HIV Peer Education: Relationships Between Adolescents’ HIV/AIDS Knowledge and Self-Efficacy

Abstract

School-based programs have been found to be effective in limiting sexual risk behaviors among adolescents. A peer-led educational program is one of the school-based approaches used to educate and empower adolescents toward healthy behaviors. The purposes of this study were to determine the effectiveness of a peer education program on improving adolescents’ HIV/AIDS knowledge and self-efficacy for limiting sexual risk behaviors and also to determine the influence of self-efficacy on adolescents’ HIV knowledge. A quasi-experimental design was used to evaluate the peer education program. The results of the study demonstrated that HIV knowledge and self-efficacy improved significantly postintervention. Since children spend a considerable time in school, more school-based programs need to be developed to promote information on risk behaviors and prevention.

KEYWORDS:

• adolescents
• HIV/AIDS
• knowledge
• peer education
• self-efficacy

INTRODUCTION

HIV/AIDS is a growing problem among all age groups. From 2004 to 2007, the estimated HIV/AIDS cases remained stable among persons aged 13 to 14 years but increased among ages 15 and above (Centers for Disease Control and Prevention [CDC], 2009). The risk for HIV is especially notable for youth of minority races and ethnicities. African Americans are disproportionately affected by HIV infections, accounting for 55% of all HIV infections reported among persons aged 13 to 24 (CDC, 2005). Further, 47% of high school students have had sexual intercourse and 7.4% of them reported their first sexual intercourse before the age of 13 (CDC, 2008). The purpose of this study was to determine the effectiveness of a peer education program in improving urban adolescents’ HIV/AIDS knowledge and self-efficacy for limiting sexual risk behaviors. A relationship between self-efficacy and HIV knowledge was also explored.

SIGNIFICANCE OF THE STUDY

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). Therefore, it is imperative that prevention programs targeted toward adolescents, especially those from minority groups, are developed and implemented to achieve this goal. Schools play an important role in providing HIV/AIDS information for a large number of receptive young people. School-based peer education has been used effectively in many areas, including nutrition education, substance use, violence prevention, and other risk areas.

Programs to prevent risk behaviors in adolescents are needed to add to the evidence of the effectiveness of peer education programs. Specifically, there is a need to evaluate school-based peer education programs that articulate culturally specific knowledge to adolescents, and to determine the effects of influential variables, such as self-efficacy in the context of adolescent HIV knowledge.

The findings of this research study will add to the field of HIV prevention and social service practice and policy. It will also provide information about the efficacy of a specific adolescent peer HIV education program and will be helpful in disseminating findings for continued exchange of information and resources on HIV/AIDS peer education. Since one of the important responsibilities of schools is to teach students how to stay healthy by avoiding risk behaviors that could result in HIV infection or transmitting infection to others, findings of this study will assist school teachers, social service providers, policy-makers, and health care providers.

THEORETICAL FRAMEWORK

Social learning theory asserts that people develop self-efficacy through direct experience and observation of role models (Bandura, 1986). Peer education is an example of a behavioral change strategy based on this theory. According to Bandura, self-efficacy is defined as a belief that one can perform a specific behavior (1978, p. 240). Self-efficacy is not concerned with the skills one has but with judgments of what one can do with whatever skills one possesses (Bandura, 1986, p. 391). A person with strong self-efficacy beliefs will expect to succeed and will apply greater efforts to master the task than will persons with weaker self-efficacy beliefs (Bandura, 1978). Social learning theory further asserts that youth can become motivated to adopt a preventive behavior after developing positive attitudes regarding preventive behaviors and negative attitudes toward risky behaviors (Karnell, Cupp, Zimmerman, Feist-Price, & Bennie, 2006). Self-efficacy has been found to be an important component in HIV risk reduction (Bandura, 1997).

As a strategy, peer education programs train adolescents to become peer leaders by providing information on adolescent HIV/AIDS. In turn, these peer leaders will communicate this information to their peers and attempt to modify their knowledge, attitudes, and behaviors.

