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Table of Contents
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 91-98

Impact of health interventions on the knowledge, perception, attitude, and misconception of HIV infection in an African rural community

1 Research Department, African Health Project, Abuja, Nigeria
2 Department of Public Health, Triune Biblical University Global Extension, NY, USA
3 Department of National Integrated Specimen Referral Network, AXIOS, Utako, FCT, Abuja, Nigeria

Date of Submission17-Apr-2020
Date of Decision19-Oct-2020
Date of Acceptance22-Dec-2020
Date of Web Publication29-Jan-2021

Correspondence Address:
Ali Johnson Onoja
Research Department, African Health Project, Abuja.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_19_20

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Background: Adequate knowledge of human immunodeficiency virus (HIV), its modes of transmission, and methods of prevention can facilitate its prevention and control among any people. This study evaluates the impact of health interventions on the knowledge, perception, attitude, and misconception of HIV infection in Bonny Kingdom of Rivers State, Nigeria. Materials and Methods: This is a quantitative survey that used a structured questionnaire to determine the impact of community-based interventions (awareness education, free counseling and testing, etc.) on the prevention of HIV/acquired immune deficiency syndrome (AIDs) among a representative sample of the general population aged 15 to 49 years in Bonny Island, Nigeria. The data obtained include the demographics; age, sex, education, occupation, marital status, and sexual-related information. Data were analyzed by using SPSS, version 25.0. Result: The study comprised 1215 participants in each of the pre- and postintervention surveys. Before intervention, only 47.2% could correctly identify three transmission routes of HIV, as compared with 82.8% after the interventions (P < 0.0001). The intervention participants were 5.37 (95% CI. 4.46–6.48) more likely to have good knowledge of HIV transmission routes than respondents without interventions. The odds of misconception about HIV transmission routes before intervention were 3.52 (95% CI 2.48–5.01; P < 0.0001). About 80.7% and 45.9% believed that they were not at risk of contracting HIV at the baseline and postinterventions, respectively. Postintervention respondents were 4.04 (95% CI 3.41–4.79; P < 0.0001) willing to share meals, 4.84 (95% CI 3.94–5.94) willing to care for, 3.73 (95% CI 3.14–4.44) willing to allow teachers infected with HIV in school, and 3.14 (95% CI 2.60–7.80) willing to buy food from an infected person as compared with the preinterventions survey (P < 0.0001). Conclusion: This study has demonstrated the positive impacts of community-based intervention programs on the knowledge, prevention methods, and levels of misconception of HIV in Bonny Kingdom. Similar interventions are needed in other rural communities to promote the quest to end HIV/ AIDS by the year 2030.

Keywords: Discrimination, HIV/AIDS, infection, intervention, misconception

How to cite this article:
Onoja AJ, Sanni FO, Onoja SI, Adamu I, Shaibu J, Abiodun PO. Impact of health interventions on the knowledge, perception, attitude, and misconception of HIV infection in an African rural community. Int J Med Health Dev 2021;26:91-8

How to cite this URL:
Onoja AJ, Sanni FO, Onoja SI, Adamu I, Shaibu J, Abiodun PO. Impact of health interventions on the knowledge, perception, attitude, and misconception of HIV infection in an African rural community. Int J Med Health Dev [serial online] 2021 [cited 2022 Aug 10];26:91-8. Available from: https://www.ijmhdev.com/text.asp?2021/26/2/91/308247

  Introduction Top

HIV and AIDS have become one of the major global health problems. A low level of knowledge of HIV has also been described as one of the challenges associated with HIV perception and misconceptions.[1] Nigeria has the second-largest HIV epidemic in the world and one of the highest rates of new infection in sub-Saharan Africa.[2],[3] Currently, 67% of people living with HIV/AIDS (PLWHA) in Nigeria are aware of their HIV status, of whom 53% are on HIV treatment; 80% (42% of all PLWHA) have their viral load suppressed.[4]

River State is ranked third among the highest HIV prevalence (3.8%) states in Nigeria behind Akwa Ibom (5.6%) and Benue (4.9%),[3] and rural areas have a higher rate of 4% as compared with 3% in urban areas.[4]

