Journal of Pediatric Nursing (2016) 31, e63–e69

HIV/AIDS Knowledge, Self-Efficacy for Limiting

Sexual Risk Behavior and Parental Monitoring
Ganga Mahat EdD, RNBC ⁎, Mary Ann Scoloveno EdD, PNP, RN,
Robert Scoloveno PhD, RN, CCRN
Rutgers, the State University of New Jersey, School of Nursing, Newark, NJ

Received 24 April 2015; revised 30 June 2015; accepted 30 June 2015

Key words:
The purpose of this study was to explore HIV/AIDS knowledge, self-efficacy for sexual risk behaviors,
HIV/AIDS;
and parental monitoring in a sample of 140 7th and 9th grade adolescents studying in an urban high
Knowledge;
school in the United States. Further, the study examined differences in HIV/AIDS knowledge, self-
Self-efficacy;
efficacy and parental monitoring by grade and gender. This study also investigated the effectiveness of
Parental monitoring;
an HIV/AIDS peer education program, Teens for AIDS Prevention (TAP), on improving adolescents'
Peer education;
HIV/AIDS knowledge. A quasi-experimental design was used to examine effects of the peer education
Adolescents
program (TAP) on adolescents' HIV/AIDS knowledge. Pearson-product–moment correlation
coefficients were calculated to examine the relationships among the variables. Independent t-tests
were used to compare adolescents' HIV/AIDS knowledge, self-efficacy, and parental monitoring scores
by grade and gender. Paired t-tests were used to determine differences in pre-intervention and post-
intervention HIV/AIDS knowledge. The results showed that HIV/AIDS knowledge improved
significantly in both 7th and 9th grade students after the intervention. HIV/AIDS knowledge was
associated with self-efficacy; however it was not associated with parental monitoring. There were no
significant differences in HIV/AIDS knowledge and self-efficacy by gender. However, there was a
significant difference in parental monitoring by gender. Pediatric nurses are well-positioned to develop
and implement evidence-based programs for adolescents. It is essential that pediatric nurses, in
conjunction with other professionals and parent groups, take the initiative in implementing peer
education programs in schools and community centers to promote healthy behaviors among adolescents.
© 2016 Elsevier Inc. All rights reserved.

ADOLESCENCE IS A developmental phase of rapid 2001–2013 (45.6%–46.8.4%). Among currently sexually

growth and development, accompanied by sexual maturation
and social pressures. Adolescents are susceptible to sexual
risk behaviors because of their impulsivity and feelings of
invulnerability. According to the 2013 Youth Risk Behavior
Survey (YRBS), many high school students nationwide are
engaged in sexual risk behaviors associated with unintended
pregnancies, sexually transmitted diseases (STDs) and
human immunodeficiency virus (HIV) infection (CDC,
2014). Although nationwide the percentage of adolescents
ever having sexual intercourse decreased during 1991–2001
(54.1%–45.6%), it did not change significantly during
⁎ Corresponding author: Ganga Mahat, EdD, RNBC.
E-mail address: gmahat@rutgers.edu.
active students nationwide, 59.1% had used a condom during
their last sexual intercourse, which did not change from 2011
(60.2%) to 2013 (59.1%). These findings indicate that
adolescents are at risk for STDs, including HIV infections;
therefore the knowledge and awareness of STDs and HIV/
AIDS prevention is a prime concern for schools and health
care providers (CDC, 2014).
One of the goals of Healthy People 2020 is to prevent HIV
infection and its related illness and death (U.S. Department
of Health and Human Services, 2013). This goal can be
achieved by implementing educational programs that will
help minimize risk and improve health outcomes of
adolescents. Since schools are responsible for health
education, implementation of peer educational programs

http://dx.doi.org/10.1016/j.pedn.2015.06.015
0882-5963/© 2016 Elsevier Inc. All rights reserved.
e64
that focus on health promotion and prevention, including
HIV prevention is warranted (Caron, Godin, Otis, &
Lambert, 2004).
In this study, the researchers explored HIV/AIDS
knowledge, self-efficacy for sexual risk behaviors, and
parental monitoring among 7th and 9th grade adolescents,
ages 11–15, attending an urban high school in the United
States. This study also examined the effectiveness of an HIV/
AIDS peer education program, Teens for AIDS Prevention
(TAP), on improving adolescents' HIV/AIDS knowledge.
