Abstract
In contrast to earlier in the HIV/AIDS pandemic, net of other demographic factors, formal education acts as a preventative factor in sub-Saharan Africa. Despite this trend, there has been almost no research on the causal mechanisms behind the widely reported education effect. Consistent with the education effect, structural equation modeling of the influence of education attainment on condom use with Demographic Health Survey data from nine sub-Saharan Africa nations collected between 2003 and 2005 finds that net of control variables, there is a robust, positive influence of education on condom use among sexually risky adults. Information-transfer and attitude change, the two most commonly assumed educational influences on the use of condoms, are tested, and although education attainment increases acquisition of basic facts and the inculcation of positive attitudes about HIV/AIDS, these factors have only weak influence on condom use. Given this, a new hypothesis about education’s enhancement of health reasoning is developed from neuro-developmental and decision-making research. Modeling finds that education robustly influences health reasoning ability and this factor mediates a significant proportion of the education effect on condom use. The results raise concern about the enormous effort by NGOs in the region to use mainly fact- and attitude-based educational programs to reduce future HIV infections. Future research on the causal mechanisms behind the association between education and HIV/AIDS prevention should focus how on schooling enhances the cognitive skills needed for health reasoning.
Similar content being viewed by others
References
Adams SJ. Educational attainment and health: evidence from a sample of older adults. Educ Econ. 2002;10(1):97–109.
Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff. 2002;21(2):60–76.
Backlund E, Sorlie PD, Johnson NJ. A comparison of the relationships of education and income with mortality: the national longitudinal mortality study. Soc Sci Med. 1999;49(10):1373–84.
Feinstein L, Sabates R, Anderson TM, Sorhaindo A, Hammond C. What are the effects of education on health? In: Desjardins R, Schuller T, editors. Measuring the effects of education on health and civic engagement: proceedings of the Copenhagen symposium. Paris: OECD; 2006. p. 171–313.
Furnée CA, Groot W, van den Brink HM. The health effects of education: a meta-analysis. Eur J Pub Health. 2008;18(4):417–21.
Kitagawa EM, Hauser PM. Differential mortality in the United States: a study in socioeconomic epidemiology. Cambridge: Harvard University Press; 1973.
Baker D, Collins JM, Leon J. Risk factor or social vaccine? The historical progression of the role of education in HIV and AIDS infection in sub-Saharan Africa. Prospects: Q Rev Comp Educ. 2009;38(4):467–86.
de Walque D, Nakiyingi-Miiro JS, Busingye J, Whitworth JA. Changing association between schooling levels and HIV-1 infection over 11 years in a rural population cohort in south-west Uganda. Trop Med Int Health. 2005;10(10):993–1001.
Gow J. The HIV/AIDS epidemic in Africa: implications for U.S. policy. Health Aff. 2002;21(3):57–69.
Kelly MJ. The encounter between HIV/AIDS and education. Harare: UNESCO, Sub-Regional Office for Southern Africa; 2000.
Peters E, Baker D, Dieckmann N, Leon J, Collins J. Explaining the education effect on health: a naturally-occurring experiment in Ghana. Psych Sci. 2010;in press
Bertozzi S, Martz T, Piot P. The Evolving HIV/AIDS response and the urgent tasks ahead: a timeline of events from 1981. Health Aff. 2009;28(6):1578–90.
Gregson S, Waddell H, Chandiwana S. School education and HIV control in sub-Saharan Africa: from discord to harmony? J Int Dev. 2001;13(4):467–85.
Lleras-Muney A. The relationship between education and adult mortality in the United States. Rev Econ Stud. 2005;72(1):189–221.
Mirowsky J, Ross CE. Education, social status, and health. New York: Aldine de Gruyer; 2003.
Phelan JC, Link BG, Diez-Roux A, Kawachi I, Levin B. “Fundamental causes” of social inequalities in mortality: a test of the theory. J Health Soc Behav. 2004;45(3):265–85.
Ross CE, Wu C. The links between education and health. Am Sociol Rev. 1995;60(5):719–45.
Hargreaves JR, Bonell CP, Boler T, Boccia D, Birdthistle I, Fletcher A, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS. 2008;22(3):403–14.
Kirby D. Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence. Sex Transm Infect. 2008;84(Suppl 2):ii35–41.
Nayga RM. Effect of schooling on obesity: is health knowledge a moderating factor? Educ Econ. 2001;9(2):129–37.
Adih WK, Alexander CS. Determinants of condom use to prevent HIV infection among youth in Ghana. J Adolesc Health. 1999;24(1):63–72.
