Knowledge level and access barriers related to sexual and reproductive health information among youth with disabilities in China: a cross-sectional study

This study sought to investigate the knowledge level and access barriers to SRH information among unmarried youth with visual, hearing and physical disabilities in China. The results show that the respondents had limited knowledge and access to SRH information, especially those from rural areas. In general, residential area and education level were significant correlates of knowledge among the respondents. Although the sources of and barriers and preferences in accessing SRH information varied across disability types, the school teachers were the primary and most preferred sources of SRH knowledge.

In this study, the respondents had poor knowledge of SRH, which is consistent with the findings observed in previous studies [31,32,33]. Among the three categories of knowledge surveyed under this study, the score for STIs/HIV/AIDS was the highest, which might be the result of the implementing HIV/AIDS awareness-raising and prevention education program in the whole country [34].

This study’s findings of the association between types of disability and SRH knowledge were similar to those of the studies conducted in Ethiopia and Ghana [35, 36]. In this study, youth with hearing impairment and physical disabilities had lower level of knowledge than those with visual impairment in all categories of knowledge. Compared with their hearing peers, youth with hearing impairment often face more barriers in accessing SRH knowledge. Due to the barrier in verbal communication, they had less ability in reading comprehension than their counterparts with visual impairment or physical disabilities [33]. Some of them did not even understand such vocabularies as menstruation, nocturnal emission, masturbation, sexual intercourse and marriage [31]. Moreover, youth with hearing impairment are more likely to be isolated from the society than their counterparts with visual impairment or physical disabilities [37]. Possibly due to this reason, respondents with hearing impairment in this study were significantly more likely to get knowledge and information from their peers and report “unaware of the available sources of accurate information” as the key barrier in accessing SRH information than their counterparts with visual impairment or physical disabilities. This study found that that the respondents with hearing impairment who had siblings reported higher level of SRH knowledge than those who were the single child in the family (aOR = 2.94). For respondents with hearing impairment, being a single child in the family is an added disadvantage in accessing SRH knowledge and information. The lower level of knowledge among respondents with physical disabilities than those with visual impairment may be explained by a higher percentage of them having received only junior high or even lower level of education (47.2% vs 15.2%).

Besides school teachers, parents were one of the major sources of information for respondents with disabilities. The finding of this study that the respondents from urban areas had higher level of SRH knowledge than their rural counterparts could be due to their significantly higher level of access to SRH knowledge and information through schools (73.5% vs. 41.4%) and parents (35.2% vs. 26.4%) and less access barrier as demonstrated by a lower percentage of them responding “unaware of the available sources of accurate information” (24.5% vs. 40.9%). The findings from in-depth interviews with the teachers of special education schools and regular schools in urban and rural areas revealed that schools in rural areas were more likely to face challenges than those in urban areas in delivering sexuality education, due to lack of teaching materials and tools, lack of professionally trained teachers, lack of awareness of the importance of sexuality education and lack of support from parents [29]. In rural schools, sexuality-related teaching contents were limited to basic information on physiological anatomy and hygiene, and relationships with the opposite sex, while urban schools provided more relevant information such as puberty change, HIV/AIDS, relationships with the opposite sex, sexual ethics and self-protection [29]. Compared with their urban counterparts, parents in rural areas were usually less educated, more conservative to sexuality education and less likely to provide SRH knowledge and information to their children [30]. Even though almost all parents in urban areas recognized the importance of sexuality education for young people with disabilities and some of them had even communicated with their children about sexuality-related issues, this communication was limited to puberty change, relationships and self-protection with topics such as pregnancy, abortion, contraception and STIs excluded [30]. The fact that the schools and families could not meet the needs of young people for SRH knowledge might explain why the Internet had become the primary preferred source of SRH information for respondents in rural areas. Findings from this study highlight the need to strengthen school and family-based sexuality education.

No gender difference in SRH knowledge was observed by this study, which was also in line with the study conducted in Ethiopia[36]. Age was significantly associated with SRH knowledge; however, this association was not observed among respondents with hearing impairment. The possible explanation for this finding was that among the respondents with hearing impairment, a higher percentage of those aged 20–24 were from rural areas compared with those aged 15–19 (46.6% vs 30.8%).

