PUBL-01-Berhan
- 1. - 1 - Factors Influencing HIV Voluntary Counseling & Testing (VCT) Service utilization among Youth of Hawassa town: a Health Belief Model Approach, Southern Ethiopia Berhan Meshesha Hirut Abstract In spite of its important role in the prevention and control of HIV/AIDS, Voluntary Counseling & testing (VCT) service is being utilized poorly (21.9%) by the youth. Identifying the influencing factors in the utilization of the service enables the behavioral change intervention process more effective & efficient. The study was conducted in Awassa town, Southern Nation & Nationality Peoples’ Region(SNNPR) of Ethiopia t o assess factors influencing utilization of Voluntary HIV Counseling &Testing service among 18 to 24 years old adolescents in Awassa town. A cross- sectional qualitative study was conducted considering Health Belief Model (HBM) approach and 05 focus group discussions & 13 in-depth interviews were conducted using semi-structured guides and audiotape recorder and the data was analyzed manually using thematic frame work (Coding Book). The three major factors perceived as inhibiting for the utilization of Voluntary Counseling & Testing (VCT) service were fear of stigma and discrimination, fear of coping with positive HIV test result and high HIV risk perception. On the other hand, the three most commonly cited perceived factor to enhance the utilization of VCT service in this study were having marriage plan, presence of Care & Support including Anti Retroviral therapy (ART) and persuasion by health professionals. It is recommended that tailored Behavioral Change Communication (B.C.C) interventions on HIV/AIDS prevention and VCT utilization should be undertaken, Advocacy, at a local level, should be made on the importance of the “voluntary” component of VCT giving emphasis on the draw backs of persuasion for HIV test. The role of HIV risk perception as a factor in influencing VCT service utilization should be further studied. Key Words: Thematic framework, Information saturation, VCT utilization Introduction More than 80% of adults living with HIV reside in sub- Saharan Africa, where the epidemic still continues to spread .In the global scale, Ethiopia hosts the third largest number of people living with HIV/AIDS (PLWHA), and ranks sixteenth in terms of prevalence (CSA, 2005). Although Ethiopia has been hit by HIV /ADIS epidemic latter than many east African countries, the ministry of health (MOH) estimates adult prevalence to be 23.4%, 19%, and 18.7% in Bahir Dar, Jijiga and Nathret respectively in 2003(MOH, 2006).
- 2. - 2 - The primary aim of VCT is preventive –to help people change their sexual behavior so as to avoid transmitting HIV to sexual partners if positive, and to remain seronegative if negative. Despite many limitations and difficulties in the implementation of VCT in sub – Saharan Africa, many studies have shown that it is effective in reducing HIV infection In Uganda, increasing number of people coming for VCT indicated that marriage plan was the reason they wish to be tested; in 1992, 6% of those attending VCT did so because of premarital testing and this figure rose to 35% in 1998 (UNAIDS, 2001). VCT is behavioral intervention not a mere diagnostic procedure. Therefore, such dramatically increasing prevalence rate of HIV necessitates the implementation of multifaceted prevention and control programs, and one of these approaches is voluntary counseling & testing. Many people with HIV in Ethiopia don’t know that they are infected. Until 2000, only small percentages of those with HIV/ AIDS have had access to reliable VCT service. As there is no cure for HIV/AIDS, voluntary HIV counseling and testing remains a key strategy to control the spread of HIV and to provide care and support to those who are positive (MOH, 2006) In one cross – sectional community based survey, which was under taken on adolescents of Harar town in 2005; it was found that only 21.9% of adolescents reported that they had ever been tested for HIV (Olijira L, 2004) A qualitative study which was undertaken in Arbaminch town in 2007 on youths identified fear of stigma & discrimination and fear of coping with positive HIV test results as the two common factors where as presence of ART and having marriage plan were identified as enhancing factor for VCT service utilization).The study also revealed that HIV risk perception was found to be a debatable issue in that it was considered as enhancing factor by some participants and as inhibiting factor by others( Meshesha B, 2007). The major discrepancy, here, is that in spite of its important role in the prevention and control of HIV/AIDS, VCT service is being utilized poorly. The important research question is, there fore “why people don’t utilize the VCT service as required and what factors contribute for utilizing and not utilizing the service”. In doing this, the perception of individual participants and respondents will be considered taking the components of Health Belief model (HBM) as guideline or framework. . In Ethiopia, different studies showed that fear of coping with the positive test results, low risk perception to HIV, fear of stigma and discrimination that follows positive test results, absence of community support, lack of perceived benefit of VCT, fear of partners’ reaction were commonly cited reasons for not utilizing the VCT service (Olijira L, 2004).
