Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) are major and growing concerns in American education (McFarland & Oliver, 1999). Numerous public health experts and health promotion advocates have identified several reasons HIV /AIDS has become an important issue for education professionals including: (a) an increasing number of reported HIV/ AIDS cases among young people (Centers for Disease Control and Prevention [CDC], 1999); (b) the need for HIV/AIDS education among students (Langer, Tubman, & Duncan, 1998) and staff (Brucker & Hall, 1996); and (c) the availability of resource personnel within the school community to provide support on HIV positive students and/or their families (McFarland & Oliver).
Between 500,000 and one million people in the United States currently are believed to be infected with HIV (CDC, 1998). It is estimated that at least half of all new infections in the United States occur in people younger than 25, and the majority of the young people are infected sexually (Center for AIDS Prevention Studies, 1999; CDC, 1999).
There is little question that school-age children and youth are at risk of either contracting HIV /AIDS themselves or being affected by the infection in a friend or significant adult (CDC, 1998). In this context, students who are infected with the virus or who are confronted with HIV / AIDS in a loved one may face grief, loss, shame, abandonment, depression, anger, anxiety, and hopelessness that can compromise academic success (Hedge, 1996; Holt, Houg, & Romano, 1999).
Role of the School Counselor In Context of HIV/AIDS Issues
School counselors routinely interact with students on the following topics: divorce, substance abuse, teen sexuality, depression, suicide, sexual and physical abuse, problems with family and friends, concerns about career and future, and questions about the meaning of life. School counselors contribute unique and valuable services within the school setting and therefore play a vital role in children's lives.
HIV/AIDS education, prevention, and support services in school are best approached using a collaborative model (Allensworth & Kolbe, 1987). Whereas health educators may be experts in dealing with the education and prevention strategies used when teaching students and staff about HIV/AIDS, counseling services provided by school counselors are essential for students experiencing pervasive issues such as psychosocial problems, stressful situations, and crises and emergencies that are often associated when working with a student infected or affected by the disease (Adelman, 1998). In addition, intervention strategies that address psychosocial factors such as low self-esteem and peer pressure, and use techniques such as problem solving, decision making, and assertiveness training, can help promote healthy behaviors that reduce the risk of contracting HIV.
As the number of children and adolescents infected or affected by HIV/AIDS has increased, so have the identified responsibilities of school counselors who work with this population (Cobia, Carney, & Waggoner, 1998; McFarland & Oliver, 1999). It is predicted that in the near future all professionals who work in schools will have direct or indirect contact with a student who is infected with or affected by HIV disease (Landau, Pryor, & Haefli, 1995).
The American School Counselor Association (ASCA, 1999), in a position statement titled The School Counselor and HIV/AIDS, suggested the following:
The school counselor focuses on AIDS and the Human Immunodeficiency Virus (HIV) as a disease and not as a moral issue. The in-service school counselor promotes prevention, health, and education, while providing a vital link to the well being of students, staff, parents, and the community. (p. 1)
This research investigated in-service and pre-service school counselors' current levels of HIV/AIDS-related knowledge and attitudes, and the demographic factors potentially associated with HIV/AIDS knowledge and attitudes. In this context, the research questions used to guide this study were:
1. What are the HIV/AIDS knowledge and attitudes among in-service school counselors and pre-service school counselors in Ohio?
2. Are there differences among in-service school counselors and pre-service school counselors in their knowledge and attitudes about HIV/AIDS?
3. Are there differences among in-service school counselors and pre-service school counselors in their knowledge and attitudes about HIV/AIDS when controlling for age?
4. Are there differences in in-service school counselors and pre-service school counselors in their knowledge and attitudes about HIV/AIDS when controlling for setting?
The participants for this study consisted of two groups, in-service school counselors and pre-service school counselors. For the purposes of this study, in-service school counselors were defined as public school counselors working in elementary, middle, or high schools in Ohio. Pre-service school counselors were defined as those individuals who were pursuing a master's degree in school counseling from institutions of higher education in Ohio at the time of this study. Data were collected in fall 1999 from 486 participants, 276 were in-service school counselors and 210 were pre-service school counselors. The majority of participants were White (93%) and female (77%). The majority of in-service school counselors ranged in age from 40 to 57 (72%), whereas the majority of pre-service school counselors ranged in age from 22 to 39 (66%). The school settings of in-service school counselors were: 29.5% elementary school, 23.4% middle school, and 45.3% high school. Pre-service counselors reported the following school settings: 31.4% elementary school, 25.7% middle school, and 35.7% high school. For the in-service counselors, 73% of the counties in Ohio were represented. For the pre-service counselors, 49% of the counties in Ohio were represented.
