INTRODUCTION:

HIV / AIDS at Global, Indian Level and in slums

Despite determined efforts to hold the HIV/AIDS epidemic in check, it shows no sign of declining.

It has stretched the health care system, wrecks the economics and destroys the very fabric of what constitutes a national, individual, families and communities¹.

Thus because of these concerns HIV/AIDS is now considered not only a health problem but also a developmental and security threat. Even if a cure against HIV/AIDS is found someday, the toll of death and suffering by 2010 will far-exceed any other recorded human catastrophe, previous epidemic, natural disaster, war etc¹. WHO statistics on HIV/AIDS documents that 33.4 million people were living with HIV/AIDS worldwide in 2008 and 2.7 million people were newly infected with the virus²

There has been feminization of epidemic with an estimated 38.4% of infected adults being female, especially where heterosexual sex is the main mode of transmission. Women are less educated, more overworked, underpaid and financially dependent on men. They fail to make use of protective measures (condoms) which are male driven, and also they lack the power to negotiate with their partner. Ironically, they are faithful but are infected by their single partner. The greatest boon of nature to women is the capacity to conceive, and the greatest curse is her inability to control the same³.

India still faces several challenges in its fight against HIV/AIDS. They include achieving high quality program management and execution and sustaining ongoing efforts in data collection⁴. The growth of HIV-1 epidemic is uncertain and it may kill several hundreds of millions of people in this country with a population of 1 billion, a large number of commercial sex workers, mobile male workers, a high prevalence of STDs, low reported condom use with non regular partners, a low prevalence of male circumcision, India is set to experience an explosion of HIV-1 cases. Only condom use and prevalence of STIs are the only factors that can be manipulated to limit the spread. Our efforts are to be geared towards understanding the transmission dynamics and providing evidence for targeted interventions^5,6.

International Institute of Population Services (2004) explored the substance abuse and indulgence in risk behaviour that makes them susceptible to HIV/AIDS among young low income migrants in the slums of Mumbai, India. It was apparent that alcohol consumption is quite common and important part of the migrant’s life. It also suggests that co-workers, blue films, pornographic magazines, friends, peer groups etc., are the major sources of information about sex related matters. There are plenty of misconceptions about sex, condom use, STD’s and HIV among the members⁷

Various studies have reported that awareness of women regarding HIV is low. 60% of women in India have never heard of AIDS and of those who have some knowledge, 33% do not know how to avoid HIV infection^8.Young women (13-24 years) are at a higher risk and more vulnerable to infection than any other age group. Unequal gender norms and lack of women’s control over their own sex and sexuality, male dominated society, little contact in the post-pubertal period with female peers and virtually no sex education forces the vulnerability to HIV/AIDS⁹.

Most previous AIDS research focused on specific groups at risk like men, male youth and sex workers. Focusing on high risk groups may leave the general population, especially the young women, under-protected or unprepared for HIV risk and its consequences¹⁰. There are several studies conducted in institutional settings like schools or HIV testing centres which do not describe the risk of young women who may experience barriers accessing services. HIV risk, factors that increase their vulnerability of young women residing in slums, especially among married and unmarried women who are two unique groups have not been adequately studied. Increasing our understanding of the variables could provide a key input into the policy decisions and to the design of better HIV risk prevention programmes exclusively for them. Young women in this study refer to two sub-groups (i.e.) unmarried or married women in the age group of 15-24 years who are residing in the selected slums of Madurai.

Statement of the Problem

A study to compare and correlate the knowledge and attitude regarding HIV/AIDS among young married and unmarried women in selected urban slums of Madurai, Tamil Nadu.

Objectives

1. To compare the knowledge regarding HIV/AIDS among the married and unmarried Young women

2. To compare the attitude related sexuality and gender norms among the married and unmarried Young women

3. To determine the relationship between HIV knowledge and attitude related to sexuality of young women.

Hypotheses

All tested at 0.05 level of significance.

H₁:There will be a significant difference in the mean HIV knowledge score between the married and unmarried young women.

