HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 3 © Oxford University Press 2004. All rights reserved.
HIV/AIDS knowledge and the implications for health promotion programs among Chinese college students: geographic, gender and age differences
1Pediatric Prevention Research Center, Wayne State University School of Medicine, Detroit, MI, USA, 2Institute of Developmental Psychology, Beijing Normal University, Beijing, China, 3Department of Mathematics, China Pharmaceutical University, Nanjing, China, 4Nanjing College for Population Program Management, Nanjing, China and 5Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV, USA
Address for correspondence: Xiaoming Li, Pediatric Prevention Research Center, Wayne State University School of Medicine, 4201 St Antoine Boulevard, Detroit, MI 48201-2196, USA, E-mail: xiaoming_li{at}wayne.edu or Chongde Lin, Institute of Developmental Psychology, Beijing Normal University, Beijing 100875, China, E-mail: cdlin{at}bnu.edu.cn
SUMMARY
Data were collected in 2000 from 1081 students from eight colleges in China to assess the overall level of AIDS knowledge, and to explore regional, gender and grade differences in AIDS knowledge. The data indicate an inconsistent level of AIDS knowledge among students, with a significant gender and grade difference. More than one-third of the students perceived themselves as having limited knowledge of AIDS. While the students could identify transmission modes, they were less knowledgeable about symptoms, activities that did not transmit the virus, treatment and preventive measures. The majority of the students reported having discussed AIDS issues with their peers and friends, but few of them had done so with their parents or teachers. AIDS knowledge varied among students by site of residence, with the highest knowledge among students from the urban areas and the lowest among those from rural areas. The data underscore the urgent need for HIV/AIDS-related health promotion and prevention efforts targeting college students as well as younger age groups in China.
Key words: AIDS; China; college students; knowledge
INTRODUCTION
The steady increase of Human Immunodeficiency Virus (HIV) infection in China since the first case of Acquired Immunodeficiency Syndrome (AIDS) was diagnosed in 1985 underscores the urgent need for education and intervention efforts (Normile, 2000
). While the actual HIV sero-prevalence in China remains uncertain, the current official estimate of numbers of persons infected with HIV exceeds 840 000, including 80 000 patients suffering from full-blown AIDS (Anonymous, 2003). Of reported cases to date, 74.5% are male and 81% are 20–39 years of age (Qi, 2002). In the absence of effective prevention strategies, it is predicted that 10 million Chinese people will be infected by 2010 (Qi, 2002). Correspondingly, the number of cases of sexually transmitted diseases (STDs) in China has steadily increased over the last three decades. There were 
860 000 reported STD cases in 2000, with an average annual rate of increase of 19.3% since 1991 (Normile, 2000; Gong 2001). The actual number of STDs is believed to be 5- to 10-fold greater than what is being reported, with an estimated 3 million new cases of STDs each year (Chen, 1999). Nationwide, the incidence of STDs increased by 420% in women and 390% in men from 1990 to 1998 (Zhang and Ma, 2002). Although HIV prevention efforts targeting adolescents and young adults in China are currently limited, there is growing interest in devising effective, affordable and culturally appropriate prevention strategies (Normile, 2000).
While still controversial (Helweg-Larsen and Collins, 1997; Svenson et al., 1997), research in the United States and other western countries has suggested that sufficient knowledge regarding AIDS is a necessary, albeit insufficient, first step toward effective AIDS prevention and intervention efforts (DiMatteo, 1991; Fisher and Fisher, 1992). The Chinese government has repeatedly emphasized the importance of AIDS knowledge and education. Over the past 5 years, leading governmental bodies from health, finance and science have called for education and prevention efforts. In October 1998, the China Ministry of Health, State Commission of Planning, Ministry of Science and Technology, and Ministry of Finance jointly issued a document entitled Medium- and Long-term Plan for AIDS prevention and Control in China: 1998–2010 (State Council, 1998). In this document, the government articulated a goal for AIDS education that 70% of the urban population, 40% of the rural population and 80% of the high-risk population (such as commercial sex-workers and drug users) would have acquired basic AIDS knowledge by 2002.
