Abstract
The HIV/AIDS epidemic is a major problem around the world and an increasing percentage of new HIV cases is reported to be by sexual transmission. Many studies have been carried out in the field of peer education on HIV/AIDS among young people, however, few studies focused on the long-term effect of this education. To evaluate both the short- and long-term effects of the peer education programme, we conducted a follow-up study to evaluate the related knowledge, attitudes and behaviour intention to HIV/AIDS among senior high-school students in Shanghai, China. We selected 1950 students from 10 senior high schools in Shanghai, from whom 968 students were selected at random for the intervention group and 982 students for the control group. The same questionnaires were carried out before intervention, one month and one year later in both the groups. In the intervention group, the knowledge score of reproductive health, HIV/AIDS and sexually transmitted disease rose from 21.66 to 31.72 one month later (P < 0.001). After one year it was still 30.97, and there was no significant difference between one month and one year (P > 0.05). The behaviour intention to HIV/AIDS prevention, such as condom use during sexual intercourse also changed before and after the intervention. After both the one month and one-year follow-up intervention, we found that more students declared that they would use condoms during sexual intercourse when compared with the control group (P < 0.001). No change was seen in either knowledge or behaviour intention in the control group. These results showed that peer education on HIV/AIDS prevention among high-school students is both effective in promoting knowledge and in changing behaviour intention long term.
Introduction
The wide prevalence of HIV/AIDS is the biggest public health and social problem in the world today. In China, a cumulative total of 191,565 HIV/AIDS cases had been reported, including 47,713 AIDS patients and 13,632 deaths by the end of 2006. 1 Among new HIV cases, sexual transmission of HIV/AIDS has obviously increased when compared with the habit of sharing injections in drug users over the same period. The most important way to control HIV/AIDS is to provide health education to young people since this disease is mainly transmitted by sexual behaviour and neither a cure nor an effective vaccination for HIV/AIDS is available. Many studies demonstrate that most Chinese youths lack basic sex information and their attitudes towards sex have become more and more open. Studies have shown that 5–20% of college students2–4 and 3–8% of senior high school students5,6 had had sexual experience. So it is very important to enhance related knowledge and attitudes and decrease high-risk sexual behaviour in young people. Much research has been conducted on the short term effects of health education on HIV/AIDS among young people,7,9 however, few studies have focused on the long-term effects and evaluated not only the changes of related knowledge and attitude but the behaviour intention.10,11 To evaluate both the short- and long-term effects of a peer education programme we conducted a follow-up study among senior high school students in Shanghai, China from 2004 to 2006.
Subjects and Methods
Sample
Ten senior high schools were chosen among schools in Shanghai, by cluster sampling. A total of 1950 students were included in the sample, in which 968 students were randomized into the peer-led HIV/AIDS prevention group (the intervention group), and another 982 students were randomized without any intervention curriculum. The 1950 sampled students completed a self-administered questionnaire before the education, after one month and one year's education in both the groups. The students were informed that participation in the survey was voluntary and the survey was anonymous.
Peer educator selection and training
Peer educators were freshmen, selected through interview by teachers from a medical school, and verified by experts. The criteria included charismatic personality, credibility, good communication and ability to establish relationships with the other students. Ten peer educators, aged 18.5–19.2 years old, were chosen and given a week's training on educational protocol design, resources identification and anchoring classroom sessions to improve the knowledge, attitude and behaviour of their classmates towards HIV/AIDS.
Intervention
Our intervention was in order to increase knowledge about the transmission and prevention of HIV; to improve behaviour and behaviour intention to protect youth from HIV/AIDS; to eliminate prejudice and stigmatization towards PLWHA (People Living with HIV/AIDS).
Outcome measures
The questionnaire was designed carefully and consisted of information on individual sociodemographic characteristics; 42 items on knowledge of reproductive health, HIV/AIDS, STDs and five items on attitudes towards PLWHA, premarital and extramarital affairs and condom use during sexual intercourse. Students were asked to respond to the knowledge items with ‘yes’, ‘no’ and ‘not sure’, and attitudes and behaviour intention items with ‘sure’, ‘maybe’ and ‘not sure’. For each item included in the scales for measuring knowledge, attitudes and behaviour intention, a score or a rate was designed for each response. For example, to evaluate participant's knowledge level, correct answers were credited with a score of one and incorrect answers with a score of zero. Then the sum of each question's score was converted into a new score, with the maximum being 42. The higher the score, the greater the knowledge. The same questionnaires were used before education, after one month and one year's education in both the intervention group and the control group at the same time.
