High and equitable tuberculosis awareness coverage in the community-driven Axshya TB control project in India.

Data from surveys on knowledge, attitudes and practice (KAP) on tuberculosis (TB) conducted under the Axshya project at two time points (baseline 2010-2011 and mid-line 2012-2013) were analysed for changes in coverage and equity of TB awareness after project interventions. Overall coverage increased from 84% at baseline to 88% at midline (5% increase, P < 0.05). In comparison to baseline results, coverage at the midline survey had significantly increased, from 81% to 87% among the rural population, from 81% to 86% among women, from 73% to 85% in the ⩾55 years age group, from 71% to 80% among illiterates and from 73% to 81% in the south zone (P < 0.05). The equity gap among the different study groups (settlement, sex, age, education and zones) decreased from 6-23% at baseline to 3-11% during the midline survey. The maximum decline was observed for type of settlement (rural vs. urban), from 10% to 3% (P < 0.05). This community-driven TB control project has achieved high and equitable coverage of TB awareness, offering valuable lessons for the global community.

Des données émanant d'enquêtes « connaissances, attitudes, pratiques ¼ (KAP) en matière de tuberculose (TB) réalisées dans le cadre du projet « Axshya ¼ à deux périodes (de 2010 à 2011 au départ et de 2012 à 2013 à mi-parcours) ont été analysées à la recherche de modifications dans la couverture et l'équité en matière de connaissances de la TB à la suite des interventions du projet. La couverture d'ensemble a augmenté de 84% au départ à 88% à mi-parcours (augmentation de 5% ; P < 0,05). En comparaison au point de départ, la couverture de l'enquête à mi-parcours a augmenté significativement de 81% à 87% dans la population rurale, de 81% à 86% chez les femmes, de 73% à 85% dans la tranche d'âge ⩾55 ans, de 71% à 80% chez les personnes illettrées et de 73% à 81% dans la zone sud (P < 0,05). La différence en termes d'équité parmi les divers groupes d'étude (lieu, sexe, âge, instruction et zones) a diminué de 6% à 23% au départ jusqu'à 3% à 11% lors de l'enquête à mi-parcours. Le déclin maximal a été observé pour la localisation (rurale contre urbaine), de 10% à 3% (P < 0,05). Le projet à base communautaire de lutte contre la TB a abouti à une couverture élevée et équitable des connaissances en matière de TB, ce qui offre des leçons à portée universelle.

Se llevó a cabo un análisis de la evolución de la cobertura y la equidad en la sensibilización a la tuberculosis (TB) después de las intervenciones realizadas en el marco del Proyecto Axshya, a partir de los resultados de las encuestas del proyecto sobre los conocimientos, las actitudes y las prácticas en materia de TB que se realizaron al comienzo entre el 2010 y el 2011 y a medio término de la intervención, del 2012 al 2013. La cobertura global aumentó de 84% al comienzo del proyecto a 88% a medio término (aumento de un 5% ; P < 0,05). En comparación con los datos iniciales, en la encuesta de mitad del período, la cobertura observada aumentó de manera considerable en la población rural de 81% a 87%, en las mujeres de 81% a 86%, en el grupo de ⩾55 años de 73% a 85%, en la población analfabeta de 71% a 80% y en la región del sur aumentó de 73% a 81% (P < 0,05). La amplitud de la brecha de equidad en los diferentes grupos del estudio (en función del asentamiento, el sexo, la edad, la educación y las zonas) disminuyó de 6% a 23% al comienzo hasta 3% a 11% en la encuesta de medio término. La máxima disminución se observó con respecto al asentamiento (rural contra urbano), de 10% a 3% (P < 0,05). Este proyecto de control de la TB dirigido por la comunidad ha logrado una alta cobertura y gran equidad en la sensibilización sobre la TB y ofrece enseñanzas valiosas a otros entornos similares en todo el mundo.

Adolescent sexuality in Saint Petersburg, Russia.

OBJECTIVES: To describe adolescent knowledge, attitudes and behavior relevant to sexuality and the prevention of AIDS in Saint Petersburg, Russia. SUBJECTS AND METHODS: A cross-sectional descriptive study was designed, taking a random sample of 10th grade students at 14 Saint Petersburg grade schools, which were stratified by socio-economic district. A total of 185 female and 185 male students completed a self-administered 46-item questionnaire, with a response rate of 94%. RESULTS: From the questionnaires, 20% of females and 31% of males reported having had sexual intercourse and 25% of females and 12% of males reported being sexually abused. These adolescents displayed much misinformation about sexual matters and AIDS prevention. Only 25% of the females and 34% of the males believed that condoms should be used just once, and 38% of each sex believed that if washed, they could be used multiple times. Many respondents, especially males, rated their knowledge about sexual matters as high or adequate. Support for sex education was strong, especially among females, and respondents generally saw sex education as improving sexual pleasure. Most information sources about sexual activity were either not considered very credible, or not adequately accessible. CONCLUSIONS: Substantial reported rates of sexual abuse, sexual experience and much misinformation and unwarranted attitudes toward condoms, safer sexual practices and HIV/AIDS suggest the need for vigorous sex education programs for Russian youth. The early and sustained education of girls is especially important. Sex education should be introduced at an early age so that children can be taught how to reduce the risks of sexual abuse, HIV infection and other sexually transmitted diseases, and to improve their sexual experiences as responsible adults.

Knowledge, attitudes and behaviour among HIV-positive and HIV-negative clients of a confidential HIV counselling and testing centre in Thailand.

