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BMC Public Health

, 19:1630 | Cite as

Awareness of HIV/AIDS and its routes of transmission as well as access to health knowledge among rural residents in Western China: a cross-sectional study

  • Tianqi Zhang
  • Yang Miao
  • Lingui Li
  • Ying BianEmail author
Open Access
Research article
Part of the following topical collections:
  1. Health policies, systems and management in low and middle-income countries

Abstract

Background

The purpose of this study was to evaluate the coverage of HIV health education among rural residents in western China by ascertaining their awareness of HIV/AIDS and its transmission routes, and to investigate how these residents receive health information.

Methods

A survey was conducted through stratified clustered sampling at 99 county hospitals in 11 provinces in western China. Information was collected on awareness of HIV/AIDS and its transmission routes, as well as residents’ access to health knowledge. Chi-square analysis was used to analyse the differences in HIV/AIDS awareness (knowing of the existence of HIV/AIDS, hereinafter referred to as “HIV awareness rate”) between different subgroups categorized by demographic status, regional factors, and different methods of access to health knowledge. To further analyse the effects of access to health knowledge on HIV awareness, a logistic regression model was established. The relationship between access to health knowledge and transmission routes was also examined using chi-square analysis.

Results

The HIV awareness rate of the total 9274 participants was 80.9%. There were statistically significant differences between subgroups classified by age (χ2 = 482.118, p<0.001), education (χ2 = 853.465, p<0.001), occupation (χ2 = 340.553, p<0.001), income (χ2 = 186.448, p<0.001), cumulative HIV cases according to province (χ2 = 59.513, p<0.001), per capita annual net income of rural households according to province (χ2 = 64.676, p<0.001), proportion of minority population according to province (χ2 = 94.898, p<0.001), direct access to health knowledge (medical staff: χ2 = 419.775, p<0.001; mass media: χ2 = 740.238, p<0.001; family members: χ2 = 12.189, p<0.001; socializing: χ2 = 48.780, p<0.001; health education activities: χ2 = 154.400, p<0.001), and indirect access to health knowledge (having a non-communicable disease with medical instructions χ2 = 78.709, p<0.001; physical examinations: χ2 = 135.679, p<0.001). The logistic regression model showed that education and mass media had the strongest impacts on HIV awareness among all methods of access. Participants had the least awareness of HIV’s mother-to-child transmission route.

Conclusion

The HIV awareness rate indicated that previous HIV health education covered 80% of the rural population in western China. Mass media should take greater responsibility in HIV health education for the general population, and special attention should be paid to the elderly, the most impoverished population, minority community as well as the mother-to-child transmission route.

Keywords

HIV/AIDS Awareness rate Transmission routes Western China Rural residents 

Abbreviations

AIDS

Acquired immune deficiency syndrome

CSW

Commercial sex worker

GRP

Gross regional product

HIV

Human immunodeficiency virus

IDU

Intravenous drug user

KAP

Knowledge-attitude-practice

NCD

Non-communicable disease

NRCMS

New rural cooperative medical system

PMTCT

Prevention of mother-to-child transmission

SPSS

Statistical package for social sciences

STD

Sexually transmitted disease

WDP

Western development program

Background

The prevalence of HIV is a worldwide threat to public health. Although there is no cure for HIV, health education is considered as the most effective preventive measure. Being the most populous country, China places great importance on health education regarding HIV [1], and public education is one of the foundations of the Chinese HIV prevention and control system [1, 2].

Since the first case was diagnosed in Beijing in 1985, the Chinese government added requirements for health education to all national planning documents. However, it was not until the outbreak of HIV/AIDS among intravenous drug users (IDU) in Yunnan, a southwestern province, around 1990, that HIV awareness started to grow. In the mid-1990s, the HIV epidemic among commercial plasma donors in the central provinces was exposed. At around the same time, the central government published the first outline for HIV/STD health education, requiring local governments to provide HIV health education for the general population. In 1998, the government established basic principles for HIV/STD health education, and published an official handbook of basic information on HIV/AIDS [3]. In this way, China built up a clear policy framework for HIV health education.

Before 1998, HIV health education in China was mainly motivated by a political responsibility to respond to World AIDS Day [1, 4]. There were also disagreements about how to facilitate condom use and sexual education [5]. After 1998, the transportation, education, public security, and postal service departments, the entertainment sector, and NGOs began to play active roles in this field [3]. The central government’s 2004 HIV education plan recognized that rural areas still lacked HIV knowledge, and called for attention to rural areas, especially minority communities [6]. In response, a manual written in five ethnic languages was published, and clergy members started engaging in HIV health education among minority communities [7, 8].

