kiến thức về suc khoe tinh duc ở trẻ vị thành niên trung quốc

Western Journal of Nursing Research, 2001, 23(2), 211-222
Western Journal of Nursing Research
March 2001, Vol. 23, No. 2

Knowledge of and Attitudes Toward
Sex Among Chinese Adolescents
Wan-Yim Ip
Janita P. C. Chau
Anne M. Chang
May H. L. Lui

This study was conducted to examine the knowledge of and attitudes toward sex of 178 Chinese
secondary school students in Hong Kong. The data were collected using a questionnaire that
comprised three parts: the Chinese version of the Mathtech Knowledge Test, the Chinese version
of the Mathtech Attitude and Value Scale, and a demographic sheet seeking sociodemographic
information. In general, students demonstrated a low level of sexual knowledge, especially in
relation to adolescent marriage, the probability of pregnancy, and adolescent sexual activity.
With regard to attitudes, students indicated positive attitudes toward importance of family and
importance of birth control. Male students in comparison with their female counterparts had a
higher level of agreement with premarital intercourse and the use of pressure and force in sexual
activity.

In Hong Kong, little is known about the sexual attitudes and behavior of
Chinese adolescents. Most studies investigating Chinese young people’s
knowledge and attitudes toward sex have been done on college students
(Chan, 1990; Tang, Lai, & Chung, 1997). As Tompkins (1999) points out,
nursing practice is effective when an exploration of the clients’ beliefs precedes nursing intervention. To provide appropriate and culturally sensitive education programs to Chinese adolescents, it is necessary to assess
their knowledge of and attitudes toward sex. This study was, accordingly,

Wan-Yim Ip, R.N., R.M.N., B.N., M.Phil., Assistant Professor, Department of Nursing,
The Chinese University of Hong Kong, Shatin, N. T., Hong Kong; Janita P. C. Chau, R.N.,

B.N., M.Phil., Assistant Professor, Department of Nursing, The Chinese University of
Hong Kong, Shatin, N. T., Hong Kong; Anne M. Chang, R.N., Dip.N.Ed., B.Ed.St., M.E.D.
St., F.R.C.N.A., Ph.D., Professor, Department of Nursing, The Chinese University of
Hong Kong, Shatin, N. T., Hong Kong; May H. L. Lui, R.N., B.N., M.Phil., Assistant Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N. T.,
Hong Kong.
© 2001 Sage Publications, Inc.
211

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designed to explore the sexual knowledge and the sexual attitudes among a
sample of Chinese secondary school students.

SEXUAL KNOWLEDGE AND BEHAVIOR

Sex education has been included in the formal and informal curricula of
primary and secondary schools of Hong Kong for many years (Hong Kong
Education Department, 1986). A number of surveys in recent years, however, have revealed that the sexual knowledge of young people was rather
limited, while the incidence of unsafe sex practice had increased (The Family Planning Association of Hong Kong, 1994, 1999; The University of
Hong Kong, 1995). In a telephone survey of 1,038 randomly selected young
people ages 15 to 29 years, 40% of respondents did not use condoms during
sex and one in five young men had used the services of prostitutes. The Family Planning Association of Hong Kong (1999), which offers an integrated
medical and counseling service in fertility and sexuality for unmarried
young people, revealed that the major service sought by women ages 16 to
25 was termination of pregnancy (31.4%) and emergency contraception

(29.3%). These findings indicate that many adolescents have limited knowledge about sexual health.

SEXUAL KNOWLEDGE AND ATTITUDES

Previous studies indicate that sexual behavior is influenced by a number
of factors including knowledge and attitudes. Chan (1990) found that
increased sexual knowledge tended to be associated with the repudiation of
sexual myths. Yi (1998), in his study on 412 Vietnamese American college
students’ knowledge of sex, reported that sexually active participants were
less knowledgeable than those who were less sexually active. Increase in
sexual knowledge alone might not affect behavior; it is equally important to
modify attitudes in designing effective sex education programs (Pleck,
Sonenstein, & Ku, 1991). Educators, sociologists, and psychologists share a
common framework, in which education modifies knowledge or attitudes,
which in turn facilitate behavioral change (Visser & Bilsen, 1994).
A World Health Organization–sponsored study (Grunseit, 1994) conducted in the United States, Europe, Australia, Mexico, and Thailand showed that comprehensive sex education programs led to safer sexual behaviors.

