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. Author manuscript; available in PMC: 2007 Sep 6.
Published in final edited form as: AIDS Educ Prev. 2004 Dec;16(6):557–570. doi: 10.1521/aeap.16.6.557.53792

WILLINGNESS TO PARTICIPATE IN HIV/STD PREVENTION ACTIVITIES AMONG CHINESE RURAL–TO–URBAN MIGRANTS

Hongmei Yang 1, Xiaoming Li 2, Bonita Stanton 3, Xiaoyi Fang 4, Danhua Lin 5, Rong Mao 6, Xinguang Chen 7, Hongjie Liu 8
PMCID: PMC1965499  NIHMSID: NIHMS25040  PMID: 15585431

Abstract

Data from 4,208 migrants aged 18–30 years old in Beijing and Nanjing, China, were analyzed to examine the correlates of willingness to participate (WTP) in HIV/STD prevention intervention activities among Chinese rural–to–urban migrants. Overall, 83.3% of the respondents would be willing to participate. Increased WTP was associated with employment in the industrial sector (OR = 1.59, 95% CI: 1.11–2.29), migrating to cities to learn more about the outside world (OR = 1.31, 95% CI: 1.08–1.59), prior experience with health maintenance (OR = 1.36, 95% CI: 1.11–1.66), higher level of HIV/AIDS awareness (OR = 1.16, 95% CI: 1.02–1.31), and perceived severity of risk behaviors (OR = 1.32, 95% CI: 1.04–1.68). Decreased WTP was associated with increased involvement in health risk behaviors (OR = 0.50, 95% CI: 0.35–0.73), increased perceptions of peer risk involvement (OR = 0.81, 95% CI: 0.68–0.98), perceived intrinsic rewards for risk behaviors (OR = 0.81, 95% CI: 0.68–0.96) and perceptions of HIV–related stigma (OR = 0.68, 95% CI: 0.53–0.89). The high level of WTP suggests that HIV/STD prevention activities are acceptable among rural–to–urban migrants. Their awareness of HIV/AIDS should be increased and HIV–related stigma should be reduced to increase the level of WTP. Recruitment and retention of individuals with high-risk behavior in prevention activities will be critical and challenging.

Population mobility has been identified as a major risk factor for HIV/STD infection and transmission in many developing countries, including China (Bloom, Urassa, Isingo, Ng’weshemi & Boerma, 2002; Hope, 2000; Zhang & Ma, 2002). In 2000, there were approximately 121 million migrants in China who moved from rural areas to urban centers for job and better lives without permanent urban residence (China National Burea of Statistics, 2001). Migration from rural to urban areas was restricted in China through the household registration (hukou) system, which divides the Chinese population into urban and rural residents. Because of the restrictions on employment and housing in urban areas (China Ministry of Health, 2003), the movement has largely been in the form of temporary migration. This “floating population” has been frequently identified by the Chinese government, the media, and international society as a vulnerable population at risk for HIV infection or other STDs (China Ministry of Health UN Theme Group on HIV/AIDS in China, 1997; Zhang & Ma, 2002). Several HIV/STD risk factors have been attributed to this population. First, being displaced and separated from one’s spouse/family because of mobility may lead to increased sexual risk behaviors, such as engaging in sex trade or causal sex (Zheng et al., 2000). Second, lack of adequate health care in urban areas may decrease these migrants’ ability to effectively prevent disease. Third, the competitive employment situation in urban areas may force some migrants into interior job sectors that place them at risk. For example, many sex workers are rural migrants who migrated to the cities but could not find other legitimate jobs (U.S. Embassy Beijing, 2000; Zheng et al., 2000). Finally, the migrant population not only is vulnerable to HIV/STD infection but also may facilitate HIV/STD transmission. Seasonal visits back home, such as those during traditional Chinese holidays, may expose residents in rural areas to risk. Given this vulnerability of migrants to HIV/STD and the fact that most migrants lack knowledge and/or skills to prevent acquisition or transmission of infection with HIV or other STDs (Liang, 2001), effective behavioral intervention strategies need to be developed to prevent HIV/STD infection among this risk population.

For any successful intervention, a prerequisite is that adequate numbers of individuals are willing to participate in it. Estimates of willingness to participate (WTP) will help researchers to determine the feasibility of prevention intervention program. Identification of associated factors may help to develop effective strategies to address those factors in the design and planning to increase WTP and, consequently, to improve participation rates.

