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They have not heard of AIDS
Public Health (1999) 113, 137±140 ß R.I.P.H.H. 1999 http://www.stockton-press.co.uk/ph
They have not heard of AIDS: HIV=AIDS awareness among married women in Bombay N Chatterjee1* 1
CHPRD RAS W-904, University of Texas-School of Public Health, UTH-HSC, PO Box 20186, Houston, Texas 77225, USA Many married women in India have still not heard of AIDS despite increasing risks, intensive health education campaigns and widespread scienti®c and media attention. Cross-sectional survey data collected from 350 married women in Bombay, India, revealed that one out of three women had not heard of AIDS. The women who had not heard of AIDS had signi®cantly fewer years of formal education, lower personal and family incomes, less exposure to the mass media and were more likely not to know of condoms in comparison to the women who had heard of AIDS. The results suggest that there are socio-economic barriers to health information. Speci®c interventions targeted to this group using speci®c channels of communication are urgently needed. Keywords: married women; awareness; HIV=AIDS; health education; India
Introduction
Methods
Data from a STD=HIV clinic in Mumbai (Bombay), India indicate that 70% of women who tested positive for HIV were housewives, many of whom had acquired the infection from their husbands.1 Other data from antenatal clinics in Maharashtra showed a seropositivity rate of 10 per 1000.2 Despite the growing evidence of increasing risk of HIV infection among married women in India,3 almost no data exist about the extent of AIDS-related knowledge, perceptions, speci®c risk situations or risk-reduction activities in this group, nor have interventions with this group been designed and implemented. Although the National AIDS Control organization (NACO) of the government of India allocated 34% of the government funds (Rs. 24 crores approximately) to Information, Education and Communication activities in 1992 ± 93 (NACO, 1994), most of the approaches consisted of sporadic advertisements in the press, posters and television messages. The targeted interventions of the government and some non-governmental agencies (NGOs) involved in HIV=AIDS prevention were aimed at commercial sex workers and their clients or the youth, especially in colleges and high schools.4 Data on the evaluation of intervention activities of the governmental agencies and the NGOs funded by international bodies is also lacking. Yet, within the context of current knowledge about HIV=AIDS, and given the economic realities of India, the use of health education to increase risk (harm)-reduction behaviour in this group of women seems to be the most feasible option. In order to develop accurate perceptions, positive attitudes, and adopt harm-reduction behaviours, is it not assumed that these women know about AIDS? This paper questions that assumption by asking whether there are married women in Bombay who have still not heard of HIV=AIDS and describing these women. Do these women who are not aware of AIDS share any common characteristics that would help public health practitioners tease out possible modes of intervention to spread awareness and boost prevention efforts in this sub-group?
Three hundred and ®fty married women were systematically sampled between June to September 1994 from among a population of women visiting patients in the inpatient wards or accompanying patients (mostly their children) in the out-patient departments (OPD) from every 6th bed or 6th case paper respectively of three public (municipal) hospitals in the North-eastern part of Greater Mumbai. If at any particular time the person visiting was not a woman or no relative or friends were available in the selected cases, then the interviewer went on to the consecutive multiple of six among hospital beds or case papers that had a married woman visiting the hospitals or waited until the next day. The instrument for data collection was adapted from the WHO=GPA Phase 2 Questionnaire on Knowledge, Attitudes, Beliefs and Practices (KABP) related to HIV=AIDS. The face-to-face structured interviews were conducted in local languages like Hindi, Marathi, English and Gujarati. Interviewers from both medical and non-medical backgrounds were trained over a one-week period using the WHO training parameters with emphasis on administration, con®dentiality and anonymity issues. The data were analzyed using SPSS Version 8.0 for Windows.5 A continuous