Supplemental Readings Survey Research of Sex Behavior & Upper-level Drug Smuggling.

Measuring sexual behaviour: methodological challenges in survey inquiry

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1. Kevin A Fentoni,
2. Anne Grand Johnsonone,
3. Sally McManustwo,
4. Bob Erens2

1. ^oneDepartment of Sexually Transmitted Diseases, Imperial Costless and University College Medical School, London WC1E 6AU, UK
2. ^twoThe National Centre for Social Research, London EC1V 0AX, Great britain

1. Dr Kevin Fenton, Department of Sexually Transmitted Diseases, Royal Complimentary and University College Medical Schoolhouse, Mortimer Market Eye, off Capper Street, London WC1E 6AU, UK kfenton{at}glue.ucl.ac.uk

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Serial editors J Thousand Stephenson, A Babiker

Introduction

The study of sexual behaviour lies at the heart of understanding the manual dynamics of sexually transmitted infections (STIs). Academic investigation into sexual behaviour dates back to the 18th century and, over time, has employed a variety of approaches including the medical and psychiatric investigation of sexual disorders, anthropological investigations, and survey research based largely on volunteer samples. More than recent studies, driven largely past the public wellness response to HIV/AIDS, have focused on big calibration probability sample survey research.^{1 – 5} Fundamental areas of inquiry have shifted towards describing population patterns of chance behaviours for STI/HIV transmission, understanding how epidemics of STIs are generated, and informing disease control strategies.

Sexual behaviour is a largely individual activity, subject to varying degrees of social, cultural, religious, moral and legal norms and constraints. A key challenge for all sex survey research is to generate unbiased and precise measures of private and population behaviour patterns. Methods are needed to minimise measurement error which may exist introduced by participation bias, call up and comprehension bug, and respondents' willingness to report sensitive and sometimes socially censured attitudes or behaviours.^{half dozen , seven} This paper briefly considers the role of different types of written report in understanding STI epidemiology. It and then focuses on potential sources of measurement error in survey enquiry and strategies for assessing and limiting them.Sex Transm Inf 2001;77:84–92

Types of report

The type of written report chosen volition depend on the purpose of the investigation. All the same, studies generally fall into four main groups: general population surveys, studies on population subgroups, partner and network studies, ethnographic and qualitative studies.

General POPULATION PROBABILITY SAMPLE SURVEYS

Cross sectional population surveys aim to describe the overall distribution of behaviours in populations. By using probability sampling techniques and maximising response rates, big scale behavioural surveys tin can provide robust estimates of the prevalence of behaviours and their determinants in the population. However, they are frequently not large plenty to determine the prevalence of behaviours among pocket-size population subgroups (for example, homosexual men) or among individuals with relatively rare experiences (for example, injecting drug use) which may exist especially of import in transmission of infection. Since cross sectional surveys provide a snapshot in time, multiple surveys are required to measure and monitor behaviour change over time. Data from Switzerland⁸ and Sweden⁹ have shown temporal changes in partner alter and rubber apply over time. In United kingdom, although 2 successive national surveys of sexual attitudes and lifestyles (NATSAL)^{three , 10} have been carried out a decade apart, at that place are few robust information for the interim period. In order to supplement data from intermittently commissioned large scale sexual activity surveys, sexual behaviour questions (as key indictors or modules) may exist added to probability sample general social surveys.^{11 , 12}

SURVEYS ON Pocket-size SUBGROUPS AT High RISK

Sexual behaviour studies frequently focus on epidemiologically of import cadre groups that maintain STI transmission in the population such equally commercial sex workers, homosexual men, injecting drug users, and STD clinic attenders. With very rare exceptions,^xiii difficulties in accessing these groups make probability sampling plush and challenging, and more cost effective sampling strategies are required, including advertising, snowballing, recruiting from STD clinics, social and commercial venues. However, findings from these studies may not be representative of the wider target population. Thus, homosexual men who nourish STD clinics have higher risk behaviours than those who do not^fourteen and STD clinic surveys will therefore tend to overestimate the prevalence of these behaviours.

