HIV/AIDS Related Knowledge, Attitude And Sexual Behaviors Among Li And Han Youth In Hainan Province: The Influence Of Mobility, Gender And Sex Related Community Context

Background and objectives: Youths face a growing number of sex related health problems in China, such as un-intended pregnancy, induced abortion, Sexually Transmitted Infections (STIs) and HIV/AIDS. These sexual and reproductive health issues are mostly connected to changes in sexual related attitudes and behaviors since the economic reforms of the past three decades. Migrants are high risk group who have very high rates of un-intended pregnancy and induced abortion. Population migration has been regarded as a risk factor for the spread of HIV in many countries.Today in China most sexual and reproductive health intervention programs have been implemented among these floating populations in urban areas (middle or large cities). What's more, most of these interventions were carried out after the migrants were already identified as a high risk population. Thus, it is important to increase our knowledge of sexual behaviors and associated factors among young people in rural areas, and to carry out intervention before migration. The associated factors include not only the individual's knowledge and attitude, but also gender, customs, peers' attitude and other contextual factors. These contextual factors play an important role in design and implementation of HIV and other STI intervention programs.This multi-disciplinary study involving quantitative and qualitative methodology assessed different HIV related knowledge and sexual behaviors among ethnic Li and Han youth in Hainan Province. We also explored contextual cultural factors such as mobility, gender and community (family, peer influence, etc.). Our findings provide evidence for culturally specific designs for HIV and other STI intervention programs among rural youth in multi-ethnic areas.Methods: We selected the A Ethnic Li Autonomous County and B County in Hainnan Province as the study sites. The four comparative groups included ethnic Li youth living in a mountainous area with only ethnic Li (W Town and Q Town in A County); ethnic Li youth living in the area where both ethnic Li and Han reside (L Town and S Town in A County); ethnic Han youth living in the area where both ethnic Li and Han reside (C Town and H Town in A County); and ethnic Han youth living in the area where only ethnic Han reside (F Town and Y Town in B County). Our study targeted residents aged between 16-30 years of age. We used a quota sampling strategy to recruit residents. In-depth interviews were carried out among 99 ethic Li and Han women and men. A questionnaire-based survey was carried out among 881 ethnic Li and Han women and men.We used in-depth interviews and a face-to-face questionnaire survey to collect data. The in-depth interview explored residents' attitudes towards sex and reproduction and their knowledge about contraception, HIV and other STIs. The survey assessed the interviewees' mobility experiences, HIV-related knowledge, sexual behaviors and condom use.The main explain variables included ethnic (ethnic Li living in a mountainous area with only ethnic Li, ethnic Li living in the area where both ethnic Li and Han reside, ethnic Han living in the area where both ethnic Li and Han reside and ethnic Han living in the area where only ethnic Han reside), gender, age group, marital status, mobility experience, sex related community context index (the total scores of seven issues about peer sexual behaviors and communication about sex among peers and family; the higher index, the more tolerant attitude of peers' toward sex) and sex related attitudes index (the total scores of seven issues about their attitude toward sexual behaviors; the higher index, the more tolerant attitude of interviewees' toward sex).The main outcome variables included HIV/AIDS related knowledge, sexual behaviors, condom use and so on.Results:1. Demographic characteristicsThe mean age of 881 interviewees is 22.2±4.0. The proportion of married women (53.1%) was higher than married men (25.0%). The proportion of married men in ethnic Li areas (17.4%) was lower than that in ethnic Han areas (32.6%). The educational level of ethnic Han interviewees was higher than ethnic Li interviewees.In-depth interviews were carried out among 99 interviewees, including 50 ethnic Li and 49 ethnic Han. The proportion of married interviewees among ethnic Li interviewees was lower than that among ethnic Han interviewees. The educational level of ethnic Han interviewees was higher than ethnic Li interviewees. 