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Can the Internet Be Used

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Journal of Adolescent Health 39 (2006) 720 –728

Original article

Can the Internet Be Used Effectively to Provide Sex Education to
Young People in China?
Chao-hua Lou, M.D.a,* Quan Zhao, M.S.a Er-Sheng Gao, M.D.a, and Iqbal H. Shah, Ph.D.b
b

a
Department of Epidemiology and Social Science on Reproductive Health, Shanghai Institute of Planned Parenthood Research, Shanghai, China
Department of Reproductive Health and Research, Special Program of Research, Development and Research Training in Human Reproduction, World
Health Organization, Geneva, Switzerland
Manuscript received June 20, 2005; manuscript accepted April 4, 2006.

Abstract:

Purpose: To assess the feasibility and effectiveness of sex education conducted through the
Internet.
Methods: Two high schools and four colleges of a university in Shanghai were selected as the
research sites. Half of these were assigned to the intervention group and the other half to the control
group. The interventions consisted of offering sexual and reproductive health knowledge, service
information, counseling and discussion to all grade one students in the intervention group. The
intervention phase lasted for 10 months and was implemented through a special website, with web
pages, online videos, Bulletin Board System (BBS) and expert mailbox. In total, 624 students from
the intervention, and 713 from the control schools and colleges participated in the baseline survey,
and about 97% of them were followed up in postintervention survey to assess changes that can be
attributed to the sex education interventions provided through the Internet.
Results: The median scores of the overall knowledge and of each specific aspect of reproductive health
such as reproduction, contraception, condom, sexually transmitted infections (STIs) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) were significantly higher in the
intervention group as compared with those in the control group at postintervention (p ⬍ .0001), although
no significant differences were found between these two groups in the baseline survey (p ⬎ .05). Group
by time interaction effects in ordinal logistic regression analysis were found on knowledge score (p ⬍
.0001) and in attitude of high school students toward sex-related issues (p ⬍ .05), suggesting that
interventions increased subjects’ knowledge significantly and changed high school students’ attitudes to
being less liberal toward sex. The intervention also had positive influence on students’ attitudes toward
providing contraceptive service for unmarried people.
Conclusions: Providing sex education to students in Shanghai through the Internet was found
feasible and effective. The Internet-based sex education program increased students’ reproductive
health knowledge effectively and changed their attitudes toward sex-related issues in terms of being
less liberal toward sex and more favorable to providing services to unmarried young people. The
Internet thus offers an important and hitherto untapped potential for providing sex education to
students and young people in China. © 2006 Society for Adolescent Medicine. All rights reserved.

Keywords:

Adolescents; Sex education; Reproductive health knowledge; Attitudes; The Internet-based program; China

*Address correspondence to: Dr. Chao-hua Lou, Department of Epidemiology and Social Science on Reproductive Health, Shanghai Institute of Planned
Parenthood Research, 2140 Xie Tu Road, Shanghai 200032, P.R. China.
E-mail address: [email protected] [email protected]

With rapid modernization, economic development and expanded exposure to media, the attitudes of Chinese adolescents (10 –19 years old) and youth (15–24 years old) toward
sexuality are becoming much more liberal. Studies show
that an increasing number of young people (10 –24 years
old) are having sex before marriage, and the age at sexual

