AIDSWEEKLY Plus, Monday, 25 November 1996
Daniel J. DeNoon, Senior Editor

Nearly one in five Americans with AIDS were infected with HIV in their teenage years; by the age of 21, more than a quarter of youths have acquired a sexually transmitted disease.

Faced with this apparent failure - and with limited funding - there is a growing sense that AIDS education should be limited to those perceived to be most at risk.

"Don't give up on education," warned Yale University researcher David J. Schonfeld. "Don't give up on children."

Schonfeld spoke in a plenary address to the International Society for HIV/AIDS Education and Prevention's Tenth International Conference on AIDS Education, held November 9- 13, 1996, in Atlanta, Georgia.

"We must remember that we, as adults, all had the opportunity to be a child, but that unless we educate children and youth about AIDS, some children will not have the chance to be an adult, and those who do will be far less prepared to meet the challenges of this pandemic," Schonfeld said.

To end universal AIDS education because of its failures to date would be like ending social studies education because fewer than half of Americans vote, he suggested.

Education is cost effective, Schonfeld argued, because research shows that it is easier to delay the onset of sexual intercourse and promote initial adoption of safe sex practices than it is to intervene once teens have already established patterns of high-risk sexual activity.

Education must begin early, as many children begin sexual experimentation sooner than is commonly thought.

"The mean age of first coitus for inner-city black male adolescents is 11 and a half years," Schonfeld said. "In New Haven [Connecticut] public schools, approximately one quarter of all students have begun engaging in sexual intercourse prior to the completion of elementary school."

Appropriate education would mean providing children with sequential lessons, taught over the course of years, in the form of developmentally appropriate curricula. Such curricula would be sensitive to growing cognitive capabilities, social skills, and expanding exposure to sexual experiences.

Education would not include the use of scare tactics intended to prevent risk behaviors. Children are already frightened by AIDS. Studies by Schonfeld and colleagues have shown that a third of elementary-age children are afraid they already have AIDS, and that half were worried that they would get AIDS (see AIDS Weekly, May 18, 1992).

"These fears are often based on misconceptions that result from a combination of the limited conceptual abilities characteristic of the young child and the ineffective and limited educational initiatives characteristic of current AIDS education efforts at the elementary school level," Schonfeld said. "Too many 'educational' efforts have concentrated on fear-evoking messages that have left our general public - especially children and youth - afraid and ignorant."

Another failure of AIDS education is that it often requires only rote memorization of facts, rather than promotion of conceptual understanding. This failure is compounded by evaluation methods that overestimate the results of AIDS education by the use of forced-choice questionnaires.

"For example, in our earlier interviews of children in kindergarten to sixth grade, we found that in response to open-ended questions, about one in four children mentioned drugs as a cause of AIDS," Schonfeld said. "Upon further questioning, the two most common drugs mentioned as a cause of AIDS were cigarettes and alcohol."

These misperceptions persist: one study found that 19 percent of high-school students believed that AIDS can be transmitted by sex between two uninfected people.

"At the very least, these findings should encourage researchers and educators to include more sophisticated measures of knowledge and comprehension in evaluating the success of educational interventions," Schonfeld said.

The good news is that intensive interviews with 800 elementary-age children showed that a developmentally-based AIDS education curriculum - even when taught by regular classroom teachers after minimal training - could increase not only factual knowledge but also conceptual understanding without increasing concerns or anxiety (see AIDS Weekly, April 24, 1995).

Central to Schonfeld's theme is the argument that knowledge is not enough: AIDS education must address attitudes and motivational factors that influence risk behavior, perceptions of personal vulnerability, behavioral intentions, competence to negotiate social situations, and the skills to implement and maintain prevention behaviors.

Schonfeld also listed a number of barriers to AIDS education:

• Lack of instructional time for health education.
• Lack of quality educational programs. "It is time to just say no to simplistic educational interventions," Schonfeld said.
• Lack of properly trained instructors. Teachers, too, have misconceptions and misunderstandings about AIDS. Training must not only provide factual health information, but also increase comfort in teaching the sensitive topics at the heart of AIDS prevention.
• Fear of controversy. "Research supports the view that education that provides sexually explicit information to adolescents and teaches them cognitive and behavioral skills needed for effective risk reduction is associated with significantly reduced sexual activity and the delayed onset of sexual activity," Schonfeld said.
• Reluctance to view children and adolescents as sexual beings. More than any other factor, unwillingness to discuss sexuality with young people had led to reliance on fear-based approaches. "Excessive fear may overwhelm and immobilize individuals and prompt them to utilize defensive avoidance to deny the relevance of an illness to them personally or even initiate reactive risk taking," Schonfeld said. "What is perceived in the adolescent as a sense of invulnerability to the risks of AIDS may thus mask an underlying excessive fear that is promoting increased risk-taking behaviors."
• Lack of strong active support from parents. Although surveys indicate that 95 percent of Americans think AIDS information should be provided in schools, it has been difficult to engage parents in school-based AIDS programs.

Schonfeld offered a series of new directions on which future AIDS education efforts should be based:

• Begin AIDS education in the elementary grades, and continue it longer. Beware of overestimating the efficacy of brief interventions.
• Study comprehensive initiatives, not isolated components of educational programs.
• Recognize that research into AIDS prevention is at least as important as research into AIDS therapies. "We must require that new approaches and methodologies become available with the same fervor that we call for the development and evaluation of new drugs," Schonfeld said. "We can not be satisfied with developing one interesting and simplistic slogan for health promotion in children - even if it works on the short term for some, sole reliance on this approach is likely to result in the development of resistant organisms."
• Borrow ideas from other fields of study. Enlist professionals from other fields, such as psychology and anthropology.
• Move beyond the individual context and address the social context of sexual behaviors. Programs should focus on the prevalence of risky and preventive activities among peer-group members and reinforce the values and norms favoring preventive behaviors. In the broader sense, factors such as poverty must be addressed.
• Study outcomes other than behavior. "Children are more than what they do," Schonfeld said. "We should look at the development of attitudes, fears, stigma, and coping in children, as well as the development of healthy sexual relationships."

Schonfeld concluded his presentation admitting that while there are limits to what education can accomplish, AIDS education is currently nowhere near those limits.

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