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Evaluation of an Intervention to Increase Human Immunodeficiency Virus Testing Among Youth in Manzini, Swaziland: A Randomized Control Trial
Journal of Adolescent Health 48 (2011) 507–513
www.jahonline.org Original article
Evaluation of an Intervention to Increase Human Immunodeficiency Virus Testing Among Youth in Manzini, Swaziland: A Randomized Control Trial Sarah M. Burnett, M.P.H., M.P.A.a,*, Marcia R. Weaver, Ph.D.a, Priti N. Mody-Pan, M.P.A., M.A.I.S.b, Liz A. Reynolds Thomas, Ph.D.c, and Corinne M. Mar, Ph.D.d a
International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, Washington Center for Workforce Development, University of Washington, Seattle, Washington c Strategic Education Centers Board, Seattle, Washington d Center for Studies in Demography and Ecology, University of Washington, Seattle, Washington b
Article history: Received January 14, 2010; Accepted August 24, 2010 Keywords: HIV education; Adolescents; Swaziland; HIV testing; Self-Efficacy Theory; Life skills; Education
A B S T R A C T
There is an urgent need for effective HIV prevention programs for adolescents in Swaziland, given the high prevalence of HIV and lack of HIV-related knowledge and skills among Swazi youth. This study set out to determine whether an HIV education intervention designed in the United States, and adapted for Swaziland, would be effective in changing participants’ HIV-related knowledge, attitudes, and protective behaviors including HIV testing. We also explored whether the components of Self-Efficacy Theory are associated with these behaviors. Data were obtained from 135 students who participated in a school-based program. The study found significant differences between the intervention and control groups regarding HIV knowledge, self-efficacy for abstinence, condom use, and getting HIV test results, outcome expectations for knowing one’s own HIV status, and the protective behavior of getting an HIV test. This is evidence that school-based HIV education programs can successfully increase HIV testing among in-school youth in Swaziland. Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.
A recent review of programs in developed and developing countries found evidence that some human immunodeficiency virus (HIV) educational programs have been effective in reducing risk behaviors related to HIV among adolescents, specifically sexual initiation, frequency of sex, number of partners, condom use, and contraception use [1]. Knowing the HIV status of one’s partner has been shown to reduce the risk of HIV infection; however, there is mixed evidence as to whether knowing one’s own HIV status also reduces the risk of HIV infection [2– 6]. We evaluated the effectiveness of a 13-week life skills-based HIV prevention education (LSBE) program at a school in Swaziland that focused on increasing HIV knowledge among the students and changing their attitudes and behaviors related to the following four behavioral outcomes: abstinence, condom use,
* Address correspondence to: Sarah M. Burnett, M.P.H., M.P.A., Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, 1127 Fairmont St NW Apt 1, Washington, DC 20009. E-mail address: [email protected] (S.M. Burnett).
knowing one’s own HIV status, and knowing the partner’s HIV status. The United Nations Joint Programme on HIV/AIDS estimates that Swaziland has a 26.1% HIV prevalence rate, which is among the highest rates in the world [7]. The recent Swaziland Demographic Health Survey showed that in adolescents aged 15–19 years, 10.1% of female adolescents and 1.9% of male adolescents were estimated to be infected with HIV [8]. Among this age group, 36.8% of female adolescents and 21.4% of male adolescents reported having had sex. Despite these high rates of infection, 52% of youth aged 15–19 years had comprehensive knowledge of HIV and only 18.9% of female adolescents and 3.5% of male adolescents reported ever having an HIV test. The evaluation of the LSBE program tested the program’s effect on HIV knowledge and attitudes and behaviors related to the following four behavioral outcomes: abstinence, condom use, knowing one’s own HIV status, and knowing the partner’s HIV status. We also tested whether Self-Efficacy Theory is related to adolescents’ risk-reduction behaviors.
1054-139X/$ - see front matter Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine. doi:10.1016/j.jadohealth.2010.08.015
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Theoretic model Self-Efficacy Theory asserts that two constructs contribute to an individual’s decision to carry out a behavior. The first, selfefficacy, indicates how confident a person is that s/he could carry out a specific task. The second, outcome expectations, relates to a person’s estimate that a given behavior will lead to a specific outcome [9]. Additionally, self-efficacy and outcome expectations are related, in that one’s perceived ability to carry out a task can affect their expectations regarding the outcome of their performance [10]. Self-efficacy has been shown to be a protective factor in delaying sexual initiation and increasing condom use among adolescents in developing countries [11,12]. Although a relationship between outcome expectancies and abstinence and condom use has been demonstrated through studies conducted on adolescents in the United States, less is known about this relationship in developing countries [13,14]. Protection Motivation Theory, another social cognitive model, has a construct similar to outcome expectations, which has been tested in southern Africa. The construct of response efficacy, perceived likelihood that a behavior will reduce the threat of an adverse event, represents one aspect of outcome expectations, but does not include other elements such as the perceived partner reaction. Response efficacy was not found to be related to sexual behavior among adolescents in Namibia [15]. However, in an STD clinic in South Africa response efficacy was shown to be related to sexual behavior among patients affected by sexually transmitted disease [12]. Clearly, more research is needed on the relationship between outcome expectations and behavior in developing countries. In testing Self-Efficacy Theory, we examine the relationship between self-efficacy, outcome expectations, and behavior. Data and methods Intervention Strategic Education Centers, a non-profit organization based in the United States, partnered with the 18th District of the African Methodist Episcopal Church to carry out The “It’s Our Future Too!” program at Hillside High School in Manzini, Swaziland. The goals of this program were to change students’ behaviors so as to reduce the incidence of HIV/AIDS and to equip Swazi youth with skills that will enable them to attain employment and/or pursue a higher academic degree. The program It’s Our Future Too! is unique in that it includes four enrichment curricula: life skills for HIV awareness and prevention, computer technology, job readiness, community outreach. The program was held over a period of 13 half-day Saturday sessions, with 1 hour per week for each of the four curricula. The LSBE curriculum, based on self-efficacy theory, was designed by PATH and modified by the International Training and Education Center for Health (I-TECH) at the University of Washington. During curriculum development, revisions were made on the basis of the feedback elicited from seven teachers who acted as program facilitators. The LSBE curriculum included modules, such as Understanding My Body; Romantic Relationships/Assertive Behavior; HIV and Sexually Transmitted Infection Basics; Prevention, Treatment, and Testing of HIV; Stigma and Discrimination; and Living with HIV. Interactive techniques, such as role playing, were used
to help students to build confidence to negotiate delay of sexual initiation, condoms use, asking a partner’s HIV status, and getting an HIV test done. The curriculum also used group discussions to help students understand and internalize possible outcomes of these various behaviors. As part of the program, a mobile HIV testing unit was available on one Saturday session, after the HIV testing module was presented. A recent Cochrane review showed that interventions to promote HIV testing are most effective when combined with access to HIV testing within 2 days of the intervention [13]. Evaluation Participants All 312 students in Form 2 (grade 9) and Form 4 (grade 11) were invited to participate, and 204 students, 101 males and 103 females, were enrolled on a first-come, first-serve basis. Students were also invited to participate in the evaluation. Parents and students gave written consent for the program and the evaluation. The study was approved by the University of Washington Office of Human Subjects. Students were randomly assigned to either the intervention or the delayed intervention group. The latter acted as the control group and did not receive any intervention until after the study. Evaluation Instruments To assess the effect of the intervention, participants completed a pre- and post-intervention questionnaire on basic demographics (gender, age, grade), HIV knowledge, attitudes (selfefficacy and outcome expectations), and behaviors regarding four HIV behavioral outcomes. HIV knowledge items The 15 items in the knowledge questionnaire, with True/False as the options given, included the three most common ways to prevent HIV, three lesser known risk factors, three misconceptions, and six common myths. Self-efficacy Self-efficacy scales were created for each of the four targeted behavioral outcomes (abstinence, condom use, knowing one’s own HIV status, and knowing the partner’s HIV status). Selfefficacy scale items that were related to abstinence and condom use were adapted from studies conducted by DiIorio et al [11] and Stanton et al [15], whereas those related to knowing one’s own and the partner’s HIV status were developed for this study. Self-efficacy scales for getting an HIV test and then the results were each measured by one item, whereas that for knowing the partner’s HIV status had seven items. For each self-efficacy item there were four possible responses: “Not at all confident,” “Somewhat confident,” “Very confident,” and “Don’t know.” In the analysis, the self-efficacy scales were grouped into binary outcomes (“Not at all confident,” “Somewhat confident,” and “Don’t know” vs. “Very Confident”) and split half reliability tests were conducted so as to determine the reliability of the scale. Each of the scales had a Spearman–Brown coefficient of .72 or greater indicating sufficient reliability. Outcome expectations Outcome expectation scales were created for each of the four targeted behavioral outcomes. Outcome expectancy scale items
