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African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20
Sex differentials in the use of centres for voluntary counselling and testing for HIV in Cameroon Emmanuel Ngwakongnwi & Hude Quan Published online: 11 Nov 2009.
To cite this article: Emmanuel Ngwakongnwi & Hude Quan (2009) Sex differentials in the use of centres for voluntary counselling and testing for HIV in Cameroon, African Journal of AIDS Research, 8:1, 43-49, DOI: 10.2989/AJAR.2009.8.1.5.718 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.1.5.718
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(1): 43–49 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2009.8.1.5.718
Sex differentials in the use of centres for voluntary counselling and testing for HIV in Cameroon Emmanuel Ngwakongnwi1* and Hude Quan1, 2 1
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
Department of Community Health Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada 2 The Centre for Health and Policy Studies, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada * Corresponding author, e-mail: [email protected] Part of the strategic response to HIV in Cameroon, West Africa, has been the institutionalisation of voluntary testing and counselling (VCT) for HIV services across the country. The study addresses the general level of awareness and use of VCT centres in Cameroon. The data were extracted from the national, cross-sectional, 2004 Cameroon Demographic and Health Survey (DHS). The survey collected information on respondents’ demographic characteristics and awareness and utilisation of VCT services, through a standard behavioural surveillance survey, administered in face-to-face interviews with males aged 15 years or older and females aged 15 to 49 years. Chi-square and logistic regression were employed for data analysis. A total of 5 280 males and 10 656 females responded to the 2004 Cameroon DHS. More of the male than female respondents had a secondary or higher education (51.8% versus 39%), slightly more of the males than females resided in urban areas (57.3% versus 54.8%), and males were more likely than females to have heard of VCT centres (37.8% versus 26.8%) and were also much more likely to have had an HIV test at a VCT centre (5.9% males versus 1.3% females). The findings indicate that awareness and use of centres offering VCT for HIV is very low in Cameroon. Further research in Cameroon is needed to assess individuals’ reasons for not using VCT, as well as studies to identify patterns of information flow regarding the dissemination of knowledge about HIV and AIDS and about VCT centres. Keywords: country programmes, demographic and health surveys, health knowledge, health services, HIV prevention, household surveys, utilisation patterns, West Africa
Introduction In 2007, UNAIDS reported a general decline in levels of HIV prevalence as compared to the world estimates reported in 2006 (UNAIDS/WHO, 2007). The report emphasised that differences in the estimates for 2006 and 2007 were largely due to refinements in data collection methods rather than to trends in the HIV pandemic itself. Of the approximately 2.1 million deaths due to AIDS reported worldwide in 2007, 76% occurred in sub-Saharan Africa, making it the most-affected region (UNAIDS/WHO, 2007). Regardless of improvements in methods, HIV prevalence estimates for Cameroon were based on 2004 data, which had shown that HIV prevalence was higher among females (6.7%) than among males (4.1%), with national prevalence at 5.4% (Ministère de la Sante [MINSANTE], 2004). Efforts to prevent the spread of HIV in Africa have often focused on promoting changes in sexual behaviour in heterosexual relationships (Turesson, 2006), whereby HIV-prevention information has been based on three key messages: 1) abstention, meaning one should not engage in sex before marriage; 2) fidelity, or having only one reliable sex partner; and 3) condom use, aimed at reducing HIV-transmission risk. HIV-prevention efforts based only on
these three key messages are being hindered by culture, sexual customs, and general beliefs and knowledge about the epidemic. UNAIDS (2005) reported that knowledge about HIV-transmission routes was still very low in sub-Saharan African populations, with females apparently less well informed than males. In 24 sub-Saharan countries (including Cameroon, the Ivory Coast, Kenya, Nigeria, Senegal and Uganda), two-thirds or more of young females aged 15 to 24 lacked comprehensive knowledge of HIV transmission (UNAIDS, 2005). UNAIDS/UNICEF/WHO (2004) reported that levels of education in a population make a large difference to levels of knowledge about the HIV epidemic. While investigating the reproductive health needs of adolescents in Africa, Onifade (1999) found a considerable level of HIV/AIDS awareness among adolescents in relation to their knowledge about other sexually transmitted diseases. However, knowledge concerning HIV transmission was identified as rudimentary in some cases. For example, a significant number of adolescents believed that HIV could be contracted through kissing and mosquito bites, the latter view perhaps stemming from the belief that since mosquitoes are vectors of malaria transmission, then the same would be true of HIV (Onifade, 1999). Persistent misconceptions about HIV and AIDS have
