Effects Of The Lifeskills-based Prevention Curriculum On HIV/AIDS Knowledge And Attitudes Among Primary And Middle School Students In Rural Areas Of Hainan Province

Background and significanceYoung people are considered as one of the most vulnerable groups to Human immunodeficiency virus (HIV) infections and Acquired Immune Deficiency Syndrome (AIDS). Adolescence, as a transitional passage from childhood to adulthood, is a very important period during which one’s attitudes toward health and behaviors may be fostered. Studies have shown that adolescents are more likely exposed to, or engaged in behaviors related to contracting HIV, such as high-risk sexual behaviors and illicit drugs use. While HIV/AIDS prevention among high-risk people (e.g. sex workers and intravenous drug users) is pressing in China, prevention of high risk behaviors among adolescent may be even more important for prevention of HIV/AIDS and sexually transmitted infections in the future.A Lifeskills-based HIV/AIDS prevention education, using participatory and interactive teaching techniques, combines HIV/AIDS prevention knowledge education with adolescents’psychosocial and interpersonal skills development. As an HIV/AIDS prevention model, it can help adolescent foster pro-social behaviors and healthy lifestyles, thereby prevent them from HIV/AIDS related high-risk behaviors. In both developed and developing countries, integration of lifeskills-based HIV/AIDS education into school curricula may be an effective way to reach most large part of youth for reducing high-risk behaviors in their adolescence.Over the past 10 years, United Nations International Children’s Emergency Fund (UNICEF) has been working on promoting the lifeskills-based education for prevention of HIV/AIDS among young people. Supported by China government, some pilot projects of life-skill-based HIV/AIDS education were implemented in college and high school students in some urban areas, but rare were done in rural areas, and almost no such project were conducted among primary and middle school students in rural areas. In addition, the most interventions were conducted among college and middle school students, and a few in primary school students in urban areas, whereas students in primary schools in rural areas of China were neglected. Sponsored by ’National AIDS prevention and care society mobilization project,2004’ and ’AIDS prevention and cure application project,2005-2007’, we developed a proposal of ’Lifeskills-based HIV/AIDS Prevention Education in Primary and Middle Schools in Rural Areas of Hainan Province, China’, and collaborated with Education Department of Hainan Province and two Education Bureaus of’China Comprehensive AIDS Response (CHINA CARES)’. The project set up a steering committee, consisting of researchers from our project team and 9 school masters or teachers of local schools from the study areas. Based on UNICEF HIV/AIDS and lifeskills education curriculum and other existing materials, the committee designed two experimental curriculum, one for 5th grade in primary school (4 class hours), and another for 7th grade in middle school (5 class hours).ObjectivesIn this dissertation, we aimed at:1. To evaluate the short-term and mid-term effectiveness of the curricula on HIV/AIDS related knowledge and attitudes towards lifeskills.2. To explore the factors that influence implementation of the curriculum in primary and middle schools in rural areas.MethodsThe project included two stages.At Stage one (started in Sept.2006 and finished in May.2007, including one autumn and one spring semesters) a total of 12 schools were selected as the experiment groups.In each experiment school, the participant classes (in 5th or 7th grade) were divided into two subgroups; the classes in subgroup I were taught the experimental curriculum in the autumn semester, then subgroup II in next spring semester.To assess students’ knowledge and self-perceived level of lifeskills and other relevant factors, three self-administered questionnaire-based surveys were conducted among participant students before (named as baseline hereafter), between and after two rounds of implementation of the experimental curricula (named as post-curricula I and II, respectively). And another 5 primary or middle school were selected as a nonrandom paralleled control group. The 5th or 7th grade students in control schools participated in the two surveys before and after the implementation of the curricula (baseline and post-curriculaⅡ).A questionnaire survey was completed among teachers of the curricula to assess their teaching abilities. Several in-depth interviews to some teachers were used in order to document their teaching experience and problems, and their suggestions for further revision of the curricula.At Stage Two (Sept.2008), we conducted a cross-sectional questionnaire survey study among 7th grade students in eight middle schools, into which a large part of the 5th grade students in previous experimental primary schools were enrolled, to evaluate the mid-term effectiveness of the experimental curricula for primary students on HIV/AIDS related awareness and self-perceived level of life skill.ResultsPartⅠ:The short- and mid-term effectiveness of the curricula on HIV/AIDS related knowledge and self-perceived level of life skill.At Stage one, approximately 6,000 students in the experiment groups from 6 primary schools and 6 middle schools, took part in the experimental curricula and three questionnaire-based surveys (baseline, post-curriculaⅠand post-curriculaⅡ).2500 students in the ’control groups’ from other 3 primary schools and 2 middle schools participated in surveys of baseline and after completion