Congestive heart failure (CHF) is an inability of the heart to supply/pump blood to the body as it needs in normal. CHF is an acute illness and a chronic disease in which the passage of time may cause other physical and psychological diseases that poses a threat to the health of the patient, and may be the cause of life limiting (American Heart Association, 2010). This indicates the poor quality of life of the patient, exacerbating health problem. Hence, those patients need to attend palliative care to improve the quality of life.

Palliative care for CHF patient is very important to relive or prevent the pain which may be able to be cause physical problems such as (respiratory disorder and sleep disorder) or psychological problems such as (depression and anxiety). Palliative care is supportive care which provides physical support, psychological support, spiritual support and social support and that is to provide the best as much as possible to improve quality of life (Davidson, Macdonald & Newton, 2010).

How can you help and support Verner from the palliative care perspective?

From the case Mr. Verner has complaining from several problems related to his state of physical, psychological, social and spiritual. In the beginning I have to consider appropriate place of care either in hospital or at home if there is sufficient support in all ways (Patient UK, 2010). Then I’ll start with him a comprehensive assessment for his situation from perspective of palliative care includes the physical and psychological, social, cultural and spiritual (existential). Mr. Verner has advanced heart failure or end stage heart failure where can be identified the stage according to Dunderdale, Thompson, Miles, Beer & Furze (2005) by the New York Heart Association (NYHA). In addition NYHA can assess a variety of the physical symptoms and restrictions. An important aspect of Mr. Verner management is communication and listening, exploring his understanding and feelings about his illness. Exploring concerns about the future can provide opportunities to discuss death and preferences for end of life care (Jaarsma et al., 2009). There are physical and psychological complications caused by CHF. For example Mr. Verner case: he does not sleep at night because he has trouble breathing, probably he has pulmonary congestion/pulmonary edema because according to (American Heart Association, 2010) pulmonary edema is one of the complications of CHF. So, medical intervention is needs in order to address the symptoms experienced by the patient, because medical care is very important to reduce patient stress and anxiety. Providing support through effective communication, skills may lift the moral of the patient. During communication I have to be honest and fidelity also in dealing with this patient must be show kindness, compassion and respect.

In order to helping Mr. Verner from the palliative care perspective I have to provide a good palliative symptom management, psychological, spiritual and social support will provide hope and reassurance. Emotional and social support is very important aspect for CHF patient. Where the presence of family, relatives and friends around of the patient would be a very strong supporter to improve the psychological status of the patient and reduce depression, anxiety, social isolation and loneliness (Jaarsma et al., 2009). I’ll ask the provider of Social Work to communicate with family members to provide the counseling and patient needs from social services. Also the family members should be encouraged in participating with palliative care team to more improve in the physical care for the patient. Moreover, he may benefit from a referral to social services and district nursing. Liaison between his primary care team and the local palliative care team is strongly recommended and Mr. Verner could be given contact numbers for the palliative care services. Hospice care for further social support and respite may be beneficial.

Providing spiritual support is one of the important aspect of palliative care whether from family or from clergy, to encourage and support the patient to let him look to the future with optimism and live with his society and daily activities in comfortable manner until he dies (Becker, 2010).

Which problems and needs can you identify?

From the case it shows to me Mr. Verner suffering from physical and psychological problems which include:

Heart disease is the main cause of worsening of his situation and increase physical problems that are:

According to Scherer et al., (2005) lack emotional and social in patients with CHF makes the psychological problems in evolution as experienced by Mr. Verner:

Physical problems

Nausea,Vomiting

Vertigo all the day time

Decreased appetite

Lack of energy

Trouble breathing

Cough in night

Sleeping disorder

Psychological problems

Depression

Anxiety

Social isolation/loneliness

Hopelessness

Fear of death

Nursing diagnosis:

Decreased cardiac output related to decreased myocardial contractility.

Impaired gas exchange related to lung congestion resulting in trouble breathing and cough in night.

Nutrition imbalanced less than body requirements related to nausea and vomiting.

Fatigue related to lack of energy.

Disturbed sleep pattern related to trouble breathing.

Ineffective coping related to chronic illness (Berman, Snyder, Kozier & Erb, 2008).

Patient’s needs:

Information about the disease process, treatment and general advice on what to do and what not to do.

Physical support and managing symptoms to relieve/reduce suffering and improve general health for live comfortably.

Emotional support to reduce the psychological symptoms, where the presence of family around him will be a catalyst for this support.

Social services to provide equipment such as stair lifts, ramps, commodes and information about packages of care.

Enhance the care, improve quality of life and provide end life care with respect culture (customs and traditions), dignity, beneficence, sympathy and empathy.

Make a nursing care plan for Verner. Explain and motivate your suggested nursing interventions in accordance with the four key areas listed in the introduction.

Patient with end stage of heart failure may present with a variety of symptoms, which are similar to patients with advanced cancer (Matzo & Sherman, 2010). A detailed history, physical examination, investigations and establishment of patient priorities will help in the management of their symptoms and improvement of quality of life. An accurate drug history is important due to the nature of complex drug regimens. The difficulties of coping with unwanted drug side effects may cause patients to be afraid to report their non-concordance, which may precipitate hospital admission. Common physical symptoms are fatigue, pain, breathlessness, dizziness, cachexia, anorexia, nausea, insomnia, difficulty in walking, constipation (Jaarsma et al., 2009).

Communication skills are very important part in palliative care between palliative care team and patients and their families. There are small things, but significant that matter to the patient and family such as: a clean, well-pressed uniform; neat and tidy hair; an upright posture; a smile; appropriate eye contact respecting gender, age, culture or disability; a clear introduction of self and most important of all: an attitude that reflect my positive interest in them as a person (Becker, 2010). Also during communicating with the patient must repeat the information. It is possible because poor cerebral blood may lead to confusion and memory problems (Patient UK, 2010).

PHYSICAL SYMPTOMS

SYMPTOM CONTROL

Trouble breathing, Cough in night and Sleeping disorder

INTERVENTIONS (N) AND RATIONAL (R)

Initial

(N) Check vital signs, heart rate, blood pressure and respiratory rate depth. Observe if any wheezes and crackles in lung bases or edema.

(R) This assessment will be noting and presence of fluid in the lung with change in heart and respiratory rate (Lewis et al., 2007).

(N) Administer O2 and put patient on semi follower position.

(R) Over volume is increased in the heart failure patient so, it results in jugular vein distention and increased hepatojugular vein also (Morton, Fontaine, Hudak, Gallo, 2005).

(N) Control pain if any, discomfort feeling.

(R) Patients may experience chronic pain such as oedematous limbs or osteoarthritis, or as a result of previous heart surgery (Morton et al, 2005).

Ongoing Monitoring (N) Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, respiratory status and urinary output (Berman, 2008).

Nausea, Vomiting, Decreased appetite and Lack of energy

(N) Encourage the patient to eat the liquid food use a small amount of alcohol.

(R) Could be good method to stimulate appetite and improving mood and general self esteem (Berman, 2008).

(N) (Dehydration) Observe skin or mucous membrane dryness and edema. ( Ongoing Monitoring ) Monitor urinary output.