Prospective monitoring of behaviours in high risk groups may exist accomplished through cohort investigations or serial surveying. Probability samples from the general population can too exist followed up to provide repeated behavioural measurements over time.¹⁵ Cohort studies enable estimation of disease incidence and monitoring of behavioural run a risk over time.^{xv – xix} In these instances, attributing lifestyle changes to behavioural interventions can exist difficult, since significant age confounding (associated with decreasing sexual activity) may occur. Compunction rates can also be problematic in accomplice studies, if those with high chance behaviours are more likely to drop out, leaving more compliant individuals. Behavioural surveillance, involving serial cross sectional surveys of a target group using the same sampling strategy over time, provides an alternative mechanism for prospective behavioural monitoring.¹² In London, annual surveys of homosexual men in social venues, STD clinics,^{14 , 20} and Gay Pride events²¹ use a stable prepare of behavioural indicators—for example, unprotected anal intercourse in the past 3 months, which are then monitored repeatedly. Both have demonstrated increasing risk behaviour among homosexual men and have provided useful behavioural trend information to inform public health interventions.

PARTNER AND NETWORK STUDIES

Partner studies are concerned with studying manual probabilities for STIs and their clan with specific sexual behaviours. In the 1980s, a series of partner studies examined the manual probability of heterosexual transmission of HIV.^{22 , 23} These relied on detailed behavioural data to exclude other sources of exposure than the index instance, and to identify risk factors for transmission. These studies established the office of unprotected vaginal intercourse in heterosexual transmission; the protective role of condoms; the increased adventure of unprotected anal intercourse; and the poor clan betwixt the number of acts of intercourse and the probability of transmission. Other studies take utilised partner notification data to estimate transmission probabilities for STIs²⁴ and to decide the part of sexual networks in maintaining endemic STI manual.^{24 – 26} These studies have highlighted the importance of "core groups"²⁷ and of item individuals inside networks, in maintaining chains of transmission. Such studies are withal highly intensive, with many practical difficulties. Nevertheless, epidemiological research on STI transmission is increasingly focusing on the importance of understanding mixing matrices, especially in "core" populations. More detailed considerations of these of import developments are across the scope of this paper.

ETHNOGRAPHIC AND QUALITATIVE STUDIES

Ethnographic and qualitative studies on sexual behaviour have made meaning contributions to our understanding of STI transmission dynamics.²⁸ Studies exploring the social context of sexual behaviour—for example, the importance of San Francisco "bath houses"²⁹ where homosexual men had large numbers of anonymous sexual contacts, were fundamental to understanding the early evolution of the AIDS epidemic.^xxx Qualitative research has enabled the exploration of concepts within communities^{31 , 32} and revealed behaviours or cultural factors which are relevant for developing prevention strategies. For example, understanding the relevance of and preference for "dry out sex" in different African communities has been an of import consideration in developing vaginal microbicides.^{33 , 34} Qualitative research has also been used to inform the design and evolution of quantitative inquiry instruments and methods. Cognitive and in-depth interviewing have been used to inform the use of appropriate linguistic communication in surveys and to identify factors which influence willingness to report such as privacy, sex of interviewers, and use of reckoner assisted self completion interviews.^{29 , 32 , 35}

Sources of measurement error in sexual behaviour survey enquiry

All epidemiological inquiry aims to achieve accuracy in interpretation. This requires minimising measurement error, which may occur at any stage of the survey from sample selection, to questionnaire content, design, and administration. Potential sources are discussed in detail below.

