PRAMS Interviewer TrainingPRAMS Interviewer TrainingPhase 6 QuestionnairePhase 6 Questionnaire

1.1. Overview of PRAMSOverview of PRAMS

What is PRAMS?What is PRAMS?

Pregnancy Risk Assessment Pregnancy Risk Assessment Monitoring SystemMonitoring System

PRAMS is…PRAMS is…

A population-based surveillance system that collects state-specific data on maternal behaviors and experiences that occur before, during, and after pregnancy.

Action oriented, meaning the data are used for policy and program.

Background Background

Established in 1987 as part of an Infant Established in 1987 as part of an Infant Health InitiativeHealth Initiative

Congressional funding to CDC to Congressional funding to CDC to establish state-based programsestablish state-based programs

Initially 6 sites awarded fundingInitially 6 sites awarded funding

Data collection began in 1988 Data collection began in 1988

GoalGoal

Reduce infant morbidity and mortality Reduce infant morbidity and mortality and maternal morbidity by impactingand maternal morbidity by impacting– maternal and infant health programsmaternal and infant health programs– policiespolicies– maternal behaviorsmaternal behaviors

Objectives of PRAMSObjectives of PRAMS

To promote the collection of population-To promote the collection of population-based data of high scientific qualitybased data of high scientific quality

To conduct methodological and content To conduct methodological and content analysesanalyses

To translate results into useable To translate results into useable informationinformation

To assist states in building capacityTo assist states in building capacity

History of PRAMS: 2009 History of PRAMS: 2009

2006

OK

AKFL

SC

AL

NY

WA

CA

GA

IN

MI

ME

WV

NYC

HI

DC

198719911996

NC

CO

NM AR

IL

LA

1999

UTOH

VT

NE

MD

2000

MS

DE

TX

ORMT ND

MN

NJ

RI

2001

TX

SDWY

WI

MO

TN

PA

MA

VA

States Participating in States Participating in PRAMS, 2009PRAMS, 2009

Newly funded in 2006

OK

AK

GA

FL

SC

AL

NC

CO

NM AR

IL

NY

ME

WV

WA

LA

UTOH

NE

HI

VT

MD

NYC

MS

OR MN

MI

TX

RI

NJ

WYWISD

PA

TN

MO VA

DE

MA

Prior to 2006

Note: With the addition of 9 new states, PRAMS will represent approximately 75% of all US live births

Point-in-Time

PRAMS MethodologyPRAMS Methodology

Standardized data collection protocol

Don Dillman’s Total Design Method – Don Dillman’s Total Design Method – multiple contacts improve response!multiple contacts improve response!– Two or three mailed surveysTwo or three mailed surveys

– Phone follow-upPhone follow-up for non-responders

SamplingSampling

Target population: women who have had Target population: women who have had a recent live birtha recent live birth

Frame: file of birth certificate records Frame: file of birth certificate records

Stratified samples (e.g., birth weight, race, Stratified samples (e.g., birth weight, race, geography)geography)

Monthly sample drawn 2-6 months after Monthly sample drawn 2-6 months after birth of infantbirth of infant

Data Collection in StatesData Collection in States

Multiple mailings each monthMultiple mailings each month– Preletter introducing the surveyPreletter introducing the survey– Mail survey packet including response Mail survey packet including response

incentiveincentive– Reminder/Thank you letterReminder/Thank you letter– 22ndnd survey packet for nonresponders survey packet for nonresponders– 33rdrd survey packet for nonresponders survey packet for nonresponders

Data Collection in StatesData Collection in States

Telephone follow-upTelephone follow-up– 15 call attempts are made to each number 15 call attempts are made to each number

before giving upbefore giving up– Trying to reach a specific person; need to Trying to reach a specific person; need to

use multiple and varied contactsuse multiple and varied contacts– Standardized, Web-based Computer Standardized, Web-based Computer

Assisted Telephone Interviewing (Web-Assisted Telephone Interviewing (Web-CATI) implemented in 2006CATI) implemented in 2006

PRAMS QuestionnairePRAMS Questionnaire

14-pages, booklet format for mail, modified 14-pages, booklet format for mail, modified version for phone surveysversion for phone surveys

