June 2008 - Volume 2, Issue 3

Knowledge, Attitudes, and Behavior Related to HIV/AIDs and Other Sexually Transmitted Diseases among Adolescents: In the Context of Bangladesh

Md. Mosiur Rahman Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi-6205, Bangladesh Correspodence: Md. Mosiur Rahman Department of Population Science and Human Resource Development University of Rajshahi, Rajshahi-6205, Bangladesh. E-mail: swaponru_2000@yahoo.com

ABSTRACT The study examined the existing research findings on adolescent knowledge, attitudes and behavior related to HIV/AIDs and other sexually transmitted diseases in Bangladesh. It is demonstrated that both adolescents and young adults had low knowledge and awareness about AIDs and other sexually transmitted diseases. Findings suggest that adolescents who live in an urban area are more aware of AIDs as compared with rural counterparts. Education of either husband or wife is positively associated with knowledge of AIDs. Mass media plays a great role in gaining knowledge of AIDs. Mobility of adolescents outside the place of residence is an important factor for achieving information on HIV/AIDs. Those adolescent who are permitted to move outside place of residence are more aware of AIDs. Our analysis also reveals that a large portion of adolescents and young adults have never discussed with their spouse HIV/AIDs prevention methods. The findings of the study reveal that adolescents whose husbands were using condoms were one of the most AIDs aware groups in the adolescent's community. Key words: AIDs, STIs, Mass media exposure, Logistic regression analysis, Bangladesh.

INTRODUCTION

Adolescence has been defined by WHO as the period of life spanning the ages between 10 and 19 years (WHO, 1999). Adolescents constitute a significant portion of the population of Bangladesh. A large number of them are out of school, malnourished, working in vulnerable situations, getting married early and are sexually active although most of them do not have knowledge about contraception and safer sex. According to The National Census of 2001, as many as 36.3 million Bangladeshis are adolescents (10-19 years of age) constituting 23% of the population. Among them 8.8 million girls and 9.3 million boys fall in the age group of 10-14 years while 8.7 million girls and 9.5 million boys belong to the 15-19 years age group. It is estimated that about 10.8 million adolescents/youths will be added to the existing population making the total 49.3 million, i.e., 36% of the total population in 2006 ( Alauddin, 1997).

In recent years the reproductive and sexual health of adolescents has been givenincreasing attention. More than half of all new HIV/AIDs virus infections today occur in young people between ages of 15 to 24 (WHO, P/133). An over populated country like Bangladesh is still fortunate to have low HIV/AIDs prevalence (less than one per 1000 adults) as compared to neighbouring countries such as India, Nepal, Thailand and Myanmar (PRB, 2002, P/21). But the presence of many on textual, behavioral and biomedical factors indicate that Bangladesh is at the beginning of an HIV/AIDS epidemic threat (Akhter, H.H., M-e-E Elahi, F. Karim, and K.K. Saha. 1999) .Adolescents are more vulnerable in the question of AIDs i.e., physiological, behavioral, and social risk factors surrounding HIV among adolescents. Global estimates suggest that more than half of all new HIV infections occur among young people 15-24 (WHO-2003, P/19).

The risk of contracting STIs including HIV/AIDs is a major public health concern for adolescents. Since the sexual habits of unmarried girls and boys of this age group are changing rapidly, knowledge of STIs is crucial. A comprehensive study conducted among adolescents reported that only 13 to 14 percent of them were aware of syphilis and gonorrhea. About one-half of the adolescents could not correctly identify a single STI symptom and more than one-half of the adolescents could not correctly identify a mode of STI transmission. Although social customs usually discourage premarital or extra-marital sexual relationships, the scant evidence from small-scale, in-depth qualitative studies indicate that such relationships are more frequent than commonly believed. These groups are especially vulnerable to unwanted pregnancy and disease, including STIs and HIV infection, and the stigma and discrimination associated with either condition. According to a study only 17% adolescent married girls have heard about AIDs, and if they need treatment for the disease, they visit quacks, pharmacists ('compounders'), Kabiraj, Hekim and other homeopathic doctors.

