alexa Does School Health Education on Voluntary Counseling and Testing Make a Significant change for HIV/AIDS Prevention? A Case of High School Students in Hossana Town, Ethiopia: A Cross Sectional Study
ISSN: 2161-0711
Journal of Community Medicine & Health Education

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Does School Health Education on Voluntary Counseling and Testing Make a Significant change for HIV/AIDS Prevention? A Case of High School Students in Hossana Town, Ethiopia: A Cross Sectional Study

Feleke Doyore*

Department of Public Health, Faculty of Medicine and Health Sciences, Wachemo University, Ethiopia

*Corresponding Author:
Feleke Doyore
Department of Public Health, Faculty of Medicine and Health Sciences
Wachemo University, Hosanna, P.O: 667, Ethiopia
Tel: +251916291489, 0932685424
E-mail: [email protected], [email protected]

Received date: January 17, 2014; Accepted date: February 21, 2014; Published date: February 24, 2014

Citation: Doyore F (2014) Does School Health Education on Voluntary Counseling and Testing Make a Significant change for HIV/AIDS Prevention? A Case of High School Students in Hossana Town, Ethiopia: A Cross Sectional Study. J Community Med Health Educ 4:277. doi:10.4172/2161-0711.1000277

Copyright: © 2014 Doyore F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Back ground: Almost three decades after the first clinical cases of acquired immunodeficiency syndrome (AIDS) were reported. Its epidemics killed millions of people and became a major public health problem. To halt the epidemics, HIV counseling and testing is one of the strategies. Though HIV testing is critical for behavior modification in getting support and entry point for engagement on treatment, many people are missing these opportunities. This study was aimed to consider how people are reacting for health communication on voluntary counseling and testing as HIV prevention messages using Extended Parallel Process Model (EPPM). Method: Cross-sectional study design was conducted using quantitative and qualitative methods of data collection. Structured and pre-tested self administered questionnaires were used to collect data. Simple random sampling method was used to select students from each school. Quantitative data were analyzed using SPSS version 16.0. Qualitative data was analyzed using Atlas software. Results: 78.68% (321/408) participants were found in fear control psychological responses where as 21.32% (87/408) participants were found in danger control responses. As independent predictors, self efficacy [AOR (95%CI)=4.13 (3.37 to 5.01)], response efficacy [AOR (95%CI)=3.21(6.89 to 9.09)] of HIV/AIDS, participants ever tested [AOR (95%CI)=4.31 (7.01 to 9.08)] and residence [AOR (95%CI)=4.13 (2.43 to 7.32)] were positively associated with danger response responses where as perceived susceptibility to [AOR (95%CI)=0.42 (0.44 to 0.61)] and perceived severity of [AOR (95%CI)=0.33 (0.21 to 0.74)] HIV/AIDS were negatively associated with danger response. The EPPM Model explained 70.09% of variance in this study. Conclusion: Despite higher number of students in fear control psychological responses, there is considerable gap between discriminative scores and actual behaviors. Therefore, due attention should be given to fill the gap of perception of risk of both threat and efficacy in their residence.

Keywords

School health; VCT; Danger or Fear control; Discriminative scores

Introduction

Almost three decades after the first clinical cases of acquired immunodeficiency syndrome (AIDS) were reported. Its epidemics killed millions of people and became a major public health problem [1,2]. Various preventive strategies have been employed to curb the spread of this infection as there is presently no cure. Abstinence, avoidance of multiple sexual partners, condom use, voluntary counseling and testing (VCT) and treatment of HIV-infected individuals form the cornerstone of HIV prevention [2]. VCT has been introduced in many low-resource settings as it helps to create awareness of an individual’s HIV status and offers the opportunity for counseling on risk behavior modification. It also lessens stigma and has become a first step to accessing care [2,3].

As HIV epidemics control strategy, some of the key benefits of learning one’s HIV status through HIV counseling and testing (HCT) include: knowledge about HIV, individual or couple-based HIV prevention counseling, education on HIV prevention strategies, linkages to other relevant services may enable them to live a longer and better quality of life with HIV especially if accessed early [4,5].

In Ethiopia, the transmission of HIV/AIDS is more of heterosexual (99%). Thus, preventive behaviors are the only choices to protect youths from the epidemic in the absence of effective medical care [6].

According to federal HIV/AIDS prevention and control office, the adult HIV prevalence in urban areas is much higher (7.7%) than rural areas (0.9%) [7]. considering this devastating effect different stakeholders and ministry of health have conducted different IEC/BCC interventions. However, behavioral change was not yet attained in a level that reduces transmission and reverses the epidemics [8].

Thus, with efforts to increase the number of individuals who know their HIV status, to decrease the prevalence of undiagnosed HIV infection, and to promote early diagnosis and treatment of HIV infection, the WHO and CDC in 2007 have recommended HCT scale up to provider-initiated HIV Counseling and testing services in health care settings while strongly supported the continued existence of VCT [2].

Since 1998, Voluntary counseling and testing for the larger community started in Ethiopia after the National HIV/AIDS policy was launched in August 1998, and VCT guidelines were developed in 2000 [9]. In January 2005, a programme to provide access to antiretroviral therapy on free of charge was launched with commitment to expanding VCT services [10].

Regardless of the enormous resources and strengthened interventions, the behavioural change was not yet attained to calm the spread of the epidemic and desired declines in HIV/AIDS infections has not been achieved [8,11]. Theories and models help to explain the process that individuals how people exchange information and as they interpret and react to different messages.