The urban–rural residence has been identified as a significant predictor of HIV/ AIDS knowledge.[5] Some recent studies have shown that rural dwellers often lack adequate understanding of HIV and AIDS.[5],[6] There is limited information on the knowledge of rural dwellers regarding HIV/ AIDS in Nigeria,[6] especially a riverine area such as Bonny Island. Determining this requires figuring out specific areas where current and future HIV/AIDS education programs need to be intensified.[6] Good knowledge about HIV/AIDS is necessary to reduce misconceptions, and to create the right attitude and empathetic response toward PLWHA in the family and society[7]; however, misconceptions about HIV/AIDS are widespread among many communities, especially in rural areas.[6]

In countries with widespread epidemics, fewer than half of the population, especially young people, have a fundamental knowledge of HIV.[6] Several studies in Nigeria have demonstrated the inadequate knowledge of HIV/AIDS and high rates of misconceptions about the disease.[6],[8],[9],[10],[11] These misconceptions associated with HIV/AIDS transmission have led to stigmatization or negative attitudes toward people living with AIDS.[12] Tackling misconceptions about the modalities of HIV transmission is as relevant as advancing knowledge of its modes of transmission.[13] Both knowledge and the level of misconception are important in evaluating the perceptions that derive from precautionary efforts. The misconception of HIV has been strongly connected with HIV-related stigma and discrimination and also with high levels of HIV risk behaviors.[1],[14] Perceived vulnerability is also as important to an individual’s protective behavior.[13] To address misconceptions that could discourage behavioral change toward healthy lifestyles[11] and also minimize the stigma toward individuals living with HIV/AIDS, several preventive efforts have aimed at improving awareness of different modes of transmission.[16],[17],[18],[19],[20],[21] Studies have reported the lagging behind of HIV preventive interventions in rural areas in Nigeria.[1],[6],[15] The objective of this study was to evaluate the impact of health interventions on the knowledge, perception, attitude, and misconception of HIV infection in Bonny Kingdom of Rivers State, Nigeria.

Bonny Island is a traditional kingdom with an estimated 30,000 indigenous Ibani people. However, with the setting of the gas plant (some $30 billion investment in oil terminals and natural liquid gas production), Nigerians of all walks of life from other tribes, and professional foreign expatriate staff employed by the company have settled in, either on permanent or transient bases. Interestingly as witnessed in other parts of the globe, the presence of Nigeria Liquefied Natural Gas (NLNG) has also attracted other service-based industries and several itinerant traders and police/ military personnel, businessmen/women, and sex workers. Since the mid-1990s, the arrival of thousands of refugees from other parts of Nigeria and other countries has left a minority of Ibani indigenous people in their own empire. The rising HIV infection rate in Bonny has also been influenced by poverty and low awareness about HIV transmission modes. In particular, a large proportion of commercial female sex workers in their 20s are employed.

To avoid further spread of the virus and to provide care and treatment for those already infected, there was an immediate need to devise and enforce a plan to combine national and state efforts to respond to the outbreak. The Ibani-Se HIV/AIDS Program is a public/private partnership program that is nongovernmental and nonpolitical. The Ibani-Se HIV/AIDs baseline survey was conducted by the Society for Family Health in 2006 and was used as a strategic document in the development of a three-year intervention program (2008–2011). The impact of the different interventions on the main generated measures of awareness, attitudes, activities, and practices and beliefs was assessed after three years of intervention.

  Subjects and Methods Top

Study area

This study was conducted in Bonny Island. The Island was a popular business area more than 400 years ago and this can be seen in its ethnic diversity. Bonny Island is located on the coast of Rivers State, occupying an area of 2.72 km2 along the eastern coastal line of the Niger Delta area in southern Nigeria. It is a traditional kingdom characterized by simple rural life and with an estimated 30,000 native Ibani people. Farming, fishing, and trading are the key occupations of people on Bonny Island. With fish responsible for as much as 80% of protein intake, fishing is a very significant economic practice.

Study population

The study was carried among the general population aged 15 to 49 years old. This relatively large sample size enhanced effective subgroup (such as age specific, sex, nature of residence, socioeconomic class) analyses.

