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. Author manuscript; available in PMC: 2013 Apr 23.
Published in final edited form as: AIDS Educ Prev. 2012 Feb;24(1):68–77. doi: 10.1521/aeap.2012.24.1.68

IMPACT OF SCHOOL-BASED HIV PREVENTION PROGRAM IN POST-CONFLICT LIBERIA

Katharine A Atwood 1, Stephen B Kennedy 1, Steve Shamblen 1, Jemee Tegli 1, Salome Garber 1, Pearl W Fahnbulleh 1, Prince M Korvah 1, Moses Kolubah 1, Comfort Mulbah-Kamara 1, Shannon Fulton 1
PMCID: PMC3633464  NIHMSID: NIHMS453720  PMID: 22339146

Abstract

This paper presents findings of a feasibility study to adapt and evaluate the impact of an evidence-based HIV prevention intervention on sexual risk behaviors of in-school 6th grade youth in post-conflict Liberia (n = 812). The study used an attention-matched, group randomized controlled trial. Four matched pairs of elementary/middle schools in Monrovia, Liberia, were randomly assigned to either an adapted eight-module HIV prevention or a general health curriculum. Three- and nine-month impacts of the intervention on sexual risk behaviors and on mediating variables are presented. The intervention significantly impacted protective peer norms and positive condom attitudes and increased frequency of condom use at the nine-month follow-up. The intervention did not impact sexual initiation or multiple sex partnerships. Future intervention research should address the salient pressures that are unique to post-conflict settings and include longer follow-up time periods and smaller class sizes to meaningfully impact sexual initiation and multiple sex partnerships.

Liberia held its first democratic elections in 2005 after a two-decade civil war. Due to a destroyed public health infrastructure, HIV surveillance and prevention efforts are in their nascent stage (Barbiero & Barh, 2007; Bropleh & Taylor, 2000; Johnson et al., 2005). In Monrovia, the nation’s capital, the HIV infection rate is 2.8% for women and 2.1% for men (LISGIS, 2008). Surveillance studies of women attending antenatal clinics are higher, with an overall prevalence rate of 5.4% (NSF, 2010). Among unmarried 15 to 19 year olds, 73% of females and 50% of males report ever having had sex, with 12% of females and 15% of males report using a condom at last sexual intercourse (LISGIS, 2008).

Post-conflict settings like Liberia introduce unique challenges to HIV prevention interventions. With destroyed justice, police, and military systems, large international peacekeeping forces are deployed in Liberia to maintain peace and rebuild governmental institutions. Local entertainment industries have developed in their midst, creating what have been referred to as “peacekeeping economies” that provide a relatively affluent pool of potential sex partners in Liberia (Jennings, 2010), potentially increasing risks of HIV infection to conflict-affected populations (Speigel, 2004). Former combatants, who were conscripted as child soldiers during Liberia’s civil war, now find themselves in early adulthood with little formal education and limited skills (Peters & Laws, 2003). They may also serve as potential sources of sexual risk taking. Schools provide potentially protective environments to promote healthy transitions to young adulthood (Sommer, 2011). Yet to our knowledge, no evidence-based HIV prevention efforts targeting in-school youth have been undertaken in Liberia (Atwood, Johnson, Kennedy, & Harris, 2006).

Reviews of school-based HIV-prevention interventions in Africa (Gallant, Maticka-Tyndale, 2004) and the developing world (Kirby, Obasi & Laris, 2006; Speizer, Magnani, & Colvin, 2003) point to the lack of rigorous evaluation, lack of comparison conditions, and their being led by teachers resistant to discussing sexual issues (Gallant & Maticka-Tyndale, 2004; Kirby et al., 2006). In this study, we adapted an evidence-based HIV-prevention intervention, Making Proud Choices! (Jemmott, Jemmott & Fong, 1998), to in-school Liberian youth, utilizing outside health educators. We present 3- and 9-month longitudinal findings of the intervention’s impact on AIDS knowledge, peer norms, attitudes, and on sexual behaviors, including sexual initiation, condom use, and number of sex partnerships. This is the first report of the effects of an evidence-based curriculum on sexual risk-taking behaviors of in-school Liberian youth.

