Received Date: April 26, 2014; Accepted Date: June 23, 2014; Published Date: June 30, 2014
Citation: Zou H, Dai X, Meng X, Wang H, Jiang C, et al. (2014) HIV/AIDS - Related Knowledge, Attitudes, and Sexual Practices among Migrant Wives in Rural Anhui Province, China. J AIDS Clin Res 5:319. doi:10.4172/2155-6113.1000319
Copyright: © 2014 Zou H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Migrant wives have been increasing in some poor rural regions of China and they may bridge HIV transmission across regions. This study aimed to assess HIV/AIDS-related knowledge, attitudes and sexual practices among this population in rural Anhui Province, China.
Methods: A cross-sectional survey was conducted with questionnaire of HIV/AIDS-related knowledge, attitudes, and sexual practices between June 2011 and May 2012. A total of 730 migrant wives and 207 local women were enrolled in this study. Unpaired T-test, Chi-square was utilized to compare the difference of HIV/AIDS knowledge, attitudes and sexual practices between migrant wives and local women.
Results: Around 80% of the migrant wives were from Yunnan, Guizhou, or Sichuan Provinces. The main sources of HIV/AIDS information were TV/radio, posters, and newspapers/periodicals. HIV/AIDS knowledge level among migrant wives was significantly lower than that among local women (e.g. 47.1% vs 57.0% (p<0.001) answered “Yes” for the question “Can an apparently healthy person be HIV-infected?”), and stigma and prejudice towards HIV/AIDS among migrant wives were more common than those among local women (e.g. 73.2% vs 65.7% (p=0.006) answered “No” for the question “If a shopkeeper or food seller had the HIV, would you buy food from them?”). Compared to local women, migrant wives were more likely to have ever had sex during menstruation (6.8% vs 3.4%, p=0.065) and extramarital sex (17.5% vs 10.1%, p=0.01), and were less likely to consistently use condoms with their husbands (45.8% vs 57.5%, p<0.001) or extramarital sex partners (48.8% vs 58.95, p<0.001).
Conclusions: Migrant wives in rural China had a low HIV/AIDS knowledge level and high prevalence of stigma and prejudice and risky sexual behaviors. Local HIV/AIDS prevention programs should target this neglected population.
HIV/AIDS; Migrant wives; Knowledge; Attitudes; Sexual practices
Since the first reported case of AIDS in 1985, the overall prevalence of HIV among the general population of China remains low with an estimated accumulated 780,000 people infected with HIV in China by the end of 2012 . However clusters of high rates of infection exist both geographically and within specific sub-groups . One group, the migrant population group, have become an important “bridge population” in the spread of the HIV/AIDS virus . In 2012, there were 63 million migrant women of child-bearing age in China, accounting for 25% of all women of child-bearing age . These women were mostly sexually active but had low HIV/AIDS-related knowledge. Coupled with risky sexual behaviors, this puts them at a higher potential risk for HIV transmission compared to the overall Chinese population .
In this paper the term “migrant wife” refers to a woman who has migrated from another province in China or an underdeveloped foreign country to marry and live with a local man in rural areas of Langxi County, Anhui Province, China . The majority of Chinese migrant wives were from Yunnan, Sichuan and Guangxi , the most HIV-prevalent provinces in China . Meanwhile, most of the foreign migrant wives were from Vietnam and Myanmar  where high HIV prevalence has been reported . These women – also known as “migrant brides” –normally relocate from economically less developed regions to comparatively richer regions. They are mostly between 15 and 45 years old, and account for almost 0.5% of the total population in some regions . Some migrant wives are former sex workers with a high probability of carrying HIV and other sexually transmitted infections .
In recent years, migrant wives have gradually captured public health attention as an increasing number of them have been detected with HIV and other STIs . In rural areas of Shandong and Shanxi provinces, HIV prevalence among migrant wives was found to be 0.39% to 3.59% [7,8]. These migrant wives were usually unaware of their HIV status before they migrated to their place of marriage, with this lack of information playing a potentially very important role in the spread of HIV amongst family members. Indeed, a 2008 study in Henan Province found that seven husbands and two babies of nine HIV positive migrant wives also tested and were found to be HIV positive .
