• Open Access

Students and their parental attitudes toward the education of children affected by HIV/AIDS: a cross-sectional study in AIDS prevalent rural areas, China

Authors


Corresponding Author: Dr Tubao Yang, Department of Epidemiology and Health Statistics, School of Public Health, Central South University, 110 Xiangya Road, Changsha, Hunan 410078, People's Republic of China; e-mail: yangtb@xysm.net

Abstract

Objective : To investigate the prevalence and determinants of student and parental attitudes toward the education of children affected by HIV/AIDS in areas of rural China where AIDS is prevalent.

Methods : A cross-sectional study of a random sample of students (n=732) and their parents (n=732) conducted in April 2010, using a questionnaire and in-depth interview.

Results : Twenty-six per cent of students and 29% of parents had a ‘good’ attitude toward the education of children affected by HIV/AIDS. Following adjustment for sociodemographic characteristics, students’ attitudes were significantly associated with knowledge of HIV/AIDS non-transmission (adjusted odds ratio [aOR]= 3.13) and their parents’ attitudes (aOR= 2.38), but not with knowledge of HIV/AIDS transmission, prevention or their parents’ knowledge. Parents’ attitudes were significantly associated with knowledge of HIV/AIDS non-transmission (aOR= 2.12) and their children's attitudes (aOR= 2.52), but not with knowledge of HIV/AIDS transmission, prevention or their children's knowledge.

Conclusion : Stigma and discrimination undermine the right to education of HIV/AIDS-affected children in rural China. Improving non-transmission knowledge may improve caring attitudes.

Implications : HIV/AIDS public health educational campaigns highlighting non-transmission and extending family education, combined with school education, may help to enhance an environment of non-discrimination and safeguard public support programs for the right to education of children affected by HIV/AIDS.

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is a global problem.1–3 Three distinct phases of the HIV/AIDS epidemic have been identified, including the HIV epidemic, the epidemic of AIDS, and the epidemic of stigma, discrimination and denial.4 The third stage brings serious barriers to HIV/AIDS prevention and treatment efforts.4 Despite the efforts of the global public health community, stigma and discrimination against people living with HIV/AIDS (PLHA) is prevalent worldwide and continues to increase in many countries.5–8 On a societal level, HIV/AIDS stigma undermines public support for social programs to assist PLHA. On an individual level, HIV/AIDS stigma creates a barrier to HIV prevention, testing, treatment and care.9 HIV infection also has an impact on the families of PLHA.10 Given these circumstances and the family-oriented structure of Chinese society,11 the right to education of children affected by HIV/AIDS could be undermined.

Education can improve the lives of vulnerable populations, particularly children. Besides conferring knowledge and life skills, education contributes to a child's psychosocial development and provides a safe, structured environment in turbulent situations.12,13 In April 2000, the 164 countries who participated in the World Education Forum in Dakar, Senegal, set out the goals of Education for All (EFA) by 2015.14 However, prejudice or discrimination against children with HIV/AIDS and their parents can challenge the ability to reach these goals. There are more than 130 million school-aged children who are not enrolled in school and it is estimated that 44 countries will not achieve the EFA goals by 2015.14

A recent survey of Chinese AIDS patients found that 6.2% of respondents under 25 years of age who should have undergone education had to drop out of school because of HIV/AIDS (UNAIDS, 2009). For children who can attend school, prejudice and discrimination can limit their ability to perform well.15 Students with HIV/AIDS often feel different from other children, and this can lead to avoidance and isolation.15 Moreover, some parents ask their children to stay away from HIV/AIDS-affected children or transfer their children from schools with children from HIV/AIDS-affected families. Given this information, we hypothesise that students may be influenced by their parents’ attitudes toward the education of children affected by HIV/AIDS. Similarly, parents may be influenced by their children's attitudes on the issue. In this study, we examined the prevalence and determinants of student and parental attitudes toward the education of children affected by HIV/AIDS in rural China.

