ANRV305-PU28-07 ARI 9 February 2007 9:14

New Challenges for

Telephone Survey Research
in the Twenty-First Century
Angela M. Kempf and Patrick L. Remington
Population Health Institute, Department of Population Health Sciences, School of
Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 53726;
email: kempf@wisc.edu; plreming@wisc.edu
Annu. Rev. Public Health 2007. 28:11326
The Annual Review of Public Health is online
at http://publhealth.annualreviews.org
This articles doi:
10.1146/annurev.publhealth.28.021406.144059
Copyright c 2007 by Annual Reviews.
All rights reserved
0163-7525/07/0421-0113$20.00
First published online as a Review in
Advance on November 9, 2006
Key Words
cell phones, caller ID, response rates, number portability, selection
bias
Abstract
Telephone surveys are critical for examining cross-sectional charac-
teristics of population subgroups, tracking trends in prevalence of
conditions and risk behaviors over time, identifying risk factors as-
sociated with multiple health conditions, and assessing the effects of
interventions. Technology has aided telephone research through ad-
vances such as computer-assisted telephone interviewing. However,
technology suchas answeringmachines andcaller IDhas contributed
to declines in response rates and has increased costs of conducting
telephone surveys. The exponential increase in cell phone utiliza-
tion presents a challenge to the tradition of randomdigit dial (RDD)
surveys of households. Because telephone surveys are used by other
industries such as marketing and public opinion polling, the market-
place may help drive innovation and adaptation. Cell phones have
made telephone communication an even greater part of the everyday
culture and could make potential telephone survey respondents even
more accessible to public health researchers.
113
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ANRV305-PU28-07 ARI 9 February 2007 9:14
BRFSS: Behavioral
Risk Factor
Surveillance System
CATI:
computer-assisted
telephone
interviewing
IVR: interactive
voice response
Cell phone: uses a
network of
short-range base
stations located in
overlapping cells
throughout a region.
Also called wireless,
mobile phone.
RDD: random digit
dial
INTRODUCTION
The telephone has proven to be a primary
doorway into the homes of the general public
and has enabled surveys to play a vital role in
public health research and practice for many
decades. Participation in telephone surveys
is critical for examining cross-sectional char-
acteristics of population subgroups, tracking
trends in prevalence of conditions and risk
behaviors over time, identifying risk factors
associated with multiple health conditions,
and assessing the effects of interventions.
The Behavioral Risk Factor Surveillance Sys-
tem (BRFSS) has elicited participation from
households nationally since 1984(34), the Na-
tional Immunization Survey (NIS) since 1994
(40), and the State and Local Area Integrated
Telephone Survey (SLAITS) since 1997 (5).
The Centers for Disease Control and Pre-
ventions BRFSS Bibliography database iden-
ties only nine scientic publications printed
in 1985 using BRFSS data; 20 years later, in
2005, nearly 150 publications are listed (31),
indicating extensive use of the survey data for
research and public health practice. Because
such data are provided at the state and lo-
cal level, they are also incorporated into many
state and local community health assessments
and tracking projects (49, 54).
As telephone survey research methods
have continued to improve, the challenges
that confront public health researchers are in-
creasing. In the fall of 1987, more than 400
participants gathered in North Carolina for
the International Conference on Telephone
Survey Methodology to discuss the current
state of telephone surveys and share their
most recent work (17). Nearly 20 years later,
in early 2006, more than 300 people gath-
ered in Miami for the second International
Conference on Telephone Survey Methodol-
ogy. In the intervening decades the landscape
of telephone survey research evolved rapidly,
often in response to changing technologies.
Survey researchers have beneted from im-
provements in call center technologies, such
as computer-assisted telephone interviewing
Table 1 Continuing and emerging
challenges for telephone survey research
Ongoing
challenges
New and emerging
challenges
Selecting participants
Sampling Cell phone sampling
Telephone coverage Number portability
Response rates Answering machines
Participation rates Caller ID
Call scheduling Privacy managers and
call blocking
Collecting information
Reliable and valid
responses
Privacy and
condentiality
Mode effects Respondent burden
(CATI), call schedulers, and interactive voice
response (IVR) systems. However, some ad-
vances in technology have presented chal-
lenges to survey researchers, including the in-
creasing use of answering machines, caller ID,
and cellular phones, and the advent of number
portability.
