Knowledge of STD / Aids among adolescent students

1 RN. Psychologist. Adjunct Professor at Nursing Department, Federal University of São Paulo. Leader of the Study Group on Corporality and Health Promotion (GECOPROS). São Paulo, SP, Brazil. jrsbretas@yahoo.com.br 2 RN. Associate Professor at Nursing Department, Federal University of São Paulo. São Paulo, SP, Brazil. consilva@denf.epm.br 3 RN. Master's student in Science Course at Federal University of São Paulo. São Paulo, SP, Brazil. dulcijardim@hotmail.com 4 RN. Master's student in Science Course at Federal University of São Paulo. São Paulo, SP, Brazil. relilima@yahoo.com.br O R IG IN A L A R IC LE


ABSTRACT
This study aims to analyze the degree of knowledge adolescents have on STD/AIDS prevention, transmission, signs, and symptoms, and to contribute with the elaboration of educational actions in the University Extension Program called Corporality and Health Promotion. The research counted on 1,087 adolescents (40% females, 60% males) and was carried out in three elementary and high schools located in the municipality of Embu. A structured, multiple choice questionnaire was applied. Data indicated the achievement of the following results: as per the prevention, 92% of girls and 78% of boys referred to the use of condoms, while 42% of girls and 43% of boys affirmed to wash their genitalia after the sexual relation; 75% females and 52% males quoted television as their source of information. As per the knowledge of STD, girls and boys indicated not to have much information on the issue. Regarding STD healing programs, 57% females and 71% males affirmed not to have any knowledge on the issue; 5% of girls and 6% of boys thought AIDS to be curable. In a general perspective, we can conclude that girls were more familiar with the study's issues than boys.

INTRODUCTION
Adolescence is a transition period between childhood and adulthood characterized by an intense period of growth and development that includes outstanding anatomical, physiologic, psychological and social transformations. Body awareness is a crucial aspect in this process, since in this period body changes occur quickly, profoundly and lastingly, affecting the rest of their lives. Such intense physical and biological changes at this stage of human development affect the process of psychosocial construction of the adolescent's identity (1) . This body, different from all others, emerges from the depths of this turbulent process, where identity is perhaps the most important developmental task of adolescence.
Biologic maturity is followed by sexual manifestations that must be integrated into the adolescent's personality. Menarche in girls and involuntary ejaculation in boys, and even masturbation, are evident physiologic expressions connected to the new and deep alterations being psychologically processed. From this moment on, one of the issues faced by the adolescent is to extend themselves, or not, to the opposite sex outside of their family ties the same feelings that once prevailed in the relationship with their parents (1) .
As we describe in this study, this stage is featured by many transitions, where sexuality holds the strongest repercussion. Sexual knowledge, however, is not restricted to that of sexual organs, not even to the first episode of sexual intercourse. It includes a personal experimental process and a sexual group culture impregnation hastened during adolescence and youth (2) .
The social body is an important part of the organic body image, since it provides each person with the foundation for conceiving and interpreting their own physical and psychological experiences. This body, going through deep transformations due to adolescence, holds an even more relevant meaning, because it will be, or not, the basis for the construction of self and group identity, as well as the perception of others.
The role each adolescent plays in society, while exploring their sexuality, can represent a health risk. In order to play the role of being a man or a woman, adolescents must practice safe sex regarding STD/Aids and life risks. Young men set themselves in dangerous situations and frequently turn to violence against their partners due to their desire for power and control; on the other hand, girls frequently risk their own health, as in sexual intercourse when the partner refuses to use a condom.
According to the World Health Organization, most adolescents initiate their sexual life earlier than ever before, most of them between the ages of 12 and 17 (2) , regardless of social responsibility which is matured even later these days. The youth in this phase are also vulnerable to sexually transmitted diseases (STDs) and to the Human Immunodeficiency Virus (HIV), a fact occurring due to sexual liberation, easy intimate contact, and also due to stimuli from communication means that encourage premature sexual contacts (3) .
