There has been a growing number of sexual health and blood-borne virus (SHBBV) surveys specifically administered to migrant populations. The purpose of this scoping review is to collate available information about how SHBBV surveys have been administered in migrant populations and the effect that mode of administration has on data quality, reliability and other practical considerations, e.g. response rates (RR) and social desirability bias. A methodological framework for scoping reviews was applied. SHBBV survey studies administered to international migrants published since 2000 were included if they contained some description of mode of administration. Ninety one studies were identified for inclusion from Embase, Medline, Web of Science, Google Scholar and supplementary grey literature. ‘Interview only’ was the most common mode of administration (n = 48), predominately comprising face-to-face interviews. Thirty six studies reported data from ‘self-completed’ surveys only, with pen-and-paper being most common (n = 17). Few studies (n = 7) combined interview and self-completed methods of survey administration. Sixty one studies did not report (or only partially reported) RR or the data necessary to calculate RR. Of the studies that reported RR, most were missing other key information including method of recruitment, consent procedures and whether incentives were offered. Strengths and limitations of all administration modes are summarised. Guidelines to inform future SHBBV survey research in migrant populations are presented.
Citation: Vujcich D, Wangda S, Roberts M, Lobo R, Maycock B, Kulappu Thanthirige C, et al. (2020) Modes of administering sexual health and blood-borne virus surveys in migrant populations: A scoping review. PLoS ONE 15(8): e0236821. https://doi.org/10.1371/journal.pone.0236821
Editor: Chaisiri Angkurawaranon, Chiang Mai University Faculty of Medicine, THAILAND
Received: February 18, 2020; Accepted: July 14, 2020; Published: August 3, 2020
Copyright: © 2020 Vujcich et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: AR, BM, RL, DV and MR received funding from the Australia Research Council: https://www.arc.gov.au/. Additional project funding was provided by the Department of Health Western Australia (https://ww2.health.wa.gov.au/), the Department of Health South Australia (https://www.sahealth.sa.gov.au/), the Department of Health and Human Services Victoria (https://www.sahealth.sa.gov.au/) and SHine SA (https://www.shinesa.org.au/) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Migrants are a priority group for the prevention and control of HIV/AIDS . Between 2007 and 2012, 42% of HIV diagnoses in Western Europe were in migrant populations . Elsewhere such as in United States of America and Australia, migrants accounted for 19% and 38% of HIV diagnoses respectively [3, 4]. Existing research suggests that migrants may encounter legal, social, economic and cultural barriers to healthcare access in relation to HIV and other sexually transmissible infections and blood-borne viruses [5–7].
In spite of the priority for this population, migrants are often under-represented in research, including in the context of general population sexual health and blood-borne virus (SHBBV) surveys [8–10]. High quality data are needed to monitor whether strategic objectives relating to this population group are being met or need to be adjusted in response to changing circumstances. As such, there has been a growing number of SHBBV surveys specifically developed for migrant populations, including the African Health and Sex Survey in England, the Advancing Migrant Access to Health Services in Europe (aMASE) study and the HIV community survey in people from culturally and linguistically diverse backgrounds in New South Wales, Australia [11–13]. Additionally, the World Health Organisation is in the process of developing a standard instrument for measuring sexual health knowledge, practices and outcomes worldwide, and has sought submissions on implementation factors including survey administration channels [14, 15].
While there are a range of factors which can affect the quality of survey data (e.g. validity of survey constructs, sampling and recruitment methods), the focus of this article is the mode of survey administration. As a recent literature review shows, the manner of survey administration can greatly affect the quality of the data collected by influencing response rates, completion rates, respondent cognition and social desirability bias . However, this review did not seek to determine whether certain modes of administration were more appropriate for specific topic areas, especially those of a sensitive nature. For instance, an Italian study on sexual behaviour in the general population compared results obtained via computer assisted telephone interviews (CATI) with self-answered questionnaires following interviews (SAQ-FI) and found that the SAQ-FI sample reported higher levels of early intercourse and same-sex attraction and had lower item non-response rates than the CATI sample .
How these differing modes of survey administration affect data quality can be even more complicated with respect to research in migrant populations. In culturally and linguistically diverse settings, self-administered questionnaires (SAQ) (which tend to be written) may be problematic because “languages spoken may not have a standard written form, or respondent literacy rates may be vastly different” . Likely reflective of such concerns, a recent review of 550 empirical surveys of asylum seekers and minority groups found that over half (n = 293) were administered through face-to-face interviews, compared to 11% (n = 55) SAQ .
