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Strategies for overcoming obstacles in AIDS education for preteens.

"I'm sitting in the back row."

"Well, I'm just going to be absent that day."

These were typical student responses upon learning that their school would be visited by a guest speaker who had tested positive for HIV (Human Immunodeficiency Virus). Respecting their feelings, their teacher was accepting and non-judgmental: "It's OK to sit at the back of the room, but it's also OK to change your mind and sit up front." When developing the school's AIDS (Acquired Immunodeficiency Syndrome) prevention program, planners took care to encourage trust and empower the 11- and 12-year-olds.

As the AIDS epidemic escalates, its impact permeates every segment of the population (Elders, 1994). More than 985,119 new cases have been reported worldwide between 1993 and 1994, which represents an annual increase of 37 percent (Pan American Health Organization, AIDS hotline). The Centers for Disease Control and Prevention (CDC) reported 80,691 AIDS cases during 1994 in the United States (U.S. Department of Health and Human Services and CDC, 1995). In recent years, those affected by AIDS are no longer almost exclusively homosexuals and intravenous drug users (Greenspan & Castro, 1990; Kolata, 1989; U.S. Department of Health and Human Services and CDC, 1994). The number of AIDS cases reported each year among U.S. teens has increased from one case in 1981 to 588 cases in 1993. A total of 1,768 cases of AIDS among teens has been reported through June 1994 (CDC, 1994). Every four months the number of reported AIDS cases among adolescents doubles (Bechtel & Sutter, 1990).

Teens are especially vulnerable to this fatal virus, given their likelihood to experiment with sexual activity and drug use and their widespread attitudes that inhibit proper AIDS prevention behavior. With no cure or vaccine to prevent the spread of AIDS coupled with high-risk behaviors among adolescents (Elders, 1994; Flax, 1989), timely and effective AIDS education is the only defense (Alteneder, Price, Telljohann, Didion & Locher, 1992; Hales & McGrew-Zoubi, 1993; U.S. Department of Health and Human Services and CDC, 1994). If AIDS education is to be effective as a preventive measure it must be made available to preteens and it must accomplish more than only imparting facts about AIDS/HIV (Fetter, 1989). Educators must help young people overcome fear and misunderstanding in order to effect responsible and preventive behaviors (Popham, 1993).

The authors describe and evaluate a comprehensive AIDS education program for preteens and identify adolescent attitudes that act as barriers to effective AIDS education (U.S. Department of Health and Human Services and CDC, 1994; Weinstein, 1989). They then present strategies for breaking down these barriers and promoting the acceptance of AIDS education, emphasizing community resources that can help combat this problem.

Problem: Adolescents' Attitudes

Many adolescents are unreceptive to AIDS education because they are: 1) immature and unable to see the consequences of their actions, 2) feel embarrassed and fear peer rejection, 3) deny and dismiss risky behaviors and 4) generally mistrust and disregard adults' advice.

1. Young teens often are unable to assume the responsibilities of being sexually active and lack the experience, foresight and maturity to realize the consequences of risky behaviors (Fisher, 1990). Therefore, they cannot readily conceptualize their vulnerability to AIDS (Basch, 1989; Patierno, 1990).

2. Teens perceive contracting AIDS as a remote risk compared to the more immediate and far greater risk of embarrassment while talking to a peer of the opposite sex about preventive measures such as abstinence or condom use (Hochhauser, 1988). Early in our AIDS prevention program, several male students characterized condoms as being "not cool," despite their knowing that they are effective in preventing venereal disease. Other males verbally supported them, while female students sat quietly. Many students, particularly females, giggled to mask their embarrassment when handling condom packages during an AIDS prevention lesson. Preteens and teens may prefer to risk infection than to risk rejection or embarrassment by insisting on safety precautions.

3. Adolescents often deny that they are at risk of contracting AIDS (Humm & Kunreuther, 1991). Basch (1989) states that denial is a primary defense mechanism against health threats. Hochhauser (1988) reports that adolescents who experiment with intravenous drugs do not identify themselves as drug addicts. Instead, they perceive AIDS as "someone else's disease" and continue to underestimate their vulnerability. These teens see no need to change their behavior, since they do not perceive themselves to be at risk (Basch, 1989). The fact that many do not personally know any peers who have AIDS fuels their denial (Kolata, 1989).

