Knowledge, Attitudes, and Behaviors Related to HIV and AIDS Among College Students in Taiwan

Article Outline

• Abstract
• Sex Education, Sources of HIV Information, and HIV Knowledge in Taiwan
• Sexual Behaviors Among College Students in Taiwan
• Methods
  • Study Design
  • Sample
  • Instrument
    • International AIDS Questionnaire—Chinese Version
    • Source of HIV/AIDS Information Questionnaire
    • Sexual History and Condom Use Scale
  • Data Analysis
• Results
  • Sample
  • HIV Knowledge and Attitudes
    • Transmission myths
    • Facts
    • Personal risk
    • Attitude
  • Sources of HIV Information
  • HIV-Related Behaviors
  • Factors Associated with Knowledge and Attitudes About HIV
• Discussion
  • Limitations
  • Implications
• Conclusions
• References
• Biography
• Copyright

HIV infection rates in Taiwan have been growing at nearly 15% per year since 1997, one of the fastest rates in Asia. Little is known about the knowledge, attitudes, and sexual behaviors of college-age young adults in Taiwan. This study assessed the knowledge, attitudes, sources of HIV information, and behaviors related to HIV among college students; it also explored variables associated with the knowledge and attitudes about HIV among college students in Taiwan. Data were collected through a self-administered questionnaire from 132 Taiwanese college students enrolled in two private universities. Study results showed that fewer than half (48.5%) of the participants were aware that HIV could be spread through infected semen, and, nearly a quarter of participants believed that HIV could be contracted through mosquito bites, toilet seats, or swimming pools. Only 29.5% reported ever having had sex. This research provides additional insights that may be used to develop effective HIV prevention strategies in Taiwan.

Key words: AIDS, attitude, college students, condom use, HIV, knowledge, nursing, sexual behavior, Taiwan

Taiwan, a democratic island country off the southeast coast of the People's Republic of China, has a population of approximately 22.7 million people (Department of Statistics, Ministry of the Interior, 2007). Taiwan's first case of HIV was diagnosed and reported in 1984 in an American physician who first developed symptoms in Thailand and was later diagnosed in Taiwan (Center for Disease Control, Department of Health, Executive Yuan of Taiwan [CDC Taiwan], 2006). In 1986, the first local case of HIV was reported in Taiwan in a male patient who had sex with men. As of June 2007, a cumulative 14,092 cases of HIV infection, including 3,278 cases of AIDS, had been reported in Taiwan (CDC Taiwan, 2007). Although the prevalence of HIV infection and AIDS cases in Taiwan is relatively low compared with other Asian countries, the incidence of HIV infection in Taiwan has increased approximately 15% every year since 1997, placing Taiwan's among the fastest rising rates of HIV in Asia (Twu, Huang, Lai, Ming, & Su, 2004). It is estimated that 30,000 Taiwanese people will be infected with HIV by 2011 if no effective prevention programs are implemented (CDC Taiwan, 2006).

Taiwan withdrew from the United Nations (UN) in 1971 (National Institute for Compilation and Translation, n.d.) and the World Health Organization in 1972 (Lee, 2003), resulting in lost opportunities for participation in international and regional HIV control programs and networks. One effect of the political decisions to withdraw from the UN and the World Health Organization is that Taiwanese people may be even more vulnerable to HIV infection and its complications.

Young people between 15 and 24 years of age account for nearly half of all new HIV infections worldwide (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2004). Young people between 20 and 29 years of age make up 38% of the HIV-infected population currently reported in Taiwan (CDC Taiwan, 2007). College students as a group are particularly vulnerable to HIV infection; they may be at higher risk of engaging in risky sexual behaviors, especially if they are under the influence of alcohol or drugs, respond to peer pressure, or lack maturity (Centers for Disease Control and Prevention, 2004). This study focused on knowledge, attitudes, and behaviors related to HIV among college students in Taiwan, an understudied group in the area of HIV knowledge and sexual behaviors. The lack of HIV and sexual behavior research among college students in Taiwan makes it difficult to develop informed prevention strategies for this population. Therefore, the goals of this study were to (a) assess the knowledge and attitudes, sources of HIV information, and behaviors related to HIV among college students in Taiwan and (b) explore the factors associated with knowledge and attitudes about HIV among college students in Taiwan.