STUDY DESIGN

Using an attention-matched, group randomized controlled trial, four matched pairs of public elementary/middle schools in Monrovia were randomly assigned to an adapted 8 module HIV prevention or a general health curriculum. Students were followed longitudinally and completed 3- and 9-month follow-up surveys to assess program efficacy. Schools were matched on school size, student age, teacher/student ratio, and gender distribution. Each matched pair of schools was selected from within one of Monrovia’s four school zones. Schools are neighborhood-based and 5–7 miles apart. With limited public transportation, the possibility of contamination across schools was less likely.

INTERVENTION AND COMPARISON CURRICULA

The HIV-prevention curriculum adapted for Liberian youth, called Making Proud Choices! (MPC) (Jemmott et al., 1998), is an eight-module program based on Social Cognitive Theory (Bandura, 1986; 1997) and the Theory of Reasoned Action (Ajzen & Fishbein, 1980). The program is designed to promote positive condom attitudes and increase skills and self-efficacy to refuse sex, negotiate condom use, and use condoms effectively (Jemmott et al., 1998). A U.S.-based randomized trial found increases in condom use and a delay in sexual initiation among inner-city adolescents exposed to MPC (Jemmott et al., 1998).

The General Health Comparison Curriculum, developed by the Liberian research team and led by health educators, is a classroom-based science curriculum. Delivered to sixth graders in our comparison schools, it includes preventive health information on malaria, tuberculosis, worm infestations, and general HIV/STD knowledge but lacks an underlying behavioral theory and HIV prevention-related skills (Massaquoi & Kennedy, 2003).

ADAPTATION PROCESS OF HIV PREVENTION-INTERVENTION

Six focus groups with public elementary/middle school students from one school and one focus group with key community stakeholders were conducted to guide curriculum adaptation (Atwood et al., 2011). To more accurately reflect the realities young people face in this post-conflict setting, we modified role plays to include sexual refusal and condom negotiation skills within age and power-discordant relationships. The curriculum was pilot-tested with a classroom of 6th grade students (n = 50) in a school not included in the study. Baseline surveys were pilot-tested with 10 in-school youth and revised accordingly.

RECRUITMENT

Each school, randomized to the intervention or comparison condition, had four sixth grade classes (approximately 50 students per class). We randomly selected two of the four classes in each intervention or comparison school (approximately n = 100 per school) to participate in the study (total n = 812). The research staff informed students about the study during health class and distributed active parental consent and participant assent forms (approved by the respective U.S. and University of Liberia Institutional Review Boards). Consent rate for participation was 83% across condition. Two health educators (one male, one female) delivered the curriculum over eight weeks (one module/week) during health class. Co-facilitators completed Implementation Quality Checklists to assess fidelity and attendance.

SURVEY ADMINISTRATION

During the randomized trial, participants completed the baseline, immediate post-test, and 3- and 9-month follow-up surveys. Students received a cash incentive (US $2) after each survey (total incentives = US $8). Follow-up rates for the 3- and 9-month surveys were 88% respectively.

MEASURES

This paper presents 3- and 9-month impacts of the adapted Making Proud Choices! curriculum on sexual risk behaviors and mediating variables. The sexual risk behaviors are: (1) ever engaging in sexual intercourse (“yes” vs. “no”); (2) frequency of condom use in the last 3 months (Likert-type scale ranging from “never” to “every single time”); and (3) number of sexual partners in the last 3 months (categorical responses ranging from 1 to 10 or more). We also examined the impact of the intervention on variables thought to mediate the relationship between the intervention and our outcomes. The mediating variables and their respective internal reliabilities among our adolescent sample are presented below.

