Health Education Research, Vol. 14, No. 5, 675-683,
October 1999
© 1999 Oxford University Press
A school-based AIDS education programme for secondary school students in Nigeria: a review of effectiveness
Department of Preventive and Social Medicine, College of Medicine, University of Ibadan, PMB 5017 GPO, Ibadan, and
1 National Postgraduate Medical College of Nigeria, PMB 1049, Ebute-metta, Lagos, Nigeria
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Abstract |
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Nigerian secondary school students are becoming sexually active at an increasing earlier age. Sexually active students are at risk of contacting STDs, including HIV infection. As a result, health education initiatives to increase level of knowledge, influence attitudes and encourage safe sexual practices are being implemented in schools, but the effectiveness of these programmes have not been evaluated. In this study, the knowledge, attitude and sexual risk behaviors of 223 students who received a comprehensive health education intervention were compared with 217 controls. At post-test, intervention students exhibited greater knowledge about HIV/AIDS transmission and prevention (P < 0.05). Intervention students were less likely to feel AIDS is a white man's disease and were more likely to be tolerant of people living with the disease (P < 0.05). After the intervention, the mean number of reported sexual partners among the experimental students significantly decreased from 1.51 to 1.06, while it increased from 1.3 to 1.39 among the controls. Among the intervention students there was also an increase in consistent use of the condom and the use of the condom at last sexual intercourse. We conclude that students can benefit from specific education programmes that transmit important information necessary to prevent risky behavior, and improve knowledge and attitudes on HIV/AIDS.
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Introduction |
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This study was carried out in Ibadan South-east local government area (LGA) of Ibadan, which is one of the five LGAs within the city. This LGA covers the traditional or old part of the city (Brieger and Adeniyi, 1981
). Thus, students in the indigenous areas of city were studied; these are the urban poor who are more at risk as a result of ignorance, poverty and high prevalence of diseases. A base-line survey was conducted in January and February 1996, to assess the AIDS-related knowledge, attitudes and sexual behavior of senior secondary school students (students in the last 3 years of schooling) in four schools in the LGA. The survey showed that most of the students (83.3%) knew AIDS was transmitted sexually but the percentages aware of other transmission pathways were much lower. Attitudes were poor, as 90 (20.0%) felt AIDS did not constitute a medical problem in Nigeria, while 372 (82.7%) students admitted they would dislike having someone with AIDS near them. Students knowledge was (positively) associated with age and class (P < 0.05), and boys appeared to be slightly more knowledgeable than girls. As regards sexual behavior, first sexual experience among female and male respondents occurred at quite an early age, 15.82 years for males and 16.32 in females. About a third of the students, 159 (35.3%), had experienced sexual intercourse before, while 120 (26.7%) had had sex in the month preceding the survey. Of the 120 students, 34 (28.3%) [consisting of 23 (67.6%) males and 11 (32.4%) females] had multiple sexual partners. The mean number of lifetime partners was 1.76. Consistent condom use was reported in 22 (19.8%) students who were sexually active in the month preceding the survey. The main reasons given for non-use were reduction of sexual enjoyment, danger to health and having sexual intercourse only occasionally. The use of unreliable methods for prevention of STDs was common—methods such as selecting sexual partners carefully, taking drinks containing lemon and ingesting excess salt. Based on these results, a school-based health education programme was designed and implemented. Evaluation of the intervention was carried out after 6 months.
Materials and methods
The multi-stage sampling technique was used. The 11 mixed-sex public schools in the LGA were divided into two groups based on their geographical location. Two secondary schools that were located next door to each other were selected as the experimental schools from one of the groups, while the control schools were selected from the other group by simple balloting. From the senior classes 1, 2 and 3, two arms (branches) of each class which consisted of between 20 and 25 students were randomly selected from each class, and all the pupils in the selected arms participated in the study. Before the study commenced permission was obtained from the State Ministries of Education and Health, and later from the school authorities. The base-line survey was developed after discussions with other researchers working on adolescent sexuality, review of published literature and help from health education experts. In addition, the suggestions of secondary students were used. Key issues were framed into questions with the help of an expert in the Yoruba language and with the contributions of some students.
