1. Public Health Information Network (PHIN) Series II Outbreak Investigation Methods: From Mystery to Mastery

3. Access Series Files Online http://www.vdh.virginia.gov/EPR/Training.asp http://www.vdh.virginia.gov/EPR/Training.asp Session slides Session activities (when applicable) Session evaluation forms Speaker biographies Alternate Web site: http://www.sph.unc.edu/nccphp/phtin/index.htm http://www.sph.unc.edu/nccphp/phtin/index.htm

4. Site Sign-in Sheet Please submit your site sign-in sheet and session evaluation forms to: Suzi Silverstein Director, Education and Training Emergency Preparedness & Response Programs FAX: (804) 225 - 3888

5. Series II Session V “Interviewing Techniques”

6. Series II Sessions TitleDate “Recognizing an Outbreak”June 2 “Risk Communication”July 7 “Study Design”August 4 “Designing Questionnaires”September 1 “Interviewing Techniques”October 6 “Data Analysis”November 3 “Writing and Reviewing Epidemiological Literature” December 1

7. CDC Outbreak Management System Software Support: National Center for Public Health Informatics outbreakms@cdc.govoutbreakms@cdc.gov / (800) 532-9929, option 6

8. OMS Applications Track demographics, case investigations, and exposure contact relationships for persons, animals, events, travel events, vehicles, objects, organizations, other organisms, and locations. Create household, social, or occupational relationships among records Run OMS on desktops or laptops [CAPI]

9. OMS User Interface Source: http://www.cdc.gov/phin/software-solutions/oms/index.htmlhttp://www.cdc.gov/phin/software-solutions/oms/index.html

10. OMS User Interface Source: http://www.cdc.gov/phin/software-solutions/oms/index.htmlhttp://www.cdc.gov/phin/software-solutions/oms/index.html

11. OMS in Virginia Contact: Michael A. Coletta, MPH Bioterrorism Surveillance Coordinator Division of Surveillance and Investigation Office of Epidemiology Telephone: (804) 864-8099 Email: michael.coletta@vdh.virginia.govmichael.coletta@vdh.virginia.gov

12. Today’s Presenters Aaron Wendelboe, MSPH Doctoral Candidate and Graduate Research Assistant, NC Center for Public Health Preparedness Erin Rothney, MPH Research Associate, NC Center for Public Health Preparedness

13. “Interviewing Techniques” Learning Objectives Upon completion of this session, you will: Recognize the interrelatedness of interview techniques and questionnaire design Understand key survey research terms Understand the advantages and disadvantages of face-to-face, telephone, and computer assisted interview methods

14. Learning Objectives (cont’d.) Understand the advantages and disadvantages of mail and Web-based survey implementation 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

15. Lecturer Aaron Wendelboe, MSPH Doctoral Candidate and Graduate Research Assistant, NC Center for Public Health Preparedness

16. 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

17. Interviewing Techniques Introduction

18. The role of interviews in outbreak investigations Types of interviewing methods Interrelatedness of interview method and questionnaire design Key survey research concepts –Sampling –Response rates

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

20. Interviewing Methods 1.Interviewer Administered –Face-to-face –Telephone 2.Self Administered –Mail-out –Email –Web-based 3.Combination of 1 and 2

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

22. Sampling

23. Sampling is the systematic selection of a portion of the larger source population. A sample should be representative of the larger source population.

24. Sampling Source Pop: Students (12,000) Sampled pop (150 students)

25. Sampling Why Sample? Because it is more efficient – saves time and money!

26. Sampling Sample size Is the purpose of the study to determine the source of the outbreak? –A small number of cases and controls can reveal risk factors for infection. Is the purpose of the study to determine the number of persons who become sick over a specific period of time [attack rate]? –A cohort study would require a larger sample.

27. Sampling Types of Sampling Simple Random Sample (SRS) Randomly select persons to participate in study. There are many variations of SRS. Convenience Sample Choose those individuals who are easily accessible.

28. Sampling Problems with Convenience Sampling Based on subjective judgment Cases may or may not be representative of the total population May lead to biased results

29. Sampling Additional Resources: http://www.sph.unc.edu/nccphp/training/all_trainings/at_sampl.htm 1.“Sampling Case Studies” 2.“Survey Sampling: Precision, Sample Size, and Conducting a Survey” 3.“Survey Sampling Terminology and Methods”

30. Response Rates

31. Response rates measure the percentage of your sample that has participated in your survey. Example: Using the campus directory, you email a survey to a random sample of 100 freshmen. 40 of those students complete the survey and return it electronically. Your response rate is 40%.

