AIDS Education and Prevention, 23(4), 341, 2011

2011 The Guilford Press

ZH AO ET AL.
CHILDREN IN RURAL CHINA

aids knowledge and hiV stigma

among children affected by hiV/aids
in rUral china
Qun Zhao, Xiaoming Li, Guoxiang Zhao, Junfeng Zhao,
Xiaoyi Fang, Xiuyun Lin, and Bonita Stanton

The current study was designed to assess the level of AIDS knowledge and
its relationship with personal stigma toward people living with HIV/AIDS
(PLWHA) among children living in communities of high HIV prevalence in
rural China. The data were collected in 2009 from 118 orphanage orphans
(children who had lost both of their parents to HIV and living in AIDS orphanages), 299 family-cared orphans (children who had lost one or both of
their parents to HIV and living with surviving parents or extended families),
326 vulnerable children (children who were living with HIV-infected alive
parents), and 276 comparison children (children from the same community who did not experience HIV-related illness and death in their family).
Children were asked to answer 20 questions of AIDS knowledge. A 10-item
stigma scale was employed to assess childrens own attitude toward PLWHA. Both bivariate and multivariate tests were performed to answer our
research questions. The data in the current study demonstrate a relatively
low percent of correct AIDS knowledge (60%) among samples. The comparison children reported the best score of AIDS knowledge and orphanage
orphans scored the lowest. The children with better AIDS knowledge have
less personal stigma toward PLWHA. The ndings in the current study suggest the need of appropriate education strategies to provide AIDS knowledge to children, particularly for HIV-affected children living in communities of high HIV prevalence in rural China.

Global literature has suggested that lack of correct knowledge of AIDS was often
associated with risk behavior initiation and stigmatization of the disease that presQun Zhao is with the School of Public Administration, Nanjing University of Information Science and
Technology, Nanjing, China. Qun Zhao, Xiaoming Li, and Bonita Stanton are with the Prevention Research Center, Carman and Ann Adams Department of Pediatrics, Wayne State University School of
Medicine, Detroit, MI. Xiaoming Li, Guoxiang Zhao, and Junfeng Zhao are with the Department of
Psychology, Henan University, Kaifeng, China. Xiaoyi Fang and Xiuyun Lin are with the Institute of
Developmental Psychology, Beijing Normal University, Beijing, China.
The study described in this report was supported by NIH Research Grant R01MH76488-4 by the National Institute of Mental Health and the National Institute of Nursing Research. The content is solely the
responsibility of the authors and does not necessarily represent the ofcial views of the National Institute
of Mental Health or the National Institute of Nursing Research.
Address correspondence to Xiaoming Li, PhD, Department of Psychology, Henan University, Kaifeng,
China; e-mail: xiaoming_li@wayne.edu

341

342

ZHAO ET AL.

ent serious barriers to young people in protecting themselves from HIV (Aggarwal,
Sharma, & Chhabra, 2000; Sullivan et al., 2010; Wu, Sullivan, Wang, RotheramBorus, & Detels, 2007). Although still controversial and complex about the relationship between AIDS knowledge and persons attitude and behavior change, research
in the United States and other Western countries has suggested that knowledge regarding AIDS is an important, albeit insufcient, factor for efcient HIV prevention
and intervention efforts (Ajzen, 1991; Fisher & Fisher, 1992).
Previous studies conducted in China suggested an inadequate level of AIDS
knowledge and awareness among adolescents and young adults (Albrektsson, Alm,
Tan, & Andersson, 2009; He & Ji, 2009; Li et al., 2010; Zhao, Li, Stanton, et al.,
2010). Some studies in China demonstrated the existence of stigma toward persons
living with HIV/AIDS (PLWHA), the positive association between HIV-related stigma, and psychopathological symptoms among PLWHA (Lin et al., 2010; Sullivan et
al., 2010; Zhao, Li, Fang, et al., 2010). However, to our knowledge, no quantitative
studies have been conducted in China to examine the level of AIDS knowledge and
its relationship with stigma among children who live in poverty-dense communities,
including those children affected by HIV/AIDS.
Many of the AIDS orphans (children who had lost one or both of their parents
to HIV) and vulnerable children (children who are living with HIV-infected alive
parents) in China known to the public are living in Henan Province, an agricultural
province in central China with a population of 96.66 million (Li, Fang, et al., 2009).
Some commercial blood stations/centers started collecting blood in remote rural areas of Henan province in the late 1980s. Because of extreme poverty, many farmers
sold their blood to blood centers that used unhygienic blood collection procedures,
resulting in a rapid spread of HIV (Cohen, 2004). Many of the infected people
have subsequently died, leaving their children orphaned (He & Ji, 2007; Zhao et
al., 2007). Since 2004, in response to the increased number of AIDS orphans, the
Chinese government has begun construction of AIDS orphanages in areas hardest
hit by AIDS and the rst of such AIDS orphanages was built in late 2004 in Henan
Province.
AIDS orphanages were set up to meet orphans basic needs: food, living quarters, medical care, and education (Zhao, Li, Kaljee, et al., 2009). The orphanages
were mainly funded by the local government or nongovernmental organizations.
Approximately 160 yuan (or about U.S.$20 in 2006-2007) was allocated to each
child per month. The children were admitted to the AIDS orphanages according
to three main informal criteria: (a) having lost both of their parents to AIDS, (b)
having no extended family members who were physically capable of taking care of
them, and (c) not being infected with HIV or other infectious diseases. The number of orphans in each orphanage in Henan Province ranged from 20 to 150. A
typical AIDS orphanage was operated in dormitory fashion with children living in
double-occupancy rooms and following a preestablished daily schedule for meals,
bedtime, entertainment (e.g., playing table tennis, board games, or watching TV),
and other activities. The administrators and caregivers in the orphanages were usually selected from the local community by village leaders. Because governmental
guidelines regarding the children-to-caregiver ratio were not established, there was a
wide variation in this ratio, ranging from 6 to 1 to 15 to 1. Some large orphanages
offered onsite classes for elementary school children; middle school and high school
children generally went to nearby village schools or public boarding schools for their
education.

