Transcript Gastroenteritis at a University in Texas

2004
Public Health Training and
Information Network (PHTIN)
Series
Site Sign-in Sheet
Please mail or fax your site’s sign-in sheet to:
Linda White
NC Office of Public Health Preparedness
and Response
Cooper Building
1902 Mail Service Center
Raleigh, NC 27699
FAX: (919) 715 - 2246
Outbreak Investigation
Methods
From Mystery to Mastery
2004 PHTIN Training Development Team
Pia MacDonald, PhD, MPH - Director, NCCPHP
Jennifer Horney, MPH - Director, Training and Education, NCCPHP
Anjum Hajat, MPH – Epidemiologist, NCCPHP
Penny Padgett, PhD, MPH – Epidemiologist
Amy Nelson, PhD - Consultant
Sarah Pfau, MPH - Consultant
Amy Sayle, PhD, MPH - Consultant
Michelle Torok, MPH - Doctoral Candidate
Drew Voetsch, MPH - Doctoral Candidate
Aaron Wendelboe, MSPH - Doctoral student
Future PHTIN Sessions
October 12th. . . . . . . . . “Analyzing Data”
December 14th. . . . . . . “Risk Communication”
Each session will be on a Tuesday from 10:00 a.m. 12:00 p.m. (with time for discussion)
Session I – VI Slides
After the airing of each session, NCCPHP will
post PHTIN Outbreak Investigation Methods
series slides on the following two web sites:
NCCPHP Training web site:
http://www.sph.unc.edu/nccphp/phtin/
North Carolina Division of Public Health, Office
of Public Health Preparedness and Response
http://www.epi.state.nc.us/epi/phpr/
Session IV
“Designing Questionnaires”
Today’s Presenters
Sarah Pfau, MPH
Consultant
NC Center for Public Health Preparedness
Kay Sanford, MSPH
Head, Injury and Violence Prevention
Branch, Division of Public Health,NC
Department of Health and Human
Services,
“Designing Questionnaires”
Learning Objectives
Upon completion of this session, you will:
1. Understand the role of questionnaire design in
an outbreak investigation
2. Know how to develop a hypothesis generating
questionnaire
3. Recognize key planning strategies for
successful questionnaire design
“Designing Questionnaires”
Learning Objectives
4. Recognize key characteristics of welldesigned questions
5. Recognize three broad question types
and when to use them
6. Understand what different question types
measure, and the type of data
(quantitative versus qualitative) they yield
“Designing Questionnaires”
Learning Objectives
7. Know how to format questionnaires for
interviewer administered or self-administered
settings
8. Recognize the impact of questionnaire design
on View design and data analysis in Epi Info
software
Designing Questionnaires
Basic Steps of an
Outbreak Investigation
1.
2.
3.
4.
5.
6.
7.
8.
Verify the diagnosis and confirm the outbreak
Define a case and conduct case finding
Tabulate and orient data: time, place, person
Take immediate control measures
Formulate and test hypothesis
Plan and execute additional studies
Implement and evaluate control measures
Communicate findings
Designing Questionnaires
Session Overview
• The importance of questionnaire design
• Hypothesis generating versus hypothesis
testing questionnaires
• Preparing for questionnaire design
• Question design
• Question type
• Questionnaire format
Why is Questionnaire Design
Important?
“The quality of the data will be no better
than the most error-prone feature of the
survey design.”
- Fowler, F.J. (1993). Survey Research Methods:
Second Edition. Sage Publications: Newbury Park.
Why is Questionnaire Design
Important?
With an understanding of good
questionnaire design principles, you will
ask only about what you need to meet
your research objectives.
Ask Only About What You Need. . .
Example:
You ask respondents to list all medications
that they are taking (difficult in terms of
respondent recall / accuracy), when you
really only need to know if they are taking
antibiotics.
Why is Questionnaire Design
Important?
Question type and response option
formatting impact how you can design an
on-screen data entry form and / or analyze
variables in your software program
Why is Questionnaire Design
Important?
Survey answers are not of interest
intrinsically; rather, the answers are
important because of their relationship to
what they are supposed to help you
measure.
Hypothesis Generating
Questionnaires
Which Questionnaire Type
Should You Use?
• Hypothesis Generating?
• Hypothesis Testing?
