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KNOWLEDGE, PERCEPTIONS AND RISKY BEHAVIOURS WITH REGARD TO HIV/AIDS AMONG SECONDARY SCHOOL STUDENTS IN CENTRAL UGANDA By SEREBE IVAN DEDICATION I have the pleasure to dedicate this piece of work to Dr Martin Odiit of Uganda HIV/AIDS Control Project who has always been there for me. May God richly reward you. ACKNOWLEDGEMENTS My heartfelt gratitude goes to, Prof JP Ntozi and Dr Emmanuel Sekatawa for their professional advice and guidance. I also thank the management and staff of Uganda HIV/AIDS Control Project in particular Dr Martin Odiit, the M&E specialist for providing me with the data and technical advice.
List of abbreviations and acronyms AIDS: Acquired Immune Deficiency Syndrome AIC: AIDS Information Centre ART: Ant-Retroviral Therapy BCC: Behavioural Change Communication HIV: Human Immune Virus KABP: Knowledge, Attitude, Belief and Practices MoH: Ministry of Health N: Total number of respondents S. E: Standard error SPSS: Statistical Package for Social Scientists STDs: Sexually Transmitted Diseases STIs: Sexually Transmitted Infections UAC: Uganda AIDS Commission UACP: Uganda HIV/AIDS Control Project UBOS: Uganda Bureau of Statistics UDHS: Uganda Demographic Health Survey UNAIDS: The Joint United Nations Programme on HIV/AIDS UNICEF: United Nations Childrens Fund USAID: United States Agency for International Development. VCT: Voluntary Counselling and Testing WHO: World Health Organisation. ABSTRACT Whereas the majority of Ugandans are knowledgeable about HIV/AIDS, young people still engage in risky behaviours.
The general objective of the study was to determine knowledge, perceptions and risky behaviors among secondary school students in central Uganda regarding HIV/AIDS. Specifically, the study determined the influence of knowledge and perception of secondary school students with risky behaviours to HIV prevention. Lot Quality Assurance Survey/ Sampling (LQAS) method was used in the collection of this data. The LQAS is a sampling technique that stratifies the study population, in this case schools in a district into at least five homogeneous strata. Subsequently, 19 individuals are randomly selected from each stratum (class) thereby giving a sample size of a total of at least 95 respondents in a school. Hence, data was collected from 23 secondary schools from five districts in central Uganda and with a total sample size of 2, 030 students/ respondents.
The data was collected in 2006 by Uganda HIV/AIDS Control Project (UACP) a project funded by the World Bank and the Government of Uganda whose objective is to support the National Strategic Framework for HIV/AIDS, 2001 to 2006. The study revealed that students are knowledgeable about the signs of sexually transmitted diseases (83. 3 %) which means that efforts should target practice other than knowledge increase but have limited knowledge about health facilities (65 %). Generally, students do think that they are at risk of getting HIV (57 %) and the main reasons of not being at risk were sexual abstinence (26. 4 %) and being young (14. 3 %) hence abstinence should be promoted in schools. Although 46. 5 % of the students had ever had sex, only 23. 9 % of the respondents were sexually active which indicates that there is secondary abstinence taking place. The study also found out that students in mixed day schools are 2. times more likely (p< 0. 05) to use condoms as compared to those in single schools suggesting a peer opposite sex positive effect on condom use.
