Rashed A. Al-Owaish, Mohamed A.A. Moussa, Shakil Anwar, Hind A. Al-Shoumer and Promila Sharma
Between January and April 1994, 116 people were interviewed in a pilot study to determine the feasibility a study on knowledge, attitudes, beliefs and practices (KABP) of the population in Kuwait about AIDS. A specifically designed questionnaire, based on the WHO AIDS programme KABP survey in 1988, was modified to suit Kuwaiti culture and norms. It was pretested on a sample of five categories of participant. Such studies can serve as baseline data for evolving strategies for AIDS awareness, prevention and control.
Etude pilote sur les connaissances, attitudes, croyances et pratiques concernant le SIDA dans la population koweïtienne
Entre le mois de janvier et d'avril 1994, 116 personnes au total ont été interviewées dans le cadre d'une étude pilote afin de déterminer la faisabilité d'une étude sur les connaissances, attitudes, croyances et pratiques (CACP) concernant le SIDA dans la population koweïtienne. Un questionnaire conçu spécifiquement sur la base de l'enquête CACP du programme mondial de lutte contre le SIDA de l'OMS réalisée en 1988, a été modifié pour être adapté à la culture et aux normes koweïtiennes. Un test préliminaire a été réalisé sur un échantillon composé de cinq catégories de participants. Ce genre d'études peut servir de base pour développer des stratégies concernant la sensibilisation et la prévention dans le domaine du SIDA et la lutte contre cette maladie.
Introduction
In 1981, when AIDS was first recognized, it did not seem to be an unusual challenge. Five years later, the disease had assumed epidemic proportions, crossing frontiers and creating profound difficulties for public health authorities worldwide in attempting to halt the spread of the HIV virus. Its alarming spread and prevalence became widely discussed and debated in scientific, medical and public health forums [1]. The extraordinarily high fatality and the modes of transmission and associated behavioural patterns raised questions about the adequacy of defences against this disease [2,3]. With no treatment or cure in sight, the disease continues to spread at an alarming rate.
The first AIDS case in Kuwait was reported in 1984 [4]. Since then a total of 479 HIV positive carriers have been detected [5]. Most of them have been deported. Kuwait shares with the world community a grave concern and a consequent determination to search for alternative strategies for AIDS prevention. With no immediate hope of a vaccine, the need for public health policies and programmes to protect individuals from contracting the illness through ignorance has focused attention on the role of education as a powerful medium for control. The World Health Organization (WHO) has advocated the role of education in spreading knowledge about AIDS transmission. This has evoked a general consensus that knowledge and awareness about AIDS need to be understood in their social context. In turn, this can be applied in modifying behaviour so that individuals and groups can protect themselves from infection [6].
The value of health education in spreading awareness and conditioning behaviour in the fight against AIDS was recognized early in Kuwait; it was employed to encourage people to abstain from risky behaviour. The governmental efforts in this direction include extensive use of the media for disseminating AIDS-related information and the organization of international conferences on AIDS in coordination with WHO every two years. Since 1988, Kuwait has been observing World AIDS Day every year and has also included information on AIDS and immunity in the secondary school syllabus. Meetings and public sessions on AIDS awareness have been held; and brochures, booklets and other printed materials have been distributed to reach the masses in an all-out effort to promote awareness of AIDS prevention and control. Since AIDS has a direct linkage to lifestyles and behaviour [7], an understanding of the extent of knowledge, attitudes, beliefs and practices of the population about AIDS assumes significance in evaluating the impact of AIDS awareness measures taken so far in Kuwait and developing effective strategies for AIDS prevention and control in the future.
The empirical basis of this study is inherent in this need, and is in response to the WHO recommendations [8] advocating the assessment of the knowledge about AIDS in different cultures, so as to ascertain requirements for overcoming ignorance and spreading awareness. Apart from a small-scale survey conducted by a group of medical students in 1989 [9], a comprehensive study on knowledge, attitudes, beliefs and practices of a representative sample of the population in Kuwait about AIDS has not been previously conducted. This paper marks the first step in this direction, and presents the findings of a pilot study conducted on a limited sample to pretest the adequacy of the instrument, ascertain its applicability in field situations and determine the feasibility of achieving the sample size within an estimated time frame.
Methodology
A questionnaire designed based on WHO's AIDS/KABP survey of 1988 [8], and consistent with Kuwaiti culture and norms, constituted the research instrument, which was administered to a sample of 116 interviewees, both Kuwaitis and non-Kuwaitis, belonging to five categories: university students (excluding medical and allied health students), schoolteachers, international travellers, primary health care attendants and the general public. The sampling method used was multistage stratified random sampling. The questionnaire, consisting of 63 questions, was divided into four broad sections: sociodemographic characteristics, knowledge and sources of information about AIDS, attitudes and beliefs about AIDS, and practices with respect to AIDS patients.
The responses were recorded through structured interviews. The completed questionnaires were checked for consistency and completeness. The Statistical package for social sciences (SPSS), version 6, was used to enter and analyse the data on an IBM personal computer.
