reliminary Evidence of an Adolescent HIV/AIDS Peer Education Program Author link
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reliminary Evidence of an Adolescent HIV/AIDS Peer Education Program
Author links open overlay panelGangaMahatEdD, RNBCMary AnnScolovenoEdD, PNPTaraDe LeonBS, RNJessicaFrenkelBS, RN
https://doi.org/10.1016/j.pedn.2007.12.007Get rights and content
Adolescent peer education has been found to be an effective method to improve adolescents' knowledge and positive health behaviors. The purpose of this study was to determine the extent to which a peer education program was effective in changing adolescents' HIV/AIDS knowledge, risk behavior intentions, and confidence to engage in safe sex. The results showed that there was a significant difference in HIV knowledge between the peer education group and the traditionally educated group, with the peer group demonstrating greater knowledge. There was no significant difference in confidence to engage in safe sex between the two groups, but students in the intervention group were more likely to engage in safe sex than students in the traditionally educated group. Nurses can provide leadership in the development, implementation, and evaluation of peer education in adolescent health.
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Key words
HIV/AIDS
Adolescent peer education
HIV-related risk behaviors
THE CONCERN ABOUT HIV/AIDS among adolescents and young adults is growing in the United States (National Institute of Allergy and Infectious Disease, 2006). Since the AIDS epidemic began, there have been an estimated 40,059 cumulative cases of AIDS among young people aged 13 to 24, with African American and Hispanic adolescents being disproportionately affected (Centers for Disease Control and Prevention [CDC], 2006). Moreover, because 10 years is the average duration from HIV infection to the development of AIDS, most adults with AIDS were likely infected as adolescents or young adults (National Institute of Allergy and Infectious Disease, 2006). It is therefore pertinent to target prevention strategies to adolescents to control HIV/AIDS.
The 2004 surveillance data demonstrate that most adolescents and young adults are exposed to HIV through sexual intercourse. Most of the males are infected through sex with men, whereas females are infected through heterosexual contact (CDC, 2007). One of the goals of Healthy People 2010 is to increase the number of adolescents who abstain from sexual intercourse or use condoms if sexually active (U.S. Department of Health and Human Services, 2004). The trends do indicate that adolescents are engaging in less risky HIV-related behavior because of a concerted educational effort by schools and other community members. However, there are still disparities among ethnic subgroups. African American adolescents report more likelihood of engaging in risky sexual behaviors than do Whites and Hispanic adolescents, and there is no change in prevalence in sexual experience among Hispanic adolescents with many of them having multiple partners (CDC, 2006). A recent progress review on HIV recommends intensifying evidence-based HIV prevention strategies for high-risk groups to reduce the transmission of the disease (U.S. Department of Health and Human Services, 2004). One of the strategies found to be effective among adolescents is peer education focused on HIV and other sexually transmitted infections (STIs).
There is an increasing body of evidence supporting the use of peer education to improve adolescents' HIV knowledge to assist adolescents in developing positive group norms and in making safe and healthy decisions regarding risk behaviors (Mason, 2003; Miburn, 1995; Pearlman, Camberg, Wallace, Symons, & Finison, 2002). The purposes of this study were to describe the implementation of a culturally appropriate HIV/AIDS peer education program and to determine the extent to which peer education is effective in changing adolescents' HIV/AIDS knowledge, risk behavior intentions, and confidence to engage in safe sex.
Phases of Peer Education Project
This study is the third phase of a peer education project. Phase 1 of the project included selection of an urban high school in a New Jersey City and a preintervention assessment of the adolescents in the selected school focusing on their HIV/AIDS knowledge, attitudes, and beliefs to prepare an intervention that targeted the learning needs of the adolescents.
