Paul C. Hewett

The Reporting of Sensitive Behavior by Adolescents: A Methodological Experiment in Kenya

Does audio computer-assisted self-interviewing (ACASI) produce more valid reporting of sexual activity and related behaviors than face-to-face interviews or self-administered interviews? This analysis, based on data collected from over 6,000 unmarried adolescents in two districts of Kenya—Nyeri and Kisumu—indicates substantial and significant differences in reported rates of premarital sex across interview modes, although not always in the expected direction. Our assumption that girls underreport sexual activity in face-to-face interviews by comparison with ACASI is not confirmed by the Nyeri data, but our results from Kisumu are considerably more promising. As for boys, who we believe exaggerate their level of sexual activity in face-to-face interviews, a more nuanced set of expectations regarding the reporting of sensitive behaviors was offered; our results from Kisumu, although not always significant, by and large conform to expectations.

Consistency in the reporting of sexual behaviour by adolescent girls in Kenya: a comparison of interviewing methods

Objectives: To investigate in a district in Kenya the level and consistency of reporting of sexual behaviour among adolescent girls randomly assigned to two modes of survey interview: face to face interview and audio computer assisted self-interview (ACASI). Methods: The analysis is based on a subsample of over 700 never married girls aged 15–21 years in Kisumu, Kenya, drawn from a population based survey of over 2100 respondents. A questionnaire with 69 questions was used, two thirds of which were considered sensitive, including questions about risky sexual behaviour, alcohol and drug use, contraceptive practice, pregnancy, induced abortions, and births. Results: ACASI produced significantly higher reporting of sex with a relative, stranger, or older man, and higher reporting of coerced sex. However, differences by mode for ever had sex and sex with a boyfriend were not significant. Relative to ACASI, the interviewer administered mode produced highly consistent reporting of sexual activity, both within the main interview and between the main and exit interviews. Conclusions: Both the mode of survey administration and the probing for various behaviours significantly affect the observed prevalence of sexual activity. The ACASI results suggest that adolescent girls in Kenya have more complex and perilous sex lives than traditional face to face surveys of sexual activity indicate. The level of consistency in the interviewer mode is argued to be suspect, particularly given the much lower levels of reporting, relative to ACASI, for types of sexual partners and coerced sexual activity.

Using Sexually Transmitted Infection Biomarkers to Validate Reporting of Sexual Behavior within a Randomized, Experimental Evaluation of Interviewing Methods

This paper examines the reporting of sexual and other risk behaviors within a randomized experiment using a computerized versus face-to-face interview mode. Biomarkers for sexually transmitted infection (STI) were used to validate self-reported behavior by interview mode. As part of a parent study evaluating home versus clinic screening and diagnosis for STIs, 818 women aged 18-40 years were recruited in 2004 at or near a primary care clinic in São Paulo, Brazil, and were randomized to a face-to-face interview or audio computer-assisted self-interviewing. Ninety-six percent of participants were tested for chlamydia, gonorrhea, and trichomoniasis. Reporting of STI risk behavior was consistently higher with the computerized mode of interview. Stronger associations between risk behaviors and STI were found with the computerized interview after controlling for sociodemographic factors. These results were obtained by using logistic regression approaches, as well as statistical methods that address potential residual confounding and covariate endogeneity. Furthermore, STI-positive participants were more likely than STI-negative participants to underreport risk behavior in the face-to-face interview. Results strongly suggest that computerized interviewing provides more accurate and reliable behavioral data. The analyses also confirm the benefits of using data on prevalent STIs for externally validating behavioral reporting.

Assessing the reporting of adherence and sexual activity in a simulated microbicide trial in South Africa: an interview mode experiment using a placebo gel.

Misreporting of adherence undermines detection of an association between product use and HIV infection in microbicide trials. This study investigates whether, in a placebo trial, audio computer-assisted self-interviewing (ACASI) produces more accurate reporting of adherence and sexual behavior than a face-to-face interview (FTFI). At three South African clinics, 849 women were enrolled and instructed to use applicators filled with placebo gel; participants were randomly assigned to FTFI or ACASI. Behavioral reports were validated through two biomarkers that detect product usage and unprotected sex. For most behaviors, ACASI generated significantly higher reporting, although differences by interview mode appeared to diminish over time. ACASI participants were more likely to report having had sex without gel, but reported and tested applicators did not indicate greater honesty about gel insertion with ACASI. While comparisons of reported unprotected sex with the validated biomarker revealed more agreement with ACASI than with FTFI, differences were small.

Sex with stitches: assessing the resumption of sexual activity during the postcircumcision wound-healing period.

