Using the PRECEDE Model to Determine Junior High School Students' Knowledge, Attitudes, and Beliefs about AIDS Ruth R. Alteneder, James H. Price, Susan K. Telljohann, Judy Didion, Ann Locher
ABSTRACT: The effectiveness of a one-period school-based A IDS education program on an adolescent population of seventh and eighth grade students (N = 585) was determined. A n instrument based on the PRECEDE model was used to assess program effectiveness. Three-way analysis of variance indicated significant differences (p v .01) between pretest to posttest scores for knowledge, attitude, and beliefs for those who received the program versus those who did not by grade and gender of students. The intervention group scored significantly higher than the comparison group on knowledge gain for both seventh and eighth grade students and for males and females. On attitude items, a significant increase occurred from pretest to posttest for eighth grade students who received the program, but not for seventh grade students. The experimental group of eighth grade students scored higher on the attitudes component than the comparison of eighth grade students on the posttest. When attitudes were examined by gender for females in the educational intervention. an increase occurred in attitude scores f r o m pretest to posttest. While belief scores increased significantly f r o m pretest to posttest for the experimental seventh and eighth grade students, significant increases occurred only for experimentat group females. Findings support the contention that a one-class period AIDS education program can affect more than just knowledge since attitudes and beliefs also were partially affected. ( J Sch Health. 1992;62(10):464-470)
A
dolescents face a high risk for HIV infection given their sexual behavior, variety of sexual activities in which they engage (intercourse, anal sex, and oral sex), their lack of contraceptive protection, and their drug use behavior.lJ They also face increased risk because of their impulsiveness, desire for immediate gratification, and their tendency to perceive themselves as invincible. Because of the long incubation period for development of AIDS (8-12 years), and because better than one in five AIDS cases are diagnosed between ages 20-29, at least one-fifth of AIDS cases probably develop during adolescence. The earliest study of adolescents' AIDS knowledge was conducted in 1983.' A multitude of surveys since then have found significant deficiencies in adolescents' AIDS-related knowledge and belief~.~-'O Some studied ' , I 2 that focused specifically on AIDS knowledge and beliefs of minority adolescents indicated further education about AIDS prevention is necessary to help maximize adolescents' understanding of AIDS. While several studies have assessed adolescents' knowledge and beliefs of AIDS, fewer studies have assessed the effects of AIDS education programs in schools. Only eight studies that evaluated the effectiveness of AIDS education programs in secondary schools were identified (Table 1). These eight studies all contained evaluation instrument deficiencies. Five did not identify reliability assessments for their instruments, six did not report validity assessments, and none used instruments based on a theoretical behavioral model.13-20 Ruth R. Alteneder, PhD, CNM, Associate Professor, Nursing, School of Nursing; and A n n Locher, BSN, RN, HIV Coordinator, Medical College of Ohio, Toledo, OH 43699; James H. Price, PhD, MPH, Professor, Health Education; and Susan K. Telljohann, HSD. Assistant Professor. Health Education, Dept. of Health Promotion and Human Performance, University of Toledo, Toledo, OH 43606; and Judy Didion, MSN, RN, Assistant Professor, Nursing, Lourdes College, Sylvania, OH 43S60. The study was funded by a grant f r o m the Medical College of Ohio Satellites. This article was submitted February 14. 1992, and revised and accepted for publication August 3, 1992.
464
Journal of School Health
The evaluation instrument deficiencies bring into question the effectiveness of secondary school AIDS education programs. If the results from these eight studies can be accepted, and the outlier scores are ignored, then one-fivehour AIDS education program may produce a 9% to 20% increase in knowledge about AIDS and a similar gain (8% to 20%) in more tolerant attitudes toward people with AIDS. None of the eight studies measured actual behavior change, but three assessed intentions to avoid AIDS-related risk behavior. One review of health education literature and AIDS risks claimed that the health belief model, the theory of reasoned action, and the PRECEDE model all make important contributions to explaining the effectiveness of HIV/AIDS education.21Yet, no research articles that specifically used the PRECEDE model to assess the effects of a one-hour AIDS education program for junior high school students could be located. Thus, this study developed a valid and reliable instrument based on the PRECEDE model to assess the effects of a onehour AIDS education program for junior high students.22 Predisposing, reinforcing, and enabling factors were examined according to grade and gender of the students since these two variables are related to the incidence of HIV risk behavior.23
METHODS Instrumentation
An open-ended, 35-item questionnaire was designed to elicit salient beliefs of adolescents about HIV and AIDS. This method, originated from the model of reasoned action, determined those beliefs most important to the respondent^.^' Questions were designed to elicit responses for major components of the PRECEDE model. Prior to administration, six junior high students reviewed the instrument questions to determine if language might be a problem. None were found. Specific examples of questions to obtain salient
December 1992, Vol. 62, No. 10
beliefs of students based on the PRECEDE model were: What do you think about people who have AIDS? (Predisposing Factor-Attitudes) What kind of people get AIDS? (Predisposing Factor-Beliefs) Where can you get condoms? (Enabling Factor) Who would be supportive of you using condoms if you engaged in sexual activity? (Reinforcing Factor) A closed-format PRECEDE instrument was developed from responses to the elicitation questionnaire. Statements given by 15% of participants were determined to be salient beliefs and were used to develop the final questions (Figure 1). In addition to responses from the elicitation survey, other items were incorporated from the AIDS literature to adequately cover the knowledge area and to incorporate items used frequently in AIDS surveys. A pilot test was conducted using 67 seventh and eighth grade students with demographic variables similar to the final sample population. No instrument problems were found. Students completed the survey in 15 minutes. The final instrument contained four sections. Section I: How the AIDS Virus Is Spread and Section 11: Facts About AIDS consisted of the predisposing factor of 20 knowledge items. Section 111: Your Feelings About AIDS consisted of the predisposing factors addressing attitudes (10 items), perceptions (eight items), values (seven items), beliefs (nine items), enabling factors (seven items), and reinforcing factors (12 items). Section IV provided demographic information about the respondents, behavior assessment, and sources of AIDS information. Sections I and I1 used a three-point scale: agree, disagree, or not sure. Section 111 used a five-point Likert Scale of strongly agree, agree, not sure, disagree, or strongly disagree. To establish content validity, the instrument was
sent to five professionals experienced in health education, application of the PRECEDE model, knowledge of AIDS education for adolescents, and visibility in nationally refereed journals. Each individual comFigure 1 Sample Items on Closed-ended PRECEDE Instrument' Number of Items In Flntl Instrument
PRECEDE Components
~
Predlrporing Ftctora Knowledge The virus that causes AIDS is spread by giving blood at a blood bank The rate of new AIDS cases is decreasing
20
Attitudes I believe someone who has AIDS should continue in school People lust like me can get AIDS
10
Plrceptlonr People who use condoms correctly are smart People often begin to shoot drugs because their friends want them to
8
v8lUO8
7
If someone I knew had AIDS, I would no longer be lriends with them If my girl/boy friend did not want me to use a condom, I would not use it. Bellefs AIDS research is necessary and important. We should make free needles available to everyone.
9
Enabling Factor8 I am embarrassed to buy condoms Clean needles. syringes, and drugs are easy to get
7
Relnforclng Factors My parents have never talked to me about AIDS. My teachers say I should not have sex.
12
'Complete instrument is available from the authors.
Table 1 Effects of School-Based AIDS Education Programs Study (Date) Miller & Downer (1988) Johnson el al (1988)
N
Grade Level
Length Intarvention
114
1 tth
50 Min.
13% increase in knowledge; 19% increase in tolerant attitudes
1,294
12th
2 x 45 Min.
9 % increase in knowledge
Outcomes'
( 1989)
230 136
Middle school High school
3 Class Periods 3 Class Periods
14% increase in knowledge 16% increase in knowledge
Brown el al
174
7th
2 x 45 Min.
139
10th
2 x 45 Min.