Theoretical Framework
TAP is a peer educational program where teen educators
teach their peers' facts about HIV/AIDS and ways that
adolescents can protect themselves from HIV infection
(Alford & Feijoo, 2002). This program is based on social
learning theory, which includes self-efficacy, the belief that a
person has the ability and capacity to influence his or her
behaviors (Bandura, 1986). According to social learning
theory, adolescents will more likely listen to and model their
behavior if they perceive that the models are similar to them
in age, gender and ethnicity (Bandura, 1986). The theory also
predicts that adolescents will engage in positive self-directed
change if they have knowledge about HIV/AIDS. Self-
efficacy has been found to be an important component in
HIV risk reduction (Bandura, 1997).
Literature Review
Several researchers have studied the relationships between
self-efficacy and the likelihood to engage in healthy behaviors.
Lee, Salman, and Fitzpatrick (2009), in their study of 734
Taiwanese adolescents, aged 16 to 18, found a significant
relationship between HIV/AIDS preventive self-efficacy
scores and risky sexual behavior (r = .70, p b .0001). Risky
sexual behavior was defined as the minimum use of safe
behaviors, including protected sex, avoiding bodily fluids, and
the ability to discuss with a partner their sexual history and
condom use. The findings indicated that adolescents who had
higher HIV/AIDS preventive self-efficacy scores had less
overall risky sexual behaviors. Van Campen and Romero
(2012), in their study of 122 minority American adolescents,
aged 13 to 18, reported that self-efficacy significantly
predicted safe sex intention such that greater sexual self-
efficacy was associated with more likelihood to have safe sex
F(4.90) = 4.77, p b .01. Theory suggests that self-efficacy
promotes the ability of individuals to influence their HIV risk
reduction behaviors (Bandura, 1997). However, empirical
studies are sparse on self-efficacy and changes in these
adolescent risk-behaviors over time.
In a longitudinal study, Chen et al. (2012) investigated the
development of condom use self-efficacy among 497 6th
grade Bahamian pre- and early adolescents, aged 10 to
13 years. The data were obtained at 6 month intervals up to
24 months and a 12-month interval from 24 to 36 months.
The results demonstrated that self-efficacy scores increased
from 2.37 (SD = 1.19) at baseline to 3.50 (SD = 1.02) at
G. Mahat et al.
36 months. Condom-use self-efficacy values at baseline
predicted levels of self-efficacy at the 6 month intervals
(b = 0.41, p b .01) and self-efficacy at 24 months predicted
the scores at 36 months (b = 0.61, p b .01). The researchers
concluded that evidence from their study will assist those
who develop HIV prevention programs for pre-adolescents
with the goal of sustaining the intervention effects
throughout adolescence.
In a clustered controlled trial of the effects of an HIV
prevention program, “Focus on Youth in the Caribbean”
(FOYC), Chen et al. (2009) collected data from 1,360 10 to
11 year old Bahamian school children who were randomly
assigned to the intervention group and a control group who
received an ecological course “The Wondrous Wetlands”
(WW). Data were collected at baseline, 6 and 12 months
after the intervention. The results found that there was a
significant difference in condom use among sexually active
youth at 12 months post-intervention (v2 = 3.30, p = .050),
whereby the intervention group used condoms more often
than the control group.
To evaluate the long-term effects of the FOYC, Stanton
et al. (2012) compared 1,997 Bahamian 10th grade students
who were from five groups. Group 1 received the FOYC
intervention in the sixth grade as described by Chen et al.,
2009. Group 2 received FOYC in the regular school
curriculum; group 3 received the trial's control condition;
group 4 received the control condition, but was not part of
the trial; group 5 did not receive the intervention or the
control condition. The results demonstrated that youth
exposed to FOYC, whether in the intervention or school
curriculum, had greater HIV knowledge (p b .01), condo-
m-use skills (p b .01), and self-efficacy (p b .01) compared
to control groups 4 years later. The researchers concluded
that the FOYC intervention in the sixth grade had lasting
effects on 10th grade students.