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The sex education classes in these countries could help young people to
postpone sexual intercourse or, if they were already sexually active, to practice safer sex and reduce their number of partners. This study also found
better knowledge when sex education programs were provided before young
people became sexually active and that programs with numerous options
were more effective in promoting safer sexual behavior than those that promote abstinence alone.

FACTORS INFLUENCING SEXUAL
KNOWLEDGE AND ATTITUDES

Specific information about sexual attitudes and knowledge is vital to the
design of effective sex education programs (Lief, Fullard, & Devlin, 1990).
Cultural and social beliefs affect individuals’ attitudes toward sex, which in
turn affect their sexual behavior (Bhugra & de Silva, 1993). Therefore, it is
important to offer culturally sensitive sex education that addresses the common misinformation among the public. Furthermore, sex education programs need to be incorporated into the total cultural system of a given country (International Council of Nurses, 1996). It is important to offer culturally
sensitive sex education that addresses the common misinformation among
the public.
In addition, demographic variables have also been found to influence a
person’s attitudes toward sex (Lewis & Bor, 1994; Payne, 1976). Gender
differences regarding sexual knowledge and attitude have been noted in past
studies (J. S. Chang, Tsang, Lin, & Lui, 1997; The University of Hong
Kong, 1995). J. S. Chang et al. (1997) found that in the Chinese culture, men
have always been more sexually permissive than women with respect to
kissing, petting, and sexual intercourse. From a sociological perspective,
adolescent males have been encouraged to be active rather than passive in
expressing their sexuality so as to develop ways of being in control and to
structure situations to meet their own needs (Macionis, 1995). Nevertheless,
the emerging autonomy for women gained from education and formal employment has exposed women to more opportunities and ideas that encourage sexual permissiveness (Chang et al., 1997). Because there are limited
studies that have explored secondary school students’ sexual knowledge and
attitudes, the purpose of this study was twofold: to examine secondary
school students’ knowledge of and attitudes toward sex and to determine the
gender differences in attitudes toward sex.

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METHOD
Design

The study used a cross-sectional descriptive design to collect data from
180 Grade 9 coeducational secondary school students prior to the commencement of a sexual health education program. Study participation was
voluntary.
Sample

The participants in the study were 178 Chinese Grade 9 students from a
secondary school in New Territories, giving a response rate of 99%. There
were 47.2% boys and 52.8% girls. The ages of the students ranged from 15
to 17 (x = 15.37, SD = 0.55), and 60.7% had no religious belief. Of the students, 57% were studying science, 41.6%, art and 1.1% commercial subjects. Most of the students (92.7%) reported having had no formal education
on sexual health. Of those 13 students having attended a formal sex education program, 10 had received it at school. Whereas approximately 12.4% of
the students had no siblings, 79.2% had one to two siblings.
Procedures

Approval to conduct the study was obtained from the Research Ethics
Committee of The Chinese University of Hong Kong and the secondary
school. All Grade 9 students in the secondary school were invited to participate in the study during the weekly assembly. The research assistant
explained the nature and purpose of the study to the students, with confidentiality and anonymity being assured. The students were also instructed that
they were free to decline to participate in the study at any time.
Instruments