Although Brazil has a successful Aids program, providing universal access to anti-retroviral medication and a partnership with civil society to develop actions aimed at different sectors of the public, the Aids epidemic still reaches sexually active juveniles. Therefore, different intervention programs aimed at the young public have resulted in the increase and acceptance of the use of condoms in this population (2,4) .
The reasons that drive adolescents to have unprotected sex are many, and numbers arising from pregnancy and STD are, without a doubt, smaller than reality (4) . Adolescents are individuals and deal with sexuality in many ways. Thus, the use of protection opposes the spontaneous behavior usually attributed to sex and youth. The use of protection must be encouraged within erotic and practical dimensions, not only by means of fear.
Bearing this in mind, this study came about due to the need to learn about and compare adolescents' knowledge regarding STD/Aids and to learn about the differences in knowledge between female and male adolescents.
This study was encouraged by our experience in the University Extension Project Corporality and Health Promotion, where sexual education activities were developed in a population comprised of adolescents and young men and women from three public schools in the Tourist City of Embú, in the state of São Paulo. All activities are linked to the Embú Assistant-Teaching Integration Program (PIDA/EMBU), established in 1970 and featuring the integration of programs developed by different academic departments of the Federal University of São Paulo for use in the population of this same municipality.
In order to respond to the needs of this project, the action concept adopted here was Sexual Education, which can be defined as a systematic intervention process in human sexuality, providing information on sexuality and organizing a means of reflection and questioning on the importance of prevention, identity, interpersonal relationships, self-esteem, gender relations, taboos, beliefs and values regarding relationships, sexual behaviors, and STDs (5) .
This study aimed at: verifying adolescents' knowledge about infection prevention, signs and symptoms of STD/ Aids; and collaborating on the development of educational programs for the University Extension Project Corporality and Health Promotion.

METHOD
This is a quantifying and descriptive study. This type of study prioritizes describing the features of a certain population, or facts and phenomena from a certain reality. It promotes a reality lineation once it describes, records, analyzes and interprets the current nature of the phenomena or procedures. The focus of this method relies on reality's dominant conditions or how a person, group or thing is conducted or works in the present, employing comparison and contrast for this purpose. In problem solving, it informs current conditions and needs and identifies how results were reached (6) .
This study's project was evaluated and approved by the Ethics Committee of the federal University of São Paulo under protocol # 1561/03; therefore, all methodological procedures established by the 196/96 Resolution, in regards to the Research Rules involving Human Beings (7) ,were followed.
The study took place throughout the period of March 2003 to June 2005, and included three public schools (junior high and high schools) in the region of Santo Eduardo in the tourist city of Embu in São Paulo state. These locations develop educational health programs for the University Extension Project Corporality and Health Promotion from UNIFESP.
The age bracket of the studied population follows the definition of the World Health Organization for Adolescence (8) , represented by individuals in the age bracket between 10 and 19 years old.
The total population for this study comprised 1087 adolescents (652 males and 435 female), between 12 and 19 years old in the schools mentioned above. As inclusion criteria, the following was adopted: being a student in one of the three participating schools in the educational activities of the University Extension Project Corporality and Health Promotion.
As methodological procedure for the data collection instrument re-dimensioning, a pre-test with 180 adolescents from both genders was carried out.
Results from this pre-test contributed to the development of the definitive instrument, including structured multiple choice questions which were self-applied; the test was applied anonymously with 14 questions representing the following variables: 1) general knowledge of STD (STD description, prevention, information sources); 2) Syphilis knowledge (transmission, signs and symptoms); 3) Gonorrhea knowledge (transmission, signs and symptoms); 4) Knowledge regarding Genital Herpes (transmission, signs and symptoms); 5) Condylomata Acuminata knowledge (transmission, signs and symptoms); 6) AIDS knowledge ( transmission, signs and symptoms); 7) knowledge of STD treatment.
