2000 ALB: Knowledge, Attitude, Practices and Behaviours Survey on Reproductive Health
Author: Carballo, M.; ICMH
This survey on reproductive and family health in Albania grew out of a growing concern by Albanian national health authorities as well as a number of international organizations, about the growing problem of HIV/AIDS and other STDs, and their possible implications for public health in Albania. Following discussions led by UNICEF, UNFPA and the Ministry of Health in conjunction with UNAIDS, UNDP, PSI, AED and ICMH, a decision was taken to initiate a broader survey. It was decided that the survey should also cover health themes such as reproductive health in general, family planning and family formation, child care and welfare, adolescent health, and drug abuse.
Purpose / Objective
The purpose of the survey would be to provide nationally representative information on :
- how people perceive and behave with respect to family planning and contraceptive use
- what are the main sources of information people turn to with respect to family planning and contraceptive methods
- how do people perceive and behave with respect to HIV/AIDS, STDs and drug abuse
- how do people perceive selected aspects of child care, health and welfare
- what are the emerging health concerns of adolescents
A random cluster sample of the entire country yielded 1,500 people spread over 12 regions/prefectures. Face-to-face interviews were conducted instead of distributing questionnaires because of the public's lack of familiarity with surveys of this kind. A total of 1,451 people were interviewed -- 30 people refused to participate and six interviews were interrupted and not included.
One setback was a major software virus ("love you") destroyed access to the data entry and processing program in Geneva and required that work be re-started.
Key Findings and Conclusions
Women's health: Only 42% of the women in the survey said they had ever had a gynecological examination of any type, and access to such essential services as Pap smear tests was very restricted. Only 34 women said that they had ever had such a test and most of these 34 women lived in Tirana and Durres. As far as breast examinations were concerned, the situation was equally poor; only 23% of the women in the 21-25 year old bracket said that they had ever heard of breast examination, and this was the highest proportion in any age group.
Maternal health: The health care available to women during pregnancy also emerged as an issue of concern. Prenatal care, for example, was very limited. Only 18% of women who had been pregnant said they had been examined in the first trimester of their last pregnancy. Another 45% were not seen until the second trimester, and 37% did not go until the last three months of their pregnancy. Education was a good indicator of this and suggests that antenatal care may be a function of at least two forces, namely the access lower socio-economic groups have to antenatal care services, and/or that it is people with higher education that understand the need to seek antenatal care.
Family planning: The proportion of people who said their last pregnancy was desired at the time was relatively small and is indicative of the poor in-roads that family planning services appear to have made in Albania. In general, the regular use of family planning methods was low and only 17% of those who were surveyed said they used them. Of the methods they did use, condoms were clearly the method of choice and those that used them were well informed about their advantages as a contraceptive device. Contraceptive pills were the next most frequently mentioned method followed by natural methods such as withdrawal. In general, family planning using modern contraceptives increased with education. Thus, while only 21% of people with no more than 8 years of schooling said they practiced contraception, the proportion rose to 50% by the time they had completed high school.
Where people go for family planning methods: The role of pharmacies as a successful outlet for family planning methods was evident in the survey and 40% of all respondents said this was where they would go or actually did go to get them. Other outlets such as hospitals and family planning clinics were relatively rarely mentioned and health care practitioners even less so.
Sexually transmitted diseases (STDs): The question was only asked of men, and only 45 men actually said they had experienced the particular symptoms that were cited by interviewers. This may reflect resistance to discussing the matter publicly as much as it reflects the true prevalence of the problem. Of those that did respond, most were in the 21-30 year old age group. Significantly, only 16 of them said they had sought medical advice/treatment and, of those that had, single men with at least eight years of education were most likely to have done so.
HIV/AIDS as a problem in Albania: In response to questions concerning the main health problems facing Albania today, approximately a third mentioned AIDS; most were under the age of 30 and 70% lived in urban districts. Only 6% of the people aged between 46-50 referred to AIDS. Among those that did not mention AIDS, cancer, heart disease, influenza, bronchitis and hypertension were the five most referred to problems in that order. Far more (53%) people had heard about the disease but again the same profile emerged, with younger people living in urban areas being far more aware of the problem than older people and people living in rural areas. Most people said they had heard about HIV/AIDS from the television.
