Abstract
India, with the third-highest global burden of human immunodeficiency virus (HIV), faces significant challenges in combating the epidemic. There is a need for enhanced interventions, since Goa’s HIV prevalence is higher than the national average. To study the knowledge, attitudes, and practices (KAPs) of family planning methods and HIV prevention among antenatal women in Goa. A hospital-based cross-sectional study with a convergent mixed-method design was conducted from August to December 2023 at a tertiary care hospital in Goa. Most participants, 318 (93.5%), were aware of HIV, with 301 (88.5%) understanding transmission routes. Support was high for HIV disclosure, 305 (89.7%), and sex education, 310 (91.2%), but lower for buying condoms, 110 (32.4%). Awareness of family planning methods was high, 305 (89.7%), but only 218 (64.1%) knew that they were free at government hospitals. Knowledge of side effects was low, 57 (16.8%), and only 171 (50.3%) felt comfortable discussing family planning with partners. HIV prevention and family planning practices were observed to be low due to barriers such as spousal disapproval, socio-cultural norms, and misinformation about HIV transmission. This study highlights the gaps in the adoption of family planning methods and HIV prevention practices. Therefore, strengthening HIV integration in antenatal care and promoting targeted education and gender-sensitive programs are essential to enhance family planning adoption and HIV prevention efforts.
Keywords: Antenatal, family planning, HIV
INTRODUCTION
As the human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS) pandemic enters its third decade, the pandemic continues apace, in some cases at alarming rates.[1] According to HIV Estimation 2021 report, India has the 3rd highest burden of HIV in the world with prevalence among adult males (15–49 years) estimated at 0.22% and among adult females at 0.19%, which reveals that the gap between the number of women and men infected with HIV/AIDS is narrowing.[2] Though India is determined to eliminate HIV by 2030, AIDS-related illnesses still remain a leading cause of death among women of reproductive age (15–49 years).[3] In India, the Southern state of Goa has an adult HIV prevalence of 0.31% which is higher than the national average.[2] The global scale-up of prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012 and must decrease to end new infections by 2030.[3]
The World Health Organization’s PMTCT strategic vision within MCH services offers mutual benefits between PMTCT services and the existing health care services. This offers HIV counseling and testing services to all pregnant women enrolled for antenatal care. It also offers postpartum family planning to prevent at-risk pregnancy.[4]
This helps couples make informed decisions about HIV prevention and reproductive health, which could reduce the number of people newly infected. Integration of HIV and family planning health services within antenatal care has its objective of getting to zero new HIV infections, as well as improved reproductive health for women and men.[5] Family planning aids HIV serodiscordant couples in safer conception strategies and is crucial for reducing preconception HIV risk. Informed choice is pivotal for successful contraceptive use and HIV prevention.[6]
Integrating FP and HIV testing services into antenatal care services helps educate the woman to meet her future need for contraception, while providing her with knowledge of the prevention of HIV. In light of the above, this study has been planned to gain an in-depth understanding of the knowledge, attitudes, and practices (KAPs) of family planning and HIV prevention among antenatal women.
OBJECTIVES
To study the KAPs of HIV prevention among antenatal women in a tertiary care hospital in Goa
To study KAPs of family planning methods among antenatal women in a tertiary care hospital in Goa.
METHODS
Study design and setting
This hospital-based cross-sectional study employed a convergent mixed-method design based on the KAPs survey approach. The study was conducted at Goa Medical College between August and December 2023.
Study population and eligibility criteria
The study population included women attending the antenatal clinic at Goa Medical College and healthcare providers (HCPs) from the Department of Obstetrics and Gynecology (OBG) and the National AIDS Control Program. The HCPs included Anti-Retro Viral Therapy (ART) counselors, medical officers, OBG residents, nurses, and family planning counselors. All antenatal women aged ≤15 years or ≥50 years, seriously ill, unable to see or hear, unmarried, HCPs with less than 1 year of work experience, and unavailable for three consecutive visits were excluded.
