International Journal of Nursing Practice 2002; 8: 8188

R E S E A R C H PA P E R

Early adolescents HIV-related knowledge, attitudes and behaviour in Finland

Ulla Muinonen MSc (Health care) Janssen-Cilag Oy, Finland Tarja Suominen PhD STAKES and Department of Nursing, University of Turku, Finland Maritta Vlimki PhD Department of Nursing, University of Tampere, Finland Christa Lohrmann Humboldt Universitet, Institut fr Medizin-Pegepedagogik und Pegewissenschaft, Germany Ian Peate MA Division of Adult Nursing and Health Sciences, University of Hertfordshire, United Kingdom Accepted for publication March 2001 Muinonen U, Suominen T, Vlimki M, Lohrmann C, Peate I. International Journal of Nursing Practice 2002; 8: 8188 Early adolescents HIV-related knowledge, attitudes and behaviour in Finland Finland had a relatively low rate of HIV infection during the rst 17 years of the epidemic, which began in 1980. Similar to other developed countries around the world, information about the infection has been readily available, and this helped to reduce the occurrence of HIV contagion, particularly among adolescents, a group that is responsible for 50% of HIV infections worldwide.This small-scale study investigated HIV-related knowledge, attitudes, and behaviour among a group of 171 youths aged 1316 years in suburban schools in southern Finland. Knowledge levels were relatively low and the disease was somewhat stigmatized, but homosexuality was less stigmatized than in other developed countries.The results suggest that Finnish adolescents need to be better informed about HIV and AIDS. Schools and school nurses could play a crucial role in providing information about this incurable disease. Key words: adolescents, homophobia, sexual risk behavior.

INTRODUCTION
The rst case of acquired immunodeciency syndrome (AIDS) was diagnosed in Finland in the early 1980s.1 Data on infectious diseases in Finland are collected by the

Correspondence: Ulla Muinonen, Ojansilta 4 B 3, 01820 Klaukkala, Finland. Email: umuinone@jac.jnj.com

National Public Health Institute (NPHI) under the Ministry of Social Affairs and Health. Physicians are obliged to report human immunodeciency virus (HIV) infections in three separate phases: (i) diagnosis of the infection; (ii) escalation to AIDS; and (iii) death of the patient.2,3 On 12 January 1999, the total number of people infected with HIV in Finland was 939, with one case aged 1314 years and six cases aged 1519 years. The total cumulative

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number of AIDS cases at this date was 295, 220 of which had resulted in death (NPHI, AIDS/HIV register). Under Finnish law, the Ministry of Social Affairs and Health is responsible for planning and supervising of prevention of infectious diseases with the expertise of the NPHI. The ultimate objectives of the nationwide AIDS programme are to distribute information about the modes of transmission, emphasize the importance of prevention, and provide information on the treatment and testing of HIV.4 Public health nurses, physicians and teachers provide health education in maternity and child welfare clinics and schools. Apart from government authorities, voluntary organizations play an active role in health education for the prevention of sexually transmitted diseases.4,5 In practice, schools provide health and sex education in various subjects. There is no national curriculum for sex education, and schools plan their own syllabi.6 Research about HIV/AIDS and adolescents has increased since the mid-1980s. The main focus has been on what adolescents know about the virus and the disease and, more recently, their attitudes, sexual behaviour and beliefs.7 In Finland, the research on HIV/AIDS and adolescents began in the late 1980s; however, relatively few studies have been conducted on adolescents HIV-related knowledge and attitudes.6 It is clear that continuous research is needed. Finnish adolescents aged 1218 years reach biological maturity much earlier than they did 20 years ago. Menstruation occurs earlier, as do ejaculations.8 Approximately 6% of girls and 7% of boys in the 7th grade (age 1314 years) have experienced intercourse, and sexual activity increases as they move on to the upper grades.9 In the 8th grade, 15% of girls and 14% of boys have experienced intercourse, and in the 9th grade, 29% of girls and 24% of boys have experienced intercourse.The most common contraceptive method is the use of condoms, but nearly one-fth out of all acts of intercourse take place without protection.5 Given the constant increase in the number of new HIV cases, it is important to study what adolescents know about HIV and AIDS. Earlier research also suggests that adolescents still have certain misconceptions and misunderstandings about HIV.7,10 Furthermore, HIV and AIDS have evoked negative, fearful and prejudicial feelings since their appearance almost two decades ago.11 All this underlines the importance of exploring the attitudes of adolescents regarding HIV and AIDS, even though Levy et al.12