In China, migrant wives often lack basic health knowledge, or opportunity to receive HIV education, counseling and testing services. They are often subject to discrimination and isolation from the local population and are less exposed to social support . Compared to local women, migrant wives are particularly vulnerable to the transmission of HIV. However, until now little has been known about the HIV/AIDS related knowledge, attitudes, and sexual practices among this population in rural Anhui Province, China. And yet, studies into these characteristics could be expected to play a critical role in guiding effective prevention strategies to combat the HIV epidemic among this group, and break the potential bridge of transmission to and from their spouses and family members.
Langxi County is located in the southeast of Anhui Province in eastern China. It has a population of 340,000 with GDP per capita of 28,000 RMB ($4,650 USD). Over 50% of the population lives in rural areas. By the end of 2013, 116 HIV/AIDS cases had been reported, resulting in a HIV/AIDS prevalence rate of 0.016%. Beginning in the 1990s, there has been an increasing number of migrant wives arriving in Langxi County to marry local men and by 2013, the number of migrant wives registered in the County’s Womens’ Federation exceeded 1,502, or 0.44% of the County’s total population. The main objective of this study is therefore to explore HIV/AIDS knowledge awareness and assess the HIV/AIDS related attitudes and practices among these migrant wives in this rural area of Anhui Province in east China.
This study was conducted in 12 rural towns in Langxi County of Anhui Province from June 2011 to May 2012. A random snow-ball sampling method was used to recruit subjects. In this study, women who were born in provinces other than Anhui Province and married to residents of Langxi County were defined as migrant wives. Eligible women were also required to be 15 to 45 years of age. To compare knowledge, attitude and behavior of HIV/AIDS between migrant wives and local people, we randomly selected local women who were neighbors of the migrant wives to act as a control group. To be eligible for participation in this control group, the local women had to be married, from the same neighborhood as the migrant wives and had to be within two years of age of their migrant neighbors.
The Institutional Ethics Board of Wannan Medical College approved this study (Approved in 2010, NO.2010011). Subjects who agreed to participate provided informed consent and answered a face-to-face questionnaire administered by trained interviewers. Investigators were medical researchers from Wannan Medical College or public health practitioners from the Anhui Provincial Center for Disease Control. They were trained in accordance with project protocols before participation in the study.
A structured questionnaire was adapted from the Family Health International HIV/AIDS Behavioral Survey and the World Health Organization Research Package: Knowledge, Attitude, and Practices on AIDS (WHO 1990) . The questionnaire included 46 questions from three categories: (1) socio-demographic characteristics (5 questions); (2) sources of acquired information about HIV/AIDS (13 questions); and (3) knowledge (16 questions), attitudes (8 questions), and practices (4 questions) related to HIV/AIDS (Cronbach’s alpha, 0.71). Correct answers were scored 1 with wrong or “don’t know” answers coded as 0. The knowledge scores were the sum total of 15 items. For the more sensitive information in the third part of the questionnaire, participants wrote their answers on answer sheets by listing only question numbers and codes for their responses. For questions on condom use, consistent condom use refers to use in every vaginal intercourse.
We used mean and corresponding standard deviation to describe the distribution of continuous variables. We used percentage and corresponding 95% confidence intervals to describe the distribution of categorical variables. The socio-demographic characteristics of the respondents were presented in terms of their distributions in the population. A chi-square test was performed to examine the differences in educational background, income, HIV-related knowledge, perceptions, and practices between migrant wives and their local counterparts. Another chi-square test was performed to examine the differences in risky sexual behaviors among women in different demographic groups. Finally, an unpaired T-test was performed to examine the differences in age and HIV/AIDS knowledge scores between the two groups. All statistical analysis was conducted using STATA 12.0 (StataCorp, Texas, US).