1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2006.04.003

C. Lou et al. / Journal of Adolescent Health 39 (2006) 720 –728

debut is declining [1]. However, adolescents and young
people in China continue to lack basic reproductive health
knowledge and skills to prevent adverse health consequences of unsafe premarital sex [1]. As a result, there has
been a marked increase in the number of unplaned pregnancies and induced abortions among unmarried young people
in China [2–5]. Also, an upsurge is witnessed in the incidence of sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV) infection in the country
[6,7].
Education is the first and most basic tool to increase the
knowledge and capacity of self- protection of young people.
As far back as the early 1980s, the Chinese government
noted the importance of sex education among young people.
Currently, sex education, which is called “puberty education” in schools, is included in the curriculum of secondary
schools in the country. However, sex education in secondary school is largely ignored because of the cultural norms
inhibiting discussion on sexual matters as well as the competition for students to enter key high schools or universities
that place subjects other than sex education on a high
priority. The contents of current sex education programs are
superficial and do not meet students’ needs. In addition, the
maner in which sex education is offered generally does not
attract students’ attention or their interest. Therefore, secondary school students in China gain relatively little sexual
and reproductive health knowledge in schools. Several studies in China show that the main source of knowledge among
students is media, such as books, periodicals, magazines,
movies and television [8 –11]. Therefore, media has become
one of the most important sources of reproduction health
knowledge among Chinese adolescents and unmarried
youth.
At present, the Internet is an important part of the Chinese media. Data show that by the middle of 2004, 87
million people had surfed the Internet in the country, and
54.1% of them were under 25 years old, which implies that
more than 10% of the Chinese population under age 25
years has ever surfed the Internet. In the large cities such as
Shanghai, the percentage is much higher than the national
average. The Internet, therefore, can have a powerful influence on young people’s learning activities and daily life,
and might serve as a primary channel for acquiring sex and
reproductive health information in China. Studies in other
countries have also indicated that the Internet could be a
practical and accessible way of delivering sexual health
education to adolescents and young people [12,13].
There are some well-designed websites that are relevant
to or that focus on adolescent sex and reproductive health
education and have been set up by some projects or institutions in other countries. However, these websites are in
the English language only. Some Chinese reproductive
health websites broadly cover family planing and reproductive health knowledge, but few of them focus on adolescents
or cover important topics of knowledge and information that

721

adolescents and young people need. In addition, there are no
rigorous studies assessing the impact of sex education via
the Internet in China. Therefore, it was considered necessary to design and implement a well-designed website for
sex education in local language especially for adolescents
and unmarried youth, and to evaluate the effectiveness of
the website in increasing adolescents’ and young people’s
knowledge and in changing their attitudes and behaviors.
Methods
The study project was designed by the staff of the Shanghai Institute of Planned Parenthood Research (SIPPR) and
was reviewed and approved by the Scientific and Ethical
Review Group (SERG) of the Department of Reproductive
Health and Research, World Health Organization, Geneva.
Study design
Two high schools in an urban district and four colleges
of a science and engineering university in Shanghai were
selected as the research sites, with one high school and two
colleges as the intervention group and the others as the
control. The selection criteria of the schools and colleges
included: (a) general high school or nonmedical college; (b)
school’s or college’s authorities agreeing to and supporting
the intervention program; and (c) schools or colleges in two
groups to be comparable in educational level of students or
family background. All the first grade students in these
schools (corresponding to 10th grade students in the U.S.
school system) and colleges were recruited as the subjects.
A baseline survey was conducted among the subjects before
initiation of the intervention in February 2003. A similar
survey was conducted in both groups after 10 months of
intervention. In total, 1337 subjects (96.3% of all eligible
students) participated in the baseline survey, among whom
624 were in the intervention group and 713 in the control
group. A total of 97.2% recruited subjects were successfully
followed up, including 96.6% from the intervention group,
and 97.8% from the control group. The survey was conducted using self-administered questionaires. Trained interviewers assisted respondents, where necessary, in understanding questions with which they might have difficulties.
All completed questionaires were reviewed by research staff
for completeness and consistency.
Intervention
Intervention activities were conducted using a specifically designed website (www.youthhood.com.cn) that offered sexual and reproductive health knowledge, service
information, counseling and discussion. Only subjects in the
intervention group, who were provided private usernames
and passwords, could browse the website. No special sexual
education was given to the students in the control group.
The intervention lasted for 10 months (March 2003 through
December 2003) and comprised four types of activities.