Parental monitoring is defined as “a set of correlated
parenting behaviors involving attention to and tracking of the
child's whereabouts, activities, and adaptations” (Dishion &
McMahon, 1998, p. 61). Monitoring by a parent provides
social safeguards against involvement in detrimental and
risky activities and reducing high-risk behaviors (DiClemente
et al., 2001). Studies have shown that parental monitoring is
associated with less engagement in risky behaviors such as
alcohol use, sexual risk behavior, lower intention to have sex
in the future, increase frequency of condom use, and delayed
onset of sexual intercourse (DiClemente et al., 2001; Kalina
et al., 2013; Strunin et al., 2013). Lenciauskiene and
Zaborskis (2008) in their study of European adolescents
reported that adolescents who had low levels of parental
monitoring had higher prevalence of early sexual behavior
than those who had high levels of parental monitoring. Based
on a literature review, Kincaid, Jones, Sterrett, and McKee
(2012) concluded that parental monitoring may be more
protective against sexual risk behaviors for boys than girls.
HIV peer education has been found to be effective in
improving adolescent's HIV/AIDS knowledge, intentions
HIV/AIDS, Knowledge, Self-Efficacy and Parental Monitoring e65

regarding condom use, self-efficacy to refuse sex, and delay Table 1 Demographic information by grade level.
in sexual behaviors (Caron et al., 2004; Mash & Mash, 7th grade 9th grade
2014). One study reported contradictory findings concluding (N = 59) (N = 81)
that a peer education program was not effective in reducing
Ethnicity
the age of sexual debut or condom use (Mason-Jones,
Caucasian 7 (12%) 10 (12%)
Mathews, & Flisher, 2011).
Hispanic 16 (27%) 34 (42%)
African-Am 32 (54%) 27 (33%)
Research Questions Asian 1 (2%) 3 (4%)
The purpose of this study was to examine HIV/AIDS Other 3 (5%) 7 (9%)
knowledge, self-efficacy for sexual risk behaviors, and Religion
parental monitoring among 7th and 9th grade adolescents. Majority Christian 54 (91%) 59 (73%)
Further the study investigated the effectiveness of the TAP Others: Buddhist, Muslim, Hindu 5 (9%) 22 (27%)
program in increasing HIV/AIDS knowledge. The following Parental education
Elementary 18 (30%) 15 (18%)
research questions were used in the study:
High school 13 (22%) 32 (40%)
College 28 (48%) 34 (42%)
1. What is the relationship between the independent
variables self-efficacy for sexual risk behavior and
parental monitoring and the dependent variable HIV
knowledge?
2. Is there is a difference in HIV/AIDS knowledge, knowledge questions, the correct (1) and incorrect (0) format
self-efficacy for sexual risk behavior and parental was used. The two alternatives (not sure and don’t
monitoring by grade? understand) were scored as incorrect answers because it
3. Is there a difference in adolescents' HIV/AIDS was assumed that the students did not know the answer. In
knowledge, self-efficacy for sexual risk behavior and the correct/incorrect format the total HIV knowledge score
parental monitoring by gender? ranged from 0 to 33; the higher the total score, the greater the
4. Is there a difference in HIV/AIDS knowledge after students' knowledge. The Department of Health and Human
implementation of the TAP peer education program? Services, CDC reviews the YRBSS for accuracy annually.
The Cronbach alpha reliability of the instrument in this study
Method was .77.
Design The third questionnaire, Self-Efficacy for Limiting Sexual
A quasi-experimental design was used to examine effects Risk Behaviors, consisted of nine items and evaluated how
of the peer education program (TAP) on adolescents HIV/ sure the adolescents were about talking about safe sex with
AIDS knowledge. This study was carried out in an urban partners, buying condoms in drug stores etc. Response
school with 7th and 9th grade students. options ranged from very sure (4) to not sure at all (0). The
total score ranged from 0 to 36; the higher the total score, the
Sample greater the self-efficacy. The alpha reliability of the scale was
The total sample (N = 140) was comprised of 7th grade previously reported as .77 (Smith, McGraw, Costa, &
(N = 59) and 9th grade (N = 81) students, aged 11 to 15 McKinlay, 1996). The Cronbach alpha for the instrument
(M = 13.2). The ages of 7th graders ranged from 11 to in this study was .72.
