There is an evolving trend in health research, investigating sensitive and/or personal issues, to use more technologically advanced data collection methods as a way to ensure the privacy of participants.1
A recent article by Tourangeau and Yan2
reviews the survey methodology research on reporting errors in surveys on sensitive topics. Their findings suggest that misreporting about sensitive topics is common and largely situational. They go on to conclude that misreporting on sensitive topics is a process in which respondents edit the information they report to avoid personal embarrassment or repercussions from third parties. One such method is the Audio Computer Assisted Self-Interview (ACASI) system. ACASI is a user friendly computer interface that guides users through a survey, using digitally recorded instructions, questions, and answers. This is in contrast to more traditional face-to-face interviews or self-administered questionnaires (SAQ), which are common in survey research.3
Generally, ACASI participants listen to a series of digitally recorded survey questions through headphones, while the corresponding text is displayed on the computer monitor. ACASI users advance through the survey by responding to the question displayed, using the keyboard and/or mouse.
Research has shown that participants who volunteer for studies that investigate sensitive and personal issues often prefer advanced methods of data collection such as ACASI for perceived privacy advantages over traditional data collection methods. We recently searched PUBMED for keyword “ACASI” in either the title or abstract of published articles and retrieved 39 such publications. As this paper is not intended to provide a comprehensive review of the ACASI literature, we will highlight only a few of those articles here and note the increasing frequency of “ACASI” and growing range of targeted study populations using or studying ACASI in publications in the literature over time.
The earliest publications were four articles from 20004–7
where each assessed the feasibility of using ACASI in a variety of settings and found ACASI to be an effective mode for collecting sensitive data in their respective settings. Additionally, two of these early publications were in HIV affected populations.4;6
These were followed by a single publication in 2001 by van Griensven and colleagues8
examining the assessment of sexual behavior, illicit drug use, HIV and sexually transmitted infections (STIs) in a sample of youth in Thailand. This study found that 10% of participants in the study had a positive urine test for methamphetamines, but in the ACASI interview, 16% of those who tested positive denied ever using methamphetamines, thus concluding that ACASI use may lead to increased, but not necessarily complete, self-reported responses to the sensitive outcomes measured in their study. In 2002, a single publication found that ACASI is an important data collection tool in reducing socially desirable responses to sensitive questions related to sexual behavior, especially among HIV seropositive participants.9
Four additional publications appeared in 200310–13
followed by eight more in 2004.14–21
This series of manuscripts included a example where ACASI was used as the data collection method in a sample of youth in Northern Thailand to assess the prevalence of not wearing a helmet while riding motorcycles,18
which is represents a different context for measuring risky behavior compared any of the previously mentioned study populations. There were eight publications which appeared in 200522–28
including one by Johnson and colleagues29
which explored different data collection modalities (ACASI versus telephone interviews) to address social desirability issues commonly associated with self-reported cancer screening behaviors and one by Johnson and Fendrich28
which modeled sources of self-report bias in an illicit drug use survey and found that both memory difficulties and social desirability concerns are independent sources of measurement error in studies of drug use epidemiology. Seven publications appeared in 200630–35
including a paper by van Griensven and colleagues36
examining the palmtop technology as a cheaper more mobile alternative to ACASI for collecting sensitive behavioral risk data. At the time of this writing, there have already been seven such publications which have appeared in the literature in 200737–42
including the published findings of a feasibility study of ACASI in a multisite, international trial.43
We further highlight two of the above examples from studies of populations affected by HIV. In a study to understand breastfeeding practices and attitudes of women affected by HIV, researchers found that a majority of women preferred ACASI to face-to-face interviews (65%) because of the added privacy and usability.27
Additionally, most respondents in this study indicated a preference for ACASI over face-to-face interviews for future studies (79%). Furthermore, Metzger and colleagues6
summarized the results of a test of ACASI system in a longitudinal study of HIV risk behavior and infection, in a sample of gay men and injection drug users (IDUs). Respondents were randomly assigned to one of two assessment modalities: ACASI or face-to-face interview at their second follow-up visit, 12 months after baseline. They found significantly more sexually active gay men who reported having sexual partners who were HIV antibody positive (OR = 1.36, 95% CI: 1.08, 1.72), and a higher proportion reported unprotected receptive anal intercourse assessed via ACASI than in face-to-face interviews. Additionally, this study found that IDUs randomized to ACASI reported higher usage of needles without cleaning them (OR = 2.40, 95% CI: 1.34, 4.30).
ACASI has several advantages over face-to-face interviewing and SAQ. First, ACASI provides anonymity, and a seemingly safe space for participants to respond honestly and candidly to questions that are highly personal and sensitive in nature or that may be regarded as socially undesirable. For example, Waruru and colleagues27
found that respondents endorsed more socially undesirable survey items using ACASI than in face-to-face interviews. Another advantage is the ability to collect critical data using complex survey instruments from populations with lower literacy levels while allowing participants to advance through the survey at their own pace. Additionally, participants at all literacy levels are able to proceed through the survey quickly because they do not have to simultaneously respond to each item of the survey and navigate complex skip patterns since those have been directly pre-programmed into an ACASI system. Data quality is also improved since data are collected directly from the participant thus minimizing data transcription and data entry errors. ACASI also provides the opportunity to minimize human errors by programming various consistency checks into the ACASI system and enforcing response constraints.
This article describes a customized ACASI system implemented in a randomized controlled clinical trial of an intervention for African American Couples conducted simultaneously at four urban clinical centers: Columbia University, Emory University, the University of California at Los Angeles, and the University of Pennsylvania (Project Eban). The primary goal of the study is to test the efficacy of a couples-based Eban HIV/STD Risk Reduction Intervention (treatment) compared to an individual focused Eban Health Promotion Intervention (control). The primary outcomes for this ongoing study are (1) the rate of condom protected sex for couples and (2) incidence of biologically confirmed sexually transmitted diseases (STDs). The primary endpoints will be assessed at baseline, immediately following the completion of the 8-week behavioral intervention (IPT), and 6- and 12-months post intervention. Due to the sensitive nature of the data collected in relation to the aims of the study, ACASI technology was implemented as the primary means to collect behavioral outcome data (condom protected sex) at each of the four assessment times. Detailed descriptions of the trial’s study design and both behavioral modification interventions are provided in other articles in this special issue.