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Sm. Sci. Med. Vol. 37. No. I, pp. 77-83, 1993
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KNOWLEDGE
AND ATTITUDES
ABOUT AIDS
RESIDENTS
OF GREATER ATHENS
0277-9536/93 %6.00 + 0.00
1993 Pergamon Press Ltd
OF
JOANNES CHLIAOUTAKIS, FOTINI SOCRATAKI, CHRISTINA DARVIRI, NIKOS GOUSGOUNIS and
DEANNETRAKAS
Department of Health Visiting, Technological Educational Institution (TEI) of Athens, Zacharov 3,
Athens 11521, Greece
Abstract-A
prospective research project on health education about AIDS is being conducted in the
Greater Athens area. In the first phase of the project, information was collected concerning the knowledge
and attitudes about AIDS of a sample of the population. The results indicated that, in general, the
population was moderately well informed about AIDS. The population groups who were best informed
were the females, those with a higher level of education and a longer period of urban residence, and those
in the occupational category merchants/sales personnel. Three attitudinal categories were identified which
could be characterized as discrimination, stigmatization and fear of those affected by AIDS. These
attitudes were linked respectively to (1) approval of the enforcement of special measures, (2) stigmatizing
of persons, behaviours and districts and (3) fear that AIDS comprises a major social threat. The attitudes
expressed by restrictive measures towards those affected and stigmatization were associated with a low
level of knowledge about most aspects of AIDS. Health education programmes directed at the population
in the districts studied should take into account the findings of this study.
Key words-AIDS,
knowledge, attitudes, discrimination, stigmatization
Since 1981, when AIDS was first recorded, the number of people who have been diagnosed as suffering
from the illness has risen sharply worldwide. There
have been accounts of public panic due to HIV
positivity and also denial of health care to AIDS
patients. Many people have noted the resemblance
between the reaction to AIDS and that to certain
historical infectious epidemics [ 1,2]. Research has
shown that the stigma attached to the diagnosis of
AIDS is far greater than and significantly different
from the stigma accompanying
the diagnosis of ‘traditional’ illness such as tuberculosis,
cancer and
psychiatric disorders [3]. This is mainly due to the fact
that in Europe and U.S. the groups in which AIDS
was first diagnosed, i.e. homosexuals
and drug addicts, were already socially stigmatized [4]. This initial
focusing of the illness in marginal and minority
groups raised the question as to which legal measures
could be taken without affecting the human rights or
lives of individuals in these groups. It also reintroduced the question
of infectious
disease control,
which has a history of measures which restrict personal freedom, in the name of health and the community, of the general population
as well as of the
patients and the health care personnel [5]. AIDS thus
acted as a strong ‘rtvtlateur
social’ of the tensions
within the community,
according to the expression
used by Clumeck [6] and raised the question: how can
we relay the message of prevention without creating
overdramatization?
In Greece the number of reported AIDS cases has
reached 559 (11% females), most of them aged
between 25 and 45 years of age [7]. According to the
Greek Ministry of Health, of the 559, 51% were
infected
through
homosexual/bisexual
contact,
22.4% through heterosexual contact, 14.8% through
transfusion,
4.1% from IV drug use and the rest by
other means. Only a few cases of intrauterine
infection have been reported.
The first 6 cases were
registered in 1984, and in 1991, 147 new cases were
recorded.
The most commonly
recorded
medical
problems are opportunistic
infections (69%), Kaposi
sarcoma (10.6%), weight loss (8%) and encephalopathy (6%) [8]. About one half of those infected have
already died. The route of transmission in heterosexuals is assumed to be through bisexual behaviour,
since there is no report of affected women prostitutes.
In the absence of data, there are several possible
explanations
for the lower incidence of AIDS in
Greece than in other occidental countries: homosexuals in the main, develop exclusive relationships,
though there is some homosexual prostitution;
prostitution, although widely practised, operates according to public health guidelines, and the prostitutes
have regular medical checks and require their customers to use condoms; homosexuality
and prostitution are not generally associated with IV drug use;
disposable syringes are available without prescription
and addicts do not usually share syringes. The Greek
health authorities, have tried to dedramatize the role
played by the high risk groups in order to reconcile
the general population
with homosexuals
and drugusers and consequently
to remove the label of social
stigma. These efforts, in conjunction with wide media
coverage of the situation
in other countries
has
resulted in a new, more realistic, confrontation
of the
77
78
JOANNFSCHLIAOUTAKIS et al.
problem: the recognition
that AIDS now concerns
everyone and more specifically the young.
