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Indian Journal of Community Medicine

Awareness of HIV/AIDS in a Remotely Located Conservative District of J&Kargil: Results of a Community Based Study

Author(s): Muzaffar Ahmed, Bashir Gaash*

Vol. 27, No. 1 (2002-01 - 2002-03)

Director, Health Services, Kashmir *Epidemiologist & Disease Surveillance Officer, Directorate of Health Services, Kashmir

Abstract:

Research question: 1. What is the level of awareness regarding various aspects of HIV/AIDS amongst adults aged 15-45 years in Kargil district of J&K. 2. What are the implications of the results for the health providers.

Objectives: To find out deficiencies in the awareness status of a very conservative remotely located Muslim community inhabiting the most backward district of the J&K state.

Study design: Cross-sectional.

Settings: In the randomly selected 955 households covering 20% of rural and 10% urban population of the 3 most populous health blocks of the district.

Participants: 15-45 years old family members, generally males.

Outcome variables: Proportion of the surveyed population having correct knowledge about various aspects of HIV/AIDS in the absence of any organized IEC intervention.

Results: Revealed a low overall awareness about HIV/AIDS with majority of respondents having no or false perceptions.

Conclusions: Study highlights an urgent need for IEC campaigns to sensitize different sections of population on various aspects of HIV/AIDS appropriate to an orthodox Muslim society.

Keywords : HIV/AIDS awareness, Household survey, Conservative society, Kargil district.

Introduction:

HIV/AIDS has become the most serious public health problem for India with one of the highest rates of spread in the world?1. Presence of infection everywhere highlights spread from urban to rural areas, from high-risk to the general population and from permissive to conservative societies2. Migration of labour, low literacy levels, gender disparities and prevalent RTI/STIs have significantly contributed to its fast spread. Ignorance and social stigma shrouding the infection favours its stealth percolation into the community and both of these contributory factors can be ameliorated through well designed IEC activities which are inevitably guided by the results of locally performed community based KAP studies.

Illiteracy, ignorance, discrimination, socio-cultural stigmatization and widely prevalent RTIs/STIs - all rampant in remotely located conservative societies make spread of newly introduced infections particularly dangerous and their control especially difficult. In this scenario urgent awareness generation campaigns tailor-made to the local needs become especially pertinent.

Material and Methods:

Kargil, the most backward district of J&K State, comprises of a total of 1.2 lakh inhabitants dispersed very sparsely (population density = 8), over 127 villages and 341 hamlets spanning an area of more than 14,000 sq. km. Majority (78%) of the population comprises of Muslims, mainly the Shiites considered to be one of the more orthodox sects. The altitude is very high (almost 9,000 ft), land rocky, terrain hilly, climate inclement (cold desert type), striking poverty and the only link road to Srinagar remaining closed for 8-9 months each year3-5. All this makes the community hard to reach and difficult to approach. Consequently, no significant community based study has ever been attempted in the area. With this consideration, two survey teams-from the Studies and Survey Section of the Directorate of Health Services, Kashmir and from the Regional Institute of Health and Family Welfare, Dhobiwan (Kashmir), performed a comprehensive survey of a randomized sample of 10% rural and 20% urban households in the 3 most populous blocks (Kargil, Sankoo and Drass, with a respective population of approximately 34,000, 26,000 and 16,000) during 18-27 October 2000. The sampled 955 households (821 rural, 134 urban) were interviewed with the help of the local interpreters to assess the awareness level on various aspects of HIV/AIDS.

Results:

Table I: Socio-demographic profile of surveyed population.

Characteristics Rural(R) Urban(U) Total(T)
Number of households surveyed 821 134 955
Population surveyed (adults aged 15-45 yr.) 2,643 591 3,234
Male (%) 50.76 49.51 50.58
Female (%) 49.24 50.49 49.42
Males in the 15-45 yr. Age group (% of total population) 23.94 25.82 24.87
Female in 15-45 yr. Age group(% of total population) 23.32 26.33 24.30
Currently married females
As % of total female population 30.63 36.40 31.52
As % of women in15-45 yr. Age group 62.97 69.77 64.09
Age break up of married women (%)
<15 yr. 1.2 0.7 1.1
15-19 yr. 1.2 2.9 1.9
>20 yr. 97.6 96.2 97.0
Occupation (%)
Farmers 23.0 13.7 21.6
Services (govt.) 12.5 16.0 13.0
House-wives 7.1 12.4 7.8
Labourers 3.3 0.2 2.9
Other 2.6 4.1 2.8
Students 51.5 53.6 51.9
Literacy (%)
Male - - 73.85
Female - - 40.96
Person - - 58.21

The proportion of males and females included in the survey, their proportion to total population, occupation and literacy status are shown in Table I.

Table II: Awareness of HIV/AIDS.

Table 2 missing

S-Sankoo; KR-Kargil rural; D-Drass; KU-Kargil urban; Figures in parentheses indicate percentages.

The study showed that a mere 19.5% of the surveyed population had heard about HIV/AIDS; urban population, however, had a higher level (26.86%) of knowledge. Kargil block revealed a comparatively higher awareness (more than 26%) as compared to a mere 9% in the Sankoo block.