11% increase in knowledge; 7% increase in tolerant attitudes; 10% decrease in attitudes toward high-risk behavior; 20% increase in coping with AIDS; 6% increase in knowledge; 10% Increase in tolerant attitudes, 20% increase in coping with a friend with AIDS
Huszti el al (1989)
284
10th
45 Min.
12%-15% increase in knowledge; 12%-20% increase in positive attitudes toward patients with AIDS; 2%-15% increase in positive attitudes toward practicing preventive behaviors
DiCiernenle el al
( 1989)
Ruder el al
358 504
10th. 11th. 12th 7th
75 Min. 75 Min.
6% increase in knowledge
( 1990)
Farley el al (1991)
186
12th
2 x 45 Min
21% increase in knowledge (16% increase in control group knowledge)
Brown el al (1991)
1,260 1.118
Junior high High school
4 7 Hours 4 7 Hours
13% increase in knowledge 8 % increase in tolerance toward people with AIDS No change in intention to avoid AIDS-related risk behaviors"
21% increase in knowledge
'Where outcomes are given as a range of scores, this is because results reported were by subgroups of respondents "Time span from pretest to postlest was only three weeks
Journal of School Health
December 1992, Vol. 62, No. 10
465
mented on the instrument either regarding the major components of the PRECEDE model or application of the instrument to adolescent participants. Several items were revised to clarify wording or expand on use of the model. Internal reliabilities of subscales were calculated using Cronbach’s alpha. Test-retest stability reliabilities for the subscales were obtained using 64 middle school students who completed the instrument twice, one week apart. Stability coefficients for subscales ranged from .44to .66. Analyses for internal consistency of components, measured in the final posttest studies, yielded Cronbach alpha coefficients ranging from .19 to .73 for the subscales (Table 2). Readability analyses were performed by two processes. Initially, the questionnaire was evaluated with the SMOG readability formula. z 5 This evaluation yielded an eighth-grade reading level (Standard Error = & 1.5). The high score in this formula resulted from frequent use of the abbreviation, AIDS, which must be analyzed as the entire polysyllabic words. Further testing with the Readability Estimatorz6computer program allowed six tests to be used with “AIDS” as a single syllable. Grades indicated by the computer formulas were Dale-Chall 6.6, Fog 6.3, Flesch 6.2, Flesch-Kincaid 4.2, Fry 4, and SMOG 5 with an average grade of 5 . 5 . Program Development
Using a quasi-experimental study format,” a onehour HIV/AIDS education program was designed for junior high school students. Program objectives were to define AIDS, describe the differences between HIV infection and AIDS, discuss the “iceberg concept,” compare morbidity and mortality statistics, explain how the AIDS virus enters the body, identify personal beliefs that are myths about casual transmission of AIDS, describe how HIV harms the body’s defense system, recognize high-risk behavior, and identify three patterns of behavior to help prevent HIV infection. The onehour presentation limitation was determined by the schools. Thus, the program was developed for presentation in one class period using slides to enhance learning. A brochure and letter, explaining the availability of the AIDS educator and the description and objectives of the program, were mailed to school administrators in the region. Participants were students in the schools that requested the educational program. One hundred seventy-seven letters were sent and 43 schools requested the program. From those requesting the program, six schools were selected randomly for the study. Students were selected for the comparison group from Table 2 Analyses for Reliability of PRECEDE Model Components Model Component Predisposing Factors (Total) Knowledge Alliludes Beliels Values Perceplions Reinforcing Factors Enabling Factors
54 20 10 9 7 0 12 7
466 * Journal of School Health
51
-
73
66 62 49 66 55 44 4a
61 49
59 52 60 19
*
December 1992, Vol. 62,
the same region and same pool of schools seeking the education program. Five schools comprised this group. Pretests were administered to the experimental group prior to the education program and posttest occurred two weeks after program completion. Data were collected in classrooms, and students were informed their responses would be anonymous and confidential. Comparison group students took tests two weeks apart. The education program was available to the comparison groups at later dates. Subjects
The sample population was drawn from seventh and eighth grade students in Ohio. Students from six schools comprised the experimental group. In this group, 604 students completed the pretest for a response rate of 96%. Two hundred fifty-five students were in seventh grade and 326 were in eighth grade, with ages ranging from 11-15 years. Most students (88.6%; N = 535) reported they were White; 18 @To) reported they were Black. Five hundred eighty-five students completed the posttest for a 97% response rate. Of this group, 256 were in seventh grade and 3 12 were in eighth grade, with ages ranging from 11-15 years. Ninety percent identified themselves as White, 3% as Black. The comparison group sample was obtained from five schools. In this group, 529 students completed the posttest for a 97% response rate. One hundred fifty students were in seventh grade and 366 were in eighth grade, with ages ranging from 11-15 years. Most (431; 81.5%) indicated they were White; 53 (10%) reported they were Black. The posttest was completed by 531 students for a 96% response rate. Of this group, 140 were in seventh grade and 369 were in eighth grade, with ages ranging from 11-15 years. Sevety-nine percent reported they were White and 9.6 reported they were Black. Data Analysis
Data analysis was completed with the Statistical Procedure for the Social Science Computer Package (SPSSX).211Each component of the PRECEDE model was tested using the sums of items designed to test each component. This process included predisposing, enabling, and reinforcing factors. Subcomponents of the predisposing factors studied for hypothesis testing included knowledge, attitudes, beliefs, values, and perceptions. Descriptive statistics described demographic characteristics, behavioral intention, and knowledge sources. Hypothesis testing of individual subcomponents of the model, demographic characteristics, and groups of study participants was accomplished using three-way analysis of variance (ANOVA). Comparisons were made between groups receiving school-based AIDS education and groups who had not received education. Data analysis for samples at pretest and posttest were for independent cross-sectional samples. Since analysis was conducted on several dependent variables, the level of significance was set at .01 or less as a conservative measure. RESULTS Grade of Subjects
The hypothesis that no differences would exist be-
No. 10
tween pretest and posttest means for AIDS knowledge between seventh and eighth grade groups with limited school-based AIDS education and those without such education was tested by a 2 x 2 x 2 analysis of variance, No significant three-way interaction was found between grade level, test (pretest, posttest), and group (whether
or not an AIDS class had been presented). Examination of significant two-way interaction 0, .O001) between test and group yielded a disordinal interaction. When both groups were considered from pretest to posttest, the experimental group began at a lower level and posttest scores indicated a higher achievement while the
Table 3 Means and Standard Deviations to Test PRECEDE Components for Grade by Groups and Tests Experimental
Comparison Potential Range Predisposing Factors Knowledge Grade 7
M
posttest M SO
SO
295 11 95 N = 140 331 13 42 N = 369
12 11 285 N = 150 2 83 13 29 N = 366
Attitudes Grade 7 Grade 8
10-50
Beliefs Grade 7 Grade 8
9-45
Values Grade 7 Grade 8
7-35
Perceptions Grade 7 Grade 8
8-40
M
posttest M SO
SO
340 11 75 N = 255 12 68 2 96 N = 326
13 94 303 N =256 3 13 14 86 N = 312
39.52 39.36
4.04 4.55
39.08 38.91
4.19 5.10
39.04 39.07
4.32 4.42
40.00 40.72
5 13 4 87
34.81 35.81
3.27 3.45
34.84 35.26
3.79 4.31
34.34 35.20
3.93 3.66
35 11 35.95
3 86 4 06
28.0 27.42
3.02 3.48
26.95 26.43
3.02 4.05
27.43 27.22
3.68 3.75
27.15 26.78
3 85 4 03
30.67 30.49
3.45 3.82
30.51 29.96
3.54 3.99
30.99 30.41
3.84 3.47
31.03 30.86
4 07 4 06
44.26 41.82
5.87 5.74
44.23 41.90
5.97 5.77
41.71 41.73
5.74 5.80
42.39 42.56
6 14 6 09
24.59 24.60
2.93 2.98
24.16 24.14
2.67 3.16
24.22 24.12
3.26 2.87
24.07 24.01
3 11 3 17
12-60
7-35
Enabling Factors Grade 7 Grade 8
