Department of Public Health and Caring Science Section of Caring Sciences
Sexually transmitted diseases in Vietnam: Knowledge, attitudes and beliefs among vocational students.
Authors: Supervisor:
Alfrida Edvinsson Pranee Lundberg
Anna Schmidt Co-supervisor:
Trieu Thi Ngoc Thu
Examiner:
Examensarbete i vårdvetenskap, 15 HP Christine Leo Swenne Sjuksköterskeprogrammet 180 hp
Vt 2011
ABSTRACT
Background: Sexually transmitted diseases (STDs) have been a increasing problem worldwide
with an estimation of 340 million new cases each year. STDs are one of the top five reasons of seeking health care in the developing countries. Aim: The aim was to investigate the
knowledge, attitudes and beliefs regarding STDs among young adults in two vocational schools in Ho Chi Minh City, Vietnam and also compare the genders regarding the issues. Method: A descriptive and comparative study was used. The 455 students between the age of 15 and 24, both male and female, participated voluntarily to answer a questionnaire. Dorothea Orem’s self-caring theory was provided as theoretical framework. Results: The students showed a low knowledge regarding STDs. Small differences between the genders could be seen regarding knowledge where the males had a higher knowledge regarding symptoms of STDs.
Conclusions: The adolescents had lack of knowledge about STDs and no greater difference
between genders have been shown. The traditional attitudes must change and follow the development of Vietnam. Further research should be performed to find out if there is any difference between students in rural and central areas of Vietnam.
Key words
Sexually transmitted diseases,Vietnamese adolescents, knowledge, attitudes, beliefs.
SAMMANFATTNING
Bakgrund: Sexuellt överförbara sjukdomar är ett ökande problem världen över med en
uppskattad siffra på 340 miljoner nya fall årligen. Sexuellt överförbara sjukdomar är en av de fem vanligaste anledningarna till att söka vård i utvecklingsländerna. Syfte: Syftet är att undersöka kunskap, attityder och kunskap gällande sexuellt överförbara sjukdomar hos ungdomar på två yrkesförberedande skolor i Ho Chi Minh City, Vietnam och att jämföra de båda könen gällande detta ämne. Metod: Studien är en deskriptiv och jämförande
tvärsnittsstudie. Kvantitativ metod användes. 455 studenter i åldrarna 15 till 24, såväl manliga som kvinnliga, deltog och inkluderades i studien. Den valda teoretiska referensramen i den här studien är Dorothea Orems självvårdande teori. Resultat: De medverkande studenterna i denna studie visade en låg kunskap gällande sexuellt överförbara sjukdomar. Det påvisades ingen större skillnad gällande kunskap mellan könen men männen hade större kunskap när det gällde symtom på sexuellt överförbara sjukdomar. Slutsats: Kunskapen gällande sexuellt överförbara sjukdomar bland deltagande i denna studie visade sig vara låg. De traditionella attityderna måste förändras och följa utvecklingen. Ytterligare forskning behöver genomföras för att kunna se skillnader gällande kunskap, attityder och tro på landsbygd respektive stadsmiljö i Vietnam.
Nyckelord
Sexually transmitted diseases, Vietnamese adolescents, knowledge, attitudes, beliefs
CONTENTS
1. BACKGROUND………..6
1.1. Symptoms and complications………6
1.2. Statistics of STDs……….…….6
1.3. Knowledge about STDs……….7
1.4. Attitudes towards STDs……….9
1.5. Beliefs about STDs………...11
1.6. Vietnam……….11
STDs in Vietnam………..12
1.7. Theoretical framework……….13
1.8. Rationale of research………13
1.9. Aim………..14
1.10. Research questions ………....14
2. METHOD………14
2.1. Design………..14
2.2. Setting ……….14
2.3. Sample……….15
2.4. Instrument………15
2.5. Procedure……….16
2.6. Analysis of data………17
2.7. Ethical considerations ……….17
3. RESULTS ………..18
3.1. Demographic characteristics ………18
3.2. Vietnamese students’ knowledge about STDs ………19
3.3. Vietnamese students’ attitude towards STD ………23
3.4. Vietnamese students’ beliefs about STD………..27
4. DISCUSSION………..29
4.1. Discussion of results ………29
Knowledge………...29
Attitude ………30
Beliefs ………..31
Gender differences………32
4.2. Method discussion……….32
4.3. Clinical implications………..34
5. CONCLUSION……….34
6. REFERENCES ……….35
Appendix 1a. Questionnaire in English……….38
Appendix 1b. Questionnaire in Vietnamese………..42
1. BACKGROUND
Sexually transmitted diseases (STDs) can be caused by bacteria or by viruses. Examples of the bacterial infections are chlamydia, gonorrhea and syphilis. HIV, genital warts, herpes and hepatitis are all caused by viruses. The infections can be avoided by using condom during intercourse. An infection caused by bacteria can be cured, while the virus infection often is harder to cure. It is often possible to slow down or relieve the symptoms of the infection caused by viruses. The bacteria and viruses can be found in sperm, vaginal secretions, saliva, pus and in the blood. It can also be found in the areas surrounding the genitals and in the body’s mucous membranes in the throat, urethra, vagina and rectum (Socialstyrelsen, 2010).
1. 1. Symptoms and complications
The normal symptom of an STD is genital ulcers, scrotal swelling, vaginal- and urethral discharge and lower abdominal pain. STD does not always have symptoms. Gonorrhea and chlamydia is two good examples that can be active and still not show any symptom. To get infected with STDs a person will have to have unprotected sex with a person carrying the infection, and some infections are more easily transmitted than others, for example chlamydia.
To get chlamydia, it is not needed to have vaginal, oral or anal intercourse. Just by getting in contact with the infected persons mucous membranes of the genitals you can get infected (WHO, 2001).