The obtained data were analyzed and interpreted under a quantitative context, expressed by numeric symbols.

RESULTS
Results were presented through the elaboration of tables and describing in words the extent of boys' and girls' knowledge, starting from the descriptive analysis of each variable.
Regarding prevention methods for STD, 92% female / 78% male pointed to the use of male condoms in all forms of sexual relations as the best prevention method; 86% female / 57% male stated that a doctor should be seen regularly; 76% female / 53% male reported the importance of being sure that the partner carries no STDs; 42% female / 43% male responded that they washed their genitals thoroughly after intercourse; and 1% female / 2% male have chosen not to use any prevention method since they are sure they will not be infected by an STD.
Regarding the source of information about STDs, 75% female / 52% male demonstrated TV was their main source of information; 73% female / 58% male stated that their teachers were their main source; 65% female / 42% male obtained information from magazines, newspaper and books; 46% female / 23% male received information from friends; 31% female / 32% male received information at home, from their parents; and 2% female / 1% male were not interested in receiving information. Regarding Syphilis signs and symptoms, 35% female / 23% male pointed to penis and vulva lesions; 11% female / 7% male pointed out pain as a clinical sign; 9% female / 5% male referred to bruises on their bodies; 13% female / 5% male to genital itching; 12% female / 4% male to the presence of vaginal discharge; 11% female / 5% male referred to a strong smell and discharge ; 2% female / 1% male to impotence; 2% female / 1% to male hair loss; 1% female / 2% male referred to death; only 1% (female/male) refer to permanent impotence, while 57% female / 60% male had no knowledge of the signs and symptoms of the disease. Regarding signs and symptoms of Gonorrhea, 30% female / 16% male pointed to discharge from the male urethral opening or the vagina; 7% female / 4% male pointed to a bloody discharge; 17% female / 12% male pointed to pain while urinating; 14% female / 4% male to genital itching; 8% female / 4% male to pain while having a bowel movement; 1% (female/male) to pharyngitis; 1% (female/ male) to impotence; 1% (female/male) to hair loss; 11% female / 6% male to male genital lesions ; and 55% female / 63% male admit to having no information on the subject. Regarding Genital Herpes symptoms and signs, 21% female / 12% male pointed to pain and a burning sensation in the area of blisters ; 21% female / 12% male pointed to blister clusters on the penis or vulva; 14% female / 9% male pointed to purulent secretions; 1% ( female/male) to hair loss; 10% female / 4% to male genital itching; 8% female / 3% male to impotence; 7% female / 3% to male discharge; 10% female / 5% to male difficulty in urinating; 63% female / 68% male refer to having no knowledge on the subject. Regarding signs and symptoms of Condylomata Acuminata (HPV), 8% female / 6% male mentioned the presence of warts on the genitals; 6% female / 5% male referred to strong smell; 6% female / 3% male to genital itching; 5% female / 2% male to pain at the location of lesions; 4% female / 3% to male difficulty in urinating; 1% ( female/male) to impotence; 5% female / 1% to male purulent secretion; 1% male / hair loss; 90% female / 79% male admit to knowing nothing about the subject. Regarding the adolescent population female and male distribution according to their knowledge of sexually transmitted disease treatment, we obtained the following data : were not able to state an opinion (57% female / 71% male); Gonorrhea (16% female /15% male); Syphilis (11% female/ 13% male); Genital Herpes (10% female and male); Condylomata Acuminata ( 6% female/5% male); Aids (5% female/ 6% male); there is no cure for STD (4% female/7% male).

DISCUSSION
Regarding general knowledge of STDs, we could observe that the theme is not totally unknown to adolescents in this study. However, knowledge and lack of knowledge, as well as misinformation, are mixed in the analyzed questions. Also, some significant differences in knowledge between boys and girls demonstrated that girls' knowledge of the subject was higher. These findings regarding the knowledge of boys and girls have corroborated the findings from other studies (3,9) .
