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African Journal of AIDS Research 2006, 5(2): 123–131 Printed in South Africa — All rights reserved
AJAR EISSN 1727–9445
Talking about sex in Botswana: social desirability bias and possible implications for HIV-prevention research Kata Chillag1*, Greg Guest2, Arwen Bunce2, Laura Johnson2, Peter H Kilmarx1 and Dawn K Smith1, 3 1
Centers for Disease Control and Prevention, MS E-45, 1600 Clifton Rd., Atlanta, Georgia 30333, USA Family Health International, PO Box 13950, Research Triangle Park, North Carolina 27709, USA 3 BOTUSA Project, PO Box 90, Gaborone, Botswana * Corresponding author, e-mail:
[email protected] 2
Evaluations of the safety, effectiveness, and feasibility of HIV prevention interventions rely on self-reported sexual behaviour data. The accuracy of such data has sometimes been questioned. The absence of a so-called objective measure of sexual behaviour complicates this. Social desirability bias (SDB) is a key factor affecting the accuracy of self-reports. Individual, semi-structured interviews focusing on possible causes of and solutions to SDB were conducted with 30 Batswana women such as those who might enrol in planned vaginal microbicide trials. Respondents pointed to shame and the fear of public talk about them as key factors contributing to inaccurate self-reports, and they stressed the importance of privacy and confidentiality. Interviewer characteristics such as age, gender and personality were often viewed as likely to affect their candour. Alternative interviewing techniques such as audio computer-assisted self-interviewing (ACASI) were appealing to some for the potential to reduce embarrassment; others were sceptical. The possible implications for HIV-prevention research are presented. Keywords: ACASI, Africa, clinical trials, methodological issues, qualitative methods, sexual behaviour, interview techniques
Introduction Botswana is second only to Swaziland in adult HIV prevalence (UNAIDS, 2004). In 2004, an estimated 34.9% of persons 15 to 49 years old were HIV-positive (NACA , 2004). Until recently, there have been no large trials in Botswana of potential HIV-prevention biomedical interventions such as vaccines, microbicides or antiretroviral pre-exposure prophylaxis. However, several Phase I, III and III clinical trials in Botswana are underway or imminent, including Phase I vaginal microbicide trials and a Phase II/III trial of the oncedaily oral Truvada® (emtricitabine and tenofovir disoproxil fumarate combination pill) for HIV pre-exposure prophylaxis. A Phase I vaccine trial has been recently completed. Proper evaluation of the safety, effectiveness and feasibility of such interventions (as well as HIV-prevention programmes such as voluntary counselling and testing) depends on reasonably accurate reports of sensitive information about sexual behaviour. HIV research and programmes in reproductive health have long recognised the inherent challenges in obtaining accurate self-reports (Catania, Gibson, Chitwood & Coates, 1990; Brody, 1995; Weinhardt, Forsyth, Carey, Jaworski & Durant, 1998). The absence of a truly objective measure is a continuous challenge to the evaluation of self-reported sexual behaviour data (Stone, Catania & Binson, 1999). The potential impact of social desirability bias A key threat to the validity of data on self-reported sexual behaviour is social desirability bias (SDB). SDB refers to
the desire to provide socially acceptable or favourable responses to sensitive questions (Phillips & Clancy, 1972). In the study described below, we examined SDB from the perspective of 30 women in Gaborone, Botswana — women similar to those who would be eligible to enrol in a prospective HIV-prevention trial. Given that critical research on sexual behaviour must rely on self-report, numerous researchers have investigated the causes of and potential strategies to mitigate SDB. Topics of inquiry have included: validation of self-report as compared to a biomarker (e.g. prostate-specific antigen [PSA]1); comparison of reports by both sexual partners; assessment of the influence of the interview setting and interviewer characteristics; methods to increase anonymity and privacy; and, the effects of question construction/ ordering on accurate self-reports (Catania et al., 1990; Padian, Aral, Vranizan & Bolan, 1995; Catania, Binson, Canchola, Pollack & Hauck, 1996; Tourangeau & Smith, 1996; Shew, Remafedi, Bearinger, Faulkner, Taylor, Potthoff & Resnick, 1997; Lawson, Maculuso, Bloom, Hortin, Hammond & Blackwell, 1998). Several researchers have evaluated the feasibility and effectiveness of alternative techniques for reporting personal behaviours, such as diaries, and postal-, telephone- and/or computer-assisted interviewing (McEwan, Harrington, Bhopal, Madhok & McCallum, 1992; Coxon, 1999; Kissinger, Rice, Farley, Trim, Jewitt, Margavio & Martin, 1999; Gregson, Mushati, White, Mlilo, Mundandi & Nyamukapa, 2004).