Ethical approval and consent
Ethical approval was obtained from the Institutional Ethics Committee at Goa Medical College. Written informed consent was obtained from all participants after explaining the purpose of the study. To ensure confidentiality, personal information was replaced with unique codes, and interviews were conducted in a private room within the OPD to ensure participants felt comfortable. All data obtained were accessible only to authorized members of the research team.
SAMPLE SIZE ESTIMATION AND SAMPLING STRATEGY
Quantitative Component: The sample size was calculated to be 340, based on the contraceptive prevalence rate of 68% (derived from NFHS-5).[7] A systematic random sampling method was employed to recruit study participants.
Qualitative Component: Purposive sampling was used to recruit antenatal women attending the antenatal clinic and HCPs from Goa Medical College. The sample size was determined by the principle of data saturation, i.e., recruitment ceased when no new themes emerged during the analysis of participants’ responses.
Data collection
Quantitative data were collected using standardized, pre-tested questionnaires, and qualitative data were gathered through semi-structured, in-depth interviews (IDIs) and semi-structured key informant interviews (KIIs).
Statistical analysis
Quantitative Analysis: Data were entered into MS Excel and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, New York, USA). Results are presented as simple frequencies and percentages.
Qualitative Analysis: Manual content analysis was performed on the qualitative data. Themes and sub-themes were derived, ensuring reliability. Analysis commenced immediately following the interviews to refine data collection and interpretation in real-time.
RESULTS
Profile of the study participants
For the face-to-face interviews, it was observed that the majority of study participants, 150 (44.1%), were in the age group of 25 to 29 years, identified as Hindu 214 (62.9%) by religion, and were unemployed 265 (77.9%). The majority had completed higher secondary school, 158 (46.5%), and 183 (53.8%) resided in urban settings [Table 1]. For the IDIs, majority of study participants, 6 (40%), were in the age group of 30–34 years, belonged to Hindu by religion, 8 (53.3%), and were unemployed, 14 (93.4%). Majority had completed Higher Secondary School, 8 (53.3%), and resided in urban settings, 13 (86.6%) [Table 1]. For the KIIs, majority of the participants, 7 (46.7%), were in the age group of 30–34 years, belonged to Hindu 9 (60%) by religion, were employed 15 (100%).
Table 1.
Socio-demographic characteristics of antenatal women and healthcare providers participating in the study
| Quantitative | Qualitative | ||
|---|---|---|---|
|
| |||
| Questionnaire | In-depth interviews | Key informant interview | |
|
|
|
|
|
| Total n=340 (%) | Total n=15 (%) | Total n=15 (%) | |
| Age group | |||
| 15–19 | 5 (1.5) | – | – |
| 20–24 | 85 (25) | 4 (26.7) | – |
| 25–29 | 150 (44.1) | 5 (33.3) | 5 (33.3) |
| 30–34 | 67 (19.7) | 6 (40) | 7 (46.7) |
| 35–39 | 27 (7.9) | – | 2 (13.4) |
| 40–44 | 5 (1.5) | – | 1 (6.6) |
| 45–49 | 1 (0.3) | – | – |
| Religion | |||
| Hindu | 214 (62.9) | 8 (53.3) | 9 (60) |
| Christian | 57 (16.8) | 2 (13.4) | 6 (40) |
| Muslim | 69 (20.3) | 5 (33.3) | – |
| Education | |||
| Illiterate | 3 (0.9) | – | – |
| Primary school | 39 (11.5) | 2 (13.4) | – |
| Middle school | 14 (4.1) | – | – |
| Secondary school | 70 (20.6) | 4 (26.7) | – |
| Higher secondary school | 158 (46.5) | 8 (53.3) | – |
| Graduate and above | 56 (16.5) | 1 (6.6) | 15 (100) |
| Occupation | |||
| Unemployed | 265 (77.9) | 14 (93.4) | – |
| Working | 75 (22.1) | 1 (6.6) | 15 (100) |
| Socio-economic class | |||
| Upper class | 166 (48.8) | – | 15 (100) |
| Upper middle class | 155 (45.6) | 15 (100) | – |
| Middle class | 15 (4.4) | – | – |
| Lower middle class | 3 (0.9) | – | – |
| Lower class | 1 (0.3) | – | – |
| Residence | |||
| Rural | 157 (46.2) | 2 (13.4) | – |
| Urban | 183 (53.8) | 13 (86.6) | 15 (100) |
Knowledge, attitude, and practice regarding HIV/AIDS
The emergent theme regarding HIV/AIDS was knowledge and misperceptions about HIV transmission and barriers to condom use and communication about safe sex. Under the first theme, misconceptions such as HIV spreading through tears, sweat, or mosquito bites were common among antenatal women, while HCPs also observed poor understanding about transmission. The second theme highlighted that women often felt hesitant to discuss or request condom use due to fear and stigma.
