The Influence of Social Desirability on Self-Reported Sexual Behavior in HIV Survey in Rural Ethiopia

doi:10.4236/wja.2013.34044

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World Journal of AIDS, 2013, 3, 345-349

Published Online December 2013 (http://www.scirp.org/journal/wja)

http://dx.doi.org/10.4236/wja.2013.34044

Open Access WJA

345

The Influence of Social Desirability on Self-Reported

Sexual Behavior in HIV Survey in Rural Ethiopia

Alexander Vu1,2*, Kiemanh Pham1,2, Nhan Tran2, Saifuddin Ahmed3

1Department of Emergency Medicine, The Johns Hopkins School of Medicine, Baltimore, USA; 2Department of International Health,

The Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; 3Department of Population, Family and Reproductive

Health and Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.

Email: *[email protected]

Received September 4th, 2013; revised October 4th, 2013; accepted October 11th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Objective: It is in order to examine associations between social desirability (SD) and self-reports of abstinence among

youths in rural Ethiopia. Methods: Youths of ag es 15 - 24 (114 participants) were administered qu estionnaire to assess

HIV knowledge and primary abstinence and a modified Marlowe-Crowne Social Desirability Scale to assess SD bias.

The relationships between SD groups (dichotomized into high and low) and abstinence by various characteristics were

assessed by using Fisher’s exact p-values. Results: The odds of individuals reporting abstinence were 13.2 times

greater in the high SD group compared to the low SD group (p-value 0.002) when adjusted for education, gender, age

group, and HIV know ledge. The differences in abstinence b etween the high and low SD score groups were also exam-

ined for selected variables. Conclusions: Individuals who exhibited more SD bias were more likely to report primary

abstinence. SD bias should be considered when conducting self-reported surveys to measure the effectiveness of HIV

prevention progra ms.

Keywords: Social Desirability Bias; Self-Reported Sexual Behaviors; HIV Surveys

1. Introduction

HIV is a significant cause of mortality in sub-Saharan

Africa. In 2010, there were an estimated 22.9 million

infected people, making up 67% of HIV infections

worldwide [1]. In response to the alarming prevalence of

the infection, the President’s Emergency Plan for AIDS

Relief (PEPFAR) was established to combat the spread

of HIV. A significant portion of PEPFAR’s efforts was

committed to prevent the spread of HIV through the

promotion of ABC programs (abstinence, being faithful,

condom use). This effort is associated with decreasing

the burden of HIV in sub-Saharan Africa where many of

PEPFAR’s priority countries are located. In Uganda and

Zimbabwe, there was an increase in abstinence and a

decrease in HIV prevalence [2,3]. Self-reported surveys

to measure the sexual behaviors of the beneficiaries of

abstinence promotion programs are commonly used to

assess the effectiveness of these programs. However,

self-reported surveys are prone to the effect of social

desirability (SD).

SD is the tendency of respondents to reply in a manner

which would be viewed positively by their peers or

which is consistent with social norms and expectations.

SD bias is a particular concern in studies, which meas-

ures HIV knowledge, attitudes, and practices (KAP) be-

cause of the sensitivity of the subject matter [4]. Ques-

tionnaires of sexual behavior have been shown to be

susceptible to misreport and underreporting [5 ]. In Africa

in particular, und erreporting of sexual activities has been

found in reports of sexual behavior in Tanzania and of

HIV KAP in rural Uganda [6,7]. Furthermore, it has been

shown that demographic factors may be associated with

differences in SD. In one study of Malawian teenagers

examining different methods of interviews, males re-

sponded to questions about sexual behavior differently

depending on the interview method while females did not

differ in their response [8]. In another study examining

reports of non-marital partnerships, there was a different

rate in response depending on age [9]. While these stud-

ies show that demographic characteristics may be associ-

ated with different responses, studies have also shown

*Corresponding a uthor.

The Influence of Social Desirability on Self-Reported Sexual Behavior in HIV Survey in Rural Ethiopia

346

that there may be differences in SD among different eth-

nic groups. One study, for example, demonstrated a dif-

ference in measures of SD between Latinos and non-

Latino Caucasians in the United States [10].

To address the issue of misreport in self-reported

questionnaires, the Marlow-Crowne Social Desirability

Scale (MC-SDS) was developed in 1960 to measure the

effect of social desirability [11]. The scale has been vali-

dated in the United States, where it was originally de-

veloped [12-14]. Subsequently, it has been tested in other

high-income countries [15] as well as in low- and mid-

dle-income (LMIC) countries [16]. No such studies have

been conducted in sub-Saharan Africa. We have tested

the MC-SDS and reported on the reliability of the MC-

SDS in four African countries [17].