Hypothesis
Generating
Hypothesis
Testing
Targets casepatients only
Targets casepatients and controls
Exploratory
questions
Person, place, time,
all possible risk
factors
Use some openended questions
Can use a
standardized
questionnaire to
guide interviews
Targeted, specific
questions
Suspected risk
factors only
Limit use of openended questions
Use investigationspecific
questionnaire
Hypothesis Generating Questionnaire
Include questions about:
 Demographics
 Clinical details of the illness
 Health care provider visits
 Water exposure
 Exposure to other ill persons
 Exposure to children in day care
 Exposure to a farm or farm animals
 Travel outside of the immediate area
Hypothesis Generating Questionnaire
If the pathogen can be spread through food
or beverages, include questions about:
Food eaten in the home
Food eaten in the homes of friends, family
Food eaten at any restaurant
Dates and times of food consumption and
any suspicious observations
Hypothesis Generating Questionnaire
Hypothesis Generating Questionnaire
Hypothesis Testing
Questionnaires
Hypothesis Testing Questionnaire
Include detailed questions about the suspected
source of infection.
Example: The local bakery is suspected as the
source of a Hepatitis outbreak in multiple
counties. The hypothesis testing questionnaire
is used with both cases and non-cases, and
includes only a food history for all possible items
on the bakery menu to pinpoint the exact food
item that is contaminated.
Hypothesis Testing Questionnaire
Hypothesis Generating versus Testing
Questions: E. coli 0157:H7
Hypothesis Generating
Account for consumption
of ground beef, lettuce,
alfalfa sprouts, unpasteurized milk or juice,
and swimming in or
drinking sewagecontaminated water
Hypothesis Testing
[beef suspected]:
Beef brand, date of
purchase, and grocery
store or restaurant where
beef was purchased or
eaten
Preparing for
Questionnaire Design
Preparing for
Questionnaire Design
There is more to questionnaire design than
writing questions. Ideally, you should first:
1.
2.
3.
4.
Have a clear purpose and research objectives
List variables to be measured
Have an analysis plan
Consider cost and other logistical aspects
Questionnaire Design
1. Have a clear purpose and research
objectives.
Is the purpose of your outbreak
investigation survey to generate a
hypothesis or to test a refined
hypothesis?
Questionnaire Design
2. List variables to be measured
Whether you are generating or testing a
hypothesis, determine your variables of
interest before you develop questions.
You will avoid asking unnecessary
questions or asking for unnecessary
details.
Questionnaire Design
1. Go to: http://www.cdc.gov
2. Under “Health & Safety Topics” in the left
margin, click on, “Diseases & Conditions”
3. Select a link to either an alphabetized list
of all diseases or diseases by topic [e.g.,
if you already know that a pathogen is
water-borne versus food-borne]
Questionnaire Design
Questionnaire Design
3. Have an analysis plan.
•
Guides the question types and response
option categories used on the questionnaire
•
Helps assure that the data collection leading
up to analysis yields variable coding that your
analysis software program can use efficiently.
Questionnaire Design
4. Consider cost and other logistical aspects
a. What is the survey sample size?
b. What is the geographic distribution of the
survey sample?
c. Will questionnaires be interviewer
administered or self-administered?
d. What is your staff capacity to work within the
parameters of a – c above?
5 minute break
Question Design
Question Design
Elements of good question design:
1.
2.
3.
4.
5.
6.
7.
Reliability
Validity
Specificity versus ambiguity
Simplicity
Only one question asked
Mutually exclusive answer choices
Refers respondents to specific dates / times for
recall
8. When feasible, make sure data can be
compared to existing sources of information
Question Design
1. A question that is designed to be
reliable will assure that the words are
interpreted the same way in any setting,
and that respondents answer the same
way in any setting.
Reliable Question Design
Question:
“Are you experiencing diarrhea?”
Interviewer then adds:
“For the purposes of this survey, we
consider diarrhea to be 3 or more loose
bowel movements in a 24 hour period.”
Question Design
2. A question that is designed to be valid
will always yield information that can be
used as a true measure of what you, the
researcher, are looking for.
Valid Question Design
Less Useful
Which is your source of drinking water at home?
a. Tap water
b. Bottled water
Better
Which is your source of drinking water at home?
a. Municipal tap water
b. Municipal tap water with additional filtration
c. Well water
d. Commercially bottled water
Question Design
3. Avoid ambiguity in question wording.
Less useful
“When did you have ‘Disease X’?”
Better
“How old were you when you had ‘Disease
X’?”
Question Design
3. Avoid ambiguity in question wording.
Less useful
“Have you been examined by a physician in the
past seven days?”
Better
“Have you been examined by a physician for
these symptoms in the past seven days?”