Complications of an untreated STD can be cervical cancer, pelvic inflammatory disease, miscarriage and ectopic pregnancy. The effects of an untreated STD in children can be
stillbirth, congenital syphilis, pneumonia, prematurely and blindness (WHO, 2001). Every year 1000-4000 newborn becomes blind because of women giving birth with an untreated
chlamydia. If a pregnant woman has untreated syphilis, the risk of giving stillbirth increases with 25%. The best way of avoiding STDs are according to WHO (2010) to abstain of sexual intercourse, have few sexually partners and correct use of latex condom.
1.2. Statistics of STDs
The World Health Organization (WHO, 2010) estimates that every year around 340 million
new cases of curable STDs (chlamydia, syphilis, gonrrehea and trichomoniasis) occurs all over
the world. In the developing countries STDs is one of the top five reasons why people seek
health care.
In a report from 2001 made by WHO, the prevalence of STDs around the world was presented.
In this report the prevalence of Chlamydia infected persons in the year of 1999 was estimated to be 92 millions and 42.89 millions of them are in south and South East Asia. Regarding gonorrhea the estimated number in 1999 was 62.35 millions of newly infected persons. The number for south and southeast Asia alone was 27.2 millions. There was 12.2 millions of newly diagnosed cases of syphilis in 1999 and south and southeast Asia represented 4.038 millions of them. This region has the highest prevalence of curable STDs of adults in the world (WHO, 2001).
1.3. Knowledge about STDs
The knowledge around the world about STDs is very uneven. A study from Sweden shows that knowledge of STDs increase with higher number of sexual partners, smoking, frequent use of alcohol and a history of STD (Andersson-Ellström & Milsom, 2002). Another study from Sweden shows that adolescents know that condom protect them from STDs even though the prevalence is very low, but the awareness of STD was very high (Persson & Jarlbro, 1992).
Mwambete & Mtaturu (2006) conducted a survey to establish the level of knowledge and behavior among youths in Tanzania. Only 77% of 635 participants knew other ways to contract STDs besides vaginal intercourse. Almost all of the participants knew that they could protect themselves but only 26% knew symptoms of an STD.
A study conducted in Pulau Pinang, Malaysia showed that 10.6% out of 1139 students, aged 14-19 claimed that they never had heard about STDs even though 12.6% of the students stated that they were sexually active. Of the sexual active youth, men were the one gender who had the highest numbers of sexual partners (Anwar, Sulaiman, Ahmadi & Khan, 2010).
Kaljee et al. (2007) showed in their study that the youths in Vietnam lack knowledge about STDs and HIV. Lan, Lundborg, Mogren, Phuc & Chuch, (2009) found that young, unmarried women living in rural areas in Vietnam demonstrated very low levels of knowledge regarding sexually transmitted infections. Most of the participants in this study did not know any
symptoms of STDs. Half of them were not aware that sexually transmitted diseases could be prevented. They also had low knowledge about that condom could be used as a protection against sexually transmitted infections. Another study from Vietnam made by Nguyen et al.
(2008) showed that women up to 50 years of age have heard about HIV and many of them
knew how to protect themselves from it. More than half of the women knew that a healthy person can be infected with HIV.
Only 58% of students who attended medical school reported that they received a lecture about HIV. On a questionnaire on general knowledge about HIV the students showed good
knowledge but some students still believed that mosquitoes and casual contact could transmit the disease (Nguyen, 2000). A study by Gellert et al. (1995) that focused on Vietnamese Americans knowledge about HIV showed that almost all participants knew that HIV can be transmitted though sexual intercourse and mother to child but very few know that sharing needles and blood transfusion. Around 50% of the participants also believed that they could get the disease by sharing toilet seats and working close to a person with AIDS. This knowledge was different between male and females. Males were the gender that showed more knowledge of HIV transmission. For example 68 % (n=532) of the females believed that transmission was possible if they attend a school where there is a child with AIDS virus. This only 40% of the males believed to be true. The difference between the to genders is not only limited to transmission of STD. This also implies on general knowledge of HIV. A study from India (McManus & Dhar, 2008) showed that adolescent females lacked the knowledge of consequences of STDs and did not know that some STDs can lead to infertility. Low
knowledge was also reported in rural areas in Vietnam where only 14,6% of 445 women knew that some untreated STDs can lead to infertility. The women also reported bad hygiene and sex during menstruation or soon after delivery as possible causes of STDs (Lan et al., 2009).
The knowledge about STDs and safe sex came from different sources. In Rio de Janeiro adolescents reported the television as the main source (Trajman, Belo, Teixeria, Dantas, Salomão, & Cunha, 2003). In India the adolescents answered that the knowledge came from friends, books, internet and their teachers. The only education about HIV and STDs was taught in science class which is an optional subject. Many students had never attended a class about STDs, HIV or safe sex (McManus & Dhar, 2008). The lack of school-educated knowledge is also reported in Tanzania. The adolescents got knowledge from media and books. There were no reports of parents or teachers as a source of information (Mwambete & Mtaturu, 2006). In China the youth reported that they received incorrect information from relatives about
transmission of STDs and HIV (Leiber et al., 2009).
A study from Rio de Janeiro shows that the participants wish for more information in the school when they all felt that the information was insufficient (Trajman et al., 2003). The need and request for information about knowledge of STDs was also reported in America among Vietnamese Americans (Gellert et al., 1995) and in China (Leiber et al., 2009).
Not much is known about sexual risks and bridging behavior among Vietnamese adolescents (Duong et al., 2007). According to Kaljee et al. (2007) adolescents seem to be aware of the spread of HIV trough sexual activity but are ignorant when it comes to other sexually transmitted diseases. They also tend to see HIV as the disease of other people in high-risk groups. According to a study performed among 886 adolescents in Vietnam there is a stigmatization regarding sex outside of marriage, especially among young women. The stigmatization of premarital sexual relations among adolescents strengthens abstinence and impairs the youths abilities to collect accurate information when it comes to STDs. It also decreases the ability to engage in safer sex. The parents of young people are generally reluctant to talk about issues regarding sexual activities and sexual health. The sexual-education in schools is also deficient (Kaljee et al., 2007).
