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Nursing and Health Sciences (2015), 17, 287–292

Research Article

Relationships between attitudes toward sexuality, sexual

behaviors, and contraceptive practices among Chinese
medical and nursing undergraduates
Yingchun Zeng, RN, MPhil,1 Taizhen Luo, RN, BN1 and Ying Zhou, RN, PhD2
1
Department of Obstetrics, Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The
Third Affiliated Hospital of Guangzhou Medical University and 2School of Nursing, Guangzhou Medical University,
Guangzhou, China

Abstract In this study, we investigated attitudes toward sexuality, the prevalence of sexual behaviors and contraceptive
use among Chinese medical and nursing undergraduates, and relationships between attitudes toward sexuality
and sexual and contraceptive practices among these participants. This was a descriptive, cross-sectional study
carried out by using a Personal Attitude toward Sexuality Scale and Sexual and Contraceptive Questionnaire.
The participants were recruited in the researcher’s lectures. A total of 158 participants joined this study.
Overall, Chinese medical and nursing undergraduates in this study held relatively conservative attitudes
toward sexuality. The prevalence of sexually-active students was relatively low, and the percentage of contra-
ceptive use among those sexually-active students was also low. Participants’ attitudes toward sexuality had
statistically-significant effects on their sexual and contraceptive practices. Nearly half of the sexually-active
participants reported never using any contraceptive method during sexual intercourse. This finding has
important public health implications, as young people represent the group with the largest rate of new
infections of HIV/AIDS in China. A more comprehensive sexual education program that extends to college
undergraduates and promotes the social acceptability of using contraception, specifically condoms, is needed.

Key words attitudes toward sexuality, contraceptive practice, China, public health, sexual practice, undergraduate.

INTRODUCTION (48.3%) failed to use any contraceptive method at all during

sexual intercourse (Yin et al., 2008). Unprotected sexual
Since the reforms undertaken by the Chinese Government in
behaviors among Chinese undergraduates could have a range of
1979, Chinese people’s way of life has modernized. Among
negative consequences, including unintended pregnancy, abor-
young people born in the 1980s and later, attitudes toward
tion, risk of infection sexually-transmitted infections (STI), and
sexuality have changed dramatically, compared to those of
even HIV/AIDS (Ma et al., 2005; Meng & Zhao, 2012). Of
preceding generations. More and more young people engage
particular concern, in China, sexually-transmitted HIV/AIDS
in premarital sex. Survey studies have reported that the
has increased significantly, from 5.5% in 1997 to 19.8% in 2003
prevalence of premarital sex has increased from 10.1% in
(State Council AIDS Working Committee Office and UN
1997 to 32% in 2006 among Chinese university students
Theme Group on HIV/AIDS in China, 2005). Half of the new
(including medical and nursing undergraduates) (Pan, 2007).
HIV infections in China can be attributed to unprotected het-
The prevalence of premarital sex among Chinese under-
erosexual encounters (World Health Organization, 2006). More
graduates was up to 38.4% in a more recently-published
than 60% (64.6%) of HIV infections are among young people in
study (Zhang et al., 2014).
China aged 15–39 years (Wang, 2014).
Increasing premarital sexual activity with a correspondingly
With increasingly unprotected sexual behaviors and the
low rate of contraceptive use can lead to serious health problems
significant negative consequences among Chinese under-
for young people and is a public health concern. Research
graduates, these issues are an important public health
conducted on Chinese university students found that nearly half
concern, and healthcare providers need to be aware of the
problem, as they have more power to affect social policy
and social attitudes than others in society might. People
Correspondence address: Yingchun Zeng, Department of Obstetrics and
with permissive attitudes toward sexuality are more likely
Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, no. 63
Doubao Road, Guangzhou 510150, China. Email: chloezengyc@hotmail.co.uk to be sexually active than those with conservative atti-
Received 9 June 2014; revision received 12 October 2014; accepted 15 October 2014 tudes (Petersen & Hyde, 2010). Studies of Chinese female

