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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 3

Assessment and predictors of HIV knowledge among vocational school adolescents in Thailand


1 Department of Community Health, Faculty of Public Health, Naresuan University, 65000 Phitsanulok - Thailand; Justice Ifeyinwa Nzeako House, #8 Port Harcourt Crescent, Area 11, Garki, Abuja-Nigeria
2 Department of Community Health, Faculty of Public Health, Naresuan University, 65000 Phitsanulok - Thailand; Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station Texas-USA; Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Bayero University, Kano-Nigeria
3 Department of Community Health, Faculty of Public Health, Naresuan University, 65000 Phitsanulok - Thailand

Date of Submission07-Dec-2020
Date of Decision17-Apr-2022
Date of Acceptance05-May-2022
Date of Web Publication25-May-2022

Correspondence Address:
Shamsudeen Yau
Department of Community Health, Faculty of Public Health, Naresuan University, 65000 Phitsanulok - Thailand; Justice Ifeyinwa Nzeako House, #8 Port Harcourt Crescent, Area 11, Garki, Abuja-Nigeria

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2773-0344.345315

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  Abstract 

Background: Despite substantial progress in the fight against human immunodeficiency virus and acquired immunodeficiency syndrome globally, it remains a threat to global adolescent health. This study assessed the level of HIV knowledge among vocational school students and identified the relevant factors.
Methods: This was an analytical cross-sectional study conducted from August to September 2019. A total of 345 students aged 15 to 19 years were selected from three vocational schools in Phitsanulok Province, Thailand, using a multistage random sampling technique. The HIV Knowledge Questionnaire (18 item version) was used to collect the data, which were analysed by mean, frequency, Chi- square and binary logistic regression.
Results: Only 38.8% of participants were fully aware of HIV knowledge; five individual items showed a significant difference in knowledge of HIV between males and females; two items relating to HIV prevention knowledge (P=0.021, 0.009); two items relating HIV transmission (P=0.028, 0.035); one item relating to HIV diagnosis (P=0.008). Factors that were significantly associated with HIV knowledge included gender (male vs. female, OR 1.83, 95% CI 1.01-3.34), residence (sub-district municipality area vs. sub-district of administrative organization area, OR 0.44, 95% CI 0.23-0.84), education (2nd and 3rd academic year vs. 1st, OR 7.00, 95% CI 2.40-20.41; OR 6.40, 95% CI 2.05-20.01) and source of income (from both parents vs. self, OR 0.07, 95% CI 0.04-0.64).
Conclusions: There are serious deficits and disparities in the knowledge of male and female adolescents on HIV transmission, prevention and diagnosis, and there is a need to expand the provision of gender-focused sexual health education programs.

Keywords: HIV/AIDS; Knowledge; Adolescents; Vocational Schools; HIV-KQ-18


How to cite this article:
Yau S, Adamu Y, Wongsawat P, Songthap A. Assessment and predictors of HIV knowledge among vocational school adolescents in Thailand. One Health Bull 2022;2:3

How to cite this URL:
Yau S, Adamu Y, Wongsawat P, Songthap A. Assessment and predictors of HIV knowledge among vocational school adolescents in Thailand. One Health Bull [serial online] 2022 [cited 2022 Jun 29];2:3. Available from: http://www.johb.info/text.asp?2022/2/1/3/345315




  1. Introduction Top


Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is still a threat to global public health. Despite the substantial progress in the fight against HIV/AIDS globally, adolescent population are at a higher risk of HIV infection than any population groups. Adolescence is a period of transition from childhood to adulthood characterized by an increase in risky behaviours, including risky sexual behaviours, which are directly or indirectly associated with the physical, biological and psychological changes taking place during this period[1],[2]. Consequently, adolescents are the only age group that has not recorded any decline in AIDS-related deaths in the period between 2005 and 2013[3].

Globally, thirty adolescents aged 15 to 19 years become newly infected with HIV every hour, and HIV/AIDS is the first and second cause of adolescent death in Africa and the world respectively[4]. Of the estimated 2.1 million new HIV infections among adolescents aged 10-19 years in 2016, 150 aged 15-19 years died every day[5].

