Knowledge, Attitude, and Practices towards HIV/AIDS among First Year Universities Students in Taiwan.

Graduate studentDr Isae MEDAH AdvisorProfessor Yi-Ming A. Chen International Health Program, Institute of Public Health National Yang-Ming University Master Thesis June 2005

Knowledge, Attitude, and Practices towards HIV/AIDS among first year universities students in Taiwan.

By Dr Isae MEDAH

A thesis submitted in partial fulfillment of the requirements for Master of Science degree in Public Health of National Yang Ming University; Taipei City, Taiwan, R.O.C

June 2005

Thesis adviser: Professor Yi-Ming Arthur CHEN

To my Mother Catherine MEDAH

Acknowledgements
I would like to thank the following Institutions and personalities without whom this study could not have been done properly. The Chairperson of the examining committee and its members. Professor Yi-Ming Arthur Chen, Chairman of Institute of Public Health, National Yang Ming University; my adviser without whom the current research could not have been done properly. His Excellency Jacques Sawadogo, Ambassador of Burkina in Taiwan, R.O.C together with his Staff and family members. National Yang Ming Universitys authorities. International Health Program (IHP) and its teaching staff. Ministry of Education of Taiwan, for financial and administrative assistance. International Cooperation and Development Fund (ICDF) for scholarship to study in Taiwan. Misses Shu-Fen Lai and Y- Ru Chang, research assistants for their paramount contribution. Mr. Shao-Yuan Chuang for assistance in data analysis. Dr Chi Kang Chang, my good friend for data keying in and all kind of assistance. My relatives and friends here, in Burkina, and elsewhere. My classmates and 1st year students from IHP, for collaboration. Taiwanese people for their hospitality during our stay here.

Dr Isae MEDAH

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Abstract

The incidence of HIV/AIDS is increasing in Taiwan. Young people, including students are the most affected. The main purposes of this study were a.) to gather information on Knowledge, Attitude, and Practices (KAP) of first-year university students on HIV/AIDS and b.) to conduct a needs assessment among student councils in different universities in Taiwan. The methodology used was a cross-sectional, descriptive design and a stratified sampling. SPSS 11.0 software was used for data analysis. The results showed that 11,847 students from 9 universities participated to the KAP study and 122 student councils returned the HIV/AIDS program need assessment questionnaires, with a response rate of 88.2 % and 75.8%, respectively. The survey indicated that the mean knowledge level was high (87.02%). However, there were many misconceptions about the transmission routes. 23.4% of the students believed that HIV may be transmitted through mosquitos bite. 36.7% ignored that oral intercourse carries risk for transmitting HIV. A relatively positive attitude towards HIV/AIDS patients was found among students. However, 43.3% of students would avoid having contact with them. Students identified school (81.5%) as main source of information followed by TV (75.4%). Ten % were sexually initiated. The mean age at first intercourse was 17.1 + 1. 5. Only 30.9% of sexually active students use condom every time. No correlation was found between knowledge level and safe behavior in this study.

 III In terms of the needs assessment, 43.1% of the universities did not have any extra curricular AIDS prevention program. 16.3% didnt have regulation for case management of HIV-infected students. In conclusion, even though the knowledge level was found to be high, there were some knowledge, attitude and practices gaps among Taiwanese first year university students concerning HIV/AIDS. Since 90% of the students did not have sexual experiences, they should be instructed about all aspects of HIV/AIDS at school, which at present is the most frequent source of information. In addition, Ministry of Education should elaborate a standard clear regulation for management of HIV-infected students. Key words: Knowledge, Attitude, Practice, Students, HIV/AIDS, Taiwan. .

 IV Contents Acknowledgements ............................................................................................................ I Abstract..............................................................................................................................II List of Tables .................................................................................................................... V List of Figures.................................................................................................................. VI 1. Introduction ............................................................................................................... 1 1.1. Background ......................................................................................................... 1 1.2. Objectives of the study: ...................................................................................... 4 2. Literature review ...................................................................................................... 5 2.1 HIV/AIDS overview in Taiwan ...................................................................... 5 2.2 HIV/AIDS knowledge of selected studies. ..................................................... 7 2.3 HIV/AIDS, attitudes of selected countries.................................................... 11 2.4 HIV/AIDS practices in selected studies........................................................ 12 2.5 Impact of intervention programs on students knowledge, attitudes, and practices. ................................................................................................................... 17 2.6 Lessons learned from the literature review................................................... 24 3. Material and Methods ............................................................................................ 25 3.1 Research design ................................................................................................ 25 3.2 Study population ............................................................................................... 25 3.3 Sampling method, sample size.......................................................................... 25 3.4 Study framework............................................................................................... 26 3.5 Survey procedure and strategy.......................................................................... 29 3.6 Study instrument ............................................................................................... 29 3.7 Statistical analysis............................................................................................. 31 4. Results ...................................................................................................................... 32 4.1_ Knowledge, attitude, and practice towards HIV/AIDS among first year university students in Taiwan. ....................................................................................................... 32 4.1.1_Prevalent demographic data............................................................................ 32 4.1.2_Knowledge regarding HIV/AIDS ................................................................... 32 4.1.3_Attitude towards HIV/AIDS ........................................................................... 33 4.1.5_Practices .......................................................................................................... 35 4.2_ HIV/AIDS Education and counseling program Needs Assessment................ 37 5. Discussion and Conclusion ..................................................................................... 40 5.1_ Knowledge, attitude, and practice towards HIV/AIDS among first year university students in Taiwan. ....................................................................................................... 40 5.2_ HIV/AIDS Education and Counseling program Needs Assessment ............... 44 5.3 Study constraints..................................................................................................... 47 5.4 Conclusion .............................................................................................................. 47 5.5 Recommendations................................................................................................... 48 References ........................................................................................................................ 49 Appendix .......................................................................................................................... 84

List of Tables
Table 1: Basic study participants records54

Table 2: knowledge score of respondents by gender 55

Table 3: knowledge score by school57

Table 4: Attitude score of respondents towards HIV/AIDS58

Table 5: Source of information about HIV/AIDS59

Table 6: Condom use patterns60

Table 7: Drugs used by students61

Table 8: HIV/AIDS Prevention Needs Assessment at school62

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List of Figures
Figure 1: Distribution of study participants by area65

Figure 2: Distribution of respondents by gender66

Figure 3: Age distribution of study participants67

Figure 4: Level of father and mothers education68

Figure 5: Knowledge score.69

Figure 6: Mean knowledge score vs. level of father and mothers education70

Figure 7: Mean Knowledge score vs. level of parents education combined. 71

Figure 8: Attitude score of respondents72

Figure 9: Mean Attitude score vs. level of father and mothers education73

Figure 10: Attitude vs. level parents education combined74

Figure 11: Mean attitude score vs. schools75

Figure 12: Relationship between knowledge and attitude76

Figure 13: knowledge and attitude vs. gender77

 VII Figure 14: Students sexual orientation78

Figure 15: Age at first sexual intercourse79

Figure 16: sexual experience vs. school80

Figure 17: Condom use patterns81

Figure 18: Distribution of drugs users by gender82

Figure 19: Distribution of drugs users by school83

1. Introduction

1.1.

Background

The HIV/AIDS pandemic is one of the most important and urgent public health challenges facing governments and civil societies around the world. Adolescents are at the center of the pandemic in terms of transmission, impact, and potential for changing the attitudes and behaviors that underlie this disease. (UNAIDS.2000). Therefore, AIDS prevention has become a priority all around the world. Because of the seriousness of AIDS, World Summit of Ministers of Health on Programs for AIDS Prevention in January 1988 decided to establish the so called World Aids Day to open channels of communication, strengthen the exchange of information and experience, and forge a spirit of social tolerance. Since then, World AIDS Day has received the support of the World Health Assembly, the United Nations system, and governments, communities and individuals around the world. Each year, it is the only international day of coordinated action against AIDS. Each year a slogan is used to raise the awareness of all the segments of international community about the disease. HIV/AIDS does create a lot of discrimination among people. For this reason the slogan for World AIDS Campaign 2002-2003 was "Live and Let live". This slogan was selected to address "Stigma and Discrimination", the major obstacles to effective prevention and care of HIV/AIDS.

World AIDS Day has a special place in the history of the AIDS pandemic. Since 1988 1st December has been a day bringing messages of compassion, hope, solidarity and understanding about AIDS to every country in the world, North and South, East and West.

It is estimated by UNAIDS that 50% of all new HIV infections are among young people (about 7,000 young people become infected every day), and that 30% of the 40 million people living with HIV/AIDS in the world are in the 15-24 year age group and 50% of them are female. This is the reason why the slogan of Word Aids Day 2004 was Women, girls HIV and AIDS. The vast majority of young people who are HIV positive do not know that they are infected, and few young people who are engaging in sex know the HIV status of their partners.

The importance of focusing on young people has been recognized at a global level by the 2001 UN General Assembly Special Session on HIV/AIDS. Why we emphasize our study on students? Because most of people 15-24 year age people in Taiwan are students. Students are easy to reach, and HIV/AIDS Education is easy to implement in campus. Moreover, students may represent a good channel to spread HIV/AIDS knowledge through the community.

In Taiwan the first case of Human Immuno-deficiency Virus was reported in 1984. CDC Taiwan (2004) report on HIV/AIDS from 1984 to 2004/9/30 showed a total number of 6635 HIV positives were identified; and1832 had developed full brown AIDS. Among

3 the 6635 HIV positives, 6152 are natives and 483 are foreigners. Among the 6152HIV positives natives, 2238 (36.4%) are heterosexual, 2161 (35, 1%) are homosexual, 661 (10.7%) are bisexual, IDU 309 (5.0%), Blood transfusion 13 (0.2%), MTCT 11 (0.2%) Unknown risk factor 705 (11.5%), and 53 (0.9%) are hemophiliacs. Most of them are male (5739 cases, 93.3%), and female with 413 cases represent 6.7%. Students have 378 cases (6.1%) Ages between 20 and 39 are the most affected by the pandemic in Taiwan 4318 cases (71.4%) (CDC Taiwan 2004). Despite these low reported cases, it is feared that the HIV/AIDS situation in Taiwan may be more dramatic than these officially published data indicate. In Taiwan the most common route of HIV transmission is through sexual contacts. Therefore, a well organized attack is required to deal with the pandemic. It has been suggested by Agrawal et al., 1999 that knowledge about STI including HIV/AIDS might influence sexual behavior among adolescents. Taiwan Department of Health has promoted wide media campaigns recommending safe sexual behavior, yet the epidemic is progressing despite these efforts. With the documented prevalence of earlier sexual debut, multiple partners, lack of consistent condom use, and the subsequent increase of STI among adolescents, and in the absence of vaccine and effective anti retroviral drugs, prevention of risky sexual behavior remains an essential intervention strategy. School-based interventions are logical venues to provide the most youth with preventive health education, which should help young students to identify their personal values and to promote positive self-esteem to enable them to resist pressure to engage in risky sexual behavior. This is of paramount importance, as these adolescents are not yet mature thinkers and so are unable to

4 adequately project into the consequences of their actions. Therefore they need to be guided for their daily living. In order to obtain data to guide future HIV/AIDS educational strategies, we conducted a questionnaire survey among first year universities students in Taiwan. Their knowledge, attitudes and sexual behavior about HIV/AIDS were assessed. Also needs assessment of universities students councils pertaining to HIV/AIDS school-based education programs was appraised. This study also was done to fulfill the requirements of Master of Science Degree of National Yang Ming University.

1.2.

Objectives of the study:

Objectives of this study were to determine the Knowledge, Attitude and practices concerning HIV/AIDS of Taiwanese first year university students and also to assess the Needs for HIV/AIDS prevention programs at school in order to provide Ministry of Education and universities authorities with new knowledge on the field that could help them to adapt or design proper suited for students HIV/AIDS Prevention Program. This may have also an impact in the whole Taiwanese society through students.

