Charles F. Turner

Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomised trial.

BACKGROUND We aimed to assess audio-computer-assisted self-interviewing (audio-CASI) as a method of reducing under-reporting of HIV risk behaviour among injecting drug users. METHODS Injecting drug users were interviewed at syringe-exchange programmes in four US cities. Potential respondents were randomly selected from participants in the syringe exchanges, with weekly alternate assignment to either traditional face-to-face interviews or audio-CASI. The questionnaire included items on sociodemographic characteristics, drug use, and HIV risk behaviours for 30 days preceding the interview. We calculated odds ratios for the difference in reporting of HIV risk behaviours between interview methods. FINDINGS 757 respondents were interviewed face-to-face, and 724 were interviewed by audio-CASI. More respondents reported HIV risk behaviours and other sensitive behaviours in audio-CASI than in face-to-face interviews (odds ratios for reporting of rented or bought used injection equipment in audio-CASI vs face-to-face interview 2.1 [95% CI 1.4-3.3] p=0.001; for injection with borrowed used injection equipment 1.5 [1.1-2.2] p=0.02; for renting or selling used equipment 2.3 [1.3-4.0] p=0.003). INTERPRETATION Although validation of these self-reported behaviours was not possible, we propose that audio-CASI enables substantially more complete reporting of HIV risk behaviour. More complete reporting might increase understanding of the dynamics of HIV transmission and make the assessment of HIV-prevention efforts easier.

AIDS: Sexual Behavior and Intravenous Drug Use

Since the acquired immunodeficiency syndrome (AIDS) epidemic is partly a social phenomenon changes in the social behaviors that spread the disease are as necessary as the development of vaccines and other therapies. To help in the design implementation and evaluation of programs to curb the spread of AIDS there is a need for greater understanding of the human behaviors that transmit human immunodeficiency virus (HIV) infection as well as the social contexts in which these behaviors occur. Toward this end the US Committee on AIDS Research and the Behavioral Social and Statistical Sciences was asked to: 1) describe what is known about the spread of HIV and AIDS in the US with special attention to the quality of information at hand and the kind of additional information that is needed; 2) identify critical populations and indicate objectives and tasks related to them; 3) describe existing research findings in the behavioral and social sciences that should be useful in planning and choosing among interventions designed to control the spread of HIV infection; 4) describe existing research on interventions intended to facilitate behavior changes and ways to evaluate their effectiveness; and 5) identify new research that should be undertaken in these areas. The 7 chapters of the resultant report are divided into 3 parts: Understanding the Spread of HIV Infection; Intervening to Limit the Spread of HIV Infection; and Impediments to Research and Intervention. Also included are 6 background papers. Among the recommendations of the Committee are: vigorous programs of basic social and behavioral research on human sexual behavior; availability of condoms and treatment for sexually transmitted diseases through local public health authorities; drug treatment upon request for intravenous drug users; trials of sterile needle programs; and anonymous HIV antibody testing with appropriate counseling on a voluntary basis.

Interview Mode and Measurement of Sexual Behaviors: Methodological Issues.

Studies of sexual and other sensitive behaviors are often fraught with a variety of reporting biases. When IAQs are used to collect data, respondents may underreport certain sensitive behaviors and overreport normative behaviors. SAQs can also pose problems: requiring that respondents be literate and able to follow skip patterns. In recent years, the development of computerized technologies--audio-CASI and T-ACASI--have begun to overcome some of the limitations of IAQs and SAQs. By providing a more private mode for data collection and standardized delivery of all questions, as well as automated skip patterns and range checks, audio-CASI and T-ACASI have been tested in a number of studies and found to be an effective way of reducing response bias, and thus, contributing to a better understanding of the prevalence and patterns of sexual and other sensitive behaviors.

Changes in sexual behavior and condom use among teenaged males: 1988 to 1995.

OBJECTIVES This study examines shifts in sexual experience and condom use among US teenaged males. METHODS Results from the 1988 and 1995 National Surveys of Adolescent Males were compared. RESULTS The proportion of never-married 15- to 19-year-old males who had had sex with a female declined from 60% to 55% (P = .06). The share of those sexually active using a condom at last intercourse rose from 57% to 67% (P < .01). Overall, the proportion of males who had sex without condoms last year declined from 37% to 27% (P < .001). CONCLUSIONS Although protective behaviors among teenagers have increased, significant proportions of teenagers--especially Black and Hispanic males--remain unprotected.

Sexual behavior in the United States 1930-1990: trends and methodological problems.

Background and Objectives Arguments for population-based research on patterns of sexual behavior are reviewed, and survey data are used to illustrate the insights that can be gained from such research. Study Design Reports of sexual behavior obtained in surveys of large probability samples of the U.S. population are analyzed and compared to make inferences about changes in the age of onset of sexual intercourse and the patterns of heterosexual and same-gender sexual behaviors of American men and women who entered adulthood during the period from 1930 to 1990. Results Strong trends are documented for both a decline in the reported age at first heterosexual intercourse and an increase in the numbers of heterosexual partners reported during adulthood. Similar evidence on patterns of same-gender contact indicate a relatively stable prevalence of reported male-male contact for cohorts of men born from the 1930s through the 1960s. Preliminary analyses suggest, however, that there has been a substantial increase in the proportion of women reporting female-female sexual contact during adulthood. Although the analyses require refinement, it appears that the prevalence of reported female-female contact may have increased by a factor of 3 to 4 for cohorts of women born between the 1930s and the 1960s. Conclusions Although the trends in reported behaviors are robust, inferences about behavior, per se, rest on the assumption that reporting biases were equivalent across cohorts. Methodological challenges in the interpretation of such findings and new technologies for conducting such research are described.