Pretast
0-20
Grade 8
Reinforcing Factors Grade 7 Grade 8
Pretest
~
~
Table 4 Means and Standard Deviations to Test PRECEDE Components for Gender by Groups and Tests Experimental
Comparison Potential
RsnOa ~
Posttort M SO
2.80 13 42 N = 257 2.93 12.61 N = 259
3.46 13.16 N = 241 12.89 3.10 N = 270
11.81 3.10 N = 271
Posttart M SO
~
Predisposing Factors Knowledge Male
0-20
Female Attitudes Male Female
10-50
Beliefs Male Female
9-45
Values Male Female
7-35
Perceptions Male Female
8-40
Reinforcing Factors Male Female Enabling Factors Male Female
Pretest M SO
Pretest M SO ~
12.68
3.23
N = 312
3.23 14.34 N =293 14.57 3.0 N = 279
39 00 39 81
4.80 3.94
37.83 39.87
5.44 4.25
38.72 39.41
4.62 4.04
39 50 41 26
5 51 4 26
35 97 35 07
3.58 3.22
34.87 35.31
4.62 3.83
35.11 34.50
3.99 3.56
35 24 35 84
4 26 3 68
26 88 28 29
3.40 3.17
25.26 27.64
4.18 3.27
26.83 27.87
3.85 3.46
25 74 28 15
4 00 3 52
30 13 30 95
4.022 3 34
29.39 30.68
4.23 3.48
30.42 30.93
3.71 3.55
30 28 31 55
4 37 3 62
41 67 43 49
5.86 5.77
41.73 43.25
5.95 5.79
41 57 41.87
5.52 6.05
41 96 43 02
6 08 6 07
24 16 25 02
3.03 2.84
23.61 24.56
3.17 2.89
24.00 24 37
3.22 2.83
23 62 24 45
3 25 2 99
12-60
7-35
Journal of School Health
December 1992, Vol. 62, No. 10
467
comparison group remained essentially unchanged. Analysis of simple effects yielded significant differences between comparison and experimental grade seven students on posttest [F (1,394) = 39.8709, p < .0001] and between comparison and experimental grade eight students [F (1,679) = 33.6442, p c .oOOl). Significant main effects for knowledge (p .OO01) were produced for grade, test, and group. The study also hypothesized no difference between pretest and posttest means for attitudes toward AIDS in the seventh and eighth grade groups who received school-based AIDS education and those who did not receive such education. Results from the three-way analysis of variance indicated no significant three-way interaction among grade, test, and group for attitudes. A significant (p < .OOOl) interaction occurred between test and group, which again was a disordinal interaction. Both groups at pretest were similar with the experimental group slightly lower but the experimental group achieved higher scores at posttest. When analysis of simple effects was completed, a significant difference existed on posttest between the eighth grade group who received AIDS education and those who did not [F (1,679) = 22.1156, p c .OOOl). Significant main effects were found for attitudes in both grades for comparison and experimental groups [F (1,2173) = 7.478, p c .01]. A third hypothesis projected no difference between pretest and posttest means for AIDS beliefs in the two groups. The 2 x 2 x 2 ANOVA on the nine belief items found no significant interaction among grade, test, and group, but a significant two-way interaction (p v .01) occurred between test and group. A disordinal interaction was evident as experimental group pretest scores were lowest, then rose to the level of comparison group at posttest. However, the comparison group dropped at posttest. Analysis of simple effects yielded significance between the groups for eighth grade students on the posttest [F (1,679) = 4.2877, p .05]. The only significant main effect was for grade [F (1,2173) = 20.141, p < .0001]. It was expected that no differences would exist between pretest and posttest means for AIDS values in the two grade groups. The three-way ANOVA to test the program’s seven value items found no significant threeway or two-way interactions. Therefore, the significant main effect of the test may be interpreted. No significant difference was seen between grades for the values component. Further, it was expected that no differences would exist between perceptions in the two adolescent grade groups. Eight items composed the perceptions scale. No significant effects were found from the three-way ANOVA in either interactions or main effects for grade, test, or group (Table 3). A three-way ANOVA to test AIDS reinforcing factors by grade of subjects yielded no significant interaction among grade, test, and group. A significant interaction was found between group x grade [F (1,2166) = 21.243, p c .0001] and for the main effect of grade (p < .OOOl). Seventh grade subjects in the comparison group on pretest achieved higher mean scores on 12 reinforcing items than any other group either before or
468
Journal of School Health
after education (Table 3). Seven items dealt with enabling factors. The threeway ANOVA to test enabling factors from pretest to posttest by grade of subjects found no significant interactions or main effects among grade, test, and group. Gender of Subjects
Hypotheses concerning gender postulated no differences between pretest and posttest means for predisposing factors (knowledge, attitudes, beliefs, values, and perceptions) between male and female adolescents having a limited AIDS education program and those not having such education. A 2 x 2 x 2 way ANOVA to test the knowledge component between male and female students was not significant. Two significant two-way interactions were found between gender and test (p c .01) and test and group (p < .OOOl). The disordinal interaction between test and group indicated that when both groups were considered from pretest to posttest, the experimental group began at a lower level and posttest scores indicated higher achievement while the comparison group remained essentially the same. Analysis of simple effects found significant differences [F (1,581) = 10.9403, p < .01] between the gender groups on the experimental pretest but not on posttest. When significant main effects are considered for gender and test, experimental female students gained significantly more than male students on their knowledge scores. Results from the three-way ANOVA indicated no significant three-way interaction for attitudes toward AIDS among gender, test, and group. Two-way interactions were significant (p < -01) between gender and test and test and group. The disordinal interaction between test and group indicated that when both gender groups were considered from pretest to posttest, the experimental group began at a lower attitude level than the comparison group. At posttest, the comparison group’s mean dropped while the experimental group score increased (Table 4). However, the analysis of simple effects indicated significant differences existed between the genders on the posttest, experimental posttest [F (1,570) = 18.1326, p < .0001], and comparison posttest [F (1,509) = 22.4875, p < .0001]. Significant main effects for attitudes were produced for gender. Both groups of males’ attitudes remained essentially unchanged from pretest t o posttest. Female scores in the comparison group were similar. However, the experimental group scored 79% on the pretest and 83% on the posttest. A significant difference also was found between grades. The 2 x 2 x 2 ANOVA to test the program’s impact on belief items did not find an interaction among gender, test, and group. Two-way analyses between gender and test and between test and group were significant (p < .OOOl). On pretest, the experimental group had lower scores than the comparison group, and this group achieved a higher level on posttest while the comparison group dropped. No significant simple or main effects were found. The three-way ANOVA to test the program’s effect on values found no significant interaction among gender, test, and group. A significant two-way ordinal
December 1992, Vol. 62, No. 10
interaction was found between gender and test, but no interaction was present between test and group. When male students and female students were considered as a group, scores dropped from pretest to posttest. Significant (p c .01) main effects were found for both group and gender. The three-way ANOVA to test the program’s effects by gender found no significant effects in either the three-way or two-way interactions for grade, test, or group. Significant main effects were found for gender and group (p c .01). Comparison and experimental groups for the males and females had virtually the same scores from pretest to posttest (Table 4). The three-way ANOVA to test AIDS reinforcing factors by gender of subjects found no significant three or two-way interactions among gender, test, and group. The main effect of gender was significant. Females scored higher than males in both groups. One significant main result related to gender occurred when enabling factors were tested. No significant interactions were evident. Female pretest means in the comparison group were higher than all other groups (Table 4).
