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Journal of HIV/AIDS & Social Services Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/whiv20
HIV/AIDS Knowledge, Sexual Activity, and Safer Sex Practices Among Female Students in Hong Kong, Australia, and the United States a
b
c
Cindy Davis PhD , Lesley Hughes PhD , Melissa Sloan PhD , d
Catherine Tang PhD & Samuel MacMaster PhD
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College of Social Work, University of Tennessee , Nashville, Tennessee, USA b
Department of Social Work , University of New South Wales , Sydney, Australia c
Department of Sociology , Drew University , Madison, New Jersey, USA d
Department of Psychology , National University of Singapore , Singapore Published online: 10 Dec 2009. To cite this article: Cindy Davis PhD , Lesley Hughes PhD , Melissa Sloan PhD , Catherine Tang PhD & Samuel MacMaster PhD (2009) HIV/AIDS Knowledge, Sexual Activity, and Safer Sex Practices Among Female Students in Hong Kong, Australia, and the United States, Journal of HIV/AIDS & Social Services, 8:4, 414-429, DOI: 10.1080/15381500903455950 To link to this article: http://dx.doi.org/10.1080/15381500903455950
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Journal of HIV/AIDS & Social Services, 8:414–429, 2009 Copyright # Taylor & Francis Group, LLC ISSN: 1538-1501 print=1538-151X online DOI: 10.1080/15381500903455950
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HIV/AIDS Knowledge, Sexual Activity, and Safer Sex Practices Among Female Students in Hong Kong, Australia, and the United States CINDY DAVIS, PhD College of Social Work, University of Tennessee, Nashville, Tennessee, USA
LESLEY HUGHES, PhD Department of Social Work, University of New South Wales, Sydney, Australia
MELISSA SLOAN, PhD Department of Sociology, Drew University, Madison, New Jersey, USA
CATHERINE TANG, PhD Department of Psychology, National University of Singapore, Singapore
SAMUEL MacMASTER, PhD College of Social Work, University of Tennessee, Nashville, Tennessee, USA
Early in the epidemic, HIV infection and AIDS were rarely diagnosed in women. Today, the HIV=AIDS epidemic represents a growing and persistent health threat to women, especially young women. The purpose of the current study was to conduct an international study with female undergraduate college students to assess knowledge and attitudes about HIV=AIDS, current and future sexual behaviors, and condom use self-efficacy. Participants included several convenience samples of female undergraduate college students from three public universities in the southern region of the United States (n ¼ 112), a large public university in Australia (n ¼ 66), and a public university in Hong Kong (n ¼ 93). This research study utilizes a quantitative survey research design. Seventy-seven percent of American women and 66% of Australian women were sexually active compared with only 21% of Chinese women (v2 ¼ 67.74, p < .001). Of the sexually Address correspondence to Cindy Davis, College of Social Work, University of Tennessee, 193E Polk Avenue, Nashville, TN 37210, USA. E-mail: cdavis3@utk.edu 414
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active women, 86% of Australian women reported regular use of safer sex practices during the past year compared with 69% of American women and 20% of Chinese women (v2 ¼ 8.9, p < .05). Although the sample as a whole scored generally high on HIV=AIDS awareness, it is not reflected in safe sex practices or intentions for future safe sex practices. Future studies should focus on further understanding the social, cultural, and psychological factors that hamper safe sex practices among this population as well as successful intervention strategies to overcome these barriers. KEYWORDS AIDS, cross-cultural, HIV, international, prevention, social work
Early in the epidemic, HIV infection was rarely diagnosed in women. Today, the HIV=AIDS epidemic represents a growing and persistent health threat to women, especially young women. Women with AIDS currently make up an increasing part of the epidemic. For example, women in the U.S. currently account for more than one quarter of all new HIV=AIDS cases (Centers for Disease Control and Prevention [CDC], 2008b). High-risk heterosexual contact was the primary source of HIV transmission reported by women, with almost 80% of HIV infections being transmitted in this way (CDC, 2008b). For women of all races and ethnicities in the U.S., the largest number of HIV=AIDS diagnoses during recent years was