学校为基础的沿海城市高中生预防艾滋病同伴干预效果及ROCCIPI策略研究
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摘要
一、研究背景
艾滋病在我国的流行是一个严重的公共卫生和社会问题,目前性传播已经成为城市青年感染艾滋病风险最大的途径。世界各国近30年的艾滋病的预防和控制经验表明,通过各种健康促进、健康教育的手段提高人群对艾滋病预防的认识,减少高危行为仍然是最有效的。在我国,高中(包括中专和职业学校)是大多数城市青少年走向社会前要经历的阶段,同时以学校为基础的健康促进研究有着良好的组织和实施条件。但是目前高中学生的预防艾滋病研究,绝大多数的都是局部地区的个别学校的研究,样本量较小,代表性较差,且研究中缺乏健康促进理论基础的支持,大多数的研究都建立在知识水平变化影响行为的简单理论假设上,量表的设计不规范,缺乏合理的评价。因此,本次研究选择了三座城市49所高中学校进行研究,基于健康促进的理论的指导,以健康促进理论综合应用模式—RECEDE-PROCEED模式为组织框架,确定最合适的干预策略并指导实施,提高高中学生艾滋病的相关知识和认知,并采纳健康安全的行为。同时创新性的使用了ROCCIPI方法开展政策和组织诊断,对高中生将艾滋病健康教育纳入课程体系的可行性进行了探讨。
二、研究目的
1.选择适宜的健康促进理论模型,规范高中生预防艾滋病健康促进的实施、评价和政策制定过程。包括制定适宜的高中生艾滋病预防健康问卷(QAHP-SS)并进行评价,证明其在健康促进效果评价中的可行性和有效性。
2.通过沿海三个城市高中生艾滋病预防量表的基线调查分析,结合通径分析方法确定艾滋病高危行为意向的影响因素,制定预防艾滋病同伴干预模式。
3.通过近期和中期随访研究,评价本次健康促进中预防艾滋病同伴干预的效果。
4.通过政策和组织诊断和过程评价,用ROCCIPI法探讨上海高中生艾滋病健康教育纳入课程体系的可行性。
三、研究方法
1.健康促进理论模型框架确定和高中生艾滋病预防健康问卷的设计与评价
(1)应用健康促进理论的综合模式—PRECEDE-PROCEED的组织框架,并在此框架的指导下实施和评估健康促进项目；(2)以大学生艾滋病预防的标准量表为基础,自制高中生艾滋病预防健康问卷。在随机性和可行性并重的情况下,选择了三个有研究基础的沿海省市和自治区49所高中和职校学生进行问卷的信度和效度评价。
2.沿海三个城市高中生艾滋病健康问卷的基线调查
(1)通过大样本的流行病学调查了解高中生的人口学特征、个人艾滋病相关的知、信、行。(2)分析影响因素,进行通径分析,进行社会学、流行病学、行为环境等诊断,确定倾向因素、强化因素和促成因素。(3)根据健康生态学模型和现况研究结果确定符合高中生需求的预防艾滋病的同伴干预措施。
3.预防艾滋病同伴干预近期和中期随访研究
(1)通过类实验的设计方案,设立干预组和对照组,对预防艾滋病同伴干预的近期效果进行评价。(2)在三个城市选择部分干预和对照人群进行为期1年的跟踪随访,评价干预的中期效果。(3)设置过程评价,对干预质量进行评估。
4. ROCCIPI法上海高中生艾滋病健康教育纳入课程体系研究
(1)用ROCCIPI策略制定的方法,从学生、师资、学校和教育行政部分四个角度对将艾滋病预防的健康促进纳入上海市高中生的日常课程进行可行性评价。(2)在引入ROCCIPI法的政策评估方法的基础上,对健康促进的综合框架PRECEDE-PROCEED模式进行补充。
四、主要结果
1.问卷的制定和评价
(1)内在信度考核：高中生艾滋病预防健康问卷大多数条目的Cronbach'sα系数在0.7-0.9之间,内在信度良好。
(2)重测信度考核：252名高中生中间隔3周的两次调查并进行了自身配对,结果显示所有条目的Spearman相关系数均大于0.7,说明该问卷有较好的重测信度。
(3)结构效度考核：因子分析结果显示QAHP-SS的结构特征良好,降维后提取5个公因子,涉及到知识、态度、信念、行为意向和行为,与健康促进理论中倾向因素的分布基本是相符合的。进一步采用Pearson相关分析和Spearman相关系数研究QAHP-SS各维度评分与总评分之间的相关性,结果显示相关性较好。
