Public Health
(1991), 105, 167-171
© The Societyof Public Health, 1991
W h a t Irish S c h o o l c h i l d r e n K n o w A b o u t A I D S 1y. G. Doyle and 2R. M. Conroy 1 Department of Public Health and Epidemiology, Camberwe//Health Authority and King's College Hospital London SE5 9PJ. 2 Department of Community Medicine, The Royal College of Surgeons in Ireland, Dublin 2, Republic of Ireland
AIDS in the Republic of Ireland has so far mainly been associated with intravenous drug use. However, because of growing public pressure to mount an AIDS campaign aimed at potentially vulnerable sub-groups, we conducted a survey of knowledge and attitudes related to AIDS among 891 Irish schoolchildren in the senior years of secondary school. Although virtually none of the children had received any classroom education on AIDS and no national education programme had been undertaken at the time of the survey, levels of knowledge were high among the pupils studied, and compared favourably with levels found using the same questionnaire among San Franciscan pupils. Higher levels of knowledge were found among urban pupils and, although some sex differences in knowledge emerged, there was no consistent pattern in these. No school surveyed showed sufficient misinformation to warrant a systematic education programme. Introduction Acquired immune deficiency syndrome (AIDS) has, in the Republic of Ireland, been mainly associated with intravenous drug use. Nevertheless, it poses a threat to the remainder of the community since many such users are also prostitutes. Any population group with a high frequency of casual sexual contact is a potential risk group for the spread of AIDS. Although cases o f A I D S are rare in adolescents to date, this may reflect the low prevalence of the condition rather than a low transmission rate in this group. We therefore conducted a survey of schoolchildren who were in the final two years of secondary school in the Republic of Ireland, using a questionnaire previously administered to schoolchildren in the San Franscisco area, ~ to determine if a formal schools A I D S education programme was warranted and to compare levels of knowledge and attitudes related to A I D S between Irish and San Franciscan schoolchildren. Materials and Methods The questionnaire administered was virtually identical with that used in a previous study in San Franscisco. 1 The only changes were those required to adapt it to the Irish setting--place names, idioms and spelling. The questionnaire comprises 30 factual and 10 attitudinal questions about AIDS. It was administered in 1987 in order to test baseline knowledge and attitudes of Irish schoolchildren before the first national information campaign on A I D S was launched by the Department of Health. Six schools were chosen, three urban and three rural. In each three schools, one was a mixed, one a girls-only and one a boys-only. N o information on which to assess the representativeness o f the schools is available, but it is unlikely that they are atypical in any important respect. N o school refused to participate in the study.
Y. G. Doyle and R. M. Conroy
168 Table I
A I D S knowledge (a) and attitudes (b) in 889 Irish schoolchildren
(a) Statement Right (%)
Percentage: Wrong Don't know (%) (%)
Older age
Effect of: Male sex
City
A I D S is a condition in which your body cannot fight off diseases
91.2
5.6
3.2
A I D S is caused by a virus
83.7
9.4
6.9
+
A I D S is a condition you are born with
88.3
5.3
6.4
+
Stress causes A I D S
96.3
0.6
3.2
If you kiss someone with A I D S you can get A I D S
85.8
7.9
6.3
If you touch someone with A I D S you can get A I D S
97.1
0.9
2.0
+++
All gay men have A I D S
92.8
3.2
4.1
+++
W h a t you eat can give you A I D S
94.6
1.6
3.9
A n y b o d y can get A I D S
93.0
5.9
1.1
+++
A I D S can be cured
84.5
2.9
t2.6
++
W o m e n are more likely to get A I D S during their period
58.8
5.3
35.9
A I D S can be spread by using someone's personal belongings like a comb or toothbrush
84.0
6.5
9.4
A I D S is not at all serious: it is like getting a cold
97.4
2.2
0.3
A I D S is caused by the same virus that causes V D
50.1
7.3
42.6
+++
The cause o f A I D S is u n k n o w n
53.1
27.3
19.7
++
Just being around with someone with A I D S can give you A I D S
96.2
1.3
2.5
Having sex with someone with A I D S is one way of getting it
98.3
1.1
0.6
If a pregnant w o m a n has A I D S , it may harm her unborn baby
90.6
1.3
8.1
Most people who get A I D S die from the disease
87.2
9.2
3.6
Using a c o n d o m during sex can lower the risk of getting A I D S
93.6
2.5
3.9
Y o u can get A I D S by shaking hands with someone who has it
97.5
1.2
1.2
Receiving a blood transfusion from infected blood can give a person A I D S
95.3
1.7
3.0
+++ ++ ++
+++
+++
++
++
++
+++
What Irish Schoolchildren Know about A I D S continued
Table I (a)
169
continued
Statement Right (%)
Percentage: Wrong Don't know (%) (%)