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Much of the theorising and research on SDB has been conducted in North America and Western Europe. However, there are notable exceptions, for example an evaluation of secret voting-box techniques in Zimbabwe (Gregson, Zhuwau, Ndlovu & Nyamukapa, 2002; Gregson et al., 2004); Morisky, Ang & Sneed’s (2002) validation of selfreported condom use among commercial sex workers in the Philippines; a discussion of concordance of reports between couples in northern Thailand (de Boer, Celentano, Tovanabutra, Rugpao, Nelson & Suriyanon, 1998); and an assessment of audio computer-assisted selfinterviewing (ACASI) with Thai adolescents (Van Griensven, Supawitkul, Kilmarx, Limpakarnjanarat, Young, Manopaiboon, Mock, Korattana & Mastro, 2001). Although the need for cultural sensitivity and attention to context has been recognised (Weinhardt et al., 1998), and caution has been suggested about assuming homogeneity within any population (Catania, 1996), little research on SDB has drawn substantially from the methodological or theoretical insights of anthropology. Specifically, anthropological techniques could provide a useful complement to existing behavioural, psychometric and epidemiologic assessments of the impact of SDB through: 1) qualitative methods designed to elicit an ‘insider’s view’ (Geary, Tchupo, Johnson, Cheta & Nyama, 2003); and 2) attention to culture as an explanatory framework (Trostle & Sommerfeld, 1996; Trotter, 1997). SDB is inherently cultural, and includes norms about sexuality, ideas about science and research, concerns about the perceptions of ‘outsiders’, indigenous status hierarchies, and notions of politeness and ‘face’2 (Brown & Levinson, 1978; Pliskin, 1997). In order to better describe the cultural underpinnings of and possible solutions to SDB in a context where accurate self-reported data on sexual behaviour are critical, this research investigated SDB from the perspective of 30 Batswana women who met the socio-demographic and basic behavioural eligibility criteria for a planned clinical trial of a microbicide. Respondents in this qualitative, individual interview study were asked about their experiences with, and perceptions of, sexual behaviour research and community norms, and their attitudes about discussing sexual issues. In addition, respondents were asked to discuss characteristics of the interviewer and the interview environment which might affect authentic selfreports. Respondents were also asked to suggest strategies that might enhance their comfort and honesty during research interviews about individual sexual behaviour. Methods This study was approved by institutional review boards at the collaborating institutions: the Health Research and Development Committee, Ministry of Health, Gaborone, Botswana; the Centers for Disease Control and Prevention (CDC), Department of Health and Human Services, Atlanta, USA; and Family Health International (FHI), Research Triangle Park, USA. Although research respondents were provided copies of the written informed consent in the language of their choice (Setswana or English), the requirement for signature documentation was waived under the United States Code of Federal Regulations Title 45: Public
Chillag, Guest, Bunce, Johnson, Kilmarx and Smith
Welfare, Department of Health and Human Services, Part 46: Protection of Human Subjects.3 Personal identification information was not collected and identifying information that was inadvertently disclosed was removed from the transcripts. This study was part of a larger project exploring SDB in three countries (Botswana, Ghana and Nigeria) where clinical trials of vaginal microbicides are planned or underway. The study populations in Ghana and Nigeria were primarily comprised of commercial sex workers (CSW), while in Botswana the study focused on sexually active women in the general population in order to reflect the target populations of the microbicide trials in those countries. For detailed discussion of the methods and results from West Africa, see Guest, Bunce, Johnson, Akumatey & Adeokun (2005). Recruitment and sample Research was conducted in Gaborone, the capital and largest city in Botswana. Gaborone is one of two major population centres in Botswana where CDC-sponsored vaginal microbicide and Truvada® trials are planned4. Formative research indicated reasonable homogeneity across the two cities with regard to language preference, perceptions of HIV clinical research, and attitudes and knowledge about HIV/AIDS. A non-random, purposive sampling strategy typical of qualitative research (Mays & Pope, 1995) was used to recruit 30 women having varied socio-demographic characteristics. Specific recruitment venues were selected to capture settings typically frequented by diverse segments of the Gaborone population. Recruitment sites included government-run primary-care clinics, shopping malls and bus ranks. Individual eligibility criteria for this interview study were defined to enhance the likelihood of including women who might be eligible to participate in HIV-prevention research, particularly clinical trials for vaginal microbicides. Specifically, potential respondents were required to be 1) 18 to 35 years old; 2) female; and 3) able to report vaginal sex with more than one male partner within the previous three months; and 4) that such sex occurred at least three or more