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Adolescents and AIDS: knowledge and attitude.

Primary prevention of AIDS remains uncoordinated, underfunded, and limited in scope because of public perception that there is no generalized threat of AIDS in the mainstream population (Bowser, 1991). However, as a result of the Magic Johnson tragedy, the public may begin to realize that the demographics of AIDS has changed greatly since its first recognition in 1981. What was thought to be strictly a homosexual disease is now known to be spreading rapidly among the heterosexual population. According to the Centers for Disease Control (CDC), AIDS is presently spreading fastest among the 24- to 30-year-old heterosexual population (CDC, 1989). People who engage in unprotected sexual activities or share needles when taking drugs intravenously are known to be at highest risk. Many adolescents fit this description (DiClemente, 1990; DiClemente, Boyer, & Morales, 1988; DiClemente, Zorn, & Temoshok, 1986).

One question asked is: If adolescents are engaging so actively in AIDS-spreading behaviors, why have only about 1% of the total reported AIDS cases, according to the Centers for Disease Control (1989), been among persons younger than 20? One reason is that AIDS has a long latency period--one to seven years (Curran, Morgan, Hardy, Jaffe, Darrow, & Dowdle, 1985). Hence, many people who develop the disease in their 20s came in contact with the human immunodeficiency virus (HIV) while in their teens. As adolescents continue to engage in unprotected sex and to use drugs intravenously, the problem will grow.

As stated by the National Academy of Science, youth need to be taught how to engage in healthy behaviors and protect themselves against HIV infection in order to prevent the further spread of AIDS (Miller, Turner, & Moses, 1990). Since schools reach 95% of U.S. youth, it makes sense for them to conduct the bulk of preventive AIDS education (Kerr, Allensworth, & Gayle, 1989; Price, Desmond, & Kukulka, 1985). The CDC has established guidelines for AIDS education (Tolsma, 1988), and many school districts have quickly developed and implemented AIDS curricula (Brown & Fritz, 1988; DiClemente, 1989; Remafedi, 1988). However, little research has assessed the effectiveness of these programs (Brown, Nassau, & Barone, 1990; King, Beazley, Warren, Hankins, Robertson, & Radford, 1989). Further, few studies have assessed adolescents' knowledge of AIDS, and almost no studies have looked at the effects on adolescents' attitudes of knowledge gained as a result of an AIDS education program.

Surveys of adolescents' baseline knowledge about AIDS indicate a general increase since 1985 and suggest grade level differences, with older students having more knowledge. However, the surveys also indicate large gaps in information that can place adolescents at continued risk. Price et al. (1985) assessed the level of AIDS knowledge in 256 16- to 19-year-old students in Ohio. They found that only 3 of 19 questions were answered correctly by 75% or more of the participants. The students were most likely to know that people are not born with AIDS, AIDS victims are likely to die, and homosexuals are likely to get the disease. The findings could have been due to the fact that in 1985 the AIDS virus was still largely associated with the homosexual population and that the adolescent population remained unconcerned. It was also found that, for some of the questions, boys were more likely than girls to answer correctly.

In a Massachusetts study using 860 students 16 to 19 years of age, Strunin and Hingson (1987) found that only 2 out of 9 questions on HIV transmission were answered correctly by 75% or more of the participants. The students were misinformed or confused about AIDS, and most had little understanding of the modes of HIV transmission. It was also found that knowledge did not guarantee an effect on behavior; of the 70% who reported being sexually active, only 15% indicated that they had modified their behavior. Only 20% of those who did modify their behavior used an effective method of protection.

In a series of studies in San Francisco involving 1,326 high school students, DiClemente et al. (1986, 1987a, 1987b) found that 12 of 30 questions were answered correctly by 75% or more of the participants. In addition, students with lower levels of AIDS knowledge saw themselves as being at higher risk of becoming infected with the AIDS virus. DiClemente et al. also found significant gender differences in overall knowledge level, with boys scoring higher than girls. However, they attributed the statistical significance more to the large sample size than to substantive gender differences.

Comparing the AIDS knowledge level of 657 high school students from two different towns in Connecticut, one predominantly white and the other predominantly black, Helgerson, Petersen, and the AIDS Education Study Group (1988) found that only 6 of 20 questions were answered correctly by 75% or more of the participants. While many of the students knew about some methods of HIV transmission, most were either misinformed or did not know how it occurs. Gender differences were found on a few questions, but there were no significant trends for either gender or race. The researchers concluded that the students' knowledge about AIDS was inadequate, that they wanted to learn more about AIDS, and that schools should provide AIDS education.

A study of 38,000 Canadian youth in the seventh, ninth, and eleventh grades, as well as college freshmen, found that while a majority of the students could accurately define AIDS and knew how the HIV virus was transmitted, they were not well informed about how to prevent infection (King et al., 1989). In addition, the higher the grade level, the more knowledgeable the students. Little peer pressure to engage in sexual intercourse and high acceptance of premarital sexual intercourse were found. About half of the 16-year-olds and 75% of the older adolescents had experienced sexual intercourse. Of those who reported engaging in sexual intercourse often, less than 25% reported protecting themselves or their partners by using condoms.

