PsychologicalReports, 1991, 69, 203-210.
O Psychological Reports 1991
UNIVERSITY STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES AND BEHAVIORAL ADWSTMENT ' DEAN AJDUKOVIC Department of Psychology University of Zagreb
AND
MARINA AJDUKOVIC Department of Soczal Work Faculty of Law University of Zagreb
Summary.-This study addresses the relations between AIDS-related knowledge, attitudes, and behavior change among university students. A questionnaire covering such issues and personal background variables was administered to 750 students at the University of Zagreb. Over-d, 62.7% of the knowledge items were answered correctly, while functional, self-protective aspects of knowledge proved to be much better than general knowledge. On the average, attitudinal responses were moderately liberal. Both self-reported change in risk-reduction behavior and personal concern due to the appearance of AIDS were very small. Correlations of risk-reducing behavior with permissive (.15) and restrictive (.14) attitude orientations and with general and functional knowledge (.08) were modest. The level of personal concern correlated neither with permissive attitudes nor with functional knowledge, while it correlated negatively with restrictive attitudes (-,201 and with general knowledge (-.08). Substantial association was only established between functional knowledge and permissive (.51) and restrictive attitude orientations (-.23). It is concluded that, in addition to knowledge and attitudes, a number of factors which restrain desired behavioral adjustment should be considered in anti-AIDS campaigns, such as perceived level of exposure to HIV i n a particular environment, young age-specific illusion of invulnerability, peer norms, and others.
The epidemic of acquired immunodeficiency syndrome, which is widely known as AIDS, has primarily afflicted adults between the ages of 30 and 39 years ( H d e y & Hearst, 1987). This reflects the fact that most AIDS patients were infected with the human immunodeficiency virus (HIV) in their 20s and early 30s, probably as a consequence of behavioral practices acquired during adolescence and early adulthood. Thus, young people became of particular importance to the behavioral and social sciences' contribution to the fight against AIDS for at least two reasons. First, there are several factors which contribute to the higher risk for HIV infection among young people (first sexual experiences, the higher proportion of sexually transmitted diseases indicates that adolescents do not adhere to the "safer sex" practices, drug abuse history often starts at this age, etc.). Second, there is a chance to establish protective health-behavior patterns which might endure into adulthood. The risk of AIDS for the young population is apparent from the epidemiological data on HIV infection, their sexual behavior patterns, and contraceptive use habits, as well as data on sexually transmitted diseases and substance abuse (Masters, Johnson, & Kolodny, 1788; Flora & Thoresen, 'Address correspondence to Dean AjdukoviC, Ph.D., Department of Psychology, University of Zagreb, Djure Salaja 3, 41000 Zagreb, Yugoslavia.
1989). AU this evidence leads to an increased interest in research on knowledge, attitudes, and behavior among young people (O'Reilly & Aral, 1988; Remafedi, 1988; Bowie & Ford, 1989; Zabin, Hardy, Smith, & Hirsch, 1988). The intention in conducting these studies is primarily twofold: (1) to study knowledge, attitudes, and behavior relations in specific groups which are at special risk for HIV infection in order to build productive prevention programs and (2) the need to gather base-line estimates for evaluating the long-term effectiveness of programs aimed at young people. The number of AIDS cases in countries like Yugoslavia with 174 reported cases at the end of 1990 (rate of 7.4 per million), does not seem impressive in comparison to the number of patients in some other countries. The fact that massive public-awareness campaigns in some major cities were launched almost simultaneously with those in the more affected countries seems self-evident as one of several explanations for this comparatively small number of patients. These preventive efforts made the AIDS problem very salient to the general population. Consequently, it was assumed that people modified their behavior according to their increased knowledge about this fatal disease. Furthermore, all public campaigns have usually attempted to promote attitudes which support preferred behavior. However, the face validity of the simple assumption that educating people about AIDS is bound to be followed by behavioral change is feeble and hindered by a number of factors (Kegeles, Adler, & Irwin, 1988; Strunin & Hingson, 1987), so a joint research group from the Department of Psychology and the Department of Social Work of the University of Zagreb began an extensive project in 1987, aimed at studying the relations between the knowledge, attitudes, self-reported behavioral practices, behavioral intentions relevant to HIV infection, and their possible correlates among young people between 15 and 30 years of age. The principal goal of this project has been to help plan and evaluate anti-AIDS programs targeted primarily at the general population. In the past few years there has been growing awareness of the considerable personal hazard due to HIV spill-over into the general heterosexual population, previously thought to be safe. In January 1988, the World Health Organization reported that the estimate of the proportion of AIDS acquired through heterosexual contact in the Americas, Europe, and Australia has increased from 1% to approximately 4%, making this goal even more meaningful. The proportion of AIDS cases caused by heterosexual transmission may increase even further in the near future (Friedland & Klein, 1987). The present paper reports relations among knowledge, attitudes, and behavioral adjustment among the university student population. Subjects I n this study, 750 students at the University of Zagreb, Yugoslavia, vol-
STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES, BEHAVIOR
205
unteered to fill out anonymously a questionnaire. The subjects were students of social work (179), psychology (139), medicine (192), law (144), and agriculture (96). They ranged in age from 19 to 26 years, with an average of 20.5 yr. There were 524 women and 226 men.