Methods

Sample

A cross-sectional study using a questionnaire and in-depth interview was conducted in April 2010 in rural areas in Henan and Yunnan provinces, China, where HIV/AIDS is prevalen. Random, stratified, cluster sampling was employed to select four primary schools and eight secondary schools. In order to diminish the possible bias caused by age difference, respondents were randomly selected from the eldest classes in the primary schools and the youngest classes in the secondary schools. A total of 732 students and 732 parents completed the questionnaire, yielding a response rate of 90.8%.

Questionnaire

Questionnaires were developed by experts in the field of HIV/AIDS research and administered to students (test-retest reliability=0.828; Cronbach's alpha=0.797) and their parents (test-retest reliability=0.714; Cronbach's alpha=0.742). The questionnaires comprised questions related to HIV non-transmission, HIV transmission, HIV/AIDS prevention, commonsense HIV/AIDS knowledge and respondent demographic characteristics. Lastly, there were a number of open questions concerning their behaviours, such as the main ideas and reasons why some students refused to attend the same class, to communicate with and to have meals with children from HIV/AIDS families; why some parents didn't want their children to attend the same class as children affected by AIDS; and how to protect the rights of HIV/AIDS-affected children to be educated. Questionnaires were anonymous, confidential and administered by trained research staff, including a medical doctor, medical sociologist and school counsellor. The questionnaires were pre-tested to ensure cultural acceptability and clarity, and modifications were made accordingly.

Measures

Knowledge

Knowledge of HIV “non-transmission” was assessed using two true/false questions asking if HIV could be transmitted through mosquito bites or by dining with affected individuals, while knowledge of HIV “transmission” was assessed using three true/false questions asking if HIV could be transmitted by blood transfusion, unsterilised needles, or from mother to child. “Prevention” was assessed using two true/false questions asking if HIV could be prevented by maintaining one sexual partner or by using condoms. “Commonsense” knowledge was assessed using a true/false question asking if an HIV-infected person could be recognised by their appearance. Respondents who correctly answered all knowledge questions were classified as having “good” knowledge.

Attitudes

Attitudes toward the education of HIV/AIDS-affected children were assessed in both the student (13 questions) and parental (9 questions) questionnaires. The questions assessed respondents’ attitudes toward multiple items pertaining to children with HIV/AIDS or HIV/AIDS-infected family members. An attitude was considered “positive” if it was related to protecting the right to education of HIV/AIDS-affected children. Students who indicated a positive response on 12 out of the 13 questions were classified as having a “good” attitude, while parents who indicated a positive response on 8 of the 9 questions were classified as having a “good” attitude.

Respondent Characteristics

Among students, assessed respondent characteristics included sex (male or female), age (≤13 years, ≥14 years or unknown), Chinese province (Yunnan or Henan), and education (primary school or secondary school). Among parents, assessed respondent characteristics included sex (male or female), age (≤39 years, ≥40 years or unknown), Chinese province (Yunnan or Henan), education (less than primary school, primary school, secondary school or college), family role (mother, father or other), and occupation (worker, farmer, teacher/technician, national civil service, self-employed, business services, unemployed or other).

Analysis

Rates and 95% confidence intervals were calculated for each measure. Knowledge measures were assessed using a correct answer rate (CAR), while attitudinal measures were assessed using a positive attitude rate (PAR). Both rates were defined as the total number of questions answered correctly by all respondents, divided by the product of the number of respondents and the total number of questions answered.

Correlation coefficients were used to analyse the association between knowledge and attitudes. In addition, multiple logistic regression modelling was used to determine the association between HIV/AIDS-related knowledge and attitudes while accounting for respondent demographic characteristics. All analyses were performed using SAS v 9.1 (SAS Institute Inc., Cary, North Carolina, USA). All hypothesis tests were two-tailed with a significance level of 0.05.

