Efficacy of HIV/AIDS Related Educational Package on Awareness and High-Risk Behavior of Adolescent Students in Kathmandu Metropolitan City

Introduction: Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) are among the most complex health problems of the 21 st century. Young people aged 15 - 24 years are the HIV/AIDS at risk group. The objective of this study was to evaluate the effectiveness of an educational interventional program on knowledge on HIV/AIDS among adolescent students of higher secondary school in Kathmandu, Nepal. Methods: The study was the pre test - post test experimental study design with an experimental and a control group conducted in the randomly selected eighteen higher secondary schools. The intervention, educational package on HIV/AIDS, was provided to all grade twelve students in the intervention group from 1st September, 2017 to 2nd January, 2018. In total, 321 from the intervention group, and 283 from the control enrolled at baseline and over 95% of these were followed up at posttest. The data were collected from self-administered questionnaires in English version and analyzed by using independence t-test and paired t-test. Results: Overall pretest knowledge of both intervention and control groups was comparable with 27.58 ± 4.05 and 28.53 ± 3.77 mean ± standard deviation respectively. But statistical analysis showed significant higher knowledge (P = 0.03) among control group. After the educational intervention, the mean knowledge score of control group increased by only 0.47, whereas the of students of intervention group. The differences in pre- and post-test knowledge scores of both intervention and control groups were statistically significant with P-value of 0.000 and 0.003 respectively. The findings of sexual risk behavior showed that 6.7% of controls and 16.8% of intervention group students reported having sexual relations. Conclusion: Educational intervention was efficacious in improving awareness of adolescent students on HIV/AIDS. The study has also indicated that remarkable numbers of adolescents are practicing high risk behavior for HIV/AIDS like having early initiation sexual intercourse, multiple sex partners, using alcohol before intercourse etc. There is need to promote education program among higher secondary schools to multiply the effects of providing opportunities to equip students with factual information on HIV/AIDS.


Introduction
Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) are among the most complex health problems of the 21st century [1]. Young people (15 -24 years old) are of international concern in the HIV/AIDS epidemic and are labelled "at risk" group. The importance of focusing on young people recognized at a global level by the 2002 United Nations General Assembly Special Session [2]. AIDS is a disease that in terms of its social problems, incidence and prevalence in active ages of society, high fatality rate and the cost of intensive care is considered among the main problems of the health care system; and control, prevention and care of patients are among the main activities that the health care institutions provide worldwide for this disease [3].
Globally, up to the end of 2014, 36.9 million people were living with HIV and 2 million people became newly infected. Over half of all new infections worldwide are among young people between the ages of 15 and 24 [4]. Adolescents aged 10 -19 years of age accounting for nearly 22% of the population of Nepal are exposed to the risk of being victims of HIV/AIDS [5]. In Nepal, 13% of all HIV cases are adolescents aged 14 -19 years [6].
As a transitional step from children to adulthood, adolescence is a crucial period for fostering healthy attitudes and behaviors to protect people from diseases [1]. Studies have reported that co-existence of high risk behaviors, particularly unsafe sexual behavior, and influence of mass media on the perception of sex, degradation of traditional value, together with inadequate knowledge and major misconceptions related to HIV/AIDS, contributes young people to increased vulnerability to HIV infection [7] [8] [9]. Thus, fostering healthy behaviors among adolescents may be more essential for the prevention of HIV/AIDS and high-risk behaviors in the general population [1]. In addition, their opinions, at-titudes, and behaviors play a critical role in constructing a compassionate social environment free from discrimination for people living with HIV and AIDS [10].
Researches carried worldwide have shown that school-based education can serve as a powerful preventive tool for HIV/AIDS prevention activities [11] [12].
There is further evidence that HIV/AIDS education does not result in an earlier age of sexual debut, and in fact, it may delay the initiation of sexual activity and encourage use of protective behavior upon sexual initiation [12] [13]. In Nepal, schools are the primary locations where young people acquire knowledge, awareness and skills. School-based HIV/AIDS health education can be more efficiently delivered than other programs that help prevent the spread of AIDS.
The objective of this study was to evaluate the effectiveness of an educational interventional program on knowledge and risk-behavior on HIV/AIDS among higher secondary school students in urban area of Kathmandu city, Nepal.