Question Design
4. Use simple language and keep
questions short.
Less useful
Were you exposed to the fomite at the
dinner party?
Better
Did you use a shared hand towel at the
dinner party?
Question Design
5. Ask only one question.
Two questions in one
Did you eat mashed potatoes and giblet gravy?
One question at a time
Did you eat mashed potatoes? Yes No
If Yes, did you eat them:
a. Plain or with butter
b. With giblet gravy
Question Design
6. For closed-ended questions, make sure that
response options are mutually exclusive.
Not useful
What is your age?
18 years old or younger
18 years old or older
Useful
What is your age?
17 years old or younger
18 years old or older
Question Design
7. Use specific date / time references to
improve respondent recall.
Less useful
Have you been swimming in a public pool
recently?
Better
Did you swim in a public pool between Monday,
June 2nd and Monday, June 9th, 2004?
Question Design
8. When feasible, make sure data can be
compared to existing sources of information.
Example:
Case-patient age
 Less than 2 years
 2 – 5 years
The U.S. Census reports population data for
age groups less than 1, 1 – 2, 3, 4, 5, etc.
Question Design:
General Guidelines
• Design clear, specific questions.
• Use simple language and keep questions
short.
• Ask only one question!
Question Design:
General Guidelines
• For closed-ended questions, make sure that
response options are mutually exclusive.
• Use specific date / time references to improve
respondent recall.
• Make sure data can be compared to existing
sources of information if you need to compare
local, state, and national statistics.
Question Type
Question Type
Questions fall into three broad categories:
1. Closed-ended
2. Open-ended
3. Fill-in-the-blank
Data collected and analysis options may
differ by question type.
Closed-ended Questions
Question Type
Closed-Ended Questions:
• Provide answer choices in pre-coded
categories that represent counts, ranges,
or demographic information.
• Yield quantitative data.
• Are preferable for self-administered and
hypothesis testing questionnaires.
Question Type
There are two ways in which categorical
measurement is carried out in closedended questions:
1. Nominal
2. Ordinal
Question Type
Nominal response options result in the
classification of a respondent into a
category for race, gender, marital status,
etc.
- Response options can be mutually
exclusive (“Select only one response”)
Question Type
Example: Nominal response options in a
closed-ended question:
Please select the one response that describes
your marital status.
Single
Married
Divorced
Widowed
Question Type
Ordinal response options result in
classification into an ordered category that
may or may not rank values that are
equidistant.
- Ordinal responses have a numeric value.
Question Type
Example: Ordinal response options in a closedended question:
When you turn off the frozen dairy dessert
machine at the restaurant’s closing time, how
frequently do you sanitize the dispenser?
1 – Every time
4 – Once a month
2 – Every other time
3 – Once a week
5 – Less than once a
month
Question Type
Likert scales contain pre-coded ordinal
responses with assigned values. You can
then calculate averages to determine the
most prevalent response.
Example: Please rate the severity of your
abdominal cramp pain (circle one):
1 – minimal
3 – moderate
5 – very painful
2 – mild
4 – painful
Question Type:
Likert Scales
3-point scale
Minimal
5-point scale
Minimal
Mild
Moderate
Moderate
Painful
Very Painful
Very Painful
Question Type:
Likert Scales
Example: Please rate the severity of your abdominal cramp pain:
1 – minimal
3 – moderate 5 – very painful
2 – mild
4 – painful
Calculate the average of responses, where
N = 35:
1. 1 = 10 people; 2 = 5 people; 3 = 20 people;
4 = 0; 5 = 0
2. 10 x 1 = 10; 2 x 5 = 10; 3 x 20 = 60
3. 10 + 10 + 60 = 80
4. 80 / 35 = 2.29 (“mild” pain)
Question Type
Using “Don’t Know” or “Not Applicable”
response options
When you have categorical, dichotomous
response options such as, “Yes” and “No,”
you may sometimes choose to add a
“Don’t Know” or “Not Applicable” option.
Open-ended Questions
Question Type
Open-Ended Questions:
• Allow respondents to provide answers in
their own words.
• Yield qualitative data.
• May yield unanticipated answers that
contribute to the study.
• Are most appropriate for hypothesis
generating versus testing questionnaires.
Question Type
Example: Open-ended questions
What restaurants did you patronize in the
past seven days?
Please list the two main symptoms you are
having with this illness:
Fill-in-the-blank Questions
Question Type
Fill-in-the-blank Questions:
• Allow respondents to provide short answers in
their own words.
