kiến thức về suc khoe tinh duc ở trẻ vị thành niên trung quốc

Lui This study was conducted to examine the knowledge of and attitudes toward sex of 178 Chinese secondary school students in Hong Kong.. In Hong Kong, little is known about the sexual a

Western Journal of Nursing Research

March 2001, Vol 23, No 2

Knowledge of and Attitudes Toward Sex Among Chinese Adolescents

Wan-Yim Ip Janita P C Chau Anne M Chang May H L Lui

This study was conducted to examine the knowledge of and attitudes toward sex of 178 Chinese secondary school students in Hong Kong The data were collected using a questionnaire that comprised three parts: the Chinese version of the Mathtech Knowledge Test, the Chinese version

of the Mathtech Attitude and Value Scale, and a demographic sheet seeking sociodemographic information In general, students demonstrated a low level of sexual knowledge, especially in relation to adolescent marriage, the probability of pregnancy, and adolescent sexual activity With regard to attitudes, students indicated positive attitudes toward importance of family and importance of birth control Male students in comparison with their female counterparts had a higher level of agreement with premarital intercourse and the use of pressure and force in sexual activity.

In Hong Kong, little is known about the sexual attitudes and behavior of Chinese adolescents Most studies investigating Chinese young people’s knowledge and attitudes toward sex have been done on college students (Chan, 1990; Tang, Lai, & Chung, 1997) As Tompkins (1999) points out, nursing practice is effective when an exploration of the clients’ beliefs pre-cedes nursing intervention To provide appropriate and culturally sensi-tive education programs to Chinese adolescents, it is necessary to assess their knowledge of and attitudes toward sex This study was, accordingly,

Wan-Yim Ip , R.N., R.M.N., B.N., M.Phil., Assistant Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong; Janita P C Chau , R.N., B.N., M.Phil., Assistant Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong; Anne M Chang , R.N., Dip.N.Ed., B.Ed.St., M.E.D St., F.R.C.N.A., Ph.D., Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong; May H L Lui , R.N., B.N., M.Phil., Assistant Pro-fessor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong.

© 2001 Sage Publications, Inc.

designed to explore the sexual knowledge and the sexual attitudes among a sample of Chinese secondary school students

SEXUAL KNOWLEDGE AND BEHAVIOR

Sex education has been included in the formal and informal curricula of primary and secondary schools of Hong Kong for many years (Hong Kong Education Department, 1986) A number of surveys in recent years, how-ever, have revealed that the sexual knowledge of young people was rather limited, while the incidence of unsafe sex practice had increased (The Fam-ily Planning Association of Hong Kong, 1994, 1999; The University of Hong Kong, 1995) In a telephone survey of 1,038 randomly selected young people ages 15 to 29 years, 40% of respondents did not use condoms during sex and one in five young men had used the services of prostitutes The Fam-ily Planning Association of Hong Kong (1999), which offers an integrated medical and counseling service in fertility and sexuality for unmarried young people, revealed that the major service sought by women ages 16 to

25 was termination of pregnancy (31.4%) and emergency contraception (29.3%) These findings indicate that many adolescents have limited knowl-edge about sexual health

SEXUAL KNOWLEDGE AND ATTITUDES

Previous studies indicate that sexual behavior is influenced by a number

of factors including knowledge and attitudes Chan (1990) found that increased sexual knowledge tended to be associated with the repudiation of sexual myths Yi (1998), in his study on 412 Vietnamese American college students’ knowledge of sex, reported that sexually active participants were less knowledgeable than those who were less sexually active Increase in sexual knowledge alone might not affect behavior; it is equally important to modify attitudes in designing effective sex education programs (Pleck, Sonenstein, & Ku, 1991) Educators, sociologists, and psychologists share a common framework, in which education modifies knowledge or attitudes, which in turn facilitate behavioral change (Visser & Bilsen, 1994)

A World Health Organization–sponsored study (Grunseit, 1994) con-ducted in the United States, Europe, Australia, Mexico, and Thailand

show-ed that comprehensive sex show-education programs lshow-ed to safer sexual behaviors

