A Youth Health Summit to Increase HIV/AIDS Knowledge Among Adolescents in Rural North Carolina, USA Janie Canty-Mitchell, PhD, RN, FAAN Musarrat Nahid, MSc School of Nursing The University of Texas Health Science Center San Antonio
The River Walk, San Antonio, Texas Tim Thompson/SACVB
Background Current trend in HIV/AIDS and patterns of sexual behavior among adolescents Rural adolescents (what is already known) Current scenario with regards to prevention efforts Objective & Research Questions Method Results Study subjects Study design and instruments Recruitment Data analysis Demographics Descriptive statistics on individual items of the questionnaire Comparison on knowledge levels Discussion Strengths & Limitations Community-University partnership: processes and challenges Conclusions & Implications
By the end of 2008, roughly 70 thousand people in 13-24 years age group were living with HIV infection in the USA According to the Center for Disease Control and Prevention (CDC), USA Youth Risk Behavior Survey (YRBS) among high school students in 2011, nearly half (47%) ever had sexual intercourse; approximately one-third (34%) had sexual intercourse with at least one person during the 3 months before the survey; two-fifth (40%) did not use a condom during last sexual intercourse; just less than one-fifth (15%) have had four or more sex partners; and 6% had sexual intercourse for the first time before age 13 years
Figure 1. Estimated number of diagnosed HIV infection cases among adolescents in the United States, 2006-2011 (data source: CDC)
Figure 2. Estimated rate of HIV infection cases among adolescents in the United States (2006-2011); (data source: CDC)
Rural adolescents (what is already known) were more than twice as likely to be sexually active and had higher levels of sexual risk taking than their urban peers were found to engage in HIV/AIDS risk behaviors as frequently as lower socio-economic minority youths in large urban areas in a representative sample of rural adolescents who were sexually active, more than two-thirds had one sex partner in the last 3 months about one-third were found to engage in STD/HIV related sexual risk behaviors (no condom use during the last sexual intercourse and having multiple sex partners in the last 3 months) were found to have inadequate knowledge about HIV/AIDS however, very few HIV/AIDS prevention interventions are targeted towards adolescents in rural communities
Current scenario (prevention efforts towards rural adolescents) School-based sex and HIV/AIDS education Has the ability to reach a large population of adolescents Structured education and has the potential to increase adolescents knowledge However, not all schools implement the program with fidelity; therefore, quality of the program across schools may vary North Carolina It is not known how uniformly it is implemented across schools Rural schools may lack resources (e.g. expertise) Rural communities are often considered to hold conservative values which may pose an obstacle to discussions about sex openly or in public Providing detailed information about HIV/AIDS and its prevention is not emphasized in the lesson plan for younger adolescents Therefore, rural adolescents in North Carolina may not have sufficient knowledge about HIV/AIDS
Objective To compare knowledge levels of 7th grade rural students in North Carolina (NC), USA before ( pre-test ) and after ( posttest ) the Youth Health Summit (YHS) Research questions Did the pre-test and the post-test groups differ in their levels of knowledge about HIV/AIDS? Did the pre-test and the post-test groups differ in their levels of knowledge about modes of transmission of HIV/AIDS?
Participants 7 th grade students living in rural southeastern North Carolina Study design Pre-test questionnaire Youth Health Summit Post-test questionnaire Youth Health Summit Setting: Campus of the University of North Carolina Wilmington Organizer: Associate Dean, School of Nursing A variety of interactive methods Keynote speech by a nationally recognized health educator- Used NC HIV/AIDS Curriculum combined with interactive and motivational topics including: goal setting, peer pressure, HIV AIDS Knowledge, decisions making, consequences of risky behaviors Poster exhibition health professionals and community agencies Small group lectures and three break-out sections
Questionnaire Knowledge of HIV/AIDS : 12 items Knowledge of Modes of Transmission of HIV/AIDS: 18 items (Four point scale: yes, no, not sure, and don t understand) Opinion about prevention methods, health topics of interest, information sources Recruitment Flyers sent to 22 schools in rural areas Parental permission forms Signed permission forms pre-test questionnaire to students Gift pack: notebooks, pens, t-shirts, and program details Venue for the YHS University campus