In this study, Extended Parallel Process Model (EPPM) attempts to explain when and why the recommended message work or fail. Since the EPPM restores the concept of fear as a central variable in investigating fear appeal. According to the initial tenets of the EPPM, when an individual is exposed to a fear appeal, two cognitive appraisals of the message will occur: first, the “appraisal of the threat” and second, the “appraisal of the efficacy” of the message’s of recommended response (as a problem (threat) and solution (efficacy information). EPPM assumes that if the perceived threat is perceived to be high (for instance, “AIDS takes life”) and the level of efficacy appraised, individuals will be appraised to follow one of two separate pathways: the danger control process and fear control process [12,13].

The model is primarily designed for campaign message evaluation to see category of individuals whether they are using the recommended response or not by Witte [8,13] which is truly analogous with this research which is aimed to evaluate the effectiveness of VCT message for HIV prevention that can show the category of respondents.

Therefore, this study is important to assess in school youths exposure of voluntary counseling and testing messages and the response they experience on messages using EPPM. Furthermore, the findings of this study will enable policy makers, schools, message developers, health educators, and researchers used as baseline data to design appropriate and effective messages.

Methods and Materials

Study area and period

This study was conducted in high school students in Hossana town. Hosanna is located 230 km south west from the capital city of Ethiopia being the capital city of Hadiya zone. In the town, there are three public and six private high schools each of the students were coming from different districts of the zones. The study period was as of April to May 2013.

Study design and populations

Cross sectional study design combined with qualitative methods of data collection was used to assess the communication factors that influence VCT message responses among Hosanna high school students as HIV/AIDS prevention strategy in Hadiya zone. All sampled students of nine high schools who were present during study period were included. For qualitative, Anti-AIDS club member students and teachers were recruited for in-depth interview and focus group discussion.

Sample size and sampling procedures

The sample size was calculated using single population proportion formula by considering 50% of estimated proportion of danger control response for voluntary counselling and testing message because there is no study conducted in related topic in the study area, margin of error 5%, a 5% level of significance (two sided) i.e. 95% confidence interval of certainty. Based on the above assumptions, with an additional 15 percent contingency for non-response; the total sample size was 425. Six in-depth interviews (IDI) were conducted with teachers and four focus group discussions (FGD) with club member students. Simple random sampling technique was used to select study participants from student roster of each school. Judgemental sampling was used for indepth interview and focus group discussion.

Measurement and variables

Outcome (Dependent) variable: Communication influences on VCT message responses as HIV/AIDS prevention message.

Exposure (Independent) variables: Communication factors, Perceived threat from HIV/AIDS, Perceived efficacy of VCT, Socio demographic factors, past risky sexual behaviors and Cues to actions.

Socio-demographics characteristics: such as age, sex, marital status, religion, pervious residence, father and mothers occupation and with whom currently living of the respondents consisting of 12 items.

Knowledge questions with response format of ‘yes’ or ‘no’. Respondents were asked not to guess, but to mark the “I don’t know” answer possibility if they did not know the correct answer.

Knowledgeable: Those respondents who have answered seventy five percent and above of all the knowledge questions about HIV/AIDS taken as knowledgeable.

Not Knowledgeable: Those respondents who could answer below seventy five percent of all the knowledge questions about HIV/AIDS.

Perceived susceptibility to HIV/AIDS is respondent’s self perception of vulnerability to HIV/AIDS measured by summed score of related belief items on 5-point Likert scale.

Perceived severity of HIV/AIDS is respondent’s hold belief concerning the effects of a given disease seriousness or condition would have on one’s state of health affairs, measured by summed score of related belief items on 5-point Likert scale.

Perceived response efficacy to use recommended response is respondent’s belief about the effectiveness of voluntary counseling and testing as strategy for HIV prevention, measured by summed score of related belief items on 5-point Likert scale.

Self-efficacy to use recommended response is respondent’s self confidence to be tested in elsewhere to prevent HIV transmission measured by summed score of related belief items on 5-point Likert scale.

Perceived threat from HIV/AIDS is respondent’s perception of one’s threat from HIV/AIDS (i.e. the sum of self perception of susceptibility to HIV/AIDS and perception of severity of HIV/AIDS) which is measured by summed perceived susceptibility and severity items of Likert scale.

Perceived efficacy of recommended response is respondent’s perception of one’s harm/threat from HIV/AIDS can be prevented by their ability and belief of effectiveness of the response (i.e. the sum of Perceived self -efficacy and response efficacy to use recommended response) which is measured by perceived self efficacy and response efficacy items of Likert scale with 25 items.

Danger control zone/responses-when we say danger control the critical value (sum of efficacy score minus sum of threat score) is positive.

Fear control zone/responses-when we say fear control the critical value (sum of efficacy score-sum of threat score) is negative.

No responses-those students’ with low threat perceptions regarding a health threat are neither engaging in danger nor fear control response or it is to mean that the critical value is Zero; i.e. the difference of weighted efficacy score and weighted threat score is neither negative nor positive. Discriminative value/critical value- are the sum of the difference between efficacy score and threat score. Responses: when we say response it is either using the recommended preventive strategy or not using the recommended preventive strategy. Score all of which eliciting responses on a five-point Likert scale format, ranging from `complete disagreement’ to `complete agreement’ are included. Each of the responses was scored as: `complete disagreement’=1, `disagreement ‘=2, `undecided/not sure’=3, ` agreement’=4 and `complete agreement ‘=5. After reversing for negatively worded items, scores was summed for each respective concept.

