Conducting Internet-based HIV/STD prevention survey research: considerations in design and evaluation

Combating Fraudulent Participation in Urban American Indian and Alaska Native Virtual Health Research: Protocol for Increasing Data Integrity in Online Research (PRIOR)

BACKGROUND

While the advantages of using the internet and social media for research recruitment are well documented, the evolving online environment also enhances motivations for misrepresentation to receive incentives or to "troll" research studies. Such fraudulent assaults can compromise data integrity, with substantial losses in project time; money; and especially for vulnerable populations, research trust. With the rapid advent of new technology and ever-evolving social media platforms, it has become easier for misrepresentation to occur within online data collection. This perpetuation can occur by bots or individuals with malintent, but careful planning can help aid in filtering out fraudulent data.

OBJECTIVE

Using an example with urban American Indian and Alaska Native young women, this paper aims to describe PRIOR (Protocol for Increasing Data Integrity in Online Research), which is a 2-step integration protocol for combating fraudulent participation in online survey research.

METHODS

From February 2019 to August 2020, we recruited participants for formative research preparatory to an online randomized control trial of a preconceptual health program. First, we described our initial protocol for preventing fraudulent participation, which proved to be unsuccessful. Then, we described modifications we made in May 2020 to improve the protocol performance and the creation of PRIOR. Changes included transferring data collection platforms, collecting embedded geospatial variables, enabling timing features within the screening survey, creating URL links for each method or platform of data collection, and manually confirming potentially eligible participants' identifying information.

RESULTS

Before the implementation of PRIOR, the project experienced substantial fraudulent attempts at study enrollment, with less than 1% (n=6) of 1300 screened participants being identified as truly eligible. With the modified protocol, of the 461 individuals who completed a screening survey, 381 did not meet the eligibility criteria assessed on the survey. Of the 80 that did, 25 (31%) were identified as ineligible via PRIOR. A total of 55 (69%) were identified as eligible and verified in the protocol and were enrolled in the formative study.

CONCLUSIONS

Fraudulent surveys compromise study integrity, validity of the data, and trust among participant populations. They also deplete scarce research resources including respondent compensation and personnel time. Our approach of PRIOR to prevent online misrepresentation in data was successful. This paper reviews key elements regarding fraudulent data participation in online research and demonstrates why enhanced protocols to prevent fraudulent data collection are crucial for building trust with vulnerable populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04376346; https://www.clinicaltrials.gov/study/NCT04376346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52281.

Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approach

BACKGROUND

Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people.

METHODS

This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms.

RESULTS

Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities.

CONCLUSIONS

The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.

The effects of tryptophan loading on Attention Deficit Hyperactivity in adults: A remote double blind randomised controlled trial

BACKGROUND

Despite the impact and prevalence of Attention Deficit Hyperactivity Disorder (ADHD), current treatment options remain limited and there is a drive for alternative approaches, including those building on evidence of a role for tryptophan (TRP) and serotonin (5-HT). This study aimed to evaluate the effect of acute TRP loading on attention and impulsivity in adults with ADHD.

TRIAL DESIGN AND METHODS

We conducted a remote double blind randomised controlled trial (RCT) using TRP loading to examine the effects of a balanced amino acid load in comparison to low and high TRP loading in individuals with ADHD (medicated, N = 48, and unmedicated, N = 46) and controls (N = 50). Participants were randomised into one of three TRP treatment groups using stratified randomisation considering participant group and gender using a 1:1:1 ratio. Baseline testing of attention and impulsivity using the Test of Variables of Attention Task, Delay Discounting Task, and Iowa Gambling Task was followed by consumption of a protein drink (BAL, LOW, or HIGH TRP) before repeated testing.

RESULTS AND CONCLUSIONS

No effects of TRP were observed for any of the measures. In the present study, TRP loading did not impact on any measure of attention or impulsivity in those with ADHD or Controls. The findings need to be confirmed in another trial with a larger number of patients that also considers additional measures of dietary protein, plasma TRP and aggression. (Registration ID ISRCTN15119603).

Sexual and Gender Minority Invisibility in Cancer Studies: A Call for Effective Recruitment Methods to Address Cancer Disparities

#LGBTQ+ people with cancer are invisibilized: A call for #intersectional cancer research (link here) #healthequity

A Peer-Led Online Community to Increase HIV Self-Testing Among African American and Latinx MSM: A Randomized Controlled Trial

OBJECTIVE

We sought to assess the effectiveness of using a peer-led online community to increase HIV self-testing among Latinx and African American men who have sex with men (MSM).

DESIGN

Randomized controlled trial.

METHODS

Throughout 6 waves, between February 18, 2017, and January 8, 2021, 900 HIV negative and/or serostatus unknown Los Angeles-based MSM (68.9% Latinx, 16.0% African American, and 7.4% White) participated in an online 12-week HIV prevention randomized controlled trial. A total of 79 trained role models (peer leaders) were randomly assigned to participants within clusters to build trust and deliver HIV testing information on Facebook groups. Participants in control groups were assigned to groups without peer leaders. Participants were not required to respond to peer leaders or to remain group members. Participants completed self-report assessments at baseline and 12-week follow-up and could receive a free HIV self-testing kit during the study period.

RESULTS

Compared with control group participants, intervention group participants were significantly more likely to accept the offer for the HIV self-testing kit (intervention 130 of 450, 29%; control 102 of 450, 22.7%; odds ratio = 1.43, 95% confidence interval: 1.04 to 1.95, P = 0.03), report having taken an HIV self-test within the past 3 months (odds ratio = 1.47, 95% confidence interval: 1.01 to 2.13, P = 0.04), and report drinking fewer glasses of alcohol in an average week (P = 0.01). Effects seemed concentrated within later study waves. Study retention was greater than 93%.

CONCLUSIONS

A peer-led online community seems to be an effective method of increasing HIV self-testing among MSM of color. We discuss the implications of the wave effects on public health research and policy.

Expanding syphilis test uptake using rapid dual self-testing for syphilis and HIV among men who have sex with men in China: A multiarm randomized controlled trial

BACKGROUND

Low syphilis testing uptake is a major public health issue among men who have sex with men (MSM) in many low- and middle-income countries. Syphilis self-testing (SST) may complement and extend facility-based testing. We aimed to evaluate the effectiveness and costs of providing SST on increasing syphilis testing uptake among MSM in China.

METHODS AND FINDINGS

An open-label, parallel 3-arm randomized controlled trial (RCT) was conducted between January 7, 2020 and July 17, 2020. Men who were at least 18 years of age, had condomless anal sex with men in the past year, reported not testing for syphilis in the last 6 months, and had a stable residence with mailing addresses were recruited from 124 cities in 26 Chinese provinces. Using block randomization with blocks of size 12, enrolled participants were randomly assigned (1:1:1) into 3 arms: standard of care arm, standard SST arm, and lottery incentivized SST arm (1 in 10 chance to win US$15 if they had a syphilis test). The primary outcome was the proportion of participants who tested for syphilis during the trial period and confirmed with photo verification and between arm comparisons were estimated with risk differences (RDs). Analyses were performed on a modified intention-to-treat basis: Participants were included in the complete case analysis if they had initiated at least 1 follow-up survey. The Syphilis/HIV Duo rapid test kit was used. A total of 451 men were enrolled. In total, 136 (90·7%, 136/150) in the standard of care arm, 142 (94·0%, 142/151) in the standard of SST arm, and 137 (91·3%, 137/150) in the lottery incentivized SST arm were included in the final analysis. The proportion of men who had at least 1 syphilis test during the trial period was 63.4% (95% confidence interval [CI]: 55.5% to 71.3%, p = 0.001) in the standard SST arm, 65.7% (95% CI: 57.7% to 73.6%, p = 0.0002) in the lottery incentivized SST arm, and 14.7% (95% CI: 8.8% to 20.7%, p < 0.001) in the standard of care arm. The estimated RD between the standard SST and standard of care arm was 48.7% (95% CI: 37.8% to 58.4%, p < 0.001). The majority (78.5%, 95% CI: 72.7% to 84.4%, p < 0.001) of syphilis self-testers reported never testing for syphilis. The cost per person tested was US$26.55 for standard SST, US$28.09 for the lottery incentivized SST, and US$66.19 for the standard of care. No study-related adverse events were reported during the study duration. Limitation was that the impact of the Coronavirus Disease 2019 (COVID-19) restrictions may have accentuated demand for decentralized testing.

CONCLUSIONS

Compared to standard of care, providing SST significantly increased the proportion of MSM testing for syphilis in China and was cheaper (per person tested).

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1900022409.

AIM against survey fraud

Objectives

Although there exists a variety of anonymous survey software, this study aimed to develop an improved system that incentivizes responses and proactively detects fraud attempts while maintaining anonymity.

Materials and Methods

The Anonymous Incentive Method (AIM) was designed to utilize a Secure Hash Algorithm, which deterministically assigned anonymous identifiers to respondents. An anonymous raffle system was established to randomly select participants for a reward. Since the system provided participants with their unique identifiers and passwords upon survey completion, participants were able to return to the survey website, input their passwords, and receive their rewards at a later date. As a case study, the validity of this novel approach was assessed in an ongoing study on vaping in high school friendship networks.

Results

AIM successfully assigned irreversible, deterministic identifiers to survey respondents. Additionally, the particular case study used to assess the efficacy of AIM verified the deterministic aspect of the identifiers.

Discussion

Potential limitations, such as scammers changing the entry used to create the identifier, are acknowledged and given practical mitigation protocols. Although AIM exhibits particular usefulness for network studies, it is compatible with a wide range of applications to help preempt survey fraud and expedite study approval.