Data analysis Descriptive statistics Composite knowledge score T-test for independent samples: 2 groups Oneway ANOVA: more than 2 groups Prevention methods Chi-squared test Reliability of the questionnaire: Chronbach s Alpha Figure3: Groups compared on knowledge levels
Demographics Gender Males Females Ethnicity Blacks Whites Hispanics Other Age (years) 13 14 15 County Columbus Duplin New Hanover Pender Other Pre-test Group % (n) 27 (43) 73 (116) - - - - 49 (77) 43 (68) 8 (13) 1 (2) 26 (42) 29 (46) 20 (31) 24 (38) Post-test Group % (n) 28 (56) 72 (144) 32 (68) 38 (82) 14 (30) 16 (34) 47 (95) 47 (96) 6 (12) 1 (2) 20.5 (44) 41 (87) 19 (40) 20 (42) N, pre-test= 159 N, post-test= 215 N, schools= 20
K n o w l e d g e o f H I V / A I D S Item Overall Males Females Pre % Post % Pre % Post % Pre % Post % 1. AIDS stands for Acquired Immune Deficiency 55 70 70 77 50 66 Syndrome. 2. HIV stands for Human Immunodeficiency Virus. 66 76 76 75 62 78 3. You can tell a person has HIV/AIDs by looking at 79 87 81 77 78 92 them. 4. Infection with HIV can lead to AIDS. 65 77 69 77 64 78 5. HIV/AIDS attacks the immune system. 69 72 69 64 70 75 6. Vaccines can prevent a person from getting 53 57 58 47 51 61 HIV/AIDS infection. 7. HIV/AIDS infection has a cure. 81 80 81 72 80 84 8. Someone can have HIV infection for years and not 84 86 88 79 83 88 know it. 9. All gay or homosexual persons have HIV/AIDS. 85 82 79 73 88 86 10. Only gay or homosexual persons can get 90 84 86 71 91 91 HIV/AIDS. 11. Persons with HIV can live ten years or longer. 43 53 42 38 44 57 12. Persons can get gonorrhea and HIV infection at the same time. 34 55 29 48 37 57
K n o w l e d g e o f m o d e s o f t r a n s m i s s i o n o f H I V / A I D S Item Overall Males Females Pre Post Pre Post Pre Post % % % % % % 13. Sharing Public Toilets and Swimming Pools with Infected Persons. 49 71 51 66 48 73 14. Using Infected Persons' Belongings Such as Clothes, Combs, and 60 81 63 67 59 86 Towels. 15. Touching Infected Persons, such as Hugging and Shaking Hands. 77 92 72 83 78 96 16. Sharing Food Utensils, Such as Forks and Knives, with an Infected 37 75 34 62 38 79 Person. 17. Contact with an Infected Person who Coughs or Sneezes. 43 65 45 59 42 67 18. Having a Tattoo Done with the Same Needles After an Infected 80 79 88 98 78 83 Person. 19. Sharing Injection Needles of an Infected Person. 95 90 98 85 94 92 20. Having Sex with Someone who is Infected. 96 93 95 87 97 96 21. Having Sex with an Infected IV Drug User. 79 81 76 76 79 82 22. Receiving Blood From an Infected Person. 91 85 93 85 90 85 23. An Unborn Baby Receiving Breast Milk from an Infected Mother. 60 67 45 66 65 67 24. Sharing a Razor with Someone who is Infected. 42 36 40 40 43 35 25. Holding Hands with Someone who is Infected. 85 86 81 72 86 92 26. Sitting in the Same Class with Someone Who is Infected. 91 91 83 83 94 96 27. Washing Clothes Together With the Clothes of Someone who is 73 89 76 79 72 93 Infected. 28. The Bite of a Mosquito. 40 51 29 40 44 55 29. Having Oral Sex with an Infected Person. 80 90 79 81 80 96 30. Kissing an Infected Person. 38 68 34 53 39 73
Level of knowledge about HIV/AIDS: Comparing pre and post tests using t-test n Mean SD All * Pre-test 159 8.05 2.48 Post-test 206 8.72 2.38 Males Pre-test 43 8.25 2.43 Post-test 53 7.98 2.94 Females** Pre-test 116 7.98 2.50 Post-test 140 9.05 2.12 *p=0.008; **p<0.0001 Mean Difference 95% CI of the Mean Difference Lower Upper -0.685-1.182-0.182 0.272-0.838 1.381-1.072-1.649-0.503 Knowledge level increased among all. Females had significantly higher scores following the summit
Level of knowledge of modes of transmission of HIV/AIDS: Comparing pre and post tests using t-test n Mean SD Mean Difference 95% CI of the Mean Difference Lower Upper All * Pre-test 159 12.40 3.18-1.50-2.169-0.828 Post-test 205 13.90 3.26 Males Pre-test 43 12.04 3.19-0.597-2.118 0.923 Post-test 53 12.64 4.12 Females * Pre-test 116 12.54 3.18-1.904-2.620-1.188 Post-test 139 14.44 2.63 Knowledge level increased among all and females significantly following the summit (p < 0.0001)
Comparison of knowledge levels between males and females in the pre-test and the post-test groups (t-test) Pre-test Post-test * Pre-test Post-test * Knowledge of HIV/AIDS n Mean SD Mean 95% CI of the Mean Difference Difference Lower Upper Males 43 8.25 2.43 Females 116 7.98 2.50 0.275-0.600 1.150 Males 53 7.98 2.94 Females 140 9.05 2.12-1.069-1.949-0.188 Knowledge of modes of HIV/AIDS transmission n Mean SD Mean 95% CI of the Mean Difference Difference Lower Upper Males 43 12.04 3.19 Females 116 12.54 3.18-0.498-1.621 0.624 Males 53 12.64 4.12 Females 139 14.44 2.63-1.805-3.017-0.592 Females significantly scored higher than males on both constructs in the post-test group There was no significant difference among ethnic groups on mean knowledge levels on either of the constructs in the post test group * p=0.018 * p<0.0001
