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
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
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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
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Volume
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3888 39554138
3950
3002
0
1000
2000
3000
4000
5000
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0
50
100
150
200
250
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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)
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The Psychiatrist, other
The Pathologist, other
The Treatment staff
(psychologists;
social workers,
sociologists, nurses,
other)
The
Client
The in-service net
The Lab
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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
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≈ 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
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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
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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)
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Average rate of missing data for selected items
reported annually over the period 2008-2013
Example #1: Item-level missing data
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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
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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
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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
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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
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1. Sociodemographics
2. Substance use and treatment
characteristics
3. Higher risk behaviour
4. Infectious diseases (self-reports
and test results)
4 pages = 4 themes
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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
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BUT …
Still, in 2015, implemented in 40 of the 105 units
(only in OST, only in the southern part of Greece)
Key questions
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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)
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Expert (qualitative) accounts
of the combined TDI-DRID form1
Content and face validity
Expert (qualitative) accounts
of the combined TDI-DRID form2
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?
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Focus on specific items
Qualitative accounts
of the combined TDI-DRID form2
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”
The Greek Reitox Focal point at the University Mental Health Research Institute
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”
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Qualitative accounts
of the combined TDI-DRID form3
Overall
The injection-, the sharing- and especially the sexual
behaviour items are considered sensitive and
intrusive ―
yet, by whom?
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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
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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
old TDI old DRID combined TDI-DRID
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)
old TDI old DRID combined TDI-DRID
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
old DRID combined TDI-DRID
old DRID combined TDI-DRID
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
old TDI combined TDI-DRIDold DRID
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
old TDI combined TDI-DRIDold DRID
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
old TDI combined TDI-DRID
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
old TDI combined TDI-DRID
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
old TDI combined TDI-DRID
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
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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
South - The form changed from 2013 onwards
North - The form remained unchanged
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
South - The form changed from 2013 onwards
North - The form remained unchanged
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
South - The form changed from 2013 onwards
North - The form remained unchanged
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
South - The form changed from 2013 onwards
North - The form remained unchanged
The Greek Reitox Focal point at the University Mental Health Research Institute
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
The Greek Reitox Focal point at the University Mental Health Research Institute
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.
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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
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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