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
44
been well documented. For instance, Orubuloye, Caldwell & Ntozi (1999) note that males in many African societies prefer younger female sex partners, in part due to the belief that younger women are less likely to be HIV-positive. Furthermore, a myth persists among some males that having intercourse with a virgin can cure AIDS illness. In Cameroon, Kuate-Defo (2004) found that young people commonly held the misperception that clean, well-dressed and good-looking people are not and cannot be infected with HIV. A willingness to have multiple sexual partners has also been noted as a societal hindrance to stopping the spread of HIV. In an observational study concerning HIV testing in a mixed Muslim-Christian town in Cameroon, males reported having had an average of 4.9 sex partners in the previous five years, compared to 2.5 partners for females (Holtedahl, Bonono & Salpou, 2005). To counter barriers to voluntary counselling and testing for HIV (VCT) utilisation, Fonchingong, Mbuagbo & Abong (2004) argued that it is imperative to incorporate counselling support into HIV prevention strategies. They base their argument on the fact that patients who use health centres for psychological and spiritual support may receive HIV testing against a backdrop of cultural standards that allow unsafe sexual intercourse and prevent discussions on sexual behaviour and sexuality. Besides hindrances related to culture, some of the largest barriers to HIV testing identified in sub-Saharan Africa include: lack of access to VCT centres, high-quality clinical services and antiretroviral (ARV) therapy; HIV stigma; potential for increased violence, loss of security, discrimination or isolation as a result of sharing information about HIV seropositivity; scarce economic resources and competing priorities; and concerns about HIV-test confidentiality (Kalichman & Simbayi, 2003; WHO, 2003; Prost, Sseruma, Fakoya, Arthur, Taegtmeyer, Njeri et al., 2007). Despite such barriers, VCT has successfully reduced higher-risk behaviours in some populations. In Uganda, for example, users of VCT showed increased condom use, reduction in average number of sex partners, and reduction in number of sex encounters (UNAIDS, 2000a). Several African countries have responded to the call for counselling in HIV prevention by creating VCT centres. In Cameroon, the Ministry of Public Health, through the National AIDS Control Committee, began by creating 11 VCT centres, geographically distributed in major cities and towns throughout the country (MINSANTE, 2000). These centres have since been providing VCT services at a subsidised cost. According to UNAIDS (2000b), VCT for HIV is the process by which an individual undergoes counselling, enabling the user to make an informed choice about testing for HIV. Holtedahl et al. (2005) emphasised that the decision to test for HIV needs to be entirely the choice of the individual and that the process must remain confidential. Accordingly, part of the process of setting up a VCT centre requires launching an information campaign by private and public media to sensitise the population, and recruiting and training local staff. Since its introduction in Cameroon, the availability of VCT has not been evaluated. We conducted this study to examine people’s level of awareness and use of centres for
Ngwakongnwi and Quan
VCT for HIV in Cameroon. The findings may provide useful information for other African countries that have recently implemented VCT programmes as well as others that are yet to adopt such strategies in response to the HIV epidemic. Methods Sampling We derived data from the 2004 Cameroon Demographic and Health Survey (DHS), a national, cross-sectional, health survey carried out in all 10 provinces and involving household residents aged 15 years or older. Details of this survey are described elsewhere (see http://www.measuredhs. com/countries/metadata.cfm?surv_id=232&ctry_ id=4&SrvyTp=ctry). A multiple-stage and complex-sampling methodology was employed to locate households in 12 clusters, all covering VCT locations. For this survey, clusters refer to small geographically defined areas, which included ones in all 10 provinces and two cities. Conducting a DHS involves a four-step process that can last 1–20 months in total (ORC Macro, 2005). The first step of the 2004 Cameroon DHS involved preparatory activities, including designing the sample and developing the survey questionnaires to meet the specific needs of Cameroon. The standard DHS consists