OBJECTIVE: To describe the clients, operation and impact of an Asian public HIV counselling and testing centre. DESIGN AND SETTING: Analysis of samples from clients attending the Thai Red Cross Anonymous Clinic (TRC-AC) in Bangkok, Thailand in 1993. SUBJECTS: HIV-positive and HIV-negative consecutive clients (250 of each). MAIN OUTCOME MEASURES: HIV seroprevalence rates, knowledge, attitudes and behaviour. RESULTS: Overall HIV-1 prevalence was 16%; 13% in men and 24% in women. Reasons for requesting an HIV test were high-risk behaviour (21%), feeling unwell (20%), checking a previous HIV test result (18%), a planned marriage or new relationship (10%), and planning a baby (5%). Heterosexual risk behaviour was reported by 85% of clients, while in each case only 1% reported male homosexual or intravenous drug use risk behaviour. Factors associated with HIV infection on univariate analysis included a history of sexually transmitted disease, not using condoms, a low level of education and salary, and being female. Knowledge about HIV transmission risks and AIDS prevention measures was good, and most clients expressed a caring attitude towards people with HIV and AIDS. A former negative HIV test result was associated with higher levels of condom use, and most clients expressed the intention to reduce their HIV risk behaviour in response to a positive or negative HIV test result (more so if positive). CONCLUSIONS: Our study demonstrates the demand for and the feasibility of confidential HIV counseling and testing services in Thailand and illustrates the value of these services in achieving behaviour changes. Such services should be considered as an additional approach for reducing HIV transmission in Asia, especially in areas with high HIV seroprevalence rates.

PIP: Data are presented from HIV serodiagnoses and knowledge, attitude, and behavior questionnaire responses for 250 HIV-positive and 250 HIV-negative consecutive clients attending the Thai Red Cross Anonymous Clinic in Bangkok, Thailand in 1993. The study was conducted to describe the clients, operation, and impact of the public HIV counseling and testing center. The men and women were of mean age 26-29 years in a range of 16-64 years. 16% overall were HIV-1-seropositive; 13% of men and 24% of women. 21% requested the HIV test in response to previous high-risk behavior, 20% felt sick, 18% were checking a previous HIV test result, 10% planned marriage or a new relationship, and 5% planned to have a baby. Heterosexual risk behavior was reported by 85% of clients, but only 1% reported male homosexual or IV drug use risk behavior. These behaviors were reported despite the existence among the sample of ample information about HIV transmission risks and AIDS prevention measures. An history of sexually transmitted disease, not using condoms, low education and salary levels, and being female were associated with HIV infection. Former negative HIV test results were associated with higher levels of condom use, while most clients expressed the intention to reduce their HIV risk behavior in response to either a positive or negative HIV test result. Most clients had caring attitudes toward people with HIV and AIDS. The authors note that sufficient demand exists for confidential HIV counseling and testing services in Thailand. Such services should be considered as a means of reducing HIV transmission in Asia, especially in areas of high HIV seroprevalence.

Female partners of AIDS patients in Uganda: reported knowledge, perceptions and plans.

OBJECTIVE: To assess reported knowledge of a partner's AIDS diagnosis, perceived risk of HIV infection, need for HIV testing and future support plans among women partners of male Ugandan AIDS patients. SUBJECTS AND METHODS: A cross-sectional descriptive survey was conducted at New Mulago Hospital, Kampala, Uganda. The subjects were women partners of consecutive male AIDS patients admitted to medical wards. RESULTS: Only 12% reported their partner's AIDS diagnosis; women who reported knowing were less likely to be financially dependent on the partner. Most women (76%) reported being at risk of HIV; in general, these women were older, in a newer relationship, had less children and were in customary rather than civil or cohabiting marriages. More than half (56%) of the women reported a need for HIV testing, though few (5%) had been tested. Those who stated the need for HIV testing were in a newer relationship, had less children and were more financially independent of their husbands; women in a cohabiting type marriage were less likely to report their need for testing than those in a civil or customary marriage. About half (56%) reported plans for future support if their husbands did not recover; these women were more likely to be in an older relationship and to have more children. CONCLUSIONS: Most women partners of AIDS patients in New Mulago Hospital reported no knowledge of their husbands' diagnosis. Over half perceived a need to be tested but very few reported having been tested, and only half reported having planned for the future of their families. Interventions are urgently needed to address barriers to knowledge and to acknowledgement of a partner's AIDS diagnosis, to HIV testing and to planning for the future.

Impact of an intervention on HIV, sexually transmitted diseases, and condom use among sex workers in Bombay, India.

OBJECTIVE: To develop and test an HIV intervention targeting sex workers and madams in the brothels of Bombay. SUBJECTS AND METHODS: In a controlled intervention trial, with measurements before and after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in red-light areas of Bombay. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use and knowledge of HIV was collected by interviewer-administered questionnaire. All subjects in the intervention group underwent a 6-month program of educational videos, small group discussions and pictorial educational materials; free condoms were also distributed. The blood tests and the questionnaire were readministered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year. RESULTS: The baseline level of knowledge about HIV and experience with condoms was extremely low among both sex workers and madams. The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (P = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly different in the two groups (all P < 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, women reported increased levels of condom use, and some (41%) said they were willing to refuse clients who wouldn't use them. However, both the sex workers and the madams were concerned about losing business if condom use was insisted upon. CONCLUSIONS: Both HIV prevalence and incidence are alarmingly high among female sex workers in Bombay. Successful interventions can be developed for these women, and even a partial increase in condom use may decrease the transmission of HIV and sexually transmitted diseases. Intervention programs of longer duration that target madams and clients and make condoms easily available are urgently needed at multiple sites in red-light areas.

PIP: The objective was to develop and test an HIV intervention targeting sex workers and madams in the brothels of Bombay. In a controlled intervention trial, with measurements before and after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in red-light areas of Bombay. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use, and knowledge of HIV was collected by questionnaires. All subjects in the intervention group underwent a 6-month program of educational videos, small group discussions and pictorial educational materials; free condoms were also distributed. The blood tests and the questionnaire were readministered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year. The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (p = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly different in the 2 groups (all p 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, there was a significant increase in knowledge of modes of HIV transmission in the intervention group (n = 334) compared to the control group (n = 190) (60% vs. 99% compared to 56% vs. 26%, p 0.001). In addition, women reported increased levels of condom use and some (41%) said they were willing to refuse clients who would not use them. However, both the sex workers and 100% of the madams were concerned about losing business if condom use was insisted upon. Intervention programs of longer duration that target madams and clients and make condoms easily available are urgently needed.

