Results from this study are presented in following sections, reflecting the mixed methodology used.
Quantitative data from questionnaires
Figure 1 shows that 95% of the fieldwork team members who took part in the survey were happy that they had participated in INSEF, with 83% reporting being very happy to have participated. None reported being very unhappy that they participated.
Figure 2 shows that both the survey participants and their organizations learned by taking part in the survey. The majority felt that both they personally and their organisations had learned a lot, and no participants reported that they/their organisations didn’t learn anything.
Figure 3 shows that 55% of the survey respondents would absolutely participate in another round of INSEF if given the chance, and 29 % would probably participate, while only 12% were unsure. No respondents stated that they would absolutely not participate in another round of INSEF.
Figure 4 shows the following distribution regarding whether it was easy or hard to get their organisation to cooperate regarding INSEF: 11.9% very hard, 14.3% hard, 28.6% neither hard nor easy, 19.0% easy, and 26.2% very easy.
In addition to the questions illustrated by Figures 1 – 4 above, there was also a multiple choice-question (up to 3 possible answers) about the local teams’ the most difficult issues with running INSEF. The replies chosen by most survey respondents were Getting personnel (50%) and Getting time to do it (45%). The other response alternatives, Getting local permission, Getting local funding, Cooperating with health centres, Practical problems regarding examination and Cooperating with labs were selected by between 7% and 20% of the survey respondents. No survey respondents selected Cooperating with INSA or Training personnel.
Finally, 83% of the survey respondents thought it would be useful to have another INSEF in a few years, while 17% thought it would be somewhat useful. None of the respondents replied that it would not be useful.
Qualitative data from the questionnaires
One of the main goals of INSEF was achieving a high participation rate to ensure representative results describing the Portuguese population .
Table 1, below, consists of a list of codes chosen during the thematic analysis  as issues or problems that made it hard to achieve both a sufficient number of participants for INSEF and to do the day-to-day work of getting the measurements, samples and filled-in questionnaires from each participant. The section below the table explains what the codes mean. These codes describe issues that were recurrent in the interviews, the free text from the questionnaires and indeed, all the documentation that was consulted while writing this article. The codes have been sorted into overarching themes. In Figure 4, the codes are sorted using Thematic Analysis. The diagram shows how the codes are connected to the overarching themes. See also the code list, Additional file 5.
Table 1: Issues that made it harder to perform the INSEF survey
Problems with leaders
Internal organisation issues (bureaucracy)
Problems with health centres
Human resources and financial issues
Recruitment of professionals
Internal organisation issues (bureaucracy)
(Local) database not updated
Problems with health centres
Explanation of the codes
- Problems with leaders (and their (missing) involvement)
Many informants expressed the opinion that they achieved what they did in spite of, not because of, their bosses. This was particularly common among nurses who were employed by the regions. “Managers uninterested in project” and “bureaucracy among high-placed managers” were replies to informant survey question about what made it hard to get their organisation to cooperate.
- Internal organisational issues (bureaucracy)Among the reported issues was changing decision-makers locally during the project period, as well as a lack of knowledge about the survey in higher managers and late payment to nurses and technicians.
- Problems with health centres
Not all health centres collaborated seamlessly with the local teams, and there were complaints about locked doors, receptionists who sent participants home claiming there was no health examination survey taking place, and surly security guards.
- Recruitment of professionals
It was difficult to get enough nurses and technicians to conduct the study among regular health centre staff, and some newly educated nurses were recruited just for the survey. All these professionals had to be available on fairly short notice to travel from health centre to health centre within their regions. In some locations, employees had to perform the survey in addition to their normal tasks.
- Financial issues
Taking part in the project required allotment of scarce resources locally, and middle management, who were given the responsibility to carry out the survey, did not always get the extra resources needed to do so, including overtime payment for the nurses
- Internal organisation issues (bureaucracy).
Negative internal collaboration within team performing the fieldwork.
- Transportation (teams)
Getting the teams to their temporary working places to perform the survey activities. This was a special problem on the Azores, where some of the local teams members had to travel from island to island to do their jobs, but many teams on the mainland also reported that they had problems getting to the health centres.
