Background : Globally, the spread of HIV/AIDS remains on the rise with young people at increased risk of infection. Sexual behavior change remains the most effective way of preventing further transmission. Aim: To gain the knowledge needed to develop appropriate interventions that will enable young people to adopt safe sexual practices. Materials and Methods: A cross-sectional study was conducted using structured questionnaires among 315 randomly selected students enrolled at a tertiary institution in Lagos State, Nigeria. Results: The mean age of the respondents was 23 years. Although the mean score of the participants’ responses to ten HIV/AIDS knowledge questions was 8.3 of 10 points, 73.5% of them did not perceive themselves at risk of being infected. Majority (53.8%) had not changed their dating behaviors as a result of concerns for HIV/AIDS and 70.3% had multiple lifetime sexual partners. Those who perceived themselves at risk of infection are significantly (P = 0.019) more likely to always use condoms. Using the AIDS Risk Reduction Model (ARRM), it was found that the students are in the first stage of behavior change process: recognition of the problem. The low risk perception has prevented movement to the second stage of making commitment to change behavior. Conclusion: The awareness and knowledge of HIV/AIDS is high among tertiary education students in Lagos, Nigeria. However, risk perception is low with high-risk sexual behaviors. The failure to perceive HIV/AIDS as a personal risk has prevented commitment to behavior change. Interventions aimed at influencing risk perception are paramount to curb the spread of this dreaded disease.
Keywords: Attitude, behavior change, HIV/AIDS, knowledge, Nigeria, practice, students
|How to cite this article:
Durojaiye OC. Knowledge, attitude and practice of HIV/AIDS: Behavior change among tertiary education students in Lagos, Nigeria. Ann Trop Med Public Health 2011;4:18-24
|How to cite this URL:
Durojaiye OC. Knowledge, attitude and practice of HIV/AIDS: Behavior change among tertiary education students in Lagos, Nigeria. Ann Trop Med Public Health [serial online] 2011 [cited 2020 Oct 29];4:18-24. Available from: https://www.atmph.org/text.asp?2011/4/1/18/80516
HIV/AIDS has become one of the most devastating diseases humanity has ever faced. It has become a major public health concern with about half of new infections occurring in young people. Sub-Saharan Africa, which has just over 10% of the world’s population, remains the most seriously affected region. 
Sexual behavior change remains the most effective way of preventing transmission. A number of behavior change theories that recognize the complexity of human behavior and other structural factors that make people vulnerable have been suggested. Some of these theories include AIDS Risk Reduction Model (ARRM), Health Belief Model, and Stages of Change. These models are of great importance in the development of HIV/AIDS programs. 
In essence, there is a need to gather information on the basic knowledge that young people have on HIV/AIDS and their sexual practices, and use these to develop appropriate preventive strategies using a behavior theory as a fundamental framework. These elements were explored in this study.
|Materials and Methods|
This study was a cross-sectional study on the knowledge of HIV/AIDS, attitude and sexual practices among tertiary institution students. The population of study consisted of students in tertiary institutions in Lagos, Nigeria. One tertiary institution was randomly selected from the eight public tertiary institutions in Lagos State, Nigeria.
The minimum sample size was determined using the formula for single proportion:
Based on the estimated awareness level of 80%, , 95% confidence level (Z-score value: 1.96) and 5% precision level, the estimated minimum sample size was approximately 245 (Z = 1.96; P = 0.8; E = 0.05). However, 315 students were sampled to allow for non-response.
Approval for the study was obtained from the Registrar of the institution. The institution has a student population of over 16,400 with nine academic schools (faculties), each with a number of departmental units. Thirty-five students (a total of 315) were randomly selected from each academic school. Informed consent was obtained from the selected students. The respondents were provided an assurance of confidentiality of information that they provide in the questionnaire. Data for the survey were collected between May and June 2008 using self-administrated questionnaires. The questionnaires consisted of closed and open-ended questions focusing on socio-demographic characteristics, knowledge on HIV/AIDS, attitudes and risk perception, and sexual behavior and practice. Prior to its administration, a draft of the questionnaire was pre-tested among 20 students from other tertiary institutions in Lagos to confirm clarity and comprehension.