Asia and the Pacific has the second highest number of people living with HIV, with Sub-Saharan Africa leading the way. Similarly, Thailand, Indonesia, Viet Nam, China, Myanmar and India account for over 90% of total HIV infections in the entire Asian region[6]. The long-standing history of high HIV/AIDS prevalence in Thailand has been the focus of attention for the government and health authorities. Over the decades, the government has shown a relentless commitment to change the nation’s position in HIV/AIDS-related morbidity and mortality[7]. Consequently, dramatic progress has been made in eliminating mother-to-child transmission of HIV by making antiretroviral therapy (ART) to people living with HIV/AIDS[8],[9]. However, this is hardly reflected among the adolescent population. Evidence has shown that the prevalence of HIV and other sexually transmitted infections (STIs) among adolescents is five times higher than the general population of Thailand[10]. Moreover, adolescents of vocational schools are more likely to have unsafe sexual activities than students in other schools[11]. According to the 2017 analysis of data from Phitsanulok provincce, HIV prevalence among adolescents aged 15-19 years has continued to rise since 2013 and the annual new infections have risen from less than 200 in 2013 to nearly 550 in 2017.

Previous reports attributed the rise in HIV infection rates to insufficient general knowledge of HIV prevention, transmission and safe sex[l2], which was synonymous with increasing research in other parts of the world[13-15]. A national survey of sexual debut condom use among young people aged 15-24 years further revealed that only 60% had reported using a condom[8], highlighting vulnerability of youth to infection. Given the increasing number of reported cases of HIV infection[4] and the prevalence of sexual risky behaviours among adolescents[16],[17], it is necessary to understand the level of HIV knowledge among this cohort. Therefore, the main purpose of this study was to conduct a cross-sectional assessment of the level of HIV knowledge and influencing factors among adolescent students of vocational schools using the brief and valid HIV Knowledge Questionnaire (HIV-KQ-18). It was anticipated that the research findings would inform program planners to target adolescents in dire need of adequate and correct information regarding HIV transmission, prevention and diagnoses, thereby helping the adolescents clear up misconceptions about HIV and enable them to make informed sexual decisions.


  2. Subjects and methods Top


2.1. study design, participants, and setting

This was an analytical cross-sectional study conducted between August and September 2019. The participants of the study were adolescents aged 15-19 years who were further categorized into middle adolescence (aged 15-16 years) and late adolescence (aged 17-19 years). A total of 345 participants were sampled. They were students at the metropolitan vocational schools in Phitsanulok province, the lower northern region of Thailand. There are six vocational schools in the metropolis, each offering a different specialized course for three years. For this research, three schools were purposively selected to participate. Purposive sampling was chosen due to the following reasons: 1) the ratio of male to female students in schools is uneven; 2) the population is unequal between the schools; 3) varying spatial locations around the city. Due to this variability, we desired to provide equal chances of inclusion to both sexes in all the selected schools, while ensuring the large geographical area was covered, we considered multi-stage random sampling to achieve high representative sample selection. This was achieved by clustering the selected schools and then stratifying each cluster according to the school year. From each academic year, we then sampled both sexes proportionate to their population sizes in the respective participating schools.

2.2. Data collection instrument

The brief and well-validated HIV-KQ-18-scale was used in the data collection. The questionnaire used for the present study consisted of two parts: the first part measured the socio-demographic variables of the participants and the second part was the HIV-KQ-18-scale to assess and measure the participants’ factual knowledge of common truths and misconceptions regarding HIV transmission, diagnosis and prevention. Although the consistency, internal validity and reliability of the HIV-KQ-18 instrument have been established[18], the internal consistency in the present study was demonstrated with a coefficient of Chrombach- α of 0.83.

2.3. Data collection

The questionnaire was self-administered. At each of the three selected schools, a conducive and quiet venue was selected for completing the questionnaire. Participants were seated separately to avoid peer discussion while filling in the questionnaire and protect the information of each participating students. Additionally, students were allowed to fill the questionnaire at their own pace to maximize the accuracy of the information they provided. The students raised their hands to indicate that they had duly completed their questionnaire which was retrieved and the students were allowed to leave the venue.

2.4. Data analyses

All analyses were performed using the IBM SPSS Statistics for Windows, Version 20.0 software. The data was completed and normally distributed. The response options for the 18 items were labelled “True”, “False” or “I don’t know”. These options were further coded into two dichotomies (0 and 1), with participants scoring “1” for any correct answer and “0” for incorrect answers or “I don’t know”. For each of the 18 items, Chi-square test was performed to see whether or not HIV knowledge was different between both genders.

