Anxiety level change before and after HIV test among Foreigners in Korea

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Master‘s thesis in Public Health and Social Medicine

Anxiety level change before and after HIV test

among Foreigners in Korea

Graduate School of Ajou University

Department of Public Health and Social Medicine

Zufan Zenebe

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Anxiety level change before and after HIV test

among Foreigners in Korea

Advisor : Soon Young Lee

I submit this thesis as the Master‘s thesis in

Public Health and Social Medicine

February, 2020

Ajou University Graduate School

Public Health and Social Medicine Major

First and for most, I would like to thank the almighty God for giving me the strength,

patience and all the blessings to accomplish my study. Without his blessings, this

achievement would not have been possible.

Secondly, I would like to express my deepest gratitude to my advisor professor Soon Young

Lee. You are the main reason to build my dream towards the completion of my study and

success. Thank you so much professor for your insightful guidance, motivations, and

inspiration for the achievement of my goal. Also I am also very thankful to my co-advisor

professor

Jakyoung Lee and my defense committee member professor Yunhwan Lee, for

continuous support and insightful comments suggestions and encouragement that enabled me

to widen my research. I would like to extend my appreciation to all members of Ajou

university preventive medicine lab meet friends and graduate office staff in facilitating my

academic processes.

I am very grateful to the Korean government particularly National Institute for International

Education Development (NIIED) to give me the scholarship chance to come to South Korea

and pursue my graduate study.

It is my pleasure to forward my special thanks to ANSAN HIV/AIDS Counseling and testing

center (Ansan, Korea) for providing the Anxiety and HIV/AIDS test seeker dataset. I would

like to extend my appreciation and to thanks all staff members of the center for their kind

cooperation. Particularly, my thanks go to nurse kime Nare for her constant assistance in

explaining the work in the problem and related issues.

My acknowledgment would be incomplete without thanking the biggest source of my

strength, my family. I am very grateful to my husband Fekadu Wondimu and my daughter

Mahilet Fekadu who have provided me their precious time and for moral and emotional

support in my life. I am grateful to my parents, my uncle, professor Solomon Gashaw his son

fisum Solomon and all other family members for supporting me in all aspects of life.

Finally, I dedicate this work to my family Zenebe ketema, Etabezawe gashawe, Biruk zenebe,

yemeserach Zenebe, Tigest Zenebe, Abrehame Zenebe, Nebeyu Zenebe, and Abule Gashawe.

Without your praying nurturing, I would not have been where I am today. Thank you Biruk

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ABSTRACT

Introduction :

This study was to assess anxiety level change and related factors at the pretest and posttest among foreigners for HIV/AIDS test. The secondary aim was to see the differences in anxiety-related variables between relieved and non-relieved groups.

Methods :

The data at an HIV/AIDS testing center were collected from 681 individuals tested for HIV between January 2012 to Jun 2015. The self-administered questionnaire at the KHAP HIV/AIDS voluntary counseling and testing center at Ansan city Korea was given to the subjects. We used standard statistical analysis and state-trait anxiety inventory (STAI) that consisted of 40 items to measure anxiety level. A cut point of 39–40 in the scale of 20-80 points to determine the level of high anxiety was selected. The data were analyzed via SPSS for window version 20.0 and descriptive analysis and multiple linear regression analyses were performed.

Results :

In this study, 1,034 participants agreed to take an HIV/AIDS test but only 681 participants agreed to submit their full personal and anxiety information. More men (554 and 127 respectively) participated for the study. Age below 29, marital status, nationality were associated with a high relive group. Previous knowledge of HIV/AIDs was also associated with anxiety levels. Bisexual participants showed a high relieved anxiety level as compared to other sexual orientation groups. Most of the participants never using a condom or inconsistency condom use were associated with high relieved after testing results. In the present study, increasing knowledge about HIV/AIDS could help them to relieve anxiety.

Conclusion : For the study participants reported higher anxiety at pretest and later showed relieved

anxiety level at the posttest these results suggest safe sexual practice must be needed in this study group, increasing knowledge of HIV/AIDS for foreigners in Korea should be followed.

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TABLE OF CONTENTS

ABSTRACT··· ⅰ TABLE OF CONTENTS ··· ⅱ 1. INTRODUCTION ··· 1 1.1. Background ··· 1 1. 2. Purpose of study ··· 2

2. DATA AND METHODS ··· 3

2.1. Study Population ··· 3

2.2. Measures ··· 3

2.3. Statistical Analysis ··· 4

3. RESULTS ··· 5

3.1. General Characteristics ··· 5

3.2. Sexual behaviors and knowledge on HIV/AIDS ··· 6

3.3. Comparison of anxiety level in between pretest and posttest ··· 7

3.4. Comparison between Relieved group and non-relived group ··· 10

3.5. Comparison of anxiety level change groups by demographics, sexual behavior, Sexual orientation, and knowledge on HIV/AID ··· 11

3.6. Multivariate analysis of anxiety level change by demographic characteristics, Sexuality, sexual behaviors, and knowledge on HIV/AIDS ··· 12

4. DISCUSSION ··· 14 5. CONCLUSION ··· 16 6. REFERENCES ··· 17 7. SUPPLEMENTS ··· 20

1

INTRODUCTION

1.1. Background

In 2018, 37.9 million people globally were living with HIV 1.7 million people became newly infected with HIV and 770 000 people died from AIDS-related illnesses [1]. 74.9 million People have become infected with HIV since the start of the epidemic. 32.0 million People have died from AIDS-related illnesses since the start of the epidemic [2].

In South Korea, 1 Korean; and 1 foreigner were reported as HIV positive in 1985 for the first time, the cumulative number of patients with HIV has increased to 15,208 (13,584 Koreans, and 1,624 foreigners) in 2016 [3]. The prevalence of HIV/AIDS in Korea is very low of 0.02% [4] as compared to 0.8% globally in 2018. The increasing number of HIV diagnoses in Korea may indicate a large population of undiagnosed HIV patients [5]. If it is true we cannot say Korea is a safe zone from HIV/AIDS.