In China, one outcome of the longstanding separation between urban and rural areas is the inequality of health services [9]. The rapidly developing economic process of urbanization drives thousands of villagers into the cities. Each year, a massive migrant population mobilizes in a country-city-country cycle. Part of this “floating population” engages in commercial sex, either as commercial sex workers (CSW) or paying customers [10]. Thus, they become a bridge population carrying HIV from high-prevalence cities to rural areas [10, 11]. More than half of those with newly diagnosed HIV in 2015 were from underdeveloped rural areas [12], and knowledge of HIV was lower in these areas [11, 13]. For these people, poor knowledge is a key factor in exposure to HIV infection and transmission [11, 14]. According to knowledge-attitude-practice (KAP) theory, knowing the existence of a disease and acquiring accurate knowledge is the foundation of health behaviour. In this context, there is a need for China to provide more HIV health education for residents of underdeveloped rural areas after getting a grasp on the effects of existing HIV health education.

On the other hand, previous research on HIV knowledge might have led to an overestimation of the effects of HIV health education [13, 15]. This overestimation could be attributed to the phenomenon of previous researchers inviting participants to fill the official questionnaire on HIV knowledge without asking whether they knew what HIV was. Therefore, some participants may just become familiar with HIV while reading the questionnaire and, if they select the correct answers, they may be assessed as having knowledge of HIV. This might contribute to a higher rate of reported HIV awareness, especially for rural areas [15]. Therefore the lack of accurate data had to be compensated.

The aim of this study was to evaluate the coverage of HIV health education in rural China by ascertaining the awareness of HIV/AIDS and its transmission routes among local residents, and to further investigate how these residents receive health information. Geographically, China can be divided into the eastern, central, and western areas. Socioeconomic development of the western area has lagged far behind since the Chinese reform and opening in 1978 [16]. In 2000, China initiated the Western Development Program (WDP), which ultimately established “western China” as a political term for an area consisting of 12 provincial divisions. It is a vast area, having more than fifty minorities living together with the Han people. The natural environment, and cultural and socioeconomic conditions, are more complex in the western part of the country than in the eastern and central areas, and these factors make health education more complicated [17]. Administratively, western China could also be categorized into two sections under a historical urban-rural dual structure. The rural area of western China is the least developed area. We conducted this research in rural western China.

Methods

Study area and setting

The study was conducted in 11 provincial administrative divisions (hereinafter “provinces”) in western China, in December 2011, as shown in Table 1. Western China covers 72% of the country’s territory, for a total of 6.86 million square kilometres. Most of this area consists of highland which is more than 1000 m above sea level. This area has a border approximately 20 thousand kilometres long and is contiguous to 10 countries, where two of the world’s main drug resources are located - the Golden Triangle and the Golden Crescent. It includes 6 provinces, 5 minority autonomous regions, and 1 municipality. Previously, Yunnan, Guangxi, and Sichuan were ranked among the top five provinces with newly diagnosed HIV cases via heterosexual transmission and intravenous drug injection [11, 12], and an outbreak of HIV also occurred in Xinjiang around 2000 [18]. One third of the Chinese population lives in this area (approximately 360 million people), and nearly 60% live in rural areas [19], including more than 50 minorities [16] with their own cultures, customs, and norms. Some also have unique languages and religions [20, 21, 22]. Religious influence is greater in this area than in the eastern or central areas – Islam forms a northwest-southeast belt extending from Xinjiang to Ningxia, whereas Buddhism forms a southwest-northeast belt extending from Tibet to Inner Mongolia [23]. Economic development, as a factor of HIV prevalence in Asian countries, is disrupting traditional society [24]. For better economic status, a large rural population moves inside this area as well as between other parts of China [11, 14, 16]. Additionally, drug trafficking, which originates in the Golden Triangle and Golden Crescent, moves from the northwestern and southwestern borders toward the coast [10], also adds pressure on HIV prevention. Finally, health care services in rural western China are insufficient - the quantity and quality of medical institutions are low, the service radius is large, the drug supply is scarce, and technical resources are limited [17].
Table 1

Construction of regional factors

Province

Category a

Area (10,000 km2) e

Population (million) f

Proportion of rural population (%)f

Per capital annual net income of rural households (RMB) g, b

Proportion of minority population (%) f, c

Cumulative cases of HIV/AIDS (in thousands of cases) h, d

Gansu

Province

42.58

25.99

64.1

3909.37(B)

9.43%(c)

1–5(1)

Guangxi

A.R.

