1. A. Fotiou - Behavioural data in TDI and DRID data .... A. Fotiou...Behavioural data in the TDI...

Behavioural data in the TDI and DRID data collection in Greece

Anastasios FotiouEpidemiology Unit

The Greek Reitox Focal point at the University Mental Health Research Institute


Drug related infectious diseases (DRID)EMCDDA Key Indicator Annual Expert Meeting

15-16 June 2015EMCDDA , Lisbon

Background

• TDI and DRID data collected since the late

1990s

• Treatment service data

• HRDUs entering treatment: routine

interviewing and testing upon entry

• Not prevalence data of the population on

treatment ― a subgroup of the TDI data


All types of treatment programsNational coverage:

• OST

• Drug free

• Low-threshold (fixed-sites)

• Detox

• Outpatient

• Inpatient

• Open settings

• Closed settings (2 prisons, since the late 2014)

Excludes: informal services offered by specialists; for-profit clinics, ad-hoc entries in public hospitals, emergencies for other reasons


Volume

69 73 77 92 103 105

4682

5501 5645 5834 5696

4894

3266

3888 39554138

3950

3002

0

1000

2000

3000

4000

5000

6000

7000

0

50

100

150

200

250

300

2008 2009 2010 2011 2012 2013

Tre

atm

en

t e

ntr

ies

an

d e

ver

PW

ID

Nu

mb

er

of

tre

atm

en

t u

nit

sTreatment units (N)

Treatment entries - TDI (N)

ever PWID - DRID (N)


The Psychiatrist, other

The Pathologist, other

The Treatment staff

(psychologists;

social workers,

sociologists, nurses,

other)

The

Client

The in-service net

The Lab


A 4-stage paper-based

data collection system

The PWUD will enter the service and, if PDUs, they will be tested for infectious diseases (IDs)

The treatment staff will collect demographic, treatment and behavioural data of the TDI form

If PDU, the medical

staff will fill-in the

DRID form with,

inter alia, the test

results

The forms will be

checked and

copies will be

sent to the FP

Stabilization


≈ 5000 forms

≈ 3500 forms

The TDI form:

• One-page form

• Font size 8

• 26 items

• Full compatibility with

EMCDDA

• More variables than

required by the TDI

Protocols

• Filled-in by treatment staff

• Designed for manual data

entry


The DRID form:

• Two pages

• Font sizes 8-10

• 16 items

• Partial compatibility with

EMCDDA

• Less variables than

recommended

• Filled-in by pathologists

• Designed for scanner


4 concerns

1. Overlap between TDI and DRID variables (gender, age, past treatment, injection history, primary substance, ever-injection, ever-sharing of syringes) (inefficient use of resources)

2. Completion of 2 different forms by 2 different people at 2 different points in time (inefficient use

of resources, data inconsistencies)

3. Manual copy-paste (?) of TDI info onto the DRID form (inconsistencies, incomplete data)

4. Separate deliveries to the FP (inefficient use of

resources, missing forms)


Average rate of missing data for selected items

reported annually over the period 2008-2013

Example #1: Item-level missing data


0,1 0,0 0,3 0,6

6,2

0,60,1 0,1 0,71,7

20,419,5

0

5

10

15

20

25

Gender Age at

treatment

start

Primary

substance

Ever

injected

Ever shared

syringes

Ever

previously

treated

TDI form (2008-2013, average annual n of forms = 2,115)

DRID form (2008-2013, average annual n of forms = 1,340)

%

Selected items, n = 212 OST clients, 2013 data

Example #2: Inconsistent data on similar

variables between TDI and DRID forms

% Inconsistent

between TDI

and DRID

McNemar's

test

Gender (male / female) 1.9% ns

Age (0 or ±1y/ higher difference) 1.9% ns

Ever injected (yes / no) 6.0% ns

Opioids_primary (yes / no) 15.8% p <.001

Previously treated (yes / no) 18.5% ns

Ever shared a syringe (yes / no) 18.6% ns


Sites Entries in

2011

DRID forms

sent to the FP

DRID client-level

coverage

Ν Ν Ν % Range, %

15 sites 579 (27%) 0 0%

7 sites 564 (26%) 219 39% 8%-48%

4 sites 144 (7%) 104 72% 63%-79%

10 sites 887 (40%) 1181 95% 85%-100%

36

sites

2,174

entries

1,504

DRID forms 69%

Data from 36 OST units; year 2011

Example #3: Missing DRID forms


3 backdrop factors pressing for

changes (sometime in 2012)

1. EMCDDA: Revisions of the variables included in the DRID and TDI indicators (DRID behavioural indicators module and TDI protocol v3.0)

