Applied Research and Evaluation NUTRITIONAL ATTITUDES OF HOMOSEXUAL PEOPLE LIVING WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV) IN CHONGQING, SOUTHWEST CHINA: A CROSS-SECTIONAL STUDY*
WENJIE ZHOU, MSc. Chongqing Medical University, China RUI MA, MSC, PH.D. Jiangsu University, China MANOJ SHARMA, MBBS, PH.D. University of Cincinnati, Ohio YONG ZHAO, MSc. Chongqing Medical University, China
ABSTRACT
This article aimed at understanding nutritional knowledge, attitudes, and behaviors of homosexual persons living with HIV/AIDS in Chongqing, China. A cross sectional design using a valid and reliable survey was used. The survey was completed in Chongqing, Southwest China (n = 172). Knowledge of nutrition was deficient regarding sources of nutrients such as calcium and iron, relationships between diet/nutrients and disease, and only 36.1% of participants knew about the Balanced Diet Pagoda for Chinese.
*Supported in part by a research grant from Global Fund’s sixth funding round for AIDS Project (No. LF-80) and Jiangsu University Fund of Advanced Talent (08JDG019).
Int’l. Quarterly of Community Health Education, Vol. 34(1) 87-100, 2013-2014 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/IQ.34.1.g http://baywood.com 87
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Eating habits did not meet the nutritional requirements, and a majority (59.3%) did not eat breakfast every day. The average score on the knowledge quiz was 51.8%. This study showed that homosexual persons with HIV/AIDS in China longed for nutrition knowledge, and this was supported by objective data. Efforts and targeted education programs aiming to improve their nutrition knowledge, attitudes, and behaviors need to be emphasized.
INTRODUCTION AIDS, as a new disease, was first recognized in 1981 [1]. HIV continues to spread among the homosexual population on a global level [2, 3]. Estimates of the number in China have increased from 650,000 in 2005 to 780,000 in 2011, although the estimated prevalence of HIV remained rather low (0.050% in 2005, 0.054% in 2007, 0.057% in 2009, and 0.058% in 2011) [4-6]. In China, STD infection and commercial sex have been monitored under current HIV prevention strategies. It has been shown that the HIV/AIDS epidemic has been growing and its characteristics have been changing. There have been an increasing number of male sexual partners over the years; hence, homosexual contact plays an important role in transmission routes of HIV/AIDS. However, homosexuals are still among the neglected populations [6-8], especially in resource-limited settings like Southwest China. Without available effective vaccine and treatment for HIV/AIDS, nutritional support is critically important for these people living with HIV [9-11]. Nutrition supplementation was found to be more effective in delaying HIV disease progression [12]. Because nutrition is intrinsically linked to immune function, it plays a vital role in the care and management of HIV and AIDS. Furthermore, risk of opportunistic infections in developing countries with AIDS-related illnesses, reduced dietary intake, malabsorption and increased energy expenditure, etc., and malnutrition is associated with decreased survival rate of HIV/AIDS patients [13-15]. However, nutrition support has long been ignored in China’s HIV/AIDS treatment and care, especially in Southwest China. Recently, Wen Hu and colleagues reported that research on the participants, hospitalized HIV positive patients, suggested that nutrition evaluation and support should be considered as integral parts of national and community HIV/AIDS treatment and care guidelines [15]. There has been a paucity of literature about education programs for homosexual persons with HIV/AIDS in China. Without healthy diet, however, treatment and rehabilitation directed toward HIV/AIDS have limited impact on the disease [16, 17]. Research has shown that both macronutrient and micronutrient deficiencies contribute to immune dysfunction and can lead to progression of the disease [18, 19]. On the one hand, AIDS might be caused by over-consumption of nutrition due to the virus replicating ad libitum [16], on the other hand HIV infection and malnutrition constitute
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a vicious pathway toward harmful progression [20-23]. Hence, balanced nutrition is vital for a program of care, and the efficacy of treatment may be compromised by improper nutrition [24]. HIV/AIDS can be treated effectively by recovering the proper nutrients, which can be enhanced by knowledge of good nutrition and proper diet for the persons suffering from HIV [25-28]. Furthermore, good nutrition is not only a method of treating disease, but also can prevent the disease from spreading [29-31]. Nutrition education is among the most cost-effective health interventions [32]. In order to provide directions for designing of nutrition interventions, it is very important to evaluate what persons with HIV already know and what they want to know. This is especially important in the subpopulation in Southwest China which is a developing area. And nutrition evaluation and support