  1. AIDS knowledge. AIDS knowledge was measured using an 11-item AIDS knowledge scale, with higher scores representing greater AIDS Knowledge (Cronbach α = .60) (Jemmott et al., 1998).

  2. Self-efficacy. Separate self-efficacy scales were used to assess three domains: sexual refusal self-efficacy assessing the respondent’s confidence in refusing sexual intercourse under a variety of circumstances (Cronbach α = 0.79) (6-item scale modified from Donohew et al., 2000); condom use self-efficacy assessing confidence in correctly and consistently using condoms (Cronbach α = 0.60) (Brien, Thombs, Mahoney, & Wallnau, 1994); and condom negotiation self-efficacy measuring respondent confidence to discuss condom use with potential sex partners (Cronbach α = 0.77) (5 item scale, Zimmerman et al., 2003). Response items ranged from “1” = “I am sure I can’t do this” to “5” = “I am sure I can do this,” with higher scores representing greater self-efficacy for each behavior.

  3. Peer norms. Peer norms about sexual behavior were assessed using a 3-item peer norms scale (Cronbach α = 0.64), adapted from Floyd’s 6-item scale (2009). Participants responded to such statements as, “Most of my friends are having sex,” with response categories ranging from “1” = “Agree a lot” to “5” = “Disagree a lot,” with higher scores representing less permissive peer norms.

  4. Condom attitudes. Positive attitudes about condoms were assessed using a 5-item outcome expectancy scale (Cronbach α = 0.86) (adapted from Jemmott et al., 1998). Participants responded to a series of statements such as, “Using condoms during sex would make me feel safer,”with response categories ranging from “1” = “Agree a lot” to “5” = “Disagree a lot.” Scores were reverse coded. Higher scores represented more positive condom attitudes.

  5. Perceived HIV risk. Perceived risk for HIV was assessed using a 6-item scale inquiring about the respondent’s vulnerability to HIV infection (Cronbach α = 0.82) (modified from Witte, Girma & Girgre, 2002). Respondents indicated how strongly they agreed or disagreed with such statements as, “People my age are too young to get HIV.” Response categories ranged from “1” = “Agree a lot” to 5 = “Disagree a lot,” with higher scores representing greater perceived HIV risk.

  6. Sexual attitudes. Sexual attitudes were assessed using a sexual attitude scale assessing the respondent’s attitudes toward sexual permissiveness (Cronbach α = 0.82) (modified from Basen-Engquist et al., 1999). Sample items included “I believe people my age should get as much sexual experience as they can.” Response categories ranged from “1”= “Agree a lot” to “5” = “Disagree a lot,” with higher scores representing protective sexual attitudes.

METHOD

SELECTIVITY BIASES DUE TO ASSIGNMENT AND ATTRITION

We examined whether assignment to condition and study attrition could serve as alternative explanations for our findings. Two logistic regression analyses were performed. The first analysis examined selectivity as a function of assignment by regressing intervention group assignment on the baseline background characteristics of age, gender, having a boyfriend/girlfriend, lifetime sexual activity, and past 3-month sexual activity. This model was only slightly better than the null model in predicting intervention status, χ2(5) = 11.45, p = .04, r2Nagelkerke = .03. There were no significant predictors of assignment to condition (p < .05); however, there were several predictors that approached statistical significance, including age and whether the participant had a boyfriend or girlfriend.

Examining attrition from the study, 80% of the participants completed all three waves of the study, with 88% of baseline participants completing the 3-month survey and 88% of baseline participants completing the 9-month survey. We performed a logistic regression analysis examining whether background characteristics, study condition, or an interaction between the two predicted attrition at any wave. These analyses addressed whether there was differential attrition or an interaction between background characteristics and condition in predicting attrition. The model did not significantly predict attrition, χ2(11) = 14.92, p = .19, r2Nagelkerke = .02; however, there was an interaction effect, suggesting that a slightly older age was related to attrition in the comparison group, while a slightly younger age was related to attrition in the intervention group (OR = .76) (Table 1). As there was evidence suggesting a small level of selectivity biases, we included age, gender, and having a boyfriend/girlfriend as covariates in our models. We did not include sexual behavior as a covariate, as this was confounded with the outcomes of interest.