23.76

47.96

60.0

5232.33(B)

37.18%(b)

50–100(3)

Guizhou

Province

17.61

35.30

66.2

4145.35(A)

36.11%(b)

10–50(2)

Inner Mongolia

A.R.

118.3

25.11

44.5

6641.56(C)

20.46%(b)

1–5(1)

Ningxia

A.R.

6.64

6.68

52.0

5409.95(B)

35.42%(b)

less than 1(1)

Qinghai

Province

72.23

5.88

55.3

4608.46(A)

46.98%(b)

1–5(1)

Shaanxi

Province

20.58

37.93

54.3

5027.87(B)

0.51%(c)

5–10(2)

Sichuan

Province

48.6

82.04

59.8

6128.55(C)

6.1%(c)

50–100(3)

Tibet

A.R.

120.22

3.24

77.3

4904.28(A)

91.83%(a)

less than 1(1)

Xinjiang

A.R.

166

23.60

57.2

5442.15(B)

59.9%(b)

10–50(2)

Yunnan

Province

39.4

47.42

65.3

4721.99(A)

33.37%(b)

100 and above (3)

a A.R.: Autonomous Region

b Regional rural residents’ economic status (RMB): A. Low-income area (less than 5000); B. Middle-income area (5000-6000); C. High-income area (6000 and above)

c Regional ethnic composition: a. Han-dominated area (less than 10%); b. Mixed area (30–60%); c. Minority-dominated area (90% and above)

d Regional HIV prevalence (in thousands of cases): 1. Low-prevalence area (less than 5); 2. Middle-prevalence area (5–50); 3. High-prevalence area (50 and above)

e The State Council of the People’s Republic of China. http://english.gov.cn/archive/

f The Sixth National Population Census, 2010

g China National Bureau of Statistics. China Statistical Yearbook 2012[M]. Beijing: China Statistic Press; 2012

h Long Yuqin. Picture: Distribution map of provincial cumulative HIV/AIDS (number of deaths included) until Oct 2014. China HIV map: homosexual transmission accounts for more than 80%. http://news.ifeng.com/a/20141202/42619936_0.shtml

Questionnaire design

For this study, we used a questionnaire written in Chinese, containing three sections. The first section was on sociodemographic information, including gender, age, education, occupation, and personal monthly income. Participants were classified into age groups of 16–40 years, 40–60 years, and above 60 years. Education was categorized into four levels – illiterate, primary, secondary, and tertiary, with reference to the revised 2011 version of the International Standard Classification of Education [25]. Occupation was classified according to the source of income, and personal monthly income classification was based on communication with local officials. The second section included 2 questions on HIV/AIDS: (1) Have you ever heard about HIV/AIDS (or do you know of the existence of HIV/AIDS)? (2) Please select all the transmission routes of HIV among blood, sex, mother-to-child, shaking hands, and droplets (multi-choice). Because implementation of the HIV health education relied on the general health education system, the third section of the questionnaire included 4 questions on access to health knowledge. Two questions were about direct access: (3) Please select the most frequently used channels to health knowledge based on your own situation among medical staff, mass media (broadcast, TV, newspapers, magazines, etc.), family members, and socializing (friends, colleagues, classmates, etc.) (multi-choice). (4) Did you participate in any health education activities in the last 6 months? Another two questions were on indirect access: (5) Have you had any physical examinations during the last year? (6) Have you had any non-communicable disease (NCD) during the last 6 months and, if so, did you receive any professional medical instructions? The 4 questions above were generated from previous studies [26, 27, 28] and adapted to our study setting. A pilot study was conducted with a small sample of the population before the main study was conducted.

Sampling strategy

In every province, according to the gross regional product (GRP) ranking, three counties representing high, middle, and low economic status were randomly selected (3 × 11 = 33 counties). County GRPs were obtained from the statistics bureau. In 2011, more than 95% of rural residents participated in the New Rural Cooperative Medical System (NRCMS). Sick individuals could be reimbursed for 60–80% of their medical costs if they visited local public medical institutions. In the current Chinese health system, county-level medical institutions are the primary comprehensive hospitals, and most patients treated there are local residents. Since household surveys and telephone surveys were not practical due to geographic and language barriers, we performed a hospital-based questionnaire study at public county-level medical institutions. Normally, each county has 3 types of county-level public medical institutions, so that 99 were included (3 × 3 × 11 = 99 county medical institutions). Questionnaires were randomly distributed to patients at the selected medical institutions through a systematic sampling process according to their order of registration. Sample size at specific medical institutions was calculated according to its annual patient volume.

