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This supplement contains selected papers from a workshop on the measurement of sexual behaviour in the era of HIV/AIDS held at the London School of Hygiene and Tropical Medicine in September 2003. The focus was on low and middle income countries, where the majority of HIV infections occur. The motive for holding such a meeting is easy to discern. As the AIDS pandemic continues to spread and as prevention programmes are scaling up, the need to monitor trends in sexual risk behaviours becomes ever more pressing. Behavioural data are an essential complement to biological evidence of changes in HIV prevalence or incidence. Biological evidence, though indispensable, is by itself insufficient for policy and programme guidance. AIDS control programmes need to be based on monitoring of not only trends in infections but also of trends in those behaviours that underlie epidemic curtailment or further spread.

For assessment of sensitive health behaviors (e.g., sexual behavior, violent behaviors, substance use), research is typically limited to an examination of self-reports of past behavior. Audio computer-assisted self-interviews (ACASI) may enhance the validity of self-report data in research and clinical settings by reducing measurement bias. This paper provides an introduction to ACASI for collection of self-reported health data. The potential benefits and cost-effectiveness of ACASI use in research and clinical settings are reviewed. We then review the theoretical underpinnings that may underlie differential reporting of health behaviors between assessment modalities. Next, we highlight studies that have investigated differences in self-reported health behaviors between assessment modalities. Lastly, we summarize potential applications of ACASI assessments within clinical settings.

PurposeLow response rates in web surveys and the use of different devices in entering web survey responses are the two main challenges to response quality of web surveys. The purpose of this study is to compare the effects of using interviewers to recruit participants in computer-assisted self-administered interviews (CASI) vs computer-assisted personal interviews (CAPI) and smartphones vs computers on participation rate and web survey response quality.Design/methodology/approachTwo field experiments using two similar media use studies on US college students were conducted to compare response quality in different survey modes and response devices.FindingsResponse quality of computer entry was better than smartphone entry in both studies for open-ended and closed-ended question formats. Device effect was only significant on overall completion rate when interviewers were present.Practical implicationsSurvey researchers are given guidance how to conduct online surveys using different devices and choice of question format to maximize survey response quality. The benefits and limitations of using an interviewer to recruit participants and smartphones as web survey response devices are discussed.Social implicationsIt shows how computer-assisted self-interviews and smartphones can improve response quality and participation for underprivileged groups.Originality/valueThis is the first study to compare response quality in different question formats between CASI, e-mailed delivered online surveys and CAPI. It demonstrates the importance of human factor in creating sense of obligation to improve response quality.

Background The popularity of ketamine for recreational use has been increasing in Asia, including Taiwan. Still, little known about the pattern of ketamine expectancies and whether such patterns are related to ketamine use. This study aimed to examine whether the positive and negative ketamine expectancies are differentially associated with ketamine-using behavior, and whether such relationship may differ by early-onset use of tobacco or alcohol. Methods Participants were recruited using respondent-driven sampling (RDS) among regular tobacco and alcohol users, aged 18 to 50, residing in Taipei from 2007 to 2010. Totally 1115 participants (with an age distribution skewed to the right, median = 26; interquartile range: 22–32) had information on substance use and completed a 12-item ketamine expectancies questionnaire (with 6 positive and 6 negative statements). Using two axes of High and Low expectancies, the four combinations of binary positive and binary negative ketamine expectancies were created. Each participant’s drug - using experience was categorized into illicit drug naïve, exclusive ketamine use, polydrug ketamine use, or other illicit drug use. Using the weights in the network output by RDS Analysis Tool, multivariable logistic regression analysis was then conducted. Results The weighted prevalence was 2.4% for exclusive ketamine use, 9.0% for polydrug ketamine use, and 9.1% for the other illicit drug use. Ketamine users (11.4%) had greater positive expectancies and lower negative expectancies, particularly the combination of High Positive with Low Negative, as compared to the illicit drug-naïve or other illicit drug users. After adjustment for early-onset tobacco (or alcohol) use and sociodemographic characteristics, High Positive, Low Negative, and their combination of High Positive-Low Negative expectancies remained strongly associated with ketamine uses, without evidence of moderation from early-onset use of tobacco or alcohol. Conclusions Positive and negative ketamine expectancies were associated in opposite directions with ketamine use, independent of early-onset use of tobacco or alcohol. Our results indicate ketamine expectancies as possible targets for future intervention and prevention of ketamine use, with a less confrontational feedback on decreasing an individual’s positive expectancies is essential in preventing young people from the initiation of ketamine use.