The issue of WTP in HIV–related programs was first addressed among intravenous drug users (IDUs) in the United States in the late 1980s (Magura et al., 1989; Marlink et al., 1987). During the past 2 decades, a growing number of studies addressing this issue have been reported among diverse populations, including men who have sex with men (MSM), bisexual men, pregnant women, and STD patients. Level of willingness and possible correlates (e.g., demographic characteristics, HIV/AIDS knowledge, health behaviors, and self–perceived susceptibility) have been examined in these studies. A broad range of willingness levels was reported among these varied populations. For example, among IDUs in methadone clinics, one study reported a WTP rate of 85% (39/46) for voluntary HIV testing, whereas another study found only a WTP rate of 38% (114/300) (Magura et al., 1989; Marlink et al., 1987). An international survey among pregnant women in 13 cities from nine developing countries reported that the overall acceptability of voluntary counseling and testing ranged from 33% to 95% (Cartoux, 1998). Similarly, a wide range of willingness among MSM was also reported by several studies (e.g., from 37% to 91%) (Bartholow et al., 1997; Hays & Kegeles, 1999; Perisse et al., 2000; Scheer et al., 1999).

In addition to the discrepancy in reported levels of WTP, mixed findings were also reported regarding the association between sociodemographic characteristics and WTP. Although no relationship was reported in several studies, some suggested that gender or educational level was associated with WTP (Lau & Wong, 2001; Meyers, Metzger, Navaline, Woody, & McLellan, 1994). Lower educational attainment was found to be related with greater willingness (Bartholow et al., 1997; Koblin et al., 1998; Perisse et al., 2000). Although in many developing countries there were concerns that women might be reluctant to be tested because of the fear of coping with a positive result (Temmerman, Ndinya–Achola, Ambani, & Piot, 1995), women were found by Bartholow et al. (1997) to be more willing to participate in HIV vaccine trials.

Previous studies have demonstrated a consistent positive association between HIV–related risk behaviors and WTP (Bartholow et al., 1997; Buchbinder et al., 1996; Gross et al., 2000; Hays & Kegeles, 1999). However, it is worthwhile to note that not all risk behaviors are associated with greater willingness. A study among IDUs suggested that IDUs who shared needles were twice as likely to report WTP in a vaccine trial, whereas measures of risk sexual behaviors (e.g., multiple sexual partners, sex trade) in the prior 6 months were not related to WTP (Meyers et al., 1994). An HIV vaccine trial study revealed that participants who reported having an HIV–1–positive partner and MSM who reported unprotected receptive anal sex were significantly more likely to be willing to participate than those who did not report these behaviors, whereas those who shared needles/equipment among IDUs and women having unprotected vaginal sex were not associated with WTP (Koblin et al., 1998).

Compared with other countries, China is still in the early stages of the HIV epidemic. However, because of the large population and coexisting HIV/STD risk factors (e.g., population mobility, sex trade, drug use), the HIV epidemic in China is accelerating. Effective behavioral intervention, particularly among high-risk populations, is of extreme importance to control the further spreading of HIV/STD. To the best of our knowledge, there were only two studies to date addressing WTP in HIV–related programs in China. One study regarding acceptability of HIV testing was conducted among rural residents in Anhui Province (Liu, Ma, & Yu, 2001) the other, also focusing on acceptance of HIV testing, was conducted among the cross–border sex networking population in Hong Kong (Lau et al., 2001). The Anhui rural residents study reported that an overall 54% of rural residents expressed their willingness to access HIV testing. However, the acceptance rate was 88% among participants who had heard of HIV/AIDS. Being male and having better HIV/AIDS knowledge were associated with increased WTP in the rural study. By contrast, only 31% acceptance rate was reported in the Hong Kong cross–border study. The study found that those who had visited more than 10 female sex workers in the past 6 months or had ever contracted STDs were more likely to express their willingness to access HIV testing. No association was found between demographic variables, attitudinal/knowledge variables, and willingness to be tested in the cross–border study. These studies suggest that WTP in HIV–related programs may vary according to the sociodemographic characteristics of the study populations.

Most of the existing studies regarding WTP were concerned with HIV testing or HIV vaccine trial participation rather than general HIV prevention intervention participation. Moreover, the existing studies focused mainly on IDUs, MSM/bisexual men, and pregnant women. No study among migrants has been reported. Accordingly, our study was designed to explore the overall level of WTP and its association with sociodemographic characteristics, HIV/AIDS knowledge, risk behaviors, and psychological factors in rural–to–urban migrants in two metropolitan areas in China. Based on the findings from the previous studies, we anticipated that greater WTP would be associated with increased HIV–related knowledge, risk behaviors, and perceived vulnerability to and severity of infection.