- 3. - 3 - Most of the studies on this problem are quantitative and So far, there is no similar study undertaken in Awassa town community (as to my search), and hence this study will deeply assess the accountable factors of VCT utilization in lights of the findings in previous studies in other areas. In spite of its important role in the prevention and control of HIV/AIDS, VCT service is being utilized poorly (21.9%) by the youth. Identifying the influencing factors in the utilization of the service enables the behavioral change intervention process more effective & efficient. The aim of this study is assessing influencing factors for utilization of VCT service for HIV so that an effective behavioral change intervention program can be developed based on the findings and hence it will specifically investigate issues related to risk perception, PIHCT, Coping with positive test results as important factors for VCT uptake in depth qualitatively. Methods and Materials Study design A cross- sectional qualitative study was conducted using a Health Belief Model (HBM) approach Area & Period The Study was undertaken in Awassa town, southern Ethiopia, from January 30 up to May 30/2011. Sample size and Sampling technique The 06 FGDs containing 6-8 participants (out of 10 planned FGDs because of INFORMATION SATURATION), and in the same way 13 in-depth interviews key informants ( out of 15 Planned) was conducted on (3 Religious leaders, 2 community leaders, 2 PLWHA, 2 street boys, 2 CSWs and, 2 counselors). A combination of convenient and maximum variation sampling technique was employed. Measurements Data collection Data was collected using FGD and in – depth interview guides by 12 trained data collectors; third year General Para med Medical Laboratory students. The FGD and the in-depth interview were audio – taped (recorded) and then Transcribed. The data collection instruments (guides and audio-tape recorder) were translated & pre-tested. Data analysis Manual analysis of the data was made after a thematic framework is developed using responses, which were transcribed, coded & compiled in a logbook.
- 4. - 4 - Pre- test of the instruments was conducted one week prior to the actual data collection. Study Themes: were developed in accordance with the constructs of Health belief model (HBM) taking the most common components making them align to the already formulated objective of the study: an approach to the MODEL but not for testing the MODEL. Conceptual framework Modifying Factors Individual Beliefs Action Fig. 1. Conceptual framework (Constructs of Health Belief model). (Source: Karen G (et, al); Health Behavior and Health education; theory, research and practice, third education, 2002.) Individual Behavior Cues to Action Perceived susceptibility to & severity of disease Perceived Benefits Perceived Barriers Perceived Self- efficacy Perceived Threat Age Gender Ethnicity Personality Socioeconomics Knowledge
- 5. - 5 - Operational Definitions Youths- are adolescents whose age group is between 18 & 24 years. Street boys – are boys who pass the day and night time over the street regardless of their family status. Commercial sex workers-are females working in bars during the night time taking sex as a primary source of income. Quality Assurance The quality of the data was assured by using translated & pre tested guides, training data collectors, making close supervision, providing data collectors and supervisors with field guide, using audio- tape recorder throughout the data collection period, and finally the data analysis process was done supported by the already transcribed, edited and Compiled data. Ethical Issues Officially written ethical clearance was obtained from Institutional Review Board of College of Medicine & Health Sciences, Hawassa University, and letter of Cooperation from COLLEGE HEAD OFFICE Results A total of six (6) FGDs, out of the planned 10, were conducted because of the saturation of information and each FGD involved 6-8 participants from different population sub-group (strata) including male youths, female youths, and street boys in private settings each session lasting for 40 minutes on average. Age of the participants ranges from 18 to 24 years. The FGD sessions were successful in achieving meaningful interactions among participants and stayed focused throughout the sessions. There was an overall consensus on the major topics discussed in most of the FGDs where as there was hot argument and debate on some of the FGDs particularly on HIV risk perception level as a factor of VCT service utilization. The explorations made by the FGDs were also made verified & further explored by IDIs of key informants: a total of 13 key informants’ interviews, out of the planned 15, were undertaken because saturation of information. Each interview lasted 30 minutes on average and conducted in private settings. The key informants involved were counselors, PLWHAs, religious leaders, community leaders, CSWs, and street boys. Age of the key informants ranges from 18 to 60 years. Theme: 1. whom should be tested for HIV? On the discussion made among participants on whom to be tested for HIV, majority of the participants in most of the FGDs cited that everybody should be tested regardless of age, sex and occupation. This finding was also verified by the IDI’s findings: The vast majority of the respondents think that everybody, regardless age, sex and health status should be tested for HIV. However, a protestant church leader mentioned that the test is important only for people who plan