Correlates of sexually transmitted bacterial infections among U.S. women in 1995.

CONTEXT Sexually transmitted diseases (STDs) of bacterial origin such as gonorrhea and chlamydial infection can lead to pelvic inflammatory disease (PID) and infertility. Identifying behaviors and characteristics associated with infection may assist in preventing these often asymptomatic diseases and their sequelae. METHODS Data from 9,882 sexually active women who participated in the 1995 National Survey of Family Growth describe the characteristics of women who report a history of infection with a bacterial STD or of treatment for PID. Multivariate analysis is used to determine which demographic characteristics and sexual and health-related behaviors affect the likelihood of infection or the occurrence of complications. RESULTS Overall, 6% of sexually active women reported a history of a bacterial STD, and 8% reported a history of PID. Women who first had sexual intercourse before age 15 were nearly four times as likely to report a bacterial STD, and more than twice as likely to report PID, as were women who first had sex after age 18. Having more than five lifetime sexual partners also was associated with both having an STD and having PID. PID was more common among women reporting a history of a bacterial STD (23%) than among women who reported no such history (7%). In multivariate analyses, age, race, age at first intercourse and lifetime number of sexual partners had a significant effect on the risk of a bacterial STD. Education, age, a history of IUD use, douching and a history of a bacterial STD had a significant impact on the risk of PID, but early onset of intercourse did not, and lifetime number of partners had only a marginal effect. CONCLUSIONS The pattern of characteristics and behaviors that place women at risk of infection with bacterial STDs is not uniform among groups of women. Further, the level of self-reported PID would suggest higher rates of gonorrhea and chlamydial infection than reported.

Risk Behaviors, Medical Care, and Chlamydial Infection Among Young Men in the United States

OBJECTIVES This study assessed factors related to chlamydial infection among young men in the United States. METHODS Data were from interviews of nationally representative samples of 470 men aged 18 to 19 years (teenagers) and 995 men aged 22 to 26 years (young adults) and from urine specimens tested by means of polymerase chain reaction. RESULTS Although a majority of the men reported occasional unprotected intercourse, only a minority perceived themselves to be at risk for contracting a sexually transmitted disease (STD). Chlamydial infection was detected in 3.1% of the teenagers and 4.5% of the young adults. A minority of those infected had symptoms or had been tested for STDs; very few had been diagnosed with STDs. CONCLUSIONS Chlamydial infection is common but usually asymptomatic and undiagnosed. Primary and secondary prevention efforts should be increased, particularly among young adult men.

Effect of Low Medical Literacy on Health Survey Measurements

Paper self-administered questionnaires (SAQs) are a standard interviewing technique for surveys of sensitive topics. Although SAQs afford respondents greater privacy than face-to-face interviews, they have several limitations. First, they require literate respondents. Second, they require forms literacy—the ability to select consistent responses, implement general survey instructions, and correctly follow branching or skip instructions. Survey respondents may have difficulty following skip instructions if they are not forms literate. This brief report examines the relationship between assessed levels of medical literacy, respondent characteristics, and the quality of measurements made in the 1997/98 Baltimore Sexually Transmitted Disease (STD) and Behavior Survey.

Using touch screen audio-CASI to obtain data on sensitive topics:

This paper describes a new interview data collection system that uses a laptop personal computer equipped with a touch-sensitive video monitor. The touch-screen-based audio computer-assisted self-interviewing system, or touch screen audio-CASI, enhances the ease of use of conventional audio CASI systems while simultaneously providing the privacy of self-administered questionnaires. We describe touch screen audio-CASI design features and operational characteristics. In addition, we present data from a recent clinic-based experiment indicating that the touch audio-CASI system is stable, robust, and suitable for administering relatively long and complex questionnaires on sensitive topics, including drug use and sexual behaviors associated with HIV and other sexually transmitted diseases.

Zenilman's anomaly reconsidered : Fallible reports, ceteris paribus, and other hypotheses

Background and Objectives: In the January‐February, 1995 issue of Sexually Transmitted Diseases, Zenilman and colleagues reported a null association between incident sexually transmitted diseases (STDs) and self‐reported condom use. That anomalous finding generated a flurry of letters to the editor, some of which were quite heated. This article reconsiders the Zenilman teams results. Study Design: New statistical analyses were conducted to test two hypotheses that sought to account for the null association: (1) deviation from study protocol, and (2) differential risks of acquiring an incident STD among segments of the study population that varied by reported level of condom use. Results: No support was found for hypotheses concerning deviation from study protocol and differential risk of acquiring an incident STD by level of condom use. Indeed, for respondents who reported multiple sexual partners, the analyses found increased rates of infection among those who reported more consistent condom use. Conclusions: Two of the most promising hypotheses for explaining Zenilmans anomalous findings are unsupported by reanalysis of the available empirical evidence. It is still possible that respondents who reported that they used condoms consistently differed from self‐reported nonusers or inconsistent users in some way that altered their risk of acquiring an STD and thus obscured the protective effects of properly used condoms. Nonetheless, as Zenilman and others suggest, fallibility in self‐reports of condom use remains the primary suspect as the cause of these anomalous results. Such fallibility may be particularly pronounced when self‐reported behavioral data are collected in contexts that include strong educational campaigns or other norm‐setting interventions.