Knowledge, Attitude and Behaviour Related to Sexually Transmitted Infections in Portuguese School (Adolescent) and College Students

The latest Portuguese report from the national monitoring center of sexually transmitted diseases (CVEDT, 2009) states that the total number of cumulative cases of HIV/AIDS was about 35 thousand with about 15 thousand of these being cases of AIDS. From the analysis of the distribution of the cases of AIDS according to the transmission categories, it appears that 40% are cases associated with heterosexual transmission. In fact, statistics suggest that the cases of AIDS confirm the epidemiological pattern recorded annually since 2000, that is, there is a proportional increase in the number of cases of heterosexual transmission.


Introduction
Many adolescents in Portugal experience serious health and social problems related to sexually transmitted infections (STIs).Sexually transmitted infections are spread by sexual contact.Treatment is available for most STIs but prevention of these diseases is the preferable option, since they can have serious, long-term, health and social implications.Prevention is the way to control STIs.
The goals of this chapter are to analyze knowledge, attitudes and behaviours related to sexually transmitted infections in Portuguese school (adolescent) and college students.

STIs: Why is it a problem?
Globally, over 100 million STIs occur each year in people under the age of 25 years old (UNAIDS, 2008), and an estimated 11.8 million people aged 15-24 were living with HIV by mid-2002.Further, about half of all new HIV infections worldwide, or nearly 6,000 cases per day, occur in young people (UNAIDS, 2008).
The latest Portuguese report from the national monitoring center of sexually transmitted diseases (CVEDT, 2009) states that the total number of cumulative cases of HIV/AIDS was about 35 thousand with about 15 thousand of these being cases of AIDS.From the analysis of the distribution of the cases of AIDS according to the transmission categories, it appears that 40% are cases associated with heterosexual transmission.In fact, statistics suggest that the cases of AIDS confirm the epidemiological pattern recorded annually since 2000, that is, there is a proportional increase in the number of cases of heterosexual transmission.
Young people are particularly vulnerable to STIs and consequent health problems because:

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They lack information about how to prevent STIs; According to UNAIDS (2008), some strategies to reduce STIs: -Provide teens with the information, skills, and support they need to practice safe sexual behaviour.This programme should be tailored to youths' needs and age appropriate, culturally sensitive and teach sexual and reproductive options.Build on current knowledge of best practices by emphasizing communication, skill-building activities, and role-playing.-Educate adolescents and young people about the risks of sexually transmitted diseases, including HIV/AIDS.Incorporate promising strategies into comprehensive STIs prevention programs including: individual and peer education, counseling, case management, after school activities, and building support systems and relationships with caring adults.-Increase access to reproductive health care.Encourage all health care providers who provide care to youth to include comprehensive, age-appropriate information on sexual health issues, including prevention of STIs.Make confidential STI screening and treatment services easily accessible to teenagers along with culturally sensitive counseling and education regarding the use of available protective measures.

Sexual behaviour, knowledge and attitudes
Many adolescents and young adults engage in sexual intercourse, often with multiple (sequential) sex partners and without using condom.In 2006, 22.7% of high school students in Portugal reported having had sexual intercourse (Reis et al., 2011), with a majority (71.1%) reporting having had sexual intercourse for the first time at 14 years old or later.In a US research, 47.8% of high school students reported having had sexual intercourse (Eaton et al., 2008), with 7.1% reporting having had sexual intercourse for the first time before age 13.Early initiation of sexual activity has been pinpointed as an important indicator in terms of sexual health (Centers for Disease Control and Prevention, 2010;UNAIDS, 2010;WHO, 2010).Some studies even report that early sexual activity is associated with other risk behaviours, such as substance use (Madkour et al., 2010).
Although most adolescents do not have concurrent sex partners at any given point in time, the number of sex partners cumulates over time.Moreover, among sexually active young adults, only 81.3% (Portuguese survey) and 61.5% (U.S. survey) reported using a condom the last time they had sexual intercourse (Reis et al., 2011;Eaton et al., 2008).In spite of the fact that many have used condoms at some time during an episode of sexual intercourse, comparatively few report using them every time they have sex (Reis et al, 2011;Eaton et al., 2008).Thus, young adults engage in sexual behaviours that place them at risk for acquiring STIs, including HIV.
According to literature, if young people possess knowledge, information and motivation on safe sexual behaviour, they may change their attitudes and their behaviours (Synovitz et al., 2002;Thompson et al., 1999).Improving knowledge related to HIV prevention and attitudes about people living with HIV are other important aims of sexual and reproductive health.Some theories claim that being well informed about transmission/preventive behaviours regarding HIV and other STIs and developing a positive attitude towards people infected with HIV are crucial to change people's behaviours.