- 6. - 6 - marriage and majority of the street boys identified Night Club workers, Street boys/girls and the non-Missionaries as individuals who need to undergo the HIV test. A 37 years old protestant church Pastor, when expressing his deep concern said: “It is only for couples who need to marry that HIV testing is encouraged and requested by our church; I think that the already married couples, who lead peaceful life and take the necessary preventive measures that the tested person would have taken, need not undertake the test, If the HIV testing leads to revenge, suicide, family and marriage distortion and social interaction break down, which were not problems before the test, I don’t think that the test is no more important”. Theme: 2. Inhibiting factors for VCT service Utilization: Concerning the factors which inhibit the utilization of VCT service, fear of stigma and discrimination and fear of coping with positive HIV test result were identified in all of the FGDs, and high HIV risk perception was identified in most of the FGDs, while lack of awareness, low risk perception and Lack of trust on BOTH the validity & confidentiality of the TEST were identified as important factors in some of the FGDs. A 20 years old grade 11 male student, when expressing his argument on the privacy issues, being nervous, said: “why do you think People go to WOLAYITA Sodo from AWASSA for HIV testing in the presence all these Health facilities here? It is for nothing but for their privacy!” The above FGD findings were also supported by the IDI findings: Stigma and discrimination attached to HIV, Seeking Care & Support and fear of coping with positive HIV test result were also mentioned by almost all the counselors as important inhibiting factors, and other factors include other Cultural & environmental influences. A 22 years old male counselor, when expressing the degree of frustration that clients manifest during HIV testing said: “Some Clients jerk when we DRAW BLOOD SAMPLE, and when I see this reaction, I myself, let alone them, worry of their future. Some of them even faint (go to shock) when we declare their positive test result” Other inhibiting factors, explored from FGDs, include Lack of proper pre-test counseling approach before TAKING BLOOD SAMPLE and lack transparency at a family level on sexual issues. A 19 years old grade 11 male student, reflected his deep concern on the approach of Councilors said: “The councilor, after she drawn my BLOOD SAMPLE, asked me what my reaction would be if my test result becomes Positive. I feel this wrong! How on earth my reaction is asked after the blood sample is already taken. It is very frustrating approach!!”
- 7. - 7 - The ideas further explored from the IDI are also suggestive of the concerns of FGD participants: fear of stigma and discrimination, fear of coping with positive test result and lack of awareness were mentioned by vast majority of the key informants, where as other factors such as hopelessness, low risk perception and, absence of privacy in the VCT centers were least mentioned. A 32 years old grade 5 female, who has been living with HIV /AIDS for the last 13 years, and currently working as a chair person in one association of females who live with HIV /AIDS, when expressing her belief and experience on VCT service utilization said: “ Recently, I was in one campaign to make people tested for HIV in rural community; I was very much disappointed by the poor readiness of the people, especially the youth, to accept VCT; they don’t want to be tested!” A 21 years old street boy has strong stand that it is FEAR of Discriminations from society that makes people not tested for HIV, and said: “They actually fear People not God!!” to capitalize his thought. Theme: 3. Enhancing factors for VCT service Utilization: The study has identified having marriage plan and presence of Care & Support (ART) as enhancing factors for the utilization of the VCT service in almost all of the FGD sessions, and high HIV risk perception and persuasion by health professionals were identified as important factors in most of the FGDs, while occurrence of repeated illness and planning for future life were identified in some of the FGDs. Other factors raised during the discussion include DV lottery, raised awareness level, importance of knowing HIV status and peer influence. An 18 years old grade 9 male student, gazing and laughing at one of his friends, when arguing against the idea of his friend on importance of peer influence, said: “You see, It is you that should start being faithful to your partner even if you think that she may not be faithful to you so that you can influence her & be a model to other friends of yours!” The issue of HIV risk perception level, generally, was a debatable topic in 1/3 of the FGDs in that some of the participants considered high HIV risk perception as enhancing factor for the utilization of VCT service while other participants considered it rather as an inhibiting factor for which a consensus was not reached through out the discussion sessions. It was noted that, there was no clear variation across the different population sub-groups (strata) in identifying fear of stigma and discrimination as inhibiting factors, and having marriage plan and presence of ART as enhancing factor for utilizations of the VCT service in the area. The Key informants, in most of the IDIs, also verified that marriage plan and presence of Care & Support (ART) are important enhancing factors for the utilization of the VCT service: almost all counselors identified marriage plan, and some of the counselors mentioned Professional risk(exposure) , raised awareness and knowledge of people as a result of shared experiences from PLWHA who are on ART, influence of religious leaders, persuasion by health professionals (PIHCT approach) and changing friends(sexual partners) as most important enhancing factors for VCT service utilization among youth.