2. Literature review
2.1 HIV/AIDS overview in Taiwan
HIV/AIDS actually is not a new topic. Since it emerged in 1980 years, many researches have been conducted to highlight as much as possible the complicated multiple facets of the pandemic. We tried to review some of them related to our topic in order to appreciate the information already available on the issue and to learn some lessons from others investigators. In Taiwan the first case of Human Immuno-deficiency Virus was reported in 1984. CDC Taiwan (2004) report on HIV/AIDS from 1984 to 2004/9/30 showed a total number of 6635 HIV positives were identified; and 1832 had developed full brown AIDS. Among the 6635 HIV positives, 6152 are natives and 483 are foreigners. Among the 6152 HIV positives natives, 2238 (36.4%) are heterosexual, 2161 (35, 1%) are homosexual, 661 (10.7%) are bisexual, IDU 309 (5.0%), Blood transfusion 13 (0.2%), MTCT 11 (0.2%) Unknown risk factor 705 (11.5%), and 53 (0.9%) are hemophiliacs. Most of them are male (5739 cases, 93.3%), and female with 413 cases represent 6.7%. Students have 378 cases (6.1%) Ages between 20 and 39 are the most affected by the pandemic in Taiwan 4318 cases (71.4%) (CDC Taiwan 2004). . Despite these low reported cases, the later are increasing in Taiwan. It is important to mention that prevalence data on HIV/AIDS are not available in Taiwan. A survey of knowledge, attitudes and practices concerning AIDS among female sex workers from massage parlors in Taiwan conducted by Chen (1997) showed a good

6 understanding of the routes of HIV1 infection. However, many misconceptions about the infections were prevalent. Their attitudes tended to be positive. They inconsistently asked their sexual partners to wear condom. Although this study provided useful information that can help to address AIDS infection among this high risk group, we did found studies in English addressing the same issue among larger groups such us young people in general community and students particularly at national level. According to CDC Taiwan (2003), many activities have been done at nation level involving public and civil society structures in order to improve the prevention measures particularly among groups of greater risk. The working team the National AIDS Prevention and Control Committee had held a several meetings to discuss a range of AIDS preventive activities such as the AIDS Awareness Campaign and the AIDS Control Everlasting Program. An achievement exposition on AIDS control was held on the World AIDS Day, December 1st, 2002 under the direction of the country President. In 2002 four meetings about 100% condoms use in all sex worker were held to discuss ways to increase the condom usage rate by AIDS-prone communities. National Health Insurance covers the payment for AIDS treatment. Eight hospitals were appointed by Department of Health to administer free HIV testing. However, only 3287 people have used the service and 59 of them were tested HIV positive. Both formal and informal classes have included sex education and AIDS control in their curriculum.

2.2 HIV/AIDS knowledge of selected studies.

A major UNAIDS Study (2002) finds Alarming Lack of Knowledge about HIV/AIDS among Young People. Young people lack information about HIV/AIDS. In countries with generalized HIV epidemics such as Cameroon, Central African Republic, Equatorial Guinea, Lesotho and Sierra Leone, more than 80 per cent of young women aged 15 to 24 do not have sufficient knowledge about HIV. In Ukraine, although 99 per cent of girls had heard of AIDS, only 9 per cent could name three ways to avoid infection. But, Harding AK (1999) Nigeria, in a study to determine the knowledge level of undergraduate students of a Nigerian university about HIV/AIDS found that students were knowledgeable about transmission and symptomatology but there were some misconceptions about the mode of transmission of HIV. Few students identified themselves to be at high risk even though majority of them (92%) were sexually experienced. Nwokocha AR (2000) Nigeria assessing Knowledge, attitude, and behavior of secondary (high) school students concerning HIV/AIDS in Enugu, Nigeria, in the year 2000 pointed out a defective knowledge of the disease. They were aware and afraid of the disease as being deadly but not sure of the cause, nature, or modes of transmission and prevention, except that illicit sexual activity should be avoided. These findings are quite similar to the one of United Nation about youth globally and portray differences within a same country. Amalraj ER (1995) India found in his study on First year medical students AIDS Knowledge that 92 percent of the students had heard about AIDS predominantly through mass media. Many students had misconception about transmission of HIV infection. Similar results were found by Anahita Tavoosi (2004) in Iran evaluating

8 Knowledge and attitude towards HIV/AIDS among Iranian students. The students identified television as their most important source of information about AIDS. Only a few students answered all the knowledge questions correctly, and there were many misconceptions about the routes of transmission. Mosquito bites (33%), public swimming pools (21%), and public toilets (20%) were incorrectly identified as routes of transmission. 46% believed that Human Immunodeficiency Virus positive (HIV positive) students should not attend ordinary schools. Most of the students wanted to know more about AIDS. In his study knowledge level was associated with students' attitudes and discipline (p < 0.001). Moderate knowledge was also found by Sevim Savaser (2003) in Turkey among High School Students. In China, Li X (2004) reported inconsistent level of AIDS knowledge among students, with a significant gender and grade difference. More than one-third of the students perceived themselves as having limited knowledge of AIDS. Li noted that the majority of the students reported having discussed AIDS issues with their peers and friends, but few of them had done so with their parents or teachers. He mentioned that AIDS knowledge varied among students by site of residence, with the highest knowledge among students from the urban areas and the lowest among those from rural areas. This difference may be explained by easier access of urban students to mass media such us television, radio, and newspapers in comparison to the rural one. Similarly, another study in China by Zhang H, (2004) described that Chinese students generally perceive a low level of vulnerability to HIV and sexually transmitted disease (STD) infection and a minimum exposure from family to drugs and risky sexual behaviors. Although students view condoms to be efficacious in preventing pregnancy or HIV/STD, but they also perceive a high level of response cost for use of condoms. These

9 findings suggest that efforts to adapt HIV/STD prevention programs targeting Chinese adolescents and young adults need to consider cultural aspects of perceptions regarding sex and condoms among Chinese students and to address the conflict between traditional Chinese cultural values and modern influences. If there is low to moderate level knowledge of HIV/AIDS among students in most of the developing countries, evidence showed different figure in most advanced countries where knowledge was found to be good. Indeed, La Torre G (2002) Italy reported good knowledge of Cassino's students about HIV transmission, in similar or higher proportion respect to analogous surveys conducted in Italy or abroad. Shapiro (1999) found that AMONG COMMUNITY COLLEGE STUDENTS IN ORANGE COUNTY,

CALIFORNIA level of student knowledge concerning HIV disease was found to be relatively high, and pronounced differences in knowledge and sexual permissiveness were identified as a function of ethnicity and religion, with Asians showing lower knowledge and lower concern about HIV, and religion/religiosity related to these variables and also to levels of sexual permissiveness. Braithwaite (2001) found AfricanAmerican and Caribbean college women* to be fairly knowledgeable about HIV/AIDS transmission and prevention, but noted that their sexual risk-taking behaviors were still relatively high. Therefore knowledge alone is not sufficient to make change in someones sexual behavior. Accordingly, Fethi Tebourski (2004) in his study in Tunisia stressed that students' attitudes toward PWA remain rather negative and unexpected. In addition, results demonstrated that much knowledge is associated with lower scores regarding misconceptions, but does not increase significantly students' positive attitudes to PWA. Certainly other factors may play role (culture, socio-economic level religion and so on).

 10 Globally Evidence shows better knowledge of HIV/AIDS among students in developed countries than their counterparts in less developed one with differences of level of knowledge within countries according to ethnicity, culture and other determinants. However, students of some middle-income countries display the same knowledge picture as developed countries. Indeed, Babikian T (2004) in his study pointed out that Armenian students knowledge of HIV transmission through sexual intercourse was markedly higher than that on intravenous transmission and prevailing myths; however, HIV/AIDS knowledge was not related to risk behaviors. Will Taiwan as a high income country present the same picture of students knowledge about HIV/AIDS as developed countries or will it follows the model of other Asian countries like India and Vietnam where students level of knowledge is quite low to moderate? Our study should bring the evidence.

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2.3

HIV/AIDS, attitudes of selected countries

Sevim Savaser (2003) analyzing attitudes of High School Students in Turkey concluded that about half of the students believed that people with HIV/AIDS should be able to attend school and should not have to stop working. On the contrary, Anahita Tavoosi (2004) noted a substantial intolerant attitude towards AIDS and HIV positive patients among Iranian High School Students. Although, Turkey and Iran are both Muslim countries; fundamentalism may explain the negative attitude of Iranian students. Because having aids in such countries is considered as a punishment for committed sexual sin. Nwokocha AR (2000) painted a defective attitude among Nigerian students. A similar picture is portrayed by Amalraj ER (1995) in his study in India where 60 percent of the first year medical students felt that physicians with AIDS/HIV infections should not be allowed to work in the clinic or hospital. However, Braithwaite (2001) found in multicultural America no significant cultural group differences that emerged on attitudes toward HIV/AIDS as a disease, HIV infected persons, and AIDS-related issues. A number of significant correlations were found. The study concludes that HIV/AIDS counseling and prevention approaches that are ethnic, cultural, and gender appropriate are vital for increasing both cognitive and behavioral changes in culturally diverse young women. Fethi Tebourski (2004) mentioned that Tunisian students' attitudes toward PWA remain rather negative and unexpected. In addition, results demonstrated that much knowledge is associated with lower scores regarding misconceptions, but does not increase significantly students' positive attitudes to PWA. He then deduced that knowledge was not sufficient to lead to more positive attitudes. Such results are also

 12 reported by other researchers who concluded that knowledge is necessary but is not sufficient. As we have noted with knowledge, better knowledge does not necessary involve a positive attitude.

2.4 HIV/AIDS practices in selected studies

Protected sex is crucial in reducing students' risk of contracting sexually transmitted diseases (STIs) including human immuno-deficiency Virus infection. Trends indicate students are knowledgeable about HIV prevention measures, yet underestimate their HIV/AIDS risk in light of their sexual behavior, which they fail to alter in significant ways. UNAIDS (2002) stressed that in many countries with high HIV prevalence rates, unmarried boys and girls are sexually active before age 15. Recent surveys of boys aged 15 to 19 in Gabon, Haiti and Malawi found that more than a quarter reported having sex before age 15. However, the findings of KAP study of HIV/AIDS among students conducted by Yaveh Negash (2003) in Ethiopia showed that sexual practice often begun as early as eleven years of age with the mean of age 16 and 18 years for females and males, respectively. Chin (2004) supports that the median age at first sexual intercourse is 27 for male and female in Singapore, 19 in Kenya, 18 for male, and 17 for female in Thailand, while 15.5 for female, and 16 for male in Cote D Ivoire. This shows differences between and within regions. Does Taiwan reality match with the existing evidence in other countries? What will be the mean age at first sexual intercourse of Taiwanese students?

 13 Harding AK (1999) Nigeria in his study of sexual behavior of undergraduate students of a Nigerian university about HIV/AIDS showed that even though these students are knowledgeable and concerned about contracting HIV/AIDS from their partners, this did not prevent them from engaging in unprotected sexual intercourse. It appears, however, that students are exercising caution when negotiating new sexual relationships, as they are likely to discuss (and insist on) using condoms and ask to have a monogamous relationship. Sekirime WK (2001) describing knowledge, attitude and practice about sexually transmitted diseases among university students in Kampala (Uganda) concluded that The level of knowledge about STDs and their prevention is not matched by sexual behavioral patterns, and male students undertake more risky sexual behaviour. Sexual education should be introduced at the university as a means of increasing students' awareness about the problem and prevention of sexually transmitted diseases including HIV/AIDS he then recommended. James S (2004) South Africa also painted a discrepancy between awareness and behavior calls for a reorientation of sexuality education to include those elements critical for behavioral change, such as addressing gender discrepancies and promoting skills for communication through planned intervention programs. Similar results have been found by Amalraj ER (1995) in India. Also, Babikian (2004) reported among Armenian students risky sexual behaviors, including inconsistent condom use, casual sex, and multiple partners. In addition to descriptive statistics delineating gender differences across the target behavioral domains, bivariate and multivariate statistical analyses were used to understand factors that contributed to increased risk, including early age of initiation and the relationship between substance use and risky sexual activity. This picture is quite common for most of

 14 the developing countries in general and for Sub-Saharan countries in particular. This may explain why HIV/AIDS prevalence rate is very high in this region. Much effort by the scientist community still needed to be done to explore why people in this part of the world are so resistant to sexual behavior change despite the ravaging effect of HIV/AIDS?

Gurman T (2004) US studying condom use among Latino college students in US mentioned that fewer than half of recently sexually active Latino students had used condoms during their last oral (4.9%), vaginal (41.3%), or anal (27.8%) sexual encounter. Predictors of condom use varied according to the type of sexual activity. Findings from his exploratory study offer current information about condom use and sexual behaviors among Latino college students and suggest that prevention interventions and messages should be tailored to students' gender and types of sexual activity. Young age certainly explains tendency of young people including students anywhere to get involve in risky activities including sexual one. According to Tapia-Aguirre V. (2004) apparently knowledge is not directly correlated with condom use among young women in Mexico.