Study 1: HBSC -Health Behavior in School-aged Children
The Health Behavior in School-aged Children (HBSC) is a collaborative WHO study, developed by 44 countries in order to study school-aged behaviour regarding health and risk behaviours in adolescence.Portugal is part of this group since 1996 (Currie et al, 2000).

Sample
The 2010 study provides national representative data of 5050 Portuguese adolescents, randomly chosen from those attending 6 th , 8 th and 10 th grade of high school.The sample included 52.3% girls and 47.7% males, whose mean age was 13.98 years (standard deviation 1.85).The majority of adolescents are of Portuguese nationality (94.4%), 30.8% attended the 6th grade, 31.6%attended the 8 th grade and 37.6% attended the 10 th grade.This study uses a subset of 8 th and 10 th graders (n=3494  The procedure followed for school and college students was similar.Data were collected through a self-administered questionnaire.In study 1, data were collected from the Portuguese sample of the Health Behavior in School-aged Children (HBSC) and all procedures were followed according to the international research protocol.Study 2 -the Sexual and Reproductive Health in University Students (HBSC / SRHCS) -is an extension of the HBSC.The sampling unit used in these surveys was the class.The 139 schools/19 colleges in the samples were randomly selected from the official national list of schools/colleges, stratified by region (North, Center, Lisbon and Tagus Valley, Alentejo and the Algarve) in the mainland.In each school /college, classes were randomly selected in order to meet the required number of students for each grade.The surveys are nationwide and were conducted in 2010 for the Ministry of Portuguese Health and for the National Coordination for HIV/AIDS Infection by the Technical University of Lisbon.These studies have the approval of a scientific committee, the Ethics National Committee and the National Commission for Data Protection and followed strictly all the guidelines for human rights protection.

Measures (study 1 and 2)
For the purpose of these studies, the following parameters were assessed as detailed below:

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Attitudes towards HIV/AIDS infected people.Young people were asked to respond to five statements about attitudes towards HIV-infected people: 1. «I wouldn't be a friend of someone if he had AIDS», 2. «Adolescents with AIDS should be allowed to go to school», 3. «I would sit near an infected student in classroom», 4. «I would visit a friend if he or she had AIDS» and 5. «HIV infected people should live apart of the rest of people».Items were rated on a 3-point rating scale (1= disagree to 3= agree).After recoding items 1 and 5, final scores ranged from 5 to 15, with high scores suggesting more positive attitudes.
Attitudes towards condom use.Adolescents and young adults were asked to respond to four statements: 1. « It would be embarrassing to buy condoms in a store», 2. « It would feel uncomfortable carrying condoms with me.», 3. «It would be wrong to carry a condom with me because it would mean that I' m planning to have sex» and 4. « It would feel uncomfortable to ask for condoms at health care services.».Items were rated on a 3-point rating scale (1= disagree to 3= agree).After recoding all items, final scores ranged from 4 to 12, with high scores suggesting more positive attitudes.

