Challenging assumptions regarding the validity of self-report measures: the special case of sexual behavior

Feasibility of remote self-collection of dried blood spots, hair, and nails among people with HIV with hazardous alcohol use

BACKGROUND

The use of biomarkers in behavioral HIV research can help to address limitations of self-reported data. The COVID-19 pandemic forced many researchers to transition from standard in-person data collection to remote data collection. We present data on the feasibility of remote self-collection of dried blood spots (DBS), hair, and nails for the objective assessment of alcohol use, antiretroviral therapy adherence, and stress in a sample of people with HIV (PWH) who are hazardous drinkers.

METHODS

Standardized operating procedures for remote self-collection of DBS, hair, and nails were developed for an ongoing pilot study of a transdiagnostic alcohol intervention for PWH. Prior to each study appointment, participants were mailed a kit containing materials for self-collection, instructions, a video link demonstrating the collection process, and a prepaid envelope for returning samples.

RESULTS

A total of 133 remote study visits were completed. For DBS and nail collection at baseline, 87.5% and 83.3% of samples, respectively, were received by the research laboratory, of which 100% of samples were processed. Although hair samples were intended to be analyzed, most of the samples (77.7%) were insufficient or the scalp end of the hair was not marked. We, therefore, decided that hair collection was not feasible in the framework of this study.

CONCLUSION

An increase in remote self-collection of biospecimens may significantly advance the field of HIV-related research, permitting the collection of specimens without resource-intensive laboratory personnel and facilities. Further research is needed on the factors that impeded participants' ability to complete remote biospecimen collection.

Inconsistencies in Adolescent Self-Reported Sexual Behavior: Experience from Four Randomized Controlled Trials

To examine the degree, correlates, and implications of inconsistent self-report data on sexual risk behaviors of adolescents. We analyzed data from four longitudinal group-randomized controlled trials of evidence-based HIV/STI/pregnancy prevention programs in Texas and California from 2000 to 2010. Across- and within-time logical inconsistencies in sexual behavior survey responses were analyzed using multilevel logistic regression. Rates of any inconsistencies ranged from 12 to 18% across the four trials. In all trials, rates were higher in males than in females. Age, normative beliefs, and race/ethnicity were most strongly associated with inconsistencies. We found substantial rates of inconsistencies in adolescents' self-reports of their sexual behavior, which did not occur at random. Studies should routinely report observed rates of inconsistencies and methods used to adjust for them so that any biases in the population to which the study generalizes are understood by public health practitioners and policy-makers looking to adopt programs for their particular population.

Individual, Relational, and Sociocultural Determinants of Sexual Function and Sexual Satisfaction in Ecuador

Aim

Various individual, relational, and sociocultural variables have been identified as determinants of sexual responding, but these have rarely been investigated in non-Western cultures that are characterized by sexual conservatism. We aimed to explore the role of socioeconomic status and religion, sexual double standards, erotophobia-erotophilia, sexual dysfunctional beliefs, and relationship satisfaction to explain sexual function and satisfaction in Ecuador.

Method

599 participants (431 women and 159 men) completed an online survey.

Main Outcomes Measures

The Female sexual function was predicted by sexual satisfaction, relationship satisfaction, sexual dysfunctional beliefs, and sexual double standards, while the male sexual function was predicted solely by sexual satisfaction. Additionally, female sexual satisfaction was predicted by sexual function, relationship satisfaction, and sexual dysfunctional beliefs, while male sexual satisfaction was predicted by sexual function and relationship satisfaction.

Results

Female Sexual Function Index, International Index of Erectile Function, Brief Sexual Opinion Survey, Sexual Double Standards Scale, Sexual Dysfunctional Beliefs Questionnaire, New Sexual Satisfaction Scale, and Couple Satisfaction Index.

Conclusion

This study provided novel information on the determinants of sexual function and satisfaction within a culture in which conservative religious beliefs still prevail. Results should be interpreted with caution given the unequal distribution of men and women, social desirability and volunteer biases, and the specific COVID-19 pandemic context during which the survey took place. Markers of sexual conservatism were inversely related to sexual function and satisfaction, mainly in women, and may, therefore, be important targets of treatment. Female sexuality seemed more context-dependent than male sexuality, although enhancing the general climate of the relationship may benefit feeling sexually satisfied in both men and women. DA Hidalgo, M Dewitte. Individual, Relational, and Sociocultural Determinants of Sexual Function and Sexual Satisfaction in Ecuador. Sex Med 2021;9:100307.