Study design

To achieve successful HIV/AIDS intervention in the kingdom, reliable base data from various risk and work groups were collected. This HIV/ AIDS survey was crucial, because it provided information from different risk groups and the general population. The community-based intervention in the kingdom includes education, training, free HIV counseling and testing, free distribution of condoms, and referral and follow-up services for people who are HIV positive. HIV education and awareness were carried out by means of handbills, leaflets, town hall meetings, workplace awareness, drama, radio, and television. Radio and TV programs include “Jann Kunne film” (AIDS), “Ireti alaafia,” “One thing at a time, Gari muna fata,” “Odejinjin” (television program), and “Abule oloke merin” (TV drama program for HIV/AIDS). The programs include TV and television programs.[16] The impacts of the interventions on knowledge, perception, attitude, and misconception of HIV transmission routes and prevention were evaluated after three years of intervention.[16]

Sample size estimation

The following formula was used to determine the sample size for the target group (people with multiple nonmarital partners).[17]

where D represents design effect, P1 and P2 are estimated values during the first survey and at some future date, respectively, and (P2P1) represents the magnitude of change that it is anticipated to be able to detect;

the z-point referring to the likelihood that a reported change in size (P2P1) would not have occurred by chance; and Z1−β is the z-score of the degree of confidence level that is needed to detect a change in size (P2P1) if there is actually a change in size (z). The value of α is 0.05, β is 0.20, and Z1−α and Z1−β are 1.96 and 0.84, respectively.[16]

Application of the formula just cited yields a sample size of 102 for each ward. Given a total of 12 wards in the entire Bonny Local government area, the total sample for the general population would be 12 × 101=1212 although 1215 were sampled.

The survey was based on a multistage probability sampling method.

Stage 1: In geographic order, all localities (towns and villages) in the local authorities were arranged with their respective approximate population by weight or size. Using the approximate population of localities, the clusters to be used for the survey were assigned to localities proportionately.

All localities (town and villages) in the local government were arranged in their geographic order, with their associated estimated population as their weights (measure of size, MOS). Using the locality’s estimated population, the clusters to be used for the survey were allocated proportionately to localities.

Stage 2: After allocating the clusters to localities; the Enumeration Area (EA, small compact units to which all geographic areas of the country are carved by the National Population Commission) was obtained for the localities, with one or more allocations of clusters during the stage 1 procedure. The EAs were also arranged in their geographic order and the numbers allocated to such localities were selected by using the systematic sampling procedure. This allows for spread of areas (cluster) to be used for the survey in the localities.

A subsample (one in two) of the EAs was selected by using a systematic procedure and classified as “Sero-Clusters (S),” that is, the clusters that are blood sample tests and behavioral interviews that will be done; however, the other cluster sites where only an interview will be conducted without a sero test are classified as “Non–Sero (NS)” clusters.

Stage 3: The EAs selected in the localities were described and listed for field data collectors to locate and start listing to form clusters of eligible respondents to be interviewed. Field officials were assigned to the area of listing in the locations to number and list household members with their ages and genders. From the household listing, eligible respondents are identified and numbered serially. The listing continues in these preselected EAs until three times the number of eligible respondents required in a cluster is obtained.

Stage 4: Systematically one in every three eligible people listed to form a cluster is selected for the final interview. Interviews were conducted by trained data collectors using structured questionnaires.

Ethical consideration and consent

Ethical approval with the approval number HREC/01/01/2007–22/07/2011 was obtained from the National Health Research Ethics Committee (NHREC), Federal Ministry of Health. In addition, the informed consent of the respondents was obtained and signed in compliance with the National Guidelines for Mobile Voluntary Counseling and Testing (VCT) before the interview was conducted. Questionnaires were translated and read aloud to respondents who could not read or write in the local language.

Data analysis

Data were entered with CSPro and analyzed with version 25.0.0. of IBM® -SPSS Statistics software. To summarize the variables, descriptive statistics were used, and the summaries were presented in tables showing the outcomes of the baseline and postintervention surveys. To assess the substantial differences between baseline and postintervention outcomes, the Chi-square analysis and odds ratio were carried out and the significant level was set at P < 0.05.

