AIDS: An understanding in rural women of South-India

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1 Original Article AIDS: An understanding in rural women of South-India Thilakavathi Subramanian, M. D. Gupte, R. Ezhil National Institute of Epidemiology, ICMR, Chennai, India Correspondence: Thilakavathi Subramanian, Asst. Director, National Institute of Epidemiology, Indian Council of Medical Research, Second Main Road, Tamil Nadu Housing Board, Ayapakkam, Chennai , Tamil Nadu, India. nieicmr@vsnl.com Abstract The study aims to find out the knowledge and understanding of acquired immunodeficiency syndrome (AIDS) in 1,200 randomly selected women in the age group of years, of 16 villages belonging to Villupuram Health Unit District, Tamil Nadu, India, using a two-stage sampling design. Data collection was done in the period from August to November 2001, using both qualitative and quantitative methods. In all, 28% of the women had not heard of AIDS at all. More than one-third of the women who had heard of AIDS considered AIDS as a serious illness; and among them, 72% ranked AIDS as the number one killer disease. The main findings showed that the rural women s knowledge was poor in areas like cause, symptoms and prevention. Level of literacy of the women was signifi cantly associated with their knowledge of HIV/AIDS (P<0.05), showing that literates had better knowledge than illiterates. Also, there were misconceptions and false beliefs about cause and spread of the infection, which were found to be more prevalent among illiterates. Television was found to be the major source of knowledge on AIDS among both literates and illiterates. This study suggests a need for innovative, group-based repeated education on AIDS, particularly for rural women, in order to impart better knowledge and understanding on AIDS. Key words: Acquired immunodefi ciency syndrome, rural women, understanding INTRODUCTION Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that 39.5 million people worldwide were living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) by the end of In this, women accounted for 48% of all adults living with HIV. [1] In India there were 5.2 million estimated HIV infections in 2005, with 38.4% being women and 57% of these infections were in rural areas. [2] At present, almost half of the new infections are in women. Young women get infected with HIV faster than any other population group. [3] A rural-based study [4] conducted in Tamil Nadu showed an overall HIV seroprevalence of 1.8% in the general community, and the rate was found to be more in rural areas (2.1%) than in urban areas (0.7%); and also higher in females (2.0%) than in males (1.4%). A study among rural tribal community [5] showed that AIDS awareness among women was lower than that among men (14% vs. 30%). Few studies in India attribute the prevalence of HIV/AIDS to the low level of awareness of HIV/AIDS in women in general and rural women in particular. [6-8] The inability of women to control the factors that place them at risk of HIV infection is compounded by the fact that many societies define the social and cultural identity of women primarily through their role as child bearers and child rearers. [9] Social and cultural determinants relating to women s dependency on men and their general lower level of education and lower access to resources are accentuated in the area of health care, particularly in their incapacity to protect themselves from sexually transmitted infections. [10] The economic dependency, coupled with illiteracy and ignorance, particularly in rural women, increases their risk of exposure to HIV infection. If we need to slow down AIDS, understanding its distribution and determinants is very essential. In order to find out How to cite this article: Subramanian T, Gupte MD, Ezhil R. AIDS: An understanding in rural women of South-India. Indian J Sex Transm Dis 2007;28: Indian J Sex Transm Dis 2007; Vol. 28, No. 1

2 the views on, and understanding of, AIDS prevalent among rural women, a pilot study was conducted in a village at Villupuram district, Tamil Nadu, covering 262 eligible women. The results showed 78% of the women had heard of HIV/AIDS, and only about 25% of the females were aware of some of the basic facts related to spread and prevention of HIV/AIDS. Based on the pilot study, main study was conducted with the aim to find out the rural women s knowledge and understanding of HIV/AIDS. MATERIALS AND METHODS The study was carried out in Villupuram Health Unit District, Tamil Nadu. Based on the pilot study, an estimated sample size of 1,200 women in the age group of years was randomly selected using a two-stage sampling design. A sample of 75 women from each of the 16 selected villages, with 1 woman from each of the 75 selected