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Demographic and Social Factors Influencing Couples Voluntary Counseling and Testing

Paper outline:

Introduction
Problem statement

Research Questions

Literature Review

Sensitization Programs Effectiveness in Changing Beliefs of Participants
Effectiveness of Community Outreach Programs and CVCT
Testing Procedures for HIV among Couples
Overcoming Perceived Barriers to VCT
Severity of HIV and Perception by Individual Couples

Theoretical Orientation
Conceptual Framework

Research Hypothesis
Methodology

Research Design
Study Population
Data Collection Tools
Variables
Statistical Analysis

Limitations, Delimitations, Significance
Reflective Essay

Abstract
There is limited researched information about the efficacy of couples voluntary counselling and testing (CVCT) as a behavioural method of preventing transmission of HIV. Most studies on related subjects indicate that spouses are the most vulnerable group of being infected with HIV. This research will seek to provide additional research findings on the demographic and social factors that influence a couple’s decision to undertake CVCT in Ethiopia. The research will confirm the hypothesis that social factors are significant influences to the behaviour of couples and their attitude towards CVCT. The research will be conducted using a survey of couples and individuals attending couples voluntary counseling and testing in six model health centers in Ethiopia. Logic regression and tabular descriptive statistical analysis shall be performed and a discussion of the findings offered in relation to the validation of hypotheses. This study may be limited by its sample size and the cooperation of the participants. This report will give a unique input on the influence of customary laws and roles to the decision of couples having CVCT. The research will add onto literature explaining the extent of the social influence factors on the choice of couples to have VCT.

