Influence of Education on HIV Infection among Pregnant Women Attending their Antenatal Care in Sekondi-Takoradi Metropolis, Ghana

Abstract

This study investigated the influence of the level of education on HIV infection among pregnant women attending antenatal care in Sekondi-Takoradi, Ghana. A cross-sectional study was conducted at four hospitals in the Sekondi-Takoradi metropolis. The study group comprised 885 consenting pregnant women attending antenatal care clinics. Questionnaires were administered and venous blood samples were screened for HIV and other parameters. Multivariable logistic regression analyses were performed to determine the association between the level of education attained by the pregnant women and their HIV statuses. The data showed that 9.83% (87/885) of the pregnant women were HIV seropositive while 90.17% (798/885) were HIV seronegative. There were significant differences in mean age (years) between the HIV seropositive women (27.45 ± 5.5) and their HIV seronegative (26.02 ± 5.6) counterparts (p = .026) but the inference disappeared after adjustment (p = .22). Multivariable logistic regression analysis revealed that pregnant women with secondary/tertiary education were less likely to have HIV infection compared with those with none/primary education (adjusted OR, 0.53; 95% CI, 0.30–0.91; p = .022). Our data showed an association with higher level of education and HIV statuses of the pregnant women. It is imperative to encourage formal education among pregnant women in this region.

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Verner N. Orish, Onyekachi S. Onyeabor, Johnson N. Boampong, Richmond Afoakwah,
Ekene Nwaefuna, Samuel Acquah, Esther O. Orish, Adekunle O. Sanyaolu, Nnaemeka
C. Iriemenam
Journal of Health Care for the Poor and Underserved, Volume 25.3,
Number 3, August 2014, pp. 982-990 (Article)
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DOI: 10.1353/hpu.2014.0149
For additional information about this article
Access provided by your local institution (14 Aug 2014 08:30 GMT)
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© Meharry Medical College Journal of Health Care for the Poor and Underserved 25 (2014): 982–990.
BRIEF COMMUNICATION
Inuence of Education on HIV Infection among
Pregnant Women Attending their Antenatal Care in
Sekondi- Takoradi Metropolis, Ghana
VernerN. Orish, MBBS, DTM, MPhil
OnyekachiS. Onyeabor, MD, MPH
JohnsonN. Boampong, BSc, MPhil, PhD
Richmond Afoakwah, BSc, PhD
Ekene Nwaefuna, BSc, MPhil
Samuel Acquah, BSc, MPhil
EstherO. Orish, BSc
AdekunleO. Sanyaolu, BSc, MSc, PhD
NnaemekaC. Iriemenam, BSc, MSc, PhD
Abstract: This study investigated the inuence of the level of education on HIV infection
among pregnant women attending antenatal care in Sekondi- Takoradi, Ghana. A cross-
sectional study was conducted at four hospitals in the Sekondi- Takoradi metropolis. The
study group comprised 885 consenting pregnant women attending antenatal care clinics.
Questionnaires were administered and venous blood samples were screened for HIV and
other parameters. Multivariable logistic regression analyses were performed to determine the
association between the level of education attained by the pregnant women and their HIV
statuses. The data showed that 9.83% (87/885) of the pregnant women were HIV seropositive
while 90.17% (798/885) were HIV seronegative. There were signicant dierences in mean
age (years) between the HIV seropositive women (27.45 ± 5.5) and their HIV seronegative
(26.02 ± 5.6) counterparts (p = .026) but the inference disappeared aer adjustment (p =
.22). Multivariable logistic regression analysis revealed that pregnant women with secondary/
tertiary education were less likely to have HIV infection compared with those with none/
primary education (adjusted OR, 0.53; 95% CI, 0.30–0.91; p = .022). Our data showed an
THE AUTHORS are aliated with the Department of Internal Medicine, Ea- Nkwanta Regional
Hospital Sekondi- Takoradi, Sekondi P. O. Box 229, Western Region, Ghana [VNO]; The Satcher Health
Leadership Institute, Department of Community Health and Preventive Medicine, Morehouse School of
Medicine, Atlanta, Georgia, USA [OSO]; The Department of Human Biology, University of Cape Coast,
Cape Coast, Central Region, Ghana [JNB, RA]; Biotechnology and Nuclear Agriculture Research Institute,
Atomic Energy Commission, Accra, Ghana [EN]; The Department of Medical Biochemistry, School of
Medical Sciences, University of Cape Coast, Ghana [SA]; Health Information and Research Services
(HIRS) Asakae Takoradi Western Region, Ghana [EOO]; Saint James School of Medicine, Anguilla,
BWI [AOS]; and the Department of Medical Microbiology and Parasitology, College of Medicine of the
University of Lagos, Idi- araba, PMB 12003 Lagos, Nigeria [AOS, NCI]. Please address correspondence
to NnaemekaC. Iriemenam, PhD: iriemeka@yahoo.co.uk.

