Evaluation of a school-based HIV/AIDS peer-led prevention programme: the first intervention trial for children of migrant workers in China

Abstract

The effectiveness of a peer-led education intervention in HIV/AIDS prevention was assessed in the Chinese children of migrant workers. A prospective study was conducted in 12 junior high schools for migrant children. Among the intervention group, a peer-education-based HIV/AIDS prevention was implemented for three months. The results during the baseline survey indicated that the level of knowledge on HIV/AIDS was lower in children of migrant workers. After three months of peer-led intervention, compared with the control group, students in the intervention group positively increased their HIV/AIDS-related knowledge, modified their attitude and improved their protection self-efficacy. Compared with attitude, intervention was more effective in the improvement of knowledge and protection self-efficacy, especially knowledge. The findings suggest that peer-led education was an effective method in improving knowledge, attitude and protection self-efficacy in Chinese children of migrant workers. Heightened concerns targeting the group students were particularly necessary, given their lower level of related knowledge and vulnerability to HIV infection.

Keywords

HIV/AIDS peer-led education adolescent migrant workers China

INTRODUCTION

HIV/AIDS in China has entered a critical stage of rapid and widespread increase.¹ It has been estimated that more than one million people in China have been infected with HIV and the rate of increase has topped the world. The number may go up to 10 million by 2010 if more intense and effective preventive measures are not adopted immediately.^2,3

As the severity of the HIV/AIDS epidemic has grown, the Chinese government devoted to take action, such as identifying at-risk groups and outlining pragmatic guidelines for behavioural interventions, to control the epidemic and maintain a low HIV prevalence. Data on emerging risk groups suggested that Chinese adolescents were increasingly exposed to sexually transmissible infections. A number of studies demonstrated that 5–20% of college students^4–6 and 3–8% of senior high-school students^5,7–9 had sexual experience. Since sexual behaviours were closely associated with HIV transmission, there was heightened concern that HIV/AIDS may threaten more and more Chinese youths. It was estimated that approximately 30% of the individuals infected with HIV were teens and young adults (15–24 years old).³

Data also demonstrated that the so-called ‘floating population’ – the approximately 130 million migrant workers, 73% of them coming from poorer regions of the country and working in the cities as labourers, restaurant workers and sex workers¹⁰ – has acted as the ‘tipping point’ for the AIDS epidemic in China.¹¹ It was shown that rural-to-urban migration may play a crucial role in shifting the HIV epidemic by broadening social and sexual mixing.^12,13 In addition, migrants' perceived HIV risk, knowledge of HIV and rates of condom use were low and they faced barriers in accessing education and health care.¹⁴ Therefore, compared with non-migrants in urban areas, HIV prevalence among rural-to-urban migrants was relatively high.¹⁵

Children, especially adolescents of migrant workers, as a special group in urban areas, may be at a greater risk of contracting and transmitting HIV not only because of their special developmental stage and close relationship with high-risk groups but also because of their fewer chances of getting health-care education. However, to the best of our knowledge, there has been no research focused on the group up to now. Therefore, it is especially necessary to investigate knowledge, attitude and behaviour intention regarding HIV/AIDS in this group children and find out an effective intervention method to educate and promote their sexual health and protection self-efficacy for HIV/AIDS.

Peer-led education on health promotion has shown a good effectiveness, particularly with respect to sexual health issues and substance misuse of young people.^16,17 In China, some pilot studies indicated that peer education intervention was a promising method in promoting risk-reduction behaviour and HIV/AIDS prevention among young people.^5,18

The present study initiated and piloted a peer-led HIV intervention programme in junior high schools for children of migrant workers in Shanghai, a big Chinese city along the southeast coast, in order to investigate knowledge, attitude and protection self-efficacy regarding HIV/AIDS in the group children and assess the effectiveness of peer education intervention in HIV/AIDS prevention.