Results
Analyses and statistical procedures were carried out in the Statistical Package for Social Sciences program (SPSS, version 19.0 for Windows).The total numbers differ according to sample use (8 th and 10 th grade sample; 8 th and 10 th grade adolescents who reported having had their first sexual intercourse) and considering that some adolescents have not replied to some parameters.
Overall, questionnaires were responded by the subset of 8 th and 10 th graders (3494 participants), between 13 and 21 years old.Findings show the majority is not sexually active (78.2%).There is significant variation by gender since boys more often have had sexual intercourse than girls ( 2 (1) = 57.31;p = .000).Of the ones that refer having already had their first sexual intercourse, 68.9% referred that it happened when they were 14 or more.The results showed that, despite both the majority of boys (63.1%) and girls (77.1%) having had their first sexual intercourse at the age of 14 or later, boys more often claim to have started younger (at 11 or less and between 12 and 13) ( 2 (2) = 19.63;p = .000).93.8% refer having used the condom in the first sexual intercourse.As for the last sexual intercourse, 95.2% refer they have used condom.Significant variation was obtained between genders in relation to condom use in first sexual intercourse ( 2 (1) = 4.19; p = .041)with girls referring more frequent use of the condom (96.2%) than boys (91.9%).
Results showed that the majority (87.3%) did not have sexual intercourse under the effect of alcohol and drugs.Yet, boys did it more frequently than girls ( 2 (1) = 11.76;p = .001),see table 2.

Study 2: Sexual and Reproductive Health in University Students (HBSC / SRHCS)
A nationwide survey was conducted for the Ministry of Portuguese Health and for the National Coordination for HIV/AIDS Infection to assess HIV/AIDS-related knowledge, attitudes, and practices among the population aged 18-35 years.The aim of this research was to identify those behaviours that put young people at risk of HIV infection.Disseminating the findings is also crucial since it may potentiate an advocacy tool in order to mainstream HIV/ AIDS prevention programs at university level.Therefore it is also expected that it can help catalyze a more effective role for universities to fight against diseases as well as contribute to build intervention strategies that raise public awareness.

Sample
The The total numbers differ considering that some young adults have not replied to sexual orientation.

Results
Analyses and statistical procedures were carried out in the Statistical Package for Social Sciences program (SPSS, version 19.0 for Windows).The total numbers differ according to sample use (complete sample; young adults who reported having had their first sexual intercourse) and considering that some young adults have not replied to some parameters.
Structured self-reported questionnaires were responded by 3278 participants, between 18 and 35 years old.From the total sample, 83.3% (N=2730) young people have already begun their sexual life.Men reported more often than women having had sexual intercourse ( 2 (1) = 29.15;p = .000).Of these, 79.2% referred that they have had their first sexual intercourse at the age of 16 or later and 86.8% used the condom in their first sexual intercourse.The results showed that, despite both the majority of men (72%) and women (82.5%) having had their first sexual intercourse at the age of 16 or later, men most often claim to have started younger (at 11 or less, between 12 and 13, and between 14 and 15) ( 2 (3) = 60.05;p = .000).
Men reported more often having used condom in the first sexual intercourse than women ( 2 (1) = 18.56; p = .000).It was also observed that among the students who already have sexual intercourse, 69% use condom usually.Significant variation was obtained between genders in relation to usual condom use ( 2 (1) = 4.41; p = .036).Regarding genders, men refer more frequent usual use of condom (71.7%) than women (67.7%).When asked about frequency of condom use on last 12 months, only 32.6% refer using it always.Results showed that the majority of men (57.4%, 53.1%, 10.7%) have occasional sexual partners and   In bold -values that correspond to an adjusted residual ≥ │1.9│ Table 10.Differences between gender and attitudes towards condoms.

