- Research article
- Open Access
- Open Peer Review
Culturally-adapted and audio-technology assisted HIV/AIDS awareness and education program in rural Nigeria: a cohort study
© Ofotokun et al; licensee BioMed Central Ltd. 2010
- Received: 11 September 2009
- Accepted: 2 February 2010
- Published: 2 February 2010
HIV-awareness programs tailored toward the needs of rural communities are needed. We sought to quantify change in HIV knowledge in three rural Nigerian villages following an integrated culturally adapted and technology assisted educational intervention.
A prospective 14-week cohort study was designed to compare short-term changes in HIV knowledge between seminar-based education program and a novel program, which capitalized on the rural culture of small-group oral learning and was delivered by portable digital-audio technology.
Participants were mostly Moslem (99%), male (53.5%), with no formal education (55%). Baseline HIV knowledge was low (<80% correct answers for 9 of the 10 questions). Knowledge gain was higher (p < 0.0001 for 8 of 10 questions) in the integrated culturally adapted and technology-facilitated (n = 511) compared with the seminar-based (n = 474) program.
Baseline HIV-awareness was low. Culturally adapted, technology-assisted HIV education program is a feasible cost-effective method of raising HIV awareness among low-literacy rural communities.
- Intervention Community
- Intervention Village
- Control Village
- Correct Response Rate
- Audio Device
The acquired immunodeficiency syndrome (AIDS) epidemic continues to be a major challenge to global health and socio-economic development in many regions of the world [1–3]. An estimated 33 million people worldwide were living with HIV by the end of 2007; 2.7 million became newly infected and 2 million died from AIDS during that year . In Nigeria, the estimated number of adults (>15 years) living with HIV in 2007 was 2.4 million [5, 6]. Effective education programs that take into consideration the information needs of the predominantly rural inhabitants are needed to improve HIV prevention knowledge. In this report, we present the findings of a 14-week longitudinal evaluation of a culturally-adapted, small audio-technology HIV awareness campaign focused upon an oral message, compared with a conventional seminars/pamphlet based program in three rural communities in the northern Nigerian State of Kano.
Three villages (Miamakawa, Gaya South, and Kutama) were recruited in consultation with local organizations (Federation of Moslem Women Association of Nigeria (FOMWAN) and the Evangelical Church of West Africa (ECWA) with an extensive grass-roots presence in Northern Nigeria. These villages were small, with each inhabited by less than 30,000 people, and were relatively remote -- about a two-hour drive on unfinished roads from the nearest major city, Kano City. Miamakawa and Gaya South were assigned together as the intervention group due to their close proximity to one another. Kutama was designated as the control village. Kutama was geographically separated from the intervention villages, helping to minimize the information crossover during the evaluation period.
HIV Education Content
HIV education materials, based on existing local HIV training curriculum, were modified to address basic knowledge about the virus, transmission risk as applicable to the community, practical risk reduction approaches, as well as local myth and misinformation that fuel the stigmatization of people living with HIV. To mirror the known cultural learning habits of these villages, the content was formatted into short stories, proverbs, parables, dramas, and folk songs in the indigenous Hausa language using characters and voices of recognized community role models (e.g., the local radio newscasters, assistants in the community place of worship, etc.). This information was arranged into a 3-hour audio program and loaded onto the specially-designed digital audio player described below. A one-page version of the content was also printed as pamphlets written in Hausa for distribution to the control community.
Digital Audio Technology
Developed by Voice For Humanity (VFH), Lexington Kentucky, U.S.A., the digital audio device resembles an MP3-player and uses voice compression technology (125X) that allows up to five hundred hours of information to be stored in a removable microchip. The units are portable, fitting into a shirt pocket, and can be powered by solar-charged batteries or by wall-outlet supplied electricity. They have no moving parts and are resistant to wind, dirt and sand. Furthermore, the microchips can be easily replaced, allowing the audio devices to be used for other health and social development programs. The greater flexibility in program format and on-demand replay afforded by this technology gives it an advantage over radio in deploying media interventions.
Intervention (HIV Awareness and Education Campaign)
The education program was conducted in the last two weeks of November 2005. In the intervention communities, trusted individuals recommended by the community chiefs (Megeri) were recruited as group leaders who would train others to play the digital devices in small listening groups. These groups included 5-10 people. After listening to the audio program, the groups were encouraged to discuss the contents. Participating villagers who expressed interest in helping with the campaign were further trained by the leaders and were provided with devices to continue in a similar manner, organizing new small learning groups. Approximately 3000 devices were disseminated in the intervention villages.