Though many of the adolescents have heard about HIV/AIDs, most of them live in a traditional context, with few discussions regarding reproductive health in the family or community. Adolescence represents a window of opportunity to prepare for a healthy adult life. Adolescents lack information and understanding about their own sexuality. Both the male and female adolescents are found to be almost equally vulnerable, the girls being especially more vulnerable. Boys suffer from peer pressure to indulge in early sexual activities, smoking and drug abuse to prove that they are men. As they mature and become sexually active, they know little about STI/AIDs, and cannot identify diseased partners. They are vulnerable to contracting RTIs/STIs/HIV. In early initiation of sex, adolescents are more likely to have multiple sexual partners. In addition, STD pathogens can more easily penetrate the cervical mucus of adolescents than that of older women (Hossain et al., 2003). Although some adolescents appear to weigh the pros and cons of engaging in certain behaviors, not all decisions are made rationally. Much of adolescent participation in unprotected sexual intercourse may, in fact, be due to a simple failure to make a decision (or the making of default decisions) because of ambivalence about pregnancy or STIs, particularly among younger adolescents. As part of their decision-making process, adolescents often look to their teachers, peers, and school environment for clues regarding various aspects of sexual behavior and to evaluate the degree, to which their beliefs agree or disagree with group norms (Koenig MA Et.al , 1998).

However, it is clear that adolescents are especially vulnerable to HIV/AIDs. Consciousness about AIDs is not satisfactory. Especially, adolescents have poorer knowledge than young adults. The present study will be helpful for the policy makers and planners and take essential steps to gain more knowledge on AIDs among adolescents.

DATA COLLECTION AND METHODOLOGY

This study utilizes the data extracted from 1999-2000 Bangladesh Demographic and Health Survey (BDHS), which were conducted under the authority of the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. The BDHS 1999-2000 employed a nationally representative two-stage probability sample design where 10,544 ever married women were interviewed successfully. The data was collected from six administrative divisions of the country- Barisal, Chittagong, Dhaka, Khulna, Rajshahi and Sylhet. This paper is based on 1,622 ever married female adolescents aged 10-19 years, which is about 17% of the total sample. It also included ever married young adults for comparative purposes. There are 3,944 ever married young adults whose age limit is 20-29. A module on awareness of AIDs was included in the BDHS 1999-2000 for the first time, which was used for the present study. Knowledge on, and awareness of AIDs were assessed by inquiring wheather they had ever heard of AIDs, and if so, sources of knowledge, perceptions about the avoidance of the diseases, and understanding of its consequences were also assessed.

Methodology
Data analytic method envisaged in this paper is percentage distribution and logistic regression analysis. A brief discussion on these methods has been incorporated in following subsections.

Percentage Distribution
Percentages distribution is employed in this study for getting the real picture of the knowledge, attitudes, and behavior related to HIV/AIDs and other sexually transmitted diseases among adolescents.

Logistic Regression Analysis
Logistic regression, also called logit regression, is used when the response variable may be quantitative, categorical, or a mixture of the two.

In logistic regression, just as linear regression, the codes for the independent variables must be meaningful. We must decode the values of the independent variables by creating a new set of variables that correspond, in some way, to the original categories. When we have a variance with more than two categories, we must create a new variable to represent the categories. The number of new variables required to represent a categorical variable is one less than the number of categories. For example, if instead of the actual values for education of the respondents, we had values of 0, 1 depending on whether the value was `no education`, and `some education`. The value ``no education`` would be represented by codes of 0 and it is called reference category. If we use indicator variables for coding, the coefficient for the new variables represent the effect of each category compared to a reference category. The coefficient for `some education` is the change in log odds when the lower primary compared to no education. The coefficients for no educations are necessarily zero, since it does not differ from itself. The logistic regression procedure will automatically create new variables for categorical variables.

KNOWLEDGE OF HIV/AIDs

Table-1 and Table-2 show the percentage of adolescents respectively, who have heard of HIV/AIDs, by background characteristics. The results show that the urban adolescents (55.6 percent) were more aware of AIDs compared to their rural counterparts (table-1). Knowledge on AIDs varied significantly in different parts of the country. About 37.4 percent of the adolescents of Dhaka division had heard of AIDs. More than one third of the adolescents of Barisal and Khulna division had ever heard of AIDS, while only 20.7 percent of adolescents of Rajshahi division had heard of AIDs. Education, of the respondents or of their husbands, had a linear and positive relationship with having knowledge of AIDs. About 56.4 percent of the adolescents with secondary/higher education had heard of AIDs compared to 25.0 percent with primary education and 10.3 percent with no education. A similar scenario was also found in case of husband's education. Access to mass media played a significant rule in having knowledge of AIDs. About 47.2 percent of adolescents who had access to mass media had ever heard of AIDs, while only 11.9 percent without such access had heard of AIDs.