should be considered integral parts of national and community HIV/AIDS treatment and care guidelines [14]. To guide the design of an effective nutritional manual for homosexual carriers, we performed a targeted needs assessment to determine the nutritional knowledge, attitudes, and behavior survey of persons with HIV/AIDS in Chongqing, mainly using a structured questionnaire investigation. METHODS Ethics Statement The study protocol and informed consent form received ethics approval from the Committee on Human Experimentation of Chongqing Medical University and Chongqing Center for Disease Control and Prevention. Written informed consent concerning conduct of the privacy of individuals in processing personal data and maintained confidentiality of individual records and accounts was obtained from all participants. Participation in this study did not affect the further free health examination and treatment which is standard protocol in China. Population and Sample According to Chinese Law on the Prevention and Treatment of Infectious Diseases, any unit must report to the Center for Disease Control and Prevention (CDC) once it finds an infectious disease, and any unit or individual must respond to the inquiries by health institutions and accept their related examinations and investigations. Once diagnosed, persons living with HIV/AIDS will be registered with their respective provincial CDC. In Chongqing, there were 15,298 persons living with HIV/AIDS in 2011, and 2,478 new infections. Of these, 91.4% was mainly via sexual contact (23.0% was homosexual contact) in the Chongqing municipality. The present study was conducted in Chongqing, which is China‘s fourth largest municipality and is directly under the central government and the economic
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center of Western China. In Chongqing municipality, transmission of HIV/AIDS occurs mainly via sexual contact, and homosexual contact accounted for about one-quarter. The homosexual persons living with HIV/AIDS were registered with the Chongqing Center for Disease Control and Prevention. This study’s data was provided by Chongqing municipality CDC. Participants were sampled by tables of random number among all homosexual persons living with HIV/AIDS who were registered in Chongqing municipality CDC by August 2011. The participants were randomly selected for a cross-sectional quantitative questionnaire survey in this study, and met the inclusion criteria: (1) positive for HIV antibody, (2) via homosexual contact, (3) ranging in age from 20-65 years, (4) must contain 20% female individuals, and (5) sampled individuals visited the CDC during the study period (August to September 2011). According to the inclusion criteria, there were a total of 172 homosexual persons living with HIV/AIDS: 136 males (79.1%) and 36 females (20.9%), aged 22-62 years (mean 35.47, SD 9.96). Instrument The questionnaire was based on the health knowledge-attitude-behavior model, specifically designed for the target population, and completed after repeated discussions with experts and pilot investigation, and had acceptable face and content validity and readability. The questionnaire contained both open-ended and closed-ended questions, including five sections: basic information, nutrition knowledge-attitude-behavior, and the needs for nutritional education. Survey Implementation The investigation was carried out after explanation of the aim of the research by investigators who had undergone unified rigorous training and were familiar with approach, objective, methodology, especially in the handling of potentially sensitive issues. Participants were informed that they could withdraw from the study at any stage and confidentiality was assured. With the approval of the participants, a private interview had been conducted in a separate room in order to ensure the information was complete and exact as much as possible. Data Analysis The questionnaire data were checked carefully before entered into the database of Epi-data3.1 software. After strict sorting, data cleaning and analyses were conducted using statistical analysis system software (version 9.0; SAS Institute, Cary, NC). Missing data were excluded and all data entries were double-checked to avoid errors. Statistical analyses mainly used the descriptive statistical analyses. All statistics were performed using a two-sided test and a p-value < 0.05 was considered statistically significant.
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RESULTS Demographic Characteristics of Participants Demographic characteristics of participants are shown in Table 1. By September 30, 2011, there were 172 homosexual persons living with HIV/AIDS, aged 22-62 years (mainly youth and middle-aged people, 20~29: 20.9%; 30~39: 33.2%; 40~49: 23.3%). Participants had various occupations and different education backgrounds. Of the participants, 54.1% were unemployed or had unstable occupations. The education backgrounds of participants ranged from primary school to undergraduate degree, and the percent of high, secondary, and elementary education was 32.1%, 30.3%, and 37.6%, respectively.
