Observe! This is an evaluation according to reasonable "traditional" goals and evaluation procedures. Thus, empowerment goals and PLA evaluation procedures are NOT applied.

Introduction 1

1. Background Information about the Sample 1

2. Knowledge about HIV/AIDS 4

3. Attitude about HIV/AIDS 9

4. Practise 13

Introduction 17

1. Background Information about the Sample 17

2. Knowledge about HIV/AIDS 18

3. Attitude about HIV/AIDS 22

4. Practise 24

PART A: KAP STUDY RESULTS FOR TANGA REGION

INTRODUCTION

This KAP Study was conducted within the framework of MEUSTA's mid-term evaluation between May 23^rd and June 30^th. KAP stands for Knowledge, Attitude and Practice and is an abbreviation for an analysis tool used with regard to HIV/AIDS.

A similar KAP Study has been conducted in January 1997 in all six district of Tanga Region. The entire sample consisted of 699 questionnaires. However, only for questions about Practice the full sample was evaluated. For questions about Knowledge and Attitude the sample, on which findings were based, was limited to 105 questionnaires from three districts (Handeni, Lushoto, Tanga).

The findings of the 1997 KAP study are compared with this more recent study, wherever it seems interesting or revealing.

The following report has four parts: Part 1 describes the characteristics of sample included in the survey, whereas part two investigates about the school children's knowledge about HIV/AIDS. In part 3 there is information about the attitude of children and about their channels of communication and collection of information with regard to HIV/AIDS. The last part shows data about the school children's sexual practices.

1. BACKGROUND INFORMATION ABOUT SAMPLE

Table 1: Number/Percentage of Students for each District (n=878)

The target was to select a sample which is comparable with the sample chosen in the 1997 KAP Study, where 699 students were included. This was achieved by attempting to have an average of 145 questionnaires per district. The fluctuation between districts are partly due to the varying number of school children available at different schools and partly due to random circumstances during field work (transport, time, etc.).

Table 2: Number/Percentage of Students in Rural vs. Urban Areas (n=878)

There is a positive bias towards rural schools, which reflects the Tanzanian reality of a vast majority of people living in rural areas.

Table 3: Number/Percentage of Students in Standard VI vs. Standard VII (n=878)

Standard V students have not been included in the study, as their exposure to EDU (Elimu dhidi ya Ukimwi) was assumed to be too little for an impact assessment.

Table 4: Age and Sex of Students

The girls are younger on average than their fellow male students. It is unclear whether this is due to earlier enrollment of girls or whether any other factor influences the picture. However, the lack of older girls in primary schools clearly points to their recruitment into household activities at a certain age.

Table 5: Religious Affiliation of Students (n=878)

Islam is the far most prevalent religion in the sample chosen. The prevalence of Catholics and Protestants is highly dependent on the historical roots of the villages chosen. Very often the villages were quite homogenous with regard to Christian religious affiliation. The Muslim dominance must be taken into consideration by future planning of MEUSTA, as religious leaders may play an important role in disseminating HIV/AIDS information.

Table 6: Tribal Affiliation of Students (n=878)

The category of "others" consist of over 50 different tribes, which shows that Tanga as a region seems to be tribally heterogeneous. This must be taken into account when considering the revival of cultural traditions as a way of preventing the rapid spread of HIV/AIDS. Which cultural traditions should be revived? Are there any common cultural values, which can be hi-jacked for HIV/AIDS prevention?

Table 7: Caretakers of Students (n=878)

The above table shows that 23.9% of the students in the sample live in single-parent households and 7.0% live with foster parents (relatives or others). The remainder of 68.5% live with both parents.

Table 8: Parents' status (n=878)

18.4% of the students have either lost their mother or father and 2.5% are orphans. The reason for parents' death has not been investigated upon. It therefore remains unclear, whether they lost their parents due to HIV/AIDS or any other reason.

Table 9: Educational Level of Parents (n= 878)

The parents of the children involved in the survey have an educational level, which is above the national average. This may either be due to children's exaggeration about parents' educational level, due to the fact that in-school are more probable to have well educated parents or any other unmentioned reason.

For the dissemination of HIV/AIDS information however, the relatively high educational level is a crucial finding. Highly literate parents can more easily be involved in the activities than others, as they are more capable of understanding and channeling information.