Test-retest stability of self-reported violence against women measures: results from the stepping stones and creating futures pilot

Background: Stability of measures in quantitative social science research is crucial to understand. There is very little evidence on the stability of violence against women and girls measures in the global South.

Objective: To assess the test-retest stability of violence against women and girls measures, amongst young (18–30) people in South Africa.

Methods: Data were collected from 124 women and 112 men at zero weeks (time 1) and two weeks (time 2), who resided in urban informal settlements in South Africa. Prevalence of each construct was assessed using chi-square contingency tables. Stability of self-report over time was assessed using Cohen’s Kappa. Bivariate logistic regression assessed factors associated with changing responses between time 1 and time 2.

Results: At group level prevalence of all measures showed no significant differences. Stability of self-report: kappas for past year physical IPV were both k0.20, for ever physical IPV (women k0.58; men k0.50). Sexual IPV in past 12m (women k0.44; men k0.18), and for ever sexual IPV (women k0.56; men k0.46). Kappas for men’s perpetration of non-partner sexual violence was k0.29 for past 12m and k0.38 ever. In bivariate regression, completion of secondary education was associated with a reduced odds of changing responses over the time-period for sexual IPV ever women (OR0.16, 0.02–1.04), sexual IPV past 12 months men (OR 0.09, 0.01–0.56), past 12 month non-partner sexual violence men (OR0.19, 0.02–1.41) and lifetime non-partner sexual violence (OR0.23, 0.04–1.19). Being male, compared to being female, was associated with an increased likelihood of changing responses for past 12 month sexual IPV (OR2.10, 1.08–4.09).

Conclusions: Prevalence estimates of violence against women measures are stable at group level, but stability of self-reported measures remains a concern. Individual statistical analyses must be treated with caution. Future studies are required to develop further understandings of stability of measures over time.

Applying network analysis to psychological comorbidity and health behavior: Depression, PTSD, and sexual risk in sexual minority men with trauma histories

OBJECTIVE

High rates of depression and posttraumatic stress disorder (PTSD) contribute to sexual risk, particularly in men who have sex with men (MSM) who have experienced childhood sexual abuse. The comorbidity between depression and PTSD and mechanisms by which they contribute to sexual risk in MSM remain unclear. This study sought to demonstrate the feasibility and utility of a network approach to (a) characterize symptom interconnections between depression and PTSD in MSM, (b) identify specific symptoms related to sexual risk behavior, and (c) compare symptom networks across groups at different levels of risk.

METHOD

Cross-sectional baseline data were collected from 296 HIV-negative urban MSM as part of a multisite randomized intervention trial. Symptoms of depression and PTSD were self-reported along with sexual risk behavior. Analyses were performed in R using regularized partial correlation network modeling.

RESULTS

Network analyses revealed complex associations between depression and PTSD symptoms and in relation to sexual risk behavior. While symptoms clustered within their respective disorders, depression and PTSD were connected at key symptom nodes (e.g., sleep, concentration). Specific symptoms (e.g., avoiding thoughts and feelings) were linked to sexual risk behavior. Network comparisons across risk groups suggested avoidant processes could be more readily activated in higher-risk individuals, whereas hyperarousal symptoms may be more salient and protective for lower-risk individuals.

CONCLUSIONS

This study is one of the earliest network analyses of depression and PTSD, and first to extend this inquiry to health behavior. Symptom-level investigations may clarify mechanisms underlying psychological comorbidity and behavioral risk in MSM and refine targets for intervention/prevention. (PsycINFO Database Record

Reproductive consequences of unwanted sexual debut among young adult women from Metro Cebu, Philippines

The circumstances surrounding sexual debut influence subsequent sexual and reproductive outcomes. We analysed longitudinal data from 397 women who participated in the Cebu Longitudinal Health and Nutrition Survey in Cebu, Philippines, to examine associations between unwanted first sex and number of pregnancies, unintended pregnancy, and use of modern contraception. 72% of women reported unwanted first sex. Women whose first sex was unwanted had increased odds of unintended pregnancy compared to women whose first sex was wanted (aOR = 2.2, 95% CI 1.3, 3.6). Nationally representative surveys should include culturally relevant questions about sexual debut to inform public health programmes aimed at improving sexual/reproductive health.

