Health Service Applications An AIDS Prevention Program for Adolescents With Special learning Needs Nancy A. Reed, Laura E. Edwards, Sandra S. Naughton
IV infection among adolescents is a growing problem in the U.S. and is well-documented, as is the need for prevention education.l-" Adolescent risk-taking behavior is characterized by a sense of invulnerability and limited capacity to perceive future time or long-term c o n s e q u e n ~ e s . ~Urgency ~J~ related to the problem of HIV transmission among adolescents is highlighted when such characteristics are coupled with a perception of unreality about the threat of AIDS because of the lengthy incubation period. Adolescents with special learning needs present an even greater challenge to health professionals and teachers. This population has historically been at risk for sexual exploitation because of their limited knowledge, lack of understanding of the implications of a variety of risk-taking behaviors, and patterns of victimization by other^.^^-^' They are vulnerable because they often are dependent on others for their basic needs, are easily coerced, are emotionally and socially insecure, and many times are not educated about sexuality. It is therefore critically important to provide necessary information as well as to teach effective self-protection skills for teens with special learning needs. Cognitive limitations and learning difficulties necessitate that materials be specifically adapted for use with this population. Additionally, more time is required for special needs students to provide basic counseling and to reinforce information. To meet the challenges of these vulnerable adolescents with learning barriers, Health Start developed a specialized approach to AIDS prevention. Adolescents with learning disabilities, Individualized Educational Plans (IEPs), or in English as a Second Language (ESL) classes were the target population for this HIV/AIDS risk assessment and intervention program. Health Start has been providing individualized HIV risk assessment and education to at-risk adolescents in its five school-based clinics in St. Paul, Nancy A. Reed, RN,C, MPH, Nurse Clinician; Laura E. Edwards, MD, Medical Director; and Sandra S. Naughton. BA, Supervisor of Health Education, Health Start Inc.. 640 Jackson St.. St. Paul, MN 55101. This program was planned and implemented by Health Start, Inc. and the Dept. of Obstetrics and Gynecology, St. Paul-Ramsey Medical Center, St. Paul, Minn. The Minnesota A IDS Funding Consortium provided partial funding for the program. This article was submitted October 4, 1991, and revised and accepted for publication March 16, 1992.
Minn., since 1987. Experience with the general population of clinic patients served in the clinics has been previously reported. The primary goal of this program for adolescents with special learning needs was to reduce the risk of HIV infection by increasing understanding of AIDS, by reducing risk-taking behaviors, and by increasing self-protection skills. The first component of this specialized program was the development, piloting, and implementation of an individualized risk assessment questionnaire and the provision of one-to-one HIV risk reduction counseling. The second component was the development, piloting, and implementation of a specialized classroom curriculum for HIV/ AIDS prevention. This paper reports experience of the individualized approach with 88 special needs students and the classroom approach with 70 special needs students during a six-month period in 1990.
INDIVIDUALIZED RISK ASSESSMENT AND INTERVENTION Assessment and Counseling
The HIV/AIDS risk assessment tool and the education and counseling protocols developed for the general population of adolescents served in the clinics were adapted for use with adolescents with cognitive limitations or learning disabilities and with adolescents whose primary language is not English. The assessment tool was piloted with students fitting this description and feedback was sought from them as well as from special education teachers. It was then revised and implemented in the school-based clinics. The questionnaire was designed to be an assessment tool as well as an educational tool. It consists of 10 knowledge questions and 18 assessment questions written in basic terms with graphics to maximize readability and comprehension. Voluntary participation, confidentiality, and anonymity were stressed verbally and in writing to each student before the questionnaire was administered. Students were offered the questionnaire as they came in for their schoolbased clinic appointments. Questionnaires were completed in a private space with a health professional available for students unable to read or who had limited reading skills. After completing the questionnaire, a health professional reviewed the responses with the student and
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provided one-to-one education and risk-reduction counseling. Objectives for the behavioral intervention were to discourage experimentation with highrisk behaviors, t o encourage abstinence, t o delay age of first intercourse, and to limit the number of sexual partners. For adolescents who were sexually active and who indicated they probably would continue to be sexually active, information about and vouchers for condoms and spermicides were provided. Followup appointments were given to assess compliance and to reinforce risk-reduction information. Knowledge and Risk levels
Of 88 respondents, 10.2% were ages 12 or 13 and 1 1.4% were age 14. Students age 18 or older made up 12.5% of the total, while the remaining were age 15-17. Asian students made up one-third (32.9%) of respondents, another third (30.7%) were White, and 18.2% Black. The remainder were of other ethnic origin. Two-thirds of respondents were female and one-third were male. Knowledge regarding transmission and prevention of AIDS/HIV infection was measured using nine true-false statements. Table 1 shows the statements and the percentage of students answering them correctly. When asked to name three ways of protecting themselves from HIV infection, the most common response was use of condoms, given by 72.7% of respondents. Abstinence was given by 68.l%, not using drugs and sharing needles by 50%. Only 4.5% mentioned single partners for intercourse as a way of protection from HIV infection. Attitudes and behaviors of the 88 respondents were measured using 12 questions. More than half (53.4%) were sexually active. Only one, less than I . 1070, reported ever using street drugs injected by a needle. Responses of the 47 sexually active students were further analyzed. None of the 13 male students and only one of the 3 1 female students reported same sex experience. Only two (4.3%) reported having anal intercourse. When asked about previous STD infections, 10.6% reported having had an infection and an additional 4.3% were unsure, whereas 8.5% reported their partners as having had an STD and 21.3% were unsure. Two-thirds (66Vo) of the students thought their partners had engaged in sex with others. One student reported that a partner had relationships with both men and women (bisexual experience). Only one student thought that a partner used drugs with needles. Almost one of five (19.2%) respondents engaged in intercourse when high on drugs. When asked if they had discussed AIDS with their sexual partner, almost half (46.8%) responded affirmatively. Only 40% had talked about condom use with their partner. When asked why they do not use condoms, 48% stated that their boy or girl friend did not like them. An additional 16% gave “they don’t feel good” as a response, whereas 20% gave “don’t have any” as their reason for not using condoms.
