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By Wendy Knowler Aug 29, Boys will be boys, so the saying goes, and it seems that for some teenage boys that means seeing an advert for a sex chat line — in a newspaper or online — and deciding to make that call.


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Try out PMC Labs and tell us what you think. Learn More. Recall and social desirability bias undermine self-report of paper-and-pencil questionnaires.

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Mobile phone questionnaires may overcome these challenges. We assessed and compared sexual risk behavior reporting via in-clinic paper-and-pencil and mobile phone questionnaires. HVTN was a prospective cohort study of 50 adult women in Soweto, who completed daily mobile phone, and eight interviewer-administered in-clinic questionnaires over 12 weeks to assess sexual risk. The show high adherence and reporting of sex on the mobile phone questionnaire.

We demonstrate feasibility in collecting mobile phone sexual risk data. In South Africa, HIV incidence remains high among women aged 15—24 years 12 with infection rates twice as high as male counterparts 2. Furthermore, in black African females aged 20—34 years had the highest HIV incidence rate, estimated at 4. The efforts to assess HIV acquisition risk 13 — 8have rarely focused on young South African women, especially as there is no standardized risk assessment methodology in this population.

HIV prevention research relies extensively on retrospective self-reported measures of sexual risk to ascertain risk for HIV exposure for recruitment and enrolment purposes. Many behavioral clinical trial studies utilize paper-and-pencil based questionnaires, completed in the research environment, through interviewer administration or having the participant complete the questionnaire on their own 9 — Women are often asked to report the of male and female sex partners, condom use, transactional sex, history of sexually transmitted infection STI diagnosis, and history of alcohol and other substance use 12 — Recall periods vary from 30 days 3 to lifetime behaviors 4.

Traditionally the daily diary method is regarded as the gold standard in reporting sexual and behavioral risk information 15and has been compared with other self-reported methods incorporating retrospective recall periods However, research evaluating the accuracy of these assessments is rarely conducted and often show inconclusive For example, while face-to-face interviewer-administered paper-and-pencil questionnaires are the most commonly used methods to assess sexual behaviors in South African HIV vaccine clinical trials, there are limited comparisons to determine the reliability and validity of these methods Self-reported data by these methods may be inaccurate due to recall bias because of memory difficulties when having to report for a specific duration e.

Problems with recall, even among those who make every effort to report their past behaviors accurately, can lead to inaccuracies in the reported incidence and frequency of specific behaviors 1823 — Generally, longer recall intervals result in underreporting or inaccurate recall of sexual practices and of partners 2829which in turn may lead to errors in the prevalence estimates of high- or low-risk behaviors To overcome these challenges, sexual risk assessment methodology may be optimized by addressing these biases with: i daily diary or momentary ecological assessments, that is, completion of measures close to real time 30 ; ii shorter recall periods; iii increased convenience for the participant; iv detachment from the clinical environment; and v more privacy to avoid participant feelings of judgment.

Innovative use of technology may offer researchers combinations of these advantages. There is a growing body of literature supporting positive experiences and attitudes towards accessing sexual health information through technology Phone sex in sa — Globally, there is an increasing trend for internet and mobile-phone based HIV prevention programs 3235 — The use of technology-based HIV programs, via the internet and mobile phone short message system SMShave been shown to be feasible in HIV prevention, especially among at-risk populations, overcoming some of the individual and intervention-level barriers, Phone sex in sa as discomfort with topics 323741 Moreover, content can be easily tailored and updated to reflect current trends and changes in health information In South Africa, mobile phone ownership is high.

The use of mobile phones for healthcare interventions creates an open channel of communication between service providers and target populations In sub-Saharan Africa, mobile phone interventions have been used to increase medication adherence for chronic conditions and improve clinic attendance among young people and adults 46for disease prevention messaging 47and to facilitate data collection However, few mobile phone applications tested within developing countries have been evaluated for efficacy and feasibility One of the secondary objectives of the study was to pilot the use of a mobile phone messaging application outside of the clinic setting to collect the type of sexual activity data which would be useful within preventive HIV vaccine trials.