The purpose of this review is to provide
an overview of current issues and emerg-
ing challenges in telephone survey research
(Table 1). Many other resources are available
for those seeking a more comprehensive or
technical review of telephone survey meth-
ods (see 17, 26, 30, 44). Following a brief
background on survey methods, we highlight
ongoing methodological issues of concern
for telephone survey researchers: telephone
coverage, reaching participants, response and
participation rates, and response validity and
reliability. The focus then shifts to a discus-
sion of new and evolving challenges for tele-
phone surveys: cell phones, number porta-
bility, and call screening. Although framed
primarily with respect to random digit dial
(RDD) surveys, most issues are applicable to
telephone survey designs ingeneral, including
mixed mode surveys, whichuse telephone sur-
veys in combination with other forms of ad-
ministration and data gathering, such as face-
to-face interviews or Web-based surveys.
114 Kempf

Remington
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BACKGROUND OF METHODS
USED IN TELEPHONE SURVEY
RESEARCH
The primary purpose of telephone surveys is
to make valid, reliable, and generalizable con-
clusions about populations on the basis of the
answers of sampled respondents. Therefore,
surveys must rst appropriately select partic-
ipants from the target population, and then
obtain valid information about the item of in-
terest, such as an attitude, behavior, or health
condition. Thorough and appropriate survey
planning and administration are necessary to
identify and prevent potential sources of se-
lection and information bias.
Selecting and Contacting
Participants
To achieve accurate estimates for the popu-
lation of interest, a representative sample of
the target population must be identied and
interviewed. Figure 1 illustrates the multiple
steps involved in this selection process, from
identication of the sampling frame to agree-
ment of participation. In the early days of tele-
phone survey research, participants were of-
ten randomly selected using a list of telephone
numbers from a phone book or directory list-
ing. However, as attention to the proportion
of the public with unlisted numbers increased,
random digit dialing (RDD) became the pre-
ferred method to permit sampling of all per-
sons with a telephone, whether listed or not.
The RDD method of sampling for tele-
phone surveys uses randomly generated
phone numbers in the area code or exchange
of interest and in doing so avoids the concern
over listed versus unlisted numbers. However,
because only some of the possible phone num-
ber combinations are in use at any one time,
the basic RDD method leads to much time
being spent calling nonworking and nonresi-
dential numbers.
The Mitofsky-Waksberg method (51) im-
proves on the basic RDD design by identi-
fying working residential numbers and then
Potential
subject
No
telephone
Landline
Not at
home
At home
Screen
calls
Do not
screen calls
Agree to
participate
Decline
Cell phone
only
Telephone
Figure 1
Steps in the selection of participants in telephone surveys.
Exchange: the rst
three digits of a local
telephone number
following the area
code
including clusters of consecutive phone num-
bers sequentially surrounding the conrmed
working residential number in the sampling
frame. Because numbers are often assigned
by phone companies in groups or sequences
rather thanrandomly, using the banks of num-
bers with an identied working residential
number improves efciency and reduces cost.
Finally, the use of a list-assisted design can
further increase the efciency of RDD tele-
phone surveys. List-assisted sampling incor-
porates information from additional sources
such as telephone directories or consumer
information databases. By identifying phone
numbers with higher probabilities of yielding
a contact, list-assisted sampling can improve
the productivity and efciency of the calling
www.annualreviews.org Telephone Survey Challenges 115
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Landline:
land-based
telephone. Standard
telephone system
that uses in-ground
and telephone pole
cables. As opposed to
wireless satellite
services
process. Increasingly sophisticated mainte-
nance and updating of directories and the
availability of sampling rms have made list-
assisted designs especially attractive. How-
ever, there is a nancial cost to purchas-
ing such lists, and potentially a methodolog-
ical cost as well if the list-assisted sample is
not representative of the true population of
interest.
Gathering Information from
Participants
Although identication of the most appropri-
ate sampling frame for the specic research
question is extremely important, the primary
survey purpose of gathering information, and
how best to do this, must also be addressed.
Because data could be collected in many
different waysin-person interviews, mailed
survey instruments, administrative datawhy
use the telephone? Lavrakas (26) suggests
three primary advantages of telephone sur-
veys for data collection: the ability to main-
tain quality control over the entire process of
data collection, cost efciency, and the speed
of data collection.
Quality control can be managed all the
way through the process, including question-
naire construction and administration. While
piloting of questions and wording can be
done for a phone survey, as with a mail sur-
vey, the success of specic questions can be
continuously monitored throughout the data-
collection process of a telephone survey, es-
pecially with the use of CATI systems. Sur-
vey administration over the phone rather than
in person also provides a much more cost-
efcient method of data collection and is of-
ten less intrusive to the potential respondent
than having an interviewer in his/her home.