722

C. Lou et al. / Journal of Adolescent Health 39 (2006) 720 –728

Table 1
Score sheet for attitudes towards sex-related issues
Statement

There is nothing wrong for unmarried boys and girls to have sexual
intercourse if they love each other.
It’s all right for boys and girls to have sex with each other provided that
they use contraceptive methods to prevent pregnancy.
‘One night sex’ is acceptable.
Most boys who have sex before marriage regret it afterwards.
Most girls who have sex before marriage regret it afterwards.
You would look down on him/her, if your boyfriend/girlfriend has had
sexual intercourse with other people before meeting you.
Girls should remain virgin until they marry.
Boys should remain virgin until they marry.

First, provision of sex and reproductive health knowledge
and services information by web pages; this was the main
intervention activity. There were more than 200 web pages
on the website, with several pictures and animations much
appreciated by adolescents and young people. Knowledge
and information on sexual physiology and psychology, sex
ethics and laws, relationships, love and marriage, STIs/HIV/
AIDS, reproduction and contraception, premarital sex and
pregnancy, induced abortion, and sexual harassment were
provided through these web pages. Information was also
provided on how and where to access reproductive health
services. An expert on sex education was responsible for
selecting and developing the educational materials. The
second activity provided was video shows on the website. In
total, 10 10-minute educational videos were posted on the
website. These videos provided knowledge on sexual physiology, self-protection, contraception and pregnancy, consequences of unprotected intercourse, the prevention of
STIs/HIV/AIDS, and the harmful effects of induced abortion (Induced abortion is available on demand and is encouraged in case of an unwanted pregnancy in China.
Therefore, many young people and adults hold the opinion
that having an induced abortion poses no risk or inconvenience and thus pay less attention to safe sex. It was considered important to provide youth with the scientific
knowledge/evidence that induced abortion may result in
infertility and has some other negative effects on women’s
health. The purpose is to raise youth’s awareness for selfprotection and encourage them to use contraception when
having sexual intercourse.). Third, professional counseling
by e-mail was provided. A well-trained counselor was responsible for responding to young people’s e-mails as well
as their questions posted on the Bulletin Board System
(BBS). The fourth activity was discussions on the BBS.
Subjects could discuss sex-related issues on the BBS to
exchange opinions and ideas. A member of the research
team coordinated the discussions. The website was updated
every 2 weeks. To make the website attractive to students,
their suggestions were adopted in designing and updating

Points
Agree

Unsure

Disagree

3

2

1

3

2

1

3
1
1
1

2
2
2
2

1
3
3
3

1
1

2
2

3
3

the website, according to the information ascertained from
focus group discussions, baseline survey, and the regular
feedback during the intervention. Moreover, students who
are interested in website design in the intervention group
were encouraged to get involved by providing educational
materials.
Measurement of outcome
There were three main measures of outcome of interest:
(a) knowledge score, (b) attitude score, and (c) proportions
of sex-related behaviors. There were 98 questions on the
knowledge of reproduction, contraceptives, condom, STIs
and HIV/AIDS in the questionaire. For each question, one
point was given if it was answered correctly and zero if not.
The original score was converted into a new scale with the
maximum score of 100. The total knowledge score and
scores of reproduction, contraceptives, condom, STIs and
HIV/AIDS were calculated respectively based on the corresponding questions, which were used to evaluate subjects’
knowledge level; the higher the score, the greater the knowledge.
There were eight statements in the questionaire on attitudes toward sex-related issues. Scores were given to the
answers according to the score sheet listed in Table 1. These
scores were summed up to indicate the overall level of
liberal sex-related attitudes manifested by the respondents;
the higher the sum, the more liberal the attitude. Finally,
four questions were asked on sex-related behaviors, i.e.,
whether subjects had experienced sex-related hugging, kissing, petting or sexual intercourse. Those who responded
“yes” were considered to have had such experience.
Statistical analyses
Data for this article come from the baseline and postintervention surveys and covered two groups: the intervention
group and the control group. Differences in the percentage
distributions of categorical variables between the two
groups were compared using chi-square tests. For non-