  Results Top

The study comprised 1215 respondents in each of the preintervention and postintervention surveys. As shown in [Table 1], both surveys had a slightly higher number of males (53.3% and 54.2%) than females (46.7% and 45.8%) respectively. Adolescents aged 15 to 24 years (42.3%) dominated the preintervention survey, whereas the majority of respondents in the postintervention survey were 35 years old or more (36.8%). Both surveys had more people who attained secondary level of education (54.7% and 61.6%) and people who had ever married (51.2% and 54.2%).
Table 1: Sociodemographic profiles of the baseline and postintervention survey respondents

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Knowledge and misconception of the route of HIV transmission and its prevention methods

As shown in [Table 2], there was a significant increase in the knowledge of the modes of transmission of HIV and prevention methods postintervention as compared with the findings before the interventions (P < 0.0001). In the preintervention survey, only 47.2% of the total respondents could correctly identify three transmission routes of HIV as compared with 82.8% after the intervention (P < 0.0001). People who benefited in the interventions were 5.37 (95% CI 4.46–6.48) more likely to have good knowledge of HIV transmission routes than their counterparts without interventions. On the other hand, the rate of misconception about HIV transmission routes was 11.5% preintervention as compared with 3.5% postintervention (P < 0.0001), with odds ratio 3.52 (95% CI 2.48–5.01).
Table 2: Respondents’ knowledge and misconception of the route of HIV transmission and its prevention methods

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Personal risk perception of contracting HIV

[Table 3] shows the risk perception of respondents, both before intervention and after intervention surveys. Although 80.7% believed they were not at risk of contracting HIV at the baseline survey, only 45.9% said they were not at risk in the survey after the interventions. In the baseline survey (P = 0.046), more females (82.7%) opined that they were not at risk than males (78.1%), as compared with the insignificant difference observed between males (48.5%) and females (46.6%) after the interventions (P = 0.509). In the before intervention survey, the proportion of respondents who believed they were not at risk of contracting HIV significantly decreased with a higher level of education (P = 0.013), as compared with no difference in the postintervention survey.
Table 3: Respondents’ risk perception of contracting HIV

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As shown in [Table 4], the level of stigmatization declined significantly after the interventions as compared with the survey findings before the interventions. Respondents at the intervention arm were 4.04 (95% CI-3.41–4.79; P < 0.0001) willing to share meals with people infected with HIV as compared with the baseline findings. The odds of willingness to care for relatives living with HIV, to allow teachers infected with HIV in school, and to buy food from infected people were 4.84 (95% CI 3.94–5.94), 3.73 (95% CI 3.14–4.44), and 3.14 (95% CI 2.60–7.80) after the interventions as compared with the findings before the interventions (P < 0.0001).
Table 4: Level of stigma and discrimination

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  Discussion Top

Knowledge and misconception of routes and prevention of HIV infection

Knowledge, perception, and attitudes toward HIV/AIDS are important tools in the prevention of the spread of the diseases. This study found an improved knowledge of the routes of HIV transmission among the people of Bonny Kingdom as a result of the three years of health interventions program carried out in the whole community. Although the majority of the baseline respondents could recognize sexual intercourse as one of the modes of transmission of HIV, only a few (less than 15%) were aware that HIV can be transmitted from mother to child and through unsterilized needles. This finding is consistent with previous scholarly reports that identified living in rural communities as a predictor of poor knowledge of HIV.[12],[13],[18] The poor knowledge of mother-to-child-transmission (MTCT) of HIV among the respondents before intervention is not unexpected, because recent studies have noted that urban women have more knowledge of MTCT than their rural counterparts.[19],[20] Studies have also reported low awareness and knowledge of MTCT of HIV among groups without proper orientation (intervention)[20],[21] and some studies have reported high knowledge, especially among women due to interventions (counseling and awareness programs).[19],[22] This underscores the need for health intervention in the prevention of the spread of HIV/AIDS, particularly in rural settlements. After the interventions, the result of the survey shows a significant improvement in the overall knowledge of the routes of HIV transmission, as 82.8% could clearly identify at least three HIV transmission routes as compared with 47.2% in the baseline survey (P < 0.0001). This is reflected in the more than 90% of whom were aware that HIV can be transmitted through infected sharp objects and sexual intercourse. Also, the majority of the after-intervention survey respondents were aware that HIV could be transmitted from mother to unborn child and the use of unsterilized needles. Similar improved knowledge and awareness of HIV due to various education interventions have been in previous studies.[17],[23],[24],[25],[26]