CHILDREN IN RURAL CHINA

343

However, based on the experience of orphan care in Africa, many public health
workers and AIDS advocates do not think institutional care is the best care arrangement for orphans (China Central Television [CCTV], 2004; Gao, 2004). In
addition, because of limited budgets from local government to fund and operate
AIDS orphanages, the existing orphanages were not sufcient to accommodate all
the needy orphans in these areas. Therefore, some other double AIDS orphans and
almost all single AIDS orphans (i.e., children who lost one of their parents to HIV/
AIDS) were living in family-based care settings (family-cared orphans). Although
previous studies have suggested signicant differences by care arrangements in terms
of psychosocial adjustments and perceived better life improvement and reported
greater life satisfaction among children affected by HIV/AIDS, data are limited regarding whether HIV-related knowledge and attitudes also differ by child orphan
status and care arrangement. Therefore, the present study attempted to compare the
level of AIDS knowledge among orphanage orphans, family-cared orphans, vulnerable children, and comparison children and to assess the relationship between AIDS
knowledge and childrens personal stigma toward HIV-infected individuals and their
families.

methods
STUDY SITE AND PARTICIPANTS
The sample in the current study consisted of participants in the third annual assessment of a longitudinal study of psychosocial needs of children affected by AIDS
in China (Li, Barnett, et al., 2009). The larger study was conducted between 2005 to
2009 in two rural counties in central China where many residents were infected with
HIV through unhygienic blood collection. Both counties have the highest prevalence
of HIV infection in the area. Because of the space limitation of the assessment instrument, the AIDS knowledge items were only included in the third annual assessment.
The participants ( n = 1,019) in the third annual assessment include 118 orphanage
orphans, 299 family-cared orphans, 326 vulnerable children, and 276 comparison
children.

SAMPLING PROCEDURE
The detailed sampling and consenting procedure for the larger study was described elsewhere (Li, Barnett, et al., 2009). Briey, the orphanage sample was recruited from four government-funded orphanages in the two counties (two orphanages in each county). To recruit orphans and vulnerable children from the family or
kinship, we worked with the village leaders to generate lists of families caring for
orphans or with conrmed diagnosis of HIV/AIDS. We approached the families on
the lists and recruited one child per family to participate in the assessment. Once
the eligibility of a child was conrmed, the interviewers provided him/her with a
detailed description of the study design and potential benets and risks (including
condentiality issues) and invited him/her to participate. Written assent or oral assent (in case of illiteracy) was used for children between 13 and 18 years, and oral
assent were used for children between 9 and 12 years. When there were siblings in an
orphanage or household, only one child was randomly selected. Written or oral permission was obtained from caregivers/legal guardians who were available to provide
the consent for their childrens participation. The research protocol, including con-

344

ZHAO ET AL.

senting procedure, was approved by the institutional review boards at both Wayne
State University in the United States and Beijing Normal University in China.

SURVEY PROCEDURE
Each child was administered an assessment inventory. During the survey, necessary clarication or instruction was provided promptly when needed. The interviewers were well-trained education and psychology graduate students and teachers
from the local universities. The entire assessment inventory typically took 75
minutes to complete, depending on the age of the children. Each child received a gift
at completion of the assessment as a token of appreciation.

