Effectiveness of sources of HIV/AIDS awareness in a rural community in Imo State, Nigeria

Transcription

1 DOI: /j x Effectiveness of sources of HIV/AIDS awareness in a rural Blackwell Oxford, HIR Health Journal XXX 2007 Information The compilation UK Publishing Author & Ltd Libraries 2007 Health Journal Libraries Group community in Imo State, Nigeria Williams E. Nwagwu, Africa Regional Centre for Information Science University of Ibadan, Nigeria Abstract Aims and objectives: The effectiveness of each of the 14 sources of acquired immunodeficiency syndrome (AIDS) awareness available to women and adolescent girls dwelling in a rural community in Imo State, Nigeria was measured in order to understand the relative contribution of the sources to the general knowledge about human immunodeficiency virus (HIV)/AIDS possessed by the women and the girls. Methods: The details of the research methods adopted in this study, which involved 734 in-school and out-of-school adolescents and 434 women, have been described previously [Nwagwu, W. Di Nwanna and the reproductive health of the girl child in Imo State, Nigeria. Final Report ( GSS) submitted to MacArthur Fund for Leadership and Development, Abuja, 2006]. Results: Friends and relatives emerged as the most effective source of AIDS awareness for women (29%), followed by community meetings (26%) and then television (20%), whereas the most effective sources for the girls were television (28%), followed by friends and relatives, and radio (17% and 14.4%, respectively). Conclusions: Each of the information sources listed made some contribution to the general knowledge about HIV/AIDS possessed by the respondents, although the level of awareness would have been low among women in the absence of friends and relatives, and among the girls in the absence of television. Information awareness programmes should be selected according to the needs of social groups and the most effective information sources concentrated upon. Introduction After South Africa, Nigeria has the second-largest rate of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) prevalence in Africa. By the turn of the century it was estimated that the HIV prevalence in Nigeria had exceeded 5%, which corresponds with approximately 4 million infected people. 1 In 2003, the HIV prevalence had exceeded 5.4%, with some estimates putting the number of infected Nigerians around 5 million. 2 The pattern of prevalence since 1991, when the first surveillance survey was carried out, is shown in Fig. 1. Correspondence: Williams E. Nwagwu, Africa Regional Centre for Information Science University of Ibadan, Nigeria. willieezi@yahoo.com Figure 1 suggests that HIV prevalence increased from 1.8% in 1991 to 4.5% in By 1999, 5.4% of persons were infected, while in 2001, the prevalence was found to be 5.8%. The figure remained unchanged in 2003 but reduced to 5.4% in 2005 and further to 4.8% in The estimated annual deaths as a result of HIV/AIDS have increased from in 1999 to over in 2004, at enormous cost to the economic and health sectors in the country. 3 Many people are of the opinion that the crisis of HIV/AIDS in Nigeria could largely be as a result of the relaxed attitude of the government in informing the population about the disease at its earliest stages of infection in 1984 when the first victim was diagnosed. Although significant reduction in the prevalence has been recorded from 38

2 Effectiveness of sources of HIV/AIDS awareness, Williams E. Nwagwu 39 Figure 1 Prevalence rates of HIV/AIDS for Nigeria Figure 2 HIV/AIDS projection for Nigeria Source: Federal Ministry of Health. HIV/AIDS, What it means to Nigeria. Available from documents/nigeria_whathivmeans.pdf in 2005 to 4.8 in 2006 a crucial strategy to further reduce the crisis by use of information, education and communication strategies should remain for a long time to come. Information is power and has been recognized worldwide as being effective in changing behaviour and attitudes essential in health situations such as HIV/AIDS where there is as yet no known cure. Therefore, the future trend of the HIV/AIDS pandemic to a large extent depends on the level of HIV/AIDS awareness and the knowledge possessed by the people. Awareness of HIV/AIDS is necessary for people to protect themselves from HIV acquired through sexual and other relations, and to protect their children from the risk of mother-to-child transmission. 