of two rounds of the curricula.At Stage two,6923 students came from 8 middle schools were surveyed. Among them, 1437 students had participated in our experiment curricula, which accounted for 83.5 percent of total ’primary school experiment group’ students two years before.1. Characteristics of the studentsThe results of baseline survey showed that demographic characteristics were different between the experiment and control groups. The proportions of rural students in experiment groups were higher than control groups (44.5% vs. 30.8% for the primary students,64.4% vs. 47.0% for the middle school students.). The median age of experiment groups were higher than the control groups (median age:12 vs.11 years old for the primary students,14 vs. 13 years old for the middle school students.). And, the proportions of experiment groups’students whose parent had an educational background in senior high school or higher and a stable income were lower than those of the control groups’.The proportions of students who reported having used the internet in the experiment groups were lower than those of the control groups (25.9% vs.32.0% for the primary school students,31.9% vs.40.6% for the middle school students.). The proportions of students who used the internet and usually used internet in an internet cafe increased at the post-curricula II surveys.The proportion of students who had ever smoked a cigarette in the experiment group was similar to that in control group (8.2% vs.7.2% for the primary school students; 9.3% vs. 9.8% for the middle school students.) in the baseline. But the proportions of smoking students increased at the post-curriculaⅡsurvey for both primary and middle school students.In the mid-term effectiveness evaluation survey, most students’characteristics in the experiment and control groups were similar. But the students in experiment group were older than control group students (median age:14 vs.13 years old.), and the proportion of rural students in experiment group was lower than that of control group (37.5% vs. 55.1%).2. The source of HIV/AIDS related knowledgeAccording to the baseline survey results, the proportions of’having heard of AIDS’in experiment groups of primary and middle schools were significantly lower than that in control groups (66.5% vs.81.5% for the primary school students,89.3% vs.96.6% for the middle school students.). The public educational campaign, including newspaper, magazine, television and broadcast, was the major source for students’HIV/AIDS related knowledge (69.4% vs.70.3% for the primary students,69.0% vs.69.4% for the middle school students). Only about one fifth of the students reported obtaining HIV/AIDS related knowledge from school.3. The effectiveness of the curricula on HIV/AIDS related knowledge3.1 In comparison with the baseline level, HIV/AIDS related knowledge increased in experiment groups of both primary and middle schools with most items up 20-40 percents. The significant increment was found in the comparison of baseline level with post-curricula I survey for subgroup I, and the comparison of post-curricula I and II surveys for subgroup II.3.2 Compared with the control groups’students, who had a 10-20 percents higher of HIV/AIDS knowledge on average in the baseline survey, the experiment groups’showed a 10-20 percents higher in proportions of HIV/AIDS awareness than those in control group at the post-curricula II survey.3.3 The mid-term effect evaluation of the experimental curriculum for primary school, at stage two, showed that, comparing with the students who had not attended the curriculum before, students who were previously in experiment group had significantly higher level in HIV/AIDS related awareness, though the levels of a couple of items decreased while comparing to their own knowledge level in post-curriculaⅡsurvey.4. The effectiveness of the curricula on students’self-perceived level of lifeskills4.1 According to the short-term assessment results, the curricula had some effect on promoting the experiment groups’students’self-perceived level of lifeskills, but the increments of self-perceived level of lifeskills were smaller than that of HIV/AIDS knowledge.4.2 At the baseline, the control groups’students had higher scores of self-perceived level of lifeskills than the students of experiment groups. The discrepancy existed but was smaller in post-curricula II survey.4.3 In the baseline survey, scores of self-perceived level of lifeskills were similar in the two subgroups of the experiment group. After the first round of curricula, scores of self-perceived level of lifeskills were higher in subgroup I who just completed the curricula, compared to subgroup II students who were still on waiting for the participation of the curricula.5. Other factors associated with HIV/AIDS knowledge and self-perceived level of life-skillsBased on the results of baseline survey, a couple of characteristics of students or their families were found to be associated with the level of HIV/AIDS knowledge and self-perceived level of lifes-kills as follows: 5.1 Students’ personal characteristicsThere were no significant gender differences in students’ knowledge and attitude scores, but differences were found in knowledge and attitudes scores among students of at different age groups in the same grades. The youngest students of each grade had the highest mean ranks of knowledge and attitude scores, while the oldest students got the lowest scores.Students who had access to the internet got higher mean ranks of scores on both of knowledge and attitude than those who did not use internet. Furthermore, there were significant differences in the level of HIV/AIDS knowledge