ASSESSING THE RELATIONSHIP BETWEEN ATTITUDE AND AWARENESS REGARDING HIV/AIDS USING CANONICAL CORRELATION ANALYSIS.

Bushra Shamshad and Maria Ejaz. Department of Statistics, University of Karachi, Pakistan. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 05 February 2019 Final Accepted: 07 March 2019 Published: April 2019

The objective of this study is to explore the relation between awareness regarding HIV/AIDS transmission and attitude towards the infected person using canonical correlation analysis. A survey was conducted in Karachi to accomplish the given objective. Initial analysis reveals that all though respondents were aware of mode of transfer of HIV/AIDS but still they have some misconceptions. Two canonical correlation has been retrieved as asymptotic statistical significance test for canonical correlation (approx. F for Wilks Λ) is significant only for two canonical correlation. Results show that students have sufficient knowledge regarding the HIV/AIDS transmission and this awareness leads participants to have sympathetic feelings for infected person.
HIV attacks on human immune system; especially CD4/T cells (infections fighting immune system cells). Once HIV attacks to a human body it reduces CD4/T cells, as immune system becomes weak and human body easily gets other infections or infection-related diseases. Time after time HIV destroys the number of CD4/T cells and the person can't fight off infections and diseases. The weak immune system indicates the person has AIDS, which is last stage of HIV infection. HIV is transmitted through the exchange of body fluids from infected individuals such as blood, breast milk, semen and vaginal secretions. These are enduring myths that HIV can be transmitted through shaking hands, hugging, kissing, sharing personal objects, food or water, coughing/sneezing, sweat, sharing clothes, and insects' bites (HIVgov(2019)). Inadequate knowledge can leads to misperception of disease among people.
First case of HIV was found 39 years ago in west-central Africa (Sepkowitz (2001)). HIV is the world's most serious health problem. It is reported that 1.9 million People died from AIDS in 2004, 1.4 million in 2010 and 940,000 in 2017 (HIVgov(2019)). Among all over the world African Region is the most affected region, where 25.7 million people were living with HIV in 2017 and it is also two thirds of the global total of new HIV infections (WHO (2019)). First HIV case in Pakistan was noticed in Karachi in the year 1988 and it was caused due to blood transfusion (Vermund et al. (2006)). In 2017, UNAIDS has reported that in Pakistan, HIV estimates for adults and children are 150,000 (130,000 -170,000), while adults, women, men aged 15 and over living with HIV are 358 140,000(130,000 -160,000), 43,000(38,000 -49,000), 99000(87,000 -110, 00) respectively whereas children aged 0 to 14 living with HIV is 3500(3000-4000). HIV prevalence rate for adult aged 15 to 49 is 0.1 (0.1 -0.1), whereas HIV prevalence rate for women and men aged 15 to 49 are <0.1(<0.1 -<0.1) and 0.2(0.1 -0.2) respectively (HIVgov (2019)).
Currently no effective cure /medicine are discovered for HIV but it can be controlled with proper medical care. Antiretroviral therapy or ART is used to treat HIV. Proper usage of this medicine keeps the HIV infected person healthy, and reduces risk of infections. In 1990s when ART was not introduced HIV used to cause AIDS in few years while now a days HIV diagnosed patients when treated with ART live healthy and active till as long as an healthy person.
Literature Review:-HIV/AIDS is major worldwide health issue. Outbreak of HIV/AIDS is increasing every day globally. According to UNAIDS in 2017, AIDS cause about Less than 1 million deaths every year and 39.7 million people were living with this infection globally. As HIV/AIDS is worldwide problem therefore, many studies in different region have been conducted. Choudhary et al. (2015), conducted study among undergraduate students in Irish university and showed that students had adequate knowledge of HIV/AIDS but had misconception regarding AIDS transmission through mosquito bite. Same result was found in Inungu et al. (2009) research which was conducted in Midwestern University, United States. Choudhary et al. (2015) study also revealed sympathetic behavior of students towards the infected. Asante and Oti-Boadi (2013) conducted study in Ghana, South Africa, and revealed that although students were aware of HIV/AIDS transmission but could not indicate that HIV is the main cause of AIDS. He also found the significant difference in HIV/AIDS knowledge between genders, as female had more knowledge than male. Which were consistent with Aluede et al. (2005) findings, that was carried out in Nigerian university for undergraduate students, they proved that male and female differ in knowledge regarding AIDS given that they had adequate knowledge but their findings revealed that male are more knowledgeable than females. These two studies are inconsistent with Pakistanis. This study revealed that majority of Pakistanis are aware of HIV infection but they have not screened for HIV, because they believe that the main reason of HIV/AIDS transmission are pre/extra marital and homosexuality, and in Islam these practices are impermissible. Therefore, Pakistan being Islamic country has less chance to develop this disease.
Research of Khan et al. (2008) at Peshawar, Pakistan, showed the satisfactory knowledge among the medical students. He found the non-medical students lack in awareness therefore he suggested that HIV awareness should be the part of our education programs for both medical and non-medical students. Mustafa et al. (2018) conducted research in four different educational institutes at Lahore, Pakistan and showed the same results that elder age, female gender and medical students have higher knowledge regarding the AIDS/HIV.

