SAMPLING METHODS FOR POPULATION AT INCREASED RISK OF HIV

Principles of Sampling

Principlesofsampling
Ali Mirzazadeh
Knowledge Hub on HIV surveillance, Kerman University of Medical Sciences, Iran

By the end of this unit, you should be able to: Explained how sampling is different from a complete count (census) Outline the purpose of sampling Understand the key theoretical, representativeness / generalizabaity, concepts in sampling Understand the source of sampling biases in HIV and AIDS bio-behavioural surveillance Often we want to survey a special group of people to measure certain characteristics of the group. The target population is the group that meets a surveys measurement objective, such as all people in the entire country, the adult population in a country, or commercial sex workers in a capital city. Example In a study addressing the prevalence of high risk injecting drug behaviors (i.e. needle sharing) among the homeless in Iran, a random sample of 200 homeless individuals visiting a particular randomly selected shelter in Tehran is interviewed. The target population in this case is all homeless individuals in Iran, while the study population is all homeless individuals visiting Tehran shelters.

Target Population: All homeless in Iran

Study Population: All homeless at Tehran shelters

Sample: Homeless at particular shelter

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Principles of Sampling

SAMPLING METHODS FOR POPULATION AT INCREASED RISK OF HIV

As you see in the above example, often practical considerations limit the scope of an epidemiological study. For example, the prevalence of high risk injecting drug behaviors may be computed for a city (i.e. Tehran), rather than for all homeless all around the country (i.e. Iran). Its often not feasible or even desirable to observe the entire study population, all individuals of the study population (census). In this instance, a sample of individuals, chosen to be representative of the study population may be observed. The remaining part of the unit, we will talk more about these key concepts:

Sampling
When you are tasked with measuring certain characteristics of a specified target population, it is not necessary or feasible to survey every member of the target population. Instead, you can systematically select a predesigned number of individuals for your survey from the population of interest. The procedure that you follow to select these individuals is called Sampling. The selected individuals form your sample.

Whatdowewantfrom asample?
The goal of sampling is to obtain estimates of certain indicators from selected individuals that can be generalized to the target population. The ways of selecting these individuals are called Sampling Approaches / Methods. How well the sample reflects the population from which it was selected is called representativeness. How well the results found in a sample reflects results that would have been found if the survey were done in the entire population is called generalisability. The more representative the sample is of the entire population, the more generalisable the results will be from the sample to the entire population. When we select a sample, we are not interested in the sample in its own right. Instead, we are interested in what the sample tells us about the target population. You want the sample to provide unbiased and precise estimates of our indicators for the target population. Bias (systematic error) can occur during the design, collection, analysis or interpretation of data. Avoiding bias due to sampling (sampling bias) ensure that your sample is like the population from which it was drawn (Study population). Target Population Selectionbias Selection biases, that pose a threat to internal validity, are distortions that result from procedures used to select subjects and from factors that influence study participation from the study population. The common element of such biases is that the estimate (for example the prevalence of condom use among homeless people) is different for those who participate and for all those who should have been theoretically eligible for study, including those who do not participate.

Study Population

Participants

Nonparticipants

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SAMPLING METHODS FOR POPULATION AT INCREASED RISK OF HIV

Principles of Sampling

Samplingbias Sampling biases are systematic differences between the study population and the target population that pose a threat to external validity. They prohibit generalisation from the study population to the target population. Example: You have been interested in estimating the effect of a new harm reduction programme among a group of female sex workers (FSWs). You select the study subjects among the volunteers from a private STI clinic in Tehran. You start the study with 200 well-treated (STI free) FSWs randomly (R) allocated into two interventional groups (100 in group A and 100 in group B). Group A is received the new harm reduction program and group B is received the routine harm reduction services. All the participants were asked to come back to the clinic to have monthly visited to check if they have recurrent STI infections. 55% of group A and 78% of group B has completed the follow-up period (6 months). i.e. remain in study till the end of follow-up. Moreover, only 80% of individuals in group A and only 82% of those in group B have applied the standard protocol (good compliance). If you find that the risk of STI was 15% and 21% in group A and group B, respectively. What would be your conclusion about the effectiveness of the new harm reduction programme. What are the considerations you should take into account when generalizing the results? Discuss about the possible biases in the design, selection, data collection and analysis phase of your study.

Target Population (Female Sex Workers)

FSWs in a private STI clinic

Participants (Volunteers)

Nonparticipants

R
Group A Group B

Comply

Do not comply

Leave study

Comply

Do not comply

Leave study

As it is obvious from the above example, there are several factors that can compromise the external validity of epidemiological studies. Even in randomized clinical trials, selection and sampling bias may occur at various stages of the trial:

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Principles of Sampling

SAMPLING METHODS FOR POPULATION AT INCREASED RISK OF HIV

Systematic differences between the study and target population (sampling bias): study patients cared for at a private STI clinic are likely to be more from high socioeconomic levels than those visited in governmental public health centers. Volunteerism (selection bias): individuals who volunteer for a study are likely to be systematically from those who decline to participate. They maybe more healthier, more motivated or better educated than non-volunteers. Loss to follow-up: Those who do not come for further visits are censured individuals. Both amount and the reason of missing in follow-up studies are important. If the reason for becoming missed is related to the outcome, the results will be biased. Compliance: in most of the cases, the compliance in the study patients would be much better than in the target population (real world).

