JOURNAL OF ADOLESCENT HEALTH 1991;12:38-43

Effects of a Peer-Counseled AIDS Education Program on Knowledge, Attitudes, and Satisfaction of Adolescents VAUGHN I. RICKERT, PSY.D.s M. SUSAN JAY, M . D . t AND ANITA GOTTLIEBr R . N . P .

Education programs for adolescents regarding acquired immunodeflciency syndrome (AIDS) have been advocated by many pmfassionals to help minimize the risk of infection in this population. This study compares a peer-led vs. an adult-led AIDS education program on the lmowledge, attitudes, and satisfaction of the adolescents with their education. Eighty-two male and female adolescents, ranging in age from 12 to 18 years, were randomly assigned to a peer (n=27), adult (n=28), and control (m= 27) group. Intervention consisted of receiving didactic information and viewing a videotape about AIDS Ixansmission and prevention. All subjects completed the AIDS Knowledge Questionnaire-Revised, AIDS Attitude Survey, and a measure of consumer satisfaction. Statistical analyses revealed a significant effect for knowledse and attitudes toward practicing personal preventive behaviors and the seriousness of AIDS; both peer- and adult-led ~proups were superior to controls (p < 0.05). With the exception of satisfaction with providers, no other significant effects were found across the intervention groups. Satisfaction with providers showed an effect for sex (p < 0.05). Female adolescents reported more satisfaction with presenters than male adolescents did. Althoush both adult and peer counselors were equally effective in pmmotin 8 knowledge gains and appropriate attitude changes, more questions were asked of the peer counselors. These data suggest that when education is presented by peer counselors, adolescents may be more likely to see AIDS as a personal danger and

From the University of Arkansas for Medical Sciencesand Arkansas Children's Hospital, Little Rock, Arkansas. These data were In'esented, in part, at the annual meeting of the Society for Adolescent Medicine, Atlanta, Georgia, 1990 Address reprint requests to: Vaughn L Rickert, Psy.D., University of Arhansas for Medical Sciences, Arkansas Children's Hospital, Department of Pediatrics, 800 Marshall, Little Rock, AR 72202. Manuscript acceptedJanuary 2, 1990 38 U0,.~J1139X/91/$3.50

that peer counselors should be considered when designing comprehensive AIDS education programs. KEY WORDS"

AIDS Adolescents Peer counseling

The risk of human immunodeficiency virus (HIV) infectiop in adolescents has been inferred from the high incidence rates of sexually transmitted diseases (1-3). Education programs designed for adolescents regarding acquired immunodeficiency syndrome (AIDS) and the modes of virus transmission have been advocated by many professionals to minimize the risk of HIV infection in this population (1-.7). However, educational efforts need systematic evaluation to prompt positive choices and decisions regarding sexual behavior (4). Despite efforts to design education programs for adolescents on AIDS, few controlled studies have evaluated effectiveness (8). Miller and Downer used a 50-min lesson plan about AIDS and found significant increases in knowledge in high school students (9). More recently,Hustzi et al. (Pediatrics,in press) examined two educational interventions compared with a no-treatment controland found significantincreasesin knowledge and parallelchanges in the attitudes of tel~thgrade students.Interventionsincluded watching a videotaped presentationabout AIDS and itsprevention,as compared to didacticpresentations. Significant increases in knowledge, immediately after both interventionsand at follow-up, were reported. These investigatorsalso determined that di-

© Society for Adolescent Medicine, 1991 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010

January 1991

dacticinstruction increased knowledge more than the film alone. Finally, Rickert et al. (JAHC, in press) compared the effects of two AIDS education programs witih a no-treatment control provided through an adolescent medical clinic. We found significant incr&ses in knowledge for both intervention groups but no demonstrable effects on attitudes. Coupons were provided that coul d be exchanged for free condoms to better understand the effects of education on the acquisition of condoms. No significant differences were found as a result of the educational interventions between groups on cosldom acquisition, but adolescents who had a past history of condom purchase who were exposed to lecture information and watched a videotape about condom use were significantly more likely to obtain condoms. Although prior studies focusing on AIDS edr:. cation have used adult health care providers, the use of peer counselors has been shown to be effective in a wide variety of settings (10-19). Peer counseling sessions have also been extended to healthrelated concerns such as venereal disease (18), smoking (19), and sexuality (10,la). Jay et al. found that the incorporation of a peer counselor into the health care team was an effective method of increasing adolescent compliance with an oral contraceptive regimen (10). The use of peer counseling to provide AIDS education has not been evaluated. Due to the influence that adolescents have on one another, the use of peer-counseling sessions directed toward increasing knowledge and changing attitudes may be an important component in an AIDS education program. The purpose of our study was to examine prospectively a peer- vs. adult-led AIDS education program on the attitudes, knowledge, and satisfaction of adolescents with the educational program. We evaluated whether adolescents who received an AIDS education program led by peer counselors were as knowledgeable as those who were presented similar information from adult health care providers. We also examined the adolescents’ satisfaction with information presented and the effect of peer counseling on the attitudes of adolescents toward AIDS, such as practicing personal preventive behaviors.