Table 1. Demographic Characteristics of Participants (n = 172) Variable
n
Percentage (%)
136 36
79.1 20.9
Age 22-29 30-39 40-49 50-59 60-62
60 57 40 11 4
34.9 33.1 23.3 6.4 2.3
Occupation Local workers Peasants Migrant workers Students Freelances Unemployed persons
47 2 13 3 14 93
27.3 1.2 7.6 1.7 8.1 54.1
Education High education Secondary education Elementary education
53 50 62
32.1 30.3 37.6
Gender Male Female
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Nutrition Knowledge The participants had poor nutritional knowledge and many misunderstandings pertaining to nutrition. The average correct score on the knowledge quiz was 51.8%. Awareness of the microelements (like calcium and iron) was especially lacking. Vitamin B and Dietary Guidelines for Chinese Residents was very low, no more than 45.0%. And participants had misunderstandings about “people living with HIV virus need foods with anti-oxidative effects.” The correct rate of the nutrition knowledge of the participants is shown in Table 2. Nutrition knowledge was particularly lacking on food nutrition. For example, only 18.0% of participants knew the correct answer to the question “Is iron in animal food better than that in vegetables?” And only 18.0% of participants had heard of the Dietary Guidelines for Chinese Residents.
Table 2. Correct Rate of Nutrition Knowledge of Participants (n = 172)
Questions Is soy protein high-quality protein?
Number of Correct correct opinion percentage holders (%) 145
84.3
Is calcium in milk better than that in bone soup?
41
23.8
Is iron in animal food better than that in vegetables?
31
18.0
Is pure water more nutritious than common water?
110
64.0
Do iron supplements help to improve immunity?
90
52.3
Is refined white flour lacking some vitamins?
77
44.8
Does eating more salt make people feel better?
122
70.9
Is the more expensive the food, the higher the nutritional value of food?
148
86.1
70
40.7
Do people living with HIV virus need extra nutritional supplements?
100
58.1
Can an apple be eaten after removing its degenerate part?
143
83.1
Have you heard of “Dietary Guidelines for Chinese Residents”?
62
36.1
1069
51.8
Do people living with HIV virus need foods with anti-oxidative effects?
Total
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Nutrition Attitudes The attitude and self-cognition of the participants toward nutrition knowledge is shown in Table 3. The attitudes of most participants toward nutrition knowledge were positive. Most participants were eager to obtain nutrition knowledge. More than 90.0% of participants (n = 155) were willing to change their eating habits for health benefits. Their general awareness rate of self-cognition of nutritional knowledge and nutritional attitude toward dietary were 55.2% and 69.8%, respectively.
Table 3. Attitude and Self-Cognition of Participants toward Nutrition Knowledge (n = 172) Variable
Number of Percentage opinion holders (%)
Attitude of the participants toward nutrition knowledge Nutrition associated with the progression of AIDS?
116
67.4
Nutrition strengthening is effective to treat the disease?
132
76.7
Are you willing to change your eating habits for health benefits?
155
90.1
Infected with HIV, have you paid more attention to health?
121
70.4
Infected with HIV, have you paid more attention to diet?
102
59.3
15 95 62
8.7 55.4 36.1
29 120 23
16.9 69.8 13.4
Self-cognition of nutritional knowledge Much General Little Self-perception of nutritional attitude toward diet Much General Little
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Nutrition Behaviors The participants’ eating habits did not meet the balanced nutritional requirements. The main foundations of food choices of the participants were the nutritional value of foods or their nutritional needs and taste or eating habits. More than half of the persons (59.3%) did not eat breakfast every day. The main reason why most of the participants did not have breakfast every day was they did not have enough time or did not want to have breakfast every day. Additionally, the dietary pattern of three meals needs to be improved. The survey also found that nearly half of the participants (47.1%) eat snacks. The types of snack foods were biscuit, dessert, candy, melon seeds, ice cream, puffed food, and fruit jelly. Great changes of food consumption have taken place for most of the people after being infected, as shown in Table 4. The percentage of persons that decreased their consumption of snack foods and home food storage was 24.0% and 28.1%, respectively, but 41.5% of participants increased their food consumption levels. The changes of appetite in persons after infection are shown in Table 5. The changes of appetite of 47.8% of persons were dwindling (29.2% persons did not want to eat food occasionally, 16.4% persons lost their appetite, and 1.2% persons had no appetite). Needs for Nutritional Education Participants had many suggestions for the development of the manual for persons with HIV/AIDS to acquire nutrition knowledge. Contents of nutrition knowledge of manuscript wanted by participants (n = 171) are shown in Figure 1, and most persons with HIV/AIDS were interested in the six content areas. They need nutrition knowledge including what nutrients are good for persons with HIV/AIDS, how to use vitamin and mineral supplements, and the balanced diet pagoda of Chinese residents.
Table 4. Changes of Food Consumption of Persons After Infection Consumption after infection
Increasing
Decreasing
No change
Snack foods (such as raisins, peanuts, chocolate, etc.)
20 (11.7%)
41 (24.0%)
110 (64.3%)
Family food storage (instant noodles, biscuits, mineral water, etc.)