REVIEW OF LITERATURE

HIV/AIDS Peer Education Program

Peer education programs have been identified as an effective approach to educate and empower adolescents, as they feel comfortable receiving information and relating to information provided by people of the same age group. Studies have shown that adolescents who believe their peers are using condoms are more than twice as likely to use condoms as are teens who do not believe their peers use condoms (DiClemente, 1991). In an early study, Slap, Plotkin, Khalid, Michelman, and Forke (1991) found that prior to the peer intervention, 44% of sexually active participants reported not using condoms compared to 33% after the peer intervention. Further, reports of sexual intercourse in the previous 2 weeks fell from 21% at baseline to 14% at follow-up. In another study, after a peer education program, there were increased reports of condom use at most recent intercourse (up from 45% to 55%) and fewer reports of unprotected sex (down from 15% to 4%) among sexually active students (O'Hara, Mesnick, Fichtner, & Parris, 1996).

Research 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; Smith, Dane, Archer, Devereaux, & Kirby, 2000), frequency of intercourse (Jemmott, Jemmott, & Fong, 1998), more conservative sexual norms (Mellanby, Reese, & Tripp, 2000), self-efficacy to refuse sex and delay sexual behaviors (Aarons et al., 2000), and volunteer activities to help other youth avoid unprotected sex (Smith et al., 2000).

Studies have compared peer-led, adult-led, and teacher-led HIV educational programs. Peer-led educators produced greater improvement in HIV/AIDS knowledge (Borgia, Marinacci, Schifano, & Perucci, 2005; Mahat, Scoloveno, DeLeon, & Frankel, 2008), positive attitude changes and higher self-efficacy (Caron et al., 2004), and less sexual intercourse among girls (Stephenson et al., 2004). Another study reported that both the peer-led groups and community health nurse-led groups (CHN) had significantly higher scores than the control group in HIV/AIDS prevention knowledge (p = .0001). The peer-led group had significantly higher knowledge scores than did students in the CHN-led group (p = .042) (Dunn, Ross, Caines, & Howorth, 1998).

Siegel, Aten, and Enaharo (2001) studied the long-term effect of the RAPP (Rochester AIDS Prevention Project for Youth) on HIV knowledge, self-efficacy regarding sexual matters, behavior intention, and self-reported behaviors among middle school and high school students. Long-term knowledge (middle school females, p < .001; and middle school males, p < .01) and sexual self-efficacy (middle school females, p < .05; and high school females, p < .01) scores were higher among the intervention groups. Intention to remain safe regarding sexual behavior was also greater among intervention groups in middle school but not in high school.

Self-Efficacy

Several researchers have studied the relationships between self-efficacy and likelihood to engage in healthy behaviors such as weight reduction, contraceptive use, intention to refrain from sexual activity, less smoking, and less substance use (Brafford & Beck, 1991; DiClemente, 1981; Goh, Primavera, & Bartalini, 1996; Lawrence & Rubinson, 1986; Ozer & Bandura, 1990). Research studies reviewed by O'Leary (1985) reveal that perceived level and strength of self-efficacy are associated with an individual's likelihood to change a given unhealthy behavior, such as smoking. Self-efficacy has also been correlated with weight reduction, substance use prevention, contraceptive use, and intention to refrain from sexual activity (Brafford & Beck, 1991; Goh et al., 1996; Ozer & Bandura, 1990).

Faryna and Morales (2000) examined multiethnic adolescents’ self-efficacy and knowledge, attitudes, and beliefs regarding HIV in relation to multiple risk categories of sexual behavior and substance use involved in HIV transmission. African American female adolescent participants randomized to the intervention reported using condoms more consistently, engaged in a greater proportion of condom-protected intercourse, and had higher HIV knowledge, favorable attitudes toward condoms, and higher condom use self-efficacy (Sales, Lang, Hardin, DiClemente, & Wingood, 2010).