SAMPLING PROCEDURES

Many early sexual behaviour studies, including those of Kinsey,^{36 , 37} relied on volunteer samples with little attempt to achieve representativeness of the demographic and behavioural characteristics of the target population. A number of studies have since shown that volunteers tend to be more sexually experienced, sensation seeking, and unconventional, and to take more relaxed sexual attitudes and behaviours than those randomly recruited from the general population.^{38 – twoscore}

Random probability sampling methods can reduce volunteer bias past yielding unbiased samples of the target population. Normally used sampling frames for general population surveys include electoral registers, postcode files, and telephone numbers; however, all may systematically underrepresent certain groups whose behaviours may differ from the full general population. In many countries, no sampling frames of households, addresses, or individuals exist. A common strategy in these circumstances is to use a multistage clustered sampling technique in which census enumeration areas are first selected, all independent households listed, and so sampled. Homeless and prison populations are missed in virtually population samples, nonetheless they have high prevalence of epidemiologically important behaviours such as injecting drug utilise or commercial sex activity.⁴¹ Similarly, telephone samples often underrepresent young people and poorer populations.⁴²

RESPONDENT VARIABLES

Survey non-response and representativeness

Achieving adept response rates in sexual practice survey enquiry is essential to improve the representativeness of the survey and reduce participation bias (run into below). Obtaining a representative sample increases our power to brand robust inferences most the source population—that is, to generalise survey findings. Generally, between 25–35% of people refuse to engage in telephone or face to face interviews designed to investigate sexual attitudes and lifestyles, and non-render rates of 40% in postal surveys of this nature are common.³⁸ Still, others have argued that non-response rates are no greater for sex research than for other studies of sensitive issues, which would suggest that the sexual nature of the questionnaire does not necessarily bias the responses.^{iv , 43} Survey non-response may become more problematic if public interest in survey participation declines, particularly in studies perceived to exist intrusive, sensitive, or of no immediate relevance. Reasons for non-participation vary but include not-contact with selected addressees, refusals in person or by proxy, respondent being ill or unable to speak the appropriate language. Methods that rely on high levels of literacy may also exclude groups particularly vulnerable to poor sexual wellness outcomes. Refusal to participate may occur at any phase of the interview but is most likely at the point of initial contact or invitation.⁶ In the National AIDS Behavioral Survey, over 80% of refusals occurred earlier respondents heard that the survey concerned AIDS related issues.⁴⁴

Participation bias

Participation bias describes error arising from systematic differences in the characteristics (for example, sexual behaviour) of those who agree to participate in a study compared with those who do not. Fifty-fifty in well designed studies, achieving response rates in excess of 80% may be difficult, although college response rates are often achieved in developing countries.² Therefore participation bias has the potential to innovate significant error in measuring estimates of behavioural gamble. Participation bias has been documented in a variety of sexual behaviour studies, and is associated with the respondents' characteristics (for case, sex, age, social class), beliefs, and sexual behaviour.⁴⁵ Clement⁴⁶ argues that the more than intrusive a survey, the higher the barrier to intimacy, and the more than likely we are to encounter participation bias that overestimates variability and frequency of sexual behaviour (since those with conservative or normative lifestyles are less likely to participate). Still, Biggar and Melbye⁴⁷ institute little divergence in the sexual behaviour of those who responded early and belatedly to a sexual behaviour survey, and Laumann et al ^v drew similar conclusions.

Particular response bias is another type of participation bias in which respondents refusing to answer a particular question(s) are systematically more or less likely to have feel of the relevant behaviour. Copas et al ⁴⁸ found older age, issues of comprehension, and ethnicity to be associated with refusal to complete more detailed and sensitive questions contained in a cocky completion booklet in the British NATSAL survey, but concluded that those who declined to answer the more than intimate questions were, if anything, likely to be at lower HIV take a chance. Dunne et al ⁴⁹ reached like conclusions with a cohort study of twins, but concluded that the effect on most measures was modest. In both cases, participation bias may have led to an overestimation of HIV risk behaviours which counteracts the observed tendency for survey respondents to minimise or underreport the frequency and diversity of their sexual behaviour.^{39 , 42 , 50}