15 (8.8%)
48 (28.1%)
108 (63.2%)
Food consumption levels
71 (41.5%)
20 (11.7%)
80 (46.8%)
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Table 5. Changes in Appetite of Persons After Infection Number of opinion holders
Percentage (%)
Had a good appetite
42
24.6
Did not want to eat food occasionally
50
29.2
Lost their appetite
28
16.4
2
1.4
49
28.7
Appetite of persons after infection
Had no appetite Did not change at all
Figure 1. Contents of nutrition knowledge participants expected to obtain.
DISCUSSION Nutrition is fundamentally important for HIV prevention, treatment, care, support, and quality of life. The deficiency of nutritional education for persons with HIV/AIDS is a common problem in the world [20], especially in developing countries [21]. This article aimed at providing the basic nutrition-related data in homosexual persons living with HIV/AIDS, and articulating recommendations for developing nutrition education programs for these people.
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The Nutrition Knowledge According to the above knowledge-attitude-behavior survey, we can find that participants had poor nutritional knowledge, and even many misperceptions. Despite one-third having higher education background, a large majority of the participants had neither the necessary knowledge of daily nutrition nor the knowledge of nutrition for AIDS, which is consistent with the former research about the knowledge of persons with HIV/AIDS in Canada [22]. These results should be ascribed to the conditions that society paid little attention to special subpopulation’s nutrition and there was little knowledge about nutrition for homosexual persons with HIV/AIDS available in media in developing countries. The Nutrition Attitudes Although participants had poor nutritional knowledge, they held positive attitude to learn. Of the 172 participants, 155 (90.0%) were willing to change their eating habits for health benefit, which is similar with the former research [14, 21]. The needs for knowledge were very urgent, and participants thought nutrition knowledge was critically important for them. The Nutrition Behaviors Nutrition behavior of participants did not meet the health requirement. Only 63.5% of participants selected food by the nutritional value or their nutritional needs. Up to 16.4% of the participants have poor appetites. The poor diet among persons with HIV/AIDS may also result from loss of appetite, thus reducing the frequency of meal and variety of the diet at the very time while their requirements are higher for the virus. We recommend that persons with HIV/AIDS have four meals a day and eat more protein. Although participants had poor behavior, they had positive attitude to change. Of the 172 participates, 90.0% were willing to change their eating habits for health benefit, which is similar results to the former research [20, 23]. Needs for Nutritional Education From the survey, the participants gave many suggestions for the development of the manual to convey nutrition knowledge (shown in result), so we should pay more attention to providing more instructions in practical behavior for them. Many studies have shown that nutrition education will be effective when it pay attention to practice [24, 29]. The nutrition knowledge and positive attitudes gained by persons with HIV/AIDS should be followed up to ensure that they are transformed into good dietary practices. The large majority (90.1%) of the study participants was willing to change their eating habits for health benefits, so developing an
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HIV/AIDS-based nutritional education program will have practical meaning. The education must help them better understand basic nutritional knowledge as well as AIDS-related contents, to promote the rational nutrition cognition, and to arrange diet. For example, which kind of food benefits more for persons with HIV/AIDS? Considering the different education backgrounds, the education manual should have different editions for different subpopulation. Additionally, it can be found that the means of obtaining nutrition knowledge were diverse. Though books were still important sources, a number of new media became more and more important, such as Twitter, Facebook, and Short Message Service (SMS) [31]. The Internet was widely used by the participants, which suggests that the manual can be presented as an electronic version for release on the website. Electronic means are increasingly used to distribute educational materials about AIDS [32], so we should not only think about the contents of education but also focus on the new conveying means [33]. This study shows that homosexual persons with HIV/AIDS in a developing country longed for nutrition knowledge, which was missing in the system. Extra efforts and targeted education programs aimed to improve their nutrition knowledge, attitudes, and behaviors need to be emphasized. Nutrition education about dietary behavior for homosexual persons with HIV/AIDS is urgent and of practical significance; in order to meet the different needs, various editions and conveying forms should be presented in a developing country.
ACKNOWLEDGMENTS We sincerely acknowledge Xiaoyang Xu, MSc., Ph.D.; Linli Han, MSc.; Yong Zhang, MSc., Ph.D.; and Huan Zeng, MSc., Ph.D. at Chongqing Medical University; Haiping Xia, MSc. at Faculty of Medical Science and Laboratory Medicine; and Xianbin Ding, MSc.; Rongrong, Lu, MSc. at Chongqing Center for Disease Control and Prevention for their kind help. The opinions expressed in this article are those of the authors and do not necessarily represent those of Global Fund or Jiangsu University Fund of Advanced Talent.
