Health Education Research Advance Access originally published online on June 15, 2004
Health Education Research 2004 19(6):730-738; doi:10.1093/her/cyg091
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Health Education Research Vol.19 no.6, © Oxford University Press 2004; All rights reserved
Evaluation of a school-based intervention for HIV/AIDS prevention among Belizean adolescents
1 School of Public Health, University of California, Los Angeles, CA 90095, USA
2 Correspondence to: J. J. Kinsler; E-mail: jkinsler{at}mednet.ucla.edu
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Abstract |
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The purpose of this study was to evaluate the impact of a cognitive-behavioral peer-facilitated school-based HIV/AIDS education program on knowledge, attitudes and behavior among primary and secondary students in Belize. Students (N = 150) were recruited from six schools in Belize City. A quasi-experimental research design was used to assess the impact of a 3-month intervention. Seventy-five students received the intervention and 75 students served as controls. The intervention was guided by constructs from the Theory of Reasoned Action and Social Cognitive Theory. At the follow-up assessment, the intervention group showed higher HIV knowledge, were more likely to report condom use, had more positive attitudes toward condoms and were more likely to report future intentions to use condoms than the students in the control group. Overall, the findings indicate that the intervention had a positive impact on participants. Given the increasing rate of HIV/AIDS in Belize, especially among adolescents, this study has important implications for the country of Belize.
The purpose of this study was to evaluate the impact of a cognitive-behavioral peer-facilitated school-based HIV/AIDS education program on knowledge, attitudes and behavior among primary and secondary students in Belize. Students (N = 150) were recruited from six schools in Belize City. A quasi-experimental research design was used to assess the impact of a 3-month intervention. Seventy-five students received the intervention and 75 students served as controls. The intervention was guided by constructs from the Theory of Reasoned Action and Social Cognitive Theory. At the follow-up assessment, the intervention group showed higher HIV knowledge, were more likely to report condom use, had more positive attitudes toward condoms and were more likely to report future intentions to use condoms than the students in the control group. Overall, the findings indicate that the intervention had a positive impact on participants. Given the increasing rate of HIV/AIDS in Belize, especially among adolescents, this study has important implications for the country of Belize.
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Introduction |
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There is a growing concern about AIDS among school-aged youth in Belize. As of 1999, the estimated HIV prevalence rate among teens and young adults (15–24) ranged from 1.75 to 2.59 per 1000 in males and 0.77 to 0.98 per 1000 in females (UNAIDS, 2001
). Approximately 30% of the individuals infected with HIV are between the ages of 15 and 24 (Belize Medical Statistics Office, 2000). Given the small population of Belize (235 000) and the large percentage of Belizeans under the age of 24 (64%), the continued increase of HIV/AIDS cases could have a devastating impact on the future of Belize's economy, health care system and society as a whole. Given that approximately 92% of youth attend primary schools in Belize City (ages 5–14) and 81% of youth attend secondary schools in Belize City (ages 15–17), schools in Belize may provide an important venue for HIV/AIDS risk reduction programs for youth [see (Kirby, 1992)]. Prior to this study, schools in Belize had not formally introduced HIV/AIDS education into their curriculum. Some high schools in Belize City teach courses on sex education or reproductive health, but these courses are offered only to those students majoring in science or engineering, the majority of which are males. Thus, the majority of females do not receive education on reproductive health issues, including HIV/AIDS. Youth in junior high school do not receive any sex-related education. Due to the increasing risk of HIV in the adolescent population of Belize, there is a need for HIV/AIDS and sex education and prevention efforts to be formally incorporated into the school curriculum for students in both primary and secondary schools.