Results

Respondent Characteristics

The demographic characteristics of study respondents are presented in Table 1. Student respondents ranged from 9 to 20 years old (mean=13.8, standard deviation=2.0). Almost 54% of student respondents were female. In contrast, parental respondents ranged from 22 to 71 years old (mean=39.4, standard deviation=6.0). Less than half of parental respondents were female (45.2%).

Table 1.  Demographic Characteristics of Study Respondents.
Parents (n=732)Students (n=732)
Characteristicn%Characteristicn%
Sex
Male
Female

401
331

54.8
45.2
Sex
Male
Female

338
394

46.2
53.8
Age (years)
≤ 39
≥ 40
Unknown

369
340
23

50.4
46.4
3.1
Age (years)
≤ 13
≥ 14
Unknown

355
373
4

48.5
51.0
0.5
Chinese Province
Yunnan
Henan

488
244

66.7
33.3
Chinese Province
Yunnan
Henan

488
244

66.7
33.3
Education Level
Less than Primary
Primary
Secondary
College

30
201
390
111

4.1
27.5
53.3
15.2
Education Level

Primary
Secondary


177
555


24.2
75.8
Family Role
Father
Mother
Other

355
302
75

48.5
41.3
10.2
   
Occupation
Worker
Farmer
Teacher/Technician
National Civil Service
Self-employed
Business Services
Unemployed
Other

56
383
71
41
63
22
47
49

7.7
52.3
9.7
5.6
8.6
3.0
6.4
6.7
   

Knowledge

Among students, the overall CAR was 77.1% (95% CI: 74.1%–80.1%). The overall percentage of students with “good” knowledge was 57.8% for “non-transmission”, 83.9% for “transmission”, 44.1% for “prevention”, and 67.5% for “commonsense” measures. The questions pertaining to HIV transmission through mosquito bites and HIV prevention by maintaining one sexual partner had the lowest CARs of 62.6% and 47.3%, respectively.

Among parents, the overall CAR was 81.8% (95%CI: 79.0%–84.6%). The overall percentage of parents with “good” knowledge was 67.6% for “non-transmission”, 83.2% for “transmission”, 62.3% for “prevention”, 69.0% for “commonsense” measures. The questions pertaining to whether HIV-infected people could be recognised by their appearance, and whether HIV could be prevented by maintaining one sexual partner, had the lowest CARs of 69.0% and 65.4%, respectively.

Both students and their parents had lower CARs for the “non-transmission”, “prevention” and “commonsense” measures when compared to “transmission” (all P values <0.05).

Attitudes

Among students, the overall PAR was 62.1%. A total of 26% of students achieved a “good” attitude. Positive attitudes were generally higher for questions related to students who had family members with HIV/AIDS, than for those related to students who were HIV/AID-infected themselves. For example, 52.3% of students indicated that students with a family member who has HIV/AIDS should continue to go to school, but only 49.2% agreed that students with HIV/AIDS should continue to go to school. A total of 57.4% of students would be willing to come into contact with a student who has a family member with HIV/AIDS. Most students indicated that students with a family member with HIV/AIDS should be respected (94.1%) and provided with more help (92.4%). However, only 56.0% believed that students with family members with HIV/AIDS should not be banned from school (Table 2).

Table 2.  Student and parental attitudes toward the education of students affected by HIV/AIDS (n=732).
Attituden% Agree95% CI
  1. Abbreviation: CI=confidence interval, HIV/AIDS= Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