Procedure The questionnaire, administered by a member of the research staff to groups of students not larger than 30, contained sets of items on knowledge, attitude, and behavior change. In addition, it tapped data on the subjects' personal background, their sources of information about AIDS, and their exposure to groups at higher risk for HIV infection. Special care was taken to ensure absolute anonymity of the respondents through the administration. The knowledge items were originally answered on a five-point scale, ranging from "absolutely true" to "absolutely false" but were dichotomized afterward. The items' contents asked about AIDS-related issues which are usually included in scales of this type (i.e., routes of transmission, prevention and risk-reduction practices, asymptomatic status of virus carriers, affected population, medical treatment, etc.). The scale reliability (Cronbach alpha) of .75 was judged appropriate considering the heterogeneity of the items' contents. However, the exploratory hierarchical principal components factor analysis yielded two latent knowledge dimensions: (1) general knowledge about AIDS (i.e., affected population, diagnosis, and treatment) and (2) knowledge with obvious self-protective functional value (i.e., means of HIV transmission and risk-reduction practices). Accordingly, two knowledge subscores were derived. The items primarily saturated by either factor were used for scoring subjects' achievement on these two knowledge aspects. One item ("ARC is the acronym for AIDS-related Complex") was not used in further analysis because it did not appear to belong to either subscale. Individual subscores could range from 6 to 12. To tap the attitudes toward AIDS-preventive measures statements whch are standard for this type of questionnaire were used. They expressed views about ways in which the problems associated with AIDS should be approached (i.e., "Children with AIDS should not be allowed to attend regular schools," "AIDS is primarily a medical problem and requires a medical solution," "People with AIDS should be quarantined," "Intentional spread of AIDS should be treated as murder," "AU AIDS patients are innocent victims," etc.). Supporting certain AIDS-preventive measures reflects one's attitudes to questions like: How should the people at higher risk for HIV infection be treated? To what extent should the individual rights of infected and sick persons be respected as opposed to the society's need to protect itself from the spread of disease? How does this influence individuals' perceptions of their own health risks and the options available to reduce them? Consistency between attitudes toward AIDS-preventive measures (including
the attitudes toward people with AIDS), attitudes toward one's responsibility for one's own health, and one's own AIDS-related behavior might be assumed. A four-point scale format was used to respond to the attitude items. I t ranged from "strongly agree" to "strongly disagree." Responses were scored according to their liberal direction, with a higher score indicating a more liberal attitude. In this context "liberal" implied attitudes which disapproved of legal or repressive actions related to the AIDS problem and which would allow infected individuals equality in all aspects of everyday life. The factor analysis helped identify two almost independent attitudinal dimensions labelled permissive and restrictive orientation toward AIDS-related issues (Ajdukovii & AjdukoviC, 1989). This means that at the same time a person can support activities which ameliorate the position of people affected by AIDS and endorse measures which restrict privacy and some other rights of people. The possible score for either attitude orientation ranged from 9 to 36. Change in behaviors attributed to the appearance of AIDS was self-assessed by the set of items which were intended to cover four aspects of adjustments in one's behavior: personal concern that one might be at risk for AIDS, risk-reducing sexual practices, general health practices, and affiliation with people at higher risk. Reported change in intravenous substance abuse was not included because the incidence in this population was low (less than 0.5%). Each item was answered with reference to the respondent's typical conduct prior to the present year. However, the factor analysis identified only two distinct behavioral adjustment dimensions, (1) concern and habits which did not have an apparent risk-reducing component (e.g., discussing possibility of AIDS infection with the partner, being concerned about infection due to a medical intervention, contemplating about being at risk for AIDS, using public toilets less often, etc.) and (2) risk-reducing behavior which had a distinctive self-protective aspect (e.g., using a condom more often, being more faithful to the partner, etc.). For either dimension individual scores could range from 5 to 15, with a score of 10 showing no change. Scores below 10 indicated diminished concern or increased frequency of behaviors which put an individual at higher risk. Scores above 10 indicated increased concern or more cautious conduct than before.
