METHODS:

Sample

The sampling frame was defined as residents aged between 15 and 49 years, from two districts, one city, and four counties (hereafter, all called counties) in China that were selected to represent three economic development levels in addition to varying levels of the seriousness of the AIDS problem. Jingan District, Shanghai Municipality and the urban area of Sanya City, Hainan Province were identified to represent the high socioeconomic urban area (high). Dongning County, near the border of Russia, Heilongjiang Province, Huidong County, Guangdong Province, and Changping District, Beijing Municipality, were identified to represent the high socioeconomic rural area (medium), and Shangcai County, Henan Province along with Baise County, Guangxi Province, were identified to represent low socioeconomic rural areas (low) (Figure 1).

Respondents were selected using multistage random sampling techniques. In the first stage, five townships or street committees were randomly selected from an administrative frame in each county. Next, two villages or neighborhood committees were randomly selected from each township or street committee selected. In the third stage, 100 households were randomly selected from each village or neighborhood committee chosen. Finally, one person aged between 15 and 49 years was randomly selected for interview from each household. When the person was unavailable or refused interview, another household was randomly selected. At least 1000 respondents from each county were enrolled in this study.

Procedures and measures

A face to face household interview was conducted with selected respondents in December 2000. A survey leader trained by the State Family Planning Commission selected the interviewers and organized interviewer training within each county. One interviewer questioned each respondent and filled out the questionnaire (no one else was present).

The survey’s 55 questions were divided into four sections, with the first covering sociodemographic information, contraception practices, and media exposure. The second section covered knowledge, including HIV transmission and prevention and the third section, health consultation and communication regarding HIV/AIDS and sources of information. The final section covered sex education and HIV/AIDS education, condoms, and perceptions of neighborhood activities (e.g., use of illegal drugs). Neighborhood perceptions will be reported elsewhere.

Statistical analysis

Since we used multistage sampling and because residents from different villages differed in their selection probabilities, we weighted the data and conducted all analyses using Software for Survey Data Analysis (SUDAAN) to account for the complex survey design (1). We estimated prevalence with 95% confidence intervals for each of the main measures, which were further examined by sociodemographic category. We also conducted bivariate analyses of selected variables by condom use. We carried out multivariate logistic regression analyses to examine the independent effects of sociodemographic factors on three outcomes: (i) ever heard of HIV (yes, no), (ii) knowledge of transmission, and (iii) knowledge of prevention. Levels of HIV transmission and prevention knowledge were dichotomized as <3 vs. >3 correct responses.

RESULTS:

A total of 7053 individuals responded to the survey but only 7022 provided usable data. Table 1 shows the sociodemographic patterns of the sample. When selected by region, almost half (48.9%) of all respondents lived in low socioeconomic areas and most respondents were aged between 30 to 39 years (43.9%). Less than half (46.4%) of respondents had middle school education; 20.9% had 10 or more years of education. The sample was almost evenly divided by sex (51.4% male) and most individuals were married (86.4%). Annual income ranged from <1500 Chinese yuan (< $181 U.S.) for 43.6% of respondents to 3500 or more yuan (> $422 U.S.) for 25.7% of respondents. When selected by occupation, over half (58.0%) of the individuals were farmers. Relatively few respondents (<12%) reported that they or their spouse had spent time out of town in the past year. Over 94% indicated that they watched television at least occasionally in the past month.

HIV/AIDS-related knowledge

An estimated 83.1% of respondents had heard of HIV (Table 2) and the remainder of this report focuses on these individuals (n=5633). In this group, 73.3% did not know the cause of HIV and 89.1% did not know how it can be detected. The great majority (90.7%) knew that HIV can be transmitted, but 22.1% did not know a single route of transmission and only 8.0% knew the four main routes (blood transfusion, sharing needles, sexual intercourse, and infected mother to newborn) (Table 3). Over half (51.5%) of the individuals did not know that transmission is possible by blood transfusion, 81.0% did not know that it can be transmitted by sharing needles, and 84.5% did not know that an infected woman can pass it to her newborn (data not shown). In contrast, 67.5% knew that AIDS can be transmitted through sexual intercourse. The great majority knew that it cannot be transmitted by shaking hands with an HIV positive individual or an individual with AIDS, neither by hugging or kissing that person, or by handling his/her belongings (>90% for each of the four actions).

