How and Where Do We Ask Sensitive Questions: Self-reporting of STI-associated Symptoms Among the Iranian General Population

Document Type : Original Article


1 Epidemiology and Biostatistics Department, Health School; and Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

2 HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

3 Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

4 School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada


Reliable population-based data on sexually transmitted infections (STI) are limited in Iran and selfreporting remains the main source of indirect estimation of STI-associated symptoms in the country. However, where and how the questions are asked could influence the rate of self-reporting. In the present study, we aimed to assess what questionnaire delivery method (ie, face-to-face interview [FTFI], self-administered questionnaire [SAQ], or audio self-administered questionnaire [Audio-SAQ]) and setting (ie, street, household or hair salon) leads to more reliable estimates for the prevalence of self-reported STI-associated symptoms.

This cross-sectional study was conducted in winter 2014 on a gender-balanced (50.0% men) sample of 288 individuals aged 18–59 years old in Kerman, Iran. Respondents were recruited in (a) crowded public places and streets, (b) their households, and (c) hair salons. Data was collected on history of current and 6-month (ie, past 6 months) STI-associated symptoms. Three different methods including FTFI, SAQ and or Audio-SAQ were applied randomly in households and non randomly in streets and hair salons to collect data among the respondents. Generalized estimating equation (GEE) was used to compare the settings and methods separately.

A total of 2.8% of men and 9.4% of women self-reported at least one STI-associated symptom. Respondents were significantly more likely to report STI-associated symptoms when completing questionnaires on the street compared to their household (P = .0001). While women were less likely to report symptoms in FTFI compared to SAQ (P = .036), no significant differences were found between men’s responses across different methods (P = .064).

Further research is needed to evaluate the effect of different combinations of methods and settings to find the optimal way to collect data on STI-associated symptoms.