In the control village, the HIV education program mirrored previous HIV campaigns in the communities in order to allow the comparison of the new approach to the existing standard for that locality. The control HIV education program included a one-time open house seminar conducted in the local Hausa language by the ECWA HIV chief educator at the community rendezvous. The event consisted of a 60 minute HIV awareness lecture, followed by an all-day interactive question-and-answer session between villagers and project staff. To ensure a wider reach, the seminar was supplemented by the distribution of approximately 3000 of the aforementioned pamphlets to households in the community by trained volunteers. These volunteers also read the pamphlets aloud to recipients who requested help. The topics discussed at the seminar and the content of the pamphlet were similar to the HIV information distributed in the intervention community.
Emory University personnel trained the 20 local field workers to administer the questionnaire using the audio device. Each field worker was assigned to districts within the target communities and instructed to go from house to house and identify individuals in his or her district who were willing to participate in the 14-week study. A local guide was paired with each field worker to ensure accurate tracking of participants during the evaluation period. As local Moslem culture restricted interactions between unrelated male and female individuals, male field workers were paired with female guides and vice-versa to ensure each team had access to both male and female participants.
Villagers were eligible to participate in the assessment if they were > 12 years of age, agreed to take part in the HIV campaign by listening to the audio device (intervention community) or to attend the HIV seminar or read the HIV education pamphlet given and/or read to them (control village). Other eligibility criteria included a willingness to participate and stay in the program for the entire duration, and having no more than a sixth grade education.
Participants responded to questions as they were played by the audio player by selecting the picture object on their answer sheet which in their view appropriately answered the question. This approach allowed for privacy in response to questions with little or no help from the field workers.
At week 14, the degree of community exposure in the intervention communities was assessed through a convenience sampling of individuals to assess whether they participated in the program or not. The reach of the seminar and pamphlet distribution was not assessed in the control village.
All participants provided oral informed consent before completion of the baseline assessment. This study was designed according to the ethical guidelines for human studies and approved by the Emory University Institutional Review Board and the ECWA Healthcare System Ethics Committee.
Demographic data and responses to HIV knowledge questions were summarized and compared between different subgroups of the population. Chi-square tests were applied to examine differences between subgroups for the ten HIV knowledge questions. Multivariable logistic regression was used to determine whether baseline knowledge differences between the control and intervention groups remained after adjusting for gender and education. The primary outcome for this cohort study was change in response over time for a set of ten HIV knowledge questions. The outcome response was a correct or incorrect answer to each HIV question. Analyses for repeated measures were needed to properly account for the correlation between multiple observations from the same participant. Two approaches were used to analyze the data. First, McNemar's test of correlated proportions was used to test within group change by assessing symmetrical change among those participants in which changes in response occurred. Were learning not truly occurring, one would expect these changes to occur at random and the off-diagonal counts would be approximately equivalent. This test was performed separately for the control and intervention group to determine within-group change (baseline to week 7 and baseline to week 14). Differences in change between the control and intervention group were tested with the Pearson chi-square test for independence . This test focused on whether the change in HIV knowledge between baseline and 7 weeks (and separately, baseline to 14 weeks) was related to the intervention. Following these univariate comparisons described above, we utilized Generalized Estimating Equations [GEE] modeling methods , which allow for covariate adjustment. The repeated response data at baseline, 7 weeks and 14 weeks were compared between intervention groups by performing a GEE logistic regression analysis implemented using SAS Proc Genmod using an exchangeable correlation structure for the repeated binary responses within participant for each of the HIV knowledge questions. These models were refit to adjust for gender and education. The model-based estimates are unbiased with unbalanced and missing data, so long as the missing data are non-informative (missing completely at random). All statistical tests were two-sided. A Bonferonni adjusted α of 0.005 (.05/10 questions) was used to assess differences in change between education programs for the HIV knowledge questions. The same adjustment for multiplicity was used when testing for within-group change at each follow-up visit for each of the HIV knowledge questions. For testing the covariates of education and gender in our GEE models, α = 0.05 was used.