for women aged 15–39 (CDC, 2008b). Unfortunately, the problems associated with HIV are not restricted to the United States, but rather, a global phenomenon affecting people worldwide, particularly young women. For example, in 2008, women in Australia constituted 14% of all newly diagnosed cases of HIV, but amongst those aged 20–29 years women were 34% of the newly diagnosed cases (National Centre in HIV Epidemiology and Clinical Research, 2009). Given the mobility of society today, an epidemic in one geographical area inevitably creates a risk for other areas. Young people under the age of 25 accounts for nearly half of all new HIV infections worldwide (UNAIDS, 2004). Although the incidence of HIV= AIDS has been declining, rates of HIV infection among young adults have not declined proportionately (CDC, 2008a). College students, as a population, are particularly vulnerable to HIV infection. The CDC, in a recent report, states that the ‘‘epicenter of the [HIV=AIDS] epidemic is college students’’ (CDC, 2004). Incidents of risky sexual behaviors are prevalent among college students, much of which occurs under the influence of drugs and alcohol (CDC, 2008a; UNAIDS, 2004). Due to risky sexual behaviors and increased incidence rates, HIV=AIDS continues to be a significant issue on American college campuses, but many college students remain relatively unconcerned about HIV=AIDS (Ajuluchukwu, Crumey, & Faulk, 1999; Leone et al., 2004).
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Compared with men, the picture is much grimmer for young women. Young women are at risk for sexually transmitted HIV for several reasons including biologic vulnerability, no recognition of their partners’ risk factors, sexual activity with older men who are more likely to be infected with HIV, gender norms, and the inability to negotiate safer sex practices within the relationship (CDC, 2008b). Some women may be unaware of their male partners’ risk for HIV infection. In a recent survey, 65% of the men who have ever had sex with men also had sex with women (Valleroy et al., 2003). Similarly, a recent study of HIV-positive African American male college students who have sex with men reported that 40% of the study’s respondents claimed to also have sex with heterosexual female students (Leone et al., 2004). A recent study by Hightow et al. (2005) in the southeastern United States revealed that newly diagnosed HIV infection was found in 37 male college students and a sexual partner network investigation linked 21 colleges, 61 students, and 8 partners or students. Some women may not insist on condom use due to inequality in the relationship and=or fear that their partners will physically abuse them or leave them (Foreman, 2003; Gupta & Weiss, 1993; Suarez-Al-Adam, Raffealli, & O’Leary, 2000). The importance of focusing on young people has been recognized at a global level by the 2001 United Nations General Assembly Special Session on HIV=AIDS, which endorsed a number of goals for young people, including: By 2005, ensure that at least 90%, and by 2010 at least 95% of young men and women have access to the information, education, including peer education and youth-specific education, and services necessary to develop the life skills required to reduce their vulnerability to HIV infection; in full partnership with youth, parents, families, educators and health care providers. (UN, 2001, pp. 7–8)
The relationship between substance use and HIV risk is quite clear for women with most women now reporting AIDS infection through heterosexual exposure to HIV or injecting drug use. An estimated one in five new HIV diagnoses for women is related to injection drug use (CDC, 2008b). Sharing injection equipment contaminated with HIV is not the only risk associated with drug use. Both casual and chronic substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol (CDC, 2008b; Leigh & Stall, 1993; UNAIDS, 2004). Research on HIV=AIDS knowledge among young people has consistently shown that knowledge alone does not predict safe sex practices (Anastasi, Sawyer, & Pinciaro, 1999; Bates & Joubert, 1993; CDC, 2008a; Gupta & Weiss, 1993, Lewis, Malow, & Ireland, 1997; Opt & Loffredo, 2004). According to the gender and power theory (Connell, 1987; Wingood & DiClemente, 1996), women’s risks of HIV infection are heavily influenced by socioeconomic factors, power imbalances within relationships, and gender-specific cultural norms. Indeed, rigid gender norms, widespread
