DECLARATION I hereby declare that this dissertation titled “EFFECT OF HEALTH EDUCATION ON HIV/AIDS RISK BEHAVIOURS AND STIGMATIZATION ATTITUDES AMONG ADOLESCENTS IN OGUN STATE, NIGERIA” is my original and individual work. It was written under the supervision of Dr O.E. Amoran. I also declare that this dissertation has not been submitted anywhere else in part or in full for any other examination. ……………………………………………….. Dr Oke, Olalekan Adeniyi Department of Community Medicine and Primary Care Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State. DEDICATION 1 This work is dedicated to Almighty God from whom all blessings and wisdom flow for making it a reality. Also in loving memory of my Late father Mr Joseph Kehinde OKE for leaving me with an enduring legacy – Education! CERTIFICATION I hereby certify that this dissertation was written by Dr Oke Olalekan A. under my supervision. Supervisor: 2 ……………………………………… Dr O.E. Amoran Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State ……………………………………………… Dr O. J. Daniel Head of Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State ACKNOWLEDGMENTS I appreciate the enormous efforts of my supervisor, Dr. O.E. Amoran whose guidance and painstaking efforts were instrumental to the actualisation of this research work. I am deeply grateful to Dr O.J. Daniel, the Head of Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu and the entire team of consultants and residents for their useful critique, advice and contributions. The entire managements of Ado-Odo/Ota and Ifo Local Governments for kindly granting the approval for the conduct of the research in their communities. Mr Kolawole Ogun and his team of Town Planning officials of Ado-Odo/Ota Local Government as well as Mrs 3 F. Atobasere and her team of Town Planning officials of Ifo Local Government are recognised for their assistance in the course of this work. The painstaking efforts of Ms Temitope Ibrahim, a Family Life Health Education (FLHE) trained teacher is appreciated especially during the training sessions for the intervention group as well as the wonderful contributions and assistance of Mr Damilola Shodiya and his team at Positive Outreach Foundation (a local community based organisation) were invaluable throughout the course of the study. I also wish to mention the assistance of the two HIV positive individuals (who have granted me permission to mention their names) that assisted me in the training sessions for the intervention group – Mr Kolawole P. Ekanoye and Ms F.A. Komolafe. I acknowledge the innumerable contributions of Dr Daniel A. Adesanya – the Medical Officer of Health, Ado-odo/Ota Local Government who spared no resource at his disposal in facilitating this research in his LGA. I must not fail to specially acknowledge and appreciate Prof. A. A. Onayade for the inspiration, words of advice and encouragement that propelled me. I am immensely thankful to Bishop Taiwo Akinola of Rhema Christian Church and Towers for his support and prayers. Special mention also of Drs Oyesola of the Department Community Medicine, Federal Medical Centre, Abeokuta and Dr Clifford Okike of FMC, Asaba, Delta State for their kind inputs. I remain in the debt of my brothers and senior colleagues in the specialty of Public Health – Drs Kehinde Fatungase and Babatunde Ipaye who never relented in pushing me all the way towards attaining the goal of bringing this work into reality. My heartfelt gratitude goes to my friend and colleague, Dr Tunde Adedokun of the Department of Epidemiology and Medical Statistics, University of Ibadan for his 4 wonderful contributions. To my bosses in the Local Government Service, in Ogun State – Engrs A.O. Egunjobi and B.A.T. Odunlami FNSE, I deeply appreciate you for your huge support. I also appreciate the entire management of the library of Bells University of Technology, Ota, Ogun State for granting permission for use of their facility. Finally, I acknowledge and remain deeply gratified by the encouragement and support of my entire family especially, from my dear wife Adepeju and our two lovely children – Oluwaseyi and Aanuoluwapo Oke. 5 TABLE OF CONTENTS 1. Declaration ……………………………………………………….i 2. Dedication……………………………………………………..ii 3. Certification ……………………………………………………iii 4. Acknowledgements……………………………………………..iv – v 5. Abstract…………………………………………………………vi - vii 6. Table of contents ………………………………………………viii 7. List of Abbreviations …………………………………………ix 8. Chapter One: Introduction i. 1.1 Background to the study………………………….1-4 ii. 1.2 Problem Statement………………………………...5-6 iii. 1.3 Justification………………………………………...7-9 iv. 1.4 Objectives of the study…………………………….10 v. 1.5 Scope and Focus of the Study……………………..11-12 9. Chapter Two: Literature Review i. 2.1 Epidemiology of HIV/AIDS………..……………….13-16 ii. 2.2 Virology and Transmission of HIV….…………….16-20 iii. 2.3 HIV/AIDS Knowledge and Attitude………….