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The sex education classes in these countries could help young people to postpone sexual intercourse or, if they were already sexually active, to prac-tice safer sex and reduce their number of partners This study also found better knowledge when sex education programs were provided before young people became sexually active and that programs with numerous options were more effective in promoting safer sexual behavior than those that pro-mote abstinence alone

FACTORS INFLUENCING SEXUAL KNOWLEDGE AND ATTITUDES

Specific information about sexual attitudes and knowledge is vital to the design of effective sex education programs (Lief, Fullard, & Devlin, 1990) Cultural and social beliefs affect individuals’ attitudes toward sex, which in turn affect their sexual behavior (Bhugra & de Silva, 1993) Therefore, it is important to offer culturally sensitive sex education that addresses the com-mon misinformation acom-mong the public Furthermore, sex education pro-grams need to be incorporated into the total cultural system of a given coun-try (International Council of Nurses, 1996) It is important to offer culturally sensitive sex education that addresses the common misinformation among the public

In addition, demographic variables have also been found to influence a person’s attitudes toward sex (Lewis & Bor, 1994; Payne, 1976) Gender differences regarding sexual knowledge and attitude have been noted in past studies (J S Chang, Tsang, Lin, & Lui, 1997; The University of Hong Kong, 1995) J S Chang et al (1997) found that in the Chinese culture, men have always been more sexually permissive than women with respect to kissing, petting, and sexual intercourse From a sociological perspective, adolescent males have been encouraged to be active rather than passive in expressing their sexuality so as to develop ways of being in control and to structure situations to meet their own needs (Macionis, 1995) Nevertheless, the emerging autonomy for women gained from education and formal em-ployment has exposed women to more opportunities and ideas that encour-age sexual permissiveness (Chang et al., 1997) Because there are limited studies that have explored secondary school students’ sexual knowledge and attitudes, the purpose of this study was twofold: to examine secondary school students’ knowledge of and attitudes toward sex and to determine the gender differences in attitudes toward sex

Design

The study used a cross-sectional descriptive design to collect data from

180 Grade 9 coeducational secondary school students prior to the com-mencement of a sexual health education program Study participation was voluntary

Sample

The participants in the study were 178 Chinese Grade 9 students from a secondary school in New Territories, giving a response rate of 99% There were 47.2% boys and 52.8% girls The ages of the students ranged from 15

to 17 (x = 15.37, SD = 0.55), and 60.7% had no religious belief Of the

stu-dents, 57% were studying science, 41.6%, art and 1.1% commercial sub-jects Most of the students (92.7%) reported having had no formal education

on sexual health Of those 13 students having attended a formal sex educa-tion program, 10 had received it at school Whereas approximately 12.4% of the students had no siblings, 79.2% had one to two siblings

Procedures

Approval to conduct the study was obtained from the Research Ethics Committee of The Chinese University of Hong Kong and the secondary school All Grade 9 students in the secondary school were invited to partici-pate in the study during the weekly assembly The research assistant explained the nature and purpose of the study to the students, with confiden-tiality and anonymity being assured The students were also instructed that they were free to decline to participate in the study at any time

Instruments

The data were collected using a questionnaire that comprised three parts Part 1 comprised items seeking sociodemographic data Two questions in particular sought information on whether the students had previously taken any formal courses on sexuality, and if so, where they had attended the courses Parts 2 and 3 were the Chinese version of the Kirby (1990) Mathtech

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Knowledge Test (MKT) and Chinese version of the Kirby (1990) Mathtech Attitude and Value (MAV) Scales, respectively

MKT The English version of the MKT scale (Kirby, 1990) is a 34-item

multiple-choice test comprising 8 areas: adolescent physical development, adolescent relationships, adolescent sexual activity, adolescent pregnancy, implications of adolescent marriage, the probability of pregnancy, birth con-trol, and sexually transmitted disease One mark is given for the correct an-swer of each item The test-retest reliability coefficient was 89 (Kirby, 1990) In the current Chinese version of MKT, two items regarding adoles-cent pregnancy and abortion rate in America were omitted, as they were not related to the degree of sexual knowledge our students possess The Kuder-Richardson 20 (KR20) coefficient for the 32-item Chinese MKT in this study was 76