Opinion about prevention methods: Between pre and post-test groups using 2 test Prevention methods Pre-test group % (n) Post-test group % (n) Abstinence 41(54) 56 (87) Education/information 20 (27) 12 (18) Personal protection 14 (19) 15 (23) Other 25 (33) 17 (27) Note: p<0.031; total, n for pre-test group=133; total, n for post-test group=155 The groups differed significantly; preference for abstinence went up by 15% Reliability of the questionnaire Only a few factors, identified by Exploratory Factor Analysis, yielded acceptable level of alpha (>=0.7)
Strengths Includes rural adolescents who had not been adequately represented in prior HIV/AIDS prevention The sample diverse in terms of ethnicity Sample size moderate Limitations Limited generalizability: only those in schools Only tracked group-level changes in knowledge, not individual level changes Measured only instant effect of the summit: not sure whether the effect sustained over a long term to initiate behavior changes Questionnaire reliability < acceptable for most of the factors
Community-university partnership: Processes & challenges Processes Recruited schools-five counties Parental approval Recruited professionals and community organizations from private and public sectors Obtained funding and in-kind supplies and services Strong faculty, staff, director Hosted by regional university Recruited volunteers from high schools in multiple counties Media highlights Challenges Coordinating youth summit with other university duties (associate dean for research, executive assistant) Sustainability of funding (supported by three sources) Continued university support in a time of dwindling resources Transportation of students from schools with limited resources Program held during university spring break only accessible time for class room space
The Summit was effective in increasing rural adolescents knowledge which is important in preventing HIV/AIDS appeared to be an effective means to educate rural adolescents en masse outside schools seemed to have provided a better learning opportunity for rural adolescents Interactive approach Watching large number of peers taking part; listening to experts Small groups and speakers and audience unknown: feelings of awkwardness eradicated while asking questions More university-community partnerships should be built in order to develop similar events as a supplement to curricula-based sex education in schools
Robert Wood Johnson Foundation Executive Nurse Fellows Program NC GlaxoSmithKline Foundation Southeast Area Health Education Center, Wilmington, NC School Administrators, Health Personnel, Counselors, Parents and Students High School Student Volunteers Health and Social Service Agencies Kwain Bryant, Motivational Speaker and Health Educator University of North Carolina Wilmington, School of Nursing Private Donors
1. Center for Disease Control and Prevention of the USA. Tables 1a, HIV Surveillance Report. 2009 (vol. 21), 2010 (vol. 22), 2011 (vol. 23). 2. Durant, RH, Ashworth, CS, et. al. AIDS/HIV knowledge level and perceived chance of having HIV among rural adolescents. Journal of Adolescent Health.1992; 13: 499-505. 3. Smith, MU, DiClemente, RJ. STAND: A peer educator training curriculum for sexual risk reduction in the rural south. Preventive Medicine. 2000; 30: 441 449. 4. Graham, RP, Forrester ML, Wysong, JA, et. al. HIV/AIDS in rural US: Epidemiology and health services delivery. Med Care Res Rev. 1995; 52:435-452. 5. National Conference on State Legislature of the USA: Rural Health. 6. Jemmott, JB, Jemmott, LS, Fong, GT. Efficacy of a theory-based abstinence-only intervention over 24 months. Arch Pediatr Adolesc Med. 2010; 164(2):152-159. 7. Weed, S, Ericksen, IH, Lewis, A, Grant, GE, Wibberly, KH. An abstinence program s impact on cognitive mediators and sexual initiation. American Journal Health Behavior. 2008; 32(1):60-73. 8. Bryant, Kwain (Senior Consultant/CEO, Empowerment Exchange.). What Youth Should Know About HIV/AIDS. Keynote speech at the 2011 Youth Health Summit, North Carolina, USA. Note: A detailed list of references was not possible to include here due to limited space
Janie Canty-Mitchell, PhD, RN, FAAN Professor & Chair Department of Family & Community Health Systems School of Nursing The University of Texas Health Science Center, San Antonio Email: cantymitchel@uthscsa.edu Musarrat Nahid, MSc Research Associate Department of Family & Community Health Systems School of Nursing The University of Texas Health Science Center, San Antonio Email: nahid@uthscsa.edu
The River Walk, San Antonio, Texas Tim Thompson/SACVB