2. Session IV Interviewing Techniques

3. Session Overview Overview of different interviewing methods Standardizing interviews Interviewer training Interviewing techniques Confidentiality

4. Learning Objectives Understand the advantages and disadvantages of various interview methods Know what to address in interviewer training Recognize good interview techniques Understand confidentiality concerns from the perspectives of both the respondent and the outbreak investigator

5. Basic Steps of an Outbreak Investigation 1.Verify the diagnosis and confirm the outbreak 2.Define a case and conduct case finding 3.Tabulate and orient data: time, place, person 4.Take immediate control measures 5.Formulate and test hypothesis 6.Plan and execute additional studies 7.Implement and evaluate control measures 8.Communicate findings

6. Role of Interviews in Outbreak Investigations Primary purpose: data collection Case identification Risk factor identification Hypothesis generation

7. Interviewing Methods 1.Interviewer Administered –Face-to-face –Telephone 2.Self Administered –Mail-out –Email –Web-based

8. Questionnaire Design Interview Method Influenced by: Length and format of questionnaire Question types used in a survey Cost considerations for survey implementation

9. Interviewing Methods Advantages and Disadvantages

10. Face-to-Face Interview Advantages: Higher response rate Longer survey instrument Can have more complex skip patterns More accurate recording of responses –Less item non-response Appropriate for hard to reach populations (e.g., illiterate, institutionalized)

11. Face-to-Face Interview Disadvantages: Costly Potential for interviewer error Less anonymous than self-administered –Potential for dishonesty Safety of interviewers

12. Telephone Interview Advantages: Less costly than face-to-face Higher response rates than mailed Quicker access to participants Supervision of interviewers feasible Can collect more sensitive information Survey design can be more efficient

13. Telephone Interview Disadvantages: Lower response rates than face-to-face Shorter questionnaires used Unable to capture important visual information (e.g., rash, working conditions) Under-coverage (e.g., population without phones)

14. Mailed Questionnaire Advantages: More anonymous May collect more honest responses No interviewer error Less expensive Respondent has more time to think about question

15. Mailed Questionnaire Disadvantages: Questionnaire must be simple Higher item non-response Lower response rate Data collection takes more time Sample population must be literate Coverage / frame deficiencies

16. Web-based Questionnaire Advantages: Among some populations, most people may have access to the Internet / e-mail Inexpensive and fast No data entry required –Improves data quality Many vendors send data in a variety of formats

17. Web-based Questionnaire Disadvantages: Mandatory access to and experience with Internet Potential connection speed and hardware / software capacity limitations Potential for multiple responses from one individual Potential for responses from non-sampled respondents Need email address list to contact sample

18. Standardizing Interviews

19. The goal of standardization is to help minimize error, thereby yielding better data quality Minimizing interviewer error is done through making surveys more standard or consistent

20. Error Interviewer Error: Deviation from expected answer due to the effects of interviewers.

21. Interviewer Error Example: Gonorrhea outbreak Bias Interviewers probe on the sexual history section more among non-whites than whites Variance A male interviewer may elicit different responses from a female respondent than a female interviewer.

22. Standardizing Interviews Contributing Factors: 1.Question wording 2.Interviewer selection 3.Interviewer training 4.Interviewing procedures 5.Supervising interviewers

23. Question Wording Criteria for Standardized Interview Questions Must be fully scripted Must mean the same thing to every respondent

24. Interviewer Selection Criteria for Telephone Interviewer Selection Ability to read questions fluently Clear and pleasant telephone voice Responds quickly to respondent’s questions Reliability

25. Criteria for Face-to-Face Interviewer Selection Logistical skills (reading maps) Good interpersonal skills Independent workers Reliability In certain circumstances, parallel demographic characteristics among interviewers and interviewees Safety

26. Interviewer Training Training is NOT optional! Trainings must be interactive Interviewers must practice reading questions out loud Provide support documentation (manual)

27. Interviewer Training Elements Purpose of survey How to use data collection instrument Respondent selection process Intent and meaning of each question How to record/code responses Administering questionnaire Addressing participants’ questions Methods for improving response rate Tracking calls / completed surveys / call- backs Confidentiality

28. Interviewer Training Respondent Selection Process Provide proxy respondent rules for adults and children because proxy response impacts: –Data quality –Sampling

29. Interviewer Training Questionnaire Administration To establish legitimacy of the survey upon first contact, tell the respondent: Who is calling What is requested Why respondent should cooperate How respondent was chosen

30. Interviewer Training Logistics Face-to-Face Reading maps Getting to respondents’ homes Reimbursement Dress code Scheduling callbacks Telephone Operation of equipment

31. Interviewer Training Other Considerations Record some resolution to each question –Are missing responses due to skip patterns or errors? Review interview after completion –Missing responses –Illegible responses

32. Interviewing Procedures Rules Read questions exactly as worded Probe inadequate answers, if necessary Record answers without interviewer discretion Maintain rapport with respondents Maintain an even pace

33. Interviewing Procedures Read questions exactly Read entire question before accepting an answer Clarify questions if necessary

34. Interviewing Procedures Read questions exactly Use only standard definitions / clarification provided Use the phrase: “Whatever x means to you”, OR “Whatever you think of as x.” When asked to repeat only one of several response options, repeat ALL options given for a question

35. Interviewing Procedures Probe A probe is a standardized way to obtain additional information from a respondent. Use probes when a respondent’s answer is unclear or irrelevant.

36. Probe Examples of responses requiring a probe: Interviewer: "In the past two weeks, have you been swimming in a public pool?” Irrelevant Response: “I swam in a lake at a national park last month." Unclear Response: “I stayed in a hotel with a pool when I was on vacation last week."

