Global AIDS - China

AIDS and Sex Education for Young People in China
Y. GaoAD, Z.Z. LuB, R. ShiB, X.Y. SunB and Y. CaiC (2001)

A - Melbourne Sexual Health Centre, The University of Melbourne, Victoria 3010, Australia.
B - Department of Health Policy and Management, School of Public Health, Peking University, Beijing 100083, China.
C - Department of Preventive Medicine, Shanghai Second Medical University, Shanghai 200025, China
To whom correspondence should be addressed.
Email address: yuangao44@hotmail.com; gaoyuan001@21cn.com

Abstract. Although China has had a rich sexual culture for thousands of years, Chinese people are usually unwilling to openly discuss issues of sex. Some parents are quite ignorant of the change in their children's sexual attitude and behaviour. In China today, adolescents are becoming much ore sexually liberated. Premarital sex and unplanned pregnancies among teenagers are increasing. Sexually transmitted diseases (STD) including HIV/AIDS are also spreading rapidly. However, young people lack basic information of AIDS/STD and do not know ho to protect themselves from these diseases or how to avoid unintended pregnancies. Several major youth peer education programmes in China are mentioned in this paper. Among them, a four-year programme entitled the Australian-Chinese AIDS/STD/Safer Sex Peer Education Programme for Youth, is discussed in some detail. The programme has so far reached over 50,000 university and school students. Evaluation results show that the programmed is effective in both significantly increasing students' knowledge about AIDS/STDs and changing their attitude towards AIDS patients. In addition, the programme is highly praised by the students.

Introduction

In China today, sex is still a very sensitive topic. Although premarital sex, extra-marital sex, and prostitution are legally not allowed, these are practised to a great extent in the society. In the light of the fast spread of HIV/AIDS and sexually transmitted diseases (STD), it is vitally important to teach people, especially young people, how to protect themselves from these diseases. However, this is not an easy task. To start with, it is very difficult to obtain permission from senior people and decision-makers to teach young people about sex, because most of them are not aware of the changes that have been occurring among young people today and how their moral attitudes have changed. Most senior people blindly believe that young people do not know much about sex or have never had sex. We need to understand why young people urgently need sex education and why senior people are very reluctant to approve it.

Sex Education in Ancient and Modern China

China has had a rich sexual culture for thousands of years (Editorial Committee for China Encyclopedia of Sexology 1998), however, Chinese people are usually unwilling to openly discuss issues of sex. Sex has always been a taboo subject. There is a popular saying: 'Lewdness is the worst of all vices'. Here, sex and lewdness are perceived more or less as the same thing. Chinese parents hope that their children are only interested in study and have no interest in sex at all. If the child starts to ask questions about sex, the parents usually become very upset and worried. They worry that if the child is unable to concentrate on study, the child's future prospects might be jeopardized. In addition, most parents are not equipped to answer their children's questions about sex issues. The most common and difficult question is: 'Mother, where did I come from?'.

In ancient China and in the first half of the 20th century, there was hardly any formal sex education. Informally, there were mainly two ways to carry out sex education. It usually took place just before or after the wedding. The bridesmaid or bride's girlfriends would teach the bride about the 'way of life' in a brief session just before the wedding. The other way was more subtle. The bride's parents would put a sex artefact in the dowry trunk among other trousseaus. The artefact was usually chinaware, which looked just like any other artefact, except that it could be split into two parts. Inside was another artefact showing a sexual intercourse position. The bride's parents hoped that the newly married couple would carefully study the sex artefact and imitate the example on their wedding night. During the day, however, the couple would put the two parts back together again. Other sex educational materials that the bride's parents put in the dowry trunk could be pornographic paintings or novels concealed in a box (Liu 2000). Such materials would be hidden away from unmarried youngsters. Fathers would never tell their sons anything about sex (Liu 2000).

Between 1949 and late 1970s, there was no sex education at all. Ignorance of sex resulted in many tragic stories. For example, young boys became worried when they had a 'wet dream' for the first time, believing themselves to be ill; girls knew nothing about their menstruation and some believed that menstruation brought them bad luck. The late premier, Mr. Zhou En-lai, realized the problems in 1963 and 1965, he instructed health and medical authorities to carry out adolescent sex education (Tan 1998). Unfortunately, nothing happened because of the subsequent arrival of the disastrous Cultural Revolution in 1966. During the next ten years, sex was regarded as wrong politically. Anyone who was caught having premarital or extra-marital sex would have his/her future ended, and could even be put in jail. Almost all the heroes and heroines in movies and Beijing operas were either bachelors or spinsters.

Since the early 1980s, sexual policy has become more and more open in China. The importance of sex education has gradually been realized. Professor Wu Jie Ping and his colleagues (1981) were the pioneers in this area. They translated a book entitled 'Sexual Medicine', which was the first scientific book on sex in the recent decades. Subsequently, the first book written by Chinese scholars entitled 'Sex Education' and edited by Hong was published in 1989. During the 1990s, numerous books on sex were published, articles appeared in newspapers and magazines, programmes were aired on the radio and TV, and sporadic sex education programmes were carried out in a few schools and universities.

