Measuring sensitive Behavioural indicators A MethodologicAl ApproAch

PollIng BooTH SuRvey (PBS) & InFoRmAl ConFIdenTIAl voTIng InTeRvIew (ICvI)

Measuring sensitive Behavioural indicators a Methodological approach
polling Booth survey (pBs) & inforMal confidential voting interview (icvi)

Measuring sensitive Behavioural indicators: a Methodological approach polling Booth survey (pBs) & informal confidential voting interview (icvi) published by director, communications, Karnataka health promotion trust for Karnataka state aids prevention society, Bangalore, india

year of publication

:

2011

copyright

:

Khpt& ihat

compiled by

:

Ms priyapillai

editorial team

:

dr. shajyisac Mr. John anthony Mr. arinkar Mr. Joesph francis Munjattu Ms. elizabeth Michael Mr. rajnishranjan prasad

layout and design copies printed publisher

: : :

M. B. suresh Kumar (artwist design lab) 500 Karnataka health promotion trust, Bangalore

contents
AKNOWLEDGEMENTS.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . i ABBREVIATIONS. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . ii PREFACE .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . iii I. INTRODUCTION .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 1 4. Timeframe of ICVI. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 14 5. Budget for ICVI. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 14 6. Limitations of ICVI. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 15 IV. Implementation Design .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 16 V. List of Appendices 1. APPENDIX A: PBS Reporting Format .. .. .. .. .. .. .. .. .. .. .. .. .. . 18 2. APPENDIX B: Questions in PBS .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 19 3. APPENDIX C: ICVI Instrument . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 21 VI. List of Figures 1. Figure 1: Example of a PBS Session .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 2. Figure 2: Example of a PBS data analysis .. .. .. .. .. .. .. .. .. .. . 5 7

II. POLLING BOOTH SURVEY (PBS) .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 3 1. Methodology .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 3 2. Field Team .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 8 3. Materials Required . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 8 4. Timeframe for PBS . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 8 5. Budget for PBS .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 8 6. Limitations of PBS .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 9 III. INFORMAL CONFIDENTIAL VOTING INTERVIEW (ICVI) .. . 10 1. Methodology .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 10 2. Field Team .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 13 3. Materials Required . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 14

3. Figure 3: ICVI Interview Method .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 12 4. Figure 4: Example of a ICVI data analysis .. .. .. .. .. .. .. .. .. .. . 13

acKnowledgeMents
This document would not have been possible without the help of several people who supported in its development. We would like to thank following organizations & peopleNational AIDS Control Organization (NACO) for supporting and funding implementation of PBS and ICVI. Mr Subash Chandra Ghosh Programme Officer (TI), NACO for providing constant support. Special acknowledgement is due to Mr. R. R. Jannu, Project Director (KSAPS) for his leadership and guidance. Joint Director (TI) and other staffs of KSAPS for their support. The TSU Karnataka team specially Mr. John Anthony, Team Leader, Mr. Arinkar, Team Leader (Strategic Planning), and Mr. Joesph Francis Munjattu, Team Leader (TI) for providing valuable inputs and reviewing the document. NGO partners and community members for supporting in development and implementation of these tools. Dr. B.M. Ramesh, Director (Monitoring and Evaluation), KHPT and Dr. Shajy Isac, Director (Research & Special Studies), KHPT for pioneering the design, implementation and use of these methodologies in the monitoring of the KHPT programme for over eight years. Also Dr. Shajy’s inputs and guidance has been invaluable in preparing the document. Karnataka Health Promotion Trust for giving permission to adapt its tool. Special thanks to PHFI for the financial support for this initiative. Strategic Initiative and Knowledge Translation (SIKT) Unit, of Karnataka Health Promotion Trust (KHPT), has been instrumental in developing this document. KHPT would like to take this opportunity to acknowledge Ms. PriyaPillai for her contribution in preparing this document.

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aBBreviations
AIDS ART BMGF CMIS CBO DAPCU FSW FTFI GFATM HIV HRG ICTC ICVI IHAT KHPT Acquired Immune Deficiency Syndrome Anti-Retroviral Therapy Bill and Melinda Gates Foundation Computerized Management Information System Community Based Organization District AIDS Prevention and Control Unit Female Sex Worker Face to Face Interview The Global Fund to Fight AIDS, Tuberculosis and Malaria Human Immunodeficiency Virus High Risk Group Integrated Counseling and Testing Centers Informal Confidential Voting Interview India Health Action Trust Karnataka Health Promotion Trust KSAPS MSM NACO NACP NGO PBS PHC PHFI PLHIV SACS SAQ SIKT TI TG TSU USAID Karnataka State AIDS Prevention Society Men having Sex with Men National AIDS Control Organization National AIDS Control Programme Non-Governmental Organizations Polling Booth Survey Primary Health Centre Public Health Foundation of India People Living with HIV/AIDS State AIDS Control Society Self-Administered Questionnaire Strategic Initiative & Knowledge Translation Targeted Intervention Transgender Technical Support Unit United States Agency for International Development