times in an average week. CSW were not specifically sought for this study, nor were they excluded. Interviews Between July and August 2004, individual interviews were conducted in English or Setswana by trained, bilingual Batswana5 interviewers. All interviews were audio recorded and voluntary consent was confirmed on tape prior to beginning the interview. Basic demographic information was also collected. An open-ended, semi-structured interview was administered. Question topics included: 1) previous participation in research that asked about sexual behaviour; 2) community and individual attitudes towards discussion of sexual matters, including condom-use and HIV; 3) perceptions of truth-telling about sexual behaviour in HIV-prevention trials; and 4) attitudes about methods designed to enhance accuracy of self-reported sexual behaviour. Interviewers asked questions in an identical sequence, but were trained to probe to elicit additional information.
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Data analysis Verbatim Setswana transcripts were translated into English, and final English transcripts were prepared using standardised translation and transcription protocols (McLellan, MacQueen & Neidig, 2003). Transcripts were thoroughly reviewed and thematic analyses were performed assisted by AnSWR, qualitative data management and analysis software (CDC, 2004). A codebook was developed by two FHI data analysts in collaboration with CDC and FHI principal investigators, using a standardised procedure (MacQueen, McLellan, Kay & Milstein, 1998). Codebook development was informed by analysis of the data from the West African sites, as well as using a standard iterative process in which codes and themes emerged from the Botswana data (Miles & Huberman, 1994; Patton, 2002). Once a draft codebook was finalised, the two analysts independently coded the transcripts. The codebook was revised and transcripts re-coded as needed until codes were refined and acceptable agreement was reached. To identify key themes, code frequency, density and combinations were examined in context, facilitated by AnSWR. Results Respondent demographics The mean age of respondents was 25 years. Consistent with low marriage rates among young adults in Botswana (NACA, 2003), all reported that they had never been married. Respondents had an average of 9.9 years of formal education (range 3–15). All were born in Botswana. Twenty percent identified themselves as belonging to the Kalanga tribal group, 17% to Mokgatla, 17% to Mongwato, and ≤10% to other groups, including Mokwena, Motswapong, Mokgalagadi, Morolong, Molete, Mmirwa and Mongwaketi. In this small sample, there was little apparent variability in responses by demographic characteristics. Previous participation in sexual behaviour research Only two respondents reported previous participation in “research that asked about women’s sexual behaviour”. Furthermore, when asked to describe that research, it was unclear whether they were referring to research or a HIVprevention programme. Perceptions about sexual behaviour research In general, respondents were positive about what they considered to be research on sexual behaviour, emphasising its potential benefits in terms of individual and community education and in mitigating the HIV epidemic. In a typical response, one participant said, ‘I find it useful because it also teaches us about AIDS.’ Almost all respondents expressed scepticism when presented selected findings from a random household survey conducted in seven health districts6 (NACA, 2003). When told that 70% of respondents reported having only one sex partner in the last year, a few respondents were initially enthusiastic about the findings in terms of the possible implications for Botswana (i.e. that the findings would indicate the HIV/AIDS epidemic was on the wane because of low rates of some risk behaviours). When questioned further, however, the same respondents said
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that they believed the findings to be untrue. Respondents questioned the veracity of those findings on the basis of: contemporary Batswana sexual norms; what they know about their own and others behaviour in their immediate community; the severity of the HIV epidemic; and methodological issues with the survey itself (Table 1). Discussing sexual matters in everyday life Because perceptions about how sexual issues are discussed in everyday life may bear upon attitudes about self-report in a clinical trial, respondents were asked about discussing personal behaviour outside a research or HIV programme context. A number of respondents emphasised the importance of discussing sexual matters given the severity of the HIV epidemic. One woman said, ‘Some think it is not polite, others don’t take it seriously. Some people when talking about these things, they think you are a sex maniac. Some people don’t want to [learn] you see, but I think we should talk about these things because it is educational.’ Many respondents asserted that free and open conversation about sexual issues had increased along with an understanding of HIV/AIDS, while traditional Batswana culture prevented public talk about sex. One woman specifically mentioned the introduction of the national antiretroviral treatment programme as a catalyst: ‘They nowadays feel free to discuss such issues since the introduction of antiretroviral treatment. They now know that if they are HIV-positive, they will be able to get treatment unlike before.’ Several reported using such discussions as educational opportunities (either to give or get information), although some expressed scepticism that it could translate into action. A few asserted that sex was not discussed in rural areas; for example: ‘In the village, especially in rural areas…women are still old-fashioned, they never show any interest even if there are discussions of such issues and they are uninformed…. If you talk about sex, they think that it’s not a good thing…. Because of being so conservative, it does not make it easy for women to talk about these issues.’ Other respondents mentioned that frank discussion and education were increasingly taking place at formal venues in rural areas or villages, such as within support groups and kgotlas (traditional public meeting and consultation places). Some explained that open, informal discussions among women were common in villages and might even be more common than in the city. Openness to discussing sex was often described in terms of age groups. Older people were generally characterised as less likely to be candid: ‘Our parents [in Setswana, this is both literally ‘parents’ and older people in general] do not talk about sex, it is something that is taboo…they are not free to talk about it. It would seem like they are encouraging their children to use a…condom, so they don’t talk about it.’ Several respondents indicated that women who were involved in formal HIV education or discussion groups, such as Total Community Mobilisation, a house-to-house HIV education programme, were more likely to be honest when asked about sexual matters.
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Table 1: Some reasons why the respondents questioned the finding that 70% of respondents in a previous survey reported only one sexual partner in the past year Key theme
Illustrative quote
Contemporary Batswana sexual norms
‘You know that Batswana are too playful, they like drinking alcohol, and partying too much. When you go to nightclubs, women use men to buy you beer or sponsor you for the night. After this they sleep together, he becomes your boyfriend for that night. The next weekend you meet a different boyfriend, and so on. Really there is no Motswana that is stable…. And there is no Motswana who knows what commitment is…. Batswana sleep with different partners.’ ‘Because I interact with some women and I am one of them, so having one sexual partner is not the thing, not these days, maybe in those days, maybe in the past, not these days.’ Respondent: ‘I think there is no truth to it. Looking at the rate of AIDS in our country, if that’s the truth the virus wouldn’t be everywhere.’ Interviewer: ‘Why do you think people were not telling the truth?’ Respondent: ‘It’s because a person would have unprotected sex knowing that it’s not the right thing to do and then they would be ashamed to talk about it.’ ‘It’s a lie…. There is no one who would have sex with one person…in a year…. It will never happen for a woman to have sex with one person in a year, maybe you were not specific in your questions on whether you asked about steady partners or not.’
Knowledge of what is happening in the community
Severity of the HIV epidemic
Survey methodological issues
Reasons for inaccurate responses in hypothetical HIVprevention research and programmes Reasons for consciously biasing responses about one’s sexual behaviour and condom-use were described by respondents both in terms of morality and risk of HIV infection. One asserted: ‘[Why someone might be untruthful] because a person would have unprotected sex knowing that it’s not the right thing to do and then they would be ashamed to talk about it…. Because she did it knowing what she was doing. Yes she knows that it is not allowed…. A lot of people advise that people use condoms when they have sex.’ In most cases, respondents described fear of judgment and labelling by others as the primary motivation for being ‘untruthful’. Several interrelated themes emerged in describing that type of fear, including: shaming oneself and/or one’s male partner; etiquette, including appearing crass; status differences, particularly those related to age; being the subject of public gossip or ridicule; and, traditional Batswana culture (Table 2). One respondent described what she thought influenced a woman’s reticence to tell the exact truth: ‘The first thing about asking someone who she has had sex with and with how many partners…the first thing that comes to their minds are that you think they are whores or they have a disease.’ Less commonly, respondents described ‘self-judgment’ as a barrier to full disclosure: that is, facing up to one’s own behaviour that might have resulted in increased HIV risk or acquisition. One explained: ‘They know they cannot talk about…because they are the ones who are increasing it by their deeds of having many partners.’ Some thought that people were simply afraid of HIV in general, and by not talking about related issues they were not linked to the epidemic. A respondent explained: ‘When she is untruthful, it will make her less afraid.’ Some respondents had difficulty getting past what people ‘should do’ in order to reflect on their perceptions of what people actually do, as illustrated in this exchange: Interviewer: So why do people lie?