4. Other obstacles are mistrust and a tendency to rebel against or disregard adult advice, especially if teens believe that the adult's message is dogmatic and unresponsive to their own point of view.

These above mentioned four attitudes tend to crystallize during the teen years. Consequently, it is wise to educate youth when they are preteens and, consequently, more receptive to AIDS education. The program description that follows shows how behavioral barriers can be reduced by facilitating development of positive AIDS prevention attitudes among preteens.

Solution: Strategies in AIDS Education

One hundred 6th-graders in five different science classes participated in a daily, three week-long AIDS education program. These 11- and 12-year-olds, from low to middle income, largely single parent families, attended an urban, multicultural school located in a Detroit suburb. The community has a large minority student population: 70 percent are African American and 15 percent are Chaldean, or Iraqi-Christian. The program objectives for preteens were to provide knowledge about AIDS prevention and to develop attitudes and values that facilitate the use of this knowledge.

Before implementing the program, the following ground rules were established: 1) no put-downs; 2) show respect for others' ideas, feelings, values and rights; 3) ask questions only to obtain knowledge and not to expose others' personal behaviors; and 4) use correct terminology. These ground rules were designed to create a sensitive, non-judgmental and compassionate environment, in which the children could feel safe to explore AIDS-related issues (Silin, 1992).

Three fundamental strategies formed the foundation of this program: 1) promote acceptance, understanding and respect for HIV-positive people by empowering students with up-to-date, factual AIDS/HIV information; 2) clarify values by engaging students' in meaningful experiences; and 3) encourage social responsibility and an understanding of multiple perspectives through peer interactions. These strategies were specifically designed to adress the four attitudes that make preteens unreceptive to AIDS education. Multiple activities were developed to implement these strategies. Outcomes, in the form of students' responses, were documented in teachers' journals, formative and summative evaluations of activity-lessons and students' work samples.

Strategy 1: Acceptance and Understanding of People with HIV Through Information. This first strategy was set in motion through a visit from an HIV-positive speaker, a timely local newspaper article and two discerning videos. The HIV-positive guest speaker, a young woman in her early twenties, possibly had the greatest impact. She related her personal story: how she contracted HIV and the physical, emotional and social experience of living with HIV. She concluded with prevention messages geared toward preteens, emphasizing that her illness was a consequence of living irresponsibly and that anyone who chooses such a lifestyle becomes susceptible to the virus. According to their written feedback, the students received the following messages from her presentation: 1) don't do drugs or share needles; 2) avoid sex, or at least use a condom; 3) stay in school and get an education; 4) don't do things that will harm you just to fit in or be cool; 5) think about your purpose in life and be responsible for yourself, no matter what others do or say. These responses illustrate that the students reflected upon and understood the speaker's strong, explicit message.

Students' additional oral and written comments showed an overwhelming respect and gratitude for the guest speaker's courage in openly revealing her personal hardships and struggles in the hope they would not make the same mistakes. Students were silent and even tearful following the talk. This personal contact with an HIV-infected person was far more valuable in helping students confront denial and stereotypes than any other teaching strategy (Legion, Levy, Cox & Shulman, 1990).

In another activity that helped develop an understanding of HIV-positive people, students reviewed factual information (Newman, DuRant, Ashworth & Gaillard, 1993) incorporated in a newspaper article titled "They Hope Baby Won't Have Virus: Infected Women Choose Pregnancy" (Bruni, 1992). Students discussed this article with their family members and recorded when they agreed or disagreed with their family members' opinions. Some students accepted an HIV-positive woman's desire to have a baby, while others suggested that she should instead adopt to satisfy her heartfelt need to have a child. Students also considered the perspectives of an infected woman's family members, expressing concerns that the father and / or the baby would become infected, that the baby or father may soon die and that the baby would be an orphan if / when the parents die. With these responses, the students demonstrated their respect for people who were HIV positive, as well as an understanding that each decision will have many consequences.

