Ali Abdel Megeid, Sawsan El Sheikh, Mervat El Ginedy and Mohammed El Araby
ABSTRACT: The knowledge of and attitudes towards reproductive health, and in particular STDs and AIDS, were assessed in 4000 women attending primary health care/family planning facilities in Alexandria, Egypt. In all, 66% did not know the significance of the term reproductive health and 50% considered female circumcision necessary. Of the 69% of women using contraceptives, 93% were using interuterine devices. The majority knew about AIDS but did not know that the use of condoms can prevent transmission of STDs, including HIV. A comprehensive programme should be initiated to increase public awareness of the issues of reproductive health.
Connaissances et attitudes en matière de santé de la reproduction et relativement au VIH/SIDA chez les utilisatrices des services de planification familiale
RESUME: Les connaissances et attitudes en matière de santé de la reproduction, et concernant plus particulièrement les maladies sexuellement transmissibles (MST) et le SIDA, ont été évaluées chez 4000 femmes fréquentant les centres de soins de santé primaires/planification familiale à Alexandrie. Au total, 66% ne connaissaient pas la signification du terme «santé de la reproduction» et 50% estimaient que la circoncision féminine était nécessaire. Sur les 69% de femmes ayant recours à la contraception, 93% utilisaient des dispositifs intra-utérins. La majorité d'entre elles avaient certaines connaissances sur le SIDA mais ne savaient pas que l'utilisation de préservatifs pouvait empêcher la transmission des MST, y compris l'infection par le virus de l'immunodéficience acquise (VIH). Un programme complet doit être mis en place pour sensibiliser le public à l'égard des questions de santé de la reproduction.
Introduction
Although the acquired immunodeficiency syndrome (AIDS) pandemic started 15 years ago, very little AIDS-related research has been done in Egypt. As cases began to be diagnosed during the second half of the eighties, the initial denial response by the authorities changed. The national authorities have now become actively involved in the prevention and control of human immunodeficiency virus (HIV) infection. AIDS cases started being reported to the World Health Organization in 1986 and since then, there are increasing numbers of patients detected each year. The Egyptian AIDS Society (EAS) was founded in 1992 as the first nongovernmental organization in Egypt concerned with programmes to prevent HIV infection, and to support AIDS patients.
After the International Conference on Population and Development held in Cairo in 1994, the terms reproductive and sexual health were widely disseminated among all community sectors. Reproductive health was defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters related to the reproductive system and to its functions and processes [1,2]. The definition of reproductive health includes many components, among which are family planning, maternal and child health, prevention of harmful practices, reduction of the spread of reproductive tract infections and other sexually transmitted diseases (STDs), including HIV/AIDS, and provision of treatment for STDs and their complications [3].
Globally, it is estimated that over 300 million new cases of STDs occur every year. One in every 20 adolescents is affected by STDs. According to a WHO prediction, by the year 2000, up to 40 million people could be infected with HIV. Adolescents, especially female adolescents, and women are particularly vulnerable because of lack of information and services, and sociocultural barriers that prevent them from taking measures to protect themselves [4,5].
Some critical issues should be considered while planning research involving AIDS/STDs such as homosexuality, migration, drugs, and unsafe abortion. Prostitution is forbidden by law in Egypt, but it is practised within private circles. However, there is no accurate information about its magnitude. In the Egyptian society, it is sometimes difficult to identify homosexual individuals and hence, this group should be considered at the highest risk [6]. There are no fewer than 3 million Egyptians living abroad. Most are temporary migrants to other prosperous neighbouring countries. Migrants are often exposed to various forms of high-risk behaviours. Illegal medical practices carry a high risk of infection; a study conducted at the High Institute of Nursing in Alexandria showed that among 1050 girls from 30 secondary schools, 80% of them had undergone female circumcision, mostly performed by unprofessional personnel. Without a medical reason to preserve the health of the mother, abortion is considered illegal in Egypt. Therefore, many women resort to unsafe abortions either performed by a poorly trained practitioner or by themselves. A review of the few Egyptian studies indicates that about 10% of all maternal deaths are directly caused by such unsafe abortions [7].