AIDS education for primary school children in Tanzania: an evaluation study.

OBJECTIVE: To test the effects of an HIV/AIDS education program. DESIGN: A quasi-experimental, nested cross-sectional design including baseline and 6-month follow-up surveys. Schools, stratified according to location, were randomly assigned to intervention (n = 6) or comparison conditions (n = 12). SETTING: Public primary schools in Arusha and Kilimanjaro regions, Tanzania. PARTICIPANTS: A total of 2026 sixth and seventh grade pupils (average age, 14.0 years) participated at baseline (85%) and 1785 at follow-up. INTERVENTION: The program was designed to reduce children's risk of HIV infection and to improve their tolerance of and care for people with AIDS. Local teachers and health workers attended a 1-week training workshop before implementing the program over a 2-3-month period (averaging 20 school hours per class). MAIN OUTCOME MEASURES: Self-reported exposure to AIDS information, communication regarding AIDS; AIDS knowledge, attitudes towards people with AIDS, attitudes towards having sexual intercourse, subjective norms regarding sexual intercourse, and intention to engage in sexual intercourse. RESULTS: Following this program, intervention pupils reported significantly higher scores for the following outcome measures than pupils attending the comparison schools: AIDS information (13.1 versus 10.5; P = 0.0001), AIDS communication (10.9 versus 7.8; P = 0.0001) AIDS knowledge (14.5 versus 11.5; P = 0.0001), attitudes towards people with AIDS (9.0 versus 6.7; P = 0.0008), subjective norms (45.5 versus 43.9; P = 0.011), and intention (1.3 versus 1.4; P = 0.020). No program effect was seen for attitudes towards sexual intercourse (47.0 versus 46.3, P = 0.44). CONCLUSIONS: These results indicate that it is feasible and effective to provide AIDS education for Tanzanian primary school children.

PIP: In the adjacent regions of Arusha and Kilimanjaro in Tanzania, researchers conducted a quasi-experimental, nested cross-sectional design to evaluate the Ngao (shield) HIV/AIDS education program for public primary school children, a culturally specific program. The baseline survey and the 6-month follow-up survey included 2026 and 1785 6th-7th grade children, respectively. Teachers of the participating schools and health workers participated in a 1-week training workshop before they implemented the program over 2-3 months. Its intent was to reduce the pupils' risk of HIV infection and to improve their acceptance of and care for people with AIDS. At baseline, the pupils in intervention and comparison schools tended to be comparable. At follow-up, however, intervention pupils had been exposed to more AIDS information (scores, 13.1 vs. 10.5), had discussed AIDS more often (10.9 vs. 7.8), and had a higher increase in AIDS knowledge (14.5 vs. 11.5) than did the comparison pupils (p = .0001 for all the above). They also had significantly more positive attitudes towards people with AIDS than the comparison pupils (9 vs. 6.7; p = .0008). Pupils in the intervention had more restrictive subjective norms regarding sexual intercourse (45.5 vs. 43.8; p = .011) and less intention to engage in sexual intercourse over the next 3 months than at baseline. Yet, they were not significantly different from comparison pupils, because the comparison pupils also had a change in attitude. These findings show that teachers in primary schools and health educators can implement a workable and effective HIV/AIDS education program for school children.

The role of AIDS knowledge, attitudes, beliefs and practices research in sub-Saharan Africa.

PIP: This review gives greater weight to WHO/Global Program on AIDS (GPA)-supported knowledge, attitudes, beliefs, and practices (KABP) surveys that have been completed in several African countries, including the Central African Republic, Chad, Ivory Coast, Lesotho, Mauritius, Rwanda, Sudan, Togo, and Tanzania. The percentage of individuals who had heard of AIDS ranged from 60% in Chad to 98% in Rwanda. Over 75% of respondents knew that AIDS is sexually transmitted. A similar proportion (except in Sudan) knew about perinatal transmission. Misconceptions nevertheless endure: e.g., over 40% of individuals in the Central African Republic, Mauritius, Togo, and Tanzania believed that insect bites transmit HIV. At least 20% of respondents in the Central African Republic, Lesotho, Mauritius, Rwanda, Togo, and Tanzania believed that HIV was transmitted through touching or sharing utensils/food. 29% of respondents in Togo, 27% of interviewees from Chad, 21% of individuals in Rwanda, and 19% of participants from Lesotho asserted that AIDS was curable. Only 40% of interviewees from Chad and 25% or fewer of respondents from Lesotho, Mauritius, Sudan, Togo, and Tanzania perceived themselves to be susceptible to AIDS. 80% or more of respondents, except from Chad, where the figure was only 23%, believed that AIDS could be prevented by behavior change. WHO/GPA data indicate that, despite widespread awareness of AIDS, the proportion who have heard of condoms varies from 33% in Chad and 39% in Togo to 77% in Lesotho and 84% in Mauritius. Excluding Mauritius, less than 20% of respondents spontaneously mentioned condoms as a mode of protection against HIV and less than 20% had ever used a condom. Data from the World Fertility Survey and Demographic and Health Survey closely support these observations, confirming that women's knowledge and use of condoms is lower in sub-Saharan Africa than elsewhere. At present, condom use by women in union in Mauritius, Botswana, and Zimbabwe is 9%, 1%, and 1%, respectively, and under 1% elsewhere.^ieng

Knowledge, attitudes and practices concerning AIDS in Ugandans.