When collecting sensitive data from potentially vulnerable populations, researchers have an ethical imperative to ensure that any foreseeable harms are proportionate to the benefits that can flow from valid and reliable research outputs. However, there is still no strong/empirical guidance to determine appropriate modes of SHBBV survey administration among migrant populations. Therefore, we aimed to perform a scoping review of SHBBV surveys administered to international migrant populations in receiver countries to understand the effect that mode of administration has on key indicators of data quality and reliability, including response rates and social desirability bias. Practical and logistical considerations associated with the different modes of administration were also considered. The PRISMA extension for scoping reviews has been followed in the reporting of this study .
Materials and methods
An unregistered protocol was developed and is available on request from the corresponding author. The methodological framework for scoping reviews developed by Arksey and O’Malley  (set out in Table 1) was applied. The broad research objective was to determine what modes of survey administration have been used to conduct SHBBV surveys in migrant populations and to ascertain the strengths and limitations associated with each mode. The following sub-questions were set to meet the stated objective:
- With what frequency have different modes of administration been used to administer SHBBV surveys to migrants?
- Is the mode of survey administration statistically associated with response rates, controlling for factors such as provision of recruitment incentives/gratuities and survey length?
- What are the reported strengths and limitations of the different modes of survey administration, in terms of social desirability bias, project resources and other factors?
The review focussed on English-language papers published or released after 2000 (in light of the technological developments in survey administration). In order to be included, papers needed to contain: (a) primary analyses of data from SHBBV surveys administered to international migrants (i.e. people living in a country other than their birth country); and (b) some description of the mode of survey administration. General population surveys were excluded unless migrant and non-migrant responses were explicitly compared in the paper. Other exclusion criteria are set out in Table 2.
Searches were run in March and April 2019. The search strategy combined terms relating to three concepts–surveys, migrants and modes of survey administration. The terms were entered into the databases Embase, Medline and Web of Science (Core Collection) using database-specific subject headings and search syntax as set out in the Supplementary table (S1 Table). Supplementary searches were conducted in Google, Google Scholar, and ProQuest Theses and Dissertations with a view to locating grey literature and unindexed publications. These supplementary searches were more focussed given the search limitations of those platforms (Survey AND (Migrant OR Refugee OR Displaced OR Emigrant OR Immigrant OR "Foreign born" OR "Culturally and Linguistically diverse") AND (STI OR STD OR BBV OR Sexual OR HIV OR "Hepatitis B" OR "Hepatitis C")). Only the first 20 pages of results in Google and Google Scholar were reviewed, consistent with accepted practice .
Results were imported into Endnote and de-duplicated using the process developed by Bramer, Giustini et al.  for this purpose (e.g. tailored use of field settings and filters). One researcher screened the title and abstract of each identified study against the inclusion and exclusion criteria set out in Table 2 and categorised each study as ‘Potential Include’ or ‘Exclude’. The full text of all studies marked ‘Potential Include’ were then independently screened by two researchers and either marked for inclusion or exclusion with reasons. If the researchers reached different decisions, each researcher explained their rationale and, if consensus could not be reached, a third member of the research team assessed the item against the inclusion and exclusion criteria.
A charting form was developed in Excel by the second-named author and tested on the included studies identified through searches in Medline, Embase and Web of Science (see S2 Table). The form was revised for charting data in the remaining studies (i.e. those identified through Google, Google Scholar and ProQuest). The revisions involved reducing the number of charting categories and introducing fixed drop-down options into the Excel table (see S3 Table). Data were extracted by one researcher and cross-checked by a second researcher. Differences in coding decisions were resolved in the same manner as for screening (described above). The extracted data included information about the studies, including study setting, recruitment methods, sample size and characteristics, response rates, mode of survey administration, and reported information about the strengths and weaknesses of survey administration methods.
Following data extraction, it became apparent that different response rate calculation methods were being used in the included studies. As such, a decision was made to collect more detailed information relevant to response rate reporting. To that end, any studies in which a response rate was reported (or capable of being calculated) were reviewed and data extracted directly into Table 4 below, with a second researcher cross-checking for accuracy. Information on instrument validation was also collected post facto in response to a suggestion from one reviewer.
