A Randomized, Controlled Trial of a School-based, Multi-faceted AIDS Education Program in the Elementary Grades: the Impact on Comprehension, Knowledge and Fears

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A Randomized,

Controlled

Trial

of a School-based,

Multi-faceted

AIDS

Education

Program

in the

Elementary

Grades:

the

Impact

on

Comprehension,

Knowledge

and

Fears

David

J.

Schonfeld,

MD*;

Linda

L. O’Hare,

MS;

Ellen

C. Perrin,

MD;

Marcia

Quackenbush,

MSj;

Donald

R. Showalter,

MPHII;

and Domenic V. Cicchetti, PhD**

ABSTRACT. Objective. Several educational theorists have suggested that young children are unlikely to ben-efit from detailed instruction regarding

AIDS

prevention

because of inherent developmental cognitive limitations. This study aims to determine whether AIDS education in the elementary grades

can

advance young children’s

un-derstanding of this illness.

Methods. A randomized, controlled trial was used to

measure the impact of a 3-week, multifaceted AIDS

ed-ucation program on conceptual understanding, factual

knowledge,

and

fears

about AIDS in 189 students in

grades kindergarten through

6th.

The ASK (AIDS Survey for Kids), a standardized, semistructured interview that measures conceptual understanding, factual information, and fears about AIDS, was administered before

and

after the intervention.

Results. Children in the intervention group, as com-pared to those in the control group, showed significant (P < .0001) gains in their level of understanding of the

concepts of causality

and

prevention of AIDS. These

results were unaffected by controlling for grade, gender, race, socioeconomic status,

and

verbal fluency. The

gains

in

children’s

understanding

of causality

of AIDS

repre-sented at least 2 years’ growth in the level of conceptual

sophistication and persisted at a follow-up evaluation several months later. After the intervention, more chil-then (P < .001)

in

the

intervention

group

than

in

the control group accurately identified causes of AIDS in

response to open-ended questions: germ/germ theory

(41%

vs

13%),

mother-to-infant transmission (54% vs

15%),

blood transmission (83% vs 40%), and sexual trans-mission (56% vs 30%). Fewer than half as many children

in

the intervention group responded incorrectly to each

of five direct questions about transmission of HIV

through

casual contact. The intervention did not increase

children’s fears about the illness.

Conclusions. A short, developmentally based,

multi-faceted AIDS education

program

in

the elementary

grades can advance children’s conceptual understanding

and factual knowledge about AIDS and decrease their

misconceptions

about

casual

contact

as a means

of

ac-From the *jpaflent of Pediatrics and the Child Study Center, Yale

University School of Medicine, New Haven, CT; Department of Pediatrics,

Yale University School of Medicine, New Haven, CF; §Department of

Pediatrics, University of Massachusetts, Worcester, MA; IAIDS Health

Project, University of California San Francisco, San Francisco, CA; liWest Haven VA Medical Center, West Haven, CT; and Department of

Psychi-atry and the Child Study Center, Yale University School of Medicine, New

Haven, CT and the West Haven VA Medical Center, West Haven, CT. Received for publication May 3, 1994; accepted Jul 26, 1994.

Reprint requests to (D.JS.) Department of Pediatrics, Yale University School

quiring the illness, without increasing their fears. Signif-icant advances in conceptual understanding about AIDS can be achieved

through

direct

educational interventions. Pediatrics

199595:480-486;

AIDS, HIV infection, AIDS education, health education, school health, conceptual de-velopment, cognitive development, health concept, illness concept.

ABBREVIATIONS. AIDS, acquired immunodeficiency syndrome;

ASK, AIDS Survey for Kids; HP!, human immunodeficiency

vi-nis; PPVT-R, Peabody Picture Vocabulary Test-Revised.

Early

and

effective

education

is currently

one

of

the

most

viable

and

available

means

of confronting

the AIDS

crisis.

Since research supports the

conclu-sion

that

health

education

is more

effective

in

pre-venting the initiation of unhealthy behaviors than it

is in modifying established behavior,” AIDS

educa-tion will have to begin at a young age before the

initiation of behaviors that place children at risk of

infection

with human immunodeficiency virus

(HIV). In addition, it is becoming increasingly clear

that even the youngest students are aware of

this

ifiness

and harbor significant misconceptions and

unwarranted anxieties.3 Many authorities, including

the Centers

for Disease

Control

and

Prevention,4

the

American Academy of Pediatrics,5 and the Surgeon

General,6 have endorsed the

need

to

begin

AIDS

education within the elementary grades, starting in

kindergarten and continuing throughout the

school

years; AIDS education is mandated in many states.

