Knowledge and perception on HIV/AIDS among the Kanuri and Shuwa people of northern Nigeria in relation to their traditional practices

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1 Knowledge and perception on HIV/AIDS among the Kanuri and Shuwa people of northern Nigeria in relation to their traditional practices 1 A Bukar, 2 O Olasoji, 1 OA Adeleke, 1 IS Danfillo, 1 OO Taiwo, 1 PH Jalo 1 Regional Centre for Oral Health Research and Training Initiatives (RCORTI) for Africa (in collaboration with the World Health Organization), Jos. Nigeria 2 University of Maiduguri Teaching Hospital, Department of Dental Surgery, Borno State Correspondence A Bukar, Regional Centre for Oral Health Research and Training Initiatives (RCORTI) for Africa, PMB 2067, Jos. Nigeria bukaradam@hotmail.con Key words: HIV/AIDS, traditional oral health practices, tattoo, Kanuri, Shuwa SUMMARY Among the Kanuri and Shuwa peoples of northern Nigeria, tattooing of lips by young girls and women is fashionable and is seen as enhancing the beauty and value of the women. A cross-sectional study was conducted to assess the knowledge and perception of HIV/AIDS among the Kanuri and Shuwa peoples in relation to traditional oral tattoo practices. A total of 1202 persons (50.4% males) responded to the questionnaire. The mean age of the subjects was (± 4.05). The majority had no formal education, and the 21-30yrs age group formed the largest proportion (32.3%). Eighty-eight percent of the respondents have heard about HIV/AIDS, out of which 53.6% were males. Only 10.5% believe that HIV/AIDS can be transmitted through traditional tattooing. Most (89.4%) will allow their daughters to be tattooed. The majority (88.4%) believe tattooing will continue for a long time. Despite the high risk of transmission of HIV/AIDS through tattooing, many people are not aware of such risk and still indulge in the practice. INTRODUCTION The acquired immunodeficiency syndrome (AIDS) has become one of the most devastating diseases that humankind has ever experienced. Globally, about 44.3 million adults and children were living with the human immunodeficiency virus (HIV/AIDS) as at the end of About 4.9 million people acquired the virus in Today, an estimated million people are living with the infection. 2 In Nigeria, the HIV epidemic continues to grow despite efforts to control it. With an estimated 5.8% of the population (7.1 million persons) already infected at the time of this study, Nigeria placed fourth among countries with the highest number of HIV infected persons worldwide. 3 Differences between the epidemiology of AIDS cases in Africa and that in Western societies have prompted speculations regarding risk factors that may be unique to Africa. 4 Due to the age and sex distribution patterns of AIDS cases in Africa, emphasis has been placed on the sexual transmission of HIV; cultural practices that are possibly connected with increased virus transmission (female circumcision and infibulations); nonsexual cultural practices that do not fit the age distribution pattern of AIDS, but which may expose individuals to HIV because of exposure to blood (eg medicinal bloodletting, rituals establishing blood brotherhood, and possibly, ritual and medicinal enemas); and practices involving the use of shared instruments (injection of medicines, ritual scarification, group circumcision, genital tattooing, oral tattooing, other body tattooing, tribal markings and shaving of body hair with unsterilized blades). 4-7 Most of these traditional practices are carried out in groups by traditional birth attendants, tattooists, and local 36 Volume 1 Number

