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Emergency Room Survey. Survey Planning, Administration and Cost. SIDUC: AN INTEGRATED SYSTEM OF DRUG USE SURVEYS. Key Informants. FORENSIC MEDICINE. Detention Centers. HOUSEHOLD SURVEYS. JUVENILE OFFENDERS . EMERGENCY ROOMS. STUDENT SURVEYS. TREATMENT CENTERS. SIDUC STANDARDIZATION.

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Emergency room survey l.jpg

Emergency Room Survey

Survey Planning, Administration and Cost


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SIDUC: AN INTEGRATED SYSTEM OF DRUG USE SURVEYS

Key Informants

FORENSIC MEDICINE

Detention

Centers

HOUSEHOLD SURVEYS

JUVENILE

OFFENDERS

EMERGENCY ROOMS

STUDENT SURVEYS

TREATMENT CENTERS



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EMERGENCY ROOMS

  • Population of reference:

    • Patients of Emergency Rooms.

  • Analyzed population:

    • a) all patients b) “typical weeks”. Judgmental sample.

  • Method of data collection:

    • Interview & laboratory analysis.


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FORENSIC MEDICINE

  • Population of reference:

    • Death by accident, homicide, suicide.

  • Analyzed Population:

    • a) all , b) “Typical weeks”.

  • Method of data collection:

    • Autopsy and laboratory analysis.


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Steps to be Taken

  • A funding source or multiple sources must be found (or no survey)

  • Decisions must then be made about who will direct the research undertaking

  • What types of expert and staff support will be needed, and

  • What is a realistic timetable

    • for the overall endeavor

    • for the major components


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Session Outline

  • Core Survey Activities

  • Personnel

  • Budget

  • Schedule


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Core Activities

  • Establishment of Advisory Committee

  • Develop Proposal

  • Seek Permission to conduct

  • Finalize Methodology

  • Training

  • Survey Implementation

    • Data Collection, Handling, Analysis, Report Writing


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Advisory Committee

Stakeholders identification/representation

  • Ministry of Health

  • Public Hospital Authority

  • ER Director

  • Police

  • Ministry of Transport

  • Rep from private hospital

  • COB Research Unit

    N.B> Can avoid problems at the end

    Can help to “sell” the survey


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Communications Regarding Survey

  • Ministerial Responsibility (CMO)

  • Institutional Responsibility

    • Public Hospital Authority (PMH, RMH)

  • Institutional Review Boards/Ethics Comm.

  • How to contact the chosen hospitals

    • Administrator

    • ER Manager


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Contact With Selected Institutions

Step 1

  • An introductory letter to the Administrator, informing him/her of the study and its purposes. It will also:

    • Ask to inform the ER Manager of decision

      Step 2

  • Contact the ER manager via telephone to confirm that everything is in orderjust prior. At this point:


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Project Personnel

  • Lead Investigator(s)

  • Core Staff

    • Site managers

    • Data Managers

  • Data Collection Staff

    • Doctors

    • Nurses

    • Medical Records Clerks

  • Consultant(s)


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Personnel Selection Process Options

  • Advisory Committee to provide oversight of the enterprise and the selection of the lead investigators

    • AD: can help to engage people or organizations needed to fund, conduct, or make use of the research

    • DIS: “too many cooks in the kitchen” and may introduce political considerations into the process

    • REC: committee should deal with the broad policy and financial issues and leave the scientific decisions to the scientists

  • Recruitment of one or more individuals to run the project

  • Individual researchers may take the initiative to conduct such a survey


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Lead Investigator

  • Ideally will be a part of the activity from beginning to end

  • Will provide the planning and integration needed to be sure that the end product matches the needs and objectives

  • Should be trained social scientists with some experience in survey research techniques


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Core Staff(Site Managers)

  • These key individuals will remain with the study for its duration

  • Participate in various activities and make sure that they are carried out according to plan.

  • Most likely will supervise various components of the study, under the general direction of the lead investigator(s)

  • Should be well educated and preferably have some experience with research activities.