Respondent: You must tell the truth as to how many men you had sex with and what you have used so that we stop telling lies. Interviewer: I like the fact that you say people should tell the truth…but…. Respondent: Yes, you must tell the truth. Interviewer characteristics The interviewer characteristics that respondents perceived to most affect honest reporting included age, gender, personal qualities such as kindness, and an interviewer’s disclosure about his/her own behaviour. Opinions were mixed about the importance of the interviewer’s age, although when a strong preference was expressed, it was usually for someone of similar age to the respondent. One based her preference on older persons seeming out of touch: ‘It becomes easier if women of the same age meet…because some youth are afraid to talk to elders. Some elderly people sometimes say things that are not suitable for them to talk about at their age. They seem to forget that we are living in a changed world.’ Respondents, when talking about negative aspects of being interviewed by someone who differed in age from them, expressed concern that such a person would be more likely to judge them. One respondent described her fears about how a younger person might view her behaviour: ‘If it were a woman, it would seem like, maybe, be of my age or a bit older than me, maybe that’s when I would be free…. The thing is if it is true that I have sex with different men, if it’s someone younger than me I would have problems [if she asked] herself why I have not made a decision about my life.’ Another explains that older persons might not respect younger persons: ‘When an older person finds another older [person] they can talk, but if she finds younger people she cannot talk because she thinks we cannot advise her wisely.’ Respondents often stated a preference for same-sex interviewers. Said one: ‘I would choose to be interviewed by
African Journal of AIDS Research 2006, 5(2): 123–131
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Table 2: Some reasons participants gave for responding inaccurately during interviews about personal sexual behaviour Key theme
Illustrative quote
Shaming oneself or one’s partner
‘Yes, that’s what really causes it, the fear of telling someone your secrets, in fear that if you tell them they are going to publish them in the newspapers. Maybe my boyfriend reads it from the newspapers and then accuses me of writing about him in the newspapers, and this might cause conflict between us. That is why it’s difficult for us Batswana…to be honest on such things.’ ‘…People think that discussing bedroom life in public…is an insult and this causes us not to receive relevant assistance.’ ‘Because most of these children are not educated, so these children do not easily open up to educated people. So they say that they are shy and that they are not educated.’ ‘Women are usually untruthful because most of them…let’s say for instance you are younger than me and you are interviewing me, I may feel insulted by being interviewed by a young person though a woman and choose not to tell the truth.’ ‘I might not say the truth, thinking that when I say the truth people might make fun of men, saying this one has got many partners. And you end up telling people that you have one partner, whereas you have four, but being afraid that they will laugh at you.’ ‘In our village we grew up knowing that we don’t talk about sex. According to our culture, it’s taboo to talk about sex. This makes it difficult to talk about these issues, and generally we have never had sex education.’