Conclusions
Regarding sexual behaviours, overall, findings show the majority of Portuguese adolescents (13-21 years old) is not sexually active (78.2%), while the majority of Portuguese young adults are (83.3%).Young Portuguese adults (18 -35 years old) reported having had their first sexual intercourse at 16 years old or later.As for Portuguese adolescents, they reported it happened at 14 or more.This suggests that there is a tendency for anticipating time of sexual initiation.These results are comparable to those that have been found in a similar nationwide US research, the Youth Risk Behavior Surveillance, with 64% of young Americans (10 -24 years old) referring not being sexually active (CDC, 2010).These may be considered similar since the age interval is broader, therefore lowering frequency of sexual activity.As for age of sexual onset, the average age for 16-20 year-olds in European countries in 2004 was 16.5 (Global Sex Survey, 2005), thus confirming our results regarding young adults.In a more recent research, 16-19 year old Brazilians reported their sexual debut to have been at 14.9 years old.(Paiva, V.; Calazans, G.; Venturi, G.; Dias, R.; & Grupo de Estudos em População, Sexualidade e AIDS, 2008.) The rates of condom use during first sexual intercourse were very high among both Portuguese adolescents (93.8%) and young adults (86.8%).Yet, they clearly are not consistent since only 69% of young adults claim using the condom usually and only 32.6% refer using it always on last 12 months.Therefore, this suggests that protective behaviours are abandoned over time.These results seem much more promising than those of a Brazilian research (Paiva, V.; Calazans, G.; Venturi, G.; Dias, R.; & Grupo de Estudos em População, Sexualidade e AIDS, 2008), where only 65.6% of adolescents reported having used condom during first sexual intercourse.
Considering other risky behaviours, such as having had occasional sexual partners, 33% (this was asked to college students only) of young Portuguese adults reported it.These results represent higher risk than those presented by an American study (Eisenberg, Ackard, Resnick & Neumark-Sztainer, 2009) with 21.5% of young adults (median age 20.5) reporting having had occasional sexual partners.
Results showed that the majority (87.3%) of Portuguese adolescents did not have sexual intercourse under the effect of alcohol and drugs, whereas the majority of young adults (53.1%) reported the situation, considering alcohol alone.The findings related to Portuguese adolescents are confirmed in the YRSB research (CDC, 2010), with 78.4% stating not having had sexual intercourse under the effect of alcohol and drugs.As for having sexual intercourse under the effect of drugs alone, the frequency of young Portuguese adults who reported it is lower (10.7%),though serious.It was also asked to young adults if they had ever had an STI and 3.3% reported having already had an STI.
In both Portuguese studies, there is significant variation by gender since boys and men more often have had sexual intercourse, claim to have started their sexual life younger, reported having had occasional partners (young adults), having had sexual intercourse under the influence of alcohol or drugs than girls and women.Conversely, in relation to condom use in first sexual intercourse, Portuguese adolescent girls referred more frequent use of the condom (96.2%) than Portuguese boys (91.9%), which was not observed in the young adults' study.These variations by gender suggest boys and men engage in risky sexual behaviours more often than girls and women.These findings are confirmed in other studies: American boys and men initiated their sexual life younger (16.9 years old) than girls and women (17.4 years old) and stated more often (29% Vs. 14%) having had occasional partners (NSSHB, 2010;Eisenberg, Ackard, Resnick & Neumark-Sztainer, 2009).
As for knowledge regarding HIV/AIDS transmission/prevention, the total mean score of general HIV/AIDS knowledge was 5.32 among Portuguese adolescents and 7.82 among Portuguese young adults, out of 9 points.The results reveal significant variation in responses by gender: girls (M = 5.58, SD = 2.49) and young women (M = 7.90, SD=0.90) demonstrated significantly more knowledge than boys (M = 5.02, SD = 2.69) and young men (M = 7.65, SD=1.33).So, overall, results revealed the majority has a moderate/high level of www.intechopen.comknowledge but boys and young men showed bigger risk acceptance, while girls demonstrated better knowledge in relation to risk-taking.Overall, most studies reveal a moderate / high level of knowledge: in a South African study (Bana et al., 2010), 56% of 15-24 year-olds reported good knowledge level about HIV/AIDS transmission and in an Iranian study, the knowledge level was considered moderately high (Tavoosi, Zaferani, Enzevaei, Tajik & Ahmadinezhad, 2004).
In STI and HIV infections in adolescents are at epidemic levels worldwide.As long as adolescents continue to engage in sexual behaviours that place them at risk for STI/HIV (e.g., sex without a condom and with multiple sequential sex partners), they will be vulnerable to these health threats.For reasons outlined above, a few of which are amenable to change, adolescents may be especially susceptible to STI/HIV.It is a public health imperative that we incorporate successfully demonstrated strategies from past prevention efforts into current adolescent STI/HIV prevention programs and that we also continue to search for new ways to protect our youth, as well as teach them to protect themselves from STI/HIV infections.
One of the most important facts is that condoms provide the best protection from STIs, including HIV.Condoms must be used consistently and correctly in each act of intercourse (DGS, 2004).
