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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20

Effects of a Peer-Led AIDS Intervention with University Students a

b

Jennifer J. Shulkin MPH , Joni A. Mayer PhD , Leland G. Wessel MD, MPH f

John P. Elder PhD, MPH & Louis R. Franzini Ph.D.

c d

e

, Carl de Moor BS ,

g

a

CA College Health 2000 at San Diego State University , USA

b

Graduate School of Public Health , USA

c

University of California, San Diego/San Diego State University, General Preventive Medicine Residency Program , USA d

Student Health Services , San Diego State, USA

e

University of Washington School of Public Health , Seattle, USA

f

Graduate School of Public Health , San Diego State, USA

g

Doctoral Training Facility , San Diego State, USA Published online: 09 Jul 2010.

To cite this article: Jennifer J. Shulkin MPH , Joni A. Mayer PhD , Leland G. Wessel MD, MPH , Carl de Moor BS , John P. Elder PhD, MPH & Louis R. Franzini Ph.D. (1991) Effects of a Peer-Led AIDS Intervention with University Students, Journal of American College Health, 40:2, 75-79, DOI: 10.1080/07448481.1991.9936259 To link to this article: http://dx.doi.org/10.1080/07448481.1991.9936259

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Effects of a Peer-Led AIDS Intervention With University Students

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Jennifer J. Shulkin, MPH; Joni A. Mayer, PhD; Leland G. Wessel, MD, MPH; Carl de Moor, BS; John P. Elder, PhD, MPH; and Louis R. Franzini, PhD Abstract. Acquired immune deficiency syndrome (AIDS) has become a major health threat to university students. This study evaluated a peer-led AIDS interventior. program with university students to (1) increase knowledge of human immunodeficiency virus (HIV) transmissiion and infection; (2) change attitudes to reflect scientific information on AIDS-related facts; and (3) change behavioral intentions to correspond with safer sexual practices. Subjects were students ( N = 142) from four undergraduate classes and were predominantly female (65%), white (82%), and sexually active (86%). A nonequivalent control group design was used, with two classes receiving the intervention and two classes receiving no information. For the intervention, peer educators presented AIDS-related information, modeled ways to use condoms safely and ways to discuss condom use with sexual partners, and led discussions on HIV infection and AIDS, relationships, sexuality, and condom use. A questionnaire was administered to assess differential changes in AIDS-related knowledge, attitudes, and behavioral intentions between the intervention and control groups. The results showed significant improvements among intervention subjects on the knowledge, attitudes, and behavioral intentions scales compared with the control group. Key Words. AIDS, HIV infection, peer education, university and college students

H

uman immunodeficiency virus (HIV), one of the most important public health issues of our time, has become a significant threat to college students. These young adults, feeling invincible, often practice unsafe sexual behaviors; experiment with alcohol and drugs, which may impair judgments about safer Jennifer J. Shulkh is project coordinator of CA College Health 2000 at San Diego State University, where Joni A . Mayer is an associate professor in the Graduate School of Public Health. L e h d G. Wessel is with the Universityof California, San Diego/San Diego State University General Preventive Medicine Residency Program and assistant director of Student Health Services at San Diego State. Carl de Moor is a doctoral candidate in biostatistics at the University of Washington School of Public Health in Seattle. John P. EIder & an associate professor and head of Health Promotion in the Graduate School of Public Health at San Diego State, and Louk R. Franrhi is a professor of psychology in the Doctoral Training Facility at San Diego State. VOL 40, SEPTEMBER 1991

