The impact of touch-tone data entry on reports of HIV and STD risk behaviors in telephone interviews

Journal of Sex Research, May, 2003 by Stephen J. Blumberg, Marcie L. Osborn Cynamon, Larry, Lorayn Olson

Policy development for human immunodeficiency virus (HIV) and sexually transmitted disease (STD) prevention calls for high-quality data to develop, target, implement, and evaluate effective prevention programs. While extensive information on HIV and STD risk and preventive behaviors has been collected for many infected and high-risk populations, the inclusion of explicit questions on risk and preventive behaviors in general population surveys has traditionally been limited by concerns about respondents' willingness to answer sensitive questions honestly. This manuscript reports on an investigation into whether telephone data entry will lead to higher population-based prevalence estimates for HIV and STD risk behaviors. Our assumption is that an increase in affirmative responses to sensitive questions on such behaviors suggests greater honesty or enhanced self-disclosure.

Respondents may be more willing to answer sensitive questions honestly when they believe that their answers will remain anonymous or confidential. It has been hypothesized, for example, that "the greater anonymity associated with telephone interviews compared with personal contact could yield more frequent reports of risky, socially disapproved behaviours" (Nebot et al., 1994, p. 413). Indeed, studies have shown that less traditional or more embarrassing sexual behavior information (such as the number of sexual partners in the past year) is more likely to be admitted over the telephone than in face-to-face interviews (Czaja, 1987; see also Nebot et al., 1994, for similar results with adolescents). Yet, questions about less sensitive and more traditional sexual behaviors (such as average frequency of sexual intercourse per week) were answered similarly in both modes.

Because increased perceptions of anonymity and confidentiality may result in more trustworthy answers, survey researchers have pursued new methods to increase these perceptions by increasing respondents' privacy. This research has led to the development of computer assisted self-interviewing (CASI) and audio-CASI (where the survey questions are presented via headphones). Both techniques protect respondents from having their individual and identifiable responses overheard or read by persons not participating in the interview. The increased privacy from these techniques has been shown to increase reporting of sexual activity, drug use, and drug use during sexual activity (Tourangeau & Smith, 1998; Tumer, Ku, et al., 1998).

The most straightforward equivalent to audio-CASI for a telephone survey is having a computerized voice read the questions and answer options and having the respondent enter the answers into the phone. When respondents use the touch-tone keys, this technique is commonly known as telephone audio-CASI (T-ACASI). Some researchers also refer to this technique as interactive voice response (IVR), although this term is best used when the computer is programmed to comprehend verbal answers. Both techniques increase reporting of sensitive behaviors (Gribble et al., 2000; Turner, Forsyth, et al., 1998). However, their impersonal nature can lead to increased interview break-offs and low response rates (Gribble et al., 2000), perhaps because they squander any rapport that the interviewer may develop with the respondent.

A more personal hybrid of T-ACASI has been recently tested in a study of the sexual behaviors of District of Columbia adolescents ages 12 to 15 (Boekeloo, Schamus, Simmens, & Cheng, 1998). In this study, interviewers read sensitive questions over the telephone and adolescents responded by pressing or dialing the appropriate telephone digit. To retrieve adolescents' responses, Digit Grabber[R] dialed-digit meters (Model TPM-32, Metro Tel Corporation, Jericho, NY) were used. When the adolescents pressed telephone digits, the numbers matching the tones were displayed to the interviewers on an alphanumeric screen. The interviewers then transferred the displayed digit to the answer form. This response mode ensured the privacy of adolescents' responses, in the event that parents or siblings were listening to the interview on a telephone extension.

The prevalence estimates for sexual behaviors among these 14- to 15-year-olds were considered reliable because they were similar to estimates from the 1995 Youth Risk Behavior Survey (YRBS) of Washington DC 9th-grade students. The YRBS is a paper-and-pencil questionnaire self-administered in schools (Kann et al., 2000). Thus, it was concluded that telephone response and Digit Grabber[R] dialed-digit meters provide a reliable way of assessing sexual behavior in adolescents.

The question we wanted to answer with this study was the following: Will touch-tone data entry (TTDE) and Digit Grabber[R] dialed-digit meters influence population-based survey estimates of adult sexual behavior? To answer this question, we used dialed-digit meters in a telephone-based field test of HIV and STD risk and preventive behavior questions using a random-digit-dial sample of the general population. This field test randomly selected and recruited 405 adults ages 18 to 49 in New Jersey. Approximately half the respondents used their touch-tone telephones when answering the HIV and STD risk behavior questions; the remaining half did not use TTDE. We hypothesized that TTDE would lead to higher prevalence estimates for sexual behaviors.