The vast majority (73.1%) of the respondents who had ever heard of the disease had no idea about its causation. More than 3/4th of the rural population (76.66%) was clueless in contrast with only 58.34% in the urban areas. The most frequent response about probable risk factors was illicit sex (13.98%); 11.29% blamed use of the contaminated instruments, needles or syringes (used for injections, surgical procedures or skin puncture) or infected blood. Barely 1% could relate HIV/AIDS to an infected mother.

Table III: Knowledge of variuos preventive measures against HIV/AIDS.

Preventive measure S KR D KU R U T
Remaining faithful to one's spouse - - 14 (13.33) 2 (12.50) 7 (19.44) 16 (10.67) 7 (19.44) 23 (12.36)
Checking blood before transfusion   (3.45) 11 (10.48) - - 3 (8.33) 12 (8.00) 3 (8.33) 15 (8.06)
Sterilization of needles/blades use 1 (3.45) 1 (0.95) 1 (6.25) 1 (2.77) 3 (2.00) 1 (2.77) 4 (2.15)
All other options, (Misconceptions) 9 (31.03) 33 (31.43) - - 10 (27.78) 42 (28.0) 10 (27.78) 52 (27.96)
No knowledge at all 18 (62.07) 46 (43.81) 13 (81.25) 15 (41.67) 77 (51.33) 15 (41.67) 92 (49.46)
Total who had heard about HIV/AIDS 29 (100) 105 (100) 16 (100) 36 (100) 150 (100) 36 (100) 186 (100)

Figures in parentheses are percentages.

Enquiries about various preventive measures revealed that the majority of respondents (50%) had no idea at all, whereas, another 28% were having false perceptions. Various scientifically sound responses included remaining 'faithful to the spouse' (12.36%) and 'checking blood before transfusion' and 'sterilizing needles/instruments before use' (10.21%).

Table IV: Perception about high risk groups for HIV/AIDS.

Perceived high risk grouping the area S KR D KU R U T
Tourists, traders and businessmen 18 (5.61) 33 (8.25) 8 (8.00) 18 (13.43) 59 (7.19) 18 (13.43) 77 (12.36)
Migrant labour from outside 0 0 22 (5.50) 6 (6.00) 14 (10.45) 28 (3.41) 14 (10.45) 42 (4.40)
Drivers 18 (5.61) 24 (6.00) 2 (2.00) 8 (5.97) 44 (5.36) 8 (5.97) 52 (5.45)
Our workers who visit other parts of the country 0 0 2 (0.50) 0 0 1 (0.75) 2 (0.24) 1 (0.75) 3 (0.31)
All other groups 80 (24.92) 148 (37.0) 35 (35.00) 42 (31.34) 263 (332.03) 42 (31.34) 305 (31.94)
Don't know 205 (63.86) 171 (42.75) 49 (49.00) 51 (38.05) 425 (51.76) 51 (38.05) 476 (49.48)
Correct idea about high risk group 36 (11.21) 81 (20.25) 16 (16.00) 41 (30.60) 133 (16.20) 41 (30.60) 174 (18.22)
Total No. of respondents 321   400   100   134   821   134   955  

Figures in parentheses are percentages

Regarding various high-risk groups likely to increase the problem in the community, half of the respondents (49.84%) had no idea, whereas, 31.94% pointed fingers at such groups which are not generally deemed responsible for introduction, transmission or perpetuation of HIV/AIDS in any community. Of those who had scientifically correct opinions, 8.06% blamed tourists, traders and businessmen; 5.45% drivers; and 4.4% migrant labour from outside. None counted their own men or women important in introduction or transmission of HIV/AIDS.

Table V: Can HIV/AIDS become a problem in Kargil?

Response S KR D KU R U T
Yes 8 (2.50) 13 (3.25) 9 (9.00) 24 (17.91) 30 (3.65) 24 (17.91) 54 (5.65)
No 155 (48.28) 105 (26.25) 24 (24.0) 24 (17.91) 284 (34.60) 24 (17.91) 308 (32.25)
Don't Know/Can't say 158 (49.22) 282 (70.50) 67 (67.0) 86 (64.18) 507 (61.75) 86 (64.18) 593 (62.10)
Total respondents 321(100) (100) 400(100) (100) 100(100) (100) 134(100) (100) 821(100) (100) 134(100) (100) 955 (100)

Figures in parentheses are percentages.

Most of the respondents (62.10%) had no idea as to what course HIV/AIDS could take in their community; 32.25% believed that it could never become a problem while a mere 5.65% thought that HIV/AIDS could be a problem if not taken care of.

Discussion:

Kargil being the most backward district of J&K State with an orthodox Muslim majority, low female literacy, low sex ratio and low income is a typical conservative society. Males can interact in Urdu - the official language of J&K State - but house-wives can communicate in their own dialect only. Issues relating to the reproductive tract and sexuality are a general taboo and, therefore, a separate KAP study of females was not feasible. Responses are thus the collective body of knowledge of the adults (15-45 years) of the household.

