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Survey Methods &
Applications in Healthcare
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospita...
2
2003 M.D. (First-Class Honors) (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics ...
3
• Overview of Surveys
• Survey Methodology
• A Sample Survey
Outline
4
OVERVIEW OF SURVEYS
5
• An activity in which many people are
asked a question or a series of
questions in order to gather
information about wh...
6
• A written set of questions that are
given to people in order to collect
facts or opinions about something
Questionnair...
7
• To know something
– Personal information
– Knowledge, Opinions & Attitudes
– Behaviors & Practice
– etc.
• About someo...
8
Examples of Surveys
Say2KFC.com
Service Satisfaction Survey (Online)
9
Examples of Surveys
http://www.kmutt.ac.th/building/pdf/application_form_2552_1.pdf
Service Satisfaction Survey (Paper-b...
10
Examples of Surveys
Image Source: http://pixabay.com/en/agent-business-call-center-18741/
Service Satisfaction Survey (...
11
SURVEY METHODOLOGY
12
• Survey Design
– Study Design
– Modes of Data Collection
• Instrument Design
• Sampling
• Survey Conduct
• Data Analys...
13
WHAT WOULD YOU DO TO
INCREASE SURVEY
RESPONSES?
14
The Tailored Design Method
1978 1999 2007 2008
Dillman et al.
15
The Tailored Design Method
2014
Dillman et al.
16
• “The development of survey
procedures that create respondent
trust and perceptions of increased
rewards and reduced c...
17
• Rewards
• Costs
• Trust
Social Exchange Theory
Dillman et al. (2007)
Image Source: http://horsebusinessschool.com/usi...
18
• “The likelihood of responding to the
request to complete a self-
administered questionnaire, and
doing so accurately,...
19
• Providing Rewards
– Show positive regard
– Say thank you
– Ask for advice
– Support group values
– Give tangible rewa...
20
• Reducing Social Costs
– Avoid subordinating language
– Avoid embarrassment
– Avoid inconvenience
– Make questionnaire...
21
• Establishing Trust
– Provide a token of appreciation in advance
– Sponsorship by legitimate authority
– Make the task...
22
• Study Design
– Cross-sectional
– Longitudinal
Survey Design
23
• Mode of Data Collection
– Self-administered survey
• Paper-based
• Online
• Telephone (Automated/IVR)
– Interviewer-a...
24
• Choose simple over specialized words
• Choose as few words as possible to pose the
question
• Use complete sentences ...
25
Problem
• Number of years lived in Idaho
Years
• Your city or town
City or Town
• Your county
County
Use complete sente...
26
Revision
• How many years have you lived in Idaho?
Years
• In what city or town do you live?
City or Town
• In what Ida...
27
Problem
• How often did you attend religious services
during the past year?
 Never
 Rarely
 Occasionally
 Regularly...
28
Revision
• How often did you attend religious services
during the past year?
 Not at all
 A few times
 About once a ...
29
Problem
• About how many books have you read for
leisure during the past year?
Number of books
Avoid too much
specifici...
30
Problem
• About how many books have you read for
leisure during the past year?
 less that 10
 11-25
 26-50
 51-75
...
31
• Distinguish undecided from neutral by
placement at the end of the scale
• Avoid bias from unequal comparisons
• State...
32
Problem
• Which one of the following do you feel is most
responsible for recent outbreaks of violence in
American’s sch...
33
Revision
• Which one of the following do you feel is most
responsible for recent outbreaks of violence in
American’s sc...
34
Problem
• From which one of these sources did you first
learn about the tornado in Derby?
 Radio
 Television
 Someon...
35
• Use cognitive design techniques to improve
recall
• Provide appropriate time referents
• Be sure each question is tec...
36
Problem
• Should the city build a new swimming pool that
includes lanes for swimming laps that is not
enclosed for wint...
37
• Soften the impact of potentially objectionable
questions
• Avoid asking respondents to make unnecessary
calculations
...
38
• Choose simple over specialized words
• Choose as few words as possible to pose the
question
• Use complete sentences ...
39
• Survey Design
– Study Design
– Modes of Data Collection
• Instrument Design
• Sampling
• Survey Conduct
• Data Analys...