The completed questionnaires were checked for completeness. After deleting some missing questionnaires, only 302 were usable for data analysis. The quantitative data were analyzed statistically using SPSS 13 statistical software. Standard descriptive statistics was used to describe some of the findings. The respondents’ knowledge of HIV/AIDS was assessed by assigning a score of 1 to each correct answer of 10 yes/no HIV/AIDS related questions. The summation of these scores formed the basis for data analysis. The possible score for the Knowledge variable ranges from 0 to 10. Higher scores indicate more accurate knowledge on HIV/AIDS. Test of significance, t-test, was used to compare the differences in mean of the knowledge on HIV/AIDS according to sex, marital status, belief that HIV/AIDS is undesirable, risk perception, change in dating behavior, taking responsibility for use of condoms and sex with an unknown person or commercial sex worker. In addition, chi-squared test was used to explore the associations between risk perception for HIV and some variables on sexual practice. The alpha level adopted was 0.05. The qualitative data (open-ended questions) were thematically analyzed and coded.
The ages of the respondents ranged from 16 to 35 years with a mean age of 23.3 years (standard deviation of 3.6). 56.6% (168) of the respondents were males. Majority of them [285 (94.4%)] were single and most of them [238 (78.8%)] were Christians [Table 1].
|Table 1: Socio-demographic characteristics (N = 302)
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Virtually all the respondents [301 (99.7%)] had heard about HIV/AIDS. The respondents’ answers to the 10 HIV/AIDS knowledge questions are shown in [Table 2].The overall mean knowledge score was 8.3 out of a possible score of 10. Majority of the respondents [294 (97.4%)] knew that HIV could be transmitted through unprotected sexual intercourse with infected persons; by sharing needles/syringes with infected persons [284 (94.0%)] and that the Human Immunodeficiency Virus (HIV) causes AIDS [275 (91.1%)]. On the other hand, about a quarter of them [77 (25.5%)] did not know that there is no cure for AIDS and that one cannot always say if someone is infected with virus [88 (29.1%)]. Most of them [286 (94.7%)] had obtained information about HIV/AIDS from the television, while parents and teachers accounted for 58.9 and 61.6%, respectively. Other (14.9%) mentioned sources of information were the Internet, religious institutions and information leaflets [Figure 1]. All the respondents were knowledgeable about ways of avoiding infection with HIV. The four commonly mentioned means of preventing HIV infection were: avoiding sharing sharp objects [248 (82.1%)], use of condoms [244 (80.8%)], avoiding sex with commercial sex workers [240 (79.5%)] and abstinence from casual sex [228 (75.5%)]. However, some respondents wrongly believed that one can avoid getting infected by seeking protection from traditional healers [7 (2.3%)] and avoiding mosquito bites (7.9%) [Table 3] 85.7% (259) of the respondents believed that HIV/AIDS is undesirable in the society and about three-quarter (222) did not perceive themselves at risk of being infected. Most of them [252 (83.4%)] were willing to care for a relative or friend at their home if he/she becomes sick with AIDS. Forty-one (13.6%) were reluctant to care for a sick relative/friends and responded to a follow-up question to establish why they were not willing to care for such relative/friends that the sick relative/friend needs a more specialized care and also that they did not want to get infected [Table 4].
|Table 2: Knowledge of HIV/AIDS (N = 302)
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|Table 3: How to avoid getting HIV (N = 302)
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|Table 4: Attitude and risk perception (N = 302)
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|Figure 1: Sources of information on HIV/AIDS (N = 302)
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61.9% (187) of the respondents have had sex before. The age at first sex ranged from 10 to 28 years with a mean of 19.7 years. Use of condoms was low [68 (36.4%)] at first sexual experience. 30% (51) of the sexually active respondents always used condoms mainly to prevent STDs/HIV and pregnancy, while one-fifth (34) had never used a condom. Trust in partners, non-availability of condoms and enjoying sex without a condom were the main reasons given by those who did not use condoms. Majority [100 (53.5%)] of them had not changed their dating behaviors as a result of HIV/AIDS concerns. 37.9% (64) of the sexually active respondents have had two to three sexual partners in their life. Notably, about one-tenth (19) had more than 10 lifetime sexual partners. In the year preceding the study, more than half [86 (52.7%)] had multiple sexual partners (two or more). About half [86 (52.3%)] of them sometimes refused sex without a condom, while one-fifth (34) had never refused. Only a few [9 (4.8%)] have had sex with an unknown person or commercial sex worker [Table 5]. The three major reasons that influence the students to have sex are fun, enjoyment of sex and fear of losing their partner. On issues relating to precautions during sex, majority [180 (96.3%)] felt that safe sex is the equal responsibility of both partners. About one-fifth (40) did not wear a condom during sexual intercourse, suggesting that it was their partner’s responsibility to take precautions. Less than half (77) used to discuss and agree with their partners on use of a condom before sex.