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preface
Dependable data on sexual behaviour are essential for the development of effective HIV/AIDS intervention strategies and an evaluation of their impact on ensuring desired behaviour outcomes. However, collection of accurate data on sexual health has often posed a challenge due to the inhibition of the participants to share information about their sexual behaviour. Assessment of condom usage and safe sex practices include sensitive questions on personal attitudes towards and experience of sexual activities -such as condom use with different partners, anal sex, experience of violence and others - inconsistent with the dominant, accepted societal norms. Hence, social desirability bias acts as a persuasive impediment in eliciting genuine data from target group populations, to assess behavioural outcomes of the HIV/AIDS prevention interventions. Given this context, techniques that reduce social desirability bias, potential embarrassment of the respondents and ensure confidentiality of their responses in sexual behaviour surveys assume significance to secure exact and authentic information. Karnataka Health Promotion Trust (KHPT) has developed simple, in-house, small-scale annual surveillance strategies: Polling Booth Surveys (PBS) among FSWs and Informal Confidential Voting Interviews (ICVI) among the MSM-T, to monitor behaviour change among the key populations in condom use and other sexual behaviours. This document details out the two techniques, explaining the significance of the tools, the methodology for conducting them, lists that materials required and outlines the budget and timeframe to facilitate its operationalisation on the ground. The limitations of each technique have also been explained. Further, the two types of implementation design for both PBS and ICVI, the respective advantages and disadvantages of each have also been included. The document is aimed at the Technical Support Unit (TSU) staff members, state programme planners, programme managers and to all others interested in implementing PBS and ICVI at the field level. It is designed as a ready reckoner, detailed out with clear, uncomplicated directions and pointers, to enable its users to easily understand, design and implement the techniques at the field level. The document was supported by Karnataka State AIDS Prevenetion Society (KSAPS), KHPT and the TSU of India Health Action Trust (IHAT). We hope the document serves its purpose to practitioners looking for easy tools to administer among key populations that capture precise information on sexual behaviour and assist in improved design and evaluation of behaviour change intervention strategies.

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introduction
The importance of accurate and reliable data that help understand the dynamics of HIV transmission and STI infections to identify HIV control strategies has been well established. Reliable and valid data on sexual behaviour and sexual behaviour change is key to design effective interventions but is often difficult to obtain. For both behavioural outcome assessment and to aid the revision of behaviour change communication strategies, rigorous evidence based empirical assessment of condom usage and other service utilisation by target group members, influenced by the interventions is indispensable. Transmission and acquisition of HIV/AIDS are primarily through high-risk behaviours, involving sexual contact considered as highly personal, sensitive and confidential. Honest and accurate self-reporting of sexual behaviour data is heavily influenced by personal and contextual barriers, such as predisposition to self-disclosure, poor recall, perceptions of confidentiality and social desirability bias among others. Hence, survey methods that offer a greater level of privacy for respondents and assure anonymity of their response are more likely to elicit comparatively accurate data.
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It is in this context that data collection methods such as Polling Booth Survey (PBS) and Informal Confidential Voting Interview (ICVI) gain value over methods of Self Administered Questionnaire (SAQ) and Face to Face Interview (FTFI). A comparison of the responses elicited through FTFI and PBS among the general population1 conducted in Mysore district in 2006 illuminates the difference clearly. To the question 'Husband (wife) ever had extra-marital sex', the percentage of married women who responded yes was 10.3 in FTFI as compared to 29.9 in PBS. The same question posed to married men, 0.5% said they had extra-marital sex in FTFI as compared to 2.7% in PBS. Polling Booth Survey is a group interview method, where the individuals give their responses through a ballot box. Informal Confidential Voting Interview constitutes a blend of FTFI and self completion methods, which is done on a one-to-one basis or in the mode of a group interview. In both the methods, the individual responses are anonymous and unlinked i.e. an individual respondent is not linked to the response. This ensures the anonymity of the respondent, thereby increasing the sense of confidentiality among the

: Alary Michel et al, Comparison of FTFI and PBS for Eliciting Sensitive Behaviours among Unmarried Subjects in the Mysore GPS. HIV/STI PREVALENCE AND

RELATED BEHA VIOUR IN THE GENERAL POPULATION OF THREE KARNATAKA DISTRICTS. 26 February, 2008.

