fasting blood sample is to be taken at the same time as a non fasting sample, then priority should be given to filling the non fasting blood tubes.

6.4 Procedure for taking the sample

1. First check with informant that they have not eaten or drunk anything (except water) in the last eight hours. Avoid using the terms 'fasted' or 'fasting' as this may mean different things to different people. Informants who have taken medication in the last 8 hours are eligible to give a fasting blood sample and you do not need to make a note. Insulin-dependent diabetic informants who had to eat in the last 8 hours before their insulin injection are eligible to give a fasting blood sample but you should make a note in CAPI.

2. Ask the informant if they are willing to give a fasting blood sample.

3. If the informant is eligible and willing to give the sample, complete the consent form BS(F) obtaining the relevant signatures to take the blood sample and send the results to the informant's GP. N.B. The fasting blood samples will not be stored, so consent for storage is not necessary.

4. Follow the procedure for preparing the informant and taking the sample as in sections 5.9 and 5.10.

7 Sending blood, saliva and urine samples to the laboratory

The samples are sent to the Royal Victoria Infirmary Laboratory in Newcastle-upon-Tyne. It is important that all samples are sent properly labelled and safely packaged and that they are despatched immediately after it has been taken.

7.1 Labelling the Blood Tubes

Label the tubes as you take the blood. It is vital that you do not confuse blood tubes within a household.

Use the set of serial number and date of birth labels (blue) to label the vacutainer tubes. Attach a serial number label to every tube that you send to the lab. Enter the serial number and date of birth very clearly on each label. Make sure you use blue biro - it will not run if it gets damp. Check the Date of Birth with the informant again verbally.

Stick blue label over the label already on the tube. The laboratory needs to be able to see on receipt how much blood there is in the tube.

We cannot stress too much the importance of ensuring that you label each tube with the correct serial number for the person from whom the blood was obtained. Apart from the risk of matching up the blood analyses to the wrong person's data, we will be sending the GP the wrong results. Imagine if we detect an abnormality and you have attached the wrong label to the tube!

7.2 Packaging the blood samples

Pack the tubes for each informant separately from those of other members of the household. All tubes from one person should be packed together in one despatch container. You have been provided with two different types of despatch containers, a small one and a large one. Depending on the total number of samples each informant provides, you will need to use the appropriate packaging:

As a rough guide, adults in sample I households will generally need a small despatch container, whilst those in sample II households will need a large despatch container. Adult informants in sample I households will provide a maximum of three blood tubes, whilst those in sample II households may provide urine and saliva samples in addition to any blood samples. The capacity of the small despatch containers is 4 sample tubes provided that there is no urine sample (3 blood plus one saliva). For 3 blood tubes plus a urine tube, you will need the large despatchers. For more that 4 sample tubes, you will also need to use the large despatchers

Adults aged 35 and over in sample II households may also provide fasting blood samples. These should be sent in a separate despatch container to the non fasting samples. The following procedures are designed to minimise accidental damage and, should there be any damage, any blood spillage.

7.3 The packaging comprises

Small Packaging

• Absorbent insert.

• Plastic container.

• 2:03 PM 1/28/2005Cardboard mailing box with foam.

Using the small packaging

1. Insert the blood sample tubes in the pockets of the absorbent insert.

2. Roll the insert with the folded despatch note¹.

3. Place the rolled insert in the plastic container and close.

4. Push the plastic container into the foam and put in the cardboard box.

¹If you find it difficult to insert the despatch note in the plastic tube, fold it and put in the cardboard box.

Please note:

• Use a separate package for each informant.
• Do not seal the mailing box with tape.

Large packaging

• Sealable bubble wrap pouch.
• Plastic container.
• Cardboard mailing box.
• A moisture absorbent sachet (stays at the bottom of the plastic container).

Using the large packaging:

1. Insert the sample tubes in the bubble wrap pouch.

2. Remove the red tape and seal the bubble wrap pouch

3. Roll the insert with the folded despatch note¹.

4. Place the rolled insert in the plastic container and close.

5. Put the large plastic container in the cardboard box.

¹If you find it difficult to insert the despatch note in the plastic tube, fold it and put in the cardboard box.

Remember to check that the serial number and dates of birth correspond on the despatch notes and blood tubes.

7.4 Posting the blood samples

The size of the packaging means you will not be able to post blood samples in a letter box. The samples will have to be taken to the post office for posting.

The samples should be posted within 24 hours of the sample been taken. Try to avoid taking samples if you think that you will be unable to post it within 24 hours.

