Lost in Translation: Language, Terminology, and Understanding of Penile–Anal Intercourse in an HIV Prevention Trial in South Africa, Uganda, and Zimbabwe

Abstract

Despite efforts to use culturally appropriate, understandable terms for sexual behavior in HIV prevention trials, the way in which participants interpret questions is underinvestigated and not well understood. We present findings from qualitative interviews with 88 women in South Africa, Uganda, and Zimbabwe who had previously participated in an HIV prevention trial. Findings suggested that participants may have misinterpreted questions pertaining to penile–anal intercourse (PAI) to refer to vaginal sex from behind and subsequently misreported the behavior. Three key issues emerge from these findings: first, the underreporting of socially stigmatized sexual behaviors due to social desirability bias; second, the inaccurate reporting of sexual behaviors due to miscomprehension of research terms; and third, the ambiguity in vernacular terms for sexual behavior and lack of acceptable terms for PAI in some languages. These findings highlight methodological challenges around developing clear and unambiguous definitions for sexual behaviors, with implications not only for clinical trials but also for clinical practice and sexual risk assessment. We discuss the challenges in collecting accurate and reliable data on heterosexual PAI in Africa and make recommendations for improved data collection on sensitive behaviors.

Reported oral and anal sex among adolescents and adults reporting heterosexual sex in sub-Saharan Africa: a systematic review

“…Male participants reported that engaging in anal sex could cause blockage of the anus and urinary system, and cancer. Both male and female participants believed that anal sex is risky and there was a need to use condom during anal sexual act.low risk of bias Duby et al 2016 [123, 159]South Africa; Uganda; ZimbabweQualitativePurposive sampling; 88 In-depth interviewsAdult women in community (GP)F: NSSome participants expressed “shock”, “disbelief”, “disgust”, “embarrassment” and “denial” about anal sex. Some believed that anal sex should not be openly discussed.…”

“…In addition to reporting gender reporting bias discussed above, there is likely to be under-reporting of these sensitive behaviours due to social desirability bias, especially for heterosexual anal sex, since this practice is not well accepted in some communities [101, 102, 159]. Many studies were assessed as having a high-risk of bias and did not provide information on how their sample sizes were determined.…”

What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis

“…It is clear from this review and others [37,38] that data collection on AI practice requires improvement, especially given how effectively HIV is transmitted during AI and how commonly it is practiced. Previous research suggests that survey items must be carefully piloted in order to minimise misunderstanding and that one effective approach may be the use of pictograms to unambiguously clarify what is meant by AI [44]. Using confidential interview methods would help reduce social-desirability bias.…”

Landscape of Oncology Clinical Trials in Africa

“…Readability and understandability of the usually long informed-consent document has been disputed, considering the varying levels of literacy among participants and numerous languages and dialects for the translation of the documents. 11 , 12 Specific to oncology clinical trials in Africa is that patients with cancer are a vulnerable population with unique needs. 13 Therapeutic misconception is common: Patients agree to participate in clinical trials without being aware of nonbeneficence but believing they will obtain better quality treatment through the clinical trials because ancillary care is scarce in limited resource settings such as Africa.…”