Quality control

Questionnaires were administered by trained students from local medical colleges. Surveyors followed standardized procedures, with strategies to overcome the barriers of dialect, culture, and religion. Ethical approval was obtained from the University of Macau. All participants were fully informed of the research, and written informed consent was obtained. Additionally, the investigator could help explain the questionnaire; in some cases, the patients’ companions or medical staff could help overcome the barriers of dialect or ethnical languages.

Statistical analysis

Descriptive statistics were used to define demographic characteristics. Chi-square analysis was used to analyse rate of awareness of HIV/AIDS (hereinafter, “HIV awareness rate”) among different subgroups. Through chi-square analysis, factors that significantly affected awareness of HIV/AIDS were put into a binary logistic regression equation by the conditional forward method, therefore allowing us to analyse the influence of access to health knowledge on HIV awareness. Chi-square was used to analyse the influence of access to health knowledge on awareness of HIV transmission routes. SPSS (Statistical Package for Social Sciences, Chicago, IL, USA), version 19.0, was used for statistical analysis. All statistical tests were two-sided, with a significance level of 0.05.

Results

Sociodemographic features

A total of 10,394 questionnaires were returned, and 9274 (89.2%) were valid. Among the 9274 participants, the age distribution quartile was 28, 40, and 53 years (range, 16–100) and 42.8% were male. Other sociodemographic features are shown in Table 2.
Table 2

Demographic features and Chi-square test for HIV awareness among rural residents in western China (N = 9274)

Variables

N

Proportion of population (%)

Rate of awareness (%)

χ2

p value

Patient type

 Inpatient

4345

46.9

80.8

0.079

0.778

 Outpatient

4929

53.1

81.0

  

Social-demographic variables

 Gender

  Male

3965

42.8

80.4

1.137

0.286

  Female

5309

57.2

81.3

  

 Age

  16–40

4962

53.5

88.7

482.118***

< 0.001

  41–60

2925

31.5

75.1

  

  above 60

1387

15.0

65.1

  

 Education

  Illiteracy

1304

14.1

60.0

853.465***

< 0.001

  Primary

2233

24.1

70.5

  

  Secondary

4523

48.8

88.0

  

  Tertiary

1214

13.1

96.1

  

 Occupation

  Farmer

4284

46.2

74.0

340.533***

< 0.001

  Migrant worker

1379

14.9

87.9

  

  Salary employee

1121

12.1

91.8

  

  Student

324

3.5

94.8

  

  Others

1338

14.4

86.3

  

  Unemployed individuals

828

8.9

75.6

  

 Personal monthly income

  No income

2621

28.3

74.1

186.448***

< 0.001

  Less than 2000 yuan

4127

44.5

80.3

  

  2000–4000 yuan

1981

21.4

88.9

  

  4000 yuan and above

545

5.9

89.2

  

Region

 Cumulative cases of HIV/AIDS

  Less than 5000

3458

37.3

77.1

59.513***

< 0.001

  5000–50,000

2064

22.3

81.0

  

  50,000 and above

3752

40.5

84.3

  

 Per capita annual net income of rural households

  Less than 5000 yuan

3654

39.4

80.1

64.676***

< 0.001

  5000–6000 yuan

3619

39.0

78.3

  

  6000 yuan and above

2001

21.6

87.0

  

 Proportion of minority population

  Less than 10%

3191

34.4

86.2

94.898***

< 0.001

  30–80%

5512

59.4

78.5

  

  90% and above

571

6.2

74.1

  

Access to HIV knowledge

 NCD (in the last 6 months) and medical instructions

  Do not have an NCD

6889

74.3

81.1

78.709***

< 0.001

  Living with an NCD with medical instructions

1930

20.8

83.8

  

  Living with an NCD without medical instructions

455

4.9

65.7

  

 Had a physical examination (in the last year)

  Yes

3515

37.9

87.0

135.679***

< 0.001

  No

5759

62.1

77.2

  

 Participated in health education activities (in last 6 months)

  Yes

2951

31.8

88.3

154.400***

< 0.001

  No

6323

68.2

77.4

  

 Received health knowledge from medical staff

  Yes

4872

52.5

88.8

419.755***

< 0.001

  No

4402

47.5

72.1

  

