This study was conducted by an international nongovernmental organisation ...
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EXECUTIVE SUMMARY
This research aimed to measure the knowledge, attitudes and practices (KAP) of 15 to 24 year old youth in urban and rural areas in relation to sexually transmitted diseases (STDs) and HIV/AIDS. Within a society where a vacuum of reliable HIV/AIDS information exists, the research found that Myanmar youths’ knowledge of HIV/AIDS modes of transmission, their attitudes towards people living with HIV/AIDS as well as their own sexual practices were reflective of a general lack of consistent and reliable information.
Respondent Profile
In total, 1,137 males and 1,145 females aged between 15 and 24 years old (yro) were surveyed. The mean age of respondents was 19 yro. The majority of youth were single and only 13.9% reported being married. Generally, more female respondents were married than were male respondents.
The majority of youth in the sample were Bamar, with Shan and Chin being the second and third most represented ethnicities, primarily due to township selection. Eight in 10 respondents could speak, read and write the Myanmar language and levels of illiteracy were very low.
Few youth had attained a tertiary level of education and the majority of respondents had left formal education after completion of middle-school and high-school. Interestingly, more females in rural and urban areas were attending or had attained a graduate level of education than males, more of whom had left education to go out to work.
About one-third of the sample reported being unemployed, more so urban than rural youth.
HIV/AIDS/STD Knowledge
Sexually Transmitted Diseases (STDs)
Awareness of and correct knowledge of STDs emerged as fairly low among youth. Fewer than six in 10 youth who were sampled reported being aware of STDs and about one-third were unable to name any male and female-related STD symptoms. Compared with male respondents, females were more unlikely to have heard of STDs, especially in urban areas, largely because they were less aware of STDs than male youth. Generally, respondents were more familiar with male-related than with female-related STD symptoms.
The findings indicated that respondents with a higher level of education were generally more aware of STDs and able to identify STD symptoms. As well, respondents who were in-school at the time of the survey were more aware of STDs than were respondents who had left formal education.
Sexually active respondents were more aware and able to identify both male and female-related STD symptoms than were non-sexually active respondents. Additionally, a higher incidence of sexually active respondents reported that condoms were effective in preventing STDs than were non-sexually active respondents.
More than three in 10 respondents who were aware of HIV/AIDS transmission through sexual intercourse were not aware of STDs.
Modes of Transmission
Awareness of HIV/AIDS was fairly high among youth compared with STD awareness, with nearly nine in 10 respondents being aware that HIV/AIDS could be transmitted between people.
More than seven in 10 respondents were able to correctly identify three modes of HIV/AIDS transmission that were covered in the study and were chosen for analysis by Care Myanmar:
• unprotected sex with PLWHA
• the sharing of unsterilised needles, and
• mother-to-child transmission.
Condom users appeared to have slightly higher levels of knowledge than non-condom users. Nearly all condom users (97.0%) knew that HIV/AIDS could be transmitted from one person to another compared with 90.0% of non-condom users.
While 20-24 yro urban females had a higher incidence of knowledge of HIV/AIDS modes of transmission than rural females, 15-19 yro rural females demonstrated superior knowledge about HIV/AIDS transmission than did urban females in the same age bracket.
Gender differences could also be seen in respondents’ overall knowledge about HIV/AIDS transmission, with more males demonstrating a higher level of transmission knowledge than female respondents.
The different levels of education among youth were also reflected in the findings. Respondents who had attained a primary level of education were less able to name the above modes of transmission than were respondents with high or tertiary levels of education.
School attendance also proved to influence respondents’ knowledge levels, with youth who were in-school at the time of the survey having more correct knowledge than youth who were out of school.
Misconceptions
Despite 76.7% of all respondents being able to name three correct modes of HIV/AIDS transmission, 80.2% still reported having misconceptions. Based on the research, rural respondents generally had higher levels of misconceptions than urban respondents. More married than single youth appeared to have misconceptions about the transmission of HIV/AIDS. Age did not appear to be a factor in respondents’ different levels of misconceptions.