© 2014 Wiley Publishing Asia Pty Ltd. doi: 10.1111/nhs.12185

288
undergraduates reported that attitudes toward sex were one
of the risk factors for ever having sex (Yan et al., 2009), and
attitudes toward sex significantly predict Chinese college stu-
dents’ intention to use condoms (Guo et al., 2014). Therefore,
the aims of this study were to investigate personal attitudes
toward sexuality, the prevalence of sexual behaviors and con-
traceptive use among undergraduates, so as to explore the
relationship between personal attitudes toward sexuality and
sexual and contraceptive practices among this study popula-
tion in China. Understanding attitudes toward sexuality and
their relationship with sexual and contraceptive practices
would provide important information for developing effec-
tive sex-education programs for undergraduates in China.
METHODS
Study design
This was a preliminarily, descriptive, cross-sectional study
carried out using a questionnaire survey. The study was con-
ducted at a medical university in Guangzhou, South China.
Inclusion criteria of study samples were third-year medical
and nursing students attending a lecture on family planning
and birth control. Exclusion criteria were students who were
not present in the lecture and were not willing to participate in
the survey.This study used the convenience sampling strategy,
and the calculation of sample size was based on the item of
measurement tools. Usually, 5–10 participants per question-
naire item can generate reliable and validated estimates (Hao
& Wan, 2000). The Sexual and Contraceptive Questionnaire
consists of seven questions, and the Personal Attitudes toward
Sexuality Scale consists of 10 items. Consequently, this study
needed 85–170 participants. The total number of third-year
students was 180 potentially providing sufficient participants.
Measures
Personal Attitudes toward Sexuality scale
The Personal Attitudes toward Sexuality (PAS) scale, origi-
nally developed by Rempel and Baumgartner (2003), was
used to measure participants’ attitudes toward sexuality in
general. This scale consists of 10 items, including statements,
such as “I feel comfortable talking about sexuality with stran-
gers” and “I wish everyone had an open attitude towards
sexuality”. High scores indicate that participants feel more
open, comfortable, and accepting of sexuality. The Chinese
version of the PAS scale demonstrates good reliability and
validity. Internal consistency by Cronbach’s alpha was 0.809.
Exploratory factor analysis identified one factor construct,
and the total explained variance was 56.39%. All items’
factor loading ranged from 0.44 to 0.69.
The sexual and contraceptive questionnaire
This questionnaire was developed specifically for this study,
and was developed based on relevant literature (Hoque,
2011; Meng & Zhao, 2012), which identified these questions
as very relevant to assess undergraduates’ sexual and con-
© 2014 Wiley Publishing Asia Pty Ltd.
Y. Zeng et al.
ceptive practices. Three items relating to sexual practice
include “current relationship status”, “sexual intercourse
experience”, and “number of sexual partners”. The first two
items were used to assess the prevalence of sexual inter-
course experience. The third was used to evaluate the risk of
sexual behaviors. Four items relating to contraceptive prac-
tice included three questions on “contraceptive use”, “con-
traceptive methods”, “frequency of use”, and “reasons for
non-contraceptive use”. The first three questions were used
to assess the prevalence and degree of contraceptive use. The
fourth question was used to explore the reasons for non-
contraceptive use for potential intervention development
in the future. The questionnaire also included demo-
graphic items, such as age, sex, and major. A small pilot study
was carried out among two nursing academics and 10
Chinese undergraduates to ensure the face validity of the
questionnaire.
Marlowe–Crowne Social Desirability Scale –
short form
As this study explored the socially-sensitive topic of personal
attitudes toward sexuality and sexual practices among under-
graduates, the effect of social desirability response bias might
potentially influence a human sexuality assessment (Li et al.,
2012). In order to increase the validity of this sensitive
research topic and minimize the effects of social desirability
response bias, an social desirability scale was applied in con-
junction with other study measures. The short form of the
Marlowe–Crowne Social Desirability Scale (MCSDS-10) was
used, as the Chinese version of the MCSDS-10 has good
reliability and validity (Li et al., 2012). The MCSDS-10 con-
sists of 10 items. High scores indicate that study respondents
will answer questions honestly related to their sexual prac-
tices and personal attitudes toward sexuality, rather than pre-
senting themselves in a social desirability version.
Data collection
Data were collected in May 2014. A small pilot study was
carried out among 10 Chinese undergraduates (2 males and 8
females) to ensure the questionnaire’s readability and clarity.
These participants were able to complete the questionnaire
in approximately 10 min without any problem. Data collec-
tion for the main study took place in the researcher’s classes
on family planning and birth control. The researcher
explained the study objectives and procedure during the
lecture break. Then the researcher invited students to com-
plete and return the questionnaire at the end of the lecture.
Ethical considerations
Ethical approval was obtained from the ethical committee of
Guangzhou Medical University. A cover letter was included
to introduce the study aim and purpose, to ensure that study
participants were well informed about them and the right to
refuse to take part and/or drop out of the study at any time.
A written, informed consent form was signed by every
Sexuality among Chinese undergraduates 289