In this paper we describe the mobile phone responses and in-clinic paper-and-pencil based responses to sexual risk questionnaires, and correlate the difference in reporting sexual and behavioral risk data collected via two different methods: traditional in-clinic paper-based and more novel mobile-phone based questionnaires. For each participant, data were collected on sexual frequency and condom use using a mobile phone application and a site-administrated questionnaire during a planned series of clinic visits.

Soweto, with a population of about one million people, is located south west of Johannesburg in the Gauteng Province of South Africa. The ability to access and use social networking applications implies access to the internet. We utilized convenience sampling to recruit eligible volunteers who were consenting, healthy, heterosexual HIV-uninfected women 18 to 25 years, who reported at least 3 sexual acts per week and were able to demonstrate successful use of a mobile phone.

Participants provided written voluntary informed consent.

At enrolment week 0all participants were issued with a Samsung Galaxy Star S smart phone pre-programed with the sexual behavior data collection questionnaire for daily completion and submission outside the clinic. Participants were shown a demonstration video on how to use the daily mobile phone questionnaire.

Thereafter, study staff explained the instruction brochure and answered any questions.

In order to determine whether participants were comfortable with the functionality of the mobile phone and questionnaire, participants had to successfully demonstrate use of the mobile phone to a study staff member, and complete a test questionnaire record on their own. For this assessment participants had to access the mobile phone by entering the phone access password on their own and showing the study staff member how they would complete the questionnaire — entering the questionnaire application, starting a new questionnaire form, entering the encrypted questionnaire password, completing each question and submitting the fully completed questionnaire.

The participant passed the functionality assessment if she could complete the process independently. Study nurses administered a behavioral risk assessment during eight scheduled clinic visits at weeks 0, 1, 2, 3, 4, 6, 8, and The mobile phone and in-clinic risk assessments differed in mode of administration, frequency of administration, nature of questions, and recall period i.

research among South African women showed that a 7 day recall period was considered optimal for correlating daily diaries in the reporting of sexual behaviors in longitudinal studies The mobile phone questionnaire was created using the SurveyCTO 56 application. Study mobile phones had two levels of password protection, known to the participant and staff providing technical support, to ensure privacy and unauthorized access.

The passwords Phone sex in sa i for access to switch on the study mobile phone and ii an encrypted password to access the SurveyCTO application for survey completion and submission. At enrolment, mobile phones were preloaded with the necessary data bundles, that is, a set quantity of mobile data for a fixed cost via mobile service providers Additional data bundles to transmit the daily questionnaires were subsequently sent to the study mobile phone.

We purposefully set up the application to allow participants to send multiple submissions so that they had the option to review their data before finalizing submissions. In cleaning and finalizing the dataset for analysis, participants with multiple daily submissions had to be contacted throughout the study to verify the valid questionnaire.

The protocol team specifically developed the mobile phone questions to support the main study objective of detecting exposure to HIV. Therefore, the questions assessed unprotected sexual exposure over 24 hours. Mobile phone questions were developed based on experience in assessing HIV risk in HIV vaccine clinical trials in South Africa 9and in assessing sexual exposure in as close to real time as possible These questions were asked to determine unprotected sex acts. The questions were displayed one at a time so that each question could be completed before proceeding to the next.

The questions addressed general sexual behavior and the last sex act in the past 7 days at the enrolment week 0 visit and at subsequent visits. Questions related to last sex act were about: type of partner, of sex acts, type of sex act vaginal, anal or oraland whether or not a condom was used. The relevance of the study de, procedures and mobile phone questionnaire were ratified by the PHRU Soweto Prevention Community Advisory Board CABwhich had also piloted the draft mobile phone questionnaire for 7 days and provided feedback in terms of its use, implementation and language.

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The Prevention CAB is comprised of representatives of key sectors of the local community, for example non-governmental organizations NGOsthe healthcare sector, the traditional healer sector, the police service, and religious leaders. They provide input on ongoing HIV prevention studies and filter their feedback and experience to the wider communities.