Mosquito bites as a mode of HIV/AIDS transmission was the most significant misconception held by four in 10 respondents in the study.
Four in 10 youth did not believe that a healthy-looking person could have HIV/AIDS. Condom users were more likely to believe that a healthy-looking person could have HIV/AIDS than non-condom users.
Respondents who were in-school at the time of the survey demonstrated fewer misconceptions than respondents who were out of school. Additionally, in a sliding scale, respondents with a primary level of education had the most misconceptions, followed by respondents with middle school, high school and tertiary levels of education.
That a healthy-looking person could be infected with HIV/AIDS was believed equally among both sexually active and non-sexually active youth.
Prevention
There was little knowledge of the methods of prevention demonstrated among youth. Respondents were more able to name modes of HIV/AIDS transmission (76.7%) than modes of HIV/AIDS prevention (42.5%).
Four in 10 respondents were able to describe the three major methods of disease prevention that were included in the survey:
• consistent condom use,
• having one uninfected, faithful partner, and
• abstinence from sex.
Urban youth were slightly more able to name prevention methods than rural youth, and males were significantly more able to name ways of HIV/AIDS prevention than were females. Higher levels of education and school attendance again impacted on respondents’ HIV/AIDS prevention knowledge.
Condom users had a higher incidence of reporting that consistent condom use would afford protection from HIV/AIDS than had non-condom users.
Comprehensive Knowledge
A very small incidence of all respondents surveyed demonstrated comprehensive, correct knowledge on three HIV/AIDS modes of transmission (Questions 42, 45, 50), the three methods of prevention (Qs 57, 58, 59) and six misconceptions (Qs 43, 44, 47, 48, 49, 53), as requested by Care Myanmar.
In fact, only 9.7% of all respondents surveyed were able to correctly give three correct modes of transmission, knew of three modes of disease prevention and had no misconceptions. Urban respondents demonstrated a better level of comprehensive knowledge than did rural respondents. Males and females had similar levels of knowledge on modes of transmission and prevention, and respondents with tertiary and high school levels of education had better overall knowledge than respondents with middle or primary levels of education. As well, respondents who were in-school at the time of the survey demonstrated superior knowledge than respondents who were out of school.
Though knowledge of HIV/AIDS modes of transmission w
as consistent among respondents in both age groups, youth aged 15-19 yro showed to have a slightly higher incidence of misconceptions than youth aged 20-24 yro. As well, youth aged 20-24 yro demonstrated more correct knowledge about methods of HIV prevention than did youth aged 15-19 yro. Youth aged 20-24 yro demonstrated a slightly higher level of comprehensive knowledge than 15-19 yro youth.
This older age group showed to have a higher incidence of receiving HIV/AIDS information from television, health staff, friends and health education sessions. Given youth in the 20-24 yro age group were more sexually active than youth aged 15-19 yro, HIV/AIDS/STD information would have been of more relevance to them and may be a major reason for the higher incidence of gaining HIV/AIDS information from various sources among this age group. Exposure to HIV/AIDS information would also explain their generally higher levels of HIV prevention knowledge and lower incidence of misconceptions.
As an exception to this trend however, rural youth in the 15-19 yro age group were more able to name modes of HIV transmission and ways of prevention than urban youth in the same age group. As a greater number of rural youth than urban youth in this age group obtained more HIV/AIDS information from teachers, this may be one factor to explain this trend.
HIV/AIDS Sources Of Information
Exposure to sources of HIV/AIDS information also directly impacted on respondents’ levels of comprehensive knowledge. Those with comprehensive correct knowledge reported obtaining more information about HIV/AIDS from health education sessions, posters/books/pamphlets and television than those with incorrect knowledge.