15 years (M = 12.05), and ages for 9th graders ranged from The fourth instrument, a six-item Parental Monitoring
13 to 15 years (M = 14.09). In 7th grade, there were 52% Scale, was used to determine whether adolescents believe
males and 48% females. In 9th grade, there were 42% males that their parents/guardians usually know where and with
and 58% females. Adolescent ethnicity, religion and level of whom the adolescents are and in what activities they are
parental education are reported in Table 1. engaging (Silverberg & Small, 1991). Response options
range from “never” (0) to “always” (4) on a 5-point Likert
Instruments scale. Averaging responses to the items produced the scale
The instrument packet consisted of four surveys. The first score. The score ranged from 0 to 24. The alpha reliability of
questionnaire assessed demographic information such as the instrument in this study was .91.
age, gender, ethnicity, and parental education level. The
second instrument assessed HIV/AIDS knowledge and was Procedure
adapted from the Youth Risk Behavior Surveillance System The data were collected after obtaining permission from
(YRBSS) developed by the Department of Health and the institutional review board and the participating school.
Human Services, Center for Disease Control and Prevention Only those students who had parental consent and gave their
[CDC] (CDC, 2002). Each of the 33 items in the HIV/AIDS assent completed the questionnaires. After the baseline data
knowledge questionnaire was rated as yes (1), no (2), not were collected, 10th grade students from the same high
sure (3), or don’t understand (4). When scoring the school implemented the TAP program to 7th and 9th grade
e66
Table 2 Mean of HIV/AIDS knowledge, total self-efficacy
and parental monitoring.
Total 7th 9th
sample graders graders
(N = 140) (n = 59) (n = 81)
Pre-HIV/AIDS knowledge 20.82 20.57 21.01
Post-HIV/AIDS knowledge 26.54 27.59 25.57
Self-efficacy 28.12 25.94 29.71
Parental monitoring 23.02 27.40 19.82
students in the students' respective classes. Peer educators
were trained by the researchers prior to executing the
program. They assisted in modifying the program to make it
culturally relevant to their peer cohort. For example, two
videos were selected that were prepared by teens. The peer
educators selected these videos because the teens in the
videos were reflective of the ethnic backgrounds of the
adolescents in the school. The modified TAP program
consisted of 5 sessions, each lasting 45 minutes. The content
included an explanation of the ground rules, a PowerPoint
presentation on HIV/AIDS information, exercises on value
clarification, communication skill building through group
discussion, videos, role-play, and games. Five weeks after
the implementation of TAP program, students completed
the same HIV/AIDS knowledge questionnaire that was given
at baseline.
Analysis
The data were analyzed using SPSS version 21.0.
Demographic information, HIV/AIDS knowledge, self-
efficacy, and parental monitoring were analyzed using
descriptive statistics. Pearson-product–moment correlation
coefficients were calculated to examine the relationships
among the variables. Independent t-tests were used to
compare adolescents' HIV/AIDS knowledge, self-efficacy,
and parental monitoring scores by gender. Paired t-tests were
used to determine differences in pre-intervention and
post-intervention HIV/AIDS knowledge.
Results
Relationships Among Variables
For the total sample, findings demonstrated that pre-
HIV/AIDS knowledge was positively correlated with
self-efficacy (r = .206, p = .015) indicating that as HIV/
AIDS knowledge increased, self-efficacy for limiting
sexual risk behavior increased. Pre-HIV/AIDS knowledge
was not correlated with any demographic variables, but
post-HIV/AIDS knowledge was negatively related to age
(r = − .293, p =.002) and grade (r = − .292, p = .002),
demonstrating that HIV/AIDS knowledge increased with
younger students in the 7th grade. Self-efficacy was
positively correlated with grade (r = .309, p = .000),
indicating that as grade increased, self-efficacy increased.
Parental monitoring was negatively correlated with age.
G. Mahat et al.
Table 3 Mean and standard deviation of variables by gender
(N = 140).
Male Female
Mean SD Mean SD
Pre-HIV/AIDS knowledge 21.27 5.00 20.44 4.78
Post- HIV knowledge 26.61 3.03 26.49 3.80
Self-efficacy 27.32 5.70 28.82 6.27
Parental monitoring 22.49 5.92 23.46 4.82
(r = − 734, p = .000), indicating that younger students had
increased parental monitoring.