- 8. - 8 - A 32 years old male nurse counselor, when expressing his deep concern on the influence of religious leaders on pre-marital testing said: “what should come first is healthy living not marriage. The religious leaders tell the couples just to be tested before marriage as a pre-requisite, but they don’t tell them how to live with HIV or how to proceed after the test is declared, if the test result is found to be positive for HIV. I don’t agree with such approaches as they are completely against the principle of VCT”. The counselors’ response on the reaction of client before and after the HIV test revealed that all of them reported that clients who pass through VCT do cope with their positive HIV test results as compared to clients who are made to pass though a PIHCT approach. They also mentioned that ongoing counseling is not as such a common practice due to some internal and external problems. Findings from other key informants also supplement to the ideas explored the FGDs above in one or the other way: a religious leader of the protestant church also suggested moral education, at the elementary school level, as a better remedy for prevention and control of HIV/AIDS than VCT service taking his own experience as a reference. A 60 years old Orthodox Church Priest capitalized on importance of Care & support services to PLWHA, and said: “When people are tested for HIV in seeking Care & support, if they are positive for the test, and not given the required support, they & other people lack trust on the service & the government commitment; I think the government should work harder in this regard!!” Discussion This study attempted to explore, verify and roughly compare the immediate and associated factors that influence the utilization of VCT service among youths in the study area. The three major factors perceived as inhibiting for the utilization of VCT service were fear of stigma and discrimination, fear of coping with positive HIV test result and high HIV risk perception. On the other hand, the three most commonly cited perceived factor to enhance the utilization of VCT service in this study were having marriage plan, presence of Care & Support (ART) and persuasion by health professionals. These findings are more or less similar to the findings of the 2007 Arbminch study. The findings are also supported by many other studies undertaken on the same study subjects using the same study design but at different areas of the nation (Meshesha B, 2007).
- 9. - 9 - Literatures showed that wider access to VCT and a large number of people’s greater awareness of their HIV status with in the community are important elements in challenging stigma, as in the case of Uganda. However, according to these literatures, for it to be effective in challenging stigma, HIV testing has to be a voluntary process associated with counseling that helps people understand their status (UNAIDS, 2001). HIV risk perception as a factor for utilization of VCT service was a debatable issue, as in the case in the 2007 Arbaminch Study, which ended up with hot argument with no consensus in 1/3 of the FGD sessions in that some of the participants argued that high HIV risk perception is considered as enhancing factor and low HIV risk perception as inhibiting factor while other participants argued other wise( the vise versa)( Meshesha B, 2007). This study also identified other factors which inhibit and enhance utilization of VCT service that were not identified by other studies reviewed for this study purpose, and these include lack of TRUST ON VALIDITY & CONFIDENTIALITY OF THE TEST as inhibiting factors while raised DV lottery as enhancing factor. Unlike the 2007 Arbaminch study, VCT Service affordability & accessibility was not reported as an inhibiting factor. The difference in these PARTICULAR findings may be attributed to the expanding service coverage, difference in awareness level & difference in the status of the study area used. Conclusion: The study revealed, unlike the assumption of Health Belief Model, that low HIV risk perception enhances VCT service utilization. This indicates for need for follow-up triangulated study; employing both quantitative & qualitative designs to determine actual association of the two variables. References: CSA (Central Statistics Agency) 2005, Ethiopian demographic & Health survey Report, pp.18- 21 EPHA (Ethiopian Public Health Association) 2005, Selected abstracts series, Annual public Health conference Report, Addis Ababa. Meshesha B, 2007, factors influencing VCT service utilization among youths of Awasa town, Southern Ethiopia, Master’s thesis, Jimma University. MOH (Ministry of Health) 2006, AIDS in Ethiopia, Fourth edition, pp.26-40 No- 2, Vol.18
- 10. - 10 - Olijira L, 2004, Utilization of voluntary counseling and testing services, perceived barriers, and preferences of adolescents 15 to 24 years of age in Harar town, Eastern Ethiopia, Ethiop. J.health dev’t, 2:21-22, Vol.18 UNAIDS (Joint United Nations program on HIV/AIDS) 2001, the impact of voluntary counseling and testing; A global review of benefits and challenges, Switzerland, Geneva. WHO (World Health Organization) 1998, AIDS prevention and control, presentations on world summit of ministers of health on program for AIDS prevention, London Acknowledgements I strongly acknowledge Hawassa University Research & Development Directorate (RDD) for motivating me to undertake the study & for funding the study. My final Acknowledgement goes to data Collectors, Supervisors & study participants for their valuable contribution for realization of this study.