RESEARCH ARTICLE URL of this article: http://heanoti.com/index.php/hn/article/view/hn1204 The Effects of Peer Education on The Regarding HIV/AIDS Transmission Prevention among Street Children in Bandung City Lia Meilianingsih*, Ridwan Setiawan*, Haris Sofyana* *Department of Nursing, Health Polytechnic of Ministry of Health in Bandung, Indonesia Email: hsofyana@yahoo.co.id ABSTRACT All adolescents are vulnerable to HIV/AIDS, including street children. The behaviors of street children are much influenced by their peers. Peer education can enhance knowledge, attitudes, beliefs, and skills and empower children to be responsible for protecting the health of themselves and their peers (Wahyuni, 2012). This study aims to determine the effects of peer health education on the HIV/AIDS Preventive of Street Children in Bandung City in 2015. The research employed a quasi-experimental method with the pre-post-test control group design. The sample was 26 people for the treatment group and 26 people for the control group, respectively, taken with purposive sampling technique. Interventions began with peer educator training and then the peer educators provided health education on HIV/AIDS transmission prevention through small group discussions for 2 days. The data in this study were not normally distributed. The paired or dependent data were analyzed using the Wilcoxon test, while the unpaired or independent data using Mann-Whitney test. The results of the research show that peer health education had effects on the knowledge and attitudes of the street children (p values and, respectively); however, there was no effect of peer health education on the actions regarding HIV/AIDS transmission prevention among the street children (p value 0.09). Hence, it is advisable to conduct health promotion with peer health education method in an effort of increasing knowledge and attitudes regarding HIV/AIDS transmission prevention among street children that is sustainable and integrated with the existing programs at puskesmas (Community Health Center). Keywords: Street children, HIV/AIDS, peer health education Background INTRODUCTION HIV is a virus that attacks the human immune system and leads to acquired immunodeficiency syndrome (AIDS), so that people with HIV infection are easily infected by various other diseases. Therefore, HIV/AIDS can cause death to someone slowly (Kemenkes RI, 2012; Setiawan, 2010). According to the WHO, it is estimated that 20-25% of HIV incidences in the world occurred among adolescents (Widastra, 2012). HIV incidence among adolescents in Indonesia is estimated to be much higher, although the exact figure is not yet known. This is because the numbers identified are far less than the actual incidence rate (Sahar, et al., 2011). WHO establishes the age of 10-20 years old as the age limit of adolescents (Sarwono, 2012). All adolescents are vulnerable to HIV because of the unstable physical and emotional transition in making high-risk decisions in sorting out good from bad attitudes to serve as the behavior to be adopted (WHO, 2007). The weak economic conditions and lack of community support have resulted in the increasing number of street children from year to year, especially in big cities. Based on the result of a social mapping of street children in West Java Province in 2013, there were 5,849 street children and the majority of them lived in Bandung, namely as many as 2,265 children. Street children are one of the groups that have a high risk of HIV/AIDS transmission. Street children bear a heavy burden that makes them seek refuge in drugs and free sex because they live together with adults, even with street commercial sex workers (Busza, 2010: Weber, 2002). Based on data from Department of Health of the Republic of Indonesia in 2010, out of 144,889 street children 8,581 of them had been infected with HIV (Hanifah, 2010). 76 Publisher: Humanistic Network for Science and Technology
Less supportive environment and inadequate information can make street adolescents acquire high risk behaviors for HIV/AIDS transmission. To overcome this, the government has conducted health education through counselling by health workers, but the results have not been optimal. Meanwhile, peer group has a very positive contribution to the personality of adolescents and is the factor that influences a street adolescent s life style (Wahyuni, 2010; Sahar, et al., 2011). In an effort of improving adolescent health, peer education is a very effective strategy. Peer education is a process of training and motivating through educational activities with peers who have similarities in age and background (Sahar et al., 2011). Several studies have shown that peer education brings changes towards positive perceptions (Caron, et al., 1998) and more conservative sexual norms (Mellanby, et al., 2000). Based on the above phenomenon, more attention has to be paid to street children s health to prevent HIV/AIDS incidence. Therefore, the researchers were interested in conducting research on the Effects of Peer Health Education on the regarding HIV/AIDS Transmission Prevention of the Street Children in Bandung in 2015. Hypothesis 1. Peer Health Education has an effect on the knowledge about HIV/AIDS transmission prevention of the street children in Bandung in 2015 2. Peer Health Education has an effect on the attitudes regarding HIV/AIDS transmission prevention of the street children in Bandung in 2015. 