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Data Collection Staff

  • Decide whether the data will be collected by individuals from outside the hospitals or not

    • ER Staff: If the patients will trust the MDs or Nurse to protect their confidentiality

    • Outside Staff: If the staffing situation presents a challenge, then staff members must be hired, trained, supervised and usually compensated

      • trained health social workers, trained field interviewers from a survey research organization, university students, etc


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Consultants

Overall Planning

  • To direct technical assistance at various stages, depending of course on the areas of expertise of the lead investigators

  • If the lead investigators are new to this area of research, consider a short-term consultation with an experienced expert in the initial planning stage, again at the analysis planning stage, and perhaps at the interpretation stage

  • If brought in from abroad, seek the assistance and support of one of the international organizations that deal with the control of drug abuse (UNODC, OAS)

    Sample Planning

  • Consultation with a sampling statistician also is likely to be very helpful, again at an early point in the planning effort

    Statistical Analysis

  • If neither a general consultant from the substance abuse field nor statistician is able to help on data analyses, seek an expert on statistical analyses.

  • The job is usually not to actually conduct the analyses but to advise on the choice of analyses and appropriate computer programs for conducting them.


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Budget Planning

Personnel Costs

Non-Personnel Costs


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Factors that May Impact Personnel Budget

  • Labor costs in the country

  • Whether it is necessary to use data collection staff from outside the hospitals

  • The method of data entry

  • The need for technical assistance

  • The size of the sample needed and the size of the country across which that sample will be spread

    • influence both staff and travel costs

  • Amount of the personnel assigned to plan and conduct the ER survey who are already on the payroll of a participating agency.



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Phase

Specific Tasks

Time Frame

Cost ($US)

Planning

Data Collection

Training

Payment to Facilitators

Other (Travel etc)

Data Handling

Coding and Editing

Data Entry

Post Cleaning

Data Analysis

Estimated Budget for Bahamas Emergency Room Drug Survey


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Report Writing

Tabulation and Graphics

Draft Report

Editing of Report

Printing and Reproduction

  • Administrative Costs

    • ?

Coordinator Fees

Supervisors Fees

Supplies

Questionnaire and other Printing

General administrative costs

Total Estimated Cost

Estimated Budget for Bahamas Emergency Room Drug Survey (Cont’d)



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Scheduling Tips

  • Considerable time and expense can be saved by undertaking several streams of activity simultaneously

  • Anticipating which efforts need to be completed before the next steps can proceed

  • Schedule should not be too abbreviated as there may be some unexpected developments

  • Effort should be made to make realistic estimates of the time necessary to complete each line of activity

  • Field staff should not be promised work until the investigators actually expect to proceed with the data collection (increased costs)


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Survey Scheduling

  • Hospital Recruitment

  • Data Collection

  • Analysis and reporting

  • Dissemination and utilization activities


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Scheduling: Hospital Recruitment

  • If participation is decided by central edict (Ministry of Health), the process may be fairly rapid.

    • If involved in the planning, this assures their willingness to cooperate

  • If the individual hospitals or hospital authorities have the authority to decline cooperation, the process of securing cooperation can be a substantial and time-consuming one.

    • Investigator(s) may have to write to each hospital administrator inviting participation

    • Conduct a follow-up call (or possibly a series of calls) to urge the hospital’s participation and answer questions

    • Communicate with higher authorities, if their approval is also required.


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Scheduling: Data Collection

  • Once the main data collection is proceeding, the responsible investigators should be monitoring carefully the quality of the data being collected, to be sure that those collecting it in the field are following instructions, and to identify problems early that might be rectified.

  • Plans can also be underway for how the data is to be collected and forwarded and how the returned data are to be coded and/or edited

  • Also, the investigators can begin planning the analyses that they would like to conduct at the completion of data collection and data cleaning.


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Scheduling: Analysis and Reporting

  • Often not accorded the attention that they deserve because not enough time and resources were set aside for them at the outset of the study.

  • Be sure to leave a significant interval for the analysis, interpretation, and writing of results.

  • At this late stage, normally only the lead investigator(s) and an analyst or two are still needed on the study staff, perhaps in addition to a secretary.


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Scheduling: Dissemination and Utilization Activities

  • Once the report is completed, arrangements should be made to get it into the hands of people likely to be influenced by its results.

  • The lead investigators may wish to meet with certain groups, or make presentations to particular audiences to whom the work has relevance.

