Knowledge, awareness and use of HIV services among the youth from nomadic and agricultural communities in Tanzania

Abstract

BACKGROUND:

Nomadic life not only prevents the community from accessing and utilising HIV services but also deters them from obtaining reliable information on HIV.

METHODS:

We conducted a cross-sectional study of youth aged 10–24 years from the Kilindi and Ngorongoro Districts in Tanzania to assess knowledge, accessibility and utilisation of HIV/AIDS services among nomadic and agricultural youths.

RESULTS:

Of 518 youths interviewed, 279 (53.9%) were males, and 276 (53.3%) were from agricultural communities. A significant proportion of youths from agricultural communities had correct knowledge of AIDS (n = 126, 45.8%; P = 0.002), HIV transmission (n = 273, 98.9%; P = 0.001) and comprehensive knowledge of HIV/AIDS (n = 78, 28.5%; P = 0.009) compared to nomads. Youths from agricultural communities were two times (OR 1.8, 95% CI 1.2–2.6) more likely to be aware of the availability of formal HIV services. Awareness of the availability of HIV services was higher among married individuals than in unmarried ones (OR 3.8, 95% CI 2.0–7.4), and significantly higher among youths with secondary/college education than in those who did not have formal education (OR 5.3, 95% CI 2.3–12.4). The uptake of HIV services was lower among nomadic youths.

CONCLUSION:

Knowledge, awareness and utilisation of HIV/AIDS transmission services were low in general, and even lower among nomadic youths, calling for more targeted interventions.

Adolescents and young people represent a significant proportion of people living with HIV worldwide.² Adolescence is a dynamic developmental phase that is associated with significant physiological and psychosocial changes that may, to some extent, contribute to increased HIV/AIDS risk, especially when there is poor and limited availability of healthcare services.¹ In 2019 alone, 460,000 young people aged 10– 24 years were newly infected with HIV, of whom 170,000 were adolescents aged 10–19 years.² This worrying global trend is even worse in sub-Saharan Africa, where young and adolescents, especially women continue to be disproportionately affected by HIV.³ Adolescents, especially those living in poverty, are at heightened risk for HIV/AIDS, and the majority drop out of school to help their families survive.⁴ Many women get pregnant or give birth before the age of 18; three times more cases are therefore reported from rural areas and poor communities.⁵

Despite recent advancements in treatment strategies, many people with HIV or at risk for HIV still do not have access to HIV services. This is particularly true for sub-Saharan Africa, where a considerable population infected with HIV are unaware of their status and, once diagnosed, experience high rates of loss to follow-up. In Tanzania, 5.1% of its population is HIV-infected, while 2% of youth aged 15–24 years are HIV-positive.⁶ The sexual debut of adolescents in Tanzania has been reported to be as low as 9 years; hence, the higher risk of acquiring HIV/AIDS and other sexually transmitted diseases.⁷ Although there has been an increase in knowledge among the youth (15–24 years), comprehensive and accurate understanding of HIV remain below average.⁸

Nomadic communities constantly change locations; ensuring the accessibility of HIV services to these communities might thus prove challenging than when dealing with communities in permanent settlements.⁹ Inadequate access to comprehensive sex education among youths who are sexually active undermine efforts aimed at protecting them from contracting HIV through access to high-quality HIV services.^9,10 Utilisation of the HIV services can also be hampered by limited financial resources, lack of health care facilities and poor means of transport.¹¹ The availability and accessibility of HIV/AIDS services, coupled with raising awareness among children approaching sexual maturity, offer the best hope in HIV prevention. This article highlights the difference in terms of HIV knowledge, awareness, accessibility, and utilisation of HIV services among youths from nomadic and agricultural communities as a means to understanding barriers to the optimal utilisation of HIV/AIDs services among such communities.

METHODS

This was a cross-sectional study conducted in 2010 involving youths from nomadic and agricultural communities living in the districts of Kilindi (Tanga Region) and Ngorongoro (Arusha Region) in Tanzania. We used both qualitative and quantitative data collection approaches. The study was conducted at three different levels: health care facilities, schools (secondary and primary) and at the community level. Data were collected using semi-structured interviews of youths aged 10–24 years and in-depth interviews with key informants (KIs).

