Drug Use in General and School Population : GPSs and School Surveys in the Czech Republic

2. Drug Use in General and School Population:GPSs and School Surveys in the Czech Republic Viktor Mravčík MD The Czech National Monitoring Centre for Drugs and Drug Addictions

3. Content • Introduction – context and methodology • EMCDDA requirements • Overview of surveys performed in CR • Results

4. 5 key indicators • drug use in population/GPS and school surveys • prevalence estimates of PDU • treatment demand indicator • drug-related infectious diseases • drug-related deaths and mortality of drug users

5. 5 key indicators 5 KIs page5 22. 8. 2014

6. Key and others core indicators

7. Drug use in general population -questions • extent and patterns of drug use? • differences (by age, gender…)? • sub-groups with different pattern of use? • perceive availability, risks,attitudes towards drugs and drug users? • trends over time? • comparable to other countries?

8. Surveys – Theory and Methodology 1 • cross-sectional studies on representative sample of population • sample of respondents in given time frame • standard tools – standard questions (questionnaires) • EMQ, ESPAD questioonnaire • sampling of respondents – when standardized/comparable, allows inter-regional comparison and trends over time • quota-sampling (stratified sampling according to basic characteristics – gender, age, region, education)

9. Studies in Adult Population • EMCDDA methodology, i.e. standard questionnaire used = EMQ (European Model Questionnaire) • questions – example: cannabis Do you personally know people who take hashish or marijuana? 1yes 2 no Have you ever taken hashish or marijuana yourself? 1 yes 2 no At what age did you take hashish or marijuana for the first time? ......... During the last 12 months, have you taken hashish or marijuana? 1 yes 2 no During the last 30 days, have you taken hashish or marijuana? 1 yes 2 no During the last 30 days, how often did you take hashish or marijuana? 1 daily or almost daily 2 several times a week 3 at least once a week 4 less than once a week

10. Data collection/interviewing • PAPI: Paper And Pencil Interviewing. Data obtained from the interview is filled in on a paper form using a pencil. • CAPI: Computer Assisted Personal Interviewing. This method is very much similar to the PAPI method, but the data is directly entered into a computer programme instead of first using paper forms. • WAPI: Web Assisted Personal Interviewing. The respondents answer the questions online, but they are also assisted online in doing so. • CASI: Computer Assisted Self Interviewing. The CASI method involves respondents taking place behind the computer themselves in order to fill in the questionnaire. • CAWI: Computer Assisted Web Interviewing. Online research in which data is obtained electronically using online questionnaires. • CATI: Computer Assisted Telephone Interviewing. The questions are usually presented to the interviewers on a computer screen, after which they ask them to the respondents. • TAPI: Tablet Assisted Personal Interviewing. This method is virtually identical to the CAPI. • TASI: Tablet Assisted Self Interviewing. This method is virtually identical to the CASI. • SAPI: Smartphone Assisted Personal Interviewing. With this method, the data is entered into a smartphone by the interviewer. • SASI: Smartphone Assisted Self Interviewing. With this method, the data is entered into a smartphone by the respondent. (http://www.inviewfieldwork.com)

11. Surveys – Theory and Methodology 2 • representativeness • random sampling • sample size: sufficient number of respondents • structure of the sample has to correspond to distribution of the characteristic in general population – gender, age,region, education... • respondence • ideally >70% (depending on study methodology) • questionnaire for non-respondents (reasons) • bias • on the side of researcher (e.g. insufficient reliability or validity ) • on the side of respondents (e.g. does not want to answer, response set)

12. Sample Size and Sampling Error

13. Measuring Drug Use • 3 time horizons • lifetime prevalence – at least once in a lifetime • use in last 12 months – „recent use“ • use in last 30 days – „current use“ • Frequency& amount • regular use: >10 times in last 30 days • daily use, binge (party) consumption… • problem(atic) drug use • other characteristics • age at first use, route of administration… • reasons for first use, context, source of drug

14. Substances Monitored Routinely • illicit drugs • cannabis, ecstasy, hallucinogens (LSD), heroin and other opiates, methamphetamine (pervitin) and amphetamines, cocaine, magic mushrooms… • licit drugs • tobacco, alcohol  used often as „warming-up“ questions • solvents/volatile substances • medicines on prescription(sedatives and tranquilizers) • use without prescription

15. Drug Use in General Population • general population • adult population • standard age group 15-64 years • young adults – aged 15-34 years • very young adults – aged 15-24 years • school population • standard 15-16 years – ESPAD • European School Survey Project on Alcohol and Other Drugs; coordinated by Swedish Council on Alcohol and Drugs and Pompidou Group of Council of Europe • 11, 13, 15 years – HBSC • Health Behaviour in School-Aged Children; coordinated by WHO

