@article{Endres-Dighe_Courtney_Farris_2017, title={HIV Bio-behavioral Risk Study Implementation in Resource-poor Military Settings}, volume={9}, url={https://ojphi.org/ojs/index.php/ojphi/article/view/7777}, DOI={10.5210/ojphi.v9i1.7777}, abstractNote={<div style="left: 64.8px; top: 230.946px; font-size: 10.2px; font-family: sans-serif; transform: scaleX(1.08133);" data-canvas-width="45.9204">Objective</div><div style="left: 75.6px; top: 241.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.01295);" data-canvas-width="270.23879999999997">We present lessons learned from over a decade of HIV bio-</div><div style="left: 64.8px; top: 253.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.04437);" data-canvas-width="286.1742599999999">behavioral risk study implementation and capacity-building in</div><div style="left: 64.8px; top: 265.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00183);" data-canvas-width="74.7864">African militaries.</div><div style="left: 64.8px; top: 288.546px; font-size: 10.2px; font-family: sans-serif; transform: scaleX(1.11766);" data-canvas-width="59.4966">Introduction</div><div style="left: 75.6px; top: 299.311px; font-size: 10.2px; font-family: serif; transform: scaleX(0.994233);" data-canvas-width="272.33693999999997">Circumstances within the military environment may place military</div><div style="left: 64.8px; top: 311.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.03685);" data-canvas-width="285.77340000000004">personnel at increased risk of contracting sexually transmitted</div><div style="left: 64.8px; top: 323.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.01111);" data-canvas-width="285.08184000000017">infections (STI) including HIV. HIV bio-behavioral risk studies</div><div style="left: 64.8px; top: 335.311px; font-size: 10.2px; font-family: serif; transform: scaleX(0.985632);" data-canvas-width="284.94617999999997">provide a critical source of data to estimate HIV/STI prevalence</div><div style="left: 64.8px; top: 347.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.02283);" data-canvas-width="283.9720799999999">and identify risk factors, allowing programs to maximize impact by</div><div style="left: 64.8px; top: 359.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00117);" data-canvas-width="162.32280000000003">focusing on the drivers of the epidemic.</div><div style="left: 64.8px; top: 382.146px; font-size: 10.2px; font-family: sans-serif; transform: scaleX(1.07289);" data-canvas-width="41.9322">Methods</div><div style="left: 75.6px; top: 392.911px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00074);" data-canvas-width="272.4012000000001">Since 2005, RTI has provided technical assistance (TA) to support</div><div style="left: 64.8px; top: 404.911px; font-size: 10.2px; font-family: serif; transform: scaleX(0.991579);" data-canvas-width="283.0959">HIV/STI Seroprevalence and Behavioral Epidemiology Risk Surveys</div><div style="left: 64.8px; top: 416.911px; font-size: 10.2px; font-family: serif; transform: scaleX(0.996051);" data-canvas-width="284.93699999999995">(SABERS) in 14 countries across Sub-Saharan Africa and Asia.</div><div style="left: 64.8px; top: 428.911px; font-size: 10.2px; font-family: serif; transform: scaleX(1.01488);" data-canvas-width="283.74258">SABERS are cross-sectional studies consisting of a survey to assess</div><div style="left: 64.8px; top: 440.911px; font-size: 10.2px; font-family: serif; transform: scaleX(0.982786);" data-canvas-width="282.9275999999999">knowledge, attitudes and behaviors related to HIV, coupled with rapid</div><div style="left: 64.8px; top: 452.911px; font-size: 10.2px; font-family: serif; transform: scaleX(0.977875);" data-canvas-width="282.94799999999987">testing for HIV and other STIs. RTI tailored each survey instrument to</div><div style="left: 64.8px; top: 464.911px; font-size: 10.2px; font-family: serif; transform: scaleX(0.986521);" data-canvas-width="282.9837">be culturally appropriate in content and methodology, trained military</div><div style="left: 64.8px; top: 476.911px; font-size: 10.2px; font-family: serif; transform: scaleX(0.984478);" data-canvas-width="284.82581999999985">personal to serve as data collection staff, and provided logistical</div><div style="left: 64.8px; top: 488.911px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00119);" data-canvas-width="138.83220000000006">support for study implementation.</div><div style="left: 64.8px; top: 511.746px; font-size: 10.2px; font-family: sans-serif; transform: scaleX(1.0852);" data-canvas-width="36.842400000000005">Results</div><div style="left: 75.6px; top: 522.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00162);" data-canvas-width="179.30580000000006">Key lessons learned are summarized below:</div><div style="left: 75.6px; top: 534.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.03291);" data-canvas-width="270.1928999999996">Data collection mode varied from paper-based to computer-</div><div style="left: 64.8px; top: 546.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.03161);" data-canvas-width="284.0536799999995">assisted surveys, depending on country preference, in-country staff</div><div style="left: 64.8px; top: 558.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00632);" data-canvas-width="281.0150999999998">capabilities, and the country’s technological capacity. Computer-</div><div style="left: 64.8px; top: 570.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.04879);" data-canvas-width="286.0222800000001">assisted data collection systems were preferable because they</div><div style="left: 64.8px; top: 582.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.01371);" data-canvas-width="283.71912">improved data quality through the use of programmed skip patterns,</div><div style="left: 64.8px; top: 594.