A study conducted in the north rural areas of Vietnam shows great lack of knowledge among 1805 women aged 15-49. About 78 % of the women did not know any symptoms and 50%
could not identify any cause of STD. The young, unmarried women and the women living in the highland or mountain areas had the lowest knowledge regarding STDs. The misconceptions regarding STDs among women in rural areas in Vietnam and also the delay of seeking care for STDs were discussed (Lan et al., 2009).
1.4. Attitudes towards STDs
In Tanzania it is considered a taboo for parents and teachers to talk about sex and STD in the
school and at home. This is because of the religious and cultural barriers and the politic
pressure reduce the sexual education in the schools (Mwambete & Mtaturu, 2006). The social
stigma in Asian countries makes it hard to talk about sex and STDs. It is still considered a
taboo to have a public discussion regarding STDs and this fact makes it hard to succeed with
education programs. For adolescents to talk about sex with their parents and/or relatives, is also
a big taboo and talking about sex openly considered inappropriate and too private. Even to talk
about sex with your partner is shameful. About 75% of 60 persons answered that they felt that
talking about sex is taboo, shameful and discouraged in the Chinese community. The only one
who would talk about sex and condoms are prostitutes. The lack of information leads to that when the wedding night comes, few people know what sex and STDs are (Leiber et al., 2009).
Sales et al. (2007) did a study in America to investigate the relation between shame of STD and the use of condom among 192 young African Americans females. They reported if they felt shame about STD also if they had low self-esteem and low control over their life. The females who had little shame related to STD had higher levels of self-esteem. Participants that lived in poorer neighborhood and those who had more social support reported less use of condom and a higher number of diagnosed STDs. The authors believed that shame over STD could be good and also increase the use of condom. But as a negative side, the persons that felt shame regarding STD waited longer to seek treatment.
The attitude towards sex in Vietnam is traditional. Women are expected to be virgins when they marry while men are supposed to be sexually experienced. Duong et al. (2007) present that Vietnamese men often loose their virginity to sex workers and that they also often visit sexual workers. Regarding attitude towards premarital sex and extramarital sex it shows an increased tolerance among the collage aged youths. Leiber et al. (2009) believed that this can be a result of the media influence and other resources that expose the youths to the world outside the traditional Chinese culture. The attitudes towards sex have changed and the inadequate knowledge regarding STDs and HIV the youth increase the risk of contracting an STD and/or HIV.
Women experience difficulties negotiating protected sex with their boyfriends and husbands and are raised to be submissive (Duong et al., 2007). The average age of first intercourse in Vietnam was 19.5 years in 1996. A survey of the general population showed that only 2.6 % of the women had experienced premarital sex while the rate among men was 17%. Homosexuality and bisexuality are looked upon as abnormal and something that should be discouraged
(Rekart, 2001).
A study of the adolescents in three different areas of Vietnam showed results that as many as
46,9% of the sexually active youths rarely or never used condom (Kaljee et al., 2007). In China
a study showed that the youth felt that condoms are only used if you are a prostitute. They felt
that you only have sex with there spouse and if they don’t want any more children the woman
get sterilized (Leiber et al., 2009).
1.5. Beliefs about STDs
Ethier, Kershaw, Niccolai, Lewis, and Ickovics (2003) showed that young females in USA underestimate the risk of getting infected with a STD. Almost all participants reported that they considered themselves to have low susceptibility of a STD. During this study one third of the participants were diagnosed at the baseline of the study with an STD and under the following year a quarter of them were diagnosed. McManus and Dhar (2008) showed that some girls in India believed that the contraceptive pill could protect them against HIV. Trajman et al. (2003) found that 63% of 945 students in Rio de Janeiro believe that a healthy looking person may have HIV and 16% believed that there is a cure for AIDS.
In a study conducted in Vietnam by Kaljee et al. (2007) who reported that a non-sexual relationship are considered pure and healthy while those relationship that involved sex were dangerous. Leiber et al. (2009) reported that in China people believe that a sexual relationship is good for the mental and physical health.
Premarital sex is considered to be a socially taboo in Vietnam (Ghuman, Loi, Huy & Knodel, 2006). Both the Vietnamese culture and the government propaganda favors sexual abstinence until marriage. According to a study made by Kaljee et al. (2007) among the Vietnamese youths, female virginity when marrying is considered to be of special value. Although it is considered to be both the man and the woman’s responsibility to keep from sexual relations before marriage it is ultimately the woman’s role to keep the relationship from becoming sexual. Many youths consider sexual feelings to be of danger. They mean a person might not be able to refrain from the sexual act even though they intended to when sexual feelings are
involved (Kaljee et al., 2007).
1.6. Vietnam
The Republic of Vietnam consists of a 332 000 km
2wide area with a population of 77 236 200
people, among which 77% are rural inhabitants. About 51.5% of the Vietnamese populations
are females and one third of the populations are under the age of 14. In 1993, the World Bank
estimated that 50% of the Vietnamese population was living in poverty and that 90% of those
people lived in rural areas. Most Vietnamese children attend Primary School, though the
dropout rate is high (Rekart, 2001).
STDs in Vietnam
The sexually transmitted infection’s is a big burden for low-income countries such as Vietnam, both regarding health and economy. STDs are often under-diagnosed and untreated in low- income countries because of lack of knowledge and/or lack of health care facilities. The presence of an ulcer-causing STD can increase the risk of spreading of HIV (Lan et al., 2009).
Since the first case of HIV was reported in 1990 the number of people infected with the virus increased heavily from 11 people per year in 1992 to 20 215 reported cases in the year of 2000 and Ho Chi Minh City were the location with most HIV-reports. The infection is most common in the age group 20 to 29 years. This group has 46% of the HIV-cases. These numbers might not be complete, since the surveillance information is deficient and the Vietnam Ministry of Health believes in an increasing number of HIV-cases in the years to come (Rekart, 2001).