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related to abstinence and condom use were adapted from studies conducted by DiIorio et al [16] and Stanton et al [9]. Outcome expectation scales for knowing one’s own and the partner’s HIV status were developed for this study. For knowing one’s own HIV status (17 items), the scale included items based on how one felt they would react if they took an HIV test and if they found out they were HIV⫹. Similar items were included for knowing the HIV status of one’s partner (10 items). The outcome expectancy scales were five-point Likert scales ranging from “Strongly Disagree” to “Strongly Agree.” Each of the outcome expectancy scales had a Cronbach’s alpha that exceeded .71, showing that the scales had sufficient reliability. An exception was outcome expectancies for abstinence, which had a Cronbach’s alpha of .58. This scale was subsequently dropped from the analysis. Behavioral outcomes For knowing one’s own HIV status, respondents were asked whether they had ever had been tested for HIV, when their most recent test was done, and whether they had obtained the results of their test. Students were also asked whether they had ever had sex, and those who had were asked about condom use and knowledge of their partners’ HIV status. All instruments were pre-tested with facilitators and student focus groups, and subsequent revisions were made. Analyses To determine whether there was a difference between the intervention and control groups before the intervention, t tests for continuous variables and 2 tests for dichotomous variables were conducted for demographic variables, knowledge, attitudes, and behavior. To determine whether there was a difference between the pre-test and post-test for the intervention and control group, paired samples t tests were conducted with the knowledge and attitude scales. These analyses were followed by linear regression for continuous variables and logistic regression for dichotomous variables, with the change from pre-test to post-test as the dependent variable, and the intervention as a dichotomous independent variable, controlling for the score at pre-test. For all analyses with scales, participants who responded to at least 80% of the items in the scale were included in the analysis. The items that they responded to were used to produce an average score for each scale. For HIV testing behavior, logistic regressions were conducted, with the behavior at post-test as the dependent variable, and the intervention as a dichotomous independent variable.
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Of 135 students, 44 (33%) had incomplete information about their sexual behavior, and the number of students who reported ever having sex was substantially lower than that reported in other studies (19% vs. 29%) [8]. A total of 17 students reported ever having sex, hence sample sizes for those using condoms and those knowing their partner’s HIV status were too small to be considered for further analysis. For knowing one’s own HIV status, measured through whether students had had an HIV test, 10 students in the intervention group and 11 in the control (16%) group did not answer at both pre-intervention and post-intervention. Statistical analyses were conducted to determine whether students with incomplete HIV test information were different from those who had complete information. No difference was found between the two groups in terms of cohort (2 (1, N ⫽ 135) ⫽ .02, p ⫽ 1.00), gender (2 (1, N ⫽ 135) ⫽ .81, p ⫽ .48), grade (2 (1, N ⫽ 135) ⫽ 1.05, p ⫽ .34), or age (t ⫽ .043, df ⫽ 133, p ⫽ .965). Comparison between intervention and control group At pre-intervention, there was no difference between the intervention and control group in terms of HIV/AIDS knowledge, self-efficacy (for three scales), outcome expectations, and two behaviors (ever having sex or ever having an HIV test) (Table 1). However, self-efficacy for getting an HIV test was significantly lower among the control group at pre-intervention. Bivariate analyses for changes in knowledge, self-efficacy, outcome expectancies, and behavior The intervention group significantly increased in seven variables: overall knowledge; self-efficacy for abstinence, condom use, getting HIV test results, and knowing their partner’s HIV status; outcome expectations for knowing their own HIV status; and HIV testing (Table 2). The control group significantly increased in two variables–self-efficacy in getting an HIV test and knowing their partner’s HIV status; however it did not show a significant increase in any other area. Multivariate analyses for changes in knowledge, attitudes, and behavior Results revealed a significant intervention effect on knowledge and self-efficacy for abstinence and condom use (Table 3). No significant intervention effects were found for self-efficacy in knowing the partner’s HIV status, getting tested for HIV, obtaining HIV test results, or for any of the outcome expectation scales. Students in the intervention group were significantly more likely to have an HIV test.
Results Self-efficacy theory and behavior change Sample Of the 204 students originally registered for the program, 135 (66.5%) completed surveys at pre-intervention and postintervention. Figure 1 describes attrition for the 69 students who did not complete both surveys. Attrition was not significantly different by gender (2 (1, N ⫽ 204) ⫽ .88, p ⫽ .35) or between the intervention and control group (2 (1, N ⫽ 204) ⫽ .06, p ⫽ .80). As shown in Table 1, there was no difference between the intervention and control group in terms of gender, grade, or age.
We examined the association between the theoretic constructs of self-efficacy and outcome expectations for abstinence and HIV testing (Table 4). Logistic regressions were conducted at pre-test and post-test, with the behaviors as the dependent variable and self-efficacy and outcome expectations as the independent variables, controlling for cohort. For abstinence, only outcome expectations were found to be significant at pre- and post-intervention. For testing, the three attitudes (self-efficacy for getting an HIV test, self-efficacy for getting HIV test results,
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Figure 1. Study flow diagram.
and outcome expectations for knowing one’s HIV status) were not found to be significant at pre- or post-intervention. However, we found moderate to high correlations between the two self-efficacy scales (pre-test: r2 ⫽ .46, p ⬍ .001, post-test: r2 ⫽ .52, p ⬍ .001), and each of the self-efficacy scales for HIV testing and the outcome expectancies scale (HIV testing – pretest: 2 ⫽ .19, p ⬍ .05; post-test: 2 ⫽ .32, p ⬍ .001; HIV test results ⫺ pre-test: 2 ⫽ .06, p ⫽ .53; post-test: 2 ⫽ .31, p ⬍ .001). The effect of each of these attitudes on HIV testing was assessed through additional logistic regressions, with HIV testing as the dependent variable and each of the attitudes as the independent variable, controlling for cohort. In these regressions, self-efficacy for getting an HIV test remained the only attitude that was significantly associated with HIV testing at pre-test. However, at post-test, self-efficacy for getting an HIV test done and outcome expectations for HIV testing were significantly associated with HIV testing. Taken together with the finding that these attitudes did not change significantly from pre-test to post-test, these results suggest that students who already had positive attitudes toward testing were more likely to get tested when the opportunity was available. Self-efficacy and outcome expectations are significantly associated with testing only after been provided a conducive environment.
Discussion This randomized control trial demonstrated some changes in knowledge, attitudes, and behavior among participants in the intervention group, supporting the idea that a school-based HIV education intervention designed in the United States could be effectively adapted for Swaziland. Because only 51% of schools in Swaziland provided LSBE for HIV in 2008, this curriculum could be used to expand LSBE to additional schools or could be used to supplement the existing curricula [7]. At pre-intervention, 62% of participants were able to cite the three most common HIV protection methods. This supports the findings of the Swaziland Behavioral Surveillance Survey, which found that 61% of secondary school youth could cite the three most common HIV protection methods [17]. At post-test, the researchers found significant differences between the intervention and control groups regarding overall HIV knowledge, self-efficacy scales related to abstinence and condom use, and in knowing one’s own HIV status. These results echo the findings of earlier studies that have demonstrated successful adaptation of U.S.-based HIV curricula to other southern African countries [15,16].