Ninety one studies were identified for inclusion following the search-and-screen process represented in Fig 1.
Key characteristics of the studies are set out in Table 3. The majority of studies (n = 51) were conducted in North America, followed by Europe/Eurasia (n = 22), Australia (n = 8), Asia (n = 6), Africa (n = 2) and Latin America and the Caribbean (LAC) (n = 2). Globally, the majority of SHBBV surveys were administered to migrants born in Asia (n = 40), LAC (n = 31) or Africa (n = 28). Only four included studies reported data from SHBBV surveys administered to migrants from Middle Eastern countries. Sample sizes ranged from six migrant participants  to 11,484 participants .
In 44 studies, existing SHBBV instruments were adapted or used. These instruments included the Brief HIV Screener , the Perceived Susceptibility to HIV Scale , the AIDS Health Belief Scale , the National Survey of Australian Secondary Students and Sexual Health , the Survey of Latino Adults [120, 121], the African Health and Sex Survey , the Bass Line Survey , UN Behavioral Surveillance Surveys  and the National Health Interview Survey Supplement on AIDS Knowledge and Attitudes . For the remaining studies, either the origin of the survey items was not reported (n = 23) or new survey instruments were developed (n = 24). Of the studies in which new survey instruments were developed, half (n = 12) did not explicitly report whether the instrument had been pretested or piloted.
As shown in Fig 2, ‘interview only’ was the most common mode of survey administration (n = 48), with face-to-face (n = 37) being the most common interview technique. Of the thirty six studies reporting data from ‘self-completed’ surveys only, pen-and-paper was the most common method of self-completion (n = 17). Few studies (n = 7) combined interview and self-completed methods of survey administration.
Fig 3 shows that some modes of SHBBV survey administration have been implemented more in some populations, compared to others. For instance, face-to-face only interviews were more commonly administered to LAC (n = 16) and Asian (n = 13) migrants; by contrast, pen-and-paper only surveys were used less frequently in LAC communities (n = 4). The small number of ‘online only’ and ‘device only’ surveys were relatively evenly distributed across LAC, Asian, African and European migrant populations.
Given the level of reporting in the included studies, it was not possible to determine whether certain modes of administration were associated with higher response rates, controlling for other factors. Sixty one studies (67%) either: (a) did not report response rates or the data necessary to calculate response rates; or (b) partially reported them (e.g. did not specifically report for overseas-born sample members or did not report response rates for all modes of administration).
Of the 30 studies where response rates were reported or able to be calculated (Table 4), the most common mode of administration was face-to-face interview only (n = 12), followed by pen-and-paper only (n = 6). By contrast, online administration was only used in four studies and was used in combination with other modes in three of those cases. Several studies noted the difficulties associated with determining the denominator required to calculate response rates when administering surveys online (e.g. Elford, Doerner et al. , Fakoya, Alvarez-Del Arco et al. , Gray, Crawford et al. ). Additionally, Ramanathan and Sitharthan  noted that noneligible persons could participate in online surveys and that the same respondent could complete the survey multiple times unless identifying data (e.g. IP addresses) were collected and stored.
The majority of the 30 studies reported response rates exceeding 50 percent, although the methods for calculating response rates varied. Generally, response rates were calculated by dividing the number of complete (and, in some cases, partial) eligible surveys by the sum of the number of ineligible cases, refusals, unsuccessful contact attempts and all cases of unknown eligibility. However, in other studies, attempts were made to estimate the number of cases of unknown eligibility which were ineligible and those cases were excluded from the denominator. For instance, Taylor, Choe et al.  reported “the overall estimated response rate was 80% among men and 82% among women (assuming the same proportions of eligible men and women among those who could and could not be contacted)”.
Additionally, there was a general lack of reporting on data relevant to assessing the quality of the response rates. For instance, 14 studies (47%) did not report whether incentives to participation were offered, 14 studies (47%) did not report on the method for obtaining informed consent, and 27 studies (90%) did not provide data to enable the characteristics of participants to be compared to non-responders.
The strengths and limitations of the various methods were discussed in the examined literature. Face-to-face interviews were considered useful when surveying populations with low levels of literacy [52, 89]. However, this method of administration was often human resource intensive and associated with logistical issues, including the need to find accessible and sufficiently private interview sites at mutually convenient times for multiple researchers and participants [64, 78, 79, 106].