Data Analysis t tests were used to compare the subjects' average scores between the two aspects of knowledge, the two attitude orientations, and the two behavior adjustment dimensions. Correlations were employed to assess association among these variables. The SPSS-PC + commercial computer package served for the analysis of the data. RESULTSAND DISCUSSION The subjects' over-all knowledge was moderately high: 62.7% of all
STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES, BEHAVIOR
207
items were correctly identified. However, a significant difference was found between the amount of functional or self-protective knowledge and that of general knowledge about AIDS (Functional knowledge: M = 11.60, SD = 0.81; General knowledge: M = 7.31, SD = 1.17; t,,, = 78.00, p < .01). These results clearly indicate that the subjects possessed satisfactory knowledge about the means of transmission of HIV, what practices reduce the risk of exposure to the disease, etc. O n the other hand, they knew far less about the symptoms of AIDS, its definition, or the extent of the AIDS epidemic. Obviously, the facts directly related to the possibility of virus transmission are what the students know and remember best. This also indicates that the primary message of a l l anti-AIDS health promotion activities has been conveyed to the general public. The attitudinal responses showed that the students favored a more permissive orientation in dealing with AIDS-related matters rather than a restrictive approach (Permissive orientation: M = 29.91, SD = 2.95; Restrictive orientation: M = 18.17, SD = 3.26; t,,, = 72.92, p < .01). They endorsed an egalitarian health policy with regards to AIDS patients and opposed any type of segregation. At the same time, however, the respondents advocated a number of precautionary measures which, in their opinion, should halt the spread of this infectious disease. These measures basically restrict individual rights and interfere with privacy of infected persons. A very small but significant negative correlation between these two orientations (-0.11) strengthened the view that a person can at the same time support the right of every person affected by AIDS to all health and social services, as well as favour the measures which restrict the person's privacy and human rights in order to protect other people from exposure to HIV (Table 1). TABLE 1 PEARSON CORRELATIONS AMONGKNOWLEDGE, ATTITUDES, AND BEHAVIORAL ADJUSTMENT VARIABLES --
1. 2. 3. 4. 5. 6. M
Permissive Attitudes Restrictive Attitudes Functional Knowledge General Knowledge Personal Concern Risk-reduction
SD
-.11* .51* .05* .02 .15* 29.91 2.95
-.23* .lo* -.20* .14* 18.17 3.26
-.08* .O1 .08* 11.60 .82
-.08* .08* 7.31 1.17
.OO 10.17 1.69
10.16 1.29
* p < .05.
The reported behavioral change on both dmensions was very modest: Concernlhealth habits: M = 10.17, SD = 1.69; Risk-reduction: M = 10.16, SD = 1.29). There was no difference between the two dimensions. Obviously, the
students did not change their usual conduct. This finding is consistent with the results reported by Baldwin and Baldwin (1988) who found that college students were engaging in few activities that would protect them from contracting the HIV. Our data are congruent with some other studies which indicated that AIDS had a limited effect on the way young people conduct their sexual lives (Strunin & Hingson, 1987; Roscoe & Kruger, 1990). This raises a critical question: Why was the students' behavior not affected by the obvious appearance of the AIDS epidemic of which they were quite aware? There are several possible explanations for this: The students probably did not perceive themselves at risk of infection with HIV because the incidence of AIDS was relatively low in this country. Perhaps they felt safe enough because they did not see themselves as belonging to any of the "high-risk groups" (such as intravenous drug abusers or homosexuals). F i n d y , the widespread notion that "AIDS happens to others" could contribute too. When these self-deceptions are combined with group social norms, which often restrain targeted behavior change (Fisher, 1988), and with particular circumstances which interfere with sustaining desired practices (i.e., saying "no" to a sexually arousing, attractive stranger), it is understandable that the probability of a change in behavior practices was slight. Furthermore, the students did not report increased concern that they might be at risk for AIDS, which could be attributed to the well-established illusion of invulnerability which prevails at this age (Cvetkovich, Grote, Bjorseth, & Sarkissian, 1975; Keeling, 1987; Masters, et a/., 1988). I t has been suggested that behavioral change is more likely when the concern about the disease is greater rather than the knowledge of the disease (Ishii-Kuntz, Whitbeck, & Simons, 1990). Since these young people did not perceive themselves at risk because AIDS occurred, they did not accept AIDS as a personal problem and did not change their usual patterns of behavior regardless of the fairly high amount of knowledge, which is consistent with