The Health Belief Model [HBM] has been applied in preventive medicine to try and explain how behaviour influences transmission of infections like HIV. Most researchers view this model to be an essential tool with respect to behaviour change interventions because not only do they identify the changes that take place but also influences their outcomes [1, 2, 3]. Additionally such interventions are easily replicated and can also be easily scaled up and modified during many interventions [4]. The Health Belief Model has been applied in a variety of interventions including improvement of respiratory hygiene practices [5].  The HBM in addition to trying to explain why individuals adopt certain decisions regarding their health also creates a conducive environment for the required changes. It targets mostly the factors that are inherent in the individual that make individuals to engage in certain unhealthy behaviours so as to encourage self- efficacy in the change processes that are required. The health belief model has also been applied to other complex lifestyle behaviours to explain why they needed to be maintained during the life of the targeted individuals [6]. Used to explain and predict more complex lifestyle behaviours that needed to be maintained over a lifetime [6, 7].  The use of HBM constructs can be exemplified in some studies that have recognized the effect of perceived susceptibility and perceived benefits on perceived barriers in undergoing HIV testing [8].

Problem statement

Although several behaviour models have been used to design interventions for behaviour change with limited success, educational interventions based on the health Belief model improves HIV/AIDs preventive behaviour and suggests that theory-based interventions strategies may create and modify certain health [9]. From the review of the previous literature it is more important to further explore the linkages between behaviour and implementation of certain health interventions.  This case control study attempted to seal these gaps by employing the HBM in the assessment the effect of the modifying factors on the adoption of HIV preventive actions. The study examined the way the participants perceived their susceptibility and the severity of HIV infection and what they considered beneficial to them when they adopted preventive behaviours like condom use. It further examined what they considered to be barriers to adoption of healthy behaviours. Previous studies failed to directly relate the components of the HBM model to the effectiveness of HIV prevention interventions although evidence seem to suggest that it is useful for other communicable disease prevention and control. To properly apply this model to behaviour change was imperative to try and understand the independent variables that could be linked to the dependent variables. Therefore this study went beyond of just describing the variables in the model but also their influence on health behaviour. This then gave an insight on relationships between the various variables and their influence on HIV behaviour change and why previous interventions may not have been very successful in HIV infection mitigation.

Relevance of the study

The transmission of HIV has a direct linkage to certain high risk behaviours among people found to be infected by the virus. The identification of these high risk behaviours by primary care physicians would allow them to identify interventions that would prove useful in reducing the risk of infection especially among high risk patients.

Research Questions

On completion the study answered the following two research questions:

1. Could the HBM constructs adequately predict high risk sexual behaviour in women of reproductive age?
2. Are the constructs of the HBM able to adequately moderate the relationship between HIV knowledge and risky sexual behaviours?

Broad Objective

To identify the predictors of HIV infection in women and use them to test the efficacy of the Health Belief Model in HIV prevention in women of reproductive age. 

Specific Objectives

1. To identify the constructs in the Health Belief Model which predict risky sexual behaviour in women of reproductive age?
2. To establish the constructs of the HBM that strongly moderates the relationship between HIV knowledge and sexual behaviour.

Introduction

The HBM identifies certain modifying factors that lead to likelihood of action including socio-demographic factors, knowledge, socioeconomic factors, ethnicity, education and personality. Several scholars have done cross-sectional studies on factors considered to be responsible for the HIV epidemic in women and some have suggested interplay of several factors to explain the higher risk of infection in women and even suggested the pathways through which they work [10]. The HBM has been applied to many interventions in different populations since its development in the 1950’s. It has been applied to try and promote condom use, to encourage adoption of seat belts to reduce injuries in accidents, medical compliance to certain treatments and in the screening for certain non-communicable diseases like breast cancer [11, 12]. Its application has been based on the belief that most people would adopt a health related action in order to avoid its negative effects and if they believe that the adopted action would make them avoid those effects. Such actions can only be adopted if they have confidence that they could successfully adopt the recommended action [13]. In the past studies done on HBM authours have identified perceived barriers as among the most important constructs for prediction of certain health behaviours. Other constructs like perceived benefits and susceptibility have also been found to play a role in modifying behaviour while perceived severity has been found to have the least significant role in behaviour change [14, 15].  According to some reviewers however there were some general limitations to the application of HBM including failure to incorporate all the constructs of the HBM model in some studies [16,17]. Several studies have adopted the HBM in HIV prevention by examining cultural and stigmatizing beliefs and knowledge in relation to condom use and only identified perceived barriers as playing a crucial role in behaviour change [18, 19].  The effect of behavioural interventions in increasing the uptake of condoms to prevent sexually transmitted infections was also examined in another study that identified the importance of applying behavioural interventions to disease prevention [20,21, 22]. Other applications of the HBM in disease prevention included adherence to treatment regimens, to explain preventive health behaviours and reduction of exposures to certain risk factors [23, 24, 25]. The Health Belief model presupposes that the motivation for healthy behaviours depends on the way the individual perceives the barriers to the recommended action, motivation to take the recommended action and whether they can successfully complete the tasks required [26]. . Empirical literature has identified several factors that could be directly linked to acquisition of HIV infection in vulnerable women. The vulnerability in the women make them unable to adopt behaviour change interventions and therefore leave them more susceptible to the infection. If these modifying factors could be identified it is possible to incorporate them in the Health Belief Model which would then help mitigate HIV infection in such women. 

