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African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20
HIV-prevention knowledge among illiterate and lowliterate women in rural Amhara, Ethiopia Gebeyehu W Bogale a
a b
b
, Henk Boer & Erwin R Seydel
b
Educational Media Agency , PO Box 3025, Addis Ababa, Ethiopia
b
Department of Psychology and Communication of Health and Risk , University of Twente , PO Box 217, 7500 AE, Enschede, The Netherlands Published online: 08 Apr 2010.
To cite this article: Gebeyehu W Bogale , Henk Boer & Erwin R Seydel (2009) HIV-prevention knowledge among illiterate and low-literate women in rural Amhara, Ethiopia, African Journal of AIDS Research, 8:3, 349-357, DOI: 10.2989/ AJAR.2009.8.3.11.932 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.3.11.932
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
African Journal of AIDS Research 2009, 8(3): 349–357 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2009.8.3.11.932
HIV-prevention knowledge among illiterate and low-literate women in rural Amhara, Ethiopia Gebeyehu W Bogale1,2, Henk Boer2* and Erwin R Seydel2 Educational Media Agency, PO Box 3025, Addis Ababa, Ethiopia Department of Psychology and Communication of Health and Risk, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands * Corresponding author, e-mail: [email protected]
1
Downloaded by [University of Connecticut] at 15:04 11 October 2014
2
More than 85% of Ethiopia’s population lives in rural areas and literacy levels in the country are relatively low. Despite this, little is known about levels of knowledge in regard to HIV/AIDS and condom use among illiterate and low-literate rural individuals. We conducted a cross-sectional study among 200 illiterate to semi-literate women, ages 13 to 24, from two rural communities in the Amhara region of northwestern Ethiopia. Nearly all the women had heard about HIV and AIDS. Among the illiterate individuals (n = 54), 24% did not know that HIV was the cause of AIDS and 48% did not know that HIV could be transmitted by sexual intercourse without a condom with an HIV-infected person. Among the same group, 59% did not know what a condom is. Literacy had a strong positive association with knowledge of HIV transmission and condoms. Thus, due to a generally higher level of literacy (grade 5–8 attainment), very young women (ages 13–20) had better knowledge of HIV transmission and condoms than did women ages 21–24 who by comparison were less literate. Given poor knowledge of HIV transmission and condoms among illiterate and low-literate women in Amhara, targeted HIV-prevention interventions are needed in this region. Keywords: condom use, East Africa, health knowledge, HIV/AIDS, illiteracy, rural communities, sexual behaviour
Introduction Estimated overall HIV prevalence in Ethiopia was 1.4% in 2005 (Central Statistics Agency, 2006), with large differences between urban and rural areas and between different HIV-risk groups (Ghys, Kufa & George, 2006; Hallet, Grasse, Bello, Boulos, Cayemittes & Cheluget, 2006; Hladik, Shabir, Jelaludin, Woldu, Tsehaynesh & Tadesse, 2006; Kloos, Mariam & Lindtjørn, 2007). A very low level of condom use has been found in communities in Ethiopia, especially rural communities (Taffa, Sandby & Bjune, 2003; Central Statistics Agency, 2006; Kloos et al., 2007; Molla, Nordrehaug Åstrøm & Berhane, 2007; Mishra, Hong, Govindasamy & Montana, 2008). In addition, condom use within marriage is highly stigmatised (Teklu & Davey, 2008) and many men and women do not use condoms when they have sex with non-cohabitating partners. In a study by Farr, Witte, Jarato & Menard (2005), only 13.4% of the women and 30.3% of the men indicated that they had used condoms during sexual intercourse with non-cohabitants. Like in other countries in Africa (see Chacko, Kipp, Lating & Kabagamber, 2007), rural people may lack factual information about condom use and may be doubtful about the efficacy of condoms to protect them from HIV infection. Some studies have found that women were significantly less aware of the correct use of condoms and less willing to use condoms during sexual intercourse (Tanaka, Kunii,
