Introduction:
Acquired Immuno Deficiency Syndrome (AIDS) was first described in 1981 as an obscure disease of unknown aetiology affecting young men who had sex with men and among intravenous drug users in the United States. [1]. In 1984, the human immunodeficiency virus (HIV) was isolated. [2]. Moreover, HIV/AIDS has emerged as a serious public health issue across the globe particularly in the developing countries. [3] Globally there were some 38 million persons across the regions are living with HIV, out of these 36.2 million were adults and 1.8 million were children (<15 years). [4] It has been estimated that there were 2.7 million (range 2.4−2.8) new infections per year worldwide. [5] A number of population-based cross-sectional and longitudinal studies have undertaken for a better understanding of HIV infection rate and prevalence trends in populations. [6-9] Studies have attempted to understand patterns of behaviours associated with HIV/AIDS within populations. [10-11] Such research designs have been indispensable in identifying factors (e.g., socio-demographic and education), levels of comprehensive knowledge and positive attitudes that have been shaping the dynamics of the HIV/AIDS epidemic. [3, 11-12] Risk reduction through sexual behavioural, comprehensive knowledge and positive attitudes serves to be cornerstones for prevention, and change remains an important means of cutting the chain of transmission of infection in high HIV occurrence regions and/or populations.
In this scenario, comprehensive knowledge becomes a key component for reducing high-risk behaviour by allowing individuals to review their living practices. However, researchers have reported that knowledge alone remains insufficient to promote safe sexual behaviour. [11,13-14] The construction of knowledge on HIV/AIDS is not limited to information, but also involves individual perception of the problem, cultural values, and behavioural models dictated by society. The power of knowledge in behaviour changes thus depends on issues that transcend technical information. The transformation of knowledge into safe practices is therefore mediated by gender, schooling, social class, cultural issues, socio-demographic factors and rural residence in population.[11-12,15] From this perspective, Ayres et al. [15] observed that behaviour change depends not only on individual will, but also on social factors that affect understanding of the questions and thus changes in attitude. Studies have revealed gaps between comprehensive knowledge and misconceptions about HIV/AIDS transmissions. [16-19] These knowledge gaps and misconceptions need to be rectified for groups at risk, specifically for the younger generations who are the building blocks of the future.
India‘s National AIDS Control Programme (NACP), implemented by the National AIDS Control Organization (NACO) under the Ministry of Health and Family Welfare, is one of the most successful public health programmes in India today. Started in 1992, with the objective of understanding the HIV disease burden and epidemiological trends, the programme has now evolved into a major public health prevention and treatment programme. [20] Prevalence of HIV infection in India was first detected in 1986 among female sex workers in Chennai. [21]. India has the third largest number of people living with HIV/AIDS in the world. [22] It is estimated that 2.39 million people were infected with HIV, of whom 39% were female and 4.4% were children. [22] As per the recently released, India HIV Estimation 2019 report, overall the estimated adult (aged 15–49 years) HIV prevalence trend has been declining in India since the epidemic’s peak in the year 2000 and has been stabilizing in recent years. At the sub-national level, three states with the highest adult HIV prevalence were from the north-eastern part of the country, namely Mizoram, Nagaland, and Manipur. Other states/UTs estimated to have adult HIV prevalence higher than the national average were Andhra Pradesh, Meghalaya, Telangana, Karnataka, Delhi, Maharashtra, Puducherry, Goa, Punjab, Dadra and Nagar Haveli, and Tamil Nadu.
Little number of studies was reported on attitudes and awareness related to HIV/AIDS in India populations. Such studies have primarily focused on hospital and paramedical staffs [23-26], school and college students [27-31], sex workers [32-34] and dental doctors and students. [35-36]
Contemporary India is composed of a sizeable number of ethnic and indigenous elements having enormous amounts of ethnic and genetic diversity. [37] The country has the largest number of indigenous people in the world and that includes diverse collections of tribal, non-tribal and caste populations. Each population, undoubtedly, has its own customs, values, institutions and ideals. These sets of customs, values, institutions and ideals have the potential to exert significant effects in the knowledge and attitudes of a particular population group to HIV and AIDS. India as a country is also characterized by poverty, illiteracy and lack of proper medical and health care especially in rural areas. The HIV/AIDS situation is diverse across the country as different cultural norms are practiced in different regions. [38-40] The situation is complicated by several socio-cultural factors, including social pressure on women to become pregnant soon after marriage, the belief that married women cannot contract HIV/AIDS, and the cultural association of HIV with immoral sexual behaviour. Such norms make women extremely vulnerable, especially when husbands are reported HIV-positive. These factors also impede timely help-seeking among those at risk or already infected. [41] To increase the efficiency of HIV intervention programmes, it is pertinent to understand how much the population knows about HIV and how much HIV preventive actions such as condom use, are being practiced. Sexual behaviour has not been widely investigated in India. Understanding how people behave when faced with sexual choices is the key in enlightening policy makers on how to design successful preventive policies. [42]. Although, there have been some serious efforts to impart the knowledge about HIV/AIDS among the various populations of the country, and adequate studies are needed to ascertain how far these populations have benefitted from the efforts. One of the key areas of concern is that involving married women from rural areas of the country. Rural married women appear to be at a greater risk than those from the urban areas. For example, men move to urban areas for work leaving their spouses behind to look after their farms, the children and elderly; remain away from their families for a long time and might indulge in high-risk behaviour. The infected men carry the infection back to their spouses in the rural areas. [43] Lack of education, inadequate access to health resources and lack of comprehensive knowledge and awareness are some of the other factors involved. [44] There appears to be a scarcity of studies that had tried to compare the knowledge and attitudes to HIV and AIDS between married urban and rural women in the country.