sexual practices; and therefore fail to perceive themselves as at risk for HIV infection.14 Dissatisfaction with the limited success of traditional educational methods has created a need for creative alternate approaches to AIDS education targeted at young adults. Teachers and physicians are not necessarily good sex educators.s For example, authority figures may have difficulty communicating with students on the topic of sexuality, even if they are comfortable with their own sexuality. In addition, students may not perceive professionals or public health experts as reliable and credible sources of health information; the credibility of instructors in schools is usually low because they often expect and encourage students to engage in health behaviors that they themselves fail to practice.6 Moreover, when used alone, traditional approaches such as posters, pamphlets, leaflets, and mass media campaigns have limited effects in changing maladaptive health behaviors.’ Nontraditional approaches to AIDS education, including peer education, live theater, and videos, have been effective in changing AIDS-related knowledge and attitudes that are necessary to promote safer sexual practices and decrease the risk of HIV Peer education, particularly on a campus, may create a social environment that supports risk-reducing behaviors as the norm rather than the exception. Furthermore, individuals are more likely to initiate and maintain healthy sexual behaviors when such behaviors become socially acceptable in a community.’ In fact, although any interpersonal action has the potential for influence, peer interactions are often the most influential in their power to shape health-related behaviors.” In recent years, peer education has been used effectively as a part of college campus outreach programs to assist, advise, inform, and counsel other students about sexual health issues.’’-” For example, at Florida Atlantic University’s student health services, a classroombased AIDS education and prevention program was devised and disseminated by peer educators. An anonymous questionnaire, administered to students immedi75

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COLLEGE HEALTH

ately following the presentation, revealed that the vast majority of students had increased knowledge of HIV infection, would recommend the presentation to a friend, and liked the use of peers as presenters.” In addition, peer leadership has been effective in other health promotion areas influenced by peer pressure-with drug abuse prevention, for example. In some studies, peer-led programs were more effective than teacher-led programs and contributed to lower prevalence rates of cigarette smoking, marijuana use, and excessive drinking.”*l These findings were not replicated in other studies; eg, Arkin” and Clarkz3failed to show that peers are more effective than adults in interventions to prevent tobacco use. The varied results on the effectiveness of peer-led programs could result from variations in peer leaders’ skills and training.24 “Project ACCEPT” (AIDS Collegiate, Counseling, Education, and Prevention Team) addressed the need for AIDS education among students at a large state university by using a peer-education training model to reduce high-risk sexual behaviors. Our study evaluated the effectiveness of Project ACCEPT, using a quasi-experimental, nonequivalent control group design. Preand posttest questionnaires were used to measure changes in AIDS-related knowledge and attitudes caused by the intervention. In addition, this evaluation measured changes in intentions regarding sexual behaviors before and after the intervention. We predicted that, relative to the control condition, recipients of the Project ACCEPT presentation would demonstrate (1) increased knowledge of HIV infection and transmission, risk categories, risk behaviors, natural history of HIV infection and AIDS, and HIV testing; (2) a positive change in attitude scores that corresponded to scientific information on HIV and AIDS-related facts; and (3) a positive change in behavioral intentions that correspond to safer sexual practices. METHOD Subjects Before we initiated our study, the university’s Committee on the Protection of Human Subjects approved the protocol and questionnaires. Subjects were 142 university students enrolled in four undergraduate general education classes at a large state university (approximately 35,500 students) in Southern California. HIV seropositive studies completed at this university revealed that 4 in every 1,OOO students were HIV i n f e ~ t e d .In ~ 1986, over 80% of participants (men and women and all sexual orientations) scored in moderate and high-risk categories on a survey of sexual behavior^.^ Our study used a nonequivalent control group design; two classes received the intervention and two classes initially received no intervention. After delivery of the program to the intervention students, the intervention was repeated for the control students. Classes were selected based on class duration (a minimum of 80 minutes), whether the course fulfilled a 76

general education requirement, time of day (daytime), and class size (approximately 30 students per class). The four lower division classes consisted of one political science class and three health science classes. The classes were composed of students with various majors. We assigned classes to condition on the basis of the day that the four instructors could replace their lectures with the Project ACCEPT presentation. The control group consisted of the political science class and one health science class, and the experimental group consisted of two health science classes. Educator Recruitment and Training

During August 1988 and February 1989, the project staff recruited undergraduate peer health educators (PHEs) from the university to participate in Project ACCEPT. PHEs, who received academic credit for participating, completed 12 hours of training provided by the project’s health educator. Training was divided into two sessions that focused on (1) the history and physiological basis of HIV infection and AIDS and (2) how to give a presentation and answer questions. PHEs learned the technical and social skills necessary to avoid HIV infection and transmission and how to communicate these skills to their peers. The health educator modeled the behaviors for the PHEs and provided them with feedback on their performances. Intervention