Certain videos also promoted acceptance and understanding. "AIDS ... Taking Action" described the true story of a preteen who died from AIDS. His classmates developed a committee in his memory to support and accept others with HIV. The students watching this video became quiet and even tearful as they empathized with the boy's classmates. They were inspired to form a similar committee in order to sensitize others in their school about AIDS. This action illustrated a deep commitment to changing behaviors in others.

A second video, "Sex, AIDS and Drugs," focused on the anger many feel towards HIV-infected individuals, particularly homosexuals and drug addicts. The students characterized such behavior as "stupid" and expressed their disapproval by gasping in a derogative fashion. They shifted their perspective, however, as they discussed the video with the teacher facilitator. Some expressed compassion for those infected and empathy toward loved ones who were in pain. Their anger about AIDS became directed at the virus, rather than the individuals. They made comments such as, "Why does this virus have to be around now when we are becoming teenagers?"

Strategy 2: Value Clarification Through Engaging in Meaningful Experiences. The second strategy incorporated a decision-making activity and simulation of real-life situations. After reading a newspaper article titled, "Teens Who Abstain: Sex 'Not Worth It'" (Abcarian, 1992), students developed the following strategies for postponing sex: "Don't go on a date alone," "Choose friends who feel the same way as you do" and "Don't date people much older than you." Next, they formulated realistic goals such as "Do not drop out of school," "Go to college" and "Have a job in order to support a family." Expressing the rationale for postponing or abstaining from sex not only helped to clarify students' values, but also promoted self-examination, self-correction and self-affirmation (Lawlor, Morris, McKay, Purcell & Comeau, 1990; Richards, 1990).

In another activity, students analyzed and evaluated real-life dilemmas, and then identified decisions that would best protect them against HIV. Some of the scenarios were: being new to a group and feeling pressured to share the same needle for ear piercing, visiting a dentist who is about to work on your teeth without wearing gloves, feeling pressure from a longtime partner to have sexual intercourse, contemplating sexual intercourse with a partner who has an "AIDS free" card, being pressured to use intravenous drugs and dealing with a close friend who is HIV-positive and dating an acquaintance of yours.

These scenarios gave students an opportunity to clarify their values about behaviors that could affect their health. They identified the facts, brainstormed for multiple options, examined each choice's consequences and made a final decision while providing a rationale. The majority of male students selected decisions designed to reduce the risk of infection, such as wearing a condom or getting an AIDS test, whereas the majority of females selected decisions to prevent HIV infection, such as saying "No" and avoiding or leaving the situation.

Strategy 3: Social Responsibility and Multiple Perspectives Through Peer Interactions. Activities included in this strategy focused on peer cooperation, peer conflict and peer pressure. Students worked in small groups to educate their peers through interactive bulletin board displays and informational pamphlets. Working in teams, they also constructed posters featuring messages like "We Care," "Feel Good" and "Love Someone with AIDS." These poster constructions expressed cooperative learning, empathy and social responsibility. They also served as a special communication to an HIV-infected guest speaker.

Students learned multiple perspectives as they used index cards to rank behaviors as "High," "Low" or "No Risk" in terms of HIV transmission (Bechtel & Sutter, 1990). They discussed their conflicting views until they reached a consensus. Each group's cards were then placed according to risk on a rope that was strung across the room. All the students agreed on the degree of risk involved in about 85 percent of the behaviors, since earlier lessons had highlighted the risk associated with these behaviors.

Behaviors that had not been previously discussed, such as "sharing a razor," "tattooing" and "ear piercing," created conflicting views. The students resolved their multiple perspectives through debate, logic and transference of existing knowledge. The dialogue exposed a number of commonly held misconceptions (e.g., condom use is a "no risk" behavior). Finally, students learned that the degree of risk depends in part on a situational context: "French" kissing, for example, in itself is not risky but becomes so if participants have open sores or blisters inside their mouths. Thus, this activity promoted the acceptance of multiple perspectives through the creative tension of criticism, contradiction and confrontation on one side and openness, receptivity and affirmation on the other (Lawlor, Morris, McKay, Purcell & Comeau, 1990).