Cognitive-behavioral school-based HIV/AIDS intervention studies have been conducted and evaluated in a number of countries, including the US (Newman et al., 1993; Main et al., 1994; Siegel et al., 1995; Kirby et al., 1997; Weeks et al., 1997; Basen-Enquist et al., 2001), Africa (Merson et al., 2000; Campbell and MacPhail, 2002; Kinsman et al., 2001) and Peru (Caceres et al., 1994). These intervention programs have led to an increase in HIV/AIDS-related knowledge (Caceres et al., 1994; Main et al., 1994; Siegel et al., 1995; Merson et al., 2000; Basen-Enquist et al., 2001), positive attitudes towards condoms (Caceres et al., 1994), self-efficacy for using condoms (Caceres et al., 1994; Basen-Enquist et al., 2001), intention to use condoms (Main et al., 1994), condom use (Merson et al., 2000), delaying the initiation of sexual intercourse (Kinsman et al., 2001), greater communication with parents on sex-related issues (Basen-Enquist et al., 2001) and more positive attitudes towards people with HIV/AIDS (Caceres et al., 1994; Siegel et al., 1995; Merson et al., 2000). The purpose of this study is to evaluate the impact of a cognitive-behavioral peer-facilitated school-based HIV/AIDS education program on knowledge, attitudes and behavior among primary and secondary students in Belize.
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Method |
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Recruitment of participants
Participants were Belizean adolescents (aged 13–17) recruited from six primary and secondary schools located in Belize City. In total, 150 youth were recruited for this study—75 youth from three schools for the intervention conditions and 75 youth from three different schools for the control conditions. Schools were chosen based on demographic characteristics of the students and location. A letter was sent to each of the schools seeking their participation and explaining the project. An orientation was held at each school expressing interest in the project. During the orientation, a summary of the intervention study was provided to prospective participants, and parental and adolescent consent forms were distributed. A total of 12 schools (60%) agreed to participate in the study. The schools that agreed to participate in the study were technical schools and schools run by Anglican or Methodist churches. All schools were located in Belize City. The remaining primary and secondary schools in Belize are under the control of the Catholic Church and were not willing to take part in this study. Thus, the participating schools may not be representative of all schools located in Belize City. Students taking part in the study received free T-shirts, hats, a daily planner, and pens and pencils with the ‘Peer Education Program of Belize’ logo.
Design and procedures
A quasi-experimental and pre-test–post-test research design was used to assess the impact of the HIV/AIDS educational intervention program. Participants were required to provide active parental consent prior to program enrollment. Adolescents providing consent participated in a 3-month intervention. Baseline surveys were administered to all program participants (intervention and control group) during week 1. This was followed by a series of seven weekly education sessions for students in the intervention group. One month after the last educational session, post-test questionnaires were administered to all program participants. Unique identifiers were assigned to each student by project staff to allow for matching of baseline and follow-up surveys. Approval for this study was obtained from the UCLA Institutional Review Board prior to initiation of program activities involving human subjects.
Intervention
The educational sessions for the intervention component of the HIV/AIDS education and prevention program were adapted from an educational intervention manual entitled Project Light (Center for HIV Identification, Prevention and Treatment Services, 1998) to meet the needs of the adolescent population in Belize, and were based on concepts from Social Cognitive Theory and Theory of Reasoned Action. Project Light uses a cognitive-behavioral approach to motivate the program participants to change their risk behaviors and adopt safer behaviors, and its efficacy has been evaluated by researchers on adolescents within the US [see (Rotheram-Borus et al., 1991)].
A meeting was held with an advisory board including government officials, teachers, church officials, health care workers, representatives of NGOs, peer educators and individuals personally affected by HIV/AIDS in Belize to review the Project Light curriculum. This group reviewed each chapter to determine the appropriateness of HIV/AIDS-related topics for Belizean youth. Certain topics were deemed inappropriate for Belizean youth (e.g. issues regarding homosexuality, oral sex, anal sex, the use of dental dams). The wording used to explain or describe certain topics was revised to meet the needs of Belizeans. After revision, the adapted version of Project Light was pilot tested on a group of 10 students from a school in Belize City that did not take part in the research project. The students who took part in the pilot were of similar sociodemographics to the teens in the participating schools. The pilot included a total of seven sessions with written feedback given to the peer educators following each session. These comments and suggestions were used to further modify the curriculum.
