Knowledge and attitudes toward AIDS among female college students ...

HEALTH EDUCATION RESEARCH Theory & Practice

Vol.15 no.1 2000 Pages 5–11

Knowledge and attitudes toward AIDS among female college students in Nagasaki, Japan E. Maswanya, K. Moji1, K. Aoyagi, Y. Yahata, Y. Kusano, K. Nagata, T. Izumi and T. Takemoto Abstract

Introduction

This study assesses knowledge and attitudes concerning HIV infection and individuals with AIDS among 383 female students attending colleges in Nagasaki, Japan. A structured questionnaire containing questions concerning knowledge about AIDS, sources of information, beliefs and attitudes toward people with HIV/ AIDS was administered during sessions set up for that purpose. The mean age of participants was 18.8 ⍨ 0.8 years (⍨ SD). The main source of information for AIDS awareness as reported by the students was the mass media. Good knowledge about AIDS was positively associated with ease of acceptance of living in the same house with a person diagnosed with AIDS [odds ratio (OR): 1.90; 95% confidence interval (CI): 1.07–3.38]. However, residing at home (OR: 0.64; 95% CI: 0.42–0.98) and involvement in nurse education programmes (OR: 0.59; 95% CI: 0.37–0.95) showed a negative association. Students demonstrated a high level of knowledge concerning AIDS and HIV, but had considerable misconceptions and prejudices about people having HIV/AIDS. Our results suggest that a more appropriate education programme in colleges in Japan may be necessary to reduce the discrepancy between general knowledge and desirable attitude regarding HIV/AIDS.

The prevalence of HIV infection and AIDS cases in Japan is low compared to Southeast Asian and Western countries (Ohi et al., 1987; Isomura and Mizogami, 1992; Kamakura et al., 1997; Kihara et al., 1997), despite the fact that the global pandemic of HIV infection and AIDS has reached catastrophic proportions, affecting men, women, adolescents and children (Modeste et al., 1994). The first reported case of AIDS in Japan was in 1983 (Isomura and Mizogami, 1992). By April 1997, there were 4088 cases seropositive for HIV and 1521 cases of AIDS in Japan (Morio, 1997). The actual number of HIV-seropositive cases is estimated to be about 5 times the number of reported cases (Ohi et al., 1987; Kihara et al., 1997), suggesting that less than 30 000 of the total population of 124 million (about 0.024%) are infected. Most of the HIV-seropositive cases and AIDS cases reside in the Tokyo metropolitan area (Kihara et al., 1997; Ohi et al., 1987). So far, 11 AIDS cases have been reported from Nagasaki Prefecture (with a population of 1.5 million). Despite this low incidence, however, public health activities relating to AIDS prevention and control are necessary, since the number of reported cases with HIV-positives and people diagnosed with AIDS are progressively increasing in Japan (Ohi et al., 1987; Isomura and Mizogami, 1992; Fukushima et al., 1997; Kihara et al., 1997). As a preventative strategy, targeting the population during the early stages of an epidemic is more costeffective than at later stages. Prevention is also much cheaper to implement than curative means (Ohi et al., 1987; New York Times, 1996).

Department of Public Health, Nagasaki University School of Medicine, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan 1Present address: Department of Biological Anthropology, University of Cambridge, Cambridge CB2 3DZ, UK Correspondence to: K. Aoyagi