(R) Occurs most often with CHF patients. Hypovolemia fluid shifts and nutritional deficits contribute to poor skin and edematous tissue (Morton et al, 2005).

Ongoing Monitoring (N) Help patient to do daily activities such as using a wheel chair.

(R) Patient needs to fully care of and need someone to help him in accomplishing daily activities at least to feel satisfied (Lewis et al., 2007).

The main symptoms related to the case that require specific interventions of the palliative care team

Causes and effects on CHF patient’s

Managing symptom

Fatigue

CHF patient’s feel constantly tired and lacking energy. The main factors contributing to fatigue are: abnormalities in skeletal muscle due to reduced perfusion and neurohumoral changes; the side effects of medications; reduced activity; anaemia; lack of appetite and muscle wasting (Scherer et al, 2005). Fatigue causes reduced quality of life because it severely restricts patient’s activities and creates difficulties in walking and getting out of the house. In the end stages of heart failure even managing personal hygiene and dressing can be difficult. Fatigue can also compound other physical symptoms such as constipation, oedema and pain (Davidson et al., 2010).

Access to exercise programmes may be of benefit to reduce fatigue and can give patients greater sense of well being.

Explanation to the patient and his family about the physiological causes of fatigue can help them understand what they are experiencing and referral to occupational therapy of physiotherapy for advice on energy conservation and exercise can be useful. Education about healthy eating and correcting anaemia can also be beneficial (Jaarsma et al., 2009).

Breathlessness

Commonly caused by pulmonary oedema due to failing left ventricular function or sometimes due to anaemia. Other causes such as chest infection should not be overlooked. Anxiety, depression and inactivity can also contribute to breathlessness (Davidson et al., 2010).

Increasing diuretics is the first line treatment for breathlessness due to increasing congestion and providing by Respiratory Consultant. Home oxygen may be useful for patients with daytime low blood oxygen saturations. The use of breathing and relaxation exercises can help reduce the anxiety, which often accompanies breathlessness (Davidson et al., 2010).

PSYCHOLOGICAL (EMOTIONAL) SYMPTOMS

Causes and effects on CHF patient’s

Managing symptom/ Management

Diagnosis of heart failure may make emotional stress. Depression, anxiety, social isolation and loneliness are common symptoms experienced by patient with end stage heart failure. The lack emotional and social support is an important predictor of morbidity and when patient become isolated and lack the ability to cope with his disease this can also be a significant predictor of mortality (Jaarsma et al., 2009). A patient’s experience of depression is often compounded by their physical symptoms. Psychological symptoms are can reduce quality of life. Mr. Verner says: “I am not my disease”, which can hinder hope for the future. From my experience when I give an opportunity to the patient as Mr. Verner condition, certainly will talk about dying. Fears of how he may die? How of pain?

Emotional support is important for the patient. Effective communication with patient and his carer is needed from diagnosis and throughout the course of the illness. To maintain hope, patients can be offered good palliation of their symptoms and exploration of their preferences for care. Information needs to be available about the disease process, common feelings experienced and local social support services. Referral to psychology services or counselors may be required and some patients may benefit from an antidepressant (Jaarsma et al., 2009). Tricyclic antidepressants are not usually advised due to their pro-arthymic side effects. Selective serotonin reuptake inhibitor antidepressants (e.g. fluoxetine 20 mg once daily) are more commonly prescribed (Morton et al., 2005).

SOCIAL AND FAMILY SUPPORT

Causes and effects on CHF patient’s

Management

Social and family support is very important element, which engaging social services are a high priority may affect adversely on some psychological problems such as social isolation, loneliness and sadness etc. Specifically the social aspect may be involved in the following problems: financial status, capacity to self care, adherence with lifestyle and carer burden (Davidson et al., 2010).

Mr. Verner misses his children and grandchildren because he does not have energy to talk on telephone. And that make him in bad condition.

Social services to provide equipment such as stair lifts, ramps, commodes and information about packages of care; District nurses for assessment of symptoms and support. District nurses are often not aware of patients living with CHF until they become hospitalized; Community physiotherapy and occupational therapy for assessment and advice on exercise, energy conservation and home adaptations to aid in activities of daily living; Benefits advice patients may be eligible for disability or attendance allowance (Dunderdale, Thompson, Miles, Beer, & Furze, 2005).

And assist in communicating with family and give advice to family in order to be near Mr. Verner, even if the move to live with his children. The presence of family, relatives and friends around of the patient would be a very strong supporter to improve the psychological state of the patient and reduce depression, anxiety, social isolation and loneliness.

SPIRITUAL (EXISTENTIAL) SUPPORT

Spiritual support is an important aspect in palliative care. CHF reflected a gradual loss of identity and increased dependence and his illness make him incapacitate. Where it feel’s the burden on society and loses a sense of worth and meaning. Some patients have religious beliefs and feel comfortable than other patients who blame the Lord and say, Where is all this time? Why the God made me like this case? (Christian medical fellowship, 2011).

Spiritual support is provided by a clinically certified interfaith chaplain and a qualified by the palliative care team. And chaplain role in this is to restore hope and existential then make the patient to cope the reality (University of Iowa Hospitals and Clinics, 2011). And small things will make Mr. Thomas in happiness or make a huge difference, such as to bring his cat or a visit from a close friend or inspiration in art, poetry, music (Becker, 2010).CONCLUSION

Patients with CHF often experience a multitude of symptoms that affect adversely on their general health therefore it may happen to them to get sudden death. Participation with palliative care team is necessary to reduce the symptoms, provide the best as much as possible to improve quality of life and provide end life care with dignity. Nursing care plays an important role in the teamwork for patients with CHF, which can addressed with a variety of interventions, to relieve physical and psychological suffering, including treatment of pain, breathing difficulties and sleeping disorders. Communication is very important between palliative care team and patients and their families to adoption key work of care approach could improve patients’ access to appropriate palliative care. In addition, good communication between all those caring people for the patient in both primary and secondary care is essential. However, palliative care needs to be accessible early in the disease beginning because in the advanced stages patients may had worsened their health and then the team cannot provide the desired care. Finally I choose this case because I think the palliative care process as a practice in health part just for cancer patients but after dealing with Mr. Verner case I add to my nursing knowledge more specialized skills about the palliative care.

INTRODUCTION

The organ responsible for producing insulin is call the pancreas when the immune system begins to destroy cells within the pancreas called betta cells the hormone responsible for converting carbohydrates into energy no longer exist and a chronic autoimmune condition call Type 1 diabetes (T1D) is established. The daily regime of someone living with T1D involves the management of multiply daily, blood glucose monitoring, insulin injections and dietary management. Those living with T1D need to be attentive of hyperglycaemia which is when you experience particularly levels of high blood glucose or low blood glucose levels known as hypoglycaemia. The serious long term health complications associated with TID are hard to comprehend as a teenager as quite often they are living for the here and now. Many trials have been conducted over the years by the Diabetes Control and Complications Trial research group (DCCT) and have been able to establish that with intensive management complication such as; retinopathy (blindness) kidney disease, heart disease, neuropathy and vascular disease can be reduced (DCCT/EDIC Research Group, 2016).