Researchers (Mueller, Gavin & Kulkarni, 2008) advocate that sexual activity during adolescence years may be a risk behaviour since adolescents are still going through their maturity (physical, emotional and psychological) process and therefore it should be part of intervention programs (mainly through sex education) to postpone the initiation of sexual activity.As a result, it is also acknowledged the potential contribution of sex education to increase condom use (Kirby, Laris & Rolleri, 2007;Mueller, Gavin & Kulkarni, 2008) as well as decrease sexual intercourse associated to alcohol or drugs (Madkour et al., 2010).
Because the rates of HIV/AIDS, particularly in young people, have always been on the top concerns (UNAIDS, 2010), increasing the level of knowledge related to HIV transmission routes and prevention and developing positive attitudes towards HIV infected people have similarly been prioritized as sex education goals (Kirby, Laris & Rolleri, 2007).These studies show that both adolescents and young adults have reasonable knowledge regarding HIV/AIDS transmission/prevention and show positive attitudes towards HIV infected people.
Overall, sexual health is a topic that requires intervention.During the last decades, since AIDS has revealed itself as a major world problem, governments, including the Portuguese, have dedicated time and money to promote safer sexual and reproductive health.The implementation of sex education may be an important part of the solution for this problem.
Our analyses suggest that overall the Portuguese youth have safe sexual behaviours, but there is still a need to improve since not all refer having protective behaviours, therefore putting themselves at risk of major negative consequences in terms of public health (Ramiro, Reis, Matos, Diniz, & Simões, 2011).The data from these two studies also clearly show the existence of a set of factors that determine individual differences in the performance of preventive sexual behaviours.It seems that boys and young adult males have a higher probability to get involved in risky sexual behaviours.
One of the most frequently studied factors is STI's knowledge, namely regarding HIV and AIDS.Though most studies reveal that knowledge is crucial, being informed is not enough in order to change people's behaviours.Beliefs related to condom use (such as "decreasing sexual pleasure"), attitudes (positive or negative), the perception of support from meaningful people (relatives, peers, among others), parental attitudes and behavioral skills related to communication, assertiveness, negotiation, self-efficacy) and the intention of having preventive sexual behaviours always are extremely important conditions when trying to explain differences in behaviours (Matos et al., 2010;Carvalho, & Baptista, 2006;Kirby, 2001).A crucial issue on this subject is the perception of risk that young people have, in other words, the least they consider they are at risk (somehow an extension of the sense of invulnerability which is characteristic of adolescence) and therefore the potential consequences of their behaviours, the greatest the likelihood of getting involved in risky behaviours.
Figures regarding the variety of sexual risky behaviours and the variety of factors involved in the performance of preventive sexual behaviours increase the importance of implementing programs and campaigns that aim specifically to change behaviours and promoting sexual and reproductive health (Matos, 2008;Matos et al, 2011).Most programs have youth as target population regardless genders and they are designed to be implemented in school context.In some cases, teachers and parents are also considered as important agents in youth change and peers may be used as opinion leaders (Matos, 2008).
It is fundamental to comprehend sexuality within the context of adolescence if we want to avoid unwanted or unplanned pregnancy in adolescence, abortion and STIs in general and HIV/AIDS in particular.Sexuality has an important role in adolescents' growth and development so their guidance is essential to enhance a positive, harmonious and responsible adolescence (Matos et al., 2011).
I n o r d e r t o f u l l y u n d e r s t a n d a d o l e s c e n c e , one has to consider the social, family and individual contexts where the adolescent interacts as well as the ways individuals organize sexual experiences.This means that the way adolescents relate sexually to others is deeply influenced by family and social models.
Considering that primary prevention is the one that aims to change behaviours, the evaluation of specific needs must consider the importance of social norms and peer groups, and the development of cognitive and behavioral skills that are essential to promoting and maintaining change.Sex education in health education context requires that the agents involved, whether direct or indirectly (family, schools, communities, institutions, NGOs, city councils, public and private institutes, and places of leisure and entertainment) gain awareness of their importance in young people's development.
Discussing sexuality with a youth audience is not an easy task.Overall, there's a huge difference between what they want to discuss and what adults consider is adequate or important to discuss with them.The main problem of sexuality in adolescence is lack of dialogue because some of the most important issues for them, such as the discovery of their own body, pleasure and their inner self are still taboo matters.
In order to enhance communication with adolescents and young people in general, both in school and university context, it must be developed an environment of understanding, empathy, truthfulness and genuine acceptance and respect for the adolescent/ young adult and his /her doubts, free from judgments.Therefore, the key point identified by experts is meaningful dialogue.