Twelve peer educators facilitated the HIV/AIDS education intervention program. The 12 peer educators were selected from an original group of 40 teens in Belize City who completed a 4-day (32 hour) HIV/AIDS training workshop to become certified as peer educators for Project Light. The original group of teens (age 14–19) were recruited from schools and youth organizations. The demographic characteristics of the peer educators, including age, ethnicity and socioeconomic status, were similar to the study population. In addition, the peer educators were recruited from the same schools in which the Project Light curriculum was implemented. The training workshops provided peer educators with essential facts on HIV/AIDS (e.g. modes of transmission and prevention, risk factors and important HIV/AIDS medical terminology); communication strategies (active listening, encouraging questions, visual and vocal dynamics, conversation openers); role-playing, skill-building and public speaking techniques; resisting peer pressure to engage in sex; and psychological and social aspects of HIV (stigma, homophobia, spiritual and ethical issues, gender bias). The workshop took place 6 months prior to the commencement of the intervention program. UCLA staff and the program coordinator in Belize selected the 12 peer educators based on their successful completion of the peer education training, demonstration of leadership skills, enthusiasm and their desire to be a peer leader. Three months prior to implementing the intervention, the 12 peer educators met on a biweekly basis with the program coordinator to review and practice the educational sessions of the intervention curriculum. The program coordinator observed and evaluated peer educators implementing the program protocols to teens similar to the target population through didactic and role-playing techniques.
The peer educators facilitated the HIV/AIDS education program in a classroom setting. A group of four peer educators (two males and two females) was assigned to each of the three schools. The intervention consisted of seven weekly 2-hour sessions. The sessions were written to address major components of the Theory of Reasoned Action and Social Cognitive Theory. The educational sessions of the intervention sought to increase HIV/AIDS-related knowledge. The interactive role-playing exercises, skills-building activities, peer role model testimonials and other strategies adapted to the specific concerns of the youth population in Belize sought to impact attitudes toward condoms (Theory of Reasoned Action), self-efficacy (Social Cognitive Theory), peer norms regarding sex and condoms (Theory of Reasoned Action), communication skills, intention to use condoms (Theory of Reasoned Action), and condom use. Peer educators provided basic information regarding HIV transmission and prevention, reviewed barriers and solutions, and assisted youth in resisting peer pressure to have sex. Weekly educational sessions were held in a classroom at each of the three schools during a designated time period established by school administrators. Peer educators were instructed to distribute a sign-in sheet at the beginning of each educational session. After each educational session, peer educators were responsible for completing Program Activity Records to document the date the session was delivered, number of students attending each session, length of time of each session and topics covered in each session. The program coordinator in Belize was responsible for collecting sign-in sheets and Program Activity Records from the peer educators on a weekly basis.
The control group received HIV/AIDS educational handbooks. These handbooks provided essential information about HIV/AIDS including medical definitions, modes of transmission, prevention and treatments. The handbook also included names and numbers of health centers/organizations that could be contacted to obtain additional information of HIV/AIDS.
To help reduce contamination, schools for the experimental condition were recruited from a different geographical region than schools for the control condition. While this strategy does not guarantee a complete absence of contamination between groups, it does reduce the likelihood that contamination did occur.
Survey
Sociodemographic data
Respondents were asked to report their gender, age, educational level, race/ethnicity, religion and family structure.
Knowledge
A 10-item scale was used to assess knowledge of transmission modes and prevention methods [see (Park et al., 2002)]. For example, respondents were asked if AIDS could be transmitted by ‘kissing a person who has AIDS’ or ‘sharing needles for intravenous drug use with someone who has AIDS’. The following response categories were used: 1 = very likely, 2 = somewhat likely, 3 = somewhat unlikely, 4 = very unlikely and 5 = impossible. The participants were also given the option of responding ‘don't know.’ Two of the scaled items were recoded to ensure that all items in the scale were coded in the same direction. The possible range of scores was 5–50. The scale was scored to obtain a mean value of knowledge. ‘Don't knows’ were treated as missing for the purpose of obtaining a mean knowledge score.
Sexual behavior
Respondents were asked to self-report if they had ever had sexual intercourse (yes/no). Several other items were used to assess sexual behavior of the participant including age at first intercourse, number of sexual partners, and sex with main versus casual partners [see (Kinsler et al., 2003)].