While one study considered face-to-face interaction to be an important element of building trust , several noted the potentially increased risk of social desirability bias when disclosing sensitive information in-person [32, 35, 44, 51, 52, 83, 89, 110], and it was noted that consideration should be given to the characteristics of the interviewer. For instance, in a study of the health knowledge, attitudes and behaviours of U.S. Latino men who have sex with men, Arevalo  warned that “[s]ocial desirability may have been magnified by the interviewer, given that he was relatively more verbal, educated and overall healthier than the average participant.” A study of the sexual behaviour of male Mexican migrants to the United States observed that extramarital sex may have been underreported to female interviewers who lived in the respondents’ community or were casually known to the respondents’ wives .
Although telephone interviews have the potential to increase respondents’ sense of ‘anonymity’, the risk of social desirability bias may still remain because telephone respondents might be unable to answer questions in a private location away from other household residents . The included studies also report that telephone interviews may result in selection bias [40, 63, 77, 100, 113]. For instance, Miller, Guarnaccia et al.  observed that recent Latino migrants to New Jersey were less likely to have residential telephones or may have “rapid turnover of telephone numbers” due to high residential mobility.
The risk of selection bias was also reported in the studies which utilised online surveys [29, 49, 92, 97]. Online surveys have the potential to exclude respondents who lack internet access or technological proficiency, or who are wary of disclosing sensitive information online. Selvey, Lobo, et al.  found that only a minority of Asian sex workers in Australia completed online versions of a survey, with most preferring pen-and-paper (although the difference may have been attributable to the recruitment methods associated with each). A study of HIV testing among African migrants living in the UK found that none of the 169 respondents completed an online follow-up survey, although 60 subsequently agreed to participate in a telephone interview; this led the authors to conclude that online data collection “was not feasible in this population group” . However, online recruitment and administration was considered advantageous in studies of migrant men who have sex with men (MSM) in Britain [46, 47]. According to Elford, McKeown, et al. , “[u]sing an online survey we were able to survey MSM across Britain from a diverse range of backgrounds.”
One study recommended the use of computer-assisted self-interviews (CASI) in future research as a means of “address[ing] the need for privacy and the low literacy levels” in some migrant populations . Empirical data on the strengths and limitations of this mode of survey administration were not presented in any of the included studies.
The primary objective of this scoping review was to determine best practices from the published literature to ensure that future SHBBV surveys are conducted both effectively and efficiently in migrant populations. However, the widespread lack of reporting on key survey characteristics made it difficult to appraise which mode of survey administration is likely to collect the most reliable data to inform future migrant SHBBV service provision and planning. Researchers are thus limited in their ability to avoid past missteps and replicate successes in study design, creating the risk of both resources and participants’ time being wasted.
Only a minority of studies in this scoping review reported response rates and, of those, few provided a comprehensive description of other key survey characteristics. The findings are consistent with a recent review of empirical surveys of asylum-related migrants and minority groups which found that “information on methodological aspects, such as response/cooperation/participation rate, sampling frames, sampling strategies … are often missing or are not specified and discussed” . These findings emphasise the need for greater adherence to (or awareness of) reporting standards . For instance, the STROBE checklist for observational studies requires details about setting (e.g. recruitment sites and sources), eligibility criteria, method of recruitment, and numbers of individuals at each stage of the study, and reasons for non-participation at each stage . Survey-specific checklists also recommend reporting additional details including description of the survey instrument and its development, pretesting processes, instrument reliability and validity, sample representativeness, mode of administration, number of attempts made to contact subjects, whether incentives were offered, methods for analysis of nonresponse error and descriptions of consent procedures (see data extraction tool published by Bennett, Khangura, et al. ).
There are also ethical implications associated with the lack of transparency. The principles of beneficence and non-maleficence require researchers “to seek the greatest benefit for research participants while minimizing harm” . When examining a sensitive subject matter (e.g. sexual knowledge and behaviours) with potentially vulnerable participants (e.g. migrants), researchers must feel confident that any potential discomfort to participants is outweighed by the expected benefits which, at the very least, should take the form of valid and reliable findings. In order to weigh the potential harms against the potential benefits, researchers need to understand how SHBBV information has been collected from migrant populations in the past, and whether those methods produced valid and reliable data (and, if not, why not). This ethical arithmetic is not easily performed based on the information reported in the studies included in this review.