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respondents to report sensitive and personal information. The many advantages of the methodologies are: a. It offers anonymity to the respondents. b. Reduces social desirability bias. c. Increases the sense of confidentiality among the respondents. d. Efficient and easy tools to administer among both literate and illiterate respondents. e. Provides exact information on condom usage and risk behaviour that will aid in analysing the outcome and impact of the intervention. f. Simple to analyze. The above listed advantages increase the efficacy of PBS and ICVI in ensuring a more favourable response rate in reporting HIV associated high risk behaviours. As these methods ensure anonymity and assure confidentiality, it greatly favours the reduction of incorrect response due to a desire on the part of the respondent to conceal socially stigmatised activities. As a result, respondents perceive a reduced risk of negative judgement or potential embarrassment, which leads to increased self-disclosure of sensitive sexual behaviours. The information gathered can be used to monitor some of the behavioural outcomes of TI programmes. It helps understand the level of condom use with different partners, STI/HIV risk perception, high-risk sexual acts like anal sex and experience of violence by the members of high-risk groups. The following two chapters detail out the methodologies of PBS and ICVI.

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polling Booth surveys
Polling Booth Surveys (PBS) are used to monitor changes in certain key behaviour outcomes in the key populations. It is not an individualised face to face interview but a group method using a moderator giving instructions. As a method, it is more suitable to collect information on sensitive and personal issues related to sexual health. The PBS is also a method easier to administer among the illiterate and analyse. This chapter describes in detail the methodology for conducting the PBS, and it's limitations.

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heterogeneity within a TI should be reflected across the different groups that form the total sample for the survey. This is to ensure that the survey captures the behaviour patterns of different sections of the larger target population. For example, if the population of both home based and street based FSWs are critical in a TI, typology would be considered as a factor determining homogeneity. Hence, there will be separate groups of home based and street based FSWs constituted to participate in the survey. As the context of sex work and determinants of their response vary significantly depending on the typology, a single group will not have a mix of home and street based FSWs. Polling booth is conducted with a homogenous group of about 1012 individuals. For one session, a maximum of 20 respondents may be sampled though all may not participate in the survey. This is to account for contingencies such as non-availability and lack of response from the sampled participants.

1. Methodology
The selection of participants for the survey can be done in multiple ways, depending on the TI context. The participants can be selected from the programme data. In such a scenario, the responses received through the survey will help monitor service delivery or change. However, if programme data is unavailable such as if PBS has to be conducted in a new TI, a different strategy will have to be employed to mobilise participants. Irrespective of the methodology employed, the overall participants recruited for the survey should be a representative sample of the entire district population. Ideally, homogeneity within groups is desirable to elicit better and comparable responses. However, the

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a. Sampling
The subjects of the PBS may be recruited using any of the probability sampling methods. Those individuals contacted at least once in the last 6 months have to be considered in the sampling frame. The study design has to be a stratified random sample with city/town and typology as the stratas. Each sample should have a homogenous group of individuals as it ensures better response from the participants. The number of PBS sessions in each city/ town is determined proportionately based on the number of FSWs contacted at least once during the last 6 months. Within each city/town/cluster, the required number of participants (20 per session) has to be selected. The stratification variables can be any indicator that defines the heterogeneity of the population. When conducting PBS in a new TI, the total size of the FSW population in a TI should have been identified through mapping. Using that as a base, respondents can be randomly sampled from each individual site if the size of the population is sufficient within a site. If not, sites can be combined to form a cluster and sampling should be done from within the cluster population. The sampled respondents can be identified with the help of a peer.

The contact details of every sex worker under the programme and the services provided can be collected from the programme monitoring data. Alternatively, the sampled participants can be identified with the help of a peer in the context of a new TI, where there is no programme data available. Each of the sampled individual has to be contacted individually and mobilised for the session. The members in the final sample list are to be informed and mobilized for the PBS.

b. Pre-session Preparations
The implementing peers or outreach staff of the partner has to mobilize because they can easily identify the members in the sampled list. The persons in the list will be contacted and invited to participate in PBS at a designated day, time and place. The actual PBS sessions are to be conducted only with the sampled FSWs, who have voluntarily come to participate in PBS. The participants should neither be pressured nor incentivized to participate in the survey. If the staff is unable to contact the sampled participants, the reasons for non-participation have to be sought and listed. The team has to identify the locations where sessions can be conducted. The identified venues should ideally be able to accommodate 15-20 people.

c. Steps in conducting PBS
1. Separate the members from each other in a 'polling booth' environment. This will provide greater privacy to each individual respondent and ensure them about the confidentiality of their response. This increases the potential of genuine responses to the questions from the participants.

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2. Give each participant 3 boxes: Red, Green and White 3. Give each participant a pack of cards. The cards will be numbered as well as have distinct common pictures. 4. Number the cards according to the number of questions in the questionnaire 5. Stack the cards in serial order. For illiterate participants, who cannot identify or read numbers, it is easy for them to pull out the corresponding response to the questions as they are read out in the same order. 6. In terms of responses, a. If the response to the question is YES, ask the respondent to put the card with the number corresponding to the question into the GREEN box. b. If the response to the question is NO, ask the respondent to put the card with the number corresponding to the question into the RED box. c. If the question is NOT APPLICABLE, ask the respondent to put the card with the number corresponding to the question into the WHITE box. d. If the participant DOES NOT WANT TO ANSWER the question, the card has to be kept OUTSIDE these boxes. 7. The moderator should explain the PBS method with an example and a practice session. This example is to ensure the participants that their response will remain anonymous and unlinked. 8. Read the questions one by one. While reading the questions, the moderator needs to: a. Make the exercise lively