concluded that adolescents are tolerant and more positively oriented towards people with AIDS than their parents. Knowledge about HIV and AIDS was dened in many different ways in earlier research. It was typically dened as knowing the risk groups as well as the ways the virus is transmitted.1318 The denition sometimes includes knowing the ways to prevent the transmission of HIV and epidemiological data of HIV.12,15,17,19,20 Adolescents seem to be familiar with the main ways in which the virus is transmitted.7,16,18,21 However, there is still some confusion and uncertainty, for example, not all adolescents know whether mosquitoes spread the virus.10 Adolescents are also well aware of the importance of protection in preventing HIV.14,16,17 Generally, girls have more information of HIV-related issues than boys.10,16,17 Furthermore, knowledge about HIV and AIDS seems to accumulate with age.12,13,16 The concept of HIV- and/or AIDS-related attitudes is usually understood in general, non-specic terms.10,18 In some earlier studies, the term was used to refer to attitudes towards people living with HIV/AIDS and to other groups, such as homosexuals.12,15,22 As previously noted, adolescents tend to have somewhat more tolerant and positive attitudes than their parents.12 Furthermore, the attitudes of girls are, on average, more positive than those of boys.10 Some studies have investigated the relationship between homophobia and HIV-related attitudes.The term homophobia is described as a fear of being present in the same room with a homosexually oriented person.23 In addition to the dimension of fear, homophobia also involves negative thoughts about people with who are homosexual.24 An uncomfortable feeling when communicating with a homosexually oriented person might also be dened as homophobia.25 Studies on homophobia have typically focused on the views and attitudes of health-care professionals. It has been shown that gender, place of residence, years of education and experience in health care affect the positive or negative attitudes towards homosexually oriented people.2629 Men, people in urban areas, people with higher education levels and people with more contact with homosexually oriented people have more positive attitudes towards homosexuality than women, people in rural areas, people with low education levels or people with little contact with homosexually oriented people.2629 Sexual-risk behaviour refers to safer sex. Each individ-

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ual is responsible for his or her own behaviour, regardless of whether their behaviour is risky.30 In general, adolescents know what constitutes sexual risk behaviour, that is, sex without protection, frequent unprotected anal intercourse, and sexual promiscuity.21 It has been reported that sexual behaviour of girls is usually safer, and that older adolescents practice riskier sex.31 Some studies have shown that boys know the function of condoms, but still do not actively use them.18,20 The purpose of this study was to describe early adolescents HIV-related knowledge, attitudes and behaviours as well as the prevalence of homophobia in Finland. In addition, we explored the associations between adolescents knowledge levels and opinions, and certain background variables. Ultimately, the aim was to produce information about adolescents, HIV and AIDS for planning an educational programme.

METHODS Subjects
The target group for this study consisted of year 7 and year 8 schoolchildren (n = 171). Over half (n = 90, 53%) of the pupils were in year 8, while just under half (n = 81, 47%) were in year 7. Pupils were 1316 years (Md (median) = 14 years, average = 13.69 years). Over half of the adolescents were girls (53%). Data were collected from two comprehensive schools in southern Finland, and the sample of adolescents were recruited by the head teachers of the schools concerned in conjunction with the researchers.

Research instrument
The questionnaire was a modication of two North American research instruments.30,32 The knowledge, attitude and homophobia components of the questionnaire were a modication of Helds instrument, and the sexual risk behaviour component was a modication of Chang and Moores research instrument. The instrument was rst translated into Finnish and then translated back into English for revision by a panel of specialists, including two native English speakers. In the last phase, the instrument was revised by a specialist in the Finnish language. The content of the questionnaire (and particularly the knowledge scale) was also evaluated by an expert specializing in infectious diseases in order to ascertain that the statements were coherent with actual circumstances in Finland. The 78-item instrument was pilot tested with 35 pupils to: (i) nd out whether the respondents understood the

