QUINTE LONGITUDINAL STUDY : PURPOSE, PRINCIPLES AND METHODOLOGICAL LESSONS LEARNED Dr. Rob Williams Professor, Faculty of Health Sciences & Coordinator, Alberta Gaming Research Institute University of Lethbridge Lethbridge, Alberta, Canada

Acknowledgements Robert Hann (Principal Investigator) Patricia McLaughlin (Project Manager) Bev West (Research Analyst) Nick White (Research Assistant) Kate King (Research Assistant) Don Schopflocher (Co-Investigator) Rob Wood (Co-Investigator) Earl Grinols (Consultant) Trevor Flexhaug (Technical Support) Funder: Ontario Problem Gambling Research Centre

Purpose and Value of Longitudinal Research To establish an etiological model to aid in prevention and treatment (risk, protective, and recovery factors)  retrospective reports are unreliable  cross-sectional correlates of problem gambling (PG) tells you nothing about their chronology and causal sequence To establish incidence of PG To establish stability of PG To establish predictive validity of PG instruments

Prior Longitudinal Studies Have been many (see el-Guebaly et al., 2008 & Slutske, 2007 for a review) Furthermore, they have provided interesting and useful findings However, they all have limitations either because they have:  An insufficient number of variables  Small sample sizes and/or insufficient numbers of ‘at risk’ gamblers  Too circumscribed an age range (e.g., just adolescents)  A short time span (e.g., just a few years)  A limited number of collection periods (e.g, 2 or 3)  Poor retention rates

Alberta Longitudinal Study Leisure, Lifestyle, Lifecycle Project (LLLP) el-Guebaly, Hodgins, Smith, Williams, Schopflocher, Wood, Casey $2.3 million; funded by Alberta Gaming Research Institute Feb 2006 – April Albertans (524 ‘at risk’) 5 initial age ranges: 13-15; 18-20; 23-25; 43-45; comprehensive assessments (2 – 4 hrs each; primarily self- administered) with 20 month intervals between the start of each assessment 73.1% retention rate after 3 assessments

Quinte Longitudinal Study Also known as the QERI or Belleville Study Quinte Region in southeastern Ontario Williams, Hann, Schopflocher, Wood, Grinols $3.1 million; funded by Ontario Problem Gambling Research Centre March 2006 – April ? 4123 residents from southeastern Ontario (1216 ‘at risk’) Initial age range: 17 – comprehensive assessments (1.5 – 2.5 hrs each; all self- administered) with 12 months between start of each assessment 94.0% retention rate after 4 assessments

Principles of Longitudinal Studies and Methodological Lessons Learned

Oversample High Risk Groups Need enough people who will become Problem Gamblers (PGs) during the course of the study  Several hundred if wish to study/understand PG subgroups This problem is compounded with declining PG rates and lower retention of PGs Oversampling Options  Gambling behaviour (frequency, expenditure, or type)  Demographics (male, young, lower socioeconomic)  Other (family PG hx, smoker, impulsivity)

Extend the Study for as Long as Possible While some people become PGs within a few years of gambling onset, others report that it took many years A study of 5 years duration will only reliably identify the etiology for the subset of people who become PGs within a 4 year time period

Try to Conduct the Assessment at the Same Time of Year Each Time Increases retention Reduces seasonal artifact  Gambling behaviour is somewhat seasonal, peaking in the summer. Even though people are being asked about ‘past year’ behaviour, their current behaviour tends to distort their past year retrospective reports Best to avoid summer and Xmas holidays

Have a Small Assessment Window A long assessment period where people are assessed anytime within a several month period results in:  widely different inter-assessment intervals between people and within the same person (unless people do their assessment at the exact same time each period)  individuals being assessed at different times of year (seasonal artifact)  greater likelihood that an important change in gambling availability will be ‘spanned’ by the cohort

A Fixed Inter-Assessment Interval is Best (1 year being optimal) Ensures people are assessed the same time each year 1 year interval capitalizes on the fact that a 12 month time frame is used in most gambling behaviour assessments  Ensures ‘coverage’ of all behaviour during the course of the study  Aids in memory recall. Even though you may be asking about the past 12 months, many people will use the last assessment (when they were last asked to evaluate this) as the demarcation point Different inter-assessment intervals (e.g., 1 year -> 2 years) creates problems:  Either have to change the questionnaire time frame each time (which is problematic), or else not have ‘coverage’ of a certain period of time  Difficult to attribute changes occurring during the longer interval to changes in measured variables, as these changes could simply be due to a longer time for them to have naturally occurred.