Study areas

The study was conducted in Ngorongoro and Kilindi Districts in Arusha and Tanga Regions, respectively. Kilindi (area: 6444 km²; population: 236,833)¹² is one of the eight districts of Tanga Region, located in the north-east of Tanzania and bordered to the east by the Handeni District and Handeni Town Council, to the north and west by the Kilimanjaro Region and the south by the Morogoro Region.

Ngorongoro District (area: 14,036 km²; population: 174,278)¹² is one of the five districts of the Arusha Region, located in northern Tanzania and bordered to the north by Kenya, to the east by Monduli District, to the south by the Karatu District and the west by the Mara Region. The district is mainly inhabited by Maasai people whose major socio-economic activity is pastoralism.

Sampling procedure and data collection

Selection of adolescents

The two districts of Ngorongoro and Kilindi were purposefully selected due to the presence of both cultivators and pastoralists. Villages in the districts were listed based on predominant economic activities (cultivators vs. pastoralists) to ensure mutual exclusivity of the population study. Four villages were randomly selected in Ngorongoro: two villages with the majority of cultivators and the remaining two villages where the majority were pastoralists. Nine villages were selected in Kilindi District, of which five villages had a large proportion of cultivators, whereas the remaining four villages had a large proportion of pastoralists. In the selected villages, we conducted interviews with both in-school and out-of-school youths (i.e., have either never been to school or have completed their primary or secondary schools, or were school dropouts). To gain access to both in-school and out-of-school youths, interviews were conducted at schools and in the community. Primary students aged 10–14 years were conveniently selected to participate in the study, while all secondary school classes were eligible for sampling and participation in the study. Systematic random sampling was used to select 10% of students from each class (primary or secondary schools). The sampling interval of 10 was used to select participants after random (simple random) selection from the list. Out-of-school youths were selected from households under the custody of the 10 cell leaders. With assistance from the 10 cell leaders, households with boys and girls aged 10–24 years were listed and selected using a simple random method, and consented respondents were interviewed. We collected data to ascertain awareness and knowledge on HIV/AIDS and HIV/AIDS services offered, as well as the perception of the accessibility and utilisation of the services. In addition, we gathered information on knowledge on possible informal sectors that offered HIV services and factors that might hinder proper HIV/AIDS service utilisation among the youth.

Selection of healthcare workers

A district hospital from each district was purposefully included in the study. In collaboration with the respective district medical office, we made two separate lists – one for all health centres and another one for all dispensaries available in each district and selected 10% of the health centres and 5% of the dispensaries (one health centre and one dispensary per district). We gathered information on possible factors considered to contribute to the low utilisation of HIV/AIDS-related services, as well as the perceived appropriateness of HIV/AIDS services delivered from healthcare workers.

Selection of the key informants

KIs were purposefully selected to cover a wide range of sources of HIV/AIDS service delivery information among youth. Key informant interviews (KIIs) were conducted with the district AIDS coordinators, council multi-sectorial HIV/AIDS coordinators and village leaders. We collected information on the availability, accessibility, and utilisation of HIV/AIDS services among youth and any perceived hindering factors.

Sample size

A minimum sample size of 572 respondents from both Kilindi and Ngorongoro Districts was calculated using a proportion of 45% of youths with comprehensive knowledge about HIV/AIDS⁶ at 80% power of a test, marginal of error 5% and 1.5 design effect to clear variations between clusters. The sample size was then adjusted by adding a non-response rate of 10% making a total of 628 respondents.

Data collection

Semi-structured questionnaires were used to collect information on HIV/AIDS awareness and service availability, accessibility and utilisation among youths. In-depth interview guides were used to gather the desired HIV services-related information from the KIs and health service providers. Before the actual data collection, pre-testing was performed to validate the questionnaire tool.

Data management and analysis

Quantitative data analysis

Data were double-entered and cleaned using EpiData v3.1 (EpiData Association, Odense, Denmark). For open-ended responses, the study team coded the responses before the actual analysis. Cleaned data were exported to Stata v3.1 (Stata Corp, College Station, TX, USA) for analysis. Cross-tabulation using the χ² test was performed to assess the relationship between dependent variables and explanatory variables. For all variables with a P value of ⩽ 0.05, univariate analysis was performed to examine the odds of one outcome for an explanatory variable which includes the background characteristics of the nomadic and agriculturalist youths.