Current evidence suggests that considerable effort will be needed to achieve these goals. For example, among 1400 public health care workers (including both prevention workers and clinicians who attended an AIDS workshop before the survey) from 11 administrative regions in China, only two-thirds of health workers correctly answered the three questions on transmission modes of HIV, and only about one-half knew that blood was the most efficient mode of transmission (Wu et al., 1999). The same investigators also surveyed 1548 young males in Yunnan Province (47% of whom were using drugs) and they found that more than half scored zero on 13 HIV and AIDS knowledge questions (Wu et al., 1997). One area that has received increasing attention is HIV awareness among Chinese college students. In two surveys conducted among college students in Beijing, only one-half of them knew that use of a condom could reduce the risk of HIV/STD infection (Niu et al., 1999; Sun et al., 1999). The global literature has suggested that in general, college students have a relatively high level of HIV/AIDS knowledge (Svenson et al., 1997). Therefore, while HIV/AIDS knowledge is limited among the general population in China, lack of knowledge among Chinese college students might be more alarming than lack of knowledge in the general population because one would expect that college students, as future leaders of the society and as highly educated individuals, would be the most knowledgeable about HIV/AIDS. Therefore, the current study was designed to assess the overall level of AIDS knowledge and to explore possible gender and grade (i.e. the year of education in college) differences in AIDS knowledge among college students from two major cities in China.
METHODS
Survey sites and participants
The participants comprised 1081 college students (52% females and 48% males) who were recruited from eight universities/colleges in March 2000 in Beijing and Nanjing, China. The participants in the present study were recruited from five universities in Beijing and three universities in Nanjing. The students were enrolled in 46 different academic programs in the participating universities. The research design received approval from the Institute of Developmental Psychology at the Beijing Normal University, and the Institute of Higher Education Research at the Nanjing University in China.
Survey procedure
Local investigators, all of whom are college professors in China, identified the target colleges and contacted administrators at each of these colleges for permission to conduct surveys in their institute. After receiving permission from the colleges, the researchers approached students in their classrooms. Having explained the nature of the research, the investigators distributed a self-administered questionnaire to the students. The students were informed that the survey was anonymous and were assured of the confidentiality of their responses. Written consent was obtained before participation. All students approached agreed to participate. The majority (94%) of the students approached (and recruited) were in their freshman, sophomore and junior years, because most of the seniors were not accessible in classrooms during the month of the survey. For the purpose of data analysis, a small number (n = 64) of seniors recruited were excluded from the current study. In addition, five questionnaires, each with more than half of the data missing, were removed from the analysis.
Measures
A self-administered questionnaire entitled AIDS Knowledge and Attitude Inventory (College Version) was compiled for the current study. The main AIDS knowledge and attitudes sections were adapted and compiled from the scales used in the 1992 United States National Health Interview Survey (Schoenborn et al., 1994) and other studies in the US [e.g. (DiClemente et al., 1986; Koopman et al., 1990; Sweat and Levin, 1995)]. The items were translated from English to Chinese, and then translated back to ensure the accuracy of translation. The following measures were used in the current study.
Individual characteristics
Individual characteristics assessed were: gender, age, year in college, ethnicity (Han or non-Han, with Han accounting for 92% of the total population nationwide), school performance (5-point scale ranging from ‘poor’ to ‘excellent’) and physical health (4-point scale ranging from ‘poor’ to ‘very good’). For the purpose of data analysis, the responses to school performance were combined into ‘average or below’ and ‘above average’. Similarly, physical health was dichotomized into ‘good’ and ‘fair’.
Family characteristics
Students were asked about their father's and mother's education level on a 6-point scale, ranging from ‘below elementary school’ to ‘postgraduate’. Responses regarding parental education were dichotomized into ‘did not finish high school’ and ‘completed high school or more’. Perceived family economic status was measured in terms of the level of family income compared with their classmates on a 3-point scale: ‘above average’, ‘average’ and ‘below average’. Family type was described as living with ‘both biological parents’ or ‘in another type of family’. Students in the Nanjing area were also asked whether they came from a rural area, a small city or a metropolitan area.
