High risk behaviours and beliefs and knowledge about HIV transmission amongst school and shelter children in Eastern Eur

1. High risk behaviours and beliefs and knowledge about HIV transmission amongst school and shelter children in Eastern Europe Robin Goodwin, School of Social Sciences and Law, Brunel University, London • George Nizharadze, Iago Kachkachishvili, Georgian Academy of Sciences • Alexandra Kozlova, Dmitri Isaev, St Petersburg State University • Galina Polyakova, Inna Kiriluk, Research Centre for Social Policy, Kiev, Ukraine • Peter Allen, University of Surrey • Anu Realo and Andu Rammer, Tartu University, Estonia • Ann Buysse, Ghent University, Belgium INTAS (EU) 2000-085, 2001-2004. Innovation Extension (INTAS) 2006-2008

2. The hidden epidemic?… • HIV epidemic now spreading rapidly in FSU. However, has received relatively little attention- the ‘hidden’ epidemic. • Approximately 1.6 million people in Eastern Europe and Central Asia were living with HIV in 2005, an increase of 20-fold in less than a decade. • Bulk of infection in Russia (c. 1.1%) and Ukraine (c. 1.5% prevalence). • Georgia high risk and part of emerging epidemic.

3. Homeless children: a high-risk population • Greatest infection amongst the young. Estimated 1% of young people in the region injecting drugs and 80% of new HIV/AIDS infections amongst people aged under 30 • Studies elsewhere suggest homeless children at particularly high risk • However, no research in Eastern Europe on this

4. Understanding high risk behaviours • Theorists from a number of different perspectives recognise need to understand the role of specific values in predicting high risk behaviours (e.g. work on sensation seeking & multiple partners) • Additionally, cultural norms recognised as significant in range of major health models e.g. theory of planned behaviour and theories of lay/ social representations

5. Social representations • Social Representations: collection of different folk theories, common sense and everyday knowledge. Justify actions, explain ‘moral panic’ ‘Out-groupings’ often associated with epidemics • Communication processes key: spreading of rumours and myths of interest, as is manner complex medical (e.g. HIV) become ‘familiar’ and anchored in existing prejudices .

6. Current work on sexual health combines these approaches by: • Examining specific individual values and beliefs that underlie high risk behaviours, using • Semi-structured interviews • Questionnaire analyses of cultural values • Societal myths and beliefs surrounding HIV and high-risk behaviours, using • Semi-structured interviews • Questionnaires • Focus groups • Media analyses

7. Extensive piloting of instruments with matched sample (N = 150, 50 in each country, including 50 homeless). Questionnaire and interviews (structured and open-ended). Media analysis Focus groups This project was in several stages

8. Questionnaires and interviews • 1531 children aged 13-17 from Russia, Georgia and Ukraine (min. 500 from each). 502 of these children were shelter children (split evenly across countries). • Completed interviews and questionnaires in shelters or school setting

9. Participant recruitment: schools Multistage • Ethical approval from regional educational authorities, schools and relevant universities • Large meetings held with parents explaining purpose and methods of study • Letters given to children asking for parental permission • Follow-up calls to check actual permission (!) • Interviews and questionnaires in private classroom setting under supervision of trained researchers.

10. Shelter recruitment: • Contact with NGOs (e.g. Doctors of the World) • Ethical approval from shelter managers and psychologists in shelters (and relevant universities) • Children selected on condition that lived on street and came to shelters to obtain food, or lived in shelters • Interviews and questionnaires in private classroom in shelters and free canteens.. • All respondents paid $5 for their co-operation: money given to adolescents in a supervised fashion in local shops (risk of drug purchase).

11. Participants by country, status, age and gender

12. Measures I: Knowledge of HIV/AIDS and representations • Knowledge of infection inventory • 10 item ‘Representations of HIV/AIDS’ questionnaire, using representations from our earlier work in this region. E.g. • It is possible to ‘get better’ if you are infected • Only particular groups gets AIDS (the ‘ill-living’ (neParadashni), homosexuals) • You can tell by looking if someone is infected • A girl should not refuse sex with her partner

13. II: Values and Beliefs • Schwartz’s individual-level values (PQIV, 40 items measuring 10 values. 2 dimensions: open to change vs. conservation; self-transcendence vs. self-enhancement, plus hedonism) • Fatalistic beliefs scale (Goodwin et al, 2002): 11 items on 10-point scale (overall  = .70). E.g. Life is like a lottery

14. Open-ended interview questions: include • How do people get infected with AIDS? • Where did you learn about AIDS? • Who have you ever discussed HIV/AIDS with? (list e.g. friends/ family/ teachers/ doctor) • Do you think that you are likely to get HIVAIDS? Why do you give that answer? • What kind of person gets HIV/AIDS? • How do people avoid getting HIV/AIDS? 