2. MobilityFour hundred and fifty seven (51.9%) interviewees had experienced mobility including 53 (6.0%) who had migrated across towns within their county; 215 (24.4%) who had migrated across counties within Hainan province; and 189 (21.5%) who had migrated to other provinces. One hundred and seventy four (38.1%) interviewees had migrated two or more times.The mean accumulative work time for ethnic Li male migrants living in a mountainous area were shortest (less than 9 months) was shorter than that for males in other groups. And the mean accumulative work time for ethnic Li female migrants living in a mountainous area (16.8 months) was shorter than that for females in the other groups. The mean accumulative numbers of towns where ethnic Han male migrants living in the area where only ethnic Han reside migrated were less than that for males in other groups.A mobility index was calculated by the accumulative numbers of towns where participants migrated divided by the duration of their migration. The higher mobility index means the migrants migrated more frequently. The median of mobility index was 0.14, minimum was 0.01 and maximum was 1.00. Younger migrants, male migrants and single migrants had a higher mobility index than elder migrants, female migrants and married migrants. Among the four groups, ethnic Li migrants living in the mountainous area had the highest mobility index, and ethnic Han migrants living in the area where only ethnic Han reside had the lowest mobility index. Migrants with a higher education level had a lower mobility index.The mean age of first job in Four hundred and fifty seven migrants was 18.7 years old with a SD of 3.0. Two hundred and thirty five (51.4%) migrants had migrated across counties within Hainan province and 142 (31.1%) migrants had migrated to other provinces. The mean duration of the first migration of ethnic Li male migrants was shorter than that for ethnic Han male migrants. One hundred and seventy four migrants went out for their most recent job at the mean age of 21.2, SD 3.3. Eighty nine (51.1%) migrants had migrated across counties within Hainan province and 66 (37.9%) migrants had migrated to other provinces. The mean duration of the most recent migration for all the four groups was shorter than the mean duration of their first migration (9.1 months compared to 11.9 months).The results of the survey and in-depth interviews showed most ethnic Li interviewees went out for work due to economic pressure. In contrast, most ethnic Han interviewees worked outside their hometown to seek development of their career. The main reasons why ethnic Li migrants quit their job were they felt tired, thought the job was boring and other personal reasons. But for ethnic Han migrants, they quit their job because they wanted to seek better career development or to get married.3. HIV/STIs and condom related knowledge and attitudesSevem hundred and twenty three (82.1%) interviewees and 470 (53.3%) interviewees heard about HIV/AIDS and STIs respectively. Four hundred and thirteen (57.1%) interviewees knew the three routes of HIV transmission, but misconceptions about transmission rates were still common. For example only 27.4% correctly answered the question "mosquitos can not transmit HIV". The results of in-depth interviews indicated that many interviewees hold misconceptions about HIV/STI prevention.The results of multivariate regression of HIV-related knowledge showed that the female interviewees had higher scores of HIV-related knowledge than the male interviewees. Interviewees who had a higher educational level had higher scores of HIV-related knowledge. Ethnic Li interviewees living in mountainous areas had lower scores of HIV-related knowledge than ethnic Han living in the area where only ethnic Han reside. Migrants had higher scores of HIV-related knowledge than non-migrants. But, migrants who had a higher mobility index had lower scores of HIV-related knowledge.Seven hundred and forty seven (84.8%) interviewees had heard about condoms and 508 (68.0%) had seen a condom. Only 39.8 percent of interviewees knew the three functions of condom (contraception, HIV prevention and STI prevention).The results of the nonparametric test of condom related knowledge showed older interviewees and interviewees with a higher educational level had higher mean scores of condom related knowledge. Male interviewees had a higher mean score of condom related knowledge than the female interviewees. Ethnic Han interviewees living in the area where only ethnic Han reside had highest mean score of condom related knowledge among the four groups.The results of the nonparametric test of condom related attitude showed male interviewees had negative attitudes to condom and the female interviewees had positive attitudes to condom. Among the four groups, the ethnic Han interviewees living in the area where only ethnic Han reside had highest mean score of condom related knowledge, but the lowest mean score of condom related attitudes. The mean score of condom related attitudes had no statistically significant positive correlation with the mean score of condom related knowledge. 