Cues to actions are conditions that may facilitate them to be opened to the elements related to HIV prevention methods in the respondents’ surroundings with 10 items with response format of ‘yes’ or ‘no’.

Communication factors are factors that include source, channel, message, and personal relevance in doing so contains eighteen items with response format of ‘yes’ or ‘No’ and nominal measurements, Past HIV/AIDS risky sexual behaviors: those students’ who don’t use at least one recommended response to prevent HIV infection or had at least a single exposure to unprotected sex measured with 11 items with a mix of nominal and scale measurements.

For validation of the instrument, factor analysis was done for confirmation of factor loading score of greater than or equal to 0.4 was accepted for construct validity after using Eigen value of greater than 1 for confirming major constructs of the model. Internal consistency of items was seen separately for each construct on which items were loaded and cronbanch’s alpha score of greater than or equal to 0.7 was accepted for ordinal scale items and spearman score have seen for dichotomized scale otherwise was removed. Items correlation with total correlation of scores greater than or equal to 0.3 was accepted after items internal consistency is assured otherwise were checked again and removed. For qualitative part, the qualitative data collection method was applied using in-depth interview and focus group discussion in order to supplement the result of the quantitative data.

Data collection instrument and procedure

Quantitative data were collected using structured self administered questionnaires by guidance of experienced data collectors. The questionnaire was adapted from literature in English to increase the comparability of the finding. The guideline which inquiries about the reason why they are testing or not, respondents logical decisions in accepting or not accepting the message, perceived difference of voluntary counselling and testing acceptors and rejecters, and preferred sources, message type, delivering style with some probing questions were prepared for students and teachers separately. Qualitative data were collected by principal investigator using focus group discussion and in-depth interview. Respective responses of informants were recorded by using tape recorder and hand written notes.

Data quality management, processing and analysis

Questionnaires were translated to local language and then back translated to English to maintain its consistency. Training was given for data collectors and pretest was done on 5% of the study subjects on similar population out of study area. Supervisors and principal investigator performed immediate supervision on a daily basis. In qualitative, the recorded voice was transcribed first in local language and translated to English and analyzed by Atlas software. The collected data were entered in SPSS 16.0 version for analysis. For uniform scoring of items of five point Likert scale response format, negatively worded items were reversed. Descriptive analysis was used to describe the percentages and number of distributions of the respondents by socio-demographic characteristics, communication factors, past sexual behaviors, cues to action and the main constructs of extended parallel process model. Furthermore, bivariate and multivariable logistic regression analyses were used to identify the influencing factors using backward variable selection techniques. All explanatory variables that were associated with outcome variable in bivariate analysis with p-value of 0.25 or less were included in the initial logistic models. The crude and adjusted odds ratios together with their corresponding 95% confidence intervals were computed and interpreted accordingly. A P-value<0.05 was considered to declare a result as statistically significant in this study.

Ethical consideration

Prior to data collection, a formal letter was obtained from the faculty of medicine and health science of Wachemo University and submitted to each school. All study participants were informed about the purpose of the study verbally and in written form. All participants’ right to self-determination and autonomy were respected. Participation is voluntary and participants can withdraw from the study at any time.

Results

Socio-demographic characteristics of the participants

Four hundred eight participants were participated in the study giving response rate of 96.0%. Accordingly, more than half, 56.6% (231/408), of the participants were females. The mean age of the participants was 17.2 ± 2.1 years (Table 1).

 Variables Categories Frequency Percent (%)
High school name Yekatit 25/67 school 179 43.9
Wachemo preparatory 99 24.2
Heto school 63 15.4
Vision academy 24 5.9
Fantu and Aberash (FA) 14 3.4
United vision academy 12 2.9
Harvard academy 8 2.0
School of Deaf 4 1.0
Akleshia 5 1.2
Grade level Nine 154 37.7
Ten 140 34.3
Eleven 56 13.7
Twelve 58 14.3
Sex of the participant Female 231 56.6
Male 177 43.4
Age of the participant 10-14 33 8.1
15-19 285 69.9
20-24 90 22.0
Previous Residence Rural 276 67.6
Urban 132 32.4
Marital status Single 393 96.3
Married 14 3.4
Divorced 1 0.2
Religion of participant Protestant 263 64.5
Catholic 52 12.7
Orthodox 54 13.2
Muslim 39 9.6
Ethnicity of participant Hadiya 245 60.0
Kembata 54 13.2
Amhara 51 12.5
Silte 40 9.8
Others* 18 4.4
 Father’s occupation Farmer 206 50.5
Employed 120 29.4
Merchant 82 20.1
Mother’s occupation Housewife 290 71.1
Employed 71 17.4
Merchant 47 11.5
With whom youcurrently live? With family 149 36.5
Alone 136 33.3
With friends 121 29.7
Others** 2 0.5

Table 1: Presents socio- demographic characteristics of the participants, high school, Hadiya zone, South, Ethiopia, May 2013 (N= 408).

Knowledge about HIV transmission, prevention and misconceptions

In this study, all the participants have heard of HIV/AIDS. With regard to VCT as HIV prevention strategy, 86.8% (354/408) of the participant stated that VCT help to know one’s own HIV status (Table 2).