The issue is no longer whether or not to tell young

children about AIDS, but rather what information is

appropriate and necessary, and what means of

in-struction are most effective.

Previous studies have shown that young children

have a limited understanding of the causes of

AIDS

and the methods to prevent the spread of HIV and

have unwarranted concerns about acquiring AIDS

through

casual

contact

with

others.1’7#{176}Despite

the

demonstration of a developmental progression in

children’s cognitive understanding of AIDS,7 there is little research that

describes

the cognitive processes

by which young children learn this information.’

Currently, there is little, other than general

theoreti-cal

constructs,

to guide

the

development

of

appro-priate curricula. Furthermore, there are no data that

support

the

claim

that

direct

educational

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tions can advance significantly young children’s con-ceptual understanding

of this

ifiness.

If young

children

are

unable

to understand

the

information taught, AIDS education programs may

only result in misinterpretations that can lead to

increased

fears

about

the

illness.

The

aim

of

this

study was to use a randomized, controlled trial to

determine

whether

a school-based,

multifaceted

ed-ucational

intervention

for elementary

school

children

can advance children’s understanding and factual

knowledge

about

AIDS

and

decrease

their

concerns

about

casual

contact

as a means

of acquiring

HIV,

without increasing their fears about the illness.

Subjects

METHODS

Children who attended regular education classes in

kindergar-ten through 6th grade in one representative New Haven Public

School were recruited for participation. Letters that described the project and consent forms were sent to parents of all children in

these classes. To minimize any discomfort to the child from the interview, the letter recommended that parents who were

con-cerned about their child’s or a family member’s HIV status (ie, those with suspected or confirmed AIDS or HIV infection) should

not participate. Children who did not return a completed consent

form were given additional copies; one phone call was made to the parents of nonresponders to verify that they had received the

information sent home with their children and to answer any questions about the study. Only those children who agreed to

participate and whose parents provided written consent were enrolled. The project was approved by the Human Investigations

Committee of Yale University School of Medicine and New Haven Public Schools.

Signed informed consent was obtained from the parents of 212

(63%) of the 337 eligible students (13% of the parents denied

consent and 24% did not respond). First interviews were

corn-pleted on 197 (93%) of the 212 students with informed consent.

Twelve children transferred out of either the school or the

partic-ipating classes before the first interview; interviews were not

completed on the remaining three children because of lack of

proficiency in English (1 student) or hearing impairment (2 stu-dents).

No child or parent requested to withdraw from the study after

the child was enrolled. Eight children transferred out of either the

school or the study classes before the intervention phase and were

excluded from the study. The final sample was 189 children (Table 1) who completed the first two interviews. The gender and racial distribution ofparticipants did not differ significantly from that of

all eligible students; the racial distribution of the study sample

was highly representative of New Haven Public Schools.7 The

distribution of school lunch status, which was used as a measure of socioeconomic status, varied significantly between the study

sample and all eligible students (chi-square, P< .0001); there were a smaller percent of children with full price lunch (13%) and a

greater percent of those with free lunch (75%) in the study sample

as compared to all eligible students (34% full price; 55% free lunch).

Measures

ASK (AIDS Survey for Kids)

The ASK is a standardized, semistructured interview com-prised of two sections. The first section consists of open-ended questions, followed by standardized probes, intended to assess the level of conceptual sophistication of children’s understanding of

causality and prevention of AIDS (Table 2), and, for comparison, of colds and cancer. This section of the interview has been shown

to measure the child’s level of conceptual understanding along a developmental continuum that characterizes children’s

acquisi-tion of key health concepts and provides richer developmental

information than true-false or multiple-choice questionnaires.7 Re-sponses to open-ended questions are scored for the concepts of

causality and prevention for each illness on an ordinal scale of I to 6, with a higher score indicating a more advanced level of

con-ceptual understanding (Table 3). Scores are based on the highest level of conceptual sophistication demonstrated in the response,

independent of its factual accuracy.

All interviews were scored using a detailed scoring guidebook by one research associate (L.L.O.), who was blind to which group the child was in and to the design of the study. Inter-rater

reli-ability, as measured using a sample of 50 interviews during an

earlier study involving the standardization of the ASK, was very

good to excellent across all concepts and illnesses, with observed agreement of 92% to 99% and weighted Kappa of 0.63 to 0.97.