4 Information awareness is one of the bases upon which projections (shown in Fig. 2) about the prevalence of HIV/AIDS in Nigeria has been made. However, HIV/AIDS prevention work in sub-saharan Africa and elsewhere has demonstrated that, while information and education about how to prevent transmission of HIV are necessary for inducing behaviour change, such an approach by itself has been unable to induce sufficiently widespread behavioural change to significantly alter the course of the epidemic. Planners and policy-makers must be cognizant of the fact that information awareness strategies function within individual and social contexts, which may render some strategies ineffective. In this study, the effectiveness of various sources of AIDS awareness available to women and girls in a rural community in Imo State, Nigeria is measured using methods defined previously by the author. 5 Despite evidence of a reduced infection rate, the absolute number of infected persons is still very large (see Fig. 1) and the impact of the spread through the general population is now more evident in rural areas than in urban areas. Infected persons in the city often return to their original homes to ease the cost of care and burial when death finally occurs. 7 Unfortunately, in addition to creating new burdens for the rural dwellers who have to then devote scarce resources of money and time to caring for victims, the rural communities are poorly served with information infrastructures which could provide the necessary awareness to people. Information in the modern era is linked to technology, in that a poor electric power supply and lack of paved roads, for example, will affect even the use of transistor radios and television systems. The absence of information infrastructures results in insufficient knowledge about the disease, a situation that has large implications both on the management and provision of care for the people who are infected, as well as exposing the healthy persons to the risk of contracting the disease. Lack of information infrastructures is also associated with the information seeking practices of people; people tend to make use of the resources which are available and accessible to them. Although the Nigerian National Action Committee against AIDS (NACA) programme increased HIV prevention and, in 1999, worked on a better information strategy, many rural communities still have poor infrastructures, suggesting that many rural dwellers still lack adequate AIDS awareness. Several studies appear to focus on awareness in the urban communities and less in the rural areas. Creating awareness of AIDS has been an important

3 40 Effectiveness of sources of HIV/AIDS awareness, Williams E. Nwagwu Information Education Communication (IEC) agenda of the World Health Organization (WHO). A priority for policy in low knowledge, low prevalence settings such as rural Nigerian communities would be to increase, not only the awareness of AIDS among the people as a means of providing some knowledge for health protection, but to strengthen those sources that could be considered very effective. Even when the sources of information are available, the general knowledge of users may not enable them to make use of this information. Most studies on awareness about AIDS in Nigeria have not addressed this critical factor, which has great implications for strengthening information sources in the communities. Blumler and Katz 8 have argued that the needs of different audiences have social and psychological characteristics, which generate certain explanations about the media, thus leading to differential patterns of exposure and use. McQuail 9 suggested further that personal social circumstances and psychological dispositions together influence both general habits of media use and beliefs, just as expectations about the benefits offered by the media influence media choice and consumption. Women and girls are generally believed to be at a disadvantage regarding accessing and using information and other resources because of social and cultural factors which make them predominantly poorer and less empowered than other members of the society. In the rural areas, this problem is very intractable; cultural observances join poor infrastructure to complicate information delivery, access and use to the rural women and girls. Data and methods Data used in this paper was extracted from a survey on the reproductive health of the adolescent girls conducted in 2005 in Uzoagba, an autonomous community in the Ikeduru North Local Government Area, formerly under the old Owerri Province in the old eastern region (see Acknowledgement). The details of the research methods adopted in this study, which involved 734 in-school and outof-school adolescents and 434 women, have been fully described in the previous study. 