The Korean government has implemented various policies to improve early detection among HIV infected individuals. Public health centers (PHCs) have waived HIV testing costs for the people in the high-risk group and have provided anonymous HIV testing since 1989[7]. In a recent study, Public health centers (PHCs) in Korea provided anonymous and free voluntary counseling and testing (VCT). PHCs in the metropolitan city of Seoul, as well as some regional PHCs outside of Seoul, have adopted rapid finger-stick HIV screening tests. Non-governmental organizations such as KHAP (Korea Federation for HIV/AIDS Prevention) have offered free counseling services and HIV testing programs. The Korean government has strengthened HIV prevention policies on health education and financial support of medical expenses to reduce the HIV/AIDS prevalence and mortality [7].

In South Korea, counseling centers for migrant workers to test HIV/AIDS have been set up since 2003. However, there are still no HIV/AIDS policies in Korea targeting foreigners in Korea. Training HIV/AIDS educators and counselors to care for migrant workers with HIV/AIDS is a continuing challenge given the multitude of nationalities represented among the migrant workers in Korea today since; each foreigner has their own culture and language. Culturally appropriate methods are should be considered when disseminating information to this diverse group of people. Currently, in Korea, Chinese workers represent the greatest portion of migrant workers in Korea, followed by those from Bangladesh and Mongolia [6].

Individuals getting an HIV test experience anxiety. A study conducted among HIV test seekers in India [16]. Reported that psychiatric morbidity existed before knowledge of HIV status and it should be managed. The common mental disorders (CMD) prevalent in India were anxiety and depression. It

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is important to diagnose distress among HIV test-seekers because distress would lead to a result in high-risk behaviors for HIV such people that could transmit HIV infection to others. Identifying distress and its related factors could be helpful to develop effective intervention strategies [16].

1.2. Purpose of study

This study was to explore the anxiety level before and after the HIV test and also to see its associated variables among foreigners in Korea. And study result would contribute to developing appropriate interventions for the migrants.

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Data and Methodology

2.1. Study Population

The data were obtained from the foreigners visiting the KHAP in Ansan, Gyeonggi Province between 2012 and 2015. A self-administered questionnaire for the study participants was translated in several languages: English, Chinese, Mongolians, Vietnamese, Thai, Indonesian, Sri Lanka, and Russian. Ansan city is this was highly industrialized areas and provides more job opportunities for migrants than other areas. The number of Participants was 1,034 at the baseline.

2.2 Measures

2.2.1 Anxiety

The STAI questionnaire was generally used to measure the presence and the severity of symptoms of anxiety status has Among the 40 items in the STAI, 20 items were to measure the State-Anxiety and the other 20 items were to measure the Trait-Anxiety subscales. Only the State Anxiety Scale (S-Anxiety) was used to evaluate the current state of anxiety, by asking subjective feelings of apprehension, tension, nervousness, worry, and activation. Responses for the intensity of current feelings are in the form of 4 Likert scales [36]. The score range is 20–80 where the higher score indicates greater anxiety. A cut point of 39–40 was recommended to detect clinically significant symptoms in the S-Anxiety scale [39, 40]; however, other studies have suggested a higher cut score of 54–55 for older adults [18]. In this study, we categorized the range of scores into three groups: less anxiety group from 20- to 37, moderate anxiety group from 38- to 44, and higher anxiety group from 45 to-80 [39]

.

2.2.2 Sexual Behaviors

Sexual Orientation means how a person identifies his/her sexual orientation–either ―heterosexual‖, ―bisexual‖, or ―homosexual‖. As for a relationship in the past 3 month, we asked if the participants a fixed partner or not. The meaning of 'fixed' in this question was a one-to-one sexual relationship for a while. The types of sexual partners were asked to categorize by types, The questions related to risky sexual behaviors and the presence or

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experiences of STDs, in the past 3 months were asked. The result of blood tests for HIV was also included in the study.

2.2.3 Knowledge

The questions on knowledge on HIV/AIDS were asked. The responses for each question were grouped into two categories ―known‖ and ―unknown.‖

2.2.4 Socio-Demographic Characteristics

Nationality was categorized in Asian-pacific, African, European, and America. The occupation was categorized in either one of the 7 groups: as, Worker, Engineer, Teacher, and student, Office worker, Businessperson or others. The other confounder‘s characteristics were age, marital status, and residency period. Age was divided into the following groups: <29, 30 to 39, >40 older. Three marital status classifications were single, married, and others (which included divorce or separation by death). The length of residence was collected from the survey in months

2.3. Statistical Analyses

Univar ate analyses were performed for anxiety level by socio-demographic characteristics. ANOVA were performed to see the changes in anxiety level at the pretest and the posttest. After adjusting for gender, age, marital status, residence period, condom use, knowledge of HIV/AIDS, a reason to test. Chi-square test and multiple logistic regressions were performed to see the association between a relieved and non-relieved group. For all statistical analysis, SPSS (version 20) package was used.

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RESULTS

General Characteristics

Table 1 showed the distribution of the study. A total of 681 participants visited the VCT (voluntary counseling and test) center and took the HIV test in Korea during the study period (January 2012-June, 2015). The majority, 81.4% of participants were males. Asia pacific nationality was 73.1%. For occupation types, worker, and engineers were 32%. Participants who stayed in Korea for less than 12 months were only 29.7%. For marital status, singles were 60.4%.

