Factors Influencing the Utilization of HIV Voluntary Counselling and Testing Services among Youth in Bukasa Community.

1.1 Introduction

Voluntary counselling and testing (VCT) is one of the key strategies used in the fight against Human Immunodeficiency Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS) in Uganda and the world at large. Globally, about 37.9 million people are living with HIV of which 68% are in Africa. East Africa has 20.6 million people living with HIV. Of the 1.7 million new HIV infections in the world, 800,000 were in Sub Saharan Africa (SSA) (World Health Organisation [WHO], 2018).

Uganda was one of the first countries to take on VCT in a bid to curb the HIV epidemic. However, people especially in rural areas including the youths have not fully embraced this service (Mafigiri, 2017). This study uncovered factors behind the low uptake of VCT services among youths in Bukasa, a rural community in Wakiso district.

Discussed in this paper is the background, problem statement, purpose, specific objectives, research questions and significance of the research to the nursing profession.

1.2 Background

The first HIV/AIDS case in Uganda was in 1982 in Kasensero, a fishing village located in Rakai district. It later spread to neighboring areas then to the urban areas. There was a high prevalence rate of HIV/AIDS of 18 percent  in 1990’s but it dropped to 6.0 percent  in 2006 owing to behavioral changes that the government had implemented ((Mugisha, van Rensburg, & Potgieter, 2010).In 2013, 35 million people were living with HIV globally and 24.7 million of those were in SSA. Globally, 1.6 million people have died due to HIV/AIDS related illnesses of which in 2012 75 percent  were in SSA. This left a financial burden on these resource-limited nations (Lubogo, 2015).

HIV is an infection of the immune system and it mainly attacks the CD4 cells and replicates within the host cell leading to crippling of the immune system of the infected person. This leaves the person vulnerable to infections, which later leads to a syndrome known as AIDS. There are two main strains of HIV, HIV-1 and HIV-2. HIV-1 is the most common in Uganda (WHO, 2018).

HIV counselling and Testing (HCT) is a service provided to someone with the intention to reveal their HIV status which can be either negative, meaning the person is HIV free or positive, meaning the person has HIV. Voluntary Counselling and Testing (VCT) is a key component of HCT where an individual willingly seeks HCT services in order to know their HIV status (Wanyenze et al., 2013).

There are two main ways of providing VCT. There is the traditional form of VCT, which is client–initiated. Here a client requests for an HIV test from the health care provider. The second is Provider initiated testing and counseling (PITC) in which a health care provider recommends VCT to the client. This takes place in a health care setting. The main aim of PITC is to diagnose the client by either confirming or ruling out HIV infection. Routine counselling and testing (RCT) is the provision of HCT services to a client regardless of their present health complaints, in this all clients who come to the health facility have an HIV test. It’s aim is to increase the uptake of HIV services like PMTCT (Prevention of Mother to Child Transmission).

Consent, counseling and confidentiality are the three main components of VCT. Every health care provider must obtain written permission from the client before conducting the HIV test. The client must receive pre and post-test counseling in preparation for the HIV test results. This tackles what the client will do if the results are positive or even when they are negative, behavioral changes like practicing safe sex; faithfulness and reduction of risky behavior like drug use are emphasized. The client must trust that HIV test results are confidential and not for public view (Kitara, Amone, & Okello, 2012).

A youth is a young person between 15-35 years of age (African Youth Charter, 2006). Youth constitute about 77 percent  of Uganda’s population. 7.3% of Ugandans are living with HIV of which 3.7% are youth. Globally, there were 4.2million youths living with HIV of which SSA is home to 72% of them. The youth are under the vulnerable and high-risk groups for HIV infection both globally and in Uganda because of their risky sexual behavior including low condom use, multiple sexual partners and limited knowledge about HIV/AIDS (Strauss, Rhodes, & George, 2015).

These groups are key in HIV prevention and transmission and yet VCT services are not fully utilized by the youth.. For this reason, youth are a focus in the control of the spread of HIV. Most studies conducted in Uganda have focused on the risky sexual behavior among youths. This has left a gap on data concerning VCT uptake among youths (Mafigiri et al., 2017). However, some research shows that there is low VCT uptake among youths because of fear of positive HIV results, fear of stigma from peers and family members and parental view of seeking VCT services as a sign of promiscuity (Sam-Agudu, Folayan, & Ezeanolue, 2016).