In March and April 1989, the two PHEs conducted a 1-hour presentation before each class. They presented AIDS information: the history of the disease, means of HIV infection and transmission, prevention methods (including the use of sterile needles), and the importance of communication between sexual partners. The didactic portion of the presentation accounted for half the sessions. The other half session allowed time for PHEs to facilitate group discussions and model ways for individuals to discuss condom use with their sexual partners. In addition, PHEs demonstrated the proper way to use condoms by rolling them onto their fingers. During the discussion, students commented frequently and asked a variety of questions. Students were provided with referral numbers for additional AIDS information, HIV testing and counseling resources, and a packet of literature containing consumer information and suggestions for condom negotiations. Evaluation Instrument and Procedures

We developed a questionnaire specifically for evaluation of the Project ACCEPT presentation; it focused on AIDS-related knowledge, attitudes, behavioral intentions, sexual behaviors, drug and alcohol use, and demographics. All questionnaire items were previously pilot tested with university undergraduates to assess clarity, brevity, and revelance to the population. The knowledge portion included 1 1 true-false questions (including a don’t know alternative) obtained from JACH

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PEER-LED INTERVENTION

a variety of resources. Questions dealt with the natural history, transmission, and screening of HIV. Attitudes about AIDS were assessed in 10 questions with five response categories ranging from strongly agree to strongly dkagree. Behavioral intentions were assessed in 8 questions with five response categories ranging from very likeI)J to very unlikely (see Appendix). We administered questionnaires to all four classes during Week 1 of the study (pretest). After 2 weeks, the control classes were surveyed again (pretest 2). The experimental classes received the Project ACCEPT presentation and questionnaire (posttest) immediately after the presentation. During the following week, the control classes were given the Project ACCEPT presentation and posttest immediately following the presentation. The questionnaire was self-administered and anonymous to reduce the likelihood of socially desirable responses. Anonymity in testing while maintaining the potential for individual follow-up was accomplished by using randomly assigned code numbers rather than names. An announcement, made before each questionnaire administration, emphasized the anonymous and voluntary nature of each student’s participation. In addition, subjects were allowed to use a blank sheet of paper to cover their answers to protect their privacy. Questionnaires were collected without inspection for completion, which helped to ensure confidentiality. Out of 142 subjects, 2 refused to complete the survey. An informed consent was not used; survey completion implied consent. Analysis

For data analysis, a composite score for each outcome measure was computed. The knowledge score was computed as the percentage of correct responses. The attitude scale score was computed by adding the scores

from the individual attitude items. Because the response choices to each of these items ranged from 1 to 5, the least preferred response to each item was scored as 1 and the most preferred choice as 5 . Thus, the scores potentially ranged from 10 to 50. The behavioral intentions scale score was computed the same way as the attitude scale score, with the least preferred response scored as 1 and the most preferred scored as 5. Scores on the behavioral intentions scale could thus range from 6 to 30. Preferred answers on the attitude and behavioral intentions scales were based on those attitudes and behavioral intentions that corresponded with scientifically accurate AIDS information. To assess instrument test-retest reliability, we computed a Pearson product-moment correlation coefficient between the mean scores of the control group’s first and second pretest scores on each outcome measure. Results showed significant correlations between tests for knowledge (r = .7541), attitudes (r = .7073), and behavioral intentions (r = .7853); p < .001 in all cases. RESULTS

Characteristics of the Sample

The majority of subjects were white (82%) and female (56%) and were juniors or seniors (74.5%). Eightythree percent (n = 119) of the subjects reported being sexually active (defined as having had sexual intercourse within the past 12 months). Of those students who were sexually active, 45.3% (n = 63) had had one sexual partner, 18.7% (n = 26) had had two sexual partners, and 21.5% (n = 30) had had three or more sexual partners. Nearly two thirds of the subjects (n = 91) had combined alcohol (to the point of intoxication) with sexual intercourse at least 25% of the time in the past 12