TABLE 1.

Condition Equivalence

Comparison
(n = 412)		 Intervention
(n = 400)		 OR Left (n = 154) Stayed
(n = 658)		 OR
(intervention)		 OR
(intervention
X character-
istic)
Age 16.25 16.48 1.10+ 16.51 16.33 1.11 .76*
% Male 55.28 56.71 .98 60.39 54.94 1.00 1.30
% Has partner 43.69 39.00 1.42+ 42.21 41.19 .72 1.10
% Life-time sex 34.41 37.24 .73+ 42.95 34.12 1.32 1.24
% Past 3 month sex 18.95 15.36 1.41 21.48 16.19 1.93+ .48
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Note.

*

p < .05

+

p < .10.

Ordinary least squares regression was used to examine the impact of the intervention on our mediating variables using the entire sample and to assess past-3-month sexual behaviors including number of sex partners and frequency of condom use, restricting the sample to those sexually active. Logistic regression analysis was used to assess differences in ever having sexual intercourse using the entire sample. All analyses regressed the 3- and 9-month outcome on the baseline standing on the outcome, intervention status, and the three background characteristics that could serve as potential confounds (age, gender, and relationship status). Standardized regression coefficients/odds ratios and statistical significance are reported in Tables 3 and 4.

TABLE 3.

Standardized Regression Coefficients for 3- and 9-Month Intervention Effects on Mediating Variables, Controlling for Baseline Standinga

3 month 9 month
β β
HIV knowledge .02 −.05
Sex refusal self-efficacy .05 .03
Condom use self-efficacy .08* .07+
Condom negative self-efficacy .06+ .05
Perceived peer norms .09* .09*
Condom attitudes .12* .08*
HIV risk perception .01 −.07+
Sexual attitudes −.01 −.10*
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Note.

+

p < .10

*

p < .05

intervention coded as 0 = comparison and 1 = intervention

a

Age, having a boyfriend/girlfriend, and gender were controlled for in all analyses.

TABLE 4.

Three- and Nine-Month Intervention Effects When Controlling for Baseline Standinga

3 month
AOR		 9 month
AOR
Ever had sex 1.03 .91
β β
3-month condom useb .16 .34*
Number of sex partnersb .32* .13
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Note.

+

p < .10

*

p < .05

intervention coded as 0 = comparison & 1 = intervention.

a

Age, having a boyfriend/girlfriend, and gender were controlled for in all analyses.

b

Limited to the sexually active population prior to 3- or 9-month follow-up survey (n = 182 and n = 239, respectively).

Assuming our smallest sample sizes available for analysis at follow-up (i.e., 740 participants in the entire sample and 249 in the sexually active sample), 80% power, and a two-tailed alpha of .05, we would be able to detect small effects in the entire sample (d = .21 or larger) and small-to-medium effects in the sexually active sample (d = .36 or larger).

RESULTS

Among those who completed the baseline survey (n = 812), 44% were female and the mean age of the sample was 16.3 (SD = 1.7) (Table 2). Sixty-nine percent of the sample lived with their mother, father, or both, 27% lived with a brother, sister, or other relative, 3% lived with non-relatives, and 1% lived alone. Thirty-six percent of the sample had ever had sex. Among those sexually active in the last 3 months (20%), 26% never used a condom during that time. Nine percent of the sample have ever been or gotten someone pregnant (Table 2).

TABLE 2.