After all interviews were scored for this study, inter-rater

reliabil-ity was reassessed with a second set of seven interviews (one from each grade level) scored by the same two scorers (D.J.S. and L.LO.) to assure that rater drift had not occurred; at least compa-rable degrees of inter-rater reliability were maintained.

The thematic content of responses to the same open-ended questions about causality and prevention were independently

scored using a separate scoring guide; all themes mentioned in the

responses were recorded and multiple scores allowed. The second

TABLE 1.

Characte ristics of Study Sample (N = 189; 94 C ontrol Group, 95 Intervention Group) Control (N) Intervention (N) Total (N) % of Total Sample

Grade

Kindergarten 10 10 20 11

1st grade 13 16 29 15

2nd grade 14 12 26 14

3rd grade 15 12 27 14

4th grade 13 10 23 12

5th grade 13 19 32 17

6th grade 16 16 32 17

Gender

Female 41 43 84 44

Male 53 52 105 56

Race

Black 56 55 111 59

Hispanic 25 24 49 26

White 12 13 25 13

Other I 3 4 2

School lunch status

Free lunch 68 73 141 75

Reduced price 14 10 24 13

Full price 12 12 24 13

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TABLE 2.

Open-Ended Questions on the ASK Related to

Cau-sality and Prevention*

Causality

How does someone get AIDS (a cold, cancer)? How does a child get AIDS (a cold, cancer)?

How do you get AIDS (a cold, cancer)?

Prevention

How can someone keep from getting AIDS (a cold, cancer)?

Probes:

What can people do so that they don’t get AIDS (a cold,

cancer)?

How can a child keep from getting AIDS (a cold, cancer)? How can you keep from getting AIDS (a cold, cancer)?

What can you do so you don’t get AIDS (a cold, cancer)?

* Modified from: Schonfeld et al.7

TABLE

4. Direct Questions on the ASK to Assess Misconcep-tions About Casual Contact and Fears About AIDS

Questions to assess misconceptions about casual contact:

if someone has AIDS and

that

person sits next to you, but

doesn’t touch you, can you get AIDS? E”SitNext”l

What if they touch you with their hand? E”TouchHand”I

What if they cough on you? [“Cough”] What if you drink from their cup? [“ShareCup”]

What if they kiss you on the cheek? [“KissCheek”]

Questions to assess fears about AIDS:

Are you afraid that you might have AIDS? [“AfraidHave”]

[Ifresponds yes], Do you think you have AIDS?

[“ThinkHave”]

Do you worry about getting AIDS? [“WorryGet”I

Do you think you are going to get AIDS? [“ThinkGet”]

TABLE 3.

Summary of Scoring Criteria for the Concept of

Causality*

1 = “I don’t know” or Off-subject response (eg, “I never had AIDS, but I once had chicken-pox”)

2 = Circular (eg, “You get AIDS by getting sick”) or Phenomenistic response, wherein the child refers to a phenomenon associated with having the illness, such as a

symptom, as if it were the cause (eg, “You get AIDS by having a fever”)

3 = Concrete, specific causal agents/actions are named (eg,

“From a virus”)

4 = Internalization is indicated (eg, “When you have sex, the

virus gets inside of you”)

5 = Specific effect of the illness causing agent is stated (eg, “The

virus gets into your body and kills your white blood

cells”)

6 = Causal mechanism or process is elaborated (eg, “When your white blood cells don’t work you can’t fight off other

sicknesses and you get real sick”)

* From: Schonfeld et al.7

section of the ASK includes a series of direct yes/no questions to

assess possible misconceptions about casual contact as a means of acquiring AIDS and several questions to assess the child’s fears about AIDS (Table 4).

Peabody Picture Vocabulary Test-Revised (PPVT-R)

The PPVT-R1 is an individually administered, norm-refer-enced, wide-range, power test of receptive vocabulary designed for administration to persons 2.5 through 40 years of age. It was

administered to all children just before the first administration of the ASK and served as a measure of verbal fluency and a proxy

estimate of cognitive abilities.

Other Data

Demographic information available from school records

in-cluded date of birth, gender, race, grade, and school lunch status (free lunch, reduced price lunch, full price), which was used as a measure of socioeconomic status.

