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. Author manuscript; available in PMC: 2020 Sep 23.
Published in final edited form as: Am J Sex Educ. 2017 Apr 4;12(3):215–236.

Sexual Health Transformation Among College Student Educators in an Arts-Based HIV Prevention Intervention: A Qualitative Cross-Site Analysis

Shannon L Dunlap a, Arianna Taboada b, Yesenia Merino c, Suzanne Heitfeld d, Robert J Gordon e, David Gere e, Alexandra F Lightfoot f
PMCID: PMC7510141  NIHMSID: NIHMS1594025  PMID: 32973413

Abstract

We examined the sexual health change process experienced by 26 college student sexual health educators from three geographic regions of the United States who participated in a multisite arts-based sexual health prevention program. We conducted eight focus groups and used a phenomenological approach to analyze data. We drew from social cognitive theory (SCT) to examine how sexual health knowledge, attitudes, self-efficacy, and communication shifted across the duration of participation. Findings suggest that the college student sexual health educators (a) developed enhanced sexual health awareness and critical consciousness, (b) questioned their own sexual health education and challenged previous beliefs, and (c) demonstrated self-efficacy related to intended behavior change and their perceived role as social justice advocates. We present both similarities and differences regarding the sexual health change process among the college student sexual health educators across the three sites.

Keywords: HIV prevention, sexual health awareness, sexual health communication, self-efficacy, young adult

Introduction

According to the U.S. Department of Education for Educational Statistics (2014), 41% of youth ages 18–24 years old in the United States were enrolled in a two-year or four-year higher education institution in 2012, making colleges and universities an ideal location for HIV prevention strategies that target emerging adults. Previous research demonstrates that overall low HIV and sexually transmitted infections (STIs) risk perception among college students often diminishes the perception of risks associated with unprotected sexual intercourse, sexual encounters while intoxicated, and sex with multiple partners (Adefuye, Abiona, Balogun, and Lukobo-Durell, 2009). At the same time, decreased risk perception influences low motivation for HIV and STI testing (Moore, 2013). Increased exposure to high risk situations combined with lower risk perception can lead to negative health outcomes, despite college students’ demonstration of technical knowledge regarding HIV and STI transmission and prevention (Moore, 2013; Fair & Vanyur, 2011; Opt & Loffredo, 2004; Buhi, Marhefka, & Hoban, 2010). To effectively address the unique needs of this population, sexual health interventions targeting young adults must not only provide medically accurate sexual health information, but also challenge normative beliefs and address contextually specific risk factors (i.e., social setting, substance use) experienced by college students.

Despite targeted prevention efforts to mitigate the incidence of HIV among young adults, this population continues to be disproportionately affected by HIV compared to the general population. In 2013, youth and young adults between the ages of 13 and 24 represented 21% of new HIV infections in the United States and within this population, 20 and 24 year olds accounted for 81% of HIV diagnoses (Centers for Disease Control and Prevention [CDC], 2015). Sexual health education programs help shape sexual health knowledge, communication skills, and attitudes of adolescents as they enter adulthood (Kirby, Laris, & Rolleri, 2007). However, prevention efforts must consider a myriad of contextual, cultural, and social factors that shape sexual health risk perceptions and behaviors. Peer norms, for example, are a key characteristic influencing the sexual health beliefs and risk behaviors of adolescents and emerging adults (Hittner & Kennington, 2008; Whitaker & Miller, 2000). Additionally, young adults continually explore and shape their sexual health attitudes, beliefs, and behaviors amidst the intersection of cultural, social, environmental, and institutional influences. Sexual health programs can be tailored to cultural and contextual factors to bridge the gap between evolving beliefs and medically accurate sexual health education by providing opportunities for skill building and dialogue about social norms.

Given the influence of peers on the development of emerging adults’ sexual health attitudes, peer and near-peer models are popular methods of providing HIV prevention messages to this population. Near-peers are typically close in age to their target audience, act as role models, and are often perceived to be both relatable and having authority over a subject matter (Milburn, 1995). However, extant literature rarely assesses the impact on the individuals delivering the interventions (Glik, Nowak, Valente, Sapsis, & Martin, 2002; Medley, Kennedy, O’Reilly, & Sweat, 2009). Additionally, theatre-based interventions in particular have the potential to address public health problems because of the ability to impact both audiences and performers (Joronen, Rankin, & Astedt-Kurki, 2008; Daykin et al. 2008). However, the potential of theatre to address HIV prevention has also been underutilized. Combining a near-peer and behavioral health model with performance and theatre-based techniques represents an underutilized strategy to providing medically accurate and socially relevant sexual health education (Taboada et al., 2016).

Intervention description

AMP! (Arts-based Multiple-intervention Peer-education) is an HIV prevention and sexual health education program launched by an interdisciplinary arts-based research center housed at a public university in southern California. The intervention was first delivered in a large racially and ethnically diverse urban school district in 2010. AMP! uses theatre-based strategies from Augusto Boal and Pablo Freire. Pablo Freire proposed a problem-posing approach to education whereby learners problematize their own views on a subject matter (Freire, 1970). Additionally, theatre is used as a medium for community engagement and empowerment (Boal, 2006; Cohen-Cruz, 2010). AMP! includes a three-part intervention as described below in Table 1.

