This study has provided information about the current state of HIV transmission knowledge, and health seeking behavior in Zambézia Province, Mozambique. We found that approximately 80% of participants had visited a traditional healer. This number is similar to what was found in a Zambian study from 2000 that reported 88% of people would visit a traditional healer if sick (Stekelenburg et al., 2005
). Our data suggested that participants showed a preference for initially visiting a clinic when ill, only seeking care from a traditional healer if they were still feeling ill. Considering the limited staffing in rural clinics, supply-chain management problems leading to empty stock of important medications, and poor quality of diagnostic equipment available in some areas, there exists strong impetus for people to find alternatives.
Of those who do use traditional healers, men are more likely to visit a traditional healer first or exclusively (52%), whereas women tend to first seek care from a health care clinic (67%) only turning to a traditional healer if they remain ill. When probed further about why men may initially avoid health care services, men suggested that a lack of respect provided by clinicians was their primary reason for avoiding the health system. This sentiment has been echoed by the results of focus group discussions assessing barriers to care throughout the province (Groh KE et al., 2010
). A limitation to these data may be the belief that the interviewers were affiliated with the local allopathic HIV/AIDS clinics, i.e., social response bias, (Fox, 1967
; Goldiamond, 1964
; O’Brien, 1989
). Improving treatment of patients at health care facilities may facilitate men’s use of allopathic medicine.
As has been found in other studies of HIV knowledge in sub-Saharan Africa, men trended towards having higher levels of HIV knowledge than women, although in our study this trend was not statistically significant (Glick & Saha, 2007
; Instituto Nacional de Estatística & Ministério da Saúde, 2005
). The number of people who knew HIV could be transmitted through sex was similar (or higher) than that found by researchers in Ethiopia, Tanzania, Nigeria, and Burkina Faso (Alene, Wheeler, & Grosskurth, 2004
; DHS, 2011
; Negash, Gebre, Benti, & Bejiga, 2004
; Nkya, Sindato, McHaro, & Kibona, 2006
; Sarker et al., 2005
; Yerdaw, Nedi, & Enquoselassie, 2002
). While the use of condoms was associated with higher levels of HIV knowledge, there remains a cultural barrier to condom use that needs to be addressed. The understanding of sexual transmission also needs to be supplemented with additional transmission and prevention messages, to empower people to make informed health care decisions (e.g., taking prophylaxis during pregnancy, exclusively using formula or breastfeeding, and taking precautions when in contact with blood). HIV knowledge was primarily limited to sexual transmission. The number of people who volunteered that HIV could be transmitted via blood or that mothers could pass the virus to their babies was surprisingly low. Higher levels of formal education did correlate significantly with increased rates of transmission and prevention knowledge, suggesting a way forward.
We were alarmed by the low proportion of participants (<1%) who identified mother to child transmission (MTCT) as a mode of transmission. Maternal use of ART prophylaxis in rural Zambézia remains low (Cook et al., 2011
), despite the availability of ART, possibly a result of low knowledge levels. In rural Tanzania, the number of people voluntarily identifying MTCT route was substantially higher (>60%)(Nkya, et al., 2006
). Recent DHS survey’s also point to better understanding of MTCT throughout the region (Department of Health, Medical Research Council, & OrcMacro, 2007
; DHS, 2011
Information provided by community health workers and teachers resulted in study participants identifying the greatest number of transmission and prevention methods. Similar results were found in rural Malawi, where researchers documented the relationship between the source of HIV knowledge to HIV knowledge scores (Barden-O’Fallon et al., 2004
). Among men, community health care workers messages resulted in higher knowledge scores, whereas among women in Malawi, those who listed media as the source of the information scored the highest(Barden-O’Fallon, et al., 2004
). People in Zambézia who reported learning about HIV prevention techniques in schools had the highest odds of knowing multiple ways to avoid infection, whereas the greatest predictor of HIV transmission knowledge was obtaining information from community health workers. There was no difference between men and women. We suggest training and deploying additional community health workers into areas that are extremely rural, particularly when educational opportunities are sparse. Qualitative data suggested that people liked speaking with community health workers about health care issues, even more than with allopathic clinicians or their friends, and saw community health workers as people they could trust.
Our study includes mixed qualitative and quantitative methods, the systematic survey methodology, and the care to interview in the local language. No such study has been reported from Zambézia Province, the second most populous province in the nation. Limitations include that opinions reflect a non-random selection of community members in three rural communities of Zambézia Province. While we attempted to remove sample bias through systematic selection, the timing of our interviews (during daytime, working hours) limited the number of full time workers enrolled in our study. In addition, translation from local languages to Portuguese (and subsequently to English) complicates analysis. The challenge of cultural understanding can be difficult in rural areas where only local languages are understood. While we have made all attempts to maintain the integrity of our data, it is possible that some words or phrases were missed during translation. Social response bias was also a possibility within our survey, particularly on questions dealing with use of traditional medicine.