Conclusion

The improvements introduced by AIM are 2-fold: (1) duplicate responses can be filtered out while maintaining anonymity and (2) the requirement for the participant to keep their identifier and password for some time before returning to the survey website to claim a reward ensures that rewards only go to actual respondents.

Incentivizing a target population to complete a survey can be at odds with maintaining privacy. Anonymous survey software typically either collects some form of personal information (eg, emails) to send rewards to participants or upholds respondents’ privacy by providing rewards without requiring personally identifiable information but risks being exploited by scammers. To address this gap, the Anonymous Incentive Method (AIM) was designed to only reimburse actual participants and allow for the detection of scammers without storing personal information of any kind. AIM can be adapted for a wide variety of commercial and research surveys. Despite not completely eradicating survey fraud, AIM can be bolstered by additional safeguards depending on the specific survey. AIM can not only increase the response rate by ensuring anonymity and making potential respondents more comfortable but also help qualify studies as exempt from full review to expedite approval by an Institutional Review Board.

Exploring the Frequency, Intensity, and Duration of Loneliness: A Latent Class Analysis of Data from the BBC Loneliness Experiment

Almost all measures of loneliness have been developed without discussing how to best conceptualize and assess the severity of loneliness. In the current study, we adapted the four-item UCLA, so that it continued to measure frequency of loneliness, but also assessed intensity and duration, providing a measure of other aspects of loneliness severity. Using data from participants resident in the UK who completed the BBC Loneliness Experiment (N = 36,767; F = 69.6%) and Latent Class Profile Analyses, we identified four groups of people who scored high on loneliness on at least one of the three severity measures. Duration of loneliness often over months or years seemed to be particularly important in distinguishing groups. Further, group membership was predicted by important demographic and psychological variables. We discuss the findings in terms of implications for research and practice. We highlight the need to explore these profiles longitudinally to investigate how membership predicts later mental and physical health, and well-being.

Suspicious and fraudulent online survey participation: Introducing the REAL framework

Online survey research has significantly increased in popularity in recent years. With its use, researchers have a new set of concerns about data collection and analysis to consider, including the possibility of fraudulent survey submissions. The purpose of this article is to demonstrate to survey researchers an innovative and systematized process for addressing online survey fraud over the course of collecting survey data, especially when respondents collect incentives for participation. We provide the Reflect, Expect, Analyze, Label Framework, which includes four sets of guiding questions for use by online survey researchers to plan for addressing survey fraud and making determinations about the inclusion or exclusion of participant submissions from the dataset based on level of suspicion. We also provide a full case example utilizing the Reflect, Expect, Analyze, Label Framework as an appendix. Those wanting to apply the Reflect, Expect, Analyze, Label Framework should keep in mind several considerations as they apply it, including determining logistical needs ahead of survey implementation, considering the ethical issues related to including or excluding data in a study, and considering the issues related to providing incentives for participating in research. Future research should assess the frequency of survey fraud, investigate the reasons for its occurrence and explore the role social networks may play in fraudulent participants sharing information. We suggest that researchers consider online survey fraud as an issue over the lifespan of their survey and apply the guiding questions we present to address the issue throughout.

An Approach to Reducing Problematic Data in an ACASI Sexual Behavior Assessment

Minimizing error in self-reported sexual behavior could reduce investigators' likelihood of rejecting truly successful interventions to decrease HIV and STI transmission risk. Sexual behavior assessments can elicit problematic data. This may manifest in the form of elevated levels of non-response, inaccurate point estimates, or misclassification errors resulting in inappropriately answering or, perhaps more importantly, skipping questions. We programed conversational interviewing elements into 20 sexual behavior questions in an exit survey of gay bathhouse patrons (N = 459) administered using ACASI. Those elements, called alternate pathways, included follow-up questions to responses to confirm that operational definitions were applied in the answer (with return to the initial question if confirmation failed), and assurances of confidentiality and requests for best guesses in reaction to non-response (including "don't know"). These elements were invoked in nearly 10% of participants, and approximately 74% of all invocations resulted in a usable numeric response, or 87% if the data need only estimate prevalence. Almost two-thirds of the problematic data issues occurred in answers to sexual contact questions, with others related to follow-up questions about specific sexual behavior. It is at this level of important filtering questions where the benefits of the approach are likely to be maximized.

Methods for Authenticating Participants in Fully Web-Based Mobile App Trials from the iReach Project: Cross-sectional Study

Background

Mobile health apps are important interventions that increase the scale and reach of prevention services, including HIV testing and prevention counseling, pre-exposure prophylaxis, condom distribution, and education, of which all are required to decrease HIV incidence rates. The use of these web-based apps as well as fully web-based intervention trials can be challenged by the need to remove fraudulent or duplicate entries and authenticate unique trial participants before randomization to protect the integrity of the sample and trial results. It is critical to ensure that the data collected through this modality are valid and reliable.

Objective

The aim of this study is to discuss the electronic and manual authentication strategies for the iReach randomized controlled trial that were used to monitor and prevent fraudulent enrollment.

Methods

iReach is a randomized controlled trial that focused on same-sex attracted, cisgender males (people assigned male at birth who identify as men) aged 13-18 years in the United States and on enrolling people of color and those in rural communities. The data were evaluated by identifying possible duplications in enrollment, identifying potentially fraudulent or ineligible participants through inconsistencies in the data collected at screening and survey data, and reviewing baseline completion times to avoid enrolling bots and those who did not complete the baseline questionnaire. Electronic systems flagged questionable enrollment. Additional manual reviews included the verification of age, IP addresses, email addresses, social media accounts, and completion times for surveys.

Results

The electronic and manual strategies, including the integration of social media profiles, resulted in the identification and prevention of 624 cases of potential fraudulent, duplicative, or ineligible enrollment. A total of 79% (493/624) of the potentially fraudulent or ineligible cases were identified through electronic strategies, thereby reducing the burden of manual authentication for most cases. A case study with a scenario, resolution, and authentication strategy response was included.

Conclusions

As web-based trials are becoming more common, methods for handling suspicious enrollments that compromise data quality have become increasingly important for inclusion in protocols.

International Registered Report Identifier (IRRID)

RR2-10.2196/10174

A systematic review of mHealth interventions for HIV prevention and treatment among gay, bisexual, and other men who have sex with men

The use of mobile health (mHealth) technologies addressing HIV disparities among gay, bisexual, and other men who have sex with men (GBMSM) has increased. A systematic review of mHealth interventions for HIV prevention and treatment among GBMSM was conducted to summarize the current evidence and provide recommendations for future research. PRISMA guidelines were followed (PROSPERO ID: 148452). Studies identified via PubMed, PsychInfo, or Embase were included that (i) were in English, (ii) were published in a peer-reviewed journal prior to July 1, 2019, (iii) presented primary results, (iv) included only GBMSM, and (v) reported the results of an mHealth intervention (e.g., text message, phone/mobile application [app]) to improve HIV prevention or treatment outcomes. Of 1,636 identified abstracts, 16 published studies met inclusion criteria. Eleven studies were conducted in the United States. One study was a fully powered randomized controlled trial (RCT), seven were single-arm pilots with pre-post assessments, four were pilot RCTs, and four tested public health campaigns with post-assessments. Seven developed study-specific apps, five used text messaging, and four used existing social networking apps. Most (81%) targeted prevention outcomes. Nine cited a specific behavioral theory. All studies found that a mHealth approach was feasible and acceptable. All interventions provided evidence of preliminary efficacy or promising trends on primary outcomes. Although mHealth interventions for HIV prevention and treatment appear feasible and acceptable, most published studies are small pilot trials. Additional research assessing the efficacy and mechanisms of mHealth interventions is needed.

Perceived Confidentiality Risks of Mobile Technology-Based Ecologic Momentary Assessment to Assess High-Risk Behaviors Among Rural Men Who Have Sex with Men

Although men who have sex with men (MSM) within rural communities are disproportionately impacted by HIV, limited HIV research and programmatic resources are directed to these communities within the U.S. There is a need for improved behavioral data collection methods to obtain more detailed information on the relationship between rural environments, sexual behavior, and substance use. Utilization of mobile health (mHealth) technologies, such as ecologic momentary assessment (EMA), has been advocated for; however, limited research has evaluated its utility among rural MSM. Forty MSM residing in rural Oklahoma were recruited to complete in-depth interviews related to participating online/mobile-based HIV prevention research. Men described a willingness to participate in HIV and substance use studies that use EMA methodologies for data collection; however, they raised various research-related concerns. In particular, participants indicated potential privacy and confidentiality concerns related to the use of the mobile technology-based EMA in public and the storage of data by researchers. Given the varying degree of sexual orientation and substance use disclosure by participants, rural MSM were largely concerned with being inadvertently "outed" within their communities. Men described the various strategies they could employ to protect private information and methods to minimize research risk. Study findings suggest that EMA is an acceptable research methodology for use among rural MSM in the context of HIV and sexual health information, when privacy and confidentiality concerns are adequately addressed. Input from community members and stakeholders is necessary to identify potential areas of concerns for participants prior to data collection.

Syphilis Self-testing: A Nationwide Pragmatic Study Among Men Who Have Sex With Men in China

BACKGROUND

Syphilis self-testing may help expand syphilis testing among men who have sex with men (MSM). China has rapidly scaled up human immunodeficiency virus (HIV) self-testing, creating an opportunity for integrated syphilis self-testing. However, there is a limited literature on implementing syphilis self-testing.