15. DV: Sexual behaviour • Have you ever had penetrative sex? • With how many partners? • With members of same/ opposite sex? • Did you use condoms always/ usually/ sometimes/ never • Did you ask about your partner’s sexual experience? • Have you had an STD? • Have you ever received gifts (money, food etc.) for sex?

16. DV: Injecting drug use • Have you ever injected drugs? • Did any of your previous partners/ your partner inject drugs

17. Findings (I): Knowledge • Most children knew what AIDS was, calling it a deadly and infectious disease • Most respondents saw sexual transmission as the main route of infection, although in subsequent questions > 90% respondents in Russia and Ukraine knew infection through drugs possible • Georgian respondents least knowledge about HIV infection e.g. only 60% Georgians (vs. > 85% of others) knew it was not possible to contract AIDS through shaking hands, and one third thought “people with AIDS eventually get better”. • Street children were significantly more ignorant about HIV transmission routes.

18. Findings (II): Sexual behaviour • 40% of shelter children vs. 29% school children reported having had penetrative sex • 36% of Russians • 33% Ukrainians • 29% Georgians • Culture effect persists when age is controlled

19. Interaction effect: sexual behaviour, country x participant group

20. Findings (III): Sexual behaviour • 57% with sexual experience had > 1 partner. Multiple partners were most likely amongst street children in Ukraine • 46% had asked partner about sexual activity • Georgian respondents and street children were least likely to report using condoms • Knowledge of AIDS does not predict sexual contact (r = .00) or drug use (r = -.01) .

21. Findings (IV): IDU • Less than 2% of the school children, but 6.5% of the street children admitted to having injected drugs • Less than 1% of Russian or Ukrainian school children admitted to injecting drugs but 9% of street children in these two countries admitted IDU.

22. Interaction effect: Injecting drug use. Country x participant group

23. Representations of HIV/AIDS: Percentage agreeing with statement

24. Hedonistic values and sexual behaviour • Hedonism most interesting predictor of sexual behaviour here and in our previous work • Hedonism highest in Russia and lowest in Georgia. • Probability of sexual behaviour also higher in Russia, especially when we allow for age. • Country differences in sexual behaviour are at least partly mediated by hedonistic values.

25. Fatalism and sexual behaviour Controlling for participant’s age, fatalists : • Likely to report > 1partner • Reported larger number of partners. • Reported previous injecting drug use • Reported less condom use • Viewed condoms as less important • Less likely to ask their partner about previous sexual experience • Less likely to ask multiple partners about sexual experience.

26. Brief conclusions from interviews and questionnaires: I • Greater sexual behaviour amongst those in shelters, and greater ignorance about risk factors. • Shelter children may be ‘overwhelmed’ by fear of non-risky behaviours (e.g. shaking hands or kissing on the cheek) possibly reflecting their generally higher perception of risk • Russians the most sexually experienced group. Hedonism may partly explain this and reported elsewhere.

27. Brief conclusions II: • School children in Georgia more sexually active and likely to use drugs • Georgians most likely to believe that ‘People should not worry too much if they get HIV/AIDS because eventually they will get better’ and ‘A woman who carries a condom is easy’. Reflects wide gender-role distinctions in this country? • Only small correlation between knowledge of HIV risks and sexual experience or drug use • Fatalism and hedonism significant predictors of sexual risk taking and drug use

28. Part 2: Media analysis… • Previous work on representations of HIV/AIDS has examined media representations as a clue to the spread of representations. • We conducted detailed content analysis of magazines and TV and radio programmes most read/ viewed by participants. • Team read two most frequently read newspapers per country and analysed TV newscasts on two days (1 Dec 2003 and matched day). • 543 newspapers and magazines read over 6 months, 30 TV and radio programmes analysed on key dates.