Table 1. General characteristics of foreign residents who got the HIV test in Korea. (N=681)

Characteristics N %

Survey year Jan to Dec/2012 219 32.2

Jan to Dec/2013 229 33.6 Jan to Dec/2014 168 24.7 Jan to Jun/2015 65 9.5 Gender Male 554 81.4 Female 127 18.6 Age Below 29 351 51.5 30 to 39 267 39.2 Above 40 61 9.0

Marital status Single 411 60.4

Married 216 31.7 Others 28 4.1 Nationality Asia-pacific 498 73.1 America 124 18.2 Europe 41 6.0 Africa 15 2.2

Occupation Worker, Engineer 220 32.3

Teacher 111 16.3 Student 67 9.8 Office worker 23 3.4 Businessperson 18 2.6 Others 198 29.1 Not working 27 4.0

A resident period in Korea Below 12 months 202 29.7

13 to 24 months 13 to 24 months 151 22.2

25 to 47 months 25 to 47 months 136 20.0

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Sexual behaviors and knowledge on HIV/AIDS

Table 2 showed the distribution of sexual orientation and knowledge of HIV/AIDS. Heterosexuals were 84.1%. Regarding knowledge of HIV/AIDS, most participants knew how to prevent HIV prevention methods (59.8%). The participant reported the reason for the visit was for counseling, represented with 40.4%. As a type of sexual partner was a known partner (19.5%). For the nationality of sexual partners, non-Korean partners were 29.4%. In the case of a lifetime experience, participants having unsafe sexual encounters were 50.2%. The location of unsafe sex happened in Korea (34.9%). The participants answered as the last possible exposure to HIV less than 3 months were 50.8%. During the last sexual encounter, participants said they used a condom (37.9%). 81.4% of participants reported they haven‘t had sexually transmitted disease infections.

Table2.Sexual orientation, sexual behaviors, the reason for visit VCT and knowledge on HIV/AIDS.

(N=574)

Characteristics N %

Sexual orientation _{Heterosexual 573 84.1}

Homosexual 50 7.3

Bisexual 24 3.5

Known knowledge of

HIV/AIDS The Difference Between HIV & AIDS 349 51.2

HIV transmission routes 392 57.6

Symptoms of HIV infection 282 41.4

Knowing no HIV transmission routes 301 44.2

How to prevent HIV transmission 407 59.8

HIV/AIDS Treatment & management 204 30.0

Reason for visit _{Counseling 275 40.4}

Unsafe sexual encounter 182 26.7

Regular check-up 166 24.4

Retest-close window period 13 1.9

Verification of test results 12 1.8

Injection drug user 1 0.1

Others 51 7.5

Lifetime experience of

unsafe sexual encounter Used 258 37.9

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Table 2. Continue

Characteristics N %

Type of sexual partner _{Known person 133 19.5}

Unknown person 45 6.6

Nationality of a sexual partner _{Sex worker 27 4.0}

Non-Korean 200 29.4

Lifetime experience of unsafe sexual encounter _{Korean 134 19.7}

Experienced 342 50.2

No experienced 269 39.5

Place of unsafe sexual encounter _{Korea 238 34.9}

Abroad 101 14.8

Last possible exposure to HIV within 3 months Yes (below 3

months) 346 50.8

No 281 41.3

Use of condom during the last sexual encounter _{Used 258 37.9}

Not used 220 32.3

Sexually transmitted diseases infected _{Had not 555 81.5}

Had 50 7.3

*note: Subtotal N=574 for Knowledge of HIV/AIDS

Comparison of anxiety level in between pretest and posttest

Table 3 showed the result of anxiety levels by socio-demographic characteristics at the pre- and post-test. Among the marital status, single showed a significant difference in anxiety level at the post-test as compared to the other marital statuses. In the post-test, Asia-pacific showed a statistical difference in the anxiety level than the other nationalities. Bisexual was statistically significant in anxiety levels at the post-test than the other sexuality groups. Participants with the knowledge on HIV/AIDS except the question for the knowledge on not knowing the HIV transmission routes showed a statistical difference in anxiety level at the post-test. Participants ever experienced an unsafe sexual encounter at the posttest showed a statistical difference in the anxiety level as compared to the others.

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Table 3. Comparison of anxiety groups between every three groups according to variables (N=681) Characteristics The anxiety level of a pre-test. The anxiety level of the Post-test.

Less Moderate Higher p-value Less Moderate Higher p-value

Total Gender 203(29.8) 125(18.4) 353(51.8) 429(63.0) 97(14.2) 155(22.8) Male 168(30.3) 105(19.0) 281(50.7) 0.314 351(63.4) 80(14.4) 123(22.2) 0.556 Female 35(27.6) 20(15.7) 72(56.7) 78(61.4) 17(13.4) 32(25.2) Age Below 29 111(31.6) 61(17.4) 179(51.0) 0.481 239(68.1) 41(11.7) 71(20.2) 0.001 30 to 39 74(27.7) 53(19.9) 140(52.4) 162(60.7) 45(16.9) 60(22.5) Above 40 18(29.5) 10(16.4) 33(54.1) 27(44.3) 11(18.0) 23(37.7) Marital status Single 127(30.9) 84(20.4) 200(48.7) 0.152 284(69.1) 50(12.2) 77(18.7) 0.002 Married 66(30.6) 33(15.3) 117(54.2) 120(55.6) 35(16.2) 61(28.2) Others 6(21.4) 4(14.3) 18(64.3) 16(57.1) 4(14.3) 8(28.6) Nationality Asia-pacific 142(28.5) 84(16.9) 272(54.6) 0.024 279(56.0) 79(15.9) 140(28.1) <.001 America 42(33.9) 27(21.8) 55(44.4) 101(81.5) 14(11.3) 9(7.3) Europe 15(36.6) 10(24.4) 16(39.0) 35(85.4) 2(4.9) 4(9.8) Africa 4(26.7) 3(20.0) 8(53.3) 12(80.0) 2(13.3) 1(6.7) Occupation Worker, Engineer 58(26.4) 42(19.1) 120(54.5) 0.485 120(54.5) 41(18.6) 59(26.8) 0.080 Teacher 37(33.3) 21(18.9) 53(47.7) 88(79.3) 12(10.8) 1(9.9) Student 24(35.8) 14(20.9) 29(43.3) 53(79.1) 7(10.4) 7(10.4) Office worker 10(43.5) 4(17.4) 9(39.1) 14(60.9) 4(17.4) 5(21.7) Businessperson 5(27.8) 2(11.1) 11(61.1) 11(61.1) 0(0.0) 7(38.9) Others 60(30.3) 33(16.7) 105(53.0) 120(60.6) 26(13.1) 52(26.3) Not working 6(22.2) 5(18.5) 16(59.3) 16(59.3) 4(14.8) 7(25.9) The resident period in Korea

