School-Based HIV-Prevention Education -- United States, 1994

Many adolescents in the United States engage in behaviors that increase their risk for human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) (1). Because 95% of all youth aged 5-17 years are enrolled in school (2), school health programs can be an efficient method to help prevent these behaviors (3). Previous studies have examined selected characteristics of HIV education in the United States (4-6); however, none provide a comprehensive assessment of HIV education policies and programs nationwide. In 1994, CDC conducted the School Health Policies and Programs Study (SHPPS), which assessed five components of the school health program: health education, physical education, health services, food service, and health policies. To provide a comprehensive assessment of HIV- prevention education programs nationwide in 1994, CDC analyzed data from the health education component of the study. This report summarizes the findings, which indicate that although HIV-prevention education has been widely implemented in U.S. schools, improvement in these programs is needed. *

SHPPS assessed the school health education component at the state, district, school, and classroom levels. Questionnaires were mailed to the state education agency in all 50 states and the District of Columbia and to a nationally representative sample of 502 school districts. In addition, personal interviews were conducted with personnel from a nationally representative sample of 766 public and private middle/junior and senior high schools and with 1643 randomly selected health education teachers in those schools. Personnel from all 51 state education agencies and 406 (81%) of the 502 sampled districts completed the state and district questionnaires, respectively. Personnel from 607 (79%) of the 766 sampled schools completed the school-level interview and 1040 (63%) of the 1643 sampled classroom teachers completed the teacher interview.

Teachers were asked about the primary focus of the courses in which they taught health education. Of the 1027 teachers who responded to this question, nearly half (46.9%) taught courses that focused primarily on health education topics; in this analysis, these teachers are referred to as health education teachers in health education classes. The other teachers (53.1%) taught courses that included some health education content but focused primarily on another subject (e.g., biology); these teachers are referred to as health education teachers in other subjects. Data from school districts, schools, and classroom teachers were weighted to provide national estimates. SUDAAN was used to compute 95% confidence intervals (CIs).

In 1994, HIV-prevention education was required in 78.7% of states and 83.0% (95% CI=plus or minus 5.3%) of school districts; the topic was taught in a required course in 85.6% (95% CI=plus or minus 4.2%) of all middle/junior and senior high schools (Table_1). Similar percentages of middle/junior and senior high schools included the following topics in their curricula: HIV prevention, alcohol- and other drug (AOD)-use prevention, dietary behaviors and nutrition, physical activity and fitness, sexually transmitted disease prevention, and tobacco-use prevention. Topics included in curricula less often than HIV prevention were conflict resolution and violence prevention, injury prevention and safety, pregnancy prevention, and suicide prevention.

In all states that required HIV-prevention education in schools, in-service training for teachers was provided on this subject (Table_2). Of the school districts that required HIV-prevention education, 61.0% (95% CI=plus or minus 8.1%) provided in-service training. For all health education topics except AOD-use prevention, the percentages of states and school districts that provided in-service training for those topics were significantly lower than for HIV-prevention education. Approximately one third (31.0% {95% CI=plus or minus 3.6}) of all teachers reported receiving in-service training on HIV prevention during the 2 years preceding the survey (Table_2). The percentage of teachers who received in-service training on HIV prevention was significantly higher than that for teachers who received training on other health education topics. Health education teachers in health education classes were significantly more likely than health education teachers in other subjects to have received training on HIV prevention during the 2 years preceding the survey (38.6% {95% CI=plus or minus 5.0%} versus 24.1% {95% CI=plus or minus 5.1%}). In addition, health education teachers in health education classes were significantly more likely than health education teachers in other subjects to have received preservice training ** in health education (21.0% {95% CI=plus or minus 3.8%} versus 4.5% {95% CI=plus or minus 2.3%}) or health and physical education (33.9% {95% CI=plus or minus 5.3%} versus 6.1% {95% CI=plus or minus 2.5%}).

Of health education teachers in health education classes, at least 50% reported teaching 16 of 17 specific HIV-prevention topics (Table_3); 37.1% (95% CI=plus or minus 4.7%) taught "correct use of condoms." Health education teachers in other subjects were significantly less likely than health education teachers in health education classes to teach each of the 17 topics; however, at least 54% taught "basic facts about HIV/AIDS," "how HIV is and is not transmitted," "how HIV affects the immune system," "sexual behaviors that transmit HIV," "needle-sharing behaviors that transmit HIV," and "reasons for choosing sexual abstinence."

Reported by: Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Since 1988, CDC has provided fiscal and technical assistance to state and local education agencies and national health and education organizations to assist schools in implementing effective HIV-prevention education for youth. These agencies and organizations develop, implement, and evaluate HIV-prevention policies and programs and train teachers to initiate effective prevention efforts and implement curricula in classrooms. As a result of these and other efforts, school-based HIV education is widely implemented in the United States. From 1987 to 1994, the number of states requiring HIV-prevention education in schools increased from 13 states (4) to 39 states plus the District of Columbia. This high level of policy support is consistent with public support; 95% of U.S. residents in a 1996 survey reported that information about AIDS should be provided in school (7).

