Evaluation Of School-based HIV/AIDS Peer-led Prevention Program And ROCCIPI Policy Research Among Senior High School Students From Coastal Cities In China

BackgroundThe epidemic of HIV/AIDS is one of the most serious public health and social problem in China and HIV infection by sexual transmission has been the most risk way among the urban youth currently.30 years of AIDS prevention experience around the world has shown that raise people's awareness of AIDS and reduce high-risk behavior by health promotion and health education is still the most effective method in HIV/AIDS control. In China, senior high school (including vocational school) is the most popular stages before acting society role among urban youth. School-based research can usually be well organized and implemented, however, most of the researches among senior high school students in AIDS prevention in China currently are local individual school studies with small samples, which are poorer representative and lack of health promotion theory supporting, while most of them are based on the theoretical assumption that knowledge change influence behavior directly. By the way, most questionnaire designs in those studies are not standardized and lack of reasonable evaluation. Therefore our research selected 49 senior high schools in three cities, based on the guidance of health promotion theory, applied comprehensive application mode-PRECEDE-PROCEED as organizational framework to determine and implement the most appropriate intervention strategies. We aimed to improve HIV/AIDS related knowledge and cognition, adopt healthy and safe behavior among senior high school students. At the same time, we use innovative ROCCIPI research method of policies and organization diagnosis to discuss the feasibility of setting HIV/AIDS health education into the curriculum of high schools.Objectives1. To choose rational health promotion theory model and conform the health promotion implementation, evaluation and policy formulation process to the standard in HIV/AIDS prevention among senior high school students. Design and evaluate the questionnaire of AIDs health promotion for senior high school students (QAHP-SS) to prove its feasibility and efficiency in health promotion.2. To determine the influence factors of high-risk behavior intention with HIV/AIDS and establish intervention model of HIV/AIDS health promotion by the baseline survey and path analysis among senior high school students of three coastal cities in China.3. To evaluate the effect of health promotion program on HIV/AIDS health promotion by two week and one year follow-up study.4. To discuss the feasibility of setting HIV/AIDS health education into the curriculum of senior high schools in Shanghai by policies and organization diagnosis and process evaluation.Methods1. Determine health promotion model framework, design and evaluation of questionnaire on HIV/AIDS prevention among senior high school students(1) Applied comprehensive health promotion mode-PRECEDE-PROCEED as organizational framework to implement and evaluation health promotion program of HIV/AIDS prevention. (2) Design the QAHP-SS based on the standardized scale among undergraduates. In the both cases of randomicity and feasibility, we chose 49 senior high schools and vocational schools among three coastal provinces and autonomous regions with well research condition to evaluate the reliability and validity of the questionnaire.2. Baseline of HIV/AIDS prevention survey among senior high school students of three coastal cities(1) To find out the demographic characteristics, personal HIV/AIDS related knowledge, attitude and practice among senior high school students through a big sample of epidemiology investigation. (2)Diagnose sociology, epidemiology, behavior environment, etc. by influence factors analyzing and path analysis to determine the predisposing factors, enabling factors and reinforcing factors. (3) To determine HIV/AIDS intervention method accord with the demand of senior high school students by health ecology model and the results of the cross-sectional survey.3. Recently and median follow-up study of HIV/AIDS prevention interventions(1) Set intervention group and control group by quasi-experiment design to evaluate recent effect of peer-led education on HIV/AIDS prevention. (2) To evaluate middle effect peer-led education on HIV/AIDS prevention by a one-year follow-up study among parts of intervention and control schools. (3) To conduct quality assessment of intervention by process evaluation.4. Research of setting HIV/AIDS health education into senior high school curriculum system in Shanghai by ROCCIPI law(1) To evaluate the feasibility of setting HIV/AIDS prevention and health promotion ion into senior high school's routine curriculum system of Shanghai with ROCCIPI strategy, which was implemented from students, teachers, schools and education administrative section.(2) To complement the health promotion of comprehensive framework PRECEDE-PROCEED model on the basis of making policy evaluation by ROCCIPI law.Results1. Questionnaire design and evaluation(1) Internal reliability assessment:The internal consistency of the most subscales of the QAHP-SS was good (Cronbach's alpha coefficients ranged from 0.7 to 0.9).(2)Test-Retest reliability assessment:252 students conducted two investigations by 3 weeks'interval. It showed that Test-Retest reliability of the QAHP-SS was good (Spearman correlation coefficient in all subscale were greater than 0.7).