H₂:There will be a significant difference in the mean sexuality attitude score between the married and unmarried young women

H₃:There will be a significant relationship between HIV Knowledge and attitudetowards sexuality among young women

METHODOLOGY:

Research Design

Descriptive comparative correlational survey design was used since the relationship between HIV Knowledge and Attitude is sought and compared between the married and unmarried young women.

Setting

The study was conducted in five selected urban slums. Each of them vary in their population from 2000 to 10,000 and situated in different zones of Madurai Corporation.

Sampling Technique :The implementation of sampling process proceeded in two stages.

Stage-1: Selection of Slums- Using stratified cluster sampling technique the slums were selected. A slum was considered as a cluster.

Table-1: Distribution of Subjects According to their Exposure to Sources of Information on HIV/ AIDS (N=650)

Sources	Married (n=155)		Unmarried (n=495)		Total (N=650)
Sources	f	%	f	%	f	%
*Had Sex Education in Schools*
Yes	28	18.06	136	27.47	164	25.23
No	127	81.94	359	72.53	486	74.77
*Heard of HIV*
Yes	139	89.68	418	84.44	557	85.69
No	16	10.32	77	15.56	93	14.31
Source of Information*
Peer group
Yes	8	5.16	58	11.72	66	10.15
No	147	94.8	437	88.2	584	89.85
School teachers
Yes	20	12.90	226	45.66	246	37.85
No	135	87.0	269	54.34	404	62.15
Magazines / books
Yes	20	12.90	109	22.02	129	19.85
No	135	87.0	386	77.97	521	80.15
Media (TV/ Radio)
Yes	72	46.45	156	31.52	228	35.07
No	83	53.54	339	68.48	422	64.92
Health workers
Yes	59	38.06	118	23.84	177	27.23
No	96	61.93	377	76.16	473	72.77
*Had been educated about condom use*
Yes	23	14.84	30	6.06	53	8.15
No	132	85.16	465	93.93	597	91.85

* has multiple responses.

The total 110 slums were stratified proportionally by size of it’s population. They were ranked from smallest to the highest in the population, then divided into four groups based on population, such as upto 2,500, 2,500 to 5,000; 5,000 to 7,500; 7,500 and above. From each group using simple random sampling one to two slums were selected for the study.

Stage-II: Selection of Individuals:-using systematic random sampling technique 495 unmarried women 155 and married women with a total of 650 were selected.

Protection of Human Subjects :The permission to conduct the study was granted by Health Officer, Madurai Corporation .Ethical clearance and approval was obtained from Institutional Review Board .Each subject was interviewed after obtaining informed consent and was assured of anonymity, privacy and confidentiality.

Data Collection Tool:

A semistructured interview schedule was modified from tool kit on HIV/ AIDS of Population council¹¹and was used for data collection.

Findings:

1.Demographic Characteristics: Among the subjects, 3/4^th (76.15%) were unmarried and the rest were married. More than 50% of young women were below 19 years of age. Nearly 80% of them were Hindus and unemployed. Three fourth of the subjects were living in slums for more than 10 years and in a nuclear family. Only 30% of the subjects had completed a higher secondary education. Partner of the married (60%) and father of the unmarried (50%) were the key decision makers for medical expenses.

Marital Status and Partner’s Characteristics:

A handful of respondents (6.45%) had been married off by 15 years of age. Most of them (95%) were living with their partner. More than 60% of their partners were Coolie workers. Nearly 35% of their partners were using alcohol and 25% were consuming tobacco.

2.Exposure to Sources of Information on HIV/ AIDS:

Table 1 depicts that only few in both the groups had been exposed to sex education i.e. 28.06%, 24.47% respectively. The major source of information has been media for married (46.45%) and for unmarried it was from school teachers (45.66%). Very meager percentage (8%) had been educated on condom use.

3.Knowledge on HIV/AIDS:

Table 2 displays the level of Knowledge among married women on various aspects related to HIV. Regarding spread, only 36.77% had adequate knowledge. Most (76.77%) of the married had inadequate knowledge on prevention and testing. With regard to STI only 1(0.65%) had adequate level of knowledge.