Considerable sociodemographic variation was seen in the percentage of people who had not heard of HIV (Table 2) and in knowledge of HIV transmission (Table 3). For example, individuals who were significantly more likely to have never heard of HIV were: (i) persons in regions with low or medium socioeconomic status, (ii) women, (iii) those with less than 10 years of school, (iv) farmers and farm workers or rural business people (hereafter, farm workers), and (v) those with annual incomes less than 3500 Chinese yuan. Those in the low socioeconomic areas (vs. high) were also significantly less likely to know that HIV can be transmitted or to know all of the primary modes of transmission. In addition, persons with less than middle school education, farmers, and the poorest group (income <1500 yuan vs. >3500) were less likely to know these facts.

A similar pattern emerged when respondents were asked about prevention of AIDS. Almost three-fourths (74.3%) thought that HIV/AIDS is preventable, but 77.2% did not know that it can be prevented through correct use of condoms, 75.9% by avoiding unsafe blood transfusions, and 82.6% by not sharing syringes or needles (data not shown). In the case of prevention by having one sex partner more than half of the individuals (61.5%) were knowledgeable. Only 9.6% could identify all the primary ways in which HIV/AIDS can be prevented, and over one-fourth (28.5%) did not know any of the ways in which it can be prevented (Table 4). The sociodemographic variation in the group of individuals who knew about HIV prevention was somewhat similar to that seen in the group of individuals who had never heard of HIV and did not know how HIV can be transmitted. Individuals living in low (vs. high) socioeconomic areas, those with less than middle school education, farmers (vs. other occupations), and those with annual incomes below 1500 yuan (vs. 3500 or more) were significantly less likely to know that HIV/AIDS can be prevented or to know at least one means of prevention (Table 4).

When asked if AIDS is curable, a substantial minority (35.6%) either did not know or believed that AIDS is curable (data not shown). One-half of respondents correctly indicated that condoms were one type of contraceptive method that could prevent HIV/AIDS, but 41.3% did not know of any contraceptive method that could prevent the disease. Three-fifths (60.7%) were not worried about getting infected, 13.4% were very worried, and 23.0% were a little worried. In terms of whether their spouses would get infected if they often left home, these percentages were comparable: 59.0%, 12.2%, and 25.5%.

Multivariate findings

Multivariate analyses showed that older people (40-49 vs. 21-39 years), women, individuals with less than 10 years of education, farmers or other farm workers, and individuals with incomes of 1500-3499 yuan (vs. 3500 or more) were significantly less likely to have ever heard of AIDS (Table 5). Similarly, individuals aged between 40 and 49 years (vs. those 21-39 years), women, individuals with less than 10 years of school, and farmers or other farm workers were significantly less likely to be fairly knowledgeable about HIV transmission (i.e., they knew less than 3 routes) or prevention (they knew less than 3 ways).

Consultation and communication, sources of information

Almost three-fourths (71.9%) of respondents said that they would consult medical personnel first if they suspected that they were infected with HIV, but 10% did not know who to consult (data not shown). Responses to several options indicated that the great majority would not call a hotline (92.6%) or take some medicine (95.6%), but neither would they do anything (94.1%), conceal it and avoid other people (98.3%), or ignore it (99.7%) (data not shown). In fact, most individuals (70.3%) would seek a further checkup. Notably, 89.4% of respondents said that they would not avoid sexual intercourse. Individuals living in high socioeconomic regions, or who had at least 10 years of school, who were not farmers or farm workers, and had incomes of 3500 yuan or more were significantly more likely to obtain a further checkup if they thought that they were infected. They were also more likely to avoid intercourse. More than 80% of persons in each category (socioeconomic region, education, occupation, and income) would not avoid sex.

In terms of communication about HIV/AIDS, most respondents had not talked to their spouse (15.3% had), work mates (18.6%), or friends of the same gender (28.4%); percentages were even lower for other choices. Men were somewhat more likely than women to talk to friends of the same gender (33.3% vs. 22.7%) and to work mates (21.9% vs. 14.8%). At least 90% of respondents said that they would not hate or blame HIV-infected acquaintances, but 40.2% would avoid contact and most would not sympathize with (72.1%) or be concerned about (61.2%) these acquaintances.