Uganda was one of the first African countries to implement VCT and by 2005; it was available in all districts. Still, due to low uptake of VCT services Uganda introduced home–based testing where clients receive VCT from their homes (Wanyenze et al., 2013).

It is against the fact that the youth have an HIV prevalence rate of 3.7% and a low VCT uptake (Mafigiri et al., 2017) and (Sam-Agudu et al., 2016)  that this study intends to explore the factors behind the low VCT uptake among youths since they are more than 50% of Uganda’s population.

1.3 Problem statement

VCT is a main strategy put in place to curb the HIV epidemic globally. Research shows that youths are not fully accessing this service. Globally, 37.9 million people are living with HIV of which 68% are living in Africa. In addition, 72% of the infected people in Africa live in SSA. About 20.6 million people are living with HIV in East Africa (WHO, 2018).

Globally, 4.2 million youths were living with HIV of which 1.6 million were in Uganda in the year 2013. There is evidence that there is low uptake of VCT services by youths both globally and in Uganda (Mafigiri, 2017). This puts HIV reduction goals at stake since more than 75% of Uganda’s population is made of youths (Lubogo, Ddamulira, Tweheyo, & Wamani, 2015).

Although there is limited information particular to Bukasa, some of the reasons for low VCT uptake among youths in Uganda are; poor attitude and customer care among health workers and need for parental consent in the process of accessing VCT services. In addition to the above, fear of being diagnosed with HIV, which comes with stigma and discrimination from peers and family members also reduces VCT uptake among youths .

1.4 Purpose/objectives

The purpose for this study is to identify the factors influencing VCT uptake among youths in Bukasa community.

1.5 Specific objectives

The specific objectives of the study are three and these include;

1. To asseess the knowledge and attitude of youth towards VCT services in Bukasa community.
2. To identify the factors favoring the utilization of VCT services by youths in Bukasa community.
3. To identify the barriers to access to VCT services by youth in Bukasa community.

1.6 Research questions

What are the factors influencing the utilization of VCT services among youth in Bukasa community?

1.7 Conceptual framework

This study seeks to address the factors influencing the utilization of VCT services among youths in Bukasa community. Bandura’s social cognitive theory of human behavior has been adopted for this study. In this model, three dynamics are responsible for the utilization of health care services including VCT services. These are; behavior, beliefs (personal) and environmental factors.

Behavioral factors; self-efficacy enables one to know that they can test for HIV. Skills; ability to correctly use a condom and also seek VCT services and skills for negotiation which enables one to talk their prospective sexual partner into an HIV test and safe sex practices before a sexual encounter. Practice; which entails consistent correct condom use and either faithfulness in a relationship or abstinence from sex greatly determine one’s decision to seek VCT services because they form a basis for expected HIV results.

Environmental factors including social norms may hinder younger youths from seeking VCT services. This is because many people think youths who seek VCT services are promiscuous. In addition, access of VCT services in the community meaning availability and cost affects their uptake by youths. The influence of others like advice from peers and family can determine whether one goes for an HIV test or not. Youths stated that home-based testing is better because of a supportive environment of family members than at school where peers may speculate about your results basing on the mood you leave the counselling room (Strauss et al., 2015).

In addition, some noted that the health facility environment is not so favorable because of separation of people who seek VCT services from those that seek general health services, which notifies all hospital clients your intention. In environments like school, some feel that the quality of privacy and confidentiality might be compromised leading to disclosure of their HIV status (Strauss et al., 2015).

The personal factors associated with VCT utilization include the belief that testing HIV positive means the end of one’s life. Furthermore, some youths believe that a positive HIV diagnosis will reduce their level of joy and happiness leading to misery.

Bandura’s social cognitive theory of 1986.

1.8 Significance

This study will provide information on the factors influencing the uptake of VCT among youth in Bukasa community. These results may be of relevance to health and nursing in that they may identify deterrents to VCT uptake among youths and modify service provision to suit youths.

