Abstract

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Objective: To determine the influence of knowledge on protective attitudes and practices against the risk of HIV/AIDS in Peruvian students from exclusively private schools from the three regions of the country.
Methodology: Following a correlational-comparative design, a sample of 849 Peruvian students from 52 private high schools was selected using cluster, stratified, and systematic sampling. Data was collected from adolescents and parents who signed informed consents, and was analyzed using the Kruskal-Wallis test and Spearman correlations.
Results: Results indicate that the level of knowledge influences attitudes but not protective practices against the risk of HIV/AIDS (r =.218, pConclusions: Private school students’ knowledge about HIV/AIDS shows a highly significant influence (pKeywords: HIV/AIDS; protective attitudes & practices; private high schools.

Introduction

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The global HIV/AIDS epidemic is stabilizing but at an unacceptably high level. Every day 3,200 people are put on HIV treatment across the world, and 7,100 more become new infected with the virus.[1] Despite of the overall trend of declining, in several high income countries there is a resurgence of HIV; and in the Philippines, Bangladesh, and five countries of the former Soviet Union, the HIV incidence increased by more than 25% between 2001 and 2009.[2] Only less than 40% of people living with HIV know their status.[3]
The number of people living with HIV in Latin America increased from 1.3 million in 2000 to 1.7 million in 2007, and there is a shift in the main mode of HIV spread, from homosexual or injection drug usage, to heterosexual transmission.[4]
The Ministry of Health of Peru (MINSA) found the top number of HIV new cases in 1996 with 1,189 infected;[5] however, it is alarming to know that between January and September 2009 a total of new 1,968 HIV cases and 404 new AIDS were reported.[6] Between 2001 and 2007, the estimate of prevalence among adult 15-49 grew from 0.4% to 0.5%, the estimate of people living with HIV grew from 57,000 to 76,000.[7]
Adolescents and HIV/AIDS
Although young people 15–24 years of age account for 45% of all new HIV infections in adults around the world,[8] HIV/AIDS epidemic among adolescents continues ranking among the leading causes of death in that age group. For instance, the rate among USA adolescents is increasing , and AIDS is a leading cause of death among 15-24 year olds.[9]
The Pan-American Health Organization office reports that HIV, risky abortion, and pregnancy complications are important causes of mortality and morbidity among youth in Latin America and Caribe, which is the 30% of population, and one out of 20 is infected with a STD; and among women, 25% of girls under 20 years of age become mothers because of lack or misuse of contraceptive methods.[10]
The HIV prevalence in Peruvian young people aged 15-24 years in 2007 was 0.5% for male and 0.3% for female,[7 ]and the 70% of the cases are among people aged 20-39 years.[5]
Adolescents’ knowledge, attitudes & behaviors toward HIV risk factors
Survey data from 64 countries indicate that fewer than 40% of males and 38% of females ages 15–24 have accurate and comprehensive knowledge about how to avoid HIV transmission.[3]
Sexual practices of adolescents in different countries show risky behaviors such us early initiation, multiple partners, and inconsistent use of condom. Sexual intercourse is started among US teenagers at an average age of 15.8, in Netherlands 17.7, in Germany 16.2, and in France 16.8.[1]1 A study among 29 African American men, with an average age of 23.39 years, reported an average of 37.12 sexual partners in their short lifetime, with number of partners ranging from 1 to 156.[12] In Jamaica, 42% of public school students, reported to initiate sexual intercourse at the age of 10 years.[13] In Peru, approximately ¼ of adolescents between ages 15 and 24 already had sexual relations, the average of initiation was 14 to 15 years,[14, 15] and 72% to 84.2% did not use a condom during their first sexual relation.[16]
Studies show a relationship between knowledge and attitudes of protection towards HIV, and toward people with AIDS, such as in China among public school students,[17] and in Hong Kong.[18]  However, studies around the world show there is no correlation between knowledge and protective behaviors. That was the reality in Catholic and public school students at Lebanon,[19] in public schools students in China,[17] in Hong Kong,[18] in Haitian adolescents living at Miami,[20] in Colombia,[21] and among high school students from Armenia, the Caribbean, Philippines, Romania, Canada, and USA.[22] Soto[23] found that Peruvian adolescents with the highest level of knowledge about STD/AIDS are the ones with a higher coital prevalence.
These facts led us to ask together to Benavides, Leon, Baker, Collins, and Halabi:[4] what kind of knowledge does the Peruvian population have about HIV. What are their attitudes toward AIDS. Is knowledge and attitude related with level of education. There is a need to keep searching what adolescents from every socio-economic status think, feel, and behave with respect to HIV/AIDS. There have been many studies in Peru about knowledge, attitudes, and practices regarding HIV / AIDS among adolescents, most of them from public schools; but no studies on what teenagers think in private high schools exclusively making a comparison to their peers from the coast, highlands, and jungle regions of Peru.
This study aimed to answer to the research question: What is the influence of knowledge on attitudes and protective practices in adolescent sophomore, junior, and senior students from exclusively private high schools of Lima, Cuzco, and Iquitos, against the risk of HIV / AIDS Also, this study attempted to discover attitudes of private schools students of the three regions towards people who are infected with AIDS.