variable `media score' assessed the exposure of the sample to the mass media; `media score' was computed as the sum of responses to three items in the questionnaire Ð watching TV, reading the newspaper, and listening to the radio, in a four week period preceding the survey. Each of these items was measured on a scale ranging from 4 ± 0: daily was four points, more than twice a week was three, once a week was two, less than once a week given a one and never was marked as a zero points. Awareness of AIDS was measured as a dichotomous (Yes=No) response to the question, `Have you ever heard of a disease called AIDS?' The associations of continuous variables such as `age', `years of school', `family income', `personal income', `years spent in Bombay, `number of children', `number of pregnancies', and `media score' to the dependent variable of awareness of AIDS were tested with a t-test procedure. Since the distribution of some continuous variables, especially years spent in Bombay, personal income, and family income were skewed, a log
*Correspondence: N Chatterjee, CHPRD RAS W-904, University of Texas-School of Public Health, UTH-HSC, PO Box 20186, Houston, Texas 77225, USA. Accepted 24 September 1998
Awareness HIV=AIDS Ð Indian married women N Chatterjee
138
transformation procedure was carried out in order to normalize the distribution of these variables and the t-tests were run on the log transformed variables. The associations of categorical variables such as `awareness of condom' and `practise religion' (yes=no response), and `language spoken at home', `place where born', `importance of religion in respondents' lives' were tested with the w-square test. A multivariate logistic regression procedure with backward elimination was used to determine personal predictors of awareness about AIDS. All variables attaining a signi®cance level of P < 0.10 in the bivariate analysis were coded as dummy variables (0, 1) and included in the stepwise regression process.6 Results The socio-demographic characteristics of the sampled women are provided in Table 1. Sixty seven percent (n 236) of the 350 married women interviewed had heard of AIDS and 33% (n 14) had not heard of AIDS at the time of the survey. The bivariate analysis revealed that women who had heard of AIDS were signi®cantly older, had more years of
schooling, and had higher personal and family incomes compared with the women who had not heard of AIDS (P < 0.01). Media exposure varied signi®cantly between the two groups with a higher `media score' of 7.6 among women who had heard of AIDS compared with the score of 4.1 in the group that had not heard of AIDS (P < 0.01). A greater percentage of women born in Bombay and women who had moved to Bombay before their marriage as well as women who said they did not practice religion were more likely to have heard of AIDS. Also, a greater percentage of women who had not heard of AIDS had not heard of condoms (P < 0.01). There were no signi®cant differences in awareness of AIDS based on the language used most frequently at home. A logistic regression model with backward elimination was conducted in order to predict lack of awareness (not having heard) of AIDS. The six variables retained in the ®nal model are shown in Table 2. Years of schooling and personal income remained predictive of the likelihood of awareness of AIDS. Years of school had a direct relation to the likelihood of having heard of AIDS: women who had
Table 1 Means of descriptor variables for the sample, and comparison of their means for women who have heard of AIDS and women who have not heard of AIDS Descriptor variables Continuous variables Age in years Years in school Years spent in Mumbai Number of pregnancies Number of living children Family income (Indian Rs.) Personal income (Indian Rs.) Log years in Mumbai Log family income Log personal income Media exposure score Nominal variables Where born In Bombay Outside Bombay When moved to Bombay Before marriage After marriage Practise religion Yes No Importance of religion Very important Somewhat important Not at all Language spoken at home Marathi Hindi Gujarati Urdu All others Heard of condoms Yes No
Sample mean [n 350] (Range) 28.67 6.87 18.62 2.52 2.14 3776 1668 2.29 7.82 6.98 6.49
(42) (20) (49) (8) (7) (39900) (9900) (6.21) (5.99) (4.61) (12)
Standard deviation
Women heard of AIDS [n 236]
Women not heard of AIDS [n 114]
P-value
7.44 5.00 12.25 1.48 1.22 4557 1610 1.69 0.89 0.99 3.71
29.49 8.59 20.89 2.49 2.10 4517 2073 2.62 8.04 7.31 7.58