MAV Scale This scale is a 70-item self-report, 5-point forced choice rating

measure (e.g., 1 = strongly disagree, 5 = strongly agree) There are 14

subscales, including the following: clarity of long-term goals (e.g., “I know what I want out of life”), clarity of personal sexual values (e.g., “I have my own set of rules to guide my sexual behavior”), understanding of emotional needs (e.g., “I know what I need to be happy”), understanding of personal social behaviors (e.g., “I usually understand how I behave around others”), understanding of personal sexual responses (e.g., “I know how I react in dif-ferent sexual situations”), recognition of the importance of the family (e.g.,

“Families are very important”), self-esteem (e.g., “I feel that I have many good personal qualities”), satisfaction with personal sexuality (e.g., “I’m happy with my sexual behavior now”), satisfaction with social relationships (e.g., “I am very happy with my friendships”), sexuality in life (e.g., “A sex-ual relationship is one of the best things a person can have”), various gender role behaviors (e.g., “Women should behave differently from men most of the time”), the importance of birth control (e.g., “More people should be aware of the importance of birth control”), premarital intercourse (e.g., “People should not have sex before marriage”), and the use of pressure and force in sexual activity (e.g., “No one should pressure another person into sexual activity”) Subscale scores were derived by summing the appropriate items, with higher scores indicating higher levels of agreement with the attitudes or values (Kirby, 1990) The internal consistency of these subscales for the Eng-lish version has been estabEng-lished with Cronbach’s alpha coefficients ranging from 94 to 58 (Kirby, 1990) The reliability coefficient for the Chinese

version in this study for the total scale was 87 and for the subscales ranged from 91 to 50 (see Table 1)

Face validity of the instruments had been assured through discussion among local experts in the field, and the instruments were considered rele-vant for use in Chinese culture Bilingual research assistants translated the MKT and MAV into Chinese, aiming for conceptual rather literal meaning

of items Back translation was carried out by another, independent bilingual research assistant (Brislin, 1970) Discrepancies between the original and back-translated English versions were identified and modified according to the opinion of bilingual experts with the necessary knowledge to understand the implied concepts in both languages Two Form 1 secondary school stu-dents were asked to complete the translated versions and did not report any difficulties in understanding the items

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TABLE 1: Mean Scores and Standard Deviations for the Chinese Mathtech

Atti-tude and Value Scale ( N = 178)

Overall Score

Attitude toward the use of pressure and force in

NOTE: Each subscale consists of 5 items.

Knowledge of Sex

The mean score for the total MKT was 15.94 (SD = 4.16) Comparison

between the subscales, each with a different number of items, was facilitated

by the use of the adjusted mean derived by dividing each subscale by the number of items in that subscale As shown in Table 2, the students had com-paratively high scores in three knowledge areas: adolescent pregnancy, ado-lescent relationships, and adoado-lescent physical development, whereas the implications of the adolescent marriage subscale had the lowest mean score

In other words, the students were quite knowledgeable about physical and social aspects of sexuality but were comparatively weak in knowledge about implications of adolescent marriage

Attitudes Toward Sex

The means and standard deviations of MAV total and subscale scores are

presented in Table 1 The computed mean ratings ranged from 4.25 (SD = 0.60) to 2.90 (SD = 1.00) Variability of ratings across students as indicated

by the corresponding standard deviations was small, ranging from 0.42 to 1.00 The highest scores were for recognition of the importance of the family and the importance of birth control Adolescents’ attitude toward premarital intercourse was scored the lowest In other words, the students place a higher value on family relationships and the importance of birth control but tended

to be neutral toward the issue of premarital sex

TABLE 2: The Adjusted Mean Scores and Standard Deviations for the Chinese

Mathtech Knowledge Test ( N = 178)

TABLE 3: Gender Differences on Sex Attitude Subscales Scores

Clarity of personal sexual values 16.10 2.93 17.22 2.85 –2.60* –.27, –1.98 Attitude toward various gender role behaviors 17.20 3.34 18.24 2.67 –2.31* –.15, –1.93 Attitude toward sexuality in life 16.83 3.35 15.62 2.80 2.64* 30, 2.14 Attitude toward use of pressure and force

in sexual activity 18.17 3.18 19.51 2.77 –3.05** –.46, –2.22 Attitude toward premarital intercourse 12.89 4.91 15.95 4.73 –4.22** –1.63, –4.48 NOTE: C.I = confidence interval.