40
• Target Population
• Sample
• Inclusion & Exclusion Criteria
• Sampling Frame
• Sampling Method/Technique
Sampling Des...
41
• Census
• Random (probability) sampling
– Simple random sampling
– Systematic random sampling
– Stratified random samp...
42
Example sequence
• Pre-notice Letter
• 1st Questionnaire Mailout
• Reminder + 2nd Questionnaire Mailout
Survey Conduct
...
43
• Sampling error
• Coverage error
• Measurement error
• Nonresponse error
– Questionnaire effects
– Data collection mod...
44
• Sampling error
• Coverage error
• Measurement error
• Nonresponse error
• Processing error
– Data entry error
– Pre-e...
45
A SAMPLE SURVEY
46
NAWANAN’S DOCTORAL
STUDY
47
Unknown State of
IT Adoption in
Thai Hospitals
Need to improve
theoretical
knowledge
This
Study
Dual Opportunities
48
• To describe current state of IT adoption in Thai
hospitals nationwide
• To test proposed conceptual framework & explo...
49
Hypothesized Model
50
• Study Design: Nationwide cross-sectional mail survey
• Sample: All hospitals in Thailand except pilot (N =
1,302)
• P...
51
• Modified from original instrument
• Face & content validity established
(Theera-Ampornpunt, 2009)
• Further modified ...
52
• Managerial: To what extent do you agree or disagree
with each statement? e.g.,
• Those who will use the information s...
53
 
• 150-baht (~US$5) incentive if completed
• Endorsed by President of the Thai Medical Informatics Association
• Funde...
54
• 64% response rate
• Some items problematic
– Differing within-hospital responses on total & IT
budgets,
No. of IT sta...
55
Hospital Characteristic Site 1 Site 2 Site 3 Site 4 Site 5
Response rate 40% 50% 70% 70% 90%
Hospital beds
Authoritativ...
56
Hospital Characteristic Site 1 Site 2 Site 3 Site 4 Site 5
2009 total budget
(million baht)
22.0
[n=1]
300.0
[n=1]
578....
57
Construct Overall Site 1 Site 2 Site 3 Site 4 Site 5
Managerial
Sophistication
3.6 ± 0.4 3.2 ± 0.2 4.2 ± 0.4 3.9 ± 0.5 ...
58
• IT Sophistication Items
Construct Intraclass
Correlation
Cronbach’s
Alpha
Managerial Sophistication 0.26* 0.91
Techno...
59
• 4 of 1,302 hospitals ineligible
• Response rate 69.9%
Characteristic Overall Responding
Hospitals
Non-
Responding
Hos...
60
Characteristic Number of Responses Statistic†
Public status
Private
Public
908
158
750
17.4%
82.6%
Teaching status
Non-...
61
Estimate (Partial or Complete Adoption) Nationwide
Basic EHR, outpatient 86.6%
Basic EHR, inpatient 50.4%
Basic EHR, bo...
62
Final Model
63
• High IT adoption rates
• Drastic changes in adoption landscape
• Local context might play a role
– Supply Side
– Dema...
64
• Overview of Surveys
• Survey Methodology
• A Sample Survey
Recap
65
• Survey Design
– Study Design
– Modes of Data Collection
• Instrument Design
• Sampling
• Survey Conduct
• Data Analys...
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Transcript of "Survey Methods & Applications in Healthcare"

  1. 1. Survey Methods & Applications in Healthcare Nawanan Theera-Ampornpunt, M.D., Ph.D. Faculty of Medicine Ramathibodi Hospital Mahidol University www.SlideShare.net/Nawanan
  2. 2. 2 2003 M.D. (First-Class Honors) (Ramathibodi) 2009 M.S. in Health Informatics (U of MN) 2011 Ph.D. in Health Informatics (U of MN) 2012 Certified HL7 CDA Specialist • Deputy Executive Director for Informatics (CIO/CMIO) Chakri Naruebodindra Medical Institute • Lecturer, Department of Community Medicine Faculty of Medicine Ramathibodi Hospital Mahidol University nawanan.the@mahidol.ac.th http://groups.google.com/group/ThaiHealthIT www.SlideShare.net/Nawanan Introduction
  3. 3. 3 • Overview of Surveys • Survey Methodology • A Sample Survey Outline
  4. 4. 4 OVERVIEW OF SURVEYS
  5. 5. 5 • An activity in which many people are asked a question or a series of questions in order to gather information about what most people do or think about something Survey Merriam Webster Dictionary
  6. 6. 6 • A written set of questions that are given to people in order to collect facts or opinions about something Questionnaire Merriam Webster Dictionary
  7. 7. 7 • To know something – Personal information – Knowledge, Opinions & Attitudes – Behaviors & Practice – etc. • About someone – Individuals – Organizations • In order to understand, create knowledge, or make decisions Why Do a Survey?