METHODS

A cross-sectional online survey was conducted among Chinese MSM in 2018. Participants completed a survey instrument including sociodemographic characteristics, sexual behaviors, syphilis self-testing, and HIV self-testing history. Multivariable logistic regression was conducted to identify correlates of syphilis self-testing. We also recorded potential harms associated with syphilis self-testing.

RESULTS

Six hundred ninety-nine MSM from 89 cities in 21 provinces in China completed the study. A total of 361/699 (51.7%) men tested for syphilis, of whom 174/699 (24.9%) men used syphilis self-testing. Among 174 who had self-tested, 90 (51.7%) reported that the self-test was their first syphilis test and 161 (92.5%) reported that they undertook syphilis self-testing together with HIV self-testing. After adjusting for covariates, syphilis self-testing was correlated with disclosure of sexual orientation to family or friends (adjusted odds ratio [aOR], 1.90; 95% confidence interval [CI], 1.32-2.73), reporting 2-5 male sexual partners (aOR, 1.81; 95% CI, 1.04-3.16), HIV self-testing (aOR, 39.90; 95% CI, 17.00-93.61), and never tested for syphilis in the hospital (aOR, 2.96; 95% CI, 1.86-4.72). Self-reported harms associated with syphilis self-testing were minimal.

CONCLUSIONS

Scaling up syphilis self-testing could complement facility-based testing in China among MSM. Self-testing may increase first-time testing and has limited harms. Our findings suggest that syphilis self-testing could be integrated into HIV self-testing services.

"They know what they are getting into:" Researchers confront the benefits and challenges of online recruitment for HIV research

Online research has become a critical recruitment modality for understanding and reducing health disparities among hidden populations most at risk for HIV infection. There is a lack of consensus and guidelines for the responsible conduct of online recruitment for HIV risk populations. Using semi-structured phone interviews, this study drew on the experiences of principal investigators (PIs) engaged in online HIV research to illuminate scientific and ethical benefits and challenges of social media recruitment. Using Thematic Analysis five major themes emerged: sampling advantages and disadvantages; challenges of data integrity; control of privacy protections; researcher competence and responsibility; and resources.

Disease knowledge and attitudes during the COVID-19 epidemic among international migrants in China: a national cross-sectional study

Background: There are more than 258 million international migrants worldwide and the majority reside in countries with ongoing novel coronavirus disease 2019 (COVID-19) epidemic outbreaks. International migrants may not receive adequate and timely disease information during epidemics, increasing vulnerability to disease transmission. This is one of very limited studies focusing on international migrants' COVID-19 prevention knowledge and attitudes during the epidemic. Methods: A national cross-sectional online survey was conducted across 100 cities and 26 regions in China from February 17 and March 1, 2020. The sample included 1,426 international migrants representing 77 countries and 6 continents. Knowledge was defined as the number of correct responses to questions about COVID-19. Attitudes included worries, expectations, and general preparedness. Multivariable ordinal logistic regressions evaluated correlates of knowledge and attitudes including information channels and preferences, and trust in Chinese institutions and groups. Results: Just half of the sample, 730/1426 (51.2%) had a good level of knowledge and 656/1426 (46.0%) had a positive attitude towards the COVID-19 epidemic. Knowledge was associated with receiving information through social media (aOR: 2.0, 95%CI: 1.2-3.2), the Internet (aOR: 1.4, 95%CI: 1.2-1.8), the community (aOR: 1.5, 95%CI: 1.2-1.8), and encountering language barriers when receiving medical services (aOR: 0.8, 95%CI: 0.7-1.0). Positive attitude was associated with the level of trust in various Chinese institutions and groups. Conclusions: Roughly half of the sample reported inadequate knowledge and poor attitudes toward prevention and control of COVID-19. Tailored public health campaigns are needed to ensure that international migrants possess adequate knowledge to protect their health during future epidemics and disasters.

Prior HIV testing behaviour is associated with HIV testing results among men, trans women and trans men who have sex with men in the United States

BACKGROUND

Among those at high risk for HIV, it is important to examine the ways in which someone who has recently tested for HIV might differ from someone who has not.

METHODS

In 2017-2018, a total of 5001 men, trans women and trans men who have sex with men from across the United States completed an online survey about their recent testing behaviour as well as self-collected oral samples for HIV testing.

RESULTS

In total, 3.8% tested HIV-positive and-among those with positive results-35% were recent HIV infections (ie, self-reported an HIV-negative test result within the 12 months prior to enrollment). Those with HIV-positive results-regardless of how recent their HIV test was prior to enrollment-differed from those with negative results in ways that are known to be associated with HIV risk: racial and income disparities, housing instability, recent transactional sex and recent methamphetamine use. Among those with HIV-positive results at enrollment, only having a primary care physician distinguished those who recently tested negative prior to enrollment versus not. Among those with HIV-negative results, there were numerous differences between those who had recently tested for HIV prior to enrollment, versus not, such that those who had not recently tested were significantly more likely to report being at higher risk for HIV.

CONCLUSION

Strategies aimed at improving more frequent HIV testing among HIV-negative persons at high risk for HIV should address other needs including stable housing, transactional sex, access to a primary care provider and methamphetamine use.

Recommendations From a Descriptive Evaluation to Improve Screening Procedures for Web-Based Studies With Couples: Cross-Sectional Study

BACKGROUND

Although there are a number of advantages to using the internet to recruit and enroll participants into Web-based research studies, these advantages hinge on data validity. In response to this concern, researchers have provided recommendations for how best to screen for fraudulent survey entries and to handle potentially invalid responses. Yet, the majority of this previous work focuses on screening (ie, verification that individual met the inclusion criteria) and validating data from 1 individual, and not from 2 people who are in a dyadic relationship with one another (eg, same-sex male couple; mother and daughter). Although many of the same data validation and screening recommendations for Web-based studies with individual participants can be used with dyads, there are differences and challenges that need to be considered.

OBJECTIVE

This paper aimed to describe the methods used to verify and validate couples' relationships and data from a Web-based research study, as well as the associated lessons learned for application toward future Web-based studies involving the screening and enrollment of couples with dyadic data collection.

METHODS

We conducted a descriptive evaluation of the procedures and associated benchmarks (ie, decision rules) used to verify couples' relationships and validate whether data uniquely came from each partner of the couple. Data came from a large convenience sample of same-sex male couples in the United States, who were recruited through social media venues for a Web-based, mixed methods HIV prevention research study.

RESULTS

Among the 3815 individuals who initiated eligibility screening, 1536 paired individuals (ie, data from both partners of a dyad) were assessed for relationship verification; all passed this benchmark. For data validation, 450 paired individuals (225 dyads) were identified as fraudulent and failed this benchmark, resulting in a total sample size of 1086 paired participants representing 543 same-sex male couples who were enrolled. The lessons learned from the procedures used to screen couples for this Web-based research study have led us to identify and describe four areas that warrant careful attention: (1) creation of new and replacement of certain relationship verification items, (2) identification of resources needed relative to using a manual or electronic approach for screening, (3) examination of approaches to link and identify both partners of the couple, and (4) handling of bots.

CONCLUSIONS

The screening items and associated rules used to verify and validate couples' relationships and data worked yet required extensive resources to implement. New or updating some items to verify a couple's relationship may be beneficial for future studies. The procedures used to link and identify whether both partners were coupled also worked, yet they call into question whether new approaches are possible to help increase linkage, suggesting the need for further inquiry.

Are we on the precipice of a new epidemic? Risk for hepatitis C among HIV-negative men-, trans women-, and trans men- who have sex with men in the United States

Emerging data from Europe have documented increases in diagnoses of acute hepatitis C virus (HCV) infection among HIV-negative men who have sex with men. We investigated risk factors for HCV and their correlates in the Together 5000 study, a U.S. national cohort study of HIV-negative men (n = 6089), transgender women (n = 40), and transgender men (n = 42) who have sex with men. We used bivariate and multivariable analyses to determine demographic and behavioral factors associated with high risk for acute HCV infection (using the HCV-MOSAIC risk indicator with a score ≥ 2.0). Mean HCV risk score was 1.38 (SD = 1.09) and 27.3% of participants had HCV risk scores ≥ 2.0. In multivariable modeling, being cisgender male (vs. not) was associated with having a lower HCV-MOSAIC risk score. Meanwhile, being white, having been incarcerated, prior use of HIV pre- or post-exposure prophylaxis, having ever been tested for HIV, and recent methamphetamine use were associated with high risk for HCV. More than one-in-four participants exceeded the threshold score for HCV risk. Those with high HCV-MOSAIC risk scores were more likely to have been in settings where they could be tested for acute HCV (i.e., HIV testing, PrEP care, PEP care, incarceration), suggesting opportunities to engage them in HCV screening, prevention, and treatment.

Seeing Is Believing? Unique Capabilities of Internet-Only Studies as a Tool for Implementation Research on HIV Prevention for Men Who Have Sex With Men: A Review of Studies and Methodological Considerations

BACKGROUND

In 2014, Grov et al published a comprehensive review cataloguing both men who have sex with men's (MSM's) sexual behavior transitions in online environments from the 1990s through 2013, as well as researchers' efforts in tandem to use the internet to engage MSM into research, treatment, and prevention.

METHODS

In this article, we discuss historical events and research having occurred in the half decade since the Grov et al publication.

RESULTS

Notable transitions include MSM's expanded use of geosocial networking apps, as well as other forms of social media accessed primarily through mobile devices, as well as the addition of biomedical prevention strategies (eg, pre-exposure prophylaxis and undetectable = untransmittable) to the proverbial HIV prevention toolkit. In tandem, researchers have rapidly expanded their employment of internet-mediated methods for the recruitment and engagement of key populations for HIV research, treatment, and prevention. In this article, we discuss methodological considerations for using the internet to conduct HIV prevention research with MSM: (1) sources of recruitment (eg, geosocial apps, Facebook, crowdsourced online panels); (2) design (eg, cross sectional, longitudinal, diaries); (3) incentives (including disincentivizing fraudulent participants and/or spam bots); (4) confidentiality; and (5) representativeness.