Main Subjects

  1. Haghdoost AA, Baneshi MR, Eybpoosh S, Khajehkazemi R. Comparison of three interview methods on response pattern to sensitive and non-sensitive questions. Iran Red Crescent Med J. 2013;15(6):500-506. doi:10.5812/ircmj.7673
  2. Tan MT, Tang ML, Tian GL, Yuen KC. Bayesian non-randomized response models for surveys with sensitive questions. Stat Interface. 2009;2(1):13-25. doi:10.4310/SII.2009.v2.n1.a2
  3. Nasirian M, Baneshi MR, Kamali K, Haghdoost AA. Population-based survey on STI-associated symptoms and health-seeking behaviours among Iranian adults. Sex Transm Infect. 2016;92(3):232-239. doi:10.1136/sextrans-2015-052060
  4. Griesler PC, Kandel DB, Schaffran C, Hu MC, Davies M. Adolescents' inconsistency in self-reported smoking: a comparison of reports in school and in household settings. Public Opin Q. 2008;72(2):260-290. doi:10.1093/poq/nfn016
  5. Langhaug LF, Sherr L, Cowan FM. How to improve the validity of sexual behaviour reporting: systematic review of questionnaire delivery modes in developing countries. Trop Med Int Health. 2010;15(3):362-381. doi:10.1111/j.1365-3156.2009.02464.x
  6. Roberts C. Mixing modes of data collection in surveys: A methodological review. London: Centre for Comparative Social Surveys; 2007.
  7. Langhaug LF, Cheung YB, Pascoe S, Hayes R, Cowan FM. Difference in prevalence of common mental disorder as measured using four questionnaire delivery methods among young people in rural Zimbabwe. J Affect Disord. 2009;118(1-3):220-223. doi:10.1016/j.jad.2009.02.003
  8. Phillips AE, Gomez GB, Boily MC, Garnett GP. A systematic review and meta-analysis of quantitative interviewing tools to investigate self-reported HIV and STI associated behaviours in low- and middle-income countries. Int J Epidemiol. 2010;39(6):1541-1555. doi:10.1093/ije/dyq114
  9. Gregson S, Zhuwau T, Ndlovu J, Nyamukapa CA. Methods to reduce social desirability bias in sex surveys in low-development settings: experience in Zimbabwe. Sex Transm Dis. 2002;29(10):568-575.
  10. Langhaug LF. How you ask the question really matters: A randomized comparison of four questionnaire delivery modes to assess validity and reliability of self-reported socially censured data in rural Zimbabwean youth[dissertaion]. London: UCL (University College London); 2009.
  11. Lessler JT, O'Reilly JM. Mode of interview and reporting of sensitive issues: design and implementation of audio computer-assisted self-interviewing. NIDA Res Monogr. 1997;167:366-382.
  12. Kuder GF, Richardson MW. The theory of the estimation of test reliability. Psychometrika. 1937;2(3):151-160. doi:10.1007/bf02288391
  13. Nasirian M, Karamouzian M, Kamali K, et al. Care Seeking Patterns of STIs-Associated Symptoms in Iran: Findings of a Population-Based Survey. Int J Health Policy Manag. 2015;5(1):5-11. doi:10.15171/ijhpm.2015.146
  14. Division UNS. Designing household survey samples: practical guidelines. United Nations Publications; 2008.
  15. Höglinger M, Jann B, Diekmann A. Sensitive questions in online surveys: An experimental evaluation of the randomized response technique and the crosswise model. Survey Research Methods. 2016;10(3):171-187.
  16. Hanley JA, Negassa A, Edwardes MD, Forrester JE. Statistical Analysis of Correlated Data Using Generalized Estimating Equations: An Orientation. Am J Epidemiol. 2003;157(4):364-375. doi:10.1093/aje/kwf215
  17. Naher AF, Krumpal I. Asking sensitive questions: the impact of forgiving wording and question context on social desirability bias. Qual Quant. 2012;46(5):1601-1616. doi:10.1007/s11135-011-9469-2
  18. Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025-2047. doi:10.1007/s11135-011-9640-9
  19. Tourangeau R, Smith TW. Asking sensitive questions: The impact of data collection mode, question format, and question context. Public Opin Q. 1996;60(2):275-304. doi:10.1086/297751
  20. Kataoka Y, Yaju Y, Eto H, Horiuchi S. Self-administered questionnaire versus interview as a screening method for intimate partner violence in the prenatal setting in Japan: A randomised controlled trial. BMC Pregnancy Childbirth. 2010;10(1):84. doi:10.1186/1471-2393-10-84
  21. McNeeley S. Sensitive Issues in Surveys: Reducing Refusals While Increasing Reliability and Quality of Responses to Sensitive Survey Items. In: Gideon L, ed. Handbook of Survey Methodology for the Social Sciences. New York, NY: Springer; 2012:377-396.
  22. Boekeloo BO, Schiavo L, Rabin DL, Conlon RT, Jordan CS, Mundt DJ. Self-reports of HIV risk factors by patients at a sexually transmitted disease clinic: audio vs written questionnaires. Am J Public Health. 1994;84(5):754-760. doi:10.2105/ajph.84.5.754
  23. Langhaug LF, Cheung YB, Pascoe SJ, et al. How you ask really matters: randomised comparison of four sexual behaviour questionnaire delivery modes in Zimbabwean youth. Sex Transm Infect. 2011;87(2):165-173. doi:10.1136/sti.2009.037374
  24. Willis GB. Cognitive interviewing: A “how to” guide. Research Triangle Park, NC: Research Triangle Institute; 1999.
  25. Brenner M. Development of a factorial survey to explore restricting a child's movement for a clinical procedure. Nurse Res. 2013;21(2):40-48. doi:10.7748/nr2013.
  26. Aviram H. What Would You Do? Conducting Web-Based Factorial Vignette Surveys. In: Gideon L, ed. Handbook of Survey Methodology for the Social Sciences. New York, NY: Springer; 2012:463-473.
  27. Liebig S, Sauer C, Friedhoff S. Using Factorial Surveys to Study Justice Perceptions: Five Methodological Problems of Attitudinal Justice Research. Soc Justice Res. 2015;28(4):415-434. doi:10.1007/s11211-015-0256-4
  • Receive Date: 31 December 2016
  • Revise Date: 19 February 2018
  • Accept Date: 21 February 2018
  • First Publish Date: 01 August 2018