A youth was regarded as having correct knowledge about HIV/AIDS when they responded correctly that a HIV-infected person is a person living with HIV, while AIDS is a state of being ill due to opportunistic infections among HIV-infected persons. When a student who correctly answered questions on HIV and AIDS was deemed to have comprehensive knowledge of HIV/AIDS. Knowledge of prevention was categorised as correct if a youth responded correctly on important aspects of behaviour: always using condoms, staying faithful to one partner and abstinence. A youth who mentioned all three was considered to have comprehensive knowledge of HIV prevention. Knowledge of HIV transmission was considered correct if a youth was able to mention any of the four transmission routes: sexual intercourse, sharing of sharp instruments with an infected person, HIV-infected blood transfusions, HIV transmission from mother-to-child. If they mentioned all four, they were considered to have comprehensive knowledge of HIV transmission.

Qualitative data analysis

Voice-recorded interviews were transcribed for content-coding and a senior social scientist went through all the transcripts and audios to confirm their correctness and completeness. A few selected interviews were individually examined by the research team to ensure quality of the transcription. The transcripts were then subjected to thematic analysis according to Braun and Clarke’s method.¹² A stepwise approach was used for the thematic analysis of the qualitative data. At first, several themes were generated from the research questions on a consensual basis (deductive logic). These were then coded, and matrices were developed based on key themes. Patterns, including similarities and differences, were documented, and important quotes in the participants’ own words were included in the data analysis. Thematic analysis was conducted to generate information on sources of HIV/AIDS service delivery among youths. The KIs were systematically analysed for their content, taking note of confounding issues or inconsistencies, as well as contradictory responses in the themes.

Ethics approval and consent to participate

The study protocol received ethical clearance from the Medical Research Co-ordinating Committee of the National Institute for Medical Research, Dar es Salaam, Tanzania, before it was implemented. All study participants aged ⩾18 years provided written informed consent; written informed consent was obtained from parents or guardians those who aged <18 years. Assent for minors, risks, benefits and comfort of the respondents were followed as required as per the research ethical guidelines.

RESULTS

Sociodemographic characteristic

Table 1 gives the sociodemographic characteristics of the participants. A total of 518 respondents were interviewed; males comprised the majority (53.9%) of the study population. The age range of the study participants was 10–24 years; mean age of youths from agricultural and nomadic communities was respectively 17.9 years (standard deviation [SD] 3.4) and 17.2 years (SD 3.6). The majority (n = 146, 53.9%) from farming communities had completed their secondary school education, compared to 98 (41.0%) youth from the nomadic communities.

TABLE 1.

Social demographic characteristics of study participants

Variable	Agriculturalist youth n (%)	Nomadic youth n (%)
District
Kilindi	137 (49.6)	99 (40.9)
Ngorongoro	139 (50.4)	143 (59.1)
Age, years
Mean ± SD	17.9 ± 3.4	17.2 ± 3.6
<18	142 (51.4)	136 (56.4)
⩾18	134 (48.6)	105 (43.6)
Sex
Male	144 (52.2)	135 (55.8)
Female	132 (47.8)	107 (44.2)
Occupation
Petty trader	23 (8.4)	5 (2.1)
Unemployed	16 (5.8)	4 (1.7)
Agriculture and animal husbandry	137 (49.8)	106 (43.8)
Student	99 (36.0)	127 (52.5)
Marital status
Married	54 (20.1)	48 (19.9)
Single	214 (79.9)	193 (80.1)
Education level
No formal education	15 (5.5)	24 (10.0)
Primary education	110 (40.6)	117 (49.0)
Secondary school education	146 (53.9)	98 (41.0)

SD = standard deviation.

Knowledge of HIV transmission and prevention

Table 2 gives information on the knowledge of HIV transmission and its prevention among youths. A higher proportion of youth from agricultural communities had correct knowledge of what constitutes AIDS than youths from the nomadic communities (45.8% vs. 32.2%; P = 0.002). Correct knowledge on whether HIV can be transmitted from one person to another was significant higher among youths from the agricultural than those from nomadic communities (98.9% vs. 92.2%; P = 0.001). Similarly, correct knowledge on whether HIV can be transmitted through sharing of sharp instruments was higher among youth from agricultural communities than in youths from nomadic communities (80.4% vs. 55.4%; P = 0.001). The majority of youth from cultivator communities were more likely to be aware that HIV is preventable (83.6% vs. 76%; P = 0.032).