• Yield qualitative data.
• Are most appropriate when possible response
categories are too numerous to list.
• Are most appropriate when the question is
measuring respondent characteristics versus
attitudes, beliefs, or behaviors.
Question Type
Example: Fill-in-the-blank Questions
1.
County of residence _____
2.
Age in years ____
3.
Number of children under age 18 in
your household ____
Question and Answer
Opportunity
5 minute break
Activity
Completion Time: 5 minutes
Activity
Instructions:
Three sample questions appear on the following
slides. Your task is to critique those questions
and write down one element that could be
improved or modified to make the question
better.
Activity
Question 1:
Did you take any prescription medications
for this illness?
Yes
No
If yes, what medications? ___________
Activity
Question 2:
Did you travel anywhere during the seven
days before your illness?
Yes
No
If airline travel, what airline? __________
Outgoing flight number ____
Returning flight number ____
Activity
Question 3:
During the seven days before your illness,
did you have any pets at home, have
contact with household pets elsewhere, or
visit a household with pets (including
reptiles)?
Yes
No
Epi Info
Impact of Question Design on
View Design and Data Analysis
Epi Info Implications
Overview:
• Field type and properties
• Check code in MakeView
• Categorical data
- Dichotomous response options
Tables
The core of your database – the largest unit of
information – where data are stored by rows and
columns
Records
Each record contains a complete set of
information on one specific subject or casepatient
– E.g., record #1 = John Doe’s name, address, date of
onset of illness, lab results, etc.
– E.g., record #2 = Jane Doe’s name address, date of
onset of illness, lab results, etc.
Fields
The smallest ‘unit’ of information in your
database. Each field contains one piece
of information about a subject / casepatient.
– E.g., field 1= “ first name”
– E.g., field 2= “street address”
Sample Database Tables
Records: “01” and “02” represent individual respondents
Fields: Client ID, First Name, Last Name, Phone Number, County
Sample Epi Info View
Each food or beverage is represented by an individual field
for data entry and analysis.
Field Type and Properties
Field Type and Properties
[Number Type]
Age in years _____
Number of children living in this household _____
[Text Type]
County of residence _____
First name _____
Field Type and Properties
Food item field format in Epi Info can be either:
a. Checkbox
b. Yes / No [pictured above]
Line Listing
Frequency Table
“95.7% of the ill people in the sample did NOT consume milk.”
Dichotomous Response Options
“Which of the following food items did you
consume in March or April of this year?”
Represents one field of data in database
Commercial milk purchased locally
Fresh clams purchased locally
Fresh oysters purchased locally
None of the above
Field Type
Yes
Yes
Yes
Yes
No
No
No
No
Contingency Table
“95.7% of the
people who are ill
did not consume
milk.”
“93.1% of the
people who are
not ill did not
consume milk.”
Dichotomous exposure variable: Milk consumption (Yes / No)
Dichotomous outcome variable: Ill?
(Yes / No)
Check Code in MakeView
Eight Check Code commands in the Field
Definition window:
Repeat Last
Required
Read Only
Soundex
Legal Values
Codes
Comment Legal
Range*
* Use only with “number” formatted fields
Check Code in MakeView
Check Code in MakeView
Field Type and Properties
“Please select the one response that
describes your marital status.”
Single
Married
Divorced
Widowed
Check Code in MakeView
Field Type and Properties
a.
b.
Field format in Epi Info can be:
a. Text with Legal Values
b. Option
Check Code in MakeView
“Comment Legal”
Question and Answer
Opportunity
Questionnaire Format
Questionnaire Format
We will now consider layout guidelines:
A. In general
B. For interviewer administered
questionnaires
C. For self-administered questionnaires
General Formatting Guidelines
General Guidelines
A well-designed questionnaire:
• Minimizes respondent burden
– Minimal time to think about each response
– Minimal time to complete entire survey
General Guidelines:
Respondent Perspective
1. Format page layout with a vertical flow
from question to question and from
response option to response option.
2. Maintain “white space” on the page.
3. Number every question.
General Guidelines:
Respondent Perspective
5. Use consistent codes for response
options.
6. Arrange questions in a logical order;
even within sub-sections if possible.
7. Use differentiating font for questions and
response options.
General Guidelines:
Respondent Perspective
9. Provide clear but brief instructions for survey
completion.
10. Indicate units for fill-in-the-blank questions.
11. Use clear cues (text or arrows) to guide
respondents through skip patterns.
12. Use transitional cues for each subsection of
questions (“The next series of questions will
ask about . . . “).