    • Policy and programmatic level




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Ethical Considerations

  • Data must remain completely confidential or completely anonymous

    • no identifying information on a patient’s questionnaire

  • If specific identifying information for the individual is contained on the questionnaires de-identify at the earliest possible stage

    • Store the personally identifying information separately from the answers to the rest of the questionnaire with some type of link system

  • Avoid publicly identifying individual hospitals if possible

  • Permission to participate at all levels

  • Commitment to use results


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Emergency Room Survey

QUESTIONNAIRE DEVELOPMENT


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Factors That Impact Final Content

  • Amount of time the medical staff can afford to make available in an A&E setting

    • Quality, completeness

    • Treatment Vs Prevention

  • SIDUC Rules

  • Possibility of including other topics due to cost sharing with other agencies

  • Ability of respondents to complete the questionnaire

    • Complexity should not exceed respondents’ capabilities



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Sequence and Priority of Elements In The Questionnaire

  • Introduction

  • Background and demographic characteristics

    • Age, Gender, Employment, Occupation

  • Use of alcohol

  • Use of illicit substances

  • Use of controlled substances



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Defining Drugs For The Respondent

  • Names and descriptions must be reviewed to see if they are appropriate in the cultural setting in which they will be asked.

  • The main point is that the names used accurately communicate to respondents which substance(s) should be included in what they report, and which substances should not, and under what circumstances.

  • To determine a list of appropriate slang or street names for various drugs, the investigators may want to speak with treatment professionals and known drug users in the age group under study.

  • If a longer question stem is required to get the definition clarified for your respondents, then that may be justified. (See SIDUC Manual)

  • For legally prescribed drugs, it is important that the respondents understand what occasions of use they should and should not report in answering the questions.




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Layout In The Event of Lab Confirmation

  • Blind Vs Not Blind

  • If Not, questions and Lab results on same form

    • No means to connect necessary

  • IF blind, questions and lab results are separated

    • Unique identifiers are needed to re-unite

      NB: identifiers can be added after A&E but before transfer to lab


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Other Useful Suggestions

  • Skip patterns are more difficult for respondents to follow correctly than a simple, uninterrupted series of questions; therefore, it is advised that they be minimized.

  • Pre-test by getting a limited number of “like” respondents to complete the questionnaire.

    • Determine average time to complete.

    • individually interview them about whether the instructions were clear and whether there were any questions or answers that they had difficulty understanding or using.

    • Determine if they understood each class of drug


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Other Useful Suggestions Cont’d

  • Pilot testing to:

    • see how the actual administration procedures in the ER will go,

    • see how long it takes the patients to answer the questions and

    • identify remaining problems in the content and clarity of the questionnaire.


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Emergency Room Survey

Data Collection Procedure


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Decisions Prior to Collection

  • WHAT What data will be collected

  • WHO Who will be responsible for data collection

  • WHEN When to collect data to ensure a “normal” sample

  • WHERE What hospitals are to be included

  • HOW How to conduct all aspects of survey administration


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What data will be collected

  • Questionnaires

    • SIDUC

    • Bahamas

  • Lab confirmation data

  • Site reports on:

    • # refusals

    • # ineligibles


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Who will be responsible for data collection

  • Conducting the interview of each section of the questionnaire

    • How to select survey leaders

      • A&E Data Flow

        • Lab sample flow

        • “routinely” collected information

  • Ensuring that a continuous supply of questionnaires are available

  • Ensuring a continuous supply of lab sampling equipment are available (?)

  • Ensuring that completed forms and lab samples are routed properly


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ER Staff

Pros:

already in the ER

know the ER and are familiar with ER routines

Patients may feel more comfortable with MD or Nurse

least expensive

Cons:

Competing interests

ER Services Vs survey completion

Research Assistant

Pros:

More consistency across hospitals

Cons

More expensive

doubts regarding the ability to convince patients to participate

E.g., Social Workers in Haiti

Selection of Survey Leader


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When to collect data

  • SIDUC - Sample

    Vs

  • Institutionalized – routinely collected as part of diagnosis


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Timing of Data Collection

  • It is important to choose a period which should not be preceded by any holiday, ensuring that the patients refer to a “normal” week or month when answering the questionnaire

  • If more than one hospital is included, it is a must to administer the data collection at the same time in all hospitals

  • In the event of inter-country comparisons (SIDUC), the time of data collection must be as similar as possiblesince the use of alcohol and other drugs vary at certain identifiable periods.