Procedures

The study design is a randomized, controlled trial of a

multi-faceted educational intervention (Fig 1). At baseline, the PPVT-R and the ASK were administered to all children. One class at each grade level was assigned randomly to either the intervention or the nonintervention (control) group. Between September 1991 and

May 1992, ASK interviews were conducted individually outside the classroom by a single research associate (L.L.O.) who was blind to the student’s group assignment and the overall design of the study. At the completion of the intervention phase, the ASK was readministered to all of the students. The change in the

concept score between the pre- and post-test was used as the

principal outcome measure. To assess the persistence of changes,

children in kindergarten, 2nd, and 4th grades were readministered

the ASK a third time, the “delayed post-test,” an average of 2.5

months after the second interview. All interviews were

audio-taped and transcribed verbatim for later blinded scoring.

Classes in the control group received no intervention. All

for-mal AIDS education lessons (with the exception of the curriculum

presented to the intervention group as described below) were

withheld until the completion of the study period, after all inter-views had been completed.

Educational

Intervention

Program

A series of six 45- to 60-minute classroom lessons was

pre-sented to dasses in the intervention group by the principal inves-tigator (D.J.S.) over a 3-week period. The curriculum was designed

by the authors (D.JS. and M.Q.). The first two lessons concern general concepts of illness, using colds as a model illness. Children are taught to differentiate between communicable and

noncom-municable illnesses, and germs are introduced as one cause of

many communicable illnesses. The means of transmitting germs

and methods to prevent their spread are reviewed. The immune system is explained as one way the body fights off germs that

manage to get into the body, and a simple functional description

of the immune system is provided with the aid of a demonstration.

The symptoms (including the notion of asymptomatic illness and incubation period) and treatment of illness (introducing the

con-cept that an illness may or may not be successfully treated) are then discussed. The remaining four lessons deal specifically with AIDS. The lessons highlight the means of transmission of HIV,

clarifying misconceptions and differentiating AIDS from other

illnesses, and review ways to prevent the spread of the virus that

causes AIDS. The curriculum contains no direct instruction about

cancer, although questions about cancer sometimes were raised by the children and answered within the class. All children in the

intervention group attended at least half and 93% attended at least

five of the six classroom lessons. Children in the intervention classes who had not provided informed consent were allowed to

remain for the lessons unless their parents returned a separate consent form requesting their child’s removal; this resulted in the removal of only two 6th grade students.

The curriculum is developmentally based and includes

dem-onstrations, drawing exercises, and interactive activities. Classes in the intervention group at all grade levels were shown the video

“AIDS: A Different Kind of Germ.”2 There were two basic ver-sions of the curriculum, one for grade levels kindergarten through 3rd and the other for grades 4th through 6th, which differed

predominantly in the selection of vocabulary used and the

sup-plementation of the curriculum for the older children with addi-tional factual information (eg, how vaccines work, or further

information about the safety of blood transfusions and blood

products). At the school’s request, specific mention of condoms was introduced first at the 5th grade level, although related

ques-tions raised by students were answered at lower grade levels as well; human sexuality was part of the social development

curric-ulum for 6th graders at the time of the study. At the 5th grade level, children were told that body fluids with high concentrations of HIV may be passed during dose sexual contact; these fluids (ie,

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Recruftment

EDUCATIONAL INTERVENTION

Rm

PPVT-R

ASK #1 Pre-test

INTERVENTION GROUP

(N-9

CONTROL GROUP (N-9

ASK#2 ASK#3

Post-test Dd Post-test

Fig 1. Study design.

blood, semen, and vaginal fluids) were specified at the 6th grade

level. At lower grade levels, children were informed that the virus

that causes AIDS could be spread by close sexual contact with

someone who has the virus in his/her body, and it was

empha-sized that common means of expressing affection that involve

causal contact, such as hugging, kissing, or holding hands, are not means of transmitting WV through “sex.”7

After each lesson, parents received a letter detailing the days

lesson and a request to assist their child with the night’s home-work assignment and to review and sign the paper before it was returned to class. Homework assignments for the lower grade levels typically involved directions for parents to discuss topics

and to assist their children in completing drawings; children in

grades 4th through 6th were given comparable written

assign-ments that they were asked to review with their parents. For example, after the second lesson on AIDS, children in grades

kindergarten through 3rd were instructed to “Tell your parents

three ways of spreading the AIDS virus”; children in grades 4th through 6th were asked to “Write three ways of spreading the AIDS virus; for each way of spreading the virus, write one thing

people can do to prevent catching AIDS that way.” Parents were provided with an educational brochure distributed by the Amer-ican Red Cross, entitled “Children, Parents, and AIDS”3 and were encouraged to correct any misconceptions and to supplement

their child’s knowledge with as much additional information as

they felt was appropriate. There also was a 1-hour presentation for

teachers in the intervention group and parents were invited to

preview the curriculum and attend an educational program (few parents attended these sessions).