General Guidelines:
Researcher Perspective
1. Include a unique identification number so
you can maintain confidentiality and link
data when applicable (e.g., in Epi Info).
2. When applicable, use numbers versus
check boxes for pre-coded response
options so they can be used for data
entry and analysis (e.g., in Epi Info).
General Guidelines:
Researcher Perspective
3. To reduce the difficulty of distinguishing
between missing data and simply all “no”
responses to a categorical list of response
options, consider alternative formatting.
Example: standard question format
Where did you see published information
about this free HIV screening?
 Billboard on subway
 Doctor’s office
 Local newspaper
General Guidelines:
Researcher Perspective
Example: alternative question format
Where did you see published information
about this free HIV screening?
Billboard on subway
Doctor’s office
Local newspaper
Yes
Yes
Yes
No
No
No
Format Guidelines:
Interviewer Administered
Questionnaire
Questionnaire Format
Interviewer administered questionnaire:
1. Differentiate between text instructions for
the interviewer and questions to be
asked (e.g., italicize or bold instructions).
2. Establish a clear system for skip patterns
(e.g., lines and arrows or clear
instructions).
Questionnaire Format
Interviewer administered questionnaire:
3. Put optional wording in parentheses.
Example: (his / her)
4. Put all words for the interviewer to say in
writing to assure standardized
interviewing (e.g., introductions,
transitions, explanations, or definitions).
Interviewer Administered
Questionnaires
Suggested Supporting
Documentation for Interviewers
Supporting Documentation:
Interviewer’s Manual
•
•
•
•
Background
Fieldwork
Interviewing Techniques
Telephone Interviewer Instructions (if
applicable)
• Terms and Definitions
• Details of the Questionnaire
• Description of the Survey Area
Supporting Documentation
Standard format for interviewer introductions for
telephone or face-to-face interviews:
– Interviewer’s name
– Health department (or organization)
represented
– One sentence description of the survey’s
purpose (e.g., “There has been an outbreak of
disease X in your county and we are calling
you to . . .”)
– A conservative estimate of how long the
interview will take
Supporting Documentation:
Interviewer Information
1. Who is the interviewer?
2. Who is sponsoring / implementing the survey?
– Who is the primary contact?
3. What is the purpose of the survey / study?
– How will results be used, and how will they
help the respondent?
Supporting Documentation:
Interviewer Information
4. How many people will be participating?
5. How did the interviewer obtain the respondent’s
name?
6. Will responses be confidential?
7. Will survey results be available to
respondents?
Supporting Documentation:
Telephone Interviewer Instructions
• What information to have available during
an interview
• How to use the telephone system (and the
CATI* software, if applicable)
• How to log calls
* Computer-assisted Telephone Interview
Supporting Documentation:
Telephone Interviewer Instructions
• How to handle angry respondents
– When to seek supervisor assistance
• What to do once a telephone interview has
been completed
Format Guidelines:
Self-Administered
Questionnaire
Questionnaire Format
Self administered questionnaire:
1. Completion of the questionnaire should be selfexplanatory; do not use detailed instructions,
because not all respondents will read them.
2. Restrict the design to closed-ended questions
(e.g., checking a box or circling a response
option).
3. Order questions from most topic-related and
easy to answer at the beginning, to most likely
to be objectionable or of a sensitive nature at
the end.
Questionnaire Format
Self administered questionnaire:
3. Strive for consistency in question type and
response option formatting whenever possible.
4. Use clean formatting with plenty of ‘white
space’ so you do not overwhelm the
respondent with clutter on the page.
5. Use skip patterns only where necessary; use
visual cues versus written instructions where
needed.
Format Guidelines
Interviewer versus
Self-Administered Questionnaires
Format Guidelines
Interviewer
Administered
Self-Administered
Format for interviewers’
navigation
Format for respondents’
navigation
Respondents are not
influenced by questionnaire’s
appearance
Need eye-appealing
format (survey length, font
size, white space, and
organization)
Include detailed instructions,
scripts, definitions, etc. for
interviewers
Include only essential,
succinct instructions or
symbols for navigation
Question stems and response Question stems and response
options must be succinct and options should be simple, but
simple
can be longer
You are not finished yet. . .
Pilot Test Questionnaires!
Pilot Test Questionnaires
• Are questions yielding the information that
they are supposed to yield?
• Do respondents understand all wording?
• Do respondents interpret the questions the
same way?
• Do closed-ended questions have a
response option that applies to each
respondent?