METHODS

SAMPLING AND DATA COLLECTION

From September 2002 to January 2003, we conducted a cross–sectional survey among rural–to–urban migrants in two cities: Beijing, capital of China, and Nanjing, capital of Jiangsu Province in eastern China. Detailed sampling and data collection methods have been described elsewhere (Li et al., this issue). Briefly, 10 occupational clusters (restaurants, hotels, barbershops/beauty salons, bathhouses, nightclubs/karaoke/dance halls/bars, small retail shops, domestic services, street venders, construction and factory workers), which employed more than 90% of the migrants, plus currently unemployed migrants in the job markets, served as the sampling frame. To achieve a representative sample of migrants in the cities, quota sampling of occupational groups was utilized so that the number of participants would be proportional to the estimated number of migrants in each occupational cluster. The workplaces (e.g., store, club, office, construction site, street) were used as the sampling units. To prevent oversampling from any single sampling unit, the number of subjects recruited from any unit did not exceed 10% of total migrants in the unit or 10 individuals, whichever was greater. After obtaining permission from gatekeepers, employers, or workplace managers, trained interviewers approached eligible migrants at the sampling units. An eligible subject was defined as one who (a) had a rural residence, (b) worked in the city without having a permanent city residence; (c) had been in the city for at least 6 months, and (d) was between 18 and 30 years of age. After providing informed consent, participants were asked to complete an anonymous self–administered questionnaire in a separate room at their workplace or a nearby place convenient to participants. The questionnaire, which was pilot–tested and revised before the survey, took approximately 45 minutes to complete. Assistance (e.g., reading questions to them) was provided to a small number of respondents with limited literacy.

MEASURES

Willingness to Participate (WTP)

Participants were asked the question “If we were to conduct an HIV/STD prevention intervention program to help people like you and your peers to protect yourselves from HIV/STD, would you be willing to participate in such a program?” Respondents were instructed to give a yes/no response or skip the question if they preferred not to answer.

Sociodemographic Characteristics

Demographics included age, gender, ethnicity (Han, Hui, Man, Mongolian, or others), marital status (single, currently married, divorced, remarried and widowed), and educational level (illiterate, elementary, middle, high school, or postsecondary education). We combined non–Han minorities into a single category of “non–Han” in data analysis since they accounted for a small proportion (3%) of the entire sample. Participants were also asked about their living and working conditions, which included type of dwelling, utilities in dwelling, working place, daily working hours, days off work per month, and monthly income. Reasons of migration was inquired by a question with multiple choices, including earning more money, learning more about the outside world, having nothing to do at home, and changing living environment.

HIV/AIDS Awareness

Participants were asked to assess their general HIV/AIDS awareness on a 4–point scale ranging from 1 (knowing nothing about HIV/AIDS at all) to 4 (knowing a lot about HIV/AIDS).

HIV/AIDS Knowledge

HIV/AIDS knowledge was assessed by 22 items covering modes of transmission, clinical outcomes, treatment, and prevention. These items were presented with a true/false or likely/unlikely response choice. A composite score of AIDS knowledge was created by summing all correct answers (possible range 0–22) of the 22 items, with higher scores reflecting higher levels of knowledge about HIV/AIDS. The 22 items were adapted from the scales used in the 1992 U.S. National Health Interview Survey (Schoenborn, Marsh, & Hardy, 1994) and other studies in the U.S. (DiClemente, Zorn, & Temoshok, 1986; Koopman, Rotheram–Boras, Herderson, Bradley, & Hunter, 1990).

HIV Risk Behavior

Participants were asked to report their involvement in several risk behaviors, including having ever used drugs (never, ex–drug user, current drug user), having engaged in sexual intercourse (no/yes), number of sexual partners over their lifetime, involvement in commercial sex (either selling or buying sex), and the number of times using a condom during the most recent three sexual intercourses. Participants were also queried about the frequency of a behavior—selling blood—which could place them at risk (none, once, twice, 3 times, 4 or more times) because HIV infection among former paid blood/plasma donors through contaminated equipment has been reported in several central provinces of China (Wu, Liu, & Detels, 1995). Because only those participants who were sexually experienced were asked to answer the questions regarding sexual activities (e.g., numbers of sexual partners, involvement in commercial sex, and condom use), we recoded these three variables so that those who had never had sex were treated as having no multiple sexual partners, having never been involved in commercial sex, and consistently using condoms.

Health–Seeking Behavior

Two questions were employed to assess participant’s health–seeking behavior, including ever having had a physical exam (yes, self-initiated; yes, being required to do so; and no) and ever having had a STD/HIV test (no, only STD test, only HIV test, both STD and HIV tests). For the purpose of data analysis in the current study, we created dichotomous responses (yes/no) for these two variables by combining any positive answers to the questions as a single category (yes).

Peer Risk Involvement

Six questions were used to assess perceived peer risk behavior involvement. Participants were asked about how many (none, few, some, and most) of their peers (including those at their home villages) had engaged in a number of HIV/STD risk behaviors, including having multiple sexual partners, having unprotected sex, trading sex (selling or buying sex), having contracted a STD, and selling blood. A composite score was created by calculating the mean value of responses to the six items, with a higher score reflecting more peer risk behavior involvement. The internal consistency for the scale was 0.79.