32. Response Rates High response rates ensure that survey data are representative of the source population, and that results will be valid.

33. Response Rates Types of Non-response Non-contact: No one at home Refusal to participate Inability to participate (due to language barrier or physical or mental condition)

34. Response Rates What is an average response rate?

35. Response Rates Determining Response Rates Refer to the American Association of Public Opinion Research website: www.aapor.orgwww.aapor.org –Link to the document titled, “Standard definitions” from the home page.

36. Interviewer Administered Data Collection Considerations

37. Interviewer Administered Data Collection Advantages and disadvantages of face-to-face interviews Advantages and disadvantages of telephone interviews Advantages and disadvantages of Computer assisted interviews

38. 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)

39. Face-to-Face Interview Disadvantages: Costly Potential for interviewer error Less anonymous than self-administered –Potential for dishonesty

40. 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

41. 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) –2.1% of total population in Virginia

42. Computer Assisted Interviewing (CAI) CATI – Telephone CAPI – Personal ACASI – Audio

43. CAPI Example: NC PHRST Teams NC PHRST Team public health professionals use PDAs* for rapid needs assessment face-to-face interviews. * PDA: Personal Digital Assistant, also sometimes called hand-held computers, palmtops, and pocket computers

44. EPI Info GIS Field Team 1Field Team 2Field Team 3 Field Team 4Field Team 5 Field data collection using IPAQ Pocket PCs equipped with GPS, GIS software and data collection forms. Wireless: WIFI 802.11 or Bluetooth Field Data Collection

47. Pros: Inexpensive No special skills required for data recording Cons: Requires double data-entry –Greater risk of data errors Clipboard and paper more cumbersome in the field Pros: Eliminates double data entry Provides routing and direction- finding for field teams Improved randomization through GIS Ability to quickly analyze and map data Cons: Technology is expensive Learning curve / required training for data entry Small screen size requires scrolling through many questionnaire pages

48. For More Information... Steven Ramsey, RS Team Leader / Industrial Hygienist PHRST-5 Guilford County Health Department, NC (336) -641-8192

49. Self Administered Data Collection Considerations

50. Self-administered Data Collection Advantages and disadvantages of mailed questionnaires Advantages and disadvantages of Web-based questionnaires

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

52. 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

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

54. 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

55. Web-based Questionnaire Example: Dartmouth University: 698 (13.8%) of 5060 students had conjunctivitis in spring 2002 To identify risk factors... –web-based questionnaire set up –E-mail sent to 3682 undergraduates –No data entry - rapid analysis 1832 responded (50% response rate) -- Source: An outbreak of conjunctivitis due to atypical Streptococcus pneumoniae. N Engl J Med. 2003;348 (12):1112-21.

56. Web-based Questionnaire For a list of vendors that provide Web- based survey tools, please visit: http://www.surveymonkey.com/Pricing.asp

57. Question and Answer Opportunity

58. 5 minute break

59. Standardizing Interviews

60. 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

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

62. 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.

63. Error Additional Resource Schwarz, N., Groves, R., and Schuman, H., “Survey Methods” Chapter 4 in Gilbert, D. et al (Eds) (1998). The Handbook of Social Psychology. Boston: McGraw-Hill; pp 143 – 179.

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

65. 1. Question Wording

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

67. 2. Interviewer Selection

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

69. 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

70. 3. Interviewer Training

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

72. 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

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

74. 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

75. Interviewer Training Logistics Face-to-Face Reading maps Getting to respondents’ homes Reimbursement Dress code Scheduling callbacks Telephone Operation of equipment Operation of CATI software (if applicable)

76. 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

77. Interviewer Training Interviewer Manual An interviewer manual serves as a reference to interviewers during interviews and as survey documentation.