DISCUSSl ON This investigation determined the effectiveness of the PRECEDE model in evaluating an AIDS education program for an adolescent population of seventh and eighth grade students. Components of the model examined included predisposing, reinforcing, and enabling factors. When students from the AIDS education groups were compared with those who did not receive AIDS education, significant differences were found from pretest to posttest by grade and gender. Increases in knowledge scores were similar to findings from previous evaluations of school-based AIDS education. Miller and Downer” reported a 13% increase in knowledge on posttest one week after an education program. Questions such as how contact with the AIDS virus is made indicated students understood that casual contact was not an avenue of infection. In this study, students understood that sexual contact is the primary source of spread for the virus, as 92% of the experimental group answered this question correctly on posttest in contrast to 88% of the comparison group. However, on the pretest this knowledge already was evident with a high percentage of correct responses in both groups (93% in the comparison group and 90% in the experimental group). It was anticipated that knowledge would improve, but the level of improvement was hampered by high levels of pretest knowledge in some areas, possibly causing a ceiling effect. Johnson et all4 demonstrated that only one more correct question was seen on posttest after two consecutive classes of 45 minutes. DiClemente et all5 found a posttest knowledge advantage of 4.2 more correct responses after three class periods with a strong trend in the middle school group. This finding contrasts with a change of two questions correctly identified in this study. When reviewing the literature, a direct comparison of the relative effectiveness of different forms of education found the lecture-discussion approach was effective. Thus, the lecture-discussion approach was used in
this study. The increase in knowledge found in this study may have related directly to the effectiveness of the presenter. The instructor was a nurse at a medical college infection control department where AIDS patients were hospitalized. This individual related to adolescents in a fashion that retained their interests during the AIDS lesson. The time allowed for presenting the content was limited by the schools that requested a one-class period presentation. However, a three-to-five-session presentation would provide more time for discussion and allow for additional exploration of the attitudinal and behavioral aspects inherent in the PRECEDE model. Students also could learn from their peers in such activities as role playing or group interactions. Only through more extensive educational interventions can one expect to effect behavior change. Females in this study increased their knowledge scores in the experimental group by 14% compared to the males’ increase of 8%. This gender difference also was apparent in the study conducted by Huszti et all’ where female students had greater knowledge about AIDS than male students in all measurement times of pretest, posttest, and follow-up. The fact the program instructor was female might have led to this difference, since female students might have associated with her in a different manner than did the males. Finally, limitations of this study should be noted. Since experimental groups were self-selected, in that they contacted the AIDS educator, these groups possibly were less knowledgeable and were perceived by their teachers as less knowledgeable about AIDS. However, study comparison groups were located in the same areas of the state. Second, accuracy of the results depended on the validity and reliability of self-reported data. Again, this limitation may have been minimized since responses were anonymous and confidential. Third, participation in the study was voluntary, thereby affecting generalizability of the results. Fourth, the study was conducted in only one area of Ohio, also affecting generalizability of results. Finally, the limited time allowed for the intervention precluded adequate educational interventions to influence the enabling and reinforcing factors of the PRECEDE model.
CONCLUSION The past decade of research on AIDS produced considerable growth in knowledge regarding molecular biology and pathophysiology of AIDS. However, knowledge of how to maximize the effectiveness of AIDS prevention programs remains limited. This study found statistically significant effects on the predisposing component (knowledge, attitudes, and beliefs) of the PRECEDE model for junior high school students who received a one-hour class presentation. Yet, the practical significance and long-term effects of the study remain unclear. However, the PRECEDE model provides a useful program evaluation tool when adequately operationalized. Further use of the PRECEDE model is recommended to assess its ability to differentiate students at high risk from those at low risk for HIV infection. To date, school-based AIDS intervention programs
Journal of School Health
December 1992, Vol. 62. No. 10
469
reported in professional journals have not answered some major questions. Future school-based AIDS interventions should address several questions. How much time should be devoted at the various grade levels for AIDS education to be beneficial? What specific content should be taught at the various grade levels? What teaching techniques maximize learning and change behavior? What in-service training approaches for teachers can maximize their effectiveness? What behaviors, or proxies for behaviors, should be assessed to measure the effectiveness of AIDS educational interventions? What political and environmental changes can help reduce AIDS risk behaviors in children and adolescents? What outcomes should be measured to assess the effectiveness of AIDS education? What forms of follow-up to school-based AIDS education can help ensure that adolescents who begin practicing safer sexual behavior do not relapse into risky sexual behavior?
References I . Alan Guttmacher Institute. United States and cross-national trends in teenage sexuality and fertility behavior, 1986. In: Cenrerfor Population Options, Fact Sheet. Washington, DC: Center for Population Options; 1987. 2. Zelnik M, Katner JF. Sexuality activity, contraception use and pregnancy among metropolitan-area teenagers: 1971-1979.Fam Plann Perspecr. 1980;12:230-237. 3 . HIVIAIDS Surveillance Report, October 1991. Atlanta, GA: Centers for Disease Control; 1991: 18. 4 . Price J H , Desmond S, Kukulka G. High school students' perceptions and misperceptions of AIDS. J Sch Health. 1985;55:107-109. 5 . DiClemente RJ, Zorn J , Temoshok L. Adolescents and AIDS: A survey of knowledge, attitudes, and beliefs about AIDS in San Francisco. A m J Public Health. 1986;76:1443-1445. 6. Strunin L. Hingson R. Acquired immunodeficiency syndrome and adolescents: Knowledge, beliefs, attitudes, and behavior. Pediatrics. 1987;79:825-828. 7. Hingson RW, Strunin L, Berlin BM, Heeren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. A m J Public Health. 1988;78:460-461. 8 . Jones H, Ellis N, Tappe M, Lindsay G. HIV related beliefs, knowledge and behaviors of ninth and eleventh grade public school students. J Healrh Educ. 1991;22:12-18. 9. Anderson JE, Kann L, Holtzman D, Arday S, Truman B,
Kolbe LJ. HIVIAIDS knowledge, and sexual behavior among high school students. Fam Plann Perspect. 1990;22:252-255. 10. Kann L, Anderson JE, Holtzman D, Ross J , Truman BI. Collins J , Kolbe LJ. HIV-related knowledge, beliefs and behaviors among high school students in the United States: Results from a national survey. J Sch Healfh. 1991;61:397-401. 1 I . DiClemente RJ, Boyer CB, Morales ES. Minorities and AIDS: Knowledge, attitudes, and misconceptions among black and Latino adolescents. A m J Public Health. 1988;78:55-57. 12. Siege1 D, Lazarus N. Krzsnovsky F, Durbin M, Chesney M. AIDS knowledge, attitudes, and behavior among inner city, junior high school students. J Sch Health. 1991;61:160-165. 13. Miller L, Downer A. AIDS: What you and y o u r friends need to know - a lesson plan for adolescents. JSch Health. 1988;58:137-141. 14. Johnson J A , Sellew F, Campbell AE, Haskell EG, Gay AA. Bell BJ. A program using medical students to teach high school students about AIDS. J Med Educ. 1988;63:522-530. IS. DiClemente RJ, Pies CA, Stoller EY. Straits C , Olivia GE, Haskin J , Rutherford GW. Evaluation of school-based AIDS education curricula in San Francisco. J Sex Rex 1989;26:188-198, 16. Brown LK, Fritz GK, Barone VJ. The impact of AIDS education on junior and senior high school students - a pilot study. J Adolesc Health Care. 1989;9:139-143. 17. Huszti HC, Clopton J R , Mason P J , Acquired immunodeficiency syndrome educational program: Effects on adolescents' knowledge and attitudes. Pediatrics. 1989;84:986-994. 18. Ruder AM, Flam R, Flatto D, Curran AS. AIDS education: Evaluation of school and worksite based presentations. NY Stare J Med. 1990;90:129-133. 19. Farley TA, Pomputius PF, Sabella W, Helgerson SD, Hadler JL. Evaluation of the effect of school-based education on adolescents' AIDS knowledge and attitudes. Conn Med. 1991;55:15-18. 20. Brown LK, Barone VJ, Fritz GK, Cebollero P, Nasswu J H . AIDS education: The Rhode Island experience. Health Educ Q. 1991 ;18: 195-206. 21. Ross MW, Rosser BRS. Education and AIDS risks: A review. Health Educ Res. 1989;4:273-284. 22. Green LW, Kreuter NW, Deeds SG, Partridge KB. Health Education Planning: A diagnostic approach. Palo Alto, Calif: Mayfield; 1980. 23. Centers for Disease Control. Selected behaviors that increase risk for HIV infection among high school students - United States, 1990. M M W R . 1992;41:231, 237-240. 24. Ajzen I , Fishbein M. Understanding Altitudes and Predicring Social Behavior. Englewood Cliffs, NJ: Prentice-Hall, Inc; 1980. 25. Office of Cancer Communications. Readability Testing in Cancer Communications. Bethesda. Md: US Dept of Health, Education and Welfare, NIH publication no 79-1689; 1979. 26. Readability Esrimator. Micro School Programs. Seattle, Wash: Berta-max. Inc; 1988. 27. Campbell DT, Stanley JC. Experimental and quasiexperimental designs for research and teaching. In: Gage NL, ed. Handbook of Research on Teaching. Chicago, Ill: Rand McNally, 1963. Reprinted as Experimenral and Quasi-Experimental Designs f o r Research. Boston, Mass: Houghton Mifflin; 1966. 28. SPSSX User's Guide, 2nd ed., Chicago, 111: SPSS Inc; 1986.
Statement of Purpose The lournu/ of School Heulrh. an official publication of the American School Health Association, publishes material related to health promotion in school settings. h u r n a l 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 ]nuniu/: copies also may be obtained from the bunral office, P.O. Box 708. Kent, OH 44240.
