HIV/AIDS AND SOUTH AFRICAN ADOLESCENTS: ATTITUDES AND INFORMATION NEEDS

HIV/AIDS is by far the most serious health hazard of our time and by far the biggest current crisis in South Africa. Prevention of the disease by way of communicating correct knowledge and information, in order to change individuals’ and communities’ attitudes and sexual behaviour, is of vital importance. This exploratory study utilised qualitative and quantitative methodology. A purposive, non-probability sampling technique was used to administer questionnaires to a sample of adolescents throughout the North West Province. The aim of the study was to assess attitudes and needs of information of high school pupils on various aspects of HIV/AIDS in order to draw up recommendations for a prospective programme to educate adolescents and to influence their attitudes towards HIV/AIDS. It was found that adolescents had an urgent need for more knowledge and information on sexuality and HIV/AIDS, that the idea of condoms has taken on with adolescents and that they have a fair to positive attitude on the problem. It is recommended that a programme be developed to educate adolescents about sexuality and HIV/AIDS in an objective and factual manner. Outsiders should be utilised to implement such a programme. Material and facilities like video’s, films, flip charts, books and posters, are indispensable in any such programme. It is vital to indigenise such a programme for use under South African circumstances. Not all schools have all the facilities to their disposal, and therefore the proposed programme should be adaptable to any circumstances.


INTRODUCTION
As the 20 th century drew to a close some 33,6 million men, women and children faced a future dominated by a fatal disease unknown just a few decades ago (Joint United Nations Programme on HIV/AIDS (UNAIDS) and the world Health Organization, 1999:10-20).About half of all people who acquire HIV become infected before they turn 25 years and typically die of the lifethreatening group of illnesses called AIDS before their 35 th birthday.This illness can be described as a deadly community disease and South Africa's biggest crisis (Beeld, 1999).The highest infection rates are found in Sub-Saharan Africa, especially in the countries of East, Central and Southern Africa.Two-thirds (20,8 million) of the world total of people living with HIV live in this region (Sutherland, 1999;Van Dyk, 1999).In comparison to other countries the situation in South Africa is bleak.AIDS has spread rapidly and has become a major public health issue (Pauw & Brener, 1997:250-273;Spies, 1999).Recent statistics estimate that 4,2 million people in South Africa are HIV-Positive (Beeld, 1999;Spies, 1999).Within five years 6 million of the 40 million South Africans will be suffering from AIDS (Beeld, 2000a).
According to statistics 200 babies are born daily in South Africa infected with the virus and about 25% of pregnant women are HIV-Positive.At the moment South Africa has about 100,000 AIDS orphans and this figure will rise to more or less 1,6 million by the year 2008 (Beeld, 1999;Fraser-Moleketi, 1999:1-8).It is predicted that about 1600 people are infected daily with the HI virus in South Africa and that 500,000 people will die annually due to AIDS-related illnesses (Fraser-Moleketi, 1999:1-8).According to Beeld 13,8 million people from Africa have already died due to AIDS and 10 500 new cases of HIV infection are reported daily on the African continent (Beeld, 2000a).Life expectancy also declined from 64 to 47 years (Beeld, 1998).
Africa and specifically South Africa have some special cultural features regarding the illness, like polygamy, prostitution, migrant labour, mobility of the population, weakening of family and community ties, the status of women, poverty, diet, urbanisation, the presence of sexually transmitted diseases, health beliefs, traditional healers, lack of condom use, unrest, crime and violence (Bernstein & Van Rooyen, 1994:375-382;Valdiserri, 1989;Viljoen, 1990:329-343).
One of the most serious obstacles in the fight against AIDS in South Africa is the cloud of secretiveness that surrounds the problem (Beeld, 1999).This culture of silence and fear of rejection and isolation that has developed around the disease leads infected persons to refrain from disclosing their HIV status.Few people admit to knowing somebody being infected and relatives are said to be dying of a "long illness" or a "slim disease" (Fraser-Moleketi, 1999:1-8).If a proper strategy is to be followed on this disease, HIV will have to be brought "out of the closet", be discussed openly and patients will have to talk more freely on the consequences of the illness and how to prevent it (Poindexter & Linsk, 1999:46-61).
South Africans are slowly changing their attitude towards the problem.However, much more will have to be done to implement preventative strategies and programmes that have already gained credibility elsewhere.The South African government considers the problem of AIDS in a serious light and recently established an AIDS Council, consisting of prominent leaders and cabinet ministers.
In January 2000 the Minister of Education, Kader Asmal, announced a five-point plan for education which would be implemented over a period of five years.Programmes to be included are related to HIV/AIDS, school efficiency, teaching professionalism, literacy, higher education and organisational efficiency of national and provincial departments (Beeld, 2000b).With regard to the HIV/AIDS programme, the focus will be on increasing awareness, communicating the correct knowledge and encouraging subsequent behavioural change (Van Dyk, 1999).
Prevention of HIV infection is of vital importance and efforts should therefore be focused on all groups in society, especially young people.The attitudes of people can only be changed by communicating correct and factual information.Communication of knowledge to pupils entails a delicate balancing act.On the one hand, young children should not be bombarded with information that they cannot handle but, on the other hand, information may be provided too late and may be of little use to children who are already sexually active.
The overriding aim of the study was to assess the attitudes and the need for information among high school pupils on various aspects of HIV/AIDS in order to draw up recommendations for a prospective programme to educate adolescents and to influence their attitudes towards HIV/AIDS.