You can get A I D S by sharing a needle with a drug user who has the disease
97.3
0.4
2.2
A I D S is a life-threatening disease
97.9
0.8
1.4
People with A I D S usually have a lot of other diseases as a result of A I D S
58.4
14.5
27.1
All gay w o m e n have A I D S
89.3
2.1
8.5
There is no cure for A I D S
7%4
7.3
13.3
I can avoid A I D S by exercising regularly
93.3
1.3
5.4
A I D S can be cured if treated early
61.0
9.2
29.8
A new vaccine has recently been developed to treat A I D S
36.6
35.2
38.3
Agree
Disagree
(%)
(%)
Don't know (%)
5.8
91.2
2.9
I am afraid o f getting A I D S
67.6
26.0
6.4
I am not the kind of person who is likely to get A I D S
39.5
43.9
16.6
I a m not worried about getting A I D S
32.7
58.5
8.8
I a m less likely than most people to get AIDS
34.7
45.5
19.8
I'd rather get any other disease than A I D S
62.3
13.2
24.5
I've heard enough a b o u t A I D S and I don't want to hear any more about it
10.1
86.3
3.6
It is imporant for pupils to learn about A I D S in school
94.8
3.0
2.1
Yes (%)
No (%)
Don't know
67.0
21.1
11.9
(b) Statement
A I D S is not a problem in Ireland
If a free blood test was available to see if you have the A I D S virus, would you take it?
(%)
Older age
Effect of: Male sex
City
+ +
+ + + + + +
+ + +
170
}I. G. Doyle and R. M. Conroy
Questionnaires were administered during school time by one of the authors who invigilated to ensure that pupils completed them unaided. No pupil refused to complete a questionnaire although they were free not to do so. In order to determine the independant effects of sex, age and area of residence of pupil on the likelihood of making the correct response, a nmltiple logistic regression was performed on each item. Results Table I shows the percentage correct, incorrect and ' d o n ' t know' responses to each question. In addition, the factors influencing the rate of correct responses is shown using the following notation: under each characteristic (being older, male and living in the city) is a symbol showing the effect of that characteristic on the level of correct response. A plus indicates a high level of correct responses, a minus a lower level. Statistical significance is shown by using one symbol for P < 0 . 0 5 , two for P < 0 . 0 1 and three for P < 0.001. Thus the symbol ' + + ' indicates a positive association at P < 0.0l and ' - - - ' indicates a negative one at P < 0 . 0 0 1 . Each item could yield 297 responses, one third o f the total 891; there were a number of missing responses per item ranging from two to eleven. These have been excluded from the calculation of percentages and significance levels without comment. U r b a n pupils showed higher levels of knowledge than rural, and there were f e m a l ~ m a l e differences in accuracy of responses to some items, hut no consistent pattern emerged in the relation of knowledge to sex. Older pupils tended to be slightly better informed. Discussion The community control of any disease which can be prevented by behavioural changes entails three steps: making the public aware that a significant problem exists, educating them in the necessary measures to take and, finally, overcoming obstacles which prevent these steps being taken. The general public in Ireland are aware that A I D S is a major health problem. Subsequent to this study, there have been several national media campaigns a b o u t A I D S and a major initiative for schools nationally, comprising an information pack for each pupil, is due to commence in the latter half of 1990. However the present study, together with the results of a survey of the adult population -~show that levels o f knowledge of how A I D S is, and is not, spread are good. In both the schools and the adult samples, levels of knowledge of the ways in which A I D S is transmitted were 90% or better. Schoolchildren were better informed a b o u t factors that do not spread AIDS. Comparison of the results of the present study with the earlier one in San Francisco ~shows that levels of knowledge are as good, and often better, a m o n g the Irish schoolchildren. These levels of knowledge were achieved without a formal education campaign either in the national media or in the classroom, although since British television can be received in m a n y areas in Eastern Ireland, the British A I D S media campaign m a y be partly responsible for the results obtained. One hundred and seventy six A I D S cases have been identified in the Republic by December 1990, via a special notification system to the D e p a r t m e n t o f Health. O f these, 68 (39%) are intravenous drug abusers and a further seven (4%) are babies of intravenous drug abusers; 71 (40%) are homo/bisexual and 17 of the remaining 30 cases are haemophiliacs. Although the n u m b e r of identified cases has almost trebled since 1987, the same pattern of infection exists with drug abusers m a n y of w h o m are probably involved in prostitution--comprising a m a j o r group of cases.