Popularly known as North Bengal, the northern part of the state of West Bengal, India, comprises of eight districts and is the home to a number of tribal (e.g., Lepcha, Rabha, Meche, Toto, Oraon, Santal and Munda) and non-tribal populations (e.g., Rajbanshi, Bengali Caste and Bengali Muslim). Given the region’s general backwardness in healthcare, educational and medical facilities, the above-mentioned populations remain very vulnerable to poor health, diseases and infections. A detailed literature search yielded a paucity of studies on the knowledge and attitudes to HIV/AIDS among individuals belonging to these populations. Given the above, the present comparative study has been designed to report the attitudes and knowledge to HIV/AIDS among married women individuals belonging to an ethnic population of North Bengal and residing in an urban and a rural area.
The assumptions of the present study are two-fold. These are described below:
a) Considering individuals belonging to a single ethnic population has the potential to nullify the effects of customs, values, institutions and ideals that may arise if individuals belonging to two or more populations.
b) The awareness and attitudes towards HIV/AIDS are expected to be lower among the rural women as compared to the urban women due to different socio-economic and living conditions.
Material and Methods
The Study Area
Popularly known North Bengal, the northern part of the state of West Bengal comprises of the eight districts of Darjeeling, Kalimpong, Jalpaiguri, Coach Behar, Alipurduar, Uttar Dinajpur, South Dinajpur and Malda. The data for the present study has been collected from a rural area and an urban area of this region. The rural area comprised of six villages located in Rajganj Block of the district of Jalpaiguri, West Bengal, and situated approximately 25 kms from the sub-divisional town of Siliguri. The data from the urban region was collected from different localities within the sub-divisional town of Siliguri, located in the district of Darjeeling, West Bengal. The sole criterion of selecting the rural and the urban areas was the predominance of Rajbanshi families in the areas.
Nature of the population and the participants
The participants of the present study married rural and urban women (aged 20-45 years) belonging to the Rajbanshi ethnic population. The Rajbanshis are chiefly distributed in the neighbouring state of Assam and few districts of North Bengal. [45-46] It is generally agreed that ethnically the Rajbanshi show resemblances with the Koch population of Assam and it is being conjectured that they belong to a mixed ethnic ethnicity of Austroasian/Dravidian and Mongolian. [45] It has also been opined that the Rajbanshis belonged to a Dravidian stock that came in contact with the heterogeneous Mongoloid populations. [47] A study on genetic markers among the populations of North-eastern India reported that the Rajbanshi was a semi-Hinduized caste group located in-between the clusters of Caucasoid caste and Mongoloid tribal populations. [46]
The women were selected based on a multi-stage random sampling method. At the initial stage, households from both rural and the urban areas were sampled to identify the Rajbanshi families. In the second stage, married women in the selected age group were identified. Once the families and the women were identified, the prospective research participants were approached to voluntarily participate in the present study. The nature and the purpose and objectives of the study were explained to them in detail before their inclusion and data collection. Extra care was taken to explain the study protocol to them, given the sensitive nature of the topic. Rapport establishment was done with the research participants in order to brief the questions for collect the data on sensitive question and sexual behaviour. In the rural areas, a total of 556 married women were approached while in the urban areas, the corresponding number was 683. After being detailed about the study, 57 rural women (10.25%) and 38 urban women (5.57%) refused to participate in the same. The overall participation rate was 92.33% (rural: 89.75%, and urban: 94.43%). Hence, the final sample size consisted of a total of 1144 Rajbanshi ever married women (rural: 499; urban: 645) in the age group between 20 to 45 years. An informed consent was subsequently taken from the women who had agreed to participate. The study permission was obtained from the Department of Anthropology, North Bengal University before the commencement of the study. The study was undertaken according to the ethical guidelines of human experimental research as laid in the Helsinki declaration.
Data Collection
The data was collected using pre-structured questionnaires and open-ended interviews. The questionnaire consisted of different socio-economic variables such as age, education level, occupation, religion, and electronic media, and duration of awareness regarding HIV/AIDS. The filling up of the questionnaires and the interviews were conducted in their respective households. Privacy and identity of the research participants were strictly maintained during the interviews due to sensitive nature of the present study. The questionnaires and the interviews were completed anonymously with the assurance that the confidentiality would be maintained.
The respondents were asked about the knowledge regarding the transmission of HIV/AIDS. Subsequently information was recorded about the relevant misconceptions relating to the mode of spreading of HIV/AIDS. They were also asked to suggest some strategies about their prevention. The knowledge level was determined using a modified version of the scale relating to the knowledge using a summary of scores developed from six questions relating to the mode of transmission of HIV/AIDS. A modified version of the scale of Farid-ul-Hasnain et al. [48] was used in the present study. One point was assigned for each correct answer and 0 for giving an incorrect answer. Hence, the score of each respondent ranged from 0 to 6. Based on the above scores, individuals were classified into three categories. These categories are as follows:
- Poor knowledge (score ≤ 2)
- Some knowledge (score = 3)
- Good knowledge (score ≥4).
The categories were then coded to create dichotomous variables from the above composite variables. The categories of ‘some knowledge’ and ‘good knowledge’ were grouped together. The ‘poor knowledge’ category was left unchanged.