METHODS

Sample and procedure

In all, there are 20 districts in Shanghai and migrant workers are settled mainly in 10 districts. Out of these 10 districts, three districts were selected for the study sample on the basis of cluster-stratified selection procedure, using geographic location, economic standard and population density as the criteria. For every district, four junior high schools for children of migrant workers were randomly selected, with two as the intervention group and the other two as the control. All the students (2237 children aged 14.20 ± 1.19 years, 57.3% boys and 42.7% girls, and 1140 children in the intervention group versus 1097 in the control) in selected schools yielded the study sample.

This study was conducted from March to June of 2006. The research aims were explained to school principals and teachers of the target schools. Permission was obtained to carry out the study, which is the usual practice in China. Among the intervention group, a peer-led HIV/AIDS prevention intervention was implemented for three months, while the students of the control group just followed the usual teacher-led heath education curriculum during this period of time. A total of 2237 sampled students completed a self-administered questionnaire before the intervention. After a three-month interval, 2179 of them participated in the endline test. (The attrition rate was 1.8% and 3.3% for the control group and the intervention group, respectively.) The students were told that participation in the survey was voluntary and the survey was anonymous.

The study was approved by the Ministry of Education of the People's Republic of China.

Selection and training of the peer educators

Peer educators were selected from grade 1 or 2 medical students of the Shanghai Jiaotong University School of Medicine. The selection criteria included personality, credibility, ability in communicating and collaborating with others and school performance. The 24 chosen peer educators were given a four-day training on intervention protocol and an invention-support package, which consisted of an adapted version of the curriculum developed by the Shanghai Jiaotong University School of medicine.

Intervention

The specific objectives of peer-led HIV/AIDS prevention intervention were as follows: (1) to increase the knowledge, especially transmission routes and prevention skills on HIV/AIDS; (2) to improve the understanding of what sexually transmitted disease (STD) is, its transmission routes and prevention measures, and its relationship with HIV/AIDS; (3) to improve protection self-efficacy; and (4) to eliminate prejudice and stigmatization towards people living with HIV/AIDS (PLWHA).

The peer-led intervention training curriculum covered five domains: (1) knowledge on HIV/AIDS, especially transmission routes and prevention skills; (2) knowledge on STD; (3) sexual knowledge; (4) knowledge on reproduction and contraception; and (5) Knowledge on drug abuse and prevention.

The peer-led intervention was integrated into the regular school health education schedule in the intervention group and the intervention was conducted for one session every two weeks. A lot of participatory activities were also used, such as group discussion (to facilitate the communication and information sharing), brain storming (to encourage prompt responses from participants and create an active atmosphere), case study (listing actual cases and discuss) and games (making students learn from playing games). These participatory activities could promote adolescents' understanding and acceptance of the knowledge and skill imparted to them. Compared with the usual teacher-led education, peer-led intervention could enlighten adolescents' activeness, interests, interaction and participation.

For the students of the control group, only the usual teacher-led heath education curriculum was conducted during this period of time. The usual teacher-led heath education curriculum covered basic knowledge on adolescent development and adolescence reproductive health care. In the health-care class, the knowledge was imparted to the students by health-care teachers and the students were just passive listeners, not learners with activeness and participation.

Evaluation on intervention process

To monitor the implementation of the intervention, some of the students participated voluntarily in a qualitative evaluation of the process. Evaluation questionnaires were filled during the process and at the end of the trial regarding the duration of the intervention, the number of attending students, the diversity of participatory activities, the arrangement of the content, the performance of peer educators, and so on.

Outcome measures

The outcome of the intervention was measured with an individual self-administered questionnaire on the following issues:

Knowledge related to HIV/AIDS: Fourteen items with response based on a three-point scale: ‘yes’, ‘not sure’ and ‘no’.

Attitude towards PLWHA: Seven items with response based on a five-point scale from agreement to objection.

Protection self-efficacy: Four items with response based on a three-point scale: ‘sure’, ‘maybe’ and ‘not sure’ (as shown in Table 1).

