The present study is part of a larger three-phase project to improve the awareness about HIV/AIDS transmission pathways and prevention measures in occupational settings in Ecuador. Several national reports have persistently indicated that the company environment has been a major factor in the spread of the disease in the country. The present work reports on the first phase of the project, namely to estimate HIV/AIDS transmission and prevention measures knowledge among company workers by means of a cross-sectional study in three provinces and three working sectors. Based on the outcome of that study, a second phase is planned to develop an educational prevention program specifically designed for companies. The third phase is intended to assess the impact of the educational intervention phase on workers’ knowledge about HIV/AIDS.
To estimate the prevalence of transmission knowledge, three questions from the “Behavioral Surveillance Surveys – Adult questionnaire” were selected which provide pertinent information on the misconception of how the disease actually spreads in the population as demonstrated by another study . In addition, prevention measures knowledge was evaluated by means of consistent condom use and mutual monogamy, the most important primary ways of avoiding HIV infection among sexually active men and women. The indicator of prevention measures knowledge is particularly useful in countries where knowledge is not high (as in Ecuador) to evaluate an educational intervention impact . According to the 2011 UNAIDS Report, the effectiveness of an HIV intervention program is strongly related to improved knowledge and practice of preventive measures relating to HIV and sexually transmitted infections in the general adult population as well as in youth and vulnerable population sub-groups . The present study used the original version of the Family Health International questionnaire. All subsequent versions of this questionnaire developed after 2000 maintained the same basic concepts and included modifications based mainly on local additions rather than altering significantly the established questions.
Clearly the proportion of workers with a lack of knowledge about HIV/AIDS in this study was high: 46.6% for transmission of the disease and 32% for prevention measures, respectively. Only 35.7% of the participants answered all five questions correctly. Risk factors were almost the same, namely male gender, older age, low education level and manual labor. By contrast, married status and previous exposure to an intervention program were protective and associated with better knowledge. The results of the “HIV/AIDS Linea de base” study sponsored by Global Fund in Ecuador in 2007 which focused on incorrect beliefs about forms of HIV transmission among men who have sex with men (MSM) and sex workers, were similar to those of the present study (good transmission knowledge: MSM 58.8% and sexual workers: 46.5%) . The main objective of that study was to establish the prevalence of HIV/AIDS among MSM and sex workers. The results regarding HIV prevalence were interpreted cautiously because of potential biases in the selection methods . The results regarding knowledge, however, were accepted and published by the Public Health Ministry of Ecuador (MPHE). Another study, the “Equidad Study” in 2006 (n = 261), revealed similar trends but was also conducted among the MSM and sex worker population and included only 2 questions about transmission knowledge (condom use: 78.2% and fidelity: 64.8%). Other studies conducted by the Ministry of Public Health of Ecuador to estimate the prevalence of HIV, namely in college students (ESPOCH, 2007), in sex workers (Red Trab Sex, 2007) and in MSM (CEPAR 2009) are worth mentioning but provide limited information on the topics discussed here . To the best of our knowledge, there are no studies that have focused on the working population.
This is the first study carried out in Ecuador focusing on HIV/AIDS knowledge in companies. As mentioned, companies are structures employing a wide spectrum of workers with respect to demographic characteristics, professional experience, family and social relations. Thus targeting company workers may be seen as an opportunity to reach a much wider population of subjects. “Care International” in Ecuador has a program in occupational settings implementing policies to avoid discrimination against HIV positive workers but no studies have been conducted to assess knowledge about HIV/AIDS transmission and prevention measures. It has been working with 470 companies in the 17 most important cities of the country; as a result, in 2009, 54% of these companies had implemented nondiscrimination policies . In 2007, the International Labor Organization implemented a program in Peruvian companies to enhance knowledge regarding HIV transmission but the results of the intervention are not available yet . In Chile, the study “HIV/AIDS knowledge and occupational risk in primary healthcare workers from Chile” evaluated the level of knowledge about HIV transmission and reported that 63.8% of healthcare workers had an appropriate level of knowledge, which is 10% more than the subjects in the present study . Most studies implemented in other Latin American countries with similar socioeconomic profiles as Ecuador were conducted in healthcare institutions among healthcare workers. A study among truckers (2009) in Morobo, Sudan (n = 300 aged 15–50 years old) reported that HIV prevention measures knowledge was very high (93% of condom use and 89% faithful with uninfected sexual partner). By contrast, their prevalence of HIV transmission knowledge was lower: 99.3% had misconceptions about HIV transmission by mosquito bites, 87.3% held incorrect beliefs about transmission by sharing a meal, however only 2.9% of respondents had the misconception that a healthy looking person cannot transmit HIV. The differences between HIV transmission and prevention measures knowledge is striking . Another report in Sudan in the Lakes States (n = 3,326) registered that 36% of female subjects (15–49 years old) had accurate knowledge of HIV transmission and prevention measures, which is similar to the present study. However, more than 2% of Sudan’s population is HIV infected and the intervention programs are well developed . A study among health care providers reported that 72% had HIV/AIDS general knowledge (HIV virology, transmission, symptoms, prevention strategies and risk assessment) in Tanzania . More than 5% of adults in Tanzania were HIV infected and the disease seems to have stabilized over time. Another study in health care workers in Tamatave (Madagascar) reported a low HIV general transmission knowledge (18%) in 2002 . In contrast to Tanzania, in Madagascar HIV cases increased every year but other factors such as low education, poverty, limited access to health and social services, high rates of partner change, and an increasingly transient population haven’t helped efforts to stabilize the epidemic.
The present study suffers from a number of limitations. The database of the “Superintendencia de Companías de Ecuador” does not contain all existing companies in the country, so that a substantial portion of the more informal companies has not been considered. In addition, despite a careful selection procedure, participation in the study was always on a voluntary basis. Therefore, the impact of factors such as education level, questionnaire fear or religious convictions is difficult to assess but should not excluded. Major efforts have been made to recruit the initial number of companies and hence to reach a large representative sample of workers, in particular by respecting the proportions of workers in the various job categories. It is clear that the material and financial resources of the companies and also their working sector (commerce, manufacturing or real estate) can influence the educational level of their workers. Therefore, the proportion of workers with a low education level in the study population may be notably underestimated. The study has been limited to three provinces; Pichincha, Guayas and Azuay. Guayas is one of the most populous provinces of Ecuador and its harbor, Guayaquil, is a main access point to outside world. Pichincha is the province of the capital, Quito, and a central commercial city in Latin America. Finally, the Azuay province with its capital, Cuenca, is more remote and close to the Amazonian region of the country, less exposed to HIV/AIDS progression. Thus, the three selected provinces should give a fairly good, although not perfect, picture of the country. Finally as already mentioned the working sectors considered in this study assemble the largest number of companies in Ecuador and also employ the greatest number of workers.