Students    
Students who have HIV/AIDS should not be isolated22731.021.6–34.5
Studentswith a family member who has HIV/AIDS are not unclean60883.180.2–85.6
Students who have HIV/AIDS arenot unclean56376.973.7–79.8
Students with a family member who has HIV/AIDS should continue to go to school38352.348.7–55.9
Students who have HIV/AIDS should continue to go to school36049.245.6–52.8
Studentswith a family member who has HIV/AIDS should be respected68994.192.2–95.6
Studentswith afamily member who has HIV/AIDS should be provided more help67692.490.2–94.1
Students with a family member who has HIV/AIDS should not be banned from attending school41056.052.4–59.6
Respondent willing to come into contact with a student who hasa family member with HIV/AIDS42057.453.8–60.9
Respondent willing to study in the same classroom as a studentwho has a family member with HIV/AIDS44060.156.5–63.6
Respondent willing to study in the same classroom as a student with HIV/AIDS38752.949.3–56.5
Parent would allow respondent to study in the same classroom as a student who has a family member with HIV/AIDS23432.028.7–35.4
Respondent would not alienate a student who has a family member with HIV/AIDS51570.467.0–73.6
Parents    
Students who have HIV/AIDS should not be isolated33545.842.2–49.4
Students with a family member who has HIV/AIDS should continue to go to school55976.473.2–79.3
Students who have HIV/AIDS should continue to go to school54073.870.5–76.8
Students who have HIV/AIDS should study in the same classroom with other student51169.866.4–73.0
Respondent would allow their child to study in the same classroom as a student who has a family member with HIV/AIDS40855.752.1–59.3
Other parents would allow their children to study in the same classroom as a studentwho has HIV/AIDS20528.024.9–31.4
Respondent would allow their child to play with a student who has HIV/AIDS37451.147.5–54.7
Respondent would allow their child to dine with a student who has HIV/ AIDS40755.652.0–59.2
The names of children affected by HIV/AIDS should not be open to the public54774.771.5–77.7

Among parents, the overall PAR was 59%. A total of 29% of parents achieved a “good” attitude. More than three-quarters (76.4%) of parents indicated that students whose family has a member with HIV/AIDS should continue to go to school, while 73.8% indicated that students with HIV/AIDS should continue to go to school. Although 69.8% indicated that HIV/AIDS-affected students should study in the same classroom as other students, only 55.7% indicated that they would allow their own children to study in the same classroom as HIV/AIDS-affected students. Only 28.0% reported that they thought other parents would allow their children to study in the same classroom as HIV/AIDS-affected students. Many parents indicated that they would allow their children to play (51.1%) or dine (55.6%) with HIV/AIDS-affected children. A majority of parents (74.7%) indicated that the names of children affected by HIV/AIDS should not be open to the public (Table 2).

Relationship between Knowledge and Attitudes

Both students’ and parents’ attitudes were positively associated with their HIV/AIDS-related knowledge for “non-transmission”, “transmission”, “prevention” and “commonsense” (all P values <0.05). The greatest observed correlation was between attitudes and “non-transmission” knowledge (rstudents=0.43, 95%CI: 0.37–0.48; rparents=0.31, 95%CI: 0.25–0.38). Students’ attitudes were positively correlated with their parents’ (r=0.43, 95% CI: 0.37–0.49).

Following adjustment for respondent demographic characteristics, students’ attitudes were significantly associated with their knowledge of “non-transmission” and “commonsense”, as well as their parents’ attitudes. However, they were not significantly associated with their knowledge of “transmission”, “prevention”, or their parents’ knowledge. Students with “good” knowledge of “non-transmission” (aOR: 3.13, 95% CI: 1.89–5.18) and “commonsense” (aOR: 2.46, 95% CI: 1.49–4.04) were more likely to have “good” attitudes. Similarly, students with a parent with a “good” attitude were more likely to have “good” attitudes (aOR: 2.38, 95% CI: 1.57–3.61), see Table 3.