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gender-based violence, fear of men’s violence, and poverty have been repeatedly cited as instrumental to the ‘‘feminization’’ of the HIV=AIDS epidemic (UNAIDS & UNIFEM, 2004; WHO, 2004). Gender scholars have argued that the global HIV=AIDS epidemic in women is largely related to women’s inability to challenge male supremacy because of their inherent inferior position in heterosexual sexual relationships, in the family, and in society (Connell, 1987; Wingood & DiClemente, 1996). Little is known about the risks factors and behaviors associated with college female students from other cultures. For example, In Chinese culture, men are often in control of both sexual and reproductive decision making, such as when and how a woman will have sexual relations. Social stigma and fear of violence also prevents many Chinese women from accessing HIV=AIDS information, from asking their male sexual partner to wear condoms, from getting diagnostic tests, and from seeking treatment for the infection. The possession of condoms has different symbolic meanings for Chinese men and women. Having condoms available for use represents sexual vigor and potency for Chinese men, but may serve as a ‘‘proof’’ of prostitution or promiscuity for Chinese women (Fung & Chung, 1999; Tang, Wong, & Lee, 2001). Some women may be unaware of their male partners’ risk for HIV infection. Some women may not insist on condom use due to inequality in the relationship and=or out of fear that their partners will physically abuse them or leave them (Foreman, 2003; Gupta & Weiss, 1993; Suarez-Al-Adam, Raffealli, & O’Leary, 2000). Sex is still a taboo topic in China, and open discussion about sexual matters is uncommon among Chinese (Fung & Chung, 1999). Given the complexity surrounding one’s decision to act responsibility to prevent the transmission of HIV among young women, this international study was conducted to assess knowledge and attitudes related to HIV=AIDS as well as current and future sexual behaviors and condom use self-efficacy among college women in the United States, Hong Kong, and Australia. These three countries were selected because they were similar in economic development yet unique in their culture and health systems. The specific research questions were as follows (1) What are the knowledge, attitudes, and behaviors related to HIV=AIDS among female college students in the United States, Australia, and Hong Kong? (2) What differences exist in the knowledge, attitudes, and behaviors among country of residence and sexual behavior subgroups? (3) What is the relationship between HIV=AIDS knowledge, attitudes, and behaviors among sexually active female college students and their country of residence?
METHODS Participants Participants included several convenience samples of female college students from three public universities in the southern region of the United States, a
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large public university in Australia, and a public university in Hong Kong. The research was conducted during social science classes as a part of a larger questionnaire. This research study uses a quantitative survey research design. Various professors were approached and asked for their permission to undertake the research during a portion of their class time. All participation was strictly voluntarily and no identifying information was obtained on any participant. A trained research assistant read the information sheet aloud to participants and distributed the information sheet and questionnaires. Participants completed the questionnaire during class time and return the questionnaires before leaving the class. Students choosing not to participate were simply asked to remain quiet while the participants complete their questionnaires or were dismissed from class early. The students were assured that their participation had no impact on their class grade. A total sample includes 112 American, 66 Australian, and 93 Chinese students. The average age of the participants was 21.5 (SD ¼ 3.9) in the American sample, 24.5 (SD ¼ 6.3) in the Australian sample, and 20.4 (SD ¼ 1.0) in the Chinese sample. In the American sample 63% self-identified as Caucasian, 32% selfidentified as African American, and 5% self-identified as some other racial= ethnic group. Twenty-four percent of the Australian sample self-identified as Caucasian, 67% self-identified as Australian, and 9% self-identified as some other racial=ethnic group. The entire Chinese sample self-identified as Chinese.