Table 1.

Intervention description.

Intervention component Component description
Sex-Ed Squad performance 30-minute show for ninth-grade high school students developed and delivered by undergraduate students weaving together humor (subjectively defined and developed by Sex-Ed Squad members through their method of storytelling), personal narrative, and medically accurate information to promote HIV prevention knowledge and strategies Post-performance interactive question and answer session where high school students could ask undergraduate performers about the scenarios
Condom negotiation workshop An interactive forum theatre workshop facilitated by undergraduate university students to teach high school students about how to properly use a condom, negotiate using condoms with a potential partner, or discuss condom use with a parent
HIV positive speakers HIV-positive advocates visit school classrooms to share personal stories of what it is like to live with HIV, how/when they learned about their diagnoses, behaviors that put them at risk, issues of disclosure, and medication routines
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Expansion of intervention to two sites in the southern U.S.

The success of the AMP! program in the large urban southern California school district attracted the attention of representatives from the Southeastern United States at a meeting convened by the Centers for Disease Control and Prevention (CDC). As a result of that interest, the center that developed AMP! reached out to two universities in the southeast to build partnerships and test the feasibility of expanding the AMP! model. Building on two years of pilot testing and refining the intervention in the California context, the AMP! course was piloted at two universities in the southeast from 2012–2013. While each of these locales has unique sociocultural factors that impacted implementation of AMP! (e.g., the need to change the name of the Sex Squad to Sex-Ed Squad in the southeast, varying levels of receptivity by public school systems, etc.), all three regions have been affected by the political and ideological shifts in the sexual health education curriculum over the past 20 years.

The legacy of abstinence-only models of sexual health education has influenced the content and delivery of sex education for many middle and high school students across the United States. According to Santelli (2008), the United States has spent over one billion dollars since 1996 on abstinence-based sexual health education programming. Abstinence can be one effective strategy to prevent HIV and STIs for some youth (Santelli et al., 2006). However, evidence suggests that abstinence as the sole strategy to prevent HIV and STIs is ineffective, especially when compared to comprehensive sexual health interventions that include sexual health communication strategies and scientifically accurate information regarding the benefits of contraception (Jemmott, Jemmott, & Fong, 2010; Lindberg & Maddow-Zimet, 2012; Markham et al., 2014, Santelli et al., 2006). For example, a nationally representative sample of youth 16–24 years of age found that compared to those who received abstinence-only lessons or no sex education at all, females who had comprehensive sexual health education (which included abstinence) in grade school were more likely to use a condom at time of first sex and less likely to have age-discrepant partners or have unwanted sex after high school (Lindberg & Maddow-Zimet, 2012). AMP!’s approach to sexual health, grounded in healthand arts-based theories and using near-peers to disseminate the intervention, provides an opportunity to examine the effectiveness of an innovative comprehensive sex education intervention that engaged both young audiences and near-peer educators to learn within a more relatable context than a traditional, and often abstinence-oriented, school-based sexual health education (Taggart et al., 2016; Lightfoot, Taboada, Taggart, Tran, & Burtaine, 2015).

Evaluating AMP!’s impact

Previously, AMP! used a pre-test, post-test quasi-experimental evaluation design to evaluate changes in high school participants’ knowledge and attitudes about HIV and AIDS (Lightfoot et al., 2015). Quantitative and qualitative data collection, which included surveys administered preand post-intervention and focus groups conducted with a subset of participants after each AMP! component (Lightfoot et al., 2015). Individual behaviors related to sexuality, sexual practice, sexual and reproductive health, and risk behaviors associated with acquiring HIV such as substance use/abuse were previously assessed among high school students. The measures included items from the Center for Disease Control and Prevention’s Youth Risk Behavior Survey (Brener et al. 2004), the World Health Organization’s knowledge, attitudes and practices survey instrument for adolescents (World Health Organization, 1989), and the Towards a Healthy Tomorrow survey (Stanton et al., 1998). All of these measures are reliable and valid for adolescents. However, anecdotal evidence suggested that the undergraduate students who delivered the AMP! intervention also benefited from the intervention experience. While we did not initially set out to understand the experiences of the undergraduate students who delivered the AMP! intervention, this newer and recent line of inquiry became increasingly relevant. This study focused on systematically and qualitatively analyzing the intervention delivery experience and subsequent impact for the undergraduate student performers.

