Knowledge and perception on HIV premarital counseling and testing among unmarried young people of Kintampo town in the republic of Ghana,

SCHOOL OF PUBLIC HEALTH

COLLEGE OF HEALTH SCIENCES

UNIVERSITY OF GHANA

By

JEAN-PIERRE KASEREKA MAKELELE (Mr.Dr)

THIS DISSERTATION IS SUBMITTED

TO THE SCHOOL OF PUBLIC HEALTH,

UNIVERSITY OF GHANA, LEGON

IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR

THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE

AUGUST 2005

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KNOWLEDGE AND PERCEPTION TOWARDS PREMARITAL COUNSELING AND TESTING ON HUMAN IMMUNODEFICIENCY VIRUS INFECTION AMONG UNMARRIED YOUNG ADULTS IN KINTAMPO DISTRICT OF GHANA

DEDICATION

To my wife Lucie Tshongo Kavira Makelele, that I missed too much and who reciprocally suffered patiently my long absence, for your motherly cordial care you provided to our children during my study leave, for your caring love and mutual understanding,

To my children Amos Makelele M'Yisa, Dieu-Exauce Makelele Vutokii, Miriam Makelele Mukiranya, Esther Kavuo Makelele and to you all my dependants for the suffering you faced from the lack of fatherly care due to my studies, and for your prayerful supports , your encouragement , your good wishes and warm regards to your father,

To my whole family members, especially my Mother Kahindo Mukiranya who kept praying for me throughout this hard course,

To every body who has ever supported me somehow; either morally, materially or financially towards the attainment of the current educational level and the successful end of this course,

To all of you, my beloved Brothers and Sisters,

Through Jesus Christ who strengthens us,

I dedicate this piece of work.

AKNOWLEDGEMENT

I acknowledge a grant from my Sponsor Word Council of Churches (COE-WCC)/Switzerland which made it possible to achieve my study dream and the Union Evangelical Mission (UEM-VEM)/Germany for the additional financial support which solved my life hardship in Ghana, thereby enabling me to produce this work.

I thank the Director Prof. Isabella A. Quakyi and the entire staff of School of Public Health of University of Ghana, Legon, for the entire knowledge they insistently and consistently imparted in us and for their moral support and encouragement.

I thank Dr Seth Owusu- Agyei and Mr. Alfred.A.D. OBUOBI, my Academic Supervisors, who, despite their busy work schedule, diligently and profoundly assisted me in planning, conducting, correcting and enriching this work; and to Dr E.T.ADJASE, my field Supervisor, for approving the study topic, for his unlimited constructive advice as well as fatherly support which made my stay in Kintampo very enjoyable and comfortable, and finally for the training care which we received while on the field. This has successfully provided me enough field knowledge, skills and experiences.

I thank the entire staffs of Kintampo District Health Directorate, of Kintampo Rural Health Training School (KRHTS) and of Kintampo Health Research Centre (KHRC) for all their fruitful, caring, supervisory, and skilled expertise and support during this study,

Finally I thank my course mates, my key informants and all respondents for their generous contribution towards the achievement of this work.