Attitude towards condoms
Three questions were used to assess attitudes towards condoms. Respondents were presented with the following statements: ‘Condom use is necessary, even when you are with the same person for a long time,’ ‘I'm concerned about AIDS, but in the heat of the moment it wouldn't stop me from having sexual intercourse without using a condom’ and ‘If your partner suggested using a condom, would you respect him or her’. Response categories included: 1 = strongly agree, 2 = agree, 3 = disagree, and 4 = strongly disagree. Each question was scored using a mean value.
Intention to use condoms
Two questions were used to assess intention to use condoms: ‘The next time you have sexual intercourse with your main partner, how likely is it that you will use a condom?’ and ‘The next time you have sexual intercourse with a partner other than your main partner, how likely is it that you will use a condom?’. Response categories included; 1 = very likely, 2 = sort of likely, 3 = sort of unlikely, 4 = very unlikely and 5 = I do not have a main/casual sexual partner. For purposes of obtaining a mean value, ‘I do not have a main/casual sex partner’ was treated as a missing value. The value 1 represents greatest intention to use condoms.
Peer norms
Four questions were used to assess peer norms regarding sex and condoms. For example, questions included ‘My friends would make fun of me if I decided not to have sexual intercourse with anyone at this stage in my life’ and ‘Has your boyfriend/girlfriend ever pressured you to have sexual intercourse?’. Response categories included: 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree and 5 = strongly disagree. Each question was scored using a mean value.
Self-efficacy
Perceived self-efficacy was assessed using Mahoney et al.'s (Mahoney et al., 1995) 18-item multidimensional scale. The subscales include skills (six items, 
= 0.92), partner's disapproval (five items, = 0.88), assertiveness (four items, = 0.86) and intoxicants (three items, = 0.92). Response categories included: 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree and 5 = strongly disagree. The possible range of scores was 5–90. Scales were scored to obtain mean values of self-efficacy, with higher scores associated with greater self-efficacy.
Parent–adolescent communication
Communication was assessed using a five-item scale [(Miller et al., 1998) = 0.94]. The scale was used to assess the quality of communication between an adolescent and his/her parent(s) concerning issues of sex. Response categories included: 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree and 5 = strongly disagree. The possible range of scores was 5–25. Scales were scored to obtain mean values of parent–child communication, with higher scores indicating better communication between parent and child.
Data analyses
All analyses were conducted with SPSS-PC version 10.0. The intervention effect on dependent variables was evaluated through analysis of covariance (ANCOVA). Dependent variables measured included knowledge, condom use, attitudes toward condoms, intention to use condoms, peer norms, self-efficacy and parent–child communication. The independent variable was the study condition (intervention or control). ANCOVA with pre-test scores, gender, age, ethnicity, religion and family structure as covariates was used to analyze post-test differences between treatment and control conditions.
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Results |
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Table I shows the baseline demographic and behavioral characteristics of the project participants. Females represented 63% of the total sample. The age of participants ranged from 13 to 17 (M = 15.3). Most students were Creole (77.3%). Approximately 37% of respondents reported being Catholic, followed by Anglican (23.3%) and Methodist (16.7%). The majority of participants (62.6%) did not live in a household with both of their biological parents. Baseline levels of gender, age, ethnicity, religion and family structure were not significantly different in the study and control groups. Refer to Kinsler et al. (Kinsler et al., 2003
) for information on sexual behavior of the participants. Baseline behavioral characteristics such as age at first sexual intercourse, sexual experience, condom use and number of sexual partners were not significantly different between the study and control groups.
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Intervention results
There were 75 participants in the intervention group (64% female) and 75 participants in the control group (63% female). We identified a number of factors, including baseline characteristics and the clustering effect among schools, which could potentially confound the association between the independent and dependent variables of the study. Baseline demographic variables such as age, gender, ethnicity, religion and family structure were controlled for in the analysis. We also tested the effect of clustering among schools by using a fixed effects model, whereby dummy codes were used for each of the six schools to assess differential effects across the schools. None of these school effects were found to be significant (P > 0.05). We computed the intraclass correlation to assess the degree of clustering among schools and this was found to be low (
= 0.025).