|Table 5: Sexual behaviors and practices
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[Table 6] shows the results of the independent-samples t-tests, which compare the differences in mean of knowledge on HIV/AIDS according to sex, marital status, belief that HIV/AIDS is undesirable, risk perception, change in dating behavior, taking responsibility for use of a condom and sex with an unknown person or commercial sex worker. Married respondents had more knowledge about HIV/AIDS than respondents who were singles (P = 0.009). Those who were of the view that HIV/AIDS is undesirable/unwanted in the society were also more knowledgeable about HIV/AIDS than those who had an opposing view (P = 0.000). More so, students who had taken responsibility to use a condom had more HIV/AIDS knowledge than those who did not (P = 0.028). However, t-tests do not indicate significant differences (at 5% level) in the HIV/AIDS knowledge with regard to gender, risk perception, change in dating behavior as result of concerns about HIV/AIDS and sex with unknown person/commercial sex worker.
|Table 6: Difference in mean of knowledge (independent sample t-test)
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[Table 7] shows the result of the chi-squared tests (χ2 ), which explore the associations between risk perception and some variables on sexual behaviors and practices. 45% (18) of those who perceived themselves at risk of getting HIV/AIDS were significantly more likely to always use a condom when they had sex (P = 0.019). More so, 53.5% (23) of those who perceived themselves at risk significantly refused sex without a condom sometimes, compared to 9.3% (4) that never refused (P = 0.042). Respondents who have had more than one sexual partner in their lifetime were significantly unlikely, than those with one partner, to perceive themselves at risk of infection (68.9% vs. 94%, respectively) (P = 0.0005). Although a slightly greater proportion [61 (50.8%)] of those who did not perceive themselves at risk have multiple sexual partners in last one year, the finding was not statistically significant (P = 0.20). The findings suggest that risk perception is significantly likely to influence use of condoms and lifetime sexual partners.
|Table 7: Risk perception and sexual practices (χ2 statistic)
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This study applies the ARRM to HIV/AIDS concepts among tertiary education Nigerian students in Nigeria. Using the ARRM as a framework provides valuable information that will help in developing appropriate interventions, which can effectively encourage positive sexual practices. The ARRM, introduced in 1990 by J.A. Catania, was chosen because it was developed specifically to look at the behaviors in the sexual transmission of HIV/AIDS.  The stages of the model and the hypothesized factors (elements) that influence the successful completion of each stage are shown in [Table 8].
|Table 8: Stages of the AIDS Risk Reduction Model (ARRM)
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The first stage of ARRM is recognizing and labeling of one’s behavior as high risk and it is influenced by knowledge of HIV transmission methods, belief that one is susceptible and that AIDS is undesirable. The study results showed that these students have high level of knowledge on HIV/AIDS, which may be related to the aggressive campaigns on HIV/AIDS that have occurred over the years. The subjects certainly know sexual activities that transmit HIV. More so, they believe that AIDS is undesirable. Those who have more accurate knowledge about HIV/AIDS are more likely to view the disease as unwanted/undesirable and to use condoms as precautions, suggesting the importance of knowledge in changing attitudes and use of condoms during sexual intercourse. Married subjects are more likely to have higher knowledge about HIV/AIDS probably because they are more matured on sex related issues. No significant difference was found in the knowledge of HIV/AIDS between the male and female respondents. The finding is most likely to be as a result of the readily accessible sources of HIV/AIDS information, which are made equally available to both sexes. The finding is, however, in contrast with those of Aluede et al.  and Chng et al.,  who reported a higher knowledge among male students and female students in Nigeria, respectively.