Materials and methods

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This is a descriptive, correlational-comparative study. The adolescent population was 4,404 high school sophomore, junior, and senior students from 155 private schools in Lima, Peru’s capital, Cuzco from the highlands, and Iquitos from the jungle region. These high schools were obtained from the official list of the Ministry of Education in 2005. The participating schools were those whose monthly tuition was less than S/. 400.00 Nuevos Soles, or US$133.
The sample consisted of 849 adolescents from 30 schools in Lima, 17 in Cuzco, and 5 in Iquitos, considering a margin of error of 4% and 95% of confidence. Adolescents were selected by multistage sampling: (1) departments (or states), cities and districts were selected through sampling with a specific purpose; (2) schools were selected using cluster sampling in each district; and finally (3) adolescents were selected through stratified sampling by years of study and systematic sampling to identify the unit of analysis.
The instrument was based on the theoretical implications of HIV/AIDS, and on the questionnaire of Hopkins et al. (2002).[22] The first part assessed knowledge through 10 multiple-choice questions with five alternatives each, of which one was correct. The second part assessed attitudes toward risky sexual behaviors, and to people infected with HIV/AIDS, with 15 questions using a Likert scale of 5 points, which range varied from strongly disagree to strongly agree. The third part evaluated the practices of sexual risk behaviors and protective measures of the students with 11 multiple-choice questions, scoring with higher points according to the level of protection.
A multidisciplinary team of medical, public health, education, and psychology professionals from the Graduate School Public Health Unit from Universidad Peruana Union in Lima, and the School of Public Health from Loma Linda University in California validated the instrument. The instrument reliability was tested by using the coefficient of Cronbach Alpha, yielding a total of 0.838, valued as high. Internal consistency was measured for each section, obtaining the following coefficients: 0.418 for Knowledge, 0.778 for Attitudes, and 0.952 for Practices, showing good levels of content validity, and criterion.
The research team was trained through a protocol for data collection in the cities of Lima, Cuzco and Iquitos. Before data collection in every school, both parents and adolescents who wanted to participate signed a letter of consent. The next day, adolescents responded to the questionnaire.
Data analysis was performed using SPSS statistical software. To relate the knowledge, attitudes and protective practices against the risk of HIV / AIDS, the Spearman correlation coefficient was used; and to compare the knowledge, attitudes and practices regarding socio-demographic characteristics, the nonparametric H of Kruskal –Wallis was used since knowledge, attitudes, and practices variables did not present a normal distribution.