TABLE OF CONTENTS

			Pages
DECLARATION...........................................................................			ii
DEDICATION..............................................................................			iii
AKNOWLEDGEMENT...................................................................			iv
TABLE OF CONTENTS..................................................................			v
ABBREVIATIONS...........................................................................			ix
ABSTRACT..................................................................................			x
LIST OF DIAGRAM, MAP, FIGURES AND TABLES			Xii
Chapter One INTRODUCTION.......................................			1
I.1. BACKGROUND INFORMATION..............................................			1
I.1.1. Marriage and its reproductive health implication.......................			1
I.1.2. Scope and objectives of premarital Screening............................			2
I.1.3. Study Area...................................................................			4
I.2. STATEMENT OF THE PROBLEM.............................................			7
I.3. CONCEPTUAL FRAMEWORK: PROBLEM ANALYSIS DIAGRAM...			10
I.4. RATIONALE OF THE STUDY.................................................			11
I.5. GOAL AND OBJECTIVES OF THE STUDY................................			12
Chapter Two LITTERATURE REVIEW.......................................			14
2.0. Definition of concepts			14
2.1. Premarital examination in Ghana and in Kintampo District..........			14
2.2. HIV-AIDS situation in west Africa and Ghana.........................			16
2.2.1. In West Africa..................................................			16
2.2.2. In Ghana.........................................................			17
2.3. HIV VCT and premarital HIV counseling and testing			20
2.4. Procurement of Materials for VCT			23
2.5. Factors influencing willingness to undergo HIV PCT			23
2.6. Reasons for undergoing HIV VCT			24
2.7. Barriers to HIV VCT/PCT			24
2.8. Marriage between HIV discordant or HIV seropositive couples			24
Chapter Three METHODOLOGY..........................................			25
3.1. STUDY DESIGN AND STUDY POPULATION ...........................			25
3.2. VARIABLES UNDER STUDY.................................................			25
3.3. DATA COLLECTION TECHNIQUES AND TOOLS ......................			28
3.3.1. Data Collection Techniques...........................................			28
3.3.2. Data Collection Tools..................................................			28
3.4. SAMPLING........................................................................			28
3.4.1. Sample size calculation ..............................................			28
3.4.2. Sampling method ......................................................			29
3.5. DATA COLLECTION............................................................			32
3.6. DATA PROCESSING AND ANALYSIS.....................................			34
3.6.1. Qualitative data ...........................................................			34
3.6.2. Quantitative data .........................................................			34
3.6.2.1. Data quality control .........................................			34
3.6.2.2. Data presentation and statistical analysis .................			34
3.6.2.3. Score allocation for level of knowledge and perception towards HIV PCT.......................................		35
3.7. SOME ETHICAL CONSIDERATIONS.......................................		35
3.8. LIMITATION OF THE STUDY................................................		36
3.9. RETRO INFORMATION AND DISSEMINATION OF FINDINGS...........................................................................		37
Chapter Four FINDINGS.......................................................		38
4. 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS..................................................................		38
4.1.1. Distribution of respondents by age and sex.............................		38
4.1.2. Educational background of respondents ...............................		39
4.1.3. Religion, ethnic group and occupation background of respondents................................................................		40
4.2. PREMARITAL SEX HISTORY AND HIV-AIDS RISK FACTORS AMONG SURVEYED RESPONDENTS.....................................		41
4.3. GENERAL AWARENESS AND KNOWLEDGE OF RESPONDENTS ON HIV/AIDS, VCT AND HIV PCT..........................................		44
4.4. SCORE OBTAINED ON AWARENESS AND KNOWLEDGE OF RESPONDENTS ON HIV PCT................................................		49
4.5. GENERAL PERCEPTION OF RESPONDENTS TOWARDS HIV PCT.		52
4.6. SCORE OBTAINED ON PERCEPTIONS OF RESPONDENTS TOWARDS HIV PCT............................................................		55
4.7. RELATIONSHIP BETWEEN SCORE OF KNOWLEDGE AND SCORE OF PERCEPTION AMONG RESPONDENTS....................		57
4.8. FACTORS INFLUENCING PERCEPTION OF THE NEED OF HIV PCT SERVICES..................................................................		58