Reporting and recall bias

Sexual behaviour is most commonly studied using cocky reported recall of behaviours across some retrospective time frame. Fifty-fifty amid respondents who try to "accurately" written report their past behaviours, problems with think tin misconstrue the reported incidence and frequency of specific behaviours.^{half-dozen , 42 , 51 – 53} Studies take found that the reliability of self reported sexual behaviour varies with a variety of factors including age,^{54 – 56} ethnicity,⁵⁷ the number of sexual partners,⁴² and the time frame for recall.⁴⁵ Incidence reports (for case, showtime sexual intercourse) are more often than not more reliably reported than frequency reports (for example, number of partners, frequency of sex). The reliability of frequency reports decreases with longer call back periods and more frequent behaviours (for example, vaginal sexual practice).^{54 , 58 – 60} Other reliability studies accept found that think of the number of partners tended to be less variable than the number of acts.^{61 – 63} In full general, longer recollect intervals consequence in either underreporting or inaccurate recall of sexual practices and partners, because a more than elaborate reconstruction of events rather than a simple scanning of more than recent events is required.^{64 – 66}

Sex related bias in self reported behaviours may also occur. In a airtight population with a counterbalanced sex ratio, men and women should report the aforementioned population hateful number of partners over a divers period. However, men consistently study a higher mean number of partners in nearly all surveys.⁶⁷ Wadsworth et al ⁶⁸ explored this relation in data from NATSAL and concluded that the discrepancy could exist reduced but not eliminated by bookkeeping for age mixing in partnership formation, underrepresentation of prostitutes, and pocket-sized assumptions virtually response bias introduced by lower response rates among men than women. Similarly, evidence from other surveys indicates that men and women may differ in what they count as "sex," with men more probable to include non-penetrative sex than women.^{62 , 69} Notwithstanding, it is probable that there remains some social desirability bias in the direction of overreporting by men and/or underreporting by women.

Other examples of social desirability bias include the general tendency for women to underreport their premarital sexual experiences.^{lxx , 71} In the 1980s, Potterat⁷² and Stoneburner et al ⁷³ showed that HIV positive military personnel were initially more than probable to written report sexual encounters with prostitutes to be the source of infection than in later interviews with civilian counsellors when they were more willing to acknowledge to homosexual exposure. Social desirability bias may too be influenced by information collection modes, with self completion modules typically eliciting higher rates of sensitive behaviours than face to face interviews (run across below).

QUESTIONNAIRE Blueprint, CONTENT, AND Delivery

The blueprint, content, and mode of administration of the survey questionnaire, whether by interviewer or cocky completed, may contribute to measurement fault. Pen and paper methods may exclude those with poor literacy, and long questionnaires may lead to poor information quality with missing data and inconsistent answers. Detailed behavioural surveys may crave elaborate skip and filtering instructions, which are difficult to follow. Words that might be considered offensive and "big words" may lead to pregnant item non-response and, equally the meanings and use of terms used in surveys vary across sexes and cultures, they should never be assumed. For example, Sanders and Reinisch⁶⁹ found that threescore% of a sample of college students did non consider oral sexual activity lonely to be "having sex." Development work for NATSAL³¹ encountered unlike assumptions well-nigh the nature of a "sexual partner." Some married respondents felt the term was also casual to refer to their married partner, while single respondents thought information technology implied a steady human relationship rather than a casual run across. A sexual partner was carefully divers to all respondents in NATSAL, as were all behaviours reported in the survey.

Although postal self completion surveys are less expensive, and may reach respondents in rural areas or who are difficult to find at home, nearly studies accept institute response rates to be poorer on postal surveys than interviewer administered surveys, despite reminders.⁴² While respondents take fourth dimension to reverberate on their answers, there is no motivational effect of the interviewer. Additionally, there is little command over how, in what order, or by whom the questionnaire is completed.

