AIDS knowledge and attitudes of pupils attending urban high schools in Israel

Patient Education and Counseling 36 (1999) 271–278

AIDS knowledge and attitudes of pupils attending urban high schools in Israel 1, Uzi Brook *

Department of Pediatrics, Edith Wolfson Medical Center, Holon 58100, Israel Received 29 September 1996; received in revised form 25 August 1998; accepted 9 November 1998

Abstract The present study compared AIDS knowledge, attitude and sources of information of 1724 students in three different high schools (academic, vocational and religious) in Holon. Forty-two percent of the students are anxious concerning the possibility of AIDS contamination; they expressed a willingness to be tested for HIV and AIDS. Pupils attending the academic school proved to have the highest knowledge concerning AIDS topics; those in the vocational school placed second; and those in the religious school came last. The knowledge increased with age ( p , 0.001). Results indicated that misconceptions were still found in a second decade of that epidemic concerning the following areas: etiology, ways of exposure; symptomatology; and prognosis. Their intolerant attitudes reflect social anxiety and vulnerability to AIDS. The most liberal and comprehensive attitudes toward AIDS patients were presented by pupils attending the academic school and after that came pupils from the vocational school, while pupils in the religious school presented the most conservative and intolerant attitudes. The sources of pupils’ information primarily included: the media – TV (92.3%); newspapers (87.6%); and school (66.1%) occupied the third place. It is remarkable that physicians and nurses at school and outside clinics were placed in the seventh (and last) place, as only 25.3% mentioned them at all. Only one third of the pupils agreed to participate as volunteers in medical and rehabilitation centers which help AIDS patients.  1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: AIDS; Adolescents; Knowledge; Attitude

1. Introduction The epidemic of AIDS is in its second decade. AIDS has now become a pandemic disease which

*Tel.: 1 972-3-5028211; fax: 1 972-3-5036408 1 Affiliated with the Sackler School of Medicine, University, Tel Aviv, Israel

threatens all races in all parts of the world. It has become the most reviewed and discussed disease [1]. It involves all body systems as well as the mental health and social relationships of carriers and symptomatic patients. In Israel, the number of reported patients until 1993–1994 was 304, 20 of whom were children; it was noted that by 1998 the total estimated number of patients had reached six hundred. The reported

0738-3991 / 99 / $ – see front matter  1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0738-3991( 98 )00142-6

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number of carriers is 1202, but the real number may be as high as 10 000 [2]. The numbers are lower in comparison with other western countries [3]; some researchers relate this to the conservative attitude of the Israel society, as well as to critical attitudes toward homosexuality, sexual liberty, and exposure to multiple sexual partners [4]. Adolescents are in a high risk group for contamination by HIV as a result of uncontrolled non-protected sexual experience and sexual contact with different partners [5,6]. The majority of young Israelis leave the country after finishing military service for several months; they travel to the Far East or South America where they can risk exposure to AIDS. In the present study, we specifically examined for a second decade the level of knowledge and the attitudes of three varied pupil population groups for a total of 1724 pupils – academic, vocational and religious schools – towards AIDS, as well as to infected people. The student population in these three schools varied in their socio-economic level, education and family status. In the absence of a cure for HIV infection, health education and prevention remain the main health care priorities; because of the significance of these areas, AIDS was chosen among all the other STDs. The importance of adequate knowledge about AIDS in relation to infection control is evident. We can suppose that accurate knowledge about AIDS will reduce risk behavior. We can expect adolescents with greater knowledge to avoid high risk behavior, though there is no guarantee in this aspect [7]. In the framework of pupils’ attitudes, some social / moral questions were asked concerning AIDS patients. For example: Is it necessary to keep HIV infected pupils away from the school? Do pupils acquiesce to sitting in class near an HIV positive pupil? Knuis et al. [8] recommended to teach the pupils the fact that one should not censure the infected pupils for their disease, and Lee [9] indicated that even these infected pupils have the right to receive treatment as well as others having acute and chronic diseases. The aims of the study were as follows: 1. To evaluate the knowledge of the students about AIDS for a second decade of epidemic and to see if there are significant differences between the

three different student populations attending academic, vocational and religious schools. 2. To investigate for a second decade the attitudes of these three varied pupil populations concerning social and moral AIDS aspects. 3. To discover from what sources of information these students learn about AIDS.