In view of these issues, it is essential to assess the knowledge and attitudes of the female population concerning different issues related to reproductive health. This will then enable us to implement appropriate programmes to improve the reproductive health of women and fight the spread of HIV infection .
Goal and objectives
The overall aim of this study was to determine the critical elements in knowledge and attitude towards reproductive health and HIV/AIDS in Alexandria, Egypt, in order to design appropriate programmes for intervention in the relevant areas.
The specific objectives were:
- To assess the knowledge and attitudes of women attending health facilities concerning HIV/AIDS.
- To assess the knowledge and attitudes of women attending health facilities on different aspects of reproductive health.
- To identify a set of fundamental indicators to be used to design programmes and activities for the improvement of reproductive health .
The Egyptian AIDS Society (EAS), in collaboration with the Clinical Service Improvement (CSI) Project, recognized the need to assess the knowledge and attitudes of women attending health facilities in Alexandria, Egypt, with regard to different aspects of reproductive health. Special attention was given to the issues related to HIV infection. Some of the questions dealt with the attitude of the women interviewed towards HIV-positive patients as well as harmful practices such as female genital mutilation.
This descriptive analytical study was designed as a cross-sectional (prevalence) survey among individuals in a well-defined population. Limitations of this kind of descriptive study are acknowledged.
Material and methods
A questionnaire was designed for data collection and it was developed in three main sections: HIV/AIDS-related issues (14 questions); reproductive health-related issues (5 questions); and family planning-related issues (8 questions). In addition, there were four questions about the main characteristics of the women interviewed.
The sample size of this study was 4000 women drawn from all women who visited four Clinical Service Improvement centres in Alexandria over the three-month period from October to December 1994.
Four teams were assigned to collect data during the three-month study period. Each team consisted of two members, most of whom were social workers, and each was assigned to one of the centres. All teams received training and participated in the pretesting of the questionnaire. The teams were supervised during the field work by the supervisor who had trained them.
Descriptive analysis of the results of the study was carried out using dbase IV and Lotus 123. Analysis was based on three specific indicators reflecting the main characteristics of the population studied. These indicators were: age, education, and occupational status. Each of the indicators was cross-tabulated with data collected on different issues of HIV/AIDS, reproductive health, and family planning.
Results
Women's profiles
Table 1 summarizes the total number of women surveyed in each centre by age, education, and occupational status. Schutz centre had the largest share in the study with 1772 women, (44% of the total), whereas Sporting centre had the least contribution with 543 women (14%). There were not many differences between the four centres regarding each indicator. As a result, analysis of the subsequent tables was based on the total population of the study.
It was noted that 21% of the women were illiterate, much lower than the corresponding national level. It was also shown that 25% of them were working women while the national level is 18%. Thus, the level of education and the working status of the women in this study were greater than the national level.
Age of marriage
Table 2 shows that the majority of the women (64%) considered the appropriate age for girls to marry is between 20-24 years and 19% considered it 25 years or more. Only 5% of women interviewed considered the appropriate age of marriage is between 16-18 years; 75% of this group were illiterate and 91% were housewives.
Reproductive health issues
Table 3 shows that only 34% of the women had heard about reproductive health. The source of information included television (56%), radio (12%), other sources (32%). This indicates the importance of mass media as a source of information. Although 66% of women interviewed did not know the term reproductive health, virtually all of them knew much of the basic information that would improve their reproductive health such as spacing between pregnancies and the importance of prenatal care. In addition, 80% of the women said they would encourage their daughters to have premarital examinations. Twenty percent (20%) of the women still did not know the advantages of breast-feeding over bottle-feeding.