Etiquette Status differences
Being the subject of public gossip or ridicule
Traditional Batswana culture
a woman. I think in some way we are the same. We had the same experience in life and she will understand me better than a man.’ For the most part, tribal affiliation was not thought to be relevant. Several expressed that they would be less likely to disclose risky behaviours to a healthcare professional since those were the persons from whom they got the HIV-prevention messages. Others preferred to be interviewed by healthcare professionals because they were known to keep things private and might be better at interviewing. Respondents often expressed that no single quality was a ‘deal-breaker’ and that their accurate responses might depend more on intangible qualities such as feeling immediately comfortable with the person interviewing or feeling that he or she is ‘trustworthy’. Others described the research context as a special professional situation in which interviewer characteristics don’t or shouldn’t matter: ‘If you are at work, it doesn’t matter whether you are young or old. If you are doing your job you must ask me some questions and I must answer you without looking at…like at the hospital, the nurses are young…our children are nurses and if she instructs me to take off my clothes to be injected, I do so without complaining that she is young.’ Occasionally, respondents indicated that an interviewer’s willingness to disclose his or her own sexual behaviour would enhance comfort and honesty. One respondent described this in terms of reciprocity: ‘Talking about your sexual behaviour first might motivate the respondent to discuss her issues. Some will tell you…fearing to cheat you since you have already told her.’ A few mentioned that they or others would be more likely to be open with an interviewer who demonstrated a serious commitment to fighting HIV/AIDS. One respondent suggested that interviewers should include themselves in a commonality of experience and susceptibility: ‘I would just encourage them not to be shy, and tell them that I am just a human being like them so that they may be truthful…. I mean I would tell them that everyone could be infected by
these illnesses or sexually transmitted diseases including myself. Therefore, there is a need for all of us to be open and free to discuss about these issues.’ Interview location Overall, respondents stressed the importance of privacy over other geographic or physical aspects of the interview space: ‘I think if you have privacy, it does not matter where you are…. If a person wants to be comfortable they would want a place where there are a few people, not where people are busy passing.’ Alternative interview techniques Respondents were asked about interviewing techniques that could increase the privacy of the responses, through the question: “In some studies women are asked about their sexual behaviour on a computer or over the phone, and do not interact with the interviewer. How do you feel about this method of interviewing on the computer or phone?” Respondents discussed both the potential advantages and disadvantages of the interviewer and respondent not being face-toface. Many respondents said that such technologies might increase honesty by reducing embarrassment. Said one: ‘Because there will be no eye contact, so a person will be free to tell the truth without having to face the interviewer as this may make the interviewee shy.’ Another said: ‘I think it is a good method. Maybe it can reduce being untruthful, because maybe if you talk to someone face-to-face you would feel embarrassed, but when using the phone you would be open, or on a computer…I think you wouldn’t know me, and you won’t see me as you said there would be no physical contact. Some people can honestly answer all the questions because they would feel they are not known and not seen.’ Others expressed scepticism and emphasised the dangers of losing nonverbal cues, the possibility of an interviewer doing things unknown to you on the other end (e.g. making fun of you), and the interviewer being unable to enforce or evaluate whether someone is telling the truth. One said: ‘I
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don’t think it is a good method to be interviewed through the computer or telephone. The issue should be done face-toface because people are different; they would ask themselves why they should be interviewed through the phone. For instance, the face expression can show you that a person is happy or unhappy or…they may become angry and you will be nearby to reassure them, unlike if it was through the phone or the computer.’ Discussion and conclusions The Batswana have been habituated by pervasive HIV/AIDS messages and programmes, and, to some extent, traditional cultural norms to provide socially desirable responses to questions about personal sexual behaviour and risk. The impact of HIV/AIDS permeates daily life, and thus personal and collective responsibility is emphasised. Citizens are repeatedly told that the very survival of the nation is at stake. The president of Botswana, Festus Mogae, once famously said that Batswana were facing extinction (Swindells, 2001). Coupled with essential elements of HIV-prevention trial designs, including ongoing risk-reduction counselling and repeated administration of sexual behaviour measures, social desirability bias (SDB) may be amplified (Geary et al., 2003). Despite this particularly difficult