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IMPLICATI 0NS Knowledge levels of these 88 students with special learning needs were higher than expected but risk behaviors in this population continue to be of concern. Though rates of IV needle use and anal intercourse were low by self-report, history of the respondent or partner having had a sexually transmitted disease was high. STD history is a reliable predictor for HIV risk and these findings show a significant rate of infection. Though condoms were cited most frequently as a method of protecting oneself from HIV infection, alarming numbers of sexually active respondents had reasons for not using them. Abstinence was the second most frequently cited method of self-protection but more than half the respondents were sexually active. These results clearly indicate that this population of students with unexpectedly high levels of knowledge still exhibit significant risk-taking behaviors. It is this assumption that leads to a classroom approach, in addition to one-to-one education, that is not simply didactic but provides opportunities for experiential and interactive learning. DEVELOPMENT OF A SPECIALIZED CURRICULUM Development and piloting of a classroom curriculum was the second component of this specialized AIDS prevention program. Because of the demonstrated success and effectiveness of two human sexuality c u r r i c ~ l a ~previously ~ ~ * ~ developed by Health Start staff, they were used as models for development and adaptation of the AIDS prevention curriculum. Objectives of the classroom intervention were to: increase knowledge of HIV infection transmission, dispel myths associated with AIDS, identify risk behaviors, encourage adolescents to abstain from sexual intercourse and drug use, identify school and community resources, and introduce self-protection skills. The three-lesson curriculum consists of didactic Table 1
Percentage of Adolescents Respondlng Correctly to True-False Satements Concerning AIDS K Correct Rssponsa Having sex with someone who has AIDS is one way 01 getting AIDS
A person can get AIDS by sharing needles and syringes with someone who has the AIDS germ
A pregnant woman who has the AIDS germ can pass the AIDS germ to her unborn child
There is a blood test available that can tell you 11you have the AIDS germ Someone who has the AIDS germ can give it to someone else Anybody can get AIDS Condoms are a good way to stop AIDS
89 8 89 8 83 0 76 1
Having sex in the anus passes the germs from one person to another
Everyone who has the AIDS germ looks and feels sick
(N = 88)
information, audiovisual materials, and experiential activities. It was designed to include hands-on involvement, repetition of information, visual materials, interactive group experience rather than individual learning, and oral rather than written communication. The adapted curriculum was piloted in three St. Paul, Minn., high schools with a total of 70 special needs students. Revisions were made based on feedback from students and teachers and a written pre/posttest was developed. The participation level of the students was high in all three days of class activities. By the third day, students were able to identify situations that could place them at risk for HIV infection and then develop role plays, scenarios, or action plans for handling hypothetical situations. Knowledge was evaluated based on individual participant's oral communication. Students demonstrated basic understanding about the prevention of HIV transmission. One major intent of the unit was to reinforce protection skills. However, it is difficult to assess whether or not behavior would change based on this three-lesson unit. Written and verbal feedback obtained from the special education teachers in these classes was positive. All of the teachers felt the content and strategies were effective and that there was an increase in knowledge levels and in self-protection skills.
CONCLUSION Since education is the primary and currently the most viable defense against the spread of HIV/AIDS, it is critical that the educational approach be suited to the needs of the population to be served. Due to possible cognitive limitations and learning difficulties in this population of adolescents, additional time is needed to assess comprehension of the information, to reinforce risk reduction education, and to provide close follow-up for those at risk for HIV infection. The clarity, brevity, use of graphics, and basic reading level employed in this assessment tool make it especially effective in meeting the educational requirements of students with special learning needs. Health Start staff also found that this simplified, graphic questionnaire is accepted by mainstream students as well. Individual education following assessment of knowledge and risk is an appropriate and effective strategy for linking learning to positive behavior change. Additionally, a comprehensive classroom curriculum which takes into account learning styles of specific student populations is an important adjunct to individualized risk reduction education.
I The challenge to health and education professionals
is to continue to recognize special vulnerabilities of adolescents and to adapt and design programs and services accordingly.
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Statement of Purpose The journal of School Health. an official publication of the American School Health Association, publishes material related to health promotion in school settings. journal readership includes administrators, educators, nurses, physicians, dentists, dental hygienists, psychologists, counselors, social workers, nutritionists, dietitians, and other health professionals. These individuals work cooperatively with parents and the community to achieve the common goal of providing children and adolescents with the programs, services, and environment necessary to promote health and to improve learning. Contributed manuscripts are considered for publication in the following categories: general articles, research papers, commentaries, teaching techniques, and health service applications. Primary consideration is given to manuscripts related to the health of children and adolescents, and to the health of employees, in public and private pre-schools and child day care centers, kindergartens, elementary schools, middle level schools, and senior high schools. Manuscripts related to college-age young adults will be considered if the topic has implications for health programs in preschools through grade 12.Relevant international manuscripts also will be considered. Prior to submitting a manuscript, prospective authors should review the most recent "Guidelines for Authors." The guidelines are printed periodically in the journal; copies also may be obtained from the journal office, P.O. Box 708, Kent, OH 44240.
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