Residence and young women’s comprehensive HIV knowledge in Ethiopia

Background: Human immunodeficiency virus (HIV) infection is a global health problem. The epidemic is very serious in sub-Saharan Africa with approximately 70% of the global cases. The disease particularly affects youth, accounting for half of the new HIV infections yearly. Inadequate knowledge may contribute to the high rates among youth. Hence, the main aim of this study was to examine the association between residence and comprehensive HIV knowledge among women aged 15–24 years in Ethiopia. Methods: This cross-sectional study used nationally representative data from the 2016 Ethiopian demographic health survey (n = 5926). Chi-square tests and multivariable logistic regression modeling were performed. Results: Approximately 23.9% of the study participants had a comprehensive HIV knowledge and 74.7% were rural residents. In the multivariable-adjusted model, we found a significant interaction between place of residence and HIV testing on comprehensive HIV knowledge (P for interaction = 0.005). In the subgroup analysis, a statistically significant associations between place of residence and comprehensive HIV knowledge was found only in women who have never been tested for HIV. In this subgroup, rural women had lower odds of having a comprehensive HIV knowledge compared to their urban counterparts (OR 0.42, 95% CI: 0.23–0.74; P = 0.003). Furthermore, in the subgroup of women who have never been tested for HIV, education and region were significantly associated with comprehensive HIV knowledge. Compared to women with no education, the odds of having a comprehensive HIV knowledge were higher in women who had primary (OR 2.86, 95% CI: 1.63–5.02; P < 0.001) and secondary or above education (OR 5.49, 95% CI: 2.92–10.32; P < 0.001), respectively. The odds of having a comprehensive HIV knowledge were lower in women from the Somali region compared to women from Addis Ababa region (OR 0.41, 95% CI: 0.18–0.90; P = 0.027). Conclusions: Rural residence was negatively associated with comprehensive HIV knowledge only in women who have never been tested for HIV. These findings suggest that the development and implementation HIV education and awareness programs should target rural areas, especially where there is limited access to HIV testing. The current study is based on the 2016 Ethiopian Demographic and Health Survey (EDHS). The 2016 EDHS is the fourth survey conducted in the country. This survey collected information on household’s and respondent’s characteristics, infants and child mortality, malaria, maternal health, maternal mortality, nutrition, tobacco use, wealth, women’s empowerment, anemia child health, domestic violence, educational status, environmental health, family planning, female genital mutilation, fertility and fertility preferences, gender/domestic violence and HIV knowledge. The primary objective of the 2016 EDHS was to provide up-to-date estimates of key demographic and health indicators of the Ethiopian population [25]. The 2016 EDHS included a nationally representative sample of women (aged 15–49 years) and men (aged 15–59 years) from the nine regions and two administrative cities in the country [25, 26]. A stratified two stage sampling method was used to produce a representative sample for the country as whole. Each region was stratified into urban and rural areas, which yielded 21 sampling strata. Samples of enumeration areas (EAs) were selected independently in each stratum in two stages. Implicit stratification and proportional allocation were achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection according to administrative units in different levels, and by using a probability proportion to size selection at the first stage of sampling. In the first stage, 645 EAs were selected with probability proportional to the EA size and with independent selection in each sampling stratum. The EA size is the number of residential households in the EA as determined in the 2007 Ethiopian Population and Housing Census (EPHC). A household listing operation was implemented in the selected EAs, and the resulting lists of households served as the sampling frame for the selection of households in the second stage. To minimize the task of household listing, the selected large EAs with more than 200 households were segmented. Only one segment was selected for the survey with probability proportional to the segment size. Household listing was conducted only in the selected segment. Thus, a 2016 EDHS cluster is either an EA or a segment of an EA. In the second stage of selection, a fixed number of 28 households per cluster were selected with an equal probability systematic selection from the newly created household listing. Only members of pre-selected households were interviewed. No replacements or changes of the pre-selected households were allowed in the implementing stages to prevent bias. All women aged 15–49 years who were usual members of the selected households or who spent the night before the survey in the selected households were eligible for the female survey [26]. For the current study, the sampling frame consists of young women aged 15–24 years (n = 6401). We excluded women with missing data on the variables of interest for the current study (n = 475). The final study sample consisted of 5926 women. Data collection for this survey took place from January 18 to June 27, 2016. Five questionnaires were used for the 2016 EDHS: The Household Questionnaire, the Woman’s Questionnaire, the Man’s Questionnaire, the Biomarker Questionnaire, and the Health Facility Questionnaire. These questionnaires were adapted from the DHS Program’s standard Demographic and Health Survey questionnaires in a way to reflect the population and health issues relevant to Ethiopia [27]. For the purpose of this study, data on women captured in the 2016 EDHS was used. The outcome variable was comprehensive knowledge on HIV among young women. Each woman was asked whether or not she agreed or disagreed with the following five items regarding transmission and misconceptions on HIV/AIDS: 1) HIV can be prevented by using condoms every time you have sexual intercourse; 2) HIV can be prevented by limiting intercourse to one uninfected partner; 3) it is possible for a healthy-looking person to have the AIDS virus; 4) the AIDS virus can be transmitted from mosquito bites; 5) a person can get HIV by sharing food with a person who has AIDS [28]. First an additive summary correct response was created to derive a comprehensive knowledge on HIV score. This score is then dichotomized resulting in a binary variable with 0 (at least one incorrect response) and 1 (correct response to the 5 questions). The primary exposure of interest was residence which was defined as urban and rural. Covariates for the study were selected based on of existing literature and included respondent’s age (“15–19”, “20–24”), marital status (“never married”, “currently married/living together”, “divorced/separated/widowed”), highest level of education (“no education”, “primary”, “secondary or higher”), household wealth index (“poorest”, “poorer”, “middle”, richer”, “richest”), religion (“Christian”, “other”), region (nine geographical regions and two administrative cities), ever been tested for HIV (“no”, “yes”), mass media exposure (“no”, “yes”), internet access (“no”, “yes”), distance to a health facility (“not a big problem”, “a big problem”). Household wealth index is a composite measure of a household’s living standard categorized into 5 quintiles which was calculated using household’s ownership of selected assets, such as televisions and bicycles, materials used for housing construction, types of water access and sanitation facilities. Mass media exposure was measured based on how often respondents read a newspaper, listened to the radio, or watched television. Those who responded at least once a week to one of these sources are considered regularly exposed to that form of media. Descriptive statistics were performed to provide a summary of the characteristics of the study sample. Rao-Scott adjusted chi-square statistic test statistic was used to examine differences in the proportions of having comprehensive HIV knowledge by place of residence and each of the covariates. Multiple logistic regression models were then used to determine the independent association of place of residence and comprehensive HIV knowledge while adjusting for the covariates. To control for confounding each covariate was retained in the multivariable-adjusted model regardless of statistical significance in the bivariate analysis. Pairwise interactions between place of residence and each covariate on comprehensive HIV knowledge were assessed. To assess the presence of collinearity, we employed regression diagnostics using a conservative cut-off value for variance inflation factor > 4. Using this approach, we found no significant collinearity between variables included in the multivariable model. The corresponding odds ratio and 95% confidence interval for the association between the place of residence and comprehensive HIV knowledge stratified by type of were reported. Two-tailed p-value < 0.05 was considered statistically significant. Sampling weights that accounted for complex survey design were incorporated in all analyses. All statistical analyses were conducted using SPSS for Windows (version 24; IBM Corp).