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Table 1 Demographic characteristics of participants at pre-intervention
Total Gender Male Female Grade Grade 9 (Form 2) Grade 11 (Form 4) Age Knowledge Overall knowledge—% correct (15 items) Know three ways to prevent HIV (3 items) Self-efficacy (% correct) Abstinence (10 items) Condom use (9 items) Know partner’s HIV status (9 items) Get an HIV test (1 item) Get HIV test results (1 item) Outcome expectations (average score, 1–5 scale) Condom use (14 items) Know partner’s HIV status (10 items) Know own HIV status (17 items) Protective behavior Ever had sex (N ⫽ 91) Used condom at last sex (N ⫽ 17) Ever had HIV test (N ⫽ 113) Knows partner’s HIV status (N ⫽ 2)
Intervention N (%) or mean (⫾SD)
Control N (%) or mean (⫾SD)
69
66
Overall
p values
12 ⫽ .07
.64
35 (51%) 34 (49%)
35 (53%) 31 (47%)
12 ⫽ .42
.60
31 (45%) 38 (55%) 17.35 (1.9)
26 (39%) 40 (61%) 17.32 (2.09)
t133 ⫽ ⫺.09
.93
.75 (.04) 46 (66%)
.74 (.14) 38 (58%)
t128 ⫽ ⫺.64 12 ⫽ 1.19
.52 .28
.72 (.31) .43 (.32) .61 (.35) 45 (69) 27 (42%)
.66 (.32) .47 (.28) .55 (.37) 27 (49) 25 (45%)
t130 ⫽ ⫺.98 t113 ⫽ .62 t117 ⫽ ⫺1.02 12 ⫽ 5.04 12 ⫽ .13
.33 .54 .31 .04 .85
t105 ⫽ ⫺.52 t105 ⫽ ⫺1.00 t124 ⫽ ⫺.32
.60 .32 .75
12 ⫽ .93 12 ⫽ .78 12 ⫽ 2.49 —
.42 .62 .18 —
3.75 (.62) 3.92 (.51) 3.92 (.43)
3.69 (.57) 3.81 (.56) 3.90 (.52)
7 (15%) 5 (72%) 11 (19%) 0 (0%)
However, no intervention effects were found for knowing the three most common ways of preventing HIV infection, three self-efficacy scales (getting an HIV test, obtaining the results, and knowing the partner’s HIV status), and the three outcome expectation scales (condom use, knowing partner’s HIV status, and knowing own HIV status). Given that the paired samples t tests showed some increase on many of the knowledge and attitude scales for the intervention and control group (Table 2), it is difficult to determine whether the increases in the control group are due to sharing of information between the intervention and control groups or participant maturation. Additionally, the data were not sufficient to test the effect of the program on three of the four targeted behaviors.
10 (22%) 5 (50%) 5 (9%) —
Although most sexual education interventions focus on sexual initiation, frequency of sex, number of partners, and condom use, given the high prevalence of HIV among youth in Swaziland and the low HIV testing rates, this intervention added knowing one’s own and partner’s status as a behavioral outcome, as well as self-efficacy and outcome expectations for these behavioral outcomes. Given that the study did not change attitudes toward HIV testing among the participants, but did increase HIV testing, students may be already willing to get tested for HIV, but merely need to be given the opportunity to do so. This supports the findings of the Swaziland Behavioral Surveillance Survey [17], which found “A majority of in-school youth reported willingness to use Voluntary Counseling and Testing services if the services were available.”
Table 2 Change in knowledge, attitudes, and behavior from pre-intervention to post-intervention— bivariate analyses Model type
Knowledge Overall knowledge—% correct (15 items) Know three ways to prevent HIV (3 items) Self-efficacy (% very confident) Abstinence scale (10 items) Condom use scale (9 items) Get a HIV test item (1 item) Get HIV test results item (1 item) Know partner’s HIV status scale (7 items) Outcome expectations (average score, 1–5 scale) Condom use scale (14 items) Know own HIV status scale (17 items) Know partner’s HIV status scale (10 items) Protective behavior Ever had sex Ever had HIV test
Intervention N (%) or mean (⫾SE)
Significance test
Control N (%) or mean (⫾SE)
Significance test
Pre
t
p values
Pre
t
Post
Post
p values
T test McNemar
.76 (.02) 46 (66)
.84 (.01) 52 (75)
t67 ⫽ 6.36 —
⬍.001 .24
.74 (.02) 38 (58)
.76 (.02) 46 (72)
t61 ⫽ 1.01
.32 .08
T test T test McNemar McNemar T test
.72 (.04) .44 (.04) 45 (69) 27 (42) .61 (.04)
.87 (.02) .65 (.03) 54 (79) 44 (65) .75 (.04)
t67 ⫽ 4.55 t61 ⫽ 5.07 — — t63 ⫽ 2.79
⬍.001 ⬍.001 .24 .004 .007
.66 (.04) .48 (.04) 27 (49) 25 (45) .55 (.05)
.72 (.04) .51 (.04) 46 (72) 32 (50) .67 (.05)
t63 ⫽ 1.16 t48 ⫽ .58
t52 ⫽ 2.37
.25 .56 .001 .80 .02
3.75 (.08) 3.94 (.05) 3.98 (.06)
3.93 (.07) 4.16 (.05) 4.07 (.06)
t53 ⫽ 1.45 t63 ⫽ 3.34 t53 ⫽ 1.29
.15 3.74 (.08) p ⫽ .001 3.90 (.07) .21 3.83 (.09)
3.90 (.08) 4.02 (.06) 3.99 (.08)
t45 ⫽ 1.97 t58 ⫽ 1.88 t43 ⫽ 1.91
.06 .07 .06
7 (15) 11 (19)
7 (15) 42 (65)
— —
1.00 ⬍.001
T test T test T test McNemar McNemar
10 (22) 5 (7.6)
11 (25) 9 (13.6)
— —
1.00 .13
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Table 3 Change in knowledge, attitudes, and behavior from pre-intervention to post-intervention—multivariate analyses Outcome measure
Knowledge Overall knowledge—% correct (15 items), N ⫽ 128 Know 3 ways to prevent HIV (3 items), N ⫽ 133 Self-efficacy (% very confident) Abstinence (10 items), N ⫽ 131 Condom use (9 items), N ⫽ 110 Get an HIV test (1 item), N ⫽ 118 Get HIV test results (1 item), N ⫽ 117 Know partner’s HIV status (9 items), N ⫽ 116 Outcome expectations (average score, 1–5 scale) Condom use (14 items), N ⫽ 99 Know own HIV status (17 items), N ⫽ 122 Know partner’s HIV status (10 items), N ⫽ 97 Protective behaviora Ever had HIV test, N ⫽ 128
Model type
Overall model F test or 2
p values
 (SE) or OR (CI)
Pre-test p values
Intervention group
OLS  (SE) Logit OR
28.24 21.86
⬍.001 ⬍.001
⫺.45 (.07) 6.22 (2.75–14.09)
⬍.001 ⬍.001
.08 (.02) .91 (.41–2.00)
.001 .81
OLS  (SE) OLS  (SE) Logit OR Logit OR OLS  (SE)
57.38 36.19 16.12 20.35 27.89
⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001
⫺.69 (.07) ⫺.63 (.08) 6.24 (2.39–16.23) 5.73 (2.44–13.44) ⫺.59 (.08)
⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001
.14 (.04) .16 (.05) .93 (.37–2.37) 2.09 (.92–4.73) .06 (.06)
.001 .001 .89 .80 .33
OLS  (SE) OLS  (SE) OLS  (SE)
32.39 37.17 23.42
⬍.001 ⬍.001 ⬍.001
⫺.72 (.09) ⫺.67 (.08) ⫺.58 (.09)
⬍.001 ⬍.001 ⬍.001
Logit OR
35.98
⬍.001
—
—
 (SE) or OR (CI)
p values
.02 (.11) .13 (.08) .03 (.09) 10.96 (4.59–26.15)
.86 .08 .78 ⬍.001
OLS, Ordinary Least Squares  (SE). a Those who had an HIV test at pre-intervention were excluded from the analysis.
