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Public Health Information Network (PHIN) Series II. Outbreak Investigation Methods: From Mystery to Mastery. Access Series Files Online Session slides Session activities (when applicable) Session evaluation forms Speaker biographies

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Public health information network phin series ii l.jpg

Public Health Information Network (PHIN) Series II

Outbreak Investigation Methods:

From Mystery to Mastery

Access series files online http www vdh virginia gov epr training asp l.jpg

Access Series Files Online

  • Session slides

  • Session activities (when applicable)

  • Session evaluation forms

  • Speaker biographies

    Alternate Web site:

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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

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Series IISession V

“Interviewing Techniques”

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Series II Sessions

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CDCOutbreak Management System

Software Support: National Center for Public Health Informatics

[email protected] / (800) 532-9929, option 6

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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]

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OMS User Interface


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OMS User Interface


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OMS in Virginia


Michael A. Coletta, MPH

Bioterrorism Surveillance Coordinator

Division of Surveillance and Investigation

Office of Epidemiology

Telephone: (804) 864-8099

Email: [email protected]

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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

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“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

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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

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Aaron Wendelboe, MSPH

Doctoral Candidate and

Graduate Research Assistant,

NC Center for Public Health Preparedness

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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

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Interviewing Techniques


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  • 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

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Role of Interviews in Outbreak Investigations

Primary purpose: data collection

  • Case identification

  • Risk factor identification

  • Hypothesis generation

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Interviewing Methods

  • Interviewer Administered

    • Face-to-face

    • Telephone

  • Self Administered

    • Mail-out

    • Email

    • Web-based

  • Combination of 1 and 2

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Questionnaire Design

Interview Method Influenced by:

  • Length and format of questionnaire

  • Question types used in a survey

  • Cost considerations for survey implementation

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

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Source Pop: Students (12,000)

Sampled pop (150 students)

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Why Sample?

Because it is more efficient – saves time and money!

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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.

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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.

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Problems with Convenience Sampling

  • Based on subjective judgment

  • Cases may or may not be representative of the total population

  • May lead to biased results

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Additional Resources:

  • “Sampling Case Studies”

  • “Survey Sampling: Precision, Sample Size, and Conducting a Survey”

  • “Survey Sampling Terminology and Methods”

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Response Rates

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Response Rates

Response rates measure the percentage of your sample that has participated in your survey.


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%.

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Response Rates

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

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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)

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Response Rates

What is an average response rate?

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Response Rates

Determining Response Rates

Refer to the American Association of Public Opinion Research website:

  • Link to the document titled, “Standard definitions” from the home page.

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Interviewer AdministeredData Collection Considerations

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Interviewer Administered Data Collection

  • Advantages and disadvantages of

    face-to-face interviews

  • Advantages and disadvantages of telephone interviews

  • Advantages and disadvantagesof Computer assisted interviews

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Face-to-Face Interview


  • 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)

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Face-to-Face Interview


  • Costly

  • Potential for interviewer error

  • Less anonymous than self-administered

    • Potential for dishonesty

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Telephone Interview


  • 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

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Telephone Interview


  • 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

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Computer Assisted Interviewing (CAI)

  • CATI – Telephone

  • CAPI – Personal

  • ACASI – Audio

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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

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Field Data Collection

EPI Info


Wireless: WIFI 802.11 or Bluetooth

Field Team 4

Field Team 5

Field Team 1

Field Team 2

Field Team 3

Field data collection using IPAQ Pocket PCs equipped with GPS, GIS software and data collection forms.

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No special skills required for data recording


Requires double data-entry

Greater risk of data errors

Clipboard and paper more cumbersome in the field


Eliminates double data entry

Provides routing and direction-finding for field teams

Improved randomization through GIS

Ability to quickly analyze and map data


Technology is expensive

Learning curve / required training for data entry

Small screen size requires scrolling through many questionnaire pages


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For More Information. . .

Steven Ramsey, RS

Team Leader / Industrial Hygienist


Guilford County Health Department, NC

(336) -641-8192

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Self AdministeredData Collection Considerations

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Self-administeredData Collection

  • Advantages and disadvantages of

    mailed questionnaires

  • Advantages and disadvantages of

    Web-based questionnaires

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Mailed Questionnaire


  • More anonymous

  • May collect more honest responses

  • No interviewer error

  • Less expensive

  • Respondent has more time to think about question

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Mailed Questionnaire


  • Questionnaire must be simple

  • Higher item non-response

  • Lower response rate

  • Data collection takes more time

  • Sample population must be literate

  • Coverage / frame deficiencies

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Web-based Questionnaire


  • 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

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Web-based Questionnaire


  • 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

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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.

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Web-based Questionnaire

For a list of vendors that provide Web-based survey tools, please visit:

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Question and Answer Opportunity

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5 minute break

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Standardizing Interviews

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Standardizing Interviews

  • 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

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Interviewer Error:

Deviation from expected answer due to the effects of interviewers.

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Interviewers probe on the sexual history section more among non-whites than whites


A male interviewer may elicit different responses from a female respondent than a female interviewer.

Interviewer ErrorExample: Gonorrhea outbreak

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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.

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Standardizing Interviews

Contributing Factors:

  • Question wording

  • Interviewer selection

  • Interviewer training

  • Interviewing procedures

  • Supervising interviewers

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1. Question Wording

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Question Wording

Criteria for Standardized Interview Questions

  • Must be fully scripted

  • Must mean the same thing to every respondent

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2. Interviewer Selection

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Interviewer Selection

Criteria for Telephone Interviewer Selection

  • Ability to read questions fluently

  • Clear and pleasant telephone voice

  • Responds quickly to respondent’s questions

  • Reliability

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Criteria for Face-to-FaceInterviewer Selection

  • Logistical skills (reading maps)

  • Good interpersonal skills

  • Independent workers

  • Reliability

  • In certain circumstances, parallel demographic characteristics among interviewers and interviewees

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3. Interviewer Training

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Interviewer Training

  • Training is NOT optional!