Since 1985, adolescents nationally have indicated an increase in knowledge of the main modes of HIV transmission (Adams & Hardy, 1991). However, information gaps persist. For example, DiClemente et al. (1986, 1987b) found that while 92% knew that sexual intercourse is the primary route of HIV transmission, only 60% knew that using condoms could reduce the risk of infection, and only 25% were aware that no new vaccine was available for treating AIDS.

The purpose of the present study was to assess ninth- and tenth-grade students' AIDS knowledge and attitude before and after the introduction of a district-mandated AIDS education program. A secondary purpose was to assess the relationship between knowledge gained from the program and attitude toward AIDS victims. The study included a control group composed of ninth- and tenth-grade students who were not exposed to the program.



The experimental group consisted of 90 ninth- and tenth-grade students (31 girls, 59 boys)--the total enrollment of four science classes. Two ninth- and tenth-grade science classes were randomly selected from each of two large urban high schools in Tennessee. The schools draw from predominantly white, middle-class to upper-middle-class communities. The science classes were targeted because they were designated by the district to receive the AIDS program.

The control group consisted of 41 ninth- and tenth-grade students (28 girls, 13 boys) from two randomly selected science classes. Students in the control group were not given the AIDS instruction until after the study was completed.


A questionnaire developed by the school district was used to assess AIDS knowledge and attitude. The questionnaire contained 30 randomly ordered true-false questions--22 knowledge questions and 8 attitude questions. Hence, the range of scores on AIDS knowledge was 0-22, and 0-8 on attitude. The test-retest reliability of the instrument (r = .62) was moderate to good, and compared well with previous studies (see Brown et al., 1990). The posttest, also developed by the district, consisted of the same questions, reworded, and placed in a different order. Previous exposure to AIDS education was also assessed.


All classes were administered the knowledge and attitude pretest in the same week. The four classes in the experimental group then attended an intensive one-week (5-day) AIDS education program. The two classes that made up the control group received their normal lessons. After the AIDS education program, all of the classes, experimental and control, completed the posttest.


Of the 90 students in the experimental group, 65 (72%) had previously been exposed to AIDS education and 25 (28%) had not. Table 1 presents the knowledge and attitude mean scores and standard deviations on the pretest and posttest for the experimental group. On the pretest, the boys and girls did not significantly differ in knowledge. However, the girls did have a significantly more tolerant attitude toward AIDS victims, t(73) = 2.92, p = .005.

The pretest baseline data indicated that 75% or more of the boys correctly answered 14 of the 22 knowledge questions. Among the girls, 75% or more correctly answered 12 of the 22 knowledge questions. At least 75% of the boys had a tolerant attitude toward AIDS victims on 2 of the 8 attitude questions. At least 75% of the girls had a tolerant attitude toward AIDS victims on 6 of the 8 attitude questions.
Table 1

Knowledge and Attitude Scores for the Experimental Group

Variable Pretest Posttest

Boys (n = 59)

Knowledge Mean 16.34 16.30
 (SD) (1.82) (2.76)

Attitude Mean 4.97 6.08
 (SD) (1.92) (1.52)

Girls (n = 31)

Knowledge Mean 15.71 17.32
 (SD) (2.22) (2.12)

Attitude Mean 6.06 6.48
 (SD) (1.57) (1.00)

There were gender differences on some of the pretest items; boys were more likely than girls to know that most new cases of HIV infection are occurring among intravenous (IV) drug users (boys, 93% correct; girls, 71% correct), ||Chi~.sup.2~(1) = 8.14, p = .004, and that one factor that makes development of an AIDS vaccine difficult is the large number of different strains of the AIDS virus (boys, 88% correct; girls, 71% correct), ||Chi~.sup.2~(1) = 4.10, p = .04. Girls were less likely than boys to feel that people with AIDS should be isolated and quarantined (boys, 80% tolerant; girls, 97% tolerant), ||Chi~.sup.2~(1) = 4.82, p = .03; to fear attending school with a person who has AIDS (boys, 71% tolerant; girls, 94% tolerant), ||Chi~.sup.2~(1) = 6.11, p = .01; to believe that students with AIDS should not be allowed to remain in classrooms with healthy students (boys, 64% tolerant; girls, 90% tolerant), ||Chi~.sup.2~(1) = 6.98, p = .008; and to feel that there is nothing they can do to prevent the spread of AIDS (boys, 75% false; girls, 97% false), ||Chi~.sup.2~(1) = 6.85, p = .009. In general, the students knew what AIDS was and the most common modes of transmission--IV drug use and sexual contact.

For the control group, the knowledge and attitude mean scores and standard deviations on the pretest and posttest are presented in Table 2. The control group did not show any significant changes pretest to posttest, nor were there any significant differences due to gender.

An analysis of covariance (ANCOVA) was conducted to compare the experimental and control groups on knowledge gains and attitude change. In both analyses, pretest scores, previous exposure to AIDS education, and grade level were controlled.