Variables Yes % No % IDN %
Has heard of HIV/AIDS 408 100.0 0 0.0 0 0.0
Has heard of HIV/AIDS prevention methods 401 98.3 7 1.7 0 0.0
Healthy looking person can have the virus 205 50.2 141 34.6 62 15.2
There is special medication for PMCT* 320 78.4 50 12.3 38 9.3
There is special medication to persons who have HIV/AIDS 345 84.6 36 8.8 27 6.6
Means of transmission Unprotected sex 386 95.0 22 5.0 0 0.0
Sharing sharp instrument 352 86.3 56 13.7 0 0.0
Blood transmission without test 344 84.3 64 15.7 0 0.0
Intravenous drug use 207 50.7 201 49.3 0 0.0
during pregnancy 275 67.4 104 25.5 29 7.1
during delivery 331 81.1 55 13.5 22 5.4
during breast feeding 318 77.9 55 13.5 35 8.6
Misconceptions about transmissions of HIV Mosquitoes bite 57 14.0 298 73.0 53 13.0
Sharing foods 35 8.6 358 87.7 15 3.7
Curse of God 227 55.6 125 30.6 56 13.7
Means of prevetion method/prevention strategy Being faithful to one partner 247 60.5 133 32.6 28 6.9
Condom use 294 72.1 80 19.6 34 8.3
Abstinence 322 78.9 59 14.5 27 6.6
Voluntary counselling and testing 354 86.8 38 9.3 16 3.9
Limit sex with one partner 371 90.9 37 8.3 0 0.0
Limit number of sexual partners 304 74.5 104 25.5 0 0.0
Avoid sex with prostitutes 330 80.9 78 19.1 0 0.0
Avoid sex with persons who have many sexual partners 340 83.3 68 16.7 0 0.0
Avoid sex with homosexuals 292 71.6 116 28.4 0 0.0
Avoidblood transfusion without test 338 82.6 70 17.2 0 0.0
Avoid sharing razors/blades 353 86.5 55 13.5 0 0.0

Table 2: Presents frequency of the participants knowledge about HIV/AIDS transmission, prevention and some misconceptions in hosanna town, Hadiya zone, Southern, Ethiopia, May 2013 (N= 408).

Source of HIV/AIDS information

Regarding sources of information, 80.1% (327/408) of the participants reported health institutions while a little number can’t recognize where they heard from (Table 3).

Sources of information Yes %
Health institutions 327 80.1
School/Teacher 273 66.9
Religious institutions 231 56.6
Friends 205 50.2
People living with HIV/AIDS 153 37.5
Parents 142 34.8
Others* 30 7.4

Table 3: Presents frequencies of the participants’ source of information for HIV/AIDS with respective percentages among hosanna high schools, South Ethiopia May 2013 (N= 408).

Source and channels preference for information

Concerning source preference, 66.2% (270/408), of the participants prefer health institution. Regarding the preference of channel, 66.9% (273/408), of the participants preferred radio followed by television 55.6% (227/408) (Table 4).

Variables Yes % No %
Preferred sources Health institutions 270 66.2 138 33.8
School/Teacher 144 35.3 264 64.7
Friends 171 41.9 237 58.1
Religious institutions 144 35.3 264 64.7
Parents 93 22.8 315 77.2
People living with HIV/AIDS 85 20.8 323 79.2
Preferred channels Radio 273 66.9 135 33.1
Peer discussions 259 63.5 149 36.5
Television 227 55.6 181 44.4
Printed materials: posters, leaflets 192 47.1 216 52.9
Others 12 2.8 396 97.2

Table 4: Presents frequencies of the preferred source of and channels for information about HIV/AIDS with respective percentages among participants of hosanna high schools, Hadiya Zone, South Ethiopia, May 2013 (N= 408).

Messages and message appeals of communication

Table 5 shows frequently heard messages; specific message heard and preferred message appeals for HIV/AIDS prevention. Voluntary counseling and testing message was heard by 46.8% (191/408) of participants following abstinence 52.9% (216/408) of participants.

Variables (messages) Yes % No %
Frequently heard message/behavior Abstinence 216 52.9 192 47.1
Being faithful 145 35.5 263 64.5
Using condom 180 44.1 228 55.9
Voluntary counseling and testing 191 46.8 217 53.2
Preferred message appeals Dramatic/funny 353 86.5 55 13.5
Factual through education 337 82.6 71 17.4
Fear arousal messages 138 33.8 270 66.2
Two sided message 269 65.9 139 34.1
One sided message 127 31.1 281 68.9
Negative message 138 33.8 270 66.2
positive message 195 47.8 213 52.2
Specific messages heard of/seen Value your life 364 89.2 44 10.8
let us fight HIV/AIDS together 366 89.7 42 10.3
Care and support for AIDS Patients 339 83.1 69 16.9
let us take care of each other 338 82.8 70 17.2
I care, do you? 333 81.6 75 18.4
Abstain from sex before marriage 295 72.3 113 27.7
Stop stigma & discrimination 285 69.9 123 30.1
Live and die 233 57.1 175 42.9
There is media in our compound 169 41.4 239 58.6

Table 5: Presents frequencies of the frequently heard behaviors, specific messages heard of/seen and preferred appeals with respective percentages among participants of hosanna high schools, Hadiya zone, South Ethiopia.(N= 408).