4.9. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT..................................................................................		59
4.10. DEDUCTION OF PROBABILITY FOR RESPONDENTS TO PERCEIVE THE NEED OF HIV PCT SERVICE AND TO INTE ND UNDERGOING HIV PCT................................................		60
4.11. PREFERENCE TO UNDERGO HIV VCT FOR MARITAL REASON OR NOT........................................................................		61
4.12. BARRIERS TO HIV PCT ACCEPTANCE AND IMPLEMENTATION IN KINTAMPO DISTRICT...................................................		61
4.13. KEY ISSUES TOWARDS HIV PCT HEALTH PRACTICE IN KINTAMPO DISTRICT................................................		64
4.13.1. Views on frequency of HIV test before marriage among would-be couples...................................................		64
4.13.2. Views of respondents on who should send would-be couples at the hospital for HIV PCT....................................................		66
4.13.3. Views on to who the HIV test result should communicated after a PCT session.......................................................		66
4.13.4. Ways to promote HIV PCT in K'po district.........		67
4.13.5. Ways to create easier accessibility to HIV PCT in K'po district........................................................		68
4.13.6. Ways to make HIV PCT more effective, acceptable and attractive for young people in K'po district........................		69
4.13.7. Health facilities where HIV PCT centre should be established in K'po district............................................................		70
4.14. POSSIBLE DECISIONS THAT WOULD-BE COUPLES ARE MORE LIKELY TO MAKE GIVEN DIFFERENT SCENARIOS OF HIV TEST RESULTS.....................................................................		71
4.15. POINTS OF VIEW OF RESPONDENTS ABOUT MARRIAGE BETWEEN DISCORDANTS COUPLES AND HIV INFECTED COUPLES............................................................................		72
Chapter Five DISCUSSION.....................................................		74
5.1. PREMARITAL SEX HISTORY AND HIV-AIDS RISK FACTORS AMONG SURVEYED RESPONDENTS....................................		74
5.2. KNOWLEDGE AND PERCEPTION OF RESPONDENTS TOWARDS HIV PCT...........................................................................		75
5.2.1. Indicators on awareness and knowledge on HIV PCT...............		75
5.2.2. Level of knowledge on HIV PCT.......................................		79
5.2.3. Indicators of perception of respondents towards HIV PCT.........		81
5.2.4. Relationship between level of knowledge and level of perception of respondents towards HIV PCT.......................................		88
5.3. FACTORS INFLUENCING PERCEPTION OF THE NEED OF HIV PCT S ERVICES..................................................................		89
5.4. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT		92
5.5. PREFERENCE TO UNDERGO HIV VCT FOR MARITAL REASON OR NOT.........................................................................		97
5.6. BARRIERS TO HIV PCT ACCEPTANCE AND IMPLEMENTATION IN KINTAMPO DISTRICT...................................................		98
5.7. KEY ISSUES TOWARDS HIV PCT HEALTH PRACTICE IN KINTAMPO DISTRICT.......................................................		102
5.7.1. Views on frequency of HIV test before marriage among would-be couples......................................................		102
5.7.2. Views on who should send would-be couples at the hospital for HIV PCT.............................................		103
5.7.3. Views of respondents on to who the HIV test result should communicated after a PCT session....................................		104
5.7.4. Ways to promote HIV PCT in K'po district............................		105
5.7.5. Ways to create easier accessibility to HIV PCT in K'po district..		108
5.7.6. Ways to make HIV PCT more effective, acceptable and attractive for young people in K'po district........................		109
5.7.7. Health facilities where HIV PCT centre should be established in K'po district............................................................		111
5.8. POSSIBLE DECISIONS THAT WOULD-BE COUPLES ARE MORE LIKELY TO MAKE GIVEN DIFFERENT SCENARIOS OF HIV TEST RESULTS AND POINT OF VIEW OF RESPONDENTS ABOUT MARRIAGE BETWEEN DISCORDANTS COUPLES AND HIV INFECTED COUPLES................................................	112
Chapter Six CONCLUSION AND RECOMMENDATIONS ................	114
REFERENCES...........................................................................	123
ANNEX 1. QUESTIONNAIRE FOR THE SURVEY.................................	A
ANNEX 2a: INTERVIEW GUIDE FOR HEALTH CARE PROVIDERS.........	H
ANNEX 2b: IN-DEPHT INTERVIEW GUIDE FOR RELIGION LEADERS.....	J
ANNEX 3: FOCUS GROUP DISCUSSION GUIDE (FGDG)........................	L
ANNEX 4. DESCRIPTION OF VARIABLES UNDER STUDY AND SCORING SCALE....................................................................	N