This report will outline evidence to support the importance of providing ongoing support for adolescents in their diabetes self-management in relation to risk taking behaviours. A session plan has been developed addressing the information for adolescents providing outcomes appropriate diabetes self-management. Although research, clinical management, technology, psychosocial and behaviour of diabetes has improved diabetes care these factors are less documented. During the teenage years they are trying to negotiate many changes including physical, cognitive and psychological, it is at this time that the susceptibility of engaging in risk taking behaviours such as alcohol and other drug use is increasing, this for some will lead to developing mental health problems (Schreiner, 2017).

Even though the threat of risk taking behaviours has been similar to adolesces without those living with T1D has been seen to be comparable in teenager with and without T1D, poor self-care and metal health conditions have been a higher for those diagnosed with T1D (Moore et al, 2013).

NEEDS ASSESSMENT

At diagnosis most education and management is directed to the parents and it is not until the child is older that the responsibility/focus of self-management is placed on the child, for some teenagers they can understand the clinical processes of giving insulin and blood glucose monitoring but not understand why these things are done. The DAWN youth study looked at some of the goals identified by adolescents along with the unique challenges of childhood diabetes (DAWN study, 2007). Some of the goals identified included: improving access to education, psychosocial support, age appropriate care, and, improved peer support with better educational and psychosocial support for parents and families (DAWN study, 2007). The DAWN Youth programme aimed to assist advocacy and action while improving the lives of children living with diabetes and their families, while particularly focusing on disabling psychosocial barriers through the use of the DAWN call to action goals. Being able to provide ongoing education in a trusting environment for your patient is essential in the long term for their development in self-management. Goal 3 in the DAWN study was defined by offering individual assistance to manage a healthier and more active self-management lifestyle.

The success of reaching a supportive and motivating diabetes care team is essential when trying to achieve effective care and good outcomes when establishing an active diabetes self-management result (Betschart Roemer, 2016). When creating a treatment plan health care professionals need to take into account the patient’s individual needs, circumstances, issues and resources, because if the plan is to be followed effectively it is essential in the management of their diabetes. When encouraging/fostering diabetes self-management for all patients it can be challenging, before considering the other demands of teenage life in an adolescent with T1D. As changes to their bodies are happening being able to maintain blood glucose levels can be increasingly challenging, adolescents are often expected at this stage to take on more accountability in the management of their diabetes. At the same time, the increasing demands of school, the possibility of getting part-time employment, and diabetes management can become increasingly less important with an evolving social life in the mind of a teenager. Some teens find it easier to quit taking care of themselves due to the competing pressures and demands (Betschart Roemer, 2016). Evidence by Moore et al 2013, found that during adolescence adherence to your diabetes self-management is particularly poor. Not only can peer pressure and the normal changes of teenage development cause conflict let alone living with a chronic condition and trying to manage it, this strain alone can form a platform for major personal, family stress and even mental illness. Part of the makeup of an adolescent is that they do not recognise that harmful things can happen to them and therefore cannot foresee potential negative consequences of their actions. Teenagers have a difficult time deciding whether to doing something or not doing something. Sadly when already confronted with T1D some risk-taking behaviours engaged in today will have an effect on them in the future. Teenagers are risk-takers and it has been shown through research by developmental experts that risk-taking behaviours are a big part of adolescent behaviour (Moore et al 2013).

Being able to provide ongoing support and education to adolescents in the prevention and guidance in risk taking behaviours may provide some insight into what can occur when consuming alcohol, taking drugs, unprotected sex and driving. Betschart Roemer (2016), reports that, risky behaviours are common among adolescence such as tobacco use, drug use alcohol consumption and unprotected sex. Adolescence don’t consider the potential consequences for their actions and those living with diabetes will often test the boundaries or are preoccupied with something else therefore skip blood glucose monitoring or insulin injections (Betschart Roemer, 2016) . The education session plan that will be covered in this assessment will look at adolescents living with T1D, focussing on education on risk-taking behaviours. Research has shown us that adolescence is naturally a time of increasing independence and self-assertiveness, but also of risk-taking (Moore et al, 2013). Therefore, determining the appropriate extent of parental involvement can be challenging. Although adolescents should be responsible for the day to day management of their diabetes, minimal or no parental supervision has been known to results in poor glycaemic control (Schreiner, 2017). While shared management between the adolescent and parents is associated with better glycaemic control, parent-child conflict over daily management leads to poor control, and adolescent depression of even a mild degree can interfere with family involvement and diabetes control (Schreiner, 2017). Levisky and Misra 2018 found that by providing family-focused teamwork sessions focusing on parent child responsibility and strategies to avoid conflict showed an overall improvement in the care of an adolescent with diabetes. The trial looked at children ranging from 8-17 years, they changed the practice in how they managed diabetes by making it more family focused compared to the normal standard multidisciplinary approach by establishing a responsibility for both the child and the parent/carer to be more involved in establishing an active family discussions resulted in increased family involvement and better glycaemic control down from 93% to 8.8% (Levisky & Misra 2018). Developing a session that can provide strategies for adolescents to understand what is happening to their bodies and provide them with options of what they need to consider before initiating drinking, drugs, blood glucose monitoring, insulin omission and sexual activity will hopefully decrease some risk-taking behaviours associated with long term diabetes complications and establish open and active family discussions.

Presentation Plan

Topic:

Risk taking behaviours in adolescents living with T1D

Date:

21/07/2018

Learner Profile:

­To support adolescents living with type 1 diabetes in developing the appropriate knowledge and skills in understanding the effects that risk taking behaviourshas on their body.

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PROGRAM OBJECTIVES / LEARNING OUTCOMES:

Being able to identify risk taking behaviours

Short-term implications – here and now

Recognise long term complications associated with risk taking behaviours

Be able to plan/prepare for risk taking situations

Be able to communicate appropriately with educators and parents regarding risk taking behaviours

Be able to self-manage their diabetes whilst continuing an open relationship with parental support

LESSON STRUCTURE:

Time	Beginning / Introduction:	Why is this included?
0830	Introduce myself and role	So that the group has a understanding of who you are and your role within the session
90 sec	Assess any prior knowledge	So that you are aware of any learning issues in case you need to change your learning style to meet the needs of the participants in the session.
	Hand out questionnaires (Appendix A)	So that the session is interactive and you can have a feel of what the participants are wanting to learn & their current behaviours.