However, this is far from enough and much more needs to be done to educate Chinese people about sex. Many Chinese parents still believe that their children do not need to be taught about sex; they would grow up and automatically know what to do on their wedding night. A widespread story tells about a married couple who were college graduates of chemistry. They failed to produce children after being married for several years. In the end, they visited a doctor for advice. After a check-up the doctor found that the woman was still a virgin - the couple thought that by lying side by side in bed the molecules in their bodies could travel between them, making the woman pregnant (Huang and Hong 1996).

Premarital Sex, Unintended pregnancy and Induced Abortion in Chinese Youth

Young people's attitude toward premarital sex is becoming more tolerant (Lu et al. 1998). More and more young people are practising premarital sex, and the age of first sexual intercourse is decreasing. About 0.9 - 5.0% of secondary school students have had a sexual experience (Liu 1992). Since there are over 60 million secondary students, even 0.9% is an enormous number - over half a million. About 6.3 - 20% of tertiary students have had sexual intercourse (Liu 1996; Song 1996). According to a survey conducted among 2000 students at 20 universities in different parts of the country, 20.8% of female students were keen to have a sexual experience, and 20% of males and 11.7% of females had had premarital sex; among 2409 women who had a premarital check-up in 1988, 73.1% of them had had sexual intercourse (Song 1996).

In China, the minimum legal age for marriage is 22 for men and 20 for women. In 1990, a population census showed that 24,030 people got married before they reached the legal age in Tianjing, a 4.2-fold increase from 1982. Of these, the youngest was only 13 years old, and the youngest mother was 14 years old (Li and Cao 1994). In Shanghai, unmarried women who have a surgically induced abortion account for 25% of the total number of induced abortions. Those aged less than 20 accounted for 25% and those aged 20 - 24 accounted for 64.7% (Ma and Yao 1993). In Guiyang, an unmarried woman had two induced abortions within 45 days, and another unmarried woman had nine induced abortions (Li and Cao 1993). In rural areas, there may be more unmarried women who have induced abortions. The percentage of unmarried women who had induced abortions was higher (28.2%) in rural areas in Sichuan province (Luo 1995). The majority of these could be avoided by providing the women with more knowledge about, and better access to, contraceptives (Yao 1993).

Current AIDS/STD Situation in China

The AIDS epidemic has been spreading fast in China since 1989 when some intravenous drug users among local residents tested HIV positive for the first time in Yunnan Province. As of the end of September 2000, 20711 HIV cases were officially recorded in China, a 37% increase on the figure reported at the same time in 1999. The main transmission route is through the sharing of needles and syringes among intravenous drug users. Of them, 741 people had progressed to AIDS and 397 had died. Among the HIV carriers, young people aged 20 - 29 accounted for 56.9% (News Release by the Chinese Ministry of Health on 31 October 2000). The authorities of the Chinese Ministry of Health state that if the current preventative measures are ineffective, the number of people living with HIV in China, which is currently at least half a million, could reach as many as 10 million by the year 2010 (Yin 2000).

Judging by the increasing spread of STDs, the foundations for the rapid sexual transmission of HIV are already in place. During the 1960s, the Chinese government claimed that China had successfully wiped out all kinds of STDs in the country. In 1977, there were only 13 officially recorded STD cases in the whole of the country. However, in 1990, the figure increased to 150,000, in 1994, this had doubled to 300,000 (Kang 1995), and by the end of 1999 the figure reached 837,000 204,000 more than that of the previous year. Of these cases, 71.5% of individuals were unmarried, 17.6% of individuals were married, 0.47% was through the mother - baby route, and the transmission route for the remaining 10.43% was unknown (National Coordination Group for STD Surveillance 2000).

According to a survey conducted among STD patients, 37% of male and 42% of female patients had had their first sexual intercourse between the ages of 18 and 20; on average, the men had 4.1 sexual partners and the women had 2.4 sexual partners; 80% of the patients were infected from having commercial sex and/or having sex with temporary sexual partners. They had a very poor sense of self-protection; 92% of the patients never used condoms, and worse still, 90% of the patients were having sexual intercourse without use of condoms even though they were experiencing STD symptoms (Zhao 1995).

The importance of studying men who have sex with men (MWSM) was recently highlighted. In a survey among 744 MWSM (including homosexual men) in 1999, it was found that in China there are about 18 - 24 million homosexual men, accounting for 3 - 5% of the population of adult men (Zhang 2000). On average, each of the homosexual men had had sex with 5.2 MWSM. Accordingly, MWSM might account for 10 - 15% of the population of adult men. In 1998, only 2.5% of MWSM were found to be HIV positive. However, in 1999, the figure had jumped to 17.7%. Of those 774 MWSM, one-third had been married, and the majority of the rest were preparing to get married or intended to get married under pressure from their families and society. The researcher worried that HIV would not only spread between MWSM, but would also spread to women and children from them (Zhang 2000).