Demographic and Social Factors Influencing Couples Voluntary Counseling and Testing Part 1
Introduction
            Voluntary Counseling and Testing is one of the behavioral change methods that are used to prevent further transmission of HIV. The success of behavioral change strategies has varies depending on the formulation of the strategy. Moreover, the success also depends on the target population and the social factors that affect the target population. The distribution of the influence of social factors along the demographics of the population also plays a part. There is little research highlighting how social factors influence the choice of couples to adapt to the behavioral change programs and thus change their HIV risk behaviors. To address this gap, this research uses the theory outlined in the Health Belief Model. The research offers a conceptual framework that has been adopted from the HBM model. This research hopes to show that social factors range have a different degree of influence on the choice of CVCT and vary along the demographics. The exact extent to which the difference in influence occurs will be demystified by the research findings.
Problem Statement
Couple Voluntary Counseling and Testing is a new concept that has been adopted in the behavioral strategies that seek to control the spread of HIV. Therefore, the amount of research available on the subject is limited. Most behavioral strategy research has focused on individuals and when couples are used, the research is limited to Prevention of Mother to Child Transmission (PMTCT) of HIV. This study will provide literature to add on to the limited literature on CVCT, specifically offering the social factors that are responsible for its low adoption as a viable behavioral strategy to be used in prevention of HIV transmission.
Research Questions
            This research will answer the following questions, are there social factors that influence the choice of undertaking couples voluntary and counseling tests? Do the social factors vary with the demographics of the given area? If so, how so the social factors vary. The research will highlight the patterns of social factors influence and whether the influence is attributed to any other factors. What is the role of each partner in their social construct and how does this influence the couples’ decision to undertake couples voluntary and counseling for HIV?
Part 2
Literature Review
This section reviews literature relevant to the topic of study. It places the topic of study in the context of the research field and brings out the knowledge gap that the research will address. The literature review addresses the various concepts of the Health Belief Model.
Sensitization Programs Effectiveness in Changing Beliefs of Participants
Byamugisha et al. (2010) conducted a survey on prenatal attendees in Uganda to investigate the influence of mother attitudes on the effectiveness of prevention of mother to child transmission of HIV. The authors note that prior to their study the HIV testing rates were exceeding 90 per cent among pregnant women. This was because of the introduction of antenatal counseling and testing in June 1996. The authors wanted to find out the opinions of the pregnant women concerning the HIV testing initiative to fill the research gap that was missing in the particular area.
In their study, the authors had 388 women participating in their survey and who were first time attendees of antenatal clinic. The authors used a pretested questionnaire and their data was analyzed with descriptive statistics and logistic regression analysis. In their findings, the authors note that the reasons for the high turnout rates for testing were attributed to the positive attitudes that the majority of the participants had about the specific kind of HIV testing. 98.5 per cent of the participant had positive attitudes and in addition to this 60 per cent of the women had knowledge, of mother to child transmission of HIV and prevention measures. The authors refer the reader to a similar study conducted in Botswana that showed similar results that positive attitude of women towards HIV testing during pre natal care is significant in influencing their acceptance of HIV testing during the same period.
The authors attribute the positive attitude exemplified by the women to the level of information access that they had. They note that those residing in urban areas and wealthier had a firmer positive attitude compared to the other participants. This arises because of their relative ease of access to information through media. On the other hand, young antenatal attendees aged 15-24 in the surveyed in the study also demonstrated positive attitudes more than their older counterparts signifying a generational gap difference did. This study is important in demonstrating the need of changing the attitudes of the target population to guarantee the success of HIV spread prevention and control.
Kennedy et al. (2010) conducted a study to measure the evidence for a differential effect of positive interventions for individuals infected with HIV and those not infected with HIV in developing countries. The authors also measured the efficacy of interventions aimed at people living with HIV. The papers reviewed were on positive prevention behavioral interventions in developing countries. The authors identified nineteen studies that they used in their analysis. They identified behavioral interventions as having a strong impact on effecting condom use among their HIV-positive participants compared to the HIV negative participants.
Almost all the studies reviewed by the authors were counseling and testing interventions. The authors note that these types of study are most likely to report serostatus compared to other behavioral interventions. Therefore, the authors had more evaluation data in their analysis and this might have increased the bias inclination of their study therefore future studies on the area need to employ a more rigorous approaches. The authors were most limited by the few published papers in peer review journals. Therefore, suggest that much of the findings contained in grey literature should be reexamined with stronger methodologies so warrant their inclusion in peer review journals and contribute to the literature on the efficacy of behavioral interventions on HIV prevention among HIV-serodiscordant couples.
The authors identify the intervention gap in developing countries where treatment of HIV+ individuals starts late when their CD4+ lymphocyte count goes below 200. This requirement leaves out a majority of HIV+ individuals who do not meet the criteria. Moreover, they note that it for the intervention to be most effective, the individuals living with HIV need to be given leadership roles in the intervention programs. Their knowledge of the conditions that their fellows facing similar health conditions face daily, thus they are best positioned to capture their trust and that on the HIV- individuals as a true testimony.
Effectiveness of Community Outreach Programs and CVCT       
In a study carried out by Allen et al (2007) where they used Influence Network Agents within the various institutions present in their communities to encourage couple to turn up for couple’s voluntary counseling and testing. The authors identified cohabiting heterosexual partners as the demographic group with the highest HIV infection rate in Africa. Use of behavior intervention method like voluntary counseling and testing targeted at couples is most effective way of reaching the target group. The study was conducted in Rwanda and Zambia within four months and had 9,900 requests for couples to turn up for the voluntary counseling and testing intervention. The study used 61 Influence Network Agents.
Couples’ VCT presents various benefits that can save lives and reduce HIV transmission as well as sexual infectious disease transmission and unwanted pregnancies. There is an increasing agreement presented by various studies that couples’ VCT should be expanded in its dissemination. The authors note that the main factor hindering the expansion of this type of behavioral intervention is cultural and logistical challenges. However, despite the challenges identified, the authors also note that influential members in most African communities are willing to increase the awareness of CVCT. Their study was carried out in two different African countries but reported similar predictions.
In their description of INAs, the authors note that INAs ascribed to specific categories among the four categories under the study, however each INA had more than one identifiable occupation and was conversant with a variety of networks such as friends, family and professional contacts. Lastly, the identification of the INA with the social setting of the target population made them most appropriate to promote CVCT. The authors note that INA presents the benefit of sustainability to an intervention program as compared to Community Workers (CW) who are discontinued when the research enrolment is reached.
