FULL TEXT ARTICLE Preliminary Evidence of an Adolescent HIV/AIDS Peer Education Program RSS Download PDF • Ganga Mahat EdD, RNBC • , Mary Ann Scoloveno EdD, PNP • , Tara De Leon BS, RN • and Jessica FrenkelBS, RN Journal of Pediatric Nursing, 2008-10-01, Volume 23, Issue 5, Pages 358-363, Copyright © 2008 Elsevier Inc. Close reading mode 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. 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 ninthgrade 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 wascorrect (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. 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 ninthgrade 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 wascorrect (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. 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