© Oxford University Press 2000

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E. Maswanya et al. Effective AIDS-related health education for adolescents in remote areas of Japan is not easy because people are not familiar with AIDS. Although Japanese adolescents have heard of AIDS, they are not familiar with the disease nor have they encountered people with HIV/AIDS. This situation may lead to unnecessary fear, ignorance and uncertainty among adolescents. Information on AIDS through the mass media tends to promote a negative attitude toward those with HIV/ AIDS by over-emphasizing the dreadfulness of HIV infection. It may produce irrational behavior in adolescents toward those with HIV/AIDS, especially in the cultural context of conservative Japanese local tradition (Fukuda, 1993; Morishita et al., 1993; Satsuta et al., 1994; Hirose et al., 1995). In Japan, there are limited school education programmes on sexually transmitted diseases including HIV/AIDS. However, there is no systematic and pragmatic AIDS education programme for college students. There have been few reports on knowledge, attitudes and behavior with regard to HIV/AIDS among Japanese college students (Morishita et al., 1993; Okada et al., 1994; Satsuta et al., 1994) and attitudes of college students in provincial cities in Japan toward people with HIV/ AIDS have been hardly reported at all. The present study examines AIDS-related knowledge and attitude among Japanese female students in Nagasaki, a city in south-western Japan, with a special emphasis on discrepancies between knowledge and attitudes. The implications of these findings for health education are discussed with regard to AIDS prevention and control among college students, as well as in relation to the development of desirable attitudes toward people with HIV/AIDS.

Methods Subjects A cross-sectional questionnaire survey for firstyear female students was conducted in Nagasaki, Japan in June 1995. Since the new academic year starts in April in Japan, the students were surveyed

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Table I. Social and demographic characteristics of 383 female students in Nagasaki, Japan Characteristics Age group (years) 18–19 20–21 Major nursing others Religion Buddhism others Living place home others

No.

%

304 79

79.4 20.6

123 260

32.1 67.9

254 129

66.3 33.7

179 204

46.7 53.3

at an early stage through their first year. We selected a woman’s college and a nursing school for the study, in which one investigator (T. T.) delivered a lecture on health promotion. There were 1460 first-year female students in Nagasaki city in 1995, and there were no differences in geographical distribution and social class structures between the schools included and those excluded from the study. Informed consent was obtained from the principals of the colleges and from individual participating students. From the selected two colleges, 412 students were eligible to take part in the study and all students voluntarily participated in the study. These students majored in nursing, nutrition, English, Japanese literature and music. Students who were absent on the day of the questionnaire were not included in the study. A total of 383 students returned fully completed questionnaires, representing a valid response rate of 93%. Clearly, the sample was not randomly drawn from the first-year female student population in Nagasaki and it cannot be regarded as strictly representative of that population nor first-year female students in general. The age of the respondents ranged from 18 to 21 years, and the age distribution is shown in Table I. The mean age was 18.8 ⫾ 0.8 years (⫾ SD). Their religious affiliation was mainly Buddhism (66%). Half of them were living at home with their families and the others at university dormitories, private apartments, etc.

AIDS knowledge and attitude among female students Table II. Sources of information on AIDS among 383 female students in Nagasaki, Japan (more than one answer possible) Sources

No.

%

Mass media newspaper magazine/weekly radio TV/video Parents Teachers Friends

373 (181) (232) (23) (346) 28 168 34

97.4 (47.3) (60.6) (6.0) (90.3) 7.3 43.9 8.9

Procedure Questionnaires were administered while the students were in the classroom after explaining the nature and anonymity of the survey, and assuring confidentiality of the personal responses. The survey was conducted during the regular school hours. Participants sat apart and were asked not to communicate with each other during administration of the questionnaire so as to encourage honest responses.

was considered inappropriate at this stage because conventional Japanese social norms prohibit sexual activities among adolescents before marriage. Admittedly, the norms have been less influential in recent years due to the influence of Western culture. Knowledge of AIDS was graded according to the number of correct answers. Those who scored correctly on 14 questions or more were classified as ‘good’ and others as ‘poor’. Students were asked questions relating to attitudes toward people with AIDS. Three hypothetical situations were presented: living in the same house with a person diagnosed with AIDS, studying in the same class and taking care of such a person without worry. Test–re-test reliability was not assessed in this study. Multiple logistic regression analysis was conducted on nine variables to explain attitudes toward individuals with AIDS through socio-demographic characteristics, information sources and knowledge scores concerning AIDS. Statistical analysis was performed using SPSS base 7.5 (SPSS, Chicago, IL).

