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A Randomized, Controlled Trial of a School-based, Multi-faceted AIDS Education Program in the Elementary Grades

Original article authored by David J. Schonfeld, MD; Linda L. O'Hare, MS; Ellen C. Perrin, MD; Marcia Quackenbush, MS; Donald R. Showalter, MPH; and Domenic Cicchetti, PhD This summary includes the following sections:

Introduction

To have the most impact on the prevention of unsafe behaviors, AIDS education should begin in the elementary grades. This notion has been endorsed by the American Academy of Pediatricians, the Surgeon General, and the Centers for Disease Control and Prevention. Research indicates that young children have a limited understanding of the causes and prevention of HIV and AIDS and hold many misconceptions and anxieties about HIV/AIDS.

Currently, there is little research upon which to build educational curricula for this topic and age group. This study used a randomized, controlled trial to analyze the effects of a school-based educational intervention on elementary school age children's conceptual and factual understanding of HIV and AIDS and their misconceptions and fears about the illness.

Methods

Subjects

Kindergarten through sixth grade students at a representative New Haven public school were recruited for enrollment. Of the 337 eligible students, 189 children returned the parent consent forms, agreed to participate, and completed both the pre- and post-test interviews. These 189 students were representative of the entire school population for gender and race.

Socioeconomic status was determined by the students' school lunch status; the sample had a higher percentage of students receiving free lunch (75% in the sample compared with 55% of the entire school).


Measures

The study used two measurement tools. The first was the Peabody Picture Vocabulary Test — Revised (PPVT-R). This tool was used primarily as an indicator of verbal fluency and approximate cognitive ability. The second measure was the AIDS Survey for Kids (ASK), a standardized interview with two sections. The first section assessed children's level of conceptual understanding of the causes and prevention of AIDS, or of colds and cancer for comparison. The questions in this section were open-ended with standardized probes. Students' responses were scored for conceptual sophistication on a six-point scale, with a score of six representing the highest level of understanding of the concepts of causality and prevention.

Scores were based on the highest demonstrated level of sophistication, regardless of factual accuracy. The second section consisted of yes/no questions which assessed children's misconceptions about HIV transmission and fears about AIDS.


Procedures

One class at each grade level was randomly assigned to either the control or intervention group. The control group classes received no program. The intervention group classes received the special study curriculum. All other regular AIDS education classes were postponed until after the study. Both the PPVT-R and the ASK were administered to all students at baseline. The ASK interviews were conducted between September 1991 and May 1992 by one interviewer who did not know each child's control/intervention group status. The ASK was administered for the second time following the educational intervention; the difference in the concept score between the pre- and posttest was the principal outcome measure.

To measure the persistence of change over time, kindergarten, 2nd grade, and 4th grade children were interviewed with the ASK a third time, approximately 2-1/2 months following the second interview. The reliability of the research associate who scored the open-ended responses was assessed and found to be acceptable.


Educational Intervention Program

Over a three-week period, a series of six 45-60 minute lessons were presented by the study's principal investigator to the intervention group. The curriculum was developmentally based and interactive. Two versions of the curriculum were created, one for kindergarten through 3rd grade, and one for 4th through 6th grades.

The first two lessons covered general concepts of illness, including germ transmission and how to prevent communicable and non-communicable illnesses, the role of the immune system in fighting illness, and symptoms and treatment of illness. The final four lessons focused specifically on AIDS, covering HIV transmission and prevention, the difference between AIDS and other illnesses, and misconceptions about AIDS. All children attended at least three of the six sessions, with 93% attending five or more sessions.

Summaries of each lesson and instructions for their child's homework assignments were sent home to parents following each session; parent participation was requested for the assignments. Parents were also encouraged to supplement children's education as they saw fit and were given an educational handout on talking with children about HIV/AIDS.


Statistical Analyses

To check that the intervention and control groups were comparable, t-tests and chi-square analyses were calculated on the pre-test data. To assess the impact of the intervention, gain scores (posttest minus pretest and delayed posttest minus pretest) were calculated and compared across intervention and control groups. To determine whether the intervention effect was similar across grades and whether background characteristics influenced intervention efforts, regression analyses were done.

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Results

  • There were no significant baseline differences between the control and intervention groups on the PPVT-R or comprehension of concepts of causality and prevention for all three illnesses. Similarly, the two groups were similar for demographic variables.

  • Across all grades, the intervention group demonstrated significant increases in conceptual understanding of causality and prevention of HIV/AIDS from pre- to posttest scores for the intervention group were also higher at delayed posttest.

  • Differences were so considerable that intervention group students' mean posttest scores for causality were equal to or greater than those for control group students two grades higher (i.e., second grade intervention group scores exceeded 4th grade and equaled 5th grade control group scores). Intervention group 3rd through 6th grade scores exceeded those for control group 6th graders.

  • The thematic content of children's responses about causality and prevention were also analyzed. A significantly greater proportion of intervention than control group children mentioned one or more of four major causes of transmission (germ/germ theory, mother-to-infant, blood, sexual) in response to the open-ended questions.

  • At posttest, intervention group children's fears of HIV/AIDS were no higher than their control group counterparts.

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Discussion

Many developmental theorists have argued that elementary school age children are too young to grasp the concepts of illness as they apply to AIDS. The results of this study do not support this argument. Rather, they illustrate that a developmentally appropriate, multifaceted, school-based education curriculum can significantly heighten children's conceptual understanding and decrease misconceptions about AIDS, without increasing their fears and anxieties, and that these gains can be maintained for at least several months.

This study had a few limitations: only 189 children from one school were sampled, no long-term impact has been measured, and it is unclear whether the results would be the same had the curricula been presented by a different instructor. Nonetheless, the results are promising and offer strong implications for future research.

In both the current study and in previous research, fears about AIDS are common among children in this age group, warranting educational intervention on the subject. To promote lasting, accurate and transferable comprehension of HIV, curricula should aim to increase children's conceptual understanding of key health concepts — rather than emphasize the memorization of facts. Curricula also should be developmentally appropriate for children's cognitive abilities.

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Implications for Educators (by the authors of the article)

  • This study represents the success of one of the first AIDS education curricula geared specifically for elementary school children.

  • The findings suggest that direct educational interventions can advance children's understanding of health concepts.

  • The current deficits in AIDS education programs for elementary grades may be due more to the lack of adequate programming, low priority for such curricula, or inadequate teacher training than to children's cognitive limitations.

Schonfeld, D.J.; O'Hare, L.L.; Perrin, E.C.; Quackenbush, M.; Showalter, D.R.; and Cicchetti, D. (1995). A Randomized, Controlled Trial of a School-based, Multifaceted AIDS Education Program in the Elementary Grades: The Impact on Comprehension, Knowledge and Fears. Pediatrics. (95)4, 480-486.

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