Surveillance shows that HIV is most common among injecting drug users (Bui et al., 2001). Of 4000 adolescents 16% reported that they had had a reproductive tract infection and only 68% of them sought treatment (Nguyen et al., 2008). Accessible treatment for HIV is very low,
especially among women. This is mainly because that they in Vietnam focus more on the infected male injecting drug users (IDU) then on the women. Of the infected women the female sex workers only represented 11% of the HIV positive women. HIV testing is mandatory for IDU, female sex workers, blood donors and prisoners and is voluntary for other people (Nguyen et al., 2008).
The HIV/AIDS-cases in Vietnam are increasing among younger people. The risk of HIV
spreading from the high-risk groups to the general Vietnamese population depends on the
sexual risk and the bridging behavior of high- and low risk population. The spreading of HIV to
the low-risk group depends on the mixing between the high-risk group and other parts of the
population. Vietnam have experienced a slower increase of the virus to the general population
in comparison with neighboring countries (Duong et al., 2007). However, recent surveillance
indicate that the infection has increased among the general population. Statistics show that
almost 48% of the virus exists among the general population (Kaljee et al., 2007). About 130
000 new cases are reported each year and this number is probably an understatement (Lan et
al., 2009). The HIV has spread to all provinces in Vietnam, but cases are mainly to be found in
the urban areas around Hanoi, Ho Chi Minh City and near the borders to China (Ghuman, Loi,
Huy & Knodel, 2006).
Many of the HIV infected persons belong to a high-risk group such as IDU and most of them are young men under 29. Even if a women is not a sex worker she still are at risk of receiving an STD from her partner that may be a IDU or a client to a sex worker. One third of all the men aged 18-55 in Hanoi have had sex with a female sex worker and approximately only one third used a condom (Nguyen et al., 2008). The tourism in Vietnam has increased since 1988 and massage parlors, sex workers and drug use with it. The number of STDs has become higher in connection to tourism being more common (Bui et al., 2001).
1.7. Theoretical framework
The chosen theoretical framework of the study is Dorothea Orem’s self-caring theory (Jahren Kristoffersen, 2006). This theory is focusing on the four concepts: the human, the environment, health and caring.
Under the focus word “the human” Orem points out that humans separates from other species because we have the ability to reflect over ourselves and our environment. The humans also are free beings and have the ability to take care of themselves normally. A central part of the human ability of self-care is to be able to learn new knowledge and act upon it in their life.
When Orem addresses the word “the environment” she points out how important the culture and the social groups are in the pursuit of self-care. The act of self-care is affected of society, values and norms that are significant of the culture and the group. For the word "health" Orem points out the importance of developing good habits and change bad habits in a way that has a positive effect of the individual human’s life. Also the importance of teaching children and youth so they develop the knowledge and skills for good self-caring is a key factor to achieve good health (Jahren Kristoffersen, 2006).
When Orem describes about caring she refers to the care the person will get when he or she for some reason can’t do it by themselves, but also the education the person gets to increase the independence in a person. If the education will be successful depends on how ready the person is to receive the knowledge and if he or she is willing to learn (Jahren Kristoffersen, 2006).
1.8. Rationale of research
Vietnam is a country facing big changes. The country is trying to adapt to an open market and a
different openness towards the rest of the world. Together with increased tourism and exposure
for the western world the adolescents in Ho Chi Minh City gets more aware of different ways of living. Western norms collide with the more traditional Vietnamese ways. Increased number of abortions and reported cases of sexually transmitted diseases make people aware of the subject sexuality, which has been considered a social taboo. Earlier studies regarding STDs, from different parts of the world points to low knowledge in this subject and Vietnam is no exception. Studies made by Lan et al. (2009) and Nguyen et al. (2008) strengthen that view.
This low knowledge and the influence of western norms regarding sexuality increase the risk of the Vietnamese adolescents contracting an STD. Therefore, it is of interest to perform this study about knowledge, attitudes and beliefs of STDs among Vietnamese adolescents in Ho Chi Minh City.
1.9. Aim
The aim is to investigate knowledge, attitudes, and beliefs regarding sexually transmitted diseases among vocational students in Vietnam and to examine if there are any differences with respect to genders.
1.10. Research questions
What are the knowledge, attitudes, and beliefs regarding sexually transmitted diseases among
vocational students in Ho Chi Minh City, Vietnam?
Are there any differences with respect to genders regarding knowledge, attitudes and beliefs?
2. METHOD
2.1. Design
The study is a descriptive and comparative study. It was performed by quantitative method with a questionnaire. The project is a collaboration between the Department of Public Health and Caring Sciences, Uppsala University in Sweden and Faculty of Nursing and Medical
Technology, University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam.
2.2. Setting
The study was carried out at two vocational schools in Ho Chi Minh City. The chosen schools
were Trung eâ´p nghe Hûng Vùòng shool and Nhan Dao Vocational Secondary School in Ho
Chi Minh City.
2.3. Sample
A purposive sampling was used for selection of the participants. The including criteria of participants was that the students were between 15-24 years old and they were willing to participate voluntarily. The age was set to 15-24 to be able to match data that was collected at another occasion made in 2010. Data was collected at two different occasions (figure 1). The students that were excluded did not match the including criteria. The total of included
participants for both of the occasions was 455 students. Once in October 2010 and once in March 2011. The data from 2010 was collected by to other students from Uppsala University.
The reason for selecting the two schools was that Trung eâ´p nghe Hûng Vùòng school has focused on IT education and the number of females is very low. The Nhan Dao Vocational Secondary School has focused on hairdressing, makeup artist and designer where the number of females is high.
Figure 1. Selection of participants.