In-service school counselors were randomly sampled (n = 558) from the state membership list of the Ohio School Counselor Association (N = 1750). Dillman's Total Design Method (Salant & Dillman, 1994) was followed: Survey packets (cover letter, survey, postagepaid return envelope) were mailed to the sample of 558 school counselors in September 1999, and a follow-up postcard was mailed to all participants one week later. Four weeks after the initial mailing, follow-up survey packets were sent to participants who had not yet responded (n = 326). Respondents were ensured confidentiality. Surveys were numbered for follow-up purposes only and names were not connected to the data. Some 279 surveys were completed, resulting in a 50% response rate for this group.
Pre-service school counselors were made up of a convenience sample. The researcher contacted faculty members in counselor education programs at 13 Ohio universities that offered school counseling programs. Eleven faculty members from 11 schools agreed to participate in the study. Participating counselor educators were asked to request voluntary participation from their school counseling students during class time, collect completed instruments, and return them to the investigator. The surveys were distributed during only one class session in school-counseling-specific courses. Prior to data collection, the Human Participants Review Boards of all participating universities approved this study.
The HIV/AIDS Knowledge and Attitudes Scales for Teachers (Koch & Singer, 1998) were developed to assess teachers' level of knowledge and attitudes toward HIV disease in general, and the level of their knowledge and attitudes about specific educational issues. The scales were adapted from previously used national surveys and reviewed by a panel of HIV/AIDS experts (Koch & Singer). The scales can also be used with pre-service education students and practicing educators other than teachers (Koch & Singer).
The HIV/AIDS Knowledge Scale for Teachers consists of two parts. The first part, General Knowledge, includes 14 true-false items regarding HIV/AIDS such as cause, symptoms, diagnosis, effects, and treatment and four true-false items specific to classroom issues. The second part, Likelihood of Transmission, contains 17 possible modes of HIV transmission and asks participants to rate likelihood of transmission on a five-point Likert scale (very likely, somewhat likely, somewhat unlikely, very unlikely, definitely not possible). As with the true-false questions, the Likelihood of Transmission questions answered on the Likert scale have only one correct answer (very likely or definitely not possible) Thus, the entire knowledge scale contains 35 items. Respondents receive one point for each correct answer. Scores on the HIV/AIDS Knowledge Scale for Teachers can range from 0 (least knowledge, 35 questions answered incorrectly) to 35 (most knowledge, 35 questions answered correctly). Selected items from the General Knowledge Scale are presented in Table 1. (See page 82.)
The HIV/AIDS Attitudes Scale for Teachers contains 25 items regarding persons with HIV/AIDS and educational issues. This scale is formatted in a five-point Likert scale (strongly agree, agree, uncertain, disagree, strongly disagree). A mean score can be calculated with a mean of 1.00 representing the most unsupportive attitudes and 5.00 indicating the most supportive attitudes. Scores on the HIV /AIDS Attitudes Scale for Teachers can range from 25 (unsupportive attitudes) to 125 (most supportive attitudes). Selected items from the Attitudes Scale are presented in Table 2. (See p. 82.)
According to Koch and Singer (1998), the psychometric properties of the instrument were: Test-retest reliability, knowledge scale, r = .87 and attitudes scale, r = .89; internal consistencies, General Knowledge, K-R 20 = .78, Likelihood of Transmission, K-R 20 = .88, and entire scale, K-R 20 = .89; Cronbach's alpha coefficient was .89.
The accuracy of data entry was examined by checking 5% of the sample for data input errors. Two errors were found indicating that the rate of error was .00006. Descriptive statistics were generated to develop the demographic profile of the sample and analyzed to indicate the HIV/AIDS knowledge and attitudes of both inservice school counselors and pre-service school counselors. Multivariate analysis of variance tests were used to examine whether significant differences did occur between in-service school counselors and pre-service school counselors on the total knowledge score and total attitude score when controlling for school setting. A multivariate analyses of covariance test found whether a significant difference occurred between inservice school counselors and pre-service school counselors on the knowledge and attitude subscales using age as a covariate.