Measures CURRENT SEXUAL ACTIVITY AND CONDOM USE The students’ extent of current sexual activity and condom use or safer sex practices were assessed by the following two questions: ‘‘How would you describe your sexual life in the past 12 months?’’ and ‘‘How would you describe your use of condoms or safer sex practices in the past 12 months?’’ The response options included: (1) none at all, (2) rarely, (3) sometimes, and (4) very often (St. Lawrence et al., 1998; Wong & Tang, 2001). These questions demonstrated good face validity and have shown good reliability in previous studies (St. Lawrence et al., 1998; Wong & Tang, 2001; Tang, Wong, & Lee, 2001). FUTURE SEXUAL ACTIVITY AND CONDOM USE Participants’ intentions for future condom use, future casual sex activity, and safer sex practices in future casual sex encounters were measured by responses to the following three questions: ‘‘When having sex will you use a condom in the future?’’ ‘‘How often will you have a ‘one-night stand’ in the future?’’ and ‘‘Assuming that you would have a ‘one-night stand,’ how
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often will you use condoms?’’ The response options included 1 (none at all), 2 (rarely), 3 (sometimes), and 4 (very often) (St. Lawrence et al., 1998; Wong & Tang, 2001). These questions demonstrated good face validity and have shown good reliability in previous studies (St. Lawrence et al., 1998; Wong & Tang, 2001; Tang, Wong, & Lee, 2001).
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HIV=AIDS
AWARENESS
The International AIDS Questionnaire (IAQ), which consists of a series of 18 statements to assess four dimensions of HIV=AIDS awareness including myths about the transmission of HIV (7 items), facts about HIV=AIDS (3 items), perceptions of personal HIV risk (3 items), and attitudes=prejudices toward persons infected with HIV=AIDS (5 items); was used to assess HIV= AIDS awareness. Respondents were instructed to respond to each statement in the IAQ on a Likert scale ranging from (1) strongly disagree to (5) strongly agree. Example statements include ‘‘HIV can be spread through coughing and sneezing’’ (myth) and ‘‘I would end my friendship if my friend had AIDS’’ (prejudice). Responses to the IAQ were coded so that a lower score indicated greater HIV=AIDS awareness. The IAQ has been validated for use with both English- and Chinese-speaking young adults (see Davis, Tang, Chan, & Noel, 1999; Davis, Sloan, MacMaster, & Huges, 2006). The IAQ was reviewed by two independent AIDS researchers for face validity. Content validity was established by reviewing other self-constructed scales used to measure similar concepts, such as HIV=AIDS knowledge (Lewis, Malow, & Ireland, 1997; Li et al., 2004; Odusanya & Alakija, 2004), attitudes (Bruce and Reid, 1998; Bruce & Walker, 2001), and perceived risk (Barling and Moore, 1990; Moore & Barling, 1991). The Cronbach’s alpha total IAQ-E scale is .88 for the English-speaking sample. CONDOM USE SELF-EFFICACY A measure designed to assess college students’ intentions and perceived ability to negotiate the use of condoms was used to measure condom use self-efficacy (Schwarzer, Hahn, & Wegner, 1993; Wong & Tang, 2001). Participants were instructed to rate a series of 12 statements, assuming that they have (a) sex partner(s), on a Likert scale ranging from 1 (very untrue) to 4 (very true). Sample items in this set include: ‘‘I am certain that I would use a condom with every new partner’’ and ‘‘Even if I intended to use a condom, I’m not sure whether I really will when the situation arises.’’ Content and face validity were established by reviewing similar instruments measuring self-efficacy of condom use (Barkley & Burns, 2000; St. Lawrence et al., 1998; Van, Marin, Tschann, Gomez, & Gregorich, 1998), and satisfactory reliability was established with a Cronbach alpha coefficient of .78. Responses were coded such that a high score indicates greater condom use self-efficacy.