=) Need for implementing added-value indicators

2. Greece: The “budgetary cut-backs” narrative

=) Need for cost-effective practices at the institutional level

3. Athens: The 2011-2012 HIV outbreak

=) Need for collecting epidemiologically meaningful data


1. Introduced in 2013 only in OST

2. 4 pages (in A3 format)

3. 10-11 font size

4. 53 variables

5. Full compatibility with TDI Protocol v3.0

6. All “core” and “additional” items of the

DRID Behavioural Indicators Module v1.0

7. Face-to-face, paper based interview

8. Designed for scanner

The combined TDI-DRID form


1. Sociodemographics

2. Substance use and treatment

characteristics

3. Higher risk behaviour

4. Infectious diseases (self-reports

and test results)

4 pages = 4 themes


BUT …

Still, in 2015, implemented in 40 of the 105 units

(only in OST, only in the southern part of Greece)

The combined TDI-DRID form in OST

Combined form

Separate TDI,

DRID forms


BUT …

Still, in 2015, implemented in 40 of the 105 units

(only in OST, only in the southern part of Greece)

Key questions


1. Did it make a good impression?

2. Are there items that raise concern?

3. Did it have an effect on measurement ?

Use of qualitative accounts (expert reports) and quantitative

indicators (descriptive and inferential statistics)

1. Visually pleasing and overall easy to complete, i.e., the

interviewers produced positive reactions (emotional

dimension)

2. Most of the key concepts were cognitively processed

as intended, thereby assuming accurate answers

(functional dimension)

3. Interviewers and respondents alike, attributed

meaning and took a conscious and reflected decision

when participating in the interview (reflective

dimension)


Expert (qualitative) accounts

of the combined TDI-DRID form1

Content and face validity

Expert (qualitative) accounts


1. No problems encountered with the gender or the age

variables – consider adding “transgender” in TDI

2. Some reacted to the homelessness item ― although in local

areas where homelessness is rather uncommon

3. Opioids are the type of drug “that causes the client the most

problems” (TDI definition), but not necessarily their “primary

drug in the last 4 weeks” (DRID indicator) – e.g., cocaine and

benzos misused

4. Ought opioids always be the primary drug in OST settings? –

should we look for consistency?


Focus on specific items

Qualitative accounts


5. DRID is interested in “less/more than 2 years since their

first injection”, but some report difficulties with recalling

the “age at first injection” (TDI)

6. What does “reuse” mean – ought the needle find the vein

or would simply puncturing do?

7. Inconsistency between “sterile needle/syringe the last

time you injected” and “using their last needle or syringe

more than once”


Used their last needle or

syringe only once Total

Yes No

Used sterile

needle/syringe

the last time

they injected

Yes 352 (58%) 253 (42%) 605 (100%)

No 13 (18%) 59 (82%) 72 (100%)

Total 365 (54%) 312 (46%) 677

Inconsistency between responses in 2 relevant items

a) “sterile needle/syringe the last time injected” and b)

“use of their last needle/syringe more than once”


Qualitative accounts


Overall

The injection-, the sharing- and especially the sexual

behaviour items are considered sensitive and

intrusive ―

yet, by whom?


Incomplete data in the “sex” itemsDifferences between “past” and “first-ever” entries

Past

treatments

(n = 565)

First

treatments

(n = 278)

Pearson

chi-

square

Sex in the last 12 months 12% 13% P = 0.789

Among those responding yes in the previous

Number of sexual

partners

3% 9% P < 0.001

Sex in exchange of drugs,

money etc

1% 6% P = 0.001

Condom use in the last

sexual intercourse

2% 5% P = 0.020

C1: current IDUs ever-sharing used needles/syringes in

the last 4 weeks (receiving or passing on)

C3: ever-IDUs, excluding known HIV-positives, who

ever-received an HIV test in the last 12 months

C4: ever-IDUs, excluding known HCV-infected, who

ever-received an HCV test in the last 12 months

Focus on the 4 core DRID indicators


C2: current IDUs ever-sharing any used injecting

paraphernalia in the last 4 weeks other than

needles/syringes (using together, receiving or passing on)

For comparability: focus on OST LT-PWID clients

N % N % N %

Male 326 59,9 126 61,2 380 57,2

Female 63 74,1 27 87,1 105 66,5

N % N % N %

< 25 y.o. 358 60,9 143 64,7 464 58,8

≥ 25 y.o. 31 75,6 10 62,5 21 61,8

N % N % N %

< 2 years inj. 378 63,1 146 64,9 472 59,6

≥ 2 years inj. 9 39,1 7 58,3 11 40,7

chi-sq=5.416,

df=1, p=0.020,

OR=0.4, 95%

C.I.=0.2, 0.9

chi-sq=0.214,

df=1, p=0.644,

OR=0.8, 95%

C.I.=0.2, 2.5

chi-sq=3.837,

df=1, p=0.050,

OR=0.5, 95%

C.I.=0.2, 1.0

old TDI old DRID combined TDI-DRID

chi-sq=3.522,

df=1, p=0.061,

OR=2.0, 95%

C.I.=1.0, 4.1

chi-sq=0.032,

df=1, p=0.859,

OR=0.9, 95%

C.I.=0.3, 2.6

chi-sq=0.118,

df=1, p=0.732,

OR=1.1, 95%

C.I.=0.6, 2.3


chi-sq=6.274,

df=1, p=0.012,

OR=1.9, 95%

C.I.=(1.1, 3.2)