- Contact worksheets
The (paper) data collection instruments for recruitment, listing names and contact data for the people selected to take part in the survey and questions about outcome of contact attempts and eligibility were made by the central INSA team, and some local technicians found them difficult to fill out.
- Sampling frame not updated
This refers to the database of health centre users which was used to sample and contact INSEF participants, which was not completely up to date with contact details for all selected individuals.
- Computer problems
All the local teams were provided with laptops by INSEF, but some teams had little experience using these tools. RedCap Electronic Data Capture Software , which was used by the survey teams, required an internet connection for functioning, and in some locations, the internet connection was not good enough.
- Laboratory problems
The blood samples were processed at local laboratories by the local teams, and there were problems getting time and space in the laboratories as well as trained lab technicians to process the blood samples.
- Geographic accessibility (survey participants and blood samples)
It was at times problematic to get the participants from their homes to the health centres for examinations in areas with little public transport.
In the survey, blood had to be kept in refrigerators or in special transport boxes and transported to laboratory hubs within a short time period to be processed.
- Problems with health centres
Some health centre facilities did not have enough space for the local teams to do their jobs without disturbing the usual health centre activities, and there were health centres where the local teams were met with a lack of understanding or even hostility.
- Recruitment of participants
This is a major challenge for all health examination surveys [4, 17, 23, 37]. Statements and references from the local teams about techniques and strategies they employed to recruit participants are included here.
- Physical facilities
The examinations were carried out in rooms that belonged to local health centres, and not all these rooms were suited for the purpose. There were reports of lacking handwashing facilities, uncomfortable temperatures for the study participants and no place for the participants to sit while their blood was collected.
- Transportation of participants
As one can see from Figure 4, many issues that were considered problems in reaching the goal of INSEF were identified. There are fewer items on the list of issues that were identified as positive for recruitment and performance of the INSEF survey, because so many of the fieldwork team members who filled in the questionnaires and took part in the focus group and the interviews pointed to the same things.
Issues that made it easier to perform the INSEF survey, identified by several members from the local survey teams:
The central team from INSA invited the local teams to regional centres for training in how to recruit participants, perform the measurements, take blood samples and fill in the online CATI questionnaires, and then role-played the whole scenario.
- The protocol
Several fieldwork team members, and some members of the central INSA team, called the study protocol, based on the EHES manual  “the cookbook”, which emphasizes that the protocol was thought to be a clear description of exactly what was supposed to happen at each step of the health examination survey.
- Internal collaboration within team
During the interviews, particularly the youngest fieldwork team members talked about how nice it was to work in a team of colleagues and about how much they had learned from working in this way. One elderly team member had such a good time that this nurse would like to come out of retirement, if necessary, to participate in any future INSEF.
- Positive communication with INSA (the central team)
Both direct communication, in groups or one-to-one, and indirect communication, such as the newsletters and Field barometers were seen in a very positive light.
- Informal strategies to solve problems
How the local teams felt empowered and proud of their ingenious ways of solving any problems that occurred, while remaining faithful to the protocol.
Focusing on the last two points, the following subsection of the results details the analysis, with particular focus on the local teams’ informal strategies to solve problems found in the free text answers from the questionnaire respondents – grouped according to these issues.
Positive communication with INSA (the central team)
The free text replies from the workers on the local teams were all positive, as seen from the following examples. The number of replies praising the work of the central INSA team was, in fact, quite overwhelming.
E1: ‘Yes, they (INSA) were spectacular in trying to solve problems and doubts that the field teams had, as well being ready to support and assist any difficulties that they experienced.’
E2: ‘The INSEF team at INSA was tireless and always available. I think it would be (good) to keep the training model and also the presence of INSA team on the first day of the project at each site. The previous visit of INSA staff to health facilities is also essential, in the project dissemination perspective and to see the facilities, in order to verify their suitability.’
E3: ‘The role (INSA played as) as facilitator during this INSEF was very good. They should do in same way in the future.’
E4: ‘…we had the INSA Team who helped us with the head of the institution.’
