2004 Public Health Training and Information Network (PHTIN) Series

1. 2004 Public Health Training and Information Network (PHTIN) Series

2. 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

3. Outbreak Investigation Methods From Mystery to Mastery

5. 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

6. 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)

7. 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/

8. Session IV “Designing Questionnaires”

9. 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,

10. “Designing Questionnaires” Learning Objectives Upon completion of this session, you will: • Understand the role of questionnaire design in an outbreak investigation • Know how to develop a hypothesis generating questionnaire • Recognize key planning strategies for successful questionnaire design

11. “Designing Questionnaires” Learning Objectives • Recognize key characteristics of well-designed questions • Recognize three broad question types and when to use them • Understand what different question types measure, and the type of data (quantitative versus qualitative) they yield

12. “Designing Questionnaires” Learning Objectives • Know how to format questionnaires for interviewer administered or self-administered settings • Recognize the impact of questionnaire design on View design and data analysis in Epi Info software

13. Designing Questionnaires

14. Basic Steps of an Outbreak Investigation • 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

15. Designing Questionnaires

16. Session Overview • The importance of questionnaire design • Hypothesis generating versus hypothesis testing questionnaires • Preparing for questionnaire design • Question design • Question type • Questionnaire format

17. 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.

18. Why is Questionnaire Design Important? With an understanding of good questionnaire design principles, you will ask only aboutwhat you need to meet your research objectives.

19. 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.

20. 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

21. 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.

22. Hypothesis Generating Questionnaires

23. Which Questionnaire Type Should You Use? • Hypothesis Generating? • Hypothesis Testing?

25. 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

26. 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

27. Hypothesis Generating Questionnaire

28. Hypothesis Generating Questionnaire

29. Hypothesis Testing Questionnaires

30. 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.

31. Hypothesis Testing Questionnaire

32. Hypothesis Generating Account for consumption of ground beef, lettuce, alfalfa sprouts, un-pasteurized milk or juice, and swimming in or drinking sewage-contaminated water Hypothesis Testing [beef suspected]: Beef brand, date of purchase, and grocery store or restaurant where beef was purchased or eaten Hypothesis Generating versus Testing Questions: E. coli 0157:H7

33. Preparing for Questionnaire Design

34. Preparing for Questionnaire Design There is more to questionnaire design than writing questions. Ideally, you should first: • Have a clear purpose and research objectives • List variables to be measured • Have an analysis plan • Consider cost and other logistical aspects

35. Questionnaire Design • 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?

36. Questionnaire Design • 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.

37. Questionnaire Design • Go to: http://www.cdc.gov • Under “Health & Safety Topics” in the left margin, click on, “Diseases & Conditions” • 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]

38. Questionnaire Design

39. Questionnaire Design • 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.

40. Questionnaire Design • Consider cost and other logistical aspects • What is the survey sample size? • What is the geographic distribution of the survey sample? • Will questionnaires be interviewer administered or self-administered? • What is your staff capacity to work within the parameters of a – c above?

41. 5 minute break

42. Question Design

43. Question Design Elements of good question design: • Reliability • Validity • Specificity versus ambiguity • Simplicity • Only one question asked • Mutually exclusive answer choices • Refers respondents to specific dates / times for recall • When feasible, make sure data can be compared to existing sources of information

44. 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.

45. 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.”

46. 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.

47. Valid Question Design Less Useful Which is your source of drinking water at home? • Tap water • Bottled water Better Which is your source of drinking water at home? • Municipal tap water • Municipal tap water with additional filtration • Well water • Commercially bottled water

48. 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’?”

49. 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?”

50. 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?