To demonstrate the advantage of using INA in their study the authors note that they INAs were most effective while addressing couples because they eliminated the burden of one spouse to carry the message to the other. The INAs understood the cultural implications of their intervention. They were best positioned to deliver their invitations in discreet ways. The discretion was most effective against the fear of stigma and allowed couples to voice openly their concerns about the social fear and stigma that they embodied. The authors note that only a tenth of their invitations were delivered to couples in their homes and out of the tenth, a third to a half of the invitations lead to the target couple seeking HIV testing. The authors attribute this efficacy to the intimate relationship between the INA and the targeted couples. To highlight the importance of discreetness, the authors note that invitations for CVCT given out in public locations were less effective as compared to those delivered in homes and workplaces of the couples.
Differences in the number of successful invitations in the two countries under study were attributed to the language variance present in each country. Rwanda, which recorded the highest number of successful invitations to CVCT, has one local language while Zambia has 72 dialects arising from five major language groups. Therefore, INA in Rwanda had a higher chance of reaching more couples because they faced little or no language barrier challenge. It is worth noting that even the INA as part of the community had fears of stigmatization should they make public announcements of their intention to invite couples for HIV VCT. Therefore, public intervention although carried out, had a significant resistance level compared to discreet delivery of interventions by INAs. Therefore, the authors recommended that to increase the level of reach for the intervention more INAs need to be identified and trained. Additional INAs will boost the sustainability of the program and result in less stigmatization of couples seeking HIV testing and INAs handing out invitations.
The highlight of the study is that there are stiff a number of obstacles present in the administration of intervention programs to check the transmission of HIV. Such obstacles include lack of money that can facilitate transportation of both INAs and personnel trained to administer home based testing. Availability of funds also makes it possible to have mobile testing units that decentralize CVCT by bringing the service closer to its targets.        The authors conclude that despite the increased infusion of donor support in HIV prevention and treatment programs in Africa, more needs to be done to enhance the role of prevention. Other prevention methods especially targeted at pregnant mothers to prevent mother to child transmission are less effective because they do not address the social challenge present among couples. CVCT captures this challenge because it involves both spouses and therefore is best suited as a HIV prevention program.
(Nuwaha et al. 2002) conducted a study to analyze the factors that affect the choice of HIV voluntary counseling and testing (VCT). They used focused group discussions (FGDs) in order to provoke the aims of VCT and then conducted a survey that estimated the proportion of people who undertook VCT in Bushenyi district of Uganda. The FGDs allowed the authors to establish the kinds of beliefs present in the region that affected choice of VCT. Interviews gave the authors data on the prevalence of the elicited beliefs among the people of Bushenyi. Their qualitative survey is beneficial because it offers a richer data than what would have been provided with a quantitative survey. FGDs provided a unique opportunity for participants to know the contributions of other participants and to add on the details missed by any of the participants. The study had men and women participation in FGDs and therefore presented a rich discussion and revelation of the assigning of roles and responsibilities among women, men or spouses.
The main factor influencing the choice for VCT was the articulation of the positive and negative consequences of VCT attributed to a positive and negative test respectively. According to the authors, there is a need to emphasize more on the fact that 75 per cent of those undergoing VCT will have a negative test result. In addition to the consequences of the test, the authors note that social pressure form sexual partners are another factor influencing the VCT choices. Other than social partners, relatives also presented a significant social pressure. Therefore, health education needs to cover the significant group of influencers in addition to the target population. The authors found out that sexual partners present the most influence on the choice for VCT therefore measures aimed at tackling VCT choice challenges and promoting VCT uptake need to have specific services for couples. Other than the choice of VCT for HIV, the study identified various barriers that hindered uptake of VCT.
Most importantly, there were barriers corresponding to accessibility to VCT services. To address these barriers, interventions need to be carried out to reduce the distance travelled to access VCT centers, provide free or cheap services to mitigate the cost of VCT as a barrier, link VCT with care of HIV+ individuals and improve the quality of care such as in the provision of confidentiality when conducting VCT. When care is linked to VCT, drugs presented should be affordable to attract a high number of individuals at risk into VCT for HIV. Care should also entail treatment of other opportunistic diseases that are known to infect those living with HIV (Terris-Prestholt, et al., 2008).
Other than addressing the barriers, early testing should be encouraged because VCT is most effective in the early stages of HIV before AIDS related symptoms appear. The authors caution against lay teachings that negate the importance of VCT and instead advocate for the careful choice of partners. The belief barriers identified in the study are a lack of awareness on the need of VCT, which reduces the number of people opting for VCT for HIV. Secondly, most of the participants attributed the delay of the issuance of test results to poor quality of care in the VCT centers. Moreover, most participants expressed additional fear for cases of mislabeling of results to indicate positive where it should be negative. The overall attitude of VCT by close friends, family and partners also played a role in influencing individuals to undertake VCT. The authors note that it is important that VCT initiatives provide visible positive consequences such as positive living, confidence gain in life as well as the abstinence of practice of safer sex (Nuwaha, Kabatesi, Muganwa, & C, 2002).
Boeras et al. (2011) conducted a study to investigate the use of algorithm of three serial rapid HIV tests. The tests were used to resolve unclear serostatuses of cohabiting couples. The authors conducted the study in response to the challenge of interpreting intermediate or discrepant results from several results conducted on the same sample. In their findings, the authors note that individuals who had an intermediate/discrepant case in most cases resolve to the same result as their partners. They report that 48 per cent of discrepant/intermediate cases resolved to “infected” for individuals having infected partners compared to 11 per cent who remained uninfected yet had infected partners.
The study identifies rapid testing of HIV as a common testing method in Africa and that a sequential testing algorithm was later infused into the testing program that adds confirmatory tests. The confirmatory tests are important for resolving partner cases where either partner has a positive of discrepant result. The authors note that only 5 per cent of the individuals with intermediate/discrepant rapid test results at the first testing got a HIV positive result in a subsequent testing. Therefore, the authors recommend that partner testing should be enhanced and campaigned for so that spouses know their risk of HIV infection. In cases where only a partner is HIV positive, then the other partner is well position to take preventive measures and facilitate the management and interpretation of intermediate rapid test results.
Therefore, the study concludes that algorithms combining rapid test should be evaluated, and note that in cases where two of the three states are negative, then the partner is negative (Hollingsworth, Laeyendecker, Shirreff, Donnelly, & David, 2010). In such a case where there is no recent high-risk exposure, then partners need not seek routine follow-up. However, for individuals having an infected partner, there is need for a routine follow-up after a month irrespective of their serostatus.
(McKenna, et al., 1997) Confirm that rapid test algorithms have a high specificity of 99.4 per cent. In addition, same day results on tests reduce the fear factor that is associated with many couples choosing not to undertake VCT. Their study findings indicate that VCT that offered same-day test results increased the confidence of couples and was a major factor in ensuring that community promotion of VCT was effective.
Concling et al. (2010) did a study to authenticate the feasibility of couples voluntary counseling and testing in antenatal care as well as measure how couples comply with prevention of mother to child transmission of HIV. The study included 3633 women who received VCT and 1619 women who received CVCT. Their study was generally homogenous in demographics. The mean of the women in the study has two previous births and had cohabited with their partners for at least five years. From the findings of their study, the authors note that the CVCT offered on weekends in high-volume antenatal clinics were reasonable. In additions, cases where partners participated together reported a high chance for the women to present the study voucher at the time of delivery indicating that they had positive attitudes about CVCT. They note that promotion of CVCT and invitations of couples to the centers increases the uptake of couples’ counseling.