37. Interviewing Procedures Standard Probe Examples Repeat the question Retrieve receipts / calendars What do you mean? How do you mean? If respondent has narrowed down answer: –Which would be closer? –If you had to choose, which would you pick?

38. Interviewing Procedures Recording Answers Do not direct respondent toward an answer (leading) Do not assume that an “answer” received in passing is correct Do not skip questions, even if “answer” was given earlier Do not remind respondent of earlier remark if answer differs from what you expect

39. Probing versus Leading Example: Interviewer: In the last 7 days, how many times did you eat prepared food at the dorm cafeteria? Would you say: a.Noned. 3 times b.Oncee. More than 3 times c.Twice Respondent: “Oh, gee, I didn’t go very often... maybe a few times.”

40. Probing versus Leading Example: Interviewer Probe (correct) “Which would be closer: none, once, twice, 3 times, or more than 3 times?” Interviewer Leading (incorrect) a. “So, would you say twice, or 3 times?” b. “Do you mean twice, or 3 times?”

41. Maintain Rapport “Any line can be said a thousand ways.” - BRFSS interviewer training Interviewers can put respondents at ease by doing the following: Read the questions in a friendly, natural manner Speak at a moderate rate of speed Sound interested Strive to be objective and non-judgmental

42. Feedback Helps Maintain Rapport Feedback is a statement or action that indicates to the respondent that s/he is doing a good job. –Give feedback only for acceptable performance - not “good" content. –Examples of feedback “I see…” “Thank you / Thanks” “That is useful / helpful information” “I want to make sure I have that right (REPEAT ANSWER)”

43. Interviewing Procedures Maintain Even Pace Pace refers to the rate of progression of the interview. Pace can vary by question type. Let the respondent set the pace.

44. Supervising Interviewers Monitoring, evaluation, and feedback given to interviewers should focus on the way interviewers handle the question-answer process. Other supervision tasks –Scheduling interviewers Number of interviewers needed Time calls / visits will be made –Setting up interview space –Tracking who has been called and who has not –Reviewing data from completed interviews

45. Confidentiality Human Subjects & Informed Consent Outbreak investigations are considered a public health emergency, with the purpose of identifying and controlling a health problem. Informed consent or Institutional Review Board (IRB) clearance are not required.

46. Confidentiality Respondent Perspective Opening statement of every interview should indicate that all information collected will be kept confidential.

47. Confidentiality Outbreak Investigation Perspective Do not discuss details about the outbreak Provide only a brief description of the purpose of the survey at first contact

48. Session Summary Questionnaire design and interview methods are interrelated in the overall process of an outbreak investigation. The primary purpose of interviews in outbreak investigations is to collect data for case identification, risk factor identification, or hypothesis generation.

49. Session Summary Interview methods can be interviewer administered (face-to-face or telephone) or self administered (mailed, emailed, or Web-based). There are advantages and disadvantages to employing either method. Survey data collection error is a result of both bias and variance in the interview process. Interviewer error can be prevented with adequate interviewer training and the standardization of survey instruments.

50. Session Summary Develop and distribute an interviewer manual to provide interviewer support. Such documentation reduces error and enhances the quality of data collected. Sound interviewing procedures include: reading questions exactly as they are worded; probing inadequate answers; recording answers without interviewer discretion; and maintaining rapport with respondents.

51. References and Resources American Statistical Association (1997). What Is a Survey? More About Mail Surveys. Alexandria, VA: Section on Survey Research Methods, American Statistical Association. American Statistical Association (1997). What Is a Survey? How to Collect Survey Data. Alexandria, VA: Section on Survey Research Methods, American Statistical Association. Centers for Disease Control and Prevention (2005). Outbreak Management System Demonstration Web site. http://www.cdc.gov/phin/software- solutions/oms/index.html.http://www.cdc.gov/phin/software- solutions/oms/index.html Fowler, F. and Mangione, T. (1990). Standardizing Survey Interviewing. Newbury Park: Sage Publications.

52. References and Resources Gregg, M. (ed). (1996). Field Epidemiology. Oxford University Press. Holstein, JA and Gubrium, JF. (1997). Active Interviewing. In Silverman, D. (Ed.) Qualitative Research: Theory, Method, and Practice. London: Sage Publications, pp. 113-129. Last, J.M. (2001). A Dictionary of Epidemiology: 4 th Edition. Oxford University Press: New York. Rubin, HJ and Rubin, IS. (1995). Interviews as Guided Conversations. Qualitative Interviewing: The Art of Hearing Data. Sage Publications, pp. 1-16, 122-144. Salant, P. and Dillman, D. (1994). How to Conduct Your Own Survey. John Wiley & Sons.

53. References and Resources Stehr-Green, J.K. (2002). Gastroenteritis at a University in Texas: Case Study Instructor’s Guide. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention. U.S. Census Bureau (2005). Profile of Selected Housing Characteristics by State: Census 2000 Summary File 3 http://factfinder.census.gov/servlet/QTTable?_bm=n&_ lang=en&qr_name=DEC_2000_SF3_U_DP4&ds_nam e=DEC_2000_SF3_U&geo_id=04000US51 http://factfinder.census.gov/servlet/QTTable?_bm=n&_ lang=en&qr_name=DEC_2000_SF3_U_DP4&ds_nam e=DEC_2000_SF3_U&geo_id=04000US51 Weiss, R.S. (1994). Learning from Strangers: The Art and Method of Qualitative Interview Studies. New York: The Free Press. Wiggins, B. and Deeb-Sossa, N. (2000). Conducting Telephone Surveys. Chapel Hill, NC: Odum Institute for Research in Social Science.