The Measurement of HIV Risk Behaviors for Treatment Research Studies

United States

Debra S. Grossman

Background

NIDA funded researchers with clinical research projects are strongly encouraged by NIDA staff to provide HIV risk reduction interventions. A number of different risk assessment questionnaires and interviews have been used to measure the effects of these efforts. However, many of the existing instruments have problems, including: 1) insufficient coverage of such issues as the relationships between sex and drug-related risk, (2) extremes of complexity/simplicity and length of time for administration, especially in regards to suitability for re-administration for ongoing risk monitoring and (3) lack of information regarding reliability and validity. In addition, the advantages and disadvantages of the two forms of administration, self-administration versus interviewer-administration, have not been well specified.

When we queried our grantees about their methods of measuring HIV risk behaviors, we found that several were using the same few instruments. Many were unaware of the lack of psychometric data available for these tests, and equally unaware of other available instruments. In light of the fact that NIDA staff is encouraging HIV risk reduction activities, it is essential to measure the outcome of such activities in a valid and reliable manner. Thus, we felt that an examination of these instruments and their psychometric properties was necessary for meaningful research on HIV risk reduction in the drug abuse treatment setting.

Purpose of Workshop

In order to advise NIDA staff of existing instruments and their psychometric properties so that they may be able to make informed recommendations, the Treatment Research Branch sponsored a 2-day workshop on September 11-12, 1997. Ultimately, it is hoped that information gleaned from this workshop will facilitate the integration of HIV risk measurement in treatment research studies so that researchers can accurately assess the efficacy of HIV risk reduction activities.

Structure of Workshop

Four types of researchers were invited to the meeting:

1. ten individuals who have developed or who were involved in the development of HIV risk behavior instruments for use in treatment research studies presented their instruments to the group and discussed psychometric data, or lack thereof;
2. four drug abuse treatment researchers who have practical experience using the available instruments commented on the pros and cons and practical utility of the most widely used instruments;
3. three sex risk researchers shed light on measurement of sexual risk behaviors of specific populations; and
4. three psychometricians commented on methodological issues in the measurement of risk behaviors.

Measurement Principles (common themes):

Several issues were discussed repeatedly during the workshop and were generally agreed upon by the majority of the participants:

1. Collect psychometric data. This was one of the most important recommendations. If the instrument is not reliable and valid, the data collected may be considered worthless.
2. Questions must be sensitive to gender and cultural differences. HIV risk is different for men and women, and different cultural groups and thus, questions should be gender and culture specific. Consider a core instrument with alternative items. The group recommended that perhaps a brief core instrument could be identified with add-on questions for different populations, i.e., women, gay men, cultural groups, etc.
3. Wording is important and terms should be defined. Many subjects may not self-identify as gay or bisexual, although they may engage in sexual behavior manifested by these groups.
4. Reading level should be considered. Valid data will not be collected if the questions are incomprehensible to the subjects.
5. Perceived risk should be considered. A strong relationship exists between behaviors and perceptions, therefore perceived risk as well as attitudes, beliefs, and self-efficacy should be assessed, as well as behavior.
6. Time frame assessed should not exceed six months. Recall is greatest within a six month time frame. Assessing more that a six month time frame produces estimates, not exact numbers. Additionally, recall is facilitated by assessing risk by partner (casual, regular, once only), one at a time.
7. Most sensitive questions should be self-administered. Not only do self-administered questionnaires eliminate effects of social desirability, but they eliminate interviewer bias and are more efficient. Alternatively, interviewer-administered questionnaires enable probing for clarification.
8. Computer-administered interviews should be evaluated. Use of the computer to collect HIV risk information reveals higher rates of divulgence of risky behaviors.
9. Some overall basic recommendations of the group when developing an instrument was to keep it brief but comprehensive, focused and simple, reliable, valid, easy to score, and sensitive to change. Avoid the issue of assessment becoming the intervention.

Action Plan:

1. An expanded executive summary of the workshop is currently being prepared. The summary will be posted on the NIDA website and distributed to the field. The summary will be helpful to researchers conducting drug abuse treatment and AIDS risk reduction research, by informing them of the currently available instruments and associated psychometric properties of the instruments. Researchers will thereby have more information when making a choice.
2. A follow-up meeting of DSCR and Office on AIDS staff is planned to discuss the possibility of the following:
   1. convening an expert panel to determine which of the available instruments are worthy of recommendation now.
   2. providing administrative supplements to grantees to (1) conduct psychometric testing of instruments they are using; (2) compare two different instruments; or to (3) compare a brief version and an extensive version of an instrument.
   3. hiring a contractor to develop a new instrument, perhaps a core instrument with add-on questions for specific populations.