26.96 3.33 13.92 2.58 2.23 2226 515 1.61 7.36 6.04 4.14
0.003 < 0.001 < 0.001 0.580 0.350 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Sample frequency (% age)
Heard of AIDS
Not heard of AIDS
157 (45%) 193 (55%)
118 (75%) 118 (61%)
39 (25%) 75 (39%)
7.75 (0.006)
200 (59%) 140 (41%)
147 (74%) 84 (60%)
53 (26%) 56 (40%)
6.89 (0.01)
300 (86%) 49 (14%)
193 (64%) 43 (88%)
107 (36%) 6 (12%)
10.55 (0.001)
135 (39%) 126 (36%) 86 (25%)
82 (61%) 87 (69%) 65 (76%)
53 (39%) 39 (31%) 21 (24%)
5.50 (0.06)
133 (39%) 73 (21%) 20 (6%) 43 (12%) 74 (22%)
94 44 13 24 56
39 29 7 19 18
266 (80%) 65 (20%)
(71%) (60%) (65%) (56%) (76%)
200 (75%) 23 (35%)
(29%) (40%) (35%) (44%) (24%)
66 (25%) 42 (65%)
w2 (P value)
7.32 (0.12)
37.65 (< 0.001)
Awareness HIV=AIDS Ð Indian married women N Chatterjee
Table 2 Predictors of lack of awareness (not having heard) of AIDS Predictor variable
OR
Years of school (vs 9 or more years) 1 through 8 y No formal school at all Age (vs 30 y or less) 31 or more years Religion (vs do not practise any religion) practise a religion Place where born (vs born in Bombay) born outside Bombay Exposure to media score (vs 8 or more) score of 7 or less Personal income (vs income greater than Rs. 1000) income of Rs. 1000 or less No income at all
1.00
(95% CI)
P-value
3.92 (1.81, 8.51) 0.001 11.82 (4.85, 28.73) < 0.001 1.00 0.494 (0.251, 0.969) 0.04 1.00 3.94 1.00
(1.44, 10.82)
0.008
2.08 1.00
(1.17, 3.69)
0.013
1.99 1.00
(1.04, 3.78)
0.036
(1.63, 120.10) (1.45, 90.36)
0.016 0.021
14.01 11.44
1 ± 8 y of school were almost four times as likely (OR 3.92, P 0.001) and women with no schooling at all were 12 times as likely (OR 11.82, P < 0.001) to have not heard of AIDS compared with those who had nine or more years of school. Notably, in comparison to those with a personal income greater than Indian Rs. 1000, women with an income of Rs. 1000 or less were 14 times as likely not to have heard of AIDS, but women with no personal income at all were 11 times as likely not to have heard of AIDS. Discussion These data show that one out of every three married women in Mumbai (33%) to be at risk of not knowing about AIDS. The pro®le of a married woman in Mumbai who has not heard of AIDS is one with few or negligible years of education, no or minimal personal income with very little exposure to the media or other sources of information. She is most likely married into a low-income family and is most probably a full-time homemaker (housewife) and not employed in the formal employment sector. If 1 out of every 3 married women is at risk of ignorance about AIDS, the calculation of who among married women is at most risk of HIV infection and a comparison of the two ratios will provide an estimate of the vulnerability of sub-groups and help the design of population-wide interventions. A further clari®cation of who would be at most risk of ignorance about AIDS is seen in the data in Table 2 which reveal that women with an income of Rs. 1000 or less had greater odds of not having heard of AIDS when compared with the group of women who had no personal income at all. Further analysis of the two groups Ð income of Rs. 1000 or less and no income Ð revealed that a statistically signi®cant 37% (n 93) of women with no personal income had nine or more years of school compared with 13.5% (n 7) in the group with income less than 1000 (P 0.004), and 17% (n 40) of women with no personal income had family incomes of more than Rs. 5000 (highest bracket in this study)
compared with 6% (n 3) of women with incomes less than Rs. 1000 (P 0.039). There was no signi®cant difference in the media exposure scores of these two groups. This ®nding suggests that it might be more important to examine the years of schooling as an indicator of the level of health information (or ignorance) of individual women than personal income in the case of countries like India. Cross-national comparisons of awareness of AIDS with other less developed countries also ®nds the awareness level of 67% in Bombay to be dismally low. In Thailand and in Zaire, nearly 96% of married women reported awareness of AIDS.7,8 Does this re¯ect the priority given to HIV=AIDS by these governments and their particular approach or does it point to the complexity of tackling a problem of this nature in a large and diverse country such as India? These data lead us to conclude that there are sociodemographic barriers to the diffusion of AIDS information in Bombay that have to be overcome urgently to stop