As expected the study has revealed a very low (about 20%) awareness among the Kargillites. This is much lower than the awareness levels revealed by studies conducted elsewhere in the country 6-16 which came out with figures ranging between 35.82% and 84.8%. The National Family Health Survey (II) also showed a comparatively higher knowledge of 31.9% in J&K17. The rapid household survey conducted by the Society for Applied Research in Humanities (1999) showed even a higher awareness level of 71.4% in males and 61.1% in females 18. These studies were conducted mainly in the Baramulla and Anantnag districts which have better literacy status.

Studies across India have shown that, because of the increased exposure to various media mainly electronic (TV, radio), people have fair to good knowledge of various routes of spread including heterosexual contact, blood and its products and vertical transmission. Levels of awareness varied between 62.1 to 92.8% in case of men and between 29.1 to 69.2% in case of women 6,8,10,12,14,15 . Some rural studies have shown that more than 89% of the respondents endorsed one or more of the accepted practices favouring spread of HIV 9; in urban areas more than 92% of males had knowledge of sexual route11. As many as 37.5% of the surveyed rural population endorsed all the 3 known routes9,10. The rapid household survey (1999) in Baramulla revealed that 82.1% males and 73% females mentioned sexual contact as the chief mode of transmission18. Blood transfusion was blamed by 55.9% males and 45.9% females, while 37.4% males and 36.6% females had knowledge of mother-to-child transmission18. Our study revealed a very low awareness: a mere 14% knew illicit sex was a risk factor and just 11% could identify blood or contaminated syringes/instruments as means of transmission and mere 1% knew about vertical transmission. Studies have shown that misconceptions regarding modes of transmission and high risk groups are widespread in India even among the educated and technical groups19. National Family Health Survey II (1998-99), however, revealed that knowledge was lower still in rural areas, the illiterates and among the scheduled castes and tribes 17. Various studies have shown that the main source of awareness of people in our country is TV6,8,17,19, while the role of health workers in enlightening people regarding various health issues has been insignificant especially in J&K State. In Kargil TV has not been able to enlighten the public in local dialect and health workers have been at their laziest in educating people.

Lack of knowledge about modes of transmission is reflected in a similarly poor awareness about preventive measures. Our study shows that only 22.57% of the respondents had correct opinion about means to avoid HIV/AIDS. The majority either had no idea at all (50%) or were carrying false perceptions (28%). Indian studies have shown much higher knowledge of the preventive methods among rural as well as urban populations6,10,13,14,17. Local surveys in Kashmir province17,18 have also shown better awareness. The rapid household survey under the Reproductive and Child Health Programme showed that in district Baramulla, use of condoms in each intercourse was vouched as a preventive method by 81.3% of males and 73.3% of females. Other methods endorsed included checking blood prior to transfusion, sterilizing needles and syringes for injection and avoiding pregnancy when having HIV/AIDS. Only 17.8% of males and 26.6% of females expressed ignorance about any preventive method and only 6.3% males and 6.5% females had scientifically wrong perceptions about means of prevention.

Although condom is being promoted as a major weapon against transmission of HIV/AIDS by the National AIDS Control Organization, it is doubtful if its advocacy is appropriate in an Islamic society. None of the respondents in our study has named it as a means of prevention.

The general indifference and complacency about HIV/AIDS in conservative societies is underlined by the fact that a negligible 5% believed that the infection could pose a serious problem for the community if not dealt with intensively. One third of the surveyed population believed that it could never become a problem while the majority (62%) had no idea at all. In the rapid household survey conducted in 1999 in J&K State more than 50% of the respondents did not know what course HIV/AIDS takes in a patient and 8-11% believed that it is a curable disease18.

Almost 50% of our respondents had no idea about various high risk groups who introduce, perpetuate and maintain HIV/AIDS in a community; another 32% had false perceptions. Only 18% of the respondents knew about the high risk groups as tourists, traders, businessmen, migrant labourers and long route drivers. Only very few (0.3%) believed that the males of the community who visit areas outside Kargil can bring the infection into the community and spread it there. Kargil being a highly religious conservative area has the distinction of not having any commercial sex workers and has never been in news for any hidden or busted sex rackets. Although various high risk individuals from outside could introduce the infection in the conservative society, the real danger is always from their own workers, businessmen and students who could contract infection in high risk areas of the country and spread it within their own community. Health education campaigns have to be designed for students especially in the face of fastly rising literacy, which has shown a 273% increase since 1981 Census. Presently student community forms the biggest occupational group (51.5% of the total population) in Kargil 20.

Conclusions:

The study shows that majority of Kargillites are either unaware of HIV/AIDS or ill-informed about modes of transmission, high risk groups and preventive measures. As has been revealed in different studies, health workers are not playing their part in educating people and media is not giving culturally-appropriate messages. While the community continues to be rigidly conservative, more and more of males are visiting different parts of the country in connection with business or education and if not made sufficiently aware may contract infection and bring it back into their community. Intensive campaigns in schools and work places are already overdue and religious leaders need to be sensitized on priority about their crucial role and responsibility in prevention and control of HIV/AIDS.

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