The results of the study may also enable health workers in Bukasa to develop strategies to increase VCT uptake, which will reduce on HIV infections and increase HCT service uptake in Uganda at large, which will reduce on the workload and the financial burden of HIV on the health sector.

This study may also provide health workers in Uganda with reasons for low up of VCT services among youths.

2.0 Chapter 2:  Literature Review

This chapter will entail review of literature regarding knowledge and attitude of VCT services among youths, reasons for taking up VCT services and the barriers to VCT services among youth.

2.1 Knowledge and attitude regarding  VCT services among youth

Most research suggests that despite the high knowledge of VCT services among youth, many do not utilize it. In a study conducted among tertiary students in Nigeria to access the knowledge and their willingness to pay for VCT services, 64 percent  were aware of VCT services but only 19 percent  of them had utilized the service meaning 81% of the youth did not utilize the service. Also,76% of youths viewed VCT as a source of crucial information regarding HIV prevention and control (Uzochukwu, Uguru, Ezeoke, Onwujekwe, & Sibeudu, 2011).

In agreement with the above research, a study conducted among youth in Kenya found  high knowledge levels and positive attitude among the participants towards VCT services but with underutilization of the service. Only 52% of the participants had tested for HIV. The main source of VCT information was media (Ndwiga & Omwono, 2014).

In addition, a cross sectional study among school students in Arusha, Tanzania found that much as 93.5% of the research participants were aware of VCT services and 79.1% of them had good knowledge regarding VCT, only 29.3% of the participants had ever had VCT although 75.9 % of them had positive attitude towards VCT (Sanga, Kapanda, Msuya, & Mwangi, 2015).

Kitara, Amone, and Okello (2012) made similar findings among youth in Gulu, Uganda where 93% of youth had knowledge about VCT, 84.9% of the youth would encourage their associates to have an HIV test but only 36.1% had an HIV test. These youth obtained information regarding VCT from media (mainly radio stations), health workers and other sources like social gatherings and VCT related posters in a ratio of (26.9% : 41.3% : 19.2%) respectively. The aim of this study was to access the knowledge and misconceptions about HIV HCT among the post-conflict youth in Gulu district.

In contrast to the above findings, a study conducted in South Africa among students found that many of the youth had a negative attitude towards VCT and many did not take HIV tests regardless of their vast knowledge about VCT (Makhubele, Dhlamini, & Khoza, 2015). In addition Amu (2014) set out to discover the knowledge and attitude amongst youth that served on Nigeria’s National Youth Service Corps and found that although 58% had a positive attitude regarding VCT, 42% had a negative attitude towards VCT which was a very big number of youths in comparison to the research analyzed above.

2.2 Factors favoring the utilization of VCT services among youth.

A research aimed at assessing factors influencing VCT uptake among youth in Zanzibar found that youth undergo VCT because of different reasons like, job requirement where the employer requires them to present their HIV results like during military recruitment. At times youth take on VCT services as a requirement by health insurance companies. Sometimes youth test for HIV as a recommendation by a health care provider like during pregnancy, as a way of diagnosing disease especially when they present with HIV symptoms, when planning to get married and when undergoing medical procedures like blood and organ donation. In addition, the same research discovered that some youths undergo VCT because of uncertainty of their HIV status especially after unprotected sex, injectable drug use, distrust of sexual partner and self-perceived HIV risk (Moh’d, 2015).

The research conducted by Dirar, Mengiste, Kedir, and Godana (2013) with the aim of finding out factors contributing to VCT uptake among college students at an Ethiopian university concluded that majority of the youths (89.9%) underwent VCT to know their sero status and 3.8% got tested because they were planning to get married.

In addition, some youth take an HIV test out of inquisitiveness just to know how the whole process goes and know their HIV status. Some of them aim at accessing early treatment in case they are infected and others desire to use VCT results as a basis for the measurement of the extent of faithfulness of their sexual partners. These were results of a research conducted in Mount Kenya university whose aim was to make an analysis on the uptake of VCT services among the university students (Museve, Gongera, George, & Loum, 2013).