Examinations of the most commonly evaluated assumptions of multivariate normality were undertaken with the data using the procedures outlined by Hair, Anderson, Tatham, and Black (1998). The examination of normality, homoscedasticity, absence of correlated errors, and linearity all resulted in suggestion of a violation of multivariate normality. However, as the detection of violations of multivariate normality are currently rather gross estimates, it is important to note that research to date suggests that multivariate analysis of variance (MANOVA) and multivariate analysis of covariance (MANCOVA) are relatively robust to violation of multivariate normality (Hair et al.). Further, a conservative approach was used in the selection of omnibus tests. In this case, the use of Wilk's lambda and Pillai-Bartlett trace were used in conjunction. Wilk's lambda is the most commonly reported omnibus test and Pillai-Bartlett trace is the most robust to violation of multivariate normality (Bray & Maxwell, 1985).
Research question 1: What are the HIV/AIDS knowledge and attitudes among in-service school counselors and pre-service school counselors in Ohio? For the inservice school counselor group, scores on the
HIV/AIDS Knowledge Scale for Teachers ranged from 6 to 28 (M = 18.86, SD = 3.89). For the pre-service school counselor group, scores on the knowledge measure ranged from 9 to 27 (M = 18.46, SD = 3.41). For the inservice school counselors, scores on the HIV/AIDS Attitude Scale ranged from 41 to 125 (M = 97.39, SD = 12.65). For the pre-service school counselors, scores on the attitude measure ranged from 66 to 125 (M = 97.64, SD = 11.12).
Selected items from the General Knowledge and Attitude Scales are presented in Tables 1 and 2, respectively. Knowledge of HIV/AIDS-related topics was fairly high in some areas, and alarmingly low in others. For example, only 12% of participants knew than transmission of AIDS by mosquito bites is not possible. On the attitude scale, 94% would support an AIDS curriculum in their school, but only 57% would feel comfortable answering students' questions about HIV/AIDS.
Research question 2: Are there differences among in-service school counselors and pre-service school counselors in their knowledge and attitudes about HIV/AIDS? MANOVA was performed to determine if there were differences on HIV/AIDS knowledge and attitudes between in-service and pre-service school counselors. No significant differences between in-service and pre-service school counselors were found F(2, 477) = 1.070, p > .344.
Research question 3: Are there differences among in-service school counselors and pre-service school counselors in their knowledge and attitudes about HIV/AIDS when controlling for age? A MANCOVA with age as a covariate was performed to determine the effects age might have on HIV/AIDS knowledge and attitudes between in-service and pre-service school counselors. No significant differences for age were found F(2, 477) = .229, p > .795.
Research question 4: Are there differences among in-service school counselors and pre-service school counselors in their knowledge and attitudes about HIV/AIDS when controlling for school setting? A MANCOVA was performed to determine the effects school setting may have on HIV/AIDS knowledge and attitudes between in-service and pre-service school counselors. No significant differences for school setting were found F(4, 910) = .766, p > .548.
The primary results of this study revealed that in-service and pre-service school counselors in Ohio had equivalent knowledge and attitudes about HIV/AIDS. Both groups had lower than expected levels of knowledge as confirmed by answering the knowledge questions correctly only 53% of the time. All participants appeared to know more about HIV/AIDS general knowledge, 66% correct, than knowledge of transmission, 40% correct. Overall, the participants in this study appeared to possess uncertain to slightly positive attitudes toward HIV/AIDS, with an average score of 97 (M = 3.88 on a 1 to 5 scale). These findings are consistent with other studies that have examined HIV/AIDS knowledge and attitudes among counselors or school personnel. Carney, Werth, and Emanuelson (1994) reported that pre-service counselors had only moderate knowledge of HIV/AIDS information. In a similar study, researchers found that special educators had limited knowledge of verified and nonverified modes of HIV/AIDS transmission (Foley & Kittleson, 1993). Bowd (1987) found significant deficiencies in the knowledge of both experienced teachers and student teachers.
Additional results of the present study suggest no significant differences in knowledge and attitudes toward individuals with HIV/AIDS between the in-service school counselor and pre-service school counselor groups by age or school setting (elementary, middle, or high schools). These findings do not support the results of previous research that suggested age (Brucker & Hall, 1991) and school setting (Boscarino & DiClemente, 1996; Dawson, Chunis, Smith, & Carboni, 2001) might make some impact on the HIV/AIDS knowledge and attitudes of school personnel.
Results also suggest that HIV/AIDS education for in-service and pre-service school counselors may be inadequate, since a substantial number of the participants in this study appear to be misinformed about HIV/AIDS. Current research suggests that an intensive HIV/AIDS education model approach for counselors could have positive effects that are maintained over a substantial period of time (Britton, Cimini, & Rak, 1999; Britton, Rak, Cimini, & Shepherd, 1999). Specific topics to be included in HIV/ AIDS education may include general facts about transmission, medical aspects, prevention, psychological aspects, and understanding the diverse subgroups of the population infected or affected (Holder, 1989).