questions; (ii) carry out reliability checks; and (iii) identify items where revision might be required. On the basis of the pilot test, some statements were revised and eight statements were omitted because they were difcult to understand. Therefore, the nal instrument consisted of 70 structured statements. The questionnaire was organized into four scales: (i) knowledge related to HIV and AIDS (25 items); (ii) attitudes towards people with HIV and AIDS and towards the disease itself (26 items); (iii) homophobia (9 items); and (iv) adolescents sexual risk behaviour (10 items). The knowledge domain included items on AIDS immunopathology, modes of transmission, disease aetiology, risk groups and universal precautions. The respondents answered the statements by circling one of three options: (1) true; (2) false; or (3) dont know. In the attitudes component, the Likert-type items (1 = strongly agree, 2 = agree, 3 = undecided, 4 = disagree, 5 = strongly disagree) dealt with attitudes towards intravenous drug users, prostitutes and persons with haemophilia. Items were also included on fears about personal safety and the safety of family and friends when caring for a person with AIDS, as well as the right to refuse care to people with AIDS. Questions of hopelessness and preparedness to meet the needs of an infected person were also included in this section. The homophobia scale measured attitudes towards homosexually oriented people, while attitudes to sexual risk behaviour measured adolescents attitudes relating to certain sexual behaviours. A 5-point Likert scale was used for the homophobia and sexual risk behaviour items. Eight background questions were included to ascertain basic demographic characteristics. The adolescents were asked: (i) to indicate their age, sex and religious preference; (ii) whether they knew a family member or anyone else with AIDS; (iii) whether they had ever been asked to care for a person with AIDS; (iv) whether they had ever refused to care for a person with AIDS; (v) whether they had ever cared for a person diagnosed with AIDS; and (vi) whether they would be willing to care for a person with AIDS. Scoring in the knowledge domain was based on the number of correct answers. The maximum score for this section was 25 (one point per each correct answer), the minimum was zero. For the attitudinal section, the average scores ranged from one to ve, whereby the higher the score, the more positive the attitude. The same scoring system was also used for the homophobia and attitudes to

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sexual risk behaviour sections.The higher the score in the homophobia section, the more positive the attitudes of the adolescents towards homosexually oriented people. In the attitude towards sexual risk behaviour section, the scoring was the other way around: the lower the score, the more positive the effect that the fear of contracting AIDS had on the sexual behaviour of the adolescents.

Table 1 Scores describing adolescents HIV-related knowledge, attitudes, homophobia and risk behaviour Adolescents (n = 169171) Minimum Mean Maximum Standard deviation Knowledge Attitudes Homophobia Risk behaviour 6.00 1.46 1.00 2.20 14.25 2.84 3.08 3.69 23.00 4.77 5.00 4.80 3.63 0.66 1.05 0.54

Procedure
The study was carried out at two Finnish comprehensive schools in 1998. The study followed established Finnish research practice. Therefore, permission to conduct the study was obtained from the head teachers of the respective schools, none of which had separate ethics commitees.The questionnaires were handed out to the pupils by the researcher during classes. Parents were not contacted to get their permission for data collection as this is not currently required in Finland. The purpose and the goals of the study were explained to the pupils, and oral and written instructions on how to complete the questionnaire were offered to every participant. It was stressed that their responses would be treated condentially and anonymously and that participation was voluntary. They were also assured that the information in the questionnaires would not harm them in any way.They were asked orally whether they were willing to take part in the study, and told that they were free to withdraw their participation at any time. Completing and returning the questionnaire was considered as an indication of informed consent. The pupils were given the researchers contact numbers if they needed to ask any questions about the questionnaire, the study, and/or the research subject. The questionnaires were distributed to 171 adolescents, who lled in the questionnaires during class (one class at a time). Completion of the questionnaire took approximately 15 min. The response rate was 100%.

80% of the items were included in the average scores (Table 1). The relationship between the average sum scores and pupils background variables (i.e. sex, willingness to care for a person with AIDS, and school grades) was examined using the MannWhitney U-test (Table 2). Pearson product-moment correlation coefcients were used to examine the correlations between scale scores and respondents ages. P-values of less than 0.05 were interpreted as statistically signicant. Cronbachs alpha values for the scales were as follows: General Attitude = 0.91, Homophobia = 0.92, and Attitudes to Sexual Risk Behaviour = 0.66.

RESULTS Subjects
The study consisted of 171 youths aged 1316 years. Over half of the pupils (53%) said they would not want to care for an infected person, 35% said they would and 12% left the question unanswered. Nearly all (98%) did not know a family person or anyone else with AIDS. Only one of the adolescents (n = 171) was asked to care for a person with AIDS and three of the adolescents (n = 171) had refused to care for a person with AIDS. One pupil (n = 170) had cared for a person diagnosed with AIDS.