2.3 Barriers to access to VCT services by youth

The low utilization of VCT services among youths is due to several factors. In Nigeria, Yahaya, Jimoh, and Balogun (2010) found that poverty which leads to inability of some youths to pay user fee for VCT services as charged by service providers hinders them to access VCT services. However, Uzochukwu et al. (2011) found that 50% of youth were willing to pay for VCT services in facilities where it was not free although 67.6% of youth felt HIV counseling and testing should be free.

In addition, fear of stigma and discrimination by peers and the community discourages some youth from taking up VCT because the community assumes that whoever takes an HIV test is infected (Mugisha, van Rensburg, & Potgieter, 2010; Sanga et al., 2015).

Knowledge deficit regarding the VCT procedure discourages some youths from testing for HIV. These findings are consistent with those of Moh’d (2015) who in addition attributed low VCT uptake due to perceptions by the  youth  that HIV results were inaccurate and not confidential, impolite service providers, lack of youth friendly services and long waiting hours at the health facilities.

According to Ndwiga and Omwono (2014) there are limited resources to provide VCT to the youth. Some of these are in form of personnel like professional counselors that leads to poor quality of services delivered. Adding to the above, youth are fearful of positive HIV test results and dread meeting their parents at the testing centers since even younger youth have to access VCT services together with adults (Fikadie, Bedimo, & Alamrew, 2014; Moh’d, 2015; Ndwiga & Omwono, 2014). This is contrary to the findings of (Gwandure, Ross, Dhai, & Gardner, 2013) who found that majority of parents are in support of youth accessing VCT as a way of combating the HIV/AIDS although they desired that all stake holders are involved in the planning process.

Adding to the above barriers, lack of proper policies regarding consent for VCT services by youths especially those below eighteen years is one of the barriers that policy makers need to address in order to improve and increase the number of youth utilizing VCT services (Govindasamy et al., 2015; Ndwiga & Omwono, 2014).

Although many youth across the globe have good knowledge regarding VCT services, there is underutilization of these services owing to the barriers identified above. The barriers specific to youth in Bukasa community are unknown therefore, this study aims at identifying the facilitators and barriers to utilization of VCT services in Bukasa village.

• Chapter three:
• Methods and Materials

This chapter presents the research methods and materials to be used in the study including the study design, setting, study population, sampling and sample procedure, inclusion criteria, sample size calculation, study variables, data collection method, study validity and reliability, data analysis plan, ethical considerations, limitations and the research dissemination process.

3.1 Study Design

The study will employ a cross sectional descriptive research design. The team will make use of this design because it will adequately help assessing the facilitators and barriers to utilization of VCT services among youth in Bukasa community.

3.2 Study Setting.

The research team will conduct the study in Bukasa village in Mende division of Busiro East County in Wakiso district in Central Uganda. Bukasa village is 2 kilometers from the main road. Bukasa village is a multi-tribe area although most of the residents are Baganda. The social activities of the people include, betting, drinking alcohol and playing board games. The nearest government health center is in Kakiri, about 7 kilometers from Bukasa. There is also Mercy Health Centre, a privately owned health facility that serves the community. Village Health Teams (VHTs) also serve the community.

3.3 Study population

The target study population will be the youth that reside in Bukasa village aged between 15-35 years at the time of data collection. The youth will be the target population because of their high-risk sexual behavior and low utilization of VCT services.

3.4 Sampling and sampling procedure

Participants will be recruited using simple random sampling method because this basic probability sampling method increases the chances of representativeness and does away with systematic bias. The research team will employ lottery method of simple random sampling where they shall write numbers on papers fold them, put them in a cardboard box, and mix them. Each participants will pick a paper of their choice. These numbers on the papers will be the discreet participants’ codes.

3.4.1 Inclusion Criteria

Youth aged 15-35 years that reside in Bukasa village will be included in the study regardless of their gender. These must be able to assent or consent depending on their age.

3.4.2 Exclusion criteria

During the selection of the sample population, the research team will exclude children below 15 years and adults above 35years from the study because the target population is between 15-35years. In addition, the study will exclude youth between 15 and 17 years whose parents will not give consent for them to participate in the study.

3.4.3 Sample size

The study will involve 271 youths who reside in Bukasa village. The sample size will be 271 youths within the village.  The sample size estimation for this study will be determined using Ireda’s formula below.