4. Sexual behaviorsFive hundreds and ninty four interviewees had sexual intercourse. Five hundreds and eight interviewees (57.7%) reported premarital sexual behavior, including 266 men (59.4%) and 242 women (55.9%). Over half of the male interviewees who reported premarital sexual behavior had their first sex with friends or schoolmates. In contrast, most female interviewees who reported premarital sexual behavior had first sex with their boyfriends. Two hundreds and eighty interviewees (31.8%) reported multiple sexual partners, and 42 interviewees (4.8%) reported multiple sexual partners in the past 6 months. Eight interviewees (0.9%) reported prostitution and 42 interviewees (4.8%) reported use of commercial sex.The multivariate Logistic regression results showed age, mobility, gender, marital status, sex related community context index and sex related attitudes index were associated with premarital sexual behavior, multiple sexual partners and use of commercial sex. Younger interviewees reported a higher proportion of premarital sexual behavior than older partivipants. Migrants had higher proportion of premarital sexual behavior than non-migrants. The interviewees who had higher sex related community context index had higher proportion of premarital sexual behavior. Male interviewees had higher proportion of multiple sexual partners than female interviewees. Married interviewees had lower proportion of multiple sexual partners than single interviewees. The interviewees who had a higher sex related community context index had a higher proportion of multiple sexual partners. And the interviewees whose sex related attitudes index was higher, had a higher proportion of multiple sexual partners. Older interviewees reported a higher proportion of use of commercial sex. Single interviewees reported higher proportion of use of commercial sex than married interviewees. The interviewees who had higher sex related community context index had higher proportion of use of commercial sex. And the interviewees who had higher sex related attitudes index had higher proportion of use of commercial sex.The results of in-depth interviews showed that both males and females had talked about sex with their peers, but that the contents of these discussions were varied between males and females. The contents of males were about sexual behaviors and the contents of females were about menses and contracption. Male interviewees accepted or even praised men who had multiple sexual partners and had used commercial sex workers. But men did not accept women who displayed these sexual behaviors and indicated that there were different between men and women. Female interviewees also accepted that men had these sexual behaviors, and agreed that there were different between men and women. They did not accept women who engaged in multiple sexual partners or commercial sex work. 5. Condom usesAmong the 594 interviewees who reported sexual activity in the past, 272 (45.8%) of them had ever used condom, including 104 (46.6%) single interviewees and 165 (51.7%) married. Nearly half of them had not used a condom in the past 6 months and less than 15.0 percent of them had used condom during every sexual encounter. Less than 40.0 percent of participants had used a condom during their most recent sex act.The multivariate Logistic regression results of condom use showed that ethnic Li living in the area where both ethnic Li and Han reside reported a higher proportion of condom use than ethnic Li living in a mountainous area with only ethnic Li. The interviewees who had higher scores of condom-related knowledge also reported higher proportion of condom use.The multivariate Logistic regression results of condom use in the past 6 months showed single interviewees had a higher proportion of condom use than married interviewees. Ethnic Han living in the area where both ethnic Li and Han reside had a lower proportion of condom use than ethnic Li living in a mountainous area with only ethnic Li. The interviewees who had higher scores of condom-related knowledge and attitudes also reported higher proportion of frequent condom use.The multivariate Logistic regression results of condom use in the most recent sex act showed women reported a higher proportion of condom use than men. Single interviewees had a higher proportion of condom use than married interviewees. The interviewees who had higher scores of condom-related attitudes also reported higher proportion of condom use.6. Pregrancy and induced abortionAmong 200 single female interviewees, 17 women (8.5%) reported pregnancy and 15 women (7.5%) reported induced abortion.Conclusions:1. Age, mobility, marital status and personnel sexual attitudes were the important factors associated with premarital sexual behavior, multiple sexual partners and commercial sexual use. Marital status, HIV related knowledge and attitude were the important factors associated with condom use.2. Attitudes and behaviors in their community were important factors associated with premarital sexual behavior, multiple sexual partners and commercial sexual use among both ethnic Li and ethnic Han people. The community sex-related index scores indicate that peer influence was a key factor in participants' sex behaviors. 3. Gender was important factor associated with sexual attitude, multiple sexual partners, commercial sexual use and condom use. Participant's exhibited dual standards in relation to sexual behaviors among men and women where it was more acceptable for men to engage in multiple sexual partners and to use commercial sex.