The data were collected using a questionnaire that comprised three parts.
Part 1 comprised items seeking sociodemographic data. Two questions in
particular sought information on whether the students had previously taken
any formal courses on sexuality, and if so, where they had attended the

courses. Parts 2 and 3 were the Chinese version of the Kirby (1990) Mathtech

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Knowledge Test (MKT) and Chinese version of the Kirby (1990) Mathtech
Attitude and Value (MAV) Scales, respectively.
MKT. The English version of the MKT scale (Kirby, 1990) is a 34-item
multiple-choice test comprising 8 areas: adolescent physical development,
adolescent relationships, adolescent sexual activity, adolescent pregnancy,
implications of adolescent marriage, the probability of pregnancy, birth control, and sexually transmitted disease. One mark is given for the correct answer of each item. The test-retest reliability coefficient was .89 (Kirby,
1990). In the current Chinese version of MKT, two items regarding adolescent pregnancy and abortion rate in America were omitted, as they were not
related to the degree of sexual knowledge our students possess. The
Kuder-Richardson 20 (KR20) coefficient for the 32-item Chinese MKT in
this study was .76.
MAV Scale. This scale is a 70-item self-report, 5-point forced choice rating
measure (e.g., 1 = strongly disagree, 5 = strongly agree). There are 14
subscales, including the following: clarity of long-term goals (e.g., “I know
what I want out of life”), clarity of personal sexual values (e.g., “I have my
own set of rules to guide my sexual behavior”), understanding of emotional
needs (e.g., “I know what I need to be happy”), understanding of personal
social behaviors (e.g., “I usually understand how I behave around others”),
understanding of personal sexual responses (e.g., “I know how I react in different sexual situations”), recognition of the importance of the family (e.g.,
“Families are very important”), self-esteem (e.g., “I feel that I have many
good personal qualities”), satisfaction with personal sexuality (e.g., “I’m
happy with my sexual behavior now”), satisfaction with social relationships

(e.g., “I am very happy with my friendships”), sexuality in life (e.g., “A sexual relationship is one of the best things a person can have”), various gender
role behaviors (e.g., “Women should behave differently from men most of the
time”), the importance of birth control (e.g., “More people should be aware of
the importance of birth control”), premarital intercourse (e.g., “People
should not have sex before marriage”), and the use of pressure and force in
sexual activity (e.g., “No one should pressure another person into sexual
activity”). Subscale scores were derived by summing the appropriate items,
with higher scores indicating higher levels of agreement with the attitudes or
values (Kirby, 1990). The internal consistency of these subscales for the English version has been established with Cronbach’s alpha coefficients ranging
from .94 to .58 (Kirby, 1990). The reliability coefficient for the Chinese

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TABLE 1: Mean Scores and Standard Deviations for the Chinese Mathtech Attitude and Value Scale (N = 178)

Overall Score
Scale
Attitude toward the importance of birth control
Recognition of the importance of the family
Attitude toward the use of pressure and force in
sexual activity
Understanding of personal social behavior
Attitude toward various gender role behaviors
Understanding of emotional needs
Clarity of long-term care goals

Clarity of personal sexual values
Understanding of personal sexual responses
Satisfaction with social relationships
Attitude toward sexuality in life
Satisfaction with personal sexuality
Self-esteem
Attitude toward premarital intercourse

Cronbach’s Alpha

M

SD

.71
.62

4.24
4.14

0.60
0.59

.50
.73
.50
.56
.79
.66
.61

.71
.65
.59
.66
.91

3.78
3.56
3.55
3.55
3.43
3.43
3.31
3.28
3.24
3.11
3.11
2.90

0.61
0.67
0.61
0.54
0.80
0.59
0.50
0.73
0.62
0.42
0.42

1.00

NOTE: Each subscale consists of 5 items.

version in this study for the total scale was .87 and for the subscales ranged
from .91 to .50 (see Table 1).
Face validity of the instruments had been assured through discussion
among local experts in the field, and the instruments were considered relevant for use in Chinese culture. Bilingual research assistants translated the
MKT and MAV into Chinese, aiming for conceptual rather literal meaning
of items. Back translation was carried out by another, independent bilingual
research assistant (Brislin, 1970). Discrepancies between the original and
back-translated English versions were identified and modified according to
the opinion of bilingual experts with the necessary knowledge to understand
the implied concepts in both languages. Two Form 1 secondary school students were asked to complete the translated versions and did not report any
difficulties in understanding the items.