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Sex Education, Sources of HIV Information, and HIV Knowledge in Taiwan 

In Taiwan, few school education programs are dedicated to prevention of sexually transmitted infections (STIs) including HIV. Although sex education has been included in the formal curricula of secondary schools in Taiwan, some teachers in schools avoid giving instructions and will merely ask students to read the text for themselves because of the teacher's discomfort with the topic (Tsai and Wong, 2003, Yeh, 2002). In recognition of the fact that sex education is inadequate in schools, the Department of Health (DOH) of the Executive Yuan of Taiwan (2004) has launched several campaigns to prevent and control HIV by stressing the importance of safer sex. For instance, the DOH has established 33 teen health centers throughout the island where medical advice, consultation, and referral services are provided for teens who are seeking help or who are interested in finding out more about safer sex. The DOH also has established a sex education Web site (http://www.young.gov.tw) that is viewed about 500,000 times per year, an indication that many are visiting the site, presumably to obtain information about safer sex or to seek online assistance.

Nevertheless, the inadequacy of formal sex education has forced Taiwanese youth to depend on informal channels (e.g., the Internet, newspapers), which might lead to an inaccurate understanding of safer sex practices. The few completed surveys in the area of HIV knowledge in Taiwan indicated that 37% of male college students did not know that HIV transmission could be prevented by the use of condoms, and 58% were unaware that HIV could be spread through infected semen (Tung, 2007). Approximately 25% of college students indicated that HIV could be transmitted through mosquito bites, swimming pools, and the sharing of cigarettes (Chen, 1993, Tung, 2007). These data suggest that low levels of knowledge about the effectiveness of condoms and misconceptions about the transmission of HIV might put Taiwanese college students at increased risk for HIV infection, thus challenging the efficacy of current HIV education programs in Taiwan.

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Sexual Behaviors Among College Students in Taiwan 

Sexual behaviors among young people in Taiwan have changed with the introduction and rapid development of a market economy, the wide exchange between Western and traditional cultures, and increased personal freedoms. Many Taiwanese young people, including college students, do not maintain the relatively conservative and traditional attitudes toward sex espoused by their parents and grandparents. Premarital sexual activity in Taiwan has markedly increased over the past decade. Yeh (1998) reported that 12% of male and 1% of female college students reported premarital sexual activities. More recent data (Chen, 2003, Tung, 2007) showed that 63% of college students in Taiwan were engaging in sexual behaviors, with the majority having their first sexual encounter during their college years. The average age of first intercourse in Taiwan was reported at 18.9 years in 2005, a significant decrease from 20.6 years reported in 2001 (Durex Global, 2005).

Increased sexual activity raises concerns about the prevalence of HIV infection among Taiwanese college students. Although consistent condom use has been shown to be effective in the prevention of HIV and other STIs among sexually active individuals (Davis and Weller, 1999, Pinkerton and Abramson, 1997, Pinkerton et al., 1998), research examining condom use among Taiwanese college students has shown that only about 25% used condoms consistently (Chen, 2003, Yang, 1997). Comprehensive sex education programs to help young people in Taiwan practice safer sex or postpone sexual intercourse are needed. Research-based data about the knowledge, attitudes, sources of HIV information, and behaviors related to HIV among college students in Taiwan is important for the development of culturally sensitive education programs. The information generated from this study could provide pertinent information for designing and implementing HIV prevention programs in Taiwan.

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Methods 

Study Design 

This study used a descriptive cross-sectional survey design to collect data from Taiwanese college students, using a self-administered questionnaire. The data were collected in March and April of 2007. Study participation was voluntary and anonymous.

Sample 

A convenience sampling method was used to recruit participants from two private 4-year universities in southern Taiwan. Subjects were eligible for inclusion if they were (a) 18 years of age or older, (b) able to read Chinese, and (c) undergraduate students in a nonhealth-related major. Students majoring in the health professions were excluded from this study because it was thought that their responses would not reflect those of the general college student population because HIV prevention was included in the curricula for health professions students.