Perceived probability of infection and cues to actions

Perception towards HIV/AIDS & its prevetion methods were assessed by using EPPM model as perceived threat from HIV/AIDS, and perceived efficacy of the recommended responses as well. (Table 6 and Figure 1).

Components/constructs Scale range Scale mean SD
perceived susceptibility 9-45 26.0 5.9
perceived severity 8-40 29.0 3.3
Weighted threat 17-85 0.8 0.3
Weighted efficacy 7-35 0.7 0.4
perceived self-efficacy of VCT use 4-20 18.3 3.6
perceived response efficacy VCT use 3-15 12.5 2.3
Cues to action 0-10 6.1 2.8

Table 6: Presents descriptive statistics for constructs of EPPM by their scale range of the participants in hosanna high schools, Hadiya zone, South Ethiopia. (N= 408).

Concerning participant’s perceived susceptibility to HIV/AIDS, 67.7% (276/408) of the participants scored less than or equal to 29 from 45 which shows relatively high susceptibility score having an average score of (mean ± standard deviation) (26.0 ± 5.9).

community-medicine-health-education-Framework

Figure 1: EPPM Model as Conceptual Framework of the Research.

Regarding perceived severity of HIV/AIDS, 63.0% (257/408) of the participants scored less than or equal to 29 from 40 which shows relatively high severity score having an average score of (mean ± standard deviation) (29.0 ± 3.3).

Regarding participant’s both perceived self efficacy and response efficacy of recommended responses (VCT), in both cases, 59.3% (242/408) and 53.9% (220/408), of the participants their score is relatively good since is approached to mean value having an average score of (mean ± standard deviation) (18.3 ± 3.6) and (12.5 ± 2.3) respectively.

As far as participant’s weighted perceived threat from HIV/AIDS and weighted perceived efficacy of VCT message were considered, participants who were found in efficacy appraisal are slightly lower than those in threat appraisals having an average score of (mean ± standard deviation) (0.7±0.4) and (0.8 ± 0.3) respectively.

Taking presence of cues to HIV into consideration, VCT related information from different sources, about 55.8% (228/408) of the participants scored < 5/10 in the composite score (mean ± standard deviation) number of cues to responses as per a participant is (6.1 ± 2.8).

Category of participants to VCT as HIV/AIDS prevention message

As far as category of participants was concerned, 78.7% (321/408), of participants were fear control zone where as 21.3% (87/408) of the participants were danger control zone based on discriminative scores (Table 7).

  Outcome Variables Total
Variable Danger Control response Fear Control response
Sex Male 31 (7.6%) 146 (35.8%) 177 (43.4%)
Female 56 (13.7%) 175 (42.9%) 231 (56.6%)
Total 87 (21.32 %) 321 (78.68%) 408 (100.0%)

Table 7: Showing responses (outcome variable) with their respective frequencies of the sex of participants in hosanna high schools, Hadiya zone, South Ethiopia, May 2013 (N= 408).

Past voluntary counseling and testing behavior

Regarding VCT, from the total sample, 69.8% (285/408) reported that they knew their HIV sero status (Table 8).

Variables Danger control Fear control Total
No % No % No %
Ever tested after sexual Intercourse (N= 142) Yes 15 10.6 58 40.8 73 51.4
No 20 14.1 49 34.5 69 48.6
Ever tested for HIV in their life (N=408) Yes 47 11.5 239 58.6 285 69.8
No 40 9.8 82 20.1 123 30.2

Table 8: Presents participants’ HIV voluntary counselling and testing experience as prevention strategies by responses (danger control or fear control) among Hosanna high school students Hadiya Zone, South Ethiopia May, 2013. (N= 408).

Regression analysis

Socio-demographic variables as predictor of message response: Regarding the socio-demographic variables as covariates (Table 1), school difference, age, previous residence, and fathers’ occupation had significant crude and adjusted effect on message response. Meaning, those participants who were from Fantu and Aregash (FA) school and united vision academy as compared to Yekatit 25/67 had higher odds of fear control responses for HIV prevention messages with odds ratio [AOR (95% CI)=.11 (1.98-33.29)] and [AOR (95% CI)=5.66 (1.60- 20.10)] respectively. Meaning, those participants who were from Fantu and Aregash school were 8.11 times more likely to be in fear control/ unintended response than Yekatit 25/67 high school and likewise those participants who were from United vision academy were 5.66 times more likely to be in fear control/unintended response than Yekatit 25/67 high school. Similarly, those participants who previously resided in rural area as compared to those who came from urban area had lowered odds of fear control responses for HIV prevention messages with odds ratio [AOR (95% CI)=0.34 (0.18-0.63)]. Participants from merchant family as compared to farmer’s family had lower odds of fear control responses for HIV prevention messages with odds ratio [AOR (95% CI)=0.41(0.17-0.96)] Meaning, those participants whose fathers’ occupation is merchant were 0.41 times more likely to be in fear control/unintended response than farmer’s family. Participants whose age is 20-24 as compared to 15-19 had lower odds of fear control responses for VCT messages with odds ratio [AOR (95% CI)=0.86 (0.75-0.98)]. Meaning, those participants whose age is 20-24 is 0.86 times more likely to be in fear control/unintended response than 15-19. The above explained variables are candidate for final prediction model (Table 9).