TABLE 1 Means on Outcome Measures for Control and Experimental Groups

Outcome measure Group 1 (experimental) Knowledge Attitudes Behavioral intentions Group 2 (control) Knowledge Attitudes Behavioral intentions

M

SD

M

Pretest 2 SD

91.2 41.5 24.2

10.1 3.6 4.4

-

88.9 41.O 22.9

10.2 3.4 3.9

89.3 40.3 22.4

Pretest

Posttest M

SD

-

98.6 43.5 26.1

3.3** 9.1* 3.7**

12.3 4.0 4.1

97.5 42.2 24.4

4.6** 4.3* 3.9**

~~

Note: Statistics include only subjects for control and experimental condition with matched data. For the main analysis, Group 1 had 57Vo of subjects with matched data. For the secondary analysis, 79% of subjects in Group 2 had matched data from the second pretest to posttest. *p < .05; * p < .001.

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COLLEGE HEALTH

months. Approximately 32% (n = 44) had combined recreational drug use with sexual intercourse at least 25% of the time in a 1-year period. Only one subject reported using intravenous drugs in the past 12 months. Forty-one percent (n = 57) of the sexually active subjects were monogamous (defined as having had only one sexual partner for the past 12 months). Of the sexually active students who responded to the question (n = 129), 86 had used condoms from never to 25% of the time; 12 had done so 26% to 50% of the time; 8, 51% to 75% of the time; and 23, 76% to 100% of the time. Only 1 1 sexually active subjects reported using condoms 100% of the time during the past 12 months. The ages of the control and intervention groups were significantly different, t = -2.46, df = 109.86, p = .016, but age was not found to be significantly correlated to any of the three scale scores. The groups were comparable on all other demographic variables (gender, class level, major field, marital status, ethnicity, and religion). Intervention Effects

Three separate one-way analyses of covariance (ANCOVAs), with baseline score as the covariate, showed a significant main effect for the intervention condition for mean change in scores (from pretest to posttest) on knowledge, F(1, 81) = 20.0, p < 4 0 1 , attitudes, F(1, 81) = 4.7, p = .033, and behavioral intentions, F(1, 81) = 24.2, p < .001. These results suggested that the intervention improved knowledge, attitudes, and behavioral intention scores. The replication of the intervention with the control group showed similar results and strengthened the internal validity of the study. A twotailed, paired t test showed a significant improvement in scores for the control group from pretest to posttest: knowledge, t = 4.28, df = 39, p < .001; attitudes, t = 2.93, df = 40,p = .006;and behavioral intentions, t = 5.63, df = 40, p < .001. The change scores from the second pretest to posttest for the control group were in the same direction as those from the main analyses (Table 1). DISCUSSION

The evaluation results supported the hypotheses that the experimental group would significantly increase on knowledge, attitudes, and behavioral intentions relative to the control group. The internal validity of the study was strengthened by the replication of these findings when the control group received the intervention. Although the control and intervention groups were not randomly assigned to condition, they were comparable on all demographic variables except for age. Further analysis showed that age did not significantly influence responses. The generalizability of the study, however, may be confined to populations with similar demographic characteristics. A second weakness is that the analyses were performed at the individual level. Analysis at the class level would have been preferred because there may have been interactions between individuals within each class. The 78