Demographic characteristics among 1205 participants in three rural Nigerian communities
(n = 1205)
(n = 594)
(n = 611)
12 - 15 years
15 - 45 years
> 45 years
Grades 1 - 3
Grades 4 and 5
Technology in the home2
Communal Level of HIV Knowledge at Baseline
HIV knowledge at baseline among 1205 participants and at 7 weeks post-intervention among 1073 participants in three rural Nigerian communities
Working near someone with the AIDS virus (No)
Eating food cooked by someone who has the AIDS virus (No)
Sharing plates, forks, or glasses with someone who has the AIDS virus (No)
Receiving injectable drugs with syringes or needles used by someone who has the AIDS virus (Yes)
An infant from his/her mother who has the AIDS virus (Yes)
Being coughed or sneezed on by someone who has the AIDS virus (No)
Having sexual intercourse with someone who has the AIDS virus (Yes) 1
A baby breast-fed by his/her mother who has the AIDS virus (Yes)
Attending school with a child who has the AIDS virus (No)
Bites by mosquitoes or other insects who have bitten a person who has the AIDS virus (No)
Sharing a bed with someone who has the AIDS virus (No)
Baseline Correct Response Summary
(n = 1205)
(n = 594)
(n = 611)
(n = 643)
(n = 558)
(n = 651)
(n = 528)
Attitudes and beliefs about HIV/AIDS and risk reduction among all residents of three rural Nigerian Communities (n = 1205)
(n = 530)
(n = 543)
The following questions ask about your beliefs regarding AIDS. Do you agree or disagree with each of the following statements?
People who have the AIDS virus often have become infected because of their own carelessness
There is little a person can do to prevent catching the AIDS virus
Healthwise, there isn't much you can do for yourself once you have the AIDS virus
In the past month, have you done any of the following to protect yourself from HIV and other STDs?
Abstained from sex
Changed the way sexual partners were selected
Reduced or limited the number of different sexual partners
Discussed HIV with sexual partner(s)
Had sex with only one partner
If you test positive for HIV, would you tell any of the following individuals about your HIV test result?
Change in HIV Awareness and Knowledge
Improved knowledge about HIV/AIDS transmission from baseline to 7 weeks post-intervention among 1073 participants in three rural Nigerian communities
Based on what you have heard about AIDS, do you think that a person can get AIDS or the AIDS virus from each of the following?
A. Working near someone with the AIDS virus - p < .0001 a
p = .57 b
p < .0001
B. Eating food cooked by someone who has the AIDS virus. - p < .0001
p = .87
p < .0001
C. Sharing plates, forks, or glasses with someone who has the AIDS virus. - p < .0001
p = .57
p < .0001
D. Receiving injectable drugs with syringes or needles used by someone who has the AIDS virus. - p = .10
p = .08
p = .0003
E. An infant from his/her mother who has the AIDS virus. - p = .36
p < .0001
p = .0015
F. Being coughed or sneezed on by someone who has the AIDS virus. - p < .0001
p = .29
p < .0001
H. A baby breast-fed by his/her mother who has the AIDS virus. - p < .0001
p = .34
p < .0001
I. Attending school with a child who has the AIDS virus. - p < .0001
p = .32
p < .0001
J. Bites by mosquitoes or other insects who have bitten a person who has the AIDS virus. - p < .0001
p = .03
p < .0001
K. Sharing a bed with someone who has the AIDS virus. - p < .0001
p = .04
p < .0001
When gender and education were taken into account through statistical modeling, the above results did not change qualitatively. For Questions A, B, C, D, E, F, I and K, the proportions of getting the correct answer were significantly higher among those who had some education than those who had no education (all p < 0.05). For Questions D, E, G, H, I, J and K, the proportion of males getting the correct answer were significantly higher than those for females (all p < 0.05). Our assessment tool also included questions relating to attitudes and belief towards HIV/AIDS, which revealed similar responses at baseline. For the majority of these questions at the 7-week follow-up, responses improved in the intervention communities while they remained similar or declined in the control communities (data not shown). The convenience poll of the intervention communities revealed that 94.1% (447/475) of villagers interviewed had listened to the audio program.
In the current report, the existing level of HIV knowledge and attitudes was assessed and the effectiveness of two educational approaches in improving the level of HIV awareness was prospectively compared. Our baseline data suggested the existence of ample room for basic HIV knowledge improvement in all three villages. For a majority of the questions (6 out of 10), the correct response rates at baseline were less than 70%. Less than a third of the respondents provided the appropriate response to the question regarding the mode of HIV transmission. Factors associated with lower HIV awareness in our sample were gender, lack of formal education, and the community. These findings are important in part because women represent the fastest growing segment of the AIDS epidemic in many regions of the world, particularly in sub-Saharan Africa where over half of the disease burden is borne by females .
