Full length articleInterviewer-administered TLFB vs. self-administered computerized (A-CASI) drug use frequency questions: a comparison in HIV-infected drug users
Introduction
Substance use among HIV-infected individuals is associated with many adverse consequences, including poor treatment outcomes (Pacek et al., 2014), low antiretroviral treatment (ART) initiation (Kapadia et al., 2005), HIV sexual risk behaviors, STI transmission (Khan et al., 2013) and hepatitis C virus (HCV; Hermanstyne et al., 2012). Substance use is prevalent among HIV-infected persons (Mimiaga et al., 2013, Pacek et al., 2014); in a recent U.S. national survey, 33.1% of those with HIV/AIDS used an illegal drug in the prior 30 days (Pacek et al., 2014). Further, non-injecting drug use is increasingly associated with HIV infection (Des Jarlais et al., 2007). Thus, developing and disseminating effective interventions to reduce drug use in this population is a public health priority. In order to test the efficacy of such interventions, or methods of disseminating them, researchers and clinicians must often measure frequency of substance use.
Measuring frequency of drug use poses significant challenges. Studies often use participant self-reports, which are relatively easy to administer, but can be vulnerable to under-reporting due to two main factors: participants’ inability to accurately recall drug use (forgetting), and social desirability bias (responding inaccurately in an interview due to the desire to appear favorably to the interviewer). Forgetting may occur when the assessment time frame is longer than a day or two, including the common time frame of the prior 30 days. Social desirability bias may occur because drug use is illegal, stigmatizing and potentially embarrassing to report (Rosenbaum et al., 2006), problems that are compounded in HIV-infected individuals who often suffer from multiple stigmatized conditions (Eaton et al., 2015, Katz et al., 2013). Consistent with this, HIV-infected persons consistently report distrust of healthcare institutions (Beer et al., 2009, Eaton et al., 2015), poor communication with providers (Flickinger et al., 2013, Messer et al., 2013), and fears about loss of confidentiality (Beer et al., 2009). In research in a healthcare setting, these issues can all contribute to under-reporting of drug use frequency. Therefore, in HIV patients, drug use frequency could vary by the measurement modality used (Beck et al., 2014, Grucza et al., 2007, Rosenbaum et al., 2006), depending on whether the modality primarily focuses on reducing forgetting, or on reducing social desirability bias.
To assess self-reported drug use frequency, two widely-used modalities are commonly used, interviewer-administered assessments and self-administered assessments. A commonly-used interviewer-administered assessment is the Timeline Follow-Back (TLFB; Sobell and Sobell, 1992). Self-administered assessments, which may consist of simple questions about frequency of drug use, often use the Audio Computer-Assisted Self Interview (A-CASI) modality. Each method has a differential emphasis on reducing forgetting or social desirability bias as a source of under-reporting, as well as other advantages and disadvantages.
In an interviewer-administered TLFB, interviewers work actively to address forgetting by assisting patients to recall events. At the beginning of a TLFB interview, an interviewer uses a calendar with the participant as a recall and memory aid (Carey et al., 2004, Richter and Johnson, 2001, Robinson et al., 2014) reviewing events that occurred in the participant’s life during the time frame of interest (e.g., past 30 days). After noting these events, the interviewer then uses unstructured questions to help the participant recall days of substance use, which are noted on the calendar and tallied later to produce measures such as drug use frequency. A major assumption about the interviewer-administered TLFB modality is that the face-to-face, interviewer-administered, semi-structured format establishes trust and rapport between interviewer and participant (Rosenbaum et al., 2006), overcoming social desirability bias. An advantage of interviewer-administered TLFBs is that interviewers can work to ensure that patients attend to each question, and can also provide additional instructions and clarifications on the procedure for patients as needed. Thus, the TLFB is seen as advantageous for diverse patients, including those with mild cognitive impairments or other characteristics potentially affecting attention and recall (Sacks et al., 2003). The major disadvantage of the TLFB is that respondents may minimize their drug use reports to present themselves in a socially desirable manner. In addition, although TLFB interviewers are trained to administer the TLFB in a standardized way, they may unintentionally offer patients varying levels of non-standardized communication and feedback (Richter and Johnson, 2001). Despite these potential influences on reporting, the TLFB has shown strong test-retest reliability across several substances (Robinson et al., 2014) and across diverse populations (Carey et al., 2004, Fals-Stewart et al., 2000, Levy et al., 2004, Sacks et al., 2003). The TLFB has also shown strong concurrent validity using biological measures(Hjorthøj et al., 2012), other interviewer-administered instruments (Dennis et al., 2004, Fals-Stewart et al., 2000) and self-report instruments (Fals-Stewart et al., 2000, Sacks et al., 2003).