470
J o u r n a l of S c h o o l Health
December 1992, Vol. 62, No. 10
ABSTRACT: The effectiveness of a one-period school-based A IDS education program on an adolescent population of seventh and eighth grade students (N = 585) was determined. A n instrument based on the PRECEDE model was used to assess program effectiveness. Three-way analysis of variance indicated significant differences (p v .01) between pretest to posttest scores for knowledge, attitude, and beliefs for those who received the program versus those who did not by grade and gender of students. The intervention group scored significantly higher than the comparison group on knowledge gain for both seventh and eighth grade students and for males and females. On attitude items, a significant increase occurred from pretest to posttest for eighth grade students who received the program, but not for seventh grade students. The experimental group of eighth grade students scored higher on the attitudes component than the comparison of eighth grade students on the posttest. When attitudes were examined by gender for females in the educational intervention. an increase occurred in attitude scores f r o m pretest to posttest. While belief scores increased significantly f r o m pretest to posttest for the experimental seventh and eighth grade students, significant increases occurred only for experimentat group females. Findings support the contention that a one-class period AIDS education program can affect more than just knowledge since attitudes and beliefs also were partially affected. ( J Sch Health. 1992;62(10):464-470)
A
dolescents face a high risk for HIV infection given their sexual behavior, variety of sexual activities in which they engage (intercourse, anal sex, and oral sex), their lack of contraceptive protection, and their drug use behavior.lJ They also face increased risk because of their impulsiveness, desire for immediate gratification, and their tendency to perceive themselves as invincible. Because of the long incubation period for development of AIDS (8-12 years), and because better than one in five AIDS cases are diagnosed between ages 20-29, at least one-fifth of AIDS cases probably develop during adolescence. The earliest study of adolescents' AIDS knowledge was conducted in 1983.' A multitude of surveys since then have found significant deficiencies in adolescents' AIDS-related knowledge and belief~.~-'O Some studied ' , I 2 that focused specifically on AIDS knowledge and beliefs of minority adolescents indicated further education about AIDS prevention is necessary to help maximize adolescents' understanding of AIDS. While several studies have assessed adolescents' knowledge and beliefs of AIDS, fewer studies have assessed the effects of AIDS education programs in schools. Only eight studies that evaluated the effectiveness of AIDS education programs in secondary schools were identified (Table 1). These eight studies all contained evaluation instrument deficiencies. Five did not identify reliability assessments for their instruments, six did not report validity assessments, and none used instruments based on a theoretical behavioral model.13-20 Ruth R. Alteneder, PhD, CNM, Associate Professor, Nursing, School of Nursing; and A n n Locher, BSN, RN, HIV Coordinator, Medical College of Ohio, Toledo, OH 43699; James H. Price, PhD, MPH, Professor, Health Education; and Susan K. Telljohann, HSD. Assistant Professor. Health Education, Dept. of Health Promotion and Human Performance, University of Toledo, Toledo, OH 43606; and Judy Didion, MSN, RN, Assistant Professor, Nursing, Lourdes College, Sylvania, OH 43S60. The study was funded by a grant f r o m the Medical College of Ohio Satellites. This article was submitted February 14. 1992, and revised and accepted for publication August 3, 1992.
464
Journal of School Health
The evaluation instrument deficiencies bring into question the effectiveness of secondary school AIDS education programs. If the results from these eight studies can be accepted, and the outlier scores are ignored, then one-fivehour AIDS education program may produce a 9% to 20% increase in knowledge about AIDS and a similar gain (8% to 20%) in more tolerant attitudes toward people with AIDS. None of the eight studies measured actual behavior change, but three assessed intentions to avoid AIDS-related risk behavior. One review of health education literature and AIDS risks claimed that the health belief model, the theory of reasoned action, and the PRECEDE model all make important contributions to explaining the effectiveness of HIV/AIDS education.21Yet, no research articles that specifically used the PRECEDE model to assess the effects of a one-hour AIDS education program for junior high school students could be located. Thus, this study developed a valid and reliable instrument based on the PRECEDE model to assess the effects of a onehour AIDS education program for junior high students.22 Predisposing, reinforcing, and enabling factors were examined according to grade and gender of the students since these two variables are related to the incidence of HIV risk behavior.23
METHODS Instrumentation
An open-ended, 35-item questionnaire was designed to elicit salient beliefs of adolescents about HIV and AIDS. This method, originated from the model of reasoned action, determined those beliefs most important to the respondent^.^' Questions were designed to elicit responses for major components of the PRECEDE model. Prior to administration, six junior high students reviewed the instrument questions to determine if language might be a problem. None were found. Specific examples of questions to obtain salient
December 1992, Vol. 62, No. 10
beliefs of students based on the PRECEDE model were: What do you think about people who have AIDS? (Predisposing Factor-Attitudes) What kind of people get AIDS? (Predisposing Factor-Beliefs) Where can you get condoms? (Enabling Factor) Who would be supportive of you using condoms if you engaged in sexual activity? (Reinforcing Factor) A closed-format PRECEDE instrument was developed from responses to the elicitation questionnaire. Statements given by 15% of participants were determined to be salient beliefs and were used to develop the final questions (Figure 1). In addition to responses from the elicitation survey, other items were incorporated from the AIDS literature to adequately cover the knowledge area and to incorporate items used frequently in AIDS surveys. A pilot test was conducted using 67 seventh and eighth grade students with demographic variables similar to the final sample population. No instrument problems were found. Students completed the survey in 15 minutes. The final instrument contained four sections. Section I: How the AIDS Virus Is Spread and Section 11: Facts About AIDS consisted of the predisposing factor of 20 knowledge items. Section 111: Your Feelings About AIDS consisted of the predisposing factors addressing attitudes (10 items), perceptions (eight items), values (seven items), beliefs (nine items), enabling factors (seven items), and reinforcing factors (12 items). Section IV provided demographic information about the respondents, behavior assessment, and sources of AIDS information. Sections I and I1 used a three-point scale: agree, disagree, or not sure. Section 111 used a five-point Likert Scale of strongly agree, agree, not sure, disagree, or strongly disagree. To establish content validity, the instrument was
sent to five professionals experienced in health education, application of the PRECEDE model, knowledge of AIDS education for adolescents, and visibility in nationally refereed journals. Each individual comFigure 1 Sample Items on Closed-ended PRECEDE Instrument' Number of Items In Flntl Instrument
PRECEDE Components
~
Predlrporing Ftctora Knowledge The virus that causes AIDS is spread by giving blood at a blood bank The rate of new AIDS cases is decreasing
20
Attitudes I believe someone who has AIDS should continue in school People lust like me can get AIDS
10
Plrceptlonr People who use condoms correctly are smart People often begin to shoot drugs because their friends want them to
8
v8lUO8
7
If someone I knew had AIDS, I would no longer be lriends with them If my girl/boy friend did not want me to use a condom, I would not use it. Bellefs AIDS research is necessary and important. We should make free needles available to everyone.
9
Enabling Factor8 I am embarrassed to buy condoms Clean needles. syringes, and drugs are easy to get
7
Relnforclng Factors My parents have never talked to me about AIDS. My teachers say I should not have sex.
12
'Complete instrument is available from the authors.
Table 1 Effects of School-Based AIDS Education Programs Study (Date) Miller & Downer (1988) Johnson el al (1988)
N
Grade Level
Length Intarvention
114
1 tth
50 Min.
13% increase in knowledge; 19% increase in tolerant attitudes
1,294
12th
2 x 45 Min.
9 % increase in knowledge
Outcomes'
( 1989)
230 136
Middle school High school
3 Class Periods 3 Class Periods
14% increase in knowledge 16% increase in knowledge
Brown el al
174
7th
2 x 45 Min.
139
10th
2 x 45 Min.