The current study

Implementing the AMP! model at three universities from 2012–2013 presented a unique opportunity to qualitatively analyze processes associated with the peer educator role. This paper describes a cross-site study initiated to examine the similarities and differences in the AMP! Sex-Ed Squad members’ experiences developing and delivering the AMP! intervention to high school students across three distinct geographic regions of the United States. Our research team included Masters and PhD level researchers, as well as graduate students from each of the three AMP! sites. We analyzed qualitative focus group data across all three sites to understand how increased medically-accurate knowledge and problem-based learning approaches in a creative setting lead to personal and sexual health transformation among Sex-Ed Squad members. Specific to sexual health, we sought to understand the experience of the undergraduate student performers, and ascertain if and how their sexual health awareness, self-efficacy, and communication changed during their tenure as Sex-Ed Squad members. As such, the two main questions posed by this study are: (a) What is the impact of a theatre-centered HIV prevention intervention on the college-aged near-peer performers’ sexual health knowledge, attitudes, self-efficacy, and communication regarding sexual health and health behaviors? (b) What can the use of behavioral health strategies along with theatre-based techniques contribute to sexual health education curriculum? We considered how both theatre techniques and health education strategies affected engagement and transformation. For the purposes of this paper, we focus primarily on health behavior constructs; however, arts-based theory enhanced our understanding of this change process.

Methods

Study design and epistemology

Our primary data analysis utilized a phenomenological qualitative approach, to understand the shared experience of Sex-Ed Squad members from three different universities participating in a theatre-based sexual health education and HIV prevention intervention for high school students across three disparate geographic sites. A vast majority of phenomenological research uses in-depth individual interviews over time (Creswell, 2013). However, phenomenological researchers also use other forms of data collection, such as observations, taped conversation, and focus groups (Creswell, 2013; Kitzinger 1995; Warr, 2005). As part of the AMP! program evaluation, research staff conducted focus groups with Sex-Ed Squad members multiple times throughout the academic year. We used focus groups for two reasons: (a) to reduce scheduling conflicts and time constraints that may arise with individual interviews, and (b) to utilize a format that encourages story sharing among participants around their shared experience (Morgan, 2010). We ran a total of eight focus group discussions: three each at two of the AMP! sites and two at the third AMP! site.

We purposively recruited Sex-Ed Squad members into the study. A total of 26 Sex-Ed Squad members agreed to participate in the focus groups across the three university sites (see Table 1) during the 2012–2013 academic year. The Institutional Review Boards (IRB) at two of the universities approved study protocol, instruments, and consent forms for focus group administration and analysis. At the third university, the study was considered a program evaluation and received a waiver, but the same protocol, consent process, and data protection process was followed at all three sites.

Sampling and recruitment

All students enrolled in the credit-bearing course at each site were eligible to participate. We distributed consent forms to the undergraduate students in the class to review prior to the first scheduled focus group if they elected to participate (see Table 2 for participant demographics). We used year in school as this appeared to be a meaningful marker of identity and peer network as opposed to chronological age. All the undergraduate Sex-Ed Squad students enrolled in the courses offered at the two Southeastern universities elected to participate, whereas 11 of the 18 undergraduate Sex-Ed Squad members from the southern California University participated. Some reasons for nonparticipation included scheduling conflicts and lack of desire or time to be involved in a research study.

Table 2.

Participant demographic characteristics (N = 26).

Southeastern University 1 (n = 5) Southern California University (n = 11) Southeastern University 2 (n = 10) Total (n = 26)
Years in school
 Freshman 0 0 3 3
 Sophomore 1 5 1 7
 Junior 2 3 2 7
 Senior 2 3 4 9
Gender
 Male 3 5 2 10
 Female 2 6 8 16
 Transgender 0 0 0 0
Race/ethnicity
 Black/African American 1 1 2 4
 Latino/Hispanic 1 3 2 6
 White 2 5 5 12
 Asian/Pacific Islander 1 1 1 3
 Mixed 0 1 0 1
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Data collection & analysis

We used a semistructured focus group guide developed by behavioral health research staff located in a separate department within the University of the original AMP! site in southern California. This initial guide was then adapted by behavioral health researchers at the other two sites to include contextual factors specific to their sites. The focus group guide assessed participants’ involvement as peer educators and sought to understand how these experiences influenced their personal transformation regarding sexual health awareness, communication, and self-efficacy. Behavioral health theories such as Albert Bandura’s social cognitive theory (SCT) is useful for describing the process of behavioral change, while theories emerging from the arts and education disciplines are useful for understanding how the method of theatre-focused sexual health and HIV prevention education influences behavioral change processes. Freire is an arts and education theorist who focused on active learners who enter the theatre scene or colearn about a subject model and actively rework that model. Our focus group guide broadly assessed both behavior change, the colearner experience, and active learning regarding their role as both student and educator.

To assess the early stages of behavioral health change, our focus group guides and group discussion emphasized sexual health awareness, communication, and self-efficacy. In line with a phenomenological approach to data collection (Creswell, 2013), we asked broad questions to gain a basic understanding of participants’ experience as Sex-Ed Squad members and then asked open-ended follow-up questions that sought to target site-specific differences and similarities. While gender is an important identity marker, we purposely did not attach a gender to participant responses or assess for gender specific experiences in an effort to prevent our own assumptions of gender from skewing the analysis. Additionally, we wanted all identity related experiences and discussions to evolve organically and without specific probing. Site-specific probing and follow up questions allowed us to understand distinct experiences regarding intervention development and implementation across different political and geographic regions of the country. One coauthor from each site (AT, YM, SD) conducted the 60–90-minute audio-recorded focus groups in a private room on each of the university campuses. Each focus group audio recording was transcribed verbatim.