Table 3 displays that similar to the married group most (96.36%) of the unmarried women also had inadequate knowledge related to STI. The overall knowledge level shows that only 2.42% had adequate knowledge regarding all the aspects of HIV/ STI.

Table -4presents that there were a few percentage in both groups who have not heard of HIV at all. One third of married (19.35%) and 1/4th of unmarried (33.13%) did not mention about HIV transmission through sexual route. Nearly half of the sample had misconceptions regarding routes of transmission such as mosquito bites and sharing food.

Table 5 displays that nearly 80% of subjects felt that Copper ‘T’ prevents HIV. Nearly 42% of young women in both groups were not aware of prevention of mother to child transmission of HIV. Using condom as a preventive measure was said by only 15% of subjects. Nearly one fourth of sample in both groups (30%) did not know about places of HIV testing, and 60% of them were not aware of places of condom availability.

From the table-6 it is inferred that 70% of the subjects were not aware of the signs and symptoms of STI.

With regard to overall attitude towards sexuality and gender norms, majority of women (76.13% and 72.12%) in both the groups had a favorable attitude as shown in table-7.

Table- 8shows that among the married women, 54.7 % felt that a girl should not get married before 18 years and majority (86.5%) of them strongly agreed that their family restricts premarital sex; 85.2% strongly disagreed it is wrong to engage in relationship with a boy friend who is trustworthy

Table2: Frequency and Percentage Distribution of Married Women According to Knowledge Level in Each Items on HIV/ STI (n=155)

Knowledge on HIV and STI	Inadequate		Moderately Adequate		Adequate
Knowledge on HIV and STI	No.	%	No.	%	No.	%
Spread	31	20.00	67	43.33	57	36.77
Prevention and Testing	119	76.77	33	21.29	3	1.94
STI	151	97.42	3	1.94	1	0.65

Table-3: Frequency and Percentage Distribution of Unmarried Women According to Knowledge Level in Each Items on HIV/ STI (n=495)

Knowledge on HIV and STI	Inadequate		Moderately Adequate		Adequate
Knowledge on HIV and STI	No.	%	No.	%	No.	%
Spread	86	17.37	184	37.17	225	45.45
Prevention and Testing	388	78.38	87	17.58	20	4.04
STI	477	96.36	9	1.82	9	1.82

Table-4: Distribution of Subjects According to the Response on each item Related to Routes of HIV/ AIDS Transmission (N=650)

Routes of HIV / AIDS Transmission	Married (n=155)		Unmarried (n=495)		Total (N=650)
Routes of HIV / AIDS Transmission	f	%	f	%	f	%
By sexual route
Yes	125	80.65	331	66.87	456	70.15
No	30	19.35	164	33.13	194	29.85
By sharing food
Yes	65	41.93	207	41.82	272	41.85
No	90	58.06	288	58.18	378	58.15
By mosquito bites
Yes	48	30.97	265	53.54	313	48.15
No	107	69.03	230	46.46	337	51.85
By blood transfusion
Yes	82	52.90	339	68.5	421	64.77
No	73	47.10	156	31.5	229	35.23
By having sex with someone who shares needles
Yes	57	36.77	302	69.10	359	55.23
No	98	63.23	153	30.90	291	44.77
Through unsterile needles
Yes	90	46.15	349	76.70	439	67.54
No	105	53.85	106	23.30	211	32.46
*Mother to new borne child*
During delivery
Yes	102	52.31	240	52.74	342	52.62
No	93	47.69	215	47.26	308	47.38
Through breast milk
Yes	67	34.36	195	42.86	262	40.31
No	128	65.64	260	57.14	388	59.69

Table-5: Distribution of Subjects According to Knowledge on HIV Prevention and Testing (N=650)