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ATTITUDES TOWARD SAFE SEX To measure attitudes toward safer sex practices, participants were again instructed to assume that they have (a) sex partner(s) and respond to a series of 17 statements (Barker, Battle, Cummings, & Bancroft, 1998; Van et al., 1998; Wong & Tang, 2001). Each item was rated on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Examples of the safer sex attitudes statements include ‘‘I am likely to talk to my partner about safer sex practices’’ and ‘‘I believe that using a condom can prevent me from getting HIV disease.’’ Responses were coded so that higher scores indicate positive attitudes toward safe sex practices. Satisfactory reliability was established with a Cronbach alpha coefficient of .76.
RESULTS The relative means and standard deviations of the IAQ and other variables for each country and sexual status (sexually active vs. not sexually active) are presented in Table 1. A total of 150 students (86 American, 44 Australian, and 20 Chinese) indicated that they had been sexually active in the past year. Seventy-seven percent of American women and 66% of Australian women were sexually active compared with only 21% of Chinese women (v2 ¼ 67.74, p < .001). Of the sexually active women, 86% of Australian women reported regular use of safer sex practices during the past year compared with 69% of American women and 20% of Chinese women (v2 ¼ 8.9, p < .05). Approximately half of the Australian (57%) and American women (51%) reported that they plan to practice safe sex in the future compared with 23% of the Chinese women (v2 ¼ 25.28, p < .001). Sixteen percent of Australian women, 13% of American women, and 4% of Chinese women stated that they would have a one-night stand in the future (v2 ¼ 2.32, NS), and assuming they would have a one-night stand, 84% of the American and 80% of the Australian women reported an intention to use condom during a one-night stand compared with only 61% of Chinese women (v2 ¼ 16.0, p < .001). As shown across the board, the relative mean scores on the IAQ and its subscales, which can range from 1 to 5, are generally low, which reveals that this sample of female college students appears to be aware of HIV=AIDS facts and risks and does not show highly prejudiced attitudes toward persons living with HIV=AIDS. The only difference among mean scores on the IAQ between sexually active vs. not sexually active was among American women. Sexually active American women had significantly less knowledge of transmission myths (t ¼ 3.33, p < .001), and more prejudices and negative attitudes toward people with AIDS (t ¼ 3.36, p < .001). A series of three (Country: Australia, Hong Kong, and United States) " two (Sexual Status: Active and Inactive) multiple analysis of
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#
3.11 3.67 3.31 1.31 3.78 1.81 1.85 1.77 1.91 1.77
(0.45) (0.49) (0.63) (0.63) (0.63) (0.58) (0.73) (0.73) (0.84) (0.63)
2.70 (1.13) 3.02 (1.03) 3.02# (0.42) 3.68 (0.49) 3.26 (0.95) 1.36 (0.69) 3.75 (0.63) 1.86 (0.63) 1.95# (0.77) 1.86# (0.77) 1.88 (0.84) 1.77 (0.59)
Sexually active (n ¼ 86)
3.33 3.77 3.23 1.52 3.89 1.51 1.48 1.46 1.48 1.68
(0.40) (0.39) (1.01) (0.78) (0.36) (0.34) (0.52) (0.47) (0.59) (0.50)
Total (n ¼ 67) 2.66 3.10 3.30 3.82 3.19 1.73 3.92 1.48 1.43 1.44 1.46 1.69
(1.26) (1.20) (0.47) (0.41) (1.08) (0.91) (0.35) (0.29) (0.43) (0.46) (0.66) (0.52)
Sexually active (n ¼ 44)
Australia
3.01 3.76 2.78 1.25 3.48 1.79 1.63 1.84 1.77 2.12
(0.29) (0.35) (1.00) (0.53) (0.87) (0.34) (0.51) (0.52) (0.54) (0.50)
Total (n ¼ 94)
t-Test (not shown) indicates a significant difference in means between sexually active and inactive within the country at p < .001.