3. Peer Health Education has an effect on the actions regarding HIV/AIDS transmission prevention of the street children in Bandung in 2015 METHODS The design of this research was pretest-posttest control group and non-equivalent control group. In this design, grouping of sample members in the treatment group and control group was not done randomly. A sample size was 52 people, divided equally into treatment group and control group. The inclusion criteria were: willingness to be a research respondent, having been on the streets at least for 1 month, and being able to fully attend peer health education. The research process began with identifying street children who met the criteria of inclusion (prospective respondents). Subsequently, treatment group and control group were determined. After measuring the behaviors (knowledge, attitudes, and actions) regarding HIV/AIDS transmission prevention of the street children through interviews and questionnaires, the treatment group was given peer health education by peer educators with small group discussions for 2 days (2 hours/day) to discuss: Peer education concepts, HIV/AIDS Concepts, HIV/AIDS Transmission Prevention, and Introduction of HIV/AIDS Risks to street children. Data was collected as numerical data so that it refers to Nugroho (2014), it was described as the minimum value, maximum value, median and standard deviation. Hypothesis testing was performed using Wilcoxon and Mann Whitney-U test. RESULTS Table 1. Distribution of,, and regarding HIV/AIDS Transmission Prevention of the Street Children in the Treatment Group before Peer Health Education 4 17 9 4.39 31 53 43 6.11 0 2 1 0.67 Table 2. Distribution of,, and regarding HIV/AIDS Transmission Prevention of the Street Children in the Treatment Group after Health Education 5 20 17 3.43 55 68 60 4.23 0 2 1 0.60 77 Publisher: Humanistic Network for Science and Technology
Based on Table 2, the lowest score for the knowledge of the street children in the treatment group after peer health education was 5 (poor), but the highest score was 20, and the median value increased to 17. The scores showed an increase in the street children s knowledge. Meanwhile, the attitudes of the street children after the implementation of health education scores 55 at the lowest, experiencing an increase from 31, with the highest score of 68 and a median of 60, which means there was a change in their attitudes after peer health education. Finally, in terms of preventive actions, some of the street children still did not perform (0) any action that might cause HIV/AIDS, but there were also street children who performed a maximum of 2 actions that could cause HIV/AIDS. This finding shows there was no change in action scores before and after peer health education. Table 3. Distribution of knowledge, attitudes, and actions regarding hiv/aids transmission prevention in the initial measurement of the street children in the control group 4 17 8.5 4.10 31 51 43 5.74 0 2 1 4.23 Table 4. Distribution of,, and regarding HIV/AIDS Transmission Prevention in the Final Measurement of the Street Children in the Control Group 4 18 9 4.32 31 68 43 9.77 0 2 1 5.82 Table 4. displays the final measurement results of the control group in terms knowledge, attitudes, and actions regarding HIV/AIDS prevention. The lowest knowledge score was 4 (poor), the highest score was 18 (good), and the median score increases to 9 (poor). Next, the final measurement of the street children's attitudes shows that the lowest score of the control group was 31, the highest score 68, and the median 43, which means there was a slight change in the scores of the control group s attitudes after the final measurement. Meanwhile, there were still some street children who did not do any action (0) that could cause HIV/AIDS; however, there were also street children who performed a maximum of 2 actions that could cause HIV/AIDS. This shows there was no change of scores after the final measurement. Table 5. Comparison of the,, and regarding HIV/AIDS Transmission Prevention of the Street Children in the Treatment Group before and after Peer Health Education -4.29-4.46-3.69 0.09 Table 5 shows the comparison of knowledge, attitudes, and actions regarding HIV/AIDS transmission prevention before and after peer health education. For knowledge, p value = <α (0.05), and the null hypothesis was rejected, which means there was an