Variables Categories No % COR (95% CI) AOR(95% CI)
High School Name Yekatit 25/67 School 179 43.9 1 1
Wachemo Preparatory 99 24.3 0.24(0.06-1.28) 0.73(0.10-5.25)
Heto 63 15.4 2.88(0.40-20.92) 5.00(0.59-42.57)
Vision academy 24 5.9 0.44(0.15-1.32)  0.65(0.20-2.10)
Fantu and Aberash 14 3.4 4.22(1.36-13.14)* 8.11 (1.98-33.29)*
United vision academy 12 2.9 7.88(2.33-26.66)* 5.66 (1.60-20.10)*
Harvard academy 8 2.0 1.00 (0.48-2.07) 1.49(0.61-3.63)
School of Deaf 4 1.0 0.77(0.31-1.07) 0.64(0.33-1.18)
Akleshia 5 1.2 0.59(0.27-1.28) 0.76(0.26-2.23)
Age 10-14 33 8.1 2.86(0.33-1.18) 2.44(0.63-1.28)
15-19 285 69.9 1 1
20-24 90 22.0 0.87(0.77-0.98)* 0.86 (0.75-0.98)*
Previous Residence Rural 276 67.6 1 1
Urban 132 32.4 0.40 (0.22-0.72)* 0.34(0.18-0.63)*
Monthly income of father Farmer 206 50.5 1 1
Employed 120 29.4 0.86(0.51-1.46) 0.53(0.25-1.13)
Merchant 82 20.1 0.32(0.15-0.71)* 0.41(0.17-0.96)*

Table 9: Presents regression analysis to see the effect of socio-demographic variables in response categories of the participants in hosanna high school, Hadiya zone, Ethiopia, May, 2013. (N=408).

EPPM constructs as a predictor of message responses (perceived probability infection)

Perceived susceptibility to HIV/AIDS had a statistical significant effect on fear control response with [AOR (95% CI)=1.61(1.40-1.86)] .i.e. From the model, the coefficient of susceptibility score implies, those participants whose considers susceptible were 1.61 times more likely to be in fear control/unintended response than those who are not.

Perceived severity to HIV/AIDS had a statistical significant effect on fear control response with [AOR (95% CI)=1.41(1.27-1.56)]. From the model, the coefficient of severity score implies those participants who consider HIV as a severe were 1.41 times more likely to be in fear control/unintended response than those who are not.

Perceived self efficacy of VCT use for HIV/AIDS prevention had a statistical significant effect on fear control responses with [AOR (95% CI)=0.68(0.61-0.76)]. Summed response efficacy of recommended responses for HIV/AIDS prevention had a statistical significant effects on fear control responses with [AOR (95% CI) = 0.13(0.14-0.76)]. Interpreted as, from the model, the coefficient of response efficacy score implies that being in fear control response results in average reduction in response efficacy score by 0.13. Those individuals who had cues to HIV information either in prevetion or its severity had positive relation with fear control and had significant association between message responses with odds ratio [AOR(95% CI)=1.69(2.10-13.94)] and it is kept for final model (Table 10).

Components/constructs Scale mean SD COR (95% CI) AOR(95% CI)
Perceived Susceptibility 26.0 5.9 1.17(1.12-1.21)* 1.61(1.40-1.86)*
Perceived Severity 29.0 3.3 1.03(1.01-1.05)* 1.41(1.27-1.56)*
Selfefficacy 18.3 3.6 0.96(0.94-0.98)* 0.68(0.61-0.76)*
Response Efficacy 12.5 2.3 0.33(0.65-0.80)* 0.13(0.14-0.76)*
Weighted Threat 0.8 0.3 1.09(1.06-1.11)* 1.97(0.94-1.02)
Weighted Efficacy 0.7 0.4 0.98(0.96-0.99)* 0.67(0.64-1.12)
Cues To Action 5.3 2.8 1.25(1.69-7.19)* 1.69(2.10-13.94)*

Table 10: Regression analysis to see the effect of EPPM constructs in message response categories of the participants in hosanna high school, South Ethiopia, May, 2013. (N= 408).

Communication factors as predictor of message response

Taking the communication factors as a predictor of message response for prediction of fear control responses (Table 11).

Variables No % COR(95%CI) AOR(95%CI)
Frequently VCT use Yes 179 44.1 3.47(0.36-0.99)* 3.54(1.37-1.92)*
No 228 55.9 1 1
Dramatic/Humour appeal Yes 353 86.5 1 1
No 55 13.5 1.41(0.23-0.73)* 1.93(1.05-3.57)*
Value your life Yes 364 90.2 1 1
No 44 9.8 2.06(1.01-4.21)* 2.46(1.45-3.67)*
Avoid stigma and discrimination Yes 285 69.9 1 1
No 123 30.1 2.17(1.92-5.24)* 1.37(1.33-4.24)*

Table 11: Crude and adjusted odds ratio to see the effect of distal factors on message response categories of the participants in hosanna high schools, Hadiya zone, South Ethiopia, May 2013.

Accordingly, participants who did not heard VCT use message frequently had slightly higher odds of fear control responses with odds ratio [AOR (95% CI)=3.54(1.37-1.92)] than those heard VCT use message frequently. In other words, who heard are more protective (danger control response) than who didn’t hear. Those participants who preferred humour appeals as compared to who didn’t preferred had significantly higher odds of fear control responses for VCT messages with odds ratio [AOR (95% CI)=1.93(1.05-3.57)] and interpreted as, participants who preferred humour appeals messages were 1.93 times more likely to be in fear control response than those participants who didn’t prefer humour appeals messages. Those participants who haven’t heard the message avoid stigma and discrimination had significantly higher odds of fear control responses for HIV [AOR (95% CI)=1.37(1.91-2.77)]. In parallel speaking, hearing the avoid stigma and discrimination message leads individuals to be danger control response.