households, was recruited. In the first stage, a random sample of 16 villages was selected based on the 1991 census using probability proportionate to size (PPS) technique. In the second stage, a simple random sample of 75 households was selected from each of the selected villages. If the number of eligible respondents was more than one in a household, the names of such respondents were listed in order according to their age and one person was selected randomly, using the random number table. Qualitative methods like free listing and ranking were used to collect data on how the respondents identified the seriousness of AIDS. Also, a semi-structured pretested interview schedule was used to collect data. The interview schedule mainly contained questions on cause, mode of spread, investigations to be done, who all could get infected, symptoms and availability of treatment and vaccine. Statement response technique was used by giving 25 statements on various aspects of HIV/AIDS to find out whether the respondents agreed or disagreed with the given statements, in order to find out their beliefs and misconceptions attached to HIV/AIDS. There were six qualified and trained interviewers used for data collection. Before proceeding with the data collection, the field staff was given enough training on qualitative and quantitative methods of data collection. RESULTS Basic characteristics of the 1,200 respondents are given in Table 1. More than half of the respondents (51.8%) were years of age. Eighty-two percent were married, more than half the respondents (50.8%) were illiterates and nearly half (48.1%) were agricultural coolies. The respondents were asked to list down Table 1: Basic characteristics of the respondents Characteristics No. (n = 1,200) % Age (in years) Marital status Married Unmarried Widowed/divorced Religion Hindu Christian Muslim Education Illiterate Primary school High school and above Occupation Unemployed Agri. Cooly Self-employed Permanent job Student Others names of fatal/killer diseases that they knew. In this, 486 (40.5%) women included AIDS in the listing. From this listing, they were asked to rank the names of diseases in the order of seriousness. Among the persons who had included AIDS in their listing, 350 (72%) ranked it as number one killer disease. Women who had not included AIDS in their listing ( %) were asked whether they had heard of AIDS. In this, 386 (54%) women mentioned Yes and 46% said that they had not heard of AIDS. In all, 336 (28%) women had not heard of AIDS at all. The socio-demographic variables and the number of women who had heard of AIDS were compared using Chi-square test. Variables such as the village in which the responded resided, the respondent s age, education, marital status and occupation were found to be statistically associated, showing differences in each category [Table 2]. In order to examine the effect of rural women s education on the probability of their having heard of AIDS, logistic regression technique was employed [Table 3]. It was found that women who had primary education had a 4.4 times probability of having heard of AIDS compared to the corresponding probability among women who were illiterates; and in the case of women who had above primary education, this probability was 10.4 times. Further analysis was done in the case of women Indian J Sex Transm Dis 2007; Vol. 28, No. 1 11

3 Table 2: Variables associated with Heard of acquired immunodeficiency syndrome univariate analysis Variables χ 2 d.f. P-value Village < Age < Education < Religion >0.05 Marital status <0.01 Occupation < Table 3: Variables associated with Heard of acquired immunodeficiency syndrome multivariate logistic regression analysis Characteristic Adjusted OR 95% C. I. P-value Age (in yrs) < >0.05 > Religion Hindu >0.05 Others 0.8 Marital status Unmarried >0.05 Married 1.1 Occupation Housewife <0.01 Employed 0.6 Education Illiterates < Primary school < Above primary 10.4 who had heard of AIDS (n = 864; 72%). As regards the cause for this infection, 4% [Table 4] mentioned through germs, and one female who was literate said virus. On the whole, 81% of the women had no idea about the cause. For the question on symptoms of AIDS, 28% mentioned of fever and 39% about weight loss. In this aspect, correct response was more from literates. The non-availability of vaccine and treatment for the cure of AIDS was reported by 45% and 58% of the women respectively. Majority (84%) of them mentioned that all (men, women and children) are prone to get this infection; however, 10.1% had no idea about the same. As regards the investigations to be done for diagnosing HIV infection, 44% of the illiterates and 62% of the literates were aware of blood test. However, 39% had no idea. With respect to spread of HIV, 