The findings in this report indicate that, despite wide implementation of HIV- prevention education in U.S. schools, improvements in HIV-prevention programs are needed. In particular, efforts are needed to increase the percentage of teachers who teach HIV prevention in a health education setting and who receive in-service training on HIV prevention. A national health objective for the year 2000 is "to increase to at least 95% the proportion of schools that provide age-appropriate HIV and other sexually transmitted disease (STD) curricula for students in 4th through 12th grade, preferably as part of comprehensive school health education, based on scientific information that includes the way HIV and other STDs are prevented and transmitted" (objective 18.10/19.12) (8). Based on the findings from SHPPS, to meet this objective, an 11% increase is needed in the percentage of middle/junior and senior high schools that implement HIV- and STD-prevention education programs.

Although all states and most school districts that required HIV-prevention education also offered in-service training on this topic, only approximately one third of teachers had received this training during the 2 years preceding the survey. Current in-service training is especially important for HIV education because new methods are being identified to assist youth in developing the skills needed to prevent HIV infection.

The SHPPS data used in this analysis are subject to at least two limitations. First, the study was not designed to explore the link between school health programs and students' health-related knowledge, beliefs, and behaviors. Second, although the state and district levels of SHPPS measured policies and programs in grades K-12, the school and classroom levels of SHPPS focused only on middle/junior and senior high schools.

CDC's Guidelines for Effective School Health Education to Prevent the Spread of AIDS recommends that qualified health education teachers provide education about AIDS (9). The findings from SHPPS indicate that health education teachers in health education classes are more likely than health education teachers in other subjects to have appropriate preservice and in-service training. Furthermore, HIV-prevention education is more comprehensive when taught within the context of health education than when taught within other subjects. However, teaching HIV prevention in other subjects may be an important adjunct to a planned course of study in health education classes.

References

1. CDC. Youth risk behavior surveillance -- United States, 1993. MMWR 1995;44(no. SS-1).

2. National Center for Education Statistics. Digest of education statistics, 1993. Washington, DC: US Department of Education, Office of Educational Research and Improvement, 1993.

3. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Rep 1994;109:339-60.

4. Schumacher M, Fraser K. The National Association of State Boards of Education HIV/AIDS education survey: profiles of state policy actions. Alexandria, Virginia: National Association of State Boards of Education, 1989.

5. National Association of State Boards of Education and Council of Chief State School Officers. AIDS, HIV, and school health education: state policies and programs, 1990. Washington, DC: National Association of State Boards of Education and Council of Chief State School Officers, 1991.

6. Britton PO, DeMauro D, Gambrell AE. Future directions: HIV/AIDS education in the nation's schools. New York: Sex Information and Education Council of the United States, 1992.

7. Kaiser Family Foundation. The Kaiser survey on Americans and AIDS/HIV. Menlo Park, California: Kaiser Family Foundation, 1996.

8. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- midcourse review and 1995 revisions. Washington, DC: US Department of Health and Human Services, Public Health Service, 1995.

9. CDC. Guidelines for effective school health education to prevent the spread of AIDS. MMWR 1988;37(no. S-2).

* Single copies of this report will be available until September 6, 1997, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023. 

** An undergraduate or graduate degree, 30 graduate credits, or certification.

TABLE 1. Percentage of states and school districts that required teaching of selected
health education topics and percentage of middle/junior and senior high schools that
included each topic in a required course, by topic -- United States, School Health
Policies and Programs Study, 1994 *
=================================================================================================
                                                                    Middle/junior and
                                 States                            senior high schools
                            requiring topic    School districts     that include topic
                                 (n=51)        requiring topic     in a required course
                            ---------------    ----------------    --------------------
Topic                              %            %    (95% CI +)       %     (95% CI)
---------------------------------------------------------------------------------------
Alcohol- and other
  drug-use prevention             75.0         86.0   (+/-5.3%)      90.4   (+/-3.1%)
Conflict resolution
  and violence prevention         38.5         61.0   (+/-8.4%)      58.3   (+/-5.8%)
Dietary behaviors
  and nutrition                   68.9         80.1   (+/-6.6%)      84.3   (+/-4.4%)
HIV prevention                    78.7         83.0   (+/-5.3%)      85.6   (+/-4.2%)
Injury prevention
  and safety                      62.2         74.5   (+/-8.0%)      66.2   (+/-5.6%)
Physical activity
  and fitness                     65.2         81.9   (+/-5.6%)      77.6   (+/-5.2%)
Pregnancy prevention              43.9         72.1   (+/-7.1%)      69.3   (+/-5.5%)
Sexually transmitted
  disease prevention              65.1         80.9   (+/-6.0%)      84.1   (+/-4.4%)
Suicide prevention                37.8         66.7   (+/-8.1%)      58.1   (+/-5.7%)
Tobacco-use prevention            71.7         83.2   (+/-6.2%)      85.6   (+/-4.0%)
---------------------------------------------------------------------------------------
* The unweighted sample size for school districts was 398 and for middle/junior and senior high
  schools was 531. Data were missing for eight school districts and 76 schools.
+ Confidence interval.
=================================================================================================