English and Spanish versionsEnglish and Spanish versions

Core questions common to all states (75%)Core questions common to all states (75%)

State specific questions (25%)State specific questions (25%)– Standard topic modules that states can select Standard topic modules that states can select

fromfrom– State developed questionsState developed questions

Selected Topics in PRAMSSelected Topics in PRAMS

Prenatal care Folic acid awareness Physical abuse Cigarette smoking and alcohol use Medicaid and WIC participation Breast-feeding Infant health and care Infant sleep position

PRAMS Data in ActionPRAMS Data in Action

Conducting needs assessments

Obtaining resources

Developing or modifying programs

Informing policies

PRAMS WebsitePRAMS Website

http://www.cdc.gov/prams/http://www.cdc.gov/prams/

Training ObjectivesTraining Objectives

By the end of this training, participants By the end of this training, participants will be able to:will be able to:– Describe the history of PRAMS and the data Describe the history of PRAMS and the data

collection methodscollection methods– Conduct a PRAMS telephone interview Conduct a PRAMS telephone interview – Correctly fill out all forms/complete all Correctly fill out all forms/complete all

WebCATI screens related to PRAMS WebCATI screens related to PRAMS telephone interviewstelephone interviews

– Identify problems that result from not Identify problems that result from not following interview protocolfollowing interview protocol

4. Getting the Right Mom4. Getting the Right Mom

Initiating ContactInitiating Contact

When calling a household use WebCATI’s When calling a household use WebCATI’s programmed telephone introduction and Case programmed telephone introduction and Case Management System Management System – Use copy of scripted telephone introduction and Use copy of scripted telephone introduction and

phone codes list (for paper survey)phone codes list (for paper survey) Protect mother’s confidentiality – do not reveal Protect mother’s confidentiality – do not reveal

the nature of the survey to other household the nature of the survey to other household membersmembers

Verify that you have reached the correct Verify that you have reached the correct mothermother

Initiating ContactInitiating Contact

Answering MachinesAnswering Machines

– Put in your state’s answering machine Put in your state’s answering machine protocol hereprotocol here

““Will Mail”Will Mail”

– Mothers rarely mail survey inMothers rarely mail survey in

– Encourage mother to complete survey nowEncourage mother to complete survey now

– Remind mothers they will be called back if Remind mothers they will be called back if their completed survey is not receivedtheir completed survey is not received

Wrong NumbersWrong Numbers

– Search another source for a good numberSearch another source for a good number

– Disconnected numbers should be tried againDisconnected numbers should be tried again

5. Obtain Informed Consent5. Obtain Informed Consent

Obtaining Informed ConsentObtaining Informed Consent

Read the complete introduction script Read the complete introduction script – It contains all the required elements of It contains all the required elements of

informed consent.informed consent.– Must be read exactly as writtenMust be read exactly as written

Consent information can allay fears or Consent information can allay fears or answer questions about the studyanswer questions about the study

It may also bring up reasonable concernsIt may also bring up reasonable concerns

Elements of Informed Elements of Informed Consent for PRAMSConsent for PRAMS

A statement that PRAMS involves A statement that PRAMS involves researchresearch and the CDC provides and the CDC provides support for the research, the support for the research, the purpose of the research and its purpose of the research and its procedures, and expected durationprocedures, and expected duration

An explanation of An explanation of how the mother how the mother was chosenwas chosen and the reason for the and the reason for the identification number on the identification number on the questionnairequestionnaire

Notification that Notification that data may be linkeddata may be linked to other sourcesto other sources

Any Any foreseeable risksforeseeable risks or or discomforts to the mother, discomforts to the mother, including a statement that some of including a statement that some of the questions may be sensitivethe questions may be sensitive

BenefitsBenefits to the participants and to the participants and others (incentive or reward, improve others (incentive or reward, improve the health of women and children)the health of women and children)

Protection of Protection of confidentialityconfidentiality to ‘the to ‘the extent provided by law’extent provided by law’

Contact informationContact information for questions for questions about the study and rights of about the study and rights of participantsparticipants

VoluntaryVoluntary participation, may choose participation, may choose not to answer certain questions or not to answer certain questions or not to participate, no penalty or loss not to participate, no penalty or loss of benefitsof benefits

If state If state child abusechild abuse reporting law reporting law requires that self reported abuse to requires that self reported abuse to teens be reported to the state, and teens be reported to the state, and the state does not have a separate the state does not have a separate questionnaire for teens, the questionnaire for teens, the requirement for reporting must be requirement for reporting must be explicitly included in the letterexplicitly included in the letter

Explicit prompt for permission to Explicit prompt for permission to continuecontinue with the interview (phone). with the interview (phone).

