1 Measuring Behavioural Outcomes with Polling Booth Surveys B.M. Ramesh, PhD Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada & Karnataka Health Promotion Trust, Bangalore, India

2 Background Focused HIV prevention program in 6 high prevalence states in India –KSAPS implementing the program in 9 districts of Karnataka –KHPT implementing the program in 16 districts in Karnataka and 3 districts in Maharashtra. Main objective is to reduce the incidence of HIV and STIs. Monitor changes in condom use and other sexual behaviours Polling Booth Surveys (PBS) among FSWs

3 What is polling booth survey? Polling booth survey is: –A group interview method –Where the individuals give their responses through a ballot box –Where the individual responses are anonymous and unlinked

4 Polling booth survey: Advantages More suitable to collect information on sensitive and personal issues Reduces social desirability bias Respondent remains anonymous Easy to administer among the illiterate Increases sense of confidentiality among participants Simple to analyze Not individualized face to face interview, but a group approach using a moderator giving instructions

5 Comparison of face-to-face interviews with PBS Among FSWs –The FTFI tends to overestimate the condom use behaviour –The PBS tends to minimize the exaggeration of reported condom use Among the general population –The FTFI tends to underestimate the risky sexual behaviours –The PBS tends to give a relatively higher reporting of risky sexual behaviours

6 Comparison of FTFI and PBS for eliciting sensitive behaviours among unmarried subjects in Mysore GPS Unmarried womenUnmarried men Year – 2005/06 FTFI (n=534) PBS (n=545) FTFI (n=882) PBS (n=484) Ever taken HIV test*0.6%2.5% 4.5% Vaginal (urethral) discharge last year3.4%20.9%0.5%7.9% Genital ulcer last year0.6%7.7%0.3%7.6% Ever seen a condom30.3%47.9%67.5%76.0% Ever had heterosexual sex0.6%2.4%8.3%20.9% Ever been paid / paid for sex0.0%0.6%1.8%6.2% Ever had anal sex with a man0.0%0.6%0.8%6.6% *Among those who have heard of HIV/AIDS

7 Comparison of FTFI and PBS for eliciting sensitive behaviours among married subjects in Mysore GPS Married womenMarried men Year – 2005/06FTFI (n=2036) PBS (n=575) FTFI (n=1201) PBS (n=409) Ever taken HIV test*6.1%14.6%3.1%6.0% Vaginal (urethral) discharge last year3.5%27.5%0.1%10.5% Genital ulcer last year0.8%17.6%0.1%6.1% Pre-/extra-marital sex ever0.8%10.3%18.7%35.9% Ever been paid / paid for sex0.3%3.1%2.3%7.6% Husband (wife) ever had extra-marital sex10.3%29.9%0.5%2.7% Husband ever had sex with FSW1.9%12.4%NA Ever had heterosexual anal sex0.5%4.4%3.0%5.6% Ever had homosexual anal sexNA0.5%5.4% *Among those who have heard of HIV/AIDS

8 Comparison of FTFI and PBS for eliciting sensitive behaviours among unmarried subjects in Belgaum Unmarried womenUnmarried men Year FTFI (n=464) PBS (n=631) FTFI (n=947) PBS (n=750) Ever taken HIV test*3.4%3.0%2.6%8.3% Vaginal (urethral) discharge last year0.7%17.1%1.9%16.5% Genital ulcer last year0.0%5.4%1.2%13.2% Ever seen a condom17.0%19.0%75.7%79.7% Ever had heterosexual sex1.1%2.7%5.6%19.9% Ever been paid / paid for sex0.0%0.2%0.8%8.5% Ever had anal sex with a man0.0%0.5%0.6%4.9% *Among those who have heard of HIV/AIDS

9 Comparison of FTFI and PBS for eliciting sensitive behaviours among married subjects in the Belgaum Married womenMarried men Year FTFI (n=2055) PBS (n=715) FTFI (n=1456) PBS (n=707) Ever taken HIV test*19.5%20.9%8.5%15.9% Vaginal (urethral) discharge last year2.3%19.9%0.6%17.7% Genital ulcer last year0.2%14.5%0.4%11.0% Pre-/extra-marital sex ever0.2%9.1%11.7%35.1% Ever been paid / paid for sex0.2%3.6%2.1%12.9% Husband (wife) ever had extra-marital sex5.9%15.5%0.1%3.7% Husband ever had sex with FSW0.9%7.3%NA Ever had heterosexual anal sex1.4%7.8%1.0%5.4% Ever had homosexual anal sexNA0.2%5.9% *:Among those who have heard of HIV/AIDS

10 PBS methods (1) Members are separated from each other in a polling booth environment Each participant is given 3 boxes (Red, Green and White) and a pack of cards Cards are numbered corresponding to the number of questions asked Cards are stacked in serial order Responses –Card with the number corresponding to the question asked is put into the Green box if the response to the question is YES –Card is put into the Red box if the response is NO –Card is put into the White box if the question is NOT APPLICABLE –Card is kept outside these boxes if the participant does not want to respond to that question