MEASURES
Demographic Characteristics. Children were asked to provide a number of individual characteristics during the survey. These characteristics include ethnicity, age,
gender, and academic marks in school (i.e., mostly As = 5, mostly Bs = 4, mostly Cs
= 3, mostly Ds = 2, and mostly
F = 1).
AIDS Knowledge. There were two sets of AIDS knowledge questions. The rst set
consisted of 10 true/false items assessing knowledge of AIDS symptoms and preventive measures (general knowledge). The second set was 10 possible/impossible
questions querying about modes of HIV transmission (transmission mode). A total
number of correct answers (i.e., correct = 1, incorrect = 0) was obtained as AIDS
knowledge score with higher score indicating more AIDS knowledge. The 20-item
scale has a Cronbachs alpha of .60 for the current study sample.
Personal Stigma Toward PLWHA. A 10-item scale was employed to assess childrens
own attitude toward HIV-infected individuals and their families. This scale was developed based on existing measures of HIV-related stigma in the literature (Berger,
Ferrans, & Lashley, 2001; Kalichman et al., 2005; Wright, Naar-King, Lam, Templin, & Frey, 2007). Children were asked with a 5-point response option (strongly
agree = 5, agree = 4, dont know = 3, disagree = 2, strongly disagree = 1) about
certain stigmatizing attitudes or actions toward PLWHA (e.g., A person infected
with HIV should be ashamed of herself/himself). A sum score was obtained for the
scale with a higher score indicating a higher level of personal stigma. The scale has
a Cronbachs alpha of .87 for the current study sample.

STATISTICAL ANALYSIS
Chi-square test (for categorical variables) and analysis of variance (ANOVA, for
continuous variables) were employed to examine the group differences of individual
characteristics, AIDS knowledge, and personal stigma among samples. To facilitate
group comparison on AIDS knowledge and personal stigma among samples, the age
were divided into two age groups
( >14 years) using the medium split, and the
14 vs.
stigma were divided into three approximately equal-proportion groups (i.e., high,
medium, and low). General linear model (GLM) analysis was used to assess the differences in AIDS knowledge by child group (i.e., orphanage orphans, family-cared
orphans, vulnerable children, and comparison children) while controlling for age (as
a continuous variable), gender, and academic marks. Finally, hierarchical multiple
regression analyses were performed to assess the associations of personal stigma
toward PLWHA with AIDS knowledge and other demographic factors (i.e., gender,

CHILDREN IN RURAL CHINA

345

TABLE 1. Demographic Characteristics of Study Sample

Variables n (%)
N (%)

overall

boys

girls

1,019(100)

497(48.8)

522(51.2)

Child group
Orphanage orphans

118(11.6)

72(14.5)

46(8.8)

Family cared orphans

299(29.3)

145(29.2)

154(29.5)

Vulnerable children

326 (32.0)

149(30.0)

117(33.9)

Comparison children

276(27.1)

131(26.4)

145(27.8)

Han ethnicity

951 (98.7)

467(98.3)

484(99.0)

14.11(2.03)

14.13(2.00)

14.09(2.06)

14

575(56.8)

285(57.8)

290(55.9)

>14

437(43.2)

208(42.2)

229(44.1)

Age (mean/SD)
Age group (years)

Academic marks
Mostly As

114(11.3)

53(10.8)

61(11.8)*

Mostly Bs

305(30.2)

136(27.6)

169(32.7)

Mostly Cs

313(31.0)

145(29.4)

168(32.5)

Mostly Ds

179(17.7)

99(20.1)

80(15.5)

99(9.8)

60(12.2)

39(7.5)

Mostly F
Note. * p < .05.

age, child group, and academic marks). The gender, age, child group, and academic
marks were rst entered into the regression model as one block, followed by AIDS
knowledge. Three dummy coding variables were created to index the comparison
among child groups with the comparison children being coded as the reference group
(i.e., DMV1 for orphanage orphans vs. comparison group, DMV2 for family-cared
orphans vs. comparison children, DMV3 for vulnerable children vs. comparison
children). All statistical analyses were performed using SPSS for Windows 17.0.

resUlts
SAMPLE CHARACTERISTICS
As shown in Table 1, the sample in the current study consisted of 497 boys (48.8%)
and 522 girls (51.2%). There were 118 (11.6%) orphanage orphans, 299 (29.3%)
family-cared orphans, 326 (32.0%) vulnerable children, and 276 (27.1%) comparison children in the current study. Almost the entire sample (98.7%) was of Han
ethnicity. The mean age for the sample was about 14 years (ranged 9 years).
More girls than boys reported mostly As in academic marks (11.8% vs. 10.8%,
p < .05).