In Phase 2, peer leaders were prepared using a health promotion intervention titled, teens for AIDS prevention (TAP; Alford & Feijoo, 2002). The TAP program is based on the concept of self-efficacy as described in social learning theory (Bandura, 1986). Social learning theory predicts that adolescents will be better able to engage in positive self-directed change if they have the knowledge about HIV/AIDS (Bandura, 1989). The TAP peer intervention program is designed to reduce adolescents' risk of contracting HIV or other STIs by increasing their knowledge and encouraging them to change their attitudes and behaviors. TAP uses creative lesson plans and trains youth to implement these plans to encourage their peers to make positive changes in their sexual health attitudes and norms (Alford & Feijoo, 2002). In this project, the peer leaders selected content from the total TAP program that was culturally appropriate and specific to their peer group.
In the third phase, peer leaders under the guidance of student nurses, nurse faculty, and their teacher implemented the peer education program to ninth-grade students. Three classes of the ninth-grade students were in the intervention group and received a modified version of the TAP program from peer leaders who were trained in the TAP program. The other three classes of ninth-grade students were in the control group and received the traditional HIV/AIDS education offered in the school health program.
Literature Review
There is support for the role of peer education in increasing adolescents' HIV/AIDS knowledge and changing their HIV-related risk behaviors. Studies have shown that peer education programs have influenced positive changes in adolescents' behavioral intentions regarding condom use (Caron, Godin, Otis, & Lambert, 2004; Kinsler, Sneed, Morisky, & Ang, 2004; Pearlman et al., 2000; Smith, Dane, Archer, Devereaux, & Kirby 2000), frequency of intercourse (Jermott, Sweet-Jermott, & Fong, 1998), more conservative sexual norms (Mellanby, Reese, & Tripp, 2000), self-efficacy to refuse sex and delay sexual behaviors (Aarons et al., 2000), and in involving themselves in activities to help other youth avoid unprotected sex (Smith et al., 2000). Other intervention studies have also shown that adolescents who received peer education demonstrated greater knowledge in the use of condoms and confidence in abstaining from sex than did the group who did not receive the peer education program (Lane, 1997; Kinsler et al., 2004). Studies have also shown that peer education is culturally sensitive, cost-effective, and efficient in transmitting knowledge (Butz et al., 1994). People are more likely to make changes in their attitudes and behaviors if they believe the messenger faces their same concerns and issues (Miburn, 1995; Sloane & Zimmer, 1993).
Research Questions
1.
What are the differences in HIV/AIDS knowledge among urban high school adolescents who participate in the peer education program and those who participate in traditional HIV/AIDS education?
2.
Are there gender-based differences in HIV/AIDS knowledge?
3.
What are the differences in confidence to engage in safe sex behavior among adolescents who participated in the peer education program and the traditional program?
4.
Are there gender-based differences in confidence to engage in safe sex behavior?
5.
What are the risk-behavior intentions among urban high school adolescents who participate in the peer education program and those who participate in traditional HIV/AIDS education?
Methods
Design and Sample
A quasi-experimental design was used to evaluate the peer education program. A convenience sample of 97 ninth-grade students in an urban high school participated in the study. Three classes of the ninth-grade students received the peer education program (n = 58 students), and other three classes received the traditional HIV/AIDS education offered in the school (n = 39).
Procedure
After obtaining permission from the institutional review board and the participating school, the investigator met with students and explained to them about the purpose of the study, confidentiality of the information, and the fact that participation was voluntary. It was explained that they could decide not to participate in the study at any time, and their refusal would not affect their grade. Only those students who had signed an assent form and had parental signed consent participated in the study.
Prior to data collection, questionnaires were given to two teachers for content validity and cultural appropriateness. A group of nine students were given the questionnaire for level of understanding, readability, and cultural relevance. Students had no problem answering the questions.
The participants in both the intervention and control group completed the questionnaires at baseline and 5 months after the program's completion. Three classes of ninth-grade students received the peer education program, consisting of seven sessions of 45 minutes each (5.25 hours total) from their peer leaders. The other three classes of ninth-grade students received traditional HIV/AIDS content offered by the school. Students in the control group are in the process of receiving the peer education program from their peer leaders.