Below 12 months 66(32.7) 37(18.3) 99(49.0) 0.854 135(66.8) 27(13.4) 40(19.8) 0.021 13 to 24 months 40(26.5) 27(17.9) 84(55.6) 102(67.5) 21(13.9) 28(18.5) 25 to 47 months 43(31.6) 22(16.2) 71(52.2) 89(65.4) 16(11.8) 31(22.8) Above 48 months 51(29.8) 35(20.5) 85(49.7) 94(55.0) 30(1.5) 47(27.5) Sexual orientation Heterosexual 173(30.2) 100(17.5) 300(52.4) 0.882 359(62.7) 82(14.3) 132(23.0) 0.002 Homosexual 12(24.0) 10(20.0) 28(56.0) 39(78.0) 6(12.0) 5(10.0) Bisexual 8(33.3) 6(25.0) 10(41.7) 20(83.3) (12.5) 1(4.2) Knowledge of the difference between HIV & AIDS

Known 97(27.8) 65(18.6) 187(53.6) 0.557 256(73.4) 41(11.7) 52(14.9) <.001 Unknown 69(30.7) 39(17.3) 117(52.0) 105(46.7) 40(17.8) 80(35.6)

Knowledge of HIV transmissionroutes

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Unknown 56(30.8) 31(17.0) 95(52.2) 90(49.5) 39(21.4) 53(29.1) Knowledge of symptoms of HIV infection

Known 73(25.9) 52(18.4) 157(55.7) 0.126 211(74.8) 29(10.3) 42(14.9) <.001 Unknown 93(31.8) 52(17.8) 147(50.3) 150(51.4) 52(17.8) 90(30.8)

Knowledge of knowing no HIV transmission routes

Known 88(29.2) 55(18.3) 158(52.5) 0.848 205(68.1) 29(9.6) 67(22.3) 0.081 Unknown 78(28.6) 49(7.9) 146(53.5) 156(57.1) 52(19.0) 65(23.8)

Knowledge of how to prevent HIV transmission

Known 124(30.5) 72(17.7) 211(51.8) 0.269 283(69.5) 46(11.3) 78(19.2) <.001 Unknown 42(25.1) 32(19.2) 93(55.7) 78(46.7) 35(21.0) 54(32.3)

Knowledge of HIV/AIDS Treatment & Management

Known 56(27.5) 38(18.6) 110(53.9) 0.653 154(75.5) 23(11.3) 27(13.2) <.001 Unknown 110(29.7) 66(17.8) 194(52.4) 207(55.9) 58(15.7) 105(28.4) Type of sexual partner

Known person 30(22.6) 23(17.3) 80(60.2) 0.082 92(69.2) 15(11.3) 26(19.5) 0.903 Unknown

person 9(20.0) 8(17.8) 28(62.2) 28(62.2) 9(34.6) 8(17.8) Sex worker 3(11.1) 2(7.4) 22(81.5) 20(74.1) 2(7.4) 5(18.5) Nationality of asexual partner

Non-Korean 55(27.5) 38(19.0) 107(53.5) 0.648 125(62.5) 31(15.5) 44(22.0) 0.060 Korean 33(24.6) 27(20.1) 74(55.2) 9(73.1) 15(11.2) 21(15.7)

Lifetime experience of unsafe sexual encounter

Experienced 84(24.6) 61(17.8) 197(57.6) 0.001 240(70.2) 43(12.6) 59(43.4) <.001 No

experienced 97(36.1) 50(18.6) 122(45.4) 146(54.3) 46(17.1) 77(28.6) Place of unsafe sexual encounter

Korea 57(23.9) 40(16.8) 141(59.2) 0.528 174(73.1) 30(12.6) 34(14.3) 0.037 Abroad 26(25.7) 20(19.8) 55(54.5) 64(63.4) 13(12.9) 24(23.8)

Last possible exposure to HIV within 3 months Yes (below 3

months) 110(31.8) 60(17.3) 17(50.9)

0.335

202(58.4) 55(15.9) 89(25.7) <.001 No 75(26.7) 58(20.6) 148(52.7) 203(72.2) 33(11.7) 45(16.0)

Use of condom during the last sexual encounter

Used 81(31.4) 44(17.1) 133(51.6) 0.461 153(59.3) 42(62.7) 63(24.4) 0.012 Not used 58(26.4) 46(20.9) 116(52.7) 157(71.4) 25(11.4) 38(17.3)

Sexually transmitted diseases infected

Had not 159(28.6) 96(17.3) 300(54.1) 1.000 348(62.7) 81(14.6) 126(22.7) 0.288 Had 12(24.0) 13(26.0) 25(50.0) 37(74.0) 3(6.0) 10(20.0)

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Comparison between Relieved group and non-relived group

Table 4 showed that anxiety relieved group and non-relived groups before and after HIV/AIDS results and getting counseling. The cut point for low anxiety, moderate anxiety, and high anxiety were 20-37, 38-44 and 45-80, respectively. The relieved group was defined as the participants changed to less anxiety level at the post-test from either less, moderate and higher anxiety level at the pre-test or changed to moderate anxiety level at the post-test from higher anxiety level at the pre-test. The sub-total number for the less anxiety level group at the post-test was 429 and the moderate anxiety level group was 59. A total of 488 (71.7%) was categorized as in a relieved group after receiving their test results.

Table 4. Anxiety relieved and non-relieved groups before and after the HIV test and counseling. (N=681)

Pre-test Post-test Each number Sub-total number 1 Sub-total number 2

Relieved group

Less anxiety Less anxiety 174

429

488(71.7%) Moderate anxiety Less anxiety 82

Higher anxiety Less anxiety 173

Higher anxiety Moderate anxiety 59 59

Unrelieved group

Less anxiety Moderate anxiety 11

29

193(28.3%) Higher anxiety 18

Moderate anxiety Moderate anxiety 27

43 Higher anxiety 16

Higher anxiety Higher anxiety 121 121

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Comparison of anxiety level change groups by demographics, sexual

behavior, sexual orientation, and knowledge on HIV/AID

Table 5 showed the comparison of anxiety level change groups by demographics, sexual behavior, sexual orientation, and knowledge. Respondents under the age below 29 showed more in the relieved group than the other age groups with a statistical significance. Among marital status, a singles participant belonged significantly more in the relieved groups than the other martial groups. Respondents with African nationality were statistically more in the relieve group than the other nationality groups. Bisexual showed more in the relieve group than the other sexuality groups with a statistical difference. Concerns to Respondents with HIV/AIDS knowledge were more in the relieved with a statistical significance. Respondents with ever experienced unsafe sex were more in the relieved group than those with no experiences with a statistical difference. Respondents who had unsafe sexual encounters in Korea were more in the relieved group than those with unsafe sex abroad. Those last possible exposures to HIV within 3 months showed more in the relieved with a statistical difference than the others.