I heard that HIV could be transmitted through tears or sweat, so I won’t allow my children to play sports or even hug someone who is HIV positive – Antenatal women.
Women seem unable to have open communication about safe sex with their partners. We need to address this fear and stigma – HCP.
The study reveals a high level of HIV knowledge among participants, with 318 (93.5%) having awareness of HIV. Among the study participants, healthcare professionals (67.9%) were the highest source of information regarding HIV, while friends and family were the lowest source (2.6%). [Figure 1] and 300 (88.2%) exhibiting knowledge regarding the prevention of HIV during sexual intercourse. Knowledge regarding the prevention of HIV during sexual intercourse was observed in 300 (88.2%) participants. [Figure 2]. Among various contraceptive methods, barrier methods were the most commonly known (88.5%), whereas injectable methods were the least known (0.3%) [Figure 3]. Moreover, 310 (91.2%) participants were informed about the availability of blood tests for HIV [Table 2]. Most of the study participants supported the need for people living with HIV/AIDS (PLWHA) to reveal their HIV status in society 305 (89.7%), to continue working or studying 289 (85%), and to live with their family or friends 210 (61.8%). A majority also supported the need for sex education programs in schools 310 (91.2%). However, lower levels of support were observed for buying condoms 110 (32.4%) and requesting high-risk or casual partners to use condoms 100 (29.4%). The study also revealed low condom usage during sexual encounters with casual partners 9 (2.6%) and minimal dual use of condoms with other family planning methods for HIV and pregnancy prevention 3 (0.9%) [Table 2].
Figure 1.
Source of information about HIV (Multiple choice) among study participants
Figure 2.
Various modes of transmission of HIV (multiple choice answers) among study participants
Figure 3.
Various Methods of Contraception. (Multiple choice answers) * among study participants
Table 2.
Knowledge, attitude and practice regarding Human immunodeficiency virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) among study participants
| Variables | |
|---|---|
| Knowledge | Correctness of responses n=340(%) |
| Awareness of HIV | 318 (93.5) |
| HIV can be transmitted from one person to another | 301 (88.5) |
| HIV can be prevented by using condoms during sexual intercourse | 300 (88.2) |
| There is a blood test to detect HIV | 310 (91.2) |
|
| |
| Attitude | Agreement with responses n=340(%) |
|
| |
| People living with HIV could reveal themselves to society | 305 (89.7) |
| People living with HIV should not be separated/isolated from their families/friends | 210 (61.8) |
| People living with HIV should be allowed to continue working or studying | 289 (85) |
| Sex education is not shameful and should be included in school health programs | 310 (91.2) |
| Buying condoms from a pharmacy is not embarrassing | 110 (32.4) |
| It is necessary to request a high-risk partner to use a condom | 100 (29.4) |
| Reported practices | |
| I have used condoms to prevent HIV transmission during sex with casual partners | 9 (2.6) |
| I have used condoms along with other family planning methods (OCPs/IUCDs) for preventing HIV transmission and pregnancy | 3 (0.9) |
HIV: Human immunodeficiency virus, OCPs: Oral contraceptive pills, IUCDs: Intrauterine Contraceptive Devices
Knowledge, attitude, and practice regarding family planning
The emergent themes regarding family planning were knowledge of family planning services and accessibility, religious and socio-cultural attitudes toward family planning, and barriers to family planning practices. Under the first theme, limited awareness was evident as many antenatal women were unaware that family planning services are available free of cost in government facilities, a finding supported by HCPs who reported similar gaps in awareness among their patients. The second theme highlighted the influence of religious and socio-cultural beliefs, with some women perceiving family planning as religiously prohibited. HCPs also confirmed that such beliefs often persisted despite repeated counseling efforts. The third theme centered on spousal disapproval and control, where women’s decisions about contraception were strongly influenced by their husbands’ opposition or reluctance. HCPs observed that even motivated women often withdrew from adopting family planning measures due to a lack of spousal support and empowerment.