The objective of this study is to examine the associa-

tion between SD bias and the self-reported levels of pri-

mary abstinence among unmarried youths, age 15 - 24, in

rural Ethiopia. To the best of our knowledge, there is no

literature to date which focused on the relationship be-

tween SD bias and self-reports of sexual abstinence. We

hypothesize that individuals who scored high on MC-S DS

were more likely to over-report primary abstinence.

2. Methods

2.1. Formative Research

During the formative phase of the study, which took

place during July 2008, the team consulted with commu-

nity leaders working in HIV preventio n programs, NGOs,

and other stakeholders in Ethiopia to assess the feasibil-

ity of the study and plan for its implementation; this in-

cluded pilot-testing of the tool, identifying locations for

the study, and defining potential populations for recruit-

ment.

A comprehensive review of the literature was then

undertaken to determine the state of knowledge on sur-

vey research on HIV in Africa and the effect of SD bias

on self-reported surveys. The literature review identified

various scales that had been developed to quantify the

effects of social desirability bias on self-rep orted surveys

including the scale developed by Edwards [18], the Lie

scale from the Eysenck Personality Inventory [19], and

the Marlowe Crowne scale. The MC-SDS was chosen

because it has been more widely cited in the literature

and had been applied in other LMIC settings.

The Marlow Crowne Social Desirability Scale was

translated into Amharic by local translators and then

back-translated to confirm the language was correct.

Under the guidance of researchers from Johns Hopkins,

local research assistants pilot-tested the translated ques-

tionnaire with a convenience sample to assess the study

population’s understanding of the translated MC-SDS.

Additional edits were made through an iterative process

to ensure that the trans lations captured the intended me an -

ing of the statements.

As the questions were initially designed for use in

high-income countries, some statements referenced cul-

tural practices that were not applicable to LMIC. Of the

MC-SDS’s original 33 statements, five were omitted

after the pilot-testing of the translated questionnaire be-

cause they referred to situations that wer e not appropriate

for the rural Ethiopian context. The process of modifying

the scale and the reliability of th e modified MC-SDS was

described in our previously published study [17].

2.2. Sample and Sampling Framework

This study was part of a larger evaluation of the Mobi-

lizing, Equipping, and Training Approach for Primary

Behavior Change in Youth (MET) Program implemented

by Samaritan’s Purse in rural Ethiopia. The goal of the

MET Project was to reduce the incidence of HIV infec-

tion through behavior modification, with an emphasis on

abstinence and fidelity using a grassroots, community

mobilization approach. To take advantage of the infra-

structure in place for assessing the program, data collec-

tion for this study was undertaken alongside the usual

monitoring and evaluation of the MET Project.

Lot quality assurance sampling (LQAS) served as the

sampling framework for this study as well as the evalua-

tion of the MET Project. A stratified, three-stage prob-

ability-sampling framework was used for recruitment.

The catchment area of the study in Ethiopia was divided

into six supervisory areas (SA’s); in each SA, 19 villages

were randomly selected based on a population propor-

tional-to-size method. In each of the 19 villages, a re-

spondent was randomly selected. Using LQAS, a total of

114 individuals were recruited from the entire catchment

area.

After the period of pilot-testing and adjustment of the

modified MC-SDS, data collectors were trained in social

desirability bias, survey methods, and research ethics in

November 2008. The trained data collectors obtained

verbal consent in private settings; discussed how the col-

lected data were strictly protected; addressed any confi-

dentiality concerns of the participants; and administered

in-person the evaluation questionnaires and the modified

MC-SDS to each respondent. The Johns Hopkins School

of Medicine Institutional Review Board reviewed and

approved the study as conforming to the University’s

policies on ethical research.

2.3. Measures

Social desirability was measured using the modified

MC-SDS with 28 items. Each of the items asked the re-

spondent to answer with a “true” or “false”, with a “true”

answer scored as 1 and a “false” answer scored as 0.

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The Influence of Social Desirability on Self-Reported Sexual Behavior in HIV Survey in Rural Ethiopia 347

Thus, the maximum score for the modified MC-SDS was

28, representing the highest degree of social desirability

bias while 0 represented the least. The Cronbach’s α co-

efficient was used to estimate the reliability of the in-

strument for question items that assessed similar con-

structs [20]. We defined the threshold of acceptable in-

ternal consistency or reliability with an α coefficient of

0.70 or greater. The Cronbach’s α coefficient for the

modified MC-SDS for this study was 0.80.