It is recommended that information be packaged for behavioural change among the students for promotion of life skills development so as to enable them transform knowledge into practice. In addition, when addressing student groups about HIV/AIDS related information, they should preferably be segmented into sexually active and those abstaining so that the right message is given to the right audience. Behavioural change related activities should be integrated in the existing school programmes TABLE OF CONTENTS DECLARATIONS ii DEDICATION iii ACKNOWLEDGEMENTS iv Abstract TABLE OF CONTENTS viii LIST OF Table CHAPTER ONE: BACKGROUND 1 1. 1 Global situation of HIV/AIDS 1 1. 2 HIV/AIDS situation in Sub-Saharan Africa. 1 1. 3 HIV/AIDS situation in Uganda 2 1. 4 PROBLEM STATEMENT 4 1. 5 Study objectives: 5 1. 5. 1 General objective 5 1. 5. 2 Specific Objectives: 6 1. 5. 3 Hypotheses: 6 1. 6 Significance of the study 6 1. 7 Operational definitions of the indicators and descriptions of terms 7 1. 7. 1 Knowledge about prevention of HIV 7 1. 7. 2 Risky behaviours 7 1. 7. 3 Perception 7 1. 8 Conceptual Framework of the relationship between HIV/AIDS knowledge, perception and risky behavior 8 1. 9 Outline of report 9 CHAPTER TWO: LITERATURE REVIEW 10 2. 1 HIV Prevention among young people 10 2. 1. 1 School based HIV prevention for young people. 11 2. 2 HIV/AIDS related knowledge 12 2. 2. 1 HIVAIDS Knowledge and Condom Use 13 2. 3 Sexually transmitted Infections among Adolescents 14 2. 4 Risk perception and preventive behaviours in risk context 16 2. 4. 1 Normalisation 17 2. 4. 2 Fear of pregnancy rather than HIV 17 2. 4. 3 Promoting secrecy about sex among young people 17 2. 4. 4 Alcohol and drug abuse 18 2. 5 Youth Friendly service Utilisation 19 2. 5. 1 Factors for poor youth friendly service utilization 19 2. 6 Conclusion 21 CHAPTER THREE: METHODOLOGY 22 3. 1 Introduction 22 3. 2 Data Source and study area 22 3. 2. 1 Sampling technique and sample size 22 3. 2. 2 Selection criteria for the Schools: 23 3. 3 Data Processing and analysis 24 CHAPTER FOUR: Background Characteristics of Students 26 4. 1 Introduction 26 4. 2 Distribution of students by socio-economic and demographic characteristics 26 4. 2. 1 Sex 26 4. 2. 2 Class 26 4. 2. 3 District location of school 26 4. 2. 4 Age 28 4. 2. 5 Respondents distribution by school category 28 4. 3 Distribution of respondents by sexual behavior 28 4. 3. 1 Sexual involvement by the respondents 28 4. 3. 2 Respondents that are sexually active. 29 4. 3. 3 Condom use among respondents that are sexually active 29 4. 4 Respondents knowledge on HIV/AIDS prevention and control 29 4. 5 Perceptions of respondents on HIV/AIDS Prevention and Control 31 4. 5. 1 Risk perception among the respondents 31 4. 6 Summary of findings 32 CHAPTER FIVE 33 5. 1 Introduction 33 5. 2 Association between background factors and knowledge on HIV/AIDs prevention 33 5. 2. 1 Background factors and knowledge of the signs of Sexually Transmitted Infections 33 5. 2. 2 Background factors and knowledge levels of a health facility that provides youth friendly services 36 5. 2. 3 Background factors and knowledge of the benefits for HIV Voluntary Counseling and Testing. 39 5. 3 Association between background factors and perception of risk to HIV/AIDS infection 41 5. 3. 1 Sex and risk perception to HIV infection 41 5. 3. 2 School category and risk perception to HIV infection 41 5. 3. 3 Age and risk perception to HIV infection 41 5. 3. 4 Class of attendance and risk perception to HIV infection 41 5. 3. 5 District location of school and risk perception to HIV infection 42 5. 4 Association between Knowledge and risk behaviours to HIV/AIDS infection 44 5. 4. 1 Knowledge and Condom use 44 5. 4. 2 Knowledge and sexual involvement 45 5. 4. 3 Knowledge and alcohol involvement 46 5. 4. 4 Knowledge of HIV. AIDS prevention and prevention behavior 46 5. 5 Factors influencing risk behavior involvement that lead to HIV infection 47 5. 5. 1 Introduction 47 5. 5. 2 Condom use and sex 47 5. 5. 2. 1 Condom use and district location of school 49 5. 5. 2. 2 Condom use and school category 50 5. 5. 3. 1 Sexual involvement and gender 51 5. 5. 3. 2 Sexual involvement and age 52 5. 5. 3. 3 Sexual involvement and district location of school 53 5. 5. 4 Likelihood of having a high-risk perception to HIV 54 Summary 55 CHAPTER SIX; SUMMARY, CONCLUSION AND RECOMMENDATIONS 56 6. 1 Introduction 56 6. 2 Summary of findings 56 6. 3 Conclusion Error! Bookmark not defined. 6. 4 Recommendations 57 6. 5 Areas for further research 58 Appendix II; Survey questioner 70 LIST OF TABLES Table 4. 1 Social demographic characteristics of the students 27 Table 4. 2. Students that had ever had sex 28 Table 4. 3 Student that had sex in last 12 months to the study (sexually active Student) Error!
Bookmark not defined. Table 4. 4. Students that had used a condom the last time they had sex 29 Table 4. 5. Students knowledge on signs of Sexually Transmitted Infections, youth friendly service provision facility and benefits of VCT. 30 Table 4. 6.
Distribution of risk perception to HIV among the Student 31 Table 4. 7. Students reasons for considering them selves to being either at a high risk or a low risk 32 Table 5. 1. Cross-tabulation between background characteristics and knowledge of the signs of Sexually Transmitted Infections (STI) 35 Table 5. 2. Cross-tabulation between background characteristics and knowledge of a health facility 38 Table 5. 3. Cross-tabulation between background characteristics and knowledge of at least two benefits for HIV Voluntary Counseling and Testing 40 Table 5. 4. Relationship between background factors and level of risk of getting HIV 43 Table 5. 5 Relationship between Knowledge and Condom use 44 Table 5. 6.