Time	Middle / Main Content:	Why is this included?
50 sec	Alcohol:  Effect of alcohol on BGL  Preventing hypoglycaemia (eg. Importance of eating too)  Frequency of testing (eg. Before going out, before bed) The buddy system (make sure close friends know what to do if you have a hypo and how to know it’s a hypo)	When drinking alcohol you can have decrease in blood glucose levels, alcohol works by blocking the production of glucose which is stored in the liver. When you blood glucose drops the emergency stores of glucose that are stored in your liver assist by raising your blood glucose levels. Once these stores are used up of glucose are used up a person who is under the influence of a lot of alcohol cannot make more straight away, this can lead to a dangerously low blood glucose level (hypoglycaemia) or even mortality (American Diabetes Association, 2017). Turner et al (2001), claims the insulin will continue to have an effect and drop the blood sugar unless you are eating. This action can happen very rapidly if no action is take. The effect of the alcohol consumption the following morning has been associated as one of the recognised risk factor for hypoglycaemia in people with T1D. Approximately one in five are estimated to have a severe hypoglycaemic episodes are attributed to alcohol consumption (Tuner et el, 2001).
50 sec	Illicitly drugs & risks associated with diabetes  Effect on BGL  Preventing hypoglycaemia/ hyperglcaemia  Frequency of testing	Although illicit drugs are less common than alcohol a study by Jaser, Yates, Dumser & Whittmore ( 2011), found that 40% of students admitted to using illicit drug and more often marijuana. Although marijuana may not have a direct effect of your blood glucose level, it is known to affect you judgment increase your appetite which will in turn have a negative effect on how you manage you diabetes management such has counting carbohydrates and insulin blood glucose corrections. Diabetic Ketoacidosis and been reported to be associated with drugs such as ecstasy are taken.
50 sec	Smoking  Long term health effects  Increase in AbA1c	Although tobacco smoking is not an illegal drug it has also been known to be the leading cause of preventable deaths worldwide. Adolescent living with T1D who smoke have a greater risk of having a higher HbA1C levels compared to those who are nonsmokers. Tobacco has been known to increase the abnormal secretion in the pituitary and counter regulatory hormones, from this you will get an increase in growth hormone and cortisol which in turn may lead to an increase in your blood glucose levels and potentially a reason for a higher HbA1C level. Further studies have shown that adults who continue to smoke have an associated with microalbuminuria, diabetic nephropathy, and retinopathy. (Hofer, Rosenbauer, & Grulich-Henn, 2009).
50 sec	Insulin omission  Long term health effects  Peer pressure  Diabetes burn out	Eating disorders are common among adolescents, particularly girls. In a study conducted by Eaton et al (2010) it was reported that ` 45% of high school students reported trying to lose weight, 41% restricted their diet. 11% went for 24 hours without eating, 5% reported taking diet pills. The study found that adolescent girls with T1D were at a 2.4 higher risk than those without T1D to have some form of eating disorder’. Insulin reduction and omission has been a common behaviour for those living with diabetes as a way of losing weight. It was reported that 31% to 36% of females living with T1D have used insulin reduction or omission to aid in weight loss (Eaton, et al, 2010). Those who reduce insulin omission place themselves at risk for early complications from diabetes. Risks of microvascular complications, including retinopathy and nephropathy, diabetes ketoacidosis as well as mortality are increase with long term insulin omission/withdrawal.
50 sec	BG monitoring  Keeps you safe  Better glycaemic control  Latest advances	It has been recommended that regular blood glucose monitoring assists patients and medical teams gage therapeutic levels, correct insulin and dose for blood glucose out of range targets, detect and prevent hypoglycaemia (Formosa, 2013). The Diabetes Control and Complication Trail(DCCT) was launched in 1981 and followed people living with T1D who kept their blood glucose levels as close to normal as possible after 6.5 years had fewer diabetes related health problems. With the introduction of the continuous glucose monitors (CGM) a small wearable device that continuously measures your glucose levels day and night. It has reduced the number of finger pricks, will alarm if you are too low or high and has been known to reduce your HbA1c by being able to monitor your blood glucose level more closely.
50 sec	Sexual health  Birth control  Sexually transmitted diseases  Nerve damage ED	It has been reported that 46% of high school students have had sexual intercourse (Eaton et al 2009). Adolescents with T1D where found to have an increased risk of unexpected pregnancies and sexually transmitted disease the study also found that only half the girls who were sexually active used a form of birth control or condoms (Schwartz, Sobota, Charron-Prochownik 2010). Girls with T1D were more likely to have unprotected sex because they falsely believed that due to their diabetes they would have difficulty conceiving (Fennoy, 1989). Sexual issues are higher in men who have poorly controlled diabetes than those who maintain good control. For men with diabetes particularly those that also smoke this can lead to nerve damage that can cause erectile dysfunction. Snow 2018, found that men who have shown to have erectile dysfunction and diabetes have a higher chance of developing heart disease, as erectile dysfunction carries the same risk factors for coronary artery disease.

CONCLUSION

This report looks at some of the risk-taking behaviours of adolescents living with T1D. Diabetes care today seems far from the norm as what it was in years gone by when one, two or three injections was the management. Today those living with diabetes are expected to self-manage their diabetes at an earlier age and is likely injecting a basal insulin once or twice a day along with fast-acting insulin at meals or use an insulin pump. Even with the advances in technology they are still being asked to check blood glucose level multiple times a day, eat healthy foods, count carbohydrates, carry supplies, exercise, maintain an insulin pump, and keep records of their blood glucose levels, it is understandable that adolescence want to escape from it all through risky behaviours (Schreiner, 2017).

While adolescents live a very active and full life, and tell us they assure us they will abstain from alcohol, cigarettes, drugs, and sex, they may also just as quickly change their minds. The session plan provided evidence why these risk taking behaviors are important in covering whether run in a group session for adolescents so that they can freely ask questions and explore ways of meeting these behaviors. By assessing behaviors regularly in clinic appointment the diabetes educator or provider can report if any risk taking behaviors have been established and ensure counseling and education is provided regularly (Moore et al, 2013). Adolescents with T1D are regularly seen every three months, establishing an open patient/educator relationship by reinforcing positive behaviors for avoiding risk taking activities. Ensuring that you allow for education and discussion about relevant risk-taking behavior appropriate for the age of the adolescent and if concerned about their management to seek the appropriated health professional to assist with ongoing management (Funnell, 2013).

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  Diabetes Care. 39, 686–693.
• Turner, B., Jenkins, E., Kerr, D., Sherwin, R., & Cavan, D. (2001). The Effect of Evening Alcohol Consumption on Next-Morning Glucose Control in Type 1 Diabetes.
  
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  24, 1888-1893.

APPENDIX 1

Assessment Questions for Adolescents with Type 1 Diabetes

Time	End/ Conclusion:	Why is this included?
90 sec	Open discussion for any questions	Allow time for any further question they may have

Eating	What do you like about your body?
	What do you not like about your body?
	Are you happy with your weight?
	Has your weight gone up or down in the past year?
	Have you done anything to try to manage your weight this year? How? How often?
	What do you think is a healthy diet?
	How much exercise do you get on an average week?
	Have you ever decreased the amount of insulin you’re supposed to take or skipped insulin doses to manage your weight?
	Do you ever skip mealtime boluses?
Drugs, alcohol, tobacco	Do any of your friends use tobacco? Alcohol? Other drugs?
	Does anyone in your family use tobacco? Alcohol? Other drugs?
	Do you use tobacco? Alcohol? Other drugs?
	Do you adjust your insulin when drinking? When using other drugs?
	Is there any history of alcohol or drug problems in your family?
Sexuality	Do you have a boyfriend or girlfriend?
	Have you ever had sex? If yes, how many people have you had sex with?
	What does the term safe sex mean to you?
	Have you ever been pregnant or worried you may be pregnant?
	Do you use condoms every time you have intercourse?
	Have you ever been forced to have sex against your will?
	Do you disconnect your insulin pump during sexual activity?

