【作者】 王筱金；

【导师】 高尔生； 楼超华； 武俊青；

【作者基本信息】 复旦大学 ， 流行病与卫生统计学， 2006， 博士

【摘要】 【研究背景】我国青少年的婚前性行为日趋增多，越来越多的青少年面临非意愿妊娠、人工流产和性传播疾病的危险。为此探索促进青少年健康、安全和负责的性行为的有效教育和服务模式并将之推广，成为青少年生殖健康研究领域的重要课题。随着生物医学模式向生物—心理—社会医学模式的转变，健康促进理论日益受到重视。健康促进有利于实现个体行为持久改变，并促进群体的健康。以健康促进理论为依据，包括5项策略（制定促进健康的公共卫生政策；营造支持性的环境；强化社区行动；发展个人技能；调整卫生服务方向）大规模的青少年生殖健康教育和服务干预项目的开展在国内尚属首次。本研究从青春健康促进项目对青少年生殖健康教育和服务支持性环境的影响、职校生生活技能培训效果及亲青服务质量与利用三个方面对该项目的过程及效果进行了全面且深入的评价。【研究目的】评价上海市青春健康促进项目对青少年性与生殖健康教育和服务的支持性环境的影响，向青少年提供生活技能培训的效果，以及向青少年提供亲青服务的质量及利用情况。【研究方法】1．通过查阅（2000年9月—2004年3月）市青春健康促进项目有关政策文件、大事记、会议和工作记录、项目办公室（半）年度工作报告、监督评估汇总表、相关文献等资料以及与39名相关部门决策者的深入访谈（2004年9月—2004年12月），评估青春健康促进项目为营造支持性环境所采取的措施和支持性环境的改变。2．以某区三所水平类似的职业学校为生活技能培训效果评估研究现场，研究对象为职校二年级学生。干预持续两个学期。其中两所学校为干预组，分别采取由心理老师担当生活技能培训课主持人加同伴教育（干预1组）和由班主任担当生活技能培训课主持人（干预2组）不同干预模式，干预持续两个学期；另外一所学校为对照组，照常进行原有的性教育活动。在干预前、中、后分别进行了基线、中期和终线（2003年5月—2004年5月）三次电脑问卷调查（中线调查目的为监察干预是否如期进行）。通过比较干预期间干预组和对照组职校生的生殖健康相关认知、态度、技能和行为变化评价干预的效果，并比较两种干预模式的差别。3．以5个区的9个亲青服务点为亲青服务评估现场，研究对象包括服务点的管理人员、服务人员和利用服务的青少年，分别评价校外市级、区级、街道级和校内（重点及非重点学校）四类亲青服务点所提供的电话、网络、面对面以及E-mail咨询的质量和利用情况（收集2003年7月—2004年6月间的咨询记录）。采用的统计分析方法主要包括t检验、卡方检验、相关分析、多元Logistic回归、一般线形模型和广义估计方程。【研究结果】1、青春健康促进项目对青少年性与生殖健康教育和服务支持性环境的影响青春健康促进项目增强了市、区级相关部门决策层的忧患意识和合作意识，打消了项目试点单位决策层的顾虑，吸引了更多的单位主动参与项目活动，并使教师和家长的态度有了积极的转变。自青春健康促进项目开展以来，上海市共出台了与青少年性与青春健康教育和服务相关的市级文件8份、区级文件57份。2000.5-2003.4期间，上海市共投入项目资金708.59万元，投入资金与项目资金之比在局部试点、局部推广和全面拓展三个阶段分别为1.8、2.4和6.6。青春健康促进项目被纳入市、区级政府的工作议事日程，教育和卫生部门、科研和宣传机构的沟通合作增强。项目共举办了28期市、区级师资培训班，共培训师资840人，其中市级师资培训班5期，培训市级师资135人。项目覆盖了全市19个区县的39个街道、11个镇、111所学校和141家企业。上海亲青服务网络从无到有逐渐建立起来，服务内容不断地扩展，质量得到不断地提高。2．生活技能培训对职校生生殖健康认知、态度、技能和行为的影响基线共调查对象1612人，其中干预1组623人、干预2组472人、对照组517人；终线时调查对象1023人，其中干预1组576人、干预2组447人、对照组486人。干预后，两干预对象各类知识及总知识得分均有明显增加，其中总知识得分增值分别为10.41和12.85；两种干预模式均提高了对象的生殖健康风险认知(OR_干预1=2.43，OR_干预2=3.61)、使用避孕套的受益认知(OR_干预1=1.03，OR_干预2=1.07)、避孕方法选择自我效能(OR_干预1=1.03，OR_干预2=1.05)、对自己做出负责的性行为决定的技能(OR_干预1=1.09，OR_干预2=1.05)以及对他人做出负责的性行为决定的技能(OR_干预1=1.04，OR_干预2=1.04)。此外，干预1模式还降低了对象避孕相关障碍认知(OR_干预1=0.67)和同伴压力(OR_干预1=0.96)、使对象对青少年婚前性行为的态度趋于保守(OR_干预1=0.96)、改善了对象对艾滋病病人的态度(OR_干预1=2.16)以及推迟了女孩的首次性行为(OR_干预1=0.25)等；而干预2模式还提高了对象的了解避孕套的受益认知(OR_干预2=1.03)，并减少了对象手淫后的焦虑或羞耻感(OR_干预2=0.22)。3．各类亲青服务点的服务质量及服务利用9个亲青服务点服务质量的综合评价指标评分值在0.6-0.8之间，多数达优级。不同服务点各类亲青服务特征分值差别较大，校内服务点在硬件设施、同伴教育、学生参与信息宣传方面分值均高于校外；市级服务点多数指标分值明显高于校外服务点。共收集9个服务点未婚青少年服务利用的咨询记录3162条。各类别亲青服务点中，市级亲青服务点的服务利用量最高（达2248例）；不同咨询方式中，网络咨询利用量最高（达2079例）。利用服务的青少年中女孩所占比例约是男孩的2倍，15—19岁和20岁以上者占绝大多数。校外服务点前三位话题依此为怀孕／避孕（36.3％）、不安全性行为（18.7％）和生理发育（19.6％）；校内服务点的前三位话题依次是学习压力（32.3％）、生理发育（20.5％）和与父母沟通（13.7％）。【结论】1．青春健康促进项目促进了良好的青少年生殖健康教育和服务的支持性环境的形成；2．生活技能培训改善了职校生生殖健康相关认知、态度、技能和健康行为；3．以心理老师担当生活技能培训主持人并结合同伴教育的干预模式效果好于以班主任担当生活技能培训主持人的模式；4．上海亲青服务从无到有建立了起来，但尚处在探索阶段，服务利用不足较为普遍。更多还原

【Abstract】 [BACKGROUND] In the recent decades, more and more unmarried adolescents and youth in China were in the high risk of unwanted pregnancy, induced abortion and STDs along with the increase of premarital sexual behavior. As a result, exploration and implementation of effective provision model of education and health care and scale up to promote youth reproductive health by helping them to have safe and responsible sexual behavior has become a hot point of social concern. In the intervention area, program based on health promotion theory has drawn more and more attention, because such program can result in long time behavioral change and increase health of youth in large scale. A program based on health promotion theory with five strategic contents (building healthy public policy, creating supportive environments; strengthening community action; developing personal skills; reorienting health services) was evaluated in this study to elucidate its effects on related policy, Cognition, attitudes, skills and behaviors of target population (adolescents in vocational school), and provision and utilization of youth friendly services.