Ethical issues

The ethical standards include institutional ethical review that has confirmed that there are no serious ethical issues including anonymity of the participants. Informed consent form was included in the data collection tool that specified that participation in the study was voluntary and only those who consented in writing were recruited. The participants were also given them option to withdraw from the study at any time without loss of entitlement to care. The participants were also not subjected to blood testing as study only recruited participants who had already undergone HIV testing and already knew their status and their confidentiality was assured by not divulging their personal details.

Four hundred and sixteen women who had undergone HIV testing within the last twelve months were randomly selected from four ante-natal facilities within Kisumu County. From each facility 100 participants were recruited out of which half were HIV negative [controls] and the rest HIV positive [cases] as per the WHO HIV testing protocols used in Kenya. The questionnaires were administered by trained enumerators. To examine perceived susceptibility patients were asked to answer five questions from the questionnaires that related to this particular question.  Those who answered three or more questions in the affirmative were viewed as those who felt they were not susceptible to the infection. Perceived threat of the disease was measured using responses to two statements; “If I had HIV infection, my family relationships will be strained and people would avoid me if I had an HIV infection”. Perceived seriousness of the disease was assessed using the response to the question “if I got AIDS I would eventually die from it”. Those who answered two or more statements in the affirmative were deemed to perceive the seriousness of the disease. In order to identify the constructs of the HBM in predicting risky sexual behaviours in women attending ANC, the dependent variable was risky sexual behaviours in the dichotomous form [low, high] coded as a binary outcome with low coded as “0” and high coded as “1”, while the predictor variables were perceived susceptibility, perceived threats, perceived seriousness, perceived barriers and perceived benefits , knowledge about HIV infection, sexual relations and decision making dominance as categorical variables. In order to assess how the HBM predicts the risk of HIV transmission, the dependent variable was HIV infection status in dichotomous form [HIV Positive or Negative], while the predictor variables were the HBM constructs, sexual relationship power and decision making dominance.

Predictors of Risky Sexual Behaviours

Table 1 below depicts the logistic regression analyses for the predictors of risky sexual behaviours. In the univariate analyses, perceived barrier and sexual relationship power were the only significant predictors of risky sexual behaviours. The results suggested that those who had high perceived barrier [OR= 2.33; 95%CI, 1.30 – 4.18] were more likely to have high risky sexual behaviours as compared to those with low perceived barrier. And those with high sexual relationship power [OR=1.66; 95%CI, 1.03 – 2.66] were more likely to have high risky sexual behaviours. However, Perceived susceptibility, perceived threat, perceived seriousness, perceived barriers, perceived benefits, knowledge on HIV and dominance in decision making were not statistically significant. Multivariate logistic regression analysis was performed on all variables with P<0.25 in the univariate analysis to determine the predictors of risky sexual behaviours. The identified factors were fitted through the binary logistic regression upon which only perceived benefits was the only factor that predicted risky sexual behaviour [P=0.001; AOR=1.76; CI=95%]. [Table 1].

Table 1: Univariate and multiple logistic regression analysis for predictors of risky sexual behaviours among women of reproductive age attending ANC.