Regarding adolescents' knowledge of Aids, a significant percentage was obtained for both genders, who affirmed having enough knowledge about the subject. Knowledge regarding Aids is an important factor in its prevention (10) . A significant percentage also pointed out answers concerning other diseases, such as Gonorrhea, Syphilis and Genital Herpes.
Although the level of adolescents' knowledge of STDs was significant, the lack of knowledge from both genders regarding Candidiasis, Trichomoniasis and especially Condylomata Acuminata (Human Papiloma Virus/HPV) was concerning.
Lack of knowledge of Candidiasis and Trichomoniasis is an important factor when it comes to adolescent corporeal knowledge and care, since these diseases are not necessarily transmitted by sexual intercourse. Its vectors (Candida albicans and Tricomonas Vaginali) are a normal part of the vaginal flora, living in the genitourinary system's mucous membrane. In addition to sexual transmission, it may also occur due to alterations in the vaginal flora related to: pregnancy, obesity, use of high-dosage oral contraceptives, hygiene habits and clothes that increase local temperature and humidity (11) . Therefore, the vaginal discharge referred to by adolescents, which generates fear and shame, can be clarified by health education.
Regarding STD prevention, girls demonstrated more knowledge than boys,mainly regarding the use of male preventatives, followed by the necessity of periodic medical appointments and knowing the health status of their sexual partner. A fact that also stands out is that both boys and girls mentioned washing the genitals thoroughly after sexual intercourse as a means of prevention. This is a dangerous and totally misguided belief, requiring clarification among adolescents.
The use of preventatives (condoms) was referred to by a large percentage of adolescents, demonstrating apparent knowledge of this prevention method. In Brazil, as well as in other countries, a significant increase in the use of preventatives by adolescents is noted (12) . However, studies with adolescents who stated that they had never used preventatives, despite knowing the risks (4) , will receive careful attention in this study.
The ratio of young men and women under 20 years old who initiated their sexual life using male preventatives has increased from 47.8% in 1998 to 65.8% in 2005, higher in young men (13) .
A national study carried out in 2004demonstrated that 57.3% of young adults between 15 and 24 years old used condoms during their last episode of sexual intercourse, 58.5% always used condoms with their casual partners, and 38.8% used this method with their fixed partner (14) .
If the use of preventatives has grown among young adults, they are still not used by all adolescents in every incidence of sexual intercourse, because their use depends, among other factors, on the level of emotional involvement at the moment, financial issues and access to methods, as well as the level of freedom and autonomy achieved in this age bracket (15) .
Another means of prevention mentioned here also deserved our attention; the fact that they learned more about their partner's health status eliminated, in an imaginary way, all risks of contracting STD/Aids; unfortunately, the adolescent does not identify the latent period of such diseases or symptoms, or that there are sub clinical forms, imperceptible to the sexual contact.
We identified that a great majority of adolescents, mainly females, identified the following as main information sources regarding STD/Aids: television, teachers, communication means such as magazines, newspapers and books, and their friends. Regarding this subject, it is worth mentioning that parents are held in low esteem as information sources regarding STDs. These are crucial data, because in addition to the teacher figure that holds a significant symbolic role, these adolescents access other sources (magazines, newspapers and books), which leads us to infer the relationship possibility between communication means and the school represented by the figure of the teacher. As for television, its value is concerning since it presents such low interactivity. On the same subject, it is important to point out that the family is not highly regarded as a reference source, which is highly concerning, since the Within the family context, parents often have difficulty in approaching the subject of sexual issues with their adolescent children, mainly because they do not wish to discuss with their adolescent children their own experiences regarding sexual behavior. Thus, many parents transfer the sexual education of their children to the school, and the school, in turn, has difficulty in performing this task. It is also important to consider the fact that the teacher may feel unprepared or ill equipped to deal with the sexual education of their students (5) .