Instruments
The questionnaire had four main sections. The first section was used to collect demographic information such as age, ethnic background, and so forth. The second section included HIV knowledge questions adapted from the youth risk behavior surveillance system (YRBSS) developed by the Department of Health and Human Services, CDC (2002). These questions focused on HIV prevention and transmission. The third section focused on risk behavior intentions, whereas the fourth section focused on confidence to engage in safe sex.
Each item in the HIV/ADS knowledge section of the questionnaire was rated as yes (1), no (2), not sure (3), or don't understand (4). The adolescent was asked to circle the one best answer for each question. When scoring the 33 knowledge questions, the format used was correct (1) and incorrect (0). The two alternatives (not sure and don't understand) were scored as incorrect answers. In the correct/incorrect format the total score ranged from 0 to 33, the higher the total score, the greater the students' knowledge.
The behavioral intention questions included five questions about behavioral intentions regarding sex and use of condoms if their intent was to have sex in the next 3 months. A yes-or-no response was used for these questions. The fourth section included six items focusing on confidence to engage in safe sex. The items were scored from 1 (definitely true) to 5 (definitely false).
The Department of Health and Human Services, CDC reviews the YRBSS for accuracy annually. The internal consistency of the youth survey was >.8 (parents) and >.9 (children; B. Krauss, personal communication, August 2, 2002). The internal consistency of the total knowledge questionnaire in this study was .81.
Data Analysis
The data were analyzed using SPSS version 14.5. Demographics of the adolescents, their general knowledge of HIV/AIDS, and the HIV risk behaviors were analyzed using descriptive statistics. Pretest HIV/AIDS knowledge scores were controlled for using analysis of covariance. t Tests were used to compare adolescents' HIV/AIDS knowledge scores and their risk behaviors by gender.
Findings
Demographic Information
In this study, adolescents' ages ranged from 13 to 15 with a mean of 14. There were 42 (43.3%) boys and 55 (56.7%) girls. Selected findings of the demographic questionnaire are presented in Table 1. There were no differences on demographic characteristics between the peer-educated group and the traditionally educated group (control group). The results of this study also showed that 13.4% (n = 13) of the participants, 9 boys and 4 girls, had sexual experiences. Most of those who reported sexual experiences had their first sexual intercourse between the ages of 10 and 14.
Table 1. Frequency and Percentages of Selected Demographic Information
(N = 97)
Frequency
Percent
Age
13
6
6.2
14
89
91.8
15
2
2.0
Sex
Male
42
43.3
Female
55
56.7
Ethnicity
African American
31
32.0
Hispanic
27
27.8
Caucasian
26
26.8
Hispanic/African American
7
7.2
Asian
6
6.2
Sexually active
Yes
13.00
13.4
No
84.0
86.6
Age sexually active
10 years
1
11 years
2
12 years
3
13 years
4
14 years
3
Adolescents' HIV/AIDS Knowledge
Table 2 shows the means and standard deviations of adolescents' HIV/AID knowledge. When the pretest HIV/AIDS knowledge scores were controlled, the covariance analysis demonstrated that there was a significant difference between the control and the intervention groups, the group receiving peer education demonstrated greater knowledge than the group taught in the traditional program, F(2,96)= 13.7, p = .000.
Table 2. Adolescents' HIV/AIDS Knowledge
N
M
SD
Peer education group
Preintervention
58
22.1
3.9
Postintervention
58
27.9
2.7
Traditional (control) group
Preintervention
39
20.1
5.1
Postintervention
39
23.6
5.7
Gender-Based HIV/AIDS Knowledge
The mean and standard deviation of gender-based HIV/AIDS knowledge are presented in Tables 3 and 4. In both peer education and control groups, there were no differences in HIV/AIDS knowledge between adolescents' boys and girls in preintervention and postintervention as well as in postintervention groups.