EFFECTS OF A I’EEKC3UKzLED

AIDS PROGRAM

39

agreed to participate, but eight subjects were excluded because they did not complete the dependent 1 measures. The 55 female and 27 male subjects who completed all measures (n = 82) ranged in age from 12 to 18 years, with a mean age of 15.8 years. To determine socioeconomic status, the Hollingshead Four Factor Index of Sociai Status was employed. a The average status score obtained was 51 (range 2266), sugge&ng that these participants were from. low to upper middle-class families. Education sesj sions were conducted by peer counselors or adult health care providers and were consistent across thi! I study. A written protocol was developed for lectures information to ensure that no differences in the in formation presented existed between peer counse lors and adult health care providers. The purpose of the study was explained to esch participant, end informed written consent was obtained. Subjects were randomly assigned tc 017~o( iirree experimental conditions: control (n = 2.7); adult-led (n = 28); or peer-led (n = 27). Adolescents participated in small group education sessions with five to nine participants. At the conclusion of each session, participants were asked to complete the AIDS Knowledge ! Questionnaire-Revised (AKQ-R), the AIDS Attitude Survey (AAS), and a measure of consumer satisfaction. In addition, participants were asked to provide demographic data (age, race, sex) and grades obtained on last report card for math, English, and, science. Peer Counselors Nine adolescents were selected as peer counselors, based on their willingness to participate. These counselors were solicrted from similar community organizations and did not differ significantly from. the subjects. All were between the ages of 14 an& 18 years of age (6 female, 3 male). Peer counselorj were Caucasian, as were all participants, to eliminate the effect of race. These adolescents attended a 4-hr training session on two consecutive days. The curriculum was designed to improve knowledge, conversational and interaction skills, problem-solving techniques, and presentation style. Training a!c< included participation in videotaped role reheLr5a.l to refine counseling skills prior to leading ed :L:u..tin sessions.

Methods Subjects

Adult Counselors

Ninety adolescents from community and church organizations were asked to participate voluntarily. All

Health care providers (‘i .I.R., A.G.), experienced in providing AJDS edclcation and working within the

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Division of Adolescent Medicine, served as adult counselors. Measures To measure the knowledge of the adolescents, the MQ-R was employed (20). This standardized instrument contains 52 questions, where subjects are asked to rate each question on a 5-point scale, ranging from definitely yes to definitely no, and has a mean of 183 (SD = 13.8). This measure has been used previously with adolescents and has appropriate reliability data to assess knowledge accurately (28). The AAS is a 26item questionnaire and contains three scales: attitudes toward persons with AIDS, attitudes toward practicing personal preventive behaviors, and a sca!c designed to assess the beliefs of the participants about the seriousness of AIDS. Again, this standardized measure has been used in prior research with adolescents and was selected because of its technical adequacy (Hustzi et al.,). Participants are asked to complete the 26 statements on a 5-point scale, ranging from strongly agree to strongly disagree. The attitudes toward persons with AIDS subtest yields scores ranging from 12 to 60. A lower score is indicative of more positive attitudes. The attitudes toward practicing personal preventive behavior range from 9 to 45 and, again, a lower score is indicative of more positive attitudes such as the use of condoms and a belief in making necessary changes in sexual behaviors. Finally, the individual’s belief in the seriousness of AIDS ranges from 5 to 25, with lower scores reflecting more seriousness or a greater personal belief that AIDS might become a personal threat. The measure of consumer satisfaction was modified from an existing measure developed by McMann and Forehand (21-22). This measure has been used wideiy to evaluate educational interventions with families. It is constructed on a y-point scale, where respondents are asked to rate the importance, difficulty, and satisfactioii with trainers to determine their satisfaction with an intervention. The importance of information was based on a combined score across five questions, difficulty of the information presented included three questions, and satisfaction about the providers of information was assessed by four questions. On these scales, lower SCOreS indicate less importance or lower satisfaction, whereas higher scores indicate greater satisfaction. Each of the scales-importance, difficuity, and satisfaction with trainers-was analyzed independently.