Current sexual activity Current condom use Condom use self-efficacy Safer sex attitudes Future condom use Future one-night stand Condom use in one-night stand Total IAQ Transmission myths Attitudes=prejudices Personal risk Facts
Total (n ¼ 112)
United States
TABLE 1 Relative Means and Standard Deviations (in parenthesis) for All Variables by Country and Sexual Status
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1.35 2.60 3.00 3.75 3.20 1.25 3.55 1.78 1.69 1.79 1.68 2.07
(0.73) (0.94) (0.29) (0.38) (0.83) (0.64) (0.76) (0.30) (0.59) (0.35) (0.57) (0.60)
Sexually active (n ¼ 20)
China
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variance (MANOVA) were performed to determine the main effects of country and sexual status, and interaction effects on participants HIV=AIDS knowledge and attitudes, condom use self-efficacy, safer sex attitudes, current sexual behaviors, and future intentions to use condoms. As shown in Table 2, the MANOVA results revealed significant main effects of country on the IAQ total scale (F ¼ 7.89; p < .001), HIV=AIDS transmission myths (F ¼ 7.03; p < .001), HIV=AIDS attitudes=prejudice (F ¼ 5.31; p < .001); HIV=AIDS facts (F ¼ 10.95; p < .001), personal risk (F ¼ 7.08, p < .001), condom use self-efficacy (F ¼ 8.02, p < .001), current sexual activity (F ¼ 31.85, p < .001), future intentions to use a condom (F ¼ 6.62, p < .01), and condom use during a one-night stand (F ¼ 7.22, p < .001). Australian women were the most knowledgeable about HIV=AIDS overall,
TABLE 2 MANOVA Results: Means with Standard Deviations in Parentheses. Overall Group Effect (F ¼ 7.52### ) Country IAQ Total IAQ Subscales: Transmission myths Attitudes=prejudice Personal risk Facts Condom use self-efficacy Safer sex attitudes Current behaviors Current sexual activity Current condom useþ Future intentions Condom use One-night stand Condom use in one-night stand
Main Effect of County (F)
United States
Australia
China
32.80a (10.31)
26.53a,b (5.24)
32.28b (5.94)
7.89###
13.16a (4.98) 8.60 (3.47) 5.76a (2.48) 5.29a (1.84) 3.16 (0.45) 3.70 (0.50)
10.11a (3.30) 7.24b (2.23) 4.24a (1.50) 4.94b (1.63) 3.34a (0.42) 3.85 (0.38)
11.57 (3.62) 9.20b (2.45) 5.20 (1.57) 6.32a,b (1.50) 3.02a (0.29) 3.76 (0.33)
7.03###
2.67a (1.18) 2.85 (1.19)
2.62b (1.23) 3.09 (1.21)
1.42a,b (0.79) 2.57 (0.93)
31.85###
3.34a (0.87) 1.32 (0.62) 3.88a (0.55)
3.27 (1.02) 1.44 (0.70) 3.90b (0.37)
2.83a (1.00) 1.30 (0.57) 3.57a,b (0.76)
6.62##
5.31### 7.08### 10.95### 8.02### 1.63
1.65
.632 7.22###
Note. There was only one main effect of sexual status (transmission myths) and no significant sexually active by country interaction effects. ## p < .01, ### p < .001, ‘‘þ’’ indicates analysis was computed for sexually active respondents only, ‘‘a’’ and= or ‘‘b’’ indicate Bonferroni multiple comparisons reveal means differ significantly at p < .01.