Statistical Analyses

To assure comparability after randomization, two-tailed t tests were used to compare the control group and the intervention

group on the following baseline variables: the mean score on the

PPVT-R and both the concepts of causality and prevention for

each of the three illnesses on the pretest ASK. Comparisons

be-tween the control and intervention groups on the dichotomous

baseline variables on the pretest regarding casual contact and fears and the mention of various content themes in response to open-ended questions were analyzed by chi-square.

To analyze the impact of the educational program on the

con-ceptual understanding of the children, the gain in concept score

between the pretest ASK and the post-test was calculated for both causality and prevention for each of the three illnesses. These

differences were used as the dependent variable in two-tailed tests to compare the intervention and control groups. To deter-mine if the increase in conceptual understanding as a result of the educational intervention persisted, the differences between the

concept scores on the pretest and the delayed post-test (the third

interview) were calculated as well and substituted as the

depen-dent variable. A multiple linear regression analysis was used to determine if the intervention effect was constant over grades and

the extent to which the following additional variables contributed

to the overall difference between the control and intervention

groups: gender, race, school lunch status, and PPVT-R score. Comparisons between the control and intervention groups on the

dichotomous variables regarding casual contact and fears and the mention of various content themes in response to open-ended

questions were analyzed by Chi-Square.

The level of statistical significance was set at .05. Analyses were

conducted using SAS/STAT System for Personal Computers (Re-lease 6.04) proprietary software.’4

RESULTS

There were no significant differences

between

the

control group and the intervention group on any of

the baseline measures. The mean scores for both

groups

on the PPVT-R

(Table

5) and

the

concepts

of

causality

and prevention for each of the three

ifi-nesses on the pretest ASK were comparable.

Simi-larly,

there

were

no

differences

between the two groups in the percent on the pretest ASK mentioning

each of various content themes (ie, germ/germ

the-ory,

mother-to-infant transmission, blood

transmis-sion, sexual transmission, and drugs) in response to

open-ended questions about the cause of AIDS and

the percent answering yes to each question about

casual contact or fears about AIDS.

Scores

in the

intervention

group

for the

causality

of AIDS

increased

considerably

from

pretest

to

post-test across grade levels. The mean pretest, post-test

and delayed post-test scores are presented in Table 6

for both control and intervention groups. Fig 2

graphically

illustrates

the

clinical

magnitude

of the

gains

in the

children’s

conceptual

understanding

of

the cause of AIDS, which is the major

focus

of the

curriculum,

as a result

of the

educational

interven-tion.

Mean

scores

for the concept

of causality

of AIDS

after the intervention were equivalent to mean scores in the control group in classes that were at least two

grade levels higher. For example, the mean score for

the intervention group in the

first

grade was

equiv-alent to that of the control group in the 4th grade; the

mean score for the intervention group in the second

grade was equivalent to that of the control group in

the 6th grade. The scores for the intervention groups

in grades

3rd through

6th exceeded

the score

for the

control

group

in the 6th grade.

Because

kindergarten

TABLE 5. Mean (Standard Error) P

and Intervention Groups

PVT-R Score for Control

Grade Control Intervention

K 73.3 (6.0) 78.9 (5.0)

1 72.2(5.1) 72.5(4.6)

2 73.9 (5.2) 78.2 (7.6)

3 78.9 (3.8) 82.6 (4.0)

4 84.8 (3.2) 77.9(7.1)

5 85.3 (6.4) 73.1 (3.1)

6 81.0 (3.5) 84.9 (2.6)

All 78.7 (1.8) 77.9(1.8)

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K 5 6

TABLE 6. Mean score (standard error) on pretest, p

AIDS for control and intervention groups

ost-test, and delayed post-test for causality of

Control Intervention

Pretest Post-test Delayed Post-test Pretest Post-test Delayed Post-test

--(N) (94) (94) (36) (95) (95) (32)