16. EMCDDA requirements – GPSs process (1)

17. EMCDDA requirements – GPSs process (2)

18. EMCDDA requirements – GPSs implementation (1)

19. EMCDDA requirements – GPSs implementation (2)

20. EMCDDA requirements – GPSs implementation (3)

21. EMCDDA requirements – School surveys implementation (1)

22. EMCDDA requirements – School surveys implementation (2)

23. EMCDDA requirements – School surveys implementation (3)

24. General (adult) population surveys in CR • Until 2002 „Attitudes and opinions of citizens“ • by Public Opinion Research Centre (PORC) • non-standardised questions (experience with „illicit drugs“) • 2004 the first GPS focused on drugs with use of EMQ • „General Population Survey on Health Status and Lifestyle of the Population of the Czech Republic“ by Institute of Health Information and Statistics (IHIS) • 2008 and 2012 repeated GPS on drugs using (extended) EMQ • General Population Survey of the Use of Psychotropic Substances and Attitudes Towards Drug Use in the Czech Republic (2008) • National survey on addictive substances use 2012 • by National monitoring centre for drugs and drug addiction

25. General (adult) population surveys in CR (2) • From 2009 on • set of standard essential questions on drug use (standard time horizons, „standard“ drugs) in annual omnibus surveys • National monitoring centre for drugs and drug addiction: outsourced data collection • Other studies • Health studies of Institute of Health Information and Statistics (IHIS) • regular Surveys on Health Status of the Population of the Czech Republic – HIS CR (1993, 1996, 1999, 2002) and following • European Core Health Interview Survey – EHIS (coordinated by Eurostat, 2008) • Prague Psychiatric Centre (PPC) • single studies and surveys on mental health, psychiatric illnesses, alcohol consumption + incorporated questions on use of illicit substances • GENACIS project (Gender, Alcohol and Culture International Study) - 2002

26. School surveys • ESPAD study – 1995, 1999, 2003, 2007, 2011 • since 2003 financed by the National monitoring centre for drugs and drug addiction • HBSC study – 2002, 2006, 2010 • both by Prague Psychiatric Centre (PPC) In past: • Public Health Service • MAD study (Youth and Drugs) – 1994, 1997, 2000 • ESPAD-like methodology, age group 14-18 years; 13 018 respondents in 2000 • Institute of Psychology of Academy of Science • NEAD study (Non-Alcohol Drugs) – ESPAD methodology, not national coverage but some regions only • SAHA study (Social and Health Assessment) - 2003

27. GPS on drugs 2004 • Survey of the Health Status and Lifestyle of the Population of the Czech Republic in 2004 • The Institute for Health Information and Statistics (IHIS) in cooperation with NMC • Data collection by INRES-SONES • Structured F2F, PAPI • Q based on EMQ, the list of monitored psychoactive substances was extended; closer attention was paid to pervitin, magic mushrooms and other natural hallucinogens, inhalants, and solvents • Age range 18-64 • A random walk: stratified sampling by age, gender, region of residence, and level of education • Altogether 3,526 interviews were carried out (out of a total of 5,433 persons contacted). 1,766 males and 1,760 females years participated in the survey • Response rate 68.2%

28. GPS on drugs 2008 • General Population Survey of the Use of Psychotropic Substances and Attitudes Towards Drug Use in the Czech Republic in 2008 • NMC i cooperation with Centre of Addictology • Data collection by INRES-SONES • Age range 15-64 years, over-sampling of 15-29 years, weighted • Two-stage sampling, a random walk as the last stage, quotas by age, gender, education, region • Gross sample size 5613 respondent, 4506 questionnaires collected, i.e. response rate = 80,3% • non-respondents: 1107 (aged 35-44 years), reasons: lack of time (37%), lack of interest (31%), distrust, doubts about purpose of the study (13%) and information misuse (13%) • Questionnaire: EMQ + 3 modules, altogether >150 items • Wording updated after pilot test (focus groups) and field testing • 3 new modules • intensive use of cannabis (CAST) • perceived availability of illicit drugs (EMCDDA) • cannabis markets

29. CAST • Cannabis Abuse Screening Test • 6 items enquiring whether a respondent had ever: • (1) used cannabis alone or • (2) before midday • (3) had memory problems as a result of cannabis use • (4) been told by friends or family members to stop or reduce their consumption of cannabis • (5) tried to stop or reduce their cannabis use without success • (6) had problems (at school, for example) because of their use of cannabis • When transformed and added up, all six variables constitute the CAST scale with values ranging from 0 to 6: • one point or none means a low risk • 2 to 3 points imply a moderate risk • 4 or more points suggest high-risk cannabis use requiring professional intervention

30. GPS on drugs 2012 (1) • NMC • Data collection by SCaC • Age range 15-64 years, over-sampling of 15-34 years • Multi-Stage Sampling • 1st stage: municipalities and cities (23 strata by population size) • 2nd stage: streets. Altogether 177 starting points (50 „backup“ starting points) • 3rd stage: selection of household by random walk according to specific instructions.36 households on the list, every third household of every third object selected. • 4th stage: respondents by Kish tables (12 types) • Each „interviewer task“ consisted of 36 households • 24 households for respondents aged 15-64 • 12 households for respondents aged 15-34