Measures The questionnaire was modified by referring to Research Package: Knowledge, Attitudes, Beliefs and Practices on AIDS (KABP) Phase 1 (WHO, 1990). All questions were translated to Japanese. The students were asked to write down their age, major, religious affiliation and place of residence. Regarding sources of information on AIDS, students were asked to choose from the following sources (more than one answer possible): newspapers, magazines/weeklies, radio, TV/videos, parents, teachers and friends (Table II). Students were also asked to choose from parents, teachers and friends (more than one answer possible) if they discuss AIDS-related topics with these individuals. They were then asked true/false questions concerning knowledge of AIDS. All 16 questions administered are presented in Table III. A true/ false response format was chosen to make the administration and completion of the questionnaire as simple as possible. No questions concerning condoms or sexual activities were included, as it

Results Information sources The main source of information about HIV/AIDS was the mass media, with TV/video ranking first, followed by magazines, newspapers and radio (Table II). Friends and parents were the leastreported sources of information. Four percent of the respondents sometimes discussed AIDS-related topics with friends, 0.8% with parents and 0.5% with teachers.

Knowledge Table III shows students’ knowledge about AIDS. The percentage of those who gave correct answers to each of the 16 questions was high (84%) and almost all of the respondents acknowledged the ‘severity of AIDS’ (98%). All students correctly answered the questions about transmission of AIDS by ‘living in the same house’, ‘living in the same room’ and ‘sharing the same swimming pool’. Again, almost all students answered correctly about

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E. Maswanya et al. Table III. Students’ knowledge about AIDS among 383 female students in Nagasaki, Japan Variables

Correct response

Mosquito bites is one possible cause of infection Infected blood can transmit the virus Sexual intercourse with an AIDS person is a possible transmission route Living in the same house with an AIDS person is a possible transmission route Living in the same room with an AIDS person is a possible transmission route Shaking hands with an AIDS person is a possible transmission route Sharing the same swimming pool with an AIDS person is a possible transmission route Sharing the same toilet with an AIDS person is a possible transmission route Sneezing and coughing are possible routes for AIDS infection Mother to fetus infection is a possible transmission route AIDS is a viral infectious disease There is no effective treatment There is an effective vaccine Patients have particular appearances People immediately show signs of sickness after infection of HIV AIDS is a life-threatening disease

‘immediate symptoms after infection’, ‘shaking hands’ and ‘particular appearance of those with AIDS’. However, some questions showed less complete knowledge. For example, 89% knew that ‘mosquito bites’ cannot transmit HIV.

Attitudes toward people diagnosed with AIDS Of the respondents, 187 (49%) indicated that they would be able to be live in the same house with a person having AIDS. Most students (85%) would be able to study in the same class with HIVpositive classmates. However, only 107 (28%) of the students responded that they could take care of a person with AIDS without worry (Table IV).

Multiple logistic regression analysis for attitudes The results shown in Table V demonstrate the adjusted odds ratios (OR) and 95% confidence intervals (CI) of variables associated with attitudes (living in the same house with a person having AIDS, studying in the same class with HIV-positive classmates and taking care of people having AIDS without worry) on HIV/AIDS people. Attitude with regard to ‘living in the same house’ was significantly associated with major (nursing/

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false true true false false false false false false true true true false false false true

Correct answer No.

%

339 364 365 383 383 379 383 373 368 335 334 348 350 375 381 374

88.5 95.0 95.3 100.0 100.0 99.0 100.0 97.4 96.1 87.5 87.2 90.9 91.4 97.9 99.5 97.7

Table IV. Attitude on AIDS people among 383 female students in Nagasaki, Japan Variables

No.a

%

Living in the same house Studying in the same class Taking care

187 327 107

48.8 85.4 27.9

aThose

who have approved the variables.

others), living place (home/others) and knowledge score (good/poor). Nursing students (OR: 0.59; 95% CI: 0.37–0.95; P ⫽ 0.03) and those residing at home (OR: 0.64; 95% CI: 0.42–0.98; P ⫽ 0.04) were less likely to choose to live in the same house with a person having AIDS without worry. Students who had a good knowledge of AIDS (OR: 1.90; 95% CI: 1.07–3.38; P ⫽ 0.03) were more likely to be able to live in the same house than those who had a poor knowledge. No associations were found in terms of ‘studying in the same class’ and ‘taking care of people having AIDS’.