Table 5. Comparison of anxiety level change groups by variables demographics, sexual behavior, sexual

orientation, and knowledge (N=681)

Characteristics Relieved group Non-relieved group p-value

Gender Male 400 (72,2) 154 (27.8) 0.514

Female 88 (69.3) 39 (30.7)

Age Below 29 262 (74.6) 89 (25.4) 0.009

30 to 39 191 (71.5) 76 (28.5)

Above 40 34 (55.7) 27 (44.3)

Marital status Single 317 (77.1) 94 (22.9) 0.001

Married 140 (64.8) 76 (35.2) Others 17 (60.7) 11 (39.3) Nationality Asia-pacific 323 (64.9) 175 (35.1) <.001 America 112 (90.3) 12 (9.7) Europe 37 (90.2) 4 (9.8) Africa 14 (93.3) 1 (6.7)

Occupation Worker, Engineer 142 (64.5) 78 (35.5) 0.051

Teacher 99 (89.2) 12 (10.8) Student 57 (85.1) 10 (14.9) Office worker 15 (65.2) 8 (34.8) Businessperson 11 (61.1) 7 (38.9) Others 136 (68.7) 62 (31.3) Not working 19 (70.4) 8 (29.6)

A resident period in Korea Below 12 months 151 (74.8) 51 (25.2) 0.026 13 to 24 months 115 (76.2) 36 (23.8)

25 to 47 months 100 (73.5) 36 (26.5) Above 48 months 110 (64.3) 61 (35.7)

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Sexual orientation Heterosexual 408 (71.2) 165 (28.8) <.001

Homosexual 44 (88.0) 6 (12.0)

Bisexual 23 (95.8) 1 (4.2)

Knowledge of the difference between HIV & AIDS

Known 279 (79.9) 70 (20.1) <.001 Unknown 130 (57.8) 95 (42.2) Knowledge of HIV transmission routes Known 294 (75.0) 98 (25.0) 0.004 Unknown 115 (63.2) 67 (36.8) Knowledge of symptoms of HIV infection Known 226 (80.1) 56 (19.9) <.001 Unknown 183 (62.7) 109 (37.3)

Knowledge of knowing no HIV transmission routes

Known 218 (72.4) 83 (27.6) 0.520

Unknown 191 (70.0) 82 (30.0)

Knowledge of how to prevent HIV transmission

Known 308 (75.7) 99 (24.3) <.001

Unknown 101 (60.5) 66 (39.5)

Knowledge of HIV/AIDS Treatment & Management

Known 165 (80.9) 39 (19.1) <.001

Unknown 244 (65.9) 126 (34.1)

Type of sexual partner Known person 100 (75.2) 33 (24.8) 0.421

Unknown person 36 (80.0) 9 (20.0) Sex worker 22 (81.5) 5 (18.5) Nationality of sexual Partner Non-Korean 143 (71.5) 57 (28.5) 0.051 Korean 109 (81.3) 25 (18.7)

Lifetime experience of unsafe sexual encounter

Experienced 270 (78.9) 72 (21.1) <.001

No experienced 170 (63.2) 99 (36.8) Place of unsafe sexual

encounter

Korea 197 (82.8) 41 (17.2) 0.013

Abroad 71 (70.3) 30 (29.7)

Last possible exposure to HIV within 3 months

Yes (below 3m) 236 (68.2) 110 (31.8) 0.003

No 222 (79.0) 59 (21.0)

Use of condom during the last sexual encounter Used 180 (69.8) 78 (30.2) 0.029 Not used 173 (78.6) 47 (21.4) Sexual transmitted diseases infected Had not 401 (72.3) 154 (27.7) 0.624 Had 38 (76.0) 12(24.0) *Chi-square test

P-value from the t-trend test if more than three groups

Multivariate analysis of anxiety level change by demographic

characteristics, sexuality, sexual behaviors, and knowledge on HIV/AIDS.

Table 6 showed the results from a multivariate analysis of anxiety level change by demographic characteristics, sexuality, sexual behaviors, and knowledge on HIV/AIDS. Respondents less than 29 years of age showed 3.8 times higher chance to have anxiety level changes than the other age groups. Respondents with the knowledge of HIV/AIDS times were more likely to be in the relieved group than those without the knowledge of HIV/AIDS. In detail, respondents with the knowledge on the difference, transmission, prevention, and treatments had the odds ratio of 6.2, 13.8, 5.9 and 1.5,

13

respectively. Those who had no possible exposure to HIV/AIDS in the last 3 months had 4.7 times more likely to be in the relieved group.