Data analysis

We sought and received permission from the IRB of the university where AMP! originated to analyze the transcripts across the three sites. Specifically, our analysis prioritized the shared phenomena of sexual health development throughout undergraduate student participants’ experience as sexual health learners, writers and creators, performers, educators, and advocates within each site. Additionally, our analysis examined the unique experiences of participants from each site to understand experiences specific to the geographic and cultural nuances of each AMP! region.

Coding process

For our analysis, we used a modified grounded theory approach. Two PhD level graduate students from two of the sites (YM and SD) analyzed and recoded qualitative focus group data from all three sites using deductive codes. They developed additional inductive codes to represent the stated experiences of participants unique to each site. Two additional researchers reviewed the analytic coding process. We coded and thematically analyzed the data using Atlas.ti 7.1.3 (Scientific Software Development, 2010) to organize codes and memos in one location. Through our coding process, we developed a list of inductive codes derived from the raw data to reflect the distinct experiences of Sex-Ed Squad members participating in the intervention across diverse geographic and political areas of the United States. As new constructs and perceptions arose with each focus group, we revisited the data to ensure we captured the depth and complexity of the participants’ experiences. Using the coded data, we had in-depth discussions regarding potential themes to describe the transformation process of participants across all three sites. We further refined and defined each theme, using participants’ coded statements to provide authenticity and meaning to each theme. Our list of data-driven and theoretically-oriented themes representing both shared and distinct experiences of the participants were further consolidated and refined following a third discussion.

Once the analysis of focus groups from each site was completed, four of the coauthors from across the three sites engaged in a group discussion to synthesize over-arching categories and further analyze salient themes. We mapped each theme to our core constructs to ensure that each theme reflected the change process of sexual health awareness, communication, and self-efficacy. Our analysis process privileged in-depth discussion among authors in tandem with careful review of theoretical constructs. We documented every phase of our analysis in analytic memos, creating the foundation for the “Findings” section of this manuscript.

Findings

Four salient themes, representing the participants’ transformative experiences related to sexual health awareness, communication, and self-efficacy during the course of their participation in the intervention arose from the data (see Table 3). The parallel and distinct experiences of participants across geographic sites are discussed in depth in this analysis.

Table 3.

Emergent themes.

Theme Description Theoretical construct(s) Exemplary quotes
Early sexual health education experiences as a driver of participation Participants indicated that their own experiences with sexual health education influenced their motivation to join the Sex-Ed Squad. Knowledge, experiential learning, reflective inquiry ″I had a sex class but no one ever talked to me about sex …. No one ever said these are the steps you need to take if you plan on being sexually active.″ (Southeastern University 1)
″I’m very open talking about sex with my friends and my sister. But that’s very different from talking about it with the actual person that you’re with. I’m a really non-confrontational person and I don’t like having hard conversations but sometimes you need to have them. So, I’m hoping it’s going to make me be able to do that.″ (Southern California University)
Raising consciousness and challenging established beliefs Through participation, the Sex-Ed Squad, participants challenged their previous attitudes and beliefs about sexual health. Attitudes, problem-posing, reflective inquiry, vicarious learning ″I come from a very Mexican culture. Like I said in my piece, the women are either virgins or they’re whores. You’re either perfect or you’re just a total mess up, and that doesn’t make sense. Why does it have to be the two extremes?″(Southern California University)
″I was a student learning. And the purpose of the performance was never separate from what we were learning—applying information and making it into a relevant scene.″ (Southeastern University 1)
Connecting with the content and communities through the use of personal experiences and a multimethod platform The process of integrating sexual health knowledge and personal stories into a theatre-based educational performance shaped participants’development as educator-actors. Communication, vicarious learning, social learning, active inquiry ″There was one [high school] girl in particular who was me four years ago. I was like ‘wow, this is really awesome that I’m reaching out to these kids and they’re getting what I never really got, and [to] see your change from a certain period in the past to now.’And so, that relationship and that communication flows both ways.″ (Southern California University)
″What we’re doing is really important because we’re starting to talk about sex in a different way that appeals to people…. And in the process, you’re learning yourself. So, it’s not like you’re lecturing. No. It’s something that’s very collaborative.″ (Southern California University)
Becoming a social advocate and developing intentions for personal behavior change The combination of inquiry and praxis provided a different way of looking at themselves, their social networks, and theworld around them. Social advocacy, reciprocal determinism ″This class has made me soooo much more aware of every aspect of sexuality. A few weeks after this class began I entered into a relationship and it was perfect timing. I am now aware of so many things that I was not before. We learned about STDs that you can get even without having sex and the importance of testing. This class has given me very valuable skills for the future (Southeastern University 1).
″It’s a new approach.We’re really learning and I feel like our methods of learning with Sex-Ed Squad are much more effective than however else we’ve been taught at the university. It stays with you and it goes with you into the person that you’re going to be in the future.″ (Southern California University)
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Early sexual health experiences as a driver of participation

Motivation to participate

Across sites, participants connected their motivation to become a Sex-Ed Squad member to their early exposure to both formal and informal sexual health education. Formal sexual health education was commonly described by participants across sites as the biological and psychological elements of sex-education curriculums received in middle and high school or from other community service providers. Participants characterized informal sexual health education as the cultural, family, peer, and gender-specific sexual health norms communicated via social networks, main-stream media, and social media. Participants described how social and sexual health norms influenced their approach to early experiences with sexual communication in their social and sexual networks and their self-efficacy navigating early sexual situations.

