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4 Knowledge
Description: Since unprotected sex is the driving force behind most HIV epidemics, AIDS programmes have focused actively on increasing people's knowledge about sexual transmission and on promoting safer sex. Efforts have sometimes been made to change the underlying social attitudes that foster unsafe sex. Very often, these are attitudes that promote double standards in sex for men and women and that concentrate the power in sexual relationships in men's hands.

Although they are all strongly interrelated, goals and indicators in the areas of knowledge of sexual transmission and sexual behaviour itself will be presented separately.

Knowledge is an important prerequisite for prevention in other areas of HIV transmission. This section, therefore, also includes a measure of knowledge in drug injecting populations and of mother to child transmission. 

Goals: Early assumptions that knowledge about AIDS and how to prevent it would lead to behaviour change have proved optimistic. However, there is no doubt that knowledge is an important prerequisite for behaviour change.

Most national programmes have put a great deal of effort into so-called "Information, Education, Communication" or "IEC" campaigns, which aim to increase knowledge about HIV, the behaviours that spread it and the ways it can be avoided. Many programmes have had a great deal of success in imparting this information. Indicators of knowledge are beginning to register high levels of correct knowledge. But behind this knowledge often lurks misinformation or misconceptions which influence the way people behave. Increasingly, programmes are turning their attention to breaking down these misconceptions. 

Key Questions: Is there a national policy on the inclusion of HIV prevention messages in school-based education programmes?
Do people know how HIV is transmitted and can be prevented?
Do they hold misconceptions which may diminish the likelihood that they will act on correct knowledge?
Do programmes exist to increase knowledge and reduce misconceptions, and are those programmes reaching their intended audiences? 
Challenges: Existing composite indicators of HIV-related knowledge focus on correct knowledge. While they ask about misconceptions, incorrect knowledge is not commonly included in an indicator.

One of the challenges in measuring knowledge is deciding how much to jog people's memory through prompted questions. It is probably true that spontaneous answers are a better reflection of the respondent's actual application of knowledge than prompted responses. For example, if a person regularly uses condoms to protect themselves from HIV, then condom use is likely to be the first answer they give when asked how HIV can be prevented. In spontaneous responses, people are also less likely to list prevention methods such as abstinence that they know intellectually to be preventive against HIV but that they do not consider to be viable options for themselves.

The trouble with unprompted or spontaneous responses (e.g., "What ways can one protect from HIV?") is that they tend to be extremely variable between populations and across time, and this variability does not always reflect true differences in knowledge. Rather, it is likely to be because of variation in the interviewer's ability to solicit spontaneous responses, and their preference for certain response codes. For the purposes of constructing standardised knowledge indicators that are comparable across time, prompted responses to specific ways of protection may be more useful.

The way the question is asked is critical. In the past, most questions have been phrased: "Can people protect themselves against HIV by...?". As knowledge about HIV increases, field tests have shown that this phrasing produces responses that are hard to interpret. Respondents may know that it is safer to have sex with a condom than without one, but they may also know that a condom does not provide full protection against HIV because of the possibility of breakage. These indicators therefore word questions slightly differently, asking whether a certain behaviour can reduce the risk of HIV infection.

Correct information about how HIV is contracted and how it can be avoided does not often vary from place to place. Misconceptions do vary however, with particular rumours gaining currency in some populations both about how HIV is spread (by witchcraft, for example) and how it can be avoided (for instance by eating a certain kind of fish or having sex with a virgin).

Indicators of misconceptions can be varied to include misconceptions that are locally common. If the two most common misconceptions are used in every setting, this should not affect cross-country assessment of indicators. The indicator is not measuring knowledge about witchcraft, after all, it is measuring incorrect knowledge about AIDS. In many societies, the common misconceptions are already well known. In others, qualitative studies may have to be undertaken before deciding which elements to include in the indicator. It is worth noting that misconceptions themselves may change over time. Indeed it is the job of AIDS programmes to erode current misconceptions, but they may be replaced by others. A country may choose to measure different misconceptions at different points in time. Again, as long as efforts are made to select the two misconceptions currently most common, the indicator of incorrect knowledge about HIV and AIDS should be comparable over time.

The relative importance accorded to correct knowledge of the major modes of transmission and misconceptions may vary with the epidemic state. In generalised epidemics where a very high proportion of people answer correctly to questions about transmission, addressing misconceptions may become a major focus of IEC campaigns. In low-level or concentrated epidemics where past IEC activities have been more limited, attention may still be focused on improving basic knowledge about modes of transmission. Indeed, in concentrated epidemics more attention may be focused on increasing knowledge within specific sub-populations about prevention methods related to the behaviours which put those sub-populations at risk.

In all indicators of AIDS-related knowledge, the denominator should be the entire population of respondents, rather than just those who have heard of AIDS. This is because those who have not heard of AIDS (and who therefore cannot have any "correct" knowledge about it) definitely represent failures of IEC campaigns. In most countries at the end of the 1990s, these people constitute only a very small proportion of the population.

In areas dealing with knowledge, attitudes and sexual behaviour--even more than in other areas of programming--it is imperative that indicators be reported separately by gender. 


USAID | UNAIDS | UNICEF | WHO | CDC | US Census Bureau
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