The results of our longitudinal assessment indicate that the implementation of an integrated audio program that accommodates the local learning culture is feasible and effective in enhancing HIV awareness in the rural setting. Appreciable and statistically significance changes in HIV knowledge were observed from baseline to week 7 following the integrated campaign compared with the control program of seminar/pamphlet distribution. Although the conventional approach of seminars and pamphlet distribution resulted in some amount of improved HIV awareness, the audio-device assisted intervention was associated with a more robust gain in knowledge for all but two (D and E) of the ten HIV knowledge questions. We attribute this gain to the multi-faceted approach employed in this intervention; the content was formatted into culturally-familiar oral modules and was delivered in a small group setting in the local language, by an easy-to-use audio platform. The use of an mp3-like device ensured that information was consistent and participants could refresh their knowledge by listening multiple times. Pamphlet distribution and large group seminars are widely used in HIV education in resource-limited settings, due to ease and their low cost. However, our data suggests that this approach was suboptimal compared to our novel audio approach. In the large group settings of group seminars, individuals tend to be less inclined to ask questions to clarify doubts. Furthermore, the impact of the pamphlets in rural settings is limited by low literacy. Pamphlets read during a visit by individuals unknown to the community are also unlikely to stimulate sustained discussion of the information.
Additionally, it was encouraging to find that the improvement in the level of HIV knowledge was sustained through the second assessment at week 14. Yet we had anticipated a greater gain in knowledge for the intervention group at week 14, as the delivery audio devices were left behind for subjects to replay and potentially reinforce learned messages. A number of factors may have accounted for this plateau, including learning saturation and fatigue from listening to the same content repeatedly, and inadequate time between assessment periods. Future work could include memory chips with multiple versions of the message, with variations of the songs, proverbs, parables and dramas, which could help to reduce fatigue.
Being male and having some education posed some advantage in this conservative Muslim society. Yet, regardless of subjects' gender or education status, improvements in HIV knowledge were observed across all segments of the population, supporting the value of this integrated approach as an effective mode of delivering information across demographics in these communities. The poll of audio program reach in the intervention villages indicated that device listening had proliferated in the community far beyond the original cohort of study participants. Admittedly, the convenience sampling method was suboptimal and future studies might prospectively plan to quantify program exposure throughout the community. The cost-effectiveness of deploying the digital audio outreach program in the intervention communities is noteworthy. The cost per individual educated by this intervention (including content development, technology, training and distribution), was less than US $3. This is extremely modest when compared to the cost person reached of $67 reported for HIV outreach program to prostitutes in Cameroon , and the estimated cost of TV and radio emission of $2566 and $383 per minute respectively .
Our study was limited by a number of factors including selection bias from the non-randomized selection of the communities, districts and individual participants. The follow-up of 14 weeks was rather short to assess long-term retention of HIV knowledge. Other designs (cluster trials) and sampling plans with longer follow-up should be considered when planning future studies of education outreach programs in this setting. Furthermore, the use of the same assessment instrument for all three visits may have altered patients' responses at follow-up. Future studies should consider incorporating a larger pool of questions, with several questions testing similar domains of knowledge. An assessment of the communal reach of the seminar and pamphlet program in the control village would have provided for a more robust comparison of the two intervention groups. Behavioral change resulting from knowledge gained was not directly measured; subsequent work might assess knowledge retention vis-à-vis behavior modification at later time points after program exposure.
In conclusion, the low baseline HIV knowledge observed in this study the underscores the need for HIV awareness programs tailored towards the information need of these rural communities. The culturally adapted, audio HIV program that we tested offers a feasible and cost-effective alternative to improving HIV knowledge in such settings.
This work was funded in part by the United States Agency for International Development (USAID) Award # 620-A-00-05-00100-00 to Society for Family Health/Voice for Humanity), Office of Global AIDS Coordinator and Emory University Center for AIDS Research, Clinical Research and Biostatistics Cores (NIH Grant # P30 AIO50409).
We also acknowledge the contributions of Hajjia Aisha Hassan - FOMWAN project coordinator in Kano State, Hajjia Habiba Meijinyawa - FOMWAN project coordinator in Kano State, Bauta Motty, PhD - Nigerian project manager, coordinated ECWA's role in the project, Rev. India Magaji - Coordinated ECWA's role in the project, Beatrice - Project driver, Rev. Samuila from ECWA assisted in project coordination; Andrew Ageleweh and Jimmy Samaila assisted in data entry. The field workers were Fatima Abubakar, Fatima Sulaiman Ahmad, Ahmad Abdullah Ahmad, Khalisa Tijjani Ahmad, Maryam Habib, Adamu Bello, Auwal Ahmed Rufai, Aisha Garba, Idris Shehu, Nimran Khalil, Sunusi Shehu, Basira Mijinyawa, Mahmoud Sulaiman, Ado Umar Sanei, Hauwa Umar, Ahmad Adamu Suleiman, Samirah Tunusa Umar, Tijjani Suleiman, Shemau Umar and Zainab Umar.
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