participant before the data were collected. All respondents in Table 1. Mean scores of PAS scale (n = 158)
this study participated on a voluntary basis. Participants were
assured of the confidentiality and anonymity of the responses Items Mean (SD)
they were providing. Participants were able to withdraw from
the study at any time. The entire questionnaire was anony- 1. I feel comfortable talking about sexuality 2.62 (1.74)
mous and without any form of identifiers. All the data were with strangers
2. I think I am a sexy person 2.70 (1.55)
only accessed by the researcher, were only used for research
3. I would feel comfortable explaining to a same 2.13 (1.44)
purposes, and were destroyed on study completion. sex sibling or friend how to masturbate
4. I wish everyone had an open attitude towards 3.26 (1.56)
Data analysis sexuality
5. Even when not in a relationship, I still feel 2.72 (1.53)
Data analysis was performed using SPSS (version 20.0; IBM like a sexual person
SPSS, Armonk, NY, USA). Descriptive statistics were used to 6. I do not feel comfortable watching movies or 3.92 (1.48)
summarize participants’ sexual and contraceptive practices by reading literature that I find sexually
frequency and percentages, and to describe attitudes toward stimulating
sexuality by means and standard deviation. Independent t-tests 7. I would not feel comfortable carefully 4.58 (1.35)
examining my genitals
were used to find associations between participants’ personal
8. I am willing to act on new sexual ideas I get 3.28 (1.57)
attitudes and their sexual and contraceptive practices.All statis- from others
tical tests were performed using two-tailed tests. P-values less 9. I use words like nipples, penis, vagina, or 3.18 (1.72)
than 0.05 were regarded as statistically significant. clitoris in conversation with no trouble
10. The main purpose of sex is for people to 3.55 (1.53)
enjoy themselves
RESULTS Total mean PAS score 31.97 (9.46)
A total of 158 participants joined in this study from a total of
180 students approached, giving a response rate of 87.7%. PAS, Personal Attitudes toward Sexuality; SD, standard deviation.
The participants’ mean age was 21.47 (standard deviation
[SD] 1.17). Most participants were female (n = 133, 84.2%).
More than half (n = 93, 58.9%) were nursing students, and Table 2. Sexual and contraceptive practices of the participants
the others were medical students (n = 65, 41.1%). (n = 158)
The total theoretical PAS scores range from 10 to 60. In this
study, the total mean PAS score among undergraduates was Variables n (%)
31.97 (9.46), indicating these participants had relatively con-
servative attitudes toward sexuality in general. By comparison Presently in a heterosexual relationship
analysis, the total mean score of PAS was higher in male than Never had 61 (38.6)
Ever had 47 (29.7)
female undergraduates (37.20 ± 9.97 vs 30.99 ± 9.06, P < 0.01).
Currently having 50 (31.6)
This indicates that Chinese male students had relatively more
Presently sexually active (having sexual intercourse)
permissive attitudes toward sexuality than female students.The Yes 31 (19.6)
participants felt relatively uncomfortable explaining how to No 127 (80.4)
masturbate (mean = 2.13, SD = 1.44) and talking about sexual- Have multiple partners
ity with strangers (mean = 2.62, SD = 1.74). The mean scores of Yes 4 (2.5)
other items are shown in Table 1. No 154 (97.5)
The description of the sexual and contraceptive practices Contraceptive use
of these participants is listed in Table 2. Of the respondents, Yes 17 (10.8)
31.6% of undergraduates were currently in a heterosexual No or not applicable 141 (89.2)
Used contraceptives during last sexual intercourse
relationship, and 19.6% (n = 31) were sexually active. In com-
Yes 14 (8.9)
parison, male students were more sexually active than female
No or not applicable 144 (91.1)
students (40% vs 15.8%, P < 0.05). Four students reported How often are contraceptives used?
having a sexual relationship with multiple partners. Never or rarely 141 (89.3)
In terms of contraceptive practices, few students (n = 17, Sometimes 4 (2.5)
10.8%) used contraception. The percentage of contraceptive Always 13 (8.2)
use among sexually-active students was 54.8%. Reasons for not
using contraception included lack of available contraceptive
service (n = 19), rejected by male partner (n = 9), did not think
about it at that moment (n = 9), and lack of knowledge (n = 8). used method was the condom, followed by oral contraceptive
Few students had used contraception during their last act of pills and withdrawal methods. With regard to other contra-
sexual intercourse (n = 14, 8.9%). The majority (86.6%) of ceptive methods, two respondents indicated using emergency
respondents never or rarely used contraception (Table 2). contraceptive pills.
For those contraceptive users, commonly-used methods of As shown in Table 3, students’ personal comfort levels
contraception are listed in Figure 1. The most commonly- toward sexuality had statistically-significant effects on their

© 2014 Wiley Publishing Asia Pty Ltd.