Additionally, telephone follow-up, as used in
the Pregnancy Risk Assessment Monitoring
System (2) and the Consumer Assessment of
Health Providers and Systems (36), can be an
efcient method to contact mail nonrespon-
dents. Finally, the telephone allows surveys
to be conducted and completed more quickly
than in-person and mail administration. This
increased efciency can be especially impor-
tant for research topics in which the tem-
porality and social context within which the
questions are being asked (and answered) is
especially important, such as data collection
conducted in the immediate aftermath of an
epidemic outbreak or natural disaster.
ONGOING TELEPHONE
SURVEY CHALLENGES
The previous sectionprovides a brief overview
of ways to identify respondents and collect in-
formation using the telephone. The follow-
ingchallengestelephone coverage, reaching
participants, response and participation rates,
and the reliability and validity of responses
have existed since telephone surveys were rst
conducted and continue to require the atten-
tion of telephone survey researchers.
Telephone Coverage
Trends and characteristics of telephone
coveragetraditionally discussed as the pro-
portion of the population with a working
landline telephonehave necessarily always
been of primary concern to those conduct-
ing telephone surveys. If the rate of telephone
coverage is extremely lowas is the case in
many developing countriesa telephone sur-
vey will likely be impractical and inefcient.
Telephone noncoverage is of greatest concern
when those people without a telephone differ
signicantly from those with a telephone in
terms of the characteristic under considera-
tion. The extent of [n]on-coverage bias is a
function of the magnitude of the noncoverage
of a telephone survey frame and the difference
in characteristics between the covered and
noncovered populations (29). Therefore, an
examinationof these twofactors illustrates the
state of the continuing challenge of telephone
noncoverage.
The percentage of the U.S. population
without a landline telephone in their home
has steadily decreased for the past century.
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ANRV305-PU28-07 ARI 9 February 2007 9:14
In 1920, 65% of all households did not have
a telephone, but this value dropped to less
than 10% by 1970 (13). Data from the Na-
tional Health Interview Survey (43) and Fed-
eral Communications Commission (13) esti-
mate that 7%8% of all households in 1986
didnot have a landline telephone. As displayed
in Figure 2, this trend continued over subse-
quent decades, with less than 5% household
noncoverage observed in 2003 (13). Non-
coverage estimates from various sources tend
to differ, likely owing in part to inconsisten-
cies and changes in the wording of questions
used to ascertain telephone ownership.
The second factor to consider is whether
households without telephones are differ-
ent from households with telephones. Those
without a household phone are more likely
to be minority, less educated, living in rural
areas, and more likely to report worse self-
rated health than those with a phone (15).
Renters are also more likely to be without a
phone than those who own their own home
(47), as are those who are unemployed (43).
To correct for the bias that telephone non-
coverage can introduce, crude results must be
appropriately weighted. One option is to use
households that now have telephone service
but have recently been without it as represen-
tative of the households not reached because
they are currently without phone service (16,
23).
Although the general trend in landline
telephone noncoverage has been decreasing,
Figure 2displays a recent upturninthe preva-
lence of noncoverage, perhaps implying that
the maximumlandline coverage rate may have
been reached. Increased cell phone use may
be leading some households to abandon their
landline phones. For reasons to be discussed
later, most RDD surveys do not include cell
phones in their sampling frame. The majority
of individuals with cell phones (approximately
90%) also have a landline phone on which
they can be reached and, therefore, still have
the potential for being included in the sam-
ple (47). However, just as the unique demo-
graphic characteristics of those without any
Telephone noncoverage 19842004
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Figure 2
Recent trends in landline telephone noncoverage by household 19842004
(13).
landline telephone service are of concern, so
are the demographics of the 6% of all U.S.
households that have a cell phone but no land-
line telephone (13).
Most recent research has indicated that the
cell-phone-only group does in fact have dif-
ferent demographic characteristics fromthose
with landline telephones and those with no
phone at all, and they appear to consist of two
distinct segments. The rst of these segments
are young, relatively wealthy, renters who
tend to live alone or with roommates. Studies
estimate that more than30%of renters, 1830
years of age, living alone or with roommates,
use only a cell phone (3), indicating a serious
undercoverage problemfor this group in tele-
phone surveys that use only landline sampling
frames. The second group of cell-phone-only
individuals tend to be poor, minority, and us-
ing only a cell phone and no landline for eco-
nomic reasons. Multiple surveys have identi-
ed urban or metropolitan areas as having a
higher proportion of cell-phone-only individ-
uals (4, 13).