• Are skip patterns followed correctly?
Question and Answer
Opportunity
Guest Expert Lecturer
Kay Sanford, MSPH
Head, Injury Epidemiology Unit
Injury and Violence Prevention Branch
NC DHHS Division of Public Health
[email protected]
919.715.6444
NC Rapid Needs Assessment:
Hurricane Isabel, September 2003
Injury and Violence Prevention Branch, NC-DHHS DPH
Rapid Needs Assessment
Background
• 3rd week September 2003, Hurricane Isabel en
route to NC coast (Beaufort County)
• RNA process had been used in other disasters,
e.g., Ankara earthquake 1999; Maine Ice Storm,
1998; Hurricane Opal, 1995,
• Decision to perform RNA made as Isabel
approached the NC coast
Injury and Violence Prevention Branch, NC-DHHS DPH
Development of Questionnaires
Injury and Violence Prevention Branch, NC-DHHS DPH
Who needed the RNA data?
• In 2003, no mandate for RAPID hurricane
data within the state
• PHP&R - DPH initiative - useful to
– Division Emergency Management
– Local emergency operations programs
– Local Health Departments
• RNA now written into State Hurricane Plan
Injury and Violence Prevention Branch, NC-DHHS DPH
Who was involved in developing
the RNA Questionnaire?
•
•
•
•
•
•
Epidemiology Section
Public Health Preparedness & Response
Injury and Violence Prevention Branch
Division of Environmental Health
Division of Mental Health
CDC specialists in mass trauma
surveillance
• PHRST members
Injury and Violence Prevention Branch, NC-DHHS DPH
How we developed the RNA
Questionnaire by committee (1)
• Selected a TEAM leader
• Identified examples to serve as prototypes
• Agreed upon goals of data collection
• Promoted our individual areas
Injury and Violence Prevention Branch, NC-DHHS DPH
Strategies for Designing the
RNA Survey Instrument
•
•
•
•
•
•
•
Limit forms to one-page
Number all questions
Preference for closed-ended questions
Omitted extremely sensitive questions
Allowed for Don’t Know as a legitimate answer
Header completed by interviewer
Questions read verbatim by interviewer
Injury and Violence Prevention Branch, NC-DHHS DPH
How we developed the RNA
Questionnaire by committee (2)
• Wrote / revised individual questions
• Prepared QxQ instructions & procedures
• COMROMISED on questions, definitions,
and protocol.
Injury and Violence Prevention Branch, NC-DHHS DPH
How many questionnaires were
needed?
1. Tracking Form
2. Survey Form
3. Referral Form
Injury and Prevention Branch, NC-DHHS DPH
Tracking Form
What data needed to be
collected for Hurricane Isabel?
• TRACKING FORM: Sampling information
– county
– cluster number
– block number
– Interview team
– Sample sequence No., Address
– Date, Time
Injury and Violence Prevention Branch, NC-DHHS DPH
What data needed to be
collected for Hurricane Isabel?
• TRACKING FORM: Response status
– Interview Conducted
– Interview started but not completed
– Interview refused
– Language barrier
– Residence not occupied
• Evacuated Vacant
• Dwelling destroyed
• Other (specify)
Seasonal occupant
Reason Unknown
Survey Instrument
What data needed to be
collected for Hurricane Isabel?
• The SURVEY FORM
– Damage to homes
– Availability of usable utilities
– Incidence of hurricane related illness / injury
– Access to medical care
– Access to food and water
– Self-identified immediate needs
Injury and Violence Prevention Branch, NC-DHHS DPH
Respondent Referral Form
Strategies for collecting the data
• Paper form - delayed data entry in the field;
more delayed data transmission
• Access database; Epi Info for data analysis
• Electronic form on laptop/iPAQ - direct data
entry; delayed data transmission
• Hurricane Isabel: Paper form w/ Delayed DEDelayed DT
• Hurricane Charley: Direct DE w/ Delayed DT
• Next time: Direct DE/Direct DT
Injury and Violence Prevention Branch, NC-DHHS DPH
What else was needed?