(Jaser et al, 2011)

Polycystic Ovarian Syndrome in the Reproductive Woman: An Epidemiological Approach

Abstract

One of the most prevalent disorders among women with reproductive age is polycystic ovarian syndrome (PCOS). Though the etiology of this syndrome is unknown, it can be diagnosed on the basis of three cardinal characteristics. This paper defines the issue along with a brief background and its significance. It also explores the prevalence and incidence rate worldwide and especially in Pakistan. Moreover, it will enlighten the major risk factors and long term concerns which have made life of women miserable. A review of treatment which includes pharmacological and non-pharmacological ways that is diet and exercises will be highlighted. Furthermore, it provides recommendation at individual, community, institutional, national and government level. It also explores the need of future researches among women with PCOS. By approaching all these aspects, women can combat with PCOS and reduce forthcoming morbidities.

Women of all ages experience multiple health issues. Particularly, women during her reproductive years encounter gynecological and endocrine disorders that exasperate their lives. Among all disorders, polycystic ovarian syndrome (PCOS) is the most common endocrinopathy. PCOS was referred as Stein-Leventhal Syndrome after Irving Stein and Micheal Leventhal, who first described it in 1935 (KINZA). However, record of PCOS dates back from atavistic era. Hippocrates, Soranus of Ephesus and Moises Maimonides identified women with oligomenorrhea, sterile conditions, masculine and healthy appearance which suggests PCOS (Azziz, Dumessic, & Goodarzi, 2011). According to National Institute of Health Conference (1990), “Women are defined to have PCOS if they have chronic anovulation and evidence of androgen excess for which there is no other cause” (Guzick, 2004, p. 181).

The diagnostic criteria’s for PCOS are convened by the National Institute of Health in 1992, the European Society for Human Reproduction and Embryology/American Society for Reproductive Medicine i.e. Rotterdam criterion in 2004 and the Androgen Excess and PCOS Society in 2006. However, a Rotterdam criterion is widely used. According to Rotterdam criterion, presence of any two cardinal features is sufficient to diagnose a woman with PCOS. These features include oligomenorrhea or anovulation, clinical or biochemical hyperandrogenism and polycystic ovaries. This criterion also defines the morphology of polycystic ovaries i.e. “the presence of 12 or more follicles measuring between 2 and 9 mm in diameter and/or an increased ovarian volume of greater than 10 cm3” (Sirmans & Pate, 2014, p. 3).

PCOS has a high prevalence and incidences not only in western areas, but also in Eastern areas, specifically in Asia. Rehman, Salahuddin and Obaid-ur-Rehman (2005) estimated 20% women from the general population, and 10% women of reproductive age suffer from PCOS. A study conducted in UK reported that 20% – 25% white women suffer from PCOS whereas the ratio was found to be much higher in South Asian women i.e. 52% (“Karachi: Seminar told ovarian disease,” 2010). A prospective study conducted in Greece, Spain and United States concluded that about 4% – 8% of women were diagnosed with PCOS (Teed, Deeks & Moran, 2010). In India, a cross-sectional study revealed that 51 out of 96 women have PCOS (Bhattacharya & Jha, 2011). Furthermore, 20.7% women of reproductive age group are affected in Pakistan (Baqai, Khanam, & Parveen, 2010). The morbidity rate of PCOS is expanding to a great momentum due to lack of awareness regarding preventive measures and inappropriate healthcare facilities. Its long term consequences do not limit to the reproductive axis; women with PCOS are at high risk for acquiring metabolic and cardiovascular illnesses (Avery & Mayer, 2007). Inspite of its deleterious impacts PCOS has persisted for many years. It also remains a challenge for the clinician’s to diagnose and manage it. However, better understanding of the complexities of PCOS will ultimately lead to improved health outcomes and effective clinical care. This compelled us to converse over the epidemiology of PCOS. “PCOS has been identified as an area of clinical need and as a public health issue” (Hailes, 2011, p. 28).

The exact etiology of PCOS is yet unknown, but several sufficient determinants are associated with its occurrence (Rehman et al., 2005). Insulin resistance is the major underlying factor. About 50-80% of the women with insulin resistance reported to have PCOS. Insulin plays both direct and indirect roles in the appearance of the disease. High levels of insulin work synergistically to the luteinizing hormone. Together they increase the androgen production of theca cells which lead to lipid abnormalities (Zacur, 2003). Moreover, elevated insulin level inhibits hepatic synthesis of sex hormone–binding globulin leading to increase amount of unbound or free testosterone (Ehrmann, 2005). Ahmed et al. (2008) highlighted genetics as an important risk factor for PCOS. Deregulation of the cytochrome P450c17 gene affects ovarian function which results in hyperandrogenism (Ahmed et al., 2008). Ehrmann (2005) reported that an abnormality in the hypothalamic-pituitary-ovarian axis (HPOA) is associated with PCOS. Rojas et al. (2014) concluded that an increase impulse frequency of HPOA raises the production of luteinizing hormone (LH). This in turn increases the synthesis of androgens, suggestive of PCOS (Ehrmann, 2005). Other factors include altered steroid metabolism that is dysregulation of 11b-hydroxy steroid dehydrogenase (Ahmed et al. 2008). In a retrospective study, women on antiepileptic drugs reported menstrual irregularities. Hence a positive relation between antiepileptic drugs and PCOS was found (Zacur, H., 2005; American Pregnancy Association, 2014). Vitamin D deficiency may place a woman to develop PCOS (Thys-Jacobs, Donovan, Papadopoulos, Sarrel, & Bilezikian, 1999). Serum 25-hydroxyvitamin D (25OHD) decreases if women have higher body mass index (BMI), fat and insulin resistance. Hence, vitamin D deficiency alters intracellular calcium, which results in ovarian dysfunction (Khan et al., 2014).

Untreated PCOS have various ramifications, including reproductive, metabolic, cardiovascular and psychological alterations. According to Legro et al. (2013), endometrial hyperplasia and endometrial cancer may occur due to deficiency of progesterone. Moreover, women with PCOS are prone to develop Diabetes Mellitus (DM) type II in later life. A case control study revealed that 7.5% of women end up with DM type II (Legro, Kunselman, Dodson, & Dunaif, 1999). In addition, PCOS can affect circulatory system in an indirect way as women develop dyslipidemia and cardiovascular diseases. Anxiety and depression are the most common psychological issues reported by women with PCOS (Way, 2013).

Lifestyle modification should be adopted by women suffering from PCOS. These amendments include weight control, stress management and dietary modification. A small amount of weight loss as little as 5% can help a woman to regulate the menstrual cycle and ovulation. Weight control can be beneficial for a woman to sustain mental well-being, and enables her to partially culminate the risk of cardiac and metabolic disorders (Boyle & Teede, 2012). Moreover, dietary management includes the consumption of low glycemic index, high fiber and low fat diet to reduce the associated symptoms of PCOS.