Fig 1: An example of a PBS session

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b. Read each question clearly, slowly and loudly, so that every participant hears the question clearly. c. The questions are to be read out in local language. d. Repeat the question if necessary. e. Use situations/stories while asking the question. f. Use local terms, and

g. Give sufficient pause and take care to not hurry through the questions. 9. At the end of administering the questions, a. Collect the cards separately: the ones that are in Green boxes, the ones in Red boxes and the ones in the White boxes. b. Count the number of cards in each box for each question and record the tallies in the reporting form (see Appendix A). 10. Share the group responses with the group. An FGD with the participants at the end of the BS can provide valuable qualitative information to understand the response patterns. 11. Document the group discussion points. 12. Once the responses are shared with the group, hand over the report to the team supervisor.

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d. Instrument for PBS
The purpose of PBS is to capture accurate information on some sensitive behavioural indicators. Hence, it is advisable to consider only such sensitive questions. The questions mainly attempt to understand condom use behaviour, barriers for condom use, the risk perception and experience of violence of the key populations. The aspects of behaviour covered by the PBS questions are as follows: 1. Condom use in the last sexual intercourse with: a. Clients (paying new or occasional clients) b. Regular Clients (paying regular clients) c. Lovers (non-paying lovers of the FSWs, who do not live together) d. Husbands or co-habiting partner (nonpaying, husband or a live-in partner) 2. Sex without condom 3. Refusal to have sex without condoms 4. Condom breakage 5. Condom use in last sexual intercourse 6. Barriers for condom use

a. Partner's choice b. Influence of alcohol c. Non-availability of condoms d. More money for sex without condoms 7. Anal sex 8. Risk perception, and 9. Experience of violence

e. Data Analysis
Given below is an example of a PBS data, which shows the condom use behaviour of the FSWs in two consecutive years (R1 and R2).

70 60 50 40 30 20 10 0 41.7 33

58.5

LastClient

Sex without condom in the pastone month

LastSex
r1 r2

As seen in the graph, the condom use with the last client was around 69% for both the years. About 42 percent FSWs had sex at least once in the past one month without a condom in year 1, which declined to 33 percent in year 2. The reduction in percent FSWs that engaged in unprotected sex indicates an improved consistent condom use over the period. Condom use at last sex (with any partner) has increased from 59 percent to 68 percent during the two rounds of PBS.

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2. FIeld Teams
A district level supervisor-in-charge of the PBS in an entire district or a couple of districts should be selected. S/he will have to liaison with the NGO and the field team. The supervisor-in-charge has the responsibility to ensure that protocols are followed while recruiting the participants for PBS and while conducting the PBS. Once the sessions are over, the field team has to compile and forward the completed PBS forms to concerned organisation for data entry, analysis and report writing. The field investigators have to be mobilised, selected and trained. The field team has to conduct polling booth sessions as per the protocol. Once the sessions are over, they should complete the reporting format as per protocol and submit them to the team supervisor. Each individual session will be manned by 2 persons - a moderator and a support staff -observing and ensuring that all the participants listen carefully to the instructions and hold the right card. An independent, externally hired monitoring team has to be constituted and trained to monitor the entire process.

The recruited team has to be thoroughly trained on concepts of sex, sexuality, condom and HIV/STI. The team should be rigorously trained on the questions in the survey. Further, they have to be trained on survey procedures, such as rapport building with the participants and administering the questionnaire. They are also briefed on the roles and responsibilities of the team members. The training also involved a field practice session, where the teams conduct a single session of the survey prior to the actual process. The teams regroup after the practice session to share their field experiences. This helps them to identify the challenges in conducting the survey and seek feedback from the trainers on ways to address them. Further, the survey findings from the practice session of each team are compared with each other. The differences in results are discussed and probable reasons for it explored. For example, lack of uniformity in administering or asking a question across the various teams may lead to very disparate and non-comparable responses being elicited from the participants. Also, if a particular field investigator(s) has been unable to get a sufficient answer from the participant(s), it may be due to the way the

question is being posed. In the discussions post field practice session, all such issues are brought to light, discussed and solutions to overcome these limitations are shared. These sessions serve as a forum for cross-learning.

3. Materials Required
For the PBS, the team should carry: a. The 3 different coloured - green, red and white - plastic boxes b. Partitions c. Card sets d. Sample list e. Questionnaires f. Polling booth cartons and g. Reporting format.

4. Timeframe for PBS
On an average, a single session including the compilation of the report will take one hour. A team of 6 persons with a supervisor can complete the survey in a district within 3 days.

5. Budget for PBS
The budget for a PBS should factor in the cost for the field staff, monitoring and evaluation, training and printing and stationary.

