University students and AIDS: a systematic review of knowledge, attitudes towards AIDS in Iran

ABSTRACT

The present research aims to systematically analyse Iranian university students’ awareness and attitude towards AIDS. We published human cross-sectional studies published in English and Persian between 1 January 1990 and 1 January 2018 in the following databases: MEDLINE, Embase Ovid, Scopus, Web of Science. The key terms searched were Student, HIV, AIDS, Iran, Knowledge, and Attitude. The operators used were AND, NOT, OR which led us to find related articles. The overall findings showed that about 30% of university students had a reasonable awareness of AIDS and 44% had an attitude towards AIDS. As the results showed, 37% of the medical students and 23% of the non-medical group had a good awareness of AIDS. This study showed the fact that despite the susceptibility of university students to high-risk behaviours, this population does not enjoy an adequate level of AIDS preventive programmes.

KEYWORDS:

• HIV
• university Students
• knowledge
• attitudes

Introduction

Human immune deficiency virus (HIV) was discovered in 1981, and ever since an epidemic infection has prevailed the globe (Al-Qahtani et al., 2019; Dadipoor et al., 2020). HIV/AIDS is still considered a public health threat as it yet has no drug for the treatment (Thakuri & Thapa, 2018). About 37.9 million people lived with HIV near the end of 2018 and 1.7 million people were just infected in 2018 worldwide (https://www.who.int/news-room/fact-sheets/detail/hiv-aids, 25 July 2019).

The largest epidemic of HIV in the Middle East belongs to Iran (Gökengin et al., 2016). In the Islamic Republic of Iran, 61 000 people were living with HIV in 2018, 4400 people were recently added, and 2600 people died of an AIDS-related disease. The quantity of AIDS-related mortalities has increased by 8% since 2010. It changed from 2400 to 2600 cases of mortality (Li et al., 2016). The real size of HIV-infected population in Iran was estimated to be five times larger, which implies that 75% of HIV-infected Iranian are not aware of being infected (M. H. Lotfi et al., 2017).

Young adults, especially those between 15 and 24 years of age are the target group susceptible most to HIV infection (Dzah et al., 2019; Marashi et al., 2019). A body of related research showed that young people were a significant population of those visiting sexually transmitted infection (STI) clinics and those afflicted with HIV (Thakuri & Thapa, 2018). University students are primarily prone to HIV, as more than half of all new infections worldwide emerge among youngsters (Tan et al., 2007).

Several factors put university students at the risk of HIV infection. These include peer pressure, lack of maturity, alcohol and drug abuse, and higher probability of high-risk behaviours such as unprotected sex (Thakuri & Thapa, 2018).

The body of research by the disease management centre of the ministry of health in Iran indicated that high-risk behaviours which could pave the way for the occurrence of AIDS were on increase. In other words, the rising age of marriage in Iran in recent years and the lower tendency of the youths to marry at lower age have led to an increase in the rate of high-risk behaviours among youngsters, especially university students (PeyghambarDoust et al., 2018). Some other research revealed that Iranian youths are at serious risk due to uncontrolled sex affairs (unhealthy), high rate of drug addiction, lack of sex education, the rising age of marriage, the prevalence of trips abroad and the vicinity of countries counted among high-risk areas. Moreover, sex education on HIV has no place in Iranian universities (Yazdi-Ravandi et al., 2015).

Prevention is the key way to resist AIDS epidemic on a global scale. A look at the trend of infection and high-risk groups shows certain obstacles to the prevention of HIV. Awareness of AIDS and how it is transmitted is one step towards its prevention. Yet, a sound knowledge of all aspects of the disease on its own does not help to improve the behaviour and needs to change attitude too (Mohsenzadeh-ledari et al., 2016). Due to the fact that university students are significantly prone to HIV infection and as preventing AIDS requires certain interventions, there is a need for time to pass and affect individuals’ awareness and attitude. A systematic review to evaluate university students’ knowledge and awareness during different years is useful and essential. An estimation of university students’ awareness and attitude, the results can be used by policy-makers and programme designers to develop and implement the required programmes for preventing the disease and increasing AIDS/HIV awareness. The present research aims to systematically analyse Iranian university students’ awareness and attitude towards AIDS.

Material and method

Search strategy and data sources

A review of the related literature was done to identify the data published after the above-mentioned body of research. We published human cross-sectional studies published in English and Persian between 1 January 1990 and 1 January 2018 in the following databases: MEDLINE, Embase Ovid, Scopus, Web of Science. In addition, search engines such as Google and Google Scholar were also used to identify all potentially eligible publications. We also scanned reference lists of relevant papers to identify additional papers (snowballing).

Moreover, we searched the grey literature and online databases which included 44 online sources and database websites.

A set of search terms was used so as to prevent the loss of the related potential content. No limits were set for the search. The search was done after consultation with a public librarian specialized in all databases.