C. Lou et al. / Journal of Adolescent Health 39 (2006) 720 –728

normally distributed data such as knowledge scores, nonparametric statistics, i.e., Wilcoxon-Man-Whitney tests,
were used. The effects of the intervention on reproductive
health knowledge and sex-related attitude were analyzed
using ordinal logistic regression models (the knowledge and
attitude scores, the dependent variables of the models, were
ordered as four categories by quartiles from low to high),
adjusting the potential confounding factors. The effect of
the intervention on sex-related behaviors including hugging,
kissing, petting and sexual intercourse were analyzed using
binary logistic regression models (whether experienced
each such outcome as the dependent variable, measured by
“Yes” ⫽ 1, “No” ⫽ 0). Data were doubly entered with
EpiInfo 6.04 software (Centers for Disease Control and
Prevention, Atlanta, GA), and then validated by comparing
the consistence between the two entries. Data were analyzed
with SAS 8.01 (SAS Institute, Inc, Carey, NC).

Results
Profiles of participants
Table 2 shows that the sociodemographic background
characteristics of two groups were broadly similar. No statistically significant differences were observed between the
intervention and control groups in type of subjects (high
school or college students), age, having a single room or
not, father’s educational level, family’s economic status,
and the degree of monitoring by family. Differences were
observed between the two groups in terms of place that
college students came from, mother’s educational level and
parents’ occupations. Subjects from the intervention group
tended to come from outside of Shanghai, and their mother
would be more likely to have a higher educational level, and
their parents to be farmers than those from the control
group. Gender disparities were also observed (Table 2).
The Internet use of participants at baseline
Two-thirds (68%) of all subjects thought the Internet was
a good way to carry out sex education. A high percentage
(90%) of all subjects had ever surfed the Internet; 88% in
the intervention group and 92% in the control group. More
than one-third (34%) of subjects had browsed reproductive
health knowledge on the Internet, and about 5% of them
browsed this type of website more than once a month. Their
opinions on these websites were: contents were not constructive (44%), pornographic (44%), inappropriate to adolescents/young people (38%) and unscientific (24%). About
one-third of subjects (30%) had visited pornographic websites, and 8% of them browsed these websites more than
once a month. They believed these (pornographic) websites
“provided unscientific information”(37%), “induced youth
to have sex”(51%), or “induced to commit sex
crimes”(26%), wheras 30% believed they “were attractive.”

723

There were no statistical differences in the above-mentioned
responses between the intervention and control groups.
Exposure to and evaluation of intervention
During 10 months of the intervention, there were 15,357
hits on the intervention website. Table 3 shows that most
subjects in the intervention group had browsed the website
and evaluations of the website were generally positive.
It was found that subjects who sought counseling by e-mail
were relatively few (only 11 persons) and although there were
452 subjects who had registered on the BBS at the end of the
intervention, only a few of them posted comments on it. In the
postintervention survey, related questions were asked to explore the reasons. The main reasons for nonuse of the e-mail
were “no question to ask”(46%) and “seldom use e-mail”/“felt
inconvenient to use e-mail” (34%). More than half of the
students (58%) “occasionally or never” used e-mail. With
regard to the reasons for nonuse of the BBS, 64% of subjects
stated “members on the BBS were too few so there was no
atmosphere of discussion,” 18% said “contents of the BBS
were too little,” and 16% reported that “time spent on the
Internet was limited.”
Effectiveness of interventions
Knowledge
Table 4 shows that the median scores of total knowledge
in the intervention and control groups at baseline were about
50 and no significant differences were found between the
two groups (p ⬎ .05). However, at the postintervention
survey, the total score of subjects in the intervention group
increased to 63.4, which was significantly higher than that
in the control group (55.1). The increase of the total score
from the baseline to postintervention in the intervention
group (14.4) was 2.8 times of that in the control group (5.1).
Similarly, the scores for each aspect of knowledge were
significantly higher in the intervention group than in the
control group at postintervention (p ⬍ .0001), whereas no
significant differences were observed between them at baseline (p ⬎ .05). Males and females showed similar changes,
although there were significant differences for most of the
scores between them.
A group ⫻ time interaction effect was found on total
reproductive health knowledge score in ordinal logistic regression analysis, providing the evidence that the difference
between the intervention and control groups varied with the
implementation of the intervention and indicates that the
intervention activities increased youth reproductive health
knowledge significantly (Table 5, Model I). Table 4 shows
that this interaction effect was owing to the similar reproductive health knowledge scores in two groups at baseline,
and higher scores in the intervention group than in the
control group at postintervention. The results of logistic
regression analysis also show that college students tended to
have more reproductive health knowledge than high school