2.4. Instrument
A questionnaire was developed by Dr. Pranee Lundberg and Ms. Trieu Thi Ngoc Thu, Head of the Department of Midwifery in English regarding to experiences and of Vietnamese culture (Appendix 1a). Ms. Trieu translated from English into a Vietnamese version (Appendix 1b) and also tested it before using at the first time in November 2010. The questionnaire consists of 32 questions of a multiple choice character and is divided into two parts. Part one consists of questions concerning demographic characteristics. Part two is divided into three sections:
knowledge, attitude and beliefs of STDs. To judge the students knowledge the questions 11-17 were used. For every correct option they chose they scored one point. For every right answered the participant receive a point. Maximum points they could obtain were 30.
Data collection 2010 Data collection 2011
11 excluded 22 excluded
222 participants 222 participants
Total 455 participants
211 participants 244 participants
Part one of the questionnaire consists of five questions concerning age, gender, year in school, religion and marital status. The scale type in part one of the questionnaire is nominal scale. In this part there is also questions about income, extra job, how long they stayed at HCMC and with whom they live with.
The second part consists of three sections, where the first section regards knowledge of STDs.
This part includes the questions from 10 to 19 and the questions 11-17 will be used for measure knowledge by receiving one point for every correct score. The participants will be asked to answer questions concerning whether they have heard of STDs and from where they have obtained this knowledge. There is also a question whether a person can have an STD and not have any symptoms. On these mentioned question a nominal scale will be used. The second part also consist of multiple answer question with both right and wrong answers regarding routes of STDs, signs and symptoms, complication of untreated STDs and what diseases count as STDs. Here an ordinal scale will be used.
The second section is regarding attitudes to STDs and are involving questions 20-28. The questions consist of statements which can be answered with one of the following options:
“agree”, “disagree” or “don’t know”. Here a ordinal scale will be used. The last question in this subcategory concerns the matter of whether the participants are worried that they will contract an STD and a nominal scale will be used. There would be no question in this part that the student could get any points from.
The third section includes the questions 29-32 and consists of questions concerning the
participants' beliefs of STDs. The questions are formed as statements to which participants can answer either “yes”, “no” or “don’t know”. If the answer is “yes” or “no” there is also a possibility to specify different reasons to these answers. The scale type in this section is also nominal scale. There would be no question in this part that the student could get any points from.
2.5. Procedure
The collection of data was set after Ms Trieu Thi Ngoe Thu, co-supervisor and Head of
Department of Midwifery, Faculty of Nursing and Medical Technology, contacted the director of the two schools. She informed the directors about the project and the purpose of the study.
Consent from the directors was received to carry out the study at the schools. The data were
collected in two different occasions. The first time was in October 2010 by Mrs. Trieu and the other two Swedish students, and the second time was in March 2011 by Mrs. Trieu and the authors. In the second time there were total three occasions for data collection. In the two of those occasions Ms Trieu and the authors were present and distributed the questionnaires. In the third occasion Ms Trieu handed out the questionnaires by herself. In addition, there was one midwifery teacher helping to hand out the questionnaires at all occasions.
Before handing out the questionnaire Ms Trieu informed the student in Vietnamese about the purpose of the study and the content of the questionnaire. The students were told that the participation is anonymous and voluntary and that they were free to leave the questionnaire blank if they wanted to. They were told that they should not look at the bench-neighbors answer and that they would answer the questionnaire under silence. After they answered the questionnaire they brought it to the authors, the midwifery teachers or the teachers. At the first occasion Ms Trieu and the midwifery teacher looked through the questionnaire before the students were allowed to hand it in to make sure that they had filled in all the questions. Ms Trieu was not present during the second occasion. At the third occasion the authors were not present and could not report how the data collection was carried out. After each collection occasion the questionnaires were counted and collected in an envelope. On the questions that the participants had the option to write an answer, Ms Trieu and a midwifery teacher translated the answer from Vietnamese into English.
2.6. Analyze of data
After collecting the questionnaires the data were analyzed using descriptive and comparative statistics in the SPSS computer program. The descriptive statistics were used to answer the first research question regarding knowledge, attitude and belief of sexually transmitted diseases. To analyze the second question about the differences between genders the independent-samples T- test and Chi-2 test were used respectively. The null hypothesis is “there is not a difference between genders regarding knowledge, attitudes and beliefs about STDs”. For significant difference the p-value has to be <0.05.
2.7. Ethical consideration
Before the questionnaires were handed out the participants received verbally information
regarding that it was voluntary to participate and that the answers would be confidential. The
participants also received written information regarding the study in the beginning of the
questionnaire. It is important that they receive information about the study and they are aware that they can end their participation at any time (Arlebrink, 2006). As sexually transmitted diseases is considered a stigmatized and sensitive subject it is important that the adolescents are informed that it is confidential. This is of great importance to increase the chance that the participants answer honest. Permission to collect data from the chosen schools was given by the schools principal verbally.
3. RESULTS
Table 1. Demographic background of the Vietnamese students
Demographic background Total
N=455 n(%)
Gender n=455
Female 188 (41)
Male 267 (59)
Age (years old) Mean=19,53
Year in school n=447
First 214 (47,9)
Second 179 (40)
Third 54 (12,1)
Religion n=448
Non religion 181 (40,4)
Buddhist 170 (37,9)
Catholic 82 (18,3)
Protestan 8 (1,8)
Others 7 (1,6)
Marital status n=443
Single 311 (70,2)
Have girlfriend 75 (16,9)
Have boyfriend 48 (10,8)
Married 7 (1,6)
Unmarried couple 2 (0,5)
Money 1 n=353
0-99.000 9 (2,6)
100.000-500.000 94 (30,7)
501.000-1.000000 114 (26,4)
1.000000- 203 (40,3)
Extra job n=437
Yes 220 (50,3)
No 217 (49,7)
Extra job 2
Guard 5
Manager 2
Sales person 20
Network manager 2
Waiter/waitress 17
Year in HCMC3 N=389
Mean=11
Living conditions n=455
Parents/family 332 (73)
Together with friends 53 (11,6)
By ownself 20 (4,4)
Other 50 (11)
1Allowance from home or income every month
2Specified extra jobs
3How many years have you stayed in Ho Chi Minh City
3.1. Demographic characteristics
The total participants in this study were 455. The demographic characteristics, such as age, gender, year in school, religion, marital status, income, extra job, year in Ho Chi Minh City and living conditions are presented in table 1.