Family planning
Table 4 shows the results of the family planning section of the questionnaire. The majority of women had heard of the family planning service for many years, which could reflect the success of the health information and education campaign in Alexandria. It also shows that 91% of women believe that family planning is not forbidden which is borne out by their being in family planning centres to receive services.
Of the women interviewed, 41% were receiving their prenatal care from a private physician, 34% at a family planning centre and 12% at a child care centre. Only 6% were having prenatal care with a traditional birth attendant.
It was found that 69% of the women surveyed were using family planning methods: 91% of them were using interuterine devices (IUDs), 5% were using the Pill, 2% were using injectable contraceptives, and only 2% were using condoms and other methods. Advice on the particular family planning method used was given by the family planning centre in 57% of the users, by a private physician in 32%, and in 6% of users it was selected by the husband.
Among those not using any form of contraception, 60% wanted more children and 31% had not yet had their first baby. About 3% of women said they could not use a family planning method because of their husbands' objections. Contrary to the common belief in Egypt, the results indicate that the women's mothers and mothers-in-law were not a constraint on using a family planning method.
Seventy-five percent (75%) of the women interviewed had visited the family planning centre before; 86 % of them had gone for the services and 14 % had gone as a companion.
With regard to client satisfaction, the most important factor was how the service providers treated their clients (with courtesy and friendliness). The second factor was the technical competence of the service providers.
Female genital mutilation
Table 5 shows the women's attitudes to what is called in Egypt "female circumcision". Half the women still believed in the importance of this procedure. Among these women, 54% attributed their belief to tradition, while 44% thought it controlled the sexual behaviour of girls. Only 2% believed it was obligatory for girls to be circumcised.
Of the 50% of women who believed in the importance of the procedure, only 35% were illiterate and 46% were educated, compared to 21% and 65%, respectively in the total study group. On the other hand, 83% of these women were housewives and 17% were working women, compared to 75% and 25%, respectively in the total group (Table 6).
HIV/AIDS
Table 7 identifies the women's knowledge of and attitudes towards some important issues related to HIV infection and AIDS. It was found that 96% of the women surveyed had heard about AIDS. The sources of information were television and radio (77%), and through general information (18%). Only 2% of the women had learned about AIDS from physicians and/or nurses.
The majority of the women who had heard about AIDS had clear and correct information about it which can be summarized as follows:
74% knew that it is caused by a virus.
88% knew that it is an infectious disease.
85% knew that it is transmitted through sexual intercourse with an infected person.
90% knew that they can avoid infection with HIV.
75% believed that there is no treatment for HIV infection at present.
84% knew that AIDS is a fatal disease.
92% believed in the importance of conducting national campaigns about HIV infection and prevention.
However, some important information was still not clear and the following misconceptions were common:
61% believed that infected persons should be avoided and segregated.
12% did not know about STDs and another 30% only had superficial information about them.
35% did not know that using a condom can prevent transmitting diseases through sexual intercourse.
Discussion
The survey was conducted among a specific target population by means of a questionnaire; this specific population are clients of health service centres which provide family planning and other reproductive health services.
The results showed the differences between the illiteracy rate (21%) and working status rate (25%) and those of the national level. Therefore, the results of this study cannot be generalized for the population of Alexandria. Nevertheless, the results indicate the considerable need for interventions to improve the reproductive health of less educated women and housewives in Egypt. For example, 66% of the women interviewed did not know the term reproductive health. This indicates the need to clarify the term and its concepts. This will necessitate dissemination of information through mass media as well as face-to-face communications.
The survey also shows that 20% of this specific population with a reasonably high education profile still did not know the advantages of breast-feeding over bottle-feeding. Therefore, all workers in the field of primary health care and family planning should initiate activities and programmes to promote breast-feeding.
Although 5% of the women interviewed considered the appropriate age for marriage was between 16-18 years, it was shown that most of those women were illiterate and housewives.