of a household questionnaire and a (A-core or B-core) questionnaire for females; the B-core questionnaire for females (used in countries with low contraceptive prevalence) was selected for Cameroon. The HIV/AIDS module was added to the household questionnaire to include topics that reflected the needs of people in Cameroon (e.g. VCT for HIV). The survey instruments were then translated into local languages, pre-tested, and finalised. The questionnaires and methods used in the process have been sufficiently revised and tested in several countries, ensuring the validity and reliability of the survey. The second stage involved training field staff and conducting fieldwork. Households scientifically selected for inclusion in the DHS sample were visited and enumerated using a household questionnaire, which included a cover sheet to identify the household and a form on which all members of the household and visitors could be listed. This form was used to record socio-demographic information about each member of the household (such as name, gender, age, education, survival of parents for children under age 18) and other data. All eligible females in a household were identified and then interviewed using the questionnaire for females. Eligible males in a subsample of 50% of all households were also identified and interviewed face-to-face using the household questionnaire. Individuals from eligible households were voluntarily enlisted for HIV testing. Prior to administering an interview, consent forms were administered to the eligible participants. The consent form clearly identified the interviewer, the name of the administering organisation, the time required to complete the questionnaire, and statements attesting to the confidentiality of the responses and a respondent’s right not to answer any question or to discontinue the interview without consequences. The third stage involved data processing, including editing, coding, entering and verifying the data, as well as
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
African Journal of AIDS Research 2009, 8(1): 43–49
45
checking for consistency. The fourth stage (completed in 2005) involved analysing the data, preparing the final report, and disseminating the survey results. At this stage the executing agency releases survey data to researchers. After making a formal request to Cameroon’s Institut National de la Statistique and submitting a research proposal to ORC Macro, access to data for this study was approved in 2006. The sample was selected with unequal probability to expand the number of cases available for certain areas or subgroups for which statistics are needed. Data for this study were generated from the HIV/AIDS module of the questionnaires for males and females. The two data sets were combined by appending the data set for females to that for males and adjusting the sample weights by dividing the original sample weights by 1 000 000, a function of the cluster sample sizes and design effects (Institut National de la Statistique [INS] & ORC Macro, 2004).
males, 26.8% of females; p < 0.001), and more males than females had actually tested for HIV at a VCT centre (5.9% of males, 1.3% of females; p < 0.001) (Table 2). However, a similar proportion of both sexes said they had visited a VCT centre (12.8% of males, 11.1% of females; p = 0.0759). The pattern of the difference between males’ and females’ responses to ‘ever heard of a VCT centre’ and ‘ever tested for HIV at a VCT centre’ was consistent across age groups and the different categories for place of residence, educational level and marital status (Table 3). After adjustment for socio-demographic variables, males were found to be more likely than females to be aware of VCT (risk adjusted odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.22–1.43) and to have tested for HIV at a centre (OR = 2.85, 95% CI = 2.17–3.74] (Table 4).
Study variables Information on the socio-demographic characteristics of the respondents included age, place of residence, education, and marital status. For this study, age was grouped into four categories: ages 15–19, 20–34, 35–49, and 50 and above. The two categories of place of residence were based on whether a respondent resided permanently in an urban or rural area. Educational level was categorised as ‘no education,’ ‘primary school’ or ‘secondary school or higher.’ Marital status was regrouped into three categories: ‘never married,’ ‘married’ and ‘other.’ The respondents were asked: ‘Ever heard of a voluntary counselling and testing centre?’; ‘Ever been to a voluntary counselling and testing centre?’; and ‘Ever tested for HIV at a voluntary counselling and testing centre?’ None of these questions was a subset of a pre-qualifying question. Also, these were stand-alone, country-specific questions added to the HIV/AIDS module of the standard household questionnaire. Each of the three questions had two response categories: ‘Yes’ or ‘No.’