5 During the survey, each respondent was asked whether she had heard of AIDS. To those who responded yes, a further question on sources of information was asked. We were able to extract 14 different sources of AIDS information from the responses we got in the survey. Thereafter, a matrix table was constructed on the sources used by the women and adolescent girls, leading to a complex set of results reflecting the number of respondents who had heard of AIDS from a combination of one or more of the 14 sources. For instance, the matrix contains information on the relationship between awareness about AIDS from, for example, radio, in relation to other sources, such as friends and relations. A multi-dimensional scaling method was used to construct the relationships between and among the sources, so that we identified sources that complement each other as well as those that do not (Nwagwu, in preparation). In this present paper, we are interested in the effectiveness and independence of each source of AIDS awareness. Our definitions of effectiveness and independence, as well as the methods adopted for computing these two indices, are described below. Effectiveness We measured effectiveness of a source as the proportion of persons in each group who had heard of AIDS from only one source, from among a group who had heard of AIDS from that particular source along with all other sources. For instance, in the present analysis, from among 520 girls who had heard of AIDS from radio along with all other sources, there were 75 adolescent girls who reported having heard of AIDS from the radio alone. Thus, the effectiveness of radio is 14.4%; i.e. (75/520) 100. This proportion captures the effect of radio when compared with those who have heard of HIV/ AIDS from both radio and the other 13 sources. Hence, 14.4% effectiveness of radio indicates that 85.96% (100 effectiveness) of the girls who had heard of AIDS from the radio had also heard of it from other sources. In other words, this 85.96% would have heard of AIDS without access to radio. Independent effect This index was taken to be the proportion of persons who had heard of AIDS from only one source, in relation to all women who had ever heard of AIDS. For instance, 46 women had heard of AIDS

4 Effectiveness of sources of HIV/AIDS awareness, Williams E. Nwagwu 41 Table 1 Effectiveness of sources of AIDS awareness in a rural community in Nigeria, Persons aware of HIV/AIDS (%) Measure of effectiveness (%) Measure of independence (%) Average number of sources Information source Women Girls Women Girls Women Girls Women Girls Radio Television Newspaper Pamphlets/magazine Clinical health worker Place of worship School teacher Community meeting Friends/relatives Workplace Cinema Exhibition Adult education programme Political leaders from television alone, whereas the 434 women expressed awareness about AIDS. We then computed the independent effect of television for the rural women to be 19.7%, that is (46/434) 100, showing the independent contribution of television in particular towards the overall awareness of AIDS among women in the population. We used this procedure to compute the effectiveness and independence effects of the various sources of HIV/AIDS information, and the results are shown in Table 1. Results The 434 women and 734 girls surveyed expressed awareness about HIV/AIDS. The percentages of awareness of AIDS by sources among the respondents are shown in Table 1. Thirty-five per cent of the women reported that they have heard of AIDS from radio, 24.1% from television and 17.8% from friends and relatives. In contrast, 55%, 44.2% and 23% of the girls have heard of AIDS from television, radio and friends and relatives. This result shows clearly that, although radio, television and friends and relatives constitute a great source of information about AIDS to the people, each of these sources serves the various groups differently although they live in the same community. Our result differs from that of the 1999 Nigeria Demographic Health Survey (NDHS) report, 9 which cited the radio, relatives and friends as the most common sources of information on HIV/AIDS. With respect to the effectiveness of the sources, Table 1 shows that friends or relatives emerged as the most effective source of AIDS awareness for women. For 29% of the women, friends or relatives were the only source of information about AIDS. The second most effective source for the women was community meetings, these being the only source of information about AIDS for more than 26% of the women. Television was the third most effective source of AIDS awareness for the rural women, with 20% of the women having heard about AIDS from television only. For the girls, the situation is a little bit different. The most effective sources was the television with more than 28% of them reporting having heard of AIDS from this source alone. The second and third most effective sources for the girls were friends and relatives and radio with (17%) and (14.4%) of the girls having heard of AIDS from these two sources, respectively. We now examine the independent effects of all the 14 sources reported by women and girls. For the women, television independently contributed 18% to AIDS awareness, followed by friends or relatives (16.6%) and radio (4.2%). We can observe that, apart from the workplace (3.5%), the proportions of those who have heard of AIDS from only one of the other sources of information could be considered