2 barbers. 6,7 preventive interventions targeted at vulnerable populations engaging in such practices is one of the realistic strategies for controlling the further spread of HIV in the country. Worldwide experience suggests that for as long as a vaccine or cure has not been developed, 8 public knowledge of HIV/AIDS is the most fundamental weapon against the HIV/AIDS pandemic. The level of knowledge of the population is thus an important index by which governments can measure the magnitude of, and understand the challenges with which they have to contend. 9 Traditional oral health practices among the Kanuri and the Shuwa include use of chewing sticks such as Salvadora persica, Azadirachta indica and Eucalyptus camaldulensis to clean their teeth. The women also stain their teeth using flowers of Solanum incanum and Nicotiana tabacum. The Kanuri and Shuwa women of northeastern Nigeria have been known to practice gingival and lip tattooing. 7 Tattooing involves piercing the lips and the gingiva using thorns, needles and syringes. Apart from the thorns which are only used on one person, the same needles and syringes are frequently used on several persons. Tattooing using these methods is always accompanied by severe bleeding. Many researchers have pointed out the possibility of HIV transmission through such procedures. 10 To assess the prospects of adopting changes in behaviour that are effective and preventive, it is crucial to ascertain current levels of the knowledge of HIV/AIDS among the Kanuri and Shuwa peoples and their perception of HIV/AIDS in relation to traditional oral tattoo practice. MATERIALS AND METHODS STUDY AREA AND STUDY PERCEPTION The study area comprised two local government areas (LGAs) in Borno State, selected out of the 18 local government areas where traditional oral health is widely practiced. Then 8 communities were chosen from each LGA by a simple random sampling technique making a total of 16 communities. The Kanuri (and by association the Shuwa people) are widespread in many parts of sub-saharan Africa; the greater majority still reside in the vicinity of Lake Chad. 1 It is the fifth largest ethnic group in Nigeria, numbering about 4% of the total Nigerian population of about 123 million. 11 The Kanuri are a widespread tribe in 18 of the 27 local government areas of Borno State in northeastern Nigeria, which is bounded by the republics of Niger in the north, and Chad and Cameroon in the east. 7 The study population was made up of traditional tattooists, women who had tattoos and men. The Borno State Ministry of Health and the responsible local authorities were informed of the study objectives and their written consent was obtained. Verbal consent was also obtained from the household heads and the respondents. METHODS A cross sectional study to assess the knowledge and perceptions of Kanuri and Shuwa peoples on HIV infection/aids in relation to traditional oral health practices focused on the Kanuri and Shuwa peoples of northern Nigeria. A previous study 7 from these areas showed the prevalence of oral tattoos at 44%, from an approximate sample size of 400 women. For the traditional tattooist, an inverse sampling 12 procedure was adopted. Selection of the men and women was done by proportionate sampling according to the population of the selected com-munities. At each location, the first house was selected using the spinthe-bottle technique, 13 and subsequent houses were taken by serial proximity until the required sample size was obtained for the locality. A questionnaire on the knowledge and perception of HIV/AIDS and the effect of this knowledge on traditional oral health practices was administered on the respondents by a trained researcher. Data were analyzed using SPSS version 11.0; the chi-square (X 2 ) test was used to calculate significant differences among proportions of categorical variables. P-values less than 0.05 were considered significant. RESULTS SOCIO-DEMOGRAPHIC CHARACTERISTICS A total of 1202 persons of which 50.4% were men responded to questions aimed at assessing their knowledge and perception of HIV infections and traditional oral health practices among indigenous African communities. The mean of age of the study subjects was (± SD 14.05,) however, the largest proportion (32.3%) of the respondents was in the age group 21 to 30. The majority (66.9%) had never attended the public school system and they could not Volume 1 Number

3 read or write; and 80% were married. The sociodemographic characteristics of the study subjects are shown in table 1. KNOWLEDGE AND PERCEPTION OF HIV/AIDS Table 2 shows that 88% of the respondents have heard about HIV/AIDS. Table 3 describes the knowledge and perception of HIV/AIDS by respondents, who have heard about HIV/AIDS, of which 53.6% were males. With the exception of location and occupation, all the other socio-demographic factors (age group, gender, educational level and marital status) were significantly associated with knowledge of HIV/AIDS (table 4). The age group accounted for highest knowledge of HIV/AIDS compared with other age groups. The respondents in age group had the least knowledge of HIV/AIDS. For those who have heard about HIV/AIDS, the majority (68.6%) knew that HIV could be transmitted through sexual intercourse with infected persons; but this dropped to 1.5% for sharing contaminated skin-piercing instruments with infected persons and 0.09% from blood transfusion (table 3). Very few (11.3%) of the respondents were able to identify three different modes of transmission of HIV/AIDS. On the other hand, 3.9% believed that a cure is available for AIDS. EFFECTS OF KNOWLEDGE OF HIV/AIDS ON TRADITIONAL TATTOO PRACTICES Among those who have heard about HIV/AIDS, most (62.7%) of the men and 37.3% of the women believe that HIV/AIDS could be transmitted through tattooing (table 5). Except for marital status, all other demographic variables are significantly associated with knowledge of HIV/AIDS transmission through tattooing (table 5). It is rather disturbing that among those who believe that HIV/AIDS can be transmitted through tattooing, 61.2% males and 38.8% females would still allow their daughters to be tattooed (table 6). Age group and location are positively associated with tattooing. The majority (88.6%) of the males who believe HIV/AIDS can be transmitted through tattooing, still prefer women with lip tattoos (table 7). Similarly, almost all (97.8%) of the women said they like their tattoos (table 8). Table 1. Socio-demographic characteristics of respondents Characteristics Number (n) % Age Male Female Urban Rural Secondary Tertiary Divorced Widowed House wife Public Servant Driving Table 2. Knowledge and perception of HIV/AIDS by the respondents (n = 1202) Male Female Total n % n % n % Ever Heard of HIV/AIDS? Yes No DISCUSSION This is the first study that has explored knowledge and perception of Kanuri and Shuwa communities in northern Nigeria on HIV/AIDS in relation to traditional tattooing. Understanding how HIV/AIDS is perceived by various cultural groups is an important first step towards changing behaviour patterns or traditions that put them at risk. Traditional oral health 38 Volume 1 Number