Sample size = (Z- Score) ² std. (1-std) / (Margin of error) ².

Z- Score = Confidence level will be taken as 90%

s.t.d = Standard deviation which is .5 and margin of error which is equivalent to a confidence interval of +/- 5% (Ireda, 2014).

SZ= (1.645)² ×.5 (.5)/ (.05)²

SZ= 2.706025 ×.25/ .0025

SZ= 0.6750625/.0025

SZ= 270.60

Therefore, the study will involve 271 participants.

3.5 Study Variables

3.5.1 Dependent variables

The dependent variable in the study is utilization of VCT services by the youths in Bukasa.

3.5.2 Independent Variables

The independent variables in the study are:

1. a) Individual factors depending on the youth like sex, level of education, occupation, religion and age, which either facilitate or hinder utilization of VCT services.
2. b) Community factors as perceived by the youth like fear of stigma that comes when seen at the VCT services area by peers and other community members.
3. c) Barriers in VCT service delivery as perceived by the youths like poor counselling skills and attitude of health workers.

3.6 Data collection methods.

During the study, the research team will collect data using a participant self-administered questionnaire, which will aid to collect data from the study participants. This will have instructions, participant’s code and contact, uniform questions and general comment. The team will use questionnaires because they enable study participants to have ample time to come up with the answers, are less expensive and ensure validity and reliability of the information. The questionnaire will consist of both closed and open-ended questions so that participants are able to express themselves more. Questionnaires will be in English. The research team will translate the questionnaire for those who cannot read or write English and those that can neither read nor write.

3.6 Data collection tools

The data collection tools will involve the use of a self-administered questionnaire with both closed and open-ended questions, which participants will answer. In question 1-6 of the questionnaire, there is a list of answers for the participant to tick the most appropriate. Question 7 will be a fill in question. Question 8 requires a general comment from the participants. In addition, VHTs and the research team will help translate the questionnaire for participants who cannot read English and those that can neither read nor write.

3.7 Data Collection Procedure

After seeking authorization from Aga Khan University School of Nursing and Midwifery (AKU-SONAM) and Bukasa village leaders, the purpose of the study shall be explained to the participants and seek ascent/consent from them as applicable. The team shall distribute the questionnaires to the study participants and VHTs will assist participants that require help in reading and writing.

3.8 Validity of tool

Heale and Twycross (2015), defined validity as the degree to which an instrument measures what it should measure. In this study, we shall employ a method of content validity where a questionnaire will address the issues of the research. In order to ensure validity, the research team will first conduct a pilot study to pre-test the questionnaire

3.9 Reliability

The research team will conduct a pilot study to check whether different participants can respond to the same questions in a similar way. If the participants respond differently to some of the questions, the research team will correct the identified questions accordingly basing on the response of the participants during the pilot study.

Reliability of an instrument is the measure of consistency of an instrument (Heale & Twycross, 2015). In order to ensure reliability, we shall pre-test the data collection tools using randomly selected youths from the sample population. In this study, participants will be encouraged to give similar answers as they did in the questions before. The co-efficient of reliability will be between 0 and 1 with perfect reliability equal to 1 and no reliability will equal to 0. This will permit reforming of the questionnaire and hence ensure consistency and accuracy.

3.10 Data Analysis Plan

The research team will collect, organize, summarize and categorize data for more analysis on a daily basis and after transfer it to a computer using software called Statistical Package for the Social Services (SPSS). The research team will present its findings using bar charts and tables. All data will be confidential.

The research team will utilize the frequency and the measures of central tendency to describe data to give a clear picture of the results. Manikandan (2011) defined a measure of central tendency as a typical value around which other figures congregate. The team will utilize central tendency because it gives a simple and precise description of the main features of the whole data and determines the value, which represents the whole series especially when working with large amounts of data. In this case, the team will obtain data from a sample population of 271 youths.

3.11 Ethical considerations

The research team will obtain an introduction letter from AKUSONAM, which will introduce them to Bukasa Village leaders. This letter will highlight their intentions in the community. The village committee will give them an approval letter to authorize them to carryout research in the village.