Study design
South Africa consists of nine provinces, but in this study schools of only the North West Province were included.It was accepted that high school pupils' attitudes in any of the provinces will be similar.After consultation with and receiving permission from the North West Department of Education: Education Support Services, it was decided to focus on pupils in Grade 10 (Standard 8; about 16 years old) as the group that can be considered as being representative of the opinions of high school pupils in South Africa (North West Department of Education: Education support services, 1998).
The study was of an exploratory nature (Grinnell & Williams, 1990;Neuman, 2000).A purposive, non-probability sampling technique was used where the researcher used his own judgement in selecting the sample (De Vos et al, 1998;Grinnell, 1993).Twenty-five secondary schools from a possible 360 schools were selected as representative of the 12 educational districts in the North West Province.
The total number of learners at secondary schools in the North West Province is 239 844 (Venter, 1999).Questionnaires were distributed to 30 adolescents by way of a pilot study, in order to maximise the questionnaire's level of validity and reliability.The 1490 questionnaires, of both a qualitative and quantitative nature, were hand delivered to pupils throughout the province and collected after two weeks.The life skills teacher at each school assisted with the administrative aspects of the distribution and collection of the questionnaires.A total of 999 questionnaires was returned correctly completed, which constitutes a 67% response rate.According to the literature, this percentage can be considered as good to excellent (Grinnell & Williams, 1990).A letter of permission had to be signed by a parent or guardian of every selected pupil beforehandon receipt of the letter of permission the respondent received his/her questionnaire for completion.

Terminology
For the purpose of this study, the following definitions of specific terms were formulated:

Adolescence
Adolescence is normally referred to as the life cycle period between childhood and adulthood, beginning at puberty and ending with young adulthood (Barker, 1997).The life stage of adolescence is often accompanied by rapid growth and physical development, heightened sexual interest/activities and a struggle to find self-identity.The peer group and peer acceptance become increasingly important, while interest in the opposite sex intensifies and they often becomes involved in sexual relationships (Naidoo, 1994).

Attitude
Attitudes stand in direct relationship with behaviour and are therefore the key to effective health promotion and counselling.Attitudes are more or less permanent, acquired and difficult to change -therefore it is important to form young people's attitudes before their ideas become too fixed.Attitudes have cognitive, affective and behavioural components, thus involving persuasion, emotions and readiness to act in certain ways (Smart, 1993).

Needs
The literature define needs as any physical, psychological, spiritual, economic, cultural and social requirements for survival, well-being, self-actualisation and general fulfilment (Barker, 1997;New Dictionary of Social Work, 1995).Needs can be experienced on a normative, perceived, expressed and/or relative level.The needs of adolescents for more knowledge and education in order to change their attitude towards HIV/AIDS can primarily be regarded as being expressed on a normative level.