A survey of the knowledge, attitudes and practices of 3928 Ugandans concerning AIDS was done in two semi-rural communities in August 1987. Eighty-eight per cent of the respondents knew that AIDS could be acquired from other people and that having multiple sexual partners was high-risk behaviour. There were, however, many incorrect beliefs about HIV transmission, including belief in transmission by insect bites (37%), witchcraft (22%) and casual contact with ill people (21%). AIDS was believed to be curable by 15% of the respondents. As part of the survey, blood was obtained from 3907 (99%) participants; 421 (10.8%) had antibody to HIV-1 by enzyme-linked immunosorbent assay (ELISA) and females were more likely to be infected than males (12.5 versus 8.8%, relative risk 1.42). Factors significantly associated with HIV infection on univariate analysis include multiple sexual partners, sexually transmitted diseases (STDs), injections, and being female. Stratified analysis of a history of STDs in people who were monogamous still showed an association with HIV infection. Information about the AIDS epidemic is reaching the Ugandan population; however, changes in behaviour are slower to follow.

PIP: Knowledge, attitudes, and practices with regard to acquired immunodeficiency syndrome (AIDS) were surveyed among 3928 adults in 2 semi-rural communities of Uganda in 1987. 54% of respondents were female; the average age was 33 years and 57% were married. 203 (5%) were personally acquainted with an AIDS victim and 74% could identify at least 1 clinical symptom of AIDS. 88% correctly identified infected individuals as the major source of disease transmission; however, 37% believed AIDS could be spread by insect bites, 22% thought it could be spread through witchcraft. 22% identified dirty drinking water as a source of AIDS, and 47% thought sharing clothes with an AIDS victim would spread the disease. Ways of avoiding AIDS cited by respondents included avoiding sex with prostitutes (92%), reducing the number of sexual partners (89%), using condoms (41%), using antibiotics (23%), and getting protection from a witchdoctor (11%). 72% indicated they would be ashamed if a family member contracted AIDS, 38% felt AIDS victims deserve their punishment, and 56% favored isolating AIDS patients from the community. As part of the survey, blood samples were obtained from 3907 respondents, 421 (11%) of whom were seropositive for infection with human immunodeficiency virus (HIV). The HIV infection rate was 12.5% among females and 8.8% among males. Multiple sexual partners and a history of sexually transmitted diseases (STDs) were the factors most strongly associated with seropositivity. Although males in this study reported more sexual partners than females, the effect of multiple partners on HIV infection was more pronounced in females. This suggests that male-to-female heterosexual transmission predominates in Uganda.

Results of a model AIDS prevention program for high school students in the Philippines.

OBJECTIVES: To describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students' AIDS-related knowledge, attitudes and AIDS-preventive behaviors. SUBJECTS AND METHODS: A cluster-randomized, controlled trial with pretest/post-test evaluation was conducted in four demographically similar public high schools in a semi-urban district of Metro Manila, the Philippines. Of 845 high school students who participated in the baseline survey, 804 (95%) completed a postintervention questionnaire. INTERVENTION: An AIDS prevention program was developed by public high school teachers together with local AIDS experts, social scientists and health educators. The teacher-led AIDS program was designed to provide students with accurate information about AIDS, particularly in dispelling misconceptions about casual contagion, to foster positive attitudes towards people with AIDS and to develop skills aimed at clarifying values and assessing intended behavior. RESULTS: At baseline, 11% of students (20% of males and 4% of females) reported ever having had sexual intercourse (mean age 14 years). Among these, condom use was low (24%). After implementation of the AIDS prevention program, statistically significant effects favoring the intervention group were observed in knowledge and attitudes towards people with AIDS. While there was no statistically significant overall effect on intended preventive behavior, the program appeared to delay the students' intended onset of sexual activity. CONCLUSIONS: A sizable number of Filipino high school students are sexually active but condom use is low. School-based AIDS prevention programs can be developed and implemented in developing countries with the assistance of school personnel to address sexual issues. Our program was successful in increasing AIDS-related knowledge and improving attitudes towards people with AIDS. Supplementation with other preventive activities may be needed to achieve lasting changes in students' risk-taking behavior.

PIP: The objectives were to describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students' AIDS-related knowledge, attitudes and AIDS-preventive behaviors by means of self-administered questionnaires. A cluster-randomized, controlled trial with pretest/post-test evaluation was conducted in 4 demographically similar public high schools in a semi-urban district of Metro Manila, the Philippines. Of 845 high school students who participated in the baseline survey, 804 (95%) completed a postintervention questionnaire. An AIDS prevention program was developed by public high school teachers together with local AIDS experts, social scientists, and health educators to provide students with accurate information about AIDS, dispel misconceptions about casual contagion, to foster positive attitudes towards people with AIDS, and to develop skills aimed at assessing intended behavior. At baseline, 80 (11%) of 804 students reported ever having had sexual intercourse (mean age 14 years). 66 were male and 14 were female (p 0.001). Among these, condom use was low (24%). Reasons for failure to use condoms were: use of other method (26%) and loss of sensitivity (25%). After implementation of the AIDS prevention program, the intervention group was more likely to answer correctly that HIV cannot be transmitted by mosquito bites (p 0.01), through a cough or sneeze (p 0.01), or by shaking hands with an infected person (p 0.01). Students who had attended the AIDS education program were less likely to avoid people with AIDS and were more compassionate toward them (p = 0.01). Changes in knowledge about modes of HIV transmission were associated with improvements in preventive knowledge (p 0.001). While there was no statistically significant overall effect on intended preventive behavior, the program appeared to delay the students' intended onset of sexual activity. The program was successful in increasing AIDS-related knowledge and improving attitudes toward people with AIDS.

Using a knowledge, attitudes and practices survey to supplement findings of an outbreak investigation: cholera prevention measures during the 1991 epidemic in Peru.