After receiving institutional review board approval from each of the universities, the researchers requested that the registrar's office of each participating university select one class per major (e.g., accounting, business, computer science, and English) from each grade (freshmen to senior) for participation. Four classes were selected from each participating school. The researchers approached students in their classrooms and invited participation in the study. After explaining the nature, purpose, and anonymity of the study, the researchers distributed a self-administrated questionnaire to students who consented. The students were assured that their responses would be confidential and that their participation was voluntary. The students were also informed that they were free to decline to participate in the study at any time.

Instrument 

The questionnaire consisted of four self-administrated instruments that took a total of 5 to 10 minutes to complete. The instruments for this study were (a) the Demographic Questionnaire, (b) the International AIDS Questionnaire—Chinese Version (IAQ-C), (c) the Source of HIV/AIDS Information Questionnaire, and (d) the Sexual History and Condom Use Scale. The Demographic Questionnaire collected information regarding sex, year of birth, academic year, student status, marital status, perception of individual health status, religious belief, and level of religiosity from each participant. The remaining three instruments were as follows.

The IAQ-C (Davis, Tang, Noel, & Chan, 1999) was used to measure HIV-related knowledge and attitudes among college students in Taiwan. The 18-item IAQ-C assessed four dimensions of HIV and AIDS: transmission myths, facts, attitudes, and personal risk. Each item was scored on a 5-point Likert scale: 1 (strongly agree), 2 (agree), 3 (don't know), 4 (disagree), 5 (strongly disagree). Total scores on the IAQ-C ranged from 18 to 90, and subscale scores ranged from 7 to 35 for transmission myths, 5 to 25 for attitudes, and 3 to 15 for personal risk and facts. Higher scores indicated positive and accurate views of HIV. The IAQ-C total scale had a Cronbach's coefficient alpha of .76 (Davis et al., 1999). The test-retest reliability was accomplished with a sample of 21 Chinese university students at a 2-week interval and was reported to be .74. In the present study, the Cronbach's alpha coefficient was .79 for all 18 items, .80 for the transmission myths subscale, .62 for the attitudes subscale, .62 for the personal risk subscale, and .46 for the facts subscale.

Participants were asked about their sources of HIV information and with whom they discussed questions about STIs or HIV. Participants were asked to identify all answers that applied (e.g., school teacher, friend, family member, and health professional).

Sexual history measured the participant's sexual orientation (heterosexual, homosexual, or bisexual), if the participant had ever been diagnosed with an STI (yes or no), the types of sexual behaviors in which the participants ever engaged (vaginal, anal, oral, masturbation, or none), the number of sexual partners since becoming sexually active, frequency of condom use when having sex (every time, almost every time, sometimes, or never), alcohol use (every day, sometimes, or not at all), and drug use (every day, sometimes, or not at all). Participants responded to each item by checking all answers that applied. For each item, the response options included other, please specify.

Data Analysis 

Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 15.0 for Windows (SPSS, Inc. Chicago, IL). The mean, standard deviation, percentage, and frequency distribution were performed to describe demographic variables, sources of HIV information, and knowledge, attitudes, and behaviors related to HIV. Independent t-test and one-way analysis of variance (ANOVA) tests were used to examine the differences in knowledge and attitudes about HIV by demographic characteristics and HIV-related behaviors. Chi-square tests were used to explore the relationships between sex (male and female), sources of HIV information, and HIV-related behaviors. For all analyses in this research, a level of p < .05 was used to determine statistical significance.

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Results 

Sample 

A total of 322 students (73 freshmen, 95 sophomores, 93 juniors, and 61 seniors) were present during the administration of the classroom surveys. All present in the classroom were invited to participate and received a questionnaire. A total of 132 students returned fully completed and valid surveys, representing a 41% response rate. Table 1 shows the demographic characteristics of the 132 participants. Participants ranged in age from 20 to 26 years with a mean age of 21.21 years (SD = 1.18). Most of the participants were female (60.6%), sophomore (61.4%), and full-time students (95.5%). The majority of the participants rated their health status as fair (51.5%) or good (30.3%). More than half (57.6%) of the students did not have a religious preference. Of those students with a religious preference, 18.2% were Buddhist and 18.2% were Taoist. None of the participants reported having ever been married.