CONCLUSION

We conclude by discussing future directions in HIV prevention research in light of forthcoming technologies such as fifth generation (5G) mobile networks, combined use of self-collected biological data alongside self-report, and the utility of metadata and metaresearch to document, evaluate, and inform best practices.

Recruiting vulnerable populations to participate in HIV prevention research: findings from the Together 5000 cohort study

PURPOSE

The aim of the article was to examine factors associated with completing enrollment milestones in the Together 5000 cohort of at-risk men (n = 8661), transmen (n = 53), and transwomen (n = 63) who have sex with men.

METHODS

Between 2017 and 2018, participants completed an online enrollment survey and were offered opportunities to complete an incentivized secondary online survey as well as self-administered at-home HIV testing (OraSure). We explored factors associated with completing each study component.

RESULTS

In total, 8777 individuals completed our enrollment survey, 6166 (70.3%) completed the secondary survey, and 5010 returned the at-home HIV test kit that was mailed to them (81.3% of those mailed a kit). In our multivariable models, those who were White, with more years of education, were more likely to complete study components, although the magnitude of these associations was small. For example, 50.9% of those enrolled, 47.9% of those completing the secondary survey, and 46.8% of those completing HIV testing were persons of color-a statistically significant, but meaningfully insignificant decline.

CONCLUSIONS

These findings highlight the need for researchers to identify barriers that may prevent persons of color and younger individuals from participating in research studies.

Pilot feasibility trial of the MyPEEPS mobile app to reduce sexual risk among young men in 4 cities

Objectives

Our study team adapted the MyPEEPS (Male Youth Pursuing Empowerment, Education, and Prevention around Sexuality) curriculum, an evidence-based human immunodeficiency virus (HIV) prevention intervention, from a face-to-face, group-based intervention to an individual-level mobile responsive web-based intervention to improve HIV risk behaviors in very young men, aged 13–18 years.

Materials and methods

In adapting the MyPEEPS intervention to mobile app, we used a series of methodologies, including expert panel reviews, weekly team meetings with the software development company, and conducted in-depth interviews with very young men. Following the iterative process, we conducted a 6-week pre–post feasibility pilot trial with 40 young men in Birmingham, AL; Chicago, IL; New York City, NY; and Seattle, WA. Primary outcomes of interest were uptake of the app, accessibility and satisfaction.

Results

Across all 4 sites, 62.5% (25/40) of participants completed all modules in the app in an average of 28.85 (SD 21.69) days. Participants who did not attend to the follow-up visit did not complete any of the app modules. Overall participants reported that the app was easy to use, useful and has the potential to improve their sexual health knowledge and behavior and awareness in risky contexts. Participants also highly rated the app, information and interface quality of the app.

Discussion

Lessons learned from the pilot included the need for reminder systems and providing anticipatory guidance about Internet connectivity when using the app. These changes will be incorporated into study procedures for our multisite trial.

Conclusion

Overall, participants found the app to be highly usable and have the potential to positively improve their sexual risk behavior.

Fraud Detection Protocol for Web-Based Research Among Men Who Have Sex With Men: Development and Descriptive Evaluation

Background

Internet is becoming an increasingly common tool for survey research, particularly among “hidden” or vulnerable populations, such as men who have sex with men (MSM). Web-based research has many advantages for participants and researchers, but fraud can present a significant threat to data integrity.

Objective

The purpose of this analysis was to evaluate fraud detection strategies in a Web-based survey of young MSM and describe new protocols to improve fraud detection in Web-based survey research.

Methods

This study involved a cross-sectional Web-based survey that examined individual- and network-level risk factors for HIV transmission and substance use among young MSM residing in 15 counties in Central Kentucky. Each survey entry, which was at least 50% complete, was evaluated by the study staff for fraud using an algorithm involving 8 criteria based on a combination of geolocation data, survey data, and personal information. Entries were classified as fraudulent, potentially fraudulent, or valid. Descriptive analyses were performed to describe each fraud detection criterion among entries.

Results

Of the 414 survey entries, the final categorization resulted in 119 (28.7%) entries identified as fraud, 42 (10.1%) as potential fraud, and 253 (61.1%) as valid. Geolocation outside of the study area (164/414, 39.6%) was the most frequently violated criterion. However, 33.3% (82/246) of the entries that had ineligible geolocations belonged to participants who were in eligible locations (as verified by their request to mail payment to an address within the study area or participation at a local event). The second most frequently violated criterion was an invalid phone number (94/414, 22.7%), followed by mismatching names within an entry (43/414, 10.4%) and unusual email addresses (37/414, 8.9%). Less than 5% (18/414) of the entries had some combination of personal information items matching that of a previous entry.

Conclusions

This study suggests that researchers conducting Web-based surveys of MSM should be vigilant about the potential for fraud. Researchers should have a fraud detection algorithm in place prior to data collection and should not rely on the Internet Protocol (IP) address or geolocation alone, but should rather use a combination of indicators.

Randomised controlled trial of incentives to improve online survey completion among internet-using men who have sex with men

BACKGROUND

HIV prevention research often involves the use of online surveys as data collection instruments. Incomplete responses to these surveys can introduce bias. We aimed to develop and assess innovative methods to incentivise respondents to complete surveys.

METHODS

Adult men who have sex with men (MSM) living in the USA were recruited through banner advertisements on Facebook from 27 April 2015 to 6 May 2015 to participate in an online survey about HIV prevention and risk behaviours. Participants were randomised to one of four conditions: a monetary incentive; a series of altruistic messages highlighting the importance of participating in research; access to a dashboard comparing their responses with statistics from other participants after completion; and no incentive. Kaplan-Meier survival methods and univariate Cox proportional hazard models were used to evaluate survey dropout by incentive group and demographic variables of interest.

RESULTS

There were a total of 1178 participants randomised to the four treatment groups. The rate of survey dropout among participants in the altruistic (HR=0.68, 95% CI 0.49 to 0.93), monetary (HR=0.44, 95% CI 0.32 to 0.61) and dashboard (HR=0.78, 95% CI 0.58 to 1.06) groups was lower than the non-incentivised control group. Regardless of condition, survey dropout was also lower among MSM aged 28-34 (HR=0.67, 95% CI 0.50 to 0.90) compared with those aged 18-22 years old, and MSM who were white (HR=0.78, 95% CI 0.60 to 1.02) compared with non-white participants.

CONCLUSION

Monetary incentives and altruistic messaging can improve survey completion in online behavioural HIV prevention research among MSM.

TRIAL REGISTRATION NUMBER

NCT02139566.

Blood Donation, Sexual Practices, and Self-Perceived Risk for HIV in the United States Among Young Adult Men Who Have Sex With Men

OBJECTIVES

In the United States, all men who have sex with men (MSM) were banned from donating blood from 1985 through 2015. In 2016, the guideline was amended such that men who had sexual contact with other men within the previous 12 months could not donate blood. We aimed to identify blood donation practices and their relationship with HIV risk and testing among young adult MSM (YMSM) at risk for having HIV.

METHODS

In 2014, we recruited HIV-negative non-Hispanic black, Hispanic, and non-Hispanic white YMSM aged 18-24 from across the United States through social media platforms to complete an online survey. Among these YMSM who previously donated blood, we conducted a secondary analysis examining the relationship between having donated blood within the past 12 months and sexual risk behavior from recent condomless anal intercourse (CAI), HIV testing, and self-perceived risk of having an undiagnosed HIV infection.

RESULTS

Of the 2261 YMSM surveyed, 1104 (48.8%) had ever previously donated blood and 305 (13.5%) had donated blood within the past 12 months. Of the 305 blood donors, 50 (16.4%) had ever had CAI before their most recent blood donation. Among YMSM who donated blood, past-12-month blood donation was more likely among YMSM who never had CAI (adjusted odds ratio [aOR] = 1.84; 95% confidence interval [CI], 1.24-2.73) than among YMSM who had CAI and more likely among YMSM who believed it was not possible at all that they had an undiagnosed HIV infection (aOR = 1.57; 95% CI, 1.14-2.16) than among YMSM who believed there was any possibility of having an undiagnosed HIV infection; it was not related to past-12-month HIV testing.

CONCLUSIONS

YMSM donated blood frequently, suggesting that the deferral process in place did not prevent YMSM from donating blood. The current donor screening process should be reconsidered if it is to prevent YMSM from donating blood. Future research could identify screening questions that permit YMSM with a low risk of HIV infection to donate blood while maintaining the safety of the blood supply.

Adaptation of a Group-Based HIV RISK Reduction Intervention to a Mobile App for Young Sexual Minority Men

There is a dearth of evidence-based HIV prevention interventions for very young men who have sex with men (YMSM) ages 13-18 years, at high risk for HIV. We adapted the MyPEEPS intervention-an evidence-based, group-level intervention-to individual-level delivery by a mobile application. We used an expert panel review, in-depth interviews with YMSM (n = 40), and weekly meetings with the investigative team and the software development company to develop the mobile app. The expert panel recommended changes to the intervention in the following areas: (1) biomedical interventions, (2) salience of intervention content, (3) age group relevance, (4) technical components, and (5) stigma content. Interview findings reflected current areas of focus for the intervention and recommendations of the expert panel for new content. In regular meetings with the software development firm, guiding principles included development of dynamic content, while maintaining fidelity of the original curriculum and shortening intervention content for mobile delivery.