AIDS awareness
Students were asked about their perceived AIDS knowledge on a 4-point scale (‘a lot’, ‘some’, ‘little’ and ‘nothing’).
Source of AIDS information
Two types of information sources were assessed: media/public and personal. For media/public sources, students were asked whether they had received AIDS information in the past month from any of 15 sources/places (e.g. television, radio, magazine articles, newspapers, billboards). Students were also asked to check one source they believed could provide the most reliable information on AIDS. In terms of ‘personal sources’, the students were asked with whom they had ever discussed AIDS (e.g. parents, teachers, friends) and were also questioned about who they would ask if they had a question about AIDS.
AIDS knowledge
There were three sets of AIDS knowledge questions in different formats. The first set consisted of 11 ‘true/false/do not know’ items assessing knowledge of definition and causation. The second set contained 13 questions with a 6-point scale (‘very likely’, ‘likely’, ‘unlikely’, ‘most unlikely’, ‘absolutely unlikely’ and ‘do not know’) querying modes of AIDS virus transmission. For the purpose of data analysis in the current study, the responses were grouped into ‘likely’ (very likely and likely), ‘do not know’ and ‘unlikely’ (unlikely, most unlikely and absolutely unlikely). The third set was four questions regarding AIDS symptoms and preventive measures with a 5-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’. The responses were combined into three categories: ‘agree’ (strongly agree and agree), ‘uncertain’ and ‘disagree’ (disagree and strongly disagree).
These 28 items were reorganized into four categories of AIDS knowledge: AIDS definition/symptoms (five items), true transmission modes (five items), false transmission modes (10 items), clinical outcomes (three items) and treatment/prevention (five items). Percent of correct answers was used as a composite score for each of the categories. Due to a printing error, one of the items concerning transmission modes (‘blood transfusion’) was omitted from the questionnaire used in Beijing.
Analysis
First, differences in individual and family characteristics by region (i.e. Beijing versus Nanjing), gender and grade (i.e. freshman, sophomore and junior) were examined using analysis of variance (ANOVA; for continuous variables) and the chi-square test (for categorical variables). Secondly, AIDS awareness was examined by region, gender and grade, as well as other selected individual and family characteristics using the chi-square test. The ‘most reliable’ ranking for media/public sources was calculated using percentage of endorsement for each of the categories. AIDS knowledge was examined overall, as well as by region, gender and grade, using the chi-square test (at item level) and ANOVA (for composite score). The perceived knowledge and actual knowledge were compared for each of the categories using ANOVA. Finally, multivariate analysis of variance (MANOVA) was employed to assess the differences in five AIDS knowledge subscales by city, gender, and grade. Main effects of city, gender, grade and their interactions were examined simultaneously in the MANOVA model. Pillais F test was used for evaluating multivariate significance and the conventional F test was used for univariate testing with individual subscales.
RESULTS
Sample characteristics
The sample consisted of 239 (22%) freshmen, 512 (47%) sophomores and 330 (31%) juniors (Table 1). Six hundred and thirty (58%) students came from the universities in Nanjing and 451 (42%) from the universities in Beijing. Mean age was 20.76 years, with 96% of the participants between 17 and 23 years of age. Ninety-three percent of the sample were of Han ethnicity and lived with both biological parents. The sample consisted of 53% females and 47% males. There were some regional and gender differences in demographic characteristics. More students in Beijing than in Nanjing reported having parents with at least high school education (66% versus 60% for father, p < 0.05; 56% versus 44% for mother, p < 0.0001), and being a good student at school (44% versus 36%, p < 0.01). Males were older than females (20.99 years versus 20.55 years, p < 0.0001). More females than males reported having mothers with at least high school education (53% versus 44%, p < 0.01) and perceived themselves to be good students (46% versus 32%, p < 0.0001). More males than females reported a below-average family economic status (23% versus 17%, p < 0.01). Among students in Nanjing, more males than females came from rural areas (43% versus 28%, p < 0.0001). The students did not differ based on their years at college on any of the demographic characteristics except age.