HIV knowledge questions used in the study were in

accordance to the pre-validated questions and indicators

set by the United Nations General Assembly Special

Session on HIV/AIDS. Primary abstinence was defined

as never having had sex. The participants in this study

were men and women between the ages of 15 and 24

who had never been married.

2.4. Statistical Analyses

For the purpose of easy interpretation and ease of use

among field practitioners, we categorized the SD score

into two groups (low and high SD score) and then exam-

ined the relationship between abstinence and SD scores

by selected characteristics (gender, age group, education

level, and HIV knowledge). The determination of SD

score cut-off threshold was based on the midpoint sepa-

ration of the scale. Those who scored below 15 were

placed in the low group while those who scored 15 or

higher were placed in the high SD score group. Those

with no education or only a primary education were

grouped into the low education group while those with at

least a secondary education were in the high education

group. HIV knowledge was defined by correctly answer-

ing five questions about how HIV is transmitted. Those

who correctly answered all five questions were grouped

in the high HIV knowledge group while those who did

not answer one of the five questions correctly were

grouped into the low HIV knowledge group. The Fisher’s

exact p-value was used to assess differences between SD

score groups. Data was collected and entered into an

EpiInfo [21] database. The data were analyzed using

Stata/IC, version 11 [22].

3. Results

The research team recruited a total of 114 participants.

Table 1 shows th e background ch aracteristics of th e par-

ticipants. There was nearly an equal number of men

(48.2%) and women (51.8%). The majority of partici-

pants (80.7%) were between the ages of 15 - 19, and

fewer participants had only a primary education than a

secondary education (43.0% and 47.4%, respectively).

Participants were divided into high and low SD score

groups. The unadjusted odds of participants in the high

SD score group reporting abstinence was 5.21 times

greater than those in the low SD score group (p-value

0.002). This relationship was stronger with further ad-

justment for education, gender, age group, and HIV

knowledge (OR = 13.2; p-value 0.002).

Table 2 shows the relatio nship between SD and absti-

nence by selected characteristics. The high SD score

group had a higher proportion of abstinent respondents

than the low SD group regardless of the characteristic.

Among males, 86.1% of high SD score participants re-

ported abstinence compared to 58.3% of low SD score

participants (p-value 0.049). Females reported a signifi-

cant difference between the two groups with 91.7% of

high SD score individuals reporting abstinence versus

63.6% of low SD score individuals (p-value 0.033).

Almost all (97.3%) of the individuals in the 15 - 19

age group who had a high SD score reported abstinence

while 77.8% of individuals in the low SD score group

were abstinent (p-value 0.013). In the 20 - 24 age group,

Table 1. Background characteristics.

Total n = 114

Sex (%)

Male 55 (48.2)

Female 59 (51.8)

Age (%)

15 - 19 92 (80.7)

20 - 24 22 (19.3)

Education (%)

None 10 (8.8)

Primary 49 (43.0)

Secondary 54 (47.4)

Table 2. Percentage of self-reported abstinence between low

and high SDS score groups by selected variables.

Percentage of abstinence (n)

Low SD

Score < 15

High SD

Score ≥ 15

Fisher’s Exact

p-value

Male Gender 58.3 (7/12) 86.1 (37/43) 0.049

Female Gender 63.6 (7/11) 91.7 (44/48) 0.033

Age 15 - 19 77.8 (14/18) 97.3 (72/74) 0.013

Age 20 - 24 0.0 (0/5) 52.9 (9/17) 0.054

Education-Low 55.6 (5/9) 98.0 (49/50) 0.001

Education-High 64.3 (9/14) 78.1 (32/41) 0.313

HIV Knowledge-Low85.7 (6/7) 93.8 (30/32) 0.457

HIV Knowledge-High50.0 (8/16) 86.4 (51/59) 0.004

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more participants who had a high SD score reported ab-

stinence than in the low SD score group (52.9% and

0.0%, respectively). However, this difference was not

statistically significant (p-value 0.054), most likely due

to the small sample size of the 20 - 24 age group.

An overwhelming majority of those who had low

education and who were in the high SD group reported

abstinence (98.0%) while just over half of those in the

low education and low SD group reported abstinence

(55.6%). This difference was statistically significant (p-

value 0.001). A similar trend was observed in the high

education group (78.1% of the high SD group reported

abstinence compared with 64.3% of the low SD score

group), though this difference was not significant (p-

value 0.313).