Results
Apart from descriptive presentation of the responses, the study sought to establish the applicability of the research instrument in interviews. Data gathered from the 116 participants are shown in Tables 1 and 2.
The sample is balanced with respect to nationality and sex but is biased towards those with university educations. This contributed to questionnaire modification. However, results of this pilot study are not representative of the whole population.
The responses received resulted in modification of the questionnaire:
The addition of new questions, such as a question regarding the respondent's willingness to take care of a relative with AIDS, and another concerning the screening of returning travellers for HIV infection, were added.
Certain open-ended questions were coded to record specific response patterns with regard to behavioural and attitudinal changes after learning about AIDS, and what in the respondent's opinion an AIDS patient should do to prevent passing the infection on to others.
The question regarding the action that the government should take in the case of a person who has AIDS was split into two to solicit specific responses related to Kuwaitis and non-Kuwaitis. The responses received for the "duration" of living continuously in Kuwait led to reducing the period from five to three years in view of the interruption caused by the Iraqi invasion. Likewise, an additional option of medical personnel was added to the list concerning a respondent's preferences in discussing AIDS.
With the above modifications, the questionnaire in its revised form is now ready for use in the main study.
The responses were analysed to shed some light on the extent of knowledge, attitudes, beliefs and practices with regard to AIDS. Although the majority of interviewees were highly educated, the results obtained about knowledge, attitudes, beliefs and practices were as follows:
Knowledge
Approximately 41% of the participants had little knowledge about AIDS; over 53% attributed AIDS transmission to mosquitoes, sharing of lavatory seats or breast-feeding; 51% considered AIDS a contagious disease, and 26% thought AIDS could be transmitted through blood donation. Our results showed that 97% of participants were aware that "sex with prostitutes" can transmit HIV infection, and 96% were aware that "sex with multiple partners" can transmit HIV infection.
Beliefs
An overwhelming majority (94%) considered the role of the religious community important in AIDS control. Among the respondents, 78% were against AIDS patients living freely in the community and 58% placed responsibility for AIDS patients' care upon the government; 54% appeared satisfied at government AIDS control measures.
Behaviour and practice
About 53% of interviewed subjects admitted to a behavioural change after learning abut AIDS. Such changes included avoiding extramarital sexual relations; practices involving blood (like tattooing); becoming more careful when travelling and using public facilities; and ascertaining that medical instruments are sterile. Changes were also noted in favour of encouraging premarital HIV testing. As many as 81% of the participants exhibited a readiness to have an HIV test, and 76% were in favour of informing their family in the event they tested positive for HIV, while 72% showed an unwillingness to take care of AIDS patients.
Information sources
A majority of the participants (69%) acquired information about AIDS from the mass media, whereas only 3.4% obtained their information directly from medical sources.
Discussion
This pilot study was the first step towards a comprehensive population-based survey on knowledge, attitudes, beliefs and practices about AIDS in Kuwait. The main study will be the first major survey to be undertaken in Kuwait and is based on a representative sample of the population. The majority of interviewed subjects in this pilot study were highly educated (60.3%). Although this did not represent the whole population, we benefited from these highly educated subjects in achieving one of the objectives of the pilot study, namely the modification of the questionnaire.
The pilot study aimed primarily at pretesting the adequacy of the research instrument and ascertaining its applicability in field surveys. It also aimed at ensuring the feasibility of achieving the sample size within the estimated time frame. After conducting the study, it became evident that these objectives were achievable based upon real-life experience. The modifications in the questionnaire, such as adding new questions, coding open-ended questions, and splitting and modifying some other questions by adding new options (resulting from the input of the pilot study) proved the adequacy of the research instrument for the main study.
Although highly educated subjects were more prevalent in the pilot study, the results indicated some preliminary impressions about knowledge, attitudes, beliefs and practices about AIDS that may not be taken as representative of the population in Kuwait at large. The study showed that the religious community can play a leadership role in AIDS prevention and control. This finding is consistent with Islamic values and norms, which invite virtue and abstinence from extramarital sex—one of the main modes of transmission of HIV.
A large proportion of interviewees admitted a change in their behaviour since learning about AIDS. This emphasizes the role of knowledge and awareness about AIDS and their impact in inducing behavioural changes in the population [10]. Their willingness to submit to an HIV test, as well as to share test results with their families in the case of a positive result illustrates the eagerness of people to protect their families from the dangers and consequences of this fatal disease. This also indicates that people are willing to comply with the preventive thrust of educational programmes on AIDS.
The majority of interviews placed responsibility of AIDS patient care on the government and voiced a strong unwillingness to take care of unrelated AIDS patients. This calls for more efforts from health authorities concerning AIDS patients' care and preventive measures. A minority of the participants had acquired their knowledge about AIDS from medical settings as a source of information about AIDS, in addition to the mass media.
Conclusion
The pilot study has achieved its objectives through establishing that the questionnaire, with its current modifications, can be effectively used in the field survey of the main study. It also proved that the study can be conducted within the defined time frame. The pilot study also demonstrated the feasibility of achieving the predefined sample size for the main study, and provided preliminary indications of knowledge, attitude, beliefs and practices concerning AIDS in Kuwait.
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