Assessment of Socio-Demographic Factors with Knowledge and Attitiudes of Pakistani Married Women (15-49 Years) towards HIV/AIDS Transmission

Introduction: Despite of improvement in knowledge, diagnostics, prevention and treatment; HIV/AIDS is highly discriminated and stigmatized worldwide. Objective: To determine the association of various socio-demographic characteristics with knowledge and attitudes towards HIV/AIDS transmission among married women. Study Design and Setting: For this purpose, secondary analysis was done using data from Multiple Indicator Cluster Survey (MICS) 2014. Materials and Methods: Study design was cross-sectional. Only ever married women were included as participants of the study. Result: Significant associations were found between sociodemographic factors i.e., women age (p-value = 0.001), women education (p-value = 0.001), wealth index (p-value = 0.001), access to media (p-value = 0.001), type of place of residence (p-value = 0.01), marital status (p-value<0.05) with knowledge and attitudes of women towards HIV/AIDS. Conclusion: Despite of having high odds of appropriate knowledge of HIV/AIDS transmission; attitudes of Pakistani women towards HIV/AIDS transmission were still negative. Programs need to be designed in order to reverse the negative attitudes of community towards HIV/AIDS transmission.


Introduction
Despite remarkable improvement in information, diagnostics, treatment and prevention of the disease in past two decades, HIV/AIDS is still a serious threat to public health in particular and to society in general [1][2][3][4] . Over 1.1 million HIV positive individuals reside in United States and approximately 20% individuals were unaware of the infection 5 . Estimates reveal that at the end of 2013, almost 35 million people were living with HIV infection and 1.5 million HIV related deaths were recorded worldwide 6 . HIV infection is more concentrated in Sub-Saharan Africa, approximately one in twenty adults is HIV positive. Almost sixty nine percent of the HIV positive individuals were from the same region 7 . First HIV case in Pakistan was identified in 1987 and after that the infection had spread to a large extent 8 ; approximately 98,000 people were living with HIV in 2009 and the main reasons for HIV/AIDS spread include unawareness, undiagnosed cases and unsafe sexual practices 9 .
Alarmingly low level of knowledge regarding HIV/AIDS was the main key for spread of HIV/AIDS infection. A study by Faust, Yaya and Ekholuenetale 10 investigated that women who were poor, residing in rural areas and low literacy levels than women with highest wealth inequality ratios had less knowledge towards HIV/AIDS transmission; thus enables execution of future evidence-based interventions among women in order to reduce HIV/AIDS transmission. Age, education and mass media such as listening radio, watching television and reading newspaper or magazine can also play an important role in increasing knowledge towards HIV/AIDS transmission among both ever married men and women 9 . A research conducted by Subaeti and his co-associates 11 identified that married women were more vulnerable to HIV/ AIDS infection because married people did not use condoms during sexual activities; therefore were at greater risk of getting HIV/AIDS infection. Though level of knowledge towards HIV/ AIDS transmission was increased but still negative attitudes towards HIV/AIDS was observed 12-15 . This was further supplemented by taboos surrounding discussions about sexuality which limit the implementation of preventive activities 16 . Moreover, certain misconceptions regarding spread of HIV/AIDS also exist in Pakistani society. However, the number of HIV/AIDS infected individuals was being increased and to deal with this health challenge, politically supported comprehensive programs are required 8 . The present study aimed to determine the association of various sociodemographic variables with knowledge and attitudes towards HIV/AIDS transmission among married women.

Methodology
The study design was cross-sectional. Data was derived from MICS Punjab, 2014 (Pakistan) and secondary analysis was done 17 . HIV/AIDS module was administered to ever married women 15-49 years of age. All the variables were derivatives of women's datasets of 2014 (N = 61286). As the research study hypothesized that socio-demographic factors determine the knowledge and attitude of women (15 to 49 years) towards HIV/AIDS transmission, therefore, sample was restricted to the variables who gave valid response to all the outcomes as well as independent variables. After removing records with missing data, the number of women included in the final analysis was 13390 women aged 15 to 45 years.

Dependent Variables
The two dependent variables (knowledge and attitude) were used for this study: Missing responses were re-coded as 9 and were excluded from the analysis. Thus, knowledge score ranges from 0-9. Respondents who correctly answered five or more than five out of nine questions means they had good and appropriate knowledge about HIV/AIDS; whereas respondents who responded less than five questions had poor or inappropriate knowledge about HIV/AIDS.

Women's attitude towards HIV/AIDS transmission
The women's attitude toward HIV/AIDS transmission was measured by the following four MICS questions: a. Would you want to keep undisclosed HIV/AIDS infection from family members? b. Would you take care of a relative who is HIV/AIDS infected? c. Would you buy vegetables from seller with an HIV/ AIDS virus? d. Should a female educator allowed to proceeds education in school with HIV/AIDS infection?
MICS categorizes above questions as yes, no and don't know.
The research re-codes (i.e., dichotomizing each item) attitude scale scores into 1 (yes for positive answer) and 0 (no or don't know for negative answer); thus composite (higher) score reflects better attitude toward HIV/AIDS. Women with missing responses were excluded from the analysis. Thus, attitude score ranges from 0 to 4. Respondents who had two or more attitude scale score were characterized as positive attitude group whereas; respondents less than two attitude scale score as negative attitude group.