We used the following search string: [‘HIV’ or ‘HIV infections’ or ‘AIDS’] AND [’disease transmission’ or ‘infectious/infectivity/infectiousness’ or ‘transmissibility’ or ‘contact/contacts/per-contact’] AND [’sexual’ or ‘heterosexual’ or ‘homosexual’ or ‘coital’ or ‘intercourse’ or ‘anal’ or ‘oral’ or ‘blood transfusion’ or ‘needle-sharing’ or ‘needle stick’ or ‘perinatal’ or ‘mother to child’] AND [‘Knowledge’ or ‘Awareness’] AND [‘Attitude’ or ‘Opinion’] AND [‘Student’ or ‘College student’ or ‘Youth’ or ‘Young’ or ‘Adolescent’] AND [Iran].

Study selection

For the initial search, two referees explored the title and abstract of the articles independently so as to use the search strategy either to accept or reject the full-text examination.

If the studies did not meet the following criteria, they were rejected (1) cross-sectional in type and being HIV-related, (2) measuring at least one consequence of AIDS-related knowledge and attitude.

Any case of disagreement on accepting or rejecting the article was solved through discussion and when necessary, a third referee was addressed.

For those academic articles that were accepted at the abstract level, an ancestry search was done for the references so as to identify other relevant studies (Conn et al., 2003).

Full-text review and data extraction

The full texts of the articles identified in the electronic and ancestry search were independently reviewed by the same two reviewers to determine if they were still eligible to undergo data extraction or not. The data were extracted from eligible articles into an electronic spreadsheet. Reviewers met to reconcile any disagreements in data extraction, and a third reviewer was met to resolve any probable dispute.

Data extraction

Data extraction was performed by two trained authors (ASM and SD). The following data were extracted: name(s) of author(s), publication year, target group, research variables (awareness/attitude), sample size, target group. Then, the data entered Excel. The data were extracted from the body of research on university students’ awareness and attitude in two groups, medical and non-medical.

Medical students were those studying a field of study associated with the ministry of health such as medical studies, dentistry, nursing, midwifery or those associated with healthcare studies and clinical majors. Other students of fields of study other than the above-mentioned are grouped as non-medical.

Quality assessment

The quality of the included academic articles was assessed using the 22-item ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) checklist (Von Elm et al., 2007). Quality assessment was performed by two trained authors (ASM and SD). The authors were the same at all stages of the study. The articles were classified as good (scores ranging between 17 and 22), medium (8–16) and poor (1–7) in terms of quality.

Classification of knowledge and attitude

The awareness findings, as extracted from the results of every single study, were reported at two levels (according to the correct response); appropriate if 60–100% of questions of knowledge were answered correctly and inappropriate if less than 60% of knowledge questions were answered correctly. Furthermore, the attitude-related information about AIDS and the affected patients were reported at three levels including positive, negative, and neutral in percentage.

Results

A total number of 15 academic articles were included within this study which agreed with the goal of the present research (exploring awareness and attitude among Iranian university students). We excluded 25 studies: Nineteen were studies related to school students, and six studies did not report sufficient results.

PRISMA guidelines were followed (Moher et al., 2009) as indicated in Fig. 1 which shows the selection process of articles that were included in this systematic review.

Figure 1. Flow diagram of the study selection process

The initial search identified 476 research abstracts. Once examined, this number was reduced to 38 articles which met the inclusion criteria.

An ancestry search of these 22 article references was conducted to identify any other relevant articles. The ancestry search yielded 22 more studies that were then selected by title. Then, the 38 full texts were reviewed from the electronic search, and the 22 articles from the ancestry search were reviewed in full too to determine if they were eligible. Only 19 of these articles were still eligible after the full-text review and were maintained for data extraction. The reason for rejecting the other 41 articles was primarily because they did not meet the study design criterion after reading the full texts. Besides, during the data extraction, 4 of the 19 articles were rejected as they did not use paired data to appropriately evaluate the outcomes. Therefore, 15 articles were included in this systematic review.