Table 10: Affiliation to Youth Group

For girls as well as for boys Meusta Clubs are the most important youth group, however, the percentage of girls being slightly higher. Boys seem to be more active in other groups, especially football clubs.

Table 10a: Affiliation to Youth Groups

Meusta Club membership is dominated by girls. This may be due to biased recruiting techniques, whereby everyone who is part of a choir or dance group becomes automatically a Meusta Club Member. In addition, boys may be already busy with their membership in football clubs.

2. KNOWLEDGE ABOUT HIV/AIDS

In some of the following questions, students were allowed to give several answers. These questions where multiple answers were possible can be identified by the lack of a row indicating the total at the bottom of the table. In these caes the sum of percentages may be above or below 100%.

The figure against which percentages were calculated can either be found in the title (if the same figure is valid for the whole table) or in the header of a specific table (if different categories are involved).

Table 11: Answers to "Who can get HIV/AIDS?" (n=878)

As in the 1997 KAP study the vast majority of students is aware that anyone can be infected by HIV/AIDS, regardless of age or sex.

Table 12: Answers to "How is HIV/AIDS spread?" (n=878)

The three top ranking ways of being infected with HIV/AIDS were the same in the 1997. The percentages of knowledge about specific way of being infected has generally risen (roughly 10% for each). However; it is very crucial to note that the rise in percentages is most significant for the category of "by sharing sharp instruments". This seems to reflect the reluctance of teachers and responsible persons to talk about the number one cause of transmitting HIV/AIDS, which is sexual intercourse (9 out of 10 HIV/AIDS positive persons are infected through sexual intercourse). It may be a refuge for shy teachers and responsible persons to insist on the sharp instruments as a way to avoid talking about issues of reproductive health.

Also it has been noticed by the consultants in focus group discussions with the children, that the nature of their knowledge is very partial and superficial. They know enough to tick the proper answer in a questionnaire, however, their knowledge does not seem to be profound enough to fully protect them from being infected (see questions raised by children). The messages which are given to the children need to become more explicit in future.

Table 13: Answers to "Can a healthy looking person be carrying HIV?"

There is a slight decrease of the percentage of children, who are not aware that healthy looking persons can be infected with HIV/AIDS (from 29.5% in 1997 to 24.9%). MEUSTA should be working more intesively to reduce the percentage, as lack of knowledge about this fact can be very dangerous. If relating to the data in table 16, where only 18.3% declare the difficulty of identifying the infected persons as being a danger, it becomes obvious that efforts with regard to this issue have to be seriously increased.

Table 14: Answers to "What are the signs/symptoms of HIV/AIDS?"

The results with regard to top ranking symptoms are very similar in the 1997 KAP study. There are slight changes of illnesses associated with HIV/AIDS infection, which are due to HIV/AIDS as such changing its face. For example, it is only recently that tuberculosis has been identified as a prevalent symptom of HIV/AIDS patients.

Table 15: Answers to "Is HIV/AIDS really dangerous?" (n=878)

The answers to this question shows that children and adolescents are very much aware about the danger of HIV/AIDS. In focus group discussions with students the consultants realized that the fear of being infected is very widespread among children, and many of them mention that they need more detailed information about reproductive health and HIV/AIDS in order to feel safer.

Table 16: Answers to "If HIV/AIDS is dangerous, why is it dangerous?" (n=878)

As mentioned above, the danger of not being able to identify those who are infected but who do not yet show visible signs of being infected is widely underestimated. A major thrust to disseminate information in that sense is urgently needed.

Table 17: Answers to "Is there a means to protect yourself from getting HIV/AIDS?" (n=878)

The vast majority of student knows that there are means of protecting oneself from being infected. However, this does not mean that they have access to these means or that they are using safe practices in their everyday life. Some means of protection, such as for example condoms, are not easily accessible or applicable for adolescents, especially in rural areas with high levels of social control in neighbourhoods.

Table 18: Answers to "If there is a means to protect yourself, how can you do so?"