(3)Constructive validity assessment:the structure of the QAHP-SS was good by factor analysis. It revealed a five-factor structure involved the knowledge, attitude, belief and behavioral intentions and practice which was consistent with the distribution of basic predisposing factors in health promotion theory. Further studies show that the correlation between subscales and total score of the QAHP-SS was good by using Pearson correlation and Spearman correlation coefficient analysis.2. Baseline survey on HIV/AIDS prevention among senior high school students of three coastal cities(1) The average reproductive health knowledge only account for 45.0%accuracy, while HIV/AIDS knowledge accuracy can reach 67.3%. The HIV/AIDS related knowledge and cognition among Shanghai's students are significantly higher than Sanming's and Beihai's. Boys'knowledge and cognition are significantly higher than girls'except for HIV/AIDS. Key senior high school students'knowledge and cognition are significantly higher than vocational school and ordinary senior high school students'. (2) 44.6%students hold the oppositive opinion to male's premarital sex and 50.5%students argued against female's premarital sex. Shanghai's students, vocational school students and male students treat premarital sex and extramarital affairs relatively open.(3) 45.9%students showed their compassion to HIV/AIDS patient and only 33.3%students declared that they wouldn't evade people living with HIV in common social occasion.(4) 79.8%students showed their confidence in refusing sexual behavior during school period and 56.2%students had confidence in refusing premarital sexual behavior.49.5%students would use condoms to protect themselves in case having sexual intercourse.46%students would persuade their partners to use condoms as safety measures. Students in Shanghai, vocational school students and male students had lower scores of premarital sex intention which were consistent with the premarital sex attitude.(5) 4.5%of senior high school students had the experience of sexual intercourse in our survey and boys and vocational school students were relative'susceptible'. Binary logistic regression analysis showed that higher HIV/AIDS knowledge, more tolerant to AIDS patient, more conservative to premarital sex and less intention to premarital sex were the protection factors against sexual intercourse behavior, while from vocational school, prone to security sex behavior and have more demand to safe sexual related education were risk factors to sexual intercourse.(6)Among senior high school students, the popularizing rate of HIV/AIDS related knowledge was less than 42%(41.6%) and contraceptive (security sexual behavior) knowledge was less than 20%(16.2%). Nearly 80 percent of high school students thought HIV/AIDS health promotion and safe sex education was necessary and essential. Sex and HIV/AIDS related knowledge came from experts and professors was most easily acceptable among senior high school students, accounting for 38.1%and followed was from classmates and friends, accounting for 28.1%.(7) Path analysis by using AMOS7.0 revealed that HIV/AIDS related knowledge acquisition would help senior high school students to strengthen cognition of susceptibility with HIV/AIDS and benefits about security sexual behavior, which would improve consciousness of self-protection to adopt safety behavioral intentions, and knowledge also contributes directly to enhance adopting safety behavioral intentions. Cognition of susceptibility with HIV/AIDS would be benefit to adopt safety behavioral intentions and reduce premarital sex intention, but cognition of benefits about security sexual had negative effect on premarital sexual behavior attitude and intention, which mean more benefits about security sexual knowledge might cause students more open toward sexual behavior attitude and prone to premarital sex.3. Recent and median follow-up studies of peer-led interventions on HIV/AIDS prevention(1) HIV/AIDS related knowledge and cognition of intervention group had been greatly improved after two weeks, such as most knowledge accuracy increased by 10%-30%when compared with baseline, meanwhile, the change in control group was not significant.(2) Positive attitude toward HIV/AIDS patient were a certain enhanced after the intervention but not as significant as knowledge change. Premarital sex attitude changes are not obvious in the short-term, but students'self-esteem was enhanced a certain, premarital sex intention score was improved obviously, more and more students tended to adopt safety sexual behaviors intervention after intervention.(3) Through the analysis of repetitive measure variance after 1 year follow-up study, we found that HIV/AIDS related knowledge, cognition and positive attitude toward patients enhanced obviously and could be persistent in the intervention group. Self-value rose apparently after the short-term intervention, but also declined obviously after one year. Self-value of control group also had the tendency of declining after one year compared with two weeks. It could be explained that the pressure of learning and preparing the entrance exam for university would increase the negative feeling and influence identity of self-worth among senior high school students.There was no significant change in the attitude toward premarital sex and extramarital affairs among senior high school students during the follow-up study. The attitude score rose up slowly among intervention group from baseline to one year after and appeared as a straight line paralleling the control group. The behavioral intention to refuse premarital sex and adopt safe sex increased overall at two week after intervention. Behavioral intentions declined slightly but still maintained at high level at one year after intervention. (4) Process evaluation of peer-led intervention showed that that the appetency degree of all intervention models got the highest score and easy understanding degree was followed by, however, participation degree and vitality degree score relatively low. Boys'evaluation of participation degree was significantly higher than girls', while girls'evaluation of appetency degree was obviously higher than boys' 4. Research of setting HIV/AIDS health education into senior high school curriculum system in Shanghai by ROCCIPI law(1)Student perspective:Senior high school students had many courses to learn so that it was possible to implement health education only in senior high school sophomore. And the curriculum needed to be improved.