Independent variables
The different variables have been categorized separately for the rural and urban women. The variables included age, education, occupation, family income and duration of awareness. The age was divided into three subgroups (e.g., 20-29 years, 30-39 years and ≥40 years) in both the rural and urban women. Among the rural women, the education level was categorized as ‘Literate up primary level’ and ‘Secondary and above’. In the urban areas literacy was categorized into ‘Up to higher secondary level’ and ‘Graduation and above’. The working status of the rural women was divided into ‘Labour/Tea labour’, ‘House wife’ and ‘Others’, while in the urban areas, the women were categorized into ‘Housewife’ and ‘Others’. In the rural area, family income was categorized in the three categories of ‘Less than Rs. 3000’, ‘Rs. 3000– Rs.4500’ and ‘Rs. 4500 and above’. Among the urban women, the categories were ‘Less than Rs. 20,000’ and ‘Rs. 20,000 and above’. The duration of awareness to HIV/AIDS was also classified dichotomously in both rural and urban women.
Statistical Analysis
Statistical analyses were done using Statistical Package for social sciences (version 16.0) and R (Version 4.0.0). A p-value of less than 0.05 was considered to be statistically significant. Data were presented using the frequency distribution and percentages. Chi-square analysis was done to find out the differences between categorical variables. The analysis has been done separately for urban and rural populations. A number of questions were asked to a number of women and a binary score is given corresponding to each of them and finally an aggregate score is obtained by adding the individual scores. Here, in the beginning, we tried to obtain how far the questions are coherent, since we are working with a multivariate set up, our intention will always be to reduce the dimension and to use the dataset effectively. To find out the coherence, we have used the internal coherence Index “Cronbach Alpha”. It is based on the variability within the scores for each of the questions. Considering the questions and answers targeted to the urban women, the Cronbach Alpha came out as 0.61, while for the rural women the value is 0.702, indicating very high coherence within the questions for both. Instead of considering all the scores separately, our next step is to find out the principal components considering the questions asked. In this particular problem, the principal component analysis has been used to reduce the dimension of the data used. The 44 variables that are used here are making the analysis cumbersome and also this may lead to a large possible error while modelling. There might be some of the variables which do not have any impact while explaining the underlying variability. Other dimension reduction techniques for example factor analysis could also have been the use of principal components has been preferred here as it usually reduces the overall variability very efficiently with minimum number of principal components. The 44 principal components were computed and the variability explained observed. It is interesting to find out that for the urban women, the first 3 principal components were able to explain 99% of the total variability and for the rural ones, the same amount of variability was explained with the first 12 principal components. By adding these prominent principal components, we are now able to get the continuous scores after scaling it properly. These scaled continuous scores can now be used for capturing the cause effect relationship between knowledge score and individual details like age, education, family income and awareness duration. Further, linear regression analysis was also done to find out the associations between the quantitative variables among rural and urban women. Here the scaled scores (obtained from the principal components) were regressed on the social and demographic variables to measure the impact of those variables on the awareness scores. The regression models had been built separately for the rural, urban and the pooled rural and urban population, so as to evaluate the overall and ethnicity specific impacts separately. For all the 2 regression models that were used here, it has been observed that the R-squared values were substantially high, which meant that the underlying variability of the dataset was efficiently captured. This clearly indicated that the rationale in favour of using principal components over other dimension reduction techniques.
Results
Demographic and Other Relevant Variables
The mean and standard deviation of the age of the rural and the urban women were 31.15 ±5.24 years and 27.54 ±4.86 years respectively. The age group wise breakup of the rural women showed that 217 (43.49%) women belonged to the age group of 20-29 years, 241 (48.30%) women belonged to the age group 30-39 years and 41 (8.22%) women belonged to the group of more than 40 years. Among the urban women, 252 (39.07%) women were in the age group of 20-29 years, 275 (42.64%) women in the age group of 30-39 years and 118 (18.29%) women in the more than 40 years category. In the rural area, only 2 (0.40%) women were illiterate, 393 (79.96%) women studied up to the primary level and 104 (20.84%) of them studied up to the secondary level. No woman from the rural area studied any further especially after marriage. In case of urban women, 159 (24.65%) completed their higher secondary education, while 486 (75.35%) of them studied up to the graduation level or more. Among the rural women, a majority of them were permanent residents, with only 80 of them (16.03%) being recent immigrants. All the women from the urban areas were permanent residents. In the rural area, the majority of the women were housewives (65.50%) and 27.50% were engaged as labour/tea-garden worker. In the urban areas the majority of women were housewives (82.80%). When the monthly family income was evaluated, 44.90% and 57.70% of the rural and urban women belonged to the Rs.<3000 and Rs.<20000 income groups respectively. Regarding the possession of electronic media, 238 (47.70%) of the rural households owned a television while all urban households possessed television in their respective households. In the urban area 168 (26.05%) of the households had computer with internet connection but in the rural area not a single household had any computer or internet facilities.