Table 1. Frequency Distribution of Demographic Variables (N = 132)

Characteristics	n	%
Sex
Female	80	60.6
Male	52	39.4
Age
20 years	41	31.1
21 years	45	34.1
22 years	31	23.5
23 years or older	14	10.6
Unknown	1	.7
Year in school
Freshman	2	1.5
Sophomore	81	61.4
Junior	45	34.1
Senior	4	3.0
Full-time student
Yes	126	95.5
No	6	4.5
Health perception
Poor	7	5.3
Fair	68	51.5
Good	40	30.3
Very good	7	5.3
Excellent	10	7.6
Religious preference
Buddhist	24	18.2
Christian	8	6.1
Taoist	24	18.2
None	76	57.6
Religiosity
Not at all religious	10	7.6
Little religious	35	26.5
Somewhat religious	47	35.6
Very religious	40	30.3

HIV Knowledge and Attitudes 

Table 2 presents the data related to knowledge of and attitudes about HIV among Taiwanese college students. The mean score for transmission myths subscale was 28.08 (SD = 5.76, range 7-35), 11.70 (SD = 2.43, range 3-15) for facts subscale, 11.70 (SD = 2.79, range 3-15) for personal risk subscale, and 16.29 (SD = 3.32, range 5-25) for attitudes subscale.

Table 2. HIV Knowledge and Attitudes (N = 132)

Item on International AIDS Questionnaire—Chinese Versiona	Mean (SD)	% Agreeb
Transmission myths	28.08 (5.76)
HIV can be spread through coughing and sneezing.	4.39 (1.11)	8.3
AIDS can be contracted through sharing cigarettes.	3.89 (1.31)	17.4
HIV/AIDS can be spread through hugging an infected person.	4.70 (.74)	2.3
HIV can be transmitted through the air.	4.48 (1.04)	6.8
HIV can be spread through swimming pools.	3.72 (1.34)	22.7
HIV can be contracted through toilet seats.	3.59 (1.42)	28.0
Mosquitoes can transmit HIV.	3.30 (1.46)	35.6
Facts	11.70 (2.43)
Condoms will decrease the risk of HIV transmission.c	1.95 (1.13)	76.5
HIV can be transmitted from mother to baby.c	1.73 (1.05)	80.3
HIV is spread through infected semen.c	2.62 (1.31)	48.5
Personal risk	11.70 (2.79)
Asians are less susceptible to contracting AIDS than Westerners.	3.73 (1.20)	15.9
AIDS only affects intravenous drug users, prostitutes, and homosexuals.	4.00 (1.32)	15.2
You can protect yourself against AIDS by being vaccinated for it.	3.97 (1.17)	11.4
Attitudes	16.29 (3.32)
People with HIV should be kept out of school.	4.37 (1.07)	6.8
I would end my friendship if my friend had AIDS.	4.05 (1.01)	6.1
I am willing to do volunteer work with AIDS patients.c	3.10 (1.18)	28.8
If a family member contracts HIV he/she should move out.	4.36 (.90)	5.3
People with HIV should stay home or in a hospital.	3.51 (1.28)	24.2

As shown in Table 2, more than one third (35.6%) agreed that HIV could be transmitted by mosquitoes, 28% agreed that HIV could be contracted through toilet seats, 22.7% agreed that HIV could be spread through swimming pools, and 17.4% agreed that HIV could be contracted when sharing cigarettes. Fewer than 10% agreed that HIV could be spread through coughing and sneezing (8.3%), through the air (6.8%), or through hugging an infected person (2.3%).

The majority of the participants agreed that condoms would decrease the risk of HIV transmission and that HIV could be transmitted from mother to baby; 76.5% and 80.3%, respectively (see Table 2). However, only 48.5% were aware that HIV could be spread through the semen of HIV-infected men.