However, a limitation of the study is that most of the women who agreed to have CVCT with their partners may represent a unique sample of the target population not reflective of the true demographic distribution. Secondly, the study was conducted in areas where PMTCT, VCT and CVCT were relatively new concepts and the result might not be very reflective of the current situation in those study areas. Nevertheless, the findings of the study are important for shoeing that couple testing is effective to some degree in addressing the transmission of HIV among couples cohabiting. In addition, the study served an important role of analysis some of the factors that affect the choice of couple in taking up CVCT such as stigmatization and awareness of the services available. A comprehensive approach incorporating the family is important in preventing transmission of HIV in sub-Saharan Africa as noted by the study and therefore, couple participation should be enhanced by using inducements and other influencing factors.
Overcoming Perceived Barriers to VCT
Coates, Ritcher & Caceres (2008) studied behavioral strategies that reduce HIV transmission. Their study notes that HIV prevention needs a radical behavioral intervention for individuals. When the intervention is successful, it should be sustained. The study recommends that behavioral strategies be detached from their strict reliance on theoretical and methodological thinking. In this case, studies should cease to focus on HIV prevention in niche areas and move into comprehensive interventions that record varied inputs, levels and outcomes. Therefore, the studies should have a social behavioral science capacity that can effectively disseminate approaches and support strategies that are developed from the ground and scaled up.
The authors highlight the need to have individuals on the ground, conversant with the behavioral science. The individuals should be able to incorporate the knowledge with a creative thought approach to evaluate prevention and assessment strategies on the ground. The need for having grounds up approach like community-based programs is that the success of such programs depends on the capacity for implementation and sustenance. Therefore, not only should funding for such programs be provided, but a capacity building aid should be provided so the community based organization are able to carry out behavioral strategies campaigns.
Most successful programs of HIV prevention incorporated aspects of community mobilization, thus elevating it to a significant role in the prevention of HIV transmission. To strengthen further the mobilization of communities, there is a need to have strong leaders at all levels of decentralizations that ensure there is commitment and sustenance of the intervention programs.
The authors note that HIV treatment in resource-rich countries has been successful at prolonging life however, worldwide a similar success rate in the prevention of HIV has yet to be achieved. In order to achieve a similar rate of success, there should be an inclusion the availability of items for elimination of social impediments that assist universal prevention of HIV. These include technologies and devices like condoms, clean needles reducing the resolve to use drug treatment, increase access to information, skills and services for prevention of HIV.            Another major impediment to HIV prevention is the objection of scientific proven methods for reducing behavioral risks. This arises out of the fear of going against cultural norms.
Ramjee et al. (2010) review their experiences in conducting multiple community-based HIV prevention trials in South Africa. The authors note that in Africa the predominant route for aids transmission was heterosexual sex in 2007. The country of study, South Africa had the highest HIV prevalence in the world as of 2008. The country in its programs to prevent HIV transmission has included male circumcision, vaccines, and microbicides among others. Behavioral interventions included the virginal diaphragm, and stepping stone trial.
The study used community-based sites that were set up with the help of local community leaders. Before the setup, several meetings were held to ensure that the community was in agreement with the new interventions that the team of researchers was bringing in. Moreover, meetings with the community stakeholders assist the researchers to get the background information on the study area. The authors point put that community stakeholders and Community Working Groups were powerful in the origination of suitable language lexis, messaging and distribution of trial results.
They also note that though their study was targeted at women, the involvement of male participants became apparent when given that women cannot practice prevention measures without the knowledge and approval of men. Therefore, in order to allow women to use preventive devices, their partners and other male had to be involved in the study, especially on the sensitization part. The benefits of their intervention was that training provided to community members allowed them to offer proper care to HIV-positive members and afforded them skills that allowed them to seek jobs. Most jobs available for the community-trained participants were in the health sector in their communities.
The main challenges of the study were in recruitment for the intervention program. Those not qualifying for recruitment after screening tests manipulated other against enrolling for recruitment such as asking them to lie about their sexual encounters. The incident demonstrates the impact that peers have on influencing behavior change among adult women. However, the relatively high reimbursement for participation in clinical trials contributed to the high turnover for recruitment. Most of the women in the study had no other source of income. Despite the income status, most of the women’s intention was altruistic. The main challenge for uptake of condom use was the participants own apathy and beliefs in addition to their fear of condemnation from their partners and family. Other minor challenges were in the difficulty of participants to keep to the schedule of contraception, the reluctance of using contraceptive because of the perceived side effects. Therefore, such participants reported cases of contraception failure that also negatively affected the decision of others.
Other challenges in the administration of the intervention were presented by the nature of rural population of the area under study who were highly mobile. Due to socio economic hardships, the populating frequently migrated to urban areas in search of employment. Therefore, follow-up measures were often required and were not very successful. Lack of health infrastructure is also a major challenge for the sustainability of intervention programs. The high burden of HIV in hospitals and clinics of developing countries strain the available human resource that has to cater also for other patients and medical conditions.
Betancourt et al. (2010) present findings and barriers of the delivery of family-centered PMTCT. They note that HIV is a family illness. HIV affects all members of a household and therefore needs to be approached like a family illness in its prevention. Therefore, there is need to involve all household members even when the main target of the prevention intervention is an individual. Provision of testing and treatment to other members of the family during the study influenced women to be more participatory in their intervention programs. Women adhered more to their PMTCT regimens and were freer at disclosing their HIV+ status to their partners. The positive result is important in any intervention program because it results to a reduced chance of registering vertical transmission of HIV. This is possible when testing is done early and there is an appropriate support and counseling of a woman sharing her test results with her partner. Disclosure among partners enhanced by the targeting of the household rather than the individual, promote the use of condoms and other prevention methods among serodiscordant couples. Moreover, the disclosure is effective in preventing future transmission in pregnancies.
The main challenges for women who are HIV+ to disclose their statuses to their spouses are the fear violence and abuse. In such cases, the partners usually have no knowledge of the importance of supporting and engaging with their partners to reduce their risk of HIV. When a household approach is used in HIV prevention, such challenges are reduced or eliminated. In Kenya, the authors note that women who turned up with their partners for testing demonstrated a high probability of returning for antiretrovirals.
The main challenge facing the adoption of family based approach is the continued focus on simplistic methods that only concentrate on the prevention of HIV from an individual’s perspective (Mayer & Pizer, 2009). The authors note that literature documenting the efficacy of family-centered care is minimal. Therefore a paradigm shift should be embraced for behavioral interventional in the treatment and prevention of HIV. There is need to move away from the current focus on segmented delivery of isolated ART or isolated PMTCT.