Grade

K 2.4 (0.3) 2.3 (0.3) 2.1 (0.4) 1.8 (0.3) 2.3 (0.4) 2.4 (0.5)

1 2.2 (0.3) 1.6 (0.3) 1.9 (0.3) 3.3 (0.2)

2 2.3 (0.4) 2.6 (0.3) 2.7 (0.4) 2.9 (0.4) 3.9 (0.4) 3.8 (0.4) 3 2.8 (0.3) 2.8 (0.4) 3.5 (0.3) 4.4 (0.2)

4 3.4 (0.3) 3.2 (0.4) 2.6 (0.4) 4.0 (0.3) 4.3 (0.2) 4.0 (01) 5 4.3 (0.2) 3.8 (0.2) 3.8 (0.2) 4.8 (0.2)

6 4.3 (0.2) 3.9 (0.1) 4.1 (0.2) 4.7 (0.2)

5.0

4.0

3.0 6.0 U)

LL

0

(I) 2.0

z w

1.0

1 2 3 4

GRADE

Fig 2. Mean score and standard error of the mean (SEM) on post-test for concept of causality of AIDS for control and intervention groups

by grade level.

children in the intervention group had somewhat

lower (P = .17) pretest scores than those children in

the control group (Table 6), their gain as a result of the intervention is inadequately reflected in the corn-parison of post-test scores (Fig 2). In fact, the

educa-tional intervention was equally effective across all

grade levels; there was no significant interaction

be-tween group status (control versus intervention) and

grade level within an analysis of variance.

Children within the intervention group, as

corn-pared to children in the control group, demonstrated a significantly greater gain from their pre- to post-test scores for the concepts of causality of AIDS and prevention of AIDS at the

P

< .0001 level; causality of colds and prevention of colds at the P < .01 level; and

causality of cancer at the P < .05 level. No significant

difference was noted between the intervention group

and the control group in the gain in children’s

un-derstanding of the prevention of cancer. These

re-suits were unaffected by controlling for the following

potential confounders in a linear regression model:

PPVT-R

score,

grade,

gender,

race,

and

school

lunch

status. In fact, none of these independent variables contributed significantly to the variance observed in

the concept scores. When the differences between the

concept scores on the pretest and the delayed

post-test (the third interview) were calculated, children in the intervention group still showed significantly

(P

< .05) greater gains than children in the control group for the concept of causality of AIDS.

The thematic content of children’s responses to

open-ended questions about the cause and

preven-tion of AIDS was also analyzed. As seen in Table 7,

on the post-test a greater proportion (P < .001) of the

intervention group, as compared to the control

group, mentioned the following accurate causes of

AIDS in response to these open-ended questions:

germ/germ theory, mother-to-infant transmission,

blood transmission, and sexual transmission.

Signif-icantly fewer children in the intervention group men-tioned drugs as a cause of AIDS, which is consistent

with the curriculum that emphasizes that drugs

do

TABLE 7. Thematic Content of Children’s Responses on Post-test to Open-Ended Questions

About Causes of AIDS

Control (N = 94; %) Intervention (N = 95; %) Chi-square (P value)

Germ/germ theory 13 41 <.0001

Mother-to-infant 15 54 <.0001

Blood transmission 40 83 <.0001

Sexual transmission 30 56 <.001

Drugs 24 8 .005

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TABLE 8.

ing Casual Tra

Percent of

Children

Respon

nsmission of AIDS

ding Incorrectly (“Yes”) on Pos t-test

to Questions

Regard-Control (N = 94; %) Intervention (N = 95; %) Chi-square (P value)

SitNext 15 4 .01

TouchHand 32 14 .003

Cough 51 24 <.001

ShareCup 64 28 <.001

KissCheek 35 15 .002

not

cause

AIDS

but

that

blood

remaining

within

needles

shared

for injection

drug

use

may

serve

as a

vehicle

for transmitting

HIV.

This

ifiustrates

that

the

increase in accurate information was not merely a

reflection

of increased

ease

of discussion

about

the

topic

and

that

common

misconceptions

about

AIDS

transmission7

can

be

effectively

inhibited

through

the provision

of accurate

information.

Fewer than half as

many

children who had

re-ceived the education program responded incorrectly

to each

of the

five

means

of casual

transmission,

as

compared

to the children

in the control

group

(Table

8). Chi-square was significant for each question.

Comparable differences were

still

evident on the

de-layed

post-test

(third

interview).

