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close this bookMeeting the Behavioural Data Collection Needs of National HIV/AIDS and STD Programmes (Implementing AIDS Prevention and Care Project - Joint United Nations Programme on HIV/AIDS - United States Agency for International Development, 1998, 41 p.)
close this folder4. What is needed to understand and track behaviour?
View the document(introduction...)
View the document4.1 The role of national programmes in behavioural data collection
View the document4.2 Key components of behavioural data collection systems
View the document4.3 Rapid assessments, mapping and qualitative studies
View the document4.4 Behavioural surveys in the general population
View the document4.5 Repeated behavioural surveys in selected population groups

4.5 Repeated behavioural surveys in selected population groups

What are they?

Repeated behavioural surveys in selected population groups also use cross-sectional designs to collect behavioural data at regular intervals (annually or biannually). Sampling approaches should be consistent and repeatable, so that trends in the selected subpopulations can be measured over time. To improve the quality of the results, probability sampling is emphasised whenever possible.

Most often targeted behavioural surveys in subpopulations aim to collect data on groups whose behaviour may put them at high risk of HIV infection but who are not easily captured using household survey approaches. In such cases, behavioural surveys may more appropriately include specific population subgroups whose profile matches the behavioural characteristics of groups targeted for interventions.

These survey systems can be set up for many different population subgroups. Experiences with FHI's behavioural survey methodology indicate a considerable level of similarity in chosen sample groups, with most countries opting for a variety of groups spanning a range of socioeconomic and occupational characteristics (see Table 2). The choice of groups will vary according to the risk situation in each country and the needs of the various organisations, communities, and individuals who may use the results. Thus, those who will use the results should be encouraged to actively participate in choosing the populations to be surveyed.

Table 1: HOUSEHOLD SURVEYS SUPPORTED BY WHO/GPA AND UNAIDS IN THE DEVELOPING WORLD

COUNTRY

TYPE OF SURVEY

COVERAGE

PERIOD OF FIELDWORK

Benin

PI

1city

1997

Botswana

KABP

national

1994

Brazil

PR

1city

1990

Burundi

KABP, PI

national

1989, 1993

Cameroon

KABP, PI

1 province, 1 city

1993,1996

Chile

PI

national

1995

Central African Republic

KABP

national

1989

Cost Rica

PI

national

1996

Cd'lvoire

PR

national

1989

Cuba

PI

national

1995

Djibouti

PI

national

1994

Ethiopia

PI

5 cities

1993

Guinea Bissau

KABP/PR

national

1990

Hong Kong

PR

national

1992

India

PI

5 states

1995

Jamaica

PI

national

1994

Kenya

KABP, PI

national, 1 city

1990,1996

Lesotho

KABP/PR

national

1989

Mauritius

KABP

national

1989

Mexico

PI

1 city

1995

Niger

KABP/PR

national

1993

Philippines

KABP, PI

1 city

1990,1996

Senegal

PI

1 city

1997

Singapore

PR

national

1990

Sri Lanka

KABP, PI

national, 1city

1989,1993

Sudan

PI

4 cities

1995

Tanzania

PR, PI

national, 1 city

1990, 1993

Thailand

PR

national

1990

Uganda

KABP, PR;PI

national, 5 districts

1991,1994

Zambia

KABP, PI

1city, 1city

1990, 1996

Zimbabwe

PI

national

1995

KABP= Knowledge, attitudes, behaviour, practices; PR=Partner relation indicators;/=Combined questionnaire

What do they deliver, and what do they require?

Behavioural surveys in selected population groups provide information on the behaviour of people who may be at high risk of HIV infection but who may not be captured in sufficient numbers and with the necessary frequency in general population surveys. These people often drive the growth of the epidemic in the early stages and may provide a conduit for HIV into the broader population. Thus, reducing the level of risk behaviours among these people is absolutely essential to effective national prevention efforts.