Items on HIV Prevention and Testing	Married (n=155)		Unmarried (n=495)		Total (N=650)
Items on HIV Prevention and Testing	f	%	f	%	f	%
I) Prevention
1) Copper- T Prevents HIV
a) Yes	126	81.3	389	78.6	515	79.23
b) No	29	18.7	105	21.2	134	20.62
c) Don’t know	--	--	1	0.2	1	0.15
2) Prevention of Mother to child transmission of HIV is through
a) Pregnant mother undergoing HIV testing and treatment	71	45.8	265	53.5	336	51.69
b) Child taking medicines	10	6.5	29	5.9	39	6.0
c) Don’t know	74	47.7	201	40.6	275	42.31
3) A person can be protected from HIV through
a) Using condoms	25	16.1	67	13.5	92	14.15
b) Being faithful	58	37.4	163	32.9	221	34.0
c) Abstaining from sex	15	9.7	85	17.2	100	15.38
d) Not shaking hands with HIV infected person	8	5.2	17	3.4	25	3.85
e) Avoiding previously used needles and syringes	20	12.9	51	10.3	71	10.92
f) Avoiding mosquito bites	2	1.3	2	0.4	4	0.62
g) Screening blood before transfusion	--	--	--	--	--	--
h) Does not know	27	17.4	110	22.2	137	21.08
II) HIV testing centres
1) Governmental Hospital	105	67.7	289	58.4	394	60.62
2) Corporation Health Centres	6	3.9	24	4.8	30	4.62
3) Non-governmental organization	3	1.9	13	2.6	16	2.46
4) Don’t know	41	26.5	169	34.1	210	32.31
III) Places of Condom Availability
1) Pharmacy	52	33.5	135	27.3	187	28.77
2) Shop/ Store	8	5.2	16	3.2	24	3.69
3) Corporation Centres	10	6.5	23	4.6	33	5.08
4) Governmental Hospital	1	0.6	7	1.4	8	1.23
5) Family Planning Centres	1	0.6	10	2.0	11	1.69
6) Don’t know	83	53.5	304	61.4	387	59.54

Table-6: Distribution of Subjects According to Knowledge on STI (N=650)

STI Items	Married (n=155)		Unmarried (n=495)		Total (N=650)
STI Items	f	%	f	%	f	%
I) STI is
1) an infection that is sexually transmitted	34	21.9	159	32.1	193	29.69
2) Caused by body heat/ Don’t know	121	78.1	336	67.9	457	70.31
II) Symptoms exhibited by woman infected with STI
1) Genital ulcer	3	1.9	7	1.4	10	0.15
2) Vaginal discharge	24	15.5	96	19.4	120	18.46
3) Lower abdominal pain	1	0.6	4	0.8	5	0.77
4) Swelling / lumps in the groin	2	1.3	7	1.4	9	1.38
5) Don’t know	125	80.6	381	77.0	506	77.85
III) Symptoms exhibited by a man with STI
1) Genital ulcer	2	1.3	7	1.4	10	1.54
2) Urethral discharge	8	5.2	65	13.1	73	11.23
3) Painful scrotal swelling	--	--	2	0.4	2	0.31
4) Swelling/ lumps on the groin	1	0.6	7	1.4	8	1.23
5) Don’t know	144	92.9	414	83.6	558	85.85

Table-7: Distribution of Subjects According to Overall Level of Attitude towards Sexuality and Gender Norms (N=650)

Attitude Level	Married (n=155)		Unmarried (n=495)		Total (N=650)
Attitude Level	f	%	f	%	f	%
Unfavourable	1	0.64	14	2.83	15	2.31
Moderately favourable	36	23.23	124	25.05	160	24.61
Favourable	118	76.13	357	72.12	475	73.08

Table-8: Attitude towards Sexuality and gendernorms among Married Young Women (n=155)

Attitude		Strongly Agree %		Agree %		Uncertain %			Disagree %		Strongly Disagree %
Attitude		f	%	f	%		f	%	f	%	f	%
1.	A girl should get married before 18 years	17	11	8	5.2		19	12.3	26	16.8	85	54.7
2.	My family restricts that I must not have sex before marriage	134	86.5	9	5.8		3	1.9	5	3.2	4	2.6
3.	It is no wrong to have relationship with a boy friend who is close and trustworthy	1	0.6	4	2.6		3	1.9	15	9.7	132	85.2
4.	Sex education must be provided in schools	94	60.7	18	11.6		16	10.3	4	2.6	4	14.8
5.	If a partner has an extra marital relationship, the wife can do nothing	6	3.9	3	1.9		27	17.4	34	21.9	85	54.9