Attrition and HIV Risk Behaviors: A Comparison of Young Men Who Have Sex with Men Recruited from Online and Offline Venues for an Online HIV Prevention Program

In addition to offline venue-based and time-space sampling, recruitment of young men who have sex with men (YMSM) into HIV surveillance and prevention studies has expanded over time to include Internet-based approaches. Despite broadening recruitment strategies, enrolling racially and ethnically diverse YMSM who are disproportionately impacted by HIV continues to be challenging. Additionally, there is little literature on the impact of recruitment venue on participant characteristics and likelihood to enroll YMSM into online randomized control trials (RCT). This study used data from the multisite RCT, Keep It Up! 2.0, to examine the impact of recruitment venue on participant demographics, behavioral HIV risks, and enrollment. A total of 2984 participants were screened for eligibility from community-based organizations, Facebook, dating apps, and outreach events. There were significant differences by venue in age (χ2[3] = 54.38, p < .001), race/ethnicity (χ2[9] = 110.78, p < .001), sexual orientation (χ2[3] = 7.85, p < .05), relationship status (χ2[6] = 27.71, p < .001), and region of recruitment (χ2[6] = 1480.51, p < .001). There were no significant differences by venue in attrition during the enrollment process. The only difference in attrition was by race/ethnicity. Compared to White participants, eligible Black (OR: 0.35, p < .01) and Latino (OR: 0.46, p < .05) participants were significantly less likely to enroll in the intervention. There were also no significant differences by recruitment venue in sexual risk behaviors among enrolled participants. These findings suggest that recruitment into online HIV interventions from a variety of venues is feasible for diverse YMSM who are at similar risk for HIV infection.

Birth Cohort Differences in Sexual Identity Development Milestones Among HIV-Negative Gay and Bisexual Men in the United States

The coming-out process for gay and bisexual men (GBM) involves crossing sexual identity development (SID) milestones: (1) self-awareness of sexual attraction to the same sex, (2) self-acceptance of an identity as gay or bisexual, (3) disclosure of this sexual identity to others, and (4) having sex with someone of the same sex. We examined trends in SID milestones by birth cohort in a 2015 U.S. national sample of GBM (n = 1,023). Birth cohort was independent of when men first felt sexually attracted to someone of the same sex (median age 11 to 12). However, with the exception of age of first same-sex attraction, older cohorts tended to pass other milestones at later ages than younger cohorts. Latent class analysis (LCA) of SID milestone patterns identified three subgroups. The majority (84%) began sexual identity development with same-sex attraction around the onset of puberty (i.e., around age 10) and progressed to self-identification, same-sex sexual activity, and coming out-in that order. The other two classes felt same-sex attraction during teen years (ages 12.5 to 18.0) but achieved the remaining SID milestones later in life. For 13% of men, this was during early adulthood; for 3% of men, this was in middle adulthood. Findings highlight the need to monitor ongoing generational differences in passing SID milestones.

Empowering With PrEP (E-PrEP), a Peer-Led Social Media-Based Intervention to Facilitate HIV Preexposure Prophylaxis Adoption Among Young Black and Latinx Gay and Bisexual Men: Protocol for a Cluster Randomized Controlled Trial

Background

Young black and Latinx, gay, bisexual, and other men who have sex with men (YBLGBM, aged 18-29 years) have among the highest rates of new HIV infections in the United States and are not consistently reached by existing prevention interventions. Preexposure prophylaxis (PrEP), an oral antiretroviral regimen taken daily by HIV-uninfected individuals to prevent HIV acquisition, is highly efficacious in reducing HIV acquisition and could help stop the HIV epidemic in YBLGBM. Use of social media (eg, Facebook, Twitter, online dating sites) is ubiquitous among young people, providing an efficient avenue to engage YBLGBM to facilitate PrEP adoption.

Objective

Our overall goal was to develop and pilot test a theoretically grounded, social media–based, peer-led intervention to increase PrEP uptake in YBLGBM. We used diffusion of innovation and information-motivation-behavioral skills frameworks to (1) identify potential factors associated with interest in and adoption of PrEP among YBLGBM; (2) develop Empowering with PrEP (E-PrEP), a social media–based, peer-led intervention to increase PrEP uptake in YBLGBM; and (3) pilot test the feasibility and acceptability of E-PrEP, and determine its preliminary efficacy for increasing adoption of PrEP by YBLGBM. We describe the development and protocol for E-PrEP.

Methods

Using a participatory research approach, we partnered with YBLGBM intervention development partners to develop a social media–based behavioral intervention to facilitate PrEP uptake, which involved an online messaging campaign disseminated by YBLGBM peer leaders to their existing online networks. We designed the 6-week campaign to provide education about PrEP, increase motivation to use PrEP, and facilitate access to PrEP. We then conducted a cluster-randomized trial of E-PrEP compared with an attention-matched general health control condition (E-Health) among YBLGBM aged 18 to 29 years to assess E-PrEP’s feasibility, acceptability, preliminary efficacy for increasing self-reported intention to use PrEP, PrEP uptake, and impact on knowledge and attitudes about PrEP at 12-week follow-up (6 weeks after the end of the online campaign).

Results

From October 2016 to March 2017, we developed, pretested, and refined E-PrEP with 6 YBLGBM intervention development partners. From May to June 2017, we recruited, enrolled, and randomly assigned 10 peer leaders (n=5 for each condition). The 10 peer leaders then recruited and enrolled 152 participants from their existing online networks (range 3-33 per peer leader), during June and July 2017. Intervention follow-up was completed after 12 weeks, in November 2017, with analyses underway.

Conclusions

We hypothesize that, compared with E-Health, participants randomly assigned to E-PrEP will be more likely to express intention to use PrEP and greater PrEP uptake, and will also show changes in potential mediators of PrEP uptake (knowledge, attitudes, stigma, and access). A Web-based biobehavioral intervention model such as E-PrEP could be rapidly scaled even with limited resources and have significant population-level impact.

Trial Registration

ClinicalTrials.gov NCT03213366; https://clinicaltrials.gov/ct2/show/NCT03213366 (Archived by WebCite at http://www.webcitation.org/71onSdcXY)

Registered Report Identifier

RR1-10.2196/11375

Surveillance Among Men Who have Sex with Men in the United States: A Comparison of Web-Based and Venue-Based Samples

Although men who have sex with men (MSM) recruited through web-based and venue-based sampling methods have been compared, no large web-based and venue-based samples using similar survey instruments have been examined in the U.S. This study describes the differences in sociodemographic characteristics and risk behaviors between the 2012 Web-based HIV Behavioral Survey (n = 3221) and 2011 National HIV Behavioral Surveillance (n = 9256). Compared with participants in the venue-based sample, participants in the web-based sample were older, less likely to be black or Hispanic, more likely to have higher socioeconomic status, and more likely to have anal sex without a condom with their last male sex partner. Web-based participants were less likely to have multiple male sex partners, ever injected drugs, been tested for HIV in the past 12 months, and received free condoms than venue-based participants. The method for sampling MSM into a behavioral survey should consider the sub-population of MSM to be reached.

Addressing Participant Validity in a Small Internet Health Survey (The Restore Study): Protocol and Recommendations for Survey Response Validation

Background

While deduplication and cross-validation protocols have been recommended for large Web-based studies, protocols for survey response validation of smaller studies have not been published.

Objective

This paper reports the challenges of survey validation inherent in a small Web-based health survey research.

Methods

The subject population was North American, gay and bisexual, prostate cancer survivors, who represent an under-researched, hidden, difficult-to-recruit, minority-within-a-minority population. In 2015-2016, advertising on a large Web-based cancer survivor support network, using email and social media, yielded 478 completed surveys.

Results

Our manual deduplication and cross-validation protocol identified 289 survey submissions (289/478, 60.4%) as likely spam, most stemming from advertising on social media. The basic components of this deduplication and validation protocol are detailed. An unexpected challenge encountered was invalid survey responses evolving across the study period. This necessitated the static detection protocol be augmented with a dynamic one.

Conclusions

Five recommendations for validation of Web-based samples, especially with smaller difficult-to-recruit populations, are detailed.

Conducting Anonymous, Incentivized, Online Surveys With Sexual and Gender Minority Adolescents: Lessons Learned From a National Polyvictimization Study

Sexual and gender minority adolescents represent an understudied and hard-to-reach population who experience higher rates of mental and behavioral health problems in comparison to their cisgender, heterosexual peers. Online surveys and the proliferation of Internet-connected devices among adolescents offer an exciting opportunity for researchers to begin addressing research gaps and past methodological limitations with these hard-to-reach populations. The purpose of this article is to provide guidance to researchers who are designing and implementing anonymous, incentivized, online surveys by examining the following critical domains-(a) recruitment and engagement: means of leveraging social media and videos to recruit and engage a more nationally representative sample; (b) safety and protection: strategies for administering informed consent and protecting participant anonymity and well-being; and (c) data integrity: mechanisms to detect dishonest and repeat responders. To facilitate discussion of these aims, concrete examples are used from SpeakOut-a 3-year, national study funded by the National Institute of Justice that utilized an anonymous, incentivized, online survey with a large sample of sexual and gender minority adolescents ( N = 1,177) to identify the prevalence, incidence, and correlates of polyvictimization. The article concludes with lessons learned from this national study and recommendations for technological innovations and future research that will strengthen the utility of anonymous, incentivized, online surveys to study sexual and gender minority adolescents and other hard-to-reach populations.