Table 6. Multivariate analysis of anxiety level change groups significant by demographic

characteristics, sexuality, sexual behaviors and knowledge on HIV/AIDS ( (N=681)

Characteristics OR 95%CI

Age Above 40 1.0

30 to 39 1.2 0.4-3.4

Below 29 3.8 0.3-42.8

Marital status Others 1.0

Married 1.6 0.6-5.9 Single 2.2 0.3-17.6 Nationality Asia-pacific 1.0 America 1.3 0.2-8.7 Europe 2.9 0.5-17.7 Africa - -

A resident period in Korea Above 48 months 1.0

25 to 47 months 1.2 0.3-4.4

13 to 24 months 1.8 0.4-8.1

Below 12 months 2.8 0.7-10.8

Sexual orientation Heterosexual 1.0

Homosexual 2.5 0.2-27.9

Bisexual 0.6 0.0-16.3

Knowledge of the difference between HIV & AIDS

Unknown 1.0

Known 6.2 1.5-25.5

Knowledge of HIV transmission routes Unknown 1.0

Known 13.8 1.9-99.0

Knowledge of symptoms of HIV infection Unknown 1.0

Known 0.5 0.1-2.1

Knowledge of how to prevent HIV transmission Unknown 1.0

Known 5.9 1.2-29.5

Knowledge of HIV/AIDS Treatment & Management

Unknown 1.0

Known 1.5 0.4-4.8

Place of unsafe sexual encounter Abroad 1.0

Korea 1.2 0.4-3.5

Last possible exposure to HIV within 3 months Yes (below 3 m) 1.0

No 4.7 1.7-13.1

Use of condom during the last sexual encounter Used 1.0

14

Discussion

Anxiety level aspect

The major finding of this study was a significant association between anxiety groups and anxiety-related variables. This study reported high levels of anxiety at pretest and relieved at posttest among the subjects at the VCT center regardless of the HIV test result [36]. Anxiety level change was associated with some of the socio-demographic characteristics. African nationality was associated with anxiety level change as compared to other nationalities. On the other hand, these women with higher anxiety levels might be the group 'driven' by their anxiety to seek knowledge of their status rather than the issues linked to seeking HIV tests. In other studies, the comparison between anxiety level change and age, older adults experienced two times more depressed than younger adults. Our study found young age group below 29 showed a more relieved anxiety level [39].

Sexual behavioral aspect

There are diverse foreigners in Korea. Some studies had reported a higher risk for HIV and STD infection among foreigners in Korea. To intervene and prevent the spread of HIV and STDs, we need evidence related to their sexual behaviors and other factors; however, there was no previous study to collect and analyze such data in Korea. In the recent study, we found the risk of sexual behavior in foreigners differed by sexual orientation after controlling unsafe sexual encounters after screening for individual sexual behavior characteristics. We also found that the association between possible exposure to HIV within 3 months and use of condom during the last sexual encounter got anxiety to relieve in posttest also were associated with significant value identifying group that had a high risk for STD and HIV behavior and highly relieved at posttest [39] Our study result showed that respondents with unsafe sexual experiences were found in the relieved group. In this study, we found single foreigners were more relieved than the other marital group. In the recent study, also supported this result, single patients reported significantly better in the overall wellbeing conditions such as better sleep, less pain, fatigue, and nausea. We found respondents‘ not using a condom was associated with anxiety relief. This result was controversial and we recommended for it might need further exploration

.

15

Knowledge of HIV/AIDS among foreigners in Korea

The respondents in this study believed that knowledge about HIV/AIDS could help them to stay in the relieve group as other studies reported [36]. The fact that educated women showed higher anxiety levels than men might indicate 'worry too much' due to better awareness and understanding of the consequences of a positive HIV test [36].

Limitations

Our study had limitations the study used cross-sectional data from convenience sampling. The other limitation was, subjective rating on their current anxiety level, which could be subject to inaccuracy like recall bias; this study results would not be represented by foreigners in Korea because it was a self-motivated voluntary HIV/AIDS testing for them.

Recommendations

These findings would be useful for the health care designing a new system or interventions for foreigners with or without HIV/AIDS. In addition to counseling and HIV testing, the VCT visitors should be able to get some advice in a culture-sensitive manner. This might help improve the performance of VCT specifically by introducing education sensitive interventions. Special counseling skills might be required for unique populations with concerns about HIV. The findings might indicate 'pre-post HIV test' anxiety level could occur because of many competing factors. One of them, it could be ‗seeking the HIV test‘ itself this study would serve for future studies on HIV/AIDS among foreigners in Korea

16

Conclusion

The result of our study showed that most foreigners did not use condoms for their sexual encounters. It might need further study research to increase their HIV/AIDS understanding and safe sex practices. The results showed that foreigners in specific conditions such as age, marital status, lack of knowledge on HIV/AIDS, etc. might require more attention for prevention, treatment, and management process.

We found that the results could be useful to increase understanding of the importance of VCT centers used by foreigners and migrants in South Korea. Further study should be warranted specifically in terms of socio-demographic characteristics, sexuality, sexual behaviors, and knowledge level about HIV/AIDS among foreigners in Korea.

17

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2. UNAIDS On the Fast-Track to end AIDS. UNAIDS 2016–2021 Strategy 20 Avenue Appia CH-1211 Geneva 27 Switzerland available at

https://www.unaids.org/sites/defult/files/media_asset/20151027_UNADS_PCB37_15_18_EN _rev1. Accessed on November 2,2019.

3. Joint United Nations Programme on HIV/AIDS the HIV-Brazil cohort study: design, methods and participant characteristics. UNAIDS data 2017

4. Korea Centers for Diseases Control and Prevention. The Status of HIV/AIDS Infection in Korea. Cheongju: Korea Centers for Disease Control and Prevention; 2016.

5. Lee, Y. H., Bang, J. H., Park, S. M., Kang, C. R. et al. Cost-Effectiveness of Voluntary HIV Testing Strategies in a Very Low-Prevalence Country, the Republic of Korea. Journal of Korean medical science vol. 33,46 e304. 18 Oct. 2018, doi:10.3346/jkms.2018.33.e304 6. Derose, K. P., Escarce, J. J. and Lurie, N. Immigrants and health care: sources of vulnerability

Health Affairs. 2007;26:1258-1268

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Increasing late diagnosis in HIV infection in South Korea: 2000-2007. BMC public health, 10, 411. doi:10.1186/1471-2458-10-411

10. Spielberger, C. Manual for the State-Trait Anxiety Inventory. rev. ed. Consulting Psychologists

11. Horwitz A. V. How an age of anxiety became an age of depression. The Milbank quarterly, (2010). 88(1), 112–138. doi:10.1111/j.1468-0009.2010.00591.

12. For use by Ashley Pasen only. Received from Mind Garden, Inc. on September, 2010, 14. 13. Arthritis Care Res (Hoboken). 2011; 63 Suppl 11(0 11):S467–S472. DOI:10.1002/acr.20561 14. Knight, R. G., Waal-Manning, H. J., & Spears, G. F. Some norms and reliability data for the State-Trait Anxiety Inventory and the Zung Self-Rating Depression Scale. British Journal of Clinical Psychology. 1983; 22: 245-249.