I feel like I faked my knowledge and didn’t ask questions because I was intimidated …. There was just this pressure to know, to be experienced, to have all the answers or you weren’t considered mature, cool. (Southeastern University 2)

Geographic location

Despite the geographic dispersion separating the three sites, we discovered many shared experiences among the participants regarding previous exposure to formal and informal sexual health education. Participants’ experiences with prior formal sexual health education also shaped their early awareness of institutional barriers influencing sexual health messaging. Specifically, participants discussed barriers within their high school experience and the disconnect between the sexual health curriculum being taught and the sexual behavior of their peers. Participants from all sites described similar experiences of realizing how institutional and social norms influenced their own early sexual health education despite differences in the geographic regions. Participants were cognizant of how location may impact the sexual health education received by their high school student audience. They were eager to challenge barriers to a comprehensive sexual health curriculum and provide alternative sexual health messages.

My parents avoided talking about it [sex], and so I didn’t want that to happen with other kids …. I’m nervous on how the teachers and the parents are gonna react. The reality is that we are in the South and I think it will be different than a California kid going into a California school. (Southeastern University 1)

In schools, abstinence is pushed so hard. But a lot of high school students are not abstaining and don’t feel like that’s something they need to do. So, it’s kind of that tug of war between what schools are promoting and what students are actually doing and what they believe. (Southern California University)

Early sexual health experiences

To better understand the first phase of the transformative process, we explored participants’ early exposure to sexual health education and social norms regarding sexual behavior and communication about sex. We found that the course influenced participants’ understanding of these early experiences. During the initial part of the course, participants engaged in critically reflective inquiry of their sexual education experiences, and how their experiences affected their level of preparedness and emotional confidence navigating unfamiliar sexual situations. This reflection is a hall-mark of Freirean pedagogy and engaged the students as cocreators in the learning process (Boal, 1979). The initial reflection process during the course was a critical junction for many students to assess the content and quality of their own sexual health experiences.

I think in my own life there are a lot of decisions that I think I would have made differently if I had known more information about sexual health. And then in working with middle schoolers and seeing how much they lack the knowledge themselves and remembering my place in that time—I want to work on changing that. (Southeastern University 2)

Through this reflection process, the participants began to identify these early formal and informal sexual health education experiences and began to connect these experiences to how they saw themselves within their communities of origin. Moreover, they developed a critical consciousness of the strategies they employed as adolescents in navigating social and sexual networks, particularly when the formal sexual health education conflicted with their own realities. As they initiated their didactic learning process within this course, participants began to transition from developing their awareness of institutional barriers and established beliefs and norms to actively engaging with new material and methods that challenged their previous experiences with formal and informal sexual health education. Both the formal and vicarious learning processes within this course helped them to integrate previous messages with new sexual health knowledge and a developing awareness of themselves.

Raising consciousness and challenging established beliefs

Participants at all three sites discussed cognitive shifts regarding their personal beliefs around culture, gender, and peer norms about sexual health. As participants’ self-awareness and sexual health awareness became more nuanced, they started to develop their own self-efficacy and began to actively challenge taboos and misinformation. Participants became more direct in their tone and expressed the intention to make changes promoting positive sexual health. Additively, the problematizing of previously accepted common knowledge to achieve a deep understanding of the content within the context of participants’ lived realities exemplified what Freire refers to as critical intervention into reality (Boal, 1979).

Vicarious learning

As the first half of the course progressed, participants engaged in observational and social learning processes through shared storytelling among members. This initial instructor-facilitated shared storytelling process evolved organically among participants as they developed stronger social ties with one another via dialogical engagement throughout the course. These group discussions exposed participants to the unique life and sexual experiences of their peers, placing them as central subjects of the material being learned, and influenced the development of their own sexual health awareness and beliefs through shared cognition.

We are going to these high schools and middle schools to talk to other students, but we’re also learning from each other, and that has a lot of excitement from both making friends and going as a community but also then taking what we’re learning to people around us, more immediate peers. (Southeastern University 2)

Connecting with the content and communities through the use of personal experiences

Participants developed a more nuanced understanding of the communities they were educating by continually placing them as central participants in the educational process. Participants spoke about the advantages of being near-peers, which allowed them to speak authentically about the high school student experience. Participants expressed excitement about developing, performing and sharing art that was informative, transformative, and reflective of their sexual health knowledge, personal sexual health development, and experiences. Moreover, participants discussed developing an enhanced self-awareness and social identity through their performances and interactions with the audience.

Being able to share my private story and reflect on my story and see how it affects other people made me realize that I should be doing such and such thing that I haven’t been doing even though I’ve been telling people to do it. (Southeastern University 2)

Valuing an innovative, applied theatre platform

Sex-Ed Squad participants found value and meaning in the fact that they created and delivered a sexual health performance to high school communities as part of the AMP! intervention. Specifically, Sex-Ed Squad members actively devised, rehearsed, and refined the performances that purposively considered community and social norms. Participants discussed their belief in the efficacy of the interactive learning and performance-based teaching approach for high school students, turning them from spectators into spectactors (Boal, 1979), as well as its impact on their own development as peer educators.