further spread among vulnerable groups. One of the shortterm measures for this group of women would be the use of alternate channels of communication such as out-reach workers or AIDS-education through peer educators in grocery stores and market places. Yet, mere increase of knowledge may not be enough, and interventions have to be equipped with skills training components as well as socio-economic empowerment tools for the negotiation of safer sex behaviour by women, especially within a relationship such as marriage, which is dif®cult in the context of a traditional and less developed society such as India. Studies of HIV=AIDS among married couples in Thailand, one of the few developing countries with substantial public health data about the HIV=AIDS epidemic, already point to the dif®culties of HIV prevention within these dyads and HIV prevention within married couples has been mentioned as the public health challenge of the future for the control of the AIDS epidemic in developing countries.9 Conclusions Any type of HIV=AIDS intervention requires that the target population to be aware of the existence of the phenomenon of HIV=AIDS let alone the threats that it poses to them. Therefore, the data in this study lead us to a larger question: Is there, then, the existence of a syndrome among certain sub-groups of women in Bombay Ð a syndrome of ignorance and dis-empowerment that leads to poor health outcomes and quality of life in general, one of those being lack of awareness of AIDS? What is the etiology or natural history of such a syndrome? Some authors have already pointed to groups that suffer from a cluster of disadvantages and that women with least control over their bodies and lives are at greatest risk of illness and ignorance.10,11 The question for public health practitioners in Bombay and similar settings is how to tackle the relation between illness and ignorance. What is the level at which we in public health have to act if we have to broaden the impact of AIDS-intervention programs and reduce rates at the population level? Does there seem to be a `fundamental'12 barrier not only to the achievement of better health status, but also to the acquisition of information about health? If health information and education is our answer to the material constraints on health, then public health has to tease out barriers to information and propose
139
140
Awareness HIV=AIDS Ð Indian married women N Chatterjee
implementable practices if we are to keep on believing that information is an important pathway to improved health. In the information-age, the socio-economic gradient in health information is as much an indicator of the general inequality within a society as the more traditional measures. Acknowledgements The author is grateful to all the respondents and interviewers and to the late Dr D Gill, UMBC, for his encouragement and inspiration. The author is also grateful to Dr S Shankaranarayanan and Dr PSN Reddy at LTM Medical College, Bombay; G Rochester and L Leonard, University of Texas, Houston, and the anonymous reviewers. References 1 AIDS Research and Control Organisation (ARCON). Summary Report for HIV Positive Cases. ARCON: Mumbai, 1995. 2 Directorate of Health Services, Maharashtra (DHS). Statistics on HIV=AIDS in the State. Government of Maharashtra, Directorate of Health Services: Mumbai, 1995.
3 Bharat S. Facing the Challenge: Household and Community Response to HIV=AIDS in Mumbai, India. Tata Institute of Social Sciences: Mumbai, 1996. 4 National AIDS Control Organization. National AIDS Control Programme, India: Country Scenario. An Update. Ministry of Health and Family Welfare, Government of India: New Delhi, 1993. 5 SPSS. SPSS Base 8.0: Applications Guide. SPSS Inc: Chicago, USA, 1998. 6 Hosmer DW, Lemeshow S. Applied Logistic Regression. John Wiley: New York, 1989. 7 Shah I et al. Knowledge and perceptions about AIDS among married women in Bangkok. Soc Sci Med 1991; 33: 1287 ± 1293. 8 Bertrand J et al. AIDS-related knowledge, sexual behavior, and condom use among men and women in Kinshasa, Zaire. Am J Public Health 1991; 81: 53 ± 58. 9 Nelson KE. The demographic impact of the HIV epidemic in Thailand. AIDS 1998; 12: 813 ± 814. 10 Chambers R. Rural Development: Putting the Last First. Longman: London, 1983. 11 Carovano K. More than mothers and whores: rede®ning the AIDS Prevention needs of women. Int J Health Serv 1991; 21: 131 ± 142. 12 Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995; 36 (Extra Issue): 80 ± 94.