Recently, many articles have appeared in national and international media on the grim HIV/AIDS situation in Henan Province in Central China where villagers have been infected mainly through selling their blood and having the blood cells injected back into them after he serum had been removed. According to media reports, the situation seems extremely serious, yet no Chinese government reports or academic reports have been made.

Sex and AIDS Education in Universities and Schools in China

In China, sex education has been increasingly promoted for several years. This includes one or more of the following: offering adolescent health courses in some schools and universities; publishing some reading materials on sexual health; broadcasting midnight radio programmes; holding training courses for family planning workers; producing video programmes on sexual health; and holding sex education exhibitions.

In some schools that do teach adolescent health, the content is generally just simple information about anatomical, physiological and hygienic facts of human reproduction. As a result, many school graduates and university students do not have basic knowledge about sex. Hardly any advice is given on how to prevent AIDS/STDs and unintended pregnancy. In addition, the information is usually taught in a classroom setting my traditional teaching methods. The effectiveness of this teaching is not satisfactory. Recently, we asked come secondary students and first year college students in Beijing and Shanghai about what they had been taught in their school courses related to sexual health or sex education. They said that their teachers only taught them the anatomical names of human reproductive organs, or simply gave them the book or reading material and asked them to go home to study by themselves. However, in recent years, numerous AIDS education programmes have been carried out in universities and schools (Chang et al. 1999; Niu et al. 1999; Sun et al. 1999; Zeng et al. 1000; Shi et al. 2000; Yang et al. 2001; Zhang et al. 2001).

Knowledge, attitude and practice of Chinese youth in relation to AIDS and sexual health

Most people are aware that there has been a rapid increase in HIV infection, STD cases and unintended pregnancy among unmarried women, including teenagers, and the number of underground prostitutes and their clients. However, knowledge about AIDS/STDs and safer sex in Chinese young people is still quite poor.

The attitudes towards AIDS are ironic. On the one hand, some people feel that the disease is a 'western disease' and still far away from their daily lives. On the other hand, they feel that AIDS is such a fearful word that anything to do with it should be avoided. Meanwhile, people have very limited knowledge about how to protect themselves from infection, and more and more people are engaging in unsafe sex and drug use.

Several surveys show that students have very limited knowledge about AIDS and sexual health (Zhang and Xia 1992; Lu 1993; Chang et al. 1999; Niu et al. 1999; Sun et al. 1999; Zeng et al. 1999; Li et al. 2000; Shi et al. 2000). For example, secondary students in Hubei province did not have any basic knowledge about menstruation (40%) and pregnancy (84%) (Zhang and Xia 1992), and about half of university students did not know that use of a condom could reduce the risk of catching AIDS/STDs - 46.7% of surveyed engineering students in Beijing (Niu et al. 1999), 53.3% of surveyed medical students in Beijing (Sun et al. 1999). Only 36.5% of the surveyed medical students and teachers training university students in Shanghai knew when a condom should be put on (Shi et al. 2000). Meanwhile, those young people have an unreasonable fear of AIDS.

Mr Zhang Zhi-gang, the Director of Moral Education, Shanghai Educational Commission, told one of the authors about an event that he had witnessed in a secondary school in Shanghai (Zhang Zhi-gang, personal communication 1999). In the school clinic that Mr Zhang was inspecting at that time, a 14-year old female student was found to be 7 months pregnant. When the doctor asked the girl how she had become pregnant, she said that she did not know. It was obvious that she did not realize that she had already had sexual intercourse. She thought that sexual intercourse with a boy was just another harmless game they had played together. Even the parents did not notice the physical change in their daughter as a result of pregnancy, mistakenly believing that she had just put on some weight. This example demonstrates how some young people are practising premarital sex with very little knowledge about sex, and how ignorant parents are of their children's moral, behavioural and physical changes.

According to a survey conducted among students at two medical universities in Shanghai, although almost all of them had heard of AIDS, their knowledge was lacking in some basic facts (Lu and Zhao 1995). For instance, 48% of the medical students knew that breastfeeding by an infected mother was one HIV transmission route; only a third of them understood that anal sex was more risky than vaginal sex; only half know that use of a condom would reduce the risk of sexual transmission of HIV; 18% thought that a healthy person could not catch the virus; 21% thought that a person could be infected by eating with an HIV carrier; about 38% knew that there was no cure for AIDS; and only 9% knew that mosquito bites did not transmit HIV.

In society, people's attitudes towards AIDS patients and HIV carriers are usually hostile. Often the infected individuals are unfairly treated even by their own family. The family members of the infected individuals are also unfairly treated. For example, in a city near Beijing, residents demonstrated in the street and demanded that the local government remove an HIV carrier and his family from the city for the 'safety' of all the other residents in the city. The local government failed to calm them down. Finally, through the help of the central government, the HIV carrier and his family were taken to a hospital in Beijing, at which point the city became peaceful again (Fang 1995). Some HIV carriers have disappeared since they found themselves to be HIV positive. A few of them even declared that they would try to infect as many people as possible (Fang 1995). These hostile attitudes have made AIDS prevention more difficult. People need more education about AIDS and its prevention, and they also need to develop a more sympathetic attitude towards AIDS patients and HIV carriers.