Sexuality
Sexuality can be seen as all the characteristics of an individual that pertain to the reproductive function, sexual traits, sex role patterns and the accompanying behavioural characteristics (Barker, 1997).Sexuality refers to the totality of being a person and thus reflects our human as well as our genital nature.

Ethical issues
Informed consent was obtained from the parents or guardians of every participant (Bailey, 1994).This was done by way of a written letter to each parent or guardian explaining the aim and objectives of the study, accompanied by a tear-off strip to be completed by the parent or guardian and sent back to the particular teacher.Only those respondents who returned their completed letters of consent could take part in the project.The matter of deception of respondents was also taken into account.Each subject knew beforehand what was expected of him/her during the study and thus every individual's right to voluntary participation was taken into consideration (Corey et al., 1993).No violation of respondents' privacy took place.Respondents could complete the questionnaire in private and in his/her own time.Privacy, anonymity, the right to self-determination and confidentiality were maintained throughout the entire study (Rubin & Babbie, 1997).Pupils were also offered the opportunity to discuss with the researcher anything from the questionnaire, on either an individual or a group basis, when the questionnaires were collected.Subjects therefore had the opportunity to attend a debriefing session in order to minimise possible harm and to restore them to their original state, as far as that is possible in working with people (Judd et al., 1991).

Statistical analysis
The SAS System for Windows Release 6.12 (1996) SAS Institute, Cary, NC, USA was utilised for the statistical analysis of the empirical data.  1 it can be deduced that the various selected groups for the study represented more or less the numbers of the various groups in the South African society as a whole.For every 10 children included in the study, more or less 6,5 were Black, 1,5 White, 1 Coloured and 1 Indian.The chosen schools also represented the North West Province as a whole regarding rural/semiurban areas.

Details of respondents
Gender, age and school grade of respondents Of the total, 535 (53,6%) were female and 464 (46,4%) male.The mean age of respondents was 17,43 years.The distribution ranged, however, from 13 to 25 years of age, with the single highest group being the 16-year-olds (21,0%).The 16-year-old group were followed by the 15-year-olds (17,6%), the 19-year-old group (15,3%), the 17-year-old group (14,6%) and the 18-year-old group (13,2%).As could be expected, the overwhelming majority of respondents, namely 84,2%, were Grade 10 pupils.The second highest group (11,9%), were Grade 9 pupils.Attitudes towards HIV/AIDS For the purpose of this presentation the "Definitely Yes" and the "Yes" categories are calculated together, as well as the "Definitely No" and "No" categories.
The highest positive responses were on the following items: There should be more programmes on television regarding HIV/AIDS (85,2%).
The government must do more to combat the spread of AIDS (75,4%).
All prostitutes should be tested for the HIV virus on a regular basis(73,9%).
Patients should be informed about the HIV status of the medical doctor they consult (71,2%).
A large number of respondents, namely 58,4%, said that sex education is lacking.Human sexuality is definitely a neglected topic, according to the literature (Woods, 1992:37-46).
The highest negative responses were on the following items: HIV-Positive pupils should not be allowed in my school (64,1%).
AIDS patients should be forced to place their names on a list in order that other people can thus be protected (58,7%).
Pregnant women that test HIV-Positive, should be forced to undergo an abortion (55,3%).
Prostitution should be legalised in South Africa (49%).
AIDS can be seen as God's punishment for human sin (46,5%).The notion that AIDS represents the punishment of God for human sin is supported in the literature (Weyers, 1990:345-356).
Would be sceptical about having a meal with an HIV-infected person (42,3%).Proper personal hygiene of food preparers is important, but the separation of eating utensils used by HIV-infected persons is unnecessary (Meer, 1994:189-199).It is thus safe to have a meal with an HIV patient and to share the same utensils.
Respondents had a rather low response overall in the Uncertain categories, except for the category on euthanasia: Euthanasia should be a legal option for anybody that is HIV-Positive (45,3%).
Patients should be informed about the HIV status of their minister of religion (25,6%).
All applicants for bursaries should undergo an HIV test and the bursary should only be awarded after an HIV-Negative result (25,3%).
Patients should be informed about the HIV status of their dentist (24,5%).
All women that test HIV-Positive should be sterilised (23%).
Adolescents feel strongly that they need more information on HIV/AIDS by way of television (85,2%), the government (75,4%), and schools and parents (58,4%).The literature also supports the need for more information, knowledge and education on HIV/AIDS (Naidoo, 1994;Searle, 1994;South African Department of Health, 1997).Any programme for young people should not only transmit knowledge, but also assist with the integration of knowledge and attitudes (Coughlan et al., 1996:255-261).
Any programme should focus on life skills education on an ongoing basis in the broadest sense of the wordin other words, advocating all activities that can reduce risk behaviour (Cornelius et al., 1999:15-32).Life skills and HIV/AIDS education should not be presented as isolated learning content, but should be integrated into the total curriculum (South Africa. Department of Education, 1999:1-57).Adolescents have strong feelings about being informed of their medical doctor's HIV status (71,2%), but they have less of a problem on their pharmacist's status (55,6%), their dentist's status (50,5%) and their minister of religion's status (46,2%).
A few of the other most interesting attitudes and their percentage positive reactions are: AIDS patients should have free care until death (68%), free medical treatment should be provided for HIV patients (65,8%), and all South Africans should be tested for the HIV virus in order to gain reliable statistics on the problem (65,1%).A large number of respondents are willing to be friends with AIDS patients (64,4%); a large number also agree that an HIV-Positive patient would deliberately try to infect other people in order not to suffer alone (59,5%), and also agree that people who test HIV-Positive should not be sexually active (58,9%).Suspected people should be forced to have themselves tested for the virus (54,5%) and homosexual people should not be allowed to donate blood (44,9%).