ABBREVIATIONS

AIDS : Acquired Immuno deficiency syndrome

BCC : Behavior change communication

CI : Confidence Interval

DA : District Assembly

DDHS : Director of District health service

DHD : District Health Directorate

DHMT : District Health Medical Team

ECC/CBCA : Eglise du Christ au Congo, Communauté Baptiste au Centre de

l'Afrique

FGD : Focus group discussion

GDHS : Ghana Demographic Health Survey

GES : Ghana Education Service

HIV : Human immuno deficiency virus

IDI : In-depth Interview or In-depth Interviewee

IEC : Information, Education and Communication.

JSS : Junior secondary school

K'po : Kintampo

KDH : Kintampo District Hospital

KDSS : Kintampo Demographic Surveillance Survey

KHRC : Kintampo Health Research centre

MPH : Master of Public Health

MTCT : Mother-to-child transmission (of HIV)

NA : Not applicable

NACP : National AIDS Control Program

NGO : Non Governmental Organization

NK : Not known or don't know

OAU : Organization of African Union

PCT : Premarital (prenuptial) counseling and testing

PLWA : People living with AIDS

PLWHA : Person living with HIV/AIDS

PMTCT : Prevention of Mother-to-child transmission (of HIV)

PMTCT : Prevention of mother-to-child transmission of HIV

RA : Research assistants (field interviewers).

SD : Standard deviation

SE : Standard error

SSS : Senior secondary school

STD : Sexually transmitted diseases

STI : Sexually transmitted infection

UG : University of Ghana

UNAIDS : United Nation-Acquired Immuno Deficiency syndrome

UNDP : United Nation Development Program

UNPFA : United Nation Population Fund

VCT : Voluntary counseling and testing

WHO : World Health organization

ABSTRACT

HIV PCT, as part of VCT, is recognized worldwide as a core strategy of limiting the spread of HIV in new couples and their offspring. The study on «Knowledge and perception towards PCT on HIV infection among unmarried young adults in Kintampo District» was one of the preliminary studies needed for the implementation of VCT services in the District.

AIM: The general objective of the study was to generate useful information on current level of knowledge and perception of unmarried young adults towards HIV premarital counseling and testing (HIV PCT) in order to predict their acceptance and behaviours towards utilization of such service and to deduce appropriate program/policy for intervention in the relevant area.

METHODS: We analyzed data from a cross sectional survey among 150 unmarried young adults between 15 and 30 years old and from FGDs and IDIs. The survey was carried out in 3 of the 8 sub-districts in the district. Compounds where to find respondents were randomly selected and an interviewer-administered questionnaire was used. We allocated scores of knowledge on HIV PCT and of perception towards HIV PCT to given answers. We also applied 2 Logit models to determine predictors of willingness to undergo HIV PCT and of perceived need towards HIV PCT service.

FINDINGS: Out of 150 respondents, 71% lived in urban and 29% in rural areas. Respondents were of a mean age of 21.0 years (SD 4.48), the majority of them (76%) being aged between 15-24 years. The sex ratio was 104 [little predominance of males (51%)]. In general 97% of respondents had Good Knowledge on HIV PCT, with 41.3% showing Adequate good Knowledge, versus 55.7% showing Average good knowledge on HIV PCT. Only 3% of respondents showed Poor knowledge on HIV PCT. The entire totality (100%) of respondents in both sexes had Adequate positive perception towards HIV PCT. There was a significant weak positive linear relationship between level of knowledge and level of perception (p-value 0.007). Willingness to undergo HIV PCT was strongly positively associated with readiness of a respondent to know and accept his/her HIV result (p<0.001). Willingness to undergo HIV PCT was negatively associated with age, post-primary educational level, being student, having ever had premarital sex, perceiving the need of HIV PCT services and suggestion that HIV PCT should be provided free of charge, with no significant associations. Willingness to undergo HIV PCT was slightly positively associated with Akan & Mo Ethnic groups, urban residence, being Christian and female, level of knowledge and level of perception towards HIV PCT and suggestion of confidentiality in PCT services, with no significant associations.

CONCLUSION: In view of the study findings showing good knowledge and adequate positive perception towards HIV PCT among unmarried young adults, HIV PCT service for would-be couples is needed and feasible at present in Kintampo District. Majority of unmarried young adults showed positive acceptance towards utilization of such service.