Results on personal risk showed that 15.9% of participants agreed that Asians are less susceptible to contracting HIV than Westerners. More than 15% of the participants (15.2%) agreed that HIV only affected intravenous drug users, prostitutes, and homosexuals, and 11.4% agreed that one could protect himself or herself by being vaccinated against AIDS.

Results on attitudes toward persons with HIV indicated that only 6.8% of participants agreed that persons with HIV should be kept out of school, 6.1% thought he or she would end a friendship with friends diagnosed with HIV, and 5.3% agreed that a family member should move out if he or she contracted HIV. Nearly 1 in 4 participants said they would be willing to do volunteer work with AIDS patients (28.8%), and nearly a quarter (24.2%) agreed that persons with HIV should stay home or in a hospital.

Sources of HIV Information 

As shown in Table 3, the main source of information about HIV was through mass media, with television ranking first (80% female vs. 73.1% male), followed by the Internet (66.3% female vs. 67.3% male). Newspapers and magazines were used by 45% of the women and 48.1% of the men. More women (56.3%) significantly cited schoolteachers as a source of information than male students (32.7%), χ² (1, N = 132) = 7.022, p = .008. Friends, neighbors, radio, family members, and health professionals were the least reported sources of information regarding HIV.

Table 3. Sources of HIV Information and Sources of Communication (N = 132)

	% of Use by Sex		Chi-Square Testa
	Female (n = 80)	Male (n = 52)	χ2	p
Sources of information
Television	80.0	73.1	.860	>.05
Internet	66.3	67.3	.016	>.05
Schoolteacher	56.3	32.7	7.022	.008
Newspaper/magazines	45.0	48.1	.120	>.05
Friends/neighbors	16.3	25.0	1.525	>.05
Radio	15.0	13.5	.016	>.05
Family member	12.5	15.4	.023	>.05
Health professional	7.5	9.6	.185	>.05
With whom to discuss HIV
Friend of the same sex	70.0	57.7	2.100	>.05
Family member	31.3	21.2	1.620	>.05
Friend of the opposite sex	25.0	15.4	1.743	>.05
Girlfriend/boyfriend	20.0	36.5	4.420	.035
Schoolteacher	16.3	15.4	.018	>.05
Health professional	12.5	17.3	.591	>.05
Online chat or e-mail with stranger	5.0	15.4	4.110	.043
Husband/wife	2.5	11.5	4.520	.033

More than half of the female (70%) and male (57.7%) participants said they would discuss STIs with friends of the same sex (see Table 3). Family members were the second most reported source of communication by female participants (31.3%) and girl/boy friends were the second most reported source for male participants (36.5%). Results from chi-square tests indicated that significantly more male participants than female participants would have discussed HIV issues with their girl/boy friends (χ² [1, N = 132] = 4.42, p = .035), online strangers (χ² [1, N = 132] = 4.11, p = .043), or husband/wife (χ² [1, N = 132] = 4.52, p = .033).

HIV-Related Behaviors 

As shown in Table 4, all male (n = 52) and 96.3% of female participants (n = 77) identified themselves as heterosexual. Only 39 participants (29.5%) in the sample of 132 reported ever having sex. Of those who reported never engaging in sexual activities (n = 93), 73.1% (n = 68) were female and 26.9% (n = 25) were male. Among those who had ever had sex, 33.3% of females and 14.8% of males had had only one sexual partner; the remainder had had two or more partners. Condom use during each sexual encounter was reported by 8.3% of women and 18.5% of men. A majority of participants used condoms sometimes; 58.3% of women and 55.6% of men, respectively. None had a history of an STI. Chi-square tests indicated that the sexual behaviors (i.e., sexual orientation, forms of sexual activities ever experienced, number of sexual partners, and frequency of condom use) of participants were not significantly related to sex.