context, enhancing the likelihood of a potential research participant’s accurate reporting of their own sexual behaviour (as well as of adherence and acceptability) is essential to meaningful interpretation of the data from trials which evaluate desperately needed microbicides and other new HIV-prevention technologies. The respondents in this qualitative interview study shared important insights about discussion of sexual behaviour in their sociocultural context, and offered specific suggestions about how to lessen SDB in HIV-prevention research in Botswana. Even in this study, SDB was in play with regard to ideals about honesty, especially in reference to HIV risk. This was particularly evident among those respondents who struggled to answer questions about why people might give incomplete or socially amended responses. More commonly, respondents themselves emphasised the importance of frank, open discussion about sexual matters and about what people ‘should do’, while many described situations in which people could not easily talk openly either in daily life or in a research setting. Many responses contained an understandable undercurrent of desperation about the HIV epidemic. This was particularly evident among those who emphasised the importance of truth-telling in order to get help, typified by the respondent who implored, ‘What I can tell you is, you should try harder to encourage people to tell you the truth…please keep on trying. Even if they keep on insulting you, I know you are trying, keep on trying so that they end up talking.’ This urgency was also clearly revealed in the responses of those who were initially excited about the data from the national survey, in terms that in fact it might indicate some measure of success in fighting the HIV epidemic. Not unexpectedly, shame and possible stigma were reported as barriers to full disclosure of personal sexual behaviours. Respondents were concerned about ridicule and gossip. Trial staff will need to demonstrate and provide
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ongoing assurance about procedures to enhance trial respondent confidentiality. The only truly salient theme emerging about the interview environment was the importance of privacy. Respondents not only made reference to the immediate interview space but occasionally to the importance of privacy throughout the entire facility and programme. For the upcoming Truvada® and microbicide trials in Botswana, research clinics were deliberately located in public malls where many activities are taking place, thus increasing the likelihood of relative anonymity for trial participants. In addition, the clinic name and design elements such as the study logo are not obviously associated with HIV. However, as the trials progress, the trials and their facilities may become increasingly identified (or misidentified) with potentially stigmatising activities. For that reason, it is important to conduct ongoing assessments of perceptions in the community at large as well as among trial participants, and address them as needed. Some respondents juxtaposed traditional Batswana norms that discourage discussion of sexual issues with increasing openness as a result of the HIV epidemic. Not surprisingly, younger people were generally perceived to be more candid. Woven throughout this discussion was the idea that increased education and information about HIV usually resulted in increased openness. However, a few respondents specifically pointed to the reluctance of older persons, particularly parents, to talk about sex with children or youth, lest they endorse or introduce the idea of the very behaviours they wished to discourage. The possible impact of age difference was clear in these discussions about interview context as well as when respondents were asked about interviewer characteristics. When possible, research staff should be selected for similarity of interviewer and interviewee age. Other interviewer characteristics of note included gender, rapport, professionalism, and reciprocity of disclosure. The data suggest that same-gender interviewers should be used when possible to minimise socially desirable amendment of responses to sexual behaviour questions. Rapport and personal qualities such as kindness were viewed as very important. While it may be difficult to ensure rapport, careful training can go far to help staff foster an appropriate sense of connection. There has been much learned from HIVspecific and general counselling literature; however, a careful distinction between the purposes of counselling and interviewing must be drawn, perhaps particularly in this context in which educating others about HIV/AIDS is the norm. In the event of serious ‘rapport failures’, trial participants should have the ability to easily change interviewers and vice versa. Professionalism, as well, can be enhanced through training. Again, confidentiality should be emphasised as a critical dimension of professionalism. In addition, what constitutes professionalism may differ culturally; and within the typical multinational trial, developing a shared understanding that incorporates elements of Batswana communication-style is important. Some respondents expressed that they would be more comfortable revealing their sexual behaviour if an interviewer did the same. This may be fuelled by fears of stigma and public ridicule. It may also reflect a lack of distinction between social conversations and research interactions.