not found to be associated with knowing one’s own HIV status. However, after examining the correlations between the attitudes, and running separate logistic regressions for each, selfefficacy for getting an HIV test was related at pre- and post-
In testing the relationship between Self-Efficacy Theory and behavior, outcome expectations were found to be related to abstinence but self-efficacy for abstinence was not. For HIV testing, self-efficacy and outcome expectations for HIV testing were
Table 4 Relationship between self-efficacy, outcome expectations and reported behaviors Outcome measure
Model typea
Overall model (2)
p values
Protective behavior Ever had sex Pre-intervention (N ⫽ 88) Post-intervention (N ⫽ 88)
Full model (OR) Full model (OR)
7.07
.07
.72 (.23–2.22)
7.17
.07
.74 (.25–2.25)
Outcome measure Model Protective behavior type
Ever had HIV test Pre-intervention N ⫽ 96 N ⫽ 100
N ⫽ 99
N ⫽ 110
Full model (OR) Individual factors (OR) Individual factors (OR) Individual factors (OR)
Ever had HIV test Post-intervention N ⫽ 96 Full model (OR) N ⫽ 100 Individual factors (OR) N ⫽ 99 Individual factors (OR) N ⫽ 110 Individual factors (OR) a
Cohort
Cohort Overall p model values (2)
p values
Self-efficacy
Outcome expectations
Abstinence
p values
Abstinence
p values
.56
.52 (.08–3.37)
.49
5.56 (1.26–24.61)
.02
.60
.53 (.07–4.08)
.55
p Self-efficacy values Get an HIV test
.27 (.09–.82)
.02
Outcome expectations p Get HIV test values results
8.66
.07
1.15 (.33–4.01)
.83
5.60 (.98–31.90)
.05
6.36
.04
1.47 (.45–4.83)
.53
4.96 (1.04–23.58) .04
1.07
.58
1.81 (.57–5.78)
.32
3.35
.19
1.94 (.61–6.17)
.26
p Know own HIV values status
.47 (.13–1.77) .27
p values
3.15 (.77–12.86)
.11
2.28 (.67–7.82)
.19
3.10 (.80–11.98)
.10
.97 (.32–2.93) .95
33.33
⬍.001
13.49 (3.79–48.08) ⬍.001
6.65 (.99–44.82)
31.62
⬍.001
12.94 (3.88–43.17) ⬍.001
7.07 (1.40–35.65) .02
26.86
⬍.001
11.36 (3.48–37.06) ⬍.001
27.65
⬍.001
11.91 (3.57–39.70) ⬍.001
Full Model indicates the odds ratio when all the attitudes are combined in the same model.
.51
.84 (.20–3.51) .81
2.54 (.82–7.84) .11
3.93 (1.06–14.56) .04
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interventions and outcome expectations for knowing one’s own HIV status were found to be associated with testing at postintervention. These findings present mixed evidence regarding the relationship between self-efficacy and outcome expectations and HIV protective behaviors among adolescents in Swaziland.
should be done to assess whether HIV testing, coupled with behavior change interventions, is effective at reducing the risk of HIV infection among adolescents in developing countries.
Limitations of the study
The authors thank Bishop Sarah F. Davis, Supervisor Claytie Davis and the 18th District of the African Methodist Episcopal Church; Constance W. Rice, PhD, Founder and President Emeritus, Strategic Education Centers Board, Suzanne Tripp, Strategic Education Centers Board; Suzanne Brainard, PhD, Center for Workforce Development, University of Washington; Michael L. Simelane, and the program staff of AME Hillside High School in Manzini, Swaziland.
This intervention was carried out at one school, which restricted the sample size to approximately 200 students and raised the possibility of cross-contamination between the intervention and control groups. Because of students leaving school and having competing Saturday activities, 36 students (21%) were lost to follow-up, which may limit the representativeness of the findings. For specific items within the survey, the response rate for sexual behavior questions was low. Although the data for surveys were collected by external study personnel, students may have been reluctant to complete the survey as the surveys were explained and handed out by teachers within the classroom. We planned to use audio computer-assisted selfinterviewing to carry out the surveys, as the response rates for sexual behavior questions is high using this method [14,18]. However, at the time of the evaluation, the new computers had not yet been installed in the school. Instead, paper surveys were used. The sample size limited analyses related to the effect of the program on abstinence, condom use, and knowing one’s partner’s status. However, this study does provide frequencies, means, and standard deviations for several attitudes and behaviors that can be used to guide sample size estimates for future studies. As demonstrated in the paired samples t tests, both the intervention and control groups showed some increase on many of the knowledge and attitude scales (Table 2). Future studies could increase the statistical power and reduce the risk of cross-contamination by recruiting more students from multiple schools. New measures were used for self-efficacy and outcome expectations related to HIV testing, with two self-efficacy measures for knowing one’s status as having only one item. Further work could be done on the development and validation of scales for HIV testing self-efficacy and outcome expectations. In terms of the results of the program in increasing HIV testing, the HIV mobile testing unit came to the school on a Saturday, when the Strategic Education Centers program was in session. Although other students from the school were invited, and the event was publicized in the community, students in the control group were less likely to come to school solely for testing. Recommendations for future research This study examined the relationship between Self-Efficacy Theory and abstinence and HIV testing behaviors among adolescents in developing countries. Future research could examine the relationship between HIV risk-reduction behaviors and other behavior change theories, such as the Health Belief Model or communitybased models. Further research could be done to determine whether students are already willing to get tested for HIV and merely need the opportunity, or whether education about HIV and testing is needed before students would be willing to get tested. Also, given the mixed evidence regarding the effectiveness of HIV testing as part of a risk reduction strategy, further research
Acknowledgements
References [1] Kirby D, Laris BA, Rolleri L. Youth research working paper No. 2: Impact of sex and HIV education programs on sexual behaviors of youth in developing and developed countries. Family Health International, 2005. Available at: http://www.fhi.org/en/Youth/YouthNet/Publications/YouthResearch WorkingPapers.htm. Accessed April 7, 2006. [2] The impact of voluntary counselling and testing: A global review of the benefits and challenges. UNAIDS, 2001 Available at: http://www.etharc. org/vct/ImpactofVCT.pdf. Accessed: January 26, 2007. [3] Varghese B, Maher JE, Peterman TA, et al. Reducing the risk of sexual HIV transmission: Quantifying the per-act risk for HIV on the basis of choice of partner, sex act and condom use. Sex Transm Dis 2002;29:38 – 43. [4] Sherr L, Lopman B, Kakowa M, et al. Voluntary counselling and testing: Uptake, impact on sexual behaviour, and HIV incidence in a rural Zimbabwean cohort. AIDS 2007;21:851– 60. [5] Corbett EL, Makamure B, Cheung YB, et al. HIV incidence during a clusterrandomized trial of two strategies providing voluntary counselling and testing at the workplace, Zimbabwe. AIDS 2007;21:483–9. [6] Cremin I, Nyamukapa C, Sherr L. Patterns of self-reported behaviour change associated with receiving voluntary counselling and testing in a longitudinal study from Manicaland, Zimbabwe. AIDS Behav 2010;14:708 –15. [7] Report on the Global AIDS Epidemic, 2008. Geneva, Switzerland: UNAIDS, 2008 Available at: http://www.unaids.org/en/KnowledgeCentre/HIVData/ GlobalReport/2008/2008_Global_report.asp. Accessed August 14, 2008. [8] Swaziland demographic and health survey, 2006 – 07. Mbabane, Swaziland: Central Statistical Office [Swaziland] and Macro International Inc, 2008. Available at: http://www.measuredhs.com/pubs/pub_details.cfm?ID⫽ 769&ctry_id⫽220&SrchTp⫽ctry. [9] Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev 1977;2:191–215. [10] Koniak-Griffin D, Stein JA. Predictors of sexual risk behaviors among adolescent mothers in a human immunodeficiency virus prevention program. J Adolesc Health 2006;38:e1297–11. [11] DiIorio C, Dudley WN, Kelly M. Social cognitive correlates of sexual experience and condom use among 13- through 15-year-old adolescents. J Adolesc Health 2001;29:208 –16. [12] Reddy P, Meyer-Weitz A, van den Borne B, Kok G. STD-related knowledge, beliefs and attitudes of Xhosa-speaking patients attending STD primary health-care clinics in South Africa. Int J STD AIDS 1999;10:392– 400. [13] Vidanapathirana J, Abramson MJ, Forbes A, et al. Mass media interventions for promoting HIV testing [Review]. The Cochrane Collaboration, 2006. Available at: http://www.thecochranelibrary.com. Accessed May 11, 2007. [14] DiIorio C, Maibach E, O’Leary A et al. Measurement of condom use selfefficacy and outcome expectancies in a geographically diverse group of STD patients. AIDS Educ Prev 1997;1:1–13. [15] Stanton BF, Fitzgerald AM, Li X. HIV risk behaviors, intentions, and perceptions among Nambian youth as assessed by a theory-based questionnaire. AIDS Educ Prev 1999;11:132– 49. [16] Karnell AP, Cupp PK, Zimmerman RS, et al. Efficacy of an American alcohol and HIV prevention curriculum adapted for use in South Africa: Results of a pilot study in five township schools. AIDS Educ Prev 2006;18:295–310. [17] Swaziland Behavioral Surveillance Survey. Mbabane, Swaziland: Ministry of health and Social Welfare, Family Life Association of Swaziland, 2002. Available at: http://www.fhi.org/en/HIVAIDS/pub/survreports/ FirstSwazilandBSS.htm. Accessed: April 29, 2007. [18] Hewett PC, Mensch BS, Erulkar AS. Consistency in the reporting of sexual behaviour by adolescent girls in Kenya: A comparison of interviewing methods. Sex Transm Infect 2004;80:43– 8.