BACKGROUND: To assess the effectiveness of the cholera prevention activities of the Peruvian Ministry of Health, we conducted a knowledge, attitudes, and practices (KAP) survey in urban and rural Amazon communities during the cholera epidemic in 1991. METHODS: We surveyed heads of 67 urban and 61 rural households to determine diarrhoea rates, sources of cholera prevention information, and knowledge, attitudes, and practices regarding ten cholera prevention measures. RESULTS: Twenty-five per cent of 482 urban and 11% of 454 rural household members had diarrhoea during the first 3-4 months of the epidemic. Exposure to mass media education was greater in urban areas, and education through interpersonal communication was more prevalent in rural villages. Ninety-three per cent of rural and 67% of urban respondents believed they could prevent cholera. The mean numbers of correct responses to ten knowledge questions were 7.8 for urban and 8.2 for rural respondents. Practices lagged behind knowledge and attitudes (mean correct response to ten possible: urban 4.9, rural 4.6). Seventy-five per cent of respondents drank untreated water and 91% ate unwashed produce, both of which were identified as cholera risk factors in a concurrently conducted case-control study. CONCLUSIONS: The cholera prevention campaign successfully educated respondents, but did not cause many to adopt preventive behaviours. Direct interpersonal education by community-based personnel may enhance the likelihood of translating education into changes in health behaviours. Knowledge, attitudes, and practices surveys conducted with case-control studies during an epidemic can be an effective method of refining education/control programmes.

PIP: The authors conducted a knowledge, attitudes, and practices (KAP) survey in urban and rural Amazon communities during the 1991 cholera epidemic to assess the effectiveness of the Peruvian Ministry of Health's cholera prevention activities. Diarrhea rates, sources of cholera prevention information, and knowledge, attitudes, and practices regarding 10 cholera prevention measures were determined by surveying the heads of 67 urban and 61 rural households. 25% of 482 urban and 11% of 454 rural household members had diarrhea during the first 3-4 months of the epidemic. Exposure to mass media education was greater in urban areas, while education through interpersonal communication prevailed in rural villages. 93% of rural and 67% of urban respondents believed they could prevent cholera. Rural respondents were slightly more knowledgeable than urban respondents about cholera. Overall, however, practices did not reflect their knowledge and attitudes; 75% of respondents drank untreated water and 91% ate unwashed produce.

Contraception and prevalence of sexually transmitted diseases among adolescents and young adults in Uganda.

The study is aimed at (i) exploring the knowledge and attitudes of adolescents (15-19 years old) and young adults (20-24 years old) towards sex and contraception (condoms) and (ii) determining their level of knowledge and attitudes towards sexually transmitted diseases (STD) as well as the prevalence of the latter among the sexually active adolescents and young adults. A sample of 4510 respondents (1545 males and 2965 females) aged 15-24 years from urban and rural areas were interviewed. The majority of adolescents and young adults surveyed have a negative attitude towards the use of condoms although most of them agreed that they prevent STD. Over 95% of the respondents have heard about STD and their level of knowledge is relatively high; slightly higher for urban residents and for young males. Approximately 21% of the male and 8% of the female respondents admitted having ever contracted STD. The gap between contraceptive knowledge and practice is rather wide. Only a small proportion of the respondents were using condoms at the time of the survey.

PIP: Between 1988 and 1990, researchers conducted the Adolescent Fertility Survey in the districts of Jinja, Kampala, Masaka, Kabale, Hoima, and Mbale in Uganda among 4510 15-24 year old urban and rural youth to examine their knowledge and attitudes toward sex, contraception, and sexually transmitted diseases (STDs). Males were more likely to experience 1st sexual intercourse at an earlier age than females. Many youth experienced their 1st sexual intercourse before age 15 and they had had more sexual partners than females. 83.9% of males and 87% of females used no contraception. Overall knowledge of condoms was high (78.2% for males and 56.6% for females) except among rural females (31.1%), especially among urban males (85.8%). Almost everyone was knowledgeable about STDs (96.1% males, 93.5% females). They tended to agree that condoms prevent STDs (urban males, 80.2%; urban females, 76%; rural males, 89.8%; and rural females 83.7%). Despite these high knowledge levels and positive attitude toward condoms, condom use levels were low, e.g., only 12.7% of males and 0.4% of females who were familiar with condoms used them. 40% of all respondents knew about the 3 most common STDs: gonorrhea, syphilis, and AIDS. Urban males were a bit more knowledgeable about these 3 STDs than were the other groups (48.8% vs. 41.2% for urban females, 41.3% for rural males, and 41.6% for rural females). In addition, STD prevalence was quite high especially among males (21.4% for males vs. 7.8% for females). The unsafe sexual practices revealed in this study indicated the need for sex education earlier than it is presently being offered in the school system and the establishment of health clinics geared toward adolescent needs.

Evaluation of two AIDS prevention interventions for inner-city adolescent and young adult women.

Two hundred and fourteen young women received acquired immunodeficiency syndrome (AIDS) prevention interventions at an inner-city family health center serving minority patients predominantly. The community in which the health center is located has a high incidence of intravenous (IV) drug abuse. Either a peer or a health care provider delivered the intervention. In the peer-delivered intervention, a trained peer educator reviewed with patients an AIDS "Rap" videotape and several AIDS brochures, which imparted information about human immunodeficiency virus (HIV), its transmission, and prevention. In the provider-delivered intervention, family practice residents, attending physicians, and nurse practitioners used a patient-centered counseling approach to convey the same information. Questionnaires administered immediately before and after the intervention and at one month follow-up evaluated changes in knowledge, attitudes, and behavior. Analyses of data from both combined intervention groups revealed significant improvements in several areas of knowledge, including the effectiveness of using a condom and cleaning IV drug implements with bleach to prevent transmission of HIV. Many improvements were retained at the one-month follow-up. In addition, subjects in both groups who were sexually active stated immediately after the intervention that asking a sexual partner about past sexual experience would now be less difficult, and at one-month follow-up they reported a significant decrease in the frequency of vaginal sex. Our findings suggest that counseling by physicians can achieve more changes in knowledge of sexual risks, whereas peer education can achieve greater changes in knowledge about IV drug use. Results show that both approaches to AIDS prevention used in this study can significantly affect knowledge, attitudes, and sexual behavior.