78. Interviewer Training Suggested Interviewer Manual Contents Background information Fieldwork Interviewing techniques Survey instrument terms and definitions

79. Interviewer Training Program Example Behavioral Risk Factor Surveillance System (BRFSS)

80. BRFSS Interviewer Training On-line training covers: Why BRFSS data are important, how data are used Interviewer responsibilities Nuts and bolts of the interviewing process Interviewing techniques

81. BRFSS Interviewer Training On-line interviewer training available at: http://apps.nccd.cdc.gov/BRFSS_Training _Int/overview.asp General information about BRFSS: http://www.cdc.gov/brfss/ http://www.cdc.gov/brfss/

82. 4. Interviewing Procedures

83. 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

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

85. 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

86. 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.

87. 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."

88. 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?

89. 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

90. 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.”

91. 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 three times?” b. “Do you mean twice, or three times?”

92. Interviewing Procedures Maintain Rapport An interviewer should be: Nonjudgmental Noncommittal Objective

93. 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 for a low-pitched voice

94. 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. –Give short feedback phrases for short responses, longer feedback for longer responses. –Specific study information and interviewer task- related comments can serve as feedback. –Telephone interviewers should give feedback for acceptable respondent performance 30-50% of the time.

95. Feedback Examples “I see…” “Uh-huh” “Thank you / Thanks” “That is useful / helpful information” “I see, that is helpful to know” “That is useful for our research” “Let me get that down” “I want to make sure I have that right (REPEAT ANSWER)” “We have touched on this before, but I need to ask every question in the order that it appears in the questionnaire”

96. 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.

97. Question and Answer Opportunity

98. Activity: Correct Interview Procedures Probing vs. Leading vs. Feedback Completion time: 5 minutes

99. Activity Interviewer: “Are you still experiencing Diarrhea?” Respondent 1: “I’m not sure” Respondent 2: “I definitely had diarrhea last Tuesday” Respondent 3: “Yes” Activity Instructions: How should the interviewer respond to these 3 answers? Provide an example of either a clarification, probe, or feedback that the interviewer could use. Try to think of one correct use of each technique.

100. Activity Suggested Answer Respondent 1: “I’m not sure” Try a clarification: “For the purposes of this survey, we consider diarrhea to be 3 or more loose bowel movements in a 24 hour period.”

101. Activity Suggested Answer Respondent 2: “I definitely had diarrhea last Tuesday” Try a Probe: “OK, but are you still experiencing diarrhea?”

102. Activity Suggested Answer Respondent 3: “Yes” Good Feedback: “I see” Bad Feedback: “Are you sure?” (leading)

103. 5. Supervising Interviewers

104. Supervising Interviewers Monitoring, evaluation, and feedback given to interviewers should focus on the way interviewers handle the question- answer process.

105. 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

106. Confidentiality

107. 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.

108. Confidentiality Human Subjects & Informed Consent If further analysis of outbreak investigation data is conducted for the purpose of research, IRB approval should be obtained.

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

110. 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

111. Question and Answer Opportunity

112. 5 minute break

113. Guest Lecturer Erin Rothney, MPH Research Associate NC Center for Public Health Preparedness

114. Overview Provide real-life examples of situations where you will use interviewing techniques –Face-to-face interviewing –Telephone interviewing Discuss advantages and disadvantages Compare interviewing methods

115. Face-to-face Interviews

116. Community Assessments Identify the needs and strengths of a particular community from several stakeholder perspectives Include interviewing community members and observing the environmental and individual characteristics and community infrastructure Similar to rapid needs assessments, but completed within a longer time frame

117. Durham, NC Community Assessment Fall 2002 - Spring 2003 Bragtown Neighborhood, Durham, NC 5 person team Interviewed residents and other stakeholders in Bragtown 4 page survey, 60 minutes in length

118. Durham, NC Community Assessment Tasks: Questionnaire design Interviewer training Interviewing Facilitating focus groups Analyzing data Presenting data to the community

119. Survey Instrument Question Examples: Life in the Community What do people in Bragtown do for recreation? What types of religion are practiced in Bragtown? What do people in Bragtown do for a living? What political or government organizations exist in Bragtown? What different cultural and ethnic groups live in Bragtown? How do these different groups interact? Do they get along? Community Assets What do you like about Bragtown? What are some organizations within your community that positively affect you or your community? –Probe: What about political groups, environmental groups, church groups? Who are the individuals within your community that you feel are positive leaders or role models? –Probe: Any others?

