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
The hidden epidemic?…
• HIV epidemic now spreading rapidly in FSU.
However, has received relatively little attentionthe ‘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. 1.4% prevalence).
• Georgia estimated figures are only around 5600
adults and children living with HIV (2005) but
high risk and part of emerging epidemic.
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
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
Social representations
• Social Representations: collection of different folk
theories, common sense and everyday knowledge.
Justify actions, explain ‘moral panic’ ‘Outgroupings’ 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 .
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
This project was in several stages
• 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
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
Participant recruitment: schools
Multistage
1. Ethical approval from regional educational
authorities, schools and relevant universities
2. Large meetings held with parents explaining
purpose and methods of study
3. Letters given to children asking for parental
permission
4. Follow-up calls to check actual permission (!)
5. Interviews and questionnaires in private
classroom setting under supervision of trained
researchers.
Shelter recruitment:
1. Contact with NGOs (e.g. Doctors of the World)
2. Ethical approval from shelter managers and
psychologists in shelters (and relevant
universities)
3. Children selected on condition that lived on
street and came to shelters to obtain food, or
lived in shelters
4. Interviews and questionnaires in private
classroom in shelters and free canteens..
5. All respondents paid $5 for their co-operation:
money given to adolescents in a supervised
fashion in local shops (risk of drug purchase).
Participants by country, status, age
and gender
Georgia
N
Russia
Ukraine
Home
Shelter Home
Shelter Home
Shelter
324
178
353
176
352
148
52
48
55
50
50
15.3
15.4
14.8
15.5
15.5
%
48
Male
M age 15.6
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’ (ne
Paradashni), homosexuals)
• You can tell by looking if someone is infected
• A girl should not refuse sex with her partner
II: Values and Beliefs
• Schwartz’s individual-level values (PQIV).
Of interest here are hedonistic values
• Fatalistic beliefs scale (Goodwin et al,
2002): 11 items on 10-point scale (overall 
= .70). E.g. Life is like a lottery
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?
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?
DV: Injecting drug use
• Have you ever injected drugs?
• Did any of your previous partners/ your partner
inject drugs
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.
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
Interaction effect: sexual behaviour,
country x participant group
Percent ever having sex
60
50
40
Georgia
Russia
Ukraine
30
20
10
0
School
Shelter
Participants
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) .
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.
Percent ever having sex
Interaction effect: Injecting drug use.
Country x participant group
10
9
8
7
6
5
4
3
2
1
0
Georgia
Russia
Ukraine
School
Shelter
Participants
Representations of HIV/AIDS: Percentage
agreeing with statement
50
45
Get better
40
35
Non proper get AIDS
30
25
Woman carrying
condom is easy
Mainly homosexuals
20
15
10
5
Tell by looking
0
School
Shelter
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.
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.
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.
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
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.
• 112 ‘media outputs’ mentioned HIV/sexual
behaviour/drugs/condoms
•
•
•
•
53 newspaper articles
48 magazine articles
7 TV reports
4 Radio reports
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
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.
Brief media themes
Russia
Focus in youth media mainly on overseas personalities.
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.
Focus group analysis. Design the same for
each of the three countries (total of 36 focus
group meetings)
Focus group members (M age
16.31)(N = 86)
Control group
(M age 16.44) (N
= 87)
Shelter (N=40) School
(N=46)
Shelter School
October
2003
Male
Fem
Male
Fem
January
2004
Male
Fem
Male
Fem
April
2004
Male
Fem
Male
Fem
N = 39
N = 48
N = 39
N = 48
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.
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)
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
• 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 Georgia most resistant to
fully participating in the meetings.
• Adolescents generally recommended more media
information, but presented in a light-hearted way.
So what might all this mean?
• 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
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.
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
Extension projects (INTAS 2006-8;
EurAsia Foundation)
• 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
• EurAsia Foundation project: nearly 3,000 children
across Georgia in focus groups.
For a copy of today’s talk, and
references….
Please follow the link on my website to my
University homepage…
www.culturefirst.com