DiClemente, Wingood, Rose, Sales, and Crosby (2010) evaluated an intervention to reduce HIV/STD-associated behaviors and enhance psychosocial mediators for pregnant African American adolescents. The intervention group received two 4-hour group sessions enhancing self-concept and self-worth, HIV/STD prevention skills, and safer sex practices. Participants in the comparison condition received a 2-hour session on healthy nutrition. Intervention participants reported greater condom use at last intercourse, consistent condom use, higher sexual communication frequency, enhanced ethnic pride, and higher self-efficacy to refuse risky sex and were less likely to fear abandonment as a result of negotiating safer sex.

In summary, the literature supports the role of self-efficacy in reducing risk behaviors in adolescents. Intervention studies have shown that there is improvement in self-efficacy communication and condom use.

RESEARCH QUESTIONS

1. How effective is the TAP program in improving HIV knowledge and self-efficacy for limiting HIV risk behavior?

2. What is the relationship between high school adolescents’ HIV knowledge and self-efficacy for limiting HIV risk behavior?

3. Is there a difference in adolescents’ HIV/AIDS knowledge and self-efficacy by gender?

METHODS

Design and Sample

This intervention study used a modified format of the established program “Teens for AIDS Prevention” (TAP), which consisted of six 45-minute sessions given by peer educators to adolescents in health classes. The main goal of the TAP program was to promote positive changes in risk behaviors in order to prevent infection with HIV and other sexually transmitted diseases. The peer educators were adolescents in the high school who demonstrated willingness and motivation toward the program. They received training by the researchers, nursing students, and their teacher. Peer educators, based on a needs assessment of the target group, chose the modified program from a 10-session program. The modified TAP program included HIV/AIDS information, exercises on value clarification, and communication skill building through group discussion, videos, role-play and games, etc.

A quasi-experimental design was used to evaluate the peer education program. A convenience sample of 143 ninth-grade, ethnically diverse students in an urban high school in Newark, New Jersey, participated at the baseline. The final sample consisted of 106 (74%) of preintervention students who were linked at postintervention with ID codes. Thirty-four students did not complete the postintervention questionnaires due to absence and other school activities. All ninth-grade students in health classes were included in the study.

Procedure

After obtaining permission from the institutional review board and the participating school, investigators met with students and explained to them the purpose of the study. Students were told that their participation was voluntary and 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. Participants completed the questionnaire prior to the implementation of the peer education program and 3 months after completion of the program. Students received the peer education program once a week for 6 weeks during their health education class. No compensation was provided to participants.

Instruments

The questionnaire had three main sections. The first section was used to collect demographic information such as age, ethnic background, etc. The second section included HIV knowledge questions adapted from the Youth Risk Behavior Surveillance System (YRBSS) developed by the U.S. Department of Health and Human Services, CDC (CDC, 2002a; CDC, 2002b). These questions focused on HIV prevention and transmission. The third section focused on self-efficacy.

Each item in the HIV/AIDS 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, correct (1) and incorrect (0) format was used. 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 was the students’ knowledge.

The U.S. 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 Cronbach alpha reliability of this study was .82.

The self-efficacy instrument consisting of nine items is used to determine how sure the adolescents are about talking about safe sex with partners, buying condoms in drug stores, etc. Response options range from very sure (4) to not sure at all (0). The total score ranged from 0 to 36; the higher the total score, the greater was the self-efficacy. The internal consistency of this scale was .77 (Smith, McGraw, Costa, & McKinlay, 1996). The Cronbach alpha of this study was .81.