Independent Variables
Owing to the study objectives and to make the bivariate analysis possible; age was categorized as 15-30 years, 31-45 years and 45 and above years with the goal of determining the effect of Vol 19 (1&2) | January-June 2019 | http://www.informaticsjournals.com/index.php/JEOH/index Rukiya Tariq, Quratulain Bashir and Tanzeel Ul Rahman increase age has on the women's HIV/AIDS knowledge and attitudes; women education as no formal education (absence of schooling), primary education (1-5 class), secondary education (5-10 class) and higher education (above 10 classes); place of residence into urban and rural regions and only those couples who are residing at the same household were considered for this study 8 ; marital status as being single (including widowed/ divorced/separated) and married 18 . Household wealth status as conceptualized in MICS was divided into 5 categories i.e., poorest (lowest), poor, middle, rich and richest (highest) income groups. Family unit (households) who had lowest score on all the assets items i.e., no electricity and one sleeping room, poor or low floor material, toilet facility and water supply were mentioned as poorest. Whereas; households (family unit) who holds all the assets items i.e. availability of electricity, three or more sleeping rooms, good floor material, toilet facility and water supply were mentioned as richest. Rest of the categories is in between these two categories 19,20 . Respondent's access to media i.e., reading newspaper or magazine, listen to the radio and watch television was hypothesized by using three categories: not at all, sometimes and almost every day 21 having a score of 0, 1 and 2 respectively for each mass media type.

Data Analysis
Descriptive statistics was used to estimate the frequency distributions of socio-demographic characteristics with knowledge and attitude towards HIV/AIDS transmission among 15 to 49 years age women through IBM SPSS Statistics Version 21. Bivariate logistic regression and distributions of dependent variables across independent variables were tested by applying Chi-square (p-value) test of associations. Odd ratios were calculated with 95% Confidence Interval (CI) as well as p-value less than 0.05 (significant).

Knowledge of Respondents towards HIV/ AIDS Transmission
To evaluate knowledge on HIV/AIDS transmission, respondents were asked list of questions (Table 1). Respondents with correct responses included as avoid HIV/AIDS cross-infection by limiting number of sexual partners to one uninfected partner (62%), condom use (64%); transmission from mother to child during pregnancy (76%); delivery (71%) and breastfeeding (68%) were graded as Appropriate Knowledge. Whereas, respondents with wrong responses had misconceptions about transmission through supernatural means (11%), mosquito bites (84%), sharing food (0.5%) and healthy looking person (37%) may have the infection were listed as Inappropriate Knowledge.

Attitude of Respondents towards HIV/AIDS Transmission
To evaluate attitude towards HIV/AIDS transmission, respondents were asked list of following questions ( Table  2); representing low magnitudes of respondents (women) with positive attitude. Respondents with correct responses included as 1% should female educator be allowed to proceeds education in school, 0.5% stated that they would buy fresh vegetables from seller and 37% reported willing to care if their household member gets infected with HIV/AIDS were graded as Positive Attitude. Whereas, respondents with wrong response included as 38% remaining a secret if household member got infected with HIV/AIDS were listed as Negative Attitude. Knowledge of HIV/AIDS transmission from mother to child during pregnancy (yes) 10176 76% Knowledge of HIV/AIDS transmission from mother to child during delivery (yes) 9507 71% Knowledge of HIV/AIDS transmission from mother to child through breastfeeding (yes) 9105 68%

Characteristics of the Respondents (women) Selected for the Study
Descriptive analysis (

Socio-Demographic Characteristics of the Respondents with Respect to their Knowledge and Attitude towards HIV/AIDS Transmission
The research study aims to assess socio-demographic characteristics with respect to knowledge on HIV/AIDS and attitude towards HIV/AIDS ( Women residing in urban settings had more appropriate knowledge i.e., 63.6% with more negative attitude towards HIV/AIDS i.e., 53.8%. Among marital status, single women had highest appropriate knowledge i.e., 57.6% and more negative attitude towards HIV/AIDS i.e., 51.9% than married women. Women with higher education had more appropriate knowledge i.e., 37.9% and more negative attitude i.e., 30% towards HIV/AIDS than women having no formal education; whereas, women with richest (highest) wealth quintile had more appropriate knowledge i.e., 37.4% and more negative attitude i.e., 26.5% towards HIV/AIDS. Appropriate knowledge towards HIV/AIDS transmission i.e., 56.3% and more negative attitude i.e., 42.1% towards HIV/AIDS was observed among women who had daily access to media than women who had no or sometimes access to mass media.