Generalisability of an online randomised controlled trial: an empirical analysis

BACKGROUND

Investigators increasingly use online methods to recruit participants for randomised controlled trials (RCTs). However, the extent to which participants recruited online represent populations of interest is unknown. We evaluated how generalisable an online RCT sample is to men who have sex with men in China.

METHODS

Inverse probability of sampling weights (IPSW) and the G-formula were used to examine the generalisability of an online RCT using model-based approaches. Online RCT data and national cross-sectional study data from China were analysed to illustrate the process of quantitatively assessing generalisability. The RCT (identifier NCT02248558) randomly assigned participants to a crowdsourced or health marketing video for promotion of HIV testing. The primary outcome was self-reported HIV testing within 4 weeks, with a non-inferiority margin of -3%.

RESULTS

In the original online RCT analysis, the estimated difference in proportions of HIV tested between the two arms (crowdsourcing and health marketing) was 2.1% (95% CI, -5.4% to 9.7%). The hypothesis that the crowdsourced video was not inferior to the health marketing video to promote HIV testing was not demonstrated. The IPSW and G-formula estimated differences were -2.6% (95% CI, -14.2 to 8.9) and 2.7% (95% CI, -10.7 to 16.2), with both approaches also not establishing non-inferiority.

CONCLUSIONS

Conducting generalisability analysis of an online RCT is feasible. Examining the generalisability of online RCTs is an important step before an intervention is scaled up.

TRIAL REGISTRATION NUMBER

NCT02248558.

Ethical Issues in Using Social Media to Deliver an HIV Prevention Intervention: Results from the HOPE Peru Study

Social media technologies have become increasingly useful tools for research-based interventions. However, participants and social media users have expressed ethical concerns with these studies, such as risks and benefits of participation, as well as privacy, confidentiality, and informed consent issues. This study was designed to follow up with and assess experiences and perceptions of ethics-related issues among a sample of 211 men who have sex with men who participated in the Harnessing Online Peer Education (HOPE) Peru study, a randomized controlled HIV prevention intervention conducted in Peru. We found that after adjusting for age, highest educational attainment, race, sexual orientation, and prior HIV research experience, participants in the intervention group were more likely than those in the control group to have safe sex (p = 0.0051) and get tested for HIV regularly (p = 0.0051). As a result of their participation, those in the intervention group benefited more positively than participants in the control group in improving HIV care (p = 0.0077) and learning where to receive sexual health services (p = 0.0021). Participants in the intervention group expressed higher levels of comfort than those in the control group in joining and seeing other people in the Facebook group (p = 0.039), seeing other people's posts (p = 0.038) and having other group members talk to them online (p = 0.040). We discuss the implications of these results as they relate to social media-based HIV research.

Implementation of a Web-Based Organ Donation Educational Intervention: Development and Use of a Refined Process Evaluation Model

Background

The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public commitment to organ donation through the broad reach of Web-based behavioral interventions. Implementing Internet interventions, however, presents challenges including preventing fraudulent respondents and ensuring intervention uptake. Although Web-based organ donation interventions have increased in recent years, process evaluation models appropriate for Web-based interventions are lacking.

Objective

The aim of this study was to describe a refined process evaluation model adapted for Web-based settings and used to assess the implementation of a Web-based intervention aimed to increase organ donation among African Americans.

Methods

We used a randomized pretest-posttest control design to assess the effectiveness of the intervention website that addressed barriers to organ donation through corresponding videos. Eligible participants were African American adult residents of Georgia who were not registered on the state donor registry. Drawing from previously developed process evaluation constructs, we adapted reach (the extent to which individuals were found eligible, and participated in the study), recruitment (online recruitment mechanism), dose received (intervention uptake), and context (how the Web-based setting influenced study implementation) for Internet settings and used the adapted model to assess the implementation of our Web-based intervention.

Results

With regard to reach, 1415 individuals completed the eligibility screener; 948 (67.00%) were determined eligible, of whom 918 (96.8%) completed the study. After eliminating duplicate entries (n=17), those who did not initiate the posttest (n=21) and those with an invalid ZIP code (n=108), 772 valid entries remained. Per the Internet protocol (IP) address analysis, only 23 of the 772 valid entries (3.0%) were within Georgia, and only 17 of those were considered unique entries and could be considered for analyses. With respect to recruitment, 517 of the 772 valid entries (67.0%) of participants were recruited from a Web recruiter. Regarding dose received, no videos from the intervention website were watched in their entirety, and the average viewing duration was 17 seconds over the minimum. With respect to context, context analysis provided us with valuable insights into factors in the Internet environment that may have affected study implementation. Although only active for a brief period of time, the Craigslist website advertisement may have contributed the largest volume of fraudulent responses.

Conclusions

We determined fraud and low uptake to be serious threats to this study and further confirmed the importance of conducting a process evaluation to identify such threats. We suggest checking participants’ IP addresses before study initiation, selecting software that allows for automatic duplicate protection, and tightening minimum requirements for intervention uptake. Further research is needed to understand how process evaluation models can be used to monitor implementation of Web-based studies.

Variations in Recruitment Yield and Characteristics of Participants Recruited Across Diverse Internet Platforms in an HIV Testing Study of Young Adult Men-Who-Have-Sex-With-Men (YMSM)

The Internet is a commonly used medium for recruiting geographically dispersed, smaller populations quickly, such as young adult men-who-have-sex-with-men (YMSM). One approach to improve reach and representativeness is to employ multiple Internet platforms to recruit this hard-to-reach population. The utility of this approach has not been studied adequately, and its impact on the study sample recruited is not yet known. Using data from a study of 18- to 24-year-old HIV-uninfected, Black, Hispanic, and White United States (US) YMSM, this investigation compared advertising and enrollment metrics and participant characteristics of those recruited across Internet platforms. Of the 2,444 participants, their median age was 22 years old; 21% were Black, 37% Hispanic, and 42% White; 90% had been tested for HIV at least once in their life; and 87% reported prior condomless anal intercourse (CAI) with another man. There were noticeable differences across platforms in the number of people accessing the study website, meeting study eligibility requirements, consenting to participate, consenting to participate per day of advertising and per click, as well as costs of advertising per consented participant. Participants recruited also varied across platform by race/ethnicity, geographic area of residence in the US, health-care insurance status, years of formal education, history of HIV testing, and CAI by partner type and sexual positioning. The investigation results indicate that the Internet platforms used for recruitment significantly impact not only enrollment but also diversity and characteristics of the sample obtained and consequently, the observations and conclusions rendered.

HIV Research with Men who Have Sex with Men (MSM): Advantages and Challenges of Different Methods for Most Appropriately Targeting a Key Population

The difficulty in accessing hard-to-reach populations as men who have sex with men presents a dilemma for HIV surveillance as their omission from surveillance systems leaves significant gaps in our understanding of HIV/AIDS epidemics. Several methods for recruiting difficult-to-access populations and collecting data on trends of HIV prevalence and behavioural factors for surveillance and research purposes have emerged. This paper aims to critically review different sampling approaches, from chain-referral and venue-based to respondent-driven, time-location and internet sampling methods, focusing on its main advantages and challenges for conducting HIV research among key populations, such as men who have sex with men. The benefits of using these approaches to recruit participants must be weighed against privacy concerns inherent in any social situation or health condition. Nevertheless, the methods discussed in this paper represent some of the best efforts to effectively reach most-at-risk subgroups of men who have sex with men, contributing to obtain unbiased trends of HIV prevalence and HIV-related risk behaviours among this population group.

Use of Videos Improves Informed Consent Comprehension in Web-Based Surveys Among Internet-Using Men Who Have Sex With Men: A Randomized Controlled Trial

Background

Web-based surveys are increasingly used to capture data essential for human immunodeficiency virus (HIV) prevention research. However, there are challenges in ensuring the informed consent of Web-based research participants.

Objective

The aim of our study was to develop and assess the efficacy of alternative methods of administering informed consent in Web-based HIV research with men who have sex with men (MSM).

Methods

From July to September 2014, paid advertisements on Facebook were used to recruit adult MSM living in the United States for a Web-based survey about risk and preventive behaviors. Participants were randomized to one of the 4 methods of delivering informed consent: a professionally produced video, a study staff-produced video, a frequently asked questions (FAQs) text page, and a standard informed consent text page. Following the behavior survey, participants answered 15 questions about comprehension of consent information. Correct responses to each question were given a score of 1, for a total possible scale score of 15. General linear regression and post-hoc Tukey comparisons were used to assess difference (P<.001) in mean consent comprehension scores. A mediation analysis was used to examine the relationship between time spent on consent page and consent comprehension.

Results

Of the 665 MSM participants who completed the comprehension questions, 24.2% (161/665) received the standard consent, 27.1% (180/665) received the FAQ consent, 26.8% (178/665) received the professional consent video, and 22.0% (146/665) received the staff video. The overall average consent comprehension score was 6.28 (SD=2.89). The average consent comprehension score differed significantly across consent type (P<.001), age (P=.04), race or ethnicity (P<.001), and highest level of education (P=.001). Compared with those who received the standard consent, comprehension was significantly higher for participants who received the professional video consent (score increase=1.79; 95% CI 1.02-2.55) and participants who received the staff video consent (score increase=1.79; 95% CI 0.99-2.59). There was no significant difference in comprehension for those who received the FAQ consent. Participants spent more time on the 2 video consents (staff video median time=117 seconds; professional video median time=115 seconds) than the FAQ (median=21 seconds) and standard consents (median=37 seconds). Mediation analysis showed that though time spent on the consent page was partially responsible for some of the differences in comprehension, the direct effects of the professional video (score increase=0.93; 95% CI 0.39-1.48) and the staff-produced video (score increase=0.99; 95% CI 0.42-1.56) were still significant.