Similar to the adjustments described above
for landline noncoverage, a similar method
can be used to adjust for the cell-phone-only
group. In this case, households with a recent
interruption in landline phone service who
had a cell phone during this break can be
www.annualreviews.org Telephone Survey Challenges 117
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ANRV305-PU28-07 ARI 9 February 2007 9:14
used to adjust for the cell-phone-only group
(22). Even without this adjustment, this cell-
only group may not be causing a very large
bias in survey estimates, and in general they
have health risk behaviors that more resem-
ble those with landline service than do those
people with no telephone service at all (4).
Reaching Participants
Scheduling initial and repeat calls to poten-
tial respondents serves the important purpose
of increasing the efciency of study adminis-
tration by maximizing the return on the time
spent calling. Early efforts examined the call
times that would produce the best response
rates, and results can vary on the basis of the
target group of interest (12, 53). The addition
of CATI systems allowed for even greater ef-
ciency by removing much of the human error
in call scheduling and providing an automated
scheduling system (52). Current efforts at call
scheduling include a focus on selecting the
conditions of the subsequent attempts based
on the call history (37). Important consider-
ations in scheduling second and subsequent
calls include length of time between call at-
tempts, the type of rst contact, and variation
in the timing and schedule of contacts.
Response and Participation Rates
Much documentation exists chronicling the
continuing decline in response rates for tele-
phone surveys over the past few decades and
the difculties these rates cause for telephone
survey research (see 1719, 42, 46). Curtin
et al. (11) report that response rates for the
University of Michigans Survey of Consumer
Attitudes have declined from 72% in 1979 to
a low of 48% in 2003, and many other studies
report similar trends. The decline in response
rates is likely due to a conuence of factors,
such as call screening, changing patterns of
when household residents are at home, and
refusals once contacted. Researchers have un-
dertaken numerous efforts to improve falling
response rates, including advance mailings
(20, 26a), adjustments to the introduction of
the interview script (21), and offering incen-
tives (38). However, the additional effort ex-
pended to increase response rates may result
in little change in the nal survey estimates
(2425), although the potential impact is de-
pendent on the survey content and subject
matter.
Reliable and Valid Responses
The nal ongoing challenge in conducting
high-quality telephone surveys is to obtain
valid information about the item of interest,
such as an attitude, behavior, or condition.
Many of the measures obtained through tele-
phone surveys for the BRFSS have been thor-
oughly examined with respect to their reli-
ability and validity. Demographic questions
and those relating to some risk factors, such
as smoking status, alcohol consumption, and
height and weight, are reported with moder-
ate to high reliability and validity (31a). Other
health behaviorssuch as diet, exercise, and
drinking and driving (31a, 42a)and ques-
tions regarding knowledge and attitudes (7a)
demonstrate less reliability.
The quality of information obtained
through telephone surveys has also been com-
pared with information obtained through
other modes, such as in-person, mailed, and
Web surveys, and the differences observed de-
pend on the question being asked. For exam-
ple, questions about visible factors, such as
body weight or smoking status, may be re-
ported more accurately in person because the
interviewer is able to conrm the response.
However, respondents may be more likely to
report sensitive behaviors, such as drug or al-
cohol use, on the telephone given the rela-
tive anonymity of the interview. Reporting
over the telephone can be further improved
for sensitive and private topics through the
use of IVR (10). Along with many other risk
behaviors and conditions, these mode differ-
ences have been examined for alcohol use (27,
39), smoking (1), respiratory symptoms (7),
and adolescent risk behaviors (48).
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ANRV305-PU28-07 ARI 9 February 2007 9:14
Although the potential for reporting bias
exists in telephone surveys, the results are
still of use for researchers and practition-
ers. For example, although body mass in-
dex may in some cases be misclassied us-
ing self-reported height and weight, the data
are still valid for the study of epidemiologi-
cal associations (41) and can be much more
efciently collected over the phone than in-
person measurement. Additionally, survey re-
searchers can take many steps to ensure the
accuracy, validity, and reliability of the in-
formation obtained through surveys. These
measures include pilot testing of survey in-
struments, validation and reliability studies of
instruments, examination of mode effects for
the research questions of interest, and utiliza-
tion of CATI and IVR technologies.
NEW AND EVOLVING
TELEPHONE SURVEY
CHALLENGES
As quickly as new technologies develop to
facilitate survey research, new challenges
arise that make it more difcult to achieve the
goal of collecting information from a target
population with a generalizable sample.
These challenges include increased use of
cell phones, number portability, and call
screening.
Cell Phones
The unique group of potential survey respon-
dents who do not have a landline telephone
andare reachable only ontheir cellular phones
cause increasing problems for telephone sur-
veys in general and random digit dial sur-
veys in particular. In 1985, fewer than half a
million Americans were cell phone users; by
1995 there were nearly 35 million users, and
by 2005 that number had exploded to more
than 200 million cell phone subscribers (9).