What Irish Schoolchildren Know about A I D S
171
We do not believe that the level of public knowledge justifies purely informational campaigns. In order to change practices so as to halt the spread of AIDS, campaigns must encourage the public to take specific steps to avoid the disease. The 1990 schools campaign by the D e p a r t m e n t of Health addresses this issue, but other campaigns have not. We are pessimistic a b o u t the success o f Irish media campaigns which stress sexual fidelity. For centuries, syphilis was a major life-threatening disease. Despite the fact that this was widely known, it continued to be spread. Sexual fidelity is particularly inappropriate in the context o f intravenous drug abusers, yet the restrictive laws regarding the sale o f contraceptives in Ireland contravene any official attempt to openly p r o m o t e the use and distribution of condoms. This has again been witnessed by the recent prosecution of the Irish Family Planning Association for the sale of condoms in a Dublin record s t o r e ) U p to 1990, these restrictions have discouraged a more robust public health campaign a b o u t AIDS, both in schools and elsewhere, which could protect society from the consequences of promiscuity of some o f its members. Furthermore research in the Irish context of factors affecting the use of condoms is required. While most campaigns are directed at men, the taking of contraceptive precautions is traditionally the role of the woman. While deploring this fact, a campaign aimed at women to 'keep a few handy' would have a greater impact on sexual practices. In the meantime, large sums are being spent on probably unnecessary A I D S information while research on the factors which might halt its spread a m o n g vulnerable groups remains comparatively neglected. References
1. DiClemente, R.J., Zorn, J. & Temoshok, L. (1986). Adolescents and AIDS: a survey of knowledge, attitudes and beliefs about AIDS in San Francisco. American Journal of Public Health, 76, 14431445. 2. Harkin, A.M. & Hurley, M. (t987). National Survey on Public Knowledge about AIDS. Dublin: The Health Education Bureau. 3. Nowlan, D. (1990). Irish condom ruling. British Medical Journal, 300, 1420-1421.
(1991), 105, 167-171
© The Societyof Public Health, 1991
W h a t Irish S c h o o l c h i l d r e n K n o w A b o u t A I D S 1y. G. Doyle and 2R. M. Conroy 1 Department of Public Health and Epidemiology, Camberwe//Health Authority and King's College Hospital London SE5 9PJ. 2 Department of Community Medicine, The Royal College of Surgeons in Ireland, Dublin 2, Republic of Ireland
AIDS in the Republic of Ireland has so far mainly been associated with intravenous drug use. However, because of growing public pressure to mount an AIDS campaign aimed at potentially vulnerable sub-groups, we conducted a survey of knowledge and attitudes related to AIDS among 891 Irish schoolchildren in the senior years of secondary school. Although virtually none of the children had received any classroom education on AIDS and no national education programme had been undertaken at the time of the survey, levels of knowledge were high among the pupils studied, and compared favourably with levels found using the same questionnaire among San Franciscan pupils. Higher levels of knowledge were found among urban pupils and, although some sex differences in knowledge emerged, there was no consistent pattern in these. No school surveyed showed sufficient misinformation to warrant a systematic education programme. Introduction Acquired immune deficiency syndrome (AIDS) has, in the Republic of Ireland, been mainly associated with intravenous drug use. Nevertheless, it poses a threat to the remainder of the community since many such users are also prostitutes. Any population group with a high frequency of casual sexual contact is a potential risk group for the spread of AIDS. Although cases o f A I D S are rare in adolescents to date, this may reflect the low prevalence of the condition rather than a low transmission rate in this group. We therefore conducted a survey of schoolchildren who were in the final two years of secondary school in the Republic of Ireland, using a questionnaire previously administered to schoolchildren in the San Franscisco area, ~ to determine if a formal schools A I D S education programme was warranted and to compare levels of knowledge and attitudes related to A I D S between Irish and San Franciscan schoolchildren. Materials and Methods The questionnaire administered was virtually identical with that used in a previous study in San Franscisco. 1 The only changes were those required to adapt it to the Irish setting--place names, idioms and spelling. The questionnaire comprises 30 factual and 10 attitudinal questions about AIDS. It was administered in 1987 in order to test baseline knowledge and attitudes of Irish schoolchildren before the first national information campaign on A I D S was launched by the Department of Health. Six schools were chosen, three urban and three rural. In each three schools, one was a mixed, one a girls-only and one a boys-only. N o information on which to assess the representativeness o f the schools is available, but it is unlikely that they are atypical in any important respect. N o school refused to participate in the study.