Lost in Translation: Language, Terminology, and Understanding of Penile-Anal Intercourse in an HIV Prevention Trial in South Africa, Uganda, and Zimbabwe

Despite efforts to use culturally appropriate, understandable terms for sexual behavior in HIV prevention trials, the way in which participants interpret questions is underinvestigated and not well understood. We present findings from qualitative interviews with 88 women in South Africa, Uganda, and Zimbabwe who had previously participated in an HIV prevention trial. Findings suggested that participants may have misinterpreted questions pertaining to penile-anal intercourse (PAI) to refer to vaginal sex from behind and subsequently misreported the behavior. Three key issues emerge from these findings: first, the underreporting of socially stigmatized sexual behaviors due to social desirability bias; second, the inaccurate reporting of sexual behaviors due to miscomprehension of research terms; and third, the ambiguity in vernacular terms for sexual behavior and lack of acceptable terms for PAI in some languages. These findings highlight methodological challenges around developing clear and unambiguous definitions for sexual behaviors, with implications not only for clinical trials but also for clinical practice and sexual risk assessment. We discuss the challenges in collecting accurate and reliable data on heterosexual PAI in Africa and make recommendations for improved data collection on sensitive behaviors.

The validity of self-reported behaviors: methods for estimating underreporting of risk behaviors

PURPOSE

When individuals underreport risk behaviors, data gathered from public health research and practice will underestimate risk. To date, there is little guidance on if or how reports can be adjusted to better reflect true levels of a risk behavior in a given cohort, sample or, by extension, population.

METHODS

We develop the underreporting correction factor (UCF), which can be used to correct estimates of the prevalence of a risk behavior using self-report of the behavior and a specific (but not necessarily sensitive) biomarker. The UCF rests on three assumptions: (1) there is no overreporting of the behavior, (2) the biomarker can only be acquired if the person engages in the behavior, and (3) the presence of the biomarker does not affect reporting of the behavior. We investigate the sensitivity of the UCF to violation of these assumptions and develop confidence intervals for the UCF and the corrected prevalence of the behavior.

RESULTS

The UCF is most sensitive to the second assumption (biomarker perfectly specific). We apply the UCF to estimates of sexual risk behaviors in various settings using a variety of biomarkers.

CONCLUSIONS

Implementation of the UCF corrects for underreporting and more accurately quantifies risk in cohorts.

The Importance of Religiosity/Spirituality in the Sexuality of Pregnant and Postpartum Women

In this article, we decided to study the representation of the Spanish pregnant and postpartum women and the importance of religiosity/spirituality and the social context for them. We analyzed the influence of religion on the woman within her social context.

OBJECTIVE

to understand how pregnant and postpartum women experience their sexuality according to their religious beliefs and the opinion of others from a socially learned perspective.

METHOD

qualitative study using ethnography. This study aims at understanding reality from the women's point of view, acknowledging that the points of view are constructed through interaction with others, through cultural and historical norms that influence the lives of individuals.

RESULTS

The findings indicate a difference in the religious beliefs and sexual behaviors of these women, which is more marked in urban than rural areas. Mothers have an influence on their daughters, conditioning their behavior. Conclusion We conclude that the process of change is underway. However, some paradoxes still persist concerning the sexual roles to be adopted, as well as some contradictions between sexual behaviors and the statements on religion. Within the scope of our study, we can confirm that pregnant and postpartum women are more or less pressured by the religious and social norms conveyed by their mothers, mainly in rural settings. From an external point of view, to be sexually free goes against the maternal and social expectations. However, the internal representation, marked by religion, that has been experienced over the years does not change the narratives of sexual experiences, assigning women to traditional role. This role brings conflict more or less assumed by women.