findings reported in a number of other studies (Simkins & Eberhage, 1984; Crawford, 1990). In studying knowledge-behavior and attitude-behavior relations the underlying assumption is that by influencing knowledge and attitudes some desirable behaviors should occur. All public awareness campaigns are based on this assumption. However, the limits of this hypothesis have been well established in social psychology. Now, anti-AIDS campaigns face the same limits too. Our data show much the same results (Table 1). The risk-reduction behavioral measure correlated significantly but modestly with both attitude orientations (0.15 with a permissive orientation and 0.14 with a restrictive one). It may be that the subjects whose attitudes toward AIDS became more articulated, at the same time reduced their risk behaviors, which could be attributed to their supposedly better functional knowledge. However, correlations between risk-reduction and either kind of knowledge
STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES, BEHAVIOR
209
scores were not significant, the fact which has been well established among the students in the USA (Baldwin & Baldwin, 1988; Ishii-Kuntz, 1988; Kegeles, et al., 1988). The measure of concern correlated neither with the permissive attitude orientation nor with the functional knowledge scores. On the other hand, it was associated with restrictive attitudes (-0.20). This shows that the students who supported repressive and legal solutions of the AIDS problem at the same time felt less personally concerned, as if they put more faith in the society's capability to protect them against the spread of AIDS. It may be that the common denominator of both responses has to do with their more general views. The lower level of personal concern was also modestly associated with better general knowledge. Perhaps the subjects who knew that, for example, AIDS virus cannot be transmitted through ordinary social contacts, were aware that only certain behaviors put them at risk. This could indicate that education efforts about the routes of transmission of the virus were effective to a certain degree in increasing the awareness among the young people. Among all correlations the highest were between the functional knowledge score and either permissive or restrictive attitude orientation (.51 and -.23, respectively). This is consistent with the known fact that knowledge and attitudes are more related to each other than to the actual behavior. Furthermore, this showed that the students who hold more permissive attitudes toward the ways of dealing with the AIDS problem know much more about protecting themselves from contracting the HIV. Apparently the interrelations of actual behavior, knowledge, and attitudes are far more complex than is usually assumed. Moreover, a number of variables, such as sex, future profession, the desire for more information about AIDS, and familiarity with persons at high risk are related to knowledge, attitudes, and behavior change scores only slightly (Ajdukovif & Ajdukovif, 1990).
Conclusions The university students who participated in this study were apparently not motivated enough to modify their behavior in line with their knowledge of risk-reduction practices. This is probably due to less exposure to the AIDS epidemic in their social environment as well as to the implicit reasoning that "AIDS happens to others" which has been noted earlier in young people. These conditions may not be adequately motivating to effect a noticeable change toward risk-reducing practice in t h s particular population. Therefore, more delicate motivational aspects for altering behaviors related to the risk for HIV infection need to be recognized and studied in greater detail.
REFERENCES A~UKOVIC, D., & A ~ U K O V I C M., (1989) Strukma stavova studenata prema AIDS-u. [Structure of AIDS-related attitudes in students.] Primjenjena psihologija, 10, 185-194. Apu~ov~C D., , & AJDUKOVIC, M. (1990) AIDS-related knowledge, attitudes and behaviour i n student population. In Dj. AjdukoviC (Ed.), Oral AIDS. New York: Elsevier Science. Pp. 201-210. BALDWIN, J. D., & BALDWIN, J. I. (1988) Factors affecting AIDS-related sexual risk-taking behavior among college students. Journal of Sex Research, 25, 181-196. BOW, C., & FORD,N . (1989) Sexual behavior of young people and risk of HIV infection. Journal of Epidemiology and Community Health, 43, 61-65. CRAWFORD, I. (1990) Attitudes of undergraduate college students toward AIDS. Psychological Reports, 66, 11-16. CVETKOVICH, G., GROTE,B., BJORSETH, A., & SARKISSIAN, J. (1975) On the psychology of adolescents' use of contraceptives. Journal of Sex Research, 11, 256-270. D. (1988) Possible effects of reference group-based social influence on AIDS-risk beavlor . and AIDS prevention. American Psychologist, 43, 914-920. FLORA,J. A,, & THORESEN, C. E. (1989) Components of a comprehensive strategy for reduc1n.g the risk of AIDS in adolescents. In V. M. Mays, G . W. Albee, & S. F. Schne~der (Eds.), Primary prevention of AIDS. London: Sage. Pp. 374-389. FRIEDLAND, G. H., & KLEIN, R. S. (1987) Transmission of