No ideal pharmacological treatment has yet been found that completely treats PCOS. However, symptomatic treatment is usually preferred. Low dose of oral contraceptive pill, cyclic progestin and metformin are used as first line treatment for PCOS. These drugs help in treating ovarian dysfunction, menstrual irregularities and hyperandrogenism (Garad, Teede, & Moran, 2011). Elter and colleagues concluded from their clinical trial that OCP in combination with metformin is more effective in suppressing the androgen level as compared to OCP alone (Ahmed, Qureshi, Anjum, Akhtar, & Anhalt, 2008). In presence of hirsutism spironolactone (200mg/d) is commonly prescribed (Guzick, 2004). Clomiphene citrate is recommended to induce fertility in women with PCOS. It triggers FSH secretion and mature ovarian follicle. Herbal therapies are also used to cure PCOS which includes liquorice, kasip fatimah, spearmint tea, etc. All three herbs have anti-androgenic properties. In Turkey, RCT concluded that women who receive spearmint tea have decreased levels of free testosterone (Goswami, Khale, & Ogale, 2012).

Recommendation and future research

PCOS is endemic in Pakistan, particularly in the reproductive women. To reduce the incidence rate following recommendation can be helpful. At an individual level, it is significant to provide psychological support to the women suffering from PCOS. This will enhance her self-confidence and enable her to cope effectively. Moreover, counseling services should be readily available for newly diagnosed women. These services should emphasize on weight management via diet and exercise. Proper instructions regarding drug dosage, side effects and the importance of compliance is crucial. The physical changes in the women with PCOS not only impact her well-being, but her family is equally affected. Therefore, family concerns should be addressed. Further, regular follow up should be stressed.

It is estimated that 70% of women with PCOS remain undiagnosed in the community due to lack of awareness (March et al., 2010). Therefore, several screening programs should be organized to assess women’s physical, metabolic, and reproductive health. These programs help women to identify any alterations in their bodily functions. Further, it helps health care workers to plan effective need based interventions for them. Community health centers should arrange weekly monitoring of blood pressure, weight and BMI. Health institutions should initiate yearly screening programs for lipid profile, glucose levels (Boyle et al., 2012) and Vitamin D levels.

Various mediums can be used to increase awareness in the population. Women should be educated to self-monitor the symptoms of PCOS. This could be achieved through the distribution of pamphlets, brochures, and flyers at institutional level. Similarly, at national level mass media like television shows and commercials, plays an important role.

Awareness is an essential tool to save future daughters, wives and mothers from PCOS. Government in affiliation with health and education sectors should make policies to initiate awareness among school going girls, regarding menstrual irregularities and warning signs of PCOS. Also, the government should introduce free health services in district and tehsil hospitals to maintain sexual health of women (Beydoun et al., 2009). In collaboration with non-governmental organizations awareness sessions and support groups should be planned for high risk and previously diagnosed women to prevent them from complications. More parks and walking tracks should be made, and specific hours should be allocated for women.

PCOS remains a debating issue for researchers as its causes and outcomes are emerging day by day. Matzke (2011) suggested that large sample studies in non-randomized clinical trials should be conducted. This would increase validity, reliability and applicability of the researches. Longitudinal studies should be conducted, and an individual should be followed for more than 5 years exactly after the diagnosis. The purpose of long term monitoring is to evaluate the significant changes that occur due to PCOS (Matzke, 2011). There is a need to modify the name of PCOS as this term only focuses on cyst and ovaries. Therefore, a name that defines its intricacy and reflects its characteristics in metabolic, hypothalamus, pituitary, ovarian, and adrenal interactions should be suggested (National Institute of Health, 2012). A few studies indicate that fertility drug such as clomiphene citrate may increase the risk of ovarian cyst if taken for a long period (American Pregnancy Association, 2014

)

. In this regard, further experimental researches should be performed to evaluate the evidence of PCOS in such women. A Chinese medicine cryptotanshinone is known for its significant effect in endocrine and metabolic disorders. However, this medicine is only tested on rats and showed a significant decrease in the symptoms of PCOS (Yu et al., 2014). Therefore, clinical trials of this drug are suggested. Ayurveda is a traditionally used treatment regimen. An experimental uncontrolled study was done to investigate the effectiveness of samprapti kriya and other herbs for curing sub-fertility in PCOS. Results showed that 85% of the women get cured and75% were able to conceive (Siriwardene, Karunathilaka, Kodituwakku, & Karunarathne, 2010). About 70% of Pakistani people prefer alternative therapies over conventional medicines (Kokab & Ahmad, 2011). Therefore, further research is required to validate the effectiveness of ayurveda treatment.

In conclusion, PCOS have emerged as a devastating endocrine disorder among women worldwide. The chief cause is unknown yet. This syndrome displays a variety of reproductive, metabolic, cardiovascular and psychological features. Management primarily focuses on lifestyle modification along with certain pharmacological medications for presenting symptoms. To eradicate this disorder, efforts are required at individual, community, institution and governmental level. Working on future research needs would help us to achieve better outcomes in upcoming years.

Since the first reported case of HIV/AIDS in 1981, the disease has had a devastating effect on all components of our society and has become the most deadly infectious disease epidemic in recent times. The disease is seen as a threat to the stability of entire nations and regions affecting the most productive members of the society. HIV/AIDS has become a global phenomenon, however the disease is most pronounced in developing countries particularly Sub-Saharan Africa. The spread of the disease has reached pandemic proportions in most parts of the African continent (WHO 2007).

The numbers of people infected with HIV keeps on increasing particularly among the young people. The estimated number of persons living with HIV worldwide in

2009 is 33 million. African continent alone had 22.5 million of the world’s estimated 33 million people living with HIV/AIDS (UNAIDS/WHO 2007).

UNAIDS estimates showed that young people under 25 accounted for about 45% of all new HIV cases (over 6800 people become infected with HIV everyday) in adults in 2007. The disease continues to ravage Sub-Saharan Africa and it remains the most serious of infectious disease that challenges Africa. The leading cause of death in Sub-Saharan Africa is HIV/AIDS (Tanaka, Kunii, Hatano & Wakai 2007).

It is true HIV/AIDS continues to spread among the population of urban communities in Rwanda, with its heavy toll on the 15 – 49 year age groups, who constitute the economically productive sector of the country’s economy. Kanombe and Muhima Districts are urban communities in Kigali City Province, which has seen increase in the spread of HIV/AIDS. Urban districts are part of the worst HIV/AIDS prevalence in Rwanda. As at 2006 it had prevalence rate of 5.1% far higher than the rural average of 2.1 the same year. Rwanda is among the ten countries in Africa most severely affected by HIV/AIDS. The country is facing a generalized epidemic. National estimates indicate that in 2006, the adult prevalence rate is in the range of 3.1% among the general population (WHO 2007).

Behavioral data serve as an early warning system and provide information to guide program design and evaluate interventions. In addition, the data provide information that can explain HIV prevalence trends.