  8. 8. 8 Examples of Surveys Say2KFC.com Service Satisfaction Survey (Online)
  9. 9. 9 Examples of Surveys http://www.kmutt.ac.th/building/pdf/application_form_2552_1.pdf Service Satisfaction Survey (Paper-based)
  10. 10. 10 Examples of Surveys Image Source: http://pixabay.com/en/agent-business-call-center-18741/ Service Satisfaction Survey (Telephone)
  11. 11. 11 SURVEY METHODOLOGY
  12. 12. 12 • Survey Design – Study Design – Modes of Data Collection • Instrument Design • Sampling • Survey Conduct • Data Analysis • Reports Survey Methodology
  13. 13. 13 WHAT WOULD YOU DO TO INCREASE SURVEY RESPONSES?
  14. 14. 14 The Tailored Design Method 1978 1999 2007 2008 Dillman et al.
  15. 15. 15 The Tailored Design Method 2014 Dillman et al.
  16. 16. 16 • “The development of survey procedures that create respondent trust and perceptions of increased rewards and reduced costs for being a respondent, which take into account features of the survey situation and have as their goal the overall reduction of survey error” The Tailored Design Dillman et al. (2007)
  17. 17. 17 • Rewards • Costs • Trust Social Exchange Theory Dillman et al. (2007) Image Source: http://horsebusinessschool.com/using-stick-and-carrot-to-motivate-employees/
  18. 18. 18 • “The likelihood of responding to the request to complete a self- administered questionnaire, and doing so accurately, is greater when the respondent trusts that the expected fix rewards of responding will outweigh the anticipated costs” Social Exchange Dillman et al. (2007)
  19. 19. 19 • Providing Rewards – Show positive regard – Say thank you – Ask for advice – Support group values – Give tangible rewards – Make the questionnaire interesting – Give social validation – Inform respondents that opportunities to respond are scarce Survey & Social Exchange Theory Dillman et al. (2007)
  20. 20. 20 • Reducing Social Costs – Avoid subordinating language – Avoid embarrassment – Avoid inconvenience – Make questionnaires appear short & easy – Minimize requests to obtain personal information – Keep requests similar to other requests to which a person has already responded Survey & Social Exchange Theory Dillman et al. (2007)
  21. 21. 21 • Establishing Trust – Provide a token of appreciation in advance – Sponsorship by legitimate authority – Make the task appear important – Invoke other exchange relationships Survey & Social Exchange Theory Dillman et al. (2007)
  22. 22. 22 • Study Design – Cross-sectional – Longitudinal Survey Design
  23. 23. 23 • Mode of Data Collection – Self-administered survey • Paper-based • Online • Telephone (Automated/IVR) – Interviewer-administered survey (structured interview) • In-person • Telephone – Mixed-mode survey Survey Design
  24. 24. 24 • Choose simple over specialized words • Choose as few words as possible to pose the question • Use complete sentences to ask questions • Avoid vague quantifiers when more precise estimates can be obtained • Avoid specificity that exceeds respondent’s potential for having an accurate, ready-made answer • Use equal numbers of positive & negative categories Instrument Design Dillman et al. (2007)
  25. 25. 25 Problem • Number of years lived in Idaho Years • Your city or town City or Town • Your county County Use complete sentences Dillman et al. (2007)
  26. 26. 26 Revision • How many years have you lived in Idaho? Years • In what city or town do you live? City or Town • In what Idaho county do you live? Idaho County Use complete sentences Dillman et al. (2007)
  27. 27. 27 Problem • How often did you attend religious services during the past year?  Never  Rarely  Occasionally  Regularly Avoid vague quantifiers Dillman et al. (2007)