Statistical analysis
Changes in knowledge before intervention, one month after and one year after within each group were evaluated by analysis of variance (ANOVA) and comparisons of knowledge among study groups were done by Student's t-tests. Changes in behaviour intention within the two study groups were performed by χ 2 tests. Epidata 2.0 (a kind of epidemic software) was used to set up a data bank and all statistical analyses were performed using SPSS for Windows 11.0 (SPSS Inc., Chicago, IL, USA). In the presentation of the results, the statistical significance level was set at P < 0.05 (two-tailed).
Results
Demographic characteristics
A total of 1950 students completed the questionnaires before intervention, one month later the total was 1878 and one year later it was 1729. The average age was 17.22 ± 0.89 years. Variances such as age and gender were compared in this section and no difference was found between the two study groups (P > 0.05). The attrition rate was 3.47% for the intervention group, 3.87% for the control group after one month. And one year later it was 7.85% and 8.66% in both the study groups (Table 1).
Attrition rate of intervention group and control group (%)
Short- and long-term effects of intervention
Knowledge
There were statistically significant differences in HIV/ AIDS-related knowledge between the intervention group and the control group at one month post-test (short-term effect) and one year post-test (long-term effect) (P < 0.001). In the intervention group, the scores rose from 21.66 to 31.72 one month later (P < 0.001), were 30.97 after one year, and there was no significant difference between one month and one year (P > 0.05). No significant increase was observed in the control groups (P > 0.05) (Table 2).
Short- and long-term change of HIV/AIDS-related knowledge between groups (mean ± SD)
Student s t-test values
P < 0.001
Analysis of covariance values
Behaviour intention
We found a higher percentage of students who declared that in future they would use condoms during sexual intercourse in the intervention group. The percentage rose from 46.2% to 65.7% one month later and it was 61.4% after one year (P < 0.001). No significant increase was observed in the control groups (P > 0.05). There was a significant difference in condom-using intention when compared with the control group (P < 0.001) (Table 3).
Comparison of behaviour intention towards condom use — percentage in each group
χ2 Test values
P < 0.01
Discussion
Many studies do suggest that peer education can bring about short-term positive changes in knowledge, attitude and behavioural intention regarding condom use,7–9 attitude towards abstinence, 12 delay in the initiation of sexual behaviour, the frequency of intercourse and the use of condoms among sexually active teens. Such effective programmes tend to be theory-based, highly structured and led by well-trained peers. Although past researches have found peer education to be effective, few evaluations have measured long-term effects of this type of programme.
In our study, both short- and long-term effects were observable 12 months following the intervention. Our peer education intervention produced a positive change in students’ HIV/ AIDS-related knowledge and behaviour intention in HIV/ AIDS prevention, such as condom use when having sexual intercourse. For example, after one year, HIV/AIDS-related knowledge scores of the intervention group decreased a little but showed no significant difference when compared with one month after intervention. It was still higher than the control group at the same time.
Several study limitations should be noted. First, the sample was not large; 1950 students from 10 schools were only a small part of Shanghai's students. Secondly, as an anonymous questionnaire survey was adopted, this may have led to loss of some information. Thirdly, our observation period was 12 months, but it was not easy to measure changing behaviour in youths for a period of one year in China; so we could measure only the behaviour intention.
Conclusion
Peer-led education relating to HIV/AIDS is effective in improving knowledge and some behaviour intentions of high-school students in Shanghai. Both short- and long-term effects were still measurable 12 months after the intervention. We suggest that peer-led education of HIV/AIDS should be popularized among adolescents in China and related effective strategies and secured supports should be set-up quickly in the future.
Footnotes
Acknowledgements
This research was funded by the Foundation of Project HOPE, Hong Kong (04PH21005). Part of the follow-up study was funded by general programme of humanities and social studies, China Ministry of Education (06JC880010). Our sincere gratitude is due to other members of the research team and all the youngsters and the schools participating in this research.