Measures to combat the problem
In this section respondents had to give their views on measures to combat the problem in a qualitative as well as a quantitative manner.Respondents could give more than one possibility on qualitative questions.Not all responses were taken into consideration, due to the fact that some gained only an insignificant number of responses.Therefore it was not possible to indicate percentages.
"Use a condom every time you have sex."(193) "I have no idea how to combat this problem."( 93) "Hold workshops in a practical manner and encourage young people to become involved and to participate in these programmes."( 79) "Have only one sex partner."( 72) "To spread knowledge to young people."( 52) "To empower women to be able to say no!" (12) The largest number of respondents (193) mentioned the use of condoms every time you have sex, whilst the idea of workshops and the spreading of knowledge received 131 responses.The lack of knowledge of ways to combat the problem received 93 responses, having only one sex partner 72, and the idea of the empowerment of women received 12 responses.The literature supports the notions of enablement and empowerment (Rhodes, 1996:1-9;South Africa Department of Health, 1997).
The following table shows the quantitative responses on measures to combat the problem.The highest positive reactions (all over 80%) on measures to combat the problem can be indicated as follows: "To use condoms at all times" (88,1%).
"Empowering young people to have the freedom to say no" (80,8%).
It was found that 84,3% of the respondents felt that using a condom during sex lowers the risk of contracting AIDS (Naidoo, 1994).The Government Gazette stresses healthy morals, sex education, guidance regarding sexual abstinence until marriage and faithfulness to their partnerssexually active persons should be advised to practise safe sex and to use condoms (South Africa. Department of Education, 1999:1-57).An important part of HIV/AIDS prevention campaigns is the encouragement of responsible condom use (Naidoo, 1994).
Some authors maintain from a Christian perspective that the Bible warns against pre-marital sex in any form and that the emphasis should be on healthy relationships for young people (De Bruyn, 1990:357-375;Van der Walt, 1999:297-315).Condom users can also be stigmatised as promiscuous or in some way morally questionable (Naidoo, 1994).Condoms are also not 100% safe and even a minute break in the latex is sufficient to allow significant passage of HIV infection through the membrane of the condom (Naidoo, 1994).
The highest negative reactions (all under 25%) on measures to combat the problem can be stated as follows: "To avoid all sexual activities" (23,9%).
"To be mature enough to do your own thing" (22,4%).
The highest uncertain responses (all under 30%) on measures to combat AIDS, can be listed as following: "To avoid homosexual activities" (27,8%).
"To be mature enough to do your own thing" (22,3%).
The idea of using condoms, honest and correct information/education to the youth and empowering young people to be able to say no stood out as highly positive reactions to this question.As far as the negative responses were concerned, almost a quarter of all respondents mentioned the highly unpractical solution of avoiding all sexual activities and the vague idea to be mature enough to do your own thing.It was surprising to see that 25% of respondents condoned the idea of having a variety of sexual partners and having homosexual relationships.Almost a third of the respondents were uncertain about avoiding homosexual activities, whilst more or less 20% were respectively uncertain on being mature enough to do your own thing, avoiding all sexual activities and the freedom to choose between right and wrong.