Description of included studies

The findings of this systematic review are summarized in Table 1. In this research, 15 academic articles met the inclusion criteria (Alipour et al., 2016; Faezi et al., 2013; Hashemipour et al., 2016; Jafari et al., 2009; Mirnejad et al., 2009; Mogarehi & Shokranian, 2003; Mohammad Nejad et al., 2012; Omidvar, 2003; PeyghambarDoust et al., 2018; Pilevarzadeh et al., 2014; P. R. S. Lotfi et al., 2011; Samie et al., 2009; Sanei et al., 2011; Shokoohi et al., 2016; Yazdi-Ravandi et al., 2015). According to the results, al studies explored awareness and 11 explored attitude (Alipour et al., 2016; Hashemipour et al., 2016; Jafari et al., 2009; Mirnejad et al., 2009; Mogarehi & Shokranian, 2003; Mohammad Nejad et al., 2012; PeyghambarDoust et al., 2018; P. R. S. Lotfi et al., 2011; Sanei et al., 2011; Shokoohi et al., 2016; Yazdi-Ravandi et al., 2015). All were conducted in a cross-sectional type. The sample size ranged between 147 and 4950. Moreover, the data belonged to two groups: a medical (n = 8) (Faezi et al., 2013; Hashemipour et al., 2016; Jafari et al., 2009; Mirnejad et al., 2009; Mogarehi & Shokranian, 2003; Omidvar, 2003; Samie et al., 2009; Yazdi-Ravandi et al., 2015) and non-medical (n = 7) (Alipour et al., 2016; Mohammad Nejad et al., 2012; PeyghambarDoust et al., 2018; Pilevarzadeh et al., 2014; P. R. S. Lotfi et al., 2011; Sanei et al., 2011; Shokoohi et al., 2016).

• N/R = Not Reported, * appropriate; correct answers to 60–100% of questions of knowledge and Inappropriate; less than 60% correct answers to questions of knowledge.

Table 1. Analysis of the literature on school students’ awareness and attitude

						Results
			Variable			Knowledge *		Attitude
Author	Publication	Target group	Knowledge	Attitude	Sample Size	Appropriate	Inappropriate	Positive	Neutral	Negative
Mogarehi And Shokranian	2003	Medical group	*	*	147	41.33	58.67	46.95	-	53.05
Yazdi-Ravandi et al.	2015	Medical group	*	*	320	8.1	91.89	80	-	20
Hashemipour et al.	2016	Medical group	*	*	380	16	84	68	-	32
Sanei Moghaddam et al.	2010	Non-Medical group	*	*	951	50.2	49.8	17.1	56.9	25.9
Mirnejad et al.	2008	Medical group	*	*	550	36.6	63.4	75	-	25
MohammadNejad et al.	2011	Non-Medical group	*	*	666	14.9	85.1	12.2	24.8	63.1
Faezi et al.	2012	Medical group	*	-	121	36.4	56.2	N/A	N/A	N/A
Alipour et al.	2016	Non-Medical group	*	*	588	12	88	77.8	-	22.2
Shokoohi et al.	2016	Non-Medical group	*	*	4950	37.3	62.7	20.7	31.7	47.6
Lotfi pur Rafsanjani et al.	2011	Non-Medical group	*	*	384	-	100	19.8	-	80.2
Samie et al.	2009	Medical group	*	-	922	37.95	62.05	N/A	N/A	N/A
Jafari et al.	2009	Medical group	*	*	109	77.25	22.75	47.75	-	52.25
omidvar	2003	Medical group	*	-	150	38	62	N/A	N/A	N/A
Pilevarzadeh et al.	2014	Non-Medical group	*	-	450	46.8	53.2	N/A	N/A	N/A
PeyghambarDoust et al.	2018	Non-Medical group	*	*	411	-	100	18.8	63	18.2

The interpretation results revealed that 15 academic articles (7 non-medical and 8 medical) explored awareness and 11 articles (6 non-medical and 5 medical) explored attitude. The overall findings showed that about 30% of university students had a reasonable awareness of AIDS and 44% had an attitude towards AIDS (Figure 2).

Figure 2. Students’ knowledge and attitude about AIDS

From among the 15 works of research on awareness, 8 belonged to medical students and 7 to non-medical university students. As the results showed, 37% of the medical students and 23% of the non-medical group had a good awareness of AIDS (Figure 3).

Figure 3. AIDS-related knowledge in medical and non-medical students

From among the 11 works of research on university students’ attitude, 5 were conducted in the medical group and 6 in the non-medical group. As the analytic results showed, 64% of the medical students, as well as 28% of the non-medical students, had a positive attitude towards AIDS and patients afflicted with AIDS (Figure 4).

Figure 4. AIDS-related attitude in medical and non-medical students

Discussion

The first effective step of health education is to raise awareness and change attitude and create a proper belief in a change of behaviour. As for the prevention of AIDS prevalence, this issue is a vital matter of concern (Tehrani & Malek-Afzali, 2008).