Questions about PRAMS Questions about PRAMS Consent ScriptConsent Script

““Do I have to say all that?” Do I have to say all that?” – You’ve heard it a lot; it’s her first and maybe only You’ve heard it a lot; it’s her first and maybe only

timetime

““If I say that, she’ll say no” If I say that, she’ll say no” – It’s important for her to know that participation is It’s important for her to know that participation is

voluntaryvoluntary

““Do I have to say all that?” Do I have to say all that?” – If you do not, it is considered a breach in protocolIf you do not, it is considered a breach in protocol

6.6. Conduct the InterviewConduct the Interview

Interviewer ResponsibilitiesInterviewer Responsibilities

Know the PRAMS Surveillance SystemKnow the PRAMS Surveillance System Understand the content of the interviewUnderstand the content of the interview

– QuestionsQuestions– Response choicesResponse choices– InstructionsInstructions

Execute the interview accuratelyExecute the interview accurately Record accurate and thorough informationRecord accurate and thorough information

Interviewer Responsibilities (2)Interviewer Responsibilities (2)

Familiarize yourself with:Familiarize yourself with: Questions on the questionnaire & word Questions on the questionnaire & word

pronunciationpronunciation Interviewer InstructionsInterviewer Instructions Skip patterns in questionnaire (Skip patterns in questionnaire (do not read do not read

skip directions to mother if doing a phone skip directions to mother if doing a phone survey on papersurvey on paper))

Answers/responses to Frequently Asked Answers/responses to Frequently Asked Questions (FAQ)Questions (FAQ)

Referral numbers & policies for your state in Referral numbers & policies for your state in case the mother asks for help or assistancecase the mother asks for help or assistance

WebCATI status codes and queuesWebCATI status codes and queues

Before you begin the Interview…Before you begin the Interview…

Remember: Remember: – You’re a strange voice to the motherYou’re a strange voice to the mother– It’s probably the first time the mother has It’s probably the first time the mother has

heard of PRAMS, so it’s all new informationheard of PRAMS, so it’s all new information– Since the mother can’t see the survey, she Since the mother can’t see the survey, she

can only rely on what she hears you saycan only rely on what she hears you say

Review the call history for each mom so Review the call history for each mom so you know what has happened with her you know what has happened with her previouslypreviously

Interviewing TechniquesInterviewing Techniques

Create rapport with motherCreate rapport with mother Avoid biasing the interviewAvoid biasing the interview Administer the survey consistently:Administer the survey consistently:

– PresentationPresentation– Vocal DeliveryVocal Delivery– PacePace– Defining, Clarifying & Using Probes Defining, Clarifying & Using Probes – Providing FeedbackProviding Feedback

Create Rapport with MotherCreate Rapport with Mother

Convey Convey confidenceconfidence

Speak with enough Speak with enough energyenergy and and enthusiasmenthusiasm to to be felt over the phonebe felt over the phone

Positive attitudes show up in your voice and Positive attitudes show up in your voice and wordswords– Sit-up straightSit-up straight– Take a deep breathTake a deep breath– Put on your smile!Put on your smile!

Create Rapport with MotherCreate Rapport with Mother Be aware of asymmetry in relationship Be aware of asymmetry in relationship

with mother:with mother:– YOU are engaging in professional activityYOU are engaging in professional activity– SHE is reporting about her private lifeSHE is reporting about her private life

Be mindful that a mother’s perception of Be mindful that a mother’s perception of what makes a question sensitive depends what makes a question sensitive depends on her:on her:– Culture, personal background and experienceCulture, personal background and experience– Situation, environment, how question is Situation, environment, how question is

askedasked

What is bias?What is bias?

