Presenters: Doris Campbell, PhD, ARNP, FAAN, University of the Virgin Island

1. Caribbean Exploratory [NIMHD] Research Center of ExcellenceUniversity of the Virgin IslandsSchool of NursingGrant Support: National Institute on Minority Health and Health Disparities, NIH (# P20MD002286). The Caribbean Exploratory [NIMHD] Research Center of Excellence and Global Health Research Collaboration: Protecting Haitian Women and Children  Earthquake Survivors from Violence and Abuse

2. METHODS, DESIGN AND ANALYSIS PLANS INCLUDING AUDIO COMPUTED ASSISTED SELF INTERVIEWS (ACASI) FOR HAITI PROJECT Presenters: Doris Campbell, PhD, ARNP, FAAN, University of the Virgin Island HosseinYarandi, PhD, Wayne State University Desiree Bertrand, MSN, RN Lorna Sutton, MPA University of the Virgin Islands Phyllis Sharps, PhD, RN, FAAN, Johns Hopkins University

3. NBNAJULY 13, 2011 OBJECTIVES: At the conclusion of this presentation participants will be able to:Discuss strategies for determining the prevalence of intimate partner violence, non partner violence, sexual abuse and emotional abuse in women and adolescent girl survivors of the Haitian earthquake. Discuss strategies designed to build an effective advisory coalition to support research on violence against internally displaced women and girls following the Haiti earthquake. Describe research design, methods and analysis plans and challenges to conducting researching on violence and abuse of internally displaced women and children following the Haiti earthquake.

4. STRATEGIES • Determine prevalence of intimate partner violence, non partner violence, sexual and emotional abuse in displaced women and girls • Audio computer assisted self interviews (ACASI) in a descriptive survey. • Develop safety education and training program to protect vulnerable women and girls from risk of violence and abuse • Brief cognitive behavioral traumatic recovery intervention adapted for the Haitian culture and current context as well as engaging the community (including boys and men) to decrease norms tolerating VAW in Haiti. • Combine the expertise of members of the Advisory Coalition from from Haiti with US consultants • Support ongoing violence prevention activities • Outcome evaluation

5. ADVISORY COALITION Strategies for developing Advisory Coalition • Identify researchers, health professionals, governmental and community organizations and advocates to participate as partners in study • Conduct focus groups for input on adapting methods for recruiting and screening participants, access, availability and utilization of services, • Identify major elements of program to protect the safety of displaced women and adolescent girl survivors of the Haitian Earthquake.

6. ADVISORY COALITION • Use the situational analysis results to adapt and develop culturally relevant and linguistically appropriate safety protocols to be implemented with internally displaced women and adolescent girl survivors in Haiti. • Identify best practices for addressing violence and abuse in Haiti, how to best work with the local government, local NGOs and community partners to develop sustainable programs for victims in communities. • May 2011 – Small team of experts visited Haiti . Met with Haitian potential partners to identify and observe the living situations for the women and children in the IDP camps

7. NEXT STEPS • Assessment of local governmental and NGOs and resources prior to the earthquake and current functioning of those agencies • Identify gaps in services • Interviews with international NGOs, service providers • Interview male survivors • Challenges in Haiti • Insuring women get appropriate treatment for IPV, depression, suicide or dangerous situations may be challenging in Haiti due to disruption of service delivery systems.

8. Conducting Surveys in Developing Countries • Conducting survey in a developing country can be a major undertaking, and the costs in terms time and money should not be underestimated. • It should be tailored to specific research questions. • It carries high potential to yield truly new insights. • Collaborating with local people on surveys is essential.

9. Collaboration • Successful surveys in developing countries depend on the support of energetic, capable research collaborators from the host country who know how to get things done within the country’s institutional, political, and social environment • They are skilled at interacting with government officials and community leaders; have developed reputations within the country that build trust; and have valuable substantive insights into the research questions. • On the flip side, collaborators pursuing agendas at cross-purposes with those of the researcher can easily frustrate research plans. • Researchers have limited ability to control either the organization or the individuals with whom they must deal.