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followed by the American and Chinese women. Bonferroni comparisons indicated that the differences between each of the countries on the total IAQ were significant at p < .001. There were also significant differences between the countries on the IAQ subscales. Compared with the Australian women, the American women reported less knowledge of transmission myths and personal risk factors, while the Chinese women reported significantly more prejudices and negative attitudes toward persons living with HIV=AIDS. In addition, the Australian women reported the most factual knowledge of HIV=AIDS and the most condom use self-efficacy, followed by the American and the Chinese women. The Chinese women reported significantly less current sexual activity (F ¼ 31.85, p < .001). Although intentions to have a one-night stand in the future did not differ by country, the Chinese women reported that they would be less likely to use a condom in future casual sex than the American and Australian women (F ¼ 7.22, p < .001). The MANOVA also revealed significant main effects of sexual status on knowledge of transmission myths only, with the sexually active respondents reporting less knowledge of HIV transmission myths (mean ¼ 11.033, SD ¼ 3.44; mean ¼ 12.83, SD ¼ 4.87; F ¼ 8.72, p < .01). There were no interaction effects on any variables for country by sexual status. Finally, to determine the relationship between HIV=AIDS awareness and actual safe sex practices, Pearson correlation coefficients between reported use of condoms or other safe sex practices were calculated among the sexually active students within each country (Table 3). Although the sample as a whole scored generally high on the IAQ and its subscales, this HIV=AIDS awareness is not reflected in safe sex practices or intentions for future safe sex practices. Among the sexually active women, there is no significant relationship between the IAQ and the use of condoms or other safe sex practices. (Note: Although some of the correlations appear moderately high in the Chinese sample, they are based on only 20 sexually active students.)
TABLE 3 Pearson Correlations between IAQ and Safe Sex Practices Among the Sexually Active Students United States
Transmission myths Attitudes=prejudices Personal risk Facts Total IAQ
Australia
China
Current condom use
Future condom use
Current condom use
Future condom use
Current condom use
Future condom use
0.044 %0.088 0.053 %0.147 %0.020
0.161 0.171 0.113 0.222 0.187
%0.040 %0.191 0.067 0.033 %0.071
0.013 0.018 0.106 0.052 0.063
%0.400 %0.013 0.145 %0.262 %0.351
%0.113 0.031 %0.007 0.166 %0.009
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DISCUSSION In this paper, we explored knowledge, attitudes and behaviors associated with HIV=AIDS among college females in the United States, Australia, and Hong Kong. In regard to HIV=AIDS knowledge and attitudes, Australian female college students scored higher than the American and Chinese students in HIV=AIDS awarenessâ&#x20AC;&#x201D;particularly in the areas of knowledge of transmission myths and awareness of personal risk. The Chinese female students reported significantly less factual knowledge of HIV=AIDS than the American and Australian students and showed more prejudiced attitudes toward persons living with HIV=AIDS than the Australian students. Thus, while overall knowledge about HIV=AIDS appears to be high across the three nations, there are significant country-based gaps in HIV=AIDS awareness. An explanation for these differences in knowledge and attitudes about HIV=AIDS is likely to be found in an examination of relevant cultural dimensions. At a general societal level, differences between countries in the degree of openness in discussing matters related to sex are likely to be relevant. More specifically, analysis of each societyâ&#x20AC;&#x2122;s stance toward HIV= AIDS, including media representations and government policies, would be instructive. Of particular significance would be the provision of education as a preventive measure. The greater knowledge and awareness of the United States and Australian students may be attributable to the inclusion in the high school curricula of relevant content, for example, the Personal Development, Health and Physical Education course undertaken by the Australian students in the study (New South Wales Board of Studies, 2006). According to Wong et al. (2006), the standard of sex education continues to be variable and inconsistent among Chinese adolescents in Hong Kong. Of course, a comparative study of how relevant topics are dealt with in the educational systems of the three countries is necessary to make a definitive pronouncement on this. In regard to current and future behaviors related to HIV=AIDS, we found significant differences in women from these three countries. The Australian and American women were significantly more sexually active compared with their Chinese counterparts. The relatively low rates of sexual activity among this Chinese sample are consistent with previous research on the topic (Davis, Noel, Chan, & Law, 1998; Wong et al., 2006; Wong & Tang, 2001). Among the sexually active participants, Australian women were significantly more likely to have engaged in safer sex practices than the American and Chinese women. Again, this may be related to inter-country differences in education about HIV transmission and safe sex. Of particular concern is the number of sexually active females in this study reporting that they were not regularly engaging in safe sex practices (14% of Australian women, 31% of American women, and 80% of Chinese women). Of further concern is the