Table 1

Demographic characteristics of study participants at baseline and endline by study groups

	Baseline			Endline
	Control group (n = 1097)	Intervention group (n = 1140)	t/χ ²	Control group (n = 1077)	Intervention group (n = 1102)	t/χ²
Age (years, mean ± SD)	13.87 (1.17)	14.52 (1.13)	13.05**^†	14.15 (1.17)	14.79 (1.09)	12.05*^†
Gender (%)			6.89*^‡			5.06*^‡
Boys	60.1	54.6		59.9	55.4
Girls	39.9	45.4		40.1	44.6
Years in Shanghai (years, %)			2.36^§			3.65^§
<1	11.4	12.5		11.4	11.5
1–2	19.4	21.4		19.4	22.6
≥3	66.2	66.2		66.2	65.8
Family income (%)			4.03^§			3.28^§
<500	9.5	7.4		9.5	7.3
500–1999	69.4	69.5		69.4	70.6
≥2000	21.1	23.1		21.1	22.0
Father's education level (%)			4.21^§			6.67^§
Illiterate/primary	19.7	22.5		19.7	22.3
Junior secondary	63.7	59.9		63.7	58.8
Senior secondary	15.6	16.8		15.6	17.4
College or above	0.9	0.7		0.9	1.5
Mother's education level (%)			1.38^§			2.24^§
Illiterate/primary	44.8	47.1		44.8	44.6
Junior secondary	46.8	44.6		46.8	46.4
Senior secondary	8.0	7.8		8.0	7.9
College or above	0.5	0.5		0.5	1.0

Family income was expressed in RMB(yuan)/person/month

^†Independent-samples t-test

^‡2*2 chi-square test

^§K*2 chi-square test

*P < 0.05; **P < 0.01

For each item included in the scales for measuring knowledge, attitudes and behaviour intention, a score was assigned for each response. Scale scores were computed as a sum of each item score; the higher the scores, the better the knowledge, the more friendly the attitudes and the higher the level of protection self-efficacy.

Statistical analysis

Statistical descriptions were made by use of the mean, standard deviation and percentages. Demographic differences between study groups were analysed by independent-samples t-test and the chi-square test.

To assess the effectiveness of intervention, independent-samples t-test was used to compare score differences between the control and intervention groups at baseline or endline, and the test was also adopted to analyse the differences between baseline and endline by study groups. To control for some confounders, multiple linear regression analyses was further conducted to evaluate the effects of the intervention on changes in the scale-scores (post-test scores minus pretest scores).

All analyses were performed using the Statistical Program for Social Sciences (SPSS Inc., Chicago, IL, USA) for Windows, version 12.5. In the presentation of the results, the statistical significance was set at P < 0.05 (two tailed).

RESULTS

Demographic characteristics of study sample

Table 1 summarizes the demographic outlines of the study sample by the study group. No significant differences were observed in years in Shanghai, family income and parents' education level between the two groups at baseline or endline survey. However, there was age difference between the two groups, with students in the control group tending to be slightly older. Gender differences were also observed. In the outcome evaluation, these differences were taken into account by multiple regression models.

Evaluation on intervention process

The questionnaire for monitoring the implementation process was completed by 30% of the students of the intervention group. The average number of training sessions that the students received was five times and the median duration of the interventions was four hours. Above 90% reported that the sessions were very useful and approximately two-thirds evaluated the peer leaders as qualified. Ninety-two percent of the students showed their appreciation for peer-led education and they praised this type of method as ‘interesting, new and meaningful’.

Evaluation on the effectiveness of peer-led education

Table 2 shows the scores and proportion in total scores for knowledge, attitude and protection self-efficacy at baseline and endline by study groups. It can be seen that there were no differences in knowledge, attitude and protection self-efficacy between the two groups at baseline. The proportion of scores in total scores was approximately 46% for knowledge, 79% for attitude and 59% for protection self-efficacy at baseline, respectively.