15. Addolorato G, Ancona C, Capristo E, Graziosetto R, Di Rienzo L, Maurizi M, et al. State and trait anxiety in women affected by allergic and vasomotor rhinitis.

16. Sahay, S.; Phadke, M.; Brahme, R.; Paralikar, V.; Joshi, V.; Sane, S.; Risbud, A.; Mate, S.; Mehendale, S. Correlates of anxiety and depression among HIV test-seekers at a voluntary counseling and testing facility in Pune, India. Qual. Life Res. 2007, 16, 41–52.

17. Anxiety and depression association of America adaa.org/living-with-anxiety/women/facts accessed on September .2019; 22

18. Choi, J., Kushner, K. E., Mill, J., Lai, D. W. L. Health experiences of Korean immigrant women in retirement. Health Care for Women International, 2014. 35, 1315-1336. doi:10.1080/07399332.2014.954700

19. Choi, H.J. Development of the Guideline for HIV Testing in South Korea with Low

Prevalence of HIV-1 Infection Based on the Expert Consensus. World Journal of AIDS. 2011 1(4) ,pp.155164.Availableat:http://www.scirp.org/journal/PaperDownload.aspx?DOI=10.423 6/wja.2011.14023.

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21. J.Y. Lee, R.A. Kearns, W. Friesen. Seeking affective health care: Korean immigrants' use of homeland medical services Health Place, 2010;16 pp. 108-115

22. Jung M, Lee J, Kwon DS, Park B-J. Comparison of Sexual Risky Factors of Men Who Have Sex with Men and Sex-buying Men as Groups Vulnerable to Sexually Transmitted Diseases. J Pre v-Med Public Health. 2012; 45(3):156–63.

23. Global information and education on HIV and AIDShttps://www.avert.org/search/site accessed on October 21, 2019

24. Korea HIV/AIDS Prevention & Support Center available at http://khap.org/?c=2/10 accessed on November 4, 2019

25. HIV/AIDS Prevention & Support Center available at http://www.iansan. Net /English/ about Ansan/living guide/Main Agencies.

26. Spitzer RL, Kroenke K, Williams JBW, Lowe B. A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Arch Intern Med. 2006;166(10):1092–1097

27. Wang, Y. Anxiety Scale. 2007, 38(6), pp.990–1009.

28. Shin, S., Kang, H.S. & Money ham, L., 2007. Characteristics of individuals seeking voluntary counseling and testing for HIV infection in South Korea. JANAC: Journal of the Association of Nurses in AIDS Care, 18(5),pp.27–33.Available

at:http://ezproxy.library.dal.ca/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=c8h&AN=2009697794&site=ehost-live.

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http://www.health24.com/Medical/HIV-AIDS/Counselling/Post-HIV-test-counselling-20120721 accessed on October 26, 2019

30. Hussain, T. Psychological distress leading to repeat HIV testing in an Integrated Counseling & Testing Centre (ICTC) at Agra, India-Case report of 10 HIV-negative clients; 2013 31. United nation development program UNDP Annual Report 2006 Nov 23, 2015 United

Nations, 2006

32. Migration, Urbanization and Sustainable Livelihoods in South Africa Southern African Migration Project, Migration Policy Brief No. 15 Loren Landau 2005.

33. White, Khan, Report on the global AIDS epidemic.2007 available at

https://books.google.co.kr/books?id=WepARRFDEAwC&pg=PA114&lpg=PA114&dq=Whit e,+2003;+Khan+et+al.,+2007&source=bl&ots=vwl5gJl9O3&sig=ACfU3U1N_4U0KFx_daZ Celao6UUbok7mIQ&hl=en&sa=X&ved=2ahUKEwjH5d_w483mAhXIZt4KHU6vBykQ6AE wAXoECAoQAQ#v=onepage&q=White%2C%202003%3B%20Khan%20et%20al.%2C%20 2007&f=false accessed on December 1,2019.

34. UNGASS Country Progress Reports 2008. Progress reports submitted by countries accessed November 1, 2019

35. McMahon T, Ward PR. HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioral HIV prevention. Syst Rev. 2012;1:56. Published 2012 Nov 20. DOI:10.1186/2046-4053-1-56

36. Anxiety and motivation: Theory and Crucial experiment,; Cattell & Scheier, 1961, 1963 37. Senn TE, Walsh JL, Carey MP. Mediators of the Relation Between Community Violence and

Sexual Risk Behavior Among Adults Attending a Public Sexually Transmitted Infection Clinic. Arch Sex Behav. 2016;45(5):1069–1082. DOI:10.1007/s10508-016-0714-6 38. Julian L. J. Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety

Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis care & research, 2011. 63 Suppl 11(0-11), S467–S472. doi:10.1002/acr.20561

19

39. Addolorato G, Ancona C, Capristo E, Graziosetto R, Di Rienzo L, Maurizi M, et al. State and trait anxiety in women affected by allergic and vasomotor rhinitis. J Psychosom Res.

1999;46:283-9

40. Arthritis Care Res (Hoboken). Author manuscript; available in PMC 2014 January 03. Published in final edited form as Arthritis Care Res (Hoboken). 2011 November; 63(0 11): . DOI:10.1002/acr.20561

20

SUPPLEMENTS

Dear Respondents:

We are surveying Factors Associated with VCT test results related to anxiety within

the VCT counseling center we will appreciate it if you could complete the following

questionnaire on time. There are no right or wrong answers and you may stop at any time;

however, completing the entire survey (about 5 – 10) minutes is greatly appreciated.

Any information obtained in connection with this study will remain confidential. No

one will be identified in any written reports and only group data will be presented. You are

free to withdraw your participation at any time.

Zufan zenebe

21

State of Anxiety Survey 1

The following sentences are used for expressing oneself. After reading

each sentence, please choose a number from 1 to 4, which best describes

how you feel at this moment.

Description

Not at all A little bit Yes Absolutely

1

I am calm.