The predominance of girls' knowledge is repeated regarding knowledge of Syphilis infection, with the most frequently mentioned means of infection being sexual intercourse (vagina and anal). Other important means were also more frequently mentioned by females, such as vertical transmission (congenital syphilis), through contact with the chancre sore (primary syphilis) and contact with other infected objects (11) . Both genders do not acknowledge signs and symptoms of Syphilis, although some were mentioned more frequently.
As for Gonorrhea infection, both young women and men demonstrated lack of knowledge of the subject, mentioning sexual means of transmission infrequently (vaginal and anal). Regarding Gonorrhea signs and symptoms, the group has shown high knowledge, predominating among young men.
The same was observed in the portion of the investigation regarding knowledge of the transmission of Genital Herpes and the signs and symptoms of Condylomata Acuminata.
The data is concerning, since adolescence is the age bracket that presents the highest incidence of STDs. Approximately 25% of all STDs are diagnosed in people younger than 25 years of age. Worldwide, available data (12) demonstrated that approximately 40% of sexually active adolescents are infected by the Human Papiloma Virus (HPV), the virus responsible for Condylomata Acuminata, an infectious disease known as genital warts or commonly called Crista de Galo (11) . No less important or concerning, infection by the genital herpes virus (Herpes simplex virus) has increased more than 50% in this population (12) .
Knowledge of the means of infection in HIV/Aids has been demonstrated as higher than other STDs, both in young men and young women. Generally, girls hold higher knowledge of the subject. HIV infection through sexual intercourse (oral, anal and vaginal sex) without the use of preventatives, by blood transfusion, by sharing needles and syringes with infected blood among injecting drugs users, mother-child transmission, and pregnancy and delivery (vertical transmission) stand out. However, breastfeeding by HIV-positive mothers and the use of infected perforating instruments (occupational transmission) (11) were not mentioned.
Regarding STD cure or treatment, a great portion of the studied population showed no knowledge of the subject, highlighting a male prevalence. It is important to highlight that, although it demonstrates a low frequency, some adolescents referred to the existence of a cure for Aids. Due to the relevance of such a belief, it deserves educational investment.
Although this study has shown that young women have more knowledge on the subject of STDs than young men, it is important to consider the vulnerability of women, which places them in an unsafe position regarding preventive measures (16) , due to the power inequality between men and women in the exercise of sexuality (17) . Young women often feel pressured from their peer group to begin having sex, especially from their boyfriends, to show love by participating in sexual intercourse, and they feel they cannot negotiate the use of a preventative (condom) (17) .
The condom is directly connected to the notion of manhood, and is very present in the culture of many Brazilian adolescents. Using a condom is seen as taking out the pleasure. It also means rationalizing or regulating sexual impulses, considering, therefore, the female partner as betraying male virility, because being a man is considered to be naturally having no control over sexual impulses and being sexually aggressive, more intensely than women.
In this context, STDs represent a serious impact on the reproductive health of adolescents, because they can cause sterility, inflammatory pelvic disease, cervical cancer, ectopic pregnancy, puerperium infection, and low birth weight infants. They also negatively influence self-esteem (18) .

FINAL CONSIDERATIONS
Through analyzing the data in this group, we were able to demonstrate that the difference in STD/Aids knowledge between young men and women is relatively significant. Young women present a reasonably superior level of knowledge in comparison to young men, with some variations in a few issues that are perhaps features of the development of each gender.
Results found here are strengthened by our conviction of the importance of sexual education, mainly on the reproductive health of adolescents. Hence, we investigated and observed the subjects with whom we worked, using a more participative approach so that we could interact with the emerging themes of the study, specifically towards the possibility of reading and understanding reality. Therefore, we adopted interventional research as our methodology to serve the improvement of perception channels and communication, and to enable the understanding of the realities with which we are in contact. From this context, we intend to approach sexuality as a natural and positive aspect of human life, providing a free discussion of mores and behavioral standards regarding sex and the debate of people's attitudes in facing their own sexuality.