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Direct reprint requests to: Yong Zhao, MSc. 228#, No. 1, Yixueyuan Road Yuzhong District School of Public Health and Management Chongqing Medical University Chongqing, 400016, China e-mail: [email protected]
WENJIE ZHOU, MSc. Chongqing Medical University, China RUI MA, MSC, PH.D. Jiangsu University, China MANOJ SHARMA, MBBS, PH.D. University of Cincinnati, Ohio YONG ZHAO, MSc. Chongqing Medical University, China
ABSTRACT
This article aimed at understanding nutritional knowledge, attitudes, and behaviors of homosexual persons living with HIV/AIDS in Chongqing, China. A cross sectional design using a valid and reliable survey was used. The survey was completed in Chongqing, Southwest China (n = 172). Knowledge of nutrition was deficient regarding sources of nutrients such as calcium and iron, relationships between diet/nutrients and disease, and only 36.1% of participants knew about the Balanced Diet Pagoda for Chinese.
*Supported in part by a research grant from Global Fund’s sixth funding round for AIDS Project (No. LF-80) and Jiangsu University Fund of Advanced Talent (08JDG019).
Int’l. Quarterly of Community Health Education, Vol. 34(1) 87-100, 2013-2014 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/IQ.34.1.g http://baywood.com 87
88 / ZHOU ET AL.
Eating habits did not meet the nutritional requirements, and a majority (59.3%) did not eat breakfast every day. The average score on the knowledge quiz was 51.8%. This study showed that homosexual persons with HIV/AIDS in China longed for nutrition knowledge, and this was supported by objective data. Efforts and targeted education programs aiming to improve their nutrition knowledge, attitudes, and behaviors need to be emphasized.
INTRODUCTION AIDS, as a new disease, was first recognized in 1981 [1]. HIV continues to spread among the homosexual population on a global level [2, 3]. Estimates of the number in China have increased from 650,000 in 2005 to 780,000 in 2011, although the estimated prevalence of HIV remained rather low (0.050% in 2005, 0.054% in 2007, 0.057% in 2009, and 0.058% in 2011) [4-6]. In China, STD infection and commercial sex have been monitored under current HIV prevention strategies. It has been shown that the HIV/AIDS epidemic has been growing and its characteristics have been changing. There have been an increasing number of male sexual partners over the years; hence, homosexual contact plays an important role in transmission routes of HIV/AIDS. However, homosexuals are still among the neglected populations [6-8], especially in resource-limited settings like Southwest China. Without available effective vaccine and treatment for HIV/AIDS, nutritional support is critically important for these people living with HIV [9-11]. Nutrition supplementation was found to be more effective in delaying HIV disease progression [12]. Because nutrition is intrinsically linked to immune function, it plays a vital role in the care and management of HIV and AIDS. Furthermore, risk of opportunistic infections in developing countries with AIDS-related illnesses, reduced dietary intake, malabsorption and increased energy expenditure, etc., and malnutrition is associated with decreased survival rate of HIV/AIDS patients [13-15]. However, nutrition support has long been ignored in China’s HIV/AIDS treatment and care, especially in Southwest China. Recently, Wen Hu and colleagues reported that research on the participants, hospitalized HIV positive patients, suggested that nutrition evaluation and support should be considered as integral parts of national and community HIV/AIDS treatment and care guidelines [15]. There has been a paucity of literature about education programs for homosexual persons with HIV/AIDS in China. Without healthy diet, however, treatment and rehabilitation directed toward HIV/AIDS have limited impact on the disease [16, 17]. Research has shown that both macronutrient and micronutrient deficiencies contribute to immune dysfunction and can lead to progression of the disease [18, 19]. On the one hand, AIDS might be caused by over-consumption of nutrition due to the virus replicating ad libitum [16], on the other hand HIV infection and malnutrition constitute
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a vicious pathway toward harmful progression [20-23]. Hence, balanced nutrition is vital for a program of care, and the efficacy of treatment may be compromised by improper nutrition [24]. HIV/AIDS can be treated effectively by recovering the proper nutrients, which can be enhanced by knowledge of good nutrition and proper diet for the persons suffering from HIV [25-28]. Furthermore, good nutrition is not only a method of treating disease, but also can prevent the disease from spreading [29-31]. Nutrition education is among the most cost-effective health interventions [32]. In order to provide directions for designing of nutrition interventions, it is very important to evaluate what persons with HIV already know and what they want to know. This is especially important in the subpopulation in Southwest China which is a developing area. And nutrition evaluation