Face up to confront (and to some extent, telephone) contact with respondents is often used in sex survey inquiry. Interviewers can explain the rationale and format of a survey directly, and they may have a motivating issue on the respondent, by providing full, articulate definitions, probing ambiguous responses, or querying inconsistent answers.⁷⁴ However, interviewers can likewise introduce reporting bias, leading to reduced disclosure of socially proscribed attitudes or behaviours (even when washed in coded fashion). Inquiry has shown that people tend to report more sexual information to female interviewers, and that in this regard, women may be more influenced than men by interviewer sexual practice differences.^{52 , 67} Delamater⁵¹ found that females were more probable to underreport proscribed behaviours to male interviewers than to female person interviewers whereas Johnson and Delamater⁷⁵ found male interviewees with good rapport with the interviewer also reported more frequent sexual activity.

Assessing measurement error

RESPONSE RATES AND REPRESENTATIVES

Strategies for assessing the extent and magnitude of participation bias remain relatively undeveloped. Checking the overall study response rates provides some indication of the representativeness and the likely magnitude of participation bias in the survey. However, formal assessment of sample representativeness usually involves comparing demographic characteristics such every bit age, sex, socioeconomic group, and geographic location with census data or other large calibration studies on less sensitive topics.^{3 , 76} Information from probability sample surveys consistently advise that non-responders are more probable to be male, older, urban residents, with lower educational attainment than responders, with no consistent relation existence noted with marital status, occupational status, and ethnicity.^{38 , 42 , 48} NATSAL obtained a 65% response rate and the accomplished sample was broadly representative of the population of Great U.k. aged 16–59 years. In common with other surveys, response rates were lower among men than women, and those least likely to respond were in the oldest age group. Parameter estimates could have been affected if recruited males were younger (therefore reporting more sexual activity) and if not-participation was related to sexual behaviours.

VALIDITY CHECKS

Validity describes the extent to which an instrument measures what it purports to measure out. It is extremely hard to determine the absolute validity of self reported sexual behaviours and therefore a number of indirect measures (internal and external) are used instead. External validation of reports may exist achieved by using contained information sources every bit external references. For case, in NATSAL, self reported abortion showed a good approximation to national statutory reports, although there was some evidence of underreporting of STD dispensary attendance.³ Similarly, information from studies among high hazard population subgroups may be triangulated for consistency with similar information on the overall spectrum of behaviour from general population surveys. Validation of survey results with those obtained from in-depth interviewing has also been used.⁷⁷

Other methods of validation include interviewing the respondents and their sexual partners separately.³⁶ These reports may vary with the stability of the relationship, caste of substance abuse, type of sexual behaviour within the relationship, and fourth dimension interval asked about.⁶ Padian et al ⁷⁸ found high levels of understanding in couples with one HIV infected partner on levels of frequency of sex, sex practices, and safe utilize. Others have found only off-white agreement in couples attending STD clinics, which tends to subtract as think periods increment.⁷⁹

Biological methods using incident STIs or urinary testing for HIV, Chlamydia trachomatis, and pregnancy are being increasingly used to assess the validity of self reports. However further evaluation of this strategy is needed. Zenilman et al ⁸⁰ in an STD clinic population, constitute like levels of incident STI in "always" condom users to "never users" suggesting evidence of reporting bias (assuming loftier condom effectiveness in preventing STIs).

INTERNAL CONSISTENCY

The internal consistency of questionnaire responses, where responses to questions asked in one part of an private's questionnaire are checked for logical agreement with related questions, may be used to appraise the reliability and validity of self reports. NATSAL^three included 158 consistency checks, and around 80% of respondents had no inconsistencies. Where differences occurred in different parts of the interview, the most common inconsistencies were greater reporting of multiple heterosexual partners and of homosexual experiences in questions completed in a cocky completion booklet compared with those in face to confront interviews.