The good work of the INSA team was also mentioned in the focus group transcript, but since two INSA representatives led the group, this was not surprising. There were no negative statements about the INSA team – see also the Quantitative results, where there were no respondents who thought it was difficult to collaborate with INSA. In the informal interviews, as well as in the focus group transcripts, there was also a lot of praise for the manual (called “the cookbook” by several respondents), which was very thorough and had solutions for many kind of foreseen problems.
Informal strategies to solve problems – direct quotations from the questionnaires
E5: ‘When users were illiterate (could not read) I tried to simplify/explain the best possible response options. Invested more time in these situations.’
E6: ‘The flow chamber* was not always available, which forced us to use it only when it was available and much time was needed for working outside ordinary working hours and / or working late. (*refers to lab equipment for aliquoting blood samples)’
E7: ‘The failure of the computer system of our service. It was resolved with the completion of all manual samples and delivery of results on paper.’
E8: ‘Health centres do not have a specific room for this service (reception room to receive samples), so we improvised a blood collection room.’
E9: ‘We performed the initial training without authorization from the leaders, which was only given later.’ (refers to top-level managers, not direct superiors)
E10: ‘Difficulty of access (to health centre), but we carried the person*’
(*the local team physically carried the respondent up the stairs to the examination room at the health centre)
E11: ‘Transportation difficulties in moving staff and blood samples. We used the private car of a member of staff.’
E12: ‘Sometimes there was a lack of communication and we solved that with a meeting.’
E13: ‘We did not have appropriate rooms, but with the cooperation of all, we decided the best way and it went very well.’
Other informal strategies that were mentioned in the interviews were using private cars to transport survey participants (E14) and phoning participants at weekends and in the evening (K), both invitations and reminders were conveyed in this manner. Several examination sites decided to expand opening hours to reach working people (E15). In a case where there was no suitable chair for taking blood samples, one nurse obtained the key to a physician’s office currently not in use and borrowed a chair (E16). One site found they needed to overbook to get enough participants to attend, and started serving coffee and tea when the waiting room was full to placate survey participants who were waiting to answer the questionnaire after the physical measurements had been taken (E17).
These and other informal strategies were employed by the local teams to solve the problems that were not foreseen by the central INSA team, and therefore were not featured in “the cookbook”. Several of the informal interviews had this as a central topic, and the first author became interested in the culture that allowed such “outside the box” thinking and problem solving , even by young employees such as the newly graduated nurses who constituted a large number of elements of the local teams.
Figure 6 (below) diagrammatically demonstrates some of the problems and the informal solutions that members of the local teams reported. The problems are shown in the orange boxes, while the blue boxes describe some of the methods that were used to fulfil the goals of the INSEF survey.
Local teams were highly motivated to take part in the INSEF survey, this is demonstrated by both the quantitative and the qualitative material. According to the interviews, they felt empowered by being given large responsibilities and worked hard to incite the invited people to attend the examination, including telephoning them outside work hours and using private cars to get people with reduced mobility or transport problems to the examination sites. One of the authors also reported that many local team members liked having a certificate of training, signed by high-level officials at INSA, to put in their CVs.
Both the local teams and their superiors believed that the manual, described informally at project meetings and interviews as a "cookbook for making a health examination survey", made it possible to maintain high scientific standards while at the same time improvising local problem solving, which was suitable in the local context. The quality of the manual, supported by a series of training workshops, where the local teams met people from the INSA research and support team and role-played different scenarios, gave the teams the confidence and knowledge to implement local solutions.
After the training sessions in each region a pilot day, observed by the trainers, was organised, followed by a meeting to evaluate the experience and identify difficulties, doubts, suggestions, etc. For each region, a short report was written, listing issues for improvement. These regional reports, mostly available as PowerPoint files, further demonstrate the ingenuity and inventiveness of the local teams. These reports show how motivated the local teams were to participate in the survey.
Local teams praised their INSA contacts, and said they were inspired to try harder to reach participants to please their contacts for interpersonal reasons. This is also supported by the questionnaire results, where there weren’t any respondents who reported that Cooperating with INSA or Training personnel had been among the three most difficult things about participating in INSEF.
These results can be explained by the close and demanding approach that was chosen throughout the entire process of implementing INSEF, a continuous improvement process. This is also documented by Kislaya et al. [2, 39].