11% increase in knowledge; 7% increase in tolerant attitudes; 10% decrease in attitudes toward high-risk behavior; 20% increase in coping with AIDS; 6% increase in knowledge; 10% Increase in tolerant attitudes, 20% increase in coping with a friend with AIDS
Huszti el al (1989)
284
10th
45 Min.
12%-15% increase in knowledge; 12%-20% increase in positive attitudes toward patients with AIDS; 2%-15% increase in positive attitudes toward practicing preventive behaviors
DiCiernenle el al
( 1989)
Ruder el al
358 504
10th. 11th. 12th 7th
75 Min. 75 Min.
6% increase in knowledge
( 1990)
Farley el al (1991)
186
12th
2 x 45 Min
21% increase in knowledge (16% increase in control group knowledge)
Brown el al (1991)
1,260 1.118
Junior high High school
4 7 Hours 4 7 Hours
13% increase in knowledge 8 % increase in tolerance toward people with AIDS No change in intention to avoid AIDS-related risk behaviors"
21% increase in knowledge
'Where outcomes are given as a range of scores, this is because results reported were by subgroups of respondents "Time span from pretest to postlest was only three weeks
Journal of School Health
December 1992, Vol. 62, No. 10
465
mented on the instrument either regarding the major components of the PRECEDE model or application of the instrument to adolescent participants. Several items were revised to clarify wording or expand on use of the model. Internal reliabilities of subscales were calculated using Cronbach’s alpha. Test-retest stability reliabilities for the subscales were obtained using 64 middle school students who completed the instrument twice, one week apart. Stability coefficients for subscales ranged from .44to .66. Analyses for internal consistency of components, measured in the final posttest studies, yielded Cronbach alpha coefficients ranging from .19 to .73 for the subscales (Table 2). Readability analyses were performed by two processes. Initially, the questionnaire was evaluated with the SMOG readability formula. z 5 This evaluation yielded an eighth-grade reading level (Standard Error = & 1.5). The high score in this formula resulted from frequent use of the abbreviation, AIDS, which must be analyzed as the entire polysyllabic words. Further testing with the Readability Estimatorz6computer program allowed six tests to be used with “AIDS” as a single syllable. Grades indicated by the computer formulas were Dale-Chall 6.6, Fog 6.3, Flesch 6.2, Flesch-Kincaid 4.2, Fry 4, and SMOG 5 with an average grade of 5 . 5 . Program Development
Using a quasi-experimental study format,” a onehour HIV/AIDS education program was designed for junior high school students. Program objectives were to define AIDS, describe the differences between HIV infection and AIDS, discuss the “iceberg concept,” compare morbidity and mortality statistics, explain how the AIDS virus enters the body, identify personal beliefs that are myths about casual transmission of AIDS, describe how HIV harms the body’s defense system, recognize high-risk behavior, and identify three patterns of behavior to help prevent HIV infection. The onehour presentation limitation was determined by the schools. Thus, the program was developed for presentation in one class period using slides to enhance learning. A brochure and letter, explaining the availability of the AIDS educator and the description and objectives of the program, were mailed to school administrators in the region. Participants were students in the schools that requested the educational program. One hundred seventy-seven letters were sent and 43 schools requested the program. From those requesting the program, six schools were selected randomly for the study. Students were selected for the comparison group from Table 2 Analyses for Reliability of PRECEDE Model Components Model Component Predisposing Factors (Total) Knowledge Alliludes Beliels Values Perceplions Reinforcing Factors Enabling Factors
54 20 10 9 7 0 12 7
466 * Journal of School Health
51
-
73
66 62 49 66 55 44 4a
61 49
59 52 60 19
*
December 1992, Vol. 62,
the same region and same pool of schools seeking the education program. Five schools comprised this group. Pretests were administered to the experimental group prior to the education program and posttest occurred two weeks after program completion. Data were collected in classrooms, and students were informed their responses would be anonymous and confidential. Comparison group students took tests two weeks apart. The education program was available to the comparison groups at later dates. Subjects
The sample population was drawn from seventh and eighth grade students in Ohio. Students from six schools comprised the experimental group. In this group, 604 students completed the pretest for a response rate of 96%. Two hundred fifty-five students were in seventh grade and 326 were in eighth grade, with ages ranging from 11-15 years. Most students (88.6%; N = 535) reported they were White; 18 @To) reported they were Black. Five hundred eighty-five students completed the posttest for a 97% response rate. Of this group, 256 were in seventh grade and 3 12 were in eighth grade, with ages ranging from 11-15 years. Ninety percent identified themselves as White, 3% as Black. The comparison group sample was obtained from five schools. In this group, 529 students completed the posttest for a 97% response rate. One hundred fifty students were in seventh grade and 366 were in eighth grade, with ages ranging from 11-15 years. Most (431; 81.5%) indicated they were White; 53 (10%) reported they were Black. The posttest was completed by 531 students for a 96% response rate. Of this group, 140 were in seventh grade and 369 were in eighth grade, with ages ranging from 11-15 years. Sevety-nine percent reported they were White and 9.6 reported they were Black. Data Analysis
Data analysis was completed with the Statistical Procedure for the Social Science Computer Package (SPSSX).211Each component of the PRECEDE model was tested using the sums of items designed to test each component. This process included predisposing, enabling, and reinforcing factors. Subcomponents of the predisposing factors studied for hypothesis testing included knowledge, attitudes, beliefs, values, and perceptions. Descriptive statistics described demographic characteristics, behavioral intention, and knowledge sources. Hypothesis testing of individual subcomponents of the model, demographic characteristics, and groups of study participants was accomplished using three-way analysis of variance (ANOVA). Comparisons were made between groups receiving school-based AIDS education and groups who had not received education. Data analysis for samples at pretest and posttest were for independent cross-sectional samples. Since analysis was conducted on several dependent variables, the level of significance was set at .01 or less as a conservative measure. RESULTS Grade of Subjects
The hypothesis that no differences would exist be-
No. 10
tween pretest and posttest means for AIDS knowledge between seventh and eighth grade groups with limited school-based AIDS education and those without such education was tested by a 2 x 2 x 2 analysis of variance, No significant three-way interaction was found between grade level, test (pretest, posttest), and group (whether
or not an AIDS class had been presented). Examination of significant two-way interaction 0, .O001) between test and group yielded a disordinal interaction. When both groups were considered from pretest to posttest, the experimental group began at a lower level and posttest scores indicated a higher achievement while the
Table 3 Means and Standard Deviations to Test PRECEDE Components for Grade by Groups and Tests Experimental
Comparison Potential Range Predisposing Factors Knowledge Grade 7
M
posttest M SO
SO
295 11 95 N = 140 331 13 42 N = 369
12 11 285 N = 150 2 83 13 29 N = 366
Attitudes Grade 7 Grade 8
10-50
Beliefs Grade 7 Grade 8
9-45
Values Grade 7 Grade 8
7-35
Perceptions Grade 7 Grade 8
8-40
M
posttest M SO
SO
340 11 75 N = 255 12 68 2 96 N = 326
13 94 303 N =256 3 13 14 86 N = 312
39.52 39.36
4.04 4.55
39.08 38.91
4.19 5.10
39.04 39.07
4.32 4.42
40.00 40.72
5 13 4 87
34.81 35.81
3.27 3.45
34.84 35.26
3.79 4.31
34.34 35.20
3.93 3.66
35 11 35.95
3 86 4 06
28.0 27.42
3.02 3.48
26.95 26.43
3.02 4.05
27.43 27.22
3.68 3.75
27.15 26.78
3 85 4 03
30.67 30.49
3.45 3.82
30.51 29.96
3.54 3.99
30.99 30.41
3.84 3.47
31.03 30.86
4 07 4 06
44.26 41.82
5.87 5.74
44.23 41.90
5.97 5.77
41.71 41.73
5.74 5.80
42.39 42.56
6 14 6 09
24.59 24.60
2.93 2.98
24.16 24.14
2.67 3.16
24.22 24.12
3.26 2.87
24.07 24.01
3 11 3 17
12-60
7-35
Enabling Factors Grade 7 Grade 8
Pretast
0-20
Grade 8
Reinforcing Factors Grade 7 Grade 8
Pretest
~
~
Table 4 Means and Standard Deviations to Test PRECEDE Components for Gender by Groups and Tests Experimental
Comparison Potential
RsnOa ~
Posttort M SO
2.80 13 42 N = 257 2.93 12.61 N = 259
3.46 13.16 N = 241 12.89 3.10 N = 270
11.81 3.10 N = 271
Posttart M SO
~
Predisposing Factors Knowledge Male
0-20
Female Attitudes Male Female
10-50
Beliefs Male Female
9-45
Values Male Female
7-35
Perceptions Male Female
8-40
Reinforcing Factors Male Female Enabling Factors Male Female
Pretest M SO
Pretest M SO ~
12.68
3.23
N = 312
3.23 14.34 N =293 14.57 3.0 N = 279
39 00 39 81
4.80 3.94
37.83 39.87
5.44 4.25
38.72 39.41
4.62 4.04
39 50 41 26
5 51 4 26
35 97 35 07
3.58 3.22
34.87 35.31
4.62 3.83
35.11 34.50
3.99 3.56
35 24 35 84
4 26 3 68
26 88 28 29
3.40 3.17
25.26 27.64
4.18 3.27
26.83 27.87
3.85 3.46
25 74 28 15
4 00 3 52
30 13 30 95
4.022 3 34
29.39 30.68
4.23 3.48
30.42 30.93
3.71 3.55
30 28 31 55
4 37 3 62
41 67 43 49
5.86 5.77
41.73 43.25
5.95 5.79
41 57 41.87
5.52 6.05
41 96 43 02
6 08 6 07
24 16 25 02
3.03 2.84
23.61 24.56
3.17 2.89
24.00 24 37
3.22 2.83
23 62 24 45
3 25 2 99
12-60
7-35
Journal of School Health
December 1992, Vol. 62, No. 10
467