Not all populations of unmarried young groups have an equal likelihood of accepting to undergo HIV PCT. Therefore Public health intervention (BCC/IEC) in the district on HIV PCT should be adapted specifically for each population segment and address perceived barriers to HIV PCT. A policy document is needed to specify the scope and procedures of premarital examinations in light of the findings in this study.

KEY WORDS: HIV/AIDS; Kintampo District; marriage, premarital counseling and testing (PCT), unmarried young adults, would-be couples.

LIST OF DIAGRAM, MAP, FIGURES AND TABLES	Page
DIAGRAMS
Diagram 1: Conceptual framework: problem analysis diagram .................................................................	10
Diagram 2: Relationship between variables: assumptions of logit models....................................	27
FIGURES
Figure 0: Map of Kintampo District showing Centroids of study (villages/Towns) and roads network...	32
Figure 1: Distribution of surveyed respondents by age and sex..................................................	39
Figure 2: Distribution of surveyed respondents by educational level and sex.................................	40
Figure 3: Distribution of Respondents by Religion, Ethnic group and Occupation...........................	41
Figure 4: Distribution of respondents by sex and age at first sexual intercourse..............................	42
Figure 5: Distribution of respondents according to their scores of knowledge on HIV PCT................	51
Figure 6: Distribution of Respondents by location and score of knowledge on HIV PCT...................	52
Figure 7: Distribution of respondents by sex and their score of perception towards HIV PCT..............	56
Figure 8: Distribution of respondents by sex and suggestion on the required number of HIV tests to undergo before marriage....................................................................................	65
Figure 9: Distribution of respondents according to their choices on the person who should send would- be couples for HIV PCT...................................................................................	66
Figure 10: Suggestion of respondents about to whom the HIV test result should be communicated after a PCT session..............................................................................................	66
Figure 11: Frequency of ways suggested by respondents to make easier accessibility to HIV PCT in the District......................................................................................................	68
Figure 12: Trend of possible decisions on marriage that respondents are more likely to make given different scenarios of HIV test results after a HIV PCT session....................................	71
Figure 13: Points of view of respondents about marriage between HIV discordant would-be couples and both infected would-be couples....................................................................	73
Figure 14. Steps and actions needed in order to promote HIV PCT in the K'po District, based on Suggestions of beneficiary respondents...............................................................	107
Figure 15: Steps and actions needed to make HIV PCT practice more acceptable and attractive for young adults in K'po district, based on suggestions of beneficiary respondents .........	110
TABLES
Table 1: Sub- districts of Kintampo District and their respective populations.................................	5
Table 2: Sampling characteristics of selected towns and villages per sub-district...........................	31
Table 3: Distribution of respondents according to premarital sex history and sex............................	41
Table 4: Trend of general awareness and knowledge on HIV/AIDS, VCT and HIV PCT...................	44
Table 5: Level of knowledge on HIV PCT..........................................................................	50
Table 6: Trend of general perception of respondents towards HIV PCT.......................................	53
Table 7: Level of perceptions towards HIV PCT..................................................................	56
Table 8: Linear Regression: Regress score of perception =score of knowledge, CL 95%.........................	57
Table 9. Factors (predictors) influencing Perceived need of HIV PCT service (p1) among unmarried young adults in Kintampo District.........................................................................	58
Table 10. Factors (predictors) influencing willingness to undergo HIV PCT service (p2) among unmarried young adults in Kintampo District..........................................................	59
Table 11: Distribution of respondents according to their probability of perceiving the need of HIV PCT and of willingness to undergo HIV PCT................................................................	60
Table 12. Distribution of respondents by sex and HIV testing choices.........................................	61
Table 13: Respondents' perception of barriers to HIV PCT acceptance and implementation...............	61
Table 14: Distribution of respondents by religion and perception of Islam as a barrier to HIV PCT Implementation.............................................................................................	64
Table 15: Suggestions from respondents on ways to promote HIV PCT in Kintampo District..............	67
Table 16 : Suggestions for the HIV PCT practice to be more effective, acceptable and attractive to unmarried young people in Kintampo district.........................................................	69
Table 17: Health facilities where respondents suggest HIV PCT services to be established................	70