Objectives:This study uses observational data collected as part of Zambias male circumcision program to measure sexual behavior in the postsurgical healing period and to model its influence on HIV transmission for men and their partners. Design/methods:From August to October 2010, 248 men about to undergo male circumcision were recruited to participate. Interviews were conducted at baseline and 6 weeks after circumcision, the recommended period of sexual abstinence for complete wound healing. Logistic and Poisson regression models were used to assess risk factors for early resumption of sex. A static-network deterministic transmission model was constructed to assess the impact of the program given early resumption of sex. Results:Twenty-four percent of circumcised men reported resuming sex prior to 6 weeks after surgery. Of men having sex, 46% had sex in the first 3 weeks, 82% reported at least one unprotected sex act, and 37% reported sex with two or more partners. The model estimates that of the 61 000 men circumcised in 1 year, early resumption of sex leads to 69 extra HIV infections (32 among men, 37 among women), but it estimates a net effect of 230 fewer HIV infections in 1 year, predominantly among men. Conclusion:Prevalence of risky sexual behavior during wound healing is high and more likely among those reporting risky sexual behaviors at baseline. Nonetheless, the net effect of the male circumcision intervention is beneficial. The impact on women, however, is very sensitive to the prevalence of early resumption of sex.

The feasibility of computer-assisted survey interviewing in Africa: experience from two rural districts in Kenya

This article explores the use of an audio computer-assisted self-interviewing (audio-CASI) methodology in a household survey of adolescents in two districts of Kenya. Computer software was developed as part of a research project comparing audio-CASI with traditional methods of interviewing about sensitive behaviors, including sexual initiation, risky sexual behavior, coerced sex, and drug and alcohol use. The article describes the experience of carrying out a household-based study using computers and explores the technical challenges faced by the data-collection teams. Few problems emerged with the computer hardware and software despite the difficult interviewing conditions. The adolescent respondents easily adapted to the computerized interview and were able to complete the survey with minimal assistance. However, the computers were not a completely neutral part of the data-collection process and added to problems encountered during the fieldwork in one of the districts. Unexpected findings regarding respondents’ perceptions of privacy and confidentiality were also observed.

Behavior change pathways to voluntary medical male circumcision: narrative interviews with circumcision clients in Zambia.

As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of mens VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate mens movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.

Using biomarkers to assess the validity of sexual behavior reporting across interview modes among young women in Kampala, Uganda

Understanding the transmission dynamics of HIV and other sexually transmitted infections is critically dependent on accurate behavioral data. This study investigates the effect of the mode of questionnaire delivery on the quality of sexual behavior reporting in a 2010 survey conducted in Kampala, Uganda, among 18-24-year-old women. We compare the reported prevalence of five sexual outcomes across three interview modes: traditional face-to-face interviewing (FTFI) in which question rewording was permitted, FTFI administered via computer-assisted personal interviewing (CAPI) in which questions were read as written, and audio computer-assisted self-interviewing (ACASI) in which participants listened to prerecorded questions and entered responses using a computer touchscreen. We then assess the validity of the data by evaluating the reporting of sexual experience against three biological markers. Results suggest that ACASI elicits higher reporting of some key indicators than FTFI does, but self-reports from all interview modes were subject to validity concerns when compared with biomarker data. The study highlights the important role that biomarkers can play in sexual behavior research.

Challenges in Measuring the Sequencing of Life Events Among Adolescents in Malawi: A Cautionary Note

Using data from two rounds of the Malawi Schooling and Adolescent Survey, this research note examines consistency of retrospective reporting on the timing and sequencing of sexual initiation, school leaving, and marriage. The analysis, which compares reporting of events both within and between rounds, indicates substantial inconsistency in reporting of event sequences and highlights difficulties in measuring transitions to adulthood in sub-Saharan Africa with survey data.

Herpes simplex virus type 2 cross-sectional seroprevalence and the estimated rate of neonatal infections among a cohort of rural Malawian female adolescents

Objective To assess herpes simplex virus type 2 (HSV-2) seroprevalence among rural Malawian adolescent women and estimate the number of neonatal herpes infections among infants of these adolescents. Methods A longitudinal cohort study of adolescents (14–16 years at entry) residing in rural Malawi was initiated in 2007 with annual observation. HSV-2 testing was introduced in 2010. In this study, we (1) determined, using cross-sectional analysis, risk factors for positive serostatus, (2) adjusted for non-response bias with imputation methods and (3) estimated the incidence of neonatal herpes infection using mathematical models. Results A total of 1195 female adolescents (age 17–20 years) were interviewed in 2010, with an observed HSV-2 seroprevalence of 15.2% among the 955 women tested. From a multivariate analysis, risk factors for HSV-2 seropositivity include older age (p=0.037), moving from the baseline village (p=0.020) and report of sexual activity with increasing number of partners (p<0.021). Adjusting for non-response bias, the estimated HSV-2 seroprevalence among the total female cohort (composed of all women interviewed in 2007) was 18.0% (95% CI 16.0% to 20.2%). HSV-2 seropositivity was estimated to be 25.6% (95% CI 19.6% to 32.5%) for women who refused to provide a blood sample. The estimated number of neonatal herpes infections among the total female cohort was 71.8 (95% CI 57.3 to 86.3) per 100 000 live births. Conclusions The risk of HSV-2 seroconversion is high during adolescence, when childbearing is beginning, among rural Malawian women. Research on interventions to reduce horizontal and vertical HSV-2 transmission during adolescence in resource-limited settings is needed.