724

C. Lou et al. / Journal of Adolescent Health 39 (2006) 720 –728

Table 2
Sociodemographic profile of participants at the baseline: intervention and control groups (%)
Characteristics

Type of subject
High school student
College student
Age (years)
ⱕ 15
16
17
18
ⱖ 19
Place subject came fromb
Shanghai
Others
Having a single room or not
Yes
No
Father’s educational level
Junior high or below
Senior high or technical school
Junior college or above
Unknown
Mother’s educational level
Junior high or below
Senior high or technical school
Junior college or above
Unknown
Father’s occupation
Workerc
Farmer
Professional personel
Administrative personel
Individual or private enterprise
owner
Mother’s occupation
Workerc
Farmer
Professional personel
Administrative personel
Individual or private enterprise
owner
Family economic status
Good
Medium
Bad
Degree of monitoring by family
Severe
Medium
Lenient

Intervention group

pa (inter.-contr.)

Control group

Total
(n ⫽ 624)

Male
(n ⫽ 376)

Female
(n ⫽ 248)

pa

Total
(n ⫽ 713)

Male
(n ⫽ 360)

Female
(n ⫽ 353)

pa

44.6
55.4

40.4
59.6

50.8
49.2

.0107

49.1
50.9

44.2
55.8

54.1
45.9

.0079

.0972

20.7
22.9
2.6
20.2
33.6

17.5
22.1
2.7
21.3
36.4

25.4
24.2
2.4
18.6
29.4

.1114

20.6
27.8
2.00
20.2
29.5

17.5
26.1
1.9
18.9
35.6

23.8
29.5
2.00
21.5
23.2

.0074

.2417

45.4
54.6

45.5
54.5

45.1
54.9

.9354

57.3
42.7

57.2
42.8

57.4
42.6

.9704

.0015

71.8
28.2

73.1
26.9

69.8
30.2

.3585

73.2
26.8

72.8
27.2

73.6
26.4

.7916

.5625

33.2
44.7
20.3
1.8

34.8
43.6
20.0
1.6

30.6
46.4
21.0
2.0

.7356

32.4
47.1
19.0
1.5

36.9
41.9
19.4
1.7

27.8
52.3
18.5
1.4

.0329

.8316

42.5
45.8
10.6
1.1

44.2
42.5
12.2
1.1

39.9
50.8
8.1
1.2

.1489

34.8
53.0
10.4
1.8

40.6
47.5
9.4
2.5

28.9
58.6
11.3
1.1

.0035

.0214

53.4
7.0
7.7
20.7
11.2

54.0
8.2
6.7
19.4
11.7

52.4
5.2
9.3
22.6
10.5

.3744

59.9
3.0
7.5
21.2
8.4

60.3
3.3
8.1
20.3
8.1

59.5
2.6
6.8
22.2
8.8

.8832

.0022

61.6
9.0
9.5
13.3
6.6

53.2
10.9
8.5
12.2
8.0

58.7
6.1
10.9
14.9
4.4

.0610

67.7
4.8
8.1
12.3
7.0

70.6
5.6
8.1
10.6
5.3

64.9
4.0
8.2
14.2
8.8

.1468

.0196

13.0
69.5
17.5

12.5
68.1
19.4

13.7
71.8
14.5

.2845

14.2
70.6
15.2

11.9
69.7
18.3

16.5
71.6
11.9

.0238

.4739

41.3
42.7
15.9

41.2
44.2
14.6

41.3
40.9
17.8

.5164

41.3
41.9
16.8

40.3
42.8
16.9

42.3
40.9
16.8

.8457

.8800

␹2 test between males and females or between the intervention and control groups.
Only for college students.
c
Including retiree, the jobless, etc.
a