Table 4. Frequency Distribution of HIV-Related Behaviors by Sex (N = 132)^a

	Female		Male
	n	%	n	%
Sexual orientation
Heterosexual	77	96.3	52	100
Homosexual	2	2.5	0	0
Bisexual	1	1.3	0	0
Forms of sexual activities experienced
Vaginal, anal, and oral	2	2.5	5	9.6
Vaginal and oral, no anal	4	5.0	17	32.7
Vaginal and masturbation	5	6.3	5	9.6
Only masturbation	1	1.3	0	0
None	68	85.0	25	48.1
Number of sexual partners in lifeb
One	4	33.3	4	14.8
Two or three	6	50.0	9	33.3
Four or more	2	16.7	8	29.6
Unknown	0	0	6	22.2
Frequency of condom use when having sexb
Every time	1	8.3	5	18.5
Almost every time	1	8.3	5	18.5
Sometimes	7	58.3	15	55.6
Never	3	25.0	2	7.4
Alcohol usec
Every day	1	1.3	5	9.6
Sometimes	38	47.5	37	71.2
Not at all	41	51.3	10	19.2
Use of illicit drugs
Every day	0	0	0	0
Sometimes	2	2.5	4	7.7
Not at all	78	97.5	48	92.3

Participant use of alcohol and illicit drugs is presented in Table 4. More men (n = 37, 71.2%) than women (n = 38, 47.5%) drank alcohol sometimes (χ² [2, N = 132] = 16.32, p = .001). There was no significant difference in illicit drug use by sex.

Factors Associated with Knowledge and Attitudes About HIV 

Table 5 lists the means and standard deviations of knowledge and attitude scores broken down by selected demographic and HIV-related behavior variables. The HIV knowledge composite score used as an indicator had an overall knowledge range of 13 to 65. Higher scores indicated that the participant was more knowledgeable. Results showed that the obtained knowledge score ranged between 28 and 65, with a mean of 51.48 (95% confidence interval [CI] = 51.37-51.60). The HIV attitude composite score had a range of 5 to 25. Higher scores indicated more favorable attitudes toward persons with HIV. The obtained attitude composite score ranged from 9 to 25, with a mean of 19.19 (95% CI = 19.14-19.24). T-test or one-way ANOVA tests were conducted to explore possible differences in knowledge and attitudes by each demographic and HIV-related behavior variable. A significant difference was found in knowledge scores by perceived health status. A one-way ANOVA and Tukey's honestly significant difference post hoc showed that those who perceived themselves to be in excellent health (M = 58.1, SD = 4.53) scored higher than those who thought their health status was fair (M = 50.2, SD = 7.79), F (3, 131) = 2.77, p = .02. However, knowledge and attitudes related to HIV did not significantly differ on other demographic and sexual behavior variables.

Table 5. Knowledge and Attitude Composite Scores by Demographics and HIV-Related Behaviors (N = 132)

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Discussion 

The goals of the current study were to (a) assess the knowledge and attitudes, sources of HIV information, and behaviors related to HIV among college students in Taiwan and (b) explore the factors associated with knowledge and attitudes about HIV among college students in Taiwan. Despite this sample being a highly educated group of college students in Taiwan, their knowledge about HIV was surprisingly poor. For example, fewer than half of the participants were aware that HIV could be spread through infected semen, and nearly a quarter of all participants believed that HIV could be contracted through mosquito bites, toilet seats, or swimming pools. These results were consistent with other research completed in Taiwan (Chen, 1993, Tung, 2007), indicating an obvious lack of HIV knowledge and understanding among these Taiwanese college students. Unfortunately, the level of knowledge about transmission of HIV has not improved since 1993; this may be partially explained by inadequate sources of HIV information and limited formal sex education in Taiwan.

Nearly a quarter of the participants thought that persons diagnosed with HIV should stay at home or in a hospital. Yet fewer than 7% of the participants thought that they personally would end a friendship with a friend diagnosed with AIDS or that persons with HIV should be kept out of schools or moved out of a family home. These participants seemed to have compassion for the person with HIV, but many still believed that persons with HIV should not be integrated into the general population. These dichotomous beliefs were likely because of a lack of knowledge and understanding about HIV transmission.