Smith L.A (2003) found difference influence in condom use among students according to ethnicity and gender features in California. His study investigates gender and ethnicity differences in the experience of not using a condom due to a partner s influence (unwanted noncondom use). Analysis of 247 anonymous questionnaires from students at urban community college campuses revealed that 46.7% had experienced unwanted noncondom use since age 16, and 37% had experienced unwanted noncondom use with their current or most recent partner. Males and females reported equal levels of unwanted

 15 noncondom use. However, African-American and Latino participants reported higher levels of unwanted noncondom use than Whites. The findings indicate that females, males, and people from ethnic groups at high risk for HIV infection need support to carry out their safer sex intentions. I think poverty may also play role in such negative behavior. Being poor, reduce ability to behave independently.

Trajman A (2003) notes a strong relationship between negative sexual behavior and lowfamily income among high school students in Rio de Janeiro, Brazil. Among 945 students aged 13-21, 59% were sexually initiated, and the median age at first sexual intercourse was 15 years (range: 7-19). Although 94% reported being aware of the need for condom use for protection, only 34% informed always using condoms during sex. Low family income was associated with unsatisfactory knowledge (OR = 9.40; 95% CI = 6.05-14.60) and inconsistent condom use (OR = 11.60; 95% CI = 5.54-24.30). However, unsatisfactory knowledge was not associated with inconsistent condom use.

Information is a very important factor in health education. Information about HIV/AIDS nowadays may be found in variety of ways. Given that information of sexuality is very sensitive issue in many communities some information channels are preferred to others. The most common information channels for students are mass media (particularly television and radio). Amalraj ER (1995) reported from his study among Indian First year medical students that 92 percent of the students had heard about AIDS predominantly through mass media. His country man Gupta S (1997) supports that Delhi students attached due importance to television and radio as sources of information about

 16 HIV/AIDS in addition to their friends. The authors, therefore, suggest an urgent need to intensify the media programs regarding HIV/AIDS in electronic media and print media Harding AK (1999) and Nwokocha AR (2000) noted that Nigerian students obtained information about HIV/AIDS primarily from the media rather than from school classrooms and homes, which suggests a need to increase educational efforts at the university. Alcohol, drugs use is frequently remarquable among students with sexually risky behaviors. This is confirmed by Fierros-Gonzalez R. (2002) who assessed high risk behaviors in a sample of Mexican-American college students. High risk behaviors for contracting HIV/AIDS examined in his study included unprotected sex, drug use, and alcohol abuse. In 1995 in the United States, HIV/AIDS was the leading cause of death in people between the ages of 25 and 44. Because use of alcohol and certain recreational drugs lowers inhibitions, their use could increase the possibility of having unprotected and unplanned sex with multiple partners. Thus, it was expected that Mexican-American college students who use drugs and alcohol would be more likely to engage in unprotected sex. Data were from 105 men and 211 women between the ages of 18 and 30 years. Drug use and alcohol abuse were significantly associated with high risk sexual behavior. Individuals in monogamous relationships were more likely to not use condoms than those involved in casual relationships. Self-reported religiosity was not correlated with high risk behaviors, although there were implications that stronger religious affiliation did alter sexual beliefs and practices. Lastly, parental communication was not significantly associated with high risk behaviors, but family unity did seem related to some risky sexual practices.

 17 Tobacco often associated with alcohol abuse is also found to be an enabling factor for risky behavior. Indeed, Babikian investigating Armenian sexual risk behavior found that tobacco and alcohol prevalence was relatively high. Students reported risky sexual behaviors, including inconsistent condom use, casual sex, and multiple partners. In addition to descriptive statistics delineating gender differences across the target behavioral domains, bivariate and multivariate statistical analyses were used to understand factors that contributed to increased risk, including early age of initiation and the relationship between substance use and risky sexual activity. The study results provided much-needed information for the development of school- and community-based AIDS prevention programs in Armenia.

2.5 Impact of intervention programs on students knowledge, attitudes, and practices.

Young People including students is a window of hope in the HIV/AIDS pandemic The HIV/AIDS pandemic is one of the most important and urgent public health challenges facing governments and civil societies around the world. Adolescents are at the centre of the pandemic in terms of transmission, impact, and potential for changing the attitudes and behaviors that underlie this disease. It is estimated that 50% of all new HIV infections are among young people (about 7,000 young people become infected every day), and that 30% of the 40 million people living with HIV/AIDS are in the 15-24 year age group UNAIDS (2002). The vast majority of young people who are HIV positive do not know that they are infected, and few young people who are engaging in sex know the HIV status of their partners.

 18 The importance of focusing on young people has been recognized at a global level by the 2001 UN General Assembly Special Session on HIV/AIDS, which endorsed a number of goals for young people, including: "By 2003, establish time-bound national targets to achieve the internationally agreed global prevention goal [adopted during the ICPD+5 Conference] to reduce by 2005 HIV prevalence among young men and women aged 15-24 in the most affected countries by 25% and by 25% globally by 2010" "By 2005, ensure that at least 90%, and by 2010 at least 95% of young men and women have access to the information, education, including peer education and youth-specific education, and services necessary to develop the life skills required to reduce their vulnerability to HIV infection; in full partnership with youth, parents, families, educators and health care providers." Keeping in mind this orientation of UNAIDS many researchers have investigated the impact of several prevention programs targeting youth in general and students in particular and aimed at improving students knowledge, attitudes, and practices related to HIV/AIDS. Cheryl Fraser (1996) assessed the impact of an undergraduate HIV/AIDS education course on students' AIDS knowledge, attitudes and sexual risk behavior in Canada. The intervention consisted in a course comprised lectures, small group discussion, and a question and answer session with a panel of five HIV-positive men and women. Her analysis indicated that, immediately after the SFU course, students had significantly higher understanding and awareness of the bio-psycho-socio spectrum of the AIDS pandemic," she reported. "Another exciting and significant result was that 97 per cent

 19 reported a greater understanding and accepting attitude toward homosexuality, up from 30 percent at the beginning of the course. These positive changes were maintained at an eight-month follow-up.

"There were no statistically significant differences between groups on a composite score of sexual risk behavior after the intervention, although AIDS education participants did report more frequent condom use and intentions to have safer sex in the future," she concluded. So, we can notice a certain discrepancy between acquiring knowledge and behavior changes. Emmanuel Uwalaka (2002) Nigeria in his study on impact concluded: It is meaningful that knowledge, a key theoretical factor in sexual behavior, has a significant positive impact on behavioral change. However, knowledge, in this regard, is not enough. Larger societal contexts, which would include such factors as the pattern of sex roles and expectations within society, inequities in gender roles and power, (Cohen & Trussell, 1996) and the cultural context of disease causation should be taken into account. Also, perceived susceptibility seems to have a negative impact on behavioral change, although the coefficient is not significant. Further study is necessary to test a causal relationship among these variables in order to explore the paths that lead to sexual behavioral change. Such study requires urgency, considering that about one-third of the population has contracted AIDS in Africa. His country man Uwakwe CB (2000) after a systematized education of Bachelor of Science (BSc) nursing students' at the University Of Ibadan, Nigeria with regard to knowledge enhancement and attitudinal transformation, the research revealed that a number of positive changes occurred over the period of the study. Not only were the nurses better informed about AIDS than previously, but their attitudes towards the disease and patient care had become considerably more liberal, as

 20 well as their disposition to comply with universal precautions. Buskin (2002) scrutinized HIV/AIDS Knowledge and Attitudes in Chinese Medical Professionals and Students before and after an Informational Lecture on HIV/AIDS and concluded that HIV transmission knowledge was good, with 90 percent to 100 percent of participants correctly identifying means of transmission. Prior to and after the lecture, 43 percent and 21 percent, respectively, were unwilling to sit or work with an HIV-infected person. He suggested that to increase the likelihood of prevention activities' success, HIV knowledge and attitudes of health care personnel in China must be monitored and improved. But unfortunately these studies done by both Buskin and Uwakwe respectively in China and Nigeria did not evaluate the behavior change. MERAKOU, KOULA (2002) after 15 years of HIV/AIDS prevention in schools analyzed the Knowledge, attitudes and behavior of students in Greece found that 72% of the questions regarding knowledge were answered accurately. 43.15% of the participants believed that their knowledge about HIV/AIDS was sufficient. They considered AIDS to be a big threat to society (89.65%), and would be embarrassed if they were HIV positive (31.75%), however, they would be compassionate to HIV positive persons. One out of three was worried about already being HIV infected, because of their risky behavior in the past, especially boys. The major change in their behavior was the use of a condom (80.9% for boys and 56.7% for girls). 64.8% of the girls did not have sexual relations, while 41.9% of the boys had sexual relations with casual partners. He concluded that after 15 years of prevention activities among young people, students have a satisfactory level of knowledge and have adopted relatively safe behavior. However, boys, younger students, students with a high sense of religiousness and students with both excellent and

 21 low school records need more intense and systematic information through suitable interventions. That contradicts the findings of Cheryl Fraser mentioned above in Canada where interventions programs did not yield significant behavior change among students. However, Netting NS (2004) in his twenty-year study analyzes changes in sexual behavior among students at Okanagan University College in British Columbia, Canada. Surveys conducted in 1980, 1990, and 2000 reveal a steady increase in safer sexual practices. Most students now question potential partners about their past, use condoms with a new sexual partner, and maintain fairly long-term monogamous relationships. Three sexual subcultures continue to coexist in fairly stable proportions: celibacy (about 30%), monogamy (about 60%), and free experimentation (about 10%). Each subculture has created its own response to the danger of HIV/AIDS: celibates exaggerate the danger they face, monogamists rely on love and fidelity for protection, and free experimenters have increased their use of condoms. While romantic feelings lead many monogamous couples to abandon condoms without objective HIV/AIDS knowledge, free experimenters still face the highest risk. Although they now use condoms more than half the time, their lifestyle, which involves multiple partners, risky sexual acts, and frequent drug and/or alcohol use, clearly remains dangerous. The persistence of distinct subcultures has implications for health education programs, which would be most effective if based on key values held by specific target groups. I do agree with the author on culture issue. I believe cultural features are strong barriers to sexual behavior change. Even in the same country cultural values make differences in peoples behavior. Because sex is a sensitive issue and taboo in many societal settings, it is difficult for young people in general and students in particular to learn from adults. Therefore,

 22 programs that put accent on peer education can make sense. Caron F (2004) Canada evaluated a theoretically based AIDS/STD peer education program on postponing sexual intercourse and on condom use among adolescents attending high school and ended up with the following results: At post-test, seniors in the experimental group were more likely to use condoms on a regular basis than those in the control group. Program effects occurred among both sexes, but a few differences in response were observed among males and females. Results suggest this type of theory-based program is effective in modifying psychosocial variables related to postponing sexual intercourse and related to condom use among adolescents. Personal involvement in designing intervention appears to be effective in modifying the behavior of peer educators concludes the author. Communication between parents and students may enable the later to get proper knowledge and better attitudes and behavior related to HIV/AIDS. Adu-Mireku S. (2003) studying Family communication about HIV/AIDS and sexual behavior among senior secondary school students in Accra, Ghana noted that twenty-five percent of the participants reported being sexually experienced, and 73.6% had talked about HIV/AIDS with parents or other family members. Of the sexually experienced students, 64.7% initiated first sexual intercourse by age 16; and 55.7% did not use a condom at last sexual intercourse. Bivariate analysis showed significant gender differences in sexual activity, condom use, and family communication about HIV/AIDS. Logistic regression analysis showed that student-family communication about HIV/AIDS was not associated with sexual activity. However, communication about HIV/AIDS between students and parents or other family members increased the odds of using a condom at last sexual intercourse. The findings of this study suggest that prevention

 23 programs that seek to educate Ghanaian school-going adolescents about sexual risk behavior must strongly encourage communication about HIV/AIDS between students and family members. I ignore the generalizability of the current study whose results are to me very surprising when we know that in many African societies particularly in rural areas adults are not use to talk to their children about sex. But I may agree that even in African societies are not identical. Some may enjoy better family members-children relationship.