Severity of HIV and Perception by Individual Couples
Beyeza-Kashesya et al. (2010) discuss the determinants of the desire to have children for partners who are serodiscordant and are receiving care in Uganda. The authors note that gender of the HIV+ partner is important in influencing the desire to have a child by the couple. In addition, the cultural significance of children and the level of communication between the partners. The study participants’ average age was 33 years and females were on average 30 years old. The study exemplified the need for serodiscordant couples in Uganda to have children. Given that serodiscordant partners are highly risked, it is worrying that a strong desire to have children negates the high risk of being infected with HIV in either of the partners. The authors note that the partner influence on the choices of the other partner in preventing HIV transmission is very significant. In 80 per cent of the studied cases, the belief that a partner wanted children and the actual desire for children were corresponding to each other. However, only 36 per cent of the study participants had talked about how to get pregnant. This highlights the relative high level of non-verbal communication that is present among HIV couples. With the knowledge that partners can perceive their spouse desire in a non-verbal way, health care providers can be able to influence the behaviors of HIV couples through one partner and thus control the transmission of HIV. Male partners who are culturally regarded as the head of the family and the decision makers therefore need to be key targets in the intervention programs for couples. Men need to be helped in understanding their tactical position in the prevention of HIV transmission.
The study notes that in all cases participants did not change their intentions to have children even after discussions with healthcare workers. The couples living with HIV believed that the participants were against their decision for childbearing. When patients shun the advice that they are given by health worker then they jeopardize the efforts to prevent transmission of HIV. While it might be possibly correct that healthcare workers actually are indecisive when childbearing by people living with HIV AIDS (PLWHA) is in questions, they are better placed to influence the choice made by couples. Health workers mostly live in the same community with their patients and therefore understand the socio economic and cultural challenges that their patients face. In this regard, health workers need empowering on information, skill so that they are more sensitive to the needs of the HIV+ people. This should be provided with the aim of ensuring that PLWHA continue childbearing by using HIV preventive approaches.
Heikinheimo & Lähteenmäki (2009) indicate that the discussion of risk of HIV should consider two factors in the view of heterosexual intercourse, the infectious of the infected partner and the risk of the uninfected spouse. They note that the circulation of the HIV load of the infected spouse highly predicts the risk of heterosexual transmission.
According to a study by (Helleringer, Kohler, & Frimpong, 2011), VCT for HIV is lower among individuals from poor households in sub-Saharan states. As a result, there is a significant inequality in the access to VCT for HIV and ARV treatment. The authors note that VCT for HIV in home-based campaigns had a higher uptake in their study among poor households because it reduced the existing socioeconomic challenges that were previously a hindrance. Among the households studied, the authors identified poor accessibility of health facilities, fatalism as some of the main barriers. Others were stigma related to HIV and defeatism that made the respondents of the study less responsive to VCT for HIV. They note that although hospitals provide routine VCT for their attendees, the accessibility of healthcare facilities by the poorest individuals was a challenge due to their socioeconomic status. Moreover, other initiatives targeting workplaces also missed the poorest that were less represented in the workplaces (Corbett, et al., 2006). The poverty status of couples also influences the probability of women depending on their husband’s approval to attend VCT services. In most cases, women were unemployment and responded in the study that they relied on the approval of their husbands who provide money for transport to health facilities.
Arthur et al. (2007) explored the behavior change of clients to VCT health centers. They report that social desirability is a major factor affecting the reporting of risky behavior among couples and during VCT sessions. The authors note that couple counseling may be a viable intervention in seeking disclosure among for HIV+ clients of VCT centers.
Thior et al. (2006) looked at socio-demographic predictors of acceptance of VCT. Their study covered post-partum women in Botswana. They note that acceptance for VCT dropped significantly as age of respondents increased. They attribute the cause of the drop to preciseness of the high risk of HIV infection by older women and the subsequent desire for protection from public shame. In addition, HIV is the lead cause for adult deaths and therefore older women are against testing for fear of getting HIV+ results. Married women had a less likelihood of accepting VCT because of the African setting where they are viewed by society to be under the authority of their husbands. Other than age and marital status, education level of the women under the study was also a major factor. Educated women were less positive about accepting VCT because they were knowledgeable of the risks of status loss due to a HIV+ result.
Part 3
Theoretical Orientation
In the attempt to use behavioral change as the means to control the spread of HIV, most programs fail because, they do not address the beliefs of their target population about HIV and related health conditions. In order to change behavior, a change of attitude toward the disease and the perceptions of the target population are paramount. Voluntary counseling and Testing is a behavioral approach of controlling the spread of HIV and other related health problems. For the practice to have a high success rate participants need to be aware of the reasons behind the exercise, they need to be convinced beyond doubt, of their safety and be assured that the program is conducted for their benefit. Until the belief resistance is concurred from the minds of the participants, no tangible progress can be sustained. It is the intention of governments and institutions carrying out voluntary counseling and testing to have a 100 per cent cooperating and success rate. Such a goal, although achievable is not easy to meet given the varied resistant factors that influence the targets of the VCT programs. So before the allocation of funds for conducting voluntary counseling and testing it is important to begin with sensitization programs for the community involved. Sensitization programs are efficient because the can be scaled to a large geographical area simultaneously to have the highest reach and maximum impact on the target population.
The theory of Health Belief Model forms the basis of this study. The theory is an address to the individual perception of threat as presented by a health problem. Moreover, the theory addresses the paybacks of evading the health threats and the factors that influence the decision to avoid the threat. In the HBM, six concepts exists that influence an individual’s health beliefs and their participation in health intervention programs aimed at preventing the transmission of HIV. According to the HBM the six constructs are the perceived susceptibility of the individual, the severity of HIV, the perceived barriers to prevention of HIV, the benefits and lastly prompts to actions and self –effectiveness (U.S. Department of Health and Human Services, 2005).
Conceptual Framework
In line with the theory of HBM, this paper reviews literature that point out some or all the six concepts outline in the theory as factors affecting the uptake of couples’ voluntary counseling and testing (CVCT). The literature reviewed in this paper highlight demographic and social factors that are responsible for the uptake of VCT among couples. This paper notes that in a couple, there exists difference in the role allocation, and the overall authority of the partnership. Therefore, in the paper presents cases where the difference in the perceive authority and roles has an influence on the choice of taking up couples voluntary counseling and testing.
This research will highlight the relevant interconnections of couples behavior and whether it matches the concepts and their applications of the Health Belief Model (HBM).
The demographic data on couples and health workers will be obtained and linked to the decisions and reasons behind the decisions given by the respondents of the research. The linkage will give rise to research data that shall then be analyzed to determine whether it agrees to the hypotheses of the research. A discussion shall be offered on the findings of the research in relation to other research findings to determine confirm the hypotheses and are the same as other literature. Unique contributions of the research findings will be highlighted as the outcomes of this study. The graphical representation of the conceptual framework is presented below and adapts to the concepts of the Health Belief Model.
 