983
Orish et al.
association with higher level of education and HIV statuses of the pregnant women. It is
imperative to encourage formal education among pregnant women in this region.
Key words: HIV, formal education, Ghana, risk factor, prevention, pregnant women.
Human immunodeciency virus (HIV) is a lentivirus that causes acquired immu-
nodeciency syndrome (AIDS).1 Globally, there are about 34.0 million (31.4
million–35.9 million) people living with HIV in 2011; 2.5 million people were newly
infected with HIV and sub- Saharan Africa accounts for about 69% of all people living
with HIV worldwide.2 In Ghana, HIV prevalence varies according to gender, age, sexual
behaviour, geographic area and urban- rural residence.3 HIV prevalence was 1.9% in
the adult population while it was 2.9% among pregnant women (aged 15–49 years).4
Women’s vulnerability to HIV infection especially in Ghana may be inuenced by gen-
der, unequal power relationships, poverty, few vocational skills, and limited education.5
However, formal education has been tagged a “social vaccine to HIV/AIDS,”6,7 and
higher education has multiple eects on individuals ranging from the acquisition of
facts and cognitive enhancement to greater social status, longer life expectancy, general
intelligence, more use of health services, fewer negative health outcomes, prestigious
occupations, and better health behaviours and outcomes.8,9 Evidence suggests that educa-
tion teaches one to think, imparting cognitive and decision- making abilities necessary
for improving one’s health,10 and that these enhanced abilities increase with schooling.11
Preventive education is oen acknowledged as the principal means of reducing the
rate of new HIV infections,12 but the quest for improved education among the general
populace in countries such as Ghana remains formidable. The 1992 Constitution of
Ghana among other things stated that basic education will be free, compulsory, and
available to all.13 Yet there are lots of nancial impediments for poor households in
sending their families to school, especially the high cost of tuition fees, clothing, foods,
and other community levies.14 Interestingly, high cost of tuition is oen cited as the
most frequent reason for non- attendance and non- enrollment in schools. Previous
research showed that health education has a positive eect on preventing mother- to-
child transmission of HIV,15 and formal education has been associated with increased
level of awareness and the need for HIV testing among people.16 In addition, pregnant
women with low educational levels, low- incomes, and more than one partner were
more likely than their counterparts not to know their HIV statuses.17,18 Furthermore,
maximizing school attendance was associated with lower risk of sexual behaviours
among young people.19
Ghana’s AIDS Commission acknowledges that the level of HIV awareness in Ghana
is almost 98% but this has not been translated into a comprehensive knowledge and
appropriate behaviour as people have low perception of the risk of HIV infection.3 Simi-
larly, studies have shown that educational interventions in Ghana have not eectively
demystied beliefs about the origin, causes, and transmission of HIV/AIDS.20,21 In a
related study in Accra, students’ HIV knowledge was good but their HIV testing was
low.22 In this study, we investigated the association of the levels of education attained
by the pregnant women attending their antenatal care clinics with their HIV statuses.