I was not aware that they are available free of cost in my nearby hospital; we usually buy it from the medical shop nearby. – Antenatal women.
It is haram according to our religion because we are preventing a living baby coming to the world. – Antenatal women.
I’ve encountered numerous cases where wives express interest in tubectomy. However, when the time comes, they often present excuses, such as their husband’s reluctance or disapproval. – HCP.
The study revealed a high level of awareness of family planning methods among participants, with 305 (89.7%) reporting awareness [Table 3]. Healthcare professionals were the most common source of information regarding family planning, while the least common was having not heard about family planning [Figure 4]. However, only 218 (64.1%) participants knew that family planning methods are available free of cost at government hospitals and health centers Knowledge regarding potential side effects of family planning methods was reported by only 57 (16.8%) participants, while 112 (32.9%) were aware of the importance of spacing pregnancies [Table 3]. Among participants who were aware of family planning methods, the most frequently reported reason for non-utilization was fear of side effects while lowest was financial constraints [Figure 5]. It is observed that 171 (50.3%) of women are comfortable discussing about family planning with partners. A total of 36 (10.6%) of participants acknowledge societal and cultural influences on family planning, while 102 (30%) recognize its importance for maternal health. Additionally, 93 (27.4%) advocates for at least a 3-year gap between pregnancies. Among the study participants, 208 (61.2%) reported satisfaction with current family planning options, and 223 (65.6%) had used contraceptives to prevent unwanted pregnancy; however, 51 (15%) discontinued contraceptive use due to side effects [Table 3].
Table 3.
Knowledge, attitude, and practice regarding family planning among study participants
| Variables | Correctness of the response n=340(%) |
|---|---|
|
| |
| Knowledge | |
| Awareness of various family planning methods | 305(89.7) |
| Knows about the free availability of family planning methods at govt. health centers and hospitals | 218 (64.1) |
| Knows potential side effects or risks associated with family planning methods | 57 (16.8) |
| Knows the importance of spacing of pregnancy | 112 (32.9) |
|
| |
| Attitude | Agreement of the responses n=340 (%) |
|
| |
| Comfortable discussing about family planning methods with a partner | 171 (50.3%) |
| There must be a minimum of 3 years’ spacing between consecutive pregnancies | 93 (27.4) |
| Believes family planning is important for personal and family well-being | 102 (30) |
| Religious and Socio-cultural factors influence the decisions in Family planning | 36 (10.6) |
| Satisfied with the current family planning options available | 208 (61.2) |
| Reported practice | |
| Used a contraceptive to prevent an unplanned pregnancy | 223 (65.6) |
| Stopped using family planning methods due to side effects | 51 (15) |
Figure 4.
Source of information regarding family planning method (Multiple choice) among study participants
Figure 5.