Weekend posting

If you miss the Saturday post collection, the sample must be posted on the following Monday morning.

Storage of blood samples

If you are unable to post the samples immediately, they can be stored at room temperature.

When you have posted the samples, fill in the time and date of posting on the office copy of the Despatch Notes.

7.5 Completing the Blood Despatch Notes

The Consent Booklet contains two Despatch Notes. DESPATCH 1 is for the non fasting blood sample, saliva and urine samples DESPATCH 2 is for the fasting blood sample only. These should be filled in and sent to the laboratory with the blood samples.

• Enter the informant's serial number very carefully. This should both correspond to your entry on page 1 of the Consent Booklet and to the serial numbers you have recorded on the tubes.
• Complete items 2, 3 and 4. Check that the date of birth is correct and consistent with entry on nurse schedule and tube label. Do not forget to code which age group category the informant belongs to.
• l Complete item 5.

On DESPATCH 1:

• At Item 6 ring a code to tell the laboratory whether or not permission has been obtained to store part of the blood. Your entry here should correspond to your entry at Item 9e on the front page of the booklet.
• At Item 7 enter your Nurse Number.

On DESPATCH 2:

• At Item 6 enter your Nurse Number.

Tear off the appropriate despatch note and send with the samples to the laboratory.

On the last page of the consent booklet complete the Office DESPATCH 3 for the non fasting blood samples, saliva and urine samples and Office DESPATCH 4 for the fasting blood samples. This tells us the date you sent the samples to the lab and indicates what we should expect back from the laboratory.

If you have only achieved an incomplete blood sample (e.g. have only filled one tube), please state this clearly on both copies of the despatch note and give the reason.

8 Saliva sample collection

We wish to obtain a measure of exposure to passive smoking. This can be detected by measuring the level of cotinine in saliva. Cotinine is a derivative of nicotine and shows recent exposure to tobacco smoke, either because the individual is a smoker or because they have been exposed to other people's tobacco smoke. Note that informants' cotinine analysis results will not be sent to them or their GP.

8.1 Eligibility

A saliva sample should be obtained from all informants aged 4 to 15 in sample I and those aged 4 and over in sample II.

8.2 Equipment

For all informants:
Plain 5 ml tube
Short wide bore straw.
Kitchen paper

Alternative equipment for adults (aged 16+):
Plain 5 ml tube
Dental roll
Kitchen paper

The straw makes it easier for people to direct their saliva sample into the tube. Its use will also minimise the amount of other items that are included in saliva, such as crumbs, which might enter the tube.

If adult or child informants prefer to dribble directly into the tube, then this method should be used.

The dental roll is available as an alternative procedure for adults, should they prefer this.

8.3 Procedure

The aim is to get as much saliva as possible into the tube.

The protocol:

1. Remove the cap from the plain tube.

2. Give the straw to the informant. Explain that you want him/her to gather up their saliva (spit) in their mouth and then let it dribble through the straw into the tube. Make sure that you are not getting sputum, i.e. that the informant is not clearing their chest for the spit.

3. Allow the informant about three minutes to do this. Collect as much as you can in this time. The saliva will be frothy, so it is easy to think you have collected more than you actually have, so do not give up too soon.

4. If informants find it difficult to use the straw they may dribble into the tube directly. This is acceptable, but encourage them to use the straw where possible.

5. If the informant's mouth is excessively dry and they can not produce saliva allow them to have a drink of plain water. Wait for a few minutes to ensure that no water is retained when they provide the saliva sample.

6. Record on the computer that you have taken the sample along with any problems you may have encountered.

NB. If an adult informant has a problem with dribbling into the tube then you can follow the protocol for using the dental roll (see below).

Using the dental roll:

The procedure is very simple, but it is crucial to make sure that an adequate amount of saliva is collected.

1. Instruct the informant to take the dental roll from the tube, insert it in his/her mouth and leave it there until soaked. The aim is to get the dental roll saturated with saliva.

2. Moving the dental roll about the mouth, without chewing, helps to ensure thorough wetting. For most people, 3 minutes will be ample to ensure thorough wetting.

3. If the informant complains of a dry mouth, and you think you will have difficulties in filling the roll, you can ask them to drink some water before starting the procedure. Wait for a few minutes to ensure that no water is retained when they provide the saliva sample.

4. When the informant has finished, ask her/him to remove the dental roll from her/his mouth and place it in the plain tube.