• Bias is systematic error in the data.• Variability among interviewers• Variability between interviews conducted by

a single interviewer • Variability between mail and phone survey

• Bias can be dealt with through careful design and implementation of a study—like training interviewers!

Avoid BiasAvoid Bias

Phone & Mail interviews must be consistentPhone & Mail interviews must be consistent

Each question is carefully designed and pre-Each question is carefully designed and pre-tested to fulfill its exact purpose: tested to fulfill its exact purpose: – to obtain specific information to obtain specific information – to be understood by the maximum number of to be understood by the maximum number of

respondentsrespondents

Techniques to Avoid BiasTechniques to Avoid Bias

Read questions as exactly as they are writtenRead questions as exactly as they are written

Read questions with a neutral voiceRead questions with a neutral voice

Emphasize only the words italicized or bolded Emphasize only the words italicized or bolded in survey and pause only at commasin survey and pause only at commas

Techniques to Avoid BiasTechniques to Avoid Bias

Never let your own opinions influence Never let your own opinions influence how you read a question how you read a question

Avoid engaging in personal Avoid engaging in personal conversation during an interviewconversation during an interview

Avoid revealing your opinions or giving Avoid revealing your opinions or giving advice on study topics advice on study topics

PresentationPresentation

Read all questions as they appear, even if a Read all questions as they appear, even if a mother already provided the answer earlier in mother already provided the answer earlier in the interviewthe interview

You can preface a question by saying: You can preface a question by saying: – ““I realize we may have touched on this earlier, but I I realize we may have touched on this earlier, but I

need to ask each question in the survey.”need to ask each question in the survey.” Always address concerns raised by the mother.Always address concerns raised by the mother.

– Let the mother know that you hear what she is Let the mother know that you hear what she is saying but you must follow standardized saying but you must follow standardized interviewing techniques.interviewing techniques.

PresentationPresentation

Keep the interview on trackKeep the interview on track

If a mother talks about an issue before a If a mother talks about an issue before a question on that issue is asked:question on that issue is asked:– Response: “Okay, well we will get to that topic in a minute. ” Response: “Okay, well we will get to that topic in a minute. ”

If a mother interrupts:If a mother interrupts:– Response: “That’s important to know and I can make note of Response: “That’s important to know and I can make note of

that at the end of the survey, the next question is…”that at the end of the survey, the next question is…”

If a mother asks for information on a topic If a mother asks for information on a topic during the survey:during the survey:– Response: “We can discuss that more when we finish the Response: “We can discuss that more when we finish the

interview.”interview.”

Vocal DeliveryVocal Delivery Use inflection to keep your speech Use inflection to keep your speech

flowing naturally: flowing naturally: – Avoid nervous pauses and “um’s”Avoid nervous pauses and “um’s”

Try for a smooth delivery: Try for a smooth delivery: – Avoid sounding choppy or too staccatoAvoid sounding choppy or too staccato

Avoid “up-speak” – having your voice Avoid “up-speak” – having your voice rise as you read:rise as you read:– Makes statements sound like questions and gives Makes statements sound like questions and gives

the impression you’re not sure what you’re talking the impression you’re not sure what you’re talking aboutabout

– This is particularly an issue when you are reading This is particularly an issue when you are reading the introduction. the introduction.

PacePace

All questions must be read at a slower All questions must be read at a slower than conversational pacethan conversational pace

Never sound rushed or hurriedNever sound rushed or hurried

Read each word distinctly, so that each Read each word distinctly, so that each syllable is enunciated clearlysyllable is enunciated clearly

Try to sound like you’re engaging her in Try to sound like you’re engaging her in conversation, rather than reading a scriptconversation, rather than reading a script

Defining and ClarifyingDefining and Clarifying

If a mother asks for the meaning of a specific If a mother asks for the meaning of a specific word, group of words or seems confused by a word, group of words or seems confused by a question: question: – Repeat the questionRepeat the question

– If available, read the definition or probe listed If available, read the definition or probe listed in the survey verbatimin the survey verbatim

– NeverNever give your own definition or give your own definition or interpretationinterpretation

– Refrain from providing too much helpRefrain from providing too much help

– Move on to the next question if the concept Move on to the next question if the concept still is not understoodstill is not understood