Young people may feel embarrassed to learn condom use in public. Some strategies that boost auto-learning are sometime used to bypass barriers. Milleliri JM (2003) used a comic book to sensitize Gabonese students on condom use and found that Knowledge about the modes of HIV/AIDS contamination improved substantially between the two questionnaires, with knowledge about the mother-child transmission pathway increasing from 47% to 75% of responders. At the same time, and without any significant difference by sex, class or province, individual adhesion to the role of the condom as a means of prevention against AIDS progressed from 64% to 95%. The students questioned wanted AIDS prevention information to be better integrated into their curriculum and, in particular, they wanted educational activities in this area in their school, either by their teachers or in special information areas. Thus, the 48-page comic book by young Gabonese artists was perceived as a good method of condom education for the young (75%) and as an excellent method for inducing awareness about it among them (89%). The book's contents had been absorbed, and the students found that the stories and the message were well matched. Moreover, the extension of the readership beyond the initial distribution at the first evaluation (7.5 readers reported per copy) showed that the

 24 messages in the book spread well beyond the student group. However I question the proper use of condom based upon a comic book. Live demonstration of condom use seems to me more effective than through a book only because people misunderstand some procedures. Thus, I would suggest the combined use of both approaches.

2.6 Lessons learned from the literature review

The lessons we drew from this literature review are in several folds: HIV/AIDS is a concern worldwide, affecting all nations and communities regardless of their culture or socio-economic development. Students Knowledge on AIDS is generally high in high income and developed countries but relatively low in less advanced countries. Attitude towards HIV/AIDS tended to be more positive in developed countries but relatively negative in many Islamic and developing countries. Safe sexual behavior was not significantly correlated to the knowledge level in most of the cases. But where the knowledge level was high attitude tended to be positive. Knowledge-based AIDS Education did tend to have positive influence on people. The review helped us to take into account some important variables in our questionnaire design.

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3. Material and Methods

3.1 Research design

A cross-sectional study design was applied because the area was diverse. The quantitative descriptive method was used to quantify the factors of knowledge, attitude, and practices. Using quantitative method we assumed that either underlying concepts were little known or the prevalent knowledge or theory may be biased. That why, quantitative descriptive design was relevant to be used in this study.

3.2 Study population

This was made up of first years Taiwanese students from nine universities out of 161 existing in the country. The total population of news students was approximately 164,341 during the academic year 2003/2004. We deliberately chose first years students because we believe they are more likely to engage in sexual intercourse given that they get more freedom when leaving their parents for universities. Thus, we believe we can indirectly measure their high school knowledge about HIV/AIDS.

3.3 Sampling method, sample size

Nine out of 161 universities were selected by stratification and included private, public, and professional schools. In Taiwan there is the so called National university entrance test. According to the scores of this test, students with high score enter public schools, students with middle score go to private schools, and those with lower score get into professional schools. Basically these tree categories of schools receive students from all

 26 around Taiwan. In addition, the general knowledge and behavior may vary from professional schools to classic schools. This is the reason why, we have chosen the stratification by type of schools which matches with Taiwan specificity rather than per areas or random sampling as it is usually the case in national studies. At each selected university, all the first years students who were present in the classroom on the day of the survey and who agreed to participate were eligible. From the target population 164,341 first years students we drew 7.2% to make up our study population. That is 11847. For the needs assessment section, all the universities in Taiwan were eligible. Finally 122 universities out of 161 returned the questionnaire.

3.4 Study framework

The conceptual framework used in this study is the Health Belief Model (HBM).The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services. The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS. Rosenstocks HBM and Swansons were reviewed. After analyzing both the models separately, we saw that each of them has advantages and some limitations. So, we decided to combine them to fit our questionnaire. (See figure) The combined Model has already been used by Li-Ya Chang (1995) for her Master Thesis in National Yang Ming University, Institute of

 27 Public Health to assess Knowledge, Attitude and Behavior about AIDS among Sex workers in Taipei Area. Our combined Model has 5 sections: Demographics, Knowledge, Attitude, Practices and Other factors. Demographics encompass age, education, parents education, residence, and gender. Knowledge includes AIDS transmission, prevention, knowledge, and diagnosis Attitude is composed of: Perceived susceptibility to HIV/AIDS Perceived seriousness or severity of HIV/AIDS Perceived benefits of preventive actions Perceived barriers to preventive actions Cues to actions

Practices are subdivided into Sexual orientation Sexual practices Substances abuse

Other factors include Source of information on HIV/AIDS STI and HIV/AIDS relationship

According to this Model we believe that Demographics factors may influence HIV/AIDS knowledge, attitude, and practices. In turn knowledge can determine attitude and

 28 practices of an individual related to HIV/AIDS. Attitude finally may dictate someones practices. Other factors may reflect on knowledge, attitude, and practices. Rosenstocks and Swanson Health Belief Model (HBM)

Demographics Age Education Parents Education Residence Gender

Knowledge AIDS transmission AIDS prevention AIDS diagnosis AIDS Knowledge

Attitude Other factors Source of information on HIV/AIDS STI and HIV/AIDS relationship Perceived susceptibility to HIV/AIDS Perceived seriousness or severity of HIV/AIDS Perceived benefits of preventive actions Perceived barriers to preventive actions Cues to actions

Practices Sexual orientation Sexual practices Substances abuse

 29

3.5 Survey procedure and strategy

Ministry of education asked all the school to cooperate with the research team. The data was collected through the Schools Administrative Office during the students orientation days in September 2004 just before students started classes in order to avoid peers influence. The research team directly collected data in some universities with the assistance of the schools. Students were assured that all information given on the form was confidential. Therefore, they completed the questionnaire privately in the classrooms.

3.6 Study instrument

The research was conducted through use of two self-administered questionnaires. One anonymous questionnaire for students on knowledge, attitudes, and practices on HIV/AIDS. The second questionnaire on HIV/AIDS Education and counseling program Needs Assessment was sent to responsible for Student Councils of all the 161 Universities. The questionnaires were developed based on the literature review and the conceptual framework. The literature review provided insights on what to emphasize in our questionnaire. Some questions were taken from previous researches and adapted to match our conceptual framework. Five professors versed in research reviewed the questionnaires. Content validity was established by majority expert approval. Only 12 close-ended and open-ended for responsible for students Councils and 56 questions for students were judged as valid and included in the study. The KAP questionnaire covered the following issues: students demographic data, knowledge about various aspects of HIV/AIDS, attitudes towards HIV

 30 infected people, and practices. The questions of this section were administered to 20 students 0f the same age as the target group in one university. Then, the questionnaire form was revised for clarity to the final form. The KAP questionnaire covered the following issues: students demographic data, knowledge about various aspects of HIV/AIDS, attitudes towards HIV infected people, and practices. The knowledge questions were answered using the options True and False. A total score for knowledge was obtained by adding the points given for each answer. For each correct answer 1 point and 0 point was assigned for each incorrect one. The sum makes up the total score which ranged between 0 and 25. A higher indicated a greater level of knowledge. The attitude score was computed using the categories: SA= Strongly Agree; A= Agree; N= Neutral; D= Disagree; SD= Strongly Disagree. When the answer was in positive way 5, 4, 3, 2, 1 points were assigned respectively to SA, A, N, D, SD. The reverse occurred when the answer went to negative way. The sum makes up the total score which ranged between 15 and 75. A higher score indicated a more positive attitude towards HIV/AIDS. After analyzing the data, the Cronbachs Alpha was calculated to assess the internal consistency of Knowledge, and Attitude questions (0.46 and 0.61 respectively), which is quite similar with the one found by Tavoosi (2004). The questionnaires were originally designed in English then translated into Chinese by one academic member. Another person then, translated them back from Chinese to English to make sure that the meanings remain the same. The research design received approval from Ministry of Education Taiwan. In addition, the Ministry of Education provided the grant and invited Universities to cooperate with researchers.

 31

3.7 Statistical analysis

The data were analyzed using the Statistical Package of Social Sciences (SPSS 11.0). Open-ended questions were analyzed manually. The data were assessed by Chi-square test, analysis of variance and Pearson correlation test, t and linear correlation tests. A pvalue of < 0.05 was considered statistically significant.

 32

4. Results
4.1_ Knowledge, attitude, and practice towards HIV/AIDS among first year university students in Taiwan.

4.1.1_Prevalent demographic data.

The distribution of study respondents was not even per areas (figure 1). A total of 11847 students (response rate 82.2%) from nine universities answered the questionnaire, of which 6009 (50.7%) were male and 5758 (48.6%) were female (Table 1). Eighty participants (0.7%) did not specify gender (Figure 2). They were aged 15-39 years (mean, 18.7 years, SD +_1.1) (Figure 3). The educational level of their father and mother was respectively primary school (9.0%, 12.8), junior high school (15.2%, 18.1%), senior high school (38.4%, 44.0%), university (30.0%, 21.7%), institute (5.9%, 2.0), and missing data (1.5%, 1.3%) (Figure 4).

4.1.2_Knowledge regarding HIV/AIDS

The majority of students had accurate knowledge about HIV/AIDS; with 63.2 to 99% students correctly answering each of questions (Table 2). According to Figure 5, the average knowledge level is 86.8%.This percentage is obtained by dividing the mean knowledge score 21.7(SD +_ 2.1) by the maximum knowledge score (25) and multiplying by hundred (figure). However, there were knowledge gaps concerning the definition of AIDS acronym. Indeed, 39.7% of respondents failed to give the correct answer. There were many misconceptions about the transmission routes. 23.4% 0f

 33 students believed that AIDS virus may be transmitted by mosquitos bites. 36.7% ignored that oral intercourse carries risk for transmitting AIDS virus, while 26.7 supported that keeping in good physical condition is the best way to prevent exposure to the AIDS virus. Females showed significantly higher knowledge level than males (p<0.001) for most of the knowledge questions but this difference was very low (Table 2). There were significant differences in mean knowledge among schools with technological universities reporting lower scores that others (Table 3). A positive linear association was found between students knowledge level and their fathers education level. Similar situation was found with mothers education level. However, negative association occurred at the mother highest education level (Figure 6). When level of father and mothers education was combined and compared with students knowledge, there was significant difference between the groups (Father low & Mother low vs. Father high & Mother high, and Father low & Mother high vs. Father high &Mother high) ( figure 7).

4.1.3_Attitude towards HIV/AIDS

According to (table 4) most of students had a relatively positive attitude towards AIDS and HIV-positive patients. Indeed, 64.1% of respondents strongly agreed or agreed that the names of individuals with AIDS should be kept confidential in order to protect them against discrimination. Moreover, 86.2% of them belied that more government funds should be spent on providing support services for people with AIDS, while 70.1% of respondents agreed or strongly agreed that students with AIDS should be allowed to attend school with students who dont have AIDS. However, 42.2% of students would

 34 avoid having contact with persons who have AIDS, and 13.6% would feel embarrassed if one of their family members had AIDS. Though, 87.1% of students stated that using a condom doesnt seem like an insult to their partner, they would feel embarrassing (26.2%) to buy them. The majority of respondents (88.5%) strongly disagreed or disagreed with the statement there is no need a girl to learn how to wear a condom. Half of respondents (50%) were afraid they might contract AIDS, while another 29% would rather have any cancer than AIDS. Students had a relatively positive attitude towards HIV/AIDS. The mean attitude score was 56.2 (SD +_ 5.6) i.e. 74.9% of positive answer (Figure 8). According to Figure 9, a higher level of parents education brought more negative student attitude towards HIV/AIDS. Better student attitude score was obtained when his or fathers education was high and his or her mothers one low but that was not statistically significant sine ANOVA Test p = 0.202 (Figure 10). Figure 11 displays various mean attitude score per school which was diverse. Knowledge was significantly correlated to attitude but this is not practically significant (Pearson correlation: 0.147; p < 0.001) (Figure 12). Knowledge and attitude were significantly correlated for Male participants and Female participants. Pearson correlation: Male: 0.182; P< 0.001. Female: 0 .074; P< 0.001 (figure 13).