Power analysis was performed to determine the required sample size needed in order to detect the intervention effect (see Table II). In Table II, we assumed a fixed sample size of 150 students, six classrooms with a cluster size of 25 and we varied the intraclass correlations to simulate the worst case scenario (lowest power) due to the clustering effect. In the analysis, it was found that in order to get a power of 80% or higher, a sample size of 150 students would be needed, assuming a worst-case intraclass correlation of 0.10. In our actual sample, where the intraclass correlation was found to be low ( = 0.025), a sample size of 150 students would have more than sufficient power to detect the intervention effects, since the computed power is 97% (one-tailed, = 0.05).
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Table III shows the mean scores for knowledge, condom use, attitudes toward condoms, intention to use condoms, peer norms, self-efficacy and communication at pre- and post-test for the intervention group and control group. In the intervention group there were significant differences between pre- and post-test means for condom use, condom attitudes, condom intentions and parent–child communication. Only intention to use condoms was significant from the pre- to the post-test for the control group. While not statistically significant, the average scores on all outcomes were higher at the post- than pre-test for the intervention group.
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A series of ANCOVAs was conducted to test for mean differences between the intervention and control groups on post-test scores for knowledge, condom use, attitudes towards condoms, intention to use condoms, peer norms, self-efficacy and communication using the pre-test score as a covariate for each outcome, respectively. The results of ANCOVAs showed that there was a significant difference between intervention and control groups on knowledge (P < 0.05), condom use (P < 0.05), attitude towards condoms (P < 0.001) and intention to use condoms (P < 0.001). Participants in the intervention group reported higher levels of HIV-related knowledge, higher levels of condom use, greater intentions to use condoms the next time they had sexual intercourse and more positive attitudes towards condoms at follow-up than participants in the control schools. There were no significant differences in peer norms, self-efficacy and communication between the intervention and control group at post-test. It should be noted that while not all outcomes were statistically significant, the intervention group had higher scores on average for all these outcomes than the control group at the post-test, with the exception of peer norms.
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Discussion |
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This study highlights the positive impact of a cognitive-behavioral HIV prevention intervention for school-aged Belizean youth. Participants in the intervention group reported higher levels of HIV-related knowledge, higher levels of condom use, greater intentions to use condoms the next time they had sexual intercourse and more positive attitudes towards condoms at follow-up than participants in the control schools. These findings are consistent with the findings of other school-based studies on knowledge (Caceres et al., 1994
; Merson et al., 2000), condom-use (Jemmott and Jemmottt, 2000; Merson et al., 2000) and attitudes toward condoms (Caceres et al., 1994; Jemmott and Jemmott, 2000). The comparison of pre- and post-test means on the outcome variables for the intervention and control group (respectively) also revealed a positive impact of the intervention. In the intervention group, there were significant differences between pre- and post-test means for condom use, condom attitudes, condom intentions and parent–child communication. Only intention to use condoms was significant from pre- to post-test for the control group. While not statistically significant, the average scores on all outcomes were higher at post- than pre-test for the intervention group.
The program had a positive impact on knowledge, condom use behavior, attitudes toward condoms, intention to use condoms and communication. The program did not seem to have an impact on peer norms regarding sex and condoms and self-efficacy. While some school-based intervention studies have documented significant changes in these factors (Caceres et al., 1994; Basen-Enquist et al., 2001), others have not (Kinsman et al., 2001; Kirby, 1992). Program activities related to these outcomes were included in the program curriculum. Potential reasons for the lack of findings on peer norms and self-efficacy may have resulted from (1) cultural influences on the intervention and (2) study limitations.
Cultural influences on the intervention
The curriculum was based on two psychological theories including the Theory of Reasoned Action and Social Cognitive Theory, which use a western-based frame of reference. While components from the Theory of Reasoned Action proved most useful for understanding condom use behavior among adolescents in Belize, components from Social Cognitive Theory were less useful in understanding condom use behavior. Components from these behavioral models may be important precursors to sexual behavioral change, but they may not be the most important factors influencing HIV risk in this study population. Cultural issues may be just as important, or more important, in explaining risk factors associated with HIV transmission among adolescents in Belize.