Given that it was wrong to assume that the individual HIV- KQ-18 items was equally relevant to overall HIV knowledge, and employing factor analysis or regression analysis did not yield any meaningful pattern, the aggregated index score was considered most suitable to quantify the overall HIV knowledge. The maximum score possible was 18 while the minimum was 0. We considered a median split to dichotomize this aggregated score equal to or less than the median value (≤8) were presented as “low knowledge” whereas those above (>8) were labelled as “high knowledge”. Additional Chi-square tests were conducted to assess the relationship between some socio-demographic variables and the two categories of HIV knowledge. Finally, a binary logistic regression model was run to identify variables associated with HIV knowledge among the study participants. All analyses, where applicable, were performed at 5% significance level and 95% confidence level.

2.5. Ethical clearance

This study was approved by the Institutional Review Board on January 19, 2019 with ethical certification number 0058/62. Participants were initially informed regarding the objectives of the study, expected roles, and of course, their right to disclose or withhold any personal information during the survey. In addition, participants were assured of the confidentiality of their personal information and the mode of disseminating findings. All participants who agreed to take part were provided with a consent form which they duly signed and returned to the researchers. For participants under legal age (aged 18 years), their proxies (parents/guardians) briefly learned about the study information and eventually signed the informed consent form on behalf of their wards.


  3. Results Top


3.1. Socio-demographic characteristics

As shown in [Table 1], nearly 60% and 53% of the total participants (n=345) were respectively females and middle adolescence (aged 15-16 years). The vast majority (97.4%) were Buddhists, 76.5% of whom were in their first academic year. Furthermore, the academic majors of the students were clustered: technical cluster (19.4%), food and nutrition (11.0%), information technology (14.8%), business computer (19.4%), business retailing (11.0%), and accounting (24.4%). Most respondents (48.7%) had a middle average monthly income, with more than half (56.5%) from both parents and only 28.7% from one of the parents. Furthermore, the residential areas of the respondents were sub-district administrative organization area (32.5%), sub-district municipality area (34.2%) and municipality area (33.3%). At the time of the survey, about four-fifths of the respondents were already in a relationship and the vast majority (44.9%) were from nuclear families with most of the parents (57.4%) still married and living together. The prevalence of lack of HIV knowledge in the present study was 61.2%.
Table 1: Socio-demographic characteristics and HIV knowledge score.

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3.2. The difference of HIV knowledge between males and females based on the individual items

[Table 2] presents the individual items correctly answered by both males and females. It can be seen that there is no much difference between the performance of males and females in answering the questions correctly. For instance, there were eight items (number 1, 2, 4, 6, 9, 10, 16, and 17) that measured the participant’s knowledge regarding HIV transmission, of which only two showed significant association with gender. Examples of items are: “All pregnant women infected with HIV will have babies born with AIDS” (P=0.028), “A person can get HIV by sitting in a hot tub or a swimming pool with a person who has HIV” (P=0.035).
Table 2: Relationship between gender and individual item of HIV knowledge (n=345).

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Furthermore, only one (item 8) of the three items measuring knowledge of HIV testing and treatment (item 8, 13, and 15) was different between males and females. The responses to the statement “There is a vaccine that can stop an adult from getting HIV” revealed a significant association (P=0.008). Similarly, of the five measuring items (item 5, 3, 11, 12, and 18) of HIV prevention knowledge, only item 5 and 12 differed. Both statements “Showering or washing one’s genitals/private parts after sex keeps a person from getting HIV” (P=0.021) and “A natural skin condom works better against HIV than does a latex condom” (P=0.009) showed significant association with gender. Contrastingly, items measuring knowledge of HIV signs and symptoms (item 7) and HIV risk (item14) did not show any association with gender.

Regardless of gender, there were only two items were correct more than 50%. The correct responses were 51.9% and 60.9% for “pulling out the penis before a man climaxes/cums keep a woman from getting HIV during sex” and “Having sex with more than one partner can increase a person’s chance of being infected with HIV”, respectively. These scores were, however, not statistically different between genders.

The aggregated knowledge score in the present study ranged from 0 to 16 (out of 18). The highest score among the males was 14 while it was 16 among the females, and the mean of overall knowledge score was 7.01±3.40 (7.25±3.15 for males and 6.85±3.55 for females) [Table 1] and [Table 2]. [Table 1] shows that more than 60% of the participants were in the “low knowledge” category. The mean difference in overall HIV knowledge between “high knowledge” (10.26±1.51) category and “low knowledge” (4.95±2.54) category was statistically different (P<0.001). In contrast, the mean difference between male and female was not statistically different (P=0.279) as shown in [Table 1].