Finally, the association between abstinence and SDS

scores was examined in relation to HIV knowledge. In

the low HIV knowledge group, those with high SD

scores were more likely to rep ort ab stinen ce th an tho se in

the low SD score group (93.8% and 85.7%, respectively),

though this difference was not statistically significant

(p-value 0.457). In the high HIV knowledge group,

86.4% of the high SD score participants reported absti-

nence compared with the low SD score group, in which

50.0% of participants reported abstinence. This differ-

ence was statistically significant (p-value 0.004).

4. Discussion

In the present study, we examined the relationship be-

tween social desirability and primary abstinence among

Ethiopian youths who participated in an HIV intervention

study. Our data showed a 13-fold difference in self-re-

ports of primary abstinence between individuals with a

high SD score compared to those with a low SD score.

The findings corroborated our original hypothesis that

individuals who scored high on the MC-SDS were more

likely to be influenced by social norms and to over-report

favorable behaviors. These individuals have a higher

tendency to want to be viewed positively among their

peers, and thus, would be more likely to give responses

regarding sexual behaviors that would conform to socie-

tal expectations.

Several factors were assessed to determine the influ-

ence on the relationship between social desirability and

self-reporting of abstinence. Our data indicated that gen-

der does not affect the relationship between SD and

self-reported abstinence. It is difficult to interpret if age

is a factor that affects SD. Both age groups showed a

trend that individuals in the high SD group were more

likely report abstinence. However, the relationship be-

tween SD and reported abstinence among the older age

group was not statistically significant. This was likely

due to the small sample size of the older sub-group. The

education level of the participant could be a factor that

affects SD. People with higher education showed no sig-

nificant difference in the reporting of abstinence. Those

with low education were more affected by SD, as noted

in the disparity in reports of abstin ence between the high

and low SD score groups. Surprisingly, the high HIV

knowledge group was more affected by SD in reports of

abstinence than the low HIV knowledge group. The high

HIV knowledge group had a statistically significant dif-

ference in reports of abstinence between the two SD

score groups, compar ed to the low HI V knowledg e group.

Perhaps with increased HIV knowledge, there is also

more awareness that certain sexual behaviors that may

increase the risk of contracting HIV are not condoned by

society. People with higher HIV knowledge may there-

fore have greater susceptibility to SD and are more likely

to report abstinence.

Whatever factors mediate the influence of social de-

sirability bias on reports of abstinence, the association

between SD and the self-reporting of sensitive subject

matters has potentially important implications for how

HIV research data in Ethiopia is in terpreted, especially in

research that looks at sexual behavior. From this study, it

appears that SD bias is high in Ethiopia. Thus, any data

collection that uses face-to-face interviews with ques-

tions that contain culturally sensitive subjects is poten-

tially susceptible to SD and misreporting. It is unclear

whether self-administered questionnaires or survey meth-

ods other than face-to-face interviews may reduce SD

bias.

This study had a few notable limitations. While the

tool has been validated, there may still have been prob-

lems with the MC-SDS. The instrument was initially

developed for use in the United States. As such, some

concepts may be tailored towards participants in high-

income countries. Key concepts in the some MC-SDS

statements may also have been lost during the translation.

In addition, participants may have been less comfortable

answering questions truthfully regarding sexual behavior

when they were interviewed face-to-face. The respon-

dents’ concerns of feeling judged by research staff or

lack of confidentiality may come into play. These con-

cerns may accentuate the SD effect. Finally, since the

study was conducted alongside the monitoring and eva-

luation of another program with budget constraints, the

sample size was sub-optimal to further the un derstanding

of how different demographic characteristics or factors

may affect the relationship between social desirability

and self-reports of sexual behaviors.

With these limitations, reproducing these results in

Ethiopia with a larger sample size, powered to detect sta-

tistical differences in the various factors that may affect

SD in sub-group analyses, would be a reasonable next

step in research on SD in Ethiopia in regards to HIV

prevention and sexual behaviors. Conducting a study to

understand the relationship between SD bias and self-

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349

reports of sexual behaviors in other African countries

would also be of value.

5. Conclusion

There is a relationship between high SD scores and

higher reports of primary abstinence. This suggests that

those who are more susceptible to social desirability bias

are more likely to report abstinence. This association has

potentially important implications for HIV programming

at large. Many HIV programs rely on self-reported sur-

veys to evaluate outcomes and impacts. If SD reflects the

possibility that respondents misrepresent socially unde-

sirable behavior, then the validity of self-reported survey

data comes into question, and the effectiveness of HIV

prevention programs may be over-estimated. It is impor-

tant for investigators conducting studies by using self-re-

ports of sensitive information to assess the potential of

social desirability bias to affect the results.

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