The results in table-1 also elucidates that about 32.3 percent of the adolescents who were allowed to go outside by themselves, had heard of AIDs compared to 43.2 percent who did not or were not allowed. More than one fifth (64.9 percent) of the adolescents whose husbands were using a condom had heard of AIDs. About 36.4 percent of the adolescents who were using other methods had heard of AIDs. One third (28.1 percent) of the adolescents who were not using any methods had ever heard of AIDs. Husband-wife discussion was positively associated with having knowledge on AIDs. About 35.5 percent of the adolescents who discussed FP with their husbands had heard of AIDs as compared to 29.3 percent who did not have any such discussion.

Regarding the sources from which the adolescents heard about AIDs, the major sources of information on AIDs were found to be: radio, television, newspaper/magazine, Pham plate/poster, health workers, schools/ teachers/community meeting and friends/relatives.

From table -2 it was found that most of the adolescents (20.1 percent) have heard about AIDs from TV, 11.7 percent from radio and friends/relatives. Moreover, different sources such as newspaper / magazine pamphlets / posters health workers school / teachers /community meeting and others have a small contribution to growing consciousness about AIDs among the adolescents.

Knowledge of Correct Ways to Avoid AIDs

To ascertain knowledge about modes of HIV/AIDs transmission, respondents were asked general questions as to whether there is anything a person can do to avoid getting AIDs or the virus that causes AIDs and, if so, what can be done. The results of the responses are shown in Table-3. Among adolescents only 31.2 percent had known at least one way to avoid getting AIDs. About 15.8 percent of the adolescents reported that they would like to avoid AIDs by using a condom during sex and 10.5 percent reported that AIDs can be prevented by avoiding sex with prostitutes.

Avoid multiple partners is a way to prevent AIDS, was reported by 9.1 percent of the adolescents. Some of the adolescents (5.1 percent) have knowledge about the prevention of AIDS by limiting sex with one partner. Abstaining from sex (5.4 percent) and avoid non-sterilized/disposable injections (4.0 percent) are another way to avoid AIDs.

Knowledge of HIV/AIDs Related Issues and Communication with Spouses

Respondents who know of HIV/AIDs were asked whether they think that a healthy-looking person can have the AIDs virus and whether they think that HIV/AIDS can be transmitted from a mother to a child. The results of the responses are shown in Table 4. Among adolescents who know of HIV/AIDs, 67.45 percent say that a healthy-looking person can have the AIDS virus and the corresponding figure for young adults is 70.7 percent.

Table-4 also shows that 89.6 percent of the adolescent women know that it can be transmitted from a mother to her child. It is also observed from table-4 that a large portion of adolescents and young adults never discussed with their spouse HIV/AIDs prevention methods and only 11.85 percent of adolescents ever discussed HIV/AIDs prevention methods with their spouse and the corresponding figure for young adults is 17.2 percent.

Awareness about Sexually Transmitted Infections (STIs)

Table-5 shows the percentage of adolescents who know of the signs and symptoms of sexually transmitted infections (STIs). Among the adolescents awareness about STIs is so poor. Various factors are involved in the spread of STIs. Adolescents are more vulnerable to the risk of STIs. The true incidence of STIs will never be known because of secrecy that surrounds them. Most of them are not even noticeable. About 91.5 percent of the adolescents had no knowledge about sexually transmitted infections. Only 1.8 percent of adolescents and young adults have known about one symptom of STIs. A few adolescents and young adults know about two or more symptoms of STIs. The same pattern is also observed for all women. Various reasons may be attributed for this cause - this may be due to the limited access to sexual health information, poverty, unemployment, inadequate health care facilities etc.

Logistic Regression Analysis

Knowledge of adolescents of AIDs was considered as an outcome variable (dependent variable) which was dichotomized, taking the value 1 for those who had ever heard of AIDs and 0 otherwise. The results and discussion of logistic regression model are presented in
table-6.