Past risky sexual behaviors as a predictor of message response

Risky sexual behaviors taken as variables of predictor of message responses by considering risky behaviors related to HIV, like ever had sex, age at first sex, kind of sex partner, experience of testing after sexual intercourse and ever testing, and decision to have sex now and for future after having test. The crude and adjusted effects of these factors were seen following description of each behavior as follows.

Accordingly, ever tested in their life had statistically significant crude and adjusted effect on fear control responses. For instance, participants who never tested in their life had lowered odds of danger control responses for HIV prevention messages as compared to whoever tested in their life with odds ratio [AOR (95% CI)=0.04(0.00- 0.65)] (Table 12).

Variables No % COR (95% CI) AOR(95% CI)
Ever tested for in their life (N=408) Yes 278 70.0 1 1
No 119 30.0 2.28(1.38-3.76)* 0.80(1.16-4.00)*

Table 12: Regression analysis to see the effect of past sexual behaviour on message response of the participants in hosanna high schools, Hadiya Zone, Southern Ethiopia, May 2013.

Final Multivariable logistic model for prediction of message responses

In final model, all the variables which were significant in bivariate analysis are fitted to predict message response by backward Likelihood regression method: the main constructs of the EPPM model, ever tested, and pervious residence were left over in the final model. Predicted final model (fear control as a variable of interest)=11.12 + 4.13 (self-efficacy) + 3.21 (response efficacy) + 4.13 (Previous residence (Rural) + 4.31 (Ever tested (yes)) - 0.42 (perceived susceptibility) - 0.33 (perceived severity). The model explained about 70.09% of prediction of message response among participants learning in the schools with goodness of fit of the model (X2/df=6.12/8, p. value=0.32) (Table 13).

Variables in the Equation Pvalue OR 95% CI for AOR
Perceived Susceptibility 0.03 0.42 0.44 0.61
Perceived Severity 0.02 0.33 0.21 0.74
Perceived Self efficacy 0.04 4.13 3.37 5.01
Perceived Response Efficacy 0.03 3.21 6.89 9.09
Previous Residence (Rural) 0.04 4.13 2.43 7.32
Ever tested 0.04 4.31 7.01 9.08
Constant   11.12    

Table 13: Multivariable logistic regression analysis for final model prediction of message response among participants of hosanna high school, South, Ethiopia May 2013.

Discussion

According to EPPM model, someone perceiving susceptibility to and severity of ill health condition gets the force to engage on healthy behavior but think over the best path to be healthier or to go through the effective strategy which adds value for his/her health provided that people are already awared in a particular health threat since the model best works in situation where participants have high level of awareness than motivational variables [8,13].

In this study, knowledge level was matching with the basic assumption of the model but as compared to other findings, the result is inconsistent with or higher than the findings of other studies conducted in Sub Saharan Africa [2] and the, DHSE, 2010 and BSS round two conducted in Ethiopia [12]. In support of this view in qualitative study almost all the informants and discussants said that “existence of HIV/AIDS and how transmitted and prevented is daily food for every individual.” The reason may be due to urban health extensions are vigorously working in increasing awareness of HIV/AIDS prevention methods. The other is improvement was also observed with different levels based on the type of intervention increased accessibility to information.

In this study, schools’ difference had significantly associated message responses. Accordingly, Fantu Aregash and United Vision Academy schools had highly significant positive association with danger control responses meaning the participants in F.A and united vision academy were practicing intended behavior as noted in findings of this study in comparative of the other schools involved in the study. Unlike that, qualitative part, Yekatit 25/67 high school, showed highly strong HIV/AIDS club programs on account of having linkage with highly committed nongovernmental organizations in which is working in prevention activities by providing health learning materials, VCT campaign…, and participating on different awareness creation meetings which helps them to discuss freely.

Male informants who is working with club members whose age of 33 said that “we use participatory approach for every aspect of discussion i.e. student themselves teach for their peers freely and even they share experiences when they took training with their friends. Sometimes health extension workers involved in coffee ceremony for discussion of HIV issues are which in turn help to hold back its incidence as well as encouraging students to engage in prevetion activities.….” In contrast to this saying, all the discussants who came from different schools said that “giving option is probably good but promoting VCT is best to have tested partner because the creator of the world create one person for one guy that is why we differ from animals.”

In this study, regarding previous residence being rural resident is more significantly positively attached with intended responses as compared to urban residents. Similar concept to this finding, a cross sectional study done in Debre Berhan high school female students showed rural dwellers are less likely to be engaged in sexual intercourse and more abstinent groups as compared to urban. The potential reason of higher significant acceptance of messages among rural residents compared to urban residents may be many exposing films, even talks, also cultural disparities in rural area attached with fear of HIV. The other potential reason of higher significant acceptance of messages among rural residents compared to urban residents may be related to fear of the threat in rural comers is attached with abstaining until marriage which in turn leads to have test.