(2)Teacher perspective:The faculty who engaged in the preventive of AIDS health education was generally weak. We lacked the professional teachers. It was difficult to do the job due to the low-status of health care teacher in senior high school.(3)School perspective:The presidents of the schools usually paid more attention to the enrollment rate than health care. Senior high schools all faced with the pressure of enrollment competition and the negative attitude of the directors made the implement of the health education not smoothly. So the directors should increase the emphasis on the prevention of AIDS health education.(4) Education administrative department perspective:Department of sports, health, art and education, moral education division of Shanghai municipal education committee played a dominant role in health education on HIV/AIDS prevention among students.They should not only consider how to ensure the HIV/AIDS prevention courses well setting and arranging, bu also overall pay attention to the stress of overmuch course among sinor high school students.Conclusion and suggestion1. The QAHP-SS had good reliability and validity in our research of HIV/AIDS prevention among senior high school students of coastal cities in China.2. The HIV/AIDS related knowledge and cognition needed to improve among senior high school students of three coastal cities in our research. It is very important to strengthen health education on HIV/AIDS among students in small coastal cities and vocational school. Boys and vocational school students should be the key crowds to reduce early sexual behavior by intervention. 3. Path analysis showed that we should firstly strengthen HIV/AIDS related knowledge and improve the students'AIDS susceptibility cognition in HIV/AIDS prevention among senior high school student. Secondly we should strengthen the education of security sexual behavior, increase knowledge of safe sex and reduce high-risk sexual behavior. At last we should also undertake education on self-respect, self-confidence and responsibility to change the negative sexual attitude, enhance sexual morality education and reduce premarital sex. Sexual attitude open or not was the dominate variable to premarital sex intention and it was relatively difficult to change, while knowledge and cognition played a leading role to security sexual behavior intention which was relatively easy to change. For the final purpose of HIV/AIDS prevention interventions, education focus much on security sexual behavior than avoiding premarital sex could be apparent effective and more easily to be accepted by students.4. The recent and median follow-up study of peer-led intervention was obviously effective on HIV/AIDS prevention and advocating safe sexual behavioral intentions among senior high school students. Senior high school students were more willing to accept experts and peers'opinions. Our intervention was conducted by excellent peer educators well trained by experts, which catered to the needs of senior high school students.5. We suggested make full use of ROCCIPI method in the process of PROCEED, namely in education and environmental changes in policy, management, organizational policy study. ROCCIPI method with the characteristics of objectivity, logic and integrity could envision problem from rule, opportunity, capacity, communication, interest, process and ideology, finding the best policy rules or legal countermeasures to improve health promotion project.6. The policy and proposal of implement for setting HIV/AIDS education into senior high school curriculum system after baseline study, intervention research and ROCCIPI policy rules analysis.(1) We should put the preventive of AIDS health education into the school courses and make it compulsory through the mandatory files.(2) Formulated on the basis of the universal education outline base on our peer intervention study to lead the teaching methods of HIV/AIDS prevention health education in senior high schools, including classroom teaching, seminars, multimedia playback appreciation, thematic claass-meetings, and blackboard paper.(3) The teaching content should be improved and we proposed to strengthen the safe sex education among senior high school students.(4) The Shanghai Municipal Education Commission will be not only the advocate who proposed to put the AIDS health education into the school courses but also the supervisor who insure the implement of the policy. The the management and control system which is responsible for Physical Health Medical Department should be established.(5) To request the administrative departments of health cooperate actively with administrative departments of education by establishing cooperative mechanism. Make full use of the existing resources-Shanghai youth HIV prevention education training center to provide the necessary technical support and health knowledge training on AIDS prevention among senior high school students.(6) To make full use of the exiting teaching resource, including health care teachers, counseling teachers and biology teachers, improve ability of self-protection against HIV/AIDS among sebior high school students through education and propaganda by multidisciplinary penetration.(7) To improve the ability by establishing cooperation mechanism in the same district and training teachers from senior high schools by the health resources around district. The benefits of the teachers should also be to given full consideration to encourage the teachers actively develop AIDS prevention health education by providing further education credit after training and giving proper policy tilt and economic compensation for the teachers.