Table 2

HIV/AIDS-related knowledge, attitude and protection self-efficacy scores at baseline and endline by study groups (mean ± SD)

	Control group	Intervention group	t ^†
HIV/AIDS knowledge score (% in total score)
Baseline	12.70 ± 4.20 (45.36)	13.08 ± 3.93 (46.71)	1.21
Endline	12.88 ± 3.91 (46.00)	18.19 ± 4.64 (64.96)	29.09**
% Change	1.4	39.07** ^†
Attitude toward PLWHA score (% in total score)
Baseline	27.91 ± 4.41 (79.74)	27.85 ± 4.21 (79.57)	−0.32
Endline	27.85 ± 4.42 (79.57)	30.62 ± 4.58 (87.49)	3.56**
% Change	−0.2	9.46** ^†
Protection self-efficacy score (% in total score)
Baseline	7.00 ± 1.31 (58.33)	6.98 ± 1.29 (58.17)	−0.09
Endline	7.11 ± 1.26 (59.25)	8.06 ± 1.39 (67.17)	3.87**
% Change	1.57	15.47** ^†

PLWHA= people living with HIV/AIDS

^†Independent-samples t-test

**P < 0.01

There were statistically significant increases in HIV/AIDS-related knowledge, attitude and protection self-efficacy from pretest to post-test in the intervention group, but no significant increase was observed in the control group. Compared with the improvement in attitude and protection self-efficacy, the improvement in knowledge was the most obvious.

To assess exactly the effectiveness of peer-led education on HIV/AIDS-related knowledge, attitude and protection self-efficacy, multiple linear regression analyses were further conducted (as shown in Table 3). After controlling for some demographic factors, intervention remained to be statistically significant in the change of knowledge (STDβ = 2.76, P < 0.01), attitude (STDβ = 2.34, P < 0.01) and protection self-efficacy (STDβ = 1.64, P < 0.01). The results also demonstrated that, compared with attitude, intervention was more effective in the improvement of knowledge and protection self-efficacy.

Table 3

Associations between intervention and scores changes (post-test scores minus pretest scores) in knowledge, attitude and protection self-efficacy by linear regression model

	Knowledge scores changes		Attitude scores changes		Self-efficacy scores changes
	STDβ	95% CI	STDβ	95% CI	STDβ	95% CI
Intervention
Peer-led versus Control	2.76**	2.40; 3.12	0.84**	0.23; 1.58	1.64**	1.23; 2.05
Baseline score
Per point	NS		−0.3*	−0.21; −0.05	NS
Age
Per year	0.18*	0.04; 0.32	−0.15*	−0.28; −0.01	NS
Gender
Female versus male			2.22**	1.91; 2.53	0.66**	0.31; 0.98
Years in Shanghai
1–2 versus <1	0.77**	0.22; 1.32	NS		NS
≥3 versus <1	1.33**	0.87; 1.80	0.37*	0.05; 0.70	0.42*	0.02; 0.81
Family income
II versus I^†	1.56**	1.04; 2.08	0.41*	0.08; 0.74	NS
III versus I	1.13**	0.54; 1.72	NS		NS
Father's education level
II versus I^‡	NS		NS		NS
III versus I	NS		NS		NS
IV versus I	NS		NS		NS
Mother's education level
II versus I^‡	NS		NS		NS
III versus I	NS		NS		NS
IV versus I	NS		NS		NS

NS = not significant; CI = confidence interval

^†Lowest family income

^‡Lowest education level

*P < 0.05; **P < 0.01

DISCUSSION

With the ongoing economic development and industrialization in China, many rural residents have migrated to urban areas; thus, the so-called ‘floating population’ has emerged. A previous study demonstrated that, by 2004, the majority of HIV-infected individuals resided in rural areas because of commercial plasma donation.¹ In addition, there was evidence that, compared with non-migrating rural residents, migrants were more likely to indulge in risk-taking behaviours.^12,13 Rural migrants may act as a ‘bridge population’ for HIV transmission between rural and urban areas.^12,15 Therefore, it is particularly necessary to initiate HIV/AIDS intervention programmes among migrants, especially those who are young.

The present study demonstrated that, in children of migrant workers, the level of knowledge on HIV/AIDS was lower and protection self-efficacy was poor. Peer-led intervention was feasible and effective in improving their knowledge, attitude and protection self-efficacy. To our knowledge, this is the first intervention programme regarding HIV/AIDS in junior high schools for children of migrant workers in China. Therefore, this study entailed an extended data-set for understanding the importance of HIV/AIDS education and prevention efforts targeting the migrant population, especially those who are young, in urban destinations.