52.5% [Table 5] of the women mentioned that it was through unprotected sexual contact. There was no significant difference in this response among the literates and illiterates (P>0.05). While 13.2% of the illiterates and 26.9% of the literates said through infected blood, infected mother to child was reported by Table 4: Acquired immunodeficiency syndrome awareness according to literacy Awareness Illiterates Literates Total (n = 338) (n = 526) (n = 864) Cause Germs Mosquitoes/flies Sexual intercourse Others No idea Symptoms* Fever Weight loss Cough Dysentery Skin problem Others No idea Vaccine Available Not available No idea Treatment (for cure) Available Not available No idea Affects All Others No idea Investigations* Blood test Others No idea *Some of the respondents gave more than one response Table 5: Knowledge on spread and preventive measures according to literacy Knowledge Illiterates Literates Total (n = 338) (n = 526) (n = 864) % % % On spread Through unprotected sexual contact Through infected blood Infected mother to child Others No idea On prevention Avoid unprotected sex Use disposable needles/syringes/ test blood before transfusion Use nirodh Others No idea Indian J Sex Transm Dis 2007; Vol. 28, No. 1

4 0.6% in total, who were all literates. With respect to prevention of AIDS, 45% mentioned of avoiding unprotected sexual contacts; nearly one-fifth of the women reported of the use of disposable/ sterilized needles and syringes. In this aspect, correct response was more (24.2%) from literates. In all, use of condom was mentioned by only 2.5% of the women. Since there are a number of beliefs and misconceptions associated with cause, spread and prevention of AIDS, in order to assess their knowledge in these areas, statement response technique was used by giving 25 statements and getting their responses. The analysis showed more literates got a satisfactory score (above 80% correct answers), and 59% of the illiterates got a fair score (64-80%). It was observed that there was a significant difference with respect to literacy level and correct response in the areas such as place of occurrence of HIV infection, nature, stigma, misconception and ignorance on spread of AIDS [Table 6]. With respect to the source of their knowledge of AIDS, in all, television ranked first (59%) as a major source of providing information. Next position for literates was radio; and for illiterates, it was through their friends. When these women were asked about their opinion on knowledge of AIDS, generally in villages, nearly two-thirds of them (61%) said the awareness was there to some extent in villages. DISCUSSION Table 6: Knowledge of acquired immunodeficiency syndrome This study showed that a little above one-fourth of the rural women had not heard of AIDS at all. In the free-listing of serious illnesses, 41% had included AIDS as one of the serious illnesses; and among them, nearly three-fourths had ranked AIDS S. No. Statement Illiterates Literates (n = 338) (n = 526) Correct % Wrong % Correct % Wrong % 1. Children will not get AIDS AIDS has not affected the people from India; it affects only people in abroad 3. Women will get AIDS easily AIDS can be cured People from the city only will get affected; not from the villages* 6. AIDS is a hereditary disease* Prostitutes only will get AIDS easily If a person is infected once, he is infected throughout his life 9. Persons who have AIDS should be isolated from the family and society* 10. AIDS is a sexually transmitted disease* When we have sex with an unknown person for the first time we will not get AIDS 12. From the infected pregnant mother to the child AIDS can spread 13. By touching the infected person* Working with the infected person in the same place* By donating blood Eating the food prepared by the infected person* Transfusing infected blood Using the vessels, mat and clothes, used by the infected person* 19. Sharing the food, coffee, tea, etc. with the infected person 20. Using unsterilized/infected needles, blades and knives By tattooing Kissing the infected person* Having sexual intercourse with an unknown person AIDS can be prevented by using nirodh whenever convenient* 25. By using nirodh at every sexual intercourse, when there is more than on sexual partner *Significant (P< 0.05), AIDS - Acquired immunodeficiency syndrome Indian J Sex Transm Dis 2007; Vol. 28, No. 1 13