The research team will obtain both verbal and written ascent and consent from the study participants depending on their age. The research team will ensure confidentiality, trustworthiness, reliability and validity while carrying out the research by keeping all information collected during the study private and under lock and key.

3.12 Limitations

One potential challenge in the study is that some of the participants might not fully complete the questionnaire because of different reasons that might lead them to leave Bukasa village abruptly for example business trips. The research team should consider getting their contacts in order to follow up.

In addition, involvement of VHTs in the collection of data might cause bias and some participants might not be open. There might be loss of information during translation.

3.13 Dissemination Process

The research team shall share the proposal with AKUSONAM, Local and health leaders in Bukasa and Uganda Nurses and Midwives Council. After editorial review, the research team will publish the study findings in journals and present it in conferences.

References

Heale, R., & Twycross, A. (2015). Validity and reliability in quantitative studies. Evidence-based nursing, 18(3), 66-67.

Ireda, A.M.A. (2014). How Can We Determine Sample Size from Unknown Population? Retrieved from https://www.researchgate.net/post/How_can_we_determine_the_sample_size_from_an_unknown_population

Manikandan, S. (2011). Measures of central tendency: The mean. J Pharmacol Pharmacother, 2(2), 140-142.

Appendices

Appendix 1: Consent form

Introduction: We are students of Aga Khan University ( Agatha Najjesero, Angel Nalwoga and Jovia Nalwoga) pursuing a Diploma in General Nursing.

The purpose for this study is to identify the factors influencing VCT uptake among youths in Bukasa community.

Process of participation

If you agre to participate in this study, we shall ask questions related to your experience concerning utilization of VCT services.The interview will take 40-50 minutes. We are also requesting you to permit us to record the interview using a phone to ensure that we do not miss any important information. We shall answer any questions you may have. All information collected will be kept confidential. Participation in this study is voluntary and you can withdraw at anytime without any explanation.

Risks

This study does not put you at risk in any way. If during the process of the interview you feel like withdrawing , we shall discontinue the interview. The interview can either be cancelled or continued another time.

Benefits

There are no direct benefits to you for participanitng in this study, however, after the study, information gathered can provide and give you more knowledge about what you initially knew about utilisation of VCT services.

Confidentiality

A code will be used for each participant for the purpose of this study. The record of your code and other information provided by you will be kept locked and the soft version will be secured with a password. The information and results from the study will be published and presented at seminars and conferences.

Invitation to participate

I would like to invite you to participate in this study if you agree to the above mentioned clauses. I would like to have your signature of permision below. In addition, a demographic form has to be filled. If you need assistance in filling the form, please do not hesitate to ask me for assistance.

Agreement to Participate

I have uderstood the conset form and i agree to participate in the study voluntarily. I understand that i can wihdraw from the study at any time without any effect on my social status.

Participant’s code                            signature of participant                                     Date———————————————————————————————

I have explained this study to the above participant

Name and signature of the researcher                                             Date———–

Appendix II: Questionnaire

Instructions

Please tick the appropriate answers and fill in the blank spaces where applicable.

Date———————participant code——————-Telephone number—————–

1. Have you heard about HIV/AIDS?

Yes——————–No———————————————————-

1. What is your main source of information about HIV/AIDS prevention and control?

Radio——–Television———–Health center/worker———–Friends———————–

2. Have you heard about voluntary counselling and Testing (VCT)?

Yes———————————————-No———————————————-

3. Have you ever gone for VCT services?

Yes—————————————–No——————————————————

4. Are you willing to go for VCT services?

Yes——————————————————No———————————————

5. Where do you prefer to get VCT services?

Private setting—————————–Government setting—————Home—————

Workplace———————————School/University—————————————-

6. Do you know what happens when you go for VCT services?

Yes                                                    No———————————————-

7. What stops you from going for VCT services?

———————————————————————————————————————————————————————————————————————————————————————————————————————————–

8. Would you encourage your friends to go for VCT services?

Yes———————————————————No——————————————

Reason—————————————————————————————————————————————————————————————————————General comment————————————————————————————————————————————————————————————————-

each appendix should appear on its own page.

Appendix III: Budget

This budget is representative of the expenditure for the estimated 6 days the research team shall spend in the field collecting data. It has three categories.

Appendix IV: Timeline