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Sm. Sci. Med. Vol. 37. No. I, pp. 77-83, 1993 Printed in Great Britain. All rights reserved Copyright 0 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. 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