In addition,

there

were

no significant

differences

in the percent

of

chil-dren in the control and the intervention groups who

responded

“yes”

on

the

post-test

to

the

questions

about

their

fears

about

AIDS

(Table

9).

DISCUSSION

Based

on

an

interpretation

of

Piaget’s

stages

of

cognitive development, several educational theorists

have suggested that young children may not be

ca-pable

of understanding

the fundamental

health

con-cepts

necessary

to guide

appropriate

behavior

to

pre-vent AIDS, even if education were provided. For

example, referring to the

immature

thought

pro-cesses

of

young

children,

Walsh

and

Bibace

state:

“Given this form of reasoning, it

does

not

seem

use-ful

to

instrUCt young children about the specific

causes

of AIDS,

or the effects

of these

causes

on the

interior

of the

body.”5

When

discussing

AIDS

edu-cation

for

children

5 through

7 years

of

age,

they

suggest “it makes little sense to teach children at this

age how to identify and explain causes of AIDS, to

instruct them on internal working of the

body

in

relations

to AIDS,

or to provide

specific

information

about

preventive

behaviors.”16

In contrast,

the

results

of

this randomized, con-trolled trial indicate that a brief, developmentally

based,

multifaceted

AIDS

education

program

in the

elementary

grades

can

advance

children’s

concep-tual understanding and factual knowledge about

AIDS. These gains in comprehension are clinically

significant, representing at least 2 years’ growth in

conceptual understanding, and persist for at least

several months. In addition to increasing

compre-hension

and

factual

knowledge

about

AIDS,

the

ed-ucational program can decrease children’s

miscon-ceptions

about

casual

contact

as a means

of acquiring

the illness. Furthermore,

this

educational

interven-tion

does

not

increase

fears

about

AIDS

in young

children.

Fears about AIDS were common (38% to 44%)

among the children interviewed. Other researchers

have found similar results. In a study with

focus

groups involving 75 5th graders, Brown et al.’ found that “a majority of children reported significant and frequent fears about getting or having

AIDS

that they did not discuss with others.” HIV

infection

and AIDS

are major concerns of elementary school children

and warrant a targeted educational intervention, at

least to

decrease

unnecessary

anxiety

about

personal

vulnerabifity

to HIV and the

risk

of disease

transmis-sion

through

casual

contact.

If

true

learning

is to

occur,

educational efforts

about AIDS should aim to advance comprehension

and not

just

promote the memorization of facts. If

children

simply memorize a

list

of very risky,

some-what risky, and not risky behaviors without

truly

understanding the reasons for the associated risk,

newly encountered behaviors often will be

misdas-sifted.

Such

memorization,

in the absence

of

compre-hension, is likely to be brief, inaccurate, and highly

vulnerable to conflicting arguments such as those

that

may

be posed

by peers.

Instead,

a

developmen-tally

based

AIDS

education

curriculum

should

be

tailored to the cognitive capabilities of the age group

and

focus

on advancing further the children’s

corn-prehension of critical health concepts. Given

this

ap-proach, even young children can understand the

fun-damental principles of the

immune

system, as

evidenced by one second grader’s description of how

AIDS

can

be transmitted

from an

infected

mother to

her fetus:

“The AIDS virus gets into the baby’s blood and white

blood cells. Itbeats up on the white blood cells and then the

germs do damage to you . . . the AIDS virus gets into the white blood cells and then it makes the white blood cells die.”

The author (D.J.S.) had the opportunity to return

to the school the year following the project to speak

to the second graders, who had

been

in first grade

during the study. The children quickly listed “close sexual contact,”

sharing

needles

for

injection

drug

TABLE 9.

to Questions

Percent of Children Responding “Y Assessing Fears of AIDS

es” on Post-test

Control Intervention Chi-square (N = 94; %) (N = 95; %) (P value)

AfraidHave 38 38 NS*

ThinkHavet 4 7 NS

WorryGet 41 44 NS

ThinkGet 5 9 NS

* NS, not significant.

J:

Only children who responded “yes” to the question “Are you

afraid that you might have AIDS?” were asked “Do you think you

have AIDS?”

at Viet Nam:AAP Sponsored on September 1, 2020

(7)

use, blood transmission, and mother-to-infant

trans-mission as the only mechanisms for transmission of

HIV. One child in the class, though, asked if you

could

transmit

AIDS

from

using

a dirty

toilet

seat.