www.jahonline.org Original article
Evaluation of an Intervention to Increase Human Immunodeficiency Virus Testing Among Youth in Manzini, Swaziland: A Randomized Control Trial Sarah M. Burnett, M.P.H., M.P.A.a,*, Marcia R. Weaver, Ph.D.a, Priti N. Mody-Pan, M.P.A., M.A.I.S.b, Liz A. Reynolds Thomas, Ph.D.c, and Corinne M. Mar, Ph.D.d a
International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, Washington Center for Workforce Development, University of Washington, Seattle, Washington c Strategic Education Centers Board, Seattle, Washington d Center for Studies in Demography and Ecology, University of Washington, Seattle, Washington b
Article history: Received January 14, 2010; Accepted August 24, 2010 Keywords: HIV education; Adolescents; Swaziland; HIV testing; Self-Efficacy Theory; Life skills; Education
A B S T R A C T
There is an urgent need for effective HIV prevention programs for adolescents in Swaziland, given the high prevalence of HIV and lack of HIV-related knowledge and skills among Swazi youth. This study set out to determine whether an HIV education intervention designed in the United States, and adapted for Swaziland, would be effective in changing participants’ HIV-related knowledge, attitudes, and protective behaviors including HIV testing. We also explored whether the components of Self-Efficacy Theory are associated with these behaviors. Data were obtained from 135 students who participated in a school-based program. The study found significant differences between the intervention and control groups regarding HIV knowledge, self-efficacy for abstinence, condom use, and getting HIV test results, outcome expectations for knowing one’s own HIV status, and the protective behavior of getting an HIV test. This is evidence that school-based HIV education programs can successfully increase HIV testing among in-school youth in Swaziland. Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.
A recent review of programs in developed and developing countries found evidence that some human immunodeficiency virus (HIV) educational programs have been effective in reducing risk behaviors related to HIV among adolescents, specifically sexual initiation, frequency of sex, number of partners, condom use, and contraception use [1]. Knowing the HIV status of one’s partner has been shown to reduce the risk of HIV infection; however, there is mixed evidence as to whether knowing one’s own HIV status also reduces the risk of HIV infection [2– 6]. We evaluated the effectiveness of a 13-week life skills-based HIV prevention education (LSBE) program at a school in Swaziland that focused on increasing HIV knowledge among the students and changing their attitudes and behaviors related to the following four behavioral outcomes: abstinence, condom use,
* Address correspondence to: Sarah M. Burnett, M.P.H., M.P.A., Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, 1127 Fairmont St NW Apt 1, Washington, DC 20009. E-mail address: [email protected] (S.M. Burnett).
knowing one’s own HIV status, and knowing the partner’s HIV status. The United Nations Joint Programme on HIV/AIDS estimates that Swaziland has a 26.1% HIV prevalence rate, which is among the highest rates in the world [7]. The recent Swaziland Demographic Health Survey showed that in adolescents aged 15–19 years, 10.1% of female adolescents and 1.9% of male adolescents were estimated to be infected with HIV [8]. Among this age group, 36.8% of female adolescents and 21.4% of male adolescents reported having had sex. Despite these high rates of infection, 52% of youth aged 15–19 years had comprehensive knowledge of HIV and only 18.9% of female adolescents and 3.5% of male adolescents reported ever having an HIV test. The evaluation of the LSBE program tested the program’s effect on HIV knowledge and attitudes and behaviors related to the following four behavioral outcomes: abstinence, condom use, knowing one’s own HIV status, and knowing the partner’s HIV status. We also tested whether Self-Efficacy Theory is related to adolescents’ risk-reduction behaviors.