The WHO and many scientists, emphasize education of the public as a means of preventing
the
spread of the illness [9-121 and reducing negative
attitudes towards those affected. In Greece, the National AIDS Committee coordinates
the information
strategies which are being developed by the media,
with the basic slogan: ‘Learn and protect yourself’.
Experience in other countries has shown that knowledge about the illness alone does not suffice to
radically alter negative attitudes [9, 13-151. What is
needed is an in-depth study of the nature of these
attitudes and how they are formed in each social and
cultural environment.
In our previous studies it has been demonstrated
that (a) respondents consider that persons belonging
to their wider social environment
have double the
possibility of being HIV infected, in comparison with
themselves and their family members [16]. (b) HIV
infected persons are generally accepted if they belong
to the wider social environment
of the people questioned. Conversely, when the relationship
is closer,
there is an increased tendency for expulsion [17]. In
Greece, many cases of refusal of medical personnel to
provide medical care for those infected, have been
reported. Also, several examples of social ostracism
have been reported and parents refusing to let their
children go to the same school as affected children.
Further, hospital personnel working among AIDS
patients have repeatedly observed that family members of these patients are often the first to reject them,
by not visiting them during hospitalization
or not
allowing them to return to the family upon discharge
[181.
These reactions can be understood
if we take into
consideration
the mechanisms
of socialization
and
social control
responsible
for the formation
and
persistence of anachronistic
opinions and beliefs in
the modern Greek society. The family, the Orthodox
Church and the Military are the fundamental
institutions which still exert a strong influence in spite of
the recent socio-economic
transformation
and the
emancipation
of women.
All these institutions
officially severely condemn
homosexual
practices and in particular the passive
homosexual male, as being opposed to the reproduction of the family and the perpetuation
of the lineal
integrity. Thus, when from the first appearance
of
AIDS in Greece it was perceived to be associated with
homosexuality
and was regarded as a threat to the
family. The division of society into ‘health’ and
‘infected’ followed.
It has already been suggested that a better understanding of the history of people with AIDS and
familiarization
with some of them will lead to more
favourable public attitudes toward these persons, and
a more realistic assessment of personal risk [19,20].
This is the direction taken in our work which began
in 1987. Its basic aims are: (a) a longitudinal study of
the knowledge, perceptions and attitudes of a sample
of residents of the greater Athens area, and (b) the
evaluation of educational intervention in a portion of
the sample. The intervention
included factual information about the mode of transmission
of HIV,
instructions
for means of prevention
and consideration of basic principles of respect for the personal
rights of others.
This paper presents the preliminary results of the
first part of our study: knowledge about AIDS and
factors correlated
with it. Attitudes
are examined
only to support the basic hypothesis of the paper, that
attitudes
of discrimination
and stigmatization
are
associated with low scores of knowledge.
METHODS
Subjects
The first phase of the study of 1552 subjects (713
men and 839 women) aged 1649 years, residents of
the greater Athens area, was completed in May 1988.
The selection of the sample was based on data (lists
and maps) provided by the Greek National Statistics
Service. The sample was stratified and was taken
from the Municipality of Athens (an area with urbanized residents) and 9 adjacent urban Municipalities of
west Attica characterized by recent internal migration
from rural areas of Greece. Within each area, interviews were conducted in randomly selected blocks,
using age and sex quotas.
Measures
Using as a guide the official specific information
produced by the Greek National AIDS Committee
[21], the first part of the questionnaire
included both
closed- and open-ended
questions to record knowledge about AIDS. All closed questions
required
answers: true/false/don’t
know. For example concerning knowledge about the mode of transmission,
there was a closed question about unlikely modes of
transmission
based on the epidemiological
data of
Greece followed by an open-ended
question where
the correct answers were expected. The second part of
the questionnaire
examined the basic social attitudes
about AIDS, and was based on the Lickert model,
with answers ranging from ‘complete agreement’
through ‘complete disagreement’.