2. Respondents and methods The target population of the study were pupils attending three representative schools which had been chosen at random in the city of Holon – academic, vocational and religious schools (classes in the religious school are smaller). There were 1724 pupils participating in the study. The students’ response rate was 85%. A self evaluation questionnaire was composed by two pediatricians and two educational consultants. The original questionnaire included 125 questions. The questionnaire had passed judge validity and the reviewers included: pediatricians (2), epidemiologists (2), teachers (2) and educational advisors (2). They reduced the number of questions by 40 items. In its final form the questionnaire included questions on 85 items: personal and familial socio-economic information – 28; AIDS knowledge – 23; attitude towards moral and social problems concerning AIDS – 22; sources of information and educational issues due to AIDS – 12. The AIDS knowledge scale was computed by summing all correct responses. Higher score indicated greater level of knowledge. In the attitude section, students responded ‘‘agree’’ or ‘‘disagree’’ to 22 statements. The attitude section included questions on the relationship with AIDS patients. As one of the schools was religious, we were limited in asking them questions concerning homosexuality and sexual behavior. Items are listed in Appendix A (knowledge) and Appendix B (attitude). Pupils completed the questionnaire anonymously during a 45 minute period of health education at school. The statistical analysis was done in the computer laboratory in the university’s department of sociology utilizing SPSS program, including the x 2 test, analysis of variance (ANOVA) and correlation tests. In all

U. Brook / Patient Education and Counseling 36 (1999) 271 – 278

analyses, the usual significance level was 5% for inclusion of potential variables.

3. Results The socio-economic data of the students is shown in Table 1. A cross section of the student seems to be from the middle socio-economic class in Israel. Regarding apprehension about possible contamination among the pupils: 15.5% (n 5 226) of the pupils feel themselves at real risk of contracting HIV; Table 1 Socio-demographic data of the participants Parameter

n

Mean6S.D.

%

Age (years) Sex ratio: Boys Girls

15.8261.14 1042 671

60.7 39.3

School: academic vocational religious

878 691 140

51.4 40.4 8.2

Fathers’ profession technical commercial teaching academic

436 783 46 245

29.3 51.2 3.1 16.4

Mothers’ profession technical commercial teaching academic homemaker

464 162 240 159 557

29.3 10.2 15.2 10.1 35.2

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42.4% (n 5 735) are interested in being personally tested for HIV [46.6% in the age group of 14–16 in comparison with 40.8% in the age group of 16–18 years ( p 5 0.004)]. Fifty-eight percent still fear contamination during treatment by a dentist [54.9% of the boys in comparison to 45.1% of the girls ( p , 0.001)]. Do students differ in their knowledge? Students in the 12th grade received the higher score for their knowledge: 18.8 vs. mean of 17.5 of all students. It was higher than students of the 11th grade class (17.9), the 10th grade class (17.6) and the 9th grade class (16.4). Students in the academic school received the higher score for their knowledge (18.3) in comparison with the vocational school (16.8) and the religious school (16.4). The knowledge of the girls was higher than that of the boys ( p 5 0.03; r 5 0.08;). The pupils’ knowledge is shown in Tables 2 and 3. The knowledge was in correlation with school grades of the students and his / her mean marks as well with class behavioral grades given to the students by his teacher (r 5 0.07; p 5 0.003). Some of the misconceptions concerning AIDS that were reported by the pupils were as follows: 15.4% of the students believe that positive HIV patients can

Table 2 Students’ AIDS knowledge – comparison among schools School

n

Scoring*

Academic Vocational

878 691

18.2863.37 16.7564.67

Religious Total

140 1709

16.4164.02 17.4963.5

p (ANOVA) (F 5 33.95) 0.00001

Years of study father mother

12.3862.76 12.5962.5

* Maximal score: 23 points.