Mobile phone questionnaire data from weeks 1—12 with the corresponding in-clinic questionnaire data are shown in Table 3 and Figure 2. All comparisons were made from week 1. Sex frequency of participants over 12 weeks shown by mobile phone and in-clinic questionnaire. Average weekly mobile phone sex frequency is the mean of the sex frequency reported each week during follow-up. Sexual behavior of female participants by partner type as reported in the in-clinic questionnaire at week 1. Risk behavior of female participants as reported in the in-clinic questionnaire at week 1.

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Sex frequency reported in the last seven days by mobile phone and during in-clinic visits. Frequencies for consistent and inconsistent condom use were determined for each questionnaire assessment at each clinic visit. With the data reported by in-clinic questionnaires, consistent condom use was defined as always using a condom.

Otherwise condom use was classified as inconsistent. On the mobile phone application, consistent condom use was defined as always using a condom in the 7 days prior to each clinic visit.

Condom use between the two assessments was compared longitudinally using a weighted generalised estimating equation GEE to adjust for missing data. Weights were derived from the fraction of days with responses weekly and by inverse probability weights drawn from the proportion attending follow-up visits. The frequencies of sex acts were evaluated for both the mobile phone application and in-clinic visits.

In the mobile phone questionnaire see Figure 1the frequency of vaginal sex was reported on a daily basis and summed over the 7 days prior to the in-clinic visit to match the equivalent clinic visit. Although, the items across the two methods both measured frequency of sex over 7 days, the questions were asked differently. For each visit, we compared vaginal sex frequency differences between the two assessments non-parametrically using the test for paired samples.

Sex frequencies were compared over time by inverse probability weighted GEE to for missing data as well as to determine the rate of decline in each assessment. We enrolled 50 black female participants with a median age of 22 years IQR—24between September and April Phone sex in sa Four participants were withdrawn during the study, for reasons pertaining insufficient time for study participation, loss-to-follow-up, and pregnancy.

Table 1 shows the in-clinic sexual risk behavior by partner type. Of questionnaires planned for delivery among the 50 participants over the 90 day period, questionnaires were actually delivered for submission by participants. Reasons for unanswered questionnaires included factors related to the mobile phone network provider participant disabled the mobile phone data connectionto the participant forgetting or being busy and to the mobile phone application one participant reset the study phone, thereby deleting SurveyCTO. A median of 2 IQR:1—3 reported sex acts within a 24 hour period was reported over the entire study duration.

Introduction

Table 3 presents the reporting of vaginal sex frequency by mobile phone matched to that reported in the in-clinic visit from weeks 1— Across all visits up to week 6, reported median frequency of vaginal sex was ificantly higher 1 when data were collected via the mobile phone questionnaire compared to the in-clinic questionnaire Table 3 and Figure 2. Overall, reported sex frequency on the mobile phone application was ificantly higher Table 3 than in-clinic estimate 0.

Reporting of sex frequencies on the mobile phone declined ificantly by 0. There was no ificant difference estimate 0.

This is the first study conducted within the HVTN in South Africa to correlate the reporting of sexual risk data using two methods of delivery, that is, a mobile phone and in-clinic paper-and-pencil questionnaire amongst healthy heterosexual young women aged 18—25 years. The high adherence to completing daily mobile phone questionnaires over the 12 week period shows acceptability and feasibility of delivering sexual risk questionnaires via mobile phone among young heterosexual women in South Africa.

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Participants reported more-frequent sexual activity via the mobile phone versus the in-clinic questionnaire, which may imply that answering questionnaires via the mobile phone on their own may have provided women with a sense of privacy and anonymity minimizing social desirability bias. Another possible explanation for the difference in sexual activity reporting may be due to recall bias. Participants may have been more likely to recall and report sexual activity for the mobile phone questionnaire as it was closer to the event than during the in-clinic questionnaire.

It is likely that the mobile phone questionnaire presents a more reliable method of data collection given reduced social desirability and recall bias.