If household member became infected with HIV/AIDS, would you want it to remain a secret (no) 5088 38%
Willing to care for person with HIV/AIDS in household (yes) 4954 37%

Relationship of Socio-demographic Characteristics with Knowledge and Attitude towards HIV/AIDS Transmission
The predictors of the knowledge and attitude towards HIV/ AIDS transmission (  63-2.48)) and low odds ratio among married women (0.76 (0.50-0.97)).
The results concluded significant associations with sociodemographic factors (Table 5) i.e., women age, women education, wealth index and access to media have p-values = 0.001 respectively, whereas, type of place of residence have p-value=0.01 while, marital status have p-value<0.05 with knowledge and attitudes of women towards HIV/AIDS.

Discussion
The studies based on assessing knowledge and attitudes researches were valuable prior to any experimental study 22 . This study examines the relationship of socio-demographic factors with the knowledge and attitude of ever married women regarding HIV/AIDS by using data of MICS 2014 of Punjab province of Pakistan. In the study under discussion cumulative percentage of appropriate knowledge among study participants is 41% while responses pertaining to inappropriate knowledge account for 59%. Precisely there was poor knowledge about HIV/AIDS, lack of right knowledge, places Pakistani women at great risk of HIV infection. In this study, as far as trend in attitude is concerned 08% women showed positive attitude toward HIV/AIDS while 92% showed negative attitude that can be portrayed due to poor knowledge. Some significant findings concluded from the secondary analysis of some socio-demographic including age of women, type of place of residence, marital status, educational status, wealth index and access to media with knowledge and attitude regarding HIV/AIDS among ever married women. Among age group, the odds of having good knowledge towards HIV/ AIDS transmission were higher among 46 and above than 15 to 30 years age women. These findings were found congruent with the study findings of Ankunda and his coauthors 1 . The older women ages, the more negative their prejudiced attitudes towards HIV/AIDS. These finding were found congruent with Masoudnia 23 results which showed that people's negative attitudes toward HIV/AIDS was associated with their knowledge and age.
Level of education signified improved knowledge towards HIV/AIDS transmission. Respondents with higher education showed high odds of appropriate knowledge than respondents with no formal education. This coincides with the study findings of Ankunda and his coauthors 1 . Negative attitude towards HIV/AIDS coincides with the study findings of Masoudnia 23 . Respondents improved knowledge for HIV/AIDS transmission and discriminatory attitude towards people with HIV/AIDS was due to the fact that firstly education enhanced knowledge of a person in general; secondly educated person had more exposure to modern media and modern health facilities.
Current study identified that there was significant difference in knowledge and attitudes regarding HIV/AIDS among urban and rural resident women. Women residing in urban areas had high odds of having good knowledge towards HIV/AIDS As far as the results pertaining to marital status were concerned, it showed variance in the level of knowledge and attitude between single and married women. Married women had low odds of having good knowledge towards HIV/AIDS transmission than single (widowed, divorced or separated) women. The findings were found consistent with the study carried by Ankunda and his coauthors 1 among Vietnamese women who described that married women had less appropriate knowledge towards HIV/AIDS transmission compared to single women. Positive attitude were found by married women towards HIV/AIDS than single women. These study findings coincides with the study findings of Huy and others 18 . It can be the reason married women believe that marriage was a safety to precarious sexual behaviors.
Wealth index was also found positively associated with HIV/AIDS knowledge level. Women in richest wealth quintile showed significant high odds of having good and appropriate knowledge towards HIV/AIDS transmission than women in poorest wealth quintile. Similar results were found in the study conducted by Yaya and his co-associates 20 and Ankunda and Asiimwe 1 . It can be due to the reason that being more economically strong was linked with education, more access to resources, employment and better access to information. Higher the wealth index, the more negative discriminatory attitude towards HIV/AIDS coincides with the study findings of Alaba 24 and Mutahar and his co-associates 25 . This was due to the fact that people with higher economic background had more good appropriate knowledge, educated, more access to media, over protective and over conscious about their health issues.
Lastly, daily access to mass media i.e., reading newspaper or magazine, listen to the radio and watch television showed significant high odds of having good and appropriate knowledge towards HIV/AIDS transmission than those who sometimes or had no access to media. Similar findings were found in the study carried out by Ankunda and Asiimwe 1 who said that people visiting social networking sites had more knowledge towards HIV/AIDS transmission; it could be due to the reason that mass media is source of information and awareness campaigns regarding HIV/AIDS were usually going on. Additionally, daily access to media yields more negative discriminatory attitude towards HIV/AIDS 26 . This argument may be explained by the fact that despite of having high odds of good knowledge about HIV/AIDS transmission; HIV/ AIDS remains dreaded and had not wane out the beliefs and perceptions about the disease transmission.

Conclusion
Despite of having high odds of appropriate knowledge among Pakistani married women towards HIV/AIDS transmission had not still wade out the misconceptions, social stigmas and discriminatory (negative) attitude of community towards people with HIV/AIDS. Programs need to be designed in order to reverse the negative attitude towards HIV/AIDS transmission which may be straightaway mandatory in this concern among Pakistani women who are vulnerable to HIV/ AIDS transmission.