 
Figure 1: conceptual framework
 
Research Hypothesis
In line with the Health Belief Model, the hypotheses for this are as follows. There is no significant influence on the choice of CVCT attributed to the gender of the partner other than the roles that each gender has been assigned by their cultures and traditions. Secondly, the social factors affecting couples are responsible for how they perceive the danger of being infected with HIV and their risk profiles of being HIV+. Awareness of the HIV risk is the key driving force for seeking CVCT and programs that are effective in creating the appropriate level of awareness are successful in instilling behavior change among couples. Couple’s social status affects their self-efficacy in changing risky behaviors.
Methodology
Before the study commences, permission will be sought from the relevant authorities governing the study area through the CDC-Ethiopia.
Research Design
The research shall use a cross-sectional design. All individuals attending the six model health centers shall have equal chance of being included in the survey. The study will use a simple random sample of the target population.
Study Population
            The study participants will come from the population of individuals and couples that are attending 6 model site health centers for VCT in Ethiopia. Sample selection will be without replacement.
Data Collection Tools
            The research shall use a survey to collect data. The survey will be conducted once. Survey questions shall be formulated before the actual research and the questions shall be included in the approval application to the IRB.
Open ended survey questionnaires will allow the participants to respond freely and will offer a chance for the surveyor to gain additional insights about the independent variables and how they relate to the dependent variables. Open ended questions also help to determine if the study findings are likely to conform to the HBM model. The survey questionnaires will contain both open ended questions and closed questions. Closed-ended questions will assist the researcher to save research resources such as time by limiting the focus on key research areas. The gender variable will fall under a categorical close ended question. The dependent variables will be examined using a likert-scale question type, which is also a close-ended type. The age of the couple’s relationship together will be gathered using a numerical close-ended questions providing ranges to be chosen by the participants. Close ended questions are reliable because they limit any chance of misinformation on the part of the researcher and in case of categorical questions, choices guide participants on the best available option to fit their answer.
Variables
Independent variables of the study will be the residence of the couples, their occupation and access to information. Dependent variables will be their education background, cultural and traditional roles assigned to spouses in the decision making process. Couples Testing or Couples Seeking Testing will be dependent variables. In addition, the length of time that the couple has been together, the couple’s perceived barriers and support for CVCT and prompts for an affirmative choice for CVCT (existing knowledge of the mechanisms of CVCT).
Residence of couples and occupation will be the independent variable to test the first hypothesis that social factors affect the perceived danger of HIV infection and the decision to take up CVCT. Gender will be the independent variable for testing the hypotheses that cultural roles assigned to spouses have an influence on the choice of CVCT. All independent variables for each hypothesis testing are dichotomous while the independent variables are all continuous. In validating the hypothesis, that awareness is a key factor influencing the choice of CVCT, access to information shall be the independent variable while the perceived barriers and current sexual practices shall be the dependent variable. The table below is a summary of variables.