TABLE 2. Percentage of states and school districts that provided training on required
health education topics and percentage of teachers who received in-service training, *
by topic -- United States, School Health Policies and Programs Study, 1994 +
================================================================================================
                                  States that
                                    provided                                 Teachers who
                                  training on     School districts that   received in-service
                                 required topic     provided training        training on
                                     (n=51)         on required topic       required topic
                                 --------------   ---------------------   -------------------
Topic                                  %             %     (95% CI &)        %     (95% CI)
---------------------------------------------------------------------------------------------
Alcohol- and other
  drug-use prevention                100.0          51.9   (+/- 9.2%)       22.9   (+/-3.3%)
Conflict resolution
  and violence prevention             93.3          41.3   (+/-10.2%)       13.9   (+/-3.1%)
Dietary behaviors
  and nutrition                       90.3          19.7   (+/- 8.6%)        9.7   (+/-2.4%)
HIV prevention                       100.0          61.0   (+/- 8.1%)       31.0   (+/-3.6%)
Injury prevention
  and safety                          42.9          10.4   (+/- 4.7%)        7.8   (+/-2.7%)
Physical activity and fitness         73.3          16.0   (+/- 5.8%)        8.9   (+/-2.1%)
Pregnancy prevention                  72.2          15.2   (+/- 6.1%)        5.7   (+/-1.6%)
Sexually transmitted
  disease prevention                  85.7          32.5   (+/- 8.3%)       15.6   (+/-2.6%)
Suicide prevention                    50.9          22.2   (+/- 7.8%)        9.5   (+/-2.9%)
Tobacco-use prevention                84.8          24.9   (+/- 6.8%)        9.3   (+/-2.2%)
---------------------------------------------------------------------------------------------
* During the 2 years preceding the survey.
+ The unweighted sample size for school districts was 397 and for teachers was 1018. Data were
  missing for five school districts and 22 teachers.
& Confidence interval.
================================================================================================

TABLE 3. Percentage of health education teachers in health education classes * and
health education teachers in other subjects + who teach specific HIV education topics,
by topic -- United States, School Health Policies and Programs Study, 1994 &
==============================================================================================
                                           Health education         Health education
                                              teachers in             teachers in
                                       health education classes      other subjects
                                       ------------------------     -----------------
Topic                                      %     (95% CI @)          %      (95% CI)
-------------------------------------------------------------------------------------
Basic facts about HIV/AIDS                86.6    (+/-3.6%)         72.2    (+/-5.3%)
How HIV is and is not transmitted         83.8    (+/-4.0%)         70.0    (+/-5.6%)
Needle-sharing behaviors
  that transmit HIV                       79.6    (+/-4.4%)         57.3    (+/-5.9%)
How HIV affects
  the immune system                       78.5    (+/-4.6%)         61.5    (+/-5.9%)
Sexual behaviors that transmit HIV        77.7    (+/-4.6%)         58.8    (+/-6.0%)
Reasons for choosing
  sexual abstinence                       77.6    (+/-4.1%)         54.5    (+/-7.4%)
Disease progression of AIDS               71.1    (+/-4.5%)         46.4    (+/-6.7%)
Influence of alcohol
  and other drugs on HIV risk
  behaviors                               69.9    (+/-4.7%)         40.3    (+/-6.8%)
Societal impact of HIV/AIDS               68.5    (+/-4.5%)         48.6    (+/-7.8%)
Perceptions of risk for HIV/AIDS          64.1    (+/-5.4%)         44.0    (+/-5.8%)
Social norms toward risk
  behaviors related to HIV                63.6    (+/-5.1%)         46.1    (+/-6.2%)
Compassion and support
  for persons living with HIV/AIDS        58.7    (+/-5.1%)         42.3    (+/-6.3%)
Statistics on adolescent death
  and disability related to HIV/AIDS      58.4    (+/-4.8%)         30.9    (+/-5.1%)
Condom efficacy/how well
  condoms work                            56.4    (+/-5.0%)         33.3    (+/-5.8%)
Information on HIV testing
  and counseling                          55.9    (+/-5.3%)         27.7    (+/-5.8%)
True prevalence of risk behavior
  related to HIV                          50.8    (+/-5.6%)         28.1    (+/-5.1%)
Correct use of condoms                    37.1    (+/-4.7%)         15.2    (+/-4.4%)
-------------------------------------------------------------------------------------
* Teachers of courses that focus primarily on health education topics.
+ Teachers of courses that include health education content but focus primarily on another
  subject.
& The unweighted sample size for health education teachers in health education classes was
  562 and for health education teachers in other subjects was 462. Data were missing for two
  health education teachers in health education classes and one health education teacher in
  other subjects.
@ Confidence interval.
==============================================================================================

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