How do they see the risk of getting HIV/AIDS: Although the level of awareness about HIV/AIDS was high, there were many misunderstandings about how HIV is transmitted from one person to another. For example, almost 26% of the 1041people that responded to the series of questions about the risk of HIV transmission thought that shaking hands was very or moderately risky, and 69% thought that having sex with someone who has HIV/AIDS even with a condom was equally risky. Slightly more than 60% of the respondents saw using public toilets as very or moderately risky as well. Of particular importance, given its implications for hospital care, was the fact that donating blood was also seen by 83% of people as very or moderately risky, and 96% said receiving a blood transfusion was also very risky.
Who knew someone with AIDS: Altogether, 48 people said they had known someone with AIDS and it is significant that of these 48 people, 23 had lived abroad for a period of time. In general, a large proportion of the survey population, especially younger people, nevertheless said they were very or moderately worried about getting HIV/AIDS and 194 people said they had friends or relatives who they thought should change their behavior to avoid getting the disease. Most (86%) were under the age of 40 and over a half of them were under the age of 30. Even in the youngest age group, namely 15-20, 19% said they knew someone who should take action to avoid getting HIV/AIDS. Even so, 14% of people in the youngest age group said they had never talked with relatives about the problem and another 17% said they had probably spoken about it no more than "once or twice".
Child welfare: There was a strong awareness of the problems facing children today in Albania. When asked to list the three most important challenges, health emerged as the single most frequently mentioned problem, followed by education and economic opportunities. In general, parents were also inclined to see children delay entry into the work force, and 54% of parents opted for delaying it until the age of 18-20, with even longer delay for girls.
The role of media: Despite the fact that only 37% of the population had a television, 93% said they managed to watch it every day, and television was, by far, the medium most people referred to as a source of information on family planning and HIV/AIDS. It was also the medium that a majority of people considered the most appropriate for diffusing information on these matters. Radio was less popular than television and only 57% of respondents said they listened to it on a daily basis. Of the three main media, newspapers were the least popular, especially among people with low levels of schooling and young people. Even in Tirana and Durres, only 21% of the respondents said they read newspapers every day and in more rural areas such as Bulqize, Delvine and Devoll, nobody said they read them every day.
Migration and migrants:
These populations need to be targeted with special services, especially reproductive health care services. Given the growing problem of STDs in many parts of Eastern Europe and the pressure on people to move within and outside of Albania, more needs to be done to ensure that people on the move in Albania are provided with relevant and timely information about the health risks involved. In particular, more needs to be done to inform migrants and would-be migrants about the risk of STDs/HIV and ways of preventing them.
Health of women:
In view of the very low number of women having access to gynecological examinations and Pap smears, more attention must be urgently given to meeting the needs of women. The use of mobile units that could cover rural as well as urban areas with information, screening, and clinical care and treatment merits consideration. In addition, more training of community-based health staff may be needed so that they can undertake more outreach work than is currently being done for women during pregnancy. Primary reproductive health care will have to be strengthened through more training, better transportation and the equipment needed to fulfil this type of work.
On the whole, there was little evidence that family planning has made the type and degree of in-road required in Albania. This is regrettable given what appears from the survey to be a relatively open-minded society. Some of the limiting factors evident in other societies, such as the adverse reactions of parents and relatives, have apparently not played a negative role with respect to family planning in Albania, and much more could be done to promote this health theme. In this regard, the strengthened role of pharmacies is mentioned elsewhere in these recommendations as one of the ways of reaching out with information, advice and counseling on family planning. In addition, there should be more social marketing of family planning through the media and through schools.
Awareness about HIV/AIDS was high. But, just as in many other countries, this awareness was not necessarily accompanied by factual knowledge about how the disease is and is not transmitted, and this could create unnecessary problems. Thus, much more attention needs to be given to HIV/AIDS education so that any misunderstandings can be avoided while, at the same time, exploiting the already present concern that exists in the population about the possibility of contracting the disease.
Television should be used more aggressively to provide information on health in general and reproductive health in particular. Given that there appeared to be a tendency for television to be less popular in some rural areas, more market research is now called for to determine if this is due to poor access to television sets or whether it is due more to the acceptability of program content. In either case, steps should be taken to improve the coverage that is already provided by current television and radio networking, and ensure that both television and radio carry much more information about health and health care, especially reproductive health care and family planning.
This KABP survey has highlighted a number of themes and issues that call for more research leading to promotional and planning initiatives designed to improve coverage by health care activities. There is also an evident need to monitor the evolving situation in Albania and to evaluate the impact interventions may have on the emerging health and social situation. In addition, however, much could be gained by undertaking in-depth studies as soon as possible to gain a better understanding about the factors and conditions motivating people, and their felt needs with respect to health and health care.
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