Intrinsic Reward

The perceived intrinsic reward of risk behaviors (e.g., anticipated personal pleasure or personal advantage for engaging in risk behaviors) was a composite measure created from four original questions in the survey. Questions such as “having multiple sexual partners is cool” were asked and each question had a 4–point response ranging from 1 (strongly disagree) to 4 (strongly agree). The composite score was the average value of responses to these four questions and had a possible range of 1 to 4, with a higher score reflecting increased perceived intrinsic reward of risk behaviors. The internal consistency for the scale was 0.63.

Severity

Perceived severity of risk behaviors was a composite measure of four original questions measuring perceived negative consequence for engaging in risk behaviors. Questions such as “If one has an STD, he/she will lose his/her friends” were asked with a 4–point response option ranging from 1 (strongly disagree) to 4 (strongly agree). The composite score was the mean value of responses to these 4 questions and had a possible range of 1 to 4, with a higher score reflecting greater perceived severity of risk behaviors. The internal consistency for the scale was 0.59.

Vulnerability

Perceived vulnerability to HIV/AIDS infection consisted of two items assessing the perceived likelihood of being infected with HIV or STDs. Participants were asked to rate the likelihood of acquiring infection on a 5–point scale (1 = impossible, 2 = little possibility, 3 = some possibility, 4 = very possible and 5 = having been infected). The composite vulnerability score had a possible range of 1 to 5, with a higher score indicating a greater perceived vulnerability. The internal consistency for the scale was 0.80.

HIV–Related Stigma

The HIV–related stigma consisted of five items focusing on attitudes toward hypothetical HIV–infected others. For each item, participants were asked to choose from a 4–point scale ranging from strongly disagree to strongly agree. A composite stigma score, using the mean value of responses to these five items, was created to measure the prejudice and discrimination directed at people perceived to have HIV/AIDS. The scale score ranged from 1 to 4 with a higher score reflecting a higher level of stigmatization. The internal consistency for the scale was 0.57.

Depressive Symptoms

Depression was measured using the Center of Epidemiological Studies Depression Scale (CES–D) (Radloff, 1977). The 20–item CES–D was introduced into China in the early 1990s (Wang, 1993). The existing Chinese version of the CES–D was reexamined and modified by the investigators to ensure the accuracy of the translation. The internal consistency was 0.85 for the current study sample. The scale score, which was the sum of responses to these 20 items, ranged from 0 to 60, with higher scores indicating higher frequency of depressive symptoms.

Satisfaction

Two questions were employed to measure participant’s satisfaction with either their current life or work on a 5–point scale ranging from 1 (very unsatisfied) to 5 (very satisfied). A composite score was created by retaining the greater response of the two questions. The possible range of this composite score was 1 to 5 with a higher score reflecting a higher level of satisfaction with their life/work.

STATISTICAL METHODS

All analyses were conducted with SPSS for Windows, Version 11.5. Chi–square tests were performed to examine differences in distribution of categorical variables by WTP, and Student t tests were employed for continuous variables. Basic demographic characteristics (i.e., age and gender) and variables that were associated with WTP in univariate analysis at a significance level of .10 were entered into a stepwise multivariate logistic regression model. To improve the statistical efficiency of logistic regression analysis, we combined some variables that were skewly distributed. For example, drug abuse and blood selling was combined into one variable—”having ever used drugs or sold blood” (0 = none, 1 = either used drugs or sold blood)—and lifetime multiple sexual partners, commercial sex involvement, and nonconsistent condom use during the most recent three sexual intercourses were combined into one item—”risky sexual behavior” (0 = none, 1 = any of the risk behaviors).

RESULTS

SAMPLE CHARACTERISTICS

A total of 4,301 migrants in Beijing and Nanjing were approached, and 24 of them (0.6%, 8 males and 16 females) declined to participate. Sixty–nine participants were deleted from the data file because of substantial missing data (e.g., more than half of the variables were missing) or missing values on key demographic variables (e.g., gender). A final sample of 4,208 (98%) was retained in our database.

Table 1 presents the characteristics of study participants. The mean age of the participants was 23 years. A large proportion of them were of Han ethnicity (97%), secondary school educated (88.4%) and single (71.7%). About one fifth lived in underground spaces or shelters, and 15% had no tap water in dwelling. On average, they worked 10.2 hours a day and took 3 days off per month. Compared with males, females were younger, less educated and more likely to be single but reported better living conditions in cities. Gender distribution by occupation was significantly different with more males working as industrial workers and more females being employed in entertainment establishments.

TABLE 1.