Conclusions

Video-based consent methods improve consent comprehension of MSM participating in a Web-based HIV behavioral survey. This effect may be partially mediated through increased time spent reviewing the consent material; however, the video consent may still be superior to standard consent in improving participant comprehension of key study facts.

Trail Registration

Clinicaltrials.gov NCT02139566; https://clinicaltrials.gov/ct2/show/NCT02139566 (Archived by WebCite at http://www.webcitation.org/6oRnL261N).

Preferences for oral fluid rapid HIV self-testing among social media-using young black, Hispanic, and white men-who-have-sex-with-men (YMSM): implications for future interventions

OBJECTIVES

We assessed preferences of social media-using young black, Hispanic and white men-who-have-sex-with-men (YMSM) for oral fluid rapid HIV self-testing, as compared to other currently available HIV testing options. We also identified aspects of the oral fluid rapid HIV self-test that might influence preferences for using this test instead of other HIV testing options and determined if consideration of HIV testing costs and the potential future availability of fingerstick rapid HIV self-testing change HIV testing preferences.

STUDY DESIGN

Anonymous online survey.

METHODS

HIV-uninfected YMSM across the United States recruited from multiple social media platforms completed an online survey about willingness to use, opinions about and their preferences for using oral fluid rapid HIV self-testing and five other currently available HIV testing options. In a pre/post questionnaire format design, participants first indicated their preferences for using the six HIV testing options (pre) before answering questions that asked their experience with and opinions about HIV testing. Although not revealed to participants and not apparent in the phrasing of the questions or responses, the opinion questions concerned aspects of oral fluid rapid HIV self-testing (e.g. its possible advantages/disadvantages, merits/demerits, and barriers/facilitators). Afterward, participants were queried again about their HIV testing preferences (post). After completing these questions, participants were asked to re-indicate their HIV testing preferences when considering they had to pay for HIV testing and if fingerstick blood sample rapid HIV self-testing were an additional testing option. Aspects about the oral fluid rapid HIV self-test associated with increased preference for using the test (post-assessment vs pre-assessment of opinion topics) were identified through multivariable regression models that adjusted for participant characteristics.

RESULTS

Of the 1975 YMSM participants, the median age was 22 years (IQR 20-23); 19% were black, 36% Hispanic, and 45% white; and 18% previously used an oral fluid rapid HIV self-test. Although views about oral fluid rapid HIV self-testing test were favorable, few intended to use the test. Aspects about the oral fluid rapid HIV self-test associated with an increased preference for using the test were its privacy features, that it motivated getting tested more often or as soon as possible, and that it conferred feelings of more control over one's sexual health. Preferences for the oral fluid rapid HIV self-test were lower when costs were considered, yet these YMSM were much more interested in fingerstick blood sampling than oral fluid sampling rapid HIV self-testing.

CONCLUSIONS

Despite the perceived advantages of the oral fluid rapid HIV self-test and favorable views about it by this population, prior use as well as future intention in using the test were low. Aspects about oral fluid rapid HIV self-testing identified as influential in this study might assist in interventions aimed to increase its use among this high HIV risk population as a means of encouraging regular HIV testing, identifying HIV-infected persons, and linking them to care. Although not yet commercially available in the United States, fingerstick rapid HIV self-testing might help motivate YMSM to be tested more than oral fluid rapid HIV self-testing.

Sexual Debut and HIV-Related Sexual Risk-Taking by Birth Cohort Among Men Who Have Sex with Men in the United States

Age-discordant and earlier sexual debut are risk factors for HIV among men who have sex with men (MSM). Despite differences in the sociopolitical landscape over time, there are no studies sampling participants from the United States that have examined the role of birth cohort in relations between sexual debut characteristics and sexual risk among MSM. We assessed sexual debut patterns and associations with sexual risk-taking in 812 adult MSM stratified by ten-year birth cohorts (i.e., before 1970, 1970-1979, 1980-1989, after 1990). Sexual debut characteristics differed by birth cohort. In multivariate models controlling for birth cohort, both younger age of sexual debut and younger age of anal sex debut were associated with an increased likelihood of condomless sex. Men born in the 1990s had increased odds of engaging in sexual risk regardless of sexual debut characteristics. Sexual risk reduction interventions tailored to the unique needs of young MSM are encouraged.

The design and conduct of Keep It Off: An online randomized trial of financial incentives for weight-loss maintenance

Background Obesity continues to be a serious public health challenge. Rates are increasing worldwide, with nearly 70% of the US adults overweight or obese, leading to increased clinical and economic burden. While successful approaches for achieving weight loss have been identified, techniques for long-term maintenance of initial weight loss have largely been unsuccessful. Financial incentive interventions have been shown in several settings to be successful in motivating participants to adopt healthy behaviors. Purpose Keep It Off is a three-arm randomized controlled trial that compares the efficacy of a lottery-based incentive, traditional direct payment incentive, and control of daily feedback without any incentive for weight-loss maintenance. This design allows comparison of a traditional direct payment incentive with one based on behavioral economic principles that consider the underlying psychology of decision-making. Methods Participants were randomized in a 2:1 ratio for each active arm relative to control, with a targeted 188 participants in total. Eligible participants were those aged 30-80 who lost at least 11 lb (5 kg) during the first 4 months of participation in Weight Watchers, a national weight-loss program, with whom we partnered. The interventions lasted 6 months (Phase I); participants were followed for an additional 6 months without intervention (Phase II). The primary outcome is weight change from baseline to the end of Phase I, with the change at the end of Phase II a key secondary endpoint. Keep It Off is a pragmatic trial that recruited, consented, enrolled, and followed patients electronically. Participants were provided a wireless weight scale that electronically transmitted daily self-monitored weights. Weights were verified every 3 months at a Weight Watchers center local to the participant and electronically transmitted. Results Using the study web-based platform, we integrated recruitment, enrollment, and follow-up procedures into a digital platform that required little staff effort to implement and manage. We randomized 191 participants in less than 1 year. We describe the design of Keep It Off and implementation of enrollment. Lessons Learned We demonstrated that our pragmatic design was successful in rapid accrual of participants in a trial of interventions to maintain weight loss. Limitations Despite the nationwide reach of Weight Watchers, the generalizability of study findings may be limited by the characteristics of its members. The interventions under study are appropriate for settings where an entity, such as an employer or health insurance company, could offer them as a benefit. Conclusions Keep It Off was implemented and conducted with minimal staff effort. This study has the potential to identify a practical and effective weight-loss maintenance strategy.

"I feel like I am surviving the health care system": understanding LGBTQ health in Nova Scotia, Canada

Background

Currently, there is a dearth of baseline data on the health of lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations in the province of Nova Scotia, Canada. Historically, LGBTQ health research has tended to focus on individual-level health risks associated with poor health outcomes among these populations, which has served to obscure the ways in which they maintain their own health and wellness across the life course. As such, there is an urgent need to shift the focus of LGBTQ health research towards strengths-based perspectives that explore the complex and resilient ways in which LGBTQ populations promote their health.

Methods

This paper discusses the findings of our recent scoping review as well as the qualitative data to emerge from community consultations aimed at developing strengths-based approaches to understanding and advancing LGBTQ pathways to health across Nova Scotia.

Results

Our scoping review findings demonstrated the lack of strengths-based research on LGBTQ health in Nova Scotia. Specifically, the studies examined in our scoping review identified a number of health-promoting factors and a wide variety of measurement tools, some of which may prove useful for future strengths-based health research with LGBTQ populations. In addition, our community consultations revealed that many participants had negative experiences with health care systems and services in Nova Scotia. However, participants also shared a number of factors that contribute to LGBTQ health and suggestions for how LGBTQ pathways to health in Nova Scotia can be improved.

Conclusions

There is an urgent need to conduct research on the health needs, lived experiences, and outcomes of LGBTQ populations in Nova Scotia to address gaps in our knowledge of their unique health needs. In moving forward, it is important that future health research take an intersectional, strengths-based perspective in an effort to highlight the factors that promote LGBTQ health and wellness across the life course, while taking into account the social determinants of health.

How Best to Obtain Valid, Verifiable Data Online From Male Couples? Lessons Learned From an eHealth HIV Prevention Intervention for HIV-Negative Male Couples

Background

As interest increases in the development of eHealth human immunodeficiency virus (HIV)-preventive interventions for gay male couples, Web-based methods must also be developed to help increase the likelihood that couples enrolled and data collected from them represent true unique dyads. Methods to recruit and collect reliable and valid data from both members of a couple are lacking, yet are crucial for uptake of novel sexual health and HIV-prevention eHealth interventions. Methods to describe best practices to recruit male couples using targeted advertisements on Facebook are also lacking in the literature, yet could also help in this uptake.

Objective

The objective of our study was to describe challenges and lessons learned from experiences from two phases (developmental phase and online randomized controlled trial [RCT]) of an eHealth HIV-prevention intervention for concordant HIV-negative male couples in terms of (1) recruiting male couples using targeted advertisements on Facebook, (2) validating that data came from two partners of the couple, and (3) verifying that the two partners of the couple are in a relationship with each other.

Methods

The developmental phase refined the intervention via in-person focus groups, whereas the pilot-testing phase included an online RCT. For both phases, couples were recruited via targeted Facebook advertisements. Advertisements directed men to a study webpage and screener; once eligible, participants provided consent electronically. A partner referral system was embedded in the consenting process to recruit the relationship partner of the participant. Both men of the couple had to meet all eligibility criteria—individually and as a couple—before they could enroll in the study. Verification of couples’ relationships was assessed via the concurrence of predetermined screener items from both partners, done manually in the developmental phase and electronically in the pilot-testing phase. A system of decision rules was developed to assess the validity that data came from two unique partners of a couple.