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AIDS awareness
As shown in Table 2, 5% of students felt that they knew ‘a lot’ about AIDS and 2% knew ‘nothing’. Two-thirds had ‘some’ knowledge and about one-quarter had ‘a little’. AIDS awareness (or perceived AIDS knowledge) differed significantly by region, with Beijing students perceiving themselves to be more knowledgeable than Nanjing students perceived themselves to be (p < 0.0001). Females felt less knowledgeable than males (p < 0.01). Perceived AIDS knowledge increased with grade (p < 0.0001). Student AIDS awareness level differed significantly by perceived health status (p < 0.001), family economic status (p < 0.01) and level of maternal education (p < 0.01). Among students in Nanjing, AIDS awareness also differed by the location of their hometown (p < 0.05). There was no difference in perceived AIDS knowledge by ethnicity, school performance, family type and paternal education.
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Source of AIDS information
Fifty-six percent of the sample reported having received, in the previous month, information about AIDS from newspapers or magazine articles, 40% from television, 27% from health department/physicians, 24% from radio, 22% from school, 21% from shop window displays or bill posters, 19% from their friends and peers, 10% from displays on buses or taxis, 8% from community organizations, 5% from parents or relatives, and 2% from an AIDS hotline. Thirteen of the 14 sources of AIDS information differed significantly between Beijing students and Nanjing students. While more students from Nanjing received AIDS information from newspapers (63% versus 46%, p < 0.0001), more students from Beijing received AIDS information from other channels (i.e. magazine, television, local health department/physicians, radio, shop windows, bill posters, friends/peers, bus/taxi displays, community organizations, parents, relatives, AIDS hotline). More males received AIDS information from newspapers, while more females received it from pubic displays such as shop windows and bill posters.
Thirty-five percent of students (25% in Beijing and 42% in Nanjing) identified ‘health department/physicians’ as the ‘most reliable source’ of AIDS information, 30% endorsed ‘television’ (35% in Beijing and 27% in Nanjing) and 16% endorsed ‘newspapers’ (25% in Beijing and 10% in Nanjing), followed by ‘school’ (9% for entire sample, 8% in Beijing and 10% in Nanjing) and ‘AIDS hotline’ (5% for entire sample, 8% in Beijing and 3% in Nanjing).
Sixty-three percent of the youth (78% in Beijing and 52% in Nanjing) reported that they had discussed HIV/AIDS issues with their friends, and 57% of the sample (25% in Beijing and 77% in Nanjing) said they had done so with their classmates. About 21% of students (27% in Beijing and 14% in Nanjing) said they had ever discussed AIDS with their parents or relatives, while 13% (21% in Beijing and 8% in Nanjing) did so with their teachers and 18% (32% in Beijing and 9% in Nanjing) with friends of opposite sex. More females than males discussed AIDS with their parents or relatives (28% versus 14%, p < 0.0001). Compared with freshmen, more sophomores and juniors had discussed AIDS with teachers (2%, 12% and 10% for freshmen, sophomores and juniors, respectively; p < 0.0001), friends (45%, 59% and 50%, respectively; p < 0.05), friends of the opposite sex (5%, 11% and 10%, respectively; p < 0.05) and classmates (67%, 80% and 83%, respectively; p < 0.0001). With regard to seeking AIDS information in the future, nearly half of the youth said they would ask physicians and nearly one-third said they would turn to an AIDS hotline. Less than one-tenth (9% females versus 4% males, p < 0.05) said they would ask their parents. More juniors (57%) than freshman (41%) and sophomores (44%) said they would seek answers from physicians (p < 0.01).
AIDS knowledge
As shown in Table 3, students responded correctly to 66% of the AIDS knowledge questions. The subcategory with the highest mean correct response rate (96%) was true transmission mode, while the one with the lowest was clinical outcomes (53%). There was no difference in AIDS knowledge by region. Males were more knowledgeable than females overall (67% versus 64%, p < 0.0001). Males were more knowledgeable than females with regard to the categories of ‘false transmission modes’ (62% versus 58%, p < 0.05) and ‘treatment/prevention’ (65% versus 56%, p < 0.0001). There was a positive trend between overall AIDS knowledge and years of education (62%, 66% and 67% for freshman, sophomore and junior, respectively; p < 0.0001). In general, juniors and sophomores were more knowledgeable than freshmen, particularly with respect to ‘definition and symptoms’ (p < 0.001), ‘false transmission modes’ (p < 0.01) and ‘treatment and prevention’ (p < 0.01).