effect of peer health education on the street children s knowledge about HIV/AIDS transmission prevention. For attitudes, p value = <α (0.05), and the zero hypothesis was rejected, which means there was an effect of peer health education on the street children s attitude towards HIV/AIDS prevention. Finally, for the preventive actions of HIV/AIDS transmission, p value = 0.09> α (0.05), and the null hypothesis was accepted, which means there was no effect of peer health education on the preventive actions of HIV/AIDS of the street children. Table 6. Comparison of the,, and regarding HIV/AIDS Transmission Prevention of the Street Children in the Control Group between the Initial and Final Measurements -0.56-1.09-0.23 0.577 0.273 0.819 78 Publisher: Humanistic Network for Science and Technology
Based on the table 6, the p value for knowledge = 0.577> α (0.05), so the null hypothesis was accepted (no difference). For attitudes, p value = 0.273> α (0.05), so that the null hypothesis was accepted (no difference). For preventive actions, p value 0.819> α (0.05), the null hypothesis was accepted (no difference). Table 7. Differences in,, and of HIV/AIDS Transmission Prevention in the Pre- /Initial Measurements between the Treatment Group and the Control Group -0.43-0.57-3.11 0.67 0.59 0.09 A comparison of the preliminary measurement results before the implementation of health education for the treatment group and the control group can be seen. In terms of knowledge, the table shows that p value = 0.67> α (0.05), so the null hypothesis was accepted, which means there was no difference in the level of knowledge between the street children in the intervention group and the control group in the initial measurement. For attitudes, p value = 0.59> α (0.05), so that the null hypothesis was accepted, meaning that there was no difference in the attitudes of the street children in the initial measurement between the intervention group and the control group. Meanwhile, in terms of preventive actions of HIV/AIDS transmission, p value = 0.09 <α (0.05), so that the null hypothesis was accepted, which means there was no difference in the preventive actions of HIV/AIDS between the intervention group and the control group in the initial measurement. Table 8. Differences in,, and regarding HIV/AIDS Transmission Prevention in the Post/Final Measurements between the Treatment Group and the Control Group -4.62-4.97-1.66 0.098 Table 8 shows the comparison of knowledge, attitudes, and actions regarding HIV/AIDS transmission prevention in the final measurements/after intervention between the treatment group and the control group. For knowledge, the obtained p value = <α (0.05), so that the null hypothesis was rejected, which means there was a difference in the street children's knowledge about prevention of HIV/AIDS between the intervention group and the control group. Meanwhile, for the aspect of attitudes p value = <α (0.05), so the null hypothesis was rejected, which means there was a difference in the attitudes of the street children towards HIV/AIDS transmission prevention between the intervention group and the control group. Finally, for actions regarding HIV/AIDs transmission, p value = 0.098> α (0.05), so zero hypothesis was accepted, which means there was no difference in the actions regarding HIV/AIDS transmission prevention of the street children in the final measurement of both the treatment group and the control group. DISCUSSION, and Regarding HIV/AIDS Transmission Prevention of The Street Children in The Treatment Group before The Implementation of Health Education In the treatment group, before the peer health education intervention was implemented, the median score for the knowledge aspect was 9 (out of the maximum score of 20). This score indicates that the knowledge of the street children before the intervention was poor, probably due to the education background of most of the respondents who were graduates of junior high school and the lack of exposure of the street children to the information related to HIV/AIDS, either from health workers or from other institutions (results of interviews with the respondents), and the economic disadvantages of the street children. This finding is in line with Notoatmodjo (2010) that one's knowledge is influenced by several factors, namely education, information, social-culture, economy, and age. In addition, inadequate knowledge about HIV/AIDS will badly affect the attitudes toward HIV/AIDS transmission prevention. This argument is in accordance with the results of the present study, in which the median score for the attitude aspect was 43 out of the maximum score of 80. This result shows that 50% of the street children had negative attitudes towards HIV/AIDS prevention. In addition, attitudes are influenced by others who are considered important. The street children s behaviors are much influenced by peers in their environment. Street children generally prefer to talk about their problems with and learn something from their 79 Publisher: Humanistic Network for Science and Technology