Name
Type
Role of Variable

Residence of couples
Nominal
Independent

Gender
Dichotomous
Independent

Occupation of the couples
Continuous
Independent

Education background
Nominal
Independent

Cultural and traditional roles assigned
Nominal
Independent

Couples seeking testing
Continuous
Dependent

Length of time couple have been together
Continuous
Dependent
 

Existing knowledge of the mechanism of CVCT
Continuous
Dependent

 
Statistical Analysis
The analysis will begin with basic descriptive statistics to estimate the mean of a variable in the population attending the six model health centers. Therefore, estimate means will be for the level of education, access to information, length of time that couples have lived together.
A multivariate analysis shall be conducted on the collected survey data to control for potential cofounders. Therefore, logic regression shall be conducted to validate the hypotheses. The description of the relationship between to variables shall be done using a tabular analysis of two way or three way tables. The variables included in the tabular analysis will be determined by the hypotheses and research questions of this study. The gender of the spouse will be tabulated with the household income of the couple and the period that the couple have lived together to determine the relationship between the variables. Tabular analysis shall be based on the frequency distribution of the dependent variables for each hypothesis testing.
Under the multivariate analysis, a multiple regression analysis shall use the independent variables like educational background in combination with other independent variables namely residence, period of time that the couples have stayed together, the gender of the spouse with more influence and their occupation. These independent variables shall be used in predicting the outcomes of an independent variable using a least square approach. The predicted outcomes of the independent variables of couples seeking tests, the length of time that the couples have been together and the existing knowledge of mechanisms of CVCT by the couples, as dependent variables shall be selected from the multiple regression analysis prediction. The dependent variables will then be correlated to determine their extent of conformation with the hypotheses and the Health Belief Model (HBM) model fit.
The priori sample is based on the alpha level of 0.05, and four predictors as the independent variable, the study assumes an anticipated effect size (f2) of 0.15 and a desired statistical level of 0.9. From a Priori sample calculation, the minimal sample size of the study will be 98 participants. The 0.15 is a considered a medium effect size for the multiple regression result for the study.
This research is feasible because it uses a practicable minimum sample size of 98. The survey method to be used is also manageable and does personnel to assist in the identification of suitable participants can be sought from health centers to be used as locations for the research. The research will not require payment to be made to participants hence contributing to its feasibility.
Limitations, Delimitations, Significance
            The small sample size of the study might not fully represent accurate facts of the situation in the study area. Another challenge for the study is a denial of permission to conduct the study be relevant authorities governing the study area. In case this happens, then the research will have to be redesigned to comply with the any regulations or be implemented in a different study area. If researchers find out during the preliminary study that the intended study population is overly illiterate then that will pose additional challenges of sourcing more research assistants. Furthermore, a reliance of third party conveyors of information in the case of open ended questions, in the survey, increases the margin of error in recording of responses that may lead to biasness in the data analysis.
This study is significant because it will add on to the literature on CVCT that is currently limited. Most studies analyzed in the literature review concentrated on the individual’s perspective of behavioral interventions. This study, will offer a couple’s perspective on the efficacy of CVCT as a behavioral intervention initiative to prevent transmission of HIV. Other studies on couples VCT have looked at discordant couples and couples already exposed to VCT as individuals. This study will over an outlook of naïve couples on VCT and the social factors that cause or influence their naivety. Lastly, the study will form a foundation on future research on the subject of CVCT and also assist practitioners in designing their programs based on the findings of this study.

References
Allen, S., Karita, E., Chomba, E., Roth, D. L., Telfair, J., Zulu, I., et al. (2007). Promotion of couples’ voluntary founseling and testing for HIV through influential networks in two African capital cities. BMC Public Health, 7, 349-352.
Arthur, G., Nduba, V., Forsythe, S., Mutemi, R., Odhiambo, J., & Gilks, C. (2007). Behaviour change in clients of health center-based voluntrary HIV conselling and testing in Kenya. Sexually Transmitted Infections, 83(7), 541-546.
Betancourt, T. S., Abrams, E. J., McBain, R., & Fawzi, M. C. (2010). Family-centered approaches to the prevention of mothr to child transmission of HIV. Journal of The International AIDS Society, 13(Suppl 2), S2.
Beyeza-Kashesya, J., Ekstrom, A. M., Kaharuza, F., Mirembe, F., Neema, S., & Kulane, A. (2010). My partner wants a child: A cross-sectional study of the determinats of the desie for children among mutually disclosed sero-discordant couples receiving care in Uganda. BMC Public Health, 10, 247-256.
Boeras, D., Luisi, N., Ettaine, K., McKinney, S., Sharkey, T., Keeling, M., et al. (2011). Interminate and discrepant rapid HIV test result in couples’ HIV testing and counselling centers in Africa. Journal of The Internatinal AIDS Society, 14, 18-24.
Byamugisha, R., Tumwine, J. K., Ndeezi, G., Karamagi, C. A., & Tylleskär, T. (2010). Attitudes to routine HIV counelins and testing, and knowledge about prevention of mother to child transmission of HIV in eastern Uganda: a cross-sectional survey among antenatal attendees. Journal of the International AIDS Society, 13(52), 1-11.
Coates, T. J., Ritcher, L., & Caceres, C. (2008). Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet, 372(9639), 669-684.
Concling, M., Shutes, E. L., Karita, E., Chomba, E., Tichacek, A., Sinkala, M., et al. (2010). Couples’ voluntary counselling and testing and nevirapine use in antenatal clinics in two African capital: a prospective cohort study. Journal of the International AIDS Society, 13, 10.
Corbett, E. L., Ethel, D., Matambo, R., Cheung, Y. B., Makamure, B., Bassett, M. T., et al. (2006). Uptake of workplace HIV Counselling and Testing: A Cluster-Randomized Trial in Zimbabwe. PLoS Medicine, 3(7), e238-e246.
Heikinheimo, O., & Lähteenmäki, P. (2009). Contraception and HIV Infection Women. Human Reproduction Update, 15(2), 165-176.
Helleringer, S., Kohler, H.-P., & Frimpong, J. A. (2011). Increasing Uptake of HIV testing and Counseling Among the Poorest in Sub-Saharan Countries Through Home-based service provision. Journal of Immune Deficiency Syndrome, 51(2), 185-193.
Hollingsworth, D., Laeyendecker, O., Shirreff, G., Donnelly, C. A., & David, S. (2010). HIV-1 Transmitting Couples Have Similar Viral Load Set-Points in Rakai, Uganda. PLoS Pathogens, 6(5), e1000876.
Kennedy, C. E., Medley, A. M., D, S. M., & O’Reilly, K. R. (2010). Behavioural interventions for HIV positive prevention in developing countries: a systematic and meta-analysis. Bulletin of The World Health Organization, 88(8), 615-623.
Mayer, K. H., & Pizer, H. (2009). HIV Prevention: A Comprehensive Approach. London: Academic Press.
McKenna, S. L., Muyinda, G. K., Mwali, M., N, N., A, M., Luo, C., et al. (1997). Rapid HIV Testing and counselling for voluntary testing centers in Africa. AIDS, 11(1), S103-S110.
Nuwaha, F., Kabatesi, D., Muganwa, M., & C, W. C. (2002). Factors influencing acceptability of voluntary counseling and testing for HIV in Bushenyi district of Uganda. East Africa Medical Journal, 79(12), 626-632.
Ramjee, G., Coumi, N., Dladla-Qwabe, N., Ganesh, S., Gappoo, S., Govinden, R., et al. (2010). Experiences in conducting multiple community-based HIV prevention trials among women in KwaZulu-Natal, South Africa. AIDS Research and Therapy, 7, 10-14.
Terris-Prestholt, F., Kumaranayake, L., Ginwalla, R., Ayles, H., Kayawe, I., Hillery, M., et al. (2008). Integrating tuberculosis and HIV services for people living with HIV: Costs of the Zambian ProTEST Initiative. 6, 2-9.
Thior, I., Gabaitiri, L., Grimes, J., Shapiro, R., Shahin, L., Kim, S., et al. (2006). Voluntary counselling and testing among post-partum women in Botswan. Patient Education Counselling, 65(3), 296-302.
U.S. Department of Health and Human Services. (2005). Theory at a Glance: A Guide For Health Promotion Practice. Author.
 