PIP: 214 women of average age 20.3 years were subject to an AIDS prevention intervention at a family health center in a high IV drug use community in Worcester, Massachusetts. 116 of the women learned about HIV, its transmission, and prevention with trained peer educators in a review of an AIDS "Rap" video and several AIDS brochures. The remaining 98 women were exposed to the same information, but in a patient-centered counseling approach with family practice residents, attending physicians, and nurse practitioners. 25 women were African-American, 105 Caucasian, 76 Hispanic, and 8 of other ethnic backgrounds. They answered questionnaires regarding their AIDS-related knowledge, attitudes, and practices immediately before, immediately after, and 1 month after exposure to either the peer educator or provider-based education sessions; only 97 completed the follow-up survey. The authors found knowledge on the effectiveness of using condoms and cleaning IV drug implements with bleach to prevent HIV transmission to have significantly improved following the interventions. Many improvements remained at the 1-month follow-up. Moreover, sexually active subjects in both groups noted immediately after the interventions that they would find it easier to ask sex partners about past sexual experiences. A significant decrease was also reported in the amount of vaginal sex at the 1-month follow-up. The authors conclude that while physician counseling may effect more change in the knowledge of sexual risks, peer education may better effect change in knowledge about IV drug use.

A malaria control trial using insecticide-treated bed nets and targeted chemoprophylaxis in a rural area of The Gambia, west Africa. 4. Perceptions of the causes of malaria and of its treatment and prevention in the study area.

Perceptions of the causes of malaria, its treatment and prevention were studied among 996 adults, selected randomly from 73 villages and hamlets in a rural area of The Gambia. Structured questionnaires and other interview techniques were used for data collection. Malaria has no specific name in the study area; it is referred to commonly as Fula kajewo (Fula fever). Only 28% of the respondents knew that mosquitoes transmitted malaria. However, most people believed correctly that August to October was the main malaria season. Eighty-six per cent of the subjects were bed net users. The majority of nets were produced locally, usually white in colour and made of sheeting fabrics. Usage of nets was correlated with ethnic group, age and polygamy but not with education, income, occupation or ownership of certain items which indicate high social status. Analysis of expenditure on mosquito coils indicated that non-users of nets spent 43% more on coils than did users. Bed nets have been used for a long time in the study area; 98% of users saw their parents using them during their childhood.

PIP: In the Gambia, malaria specialists at the Medical Research Council Laboratories oversaw interviews of 996 men and women from, 73 villages and hamlets on the south bank of the River Gambia to learn their perceptions of the causes of malaria and of its treatment and prevention. No specific local term for malaria existed. The most common term used by all ethnic groups, except the Fulas, was Fula kejewo (Fula fever). Just 28% of all adults knew that mosquitoes transmit malaria. Men were more likely to know the real cause of malaria than women (p .001). Knowledge about the cause of malaria increased with education p =.01). Most people (90%) knew that malaria transmission occurs most often during August-October. 86% of adults and 81% of their children less than 10 years old used bed nets. Girls were more likely to sleep under bed nets than boys (p = .005). Local tailors made most bed nets with either second hand or new fabrics. They tended to be made of sheeting fabrics and white in color. Most adults were willing to treat their bed nets with the insecticide permethrin to protect against mosquitoes. Ethnic group (Fulas less likely, p .001), age (older people more likely, p .001), and polygamy (p = .002) were correlated with bed net use. Education, income, and occupation or ownership of items indicating high social status were not correlated with bed net use. Nonusers of bed nets spent 43% more on mosquito coils, used to smoke out mosquitoes from rooms before going to sleep, than did users (p = .001). Almost all adults (98%) remembers their parents using bed nets when they were children. The bed nets users who were at least 70 years old said that the Mandinkas mainly used bed nets. These findings should prove useful to the government as it develops a national impregnated bed net program to control malaria in rural areas.

U.S. women's perceptions of and attitudes about the IUD.

PIP: Two recent surveys provide insights into U.S. women's attitudes toward and perceptions of the IUD. The first study was based on in-depth interviews conducted with 300 women 21-54 years of age in 6 cities; the second was based on telephone interviews with 1852 low-income, predominantly Black and Hispanic women 18-34 years of age from New York City. Compared to other contraceptive methods such as the pill, condoms, and sterilization, respondents judged themselves to be not very knowledgeable about the IUD. Although women placed a high value on a method that was safe, easy, convenient, and protective against sexually transmitted diseases, their current methods tended to lack these attributes. Women were likely to recognize that the IUD requires no daily attention on their part, but did not perceive safety as a prominent IUD characteristic. Women's perceptions of the IUD tended to be based on hearing others talk about the method rather than on personal experience. Only 18% of respondents in the first study had ever used the IUD and only 4% were current users; most of these current users were 35 years old and above. Among the low-income younger women in the second study, 3% were past IUD users and 1% were current users. While 17% of women in the first survey said they were likely to discuss the IUD with their physician in the future, this statistic rose to 46% after women were read a description of the method. In the second study, 9% of women who had never used the IUD said they would consider its use in the future. Younger women and those born outside the US were most likely to consider future IUD use, presumably because they had not been exposed to negative publicity surrounding the Dalkon Shield.^ieng

Condom awareness and use in the Arusha and Kilimanjaro regions, Tanzania: a population-based study.