In the A-CASI modality, questions about drug use frequency (simple or complex) are self-administered without an interviewer, allowing patients to respond privately and thus reducing the threat of social desirability bias (Estes et al., 2010, Richter and Johnson, 2001). This privacy could result in more accurate and honest responses, yielding greater reports of drug use. For example, patients may feel uncomfortable reporting substance use behaviors to an interviewer due to fear of stigmatization. The confidentiality of the A-CASI format is assumed to eliminate this (Dolezal et al., 2012, Estes et al., 2010). Another A-CASI advantage is the consistency in administration of questionnaire items within and across patients. The same program and questions are always used, ensuring a standardized protocol. In addition, the program used to administer the A-CASI questionnaire automatically generates a data file for analysis, eliminating the need for post-interview data entry and tallying. However, A-CASI administration leaves the study team reliant on patients' willingness and ability to read questionnaire items carefully and enter their data accurately, with no way of identifying data entry errors and outlier responses. This could yield some responses that appear implausible, with no obvious way to resolve them (Rosenbaum et al., 2006, Wright et al., 1998). Drug use frequency questions administered in the A-CASI modality have demonstrated good test-retest reliability (McNeely et al., 2014) and validity (Qian et al., 2014, Simões and Bastos, 2004) to measure drug use in primary care patients and in drug users (Islam et al., 2012).
Past research has typically demonstrated that respondents report higher rates of drug and alcohol use with a self-administered questionnaire than a face-to-face interview (Bjarnason and Adalbjarnardottir, 2000, Rosenbaum et al., 2006). However, little is known about the agreement between the interviewer-administered TLFB and other questions on frequency of drug use administered via A-CASI to HIV-infected patients who are drug users. Substantial disagreement would indicate that studies using one method should not be compared to similar studies that used the other method, impairing the field's ability to aggregate data across studies. Further, knowledge is limited on whether or not disclosure of drug use between the two modalities varies by patient characteristics. Previous studies suggest that in general, demographic characteristics such as age (Ledgerwood et al., 2008, Vigil-Colet et al., 2015, Welte and Russell, 1993), race (Johnson and Fendrich, 2005, Ledgerwood et al., 2008, White et al., 2014) gender (Bjarnason and Adalbjarnardottir, 2000, Dolezal et al., 2012) and socioeconomic status (Welte and Russell, 1993) may be related to differential reporting of sensitive health behaviors. Whether these characteristics differentially affect reporting of drug use frequency in interviewer-administered vs. A-CASI-administered assessments among HIV positive patients is presently unknown.
The main purpose of this study was therefore to test the agreement on drug use frequency in the prior 30 days between questions administered in an A-CASI battery and in data tallied from interviewer-administered TLFB interviews. We also examined whether the agreement between A-CASI and TLFB data was associated with patient demographic and clinical characteristics.
Section snippets
Procedures
The current study uses baseline data from an ongoing randomized trial of brief interventions to reduce non-injection drug use (NIDU) in HIV primary care patients (Aharonovich et al., 2012). Participants were recruited from two large HIV primary care clinics in New York City between 2011 and 2014. The HIV clinics mainly serve low-SES, minority patients from all five boroughs of New York City. Participants were referred by clinic staff to a bi-lingual study coordinator, who screened patients for
Results
As shown in Table 1, most patients were male (82.8%) and African American (66.5%). Participants were primarily in mid-adulthood (mean age: 46.6 years) and had at least a high school education (68.1%). Many identified cocaine or crack as their primary drug (70.2%), about a fifth reported receiving alcohol or drug treatment outside the study (17.6%), and about one-third were binge drinkers (34.3%).
Participants reported using their primary drug an average of 10.0 days in past 30 days with the
Discussion
The aims of this study were to assess the agreement between two widely used methods to assess frequency of illicit drug use, i.e., days used primary drug in the prior 30 days. Each of these measures attempts to reduce under-reporting, but focuses on different ways of accomplishing this. One measure consisted of structured questions self-administered via computer (A-CASI), a modality that provides participant privacy to reduce under-reporting due to social desirability. The other measure, the
Conflict of interest
No conflict declared.
Funding
Financial support for this research was provided by the National Institutes of Health grants R01 DA024606 (EA) and R01 AA023163 (DSH) and the New York State Psychiatric Institute (DSH). The funding sources had no further involvement in this research.
Contributors
EA and DSH conducted the original trial from which data were used. EMD was responsible for statistical analyses and drafting of the manuscript. EMD, EA, and DSH participated in interpretation of data, critical revisions, and approval of the manuscript.
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