5 42 Effectiveness of sources of HIV/AIDS awareness, Williams E. Nwagwu negligible. For the girls, the independent effects of television (21.1%) are followed closely by friends and relatives (19.1%), with schoolteachers accounting for only 3.1%. The independent effects of the other sources were again negligible. Table 1 also shows that rural women and adolescent girls had, on average, heard of AIDS from 1.9 and 2.6 sources, respectively. Hence, it can be seen from the measures of effectiveness and independence above that, although a high level of awareness about HIV/AIDS has been recorded in the rural community under study, different information sources contributed differently to the general knowledge about HIV/AIDS possessed by the different categories of respondents. While friends and relatives, community meetings and television serve the women more effectively than the other sources, television, friends and relatives and radio serve the girls better. Discussion This study shows clearly that evidence of availability and even actual use of information sources about HIV/AIDS are not sufficient to understand the level of awareness which the targeted audiences are receiving from the information sources. Each of the information sources accounts for different degrees of awareness and consciousness about the pandemic. Overall, there is evidence that HIV/AIDS awareness is still high among the respondents, with all the respondents expressing awareness about the existence of the disease, a different situation from that in the general population as reported by the NDHS in and The present study has considered only the crude construct of AIDS awareness, which does not reflect the complexity of knowledge acquisition, let alone the response to knowledge in terms of behaviour change. This observation is important in view of the fact that there are several variables that mediate between awareness and implementation of knowledge obtained. For instance, a study of Nigerian truck drivers showed how beliefs and feelings mediated the relationship between AIDS awareness and condom use. In the case of women, there is the additional complexity of gender relations that limits their capability to negotiate condom use even where awareness of AIDS is substantial. In the case of the girls, and with particular respect to the community under study, there exist cultural factors related to peculiar reproductive health behaviour, which discourage protected sex a matter that has been discussed previously. 5 Our study shows that the role of friends and relations in AIDS awareness in the rural areas is very significant, emerging as the most effective for the women and the second most effective for the girls. It would appear that the women tend to learn more about HIV/AIDS when talking with others. Person-to-person discussions guarantee deeper understanding and sharing of personal experiences, and have great advantages in galvanizing information received from various sources, to which the educators also have access. In addition, the personto-person method can be employed by educators using questions and answers, illustrations within the language and social background of the group. Even in terms of scheduling of activities, there is some flexibility in, among others, meetings, venues, timing, and course content to guarantee that adequate knowledge is passed on. Rural girls, however, should be targeted with television and other related media. This implies that girls might prefer anonymous schemes which give the individual user control over the information media. As with the majority of young people, the girls would prefer privacy regarding information dealing with their personal identity, models of behaviour and issues about their health. In Nigeria, the national policy regarding HIV/ AIDS does not seem to have made systematic use of person-to-person communication; for example, using opportunistic contacts with health workers for purposes of family planning, maternity care or child health in the rural communities. The Chinese experience has indicated that a reorientation can be accomplished on a substantial scale. 11 There are several components in our results that show that increasing person-to-person contact in AIDS awareness programmes might be of great advantage to women in rural settings. For instance, community meetings appear very effective in the education of the rural women. The structure of community meetings often requires leaders of the associations, who are usually more knowledgeable, to inform others about events of significance.