AIDS KNOWLEDGE
As shown in Table 2, children responded correctly to 60.4% of the AIDS knowledge
questions. The lowest correct response rate (33.0%) was for the question Early
infection of HIV may not be found, and the one with the highest correct response
rate (76.2) was the question people can reduce the chance of HIV infection by not
sharing needles. Within the two sets there was substantial variation by item. For

346

ZHAO ET AL.
TABLE 2. AIDS Knowledge (% of Correct Answers)
gender
overall

male

female

general knowledge
Everyone can catch HIV. (true)

33.9

37.6

30.3**

Early infection of HIV may not be found. (true)

33.0

33.2

32.9

You can tell HIV infection by experience. (false)

73.8

72.0

75.6

AIDS patients can be cured if treated early. (false)

46.7

46.6

46.8

HIV can reduce the bodys natural protection against disease. (true) 67.3

68.6

66.0

AIDS patients usually die in a short period of time. (false)

75.2

74.4

76.0

There is no cure for AIDS at present. (true)

52.2

52.7

51.6

Using condoms can prevent HIV. (true)

64.1

68.0

60.3 **

A vaccine is available that protects a person from getting HIV. (false) 40.9

41.4

40.5

People can reduce the chance of HIV infection by not sharing

needles. (true)

76.2

76.3

76.2

Working/studying near someone with HIV (unlikely)

66.2

64.2

68.1

Share plates, fork or glasses (unlikely)

66.7

66.2

67.2

Sharing needles for drug use with someone who has HIV (likely)

63.3

61.8

64.8

Having sex with someone who has HIV (likely)

62.6

62.2

63.1

Using public swimming pool or public toilets (unlikely)

68.5

66.7

70.3

Being bitten by mosquitoes or other insects (unlikely)

53.4

52.0

54.8

Being coughed or sneezed on by someone who has HIV (unlikely)

63.1

62.9

63.2

Shaking hands with or hugging (unlikely)

72.7

72.7

72.6

Selling and drawing blood at unhygienic blood centers (likely)

66.4

65.1

67.6

Using blood or blood products with HIV (likely)

64.5

63.8

65.1

60.4

60.3

60.5

transmission mode

Full scale (20 items)

Note. ** p < .01.

example, correct responses ranged from 33.0% to 76.2% for general knowledge
and 53.4% to 72.7% for transmission mode. There was no difference in overall
AIDS knowledge by gender. However, more boys responded correctly in the items
Everyone can catch HIV ( p < .01), and using condoms can prevent HIV ( p <
.01).

GROUP DIFFERENCE OF AIDS KNOWLEDGE AND STIGMA

As shown in the left part of Table 3, the correct responses in overall AIDS knowledge
differed by childrens group (i.e., 11.25 for orphanage orphans, 11.95 for familycared orphans, 12.24 for vulnerable children, 12.41 for comparison children, p <
.05). There was a linear relationship between academic marks and AIDS knowledge
with the children reporting mostly As scoring the highest in AIDS knowledge ( p <
.0001). Older children reported better AIDS knowledge than younger children ( p <
.0001). There was a reverse linear relationship between AIDS knowledge and HIV
stigma with higher AIDS knowledge being associated with a lower level of personal
stigma toward PLWHA ( p < .0001). The right part of Table 3 showed the group
difference of personal stigma toward PLWHA. The comparison children had less
personal stigma toward PLWHA than the children affected by HIV ( p < .05). There

CHILDREN IN RURAL CHINA

347

TABLE 3. Group Difference of AIDS knowledge and Stigma

aids knowledge

stigma

a
mean (SD)

p-value

mean (SD)

p Value

Orphanage orphans

118

11.25(3.86)

Family cared orphans

299

11.95(4.10)

24.17(8.29)
23.95(7.90)

.047

Vulnerable children

326

12.24(3.84)

24.88(9.33)

Comparison children

276

12.41(3.66)

23.02(6.44)

Mostly As

114

13.35(3.66)

Mostly Bs

305

12.48(3.96)

22.86(6.94)

Mostly Cs

313

11.90(3.87)

24.40(8.64)

Mostly Ds

179

11.81(3.72)

25.21(8.67)

Mostly Fs

99

10.39(3.58)

27.77(8.76)

14

575

11.44(3.60)

>14

437

12.96(4.08)

Boys

497

12.06(3.97)

Girls

522

12.11(3.80)

High

344

10.74(3.43)

Medium

406

12.40(3.96)

Low

264

13.36(3.79)

Child group
.039

Academic marks
<.0001

2.99(6.34)

<.0001

Age group (years)

<.0001

25.88(8.62)

<.0001

21.57(6.59)

Gender
.860

24.69(8.13)

.010

23.38(8.03)

Stigma
<.0001

Note. The total score of correct answer is 20.

a

was a linear relationship between academic marks and stigma with better academic
marks being associated with a lower level of stigma ( p < .0001). Older children reported the lower level of stigma than younger children ( p < .0001) and boys were
higher than girls in the level of stigma ( p = .01).