Results

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There was a participation of 849 students, of whom 52.8% were male and 47.2% female. The average age of participants was 14.95 ± 1,119 years, with 45.7% from Lima, 30% from Cusco, and 24.3% from Iquitos. Of the participants, 30.6% were sophomores, 34.5% juniors, and 34.9% seniors. Regarding the educational level of parents/guardians, 31.1% of mothers had completed secondary education and 46.2%, higher education, while 32.2% of fathers had completed secondary education and 53.4% higher education.
Table 1 shows the frequency and percentage of correct answers to questions regarding knowledge of HIV/AIDS.  (INSERT Table 1 HERE).
For reporting attitudes towards risky sexual behavior, and towards people with HIV/AIDS, three categories were used: positive, indifferent, and negative. The positive and negative categories resulted from the merger of the strongly disagree and disagree alternatives, and agree and strongly agree categories, as negative or positive respectively. (INSERT Table 2 HERE).
Regarding attitudes, Table 2 shows that most have active attitudes of protection against the spread of HIV/AIDS. Among the attitudes of students towards people with HIV/AIDS, the highest percentage of positive attitudes occurred in relation to "AIDS infected people attending the same church as other church members" and " visiting an AIDS patient,” 84.7% and 78.7%, respectively; whereas the highest percentage of negative attitude was "to continue dating my boyfriend even though he/she is infected with AIDS” (54.3%).
Table 3 presents the sexual behavior practices regarding HIV/AIDS risk. Of the total sample, 74% of students in the study reported not having had sex; however, out of the 220 teen students of private schools (26% of the total sample) who had sexual experiences, 10.5% reported that their first intercourse was when they were less than 11 years old, which may suggest cases of rape. Crossing tables it was found that children under 11 who have had their first sexual experience with a family member was at home. (INSERT Table 3 HERE).
From those who had sex, most reported that his/her first partner was his/her boyfriend/girlfriend (56.9%), and only in males was the first partner a prostitute or a homosexual. Regarding the place of their first encounter, the majority (57.5%) mentioned having had their first experience at home and/or at the home of his/her date. Most (65.1%) mentioned that the circumstances that led them to this experience was because they were in love, whereas 10.2% were under the influence of alcohol or drugs. At the moment of the assessment, 36.6% of adolescents reported to continue having sexual intercourse. Regarding sexual practices, most (32.0%) reported having had oral sex and/or anal sex, a smaller percentage (3.3%) had sex with objects, and 3.1% reported having had sexual experiences of all forms.
Table 4 presents the protective practices in sexual behavior on HIV/AIDS among those who reported having sex. (INSERT Table 4 HERE).
The correlation tests show that the level of knowledge influences attitudes but not protective practices against the risk of HIV/AIDS (r =.218, p< .01; r =-.008 p< 0.05 respectively); however, attitudes have a significant influence on the protective practices against the risk of HIV/AIDS (r =.132, p< .01).
When comparing knowledge, attitudes, and practices regarding socio-demographics, it was found age and year of studies have highly significant difference (X2= 13.757, p< 0.01; and X2= 29.911, p< 0.01 respectively) on knowledge, showing that those older in age and in higher grades are those who reach the highest ranks in knowledge about HIV/AIDS. Gender and parent's educational level also show significant difference (X2= 5.433, p< 0.05; and X2= 13.141, p< 0.05 respectively) in knowledge. Those in the male student groups and with parents with a higher level of education reached the highest rank in knowledge.
Gender and place of origin are the demographic indicators which show highly significant difference (X2= 47.813, p< 0.01; and X2= 11.251, p< 0.01, respectively) in attitudes; girls and adolescents from Lima show better attitudes towards people with HIV/AIDS and have better attitudes towards protective sexual behaviors; the level of education of the mother shows a significant difference (X2= 11.736, p< 0.05) in attitudes, with students whose mothers have a higher level of education reaching the highest rank in attitudes.
Gender, age, and place of origin are the demographic indicators that show highly significant difference (X2= 53.163, p< 0.01; X2= 19.759, p< 0.01; and X2= 9.870, p< 0.01, respectively) in protective practices against the risk of HIV/AIDS, showing that younger female students coming from Cusco show better protective practices.