Data Analysis

The data were analyzed using SPSS version 16.0. Demographic information and HIV/AIDS knowledge were analyzed using descriptive statistics. Paired t-tests were used to determine differences in preintervention HIV knowledge and self-efficacy scores and postintervention scores. Coefficient correlations were used to show the relationships among the variables. The t-tests were used to compare adolescents’ HIV/AIDS knowledge and self-efficacy scores by gender. One-way ANOVA was used to compare HIV/knowledge and self-efficacy by ethnicity. Further, the preintervention was dichotomized into those who had prior HIV information and those without prior information. Pearson's chi square was used to evaluate the prior HIV information by gender.

RESULTS

Demographic Information

The demographic information at the baseline is presented in Table 1. The participants’ age ranged from 13 to 15 years (mean = 14.1) and the majority of them were Hispanic or African American. Seventy-two of them were Christian and others were Hindu, Muslim, or Buddhist. Nineteen percent of them did not report their religion. Very few subjects reported that they knew someone with HIV (18.6%). The main sources of HIV information reported were school/teachers (27%) and the Internet (23%). Other sources were parent/family, media, and physicians. Twenty-eight percent did not report the main source of HIV information.

TABLE 1 Frequency and Percentages of Demographic Information (N = 106)

	Frequency	Percentage
Age
13 years	4	3.6
14 years	88	82.6
15 years	14	13.8
Gender
Male	46	43.4
Female	60	56.6
Ethnicity
Hispanic	38	35.9
African American	37	35.3
Caucasian	15	14.4
Asian	4	3.6
Others	12	10.8
Parental education
Elementary	22	20.4
High School	43	40.1
College	41	39.5
Know someone with HIV?
Yes	20	18.6
No	86	81.4

In the preintervention group (n = 143), students were dichotomized into two groups, those with and those without prior HIV information. Pearson chi square was used to evaluate differences between female and male students’ prior information. Male students had significantly more HIV prior information than did female students (χ² = 4.66, df = 1, p = .02). However, female students knew more people with HIV than did their male counterparts (χ² = 6.31, df = 2, p = .04).

HIV/AIDS Knowledge

The mean of the total HIV/AIDS knowledge score for the final sample (n = 106) at the baseline was 20.8 (SD = 5.1). When the sample was stratified into high (scores of 25 to 33), moderate (scores of 16 to 24), and low (scores below 15) knowledge groups, the data showed that the majority of students had moderate knowledge (n = 69, 65.3%) and that some had high (n = 25, 23.4%) and some had low (n = 12, 11.3%) knowledge scores. Table 2 shows the percentage of correct responses to HIV/AIDS knowledge questions by subcategories at baseline and postintervention. The mean score of total HIV/AIDS knowledge after the peer education implementation was 25.6 (SD = 3.5), The paired t-test showed that HIV/AIDS knowledge improved significantly after the peer education program (t = 12.8, df = 105, p < .001). After the intervention, 76 students (71.4%) had a high level of knowledge and 30 (28.6%) had a moderate level of knowledge. In the preintervention data, one-way ANOVA demonstrated that African American students had slightly higher HIV knowledge mean scores than did Hispanic and Caucasian students; however, it was not significant.

TABLE 2 Percentage of Correct Responses at the Baseline and after the Peer Education Program (N = 106)

HIV/AID knowledge items	Baseline	After peer education
Modes of transmission
Sexual intercourse without a condom	97	97.2
Sharing needles to take drugs	85.6	99
Infected pregnant women to unborn baby	73.1	82.9
Being blood brothers/sisters	70.1	87.6
Sharing tattoo needle	61.1	91.4
Having oral sex	57.5	83.8
Having sex with a drug user who uses needle	53.9	87.6
Having anal intercourse	47.9	82.9
Sharing razor with someone who is HIV positive	44.3	60
Sharing crack pipe with person having cracked lips	42.5	72.4
Misconception about transmission
Being in the same classroom with person	88.6	98.1
Being married prevents from getting HIV/AIDS	82	89.5
Gets HIV from having a blood test	79	87.6
Washing clothes with clothes of HIV person	66.5	85.7
Using public toilet seat	59.3	79
Mosquito bites	39.5	54.3
Gets HIV by donating blood	32.3	38.1
Prevention and perceived risk
Safe to pick discarded needle	81.4	93.3
Lower chances by staying virgin	76.6	93.3
Lower chances by taking birth control pills	64.1	91.4
Lower chances by using latex condom	60.5	77.1
Lower chances by wearing surgical gloves	56.3	74.3
Use oil based lubricants with latex condom	49.7	64.8
Use lambskin condom	20.4	46.7
General knowledge
Have HIV for many years without knowing	88.6	90.5
All gay men have HIV	84.4	93.3
Only gay men get HIV	78.4	92.4
HIV infection has cure	74.9	88.6
HIV attacks immune system	74.3	85.7
Can tell that a person has HIV by just looking	73.1	91.4
HIV/AIDS person can live ten years or more	57.5	80
Vaccine can stop from getting HIV	52.7	69.5
HIV is easier to catch than other STIs	15.6	13.3