1054-139X/$ - see front matter Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine. doi:10.1016/j.jadohealth.2010.08.015
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Theoretic model Self-Efficacy Theory asserts that two constructs contribute to an individual’s decision to carry out a behavior. The first, selfefficacy, indicates how confident a person is that s/he could carry out a specific task. The second, outcome expectations, relates to a person’s estimate that a given behavior will lead to a specific outcome [9]. Additionally, self-efficacy and outcome expectations are related, in that one’s perceived ability to carry out a task can affect their expectations regarding the outcome of their performance [10]. Self-efficacy has been shown to be a protective factor in delaying sexual initiation and increasing condom use among adolescents in developing countries [11,12]. Although a relationship between outcome expectancies and abstinence and condom use has been demonstrated through studies conducted on adolescents in the United States, less is known about this relationship in developing countries [13,14]. Protection Motivation Theory, another social cognitive model, has a construct similar to outcome expectations, which has been tested in southern Africa. The construct of response efficacy, perceived likelihood that a behavior will reduce the threat of an adverse event, represents one aspect of outcome expectations, but does not include other elements such as the perceived partner reaction. Response efficacy was not found to be related to sexual behavior among adolescents in Namibia [15]. However, in an STD clinic in South Africa response efficacy was shown to be related to sexual behavior among patients affected by sexually transmitted disease [12]. Clearly, more research is needed on the relationship between outcome expectations and behavior in developing countries. In testing Self-Efficacy Theory, we examine the relationship between self-efficacy, outcome expectations, and behavior. Data and methods Intervention Strategic Education Centers, a non-profit organization based in the United States, partnered with the 18th District of the African Methodist Episcopal Church to carry out The “It’s Our Future Too!” program at Hillside High School in Manzini, Swaziland. The goals of this program were to change students’ behaviors so as to reduce the incidence of HIV/AIDS and to equip Swazi youth with skills that will enable them to attain employment and/or pursue a higher academic degree. The program It’s Our Future Too! is unique in that it includes four enrichment curricula: life skills for HIV awareness and prevention, computer technology, job readiness, community outreach. The program was held over a period of 13 half-day Saturday sessions, with 1 hour per week for each of the four curricula. The LSBE curriculum, based on self-efficacy theory, was designed by PATH and modified by the International Training and Education Center for Health (I-TECH) at the University of Washington. During curriculum development, revisions were made on the basis of the feedback elicited from seven teachers who acted as program facilitators. The LSBE curriculum included modules, such as Understanding My Body; Romantic Relationships/Assertive Behavior; HIV and Sexually Transmitted Infection Basics; Prevention, Treatment, and Testing of HIV; Stigma and Discrimination; and Living with HIV. Interactive techniques, such as role playing, were used
to help students to build confidence to negotiate delay of sexual initiation, condoms use, asking a partner’s HIV status, and getting an HIV test done. The curriculum also used group discussions to help students understand and internalize possible outcomes of these various behaviors. As part of the program, a mobile HIV testing unit was available on one Saturday session, after the HIV testing module was presented. A recent Cochrane review showed that interventions to promote HIV testing are most effective when combined with access to HIV testing within 2 days of the intervention [13]. Evaluation Participants All 312 students in Form 2 (grade 9) and Form 4 (grade 11) were invited to participate, and 204 students, 101 males and 103 females, were enrolled on a first-come, first-serve basis. Students were also invited to participate in the evaluation. Parents and students gave written consent for the program and the evaluation. The study was approved by the University of Washington Office of Human Subjects. Students were randomly assigned to either the intervention or the delayed intervention group. The latter acted as the control group and did not receive any intervention until after the study. Evaluation Instruments To assess the effect of the intervention, participants completed a pre- and post-intervention questionnaire on basic demographics (gender, age, grade), HIV knowledge, attitudes (selfefficacy and outcome expectations), and behaviors regarding four HIV behavioral outcomes. HIV knowledge items The 15 items in the knowledge questionnaire, with True/False as the options given, included the three most common ways to prevent HIV, three lesser known risk factors, three misconceptions, and six common myths. Self-efficacy Self-efficacy scales were created for each of the four targeted behavioral outcomes (abstinence, condom use, knowing one’s own HIV status, and knowing the partner’s HIV status). Selfefficacy scale items that were related to abstinence and condom use were adapted from studies conducted by DiIorio et al [11] and Stanton et al [15], whereas those related to knowing one’s own and the partner’s HIV status were developed for this study. Self-efficacy scales for getting an HIV test and then the results were each measured by one item, whereas that for knowing the partner’s HIV status had seven items. For each self-efficacy item there were four possible responses: “Not at all confident,” “Somewhat confident,” “Very confident,” and “Don’t know.” In the analysis, the self-efficacy scales were grouped into binary outcomes (“Not at all confident,” “Somewhat confident,” and “Don’t know” vs. “Very Confident”) and split half reliability tests were conducted so as to determine the reliability of the scale. Each of the scales had a Spearman–Brown coefficient of .72 or greater indicating sufficient reliability. Outcome expectations Outcome expectation scales were created for each of the four targeted behavioral outcomes. Outcome expectancy scale items
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related to abstinence and condom use were adapted from studies conducted by DiIorio et al [16] and Stanton et al [9]. Outcome expectation scales for knowing one’s own and the partner’s HIV status were developed for this study. For knowing one’s own HIV status (17 items), the scale included items based on how one felt they would react if they took an HIV test and if they found out they were HIV⫹. Similar items were included for knowing the HIV status of one’s partner (10 items). The outcome expectancy scales were five-point Likert scales ranging from “Strongly Disagree” to “Strongly Agree.” Each of the outcome expectancy scales had a Cronbach’s alpha that exceeded .71, showing that the scales had sufficient reliability. An exception was outcome expectancies for abstinence, which had a Cronbach’s alpha of .58. This scale was subsequently dropped from the analysis. Behavioral outcomes For knowing one’s own HIV status, respondents were asked whether they had ever had been tested for HIV, when their most recent test was done, and whether they had obtained the results of their test. Students were also asked whether they had ever had sex, and those who had were asked about condom use and knowledge of their partners’ HIV status. All instruments were pre-tested with facilitators and student focus groups, and subsequent revisions were made. Analyses To determine whether there was a difference between the intervention and control groups before the intervention, t tests for continuous variables and 2 tests for dichotomous variables were conducted for demographic variables, knowledge, attitudes, and behavior. To determine whether there was a difference between the pre-test and post-test for the intervention and control group, paired samples t tests were conducted with the knowledge and attitude scales. These analyses were followed by linear regression for continuous variables and logistic regression for dichotomous variables, with the change from pre-test to post-test as the dependent variable, and the intervention as a dichotomous independent variable, controlling for the score at pre-test. For all analyses with scales, participants who responded to at least 80% of the items in the scale were included in the analysis. The items that they responded to were used to produce an average score for each scale. For HIV testing behavior, logistic regressions were conducted, with the behavior at post-test as the dependent variable, and the intervention as a dichotomous independent variable.
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Of 135 students, 44 (33%) had incomplete information about their sexual behavior, and the number of students who reported ever having sex was substantially lower than that reported in other studies (19% vs. 29%) [8]. A total of 17 students reported ever having sex, hence sample sizes for those using condoms and those knowing their partner’s HIV status were too small to be considered for further analysis. For knowing one’s own HIV status, measured through whether students had had an HIV test, 10 students in the intervention group and 11 in the control (16%) group did not answer at both pre-intervention and post-intervention. Statistical analyses were conducted to determine whether students with incomplete HIV test information were different from those who had complete information. No difference was found between the two groups in terms of cohort (2 (1, N ⫽ 135) ⫽ .02, p ⫽ 1.00), gender (2 (1, N ⫽ 135) ⫽ .81, p ⫽ .48), grade (2 (1, N ⫽ 135) ⫽ 1.05, p ⫽ .34), or age (t ⫽ .043, df ⫽ 133, p ⫽ .965). Comparison between intervention and control group At pre-intervention, there was no difference between the intervention and control group in terms of HIV/AIDS knowledge, self-efficacy (for three scales), outcome expectations, and two behaviors (ever having sex or ever having an HIV test) (Table 1). However, self-efficacy for getting an HIV test was significantly lower among the control group at pre-intervention. Bivariate analyses for changes in knowledge, self-efficacy, outcome expectancies, and behavior The intervention group significantly increased in seven variables: overall knowledge; self-efficacy for abstinence, condom use, getting HIV test results, and knowing their partner’s HIV status; outcome expectations for knowing their own HIV status; and HIV testing (Table 2). The control group significantly increased in two variables–self-efficacy in getting an HIV test and knowing their partner’s HIV status; however it did not show a significant increase in any other area. Multivariate analyses for changes in knowledge, attitudes, and behavior Results revealed a significant intervention effect on knowledge and self-efficacy for abstinence and condom use (Table 3). No significant intervention effects were found for self-efficacy in knowing the partner’s HIV status, getting tested for HIV, obtaining HIV test results, or for any of the outcome expectation scales. Students in the intervention group were significantly more likely to have an HIV test.
Results Self-efficacy theory and behavior change Sample Of the 204 students originally registered for the program, 135 (66.5%) completed surveys at pre-intervention and postintervention. Figure 1 describes attrition for the 69 students who did not complete both surveys. Attrition was not significantly different by gender (2 (1, N ⫽ 204) ⫽ .88, p ⫽ .35) or between the intervention and control group (2 (1, N ⫽ 204) ⫽ .06, p ⫽ .80). As shown in Table 1, there was no difference between the intervention and control group in terms of gender, grade, or age.