When asked about where they obtained or what type and where they preferred to obtain HIV/AIDS-related information, over two-thirds (68.0%) obtained their information from TV, 34.3% from books or newspapers, and 17.4% from radio. Less than 10% received information from medical experts or personnel or from the Department of Information, Education and Communication (IEC) activities or family planning agencies, the Internet, or a telephone hotline. Sixty-three percent of respondents said that they would prefer to receive this kind of information from TV, 28.1% from books or newspapers, and 16.3% from the radio. Less than 10% would prefer to receive information from IEC activities or family planning agencies, the Internet, or a telephone hotline, but 16.8% would prefer to receive it from medical experts/personnel. Preferred types of information were brochures (38.8%), calendars (32.3%), wall charts (30.5%), and video compact disks (CDs) (24.1%).

Awareness of STDs other than AIDS was modest, with 56.3% of the individuals aware of syphilis and 46.9% knowing about gonorrhea. There was very little awareness of other STDs such as Condyloma accuminatum, nongonococcal urethritis, genital herpes, chancres, lymphogranuloma venereum, and hepatitis B. Just under three-fourths (73.6%) of respondents thought that it was necessary to know about HIV/AIDS/STDs.

Attitudes about HIV/AIDS education, condoms and condom use

Almost four-fifths (78.7%) of respondents thought that it was necessary for schools to teach sex education, and a somewhat greater percentage (83.8%) thought it was necessary for schools to educate on HIV/AIDS prevention. Middle school was considered the most appropriate time for adolescents to receive sex education (63.0%) while the teen years the appropriate time to learn about HIV/AIDS (62.1%). Most individuals (76.4%) thought that it was necessary for unmarried young people to learn about contraception, but only 35.9% thought that contraceptives should be provided to them (here, the choices were yes, no, depends on the situation). More than half (58.4%) did not think that premarital sex was acceptable for a couple intending to marry.

Shops and drug stores (40.7%) and family planning agencies (37.8%) were the most popular choices for places where condoms should be obtained. Only 28.4% of respondents reported that they or their spouse had ever used condoms, and most (66.7%) were embarrassed to buy condoms in a shop or drug store. Based on a series of statements in which respondents were asked to express their agreement or disagreement, 62.7% believed that the correct use of condoms can prevent pregnancy, but 31.1% of respondents felt that sex was less comfortable with condoms. About half of individuals (51.6%) said that the correct use of condoms can prevent STDs and 42.5% said that it can prevent AIDS. Relatively few respondents disagreed with these statements, but many indicated that they “did not know.” Persons who lived in high socioeconomic areas, individuals who were 21 years or older, individuals with 10 or more years of education, those who were not farmers or farm workers, and those with incomes of 3500 yuan or more were significantly more likely to believe that the correct use of condoms can prevent AIDS.

We further examined our two measures of condom use (currently usage of condoms for contraception and whether they or their spouse had ever used condoms) in relation to beliefs and attitudes about condoms and AIDS. Although 5.5% of respondents reported that they currently used condoms for contraception (female sterilization was the most common current contraceptive method, reported by 40.5% of respondents), over three-fourths (77.3%) of respondents in this group believed that condoms can prevent HIV/AIDS. This percentage was significantly greater than the remainder (22.8%) who incorrectly believed that other methods of contraception can prevent AIDS.

Similarly, among the 28.4% who had ever used condoms (spouses included), the majority (69.3%) knew that condoms can prevent HIV/AIDS, significantly above the 30.7% who thought that other methods of contraception (e.g., sterilization, IUD, the pill, spermicide, rhythm, implant) can prevent the infection. Quite the reverse was observed in the group of respondents who said that they had never used condoms. Among this group, less than half (42.2%) indicated that condoms can prevent infection, while 57.8% believed that other methods of contraception can prevent HIV/AIDS. We also found that the ever use of condoms was associated with the belief that condoms can prevent STDs or AIDS. Among those who had never used condoms, 74.3% agreed that the correct use of condoms can prevent STDs and 72.7% agreed that the correct use of condoms can prevent AIDS. Only 7.0% and 5.7% of the individuals in this group, respectively, disagreed with these statements; the remainder responded that they did not know.

Finally, we examined the associations between current sources of HIV/AIDS information and correct HIV/AIDS knowledge as measured by the proportion of respondents who knew the cause of AIDS, how it can be detected, and whether it can be transmitted. In contrast to our findings for all respondents, those with correct knowledge were less likely to receive information about HIV/AIDS from media sources (TV, books/newspapers, or radio) and more likely to receive information from the Internet (34.1%), activities organized by family planning agencies (23.3%), and medical experts or health professionals (19.6%).

References