Mirza Imran Raza ( Punjab AIDS Prevention and Control Program, 24-Cooper Road, Lahore. )
Ahmed Afifi ( Punjab AIDS Prevention and Control Program, 24-Cooper Road, Lahore. )
Abdul Jamil Choudhry ( Department of Epidermiology, Institute of Public Health, Mayo Hospital, Lahore. )
Humayun Iqbal Khan ( Department of Paediatrics, Mayo Hospital, Lahore. )
Objective: To assess the knowledge, attitude and behaviour regarding AIDS among educated young people in Lahore, Pakistan.
Methods: An anonymous survey of 733 males and 355 females was carried out using structured questionnaire among educated youth, selected randomly from non-medical educational institutions and work places.
Results: Knowledge on existance of AIDS in Pakistan was expressed by 698 (95.2%) males and 273 (76.9%) females, in, while only 189 (25.7%) males and 76(21.4%) females knew its cause. Knowledge of the different modes of transmission was good, however 59%, 48%, 68% and 43% males; 28%, 45%, 59% and 35% females believed that it could be transmitted through sharing of utensils, mouth kissing, casual contact and mosquito bite, respectively. Ninety one percent males and 86% females believed that AIDS sufferers should be isolated. Extra marital sex was experienced by 6% subjects and only 5% used condoms. Generally, males had better knowledge than females except in attitudes towards monogamy and having sex with someone known.
Conclusions: The study revealed gaps in the knowledge of females regarding AIDS and its transmission. The results indicates an urgent need to include health education syllabi emphasising AIDS and other Sexually Transmitted Diseases in the Curriculum of schools/colleges to convey the message adequately to the youth (JPMA 48:179, 1998).
Globally AIDS was recognised in 1981, although cases which had presented during the late 1970s were diagnosed retrospectively1,2. Currently Joint United Nations Program on HI V/AIDS (UNAIDS) estimates suggest, that over 22 million people world-wide are living with Hl V/AIDS, 3.1 million new HIV infections occurred in 1996 and the proportion of women with HIV and AIDS has increased dramatically3. In Asia, AIDS is no longer an emerging problem. In Thailand the overall HIV 1 prevalence is 13% in men and 24% in women4. In India there are more than 2 million estimated cases of HIV/AIDS.
In Pakistan, the first case of HI V/AIDS was reported in 1987, by 1990 there were 56 reported cases, which increased to 240 cases in 1993 and 1021 cases in 19955. Inone of the HIV seroprevalence studies in Pakistan 11.5% dmg users, 3.7% Sexually Transmitted Disease (STh) clinic attendees and 0.6% antenatal attendee’s in Lahore, 3.7% Out-Patient Department (OPD) clinic attendee’s in Peshawar, 2.8% tuberculous patients in Quetta and 0.2% STD clinic attendees in Karachi were found positive for HIV infection5. A WHO/UNAIDS projection model estimates that as many as 80,000 Pakistanis might have been infected with the HIV by the end of 1996.
High cost of effective therapy and absence of any cure has forced most public health experts to agree that AIDS money should be spent on prevention and health education instead of on expensive treatments specially in developing countries6. Therefore, the knowledge, beliefs and practices of the people are important in the development of a well-targeted and effective health education and awareness campaign in these countries. In Pakistan, no survey has been reported so far to assess the knowledge, attitude and behaviour towards HIV/AIDS among educated young people, it is pertinent to study this aspect of HIV/AIDS in this group.
Materials and Methods
The educational institutes and work places offers a major opportunity to gain access to and communicate with a large population of the educated youth. Youth (age 20-35 years) with minimum qualification of Secondary School Certificate (10-years) from different educational institutions (non-medical) and work places (Financial, Business centres, etc.) in Lahore were included in the study. During 1996, 1088 structured questionnaires were distributed among target group, through volunteers from Department of Sociology, University of the Punjab, Dept. of Psychology, Government College, Lahore and HOPE. (a non-governmental organisation), Lahore, randomly after obtaining their consent. To maintain the anonymity of the respondents the names and adresses were not asked. The questionnaires were filled and returned by the respondents immediately. Respondents were asked about theirknowledge and beliefs regarding AIDS, their attitude towards AIDS patients and HlV carriers and their own practices regarding usage of condom. The data was compiled and analysed using computer software Epi Info version 6.0. Uncorrected Chi-Square test was used as the test and p<0.05 was used as a cut off point for statistical signficance.
Out of a total of 1088 respondents, 733 were males and 355 were females, of which 698(95.2%) males were aware of the presence of AIDS in Pakistan as compared to 273(76.9%) females (p<0.001). Regarding the causative agent, only 189 (25.7%) males and 76 (21.4%) females had the correct knowledge, but the difference was statistically not significant (p0.115).
While responding to the questions about routes of transmission of HIV/A~DS, more than 80% respondents possessed correct information that it is transmitted through sexual intercourse, blood transfusion, from pregnant mother to newbornbaby and using contaminated syringes, while mall the cases males had significantly more correct knowledge as compared to the females ( Table I ).