Implications for School Counselors
The results of this study suggest that counselor education programs and school districts need to do a better job in educating school counselors about HIV/AIDS. School counselors in particular need to be prepared to do AIDS prevention and counseling with adolescents and young adults, one of the populations at highest risk of contracting HIV. To obtain this education, counselor education faculty may consider partnering with health educators to provide in-services for school counselors already in the field. In turn, the counselors in the field could help with educating students and staff about HIV/AIDS.
Of greater concern, however, was the lack of knowledge many participants appeared to have about the transmission of HIV/AIDS. There seems to be a great deal of misinformation about the spread of the disease. These knowledge deficits and faulty thoughts about transmission may be debunked by teaching school counselors the clinical facts about the transmission of the disease. Rather than just stating the routes of transmission as fact, a scientific lesson on transmission may help school counselors come to a clearer understanding of how HIV/AIDS can be transmitted based on knowledge rather than fear. In addition, it may be important to educate school counselors on the most effective ways to protect oneself from transmission. Finally, training on how to protect oneself and others in the school setting may also be particularly beneficial.
Initially, in-service and pre-service school counselors need an education on basic knowledge about HIV/AIDS, particularly in the area of how HIV is and is not transmitted. It is important for in-service school counselors and pre-service school counselors to also explore their attitudes about the disease, and feelings about people who have the disease. In particular, school counselors must understand that the school-age population is at risk for HIV infection, and that HIV/AIDS can affect people of all ages, ethnicities, socioeconomic classes, education levels, and sexual orientations.
Sensitivity training is critical, especially when one considers the role of a school counselor. It appears that one third of the participants in this study viewed HIV/AIDS as a "gay disease," or a disease that is caused due to "immoral behavior" such as sexual promiscuity or drug use. Oftentimes the school counselor is the individual in a school to whom a student turns. Therefore, school counselors should explore their feelings and fears about the disease in order to be able to support a student who is either infected or affected by HIV/AIDS in some way.
This study had limitations. The sample was drawn only from in-service and pre-service school counselors in Ohio, which limits generalizability. A limitation of this study can also be found in the use of the Ohio School Counselor Association mailing list to solicit inservice school counselor participants. A 50% response rate from the in-service counselors may also reflect some bias in this study. In addition, the instrument used may have only examined samples of knowledge and attitudes. Other important aspects of knowledge or attitudes may have gone unexamined.
Based on the results of the present study, however, there are several recommendations for future research. The first recommendation involves replicating the study in other states. Since very few studies have explored school counselors' knowledge and attitudes about
HIV/AIDS, further examination is warranted. In addition, the HIV/AIDS Knowledge and Attitudes Scales for Teachers provide no norming groups for populations of school counselors and school counseling students. A replication study may possibly substantiate the findings of the present study and contribute to the creation of a norming group for school counselors and school counseling students.
Research to date has not explored the type or amount of HIV/AIDS education that in-service school counselors or pre-service school counselors are receiving from their graduate programs or other school-based in-service programs. It may also be beneficial to use the instrument as a pre-test / post-test measure before and after school counselors receive further HIV/AIDS education. In addition, qualitative research is needed in order to assess additional variables that may contribute to the HIV/AIDS knowledge and attitudes of pre-service and in-service school counselors.
Adelman, H. (1998). School counseling, psychological, and social services. In E. Marx & S. Wooley (Eds.), Health is academic: A guide to coordinated school health programs (pp. 142-168). New York: Teachers College Press.
Allensworth, D. D., & Kolbe L. J. (1987). The comprehensive school health program: Exploring an expanded concept. Journal of School Health, 57, 409-412.
American School Counselor Association. (1999). The school counselor and HIV/AIDS (Position statement). Alexandria, VA: Author.
Boscarino, J. A., & DiClemente, R. J. (1996). AIDS knowledge, teaching comfort, and support for AIDS education among school teachers: A statewide study AIDS Education and Prevention, 8, 267-277.
Bowd, A. D. (1987). Knowledge and opinions about AIDS among student teachers and experienced teachers. Canadian Journal of Public Health, 78, 84-87.
Bray, J. H., & Maxwell, S. E. (1985). Multivariate analysis of variance. Newbury Park, CA: Sage.