A cross-sectional study of condom awareness, perceived availability, and use was conducted using a questionnaire in the Arusha and Kilimanjaro regions in northern Tanzania. The questionnaire was administered to a random sample (n = 1,081) of males and females (15-54 years of age) from four localities in the Arusha, Babati, Moshi, and Same districts. Of the 1,081 respondents, 69.9% knew what condoms are and, of these, 31.7% reported having ever used a condom, while 20.7% stated that they used condoms regularly. Furthermore, of the 756 respondents who knew what condoms are, 62.2% stated that condoms were available in their localities and, of these, 44.1% reported having used condoms regularly. The results suggested that, while the majority of the respondents knew about condoms and stated that condoms were available in their localities, reported regular condom use was low. Age, gender, marital status, occupation, and place of residence appeared to be significant determinants of condom awareness and use, while educational status was not. Although barmaids and professional drivers have been shown to practice high-risk sexual behavior, reported condom use among them was low.

PIP: A cross-sectional study of condom awareness, perceived availability, and use was conducted using a questionnaire in the Arusha and Kilimanjaro regions in northern Tanzania. The questionnaire was administered to a random sample (n = 1081) of males and females (15-54 years old) from 4 localities in the Arusha, Babati, Moshi, and Same districts. Of the 1081 respondents 507 were males and 574 females. Overall, 52.3% of the respondents were married and 34.0% were single. The mean age of the population was 29.3 years. 756 (69.9%) knew what condoms were; of these, only 343 (31.7%) reported having ever used a condom, and 224 (20.7%) stated that they used condoms regularly. Respondents in the 25-34 year age group had the highest level of condom awareness and use. Men were significantly more aware of condoms than women (81.9% vs. 59.4%, p 0.0001) and reported more regular condom use than women (27.6% vs. 14.6%, p 0.0001). Unmarried individuals had a significantly higher proportion of reported regular condom use (28.6% vs. 16.1%) compared with married individuals (p 0.001). Furthermore, of the 756 respondents who knew what condoms were, 470 (62.2%) stated that condoms were available in their localities and, of these, 44.1% reported having used condoms regularly. 196 (25.9%) said that they had condoms at home. Significantly more men (80.7%) than women (71.6%) knew where to get condoms (p 0.01). Awareness of condom availability was significantly associated with occupation (p 0.0001), but having condoms at home was significantly lower among farmers and housewives than among people in other occupations (p 0.0001). The results suggested that, while the majority of the respondents knew about condoms and stated that condoms were available in their localities, reported regular condom use was low. Age, gender, marital status, occupation, and place of residence appeared to be significant determinants of condom awareness and use, while educational status was not. Although barmaids and professional drivers have been shown to practice high-risk sexual behavior, reported condom use among them was low.

Scale reliability and construct validity: a pilot study among primary school children in Northern Tanzania.

Based on the World Health Organization's standardized survey inventories assessing AIDS-related knowledge, attitudes, beliefs, and practices (KABP) for adolescents, a written questionnaire was developed and pilot tested among primary school children in Northern Tanzania. Subjects included 472 fifth and sixth graders at four schools in Arusha and Kilimanjaro regions. Results indicated that the large majority of the students understood the questions and were able and willing to complete the survey. Non-response patterns did not seem to be related to the sensitivity of included questions. AIDS-related knowledge and attitudes toward engaging in sexual behavior had acceptable reliability and construct validity when compared with similar surveys in Western countries, while perceived social norms and self-efficacy need further development. KABP questionnaires may serve as a useful method in AIDS-related surveys and evaluation studies among school children in Tanzania if survey instruments are adapted to reflect the local social and cultural context.

AIDS knowledge in three sites in Bas-Zaire.

This study surveyed 5,494 women in one urban and two rural sites of Bas-Zaire on their knowledge, attitudes, and practices regarding AIDS. The AIDS Risk Reduction Model (ARRM) was used to analyze the results to better understand factors that may be related to motivation for behavior change. The results show that there are considerable barriers to achieving the first stage of the 3-stage model. Most notably, only a third of the women believed they were at risk of getting AIDS. Those aged 25-29, educated, and married felt themselves to be most at risk. Results are compared to other knowledge, attitudes, and practices studies conducted in Zaire. Policy implications of these results are discussed.

PIP: In Zaire, data on 5494 15-49 year old women living in the city of Matadi and rural Sona Bata and Nsona Mpangu in Bas-Zaire were analyzed to assess knowledge, attitudes, and practice about AIDS. Women living in Matadi and Sona Bata were more likely to be aware of AIDS than those in Nsona Mpangu (84% and 79% vs. 32%; p.001). 83% of knowledgeable women knew the 4 modes of HIV transmission, yet they also reported incorrect modes such as swelling in the same household as someone with AIDS. 50% believed that someone could have an HIV infection and not know it. 20-40 year old educated women living in Matadi had the best understanding for the latency period. Even though 75-90% of the women mentioned reducing the number of partners as a means to prevent HIV transmission, only 40% in Nsona Mpangu, 35% in Matadi, and 14% in Sona Bata mentioned condoms. Around 50% knew about them than other women regardless of residence. Wide spread fears and misconceptions about condoms existed, e.g., condoms stay in the vagina. About 1/2 did not consider themselves to be at risk of acquiring AIDS. The perceived risk was greatest among married 25-29 year old women regardless of educational status and residence. Most women learned about AIDS through the radio followed by TV. 96% wanted more information about AIDS. 52-62% of the women were willing to be tested for HIV mainly to make sure they were not infected. The other women did not want to be tested mostly because they did not believe they were infected. 91% of all women believed a woman with AIDS should not become pregnant mainly due to fear of infecting the infant. The results showed that the women were not prepared to advance beyond the 1st stage of the AIDS Risk Reduction Model--labeling sexual activities as problematic.

AIDS and condoms in Brasilia: a telephone survey.