Caldwell JC, Caldwell P, Quiggin P. The social context of AIDS in sub-Saharan Africa. Popul Dev Rev. 1989;15(2):185–234.
Glick P, Sahn D. Are Africans practicing safer sex? Evidence from demographic and health surveys for eight countries. Econ Dev Cult Change. 2008;56(2):397–439.
Heald S. It’s never as easy as ABC: understandings of AIDS in Botswana. AJAR. 2002;1(1):1–10.
Houston V, Hovorka A. HIV/AIDS messages in Malawi and their implications for effective responses. AJAR. 2007;6(3):205–14.
Kirby D, Short L, Collins J, Rugg D, Kolbe L, Howard M, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Rep. 1994;109(3):339–60.
Merson MH, O’Malley J, Serwadda D, Apisuk C. The history and challenge of HIV prevention. Lancet. 2008;372(9637):475–88.
Snelling D, Omariba DWR, Hong S, Georgiades K, Racine Y, Boyle MH. HIV/AIDS knowledge, women’s education, epidemic severity, and protective sexual behaviour in low- and middle-income countries. J Biol Sci. 2007;39(3):421–42.
Horton R, Das P. Putting prevention at the forefront of HIV/AIDS. Lancet. 2008;372(9637):421–2.
Blair C. How similar are fluid cognition and general intelligence? A developmental neuroscience perspective on fluid cognition as an aspect of human cognitive ability. Behav Brain Sci. 2006;29(02):109–25.
Duncan J, Burgess P, Emslie H. Fluid intelligence after frontal lobe lesions. Neuropsychologia. 1995;33(3):261–8.
Eslinger PJ, Flaherty-Craig CV, Benton AL. Developmental outcomes after early prefrontal cortex damage. Brain Cogn. 2004;55(1):84–103.
Shallice T, Burgess P. Higher-order cognitive impairments and frontal lobe lesions in man. Frontal lobe function and dysfunction. New York: Oxford University Press; 1991. p. 125–38.
Waltz JA, Knowlton BJ, Holyoak KJ, Boone KB, Mishkin FS, Santoa MM, et al. A system for relational reasoning in human prefrontal cortex. Psychol Sci. 1999;10(2):119–25.
Eslinger PJ, Blair C, Wangb JL, Lipovsky B, Realmuto J, Baker DP, et al. Developmental shifts in fMRI activations during visuospatial relational reasoning. Brain Cogn. 2009;69(1):1–10.
Ceci SJ. How much does schooling influence general intelligence and its cognitive components? A reassessment of the evidence. Dev Psychol. 1991;27(5):703–22.
Christian K, Bachman HJ, Morrison FJ. Schooling and cognitive development. In: Sternberg RJ, Grigorenko E, editors. Environmental effects on cognitive abilities. Hillsdale: Lawrence Erlbaum Associates; 2001. p. 287–335.
Cole M. Cultural psychology: a once and future discipline. Cambridge: The Belknap Press of Harvard University Press; 1996.
Luria AR. Cognitive development: its cultural and social foundations. Cambridge: Harvard University Press; 1976.
Stevenson HW, Parker T, Wilkinson A, Bonnevaux B, Gonzalez M, Greenfield PM. Schooling, environment, and cognitive development: a cross-cultural study. Monogr Soc Res Child Dev. 1978;43(3):1–92.
Stevenson HW, Chen C, Booth J. Influences of schooling and urban-rural residence on gender differences in cognitive abilities and academic achievement. Sex Roles. 1990;23(9):535–51.
Bruine de Bruin W, Parker AM, Fischhoff B. Individual differences in adult decision-making competence. J Pers Soc Psychol. 2007;92(5):935–56.
Peters E, Västfjäll D, Slovic P, Mertz CK, Mazzocco K, Dickert S. Numeracy and decision making. Psychol Sci. 2006;17(5):408–14.
Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Stud Fam Plann. 2004;35(1):39–47.
Padian NS, Buvé A, Balkus J, Serwadda D, WJr Cates. Biomedical interventions to prevent HIV infection: evidence, challenges, and way forward. Lancet. 2008;372(9638):585–99.
Duncan OD. Introduction to structural equation models. New York: Academic Press; 1975.
Bollen KA. Structural equations with latent variables. New York: Wiley; 1989.
Kline RB. Principles and practice of structural equation modeling. New York: Guilford Press; 1998.
Luke N. Economic status, informal exchange, and sexual risk in Kisumu, Kenya. Econ Dev Cult Change. 2008;56(2):375–96.
Cleland J, Ali MM. Sexual abstinence, contraception, and condom use by young African women: a secondary analysis of survey data. Lancet. 2006;368(9549):1788.