Habitation conditions: number of persons number of rooms

4.8761.15 4.5661.21

Table 3 Students’ AIDS knowledge – comparison according to age (class level)

Family cohesion married divorced deceased School grades mean (out of 10) behavior (in class)

Class 1500 94 3.8

92.9 4.8 2.3 7.0860.99 8.7761.01

Age (years)

n

Scoring

12th 11th

17–18 16–17

303 434

18.7962.87 17.8863.71

10th 9th Total

15–16 14–15 14–18

495 492 1724

17.5563.58 16.4065.01 17.4963.5

p (ANOVA) (F 5 23.86) 0.00001

U. Brook / Patient Education and Counseling 36 (1999) 271 – 278

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spread the disease by cough and contamination by sputum; 17% believe that contamination can occur by kissing an AIDS patient; approximately half of the students think that a dog’s or cat’s bite can spread the virus; 74% of the students think that AIDS is caused by a bacterium; and 17% believe that AIDS can be cured if treated early enough. Do students differ in their attitude towards positive HIV patients? The scores of students’ attitudes is shown in Tables 4 and 5. Thirty-seven point two percent of the pupils think that all students should be informed about a HIV positive pupil attending their school. Twenty-nine point seven percent think that all parents in the class should also know about a HIV positive pupil attending their class; 13.6% of the pupils think that a HIV positive student should be dropped from school in order to decrease the risk of contamination in school [boys had this attitude more than girls ( p 5 0.01)]. That attitude decreased with age ( x 2 5 0.06), and was expressed mostly by pupils attending vocational schools, followed by pupils in the academic and religious schools ( x 2 5 0.0002); 33.2% of the pupils declared that they prefer not to sit in a class near a HIV positive student [the boys had this attitude more Table 4 Students’ intolerant attitudes toward positive HIV patients in different schools School

n

Scoring*

Academic Vocational

878 691

10.5463.28 10.7363.81

Religious

140

11.163.13

p (ANOVA) (F 5 1.77) N.S.

than girls [(69.5% vs. 30.5%) ( p , 0.001)]. That attitude was expressed mostly by pupils attending vocational schools, followed by pupils in the religious and academic schools ( p 5 0.025)]. Other opinions regarding AIDS expressed by the pupils are as follows: 10.4% of the pupils declared that they would discontinue any relationship with a friend who had become a positive HIV patient [this attitude was more frequent among boys than among girls ( p , 0.001) and was expressed mostly by pupils attending vocational schools, followed by pupils in academic and religious schools ( p , 0.001)]; 24.1% of the pupils think that an adopted baby who had been diagnosed at two years of age as HIV positive should be returned to the institution from which the child had been taken for adoption [boys had this attitude more than girls (69.2% vs. 30.8%) ( p , 0.001); this was expressed mostly by pupils attending vocational schools, followed by pupils in academic and religious schools ( p , 0.001)]; 39% of the pupils believe that there is no reason to keep the diagnosis of AIDS in medical confidence, because of the possibility of contamination and its consequences. Sources of information on AIDS are summarized in Table 6. The media is the most powerful, but not necessarily credible source: TV (92.3%) and newspapers (87.6%). Sixty-six percent of the students learned about AIDS at school. Physicians and nurses were found to be in the last place for teaching students about AIDS (25.7%). Finally, responding to the three supplemental questions, 65.5% of the pupils believe that the Ministry of Education should include the topic of

* High scoring reflects criticism and intolerant attitudes toward the ill patient and their disease. (Maximal scoring 21 points.) Table 6 Sources of pupils’ knowledge about AIDS Table 5 AIDS intolerant attitudes among the students in the various classes Age (years)

Class

n

Scoring*

14–15 15–16 16–17

9 10 11

482 495 434

10.0663.84 11.0663.08 10.8163.56

p (ANOVA)

(F 5 7.42) 0.00001 17–18

12

303

10.7463.32

* High scoring reflects criticism and intolerant attitudes toward the ill patient and their disease. (Maximal scoring 21 points.)

Source

n

%

TV Newspapers School Informational pamphlet (from the Ministry of Education or Health) Radio Parents Friends Books (popular) Physicians and nurses

1499 1518 1146 985

92.3 87.6 66.1 56.8

879 773 738 546 445

50.7 44.6 42.6 31.5 25.7

U. Brook / Patient Education and Counseling 36 (1999) 271 – 278

AIDS even in the curriculum of elementary school, while 95.8% think it should be taught regularly only in high school. Eighty-nine point three percent of the pupils think that the placement of ‘‘condomats’’ (condom dispensers) in high schools is justified and this opinion was expressed mostly by pupils attending academic schools, then followed in order by pupils in the vocational and religious schools ( p , 0.001)]. As for the volunteer question, 37.4% of the pupils agreed to be volunteers in AIDS medical centers or hospices at least once a week. Girls agreed to invest this time more than boys ( p , 0.001) and this opinion was expressed mostly by pupils attending academic schools (42.1%), followed in order by pupils in the religious (37%) and vocational schools [(32%) ( p , 0.001)].