11 PBS Method (2) The moderator explains the PBS method with an example and a practice session Questions are read one by one The moderator needs to –Make the exercise lively –Ask each question clearly, slowly and loudly so that every participant hears the question clearly, repeating the question as required –Use situations/stories while asking the question –Use local terms –Give sufficient pause, and not to hurry

12 PBS Method (3) At the end of administering the questions: –Collect the cards separately: the ones that are in the Green boxes, the ones that are in Red boxes and the ones that are in the White boxes –Count the number of cards in each box for each question and record the tallies in the reporting form Share and discuss the group responses with the participants Document group discussion points

13 Sampling in PBS The subjects for the PBS may be recruited using any of the probability sampling methods

14 Example 1: PBS among FSWs in Avahan/KHPT program in Karnataka 20 polling booth sessions per district, which is fixed Separate PBS sessions in rural and urban areas in 5 districts –Belgaum, Bagalkot, Bijapur, Bellary and Gulbarga Each session will include FSWs identified 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 Samples will be drawn from among the FSWs contacted at least once during the past 6 months Within each city/town, the required number of participants (20 per session) will be selected with the site as stratification variable NGOs/KHPT/KSAPS to mobilize the selected FSWs for PBS

15 Polling booth questions Only the questions that have a definitive YES or NO as answers are suitable to be canvassed in PBS –How often do you use condoms with your regular clients? (Not suitable for PBS)

16 Challenges/Limitations Non-response could be higher as not all selected individuals are able to participate in a group at the designated time and place Can include only the questions that have a YES or NO answers Can ask only a limited number of questions – questionnaire cannot be as long as the one that could be used in a face-to-face interview Can get only the group-aggregated data, and cannot be analyzed with linkages to individual characteristics

17 For more information Dr. B.M. Ramesh, Director, Monitoring and Evaluation Karnataka Health Promotion Trust IT Park, 5th Floor, #1-4 Rajajinagar Industrial Area Rajajinagar, Bangalore – , INDIA Ph:

18 Example 2: PBS among the general population under USAID/KHPT Link Worker program in Karnataka Selection of villages Identification of selected village Identification of segments Selection of segments for specific target groups Selection of respondents

19 Selection of villages 200 villages from 12 districts Villages selected in proportion to the number of villages selected for the program Additional 40 villages from Bagalkot and 20 villages from Belgaum In each selected village, 6 PBS sessions (1 in each demographic group) will be conducted Each PBS session will include at least 10 eligible respondents Districts# of villages Bagalkot34+40 Bangalore Rural15 Belgaum30+20 Bellary10 Bijapur15 Davanagere12 Dharwad11 Gulbarga23 Hassan10 Kolar12 Mysore15 Tumkur13 Total200+60

20 Identification of segments Use the village sketch map prepared during SNA Identify the number of segments in the village Identify the boundaries of each segment using the segment map Village and segment maps are available with the LW in- charge of the village

21 Selection of segments If the number of segments in the village is >6 Calculate a sampling interval for selection The sampling interval, I=Total number of segments/6 Select the one segment in the north most ®. Serially number the segments 1,2,,3 etc in clock- wise direction starting with the one selected ® Add the sampling interval (I) to 1 (R-the first selected segment) and the segment corresponding to the number will be selected

22 Selection of segments If the number of segments in the village is >6 Consider only the integer part of R+I for selection Calculate R+2*I (here R=1) and select the segment number corresponding the integer part (R+2*I) Continue selecting segment corresponding to the numbers R+3*I, R+4*I, R+5*I Serially number the selected segments (i,ii,iii,iv,v,vi) in the order its selection

23 Selection of segments If the number of segments in the village is = 6 Select one segment in the north most and number the segment 1 Serially number the other segments in clockwise direction starting from 2,3,4,5,6 Select all the segments and assign the segments its serial number Serially number the selected segments (i,ii,iii,iv,v,vi) in the order its selection

24 Selection of segments If the number of segments in the village is < 6 Select one segment in the north most and number the segment 1 Serially number the other segments in clockwise direction starting from 2,3… Once we exhaust the total segments, once again follow the same process until we select 6 segments Number the selected segments serially (i,ii,iii,iv,v,vi) in its order of selection

25 Fixing the segment for target groups The selected segments will be serially numbered by order of selection The following table gives the selected segment # and the assigned target group Segment Sel #Target group iUnmarried male (15-24 yrs) iiUnmarried female (15-24 yrs) iiiMarried female (15-29 yrs) ivMarried female (30-49 yrs) vMarried male (15-29 yrs) viMarried male (30-49 yrs)

26 Selection of respondents-1 Select one household (HH) randomly from the selected segment Contact the head of the HH and list out the eligible person of the group identified for the segment If an eligible person is listed, contact the person and confirm the eligibility by screening for age and marital status If eligible, invite him/her for the PBS Escort him/her to the PBS venue

27 Selection of respondents-2 Select the immediate HH in clock-wise direction and screen members for eligibility Continue selection of households in clock-wise direction until we get a minimum of 10 eligible persons consented for PBS Assemble all the selected persons to the PBS venue Conduct the PBS While selecting the HHs, please ensure that we are not crossing the boundary of the segment and selecting HHs from the non-selected segment