restrictions of time, resources, and availability of classes precluded recruiting enough classes for an adequate sample size. Finally, because of time limitations of the semester and the class instructors, the study did not assess overt behavior change, nor did it measure the potential decay in behavioral intentions. Behavior change was not assessed because a follow-up measure of at least 6 months would have been required. We did not consider mailing a follow-up survey because obtaining addresses would have compromised anonymity. Rather, we used behavioral intention measures to approximate actual behavior change following the Project ACCEPT presentation. Behavioral intentions with respect to cigarette smoking have generally been found to be good predictors of subsequent behavior. Because changes in AIDS-related knowledge, attitudes, and behavioral intentions could be attributed to the Project ACCEPT intervention, it would be expected that this peer intervention would generalize to other demographically similar university settings. In addition, while this relatively efficient intervention demonstrated that changes can occur with brief interventions, longer interventions may lead to even greater changes. Consequently, future research should evaluate the short- and long-term effects of multiple sessions on AIDS-related knowledge, attitudes, and behaviors. The significant improvement in knowledge demonstrated the need for factual information to replace myths generated by fear, denial, and ignorance. Although significant changes were reported in attitudes, these changes could be enhanced by extending Project ACCEPT’S discussion of topics to include misconceptions about persons with AIDS. We found it encouraging that behavioral intentions to perform safer sex, which may be reasonable predictors of actual behavior change, improved following the intervention. The base rates of alcohol use combined with sex were relatively high in this study. Because alcohol may reduce the likelihood of using condoms, the correlates of this combination of behaviors should be studied. A clearer understanding of this potential barrier to safer sex may lead to more powerful interventions with college students. The results of this evaluation justify the continued implementation of peer-led AIDS interventions at all levels of higher learning to facilitate change that encourages safer sexual behaviors. Finally, because individuals are becoming HIV infected at younger ages, it would seem appropriate for AIDS interventionists to target the secondary school level as well.

’’

APPENDIX Questionnaire Items

Knowledge (True, False, Don ’t know) 1. Only gays, intravenous (IV) drug abusers, and people who have had blood transfusions can get AIDS. 2. Using a latex condom during sexual intercourse signif-

JACH

PEER-LED INTER VENTION

icantly lowers the risk of passing the AIDS virus between partners. 3. You can get AIDS by giving blood. 4. AIDS can be transmitted by dry kissing, shaking hands, or hugging an infected person. 5. AIDS can be transmitted via sexual intercourse or by sharing IV drug needles with an infected person. 6. AIDS is caused by a virus. 7. If detected early, AIDS can be cured. 8. The AIDS screening test now in use (ELISA) measures antibodies to the AIDS virus and not the AIDS virus itself. 9. Latex condoms can be used safely more than once. 10. Feeling drunk or high tends to make a person less likely to use condoms during intercourse. 11. AIDS can be transmitted by a person who doesn’t show any symptoms of the disease.

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Attitudes (Likert scale: SA = strongly agree, A = agree, U = undecided, D = disagree, SD = strongly disagree)

12. I feel that the prevention of AIDS is a shared responsibility of both partners in a sexual encounter. 13. I feel that I have little or no chance of ever getting AIDS. 14. People with AIDS should be allowed to attend college classes.

15. Safer sex doesn’t apply to me because I can tell who has AIDS and will just avoid having sex with them.

16. Intimacy in a relationship can be achieved without having sexual intercourse.

17. Sexual intercourse without condoms shows trust and/or love.

18. If I have a “new” (frst-time) sexual partner, their reaction will concern me if I tell them I want to use a condom during intercourse.

19. If I have a new sexual partner, it is important to me that we use a condom during intercourse. 20. I am comfortable talking about safer sex with my sexual partner. 21. I would take the risk of getting infected with the AIDS virus instead of wearing a condom during sexual intercourse (or having my partner wear a condom). Behavioral Intentions (Likert scale: 1 = very likely, 2 = somewhat likely, 3 = 50-50 chance, 4 = somewhat unlikely, 5 = very unlikely)

22. If I am in the same class as a student who is known to have AIDS or is HIV positive, I will avoid sitting next to him/her .

23. If I meet someone who is known to have AIDS or is HIV positive, I will shake hands with him/her. 24. If I have a new sexual partner, I will be tested for the AIDS virus before we have intercourse. 25. If I have a new sexual partner, I will ask that he/she be tested for the AIDS virus before we have intercourse. 26. If I have a new sexual partner, I will discuss safer sex with him/her before we have intercourse. 27. I will have a new condom readily available at all times. REFERENCES 1. Bettencourt M. Authority on AIDS informs SDSU campus of the facts. Daily Aztec. March 1989;l-2. 2. Keeling RP. Risk communication about AIDS in higher education. Sci Tech & Hum Values. 1987;12:26-36. 3. Wessel L, Shechter S, Shultz B. Project ACCEPT peer health educator training packet. Unpublished manuscript. San Diego: San Diego State University, Student Health Services;

1987.