and attitude scores among students who accessed the internet in different places. The students who usually got access to the internet at home scored the highest mean ranks of knowledge and attitude marks.The mean ranks of attitude scores were significant lower for smoking students than those of non-smoking students; especially in scores of’deal with negative emotion and pressure’ and ’critical thinking’.5.2 Family and community factorsThe students from towns got higher mean ranks of scores on both of knowledge and attitude than students from villages did.And, the scores of knowledge and attitude varied by their parents’ educational backgrounds and if parents had a stable income. Students tended to score the highest in mean ranks of marks on both of knowledge and attitude, if their parents had a regular income or/and an education of senior high school or higher. The middle school students who lived with their both parents got the highest scores of knowledge and attitude compared to those who live with one parent or who did not.6. Results of path analysisAccording to the project objective and hypothesis and results of multivariable analysis, we used nine variables to in the path analysis modeling, including variables of students’ personal and family characteristics in addition to a variable of intervention (if attending the experimental curricula). We explored the relationships among those variables, and their independent effects on student’s scores of knowledge and attitude, through comparing the path analysis models of the baseline and post-curriculaⅡsurveys for primary students or for middle school students.Comparing with the baseline path analysis results, the total effects of ’attending curricula’ on ’knowledge’ of the post-curricula models increased remarkably (standard effect coefficient from -0.16 to 0.19 in the primary school models, from -0.06 to 0.15 in the middle school models). Moreover, in replace of the parents’ education level,’attending curricula’ became the major contributor to ’knowledge scores’ in the post-curriculaⅡmodels. The positive effects of knowledge score on attitude scores were significantly improved (standard effect coefficient from 0.19 to 0.38 in the primary school models, from 0.39 to 0.56 in the middle school models) in the post-curriculaⅡmodels as well.Controlling for other factors,’attending curricula’ did not show positive direct effects on ’attitude scores’ in the models for primary and middle school students. These path models indicated attending curricula only indirectly influenced ’attitude’ through improving knowledge.Several variables, such as parents’ educational level and residence place, had been shown positive effects on ’knowledge’ and ’attitude’ in the baseline models, but the effects became weaker or disappeared in post-curricula models. The differences in attitude scores among different age groups decreased, but the ’knowledge’ differences among different age groups were increased in the post-curriculaⅡmodels.PartⅡ:The factors related to implementation of the curricula1. Students’ acceptability of the curriculaThe results of the post-curricula scurvies showed approximately eighty percent of students liked the curricula. They thought’knowledge of illicit drugs’ was most helpful but ’knowledge of adolescence’ and activity of ’crossing the dangerous zones’ (only in middle school’s curricula) were not useful. The in-depth interviews to the teachers showed that students were more active in the curricula than in other classes; they showed particular interests in the HIV/AIDS related knowledge.About 70% primary students reported well understanding the curriculum or understanding most parts of the curricula; those who could not understand or who could only understand little were counted less than five percent. 2. Factors of context of school or teachingThe in-depth interviews to the teachers showed that, most teachers thought that teaching knowledge were much easier than role plays or case discussion.. Some sensitive topics such as sexual transmission of HIV were sometime embarrassing to some young woman teachers. The different for the curricula arrangement in each school (e.g. scheduled the curricula in formal classes or in after-school) affected students’attendance and their concentration to the curricula. Furthermore, it added more difficulties in interactive activities because of too much content, or too many students in one class in these rural schools.Suggestions on how to integrate the experiment curricula into primary and middle school education by the teachers are included in the dissertation.ConclusionsThe’4 or 5-hours lifeskills-based HIV/AIDS prevention curricula’, can improve students’ HIV/AIDS knowledge and self-perceived level of life-skills in a short time. And these positive effects can maintained at least about 2 years after the curricula.This study demonstrates that level of HIV/AIDS knowledge is positively associated with level of positive perception of level of life-skills among the primary and middle school students. It is imperative to integrate the lifeskills-based HIV/AIDS prevention into curricula of rural primary and middle schools to improve their knowledge and to shape their healthy attitudes because a large part of the youth in rural areas is unable to continue their schooling after middle school.Though some barriers to implementation of the curricula existing in the rural schools, promoting the lifeskills-based HIV/AIDS education prevention curriculum in rural areas is still feasible if supported by policy of local government, if further integration into other relevant curricula, and if capacity of local teachers continuingly improved.