The distribution between the genders was 267 males and 188 females. Their ages ranged from 15 to 24 years old and the mean age was 19.53 (SD 2.25). They were in the first, second or high school year in the two schools and their vocational subjects were design, hair design, tailoring, electric, mechanic, and computer science. Seventy-three percent of the students lived with their parent or family. Regarding the marital status, 70.2% were singles and 7% were married.
3.2. Vietnamese students’ knowledge about STDs
The mean number for correct answer is 11 with a SD of 4.95. The highest score a participant got was 26 and the lowest was zero (figure 2). There was a significant difference between genders regarding total score of knowledge (p = 0.011).
Figure 2: Total Knowledge scores
Total Knowledge scores
25 23 20 18 16 14 12 10 8 6 4 2 0
Frequency
40
30
20
10
0
Eighty-eight percent (396/452) reported that they knew other STDs then HIV that you can get though sex. Three percent (13/455) of the students knew that Chlamydia is an STD. Five percent of the students could identify herpes, hepatitis C (6%) and hepatitis B (11%) as an STD. HIV/AIDS was the most well known STD with 92% (418/455) (table 2).
The correct possible causes of STDs that the student chose were bacteria (45%, 205/455), virus (47%, 213/455) and blood transfusion (35%, 158/455) (table 2).
Table 2. Knowledge of STDs about causes and diseases among 455 students in Vietnam.
Knowledge of STDs Total Male Female p-value1
N=455 N=266 N=187
n (%) n (%) n (%)
Possible causes of STD
Bacteria 205 (45) 124 (46) 81 (43) NS
Virus 213 (47) 143 (54) 70 (37) 0.001
Fungus 163 (36) 92 (34) 71 (38) NS
Bad hygiene of woman 216 (47) 132 (49) 84 (45) NS
Bad hygiene of man 183 (40) 118 (44) 65 (35) 0.03
Usin unclean water 90 (20) 51 (19) 39 (21) NS
Sex during menses 144 (31) 84 (31) 60 (32) NS
Have sex soon after delivery 67 (15) 40 (15) 27 (14) NS
Blood transfusion 158 (35) 97 (36) 61 (32) NS
Infected swimming pool water 76 (17) 44 (16) 32 (17) NS
Don't know 32 (7) 14 (0.5) 18 (10) NS
Which diseases are STDs
Tuberculosis 16 (4) 6 (0.2) 10 (5) NS
Gonnorhea 248 (55) 155 (58) 93 (49) NS
Syphilis 297 (62) 192 (72) 155 (56) 0.000
HIV/AIDS 418 (92) 246 (92) 172 (91) NS
Hepatitis B 50 (11) 33 (12) 17 (9) NS
Hepatitis C 29 (6) 20 (7) 9 (5) NS
Chlamydia 13 (3) 10 (4) 3 (2) NS
Herpes 22 (5) 17 (6) 5 (3) NS
Don't know 22 (5) 8 (3) 14 (7) 0.029
Others 4 (1) 3 (1) 1 (0.05) NS
1Chi-square statistics compares male and female groups.
Italics style is a correct answer.
Ninety percent of the students (408/455) knew that they can get an STD via sexual intercourse.
The other correctly reported options to receive STDs were blood transfusion (33%), sharing
needles (35%) and mother to child (40%) (table 3).
Table 3. Knowledge of STDs about routes, symptom, and complications of STDs among 455 students in Vietnam.
Knowledge of STDs Total Male Female p-value1
N=455 N=266 N=187
n (%) n (%) n (%)
Routes of STDs
Sexual intercourse 408 (90) 249 (93) 159 (85) 0.003
Blood transfusion 151 (33) 96 (36) 55 (29) NS
Sharing needle 157 (35) 98 (37) 59 (31) NS
Sharing clothes/things 60 (13) 36 (13) 24 (13) NS
Sharing food 4 (1) 1 (0.04) 3 (2) NS
Mother to child 181 (40) 113 (42) 68 (36) NS
Don't know 16 (4) 5 (2) 11 (6) 0.023
Other 2 (0.04) 1 (0.04) 1 (0.05) NS
Symtoms of STDs
Abdominal pain 30 (7) 16 (6) 14 (7) NS
Discharge from penis/vulva 135 (30) 85 (32) 50 (27) NS
Itching in genital area 236 (52) 154 (58) 82 (44) 0.003
Burning pain in urination 168 (40) 107 (40) 61 (32) NS
Pain during intercourse 143 (31) 86 (32) 57 (30) NS
Genital ulcers or open sores 236 (52) 156 (58) 80 (43) 0.001 Swelling in the genital area 220 (48) 144 (54) 76 (40) 0.005
Blood in urine 95 (21) 59 (22) 36 (19) NS
Failure to pass urine 96 (21) 66 (25) 30 (16) 0.024
Loss of weight 69 (15) 49 (18) 20 (11) 0.024
Weakness 80 (18) 59 (22) 21 (11) 0.003)
Don't know 121 (27) 51 (19) 70 (37) 0.000)
Other 10 (2) 9 (3) 1 (0.05) 0.042
Complications of STDs
Infertility 214 (47) 134 (50) 80 (43) NS
Premature birth 70 (15) 49 (18) 21 (11) 0.035
Stillbirth 81 (18) 53 (20) 28 (15) NS
Etopic pregnancy 57 (13) 35 (13) 22 (12) NS
Miscarriage 71 (16) 51 (19) 20 (11) 0.014
Cervix cancer 183 (40) 120 (45) 63 (34) 0.014
Don't know 156 (34) 83 (31) 73 (39) NS
Other 22 (5) 14 (5) 8 (4) NS
1Chi-square statistics compares male and female groups.