They have not heard of AIDS: HIV=AIDS awareness among married women in Bombay N Chatterjee1* 1
CHPRD RAS W-904, University of Texas-School of Public Health, UTH-HSC, PO Box 20186, Houston, Texas 77225, USA Many married women in India have still not heard of AIDS despite increasing risks, intensive health education campaigns and widespread scienti®c and media attention. Cross-sectional survey data collected from 350 married women in Bombay, India, revealed that one out of three women had not heard of AIDS. The women who had not heard of AIDS had signi®cantly fewer years of formal education, lower personal and family incomes, less exposure to the mass media and were more likely not to know of condoms in comparison to the women who had heard of AIDS. The results suggest that there are socio-economic barriers to health information. Speci®c interventions targeted to this group using speci®c channels of communication are urgently needed. Keywords: married women; awareness; HIV=AIDS; health education; India
Introduction
Methods
Data from a STD=HIV clinic in Mumbai (Bombay), India indicate that 70% of women who tested positive for HIV were housewives, many of whom had acquired the infection from their husbands.1 Other data from antenatal clinics in Maharashtra showed a seropositivity rate of 10 per 1000.2 Despite the growing evidence of increasing risk of HIV infection among married women in India,3 almost no data exist about the extent of AIDS-related knowledge, perceptions, speci®c risk situations or risk-reduction activities in this group, nor have interventions with this group been designed and implemented. Although the National AIDS Control organization (NACO) of the government of India allocated 34% of the government funds (Rs. 24 crores approximately) to Information, Education and Communication activities in 1992 ± 93 (NACO, 1994), most of the approaches consisted of sporadic advertisements in the press, posters and television messages. The targeted interventions of the government and some non-governmental agencies (NGOs) involved in HIV=AIDS prevention were aimed at commercial sex workers and their clients or the youth, especially in colleges and high schools.4 Data on the evaluation of intervention activities of the governmental agencies and the NGOs funded by international bodies is also lacking. Yet, within the context of current knowledge about HIV=AIDS, and given the economic realities of India, the use of health education to increase risk (harm)-reduction behaviour in this group of women seems to be the most feasible option. In order to develop accurate perceptions, positive attitudes, and adopt harm-reduction behaviours, is it not assumed that these women know about AIDS? This paper questions that assumption by asking whether there are married women in Bombay who have still not heard of HIV=AIDS and describing these women. Do these women who are not aware of AIDS share any common characteristics that would help public health practitioners tease out possible modes of intervention to spread awareness and boost prevention efforts in this sub-group?
Three hundred and ®fty married women were systematically sampled between June to September 1994 from among a population of women visiting patients in the inpatient wards or accompanying patients (mostly their children) in the out-patient departments (OPD) from every 6th bed or 6th case paper respectively of three public (municipal) hospitals in the North-eastern part of Greater Mumbai. If at any particular time the person visiting was not a woman or no relative or friends were available in the selected cases, then the interviewer went on to the consecutive multiple of six among hospital beds or case papers that had a married woman visiting the hospitals or waited until the next day. The instrument for data collection was adapted from the WHO=GPA Phase 2 Questionnaire on Knowledge, Attitudes, Beliefs and Practices (KABP) related to HIV=AIDS. The face-to-face structured interviews were conducted in local languages like Hindi, Marathi, English and Gujarati. Interviewers from both medical and non-medical backgrounds were trained over a one-week period using the WHO training parameters with emphasis on administration, con®dentiality and anonymity issues. The data were analzyed using SPSS Version 8.0 for Windows.5 A continuous variable `media score' assessed the exposure of the sample to the mass media; `media score' was computed as the sum of responses to three