There is a great difference between school students and university students in ways of obtaining information of sex. According to surveys, the majority of secondary students thought that they would like to obtain information on sex from teachers, parents, and classmates/friends. These three sources were almost equally important to them. However, over 80% of tertiary students would like to obtain information on sex from classmates and friends (Liu 1996). In both cases, friends and class mates play a very important part in influencing their peers. Therefore, it has been suggested that trained medical students would be suitable AIDS/STD/safer sex educators for both secondary and tertiary students. This had been proven by peer education projects in Melbourne, Beijing and Shanghai (Short 1998; Chang et al. 1999; Lu and Gao 1999; Niu et al. 1999; Sun et al. 1999; Zeng et al. 1999; Shi et al. 2000).

The Chinese Government Policy on AIDS Prevention and Sex Education

In January 1998, the Chinese Ministry of Health and another eight ministries jointly issued a document entitled 'Principles of AIDS Publicity and Education'. In this document, the Chinese Government calls for the whole nation to get involved in AIDS prevention and control. It emphasizes that publicity and education are the main approaches to AIDS prevention and control and will be for a long time to come. The central government instructed local governments and all governmental departments concerned to carry out publicity and education through all possible media, including TV, radio broadcasts, video programmes, newspapers and magazines. Education and counselling services on AIDS/STDs and sexual health must be given regularly and free of charge. School and university staff should be given the necessary education. Information on AIDS/STDs must be added to the curricula of Health Education for school and university students and the contents should be strengthened (Nine Ministries and Commissions 1998).

Very recently, the Chinese Ministry of Health issued a guideline for implementing China's med to long-term plan for AIDS prevention and control between 1998 and 2010. In the document, AIDS/STD education among youth/children, women and other groups of the general population is once again regarded as one of the main measures of AIDS/HIV prevention and control (Chinese Ministry of Health 2001).

Some Issues To Be Considered in Sex Education in China

Should the use of condoms be promoted?

Judging from the above Chinese government documents, the Chinese government treats the issues of AIDS, STDs and adolescent sexual health very seriously. The government regards AIDS prevention and control as a national strategic issue, which could threaten the country's future (Chinese Ministry of Health 1995), and calls for greater efforts on HIV/AIDS prevention and control including AIDS education and sexual health education (Chinese Ministry of Health 1995, 1998, 2001; Nine Ministries and Commission 1998; State Council of China 1998).

Therefore, although talking about sex is still sensitive, it is no longer an issue of whether AIDS/sex education should be conducted among young people. The content and focus of AIDS/sex education programmes often draw public attention and arouse debate. The debate is about whether young people should be taught about safer sex, especially about the correct use of condoms, or whether the programme should focus on abstinence only, or, at least, no sex before marriage. In China, the latter approach is often called chastity education or morality education.

The debate about whether or not the use of condoms is effective in HIV/AIDS prevention often appears in various media. Safer sex educators focus on the point that consistent and correct use of condoms can greatly reduce the risk of sexual transmission of HIV, other STDs and unintended pregnancy. On the other hand, chastity educators focus on the point that use of condoms is not 100% effective; condoms have a failure rate as a contraceptive. They argue that the only completely effective way of HIV/AIDS prevention is to practice abstinence or no sex before marriage. Therefore, they claim that chastity education is the only way to go.

In China, there are several myths about safer sex education, making it very difficult to promote safer sex and condom use. First, senior people feel that young people should not be taught about sex, because if they do not know anything about it they will not try it. Therefore, safer sex education might encourage them to have sex. Second, the use of condoms is not effective in protecting people from the risk of HIV infection, which has been strongly emphasized by senior people who are against safer sex education. Third, only chastity education is effective in providing protection.

More education is needed to dispel these myths and inform the public of the scientific facts. A lot of research has shown that well-designed sex health education dose not encourage experimentation or increased sexual activity, rather it postpones the first sexual intercourse and increases safe practices, such as the effective use of contraceptives in young people (UNAIDS 1997). One of the tertiary students in our AIDS education programme gave a very good description of what he understood about this issue: 'Teaching a child how to correctly light a match does not mean the child will set a house on fire'. Recently, the Vice Minister of Health, Professor Yin Da-kui, made the following statement about the use of condoms for HIV/AIDS prevention, which hopefully will put an end to the debate about condom use: 'Why are we still debating on condoms? Some people speculate that promotion of condoms would encourage promiscuity. May I ask: our family planning system has promoted condoms for many years. Has it encouraged promiscuity? At present, it is not realistic to use just one approach to put an end to people's risky behaviours in our country. Under this circumstance, we must, therefore, vigorously popularise safer sex behaviour and condom use' (Yin 2000).

Should the programme be called sex education or AIDS education?