Y. G. Doyle and R. M. Conroy
168 Table I
A I D S knowledge (a) and attitudes (b) in 889 Irish schoolchildren
(a) Statement Right (%)
Percentage: Wrong Don't know (%) (%)
Older age
Effect of: Male sex
City
A I D S is a condition in which your body cannot fight off diseases
91.2
5.6
3.2
A I D S is caused by a virus
83.7
9.4
6.9
+
A I D S is a condition you are born with
88.3
5.3
6.4
+
Stress causes A I D S
96.3
0.6
3.2
If you kiss someone with A I D S you can get A I D S
85.8
7.9
6.3
If you touch someone with A I D S you can get A I D S
97.1
0.9
2.0
+++
All gay men have A I D S
92.8
3.2
4.1
+++
W h a t you eat can give you A I D S
94.6
1.6
3.9
A n y b o d y can get A I D S
93.0
5.9
1.1
+++
A I D S can be cured
84.5
2.9
t2.6
++
W o m e n are more likely to get A I D S during their period
58.8
5.3
35.9
A I D S can be spread by using someone's personal belongings like a comb or toothbrush
84.0
6.5
9.4
A I D S is not at all serious: it is like getting a cold
97.4
2.2
0.3
A I D S is caused by the same virus that causes V D
50.1
7.3
42.6
+++
The cause o f A I D S is u n k n o w n
53.1
27.3
19.7
++
Just being around with someone with A I D S can give you A I D S
96.2
1.3
2.5
Having sex with someone with A I D S is one way of getting it
98.3
1.1
0.6
If a pregnant w o m a n has A I D S , it may harm her unborn baby
90.6
1.3
8.1
Most people who get A I D S die from the disease
87.2
9.2
3.6
Using a c o n d o m during sex can lower the risk of getting A I D S
93.6
2.5
3.9
Y o u can get A I D S by shaking hands with someone who has it
97.5
1.2
1.2
Receiving a blood transfusion from infected blood can give a person A I D S
95.3
1.7
3.0
+++ ++ ++
+++
+++
++
++
++
+++
What Irish Schoolchildren Know about A I D S continued
Table I (a)
169
continued
Statement Right (%)
Percentage: Wrong Don't know (%) (%)
You can get A I D S by sharing a needle with a drug user who has the disease
97.3
0.4
2.2
A I D S is a life-threatening disease
97.9
0.8
1.4
People with A I D S usually have a lot of other diseases as a result of A I D S
58.4
14.5
27.1
All gay w o m e n have A I D S
89.3
2.1
8.5
There is no cure for A I D S
7%4
7.3
13.3
I can avoid A I D S by exercising regularly
93.3
1.3
5.4
A I D S can be cured if treated early
61.0
9.2
29.8
A new vaccine has recently been developed to treat A I D S
36.6
35.2
38.3
Agree
Disagree
(%)
(%)
Don't know (%)
5.8
91.2
2.9
I am afraid o f getting A I D S
67.6
26.0
6.4
I am not the kind of person who is likely to get A I D S
39.5
43.9
16.6
I a m not worried about getting A I D S
32.7
58.5
8.8
I a m less likely than most people to get AIDS
34.7
45.5
19.8
I'd rather get any other disease than A I D S
62.3
13.2
24.5
I've heard enough a b o u t A I D S and I don't want to hear any more about it
10.1
86.3
3.6
It is imporant for pupils to learn about A I D S in school
94.8
3.0
2.1
Yes (%)
No (%)
Don't know
67.0
21.1
11.9
(b) Statement
A I D S is not a problem in Ireland
If a free blood test was available to see if you have the A I D S virus, would you take it?