Knowledge and misconception of HIV/AIDS
A very low proportion of the rural women (32.06%) were aware about the term or disease ‘HIV/ AIDS’ transmission risks whereas 98.76% of the urban women were aware of the same. However, the overall analysis of the data was presented based on the total research subjects participated in the present study, but not excluding to those who have not aware about the disease terminology or transmission. The detailed analysis is appended below:
Rural Women (N=499)
The results of the present study showed that the knowledge relating to the transfusion of HIV/AIDS was very poor among the rural women (Table 1). Only 11.42% and 7.21% of the women knew that HIV/AIDS transmitted through unprotected sexual contact and blood transfusion. Very few rural women were aware that reusable syringes (6.00%) and sharp blades (13.23%) could spread HIV/AIDS respectively. Only 20.04% rural women were reported that HIV/AIDS could be transmitted during pregnancy and 15.03% of the rural women answering HIV/AIDS could be transmitted from an infected mother to her new born child during breast feeding. The prevalence of misconceptions was also observed to be very high among the rural women. A high percentage of the rural women reported that HIV/AIDS could be spread by ‘eating with a HIV/AIDS positive person’ and by ‘coughing/sneezing from a HIV/AIDS affected person’ (88.80% and 93.40% respectively). A very high proportion of the rural respondents thought that HIV/AIDS could be spread by mosquito bites (94.00%) and shaking hands (81.40%). According to the classification of the knowledge scale, a very high frequency (89.38%) of the rural women exhibited ‘poor knowledge’ relating to the mode of transmission.
Urban Women (N=645)
The results of the present study showed that that the prevalence of ‘poor knowledge’ according to the classification of knowledge scale was appreciably lower (19.53%) among the urban women in Table 1. It was also observed that these women were aware about the route of transmission of HIV/AIDS. A high percentage of them knew about the route of unprotected sexual contact (77.50%), 71.00% about positive blood transfusion, 90.20% about using reusable syringes and 76.40% about using sharp blades. Moreover, 67.60% and 58.80% of them knew that HIV/AIDS could be transmitted during pregnancy and from an infected mother to her new born respectively. Interestingly, the incidence of misconception was also found to be relatively high, as 35.20% and 35.80% of the urban women have reported that HIV/AIDS could be spread through eating with HIV/AIDS patients and mosquito bites respectively. Another misconception was regarding shaking hands and coughing/ sneezing. 7.60% believed that HIV/AIDS can be transmitted by coughing/sneezing and 25.3% by shaking hands. The difference in relating to the knowledge and routes of transmission and misconception was assessed using chi-square analysis (Table 1). The differences were found to be statistically significant using in all categories between the rural and urban women (p<0.05).
| Table 1: Views regarding mode of transmission and misconceptions towards HIV/AIDS among the Rajbanshi women |
Factors |
Rural (N=499) |
Urban (N=645) |
Total(N=1144) |
Chi-square |
P |
Unprotected sexual contact |
57 (11.42) |
500 (77.5) |
557 (48.69) |
189.77 |
0.00 |
Positive blood transfusion |
36 (7.21) |
458 (71.0) |
494 43.18) |
207.06 |
0.00 |
Reuse syringe |
30 (6.0) |
582 (90.2) |
612 (53.50) |
283.93 |
0.00 |
Use of sharps/blade/razor |
66 (13.23) |
493 (76.4) |
559 (48.86) |
171.41 |
0.00 |
Through HIV/AIDS infected mother to babies during pregnancy or child birth |
100 (20.04) |
436 (67.6) |
536 (46.85) |
99.13 |
0.00 |
Transmission from mother to newborn through breast feeding |
75 (15.03) |
379 (58.8) |
454 (39.69) |
103.69 |
0.00 |
Eating with HIV/AIDS positive |
443 (88.8) |
227 (35.2) |
670 (58.57) |
85.70 |
0.00 |
Coughing/sneezing from the HIV/AIDS positive person |
466 (93.4) |
49 (7.6) |
515 (45.02) |
320.57 |
0.00 |
Shaking hands/talking/ with HIV/AIDS positive person |
406 (81.4) |
163 (25.3) |
569 (49.74) |
117.29 |
0.00 |
Mosquitoes bites from the HIV/AIDS positive person |
469 (94.0) |
231 (35.8) |
700 (61.19) |
95.20 |
0.00 |
Can pregnant women be infected with HIV/AIDS? |
113 (22.65) |
474 (73.5) |
587 (51.31) |
100.79 |
0.00 |
| Values in parentheses indicates percentage |
Awareness and attitude towards HIV/AIDS
The results showed that that awareness and attitude levels regarding HIV/AIDS transmission among rural women were lower than the urban women (Table 2).
Rural Women
It is evident from the Table 2 that rural women were avoiding from sexual intercourse with HIV positive men and were also refraining from reuse of syringes. However, only 11.62% of the rural women reported use of condoms during sexual intercourse to avoid HIV infections. The results showed that 5.40% women reported to work the HIV/AIDS affected persons and 23.04% women are willing to live with HIV/AIDS person within the community. The results also tend to showed that 39.90% and 92.60% of the rural women reported that they will faithful to one marital partner and avoid the used items (e.g., utensil, cloths) of the HIV/AIDS person, respectively. Only 7.61% of the rural women reported that HIV/AIDS should allow working in the community.