Sex education can include AIDS education, and vice versa. However in China, if a programme is called a sex education programme it would meet enormous resistance, because the first impression people have is that the focus of such a programme would be mainly on sex. Therefore, it is difficult to get approval for such a programme. However, if the programme is called an AIDS education programme, it gives people the impression that such a programme is mainly on AIDS prevention and they are more likely to give their approval, even if the two programmes had exactly the same content.

Using frank language or subtle language in a programme

Culturally, Chinese people often use subtle or indirect language. In relation to sex, the words people use become even more indirect, which makes the message itself difficult to understand and open to misinterpretation. For example, when it comes to the part of an educational video programme on sexual intercourse, the image on the screen would most likely be a pair of butterflies flying about over flowers; when referring to sexual intercourse, people would say 'when we do that'; and a peasant's wife became pregnant in spite of him 'using' a condom when having sex with her, because he put the condom on his thumb, exactly how the family planner had shown him.

Recently, in one of the training sessions of the Australian-Chinese AIDS/STD/Safer Sex Peer Education for youth Programme in Gunagxi, a university student was asked to list the behaviours that put people at the risk of HIV infection. One of the behaviours he mentioned was 'unclean sex', which is a phrase very widely used in the media and books and which actually means 'having sex with prostitutes', 'multiple sexual partners' or 'pre- or extra-marital sex'. The student was asked to explain what 'unclean sex' meant. He answered: 'I am not sure. It probably means that sexual intercourse is taking place in an unclean place, such as a room with dust or a storeroom. Or it might even mean that the man and the woman did not take a shower to wash the genital parts clean before sexual intercourse'.

Therefore, subtle or indirect language used in AIDS education or sex education can be misleading, and should be avoided wherever possible. Instead, frank and direct language should be used to describe exactly what is meant.

Current Peer Education Programmes in China

For the last several years, more and more organizations and individuals in China have been using youth peer education in HIV/AIDS prevention and education, because it is an effective approach (UNAIDS 1999). Currently, there are a number of peer education programmes in China. The following are some major ones.

The China Family Planning Association started a youth peer education programme in Beijing and Shanghai three years ago with support from UNFPA and Marie Stopes International. The programme reached some middle schools in Shanghai and some universities in Beijing.
UNICEF has been supporting youth peer education projects in several counties in Sichuan Province in southwest China for the last three years. The programme is focusing on enhancing life skills of middle school I students.
The Australian Red Cross has been working with Yunnan Provincial Red Cross Society of China on a youth peer education project in Yunnan Province since 1994. It is a part of the Mekong Subregional HIV/AIDS project, focusing on Yunnan Province and Xinjiang Uygur Autonomous Region. The activities include youth peer education, self-care workshops and peer education by and for people with HIV.
Since 1997, the Australian-Chinese AIDS/STD/Safer Sex Peer Education Programme for Youth has been conducted mainly in Beijing and Shanghai. This is a collaborating programme carried out by Australia's Melbourne University, China's Peking University Health Science Centre (formerly Beijing Medical University) and Shanghai Second Medical University.

The Australian-Chinese AIDS/STD/Safer Sex Peer Education Programme for Youth

Establishment of the programme

In 1995, a delegation from the Chinese Ministry of Health visited Monash University in Melbourne, Australia. The delegates were shown a video programme that had been produced by some third-year Monash medical students. It showed how these students, as peer educators, carried out safer sex education in some schools. This adolescent peer education programme was successfully pioneered by Professor Roger Short in Melbourne, Australia. The educational style was so lively that it impressed the delegates deeply. One of them asked Professor Short if it was possible to introduce this kind of AIDS education programme to China, which was experiencing a rapid spread of HIV and urgently needed innovative ways of HIV/AIDS prevention.

In 1996, with a travel grant from the Wellcome Trust in the UK, one of the authors, Dr Yuan Gao, visited Beijing, Shanghai, Guangzhou and Hong Kong to investigate the feasibility of establishing a similar peer education programme for Chinese young people. After discussions with Chinese governmental officials, doctors, university professors and lecturers, and medical students, it became obvious that China needed such a peer education programme on HIV/AIDS prevention, and that it would be possible to establish it as long as the programme could be modified to suit Chinese culture.

The programme was proposed and filed with the Chinese Ministry of Health and, in 1997, with financial support from Schering AG (Germany) and the London International Group that produced Durex condoms, now a part of SSL Healthcare (UK), the Australian-Chinese AIDS/STD/Safer Sex Peer Education Programme for Youth was established. NV Organon (Holland) subsequently joined the two sponsors for nearly three years, and then the Ford Foundation (USA) came in and has co-sponsored the programme since mid 2000.
How the programme was carried out

After pilot studies were carried out to collect the baseline information on medical students in Beijing and Shanghai in 1997 (Lu et al. 1998; Yu et al. 1998; Qian et al. 1999; Zhao et al. 1999), a training manual was developed and then the training and peer education was started in 1998. By the end of 2000, about 30 male and 30 female senior medical students from Peking University Health Science Centre and Shanghai Second Medical University were selected and trained as peer educators on how to teach their junior peers about HIV/AIDS, STDs and safer sex; with the skills learnt, they then educated about 1800 first-year students (about 19 years of age) from eight universities, and 830 students (about 17 years of age) from two senior high schools and two vocational schools. In addition, after the intensive education programme in the classroom and questionnaire surveys were completed, AIDS awareness campaigns were carried out on the campuses for all students in the eight intervention and eight control universities (reaching about 40000 students aged 16-24) and four intervention and four control schools (reaching about 8000 students aged 13-18). On or around World AIDS Day in 1998, 1999 and 2000, similar campaigns were carried out in the streets in Beijing and Shanghai for local residents (reached about 12000 residents of all ages).