Prevention supports of donor agencies and the government have been working assiduously to curb the HIV/AIDS epidemic but there has not been any considerable decrease in the prevalent rate within Kigali City Province. A critical question here is; what could have accounted for this? Prevalence in 15-24 years group shows an increase trend though efforts have been made to slow down the spread. Young female adolescents are vulnerable and may be influenced into high-risk behaviors. The gab between male-female percentage regarding condom use in Rwanda is 40.9 and 19.7 respectively (WHO 2007).

The aim of this study was to investigate the knowledge, perceptions, and attitudes of adolescents towards HIV/AIDS in order to institute meaningful preventive measures for the control of HIV/AIDS in Kigali City urban community. The findings of this study can be added to the existing body of knowledge on HIV/AIDS in Kigali City Province and in Rwanda as a whole. The findings of this study will help policymakers and healthcare professionals to develop adolescent centered, all-round and intensive programs that will curtail the spread of HIV in the province.

2. LITERATURE REVIEW

2.1 HIV/AIDS – Definition

HIV is the short form of Human Immunodeficiency Virus, the virus that causes AIDS. (Levy. 1993). AIDS is an abbreviation for Acquired Immunodeficiency Syndrome. Simply put Acquired Immunodeficiency Syndrome (AIDS) is caused by the human immunodeficiency virus (HIV), which destroys the cells in the human body that combat infections. Dr. Samuel Border, formerly at the National Cancer Institute in the United States of America, reminds us the history of HIV/AIDS. He said “In June of 1981 we saw a young gay man with the most devastating immune deficiency we had ever seen. We said, we don’t know what this is, but we hope we don’t ever see another case like it again” (WHO 1994).On 5th June, 1981, AIDS was first reported in Los Angeles, California. (Centers for Disease Control 1981). According to Broder S 1984 cited by Katrak 2006, the Human Immunodeficiency Virus type 1 (HIV – 1) was discovered in 1983 as the root cause of Acquired Immunodeficiency Syndrome (Katrak 2006).

Kahende (2001), in his thesis viewed HIV/AIDS as a cause as well as a symptom

of underdevelopment. Its long incubation period makes it hard to predict the social and economic effects it may have on households and national development as a whole. The disease mostly affects individuals in their prime between the ages of 15 to 49 years and sizable number of those in this category will have major social and economic effects in the long run (World Bank 2007, International Development Committee (IDC) 2001). The United Nations International Labor Organization’s (ILO) report in Akukwe (2006), suggest that “a minimum of 26 million people worldwide living with HIV/AIDS are in the workforce with at least two-thirds of them living in Africa”. The consequence of this is that the labor force in Africa will be in jeopardy in the near future. The disease has an incubation period of about 8 years and someone infected with the virus could infect many other people (Kahende, 2001). This means that a person infected with HIV may not show any noticeable symptoms until between 8years to 10 years when the body’s immune system can no longer withstand the HIV virus. During this time many more persons will have become infected [around 6800 new infections per day at present) USAIDS (2007)]. This creates continuing rolling burden and a vicious cycle of illness and deaths which effects could be perilous to the affected countries. This makes AIDS much more dangerous than other diseases since diseases without incubation periods can be easily identified and treated (Kahende, 2001). Cure for HIV/AIDS has not been found yet, however, anti-retroviral therapy can prolong the lives of individuals living with HIV/AIDS (Akukwe 2006). This therapy is however currently expensive and not available to majority of infected people in sub-Sahara Africa (Fry 2007).

2.2 Rwanda Country Profile

2.2.1 Rwanda History

Rwanda is a small, landlocked country in Central Africa with 9.7 million and a high population density (368 people per sq. km). Rwanda became independent in 1962 after colonization by Germany (1899) and Belgium (1919). In 1961 its monarchical government was formally abolished by a referendum and the first parliamentary elections were held.

Political turmoil over the sharing of power and access to opportunities resulted in explosions of ethnic violence which have marked much of the recent history of the country. A civil conflict pitting the Hutu-led government against the Rwanda Patriotic Front (RPF), a Tutsi-led rebel movement, culminated in genocide, between April and June 1994. About 800,000 people were massacred by the army and the extremist Interahamwe militia. The RPF overthrew the regime in June 1994.

While the country is currently at peace, Rwandans continue to struggle with the legacy of genocide. National reconciliation is a long-term endeavor that has the full commitment of the Government and the support of the international community. The Rwandan Government has undertaken significant measures to consolidate reconciliation including the continuation of the demobilization and reintegration project for ex-combatants and a model of democratization focused on a decentralized administration (World Bank 2009).

2.2.2 Economic and Social Progress

Rwanda has made remarkable progress since the 1994 genocide and civil war. Peace and political stability have been re-established, reconciliation efforts are continuing, and democratic institutions and processes are being strengthened. Poverty and social indicators have also improved. Rwanda has been able to maintain overall macroeconomic stability and implement extensive reforms which have contributed to a strong growth performance.

Rwanda is on track to achieve several of the Millennium Development Goals (MDGs): MDG 2 on universal primary education; MDG 3 on gender equality; and MDG 6 on HIV/AIDS and malaria. Net primary enrollment is currently 95 percent, with 97 percent enrollment of girls. However, low completion rates and poor quality of basic education show that there are still major challenges to meeting MDG 2. HIV prevalence is estimated at about 3 percent with female infection rates (3.6 percent) substantially higher than those of males (2.3 percent). Rwanda is also on track to achieve the targeted reduction in malaria incidence (World Bank 2009).

2.3 Adolescents and HIV/AIDS

Adolescence is one of the most captivating and complex transitions in the life span. It is a period of tremendous adjustment for children and parents. As children transition from childhood to adulthood, they undergo many physical, emotional and behavioral changes. These changes include; very fast physical growth, the rise of reproductive sexuality, new social roles, growth in thinking, feelings and morals. The sequence of pubertal changes is relatively predictable and consistent; however, their timing is extremely variable (National Academies Press 1999, 1-2.).

Nearly 50% of the world’s population is under 25 (UNFPA 2003). The threat of

HIV pandemic to young people cannot be over emphasized as UNAIDS estimates showed that young people under 25 accounted for about half of all new

HIV cases in adults in 2007 and more than half of them still lack accurate and comprehensive information about how to avoid exposure to the virus (USAID

2008).The indication that less than 40% of young people globally have accurate and comprehensive knowledge about HIV (UNGASS indicator 13) is unacceptably low and consequently worrisome. Previous studies done in USA (DiClemente, Zorn, Temoshok, 1986; Bhattacharya, Cleland, Holland, 2000),Nepal (Mahat G & Scoloveno 2006) and Turkey ( Savaser 2003) where adolescents in those studies knew of only sexual route of transmission. There is the need to step up HIV/AIDS education among the youth particularly in Sub-Sahara Africa where various cultures frown at sex education among adolescents.