We got to see the different ways that you can ‘do’ public health and sex education. I love theatre and I think it’s a great medium to get things across to people in a really personal way that lecturing and reading a book can’t do. (Southeastern University 1)

I enjoyed taking the performance into the schools, seeing the reaction of the students, teachers, and administrators. And the way we talk about sex is something that I had never experienced in the school setting …. I think that we learned a lot of skills … throughout the performance and the workshops. (Southeastern University 2)

Participants discussed how their role and active participation in the process as learners-educators-actors influenced their self-perception and self-efficacy. Participants began to engage in the simultaneous process of changing internalized stigma and shame, while critically evaluating their own sexual health behaviors and actively working to develop alternative sexual health strategies.

I feel like once I got to know everyone, it really helped me feel comfortable in my own skin. I feel like it really helped me reconcile any shame, [or feeling I had done] something bad. I was able to transform ugly into something beautiful by making art that makes people feel less shameful about themselves and their actions. You, yourself, end up feeling less shameful and less ugly. (Southern California University)

I guess I’ve changed a couple of things. One is being more open to share with people as something to learn from as I have done … since I can’t practice what I preach effectively, I’ve quit practicing. So no longer sexually active until I feel like I can be 100% comfortable and effective and in control of my own experience. So even though I haven’t done that I’m working towards that. (Southeastern University 2)

Participants endorsed this innovative, theatre-based approach to learning and educating as new and transformative, both personally and for the audience. Through this approach, participants developed a critical lens, analyzed early life experiences, and subsequently delivered clear, strong, and educational messages about sexual health. Additionally, they engaged their audience by asking questions and opened up the space for critical reflections with the audience. This process exemplifies what Freire refers to as fuller humanity achieved through solidarity and dialogue (Boal, 1979).

Becoming a social advocate and developing intentions for personal behavior change

Participants learned to understand and utilize theatre both as a platform to communicate messages to others and as a tool for personal growth, using theatre as the language for engaging audiences in discourse. Participants discussed a desire to incorporate learned skills into future work and activities. Specifically, participants expressed an intention to be agents of change.

Acting and being on stage teaches you so much about interactions with people and how you speak, stand, and present yourself. That helps a lot when trying to get a message across— theatre as a tool. (Southeastern University 2).

The simplest conversation we’ve had with each other outside of here can change so much about how you see it [HIV]. With my friends now, I can bring it [HIV] up and to be able to just confront it and get to the root of the issue. (Southeastern University 1)

The challenges faced by the participants reflected universal themes that emerged from institutional, community, and social norms despite living in disparate geographic regions of the country. Through these challenges, participants developed strategies to manage and navigate barriers to achieving sexual health while at the same time reinforcing the dialogical principles of the course. Participants gained a sense of purpose using advanced sexual health communication strategies and participatory theatre techniques to convey sexual health messages and facilitate discussion about difficult issues. Within their social networks, participants developed the self-efficacy necessary to have direct conversations regarding sexual health and sex-safety, and set new intentions for their own sexual health behaviors.

After being in this in the class and in the show, I’m better about practicing what I preach. Because in high school I would say, ‘Use condoms, get tested,’ like all these things, but I wasn’t necessarily doing them myself. I’m better [now] about everything I learned applying to myself …. And I think just even that feels so great, that I was finally taking charge of my sexual health. (Southeastern University 2)

I’ve become more open. I enjoy talking about sex and sexual health with my friends … making sure that I’m not the only one who’s benefiting from Sex Squad, but my friends as well. (Southern California University)

Lastly, participants discussed increased self-efficacy when communicating with sex-partners and advocating for their own sexual health-related needs and rights.

Participants discussed self-efficacy in terms of enhanced comfort and confidence within sexual relationships. However, participants also emphasized that navigating sexual health within intimate relationships is an ongoing learning process replete with complex challenges and emotions.

I used to believe that condoms were only necessary if you didn’t trust the person you were with. Ludicrous! I also did not truly believe in verbal consent if a person was giving you physical consent. Now I believe in the power of words.” (Southeastern University 2)

[I was] speaking to [my partner] about testing and how it’s non-negotiable for me and he made it seem like, ‘Yeah, I’ll do it,’ but he’s putting up all these reservations, reasons he shouldn’t …. Since he decided to take the stubborn way, there’s obviously consequences. I’m not going to compromise.” (Southern California University)

Here, the participants’ communication strategies and sexual health intentions were clearly rooted in their enhanced sexual health awareness. Participants understood sexual health implications for their peers and themselves and developed the language and self-efficacy to have critical conversations advocating for behavior change. Additionally, participants reflected on how to apply this new awareness to their own lives and more confidently expressed their intention to make healthy sexual choices.