DESCRIPTION OF STUDY SAMPLE BY SEX

Total (N = 4208)
Male (N = 2509)
Female (N = 1699)
Characteristics n % n % n %
Age (x ± sd ) 23.49 ± 3.80 23.94 ± 3.90 22.82 ± 3.55***
Han Ethnicityb 4053 97 2430 97.4 1623 96.1*
Educationab
 Elementary 252 6 121 4.9 131 7.8
 Middle school 2313 55.5 1464 58.9 849 50.5
 High school 1372 32.9 774 31.1 598 35.6
 Postsecondary 231 5.5 128 5.1 103 6.1
Singleb 2921 71.7 1646 68 1275 77.1***
Type of dwellingab
 Building 1349 32.2 647 25.9 702 41.5
 Flat 1855 44.2 1183 47.3 672 39.7
 Underground 515 12.3 276 11 239 14.1
 Shelter 348 8.3 319 12.8 29 1.7
 other 126 3 76 3 50 3
Utilities in dwellingb
 Toilet 2434 58.1 1322 52.9 1112 65.8***
 Kitchen 1896 45.2 1117 44.7 779 46.1
 Tap water 3617 86.3 2096 83.8 1521 90.0***
 Gas/Cylinder 1767 42.2 998 39.9 769 45.5***
 Telephone 1400 33.4 762 30.5 638 37.8***
 TV set 2290 54.6 1330 53.2 960 56.8*
 Shower/Bathtub 1710 40.8 977 39.1 733 43.4**
 None of the above 347 8.3 257 10.3 90 5.3***
Type of current workab
 No job 149 3.6 95 3.8 54 3.2
 Self–employed 380 9.1 232 9.3 148 8.7
 Entertainment establishment 2229 53.2 968 38.8 1261 74.5
 Industrial worker 1084 25.9 950 38.1 134 7.9
 Other 346 8.3 250 10 96 5.7
Monthly income (RMB) 846.41 ± 732.63 872.02 ± 723.52 808.64 ± 744.46**
Daily working hours 10.16 ± 3.30 10.20 ± 3.15 10.09 ± 3.51
Days rest per month 2.88 ± 2.25 2.77 ± 2.26 3.04 ± 2.22***
HIV–related measures:
 HIV/AIDS knowledge 14.10 ± 2.89 14.01 ± 2.92 14.23 ± 2.85*
 HIV–related stigma 2.33 ± 0.48 2.34 ± 0.49 2.32 ± 0.47
 Having used drugs or sold bloodb 203 4.9 137 5.5 66 3.9*
 Having sexual experienceb 2153 51.6 1425 57.1 728 43.5***
 Having risky sexual behaviors b 1750 44.5 1188 50.4 562 35.7***
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*

Note. p <0.05.

**

p <0.01.

***

p <0.001.

a

There was a significant gender difference (p <0.001);

b

The difference between the sum of subgroup and the total as reported in the top row was due to the omission of missing cases. The percentages of missing cases for these variables ranged from 0.4% to 1%, except the variables of marital status (3.1%) and having risky sexual behaviors (6.5%).

Among 4,208 participants, 2,153 (51.6%) reported having had sexual intercourse. The proportion of having sexual experience was higher for men than for women (57.1% vs. 43.5%, p <.001). Having any sexual risk behaviors (i.e., multiple sexual partners, commercial sex involvement, and inconsistent condom use during the most recent three sexual intercourses) was reported by 50.4% of men and by 35.7% of women. Nearly 6% of men and 4% of women reported being ever used drugs or sold blood.

WTP IN HIV/STDS PREVENTION INTERVENTION ACTIVITIES

Among all the participants interviewed, 83 (2%) skipped or had invalid answers to the question assessing WTP. Among those who responded, 3,435 (83.3% overall, 83.0% female, and 84.0% male) indicated that they would be willing to participate in HIV/STD prevention intervention activities.

CORRELATES OF WTP

Differences in sociodemographics, HIV–related knowledge, risk behaviors, health–seeking behaviors, and psychological factors between those who were WTP (i.e., WTP group) and those who were not WTP (i.e., non–WTP group) are summarized in Table 2. Compared with the non–WTP group, more WTP participants were Han ethnic (97.3% vs. 94.7%, p = .000). More WTP participants than non–WTP participants worked in entertainment establishments (53.4% vs. 51.7%) or industrial sectors (26.6% vs. 22.8%) (p = .009). Other demographic variables were not associated with differences in WTP.

TABLE 2.