Procedure
The questionnaires
were administered
by personal
interviews, conducted
homes by health visitors. At
the end of the interview, the health visitor discussed
with the respondent
the correct replies regarding
knowledge, and emphasized the fact that there is no
social danger from those affected, as long as there is
no sexual intercourse
or sharing of needles and
syringes with them. An information
pamphlet from
the Ministry of Health and Welfare was provided
with the request that it be studied carefully.
Knowledge and attitudes about AIDS
Table 1. The score of ‘accurate knowledge’ abouts AIDS grouped into 4 levels
(31 questions)
Levels of
accurate
knowledge
1349.9
50-69.9
70-89.9
90-I 00
Total
n
%
138
651
570
187
1552
8.9
42.3
36.7
12.0
100.0
‘Accurate knowledge’=correct
answers/
total of questions - ‘I don’t know’.
19
Table 3. Perceived ways of HIV soread
Perceived ways
True
False
Dental care
n = 527
34.0
” = 1019
65.6
Common use of
toilet facilities
n = 212
13.7
n = 1335
86.0
Mosquitoes
n = 208
13.4
n = 1339
86.3
n = 189
12.2
n = 1358
87.5
n = 122
1.9
n = 1425
91.8
n = 118
1.6
n = 1429
92.1
n =23
1.5
n = 1524
98.2
Handles
n =21
1.4
n = 1526
98.3
Caresses
n = 17
1.1
n = 1532
97.1
Airborne
transmission
Smoking
cigarette
another’s
RESULTS
Of the individuals responding,
138 subjects (8.9%)
had a low (less than 50%) level of ‘accurate knowledge’, whilst an excellent
level (9&100%)
was
recorded by 187 subjects (12%) (Table 1). Knowledge
of specific topics is presented below.
Knowledge
Exchange
utensils
of household
of risk factors for AIDS
Nine hundred and sixty subjects (61.9%) stated
that AIDS is a ‘recent’ illness and 1237 subjects
(79.7%) stated that it is a contagious illness which
causes death. The age groups thought to be chiefly
affected were young adults and adolescent (95.7%)
and 80.7%, respectively) followed by middle age and
old age (75.4% and 70.2%, respectively). The groups
of people affected were reported to be mainly homosexuals and drug-addicts
(91.5% and 81.0%, respectively),
followed
by prostitutes
(61.9%)
and
multiple-transfused
persons (56.3%) and those with
multiple sexual partners (38.3%).
Knowledge
Kissing
about symptoms
of AIDS
Slightly more than 50% of the sample population
knew about each symptom with the exception of
weight loss (79.7%), and certain symptoms such as
breathlessness
and dry cough, knowledge of which
was found to be very low (36.3%) (Table 2).
Table 2. Knowledge
about symptoms
of AIDS
True
False
Weight loss
n = 1235
79.7
n = 203
13.1
Diarrhoea
n = 952
61.3
n = 486
31.4
Fever
n =941
60.6
n = 496
32.0
Skin disease
n =819
52.8
n =619
39.9
Tiredness
n=764
49.2
n = 674
43.4
Swollen glands
n = 692
44.6
n=746
48.1
Breathlessness,
dry cough
II=564
36.3
n = 873
56.3
Symptoms
7.2% (1 I I subjects), answered ‘I don’t know’ to this
question.
Exchange
of clothes
n = 16
1.0
n = 1531
98.6
Telephone
receivers
n = 11
0.7
n = 1536
99.0
0.4% (5 subjects)
question.
answered
‘I don’t
know’
Knowledge about modes of transmission
to this
of AIDS
The modes of transmission
stated in the open
question were: sexual contact (78.9%), blood (63.4%)
and sperm (30.2%). However, on closed questions
regarding mode of transmission,
many selected other
modes such as dental care (34%), mosquitoes
(13.4%), airborne transmission
12.2% and by smoking another’s cigarette (8%) (Table 3). Finally, 96%
recognized use of the condom as a method of protection from the virus.
Basic social attitudes towards AIDS and those affected
by it
Factor analysis for the identification
of the social
attitudes towards AIDS and those affected revealed
three factors. Table 4 presents the calculated loadings
of the variables on each of these three factors as well
as their content and the form of the attitudinal
statements.