Young People between the ages of 15 to 24 accounts for 30% of all people living with HIV/AIDS (UNSAIDS 2001). The disease keeps on spreading especially among young people making it even harder to control. The HIV/AIDS epidemic remain invisible to both young people and the society, people usually carry the disease for years without their knowledge. As a result, the epidemic is spreading among young people at an alarming rate.

In sub-Sahara Africa, the situation looks gloomier. More than half of sub-Saharan

Africa have generalized HIV/AIDS epidemic, this means 5% or more of the young

people are infected (UNAIDS 2000). The youth constitute one-fifth of the world’s population and nearly two-fifths in the developing countries’ populations (Population Reference Bureau (PRB) 2000). All hands must be on deck to reverse the trend in order to salvage our youth from the scourge of HIV pandemic, the future looks bleak if current situation must be allowed to continue.

Young people have been designated as a group at high risk of acquiring HIV/AIDS due to their involvement in sexual experimentation and the use of recreational drugs. Vulnerability of young people to HIV/AIDS can be attributed to physical, social, economical and psychological features of adolescents (Offer, Ostrov, Howard, & Atkinson, 1988, 270 & Senderowitz, 1995). Socially and economically, most adolescents are dependent and inexperienced therefore, they are unable to protect themselves from infections, and have less access to health care than adults. Again, young people’s vulnerability to HIV/AIDS increases as result of cultural practices that shape their behaviors. Adolescence is a stage where young people establish their sexual identities, in doing so they are faced with pressures from society as well as their peers.

2.4 Adolescents’ knowledge, attitudes, perceptions and prevention of HIV/AIDS

HIV/AIDS has caused indescribable suffering to millions of people world wide.

The fight against the scourge and epidemic of HIV/AIDS is and continue to be one of the biggest challenges facing the world today. The impact of the disease touches on the lives of the global community in different predictable and unpredictable ways. Though the severity of the crisis is obvious, biochemical and pharmaceutical development of vaccines continue to have limited success; current drugs available can suppress the virus but they do not cure HIV infections or AIDS (The National Institute of Allergy and Infectious Diseases (NIAID), 2009).Therefore, promotion of prevention strategies needs to be intensified in order to halt the spread of HIV.

It is now a common knowledge as reported in many studies that Transmission of human immunodeficiency virus (HIV) via sexual contact is the most common(UNAIDS 2002) and accounts for 75 to 85 percent of all infections(Royce, Seña, Cates, & Cohen, 1997). Over the past two decades, rates of infection with sexually transmitted diseases have continued to increase among teenagers. Roscoe and Kruger (1990) in their article titled ‘Late adolescents’ knowledge and its influence’ concluded that although adolescents’ knowledge of HIV transmission might have improved over the past few years, their risk-related behaviors remain unchanged. This, no doubt can be linked to Adolescents’ sexual behavior and knowledge, attitudes, perceptions towards HIV/AIDS.

Numerous studies have been done on adolescents’ sexuality, knowledge, attitudes, and/or behaviors relevant to AIDS in order to improve the over all sexual behavior of adolescents. It is important at this point to consider such surveys of adolescents. A random-sample surveyed by Strunin and Hingson (1987) of 860 adolescents, 16 to 19 years of age, concerning their knowledge, beliefs, attitudes, and behaviors regarding AIDS indicated 70% were sexually active (having sexual intercourse or other sexual contact) but only 15% of them reported changing their sexual behavior because of concern about contracting AIDS, and only 20% of those who changed their behavior used effective methods.

Several prominent studies showed high engagement in unsafe sexual behaviors such as sex with multiple partners, sex with unknown persons, as well as negative views about condom use, and a low rate of behavior change even after learning about HIV/AIDS (Buysse, 1996, Gray & Saracino, 1989). This corroborates the suggestion that a moderate to high knowledge level of AIDS may not be a predictor of safe sexual behavior practices (Gray & Saracino, 1989). However, a study conducted by Roscoe & Kruger, (1990) of 300 late adolescents suggests that one-third had altered their sexual behavior as a result of fear of the disease. Available Research on the effects of beliefs of susceptibility to AIDS indicates that adolescents and adults who report high perceived risk for AIDS practice safer sexual behaviors, whereas those who perceive low risk for contracting AIDS report practicing unsafe sexual behaviors (Gray & Saracino, 1989 Villarruel, A.M., Jemmolt, Howard, Taylor, & Bush, 1998).

Youth Education and prevention programs have been used as the primary means of decreasing rate of HIV infections among adolescents, it can be summed up in three letters ABC(A=Abstinence, B=Be Faithful, C=Condoms). Barnett and Parkhurst (2005) have described abstinence as the best followed by faithfulness to one partner and condom use as last. Anytime ABC is mentioned Ugandan situation comes to mind, in 1991, the government, opinion leaders and the people of Uganda had the courage to change the attitudes and behaviors that were spreading the HIV. A Harvard study in Uganda finds HIV rates drop 50% within eight years. The study credits abstinence education in reducing HIV/AIDS in Uganda (Trafford 2002). Again, it has been argued that condoms have about 10-13% failure rate in preventing pregnancy and 10-20% failure rate in preventing HIV for several reasons. Museveni (2004) in his commentary on HIV titled ‘Behavioral Change Is the Only Way To Fight AIDS’ cited Uganda as being excellent in this direction; it has successfully managed to bring the seroprevalence rate from 18.6% to 6.1% using just social vaccine (behavior change), approximately 70% reduction. Molomo 2008, National coordinator of NACA(National Action Committee on AIDS) said “behavioral change is the responsibility of the individual and not the community”. He explained the latter could provide enabling environment within which the former can effect behavioral change. Attitudes, beliefs, and/or intentions have been described by many theories as proximal determinants of behavior. Consequently, changes in attitudes toward abstinence and condoms, and Perceptions of personal risk or susceptibility to HIV should be the main goals in any HIV/AIDS prevention program.

3. AIMS AND OBJECTIVES OF THE STUDY

The aim of this study is to investigate the knowledge, perceptions, and attitudes of adolescents (15-24) towards HIV/AIDS in order to institute meaningful preventive measures for the control of HIV/AIDS.

Ultimately, the study will provide information on appropriate intervention methods necessary for preventing HIV/AIDS among adolescents in the community.

3.1 Research Questions

With respect to the theme of our research, the following research questions shall be addressed:

1. What knowledge do adolescents in Kigali City Province have about HIV/AIDS?

2. What are the perceptions and attitudes by adolescents towards HIV/AIDS preventions?

3. Which preventive method(s) do they use?

4. Do they perceive any risk of contracting/getting HIV/AIDS?

4. RESEARCH METHODS AND DATA SOURCES

Qualitative research approach will be used to address HIV/AIDS prevention among adolescents. Qualitative methodology or deductive approach according to

Pope and Mays (1995) is used to explore, interpret or illustrate the actions and/or subjective experiences of research participants. In other words qualitative research tends to give a comprehensive data about human observations, thoughts and feelings; it tries to establish meaning from human life experiences.

As the focus of our study is to investigate the knowledge, perceptions, and attitudes of adolescents and young adults towards HIV/AIDS and its prevention, a qualitative approach will allow the participants to express their feelings and experiences genuinely (Punch 1998).