Characteristics of participants
Women’s socio-demographic characteristics are summarized in Table 1. We approached 751 (50%) migrant wives in Langxi County. 16 (2.1%) did not participate because they went to other regions to work while a further five (0.67%) refused to participate in this study. As a result 730 (97.2%) migrant wives were included of which two had been diagnosed with HIV/AIDS since 2007. Conversely, a total of 207 local women were recruited for the control group. Average ages were 28.6 ± 5.8 years for the migrant wives and 28.0 ± 6.3 years for the local women (p=0.21). Of the participants, 54% of migrant wives and 60% of the local women had either only a primary school education or were illiterate. Over 50% of the respondents in both groups did not have a steady income. There was no significant difference in age, education and income between the migrant wives and the local women. Among the migrant wives, 46.3% came from Yunnan province, 11.1% were from Guizhou province, and 8.1% came from Sichuan province.
|Age (year mean±SD)||28.6±5.8||28.0±6.3||1.27||0.21|
|Time since migration (year, mean±SD)||11.0±6.4|
|illiterate||26 (12.6)||136 (18.6)|
|Primary school||85 (41.1)||304 (41.6)|
|Junior middle school||77 (37.2)||248 (34.0)|
|Senior high school and above||19 (9.2)||42 (5.8)|
|<500 yuanc||41 (19.8)||148 (20.3)|
|500-1000 yuan||30 (14.5)||130 (17.8)|
|>=1000 yuan||19 (9.2)||48 (6.6)|
|unsteady||117 (55.5)||404 (55.3)|
|Rank of current marriagea|
|First marriage||688 (94.3)||198 (95.7)||0.62||0.431|
|Second marriage||42 (5.7)||9 (4.3)|
|Gynecological diseases historyb|
|Yes||256 (35.1)||62 (30.0)||1.89||0.17|
|No||474 (64.9)||145 (70.0)|
|Province of origin|
|Other provinces||323 (34.5)|
aRank of current marriage: order of the current. Some women were in their first marriage and some were in their second marriage.
bGynecological diseases history were self-reported by women.
c6.2 yuan equals 1 US dollar at time of study.
Table 1: Socio-demographic characteristics of migrant wives in rural Anhui, China
Sources of HIV/AIDS related information
Migrant wives had less access to HIV/AIDS information compared to the local women (Table 2). Only 18.9% of migrant wives obtained information on HIV/AIDS from posters compared to 31.9% of local women (p<0.001). A significantly lower proportion of migrant wives obtained information from posters, neighbors and friends, preventive medicine staff, expert lectures, communication with family members, and village doctors compared to local women. The proportion of migrant wives who accessed HIV/AIDS information via the Internet were 1 (1.9%), 2 (2.4%), 13 (16.9%) and 5 (26.3%) among those who were illiterate, those with primary school education, those with junior middle school education and those with higher education (p-trend<0.01), respectively.
|Newspaper and periodical||216||29.6||68||32.9||.81||0.368|
|Neighbor and friend||138||18.9||66||31.9||15.95||<0.001|
|Preventive medical staff||124||17.0||51||24.6||6.22||0.013|
|Communication in family||82||11.2||44||21.3||13.92||<0.001|
Table 2: Sources of HIV/AIDS-related knowledge among migrant wives and local women in rural Anhui, China
Table 3 lists responses to questions about possible transmission mechanisms for HIV/AIDS. The accuracy of responses for the migrant wives ranged from 31.0% to 75.3%, significantly lower than the correct response rates for the local women (Table 3). Overall there was a major misunderstanding of HIV/AIDS facts related to transmission mechanisms. For example, 69% of migrant wives incorrectly responded that they believed HIV could be transmitted by mosquito bites. This compared unfavorably to responses by local women where 56.5% in this group believed mosquito bites acted as a transmission mechanism.
|Items||n||Migrant Wives (N=730)||n||Local women
|Can an apparently healthy person be HIV-infected||300||41.1||118||57.0||16.69||<0.001|
|HIV cannot be transmitted through|
|Shaking hands or hug||476||65.2||157||75.9||8.33||0.004|
|Sharing tools and vehicles||480||65.8||161||77.8||10.79||0.001|
|Sharing public swimming pools||364||49.9||131||63.3||11.66||<0.001|
|Sneezing and coughing||336||46.0||131||63.3||19.21||<0.001|
|Sharing the towels||326||44.7||118||57.0||9.68||0.002|
|Sharing shaver blade||368||50.4||109||52.7||.33||0.568|
|Receiving blood from an infected person||560||76.7||173||83.6||4.46||0.035|
|Mother-to-child transmission during pregnancy||510||69.9||168||81.2||10.29||0.001|
|Mother-to-child transmission during delivery||450||61.6||152||73.4||9.75||0.002|
|Mother-to-child transmission during breastfeeding||466||63.8||164||79.2||17.34||<0.001|
|Overall score of HIV knowledge (mean±SD)||8.99±2.11||10.61±2.83||8.99||<0.001|
Table 3: HIV/AIDS-related knowledge among migrant wives and local women in rural Anhui, China.