 35

4.1.5_Practices
Students identified School (81.5%) and Television (75.4%) as main source of information about HIV/AIDS followed by Print (55.4%) Internet (46.0%), friends (25.3%), and Doctor or nurse (45.2%) (Table 5). The overwhelming majority of them were heterosexual 11049 (93.3%), 62 (.5%) homosexual, 133 (1.1) bisexual, and 455 (3.8%) undecided (Figure 14). Fewer respondents were sexually active 1179 (10%). The mean age at first sexual intercourse was 17.1 (SD +_ 1.5). Female students a bit earlier entered sexual life as compared to male students (Figure 15). Professional universities such as technological universities recorded greater percentage of sexually active students (Figure 16). Among sexually active students only 30.9% used condom every time while 16.4% other never used it according to (Figure 17). Three hundred and eighty four (32.5%) out of 1179 had more than one sexual partner. Male students significantly had more than one sexual partners than female students(X2 6.142
P< 0.046). 9.9% of participants were alcohol consumers. Very few students 157(1.3%)

were found to be drug users. Drugs users were predominantly male students (80.9%) versus female students (18.5%). O.7% of respondents did specify their gender (Figure 18). Once again professional universities showed the highest percentage of drugs users (Figure 19), and this was statistically significant (Pearson x2 = 63. 210 P< 0.001). . Drugs more frequently used were MDMA 63.7%, Ketamine 56.7%, and Magic mushroom 16.1% (Table 7). According to figure 17, the distribution of drugs users per school was uneven. Students got drugs mainly from friends 58.6% in Pub 45.2% at school 21.6%, and at Home party 21.6%. Injectable drug use was almost inexistent

 36 among first years students given that only 10(.08%) students out of 11847 reported drug injection. No correlation was found between knowledge and practices variables in this study.

 37

4.2_ HIV/AIDS Education and counseling program Needs Assessment

A total of 161 Universities received the questionnaire, but actually 122 participated in the study (response rate 75.8%). Among the later, 1 university instead of filling in 1 questionnaire decided to duplicate it for its 5 Departments and another one did the same for its 2 Departments. Since the answers were significantly different from one department to another, we considered all of them bringing the total number of respondents to 128. No University responded to all questions.

Responses of close-ended questions are displayed in (Tables 8). 70 universities out of 123 respondents (56.9%) were found to have an extra curricular formal HIV/AIDS prevention program for students. However, 53 universities (43.1%) did not have any extra curricular program. Among universities having extra curricular program, 24 (34.8%) cited Student Association as structure responsible for it, 43 (62.3%) named Office of Students Affairs or School Military Training Office, 9 (13%) mentioned Hospital or Public Health Office, and 4(4.4%) indicated NGOs. One university did not respond to that question. AIDS conferences, Informal discussions on AIDS, HIV/AIDS Week, HIVblood testing, Condom use were topics that mattered the above organizations.

In 123 universities out of 124 (97.6%) had material resources for HIV/AIDS prevention activities. Among these, which had material resources, 90.1 % had IEC material (condoms, pamphlet, booklet) while, 85.1% had Audio visual (DVD player, video player, video cassettes on HIV/AIDS). Most of the organizations expressed need for new

 38 IEC material (audio visual material, condoms, posters, Models ...etc), funds for

HIV/AIDS activities, teachers on HIV/AIDS, collaboration with People living with HIV, and Assistance of NGOs in dealing with HIV/AIDS education.

In response to a question about the existence of any regulation within university for the management of HIV/AIDS infected students as a legally reported disease, 81.1% of respondents universities said YES, and 18.9% answered NO. However, data review using universities websites showed that indeed, 83.7% had written regulation for HIV/AIDS case management and 16.3% did not. Asked what they will do if student is infected with communicable disease? 82.1% universities said they will ask student to leave school; 6.5% will ask student to leave dormitory, and 2.4% will assist student. 6 out of 124 (4.8) universities had dealt with HIV infected student, and all of them provided him with assistance. Among those universities that had not dealt with HIV infected student, 80% will provide particular assistance to him, 0.9% will forbid student to attend school restaurant, 5.5% will expel him from dormitory, and 0.9% will ask student to quit school, 9.1% will ask him to leave school temporally, 4.5% student will leave school, and 6.4% student temporally will leave school.

All the universities that participated in the study (100%) thank that it is important to educate students about HIV/AIDS. Furthermore, how to say no (assertiveness) 88.1%, living with HIV/AIDS 82.5%, caring for the infected person 54.8%, and outreach (helping in the community) 15.9% were picked up by universities as the kind of information students in general would be interested in.

 39

104 out of 124 (83.9%) respondents claimed that their were ready to provide HIV/AIDS counseling to students, while 16.1% found themselves not ready to do so. 99.2% of students councils responsible would like to make personal help to HIV/AIDS prevention against 0.8% who would not. Among these students council authorities, 2 (1.6%) had experienced a case of HIV infected student in their university. Surprisingly 9 others universities claimed that they have provided assistance to HIV + student in their school such as counseling, health education, permission to pursue studies, support in every day life, and assistance to get medical care. 42 (32.8%) respondents gave some suggestions on what they would like to see happening around HIV/AIDS on campus which fell in prevention, promotion of HIV+ students rights, fight against HIV/AIDS stigmatization, safe sex education, and student empowerment to face prostitution, medical care for students.

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5. Discussion and Conclusion

5.1_ Knowledge, attitude, and practice towards HIV/AIDS among first year university students in Taiwan.
The present study evaluated the knowledge, attitude, and practices of first year Taiwanese university students regarding HIV/AIDS. In general, the level of knowledge was quite high (86.7%). This is consistent with the findings of Braithwaite( 2001); Buskin,(2002); Harding(1999); James S( 2004); La Torre G( 2002); Merakou(2002), but not consistent with studies of Anahita Tavoosi( 2004); Atulomah NO( 2002); Nwokocha AR( 2002); and Sevim Savaser( 2003). However, 39.7% of students failed to correctly define the acronym AIDS. This may be due to poor students knowledge in English since these features were mentioned in English. Although the study participants were relatively well aware of the sexual transmission modes of HIV/AIDS, the results indicated some knowledge gaps regarding specific routes of transmission meaning that students still have many misconceptions about the transmission routes of HIV/AIDS. Indeed, 23.7% of students believed that AIDS virus may be transmitted by mosquitos bites; 36.7% ignored that oral intercourse carries risk for transmitting AIDS virus, and 23.4% did not acknowledged that STI infected people are at risk for contracting AIDS virus. This is consistent with findings of Babikian (2004); Harding (1999); Fethi Tebourski (2004); Anahita Tavoosi (2004), and Almalraj (1995). Female participants showed a slightly higher level of knowledge in comparison with male participants; this difference is small and practically insignificant but consistent with studies of Anahita Tavoosi. Most of the surveyed students (78.7%) belied that AIDS could be a threat for Taiwanese. This means that students consider AIDS as a serious issue, which actually threatens the whole

 41 humanity, and this is consistent with the findings of Anahita Tavoosi. However, still they were a bit biased against infected individuals as some of them would be embarrassed if one of their family members got AIDS. Public universities demonstrated better knowledge score than private and technological schools. The latter reported the lowest scores. This may be due to the university entrance policy in Taiwan. Students with highest entry examination score go to Publics schools, those with middle score to Private one and students with the lowest score are admitted to technological schools. A positive linear association was found between students knowledge level and their fathers education level. This is consistent with the findings of Sevim Savaser. Similar correlation was found with mothers education level. However, negative correlation occurred at the mothers highest education level. Further investigations needed to understand this situation.

Although Taiwanese first years students overall had a relative positive attitude towards HIV/AIDS, 42.9% of them would avoid having contact with persons who have AIDS, and 36.9% were undecided; 15.8% strongly disagreed or disagreed that the names of individuals with AIDS should be kept confidential in order to protect them against discrimination, while 19.7% could make a decision about it. This may express a kind of fear that Taiwanese students have of AIDS disease. This was found to be true in the study of Gray L.A (1999) in India, and Nwokocha AR (2002) in Nigeria. These facts are serious issues may be due to lack of proper education about HIV/AIDS and need to be addressed. Overall, attitude was not correlated to knowledge level, which means that better knowledge doesnt necessary lead to positive attitude. Many efforts still need to be

 42 done to improve students attitude towards HIV/AIDS. Knowledge was significantly correlated to attitude but this association was low (Pearson Correlation: 0.14) and not practically significant. This may be explained by the big sample size.

Students identified School (81.5%) identified School as the main source of information about HIV/AIDS. This offers a good opportunity to establish or improve an appropriate AIDS prevention program at school. Television was picked as the second source which is consistent with studies of Anahita Tavoosi (2004) in Iran. 195 (1.6%) of sexually active students were found to be Homosexual or Bisexual. Although small, if this proportion of students will tend to grow, then undoubtedly this may carry a big risk to spreading HIV/AIDS. Hence, preventive measures should be taken to assist this subpopulation of students. The mean age at first sexual intercourse was 17.14 (SD +_ 1.45). This is a relatively a late sexual debut compared to other regions such as Latin America and Sub-Saharan Africa. For instance, Trajman (2003), and Adu-Mireku S (2003) reported earlier sexual debut among students respectively at 15 and 16 years in Brazil and Ghana. However, this indicates that University is the right place where emphasis should be put on HIV/AIDS prevention since most of the students did not start yet sexual life. A small proportion of participants were drug users (1.3%), and 9.9% were alcohol consumers. Vigilance should be observed to keep them away from abuse which may also lead to unsafely sexual behavior. In this study no correlation was found between knowledge level and practice. For instance, despite the high knowledge level, sexually active were found to be inconsistent condom users. This is consistent with previous

 43 studies by Smith L.A (2003) in USA; Babikian (2004) in Armenia; Atunes (2002) in Brazil; Adu Mireku (2003) in Ghana.

 44

5.2_ HIV/AIDS Education and Counseling program Needs Assessment

The present study evaluated the needs of Taiwanese universities in terms of HIV/AIDS education at school. Data indicated that slightly more than half (56.9%) of universities had an extra curricular HIV/AIDS prevention program, which is encouraging but not enough. We believe that every university should have an extra curricular program that could be more attractive for students than an in-curricular one since HIV/AIDS topic is a sensitive one.

Among universities with extra curricular programs, Students Associations were found to run these programs in only 34.8% of cases. Students should be encouraged to take more active part in their own sexual education. Peers education has been proved to be more effective in HIV/AIDS prevention worldwide. Even though, the bulk of universities had IEC material, they expressed a need for its replenishment. More over some of them lacked of any material. The quest for funds stressed by most of the respondents suggests that universities may not have enough money for HIV/AIDS prevention program at their disposal if any. Many respondents asked for NGOs and PLWHIV assistance. This may be an expression of a need for more competences from outside the campus to assist students council personal to deal with AIDS issues at school.

Taiwan has regulation for the management of students infected by a legally reported disease at schools. But when universities were asked whether they have such a regulation, 81.1% of respondents said No. Some talked about severe diseases, or

 45 Diseases affecting Public Health and others mentioned Untreatable diseases. So, obviously there is a confusion of terms pertaining to the regulation which suggest a need for the Ministry of Education to elaborate a clear Standard Regulation for HIV/AIDS case management for all the country universities. Furthermore, when we checked in the universities websites we found that 83.7% of universities against 18.9% determined by the questionnaire actually possessed regulation for management of legally reported diseases. This may mean that some universities either dont consider HIV/AIDS as a legally reported disease or simply ignore the existence of regulation.

The study revealed a certain lack of knowledge about HIV/AIDS among students council authorities. That may explain the fact that 9.1% of respondents stated they will ask HIV+ student to leave school temporally, yet Aids is an incurable disease; 5.5% said they will expulse student from the school dormitory, wile other 0.9% students council responsible declared that they will ban student to attend school restaurant or ask him to quit school.

Students council authorities enumerated the type of information they think students in general would be interested in ranged from assertiveness (88.1%), living with AIDS (82.5%), caring for the infected person (54.8%), to outreach program only (15.9%). W e believe that more interest should be put in outreach program because of it effectiveness. Therefore, we will recommend more attention to assertiveness, outreach program, living with AIDS than spending energy for AIDS care which is much more a technical issue difficult to manipulate at community level. Also, this may indicate a misinformation

 46 concerning a cure for AIDS. This is consistent with the findings of Agrawal et al, and can be attributed to the many false claims published in media and other mode of advertisement.

16.1% of universities though themselves not ready to provide HIV/AIDS counseling to students. This may be explained by the relative lack competences and material mentioned above, or by the insufficiency in funding HIV/AIDS education activities within schools. We believe that a training program on AIDS for students council authorities will make them more competent to assist students Association in turn.

In our findings, one responsible for students council would not like to make any personal contribution to HIV/AIDS prevention. This is surprising and may indicate either his lack of knowledge about HIV/AIDS phenomenon, or he has just a negative attitude towards those infected by the disease. The two combined give a signal for sensitizing such students authority, who was supposed to have more positive attitude in order to assist his students.