 Received health knowledge from the mass media

  Yes

6653

71.7

87.9

740.238***

< 0.001

  No

2621

28.3

63.2

  

 Received health knowledge from family members

  Yes

795

8.6

76.2

12.189***

< 0.001

  No

8479

91.4

81.3

  

 Received health knowledge by socializing

  Yes

1696

18.3

86.9

48.780***

< 0.001

  No

7578

81.7

79.5

  

 Overall

9274

100.0

80.9

***P < 0.001

HIV awareness

For the 9274 participants, HIV awareness rate (the rate of knowing of the existence of HIV) was 80.9% [95% CI: 80.1–81.7%]. Subgroup analysis was applied to regional factors, sociodemographic factors, and access to health knowledge. Three regional factors, regional rural residents’ economic status, regional ethnic composition, and regional HIV prevalence were constructed, respectively, by province-level of per capita annual net income of rural households, proportion of minority population, and cumulative cases of HIV/AIDS. Details are shown in Table 1. In the analysis of regional factors, participants’ HIV awareness rate increased with increase in cumulative cases of HIV/AIDS, from 77.1 to 84.3% (χ2 = 59.513, p<0.001). Per capita annual net income of rural households also had a positive influence on HIV awareness, with a cut-off point at 6000RMB (χ2 = 64.676, p<0.001). Simultaneously, awareness rate was lower in regions with more ethnic minorities, ranging from 86.2% in a Han-dominated area to 74.1% in Tibet (χ2 = 94.898, p<0.001), where more than 90% residents are minorities. Inpatient and outpatient status had no statistically significant effect on HIV awareness rates, and no difference was seen between the two genders. However, HIV awareness rate declined with increasing age, from 88.7% in young people (16–40 years) to 75.1% in middle-aged individuals (40–60 years), and 65.1% in the elderly (above 60 years) (χ2 = 482.118, p<0.001). In contrast, we noted an upward trend from 60.0 to 96.1% with participants’ educational levels increasing from less than primary education (the illiterate) to tertiary education (χ2 = 853.465, p<0.001), as well as from 74.1 to 89.2% with participants’ personal monthly income increasing from no income to RMB4000 and above (χ2 = 186.448, p<0.001). Three levels of HIV awareness rate were noted among different occupations (χ2 = 340.533, p<0.001): farmers and unemployed individuals (approximately 75%), migrant workers and others (approximately 87%), and students and salary employees (greater than 90%). Individually, the HIV awareness rates were 88.8, 87.9, and 86.9% of participants who received health knowledge from medical staff, mass media, or socializing, respectively, which were all greater than for those who did not. Participants who took part in health education activities and physical examinations both had a 10% higher awareness rate than those who did not. Conversely, those who received health knowledge from family members had a 5% lower HIV awareness rate than those who did not. We noted that only 795 participants belonged to this subgroup, accounting for 8.6% of the sample population. Participants who had an NCD in the previous 6 months and received medical instructions had the similar level of awareness (83.8%) as those who did not have an NCD (81.1%). In contrast, only 65.7% of participants who had an NCD but did not receive medical instructions knew of the existence of HIV. These results are shown in Table 2.

Factors associated with HIV awareness

Except for patient type and gender, all demographic factors, regional factors, and methods of access to health knowledge were entered into a binary logistic regression model as dependent variables. HIV awareness rate was adopted as the independent variable. For demographic variables, participants who were 16 to 40 years old, illiterate, farmers, and had no income were the reference groups, respectively, for the categories of age, education, occupation, and personal monthly income. For regional variables, one variable - regional rural residents’ economic status - was excluded by forward conditional analysis. Low-prevalence area and low proportion of minority population were the reference groups, respectively, for regional HIV prevalence and regional ethnic composition. For access to health knowledge, the reference groups were those with individuals who did not receive health knowledge from medical staff, mass media, family members, and socializing; those who did not participate in health education activities; those who did not have a physical examination; and those who did not have an NCD. As shown in Table 3, compared with young people (16–40 years), middle-aged individuals (41–60 years) were less likely to know about HIV (OR = 0.533, 95% CI: 0.462–0.615, p<0.001) and older people (60 years and above) were even less likely (OR = 0.395, 95% CI: 0.329–0.474, p<0.001). Compared with farmers, students were more likely to know about HIV (OR = 2.469, 95% CI: 1.455–4.188, p < 0.01). Compared with the illiterate, those who had finished secondary education were more likely to know about HIV (OR = 2.275, 95% CI: 1.903–2.720, p<0.001), and having finished tertiary education increased this likelihood (OR = 4.519, 95% CI: 3.130–6.525, p<0.001). People who received health knowledge from medical staff (OR = 2.557, 95% CI: 2.244–2.914, p<0.001) and the mass media (OR = 3.812, 95% CI: 2.800–3.618, p<0.001) were more likely to know about HIV. Interestingly, people in high-prevalence areas and low-prevalence areas had the same likelihood of being aware about HIV (OR = 1.024, 95% CI: 0.882–1.188, p = 0.760), whereas those in middle-prevalence areas were less likely to know about HIV (OR = 0.722, 95% CI: 0.608–0.856, p<0.001). Finally, the likelihood of knowing of HIV decreased with an increased proportion of minorities (minority proportion according to province 30–80%: OR = 0.864; minority proportion according to province > 90%: OR = 0.453).
Table 3