Young Adults’ Implicit and Explicit Attitudes towards the Sexuality of Older Adults

L’intérêt sexuel et la capacité sexuelle peut s’étendre loin dans la vie plus tard, entraînant de nombreux effets positifs sur la santé. Cependant, il y a peu de soutien pour l’expression sexuelle dans la vie plus tard, notamment chez les jeunes adultes. Cette étude a évalué et comparé les attitudes implicites et explicites de jeunes adultes face à la sexualité des adultes âgés. Un échantillon de 120 participants (18-24 ans, dont 58 pourcent femmes) ont rempli un auto-évaluation et une série de tests d’associations implicites, capturant les attitudes envers la sexualité parmi les personnes âgées. Malgré des rapports des attitudes explicites positifs, les jeunes ont révelé un biais implicite contre la vie sexuelle des personnes âgées. En particulier, les jeunes adultes ont montré des partis pris implicites favorisant les activités générales, par rapport aux activités sexuelles, et les jeunes adultes sur les adultes plus âgés. En outre, les biais favorisant les activités générales ont été amplifiées à l'égard de personnes âgées par rapport aux jeunes adultes. Nos résultats mettent en doute la validité de la recherche en s'appuyant sur les déclarations des attitudes sur la sexualité des adultes plus âgés.

'Behold, a virgin is with HIV!' misreporting sexual behavior among infected adolescents

In four Southern African countries where the HIV prevalence rate is among the highest in the world, 46.4% of a sample of female adolescents infected with HIV report having never engaged in sex. This would indicate either the dominance of non-sexual modes of HIV transmission or rampant misreporting of sexual behavior in the sample. We propose a method to estimate the extent of misreporting and calculate that the true percentages of virgins among the sample of HIV-infected adolescent women is 32.1%. After accounting for misreporting, the contribution of sexual modes of HIV transmission is projected as 50.4%, compared with an estimate of 35.5% if we assume no misreporting.

Social desirability bias in sexual behavior reporting: evidence from an interview mode experiment in rural Malawi

CONTEXT

Social desirability bias is problematic in studies that rely on self-reported sexual behavior data. Where gender norms create different expectations about socially acceptable behavior, males and females face distinct pressures in reporting certain outcomes, which can distort assessments of risk for HIV and STIs.

METHODS

In 2009, relationship and sexual behavior data were collected from 1,750 never-married males and females aged 16-18 via audio computer-assisted self-interviewing (audio-CASI) during the third round of the Malawi Schooling and Adolescent Study. A comparison group of 311 youth completed an identical questionnaire in face-to-face interviews. To assess whether interview mode may have influenced participants' reporting of sensitive behavior, reports of sexual experience in the two groups were compared. Multiple logistic regression analysis was used to identify associations between interview mode and reports of these behaviors, by gender.

RESULTS

In adjusted regression models, males were less likely to report ever having had a girlfriend in audio-CASI than in face-to-face interviews (odds ratio, 0.4), but they were more likely to report having had sex with a relative or teacher (3.5). For females, reports of ever having had a boyfriend or having had sex did not differ between modes. A small proportion of females reported ever having had sex with a relative or teacher in audio-CASI, while none did so in face-to-face interviews.

CONCLUSIONS

The method used for collecting relationship and sexual behavior data may influence the reported prevalence of some key behaviors, particularly among males. Further research is needed to improve methods of collecting sensitive data.

The effect of school status and academic skills on the reporting of premarital sexual behavior: evidence from a longitudinal study in rural Malawi

PURPOSE

Reliable data on sexual behavior are needed to identify adolescents at risk of acquiring human immunodeficiency virus or other sexually transmitted diseases, as well as unintended pregnancies. This study aimed to investigate whether schooling status and literacy and numeracy skills affect adolescents' reports of premarital sex, collected using audio computer-assisted self-interviews.

METHODS

We analyzed data on 2,320 participants in the first three rounds of the Malawi Schooling and Adolescent Study to estimate the level of inconsistency in reporting premarital sex among rural Malawian adolescents. We used multivariate logistic regressions to examine the relationships between school status and academic skills and premarital sexual behavior reports.