items in the questionnaire Ð watching TV, reading the newspaper, and listening to the radio, in a four week period preceding the survey. Each of these items was measured on a scale ranging from 4 ± 0: daily was four points, more than twice a week was three, once a week was two, less than once a week given a one and never was marked as a zero points. Awareness of AIDS was measured as a dichotomous (Yes=No) response to the question, `Have you ever heard of a disease called AIDS?' The associations of continuous variables such as `age', `years of school', `family income', `personal income', `years spent in Bombay, `number of children', `number of pregnancies', and `media score' to the dependent variable of awareness of AIDS were tested with a t-test procedure. Since the distribution of some continuous variables, especially years spent in Bombay, personal income, and family income were skewed, a log
*Correspondence: N Chatterjee, CHPRD RAS W-904, University of Texas-School of Public Health, UTH-HSC, PO Box 20186, Houston, Texas 77225, USA. Accepted 24 September 1998
Awareness HIV=AIDS Ð Indian married women N Chatterjee
138
transformation procedure was carried out in order to normalize the distribution of these variables and the t-tests were run on the log transformed variables. The associations of categorical variables such as `awareness of condom' and `practise religion' (yes=no response), and `language spoken at home', `place where born', `importance of religion in respondents' lives' were tested with the w-square test. A multivariate logistic regression procedure with backward elimination was used to determine personal predictors of awareness about AIDS. All variables attaining a signi®cance level of P < 0.10 in the bivariate analysis were coded as dummy variables (0, 1) and included in the stepwise regression process.6 Results The socio-demographic characteristics of the sampled women are provided in Table 1. Sixty seven percent (n 236) of the 350 married women interviewed had heard of AIDS and 33% (n 14) had not heard of AIDS at the time of the survey. The bivariate analysis revealed that women who had heard of AIDS were signi®cantly older, had more years of
schooling, and had higher personal and family incomes compared with the women who had not heard of AIDS (P < 0.01). Media exposure varied signi®cantly between the two groups with a higher `media score' of 7.6 among women who had heard of AIDS compared with the score of 4.1 in the group that had not heard of AIDS (P < 0.01). A greater percentage of women born in Bombay and women who had moved to Bombay before their marriage as well as women who said they did not practice religion were more likely to have heard of AIDS. Also, a greater percentage of women who had not heard of AIDS had not heard of condoms (P < 0.01). There were no signi®cant differences in awareness of AIDS based on the language used most frequently at home. A logistic regression model with backward elimination was conducted in order to predict lack of awareness (not having heard) of AIDS. The six variables retained in the ®nal model are shown in Table 2. Years of schooling and personal income remained predictive of the likelihood of awareness of AIDS. Years of school had a direct relation to the likelihood of having heard of AIDS: women who had
Table 1 Means of descriptor variables for the sample, and comparison of their means for women who have heard of AIDS and women who have not heard of AIDS Descriptor variables Continuous variables Age in years Years in school Years spent in Mumbai Number of pregnancies Number of living children Family income (Indian Rs.) Personal income (Indian Rs.) Log years in Mumbai Log family income Log personal income Media exposure score Nominal variables Where born In Bombay Outside Bombay When moved to Bombay Before marriage After marriage Practise religion Yes No Importance of religion Very important Somewhat important Not at all Language spoken at home Marathi Hindi Gujarati Urdu All others Heard of condoms Yes No
Sample mean [n 350] (Range) 28.67 6.87 18.62 2.52 2.14 3776 1668 2.29 7.82 6.98 6.49
(42) (20) (49) (8) (7) (39900) (9900) (6.21) (5.99) (4.61) (12)
Standard deviation
Women heard of AIDS [n 236]
Women not heard of AIDS [n 114]
P-value
7.44 5.00 12.25 1.48 1.22 4557 1610 1.69 0.89 0.99 3.71
29.49 8.59 20.89 2.49 2.10 4517 2073 2.62 8.04 7.31 7.58
26.96 3.33 13.92 2.58 2.23 2226 515 1.61 7.36 6.04 4.14