Most suggestions made on HIV/AIDS activities at schools converged to promotion of HIV+ students rights, safe sex education particularly for homosexuals, fight against stigma, and empowerment of girls-students to face temptation for prostitution. This may indicate the most common issues students council authorities meet when dealing with HIV infected student and need to be taken into account in the school HIV/AIDS education agenda.

 47

5.3 Study constraints

First, the research team was not able to collect the data in all universities on its own. School Military office helped us to collect most of the data. This may have influenced the students acceptance to fill in the questionnaire resulting in a very high response rate. Second, because of the self-report nature of the questionnaire, the honesty of respondents answers should be questioned. However, the questionnaire was anonymous and only informed consent students participated to study, which should have encouraged accurate and fair disclosure. Third, no action was taken to catch up students who were absent in the classroom on the day of the survey, which could have improved far much the response rate even though high. Fourth, we did not use a random sampling method.

5.4 Conclusion
Overall we saw that the mean knowledge score was high with statistically significant gender and school sensitivity. Students had a relatively positive attitude towards HIV/AIDS despite signs of fears. Overwhelming majority of them (90%) were sexually inexperienced. Those sexually active were using condom inconsistently. Drugs use was not common among students since only 157 (1.3%) were involved in. correlation was found between knowledge level and safe practice behavior. no

 48

5.5 Recommendations
The recommendations are in tree folds based on our results: A) At policy level The current sexual education policy in Taiwan is good and should be strengthened since it starts around age 13. Ministry of Education of Taiwan should include HIV/AIDS Education as an integral part of high school and university curriculum. In addition a standard clear Regulation for management of HIV+ students at school should be elaborated by MOE. This is actually underway after the results of the HIV/AIDS Needs Assessments section were presented to AIDS Education Committee of Ministry of

Education of Taiwan during last AIDS day in December 2004. All the universities have been instructed to review the existing regulation. Next December 2005 will be the checking point. B) Recommendations related to Health Education According to our findings, students should be instructed about all aspects of HIV/AIDS at junior and senior high school level so that they can be well equipped with HIV/AIDS knowledge before getting into sexual life. Starting point will be age 11, 12. C) Further research HIV/AIDS prevention needs assessment at senior high school from students perspectives. Determinants of knowledge and behavior gap among students in technological universities. Similar study will be conducted in Burkina Faso my home country for comparison if resources are provided.

 49

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Amalraj ER. First year medical students AIDS Knowledge and attitude. Indian Journal of Community Medicine. 1995 Jul-Dec; 20(1-4): 36-0

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Antunes MC. Differences in AIDS prevention among young men and women of public schools in Brazil. Rev Saude Publica. 2002 Aug; 36(4 Suppl):88-95.

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Atulomah NO. Knowledge, perception and practice with regards to occupational risks of HIV/AIDS among nursing and midwifery students in Ibadan, Nigeria. Afr J Med Sci. 2002 Sep;31(3):223-7.

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Babikian T. An Assessment of HIV/AIDS Risk in Higher Education Students in Yerevan, Armenia. AIDS and Behavior 61(15) March 2004, vol. 8, no. 1, pp. 47-

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Braithwaite. HIV/AIDS knowledge, attitudes, and risk-behaviors among African-American and Caribbean college women. International Journal for the Advancement of Counselling. 23(2):115-129, June 2001

8. Buskin. HIV/AIDS Knowledge and Attitudes in Chinese Medical Professionals and Students before and after an Informational Lecture on HIV/AIDS. Journal of Public Health Management & Practice. 8(6):38-43, November 2002.

 50 9. Caron F. Evaluation of a theoretically based AIDS/STD peer education program on postponing sexual intercourse and on condom use among adolescents attending high school. Health Educ Res. 2004 Apr; 19(2):185-97. Related Articles, Links 10. Chen YM. A survey of knowledge, attitudes and practices (KAP) concerning AIDS among female sex workers from massage parlors in Taiwan. Chin J Public Health (Taipei), 16:37-51, 1997. 11. Cheryl Fraser. "The impact of an undergraduate HIV/AIDS education course on students' AIDS knowledge, attitudes and sexual risk behavior," 12. Fethi Tebourski. Knowledge and attitudes of high school students regarding HIV/AIDS in Tunisia: does more knowledge lead to more positive attitudes? J Adolesc Health. 2004 Mar;34(3):161-2. 13. Fierros-Gonzalez R. High risk behaviors in a sample of Mexican-American college students. Psychol Rep. 2002 Feb;90(1):117-30. 14. Gray, L. A. Knowledge, attitudes, and beliefs about HIV/AIDS among Hindu students from a government women's college of South India. International Journal for the Advancement of Counseling. 21(3):207-219, September 1999. 15. Gupta S. India. Assessment of knowledge, attitude and practices (KAP) among college students about AIDS in Delhi. Health and Population- Perspectives and Issues. 1997 Oct-Dec; 20(4): 177-90 16. Gurman T. Condom use among Latino College students. J Am Coll Health. 2004 Jan-Feb; 52(4):169-78.

 51 17. Harding AK. Nigerian university students' knowledge, perceptions, and

behaviors about HIV/AIDS: are these students at risk? J R Soc Health. 1999 Mar; 119(1):23-31. 18. James S. Young people, HIV/AIDS/STIs and sexuality in South Africa: the gap between awareness and behavior. Acta Paediatr. 2004 Feb; 93(2):264-9. . 19. La Torre G. Knowledge, attitudes, and practices regarding sexually transmitted diseases among students in 3 high schools in Cassino. Ann Ig. 2002 MayJun;14(3):233-42 20. Li X. HIV/AIDS knowledge and the implications for health promotion programs among Chinese college students: Health Promotion International Vol. 19. No 3. 21. MERAKOU, KOULA. Knowledge, attitudes and behavior after 15 years of HIV/AIDS prevention in schools. European Journal of Public Health. 12(2):90-93, June 2002. 22. Milleliri JM. Sensitization about condom use in Gabon (1999): evaluation of the impact of a comic book. Sante. 2003 Oct-Dec; 13(4):253-64. 23. Netting NS. Twenty years of student sexual behavior: subcultural adaptations to a changing health environment. Department of Sociology, Okanagan University College, 3333 College Way, Kelowna, British Columbia, V1V 1V7, Canada. nnetting@ouc.bc.ca 24. Nwokocha AR. Knowledge, attitude, and behavior of secondary (high) school students concerning HIV/AIDS in Enugu, Nigeria, in the year 2000. PubMed.

 52 25. Peltzer K et al. Attitudes towards HIV-antibody testing and people with aids among university students in India, South Africa and United States. Indian J Med Sci. 2004 Mar;58 (3):95-108. 26. Sekirime WK. Knowledge, attitude and practice about sexually transmitted diseases among university students in Kampala. Afr Health Sci. 2001 Aug; 1(1):16-22. 27. Sevim Savaser. Knowledge and Attitudes of High School Students about AIDS: A Turkish Perspective. Public Health Nursing 28. Volume 20 Issue 1 Page 71 - January 2003. Shapiro. SEXUAL BEHAVIOR AND AIDS-RELATED KNOWLEDGE AMONG COMMUNITY COLLEGE STUDENTS IN ORANGE COUNTY, CALIFORNIA. Journal of Community Health. 24(1):29-43, February 1999. 29. Smith LA. Partner influence on noncondom use: gender and ethnic differences. J Sex Res. 2003 Nov;40(4):346-50. 30. Tapia-Aguirre V. Associations among condom use, sexual behavior, and knowledge about HIV/AIDS. Archives of Medical Research 35 (2004) 334-343. 31. Taylor M. Understanding high school students' risk behaviors to help reduce the HIV/AIDS epidemic in KwaZulu-Natal, South Africa. J Sch Health. 2003 Mar; 73(3):97-100. 32. Trajman A. Knowledge about STD/AIDS and sexual behavior among high school students in Rio de Janeiro, Brazil. Cad Saude Publica. 2003 Jan-Feb; 19(1):127-33. Epub 2003 Apr 01. 33. UNAIDS annual report 2002

 53 34. UNAIDS annual report 2003 35. Uwakwe CB. Systematized HIV/AIDS education for student nurses at the University of Ibadan, Nigeria: impact on knowledge, attitudes and compliance with universal precautions. J Adv Nurs. 2000 Aug; 32(2):416-24. 36. Yayeh Negash. A community based study on knowledge, attitude and practice (KAP) on HIV/AIDS in Gambella town, Western Ethiopia. Ethiop. J.Health Dev.2003;17(3):205-213. 37. Zhang H. Perceptions and attitudes regarding sex and condom use among Chinese college students: a qualitative study. AIDS Behav. 2004 Jun; 8(2):10517.

 54

List of Tables Table 1. Records of 1st year students academic year 2004/2005 of selected Universities
Name of University Number of 1st year students per gender 2004/2005 Male Female Total 852 774 835 166 1128 2309 216 470 690 7440 453 440 338 177 1594 2414 505 920 133 6448 1305 1214 1173 343 2722 4723 721 1390 823 14414 Total all undergraduates Study participants distribution school
Frequency Percent Response rate

Type of University

National Central University National Tsing Hua University National Chiao Tung University National Yang Ming University Soochow University Chinese Culture University National Taipei Teacher University Yu Da University Tung Nan University Total

5428 5065 4786 1816 11675 21808 2877 5929 2144 61528

1171 1096 767 343 1530 4319 680 1310 631 11847

9.9 9.3 6.5 2.9 12.9 36.5 5.7 11.1 5.3 100.0

89.7 90.2 65.4 100 56.2 91.4 94.3 94.2 76.7 82.2

Public Public Public Public Private Private Professional Teacher Professional technological Professional technological

 55

Table 2. knowledge score of respondents by gender

Knowledge questions 1. HIV means Human Immunodeficiency Virus Human Imaginary Vision 2. AIDS means: Active Infectious Disease Surveillance Acquired Immuno-Deficiency Syndrome 3. AIDS is a threat for Taiwanese 4. Most of the people who transmit the AIDS virus look unhealthy. 5. STI (Sexual Transmitted Infection) infected people are at risk for contracting AIDS virus. 6. Anal intercourse is high risk for transmitting the AIDS virus. 7. Oral intercourse carries risk for AIDS virus transmission. 8. AIDS virus may be transmitted through mosquitoes bites. 9. HIV- positive mothers may transmit the virus to her child 10. Sharing the same public facilities (toilets, dormitory, restaurant etc.) with AIDS infected student exposes to AIDS virus. 11. A person can be exposed to the AIDS virus in one sexual contact. 12. Keeping in good physical condition is the best way to prevent exposure to the AIDS virus. % choosing correct answer Male Female 88.9 91.2 63 81.5 82.0 72.4 89.2 63.0 77.6 93.7 93.0 98.3 73.7 63.6 76.7 85.6 81.7 89.6 63.4 75.4 94.8 95.2 98.1 72.6 total 90.0 63.3 79.1 83.7 76.9 89.4 63.2 76.5 94.2 94.1 98.2 73.1 P-value .001 .001 .001 .001 .001 .488 .586 .006 .015 .001 .603 .163

 56

Table 2. knowledge score of respondents by gender (continued)

Knowledge questions % choosing correct answer total 92.4 84.6 96.4 90.8 96.6 95.7 98.2 83.4 90.5 94.6 99.0 83.1 96.6 P-value .001 .002 .000 .004 .001 .224 .001 .008 .001 .001 .001 .001 .001

Male Female 13. It is unwise to touch a person with AIDS. 90.4 94.5 14. Condoms make intercourse completely safe. 83.6 85.6 15. When people become sexually exclusive with 94.9 97.9 one another, they no longer need to follow safe sex guidelines. 16. HIV can be detected by blood text. 90.1 91.6 17. Most people who have been exposed to the 95.9 97.4 AIDS virus quickly show symptoms of serious illness. 18. By reducing the number of different sexual 95.9 95.5 partners and using condom, you are effectively protected from AIDS. 19. Female-to-male transmission of the AIDS 97.5 99.0 virus has not been transmitted. 20. Sharing toothbrushes and razors can transmit 84.3 82.5 the AIDS virus. 21. AIDS causes death. 86.1 95.0 22. The chances of contracting AIDS can be 95.2 93.9 significantly reduced by using a condom. 23. Condom may be used several times. 98.3 99.6 24. The chances of contracting AIDS are low by 84.5 81.7 having sex with only one partner. 25. I can get AIDS even if I am only having sex 95.6 96.9 with one partner.