Logistic regression results of HIV awareness among rural residents in western China (N = 9274)

Variables

OR

95% CI

p value

Lower

Upper

Social-demographic variables

 Age

  16–40

1

   

  41–60

0.533

0.462

0.615

< 0.001

  Above 60

0.395

0.329

0.474

< 0.001

 Education

  Illiterate

1

   

  Primary

1.340

1.137

1.579

< 0.001

  Secondary

2.275

1.903

2.720

< 0.001

  Tertiary

4.519

3.130

6.525

< 0.001

 Occupation

  Farmer

1

   

  Migrant worker

1.137

0.928

1.394

0.215

  Salary employee

1.346

1.017

1.783

0.038

  Student

2.469

1.455

4.188

0.001

  Others

1.349

1.093

1.666

0.005

  Unemployed individuals

1.315

1.072

1.614

0.009

 Personal monthly income

  No income

1

   

  Less than 2000 yuan

1.449

1.254

1.764

< 0.001

  2000–4000 yuan

1.636

1.323

2.021

< 0.001

  4000 yuan and above

1.412

1.011

1.971

0.043

Region

 Cumulative cases of HIV/AIDS

  Less than 5000

1

   

  5000–50,000

0.722

0.608

0.856

< 0.001

  50,000 and above

1.024

0.882

1.188

0.760

 Proportion of minority population

  Less than 10%

1

   

  30–80%

0.864

0.751

0.995

0.042

  90% and above

0.453

0.347

0.591

< 0.001

Access to health knowledge

 NCD (in the last 6 months) and medical instructions

  Do not have an NCD

1

   

  Living with an NCD with medical instructions

1.218

1.023

1.451

0.027

  Living with an NCD without medical instructions

0.689

0.542

0.875

0.002

 Had a physical examination (in the last year)

    

  Yes

1.310

1.125

1.525

< 0.001

  No

1

   

 Participated in health education activities (in last 6 months)

  Yes

1.413

1.204

1.658

< 0.001

  No

1

   

 Received HIV knowledge from medical staff

  Yes

2.557

2.244

2.914

< 0.001

  No

1

   

 Received HIV knowledge from the mass media

  Yes

3.812

2.800

3.618

< 0.001

  No

1

   

 Received HIV knowledge from family members

  Yes

0.816

0.669

0.996

0.046

  No

1

   

 Received HIV knowledge by socializing

  Yes

1.524

1.282

1.812

< 0.001

  No

1

   

Relationship between access to health knowledge and awareness of HIV transmission routes

Table 4 shows the awareness rates of HIV transmission routes among different subgroups. When comparing the awareness rates of the three transmission routes among subgroups in each category of access to health knowledge, the mother-to-child route had the lowest level. Among all subgroups, the awareness rates of mother-to-child route were more than 10% smaller than the other two routes. In the aspect of subgroup analysis, low levels of awareness were showed of all three transmission routes among those who did not receive health knowledge from medical staff (blood, mother-to-child, sex: 56.5, 45.5, 56.3%, respectively) and mass media (blood, mother-to-child, sex: 48.5, 32.5, 46.1%, respectively). However, the awareness level of all three transmission routes was lower among those who received health information from family members (blood, mother-to-child, sex: 64.5, 53.5, 63.6%, respectively). Moreover, those who had an NCD without medical instructions also had low awareness levels; specifically, 51.0, 39.3, and 47.4% for the blood route, mother-to-child route, and sex route, respectively.
Table 4