Howtoavoidselectionbias
Avoiding selection bias requires a random/probability sample. In a probability sample, each person in the survey has a known, non-zero probability of selection. In order to run a probability sampling, we have to develop a sampling frame. A sampling frame is a list of individuals (units) from which a sample may be selected. For example, in the study of the effect of a new harm reduction programme among FSWs in a STI clinic, the list of registered cases in the clinic could be used as the sampling frame of the study. You can assign each case a number, then select a random number between 1 to 200 from a random number table or by specific software providing such facilities; and then divide them into two groups, A or B. The basic of probability sampling methods are discussed in the next chapter.

Preciseestimates
It is important that any given sample provide precise estimates. The information inferred from a sample only provides an estimate of the true population measure. There are many possible samples that could be selected from the population. Because of chance, each sample selected would produce a different estimate of our indicators. The variation in measurement that comes about by chance through sampling must be taken into account when using a sample to make inferences about a larger population. When using probability sampling, how much our sample estimate may vary from the true population measure can be estimated. This estimation of precision is called the standard error. It can be used to construct a range of values within which the true population measure is likely to fall. A 95% confidence interval is the likelihood that the true population measure lies in our range, and what to aim for when taking a sample from a population. One way that can increase the precision (that is, decrease standard error) of an estimate is increase the sample size. Standard equations are available to calculate required sample size, depending on: the type(s) of variable (categorical or continuous) that you want to make an estimate.

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SAMPLING METHODS FOR POPULATION AT INCREASED RISK OF HIV

Principles of Sampling

whether there are existing data on variable of interest. whether you want to measure a certain variable at one in time or whether you want to measure the change in that variable over two or more points in time (between surveillance rounds) the confidence interval necessary to determine that the true population measure falls within confidence limits (the precision of the study)

Talking about the sample size formula is beyond the scope of this manual.

Samplingmostatriskpopulation
There are some important points in sampling most-at-risk population: 1. ConsistentSamplingRequired Behavioral surveillance often aims to measure trends over time. Therefore, it is essential that the different survey rounds define and sample a sub-population consistently over time. If we do not do this, we do not know if any observed changes are real or due to changes in methodology. Sometimes it is appropriate to change the sampling strategy because new and better techniques are developed. In this case, we can sample the population using both the old and new methods to compare estimates. 2. Generalpopulationsurveyscanrarelybeusedtoaccesshighriskgroups Household/general population surveys are rarely an appropriate method for locating members of high-risk groups. The group members may not be found in households in sufficient numbers through a household survey. Behaviors may be too sensitive to discuss in a household setting. It is usually impossible to make a sampling frame of all the members of a high-risk group. One solution is to identify the places high-risk groups congregate, define them as clusters and sample them. The table shows examples of possible clusters for high-risk groups.
Highriskgroup Brothelbasedsexworkers Nonbrothelbasedsex workers Menwhohavesexwithmen Injectingdrugusers Truckers Migrants Possiblecluster Brothel Streets,bars,hotels, guesthouses Cruisingsites Shootinggalleries,injecting sites Loading/unloading/halting points Households,workplaces

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Principles of Sampling

SAMPLING METHODS FOR POPULATION AT INCREASED RISK OF HIV

3. Clustersamplingcanbedifficultwhenclustersarenotstable Unless clusters are all the same size, we need a measure of cluster size in order to ensure the sample is like the target population. It can be hard to measure the size of locations where high-risk groups congregate. Some reasons are:

The individuals at the cluster are not fixed (for example, sex workers may move from one site to another). The type of people in a cluster may also vary (for example, sex workers who work in the afternoon may have different risk behaviors than sex workers who work in the evening).

It is difficult to select a sample that is representative of the entire target population using conventional cluster sampling. 4. Membersofhighriskgroupsmaybedifficulttoidentifyandaccess High-risk groups can be hard to reach. Members may be hidden and unwilling to be identified or to acknowledge their risk behavior. These difficulties have many implications for sampling:

Constructing a sample frame of clusters can be difficult if people do not want to disclose the location (for example, brothels) Gatekeepers (those who control access into the location) may oppose participation. This would make including those clusters in the sample difficult.

Constructing sample frames within the selected clusters may be difficult. Individuals may not want to be identified as members of the population. 5. Clustersamplingisimpossibleifgroupmembersdonotcongregate Some high-risk groups do not congregate, making cluster sampling unfeasible. For example, it is difficult to think of a feasible cluster for home-based sex workers unless they all live in the same area. Among other high-risk groups, only some of the population congregates. For example, it is possible to use cruising areas as clusters for some men who have sex with men (MSM). However, not all MSM frequent cruising areas, so an important section of the MSM population could be missed. 6. Potentialsolutionsareprovidedfortheseissues The international community has debated the best way to get around these sampling challenges. This tool was developed to help you:

Use different sampling strategies for different groups.

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SAMPLING METHODS FOR POPULATION AT INCREASED RISK OF HIV

Principles of Sampling

Use conventional sampling methods in unconventional ways. Consider using sampling techniques such as respondent driven sampling (RDS).

References
Introduction to HIV, AIDS and Sexually Transmitted Infection Surveillance for the Eastern Mediterranean and North Africa Region, 2008. Eastern Mediterranean regional office. Zagreb, Croatia. Rothman, Kenneth J.; Greenland, Sander; Lash, Timothy L. Modern Epidemiology, 3rd Edition, 2008, Lippincott Williams & Wilkins Rebecca G. Knapp, M. Clinton Miler. Clinical epidemiology and biostatistics, William & Wilkins, 1992. Baltimore, Maryland Miguel A. Hernan, Sonia Hernandez-Daz, and James M. Robins. A Structural Approach to Selection Bias, Epidemiology 2004;15: 615625 http://globalhealthsciences.ucsf.edu/PPHG/surveillance/CDC-MARPs/index.htm

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