The ANCOVA for knowledge gained as a result of the AIDS education indicated no significant main effects due to treatment or gender. However, a significant gender by treatment interaction was indicated; only the girls significantly increased in knowledge as a result of the AIDS education, F(1, 122) = 5.95, p |is less than~ .01. The boys' knowledge level was unaffected by the AIDS education. The analysis also indicated a significant effect due to grade level among both boys and girls; the higher the grade level, the less the knowledge gain, F(1, 122) = 7.70, p |is less than~ .01. There was no significant effect due to previous exposure to AIDS education.

The ANCOVA for attitude change as a result of the AIDS education indicated a significant main effect for treatment; both the boys and the girls became more tolerant of AIDS victims, F(1, 122) = 4.76, p |is less than~ .05. There was no significant main effect due to gender or gender by treatment interaction. As with knowledge, the analysis indicated a significant effect due to grade level; there was less attitude change as grade level increased, F(1, 122) = 8.54, p |is less than~ .01. There was no significant effect due to previous exposure to AIDS education.
Table 2

Knowledge and Attitude Scores for the Control Group

Variable Pretest Posttest

Boys (n = 13)

Knowledge Mean 16.92 17.00
 (SD) (2.43) (2.04)

Attitude Mean 4.92 5.54
 (SD) (1.98) (2.30)

Girls (n = 28)

Knowledge Mean 15.86 15.57
 (SD) (2.12) (2.28)

Attitude Mean 5.32 5.25
 (SD) (1.44) (1.77)

Two crosslag correlations were calculated to assess the relationship between knowledge and attitude. The first correlation was between the pretest attitude and the gain in knowledge (|C.sub.1~). This correlation indicated whether the students' initial attitude about AIDS affected the amount of knowledge gained. The second correlation was between the posttest attitude and the gain in knowledge (|C.sub.2~). This correlation indicated whether the students' gain in knowledge affected their attitude.

Table 3 shows the two correlations (|C.sub.1~ and |C.sub.2~) for the boys and girls. For boys, initial attitude was unrelated to knowledge gain, while knowledge gain did significantly relate to greater tolerance toward AIDS victims. For girls, Table 3 indicates that those who had the most tolerant attitude toward AIDS victims tended to gain the least knowledge from the AIDS education. In turn, those girls who gained the most knowledge from the AIDS curriculum were more likely to have a less positive attitude toward AIDS victims. These findings for girls, although nonsignificant, clearly indicate an inverse relationship.


There is a paucity of research evaluating the effectiveness of AIDS education among adolescents. Most of the surveys on adolescents' baseline knowledge and attitude about AIDS and AIDS victims indicate few differences due to gender (DiClemente et al., 1986, 1987b; Adams & Hardy, 1991). The present study also found little difference due to gender on a pretest of knowledge about AIDS. However, girls had a significantly more tolerant attitude toward AIDS victims than did boys.
Table 3

Crosslag Correlations Between Attitude and Knowledge Gain

 N |C.sub.1~ |C.sub.2~

Boys 59 .01 .30
 (p = .92) (p = .02)

Girls 31 -.32 -.23
 (p = .08) (p = .20)

Note. The p-values are at the two-tailed level of significance.

Using a control group of ninth- and tenth-grade students who had not been exposed to a district-mandated AIDS education program, the present study found that only the girls gained significantly in knowledge as a result of the AIDS education. The boys' knowledge was unaffected by the AIDS education.

As previous surveys (Brown et al., 1990; King et al., 1989) have also indicated, the adolescents' baseline knowledge of AIDS and tolerance toward AIDS victims increased by grade level. However, gains in knowledge and tolerance due to the AIDS education decreased by grade level. This points to a plateau effect in junior and senior high school with regard to both knowledge about AIDS and tolerance toward AIDS victims. Future research needs to compare the impact of an AIDS education program on seventh- and eighth-grade students with its impact on ninth- and tenth-grade students. Given that there could be a plateau effect, it would be most beneficial for the adolescents' health if that plateau could be reached earlier. In turn, it would be important to ascertain whether there is an age or grade at which AIDS education has a maximal impact.

While both boys and girls in the present study gained in tolerance toward AIDS victims, it was the knowledge gained by the boys that led to the more tolerant attitude. The girls started out with a very tolerant attitude toward AIDS victims, and those with the most tolerant attitude tended to gain the least knowledge from the AIDS education. In turn, as the girls gained in knowledge about AIDS and its transmission, their tolerance for AIDS victims tended to decrease. Since there is a lack of research in this area, this trend is hard to interpret. It could be that the girls' baseline tolerance toward AIDS victims merely reflected the virtue of being nice to those less fortunate in the face of little knowledge. As girls' knowledge increased as a result of education, they began to readjust their attitude. Future research needs to look further at gender differences and the impact of AIDS education programs. As in the present study, it is critical to focus on possible gender differences and the interrelationship of knowledge and attitude.


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Author:Steitz, Jean A.; Munn, Judith A.
Date:Sep 22, 1993
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