chi-sq=7.919,

df=1, p=0.005,

OR=4.3, 95%

C.I.=1.4, 12.7

chi-sq=4.492,

df=1, p=0.034,

OR=1.5, 95%

C.I=(1.0, 2.1)


N % N %

Male 137 66,5 446 68,6

Female 27 87,1 118 77,6

N % N %

< 25 y.o. 153 69,2 540 70,2

≥ 25 y.o. 11 68,8 24 70,6

N % N %

< 2 years inj. 154 68,4 544 70,8

≥ 2 years inj. 10 83,3 16 57,1

chi-sq=1.185,

df=1, p=0.276,

OR=2.3, 95%

C.I .=0.5, 10.8

chi-sq=2.428,

df=1, p=0.119,

OR=0.5, 95%

C.I .=0.3, 1.2

old DRID combined TDI-DRID

chi-sq=0.002,

df=1, p=0.968,

OR=1.0, 95%

C.I .=0.3, 2.9

chi-sq=0.002,

df=1, p=0.963,

OR=1.0, 95%

C.I .=0.5, 2.2



chi-sq=5.360,

df=1, p=0.021,

OR=3.4, 95%

C.I .=1.1, 10.1

chi-sq=4.799,

df=1, p=0.028,

OR=1.6, 95%

C.I .=1.0, 2.4

% Ever-sharing of

paraphernalia (yes)

% Ever-sharing of

syringe (yes)

N % N % N %

Male 326 59,9 126 61,2 380 57,2

Female 63 74,1 27 87,1 105 66,5

N % N % N %

< 25 y.o. 358 60,9 143 64,7 464 58,8

≥ 25 y.o. 31 75,6 10 62,5 21 61,8

N % N % N %

< 2 years inj. 378 63,1 146 64,9 472 59,6

≥ 2 years inj. 9 39,1 7 58,3 11 40,7

old TDI combined TDI-DRIDold DRID

chi-sq=0.214,

df=1, p=0.644,

OR=0.8, 95%

C.I.=0.2, 2.5

chi-sq=5.416,

df=1, p=0.020,

OR=0.4, 95%

C.I.=0.2, 0.9

chi-sq=3.837,

df=1, p=0.050,

OR=0.5, 95%

C.I.=0.2, 1.0


chi-sq=0.032,

df=1, p=0.859,

OR=0.9, 95%

C.I.=0.3, 2.6

chi-sq=3.522,

df=1, p=0.061,

OR=2.0, 95%

C.I.=1.0, 4.1

chi-sq=0.118,

df=1, p=0.732,

OR=1.1, 95%

C.I.=0.6, 2.3


chi-sq=7.919,

df=1, p=0.005,

OR=4.3, 95%

C.I.=1.4, 12.7

chi-sq=6.274,

df=1, p=0.012,

OR=1.9, 95%

C.I.=(1.1, 3.2)

chi-sq=4.492,

df=1, p=0.034,

OR=1.5, 95%

C.I=(1.0, 2.1)