Ways of education
In this section four aspects of education were addressed: how do respondents regard their knowledge on AIDS, the explanation for this reply, the degree of interest of respondents in knowing more about AIDS and the way in which the information should be given.From the above data it is obvious that more than 70% of the respondents regarded their level of knowledge as "uncertain" and "inadequate".This can only mean that there is an urgent need to spread correct and factual information/knowledge amongst pupils in the category that the study was based on.

THE QUALITATIVE MOTIVATION FOR THE LEVEL OF KNOWLEDGE ON AIDS
"I have no knowledge on AIDS -the teachers avoid the topic of AIDS.From the selected qualitative quotations on the knowledge of respondents regarding AIDS, the urgent need to spread knowledge/information is obvious.It can be regarded as significant that respondents also gave their opinions on the ideal ways in which knowledge can be communicated to pupils, for instance, an outside person visiting on a regular basis, the use of videos, films and literature.
The degree of interest in knowing more about AIDS

The way in which information should be given
The respondents who answered "Yes" to the previous question, namely 864, had to mark their preference on the way in which the information should be given.The ones that answered "Uncertain" or "No" were thus not included in the following table.

Manner of information Frequency
In

CONCLUSIONS
There is an urgent need among adolescents for more knowledge and information on sexuality and HIV/AIDS in general.
The idea of using condoms has been accepted by adolescents.
Respondents have a fair to positive attitude to the problemfactual and correct knowledge on HIV/AIDS will, however, sustain a knowledgeable attitude.
Information should preferably be given by an outside person on regular occasions by way of aids and facilities like videos, films, flip charts, books and posters.
The vast majority of adolescents preferred mixed boys and girls groups for the group sessions on sexuality and HIV/AIDS.

RECOMMENDATIONS
It is recommended that a programme be developed to educate adolescents about sexuality and HIV/AIDS in an objective and factual manner.This programme should encompass aspects like human sexuality, sexual functioning, the correct use of condoms, the immune system, ways in which HIV transmission can take place, knowledge on HIV/AIDS and attitudes towards the problem.
It is also recommended that outsidersmeaning not a teacher from the specific schoolbe utilised to implement such a programme.The ideal would be to recruit and train specific persons to do this task.
The programme can be offered in a number of sessions with regular intervals with the same facilitator in mixed adolescent boys and girls groups of the same age.On specific occasions it might be deemed necessary to have separate discussions for boys and girls.
Material and facilities like videos, films, flip charts, books and posters are indispensable in any programme on HIV/AIDS.This is specifically important in working with adolescents in a group context.A variety of aids already exist that have been developed nationally and internationally.As part of the development of the correct material for such a programme, all the existing material should be investigated and scrutinised for their suitability.If the existing material or part of it is found to be suitable for the purpose of this programme, the relevant material should be developed and put at the disposal of the facilitators of this programme.
It is important to give the programme an indigenous character for use in South African circumstances.It should be kept in mind that not all schools have all the necessary facilities at their disposal.The programme should therefore be adaptable to any circumstances (for instance, the non-availability of electricity at some schools).

TABLE 5 INTEREST IN KNOWING MORE ABOUT AIDS
It is obvious from Table6that the majority of respondents, almost 71%, preferred to gain the knowledge in a mixed boys and girls group context, while 15% and 14% of respondents mentioned that they would like to gain the knowledge by way of individual discussion and in separate boys and girls group context, respectively.