Public awareness of three major infectious diseases in rural Zhejiang province, China: a cross-sectional study

Infectious with the human immunodeficiency virus (HIV), tuberculosis (TB) and hepatitis B virus (HBV) infection are major public health problems in many parts of the world. In China, approximately 780,000 people live with HIV; 26,000 died from Acquired Immune Deficiency Syndrome (AIDS) in 2009 [1], while 4.5 million Chinese have been infected with active pulmonary TB, 1.5 million of whom are smear-positive [2]; meanwhile 120 million people have been chronically infected with HBV [3], and more than 300,000 people die from HBV-related diseases every year [4]. According to the 6^th national population census, over 0.67 billion people live in rural areas and account for 50.32% of the entire population. Rural residents differ from urban residents in terms of socioeconomic status, which can lead to heightened infectious diseases risks [2, 5].

Public awareness of infectious diseases plays an important role in disease control; a lack of reasonable knowledge of infectious diseases leads to low detection rates, the interruption of treatment, discrimination and stigma. Therefore, to stop the spread of HIV, TB and HBV in China, the Chinese ministry of health launched specific national disease control plans [6–8], using posters, advertisements on television and printed media and other methods to improve the awareness of these diseases in the general population. The assessment of the awareness levels in rural residents is very important because it helps determine the impact of previous prevention efforts made by the government and gauge the need for interventions.

Although several researchers have investigated the awareness of HIV, TB and HBV of rural Chinese inhabitants, these studies have often focused on high-risk groups, such as men who have sex with men, pregnant women, or healthcare and public health professionals [9–12], and involve only one infectious disease. Very little research exists that sheds light on knowledge of and beliefs related to infectious diseases among the general rural population in China. A study [9] examining TB knowledge in a national survey conducted in China revealed that 89% of all respondents were aware of TB; the proportions were 87.3% and 95.5% in rural and urban areas, respectively. In addition, HIV infection is an important risk factor associated with active TB disease and the natural progression of liver disease caused by infection with HBV [13, 14]. It is necessary to investigate the knowledge of these three infectious diseases together for their possible connection.

Zhejiang Province is one of the most densely populated provinces in China, with approximately 33.5 million urban residents and 20.9 million rural residents. In this study, we conducted a population-based epidemiological study to assess current levels of awareness of HIV, TB and HBV among rural residents in Zhejiang Province and to explore sociodemographic determinants of the awareness of these three infectious diseases.

This study was a population-based cross-sectional study, utilising a representative sample design and based on face-to-face interviews; the goal of the study was to assess whether rural residents had knowledge of HIV, TB, and HBV.

Raising the level of knowledge of infectious diseases could not only help the general population protect themselves, but also promote those suspected suffers of being infected to seek medical help early and treat more completely [9]. In this study, respondents were more aware of HBV than the other two infectious diseases, and less than half of the respondents scored satisfactory levels of awareness of HIV. In China, the prevalence of infection with HBV is over 20 times higher than that of HIV and TB, and HBV infection causes more deaths every year than the other two diseases combined [12]. Therefore, significant differences in prevalence and mortality partly contribute to the unbalanced distribution of awareness of these three infectious diseases.

Many studies have been conducted to measure awareness levels of these three infectious diseases among the general public. One study conducted in seven provinces of China [17] found that 43% of participants had full and accurate knowledge of HIV; a similar proportion was found in the present study (44.21%). In another study conducted in Hyderabadi in the south of India [18], knowledge of HIV was higher than in this study (80.63% vs. 62.18%). Infection with HIV is strongly stigmatised in China [17, 19]; increasing full and accurate knowledge of the disease is one of the most important ways of reducing negative attitudes toward person living with HIV/AIDS (PLWHA). In this study, less than half of the participants (46.36%) made it clear that PLWHA should not be isolated; this proportion is lower than that found by Lau et al. [20], possibly because our subjects were all rural residents. In Li’s study, there were still 12.3% of doctors and nurses expressed opinions that PLWHA should be isolated [21]. However, in Karnataka, nearly four-fifths of the respondents were of the opinion that PLWHA should not be isolated from society [22]. It is necessary to provide health education programmes with information on the mode of transmission of the disease and to develop a series of policies and measures to fight against HIV stigmatisation and discrimination in China [23]. Awareness alone is not sufficient for eliminating stigmatising attitudes and behaviour. The completeness and equity of relevant laws to PLWHA are also necessary for decreasing discrimination against PLWHA.