How the programme was evaluated

Classes of students were randomly assigned to the intervention groups, internal control groups (in the same university or school that had the intervention groups) or external control groups (in different universities or schools of the same kind). Subsequently, the students in the intervention groups received the intensive peer education programme in the classroom. The effectiveness of the education programme was assessed by comparing the data from questionnaire surveys on students' knowledge, attitude and practice conducted before and after the education program. A total of 15180 copies of the questionnaire were collected. Focus group discussions and in-depth interviews were also carried out to obtain additional qualitative information. Process evaluation was also conducted during the educational sessions to assess the quality of the sessions and the performance of the peer educators.

The content of the programme

The content of the programme was designed to be as holistic or comprehensive as possible. It comprised six modules that contained basic scientific information, games, stories, slide shows, quizzes, mini-plays, discussions, and questions and answers. Each module dealt with HIV/AIDS, STDs, safer sex, negative impacts of AIDS, contraception, or increasing self-esteem. For some universities, a medical expert was invited to tell the students about AIDS patients and treatment. Each module lasted for about 90 minutes.

Brief results

The data from the Beijing and Shanghai project sites are currently being .pooled and analysed. According to limited analysed data from some universities and schools, the education programme is effective in increasing the students , knowledge about AIDS, STDs and safer sex, and in changing their attitudes.

The average rate of the students' attendance at the education programme was 92%. Given the programme was usually carried out in evenings during the week or on the weekends and was competing with other student activities and lectures, this attendance rate was high. For process evaluation, in an anonymous questionnaire, the students were asked to score each of the peer educators and each of the modules on a 5-point scale (5 being the best and 1 being the worst). The average marks were 4.35, indicating that the students liked the programme (Sun et al. 1999; Shi et al. 2000).

Before the education programme was carried out, the knowledge level about HIV/AIDS, STDs and reproductive health across the three groups was about the same (?>0.05).

After the education program, the knowledge level of the students in the intervention groups was increased significantly (P<0.01); it was also significantly higher than that of the internal and external control groups (P<0.01). It was similar across different university student groups-science students (Chang et al. 1999), engineering students (Niu et al. 1999), medical students (Sun et al. 1999) in Beijing, and medical students and teachers training students in Shanghai (Shi et al. 2000). About 91% of the students in the intervention groups indicated that they liked the program, 1% said that it was average, 7% did not respond to this question, and only 1% of the students said that they did not like the programme (Shi et al. 2000).

Results from a follow-up study on medical students in Beijing six months after the end of the peer education programme showed that the knowledge level of the intervention groups decreased significantly (P<0.05) compared with the level shortly after the end of the education program. However, it was still significantly higher (P<0.05) than that of the internal and external control groups (Zeng et al. 1999).

Results from focus group discussions and in-depth interviews indicated the following:

the students think that such an AIDS education programme is necessary for and should be provided to young people, and that it meets the needs of young people;
the programme makes young people understand how to protect themselves from HIV infection and eliminate unnecessary fear of HIV;
use of condoms is one of the necessary options for young people;
they like the peer education; many students expressed the wish that they would like to become peer educators in the near future;
after the education program, the attitudes of many students towards AIDS patients or HIV carriers became more sympathetic.

Additional achievements of the Australian-Chinese AIDS/STD/Safer Sex Peer Education Programme for Youth

The education programme has been taken as an elective medical course for first-year students at Shanghai Second Medical University since 1998. Students who complete the course obtain an additional credit. In 2001, the peer education programme was awarded the First Prize for Achievement in Education by the University. Subsequently, it was awarded the First Prize for Achievement in Education in Shanghai by the Education Commission of the Shanghai Municipal Government. In Beijing, the major content of the peer education programme has been used in the elective course entitled Health Education and Health Promotion, which is offered by Peking University Health Science Centre to its own medical students and students from other universities nearby.

In November 1999, Mrs Annan, the wife of Mr Kofi Annan, the Secretary-General of the United Nations, inspected this peer education programme during the couple's visit to Beijing. After inspecting how the peer educators taught their peers about HIV/AIDS prevention, she wrote the following endorsement to the young people: 'What you are learning is important to save lives'.

The programme has reached the stage where it should be expanded to other parts of China, but as of April 2001, the current sponsorship has come to the end and therefore other financial support is the needed. As the first step in this direction, Guangxi Red Cross has adopted this youth peer education programme to educate young people about HIV/AIDS/STDs in Guangxi Zhuang Autonomous Region's seven counties bordering Vietnam for the period April 2001 to April 2002. This new programme has received financial support from AusAID, the Australian Government's foreign development agency.