Using ProbesUsing Probes

Probes are neutral prompts provided on Probes are neutral prompts provided on the questionnairethe questionnaire

Avoid directive probesAvoid directive probes– Don’t direct or lead her to an answerDon’t direct or lead her to an answer

Use nondirective probesUse nondirective probes– Be neutralBe neutral

Limited use of probesLimited use of probes

Avoid Directive ProbesAvoid Directive Probes

Do not re-phrase questions or provide Do not re-phrase questions or provide your own definitionsyour own definitions

Do not lead or suggest a responseDo not lead or suggest a response

It’s okay if mother cannot or will not It’s okay if mother cannot or will not answer a questionanswer a question

Do not interpret a response for herDo not interpret a response for her

Use Nondirective ProbesUse Nondirective Probes

Acceptable nondirective probes include:Acceptable nondirective probes include:– Silence or pauseSilence or pause– Repeat the questionRepeat the question– Repeat the mother’s responseRepeat the mother’s response– Ask the mother what she would like Ask the mother what she would like

recordedrecorded

FeedbackFeedback

Standardized, neutral feedback should be Standardized, neutral feedback should be given periodically during the interviewgiven periodically during the interview– Encourages further thoughtful participation from Encourages further thoughtful participation from

the mother.the mother.

Feedback is given by saying a short phrase Feedback is given by saying a short phrase to the mother after an acceptable response is to the mother after an acceptable response is givengiven

Feedback needs to be given in a neutral Feedback needs to be given in a neutral voice, so that you avoid influencing the voice, so that you avoid influencing the mother’s answersmother’s answers

Top Ten List of Things to Top Ten List of Things to RememberRemember

1)1) Always read the script and survey exactly as Always read the script and survey exactly as writtenwritten

2)2) Remember the purpose of PRAMSRemember the purpose of PRAMS3)3) Never begin an interview without preparationNever begin an interview without preparation4)4) Present a neutral frontPresent a neutral front5)5) Demonstrate aware hearingDemonstrate aware hearing6)6) Think about appearance (who you represent)Think about appearance (who you represent)7)7) Interview in a comfortable placeInterview in a comfortable place8)8) Be respectfulBe respectful9)9) Practice, practice & practice some morePractice, practice & practice some more10)10) Be cordial and appreciative of motherBe cordial and appreciative of mother

Recording ResponsesRecording Responses

Close-ended questionsClose-ended questions– Limited number of responses to choose Limited number of responses to choose

fromfrom– Each response has a specific numeric Each response has a specific numeric

code or radio button (if using mouse entry)code or radio button (if using mouse entry)– Example: Example:

8. 8. Before Before you got pregnant with your new baby, did you you got pregnant with your new baby, did you ever have any other babies who were born alive?ever have any other babies who were born alive?1=NO 1=NO 2=YES2=YES8=REFUSED 8=REFUSED 9=DK/DR9=DK/DR

Recording ResponsesRecording Responses

Open-ended questionsOpen-ended questions– Defined response options not providedDefined response options not provided– Interviewer records any response given by the Interviewer records any response given by the

mothermother– Example: Example: How many weeks or months pregnant were you when How many weeks or months pregnant were you when you were sure you were pregnant?you were sure you were pregnant?

• 1 ______ WEEKS OR1 ______ WEEKS OR• 2 ______ MONTHS 2 ______ MONTHS [Range: 1-40 weeks/1-9 months][Range: 1-40 weeks/1-9 months]

• 7=DON'T REMEMBER7=DON'T REMEMBER• 8=REFUSED8=REFUSED

Recording ResponsesRecording Responses

Comments:Comments:– All comments should be recorded verbatimAll comments should be recorded verbatim– Additional information shared about the Additional information shared about the

mother’s experiences that is not specifically mother’s experiences that is not specifically asked for in interview questionsasked for in interview questions

– Mother may share information at the end of Mother may share information at the end of the interviewthe interview

Ending the InterviewEnding the Interview

Remember to thank the motherRemember to thank the mother

Reiterate how useful/important her Reiterate how useful/important her contribution has beencontribution has been

Provide referrals or educational materials Provide referrals or educational materials (only if the mother requests) as determined (only if the mother requests) as determined locallylocally