5. Check that the roll is well soaked. The tube should feel noticeably heavier than an unused one. If the dental roll rattles around in the tube like a pea, it is not sufficiently wet, and you should ask the informant to put it back in her/his mouth for a further period.

6. Record on the computer that you have taken the sample, and mention any problems you might have encountered.

8.4 Packaging the saliva sample

1. Make sure that the lid of the salivary tube is secure.

2. Label the tube (using the blue labels provided for blood samples). Enter the informant's serial number and date of birth on the label.

3. Insert the tube in the packaging, either together with that informant's blood container and urine sample (if obtained), or on its own. The choice of the appropriate size of packaging will depend on the total number of samples obtained by each informant as explained in Section 7.2 (three or less samples go in a small despatcher, more than 3 samples go in a large despatcher).

Continue to pack as instructed in Section 7.2 'Packaging the blood samples'.

'Saliva-only' households: If no blood and urine samples are obtained, all saliva samples from the same household can go in the same despatch container. In this case all relevant despatch notes should be put into the box. NB this only applies to informants for whom a blood or urine sample was not collected!

9 Spot urine sample collection protocol

9.1 Introduction

Dietary sodium (salt) consumption has been shown to relate to high blood pressure and cardiovascular disease. Sodium consumption can be assessed by measuring its levels in urine.

9.2 Eligibility

In sample II households, all informants aged 16 years and over will be eligible. Women who have their periods are still eligible to give a urine sample. Those in sample I households are not eligible.

9.3 Feedback to informants

We will not be sending the results of individual urine tests to informants or their GPs. If asked, use the information below to explain to informants why this is the case.

The level of salt in an individual's urine is heavily influenced by their dietary salt intake during that day. If we were able to measure an individual's salt levels over a three or four day period and take an average from all the measurements, we would obtain an accurate estimate of their salt levels. However, if for example an individual has had a Chinese take away on the day we take our sample, his/her levels will be higher than normal on that occasion and the individual measurement (spot sample) will not be an accurate reflection of the individual's salt levels.

The spot sample is therefore an inadequate indicator of dietary sodium on an individual basis, and individual results will not be useful or meaningful to individuals or their GPs. However, at a population level the peaks and troughs will even out, providing us with useful information for analysis.

9.4 Equipment

• A 100ml Polypropylene disposable beaker for urine collection.
• A 10ml Sarstedt urine collection syringe containing a small amount of a preservative.
• An instructions card on how to use and fill the Sarstedt syringe.
• Labels.

9.5 Procedure

Nurses will explain the procedure to informants and show them how to fill the Sarstedt syringe from the urine collection beaker. A demonstration set that consists of a syringe and a beaker which can be filled with water can be used for this purpose. The instruction card (page 185) can be left with the informant for easy reference while performing the urine collection in private, if required.

Informants will be asked to wash their hands with soap and water prior to voiding. The syringe should be filled immediately following voiding. The idea is to minimise specimen exposure to air. It is important that the inside of the urine collection container is not touched or allowed to come into contact with any part of the informant's body or clothing or any external surfaces.

Please ask informants to collect a mid-flow sample of their urine. The urine will be passed in the disposable collection beaker. The syringe has a removable extension tube for withdrawing the urine from the beaker. After the syringe has been filled, the extension tube is removed, the end of syringe sealed with a plastic cap, and the syringe plunger stalk snapped. The instruction card shows the steps for the urine sample collection. Ask the informants to wash the outside of the filled and sealed syringe and dry it using toilet roll when the sample collection is complete.

If the informant is unable to fill the syringe themselves, or would rather not do so, you can offer to do this for them. Ask the informant to give you the urine collection container immediately after voiding, and fill the syringe yourself.

9.6 Packaging, labelling and despatching the urine sample

1. Make sure that the plastic cap is securely sealed, and the syringe plunger stalk snapped.

2. Label the urine sample tube (using the blue labels provided for blood samples). Enter the informant's serial number and date of birth on the label.

3. Insert the tube in the despatch container, either together with that informant's blood container and/or saliva sample (if obtained), or on its own. The choice of the appropriate size of packaging will depend on the total number of samples obtained by each informant as explained in Section 7.2 (three or less samples go in a small despatcher, more than 3 samples go in a large despatcher).

Continue to pack as instructed in Section 7.2 'Packaging the blood samples'.

'Urine-only' households: If no blood and saliva samples are obtained, all urine samples from the same household can go in the same package. In this case all relevant despatch notes should be put into the box. NB this only applies to informants for whom a blood or saliva sample was not collected!

Urine sample syringe instructions

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