  28. 28. 28 Revision • How often did you attend religious services during the past year?  Not at all  A few times  About once a month  Two to three times a month  About once a week  More than once a week Avoid vague quantifiers Dillman et al. (2007)
  29. 29. 29 Problem • About how many books have you read for leisure during the past year? Number of books Avoid too much specificity Dillman et al. (2007)
  30. 30. 30 Problem • About how many books have you read for leisure during the past year?  less that 10  11-25  26-50  51-75  76 or more Avoid too much specificity Dillman et al. (2007)
  31. 31. 31 • Distinguish undecided from neutral by placement at the end of the scale • Avoid bias from unequal comparisons • State both sides of attitude scales in the question stems • Eliminate check-all-that-apply question formats to reduce primacy effects • Develop response categories that are mutually exclusive Instrument Design Dillman et al. (2007)
  32. 32. 32 Problem • Which one of the following do you feel is most responsible for recent outbreaks of violence in American’s schools?  Irresponsible parents  School policies  Television programs Avoid bias from unequal comparisons Dillman et al. (2007)
  33. 33. 33 Revision • Which one of the following do you feel is most responsible for recent outbreaks of violence in American’s schools?  The way children are raised by parents  School policies  Television programs Avoid bias from unequal comparisons Dillman et al. (2007)
  34. 34. 34 Problem • From which one of these sources did you first learn about the tornado in Derby?  Radio  Television  Someone at work  While at home  While traveling to work Mutually Exclusive Dillman et al. (2007)
  35. 35. 35 • Use cognitive design techniques to improve recall • Provide appropriate time referents • Be sure each question is technically accurate • Choose question wordings that allow essential comparisons to be made with previously collected data • Avoid asking respondents to say yes in order to mean no • Avoid double-barreled questions Instrument Design Dillman et al. (2007)
  36. 36. 36 Problem • Should the city build a new swimming pool that includes lanes for swimming laps that is not enclosed for winter use?  Yes  No Double Barreled Dillman et al. (2007)
  37. 37. 37 • Soften the impact of potentially objectionable questions • Avoid asking respondents to make unnecessary calculations Instrument Design Dillman et al. (2007)
  38. 38. 38 • Choose simple over specialized words • Choose as few words as possible to pose the question • Use complete sentences to ask questions • Avoid vague quantifiers when more precise estimates can be obtained Instrument Design Dillman et al. (2007)
  39. 39. 39 • Survey Design – Study Design – Modes of Data Collection • Instrument Design • Sampling • Survey Conduct • Data Analysis • Reports Survey Methodology
  40. 40. 40 • Target Population • Sample • Inclusion & Exclusion Criteria • Sampling Frame • Sampling Method/Technique Sampling Design
  41. 41. 41 • Census • Random (probability) sampling – Simple random sampling – Systematic random sampling – Stratified random sampling – Cluster random sampling – Multi-stage random sampling • Non-probability sampling – Purposive sampling – Convenience sampling – Snowball sampling – etc. Sampling Design
  42. 42. 42 Example sequence • Pre-notice Letter • 1st Questionnaire Mailout • Reminder + 2nd Questionnaire Mailout Survey Conduct Simplified from Dillman et al. (2007)
  43. 43. 43 • Sampling error • Coverage error • Measurement error • Nonresponse error – Questionnaire effects – Data collection mode effects – Interviewer effects – Respondent effects • Processing error Errors in Surveys Dillman et al. (2007) & Office of Management and Budget (2001)