6 Effectiveness of sources of HIV/AIDS awareness, Williams E. Nwagwu 43 Forums like community meetings give equal opportunities to members of the community so that those who do not have access to radios and televisions can also learn. Hence, community level activities offer the potential to reach marginalized or underserved groups who might not make full use of the existing health service infrastructure, let alone enjoy full access to the range of information media. In recent years, there is an emphasis on community-based (CBO) activities, which are expected to be conduits of both the governments and NGOs in disseminating information. Among electronic media, television, which ranks third in the first three effective sources for women, ranks number one in effectiveness for girls, while radio, which does not rank in the first three for women, ranked third for the girls. 12 Increasing access to television could therefore be anticipated to provide further gains in AIDS awareness among girls. Television is entertaining and combines the advantages of visual with audio power to engage the user. However, radios are cheap, are portable, easy to operate and adaptable to low-technology environments, an advantage that might account for its relative penetration in the rural communities. Further studies are required to show how messages obtained from television and other media are translated into conversation and discussion within social networks. For instance, after listening to a communication on AIDS on television, discussion with husbands and relations would be expected to be mainly in terms of the issues learnt from the media. 13 This is necessary to determine the extent to which dissemination of knowledge using specific media automatically translates into conversations with the sexual partner about personal risk. We also need to understand the social relations and gender dynamics in rural areas, which may provide additional knowledge on use and implementation of media information. The result shows that substantial numbers of women have not gained knowledge of AIDS as a result of using television or any of the electronic media sources alone. Hence, simply increasing women s access to television may not in itself guarantee greater levels of AIDS awareness, particularly in rural areas. In addition, it is necessary to examine the timing of public information programmes, their design in relation to actual social conditions and the use of branded vs. generic advertisements. 14 This suggestion follows on from our result, which shows that the contribution of radio to current levels of AIDS awareness in the community is low among the women. Radio transmission in Nigeria started as far back as the 1950s, and a number of private and public frequency modulation (FM) and other types of stations have been created as a result of government deregulation of the communication sector in If radio is to have an impact in the future on awareness programmes on HIV/AIDS, changes in approach are needed, such as new content in mainstream stations or specialized stations focusing on women s issues. Such strategies might consist of phone-in programmes that could enable information seekers to engage in person-to-person information exchange with HIV/AIDS educators. Furthermore, the evidence that mass media seem to dominate information sources available in communicating knowledge to the rural women carries a risk of excluding vulnerable subgroups of the population, creating a media underclass. 15 It should be a matter of concern that, from our study, places of worship do not seem to have paid sufficient attention to the challenge of educating rural people about HIV/AIDS, despite an increasing number of churches, mosques and other religious organizations. It may be that either ignorance about the disease by religious leaders, or mere complacency towards the sexual activities that are prevalent with adherents, might be an explanation for this observation. The opposite is the case in Uganda and other south and eastern African countries, where churches are known to have played significant roles in HIV/AIDS information. In 2002, churches in southern and eastern Africa formed a coalition known as Churches United in the Struggle against HIV/AIDS in Southern and Eastern Africa (CUAHA), in collaboration with Finnish churches and Christian organizations, to fight the HIV/AIDS pandemic. The project was initiated by a need expressed by the African partners, and it aimed at making HIV/AIDS work an integrated part of all activities carried out by churches and Christian organizations in the region. 16 Some impact of the project was reportedly seen in national churches and organizations: the HIV/AIDS theme gained new emphasis because of support

7 44 Effectiveness of sources of HIV/AIDS awareness, Williams E. Nwagwu by the international network, ecumenical contacts and examples from partners ( index2.php). Despite extension of membership of CUAHA to countries outside the south and east African regions, Nigeria is not a member of the coalition, and neither is there any such coalition locally, although individual pockets of activities that show HIV/AIDS consciousness can be identified. The roles of churches and CBOs necessarily depend on local capacity, social relations and political conditions, but can be encouraged through supportive policy and programming by relevant agencies and donors. Our findings highlight the importance of designing interventions that make use of existing social networks of friends and family, shown to be effective means of dissemination of AIDS awareness. As expected, the print media do not seem to offer