Relationship between Knowledge and sexual involvement 45 Table 5. 7. Relationship between Knowledge and Alcohol involvement 46 Table 5. 8. Background factors with the influence of condom use to HIV infection 49 Table 5. 9. Background factors with Sexual involvement to HIV infection 51 Table 5. 10. Background factors with Risk perception to HIV infection 54 CHAPTER ONE: BACKGROUND 1. 1 Global situation of HIV/AIDS Since the first cases of acquired immunodeficiency syndrome (AIDS) were reported in 1981, infection with human immunodeficiency virus (HIV) has grown to pandemic proportions, resulting in an estimated 65 million infections and 25 million deaths (UNAIDS, CDC, 2006).
During 2005 alone, an estimated 2. 8 million persons died from AIDS, 4. 1 million were newly infected with HIV, and 38. 6 million were living with HIV (UNAIDS, 2006). HIV continues to disproportionately affect certain geographic regions (e. g. , sub-Saharan Africa and the Caribbean) and subpopulations (e. g. , women in sub-Saharan Africa, men who have sex with men [MSM], injection-drug users [IDUs], and sex workers). The global HIV/AIDS situation for adolescents is very serious, and the need for a stronger, focused response is urgent. Young people are particularly vulnerable to HIV infection because of risky sexual behaviour and substance use due to lack of access to accurate and personalized HIV information and prevention services as well as for a host of other social and economic reasons.
At the end of 2005, an estimated 12. 4 million young people aged 15 - 24 years were living with HIV/AIDS representing one third of the global total of people living with HIV/AIDS (UNAIDS, 2006). 1. 2 HIV/AIDS situation in Sub-Saharan Africa. Approximately 10 % of the world population lives in sub-Saharan Africa, but the region is home to approximately 64 % of the world population living with HIV (UNAIDS, 2006). Transmission is primarily through heterosexual contact, and more women are HIV infected than men. Southern Africa is the epicenter of the AIDS epidemic; all countries in the region except Angola have an estimated adult (i. e. , aged 15 -- 49 years) HIV prevalence exceeding 10 % (UNAIDS, 2006). In Botswana, Lesotho, Swaziland, and Zimbabwe, the estimated adult HIV prevalence exceeds 20 % (UNAIDS/WHO, 2006).
South Africa, with an HIV prevalence of 18. 8 % and 5. 5 million persons living with HIV, has, along with India, the largest number of persons living with HIV in the world (UNAIDS, 2006). Recently, declines in adult HIV prevalence have been observed in Kenya, Zimbabwe, and urban areas of Burkina Faso. Although in these countries, HIV-related sexual risk behaviors and HIV incidence have decreased, AIDS death rates continue to rise. In sub-Saharan Africa, 17 % of the estimated number of persons in need of ART received it in 2005 (WHO, 2005). HIV/AIDS is the leading cause of death in this region.
It was projected that HIV/AIDS would reduce average life expectancy in some of the southern African countries from 47 to around 39 years between 2001 and 2010 (UNAIDS, 2002; Kiragu, 2001). Though both males and females are getting infected with HIV, adolescent girls stand a special risk. That is, more than two thirds of newly infected 15 - 19 year-olds are females. In major urban areas of eastern and southern Africa, epidemiological studies have shown that 17 - 22 % of girls aged 15 - 19 years were already infected compared to 3 - 7 % of boys of similar age. As in most countries in the world, girls in sub-Saharan Africa are at an increased rate of HIV infection because many older men prefer having sex with young girls thinking that they are free from HIV (UNICEF, 2002). 1. 3 HIV/AIDS situation in Uganda In Uganda, an estimated cumulative total of 2. 2 million people have been infected with the virus, about 2 million people are currently estimated to be living with HIV/AIDS and about 900, 000 HIV/AIDS related deaths have occurred since its on-set in the country (MoH, 2005). By 2003 literature indicated that there had been a steady decline in HIV prevalence since 1992 when prevalence reached a high of 30. 2 % in one of the urban areas (Mbarara) of Uganda (MOH, 2003).