4 Table 3. Knowledge and perception of HIV/AID by those who have heard about HIV/AIDS (n-1058) Male Female Total n % n % n % Do you believe HIV/AIDS exist? Yes No If yes, do you know how it is transmitted? Yes No If yes to above, how is HIV/AIDS transmitted? 1. Sexual Intercourse Contaminated Instruments Blood Transfusion & & , 2 & Is there any cure for HIV/AIDS? Yes No practices, such as tattooing among Kanuri and Shuwa communities remains uncontrolled and is performed by traditional birth attendants (TBAs), local barbers and circumcisionists. Our results provided baseline data on the knowledge and perception of HIV/AIDS and its relation to traditional tattoo practice among the Kanuri and Shuwa communities. The study shows that a majority of the respondents are aware of HIV/AIDS, and have some knowledge of its mode of transmission. Considerable proportions of the respondents associated HIV/AIDS transmission with sexual relations. This is comparable to studies done elsewhere in Nigeria and other African countries However, the finding that only 1.5% knew that HIV/AIDS can be transmitted through the use of contaminated instruments and another 0.9% knew of blood transmission with no mention of mother-tochild transmission (table 3) indicates the absence of health education campaigns among these communities. Similar studies conducted in China and Senegal indicated lack of knowledge about HIV transmission among the general population. 9,13 It was observed in this study that males are more aware of HIV/AIDS and its modes of transmission than females. This finding is comparable to similar studies in (Jos and Zaria) Nigeria 17 and China. 9 Our result is also consistent with a study conducted by the United Nations 18 in 39 African countries where the level of awareness in most of the countries was observed to be higher among men than women. However, these results cannot be generalized across settings. For example, in a study conducted in an Indian community, 19 women were more aware of HIV/AIDS and its modes of transmission than men. In terms of place of residence, our study did not find any correlation between urban and rural populations with respect to knowledge and perception of HIV/AIDS, which is similar to a study conducted in Madagascar 16 where no difference was observed between urban and rural areas. However, this particular finding is in contrast to the UN study 18 which found that urban residents are much more aware of HIV/AIDS than rural populations. This might not be unconnected with the proliferation of mass media outlets, such as radio, television, and newspapers which are far more prevalent in the urban areas. Despite the fact that among the men and women who believe that HIV/AIDS can be transmitted through tattooing, most are still willing to allow their daughters to be tattooed; one reason that can be extrapolated from this may be that the perceived risk is a possibility but not a probability, and therefore it is not a driving force in behaviour change in this population subset. This is an illustration of the complexity of modelling human behaviour and a case can thus be made for further culture-specific HIVbehavioural research. On the other hand, it may also Volume 1 Number

5 be part of the cultural or traditional norm that leaves women with little choice over their exposure to HIV infection. Perhaps these people do not believe they could be at any risk of HIV through such practices. For instance, the 2003 National HIV/AIDS and Reproductive Health Survey in Nigeria reported that 72% of the population believed that they were not at risk at all of contracting HIV. 15 Table 4. Socio-demographic characteristics of the respondents with knowledge of HIV/AIDS (n = 1058) Knowledge of HIV Characteristics Yes No P Value n % n % Male Female Urban Rural Post Divorced Housewife Public servant Driving Table 5. Effect of knowledge of HIV/AIDS on traditional tattoo practices (n = 1058) Knowledge of HIV Characteristics Yes No P Value n % n % Male Female Urban Rural Volume 1 Number

6 Knowledge of HIV Characteristics Yes No P Value n % n % Post Divorced Widowed Housewife Public servant Driving Table 6. Tattooing of daughters among those who believe that HIV/AIDS can be transmitted through tattooing (n = 116) Will you allow your daughter to be tattooed? Characteristics Yes No P Value n % n % Male Female Urban Rural Post Divorced Widowed Housewife Public servant Driving Volume 1 Number