The first factor is a dimension expressing restrictive
opinions
against
those affected,
supporting
for
example, dismissal and eviction of those affected. We
refer to this factor as discrimination.
The second
factor is a dimension
reflecting stigmatization
of
social groups, the sexual behaviour of their members,
and certain areas of Athens and the third factor
expresses the sentiment of fear towards AIDS.
To get a picture of the precise level of the central
social attitudes, for each factor a total score was
obtained by averaging all items with loadings >0.24.
80
JOANNES CHLIAOUTAKIS et al.
Table 4. Social attitudes towards AIDS and those affected, results of factor analysis
(factors of discrimination,
stigmatization
and fear)
Questions
Discrimination
Rejection of affected
sexual partner
Dismissal of those affected
Eviction of those affected
Re-establishment
of leper
colonies for HIV victims
State services and hst of
those affected
Those affected are people wth
promiscuous sexual behavior
Connectmn of those affected
wth ‘fringe‘
Danger of spread of AIDS
due mainly to homosexuals
Link between AIDS and
certain areas of Athens
Request for test by
sexual partner
Classilication
of AIDS in the
main scale of xxial problems
Danger of spread of AIDS
by tourism
Reglstratmn of infected case\
Danger of contamination
from dental care
Demand for research by doctors
Investigation
of sexual
partners of those affected
The questions
0.20
0.002
-0.11
OLT
9.t.
0.23
0.10
0.59
0.26
0.06
0 009
0.66
0.02
0.25
o.PZ
.0.07
0.02
o,si
0.33
0.20
0.46
0.05
-0.04
0.23
with
and
analvsis
lndependant
variables
Sex (female)
Municipality (W AttIca)
Age
Marital rtatus (unmarried)
Married
Dwxced:wdowed
Birth place (village)
Countrv capttal
Provin&l
tow”
Educatmn (illiterate)
Few years primary
Primary certificate
High school certificate
Higher educatm” grad. degree
Professlo” (Housewives)
Scientists,‘professionals
office employees
Merchants, sales assistants
Workmg in the berwces
Skilled;unskilled
labourers
Pupils. Students
Unemployed
Attitudes
DiscrmGnation
Stigmatization
FtXr
-0.14
0.39
-0.09
0.37
~ 0.04
0.04
0.10
0.09
0.36
0.02
0.02
0.24
0.15
0.56
0.07
‘Accurate knowledge’ about AIDS on the basis of
social characteristics and attitudes ton.ard.7 AIDS
reeression
-0.19
0.16
0.05
0.78
The means and standard deviations for the scores of
each factor are respectively 1.33 0.48: 1.52, 0.28 and
1.40, 0.19. These results suggest that the respondents
tended to choose the index ‘agreement’ of the Lickert
scale. for the items of each factor.
Table 5. Multmle
Fear
0.34
which the weights are underlined
Multiple regression analysis was performed
the dependent
variable ‘accurate knowledge’
Stigmatization
contribute
0s
more to the particular
factor
independent variables (I) sex, age, place of residence
(central Athens vs the 9 communities of west Attica),
place of birth, marital status, educational
level and
profession,
and (2) the three factors which were
revealed in the analysis of social attitudes towards
those affected.
As is shown in Table 5, a statistically
significant relationship was demonstrated
between the independent variables and ‘accurate knowledge’, specifically:
of knowledae
about AIDS CR’ = 41%)
Multiple regression
coefficient (B)
P
-0.012
0.150
0.00061
0.0805
0.000
0.560
0.0076
0.0022
0.444
0.6.51
0.0017
0.0096
0.369
0.691
0.103
0.1 I8
0.134
0.132
0.0390
0.001
0.000
0.001
0.025
0.022
0.035
0.013
0.015
0.0045
0.018
0.06 I5
0.0730
0.0104
0.404
0.162
0.67 I
0.342
- 0.02 I
-0.020
0.0048
0.000
0.000
0.621
Knowledge and attitudes about AIDS
(a) Men tended to be less well informed
than
women.
(b) Residents of central Athens had a higher score
of knowledge than the residents of the municipalities of west Attica.