comparison group remained essentially unchanged. Analysis of simple effects yielded significant differences between comparison and experimental grade seven students on posttest [F (1,394) = 39.8709, p < .0001] and between comparison and experimental grade eight students [F (1,679) = 33.6442, p c .oOOl). Significant main effects for knowledge (p .OO01) were produced for grade, test, and group. The study also hypothesized no difference between pretest and posttest means for attitudes toward AIDS in the seventh and eighth grade groups who received school-based AIDS education and those who did not receive such education. Results from the three-way analysis of variance indicated no significant three-way interaction among grade, test, and group for attitudes. A significant (p < .OOOl) interaction occurred between test and group, which again was a disordinal interaction. Both groups at pretest were similar with the experimental group slightly lower but the experimental group achieved higher scores at posttest. When analysis of simple effects was completed, a significant difference existed on posttest between the eighth grade group who received AIDS education and those who did not [F (1,679) = 22.1156, p c .OOOl). Significant main effects were found for attitudes in both grades for comparison and experimental groups [F (1,2173) = 7.478, p c .01]. A third hypothesis projected no difference between pretest and posttest means for AIDS beliefs in the two groups. The 2 x 2 x 2 ANOVA on the nine belief items found no significant interaction among grade, test, and group, but a significant two-way interaction (p v .01) occurred between test and group. A disordinal interaction was evident as experimental group pretest scores were lowest, then rose to the level of comparison group at posttest. However, the comparison group dropped at posttest. Analysis of simple effects yielded significance between the groups for eighth grade students on the posttest [F (1,679) = 4.2877, p .05]. The only significant main effect was for grade [F (1,2173) = 20.141, p < .0001]. It was expected that no differences would exist between pretest and posttest means for AIDS values in the two grade groups. The three-way ANOVA to test the program’s seven value items found no significant threeway or two-way interactions. Therefore, the significant main effect of the test may be interpreted. No significant difference was seen between grades for the values component. Further, it was expected that no differences would exist between perceptions in the two adolescent grade groups. Eight items composed the perceptions scale. No significant effects were found from the three-way ANOVA in either interactions or main effects for grade, test, or group (Table 3). A three-way ANOVA to test AIDS reinforcing factors by grade of subjects yielded no significant interaction among grade, test, and group. A significant interaction was found between group x grade [F (1,2166) = 21.243, p c .0001] and for the main effect of grade (p < .OOOl). Seventh grade subjects in the comparison group on pretest achieved higher mean scores on 12 reinforcing items than any other group either before or
468
Journal of School Health
after education (Table 3). Seven items dealt with enabling factors. The threeway ANOVA to test enabling factors from pretest to posttest by grade of subjects found no significant interactions or main effects among grade, test, and group. Gender of Subjects
Hypotheses concerning gender postulated no differences between pretest and posttest means for predisposing factors (knowledge, attitudes, beliefs, values, and perceptions) between male and female adolescents having a limited AIDS education program and those not having such education. A 2 x 2 x 2 way ANOVA to test the knowledge component between male and female students was not significant. Two significant two-way interactions were found between gender and test (p c .01) and test and group (p < .OOOl). The disordinal interaction between test and group indicated that when both groups were considered from pretest to posttest, the experimental group began at a lower level and posttest scores indicated higher achievement while the comparison group remained essentially the same. Analysis of simple effects found significant differences [F (1,581) = 10.9403, p < .01] between the gender groups on the experimental pretest but not on posttest. When significant main effects are considered for gender and test, experimental female students gained significantly more than male students on their knowledge scores. Results from the three-way ANOVA indicated no significant three-way interaction for attitudes toward AIDS among gender, test, and group. Two-way interactions were significant (p < -01) between gender and test and test and group. The disordinal interaction between test and group indicated that when both gender groups were considered from pretest to posttest, the experimental group began at a lower attitude level than the comparison group. At posttest, the comparison group’s mean dropped while the experimental group score increased (Table 4). However, the analysis of simple effects indicated significant differences existed between the genders on the posttest, experimental posttest [F (1,570) = 18.1326, p < .0001], and comparison posttest [F (1,509) = 22.4875, p < .0001]. Significant main effects for attitudes were produced for gender. Both groups of males’ attitudes remained essentially unchanged from pretest t o posttest. Female scores in the comparison group were similar. However, the experimental group scored 79% on the pretest and 83% on the posttest. A significant difference also was found between grades. The 2 x 2 x 2 ANOVA to test the program’s impact on belief items did not find an interaction among gender, test, and group. Two-way analyses between gender and test and between test and group were significant (p < .OOOl). On pretest, the experimental group had lower scores than the comparison group, and this group achieved a higher level on posttest while the comparison group dropped. No significant simple or main effects were found. The three-way ANOVA to test the program’s effect on values found no significant interaction among gender, test, and group. A significant two-way ordinal
December 1992, Vol. 62, No. 10
interaction was found between gender and test, but no interaction was present between test and group. When male students and female students were considered as a group, scores dropped from pretest to posttest. Significant (p c .01) main effects were found for both group and gender. The three-way ANOVA to test the program’s effects by gender found no significant effects in either the three-way or two-way interactions for grade, test, or group. Significant main effects were found for gender and group (p c .01). Comparison and experimental groups for the males and females had virtually the same scores from pretest to posttest (Table 4). The three-way ANOVA to test AIDS reinforcing factors by gender of subjects found no significant three or two-way interactions among gender, test, and group. The main effect of gender was significant. Females scored higher than males in both groups. One significant main result related to gender occurred when enabling factors were tested. No significant interactions were evident. Female pretest means in the comparison group were higher than all other groups (Table 4).
DISCUSSl ON This investigation determined the effectiveness of the PRECEDE model in evaluating an AIDS education program for an adolescent population of seventh and eighth grade students. Components of the model examined included predisposing, reinforcing, and enabling factors. When students from the AIDS education groups were compared with those who did not receive AIDS education, significant differences were found from pretest to posttest by grade and gender. Increases in knowledge scores were similar to findings from previous evaluations of school-based AIDS education. Miller and Downer” reported a 13% increase in knowledge on posttest one week after an education program. Questions such as how contact with the AIDS virus is made indicated students understood that casual contact was not an avenue of infection. In this study, students understood that sexual contact is the primary source of spread for the virus, as 92% of the experimental group answered this question correctly on posttest in contrast to 88% of the comparison group. However, on the pretest this knowledge already was evident with a high percentage of correct responses in both groups (93% in the comparison group and 90% in the experimental group). It was anticipated that knowledge would improve, but the level of improvement was hampered by high levels of pretest knowledge in some areas, possibly causing a ceiling effect. Johnson et all4 demonstrated that only one more correct question was seen on posttest after two consecutive classes of 45 minutes. DiClemente et all5 found a posttest knowledge advantage of 4.2 more correct responses after three class periods with a strong trend in the middle school group. This finding contrasts with a change of two questions correctly identified in this study. When reviewing the literature, a direct comparison of the relative effectiveness of different forms of education found the lecture-discussion approach was effective. Thus, the lecture-discussion approach was used in
this study. The increase in knowledge found in this study may have related directly to the effectiveness of the presenter. The instructor was a nurse at a medical college infection control department where AIDS patients were hospitalized. This individual related to adolescents in a fashion that retained their interests during the AIDS lesson. The time allowed for presenting the content was limited by the schools that requested a one-class period presentation. However, a three-to-five-session presentation would provide more time for discussion and allow for additional exploration of the attitudinal and behavioral aspects inherent in the PRECEDE model. Students also could learn from their peers in such activities as role playing or group interactions. Only through more extensive educational interventions can one expect to effect behavior change. Females in this study increased their knowledge scores in the experimental group by 14% compared to the males’ increase of 8%. This gender difference also was apparent in the study conducted by Huszti et all’ where female students had greater knowledge about AIDS than male students in all measurement times of pretest, posttest, and follow-up. The fact the program instructor was female might have led to this difference, since female students might have associated with her in a different manner than did the males. Finally, limitations of this study should be noted. Since experimental groups were self-selected, in that they contacted the AIDS educator, these groups possibly were less knowledgeable and were perceived by their teachers as less knowledgeable about AIDS. However, study comparison groups were located in the same areas of the state. Second, accuracy of the results depended on the validity and reliability of self-reported data. Again, this limitation may have been minimized since responses were anonymous and confidential. Third, participation in the study was voluntary, thereby affecting generalizability of the results. Fourth, the study was conducted in only one area of Ohio, also affecting generalizability of results. Finally, the limited time allowed for the intervention precluded adequate educational interventions to influence the enabling and reinforcing factors of the PRECEDE model.