Urban Women
The results of the present study showed that awareness and attitude reported by the urban women were very high. A high percentage of them, 88.81% and 90.23%, reported that they would avoid sexual relation with HIV/AIDS persons and reuse of syringe respectively. The uses of condom to protective measures against HIV infection have been reported by 54.00% urban women. The results also shows that 67.10% and 48.40% urban women were willing to work with the HIV/AIDS infected persons and willing to live with HIV/AIDS infected individuals. Results also showed that 86.40% urban women suggested that remain faithful to only marital partner to prevent HIV/AIDS prevention. The suggestion towards the HIV infected individuals should be allowed to work was reported by 55.50% of the urban women, whereas 68.50% of the women reported they would avoid the used items (e.g., utensil, cloths) of the HIV/AIDS individuals. The differences in the reported frequencies of the suggestion made towards the awareness and attitude among the rural and urban women were evaluated using chi-square analysis (Table 2). The differences were observed to be statistically significant in case of all the questions (p<0.05).
| Table 2: Suggestions given towards awareness and attitude of HIV/AIDS among the Rajbanshi women |
| Factors |
Rural (N=499) |
Urban (N=645) |
Total (N=1144) |
Chi-square |
P |
Avoiding sex with HIV/AIDS positive person |
215 (43.09) |
573 (88.81) |
788 (68.88) |
53.45 |
0.00 |
Using new syringe or avoid reuse of syringe |
469 (93.98) |
582 (90.23) |
1051 (91.87) |
0.225 |
0.63 |
Infecting with HIV/AIDS by working near someone with |
27 (5.40) |
433 (67.10) |
460 (40.20) |
212.13 |
0.00 |
Use of condom during sexual intercourse to protect against HIV infection |
58 (11.62) |
348 (54.00) |
406 (35.49) |
111.99 |
0.00 |
Willing to live with HIV/AIDS having subjects in the same ethnic group or community or area |
115 (23.04) |
312 (48.40) |
427 (37.32) |
36.37 |
0.00 |
Should HIV infected person allow to work |
38 (7.61) |
358 (55.50) |
396 (34.62) |
149.94 |
0.00 |
Faithful to only marital partner |
199 (39.90) |
557 (86.40) |
756 (66.08) |
58.59 |
0.00 |
Avoiding used items of HIV/AIDS person (e.g., utensils, clothes etc) |
462 (92.6) |
442 (68.50) |
904 (79.02) |
11.37 |
0.00 |
Avoiding extramarital sexual relationship |
18 (3.60) |
498 (77.20) |
516 (45.10) |
267.05 |
0.00 |
| Values in parentheses indicates percentage |
Principal component and regression analysis
The 44 principal components were computed and the (% of) variability explained was observed. Tables 3 and 4 respectively shows the Eigen values and the percentage of variability explained for the rural and urban population respectively. Figures 1 and 2 showed the scree plots explaining the variability and the reason behind choosing the number of principal components for rural and urban population, respectively. As noted earlier, the 44 principal components were computed and the variability observed. For the urban women, the first 3 principal components were able to explain 99% of the total variability and for the rural ones, the same amount of variability was explained with the first 12 principal components. The results of the multiple regression analysis are detailed in Table 5 (for rural women) and Table 6 (for urban women). For the urban women both age (p<0.01) and family income (p<0.05) have strong impacts on awareness of AIDS. But for the rural women, family income (p>0.05) was not a significant factor. Instead, education level played a huge role on the awareness of AIDS. This phenomenon was observed primarily because education levels among rural women were low but among urban women, on an average most of them has attained a certain level of education and hence education is hardly a factor in calculating the knowledge scores. Interestingly, both for rural as well as urban women, in the regression equation the negative coefficient for age suggested that with age the score corresponding to the awareness of AIDS decreased. In particular, with one unit increase in age the knowledge score for AIDS decreased 0.0411 units for the rural women, while for the urban women, the decrement is 0.0303. From the result, it is clear that those who were well off financially were expected to perform better in terms of knowledge of AIDS. If the same questions were asked to the rural women, things got changed. Here only those covariates were used which were not constant within the urban and rural women separately. Education level affected the knowledge score positively. An illiterate woman would surely have lesser knowledge score compared to the literate ones. Interestingly, for the rural ones, a permanent resident was 0.22 times less knowledgeable compared to a migrant. Both the regression models could explain more than 50% of the underlying total variability, indicating towards a moderately good fit.
| Table 3: Showing the selected results from the principal component analysis for the rural Rajbanshi women |
Principal Components |
Eigen Values |
% of variables explained out of total |
1 |
9.6112 |
81.35% |
2 |
0.8191 |
6.93% |
3 |
0.3081 |
2.61% |
4 |
0.2701 |
2.29% |
5 |
0.1868 |
1.58% |
6 |
0.1450 |
1.23% |
7 |
0.1036 |
0.88% |
8 |
0.0840 |
0.71% |
9 |
0.0584 |
0.49% |
10 |
0.0499 |
0.42% |
11 |
0.0345 |
0.29% |
12 |
0.0295 |
0.25% |
Total |
|
99.03% |
Since the first 12 principal components can explain more than 99% of the total variability, we chose to retain these.
| Table 4: Showing the selected results from the principal component analysis for the urban Rajbanshi women. |
Principal Components |
Eigen Values |
% of variables explained out of total |
1 |
0.2489 |
84.51% |
2 |
0.0380 |
12.91% |
3 |
0.0051 |
17.35% |
Total |
|
99.16% |
Since the first 3 principal components can explain more than 99% of the total variability, we chose to retain these.