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Increased familiarity with research goals and procedures may somewhat diminish such expectations, although they are unlikely to disappear completely in this context. Research staff cannot disclose their own sensitive personal information because it would undermine the professionalism of the encounter and potentially shape participant responses. A feasible proxy is to use statements and questions that normalise sensitive behaviours, for example by expressing that “many people do X or Y”. Because desire for reciprocity may be viewed as a kind of ‘privacy insurance’, continued emphasis on confidentiality and professionalism is important in addressing this issue as well. Many participants thought that indirect methods using the telephone or a computer might enhance honesty by reducing potential embarrassment. Nonverbal cues, interaction, and trust were important — not surprising in Botswana where politeness and consensus are particularly valued. Computerised applications such as automatic teller machines (ATMs) and internet cafes are prevalent in urban areas of Botswana, so the technology itself is not unfamiliar.7 On the other hand, the absence of face-to-face interaction was reported to be problematic for some. In upcoming microbicide and TDF trials, we will be using and evaluating computer-assisted respondent education and data collection techniques; and, informal piloting has given us cause to be optimistic about initial enthusiasm and feasibility. Our strategy of conducting some face-to-face and some computer-assisted interviews, as well as the presence of other opportunities for staff-respondent relationship-building, may ease concerns about impersonality. Study limitations Despite training, probing appears to be very difficult for the young Batswana interviewers we have used for several qualitative studies. The open-ended nature of questions, the use of inductive probing, and translation into different languages infused a degree of variability into how questions were asked and in the subsequent responses. However, training and careful ongoing quality assurance of interview techniques, transcription and translation has enhanced reliability. This qualitative study relied on a small, relatively homogeneous sample of women, and some of the findings are not necessarily generalisable. However, many of the findings were similar to those from the West African studies (in Ghana and Nigeria). These findings included: generally positive perceptions of research that is related to potential personal benefit; fear of shame and damage to one’s reputation as reasons for inaccurate reporting; and, emphasis on the importance of privacy in the interview environment. Notes 1
2
For additional examples of empirical research using PSA as a marker for behaviour as well as discussions about utility and limitations, see Macaluso, Lawson, Hortin, Duerr, Hammond, Blackwell & Bloom (2003); Steiner, Feldblum & Padian (2003); Galvão, Oliveira, Díaz, Kim, Marchi, van Dam, Castilho, Chen & Macaluso (2005); and Zaviacic & Ablin (2005). The concept of “face” is “the public self-image that every member wants to claim for himself” (Brown & Levinson, 1987, p. 61).
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Under these regulations, the requirement for documentation of signature can be waived if: 1) the signature is the only identifying link between the respondent and the research data; and 2) the study presents no more than minimal risk to the respondents. This study met both requirements. According to the national census in 2001, the total population of Botswana is approximately 1.7 million. The populations of Gaborone and Francistown are approximately 190 000 and 82 000, respectively (Central Statistics Office, Republic of Botswana, 2001). In Setswana, this is the plural for ‘those from Botswana’. The singular is Motswana. This question was based on results from the Makgabaneng Radio Listenership survey, a random household survey of 807 male and female respondents, aged 15–49. The survey was conducted in seven health districts in Botswana, areas that cover approximately 50% of the total population of the country (Koppenhaver, personal communication). The question used in this research approximates the survey findings that, among those respondents who were sexually active in the last year, 68.3% of men and 83.1% of women reported having one sexual partner during the same time period. It is important to note that information about use of computerised applications in Gaborone and Francistown is anecdotal, based on, for example, lines at ATMs on paydays. Apparent use for such purposes may or may not indicate skill or comfort that actually translates to ease of use of computerised educational and data collection tools in the research context. For that reason, it is critical to include ongoing training for trial participants.
Author’s note The findings and conclusions in this article are those of the authors and do not necessarily represent the views of USAID (Washington, DC), the CDC (Centers for Disease Control and Prevention) or ATSDR (Agency for Toxic Substances and Disease Registry) (Atlanta, USA). Acknowledgements — Financial support for this research was provided by USAID through Family Health International. We wish to acknowledge the women who participated in the study; the staff of Premiere Personnel, Gaborone, Botswana who expertly administered and conducted data collection; the staff of the BOTUSA Project who facilitated this research in various ways; and M Cassell, G Goodwin and E McLellan-Lemal for their thoughtful reviews and comments on the manuscript. The authors — Kata Chillag is a social scientist with the HIV Epidemiology Branch, US Centers for Disease Control and Prevention. Her current work focuses on the social, cultural, and ethical aspects of new biomedical HIV-prevention technologies. Greg Guest is a behavioural scientist at Family Health International, where he conducts research on the socio-behavioural aspects of reproductive health. Arwen Bunce is a research associate and qualitative specialist at Family Health International. Laura Johnson is a Research Associate at Family Health International. She is currently working as an analyst and data manager for the formative research connected to the oral Tenofovir clinical trial, taking place in several countries in Africa. Peter H. Kilmarx is currently the chief of the HIV Epidemiology Branch, US Centers for Disease Control and Prevention. Dawn K. Smith is the Associate Director for HIV Prevention Research, BOTUSA Project and a senior medical epidemiologist with the HIV Epidemiology Branch, CDC. She is principal investigator of Phase II/III trial of Truvada® for HIV preexposure prophylaxis in Botswana, and upcoming microbicide trials in that country.
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