  44. 44. 44 • Sampling error • Coverage error • Measurement error • Nonresponse error • Processing error – Data entry error – Pre-edit coding errors – Editing errors – Imputation errors Errors in Surveys Dillman et al. (2007) & Office of Management and Budget (2001)
  45. 45. 45 A SAMPLE SURVEY
  46. 46. 46 NAWANAN’S DOCTORAL STUDY
  47. 47. 47 Unknown State of IT Adoption in Thai Hospitals Need to improve theoretical knowledge This Study Dual Opportunities
  48. 48. 48 • To describe current state of IT adoption in Thai hospitals nationwide • To test proposed conceptual framework & explore relationships between organizational characteristics, IT management, and IT adoption Study Objectives
  49. 49. 49 Hypothesized Model
  50. 50. 50 • Study Design: Nationwide cross-sectional mail survey • Sample: All hospitals in Thailand except pilot (N = 1,302) • Pilot: 5 hospitals (10 respondents each) • Sampling Frame: List of hospitals from Ministry of Public Health’s Web site • Subjects: Hospital’s staff responsible for managing information systems (CIO/IT manager or equivalent; hospital director if N/A) • Data Collection Period: 16 weeks Design & Population
  51. 51. 51 • Modified from original instrument • Face & content validity established (Theera-Ampornpunt, 2009) • Further modified based on pilot findings • Translated to Thai Section 1 Hospital Profile Section 2 IT Adoption & Use Profile Section 3 Respondent’s Information English version Survey Instrument
  52. 52. 52 • Managerial: To what extent do you agree or disagree with each statement? e.g., • Those who will use the information systems are fully involved in hospital IT development • Functional: How much is each activity supported by computerized information systems in your hospital? • Technological: To what extent is each technology made available in your hospital? • Integration: To what extent is information shared or transmitted among information systems within/outside your hospital? Sample Questions
  53. 53. 53   • 150-baht (~US$5) incentive if completed • Endorsed by President of the Thai Medical Informatics Association • Funded by a leading medical school with known informatics focus • Anonymous unless contact information provided for incentive & results mailing Survey Methodology (Nationwide)
  54. 54. 54 • 64% response rate • Some items problematic – Differing within-hospital responses on total & IT budgets, No. of IT staff, quality accreditation status – Poor interrater reliability for some dimensions • Quality accreditation status dropped • Item wording revised & survey shortened • Integration sophistication items restructured Pilot Study Findings
  55. 55. 55 Hospital Characteristic Site 1 Site 2 Site 3 Site 4 Site 5 Response rate 40% 50% 70% 70% 90% Hospital beds Authoritative source 30 ± 0 30 120.2 ± 0.4 (120-121) 120 360 ± 0 335 303.1 ± 9.4 (282-307) 305 1,058.1 ± 187.1 (863-1,500) 938 Public Private 100% 0% 0% 100% 100% 0% 100% 0% 100% 0% Accreditation status Not accredited & without plan Not accredited, with plan but no significant progress Not accredited, with plan and significant progress Accredited 25% 75% 0% 0% 0% 40% 40% 20% 0% 0% 0% 100% 0% 14% 86% 0% 0% 0% 0% 100% Number of IT staff None 1-5 6-20 21-50 51 or more 0% 75% 25% 0% 0% 0% 80% 20% 0% 0% 0% 100% 0% 0% 0% 0% 43% 57% 0% 0% 0% 0% 22% 11% 67% Pilot Study Findings