7 Table 7. Male preference for women with tattoos even though they believe that HIV/AIDS can be transmitted through tattooing Do you prefer women with tattoos? (n = 70) Characteristics Yes (n) % Male Post Pry Pub.Servant Driving Table 8. Preferences of women with tattoos among women who believe that HIV/AIDS can be transmitted through tattooing Do you like your tattoos? (n = 46) Characteristics Yes (n) % Female Urban Rural Education status Post Marital status Divorced Widowed Housewife Public servant Volume 1 Number

8 CONCLUSION The growing epidemic of HIV/AIDS requires targeted interventions at populations who are at greatest risk of contracting the infection inadvertently through cultural practices. This study of the Kanuri and Shuwa communities has confirmed that many in this population have participated and are still willing to participate in traditional practices, (such as tattooing) which increases their risk of exposure to HIV/AIDS infection. Tattooing is meant to enhance beauty and attract husbands and it is unlikely to die out. Health promoting practices therefore need to be assimilated. Intensive health campaigns should be targeted at the population and particularly at sensitizing the traditional tattooists and other similar professionals in safe health practices. Religious and community leaders need to be enlightened about their crucial role and responsibility in the prevention and control of HIV/AIDS. In order to prevent the likely transmission of HIV/AIDS in the process of tattooing, every individual needs to informed that needles or syringes should not be shared, but should be used by only one person and then discarded immediately. Since tattoo practitioners are recognized in the society, they should be taught the basic principles of hygiene and infection control. Health workers also need to be encouraged to perform their duties in educating the community on vital health issues. ACKNOWLEDGEMENTS The authors thank all the individuals who accepted to participate in this study and the local government officials for their support. We also thank Prof. Ogunbodede for his contribution in the design of the questionnaire. We also acknowledge the Oral Health Unit of the WHO/AFRO for providing the funding through the Regional Centre for Oral Health Research and Training Initiatives (RCORTI) for Africa, Nigeria. We are especially grateful to Prof. C. Enwonwu (Chairman, RCORTI) for the encouragement he has provided. REFERENCES 1. UNAIDS. AIDS Epidemic Update org./wad 2004/report. 2. The World Health Report Geneva: World Health Organization; Ugboga A.N, Ademola JA. Knowledge of AIDS and HIV risk-related sexual behaviour among Nigerian naval personnel. BMC Public Health 2004; 4:24 4. Daniel BN, Cultural practices contributing to the transmission of human immunodeficiency virus in Africa. Reviews of Infectious Diseases, 1987; 9: Rosalia V. HIV/AIDS knowledge Differentials by geopolitical, social and economic status: evidence from surveyed children in South East Asia. University of St. Gallen, Swiss Institute for International Economics and Applied Economic Research, March Oyekanmi, FAD. Socio-cultural implications of AIDS in the Nigerian family (1995): 9 th Annual Conference of the Population Association of Nigeria, Benin City, Nigeria. 7. Bukar A, Danfillo IS, Adeleke AO, Ogunbodede.EO. Traditional oral health practices among Kanuri women of Borno State, Nigeria. Tropical Dent J. 2004; 107: UNAIDS and WHO. HIV/AIDS Awareness and Behaviour. New York: United Nations Publication, Jiajian C, Chen S, Minja C. Who has correct information and Knowledge about HIV/AIDS in China? Asia-Pacific Population Journal Dec Getu DA, Melkie E. Knowledge, attitudes and practices involved in harmful health behaviour in Demba District, northwest Ethiopia. Ethiop. J Health Dev. 2002; 16 (2): Waziri M. Meanings of Kanuri Personal Names. Maiduguri: Gargam Publishers; 2000: Cochran William G. Sampling Techniques 3 rd edition, New York: Wiley ; Largarde E, Enel C, Seek K, Gueye-Ndiaye A, Piqu J. Religion and protective behaviours towards AIDS in rural Senegal. AIDS 2000; 14(13): Holtzman D, Chen S, Zhang S, Hsia J, Rubinson R, Bao FY. Current HIV/AIDS related knowledge, attitudes and practices among the general population in China. Implications for action. AIDScience 2003; 3: Lanouette NM, Noelson R, Ramamonjisoa A, Sheldon J, Jeffrey MJ. HIV-and AIDS-related knowledge, awareness, and practices in Madagascar. American Journal of Public Health 2003; 93 (6). 16. Uche CI. Extramarital relations and perceptions of HIV/AIDS in Nigeria. Health Transition Review 1994; 4: Muzaffar A, Bashir G. Awareness of HIV/AIDS in a remotely located conservative district of Kaigil: Result of a community based study. Indian J. Community Medicine 2002; 27 (1): 18. Volume 1 Number