| Table 5: Regression analysis for rural Rajbanshi women of North Bengal |
| Variables |
Estimate |
P – value |
Intercept |
2.750 |
0.8118 |
Age |
-0.0411 |
3.03e-09 |
Education (Class IX) |
7.020 |
< 2*10-16 |
Education (Class VII) |
7.511 |
< 2*10-16 |
Education (Class VIII) |
7.154 |
< 2*10-16 |
Education (Class X) |
7.192 |
< 2*10-16 |
Education (Graduate) |
6.973 |
< 2*10-16 |
Education (Higher Secondary) |
7.460 |
< 2*10-16 |
Education (Illiterate) |
-0.3019 |
0.6659 |
Education (Madhomik) |
6.687 |
< 2*10-16 |
Education (Primary) |
7.452 |
< 2*10-16 |
Education (Secondary) |
7.927 |
< 2*10-16 |
Residence (Permanent) |
-0.2203 |
0.0253 |
Occupation (Health Worker) |
1.481 |
0.1806 |
Occupation (House Wife) |
1.540 |
0.1206 |
Occupation (Labour) |
1.573 |
0.1163 |
Occupation (NCDS) |
1.215 |
0.2262 |
Occupation (Nurse) |
1.224 |
0.3118 |
Occupation (Primary School Teacher) |
1.240 |
0.2636 |
Occupation (School Teacher) |
1.137 |
0.3051 |
Occupation (Student) |
6.603 |
0.5853 |
Occupation (Tea Garden Labour) |
1.799 |
0.0700 |
Family Income |
-0.00001 |
0.3346 |
| Adjusted R-squared= 0.5185 |
| Table 6: Regression analysis for urban Rajbanshi women of North Bengal |
| Variables |
Estimate |
P - value |
Intercept |
5.329 |
4.07*10-05 |
Age |
-0.0304 |
0.0005 |
Education (Graduate) |
0.7122 |
0.1687 |
Education (Higher Secondary) |
0.7348 |
0.1619 |
Education (M.A) |
1.229 |
0.0394 |
Education (M.Sc) |
0.7283 |
0.1997 |
Education (M.Tech) |
0.7797 |
0.1827 |
Residence (Permanent) |
0.0707 |
0.2202 |
Occupation (College Lecturer) |
-0.0913 |
0.9469 |
Occupation (Corporation Employee) |
0.0305 |
0.9823 |
Occupation (Doctor) |
0.0862 |
0.9499 |
Occupation (Engineer) |
0.0147 |
0.9147 |
Occupation (Govt. Service) |
0.0182 |
0.8546 |
Occupation (Health Department Worker) |
0.0117 |
0.9323 |
Occupation (High School Teacher) |
1.1310 |
0.2699 |
Occupation (House Wife) |
-0.2385 |
0.8064 |
Occupation (ICDS) |
0.1624 |
0.8915 |
Occupation (Music Teacher) |
0.0305 |
0.9823 |
Occupation (Nurse) |
0.4212 |
0.7597 |
Occupation (Police) |
0.0914 |
0.9388 |
Occupation (Politician) |
0.0208 |
0.8797 |
Occupation (Primary School Teacher) |
0.0823 |
0.9343 |
Occupation (Social Service) |
0.1523 |
0.9118 |
Occupation (Student) |
0.6334 |
0.5316 |
Family Income |
2.334*10-05 |
0.0056 |
| Adjusted R-squared= 0.5685 |
Discussion
HIV infection in humans is considered pandemic by the World Health Organization (WHO) and complacency regarding HIV plays a key role in HIV risk. There is considerable diversity in the spread of HIV within the country, with the highest prevalence seen in the mid-western state of Maharashtra, the southern states of Tamil Nadu, Karnataka and Andhra Pradesh, and North-East India. To prevent future spread of the HIV epidemic it is important to evaluate the comprehensive knowledge, attitudes towards HIV/AIDS, and also to educate and aware the people with correct information and sexual behaviours. [12,49] The overall findings from the present study has reflected that gaps in comprehensive knowledge and awareness existed among the rural and urban married women (aged 20-45 years) of Rajbanshi population, regarding the modes of spread and ways of preventing the further transmission of the HIV/AIDS. The results of the present study also showed that individuals belonging to the lower socio-economic groups were the most affected and had poor knowledge and awareness of disease transmission and prevention. However, the urban women had a better knowledge and attitudes to HIV and AIDS. It was reassuring to observe that only 1.24% urban women and 12.82% rural women were unaware or did not know there is a disease called HIV/AIDS. The present study reported that 11.42% (in rural) and 77.5% (in urban) women believed that HIV/AIDS could be transmitted through unprotected sexual relationship. The present study reported 11.62% (in rural) and 54.0% (in urban) women were aware about use of condom during sexual intercourse as a protection against HIV infection or any disease transmission. It is also found that 39.90% (in rural) and 86.40% (in urban) women were suggested that remained faithful to only their marital partner to prevent HIV/AIDS disease transmission (Table 2). This indicates significant knowledge gap and awareness pertaining to the HIV/AIDS transmission exists especially among the rural that urban women. Merakou et al. [50] reported that 64.8% of the girls did not have sexual relations, while 41.9% of the boys had sexual relations with casual partners. In the present study 5.40% and 23.04% rural women were reported to work with the HIV/AIDS infected person, and willing to live with them within the same community respectively. However, 67.10% and 48.40% urban women reported that they were willing to work near with the HIV/AIDS infected persons and willing to live with HIV/AIDS infected individuals. Aggarwal & Panat [35] observed that 77.7% of the dental students showed positive attitudes towards HIV/AIDS. In their study, Mukherjee and Sikdar [51] reported the mean scores obtained by the sample of illiterate, primary, secondary and higher educated people about awareness test towards AIDS were 80.92%, 84.06%, 72.40% and 71.68 respectively and attitude towards AIDS were 66.48%, 66.72%, 70.40% and 70.86 respectively. Sudha et al. [52] reported that knowledge of 80.63% respondents about HIV was fairly good, most people did not know anything more than the words HIV or AIDS among population in Hyderabad, India. Approximately 50.0% of them did not know the term of HIV/AIDS. Kalasagar et al. [53] in a study conducted among metropolitan dwellers observed that only 30% of males and 22% of females knew about the possible symptoms of AIDS and 45% of males and 62% of females considered whooping as mode of transmission, reflecting a lack of complete understanding of the modes of the spread of disease.