the human immunodeficiency virus. New England Journal of Medicine, 317, 1125-1135. HULLEY,S. B., & HEARST,N . (1989) The worldwide epidemiology and prevention of AIDS. In V. M. Mays, G. W. Albee, & S. F. Schneider (Eds.), Primary prevention of AIDS. London: Sage. Pp. 374-389. ISHII-KUNTZ,M. (1988) AIDS and sexual behavior changes in a college student sample. Sociologv and Social Research, 73, 13-18. Ism-KUNTZ,M., WHITBECK,L. B., & SIMONS,R. L. (1990) AIDS and perceived change in sexual practice: an analysis of n college student sample from California and Iowa. Journal of Applied Social Psychology, 20, 1301-1321. KEELING, R. P. (1987) Effect of AIDS on young Americans. Medical Aspects of Human Sexuality, 22, 26-29. KEGELES,S. M., ADLER,N. E., & IRWIN, C. E. (1988) Sexually active adolescents and condoms: changes over one year on knowledge, attitudes and use. American Journal of Public Health, 78, 460-461. MASTERS, W. H . , JOHNSON, V. E., & KOLODNY, R. C. (1988) Crisis: heterosexual behavior in the age of AIDS. New York: Grove Press. O'REJUY,K. R., & ARAL,S. 0. (1988) Adolescence and sexual behavior: trends and implications for STD. Sexually Active Teenagers, 2, 43-51. REMAFEDI,G. J. (1988) Preventing the sexual transmission of AIDS during adolescence. Journal of Adolescent Health Care, 9, 139-143. ROSCOE,B., & KRUGER,T. L. (1990) AIDS: late adolescents' knowledge and its influence on sexual behavior. Adolescence, 25, 39-48. S ~ K I N SL., , & EBERHAGE, M. (1984) Attitudes toward AIDS, Herpes 11, and Toxic Shock Syndrome. Psychological Reports, 55, 779-786. STRUNM,L., & HINGSON,R. (1987) Acquired Immunodeficiency Syndrome and adolescents: knowledge, beliefs and behaviors. Pediatrics, 79, 825-828. WHO. (January 1988) Update. American Journal of Public Health, 78, 410. ZABM, L. S., HARDY,J. B., SMITH,E . S., & HIRSCH,M. B. (1988) Substance use and its relation to sexual activity among imer-city adolescents. Sexually Active Teenagers, 2, 52-63.
Accepted August 3, 1991.
O Psychological Reports 1991
UNIVERSITY STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES AND BEHAVIORAL ADWSTMENT ' DEAN AJDUKOVIC Department of Psychology University of Zagreb
AND
MARINA AJDUKOVIC Department of Soczal Work Faculty of Law University of Zagreb
Summary.-This study addresses the relations between AIDS-related knowledge, attitudes, and behavior change among university students. A questionnaire covering such issues and personal background variables was administered to 750 students at the University of Zagreb. Over-d, 62.7% of the knowledge items were answered correctly, while functional, self-protective aspects of knowledge proved to be much better than general knowledge. On the average, attitudinal responses were moderately liberal. Both self-reported change in risk-reduction behavior and personal concern due to the appearance of AIDS were very small. Correlations of risk-reducing behavior with permissive (.15) and restrictive (.14) attitude orientations and with general and functional knowledge (.08) were modest. The level of personal concern correlated neither with permissive attitudes nor with functional knowledge, while it correlated negatively with restrictive attitudes (-,201 and with general knowledge (-.08). Substantial association was only established between functional knowledge and permissive (.51) and restrictive attitude orientations (-.23). It is concluded that, in addition to knowledge and attitudes, a number of factors which restrain desired behavioral adjustment should be considered in anti-AIDS campaigns, such as perceived level of exposure to HIV i n a particular environment, young age-specific illusion of invulnerability, peer norms, and others.
The epidemic of acquired immunodeficiency syndrome, which is widely known as AIDS, has primarily afflicted adults between the ages of 30 and 39 years ( H d e y & Hearst, 1987). This reflects the fact that most AIDS patients were infected with the human immunodeficiency virus (HIV) in their 20s and early 30s, probably as a consequence of behavioral practices acquired during adolescence and early adulthood. Thus, young people became of particular importance to the behavioral and social sciences' contribution to the fight against AIDS for at least two reasons. First, there are several factors which contribute to the higher risk for HIV infection among young people (first sexual experiences, the higher proportion of sexually transmitted diseases indicates that adolescents do not adhere to the "safer sex" practices, drug abuse history often starts at this age, etc.). Second, there is a chance to establish protective health-behavior patterns which might endure into adulthood. The risk of AIDS for the young population is apparent from the epidemiological data on HIV infection, their sexual behavior patterns, and contraceptive use habits, as well as data on sexually transmitted diseases and substance abuse (Masters, Johnson, & Kolodny, 1788; Flora & Thoresen, 'Address correspondence to Dean AjdukoviC, Ph.D., Department of Psychology, University of Zagreb, Djure Salaja 3, 41000 Zagreb, Yugoslavia.