Discussion

College presents unique challenges and opportunities as students integrate sexual health norms and lessons learned during adolescence with new expectations, pressures, and unfamiliar social and sexual situations. Many studies have captured sexual health risk and protective behaviors among adolescents and young adults (Buhi et al., 2010; Bynum, Brandt, Friedman, Annang, & Tanner, 2011; Fair & Vanyur, 2011; Hirschler, Hope, & Meyers, 2015). Specifically, extant research primarily focuses on behavioral health outcomes of audience members such as increased condom use, abstinence from sex, and reducing the number of sex partners (Adefuye et al., 2009; Buhi et al., 2010; Jemmott et al, 2010; Markham et al., 2014). Few studies at present, however, have sought to understand the process of sexual health transformation and the inter-related steps that lead to behavior change among college student sexual health educators (Grewe et al., 2015).

While SCT was useful for understanding the early stages of behavior change, the theory fell short in explaining how the method of information delivery completed the theoretical picture that framed the AMP! intervention and affected these change processes. Freire’s focus on active learners provided an artistic method, which allowed near-peers to engage in observational colearning and active (re)creation of sexual health related experiences and messages. A key goal of this approach was to increase participant engaged learning through communication, observation, and interaction. Additionally, our focus group questions did not purposefully incorporate SCT’s central concept of reciprocal determinism. However, we found that the concept emerged throughout our focus group discussions. According to Bandura (2004), reciprocal determinism is defined as “a model of reciprocal causation whereby behavior, cognition, other personal factors, and environmental influences all operate as interactional determinants that influence each other bi-directionally” (Bandura, 2004, p. 2). In line with SCT, we saw how reciprocal determinism (Bandura, 2004) influenced the participants’ sexual health development throughout their tenure as Sex-Ed Squad members.

Implications

Our findings provide evidence that interventions designed to enhance sexual health knowledge, attitudes, self-efficacy, and communication among high school youth (Lightfoot et al., 2015) may also impact the near-peer college-aged sexual health educators who develop and deliver the artistic and sexual health content of an intervention. Our thematic analysis of eight focus group discussions with 26 participants yielded four key themes directly linked to sexual health awareness, sexual health communication, and self-efficacy. The cognitive and identity shifts that occurred among participants exemplified how AMP!’s multipronged approach of technical, problem-based, and social and dialogic learning can lead to enhanced critical thinking and critical consciousness skills for the individuals delivering an intervention, in addition to the beneficiaries (Lightfoot et al., 2015). In addition, participants developed and integrated their evolving identity as advocates into shifting roles within their social networks, suggesting that the effects of the intervention may be long lasting and diffused throughout peer groups.

Participants awareness of their past informal and formal sexual health education experiences and norms combined with their role as near-peers placed them as central subjects in their self-exploration and sexual health development, providing a critical lens through which they could contextualize the material being studied. Our findings echo findings from previous research suggesting that sexual health knowledge and awareness are key predictors in self-efficacy to apply strategies to various contextual situations (Gulbrandsen, Jensen, Finset, & Blanch-Hartigan, 2013), an important factor in fostering positive sexual health outcomes among this emerging adult population (Black, Sun, Rohrbach, & Sussman, 2011). Research has documented the importance of awareness of oneself and awareness of others as critical to developing the self-efficacy to communicate with networks and change behavior (Foster, Neighbors, & Young, 2014; Moyer-Guśe, Chung, & Jain, 2011). Through the course’s emphasis on shared storytelling techniques, participants began to integrate previous didactic sexual health lessons with peer, cultural, and family norms into an evolving critical consciousness of their own sexual health and personal identities. Specifically, participants developed a more nuanced understanding of sex, sexual relationships, and the many different types of norms influencing behavior within a wide variety of sexual health contexts.

Participants demonstrated increased self-efficacy within their role as educators and within their social networks as evidenced by enhanced communication strategies, self-confidence, behavioral intention, and social advocacy. This finding echoes other research suggesting that self-efficacy, negotiation strategies, and assertiveness are critical elements of effective HIV prevention strategies for those who experience gender and power inequality within sexual relationships (Payton, Kvasny, & Kiwanuka-Tondo, 2014). The finding that self-efficacy impacts communication strategies across social and sexual networks, was evident across all sites. Participants often discussed communication and self-efficacy together, where enhanced confidence led to the perceived ability to communicate with partners and peers. As participants moved through the course, they engaged in a process of critical thinking whereby they developed a deeper awareness of past experiences and lessons while simultaneously reconciling these in an effort to apply newly acquired communication strategies. At the same time, participants began to critically assess their role within their social and sexual relationships and developed behavioral intentions that can augment opportunities for positive sexual health outcomes.