One might think that increasing numbers of
telephone users in any form would be an ad-
vantage such that it provides more avenues
through which potential respondents can be
reached. However, the complex logistics of
conducting surveys with cell phones have not
yet allowed the research industry to take full
advantage of the increasing popularity of cell
phone use among the general public.
First, identifying a cell phone sampling
frame is not quite as straight forward as iden-
tifying a traditional landline sampling frame.
The cell phone and landline sampling frames
are not completely distinct, thus preventing
the simple merger of the two sampling frames
into one. More than half of all households
have access to both a landline telephone and a
cell phone (47). Additionally, cell phones usu-
ally belong to a specic individual, in contrast
to landlines, which are most often used for
sampling at the household level.
Traditionally, business exchanges have
been removed from or screened out of the
sampling frame for household telephone sur-
veys to maximize call efciency. This way
the interviewer is reasonably condent that
the vast majority of the numbers called will
be landline telephones located within house-
holds. Although cell phone numbers can usu-
ally be identied as such, it is not quite as
easy to identify the cell phones owner and
whether the phone is used for business or per-
sonal matters. Further research is also needed
to examine the potential impact of embedded
cellular technologies, suchas General Motors
OnStar service, and their potential inclusion
in cell phone sampling frames. Additionally,
the wide availability of prepaid cell phones
leads to a continual ux of activated and de-
activated cell numbers.
If cell numbers are included in sampling
frames, it will increase the probability of se-
lection for some households and members of
households, including teens and preteens, a
demographic with increasing access to its own
cell phone. Extra care is required in these
cases to identify not only how many land-
line phones are associated with a household,
but also how many cell phones are associ-
ated with the household members. Because
many people can be reached by both land-
line telephone and cell phone, appropriately
www.annualreviews.org Telephone Survey Challenges 119
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ANRV305-PU28-07 ARI 9 February 2007 9:14
combining these two overlapping and incom-
plete sampling frames requires special effort.
Sampling frames for landline telephone
surveys are often constructed around specic
geographic areas of interest. Using the tele-
phone exchanges associated with specic ar-
eas, sampling of phone numbers can be re-
stricted predominately to those in the region
of interest (see discussion of number portabil-
ity below). However, because cell phones are
not tied to a physical landline they are much
more portable, and one can not simply assume
that the individual contacted is currently re-
siding in the area associated with their tele-
phone exchange or even their area code. This
trend is also likely to be found more often
among certain highly mobile groups, such as
college students and other young adults. A re-
cent marketing survey conducted by Arbitron
with a cell phone sampling frame found that
more than 30% of cell-phone-only house-
holds were not living in a county within the
radioratingcenter associatedwiththeir phone
number (14).
In addition to sampling concerns, a sec-
ond potential barrier to cell phone surveys
is the nancial burden placed on the respon-
dent. For many cell phone plans, incoming
calls count against a subscribers total minutes
purchased for the month. Therefore, unlike
landline telephones, for whichthe caller is pri-
marily responsible for the cost of the call, cell
phone respondents may consider the nancial
cost of the call in their decision of whether to
participate in a telephone survey. This nan-
cial burden placed on the cell phone respon-
dent could be somewhat mitigated by keeping
the duration of the call to a minimum and/or
by taking advantage of time periods of a re-
duced price for incoming calls, which many
subscribers are offered (i.e., free nights and
weekends).
Legal risks and concerns constitute a third
challenge for cell phone surveys. These chal-
lenges have resulted in part from recent back-
lash against the telemarketing industry and
fear that such marketing will become perva-
sive on personal cell phones. The Telephone
Consumer Protection Act of 1991 places re-
strictions on the use of auto-dialer machines
and does not allow for them to be used to call
cell phones, even for research purposes. Until
this restriction is lifted, cell numbers can still
be called as long as the numbers are dialed by
hand, although this can substantially increase
the time and costs necessary for completing a
survey.
In addition, clear guidelines for con-
ducting surveys with respondents using cell
phones have not been established, and many
are unsure of the potential legal risks inher-
ent when participants may be completing sur-
vey questions in an unknown location. Un-
less a home landline telephone number has
been forwarded to ring somewhere else, the
researcher can be reasonably sure when call-
ing a landline telephone that they are reaching
respondents in their home. However, when
calling a cell phone, the potential respondent
could be at home or at work, at the store or
in the car. Therefore, respondents will likely
need to be screened for their current loca-
tion to be sure that they are not in a situa-
tion, such as driving, where talking on their
cell phone would be potentially dangerous for
themselves or others.