Consider More Frequent Assessments for a Small Percentage of People Yearly assessments of past year behaviour do not provide a fine grained chronology of gambling (in many ways a 5 yr longitudinal study is just a collection of 5 past-year retrospective reports) Diaries (daily, weekly, monthly) or bi-annual assessments can help rectify this

Avoid Mixing Administration Formats There are statistically significant differences in responses obtained via phone vs face-to-face vs mail vs online  These differences most prominent for ‘sensitive’ questions  Attributable to differences in anonymity, interviewer-interviewee interaction effects, time to answer, ability to re-read, ability to go back, etc. Self-administered computerized format is optimal  Maximizes anonymity  Respondent proceeds at their own pace  Ensures consistency of administration and automated data recording  Less costly

Have a Comprehensive, Efficient, and Well-Tested Questionnaire Needs to comprehensively survey all areas relevant to the etiology of gambling and PG Avoid redundancies in the questions and/or scales Make sure that the questionnaire is pre-tested for wording and robustness of the programming Try to make the questionnaire ‘interesting’

Maximize Retention Poor retention usually produces a nonrepresentative sample as drop-outs much more likely to be young, male, single, minority group, with significantly higher rates of pathology (substance use, mental health problems, etc) This is a particularly serious problem if these individuals are your primary group of interest! Post-hoc weighting does not necessarily correct this bias

Maximize Retention Hire the Right People to do the Study Probably the most important consideration Participant retention most strongly related to personal engagement with people conducting the study Preferable to have small number (e.g., 3 – 5) of full time staff rather than many part timers Want staff who a) will continue throughout entire duration of project b) are good at working with people c) are highly organized d) get along with each other e) have different skill sets f) are from the region that is being assessed g) are neutral with respect to gambling

Maximize Retention Offer Convenient Assessment Options i.e., office-based, online, or mail-in i.e., paper & pencil or computerized Also helps to improve the response rate and thereby, the representativeness of your initial sample

Maximize Retention Be attentive to the needs of each and every participant Even though the project may be important and interesting to you, it is often emotionally draining, somewhat boring, and time consuming for participants! This can be offset by having a positive interaction with staff who are professional, enthusiastic, supportive, and caring The experience of each completed assessment shapes the person’s motivation for the next one All participant complaints and suggestions have to be responded to in a timely way

Maximize Retention Have an Office in Each Region Increases public profile and legitimacy of project Allows people to drop in and maintain contact & provide change of address

Maximize Retention Incentives are Important for Both Participants and Staff Participants:  Minimum of $25/hr or $40/assessment  Highest payment for initial participation (to improve response rate) and for the 2 nd assessment.  Increasing amounts to take yearly inflation into account. Staff:  Significant monetary bonuses for goal attainment  Setting goals to work toward is as important (if not more important) than the financial reward for achieving these goals  Praise and celebration of good work  Allowing independence and flexibility in how they achieve the goals  Utilizing a collaborative team approach

Maximize Retention Use Staff Time Efficiently 2/3rds of people will respond with 1 invitation 1/3 require multiple reminders, and, the majority of these people tend to be the same people each time  Significant time and monetary savings are realized by analyzing the characteristics of your initial cohort (i.e., procrastinators; in-office people; people needing assistance) & concentrating your subsequent efforts on the people who need help/encouragement

Maximize Retention Need a Comprehensive and Versatile ‘Contact Database’ Contains exhaustive list of ways of contacting the person  Home phone, home address, cell phone, work phone, work address, employer, home and work s, vacation home address, social networking sites (e.g., Facebook), Chat systems (e.g., MSN), complete contact details for 2 people familiar with the person Identifies person’s ‘category’ (special needs, procrastinator, etc.) Records all contact attempts and responses Contains an Appointment Scheduler Records a myriad of other info useful to staff that can be analyzed to improve efficiency (much of which I’m not aware of myself!)

Maximize Retention Use a Different Format and Message for each Reminder Start with a personalized letter invitation (returned mail provides you with an early alert to participants who have moved) Follow with an invitation Follow with a personalized postcard reminder Follow with an reminder Follow with a phone call(s)

Maximize Retention Mass Requires Special Attention Check with your ISP concerning  Spam filter triggers  Capacity limitations (sending out; bounce backs) Send Reminders at the Beginning of the Week In Canada, people are much less likely to complete the assessment on weekends and holidays

Maximize Retention Maintain Contact Between Assessments Maintains ‘rapport’ Allows you to identify changed addresses before the assessment Reminds people to contact you with their new address ‘Newsletter’ an efficient way of doing this

Maximize Retention Have an Easily Remembered Project Logo e.g. QERI, LLLP On exterior office signage; website; all outbound communications (including cheques) This ‘branding’ allows participants to easily identify project mailings (and distinguishes them from the large volume of junk mail/ they receive)

Maximize Retention When these things are done right then you can expect most drop-off after the first assessment but decreasing drop- off in all subsequent assessments  People have confidence it is a legitimate survey  They are familiar with the survey  They are confident they will get paid  They have a history of positive interactions with staff When these things are not done right then you may get increased rates of drop-off with each assessment  Survey increasingly aversive  History of negative interactions

Have a Website Provides means of communication for the cohort, funders, and the general public Provides reassurance of legitimacy Common storage site for data

Logistics Success at conducting a large scale longitudinal study is not due to a few critical things, but a thousand little things and the ongoing ability to quickly identify and rectify the many issues that continually arise