Comparison of Sociodemographic, Risk Behaviors and Psychological Factors Between Migrants WTP and Those Not WTP

WTP (N=3435)
Not–WTP (N=690)
Characteristics n % n %
Sociodemographic factors
 Age (x ± sd) 23.48 ± 3.75 23.60 ± 4.03
 Male 2060 60 401 58.1
 Han Ethnicity 3330 97.3 643 94.7***
 Single 2413 72.1 459 69.2
 Education
  Elementary 190 5.6 56 8.2
  Middle school 1893 55.4 378 55.5
  High school 1141 33.4 211 31
  Postsecondary 191 5.6 36 5.3
 Type of current worka
  No job 115 3.4 32 4.6
  Self–employed 292 8.5 81 11.8
  Entertainment establishment 1828 53.4 356 51.7
  Industrial worker 910 26.6 157 22.8
  Other 278 8.1 63 9.1
 Monthly income (RMB) 839.7 ± 713.0 877.7 ± 834.3
 Daily working hours 10.14 ± 2.96 10.24 ± 4.77
 Days rest per month 2.91 ± 2.25 2.76 ± 2.26
 Migrating to earn more money 1740 50.7 390 56.5**
 Migrating to learn more about the outside world 2202 64.2 361 52.3***
Knowledge and behavior
 General AIDS awareness 2.35 ± 0.79 2.19 ± 0.82***
 HIV/AIDS knowledge 14.18 ± 2.84 13.76 ± 3.12**
 Having ever used drugs or sold blood 131 3.8 67 9.7***
 Having sexual experience 1726 50.6 393 57.3**
 Having risky sexual behaviors 1420 43.8 308 49.2*
 Ever had a physical exam. 2460 71.9 431 62.7***
 Ever had a STD/HIV test 369 10.8 97 14.1*
Psychological factors
 Peer risk involvement 1.37 ± 0.48 1.49 ± 0.59***
 Perceived intrinsic reward of risk behaviors 2.10 ± 0.56 2.24 ± 0.61***
 Perceived severity of risk behaviors 2.72 ± 0.52 2.53 ± 0.55***
 Perceived vulnerability to HIV/STD 3.66 ± 0.51 3.63 ± 0.61
 HIV–related stigma 2.30 ± 0.48 2.47 ± 0.49***
 Depression 11.22 ± 9.36 12.90 ± 9.64***
 Satisfaction with life/work 3.31 ± 0.97 3.26 ± 1.02
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*

Note. p <0.05.

**

p <0.01.

***

p <0.001.

a

There was a significant difference in proportion of occupation by WTP (p = 0.009).

Contextual variables, such as monthly income, daily working hours, and days off work per month did not differ by WTP. However, some motivations for migration, such as earning more money and learning more about the outside world, were significantly associated with WTP (see Table 2). Compared with the non–WTP group, more WTP participants said that they migrated to cities to learn more about the outside world (64.2% vs. 52.3%, p <.001), whereas more non–WTP participants said that they migrated to cities for the purpose of making more money (56.5% vs. 50.7%, p <.01).

HIV/AIDS awareness and knowledge were significantly associated with WTP. Those who were WTP had a higher level of awareness or better knowledge of HIV/STD. HIV–related risk behaviors were also associated with WTP. Those who were not willing were more likely to report having ever used drugs or sold blood, having had sexual experiences, and having engaged in risk sexual behaviors (see Table 2). Health–seeking behaviors, such as ever having had a physical exam, were also significantly related to WTP as those who were WTP tended to have more health–seeking behavior (see Table 2).

Significant differences were found in several psychological factors between the two groups. Those who were not willing to participate perceived more peer risk involvement, a higher level of intrinsic reward of the risk behaviors, a lower level of perceived severity of the risk behaviors, a higher level of HIV–related stigma, and more depressive symptoms. Satisfaction with life/work and perceived vulnerability for HIV/STD infection did not differ by WTP (see Table 2).

LOGISTIC REGRESSION ANALYSES

Table 3 depicts the results of multivariate logistic regression analyses, which confirmed the univariate results. Migrants in the industrial sectors tended to be more willing to participate (OR = 1.59, 95% CI: 1.11–2.29). Other factors associated with increased WTP included a “learning motive” of migration (e.g., migrating to cities to learn more about the outside world (OR = 1.31, 95% CI: 1.08–1.59), general HIV awareness (OR = 1.16, 95% CI: 1.02–1.31), having ever had a physical exam (OR = 1.36, 95% CI: 1.11–1.66) and perceived severity of risk behaviors (OR = 1.32, 95% CI: 1.04–1.68). Factors that appeared to be negatively associated with WTP included having ever used drugs or sold blood (OR = 0.50, 95% CI: 0.35–0.73), a higher level of peer risk involvement (OR = 0.81, 95% CI: 0.68–0.98) and higher intrinsic reward of the risk behaviors (OR = 0.81, 95% CI: 0.68–0.96). Higher perception of HIV–related stigma was also significantly associated with less WTP (OR = 0.68, 95% CI: 0.53–0.89) (see Table 3).