10. Collaboration • It is critical to cultivate a positive working relationship. • Making sure that the collaborators perceive benefits to making the collaboration a success. • get them excited about the important contribution of the research • encourage collaborative research products • help the collaborators realize their own intellectual goals • provide adequate compensation for services • take the time to develop personal relationships

11. Sampling • Sampling is one of the most critical aspects of any survey because it forms the basis for the key claim of generalizability, which is the main strength of quantitative research. • Sampling designs can be very complicated, depending on the goal of the research • The first step in sampling is to clearly define the population of interest • The next step is to develop a sampling frame, or a list of possible respondents.

12. Sampling • Researchers must consider trade-offs among sampling error, nonsampling error, and cost in making decisions in the field regarding sample selection. • Statistically, a larger sample makes it possible to measure the relationships between variables with greater precision. • In general, sample sizes of fewer than 200 observations often make it challenging to employ appropriate empirical methods or to produce results that are statistically significant.

13. Questionnaire Design • Clearly defining the research question is the first step in designing an effective questionnaire. • Do not ask an exhaustive set of questions about everything without having a clear research question or methodology in mind. • the quality of information that survey respondents provide declines significantly after more than 60 minutes • Questions included in survey instruments should be worded in culturally appropriate language. • Active participation by local collaborators, informants, and study subjects is invaluable. • Questions should be simple, direct, and familiar to respondents.

14. ACASI Software Systems • ACASI stands for Audio Computer-Assisted Self-Interview. This questionnaire system is especially well suited for collecting sensitive data on topics such as alcohol and illegal drug use, risky sexual behavior, or intimate partner violence.

15. ACASI Advantages • Allows subjects to privately answer sensitive personal questions on a computer with headphones • Eliminates data entry time and errors • Questions are asked in the exact same way. • Works well for subjects with literacy issues

16. ACASI Possible Question Types • Yes/No • Multiple Choice – Select One Answer • Multiple Choice – Select All That Apply • Scale • Numeric Entry • Text Entry • Interviewer-Administered • Multiple Language

17. Translated Adult Questionnaire (Excerpt) English Adult Haitian Creole Adult B.4. nan tan lontan 2 ane sa yo, anvantranbleman de tè a, te genyonmounfòse ou pou genaktiviteseksyèl? a. Wi b. Non B.4.1 pa te si wi, mounkifè sa pou ou? (Lè sa a, tout sa aplikecircle) a. Mari b. ansyen-mari c. amoure d. ansyen-anmore e. patnè (bwa) f. ansyenpatnè g. famillòt • B.4.1 Since the earthquake, has anyone forced you to have sexual activities? Yes No • B.4.1.If yes, who did this to you? • (Circle all that apply) • a. Husband • b. Ex-husband • c. Boyfriend • d. Ex-Boyfriend • e. Partner (same sex) • f. Ex-Partner • g. Other

18. Translated Interview (Excerpt) English Adolescent Haitian Creole Adolescent SCREENING (AAS) • B.1. Before the earthquake, had you ever been emotionally or physically abused by someone important to you? Yes No • B.1.i If yes, who did this to you? (Circle all that apply) • Boyfriend • Ex-Boyfriend • Partner (same sex) • Ex-Partner • Other family member

19. Managing the Data • Individuals responsible for interviewing respondents play a critical role in determining the quality of survey data. • They can be university students, research institute staff, or professional survey staff. • Training of collaborators should include basic interview techniques; explanation of the goals of the research; and discussion of survey protocols, the meaning and purpose of each survey question, and protocols to follow when respondents do not understand questions or refuse to answer. • It is critical that the work of collaborators be monitored systematically.

20. Managing the Data • Data entry and cleaning. • It is often cost effective to enter the data while in the host country. • Some surveys now enter the data in the field, by means of notebook computers • improve data quality, • Can increase costs because of greater hardware requirements

21. Analysis of Survey Data • The analysis of survey data may take many forms. • Most often, descriptive statistics are used to summarize responses. • When quantitative data such as age are collected, we should present summary measures (mean, standard deviation, minimum, and maximum). • With categorical data, we should report the frequency of responses to specific questions. • These frequencies are typically converted to a percentage of the total sample. • For example, we might report that 40% of the sample was male and 60% was female, or in a question about opinions, that 25% strongly agree, 30% agree, 8% disagree, and so on.