We examined the association between the theoretic constructs of self-efficacy and outcome expectations for abstinence and HIV testing (Table 4). Logistic regressions were conducted at pre-test and post-test, with the behaviors as the dependent variable and self-efficacy and outcome expectations as the independent variables, controlling for cohort. For abstinence, only outcome expectations were found to be significant at pre- and post-intervention. For testing, the three attitudes (self-efficacy for getting an HIV test, self-efficacy for getting HIV test results,
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Figure 1. Study flow diagram.
and outcome expectations for knowing one’s HIV status) were not found to be significant at pre- or post-intervention. However, we found moderate to high correlations between the two self-efficacy scales (pre-test: r2 ⫽ .46, p ⬍ .001, post-test: r2 ⫽ .52, p ⬍ .001), and each of the self-efficacy scales for HIV testing and the outcome expectancies scale (HIV testing – pretest: 2 ⫽ .19, p ⬍ .05; post-test: 2 ⫽ .32, p ⬍ .001; HIV test results ⫺ pre-test: 2 ⫽ .06, p ⫽ .53; post-test: 2 ⫽ .31, p ⬍ .001). The effect of each of these attitudes on HIV testing was assessed through additional logistic regressions, with HIV testing as the dependent variable and each of the attitudes as the independent variable, controlling for cohort. In these regressions, self-efficacy for getting an HIV test remained the only attitude that was significantly associated with HIV testing at pre-test. However, at post-test, self-efficacy for getting an HIV test done and outcome expectations for HIV testing were significantly associated with HIV testing. Taken together with the finding that these attitudes did not change significantly from pre-test to post-test, these results suggest that students who already had positive attitudes toward testing were more likely to get tested when the opportunity was available. Self-efficacy and outcome expectations are significantly associated with testing only after been provided a conducive environment.
Discussion This randomized control trial demonstrated some changes in knowledge, attitudes, and behavior among participants in the intervention group, supporting the idea that a school-based HIV education intervention designed in the United States could be effectively adapted for Swaziland. Because only 51% of schools in Swaziland provided LSBE for HIV in 2008, this curriculum could be used to expand LSBE to additional schools or could be used to supplement the existing curricula [7]. At pre-intervention, 62% of participants were able to cite the three most common HIV protection methods. This supports the findings of the Swaziland Behavioral Surveillance Survey, which found that 61% of secondary school youth could cite the three most common HIV protection methods [17]. At post-test, the researchers found significant differences between the intervention and control groups regarding overall HIV knowledge, self-efficacy scales related to abstinence and condom use, and in knowing one’s own HIV status. These results echo the findings of earlier studies that have demonstrated successful adaptation of U.S.-based HIV curricula to other southern African countries [15,16].
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Table 1 Demographic characteristics of participants at pre-intervention
Total Gender Male Female Grade Grade 9 (Form 2) Grade 11 (Form 4) Age Knowledge Overall knowledge—% correct (15 items) Know three ways to prevent HIV (3 items) Self-efficacy (% correct) Abstinence (10 items) Condom use (9 items) Know partner’s HIV status (9 items) Get an HIV test (1 item) Get HIV test results (1 item) Outcome expectations (average score, 1–5 scale) Condom use (14 items) Know partner’s HIV status (10 items) Know own HIV status (17 items) Protective behavior Ever had sex (N ⫽ 91) Used condom at last sex (N ⫽ 17) Ever had HIV test (N ⫽ 113) Knows partner’s HIV status (N ⫽ 2)
Intervention N (%) or mean (⫾SD)
Control N (%) or mean (⫾SD)
69
66
Overall
p values
12 ⫽ .07
.64
35 (51%) 34 (49%)
35 (53%) 31 (47%)
12 ⫽ .42
.60
31 (45%) 38 (55%) 17.35 (1.9)
26 (39%) 40 (61%) 17.32 (2.09)
t133 ⫽ ⫺.09
.93
.75 (.04) 46 (66%)
.74 (.14) 38 (58%)
t128 ⫽ ⫺.64 12 ⫽ 1.19
.52 .28
.72 (.31) .43 (.32) .61 (.35) 45 (69) 27 (42%)
.66 (.32) .47 (.28) .55 (.37) 27 (49) 25 (45%)
t130 ⫽ ⫺.98 t113 ⫽ .62 t117 ⫽ ⫺1.02 12 ⫽ 5.04 12 ⫽ .13
.33 .54 .31 .04 .85
t105 ⫽ ⫺.52 t105 ⫽ ⫺1.00 t124 ⫽ ⫺.32
.60 .32 .75
12 ⫽ .93 12 ⫽ .78 12 ⫽ 2.49 —
.42 .62 .18 —
3.75 (.62) 3.92 (.51) 3.92 (.43)
3.69 (.57) 3.81 (.56) 3.90 (.52)
7 (15%) 5 (72%) 11 (19%) 0 (0%)
However, no intervention effects were found for knowing the three most common ways of preventing HIV infection, three self-efficacy scales (getting an HIV test, obtaining the results, and knowing the partner’s HIV status), and the three outcome expectation scales (condom use, knowing partner’s HIV status, and knowing own HIV status). Given that the paired samples t tests showed some increase on many of the knowledge and attitude scales for the intervention and control group (Table 2), it is difficult to determine whether the increases in the control group are due to sharing of information between the intervention and control groups or participant maturation. Additionally, the data were not sufficient to test the effect of the program on three of the four targeted behaviors.
10 (22%) 5 (50%) 5 (9%) —
Although most sexual education interventions focus on sexual initiation, frequency of sex, number of partners, and condom use, given the high prevalence of HIV among youth in Swaziland and the low HIV testing rates, this intervention added knowing one’s own and partner’s status as a behavioral outcome, as well as self-efficacy and outcome expectations for these behavioral outcomes. Given that the study did not change attitudes toward HIV testing among the participants, but did increase HIV testing, students may be already willing to get tested for HIV, but merely need to be given the opportunity to do so. This supports the findings of the Swaziland Behavioral Surveillance Survey [17], which found “A majority of in-school youth reported willingness to use Voluntary Counseling and Testing services if the services were available.”
Table 2 Change in knowledge, attitudes, and behavior from pre-intervention to post-intervention— bivariate analyses Model type
Knowledge Overall knowledge—% correct (15 items) Know three ways to prevent HIV (3 items) Self-efficacy (% very confident) Abstinence scale (10 items) Condom use scale (9 items) Get a HIV test item (1 item) Get HIV test results item (1 item) Know partner’s HIV status scale (7 items) Outcome expectations (average score, 1–5 scale) Condom use scale (14 items) Know own HIV status scale (17 items) Know partner’s HIV status scale (10 items) Protective behavior Ever had sex Ever had HIV test
Intervention N (%) or mean (⫾SE)
Significance test
Control N (%) or mean (⫾SE)
Significance test
Pre
t
p values
Pre
t
Post
Post
p values
T test McNemar
.76 (.02) 46 (66)
.84 (.01) 52 (75)
t67 ⫽ 6.36 —
⬍.001 .24
.74 (.02) 38 (58)
.76 (.02) 46 (72)
t61 ⫽ 1.01
.32 .08
T test T test McNemar McNemar T test
.72 (.04) .44 (.04) 45 (69) 27 (42) .61 (.04)
.87 (.02) .65 (.03) 54 (79) 44 (65) .75 (.04)
t67 ⫽ 4.55 t61 ⫽ 5.07 — — t63 ⫽ 2.79
⬍.001 ⬍.001 .24 .004 .007
.66 (.04) .48 (.04) 27 (49) 25 (45) .55 (.05)
.72 (.04) .51 (.04) 46 (72) 32 (50) .67 (.05)
t63 ⫽ 1.16 t48 ⫽ .58
t52 ⫽ 2.37
.25 .56 .001 .80 .02
3.75 (.08) 3.94 (.05) 3.98 (.06)
3.93 (.07) 4.16 (.05) 4.07 (.06)
t53 ⫽ 1.45 t63 ⫽ 3.34 t53 ⫽ 1.29
.15 3.74 (.08) p ⫽ .001 3.90 (.07) .21 3.83 (.09)
3.90 (.08) 4.02 (.06) 3.99 (.08)
t45 ⫽ 1.97 t58 ⫽ 1.88 t43 ⫽ 1.91
.06 .07 .06
7 (15) 11 (19)
7 (15) 42 (65)
— —
1.00 ⬍.001
T test T test T test McNemar McNemar
10 (22) 5 (7.6)
11 (25) 9 (13.6)
— —
1.00 .13
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Table 3 Change in knowledge, attitudes, and behavior from pre-intervention to post-intervention—multivariate analyses Outcome measure
Knowledge Overall knowledge—% correct (15 items), N ⫽ 128 Know 3 ways to prevent HIV (3 items), N ⫽ 133 Self-efficacy (% very confident) Abstinence (10 items), N ⫽ 131 Condom use (9 items), N ⫽ 110 Get an HIV test (1 item), N ⫽ 118 Get HIV test results (1 item), N ⫽ 117 Know partner’s HIV status (9 items), N ⫽ 116 Outcome expectations (average score, 1–5 scale) Condom use (14 items), N ⫽ 99 Know own HIV status (17 items), N ⫽ 122 Know partner’s HIV status (10 items), N ⫽ 97 Protective behaviora Ever had HIV test, N ⫽ 128
Model type
Overall model F test or 2
p values
 (SE) or OR (CI)
Pre-test p values
Intervention group
OLS  (SE) Logit OR
28.24 21.86
⬍.001 ⬍.001
⫺.45 (.07) 6.22 (2.75–14.09)
⬍.001 ⬍.001
.08 (.02) .91 (.41–2.00)
.001 .81
OLS  (SE) OLS  (SE) Logit OR Logit OR OLS  (SE)
57.38 36.19 16.12 20.35 27.89
⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001
⫺.69 (.07) ⫺.63 (.08) 6.24 (2.39–16.23) 5.73 (2.44–13.44) ⫺.59 (.08)
⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001
.14 (.04) .16 (.05) .93 (.37–2.37) 2.09 (.92–4.73) .06 (.06)
.001 .001 .89 .80 .33
OLS  (SE) OLS  (SE) OLS  (SE)
32.39 37.17 23.42
⬍.001 ⬍.001 ⬍.001
⫺.72 (.09) ⫺.67 (.08) ⫺.58 (.09)
⬍.001 ⬍.001 ⬍.001
Logit OR
35.98
⬍.001
—
—
 (SE) or OR (CI)
p values
.02 (.11) .13 (.08) .03 (.09) 10.96 (4.59–26.15)
.86 .08 .78 ⬍.001
OLS, Ordinary Least Squares  (SE). a Those who had an HIV test at pre-intervention were excluded from the analysis.