RESULTS

Males were more likely than females to report premarital sex at baseline, whereas females were more likely than males to report sex inconsistently within and across rounds. School-going females and males were more likely to report never having had sex at baseline and to retract reports of ever having sex across rounds than were their peers who had recently left school. School-going females were also more likely to report sex inconsistently at baseline. Literate and numerate respondents were less likely to report sex inconsistently at baseline; however, they were more likely to retract sex reports across rounds.

CONCLUSIONS

The level of inconsistency both within a survey round and across rounds reflects the difficulties in collecting reliable sexual behavior data from young people in settings such as rural Malawi, where education levels are low and sex among school-going females is not socially accepted.

Gender differences in associations of sexual and romantic stimuli: do young men really prefer sex over romance?

Theory and research emphasize differences in men's and women's sexual and romantic attitudes, concluding that men have stronger preferences for sexual than romantic stimuli as compared to women. However, most of the research on gender differences have relied on self-reports, which are plagued by problems of social desirability bias. The current study assessed young men's and women's implicit attitudes toward sexual and romantic stimuli to test whether, in fact, men have a stronger preference for sexual over romantic stimuli compared to women. We also assessed associations between implicit and explicit attitudes, as well as sex role ideology and personality. College students (68 men and 114 women) completed an Implicit Association Test (IAT) that assessed strengths of associations of sexual and romantic stimuli to both pleasant and unpleasant conditions. Results revealed that both men and women more strongly associated romantic images to the pleasant condition than they associated the sexual images to the pleasant condition. However, as predicted, women had a stronger preference toward romantic versus sexual stimuli compared to men. Our study challenges a common assumption that men prefer sexual over romantic stimuli. The findings indicate that measures of implicit attitudes may tap preferences that are not apparent in studies relying on self-reported (explicit) attitudes.

The relationship between early sexual debut and psychosocial outcomes: a longitudinal study of Dutch adolescents

In a longitudinal dataset of 470 Dutch adolescents, the current study examined the ways in which early sexual initiation was related to subsequent attachment, self-perception, internalizing problems, and externalizing problems. For male adolescents, analyses revealed general attachment to mother and externalizing problems at Wave 1 to predict to early transition at Wave 2. However, there was no differential change in these psychosocial factors over time for early initiators of sexual intercourse and their non-initiating peers. For female adolescents, the model including psychosocial factors at Wave 1 did not predict to sexual initiation at Wave 2. However, univariate repeated measures analyses revealed early initiators to have significantly larger increases in self-concept and externalizing problems than their non-initiating female peers. While the difference between female early initiators and non-initiators were statistically significant, the mean levels of problem behaviors were very low. The findings suggest that, contrary to previous research, early sexual initiation does not seem to be clustered with problem behaviors for this sample of Dutch adolescents.

A cognitive analysis of college students' explanations for engaging in unprotected sexual intercourse

Young adults, including college students, engage in high levels of unprotected sexual activity despite relatively high rates of HIV/STI and pregnancy-related knowledge. Little is known about the cognitive strategies that young people use to explain this inconsistency. The current study examined young people's explanations for engaging in unprotected sexual activity in their committed relationships. A total of 63 young adults (32 women and 31 men) completed daily diaries over a 3-week period, providing a total of 1,284 daily reports tracking their condom use and non-use during intercourse. Diary collection was followed by in-depth interviews designed to explore participants' decision-making regarding their participation in sexual intercourse unprotected against infection or unwanted pregnancy. Less than a quarter of the sample used condoms or oral contraceptives consistently. Participants primarily viewed condoms as a means of preventing pregnancy; few described disease prevention as a main motivation for their use. Analysis of the cognitions underlying explanations for condom and contraception non-use were classified as (1) general biased risk evaluation, (2) biased evidence evaluation, (3) endorsement of poor alternatives, (4) focus on spurious justifications, (5) dismissing risk, and (6) ignoring risk. Prevention interventions should incorporate methods to challenge young people to acknowledge personal risk and commit themselves to taking steps to reduce this risk.

Reporting on first sexual experience: The importance of interviewer-respondent interaction

Survey methodologists typically seek to improve data on sensitive topics by standardizing surveys and avoiding the use of human interviewers. This study uses data collected from 90 never-married young adults in rural Malawi to compare reports on first sexual encounters between a standard survey and an in-depth interview. A significant fraction of young women who claimed in the survey to have never been sexually active affirmed sexual experience during the in-depth interview, fielded shortly thereafter. Two elements of the in-depth interview, flexibility and reciprocal exchange, foster trust and more truthful reporting. The findings contradict the long-standing presumption that face-to-face interviews are inherently threatening when the topic is sex.