Despite the relatively high knowledge about sexual transmission of HIV, 74% of the subjects did not believe that they are personally susceptible to HIV. This figure is comparable to other studies which reported a risk perception of 72-78% among students in Nigeria. , This low risk perception could be that the students believe in their own invulnerability to AIDS which can be explained by the less emphasis placed on HIV/AIDS in Africa. The reasons for such reaction include misconception, ignorance, poverty, repudiation, shame, guilt, and silence as a result of association of the infection with sinful sexual acts. , Social networks and norms influence individuals by disapproving high-risk behaviors and approving safe alternatives. Social networks and norms may have hindered the use of safer alternatives among the students as some of them find buying condoms embarrassing and are influenced to have sex by peer pressures.
In the second stage, the individual makes a commitment to change his sexual behaviors and practices through a series of actions. In order to make a decision, the individual compares the perceived cost and benefits. Enjoyment of sex, apparent success in reducing risk of infection and belief in one’s own ability to execute the actions are crucial in making commitment to change sexual practices. Most of the sexually active students in this study have had sex for fun and enjoyment, and some believed that sex is more enjoyable without a condom. In addition, some of them did not believe in their ability to use condoms as they felt it was their partners’ responsibility. Clearly, the students have not moved from stage one to make commitments to increase low-risk activities and reduce high-risk sexual contacts.
In stage three, actions are taken to change behavior through three phases: information seeking, finding solutions and enacting the solutions. These phases may take place at the same time or be omitted. This stage may be influenced by self-help, informal and formal help. The students are actively provided with the information, solutions and ways to enact the solutions in order to change sexual behaviors as regards HIV/AIDS control. Virtually, all the students have heard of HIV/AIDS and are knowledgeable about ways to prevent transmission. They identified the mass media as the major source of information on HIV/AIDS. This is consistent with the findings of most studies on HIV in Nigeria, which also found the mass media as the primarily source of information. ,
There are other internal and external factors which may motivate movement across the stages. Public health messages received by the students through the various sources may stimulate changes in sexual practices by enlightening them of their susceptibility.
Essentially, majority of the students have not reached the first stage of recognizing and labeling their behavior as high risk since they do not personally believe that they are susceptible to contracting HIV. Interestingly, some have taken actions to reduce the risk of contracting HIV as they use condoms to prevent STDs/HIV. This may have occurred as the stage three phases of information, remedies and enacting solutions are actively provided by the various sources of information on HIV/AIDS, which the students do not actively seek. Consequently, some stage three actions may have been taken by the students, probably as a result of positive attitudes toward HIV/AIDS prevention programs, even though that they have not moved through the first and second stages. Undoubtedly, the findings from this study that risk perception influences use of condoms during sex, number of sexual partners and frequency of sexual intercourse are essential for HIV/AIDS prevention initiatives in Nigeria.
The study is limited in that it was carried out in a school environment involving 315 students, thereby making the research participants very selective. Any generalization of the results of this study must be made with caution. More so, sexual behaviors and practices are sensitive topics that many young people are reluctant to talk about. As such, there could be some bias in the reported sexual practices.
This study has shown that students in tertiary education institution in Nigeria are highly knowledgeable about HIV/AIDS, which should be maintained by service providers. There is also need to embark on sustained HIV/AIDS educational programs that will reinforce safe sexual behaviors. The following recommendations are essential for developing an effective HIV/AIDS preventive strategy
HIV/AIDS programs should focus not only on abstinence, avoiding multiple sexual partners, consistent use of condoms, but also on changing risk perception and communication processes that will enhance safer practices.
Parents, teachers and sex educators should be more involved in HIV/AIDS education and prevention strategies.
HIV services should be closely integrated with key service systems, with particular attention to sexual and reproductive health.
In conclusion, this study has shown that among tertiary education students in Lagos, Nigeria, the knowledge and awareness of HIV/AIDS is high with low risk perception. The failure to perceive HIV/AIDS as a personal risk has prevented majority of the students from making commitment to sexual behavioral change. Thus, messages and interventions that will influence risk perception are paramount in this population. Further extensive studies that will explore the paths leading to sexual behavioral change and assess the reasons for the low risk perception among youths are recommended.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]