Study Design
The study consisted of pre test -post test experimental design with an experimental group and a control group using a self-administered questionnaire for both gender. The educational intervention provided to the experimental group was a brief one hour session and the study had a follow-up time of 3 months.

Study Site and Population
The study was conducted in the Kathmandu from 1st September, 2017 to 2nd January, 2018. It is the capital city of Nepal with a population of 1.5 million in the city proper [14]. The Kathmandu city was selected as research site because it is one of the urban and the largest metropolitan area that is likely to be the center of an epidemic. Among 257 higher secondary schools (HSS), 18 HSS, located and dispersed widely within Kathmandu Metropolitan City, were randomly selected and assigned, to either intervention or control group (9 in each). After being informed about the purpose of the study, all of 18 HSS agreed to participate. The experimental and control schools were similar with respect to curricula and organization, and average number of students per class. One section of class 12 of each school was selected with the lottery method. The population was adolescent students studying in class 12 of HSS. No other selection criteria were set for selecting the students. The students of the selected schools were informed of the purpose of the study before the intervention and a consent letter was given to all of them. Finally, all of the students of selected classes agreed to participate in the study.

Pre Test
A self-administered questionnaire was distributed to all the students of both intervention and control group for assessing their baseline knowledge and

Post Test Evaluation
After a period of 3 months, a post test questionnaires were administered among the same students using the same questionnaire used for pre test. A lag period of 3 months was given after the health education, to assess the long term memory of the participants. After collecting back the filled questionnaire, a doubt clearance session was arranged for reinforcing the knowledge.

Ethical Considerations
The permission for conducting the research was obtained from the Institutional Review Board, Tribhuwan University, Institute of Medicine before commencement of the study. The research steps were explained and formal permission was obtained from the administration of selected 18 HSS. Informed written consent was also obtained from each respondent before data collection.

Randomization Procedure
The list of all names of HSS of the Kathmandu Metropolitan City served as the sampling frame. Participants were not aware of group assignment (single blind).
The names of schools were randomly selected from the sampling frame of 257 HSS located within the Kathmandu Metropolitan City. The selected 18 HSS were randomly assigned using a computer generated table of random numbers into intervention and control groups (9 HSS in each group).

Sample Size Calculation
The sample size was calculated using odds ratio between the knowledge of expe-

Data Collection Procedures
Data collection was carried out in the period 1st September, 2017 to 2nd January, 2018. A validated self-administered printed questionnaire was used as the test instrument among the both group. The questionnaire consisted of three main sections that required approximately 25 -30 minutes to complete. A total of 604 students completed the test before the intervention, and 572 students were successfully followed up after the intervention. Questionnaires were handed out and collected by teams of researchers and trained research assistants in the class during school hours. Data were collected at baseline and 3 month's post-intervention.

Instruments
The test instrument was developed on the basis of literature review and HIV/AIDS/STD behavioral surveillance survey (BSS) questionnaire for youth [15]. The HIV-related knowledge questionnaire consisted of 34 items with "true" The tests before and after the intervention were the same questionnaire, however, the students were not required to fill out the part on high-risk behaviors after the intervention test.

Statistical Analysis
Data were entered in, and analyzed using the Statistical Package for Social Sciences software (SPSS) version 16.0. Descriptive analysis was done on the socio-demographic characteristics and measured the rate of HIV/AIDS knowledge awareness. Pre intervention and post intervention knowledge scores of students were analyzed using paired t-test using SPSS and a p-value of less than 0.05 was considered as statistically significant.