3.3. Relationship between knowledge and other socio-demographic variables

[Table 3] shows the results of the univariate analysis between knowledge level and socio-demographic variables. Age was associated with the level of HIV knowledge as it could be seen that 47.5% of the participants in late adolescence (aged 17-19 years) had high HIV knowledge compared to only 31.1% of the participants in middle adolescence (15-16 years). This difference was statistically significant (P<0.001). In addition, only approximately 35% of females had high HIV knowledge compared to 45% of males. However, the Chi-square statistics showed no significant difference between genders (P=0.05). Upon examining the academic majors, more than half (53.7%) of the participants in electrical/mechanics majors had a high level of HIV knowledge, followed by business retailing (47.4%), and the lowest was business computer (25.4%). Chi-square test revealed that the knowledge difference was statistically significant (P=0.01).
Table 3: Relationship between knowledge and socio-demographic characteristics (n=345).

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Furthermore, the academic year was also associated with high HIV knowledge (P<0.001), as the vast majority (82.9%) of the participants in the third year had high HIV knowledge, followed by the second year (39.1%). The residential area was also associated with high HIV knowledge. According to the survey on HIV knowledge by residential area, the municipality area accounted for the highest proportion (47.0%), followed by the sub-district municipality area (44.9%) and the sub-district of administrative organization area (24.1%). This knowledge difference was determined significant (P<0.001). The participants’ sources of income were also associated with high HIV knowledge. It was found that 57.1% of the participants got their monthly incomes from relatives, 47.5% from one parent, 33.8% from both parents and only 30.0% were financially independent. The Chi-square statistics revealed that the HIV knowledge difference was statistically significant (P=0.03).

3.4. Factors associated with overall HIV knowledge

[Table 4] demonstrates the factors that were significantly associated with HIV knowledge. The results showed that the HIV knowledge level of males was higher than that of females (OR 1.83; 95% CI 1.01-3.34; P=0.04), nearly twice that of females. Similarly, the result revealed that being in the second year (OR 7.00; 95% CI 2.40-20.41; P=0.001) and the third year (OR 6.4; 95% CI 2.05-20.01; P<0.001) was associated high HIV knowledge. Compared with the students in first year, the second-year and third-year students were 7.00 and 6.40 times more likely to have high HIV knowledge, respectively.
Table 4: Binary logistic regression controlling for influencing factors.

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Compared to participants living in sub-district of administrative organization, participants residing in the sub-district municipality were 56% less likely to have high HIV knowledge (OR 0.44; 95% CI 0.23-0.84; P=0.01). Additionally, the source of income played a role in the level of HIV knowledge. It was observed that the proportion of financially independent participants with high HIV knowledge was 83% higher than those whose income came from their parents (OR 0.17; 95% CI 0.04-0.64; P=0.01). Age was not associated with having high HIV knowledge after controlling for other variables in the multivariate logistic regression model.


  4. Discussion Top


Although the sample of the present study might not be nationally representative, it revealed the lack of HIV knowledge among Thai vocational schools adolescents which might in part be a direct consequence of the increased number in new HIV infections among this cohort[4]. In addition, among sexually active Thai youth, high- risk sexual behaviours such as the prevalence of multiple sexual partners, increasing inconsistent condom use and never being tested for HIV may also be related to lack of HIV knowledge[16]. The findings of the present study showed that participants’ responses to the individual 18 items were mostly incorrect and the level of HIV knowledge based on these responses was different between genders. For example, 60.0% of males and 47.3% of females incorrectly believed that genital washing after sex prevented HIV infection. Only 40.7% of males and 27.3% of females correctly believed that natural skin condoms were not better than latex condoms in HIV prevention. However, the majority of the students had no understanding of the effectiveness of different condom types. Regarding knowledge of HIV diagnosis, 60.7% of males and 74.1% of females incorrectly believed that there was a vaccine available to prevent HIV infection. This huge misconception could cause the adolescents to make unsafe sexual decisions, leading to adverse consequences. Additionally, participants had serious misconceptions about HIV transmission. Even though Thailand has done so well in eliminating mother-to- child transmission of HIV[9], the adolescents were not adequately informed about mother-to-child transmission, 68.6% of males and 79.0% of females in the present study wrongly believed that all babies born to HIV-infected mothers would definitely be infected. This was consistent with the findings on growing misconception about HIV transmission in several other studies[13],[19],[20]. It was also discovered that adolescents did not understand the means of HIV transmission as 67.9% of males and 56.6% of females wrongly thought that HIV can be transmitted by sitting in a hot tub or swimming pool with an infected person. These findings of poor knowledge of HIV means of transmission align with the previous findings among low-income African American adolescents[21].