peers instead of someone who puts him/herself in the position to advise and manage their lives (Sahar, et al., 2011). Peer groups, thus, have a very positive contribution to the personality of adolescents and are factors that influence how a street adolescent lives his or her life (Wahyuni, 2010; Sahar, et al., 2011). Street children do not have formal rules in their daily life, but there are values agreed upon by the members in the group. Furthermore, attitude is often assumed to be the most determining factor of how individuals act, but attitudes and actions are often different because actions are not only determined by attitudes alone, but there are other determining factors. This argument is corresponding to the result of the present research, where in the treatment group there were street children who did not take any actions that could cause HIV/AIDS, but there were also street children who performed the maximum actions that could cause HIV/AIDS. From the results of questionnaires, the most frequently done actions were piercing and tattoos. The,, and regarding HIV/AIDS Transmission Prevention of the Street Children after the Implementation of Health Education Based on the research results, the knowledge, attitudes, and actions of the street children in the treatment group changed after the peer health education. The median score for the knowledge of the street children in the treatment group after peer health education increased to 17. This indicates an increase in their knowledge. The increased knowledge was made possible through peer health education. In peer education activities, there is a process of delivering information through organized but informal educational activities with peers. The attitudes of the street children after the peer health education were also improved, or there was a positive change. Several studies have shown that peer education indeed brings positive changes in perceptions (Caron, et al., 1998) and more conservative sexual norms (Mellanby, et al., 2000). According to Widyantoro & Lestari (2008), peer education is an important means in spreading HIV/AIDS awareness because it can transfer knowledge and communication that is done openly and freely in peer groups. Peer education can also influence changes at the group level by modifying norms towards the positive direction. Meanwhile, in terms of preventive actions there were still some street children who did not perform any actions (0) that could cause HIV/AIDS, but there were also some street children who performed actions that could cause HIV/AIDS. This finding indicates no change in their preventive actions regarding HIV/AIDS transmission after peer health education. To be able to avoid actions that can transmit HIV/AIDS, support and motivation from the environment is necessary. Environmental conditions that are less supportive and inappropriate information can make street adolescents acquire high-risk HIV/AIDS behaviors. Results of Preliminary Measurement of the,, and regarding HIV/AIDS Transmission Prevention of the Street Children in the Control Group The results of the initial measurements of the control group on the knowledge, attitudes, and actions regarding HIV/AID prevention showed a median value of 8.5 (poor) for the aspect of knowledge. This result is likely to be related to the fact that the respondents were adolescents and their education level was mostly junior high school. The results of basic health research by Sudikno, et al. (2011) reported that adolescents who graduated from education level higher than junior high school tended to have better knowledge about HIV/AIDS. In addition, based on interviews with some of the respondents, it is found that they had never received any information or counseling about HIV/AIDS. The results of initial measurements of the street children s attitudes in the control group indicate that the children had negative attitudes towards HIV/AIDS prevention. The street children who see their friends having sex, wearing tattoos, and piercing tend to follow these habits for the sake of solidarity. According to Kohlberg in Ridwan (2012), teenagers prefer the norms of their group friends as a moral reference because they think the group can be used as a guide in determining which attitudes to adopt. On the other hand, the measurement of HIV/AIDS preventive actions shows that there were still street children who did not do any (0) actions that could cause HIV/AIDS, but there were also some street children who performed a maximum of 2 actions that could cause HIV/AIDS. The tendency of the street children to take the HIV/AIDS high-risk actions can be explained because adolescence is a transitional period in which adolescents have the desire to be accepted by their friends, so they tend to follow the activities or perform actions committed by the group such as wearing tattoos and doing piercing (Ridwan, 2012). Results of the Final Measurement of the,, and regarding HIV/AIDS Transmission Prevention of the Street Children in the Control Group 80 Publisher: Humanistic Network for Science and Technology