The students learned about the process of HIV transmission through an activity that addressed social responsibility and peer pressure. Each student received a card that was stapled to conceal its contents. Two cards were marked "A" for AIDS, two were marked "C" for condom users and the remaining cards were blank, representing non-condom users. Additionally, two selected cards included instructions on the outside, stating "Do not sign anyone's card and do not let others sign yours."

Students were asked to mingle and obtain three signatures within a three-minute time frame. Upon opening their cards they realized that those with an "A" inscribed on their card had AIDS and had unknowingly transmitted the virus to others. Some found a "C" card that signified low risk because of condom use. Those who had blank cards did not use condoms and were at high risk of getting AIDS from others. Students who did not get signatures according to the instructions outside the card had abstained and were not at risk of contracting HIV. Finally, some became "infected" through second- and third-generation transmission.

Students took this simulation strategy seriously. Two students who held the original "A" cards bemoaned their status, hid their cards and buried their faces. Others expressed relief and some giggled at those initially infected. Their laughter dissipated when they realized that they too were exposed to the AIDS virus through second- and third-generation contact. Students who were instructed to abstain found it difficult to refuse signatures, leading to a discussion about peer pressure. They had felt left out of the group. In fact, one of them surrendered to peer pressure, only to regret it later.

This exercise effectively illustrated how an impetuous decision may have profound long-term effects. It enabled them to realize their social responsibility. The students realized that they will have "intimate contact" with everyone with whom their partner has had intimate, unprotected contact. They also realized how peer pressure affects the decision-making process (Weinstein, 1989).

Recommendations and Summary

The above AIDS/HIV education program could be even more effective by implementing the following recommendations:

* Provide outreach in multiple settings. The authors recommend replicating, extending, modifying and adopting these strategies in multiple settings and venues. The groups of pre-adolescents and adolescents with the highest risk for contracting AIDS are school dropouts and runaways (Rotheram-Borus, Koopman, Haignere & Davies, 1991), intravenous drug users and minorities (CDC, 1994; DuRant, Ashworth, Newman & Gailard, 1992). DiClemente and Houston-Hamilton (1989) recommend that AIDS education programs targeting adolescents, particularly minority teenagers, become a higher priority.

To be most effective, a program such as this should also be conducted in non-school settings such as shelters for homeless families, half-way homes for pre-teens, pediatric and birth control clinics, juvenile detention centers and as part of extracurricular programs. Professionals who work with preteens outside the classroom, such as pediatricians, community health workers, counselors, sports coaches, scout leaders, recreational counselors and ministers, should also be encouraged to become informed facilitators of AIDS education. These professionals must take care not to overemphasize their personal values, and make an effort to understand teens' values, attitudes and agendas (Basch, 1989). Preteen outreach is far more effective when such professionals team up with educators.

* Provide support to families. Each school should have an AIDS committee that includes a school/community health worker, teachers, parents and preteens and teens who are highly committed to HIV / AIDS prevention. This committee could provide needed support by reaching out and collaborating with classroom teachers, serving as resources and networking with community organizations.

* Provide effective teacher education. Inservice and preservice curricula should include AIDS education. Many teachers lack confidence in teaching AIDS education (Shayne & Kaplan, 1988), partially due to a lack of training. State and district curriculum development specialists should be involved in AIDS education programs and may also need inservice courses.

Conclusion

Pre-adolescent and adolescent behavioral experts, educators, community members and health care professionals must collaborate to effectively reach preteens. A better understanding of preteens' and adolescents' attitudes and behaviors is imperative in order to design programs that will effectively meet this high-risk group's needs. Programs must also be evaluated for effectiveness (Yarber & Torabi, 1990/1991) and the findings should be easily accessible and replicable. Finally, successful programs must be sustained within a larger context of support services.

The preteens' responsiveness to the aforementioned activities provides evidence of this program's impact. In addition, the students learned important facts about AIDS prevention and developed attitudes displaying sensitivity toward HIV-positive individuals, which leads one to hope that they will learn to be responsible and use preventive practices. This preteen population was more readily receptive to modifying their views and behaviors than older adolescents, many of whom have solidified their attitudes about responsible behavior, and some of whom may already be sexually active (Cohen, 1995). This reinforces the idea that AIDS education should begin early.