• Introductory script
– English and Spanish
• Question by Question instructions
– Standard in formal epidemiologic research
– Often only form of procedure manual when
preparation time limited RNA situations
– Often deciding factor in complicated analysis
Injury and Violence Prevention Branch, NC-DHHS DPH
Scripting: English Introductory Script
Introductory Script
• Identifies and legitimizes the interviewer
• States reasons for conducting the survey
– Safe living conditions
– Need within household for medical care
• Assures respondent of the confidentiality
of responses
• Selects the household respondent
Injury and Violence Prevention Branch, NC-DHHS DPH
Question by Question
Instructions
• Refresher guide to interviewers after
training
• Standardized definitions
• Instructions for probing
• Instructions for recording or reading
response categories
• Instructions for when to refer
Injury and Violence Prevention Branch, NC-DHHS DPH
Survey Instrument
• Header
– Date
– Interviewer
– Sampling information
– Respondent information
Injury and Violence Prevention Branch, NC-DHHS DPH
Survey Instrument
• Household information
– type
– usual number of residents
– residents during the storm
• persons at increased risk
Injury and Violence Prevention Branch, NC-DHHS DPH
Survey Instrument
• Damage to house from the hurricane
– habitability of structure
– tarp needed
– amount of flood water in the house
– missing: amount of mud or debris
Injury and Violence Prevention Branch, NC-DHHS DPH
Survey Instrument
• Current status of household utilities
– running water
– power
– toilet
– telephone
– radio
– use of generator
– use of charcoal
Injury and Violence Prevention Branch, NC-DHHS DPH
Interviewer Training
Injury and Violence Prevention Branch, NC-DHHS DPH
Interviewer Training – Recap
from August Lecture
•Training is NOT (never) optional!
•Trainings must be interactive
•Interviewers must practice reading
questions out loud
•Provide support documentation
(manual)
Injury and Violence Prevention Branch, NC-DHHS DPH
Interviewer Training
• Planning and implementation logistics
• Explanatory notes for interviewers
– Scripting
– Terms defined
– Instructions for probing
– Rapport and feedback
– Instructions for disaster relief referrals
– Other. . .
Injury and Violence Prevention Branch, NC-DHHS DPH
Interviewer Training
Maintaining rapport is more complex during a
public health crisis than during a routine survey.
An interviewer should be:
• Nonjudgmental
• Noncommittal
• Objective
• And yet, interviewer must provide
reassurance.
Injury and Violence Prevention Branch, NC-DHHS DPH
Interviewer Instructions
Interviewer Training
Terms Defined in QxQ’s
• 10. [INTERVIEWER] What type of dwelling
is this? ___
• 1= single family
• 2= mobile home
• 3= 2-5 family
• 4= 6 or more family
• 5= other
– QxQ: Selection based on type of housing, not
the number of families living in the premises
Injury and Violence Prevention Branch, NC-DHHS DPH
Interviewer Training
Terms Defined in QxQ’s
• 11. How many people lived in this residence
before the hurricane? ____
• QxQ: Enter the number of people who routinely
slept and ate at least one of their meals at this
residence prior to 9/18/03, e.g., exclude students
or military personnel living away from home,
overnight guests, etc. Enter “99” for Don’t Know.
• At issue: simple question; complex definition;
probing likely; provision for Don’t Know.
Injury and Violence Prevention Branch, NC-DHHS DH
Interviewer Training
Terms Defined in QxQ’s
• 13. How much external damage was there
from the hurricane to the residence? ___
• 1= none or minimal
• 2= damaged, but habitable
• 3= damaged, but uninhabitable
• At issue: categories are read aloud;
habitable means safe to live in; based on
respondent’s answer; skip pattern.
Injury and Violence Prevention Branch, NC-DHHS DPH
Interviewer Training
Terms Defined in QxQ’s
•
•
•
•
16.e Does the indoor toilet work? ___
1= yes
2= no
3= never had
9= Don’t know
Enter YES (1) even if waste material can be
flushed by pouring water into commode. Enter
Never Had (3) when the residences does not
have any kind of indoor standard toilet.
• At issue: complex definitions; skip pattern;
potential for referral.
Injury and Violence Prevention Branch, NC-DHHS DPH
Lessons Learned
Injury and Violence Prevention Branch, NC-DHHS DPH
Lessons Learned (1)
• Include representative from Latino
(minority) community from the beginning
– Cultural sensitivity / correctness
– Translation of forms, scripts
• Include question on the presence of mud
or debris in survey questionnaire
– Appropriate for mountains and flatlands
Injury and Violence Prevention Branch, NC-DHHS DPH
Lessons Learned (2)
• Discuss at outset need for including
questions on current conditions versus risk
factors for potential problems
– Landslides often occur days after hurricane
– Floods often occur days or weeks after event
Injury and Violence Prevention Branch, NC-DHHS DPH
Lessons Learned (3)
• Emotional / mental stress is frequent after
mass trauma – how to craft questions that
will identify stress that is not easily abated
– Cost-benefit of asking about highly
emotionally charged events, e.g., death of
family member(s)
Appendix
Spanish Introductory Script
Spanish RNA Survey Instrument
Session Summary
Session Summary
With an understanding of good questionnaire
design principles, you will ask only about what
you need to meet your research objectives.