Table 4 .
Differences between gender and attitudes towards HIV-infected people.Knowledge, Attitude and Behaviour Related to Sexually Transmitted Infections in Portuguese School (Adolescent) and College Students 207 www.intechopen.com1The total numbers differ considering that some adolescents have not replied to some paremeters.*p≤0.05;**p≤0.01;***p≤0.001In bold -values that correspond to an adjusted residual ≥ │1.9│

Table 5 .
Differences between gender and attitudes towards condoms.
sample is composed of 3278 Portuguese college students, between 18 and 35 years old, randomly chosen from those attending university during the academic year of 2009/2010.

Table 7 .
Differences between gender and risky sexual behaviours.

Table 8 .
Differences between gender and knowledge regarding HIV/AIDS transmission/prevention. Attitudes towards HIV-infected people: the distribution of each item is shown in Table9.
www.intechopen.com1The total numbers differ considering that some young adults have not replied to some parameters.*p≤0.05;**p≤0.01;***p≤0.001 (Kirby, van der Sluijs & Currie, 2010)Ahmadinezhad, 2004)an total score was 12.84 (SD= 2.24) among Portuguese adolescents and 14.61 (SD= 1.03) among Portuguese young adults.Final scores ranged from 5 to 15 points.The results reveal significant variation in responses by gender, with boys (M = 12.42, SD=2.35) and young men (M = 14.42,SD=1.28)showingsignificantlylesspositiveattitudesthangirls (M = 13.19,SD=2.09)andyoungwomen(M=14.69,SD=0.90).So, overall, results revealed the majority has a moderate/very positive attitude towards HIV infected people but boys and young men showed less tolerance, while girls demonstrated more tolerant attitude.Results are much higher than in an Iranian research with 15 -17 year old students, where an intolerant attitude towards HIV infected people, especially when boys were concerned, was observed(Tavoosi, Zaferani, Enzevaei, Tajik & Ahmadinezhad, 2004).As for attitudes towards condoms, the mean total score was 8.73 (SD= 2.50), among Portuguese adolescents and 10.10 (SD= 2.08) among Portuguese young adults.Final scores ranged from 4 to 12 points.The results revealed significant variation in responses by gender among adolescents, with boys showing significantly more positive attitude (M = 8.86, SD=2.53) than girls[(M = 8.63, SD=2.46).So, overall, results revealed the majority has a moderate/very positive attitude towards asking for, buying and carrying condoms but girls showed more difficulty in those behaviours than boys, who demonstrated a more proactive attitude.The Portuguese results are corroborated in the HBSC Scottish national sample, both in relation to overall attitude towards condom and for gender differences(Kirby, van der Sluijs & Currie, 2010).