 57

Table 3. knowledge score by school

Knowledge questions K1 K2 K3 K4 K5 K6 K7 K8 K9 K10 K11 K12 K13 K14 K15 K16 K17 K18 K19 K20 K21 K22 K23 K24 K25 Correct answer 1 2 True False True True True False True False True False False False False True False True False True True True False True True % choosing correct answers per school T 98.4 89.9 80.8 83.5 71.6 90.8 60.5 81.9 93.1 95.9 98.8 75.5 93.4 89.0 95.3 87.4 96.3 95.9 96.9 79.3 85.9 94.3 97.4 83.2 97.4 Y 99.7 90.4 77.1 84.4 63.0 94.4 59.1 88.6 96.8 99.7 98.8 85.1 96.8 87.7 98.5 83.0 99.4 96.2 98.8 79.2 88.3 95.0 98.8 84.8 98.5 CT 99.2 90.4 80.2 85.6 65.0 92.5 62.7 83.1 95.3 97.2 98.7 72.4 95.1 88.6 96.6 89.3 98.2 97.6 98.3 79.5 84.0 96.2 98.7 87.1 97.5 CU 97.4 81.4 79.7 84.4 71.3 90.3 64.9 80.6 94.9 95.1 98.5 77.3 94.2 86.7 95.9 87.7 97.3 97.2 98.3 84.0 85.6 95.7 98.6 85.4 96.6 TT 97.0 70.9 78.3 86.4 75.6 91.3 67.2 77.5 94.0 96.2 97.3 73.4 94.8 86.0 97.5 90.3 99.0 97.0 99.1 81.0 89.2 94.2 99.3 83.6 97.2 S 96.6 69.0 75.2 85.3 78.0 90.0 63.7 78.3 94.6 96.8 99.2 73.9 95.5 87.6 97.9 89.9 98.8 96.2 99.0 83.1 91.4 94.2 99.3 83.5 97.3 C 89.9 48.3 77.6 84.3 78.7 89.3 62.4 76.8 94.3 95.2 98.4 73.5 93.2 84.3 96.6 91.9 97.0 95.1 98.5 84.3 91.9 94.0 99.2 83.2 96.1 TN 67.8 37.5 84.0 77.3 85.5 86.3 65.9 66.8 92.9 84.9 97.9 64.3 84.1 72.7 93.0 95.1 92.1 94.3 96.7 86.3 93.3 95.2 98.9 79.2 92.5 YD 67.0 35.7 85.0 80.1 86.4 84.4 64.1 62.7 93.4 85.1 95.4 67.1 83.6 77.9 95.2 94.8 91.5 94.3 97.5 86.7 95.9 94.4 99.3 79.0 93.9 Total 90.0 61.5 79.1 83.7 76.9 89.4 63.2 76.5 94.2 94.1 98.2 73.2 92.4 84.5 96.3 90.8 96.6 95.7 98.2 83.4 90.4 94.5 98.9 83.1 96.2 P-value .001 .001 .001 .001 .001 .001 .043 .001 .098 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .229 .001 .001 .001

 58

Table 4. Attitude score of respondents towards HIV/AIDS

Answer options in % Attitude questions 1. There is no need for the average person to become concerned about AIDS. 2. The names of individuals with AIDS should be kept confidential in order to protect them against discrimination. 3. There is no need for a girl to learn how to wear a condom. 4. If I get AIDS I will avoid transmitting the disease. 5. More government funds should be spent on providing support services for people with AIDS. 6. I would avoid having contact with persons who have AIDS. 7. I would feel embarrassed if one of my family members had AIDS. 8. I would immediately go to visit a doctor if I get a Sexual transmitted Infection 9. It is important to exercise safety precautions in ones sex behavior in order to prevent AIDS. 10. Students with AIDS should be allowed to attend school with students who dont have AIDS. 11. I would rather have any cancer than AIDS 12. If a condom is not available during sexual intercourse it should be wise to avoid penetration 13. It is embarrassing (to me) to buy condoms. 14. I am afraid I might contract AIDS. SA
2.0

A
8.2

SD

17.4 47.0 25.0

25.1 39.0 19.7 11.6 4.2

1.0

1.5

8.3 6.9

44.0 44.5 2.9 1.2 1.8 1.0

41.7 46.3

46.4 39.8 11.2

12.0 30.9 36.9 15.3 4.6 2.9 10.7 25.0 37.8 23.1 6.3 3.4 .6 .5 .4 .5

51.0 41.4 66.6 28.7

30.9 39.2 19.0

7.4

3.1

11.0 18.0 47.2 12.7 10.4 8.9 4.4 23.6 39.9 16.6 10.2 21.8 33.4 25.8 14.3

22.9 27.1 23.6 12.2 13.8 .9 10.6 33.5 53.6

15. Using a condom seems like an insult to my partner. 1.1

 59

Table 5: Source of information about HIV/AIDS

Source of information about HIV/AIDS At school Television Print Internet Doctor Friends Other

Count data 9658 8930 6558 5450 5352 3000 211

frequencies 81.5% 75.4% 55.4% 46.0% 45.2% 25.3% 1.8%

 60

Table 6: Condom use patterns

Frequency of condom use Every time > 50% < 50% Never

Percentage 30.9% 34.8% 21.8% 16.4%

 61

Table 7: Drugs used by students

Drug name MDMA Ketamine PCP superglue Magic mushroom FM2 Amphetamine Secobarbital Lysergic acid GHB cocaine Opium/Heroin Pentazocine Other Total Number of users 100 89 13 18 25 21 17 11 17 14 13 13 9 18 157 Percentage (63.7%) (56.7%) (8.5%) (11.7%) (16.1%) (13.7%) (11.1%) (7.2%) (11.1%) (9.2%) (8.5%) (8.5%) (5.9%) (11.7%) 1.3%

 62

Table 8: HIV/AIDS Prevention Needs Assessment at schools (1)

. Variable 1. Is there any extra curricular formal HIV/AIDS prevention program for students in your universityincluding student society? Yes No 3. What material resources are available in your university for HIV/AIDS prevention activities? NO YES 3.1. What kind of material IEC material (condoms, pamphlet, booklet) N=128 %

70/123 53/123 3/124 121/124 109/121

56.9 43.1 2.4 97.6 90.1 85.1

Audio visual material (DVD player, Video player, Video 103/121 cassettes on HIV/AIDS) 5. Is there any regulation within your university for the management of HIV/AIDS infected students as a legally reported disease? Yes NO Universities have regulation on communicable diseases.( Data review) Yes No IF student is infected with communicable disease, what will you do with him University asks student to leave school University asks student to leave dormitory Assist the student

23/122 99/122

18.9 81.1

103/123 20/123

83.7 16.3

101/123 8/123 3/123

82.1 6.5 2.4

 63

Table 8: HIV/AIDS Prevention Needs Assessment at schools (2)

Variable 6. Is there any student that has been HIV infected in your University? Yes No 6.1 If yes what has been done for his management? Student temporally leaves school Student leaves school by himself University asks student to leave school temporally University asks student to quit school Expulsed from the dormitory Forbidden to attend university restaurant Gets particular assistance from the university. If so, please specify 6.2 If not, what will be done in your university if student get infection by HIV/AIDS? Student temporally leaves school Student temporally leaves school University asks student to leave school temporally University asks student to quit school Expulsed from the dormitory Forbidden to attend university restaurant Gets particular assistance from the university. If so, please specify N=128 %

6/124 118/124 0/6 0/6 0/6 0/6 0/6 0/6 6/6 7/110 5/110 10/110 1/110 6/110 1/110 88/110

4.8 95.2 0 0 0 0 0 0 100 6.4 4.5 9.1 0.9 5.5 0.9 80.0

 64

Table 8: HIV/AIDS Prevention Needs Assessment at schools (3)

Variable 7. Do you think it is important to educate students about HIV/AIDS? Yes No 7.2.1 If yes, what kind of information about HIV/AIDS would student in general is interested in? Please tick the most important aspects (no more than 3) How to say no (assertiveness)? Living with HIV/AIDS Caring for the infected person Outreach ( helping in the community) 8. Is your university ready to provide HIV/AIDS counseling to students? Yes No 9. Would you like to make any personal help to HIV/AIDS prevention? Yes No 10. Have you experienced with a case of HIV infected student in your university? Yes No N=128 % 100 0

127/127 0/127

111/126 104/126 69/126 20/126

88.1 82.5 54.8 15.9

104/124 20/124 125/126 1/126 2/126 124/126

83.9 16.1 99.2 0.8 1.6 98.4

1000

1500

2000

2500

3000

500 1940 1116 663 589

Numbe r 3458 3500

List of figures

The dis tribution of pa rticipa nts pe r country a re a s

Figure 1. Distribution of study participant by country areas

408 407 327 302 291 260 232 195 185 181 178 139 123 112 99 75 60 33 31 9

65

Ta i Ta pei C ip Ta ei C ity oy ua oun ty n Ta C o ic un h t Ka ung y oh C i H siun ty s in g Ci Ta c hu t Co y ic hu u ng nty C ou Ch Tai nty a n nan gh ua C ity C o Y ila unt y n M Co ia o unt Ta li C y in oun an ty Ch C o u ia yi nty C Y un ou lin nty K C ou e K ao e lu nty hs ng iu ng City Co H u s Pi inc nty ng hu tu n Ci H g C ty ua o lie unt y N nC an ou ti n T a u C ty itu ou ng nty Ch Co ia unt Pe yi C y ng ou h n K u C ty in o Li me unt en y n ch Co ia u ng nty C ou nt y

City

 66

Gender of respondent: 1 Male, 2 Female.

Missing .7%

2 48.6%

1 50.7%

Figure 2: Distribution of study participants by gender

 67

Range: 15-39
7000 6000 5000 4000 3000 2000 1000 0 15.0 17.5 20.0 22.5 25.0 27.5 30.0 32.5 35.0 37.5 40.0 Std. Dev = 1.11 Mean = 18.7 N = 11720.00

Frequency

AGE2

Figure 3: Age distribution of study participants

 68

6000

6000

5000

5000

4000

4000

3000

3000

2000

2000

Frequency

F re q u e n c y

1000

1000

0 1 2 3 4 5

0 1 2 3 4 5

Father

Mother

Figure 4: Level of father and mothers education

 69

Histogram
6000

5000

4000

3000

2000

F re q u e n cy

1000 0 0.0 2.5 5.0 7.5 10.0 12.5 15.0 17.5 20.0 22.5 25.0

Std. Dev = 2.14 Mean = 21.7 N = 11847.00

Knowledge score

Figure 5: Knowledge score

 70

M E A n k n o w l e d g e s c o r

22.2 22.0 21.8 21.6 21.4 21.2 21.0 1 2 3 4 5 Father Mother

Education level: 1. Primary school, 2.Junior high school, 3.Senior high school, 4.University, 5. Graduate Institute

Figure 6: Mean knowledge score vs. level of father and mothers education

 71

22.0 21.8
Mean knowledge

21.6 21.4 21.2 21.0

F_ Hi gh &M _H ig h F_ Lo w &M _H ig h F_ Hi gh &M _L ow F_ Lo w &M _L ow
ANOVA Test p <.0001 Difference between groups: F_low & M_low vs F_high &M_high F_low & M_high vs F_high &M_high

Figure 7: Mean Knowledge score vs. level of parents education combined.