HIV/AIDS related attitudes
We observed a high proportion of negative attitudes toward people living with HIV/AIDS (PLWHA) among both migrant wives and local women, (Table 4) although the proportion of negative attitudes toward HIV/AIDS patients was significantly higher amongst the migrant wife sample. 73.2% of migrant wives and 65.7% of local women refused to buy food from a HIV-infected shopkeeper or seller (p=0.006), while 49.6% of the migrant wives and 39.5% of local women answered that they would not be willing to shake hands with PLWHAs (p=0.021).
|Item||Answer||n||Migrant Wives (N=730)||n||Local women
|If a teacher has HIV but is not sick, should he or she be allowed to continue teaching in school?||No||212||29.0||77||37.2||5.06||0.080|
|If a person has HIV, should he or she be quarantine?||Yes||412||56.4||105||50.7||2.47||0.291|
|Would you be willing to share a vehicle with PLWHAs?||No||216||29.6||71||34.3||2.81||0.245|
|Would you be willing to share tools with PLWHAs?||No||240||32.9||71||34.3||4.07||0.131|
|Would you be willing to share a meal with PLWHAs?||No||382||52.3||106||51.2||0.09||0.955|
|Would you be willing to shake hands with PLWHAs?||No||342||46.9||82||39.5||7.76||0.021|
|If a shopkeeper or food seller had the HIV, would you buy food from them?||No||534||73.2||136||65.7||10.11||0.006|
|If a student has HIV but is not sick, should he or she be allowed to continue attending school?||No||258||35.4||84||40.6||13.37||0.004|
Table 4: Attitude towards PLWHA among migrant wives and local women in rural Anhui, China.
Sexual risk behaviors stratified by socio-demographic characteristics among all women are summarized in Table 5. Ever having sex during menstruation was associated with lower literacy (p<0.001). Ever having extramarital sex was positively associated with being younger (p<0.001), being a migrant (p=0.01), having lower literacy (p=0.049), being low income (p<0.001), being from Yunnan or Guizhou Provinces (p=0.009) and gynecological disease history (p=.003). Consistent condom use during extramarital sex in the past six months was associated with migrant status (p=0.01), lower literacy (p=0.001), and being from Yunnan or Guizhou Provinces (p=0.024). Consistent condom use during sexual intercourse within their marriages during the previous six months was associated with migrant status (p=0.01), lower literacy (p<0.001), and being from Yunnan or Guizhou Provinces (p<0.001).
|Characteristics of women||Ever having
menstruation n, %
sex n, %
|Consistent condom use during extramarital sexual intercourse in past 6 months n, %||Consistent condom use during sexual intercourse with husband in past 6 months n, %|
|Age group (p-value)||0.642||<0.001||0.562||0,381|
|<20||0 (0)||7 (53.8)||7 (53.8)||5 (38.5))|
|20-30||15 (5.7)||35 (13.3)||154 (58.3)||142 (53.8)|
|>30||37 (6.1)||76 (12.5)||297 (49.0)||288 (47.5)|
|Migrant daughter-in-law||50 (6.8)||128(17.5)||356 (48.8)||334 (45.8)|
|Local women||7 (3.4)||21 (10.1)||122 (58.9)||119 (57.5)|
|Illiterate||22(13.6)||31(19.1)||65 (40.1)||63 (38.9)|
|Primary school||15 (3.9)||70(18.0)||188 (48.3)||174 (44.7)|
|Junior middle school||16 (4.9)||44(13.5)||186 (57.2)||177 (54.5)|
|Senior high school and above||4 (6.6)||4 (6.6)||39 (1.0)||39 (63.9)|
|Monthly income (p-value)||0.545||<0.001||0.624||0.578|
|<500 yuan||45 (6.3)||135 (19.0)||357 (50.3)||332 (46.8)|
|500-1000 yuan||10 (6.3)||8 (5)||83 (51.9)||83 (51.9)|
|>=1000 yuan||2 (3.0)||6 (9.0)||38 (56.7)||38 (56.7)|
|Rank of marriage (p-value)a||0.507||0.406||0.216||0.261|
|First marriage||55 (6.2)||143 (16.1)||445 (50.2)||420 (47.4)|
|Second marriage||2 (3.9)||6 (11.8)||33 (64.7)||33 (64.7)|
|Source province (p-value)||0.725||0.009||0.024||<0.001|
|Yunnan or Guizhou||34 (6.3)||100 (18.6)||264 (49.1)||246 (45.7)|
|Other provinces||23 (5.8)||49 (12.3)||214 (53.6)||207 (51.9)|
|Gynecological diseases history (p-value)b||0.633||0.003||0.624||0.702|
|Yes||21 (6.6)||35 (11.0)||166 (52.2)||157 (49.4)|
|No||36 (5.8)||114 (18.4)||312 (50.4)||296 (47.8)|
aRank of current marriage: order of the current. Some women were in their first marriage and some were in their second marriage.