TABLE 3.

Results of Multivariate Logistic Regression Analysis, with Sociodemographic, Knowledge, Behavior, and Psychological Factors

95% CI for OR
Correlates p value OR Lower Upper
Age .503 1.01 .98 1.04
Gender (F/M) .075 .83 .67 1.02
Educational attainment .923 .99 .86 1.14
Ethnicity (non–Han/Han) .189 .74 .47 1.16
Type of current work (no job/all others) .341 1.31 .75 2.30
Type of current work (self–employed/all others) .927 .98 .65 1.48
Type of current work (entertainment establishment/all others) .075 1.36 .97 1.92
Type of current work (industrial worker/all others) .012 1.59 1.11 2.29
Migrating to earn more money (yes/no) .106 .85 .70 1.03
Migrating to learn more about the outside world (yes/no) .006 1.31 1.08 1.59
General AIDS awareness .019 1.16 1.02 1.31
HIV/AIDS knowledge .201 1.02 .99 1.06
Ever had a physical exam (yes/no) .003 1.36 1.11 1.66
Having sexual experience (yes/no) .755 .93 .57 1.51
Having ever used drugs or sold blood (yes/no) .000 .50 .35 .73
Ever had a STD/HIV test (yes/no) .228 .84 .63 1.12
Having risky sexual behaviors (yes/no) .867 1.04 .65 1.66
Peer risk involvement .029 .81 .68 .98
Perceived intrinsic reward of risk behaviors .015 .81 .68 .96
Perceived severity of risk behaviors .022 1.32 1.04 1.68
HIV–related stigma .004 .68 .53 .89
Depression .520 1.00 .99 1.01
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Note. Dependent variable: willingness to participate. Overall goodness of fit of the full model: χ2 (df = 8) = 12.48, p = 0.131.

DISCUSSION

A large proportion of rural–to–urban migrants reported WTP in future HIV/STD prevention intervention activities. Increased willingness was associated with being industrial workers, awareness of HIV/AIDS, and perceived severity of risk behaviors. Peer risk involvement, perceived intrinsic reward of the risk behavior and HIV–related stigma were associated with lower WTP. Sexual risk behaviors and other HIV–related risk behaviors such as drug use or blood selling were also associated with less WTP, although the association did not reach statistical significance for sexual risk behaviors in the logistic regression model.

The willingness level observed in this study was higher than those observed in the previous studies in China (Lau & Wong, 2001; Liu et al., 2001). When comped with the Anhui rural residents study, one possible reason for this is that our sample had higher educational attainment than that in the rural residents study (94% vs. 53.2% reporting having received at least 6 years of formal schooling). Higher educational attainment was found to be related to greater WTP in both studies (though it was not significant in our study). Several possible macro factors might also contribute to the higher level of willingness found in our study. The rural residents study was conducted in 1997. There has been increased national attention on the HIV/AIDS situation in China since 1998. In 1998, the Chinese government issued a national medium– and long–term strategic plan for HIV/AIDS prevention and control, which stresses prevention and health education. In 2001, an action plan was issued for implementation of the medium– and long–term strategic plan (Ministry of Health, 2001). In the same year, the First National AIDS conference was held successfully in Beijing, just 1 year before our survey. All these activities and efforts may increase Chinese awareness of HIV/AIDS. Meanwhile, some recently highly publicized event regarding HIV/AIDS in China such as “needle attacks” may motivate Chinese migrants learn more about how to protect themselves from HIV/AIDS infection (Lev, 2002). The lower willingness level in the Hong Kong cross–border study might be attributed to the higher level of risk involvement among the cross–border commercial sex networkers. However, future study is needed to confirm our speculations regarding those differences.

Our study suggests that general AIDS awareness is associated with increased WTP. Similar findings have been reported in other studies (Bartholomeyczik, Devine, & Darrow, 1989; Liu et al., 2001). The positive association between awareness of HIV/AIDS and WTP supports the perspective that knowledge is necessary, albeit not sufficient, to facilitate formation of behavior–changing motivation (Fisher, Fisher, Williams, & Malloy, 1994). Increasing HIV–related knowledge among rural–to–urban migrants is especially relevant given that more than half of our participants (54% of those with WTP and 62.3% of those without WTP) perceived themselves knowing a little or nothing about AIDS.