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The budget for the field staff should include the following: Š Cost of their salary Š Daily allowance Š Travel reimbursement and accommodation costs. Š The travel cost of hiring vehicles and fuel to transport the polling booth teams from base to the polling booth stations Š Miscellaneous costs such as for mobile bills for supervisors The training budget should include the following: Š Cost of daily allowance for the field staff Š Food and transportation cost Š Cost of training materials The monitoring and evaluation budget should include the following: Š Cost of travel Š Accommodation cost Š Daily allowance for the monitoring and evaluation team. The printing and stationary budget will include the following: Š Cost for PBS materials Š Cost for printing of questionnaires and materials. The NGO has to budget: Š Cost of mobilising the selected respondents, Š Travel and refreshment costs for the participants.

6. Limitations
The challenges/limitations associated with PBS are: Š Higher probability of non-response as not all selected individuals will be able to participate in a group at the designated time and place. Š Only questions that have a YES or NO answers can be included Š Only a limited number of questions can be asked unlike in a face-to-face interview Š The analysis will provide only group-aggregated data, and cannot be analyzed with linkages to individual characteristics

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III

inforMal confidential voting interviews (icvi) aMong the MsM-t coMMunity
Informal Confidential Voting Interview is a technique of data gathering suitable to collect sensitive and personal information about sexual health and monitor changes in certain key behaviour outcomes in the key populations. ICVI is administered more with the MSM-T population than FSWs, as there are more literates with in MSM-T. Also, as a group they are less amenable to being collectivised than FSWs. However, it can be used among both literates and illiterates. This chapter describes in detail the methodology for conducting the ICVI, the preparations required and the limitations. A moderator from the MSM-T community has to be selected to conduct the ICVI. The affiliation between the participants and the moderator because of being from the same community will create an atmosphere of comfort, wherein the likelihood of open responses from the sampled respondents will be higher.

a. Sampling
Sample size per TI can be decided based on the indicator of interest and on the expected changes in the parameter. For example, if the targeted completed ICVI interview per district is at 150-200, the sampling will be done in different ways as described below: The respondents can be selected through random sampling from the programme data. The stakeholder registration details can be used to select the required samples. Alternatively, the contacted MSM-T during a specified period of time under the programme can be used as a sampling frame. That is, randomly select

1. Methodology
ICVI can be conducted on a one-to-one basis, where the interviewer administers the survey questionnaire to a single respondent. This becomes necessary as it may not always be possible to mobilise the MSM-T into a group. ICVI can also be conducted on a oneto-group basis, where a single interviewer administers the survey questionnaire to a group of respondents.

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the required number of MSM T from either the registered MSM T or those contacted 6 months period prior to the survey. In case if ICVI is planned in a new TI, the program may not have detailed contact details or line listing. In such cases, the sampled respondents can be identified and approached with the help of a peer from the list of spots identified from mapping. Each of the sampled individual has to be contacted individually and mobilised for the session. 1. About 10-20 MSM-T cruising sites will be selected per district. 2. In each selected site, a total of 10-15 respondents are randomly selected for the survey. 3. The ICVI team will visit the selected site, along with the local MSM-T peer, and approach all available members for ICVI, until the targeted sample from the site is achieved. 4. If the required number of respondents is not available, the team should visit the site at a different time and/or on a

different date to complete the sample. 5. A maximum of three visits may have to be made to achieve the required sample of ICVIs. 6. If the required number cannot be achieved in a site even after three visits, the short fall has to be adjusted by increasing the number of ICVIs in other selected sites.

The team has to identify the locations where sessions can be conducted. If the interview is a one-to-group session, then the identified venues should ideally be able to accommodate 10-15 respondents. As ICVI is mostly a one on one session, it is not always necessary for the participants to group in an identified location. The investigating team can travel to the location of the participant and conduct the interview.

b. Pre-session Preparations
The implementing peers or outreach staff of the partner has to mobilize because they can easily identify the members in the sampled list. The persons in the list will be contacted and invited to participate in PBS at a designated day, time and place. The actual ICVI sessions are to be conducted only with the sampled MSM-T, who has volunteered to participate in the survey. The participants should neither be pressured nor incentivized to participate in the survey. If the staff is unable to contact the sampled participants, the reasons for non-participation have to be sought and listed.

c. Steps in conducting ICVI
1. For literate respondents, the steps include: a. The moderator shares the blank questionnaire with the respondents b. The respondents fill the questionnaire as per the instructions on the questionnaire c. In case of lack of clarity with the questions, the respondents can ask the moderator for further explanation. d. The filled-in questionnaires are dropped into the sealed ballot box e. The ballot box to be opened only at the time of data entry 2. For illiterate respondents, the steps include:

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a. Seat the respondent comfortably. b. Place a barrier between the respondent and the interviewer. c. The interviewer should ask the respondent the questions for information about his profile, then fill in the answers and give the respondent n id. This is to collect information on the socio-demographic characteristics of the respondent. Also, this step helps establish motivation, build a strong rapport between the interviewer and the respondent and sensitise the respondent to the purpose of the study. d. Give the respondent the questi onnaire, sketch pen and

e. The interviewer, using a trail question, should explain the method to the respondent till he demonstrates a good understanding of the procedures. f. The interviewer should then read out the question one by one. The questions should be accompanied with instructions on how to record the response for each question.

g. The respondent using the markers has to colour according to the answer. h. If the answer to the question is NO, instruct the respondent to colour the circle on the card. If the answer to the question is YES, instruct the respondent to colour the square box on the card. i. The respondent should then be asked to fold the completed questionnaire and drop it into the ballot box.

the sealed ballot box. Corresponding to each question will be a card with an unique identification number on one side and a circle and a rectangle on the other side.

Example of Voting Card

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d. Instrument for ICVI
The purpose of ICVI is to capture accurate information on some sensitive behavioural indicators. The questions mainly attempt to understand condom use behaviour, frequency of sexual intercourse, the risk perception and experience of violence. A total of 24 questions will be asked in ICVI (see Appendix C for the ICVI questionnaire). The questions should cover the following aspects: 1. Condom use in the last anal sex 2. Condom use with main regular male anal sex partner 3. Condom use with known (repeat) male anal sex partner 4. Condom use with unknown (new) male anal sex partner 5. Condom use in sexual intercourse with a female sex worker 6. Condom use in sexual intercourse with the main female sexual partner

7. Number of anal sex partners in the past 1 week 8. Frequency of sexual intercourse with the main female sexual partner in a typical month 9. Intention to get an HIV test 10. Ever tested for HIV 11. Experience of sexual violence in the past one year

e. Data Analysis
Given below is an example of an ICVI data that shows the percent of MSM-T who used condoms at last anal sex by identity. As the graph shows, the use of condoms at last anal sex has been over 70% for majority of the MSM-T identities. Around 78% of the Kothis and 74% of the DDs had protected anal sex. The percent of Hijras and Bisexuals who used condom at last anal sex was 77%.

2. Field Teams
A district level supervisor-in-charge of the ICVI in an entire district or a couple of districts should be selected. S/he will have to

Fig 4: % MSM-T that used Condoms at Last Anual Sex
100 80 60 40 20 0 Kothi dd hijra Bisexual others 78.3 73.5 77.1 76.7 62.5

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liaison with the NGO and the field team. The supervisor-in-charge has the responsibility to ensure that protocols are followed while recruiting the participants for ICVI. The NGO partner will help the research team to mobilise the interviewers. Literate MSM-T community members with a basic command on English will be recruited as interviewers. They will help identify and interview potential respondents in the cruising sites. Community members are chosen as interviewers as they best understand the MSM-T dialect, the local MSM issues and help reduce inhibition among respondents when talking about stigmatised sexual behaviour. The interviewers have the responsibility to administer the consent forms and interview consenting respondents. An independent, externally hired monitoring team has to be constituted and trained to supervise and monitor the field team. In addition, the zonal M&E officer and the district supervisor-in-charge will do quality control checks to ensure the quality of the data collected. The field team will undergo a three day training including the mock field practice sessions. The training will include lectures on HIV/AIDS, survey methods and interview techniques. The roles and responsibilities of the team members will be discussed. The

team will then go into the field and administer the questionnaire to randomly chosen and willing MSM-T respondents to familiarise themselves with the process. On their return from the field, a debriefing session will be held to clarify and sort out any difficulties faced during the process. The session becomes a forum for cross-learning, where the team will share their experiences and compare the results. The discussion will help the team members to reflect on the challenges, seek ways to overcome them and further refine the ways of administering the questionnaire.

3. Materials Required
The following materials will be required for ICVI: 1. Questionnaire 2. Sealed ballot box 3. Voting Cards 4. Sketch pens 5. Barriers (curtains, cardboard materials etc)

4. Timeframe for ICVI
On an average, a single interviewer can conduct 8-10 interviews per day. A field team of 5 interviewers can complete the survey in a district within 4-5 days.

5. Budget for ICVI
The budget for ICVI should factor in the cost for the field staff, monitoring and evaluation, training and printing and stationary.

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The budget for the field staff should include the following: Š Cost of their salary Š Daily allowance Š Travel reimbursement and accommodation costs. Š The travel cost of hiring vehicles and fuel to transport the polling booth teams from base to the polling booth stations Š Miscellaneous costs such as for mobile bills for supervisors The training budget should include the following: Š Cost of daily allowance for the field staff Š Food and transportation cost Š Cost of training materials. The monitoring and evaluation budget should include the following: Š Cost of travel Š Accommodation Š Daily allowance for the monitoring and evaluation team. The printing and stationary budget will include the following: Š Cost for ICVI materials Š Printing of questionnaires and materials.