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4. Freimuth VS, Edgar T, Hammond SL. College students’ awareness and interpretation of the AIDS risk. Sci Tech &Hum Values. 1987;12:3740. 5 . Amdur MJ, Nichols M, Boroto DR, Shay BL. Issues in developing a multidisciplinary sex education program in a public university. J A m CONHealth. 1974;22:364-368. 6. US Congress, Office of Technology Assessment. How wfective Is AIDS Education? Washington, DC: US Government Printing Office; 1988. 7. Friedman SR, Des Jarlais DC, Sotheran JL. AIDS health education for intravenous drug users. Health Educ Q. 1986;13:383-393. 8. Evans RI, Rozelle RM, Mittelmark MB, Hansen WB, Bane AL, Havis J. Deterring the onset of smoking in children: Knowledge of immediate physiological effects and coping with peer pressure, media pressure and parent modeling. J Appl SOCPsychol. 1978:8:126-135. 9. Rugg D. Evaluation of an innovative strategy for AIDS education: The impact of live theater. Unpublished manuscript. San Diego: San Diego State University, Graduate School of Public Health; 1987. 10. Solomon MZ, DeJong W. Preventing AIDS and other STDs through condom promotion: A patient education intervention. A m J P u b Health. 1989;79453458. 11. Sciacca JP, Melby CL, Femea PL. Peer consultation among college undergraduates: Implicatoins for student health education. Eta Sigma Gamman. 1986;18%-24. 12. Salovey P, D’Andrea V. A survey of campus peer counseling activities. J A m Coll Health. 1984;32:262-265. 13. Scott S, Warner R. Peer counseling. Personnel and Guidance J. 1975;53:228-231. 14. Carey MI. Peer health advisor program to reduce the health risks of university students. P u b Health Rep. 1984;

99(6):6 14-620. 15. Jordheim A. A comparison study of peer teaching and traditional instruction in venereal disease education. J A m Coll Health. 1976;24:286289. 16. Margulies E, Ito K. PEP: Peer education in health for student empowerment. Hawaii Med J. 1990;49(2):57-59. 17. Sciacca JP, Seehafer R. College peer health education: Program rationale, support, and example. Wellness Perspectives. 1986;3:3-8. 18. Richie ND, Stenroos D, Getty A. Using peer educators for a classroom-based AIDS program. J A m Coll Health. 1990,39(2):%-99. 19. Botvin G, Baker E, Renick E, Filazzalo A, et al. A cognitive-behavioral approach to substance abuse prevention. Addict Behav. 1984;9:137-147. 20. Leupker R, Johnson C, Murray D, Pechacek T. Prevention of cigarette smoking: Three-year follow-up of an education program for youth. J Behav Med. 1983;6(1):53-62. 21. Murray D, Johnson C, Leupker R, Mittelmark M. The prevention of cigarette smoking in children: A comparison of four strategies. J Appl SOCPsychol. 1984;14(3):274-288. 22. Arkin R, Roemhild H, Johson C, Leupker R, et al. The Minnesota smoking prevention program: A seventh grade health curriculum supplement. J Sch Health. 1981;51(9):

611-616. 23. Clark J, Macpherson B, Holmes D, Jones R. A comparison of peer-led, teacher-led, and expert interventions. J Sch Health. 1986;56(3):102-106. 24. Young RL, Elder JP, Green M, deMoor C, Wildey MB. Tobacco use prevention and health facilitator effectiveness. J Sch Health. 1988;58(9):370-373. 25. McGrath PJ, Firestone P, eds. Pediatric and Adolescent Behavioral Medicine: Issues in Treatment. New York: Springer; 1983.

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Effects of a peer-led AIDS intervention with university students.

Acquired immune deficiency syndrome (AIDS) has become a major health threat to university students. This study evaluated a peer-led AIDS intervention ...
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