Relationship between access to health knowledge and awareness of HIV transmission routes (N = 9274)

Access to health knowledge

N

Blood (%)

χ2

p value

Mother-to-Child (%)

χ2

p value

Sex (%)

χ2

p value

NCD (in the last 6 months) and medical instructions

 Do not have an NCD

6889

69.0

65.931***

< 0.001

57.2

57.474***

< 0.001

69.3

96.467***

< 0.001

 Living with an NCD with medical instructions

1930

69.7

  

54.3

  

70.4

  

 Living with an NCD without medical instructions

455

51.0

  

39.3

  

47.7

  

Had a physical examination (in the last year)

 Yes

3515

74.0

87.052***

< 0.001

58.9

23.497***

< 0.001

75.4

126.968***

< 0.001

 No

5759

64.7

  

53.8

  

64.2

  

Participated in health education activities (in last 6 months)

 Yes

2951

76.1

125.255***

< 0.001

61.4

56.120***

< 0.001

76.1

117.298***

< 0.001

 No

6323

64.5

  

53.1

  

64.9

  

Received health knowledge from medical staff

 Yes

4872

78.9

535.575***

< 0.001

65.0

356.523***

< 0.001

79.4

570.262***

< 0.001

 No

4402

56.5

  

45.5

  

56.3

  

Received health knowledge from mass media

 Yes

6653

76.0

656.038***

< 0.001

64.9

802.594***

< 0.001

77.3

846.813***

< 0.001

 No

2621

48.5

  

32.5

  

46.1

  

Received health knowledge from family members

 Yes

795

64.5

5.475***

0.019

53.5

1.845

0.174

63.6

9.326**

0.002

 No

8479

68.6

  

56.0

  

68.9

  

Received health knowledge by socializing

 Yes

1696

75.9

56.197***

< 0.001

64.0

57.762***

< 0.001

77.5

79.168***

< 0.001

 No

7578

66.5

  

53.9

  

66.4

  

Overall

9274

67.8

55.4

68.1

**P < 0.01, ***P < 0.001

Discussion

The results revealed that the overall HIV awareness rate was 80.9% and we noted the following differences according to age group: HIV awareness rates were 88.7, 75.1, 65.1% among the young (16–40 years), middle-aged (41–60 years), and elderly (older than 60 years), respectively. Age was a suppressing factor for knowing of HIV/AIDS in a regression model. This result corresponded to a sharp increase in HIV infection among the Chinese elderly in recent years [12]. This phenomenon was partly attributed to older men’s engagement in commercial sex and older women’s participation in extramarital sex, with poor knowledge of HIV [29]. Moreover, HIV health education for the elderly was neglected in the early years [29, 30, 31]. Thus, there was a need to improve HIV health education for this age group. The HIV awareness rate for farmers or unemployed individuals was approximately 75%, which was about 10% less than for migrant workers and about 20% less than for students and salary employees. Personal monthly income had a positive effect on HIV awareness, but more than two thirds of participants had a personal monthly income of less than 2000RMB. When occupation and personal income were considered together, we found that those with the lowest income may need special attention. In the current economic structure of China, rural residents often leave home yearly for better wages as migrant workers. In comparison, those who remained unemployed or who stayed to work on farms fared worse in the labour market. Living in remote villages, they had insufficient health care resources and access to health information. Furthermore, considering the different categories, poor farmers and the unemployed, residents with no income, and those who had an NCD without professional medical instructions, had a great overlap, and might be a same group of people. This small population may be the most impoverished, and more aggressive strategies should be taken to increase HIV awareness in this group, such as in-person education.

As to awareness of the routes of HIV transmission, sexual transmission and blood transmission were at similar awareness levels in each subgroup, out of all the categories classified according to access to health knowledge. In contrast, awareness of mother-to-child transmission was more than 10% lower than the other two routes in each subgroup. This finding was similar to those of other studies in the same region [32]. Other studies showed that China’s program for preventing mother-to-child transmission (PMTCT) was effective on the basis of adequate publicity [1], and some cases of PMTCT failure were attributed to lack of knowledge of HIV and the PMTCT program [33, 34]. The mother-to-child transmission route and the PMTCT program deserve more publicity.