Results
This study was done among 604 students. The mean age of respondent of inter-Open Journal of Nursing .5%) lived with their parents. Furthermore, 40.5% and 36.7% mothers of respondents had studied eight class or less in intervention and control group respectively, 37.4% and 39.2% fathers of respondents from intervention and control group had higher secondary education (Table 1).
In the pretest and posttest knowledge results of both control and the intervention group, majority of the control group respondents knew the cause, transmission and non-transmission routes of HIV/AIDS. It shows that there is nominal increase in between the pretest and posttest knowledge of the control group. Regarding the basic knowledge of AIDS in pre-test of the intervention group, majority (87.2%) replied correctly on cause, 96.6% said sexual intercourse as a main transmission route, 80.4% replied hugging as a non transmission route. Regarding intervention group's response on posttest, it shows that most of the respondents of intervention group gave the correct response on the cause, transmission and non-transmission routes of HIV/AIDS during post test. It shows that there is increase in the knowledge after the post test of the intervention group ranging from 3.4% (main mode of transmission) to 44.5% (full form of AIDS) ( Table 2). Majority of the control group respondents were known about the risk group of HIV/AIDS. Whereas regarding other variables, 73.1% said weight loss as major sign, more than half answered correctly on preventive measures and nearly half were known about the treatment of HIV/AIDS. There is minimal change in post test knowledge among control group.
Regarding the knowledge of risk group in pre-test of the intervention group, majority (85.0%) identified multiple sex partners as main risk group. 68.5% said being faithful is the effective measure to prevent HIV/AIDS, and more than one third replied correctly about the treatment of HIV/AIDS. Regarding intervention group's response on posttest, most of the respondents of intervention group gave the correct response on risk groups, sign and symptoms, prevention and treatment of HIV/AIDS during post test. It shows that there is increase in the knowledge after the post test of the intervention group ranging from 15.0% (high risk for multiple sex partners) to 50.8% (prolonged diarrhea as sign) ( Table 3).
The pre-test knowledge score of intervention and control groups shows that the baseline knowledge is significantly higher (0.03) in the control group than in the intervention group (Table 4). The post-test knowledge score of intervention and control groups. It shows that posttest knowledge score is significantly higher (p < 0.001) in the intervention group than the control group as tested by Independent sample "t" test ( Table 5). The mean and SD of control group at pre-test   was 28.51 ± 3.79, which is lower than the mean and SD 29.63 ± 3.97of post-test. P-value shows that there is significant difference between the pre-test and post-test level of knowledge ( Table 6). The mean and SD of the intervention group at pre-test was 27.59 ± 4.06, which is lower than the mean and SD 38.77 ± 3.82 of post-test. It shows that there is significant difference between the pre-test and post-test level of knowledge in the intervention group ( Table 7). The findings of sexual risk behavior show that 6.7% of controls and 16.8% of intervention group students reported having sexual relations. Among sexually active students, 12 (54.5%) of controls and 47 (74.7%) were having sex for two or more times during the past 12 months. 77.2% and 58.8% of them had had sex with two or more people in the past 12 months in control and intervention group respectively. 72.8% of controls and 69.8% of intervention group had always used condom. Only 4.5% of controls and 15.8% of intervention groups had taken alcohol before having sex. Majority (68.1% controls; 79.3%-intervention) had sexual relationship with their girlfriend. Extremely few (0.4% in control; 3.7% in int.) had taken drugs in past 12 months. Likewise, 0.4% and 25.0% of them had shared needle and 1.1% and 3.4% had been tested for HIV in the control and intervention group respectively (Table 8).