290
sexual and contraceptive practices. Students who were cur-
rently sexually active and used contraceptives at a relatively
high frequency reported higher total PAS scores (all
P < 0.05).
In order to reduce the potential social desirability bias,
the MCSDS-10 was included in this survey. The total
mean social desirability score (range = 1–10) was 5.14 (1.85)
among Chinese undergraduates. According to previous
research estimates (Li et al., 2012), the possible cut-off
point of MCSDS-10 might be 5. Therefore, most Chinese
undergraduates in this study gave non-social desira-
bility responses. This finding was further proven by no
statistically-significant correlation between total social desir-
ability scores and total mean of PAS scores (r = 0.096,
P > 0.05).
DISCUSSION
With regards to personal attitudes toward sexuality, Chinese
young people hold more permissive attitudes toward sexu-
ality in general than preceding generations. Yet in this
study, Chinese undergraduates still reported relatively
conservative attitudes toward sexuality. As Chinese thought
and culture are heavily influenced by the teachings of Con-
fucius, sex is viewed as serving a purely procreative
role, according to Confucian philosophy (Khoo, 2009).
Chinese cultural traditions also value modesty and
restrained sexual behavior (Abraham, 1999). Thus, more
than 3000 years of history of sexual suppression has led to
Figure 1. Types of contraceptive methods used by participants (■)
Participants (n).
Table 3. Relationships of PAS with sexual and contraceptive practices (n = 158)
Total PCS scores (mean ± SD)
Variables Yes
Presently sexually active 35.00 ± 11.09
Have multiple partners 40.75 ± 11.78
Contraceptive use 36.82 ± 11.85
Frequency of contraceptive use 37.17 ± 11.51
†Comparisons used by independent sample t-tests. Numbers in bold indicate statistically significance with P < 0.05. PAS, Personal Attitudes
toward Sexuality; PAS, Personal Attitudes toward Sexuality; SD, standard deviation.
© 2014 Wiley Publishing Asia Pty Ltd.
Y. Zeng et al.
the development of a culture of sexual conservativeness in
China (Zeng, 2004).
Although 31.6% of undergraduates were currently in a
heterosexual relationship, 19.6% reported being sexually
active and having sexual intercourse. In comparison, in
studies conducted among Western college students, that
figure ranged from 69% to 85% (Adefuye et al., 2011;
Stulhofer et al., 2011); Chinese undergraduates have rela-
tively less sexual experience. While social desirability effects
might have led to underreporting of sensitive topics of
sexual behaviors (Chi et al., 2012), this study included a social
desirability scale and found that undergraduates in this
study gave non-social desirability responses, rather than
socially-desirable responses. A study using a nationally-
representative sample of Chinese university students from
different majors reported that 14.4% of students had ever
had sexual intercourse (Zhou et al., 2009). While the preva-
lence of sexual intercourse in the present study was slightly
higher, the frequency of risky sexual behaviors was lower
than found in previous studies in China. This study found that
2.5% of students had multiple sexual partners, compared
with Yan et al.’s (2009) finding of 5.31% of students with
multiple partners. Previous research in China has reported
that university students who major in the arts (vs the sci-
ences) were more likely to have experienced sexual inter-
course and risky sexual behaviors (Liu et al., 2008). In
mainland China, nursing and medical majors are categorized
as the sciences.
Nearly half of sexually-active participants (45.2%)
reported never using contraception during sexual inter-
course. This finding was consistent with other research. Yin
et al. (2008) reported in their studied sample of university
students that as many as 48.3% of students indicated they
had never used a contraceptive during sexual intercourse.
When compared with their Western counterparts, contracep-
tive use by Chinese undergraduates was far lower. As Lally
et al. (2014) reported, 94.7 % of sexually-active Irish students
used contraception, and indicated that condoms were the
most frequently-used method. While the most common con-
traceptive method used by Chinese undergraduates was also
condoms, most undergraduates indicated that the difficulty
in accessing contraceptive services was one of the most
common reasons for non-contraceptive use. Other research
indicated that accessibility is an important predeterminant
of actual condom use (Munoz et al., 2010). Thus, providing a
No P-value†
31.23 ± 8.91 0.047
31.74 ± 9.33 0.060
31.08 ± 8.99 0.022
30.92 ± 9.02 0.012
Sexuality among Chinese undergraduates 291