The NGO has to budget the following: Š Cost of mobilising the selected respondents Š Travel and refreshment costs for the

participants

6. Limitations
The challenges or limitations of the method are: a. Chances of misreporting due to inability of the interviewers to check the internal consistency of the responses during interviews. b. May require more time to conduct due to the difficulty in bringing the sampled MSM-Ts together in one location. c. Requires skilled interviewers thoroughly trained and supervised. d. Limits the complexity of questions that can be asked. Simple questions that warrant YES or NO are best suited for ICVI.

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IV

iMpleMentation design
For an assumed size of 1000 targeted population per TI, about 15-20 PBS will have to cover the entire TI. The two different scenarios for conducting PBS are: (a) PBS conducted by individual TI, and (b) PBS conducted at SACS level. Š The entire survey can be completed in lesser time. The disadvantages of this model are: Š Training will not be uniform as different resource persons impart training in each TI. This will result in incomparable results of PBS across TIs. Š Increased costs due to hiring of multiple research teams, costs of training each team and supervisor for each team. Š Lack of availability of quality researchers at the TI level. Š Reduced quality of the survey, due to potential biases involved in asking questions resulting out of familiarity of the interviewer and the subject.

a. PBS conducted by individual TI
TI will train, monitor and analyse the research team. In this model, each TI will have to employ an independent research team. This means, team will be identified, hired, trained for conducting 15-20 PBS sessions. In other words, a pair of researchers can complete the desired number of PBS in about 5-7 days time. The advantages of this model are: Š PBS can be rolled out simultaneously across districts as there are separate teams conducting the survey in each TI.

b. PBS conducted at SACS level
In this model, a centrally hired research team will conduct the survey across the district. One team can conduct 2-3 PBS sessions per day, and multiple team can be placed in a district to complete the PBS.

16

Only, one supervisor will have to be hired to monitor multiple teams in a district. The advantages of this model are: Š The research team will undergo a single training session ensuring uniformity of training received, ensuring comparable data across TIs. Š Reduced costs, both of training and of supervisors. Š Availability of researchers. trained and skilled

Š Improved quality of the survey, due to absence of potential biases resulting from unfamiliarity between the researchers and the subjects. The disadvantage of this model is that survey might take comparatively longer as each TI is not assigned a research team. However, by increasing the size of the central team, this limitation can be addressed. Thus, it is advisable to hire an external team of researchers to conduct a PBS, as it improves quality and reduces cost. Similar to PBS, there are two scenarios for conducting ICVI - (a) ICVI at the TI level, and (b) ICVI at the SACS level. The advantages and disadvantages of both the models remain the same.

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appendix a

polling Booth survey reporting forMat
District :__________________________ City/Town :______________________________PBS#________________________ Date of PB : ______________________ DAY__________________________________MONTH Time start (24 hours) : Time end (24 Number of participants in PB : Name of the Moderator : Name of the Assistant : Details of participants Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 Name Age Type of sex work ID

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appendix B

Questions in polling Booth survey
QUESTION 1. Did your last client use a condom with you? 2. During the past one month, was there any occasion when you had sex with a client without using a condom? 3. Do you have a regular client? 4. The last time you had sex with your regular client, did he use a condom? 5. Do you have a lover? 6. The last time you had sex with your lover, did he use a condom? 7. Are you currently living with your husband? 8. Did your husband use a condom when he last had sex with you? 9. When you last used a condom, did the condom break? 10. Was a condom used when you last had a sexual intercourse? 11. During the past one month, was there a time when you wanted to use condom during sex but did not because your partner did not want to wear a condom? 12. During the past 12 months, have you ever refused to have sex with a client/non-regular partner because of not having or refusing to use a condom? YES NO NOT APPLICABLE NO ANSWER TOTAL

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13. During the past one month, was there a time when you intended to use a condom with a partner but did not use it because either of you had been drinking alcohol? 14. During the past one month, was there a time when you intended to use a condom with a partner but did not use it because the condom was not available at that time and place? 15. Did your last client offer you more money for sexual intercourse without a condom? 16. Did your last client ask for anal sex? 17. Did you ever have anal sex? 18. The last time you had anal sex, was a condom used? 19. Are you interested in knowing if you have HIV infection? 20. Have you ever taken an HIV test? 21. Have you ever taken HIV test during the past six months? 22. The last time when you tested for HIV, did you obtain test result? 23. Have you ever been registered in ART (Anti Retroviral Therapy) center? 24. Are you currently taking ART (Anti Retroviral Therapy)? 25. In the past one year, were you ever beaten or otherwise physically forced to have sexual intercourse with someone even though you did not want to?

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appendix c

inforMal confidential voting interview (icvi)
District:__________________________________________________________City/Town:____________________________________________ Site:_____________________________________________________________Sample Number: ______________________________________ Date:__________________________________________________Day___________________________Month__________________________ Year_______________________ PROFILE No. 1 2 QUESTIONS AND FILTERS How old are you? Can you read and write? CODING CATEGORIES AGE IN COMPLETED YEARS. YES . NO . 1 . 0 SKIP DON'T KNOW_____98

What is the highest grade you have completed?