Finally, the portable nature of cell phones
and the mobility of their users contribute ad-
ditional logistical barriers to completing tele-
phone surveys with cell phone respondents.
Not only is a respondent who is driving while
on the phone in a potentially dangerous situ-
ation, but they are also likely to be distracted
as they respond to survey questions. The po-
tential for the connection to be dropped in
the middle of the survey administrationan
event likely to happen more frequently if the
respondent is moving in and out of areas
with cell servicerequires procedures to be
in place for appropriately handling the dispo-
sition of these dropped calls.
Although distinct challenges exist for the
incorporation of cell phones into telephone
surveys in the United States, such surveys
are being conducted more frequently in other
areas of the world. Some of the barriers found
120 Kempf

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ANRV305-PU28-07 ARI 9 February 2007 9:14
in the United States are not as problematic
in other countries, such as restrictions on the
use of auto-dialers. In Brazil, cell phone users
receive incoming calls for free, thereby elim-
inating the cost burden for the respondent
(35). In France, nearly 17% of households
are cell-only (50), facilitating the use of these
cell phones for telephone surveying. Further
attention must be given to addressing these
barriers and including cell phones in survey
sampling frames.
Number Portability
As a result of the issues outlined above for cell
phone surveys, cell phone exchanges are usu-
ally excluded fromtelephone survey sampling
frames. However, the advent of number porta-
bility regulations means that phone numbers
associated with cell phones cannot always be
immediately identied based simply on their
exchange. Telephone numbers can be ported
in four different ways: cell to cell, landline to
landline, cell to landline, and landline to cell.
Because the rst two types do not cross ser-
vices, they pose little problem for telephone
survey research and can still be appropriately
identied using only the information associ-
ated with the exchange. They can, however,
potentially cause the same difculty discussed
above for cell phones with regard to breaking
the link between an identied geographic area
and the exchange or area code.
Numbers ported between cell phones and
landlines are more difcult to identify and can
cause the most problems for survey research.
National databases of numbers ported from
landlines to cell lines are usually used to iden-
tify these numbers and remove themfromthe
calling database to prevent contacting a cell
phone number with an auto-dialer. However,
individuals with cell numbers that have been
ported to landlines may be automatically ex-
cluded fromthe sample if their number is mis-
takenly identied as still being a cell number,
even though it is now technically a landline
and could be called with an auto-dialer.
Portability: the
ability to keep the
same telephone
number when
switching carriers or
services (e.g.,
wireless to landline)
Call Screening
Some landline telephones and most cell
phones provide the user with the ability to
screen their incoming calls, either through
providing caller identication information
(caller ID) or allowing the call to be picked
up by an answering machine or voicemail.
These devices andcapabilities have beenmore
thoroughly examined as they relate to land-
line telephone surveys, but their interaction
with cell phones is likely similar. Both caller
ID and answering machines pose difcul-
ties for researchers hoping to make it past
these devices and speak with potential respon-
dents. Throughout the 1990s, the percentage
of households using an answering machine
increased, along with the use of the answer-
ing machine to screen calls (32, 46). In 1999,
researchers found that answering machines
tended to be found more frequently in the
homes of those who were white, under age
65, more highly educated, and living in more
densely populated areas (28). As caller ID use
and availability increases, the answering ma-
chine has become a less efcient and less desir-
able method to screen calls, and in turn may
also have become less of a concern for tele-
phone survey research.
The prevalence of caller ID is increasing
more quickly than answering machines did
in the past, and caller ID tends to be used
more frequently for screening calls. During
the same time frame in which a 7% increase
in answering machine use was observed, caller
ID use increased from 10% to nearly 50%
of households; and among those with caller
ID, two thirds use it at least most of the
time for screening calls (46). Although the
characteristics of those with caller ID are
slightly different from those with answer-
ing machines, the highest rates of screening
with either of these devices have been found
among young adults, those who have never
been married, Hispanics, African Americans,
households with young children, and those
living in more densely populated areas
(46).
www.annualreviews.org Telephone Survey Challenges 121
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Despite the increased prevalence of these
devices and their use for call screening,
we do have reasons to be optimistic about
why call screening may not eliminate the
ability to identify representative samples in
phone surveys. To complete an interview,
households with screening devices may re-
quire more call attempts and an increased
cost than those without such devices (35a);
however, researchers have still been suc-
cessful in completing interviews with those
self-reporting as call screeners (28). One
study even found higher participation among
households in which an answering machine
was reached on the rst contact attempt com-
pared with a rst attempt of busy or no answer
(45).