not found to be associated with knowing one’s own HIV status. However, after examining the correlations between the attitudes, and running separate logistic regressions for each, selfefficacy for getting an HIV test was related at pre- and post-
In testing the relationship between Self-Efficacy Theory and behavior, outcome expectations were found to be related to abstinence but self-efficacy for abstinence was not. For HIV testing, self-efficacy and outcome expectations for HIV testing were
Table 4 Relationship between self-efficacy, outcome expectations and reported behaviors Outcome measure
Model typea
Overall model (2)
p values
Protective behavior Ever had sex Pre-intervention (N ⫽ 88) Post-intervention (N ⫽ 88)
Full model (OR) Full model (OR)
7.07
.07
.72 (.23–2.22)
7.17
.07
.74 (.25–2.25)
Outcome measure Model Protective behavior type
Ever had HIV test Pre-intervention N ⫽ 96 N ⫽ 100
N ⫽ 99
N ⫽ 110
Full model (OR) Individual factors (OR) Individual factors (OR) Individual factors (OR)
Ever had HIV test Post-intervention N ⫽ 96 Full model (OR) N ⫽ 100 Individual factors (OR) N ⫽ 99 Individual factors (OR) N ⫽ 110 Individual factors (OR) a
Cohort
Cohort Overall p model values (2)
p values
Self-efficacy
Outcome expectations
Abstinence
p values
Abstinence
p values
.56
.52 (.08–3.37)
.49
5.56 (1.26–24.61)
.02
.60
.53 (.07–4.08)
.55
p Self-efficacy values Get an HIV test
.27 (.09–.82)
.02
Outcome expectations p Get HIV test values results
8.66
.07
1.15 (.33–4.01)
.83
5.60 (.98–31.90)
.05
6.36
.04
1.47 (.45–4.83)
.53
4.96 (1.04–23.58) .04
1.07
.58
1.81 (.57–5.78)
.32
3.35
.19
1.94 (.61–6.17)
.26
p Know own HIV values status
.47 (.13–1.77) .27
p values
3.15 (.77–12.86)
.11
2.28 (.67–7.82)
.19
3.10 (.80–11.98)
.10
.97 (.32–2.93) .95
33.33
⬍.001
13.49 (3.79–48.08) ⬍.001
6.65 (.99–44.82)
31.62
⬍.001
12.94 (3.88–43.17) ⬍.001
7.07 (1.40–35.65) .02
26.86
⬍.001
11.36 (3.48–37.06) ⬍.001
27.65
⬍.001
11.91 (3.57–39.70) ⬍.001
Full Model indicates the odds ratio when all the attitudes are combined in the same model.
.51
.84 (.20–3.51) .81
2.54 (.82–7.84) .11
3.93 (1.06–14.56) .04
S.M. Burnett et al. / Journal of Adolescent Health 48 (2011) 507–513
513
interventions and outcome expectations for knowing one’s own HIV status were found to be associated with testing at postintervention. These findings present mixed evidence regarding the relationship between self-efficacy and outcome expectations and HIV protective behaviors among adolescents in Swaziland.
should be done to assess whether HIV testing, coupled with behavior change interventions, is effective at reducing the risk of HIV infection among adolescents in developing countries.
Limitations of the study
The authors thank Bishop Sarah F. Davis, Supervisor Claytie Davis and the 18th District of the African Methodist Episcopal Church; Constance W. Rice, PhD, Founder and President Emeritus, Strategic Education Centers Board, Suzanne Tripp, Strategic Education Centers Board; Suzanne Brainard, PhD, Center for Workforce Development, University of Washington; Michael L. Simelane, and the program staff of AME Hillside High School in Manzini, Swaziland.
This intervention was carried out at one school, which restricted the sample size to approximately 200 students and raised the possibility of cross-contamination between the intervention and control groups. Because of students leaving school and having competing Saturday activities, 36 students (21%) were lost to follow-up, which may limit the representativeness of the findings. For specific items within the survey, the response rate for sexual behavior questions was low. Although the data for surveys were collected by external study personnel, students may have been reluctant to complete the survey as the surveys were explained and handed out by teachers within the classroom. We planned to use audio computer-assisted selfinterviewing to carry out the surveys, as the response rates for sexual behavior questions is high using this method [14,18]. However, at the time of the evaluation, the new computers had not yet been installed in the school. Instead, paper surveys were used. The sample size limited analyses related to the effect of the program on abstinence, condom use, and knowing one’s partner’s status. However, this study does provide frequencies, means, and standard deviations for several attitudes and behaviors that can be used to guide sample size estimates for future studies. As demonstrated in the paired samples t tests, both the intervention and control groups showed some increase on many of the knowledge and attitude scales (Table 2). Future studies could increase the statistical power and reduce the risk of cross-contamination by recruiting more students from multiple schools. New measures were used for self-efficacy and outcome expectations related to HIV testing, with two self-efficacy measures for knowing one’s status as having only one item. Further work could be done on the development and validation of scales for HIV testing self-efficacy and outcome expectations. In terms of the results of the program in increasing HIV testing, the HIV mobile testing unit came to the school on a Saturday, when the Strategic Education Centers program was in session. Although other students from the school were invited, and the event was publicized in the community, students in the control group were less likely to come to school solely for testing. Recommendations for future research This study examined the relationship between Self-Efficacy Theory and abstinence and HIV testing behaviors among adolescents in developing countries. Future research could examine the relationship between HIV risk-reduction behaviors and other behavior change theories, such as the Health Belief Model or communitybased models. Further research could be done to determine whether students are already willing to get tested for HIV and merely need the opportunity, or whether education about HIV and testing is needed before students would be willing to get tested. Also, given the mixed evidence regarding the effectiveness of HIV testing as part of a risk reduction strategy, further research
Acknowledgements
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