Overall prevalence in the adult population has also declined from a high 18. 5 % in late 1980 s to 6. 4 % in 2004 - 05. In 2004 - 05 the prevalence ranged from 5. 7 % in rural areas to 10. 1 % in urban areas. Some sentinel surveillance sites have shown persistent decline in prevalence between 2002 and 2005 i. e Lala from 4. 7 % in 2002, to 2 % in 2005, Toronto (6. 3 % to 5. 8 %), Moyo (4. 3 % to 2 %), Many (0. 7 % to 0 %), Nsambya (8. 5 % to 7. 8 %), Rubaga (8. 1 % to 7. 1 %) and Kagadi (6. 4 % to 1, 3 %). However, some ANC surveillance sites have shown an increase in HIV prevalence between 2002 and 2005 for example; Are (4. 6 % to 9. 3 %), Masindi (4. 7 % to 7. 9 %), Make (5. 9 % to 7. 3 %), Mbarara (10. 8 % to 11. 9 %), Mutolere (1. 5 % to 4. 7 %), Nebbi (1. 3 % to 3. 3 %), Sort (4. 6 % to 7. 1 %) and Jinja (5 % to 8. 4 %) (Ntozi J. P.
M, 2007) Uganda has predominantly a young population and the 2002 population and Housing Census reported that adolescent 10 - 19 years constituted 23. 3 % while in the age group of 10 - 24 years was 35. 5 % of the total population (UNFPA, 2003). As a result of the growing adolescent population, the importance of addressing concerns regarding sexual and reproductive health is ever increasing. Twenty five percent of Ugandan adolescents between 15 and 19 years of age will have had their first sexual encounter by age 15. Uganda Bureau of Statistics reports that by age 19, 14 % had the first sexual intercourse and by age 24, 20. 5 % had had sex.
About 67 % of Ugandan girls have their sexual experience by age 18 and some result in HIV infection or other health consequences (UBOS and ORC 2001). The prevalence of STD's and HIV is high among Ugandan youth. It is estimated that more than 50 % of those infected with HIV are among the young people below the age of 25 years and again, young girls are particularly at risk (UNFPA, 2003). The national response to the epidemic has been one of openness about HIV/AIDS, backed by strong political commitment at all levels, as well as adoption of a multi-sectoral approach, which includes mainstreaming of HIV/AIDS into all sectors and the decentralization of the implementation plans.
The prevention strategy focuses on intensive Information, Education & Communication (IEC) with Behaviour Change Communication (BCC) campaigns targeting Commercial Sex Workers, Long Distance Truck Drivers, fishing communities and high risk, primary and secondary schools, and condom use promotion and distribution. The management of STIs and opportunistic infections, as well as the provision of services to promote VCT, PMTCT and infection control as part of the universal precaution in health units and community settings are also being established. A comprehensive patient care package has been developed which includes the management of opportunistic infections including TB, palliative care, home based care and the provision of antiretroviral drugs for post-exposure prophylaxis and treatment. Epidemiological surveillance for STI/HIV/AIDS has been established to support programme monitoring and evaluation.
Despite the achievements made, many challenges remain. These include sustaining the momentum to scale up the core interventions, avoiding complacency, promoting condom use, and ensuring their quality and overcoming related negative politico-cultural and religious factors, improving access to effective IEC/BCC messages, limited translated materials on STI/HIV/AIDS, shortage of human resource particularly counsellors in some districts, stronger involvement of men in VCT and PMTCT services, the scaling up of new initiatives like the ARVs, the inclusion of children and older people in the prevention and control, care and treatment of HIV/AIDS. PROBLEM STATEMENT Young people have been affected greatly by HIV/AIDS. Sentinel surveillance data indicates that HIV infection begins to increase in the 15 - 24 years age group (MOH, 2005). Young people in Uganda experience increased vulnerability to HIV infection due to the many of them who start engaging in sex at an early age (16. 6 years for girls and 17. 4 years for boys) (UBOS and Macro 2001).
Most of the sexual encounters result from peer pressure to attain status, favours and money and accompanied with inconsistent and incorrect condom use. About half of the 6, 000 new infections each day occur among young people. It is estimated that about half of all people who have had HIV were infected when they were between the ages of 15 and 24 years, and nearly one third of those currently living with HIV/AIDS are between 15 and 24 years. If current trends continue, it is expected that the number of young people infected with HIV could increase to 21. 5 million by 2010. (UNFPA, 2004). Adolescents can easily be reached through schools at a low cost.
From an adolescent perspective, schools afford anonymity with a relative freedom from in habitations in the home and community. In addition, schools allow for discussion among fellow students with associated benefit from peer pressure. Schools also allow for the involvement of teachers, nurses and counselors in a systematic way. Additionally, in Uganda, an increasing number of adolescents are entering school and schools are increasing number. Uganda had 10, 500 primary schools and 625 secondary schools (Ministry of Education and Sports 1999). But by 2001, these numbers had grown to 12, 280 primary schools and 1, 850 secondary Schools... (Ministry of Education and Sports 2001) Despite high drop-out rates, an increasing number
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