Britton, P J., Cimini, K. T., & Rak, C. F. (1999). Techniques for teaching HIV counseling: An intensive experiential model. Journal of Counseling and Development, 77, 171-176.
Britton, P. J., Rak, C. F., Cimini, K. T., & Shepherd, J. B. (1999). HIV/AIDS education for counselors: Efficacy and training. Counselor Education and Supervision, 39, 53-65.
Brucker B. W., & Hall, W. H. (1991). AIDS in the classroom: Are
teacher attitudes changing? Early Child Development and Care, 77, 137-147.
Brucker, B. W., & Hall, W. H. (1996). Teachers' attitudes toward HIV/AIDS: An American national assessment. Early Child Development and Care, 115, 85-98.
Carney, J., Werth, J. L., & Emanuelson, J. (1994). The relationship between attitudes toward persons who are gay and persons with AIDS, and HIV /AIDS knowledge. Journal of Counseling and Development, 72, 646-650.
Center for AIDS Prevention Studies. (1999). What are adolescents' HIV prevention needs? Retrieved February 14, 2002, from
Centers for Disease Control and Prevention. (1998, August 25). Surveillance report: HIV and AIDS cases reported through June 1998. Retrieved March 13, 2002, from http://www.cdc.gov/hiv/stats/ hasr1001.htm
Centers for Disease Control and Prevention. (1999). Young people at risk: HIV(AIDS among America's youth. Retrieved February 14, 2002, from http://www.cdc.gov/nchstp/hiv_aids/pubs/facts/ youth.html
Cobia, C., Carney, J., & Waggoner, I. (1998). Children and adolescents with HIV disease: Implications for school counselors. Professional School Counseling, 1(5), 41-45.
Dawson, L. J., Chunis, M. L., Smith, D. M., & Carboni, A. A. (2001). The role of academic discipline and gender in high school teachers' AIDS-related knowledge and attitudes. Journal of School Health, 71(1), 3-8.
Foley, R. M., & Kittleson, M. J. (1993). Special educators' knowledge of HIV transmission: Implications for teacher education programs. Teacher Education and Special Education, 16, 342-350.
Hair, J., Anderson, R., Tatham, R., & Black, W. (1998). Multivariate data analysis (5th ed). Upper Saddle River, NJ: Prentice Hall.
Hedge, B. (1996). Counseling people with AIDS, their partners, family and friends. In J. Green & A. McCreaner (Eds.), Counseling in HIV infection and AIDS (2nd ed., pp. 66-82). Cambridge, MA: Blackwell Scientific.
Holder, J. R. (1989). AIDS: A training program for school counselors. The School Counselor, 36, 305-309.
Holt, J. L., Houg, B. L., & Romano, J. L. (1999). Spiritual wellness for clients with HIV /AIDS: Review of the counseling issues. Journal of Counseling and Development, 77, 160-169.
Koch, P. B., & Singer, M. D. (1998). HIV /AIDS knowledge and attitudes scales for teachers. In C. Davis, W. Yarber, R. Bauserman,
G. Schreer, & S. Davis (Eds.), Handbook of sexuality-related measures (pp. 317-320). Thousand Oaks, CA: Sage.
Landau, S., Pryor, J. B., & Haefli, K. (1995). Pediatric HIV: Schoolbased sequelae and curricular interventions for prevention and social acceptance. School Psychology Review, 24, 213-229.
Langer, L. M., Tubman, J. G., & Duncan, S. (1998). Anticipated mortality, HIV vulnerability, and psychological distress among adolescents and young adults at higher and lower risk for HIV infection. Journal of Youth and Adolescence, 27, 513-538.
McFarland, W. P, & Oliver, J. (1999). Empowering professional school counselors in the war against AIDS. Professional School Counseling, 2, 267-274.
Salant, P., & Dillman, D. A. (1994). How to conduct your own survey. New York: John Wiley.
Amanda C. Costin, Ph.D., NCC, is an assistant professor, and Betsy J. Page, Ed.D., LPCC, NCC, ACS, is an associate professor; both are with Counseling and Human Development Services, Kent State University, Kent, OH.
Dale R. Pietrzak, Ed.D., LPC-MH, CCMHC, is an associate professor, Counseling and Psychology in Education, University of South Dakota, Vermillion, SD. Dianne L. Kerr, Ph.D., CHES, is an associate professor, and Cynthia W. Symons, D. Ed., CHES, is a professor; both are with Health Education and Promotion, Kent State University, Kent, OH.…