2.沿海三个城市高中生艾滋病预防健康问卷的基线调查
(1)三地生殖健康知识平均正确率只有45.0%,艾滋病知识的正确率达到67.3%。上海学生知识和认知明显高于三明和北海。除艾滋病知识外,男生知识和认知均高于女生。重点高中学生的知识和认知得分均高于职业中学和普通高中。
(2)有44.6%的学生明确表示反对男性婚前性行为,50.5%的学生明确表示反对女性婚前性行为。上海地区学生、职业中学学生以及男性学生对待婚前婚外性行为的态度方面相对较开放。
(3)在对待艾滋病病人的具体态度方面,有45.9%的高中学生认为艾滋病患者是值得同情的,只有33.3%的高中学生不会在一般社交下躲避艾滋病感染者。
(4)有79.8%的学生表示有信心在学习期间不发生性行为,有56.2%的学生表示有信心在婚前不发生性行为。有49.5%的学生表示万一发生性行为,将使用安全套作为保护措施,有46%的学生表示万一发生性行为,会说服对方来使用安全套作为保护措施。上海的学生、职业学校的学生和男性学生的婚前性行为意向得分较低与婚前性行为态度情况是一致的。
(5)本次调查发现高中阶段学生发生性交行为比例为4.5%。在性行为发生方面,男生和职业中学学生相对“易感”。二分类Logistic回归分析结果显示艾滋病知识得分高、对待艾滋病病人态度得分高(宽容)、对待婚前性行为态度得分高(保守)、婚前性行为意向得分高(不倾向于发生婚前性行为)是发生性交行为的保护因素,而学校性质为职业中学、安全性行为意向得分高(倾向于发生安全性行为)以及教育必要性得分高(对安全性教育有更多需求)是性交行为发生的危险因素。
(6)高中生中艾滋病相关知识的普及率不到42%(41.6%),避孕知识(安全性行为方面)的普及不到20%(16.2%)。近80%高中阶段学生认为艾滋病的健康教育和安全性行为教育是必要和非常必要的。高中生的性及艾滋病相关知识最容易接受的途径中最高的是专家和教授,占38.1%,其次是同学和朋友,占28.1%。
(7)通过AMOS7.0软件的通径分析显示,艾滋病知识的获得有助于高中阶段学生加强对安全性行为益处和艾滋病易感性的认知,从而增强自我保护意识来采纳安全性行为意向,同时知识也直接有助于增强采纳安全性行为的意向。对艾滋病易感性的认知,有助于采纳安全性行为和减少婚前性行为意向,但是安全性行为益处的认知却对婚前性行为态度和意向有反向作用,也就是说有越多的安全性行为益处知识可能会导致性行为态度的较为开放从而倾向于发生婚前性行为。
3.预防艾滋病同伴干预近期和中期随访研究
(1)干预措施实施后两周,干预组艾滋病相关知识和认知有了很大的提高,知识水平的正确率大都较基线水平提高了10%-30%,而同期对照组没有明显改变。
(2)干预组在干预后对待艾滋病的态度正向态度得分得到了一定的提高,但是不如知识增加幅度大。虽然干预组学生短期内婚前性行为态度的变化并不明显,但在干预后自我价值和自尊方面有了一定提高,婚前性行为意向的得分明显提高,也有更多的学生在干预后倾向于采纳安全性行为意向。
(3)随访1年研究后,通过重复测量的方差分析,我们发现干预组的知识和认知得分及艾滋病正向态度方面的提高效果明显,且有持续性。自我价值干预后短期明显上升,但是1年后也明显回落,对照组也在1年后较2周时有下降趋势,说明由于学习和升学的压力日趋增加,学生容易出现消极情绪,影响自我价值的认同。
在对待婚前婚外性行为的态度方面的随访中发现,干预组在干预前、干预后2周和干预后1年的态度水平呈现出平缓上升的直线,与对照组几近平行,也就是干预后的态度改变不明显,与对照组没有统计学差异。在行为意向的随访研究中,干预组在干预后2周在对待婚前性行为的意向得分和安全性行为意向都有所上升,干预后1年调查发现行为意向较干预后2周略有下降,但仍维持在较高水平。
(4)同伴干预过程评价发现所有模式的亲切程度方面赢得了较高评价,得分最高,其次是易理解程度,参与性程度和生动性评分相对较低。男生对参与性的评分明显高于女生,而女生对亲切程度的评分明显高于男生。