MULTIVARIATE ANALYSIS
The GLM analysis (Table 4) revealed signicant difference ( p = .019) in AIDS
knowledge by child group (i.e., orphanage orphans, family-cared orphans, vulnerable children, and comparison children) while controlling for age, gender, and academic marks. Age and academic marks were signicant covariates for childrens
AIDS knowledge in GLM analysis ( p < .0001 for both variables). The interaction
term of gender and child group was not signicant ( p = .69). The hierarchical multiple regression analysis (Table 5) revealed that among the HIV-affected children
in rural China, age, gender, and academic marks were signicantly associated with
their personal stigma toward PLWHA. AIDS knowledge was signicantly associated
with childrens personal stigma toward PLWHA, independent of childrens demographic characteristics.

348

ZHAO ET AL.
TABLE 4. GLM analysis of AIDS Knowledge
main effect

aids knowledge
df
Mean square

a
child group

interaction covariates
gender group by gender

age academic marks

1

44.57

3.09

6.59

1166.67

F value

3.33

0.23

.49

87.13

528.62
39.48

p value

0.019

0.63

.69

<.0001

<.0001

Note. a child group (i.e., orphanage orphans, family-cared orphans, vulnerable children, comparison children)

discUssion
The data in the current study demonstrate relatively low AIDS knowledge (60%
correct response rate) among children living in communities of high HIV prevalence in rural China. This nding was consistent with the results of previous studies
showing that AIDS knowledge was inadequate among children and adolescents in
China (Albrektsson et al., 2009; He & Ji, 2009; Li et al., 2010; Zhao, Li, Stanton,
et al., 2010). In the current study, the orphanage orphans scored the lowest in AIDS
knowledge among all four child groups and the older children scored better on AIDS
knowledge than the younger ones. These ndings were consistent with results of one
previous qualitative study among orphanage orphans in China, which suggested that
most children in orphanages knew little about AIDS and the knowledge of AIDS was
even more limited among younger children (Zhao et al., 2009). One of the reasons
perceived by children in the AIDS orphanage for the lack of AIDS knowledge was
that their caregivers (orphanages workers) or school teachers purposely avoid discussing the topic of AIDS with them because of the fears of upsetting the children
who lost both of their parents to HIV (Zhao, Li, Kaljee, et al., 2009). One of the
possible explanations in the current study for the lower AIDS knowledge among
HIV-affected children might also be that persons around them purposely avoid discussing AIDS and the children might also try to avoid conversation or discussion
about AIDS because of their devastating memories associated with AIDS-related loss
in their families.
Another nding of this study is that children with better AIDS knowledge had
less personal stigma toward PLWHA. The result is consistent with ndings of other
studies in China that have demonstrated the important role of improvement of AIDS
knowledge in reducing stigma toward PLWHA (Chen, Choe, Chen, & Zhang, 2007;
Lau & Tsui, 2005; Sullivan et al., 2010). The current study conrmed that dissemination of accurate AIDS knowledge may be important for the reduction of HIVrelated stigma among children.
There are several limitations in the current study. First, all the data were selfreported, which might be subject to self-reporting bias. Second, some important
information (e.g., the sources of AIDS knowledge for children) was not available for
analysis in the current study. Because these factors might inuence the accuracy of
AIDS knowledge, future study, including information of these factors, may provide
us with a greater insight about the effective approach for HIV prevention and education among these children.
Despite these limitations, the ndings of this study still have some important
implications for HIV prevention and education among children. It is necessary to

CHILDREN IN RURAL CHINA

349

tailor culturally and developmentally appropriate education strategies for providing

information on AIDS-related knowledge to children. The AIDS education is particularly important for HIV-affected younger children, who were less knowledgable
about AIDS than their counterparts. This study also suggests that AIDS educators
and public health workers may be able to reduce childrens stigmatizing attitudes toward PLWHA by improving their AIDS knowledge. Future HIV intervention efforts
should encourage caregivers, teachers, orphanages workers, and other community
members to communicate with children, in a culturally and developmentally appropriate way, on the topic related to HIV infection prevention, treatment, and care.

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