The results of final measurement of the control group show poor knowledge score. There was an increase in the highest and the median scores (though still poor), which was likely to be influenced by information disseminated by mass media such as the internet and television. The final measurement of the street children s attitudes indicates a median score of 43 for the control group, which means there was a slight change of score in the control group, though still negative. The negative perceptions of the street children might be influenced by mass media which present a lot of information that contain pornography. Meanwhile, there were still street children who did not do (0) any actions that could cause HIV/AIDS, although there were also street children who performed a maximum of 2 actions that could cause HIV/AIDS. This finding shows there was no change of score. The Effects of Peer Health Education on (,, and ) regarding HIV/AIDS Transmission Prevention of the Street Children Wilcoxson test results on knowledge show p value of <α (0.05), so the null hypothesis was rejected, which means peer health education had an effect on the street children s knowledge about HIV/AIDS transmission prevention. On the other hand, the results of the test on attitudes indicates p value of 00 <α (0.05), so that the null hypothesis was rejected, which means there was an effect of peer health education on the street children s attitudes regarding HIV/AIDS transmission prevention. This result is in line with the results of Widastra s study, where he found that there was a significant effect of the method of peer education on the level of adolescents knowledge about HIV/AIDS (p value ). This finding is also in line with that of the research conducted by Hidayati & Apriyani (2010), which describes that health education with peer education method could increase the knowledge and attitudes of primigravida mothers about breastfeeding. This finding is also similar to the research of Harahap (2014) which states that the method of peer health education was more effective in increasing knowledge and attitudes that contribute positive values in tackling HIV/AIDS. On the same note, the research conducted by Riyanto (2014) shows that there was a significant effect of health education intervention with peer education method on adolescents premarital sex perception (p value ). Peer health education method can increase adolescents knowledge about HIV/AIDS. This is because the process of delivering information is conducted between peer groups, where in this case the peers act as facilitators and a source of information. Delivery of information that is clear and appropriate by the facilitators will be able to improve the knowledge of adolescents. Increased knowledge through peer health education method is the proof that the method is very effective because the explanations given by individuals who have built trust with the peer group, in this case the adolescents, will be more easily understood, and the implementation of education can be done repeatedly with open communication between groups of peers who have more intimate relationships so that the target group will have more comfort in discussing the issues. Peer health education method is also more useful because the process of education is implemented by the peer groups; hence, communication becomes more open. Given the fact that the respondents in this study consisted of adolescents who were in their period of transition influenced both by individual factors (biological, cognitive, and psychological) and the environment (peers), it can be said that their peers attitudes, talks, interests, and appearance have a great influence on the information delivered. Teenagers will feel comfortable discussing matters with their peers because they are in the same position, so that they can communicate openly. Peer education can also influence changes at the group level by modifying norms towards the positive ones (Widyantoro & Lestari, 2008). Based on the results of the present study, it is also shown that peer norms affect the process of adolescents sexual initiation (Carvajal, et al., 1999). Meanwhile, the results of analysis of the preventive actions of HIV/AIDS transmission show that p value = 0.09> α (0.05), so that the null hypothesis was accepted, which means there was no effect of health education on preventive actions of HIV/AIDS of the street children. This is probably because to change actions takes a long time, whereas in this study the distance from the treatment of peer health education to the measurement of the