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Within all the subcategories except ‘true transmission modes’, there was substantial variation by item. For example, correct responses ranged from 53% to 80% for ‘symptoms/definition’, 48% to 89% for ‘false transmission modes’, 13% to 93% for ‘clinical outcomes’, and 43% to 80% for ‘treatment/prevention’.
While students were knowledgeable about the true transmission modes of the AIDS virus, there were many misperceptions about other ‘false’ transmission modes. About half of the sample thought that (or were not sure whether) a person could contract HIV by ‘sharing plates, fork or glass’ (46%), ‘using a public toilet’ (49%), ‘being coughed or sneezed on’ (41%), ‘receiving medical care from someone who has the AIDS virus’ (51%) or ‘using a public swimming pool’ (52%). Only about two-thirds of the sample did not think they would be likely to contract the AIDS virus from mosquitoes or other biting insects. Knowledge about the clinical outcomes of AIDS was mixed. While the majority of the sample knew that AIDS can reduce the body's natural protection against disease, only 13% of youth knew that AIDS could damage the brain. Knowledge about the treatment and preventive measures for AIDS was low. Only one-third of females (35%) and less than one-half of youth overall (43%) knew that condoms could prevent HIV transmission.
HIV/AIDS awareness (i.e. perceived knowledge) was positively correlated with actual knowledge among the participants (correct response rates were 71%, 69%, 62% and 43% for perceptions of knowing ‘a lot’, ‘some’, ‘little’ and ‘nothing’, respectively; p < 0.0001). The students, however, who perceived themselves as knowing ‘a lot’ about AIDS had a <70% correct response rate on four of the five knowledge categories, with only 57% and 65% for the questions related to ‘clinical outcome’ and AIDS ‘definition/symptoms’, respectively. The students in Beijing self-perceived a higher level of AIDS awareness than those in Nanjing (e.g. 80% versus 65% thought that they knew ‘a lot’ or ‘some’). However, there was no difference in the level of actual AIDS knowledge between the two cities.
Multivariate analysis conducted on categorical scores of AIDS knowledge (Table 6) confirmed the bivariate analyses with significant main effects of gender (Pillais F = 5.41, p < 0.0001) and grade (Pillais F = 2.26, p < 0.05). There were significant interactions between city and grade (F = 1.90, p < 0.05), and between gender and grade (F = 1.88, p < 0.05). Further inspection of the interactions suggested that freshmen in Beijing had a higher level of AIDS knowledge than freshmen in Nanjing. Likewise, male sophomores and juniors had a higher level of AIDS knowledge than their female counterparts.
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DISCUSSION
Given the early stage of the HIV/AIDS epidemic in China, awareness and appropriate knowledge may play an important role in preventing the further spread of HIV/AIDS among the general population. The data in the current study indicated an inconsistent level of AIDS knowledge among college students in China compared with the goal of 70% knowledge in the urban population. More than one-third of students acknowledged that they had very limited knowledge of AIDS. While the students could identify transmission modes, they were less knowledgeable about symptoms, activities that did not transmit the virus, treatment, and preventive measures.
The data in the current study revealed a significant gender difference in AIDS knowledge among college students in China, with males being more knowledgeable than females, particularly in the areas concerning HIV/AIDS treatment and prevention. This finding is not consistent with studies in the United States [e.g. (Hardy, 1990; Greenlee and Ridley, 1993)], which found that AIDS knowledge did not differ among college students on the basis of gender. However, gender differences in AIDS knowledge and attitudes have been found in other countries such as Kuwait (Al-Owaish et al., 1999). Similar to the studies in the United States (Fisher and Misovich, 1990; Hardy, 1990), there was a positive correlation of knowledge with increasing college education in the present study.