In preparation for questionnaire design, you
should: have clear research objectives; list
variables to be measured; identify an analysis
plan; and consider cost and logistical aspects.
Session Summary
Use a hypothesis generating questionnaire to
explore all potential sources of infection, but with
a small number of cases and no comparison
group.
A hypothesis testing questionnaire literally tests
a research hypothesis based on data collected
via a hypothesis generating questionnaire.
Include both cases and controls in the survey
sample population.
Session Summary
The three broad question types are: closedended; open-ended; and fill-in-the-blank. You
may use only one or a combination of all,
depending on the purpose of your survey.
Key elements of question design are: reliability;
validity; specificity; simplicity; asking only one
question; mutually exclusive answer choices;
providing date / time references; and using
response options that parallel existing data
sources.
Session Summary
A well-formatted questionnaire minimizes
respondent burden by: using question order,
spacing, distinctive font, symbols, and simple,
short instructions to facilitate navigation; and
using customized components for interviewer
administered versus self-administered settings.
Question type and response option formatting
impact how you can design an on-screen data
entry form and / or analyze variables in your
software program.
References and Resources
1. American Statistical Association (1999). What Is a
Survey? Designing a Questionnaire. Alexandria, VA:
Section on Survey Research Methods.
2. American Statistical Association (1997). What Is a
Survey? More About Mail Surveys. Alexandria, VA:
Section on Survey Research Methods, American
Statistical Association.
3. Centers for Disease Control and Prevention, Food
borne and Diarrheal Diseases Branch, Food borne
Outbreak Response and Surveillance Unit (2003).
Outbreak Investigation Toolkit: Standard
Questionnaire. Online resource:
http://www.cdc.gov/foodborneoutbreaks/standard_questionnaire.ht
m
References and Resources
4. Centers for Disease Control and Prevention. Standard
Food Borne Disease Outbreak Questionnaire. (PDF
file) at:
http://www.cdc.gov/foodborneoutbreaks/question/stand
ard_questionnaire.pdf
5. Fowler, F.J. (1993). Survey Research Methods:
Second Edition. Sage Publications: Newbury Park.
6. Reingold, A. (1998). Outbreak Investigations – A
Perspective. Emerging Infectious Diseases. Vol. 4 No.
1: January – March 1998.
References and Resources
7.
Salant, P. and Dillman, D. (1994). How to Conduct
Your Own Survey. John Wiley & Sons, Inc.: New
York.
8.
Stehr-Green, J.K. (2002). A Multi-state Outbreak of E.
coli 0157:H7 Infection: Case Study Instructor’s Guide.
Atlanta, GA: U.S. Department of Health and Human
Services, Public Health Service, Centers for Disease
Control and Prevention.
http://www.phppo.cdc.gov/phtn/casestudies/classroom/
ecoli.htm
References and Resources
9. Stehr-Green, J. and Stehr-Green, P. (2004).
Hypothesis Generating Interviews. Module 3 of a Field
Epidemiology Methods course being developed in the
NC Center for Public Health Preparedness, UNC
Chapel Hill.
10. Torok, M. (2004). FOCUS on Field Epidemiology.
“Case Finding and Line Listing: A Guide for
Investigators.” Volume 1, Issue 4. NC Center for Public
Health Preparedness.
11. Wiggins, B. and Deeb-Sossa, N. (2000). Conducting
Telephone Surveys. Chapel Hill, NC: Odum Institute
for Research in Social Science.
Slides from Today’s Session
Following this program, please visit one of the
web sites below to access and download a copy
of today’s slides:
NCCPHP Training web site:
http://www.sph.unc.edu/nccphp/training/index.html
North Carolina Division of Public Health, Office
of Public Health Preparedness and Response
http://www.epi.state.nc.us/epi/phpr/
Next Session October 12th
10:00 a.m. - Noon
Topic: “Analyzing Data”
Site Sign-in Sheet
Please mail or fax your site’s sign-in sheet to:
Linda White
NC Office of Public Health Preparedness
and Response
Cooper Building
1902 Mail Service Center
Raleigh, NC 27699
FAX: (919) 715 - 2246