(%)
Older age
Effect of: Male sex
City
+ +
+ + + + + +
+ + +
170
}I. G. Doyle and R. M. Conroy
Questionnaires were administered during school time by one of the authors who invigilated to ensure that pupils completed them unaided. No pupil refused to complete a questionnaire although they were free not to do so. In order to determine the independant effects of sex, age and area of residence of pupil on the likelihood of making the correct response, a nmltiple logistic regression was performed on each item. Results Table I shows the percentage correct, incorrect and ' d o n ' t know' responses to each question. In addition, the factors influencing the rate of correct responses is shown using the following notation: under each characteristic (being older, male and living in the city) is a symbol showing the effect of that characteristic on the level of correct response. A plus indicates a high level of correct responses, a minus a lower level. Statistical significance is shown by using one symbol for P < 0 . 0 5 , two for P < 0 . 0 1 and three for P < 0.001. Thus the symbol ' + + ' indicates a positive association at P < 0.0l and ' - - - ' indicates a negative one at P < 0 . 0 0 1 . Each item could yield 297 responses, one third o f the total 891; there were a number of missing responses per item ranging from two to eleven. These have been excluded from the calculation of percentages and significance levels without comment. U r b a n pupils showed higher levels of knowledge than rural, and there were f e m a l ~ m a l e differences in accuracy of responses to some items, hut no consistent pattern emerged in the relation of knowledge to sex. Older pupils tended to be slightly better informed. Discussion The community control of any disease which can be prevented by behavioural changes entails three steps: making the public aware that a significant problem exists, educating them in the necessary measures to take and, finally, overcoming obstacles which prevent these steps being taken. The general public in Ireland are aware that A I D S is a major health problem. Subsequent to this study, there have been several national media campaigns a b o u t A I D S and a major initiative for schools nationally, comprising an information pack for each pupil, is due to commence in the latter half of 1990. However the present study, together with the results of a survey of the adult population -~show that levels o f knowledge of how A I D S is, and is not, spread are good. In both the schools and the adult samples, levels of knowledge of the ways in which A I D S is transmitted were 90% or better. Schoolchildren were better informed a b o u t factors that do not spread AIDS. Comparison of the results of the present study with the earlier one in San Francisco ~shows that levels of knowledge are as good, and often better, a m o n g the Irish schoolchildren. These levels of knowledge were achieved without a formal education campaign either in the national media or in the classroom, although since British television can be received in m a n y areas in Eastern Ireland, the British A I D S media campaign m a y be partly responsible for the results obtained. One hundred and seventy six A I D S cases have been identified in the Republic by December 1990, via a special notification system to the D e p a r t m e n t o f Health. O f these, 68 (39%) are intravenous drug abusers and a further seven (4%) are babies of intravenous drug abusers; 71 (40%) are homo/bisexual and 17 of the remaining 30 cases are haemophiliacs. Although the n u m b e r of identified cases has almost trebled since 1987, the same pattern of infection exists with drug abusers m a n y of w h o m are probably involved in prostitution--comprising a m a j o r group of cases.
What Irish Schoolchildren Know about A I D S
171
We do not believe that the level of public knowledge justifies purely informational campaigns. In order to change practices so as to halt the spread of AIDS, campaigns must encourage the public to take specific steps to avoid the disease. The 1990 schools campaign by the D e p a r t m e n t of Health addresses this issue, but other campaigns have not. We are pessimistic a b o u t the success o f Irish media campaigns which stress sexual fidelity. For centuries, syphilis was a major life-threatening disease. Despite the fact that this was widely known, it continued to be spread. Sexual fidelity is particularly inappropriate in the context o f intravenous drug abusers, yet the restrictive laws regarding the sale o f contraceptives in Ireland contravene any official attempt to openly p r o m o t e the use and distribution of condoms. This has again been witnessed by the recent prosecution of the Irish Family Planning Association for the sale of condoms in a Dublin record s t o r e ) U p to 1990, these restrictions have discouraged a more robust public health campaign a b o u t AIDS, both in schools and elsewhere, which could protect society from the consequences of promiscuity of some o f its members. Furthermore research in the Irish context of factors affecting the use of condoms is required. While most campaigns are directed at men, the taking of contraceptive precautions is traditionally the role of the woman. While deploring this fact, a campaign aimed at women to 'keep a few handy' would have a greater impact on sexual practices. In the meantime, large sums are being spent on probably unnecessary A I D S information while research on the factors which might halt its spread a m o n g vulnerable groups remains comparatively neglected. References
1. DiClemente, R.J., Zorn, J. & Temoshok, L. (1986). Adolescents and AIDS: a survey of knowledge, attitudes and beliefs about AIDS in San Francisco. American Journal of Public Health, 76, 14431445. 2. Harkin, A.M. & Hurley, M. (t987). National Survey on Public Knowledge about AIDS. Dublin: The Health Education Bureau. 3. Nowlan, D. (1990). Irish condom ruling. British Medical Journal, 300, 1420-1421.