respondents actions was only 1 week. Finally, the results of the analysis of initial and final measurements in the control group showed no effect of peer health education on knowledge, attitudes, and actions with p value of 0.577, 0.273, and 0.819, respectively. This probably happened because no intervention was done to the group. Differences in,, and regarding HIV/AIDS Transmission Prevention between the Street Children in the Control Group and the Treatment Group during the Pre/Initial and Post/Final Measurements In the pre/initial measurement, there were no differences in knowledge, attitudes, and actions between the treatment group and the control group with p value of > 0.05. This illustrates that both groups had the same starting point in the study. However, in the final measurement/post analysis results, there were significant differences in knowledge and attitudes between the treatment group and the control group (p values and 81 Publisher: Humanistic Network for Science and Technology
, respectively), although no difference was found in terms of preventive actions. These results can mean that peer health education is meaningful or influential on the aspects of knowledge and attitude alone. The findings are in line with those of Yusuf (2008) who reported that the interaction of adolescents in peer groups can stimulate patterns of new responses through learning. In this case, the method of peer health education can improve knowledge and attitudes in maintaining and protecting adolescents health. The approach of health education through peer education method to adolescents is considered necessary to convey information and messages of reproductive health to adolescents by the adolescents themselves (Widyantoro & Lestari, 2008). Adolescents are more comfortable and open when discussing issues related to sexual behavior or reproductive health with their peers than with their parents or other adults. CONCLUSION Based on the results of research can be concluded that peer education can improve the behavior of street children in Bandung city about the prevention of HIV / AIDS. Thus, peer education can be used as one of the selected methods in preventing HIV-AIDS transmission in street children. REFERENCES Busza, J. R., Balakireva, O. M., Teltschik, A., Bondar, T. V, Sereda, Y. V., Meynell, C., Sakovych, O. (2010). Street based adolescents at high risk of HIV in Ukraine. Journal of Epidemiology and Community Health, 65(12), 1166-1170. Caron, et al., F., Otis, J., Pilote, F. (1998). Evaluation of an AIDS, peer education program multiethnic adolescents attending an urban high school in Quebec. Canada Journal of HIV/ AIDS Education and Prevention for adolescent and children. Carvajal, S. C., Parcel, G. S., Banspach, S. W., Basen-Engquist, K., Coyle, K. K., Kirby, D., Chan, W. (1999). Psychosocial predictors of delay sexual intercourse by adolescent. Health Psychology, 18(5), 443-52. Harahap, J. (2014). Pengaruh peer education terhadap pengetahuan dan sikap mahasiswa dalm menanggulangi HIV/AIDS di Universitas Sumatera Utara. Skripsi. Medan: Fakultas Kesehatan Masyarakat, Universitas Sumatera Utara. Hidayati, T., Apriyani, N. (2010). Pengaruh peer education terhadap pengetahuan dan sikap ibu primigravida tentang menyusui di wilayah kerja Puskesmas Mergangsan Yogyakarta. Tesis. Yogyakarta: Program Studi Ilmu Keperawatan, Universitas Muhammadiyah Yogyakarta. Kemenkes RI. (2012). Laporan perkembangan HIV/AIDS di Indonesia. Jakarta: Kementerian Kesehatan Republik Indonesia. Notoatmodjo, S. (2010). Ilmu perilaku kesehatan. Jakarta: Rineka Cipta. Mellanby, A. R., Rees, J, B., Tripp, J. P. (2000). Peer-led and adult-led school health education: a critical review of available comparative research. Health Edication Research, 15(5), 533-545. Ridwan, A. F. (2012). Tindakan berisiko tertular HIV-AIDS pada anak jalanan di Kota Makasar. Sahar, J., Widyastuti, Winarsih, W., Mulyadi, B. (2011). Pedoman fasilitator pendidik sebaya dalam pencegahan penularan HIV dan penatalaksanaan AIDS pada anak jalanan. Depok: Kelompok Ilmu Keperawatan FIK UI. Setiawan, H. H. (2010). Pemberdayaan anak jalanan dalam mencegah penyebaran HIV/AIDS. Yayasan Rumah Kita. Wahyuni. (2010). Peer educator. Sub-Bid Promosi IAKMI. Weber, A. E., Boivin, J. F., Blais, L., Haley, N., Roy, E. (2002). HIV risk profile and prostitution among female street youth. Journal of Urban Health, 79(4), 525-35. WHO. (2007). Guidance on provider-initiated IV testing and counseling in health facilities. Geneva: World Health Organization. Widastra, I. (2012). Metode peer education berpengaruh terhadap tingkat pengetahuan remaja tentang HIV/AIDS. Widyantoro, N., Lestari, H. (2008). Panduan peer education seksualitas dan kesehatan reproduksi. Yayasan Pendidikan Kesehatan Perempuan. Yusuf, S. (2008). Psikologi perkembangan anak dan remaja. Bandung: Remaja Rosdakarya. 82 Publisher: Humanistic Network for Science and Technology