Our study assessed the level of awareness and use of centres for VCT for HIV in Cameroon using data from the 2004 DHS. We found that: 1) awareness of VCT services and the actual use of HIV testing at VCT centres was very low among Cameroonians (although the national VCT programme had been implemented a year prior to the survey); and 2) awareness and use of VCT was lower among females than males (only 1 in 10 females compared to 1 in 2 males who had visited a VCT centre had actually tested for HIV). Aday & Andersen (1974) developed a model for studying the utilisation of health services (see also Andersen, 1995). This model has been used in studies of determinants of utilisation behaviours. The model explicates that utilisation of health services is determined by: 1) population characteristics (including the predisposing, enabling, and need factors and beliefs); 2) the features of the healthdelivery system; and 3) the patients’ levels of satisfaction. Unfortunately, there is limited information about quality of care and patients’ satisfaction with VCT. Our possible explanations focus on the population characteristics of the survey respondents. The first possible explanation for respondents’ low level of awareness and use of VCT centres is lack of information. Notably, Cameroon’s strategic plan for a national HIV/ AIDS response has involved a multi-sector, decentralised approach. This was planned to run from 2000–2005 and was meant to include an urgent phase (2000–2002) aimed at achieving three goals: 1) 100% utilisation of condoms (either male or female condoms); 2) setting up VCT centres; and 3) providing HIV-related information, education and communication to ensure behavioural change among youths. By 2003, 11 VCT centres had been installed, geographically distributed across major cities and towns at the national level; the centres were meant to provide HIV counselling and testing services at a subsidised cost (MINSANTE, 2000). Prior to setting up each VCT centre, activities during the preceding 12 weeks included getting private and public media to organise an information campaign intended to sensitise the population, and training personnel for each centre. In addition, the sensitisation of workers at various
Statistical analysis The characteristics of the study population were described using descriptive statistics. Sample weights were applied to compute proportions of the study variables. Chi-square was used to test for statistical differences between males’ and females’ responses. Sex-specific variables were calculated and logistic regression was used to estimate the association between dependent variables (i.e. ‘ever heard of VCT,’ ‘ever been to a VCT centre,’ and ‘ever had an HIV test at a VCT centre’) and the explanatory variables (i.e. sex, age group, place of residence, level of education, and marital status). Results A total of 5 280 males and 10 656 females responded to the 2004 Cameroon DHS. Slightly more males than females resided in urban areas (57.3% versus 54.8%) and more males had a secondary school or higher education (51.8% versus 39%) (Table 1). A significantly higher proportion of males than females said they had heard of centres for VCT for HIV (37.8% of
Discussion
46
Ngwakongnwi and Quan
Table 1: Socio-demographic characteristics of the respondents to the 2004 Cameroon Demographic and Health Survey
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
Variable Age group (years) 15–19 20–34 35–49 ≥50 Place of residence Urban Rural Level of education No education Primary school Secondary school or higher Marital status Never married Married Other
% males (n = 5 280)
% females (n = 10 656)
23.2 45.2 22.8 8.8
25.2 50.2 24.6 0
57.3 42.7
54.8 45.2
11.5 36.7 51.8
22.4 38.6 39
African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20
Sex differentials in the use of centres for voluntary counselling and testing for HIV in Cameroon Emmanuel Ngwakongnwi & Hude Quan Published online: 11 Nov 2009.
To cite this article: Emmanuel Ngwakongnwi & Hude Quan (2009) Sex differentials in the use of centres for voluntary counselling and testing for HIV in Cameroon, African Journal of AIDS Research, 8:1, 43-49, DOI: 10.2989/AJAR.2009.8.1.5.718 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.1.5.718
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(1): 43–49 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2009.8.1.5.718
Sex differentials in the use of centres for voluntary counselling and testing for HIV in Cameroon Emmanuel Ngwakongnwi1* and Hude Quan1, 2 1
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
Department of Community Health Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada 2 The Centre for Health and Policy Studies, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada * Corresponding author, e-mail: [email protected] Part of the strategic response to HIV in Cameroon, West Africa, has been the institutionalisation of voluntary testing and counselling (VCT) for HIV services across the country. The study addresses the general level of awareness and use of VCT centres in Cameroon. The data were extracted from the national, cross-sectional, 2004 Cameroon Demographic and Health Survey (DHS). The survey collected information on respondents’ demographic characteristics and awareness and utilisation of VCT services, through a standard behavioural surveillance survey, administered in face-to-face interviews with males aged 15 years or older and females aged 15 to 49 years. Chi-square and logistic regression were employed for data analysis. A total of 5 280 males and 10 656 females responded to the 2004 Cameroon DHS. More of the male than female respondents had a secondary or higher education (51.8% versus 39%), slightly more of the males than females resided in urban areas (57.3% versus 54.8%), and males were more likely than females to have heard of VCT centres (37.8% versus 26.8%) and were also much more likely to have had an HIV test at a VCT centre (5.9% males versus 1.3% females). The findings indicate that awareness and use of centres offering VCT for HIV is very low in Cameroon. Further research in Cameroon is needed to assess individuals’ reasons for not using VCT, as well as studies to identify patterns of information flow regarding the dissemination of knowledge about HIV and AIDS and about VCT centres. Keywords: country programmes, demographic and health surveys, health knowledge, health services, HIV prevention, household surveys, utilisation patterns, West Africa