Primary sources of information related to HIV for nearly two thirds of the participants were television and the Internet, and few participants indicated that they would seek information from family members or health professionals. This may reflect traditional Taiwanese/Chinese beliefs that open discussion about sex is taboo and obtaining HIV information from family members or health professionals would be inappropriate or unseemly (Yeh, 2002). Therefore, college students might turn to the television or the Internet for HIV-related information. It should be noted that even with information from television and Internet sites, there was still a serious HIV knowledge deficit among participants. This implies that obtaining HIV-related information through television and Internet sources was problematic. It could be that Chinese language versions of HIV information were limited, inaccurate, or difficult to understand. It was also possible that some of the HIV information available on the Internet was inaccurately translated from English to Chinese, or perhaps that study participants did not know how to evaluate the accuracy of Web site content related to HIV. This reinforced the importance of involving health professionals, schoolteachers, students, and parents in HIV education programs.

Male students were more likely to discuss STIs or HIV issues with online strangers than female students. Men were also less likely to use schoolteachers as a source of information. However, if college-age men in Taiwan did not seek information about STIs or HIV from credible sources (e.g., health professionals), this could have made their sexual partners more vulnerable to infection because of a lack of accurate information.

Only 29.5% of the participants in this study were sexually active. In comparison with previous studies (Chen, 2003, Tung, 2007), which reported that 63% of college students in Taiwan were sexually active, the college students in this study were less sexually active at the time of the study. One possible reason for this difference may have been because of sampling and methodological differences. Whereas Y. C. Chen (2003) investigated college students in Taipei, a metropolitan area in northern Taiwan, this study was conducted in southern Taiwan, a more conservative region. Further, Tung (2007) surveyed only male college students, and this study included both men and women. Differences among male and female college populations regarding sexual activity have been noticed, with Chinese men reporting more sexual activity than women (Abdullah et al., 2003, Huang et al., 2005).

Among sexually active students in this study, over 50% indicated that they used condoms “sometimes” during sexual activity, and more than 60% indicated that they had had two or more sexual partners; yet only 18.5% of the men and just over 8% of the women indicated they “always” used a condom when engaging in sexual activity. The participants seemed to be generally aware of condom use, but the reasons participants used condoms were unclear. It may be that condom use in Taiwan is an attempt to prevent pregnancy more than to protect against STIs. Factors regarding consistent use of condoms during sexual activity were not explored in this study. Future research should include perceptions about the use of condoms among college-age students in Taiwan and what factors contribute to the consistent use of condoms during sexual activity (e.g., use of condoms with first sexual experience). Relationships among various risky health behaviors (e.g., using drugs and drinking alcohol) could also be explored, which may lead to better general and specific health promotion/prevention policies in Taiwan.

Health perception was the only factor significantly and positively associated with HIV knowledge and attitudes. Participants who perceived themselves to be in excellent health scored higher than those who described their health status as only fair. Whereas the reason for this was unclear, it may have been that students who were more concerned about health and worked to maintain a healthy lifestyle were more likely to seek accurate information about health promotion and disease prevention.

There was no relationship between sex and sexual behaviors (e.g., the number of sexual partners and frequency of condom use) and HIV knowledge and attitudes in this study. However, disparities regarding acceptable sexual behaviors of men and women in Taiwan still exist. For example, a man visiting a sex worker in Taiwan is tolerated within the society, whereas female virginity before marriage and fidelity after marriage are highly valued. Wang and Lin (1996) reported that 58% of men in Taiwan reported having visited sex workers; and less than 20% ever used a condom during sexual intercourse with sex workers. Additionally, in Taiwanese tradition women are expected to be submissive to their father at home, their husband after marriage, and their sons after the death of their husband (Yeh, 2002). If men in Taiwan engage in high-risk sexual behavior (e.g., multiple sexual partners and inconsistent condom use), gender roles and cultural expectations are likely to contribute to the escalating rates of HIV infection in Taiwan. More research is needed to examine and understand the influence of gender roles and societal expectations related to HIV transmission in Taiwan.

Limitations 

This study was limited by a small, nonrandom sample from two private universities in southern Taiwan, in which only 29.5% of participants reported ever having sex. Caution should be taken in generalizing the results of this study to other college student populations in Taiwan. Future studies, including a larger sample from a more geographically diverse group randomly chosen from more universities, would provide more representative information of Taiwanese college students' knowledge, attitudes, and behaviors related to HIV. Second, this study used a self-reported questionnaire, which may have been subject to self-selection, social desirability, and recall bias. Finally, reported reliability coefficients of the attitude, personal risk, and facts subscales in the IAQ-C were below the accepted norm of .70.