Table 3. Gender-Based Adolescents' HIV/AIDS Knowledge Peer Education Group
N
M
SD
Preintervention
Boys
24
22.5
3.8
Girls
34
21.7
3.9
Postintervention
Boys
24
27.2
2.9
Girls
34
28.4
2.7
Table 4. Gender-Based Adolescents' HIV/AIDS Knowledge Control Group
N
M
SD
Preintervention
Boys
18
21.4
4.8
Girls
21
20.4
5.3
Postintervention
Boys
18
23.4
5.8
Girls
21
23.8
5.7
Reported Intention to Change Behavior
Because the sample size was small, and there were only few intention questions, sophisticated tests of statistical significance were inappropriate. Therefore, the data were treated as descriptive data. In this total sample of adolescents, most of the students did not plan to have sex. Of the adolescents who planned to have sex, the intervention group was more likely than the control group to have sex with only one partner, planned to use condoms, and planned to get their partner to use condoms (Table 5).
Table 5. Percentage of Adolescents' Responses in Intention to Engage in Risk Behaviors
Preintervention
Postintervention
Do not plan to have sex
Total
82.5
87.6
Control group
79.5
89.7
Intervention group
84.5
86.2
Plan to have sex with one
Total
12.4
11.3
Control group
15.4
7.7
Intervention group
10.3
13.2
Plan to have sex with more than two
Total
5.2
1.0
Control group
5.1
2.6
Intervention group
5.2
0
Plan to use condom
Total
15.5
15.5
Control group
17.9
10.3
Intervention group
13.8
19.0
Plan to get my partner use condom
Total
24.7
24.7
Control group
28.2
20.5
Intervention group
22.4
27.6
Adolescents' Confidence to Engage in Safe Sex Behavior by Groups
There was no significant difference between the intervention group and the control groups in confidence to engage in safe sexual behavior preintervention and postintervention.
Gender-Based Adolescents' Confidence to Engage in Safe Sex Behavior
In preintervention (N = 97), there was a significant difference between adolescent boys and girls in their confidence to engage in safe sexual behavior; girls reporting more confidence than boys, t(95) 3.2, p = .002. Similarly in postintervention (N = 97), there was a significant difference in safe sexual behavior, girls reporting having more confidence than boys, t(95) = 4.1, p < .001.
Discussion and Nursing Implications
A peer education program is a common means of addressing youth's sexual and reproductive health, and it is an effective strategy to educate and empower adolescents.
It has been reported in the literature that theoretically based peer education programs have been effective in improving adolescents' knowledge on sexual risk behaviors and, thus, have helped in changing their risk-taking behaviors. The literature also supports the use of interventions over time to effect behavioral change (Rotheram-Borus, Gwatz, Fernandez, & Srinivasan, 1998). The finding of this study demonstrated that ninth-grade students' knowledge on HIV/AIDS improved after both the peer education program and traditional education offered by the school. However, there was a significant difference between these two groups: The group receiving peer education showed greater HIV/AIDS knowledge than the group receiving traditional program. This finding is very encouraging and is consistent with the findings of previous peer education studies (Kinsler et al., 2004; Lane, 1997) and school-based studies on HIV/AIDS (Merson, Dayton, & O'Reilly, 2000; Jermott & Jermott, 2002). Because of the small sample size of adolescents who were sexually active, the results can not be generalized. However, there are some indications that adolescents in the intervention group were more likely to engage in safe sexual practices if they were sexually active. Furthermore, it should be cautioned that adolescents may provide socially acceptable answers to questions of sexual activity. There was no significant difference between the peer education group and the control group in confidence to engage in safe sex behavior. However, in both preintervention and postintervention, there was a significant difference between boys and girls in their confidence to engage in safe sex behavior, with girls reporting more confidence than boys.