and support should be considered integral parts of national and community HIV/AIDS treatment and care guidelines [14]. To guide the design of an effective nutritional manual for homosexual carriers, we performed a targeted needs assessment to determine the nutritional knowledge, attitudes, and behavior survey of persons with HIV/AIDS in Chongqing, mainly using a structured questionnaire investigation. METHODS Ethics Statement The study protocol and informed consent form received ethics approval from the Committee on Human Experimentation of Chongqing Medical University and Chongqing Center for Disease Control and Prevention. Written informed consent concerning conduct of the privacy of individuals in processing personal data and maintained confidentiality of individual records and accounts was obtained from all participants. Participation in this study did not affect the further free health examination and treatment which is standard protocol in China. Population and Sample According to Chinese Law on the Prevention and Treatment of Infectious Diseases, any unit must report to the Center for Disease Control and Prevention (CDC) once it finds an infectious disease, and any unit or individual must respond to the inquiries by health institutions and accept their related examinations and investigations. Once diagnosed, persons living with HIV/AIDS will be registered with their respective provincial CDC. In Chongqing, there were 15,298 persons living with HIV/AIDS in 2011, and 2,478 new infections. Of these, 91.4% was mainly via sexual contact (23.0% was homosexual contact) in the Chongqing municipality. The present study was conducted in Chongqing, which is China‘s fourth largest municipality and is directly under the central government and the economic
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center of Western China. In Chongqing municipality, transmission of HIV/AIDS occurs mainly via sexual contact, and homosexual contact accounted for about one-quarter. The homosexual persons living with HIV/AIDS were registered with the Chongqing Center for Disease Control and Prevention. This study’s data was provided by Chongqing municipality CDC. Participants were sampled by tables of random number among all homosexual persons living with HIV/AIDS who were registered in Chongqing municipality CDC by August 2011. The participants were randomly selected for a cross-sectional quantitative questionnaire survey in this study, and met the inclusion criteria: (1) positive for HIV antibody, (2) via homosexual contact, (3) ranging in age from 20-65 years, (4) must contain 20% female individuals, and (5) sampled individuals visited the CDC during the study period (August to September 2011). According to the inclusion criteria, there were a total of 172 homosexual persons living with HIV/AIDS: 136 males (79.1%) and 36 females (20.9%), aged 22-62 years (mean 35.47, SD 9.96). Instrument The questionnaire was based on the health knowledge-attitude-behavior model, specifically designed for the target population, and completed after repeated discussions with experts and pilot investigation, and had acceptable face and content validity and readability. The questionnaire contained both open-ended and closed-ended questions, including five sections: basic information, nutrition knowledge-attitude-behavior, and the needs for nutritional education. Survey Implementation The investigation was carried out after explanation of the aim of the research by investigators who had undergone unified rigorous training and were familiar with approach, objective, methodology, especially in the handling of potentially sensitive issues. Participants were informed that they could withdraw from the study at any stage and confidentiality was assured. With the approval of the participants, a private interview had been conducted in a separate room in order to ensure the information was complete and exact as much as possible. Data Analysis The questionnaire data were checked carefully before entered into the database of Epi-data3.1 software. After strict sorting, data cleaning and analyses were conducted using statistical analysis system software (version 9.0; SAS Institute, Cary, NC). Missing data were excluded and all data entries were double-checked to avoid errors. Statistical analyses mainly used the descriptive statistical analyses. All statistics were performed using a two-sided test and a p-value < 0.05 was considered statistically significant.
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RESULTS Demographic Characteristics of Participants Demographic characteristics of participants are shown in Table 1. By September 30, 2011, there were 172 homosexual persons living with HIV/AIDS, aged 22-62 years (mainly youth and middle-aged people, 20~29: 20.9%; 30~39: 33.2%; 40~49: 23.3%). Participants had various occupations and different education backgrounds. Of the participants, 54.1% were unemployed or had unstable occupations. The education backgrounds of participants ranged from primary school to undergraduate degree, and the percent of high, secondary, and elementary education was 32.1%, 30.3%, and 37.6%, respectively.