 72

Histogram
5000

4000

3000

2000

Frequency

1000

Std. Dev = 5.17 Mean = 56.2 N = 11847.00 20.0 25.0 30.0 35.0 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0

Attitude score

Figure 8: Attitude score of respondents

 73

M E A n a t t i t u d e s c o r e

56.4 56.3 56.2 56.1 56.0 55.9 55.8 1 2 3 4 5 Father Mother

Education level: 1. Primary school, 2.Junior high school, 3.Senior high school, 4.University, 5. Graduate Institute

Figure 9: Mean Attitude score vs. level of father and mothers education

 74

56.5

56.4

56.3

Mean of Attitude score

56.2

56.1

56.0 F_Low and M_Low F_high and M_Low F_High and M_High F_Low and M_High

Level of Father and Mothers education

Figure 10: Attitude vs. level parents education combined

 75

57.0

1. Y
56.5

2. CU 3. T 4. CT

56.0

Mean of Attitude score

5. TT 6. S
55.5

7. C 8. YD 9. TN

55.0 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00

SCHOOLG

Figure 11: Mean attitude score vs. schools

 76

70 .00
A

60 .00

Attitude score

A A A A

50 .00
A A

40 .00

A AA AA A A AA A AA A A A A A A AA A A A A A A AA A A A A A A A AA A A A A A A AA A A A A AA A AA A A A AA A A A A A A AA A A A A A A AA AA AA AA AA AA AA A AAA AA AA AA AA A A A A AA A AA AA A A A AA A AA A AA A A A AA AA A AA A AA A AA AA A A A A AA A A AA A AA A A AA AA AA A AA AA AA AA AA A AA AA A AA A A A A AA AA A AA AA AA A AA A AA A AA A A A A A A A AA A A AA A AA AA AA AA AA A A A A A A AA AA AA AA A AA A AA AA AAA A A A AA A A AA AA A AA AA A ttitude score = 48.47 + 0.35 *A know_sco AA A A A AA AA AA AA AA A A A AA A A A A A A AA A AA A AA AA AA AA A AA AA AA A A A A AA A AA A A Aquare = 0.02 R-S A AA AAA AA A AA A AA A A AA AA A AA A A AA A AA A AA A AA A AA A AA A AA A AA A A A A A A A A AA A AA A A A A A A A AA A AA A A A A A A A A AA A AA A AA A AA A A A A A A A AA AA AA A A A A A A A A A AA A A A A AAA A A A A AA A A A A A AA A A A AA A A A AA A AA A A A A A A

Linear R egression

30 .00

20 .00 0.00 10.00

20 .00

Knowledge score

Pearson correlation : 0.147; p < 0.001

Figure 12: Relationship between knowledge and attitude

 77

80

70

60

50

Pearson correlation: M ale:0.182 P< 0.001 Fem ale: 0 .074 P< 0.001

40

Attitude score

30 F em ale 20 -10 0 10 20 30 M ale

Know ledge score

Figure 13: knowledge and attitude vs. gender

 78

100 80 PERCENTAGE 60 40 20 0

93.3

0.05 Heterosexual Hom osexual

1.1 bisexual

3.8 Undecided

Figure 14: Students sexual orientation

 79

num ber 400 350 300

363 f em al e 292 251 m al e t ot al 179

250 200 150 100 50 0 11 female male total 1 0 1 12 1 3 4 13 3 1 4 14 8 21 29 15 21 58 80 16 55 129 186 17 109 251 363 18 111 179 292 19 30 45 76 20 8 32 41 21 0 5 5 186 129 109 80 58 55 29 21 21 1 0 1 13 4 3 1 4 8

111 76 45 30 41 32 8 0 5 5 04 4 0 1 1 01 1 0 1 1 22 0 4 4 23 0 1 1 24 0 1 1 28 0 1 1

91

missin g

91

age at f i r st sex i nt er cour se per gender

Figure 15: Age at first sexual intercourse

 80

35.0 30.0 25.0 20.0 % 15.0 10.0 5.0 0.0 1 2 3 4 5 6 7 8 9 M F

1. Y 2. CU 3. T 4. CT 5. TT 6. S 7. C 8. YD 9. TN X2 test, P< 0.001 M X2 test, P< 0.001 F

Schools

Figure 16: sexual experience vs. school

 81

35 30 25 20 15 10 5 0 Every time 30.9

34.8

21.8 16.4

>50%

<50%

Never

Figure 17: Condom use patterns

 82

0.6% 18.5% male female missing

80.9%

Figure 18: Distribution of drugs users by gender

 83

4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0%

%
3.4%

2.1% 1.5% 1.0% 0.6% 0.3% 0.3% 1.0% 1.2%

C U

C T

TT

TN

Y D school

Pearson x2 = 63. 210 P< 0.001

Figure 19: Distribution of drugs users by school

 84

Appendix

KAP questionnaire
Survey on knowledge, attitude and practice of Taiwanese universities students to HIV/AIDS supported by the Ministry of Education Informed Consent
Dear Student, This survey is in the process of improving HIV/AIDS programs so that these are relevant, and to the benefit of the entire student body. Your input is very crucial in helping us attain this goal. There three parts in this questionnaire including HIV/AIDS Knowledge, HIV/AIDS Health Attitude, and HIV/AIDS Practice. It should take about 20 minutes of your time. Please complete this anonymous questionnaire. Thank you very much. Institute of Public Health National Yang-Ming University
------------------------------------------------------------------------------------------------------------

Demographics
Todays date: year/month/day: 2004 Name of the university: Department of study: Name of the Senior high school: Age: . Year . . Where your Senior high school: . . .

Gender: Male Female

 85 Education of your father: Primary school Junior high school Senior high school University Institute Education of your mother: Primary school Junior high school Senior high school University Institute

HIV/AIDS Health Knowledge

There 25 questions about HIV/AIDS knowledge in this part, please choose the correct answers. Thank you.

1. HIV means Human Immunodeficiency Virus Human Imaginary Vision 2. AIDS means: Active Infectious Disease Surveillance Acquired Immuno-Deficiency Syndrome True False 3. AIDS is a threat for Taiwanese 4. Most of the people who transmit the AIDS virus look unhealthy. 5. STI (Sexual Transmitted Infection) infected people are at risk for contracting AIDS virus. 6. Anal intercourse is high risk for transmitting the AIDS virus. 7. Oral intercourse carries risk for AIDS virus transmission. 8. AIDS virus may be transmitted through mosquitoes bites. 9. HIV- positive mothers may transmit the virus to her child 10. Sharing the same public facilities (toilets, dormitory, restaurant etc.) with AIDS infected student exposes to AIDS virus. 11. A person can be exposed to the AIDS virus in one sexual contact. 12. Keeping in good physical condition is the best way to prevent exposure to the AIDS virus. 13. It is unwise to touch a person with AIDS. 14. Condoms make intercourse completely safe. 15. When people become sexually exclusive with one another, they no longer need to follow safe sex guidelines. 16. HIV can be detected by blood text. 17. Most people who have been exposed to the AIDS virus quickly show symptoms of serious illness. 18. By reducing the number of different sexual partners and using condom, you are effectively protected from AIDS. 19. Female-to-male transmission of the AIDS virus has not been transmitted. 20. Sharing toothbrushes and razors can transmit the AIDS virus.

 86 21. AIDS causes death. 22. The chances of contracting AIDS can be significantly reduced by using a condom. 23. Condom may be used several times. 24. The chances of contracting AIDS are low by having sex with only one partner. 25. I can get AIDS even if I am only having sex with one partner.

 87

HIV/AIDS Health Attitude

There 15 questions about HIV/AIDS health attitude in this part. Please respond the following items on a 5-category rating scale. Choose the appropriate rating following each item to indicate your response. Use the key below when selecting your ratings: SA = Strongly Agree, A = Agree, N = Neutral, D = Disagree, SD = Strongly Disagree. SA A N D SD

1. 2.

There is no need for the average person to become concerned about AIDS.

The names of individuals with AIDS should be kept confidential in order to protect them against discrimination. 3. There is no need for a girl to learn how to wear a condom. 4. It is meant to be that I get AIDS there is nothing I can do to prevent getting the disease. 5. 6. 7. 8. More government funds should be spent on providing support services for people with AIDS. I would avoid having contact with persons who have AIDS. I would feel embarrassed if one of my family members had AIDS.

I would immediately go to visit a doctor if I get a Sexual transmitted Infection 9. It is important to exercise safety precautions in ones sex behavior in order to prevent AIDS. 10. 11. 12. 13. Students with AIDS should be allowed to attend school with students who dont have AIDS. I would rather have any cancer than AIDS If a condom is not available during sexual intercourse it should be wise to avoid penetration It is embarrassing (to me) to buy condoms.

 88 14. 15. I am afraid I might contract AIDS. Using a condom seems like an insult to my partner.

 89

HIV/AIDS Health Practice

There13 questions about HIV/AIDS practices in this part. Please answer the following questions.

1. Where do you get information about HIV/AIDS? Friends At school Internet Television Doctor, nurse Print Other, please specify 2. Sexual orientation? Heterosexual Homosexual Bisexual undecided/dont know

90 3. Did you have sexual intercourse? Yes. At which age did you have your first sexual intercourse? At .years old. I never have sexual intercourse. Please skip to question 7 4. Did you have sexual intercourse during the last 3 months? Yes No 5. How often do you use condom when having sexual intercourse? Every time 50% 50% Never 6. How many sexual partners do you have? One More than one. Total 7. Do you drink? Yes, Every

days/1 time. Never

8. Do you use Marijuana (Joint)? days/1 time. Never Yes, Every

91 9. What kind of drug have you even used? Superglue/ Organic solvent Amphetamine Secobarbital (Seconal)/ Amobarbital(Amytal)/ Methaqualone(Normi-Nox) FM2 (Flunitrazepam, RohypnolR)/ Diazepam (ValiumR)/ Triazolam/ Alprazolam (XanaxR) MDMA (3,4-Methylenedioxymethamphetamine) Phencyclidine (PCP, angle dust) Ketamine(Special K) Gamma Hydroxybutyrate (GHB) Lysergic Acid Diethylamide (LSD) Magic mushroomPsilocybine Cocaine HCl (Crack) Opium/ Morphine/ Heroin Pentazocine Other please specify . 10. How often do you use drug? Always Often Sometime Rarely 11. Where do you get the drugs? Family At school Pub Print KTV, MTV Friends Home party Drugstore TV or Radio Other please specify 12. How often do you inject drugs? Always Often Sometime Rarely 13. Had you ever share needle with other person? No One Two More than Two. Total . Never

Never

92

Needs assessment questionnaire

Needs Assessment questionnaire

(ONLY FOR THE RESPONSIBLE OF STUDENT COUNCIL)
The present questionnaire is complementary to the one designed for a study of knowledge, attitude and practices of Taiwanese universities students to HIV/AIDS. The purpose is to provide universities authorities and Ministry of Education with a overall picture of HIV/AIDS estimate situation among Taiwanese students. This will help to design further a proper knowledge-based HIV/AIDS prevention program for students as part of Taiwanese youth threaten by the pandemic.

Your assistance by filling this questionnaire will help reach the goal. Name of the UNIVERSITY Quality of the person who completed the questionnaire... . 1. Is there any extra curricular formal HIV/AIDS prevention program for students in your universityincluding student society?if not, skip to question 3 Yes 2. No

If yes, what is the structure (organization) responsible for it? Administrative structure Student societies involved in HIV/aids education

Please list down the name, addresses funding, and the subject matter of these organization.

93 3. What material resources are available in your university for HIV/AIDS prevention activities? IEC material (condoms, pamphlet, booklet) Audio visual material (DVD player, Video player, Video cassettes on HIV/AIDS) Other Please specify None 4. 5. What would be the needs of your organization on HIV/AIDS? Is there any regulation within your university for the management of HIV/AIDS infected students as a legally reported disease? Yes If yes it is written ? No Unwritten?

Please attach the regulation document. 6. Is there any student that has been HIV infected in your University? Yes No

6.1 If yes what has been done for his management? Student temporally leaves school University asks student to leave school temporally University asks student to quit school Expulsed from the dormitory

94 Forbidden to attend university restaurant Gets particular assistance from the university. If so, please specify .. 6.2 If not, what will be done in your university if student get infection by HIV/AIDS? Student temporally leaves school University asks student to leave school temporally University asks student to quit school Expulsed from the dormitory Forbidden to attend university restaurant Gets particular assistance from the university. If so, please specify -------------------------------------------------------------------------------------7. Do you think it is important to educate students about HIV/AIDS? Yes 7.1.1 If no, why? 7.1.2 If yes, what kind of information would STUDENTS IN GENERAL be interested in? Please tick the most important aspects (no more than 3) No

95 How to say no (assertiveness) Living with HIV/AIDS Caring for the infected person Outreach ( helping in the community) Other (state as many as possible)

96

97

HIV/AIDS 20

2004 / 3

98

HIV/AIDS
25 1. HIV Human Immunodeficiency Virus Human Imaginary Vision 2. AIDS Active Infectious Disease Surveillance Acquired Immuno-Deficiency Syndrom 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

99

15 5

13. 14. 15. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

100

13 1. HIV/AIDS

2. 3.

4. 5. > 50 < 50% 6. 7.

8.

101 9.

FM2 / Diazepam / Triazolam / Alprazolam MDMA (PCP) K GHB LSD 10. 11. PUB KTVMTV 12. 13.