TABLE 2:

Knowledge of HIV transmission, prevention and comprehensive knowledge of HIV/AIDS among youth from agriculturalist and nomadic communities

Variable	Agriculturalist n (%)	Nomad n (%)	P value
Knowledge of HIV transmission
Correct knowledge of HIV	84 (30.7)	82 (33.9)	0.434
Correct knowledge of AIDS	126 (45.8)	78 (32.2)	0.002
Correct knowledge of whether HIV can be transmitted from one person to another	273 (98.9)	223 (92.2)	0.001
Correct knowledge of whether HIV can be transmitted through sexual intercourse	247(89.5)	204 (84.7)	0.10
Correct knowledge whether HIV can be transmitted through sharing of sharp instruments with an infected person	222 (80.4)	134 (55.4)	0.001
Correct knowledge of whether HIV can be transmitted through infected blood transfusions	77 (27.9)	62 (25.6)	0.559
Correct knowledge of whether HIV can be transmitted from mother to child	30 (10.9)	24 (9.9)	0.723
Knowledge of HIV prevention
Correct knowledge of whether HIV is preventable	225 (83.6)	184 (76.0)	0.032
Correct knowledge of whether HIV can be prevented through the use of a condom during sexual intercourse	160 (58.0)	96 (39.7)	0.001
Correct knowledge of whether HIV can be prevented through avoidance of sharing of sharp instruments	138 (50.0)	94 (39.0)	0.012
Correct knowledge of whether HIV can be prevented through sexual abstinence	95(34.4)	99 (40.9)	0.128
Correct knowledge HIV can be prevented through sexual intercourse with one non-infected partner	35 (12.7)	43(17.8)	0.106
Comprehensive knowledge of HIV/AIDS
Comprehensive knowledge of HIV/AIDS	78 (28.5)	45 (18.6)	0.009
Comprehensive knowledge of HIV transmission routes	18 (6.5)	17 (7.1)
Comprehensive knowledge of HIV preventive routes	8 (2.9)	3 (1.2)

Awareness on the availability and utilization of HIV/AIDS preventive and care services

Table 3 shows that youths from agricultural communities were more likely to be aware (OR 2.4, 95% CI 1.6–3.6) of the availability of formal health care facilities with HIV counselling services than youths from nomadic communities. Youths from farming communities were more likely to be aware of the available formal healthcare facilities with HIV testing and care and treatment services in their communities than youths from nomadic communities. It was unlikely for youths from nomadic to be aware of the presence of traditional healers, religious leaders and community leaders who deliver HIV services in their communities (OR 0.3, 95% CI 0.1–0.7; OR 0.6, 95% CI 0.4–0.9; and OR 0.5, 95%CI 0.3–0.9, respectively). The use of informal health care facilities for HIV services was lower among youths from nomadic communities than their agricultural counterparts (OR 0.6, 95% CI 0.4–0.9). Youths from nomadic communities were more likely (OR 4.0, 95% CI 2.7–6.0) to spend more than 30 minutes to get to the nearest healthcare facility with HIV services than youths from agricultural communities.

TABLE 3.

Awareness of youth on the availability and utilisation of formal and informal healthcare services in their communities ^*

Variable	Total	Agriculturalist youth n (%)	Nomadic youth n (%)	OR (95% CI)
Awareness of the availability of the following formal health care facilities:
HIV counselling	285	174 (61.1)	111 (39.0)	2.4 (1.6–3.6)
HIV testing	303	186 (61.4)	117 (38.6)	2.6 (1.7–3.8)
Care and treatment	222	131 (59.0)	91 (41.0)	1.8 (1.2–2.7)
Awareness of the availability of informal healthcare facilities with HIV services
Traditional healers	48	14 (29.2)	34 (70.8)	0.3 (0.1–0.7)
Religious leaders	104	44 (42.3)	60 (67.7)	0.6 (0.4–0.9)
Community leaders	85	34 (40.0)	51 (60.0)	0.5 (0.3–0.9)
Ever attended health care facility for HIV services
HIV counselling	173	94 (54.30	79 (45.7)	1.1 (0.8–1.6)
HIV testing	180	102 (56.7)	78 (43.3)	1.3 (0.9–1.8)
Care and treatment	40	21 (52.5)	19 (47.5)	1 (0.5–1.9)
Informal health care facility for any HIV services	72	30 (41.7)	42 (58.3)	0.6 (0.4–0.9)
Average time to the nearest formal health care facility with HIV services, min
<30	179	133 (74.3)	46 (25.7)	4.0 (2.7–6.0)
⩾30	324	136 (42.0)	188 (58.0)

* Nomadic community is the reference group.