Comparisons of HIV/AIDS Knowledge, Self-Efficacy
and Parental Monitoring by Grade Level
Mean and standard deviation of HIV/AID knowledge,
self-efficacy and parental monitoring are presented in
Table 2. An independent t-test showed that there was no
difference in pre-HIV/AIDS knowledge by grade level,
demonstrating that HIV/AIDS knowledge was similar in
both groups at baseline. However, there was a significance
difference in post-HIV/AIDS knowledge (t = 3.14, df =
138, p = .002), self-efficacy (t = 3.81, df = 138, p = .000)
and parental monitoring by the grade level (t = 11.50, df =
138, p = .000). Seventh grade students had significantly
greater post-HIV/AIDS knowledge and parental monitoring
than did 9th graders. Mean self-efficacy scores were higher
for 9th graders than for 7th graders.
When relationship among variables were analyzed by
grade level, there was a positive relationship between
pre-HIV/AIDS knowledge and self-efficacy among
both 7th grade (r = .429, p = .041) and 9th grade students
(r = .279, p = .012). Parental monitoring was not related to
either HIV/AIDS knowledge or self-efficacy among 7th and
9th graders.
Comparison of Variables by Gender
The mean and standard deviation of variables by gender
in the total sample is presented in Table 3. In the total sample,
parental monitoring was found to be significantly different
by gender (t = 1.08, df = 138, p = .01), whereby girls had
greater parental monitoring than did boys. The mean and
standard deviation of variables by gender in 7th and 9th
grade students is presented in Table 4.
Comparison of Pre- and Post-HIVAIDS Knowledge
In the total sample, adolescents' HIV/AIDS knowledge
significantly improved after the peer education program
(t = 13.78, df = 107, p = .000), demonstrating that the
program was effective in improving knowledge. When the
sample was divided into two groups by grade level, students'
HIV/AIDS knowledge improved significantly after the peer
education both in 7th graders (t = 9.13 df = 55, p = .000)
and in 9th graders (t = 10.94, df = 51, p = .000).
HIV/AIDS, Knowledge, Self-Efficacy and Parental Monitoring e67

Table 4 Mean and standard deviation of 7th and 9th grade Post-intervention knowledge scores increased significantly
students' HIV/AIDS knowledge, self-efficacy and parental in both the 7th and 9th graders; however the post-HIV/AIDS
monitoring by gender. knowledge scores increased more among 7th graders than
7th grader 9th grader 9th graders, which is an interesting finding. It is possible that
7th graders, being slightly younger and having less exposure
Mean SD Mean SD
to HIV information and education than 9th graders, were
Pre-HIV/AIDS knowledge more curious to learn about HIV/AIDS and were attentive to
Male 21.22 4.79 21.32 5.26 their peer educators. Pediatric nurses, educators and others
Female 19.85 4.40 20.78 5.00 associated with children should plan and implement
Post-HIV/AIDS knowledge
developmentally appropriate peer educational programs to
Male 27.46 2.68 25.36 3.14
Female 27.75 3.88 25.67 3.57 younger students and across grades.
Self-efficacy Self-efficacy has been reported to be an important
Male 25.48 6.74 29.00 3.95 predictor of adolescents' risky behaviors (Van Campen &
Female 26.46 6.56 30.23 5.72 Romero, 2012). In this study, both 7th and 9th grade students
Parental monitoring had moderately high levels of self-efficacy, and self-efficacy
Male 26.83 4.22 18.52 4.24 was correlated with pre-HIV/AIDS knowledge. Ninth grade
Female 28.03 2.74 20.76 3.58 students had a higher self-efficacy mean score than 7th
graders. Similarly, both 7th and 9th grade students had
moderately high levels of parental monitoring mean scores;
7th graders had higher mean scores than 9th graders. This
Discussion and Nursing Implications finding was supported by the finding in this study that
Knowledge is one of the main factors that promotes parental monitoring was negatively correlated with the age.