…….21-23 iv. 2.4 Sexual Behaviour……………………………………23-27 v. 2.5 HIV/AIDS and Drug Abuse and Addiction…………27-28 vi. 2.6 Stigma & Discrimination Associated with HIV/AIDS…28-30 vii. 2.7 Stigma and Discrimination Reduction……….…….30-35 viii. 2.8 Signs and Symptoms of HIV/AIDS………………..36-38 6 ix. 2.9 Diagnosis of HIV…………………………………….38-40 x. 2.10 Classification of HIV Infection……………………40-41 xi. 2.11 Prevention of HIV/AIDS……...…………………..41-46 xii. 2.12 Management of HIV/AIDS………………………..46-52 xiii. 2.13 Impact of HIV/AIDS………………………………..52-55 xiv. 2.14 Religion and HIV/AIDS….……………………….55-58 xv. 2.15 Role of Government and Non-Governmental Organisations in Addressing HIV/AIDS Stigma…………………………….58-59 10. Chapter Three: Materials and Methods i. 3.1 Study Area……………………………………….60-63 ii. 3.2 Study Population…………………………………63 iii. 3.3 Study design……………………………………..63 a) 3.3.1 Pre-Intervention Phase………………...64-66 b) 3.3.2 Intervention Activities…………………66-67 c) 3.3.3 Post-Intervention Phase………………67-68 iv. 3.4 Sample size determination……………………....68-69 v. 3.5 Subject Selection and Sampling Methods….……70-73 a) 3.5.1 Inclusion Criteria……………………….73 vi. 3.6 Research Instrument and Data collection…….....73-75 vii. 3.7 Data management and analysis……………........75-78 viii. 3.8 Ethical Considerations…………………………..78-79 ix. 3.9 Limitations……………………………………….79 11. Chapter Four: Results 7 i. Results of Quantitative Study……………………….80 – 118 ii. Results of Qualitative Study (FGDs)……………….119 - 128 12. Chapter Five: Discussion……………………………………..129 - 147 13. References ……………………………..…………………….148 - 170 14. Appendix 1 (Study Questionnaire)……..…………………..171 - 180 15. Appendix 2 (Informed Consent Form).…………………….181 – 186 16. Appendix 3 (Focus Group Discussion Guide)………………187 - 191 17. Appendix 4: Ogun State Senatorial Zones and LGAs………….192 18. Appendix 5: List of Wards in Selected LGAs…………………..193-194 19. Appendix 6: Workplan of Activities…………………………….195-198 20. Appendix 7: NPMCN Approval for the study…………………199 21. Appendix 8: Health Research Ethics Committee Approval……200 22. Appendix 9: Official Permission by Ado-Odo/Ota LGA………..201 23. Appendix 10: Official Permission by Ifo LGA…………………….202 8 ABSTRACT Background: Adolescents in Nigeria constitute an important group in HIV control due to their vulnerability and sexual inexperience. Even though there is a high level of awareness about HIV among young people in Nigeria, there are still relatively high levels of misconceptions and stigma. Improvement of knowledge about HIV transmission and prevention and correction of stigma and discriminatory attitudes will help in the fight against HIV among young persons in Nigeria. The objective of this study is to determine the effect of health education on HIV/AIDS risk behaviours and stigmatization attitudes among adolescents in Ogun State, Nigeria. Methodology: A quasi-experimental study with a pre and post test design was used to determine the effect of a structured health education programme on HIV/AIDS risk behaviours and stigmatization attitudes in two Local Government Areas in Ogun State. A multistage sampling technique was used to select 215 study participants each in the intervention and control groups. Semi-structured interviewer-administered questionnaires were used to collect data on HIV/AIDS knowledge and misconceptions, personal risk perception, stigmatizing attitudes towards PLWHA, HIV testing, and sexual behaviour. Stigma, HIV Knowledge and sexual behaviour were compared over the follow up times and between the intervention and control groups using Paired t test, McNemar’s Chi square test, Independent samples t test and the z test. Multiple linear regression was also applied. Level of significance of all tests was at 5%. Results: At baseline, participants in the intervention and control groups were not significantly different concerning age (X2 = 2.69, p = 0.101), gender (X2 = 2.31, p = 9 0.128), parents’ marital status (X2 = 0.12, p = 0.729), father’s education (X2 = 2.88, P =0.237), mother’s education (X2 = 4.75, p = 0.093) and family type (X2 = 5.57, p = 0.062). There was a 42.5% reduction in risky sexual behaviour in the intervention group compared to 27.4% of controls at 4 months compared to baseline (Z = 1.34, p = 0.163). The change in proportion that had sex 12 months before the study was significantly higher among controls (19.2%) compared to the intervention group (8.8%) (Z = 2.94, p = 0.002). Also, condom use last sex was much improved in the intervention (72.2%) compared to control group (32.5%) (Z = 3.04, p = 0.003). There was no significant difference in the reduction in stigma scores between the intervention (mean 2.2, SD = 4.8) and control groups (1.8 (SD = 5.4) (U = 11586, p = 0.952). However, there was a significantly higher improvement in knowledge scores among adolescents in the intervention (mean = 1.3) compared to control groups (mean = 0.6) (p = 0.043). There was an increase in the proportion that ever tested for HIV of 3.2% in the intervention group compared to a reduction of 4.2% for the control group (Z = 3.82, p < 0.001).