29. 112 ‘media outputs’ mentioned HIV/sexual behaviour/drugs/condoms • 53 newspaper articles • 48 magazine articles • 7 TV reports • 4 Radio reports • 50% feature articles, 23% news reports.

30. Media coding included: • Length of article/ broadcast • Article type (feature article, news report etc.) • Placement of article in newspaper (position in newscast) • Authorship (printed media) and figures interviewed • Use (and description) of images • Key topics (HIV/ drugs/ sexual behaviour/ STDs/ condoms) • Tone and style of article

31. Some brief findings • 75% in main sections of the newspapers • Half articles specifically mentioned the country of study. • Authorship mainly by journalists (38%) or professionals (29%). • Most neutral (52%) or overtly pessimistic (24%) in tone • 75% newspaper articles serious in style of presentation. But magazine articles more ‘playful’ in manner.

32. Brief media themes Russia Focus in youth media mainly on overseas personalities, whilst Russia newspapers warned of dangers of drugs and sexual disease. Much in the format of reader’s letters / question Georgia Most coverage ‘in passing’, largely in context of other countries Ukraine Problems of own country (particularly drugs and sex trade). Articles longer and more feature articles.

33. Focus group analysis. Design the same for each of the three countries (total of 36 focus group meetings)

34. Focus group content: • Meeting 1. • Questionnaire on sexual behaviour and drug use, representations of HIV/AIDS and knowledge about epidemic. • General discussion about HIV. Free associations around HIV/AIDS • Meeting 2 (+ 3 months). • Discussion of media representations and analysis of leaflets • Meeting 3 (+ 3 months). • Questionnaire on sexual behaviour and drug use, representations of HIV/AIDS and knowledge about epidemic. • Discussion of intervention strategies for young people.

35. Brief Focus Group findings • Significant knowledge-change effects. Those in focus groups significantly more likely to have increased their knowledge about the epidemic and its spread compared to the control group • Some representational change Those in focus groups now less likely to believe ‘it is the non-proper who get AIDS’ and ‘safe sex is not necessary when you trust someone’ • Complex behaviour change Shelter children reported fewer partners, but not the expected effect for school children. No effects for condom use or drug injection (floor effect)

36. Further focus group findings: • Little evidence of clear ‘outgrouping’ in discussions • Fear of contamination in medical settings, and accidental contamination from needles in parks etc. in the Ukraine. Complaints about high price of reliable condoms • Some confusion about overt symptoms of virus, with some of the Georgian schoolgirls arguing personal hygiene was important. In contrast, some free associations with HIV amongst the girls in shelters in Russia were more with madness

37. All focus group participants said found group meetings a positive experience and discussed the issues raised in the groups with their friends although school boys in George most resistant to fully participating in the meetings. • Adolescents generally recommended more media information, but presented in a light-hearted way.

38. So what might all this mean? • More data to be ‘mined’ – analysis currently superficial. • Significant cultural and group (shelter vs. school) differences in sexual behaviour and knowledge of and representations of HIV/AIDS. This at least partly explained by differences in hedonistic values. • Media portrayals also appear to differ between countries, with little detailed discussion of the epidemic in Georgia and Russian youth media focusing more on overseas stories

39. Conclusions (2) • Focus group intervention seems to influence the behaviour of the Russian and Ukrainian shelter children but did not have the desired impact on school children. Notably, information on HIV was more available for shelter than school children in Georgia. • All focus groups members however increased knowledge of epidemic and reduced some misrepresentations.

40. Conclusions (3) • Cross-cultural researchers should continue to use multiple methods to help interpret the individual, sub-group and cultural level influences that might influence sexual behaviour. • Aim for reciprocal designs, so that, for example, quantitative differences can be ‘unpacked’ using qualitative methods, helping form questions to be tested in further quantitative analyses

41. Extension project (INTAS 2006-8) • Georgian school children most ignorant about HIV, and higher rates of drug use and less condom use • Currently we are working on a small grant extension with television writers and producers on a small project to create posters, leaflets and short TV advertisements to be shown in Georgia. • We also will conduct focus groups across the country aimed at challenging some of the myths currently held in school populations

42. For a copy of today’s talk, and references…. Please follow the link on my website to my University homepage… www.culturefirst.com