31. Kish tables

32. GPS on drugs 2012 (2) • Gross sample size • Basic sample – 4248 households • Additional sample – 2124 households • Nett sample size: • 2000 from the basic sample (670 aged 15-34 and 1330 aged 35-64) • 330 from the additional sample aged 15-34 • Finally 2134 due to methanol intoxications (inclusion of additional module along with decreasing sample size) • Double data entry • SPSS data format • 3 weights: basic, oversampled, 15-34

33. GPS on drugs 2012 (3) • EMQ-based Q • intensive use of cannabis (CAST) • perceived availability of illicit drugs reduced (EMCDDA) • cannabis markets • new drugs • gambling module • additional module on alcohol consumption and availability during temporary prohibition • Pilot testing • 5 interviewers, each 4 respondents • Cards with names of medical drugs (sedatives and analgesics) • Manual for interviewers

34. GPS on drugs 2012 (4) • Time-schedule

35. Omnibus surveys Czech citizens • 2008, 2009, 2010, 2012 • PAPI, F2F in households • 2184 persons contacted, 1802 respondents in 2012, • Aged 15+ • Quota sampling by gender, age and regions • Omnibus with modules: • Health care, opinions on evolution and present state • Health and care of own health, prevention • Drug use (ours) • plus demographic data

36. Omnibus survey by PPM Factum • 2010, 2011, 2012 • CAPI, F2F in households, without incentives for respondents • 1000 respondents 15+ let • Quota sampling by gender, age (15–29, 30–44, 45–59, 60+), education (4 grades), size of residence (5 groups), regions(14) • Selection up to interviewersby individual quota • Omnibus with 4 modules: • Alcohol drinking habits • Fuel customs • Drug use (ours) • Election preferences • plus demographic data • Short questionnaire (16 minutes on average)

37. 2008 story Drug survey versus Health survey

38. 2008 surveys • General Population Survey of the Use of Psychotropic Substances and Attitudes Towards Drug Use in the Czech Republic in 2008 • 15-64 years, over-sampling of 15-29 years, weighted • A random walk: stratified sampling by age, gender, education, region • Gross sample size 5613 persons, 4506 respondents, i.e. response rate = 80,3% • EHIS 2008 • 15+ • Two-stage sampling (310 municipalities, gross sample 4000 persons) • 1995 respondents (response rate 50 %) • In principle the same questions asked

39. 2008: Drugs versus Health - lifetime

40. 2008: Drugs versus Health – 12 months

41. 2008: Drugs versus Health – 30 days

42. 2008: reasons for differences (1) • different formulations of questions and their context in the questionnaires (no effect – proven by subsequent survey) • varying data collection methodologies and procedures • differences in the construction of samples • lower degree of privacy in responding to questions in health study • lower response rate in health study • sampling bias: individuals who could not be reached at home probably more engaged in risk behaviours and may be assumed to show a higher level of drug use • the crucial role: context of questions (health versus drug)

43. 2008: reasons for differences (2) • different context: • personal interpretation of the question in view of the focus of research – the respondent tends to adjust their answers according to what they think they are expected to report (for example, to lead a healthy lifestyle, to be “IN”); • the more elaborate questions asked in a monothematic drug survey – the respondent may be offered examples which help them recall their behaviour and specify what the question really means; • priming – respondents are better at recalling a topic to which they have been exposed over time; • a tendency to provide consistent responses, which may result in the underestimation of the prevalence of drug use in research concerned with health issues and, on the contrary, in the overestimation of prevalence rates in research studies focusing specifically on drugs; • social expectations which the focus of some research studies may, albeit involuntarily, arouse. Škařupová, K. (2010) Health and Drug Surveys. Report for the EMCDDA. Unpublished.

44. Studies in Specific Groups • drug use in recreational settings • Dance and Drugs 2003, 2007, 2010 • questionnaire filled in through website (www.drogy-info.cz) • 2 433 respondents, self-nomination technique in 2007 • data collection June-September 2007 • prevalence of illicit drug use • alcohol consumption • assessment of risks related to drug use • problems experienced in connection with drug use • drug dealing • drugs and safe sex • drugs and driving • drug use in ethnic minorities • very few data available • drug use among prisoners • surveys in 2010 and 2012

45. Task Group • task group „Population and School Surveys on Drug Use“ – aims and results: • exchange of information • methodology consultations • preparation of surveys • Czech version of European Model Questionnaire • minimum set of questions for GPS and school surveys • feedback on chapter on Drug Use in Population of the Annual Report • members: conductors of surveys, representatives of research institutes (PPC, IHIS, CPOP, IPAS, Centre of Addictology), representative of agency doing field data collection (cca 10 people) • meetings 1-2 times per year • before GPS 2004 meetings 5 times per year – preparation of the questionnaire, methodology, discussions on financing, sampling • minutes of meetings are available on www.drogy-info.cz

46. Public opinion pools (up to 2002) • Lifetime use of illicit drug (%)

47. 15-64 or 18-64 GPS: 2002-2008 Life time use Last year (recent) use

48. GPS: 2002-2008 • Cannabis use

49. GPS: 2002-2008 • Selected drugs among young adults (LYP)

50. GPS 2008 (15-64)