Discussions and Conclusion

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This study shows that the level of knowledge among Peruvian adolescents of private schools in the three regions of Peru was high about the mode of transmission (89.1%), and about the causes of AIDS (85.2%), but was low (34.7%) about the risks of contracting HIV/AIDS, and about the ways to prevent it: only 35.4% of respondents said that the safest method to prevent HIV infection is to avoid having sex. The low knowledge about risks of contracting HIV was similar to what Vinaccia et al, [24] found in Colombian adolescents from public and private schools. Globally, correct knowledge about HIV among both young men and women has increased slightly since 2003, only 34% has comprehensive knowledge, and this is only slightly greater than one third of the target of 95%. [2]
Regarding knowledge, this study found that the older the adolescents are in age and the higher school grade they belong to, the higher knowledge of HIV/AIDS they have (p Regarding attitudes, in this study adolescent women have better protective attitudes toward risk of HIV/AIDS than men (p One of the main problems contributing to the spread of the disease is the state of innocence and vulnerability of adolescents due to idealism appropriate to their age that leads them to adopt attitudes and responses that are more emotional than rational against the risk of contracting HIV/AIDS; this is shown in the study, when 54.3% of teens surveyed said that if his/her boy/girlfriend gets infected by AIDS, they would continue the relationship (see Table 2).
In attitudes, being female and being from the city of Lima reported highly significant differences, better attitudes towards sexual behaviors of protection, and towards people with HIV/AIDS. And in protective practices against the risk of HIV/AIDS, a highly significant difference was found in being female, being less than 14 years old, and being originally from the city of Cusco. Similarly, Cáceres, Yon, Mendoza, Rosasco, and Cabezudo[28] found in Cusco there is more sexually "conservative" behavior.
The findings of this research regarding attitudes show that female gender, place of origin, and mother’s level of education are indicators that show significant differences among women compared to males, in favorable protection attitudes toward HIV and towards protective sexual behavior. Culturally in Peru, particularly in the highlands region cities, there is still a close relationship of submission and/or friendship between mother and daughter.
Regarding practices, 74.0% reported no having had sex, while 26% reported sexual experience (see Table 3). This proportion replicates what had been found before: one quarter of Peruvian adolescents 15 to 24 years of age already had sex.[29, 14] In contrast, at Lebanon, public school students were more likely to admit having sexual experience than Catholic school students where 15 did not respond, which could mean that the actual differences among public and private schools are not as great.[19]
Regarding protection methods used during sexual intercourse, the frequency of condom use was low: only 37.4% always used it. One of the explanations given by them was they did not feel sexual pleasure (see Table 4), constituting myths and prejudices that are transmitted to adolescents by their family environment and peers.[16] A 17.4% of teens that had sexual intercourse said they had never used condoms during sex, indicating the high risk to which they are exposed. Use of condoms is mediated by the attitude of approval or rejection of their use by the partner as well as self-efficacy and condom negotiation skills in sexual intercourse.[30]
In the present study it was found that, although the overall level of knowledge do not affect protective practices, however, it affects positively protective attitudes of Peruvian high school students of private schools (r =-.008, pFinally, this study showed that attitudes significantly influence protective practices against the risk of HIV/AIDS (r =.132, p< .01), contrary to what was found in Hong Kong where no correlation was found neither between knowledge and behavior, nor attitude and behavior. This is very interesting in the study: Knowledge correlates attitudes, and attitudes correlates behavior, but there is no correlation between knowledge and behavior, for having high knowledge of preventative measures to prevent HIV, per se is not sufficient to adopt preventative practices.[22]

References

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Acknowledgement

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To Gary Hopkins, PhD, for his guidance and support, and to Yesenia Tantamango, M.D., for her effective research work.
To the Institute for Prevention of Addictions, of Andrews University, Michigan, and the Stevens Foundation, USA, for their grant awarded to conduct this study.

Ethical approval

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The Graduate School Committee of Ethics in Research of Universidad Peruana Union of Lima, Peru, authorized the instrument, and the data collection, subject to the approval by each high school board. So, every participant school in this research authorized the study through its administrative board. In addition, parents who were informed in detail of the study through a letter, and wanted their children to participate, signed an informed consent together with their adolescents.

Source(s) of Funding

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The Institute for Prevention of Addictions, of Andrews University, Michigan, and the Stevens Foundation, USA funded this study.

Competing Interests

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None declared.

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