4.将艾滋病健康教育纳入高中生课程体系存在的困难
(1)学生角度：高中学生课业负担较重,课程设置紧张,只有在高一或高二阶段,实施健康教育的可能性较大。在课程设置的内容方面还有待于进一步改进。
(2)师资角度：预防艾滋病健康教育的师资力量普遍比较薄弱,专业教师缺乏,卫生保健老师的地位较低,工作实施难度大。
(3)学校角度：学校领导往往重升学率轻保健,学校领导的重视程度直接影响到实施健康教育的过程,高中学校都面临着升学竞争的压力,学校领导对预防艾滋病健康教育的重视程度有待提高。
(4)教育行政管理部门角度：上海市教育委员会的体卫艺教科、德育科等在学生艾滋病预防工作中起着主导作用。教育主管部门既要考虑如何保证预防艾滋病课时的设置和安排,又要统筹兼顾高中学生课程压力过大的问题。
五、结论与政策建议
1.我国沿海城市高中生中进行艾滋病预防研究的QAHP-SS量表具有较好的信度和效度。
2.沿海三城市高中生艾滋病相关知识和认知还有待于提高。中小沿海城市、职业中学学生更需加强教育。男生和职业中学人群应该是干预的重点,减少其过早发生无保护性行为。
3.通径分析显示高中学生预防艾滋病应该首先加强艾滋病的相关知识,提高对学生艾滋病易感性的认知。其次应加强安全性行为方面的教育,增加安全性行为知识,减少高危性行为。还应进行自尊、自信和责任感方面的教育,改变不良的性观念,增强性道德教育,减少婚前性行为的发生。支配婚前性行为意向的主要变量是性态度是否开放,相对比较难改变,而对安全性行为意向起到主导作用的是知识和认知,相对比较容易改变,对艾滋病预防干预的最终目的而言,以安全性行为教育为重,可能比以避免婚前性行为教育的成效更明显,更容易被学生接受。
4.同伴干预在对高中阶段学生预防艾滋病、倡导安全性行为意向中的近期和中期效果明显。高中阶段学生更乐于接受专家和同伴的意见,本次健康干预的方式就是采用专家培训优秀的同伴教育者来实施干预,迎合了高中阶段学生的需要。
5.我们建议在健康促进研究的PROCEED模式中,在研究教育和环境改变的政策、管理与组织中,从方法学上加以改进,可以利用ROCCIPI法政策研究的客观性、逻辑性和整体性,从规则、机会、能力交流、利益、过程和意识七个方面,从不同角度进行探讨来透视问题、寻求最佳政策规则和法律对策。
6.通过基线研究、干预研究和ROCCIPI法策略分析,我们对将预防艾滋病健康教育纳入高中课程的政策提出实施建议：
(1)应该通过指令性文件的形式,将预防艾滋病健康教育强制纳入学校教学计划。
(2)在本次同伴干预研究的基础上,制定普适性的教育大纲,指导学校开展多样化的教学方法,包括课堂教学、专题讲座、播放多媒体教学片、主题班会、黑板报等多种形式开展预防艾滋病健康教育。
(3)在高中预防艾滋病健康教育的教学内容增强安全性行为教育。
(4)上海市教育委员会作为将艾滋病健康教育纳入课程设置的倡导者,同时是保证该政策实施的监督者,要建立以体卫医科处负责的健全的管理和监督机制,并制定监督和评估方案。
(5)建立多部门合作机制,要求卫生行政部门积极配合教育行政部门,并充分利用现有的资源—上海市青少年预防艾滋病健康教育培训中心的力量,为开展高中生预防艾滋病健康教育提供必要的技术支持和健康知识培训。
(6)要充分利用现有的师资力量,包括卫生保健老师、心理咨询老师、生物学老师等,通过多学科渗透对学生进行宣传教育,提高学生抵御艾滋病侵袭的能力。
(7)加强能力建设,可以建立区内合作机制,利用区内卫生资源对学校师资进行培训。同时要充分顾及到师资的利益,培训后给予继续教育学分,并通过适当的政策倾斜和经济补偿,鼓励师资主动开展预防艾滋病健康教育活动。
Background
The 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.
Objectives
1. 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.