SELF-EFFICACY

The mean of the self-efficacy for limiting HIV risk behavior score also improved after the peer education program (31.7, SD = 4.4) compared to the preintervention mean (29.4, SD = 5.8). The paired t-test showed self-efficacy scores improved significantly after the peer education program (t = 5.5, df = 105, p < .001). One-way ANOVA revealed African American students had significantly greater self-efficacy than Hispanic and Caucasian students [F(2,142) = 4.13, p = .018].

RELATIONSHIP BETWEEN HIV/AIDS KNOWLEDGE AND SELF-EFFICACY

The total HIV knowledge was significantly correlated with total self-efficacy at baseline (r = .35, p < .001). After the intervention, HIV knowledge was also positively related to self-efficacy (r = .22, p = .03).

HIV/AIDS KNOWLEDGE AND SELF-EFFICACY BY GENDER

The mean of the total HIV knowledge at the baseline was 20.5 (SD = 5.4) for males and 21.0 (SD = 4.9) for females. Similarly, the mean of the total HIV knowledge score after the intervention was 25.3 (SD = 3.4) for males and 25.9 (SD = 3.4) for females. Although knowledge improved for both males and females after the intervention, there were no significant differences based on gender.

At the baseline, the mean of the self-efficacy scores was 28.0 for males (SD = 6.6) and 30.5 for females (SD = 4.9). After the peer education program, the mean of the self-efficacy scores was 31.0 for males (SD = 4.1) and 32.2 for females (SD = 4.6). There was no significant difference in self-efficacy scores before or after intervention based on gender.

DISCUSSION

The TAP program was effective in improving adolescents’ HIV/AIDS knowledge and self-efficacy for limiting risky behavior. The majority of students had a moderate level of knowledge. Most students were aware that HIV is transmitted via sexual intercourse, sharing needles to take drugs, and through an HIV-infected mother to her unborn baby. However, many of them did not perceive that HIV is transmitted via anal and oral intercourse and sharing crack pipes and razors. Many students also had misconceptions about the transmission of HIV. More than 60% reported that HIV is transmitted by mosquito bites and by donating blood. In the subcategory, prevention and perceived risk, many students knew that it is unsafe to pick up discarded needles but many students reported that wearing lambskin condoms and using oil-based lubricants with a latex condom prevented HIV. Although 76.6% of the adolescents agreed that being sexually abstinent would prevent them from getting HIV, 23.3% lacked this knowledge. In the general knowledge subcategory, more than 70% of students’ responses were correct. Students lacked knowledge only in few items. For example, they perceived that vaccines can prevent HIV and that HIV is easier to catch than other sexually transmitted infections.