ExperimentaalConditions Control Adolescents III this condition were asked to complete the AKQ-R and AAS, as well as demographic information. The purpose of this group was to control for prior education and attitudes against which the effectiveness of interventions could be compared. After subjects had completed these measures, they received the peer-led education program. Because prior studies have reported that adolescents are misinformed about this disease, we felt ethically responsible to provide AIDS education to all participants. Adult Counselors Adolescents in this group were given a brief lecture about AIDS according to the guidelines published by the Centers for Disease Control (23). This material included basic information on the HIV virus, how AIDS is transmitted, and preventative measures. In addition, the adolescents were shown the video entitled “AIDS: Can I Get It?” (24), as well as given the booklet “What Everyone Should Know About AIDS’ (25), to provide a multimedia education session. After questions of the participants were answered, they were instructed to complete the various dependent measures. Peer Counselors Adolescents in this group received the same educational information and videotape presentation as the adult-led group. All questions asked by participants were answered by the peer counselors. Counseling sessions were done by a minimum of two peers who worked as a team. On one occasion, peer counselors could not answer a particular question. This resulted in one of the counselors excusing themselves from the session to consult with the professional staff and then returning to provide the requested information. To ensure that lecture information was consistent across groups, an adult counselor listened to the entire lecture on thne random occasions. By using the standardized script, reliability of information presented was calculated to be 98% or better.

Statistical Analyses A randomized post-test-only control group design was used where individual scores from dependent

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measures were subjected to statistical analyses. This design best controls for initial biases between groups and also does not contaminate the effect of the educational intervention due to pretest surveys. That is, pretesting subjects on AIDS attitudes and knowledge would have alerted subjects to what was important and the effect of intervention could not have been assessed accurately because this contamination cannot be eliminated (26). To determine the effects of the intervention, analysis of variance (ANQVA) and analyses of covariance (ANCOVA) were employed. Newman-Keuls post hoc analyses were computed to determine whether one treatment was superior to another.

Results Analyses were conducted to determine whether differences existed between the three groups on socioeconomic status, sex, age, and grade-point average. Grade-point average was determined by assigning numerals on a Cpoint scale to the letter grades provided by each adolescent. These were summed and divided by three. A chi-square analysis was computed on sex, and no significant differences were found across experimental conditions (chi-square = 5.38; p > 0.05). To determine whether or not differences existed across groups with regard to age, socioeconomic status, and grade-point average, oneway analyses of variance were performed. These analyses revealed that no significant differences existed between age [F (2,79) = 0.71, p > 0.05] or socioeconomic status [F (:,79) = 1.51, p > 0.05]. However, the analysis of grade-point average revealed a significant difference between groups. Those adolescents in the control group had significantly lower grade-point averages than participants in either intervention group [F (2.79) = 4.27, p < 0.051. As a result, ANCOVA was used to control statistically for the effect of grade-point average. Two-way ANCOVAs were computed on the AKQ-R and the three scales of the AAS. The independent variables were group assignment and sex of the subject. No significant interactions were found on either the AKQ-R or AAS. A significant main effect for groups was found on the AKQ-R [F (2,78) = 4.77, p < 0.051. Significant main effects for groups were also found on two of the three scales of the AAS: personally practicing preventive behaviors [F (2,78) = 3.13, p < 0.051; and seriousness of AIDS ]F (2,78) = 7.03, p < 0.051 but not attitudes toward persons with AIDS [F (2,78) = 2.65, p > 0.051. No significant effect for sex was found on

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41

either measure. Finally, to detect whether a main effect existed between the intervention groups regarding satisfaction, two-way ANOVAs (groul> and sex) were employed, as the intervention groups did not differ in their grade-point averages. These analyses found no significant differences between the intervention groups on the importance of information presented [F (1,53) = 0.58, p > 0.051, difficulty of the information presented [F (1,53) = 0.84, p > 0.051; or satisfaction with the group leader [F (1,53) = 0.20, p > 0.051. Although no interactions were found on any of these variables, a main effect for sex was found for satisfaction with group leaders [F (1,53) = 5.85, p < 0.051. This finding suggests that female adolescents were more satisfied with providers, regardless of their group assignment, than males were. Subsequent Newman-Keuls post hoc comparis3ns were made to determine which intervention resulted in significantly greater knowl,edge about AIDS and its transmission. This analysis found that adult providers, as well as peer counselors, were significantry more effective than the control condition (p < 0.05) but not better than one another. Post hoc comparisons on the two scales of the AAS found significant but modr!stly more positive attitudes toward practicing personal preventive behaviors with the peer-counseled p&-icipants as compared to the controls (p < 0.05). However, the peer-counseled group was not significantly different in their per!;onal preventive attitudes than the adult-counseled group. With regard to the seriousness of -4IDS, adolescent participants led by adults or peers were significantly more likely to personally believe that they were more susceptible to this fatal disease (p < 0.05) compared to controls. These change4 were modest. and one intervention group was not significantly better than the other (see Fig. 1).