Glick P, Sahn D. Are Africans practicing safer sex? Evidence from demographic and health surveys for eight countries. Econ Dev Cult Change. 2008;56(2):397–439.
Hargreaves JR, Bonell CP, Morison LA, Kim JC, Phetla G, Porter JD, et al. Explaining continued high HIV prevalence in South Africa: socioeconomic factors, HIV incidence and sexual behaviour change among a rural cohort, 2001–2004. AIDS. 2007;21(Supplement 7):S39–48.
Rehle T, Shisana O, Pilay V, Zuma K, Puren A, Parker W. National HIV incidence measures—new insights into the South African epidemic. S Afr Med J. 2007;97(3):194–9.
Adih WK, Alexander CS. Determinants of condom use to prevent HIV infection among youth in Ghana. J Adolesc Health. 1999;24(1):63–72.
Brockerhoff M, Biddlecom AE. Migration, sexual behavior and the risk of HIV in Kenya. Int Migr Rev. 1999;33(4):833–56.
Hendriksen ES, Pettifor A, Lee SJ, Coates TJ, Rees HV. Predictors of condom use among young adults in South Africa: the reproductive health and HIV research unit national youth survey. Am J Public Health. 2007;97(7):1241–8.
Prata N, Morris L, Mazive E, Vahidnia F, Stehr M. Relationship between HIV risk perception and condom use: evidence from a population-based survey in Mozambique. Int Fam Plan Perspect. 2006;32(4):192–200.
Tassiopoulos K, Kapiga S, Sam N, Ao TT, Hughes M, Seage GRIII. A case-crossover analysis of predictors of condom use by female bar and hotel workers in Moshi, Tanzania. Int J Epidemiol. 2009;38(2):552–60.
Blair C, Gamson D, Thorne S, Baker D. Rising mean IQ: cognitive demand of mathematics education for young children, population exposure to formal schooling, and the neurobiology of the prefrontal cortex. Intelligence. 2005;33(1):93.
Stevenson HW, Chen C, Lee SY, Fuligni AJ. Schooling, culture, and cognitive development. In: Lynn Okagaki RJS, editor. Directors of development: influences on the development of children’s thinking. Hillsdale: Lawrence Erlbaum Associates; 1991. p. 243–68.
Keselman A, Kaufman DR, Patel VL. “You can exercise your way out of HIV” and other stories: the role of biological knowledge in adolescents. Sci Educ. 2004;88(4):548–73.
Keselman A, Kaufman DR, Kramer S, Patel VL. Fostering conceptual change and critical reasoning about HIV and AIDS. J Res Sci Teach. 2007;44(6):844–63.
Gleason-Morgan D. Dispelling common myths about HIV infection. J Pediatr Health Care. 1991;5(5):264–6.
Green EC, Halperin DT, Nantulya V, Hogle JA. Uganda’s HIV prevention success: the role of sexual behavior change and the national response. AIDS Behav. 2006;10(4):335–46.
Paul-Ebhohimhen V, Poobalan A, van Teijlingen E. A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa. BMC Public Health. 2008;8(4):1–13.
Plummer ML, Wight D, Obasi AIN, Wamoyi J, Mshana G, Todd J, et al. A process evaluation of a school-based adolescent sexual health intervention in rural Tanzania: the MEMA kwa Vijana programme. Health Educ Res. 2007;22(4):500–12.
Cohen S. Beyond slogans: lessons from Uganda’s experience with ABC and HIV/AIDS. Reprod Health Matters. 2004;12:132–5.
Dworkin SL, Ehrhardt AA. Going beyond “ABC” to include “GEM”: critical reflections on progress in the HIV/AIDS epidemic. Am J Public Health. 2007;97(1):13–8.
UNESCO. EFA global monitoring report: education for all by 2015, will we make it? Paris: UNESCO; 2008.
Acknowledgments
This research is supported by NSF Grant SES-0826712, and the authors thank Ashley Frost and Francis Dodoo for comments on earlier drafts.
Author information
Authors and Affiliations
Corresponding author
Additional information
The views and opinions presented here are those of the authors and do not necessarily represent those of the U.S. Agency for International Development or the U.S. Government.
Rights and permissions
About this article
Cite this article
Baker, D.P., Leon, J. & Collins, J.M. Facts, Attitudes, and Health Reasoning About HIV and AIDS: Explaining the Education Effect on Condom Use Among Adults in Sub-Saharan Africa. AIDS Behav 15, 1319–1327 (2011). https://doi.org/10.1007/s10461-010-9717-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-010-9717-9