The answers given reflect many crucial issues, especially when data is compared with the findings of the 1997 study. The percentage of "sexual abstinence" and "avoiding common use of sharp instruments" have significantly risen. On the other hand the percentage of "using condoms" and "having sex with only one partner" have significantly gone down. This reflects the messages as given out by MOEC through EDU. For the category of "having sex with only one partner" there seems to be a great confusion in society, as the definition of its meaning is not accurate enough. It is not explicitly stated whether it means having only one partner in your entire life or whether it may be synonymous with sequential monogamy (i.e. having one partner after another, but only one at the time). Also, there is no word that your only sexual partner may already be infected with HIV/AIDS. The category seems to become very inadequate with respect to these findings.

The fact that an average of 13.3% of students fear of being infected with HIV/AIDS when giving blood, reflects the partial character of their knowledge. They know that the disease is transmitted through blood, but they were not taught intensively enough to distinguish different practices related to blood donation and transfusion.

As mentioned above, EDU has to speak a clearer language in order to avoid confusion within children's and adolescents' heads.

Table 19: Answers to "Do you know, where people can go for an HIV/AIDS test?" (n=878)

Three quarters of the students seem to know where to seek assistance, in case someone wants to be tested. However, this does not link with common practices. Experience has shown, that the process from knowing where to go until an individual actually overcomes the fear of being tested is a very long one (Source: CCBRT Programme Manager). There might also be social and financial barriers preventing young people to seek advice, counseling and testing services.

Table 20: Answers to "If yes, where can they go for an AIDS test?"

The outcome of this question shows that even in rural areas the traditional healers are not considered to be a major option for HIV/AIDS testing. To facilitate the access of young people to health facilities in general and specifically with regard to HIV/AIDS related services, guided visits to SDP might be a powerful instrument of raising awareness and improving accessibility. These visits might be organized through MUESTA Clubs.

Table 21: Answers to "Where did you get information about HIV/AIDS?"

The impact of school based information has very significantly risen since the 1997 KAP study, which is definitely a MEUSTA achievement. Also, the extent to which peers and parents have become sources of information have risen. The importance of mass media has decreased since 1997.

However, there is still ample space for improving the accessibility of information about HIV/AIDS. Some of the sources of information (e.g. parents, siblings, friends and religious institutions) could become more important in the future. When strengthening sources of information it is however crucial to also supervise the contents and accuracy of the information disseminated. The consultants were struck by finding a lot of wrong and inaccurate information circulating in society. Some of it was even strategically inserted into society in order to pursue institutional or personal interests (e.g. condoms being infected with the HIV/AIDS virus, etc.)

Table 22: Answers to "Do you know any other STDs?" (n=878)

Students seem to know the term STDs, many of them could even state the names of the most prevalent STDs in Tanzania. As with other subjects related to reproductive health, however, their knowledge is very restricted.

Table 23: Answers to "If you know STDs, is there any link between HIV/AIDS and STDs?" (n=557)

The majority of students sees a link between HIV/AIDS and STDs, but as shown in table 24 their knowledge is very blurry. Often it is limited to the fact that both have something to do with sexual intercourse.

Table 24: Answers to "If there is a link, what does the link look like?" (n=394)

As mentioned above, many of the students are not able do define the link between HIV/AIDS and STDs. They left the lines for explanations empty, they listed all the STDs they knew or they state that both is related to sexual intercourse. However, that there is an increased danger of being infected with HIV/AIDs when having STDs and vice versa was not mentioned by any student. Proper treatment of STDs should be propagated for all age groups in order to reduce the probability rates of HIV/AIDS infection.

Table 25: Answers to "How can STDs be avoided?" (n=557)

Efforts should be made to rise the percentages of "avoiding sexual intercourse with infected persons" and "using condoms". The relatively high percentage of students identifying prostitutes as a source of STDs points to the social perception of STDs being something "dirty and socially unacceptable". This perception is a serious hurdle, which prevents adolescents from seeking treatment for STDs. There is a need for advocacy in society with regard to STD prevalence and treatment.

Table 26: Answers to "Where can people go to treat STDs?"

This and the following table show clearly that the reforms of MCH service delivery have not yet taken momentum. According to the reforms, MCH Clinics should be open to all persons in reproductive age, i.e. including matured adolescents of male and female sex. In reality however, it seems difficult to change the common perception of MCH Clinics being a service delivery point for pregnant women and mothers. As it is now, accessibility to reproductive health services is very restricted for young people.