healthy behaviors and reduces risk-taking behaviors. An This was a positive finding as studies have reported that
increase in HIV/AIDS knowledge was observed in both 7th higher parental monitoring was associated with decreased
grade and 9th grade adolescents after the peer education sexual risk behaviors (Biddlecom, Awusabo-Asare, &
program, which indicates the effectiveness of the interven- Bankole, 2009; Kalina et al., 2013; Van Campen & Romero,
tion program. This finding was consistent with previous 2012). However, in this study, parental monitoring was not
research (Caron et al., 2004; Mahat & Scoloveno, 2010; associated with either pre-HIV/AIDS knowledge or
Mash & Mash, 2014). Social learning theory postulates that self-efficacy.
the likelihood of a participant's adopting a preventing When the variables were analyzed by gender, there was
behavior is determined in part by respondent's knowledge of no significant difference in male and female students'
how HIV is transmitted (Karnell, Cupp, Zimmerman, knowledge mean scores post-intervention. This finding was
Feist-Price, & Bennie, 2006). Thus it can be concluded consistent with previous findings (Mahat & Scoloveno,
that the peer education programs could be effective in 2010). It is possible that both female and male students in
reducing risky behaviors among adolescents. Pediatric this sample felt comfortable talking about issues related to
nurses can play a significant role in preventing HIV/AIDS sexual health, therefore acquiring similar HIV/AIDS knowl-
infection among adolescents by educating them on HIV/ edge. Similarly, there was not a significant difference in
AIDS in outpatient clinics, during hospitalization and in self-efficacy by gender, although female students had
school and community settings. Pediatric nurses working in slightly higher self-efficacy mean scores than male students.
school and community settings can prepare peer educators Wang, Cheng, and Chou (2008), in their study of sexually
and implement peer education programs using a health inexperienced Taiwanese adolescent boys and girls, found
promotion intervention titled, Teens for AIDS prevention that adolescent girls had better self-efficacy for contraception
(TAP) program (Alford & Feijoo, 2002). The TAP peer use than did adolescent boys. In contrast to these findings, a
intervention program is designed to reduce adolescents' risk study (Boafo, 2011) reported that adolescent girls were more
of contracting HIV or other sexually transmitted infections likely to have low self-efficacy relative to condom use skills.
(STIs) by increasing their knowledge and encouraging them The mean score of parental monitoring was significantly
to change their attitudes and behaviors through creative higher among females than males. Cunningham, Mars, and
lesson plans. The preparation of peer educators and content Burns (2012) in their study of urban African-American
of the modified format of the program "Teens for AIDS adolescents found that older adolescent females reported
Prevention" (TAP) that is used in this study can be found in a higher levels of parental monitoring than did their adolescent
previous publication (Mahat, Scoloveno, Ruales, & male counterparts. In a review of the literature, Kincaid et al.
Scoloveno, 2006). (2012) demonstrated that parental monitoring may be more
Prior to the peer education program, both 7th and 9th of a buffer against sexual risk behavior for boys than girls,
grade students had similar mean scores on the HIV/AIDS whereas parental warmth and emotional connection may be a
knowledge questionnaire, determining that there was no protective factor for girls. These findings suggest that gender
difference in knowledge between the groups at baseline. is an important variable in the study of risk behaviors and
e68
family behaviors, such as parental monitoring. Pediatric
nurses should consider that there may be a difference in
parental monitoring based on socialization, cultural factors,
and age. Thus, the development of programs for adolescents
should include parent participation.
Pediatric nurses are well-positioned to develop and
implement evidence-based programs for adolescents. They
have integral knowledge of adolescent growth and develop-
ment and adolescent risk taking behaviors. Working with
schools and communities, in conjunction with other
professionals and parent groups, will help ensure healthy
outcomes for adolescents. Through peer education programs,
adolescent knowledge and health-promoting behavior can
be enhanced.
Limitation of the Study
One of the limitations of this study was the reliance on the
self-reported responses from adolescents. The second
limitation was the use of a convenient sample; therefore
the findings of this study cannot be generalized. Another
limitation is that only HIV/AIDS knowledge was assessed
5 weeks after the peer education program. Self-efficacy and
parental monitoring questionnaires were not administered
after the peer education program, which would have
provided an assessment of their impact over time. There
is a need for longitudinal studies of the effects of peer
education on HIV-AIDS knowledge and the impact of
self-efficacy and parental factors on adolescent sexual
risk behaviors.
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