bGynecological diseases history were self-reported by women.
Table 5: Sexual behaviors among migrant wives and local women in rural Anhui, China.
This is the first study from China to report on HIV/AIDS related knowledge, attitudes and sexual practices among a large sample of migrant wives in a rural area of Anhui Province in eastern China. Conversely, existing Chinese studies about this population have mostly only reported on either HIV/AIDS related knowledge and/or attitudes . With China’s economic transformation and urbanization, tens of millions of women in rural areas are migrating to urban areas to look for work. This has resulted in men in some rural areas significantly outnumbering women, and causing many men around marital age to try and find wives from other regions. These potential marriage candidates then tend to migrate from other less economically developed regions to live with their husbands . Despite these migrant wives having comparable socio-demographic characteristics like age, education and income with local women, they are less exposed to HIV/AIDS knowledge, are more likely to have a prejudice against PLWHAs and are more likely to practice high risk behaviors that aid HIV transmission [7,8].
The main sources of HIV/AIDS related knowledge among migrant wives were the TV or radio with only a small fraction of these women accessing information via the internet, despite the fact that more health education resources are available online compared to either TV or radio. Despite this however, there was a correlation between education level and internet access. Research showed migrant wives who have higher levels of education being more likely to access health related knowledge via the internet. For example, the proportion of migrant wives accessing HIV/AIDS related knowledge via the Internet increased from 4% among those who were illiterate to 26% among those with at least senior high school or above (p-trend<0.01). This indicates that strategies for disseminating sexual health information should target women based on their education level.
Compared to local women, migrant wives had a poorer knowledge of key issues related to HIV/AIDS. For example, half of all migrant wives surveyed believed that sharing a public swimming pool could result in HIV transmission compared to only 37% of local women. This is consistent with other studies [7,8]. In some places, the proportions of migrant wives who can correctly answer HIV/AIDS related questions were mostly lower than 40% . There are a few reasons for the existence of barriers that prevent migrant wives from accessing HIV/ AIDS related information. Firstly, most migrant wives in the sample came from rural areas with few sources of information on HIV/AIDS. Therefore, the participants generally had little knowledge of HIV/ AIDS and had particularly high numbers of misconceptions with regards to casual social contact, as evidenced by their responses to the question “whether HIV is transmitted by mosquito bites or not.” Secondly, because of the differences in dialects and cultures between regions, migrant wives may have had difficulties in communicating with members of the local population . As such, they may have underutilized the various sources of information available on HIV/ AIDS, such as posters, neighbors and friends, preventive medicine staff, expert lectures, communication with family members, and village doctors. This finding necessitates the development of feasible and accessible sources of HIV/AIDS information for migrant wives, such as peer education, expert lectures and other innovative strategies.
Compared to local women, migrant wives share similar attitudes towards PLWHAs in certain items but vary in others. 73.2% of migrant wives would not buy food from a shopkeeper or food seller who had HIV compared to 65.7% of local women (p=0.006). Consistent with responses from local women, over half of migrant wives thought HIVinfected people should be quarantined. This may be largely due to their limited knowledge of HIV/AIDS. Stigma and discrimination is also a documented barrier for the prevention and control of HIV . Education should not only include how to protect migrant wives from being infected, but also on how to correctly judge and treat PLWHAs.