Telephone survey researchers have begun
to focus instead on howbest to use these tech-
nologies and incorporate theminto the survey
process. Answering machines (and voicemail)
can be used to leave a message in an attempt
to increase the likelihood that the potential
respondent will answer the phone on the next
call attempt. Inthese cases, researchregarding
the most appropriate types of messages and
when to leave them is imperative. Answering
machine messages can also be used to reduce
respondent burden by providing a toll free
number for respondents to call at their conve-
nience to complete the survey. For caller ID,
what appears on the caller ID display affects
response and participation rates. The famil-
iarity of the potential respondent with the or-
ganization name displayed and the potential
respondents level of respect for the organi-
zation inuence differences in response rates
found in trials with randomized assignment of
households to varying caller ID display texts
(8, 33).
The telephone survey researchcommunity
has been faced with the above and other chal-
lenges for many years, and innovative mecha-
nisms for addressing these issues continue to
evolve. Table 2 provides a summary of some
strategies for addressing the spectrumof chal-
lenges facing telephone survey researchers
both the continuing challenges of the past
Table 2 Potential strategies for addressing methodological issues in telephone
survey research
Telephone survey challenge Strategy options
Telephone coverage Multi-mode (or alternative) design
Incorporate cell phone sampling frame
Use recent no-phone (or cell-only) group as a proxy
Weighting based on demographic data of no-
phone (cell-only) group
Reaching participants Call scheduling
Adjust scheduling on the basis of call history
Optimize number of attempts
Answering machine messages
Use caller ID display
Text messages
Response and participation rates Advance letters
Interview introduction
Incentives
Interviewer factors
Reduce respondent burden
Reliability and validity of responses Mode (IVR, etc)
Question type
Question order
Cognitive aspects of survey methodology
122 Kempf

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ANRV305-PU28-07 ARI 9 February 2007 9:14
and the evolving challenges of the present and
future.
CONCLUSION
Telephone surveys play a vital role in pub-
lic health research and practice, and tele-
phone survey research has been constantly
improving through advances in the meth-
ods and technology used to contact the pub-
lic and administer survey instruments. How-
ever, the research community has been faced
with many challenges including telephone
coverage, nonresponse, answering machines,
and caller ID. Some challenges, such as cell
phones, have proven more difcult to ad-
dress, and other predicted problems, such as
videophones, never posed problems of the
magnitude once feared (26). In many cases,
the changes have contributed to continu-
ing declines in response rates and increas-
ing costs of conducting telephone surveys.
However, as we continue to cope with these
challenges, new and innovative ways to ad-
dress the emerging issues are beginning to de-
velop. Because telephone surveys are used by
other industries such as marketing and pub-
lic opinion polling, the marketplace may also
help drive innovation and adaptation. Even
the largest current challengecell phones
should be viewed as an opportunity rather
than a roadblock. Cell phones have made tele-
phone communication an even greater part of
the everyday culture and could make poten-
tial telephone survey respondents even more
accessible to public health researchers.
SUMMARY POINTS
1. Telephone surveys play a vital role in public health research and practice.
2. Technological and methodological advances have improved survey administration.
3. Answering machines, voicemail, caller ID, and cell phones have contributed to
decreasing response rates.
4. Increasing use of cell phones creates a challenge for traditional telephone surveys
using random-digit-dialing to landline telephones.
5. The near-ubiquitous use of cell phones could make potential telephone survey re-
spondents even more accessible to researchers in the future.