Discussion:-
The study was conducted to evaluate the knowledge among students from various universities in Karachi accruing degrees in various fields like, pharmacy, dentistry, chemistry, physiology, psychology, engineering, clinical pathology, medicine, computer science, finance, statistics etc., regarding a viral disease HIV/AIDS. Conventional sampling was done to collect the data. Through a questionnaire consist of 20 questions. In a sample of 257 respondents, 68% females and 32% males were participated. The respondent's age mostly varies from 16-29 years, having few outside this range. Among them only 13% claim that they can recognize the person having HIV by their physical appearance. Whereas, almost 51% cannot recognize the person. The study showed that the students have partial understanding regarding HIV/AIDS transmission as although a reasonable proportion of students are able to identify main cause of HIV/AIDS transmission but have misconceptions too of correctly identifying the causes.
Many multivariate test are available in different software for the significant of canonical correlation. Many criteria are used to test the relation between independent and dependent set of variables, which includes Wilks' lambda, Lawley-Hotelling statistics, Pillai's test, and Roy's. F-Approximation are calculated for all above four statistics to test the significance of canonical correlation (Hair et al. (2005); Rencher (2002). Cross loadings and loadings/ canonical structure correlation are considered important for interpreting canonical correlation (Sherry & Henson (2015)). Canonical loadings are the correlation between original variable and canonical variate. Whereas, cross loadings are the correlation between original dependent variable and independent canonical variate, vice versa is also true for above cases. Those variables are considered significant whose loadings are greater than 0.3 as it indicated that original variable shared 9% of variance with canonical variate (Lambert & Durand (1975)).

Results:-
The missing values in the data set are replaced by using a multivariate imputation by chained equations (mice) package (Buuren et. al (2019)) in R software. The package include following four different methods to impute missing values. 1) Linear regression for continuous data 2) logistic regression for categorical data with two levels 3) Bayesian polytomous regression for categorical data with two or more levels and 4) proportional odds model for ordered categorical data. This package first, impute the missing values n times and then pool the results of n completed data sets. Then it stores the imputed values. Once the missing values are replaced we applied the canonical correlation technique to find the relationship between awareness about HIV in the society (independent set of variables) against behavior of individuals towards the infected persons (dependent set of variables).
The Cronbach's for 32 items in the survey give a value 0.583 in order to test the reliability of the survey. The value increases from 0.583 to 0.641 after deleting age variable. Table 2 shows the significance test for entire model. All p values are less than 0.05 which rejects Ho and indicates that there is a relationship between two sets of variables. Table 3 shows the canonical correlation for canonical variates. Table 3 displays that first canonical correlation can explain 17.41% of variation in dependent set of variables due to independent set of variables, and second canonical correlation can explain 11.13% of variation in dependent sets by independent variable sets.    Table 4 depicts the significance test for canonical correlation. It has been proposed that number of canonical correlations are equal to the smaller number of variables in both set (dependent and independent sets), therefore only 6 functions are derived. Only first two canonical correlation are significant (i.e. p-value <0.05), therefore only two canonical correlations will be retrieved for further analysis. Table 5 shows the structural loadings regarding HIV/AIDS awareness and behavior towards infected person. This table reflects that the most important variables for the prediction of behavior towards infected person in first canonical variates are   Table 6: Labels Assigned to Variables for Figure 1 In Fig 1, graph (a) shows the representation of variables on two sets of canonical function and graph (b) shows representation of individual participant on two sets of canonical function.
It can be observed from graph (a) that all variables of behavior towards HIV/AIDS infected person have impact on both canonical functions within circle of radius 0.5. Infected deserves good job (q16d) has significant influence on second canonical function. Whereas, infected bears a bad character (q16a) has significant impact on first canonical function.
Among the variables of HIV/AIDS awareness, transmission of AIDS by blood transfusion (q7b) and through mother to unborn child (q7c) have significant impact on first canonical function. Transmission of AIDS through sharing toilets (q7e) and through sexual interaction (q7a) have greater impact on second canonical function.
Transmission of AIDS through mosquito bites (q7j) has no impact on either of canonical function. Transmission of AIDS through sharing sharp objects (q7d) has almost same impact on both canonical functions.

Conclusion:-
This research shows that students have adequate knowledge regarding the HIV/AIDS transmission as percentages for correct mode of transmission are sufficiently high but students also have some misconceptions regarding the mode of HIV/AIDS transmission. It has been observed that 39% students believe AIDS can be transmitted by sneezing and coughing. This is the highest percentage among all misconceived variables for HIV/AIDS transmission. It is proved from canonical correlation analysis that adequate knowledge regarding HIV/AIDS leads sympathetic attitude towards the infected. As students have false conception regarding the HIV/AIDS transmission, 365 therefore it is recommended either to conduct workshops on the awareness of HIV/AIDS transmission or incorporate some modules related to HIV/AIDS awareness in educational programs.