The students' obvious warmth care and compassion toward the HIV-positive guest speaker typified their attitude changes during the final days of the AIDS prevention program. They eagerly filled the front rows closest to the speaker, and stayed after the presentation to shake her hand and thank her.

APPENDIX: AIDS RESOURCES

Many school systems, public libraries and/or public health departments have these resources available to teachers.

Videos

1. AIDS . . . Taking Action. All Media, 1988. This video defines AIDS, defines the levels and characteristics of HIV infection, dispels AIDS rumors, explains how abstinence or condom use can prevent or reduce the risk of infection, and encourages sensitivity towards people with AIDS.

2. Sex, Drugs & AIDS. ODN Productions and Dimension Communications Network (DCN), 1987).

This video presents how AIDS is contracted through IV drug use or sexual intercourse, discusses personal choices regarding sexual intercourse and condom use and explains how to prevent and reduce the risk of AIDS infection. The information is provided by a teen to teenage audiences.

AIDS Education Resources and Teaching Materials

1. AIDS School Health Education Database. Centers for Disease Control and Prevention, National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003.

This source offers citations and descriptions of professional resources for educating children and teens about HIV infection and AIDS.

2. CDC National AIDS Clearinghouse. Centers for Disease Control and Prevention, Atlanta, GA, 800-458-5231.

This source distributes copies of selected reprints from CDC's Morbidity and Mortality Weekly Report (MMWR) series, the HIV/AIDS Surveillance report and other educational materials.

3. Education Technology Research Associates, 800-321-4407.

Developers of educational materials on many health topics, including AIDS.

4. How To Find Information About AIDS. Huber, J. (Ed.) (1991). New York: Haworth Press. A directory of resources for HIV/AIDS information, including organizations, health departments, electronic and print sources, and hotlines.

5. The National Association of People with AIDS (NAPWA), P.O. Box 18345, Washington, DC 20005, 202-898-0414.

This association provides information regarding HIV-positive guest speakers.

6. National School Boards Association, 1680 Duke Street, Alexandria, VA 22314, 703-838-6722 (Fax 703-683-7590).

The HIV and AIDS Education Project database for policymakers and educators includes sample school district policies and information on curricula, medical and behavioral research, court decisions, books, journals and videotapes.

7. National Pediatrics HIV Resource Center, 15 South 9th Street, Newark, NJ 07107. 800-362-0071.

Resources, consultations and publications for doctors, nurses and teachers.

8. AIDS Partnership Michigan, 845 Livernois, Ferndale, MI 48220, 800-872-AIDS.

This non-profit organization provides free educational information about AIDS, and non-financial support services to all individuals affected in any way by AIDS. Among the services provided by staff and volunteers are an AIDS hotline, support groups, guest speakers and buddy assignments for those who are HIV-infected.

Health Information

1. Pan American Health Organization, 24-hour AIDS Hotline, Regional Office of World Health Organization, 202-861-4346, recorded message.

2. Centers For Disease Control and Prevention, 24-hour National AIDS Hotline, 800-342-AIDS.

References

Abcarian, R. (1992, January 5). Teens who abstain: Sex "not worth it." Los Angeles Times, pp. 1, 8.

Alteneder, R., Price, J. M., Telljohann, S. K., Didion, J., & Locher A. (1992). Using the PRECEDE model to determine junior high school students' knowledge, attitudes, and beliefs about AIDS. Journal of School Health, 62(10), 464-470.

Basch, C. E. (1989). Preventing AIDS through education: Concepts, strategies, and research priorities. Journal of School Health, 59(7), 296-300.

Bechtel, L. J., & Sutter, M.D. (1990). Teaching techniques: HIV risk continuum. Journal of School Health, 60(6), 283-284.

Bruni, F. (1992, January 25). They hope baby won't have virus: Infected women choose pregnancy. Detroit Free Press, p. 7.

Centers for Disease Control and Prevention. (1994, December). Facts about adolescents and HIV/AIDS. Atlanta, GA: Author."

Cohen, D. L. (1995, March). Learning to say no. Teacher Magazine, 12-13.

DiClemente, R., & Houston-Hamilton, A. (1989). Health promotion strategies for prevention of Human Immuno-deficiency Virus Infection among minority adolescents. Health Education, 20(5), 39-43.