Nearly half of youth named television as their primary source of information on HIV/AIDS. Of these, half demonstrated comprehensive correct knowledge. Television and parents/elders were preferred sources of female youth to attain information on HIV/AIDS while male youth preferred talking to their friends. A third of all respondents said posters/pamphlets and friends were other convenient sources of HIV/AIDS information.
More urban youth received information from television, posters/pamphlets, friends and health education sessions, while more rural youth received information from teachers and health staff.
Television was clearly the most used source for both condom users and non-users to gain HIV/AIDS information. Condom users however, showed a higher incidence of receiving information about HIV/AIDS from television, as well as from health education sessions than were non-condom users.
Access To Condoms
The findings showed that slightly over two-fifths of all youth surveyed did not know where to obtain condoms. This was especially evident among female respondents, more than half of whom did not know where condoms could be bought or obtained.
More rural than urban male youth were unaware of where they could obtain condoms. This general lack of awareness of condom availability appeared to impact on levels of condom usage in urban and rural areas, with about four in 10 respondents in rural areas reporting condom use compared with nearly six in 10 respondents in urban areas.
Respondents who did not report using condoms either the first or last time they had sexual intercourse were much less likely to know of places to obtain condoms than were condom-users.
National Program And Behavior Indicator
The percentage of respondents who were able to both correctly identify ways of preventing the sexual transmission of HIV and to reject major misconceptions about HIV transmission, according to the National Program and Behavior Indicator set by United Nations General Assembly Special Session on HIV/AIDS (UNGASS) was 19.6% (See Appendix 1).
The UNGASS indicator was constructed with responses to the following set of questions:
• Can the risk of HIV transmission be reduced by having sex with only one faithful, uninfected partner?
• Can the risk of HIV transmission be reduced by using condoms?
• Can a healthy-looking person have HIV?
• Can a person get HIV from mosquito bites?
• Can a person get HIV by sharing a meal with someone who is infected?
Urban respondents demonstrated better correct knowledge than did rural respondents. As well, youth who were in-school had better knowledge levels than youth who were out of school according to UNGASS Indicator parameters.
Attitudes And Beliefs
Accepting Attitudes
Gender inequality was reflected in youth attitudes towards sex education for females. Four in 10 youth surveyed believed that girls/women should not learn about sexuality. Interestingly, in rural areas, more 15-19 yro youth agreed that females should learn about sexuality compared with 20-24 yro youth. A similar pattern was found in urban areas and can be directly related to school attendance. Females in both rural and urban areas were equally unsupportive of female sex education as males.
However, despite more 15-19 yro male youth agreeing with female sex education than 20-24 yro male youth, female respondents in both age groups agreed equally that girls/women should learn about sexuality. This is likely to be related to a higher incidence of females who were staying in education longer in both urban and rural areas.
The findings reinforced that people living with HIV/AIDS (PWLHA) were strongly stigmatised against in the community. Half of youth said they were not willing to share a meal with an HIV infected person, while four in 10 said they would stop buying food from vendors whom they believed were HIV positive. Six in 10 youth even believed that HIV infected children should not be allowed to attend school.
One-quarter of all respondents demonstrated accepting attitudes toward PLWHA according to the UNAIDS Stigma and Discrimination Indicator 1 (See Appendix 1). While not all measurements to determine this Indicator were included in the study, three measurements that were incorporated have been used:
• If a member of your family became sick with the AIDS virus, would you be willing to care for him or her in your household?
• If you knew a shopkeeper or food seller had the AIDS virus, would you buy fresh vegetables from him/her?
• If a student has the AIDS virus but is not sick, should he/she be allowed to attend school?
Urban respondents demonstrated more correct attitudes than rural respondents, as did youth who were in-school and those with higher levels of education.
Additionally, respondents who had been exposed to reliable HIV/AIDS information sources had a higher incidence of accepting attitudes. Respondents who had heard about HIV/AIDS from health educators (41.2%) demonstrated more accepting attitudes than those who had not (20.3%). Equally, youth who had received HIV/AIDS information from books/pamphlets (37.3%) demonstrated more accepting attitudes than those who did not (19.1%).