Despite reassurances that the AIDS virus can not be

transmitted

through

casual

contact,

he

remained

concerned and asked the question on another

occa-sion.

After

class

the

child

explained

that

his

uncle

had

stomach

problems

and

had

blood

in his

stool,

which

was

often

found

on the

toilet

seat.

His

sister

was

a toddler

who

played

with

the

toilet

seat

and

then

placed

her fingers

in her mouth.

He was

appro-priately

concerned

about

possible

HIV transmission

through

this

mechanism,

even

though

the superficial

content

of

his

questions

(ie,

“catching

AIDS

from

a dirty toilet seat”) may have seemed to indicate a

poor understanding. In fact, since he actually

under-stood

the

means

of transmission

of HP!,

he did

not

dismiss “dirty toilet seats” as an incorrect means of

transmission.

Implications

As

Siegel

has

stated:

“In

the

rush

to get

(AIDS)

education

programs

in place,

most

curricula

are not

well

grounded

in theory,

and

theoretical

frameworks

have

not

been

used

to

guide

the

measurement

of

variables for

program

evaluation.”7

Although

this

study

included

only

189

children

drawn

from

one

school and measured the short-term (ie, several

months)

impact

of a school-based

educational

pro-gram,

it represents

one

of the

first

reports

of a

suc-cessful AIDS education intervention in the elemen-tary

grades.

The

authors

are currently

completing

a

replication

study

involving

a slightly

larger

sample

in a different

elementary

school,

using

the same

cur-ricula

but

taught,

instead,

by

regular

classroom

teachers.

The

intervention

was

successful

not

only

in

ad-vancing

factual

knowledge

and

in decreasing

mis-conceptions,

but

also

in increasing

the

level

of

con-ceptual

sophistication

of children’s

understanding

of

critical

health

concepts.

These

findings

therefore

have broad implications, even beyond the domain of

AIDS education, and suggest that significant

ad-vances in conceptual understanding can be achieved

through

direct

educational

interventions.

These

‘re-sults support a knowledge-based theoretical

orienta-tion to cognitive development, wherein the child is

seen

as progressing

along

a continuum

from

novice

to expert through the accumulation of information, as opposed to a reliance on a strict view of cognitive

development

as a stage-like

process

solely

based

on

maturation.1#{176} Although limits obviously exist in

what

children

can be helped

to understand

at

differ-ent ages,

this

research

suggests

that

our

current

lim-itations

in elementary

school

health

education

in the

area

of AIDS

education

probably

result

more

from

extrinsic

deficits

(eg,

the lack

of well

developed

cur-ricula,

inadequate

priority

given

to

school-based

AIDS education, insufficient teacher in-service,

inad-equate

classroom

instruction

time,

and

adults’

mis-information

and

anxieties

about

AIDS)

than

from

intrinsic limitations of children’s cognitive abilities.

ACKNOWLEDGMENTS

This work was supported in part by a FIRST Award from the National Institute of Mental Health (5 R29 MH47251) awarded to

D.J.S. and a VA Merit Review Grant (MRIS 1416) awarded to D.V.C.

We acknowledge Lisa Schmidt, Karen Amos, and Stacia

More-house for secretarial assistance, Eugene Shapiro, MD and John

Leventhal, MD for critical review of the manuscript, and, most

importantly, the continuing assistance of the administration, staff and students of New Haven Public Schools that has allowed this

project to be conducted.

Presented in part at the Seventh International Conference on AIDS Education, Chicago, IL, November 16, 1993, the 33rd annual

meeting of the Ambulatory Pediatric Association, Washington,

DC, May 6, 1993 and the 1993 Annual Meeting of the American Academy of Pediatrics, Washington, DC, November 3, 1993.

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1995;95;480

Pediatrics

Showalter and Domenic V. Cicchetti

David J. Schonfeld, Linda L. O'Hare, Ellen C. Perrin, Marcia Quackenbush, Donald R.

Fears

Program in the Elementary Grades: the Impact on Comprehension, Knowledge and

A Randomized, Controlled Trial of a School-based, Multi-faceted AIDS Education

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1995;95;480

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Showalter and Domenic V. Cicchetti

David J. Schonfeld, Linda L. O'Hare, Ellen C. Perrin, Marcia Quackenbush, Donald R.

Fears

Program in the Elementary Grades: the Impact on Comprehension, Knowledge and

A Randomized, Controlled Trial of a School-based, Multi-faceted AIDS Education

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