Methods
1. 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.
Results
1. 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 suggestion
1. 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.
艾滋病在我国的流行是一个严重的公共卫生和社会问题,目前性传播已经成为城市青年感染艾滋病风险最大的途径。世界各国近30年的艾滋病的预防和控制经验表明,通过各种健康促进、健康教育的手段提高人群对艾滋病预防的认识,减少高危行为仍然是最有效的。在我国,高中(包括中专和职业学校)是大多数城市青少年走向社会前要经历的阶段,同时以学校为基础的健康促进研究有着良好的组织和实施条件。但是目前高中学生的预防艾滋病研究,绝大多数的都是局部地区的个别学校的研究,样本量较小,代表性较差,且研究中缺乏健康促进理论基础的支持,大多数的研究都建立在知识水平变化影响行为的简单理论假设上,量表的设计不规范,缺乏合理的评价。因此,本次研究选择了三座城市49所高中学校进行研究,基于健康促进的理论的指导,以健康促进理论综合应用模式—RECEDE-PROCEED模式为组织框架,确定最合适的干预策略并指导实施,提高高中学生艾滋病的相关知识和认知,并采纳健康安全的行为。同时创新性的使用了ROCCIPI方法开展政策和组织诊断,对高中生将艾滋病健康教育纳入课程体系的可行性进行了探讨。
二、研究目的
1.选择适宜的健康促进理论模型,规范高中生预防艾滋病健康促进的实施、评价和政策制定过程。包括制定适宜的高中生艾滋病预防健康问卷(QAHP-SS)并进行评价,证明其在健康促进效果评价中的可行性和有效性。
2.通过沿海三个城市高中生艾滋病预防量表的基线调查分析,结合通径分析方法确定艾滋病高危行为意向的影响因素,制定预防艾滋病同伴干预模式。
3.通过近期和中期随访研究,评价本次健康促进中预防艾滋病同伴干预的效果。
4.通过政策和组织诊断和过程评价,用ROCCIPI法探讨上海高中生艾滋病健康教育纳入课程体系的可行性。
三、研究方法
1.健康促进理论模型框架确定和高中生艾滋病预防健康问卷的设计与评价
(1)应用健康促进理论的综合模式—PRECEDE-PROCEED的组织框架,并在此框架的指导下实施和评估健康促进项目；(2)以大学生艾滋病预防的标准量表为基础,自制高中生艾滋病预防健康问卷。在随机性和可行性并重的情况下,选择了三个有研究基础的沿海省市和自治区49所高中和职校学生进行问卷的信度和效度评价。
2.沿海三个城市高中生艾滋病健康问卷的基线调查
(1)通过大样本的流行病学调查了解高中生的人口学特征、个人艾滋病相关的知、信、行。(2)分析影响因素,进行通径分析,进行社会学、流行病学、行为环境等诊断,确定倾向因素、强化因素和促成因素。(3)根据健康生态学模型和现况研究结果确定符合高中生需求的预防艾滋病的同伴干预措施。
3.预防艾滋病同伴干预近期和中期随访研究
(1)通过类实验的设计方案,设立干预组和对照组,对预防艾滋病同伴干预的近期效果进行评价。(2)在三个城市选择部分干预和对照人群进行为期1年的跟踪随访,评价干预的中期效果。(3)设置过程评价,对干预质量进行评估。
4. ROCCIPI法上海高中生艾滋病健康教育纳入课程体系研究
(1)用ROCCIPI策略制定的方法,从学生、师资、学校和教育行政部分四个角度对将艾滋病预防的健康促进纳入上海市高中生的日常课程进行可行性评价。(2)在引入ROCCIPI法的政策评估方法的基础上,对健康促进的综合框架PRECEDE-PROCEED模式进行补充。
四、主要结果
1.问卷的制定和评价
(1)内在信度考核：高中生艾滋病预防健康问卷大多数条目的Cronbach'sα系数在0.7-0.9之间,内在信度良好。
(2)重测信度考核：252名高中生中间隔3周的两次调查并进行了自身配对,结果显示所有条目的Spearman相关系数均大于0.7,说明该问卷有较好的重测信度。
(3)结构效度考核：因子分析结果显示QAHP-SS的结构特征良好,降维后提取5个公因子,涉及到知识、态度、信念、行为意向和行为,与健康促进理论中倾向因素的分布基本是相符合的。进一步采用Pearson相关分析和Spearman相关系数研究QAHP-SS各维度评分与总评分之间的相关性,结果显示相关性较好。