  • Trainings must be interactive

  • Interviewers must practice reading questions out loud

  • Provide support documentation (manual)

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Interviewer TrainingElements

  • 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

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Interviewer Training

Respondent Selection Process

Provide proxy respondent rules for adults and children because proxy response impacts:

  • Data quality

  • Sampling

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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

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Reading maps

Getting to respondents’ homes


Dress code

Scheduling callbacks


Operation of equipment

Operation of CATI software (if applicable)

Interviewer TrainingLogistics

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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

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Interviewer Training

Interviewer Manual

An interviewer manual serves as a reference to interviewers during interviews and as survey documentation.

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Interviewer Training

Suggested Interviewer Manual Contents

  • Background information

  • Fieldwork

  • Interviewing techniques

  • Survey instrument terms and definitions

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Interviewer Training Program Example

Behavioral Risk Factor Surveillance System (BRFSS)

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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

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BRFSS Interviewer Training

On-line interviewer training available at:

General information about BRFSS:

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4. Interviewing Procedures

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Interviewing Procedures


  • Read questions exactly as worded

  • Probe inadequate answers, if necessary

  • Record answers without interviewer discretion

  • Maintain rapport with respondents

  • Maintain an even pace

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Interviewing Procedures

Read questions exactly

  • Read entire question before accepting an answer

  • Clarify questions if necessary

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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

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Interviewing Procedures


A probe is a standardized way to obtain additional information from a respondent.

Use probes when a respondent’s answer is unclear or irrelevant.

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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."

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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?

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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

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Probing versus Leading


Interviewer: In the last 7 days, how many times did you eat prepared food at the dorm cafeteria? Would you say:

  • Noned. 3 times

  • Oncee. More than 3 times

  • Twice


    “Oh, gee, I didn’t go very often . . . maybe a few times.”

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Probing versus Leading


Interviewer Probe (correct)

“Which would be closer: none, once, twice, 3 times, or more than 3 times?”

Interviewer Leading (incorrect)

  • “So, would you say twice, or three times?”

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

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Interviewing Procedures

Maintain Rapport

An interviewer should be:

  • Nonjudgmental

  • Noncommittal

  • Objective

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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

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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.

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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”

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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.

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Question and Answer Opportunity

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Activity: Correct Interview ProceduresProbing vs. Leading vs. Feedback

Completion time: 5 minutes

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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.

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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.”

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Suggested Answer

Respondent 2:

“I definitely had diarrhea last Tuesday”

Try a Probe:

“OK, but are you still experiencing diarrhea?”

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Suggested Answer

Respondent 3: “Yes”

Good Feedback: “I see”

Bad Feedback: “Are you sure?” (leading)

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5. Supervising Interviewers

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Supervising Interviewers

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

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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

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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.

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Human Subjects & Informed Consent

If further analysis of outbreak investigation data is conducted for the purpose of research, IRB approval should be obtained.

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Respondent Perspective

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

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Outbreak Investigation Perspective

  • Do not discuss details about the outbreak

  • Provide only a brief description of the purpose of the survey at first contact

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Question and Answer Opportunity

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5 minute break

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Guest Lecturer

Erin Rothney, MPH

Research Associate

NC Center for Public Health Preparedness

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  • 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

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Face-to-face Interviews

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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

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Durham, NCCommunity Assessment

  • Fall 2002 - Spring 2003

  • Bragtown Neighborhood, Durham, NC

  • 5 person team

  • Interviewedresidents and other stakeholders in Bragtown

  • 4 page survey,60 minutes in length

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Durham, NCCommunity Assessment


  • Questionnaire design

  • Interviewer training

  • Interviewing

  • Facilitating focus groups

  • Analyzing data

  • Presenting data to the community

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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?

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Interviewer Training

  • Active listening skills

  • Showing empathy

  • Using probes

  • Practice interviewing, not just reading questions

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Hard to find people at home

People may not want to invite a stranger into their home

Costly and time-intensive method of interviewing


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

Face-to-face Interviews

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Lessons Learned

  • Study community demographics and characteristicsbefore you interview

  • Train interviewers before an immediate need

  • People like to tell you their stories- could lead to relevant information

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Telephone Interviews2004 E. coli Outbreak Investigation

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E. coli Outbreak Investigation Telephone Interviews

  • Illness onsetOctober - November 2004

  • Geographically dispersed cases in multiple states

  • Case-control study

  • Train-the-trainer, interviewer

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E. coli Outbreak InvestigationTelephone 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

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Lessons Learned

  • Practice reading through the questions and conducting an interview

  • The media can be your friend

  • Use an introductory script torelate 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

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Community Assessment

Establish rapport

Identify people in a small geographic area

Assess the environment of the area


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


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Question and Answer Opportunity

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Session Summary

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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.

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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.

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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).

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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.

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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.

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Next Session November 3rd1:00 p.m. – 3:00 p.m.

Topic: “Analyzing Data”

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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.

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References and Resources

  • Fowler, F. and Mangione, T. (1990). Standardizing Survey Interviewing. Newbury Park: Sage Publications.

  • 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: 4th Edition. Oxford University Press: New York.

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References and Resources

  • Levy, P. and Lemeshow, S. (1991). Sampling of Populations. John Wiley & Sons.

  • 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.

  • 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.

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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

  • 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.

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