    e.g. December (Christmas) ↑

    January (Recuperation) ↓

    Holidays ↑

    Lent ↓


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Where will data collection take place

  • Geographic location

    • Islands

  • Hospitals

    • Public

      • Princess Margaret (Nassau)

      • Rand Memorial (Freeport)

    • Private

      • Doctors (Nassau)


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Activities During Administration

  • Instructions to the Survey Data Collection Staff

  • Instructions to the patients

  • Stress anonymity and confidentiality


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Who Should Complete Survey

  • Inclusion Criteria

  • Exclusion Criteria

    • Persons < 12 years of age

    • Gynae patients

    • Language barriers (Non-English speaking)

    • Unconscious patients (?)

      • If hospitalized and no identifiers to follow-up


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Patients who Refuse

Concern is due to the possible association between refusal and drug use:

  • It is important that the number of refusals be documented

  • Could compare % refusals from low and high prevalence areas

  • It is important that refusals are treated in the same way in all participating hospitals and countries.


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Survey Administration:Instructions to Patients

Survey Instructions can be written on the front pageof the questionnaire and should include information on:

  • The purpose of the study (If not incorporated into the system)

  • The selection of patients (All selected during study period)

  • The study is anonymous and/or confidential

  • Steps to ensure anonymity

  • Participation is important but if not willing, that is their choice


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To Ensure Anonymity

Following SIDUC Method

  • Questionnaires should not contain any identifiers

    • Name

    • hospital record #, etc.


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Survey Administration:Report

A report should be completed (periodically) by the survey leader

  • Total number of refusals

  • If the study only targets a specific group, the number of those excluded


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Checklist For Data Collection

  • Chose a survey leader trusted by the patients

  • Instructions to the survey leader

  • Describe how to treat patients not belonging to the target population

  • Describe how to treat refusals

  • Careful planning of the contacts with selected institutions

  • Safe transportation of material (lab component)

  • Detailed planning of the survey administration, including

    • stress anonymity and confidentiality

    • instructions to the survey leader

    • instructions to the patients

    • Shift report


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Overview of Methodological Issues:

Interpretation Of Data


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Overview of Session

  • Representativeness – the extent to which a sample mirrors the population of interest

  • Reliability – the extent to which repeated measurements used under the same conditions produce the same result

  • Validity – the extent to which answers are accurate representations of the underlying reality that they are intended to measure


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Factors that Influence Representativeness

  • The sampling method

  • The size of the sample

  • Response rate: The number of eligible non-gynae emergency room patients that agree to participate in the survey


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The Method of Sampling: Target Population

The target population in the Emergency Room survey is, by definition, persons who chose to come to the emergency room and excluding other individuals who, for whatever reason, chose not to attend.

  • Beware that all injured persons do not come in due to a number of reasons (choice, inaccessibility, etc.)

  • Less-severely injured persons who do not come in may be the result of reasons related to substance use

  • Large differences in emergency room attendance (access, availability) between countries may make it difficult/impossible to make meaningful international comparisons


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Method of Achieving Representativeness

  • Random sampling is fundamental to obtaining a sample that is representative of the population

  • OR

  • Sample the entire target group


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Sample Size and Representativeness

  • the number of sampled patients must be of sufficient size

  • considerations must be given to the extent of the analysis of drug habits in different subgroups

    • always important to sample enough patients to be able to analyse data separately for males and females

  • Response rate must be sufficiently high to enable representative data to be obtained


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Categories of Response Rates

  • Institutional Cooperation

    • Public and Private Hospitals

  • Patient Cooperation For Interview

  • Proportion Participating in Lab Analysis


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Issues Impacting Institutional Cooperation

  • An increased number of proposed surveys has made hospitals in some countries somewhat reluctant to allow patients to participate directly in such surveys

    • highlights the necessity of approaching institutions with emergency rooms formally and in a way that makes them feel that they are part of an important study


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Issues Impacting Patient Participation

  • Participation should always be voluntary

  • Suspicions regarding “True” objectives has made patients somewhat reluctant to take time to participate in such drug surveys

    • highlights the necessity of approaching patients in a way that makes them feel that they are part of an important study

  • All questionnaires should be treated confidentially

    • The use of questionnaires without names or other kinds of identification

    • Guaranties of confidential treatment of questionnaires and data

    • Promises not to report data for individual patients


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Decisions Regarding Non-Participation

  • If hospitals with a large percentage of overall ER visits refuse to participate it is essential to do a careful analysis of the reasons

  • Ifsystematic errors is suspected, interpretation might be difficult and international comparisons may be jeopardised.