2.沿海三个城市高中生艾滋病预防健康问卷的基线调查
(1)三地生殖健康知识平均正确率只有45.0%,艾滋病知识的正确率达到67.3%。上海学生知识和认知明显高于三明和北海。除艾滋病知识外,男生知识和认知均高于女生。重点高中学生的知识和认知得分均高于职业中学和普通高中。
(2)有44.6%的学生明确表示反对男性婚前性行为,50.5%的学生明确表示反对女性婚前性行为。上海地区学生、职业中学学生以及男性学生对待婚前婚外性行为的态度方面相对较开放。
(3)在对待艾滋病病人的具体态度方面,有45.9%的高中学生认为艾滋病患者是值得同情的,只有33.3%的高中学生不会在一般社交下躲避艾滋病感染者。
(4)有79.8%的学生表示有信心在学习期间不发生性行为,有56.2%的学生表示有信心在婚前不发生性行为。有49.5%的学生表示万一发生性行为,将使用安全套作为保护措施,有46%的学生表示万一发生性行为,会说服对方来使用安全套作为保护措施。上海的学生、职业学校的学生和男性学生的婚前性行为意向得分较低与婚前性行为态度情况是一致的。
(5)本次调查发现高中阶段学生发生性交行为比例为4.5%。在性行为发生方面,男生和职业中学学生相对“易感”。二分类Logistic回归分析结果显示艾滋病知识得分高、对待艾滋病病人态度得分高(宽容)、对待婚前性行为态度得分高(保守)、婚前性行为意向得分高(不倾向于发生婚前性行为)是发生性交行为的保护因素,而学校性质为职业中学、安全性行为意向得分高(倾向于发生安全性行为)以及教育必要性得分高(对安全性教育有更多需求)是性交行为发生的危险因素。
(6)高中生中艾滋病相关知识的普及率不到42%(41.6%),避孕知识(安全性行为方面)的普及不到20%(16.2%)。近80%高中阶段学生认为艾滋病的健康教育和安全性行为教育是必要和非常必要的。高中生的性及艾滋病相关知识最容易接受的途径中最高的是专家和教授,占38.1%,其次是同学和朋友,占28.1%。
(7)通过AMOS7.0软件的通径分析显示,艾滋病知识的获得有助于高中阶段学生加强对安全性行为益处和艾滋病易感性的认知,从而增强自我保护意识来采纳安全性行为意向,同时知识也直接有助于增强采纳安全性行为的意向。对艾滋病易感性的认知,有助于采纳安全性行为和减少婚前性行为意向,但是安全性行为益处的认知却对婚前性行为态度和意向有反向作用,也就是说有越多的安全性行为益处知识可能会导致性行为态度的较为开放从而倾向于发生婚前性行为。
3.预防艾滋病同伴干预近期和中期随访研究
(1)干预措施实施后两周,干预组艾滋病相关知识和认知有了很大的提高,知识水平的正确率大都较基线水平提高了10%-30%,而同期对照组没有明显改变。
(2)干预组在干预后对待艾滋病的态度正向态度得分得到了一定的提高,但是不如知识增加幅度大。虽然干预组学生短期内婚前性行为态度的变化并不明显,但在干预后自我价值和自尊方面有了一定提高,婚前性行为意向的得分明显提高,也有更多的学生在干预后倾向于采纳安全性行为意向。
(3)随访1年研究后,通过重复测量的方差分析,我们发现干预组的知识和认知得分及艾滋病正向态度方面的提高效果明显,且有持续性。自我价值干预后短期明显上升,但是1年后也明显回落,对照组也在1年后较2周时有下降趋势,说明由于学习和升学的压力日趋增加,学生容易出现消极情绪,影响自我价值的认同。
在对待婚前婚外性行为的态度方面的随访中发现,干预组在干预前、干预后2周和干预后1年的态度水平呈现出平缓上升的直线,与对照组几近平行,也就是干预后的态度改变不明显,与对照组没有统计学差异。在行为意向的随访研究中,干预组在干预后2周在对待婚前性行为的意向得分和安全性行为意向都有所上升,干预后1年调查发现行为意向较干预后2周略有下降,但仍维持在较高水平。
(4)同伴干预过程评价发现所有模式的亲切程度方面赢得了较高评价,得分最高,其次是易理解程度,参与性程度和生动性评分相对较低。男生对参与性的评分明显高于女生,而女生对亲切程度的评分明显高于男生。
4.将艾滋病健康教育纳入高中生课程体系存在的困难
(1)学生角度：高中学生课业负担较重,课程设置紧张,只有在高一或高二阶段,实施健康教育的可能性较大。在课程设置的内容方面还有待于进一步改进。
