High prevalence of self-reported sexually transmitted diseases among older adults in Tanzania: results from the list experiment

In 2020, there were estimated 374 million new infections of four curable sexually transmitted infections (STIs) (chlamydia, gonorrhea, syphilis, and trichomoniasis) among people aged 15-49 years worldwide, and about 26% (96 million) of these occurred in the African region [1]. In 2016, the World Health Organization made a global priority to better understand the epidemiology of STIs and strengthen STIs screening and treatment programme at national and regional levels [2]. In East Africa, the prevalence of chlamydia and other STIs (except HIV) is estimated approximately 3% among individuals aged 15-49 years in clinic or community settings and 10% in high-risk groups [3]. However, the current surveillance of STIs largely focus on individuals at reproductive age, and there are no estimates available among adults aged ≥50 years.

The society often considers that “older people” do not engage in sexual behaviors therefore not at risk of acquiring STIs, which is clearly misconception [4], [5]. There is a trend for increasing STIs in older populations across the globe including North America [4], Asian regions [6], [7], and sub-Sharan Africa (SSA) [8], [9]. In SSA, the region accounting for more than 70% global burden of HIV infection [10], the emerging epidemic of STIs occurs in parallel as the life expectancy in the population including those living with HIV increases [11]. People living with HIV are also ageing across SSA [12], [13]. For example, about 15% of people enrolled in the HIV care and treatment programme were at the age of ≥50 years in Tanzania [14].

In many low-and-middle-income settings with lack of routine laboratory diagnosis for STIs surveillance, the Demographic and Health Survey (DHS) measures self-reported data for STIs and sexual behaviours. However, self-reported measurement of sexual behaviors is subject to biases such as interviewers bias or social desirability bias, leading to under- or over-estimation of sexual behaviors [15], [16], [17]. Computer-assisted self-interview (CASI) is an alternative way of face-to-face interviews to standardize data collection and reduce interview-related variability in responses [18] and has been shown feasible for completing quantitative sexual behaviour questionnaires [19]. However, several studies have shown that CASI surveys for sexual behaviors do not necessarily yield more accurate estimates, and responses can greatly vary compared to face-to-face interviews [16].

List experiment is a methodology that can be used to indirectly ask questions about sensitive items, such as sexual behaviors or stigmatized health events, and obtain more accurate estimates of prevalence while mitigating the effect of social desirability bias [20]. Respondents are more likely to honestly report as responses are collected only in an aggregate estimation without revealing answers to specific items. It has been used to measure risky sexual behaviour [21], illicit drug use [22], and abortion [23] in the health research and other social science fields [24]. To our knowledge, no study has applied the list experiment to measure the prevalence of STIs. The objective of this study is to estimate the underlying rate of experiencing STIs in the recent year among older adults in urban Tanzania using list experiment and to compare that with the estimate from direct questioning.

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