Grade Currently Married Separated Divorced Widowed Never Married No Answer Predominantly Kothi Predominantly Panthi Double Decker 1 2 3 4 5 99 1 2 3 4 5 6 97

What is your current marital status?

How do you identify yourself?

Hijra Akwa Hijra Nirvaan Bisexual No Specific Identity

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icvi Questions
SL. No 1 QUESTIONS Was a condom used when you last had anal intercourse? Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. In the past six months, was there a time when you wanted to use a condom during anal intercourse but did not? Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. The last time you used a condom in anal intercourse, did the condom break? 3 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. Have you ever used a lubricant while having anal sex? I mean something that that will make your penis or your partner's penis more slippery and easier to insert into the anus? Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. Was lubricant used when you last had anal intercourse? 5 Circle 1 if YES and circle 2 if NO. If never used lubricants or is not interested to answer the question, do not circle any number and proceed to the next question. RESPONSES 1 2

2

1 2

1 2 1

4

2 1 2

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Do you have a main (regular) male sexual partner? 6 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. The last time you had anal intercourse with this partner was a condom used? 7 Circle 1 if YES and circle 2 if NO. If you do not have a main (regular) male sexual partner, or if you are not interested to answer the question, do not circle any number and proceed to the next question. Have you ever received cash or gifts in return for anal sex? 8 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. The last time you had anal sex, did you receive cash or gift in return for anal sex? 9 Circle 1 if YES and circle 2 if NO. If you have not received any cash or gift in return for anal in tercourse or if you are not interested to answer the question, do not circle any number and proceed to the next question. Have you ever paid cash or given gifts in return for anal sex? 10 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. The last time you had anal sex, did you pay cash or give gift in return for anal sex? 11 Circle 1 if YES and circle 2 if NO. If you have never paid cash or given gift in return for anal sex, or if you are not interested to answer the question, do not circle any number and proceed to the next question.

1 2

1 2

1 2

1 2

1 2

1 2

23

In the past one week, how many different men did you have anal intercourse with? 12 Circle the number that corresponds to the number of different men you had anal intercourse 0 1 2 3 4 5 6 7 8 9 10 11 12 with in the past one week. If not interested to answer the question, do not circle any number and 13 14 15 16+ proceed to the next question. The last time you had anal intercourse with a known (repeat) male partner was a condom used? 13 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. Was a condom used when you last had anal sex with a man that you didn’t know or recognize (new)? Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. Did you ever have anal intercourse with a Hijra? 15 Circle 1 if YES and circle 2 if NO. If you are not interested to answer the question, do not circle any number and proceed to the next question. Was a condom used when you last had anal sex with a Hijra? 16 Circle 1 if YES and circle 2 if NO. If you never had sex with a Hijra or if you are not interested to answer the question, do not circle any number and proceed to the next question. Have you ever had sexual intercourse with a female sex worker in the last year? answer the question, do not circle any number and proceed to the next question. Was a condom used when you last had sexual intercourse with a female sex worker? 18 Circle 1 if YES and circle 2 if NO. If never had sex with a female sex worker or you are not interested to answer the question, do not circle any number and proceed to the next question. 1 2

14

1 2

1 2 1 2 1 2 1 2

17

24

Do you have a main female sexual partner? 19 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. How many times do you have sexual intercourse with her in a ‘normal’ month?

1

20

0 1 2 3 4 5 6 7 8 9 10 11 12 Circle the number that corresponds to the number of times you had sexual intercourse with your 13 14 15 16 + main female sexual partner in a typical month. If you do not have a main female sexual partner or if you are not interested to answer the question, do not circle any number and proceed to the next question. Was a condom used the last time you had sexual intercourse with her? 1 2 1

21

Circle 1 if YES and circle 2 if NO. If you do not have a main female sexual partner or if you are not interested to answer the question, do not circle any number and proceed to the next question. During the past 12 months, have you ever refused to have sex with a client/non-regular partner because of not having or refusing to use a condom? Circle 1 if YES and circle 2 if NO. In the past one year, were you ever beaten or otherwise physically forced to have sexual intercourse with someone even though you did not want to? Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question. Are you interested in knowing if you have HIV infection?

22

2 1

22

2 1 2

23

Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number and proceed to the next question.

25

Have you ever taken HIV test? 24 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number. Have you eVer taken an HIV test during past 6 months? 25 Circle 1 if YES and circle 2 if NO. If not interested to answer the question, do not circle any number. The last time when you tested for HIV, did you obtain

1 2 1 2 1

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KHPT
Karnataka Health Promotion Trust

Karnataka Health Promotion Trust IT/BT Park, 5th Floor, # 1-4 Rajajinagar Industrial Area, Rajajinagar, Bangalore – 560 004 Phone: 91-080-40400200, Fax: 91-080-40400300 www.khpt.org

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