(2)师资角度：预防艾滋病健康教育的师资力量普遍比较薄弱,专业教师缺乏,卫生保健老师的地位较低,工作实施难度大。
(3)学校角度：学校领导往往重升学率轻保健,学校领导的重视程度直接影响到实施健康教育的过程,高中学校都面临着升学竞争的压力,学校领导对预防艾滋病健康教育的重视程度有待提高。
(4)教育行政管理部门角度：上海市教育委员会的体卫艺教科、德育科等在学生艾滋病预防工作中起着主导作用。教育主管部门既要考虑如何保证预防艾滋病课时的设置和安排,又要统筹兼顾高中学生课程压力过大的问题。
五、结论与政策建议
1.我国沿海城市高中生中进行艾滋病预防研究的QAHP-SS量表具有较好的信度和效度。
2.沿海三城市高中生艾滋病相关知识和认知还有待于提高。中小沿海城市、职业中学学生更需加强教育。男生和职业中学人群应该是干预的重点,减少其过早发生无保护性行为。
3.通径分析显示高中学生预防艾滋病应该首先加强艾滋病的相关知识,提高对学生艾滋病易感性的认知。其次应加强安全性行为方面的教育,增加安全性行为知识,减少高危性行为。还应进行自尊、自信和责任感方面的教育,改变不良的性观念,增强性道德教育,减少婚前性行为的发生。支配婚前性行为意向的主要变量是性态度是否开放,相对比较难改变,而对安全性行为意向起到主导作用的是知识和认知,相对比较容易改变,对艾滋病预防干预的最终目的而言,以安全性行为教育为重,可能比以避免婚前性行为教育的成效更明显,更容易被学生接受。
4.同伴干预在对高中阶段学生预防艾滋病、倡导安全性行为意向中的近期和中期效果明显。高中阶段学生更乐于接受专家和同伴的意见,本次健康干预的方式就是采用专家培训优秀的同伴教育者来实施干预,迎合了高中阶段学生的需要。
5.我们建议在健康促进研究的PROCEED模式中,在研究教育和环境改变的政策、管理与组织中,从方法学上加以改进,可以利用ROCCIPI法政策研究的客观性、逻辑性和整体性,从规则、机会、能力交流、利益、过程和意识七个方面,从不同角度进行探讨来透视问题、寻求最佳政策规则和法律对策。
6.通过基线研究、干预研究和ROCCIPI法策略分析,我们对将预防艾滋病健康教育纳入高中课程的政策提出实施建议：
(1)应该通过指令性文件的形式,将预防艾滋病健康教育强制纳入学校教学计划。
(2)在本次同伴干预研究的基础上,制定普适性的教育大纲,指导学校开展多样化的教学方法,包括课堂教学、专题讲座、播放多媒体教学片、主题班会、黑板报等多种形式开展预防艾滋病健康教育。
(3)在高中预防艾滋病健康教育的教学内容增强安全性行为教育。
(4)上海市教育委员会作为将艾滋病健康教育纳入课程设置的倡导者,同时是保证该政策实施的监督者,要建立以体卫医科处负责的健全的管理和监督机制,并制定监督和评估方案。
(5)建立多部门合作机制,要求卫生行政部门积极配合教育行政部门,并充分利用现有的资源—上海市青少年预防艾滋病健康教育培训中心的力量,为开展高中生预防艾滋病健康教育提供必要的技术支持和健康知识培训。
(6)要充分利用现有的师资力量,包括卫生保健老师、心理咨询老师、生物学老师等,通过多学科渗透对学生进行宣传教育,提高学生抵御艾滋病侵袭的能力。
(7)加强能力建设,可以建立区内合作机制,利用区内卫生资源对学校师资进行培训。同时要充分顾及到师资的利益,培训后给予继续教育学分,并通过适当的政策倾斜和经济补偿,鼓励师资主动开展预防艾滋病健康教育活动。
Background
The 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.
Objectives
1. 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.
Methods
1. 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.
Results
1. 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 suggestion
1. 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.
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