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.983977);" data-canvas-width="282.79499999999996">range, and consistency checks. By eliminating the need for data entry,</div><div style="left: 64.8px; top: 606.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.993299);" data-canvas-width="283.05713999999995">computer-assisted systems also saved program resources and enabled</div><div style="left: 64.8px; top: 618.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00161);" data-canvas-width="148.70580000000007">faster access to the data for analysis.</div><div style="left: 75.6px; top: 630.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.03911);" data-canvas-width="275.2265999999999">Survey administration method varied from self-administered</div><div style="left: 64.8px; top: 642.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.999392);" data-canvas-width="284.72688">to interviewer-administered surveys. Literacy rates, technological</div><div style="left: 64.8px; top: 654.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.07732);" data-canvas-width="286.71180000000004">familiarity, and confidentiality concerns were key drivers in</div><div style="left: 64.8px; top: 666.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.0339);" data-canvas-width="285.8549999999999">determining the best data collection method. Self-administered</div><div style="left: 64.8px; top: 678.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.04621);" data-canvas-width="286.22628">surveys such as computer-assisted self-interview (CASI) were</div><div style="left: 64.8px; top: 690.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.01124);" data-canvas-width="285.30318">preferable due to the high-level of confidentiality they provide,</div><div style="left: 64.8px; top: 702.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.03685);" data-canvas-width="285.94679999999994">but required a high-level of literacy and computer familiarity.</div><div style="left: 64.8px; top: 714.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.96184);" data-canvas-width="284.43209999999993">If confidentiality was a big concern in low-literacy settings, audio</div><div style="left: 64.8px; top: 726.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.995424);" data-canvas-width="283.1152800000001">computer-assisted self-interview (ACASI) was used if the population</div><div style="left: 64.8px; top: 738.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00336);" data-canvas-width="284.9033400000001">had some computer familiarity. Interviewer-administered surveys</div><div style="left: 64.8px; top: 750.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.96098);" data-canvas-width="284.1617999999999">such as computer-assisted personal interview (CAPI) were used in</div><div style="left: 64.8px; top: 762.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00105);" data-canvas-width="107.94660000000003">most low-literacy settings.</div><div style="left: 75.6px; top: 774.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.985436);" data-canvas-width="273.7047599999999">Tailoring the survey instrument and administration for cultural</div><div style="left: 64.8px; top: 786.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.968245);" data-canvas-width="284.43822">appropriateness was vital to the acquisition of sound, viable data.</div><div style="left: 64.8px; top: 798.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.01683);" data-canvas-width="285.42557999999997">Sexual behaviors and the definition of “regular sexual partner”</div><div style="left: 64.8px; top: 810.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.996848);" data-canvas-width="285.1981199999999">and other terms varied according to local custom. The sensitive</div><div style="left: 64.8px; top: 822.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.03412);" data-canvas-width="284.14140000000015">nature of the survey questions also impacted survey administration</div><div style="left: 64.8px; top: 834.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.09808);" data-canvas-width="287.2218000000001">operationally. The preference for same-sex or opposite sex</div><div style="left: 64.8px; top: 846.511px; font-size: 10.2px; font-family: serif; transform: scaleX(0.993966);" data-canvas-width="283.16424">interviewers varied by country and military setting. It was imperative</div><div style="left: 64.8px; top: 858.511px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00913);" data-canvas-width="88.38300000000002">to pre-test the survey.</div><div style="left: 378px; top: 229.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.967649);" data-canvas-width="273.60276">A skilled workforce and staff retention are essential to provide</div><div style="left: 367.2px; top: 241.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00058);" data-canvas-width="285.0155400000001">high quality data. Literacy levels, technological familiarity, HIV</div><div style="left: 367.2px; top: 253.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.991984);" data-canvas-width="285.01349999999996">knowledge, and time commitments must all be considered when</div><div style="left: 367.2px; top: 265.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00815);" data-canvas-width="285.2572799999997">selecting data collection staff. Retention of staff throughout the</div><div style="left: 367.2px; top: 277.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.02283);" data-canvas-width="283.9200599999999">duration of data collection activities can be a major issue especially</div><div style="left: 367.2px; top: 289.