0.003 < 0.001 < 0.001 0.580 0.350 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Sample frequency (% age)
Heard of AIDS
Not heard of AIDS
157 (45%) 193 (55%)
118 (75%) 118 (61%)
39 (25%) 75 (39%)
7.75 (0.006)
200 (59%) 140 (41%)
147 (74%) 84 (60%)
53 (26%) 56 (40%)
6.89 (0.01)
300 (86%) 49 (14%)
193 (64%) 43 (88%)
107 (36%) 6 (12%)
10.55 (0.001)
135 (39%) 126 (36%) 86 (25%)
82 (61%) 87 (69%) 65 (76%)
53 (39%) 39 (31%) 21 (24%)
5.50 (0.06)
133 (39%) 73 (21%) 20 (6%) 43 (12%) 74 (22%)
94 44 13 24 56
39 29 7 19 18
266 (80%) 65 (20%)
(71%) (60%) (65%) (56%) (76%)
200 (75%) 23 (35%)
(29%) (40%) (35%) (44%) (24%)
66 (25%) 42 (65%)
w2 (P value)
7.32 (0.12)
37.65 (< 0.001)
Awareness HIV=AIDS Ð Indian married women N Chatterjee
Table 2 Predictors of lack of awareness (not having heard) of AIDS Predictor variable
OR
Years of school (vs 9 or more years) 1 through 8 y No formal school at all Age (vs 30 y or less) 31 or more years Religion (vs do not practise any religion) practise a religion Place where born (vs born in Bombay) born outside Bombay Exposure to media score (vs 8 or more) score of 7 or less Personal income (vs income greater than Rs. 1000) income of Rs. 1000 or less No income at all
1.00
(95% CI)
P-value
3.92 (1.81, 8.51) 0.001 11.82 (4.85, 28.73) < 0.001 1.00 0.494 (0.251, 0.969) 0.04 1.00 3.94 1.00
(1.44, 10.82)
0.008
2.08 1.00
(1.17, 3.69)
0.013
1.99 1.00
(1.04, 3.78)
0.036
(1.63, 120.10) (1.45, 90.36)
0.016 0.021
14.01 11.44
1 ± 8 y of school were almost four times as likely (OR 3.92, P 0.001) and women with no schooling at all were 12 times as likely (OR 11.82, P < 0.001) to have not heard of AIDS compared with those who had nine or more years of school. Notably, in comparison to those with a personal income greater than Indian Rs. 1000, women with an income of Rs. 1000 or less were 14 times as likely not to have heard of AIDS, but women with no personal income at all were 11 times as likely not to have heard of AIDS. Discussion These data show that one out of every three married women in Mumbai (33%) to be at risk of not knowing about AIDS. The pro®le of a married woman in Mumbai who has not heard of AIDS is one with few or negligible years of education, no or minimal personal income with very little exposure to the media or other sources of information. She is most likely married into a low-income family and is most probably a full-time homemaker (housewife) and not employed in the formal employment sector. If 1 out of every 3 married women is at risk of ignorance about AIDS, the calculation of who among married women is at most risk of HIV infection and a comparison of the two ratios will provide an estimate of the vulnerability of sub-groups and help the design of population-wide interventions. A further clari®cation of who would be at most risk of ignorance about AIDS is seen in the data in Table 2 which reveal that women with an income of Rs. 1000 or less had greater odds of not having heard of AIDS when compared with the group of women who had no personal income at all. Further analysis of the two groups Ð income of Rs. 1000 or less and no income Ð revealed that a statistically signi®cant 37% (n 93) of women with no personal income had nine or more years of school compared with 13.5% (n 7) in the group with income less than 1000 (P 0.004), and 17% (n 40) of women with no personal income had family incomes of more than Rs. 5000 (highest bracket in this study)
compared with 6% (n 3) of women with incomes less than Rs. 1000 (P 0.039). There was no signi®cant difference in the media exposure scores of these two groups. This ®nding suggests that it might be more important to examine the years of schooling as an indicator of the level of health information (or ignorance) of individual women than personal income in the case of countries like India. Cross-national comparisons of awareness of AIDS with other less developed countries also ®nds the awareness level of 67% in Bombay to be dismally low. In Thailand and in Zaire, nearly 96% of married women reported awareness of AIDS.7,8 Does this re¯ect the priority given to HIV=AIDS by these governments and their particular approach or does it point to the complexity of tackling a problem of this nature in a large and diverse country such as India? These data lead us to conclude that there are sociodemographic barriers to the diffusion of AIDS information in Bombay that have to be overcome urgently to stop further spread among vulnerable groups. One of the shortterm measures for this