Data analysis
The demographic variables and individual items were analysed using descriptive statistics. The mean score of the knowledge scale was calculated by adding the number of correct answers (one point per each correct answer). Next, the average mean scores for general attitudes, homophobia and attitudes to sexual risk behaviours were formed, where each question was worth 15 points. The points were added together within each domain and then divided by the number of statements in the domain. Only those cases in which responses were received to at least

Knowledge level
The overall knowledge level among the adolescents was quite low, with the mean of correct answers being 14.25 (SD, 3.63), ranging from six to 23 out of the maximum of 25.The adolescents (95%) were well aware of the groups that are at a high risk of contracting AIDS.The vast majority (89%) also knew that people can get AIDS by sharing the same needle with an intravenous drug user who is

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Table 2 The relationship between knowledge level, attitudes to HIV/AIDS, homophobia and adolescents gender, school grade, and willingness to care for a person with AIDS Knowledge level Median P Attitudes to HIV/AIDS Mean Median P Homophobia Median P

Mean Gender Female Male School grade 7

Mean

14.60 13.85 12.75

15.00 14.00 13.00

< 0.050

3.01 2.66 2.67

2.92 2.65 2.64

= 0. 001

3.42 2.70 2.79

3.44 2.55 2.67

< 0.0001

< 0.0001 8 15.59 15.05 Willingness to care for a person with AIDS Yes 14.95 16.00 = 0.003 No 13.61 13.50 2.57 2.60 2.99 3.22 2.92 3.25

= 0.001 3.34 3.69 < 0.0001 2.60 2.55 3.33 3.78

= 0.001

< 0.0001

infected. Most adolescents were aware that AIDS can be transmitted through blood and blood products (87%). The highest proportion of false answers (60%) was received to the statement that a positive antibody test means that the person has AIDS. There were also some statements where there was much uncertainty among the respondents. Approximately 72% of respondents did not know whether or not the symptoms of HIV infection occur within 6 months of transmission. Of respondents, 67% were also not sure whether or not the fetus can be infected by HIV before birth. The pupils of the 8th grade knew signicantly more than pupils of the 7th grade (mean, 15.59; Md, 15.05 vs mean, 12.75; Md, 13.00; P < 0.0001). The relationship between the willingness to care for a person with AIDS and knowledge was also signicant. Those who were willing to care for a person with AIDS were more knowledgeable compared to those not willing to care for an infected person (mean, 4.95; Md, 16.00 vs mean, 13.61; Md, 13.50; P = 0.003). Female adolescents were more knowledgeable than male adolescents (mean, 14.60; Md, 15.00 vs mean, 13.85; Md, 14.00); however, the difference between the groups was not statistically signicant.

bilitation centres for drug users were found to be the most positive, in the opinion of 70% of the respondents. Over half of the adolescents (58%) thought that health-care institutions should not have the right to refuse treatment to people with AIDS. Almost half (48%) felt that it was worthwhile to spend time and energy in caring for a person with AIDS who is dying. Seventy-ve percent of adolescents felt more sympathetic towards people who had acquired AIDS from blood transfusions than towards those who had acquired the disease through intravenous drug use. Sixty-six percent of adolescents were afraid of contracting AIDS if they dealt with people who had AIDS. The attitudes of the boys were more negative than those of the girls (mean, 2.66; Md, 2.65 vs mean, 3.01; Md, 2.92; P = 0.001). Pupils in year 7 had more negative attitudes than pupils in year 8 (mean, 2.67; Md, 2.64 vs mean, 2.99; Md, 2.92; P = 0.001). Furthermore, those pupils who were willing to care for a person with AIDS had more positive attitudes than those who were not willing to care for infected people (mean, 3.22; Md, 3.25 vs mean, 2.57; Md, 2.60; P < 0.0001).

Homophobia Attitudes to HIV and AIDS

Overall attitudes to HIV and AIDS were not very positive. The mean attitude score was 2.84 (SD, 0.66), with a range of 1.464.77 out of 5.00. Attitudes towards drug rehaAttitudes towards homosexually oriented people were more positive than attitudes towards HIV and AIDS. The mean score for this section was 3.08 (SD, 1.05), ranging from 1 to 5.The highest possible score was 5. Almost half