Hattano & Wakai, 2008). Instead of condoms, some people in rural areas in Ethiopia may use herbs to protect themselves from HIV or AIDS, as some studies have indicated that people in developing countries often use herbs to prevent or treat HIV or AIDS (Sebit, Chandiwana, Latif, Gomo, Acuda, Makoni & Vushe, 2002; Singhal & Rogers, 2003; Liu, Manheimer & Yang, 2005). Different types of media, such as radio, television and print, have been used in Ethiopia to disseminate information and create awareness about HIV and AIDS (Mekonnen, Sanders, Aklilu, Tsegaye, De Wit, Schaap et al., 2003; Ethiopian Federal Ministry of Health, 2006; Smith, Downs & Witte, 2007). Non-governmental organisations have also played a major role in HIV-prevention education in Ethiopia (Farr et al., 2005; Ethiopian Federal Ministry of Health, 2006). Unfortunately, HIV-prevention education in Ethiopia faces many challenges. Ethiopia is one of the poorest countries in the world, ranking 169 out of 177 countries in the Human Development Index 2007/2008 (United Nations Development Program, 2008). About 85% of Ethiopia’s population lives in rural areas (Central Statistics Agency, 2006) and poor infrastructure makes it difficult to reach them. The country’s literacy level is low (35.9%), ranking 132 out of 177 countries in the Human Development Index 2007/2008 (United Nations Development Program, 2008). According to the available data, about 62% of men and 77% of women have had no formal education. Literacy however is an important factor
Downloaded by [University of Connecticut] at 15:04 11 October 2014
350
for healthy living, both among men and women, particularly in rural areas. Women’s education is one of the strongest determinants of health, since educated women are more likely to break with cultural norms and taboos that can be detrimental to their health (Berhane, Högberg, Byass & Wall, 2002). In Ethiopia, a number of studies have focused on HIV-related knowledge among students (e.g. Andargie, Kassu, Moges, Kebede, Gedefaw, Wale et al., 2007) and urban adults (e.g. Teklu & Davey, 2008), indicating satisfactory levels of knowledge about HIV and AIDS. However, little is known about the extent of knowledge of HIV transmission and prevention methods among illiterate and low-literate women living in rural areas. Studies from other African countries have found significant gaps in HIV/ AIDS knowledge among the youth, specifically among females (Eaton & Flisher, 2000; Barden-O’Fallon, De Graft-Johnson, Biska, Sulzbach, Benson & Tsui, 2004; Smith, 2004; Slonim-Nevo & Mukuka, 2005; Terry, Mhloyi, Masvaure & Adlis, 2006; Salyer, Walusimbi & Fitzpatrick, 2008). For instance, in Nigeria it was observed that females were much less knowledgeable in HIV-prevention methods than were males (28.9% versus 73.2%, respectively) (Bassery, Elemuwa & Anukam, 2007). In Ethiopia, Alene, Wheeler & Grosskurth (2004) found that many women were involved in unsafe sexual practices and had wrong beliefs about transmission, such as believing HIV could be transmitted through mosquito bites or by kissing. Likewise, in other parts of Africa, studies have indicated that a high prevalence of HIV and other sexually transmitted infections among rural women stems from inadequate knowledge of the major modes of transmission and inadequate use of preventive methods (Nkuo-Akenji, Nyasa, Tallah, Ndip & Angwafo, 2007). The study by Alene et al. (2004) revealed a large knowledge gap between urban and rural dwellers in Ethiopia concerning HIV prevention. In Ethiopia the spread of HIV infections from urban to rural communities is partly related to unsafe sexual contacts and practices among merchants, who frequently travel to urban areas (Shabir & Larson, 1995), and that of university students who attend schools in urban areas and then return to visit their rural families (Alene et al., 2004). Not only lack of knowledge may make women vulnerable to HIV infection. Cultural practices, such as polygamy, widow inheritance, ‘widow cleansing’ and various environmental factors may also be barriers for HIV protection, even if the risk of contracting HIV is high. These practices happen mostly in rural communities, where knowledge about HIV infection and transmission routes is generally low. Women’s economic dependency on men and a gender-based power imbalance often make them unable to negotiate condom use with male partners (Barrientos & Bozon, 2007; Boer & Mashamba, 2007). Also, some studies in Africa have shown that women may choose unprotected sex in order to have a child (e.g. Chacko et al., 2007; Tanaka et al., 2008). Some socio-demographic factors may be related to individuals’ level of awareness of HIV and AIDS, such as age and education. Some studies have found that older youths have more knowledge about HIV prevention