Introduction In 2007, UNAIDS reported a general decline in levels of HIV prevalence as compared to the world estimates reported in 2006 (UNAIDS/WHO, 2007). The report emphasised that differences in the estimates for 2006 and 2007 were largely due to refinements in data collection methods rather than to trends in the HIV pandemic itself. Of the approximately 2.1 million deaths due to AIDS reported worldwide in 2007, 76% occurred in sub-Saharan Africa, making it the most-affected region (UNAIDS/WHO, 2007). Regardless of improvements in methods, HIV prevalence estimates for Cameroon were based on 2004 data, which had shown that HIV prevalence was higher among females (6.7%) than among males (4.1%), with national prevalence at 5.4% (Ministère de la Sante [MINSANTE], 2004). Efforts to prevent the spread of HIV in Africa have often focused on promoting changes in sexual behaviour in heterosexual relationships (Turesson, 2006), whereby HIV-prevention information has been based on three key messages: 1) abstention, meaning one should not engage in sex before marriage; 2) fidelity, or having only one reliable sex partner; and 3) condom use, aimed at reducing HIV-transmission risk. HIV-prevention efforts based only on
these three key messages are being hindered by culture, sexual customs, and general beliefs and knowledge about the epidemic. UNAIDS (2005) reported that knowledge about HIV-transmission routes was still very low in sub-Saharan African populations, with females apparently less well informed than males. In 24 sub-Saharan countries (including Cameroon, the Ivory Coast, Kenya, Nigeria, Senegal and Uganda), two-thirds or more of young females aged 15 to 24 lacked comprehensive knowledge of HIV transmission (UNAIDS, 2005). UNAIDS/UNICEF/WHO (2004) reported that levels of education in a population make a large difference to levels of knowledge about the HIV epidemic. While investigating the reproductive health needs of adolescents in Africa, Onifade (1999) found a considerable level of HIV/AIDS awareness among adolescents in relation to their knowledge about other sexually transmitted diseases. However, knowledge concerning HIV transmission was identified as rudimentary in some cases. For example, a significant number of adolescents believed that HIV could be contracted through kissing and mosquito bites, the latter view perhaps stemming from the belief that since mosquitoes are vectors of malaria transmission, then the same would be true of HIV (Onifade, 1999). Persistent misconceptions about HIV and AIDS have
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
44
been well documented. For instance, Orubuloye, Caldwell & Ntozi (1999) note that males in many African societies prefer younger female sex partners, in part due to the belief that younger women are less likely to be HIV-positive. Furthermore, a myth persists among some males that having intercourse with a virgin can cure AIDS illness. In Cameroon, Kuate-Defo (2004) found that young people commonly held the misperception that clean, well-dressed and good-looking people are not and cannot be infected with HIV. A willingness to have multiple sexual partners has also been noted as a societal hindrance to stopping the spread of HIV. In an observational study concerning HIV testing in a mixed Muslim-Christian town in Cameroon, males reported having had an average of 4.9 sex partners in the previous five years, compared to 2.5 partners for females (Holtedahl, Bonono & Salpou, 2005). To counter barriers to voluntary counselling and testing for HIV (VCT) utilisation, Fonchingong, Mbuagbo & Abong (2004) argued that it is imperative to incorporate counselling support into HIV prevention strategies. They base their argument on the fact that patients who use health centres for psychological and spiritual support may receive HIV testing against a backdrop of cultural standards that allow unsafe sexual intercourse and prevent discussions on sexual behaviour and sexuality. Besides hindrances related to culture, some of the largest barriers to HIV testing identified in sub-Saharan Africa include: lack of access to VCT centres, high-quality clinical services and antiretroviral (ARV) therapy; HIV stigma; potential for increased violence, loss of security, discrimination or isolation as a result of sharing information about HIV seropositivity; scarce economic resources and competing priorities; and concerns about HIV-test confidentiality (Kalichman & Simbayi, 2003; WHO, 2003; Prost, Sseruma, Fakoya, Arthur, Taegtmeyer, Njeri et al., 2007). Despite such barriers, VCT has successfully reduced higher-risk behaviours in some populations. In Uganda, for example, users of VCT showed increased condom use, reduction in average number of sex partners, and reduction in number of sex encounters (UNAIDS, 2000a). Several African countries have responded to the call for counselling in HIV prevention by creating VCT centres. In Cameroon, the Ministry of Public Health, through the National AIDS Control Committee, began by creating 11 VCT centres, geographically distributed in major cities and towns throughout the country (MINSANTE, 2000). These centres have since been providing VCT services at a subsidised cost. According to UNAIDS (2000b), VCT for HIV is the process by which an individual undergoes counselling, enabling the user to make an informed choice about testing for HIV. Holtedahl et al. (2005) emphasised that the decision to test for HIV needs to be entirely the choice of the individual and that the process must remain confidential. Accordingly, part of the process of setting up a VCT centre requires launching an information campaign by private and public media to sensitise the population, and recruiting and training local staff. Since its introduction in Cameroon, the availability of VCT has not been evaluated. We conducted this study to examine people’s level of awareness and use of centres for