Exam-RETEST RELIABILITY

Readministration of the same items after a cursory fourth dimension interval has been used to assess optimal recall fourth dimension frames or the stability of responses (exam re-test reliability)^{42 , 58 , 64} and to compare dissimilar techniques for enhancing retention. This provides an index of the stability of people's estimates of their sexual behaviours over time. A variety of studies have examined the reliability of reports of a range of behaviours across dissimilar populations. Factors increasing reliability include age (adolescents have college test-retest coefficients than adults), rarity of events, incidence reports compared with frequency reports, and shorter menstruation of recall.^{42 , 45 , 58 , 64} In 1990, Catania argued that existing test-retest data represented a "mixed bag" and called for studies which examine reliability for different reporting periods across specific sexual behaviours, in different population subgroups.

Reducing measurement error

IMPROVE SAMPLE DESIGN

In a probability sample survey, increasing the size of the study can reduce sampling error and increase study precision (thereby providing more robust parameter estimates). However, this must exist balanced against increasing enquiry costs. Stratifying the sample, or sorting the sampling frame earlier selection, ensures that the sample proportion from whatever particular stratum equals the population proportion. Variable sampling fractions can as well be applied to increase the sample size of small groups of detail interest—for case, to accomplish adequate confidence intervals for estimates based on different ethnic or regional groups, and to increase the precision of estimates past oversampling more variable strata. Weighting can be practical to correct for dissimilar selection probabilities resulting from the utilise of variable sampling fractions or to control for random variations in the sample numbers across strata.

REDUCE PARTICIPATION BIAS

Any intervention that improves response rates will reduce participation bias. Respondent phone call-backs, re-invitations to participate, and postal reminders take been used to obtain interviews with the selected participant. Laumann et al ^five used incremental payments to encourage participation in those initially declining to participate. Interviewer characteristics and preparation, and the perceived public health importance of the survey topic may also influence response rates.⁸¹ Methods that brand the interview procedure less invasive or more private (for example, apply of reckoner assisted cocky interviewing techniques) may reduce participation bias since embarrassment and worries about confidentiality, oftentimes of principal business organization to participants, are reduced.

However, even if very high response rates were achieved, estimates of rarer behaviours remain sensitive to participation bias and in that location are no elementary techniques to reduce their effect in assay. If the demographic differences between the sample and the population are known and then statistical weighting techniques tin be used to adjust for differential non-response. Typically, results are weighted to the known demographic structure (age, marital condition, region, etc) of the target population to provide population estimates. Withal, this method assumes that the prevalence of behaviours is the same as in responders (at to the lowest degree within demographic classes). It cannot overcome participation bias that arises independently of demographic factors. Alternatively, special studies with non-participants may be undertaken to characterise the magnitude of, and subsequently adjust for, participation bias.^{38 , 48} A sensitivity assay approach may then exist employed to summate and nowadays parameter estimates, which have into account dissimilar assumptions of this (participation bias) effect.⁴⁸

IMPROVE QUESTIONNAIRE DESIGN AND CONTENT

The terms used to describe or investigate sexual behaviour may influence respondents' willingness to participate in the written report or to provide accurate and reliable answers. Items should exist specific, articulate, and utilize defined time periods to inquire about sexual behaviour. They should also avoid acquiescence bias (implying a "mid point" or "norm") and undue embarrassment.⁸²

Using appropriate and comprehensible language and terminology is of import. Binson and Catania⁸³ country that one approach to establishing appropriate linguistic communication is to ask each respondent to select the sexual terminology they would prefer the interviewer to apply.^{36 , 37 , 74} This technique has been shown to elicit higher reporting of sensitive behaviours⁸³; however, tailoring language to each respondent is less feasible on a large scale, heterogeneous, general population sample. It also places demands on the interviewer, and may create problems in quantifying precise and standardised behaviours. Spencer et al ³¹ also found general population respondents felt awkward about providing their own definitions for sexual practices. While colloquial or street linguistic communication has been found suitable for specific populations, such as bar attending homosexual men, drug users, and prostitutes, full general population surveys have tended towards the formal. NATSAL development work institute a strong preference for "formal rather than street language"³¹ and ACSF used "technical anatomical terms."⁵⁰