Father’s occupation had significant effect in message responses. This is similar, to the study conducted in Addis Ababa on risk sexual behavior of in school youths that showed significant positive risk protective effect of monthly income [14]. In contrast to this findings, in qualitative part, one of the male informants from Yekatit 25/67 high school with age of 29 years said that “sometimes parents are the agents for their siblings to push to sex by providing much money and on the other side…those female students who came from poor families have high tendency to be engaged in multiple sexual partners; so, both extremes are not good.”

In this study, perceived susceptibility to HIV/AIDS is directly attached with fear control response which in turn reduces the protective effects of the individuals increasing the likelihood of fear control response. Similarly, a cross sectional study conducted in Ethiopia on message response of Hossana college students were similar findings that a belief of personal perceived susceptibility to HIV risk in relation to condom use is low [15].

This study, concerning perceived severity of HIV/AIDS showed positive effect on fear control response. In line with this result in qualitative part, one of the female participants with age of 18 years said that “young generation wants to hear the message focus on being faithfulness (having boy /girl friend); on the other hand those messages focused abstinence considered as layman teaching since this day is full of sexual intercourse. Therefore, having VCT to have healthy partner should be a must.” However, as compared to the finding of this study, the study conducted in Kenya at university students the results indicated that almost all the students perceived severity to HIV/AIDS is very serious resulting in lack of variance in the measure. The potential reason may be peoples are familiarized HIV as not to have immediate consequences rather it lasts long period.

In this study, over all perceived self efficacy of HIV/AIDS showed negative effect on fear control response which in turn enhances the protective effects of the individuals decreasing the likelihood of fear control response which really parallels with the idea of EPPM model in message evaluation since directly linked with danger control responses.

This study, concerning perceived response efficacy of HIV/AIDS showed negative effect on message response which in turn enhances the protective effects of the individuals reducing the likelihood of fear control response which exactly parallels with the idea EPPM model in message evaluation since directly linked with danger control responses. In qualitative part, one of the female participants from Wachemo preparatory with age 19 said that “... I abstain until marriage, I am confident that I can have HIV test every where...I think most of who are abstaining does that....?

Concerning communication factors, participants who did not hear abstinence message frequently had slightly higher crude and adjusted odds of fear control than those heard abstinences message frequently. In other words, they are less protective than those who heard VCT frequently. In qualitative part, one of the participants with age of 31 from Yekatit 25/67 high school said that “…the message focuses on being faithfulness is more accepted than any other three and next to that VCT is expected to be delivered; however we are wasting time on abstinence which are mostly rejected particularly in this age bracket since majority of students wants to engaged in sexual intercourse ….am not saying … don’t promote abstinence and condom use rather let us start our message from being faithfulness with tested partner which in turn helps to have HIV test.

The current study used tested model for message evaluation as theoretical framework that outlines how to measure the components explicitly so that they are easily summarized. Qualitative and quantitative data were triangulated. But, in reality, once the individual is exposed to communication messages, it may be difficult to get that individual in zero discriminative value rather may be obtained in calculation and even leads in false conclusion. One limitation of model is it may have the gap between the actual behavior and psychological responses.

In conclusion, participants’ acceptance or rejection of message was determined mostly by individual perception on what they have for HIV and its prevention methods. Despite high proportion of students were in fear control psychological responses, there is similarity with current behavior of prevention of HIV/AIDS. As is, the main constructs had significantly associated with message responses particularly susceptibility to and severity of HIV/AIDS were directly attached with fear control responses, where as ever tested, being rural resident, self efficacy and response efficacy to HIV prevention messages are directly linked with danger control response which is congruent with the assumption and general idea of EPPM model. The way how to deliver message mostly determine its effectiveness in encouraging the acceptance of message; particularly, humour appeal messages produces danger control responses. Involvement of health personnel and radio channel is preferable source of information to students. Generally, the independent predictors of the message response are the main constructs of EPPM model, ever tested and previous residence either in acceptance or in rejection of message.

To schools, HIV/AIDS prevention and control offices, message developers, researcher and any organizations working in the area of HIV/AIDS prevention should follow the following recommendations.

Regional Health bureau should focus on practical and technical aspects of the message development that developers will be well equipped in order to fill the gap in message production and acceptance.

Zonal health department should directly go to the grass-root level and should undergo continuous orientation and refreshments for the HIV mainstreaming heads and should also fix time to evaluate the effectiveness of IEC in touching the required behavioral change.

Message developers should have to consider the actual needs of the participants through needs assessment to maximize perception of their risk of susceptibility and severity.

Message developers, even though focus demands needs sacrifices, should tailor message based on participants’ residence so that more acceptance in uniform categories is assured.

Schools should have continuous IEC/BCC intervention programs since lack of critical thinking between threat and efficacy was observed.

Schools should further promote both self efficacy and response efficacy of VCT inaugurating with being faithfulness.

Schools should give emphasis to ensure access for young people to sex education, HIV/STIs, including information about some misconceptions.

Acknowledgement

My earnest gratitude goes to research and publication committee of Wachemo University for proper review and approval of this paper. I am very happy to be in a position to thank data collectors to bring us these valuable findings. My gratitude thanks goes to Hadiya zone education department to their contribution in providing me baseline information and coordinating students to fill the questionnaire at a time of data collection. I would also like to extend my gratitude to students of the nine schools for their patience to fill questionnaires and for their involvement in focus group discussion to share information. My special thanks also extended to Wachemo University for financial support for this study.

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