Conclusion

In conclusion, HIV/AIDS is spreading rapidly in China. ~More AIDS education and safer sex education are urgently needed as part of the AIDS prevention and control efforts. It seems that the Australian-Chinese AIDS/STD/Safer Sex Peer Education Programme for Youth is effective in educating young people about adopting safe behaviours and protecting themselves from AIDS/STD infection. Such a programme should be further expanded in China, but financial support is needed.

Acknowledgments

Roger Short is my mentor. He always inspires his colleagues and students with bright ideas. He once said that he would like to be somebody who lit a torch and passed it to his students, who would, in turn, run with it, and hopefully the torch would become a great fire. This is exactly what has been happening in HIV/AIDS youth peer education in Australia and China. In the late 1980s and early 1990s, Roger Short pioneered a peer education programme at Monash University in Melbourne, using senior medical students as peer educators to teach other students on the university campus and in schools about how to protect themselves from HIV/AIDS, other sexually transmitted diseases and unplanned pregnancies. The programme enjoyed great popularity with the young people and was successful in reaching thousands of school students. With my Chinese colleagues, I, Roger Short's colleague and former PhD student, have tried this style of AIDS education in China since 1997. So far this peer education programme has successfully been carried out among young people in Beijing and Shanghai. It has recently expanded to Guangxi Zhuang Autonomous Region and it will expand to Hainan Province in 2002. I hope that the torch of HIV/AIDS youth peer education that Roger Short passed to me will become a bushfire in the future. Yuan Gao.

The authors are grateful for financial support for the programme from Schering AG (Germany), SSL Healthcare (UK), NV Organon (Holland), The Ford Foundation (USA) and AusAID (Australia). Special thanks to Professor Roger Short for his all time, support and guidance.