Table-9: Attitude towards Sexuality among Unmarried Young Women (n=495)

Attitude		Strongly Agree %		Agree %		Uncertain %		Disagree %		Strongly Disagree %
Attitude		f	%	f	%	f	%	f	%	f	%
1.	A girl should get married before 18 years	44	8.9	27	5.5	41	8.3	84	17.0	299	60.3
2.	My family restricts that I must not have sex before marriage	346	70.0	71	14.3	25	5.1	22	4.4	31	6.2
3.	It is no wrong to have relationship with a boy friend who is close and trustworthy	26	5.3	14	2.8	29	5.9	84	17.0	342	69.0
4.	Sex education must be provided in schools	264	53.3	103	20.8	59	11.9	14	2.8	55	11.2
5.	If a husband has an extra marital relationship, the wife can do nothing	15	3	24	4.8	75	15.2	234	47.3	147	29.7

With regard to sex education, majority felt that it should be provided in schools. Nearly 60% of married strongly disagreed that wife can do nothing about an extramarital relationship, her partner has.

Table 9 reveals that the attitude of unmarried women was similar to the married women. Only one third (29.7%) of the unmarried women strongly disagreed that if a partner has extramarital relationship the wife can do nothing about it. Except for 86% of the subjects, the rest felt that it is nothing wrong to have relationship with a boy friend.

Table-10: Comparison of Mean Scores in Knowledge and attitude Between the Married and Unmarried Women (N = 650)

Dimensions	% Mean	SD	‘t’ Value
*Knowledge*
Married (n=155)	27.68	15.32	t = -1.175 NS
Unmarried (n=495)	29.41	17.69	t = -1.175 NS
*Attitude*
Married (n=155)	82.74	25.02	t = 2.868 S***
Unmarried (n=495)	76.45	19.47	t = 2.868 S***

*p<0.05, **p<0.01, ***p<0.001

It is apparent from the above table-10 that there is a significant difference between married and unmarried young women in attitude (t=2.268, p<0.001) The difference in knowledge was insignificant.

Figure-1: Correlation Between HIV Knowledge and Attitude among the Unmarried Young Women

From the above figure it is inferred that among unmarried women there was significant positive relationship between knowledge and attitude (r=0.18 at p<0.000). So the research hypothesis is accepted and null hypothesis is rejected

Table-11: Correlation Between Knowledge and Attitude among Married (n=155).

Variables	Mean	S.D	‘r’ Value
HIV knowledge	27.68	15.32	r = 0.144 NS
Attitude	82.74	25.02	r = 0.144 NS

NS = Not significant

Table11 revealed that there was no significant relationship between knowledge and attitude among the married women.

DISCUSSIONS:

a) Knowledge

More than half (60.31%) in both the groups who had inadequate knowledge posed a higher risk for acquiring HIV. Only 2% of subjects were aware of STI. Lot of misconceptions regarding routes of transmission, and prevention of HIV was evident. The findings suggest that the unmarried young women require immediate interventions for preventing the risk before they enter into family life. Misconceptions are to be alleviated with the right information.

b) Attitude

Most of the subjects in both the groups (nearly 73%) displayed a favourable attitude towards gender norms and human sexuality and hence were at lower risk for HIV. Nearly 23% of the subjects in both the groups perceived that the wife can do nothing about an extramarital relationship her partner has. Most of the subjects in both the groups (nearly 80%) strongly felt that it is undesirable to have pre-marital sex and it was not okay to engage in sexual relationship with a friend even if he is trust worthy. This positive attitude should be further strengthened to sustain the behavioural change.