[OBJECTIVES] The objective of the study was to evaluate the effect of Adolescent Reproductive Health Promotion Program on the establishment of supportive environment, the effect of life skills training on adolescent’s sex-related cognition, attitudes and behaviors, and the quality and utilization of youth friendly service initiated by the program.[METHODS] 1. Data related to effect of the health promotion program on the suppotive environment was collected by documentation (dated from 2000.5 to 2004.3) review and in-depth interview (2004.9-2004.12). Data and information for building supportive enviornment and changes occurred before and after the program were analyzed. 2. Three vocational schools in one district of Shanghai were selected as research site to evaluate the effect of life skills training on students’ related cognition , attitudes, skills and behaviors, two as interventional group and the other as control group. The intervention lasted for two semesters (2003-2004) Two intervention models were applied in two interventional groups respectively. In intervention group one, intervention model is life skills training facilitated by the psychology teacher plus peer education activities; in intervention group two, the intervention model is life skills training only facilitated by the teachers in chief of the class. There was no special educational program in the control school except normal education activities as usual. The subjects were grade two students in the three study schools. The intervention lasted for one academic year. Baseline, interim and post-intervention surveys (2003.5-2004.5) were conducted by computer-based questionnaire survey. The effect of the intervention on students’ cognition, attitudes and behaviors, and the difference of the effect of two intervention models were analyzed by comparing the change from baseline to post-intervention among different groups. 3. Nine adolescents friendly services centers was selected as research sites to evaluate quality and utilization of the service (dated from 2003.7-2003.6). Statistical methods used in the study included t-test, Chi-square test, correlation analysis, logistic regression, GLM and GEE.[RESULTS]1. The effect of the Adolescent Reproductive Health Promotion Program on the building supportive environmentThe program helped policy makers to realize the seriousness of reproductive health problem of adolescents and the significance of reproductive health education and service provision. It also removed the worry of people at district level in the pilot institures and attracted more and more organizations to join in the program. Attitude of teachers and parents toward sexual education were also changed by the program. During the program period, eight city level documents and 57 of district level documents for promoting adolescent reproductive health were issued. The total of 7.08 million RMB was input into the program by local government during May, 2000 to April, 2003. The ratio of money given by government to by the program was 1.8, 2.4 and 6.6 respectively in the pilot, development and widely extension period. The program also increased the cooperation of related departments, such as education, health and research departments. Twenty-eight training workships were held and 840 trainers were trained. Among them 5 workshops were in city level and 135 trainers