Practice
Sexual Activity And Condom Use
While it appeared that many youth were saving themselves for marriage, given the small incidence of premarital sex (10.1%), those who had sexual intercourse demonstrated various degrees of condom usage with different partner types.
Only one-quarter of respondents reported that they had had sexual intercourse, more so among urban than rural respondents, and among males than females.
It was found that one in 10 youth aged 15 to 19 yro, and nearly four in 10 respondents aged 20-24 yro had had sexual intercourse. The reported mean age of first sex was 19 yro.
Only 6.2% (n=39) female respondents aged 15-19 yro reported being sexually active and only one of these was single. Again, only nine sexually active females aged 20-24 yro reported being single. The rest were married.
Spouses and sweethearts were the most frequently reported first sexual partner types for sexually active respondents. While sweethearts we
re the first sexual partners reported by half of the sexually active males in the group, spouses were the first partner for nearly all of the sexually active females.
As well, CSWs were the first sexual partners for 29.0% of youth aged 15-19 yro and for 23.2% of youth aged 20-24 yro.
In the following analysis of first sex, last sex, commercial sex and sex with multiple partners, respondents who were in-school at the time of the survey were more likely to report condom usage during all the above types of sex than were those who were out of school. Equally, on a sliding scale, respondents with tertiary levels of education reportedly used condoms more frequently during all sex than did respondents with high school, middle school and primary school levels of education.
First Sex
Condom use at first sex was reportedly low among sexually active youth (20.8%), and was found to be more predominant among urban than rural male youth. About four in 10 of those who did not use a condom the first time they had sex believed that they could be at-risk of HIV infection. Of these, two-fifths demonstrated incorrect beliefs.
Only nine single females reported being sexually active and seven of these did not use a condom at first sex.
Last Sex
Seven in 10 sexually active respondents reported having sexual intercourse in the past 12 months. A greater number of male respondents aged 20-24 yro reported having sex in the past 12 months compared with 15-20 yro male respondents. However more of the respondents aged 15-20 yro reported using condoms the last time they had sex than did respondents aged 20-24yro. This is because there were more single respondents found in the 15-20 yro group and more married respondents in the 20-24 yro group.
The majority of married men reported that they did not use condoms the last time they had sex compared with less than two-fifths of sexually active single men.
Four in 10 of both single and married youth who did not use a condom the last time they had sex believed they were at-risk of HIV infection.
As well as marital status, access to condoms also appeared to influence respondents’ degree of condom usage at last sex, since, of those who did not report using a condom the last time they had sex (n=268), 40.2% said they did not know of a place to obtain them.
Respondents with higher levels of comprehensive knowledge were more likely to have used condoms at both first and last sex.
Commercial Sex
Very few respondents reported having sex with CSWs in the last 12 months. In fact only 68 sexually active respondents reported they had had commercial sex. More urban than rural males reported having commercial sex.
More males in the 15-19 yro age bracket reported having commercial sex than did males in the 20-24 yro age group.
Condom use with commercial partners was high among respondents, with 59 of the 68 respondents who had commercial sex reportedly using condoms.
Again, youth aged 15-19 yro reported a higher incidence of condom use with commercial partners than males aged 20-24 yro.
Respondents’ levels of HIV/AIDS transmission and prevention knowledge did not appear to influence condom use with CSWs.
That consistent condom use would protect individuals from HIV infection was advocated by more condom users than non-users.
Multiple Partners
One-fifth of sexually active youth reported having more than one sexual partner in the past 12 months, more so in urban than in rural areas. The findings revealed that slightly fewer males in the 15 to 19 yro age group had multiple partners than youth in the 20-24 yro age group.
Three-quarters of sexually active youth reported they had used a condom with their non-marital, non-regular and non-cohabiting partners at last sex. Among non-condom users (n=18), over half did not believe they were at-risk of HIV/AIDS infection. Of these, four had incorrect beliefs.