b

students; students who had browsed reproductive health
knowledge on the Internet (except the website www.
youthhood.com.cn) or browsed pornographic websites and
who had discussed sex-related issues with father or friends
were likely to have more reproductive health knowledge. It
was also shown that the intervention increased each of five

knowledge scores significantly. Reproduction knowledge
was increased by the intervention most significantly, with
10.651 of odds ratio (OR) (95% confidence interval [CI]
7.690 –15.047, p ⬍ .0001) for the group ⫻ time interaction
effect, followed by the knowledge of STIs (OR ⫽ 2.213,
95% CI 1.612–3.038, p ⬍ .0001), condom (OR ⫽ 2.121,

C. Lou et al. / Journal of Adolescent Health 39 (2006) 720 –728

725

Table 3
Participation and evaluation of the intervention activities (%)
Participation and evaluation
Main place for using the Internet
Home
School/college (incl. computer room, library and dormitory)
Internet café
Others
Number of times browsing the website
ⱖ 5 times per month
1–4 times per month
⬍ 1 times per month
Never
Time spent browsing the website at each [email protected]
ⱖ 20 minutes
10–20 minutes
⬍ 10 minutes
Benefit of the websiteb
Great
Some
Nothing
Whether contents of the website are appropriate to youth or notb
Very appropriate/appropriate
Inappropriate
Whether layout of the website is good or notb
Very good /good
No so good
Bad
Whether website raised the attention to RHb
Yes
No
Whether encouraged to obtain RH knowledge from other sources by using the websiteb
Yes
No
a
b

Total
(n ⫽ 603)

Male
(n ⫽ 357)

Female
(n ⫽ 245)

pa

35.0
44.1
19.2
1.7

31.0
41.2
26.9
0.9

41.1
48.5
7.4
3.0

⬍.0001

5.7
61.1
26.9
6.3

6.5
59.8
26.4
7.3

4.5
63.3
27.3
4.9

.4484

39.9
43.8
16.3

40.9
43.0
16.1

38.6
45.1
16.3

.8555

13.5
69.8
16.7

12.7
67.0
20.3

14.7
73.7
11.6

.0250

94.7
5.3

92.7
7.3

97.4
2.6

.0145

86.5
8.2
5.3

82.7
9.4
7.9

91.9
6.4
1.7

.0018

53.3
46.7

50.8
49.2

56.7
43.3

.1557

40.6
59.4

42.0
58.0

38.8
61.2

.4334

␹2 test between males and females.
Only for those who had visited the website.

95% CI 1.540 –2.921, p ⬍ .0001), HIV/AIDS (OR ⫽ 1.925,
95% CI 1.403–2.641, p ⬍ .0001) and contraceptives (OR ⫽
1.770, 95% CI 1.289 –2.432, p ⫽ .0004).
Attitudes
A group ⫻ time interaction effect on attitude was found
among high school students (Table 5, Model II) but not
among university students (p ⬎ .05). The results indicate
that the intervention might change high school students’
attitude and made their attitude toward sex-related issues
more conservative. However, the significance was marginal.
At baseline, 50% of subjects in the control group and
51% in the intervention group disagreed with the statement
that “Providing contraceptives for young people means encouraging them to have sex” and no difference was observed between the two groups (p ⬎ .05). The proportions
increased in both the control and intervention groups after
the intervention period, but the increase in the intervention
group was significantly higher than that in the control group
(64% and 56% respectively, p ⬍ .01). The results indicate
that the intervention might have changed young people’s
attitude toward the provision of contraceptive service to