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of the pupils (42%) thought that homosexuality was not a lifestyle that should be condemned. Furthermore, 41% did not agree with the statement that homosexuals who contract AIDS are getting what they deserve. Thirty-three pupils felt uncomfortable dealing with a homosexually oriented person, 29% said that dealing with homosexuals was uncomfortable regardless of whether they were infected by HIV. Lesbians also generated more uncomfortable feelings among adolescents (28%) than women who were not identied as lesbians. The association between background variables and homophobia was very similar to that between background variables and attitudes where girls took a more positive attitude towards homosexuals than boys (mean, 3.42; Md, 3.44 vs mean, 2.70; Md, 2.55; P < 0.0001) and pupils in year 8 had more positive attitudes towards homosexual people than pupils in year 7 (mean, 3.34; Md, 3.33 vs mean, 2.79; Md, 2.67; P = 0.001). Pupils who were willing to care for a person with AIDS showed more positive attitudes towards homosexuals than did those who were not willing to care for a person with AIDS (mean, 3.69; Md, 3.78 vs mean, 2.60; Md, 2.55; P < 0.0001). There was a strong association between adolescents general and homophobic attitudes, as pupils who showed more positive general attitudes to AIDS and persons with AIDS also had more positive attitudes towards homosexually oriented people (r = 0.78, P < 0.0001).

Risk behaviour
The adolescents had a fairly clear picture of what is meant by sexual risk behaviour. Their own behaviour had been affected by the fear of contracting AIDS. Seventy-four percent knew that regular use of condoms reduces the risk of contracting HIV. In addition, 64% agreed that refusing to have sex without protection reduces the risk, and 47% agreed that knowing the sexual history of ones partner decreases the risk of HIV transmission. There were again some statements where uncertainty score were quite high (5368%). These statements concerned oral and anal sex, saying that oral and anal sex increases the risk of contracting HIV regardless of whether it was performed on others or received from others. No signicant association was found between the background variables and sexual risk behaviour.

DISCUSSION
This HIV-related study was carried out in a country that has a comparatively small HIV-infected population and rel-

atively little prior research on the subject. Despite the low incidence of this incurable disease, it is still an extremely serious problem when confronted. Biological maturation, increased sexual activity and other life experiments sometimes put adolescents at risk for contracting HIV. Increasing intravenous drug use among Finnish adolescents is another signicant risk factor. Investigations of HIVrelated knowledge, attitudes and behaviour, therefore, provide valuable clues for the development of methods and programmes aimed at the prevention of HIV infection. Although the knowledge level among Finnish adolescents was quite low, our ndings lend support to earlier results that indicate that adolescents have good knowledge of risk groups and the main forms of transmission of the HIV infection. 9,14,19,20,23 There were, however, some issues on which there was much uncertainty (e.g. vertical transmission, results of HIV testing, symptoms). The largest number of false answers was found in items concerning AIDS immunopathology and aetiology. This might be explained by the nationwide AIDS programme in Finland, in which the emphasis is on providing information about transmission, protection and testing facilities (i.e. where and how to get tested). There is an obvious need, then, for a broader education programme. The key role of school nurses (public health nurses) should also be emphasized as they have current knowledge about diseases including HIV. Over half of the pupils in this study said they would not want to care for people infected by HIV. Of interest is that over half also thought that a homosexual lifestyle should be condemned and that HIV-infected homosexuals get what they deserve. This might be explained by the low incidence of HIV infections in Finland, which is why the disease remains somewhat distant to adolescents. Homophobic attitudes can be changed favourably by increasing the level of knowledge with relevant intervention methods. School nurses (public health nurses) have a particularly crucial role to play in the choice of these intervention methods. There were certain limitations in this study that need to be mentioned. First, the original questionnaire was designed in the USA and, therefore, culture and language (i.e. the translation process) might have affected the results. Also, the original research instruments were developed in the late 1980s, and the world has of course changed quite considerably since then. In todays world, the essential statements might not be exactly the same, even though they were consistent with the actual circum-

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stances in Finland. Furthermore, some of the statements were quite long, which might adversely affect understanding. Finally, the number of respondents in this study was quite small, which means that the results cannot be generalized to include all years 7 and 8 pupils in Finland. Despite methodological limitations, the ndings of our small-scale study provide useful information for the planning and implementation of an educational intervention. The results suggest that a higher level of knowledge decreases negative attitudes towards HIV, AIDS and homosexually oriented people among adolescents. Also, adolescents who were willing to care for HIV-infected persons had higher levels of knowledge and more positive general and homophobic attitudes towards HIV-infected people than those who were not willing to care. The results also highlight certain areas of uncertainty, misunderstandings and prejudices. By exploiting this specic and valuable information, and by focusing education on the areas where there is the most uncertainty, it should be possible to inuence schoolchildren in a positive manner. Furthermore, 42% of the participants felt that they did not have enough information or education about HIV and AIDS to avoid contracting the disease.This clearly underlines the role that school nurses can play as a source of information and education. Indeed, schools themselves are certainly the best place for informing large groups of pupils about this incurable disease.

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