Table 27: Answers to "Where would you go if you wanted treatment for STDs?"

Table 28: Answers to "Where did you get information about STDs?" (n=557)

As mentioned with regard to knowledge about HIV/AIDS it is most crucial to increase the percentages of information being given out from within the social environment of the children (i.e. parents, religious institution, siblings and friends). However, quality of information has to be guaranteed.

3. ATTITUDE/PERCEPTION ABOUT HIV/AIDS

The results shown in tables 29 to 41 have to be handled with precaution. This is due to several facts:

• Firstly, students not accurate when filling the questionnaires. They mentioned that they talk to a specific category, but at the same time they ticked reasons for not talking to the same category of persons. It seems that perception of how reality should be and their actual practices are highly conflicting.
• Secondly, focus group discussions with children revealed that there the children do not discuss as much as they expressed in the questionnaires. They express that talking about matters of reproductive health and HIV/AIDS are almost strictly done between person of the same sex within the family (i.e. between mothers and girls, fathers and boys, etc.).
• Thirdly, the term "talking to" has not been defined well enough. When investigated upon during focus group discussions, the students mention that there is no real discussion, that parents just mention things without expecting feed-back and that they do not get as much detailed information as they would like to get.

The consultants ask any reader of the following tables to carefully remind these introductory statements when looking at the data.

Table 29: Answers to "Do you discuss about HIV/AIDS with your peers?"

Table 30: Answers to "If you discuss with peers, what is the sex of the peers you discuss with?"

According to the above table most of the children talk to parents of both sexes and one can only slightly discern that girls are more prone to talk with mothers alone and boys with fathers alone. However, all of the consultants' interlocutors admitted that the reality is not as depicted in this table. Sexual segregation for discussions about issues of reproductive health and HIV/AIDS is still very much practiced.

Table 31: Answers to "How often do you talk about HIV/AIDS with them?" (n=753)

Table 32: Answers to "If you don't talk to them, why is it?" (n=106)

Table 33: Answers to "Do you talk about HIV/AIDS with your parents?"

This data could be valuable for MEUSTA with regard to MISC activities. If children really talk as much to their parents as the tables seems to suggest, there is ample potential for integrating parents as a major source of information. It also means that they have to be given advocacy and training on how to teach children about reproductive health and HIV/AIDS these days. The existence of the disease has changed the situation radically, as whether to teach children about reproductive health and HIV/IADS is not any longer only a question of cultural values, but as much a question of survival.

Table 34: Answers to "If you talk to parents, whom do you discuss with?"

Table 35: Answers to "How often do you talk about HIV/AIDS with them?" (n=559)

Table 36: Answers to "If you don't talk to parents about HIV/AIDS, why is it?" (n=290)

Table 37: Answers to "Do you talk about HIV/AIDS with religious leaders?" (n=878)

Table 38: Cross tabulation of "religious affiliation" with "do you talk to religious leaders"

The catholic church seems to be the most active one in disseminating information about HIV/AIDS in Tanga Region, followed by Islam and the Protestant church. This is an important fact for designing future interventions within the network of social institutions.

Table 39: Answers to "If you don't talk to religious leaders, why is it so?" (n=579)

Table 40: Answers to "What are the other reasons for not talking to religious leaders?" (n=48)

Table 41: Answers to "Are there other people you talk to about HIV/AIDS?" (n=878)

Table 42: Answers to "Who are these other people you talk to about HIV/AIDS?" (n=268)

The selection of people mentioned by the students largely points at the traditional system of disseminating touchy information within the family and to the impact of EDU in schools. Relatives who are not linked to the child in a direct parent-child relationship were often used for channeling touchy information to the children. Between parents and their children "aibu" (shyness) is still very prevalent.

Table 43: Answers to "What is your feeling towards people with HIV/AIDS?" (n=878)

Compared to the 1997 KAP study, children have a more positive attitude towards persons infected with HIV/AIDS. This may be due to the fact that many of them had a close relative or friend being infected, and thereby the perception of persons carrying the disease changed. From a point of view of humanity, this development is welcomed.

4. PRACTISE

Table 44: Answers to "Have you ever had sexual intercourse?"