Discussion Health providers are becoming increasingly aware that adolescents are 3 3c:pulation at risk for contracting AIDS (l-7). Although adolescent AIDS cases reported to the Centers for Disease Control account for only 1% of the total repo:-ted, there is increasing evidence that a number of the young adult population may have become infected during their adolescent years (5). Prevention education is important to minimize infection, along with assisting the adolescent to develop positive health practices (4). The present study suggests that peer counselors can be an effective alternative to traditional adult counsel-

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15

Control Adult-Led

10

m

Peer-Led

2,l

p < .05

3,l

p .C5

5

Figure 1. Meanattitudeson seriousness ofAIDS acrossgroups.Lower scowsreJ?ect greaterbeliefofseriousness.

ors and a useful adjunct to professional teams in providing information and education about HIV infection. The present study targeted white middleclazs adolescents. Walker et al. reported that sexuality issues (venereal disease, sex, and birth control) are a greater health concern to white middleclass adolescents than to lower socioeconomic min,>+ies (27). In another study with primarily white suburban adolescents who had ready access to mediczl care, fewer than half of those surveyed stated that they would see a physiciun regarding sexually r&airedhealth needs (28). These researchers found the youths to engage in high rates of sexual activity and alcohol and drug use but found that the adolescents may be overlooked because they do not seek C7E.

Our results suggest that a brief lecture, combined with a video presentation, significantly improves the understanding of ad&scents regarding HIV infection and prevention and appropriate but modest attitude changes. Moreover, peer counselors produced the greatest attitude changes related to the adolescents’ perception of their personal risk of HIV infection, as well as more positive changes in personal attitudes to help prevent transmission. Adult and peer counselors were equally as effective in promoting knowledge gains and in satisfaction of participants; however, our limited sample size may have affected our ability to detect differences between intervention groups on knowledge: attitude, c;l:c? satisfaction measures. Further research compariilg peer and adult counselors with larger numbers of adolescents needs to be conducted to ensure the validity Of our results. Interestingly, the present

study found that more questions were asked of the peer counselors. Possible explanations for this finding are that subjects were confused by the information presented or participants were more comfortable in asking questions of these counselors. We believe that there was a higher degree of comfort between peer counselors and adolescents because of the high degree of reliability between indormation presented and data obtained from the satisfaction measure. Thus, data obtained from our study suggest that not only were our adolescents more likely to see AIDS as a personal danger, but peer counselors may promote more positive attitudinal changes effecting behavior because of interactive discussions. It was not possible to conduct a follow-up eva!.uation to assess whether these knowledge and attitude changes were maintained. across time since the control subjects received education. The inclusion of minorities in our participant population would have been confounded by the use of Caucasian peers. Nonetheless, our data suggest that the use of peer counselors can be an effective, as -well as a less expensive, adjunct in providing education to a cross section of white middle-class adolescents. However, the use of peer counseling needs further evaluation in other adolescent risk groups such as minorities, those in juvenile detention facilities, intravenous drug users, and runaways.

Conclusion Many professionals have urged the development of AIDS education programs lo address the information needs and to impact positively on the health practices of adolescents (1,2,4,5,S). Because adolescents who may be at greater risk may not attend school, the message must be carried to youth groups, health clinics, and malls where adolescents congregate. Our results suggest that providing an educational intervention my using peer counselors and adult health care providers is viable and effective for providing AIDS education and positively impacting attitudes that may effect behavior change later. Those adolescents who were counseled by peers were more likely to engage in interactive discussion following the educational intervention than those counseled by the adult health care providers. Thus, although there were no statistical differences between adult or peer counselors, the adolescents in this study may have been more comfortable asking questions of a peer. Peer counselors can be used easily in unconventional settings arld should be con-

January

1991

sidered in the development education programs.

EFFECTS OF A PEER-COUNSELED AIDS PROGRAM

of comprehensive

AIDS

We acknowledge the Arkansas Department of Health, who provided support for this project. Moreover, we recognize Laura Stanley, Michelle Honea, Angela Freeman, EiMRhoenbeck, Angela Horton, Cici Conger, Shane Pierce, and Bill Leath for their enthusiastic and dedicated teaching efforts.

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12. Utech DA, Having KL. Patient and peers as competing influences on the decisions of children of different ages. J Sot Psychol 1969;78:267. 13. Davis AK, Weener JM, Shute RE. Positive peer influence school based prevention. Health Ed 1977;8:20. 14. Nadelson CC, Notman M. Gillon IW. Sexual knowledge and attitudes of adolescents: Relationship to contraceptiv: use. Obstet Gynecol 1980;55:340. 15. Hamburg 5A, Varenhorst BB. Peer counseling in the secondary schools: A community health project for youth. Am J Orthopsychiatry 1972;42%6. 16. Vriend T. High performing inner city adolescents assist low performing peers in counseling groups. Personnel Guid J 1969;48:897.

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