However, rural women had difficulties to distinguish between HIV and AIDS. The misconceptions was found to be higher among the rural women, where 88.80% and 93.40% of the women knew that HIV/AIDS could be spread by ‘eating with HIV/AIDS positive person’, by ‘coughing/sneezing from the HIV/AIDS individuals’ respectively. The results of the present study showed that a very high proportion of rural women reported misconceptions towards HIV/AIDS (94.00%: mosquito bite; 81.40%: shaking hands). Further, it is to be mentioned here that despite of the knowledge of transmission, a significant proportion of the rural and urban women have reported misconception indicates incomplete or insufficient knowledge and awareness related to HIV/AIDS transmission. A study conducted by Tavoosi et al. [54] among Iranian students observed that 33% of them believed HIV/AIDS transmitted through mosquito bites. According to the classification of the knowledge scale a very high frequency of rural women showed ‘poor knowledge’ of relating the mode of transmission (89.38%). In case of urban women the incidence of misconception was also observed to be very high, where 35.20%, 35.80%, 7.60% and 25.30% of the urban women reported that HIV/AIDS could be spread through eating with HIV/AIDS patients, mosquito bites, coughing/sneezing and shaking hands respectively. A study among adolescents in Isfahan city, reported that 84.0% of the adolescents were aware of the existence of HIV/AIDS, commonest source of information being electronic media though their knowledge of routes of transmission and modes of prevention of the disease was erroneous and inadequate due to several misconceptions. [55] A study conducted among 600 Nigerian university students reported that 25% (143) of them showed inadequate knowledge of the mode of transmission of the disease. [56] In their study among secondary school adolescents in Ado Ekiti, South Western Nigeria, Amu and Adegun [57] reported that 22% of the respondents knew that HIV/AIDS could be transmitted through coughing/sneezing, and 12.2% reported as sharing clothes or utensils could be a transmitting route of the disease. Qian et al. [58] in rural China misconceptions about HIV transmission were widespread. High proportions of participants believed that HIV infection can be acquired by swimming (41.8%), sharing meals (26.5%), shaking hands (24.6%) and speaking face to face (24%) with an infected person; 70.4% thought that mosquito bites could transmit HIV disease.
It was noticed that the awareness and attitudes reported by urban women were very high among them. A high percentage of them reported that they would avoid sexual relations with the HIV/AIDS persons and reuse of syringe respectively. The use of condom as a protective measure against HIV or any sexually transmitted infectious diseases have been reported more than half of Rajbanshi women. A sizeable number of them agreed to work with the HIV/AIDS infected person and was willing to live with a HIV/AIDS infected person. A high percentage of urban women were reported to be faithful to only marital partner to prevent HIV/AIDS prevention or related diseases. High proportion of respondents reported that a person can get HIV from sexual intercourse (94.8%) and that risk can be reduced by being faithful (93.1%), abstaining from sex (91.0%) and using condoms (83.6%) on a study from China. [58] The present study reported a low 11.62% of rural women and a high 54% of urban women were aware about use of condom during sexual intercourse as a means of protection against HIV infection. The present study revealed that 92.8% of urban women were aware or heard about HIV/AIDS whereas it was 96% in a study conducted in Punjab. [59] The present study reported that 20.04% of rural women and 67.6% of urban women were aware of mother to child transmission during pregnancy. Ghasem et al. [55] observed that 78.8% reported HIV/AIDS can be transmitted through breast feeding, and 72.8% believed that the disease can also be transferred from mother to child during pregnancy. The present study also showed that 85% of participants had previously received HIV and AIDS information, from radio and television. Lanouette et al. [60] in a study done in Madagascar, reported that 88% of participants got such information by audio means such as radio. In another Iranian study, most information was gathered from audio-visual means such as television. [54] Al-Serouri et al. [61] in a study in Yemen also reported that television was the most common source of information. In fact, is has been very aptly summed up by Agrawal et al. [6] when they observed that the media was very important for disseminating knowledge on HIV/AIDS in India. The incidences of misconceptions were also observed to be very high among the rural women. A high percentage of the rural women reported that HIV/AIDS could be spread by eating with a HIV/AIDS positive person and by coughing/sneezing from a HIV/AIDS affected person (88.80% and 93.40% respectively). A very high proportion of the rural respondents thought that HIV/AIDS could be spread by mosquito bites (94.00%) and shaking hands (81.40%). In their study Jahanfar et al. [62] observed that that 57.4% of the subjects had a high level of knowledge, while only 17.2% had a low level. The main risk factors were education, socio-economic group, family size and income. In case of the rural individuals, the impact was even more. Kaur et al. [63] observed that majority of individuals both in rural (88%) as well as in urban (85.6%) area knew that AIDS is a preventable disease. The same study observed a lack of knowledge about sign and symptoms of AIDS, as observed in the present study. Sudha et al. (2005) reported that only 43.25% were aware of the fact that HIV can be transmitted through breast-feeding, 64% were unsure/unaware of the transmission through mosquito bites.