References

Chang, C., Lu, Z. Z., Niu, W Y., Sun, X. Y., Short, R. V:, and Gao, Y. (1999). Application of peer education in AIDS/STD/safer-sex education among science and engineering university students. Chin. J: Health Educ. 15, 16-19.
Chinese Ministry of Health (1995). Strengthening on HIV/AIDS prevention and control. (Chinese Ministry of Health: Beijing.)
Chinese Ministry of Health (1998). The key messages of AIDS prevention and education. (Chinese Ministry of Health: Beijing.)
Chinese Ministry of Health (2001). Guidelines of implementing China's mid/long term plan for AIDS prevention and control, 1998-2010. (Chinese Ministry of Health: Beijing.)
Editorial Committee of China Encyclopedia of Sexology (1998). 'China Encyclopedia of Sexology' .(Press of China Encyclopedia of Sexology: Beijing.)
Fang, G. (1995). 'AIDS is Approaching China'. (The Jiling People's Press: Jiling Province.)
Hong, J. M. (Ed.) (1989). 'Sex Education'. (Shanghai People's Press: Shanghai.)
Huang, J. H. and Hong, J. M. (1996). 'Sexual Health Education'. (Hainan Press Company: Haikou, Hainan Province.)
Kang, L. Y. (1995). Economic growth and urbanisation in China leads to an increase in STDs. AIDS Anal. Asia 1, 14-15.
Li, A. L., Liu, Z. R. Zhang, G. Z. Huang, T., and Huang, Y. Q. (2000). Qualitative study on needs of AIDS. STD education and intervention for university students. J China AIDS/STD Prev. Control 6, 104--6.
Li, C. Y., and Cao, F. Q. (1994). Necessity of sex education for adolescents. Sexology (China) 2, 30-1.
Liu, D. L. (1992). The necessity of and problems in Adolescent Sex Education. Sexology (China) 2, 4-6.
Liu, D. L. (1996). 'Sexual Behaviour in Modem China: a Report of the Nation-wide Sex Civilisation Survey of 20,000 Subjects in China'. (Shanghai San Lian Bookshop: Shanghai.)
Liu, D. L. (2000). 'Chinese Sex Artifacts over 5,000 Years'. (Ming Pao Publications Limited: Hong Kong.)
Lu, H., and Zhao, P. F. (1995). A KAP survey on the knowledge level about HIV/AIDS among medical students in Shanghai. Sexology (China), 4, 48-54.
Lu, Z. Z. (1993). Problems in AIDS and health education for students in Beijing, Chendu and Guangzhou. Chin. J Health Educ. 9, 25-7.
Lu, Z. Z., and Gao, Y. (1999). Designing evaluation of AIDS/STD/safer-sex peer education programs. Chin. J. Health Educ. 15, 5-8.
Lu, Z. Z., Niu, W. Y., Gu, S. G., Short, R. \I:, and Gao, Y. (1998). Needs of Beijing Medical University students for AIDS/STD/safer-sex education - a qualitative study. Chin. J. School Health 19, 1-6.
Luo, L. (1995). Induced abortion among unmarried women in Sichuan province, China. Contraception 51, 59-63.
Ma, Q. T., and Yao, B. Z. (1993). Analysis on the occurrence of unintended pregnancy in unmarried women in Shanghai. Chin. J Fam. Plann. 5, 281-3.
National Co-ordination Group for STD Surveillance (2000). Epidemiological analysis on nation-wide STD pandemic in 1999. J. China AIDS/STD Prev. Control 6, 129-32, 140.
Nine Ministries and Commissions (1998). 'Principles of AIDS Publicity and Education.' (The Chinese Ministry of Health: Beijing.)
Niu, W. Y., Sun, X. Y., Lu, Z. Z., Short, R. V., and Gao, Y. (1999). Short-term effects of AIDS/STD/safer-sex peer education among engineering college freshmen. Chin. J. Health Educ. 15, 12-15.
Qian, H. Z., Zhao, P. F., Yu, H., Gu, S. G., Short, R. V., and Gao, Y. (1999). KAP study on reproductive health among medical freshmen: assessment of reproductive health needs. Chin. J. School Doctor 13, 245-7.
Shi, R., Qiu, X. Q., Mao, D. J., Qiu, Y. L., Hu, H. H., Short, R. V., and Gao, Y. (2000). Effectiveness of a peer education program on AIDS among college students in Shanghai. Chin. J. School Health 21, 10-11, 13.
Short, R. V. (1998). Teaching safe sex in school. Int. J. Gynecol. Obset. 63 (Suppl. 1), 147-51.
Song, Q. X. (1996). 'Facing the challenge of AIDS. In 'AIDS'. (Eds C. Q. Chen and G. Y. Wang.) pp. 21-30. (Department of Diseases Control, Ministry of Health: Beijing.)
State Council of China (1998). 'Mid/Long term Plan for AIDS Prevention and Control, 1998-2010'. (The State Council of China: Beijing.)
Sun, X. Y., Lu, Z. Z., Niu, W. Y., Chang, C, Short, R. V., and Gao, Y. ( 1999). Process evaluation of an AIDS/STD/safer-sex peer education program for college freshmen. Chin. J. Health Educ. 15, 9-11, 8.
Tan, D, Z, (1998), 'Sexual Culture and Law'. (Shanghai People's Press: Shanghai.)
Wu, J. P., Fang, G. D., Pan, Z. D., Yin, F., Zhu, X. M., Chen, J. M., and Sun, Y. T. (1981). 'Sexual Medicine'. (Science & Technology Documentation Press: Beijing.)
UNAIDS (1997). 'Impact of HIV and Sexual Health Education on the Sexual Behaviour of Young People: a Review Update'. (UNAIDS: Geneva.)
UNAIDS (1999). 'Peer Education and HIV/AIDS: Concepts, Uses and Challenges'. (UNAIDS: Geneva.)
Yang, J., Zhang, R, S., and Hu, W B. (2001). Evaluation of the short-term results of AIDS education among the students in Honghe Health School in Yunnan Province using a booklet known as 'AIDS Knowledge.' J. China AIDS/STD Prev. Control 7, 95-7.
Yao, Z. B. (1993). Investigation on the current situation of artificial termination of pregnancy in Shanghai. Chin. J. Fam. Plann. 2, 86-91.
Yin, D. K. (2000). Summary speech given by the Vice-Minister of Health, Mr Yin Da Kui, at the meeting reflecting on the Durban AIDS Conference. J. China AIDS/STD Prev. Control 6, 193-6.
Yu, H., Qian, H. Z., Zhao, P. F., Gu, S. G., Short, R. V., and Gao, Y. (1998). KAP study on reproductive health among medical freshmen: the role of gender in reproductive health education programs. Chin. J. School Doctor 12, 241-5.
Zeng, Y., Chang, C., Lu, Z. Z., and Gao, Y. (1999). A follow-up evaluation of an AIDS/STD/safer-sex education program among medical students. Chin. J. Health Educ. 15,20-3.
Zhang, B. C. (2000). Men who have sex with men and AIDS epidemic. J. China AIDS/STD Prev. Control 6, 26-7.
Zhang, F., Li, F., Cao, X. B., Ai, B. B., Liu, H. B., and Ju, L. C. (2001). Evaluation of effectiveness of AIDS related education programmes in universities and technical secondary schools in Urumiqi. J. China AIDS/STD Prev. Control 7, 92-4.
Zhang, S. B. (1993). Views on AIDS in college students. Sexology (China) 2, 37-41.
Zhang, Z. X., and Xia, J. Z. (1992). Investigation and reflection of sex education for secondary schools in mountain areas. Sexology (China) 3, 44-6.
Zhao, P. F. (1995). Sociological research in and importance of the policy of reproductive health in China. Reprod. Contracept. (China) 14, 150-7.
Zhao, P. F., Qian, H. Z., Yu, H., Gu, S. G., Short, R. V., and Gao, Y. (1999). KAP study on reproductive health among medical freshmen: a survey of AIDS related knowledge and attitudes and their implications. J. Reprod. Med. (China) 8 (Suppl. 1), 6-11.