Interpretation of the present works of research showed that 37% of medical students and 23% of non-medical peers enjoyed a reasonable level of awareness. In their research in China, Li et al. found the affliction rate of AIDS among university students about 79.41% (5). In some other research, Dalia Haroun et al. in UAE estimated the awareness rate of AIDS to be 61% among university students (Haroun et al., 2016). In another study, Mostafa et al. reported the awareness level of Nursing students in Saudi Arabia 72.93% on average (Abolfotouh et al., 2013). Nurilign found that 63.8% of healthcare university students had a reasonable awareness of AIDS (Nurilign et al., 2015). Comparison of the present review article and the above-mentioned body of research shows that Iranian university students’ awareness of AIDS is low. This divergence can, to some extent, be explained by socio-cultural differences of countries as well as different fields of study, academic semester, research population and difficulty of the questionnaire items (Mirnejad et al., 2009). Considering the negative effects of unawareness of AIDS epidemic, it is essential to raise individuals’ awareness. Thus, it is necessary to heed to the educational needs of the youths, who are among the groups at a high risk of infection with AIDS. Thus, the following are suggested to fight back the disease: broadcasting appropriate educational programmes in mass media (radio and TV), educational workshops, instructional sessions, scientific seminars, exclusive university courses with the aim of awareness-raising, changing negative attitudes and developing appropriate behaviours to stand against the disease.

In the light of the body of research reviewed, medical students had a higher knowledge of AIDS. Similar to the findings reported by Maimaiti et al., medical students had a better knowledge than non-medical university students (Maimaiti et al., 2010). In some other research by Nei and Shen, a statistically significant difference was found between medical and non-medical university students’ awareness level (Nei & Shen, 2006). Tan showed that medical university students’ awareness, attitude and performance concerning AIDS were better than non-medical students (Tan et al., 2007). These results indicated a higher awareness of medical university students than the non-medical which was quite expected due to the course content covered related to this during their academic years. However, this level of awareness in the body of research conducted in Iran among medical students has not been high considering the risk of exposure to high-risk factors of AIDS infection in their educational and professional environment. Therefore, as medical science groups especially physicians and nurses are prone to infection, so as to prevent affliction with AIDS, attempts should be made to raise students’ awareness and there is a need for more precise and comprehensive plans. Moreover, holding educational courses and using mass media can help to raise awareness in other susceptible groups including non-medical university students who have been deprived of any effective attempt of awareness raising in their academic sphere.

Analysis of the results showed that about two-third of the medical students had a positive attitude towards AIDS. Consistent with the present findings, Maimaiti et al. found that one-third (33.3%) of medical students had a positive attitude to HIV/AIDS (Maimaiti et al., 2010). Similarly, in Li et al.’s work of research, 93.68% of dentistry students had a negative attitude towards AIDS (Li et al., 2016). These divergences can be partially explained by the type of items within questionnaires, culture, ethnicity and academic year of education for students in different geographical areas.

In the light of the present findings, less than one-third of non-medical university students had a positive attitude towards AIDS and those affected. Contrary to the present findings, Regassa and Mulu et al. found that more than half of the non-medical university students had a positive attitude towards AIDS (Mulu et al., 2014; Regassa & Kedir, 2011, p. 34, 35). This contradiction can be at least partly due to the difference between Iranian culture and that of other countries. AIDS is socially condemned in Iran and is left unspoken and untouched due to religious beliefs. Thus, it is quite expected that non-medical associates who suffer from a low awareness of AIDS have a negative attitude towards this disease.

Conclusion

Overall, the awareness and attitude of the participants were not at an acceptable level. This study showed the fact that despite the susceptibility of university students to high-risk behaviours, this population does not enjoy an adequate level of AIDS preventive programmes. According to the results, such measures as appropriate educational programmes through mass media, exclusive course credits or seminars at university, mass media, more qualitative and quantitative educational programmes on AIDS and making certain changes to students’ curriculum can help to raise their awareness and change their attitude and thus prevent the disease.

Limitations

There are certain limitations in a systematic review. Only those in English and Persian language were included. Moreover, all articles depended on the self-reported questionnaire completion and were quantitative (cross-sectional). As this review only covered school students in Iran, it may not be generalized to other school students from a different setting. In addition, the results were not synthesized conclusively and therefore there can be little interpretation of what the results can mean to take effective measures in Iran. Most of the analysed corpus merely examined the awareness and attitudes associated with HIV/AIDS. Thus, there is a sparse interpretation of what the results mean for further action in Iran. This can lower the quality of this research and can be considered as an e limitation.

Acknowledgements

This research was part of a pajohan coded as 13781 approved by the Student Research Committee of the Shahid Beheshti University of Medical Sciences in Tehran, Iran. We are grateful to the Student Research Committee and the Research and Technology Chancellor in the target university for their financial support.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

No external funds were used in this study.

Notes on contributors

Sakineh Dadipoor

Sakineh Dadipoor is a Ph.D. student in health education and health promotion. His recent research is on women’s behavior.

Mohtasham Ghaffari

Mohtasham Ghaffari is associate Professor of Health Education and Health Promotion in Shahid Beheshti University of Medical Sciences, Tehran, Iran. He is working on subjects related to health education and behavior.

Ali Safari-Moradabadi

Ali Safari-Moradabadi is a Ph.D. student in health education and health promotion. The main focus is on change behavior. His research is about lifestyle related behaviors.