The only published study using the IAQ-C to examine HIV knowledge among Chinese adolescents and college students in Hong Kong also had low reliability for the same three subscales: .66 for attitudes; .48 for the personal risk; and .45 for facts (Davis, Tang, et al., 1999). With the low reliability coefficients for the IAQ-C subscales of attitude, personal risk, and facts in the current study as well as the previous study (Davis, Tang, et al., 1999), it is possible that some of the items in the IAQ-C are problematic or unreliable. Also, the reason for low reliability may have been that there were only three items in each of the personal risk and facts subscales. Another explanation may be that the IAQ-C was originally developed in Hong Kong, and there may be cultural as well as language differences between the two populations (e.g., Chinese/Cantonese in Hong Kong and Chinese/Taiwanese in Taiwan). Future studies should test the reliability of the instrument and/or explore psychometric issues related to translation and use of the IAQ-C among different populations.

Implications 

In spite of the limitations noted, results from this study have important implications for nursing and public health. First, accurate information about HIV needs to be emphasized for college students on university campuses. Nursing and public health professionals who have access to this population could incorporate study results into intervention strategies aimed at increasing the level of HIV-related knowledge. In addition, program developers should consider differences and preferred ways of receiving information on sexuality and sexual activity for men and women as they develop HIV education programs. Because of the general cultural expectation that women in Taiwan remain virgins until marriage and that they are subject to male domination, special attention must be given to developing strategies that empower women and encourage them to actively engage in HIV prevention strategies (e.g., negotiating condom use with sexual partners).

Second, although most of the participants hold positive attitudes toward persons diagnosed with HIV, more work must be done to reduce the stigma associated with HIV.

Third, this research underscored the importance of providing accurate, accessible, and appropriate information to young adults in Taiwan. The fact that more than 15% of participants thought that persons of Asian descent were less susceptible to HIV than Westerners is especially problematic in a country in which values and norms regarding sexual activity are changing. Young adults in Taiwan need to know the health risks associated with HIV, how it is spread, and what steps they must take to protect themselves from infection.

Fourth, data from this study suggest that sexually active students do not routinely practice safer sex (e.g., participants reported multiple sexual partners and inconsistent condom use). HIV education and prevention programs need to emphasize the importance of minimizing the number of sexual partners and addressing other risky behaviors.

Fifth, accurate sources of HIV information are essential elements in preventing the spread of this epidemic. Formal sources of information must be strengthened, and individuals who are powerful within a society (e.g., teachers and health care providers) must be involved in developing strategies for informing Taiwanese youth about HIV. Additionally, television executives should be encouraged to include an emphasis on dispelling common myths about the transmission of HIV in their programming. The role of the Internet in HIV prevention programs should be recognized, because the Internet served as the main source for HIV information for study participants. Health professionals, educators, and politicians must unite to ensure that HIV-related information available on the Internet is accurate and readily accessible. Web sites developed and maintained specifically for college students in Taiwan would be useful for providing culturally specific, properly reviewed, and accurate information.

Sixth, schoolteachers should be encouraged to teach students about HIV and to direct students to accurate and current sources of information about HIV transmission, prevention, and treatment.

Finally, although only a small number of participants in this study reported ever having sex, HIV prevention education efforts should begin at an early age. It is likely that rates of sexual activity among Taiwanese youth will only increase over time; therefore, they must receive early, frequent, and accurate information about HIV transmission and prevention.

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Conclusions 

This research attempted to capture knowledge and attitudes about HIV among college students in Taiwan. The research was important because more young adults in Taiwan are becoming sexually active at an earlier age, and it is imperative that health promotion strategies change to meet the needs of this and future generations. This research suggests that young adults in Taiwan lack a sufficient knowledge base upon which to build their understanding of HIV. Although knowledge alone may not be sufficient in preventing HIV, young adults must have knowledge to make informed decisions.

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