For the migrant wife sample, low awareness of HIV/AIDS knowledge and high stigma and prejudice against PLWHAs exist in parallel with low awareness of HIV voluntary counselling and testing (VCT) services. This is despite the existence of over 1,700 VCT clinics across China . Zhang et al. reported that only 38.8% of migrant women in Shanghai have ever heard of VCT clinics with their willingness to access VCT services positively associated with education level (p<0.05). When informed of the free VCT services, over three quarters of women were willing to attend a VCT clinic, unfortunately though, most VCT clinics are located in medium and large sized cities and counties. This makes it relatively difficult for people from rural areas to access free VCT services. It is recommended that these free services include rural areas, especially those with high and increasing numbers of migrant wives.
Compared to local women, migrant wives are more likely to practice risky sexual behaviors implying HIV transmission. They are also more likely to report having ever had sex during menstruation. Existing data support the hypothesis that the level of HIV-1 RNA in cervical secretions is influenced by the menstrual cycle, suggesting that the risk of heterosexual transmission of HIV-1 may increase as menses approaches or during menstruation . Migrant wives are also more likely to have engaged in extramarital sex. Disappointingly, migrant wives are also more likely to not use a condom, either with their husbands or extramarital partners. All these factors generally put them at a higher risk for HIV transmission compared to local women. In line with our study, Li et al. reported that compared to local women, a much higher proportion of migrant wives had engaged in sexual experiences before marriage (38.0% vs 3.4%, p<0.001), had engaged in extramarital sexual relationships (6.7% vs 0.8%, p<0.001) and had had an abortion (27.9% vs 16.4%, p<0.001) .
In our sample, two (0.3%) migrant wives were HIV-positive. This ratio is similar to some other studies,  with others finding a higher prevalence of HIV and/or other STIs among migrant wife populations. For example, a 2009 study of 2,028 migrant wives in Shandong Province found the prevalence rates of HIV, syphilis, HBsAg and HCV to be 0.6%, 2.7%, 10.8% and 1.9%, respectively . A further study of 199 migrant wives in Ruzhou, Henan Province in 2004 found the prevalence of HIV to be 9.6% with over 60% of the 19 HIV-infected women coming from Myanmar. Among the husbands of the 19 HIV-infected women, six (31.6%) were confirmed to also carry the HIV infection while for the four women who had children, one child (25%) was confirmed with to be infected with HIV.
Many migrant wives are from regions with higher-than-average HIV/AIDS infection rates among the general population . In this study around half of those infected were from Yunnan Province, China’s highest province for rate of HIV infection . Of course, migrant wives also come to China from other countries with high rates of HIV infection. For example, the past decade witnessed an increasing number of wives migrating from Myanmar and Vietnam . This has clearly added to the challenges faced by China in its efforts to control and prevent the spread of HIV.
There are a few limitations in our study. Firstly, our sample was limited to migrant wives from rural Anhui Province and they may not be representative of all migrant wives in China. Secondly, data on detailed sexual behaviors and STI detection was not available. Thirdly, data on HIV transmission within family was not obtained as only two of the migrant wives sampled had HIV. Longitudinal studies are necessary to study interventions aimed at increasing HIV/AIDS knowledge, decreasing stigma and prejudice, and minimizing unprotected sexual behaviors among this population.
Prevention efforts are needed to address the potential risk for HIV transmission among migrant wives in rural Anhui Province. These efforts would potentially include enhanced surveillance of HIV and other STIs, promotion of condom use, timely mother-to-child HIV transmission blockage where possible, providing preventative measures for sero-negative partners and children, sexual health education and other innovative interventions where available.
In general, migrant wives have limited HIV/AIDS related knowledge and exhibit high stigma and prejudice against PLWHAs. They also tend to engage in risky sexual behaviors that promote HIV transmission. In China, HIV/AIDS prevention and control policies should be tailored to address the particular characteristics of this subset of the population.
This study was supported by China Global Fund Program on AIDS Round Three.