5 as number one killer disease. As expected, level of literacy was found to be closely associated with their knowledge of HIV/ AIDS, as literate women were found having better awareness than the illiterates, particularly in the areas such as cause, spread and nature of the disease. Misconceptions and wrong beliefs associated with HIV/AIDS were found to be more prevalent among women who were illiterates. Major source of their awareness of HIV/AIDS was television. Similarly in a study [7] conducted on AIDS awareness and knowledge of Indian women covering 13 states, including Tamil Nadu, low rates of knowledge and awareness were reported more among rural and illiterate women. Multivariate analysis found rural, poorly educated and poor women to be the least likely to be AIDS-aware and, if aware, to be having the poorest understanding of AIDS. It was also reported [6] that only about one-sixth of the women had ever heard of AIDS; and among them, 18% could not identify a single mode of transmission and 42% believed that AIDS could be transmitted through kissing. AIDS knowledge was more among those older than 20 years, urban residents, more educated women and those who had greater exposure to mass media. Television was the greatest source of AIDS information. Another study conducted in a rural area near Delhi and Haryana [10] revealed that only 12% of the rural women had heard of AIDS, and all those who had heard of AIDS knew of the sexual route of transmission. Mass media and friends were mentioned as major sources of information on HIV/AIDS for this group. In the present study, 72% had heard of AIDS; and among them, more than half were aware of the sexual route of transmission. Also, television, radio and friends were reported as the main sources of information on AIDS in the present study. Another study conducted in Maharashtra and Tamil Nadu [8] showed that although 47% of all rural women in Maharashtra were aware of AIDS, only about 28% knew that one could avoid it; and only about 16% possessed correct knowledge about its transmission. In Tamil Nadu, where overall 82% of rural women had awareness of AIDS, about 71% knew that one could avoid the disease; but only about 31% possessed correct knowledge about its transmission. In the present study, more than half of the women were aware of transmission of HIV through unprotected sexual contact. (94%) had heard of HIV/AIDS and 60% of them had relatively good knowledge regarding risk factors for HIV transmission. However, 48% did not know that there are means to prevent mother-to-child HIV transmission. [11] In the present study, many of them were not aware of mother-to-child transmission (99.4%). Though a number of IEC programs are organized by governmental and non-governmental institutions in various places, including villages, the present lower level of the basic knowledge required indicates the need for imparting innovative, group-based repeated education about AIDS to these rural women. ACKNOWLEDGMENT The authors are thankful to Mr. Paul A. Tamby, Systems Analyst, and his team for data processing and data management. The authors also thank the interviewers for data collection and the women participants, for their coopeartion to be our respondents. REFERENCES 1. UNAIDS/WHO AIDS Epidemic Update: December National AIDS Control Organization (NACO), Ministry of Health and Family Welfare, Government of India, HIV/AIDS epidemiological, Surveillance and Estimation report for the year Madhivanan P, Newsmann S, Sarin P. Issues affecting Women with HIV/AIDS in India, HIV-INDIAN SCENE-Proceedings of Dicennial Commemoration Conference of Indo-UK Link Project on HIV/AIDS. Chennai; p : Krishnamurthy P. Community Prevalence of STD in Tamil Nadu: A research study of APAC-VHS-USAID. HIV-INDIAN SCENE-1999, Proceedings of Dicennial Commemoration Conference of Indo-UK Link Project on HIV/AIDS. Chennai; p : Naik E, Karpur A, Taylor R. et al. Rural Indian tribal communities: An emerging high-risk group for HIV/AIDS. BMC Int Health Hum Rights 2005;21:1. 6. Lahiri S, Balk D, Pathak KB. Women in 13 states have little knowledge of AIDS. Natl Fam Health Surv Bull 1995;2: Balk D, Lahiri S. Awareness and knowledge of AIDS among Indian women: Evidence from 13 States. East-west Center Working papers, Population Series. 1996: Pallikadavath S, Sannath A, McWhirter JM, Stones RW. Rural women s knowledge of AIDS in the higher prevalence states of India: Reproductive health and sociocultural correlates. Health Promot Int 2005;20: Julie H, Elizabath R. Women, the HIV epidemic and human rights: A tragic imperative. UNDP 1993;8: Chuttani C, Gupta SP, Chaturvedi TV. Awareness and knowledge about AIDS among rural population in India. CARC Calling 1990;3: Rogers A, Meundi A, Amma A, Rao A, Shetty P, Antony J, et al. HIV- related knowledge, attitudes, perceived benefits and risks of HIV testing among pregnant women in rural southern India. AIDS Patient Care STDs 2006;20: Among pregnant women in rural southern India, [11] out of the total 202 women surveyed, 189 women Source of Support: Nil, Conflict of Interest: None declared. 14 Indian J Sex Transm Dis 2007; Vol. 28, No. 1

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