Apendice
Appendices
IRB approval
This research aims at finding out the influence that social and demographic factors have on the choice of couples to have couples voluntary testing and counseling.
In line with the Health Belief Model, the hypotheses for this are as follows.

There is no significant influence on the choice of CVCT attributed to the gender of the partner other than the roles that each gender has been assigned by their cultures and traditions.
The social factors affecting couples are responsible for how they perceive the danger of being infected with HIV and their risk profiles of being HIV+.
Awareness of the HIV risk is the key driving force for seeking CVCT and programs that are effective in creating the appropriate level of awareness are successful in instilling behavior change among couples.
Couple’s social status affects their self-efficacy in changing risky behaviors.

The method of research will be a survey on the individuals and couples seeking VCT services in the six model health centers in Ethiopia. The survey shall be conducted only once. This research shall be conducted using administrative assistance from the CDC Ethiopia.
The research questions are:
RQ 1   What is the relationship of occupation type and reasons for testing?
Null:   There is a relationship between professional occupation types and pre-marital reasons for testing.
Alt:      There is no significant relationship between professional occupation type and pre-marital reasons for testing.
 
RQ2    What is the relationship of urban versus rural residence and reasons for testing?
Null:    There is a relationship between urban residence and couples that seek VCT.
Alt:      There is no relationship between urban residence and couples that seek VCT.
 
RQ3: What is the relationship between sex practices and couples that seek VCT?
Null: There is no significant relationship between persons that have a history of a sexually transmitted infection and seeking of couple VCT.
Alt: There is a relationship between persons that have a history of a sexually transmitted infection and seeking of couple VCT.
 
 
 
RQ4    How does mechanism knowledge of Couples VCT influence couples to seek VCT?
Null:    There is a significant relationship between outreach and couples seeking couple VCT.
Alt:      There is no relationship Knowledge between outreach and couples seeking couple VCT.
Recruitment for participants to the survey shall be done by informing the target population through posters and using the staff of the six model health centers in Ethiopia where the study will be conducted.
Sample Survey Questions

Name, Age, Residence and Occupation
How long have you been in the relationship as a couple living together?
How did you hear about this study?
How much income do you get in a month?
What is the portion of your income that you spend in healthcare?
Is the portion of your income spent on healthcare good enough or would you add on it if your income increases?
Do you have any children as a couple? How many?
Do you know the health status of your spouse? How often do you discuss about the health of your spouse?
Does customary law influence the sex discussion topics in couples?
Do you use any protective measures against HIV transmission?
Name the things that affect your decision concerning HIV prevention methods you use.
How would you relate to your spouse if you found out that they are infected with HIV?
Do your religious beliefs affect the way you relate to preventive methods of HIV transmission?
Are there cultural implications of being HIV positive?
Is it correct to undergo counselling with your spouse?
Who is the decision maker in your relationship and how do you make decisions?
Does your place of residence affect your choice of having CVCT?

Reflective Essay
I am grateful for the tremendous knowledge and skills that I have acquired during the session of this course. The course has played a crucial part in increasing my professional writing ability and my thinking capacity. I am now able to look at posits much more objectively than I did previously because of the course. I can make calculated judgments and argue defensively and professionally in favour of my thesis. While previously it was difficult for me to read through research papers and fully comprehend the findings in relation to the methodologies outlined, I can now grasp the concepts with little effort thanks to the hands on practice that this course has provided. As a result, I am able to not only review critically other research papers but can also incorporate their methodologies, hypotheses and findings into new research than I am doing.
            During this session I have completed a preliminary dissertation proposal for the approval of my dissertation topic. I have also completed a dissertation proposal that included various units addressed in the different modes of this session. During the session, there have been several discussions, formal and informal, that have assisted me in the comprehension of the course work. I now understand the importance of a literature review to provide the background of the study and in placing the study topic and objective in the context of existing literature about the subject.
In my opinion, the data analysis section of the course was the most difficult; it would require that I do further practice in that particular area. To enhance the learning experience and accommodate the different ways that students understand the same concept, I feel that there should be more sample lessons on data analysis. This opinion is informed by outcomes of discussions with other students who also expressed similar thoughts on the matter. The efficacy on my study is measurable through the quality of the final dissertation that I submit at the end of the course. My ability to tackle related tasks in future and to comprehend other research papers is also a measure of my learned skill in this session. I feel that I have achieved the course objectives after finishing all the required exercises in this session.
 
 
 
 
 
 


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