To our knowledge this is one of the first studies to understand how a theatre-based intervention can use arts-based and public health theories to influence health transformation among youth sexual health educators across disparate geographic regions. Our analysis demonstrated that using problem-posing and vicarious learning approaches within this theatre platform empowered Sex-Ed Squad members to use critical thinking skills, develop contextual awareness of health issues, and become motivated to engage in social advocacy. One recent study used Freire’s problem-posing pedagogy to move beyond the power dynamics and passive learning approaches imposed by the traditional teacher-student/consumer educational platform and empowered community members to develop an HIV prevention toolkit reflective of their community’s experience (Rikard, Thompson, Head, McNeil, & White, 2012). Specifically, this study found that, through this problem-posing methodology, African-American community members moved beyond the role of consumer and instead had a stake in the HIV prevention toolkit development process and became change-agents within their community (Rikard et al., 2012). Our study expanded upon Rikard and colleagues’ study by demonstrating that the use of multiple methods and theoretical approaches empowered Sex-Ed Squad members to become change-agents while at the same time inspired them to make cognitive, emotional, and interpersonal shifts critical to future health behavior changes.

Limitations

Our findings should be considered within the context of the study limitations. First, students who choose to become Sex-Ed Squad members may be more open to engaging in sexual health-related material, having personal and critical conversations, and be more open to using a theatre platform than the general college student population. Second, the duration of the intervention was only four months and we did not collect longitudinal data, which would have allowed us to track whether intended behavior change occurred. Third, the findings may not translate to other schools or communities. Despite these limitations, we consider the findings to make a significant contribution to the body of research that aims to engage youth in innovative intervention strategies to enhance sexual health and mitigate the risk for HIV/STIs and other negative sexual health outcomes. The present research emphasizes the early stages of behavior change processes often neglected by extant research prioritizing health outcomes. Although behavioral outcomes are critical, we believe that changes in self-awareness and critical consciousness, effective communication strategies, and self-efficacy are vital to developing concrete strategies for positive sexual health behaviors among college student sexual health educators.

Future directions

The inherently dialogic nature of theatre, including specific techniques for audience participation, creates a structure enabling Sex Ed Squad members to use theatre to engage with and empower community (Boal, 2006; Cohen-Cruz, 2010). A cocreated and dialogic learning environment that transcends traditional teacher-student dynamics moves from what Bandura (2004) refers to as human agency into collective agency of the broader social environment or community. This approach serves as a means through which learners can look more critically at their own assumptions and explore material in more depth than traditional, didactic forms of education (Freire, 1970). As such, this participatory approach has the potential to create stronger and more durable impacts on the sexual health behaviors of adolescents than banking education methods (Freire, 1970; Boal, 2006). Further research is needed to compare the effects of arts-based sexual health education interventions with more traditional educational interventions.

AMP! continually evolves through the lived experiences of the intervention’s near-peers who cocreate and deliver HIV prevention and sexual health education messages to high school students. Previous research indicates that while practicing condom use, enhanced communication strategies, and acquiring medically accurate HIV/sexual health knowledge promotes safer sex practices, these strategies may not fully address the stigma and stereotypes associated with testing and STIs (Hirschler et al., 2015). Research also suggests that image management associated with more common and less shocking sexual health educational messages has been shown to be an important element to reduce stigma associated with sensitive topics such as HIV (Payton, 2015). Payton’s (2015) findings demonstrated the power of the iterative process attached to a cocreated HIV prevention educational platform. According to Payton, this process helps to instill a sense of ownership, dedication, personal connection to the content and audience as well as emotional identification as an advocate within the larger social networks of participants (Payton, 2015). The implications afforded by Payton’s (2015) and Hirschler’s (2015) research provide a similar future direction toward broadening AMP!’s reach to include the cocreation process among high school students who cocreate their own theatre-based sexual health interventions for their immediate peers within their social environment to improve sexual health strategies and simultaneously reduce stigma and misinformation associated with both testing and HIV/STIs. AMP! is currently in the process of using the college-age Sex-Ed Squad members to mentor high school students within the development of their own Sex-Ed Squads, providing theatre and peer-based sexual health education information within their own communities. This interdisciplinary and evolving approach to sexual health education can be further developed, used and researched to actively engage youth in their own learning and sexual health transformation processes. Furthermore, this interdisciplinary approach to sexual health education can be further developed and used to actively engage youth in their own learning and sexual health transformation processes. To achieve this, further research is required to better understand how participation in interdisciplinary and participatory sexual education programs such as AMP! affect various communities of participant-educators. Finally, as participatory sexual health education programs continue to grow in popularity among adolescents and emerging adults, it will be important to understand how participation in these programs influences identity development and sexual health throughout the life course.

Acknowledgments

We thank the college students for their participation in this study. We also would like to thank Lisa Park, the AGHG Fund Manager. Lastly, we would like to thank the course instructors for each of the three AMP! locations who allowed time and space for researchers to visit the classroom and recruit participants.

Funding

This work was supported by a developmental grant from the University of North Carolina (UNC) at Chapel Hill Center for AIDS Research (CFAR) NIH-funded program P30 AI50410, the AIDS Institute at the University of California, Los Angeles (UCLA), UCLA Center for AIDS Research (AI28697), the UCLA Clinical and Translational Science Institute, NCRR and NCATS (UL1TR000124), National Center for Advancing Translational Sciences UCLA CTSI Grant UL1TR000124. Additional support was provided by the Ford Foundation (Grant 1120-1496), the David and Linda Shaheen Foundation, the AIDS Healthcare Foundation, and the Ueltschi course development grant from the University of North Carolina’s Center for Public Service’s APPLES Service-Learning Program.

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