Partially because of the recent progress in TB prevention in China, most questions related to TB knowledge in our survey were correctly answered by more than half of the participants. Three-quarters of the participants (76.42%) knew that TB is curable in our study, while only 58.5% of the respondents in a large national survey [9] and 32% of respondents in a US National Health Interview Survey (2000–2005) [24] were aware of this fact. Nevertheless, we found that only one-third of rural participants were aware of the main TB symptom; this lack of knowledge could delay or prevent suspected infected people from seeking professional help.

The rural residents also fell short when it came to knowledge of HBV infection, and only half of the participants were accurately aware that HBV infection can cause liver cancer; 73.61% of participants recognised that HBV could be congenitally transmitted, a proportion similar to that found in a study of Chinese immigrants [25, 26]. In other published studies [12, 15] conducted among Chinese sub-groups, approximately one-third (29%) of high trained Chinese healthcare and public health professionals did not know that the chronic HBV infection confers a high risk of liver cancer, and 34% of respondents failed to identify all of modes of HBV transmission; similarly, only 39.2% of Chinese and southeast Asian Canadians accurately answered the question. Such a lack of knowledge in the general population and in sub-groups in China is a result of insufficient preventive practices that enable the persistence of high rates of HBV infection.

The Chinese government has implemented universal hepatitis B vaccination as part of their national infant immunisation program since the 1990s to reduce the hepatitis B burden in the overall population of China [27, 28]. Since then, the prevalence of hepatitis B in China has apparently declined, especially in children, though the prevalence in adults is still high. Based on our findings, 81.76% of rural residents thought that hepatitis B can be prevented by vaccines; however, only 66.79% of participants would be willing to pay for such a vaccine. Consequently, nearly 15% of rural residents would not pay for the hepatitis B vaccine even with knowledge of its effective protective ability. The main reason for this might be the lack of individual economic means [29] and low levels of awareness of HBV. Therefore, free hepatitis B vaccination should be applied to the adults of rural areas to reduce the heavy burden of health systems.

Age and education were significantly associated with awareness of these three infectious diseases. Older respondents and those with a low educational level had lower levels of knowledge of all aspects of these three infectious diseases. In addition, farmers and the unemployed tended to have low level of knowledge of HIV and HBV. Students and factory workers were more likely to have low levels of TB awareness than farmers. We were gratified to find that nearly three-quarters of rural residents have been exposed to health publicity related to these three infectious diseases in the last year and we were encouraged to see that those who received health publicity tended to have higher levels of awareness of these diseases. The main sources of health education were television, newspaper and magazine, which may be difficult for the elderly and minimally educated subjects to understand. It is clear that there is a need for more multifaceted, comprehensive health publicity campaigns in schools, factories, and community health services to successfully increase the levels of awareness of these infectious diseases among rural residents. In rural areas of China, old age and farming have always been associated with low levels of education. Therefore, education should always be a national long-term strategy [9].

To control these three main infectious diseases, the government has made efforts to provide care and support to infected people and to prevent the occurrence of these diseases among the general population. From the first “Medium-and Long-Term Programs for the Prevention and Control of AIDS” in 1997 to the “Four Frees and One Care” program in 2004 [30], the government has prioritised interventions to control this epidemic in high risk populations, implemented routine HIV testing in population and provided free treatment of infected individuals [31]. Meanwhile, the Directly Observed Treatment, Short-course (DOTS) strategy [32] and a free hepatitis B vaccine program recommended by WHO for all neonates [12] were implemented in China. These policies in China have had significant impacts on the enhancement of disease control. In our study, approximately one third of rural residents were fully satisfied with the policies. The HIV policy was found to be highly satisfactory to the highest number of people, while the TB policy was found to be the least satisfactory. However, the majority of rural residents were dissatisfied with the HBV policy, possibly because the Chinese governments have supplied free treatment for HIV and TB but not for HBV infection. As a life-long disease, the cost of treating HBV infection can only be partly reimbursed by rural cooperative medical insurance; it therefore constitutes a heavy burden for the majority of rural patients. The gap between national policies and actual practices, especially in HBV infection, remains a problem.

One of the limitations of this study was the selection bias due to the unavailability of seasonal workers who worked away from their village of residence. Rural population flow has always been a common social phenomenon in Chinese society and seasonal workers are always at high risk of major infectious diseases. Secondly, other factors such as financial situation and family history that could have affected the findings of this study were excluded; these factors should be the subject of further research.

This population-based study demonstrated that the present level of awareness of major infectious diseases in rural residents in China is still very low; further effective health education campaigns for major infectious diseases are urgently needed. In addition, older and less educated individuals and farmers were less knowledgeable about these diseases. Prevention programs should target these individuals and provide more acceptable patterns of publicity for them. This study might also be useful for planning policies for the prevention and control of major infectious diseases. Future national disease control plans in rural areas may consider using the results of the present study as a baseline for assessing the effectiveness of the disease campaigns.