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AR305-FM ARI 26 February 2007 18:0
Annual Review of
Public Health
Volume 28, 2007
Contents
Symposium: Public Health Preparedness
Introduction: Preparedness as Part of Public Health
Nicole Lurie p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p pxiii
Assessing Public Health Emergency Preparedness: Concepts, Tools,
and Challenges
Christopher Nelson, Nicole Lurie, and Jeffrey Wasserman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Quality Improvement in Public Health Emergency Preparedness
Michael Seid, Debra Lotstein, Valerie L. Williams, Christopher Nelson,
Kristin J. Leuschner, Allison Diamant, Stefanie Stern, Jeffrey Wasserman,
and Nicole Lurie p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 19
Risk Communication for Public Health Emergencies
Deborah C. Glik p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 33
First Responders: Mental Health Consequences of Natural and
Human-Made Disasters for Public Health and Public
Safety Workers
David M. Benedek, Carol Fullerton, and Robert J. Ursano p p p p p p p p p p p p p p p p p p p p p p p p p p p p 55
Epidemiology and Biostatistics
Network Analysis in Public Health: History, Methods, and Applications
Douglas A. Luke and Jenine K. Harris p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 69
Methods for Improving Regression Analysis for Skewed Continuous or
Counted Responses
Abdelmonem A. A, Jenny B. Kotlerman, Susan L. Ettner,
and Marie Cowan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 95
New Challenges for Telephone Survey Research in the Twenty-First
Century
Angela M. Kempf and Patrick L. Remington p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 113
Seasonality of Infectious Diseases
David N. Fisman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 127
vii
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AR305-FM ARI 26 February 2007 18:0
Health Impact Assessment: A Tool to Help Policy Makers Understand
Health Beyond Health Care
Brian L. Cole and Jonathan E. Fielding p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 393
Social Environment and Behavior
Physical Activity and Weight Management Across the Lifespan
Jennifer H. Goldberg and Abby C. King p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 145
The Hitchhikers Guide to Tobacco Control: A Global Assessment of
Harms, Remedies, and Controversies
Ronald M. Davis, Melanie Wakeeld, Amanda Amos,
and Prakash C. Gupta p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 171
Youth Violence Prevention Comes of Age: Research, Training, and
Future Directions
Kara Williams, Lourdes Rivera, Robert Neighbours, and Vivian Reznik p p p p p p p p p p p p p 195
Church-Based Health Promotion Interventions: Evidence and Lessons
Learned
Marci Kramish Campbell, Marlyn Allicock Hudson, Ken Resnicow,
Natasha Blakeney, Amy Paxton, and Monica Baskin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 213
Risk Communication for Public Health Emergencies
Deborah C. Glik p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 33
Environmental and Occupational Health
The Epidemiology of Autism Spectrum Disorders
Craig J. Newschaffer, Lisa A. Croen, Julie Daniels, Ellen Giarelli,
Judith K. Grether, Susan E. Levy, David S. Mandell, Lisa A. Miller,
Jennifer Pinto-Martin, Judy Reaven, Ann M. Reynolds, Catherine E. Rice,
Diana Schendel, and Gayle C. Windham p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 235
Beryllium: A Modern Industrial Hazard
Kathleen Kreiss, Gregory A. Day, and Christine R. Schuler p p p p p p p p p p p p p p p p p p p p p p p p p p p 259
Adverse Late Effects of Childhood Cancer and Its Treatment on
Health and Performance
Kirsten K. Ness and James G. Gurney p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 279
First Responders: Mental Health Consequences of Natural and
Human-Made Disasters for Public Health and Public Safety Workers
David M. Benedek, Carol Fullerton, and Robert J. Ursano p p p p p p p p p p p p p p p p p p p p p p p p p p p p 55
Health Services
Managed Behavioral Health Care Carve-Outs: Past Performance and
Future Prospects
Richard G. Frank and Rachel L. Gareld p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 303
viii Contents
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AR305-FM ARI 26 February 2007 18:0
Rationale and Public Health Implications of Changing CHD Risk
Factor Denitions
Robert M. Kaplan and Michael Ong p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 321
Delivery of Health Services to Migrant and Seasonal Farmworkers
Thomas A. Arcury and Sara A. Quandt p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 345
Public Health Practice
Lessons from Cost-Effectiveness Research for United States Public
Health Policy
Scott D. Grosse, Steven M. Teutsch, and Anne C. Haddix p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 365
Health Impact Assessment: A Tool to Help Policy Makers Understand
Health Beyond Health Care
Brian L. Cole and Jonathan E. Fielding p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 393
How Can We Increase Translation of Research into Practice? Types of
Evidence Needed
Russell E. Glasgow and Karen M. Emmons p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 413
Community Factors in the Development of Antibiotic Resistance
Elaine Larson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 435
Assessing Public Health Emergency Preparedness: Concepts, Tools,
and Challenges
Christopher Nelson, Nicole Lurie, and Jeffrey Wasserman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Quality Improvement in Public Health Emergency Preparedness
Michael Seid, Debra Lotstein, Valerie L. Williams, Christopher Nelson,
Kristin J. Leuschner, Allison Diamant, Stefanie Stern, Jeffrey Wasserman,
and Nicole Lurie p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 19
Indexes
Cumulative Index of Contributing Authors, Volumes 1928 p p p p p p p p p p p p p p p p p p p p p p p p 449
Cumulative Index of Chapter Titles, Volumes 1928 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 454
Errata
An online log of corrections to Annual Review of Public Health chapters (if any, 1997
to the present) may be found at http://publhealth.annualreviews.org/
Contents ix
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