* p < 05 ** p < 01.

Gender Differences on Attitudes Toward Sex

Differences between genders were examined using t tests for the 14

MAV subscales Table 3 shows that there were significant differences between male and female students for five MAV subscale scores, including clarity of personal sexual values, attitude toward various gender role behav-iors, attitude toward sexuality in life, attitude toward use of pressure and force in sexual activity, and attitude toward premarital intercourse In other words, male students in comparison with their female counterparts had lower levels of agreement on clarifying their personal sexual values and develop-ing positive sexual relationships but had higher levels of agreement on pre-marital intercourse and the use of pressure and force in sexual activity Con-cerning gender role behavior, female students appeared more likely to have attitudes consistent with their gender role status

DISCUSSION

This group of students generally had a low level of knowledge of sex, particularly with regard to the issues of marriage, sexual activity, birth control, and the probability of pregnancy The low level of knowledge about the implications of marriage while still an adolescent was not unex-pected The low level of knowledge of birth control, sexually transmitted disease, and the probability of pregnancy indicated the areas that need to be addressed in the development of sex education programs The lack of such knowledge may result in young adolescents’ unsafe sex practices (Matasha & Ntembelea, 1998)

In fact, these findings of inadequate sexual knowledge by the adolescents were consistent with previous research results (Chan, 1990; Chau & Chang, 1999; Shek & Mak, 1989) This phenomenon may be explained by inade-quacy in the access to sources of information accessible by this group of stu-dents as only a minority had attended formal sex education in school Although the Hong Kong Education Department (1986) has advised schools

to provide quality sex education programs that cover sensitive and conten-tious issues about sex, the findings of this current study indicate that sex edu-cation may not have been fully implemented According to Shek and Lam (1985), sex education should be regarded as a formal subject in the school curriculum in Hong Kong secondary schools The current sex education pro-grams tend to be more ad hoc and reliant on extracurricular activities

The findings that the students’ attitudes toward the majority of the items related to sexual health, particularly premarital sex, tended toward neutral suggests that the students in that group may not have formed a definite opin-ion about what is an acceptable or unacceptable expressopin-ion of sexuality In most Chinese families, social order and control of emotions and feelings are highly valued, therefore, open discussion and expression of sexuality may

be unusual for teenagers (Hirayama & Hirayama, 1986) Moreover, because attitudes toward sexuality may not be reflected in behaviors (J S Chang

et al., 1997), it is necessary to investigate the sexual practice of this cultural group in future studies

In this study, adolescents’ attitudes toward the importance of the family and the importance of birth control were particularly strong Family is one of the many factors that could be influential in the development of adolescent attitudes about sex (Bhugra & de Silva, 1993) Such a high level of agree-ment with the importance of positive attitudes toward the family was dem-onstrated in this study Chinese sexuality is based mainly on the Confucian and Taoist traditions, which emphasize procreation and social order, with sex for pleasure and outside wedlock being prohibited as it may break family relationships (J Chang, 1997; Ng & Lau, 1990) Besides, talking about sex

is a taboo area in many traditional Chinese families, with most of the older generation’s having received no sex education themselves and not knowing how to approach the subject (J Chang, 1997) Therefore, to enhance the pos-itive influence of the family on adolescents’ attitudes toward sex, health care professionals should provide appropriate sex education for parents who do not know how to engage children in discussion on the sensitive subjects about sex

The awareness of using birth control demonstrated by the adolescents in this study was relatively high, although the actual number of students who knew how to use condoms had not been recorded In another Hong Kong study by the Social Science Research Center (The University of Hong Kong, 1995), however, the actual number of adolescents who reported using con-doms was lower than the number who reported their intention to use them Ignorance about condoms and the low rate of usage might lead to the spread

of AIDS, STDs, and pregnancy among teenagers (Schwartz, 1996) Further studies are needed to investigate the barriers and the benefits encountered by adolescents in using condoms and other birth control methods (Hanna, 1999) Last but not least, the finding that boys were more permissive toward pre-marital intercourse is consistent with the finding reported by Minakshi (1997) In addition, Sue’s (1979) findings that a higher proportion of men than women fantasized about forcing others into sexual relationships may

220 Western Journal of Nursing Research