The relationship between the level of education and SRH knowledge has been documented by many studies [38, 39]. In this study, a strong relationship between the education level and SRH knowledge was also observed among respondents with visual and hearing impairments. The finding that only marginally significant association was observed among respondents with physical disability might be due to small sample size on the one hand, and the high percentage of non-students (over fifty percent) on the other hand. Compared with students, non-students were more likely to be in the age group of 20–24 (72.7% vs 15.1%) and have junior high or lower education (65.5% vs 32.1%). Reports from China and other countries show that not all people with disabilities have access to education [40,41,42]. According to the data released by the China Disabled Persons' Federation in 2013, only 72.7% of children with disabilities between the ages of 6 and 14 received nine years of compulsory education nationwide [41], compared to 99.7% of children without disabilities [43], a gap of nearly 30% between the two groups. Fortunately, China has made considerable efforts to accelerate the development of special education. Over the past seven years, the number of students enrolled in special education schools had more than doubled from 368,000 in 2013 to 881,000 in 2020 (an increase of 139%), according to statistics released by the Ministry of Education [44]. The Program for Promoting Special Education: Phase II (2017–2020) released by the Ministry of Education and six other state agencies in July 2017 introduced the target of achieving an enrollment rate of over 95% for children with disabilities in compulsory education by 2020 [45]. This makes it possible for young people with disabilities to receive sexuality education at school. Given that school is the most important place to learn knowledge and skills systematically, and that the enrollment rate of children with disabilities in compulsory education is increasing, the promotion of school-based sexuality education should be given priority in China in order to raise the level of SRH among youth with disabilities.

As shown in this study, although differences in the needs and preferences in accessing SRH information were observed across disability types, residential areas and gender, respondents with disabilities had similar SRH information needs and preferred sources. Puberty changes and health care, friendship/love/marriage, sexual harassment/abuse/self-protection and STIs/HIV prevention were the most frequently mentioned topics. School/teachers and the Internet were the most frequently mentioned preferred sources. In the traditional Chinese society, it remains a taboo to talk about sex in public or between different generations [46]. Even if parents realized the importance of sexuality education for their children, only very few communicated with their children about sex-related topics [47]. Not surprisingly, parents were only the third or fourth preferred source of information, as reported by respondents with different characteristics in this study. The most significant difference was observed in ways of obtaining SRH information between urban and rural areas. Classroom teaching/lecturing was the predominant way of acquiring SRH information in urban areas, while books/newspapers and TV/radio were the two leading ways of acquiring SRH information in rural areas possibly due to limited access to school-based sexuality education.

Sexuality education is essential to the health and wellbeing for youth with disabilities. Understanding their needs and access barriers to sexuality education is the first step to address their unmet needs. To the best of our knowledge, this was the first study about the understanding of SRH knowledge, as well as barriers and preferences in accessing sexuality-related information among unmarried youth with different types of disabilities in both urban and rural areas in China. In addition, this study sheds lights on how to address the barriers to sexuality education for youth with different types of disabilities living in the Chinese culture. First, there is an urgent need to raise awareness among relevant government officials, school teachers and educators as well as parents about the importance of providing sexuality education for youth with disabilities, particularly in rural areas. Raising awareness about the SRH needs and rights of youth with disabilities is necessary to overcome stigma, discrimination and misunderstanding. Second, school and family-based sexuality education should be promoted and tailored to the needs of youth with different types of disabilities, with more priority given to school-based sexuality education. Third, policies, systematic supervision and evaluation, disability-friendly teaching and learning materials and relevant curriculum standards should be improved, developed or implemented to support school-based sexuality education. Efforts should be made to support capacity building among teachers and parents. Finally, youth with disabilities must be empowered to seek information proactively.

The study has some limitations. First, given the difficulties in reaching enough respondents with disability, the convenient sampling method was used to recruit participants. Findings in this study may not necessarily represent the overall population of youth with disabilities in China. For example, all of the participants in this study were literate, while only 72.7% of disabled children aged 6–14 received compulsory education nationwide [41], suggesting an even lower level of SRH knowledge and more barriers in accessing sexuality education for the whole population of youth with disabilities. The second limitation was the response bias of self-reporting data. However, efforts were made throughout the process to minimize the bias by ensuring confidentiality and anonymity. Finally, the data of this study was collected several years ago. However, no new relevant data has been made available since then. Although the Chinese government had committed itself to improving education for the reproductive rights of the disabled, there has been little progress in the provision of sexuality education in China during recent years. The challenges of providing sexuality education for children and youth remain in terms of the gaps in the stakeholders’ perspectives and involvement, culture barriers, lack of teaching and learning materials and trained teachers, as well as weak monitoring and evaluation mechanisms[48, 49].

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