    E.g.

    • refusing patients come from areas where drug and/or alcohol consumption is known to be high


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Reliability

The extent to which repeated measurements used under the same conditions produce the same result

Or

Whether an indicator is consistent across time and observers


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Methods of Measuring Survey Reliability

  • To conduct repeated studies using same methodology

  • By using data from different questions within a questionnaire

  • Laboratory Confirmation


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Factors Influencing Study Reliability

  • Completeness - proportion of total information known

    • All respondents answer questions

    • All targeted respondents take survey

  • Sources of Error

    • Instrument

    • Person

      • MD, Nurse, Med. Rec Clerk

      • Study Subject or Respondent

    • May occur at

      • subject selection

      • data collection (Subjective)

        • Kappa Statistic

      • analysis and interpretation


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Sources of Error: Instrument and Procedures

  • Poor selection of questions and variables (SIDUC)

  • Ambiguous questions (additional questions)

  • Non-response

  • Poor selection of study subjects (friendliest)

  • Failure to validate measurements, recordings

    • lab


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Sources of Error:

Person

Interviewer

  • Inter-observer variation

    • the way medical staff explain and/or ask questions

    • Opinions on extent drug/alcohol use contributed to injury

      Subject

  • Inter-subject variation

    • Different Interpretation of questions (what drugs were thought of without prompting)

    • willingness, survey environment


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To Achieve Reliable Data

  • Thorough knowledge of study population

  • Unbiased selection of study subjects

  • Standardized, calibrated and consistent instrument(s)

  • Clear, unambiguous questions

  • Minimal personal discomfort or discomfiture

  • Interviewers, recorders thoroughly and equally well trained

  • Need to validate


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Validity

The extent to which answers are accurate representations of the underlying reality that they are intended to measure.

In the context of emergency room surveys, the degree to which the questionnaire measures the aspects of patients’ drug consumption that it was intended to measure.


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Strategies to Enhance Validity

  • Studies must guarantee anonymity and confidentiality

    • One is to use a data collection leader trusted by the patients

    • Stress anonymity during the introduction

    • no names or other identification marks should be on the questionnaire (SIDUC)

  • The patients must also have enough time to answer the questionnaire

    • important that the questionnaire is not too long

  • They must understand the questions

  • They must be willing to answer the questions honestly


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Strategies to Assess Validity

  • Patients’ willingness to co-operate

  • Patients’ comprehension

  • Missing data rates

  • Logical consistency

  • Reported willingness to answer honestly

  • The cultural context in which a survey is conducted


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Strategies to Assess Validity: Cultural Context

  • Questions must be culturally or locally appropriate

    • Use the appropriate “street-names” or “nicknames” used for different drugs

  • Willingness to admit drug use may be influenced by the attitudes towards drugs in a given society

    • perceived risk of substance use, disapproval of different kinds of substance use and the availability of different drugs differ between countries.

    • Low availability + Negative attitude = less willing to admit

    • High availability + Positive attitudes = more willing to admit

  • Survey Tradition

    • Persons in countries where surveys are less common may feel less comfortable answering questions about sensitive behaviours.


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Checklist For Survey Methodology

  • Representativeness

    • Define the target population

    • Assess the importance of non-students in the same age groups as the target population

    • Decide a proper time for the data collection (if international comparisons are planned)

    • Assess the importance of non-participating schools/classes

    • Assess the importance of non-participating students

  • Reliability

    • Assess reliability (whenever possible by using data in the questionnaire)


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Checklist For Survey Methodology Cont’d

  • Validity

    • Anonymous and confidential data collection

    • Measure and report

    • Number of eliminated questionnaires

    • Survey leader information (from the classroom report)

    • Time to answer the questionnaire

    • Proportion of unanswered questions

    • Logical consistency

    • Possible use of a “willingness question”

    • Possible reported use of a dummy drug

    • Construct validity



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Really

The End


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