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.959314);" data-canvas-width="284.4525">among military personnel who were often called away from study</div><div style="left: 367.2px; top: 301.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00132);" data-canvas-width="147.04320000000004">activities to perform military duties.</div><div style="left: 378px; top: 313.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.974412);" data-canvas-width="272.13701999999995">Host military ownership was integral to the success of the SABERS</div><div style="left: 367.2px; top: 325.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.02179);" data-canvas-width="283.98839999999984">program. By engaging military leadership early and involving them</div><div style="left: 367.2px; top: 337.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00262);" data-canvas-width="283.40598">in all decision making processes we ensured the partner military was</div><div style="left: 367.2px; top: 349.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00891);" data-canvas-width="283.5549">invested in the study and its success and found value in the resulting</div><div style="left: 367.2px; top: 361.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.995404);" data-canvas-width="283.14282">data and findings. Host militaries were actively involved in SABERS</div><div style="left: 367.2px; top: 373.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00319);" data-canvas-width="283.41923999999995">by providing staff for data collection, leading sensitization activities,</div><div style="left: 367.2px; top: 385.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00353);" data-canvas-width="213.6186">and monitoring data collection activities in the field.</div><div style="left: 378px; top: 397.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.10175);" data-canvas-width="278.5211999999999">Inclusion of capacity building elements during study</div><div style="left: 367.2px; top: 409.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.02701);" data-canvas-width="285.7662599999998">implementation led to increased host military buy-in. Capacity</div><div style="left: 367.2px; top: 421.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.03495);" data-canvas-width="284.1617999999999">building included staff trainings and practical experience in survey</div><div style="left: 367.2px; top: 433.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.988528);" data-canvas-width="284.72891999999985">methodology, use of electronic data collection instruments, study</div><div style="left: 367.2px; top: 445.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00083);" data-canvas-width="121.26780000000001">logistics and data monitoring.</div><div style="left: 378px; top: 457.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.978503);" data-canvas-width="272.10540000000015">Confidentiality of survey data and HIV test results was of increased</div><div style="left: 367.2px; top: 469.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.975054);" data-canvas-width="284.7319800000003">concern given that these studies were conducted in a work place</div><div style="left: 367.2px; top: 481.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.999359);" data-canvas-width="283.31825999999995">environment. For this reason, it was imperative to assure participants</div><div style="left: 367.2px; top: 493.711px; font-size: 10.2px; font-family: serif; transform: scaleX(0.970055);" data-canvas-width="284.43618">that disclosures of drug or alcohol use and positive HIV/STI test</div><div style="left: 367.2px; top: 505.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00859);" data-canvas-width="283.4804400000001">results would remain confidential and would not affect their military</div><div style="left: 367.2px; top: 517.711px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00093);" data-canvas-width="53.55">employment.</div><div style="left: 367.2px; top: 540.546px; font-size: 10.2px; font-family: sans-serif; transform: scaleX(1.10322);" data-canvas-width="61.2102">Conclusions</div><div style="left: 378px; top: 551.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.0217);" data-canvas-width="274.85327999999953">Based on our experience, the following are required for the</div><div style="left: 367.2px; top: 563.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.02671);" data-canvas-width="283.8864000000001">successful implementation of an HIV Bio-behavioral Risk Study in</div><div style="left: 367.2px; top: 575.311px; font-size: 10.2px; font-family: serif; transform: scaleX(0.97811);" data-canvas-width="282.80418">resource-poor military settings: (1) selection of a data collection mode</div><div style="left: 367.2px; top: 587.311px; font-size: 10.2px; font-family: serif; transform: scaleX(0.987916);" data-canvas-width="284.86560000000026">and survey administration method that is context-appropriate, (2)</div><div style="left: 367.2px; top: 599.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00498);" data-canvas-width="283.43657999999994">utilization of local wording and customs, (3) a skilled workforce, (4)</div><div style="left: 367.2px; top: 611.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00379);" data-canvas-width="283.4529">local buy-in/partnership, (5) inclusion of capacity building elements,</div><div style="left: 367.2px; top: 623.311px; font-size: 10.2px; font-family: serif; transform: scaleX(1.00993);" data-canvas-width="147.01260000000005">and (6) assurance of confidentiality.</div>}, number={1}, journal={Online Journal of Public Health Informatics}, author={Endres-Dighe, Stacy M. and Courtney, Lauren and Farris, Tonya}, year={2017}, month={May} }