any opportunities for AIDS awareness, probably mainly in view of the rural nature of the place of study. This would also explain the absence of cinema and newspapers. Furthermore, this result shows that politicians and their campaign trains have not considered the combating of AIDS strategic in their politicking. Also, one could question the relative absence of any influence of clinical and health workers in the communities, both for girls and women. In an era when Family Life and HIV/AIDS Education (FLHE) as a strategy for strengthening HIV/ AIDS awareness in schools has gained ground, it would appear that NGOs and other organizations providing such training have not penetrated the schools in the rural areas. Furthermore, employers do not seem to have incorporated HIV/AIDS education in the workplace, except possibly by the exchange of information amongst workers. Finally, the finding shows that only a few sources of information are actually effective in addressing the issue of disseminating HIV/AIDS information to various stakeholder communities. A satisfactory success in the use of information education and communication strategy in creating awareness about HIV/AIDS could be achieved when these effective sources are strengthened. Acknowledgement This paper was developed from a larger project funded by MacArthur Funds for Population and Development, Abuja, Nigeria in 2005 (number GSS). Key Messages Implications for Policy Prevention programmes cannot succeed until women s health and rights, particularly in the rural areas, are placed at the centre of the fight against HIV/AIDS. It is under this kind of consciousness that factors that limit the access of women and girls to information sources could be discovered and addressed. Different techniques and strategies for reaching persons of different social classes, such as girls and women in rural communities, should be incorporated in the policy instrument for creating rural awareness about the disease. Part of the efforts to reach the rural communities with HIV/AIDS information should include training of community leaders. Effective intervention must target, not only individual perceptions and behaviour, but also the larger context within which those perceptions and behaviours are shaped, such as cultural factors that inhibit access of women and girls to information. Considering the poor electric power situation in the rural communities and the relatively high level of poverty which prevent girls from making the best use of television and other electronic media sources, community telecentres, which rely on alternative power supply sources, may deliver HIV/AIDS information closer to the girls. Implications for Practice Clinical and health workers in the rural areas should adopt interpersonal and discursive methods while educating rural women about HIV/AIDS. Opportunistic contacts by both health workers and others who are sufficiently informed about the pandemic should be employed to engage women in the rural communities in discussions about HIV/AIDS. Churches/mosques should assimilate roles in information awareness about HIV/AIDS in their spiritual assignments.

8 Effectiveness of sources of HIV/AIDS awareness, Williams E. Nwagwu 45 References 1UNAIDS and WHO. Epidemiological Fact Sheet on HIV/ AIDS and Sexually Transmitted Infections: Nigeria. Revised edition. Geneva: World Health Organization, UNAIDS and WHO. Epidemiological Fact Sheet on HIV/ AIDS and Sexually Transmitted Infections: Nigeria. Revised edition. Geneva: World Health Organization, National Population Commission Nigeria. Nigeria Demographic Health Survey (NDHS) Calverton, MD: National Population Commission and ORC, Boer, H. & Emons, P. A. A. Accurate and inaccurate HIV transmission beliefs, stigmatizing and HIV protection motivation in northern Thailand. AIDS Care 2004, 16, Nwagwu, W. Di Nwanna and the reproductive health of the girl child in Imo State, Nigeria. Final Report ( GSS) submitted to MacArthur Fund for Leadership and Development, Abuja, Federal Ministry of Health. HIV/AIDS, What It Means to Nigeria Available from: Nigeria_WhatHIVMeans.pdf (accessed 14 April 2007). 7 Oladele, O. O. & William, R. B. Rural urban mobility in south-western Nigeria: implications for HIV/AIDS transmission from urban to rural communities Health Education Research 1994, 9, Blumler, J. G. & Katz, E. The Uses of Mass Communications: Current Perspectives on Gratifications Research. Beverly Hills, CA: Sage, McQuail, D. Mass Communication Theory: An Introduction, 2nd edn. London: Sage, National Population Commission Nigeria. Nigeria Demographic Health Survey (NDHS). Calverton, MD: National Population Commission and ORC, Wu, Z., Detels, R., Guoping, J., Chen, X., Keming, R., Huancheng, D. Diffusion of HIV/AIDS knowledge, positive attitudes and behaviors through training of health professionals in China. AIDS Education and Prevention 2002, 14, Das, S. Radio Days in Indian Villages Available from: (accessed 9 February 2004). 13 Chatterjee, N. AIDS-related information exposure in the mass media and discussion within social networks among married women in Bombay, India. AIDS Care 1999, 11, Agha, S. The impact of a mass media campaign on personal risk perception, perceived self-efficacy and on other behavioural predictors. AIDS Care 2003, 15, Johnson, K. Media and social change: the modernizing influences of television in rural India. Media, Culture and Society 2001, 23, Churches United in the Struggle Against HIV/AIDS. Churches United in the Struggle Against HIV/AIDS, in Southern and Eastern Africa Available from: (accessed 14 April 2007). Received 2 November 2006; Accepted 6 June 2007