1989). AU this evidence leads to an increased interest in research on knowledge, attitudes, and behavior among young people (O'Reilly & Aral, 1988; Remafedi, 1988; Bowie & Ford, 1989; Zabin, Hardy, Smith, & Hirsch, 1988). The intention in conducting these studies is primarily twofold: (1) to study knowledge, attitudes, and behavior relations in specific groups which are at special risk for HIV infection in order to build productive prevention programs and (2) the need to gather base-line estimates for evaluating the long-term effectiveness of programs aimed at young people. The number of AIDS cases in countries like Yugoslavia with 174 reported cases at the end of 1990 (rate of 7.4 per million), does not seem impressive in comparison to the number of patients in some other countries. The fact that massive public-awareness campaigns in some major cities were launched almost simultaneously with those in the more affected countries seems self-evident as one of several explanations for this comparatively small number of patients. These preventive efforts made the AIDS problem very salient to the general population. Consequently, it was assumed that people modified their behavior according to their increased knowledge about this fatal disease. Furthermore, all public campaigns have usually attempted to promote attitudes which support preferred behavior. However, the face validity of the simple assumption that educating people about AIDS is bound to be followed by behavioral change is feeble and hindered by a number of factors (Kegeles, Adler, & Irwin, 1988; Strunin & Hingson, 1987), so a joint research group from the Department of Psychology and the Department of Social Work of the University of Zagreb began an extensive project in 1987, aimed at studying the relations between the knowledge, attitudes, self-reported behavioral practices, behavioral intentions relevant to HIV infection, and their possible correlates among young people between 15 and 30 years of age. The principal goal of this project has been to help plan and evaluate anti-AIDS programs targeted primarily at the general population. In the past few years there has been growing awareness of the considerable personal hazard due to HIV spill-over into the general heterosexual population, previously thought to be safe. In January 1988, the World Health Organization reported that the estimate of the proportion of AIDS acquired through heterosexual contact in the Americas, Europe, and Australia has increased from 1% to approximately 4%, making this goal even more meaningful. The proportion of AIDS cases caused by heterosexual transmission may increase even further in the near future (Friedland & Klein, 1987). The present paper reports relations among knowledge, attitudes, and behavioral adjustment among the university student population. Subjects I n this study, 750 students at the University of Zagreb, Yugoslavia, vol-
STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES, BEHAVIOR
205
unteered to fill out anonymously a questionnaire. The subjects were students of social work (179), psychology (139), medicine (192), law (144), and agriculture (96). They ranged in age from 19 to 26 years, with an average of 20.5 yr. There were 524 women and 226 men.
Procedure The questionnaire, administered by a member of the research staff to groups of students not larger than 30, contained sets of items on knowledge, attitude, and behavior change. In addition, it tapped data on the subjects' personal background, their sources of information about AIDS, and their exposure to groups at higher risk for HIV infection. Special care was taken to ensure absolute anonymity of the respondents through the administration. The knowledge items were originally answered on a five-point scale, ranging from "absolutely true" to "absolutely false" but were dichotomized afterward. The items' contents asked about AIDS-related issues which are usually included in scales of this type (i.e., routes of transmission, prevention and risk-reduction practices, asymptomatic status of virus carriers, affected population, medical treatment, etc.). The scale reliability (Cronbach alpha) of .75 was judged appropriate considering the heterogeneity of the items' contents. However, the exploratory hierarchical principal components factor analysis yielded two latent knowledge dimensions: (1) general knowledge about AIDS (i.e., affected population, diagnosis, and treatment) and (2) knowledge with obvious self-protective functional value (i.e., means of HIV transmission and risk-reduction practices). Accordingly, two knowledge subscores were derived. The items primarily saturated by either factor were used for scoring subjects' achievement on these two knowledge aspects. One item ("ARC is the acronym for AIDS-related Complex") was not used in further analysis because it did not appear to belong to either subscale. Individual subscores could range from 6 to 12. To tap the attitudes toward AIDS-preventive measures statements whch are standard for this type of questionnaire were used. They expressed views about ways in which the problems associated with AIDS should be approached (i.e., "Children with AIDS should not be allowed to attend regular schools," "AIDS is primarily a medical problem and requires a medical solution," "People with AIDS should be quarantined," "Intentional spread of AIDS should be treated as murder," "AU AIDS patients are innocent victims," etc.). Supporting certain AIDS-preventive measures reflects one's attitudes to questions like: How should the people at higher risk for HIV infection be treated? To what extent should the individual rights of infected and sick persons be respected as opposed to the society's need to protect itself from the spread of disease? How does this influence individuals' perceptions of their own health risks and the options available to reduce them? Consistency between attitudes toward AIDS-preventive measures (including