120. Interviewer Training Active listening skills Showing empathy Using probes Practice interviewing, not just reading questions

121. Face-to-face Interviews Challenges Hard to find people at home People may not want to invite a stranger into their home Costly and time-intensive method of interviewing Solutions Schedule time ahead by phone or stop by and schedule more convenient time Use the skills you learned in interviewer training to gain trust Have someone on staff train others on interviewing techniques; carpool; set time limits

122. Lessons Learned 1.Study community demographics and characteristics before you interview 2.Train interviewers before an immediate need 3.People like to tell you their stories- could lead to relevant information

123. Telephone Interviews 2004 E. coli Outbreak Investigation

124. E. coli Outbreak Investigation Telephone Interviews Illness onset October - November 2004 Geographically dispersed cases in multiple states Case-control study Train-the-trainer, interviewer

125. E. coli Outbreak Investigation Telephone Interviews Between 3 and 6 interviewers Calls made between 3 p.m. and 8 p.m. Quality control with one central interviewing location News coverage piqued people’s interest in the outbreak investigation

126. Lessons Learned 1.Practice reading through the questions and conducting an interview 2.The media can be your friend 3.Use an introductory script to relate the purpose of the phone call to the individual quickly –Identify and legitimize the interviewer –State reasons for conducting the survey –Assure that responses will be confidential

127. Summary [Face-to-face] Community Assessment –Establish rapport –Identify people in a small geographic area –Assess the environment of the area [Telephone] Outbreak Investigation –News coverage helped in recruiting people to participate –Widely distributed sample –We had the phone numbers of all the people who pre- bought tickets

128. Question and Answer Opportunity

129. Session Summary

130. 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.

131. 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. Sampling is the systematic selection of a representative portion of the larger source population to be interviewed. If the purpose of your study is to determine the point source of infection, you may be able to interview a smaller sample; if the purpose of your study is to calculate an attack rate, you may need to interview a larger sample.

132. Session Summary Survey response rates measure the percentage of your sample that has participated in your survey. Average response rates vary from as little as 56% for mailed surveys to 75% for face- to-face surveys. Non-response to surveys can be a result of no one being home, refusal to participate, or individual inability to participate (e.g., because of a language barrier or physical or mental condition).

133. Session Summary 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.

134. 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.

135. Next Session November 3rd 1:00 p.m. – 3:00 p.m. Topic: “Analyzing Data”

136. References and Resources 1.American Statistical Association (1997). What Is a Survey? More About Mail Surveys. Alexandria, VA: Section on Survey Research Methods, American Statistical Association. 2.American Statistical Association (1997). What Is a Survey? How to Collect Survey Data. Alexandria, VA: Section on Survey Research Methods, American Statistical Association. 3.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

137. References and Resources 4.Fowler, F. and Mangione, T. (1990). Standardizing Survey Interviewing. Newbury Park: Sage Publications. 5.Gregg, M. (ed). (1996). Field Epidemiology. Oxford University Press. 6.Holstein, JA and Gubrium, JF. (1997). Active Interviewing. In Silverman, D. (Ed.) Qualitative Research: Theory, Method, and Practice. London: Sage Publications, pp. 113-129. 7.Last, J.M. (2001). A Dictionary of Epidemiology: 4 th Edition. Oxford University Press: New York.

138. References and Resources 8.Levy, P. and Lemeshow, S. (1991). Sampling of Populations. John Wiley & Sons. 9.Ramsey, S. et al (2005). Using GIS and GPS to Improve Public Health Response. Guilford County, NC Health Department Public Health Regional Surveillance Team 5. 10.Rubin, HJ and Rubin, IS. (1995). Interviews as Guided Conversations. Qualitative Interviewing: The Art of Hearing Data. Sage Publications, pp. 1-16, 122-144. 11.Salant, P. and Dillman, D. (1994). How to Conduct Your Own Survey. John Wiley & Sons.

139. References and Resources 12.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. 13.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&q r_name=DEC_2000_SF3_U_DP4&ds_name=DEC_2000_SF3_U &geo_id=04000US51 http://factfinder.census.gov/servlet/QTTable?_bm=n&_lang=en&q r_name=DEC_2000_SF3_U_DP4&ds_name=DEC_2000_SF3_U &geo_id=04000US51 14.Weiss, R.S. (1994). Learning from Strangers: The Art and Method of Qualitative Interview Studies. New York: The Free Press. 15.Wiggins, B. and Deeb-Sossa, N. (2000). Conducting Telephone Surveys. Chapel Hill, NC: Odum Institute for Research in Social Science.