CONCLUSION The past decade of research on AIDS produced considerable growth in knowledge regarding molecular biology and pathophysiology of AIDS. However, knowledge of how to maximize the effectiveness of AIDS prevention programs remains limited. This study found statistically significant effects on the predisposing component (knowledge, attitudes, and beliefs) of the PRECEDE model for junior high school students who received a one-hour class presentation. Yet, the practical significance and long-term effects of the study remain unclear. However, the PRECEDE model provides a useful program evaluation tool when adequately operationalized. Further use of the PRECEDE model is recommended to assess its ability to differentiate students at high risk from those at low risk for HIV infection. To date, school-based AIDS intervention programs
Journal of School Health
December 1992, Vol. 62. No. 10
469
reported in professional journals have not answered some major questions. Future school-based AIDS interventions should address several questions. How much time should be devoted at the various grade levels for AIDS education to be beneficial? What specific content should be taught at the various grade levels? What teaching techniques maximize learning and change behavior? What in-service training approaches for teachers can maximize their effectiveness? What behaviors, or proxies for behaviors, should be assessed to measure the effectiveness of AIDS educational interventions? What political and environmental changes can help reduce AIDS risk behaviors in children and adolescents? What outcomes should be measured to assess the effectiveness of AIDS education? What forms of follow-up to school-based AIDS education can help ensure that adolescents who begin practicing safer sexual behavior do not relapse into risky sexual behavior?
References I . Alan Guttmacher Institute. United States and cross-national trends in teenage sexuality and fertility behavior, 1986. In: Cenrerfor Population Options, Fact Sheet. Washington, DC: Center for Population Options; 1987. 2. Zelnik M, Katner JF. Sexuality activity, contraception use and pregnancy among metropolitan-area teenagers: 1971-1979.Fam Plann Perspecr. 1980;12:230-237. 3 . HIVIAIDS Surveillance Report, October 1991. Atlanta, GA: Centers for Disease Control; 1991: 18. 4 . Price J H , Desmond S, Kukulka G. High school students' perceptions and misperceptions of AIDS. J Sch Health. 1985;55:107-109. 5 . DiClemente RJ, Zorn J , Temoshok L. Adolescents and AIDS: A survey of knowledge, attitudes, and beliefs about AIDS in San Francisco. A m J Public Health. 1986;76:1443-1445. 6. Strunin L. Hingson R. Acquired immunodeficiency syndrome and adolescents: Knowledge, beliefs, attitudes, and behavior. Pediatrics. 1987;79:825-828. 7. Hingson RW, Strunin L, Berlin BM, Heeren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. A m J Public Health. 1988;78:460-461. 8 . Jones H, Ellis N, Tappe M, Lindsay G. HIV related beliefs, knowledge and behaviors of ninth and eleventh grade public school students. J Healrh Educ. 1991;22:12-18. 9. Anderson JE, Kann L, Holtzman D, Arday S, Truman B,
Kolbe LJ. HIVIAIDS knowledge, and sexual behavior among high school students. Fam Plann Perspect. 1990;22:252-255. 10. Kann L, Anderson JE, Holtzman D, Ross J , Truman BI. Collins J , Kolbe LJ. HIV-related knowledge, beliefs and behaviors among high school students in the United States: Results from a national survey. J Sch Healfh. 1991;61:397-401. 1 I . DiClemente RJ, Boyer CB, Morales ES. Minorities and AIDS: Knowledge, attitudes, and misconceptions among black and Latino adolescents. A m J Public Health. 1988;78:55-57. 12. Siege1 D, Lazarus N. Krzsnovsky F, Durbin M, Chesney M. AIDS knowledge, attitudes, and behavior among inner city, junior high school students. J Sch Health. 1991;61:160-165. 13. Miller L, Downer A. AIDS: What you and y o u r friends need to know - a lesson plan for adolescents. JSch Health. 1988;58:137-141. 14. Johnson J A , Sellew F, Campbell AE, Haskell EG, Gay AA. Bell BJ. A program using medical students to teach high school students about AIDS. J Med Educ. 1988;63:522-530. IS. DiClemente RJ, Pies CA, Stoller EY. Straits C , Olivia GE, Haskin J , Rutherford GW. Evaluation of school-based AIDS education curricula in San Francisco. J Sex Rex 1989;26:188-198, 16. Brown LK, Fritz GK, Barone VJ. The impact of AIDS education on junior and senior high school students - a pilot study. J Adolesc Health Care. 1989;9:139-143. 17. Huszti HC, Clopton J R , Mason P J , Acquired immunodeficiency syndrome educational program: Effects on adolescents' knowledge and attitudes. Pediatrics. 1989;84:986-994. 18. Ruder AM, Flam R, Flatto D, Curran AS. AIDS education: Evaluation of school and worksite based presentations. NY Stare J Med. 1990;90:129-133. 19. Farley TA, Pomputius PF, Sabella W, Helgerson SD, Hadler JL. Evaluation of the effect of school-based education on adolescents' AIDS knowledge and attitudes. Conn Med. 1991;55:15-18. 20. Brown LK, Barone VJ, Fritz GK, Cebollero P, Nasswu J H . AIDS education: The Rhode Island experience. Health Educ Q. 1991 ;18: 195-206. 21. Ross MW, Rosser BRS. Education and AIDS risks: A review. Health Educ Res. 1989;4:273-284. 22. Green LW, Kreuter NW, Deeds SG, Partridge KB. Health Education Planning: A diagnostic approach. Palo Alto, Calif: Mayfield; 1980. 23. Centers for Disease Control. Selected behaviors that increase risk for HIV infection among high school students - United States, 1990. M M W R . 1992;41:231, 237-240. 24. Ajzen I , Fishbein M. Understanding Altitudes and Predicring Social Behavior. Englewood Cliffs, NJ: Prentice-Hall, Inc; 1980. 25. Office of Cancer Communications. Readability Testing in Cancer Communications. Bethesda. Md: US Dept of Health, Education and Welfare, NIH publication no 79-1689; 1979. 26. Readability Esrimator. Micro School Programs. Seattle, Wash: Berta-max. Inc; 1988. 27. Campbell DT, Stanley JC. Experimental and quasiexperimental designs for research and teaching. In: Gage NL, ed. Handbook of Research on Teaching. Chicago, Ill: Rand McNally, 1963. Reprinted as Experimenral and Quasi-Experimental Designs f o r Research. Boston, Mass: Houghton Mifflin; 1966. 28. SPSSX User's Guide, 2nd ed., Chicago, 111: SPSS Inc; 1986.
Statement of Purpose The lournu/ of School Heulrh. an official publication of the American School Health Association, publishes material related to health promotion in school settings. h u r n a l 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 ]nuniu/: copies also may be obtained from the bunral office, P.O. Box 708. Kent, OH 44240.
470
J o u r n a l of S c h o o l Health
December 1992, Vol. 62, No. 10