Reason for non utilisation of Family planning Method (Multiple choice answers) among study participants
DISCUSSION
In this study, the majority of participants, 318 (93.5%), had awareness of HIV similar to a study done by Sonali Sain et al.[8] in Maharashtra, where awareness of HIV was 93.8%. However, HIV awareness in this study was higher compared to the findings of Uruj Jahan et al.[9] conducted in Uttar Pradesh, where awareness of HIV was 54.9%. This difference may be due to the variation in study settings, as the current study was hospital-based, while Uruj Jahan et al.[9] conducted a community-based study. Further, healthcare personnel emerged as the foremost source of information. In contrast to these results, other studies by Harshadayani et al.[10] in Bangalore, Lucksom PG et al.[11] in northeast India, and Maimaiti et al.[12] in China highlighted the importance of the media as a key source of information. This difference could be due to regional variations in media reach, literacy levels and the presence of structured awareness campaigns in those areas.
In this study, the majority of participants had awareness of unprotected sexual intercourse as a mode of HIV transmission, similar to studies done by Shree V et al.[13] in Patna, Bhalge U et al.[14] in central India, and Lal P et al.[15] in Delhi. In this study, 89.7% of respondents were aware of various family planning methods, while a study by Sangavi R et al.[16] reported that 78% of study participants had knowledge about family planning and this may be due to difference in sample size.
In this study, condoms were the most commonly used family planning method, consistent with findings from studies by Handady SO et al.[17] in Sudan, Prachi R et al.[18] in Sikkim, and Renjhen P et al.[19] in Sikkim. This reflects the availability, affordability, and promotion of condoms as both a family planning and HIV prevention method. However, in a study by Ibrahim G et al.[20] in Nigeria, oral contraceptives and injectables were the most commonly used contraceptives and this difference likely arises from cultural preferences and variations in healthcare delivery systems.
Further, this study showed that antenatal women, despite having positive knowledge and attitudes toward family planning and HIV prevention, actual practice remains low. Key barriers include religious and cultural opposition and misconceptions about contraception, spousal disapproval, fear and stigma surrounding HIV testing and condom use, as well as poor awareness of free services and widespread misinformation about HIV transmission.
CONCLUSION AND RECOMMENDATION
This study highlights high HIV knowledge among study participants. Study participants demonstrate positive attitudes toward PLWHA, but stigma persists around condom use. Policymakers should focus on enhancing awareness of family planning options, particularly those available at no cost, and ensure that gender-sensitive programs support women in making informed reproductive health choices. To improve public health outcomes, it is crucial to strengthen the integration of HIV prevention in antenatal care and promote targeted education on both HIV transmission and contraceptive methods. Addressing stigma through community outreach and ensuring open communication in partnerships are essential strategies.
Limitation
The study’s findings may not fully represent all antenatal women, as it only included those attending a specific hospital and excluded younger (<15 years) and older (>50 years) women. Moreover, since the research was conducted at a single tertiary care center, the results may not be applicable to other settings or populations, which limits the generalizability of the findings. A deeper statistical analysis to explore relationships was not done.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Goa State AIDS Control Society
REFERENCES
- 1.Epstein H, Whelan D, van de Wijgert J, Mane P, Mehta S. HIV/AIDS prevention guidance for reproductive health professionals in developing-country settings. Population Council. 2002 [Google Scholar]
- 2.National AIDS Control Organization and ICMR-National Institute of Medical Statistics. India HIV Estimates 2021: Fact Sheet. New Delhi: NACO, Ministry of Health and Family Welfare, Government of India; 2022. [[Last accessed on 2024 Jan 11]]. Available from: https://naco.gov.in/sites/default/files/India. HIV Estimates 2020-21Fact Sheets Final Shared 24 08 2022.pdf. [Google Scholar]
- 3.Bhatta M, Majumdar A, Ghosh U, Ghosh P, Banerji P, Aridoss S, et al. Sexually transmitted infections among key populations in India: A protocol for systematic review. PLoS One. 2023;18:e0279048. doi: 10.1371/journal.pone.0279048. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Guidance on Global Scale-Up of the Prevention of Mother-to-Child Transmission of HIV: Towards Universal Access for Women, Infants and Young Children and Eliminating HIV and AIDS among Children. Geneva: World Health Organization; 2007. [[Last accessed on 2024 May 12]]. Available from: https://apps.who.int/iris/handle/10665/43728 . [Google Scholar]
- 5.Integrating Family Planning into HIV Programs: Evidence-Based Practices. [[Last accessed on 2024 Apr 23]]. Available from: https://www.fhi360.org/wp-content/uploads/drupal/documents/fp-hiv-evidencebasedpractices2013.pdf .