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finding that 16% of Australian women, 13% of American women, and 4% of Chinese women stated that they would have a one-night stand in the future, and assuming they would have a one-night stand, 16% of the American women, 20% of the Australian women, and 39% of Chinese women would not use a condom during these encounters. The Australian women reported the most condom use self-efficacy, followed by the American and the Chinese women; however, there were no differences among these women in their attitudes toward safer sex. Previous research suggests that HIV=AIDS is a significant issue on American college campuses (Hightow et al., 2005; Leone et al., 2004), and that many college students remain relatively unconcerned about HIV=AIDS (Ajuluchukwu et al., 1999). These finding raise concerns about the need to increase HIV=AIDS prevention efforts and to develop strategies for empowering women of all cultures to engage in safe sex practices. This study and previous research of HIV=AIDS knowledge among college students has consistently shown that knowledge alone does not predict safe sex practices (Anastasi et al., 1999; Bates & Joubert, 1993; CDC, 2004; Gupta & Weiss, 1993, Lewis & Malow, 1997; Opt & Loffredo, 2004). Within the three countries studied here, HIV=AIDS awareness among female college students is not associated with safer sex practices. Although the sample as a whole scored generally high on the IAQ and its subscales, this HIV=AIDS awareness is not reflected in safe sex practices or intentions for future safe sex practices. Contrary to previous research (Silver & Bauman, 2006), sexually active respondents reported less knowledge of HIV transmission myths. On one hand, it might be viewed as disconcerting that even among this population of educated young adults, we find that students who are currently sexually active are less knowledgeable about HIV=AIDS than those who are not sexually active. However, on the other hand, it might be that students with increased knowledge about HIV=AIDS are more likely to practice abstinence. Furthermore, there was no difference in sexually active and abstaining students with regard to condom self-efficacy or attitudes toward safer sex. Because of this, explanations need to be sought for the nontransfer of college womenâ&#x20AC;&#x2122;s knowledge into safe sex practice. The fact that women who are more knowledgeable seem to avoid sex rather than practice safe-sex suggests that women may find it easier=preferable to abstain from sex rather than to negotiate or insist that a male partner use a condom. This study is not without limitations. Our sample is limited to a convenient sample of college female students in three countries. The present study attempted to minimize, but could not rule out, the shortcomings of the self-reported method, which may be subject to self-selection, social desirability, and recall bias. Participants were not asked about their marital status or sexual orientation, which may have impacted their frequency of condom use. Another limitation with regard to sexual behavior is that intentions may not equal actual behavior. Despite these limitations, these results are
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significant as they provide evidence on the current and future sexual behaviors of this sample population. Further intervention-based research needs to be conducted on how to increase safe sex practices among this vulnerable population and increase condom self-efficacy. HIV=AIDS prevention programs have been the primary focus of controlling the spread of this disease since the epidemic was discovered, but effective interventions require the understanding of the target groups’ characteristics, particular stage of needs, and predicting factors specific to their behavior change. Wingood and DiClemente (1996) have noted that effective HIV=AIDS interventions for women tend to share several characteristics. First, they are guided by social psychological theory, include skills training in condom use and sexual communication, and emphasize gendered power imbalance and sexual assertiveness. Effective HIV=AIDS interventions for women also tend to be multiple-session programs that are strongly peer influenced through interaction and discussion, as well as being led by gender-sensitive health educators from similar ethnic, cultural, and marital backgrounds. Future studies should focus on further understanding the social, cultural, and psychological factors that hamper safe sex practices among this population as well as successful intervention strategies to overcome these barriers.
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