Baseline Characteristics of the Sample Population (n = 812)

Mean (SD)
Age 16.3 (1.7)
n (%)
Female 357 (44)
Live with mother 276 (34)
Live with father 146 (18)
Live with mother and father 138 (17)
Live with other relatives 113 (14)
Live with sister/brother only 105 (13)
Live with non-relatives 24 (3)
Live alone 8 (1)
Ever had sex 292 (36)
Sexual intercourse (last 3 months) 162 (20)
Never used condoms (last 3 months)a 36 (26)
Ever been/gotten someone pregnant 73 (9)
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Note.

a

Among sexually active in the last 3 months at baseline (n = 137, missing n = 25)

We found intervention effects for the adapted Making Proud Choices! intervention at the 3-month follow-up period that persisted at the 9-month follow-up period for condom use self-efficacy (β3mth = .08, p < .05; β9mth = .07, p < .10), perceived peer norms (β3mth = .09, p < .05; β9mth = .09, p < .05), and positive condom attitudes (β3mth = .12, p < .05; β9mth = .08, p < .05), when controlling for each of these mediating variables at baseline in a series of ordinary least squares regression models (Table 3). There was an effect in the wrong direction for protective sexual attitudes, suggesting that protective sexual attitudes were lower in the intervention group at the 9-month follow-up, when controlling for baseline (B3mth = −.10, p < .05); however, the effect was absent at the 3-month follow-up period (B9mtth = −.01, ns).

As can be seen in Table 4, when limiting the analysis to those who were sexually active 3 months prior to the baseline survey and were sexually active prior to the 3- or 9-month follow-up survey, we found a significant effect on frequency of consistent condom use at the 9-month follow-up period, suggesting that the intervention group used condoms more consistently in the last 3 months when compared to the comparison group (B9mth = .34, p < .05), controlling for condom use at baseline. We did not find a similar impact at the 3-month follow-up period (B3mth = .16, ns), suggesting a delayed effect for this behavior.

There was no evidence to suggest that the intervention had an impact on the number of sex partners at the 9-month follow-up survey (p > .15). However, we did find an initial increase in the number of sex partners at the 3-month follow-up survey (B3mth = .32, p < .05); but this increase did not persist at the 9-month follow-up survey (B9mth = .13, ns). We also did not see a significant impact on sexual initiation rates for the whole sample at 3- and 9-month follow-up (Table 4) nor did we see differences in the impact of our intervention on our outcomes or mediating variables for specific subgroups (males vs. females, sexually experienced vs. sexually inexperienced, data not shown).

DOSAGE

Analyses identical to the primary analyses of the paper were performed to examine the effects of student attendance on our mediating and sexual behavior outcomes. Data were subset to those who participated in the intervention condition, and a continuous count of prevention sessions attended was used in place of the condition dummy variable in all models. The dosage analyses suggest that the number of prevention sessions attended was positively related to only one mediator, HIV knowledge, at the 3-month follow-up (B3mth = .14, p < .05). Greater attendance was inversely related to ever having sex (OR = .83, p < .05) at the 3-month follow-up but did not persist at the 9-month follow-up. For each additional session attended, participants were 1.20 times more likely not to have had sex in their lifetime at the 3-month follow-up. There were no effects on number of sex partnerships or frequency of condom use when restricting analyses to the sexually active population (data not shown).

DISCUSSION

The adapted Making Proud Choices! program was well accepted, with high follow-up rates (88%), which is noteworthy in this post-conflict environment. Survey measures had strong reliability (Cronbach α range = .60–85), and the intervention significantly impacted protective peer norms and positive condom attitudes which persisted at the 9-month follow-up. Condom use self-efficacy increased significantly at the 3-month follow-up and remained marginally significant at the 9-month follow-up period. Surprisingly, permissive sexual attitudes increased significantly at the 9-month follow-up period. The intervention did not have an effect on HIV/AIDS knowledge or sexual refusal self-efficacy. Bivariate analysis using paired sample t tests found that HIV/AIDs knowledge increased in both the intervention and comparison arms at 3- and 9-month follow-up (data not shown). Two modules in the General Health curriculum focused on facts about HIV/AIDS transmission that may account for increases in HIV/AIDs knowledge in the comparison condition.