(c) Respondents with the minimum of a few years
of primary education
had more knowledge
than the illiterate.
(d) Merchants/sales
personnel had a statistically
significantly higher knowledge than those in
other
professional
categories,
and scientists/professionals
and office employees were
better informed than housewives.
(e) Attitude expressing discrimination
and that of
stigmatization
were found to be associated
with the lowest knowledge levels.
DISCUSSION
According
to the results of this study, the age
groups believed to be most infected by HIV are young
adults and adolescents. This does not correspond to
the epidemiological
data for Greece as the overwhelming majority of Greek cases are reported in the
age group 25-45 years [7]. Evidently, the information
of the respondents
is affected by international
findings. Even the adolescents and the young people in
the sample consider themselves as belonging to the
age groups at highest risk, and they also think that
in the future there will be a rise in the number of cases
in the pandemic and that the young will be the most
affected. The middle-aged
and elderly, on the other
hand, are evidently thought to be an age group with
comparatively
low sexual activity, people who are
socially integrated and thus at reduced risk of attack
by the virus.
The identification of drug users as one of the main
groups infected by AIDS indicates that the respondents have been influenced by the initial information
which came from abroad about the illness. In Greece,
on the contrary, the percentage of AIDS victims who
have been infected through IV drug use (4.1%) is
exceptionally
low [8], perhaps due to the lack of
sharing syringes which are available in pharmacies
without prescription. There are, nevertheless, internationally cited indications
of a wider spread of the
illness in populations
other than those originally
characterized
as high risk groups: e.g. a spread of
AIDS and HIV through heterosexual
intercourse
[22,23]. Such indications are lacking or not foreseen
in the population studied. The low percentage of the
sample who reported that those with multiple sexual
partners (‘promiscuous’
or unmarried)
are at risk
from HIV suggests that the public is not convinced
that the illness concerns everyone, as has been noted
in another of our studies [16].
The adequate knowledge in the sample population
about the signs and symptoms may be due to the fact
that information
campaigns, in attempting to reduce
the number of cases and carriers of the disease, have
81
emphasized modes of infection and dealt less with the
clinical signs. The lack of awareness about symptoms,
however, may result in a delay of request for medical
assistance,
which favours the spread of HIV to
others. A discrepancy is noted between the relatively
low percentage of respondents with knowledge of the
modes of transmission-sexual
contact, blood and
sperm and the high percentage of positive responses
for use of the condom as a means of protection.
Although they know that the condom protects, they
do not report blood and sperm in correspondingly
high percentages as sources of transmission.
Concerning
the attitudes
of the respondents
towards those affected (Table 4):
The first factor is associated
with restrictive
measure against those affected; measures which begin
with leaving sexual partners, and progress to their
exclusion from the immediate environment
and public ostracism. This reactionary
attitude of discrimination has been noted in cases of other new infectious
diseases, but historically has been condemned by the
public democratic
conscience
[24,25]. Given the
nature of contemporary
Greek society, it neither has
discriminatory
laws (e.g. racial segregation),
nor a
tradition
of mass public demonstrations
directed
against any kind of minorities. To try to resolve, or
at least shed light on this attitude of discrimination,
we reviewed sociocultural
sources regarding Greek
society.
In Ancient Greece, public ostracism was handled
through democratic means; ballots, the ostraka, were
cast to determine whether or not an individual would
become a social outcast. The ancient ceremony of
ritually slaughtering a black ox might be interpreted
as a means for managing discrimination.
Before the
slaughter, the ox was designated to carry to his death
the disorder.
Through the slaughter,
the noxious
elements of society were removed and social balance
restored [26].
In contemporary
Greek culture, while the ceremony, described above, is no longer conducted, its
ideological significance is suggested to be a latent
characteristic
of Greek mentality. In a sense, those
affected (usually perceived to be homosexuals) are the
transformation
of the black ox of Ancient Greece.
The solution to AIDS is metaphorically
seen as one
which requires ostracism-the
symbolic ‘slaughter’.