1

2

3

4

2

I feel secure.

1

2

3

4

3

I am nervous.

1

2

3

4

4

I feel regret and am unsatisfied.

1

2

3

4

5

I feel comfortable.

1

2

3

4

6

I do not know what to do and am in dismay.

1

2

3

4

7

I worry about the future.

1

2

3

4

8

I feel relieved.

1

2

3

4

9

I am insecure.

1

2

3

4

10

I feel at ease.

1

2

3

4

11

I am confident.

1

2

3

4

12

I am annoyed.

1

2

3

4

13

I feel uneasy.

1

2

3

4

14

I am extremely nervous.

1

2

3

4

15

I feel comfortable as my tension has been

relieved.

1

2

3

4

16

I am satisfied.

1

2

3

4

17

I am worried.

1

2

3

4

18

I do not know what to do as I am too excited.

1

2

3

4

19

I am delighted.

1

2

3

4

22

Visitor Questionnaire

KHAP

Korea HIV/AIDS Prevention & Support Center

**Please help us compile statistics about those who use our services by answering the following questions. The information you provide is important and will help us continue to develop our program. Completing this questionnaire may also make it easier to help you in making any desired changes in your behavior by putting words to your experience. Be assured that all information on this form will remain anonymous.

I. General Information

1. Gender: ☐ Male ☐ Female

2. I self-identify as ☐ Heterosexual ☐ Homosexual ☐ Bisexual 3. Age: ______

4. Nationality: ___________________

5. Marital Status: ☐ Married ☐ Single ☐ Other 6. Total duration of residence in Korea: ___________

7. Job: ☐ Teacher ☐ Student ☐ Businessperson ☐ Military ☐ Entertainer ☐ Migrant Worker ☐ Engineer ☐ Unemployed ☐ Other(please specify)______

8. HIV/AIDS Knowledge: Please check all that apply

I know…

☐ The difference between HIV and AIDS ☐ HIV transmission routes

☐ Symptoms of HIV infection ☐ How to prevent HIV transmission

☐ HIV/AIDS treatment and management

II. Please check the reason for your visit

☐ Recently experienced an unsafe sexual encounter(condomless sex) ☐ Retest to close the window period

23

☐ Verification of HIV Test Results ☐ IDU (Injection Drug User) ☐ (Regular) Check-up ☐ Counseling

☐ Other ( )

III.

Will you take the HIV test? ☐ Yes ☐ No

1. Was your last possible exposure to HIV more than 3months ago?

☐ Yes

☐ No. It happened about ________ days/weeks ago

2. Did you use a condom during your last sexual encounter? ☐ Yes ☐ No

3. Have you been tested for HIV before?

☐ No, this is my first time

☐ Yes, and my last test result was negative

☐ Yes, and my last test result was positive

☐ Yes, and my last test result was undetermined

☐ Yes, but I don‘t know what the results of the last test were.

**If YES, when was your last test? ______________________

4. Have you had a major operation during the past 12 months? ☐ Yes ☐ No

5. If female, are you pregnant? ☐ Yes ☐ No

IV.

Sexual Behavior

*These are not compulsory questions but it will be very helpful if you answer them.

1. Have you ever had an unsafe sexual encounter? ☐ Yes ☐ No

2. Place of unsafe sexual encounter: ☐ Korea ☐ abroad

*If in Korea, was your partner:

☐ A Sex Worker ☐ Someone Known ☐ Someone Unknown

3. Do you currently have a sexual partner? ☐ Yes ☐ No

4. Have you ever had a sexually transmitted disease? ☐ Yes ☐ No

If YES, what was it?

☐ Bacterial Vaginosis (BV) ☐ Human Papillomavirus (HPV)

☐ Chlamydia☐ Pelvic Inflammatory Disease (PID)

24

☐ Gonorrhea ☐ STDs and Infertility

☐ Hepatitis, Viral☐ Syphilis

☐ Herpes, Genital☐ Trichomoniasis

☐ HIV/AIDS & STDs☐ Other STDs

V.

How did you hear about KHAP?

* is it your first time to visit the KHAP center? □Yes □No:(Seoul/Ansan/Busan)

☐ Information brochure or leaflet

☐ Web Search  (☐ Google ☐ Yahoo ☐ YouTube ☐ Other [ ]

☐ Advertisement on the website "Work & Play"

☐ Campaign  (☐ Street ☐ Bar ☐ Community)

☐ Referred by a person  (☐ Friend ☐ Coordinator)

25

State of Anxiety Survey 2

The following sentences are used for expressing oneself. After reading each

sentence, please choose a number from 1 to 4, which best describes how you

feel at this moment

Description

Not at all A little bit Yes

Absolutely

1

I am calm.

1

2

3

4

2

I feel secure.

1

2

3

4

3

I am nervous.

1

2

3

4

4

I feel regret and am unsatisfied.

1

2

3

4

5

I feel comfortable.

1

2

3

4

6

I do not know what to do and am in dismay.

1

2

3

4

7

I worry about the future.

1

2

3

4

8

I feel relieved.

1

2

3

4

9

I am insecure.

1

2

3

4

10

I feel at ease.

1

2

3

4

11

I am confident.

1

2

3

4

12

I am annoyed.

1

2

3

4

13

I feel uneasy.

1

2

3

4

14

I am extremely nervous.

1

2

3

4

15

I feel comfortable as my tension has been

relieved.

1

2

3

4

16

I am satisfied.

1

2

3

4

17

I am worried.

1

2

3

4

18

I do not know what to do as I am too excited.

1

2

3

4

19

I am delighted.

1

2

3

4

26

Department of Preventive Medicine and Public Health

School of Medicine

Ajou University

March 2014

To Korea HIV/AIDS Prevention and Support Center Ansan

Dear Sir/Madam:

A student from our department named Zufan Zenebe has asked for an official letter

so that you can give her the data she has requested for her academic research.

This is to confirm that the above mention student is from our department and

she will use the data for only her academic research and no for other use what is so ever.

We sincerely thank you for your cooperation in providing the necessary data she has

requested and for any other support, she might require.

Sincerely,

Sign