Table 3.  Unadjusted and adjusted association between respondents’ knowledge and attitudes toward the education of HIV/AIDS-affected children.
 “Good” AttitudeUnadjusted Odds of “Good” AttitudeAdjusted Odds of “Good” Attitude
Variablen (%)OR95% CIORa95% CI
  1. Abbreviation: CI=confidence interval, HIV/AIDS= Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome, OR=odds ratio

  2. a Among n=709 cases with complete answers. Adjusted for students sex, age, province, and education, as well as parents sex, age, province, education, family role, and occupation

  3. *Statistically significant (alpha=0.05)

Student HIV/AIDS Attitudes      
Student HIV/AIDS Knowledge
 Non-transmission
 Transmission
 Prevention
 Commonsense

142 (33.6%)
164 (26.7%)
99 (30.7%)
155 (31.4%)

2.75*
1.29
1.54*
2.65*

1.90–3.97
0.81–2.07
1.11–2.15
1.77–3.98

3.13*
0.89
1.44
2.46*

1.89–5.18
0.48–1.66
0.91–2.27
1.49–4.04
Parent HIV/AIDS Knowledge
 Non-transmission
 Transmission
 Prevention
 Commonsense

146 (29.5%)
167 (27.4%)
136 (29.8%)
156 (30.9%)

1.84*
1.64*
1.75*
2.54*

1.26–2.68
1.01–2.67
1.22–2.50
1.68–3.83

0.95
1.02
1.35
1.60

0.57–1.58
0.53–1.97
0.83–2.21
0.93–2.75
Parent HIV/AIDS Attitudes 91 (42.9%)3.20*2.26–4.532.38*1.57–3.61
Parent HIV/AIDS Attitudes     
Parent HIV/AIDS Knowledge
 Non-transmission
 Transmission
 Prevention
 Commonsense

173 (34.9%)
188 (30.9%)
153 (33.6%)
169 (33.5%)

2.73*
1.84*
1.86*
2.15*

1.85–4.03
1.14–2.97
1.31–2.63
1.47–3.15

2.12*
1.22
1.27
1.52

1.31–3.43
0.66–2.25
0.82–1.99
0.94–2.47
Student HIV/AIDS Knowledge
 Non-transmission
 Transmission
 Prevention
 Commonsense

140 (33.1%)
184 (30.0%)
98 (30.3%)
154 (31.2%)

1.63*
1.38
1.13
1.41

1.17–2.27
0.87–2.17
0.82–1.55
0.99–2.00

1.15
1.33
0.96
0.95

0.75–1.78
0.75–2.36
0.64–1.45
0.62–1.46
Student HIV/AIDS Attitudes 91 (47.9%)3.20*2.26–4.532.52*1.66–3.83

Following adjustment for respondent demographic characteristics, parents’ attitudes were significantly associated with their knowledge of “non-transmission” and their children's attitudes. However, parents’ attitudes were not significantly associated with their knowledge of “transmission”, “prevention”, “commonsense”, or their children's knowledge. Parents with “good” knowledge of “non-transmission” were more likely to have “good” attitudes (aOR: 2.12, 95% CI: 1.31–3.43). Similarly, parents with a child with “good” attitudes were more likely to have “good” attitudes (aOR: 2.52; 95% CI: 1.66–3.83), as shown in Table 3.

Discussion

Stigma and discrimination related to HIV/AIDS occur in every region of the world and are the greatest barriers to preventing further infections, alleviating the impact of HIV/AIDS, and providing adequate care, support, and treatment.16 In addition to stigma and discrimination, children from families affected by HIV/AIDS are also faced with psychosocial stress, an ill caregiver, reduced parenting, a shift in family structure and financial deprivation.17. These challenges can lead to emotional and behavioural changes in children, such as depression and delinquency.18–20 Therefore, from a public health perspective, it is imperative that actions are taken to identify and eliminate stigma and discrimination related to HIV/AIDS.21