Bogale, Boer and Seydel
than younger youths (i.e. Maswaneya, Moji, Horiguchi, Nagata, Aoyagi & Honda, 1999; Boer & Mashamba, 2005; Slonim-Nevo & Mukuka, 2005) while other studies have found no association between age and level of HIV/AIDS knowledge (i.e. Eaton & Flisher, 2000). Many studies indicate a positive association between educational attainment and HIV/AIDS knowledge (e.g. Eaton & Flisher, 2000; Barden-O’Fallon et al., 2004; Vavrus, 2006; Haile, Chamber & Garrison, 2007; Ritieni, Moskowitz & Tholandi, 2008). Many women with lower education or income levels also have a greater extent of misconceptions about HIV transmission (Zulu, Dodoo & Ezeh, 2002). This study aimed to investigate the level of HIV/AIDS awareness and knowledge of HIV transmission and prevention among illiterate and low-literate rural women in Ethiopia. We also studied the influence of age and literacy levels on HIV/AIDS awareness and knowledge of HIV transmission and prevention. The findings may help to produce and implement HIV-prevention programmes for illiterate rural women in Ethiopia. Methods Participants and procedures This study used a cross-sectional design. A power analysis, assuming a percentage of 50, a confidence level of about 7% and a significance level of α = 0.05, indicated that 200 participants would be appropriate. The study was conducted in February and March 2007 in two kebeles (communities) in the Amhara region: Koncher Sasaberai and Borebor Sencha. In total, these communities had 5 199 female inhabitants. The communities are part of the Dejen woreda (district), with 48 326 inhabitants, located in rural Amhara, 250 km northwest of Addis Ababa. The two communities are typical of rural Ethiopia and the participants recruited from the communities seemed typical of rural women in the region. The communities were situated in a remote rural area 5 to 10 km away from the main road and the small town of Dejen; there was no vehicle access and the only means of transportation were on foot or by horseback. Each community (kebele) had ten sub-kebeles, located at different places in the area; hence, from each sub-kebele ten women aged 13–24 were randomly selected in cooperation with the kebele women’s coordinator. Thus, the sample included 100 illiterate, low-literate, or semi-literate women from each community, ages 13–24 years, who voluntary agreed to participate (n = 200; 100% response rate). In cooperation with the local HIV/AIDS-prevention coordinator, we selected 20 literate females from the same two communities to act as data collectors since rural people in Ethiopia are not inclined to reveal personal information to someone they do not know well. We trained the data collectors on how to communicate with illiterate rural women and how to collect data using a structured questionnaire. Each data collector communicated with two respondents per day. It was estimated that each data collector would stay between 1.5 and 2 hours with one respondent in order to complete the questionnaire. Since most respondents could not read and write, the data
African Journal of AIDS Research 2009, 8(3): 349–357
Downloaded by [University of Connecticut] at 15:04 11 October 2014
collectors read the items aloud, giving explanations when necessary, and recorded the responses. After completion, ten birr (about US$1) was given to each respondent as compensation for the time she had spent participating in the study. Measures We used closed-ended questions with ‘yes’ or ‘no’ alternatives to asses HIV/AIDS awareness, knowledge of HIV transmission, and knowledge of HIV prevention and condom use. Close-ended questions are appropriate for respondents who have little knowledge of the subject matter and these require little time to answer (Ary, Jacobs & Razavieh, 2002). Awareness of HIV/AIDS was measured by three items: ‘Have you ever heard about HIV?’; ‘Have you ever heard about AIDS?’; and ‘Have you ever heard about a person who died of AIDS in your locality?’ Knowledge about HIV transmission was measured by five items: ‘HIV is spread by having unprotected sexual intercourse with many partners’; ‘HIV is transmitted by having sexual intercourse without condoms’; ‘HIV is transmitted by sharing needles with an HIV-infected person’; ‘HIV is transmitted by sharing razor blades with an HIV-infected person’; and ‘HIV is transmitted by having a blood transfusion from an HIV-infected person.’ Knowledge about HIV-prevention methods and condom use were measured by four items: ‘Did you ever ask for condoms?’; ‘Do you use condoms during sexual intercourse?’; ‘HIV can be prevented using different types of herbs’; and ‘HIV can be prevented using traditional medicine.’ We also noted the respondent’s age, level of education and religion (i.e. Ethiopian Orthodox Christian and Muslim). The questionnaire was pre-tested, and the content, language clarity, and appropriateness to the local community were checked by a local HIV/AIDS-prevention expert as well as by rural females living in the sample area. Analyses The data were cleaned and analysed using SPSS version 16. We used frequency distribution, cross-tabulation and chi-square analyses. The primary analysis focused on the relation between age, literacy level and knowledge of HIV and AIDS. The women’s age was classified as 13–16 years, 17–20 years or 21–24 years. Their literacy level was classified as: illiterate, grade 1–4 attainment (low literate), or grade 5–8 attainment (semi-literate). Results Characteristics of the participants There was a significant negative relation between age and literacy level among the women in the sample (χ2 [4, n = 200] = 28.89; p < 0.001), with more illiterate individuals among the older age groups (see Table 1). Of the 54 illiterate women in the sample, 25 women (46%) were age 17–20 years, and 19 women (35%) were age 21–24 years. Of the 93 semi-literate women (grade 5–8 attainment), 53 (57%) were age 13–16 years, and 34 (37%) were age 17–20 years. Marital status was significantly associated with literacy levels (χ2 [4, n = 200] = 17.83; p
African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20
HIV-prevention knowledge among illiterate and lowliterate women in rural Amhara, Ethiopia Gebeyehu W Bogale a
a b
b
, Henk Boer & Erwin R Seydel
b
Educational Media Agency , PO Box 3025, Addis Ababa, Ethiopia
b
Department of Psychology and Communication of Health and Risk , University of Twente , PO Box 217, 7500 AE, Enschede, The Netherlands Published online: 08 Apr 2010.
To cite this article: Gebeyehu W Bogale , Henk Boer & Erwin R Seydel (2009) HIV-prevention knowledge among illiterate and low-literate women in rural Amhara, Ethiopia, African Journal of AIDS Research, 8:3, 349-357, DOI: 10.2989/ AJAR.2009.8.3.11.932 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.3.11.932
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
African Journal of AIDS Research 2009, 8(3): 349–357 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2009.8.3.11.932
HIV-prevention knowledge among illiterate and low-literate women in rural Amhara, Ethiopia Gebeyehu W Bogale1,2, Henk Boer2* and Erwin R Seydel2 Educational Media Agency, PO Box 3025, Addis Ababa, Ethiopia Department of Psychology and Communication of Health and Risk, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands * Corresponding author, e-mail: [email protected]
1
Downloaded by [University of Connecticut] at 15:04 11 October 2014
2
More than 85% of Ethiopia’s population lives in rural areas and literacy levels in the country are relatively low. Despite this, little is known about levels of knowledge in regard to HIV/AIDS and condom use among illiterate and low-literate rural individuals. We conducted a cross-sectional study among 200 illiterate to semi-literate women, ages 13 to 24, from two rural communities in the Amhara region of northwestern Ethiopia. Nearly all the women had heard about HIV and AIDS. Among the illiterate individuals (n = 54), 24% did not know that HIV was the cause of AIDS and 48% did not know that HIV could be transmitted by sexual intercourse without a condom with an HIV-infected person. Among the same group, 59% did not know what a condom is. Literacy had a strong positive association with knowledge of HIV transmission and condoms. Thus, due to a generally higher level of literacy (grade 5–8 attainment), very young women (ages 13–20) had better knowledge of HIV transmission and condoms than did women ages 21–24 who by comparison were less literate. Given poor knowledge of HIV transmission and condoms among illiterate and low-literate women in Amhara, targeted HIV-prevention interventions are needed in this region. Keywords: condom use, East Africa, health knowledge, HIV/AIDS, illiteracy, rural communities, sexual behaviour