The baseline knowledge, attitude and behaviour intention

The present study demonstrated that, in children of migrant workers, the level of knowledge on HIV/AIDS was lower and protection self-efficacy was poor among both groups during the baseline survey. Compared with their peers in general public schools, students in the study group generally perceived a low level of baseline knowledge and protection self-efficacy.^19,20

In general, as a special group in China, children of migrant workers faced several challenges to effectively protect themselves from HIV infection. First of all, due to educational and informational restrictions, as well as other barriers including social marginalization, they were lacking basic health-care knowledge and risk and self-protection perception. Our survey showed that schools for them were poorly equipped and teachers were not qualified enough. In addition, because of economic and educational restrictions, most parents of these children possessed a low level of health-care knowledge. They either did not impart necessary health information or transmitted incorrect information to their children. Secondly, since the students lived in the high-HIV-prevalence group, they faced more danger of HIV infection and anxiety of living with HIV-positive people and they needed information to protect themselves and dispel their fears. Finally, the majority of them would find a job in the city after graduation from junior high school. Thus, effective youth-friendly programmes with information dissemination and self-efficacy building are critically important to the group children.

Effectiveness of peer-led intervention

Our study showed that after three months of peer-led intervention, students were more aware of how to protect themselves from HIV as well as more likely to care for people living with HIV. In addition, intervention was helpful to strengthen students' protection self-efficacy, such as how to resist pressure to have sex. Moreover, the intervention was effective in mitigating students' fear of AIDS and building their HIV and AIDS awareness in a friendly atmosphere. Compared with previous sex education projects conducted in rural areas of China,^8,9 the interactive methods used in this study seem more effective, which not only increased respondents' knowledge, promoting their friendly attitudes to HIV-infected persons, but also resulted in positive changes in protection self-efficacy.

However, the present study demonstrated that, compared with knowledge and protection self-efficacy, the improvement in attitude was somewhat slight. This may be due to the fact that, except for knowledge, students' attitudes to HIV/AIDS may also be correlated to traditional values, sexual mores, ethics and environments. In addition, although the three-month intervention may be long enough to lead to changes in knowledge and protection awareness, it may be too short to modify attitude since attitude is a multidimensional conception. A repeated and long-term intervention may be more effective in the modification of attitudes towards HIV/AIDS; however, this hypothesis should be prospectively confirmed by new studies. Moreover, because of the first intervention targeted to children of migrant workers – a special group – the design and implementation of peer-led prevention programmes may be not adaptive and matched enough.

There are several limitations that should be considered in interpreting these results. Firstly, social desirability bias and inaccuracy perhaps existed in answering the questionnaires despite the assurance of guaranteed anonymity. The second limitation existed in the mechanism by which the peer educators were selected. In this research, most peer educators were chosen on the basis of their ability in communicating and establishing relationships. However, few were chosen by teachers based on their academic skills, although efforts had been made to avoid this. Finally, perhaps the duration of the study was not long enough to observe greater changes in attitudes towards HIV/AIDS.

CONCLUSION

Children of migrant workers should be the target of specific intervention, given their restriction in accessing health-care education and close association with high-risk groups. The peer-led education of HIV/AIDS was effective in improving the knowledge on HIV/AIDS and helpful in strengthening students' protection self-efficacy, but was not so effective in changing the attitude, which indicates long-term intervention or more comprehensive intervention programmes should be outlined and adopted.

Footnotes

ACKNOWLEDGEMENT

This study was funded by Grants from Shanghai Key Laboratory of Children's Environmental Health (06DZ22024), National Natural Science Foundation of China (30700670), Innovation Program of Shanghai Municipal Education Commission (09YZ92), Program for Excellent Young Teachers in Shanghai (jdy-07011); Chenxia Award Project for Young scholar in Shanghai Jiaotong University and New Bairenjihua in Shanghai Jiaotong University School of Medicine.

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