ObjectivesTo assess the impact of computer-assisted interview compared with pen and paper on disclosure of sexual behaviour, diagnostic testing by clinicians, infections diagnosed and referral for counselling.MethodsTwo-centre parallel three-arm randomised controlled open trial. Computer-generated randomisation with allocation concealment using sealed envelopes.SettingTwo London teaching hospital sexual health clinics.Participants2351 clinic attenders over the age of 16 years.InterventionsComputer-assisted self-interview (CASI). Computer-assisted personal interview (CAPI). Pen and paper interview (PAPI).Main Outcome MeasuresDiagnostic tests ordered, sexually transmitted infections (STI).Secondary OutcomesDisclosure of sexual risk, referral for counselling.Results801, 763 and 787 patients randomly allocated to receive CASI, CAPI and PAPI. 795, 744 and 779 were available for intention-to-treat analysis. Significantly more diagnostic testing for hepatitis B and C and rectal samples in the CAPI arm (odds for more testing relative to PAPI 1.32; 95% CI 1.09 to 1.59). This pattern was not seen among CASI patients. HIV testing was significantly lower among CASI patients (odds for less testing relative to PAPI 0.73; 95% CI 0.59 to 0.90). STI diagnoses were not significantly different by trial arm. A summary measure of seven prespecified sensitive behaviours found greater reporting with CASI (OR 1.4; 95% CI 1.2 to 1.6) and CAPI (OR 1.4; 95% CI 1.2 to 1.7) compared with PAPI.ConclusionCASI and CAPI can generate greater recording of risky behaviour than traditional PAPI. Increased disclosure did not increase STI diagnoses. Safeguards may be needed to ensure that clinicians are prompted to act upon disclosures made during self-interview.Trial registrationISRCTN: 97674664.

Background STD Clinics are one venue in which to identify HIV-diagnosed persons disengaged from HIV care. Methods We analysed data from previously HIV-diagnosed patients seen in the STD Clinic in Seattle, Washington, USA, October 2010-December 2012. The clinic uses a computer-assisted self-interview (CASI) during new problem visits, which queries HIV-diagnosed patients about their HIV care history. Clinicians interview patients who do not complete the CASI. We used chi-squared tests to compare the reasons for STD Clinic visits and HIV transmission risk factors in visits at which patients were non-engaged (self-reported out of care or > 6 month gap in care) compared to engaged in HIV care. Results Of 1369 visits among previously diagnosed HIV-infected persons, 913 (67%) included CASI. CASI visit patients were younger (median age 40 vs. 44 years, p < 0.001) and more often MSM (96% vs. 88%, p < 0.001) than non-CASI visit patients. Of the 1233 (90%) visits with HIV care data, 20% were non-engaged. More CASI than non-CASI visits were ascertained as non-engaged (22% vs. 11%; p < 0.001). Symptoms were the visit reason more frequently at non-engaged than engaged visits (47% vs. 40%; p = 0.001), and non-engaged visits were more likely to result in a diagnosis of gonorrhoea (27% vs. 17%, p < 0.001) or syphilis (13% vs. 9%, p = 0.04). Although patients reported unprotected anal intercourse with HIV-negative or unknown status partners (nonconcordant UAI) in the past year in 36% of both non-engaged and engaged visits, self-report of a detectable serum HIV RNA level plus nonconcordant UAI was more frequent in non-engaged than engaged visits (23% vs. 11%; p < 0.001). Conclusions Many persons who are disengaged from HIV care seek evaluation in STD clinics. These patients are at elevated risk for transmitting HIV. Computer-based efforts to assess HIV care engagement increase identification of out-of-care persons, an important first step for re-linkage to HIV care.

Background Health risk behavior (HRB) is of concern during adolescence. In sub-Saharan Africa, reliable, valid and culturally appropriate measures of HRB are urgently needed. This study aims at assembling and psychometrically evaluating a comprehensive questionnaire on HRB of adolescents in Kilifi County at the coast of Kenya. Methods The Kilifi Health Risk Behavior Questionnaire (KRIBE-Q) was assembled using items on HRB identified from a systematic review and by consulting 85 young people through 11 focus group discussions and in-depth interviews with 10 key informants like teachers and employees of organizations providing various services to young people in Kilifi County. The assembled list of HRB items were back and forward translated from English to Swahili and harmonized by a panel of experts. A total of 164 adolescents completed the assembled Swahili questionnaire at baseline and two weeks later 85 of them completed the questionnaire again. A classical test theory approach was utilized for psychometric evaluation. We computed the amount of missing data at item-level to verify data quality. Scaling evaluation was assessed by spread of responses across options at an item-level. Using Gwet’s AC1 coefficient, test-retest reliability was assessed using data from the 85 adolescents who answered the questionnaire twice. Observations and completion of a brief questionnaire were done for non-psychometric evaluation of the KRIBE-Q administered via audio-computer assisted self-interview (ACASI) in Swahili language to 40 adolescents. Results The KRIBE-Q showed high data quality, good spread of responses across options and a very good test-retest reliability (Gwet’s AC1 = 0.82). It comprised 8 components with acceptable test-retest reliability: behavior resulting in unintentional injury and violence (0.85); tobacco use (0.85); alcohol and drug use (0.96); sexual behaviors (0.94); dietary behaviors (0.60); physical activity (0.74); gambling (0.73); and hygiene behavior (0.89). About 96% of the adolescents found the ACASI private and easy to use. Prevalence of bullying (32%), physical fights (40%) and engagement in gambling (26%) was high. Conclusion The KRIBE-Q assembled in this study is a psychometrically sound instrument for adolescents in rural coastal Kenya and feasible to administer via ACASI. This measure may be useful for surveys and planning interventions in similar settings.