Majority of the respondents, both male and female, considered that HIV/AIDS is also transmitted through mosquito bite and mouth kissing while it cannot be spread by ear piercing. A large proportion of respondents incorrectly considered that sharing untensils and touching/hand shaking also transmits the disease. In all these cases the knowledge was more incorrect in case of females, while the difference was statistically significant in case of knowledge regarding sharing of utensils, touching/hand shaking and mosquito bite.
Table II shows the various beliefs and attitudes of the respondents towards AIDS. It was alarming to observe that 9 1.0% of males and 86.2% of females believed that AIDS patients should be isolated. Very small proportion of respondents, 14.19% of males and 5.07% of females, knew that STDs increase the risk of acquiring HlV/AIDS (p<0.001).
In response to a questione regarding pre/extra marital sexual expenence, among those who responded 63 (14.7%) males and 2 (3.4%) females had a pre/extra marital sexual experience. Nine (1%) males had more than one sexual partner, 366 males and 57 females did not have such an experience, while 304 males and 296 females declined to answer. The use of condoms was admitted by 51(6.96%) males and 2 (0.56%) females. The reasons for not using condoms are stated in Table III.
The results of this study showed that a high percentage of the males and females youth were aware of the existence of AIDS, which are much better than the results of a study conducted in India in 1994 where even 65% of health workers had not heani of AIDS7 and substantial proportion of nurses lacked basic AIDS information in Scotland8. The increase in awareness may be due to a change in the level of knowledge as the pandemic grows. Incorrect knowledge about the aetiology of the disease, as stated by 544(74.2%) males and 279(78%) females coincides with reports from other parts of the world9,10.
Majority of the respondents had a correct knowledge about the mode of transmission. Males were significantly better than females. However, it is important to note that a large proportion of both genders believed that HI V/AIDS is also transmitted through sharing of utensils, casual contact, mosquito bite which were also reported in studies from Saudi Arabia11. These wrong perceptions may be due to lack of education. Sixty five percent females believed that HIV infection can not spread through ear piercing. This is very significant as almost all women folk in our country get their ears or noses pierced.
A large number of respondents, both males and females, were certain that some people have a natural pmtecion against AIDS. It was astonishing to note the misconception that AIDS is a disease of non-Muslims, which can prove dangerous, in transmission of the disease man Islamic country like Pakistan, with a culture influenced by religion.
There is now strong evidence that other sexually transmitted diseases (STDs) facilitate HIV transmission. The evidence comes from studies on viral shedding in genital fluids and from epidemiological research12. As majority of women have no choice on the use of protective measures, a high proportion acquire HIV infection from their infected partners through sexual intercourse13, By 1994, women between the ages 15 to 24 years represented 40% of all new AIDS cases and 50% of HIV infections. In our study only 18 females knew that STDs increases the risk of acquiring HIV infection due to same social factors. These findings are similar to the results of a Moroccan study, where majority of the women responded in negation14.
The most effective method of preventing the spread of AIDS, other than abstinence from sex, is the use of condoms15,16. A large proportion of the respondents were aware of this preventive measure, but majority did not prefer the method. The main reasons stated by both males and females was itbeing un-Islamic. The menalsofoundcondoms to make sexless exciting. Reasons of nonacceptability by male partners and sexual disatisfaction was also reported in other studies17-18.
Reports have shown that sexual contact accounts for about 90% of HIV transmission and persons with multiple sexual partners are at a higher risk of having AIDS19,20. Epidemiologically, the transmission of HIV depends on polypartnerism21. In our study only 6% of the youth interviewed claimed to have pre/extra marital sexual experience, while nine had multiple partners. The percentage may be higher considering the fact that people are unlikely to admit this practice in our culture.
There was generally an aversion of the respondents to the AIDS patients and HIV carriers. Majority of participants opined, that they should be isolated, which coincides with studies in other countries where, 30% of the medical consultants18 and 46% of health workers22 would like to avoid contact with a HIV positive patients.
The AIDS epidemic is generally viewed as a health problem, largely exacerbated by the risk behaviour of people who either do not know how to change, do not want to change ordo not have the means to change their level of infection risk. This perspective of AIDS has dominated prevention efforts.
Although this study can provide a basis for future research on this subject in Pakistan, there are limitations in genemlising these results. In the absence of any financial support a number of logistic issues were not handled adequately, including a relatively small sample size, unequal gender distribution, and restriction of target group to a homogeneous educated group. Further, as the questionnaires were filled by only those who consented to respond, it may be possible that this group had an altered awareness towards AIDS as compared to those who refused to respond.
The survey indicates that although young educated males and females were aware of the existence of AIDS, their knowledge about transmission and prevention of AIDS was insufficient, specially among females. It could be concluded from the study that an urgent need for an intensive and effective health education campaign aginst AIDS in youth in particularly among females is required. Prevention programmes should attempt to motivate people to reduce their risk behaviour, levels, or maintain a low-risk behaviour, through persuasion. Information, education, counselling and other services should be provided to influence individual psychological processes and to correct some existing dangerous beliefs that might hinder the control of AIDS. More epidemiological studies are warranted to bridge the gap between the existing knowledge and the prevalent practices.
The authors would like to extend their gratitude to the students and volunteers of Department of Scoiology, University of the Punjab, Department of Psychology, Government College, Lahore and NGO, H.O.P.E., Lahore for helping us in the collection of data.
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