The right to education is a fundamental human right. The findings from this study reveal that stigma and discrimination among parents and their children are undermining the right to education of HIV/AIDS-affected children in rural China. More specifically, only about one-quarter of surveyed students (26%) and parents (29%) were found to have a “good” attitude toward children affected by HIV/AIDS. Consistent with previous reports, variability in respondents’ attitudes was observed across measures.22,23 For example, almost half of students and three-quarters of parents reported that children with HIV/AIDS should continue to go to school. However, less than half of student respondents indicated that they would be willing to study in the same classroom as a student with HIV/AIDS, and only half the parents reported that they would allow their child to play or dine with a student with HIV/AIDS. The study also found that respondents generally had more positive attitudes toward children who had a family member with HIV/AIDS than children with actual HIV/AIDS. These negative attitudes toward children who have family members with HIV/AIDS could be attributable to moral perceptions about HIV infection.24–26

Previous studies have demonstrated that HIV/AIDS-related knowledge can significantly influence individuals’ attitudes.27,28 In the present study, HIV/AIDS-related attitudes were found to be positively correlated with measures of HIV/AIDS-related knowledge, particularly with regard to non-transmission. Following adjustment for demographic factors, students and parents with “good” knowledge of HIV/AIDS non-transmission were also more likely to have a “good” attitude toward the education of HIV/AIDS-affected students. Therefore, HIV/AIDS non-transmission knowledge may play an important role in influencing misconceptions and prejudice toward individuals with HIV/AIDS.29–31 As such, future HIV/AIDS public health educational campaigns should highlight non-transmission knowledge.

This study also documented a positive association between the HIV/AIDS-related attitudes of students and their parents. Even after adjustment for demographic factors, students with “good” attitudes toward the education of HIV/AIDS-affected children were more likely to have parents with the same attitudes, and vice versa. China is a family- oriented society,32 and the family can serve an important role in influencing children's thoughts and behaviour. Maswanya et al. reported that students who obtain HIV/AIDS-related information from their parents are less likely to engage in high risk sexual behavior.33 However, in the same respect, parents’ discriminatory attitudes and prejudices toward HIV/AIDS-affected individuals can be instilled in their children. Nonetheless, research suggests that a vast majority of students obtain HIV/AIDS-related information from the mass media, while few communicate with parents or teachers on the issue.22,23 This finding underscores the importance of involving parents, teachers and students in HIV/AIDS education programs. Stimulating interest among parents and teachers may encourage these individuals to provide their children and students with factually correct information related to HIV/AIDS transmission and prevention. Similarly, introducing HIV/AIDS education programs into school curriculum could improve students’ attitudes, which in turn could enhance parents’ attitudes.

This study is subject to certain limitations that should be considered when interpreting these results. First, the study was carried out in rural areas of the Henan and Yunnan provinces in China; therefore, the results may not be generalisable beyond these populations. Secondly, data were collected using self-administered questionnaires, which could result in biased estimates. For example, respondents may over-report socially desirable answers and under-report undesirable ones. Finally, this study was not able to assess the attitudes of educators or students with HIV/AIDS. Future studies are needed to help inform the development, implementation and sustainability of HIV/AIDS education programs in areas with high HIV/AIDS prevalence.

In conclusion, stigma and discrimination among students and their parents undermines the right to education of HIV/AIDS-affected children in rural China. Strengthening AIDS-related knowledge education, especially non-transmission, helps to improve students and parents’ caring and supporting attitudes. Improving parents’ attitudes also helps to improve their children's attitudes, and vice versa. It is necessary that students, parents, and educators work together to safeguard the rights to education of children affected by HIV/AIDS. Public health educational campaigns highlighting non-transmission knowledge and further exerting family education combined with school education may help to establish non-discrimination environment and safeguard public support programs for the rights to education in the future.

Acknowledgements

The study was approved by the China Ministry of Health and the China Ministry of Education. Funding was provided by the United Nations International Children Emergency Fund (UNICEF). The authors thank the China Ministry of Health, the China Ministry of Education, UNICEF and the questionnaire respondents for their contributions to this study. This manuscript greatly benefited from the editing assistance of Dr Brian King at US CDC.

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