Results

Several important lessons were learned from these experiences, resulting in recommendations for future eHealth studies involving male couples. Use of certain “interests” and types of images (eg, shirtless) in targeted Facebook advertisements should be avoided or used sparingly because these interests and types of images may generate adverse reactions from a broader audience. Development of a systematic approach with predetermined criteria and parameters to verify male couples’ relationships is strongly recommended. Further, researchers are encouraged to develop a system of decision rules to detect and handle suspicious data (eg, suspicious email addresses/names, multiple entries, same IP address used in multiple entries) to help validate the legitimacy of male couples’ relationships online.

Conclusions

These lessons learned combined with recommendations for future studies aim to help enhance recruitment efforts and the validity and reliability of collecting dyadic data from male couples for novel eHealth HIV-preventive interventions.

The HOPE social media intervention for global HIV prevention in Peru: a cluster randomised controlled trial

BACKGROUND

Social media technologies offer new approaches to HIV prevention and promotion of testing. We examined the efficacy of the Harnessing Online Peer Education (HOPE) social media intervention to increase HIV testing among men who have sex with men (MSM) in Peru.

METHODS

In this cluster randomised controlled trial, Peruvian MSM from Greater Lima (including Callao) who had sex with a man in the past 12 months, were 18 years of age or older, were HIV negative or serostatus unknown, and had a Facebook account or were willing to create one (N=556) were randomly assigned (1:1) by concealed allocation to join intervention or control groups on Facebook for 12 weeks. For the intervention, Peruvian MSM were trained and assigned to be HIV prevention mentors (peer-leaders) to participants in Facebook groups. The interventions period lasted 12 weeks. Participants in control groups received an enhanced standard of care, including standard offline HIV prevention available in Peru and participation in Facebook groups (without peer leaders) that provided study updates and HIV testing information. After accepting a request to join the groups, continued participation was voluntary. Participants also completed questionnaires on HIV risk behaviours and social media use at baseline and 12 week follow-up. The primary outcome was the number of participants who received a free HIV test at a local community clinic. The facebook groups were analysed as clusters to account for intracluster correlations. This trial is registered with ClinicalTrials.gov, number NCT01701206.

FINDINGS

Of 49 peer-leaders recruited, 34 completed training and were assigned at random to the intervention Facebook groups. Between March 19, 2012, and June 11, 2012, and Sept 26, 2012, and Dec 19, 2012, 556 participants were randomly assigned to intervention groups (N=278) or control groups (N=278); we analyse data for 252 and 246. 43 participants (17%) in the intervention group and 16 (7%) in the control groups got tested for HIV (adjusted odds ratio 2·61, 95% CI 1·55–4·38). No adverse events were reported.

INTERPRETATION

Development of peer-mentored social media communities seemed to be an efficacious method to increase HIV testing among high-risk populations in Peru. Results suggest that the HOPE social media intervention could improve HIV testing rates among MSM in Peru.

FUNDING

National Institute of Mental Health.

The Feasibility and Acceptability of Using Technology-Based Daily Diaries with HIV-Infected Young Men Who have Sex with Men: A Comparison of Internet and Voice Modalities

This study delivered a daily diary to 67 HIV-infected men who have sex with men (MSM) between 16 and 24 years old for 66 days to measure HIV-risk behaviors and other psychosocial variables via two diary modalities: internet (accessible via any web-enabled device) and voice (accessible via telephone). Participants were randomized to complete one diary modality for 33 days before switching to the second modality for 33 days. The study was implemented in three urban HIV health care centers in the United States where participants were receiving services. Through diary data and qualitative interview data, we examined the feasibility and acceptability of the dairies and identified barriers and facilitators of dairy compliance. Results show high participant retention in the daily diary (93.4 %) and high compliance for the number of dairies completed (72.4 %). Internet diaries were preferred by 92 % of participants and completed at a significantly higher rate (77.5 %) than voice diaries (67.7 %). Facilitators included opportunities for self-reflection and cathartic sharing, monetary compensation, relationships with study staff, and daily reminders. Barriers included being busy or not having privacy at the time of reminders, forgetting, and falling asleep. Participants also described barriers and facilitators unique to each modality. Overall, both modalities were feasible and acceptable for use with our sample of HIV-infected MSM.

Project SMART: Preliminary Results From a Test of the Efficacy of a Swedish Internet-Based HIV Risk-Reduction Intervention for Men Who Have Sex With Men

In Sweden, 57 % of HIV transmission occurs among MSM, and other sexually transmitted infections are increasing, supporting the need for innovative interventions. The Internet is a potentially useful HIV-prevention platform, but there is a lack of such programs in Sweden. The purpose of this exploratory study was to test the efficacy of the Internet-based SMART intervention to decrease HIV sexual risks in Swedish MSM. The intervention was adapted from the Wyoming Rural AIDS Prevention Project to the Swedish context, which was guided by the Information-Motivation-Behavioral (IMB) skills model and consisted of six sessions. A total of 112 men responded to a pretest questionnaire and were randomly assigned to the SMART intervention or to a waitlist group. Fifty-four men dropped out, leaving a final sample of 58 participants. Twenty-five were assigned to the SMART intervention and 33 to a waitlist group. One month post intervention, the number of casual anal sex partners significantly decreased (t = 2.19, p = .04). Compared with the waitlist group, men in the intervention group increased their HIV knowledge (β = 0.70, p = .01), their belief of condom use as an act of responsibility (β = 1.19, p = .04), their willingness to use a condom with every new partner all the time (β = 1.39, p = .03), and their confidence in using condoms in challenging situations (β = 1.65, p = .02). Condom use was not analyzed due to the small sample size. Despite the small sample, high drop-out, and short follow-up, the study provides support for the efficacy of the Internet interventions, the SMART intervention specifically, for reducing the proportion of casual anal sex partners and improving the three cognitive components of the IMB model for Swedish MSM.

Online Versus Telephone Methods to Recruit and Interview Older Gay and Bisexual Men Treated for Prostate Cancer: Findings from the Restore Study

Background

Recently, researchers have faced the challenge of conflicting recommendations for online versus traditional methods to recruit and interview older, sexual minority men. Older populations represent the cohort least likely to be online, necessitating the use of traditional research methods, such as telephone or in-person interviews. By contrast, gay and bisexual men represent a population of early adopters of new technology, both in general and for medical research. In a study of older gay and bisexual men with prostate cancer, we asked whether respondents preferred online versus offline methods for data collection. Given the paucity of research on how to recruit older gay and bisexual men in general, and older gay and bisexual men with prostate cancer in particular, we conducted an observational study to identify participant preferences when participating in research studies.

Objective

To test online versus offline recruitment demographic data collection, and interview preferences of older gay and bisexual men with prostate cancer.

Methods

Email blasts were sent from a website providing support services for gay and bisexual men with prostate cancer, supplemented with an email invitation from the web-host. All invitations provided information via the study website address and a toll-free telephone number. Study tasks included respondents being screened, giving informed consent, completing a short survey collecting demographic data, and a 60-75 minute telephone or Internet chat interview. All materials stressed that enrollees could participate in each task using either online methods or by telephone, whichever they preferred.

Results

A total of 74 men were screened into the study, and 30 were interviewed. The average age of the participants was 63 years (standard deviation 6.9, range 48-75 years), with most residing in 14 American states, and one temporarily located overseas. For screening, consent, and the collection of demographic data, 97% (29/30) of the participants completed these tasks using online methods. For the interview, 97% (29/30) chose to be interviewed by telephone, rather than Internet chat.

Conclusions

Older gay and bisexual men, when given choices, appear to prefer a mixed methods approach to qualitative investigations. For most aspects of the study, the older men chose online methods; the exception was the interview, in which case almost all preferred telephone. We speculate that a combination of the deeply personal nature of the topic (sexual effects of prostate cancer treatment), unfamiliarity with online chat, and possibly the subject burden involved in extensive typing contributed to the preference of telephone versus online chat. Recruitment of older men into this study showed good geographic diversity. We recommend that other qualitative researchers consider a mixed methods approach when recruiting older populations online.

Correlates of a Single-Item Indicator Versus a Multi-Item Scale of Outness About Same-Sex Attraction

In this study, we investigated if a single-item indicator measured the degree to which people were open about their same-sex attraction ("out") as accurately as a multi-item scale. For the multi-item scale, we used the Outness Inventory, which includes three subscales: family, world, and religion. We examined correlations between the single- and multi-item measures; between the single-item indicator and the subscales of the multi-item scale; and between the measures and internalized homonegativity, social attitudes towards homosexuality, and depressive symptoms. In addition, we calculated Tjur's R (2) as a measure of predictive power of the single-item indicator, multi-item scale, and subscales of the multi-item scale in predicting two health-related outcomes: depressive symptoms and condomless anal sex with multiple partners. There was a strong correlation between the single- and multi-item measures (r = 0.73). Furthermore, there were strong correlations between the single-item indicator and each subscale of the multi-item scale: family (r = 0.70), world (r = 0.77), and religion (r = 0.50). In addition, the correlations between the single-item indicator and internalized homonegativity (r = -0.63), social attitudes towards homosexuality (r = -0.38), and depression (r = -0.14) were higher than those between the multi-item scale and internalized homonegativity (r = -0.55), social attitudes towards homosexuality (r = -0.21), and depression (r = -0.13). Contrary to the premise that multi-item measures are superior to single-item measures, our collective findings indicate that the single-item indicator of outness performs better than the multi-item scale of outness.