22. Analysis of Survey Data • Percentages should always be accompanied by reference to the total sample size, so that the reader can determine the actual number of responses in each category. • Percentages are usually more meaningful than actual frequencies because sample sizes may differ greatly among studies. • Another common approach to data analysis involves the description of relationships between two or more sets of responses. • The chi-square test can be used to examine this relationship statistically, to determine if there is a significant relationship between the two variables.

23. Analysis of Survey Data • Depending on the length and complexity of the questionnaire, we can present response percentages for all questions on the survey, or they may simply summarize the more important relationships that were studied. • Some reports present purely narrative descriptions of the results; others include tables showing the responses to each question. We must determine which type of presentation will be most effective for the data.

24. Final Thoughts • Many unexpected things can occur during field research, such as • Delays due to political events, • Natural disasters, • Institutional factors, and so on. • Demands for more money, • Restrictions on research activity • It is a good idea to think about contingency plans for accomplishing the research goals well ahead of time, just in case things do not go as planned.

25. Data Collection Challenges • Identify the best methods to screen and collect data from abused women and girls residing in Haiti. • Develop and implement screening and data collection methods that are culturally sensitive and will facilitate Haiti women and girls disclosing their abuse status and experiences.

26. Data Collection Challenges SELECTION OF INTERVIEWERS – CONSIDERATIONS: • Probability of interacting with participants post-interview unpredictable due to lack of stable living situation. • Hundreds of thousands still living in temporary housing in tent cities in and around Port au Prince • Collecting sensitive information

27. Audio Computer Assisted Self Interview SOLUTION: • Use audio computer assisted screening- ACASI • Intense initial and periodic training on confidentiality issues

28. ACASI Background Computer Assisted Screening • Software = Talker – developed by David Bertollo • Software is designed so researchers can use basic computer programming skills to develop simple scripts • Comprehensive questionnaire that uses text and audio for each question • Answers can be scored as participants responds to questions

29. ACASI Screening Computer Assisted Screening: Talker Software • Questions are presented one screen at a time • Text is clear and LARGE • BIG ANSWER BUTTONS • Equipment • Tablet PCs • Touch Screen or stylus

30. ACASI: First Screen

31. ACASI Screen: Demographics

32. ACASI: Screening for IPV

33. ACASI Screen: Partner

34. ACASI Screen: IPV and Partner

35. ACASI Screen: IPV &Relationship

36. ACASI Screen: Eligible

37. ACASI Screen: Ineligible

38. Advantages of ACASI • Increases access to health care by: • Using culturally competent approach to Gender Based Violence Screening including IPV screening for women in all health care settings . • Increasing accurate identification of IPV, rape and other acts of violence against women and girls • Increases collaboration with community resources through referrals • Increases collaboration with whole community by increasing awareness of unmet health care needs of abused women

39. Methods: Pilot of ACASI • Pilot Sample: US • Eligibility criteria • Women aged 18-55 years • Self-identify as Afro Caribbean or African American • Report of a male sex partner in the past two years • Women recruited from primary care, prenatal or family planning clinics • Questionnaire administered on a touch screen computer with optional headphones - an important methodological strategy • For women of low literacy • For sensitive information • Alerts interviewer if high score on DA or suicidality • Allows increased recruitment among Spanish speaking • Recording in Spanish & English by USVI residents • for increased cultural appropriateness • Study period: 2007 - 2012 – data collection began 12/2009

40. Pilot Sample Responses (US) • 3 of 21 participants preferred paper/pencil administration of questionnaires • All 21 participants stated ACASI was easy to use • 50% of the participants needed help with the ACASI system

41. Lessons Learned for Haiti Study • Use bilingual speakers for recording of questionnaires • Incorporation of culturally appropriate language into French and French Creole translations • Words • Dialects • ACASI system will be pilot tested with representative sample of Haitian women and adolescent girls prior to beginning study • Displaced since earthquake • Woman and adolescent girls 12-44 • Speak Haitian Creole, French or English

42. THANK YOU!! QUESTIONS?