Table 2: EXAMPLES OF BEHAVIOURAL SURVEYS IN SELECTED POPULATION GROUPS


CAMBODIA

INDIA (TAMILNADU)

INDONESIA

SENEGAL

THAILAND

FEMALE

Sex workers Beer vendors Working women

Sex workers Factory Workers University students

Brothel-based sex workers Non-brothel-based sex workers Factory workers High school students

Registered sex workers University students Secondary school students Domestic housekeepers Women in income- generating groups Office workers

Direct sex workers Indirect sex workers Factory workers Vocational students

MALE

Military/police Motorcycle drivers Vocational students

Truckers/helpers factory workers University students
STD clinic attenders

Truck drivers Sailors/seaport labourers
Factory workers High school students

University students Secondary school students Truck drivers Apprentices in the informal sector Workers

Army conscripts Factory workers Vocational students

Accordingly, many countries choose to target their initial prevention initiatives at those with higher levels of risk behaviour. This is particularly valuable early in the HIV epidemic because if these individuals adopt safer behaviours, the virus may spread more slowly into the general population. By tracking trends in these groups, the repeated behavioural survey approach can indicate whether behaviour has indeed changed following the introduction of prevention efforts and whether those changes are sustained. These systems can also highlight ongoing risk behaviours that need to be addressed in future prevention efforts.

The key requirements for successful surveys in selected population groups are definable and accessible populations and workable sampling frames. Both are easier to achieve in some vulnerable communities than in others. Brothel-based sex workers, for example, are easier to enumerate than drug injectors or non-brothel-based sex workers. Men who have sex with men will be easier to sample in areas where organised social settings, such as gay bars, exist than in places where male-male sex most often happens outside of socially well-defined homosexual contexts.

In addition, members of these groups need to be accessible in large enough numbers to allow identification of behavioural trends. In countries where these behaviours can lead to social ostracism and even imprisonment, it may be difficult and in some cases ethically unacceptable to fulfill this criterion.

Other points for consideration

The repeat cross-sectional methodology of target-group-based behavioural surveys provides programmes with short-term indications of progress. This is in contrast to epidemiological data such as HIV prevalence trends, where the impact of a prevention programme is not evident for several years and which are influenced by many other factors unrelated to interventions.

Surveys in selected population groups concentrate resources on measuring behaviour among those who are most likely to be driving the epidemic and/or whose behaviour may change more rapidly than that of the general population. This can help keep the focus on where HIV transmission is occurring rapidly and build support for prevention efforts among these populations. Both results are particularly important in the early stages of the epidemic, when resources are scarce and reducing risk behaviour among groups exhibiting high HIV transmission has the greatest impact on the course of the epidemic.

Because this survey approach reaches people outside of the household, they may be able to speak more freely about their sexual and other risk behaviours. To date however, there is little evidence to suggest that the results of well-designed and well-administered household surveys are less valid than those of surveys conducted in other venues. This is clearly a topic for further research.

Survey systems in selected population groups often concentrate attention on behaviours that many prefer to ignore or on groups that are frequently marginalised. As a consequence, behavioural information on selected subpopulations produce problematic reactions from policymakers in some countries. Surveys among youth, for example, are often disregarded, as community leaders in many societies are extremely reluctant to admit the extent of sexual activity among young people. Surveys among sex workers may be used to advocate for increased enforcement efforts against them, which make sex workers inaccessible for prevention efforts but do nothing to reduce the demand for their services. Thus, if these systems are to be used to mobilise further action, it is essential that key stakeholders, including policymakers, be involved in their development. Furthermore, it is important that results be disseminated in ways that are sensitive to the concerns of stakeholders but do not exacerbate the marginalisation of the surveyed populations.

Many population groups, such as sex workers or factory workers, experience turnover or rapid in- and out-migration. Since the purpose of behavioural surveillance is to track behavioural trends for population subgroups, such rapid turnover is of minor consequence for sampling purposes. However, since knowledge of rapid turnover is important for interpreting behavioural surveillance data and for programme implementation, questions on background characteristics and length of contact with the sample site/location should be included in the questionnaire.

Repeated surveys among hard-to-reach populations with higher levels of HIV risk are new to most countries. They require skill, sensitivity, and the backing of the communities involved, all of which may take time to develop. These skills and community involvement must then be maintained over time, requiring careful selection of a sustainable community or institutional base. Nonetheless, the value of the information they provide makes such efforts worthwhile. The resulting increased capacity of research institutions will also serve data collection activities for the country at a whole.

As with general population surveys, repeated behavioural surveys in specific populations should be complemented by qualitative follow-up to interpret their findings in a meaningful way that can inform programme design and direction.