4. Discussion The current study examined differences in knowledge and attitudes of three high school populations: academic, vocational and religious. Reports of the rapid spread of AIDS in various populations increase the level of anxiety concerning contagion among adolescents and young adults. This may explain the desire of 42.4% of the pupils to be tested for AIDS. Fifty-six point eight percent feel they are at risk of contamination while undergoing dental treatment or while being treated with surgical instruments which have been previously used on other patients. In general, the knowledge of the students regarding HIV and AIDS was fair to good. The basic knowledge of all students was between 70–80%. Students in academic schools presented the highest level of knowledge amongst the three schools’ populations, followed by students from vocational schools and then the religious school students. This diversity can be explained by length of exposure to the media (number of hours of watching TV and / or reading newspapers or teenage periodicals). Knowledge increased with age, and higher knowledge on these topics was associated with greater education ( p 5 0.00001), an increase which was also found in other studies [10,11]. Girls demonstrated a higher level of knowledge in comparison with boys ( p 5 0.03). This is a finding consistent with the study of

275

Green et al. [12]. Knowledge gaps still remain concerning mode of contamination, etiology, symptoms and prognosis. Seventy-four percent of students think the disease is caused by a bacterial agent (instead of virus). A higher and exact knowledge has influence upon late careful behavior. In the present study, AIDS knowledge correlated with students’ grades, including class behavioral evaluations; this finding can be explained by the fact that diligent students read studies, and knew more about AIDS. This was mentioned in other studies as well [13,14]. AIDS knowledge was not influenced by economic level, nor by other demographic variables. This was also found to be true in the study by Brown et al. [10], but contradicts the findings of Green et al. [12]. There was a substantial intolerant attitude towards AIDS and HIV patients. Students attending academic schools demonstrated the most liberal and permissive opinions toward AIDS and HIV positive patients, followed by pupils in vocational schools. Students attending religious schools received the highest scores for their intolerant and negative attitudes toward an infected patient and the disease. This might be influenced by the social environment in which students live as well as by their level of knowledge and by exposure to TV. The intolerant attitude of religious students can reflect their level of prejudice against other disparaged groups, such as homosexuals and drug users. As far as age is concerned, strict and negative attitudes decreased with age ( p 5 0.04). We believe that this might be due to societal and peer pressure as well as exposure of the older pupils to stories of AIDS contamination and its consequences on TV and in the newspapers. This was found to be true in a study by Brown et al. [10]. The students’ attitudes were not influenced by socioeconomic level; this is consistent with the findings of Brown et al. [10]. The present study did not find a correlation between knowledge and attitude, similar to findings by Morton et al. [15], but in contradiction to the studies of Brown et al. [10] and Krasnik et al. [16]. A possible explanation for this lack of correlation between knowledge and attitude can be that attitude is acquired and learned mostly at home; while knowledge is acquired mostly by the media.

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U. Brook / Patient Education and Counseling 36 (1999) 271 – 278