Additionally, in the present day, a central principle
in sociocultural organisation
is the concept of ‘ours’
and ‘foreign’, or ‘inside/outside’
[27]. The first point
of discrimination
is the family; non-members
are
considered ‘foreigners’. Other institutions
act to assimilate the ‘foreigner’ as ‘ours’; e.g. ritual kinship,
the formation
of collective groups and bonds of
friendship. The category of ‘ours’ may be extended to
‘foreigners’ when appropriate
conformity
to social
codes of conduct are observed.
The second factor (Table 4) is associated
with
prejudice and stigmatization
of certain social groups
and areas. Those affected are perceived as different to
82
JOA~IFS CHLIAOUTAKIS ef al.
the respondents,
as belonging
to the ‘other’ side on
the fringe, and having different sexual behaviour;
“They carry the miasma” according to the expression
of M. Douglas [28]. This is an attitude that labels
those affected without,
however, demanding
their
suppression.
Persons with AIDS are ‘outsiders’ and,
in particular, all homosexuals who are believed to be
the main transmitters of HIV. In the context of Greek
society, persons with AIDS represent an aggressive
threat to the integrity of the family and community,
and as such, ‘must’ be classified as ‘outsiders’ and
‘strangers’ even to their own families [I 71.
The third factor expresses an attitude of anxiety
and fear of AIDS which is perceived by the respondents as one of the most serious problems of Greek
society. Thus it is requested that each case of infection should be reported. At the same time there is a
fear of undergoing testing even if the sexual partner
requests this.
Concerning
the relationship
between the sociodemographic
characteristics
and the ‘accurate knowledge’ of the sample population (Table 5) it was found
that men were less informed than women. In spite of
the fact that AIDS was perceived to be of more
concern to men than to women and therefore an
increase in their health awareness and a higher information level would be expected, it was found that
women tended to know more. With the dispersion of
HIV in Greece, increasingly
affecting women all
attempts to improve information
must be directed at
both sexes.
The place of residence also seemed to be related to
the information
status, to a slight statistically significant degree. This finding is related to the composition
of the population
of the study areas. The difference
in knowledge can be explained by the fact that central
Athens constitutes
a cultural environment
of longstanding
urbanization
whereas
the more recent
migrants of west Attica retain the cultural characteristics of the village.
As was expected, increasing educational
level is
associated with increasing knowledge about AIDS,
but this does not necessarily mean that the category
of scientists/professionals
had a greater knowledge of
AIDS than the category merchants/sales
personnel. It
seems here that the knowledge level is also dependant
on the time spent outside the home, the wider range
of social contact and the exchange of information
which occurs in certain places of work.
Both discrimination
and stigmatization
attitudes
were related with low levels of knowledge
about
AIDS. This finding confirms our working hypothesis
and conforms
with general sociological
theory regarding social stigmatization,
in particular reference
to AIDS. It appears that the attitude towards AIDS,
as well as towards those affected by the disease, as
morally repugnant is related to the lack of willingness
to learn about it, which in turn may be dangerous to
those who hold this attitude. As an explanation
of
this social phenomenon,
we note that in every
country
where discrimination
and stigmatization
were practised the fanatics were mostly individuals
with a low level of knowledge
about the special
abilities of the group persecuted,
and little will to
learn. In addition, the ostracism of a specific social
group (characterized
in our case as a risk group and
turned into ‘guilt’ group) is easier because individual
or social behaviour
is hard to identify but social
groups are often easier to pinpoint by their more or
less relevant visible biological and surface characteristics [29].
The study confirms the findings of other similar
studies which document prejudice against those with
AIDS. The working hypothesis
of the study was
confirmed that the degree of prejudice, whether expressed as an attitude by discrimination
or as a
stigmatization
of those affected by AIDS, was associated with a low level of knowledge about AIDS.
In conclusion,
the findings of this study indicate
that health education campaigns should be promoted
for the residents of the greater Athens area with the
aim of improving
the level of knowledge
in the
population.
The design of such campaigns
should
take into account the cultural differences
of the
populations in the different boroughs and their socioeconomic characteristics,
when selecting the content
and mode of dissemination
of the information
to be
used.
Acknowledgements-This
study was financed by the TEI of
Athens.
We are deeply indebted
to the Committee
of
Research of the Institution for the support of our work and
to the students of the department
of Health Visiting who
involved themselves so generously in this project. We also
gratefully acknowledge
the useful comments of our anonymous reviewers.
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