Female genital mutilation (female circumcision) is a deep-rooted traditional practice in Egypt, especially in rural areas. The results of this survey indicate an important positive attitude as 50% of the women believe that it is an unnecessary procedure for girls. It is also shown that among the other 50% who believe it is a necessary procedure, 54% of them attribute its importance to tradition, another 44% think it is important because it controls the sexual behaviour of girls. This suggests that if this problem is addressed in a well-designed programme, it is likely to have an extremely positive impact on attitudes to female genital mutilation.
As expected with this specific group of women, most of them had known about family planning for a long time and believed that family planning was not forbidden. They generally went to professionals for their prenatal care, and they had a 69% contraceptive prevalence rate.
The high percentage of women using IUDs (91%) raised the question about the client's freedom of choice regarding contraceptive method and whether this figure indicated a bias on the part of the service provider. Therefore, a short study was conducted among those clients using contraceptives to compare their intention of using a specific method with the method actually received. It was found that 95% of women received their intended method. A specific study should be conducted to assess the determinants and outcomes of this one-method programme [8,9]. The survey highlights an interesting finding in that mothers and mothers-in-law are not considered obstacles to women using contraceptives.
With regard to the health facility services, the women considered them of a good quality since the service providers treated them courteously and with respect, the service providers were technically competent, and the health facility was clean. This result confirms again that the quality of care is crucial in order to attract women to use the services of health facilities [10].
Only 2% of the women interviewed had learnt about AIDS from service providers (physicians/nurses). The women generally obtained information about AIDS through the mass media. This figure draws attention to the importance of equipping medical staff with knowledge and skills in order to involve them in the efforts to increase public awareness about HIV/AIDS .
The majority of women interviewed had clear information about what is meant by AIDS. However, three important points were not well known. First, 35% of women did not know that the use of condoms can protect them from contracting HIV as well as other STDs. This is a fundamental fact that should be known by everybody, especially those users of health facilities. This lack of knowledge was confirmed by the almost zero per cent of condom usage amongst the women. Second, many of the women had no knowledge of STDs, or only superficial information, including the method of transmission. Third, 61% of women interviewed still believed it important to segregate persons infected with HIV and to avoid them. Serious efforts should be made to correct this lack of information and associated misconceptions.
Recommendations
- A complete programme should be set up to highlight the importance of breast-feeding for infants and mothers, and its advantages over bottle-feeding.
- A health education campaign should be launched to fight misconceptions, improve knowledge, and change attitudes towards female genital mutilation practices in Egypt.
- Operations research should be conducted to identify the determinants and assess the outcomes of the high prevalence of IUDs as the sole contraceptive method in the centres studied.
- Activities to increase awareness about the disadvantages of early marriage should be included in primary health care/family planning centres.
- The fact that the quality of care is the most critical factor which will enable the primary health care/family planning programmes to attract more clients and improve the reproductive health of women should be widely disseminated.
- Many women in this group knew little about STDs/HIV and the importance of condoms as an effective method to prevent STDs. It is important to strengthen mass media involvement in AIDS prevention activities as it is the main channel of information for the majority of women in Egypt. Specific messages about condom use in relation to STD/HIV infections should be considered.
- A comprehensive programme which includes updating training for service providers, extensive information and health education campaigns, and advocacy to support HIV-positive patients should be integrated into the primary health care/family planning system in order to target different population sectors to improve their knowledge and change their attitudes.
- Other surveys and studies should be carried out which target other important groups of the population such as:
women who are not users of health facilities
women in rural areas
higher-risk groups such as prisoners, addicts, homosexuals and prostitutes.
These studies will give policy-makers, executing agents and health managers a complete picture about these sensitive issues, and will equip them with the necessary data to set up appropriate health programmes concerned with improving reproductive health, which involves the prevention of STD/HIV infections.
Acknowledgements
The authors thank the physicians, nurses, and social workers at the CSI centres, Alexandria, who helped in the collection of the data for this study. This project was supported by a grant from UNICEF, Egypt.
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