Discussion The vast majority of students in this study got their information on HIV/AIDS from the mass

AIDS knowledge and attitude among female students Table V. Adjusted ORa and 95% CI of variables for attitude on AIDS people among 383 female students in Nagasaki, Japan Variables

Living in the same house

P

Studying in the same class

P

Taking care

P

Age (18–19/20–21 years) Major (nursing/others) Religion (Buddhism/others) Living place (home/others) Information sources (mass media/others) Information sources (parents/others) Information sources (teachers/others) Information sources (friends/others) Knowledge scoreb (good/poor)

0.84 0.59 1.19 0.64 0.85 0.81 1.05 1.32 1.90

0.52 0.03 0.43 0.04 0.81 0.59 0.84 0.46 0.03

1.33 1.61 1.18 1.28 0.30 2.18 0.94 0.94 0.60

0.48 0.15 0.61 0.42 0.10 0.10 0.85 0.91 0.15

1.36 (0.76–2.44) 0.65 (0.39–1.08) 0.76 (0.46–1.26) 0.93 (0.59–1.47) 0.27 (0.03–2.20) 0.60 (0.27–1.34) 1.14 (0.70–1.85) 1.56 (0.66–3.69) 1.31 (0.72–2.39)

0.30 0.10 0.29 0.75 0.22 0.21 0.60 0.32 0.39

(0.49–1.44) (0.37–0.95) (0.77–1.86) (0.42–0.98) (0.23–3.17) (0.38–1.74) (0.67–1.63) (0.63–2.79) (1.07–3.38)

(0.60–2.95) (0.84–3.09) (0.62–2.25) (0.71–2.30) (0.07–1.26) (0.87–5.44) (0.51–1.75) (0.34–2.64) (0.29–1.22)

The 95% CI are in parentheses. aAdjusted OR were calculated for 383 female students, adjusting for all variables listed in the table. bThe score was graded according to correct answer rates on knowledge questions about AIDS; those who scored 14 and over correct answers for 16 questions (see Table III) were classified ‘good’ (n ⫽ 321), others ‘poor’ (n ⫽ 62).

media. Very little communication regarding HIV/ AIDS occurred between themselves and their parents or teachers. This suggests the importance of involving parents, teachers and students in AIDS education programmes. The stimulation of interest in parents and teachers concerning HIV/AIDS may help them to educate themselves and their children/ students (Maswanya et al., 1999), and may counter unnecessary fear and/or discrimination against people with HIV/AIDS. The severity of AIDS was well acknowledged, as 98% of them agreed that it is a life-threatening disease. It appears that the mass media have succeeded in raising AIDS awareness, but have produced little effect in changing students’ attitudes toward those with HIV/ AIDS. Although attitudes concerning AIDS probably cannot be improved at once, it could be effective to initiate a campaign through the mass media, aimed at attitude modification. Most students demonstrated good knowledge of HIV/AIDS. Misconceptions do exist, however. A small percentage of students identified ‘mosquito bites’ (11%), ‘sharing the toilet’ (3%) and ‘sneezing and coughing’ (4%) as possible transmission routes. These kinds of misunderstandings tend to produce prejudices against those having HIV/AIDS (Fukuda, 1993). One of the most surprising findings in this study was the level of prejudice against people diagnosed