Because peer education programs seem to be effective in improving adolescents' knowledge on HIV/AIDS, nurses and the educators may need to think strongly in using peer education programs in schools and community centers. They can play active role in planning and implementing the program because they are knowledgeable about adolescents' growth and development and their risk-taking behaviors. When planning and implementing the program, it is important that nurses and educators keep in mind the needs of the target population and adolescents' social and cultural backgrounds. It is also essential to involve these adolescents' parents and few influencing members of the community in planning the program to sustain the program and help in changing adolescents' positive behaviors. Peer leaders also need to be involved in planning, implementing, and evaluating the program, because it empowers them, and they know the target population and the community best.
Nurses and other personnel who are involved in peer education programs also need to consider another important fact that ethnic minorities are disproportionately affected by HIV epidemics. Therefore, these populations need to be targeted. The CDC has already initiated programs to prevent HIV infection among African Americans (Kinsler et al., 2004). The CDC provides national leadership to help control the HIV epidemic by working with community, state, national, and international partners in surveillance, research, prevention, and evaluation activities (CDC, 2006). Nurses can also provide leadership in assisting members of the community develop programs for adolescents in preventing HIV/AIDS.
Conclusion
Planning and implementing a peer education program is challenging because sensitive and controversial information has to be rendered in a nonthreatening way. It becomes tougher if the target population is diverse. Since peer education programs have proven to be one of the effective programs for adolescence, it is sensible to meet this challenge and implement peer education program in prevention and control of HIIV/AIDS. Nurses can play a pivotal role in this effort because they have the opportunities to interact with children and adolescents in a variety of settings and are prepared to meet this challenge. To implement a peer program successfully, nurses or the program manager needs to assess the target population and involve peer leaders and influential people in the community during the planning phase.
Working with teens in school settings is helpful because attendance at the peer education program is almost assured if it is part of the school curriculum. Richie and Getty (n.d.) have found that those students who attended AIDS peer education program were more likely than nonattendees were to engage in behaviors that were aimed at prevention of HIV infection. When all is said and done, working with teens in implementing peer education is both a challenging and rewarding experience.
Review questions for article:
Mahat, G. Scoloveno, M., DeLeon, T, & Frenkel, J. (2008). Preliminary Evidence of an Adolescent HIV/AIDS Peer Education Program. Journal of Pediatric Nursing, 23(5), p. 358-363.
1.) What percent of the total sample received the peer education program?
2.) What type of sampling method was utilized? Was it probability or non-probability sampling?
3.) The total knowledge score could range from 0 to 33. What level of measurement is the total knowledge score?
4.) Look at Table 1. What was the cumulative percent of students who were fourteen years old or younger?
5.) What was the mean age of the participants in the sample?
6.) Was there an equal number of male and female participants?
7.) Were the control and experimental groups similar in demographic make up?
8.) Was there a significant difference in the HIV/AIDS knowledge between adolescents’ boys and girls pre and post intervention?
9.) If a future large study reported that the educational interventions do result in a significant difference in the HIV/AIDS knowledge between adolescent boys and girls you would know that the results found in this study regarding gender differences in HIV/AIDS knowledge post intervention were an example of what type of error? What would be the most likely cause of this error?
10.) Comparing the confidence to engage in safe sex between boys and girls was done using what test? Why?
(N = 97)
Frequency
Percent
Age
13
6
6.2
14
89
91.8
15
2
2.0
Sex
Male
42
43.3
Female
55
56.7
Ethnicity
African American
31
32.0
Hispanic
27
27.8
Caucasian
26
26.8
Hispanic/African American
7
7.2
Asian
6
6.2
Sexually active
Yes
13.00
13.4
No
84.0
86.6
Age sexually active
10 years
1
11 years
2
12 years
3
13 years
4
14 years
3
Explanation / Answer
4)
cumulative percent =(cumulative frequency/total frequency)*100
=((89+6)/97)*100
=(95/97)*100
=97.93%
hence the cumulative percent of 14 years old is 97.3%.
5)Mean age of participants =((13*6)+(14*89)+(15*2))/(6+89+2)=13.9587
which is approximately 14.
6) The number of female(55) is greater than that of male(42).
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