Discussion
In baseline, 85.9% from control group and 87.2% from experimental group could answer that AIDS is caused by a virus, but greater percentage (94.8%) of students were aware of this information before the health education intervention in a study done by Sugathan and Swaysi [16].
In pre-test, 56.2% and 62% of students from control and intervention group could state that mosquito bite cannot transmit HIV/AIDS, which increased to 58.8% and 89.7% in both groups respectively. Similar types of finding was reported by Cheng et al., where insect bites' no risk of transmitting HIV was significantly higher in the intervention group (85.5%) than in the control group (27.6%) at post-test [10].
As for transmission of HIV/AIDS, nearly equal (68.9% and 69.5%) were aware of possibility of transmission to baby by lactating mother in both groups in pretest but, the percentage of correct response increased in intervention group    (95.5%) after education. Similar finding was reported by a study done in rural north Kerala of India [17]. In present study, more than 90% on both groups could answer that sexual intercourse with HIV infected can transmit the HIV/AIDS at baseline. In other areas of transmission and non-transmission, around 70% -80% of respondents from both groups answered correctly in pre-test. The increment of correct response in post-test was ranging from 1.2% to 6.5% in control group, and 13.6% to 44.5% intervention group. Students of both groups had an intermediate level of knowledge regarding risk groups for HIV/AIDS. However, the intervention group students showed an increased rate of knowledge in post intervention evaluation. In this study, similar results were observed on signs and symptoms of HIV/AIDS also where students gained increased knowledge after health education. There were 51.6% students in control and 44.2% students in experimental group who could correctly answered that HIV/AIDS is a preventable disease which increased to 56.5% in control group and 82.3% in intervention group after health education. Sugathan and Swaysi had noted that 92.4% of students were aware of its preventable nature and reached to 93.6% in post-test [15]. Similarly, the same study has revealed that 94.8% of students were having knowledge that there is no complete cure for AIDS before the intervention [15]. Contrary to this, present study showed that only 42.4% of control group and 39.9% intervention group students were aware of this fact prior to the educational intervention.
Overall pretest knowledge of both intervention and control groups was com- .77 mean ± SD respectively. But statistical analysis showed significant higher knowledge (P = 0.03) among control group students than their counterparts in intervention group. After the educational intervention, the mean knowledge score of control group increased by only 0.47, whereas the same score increased by 11.57 and reached 39.15 ± 3.7 in post-test for intervention group. The difference in post-test score was statistically highly significant (P < 0.001). The difference in pre and post-test knowledge scores of both intervention and control groups were statistically significant with P-value of 0.000 and 0.003 respectively tested by paired t test. Similar finding was noted in a study done in Trinidad and Tobago among school students where both groups had statistically significant higher posttest scores on the variables of knowledge, susceptibility, and self-efficacy as it pertains to youth being able to speak about condoms and condom use [18]. Contrary to the present study, this study had covered wide dimensions of HIV/AIDS knowledge, practice, attitude and self-efficacy. A systemic review of 17 similar scientific papers regarding effectiveness of school based education on HIV knowledge and practice concluded that out of the 17 studies, 10 assessed the intervention's effects on knowledge. All 10 studies indicated that certain interventions could increase knowledge about one or more subjects which included STIs/HIV and their prevention [19].
Regarding the high risk sexual behavior, 6.7% of controls and 16.8% of intervention group reported having sexual relations. In support with this finding is a study where 11% reported that they had had sex before the age of sixteen [20]. Similar finding was reported in study done in Ethiopia [21]. In present study, nearly same (7.4% and 11.8%) students reported being forced for sex in control and intervention group respectively. Among sexually active students, 54.5% of controls and 74.7% were having sex for two or more times during the past 12 months. Among them, 77.2% and 58.8% of them had had sex with two or more people in the past 12 months in control and intervention group respectively. A study done in Nigeria among high school students revealed comparatively smaller proportion (20.5%) of the respondents who committed sex had sex with two and more sexual partners in their life time, 8.7% committed sex with more than one sexual partner [22]. Among the sexually active students, 72.8% of controls and 69.8% of intervention group had always used condom. Even 4.5% of controls and 15.8% of intervention groups had taken alcohol before having sex. Extremely few (0.4% in control; 3.7% in int.) had taken drugs in past 12 months.

Conclusion
The research finding showed that, there was significant difference between mean score of pre and post-test knowledge on HIV/AIDS, with higher knowledge in post-test of intervention group than their counterparts in control group. By this finding, the research hypothesis ''there is significant difference on awareness level of adolescent students about HIV/AIDS before and after educational intervention among intervention and control group" has been accepted. It concludes that the educational intervention was efficacious in improving awareness of adolescent students on HIV/AIDS. The study has also indicated that remarkable numbers of adolescents are practicing high risk behavior for HIV/AIDS like having early initiation sexual intercourse, multiple sex partners, using alcohol before intercourse etc. and very few sexually active students have tested their HIV/AIDS status.

Recommendation
Based on the finding of this study, it is expedient that HIV/AIDS education to students be provided during their higher secondary level study period. Decision-makers as well as school principal and teachers should realize that school education is an effective solution to prevent the spread of the HIV/AIDS epidemic. HIV/AIDS education should form part of school curriculum. Students should be periodically assessed for high risk sexual behavior. Counseling and referral service should be provided to the students with high risk behavior.

Limitations
Firstly, the population of the study only included Grade Twelve students from each selected HSS and did not include adolescents not attending such schools.
Therefore, the results cannot be used to make a generalization about out-of-school adolescents. The honesty of some responses should also be interpreted with caution, especially those that pertain to questions about sex activities and drug abuse, because the data were self-reported by the students.