Ngwakongnwi and Quan
VCT for HIV in Cameroon. The findings may provide useful information for other African countries that have recently implemented VCT programmes as well as others that are yet to adopt such strategies in response to the HIV epidemic. Methods Sampling We derived data from the 2004 Cameroon Demographic and Health Survey (DHS), a national, cross-sectional, health survey carried out in all 10 provinces and involving household residents aged 15 years or older. Details of this survey are described elsewhere (see http://www.measuredhs. com/countries/metadata.cfm?surv_id=232&ctry_ id=4&SrvyTp=ctry). A multiple-stage and complex-sampling methodology was employed to locate households in 12 clusters, all covering VCT locations. For this survey, clusters refer to small geographically defined areas, which included ones in all 10 provinces and two cities. Conducting a DHS involves a four-step process that can last 1–20 months in total (ORC Macro, 2005). The first step of the 2004 Cameroon DHS involved preparatory activities, including designing the sample and developing the survey questionnaires to meet the specific needs of Cameroon. The standard DHS consists of a household questionnaire and a (A-core or B-core) questionnaire for females; the B-core questionnaire for females (used in countries with low contraceptive prevalence) was selected for Cameroon. The HIV/AIDS module was added to the household questionnaire to include topics that reflected the needs of people in Cameroon (e.g. VCT for HIV). The survey instruments were then translated into local languages, pre-tested, and finalised. The questionnaires and methods used in the process have been sufficiently revised and tested in several countries, ensuring the validity and reliability of the survey. The second stage involved training field staff and conducting fieldwork. Households scientifically selected for inclusion in the DHS sample were visited and enumerated using a household questionnaire, which included a cover sheet to identify the household and a form on which all members of the household and visitors could be listed. This form was used to record socio-demographic information about each member of the household (such as name, gender, age, education, survival of parents for children under age 18) and other data. All eligible females in a household were identified and then interviewed using the questionnaire for females. Eligible males in a subsample of 50% of all households were also identified and interviewed face-to-face using the household questionnaire. Individuals from eligible households were voluntarily enlisted for HIV testing. Prior to administering an interview, consent forms were administered to the eligible participants. The consent form clearly identified the interviewer, the name of the administering organisation, the time required to complete the questionnaire, and statements attesting to the confidentiality of the responses and a respondent’s right not to answer any question or to discontinue the interview without consequences. The third stage involved data processing, including editing, coding, entering and verifying the data, as well as
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
African Journal of AIDS Research 2009, 8(1): 43–49
45
checking for consistency. The fourth stage (completed in 2005) involved analysing the data, preparing the final report, and disseminating the survey results. At this stage the executing agency releases survey data to researchers. After making a formal request to Cameroon’s Institut National de la Statistique and submitting a research proposal to ORC Macro, access to data for this study was approved in 2006. The sample was selected with unequal probability to expand the number of cases available for certain areas or subgroups for which statistics are needed. Data for this study were generated from the HIV/AIDS module of the questionnaires for males and females. The two data sets were combined by appending the data set for females to that for males and adjusting the sample weights by dividing the original sample weights by 1 000 000, a function of the cluster sample sizes and design effects (Institut National de la Statistique [INS] & ORC Macro, 2004).
males, 26.8% of females; p < 0.001), and more males than females had actually tested for HIV at a VCT centre (5.9% of males, 1.3% of females; p < 0.001) (Table 2). However, a similar proportion of both sexes said they had visited a VCT centre (12.8% of males, 11.1% of females; p = 0.0759). The pattern of the difference between males’ and females’ responses to ‘ever heard of a VCT centre’ and ‘ever tested for HIV at a VCT centre’ was consistent across age groups and the different categories for place of residence, educational level and marital status (Table 3). After adjustment for socio-demographic variables, males were found to be more likely than females to be aware of VCT (risk adjusted odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.22–1.43) and to have tested for HIV at a centre (OR = 2.85, 95% CI = 2.17–3.74] (Table 4).