The findings are very similar to those of the 1997 KAP study. There are generally more boys who report to have had sexual intercourse (52.2% for boys vs. 17.2% for girls), and the girls are more often silent about their sexual practices (i.e. no answer).

It is an outstanding fact, that one third of all students openly declare to have had sexual intercourse! Roughly 40% deny having had sexual intercourse. The large proportion of students not indicating whether they already have had sexual intercourse or not leaves the picture a bit blurry. However, one can assume on good grounds that a good proportion of the silent ones was also involved in sexual activities.

Table 44a: Answers to "Have you ever had sexual intercourse?"

Another way of depicting the same data as in table 44 shows that the number of those who already had sexual intercourse is strongly dominated by boys. The imbalance between the two sexes raises important questions:

• Are girls less open about their sexual activities?
• Do girls who practice sexual intercourse sleep with several different young boys?
• Are boys satisfying their needs with other boys?

The answers to these questions must be explored upon more closely, as they have important implications for the young students involved.

Table 45: Answers to "If you had sexual intercourse already, at what age did you start?"

Table 45a: Aggregate answers to "If you had sexual intercourse already, at what age did you start?"

The above table shows that the window of hope is very limited in the sample included in the survey. When designing interventions to efficiently protect the students from being infected, it is important to acknowledge the early age at which children and adolescents start sexual practices.

Table 46: Answers to "How old was your partner?"

The data shows that girls more often have sexual intercourse with men who are (significantly) older than they themselves. Very few girls have sex with younger partners. For boys the situation is quite different. The majority of boys has sexual intercourse with persons of the same age or younger ones.

Table 47: Answers to "When did you start to have sexual intercourse?" (n=294)

As table 45 states, students start sexual practices earlier than commonly acknowledged in society. This question was included in the questionnaire in order to cross-check whether students really start early with having sexual intercourse. According to the data presented, is time to open one's eyes to this reality in order to design interventions, which protect the future generations of Tanzania.

Table 48: Answers to "Do you have a bodily lover now?" (n=294)

Out of those students who indicate that they ever had sexual intercourse, roughly 50% admit to have a partner at the time of the survey.

Table 49: Answers to "Whom did you have sexual intercourse with?" (n=294)

Table 50: Answers to "Did you plan to have sexual intercourse?"

The above table shows that a greater proportion of boys plan having sexual intercourse. They may therefore be defined as the initiators of the act, while girls are more often pulled into it.

Table 51: Answers to "Why did you have sexual intercourse?"

The above table reveals a very important fact: the vast majority of young people do not have sex, because they are tempted or forced, but because their body develops and with this process of maturing the desire to have sexual intercourse and to experiment with the developing organs increases. These natural feeling are still very much denied in society, and it is time for things to change.

This insight also has a very important consequence for IEC materials: the previous practice of relating any early sexual contact with "vishawishi, vyombo vya kutoa" (temptations) and "uasherati" (prostitution or promiscuity) has to be abolished. From a gender perspective these terms are also very undesirably as they suggest that the main problem lies in young girls unable to resist.

Young people should be given a right to their human feelings.

Table 52: Answers to "Did you or your lover ever use a condom?" (n=294)

With regard to HIV/AIDS it is scary to know that more than 60% of all young people being involved in early sexual practices have not been using condoms. There are obvious physical barriers (size of penis), however, ingenious young people concerned with their own health and survival have found ways to overcome these limitations (e.g. by tying condoms with rubber bands to fit the size of the penis).

Table 53: Answers to "If you used condoms, why did you do so?" (n=103)

There is need for more information among young people about condoms, as different institutions disseminate contradictory information (especially fundamentalist church organizations are very prone to distort information according to their needs). Condoms should be introduced as a simple, cheap and efficient technology for preventing pregnancies and HIV/AIDS, as it is scientifically proven. Examples from success stories (e.g. AIDS campaign in Uganda) need to be made more public.

Table 54: Answers to "If you did not use condoms, why not?" (n=182)

Barriers to condom use should be gradually reduced, as they endanger the health of sexually active persons (young and old). There is also a need for more explanation about the proper use of condoms (how to check quality, how and when to put them, how and when to remove and throw them away).

Table 55: Answers to "What other reasons are there for not using condoms?" (n=17)