The self-administered questionnaire consisted of 50 questions. The questionnaire addressed the following issues (1) socio-demographic characteristics, (2) knowledge on the transmission and prevention of AIDS, (3) attitudes to the disease and individuals with the disease, (4) sexual practices including use of the condom, and (5) suggestions for the education programme, i.e. topics to be addressed. An end-line evaluation was carried out. Some of the questions were open-ended while others were closed. The Likert scale was used to assess attitudes. The questionnaire was pilot tested on 29 students in schools similar to the study schools, but in a different area of the city. After this some of the questions were reframed as appropriate. Base-line information (pre-test) was collected in January and February 1996, on 450 students, consisting of 233 intervention students and 217 controls.
Before the students completed the questionnaire, the purpose of the study was explained to them and they were encouraged to write only the truth. To ensure confidentiality, no names were recorded. They were also assured that their responses would not be seen by their friends or by members of staff. The questionnaire was in the native language, Yoruba. The questionnaires were completed in the school hall or the school library, which were large and spacious rooms, hence no one could see the responses of the others.
Based on the base-line findings, areas of misconceptions, knowledge gaps and students' sexual activity were noted. A comprehensive health education curriculum was developed in conjunction with health education experts from the Sub-department of Health Promotion and Education of the Department of Preventive and Social Medicine. Also the contributions of non-governmental organizations who work in this area were sought and they provided some of the educational materials for the intervention.
Six weekly AIDs/HIV education sessions were implemented in the two experimental schools by the main investigator (a community physician) with the assistance of two trained teachers. Each session lasted between 2 and 6 h. The programme included the use of health education tools such as lectures, film shows, role-plays, stories, songs, debates and essays. A demonstration on the proper use of condoms was done after receiving approval from the school principal who complained about the intense sexual activity of the students and the occurrence of unwanted pregnancies. To address the different needs of the students and enable them to feel at ease to ask questions, the education programme was done separately for each of the senior classes 1, 2 and 3. All the students participated in the intervention programme.
Evaluation was carried out 6 months later by the researchers. The questionnaire used at base-line was adjusted as necessary and was used again at end-line. Furthermore, analysis of the results was done by an independent observer, a statistician. Seventeen students (3.8%) were lost to follow-up, therefore 223 experimental students and 210 controls filled the questionnaire.
Base-line and end-line data were analyzed on a micro-computer, using EPI-INFO and SYS-STAT statistical software packages. The frequency distribution of the variables, 
2 and analysis of variance were done.
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Results |
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Base-line comparisons
At base-line the control and experimental group were matched.
Demographic aspects
There was no statistical difference (P > 0.05) in the mean age, sex, class, religion and parental background of the students in the experimental and control groups. For example, the mean age was 17.6 and 17.8 years in the experimental and control groups, respectively; In the experimental classes females were 53.2%, while in the controls they were 57.1%. About a third were from each of the senior classes in both the experimental and control schools; also, 97.9 and 99.5%, respectively, were Yorubas, while 55.4 and 51.2% were Moslems. Seventy-six (32.6%) mothers of students in the experimental group had no education, whereas 66 (30.4%) mothers in the control group had none.
Knowledge and attitudinal aspects
Also, there was no significant difference (P > 0.05) in the different methods of transmission and prevention between the two groups (Figures 1 and 2). For example, 192 (82.4%) and 183 (84.3%) of students in the experimental and control groups, respectively, knew AIDS was transmitted through indiscriminate sexual intercourse. Attitude to the disease and people with the disease were also not significantly different (P > 0.05) in both groups. Eighty-one (34.8%) of the intervention students felt AIDS was a `white man's disease', while 63 (29.0%) of the controls had this attitude. Also, 39 (16.7%) and 39 (18.0%) would dislike having someone with AIDS near them. Students' knowledge and attitude scores are shown in Tables I and II.
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Sexual behavior
There was no significant difference in the proportion of students who were sexually active. About a third, i.e. 76 (32.6%) and 83 (38.7%) of the experimental and control students, respectively, had ever experienced sexual intercourse (Table III
). Similarly, the mean age at first intercourse was 16.2 and 15.9 years, respectively. There was also no significant difference in the use of condom at last sexual intercourse [40 (52.6%) and 36 (42.8%)], consistent use of the condom [12 (15.8%) and 11 (13.1%0 and past medical history of STD [3 (3.9%) and 2 (2.4%)], respectively (P > 0.05) (Table IV).