The Project Light curriculum was chosen because researchers in the US and Belize felt it was a comprehensive curriculum that would meet the HIV-related educational needs of Belizean adolescents. However, this curriculum focused mainly on changing individual behaviors, and did not take into consideration the social, cultural, economic and political forces impinging on the student outside of the school context. For example, the way gender relations are hierarchically organized in Belize may be a precursor to engaging in risk-related sexual behavior (e.g. machismo and marianismo). Other potential precursors to engaging in risk-related sexual behavior include a disrupted family environment, poverty, and societal norms regarding appropriate sexual behavior and the acceptance of condoms.
It is possible that using these theories in the absence of cultural, structural, political and economic considerations may have important implications. Translating or adapting western-based theory and research for cross-cultural application may prove difficult in cultures and societies with often different understandings of sexual expression and sexual practices. Incorporating a systematic qualitative ‘meaning-centered’ component into this research study could have facilitated a deeper understanding of risky and preventive behavior in the context of human relationships, and made a key contribution to the kinds of knowledge and understanding that will ultimately be necessary to develop more effective responses to the risk posed by HIV in Belize.
Study limitations
The Project Light curriculum was designed to be delivered in small group settings of eight to 10 people. For this study, the program was implemented in schools. All sessions were held in classroom settings. The average number of students per classroom was 25. The school environment may not have been the best location for this intervention. Students indicated that they would have felt more relaxed if the sessions were held in an unstructured environment. However, schools were chosen as the basis for this study because of the structured environment. It was believed that students regularly attend school and, thus, there would be less chance of attrition.
The follow-up period of the evaluation was very short, only 3 months (March 2000 to June 2000). It would have been ideal to have a booster session at 6 months and 1 year post-intervention. However, due to time and money constraints, and the inability to efficiently track students, it would have been difficult to follow-up with the same students. The students in the participating classrooms would not all be together the following school year. Also, some students change schools, drop out of school or move to other districts.
Condom use, the key outcome variable in this study, was assessed using a single ordinal level item. More sensitive measures, such as scales or multiple items, could have resulted in greater reliability. Questions should include preliminary condom use behaviors [e.g. possessing condoms, condom use (past and present), information regarding the time frame of condom use (e.g. ‘condom use at last intercourse’, ‘condom use during the past 3 months’, ‘condom use during the past 6 months’ and ‘has the respondent ever used condoms’) and the situational context in which condoms are used]. Perceived risk for contracting HIV was also assessed using a single dichotomous item, and condom attitudes and peer norms regarding sex and condoms were each assessed using three items. More sensitive measures for the above-mentioned variables such as scales and multiple items should be used in future research.
Process evaluation and program monitoring activities were incorporated into the program design to determine whether the program was being carried out as planned. These activities were meant to facilitate the linking of program activities to program outcomes. All educational sessions were to be documented on Program Activity Records. The Process Evaluation Forms and program monitoring activities were either incomplete or not carried out on a consistent basis. Thus, it is not fully known if all components of the program were delivered as planned. It is possible that some peer educators were not 100% adherent to program protocols (delivered all components for only some of the sessions or partially delivered components for each session).
Finally, many schools declined to participate and schools in rural areas in Belize or other districts in Belize were not included in the study. Thus, our selection of schools also limits generizability. There is greater poverty in rural regions of Belize, and less access to sex education and condoms, thus sociodemographic characteristics of adolescents in our study may differ from sociodemographic characteristics of adolescents in rural regions.
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Acknowledgments |
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The researchers would like to thank Dana Rhamdas from the National AIDS Task Force (NATF) in Belize and Nigel Miguel for their assistance with project coordination and administration in Belize. This research was supported by the National Institutes of Health-Fogarty Center (AIDS-Firca) grant TWO1118-01 to D. E. M. for the research of J. K., and by the Universitywide AIDS Research Program through a grant to the UCLA California AIDS Research Center, CC99-LA-002. This research was supported in part by a grant from the Universitywide AIDS Research Program to C. D. S. (K00-LA-079).
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Received on February 4, 2003; accepted on October 6, 2003
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