*Significant at P<0.05, uOR; unadjusted Odd ratio, aOR; adjusted Odd ratio

HIV knowledge and risky sexual behaviour in women attending ANC

The univariate analysis in table 1 revealed that respondents with low perceived barriers [P=0.004] and more sexual relationship power [P=0.038] were less likely to be HIV positive as compared to those who had high perceived barriers and low sexual relationship power. Multivariate logistic regression analysis was performed in order to identify the predictors of risky sexual behaviours. All variables with P value < 0.0.05 during the univariate analysis were considered in the multivariate analysis. Upon fitting all these factors using binary logistic regression and by specifying backward conditional progressive stepwise method with exclusion at P < 0.05, perceived benefit was that only construct that strongly predicted the HIV infection status. Table 2 below depicts the moderation effects of the relationship between risky sexual behaviours and HIV knowledge. The regression coefficient of the interaction between perceived benefits and HIV knowledge was the only statistically significant term [P=0.000]. The study therefore concludes that perceived benefit modifies the relationship between knowledge and risky sexual behaviours [Table 2].

Table 2: Moderators of the relationship between HIV knowledge and risky sexual behaviour in women attending ANC.

Although most countries in the Sub-Saharan Africa have access to Highly Active Antiretroviral therapy most women have problems with access to care especially those from resource poor areas [28]. A study conducted in Trans Nzoia County in Kenya identified certain perceived benefits that included improvement in their health and barriers to HIV care such as poverty, inadequate supplies, poor staffing, travelling long distances to access care and poor professional etiquette [29]. In the current study indicate that perceived benefits and perceived barriers were the key predictors of increased condom use. Participants who felt that they were susceptible to HIV infection and possessed few barriers to condom use were likely to have used condoms in the past one year. The results of this study concur with other studies done in Kenya and other countries that identified perceived barriers as the only factor associated with significant condom use [31-37]. This study has also revealed that participants with perceived benefits of condom use predicted risky sexual behaviour and that those with high perceived benefits had a higher risk of having participated in risky sexual behaviour. This result is quite surprising although other studies on perceived benefits have also yielded conflicting results [38]. This could be explained by the interaction between perceived barriers and perceived benefits in which case perceived barriers reduced the effects of the perceived benefits. Some of these barriers included reduced sexual pleasure, knowledge of the partner’s sexual history and reduction in intimacy when using the condoms. The implications of these results are serious because they seem imply that knowing the benefits alone is not enough for adoption of positive sexual behaviours. The study has established that perceived benefit modifies the relationship between knowledge and risky sexual behaviours. Although there was adequate knowledge of HIV infection among the participants perceived benefits of condom use determined whether women used condoms or not. Therefore having sufficient knowledge of HIV infection is not enough reason for women to use prevention measures against HIV infection. This results concurs with the studies done in Uganda and Nigeria that found that knowledge and awareness alone did not increase the adoption of condom use for adolescents [39, 40]. This study has established that the most significant single factor associated with HIV in women of reproductive age was failure to use condoms due to failure to perceive the benefits of condom use despite high knowledge. Among the positives only 4.3% [n=208] used condoms consistently while among the negatives none used condoms consistently [n=208]. This trend is worrying as it shows that there are factors that hinder women from consistently using protection during sexual intercourse and since some of the positive had multiple sexual partners the chances of spreading infection to others is higher. Despite the increase in the uptake of condoms in the last decade for most countries there are still certain factors that are hampering condom use especially in women such as fertility desires and sexual conformity with the societal and cultural norms [41- 45]. Other reasons for the poor adoption of condom use include beliefs that it reduces the enjoyment of sex, that they are uncomfortable and that they can come inside the woman and get lost have reduced the gains achieved in condom use [46, -51].

Conclusions

The study has identified perceived seriousness as one of the most important constructs that can predict behaviour change. This together with sexual relationship power can be used by primary care physicians to mitigate the spread of HIV infection in the community. Woman within many relationships possess the power to use condoms but still do not use them consistently and the reasons why they do not use condom has been explained using the HBM model. Although further investigation is still needed, the overall impression is that this study suggests that the HBM as a model does not adequately explain HIV transmission among women of reproductive age apart from one of the constructs which is perceived seriousness of the disease. We therefore conclude that perceived barriers together with female education are important and direct determinants of consistent condom use and should be incorporated in HIV prevention programs.

Recommendations

From the study findings, it is recommended that future messages used in behaviour change education programmes should incorporate the aspect of barriers and benefits of the intervention which may change the perception of many women in adoption of condom use. In conclusion therefore it is important that HIV programme planners, policy makers and primary care providers and educators understand the importance of focussing on the benefits and barriers to adoption of preventive behaviours to mitigate the spread of HIV infection among women.

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