DuRant, R. H., Ashworth, C. S., Newman, C., & Gailard, G. (1992). High school students' knowledge of HIV/AIDS and perceived risk of currently having AIDS. Journal of School Health, 62(2), 59-63.

Elders, J. (1994). Surgeon General's report to the American public on HIV. Atlanta, GA: Center for Disease Control and Prevention, Public Health Service.

Fetter, P.M. (1989). AIDS education: Every teacher's responsibility. Childhood Education, 65, 150-152.

Fisher, W. A. (1990). All together now: An integrated approach to preventing adolescent pregnancy and STD/HIV infection. SIECUS Report, 18(4), 1-11.

Flax, E. (1989, October 25). "Explosive" data confirm prediction: AIDS is spreading among teenagers. Education Week, 9(8), 1, 12.

Greenspan, A., & Castro, K. G. (1990). Heterosexual transmission of HIV infection. SIECUS Report, 19(1), 1-8.

Hales, L. W., & McGrew-Zoubi, R. R. (1993). Knowledge and attitudes of students in rural schools examined by gender and grade level. Rural Educator, 15(1), 1-5.

Hochhauser, M. (1988, August). AIDS: It's not what you know, it's what you do. Paper presented at the meeting of the American Psychological Association, Atlanta, GA.

Humm, A., & Kunreuther, F. (1991). The invisible epidemic: Teenagers and AIDS. Social Policy, 21(4), 40-46.

Kolata, G. (1989, October 8). AIDS is spreading in teenagers, a new trend alarming to experts. The New York Times, p. 1.

Lawlor, W., Morris, R. W., McRay, A., Purcell, L. F., & Comeau, L. (1990). Human sexuality education and the search for values. SIECUS Report, 18(6), 4-14.

Legion, V., Levy, S. R., Cox, K., & Shulman, M. (1990). Giving AIDS a human face: Why people with AIDS are effective in providing AIDS education to adolescents. SIECUS Report, 19(1), 9-19.

Newman, C., DuRant, R. H., Ashworth, C. S., & Gaillard, G. (1993). An evaluation of a school-based AIDS / HIV education program for young adolescents. AIDS Education and Prevention, 5(4), 327-399.

Patierno, C. (1990). Empowering teenagers. SIECUS Report, 19(3), 5-12.

Popham, W.J. (1993). Wanted: AIDS education that works. Phi Delta Kappan, 74(7), 557-562.

Richards, D. E. (1990). Values and sexual health. SIECUS Report, 18(6), 1-3.

Rotheram-Borus, M., Koopman C., Haignere, C., & Davies, M. (1991). Reducing HIV sexual risk behaviors among runaway adolescents. Journal of the American Medical Association, 266, 1237-1241.

Shayne, V. T., & Kaplan, B.J. (1988). AIDS education for adolescents. Youth & Society, 20(2), 180-208.

Silin, J. G. (1992). Children, teachers, and the human immunodeficiency virus: Authorizing AIDS education in the curriculum. Journal of Education, 174(1), 52-69.

U.S. Department of Health and Human Services and Centers for Disease Control and Prevention. (1994). AIDS prevention guide. Washington, DC: Author.

U.S. Department of Health and Human Services and Centers for Disease Control and Prevention. (1995, February 3). Update: Acquired Immunodeficiency Syndrome - United States, 1994. Morbidity and Mortality Weekly Report, 44(4), 64-67.

Weinstein, E. (1989). Health educators: Where are you? Health Education, 20, 21-22.

Yarber, W. L., & Torabi, M. R. (1990/1991). HIV prevention knowledge test for teenagers. SIECUS Report, 19(2), 28-32.

Linda Rodrick-Athans is Middle School Science Teacher, Avondale School District(*), Auburn Hills, Michigan. Navaz Peshotan Bhavnagri is Associate Professor, Early Childhood Education, Wayne State University, Detroit, Michigan.

* The program described in this article took place in a different school district.
COPYRIGHT 1996 Association for Childhood Education International
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Bhavnagri, Navaz Peshotan
Publication:Childhood Education
Date:Dec 22, 1996
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