with HIV/AIDS. The students in this study demonstrated considerable discrepancies between knowledge and attitudes. Even though most students have good knowledge of AIDS, about half of them responded that they would not live in the same house with a person having HIV/AIDS without worry. More than two-thirds would not take care of people having HIV/AIDS without worry. Thus, it seems that knowledge alone does not seem to be enough to change attitudes toward people having HIV/AIDS. Previous studies of students in the US (Skurnick et al., 1991) and Nigeria (Oladepo and Brieger, 1994) reported that knowledge about AIDS was high, but exaggeration of risk from social contacts was common. However, educational interventions could change attitudes toward people with HIV/AIDS. Clift and Stears (Clift and Stears, 1988) reported that college students in the UK were less worried over social and non-sexual physical contact with people having HIV/AIDS after a nation-wide information campaign and education in colleges. Another study from Norway reported that the longer the educational plans, the lower were the negative attitudes (Rise and Jakobsen, 1995). A more appropriate education programme based on behavioral science is desirable to lessen the discrepancy between general knowledge and desirable attitudes (Hirose et al., 1995). There are few people with AIDS in Nagasaki,

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E. Maswanya et al. Japan, and most students in this study have never met such a person, so they lack practical experience. Therefore, in addition to AIDS health education in colleges, efforts should be made to invite people diagnosed with HIV/AIDS to come to colleges and talk to students about their illness. This may help students to understand AIDS more deeply. Reports from Australia and Guam have indicated that positive changes in students’ perception/behavior toward those having HIV/AIDS were noted after talks by HIV-seropositive people to colleges students (Paxton, 1997; Wood, 1997). The same approach may be tried in Nagasaki colleges by designing socially and culturally acceptable studies. Good knowledge was positively associated with living in the same house with people having AIDS without worry. It appears that people with good knowledge concerning AIDS do become more tolerant of people with HIV/AIDS. A report from the Philippines demonstrated a positive change in attitude among nurses and midwives after receiving accurate information and interactive role-play concerning HIV/AIDS (Tomas et al., 1997). In addition, a study of Filipino high school students found a positive association between good knowledge concerning AIDS and tolerance of people with HIV/AIDS (Aplasca et al., 1995). A higher level of knowledge and more positive attitudes among Japanese nursing students have also been reported by Okada et al. (Okada et al., 1994) and Satsuta et al. (Satsuta et al., 1994). Qualified nurses were found to have a more positive attitude compared with assistant nurses (Morishita et al., 1993). Nursing students in the present study were less likely to be able to live in the same house with a person having AIDS without worry. It is possible that the nursing students did not get sufficiently accurate information on HIV/AIDS because they were in the early stage of their course. The nursing profession occupies a very important position in the care of people diagnosed with AIDS, and it might be helpful to better integrate AIDS-related content and issues into the nursing curriculum. AIDS is a present and future health care concern.

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With better prepared nurses, the quality of care for persons with AIDS should improve (Wood, 1997). This study has several limitations. As this study was designed as a self-administered questionnaire, it is difficult to validate the students’ answers. Students may over-report socially desirable answers and underreport undesirable ones. Furthermore, we did not ask questions related to sexual behavior and condom use, mainly because of ethical and cultural concerns in Japan. However, since sexual behavior and condom use are considered to be the major avenues of HIV/AIDS transmission, this omission was unfortunate. The inclusion of such data would have provided useful information on the activities and condom use among students. Further studies including sexual behavior and condom use are needed to plan comprehensive educational programmes for AIDS in Japan. Finally, the results may not be extrapolated to other population groups in Japan who may differ substantially in age, sex distribution, educational level and economic status. Still, the students surveyed represent an important subgroup of the Japanese population and the information generated will be useful in the planning of future AIDS education programmes in colleges.

Acknowledgements The authors wish to thank the directors of Kwassui Women’s College and Nagasaki University School of Allied Medical Sciences for their kind cooperation in conducting the study, as well as all the college students for their participation. We also thank Dr Timothy Othman of the Department of Environmental Physiology, Institute of Tropical Medicine, Nagasaki University and Dr Sumihisa Honda of the Department of Radiation Epidemiology, Atomic Bomb Disease Institute, Nagasaki University School of Medicine, for their helpful suggestions in the preparation of the manuscript.

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