Introduction Estimated overall HIV prevalence in Ethiopia was 1.4% in 2005 (Central Statistics Agency, 2006), with large differences between urban and rural areas and between different HIV-risk groups (Ghys, Kufa & George, 2006; Hallet, Grasse, Bello, Boulos, Cayemittes & Cheluget, 2006; Hladik, Shabir, Jelaludin, Woldu, Tsehaynesh & Tadesse, 2006; Kloos, Mariam & Lindtjørn, 2007). A very low level of condom use has been found in communities in Ethiopia, especially rural communities (Taffa, Sandby & Bjune, 2003; Central Statistics Agency, 2006; Kloos et al., 2007; Molla, Nordrehaug Åstrøm & Berhane, 2007; Mishra, Hong, Govindasamy & Montana, 2008). In addition, condom use within marriage is highly stigmatised (Teklu & Davey, 2008) and many men and women do not use condoms when they have sex with non-cohabitating partners. In a study by Farr, Witte, Jarato & Menard (2005), only 13.4% of the women and 30.3% of the men indicated that they had used condoms during sexual intercourse with non-cohabitants. Like in other countries in Africa (see Chacko, Kipp, Lating & Kabagamber, 2007), rural people may lack factual information about condom use and may be doubtful about the efficacy of condoms to protect them from HIV infection. Some studies have found that women were significantly less aware of the correct use of condoms and less willing to use condoms during sexual intercourse (Tanaka, Kunii,
Hattano & Wakai, 2008). Instead of condoms, some people in rural areas in Ethiopia may use herbs to protect themselves from HIV or AIDS, as some studies have indicated that people in developing countries often use herbs to prevent or treat HIV or AIDS (Sebit, Chandiwana, Latif, Gomo, Acuda, Makoni & Vushe, 2002; Singhal & Rogers, 2003; Liu, Manheimer & Yang, 2005). Different types of media, such as radio, television and print, have been used in Ethiopia to disseminate information and create awareness about HIV and AIDS (Mekonnen, Sanders, Aklilu, Tsegaye, De Wit, Schaap et al., 2003; Ethiopian Federal Ministry of Health, 2006; Smith, Downs & Witte, 2007). Non-governmental organisations have also played a major role in HIV-prevention education in Ethiopia (Farr et al., 2005; Ethiopian Federal Ministry of Health, 2006). Unfortunately, HIV-prevention education in Ethiopia faces many challenges. Ethiopia is one of the poorest countries in the world, ranking 169 out of 177 countries in the Human Development Index 2007/2008 (United Nations Development Program, 2008). About 85% of Ethiopia’s population lives in rural areas (Central Statistics Agency, 2006) and poor infrastructure makes it difficult to reach them. The country’s literacy level is low (35.9%), ranking 132 out of 177 countries in the Human Development Index 2007/2008 (United Nations Development Program, 2008). According to the available data, about 62% of men and 77% of women have had no formal education. Literacy however is an important factor
Downloaded by [University of Connecticut] at 15:04 11 October 2014
350
for healthy living, both among men and women, particularly in rural areas. Women’s education is one of the strongest determinants of health, since educated women are more likely to break with cultural norms and taboos that can be detrimental to their health (Berhane, Högberg, Byass & Wall, 2002). In Ethiopia, a number of studies have focused on HIV-related knowledge among students (e.g. Andargie, Kassu, Moges, Kebede, Gedefaw, Wale et al., 2007) and urban adults (e.g. Teklu & Davey, 2008), indicating satisfactory levels of knowledge about HIV and AIDS. However, little is known about the extent of knowledge of HIV transmission and prevention methods among illiterate and low-literate women