Finally, care in the ordering of questions is besides important. Spencer et al ³¹ institute that both interviewers and respondents preferred the questionnaire to begin with neutral questions, leading in to more than intimate and sensitive ones once rapport had been developed. General questions also provided a "contextual framework" into which life events could be situated to help remember. Nonetheless, start with first sexual experiences may be specially sensitive if the age was perceived by the respondent to be very early or late, or involved abuse. In NATSAL^three and the American NHSLS,⁵ attitude questions are asked towards the cease of the interview and after the sexual behaviour questions to avoid possible reinforcement of social norms in reporting on partners and practices.

Phone INTERVIEWING

Telephone surveys have gained increasing popularity over the by 2 decades and are a mainstay of market oriented research. Telephone interviews were used for the French (ACSF),⁴ other national sexual practice surveys and others.^{62 , 84 – 86} Telephone interviewing allows for an unclustered sample at a lower cost than could be achieved face to face up. Information technology allows faster data collection, greater command over and monitoring of the interview process. Still, phone interviews need to be shorter, require simple questions, and do not permit the utilise of show cards or long lists. It may too exist more difficult to guarantee privacy as other household members may be listening in. Nevertheless, in the French survey, Bajos and Spira⁸⁷ compared phone interviewing and face to face interviewing with pen and newspaper cocky completion and establish that questions were "more easily answered" and answers were more coherent in the telephone report. New systems are bachelor for both individual call-in and call-out phone interviews. With a call-in system, respondents phone a live interviewer; with call-out, alive interviewers screen households and recruit participants. Some of the questionnaire is administered directly, with respondents transferred to an automated organisation for the sensitive sections.

SELF COMPLETION QUESTIONNAIRES

Cocky completion questionnaires reduce the demand for respondents to disclose sensitive behaviours to the interviewer and may result in more than valid reports than interviews.⁶ Paper self completions should exist simple and short with limited filtering and few open ended questions. Combinations of pen and paper cocky completion and interviewer techniques accept been used in many of the large surveys and combine the benefits of face to face interviewing with the privacy of self completion for more sensitive questions. Johnson et al ³ reported increased disclosure of censured behaviours (for example, homosexual experience) in self completion compared with face to face up questioning. Davoli et al ⁸⁸ reported skillful correlation between self completion and confront to face interviews among Italian adolescents for reported coital experience and historic period at first intercourse; however, interviews underreported coitus and overreported condom use when administered before the questionnaire. Despite expert reproducibility, social desirability bias had occurred.

Calculator ASSISTED INTERVIEWS

In the past decade at that place have been major developments in the use of technologies for undertaking figurer assisted personal interviews (CAPI) and self completion interviews. Face up to face and phone interviews are undertaken with responses keyed directly into computers by interviewers. Computer assisted self interviews (CASI) are increasingly beingness used where the respondents central their response to questions on the screen directly into a laptop calculator. These methods are well suited to complex questionnaires since skips and routing can be automatically programmed without respondents having to follow complex instructions on paper.

In sound-CASI, respondents listen to prerecorded questions on headphones and key in advisable responses. All respondents can hear the aforementioned standardised commitment of questions (with voice quality, not computer generated words). Sound-CASI helps overcome literacy problems and tin can provide prerecorded questionnaires in different languages and can also exist used for telephone interviews. In comparing CAPI, CASI, and audio-CASI, Tourangeau and Smith⁸⁹ found audio-CASI elicited highest mean number of reported partners and highest reporting of anal sexual activity. They plant that respondents felt a greater sense of privacy, that CASI gave the study an air of "legitimate and scientific value," and that audio input (whether on face to face or audio-CASI) facilitated comprehension. Des Jarlais et al ⁹⁰ assessed sound-CASI as a method of reducing underreporting of HIV take chances behaviour among injecting drug users and noted significantly increased reporting of HIV risk and sensitive behaviours, such as borrowing or renting used injecting equipment, in audio-CASI than in face up to face interviews.