unmarried young people and made them more favorable to
the provision of such services.
Behavior
Compared with the change of knowledge and attitude,
change in behaviors is generally more difficult. In this
study, binary logistic regression analysis showed that the
group ⫻ time interaction effects on all the sex-related behaviors such as hugging, kissing, petting and sexual intercourse were not statistically significant (hugging: OR ⫽
.862, 95% CI .612–1.214; kissing: OR ⫽ .880, 95% CI
.596 –1.300; petting: OR ⫽ 1.137, 95% CI .750 –1.724;
sexual intercourse: OR ⫽ .501, 95% CI .204 –1.231). No
discernable changes are, therefore, concluded for the change
in sex-related behavior.
Discussion
Provision of sex education through the Internet brings
tremendous challenges to the traditional education system.
Compared with the traditional pattern, there are several
advantages for conducting sex education through the Inter-

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C. Lou et al. / Journal of Adolescent Health 39 (2006) 720 –728

Table 4
Knowledge scores at baseline and postintervention in the intervention and control groups (Median)
Knowledge

Reproduction
Baseline
Postintervention
Contraception
Baseline
Postintervention
Condom
Baseline
Postintervention
STIs
Baseline
Postintervention
HIV/AIDS
Baseline
Postintervention
Total
Baseline
Postintervention

Intervention group

Control group

Total

Male

Female

Total

Male

Female

54.6
81.8*

59.1
81.8*

54.6
81.8*

54.6
63.6

63.6
63.6

54.6
63.6

24.2
48.5*

27.3
51.5*

18.2
42.4*

21.2
30.3

24.2
30.3

21.2
27.3

66.7
88.9*

66.7
88.9*

55.6
77.8*

66.7
66.7

66.7
66.7

55.6
66.7

48.2
70.4*

55.6
77.8*

44.4
63.00*

51.8
55.6

55.6
59.3

44.4
51.8

85.0
90.0*

85.0
90.0*

82.5
90.0*

85.0
85.0

85.0
85.0

85.0
85.0

49.0
63.4*

53.1
71.4*

43.9
64.3*

50.0
55.1

54.1
57.1

45.9
53.1

* p ⬍ .0001, Wilcoxon test between the intervention and control groups.

net. For example, it allows the learner to choose a convenient time and place for learning and to come across a wide
variety of learning styles; it enables the learner to move
through educational materials at a speed that meets individual learning needs and allows participants with varying
degrees of knowledge and skills to access instruction in a
comfortable, nonthreatening maner. These advantages of
the Internet and young people’s high access to this new
learning source make it feasible to carry out sex education
on the Internet. Findings presented in this article provide
evidence that high school and university students made
good use of this educational style and considered the provision of sex education though the Internet highly feasible.
It can be concluded from the study that the Internet
education program increased students’ reproductive health
knowledge effectively and also had a minor influence on

their attitudes toward sex-related issues. The results are
consistent with a growing body of evidence from previous
school- and community-based intervention studies on sex
and reproductive health education [14 –16] and proved that
the Internet can be an effective way to conduct the education. However, although behavior change is the final goal of
any education program and has been observed in another
intervention study [17], this study provided no evidence that
the intervention program changed subjects’ sex-related behaviors, as in other studies [18]. There may be two possible
explanations. First, the original study was designed to evaluate the effects of the intervention on subjects’ knowledge
and attitude, so the sample of the study was not large
enough to detect any changes in behaviors. Second, behavior change needs a relatively longer intervention than provided in the study. The effect of intervention on behaviors

Table 5
Ordinal logistic regression analysis with reproductive health knowledge of all subjects as outcome variable (Model I) and with attitude of high school
students towards sex-related issues as outcome variable (Model II)
Variables
Model I (Reproductive health knowledge of all subjects)
Group (intervention vs. control)
Time (postintervention vs. baseline)
Group ⫻ time
Model II (Sex-related attitude of high school students)
Group (intervention vs. control)
Time (postintervention vs. baseline)
Group ⫻ time

OR

95% CI

p

1.099
2.383
2.845

.882–1.369
1.914–2.967
2.059–3.930

.4021
⬍.0001
⬍.0001

1.124
1.934
.628

.812–1.555
1.356–2.758
.398–.991

.4818
.0003
.0459

Note: For both models, adjusted gender, type of subjects, place subjects came from, parents’ education level, parents’ occupation, family economic status,
having browsed reproductive health knowledge on the Internet or not, having browsed pornographic websites or not, having discussed sex-related issues with
parents or friends or not.