Our intervention had a significant impact on increasing condom use at the 9-month follow-up period among those sexually active, but not at the 3-month survey, suggesting a delayed effect in behavior change, similar to findings in other HIV prevention studies in sub-Saharan Africa (SSA) (Paul-Ebhohimhen, Poobalan, & Teijlingen, 2008). The increase in condom use aligns with Jemmott’s original findings with minority adolescents in the United States (Jemmott et al., 1998). However, in reviews of interventions targeting adolescents in SSA, condom use remains an elusive outcome (Foss, Hossain, Vickerman, & Watts, 2007; Paul-Ebhohimhen et al., 2008).

Our intervention did not reduce sexual initiation rates or number of sex partnerships. Impacts on these other sexual behaviors have mixed results in SSA. Jemmott and colleagues (2010) in their intervention targeting 6th graders in South Africa found significant impacts on unprotected sex and multiple sex partnerships, but not on sexual initiation rates (Jemmott et al., 2010). A life skills education program in South Africa (n = 2222) found increases in condom use but not on sexual initiation or number of sex partners (Magnani, MacIntyre, Karim, Brown, & Hutchinson, 2005).

We also found that those who attended more sessions were less likely to initiate sex, but this did not persist at the 9-month follow-up. While intervention studies have looked at fidelity of implementation, few have noted effects by adolescent attendance (James et al., 2006).

LIMITATIONS

Because of the feasibility nature of this study, we did not assess the long-term effects of the adapted Making Proud Choices! (MPC) program and limited the study to eight schools, reducing generalizability. The original MPC study in the United States was implemented in groups of 8–12 participants, but we implemented the intervention in classrooms of 50 students. Schools were randomized to condition, students were not, implying that the samples in the two conditions may have been somewhat different at baseline. We examined baseline differences in socio-demographic characteristics hypothesized to have an impact on our mediating variables and found that those in the intervention condition were slightly older and more likely to have a boyfriend/girlfriend, potentially underestimating intervention effects. Finally, similar to other behavioral interventions, our findings relied on self-report, posing the potential for survey response bias.

Reviews of behavioral interventions suggest that they should be theoretically based, use active learning methods, address social pressures, and include sessions to practice acquired skills (Kirby, 2000; Kirby, Obasi, & Laris, 2006; Schaalma, Abraham, Gillmore & Kok, 2004). All of these elements were included in the adapted intervention. In addition, the evaluation design had several strengths, matched pairs of schools were randomized to condition, and an attention-matched comparison intervention was used. None of the schools dropped out of the study, enrollment and survey completion were reasonably high, and fidelity and attendance were assessed, all of which strengthen the internal validity of our findings.

CONCLUSIONS

Long-term civil conflicts are likely to impact HIV risk and transmission patterns due to destroyed public health infrastructures, large population displacements, deployment of international peacekeeping forces, and emerging commercial establishments. With limited resources to address nascent HIV/AIDS epidemics in post-conflict environments, prevention interventions should include sexual scenarios that are rooted in the realities young people face. Although our adapted intervention significantly increased condom attitudes, peer norms, and condom use among in-school youth, it did not reduce number of sex partners, delay sexual initiation, or increase sexual refusal skills. Future intervention research should continue to identify and address the salient pressures that are unique to post-conflict settings and include longer follow-up time periods and smaller class sizes to meaningfully impact these behaviors.

Acknowledgments

The authors gratefully acknowledge the support of the UL-PIRE Africa Center research staff as well as the support of the Ministry of Education (MoE) in Monrovia, Liberia.

Funding for this research was supported by the National Institute of Mental Health (NIMH), Grant #R21 MH 82666-01, of the National Institutes of Health (NIH) in Bethesda, MD.

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