Findings of a study done among slum dwellers of Chennai, Tamilnadu revealed that 55% of females did not know about sexual mode of transmission; 11% of females did not know anything about a disease called AIDS. Majority of the study sample felt that AIDS can be treated by traditional medicine. A study on HIV/ AIDS and STI related knowledge, attitude and practice among high school students in Kathmandu Valley, India revealed that nearly 50% of them had some awareness related to HIV but knowledge on STI was low. The knowledge of females was low (43.2%) compared to males (48%)¹².

Misconceptions and lack of knowledge need to be corrected through education and awareness to prevent HIV infection¹³.

C) Sources for Information on HIV :

Only one fourth (25.23%) had been exposed to sex education; 14.3% of the young women have never heard about HIV, 5.16% of married and 11.72% of unmarried had heard of HIV from friends. The major source of information has been media for 46.45% of married, which indicates that media can have an impact on their attitude whereas in unmarried 45.66% received information from school teachers suggesting that there has been an influence on the knowledge of girls by the schools. This emphasizes that schools can be used as a weapon for reaching the adolescent girls with the right information. A very low percentage (8.15%) have been educated on condom use. Only a few women in both the groups (38% and 23.84%) have received HIV related health messages from health workers. The sex education is overwhelmingly school based, focusing on biology of reproduction rather than issues such as relationships and communications. It has not reached the girls out of schools. Similar Findings are reported in other studies .Mass media has been the most popular source of information on HIV/ AIDS¹⁴. Conventional IEC methods targeting general population via mass media are not reaching the slum dwellers even in a metropolitan city. A specially designed targeted intervention is needed ¹⁵

D) Comparison of Knowledge And Attitude between the Married and the Unmarried Young women :

There was significant difference between the married and unmarried women on their attitude (t=2.868, p<0.001) The difference in Knowledge was insignificant reflecting that they are heterogeneous groups .HIV related interventions should consider these differences.

E) Relationship between knowledge and Attitude

For the unmarried group, there was significant positive relationship between knowledge and attitude (r=0.18 at p<0.000) but for the married the relationship was insignificant. The findings demonstrate that these dimensions are interrelated.HIV education programmes must focus on improving knowledge. Besides improving knowledge there is a greater need to foster motivation towards safer sexual behaviours. In a study among male freelance labourers of Vietnam, men who were better informed and motivated displayed higher self-efficacy towards HIV prevention¹⁶

IMPLICATIONS

The following implications emerge from the study findings.

Nursing Practice

ª Nurses should act as advocates for social change and not blame or marginalize the women in slums. Provide access to confidential youth friendly care. Nurses must empower women with life skills, and sexual assertiveness skills for consistent condom use.

Nursing Education

ª They must target the youth and equip them with the right information to make healthy decisions and create learning resources that are adaptable to these heterogenous groups .They must provide formal clinical counseling to married young women about sexuality and contraception especially about condoms. During sexuality education among adolescents, their worrisome issues are to be discussed freely for which, nurses should be equipped with counseling skills

Nurse Administrators

ª Nurse administrator should design modules on HIV/ sexuality education and update it with the current needs of adolescents and married women. Ask for budget to design youth friendly strategies to meet the reproductive needs of adolescents. Must negotiate with Government to enact laws and train civil servants, police etc., to empower women.

Nursing Research Recommendations

1. A randomized clinical trial of HIV risk reduction interventions on the risky behaviour can be evaluated. Other factors that may influence HIV risk apart from knowledge and attitude can be undertaken. A qualitative approach using other methods of data collection can be considered.

2. A comparative study between urban and rural young women can be undertaken.

3. A similar study can be replicated with a larger sample across different slums and different population.

LIMITATIONS:

Having used self report as a method of data collection, there is a chance of measurement bias.

CONCLUSION:

The findings revealed that the sample had inaccurate and inadequate knowledge. Risk of acquiring HIV can be reduced by Information, Education and Communication (IEC) and Behaviour Change Communication (BCC).to delay their first sexual experience and ensure that those who do engage in sexual activity have adequate means to prevent HIV infection.

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Received on 09.07.2012 Modified on 16.08.2012

Asian J. Nur. Edu. and Research 2(3): July-Sept. 2012; Page 118-125