Studies comparing CASI with identical questions using pen and paper self completion have demonstrated the potential of CASI to meliorate the quality of data, and to increase respondents' willingness to report sensitive behaviours.^{91 , 92} Turner et al ⁹² reported significant audio-CASI effects for the reporting of several sensitive behaviours. However, their sample was restricted to adolescent males, many from disadvantaged backgrounds, and the study used audio-CASI to get over potential literacy problems in this group. Johnson et al,^x in a methodological experiment in a British general population sample, found no consequent testify of increased reporting of take a chance behaviour when comparing CASI with pen and paper cocky completion, although item response and information consistency were improved using CASI. Method effects may be related to the caste of perceived social censure of particular behaviours and these vary between cultures and demographic groups.

SEXUAL DIARIES

Sexual diaries have been proposed as a ways of improving reliability of reported behaviours. If kept regularly they can allow prospective collection of data and minimise problems associated with long term recall.⁴² Verbal diaries, regularly collected by an interviewer, have also been used with poorly literate respondents. This may exist peculiarly useful given that call back of sexual partners is more likely to exist cited as a difficulty past the most sexually active respondents, and that infrequent practices are easier to retrieve than frequent ones.⁹³ In a study among commercial sex workers, Ramjee et al ⁹⁴ institute a significantly greater hateful number of clients, condoms used, vaginal acts and anal acts reported in diary format compared with call up questionnaire. While McLaws et al ⁹³ found most respondents preferred using the diary to the recall questionnaire, their sample of homosexual men, similar Coxon's,⁹⁵ may have been peculiarly well motivated. The brunt of a regular diary may be too time consuming a task to await of most respondents, and measuring behaviours may in turn produce changes in the behaviour beingness measured (monitoring effects). Consequently McLaws concluded that data collected by recall were, in fact, more than consistently reliable than information collected by diary.⁹³

Conclusions

Reliable data on sexual behaviour remain difficult to collect. Withal, many of the methodological challenges of sexual behaviour inquiry are common to other areas of self reported behaviour including diet, smoking, and alcohol consumption. Improvements in social research methods provide a number of strategies for reducing measurement error. Reckoner assisted techniques, past improving internal consistency and increasing privacy and interviewee control, offer exciting possibilities for improving survey validity. And so too does our increasing ability to triangulate survey results with focused qualitative investigations and a variety of social research and surveillance data. Increasingly available not-invasive diagnostic techniques provide biological outcome measures, which in turn offer new opportunities for studying the relation between behaviours and STI epidemiology.

Continued methodological research is needed to better identify the sources and magnitude of measurement mistake. Achieving high response rates in population based studies remains a challenge, despite technological developments, increasing public discourse about sex, and greater awareness of sexual health matters. In many developed countries, this is farther compounded by a reduction in the perceived threat posed by the HIV/AIDS epidemic, undoubtedly a stimulant for much progress over the past two decades. As a result, waning public interest and changing political prioritisation tin can only serve to increment these difficulties. Spiralling research costs mean that large scale studies of sexual behaviour are becoming less attractive to policy makers. Price effective and robust strategies for monitoring sexual behaviour are required, and behavioural surveillance programmes (ongoing population based prospective monitoring of sexual behaviour) are urgently needed. A potential way to develop this surveillance in the United Kingdom and elsewhere may involve adding a minor module of fundamental sexual behaviour questions to other routine surveys (for case, general health surveys). Such surveillance programmes would not obviate the need for targeted or in-depth studies of sexual behaviours but would, in concert, continue to increase our understanding of illness epidemiology and strategies to promote sexual health.

Series editors J One thousand Stephenson, A Babiker

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