the attitudes toward people with AIDS), attitudes toward one's responsibility for one's own health, and one's own AIDS-related behavior might be assumed. A four-point scale format was used to respond to the attitude items. I t ranged from "strongly agree" to "strongly disagree." Responses were scored according to their liberal direction, with a higher score indicating a more liberal attitude. In this context "liberal" implied attitudes which disapproved of legal or repressive actions related to the AIDS problem and which would allow infected individuals equality in all aspects of everyday life. The factor analysis helped identify two almost independent attitudinal dimensions labelled permissive and restrictive orientation toward AIDS-related issues (Ajdukovii & AjdukoviC, 1989). This means that at the same time a person can support activities which ameliorate the position of people affected by AIDS and endorse measures which restrict privacy and some other rights of people. The possible score for either attitude orientation ranged from 9 to 36. Change in behaviors attributed to the appearance of AIDS was self-assessed by the set of items which were intended to cover four aspects of adjustments in one's behavior: personal concern that one might be at risk for AIDS, risk-reducing sexual practices, general health practices, and affiliation with people at higher risk. Reported change in intravenous substance abuse was not included because the incidence in this population was low (less than 0.5%). Each item was answered with reference to the respondent's typical conduct prior to the present year. However, the factor analysis identified only two distinct behavioral adjustment dimensions, (1) concern and habits which did not have an apparent risk-reducing component (e.g., discussing possibility of AIDS infection with the partner, being concerned about infection due to a medical intervention, contemplating about being at risk for AIDS, using public toilets less often, etc.) and (2) risk-reducing behavior which had a distinctive self-protective aspect (e.g., using a condom more often, being more faithful to the partner, etc.). For either dimension individual scores could range from 5 to 15, with a score of 10 showing no change. Scores below 10 indicated diminished concern or increased frequency of behaviors which put an individual at higher risk. Scores above 10 indicated increased concern or more cautious conduct than before.
Data Analysis t tests were used to compare the subjects' average scores between the two aspects of knowledge, the two attitude orientations, and the two behavior adjustment dimensions. Correlations were employed to assess association among these variables. The SPSS-PC + commercial computer package served for the analysis of the data. RESULTSAND DISCUSSION The subjects' over-all knowledge was moderately high: 62.7% of all
STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES, BEHAVIOR
207
items were correctly identified. However, a significant difference was found between the amount of functional or self-protective knowledge and that of general knowledge about AIDS (Functional knowledge: M = 11.60, SD = 0.81; General knowledge: M = 7.31, SD = 1.17; t,,, = 78.00, p < .01). These results clearly indicate that the subjects possessed satisfactory knowledge about the means of transmission of HIV, what practices reduce the risk of exposure to the disease, etc. O n the other hand, they knew far less about the symptoms of AIDS, its definition, or the extent of the AIDS epidemic. Obviously, the facts directly related to the possibility of virus transmission are what the students know and remember best. This also indicates that the primary message of a l l anti-AIDS health promotion activities has been conveyed to the general public. The attitudinal responses showed that the students favored a more permissive orientation in dealing with AIDS-related matters rather than a restrictive approach (Permissive orientation: M = 29.91, SD = 2.95; Restrictive orientation: M = 18.17, SD = 3.26; t,,, = 72.92, p < .01). They endorsed an egalitarian health policy with regards to AIDS patients and opposed any type of segregation. At the same time, however, the respondents advocated a number of precautionary measures which, in their opinion, should halt the spread of this infectious disease. These measures basically restrict individual rights and interfere with privacy of infected persons. A very small but significant negative correlation between these two orientations (-0.11) strengthened the view that a person can at the same time support the right of every person affected by AIDS to all health and social services, as well as favour the measures which restrict the person's privacy and human rights in order to protect other people from exposure to HIV (Table 1). TABLE 1 PEARSON CORRELATIONS AMONGKNOWLEDGE, ATTITUDES, AND BEHAVIORAL ADJUSTMENT VARIABLES --
1. 2. 3. 4. 5. 6. M
Permissive Attitudes Restrictive Attitudes Functional Knowledge General Knowledge Personal Concern Risk-reduction
SD
-.11* .51* .05* .02 .15* 29.91 2.95
-.23* .lo* -.20* .14* 18.17 3.26
-.08* .O1 .08* 11.60 .82
-.08* .08* 7.31 1.17
.OO 10.17 1.69
10.16 1.29
* p < .05.
