Validation of self-reports against biomarkers for sexual activity were rarely available. Where sample sizes were sufficient, results suggest more accurate reporting using ACASI than face-to-face interviewing.
These studies also support the acceptability and feasibility of using computers in developing country settings. In those studies where it was examined, ACASI and its derivatives were found acceptable, easy to use, and respondents, particularly young women, reported feeling more comfortable using a computer to report sensitive behaviours than they did with other methods (Rumakom et al. 2005
; Le et al. 2006
; Langhaug et al. 2007
). Similar findings have emerged from Zimbabwe and the US (Millstein & Irwin 1983
; Kissinger et al. 1999
; Metzger et al. 2000
; van de Wijgert et al. 2000
; Kurth et al. 2004
). Acceptability of computer technologies may vary geographically and be related to level of exposure. Generally, an increased sense of trust and sense of privacy is expressed by those who live in countries where computers are less commonly used. Only one study compared ACASI against ICVI and found less reporting of sensitive behaviours using ICVI (Langhaug et al. 2007
). Results of studies using ICVI or interactive interviewing which did not compare ACASI emphasize that any effort made to improve privacy levels when answering sensitive questions increases the reporting of sexual behaviours (Gregson et al. 2002
; Hanck et al. 2008
; Jaya et al. 2008
). ACASI has not been compared against interactive interviewing. This research is needed in order to better establish their comparative strengths and limitations.
Equally encouraging is the work of Mensch 2008
is research in adol in Malawi and Hewett 2004
is research in Kenya, which suggests that levels of literacy per se may not affect ACASI, as it was used successfully among rural youth. Potdar and Koenig (2005)
used ACASI (and not SAQ) among young people living in Indian slums, where despite differences in reporting to college-educated peers, no mention was made of their inability to use the computers. However, evidence from three studies is not sufficient to suggest that ACASI can always be used in settings with low literacy rates; more feasibility research is required.
While coital diaries also demonstrated increased reporting of sensitive behaviours (Ramjee et al. 1999
; Allen et al. 2007
), they carry requirements which render them less suitable for large surveys: more logistical support, more time for data entry, and specific training to ensure appropriate completion. Coital diaries have a low completion rate (20% in one study). However, including coital diary data from a sub-sample of a large survey population can complement the data collected by other means.
One of the strengths of this review is that a number of the studies reported both socially censured and socially condoned behaviours (Lau et al. 2003
; Sedyaningsih-Mamahit et al. 2003
; Potdar & Koenig 2005
; Le et al. 2006
; Simoes et al. 2006
; Minnis et al. 2007
; Hanck et al. 2008
). Conclusions drawn from these studies are strengthened when users of a mode are not only more likely to report socially censured behaviours but also less likely to report socially acceptable behaviours(Catania et al. 1990
). Reports for computer self-administered questionnaires followed this pattern. In India, more college men using ACASI reported behaving violently after drinking than those using FTFI (3.0 vs. 1.7%) (Potdar & Koenig 2005
). Similarly, in a study in Zimbabwe where hormonal contraceptive use was a prerequisite for participation, women were more likely to report that they were not using them in ACASI than in FTFI (Minnis et al. 2007
). Equally heartening is the growing comparative literature around questionnaire delivery modes in developing countries and the increased interest in ACASI and its derivatives.
There are, some limitations to this review. A number of studies did not show statistically significant differences around reporting of sexual behaviours between questionnaire delivery modes. This is in part attributable to the small sample size of these studies, or when youth were sampled, to the small number who reported sexual behaviours overall. Studies did not report the same sexual behaviour outcomes, nor did they always disaggregate their data by gender or age. This made it difficult to make comparisons across studies. Only four studies included biological markers of sexual behaviour as part of their analysis. Biological markers offer complimentary evidence that can be used to explore directions of effect. As mentioned above, for most sexual behaviors which are socially censured, particularly for young people, it is assumed that an increase in reporting indicates a improved validity of that report, but the ability to triangulate against objective data improves our understanding of the differences in self-reported sexual behaviours between questionnaire delivery modes. Researchers should incorporate biological markers (or other externally valid outcomes) into evaluations whenever possible to broaden the evidence within comparative studies. We did not examine the effect of interviewer age or gender. Research on this has been extensive but inconclusive (Becker & Sosa 1992
; Blanc & Croft 1992
; Catania et al. 1996
; Elam & Fenton 2003
; Wellings et al. 1990).
In 2003, a technical meeting on “Measurement of Trends in Sexual Behaviour” called for more rigorous comparative studies before anything more definitive could be concluded (Cleland et al. 2004
). Since then, there has been a noteworthy increase in the number of published articles in peer-reviewed journals comparing questionnaire delivery modes. Most articles considered in this review, which focussed exclusively on research performed in development country settings, were published after 2003 (n=21/28). Their data strongly suggest the use of computer-assisted methods.
This is important in view of the fact that the principal data collection tool for sexual behaviours in developing countries remains the interviewer-administered questionnaire. While interviewer-administered questionnaires remain an important tool for collecting survey data, this review provides good evidence that self-administered options, especially those using computers, will enhance data quality, particularly of socially sensitive data.