Thirteen point six percent of the pupils support the removal of a positive HIV pupil from school and 10.4% admitted that they would terminate a relationship with a good friend who had become HIV positive. A third of the pupils expressed unwillingness to sit near a HIV positive pupil in class. These data necessitate class discussions with educational advisors about the disease, maintaining the dignity of the ill patient, mutual aid and meaning of friendship for chronic patients [17]. Zimet et al. pointed out in their study that US adolescents suffered from increased anxiety while interacting with a positive HIV person [11]. Sixty-five percent of the pupils believe that it should be an obligation of the medical staff to treat and / or operate on a HIV positive patient, but on that issue even medical care providers have differences of opinion. Merrill et al. [18] pointed out that half of the 4100 physicians in Houston, Texas, believe that they have the right to refuse treatment to AIDS patients. Andre [19] found that a third of nurses in a hospital in Massachusetts stated that they would refuse to treat symptomatic AIDS patients because of their real fear of contamination. Education and medical advisers should talk and explain in public schools the meaning of the Hippocratic Oath that all physicians take when they graduate. Students (as well as the general population) should be instructed about all aspects of AIDS by the media, which is the most frequent but not necessarily credible source of information. Ross [20] and Nutbeam et al. [21] note the positive influence of the media upon the knowledge and attitudes of adolescents towards AIDS. There should also be a big push to increase teaching efforts in schools. This type of intervention is also recommended in other studies [16,22,23]. It is regrettable that physicians and nurses in schools and clinics are in the last place in instructing adolescents about AIDS. Hingson et al. [24] noted that among 1782 pupils in Massachusetts in 1988 only 13% talked with their physicians about AIDS. Pediatricians, family physicians and school doctors can raise the subject during each patient visit and / or examination of an adolescent [25]. As mentioned the different sources decrease according to their frequency, but it does not guarantee their credibility. To summarize, there is considerable rationale to

include AIDS as an integral part of the curriculum in the high school curriculum [26,27]. Instruction regarding AIDS should be implemented using audiovisual aids. A good suggestion that would be of benefit is to have ill AIDS patients speak to high school classes in order to tell their personal story, as well as their mode of contamination. Educational advisors, physicians and nurses should discuss with students modes of prevention of HIV contamination, as well as moral responsibility toward HIV infected people and carriers.

Acknowledgements This study was supported by the scientific adviser of the Israeli Health Ministry [No. 2313].

Appendix A

THE KNOWLEDGE SCALE ITEMS (Responses were correct or incorrect.) 1. The modes of AIDS contamination include: 1.1. Touching. 1.2. Coughing. 1.3. Kissing. 1.4. Sexual relations. 1.5. Drinking from the same glass. 1.6. Receiving contaminated blood transfusion. 1.7. Shaking hands. 1.8. Living in the same apartment. 1.9. Dog’s or cat’s bite. 1.10. Drug injection utilizing infected needles. 1.11. Swimming in a public pool. 2. AIDS is a weakness of the body to defend itself against germs or viruses. 3. AIDS is caused by a powerful germ. 4. The incubation period for HIV is two months. 5. A third of newborns of a positive HIV mother will be contaminated during pregnancy. 6. AIDS patients suffer from chronic diarrhoea and weight loss. 7. AIDS patients suffer from mediastinal tumors in their bones and skin. 8. AIDS can be cured if diagnosed and treated early.

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9. The following subgroups are included nowadays in the high risk group which may be contaminated by HIV: 9.1. Patients with chronic disease. 9.2. Patients who have received blood transfusions in the past. 9.3. People who had been involved in accidents and suffered from cerebral hemorrhage. 9.4. Heterosexuals. 9.5. All newborns of an infected mother.

Appendix B

ITEMS CONCERNING ATTITUDE TOWARDS AIDS (Responses were agree or disagree.) 1. All students at school should be examined for positive HIV carriers. 2. The following subgroups should be informed as to the existence of a positive HIV student at school: 2.1. School authorities. 2.2. Head teacher and all teachers of his classes. 2.3. Student’s parents. 3. A positive HIV student should be removed from school. 4. An AIDS patient should be quarantined in a hospice for all his life. 5. I don’t want to sit in class near a positive HIV student. 6. Medical staff cannot refuse to treat AIDS patients. 7. I’ll cut off a relationship with a positive HIV student even though he is an old friend. 8. A two-year-old adopted baby should be returned by his parents to an orphanage or institution if he is diagnosed as HIV positive. 9. Testing for AIDS should be part of the agreement of a young couple before their marriage. 10. The authorities should forbid the entry of a HIV positive person to the country. 11. The government should compensate all AIDS patients who had been contaminated while receiving blood transfusions in the hospital.

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12. AIDS patients should not be allowed to circulate freely in the community. 13. Surgeons cannot refuse to operate on HIV positive patients. 14. Physicians and nurses should be examined periodically for HIV detection. 15. An HIV positive medical staff person should quit his medical career in order to avoid contaminating patients. 16. The names of AIDS patients should not be kept secret. 17. Dentists cannot refuse to treat AIDS patients. 18. If I was a physician, I’d treat without hesitation HIV positive patients the same as all other patients.

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