group of women would be the use of alternate channels of communication such as out-reach workers or AIDS-education through peer educators in grocery stores and market places. Yet, mere increase of knowledge may not be enough, and interventions have to be equipped with skills training components as well as socio-economic empowerment tools for the negotiation of safer sex behaviour by women, especially within a relationship such as marriage, which is dif®cult in the context of a traditional and less developed society such as India. Studies of HIV=AIDS among married couples in Thailand, one of the few developing countries with substantial public health data about the HIV=AIDS epidemic, already point to the dif®culties of HIV prevention within these dyads and HIV prevention within married couples has been mentioned as the public health challenge of the future for the control of the AIDS epidemic in developing countries.9 Conclusions Any type of HIV=AIDS intervention requires that the target population to be aware of the existence of the phenomenon of HIV=AIDS let alone the threats that it poses to them. Therefore, the data in this study lead us to a larger question: Is there, then, the existence of a syndrome among certain sub-groups of women in Bombay Ð a syndrome of ignorance and dis-empowerment that leads to poor health outcomes and quality of life in general, one of those being lack of awareness of AIDS? What is the etiology or natural history of such a syndrome? Some authors have already pointed to groups that suffer from a cluster of disadvantages and that women with least control over their bodies and lives are at greatest risk of illness and ignorance.10,11 The question for public health practitioners in Bombay and similar settings is how to tackle the relation between illness and ignorance. What is the level at which we in public health have to act if we have to broaden the impact of AIDS-intervention programs and reduce rates at the population level? Does there seem to be a `fundamental'12 barrier not only to the achievement of better health status, but also to the acquisition of information about health? If health information and education is our answer to the material constraints on health, then public health has to tease out barriers to information and propose
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Awareness HIV=AIDS Ð Indian married women N Chatterjee
implementable practices if we are to keep on believing that information is an important pathway to improved health. In the information-age, the socio-economic gradient in health information is as much an indicator of the general inequality within a society as the more traditional measures. Acknowledgements The author is grateful to all the respondents and interviewers and to the late Dr D Gill, UMBC, for his encouragement and inspiration. The author is also grateful to Dr S Shankaranarayanan and Dr PSN Reddy at LTM Medical College, Bombay; G Rochester and L Leonard, University of Texas, Houston, and the anonymous reviewers. References 1 AIDS Research and Control Organisation (ARCON). Summary Report for HIV Positive Cases. ARCON: Mumbai, 1995. 2 Directorate of Health Services, Maharashtra (DHS). Statistics on HIV=AIDS in the State. Government of Maharashtra, Directorate of Health Services: Mumbai, 1995.
3 Bharat S. Facing the Challenge: Household and Community Response to HIV=AIDS in Mumbai, India. Tata Institute of Social Sciences: Mumbai, 1996. 4 National AIDS Control Organization. National AIDS Control Programme, India: Country Scenario. An Update. Ministry of Health and Family Welfare, Government of India: New Delhi, 1993. 5 SPSS. SPSS Base 8.0: Applications Guide. SPSS Inc: Chicago, USA, 1998. 6 Hosmer DW, Lemeshow S. Applied Logistic Regression. John Wiley: New York, 1989. 7 Shah I et al. Knowledge and perceptions about AIDS among married women in Bangkok. Soc Sci Med 1991; 33: 1287 ± 1293. 8 Bertrand J et al. AIDS-related knowledge, sexual behavior, and condom use among men and women in Kinshasa, Zaire. Am J Public Health 1991; 81: 53 ± 58. 9 Nelson KE. The demographic impact of the HIV epidemic in Thailand. AIDS 1998; 12: 813 ± 814. 10 Chambers R. Rural Development: Putting the Last First. Longman: London, 1983. 11 Carovano K. More than mothers and whores: rede®ning the AIDS Prevention needs of women. Int J Health Serv 1991; 21: 131 ± 142. 12 Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995; 36 (Extra Issue): 80 ± 94.