  56. 56. 56 Hospital Characteristic Site 1 Site 2 Site 3 Site 4 Site 5 2009 total budget (million baht) 22.0 [n=1] 300.0 [n=1] 578.0 [n=1] 368.4 ± 93.7 [n=3] 7,000.0 ± 1,414.2 [n=2] 2009 IT budget (million baht) 0.4 [n=1] 10.0 [n=1] 2.1 ± 1.6 [n=3] 5.5 ± 0.7 [n=2] 93.0 ± 40.0 [n=3] Number of computers in hospital 23.8 ± 4.8 (20-30) 106.7 ± 90.2 (20-200) 170.0 ± 108.9 (10-300) 207.1 ± 82.2 (100-290) 2,350.0 ± 1,332.3 (100-4,000) Calculated percentage of 2009 IT budget according to provided amount 1.8% [n=1] 3.3% [n=1] 0.5% [n=1] 1.4% [n=2] 1.3% [n=1] Subjective estimated percentage of 2009 IT budget (if amount not provided above) Below 1% 1-4% 5-8% Above 8% 0% 75% 25% 0% 0% 40% 40% 20% 20% 60% 20% 0% 0% 86% 14% 0% 0% 17% 50% 33% Pilot Study Findings
  57. 57. 57 Construct Overall Site 1 Site 2 Site 3 Site 4 Site 5 Managerial Sophistication 3.6 ± 0.4 3.2 ± 0.2 4.2 ± 0.4 3.9 ± 0.5 3.8 ± 0.4 3.2 ± 0.9 Technological Sophistication 3.5 ± 0.3 3.1 ± 0.2 3.4 ± 0.6 3.7 ± 1.0 3.4 ± 0.5 3.8 ± 0.5 Functional Sophistication 4.0 ± 0.3 3.5 ± 0.5 4.4 ± 0.4 4.1 ± 0.6 4.2 ± 0.5 4.0 ± 0.3 Integration Sophistication (Within Hospital) 3.8 ± 0.3 3.8 ± 0.3 4.2 ± 1.2 3.8 ± 0.6 3.7 ± 0.5 3.4 ± 0.7 Integration Sophistication (Outside Hospital) 2.3 ± 0.9 1.1 ± 0.04 2.5 ± 1.4 3.6 ± 0.8 2.0 ± 0.9 2.1 ± 0.5 Overall IT Sophistication 3.4 ± 0.4 2.9 ± 0.2 3.7 ± 0.7 3.9 ± 0.6 3.4 ± 0.3 3.3 ± 0.4 Pilot Study Findings
  58. 58. 58 • IT Sophistication Items Construct Intraclass Correlation Cronbach’s Alpha Managerial Sophistication 0.26* 0.91 Technological Sophistication 0.04 0.81 Functional Sophistication 0.20 0.93 Integration Sophistication (Within Hospital) 0.00 0.89 Integration Sophistication (Outside Hospital) 0.50* 0.97 Overall IT Sophistication 0.30* 0.96 *p < 0.05 on F-test. Pilot Study Findings
  59. 59. 59 • 4 of 1,302 hospitals ineligible • Response rate 69.9% Characteristic Overall Responding Hospitals Non- Responding Hospitals N of eligible hospitals 1,298 908 390 Bed size** 106.9 117.5 82.9 Public status** Private Public 24.0% 76.0% 17.4% 82.6% 39.2% 60.8% Geography* Central East North Northeast South West 33.4% 7.5% 11.1% 27.1% 15.3% 5.6% 31.1% 7.8% 13.5% 26.9% 14.9% 5.8% 39.0% 6.7% 5.4% 27.7% 16.2% 5.1% *p < 0.01, **p < 0.001. Nationwide Findings
  60. 60. 60 Characteristic Number of Responses Statistic† Public status Private Public 908 158 750 17.4% 82.6% Teaching status Non-teaching Teaching 901 716 185 79.5% 20.5% Total employees 890 368.2 ± 573.5 (10-5269) IT employees 901 4.3 ± 5.3 (0-60) Total budget (million baht) 443 146.67 ± 313.60 (0.25-3,067) IT budget (million baht) 598 2.77 ± 8.79 (0-100) Ratio of IT budget to total budget‡ < 1% 1-4% 5-8% > 8% 416 135 218 40 23 2.7% ± 4.6% (0-43.3%) 32.5% 52.4% 9.6% 5.5% Extent of overall IT utilization Very low Low Moderate High Very high 905 5 35 169 454 242 0.6% 3.9% 18.7% 50.2% 26.7% Total PCs in use 883 126.1 ± 218.6 (0-3,000) Nationwide Findings
  61. 61. 61 Estimate (Partial or Complete Adoption) Nationwide Basic EHR, outpatient 86.6% Basic EHR, inpatient 50.4% Basic EHR, both settings 49.8% Comprehensive EHR, outpatient 10.6% Comprehensive EHR, inpatient 5.7% Comprehensive EHR, both settings 5.3% order entry of medications, outpatient 96.5% order entry of medications, inpatient 91.4% order entry of medications, both settings 90.2% order entry of all orders, outpatient 88.6% order entry of all orders, inpatient 81.7% order entry of all orders, both settings 79.4% Adoption Estimates
  62. 62. 62 Final Model
  63. 63. 63 • High IT adoption rates • Drastic changes in adoption landscape • Local context might play a role – Supply Side – Demand Side • International Comparison – Relatively higher adoption Discussion
  64. 64. 64 • Overview of Surveys • Survey Methodology • A Sample Survey Recap
  65. 65. 65 • Survey Design – Study Design – Modes of Data Collection • Instrument Design • Sampling • Survey Conduct • Data Analysis • Reports Recap
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