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End-line comparisons
Knowledge
At end-line, there was a statistically significant difference in knowledge on the transmission and prevention of AIDS, as shown in Figures 3 and 4
, respectively. Knowledge of indiscriminate sex, transfusion with infected blood, the use of unsterile instruments, sharing of needles and syringes, and transplacental transmission as methods of HIV transmission were all significantly higher (P < 0.05) among the experimental students than the control group. For instance, 211 (94.6%) intervention students knew that AIDS could be transmitted from a pregnant mother to her unborn baby, while only 90 (42.8%) of the controls knew this. Concerning the prevention of AIDS (Figure 4), knowledge about avoidance of indiscriminate sexual intercourse, use of condoms, sterilizing instruments, avoiding sharing of needles, brushes and combs, and having a faithful partner were all significantly higher (P < 0.05) among intervention students. The majority [205 (91.9%)] of the students in the experimental group knew that an individual may be infected with HIV and still look healthy, compared with only 87 (41.4%) among the controls.
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Attitudes
As with knowledge, there were also differences in the attitudes of the students. For example, 207 (92.8%) of the intervention students felt AIDS was present in Nigeria and constituted a problem, while 119 (56.7%) controls had this attitude. Similarly, 177 (79.4%) and 30 (14.3%) of both groups, respectively, could touch and care for someone with AIDS. These responses were scored and were statistically significant (P < 0.05), indicating that the intervention students had better attitudes.
Sexual behavior
Table III
shows there was a significant difference (P < 0.05) between the experimental and control group in the proportions of students who were sexually active. Also, the mean number of sexual partners was 1.060 and 1.312, respectively (P < 0.05). A higher proportion of students in the experimental group [29 (53.7%)] than in the control group [34 (42.5%)] reported that they used the condom during their last sexual exposure; similarly, 11 (20.4%) of the experimental students reported consistent use of the condom, while 10 (12.5%) controls did. Recent history of STD was one (1.8%) and two (2.5%), respectively. Although these differences were not statistically significant (P > 0.05), intervention students had safer sexual practices (Table IV).
Education programme
The students' opinion of the education programme is shown in Table V. Most of the intervention students [210 (94.2%)] liked the education programme. The main lesson learnt from the education programme was said to be the health benefit of sexual abstinence, this was by 102 (45.7%) students. This was followed by knowledge of the different methods of preventing infection with the HIV by 45 (20.2%) and the proper use of the condom by 37 (16.6%). As regards their reservation about the programme, 202 (90.8%) had none, while nine (4.0%) felt uncomfortable with the fact that physical contact can be maintained with people living with AIDS and 12 (5.4%) students felt it was unnecessary to educate students about the proper use of condoms. Table VI shows the students suggestions for subsequent programmes; 43 (19.4%) wanted the government to be involved in the programme to ensure its sustainability, while others [11 (4.9%)] suggested that parents should also be allowed to participate in the programme to reinforce the key messages, and some wanted medical examinations and tests to be carried out [11 (4.9%)].
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Discussion |
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The community control of any disease which can be prevented by changing behavior entails, amongst others, making the community understand that a significant problem exists. This could be done by increasing their awareness and knowledge on the disease as a first step to a change in their behavior (WHO/Family and Reproductive Health, 1996). At base-line, there was no significant difference in the socio-demographic characteristics, knowledge, attitudes and sexual practices of students in the experimental and control groups. This suggested that the students had the same background and perhaps similar exposure to information on AIDS.
Following the education programme, knowledge on modes of transmission, methods of prevention and the latent period of AIDS improved, as did attitudes to the disease and individuals with the disease. The only question on `attitudes' which was not significantly different among both groups was: `fear of AIDS and invulnerability to AIDS', although the intervention students were found to have better attitudes.
Comparison of responses between base-line (Figures 1 and 2) and end-line (Figures 3 and 4) in the experimental group also shows a remarkable improvement, while in the control group there were almost no improvements in responses. These improvements are attributed to the education programme. Similar improvements were also found by other authors (Farley et al., 1991; DuRant et al., 1992; Main et al., 1994). Although Newman et al. (Newman et al., 1993) reported that significant learning could also occur from the administration of the questionnaire alone to controls and that testing alone could generate questions and discussions among the control group, and thereby prompt them to seek information on HIV and AIDS, this did not happen in this study.
The education programme succeeded in improving students' sexual practices. This was especially so for some behaviors such as the frequency of sexual intercourse and the mean number of sexual partners. Although the proportion of students who engaged in sexual intercourse in the month preceding the post-test survey decreased between base-line and post-test, a greater reduction was observed among the experimental students than the controls. Only modest improvements were recorded in condom use at last sexual intercourse and consistent condom use, suggesting that this behavior needs to be learned, and may require time and motivation. Motivation may be by reducing cost or giving away free condom.