Italics style is a correct answer.
The correct symptom that got the highest score 52% (236/455) was itching in the genital, genital ulcers and open sore 52% (236/455) and swelling in the genital area 48%
(220/455). The p-value shows a significant difference between the genders in these options where the males had more knowledge (p=< 0.005) (table 3).
The most well known complications if untreated STD were infertility 47% (214/455) and
cervix cancer 40% (183/455) (table 3).
Regarding the question if a woman can have an STD except HIV without any symptoms, 59%
of the students know that to be correct. The p-value shows that there is a significant difference between males and females in this question (table 4). Thirty-eight percent of the students reported that they had friends that have had an STD (table 5).
Table 4. Knowledge of STDs.
Knowledge of STDs Total Male Female p-value1
n (%) n (%) n (%)
Have you ever heard about infections or diseases
other than HIV that one can get through sex? N=452 N=265 N=187
Yes 396 (88) 242 (91) 154 (82) 0.01
No 27 (6) 13 (5) 14 (7) 0.01
Don't know 29 (6) 10 (4) 19 (10) 0.01
Do you think it is possible for a man to have a STD
(other than HIV) but not have symptoms? N=455 N=266 N=188
Yes 265 (58) 169 (63) 96 (51) 0.000
No 68 (15) 48 (18) 20 (11) 0.000
Don't know 122 (27) 50 (19) 72 (38) 0.000
Do you think it is possible for a woman to have a
STD (other than HIV) but not have symptoms? N=455 N=266 N=188
Yes 267 (59) 164 (61) 103 (55) 0.014
No 92 (20) 59 (22) 33 (18) 0.014
Don't know 96 (21) 44 (16) 52 (28) 0.014
1 Chi-square statistics compares male and female groups.
Italics style is a correct answer.
The p-value shows a significant difference between the males and females regarding what they
reported to be the source of the information regarding STDs (p= <0.024) (table 5). A total of
55% of the students reported that they got the information from friends.
Table 5. Knowledge of STDs about information and different sources among 455 students in Vietnam.
Knowledge of STDs Total Male Female p-value1 N=455 N=266 N=187
n (%) n (%) n (%) How do you know information/knowledge
about sexually transmitted diseases.
Friends 252 (55) 171 (64) 81 (43) 0.000
Family 182 (40) 111 (42) 71 (38) 0.000
Youth club 104 (23) 80 (30) 24 (13) 0.000
School/college 303 (67) 199 (75) 104 (55) 0.000
TV 311 (68) 196 (73) 115 (61) 0.006
Radio 122 (27) 93 (35) 29 (15) 0.000
Magazine 362 (80) 222 (83) 140 (74) 0.024
Internet 326 (72) 219 (82) 107 (57) 0.000
Hospital/Clinic 180 (40) 120 (45) 60 (32) 0.005
Others 19 (4) 16 (6) 3 (2) 0.021
Have you heard any of the following people tell you that they had a sexuelly transmitted disease other than HIV?
Friends 171 (38) 119 (45) 52 (28) 0.000
Parents 36 (8) 23 (9) 13 (7) NS
Brother/Sister 38 (8) 22 (8) 16 (9) NS
Other family members 47 (10) 29 (11) 18 (10) NS
Spouse/living partner 18 (4) 10 (4) 8 (4) NS
Sexual partners/lovers 43 (11) 30 (11) 13 (7) NS
Others 213 (47) 114 (54) 99 (53) 0.036
1 Chi-square statistics compares male and female groups.
Gender differences regarding knowledge
Forty-five percent (84/187) of the female students stated incorrectly about bad hygiene of woman as a possible cause of STD, while 49% (132/266) of the male students reported incorrectly (table 2). In general the male students had a higher knowledge than the female students regarding complications. Forty-five percent (120/267) of the males and 34% (64/188) of the female students identified correctly cervix cancer as a complication. The males chose more often a correctly complication then the female. Ninety percent (408/455) of the students knew that they can get an STD via sexual intercourse but there were more males 93%
(249/267) than females 85% (159/188) who had knowledge about this (table 3).
Regarding the symptoms of STDs the male more often chose a correct answere. Fifty-eight
percent (154/266) of the males chose itching in the genital area compare to 44% (82/187) of the
females. The male chose swelling in the genital areas 54% (144/266) compare to 40% (76/187)
of the female. Fifty-eight percent (154/266) of the males chose genital ulcer or open sour compare to 43% (80/187) of the female (table 3).
More males 63% (169/266) then females 51% (96/188) knew that a male can have a STD without any symptoms (table 4). The male students had higher scores for all possible sources of knowledge. The highest reported scores was magazine. This option 83% (222/267) of the males and 74% (140/188) females students chose. Internet 72% (326/455) was the second most reported source. Sixty-four percent (171/267) of the males reported their friends as a source compare to 43% (81/188) of the females. More males 45% (119/266) then females 28%
(52/187) reported that they had a friend that who had a STD (table 5).
3.3. Vietnamese students’ attitudes towards STDs
Thirty-six percent (163/454) of the students agreed that STDs are not dangerous because they can be cured. Ninety-four percent (426/455) did believe that young adults who get infected by a STD must be treated (table 6). Seventy-three percent (332/455) of the students were very worried about catching a STD in the future (table 7). Ninety-four percent (427/455) of the students thought that a young adult should contact health care if they are not sure of the
symptoms of a STD. Twenty-five percent (112/454) of the students believed that a person who is infected with a STD should be avoided because they can transmit the disease to another person (table 6).
Ninety-six percent (435/455) of the students thought that young adults should receive more information and knowledge about STDs in order to prevent these diseases. Ninety-six percent (435/454) also thought that this education should be given at school (table 7).