Terminate the callTerminate the call

Review of Phase 6 SurveyReview of Phase 6 Survey

Read all of the questions exactly as Read all of the questions exactly as writtenwritten– Repeat the questionRepeat the question– Use probes providedUse probes provided– Repeat the stem (for long lists)Repeat the stem (for long lists)

Bold italicizedBold italicized type is used to call type is used to call something to your attention:something to your attention:– Time periodsTime periods– Choose oneChoose one

Review of Phase 6 SurveyReview of Phase 6 Survey

Be aware of what to read and what not to readBe aware of what to read and what not to read– WebCATI and Paper Phone survey:WebCATI and Paper Phone survey: Instructions Instructions

that are not to be read aloud are all CAPITALIZED or that are not to be read aloud are all CAPITALIZED or included in an Interviewer instruction boxincluded in an Interviewer instruction box

Long lists of questionsLong lists of questions– Pause after each one for the mom to answerPause after each one for the mom to answer– Repeat the stem after every 2-3 itemsRepeat the stem after every 2-3 items

Long list in response optionLong list in response option– Read them allRead them all– Tell mom you have to read them all even if she Tell mom you have to read them all even if she

answers before you finish.answers before you finish.

Review of Phase 6 SurveyReview of Phase 6 Survey

Be aware of UnitsBe aware of Units– Tobacco (cigarettes per day)Tobacco (cigarettes per day)– Alcohol (drinks per week)Alcohol (drinks per week)– Binge drinking (4 drinks at one sitting)Binge drinking (4 drinks at one sitting)– Height (feet/inches vs. meters)Height (feet/inches vs. meters)– Weight (pounds vs. kilos)Weight (pounds vs. kilos)– Dates (month/day vs. day/month)Dates (month/day vs. day/month)

PronunciationPronunciation

((you may want to insert a slide here to you may want to insert a slide here to review some of the words in the review some of the words in the pronunciation guide)pronunciation guide)

7. Wrapping up the Interview7. Wrapping up the Interview

After Terminating the CallAfter Terminating the Call

WebCATI system will guide the WebCATI system will guide the interviewer through several more interviewer through several more screens where:screens where:– line level comments can be entered line level comments can be entered – summary of the final disposition of that summary of the final disposition of that

mother enteredmother entered All operational and questionnaire All operational and questionnaire

information will be saved in the systeminformation will be saved in the system

For Surveys Completed on PaperFor Surveys Completed on Paper– Review and edit the interview & code sheet Review and edit the interview & code sheet

for coding errorsfor coding errors– Check for completeness and legibilityCheck for completeness and legibility– Call the mother back, if necessaryCall the mother back, if necessary– Record the operations dataRecord the operations data– Put the interview and consent forms in a Put the interview and consent forms in a

secure placesecure place– Record call attempt info and survey Record call attempt info and survey

responses in WebCATI using external responses in WebCATI using external events featureevents feature

After Terminating the CallAfter Terminating the Call

Monitoring (1)Monitoring (1)

The PRAMS protocol requires that The PRAMS protocol requires that phone interviewers be monitored 10% of phone interviewers be monitored 10% of the time they are placing callsthe time they are placing calls– To ensure that consent is properly obtainedTo ensure that consent is properly obtained– To ensure that phone codes are being used To ensure that phone codes are being used

properlyproperly– To ensure that the survey is administered To ensure that the survey is administered

correctlycorrectly

Monitoring (2)Monitoring (2)

Insert some information about who will be Insert some information about who will be doing monitoring, whether the interviewers doing monitoring, whether the interviewers will know they are being monitored, and will know they are being monitored, and any other details of the monitoring process any other details of the monitoring process you think is important. See the manual you think is important. See the manual development box in Section 4.4development box in Section 4.4

Proof of LearningProof of Learning

By the end of the training By the end of the training interviewers will have:interviewers will have:– Practiced successfully contacting a Practiced successfully contacting a

participant and obtained informed consentparticipant and obtained informed consent– Conducted a PRAMS interviewConducted a PRAMS interview– Completed WebCATI screens/filled out all Completed WebCATI screens/filled out all

PRAMS formsPRAMS forms– Identified problems and potential solutionsIdentified problems and potential solutions