participated in the training. The program has extent to 39 sub-districts, 11 towns, 111 schools and 141 companies in 19 districts of Shanghai. The network of Youth friendly service was established, the contents of service was expanded and the service quality was improved continuously.2. The effect of life skills training on the cognition , attitudes, skills and behaviors of students in vocational schoolsThe total of 1,612 students were surveyed at baseline, 623 in intervention group one, 472 in intervention group 2, and 517 in the control group. At post-intervention survey, the number of students in each school was 576, 447, and 486 respectively, and the total number was 1,023. The intervention effectively increased students’ knowledge, the mean of increase score was 10.41 and 12.85 respectively in two intervention groups. The intervention also effectively improved perceived risk of students (OR was 2.43 in intervention group one and 3.61 in intervention group two), perceived self-efficacy in contraceptive use (OR was 1.03 in intervention group one and 1.05 in intervention group two), perceived self-efficacy in making a decision of responsible sex (OR was 1.09 in intervention group one and 1.05 in intervention group two). In addition the first intervention model decreased the perceived barrier for contraceptive use (OR was 0.67) and peer pressure (OR was 0.96), made more conservative attitude toward premarital sexual behavior (OR was 0.96), and attitude toward AIDs patients more friendly (OR was 2.16) as well as postponed sex initiation of girls (OR was 0.25). The second intervention model increased the perceived benefit of learning condom (OR was 1.03) and decreased feeling of shame and worries after masturbation (OR was 0.22).3. Quality and utilization of youth friendly servicesThe comprehensive quality score ranged between 0.6～0.8 among nine service centers, most centers were of high level. The scores of different sub-terms varied among different centers. Centers in school have high scores in facility characteristic of youth friendly servicess, peer education, user participation. City level centers have higher scores in most iterms than centers out of school. Totally 3,162 counseling cases were recorded in nine centers, among them 2,248 were provided by city level centers. The most welcomed and utilized counseling way was through web-site (2,079), followd by face-to-face counseling and telephone counseling. The utilization of web-site counseling increased during the study year. The number of girls who used sevices was two time of that of boys. Of all counseling services users, youth aged 15 years of older accounted for the most majority. The counseling topic was very wide. In centers outside of school, the frequently asked questions included pregnancy/contraception (36.3%), unsafe sexual behavior (18.7%) and physical development (19.6%). In centers in school, the most questions frequently asked included study pressure (32.3 % ), physical development (20.5%) and communication with parents (13.7%).[CONCLUTION] 1. The project has successfully improved establishment of the supportive environment for adolescent reproductive health education and services; 2. Life skills training program had positive effect on students’ cognition, attitudes, skills and behaviors; 3.The impact of life skills training facilitated by psychologic teacher plus peer education was larger than that facilitated by teacher in chief of the class; 4.Youth friendly services came into being but still in the progress of exploration, counseling services were not fully utilized yet.更多还原