living in rural areas. Studies from other African countries have found significant gaps in HIV/ AIDS knowledge among the youth, specifically among females (Eaton & Flisher, 2000; Barden-O’Fallon, De Graft-Johnson, Biska, Sulzbach, Benson & Tsui, 2004; Smith, 2004; Slonim-Nevo & Mukuka, 2005; Terry, Mhloyi, Masvaure & Adlis, 2006; Salyer, Walusimbi & Fitzpatrick, 2008). For instance, in Nigeria it was observed that females were much less knowledgeable in HIV-prevention methods than were males (28.9% versus 73.2%, respectively) (Bassery, Elemuwa & Anukam, 2007). In Ethiopia, Alene, Wheeler & Grosskurth (2004) found that many women were involved in unsafe sexual practices and had wrong beliefs about transmission, such as believing HIV could be transmitted through mosquito bites or by kissing. Likewise, in other parts of Africa, studies have indicated that a high prevalence of HIV and other sexually transmitted infections among rural women stems from inadequate knowledge of the major modes of transmission and inadequate use of preventive methods (Nkuo-Akenji, Nyasa, Tallah, Ndip & Angwafo, 2007). The study by Alene et al. (2004) revealed a large knowledge gap between urban and rural dwellers in Ethiopia concerning HIV prevention. In Ethiopia the spread of HIV infections from urban to rural communities is partly related to unsafe sexual contacts and practices among merchants, who frequently travel to urban areas (Shabir & Larson, 1995), and that of university students who attend schools in urban areas and then return to visit their rural families (Alene et al., 2004). Not only lack of knowledge may make women vulnerable to HIV infection. Cultural practices, such as polygamy, widow inheritance, ‘widow cleansing’ and various environmental factors may also be barriers for HIV protection, even if the risk of contracting HIV is high. These practices happen mostly in rural communities, where knowledge about HIV infection and transmission routes is generally low. Women’s economic dependency on men and a gender-based power imbalance often make them unable to negotiate condom use with male partners (Barrientos & Bozon, 2007; Boer & Mashamba, 2007). Also, some studies in Africa have shown that women may choose unprotected sex in order to have a child (e.g. Chacko et al., 2007; Tanaka et al., 2008). Some socio-demographic factors may be related to individuals’ level of awareness of HIV and AIDS, such as age and education. Some studies have found that older youths have more knowledge about HIV prevention
Bogale, Boer and Seydel
than younger youths (i.e. Maswaneya, Moji, Horiguchi, Nagata, Aoyagi & Honda, 1999; Boer & Mashamba, 2005; Slonim-Nevo & Mukuka, 2005) while other studies have found no association between age and level of HIV/AIDS knowledge (i.e. Eaton & Flisher, 2000). Many studies indicate a positive association between educational attainment and HIV/AIDS knowledge (e.g. Eaton & Flisher, 2000; Barden-O’Fallon et al., 2004; Vavrus, 2006; Haile, Chamber & Garrison, 2007; Ritieni, Moskowitz & Tholandi, 2008). Many women with lower education or income levels also have a greater extent of misconceptions about HIV transmission (Zulu, Dodoo & Ezeh, 2002). This study aimed to investigate the level of HIV/AIDS awareness and knowledge of HIV transmission and prevention among illiterate and low-literate rural women in Ethiopia. We also studied the influence of age and literacy levels on HIV/AIDS awareness and knowledge of HIV transmission and prevention. The findings may help to produce and implement HIV-prevention programmes for illiterate rural women in Ethiopia. Methods Participants and procedures This study used a cross-sectional design. A power analysis, assuming a percentage of 50, a confidence level of about 7% and a significance level of α = 0.05, indicated that 200 participants would be appropriate. The study was conducted in February and March 2007 in two kebeles (communities) in the Amhara region: Koncher Sasaberai and Borebor Sencha. In total, these communities had 5 199 female inhabitants. The communities are part of the Dejen woreda (district), with 48 326 inhabitants, located in rural Amhara, 250 km northwest of Addis Ababa. The two communities are typical of rural Ethiopia and the participants recruited from the communities