Unit 2: Measures and indicators for behavioural surveillance

1. Unit 2: Measures and indicators for behavioural surveillance

2. After completing this unit you should be able to: • Understand the characteristics of a good indicator • Select indicators for behavioural surveillance • Understand the main methodological difficulties with indicators for behavioural surveillance • Discuss using standardised versus locally adapted indicators

3. What makes a good indicator? • A good indicator: • measures something of relevance to the topic • measures the item of interest accurately • is easy to interpret and defined in clear terms • can be compared across different population groups and across time • is feasible to collect in terms of effort/cost.

4. How to select indicators for behavioural surveillance Behavioural surveillance indicators should define aspects of behaviour that are key to the spread of HIV. These include behaviours that determine the likelihood that an uninfected person will come into contact with an infected person, such as: • number and type of sexual partners • patterns of needle exchange

5. How to select indicators for behavioural surveillance, cont. Behaviours that determine the likelihood that transmission of HIV will occur if contact with an infected person occurs: • level of condom use • equipment sharing practices

6. What behavioural indicators are most important for assessing the risk of HIV? General population and clients of sex workers: • Proportion who had commercial sex in past year • Frequency of commercial sex in past year • Proportion who had non-regular/casual partners in past year • Frequency of having non-regular/casual partners in past year • Last time and consistent condom use by type of partner • Proportion who used or injected drugs in past year

7. What behavioural indicators are most important for assessing the risk of HIV?, cont. IDU sub-populations • Proportion who shared needles on last drug use • Proportion who did not consistently use clean needles in past week (or other time of reference period) Commercial sex workers: • Last time and consistent condom use with clients • Proportion who used or injected drugs in past year

8. It can also be important to collect information on: • Factors that promote or reduce high-risk behaviours, such as alcohol or drug use • Aspects of background information helpful in programme planning or interpreting changes in behaviour over time (e.g., socio-demographic information)

9. Methodological issues for behavioural indicators Defining behaviours: • Definitions need to be clear so everyone knows exactly what the indicator is measuring. • Definitions need to be consistent across times so we can measure trends. • Definitions need to be meaningful in the local context and epidemic.

10. Defining time reference periods: • Time reference periods can affect how accurately behaviours are measured. • If a behaviour is very common, respondents may have difficulty remembering their behaviour if time reference periods are long. • If the behaviour is very rare, measurement over a short reference period may not capture exposure significantly. For example, it would be difficult for many IDUs to remember how many times they injected in the last year. If we asked about injecting in the last hour, the IDU would remember, but most people would respond “Not at all,” and we would not get a good idea of the risk behaviours. We need a balance.

11. Group work Work in groups to improve the following indicators. Your instructor will give you a time limit and further instructions. Indicator 1: The average number of unsafe injections per drug user per year Indicator 2: Number of men who had sex with more than one male partner in the last 12 months Indicator 3: The percentage of sex workers who used a condom at last sex

12. Standardised versus locally adapted indicators • The needs of the country, in terms of indicators, should come first. • If indicators are not locally appropriate in terms of reference periods and definitions, they are useless. But… (next slide)

13. Standardised versus locally adapted indicators, cont. • International bodies want to compare standardised indicators across regions and the globe. • Donors want to evaluate their programmes. • The indicators required to do this may not be those most useful to the country. Who wins? Or is there a compromise?

14. Small group discussion • What things we would need to define in order to measure high-risk sex in the general population? • Discuss the following questions and how well the definitions would work in your country context: a. How can we define ‘regular’ and ‘non-regular’ sexual partners? b. Can single people have regular partners? What if they don’t live together? c. What do we mean by ‘commercial’ sex?

15. Case study What do the following indicators measure? Which is more useful? a. Married men who go to a sex worker b. Men who go to sex workers who are married