Biomarker validation of reports of recent sexual activity: results of a randomized controlled study in Zimbabwe

Challenges in the accurate measurement of sexual behavior in human immunodeficiency virus (HIV) prevention research are well documented and have prompted discussion about whether valid assessments are possible. Audio computer-assisted self-interviewing (ACASI) may increase the validity of self-reported behavioral data. In 2006-2007, Zimbabwean women participated in a randomized, cross-sectional study that compared self-reports of recent vaginal sex and condom use collected through ACASI or face-to-face interviewing (FTFI) with a validated objective biomarker of recent semen exposure (prostate-specific antigen (PSA) levels). Of 910 study participants, 196 (21.5%) tested positive for PSA, an indication of semen exposure during the previous 2 days. Of these 196 participants, 23 (11.7%) reported no sex in the previous 2 days, with no difference in reported sexual activity between interview modes (12.5% ACASI vs. 10.9% FTFI; Fisher's exact test: P = 0.72). In addition, 71 PSA-positive participants (36.2%) reported condom-protected vaginal sex only; their reports also indicated no difference between interview modes (33.7% ACASI vs. 39.1% FTFI; P = 0.26). Only 52% of PSA-positive participants reported unprotected sex during the previous 2 days. Self-report was a poor predictor of recent sexual activity and condom use in this study, regardless of interview mode, providing evidence that such data should be interpreted cautiously.

What are the consequences of relying upon self-reports of sexually transmitted diseases? Lessons learned about recanting in a longitudinal study

PURPOSE

Self-reports are the standard measure of STD history used in survey research. We explored to what extent self-reports of ever having an STD are recanted in a follow-up data collection.

METHODS

Using the National Survey of Adolescent Males (NSAM), we assessed consistency over time in self-reports of ever having an STD in a sample of young men transitioning from adolescence to young adulthood (aged 15-26 years), a population in which STDs are particularly prevalent.

RESULTS

Approximately 7% of all sexually experienced young men rescinded STD self-reports over time. Thus, self-reports at one point in time likely underestimate true STD history, using earlier self-reports as the criterion. Among men who ever report an STD, 94-98% recant their reports in later waves.

CONCLUSIONS

Knowledge of the extent of underreporting can potentially be used to adjust cross-sectional estimates of STDs based on survey self-reports. These study findings move us one step closer to estimating just how much underreporting of STDs in self-reports is.

Test-retest reliability of self-reported HIV/STD-related measures among African-American adolescents in four U.S. cities

PURPOSE

To evaluate the test-retest reliability of self-reported sexuality-related data in a sample of African American adolescents residing in four U.S. cities.

METHODS

Using audio computer-assisted self-interviewing (ACASI), 156 African American teens (mean age = 15.5 years) provided data on lifetime and recent sexual behavior, HIV/sexually transmitted disease (STD) testing, and theoretical antecedents of sexual risk behavior on two occasions separated by 2 weeks.

RESULTS

Most self-reports of lifetime sexual behavior and STD/HIV testing were stable across the two assessment points. Test-retest agreement was substantial for dichotomous indices of lifetime sexual behaviors and STD testing (kappas ranging from .61-.87), and for 3-month recall of vaginal sex (kappa = .72) and number of sexual partners (intraclass correlation coefficient [ICC] = .68). Lower reliability estimates emerged for count data of unprotected vaginal sex occasions (ICC = .44). Test-retest reliability estimates for antecedents of sexual risk behavior were highest for a validated measure of HIV-related knowledge (r = .73), but somewhat lower for peer norms (r = .58) and condom use self-efficacy (r = .50).

CONCLUSIONS

Although variability in the stability of self-report data was observed, findings confirm that most sexual behavior, STD and HIV testing history, and psychosocial measures can be assessed reliably among adolescents. Research should continue to identify strategies to enhance the reliability of self-report sexual behavior data from youth at risk for HIV and other sexually transmitted infections.