The data suggest that the majority of Chinese college students have discussed AIDS issues among their peers and friends, but few of them have done so with their parents or teachers. Discussion related to sexual matters is rarely conducted among family members, especially cross-generations, in Chinese society because sex is a taboo topic in traditional Chinese culture (Gao et al., 2001). It is also possible the older generation (e.g. parents, teachers and physicians) did not receive any sex education themselves and thus do not know how to approach the subject (Chang, 1997). In addition, families in China tend to live in more crowded, shared spaces, reducing the opportunity for private discussion on sensitive topics such as sex (Kulich, 2002).
Consistent with findings in the United States [e.g. (DiClemente et al., 1986; Dorman and Rienzo, 1988)] and other nations [e.g. (Porter, 1993)], college students in China appear to rely on the public media (e.g. newspaper, television, radio) as their primary source of AIDS information. While ‘health department/physicians’, ‘schools’ and ‘AIDS hotline’ were ranked among the top five sources the students believed to provide the ‘most reliable information’ about AIDS, only about one-quarter of the students reported having received AIDS information from health care professionals, about one-fifth from school, and 2% from an AIDS hotline.
AIDS knowledge appears to vary among students based on site of family residence, with the highest knowledge among students from metropolitan areas and the lowest among students from rural areas. This finding is consistent with other studies in different cultures [e.g. (Warren, 1999)] and may reflect the differences in levels of AIDS education efforts and information access in different geographical areas in China. Given the vast geography and population, consisting of multi-ethnic groups, AIDS education and prevention efforts in China should be tailored to meet the particular needs of each geographical ethnic niche.
These data are limited in their representativeness of the general population in China since only one-tenth of youth in China attend a university (China Ministry of Education, 2000). However, the fact that the data were obtained from eight different universities and 46 different academic programs provides a strong indication of the need for AIDS education among college students.
The findings in the present study have several implications in terms of health promotion and HIV/AIDS prevention among Chinese adolescents and young adults. First, education efforts and wider health promotion and prevention programs targeting adolescents are needed in China. While such efforts should include college students, clearly programs need to begin at an earlier age level (e.g. middle and high schools) to reach the majority, rather than a small minority, of Chinese youth, because many high school students do not attend colleges in China. There is no standard sex education curriculum in most Chinese middle and high schools (Gao et al., 2001). Although there is a course on ‘physiology and hygiene’ that is given to all students in junior high school, the course is not oriented toward sex education and disease prevention. School teachers often omit sex-related content (e.g. puberty, reproductive health) in instruction or assign it as a self-learning assignment (Gao et al., 2001).
Secondly, the gap between students' high level of trust but low level of utilization of health care providers and schools underscore the great potential of these traditional health care sources in HIV/AIDS education and prevention. As the current efforts in China with regard to HIV awareness promotion and prevention have largely relied on peer education (Gao et al., 2001) and public media campaigns (Qi, 2002), the mobilization and active involvement of health care providers and schools in HIV education and prevention would be critical in fighting the HIV/AIDS epidemic in China.
Thirdly, the knowledge gap between mode of transmission and preventive measures suggests that the role of condoms and other components of ‘safer’ sex should be emphasized in education and prevention efforts. While almost all of the students (98%) recognized that HIV could be transmitted through sexual intercourse, less than one-half of students agreed that using condoms could prevent HIV. In addition, substantial global experience supports the observation that mere possession of accurate information does not necessarily lead to behavioral change (Hays and Hays, 1992; Mann et al., 1992). Other effective prevention components, including efficacy building, stigma reduction and skill acquisition regarding preventive measures (e.g. condom use), are needed beyond information dissemination. Further, information campaigns should be designed based upon the understanding that people's reactions to knowledge rather than the knowledge itself may be the important determinant of behavior change (Petty and Cacioppo, 1986; Helweg-Larsen and Collins, 1997). Finally, the role of peers in AIDS awareness promotion needs to be recognized, as peers and friends serve as the main source for AIDS knowledge. The format and presentation of facts in AIDS awareness promotion and prevention should be informed by past educational efforts in China [e.g. (Gao et al., 2001)], and should be tailored to be sensitive to differences in cultures, economics and education among target populations.
ACKNOWLEDGEMENTS
The authors wish to thank Mary Bane for assistance in preparing this manuscript. This study was supported in part by the World AIDS Foundation [WAF-218 (00–014)].
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