Table 1. Demographic Characteristics of Participants (n = 172) Variable
n
Percentage (%)
136 36
79.1 20.9
Age 22-29 30-39 40-49 50-59 60-62
60 57 40 11 4
34.9 33.1 23.3 6.4 2.3
Occupation Local workers Peasants Migrant workers Students Freelances Unemployed persons
47 2 13 3 14 93
27.3 1.2 7.6 1.7 8.1 54.1
Education High education Secondary education Elementary education
53 50 62
32.1 30.3 37.6
Gender Male Female
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Nutrition Knowledge The participants had poor nutritional knowledge and many misunderstandings pertaining to nutrition. The average correct score on the knowledge quiz was 51.8%. Awareness of the microelements (like calcium and iron) was especially lacking. Vitamin B and Dietary Guidelines for Chinese Residents was very low, no more than 45.0%. And participants had misunderstandings about “people living with HIV virus need foods with anti-oxidative effects.” The correct rate of the nutrition knowledge of the participants is shown in Table 2. Nutrition knowledge was particularly lacking on food nutrition. For example, only 18.0% of participants knew the correct answer to the question “Is iron in animal food better than that in vegetables?” And only 18.0% of participants had heard of the Dietary Guidelines for Chinese Residents.
Table 2. Correct Rate of Nutrition Knowledge of Participants (n = 172)
Questions Is soy protein high-quality protein?
Number of Correct correct opinion percentage holders (%) 145
84.3
Is calcium in milk better than that in bone soup?
41
23.8
Is iron in animal food better than that in vegetables?
31
18.0
Is pure water more nutritious than common water?
110
64.0
Do iron supplements help to improve immunity?
90
52.3
Is refined white flour lacking some vitamins?
77
44.8
Does eating more salt make people feel better?
122
70.9
Is the more expensive the food, the higher the nutritional value of food?
148
86.1
70
40.7
Do people living with HIV virus need extra nutritional supplements?
100
58.1
Can an apple be eaten after removing its degenerate part?
143
83.1
Have you heard of “Dietary Guidelines for Chinese Residents”?
62
36.1
1069
51.8
Do people living with HIV virus need foods with anti-oxidative effects?
Total
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Nutrition Attitudes The attitude and self-cognition of the participants toward nutrition knowledge is shown in Table 3. The attitudes of most participants toward nutrition knowledge were positive. Most participants were eager to obtain nutrition knowledge. More than 90.0% of participants (n = 155) were willing to change their eating habits for health benefits. Their general awareness rate of self-cognition of nutritional knowledge and nutritional attitude toward dietary were 55.2% and 69.8%, respectively.
Table 3. Attitude and Self-Cognition of Participants toward Nutrition Knowledge (n = 172) Variable
Number of Percentage opinion holders (%)
Attitude of the participants toward nutrition knowledge Nutrition associated with the progression of AIDS?
116
67.4
Nutrition strengthening is effective to treat the disease?
132
76.7
Are you willing to change your eating habits for health benefits?
155
90.1
Infected with HIV, have you paid more attention to health?
121
70.4
Infected with HIV, have you paid more attention to diet?
102
59.3
15 95 62
8.7 55.4 36.1
29 120 23
16.9 69.8 13.4
Self-cognition of nutritional knowledge Much General Little Self-perception of nutritional attitude toward diet Much General Little
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Nutrition Behaviors The participants’ eating habits did not meet the balanced nutritional requirements. The main foundations of food choices of the participants were the nutritional value of foods or their nutritional needs and taste or eating habits. More than half of the persons (59.3%) did not eat breakfast every day. The main reason why most of the participants did not have breakfast every day was they did not have enough time or did not want to have breakfast every day. Additionally, the dietary pattern of three meals needs to be improved. The survey also found that nearly half of the participants (47.1%) eat snacks. The types of snack foods were biscuit, dessert, candy, melon seeds, ice cream, puffed food, and fruit jelly. Great changes of food consumption have taken place for most of the people after being infected, as shown in Table 4. The percentage of persons that decreased their consumption of snack foods and home food storage was 24.0% and 28.1%, respectively, but 41.5% of participants increased their food consumption levels. The changes of appetite in persons after infection are shown in Table 5. The changes of appetite of 47.8% of persons were dwindling (29.2% persons did not want to eat food occasionally, 16.4% persons lost their appetite, and 1.2% persons had no appetite). Needs for Nutritional Education Participants had many suggestions for the development of the manual for persons with HIV/AIDS to acquire nutrition knowledge. Contents of nutrition knowledge of manuscript wanted by participants (n = 171) are shown in Figure 1, and most persons with HIV/AIDS were interested in the six content areas. They need nutrition knowledge including what nutrients are good for persons with HIV/AIDS, how to use vitamin and mineral supplements, and the balanced diet pagoda of Chinese residents.
Table 4. Changes of Food Consumption of Persons After Infection Consumption after infection
Increasing
Decreasing
No change
Snack foods (such as raisins, peanuts, chocolate, etc.)
20 (11.7%)
41 (24.0%)
110 (64.3%)
Family food storage (instant noodles, biscuits, mineral water, etc.)