The Joint United Nations Programme on HIV/ AIDS (UNAIDS) indicator for knowledge of prevention methods is a very useful, universal indicator for correct knowledge of HIV prevention methods. The indicator specifically measures whether individuals can correctly respond to prompted questions that a person can reduce the risk of contracting HIV by abstinence, by using condoms, and by having sex with only one faithful uninfected partner. Respondents in the baseline survey demonstrated a very poor knowledge of ways of preventing the spread of HIV (below 20% overall). Only a few of the respondents were aware that HIV can be prevented by abstinence from sex, use of condom, and being faithful to a faithful uninfected partner. With the interventions, more people were aware of the various means of prevention of HIV but this improvement was still below acceptable level as less than half of the participants has a good knowledge of the prevention methods. Several factors could have contributed to this suboptimal improvement. It could be the kind of lifestyle of exchange of sex for money that rampaged this community,[27] or the cultural belief that encourages males to have multiple sexual partners.[28]

In the fight against HIV/AIDS, there exist some misconceptions about HIV transmission. These misconceptions have affected how it is perceived and, as such, undermine prevention efforts aimed at curbing the spread of the disease. Misconception can also lead to an increased level of stigma and discrimination against people with HIV/AIDS.[6],[12],[29] The baseline findings show that the level of misconception of HIV transmission routes (such as sharing of toilets, and eating utensils, mosquito or bed bug bites, witchcraft activities, and kissing/hugging) ranged from 10.1% to 15.%), whereas there was a significant reduction after the intervention to the range of 2.7% to 4.8%. The misconceptions recorded in the baseline survey are in agreement with those in previous studies, that sharing of food and clothes, mosquito bites,[29],[30],[31] kissing,[1],[6],[7],[13],[30],[32] eating with infected people,[31] sharing a drinking glass,[1] and sharing of the toilet seat[1] are forms of misconception among study subjects, especially among people living in rural areas.[6] The decreased rates of misconception of HIV transmission routes after the interventions can be attributed to the intensive radio and television awareness in conjunction with other intervention activities carried out in the whole kingdom during the three-year program.

Another area of misconception among the baseline respondents includes the belief that taking antibiotics, prayer, and seeking protection from traditional healers are ways to avoid contracting HIV. This agrees with previous reports that people believed HIV can be cured or prevented through prayers,[11],[29] taking antibiotics,[1],[6] and by seeking protection from traditional healers.[29],[30] This is also in agreement with the report of Ayodele and Ayodele that misconceptions about HIV/ AIDS are associated and sustained by complex cultural beliefs in the rural communities.[6] This calls for regular and consistent awareness campaigns, speeches, conferences, seminars, and counseling, which will enable people in the rural communities to overcome misconceptions about HIV.

Risk Perception of Contracting HIV and the Level of Stigmatization Against PLWHA

Personalization of risk enables an individual to adopt appropriate protection measures against contracting HIV. Respondents were asked to rate their chances of being infected with HIV. At the preintervention survey, a high proportion of the respondents believed that they were not at risk of contracting HIV. After the intervention, less people believed that they were not at risk of contracting the disease. A study in Nigeria has reported low-risk perception among the study subjects[13],[15] and studies have emphasized that the consequences of low-risk perception are high-risk behavior and vulnerability, especially among youth.[6],[13],[14],[15],[31] This is an indication of more intervention to completely eradicate the transmission of HIV/ AIDS in rural communities.

In this study, the postintervention survey results show an impressive response and willingness to eat from the same dish with a person who had HIV, willing to care for a relative with HIV, allow an HIV infected teacher to continue teaching, buy food from HIV infected food seller and would not want to keep a family member infected with HIV secret as compared to the responses obtained from preintervention survey, which showed high level of discrimination against PLWHA. This should be conceded as a milestone to the fight against HIV/AIDS in this community.

  Conclusion Top

This study has demonstrated the impacts of community-based intervention programs in improving the knowledge of HIV transmission routes and its prevention methods and in reducing the level of misconception of the transmission routes and methods of prevention. The study also reduces the negative perception of the people about not being at risk of contracting HIV, which may significantly contribute to risky behaviors and, consequently, increase the spread of the disease, even beyond the community. Based on responses obtained from the study participants, the study recorded a landmark achievement in the reduction of discrimination against PLWHA. It is advocated that similar and consistent interventions such as awareness creation, free HIV counseling and testing, distribution of condoms, and treatment for infected people be carried out in other rural communities; this will promote the quest to end HIV/ AIDS by the year 2030.



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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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