C. Lou et al. / Journal of Adolescent Health 39 (2006) 720 –728

might not surface within 10 months of intervention. The
findings do reinforce the thought that the provision of sex
education does not lead to increased sexual behavior. This is
a positive finding and puts to rest the critics, both inside and
outside China, who argue that sex education promotes promiscuity and sexual behavior. It is nevertheless suggested
that future longer-term studies should address the behavior
change.
The Internet-based intervention program proved successful not only on the basis of the evaluation results, but also
by the feedback from the public. The website has been open
to the public since the completion of the study in April
2004. Up to mid-2005, there are about 4000 hits on the
website per month on average. A local education department plans to combine the website with “Life Education” in
secondary schools. Moreover, it has attracted more than 20
national and local newspapers and TV stations to make a
series of reports. For example, the three main newspapers of
Shanghai, Jie Fang Daily, Wen Hui Bao, and Xin Ming
Evening Newspaper have all reported on the website with
titles such as “Talk stealthily to a unseen teacher,” “No
obstacle to obtain sex-related knowledge,” and “Establish
positive life value.” It is also noteworthy that there has been
a significant increase in the number of people who sought
counseling by e-mail and posted on the BBS since it opened
to public, especially the BBS, where the numbers of members and posts have reached 8,000 and 18,160, respectively.
The intervention was designed to provide sex and reproductive health education with web pages, online educational
videos, BBS, and e-mail counseling. At the baseline survey,
“expert e-mail” was cited by more than half of the subjects
(54%) as a favorite method to obtain reproductive health
knowledge and “online discussion” by 30%. However, only
a few subjects in the intervention group actually sought
counseling by e-mail or posted on the BBS during the
intervention. It is indicated that the difference between favored and actual use, which largely depends on the real
needs and the accessibility of the method, should be taken
into account when designing a program to be operated in a
small sub-population.
Adolescent sex education in China remains controversial
and disputed. At the time the study was conducted, the
disputed issue was no longer whether the education should
be provided or not but what kind of sex and reproductive
health education and service should be provided and how
they should be provided [19]. In recent years, adolescent sex
education in Shanghai has attracted greater interest among
local authorities, academic institutions, nongovernmental
organizations and other social organizations, but there is no
systematic, complete and comprehensive program yet, neither is there adequate awareness of the responsibility nor
action from society. The rise in problems concerning youth
sex and reproductive health calls for inovative methods and
improvement in relevant education and services. Among the
variety of efforts being made, sex education through the

727

Internet provides another possible solution. Therefore,
while the Internet is developing rapidly in China, its use
should be promoted for adolescents’ sex and reproductive
health education, especially in those places where welltrained educators or trainers for sex education are not available at present. Considering the wide reach of information
on the Internet, it does not make much sense to set up
numerous such websites. The experience of this intervention program suggests that the website should be credible,
lively, and fit for the taste of adolescents. An additional
important suggestion for future research is to explore constructing a website that would attract the attention and
involvement of both adolescents and adults, so that the
communication among adolescents and between adolescents and adults can be promoted. Our results call for the
use of the immense and cost-effective potential, hitherto
untapped, offered by the Internet to provide sex education to
young and unmarried people.
Acknowledgments
The authors thank United Nations Development Programs/
United Nations Population Fund/World Health Organization/
World Bank Special Program in Human Reproduction for its
generous financial and technical support, which enabled the
implementation of this study. Thanks are also due to the staff
of Education Bureau of Zha Bei District, East China University
of Science and Technology, Xiang Dong High School and
Gong He High School for their enthusiastic help and support.
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