OR = odds ratio; CI = confidence interval.

Perception of the key informants on the quality, accessibility and utilisation of HIV services

A total of 14 key informants (6 men, 8 women) with over 10 years’ working experience were interviewed; of these, half were from Ngorongoro. Two were district HIV/AIDS coordinators, two council HIV/AIDS coordinators, two community leaders and eight healthcare workers working at either of the following departments: care and treatment centres, prevention of maternal to child transmission of HIV, and voluntary counselling and testing. We also interviewed nurses in charge of the healthcare facilities. Ten KIs had secondary school education with additional professional training, 3/14 had secondary school education and 1/14 had received primary school education. Nine were married, four were single and one was widowed.

Of the 54 healthcare facilities with any of the HIV services, 25 (46.3%) were located in nomadic communities compared to 29 (53.7%) in agricultural communities. Only six facilities in each community provided care and treatment services. Informal service providers that extend HIV services to clients were also available in both communities. Six out of seven KIs from nomadic communities and 2/7 from agricultural communities reported having traditional healers, religious leaders and non-governmental organisations that provide HIV services. Traditional healers were reported to provide traditional remedies that cure HIV and other opportunistic infections. Religious leaders were reported to provide spiritual services that can cure HIV. HIV services provided in nomadic communities were reported by 6/7 KIs to be poor, with insufficient supply of HIV test kits, antiretrovirals (ARVs) and lack of qualified staff. Five of the seven KIs from agricultural communities reported that services to be very good because of the availability of well-trained staff, equipment, reagents and HIV test kits and ARVs. More than 50% of employees who provided HIV services in both communities had received on-the-job training in HIV services. During the quantitative interviews, it was noted that 63 (34.2%) youths from nomadic communities could not get all HIV services they needed during their last visit to a health facility for HIV services; 62 (40.0%) youths from agricultural communities reported similar observations. Missing services included voluntary counselling and testing, as well as HIV education, supply of condoms, ARVs, sexually transmitted infection services and sexual reproductive health education. Some of the youths reported returning home without HIV service due to long queues.

KIs also reported lack of youth-friendly services, nomadic life, low education among communities, misleading beliefs (for e.g., nomadic communities, especially the Maasai cannot be affected by HIV), poor infrastructures, distant healthcare facilities and widely dispersed communities as contributing factors for the underutilisation of HIV services.

…stigmatisation among groups of young people and wrong perception about HIV contribute to the failure of many young people to access and utilise HIV services. (KI from a nomadic community)

Challenges highlighted by the majority of the KIs in nomadic communities included the inferior position of women, especially in the Maasai communities, where the majority of women do not participate in HIV education. Traditional beliefs, cultural values and customs that govern the Maasai community with regard to matters of sexuality and sex education affecting their children continued to be a barrier to providing HIV-related education in these communities. Some patients mentioned that food scarcity prevented them from taking ARVs. Factors contributed to poor accessibility and utilisation of HIV services among youths from agricultural communities included distance of facilities from the community, food scarcity that made some patients discontinue ARV intake, and lack of confidentiality and lack of financial resources to execute planned HIV activities.