984 Inuence of education on HIV infection among pregnant women in Ghana
Methods
The study took place in Sekondi- Takoradi metropolis, Ghana. Pregnant women
attending their antenatal care clinics at Ea- Nkwanta Regional Hospital, Takoradi
and Esikado Hospitals and Jemima Hospital were conscripted for the study. Details of
the study design and population have been published elsewhere.23 Briey, this cross-
sectional study was carried out between January and October, 2010 with consenting
pregnant women attending antenatal care. Each facility was visited once a week during
their routine antenatal care visits. Written informed consents were obtained from the
pregnant women and ethical clearance was obtained from the Ghana Health Service
Research Ethical Review Committee, Accra.
Five mls of blood were collected by a well- trained laboratory technician from the
median cubital vein. The blood samples were collected in EDTA bottle and transported
to the laboratory for same day analysis and storage. HIV screening for the pregnant
women were performed and statuses of the women were obtained from the preventing
mother- to- child transmission (PMTC) clinic. The sero- statuses were determined by
applying the national diagnostic algorithm of two rapid antibody tests and western blot
conrmation while indeterminate cases were conrmed at the public health reference
laboratory at Ea- Nkwanta Regional Hospital.
Socio- demographic characteristics were analysed by Pearson chi- squared test (χ2)
and ANOVA for the comparison of mean. Univariable and multivariable logistic regres-
sion models were used to identify the association with HIV statuses and the levels of
education attained aer adjusting for confounding factors. To improve precision and
maximise sample size, we merged pregnant women with no education with primary
education and also secondary education with tertiary education using no education/
primary as the reference in the multivariable logistic regression analysis. Confounding
was considered based on biological plausibility and a +/− 10% change in odds ratio
(OR) estimate. The nal parsimonious multivariable model was selected aer regres-
sion assumptions, confounding, and the results of univariable analysis. OR and 95%
condence interval (CI) were used to measure the strength of the associations. All tests
were two- tailed and statistical signicance was dened as p < .05. Data were analysed
using IBM SPSS Statistics version 21.0 (IBM Corporation, Armonk, NY, USA).
Results
A total of eight hundred and eighty ve (885) pregnant women were recruited for
this study. Table 1 shows the general characteristics of the pregnant women with HIV
status. Overall, 9.83% (87/885) were HIV seropositive while 90.17% (798/885) were
HIV seronegative. There were signicant dierences in mean age of the HIV positive
women (27.45 years ± 5.5) versus their HIV negative (26.02 years ± 5.6) counterparts.
The median age of the HIV positive was 28 years (range, 15–39) while that of HIV
negative was 25 years (range, 15–46). There were no dierences with gravidae, occupa-
tion and trimester of the pregnant women with HIV infection. However, there were
signicant dierences with HIV infection and the levels of education attained (Table 1).
Table 2 shows the multivariable logistic regression analysis of the risk of HIV with

985
Orish et al.
education. In univariable analysis, dierences were found with age and primigravidae
but disappeared aer adjustment signifying confounding factors. In order to improve
precision and maximise power, we also examined the association with the levels of
education of the pregnant women attained by modelling the levels of education into two
categories; (a) none/primary education, and (b) secondary/tertiary education. Our data
indicated that pregnant women with secondary/tertiary education were less likely to
have HIV infection. The unadjusted OR was 0.53 (95% CI, 0.34–0.83; p = .006) (Table
2). This inference remained signicant aer adjusting for age, adolescence versus adult,
gravidae, occupation, parasitic diseases, co- infection, and area of residence as potential
Table 1.
CHARACTERISTICS OF THE PREGNANT WOMEN WITH
HIVSTATUS
Characteristics
HIV negative
n = 798 (%)
HIV positive
n = 87 (%) p valuea
Age (years)
Mean ± SD 26.02 ± 5.6 27.45 ± 5.5 .026
Age group (years)
≤19 12.7 9.3
20–29 61 54.7 .071
30–39 24.4 36
≥40 1.9 0
Level of education attained
None 18.4 30.2
Primary 14.2 17.4 .030
Secondary 63.2 50
Te r ti a r y 4.2 2.3
Gravidae
Primigravidae 60.2 49.4
Secundigravidae 31.6 35.6 .053
Multigravidae 8.2 14.9
Occupation
Civil service 2.3 1.4
Farmer/Trader/Caterer/ 95.2 97.2 .756
Fishing
Teacher/Student 2.5 1.4
Trimester
1st trimester 21.6 24.4
2nd trimester 65.6 57 .215
3rd trimester 12.8 18.6
ap- values derived from Pearson chi- square test for categorical variables and ANOVA for the mean
of continuous variable.

986 Inuence of education on HIV infection among pregnant women in Ghana
confounders in the multivariable logistic regression analysis. The adjusted OR was 0.53
(95% CI, 0.30–0.91; p = .022) (Table 2). When secondary/tertiary education was used
as the indicator in the multivariable logistic regression analysis, pregnant women with
none/primary education were more likely to be HIV positive (adjusted OR, 1.70; 95%
CI, 1.05–2.75; p = .031) (data not shown).
Discussion
Results from this study suggest that pregnant women with higher education were less
likely to be infected with HIV than those with low level of education. A similar study
from Ghana revealed that mother’s years of formal education was strongly associated
with health knowledge.9 In addition, previous study indicated that higher education
or more years of formal schooling was widely associated with better health but the
underlying causes are unclear.11 As expected, individuals with higher level of education
were more likely to practice protected health behaviours (e.g., cognitive and decision-
making abilities) but these greater understanding did not inuence their HIV/AIDS
knowledge.11 Knowledge is oen considered necessary but also insucient in terms
Table 2.
MULTIVARIABLE LOGISTIC REGRESSION ANALYSIS OF THE
RISK OF HIV
Variab l e
Unadjusted OR
(95% CI) p value
Adjusted OR
(95% CI) p value
Age (Years) 1.05 (1.01–1.09) .026 1.07 (0.96–1.19) .22
Age groups (Years)
≤19 1 1
20–29 1.22 (0.56–2.67) .62 1.48 (0.28–7.84) .64
30–39 2.02 (0.89–4.56) .091 1.34 (0.15–11.75) .79
≥40 0.00 (0–0) .99 0.00 (0–0) .99
Gravidae
Primigravidae 0.45 (0.23–0.89) .021 0.82 (0.42–1.59) .55
Secundigravidae 0.62 (0.31–1.26) .19 1.09 (0.42–2.84) .86
Multigravidae 1 1
Occupation 0.95 (0.29–3.11) .93 0.93 (0.25–3.49) .92
Trimester 1.09 (0.75–1.59) .66 1.20 (0.77–1.87) .41
Level of education
attained
None/Primary 1 1
Secondary/Tertiary 0.53 (0.34–0.83) .006 0.53 (0.30–0.91) .022
OR = odds ratio
CI = condence interval