In this paper, the data that we have used is high dimensional in nature. To reduce the dimensions, we took the help from Principal Component Analysis (PCA) to identify the principal components which can further be used for evaluating the impacts of the covariates on the scores. The resulting 3 and 12 principal components (respectively for the urban and rural data) are able to explain almost 99% of the total underlying variations of the dataset, which clearly indicates that the principal components can very well be the replacements of the existing dimensions. We chose the number of principal components in such a way, so that it can explain the underlying variation almost entirely. This in turn helped us to get moderately high values of the residual sum of squares while performing regression analysis with these principal components.
The data in this paper is high dimensional in nature. To reduce the dimensions, they took the help from Principal Component Analysis (PCA) to identify the principal components which can further be used for evaluating the impacts of the covariates on the scores. The resulting 3 and 12 principal components (respectively for the urban and rural data) were able to explain almost 99% of the total underlying variations of the dataset, which clearly indicated that the principal components could very well be the replacements of the existing dimensions. The authors chose the number of principal components in such a way, so that it could explain the underlying variation almost entirely. This in turn helped them to get moderately high values of the residual sum of squares while performing regression analysis with these principal components.
A literature search has revealed that there have been some studies where statistical tools such as multiple logistic regression or factor analysis or principal component analysis have been used to understand the awareness of the people to HIV and AIDS. Pallikadavath et al. [64] analysed the sources of AIDS awareness among rural and urban Indian women were analysed using data from the National Family and Health Survey (1998-2000). They concluded that television was the most effective medium, and also had the highest independent effect. Radio and print had very low effectiveness and independent effect. Recently, a study conducted among youths from Gujrat, India has used multiple logistic regression to show that age, education, occupation, and mass media exposure were found to be the major determinants of their knowledge with regard to HIV/AIDS. [65] Chi-square and Fischer's exact test were used in their study by Mehra et al. [66] which depicted that mass media (television, posters, and newspapers) followed by friends or peer group were the main sources of information for the respondents and that education was found to have a direct relation to the awareness levels of the respondents. Haque et al. [67] used data from 2014 Bangladesh Demographic and Health Survey (BDHS) to assess awareness and attitudes to HIV and AIDS and concluded that respondents' education status, mass-media access, place of living, and working status played significant role on the awareness. As expected, respondents with higher education were more aware than those with no education [odds ratio (OR) = 3.56, 95% confidence interval (CI): 2.99-4.23]. Moreover, respondents who had access to the mass media were more likely to be aware compared to those who did not have the access. Using variance partition coefficient, median odds ratio and principal component analysis, higher levels of knowledge about the role of condoms in HIV prevention and condom use were associated with low HIV prevalence at the district level in an all Indian study by Joshi and Mehendale. [68] Iqbal et al. [3] carried out a secondary data analysis was carried out using the national representative dataset of the 2012-13 Pakistan Demographic and Health Survey. Using multilogistic regression analysis, they concluded that women residing in urban areas, having at least secondary-level education, with high autonomy, belonging to the richest wealth quintile and having exposure to mass media had high overall knowledge and positive attitudes towards people living with AIDS. Studies from the state of West Bengal, India include those of Bandyopadhyay et al. [69] and Balk and Lahiri. [70] Multivariate analysis observed that rural, poorly educated, and poor women to be the least likely to be AIDS-aware, and if aware, to have the poorest understanding of what AIDS is. A strong positive association was nonetheless found between AIDS awareness and knowledge and condom use. [70] Using logistic regression, Bandyopadhyay et al. [69] observed that education, media exposure, marriage, and possessing above poverty level (APL) status, all had stronger positive association with youths (more in men) having comprehensive knowledge of AIDS. Our results are in conformity with those cited above.
These comparisons suggest that women in rural areas lack comprehensive knowledge of HIV/AIDS transmission not because of (or only because of) where they live, but because of their characteristics, namely their low levels of education attainment, socio-economic status and income. This does not change the imperative of targeting rural populations for information campaigns. However, such programs need to be tailored to account for the lack of education and resources of the audience rather than simply transplanted from urban environments. To take one possible example, information dissemination based around health or maternity clinics may be ineffective for poor rural women who rarely visit such facilities. As noted, information on HIV is probably harder to come by in rural areas.
Conclusion
The present study has focused on the knowledge and attitudes towards HIV/AIDS among rural and urban married women belonging to the Rajbanshi indigenous population of India. The results have shown that there is significant gaps exist between these rural and urban women with respect to the knowledge and attitudes towards HIV/AIDS. Urban married women portrayed a better idea towards knowledge and attitudes towards HIV/AIDS when compared to the rural women. The poor knowledge, awareness and high misconception among rural women could be attributed to their nature of residence, socio-demographic conditions, education attainment, occupation and relatively less exposure with surrounding than their urban counterparts. The statistical results have laid credence to this. There has to be sincere efforts by the local bodies, non-governmental agencies and the Government to create awareness towards HIV/AIDS especially, among the rural population. Further, the comprehensive knowledge gap and misconception must be eradicate in order to reduce the relative risks of disease transmission by implementing target oriented awareness programme especially in rural areas, thus change or improvement in knowledge and positive attitude among vulnerable segments of the population.
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