- 6.India's vision FP 2030. New Delhi. Family planning Division. Ministry of Health and Family Welfare. 2022. [[Last accessed on 2024 Apr 13]]. Available from: https://www.fp2030.org/app/uploads/2023/08/India_FP2030_Vision_Document.pdf .
- 7.International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21. I. Mumbai: IIPS; 2021. [Google Scholar]
- 8.Sain S, Dey I, Mukhopadhyay P. Knowledge and awareness of HIV/AIDS: A study among antenatal mothers attending a tertiary hospital of West Bengal. IOSR J Dent Med Sci. 2018;17:23–7. [Google Scholar]
- 9.Jahan U, Verma K, Gupta S, Dwivedi S, Yadav A. Awareness, knowledge and attitude of pregnant women towards HIV/AIDS in tertiary care hospital: A community based study. Int J Adv Res. 2017;5:494–500. [Google Scholar]
- 10.Harshadayani, Jagadevi, Padmashri Awareness regarding mother to child transmission of HIV among antenatal patients attending antenatal clinic in a tertiary medical hospital, Bangalore. J Med Sci Clin Res. 2017;5:22821–8. [Google Scholar]
- 11.Lucksom PG, Upadhya R, Kharka L, Dubey S, Choudhary N, Yadav R. KAP study on HIV/AIDS among antenatal women attending central referral hospital of north east India. J Obstet Gynaecol India. 2016;66(Suppl 1):55–9. doi: 10.1007/s13224-015-0767-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Maimaiti R, Andersson R. Awareness and attitudes about HIV among pregnant women in Aksu, northwest China. Open AIDS J. 2008;2:72–7. doi: 10.2174/1874613600802010072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Shree V, Prasad RR. Awareness of HIV/AIDS amongst pregnant women of rural areas, Patna: A community based study. Int J Sci Res. 2015;4:106–10. [Google Scholar]
- 14.Bhalge UU, Khakse GM, Brahmapurkar KP, Thorat R, Shrote VK. Awareness regarding HIV/AIDS in ANC client in tribal district of central India. J Dental Med Sci. 2012;2:44–9. [Google Scholar]
- 15.Lal P, Nath A, Bandhan S, Ingle GK. The study of awareness about HIV/AIDS among senior secondary school children of Delhi. Indian J Community Med. 2010;33:190–2. doi: 10.4103/0970-0218.42063. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Sangavi R, Hatnoor S. Knowledge attitude and practice of contraception among antenatal care patients. Int J Reprod Contracept Obstet Gynecol. 2018;7:3065–9. [Google Scholar]
- 17.Handady SO, Naseralla K, Sakin HH, Alawad AM. Knowledge, attitude and practice of family planning among married women attending primary health center in Sudan. Int J Public Health Res. 2015;3:243–7. [Google Scholar]
- 18.Prachi R, Das GS, Ankur B, Shipra J, Khati B. A study of knowledge, attitude and practice of family planning among the women of reproductive age group in Sikkim. J Obstet Gynecol India. 2008;58:63–6. [Google Scholar]
- 19.Renjhen P, Kumar A, Pattanshetty S, Sagir A, Samarasinghe CM. A study on knowledge, attitude and practice of contraception among college students in Sikkim, India. J Turk Ger Gynecol Assoc. 2010;11:78–81. doi: 10.5152/jtgga.2010.03. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Ibrahim G, Rabiu A, Abubakar IS. Knowledge, attitude and practice of contraceptives among grand multiparous women attending antenatal clinic in a specialist hospital, Kano, Nigeria. Niger J Basic Clin Sci. 2015;12:90–4. [Google Scholar]