The reported behavioral change on both dmensions was very modest: Concernlhealth habits: M = 10.17, SD = 1.69; Risk-reduction: M = 10.16, SD = 1.29). There was no difference between the two dimensions. Obviously, the
students did not change their usual conduct. This finding is consistent with the results reported by Baldwin and Baldwin (1988) who found that college students were engaging in few activities that would protect them from contracting the HIV. Our data are congruent with some other studies which indicated that AIDS had a limited effect on the way young people conduct their sexual lives (Strunin & Hingson, 1987; Roscoe & Kruger, 1990). This raises a critical question: Why was the students' behavior not affected by the obvious appearance of the AIDS epidemic of which they were quite aware? There are several possible explanations for this: The students probably did not perceive themselves at risk of infection with HIV because the incidence of AIDS was relatively low in this country. Perhaps they felt safe enough because they did not see themselves as belonging to any of the "high-risk groups" (such as intravenous drug abusers or homosexuals). F i n d y , the widespread notion that "AIDS happens to others" could contribute too. When these self-deceptions are combined with group social norms, which often restrain targeted behavior change (Fisher, 1988), and with particular circumstances which interfere with sustaining desired practices (i.e., saying "no" to a sexually arousing, attractive stranger), it is understandable that the probability of a change in behavior practices was slight. Furthermore, the students did not report increased concern that they might be at risk for AIDS, which could be attributed to the well-established illusion of invulnerability which prevails at this age (Cvetkovich, Grote, Bjorseth, & Sarkissian, 1975; Keeling, 1987; Masters, et a/., 1988). I t has been suggested that behavioral change is more likely when the concern about the disease is greater rather than the knowledge of the disease (Ishii-Kuntz, Whitbeck, & Simons, 1990). Since these young people did not perceive themselves at risk because AIDS occurred, they did not accept AIDS as a personal problem and did not change their usual patterns of behavior regardless of the fairly high amount of knowledge, which is consistent with findings reported in a number of other studies (Simkins & Eberhage, 1984; Crawford, 1990). In studying knowledge-behavior and attitude-behavior relations the underlying assumption is that by influencing knowledge and attitudes some desirable behaviors should occur. All public awareness campaigns are based on this assumption. However, the limits of this hypothesis have been well established in social psychology. Now, anti-AIDS campaigns face the same limits too. Our data show much the same results (Table 1). The risk-reduction behavioral measure correlated significantly but modestly with both attitude orientations (0.15 with a permissive orientation and 0.14 with a restrictive one). It may be that the subjects whose attitudes toward AIDS became more articulated, at the same time reduced their risk behaviors, which could be attributed to their supposedly better functional knowledge. However, correlations between risk-reduction and either kind of knowledge
STUDENTS AND AIDS: KNOWLEDGE, ATTITUDES, BEHAVIOR
209
scores were not significant, the fact which has been well established among the students in the USA (Baldwin & Baldwin, 1988; Ishii-Kuntz, 1988; Kegeles, et al., 1988). The measure of concern correlated neither with the permissive attitude orientation nor with the functional knowledge scores. On the other hand, it was associated with restrictive attitudes (-0.20). This shows that the students who supported repressive and legal solutions of the AIDS problem at the same time felt less personally concerned, as if they put more faith in the society's capability to protect them against the spread of AIDS. It may be that the common denominator of both responses has to do with their more general views. The lower level of personal concern was also modestly associated with better general knowledge. Perhaps the subjects who knew that, for example, AIDS virus cannot be transmitted through ordinary social contacts, were aware that only certain behaviors put them at risk. This could indicate that education efforts about the routes of transmission of the virus were effective to a certain degree in increasing the awareness among the young people. Among all correlations the highest were between the functional knowledge score and either permissive or restrictive attitude orientation (.51 and -.23, respectively). This is consistent with the known fact that knowledge and attitudes are more related to each other than to the actual behavior. Furthermore, this showed that the students who hold more permissive attitudes toward the ways of dealing with the AIDS problem know much more about protecting themselves from contracting the HIV. Apparently the interrelations of actual behavior, knowledge, and attitudes are far more complex than is usually assumed. Moreover, a number of variables, such as sex, future profession, the desire for more information about AIDS, and familiarity with persons at high risk are related to knowledge, attitudes, and behavior change scores only slightly (Ajdukovif & Ajdukovif, 1990).
Conclusions The university students who participated in this study were apparently not motivated enough to modify their behavior in line with their knowledge of risk-reduction practices. This is probably due to less exposure to the AIDS epidemic in their social environment as well as to the implicit reasoning that "AIDS happens to others" which has been noted earlier in young people. These conditions may not be adequately motivating to effect a noticeable change toward risk-reducing practice in t h s particular population. Therefore, more delicate motivational aspects for altering behaviors related to the risk for HIV infection need to be recognized and studied in greater detail.
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Accepted August 3, 1991.