Study variables Information on the socio-demographic characteristics of the respondents included age, place of residence, education, and marital status. For this study, age was grouped into four categories: ages 15–19, 20–34, 35–49, and 50 and above. The two categories of place of residence were based on whether a respondent resided permanently in an urban or rural area. Educational level was categorised as ‘no education,’ ‘primary school’ or ‘secondary school or higher.’ Marital status was regrouped into three categories: ‘never married,’ ‘married’ and ‘other.’ The respondents were asked: ‘Ever heard of a voluntary counselling and testing centre?’; ‘Ever been to a voluntary counselling and testing centre?’; and ‘Ever tested for HIV at a voluntary counselling and testing centre?’ None of these questions was a subset of a pre-qualifying question. Also, these were stand-alone, country-specific questions added to the HIV/AIDS module of the standard household questionnaire. Each of the three questions had two response categories: ‘Yes’ or ‘No.’
Our study assessed the level of awareness and use of centres for VCT for HIV in Cameroon using data from the 2004 DHS. We found that: 1) awareness of VCT services and the actual use of HIV testing at VCT centres was very low among Cameroonians (although the national VCT programme had been implemented a year prior to the survey); and 2) awareness and use of VCT was lower among females than males (only 1 in 10 females compared to 1 in 2 males who had visited a VCT centre had actually tested for HIV). Aday & Andersen (1974) developed a model for studying the utilisation of health services (see also Andersen, 1995). This model has been used in studies of determinants of utilisation behaviours. The model explicates that utilisation of health services is determined by: 1) population characteristics (including the predisposing, enabling, and need factors and beliefs); 2) the features of the healthdelivery system; and 3) the patients’ levels of satisfaction. Unfortunately, there is limited information about quality of care and patients’ satisfaction with VCT. Our possible explanations focus on the population characteristics of the survey respondents. The first possible explanation for respondents’ low level of awareness and use of VCT centres is lack of information. Notably, Cameroon’s strategic plan for a national HIV/ AIDS response has involved a multi-sector, decentralised approach. This was planned to run from 2000–2005 and was meant to include an urgent phase (2000–2002) aimed at achieving three goals: 1) 100% utilisation of condoms (either male or female condoms); 2) setting up VCT centres; and 3) providing HIV-related information, education and communication to ensure behavioural change among youths. By 2003, 11 VCT centres had been installed, geographically distributed across major cities and towns at the national level; the centres were meant to provide HIV counselling and testing services at a subsidised cost (MINSANTE, 2000). Prior to setting up each VCT centre, activities during the preceding 12 weeks included getting private and public media to organise an information campaign intended to sensitise the population, and training personnel for each centre. In addition, the sensitisation of workers at various
Statistical analysis The characteristics of the study population were described using descriptive statistics. Sample weights were applied to compute proportions of the study variables. Chi-square was used to test for statistical differences between males’ and females’ responses. Sex-specific variables were calculated and logistic regression was used to estimate the association between dependent variables (i.e. ‘ever heard of VCT,’ ‘ever been to a VCT centre,’ and ‘ever had an HIV test at a VCT centre’) and the explanatory variables (i.e. sex, age group, place of residence, level of education, and marital status). Results A total of 5 280 males and 10 656 females responded to the 2004 Cameroon DHS. Slightly more males than females resided in urban areas (57.3% versus 54.8%) and more males had a secondary school or higher education (51.8% versus 39%) (Table 1). A significantly higher proportion of males than females said they had heard of centres for VCT for HIV (37.8% of
Discussion
46
Ngwakongnwi and Quan
Table 1: Socio-demographic characteristics of the respondents to the 2004 Cameroon Demographic and Health Survey
Downloaded by [University of Saskatchewan Library] at 06:46 03 January 2015
Variable Age group (years) 15–19 20–34 35–49 ≥50 Place of residence Urban Rural Level of education No education Primary school Secondary school or higher Marital status Never married Married Other
% males (n = 5 280)
% females (n = 10 656)
23.2 45.2 22.8 8.8
25.2 50.2 24.6 0
57.3 42.7
54.8 45.2
11.5 36.7 51.8
22.4 38.6 39