It is important to note that HIV–related risk behaviors (e.g., drug use and sexual risk behavior) were associated with less WTP, although sexual risk behavior was not significant in multiple logistic regression analyses. This result was not consistent with findings from some previous studies, which suggested a positive association between HIV–related risk behaviors and WTP (Buchbinder et al., 1996; Gross et al., 2000; Hays & Kegeles, 1999). A negative association was reported previously in one vaccine trial among young Thai men, which found that having sex with sex workers was associated with diminished WTP (Jenkins et al., 2000). The negative association of WTP with risk behaviors in our study may be due to the fear of self-revelation of risk behaviors in the prevention intervention activities, as these risk behaviors (i.e., multiple sex, commercial sex, and drug use) are strongly stigmatized in the Chinese culture (Liu, Detels, Li, Ma, & Yin, 2002). This finding is relevant for implementing HIV/AIDS intervention programs in China. It suggests that it may be difficult to reach and to retain those at high risk for HIV/AIDS in prevention and intervention efforts. Rural–to–urban migrants have been reported to engage in more high–risk activity than permanent residents of either rural or urban areas (Liu et al., 1998). Our study also identified considerable involvement in risk behaviors among the migrants, with 5% having used drugs or sold blood and 45% having at least one of three risky sexual behaviors, including multiple sexual partners, commercial sex, and inconsistent condom use. Because individuals with high-risk behavior represent an important target population for intervention activities, more efforts should be made to understand reasons behind the unwillingness to participate in order to improve the recruitment and retention of those who are at high risk in prevention intervention programs.

Several studies of WTP indicated that perceived vulnerability to HIV/STD infection was associated with greater WTP in either HIV vaccine trial or HIV test (Bartholomeyczik et al., 1989; O’Connell et al., 2002). By contrast, the study among the Hong Kong cross–border sex–networking population (Lau & Wong, 2001) and the present study did not find a significant correlation between perceived vulnerability and WTP. Further study is needed to explore the possible reasons for such a discrepancy in this regard.

The current study indicated that higher levels of HIV–related stigmatization were associated with less WTP. Similar results were reported in a previously published study (Fortenberry et al., 2002). These findings support the assumption that HIV/STD stigma delays health seeking and impedes HIV/STD prevention (Centers for Disease Control and Prevention, 2001; Chesney & Smith, 1999). Health workers in China must consider the reduction of HIV–related stigma as an important component of a successful HIV/AIDS action plan.

POTENTIAL LIMITATION

There are several potential limitations in our study. First, our sample was a convenience sample. Therefore caution is indicated when generalizing results to other migrant populations. Second, information collected was by self–report. The level of WTP might be overreported because a positive answer to the question might be perceived by the participants as socially desirable, whereas risk behaviors might be underreported since risk behaviors are not socially desirable. Third, although the current study was not designed to answer certain research questions regarding WTP in HIV/STD prevention intervention programs, the study still produces hypothesis–generating data. Fourth, our outcome variable was defined based on a general question of whether the respondents would be willing to participate in an “HIV/STD prevention intervention program” to protect them from HIV/STD, rather than a specific intervention activity. Although we had encouraged respondents to ask questions for clarification, the contents or nature of the HIV/STD prevention intervention program in the survey might be too general for some respondents. Finally, the cross–sectional nature of the data precludes any causal interpretation of the findings in the current study.

IMPLICATIONS OF THE FINDINGS

Rural–to–urban migrants are at high risk for HIV/STD infection. HIV prevention intervention efforts among this population are of great urgency in China. A general high level of WTP suggests that HIV/STD prevention activities are acceptable among rural–to–urban migrants. However, the negative association of WTP with risk behavior indicates those at highest risk for HIV/AIDS infection may be the most difficult group to be recruited into health education and promotion. The negative association of WTP with HIV–related stigma highlights the importance of HIV–related stigma reduction. Health policy makers must realize this phenomenon and view stigma reduction as an important component of an effective HIV prevention plan. Health care professionals should work together with professionals from other sectors, especially those from mass media, to reduce both risk behaviors and discrimination, fear, or hostility toward people with HIV.

Acknowledgments

The study is funded by NIMH/NIH Grant R01MH64878. The authors thank their participating investigators at Beijing Normal University Institute of Developmental Psychology, Nanjing University Institute of Mental Health and West Virginia University School of Medicine for their contributions to questionnaire development and data collection. The authors also thank Matthew L. Cole, M.A. for his assistance during manuscript preparation.

Contributor Information

Hongmei Yang, Wayne State University Pediatric Prevention Research Center, Detroit, MI.

Xiaoming Li, Wayne State University Pediatric Prevention Research Center, Detroit, MI.

Bonita Stanton, Wayne State University Pediatric Prevention Research Center, Detroit, MI.

Xiaoyi Fang, Beijing Normal University Institute of Developmental Psychology.

Danhua Lin, Beijing Normal University Institute of Developmental Psychology.

Rong Mao, Nanjing University Institute of Mental Health.

Xinguang Chen, Wayne State University Pediatric Prevention Research Center, Detroit, MI.

Hongjie Liu, Wayne State University Pediatric Prevention Research Center, Detroit, MI.

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