A telephone survey was conducted to measure AIDS knowledge, media usage and condom attitudes and behaviors among 500 adults aged 18 to 49 in Brasilia, as well as to evaluate the feasibility of the telephone survey method in a developing country. The response rate was 91.6%. Respondents had good knowledge about correct modes of HIV transmission and prevention but also believed HIV was transmitted through blood donation, public toilets, swimming pools, and mosquito bites. TV and newspapers were the most important sources of information on health matters and AIDS, though health workers were considered the most credible sources of such information. Only 19% of sexual encounters in the 4 weeks prior to the survey included condoms. Single and younger respondents and those with more positive attitudes used condoms more frequently. More work is needed to identify appropriate messages to motivate people to use condoms. Telephone surveys regarding AIDS and sexual attitudes and behaviors are feasible in Brasilia, a planned community with universal telephone coverage.

PIP: This study examines the knowledge, attitudes, and behavior of AIDS and condom use in Brazil. Data were obtained during March-April 1994 from 500 completed telephone interviews among a sample of adults 18-49 years old living in the Plano Piloto sector of Brasilia, Brazil. The survey was conducted about 2 months after a national television and radio campaign on AIDS prevention, use of condoms, and avoidance of sharing syringes or needles. The questionnaire was based on questions from the Global Program on AIDS protocol. 99% of the sample reported that AIDS was one of the most important health problems facing Brazil today. The other health problems mentioned were cancer, famine, and cholera. 27% did not consider themselves at risk of AIDS. 2% considered themselves at great risk. The rest believed they had a small to moderate risk. 93% were aware that people with AIDS might appear healthy looking. 95% indicated sexual contact as a mode of transmission. 34% reported condom use as a means of avoiding AIDS transmission. 19% reported sexual abstinence as a preventive measure. 15% reported that people should inform others of their AIDS status as a way to avoid transmitting AIDS. 41% knew someone with AIDS. Less educated respondents held more inaccurate beliefs about the general means of transmission, but there were no educational differences about safe activities involving specific contact with persons infected with AIDS. Most misinformation pertained to public toilets, blood donations, use of swimming pools, and mosquito bites. 89% believed in a high risk at dental clinics used by AIDS patients. 72% were regular television users. Television and newspapers were the most important sources of information on AIDS and health. Only 19% used condoms in sexual activity occurring in the prior 4 weeks. Psychosocial factors were more important than demographic factors in predicting condom use.

Gender differences in AIDS-relevant condom attitudes and condom use.

Two studies, conducted approximately one year apart, examined gender differences in AIDS-relevant condom attitudes, condom use behaviors, and relationships among attitudes and condom use behaviors. Subjects (N = 248, N = 528) were undergraduates, primarily heterosexual. Females reported more favorable attitudes, with the exception of greater inhibition about buying and possessing condoms. Men engaged in preliminary condom use behaviors (carrying and keeping condoms at home) substantially more often than did women. Preliminary condom use behaviors predicted past and intended condom use more consistently for men than for women. Relationships between condom attitudes and condom use behaviors were generally similar for both sexes, with poorer self-control explaining the most variance in past and intended condom use. These results, interpreted from the perspective of Eagly's (1987) gender role theory, suggest that although females may indirectly influence condom use decisions, providing condoms is the expected role of males, infusing them with greater control over the interpersonal process.

PIP: 2 studies were conducted 1 year apart exploring gender differences in AIDS-relevant condom attitudes, condom use behaviors, and relationships among attitudes and condom use behaviors. 248 self-reported heterosexual undergraduates were studied in the 1st study. Participants were 65% female, 96% self-reported heterosexuals, 87% white, and of average age 22.77 years. 71% reported having sexual intercourse at least once in the preceding 2 years and 64% reported using a condom at least once during sex in the preceding 2 years. The 2nd group of 528 individuals sampled in the 2nd study had characteristics which were highly similar to those of the 1st study, except that 74% of the participant were female. Females generally had more favorable attitudes than men about condoms, but were more inhibited than men about buying and possessing them. Men carried and kept condoms at home far more often than did women. This behavior predicted past and intended condom use more consistently for men than for women. Generally similar relationships were found for both sexes between condom attitudes and condom use behaviors; poorer self-control explained the most variance in past and intended condom use. The results suggest that while females may indirectly influence condom use decisions, providing condoms is the expected role of males. Interventions with the objective of increasing the use of condoms during sexual intercourse should be designed accordingly.

AIDS and sexual practices: knowledge, attitudes, behaviors, and practices of health professionals in the People's Republic of China.

PIP: 68 upper level health professionals from 20 provinces in China completed to a questionnaire while attending either a health education workshop in Guangzhou in August 1989 or a similar workshop in Beijing in December 1989. The aim of the study was to determine their knowledge and attitudes since they were opinion leaders and key players in future AIDS prevention programs and to learn about sexual practices. 90% knew that a pregnant woman can transmit HIV to her infant and that sharing unclean needles can transmit HIV, but only 82.1% knew that someone with HIV can transmit it to a partner during sexual intercourse. 29.9% thought one can tell if someone has AIDS by looking at him or her. Newspapers and professional journals provided most of them with information on AIDS (80.6% and 73.1% respectively), but friends and government only provided this information to 29.9% and 19.4%. Overall the participants viewed AIDS as a threat to others and not themselves or families. 85-95% believed certain population groups such as policy makers, high school students, and the public should undergo sex education. Only 43.3% believed elementary schools should provide sex education, however. Participants tended to approve premarital sex and sex between individuals with emotional or long term ties more than extramarital sex. Nevertheless considerable percentage did condone extramarital sex. 95.8% experienced their 1st sexual relationship with their spouses. Even though participants tended to feel condoms did not make sex enjoyable, 81.6% and 72.5% believed condoms prevent pregnancy and sexually transmitted diseases respectively. 82% thought they were easy to use. 35% used condoms for contraception. Before using these upper level health workers to conduct AIDS training for lower level workers, they need to have a more thorough understanding of HIV transmission and the signs and symptoms of AIDS.^ieng