Overall, the prevalence of adequate HIV knowledge in the present study was considerably low (38.8%), which strongly coincides with a past study conducted in the Democratic Republic of Congo and Nigeria where HIV knowledge among the participants was merely 28% and 34% respectively[22]. The United Nations General Assembly Special Session on HIV/AIDS in June 2001 set low-level knowledge targets to ensure that 95% of the world’s young people aged 15-24 years have access to adequate and correct information and services to accelerate reduction in HIV new infections[23].

Although the female gender outperformed the male gender in certain individual items, the overall HIV knowledge significantly better among males who were almost twice as likely as females to have high level of HIV knowledge. This was consistent with the findings of a similar study conducted in Malaysia[24]. However, it was not clear whether there was an evidence to support the reasons why males genarally have more accurate knowledge of HIV than females. It could not be ruled out that the males are more sexually experienced and exhibiting higher rates of risky sexual behaviours and may be exposed to sexual education materials more frequently than the females.

Surprisingly, there was no observed association between knowledge and age, although statistically insignificancent (P=0.05). This is discordant to growing evidence that increasing age was associated with adequate HIV knowledge[21],[22],[24],[25]. The academic year of the students was strongly associated with high HIV knowledge. As compared to the 1th graders, the adolescents in the 2th and 3th grades were substantially more likely to have higher HIV knowledge. Despite the lack of evidence in the present study to suggest an association between age and knowledge, the huge knowledge gap associated with the higher academic year in the present study could be attributed to age because we found that 83% of the second year and 100% of the third-year students were in late adolescence, while only one-third of the first-year students were in late adolescence. Therefore, this might signify the possibility of an age-knowledge association since the p-value was barely insignificant (0.05), which might be due to technical errors inherent in the sampling procedure.

Furthermore, when we examined the participants’ average monthly income, no significant association was detected. However, the source of income was surprisingly associated with high HIV knowledge. We observed that participants who earned income from their jobs were more likely to have high HIV knowledge. Therefore, employment and financial independence increased the tendency towards high levels of HIV knowledge. It is probablly that the financial freedom, the nature of the job and both the professional and social interactions with older colleagues at work could make them more informed about HIV.

What was particularly unusual about the difference in HIV knowledge based on the area of residence. We observed that residents of sub-district of administrative organization area (which can be described as a semi-urban city area) had higher HIV knowledge than residents of sub-district municipality area (which can be described as urban city area). This was unusually surprising as previous findings of past studies stressed that residents of urban areas[17] had a higher HIV knowledge than rural residents[22],[26].


  5. Conclusions Top


Although Thailand’s aspiration to end the AIDS epidemic in the next decade has contributed to the recent decline in HIV prevalence, the country is fast approaching its 2020 target of 90-90-90 (90% of people living with HIV know their HIV status, 90% of people diagnosed are on ART, and 90% of people on ART achieved viral suppression by the year 2020)[9]. However, the number of new infections among the adolescents is still on the rise, and unless vital decisions are taken to address the HIV knowledge deficits among this cohort, it will continue to be a cause for concern and may impede progress in the nation’s fight against HIV/AIDS. Therefore, the concerned authorities must take strategic actions to bridge the gaps of all aspects of HIV knowledge (HIV transmission, prevention and diagnosis) among this young generation. This can be achieved through several approaches. One of such approaches is through school-based comprehensive sexual education to as many adolescents as possible. Unfortunately, the most comprehensive sexual education programs in Thailand are not really in the sense that the contents do not teach essential components such as gender and sexual rights, and even within the limited teaching time and teacher skills, the content is centred more around information delivery rather than building critical thinking and negotiation skills[27]. The second viable option that may be useful is by incorporating gender- based sexual health education into the routine adolescent health care services. Lastly, establishing centres for sexual and reproductive health information in schools will make such information both available and accessible to many adolescents.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Acknowledgements

The authors wish to acknowledge Primprapha Konkaew, Benchamaphorn Nakamadee, Dr Rishad Choudhury Robin and Supranee Joyrod for their immense contributions during the data collection exercise.

Funding

The study received no extramural funding.

Authors’ contributions

Yau S and Songthap A conceived the research questions, conceptualized and designed the study, and coordinated the data collection. Yau S and Wongsawat P conducted data analysis. Yau S, Wongsawat P, Songthap A and Adamu Y drafted the manuscript and finalized it together. Songthap A supervised the overall processes of conducting the study and writing of the manuscript. All authors read and approved the final version of the manuscript.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
1. Introduction
2. Subjects and ...
3. Results
4. Discussion
5. Conclusions
References
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