In order to prevent STDs 86% (391/453) of the students reported that condom should be used during sexual intercourse. Nineteen percent reported that use of emergency contraception can prevent them from getting infected with a STD (table 7).
Gender difference regarding attitude
Still, the last question regarding attitudes towards STDs show a result of high concern among
the participants of getting infected with an STD. Seventy percent (187/267) of the male
students were very worried about catching an STD. Seventy-seven (145/188) percent of the female were very worried of catching an STD (table 7).
Ninety-two percent (244/265) of the male students reported that condom should be used to prevent STDs while only 78% (147/188) of the female students thought the same. There were more males 22% (57/265) then females 15% (29/188) that reported that using contraception pill could protect themselves from STDs (table 7).
Table 6. Attitudes towards STDs among 455 Vocational students in Vietnam.
Attitudes towards STDs Total Male Female p-value1
n (%) n (%) n (%)
STDs are not dangerous because they can be
cured N=454 N=266 N=188
Agree 163 (36) 100 (38) 63 (34) 0.027
Disagree 215 (47) 132 (50) 83 (44) 0.027
Don't know 76 (17) 34 (13) 42 (22) 0.027
It's necessary to avoid the person who get a STD because they can transmit the disease to another
person. N=454 N=267 N=187
Agree 112 (25) 65 (24) 47 (25) NS
Disagree 294 (65) 181 (68) 113 (60) NS
Don't know 48 (11) 21 (8) 27 (14) NS
Young adults who get STDs must be treated. N=455 N=267 N=188
Agree 426 (94) 255 (96) 171 (91) 0.009
Disagree 6 (1) 5 (2) 1 (0.5) 0.009
Don't know 23 (5) 7 (3) 16 (9) 0.009
If young adults are not sure about symtoms of STD they must contact directly with health
personal. N=455 N=267 N=188
Agree 427 (94) 252 (94) 175 (93) NS
Disagree 8 (2) 4 (2) 4 (2) NS
Don't know 20 (4) 11 (4) 9 (5) NS
1 Chi-square statistics compares male and female groups.
Table 7. Attitude towards STDs among 455 vocational students in Vietnam.
Attitudes towards STDs Total Male Female p-value1 n (%) n (%) n (%)
Young adults should get information/knowledge
about STDs in order to prevent these diseases. N=455 N=267 N=188
Agree 435 (96) 256 (96) 179 (95) NS
Disagree 4 (1) 2 (1) 2 (1) NS
Don't know 16 (4) 9 (3) 7 (4) NS
Young adults should be educated on knowledge of
STDs at school to prevent these diseases. N=454 N=266 N=188
Agree 435 (96) 258 (97) 177 (94) NS
Disagree 6 (1) 3 (1) 3 (2) NS
Don't know 13 (3) 5 (2) 8 (4) NS
The person who do not want to become infected with a STD should use condom when having
sexual intercourse. N=454 N=266 N=188
Agree 391 (86) 244 (92) 147 (78) 0.000
Disagree 18 (4) 7 (3) 11 (6) 0.000
Don't know 44 (10) 11 (5) 30 (16) 0.000
The person who do not want to become infected
with a STD should use emergency contraception. N=453 N=265 N=188
Agree 86 (19) 57 (22) 29 (15) 0.000
Disagree 284 (63) 175 (66) 109 (58) 0.000
Don't know 83 (18) 33 (13) 50 (27) 0.000
How worried are you that you might catch an
STD? N=455 N=267 N=188
Not worried at all 13 (3) 10 (4) 3 (2) NS
Worried a little 42 (9) 33 (12) 9 (5) 0.006
Very worried 332 (73) 187 (70) 145 (77) NS
Don't know 69 (15) 38 (14) 31 (17) NS
1 Chi-square statistics compares male and female groups.
3.4. Vietnamese students’ beliefs about STDs
Seventy-four percent (337/454) of the students believed that young adults are a high risk group of getting infected with STDs and 18% (82/454) were not sure. Sixty-seven percent (126/187) of the female students believed that young adults are a high-risk group of getting infected with STDs while the male students reported 79% (211/267) (table 8) p= 0.000.
Table 8. Beliefs about STDs among 455 vocational students in Vietnam.
Beliefs about STDs Total Male Female p-value1 n (%) n (%) n (%)
Do you believe that young adults
are high risk group to catch an STD? N=454 N=267 N=187
Yes 337 (74) 211 (79) 126 (67) 0.000
No 35 (8) 25 (9) 10 (5) 0.000
Don't know 82 (18) 31 (12) 51 (27) 0.000
Do you believe that STDs can be
cured? N=449 N=262 N=187
Yes 240 (54) 158 (60) 82 (44) 0.000
No 73 (16) 47 (18) 26 (14) 0.000
Don't know 136 (30) 57 (22) 79 (42) 0.000
Do you believe that STDs can be
prevented? N=455 N=267 N=188
Yes 354 (78) 227 (85) 127 (68) 0.000
No 13 (3) 7 (3) 6 (3) 0.000
Don't know 88 (19) 33 (12) 55 (29) 0.000
1 Chi-square statistics compares male and female groups.
Fifty-four percent (240/449) of the participants believed that STDs can be cured. Many students were unsure regarding this question and 30% (136/449) answered Don’t know. A majority of the students, 78% (354/455), believed that an STD can be prevented.
Gender differences regarding belief
There was a difference in the beliefs if STD can be cured or not between male and female gender. Of the female students, 42% (79/187) were unsure while only 22% (57/262) of the male participants were unsure. Eighty-five percent (227/267) of the male student believed that STDs can be prevented compare to 68% (127/188) of the female students (table 8).
4. DISCUSSION
The result shows a general lack of knowledge when it comes to STDs. The adolescents also report wanting more information of STDs and considering youth a high risk of contract an STD. A small difference between the genders showed regarding knowledge of symptoms of STDs but no greater differences were shown regarding attitudes and belief.
4.1. Discussion of results