Youth feels embarrassed to take HIV test and pick-up condoms from the open areas free of charges; instead, they find some other [more discrete] ways of getting condoms or having unprotected sex. (KI from an agricultural community)

DISCUSSION

The results from this study highlight several differences in awareness, knowledge, perception and utilisation of HIV among youths from nomad and agricultural communities. Youths from agricultural communities were more knowledgeable, with correct perceptions about prevention and control of HIV, including the availability of formal HIV services than their counterparts from nomadic communities. Although causality cannot be determined from cross-sectional data, it is reasonable to assume that youth with correct knowledge about HIV transmission and prevention have a better understanding of HIV risk factors, and possibly may feel more capable of reducing their risk of contracting HIV as reported previously.^13,14 The nomadic way of life may deprive nomad communities of being reached by health and development programmes.⁹

Although knowledge of HIV/AIDS was found to be higher among youths from agricultural families, only one third of youth in both communities had correct knowledge of AIDS. More than three quarters of youth living in both communities failed to differentiate between HIV and AIDS. These results contradict those of the general population reported by the Tanzania Demographic and Health Survey 2010,⁶ which reported that the majority of Tanzanian adults were aware that people infected with HIV do not necessarily show signs of infection. In this survey, 85% of women and 87% of men were reported to know that a healthy-looking person could have the virus that causes AIDS.⁶ The difference between the two studies can be attributed to the communities involved in the studies. In our study, we involved two very rural communities, whereas the 2010 demographic survey involved both urban and rural communities; data from urban communities may conceal the knowledge gap that exists in remote areas of the country. Moreover, nomadic communities tend to be reserved and non-inclusive that are fiercely attached to their norms and cultural values. The huge difference in the knowledge between the two communities from that of the general population calls for more efforts targeted to these communities.

In Tanzania, HIV/AIDS prevention programmes focuse on three important aspects of behaviour: the use of condoms, staying faithful to one partner and delaying sexual debut (abstinence) in the young and never-married adults. The level of HIV knowledge among youths was higher in agricultural than in nomadic families; however, less than 50% of the youths in both communities could only mention at least one correct method of HIV prevention. Less than 5% of the youth in both study communities had a correct comprehensive knowledge of HIV prevention. Previous studies have shown that a low level of knowledge of HIV/AIDS and HIV prevention routes have been negatively associated with a variety of sexual health-related attitudes and beliefs.^15,16 Contrary to the data from the Tanzania Demographic and Health Survey 2010 that show more than 70% of individuals aged 15–24 had a correct comprehensive knowledge of HIV transmission,⁶ our study demonstrates that this is not the case among the nomadic and agricultural communities living in Kilindi and Ngorongoro Districts, where a high number of youths lacked comprehensive knowledge on how HIV/AIDS is transmitted. Although HIV prevalence in the study communities is still very low,¹⁷ the high rate of urbanisation and movement of people between urban and rural areas may subject the youth to the increased risk of HIV transmission,¹⁸ especially if infected youth enter the circle.

Formal healthcare facilities with quality HIV services were more available in agricultural than in nomadic communities. Awareness about the availability of formal HIV services was two times higher among youths living in agricultural communities. Other studies have shown that the availability and awareness of the services are mandatory in any service utilisation; the opposite may deter somebody from seeking and utilising such services.^18,19 Married youths had increased odds of awareness than those who were not married from both communities, while utilisation of formal HIV services was higher among youths from agricultural communities than those from nomadic communities. Informal health care facility utilisation for the same services was lower in nomadic communities. Although in the recent past, the focus has shifted from a health care perspective to multi-sectoral approaches for the delivery of HIV services, the services offered by some informal sectors (traditional healers and religious leaders) in the two districts are far beyond the scope of their capacities. Such services included claiming to treat HIV/AIDS, offering HIV counselling and testing.

HIV services in nomadic communities were located far from their homes, and youths had to spend more than half an hour to get to the nearest health care facility with HIV services. However, factors such as lack of youth-friendly services and privacy in healthcare facilities may prevent some from seeking the services. Hunger was highlighted in this study as one of the barriers to accessing and utilising HIV services; in some cases, patients discontinued ARV use due to lack of food. Similar findings have been reported previously.¹⁴ The remoteness of the nomadic communities, poor infrastructures such as roads, and poor distribution of healthcare facilities may explain the problems besetting these communities.

Limitation

Possible limitations of this study include possible biases such as recall bias. In addition, we did not assess the impacts of other barriers (e.g., sociocultural and financials barriers) to accessibility and utilisation of HIV services.

CONCLUSION

Knowledge and utilisation of HIV/AIDS transmission and prevention services were low among youths in both communities. However, youths from nomadic communities had significantly lower knowledge and less awareness of HIV and AIDS than youths from agricultural communities. Provision of continued education about HIV/AIDS transmission and prevention is therefore imperative.