The information that we have about the use of online SHBBV surveys in migrant populations offers a case in point. There has been an increase in the use of online surveys for SHBBV research in migrant populations since 2010, as is evident in Table 3; this reflects increased general access to the internet and the development of a number of affordable and accessible survey software development tools [129, 130]. However, the included studies in this scoping review broach some important considerations about the appropriateness of online SHBBV surveys in migrant settings. For instance, Selvey, Lobo et al.  and Evans, Suggs et al.  had limited success in using online surveys to obtain data from Asian Australian sex workers and African migrants living in the UK respectively. By contrast, Elford et al. [46, 47] considered SHBBV online surveys a useful tool. Based on the available information, future researchers are faced with a dilemma as to whether they can reasonably expect valid and reliable SHBBV data from online surveys in migrant populations. More data are needed to provide guidance to researchers considering the use of this mode of survey administration. As Poynton, DeFouw, et al.  note, online survey methods “will continue to be poorly understood until researchers plan for and more thoroughly report information related to response rates.” Their specific recommendations for the conduct and reporting of online survey research should be heeded (e.g. create separate links to the survey for each mode of invitation or dissemination; document undeliverable emails; keep records of the number of people on electronic mailing lists and in online discussion boards) .
Despite the dearth of data reported in the included studies, the following principles are suggested to guide the administration of SHBBV surveys in migrant contexts:
- SHBBV survey researchers should begin the survey design process with a clear profile of their sample population. The profile can either be created by drawing upon existing data or in consultation with informed community stakeholders. Where possible, the profile should include information about: (a) languages spoken; (b) written literacy; (c) access to relevant technology (e.g. internet, phones) and technological proficiency; (d) social customs governing researcher/participant interactions (e.g. gender/class considerations); and (e) perceived attitudes to the subject areas that are the focus of the survey.
- The sample profile should inform the choice of survey administration mode, based on mode-specific considerations which include those set out in Table 5.
- Where possible, consideration should be given to mixed-modes of survey data collection to overcome the limitations associated with using each mode in isolation . However, mixed-mode survey administration is not, in itself, a magic bullet and care still needs to be taken to avoid measurement (and other) errors that may affect the validity and reliability of the findings [132, 133].
- In the absence of clear guidance on best practice in the administration of SHBV surveys in specific migrant populations, pre-testing and pilot testing are essential. Pre-testing will enable “the capabilities of the selected mode[s] of data collection” to be evaluated, while pilot testing can be used to estimate response rates and ascertain whether a proposed mode of administration is appropriate for meeting research objectives . Where issues are identified through pre-testing and piloting, appropriate revisions should be made in line with relevant guidelines (e.g. the Guidelines for Best Practice in Cross-Cultural Surveys ).
The main limitation of this scoping review is that it relied solely on information reported in the included studies. It is possible that a larger number of studies and data may have been included if authors had been approached to provide more information about the way in which their surveys were administered. Better reporting in the form of adherence to checklists such as STROBE  for observational studies and survey-specific guidelines (see Bennett, Khangura et al. ) will assist future researchers to undertake more comprehensive reviews into this subject area and facilitate their ability to produce rigorous meta-syntheses. Future reviews of survey research in migrant populations would also benefit from using appropriate tools to critically appraise the quality of included studies (e.g. checklists developed by the Joanna Briggs Institute or the Critical Appraisal Skills Program) [137, 138].
As Méndez and Font  note, “[t]he demand for more data about immigrants and ethnic minorities from national and supra-national bodies makes us confident that the number of surveys addressed to these populations will increase in the future.” The challenge for researchers is to ensure that future SHBBV surveys are designed with reference to, and with a view to building on, the evidence base about which mode of survey administration is best suited to collecting valid and reliable evidence about migrants’ knowledge, behaviours and practices. Additionally, other factors influencing quality should also be examined, including sampling methods, survey translation and instrument validation. Research in this area is particularly salient, given the World Health Organizations current project to develop a “standard, globally-recognized instrument to measure sexual practices, behaviours and sexual health related outcomes”  which would facilitate comparisons across populations.
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.
S1 Table. Search strategy for scoping review, by concept and database.
S2 Table. Architecture for excel data charting table.
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