15 (8.8%)
48 (28.1%)
108 (63.2%)
Food consumption levels
71 (41.5%)
20 (11.7%)
80 (46.8%)
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Table 5. Changes in Appetite of Persons After Infection Number of opinion holders
Percentage (%)
Had a good appetite
42
24.6
Did not want to eat food occasionally
50
29.2
Lost their appetite
28
16.4
2
1.4
49
28.7
Appetite of persons after infection
Had no appetite Did not change at all
Figure 1. Contents of nutrition knowledge participants expected to obtain.
DISCUSSION Nutrition is fundamentally important for HIV prevention, treatment, care, support, and quality of life. The deficiency of nutritional education for persons with HIV/AIDS is a common problem in the world [20], especially in developing countries [21]. This article aimed at providing the basic nutrition-related data in homosexual persons living with HIV/AIDS, and articulating recommendations for developing nutrition education programs for these people.
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The Nutrition Knowledge According to the above knowledge-attitude-behavior survey, we can find that participants had poor nutritional knowledge, and even many misperceptions. Despite one-third having higher education background, a large majority of the participants had neither the necessary knowledge of daily nutrition nor the knowledge of nutrition for AIDS, which is consistent with the former research about the knowledge of persons with HIV/AIDS in Canada [22]. These results should be ascribed to the conditions that society paid little attention to special subpopulation’s nutrition and there was little knowledge about nutrition for homosexual persons with HIV/AIDS available in media in developing countries. The Nutrition Attitudes Although participants had poor nutritional knowledge, they held positive attitude to learn. Of the 172 participants, 155 (90.0%) were willing to change their eating habits for health benefit, which is similar with the former research [14, 21]. The needs for knowledge were very urgent, and participants thought nutrition knowledge was critically important for them. The Nutrition Behaviors Nutrition behavior of participants did not meet the health requirement. Only 63.5% of participants selected food by the nutritional value or their nutritional needs. Up to 16.4% of the participants have poor appetites. The poor diet among persons with HIV/AIDS may also result from loss of appetite, thus reducing the frequency of meal and variety of the diet at the very time while their requirements are higher for the virus. We recommend that persons with HIV/AIDS have four meals a day and eat more protein. Although participants had poor behavior, they had positive attitude to change. Of the 172 participates, 90.0% were willing to change their eating habits for health benefit, which is similar results to the former research [20, 23]. Needs for Nutritional Education From the survey, the participants gave many suggestions for the development of the manual to convey nutrition knowledge (shown in result), so we should pay more attention to providing more instructions in practical behavior for them. Many studies have shown that nutrition education will be effective when it pay attention to practice [24, 29]. The nutrition knowledge and positive attitudes gained by persons with HIV/AIDS should be followed up to ensure that they are transformed into good dietary practices. The large majority (90.1%) of the study participants was willing to change their eating habits for health benefits, so developing an
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HIV/AIDS-based nutritional education program will have practical meaning. The education must help them better understand basic nutritional knowledge as well as AIDS-related contents, to promote the rational nutrition cognition, and to arrange diet. For example, which kind of food benefits more for persons with HIV/AIDS? Considering the different education backgrounds, the education manual should have different editions for different subpopulation. Additionally, it can be found that the means of obtaining nutrition knowledge were diverse. Though books were still important sources, a number of new media became more and more important, such as Twitter, Facebook, and Short Message Service (SMS) [31]. The Internet was widely used by the participants, which suggests that the manual can be presented as an electronic version for release on the website. Electronic means are increasingly used to distribute educational materials about AIDS [32], so we should not only think about the contents of education but also focus on the new conveying means [33]. This study shows that homosexual persons with HIV/AIDS in a developing country longed for nutrition knowledge, which was missing in the system. Extra efforts and targeted education programs aimed to improve their nutrition knowledge, attitudes, and behaviors need to be emphasized. Nutrition education about dietary behavior for homosexual persons with HIV/AIDS is urgent and of practical significance; in order to meet the different needs, various editions and conveying forms should be presented in a developing country.
ACKNOWLEDGMENTS We sincerely acknowledge Xiaoyang Xu, MSc., Ph.D.; Linli Han, MSc.; Yong Zhang, MSc., Ph.D.; and Huan Zeng, MSc., Ph.D. at Chongqing Medical University; Haiping Xia, MSc. at Faculty of Medical Science and Laboratory Medicine; and Xianbin Ding, MSc.; Rongrong, Lu, MSc. at Chongqing Center for Disease Control and Prevention for their kind help. The opinions expressed in this article are those of the authors and do not necessarily represent those of Global Fund or Jiangsu University Fund of Advanced Talent.
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