The findings of this study showed that students’ HIV/AIDS knowledge improved significantly after the peer education program, which was consistent with other findings (Mahat et al., 2008; O'Hara et al., 1996; Siegel et al., 2001). Self-efficacy for limiting HIV risk behaviors also improved significantly after the intervention, indicating that the higher the self-efficacy, the higher was the HIV/AIDS knowledge among adolescents. Previous studies have also shown higher knowledge and self-efficacy scores after interventions (DiClemente et al., 2010; Ross, Timpson, Williams, & Bowen, 2007). However, the findings of one study showed that self-efficacy did not improve after the intervention (Morrison et al., 2007). This contradictory finding suggests the need for further study with larger sample sizes and different populations.

In the present study, the total HIV/AIDS knowledge score was significantly correlated with the total self-efficacy scores both at baseline and postintervention. The results also showed that females’ mean scores on the self-efficacy scale were higher than those of the males at baseline and postintervention. However, the differences were not significant. A previous study showed that girls scored higher than boys on the AIDS risk self-efficacy scale for sexual activity but that the differences were not significant (Faryna & Morales, 2000). More research needs to be done comparing adolescent girls and boys on self-efficacy. Relative to ethnicity, African American students had significantly greater self-efficacy than Hispanic and Caucasian students. This was an interesting finding that needs further exploration.

This study adds to the body of literature that attests to the effectiveness of peer-led education in improving adolescents’ HIV/AIDS knowledge and self-efficacy. A limitation of this study is some of the findings are based on the self-reported data completed by adolescents and it is possible that adolescents did not accurately report. However, to minimize this limitation, the instruments were coded and confidentiality was assured. Other limitations of the study were that a convenience sample, rather than a randomized sample, was used, and the subjects were from only one urban school. Furthermore, the sample size was small, the same instrument was used before and after the intervention, and there was a lack of long-term follow-up evaluation.

IMPLICATIONS OF THE STUDY

School personnel, health educators, social service personnel, and policy-makers may play an important role in preventing the spread of HIV by educating and empowering students through peer-led education programs. The TAP peer education program was found to be effective in improving adolescents’ HIV/AIDS knowledge and behavior. Properly selected and trained peer leaders can assist schools in their efforts to help children and adolescents stay healthy and avoid risk behaviors. Since it is more efficient and cost-effective to help children develop positive health practices before they develop unhealthy health practices, it may be worthwhile to implement a developmentally appropriate peer education program at an earlier age. Policy-makers need to consider findings of HIV peer education in implementing community-based and school-based programs.

Despite some of the limitations of the research, a number of implications for clinical practice can be made. Results of the study showed that adolescents are very receptive to information from their peers regarding HIV knowledge, transmission, and risk behaviors. Perhaps one of the most salient findings is that HIV peer education programs for adolescents increases self-efficacy. Future interventions should incorporate this finding when designing and implementing risk-prevention programs for ethnically diverse youth. Congruent with other studies, school-based peer-education programs are effective and should be considered by clinicians and social policy-makers. Schools need to be vigilant about new information and evidence based practices related to HIV/AIDS prevention in the development of programs and policies that will promote safer sexual health practices among children and adolescents.

Since the peer education program described in this study only assessed the short-term effects of the TAP program, a prospective study is needed to determine the sustainability of the results. The study should be done with diverse groups in a variety of settings. A larger sample size will help in exploring the theoretical relationship of self-efficacy on adolescent HIV knowledge and risk. Other variables may also contribute to the effectiveness of HIV peer education programs.

CONCLUSION

The findings of this study demonstrated that the TAP peer education program was effective in increasing adolescent HIV knowledge. Adolescent knowledge increased from baseline to 3-month follow-up. Based on self-efficacy theory, individuals with strong self-efficacy will apply greater efforts to master tasks. Participants in the TAP peer education program demonstrated higher self-efficacy after the intervention. School-based programs have demonstrated success in promoting health and decreasing risk behaviors among adolescents. Furthermore, children spend considerable amount of time in school and they are more likely to change behaviors as a result of peer instruction provided in the school environment. Therefore, more attention should be given to educational policy decisions relative to school-based intervention programs.

The authors would like to thank Rutgers, The State University of New Jersey, College of Nursing, for partial funding.