convenient contraceptive service might be one strategy Conclusions and implications

for promoting actual contraceptive use among Chinese
This is the first study applied the PAS scale into Chinese
undergraduates.
medical and nursing students, and established its reliability
For the relationship between personal attitudes toward
and validity. This study also updated estimates of the preva-
sexuality and sexual and contraceptive practice, there were
lence of engaging in premarital sex among this study popu-
statistically-significant differences between permissive atti-
lation. The study findings examined the relationship between
tudes and conservative attitudes toward sexuality. Those with
attitudes toward sexuality and sexual and contraceptive
relatively permissive attitudes toward sexuality were more
practice, and found that attitudes towards sexuality were sig-
likely to be sexually active and to more frequently use con-
nificantly associated with their sexual behaviours and contra-
traception during sexual intercourse. This finding was consist-
ceptive practice.
ent with the latest research. Guo et al. (2014) reported that
Chinese medical and nursing undergraduates reported
attitudes toward sex significantly predict Chinese college stu-
relatively conservative attitudes toward sexuality, which act
dents’ intentions to use condoms. It is well known that
as a potential barrier to contraceptive use. Sex education
condom use can not only prevent unintended pregnancy, but
should assist Chinese undergraduates in developing a more
also STI and HIV infections. This study also found that the
positive and liberal view of sexuality. Among those sexually-
lack of available contraceptive service was one of most
active participants, nearly half reported never using any con-
common barriers and reasons for non-contraceptive use.
traceptive during sexual intercourse. This finding has
While sex education should assist Chinese undergraduates in
important public health implications, as young people repre-
developing a more positive and liberal view of sexuality, and
sent the group with the largest rate of new infections of
promote contraceptive use (Chi et al., 2012), Chinese health-
HIV/AIDS in China. A more comprehensive sex-education
promotion organizations providing free or easily-accessible
program that extends to college undergraduates and pro-
condoms might be one of the most effective strategies in
motes the social acceptability of using contraception, specifi-
promoting contraceptive use.
cally condoms, is needed, as it increases the accessibility of
This study also found that lack of knowledge was one of
contraceptives. In addition, more formal university-provided,
the reasons for non-contraceptive use among Chinese under-
sex-education programs or curricula are needed to be incor-
graduates. Although sex education has been included in the
porated into first- and second-year undergraduate programs.
formal curriculum of secondary schools in China since 1988
Early and continuous sex-education intervention could
(Sun et al., 2013), sex education for Chinese teens or young
enhance students’ awareness of safe-sex behaviors, and
adults might still be limited in practice, as previous studies
promote the sexual well-being of Chinese undergraduates as
indicate that the lack of sex education in the early years of
a whole.
tertiary education has compelled many Chinese college stu-
dents to seek HIV/AIDS information from other informal
channels, such as the mass media (Tan, 2008). For example,
ACKNOWLEDGMENT
Meng and Zhao (2012) reported that more than half of
Chinese university students (57%) access contraceptive The authors thank Dr John Rempel for permission to use the
knowledge from the Internet. Thus, more formal sex- sexuality scale used in this study. Our thanks also to Qingmei
education programs related to contraception are needed for Lei, Yongshan Zhong for their assistance in data collection,
Chinese undergraduates. In addition, universities are one of and to all the research participants.
the places where people have much more freedom, relatively
speaking, to discuss sexuality (Chi et al., 2012), and university
students tend to be more easily able to adopt new ideas and CONTRIBUTIONS
perspectives on sexuality (Huang et al., 2009). Future sex-
Study Design: ZYC, LTZ.
education programs, especially contraceptive-education pro-
Data Collection and Analysis: ZYC, LTZ, ZY.
grams, should be incorporated into the early years of tertiary
Manuscript Writing: ZYC, ZY.
education.
This study had several limitations. First, this preliminary
study was conducted at a medical university, so the genera-
lizability of study findings was limited. Further studies at
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