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TABLE 2: The Adjusted Mean Scores and Standard Deviations for the Chinese
Mathtech Knowledge Test (N = 178)

Scale

Number of Items

Adolescent physical development
Adolescent relationships
Adolescent sexual activity
Adolescent pregnancy
Adolescent marriage
Birth control
Sexually transmitted disease
The probability of pregnancy

7
2
3
2
3
7
5
3

M

SD

.62
.67
.41
.70
.27
.47
.48
.37

.18
.34
.31
.30
.23
.21
.21
.29

RESULTS
Knowledge of Sex

The mean score for the total MKT was 15.94 (SD = 4.16). Comparison
between the subscales, each with a different number of items, was facilitated
by the use of the adjusted mean derived by dividing each subscale by the
number of items in that subscale. As shown in Table 2, the students had comparatively high scores in three knowledge areas: adolescent pregnancy, adolescent relationships, and adolescent physical development, whereas the
implications of the adolescent marriage subscale had the lowest mean score.
In other words, the students were quite knowledgeable about physical and
social aspects of sexuality but were comparatively weak in knowledge about
implications of adolescent marriage.
Attitudes Toward Sex

The means and standard deviations of MAV total and subscale scores are
presented in Table 1. The computed mean ratings ranged from 4.25 (SD =
0.60) to 2.90 (SD = 1.00). Variability of ratings across students as indicated
by the corresponding standard deviations was small, ranging from 0.42 to
1.00. The highest scores were for recognition of the importance of the family
and the importance of birth control. Adolescents’ attitude toward premarital
intercourse was scored the lowest. In other words, the students place a higher

value on family relationships and the importance of birth control but tended
to be neutral toward the issue of premarital sex.

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TABLE 3: Gender Differences on Sex Attitude Subscales Scores

Male (n = 84)
Subscale
Clarity of personal sexual values
Attitude toward various gender role behaviors
Attitude toward sexuality in life
Attitude toward use of pressure and force
in sexual activity
Attitude toward premarital intercourse
NOTE: C.I. = confidence interval.
*p < .05. **p < .01.

Female (n = 94)

M

SD

M

SD

t

95% C.I.

16.10
17.20
16.83

2.93
3.34
3.35

17.22
18.24
15.62

2.85
2.67
2.80

–2.60*
–2.31*
2.64*

–.27, –1.98
–.15, –1.93
.30,

2.14

18.17
12.89

3.18
4.91

19.51
15.95

2.77
4.73

–3.05**
–4.22**

–.46, –2.22
–1.63, –4.48


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Gender Differences on Attitudes Toward Sex

Differences between genders were examined using t tests for the 14
MAV subscales. Table 3 shows that there were significant differences
between male and female students for five MAV subscale scores, including

clarity of personal sexual values, attitude toward various gender role behaviors, attitude toward sexuality in life, attitude toward use of pressure and
force in sexual activity, and attitude toward premarital intercourse. In other
words, male students in comparison with their female counterparts had lower
levels of agreement on clarifying their personal sexual values and developing positive sexual relationships but had higher levels of agreement on premarital intercourse and the use of pressure and force in sexual activity. Concerning gender role behavior, female students appeared more likely to have
attitudes consistent with their gender role status.

DISCUSSION

This group of students generally had a low level of knowledge of sex,
particularly with regard to the issues of marriage, sexual activity, birth
control, and the probability of pregnancy. The low level of knowledge
about the implications of marriage while still an adolescent was not unexpected. The low level of knowledge of birth control, sexually transmitted
disease, and the probability of pregnancy indicated the areas that need to be
addressed in the development of sex education programs. The lack of such
knowledge may result in young adolescents’ unsafe sex practices (Matasha &
Ntembelea, 1998).
In fact, these findings of inadequate sexual knowledge by the adolescents
were consistent with previous research results (Chan, 1990; Chau & Chang,
1999; Shek & Mak, 1989). This phenomenon may be explained by inadequacy in the access to sources of information accessible by this group of students as only a minority had attended formal sex education in school.
Although the Hong Kong Education Department (1986) has advised schools
to provide quality sex education programs that cover sensitive and contentious issues about sex, the findings of this current study indicate that sex education may not have been fully implemented. According to Shek and Lam
(1985), sex education should be regarded as a formal subject in the school
curriculum in Hong Kong secondary schools. The current sex education programs tend to be more ad hoc and reliant on extracurricular activities.