The education was unique in that the whole school was interested and involved. The principal and teachers participated in some of the sessions. They were also involved in reviewing the essay and in the debates. This was done during the literary and debating periods off the school period. It was a new experience to most of the students; the role-plays and songs composed are still sung by the students. Although the intervention was for 1 month, the researchers' interaction in the school was for much longer. The investigators were available to refer students and teachers with reproductive health problems to the appropriate clinics. This was done in a sympathetic and in a non-jugdemental manner.
The opinion of the students on the education programme was sought for two reasons: (1) to evaluate the programme and (2) to identify how subsequent programmes can be improved upon. Most of the students were happy to have an AIDS education programme in their school. This may be because the sessions were interesting and active participation was encouraged. Different methods were employed to improve students' knowledge and practices of AIDS. Also, it was the first time they would be addressed on a health issue or by a health care provider in the school and it was a welcome addition to the normal school routine. The use of condoms was said to be one of the main lessons learnt by some of the students, suggesting that some students were ignorant about condom use prior to the education programme. However, a few students felt it was wrong to educate students on how to use condoms, because it might encourage indiscriminate sexual intercourse and the desire to engage in sexual experimentation. The reason for this fear was stated to be removal of the fear of unwanted pregnancy and contacting STDs.
The suggestions of the students reflected that they found the education programme beneficial, and were concerned about how it could be sustained and extended to more schools. The need to train people living with HIV/AIDS to speak to the public on AIDS is highlighted, as some students refused to be convinced that the disease existed unless they saw an infected person. This is in addition to the use of other approaches such as peer educators, trained teachers, adolescent role models and religious leaders who would be equipped with the skills to enable them to carry out the education programmes. Health care workers at local government level should be trained to carry education on AIDS to students and other high-risk groups. This is presently being done mainly by the tertiary health institutions, as was the case in this study. The assistance of governmental and non-governmental agencies will be required.
The AIDS education programme was able to improve knowledge and attitudes considerably; it should therefore be extended to more schools to multiply its effect. It provides a good opportunity to equip adolescents with factual information on HIV/AIDS. This is important as young people often have limited access to counselling and advice, STD clinics, and family planning services which could serve as sources of information about AIDS (Appropriate Health Resources and Technology Action Group-AIDS Action, 1994a,b). Also, it has the advantage that a large number of adolescents and youths attend school or are in contact with those who do (WHO/UNESCO, 1992). Thus, schools should play a significant role in preventing HIV infection, adopting safer sex practices or abstaining from sexual intercourse (Jones and Bunde-Binusite, 1993).
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Acknowledgments |
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We are grateful to Professor J. D. Adeniyi, Professor A. B. O. O. Oyediran and Dr A. O. Fawole for their useful comments, and Mrs. F. Osunsola for her secretarial services.
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References |
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Appropriate Health Resources and Technology Action Group-AIDS Action (1994a) Young people first. AIDS Action, 25, 1–8.
Appropriate Health Resources and Technology Action Group-AIDS Action (1994b) All about STDs. AIDS Action, 26, 3.
Brieger, W. R. and Adeniyi, J. D. (1981) Urban community health education in Africa. International Quarterly of Community health Education, 2, 109–121.
DuRant, R. H., Ashworth, C. S., Newman, C. L., McGill, L., Rabun, C. and Baranowski, T. (1992) AIDS/HIV knowledge level and perceived chance of having HIV among rural adolescents. Journal of School Health, 13, 499–505.
Farley, T. A, Pomputius, P. F., Sabella, W., Helgerson, S. D. and Hadler, J. L. (1991) Evaluation of a school-based education on AIDS knowledge and attitudes. Connecticut Medicine, 55, 15–18.[Medline]
Jones, J. and Bunde-Binuste, A. (1993) Strengthening the role of schools in the prevention of HIV infections, sexually transmitted diseases and other important health problems. International Journal of Health Education, 3, 22–25.
Main, D. S., Iverson, D. C., McGlion, J., Banpach, S. W., Collins, J. L. and Kolbe, L. J. (1994) Preventing HIV infection among adolescents: evaluation of a school based education programme. Preventive Medicine, 4, 409–417.
Newman, C., Du Rant, R. H., Ashworth, C. S. and Gaillard, G. (1993) An evaluation of a school based AIDS/HIV education programme for young adolescents. AIDS Education Preventive, 4, 327–339.
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WHO/Family and Reproductive Health (1996) Improving reproductive health in Africa. Safe Motherhood, 3, 4.
Received on January 2, 1998; accepted on January 18, 1999
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