Our results were consistent with previous research which showed that residents mainly rely on traditional sources of health knowledge in rural western China, such as medical personnel, radio and TV, magazines, and leaflets [17]. In this study, residents who received health knowledge from medical staff had the best results on questions about HIV transmission, and this result revealed that efforts to implement HIV health education relied too heavily on medical staff. The second source of information was mass media, which was also the most efficient. This result was consistent with other studies [17, 26], and called for mass media to take more responsibility in HIV health education and prevention. The third source of information was socializing. This finding was consistent with another result of this research which indicated that better performance was seen among those who had engaged in health education activities. However, due to the remote setting, it is not an efficient strategy to encourage frequent socializing and participation in activities in this area. Finally, only 8% said that they gained health knowledge from family members. The HIV awareness rate and the awareness rates for all three transmission routes among this small subgroup were more than 10% lower than the rates for the majority, which exposed a low level of health literacy in this area at the family or household level.

As mentioned above, this research indicated that the elderly and the most impoverished populations needed special attention in an individual aspect. Geographically, this research showed that regional economic development had little impact since the variable of regional rural residents’ economic status was excluded from the regression model. Regions with complex ethnic compositions deserve more attention since the proportion of minority populations was a suppressing factor for HIV awareness. From a longitudinal viewpoint, it was still an issue of how to elevate the population’s literacy level by educating the minorities within the community [35]. The results of this investigation also showed that education was the strongest factor promoting residents in rural areas to know about HIV and, hence, education was a key determinant of HIV awareness in the context of rural west China. Both general education and HIV health education were important [36]. Improving the general education level could diminish HIV discrimination, as well as enhance the ability of people of low socio-economic status to understand health information [37, 38]. However, it was impossible to improve the level of general education at one strike in such a complicated area. Health education was more direct in cultivating behavioural changes concerning health and to improve health literacy. Chinese government regarded the systematic health education in schools as one of the key strategies to improve the health literacy of general population, anticipating the students to spread the right knowledge to their family members and communities [39]. On this basis, apart from multiple publicity access, the Chinese government strengthened HIV health education in schools [6]. Although few investigations focused on the effects of such a strategy on the family, it was rational to infer that educating the children would raise the awareness of parents through policy promotion and parent-child interaction. During the past several years, the Chinese government has mobilized university students to play an active role in HIV health education in a series of voluntary HIV prevention programmes [1]. Minority university students, especially those growing up in minority communities, had huge advantages in HIV education activities [40]. On this basis, the strategy of encouraging students to spread their knowledge of HIV at their homes or back in their hometowns should be strengthened.

Limitations

There were three major limitations to this study. First, all participants were patients at local public hospitals, which could introduce a bias from being in contacting with medical institutions. Second, the main source of health knowledge was general, especially mass media. More specific access to the source of information, for example through journals, broadcasts, online resources, or mobile devices, was not analysed. Third, demographic factors, regional factors, and access to health information were analysed individually, whereas empirically they were not mutually exclusive and their collaborative effects should be considered [41].

Conclusion

HIV health education covers 80% of the rural population in western China, and more active health education measures are needed for the elderly, the most impoverished population, and the minority community. Mass media should take greater responsibility in HIV health education for the general population. The mother-to-child transmission route called for special attention. In the long run, the strategy of delivering HIV knowledge through school students to their original communities and family members should be continuously encouraged. Strengthening education programs could have great importance in fostering HIV awareness.

Notes

Acknowledgements

The authors would show the highest appreciation to the supports from all levels of health authorities, Centers for Disease Control, and other local health institutes in the organization for field study in the 11 provinces of western China, as well as sincerely thankfulness for 11 collaborative research teams in local universities. Gratefulness would also be given to all the participants for their cooperation.

Author’ contributions

YB and LGL designed the study and organized the field study. TQZ analyzed the data, build the statistical model and drafted the manuscript. YM were analysis assistant and revised the initial drafts of the manuscript. All authors read and approved the final manuscript.

Funding

The study was supported by two research funds to YB from the University of Macau, which was MYRG106(Y1-L3)-ICMS13-BY and MYRG2015–00190-ICMS-QRCM. The funding body played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Ethics approval and consent to participate

Ethical approval was obtained from the University of Macau. Participants were fully informed of the objective of this study as well as their information was for academic use only. Additionally, all juvenile participants were guided or aided by their custodians, and similar assistance also provided for some elderly participants to guarantee they fully understood the questionnaire’s content and ethical issues. Written informed consent was obtained from all of the participants or their custodians.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Authors and Affiliations

  1. 1.Institute of Chinese Medical Sciences & State Key Laboratory of Quality Research in Chinese MedicineUniversity of MacauMacauChina
  2. 2.College of ManagementNingxia Medical UniversityYinchuanChina

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