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The findings that the students’ attitudes toward the majority of the items
related to sexual health, particularly premarital sex, tended toward neutral
suggests that the students in that group may not have formed a definite opinion about what is an acceptable or unacceptable expression of sexuality. In
most Chinese families, social order and control of emotions and feelings are
highly valued, therefore, open discussion and expression of sexuality may
be unusual for teenagers (Hirayama & Hirayama, 1986). Moreover, because
attitudes toward sexuality may not be reflected in behaviors (J. S. Chang
et al., 1997), it is necessary to investigate the sexual practice of this cultural
group in future studies.
In this study, adolescents’ attitudes toward the importance of the family
and the importance of birth control were particularly strong. Family is one of
the many factors that could be influential in the development of adolescent
attitudes about sex (Bhugra & de Silva, 1993). Such a high level of agreement with the importance of positive attitudes toward the family was demonstrated in this study. Chinese sexuality is based mainly on the Confucian
and Taoist traditions, which emphasize procreation and social order, with
sex for pleasure and outside wedlock being prohibited as it may break family
relationships (J. Chang, 1997; Ng & Lau, 1990). Besides, talking about sex
is a taboo area in many traditional Chinese families, with most of the older
generation’s having received no sex education themselves and not knowing
how to approach the subject (J. Chang, 1997). Therefore, to enhance the positive influence of the family on adolescents’ attitudes toward sex, health care
professionals should provide appropriate sex education for parents who do
not know how to engage children in discussion on the sensitive subjects
about sex.
The awareness of using birth control demonstrated by the adolescents in
this study was relatively high, although the actual number of students who
knew how to use condoms had not been recorded. In another Hong Kong
study by the Social Science Research Center (The University of Hong Kong,
1995), however, the actual number of adolescents who reported using condoms was lower than the number who reported their intention to use them.
Ignorance about condoms and the low rate of usage might lead to the spread
of AIDS, STDs, and pregnancy among teenagers (Schwartz, 1996). Further

studies are needed to investigate the barriers and the benefits encountered by
adolescents in using condoms and other birth control methods (Hanna, 1999).
Last but not least, the finding that boys were more permissive toward premarital intercourse is consistent with the finding reported by Minakshi
(1997). In addition, Sue’s (1979) findings that a higher proportion of men
than women fantasized about forcing others into sexual relationships may

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help explain the boys’ higher agreement with the use of pressure and force in
sexual activity. Notwithstanding, the potential self-reporting bias should
be taken into consideration in the interpretation of the results, as young
boys and girls might report what they perceive to be socially desirable
responses rather than report their actual attitudes (Leighton & Freya, 1992).
Qualitative data might be needed to gain insight into the basis on which boys
and girls formulate their responses with respect to the items. Clearly, sex
educators should always be sensitive to the differences between girls’ and
boys’ attitudes regarding expression of sexuality and should incorporate it
into the plan of sex education programs.
This study provides a beginning exploration of knowledge and attitudes
toward sex among Chinese secondary school students. The results suggest
that health care professionals need to build partnerships with schools to
develop appropriate sex education programs and counseling to the students.
In doing so, nurses should be sensitive to young people’s sexual health needs
and help clarify positive attitudes and values toward sex. The limitations of
this study include the use of a convenience sample that reduces the ability to

generalize the findings. An additional limitation is the low reliability estimates of some of the MAV subscales that indicate instability in the relationships between the items in those scales. Further testing of the reliability of
the instrument is needed. Further research on a larger sample with a wider
age range would help to identify the students’ needs for sex education.

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