987
Orish et al.
of behavioural change. The majority of HIV intervention programmes in sub- Saharan
Africa are normally built on biomedical and social cognitive models with the supposition
that individuals are aware of their sexual risk behaviours. However, though knowledge
and awareness of HIV may be high in Ghana, there remain myths and misconceptions
about how HIV is transmitted.21
Over the years in Ghana, knowledge of preventing HIV/AIDS along with miscon-
ception that propagated stigma and discrimination against infected people has varied.24
While implementation of various HIV prevention and treatment programmes have
commenced in Ghana since 2003, uptake of HIV testing is still slow, oen attributed
to HIV- related stigma.25 HIV treatment has been recognised as a form of prevention
especially in developing countries like Ghana, but that still depends on the uptake for
HIV testing which is unfortunately low during pregnancy in developing countries.26
In a previous study conducted in Ghana, signicant negative interaction was found
between risky sexual behaviours and community stigma especially among females
who live in communities with high levels of stigma.25 In a related study, majority of
Ghanaian women (especially from the rural areas) have not been tested for HIV infec-
tion but would want to if provided with the opportunity.27 Thus, the signicance of
determining HIV statuses of pregnant women is vital to HIV preventive programme
in terms of bridging perinatal transmission as well as counselling. With the low HIV
testing observed during pregnancy, World Health Organisation (WHO) encouraged
countries to adopt the routine oer of HIV testing also known as an opt- out strategy.28
This approach oers routine voluntary HIV testing to all pregnant women accessing
antenatal care, and by this means changing the emphasis from client- initiated voluntary
counselling and testing (opt- in) to provider counselling and testing with patient’s right
to refuse test (i.e., to opt out). The strategy has been widely accepted by the majority
of pregnant women surveyed in the Wa municipality of Ghana.29
HIV preventive education which oen happens in formal educational settings is
recognised as the primary means of decreasing the rate of new HIV infection and its
goal is to prevent infection, reduce stigma and discrimination, change people’s attitude
towards HIV/AIDS and infected people as well as adoption of lifestyles that will not
predispose people to the infection. In a previous study from eastern Ghana, 8% of
pregnant women were HIV seropositive.30 Similarly, a recent Kenyan study indicated
that the vast majority of HIV- infected persons were not aware of their HIV status,
posing a major hurdle to HIV prevention.31 In Brazil, pregnant women are at increased
risk of HIV infection as they remain sexually active without the use of condom.32 In
United States of America, women who believe that they have no risk of getting HIV
were more likely to have less education.33 In a related study in Kumasi, Ghana, the
authors found that low HIV/AIDS knowledge, and non- disclosure of partners HIV
status, were associated with inconsistent condom use thereby increasing the risk of HIV
and sexually transmitted infections.34 These evidences showed that empowerment of
women through formal education especially in developing countries will not only lead
to greater human capital development but also increase their sensitivity and awareness
for their health and the health of their unborn children through safer sexual health
behaviours and HIV testing.

988 Inuence of education on HIV infection among pregnant women in Ghana
Conclusion
This study has shown the association between the level of education attained among
pregnant women and their HIV statuses. Our study revealed that pregnant women with
higher education were less likely to have HIV infection when compared with those
with lesser education. It is imperative to encourage formal education among pregnant
women especially in the rural regions.
Conict of interest
The authors declare that they have no conict of interest.
Acknowledgments
The authors wish to express their gratitude to all pregnant women that participated in
the study. We thank the laboratory and clinical personnel of the four dierent hospitals
for their technical support and encouragement.
Notes
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