seemed typical of rural women in the region. The communities were situated in a remote rural area 5 to 10 km away from the main road and the small town of Dejen; there was no vehicle access and the only means of transportation were on foot or by horseback. Each community (kebele) had ten sub-kebeles, located at different places in the area; hence, from each sub-kebele ten women aged 13–24 were randomly selected in cooperation with the kebele women’s coordinator. Thus, the sample included 100 illiterate, low-literate, or semi-literate women from each community, ages 13–24 years, who voluntary agreed to participate (n = 200; 100% response rate). In cooperation with the local HIV/AIDS-prevention coordinator, we selected 20 literate females from the same two communities to act as data collectors since rural people in Ethiopia are not inclined to reveal personal information to someone they do not know well. We trained the data collectors on how to communicate with illiterate rural women and how to collect data using a structured questionnaire. Each data collector communicated with two respondents per day. It was estimated that each data collector would stay between 1.5 and 2 hours with one respondent in order to complete the questionnaire. Since most respondents could not read and write, the data
African Journal of AIDS Research 2009, 8(3): 349–357
Downloaded by [University of Connecticut] at 15:04 11 October 2014
collectors read the items aloud, giving explanations when necessary, and recorded the responses. After completion, ten birr (about US$1) was given to each respondent as compensation for the time she had spent participating in the study. Measures We used closed-ended questions with ‘yes’ or ‘no’ alternatives to asses HIV/AIDS awareness, knowledge of HIV transmission, and knowledge of HIV prevention and condom use. Close-ended questions are appropriate for respondents who have little knowledge of the subject matter and these require little time to answer (Ary, Jacobs & Razavieh, 2002). Awareness of HIV/AIDS was measured by three items: ‘Have you ever heard about HIV?’; ‘Have you ever heard about AIDS?’; and ‘Have you ever heard about a person who died of AIDS in your locality?’ Knowledge about HIV transmission was measured by five items: ‘HIV is spread by having unprotected sexual intercourse with many partners’; ‘HIV is transmitted by having sexual intercourse without condoms’; ‘HIV is transmitted by sharing needles with an HIV-infected person’; ‘HIV is transmitted by sharing razor blades with an HIV-infected person’; and ‘HIV is transmitted by having a blood transfusion from an HIV-infected person.’ Knowledge about HIV-prevention methods and condom use were measured by four items: ‘Did you ever ask for condoms?’; ‘Do you use condoms during sexual intercourse?’; ‘HIV can be prevented using different types of herbs’; and ‘HIV can be prevented using traditional medicine.’ We also noted the respondent’s age, level of education and religion (i.e. Ethiopian Orthodox Christian and Muslim). The questionnaire was pre-tested, and the content, language clarity, and appropriateness to the local community were checked by a local HIV/AIDS-prevention expert as well as by rural females living in the sample area. Analyses The data were cleaned and analysed using SPSS version 16. We used frequency distribution, cross-tabulation and chi-square analyses. The primary analysis focused on the relation between age, literacy level and knowledge of HIV and AIDS. The women’s age was classified as 13–16 years, 17–20 years or 21–24 years. Their literacy level was classified as: illiterate, grade 1–4 attainment (low literate), or grade 5–8 attainment (semi-literate). Results Characteristics of the participants There was a significant negative relation between age and literacy level among the women in the sample (χ2 [4, n = 200] = 28.89; p < 0.001), with more illiterate individuals among the older age groups (see Table 1). Of the 54 illiterate women in the sample, 25 women (46%) were age 17–20 years, and 19 women (35%) were age 21–24 years. Of the 93 semi-literate women (grade 5–8 attainment), 53 (57%) were age 13–16 years, and 34 (37%) were age 17–20 years. Marital status was significantly associated with literacy levels (χ2 [4, n = 200] = 17.83; p