Residence (urban-rural) was a significant predictor of knowledge of AIDs. The analysis revealed that the urban adolescents were 3.15 times more likely to have knowledge of AIDs compared to their rural counterparts. Table-4 also shows that knowledge of AIDs varied significantly in different parts of the country. The adolescents of Dhaka division are 1.159 times more likely to have knowledge of AIDs as compared to Barisal division. However, the adolescents of all other divisions areless likely to have knowledge of AIDs compared to the adolescents of Barisal divisions. Education was another significant predictor of knowledge of Aids.

The adolescents with secondary/higher education were 4.5 times more likely to have knowledge of AIDs compared to the adolescents with no education. Similar findings were also observed for the adolescents whose husbands had secondary/higher education. Knowledge of the adolescents of AIDs was also significantly associated with their use of contraceptives. The adolescents whose husbands were using condoms were 1.8 times more likely to know about AIDs compared to their counterparts who were not using any method of contraception.

The adolescents who were using any other methods were 1.199 times more likely to know about AIDs compared to their counterparts who were not using any method of contraception. The young adults also show the same pattern of results. Among the adolescents, who were permitted to go out they had 1.436 times more knowledge about AIDs than those who were not permitted.

CONCLUSION AND RECOMMENDATION

It is demonstrated that both adolescents and young adults had low knowledge and awareness about AIDs. Adolescent friendly environments are not available here. Moreover, adolescents tend to avoid consulting sexual information on HIV/AIDs. Although HIV/AIDs prevalence in Bangladesh is not alarmingly high, the high-risk behavior is well established. It is the right time for growing consciousness among the adolescents about HIV/AIDs.

Findings suggest that adolescents who live in an urban area are more aware of AIDs as compared with rural adolescents. It may be due to the available opportunity or easy mobility of urban adolescents. Regional variation did not show significantly more knowledge of HIV/AIDs among the adolescents and young adults. Education either of husband or wife is positively associated with the knowledge of AIDs. Mass media plays a great role in giving knowledge on AIDs. Mobility of the adolescents to the outside place of residence is an important factor for achieving information on HIV/AIDs. Those adolescents who are permitted to move outside place of residence are more aware of AIDs.

The findings of the study reveal that adolescents whose husbands were using condoms were one of the most AIDs aware groups in the adolescent community.

By analyzing the above findings the following recommendations are made:

1. The findings of this study suggest providing available educational opportunities for all. Only education can help a person to know himself and his surroundings. Special emphasis should be given to the female adolescents for education. The Bangladesh government has already taken on such programs for adolescents.
   
2. 2. In our study we observe that mass media plays a great role in gaining knowledge on AIDs/STIs. Besides, some additional programs such as face-to-face communication and sexual education in institutions may be effective. Governments should encourage religious leaders, teachers, health workers, principles of mosques/church/temples and community leaders to achieve the success in HIV/AIDS/STDs related problems.
   
3. 3. A campaign is needed about condom use during pre- and extra- marital sex. Further, adolescents may have difficulties in obtaining condoms and knowing how to use them correctly. Fortunately, family planning campaigns have endeavoured to popularize the use of condoms as a method of contraception through a behavioral change campaign (BCC). Nevertheless, adolescents need to have the skills to use condoms consistently and correctly.
4. 4. Integrated reproductive health services that include STI prevention and screening can attract adolescents.
   

REFERENCES

Allauddin, M. (1997). Maternal Mortality in Rural Bangladesh: the Tangail District. Studies in Family Planning 17(10' 13-21.

Akhter, H.H., M-e-E Elahi, F. Karim, and K.K. Saha. (1999). Knowledge Attitude and Practice of Mothers and Female Guardians on Nutrition of Adolescent Girls in Rural Bangladesh. Dhaka: BIRPEHET.

Hossain et. Al. (2003). Reports on Needs Assessments on Reproductive Health Information and Care among Adolescents in Paurashava School and Colleges, Dhaka. BHRPERHT (BHRPERHT Publications No. 123, Technical Report No. 71).

Koenig MA et.al. (1998). Maternal Mortality in Matlab, Bangladesh: 1976-1985. Studies in Family Planning 19(20:69-80.

World Health Organization (1999). "Programming for Adolescent Health and Development, Geneva, World Health Organization. WHO Technical report Series No. 886.

World Health Organization (2003). Skilled Birth Attendance: review of evidences in Bangladesh, Dhaka. WHO Country Office Bangladesh.