N % N %

477 90,3 564 90,0

78 95,1 139 93,3

N % N %

519 90,6 676 90,5

36 97,3 28 93,3

N % N %

535 91,9 681 91,4

15 68,2 18 69,2

chi-sq=14.596,

df=1, p<0.001,

OR=0.2, 95%

C.I.=0.1, 0.5

old TDI combined TDI-DRID

chi-sq=14.679,

df=1, p<0.001,

OR=0.2, 95%

C.I.=0.1, 0.5

chi-sq=1.978,

df=1, p=0.160,

OR=2.1, 95%

C.I.=0.7, 5.9

chi-sq=0.273,

df=1, p=0.601,

OR=1.5, 95%

C.I.=0.3, 6.3


chi-sq=1.914,

df=1, p=0.167,

OR=3.7, 95%

C.I.=0.5, 27.9

chi-sq=1.573,

df=1, p=0.210,

OR=1.6, 95%

C.I.=0.8, 3.1

% Ever-tested for HCV (yes)old TDI combined TDI-DRID

N % N %

Male 466 88,1 545 88,5

Female 76 93,8 138 93,2

N % N %

< 25 y.o. 507 88,5 658 89,4

≥ 25 y.o. 35 94,6 26 89,7

N % N %

< 2 years inj. 521 89,7 658 89,8

≥ 2 years inj. 16 72,7 21 80,8


chi-sq=6.245,

df=1, p=0.012,

OR=0.3, 95%

C.I.=0.1, 0.8

chi-sq=2.156,

df=1, p=0.142,

OR=0.5, 95%

C.I.=0.2, 1.3


chi-sq=1.311,

df=1, p=0.252,

OR=2.3, 95%

C.I.=0.5, 9.7

chi-sq=0.002,

df=1, p=0.965,

OR=1.0, 95%

C.I.=0.3, 3.5

% Ever-tested for HIV (yes)old TDI combined TDI-DRID

chi-sq=2.334,

df=1, p=0.127,

OR=2.1, 95%

C.I=(0.8, 5.3)

chi-sq=2.864,

df=1, p=0.091,

OR=1.8, 95%

C.I.=(0.9, 3.6)

QUANTITATIVE

ACCOUNT OF

THE EFFECT OF

THE COMBINED

TDI-DRID FORM

ON TRENDS


0

20

40

60

80

100

2008 2009 2010 2011 2012 2013

Ever-paraphernalia sharing - DRID vs combined TDI-DRID form

South - The form changed from 2013 onwards

North - The form remained unchanged

0

20

40

60

80

100

2008… 2009… 2010… 2011… 2012… 2013…

Ever-syringe sharing - DRID vs combined TDI-DRID form



0

20

40

60

80

100

2008

(636;370)

2009

(804;668)

2010

(653;1017)

2011

(1039;1234)

2012

(1372;1094)

2013

(852;642)

Ever-syringe sharing - TDI vs Combined TDI-DRID form



QUANTITATIVE

ACCOUNT OF

THE EFFECT OF

THE COMBINED

TDI-DRID FORM

ON TRENDS

50,0

60,0

70,0

80,0

90,0

100,0

2008

(636;370)

2009

(804;668)

2010

(653;1017)

2011

(1039;1234)

2012

(1372;1094)

2013

(852;642)

Ever tested for HIV - TDI form



50,0

60,0

70,0

80,0

90,0

100,0

2008

(636;370)

2009

(804;668)

2010

(653;1017)

2011

(1039;1234)

2012

(1372;1094)

2013

(852;642)

Ever tested for HCV - TDI form




Three headlines• The combined TDI-DRID form has been well accepted, while

also it is resource-efficient, relative to the previous system

• The combined TDI-DRID form has (seemingly) not affected

significantly measurement or trends

• The behavioural variables cause some concern and some

may elicit invalid data, suggesting a need for flexibility in

interviewing and more support for the interviewers

...and two challenges:

• Increase the coverage of the combined TDI-DRID form

(geographic, treatment type) ― totally replace the old forms

• Implement a proper validation study based on mixed

methods


Thank you for your attention

Special thanks to data providers in Greece and to Ms Argyro Andaraki , Ms Efi Vlassopoulou and Ms Eleftheria

Kanavou at the Greek Focal Point for their preliminary work on some of the data presented here.


A11: ever-IDUs who report an opioid as

their primary drug in the last 4 weeks

A10: ever-IDUs with less than 2

years since their first injection

A9: females among ever-IDUs

A8: ever-IDUs under age 25

5. SEX

12. PRIMARY DRUG

21. AGE OF 1ST INJECTION

6. AGE AT TREATMENT START

22. HIV TESTING

23. HCV TESTING

24. SYRINGE SHARINGC1: current IDUs sharing used needles/syringes in the last 4

weeks (receiving or passing on)

C3: ever-IDUs, excluding known HIV-positives, who received

an HIV test in the last 12 months

C4: ever-IDUs, excluding known HCV-infected, who received

an HCV test in the last 12 months

Focus on the 4 core DRID indicators


C2: current IDUs sharing any used injecting paraphernalia in

the last 4 weeks other than needles/syringes (using together,

receiving or passing on)

A7: % opioid using ever-IDUs who were in opioid substitution therapy in the last 4 weeks

A6: % current IDUs who report having 15 or more sterile needles / syringes available for

personal use in the last 4 weeks

A5: % ever-IDUs who report sexual intercourse with more than one partner in the last 12m

A4: % ever-IDUs who report the use of a condom at last sexual intercourse

A3: % ever-IDUs who received money, drugs or other benefits in exchange for sex in the last

12 months

A2: % current IDUs injecting once per day or more in the last 4 weeks

A1: % current IDUs who report the use of a sterile needle/syringe the last time they injected

A14: % ever-IDUs who lived without a steady home, on the streets or …, any time in the last

12 months

A12: % ever-IDUs who report having ever been in prison

A13: % ever-IDUs born outside the country of study

DRID but not TDI INDICATORS

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