Objective: This study examined the prevalence and correlates of exchanging sex for drugs or money among a nationally representative sample of 13 294 adolescents in the United States. Methods: Data are from the National Longitudinal Study of Adolescent Health, waves I and II. The lifetime prevalence of exchanging sex was estimated and a cross sectional analysis of sociodemographic and behavioural correlates was conducted. Unadjusted odds ratios were obtained. Results: 3.5% of adolescents had ever exchanged sex for drugs or money. Two thirds of these youths were boys. The odds of having exchanged sex were higher for youths who had used drugs, had run away from home, were depressed, and had engaged in various sexual risk behaviours. 15% of boys and 20% of girls who had exchanged sex reported they had ever been told they have HIV or another sexually transmitted infection (STI). Conclusions: Adolescents with a history of exchanging sex have engaged in other high risk behaviours and may experience poor health outcomes, including depression and HIV/STIs. These findings should help inform strategies to prevent this high risk sexual behaviour and its potential consequences.

Self-administered paper or electronic surveys can create accessibility issues for people with language barriers and limited literacy, whereas face-to-face interviews can create privacy issues and give rise to reporting biases, particularly in the context of sensitive subject matters. An audio computer-assisted self-interview (ACASI) offers an alternative mode of survey administration, and its use has been tested against other survey modes to determine whether the presence of a background narration helps overcome literacy and privacy issues. There are still gaps with the ACASI survey administration because audio narration alone does not assist respondents with limited literacy in choosing response options. To overcome literacy issues, a few studies have used illustrated pictures for a limited number of response options. This study aimed to illustrate all the questions and response options in an ACASI application. This research is part of a larger study comparing different modes of survey administration (ACASI, face-to-face interviews, and self-administered paper surveys) to collect data on hepatitis B knowledge, attitudes, and practices among the Myanmar-born community in Perth, Australia. This study describes the 2-phase process of developing a web-based ACASI application using illustrated pictures. The first phase was the preparation of the ACASI elements, such as questionnaire, pictures, brief descriptions of response options, and audio files. Each element was pretested on 20 participants from the target population. The second phase involved synchronizing all the elements into the web-based ACASI application and adapting the application features, in particular, autoplay audio and illustrated pictures. The preprototype survey application was tested for user acceptance on 5 participants from the target population, resulting in minor adjustments to the display and arrangement of response options. After a 12-month development process, the prototype ACASI application with illustrated pictures was fully functional for electronic survey administration and secure data storage and export. Pretesting each element separately was a useful approach because it saved time to reprogram the application at a later stage. Future studies should also consider the participatory development of pictures and visual design of user interfaces. This picture-assisted ACASI survey administration mode can be further developed and used to collect sensitive information from populations that are usually marginalized because of literacy and language barriers.

Purpose Standardized measures of physical symptoms predict mortality and healthcare utilization, but clinicians remain uncertain about how to apply them in routine clinical care. Recognizing the tendency for physician documentations to routinely underestimate symptom burden, we assessed whether or not severity was an important dimension of symptom assessments that may determine their usefulness in clinical encounters. Methods Retrospective cohort study using data from audio computer-assisted self-interviews augmented by chart review of patients from a primary care clinic of an urban health system. Results We sampled 145 patients who completed the Memorial Symptom Assessment Scale (MSAS) short form—physical symptom severity measurement—before their primary care visit. Most were women (60 %), and non-Hispanic black (59 %), and many responded in Spanish (19 %). All but three reported > 1 symptom. Overall, 79 % of elicited symptoms were not documented in physician notes from the same day. Severe symptoms were more likely to be documented [MSAS mean (95 % confidence interval): documented 2.2 (1.9, 2.4) vs. undocumented 1.8 (1.7, 1.9)]. Conclusion Documentations reflect usual patient-clinician communications that prioritize severe symptoms, while standardized instruments target their comprehensive assessments. Among the many validated instruments, those eliciting the severity of physical symptoms may simultaneously help clinicians with prioritization and risk assessments.