Using Brochures as Educational Tools to Promote Routine HIV Testing in Youth

Research Article

Austin J Pediatr. 2014;1(2): 1008.

Using Brochures as Educational Tools to Promote Routine HIV Testing in Youth

Carina Rodriguez*

Department of Infectious Disease, University of South Florida

*Corresponding author: Carina Rodriguez, Assistant Professor of Pediatrics, Department of Infectious Disease, University of South Florida, USA, 17 Davis Blvd., Suite 200, Tampa, FL 33606

Received: April 17, 2014; Accepted: June 15, 2014; Published: June 19, 2014


About 60% of American youth with HIV are unaware of their infection. Whereas routine HIV testing of youth ages 16-18 is recommended, the level of awareness of the recommendation is low. The purpose of this study was to develop evidence-based brochures that can be used to promote routine HIV testing of youth and to evaluate their effectiveness and acceptability. Brochure development was undertaken in five steps. Twenty-six youth and 30 adults completed a survey on perception of effectiveness and acceptability of the brochures. Adults were more likely than youth to report a change in belief on the need of HIV testing (OR = 5.3, 95% CI: 2.9, 9.7) and perceive brochures as containing enough information to decide to get tested (OR = 2.7, 95% CI: 1.2, 6.0). Attention to content, readability, and appearance of messages is key to production of evidence-based brochures.

Keywords: Health information; Dissemination of health information; HIV/ AIDS; Printed medium; Risk communication; Sexually transmitted infections


Human Immune-deficiency Virus (HIV) continues to be a major public health burden in the United States [1]. Despite great progress in treatment and efforts to screen targeted populations, the Centers for Disease Control and Prevention (CDC) reports that about 50,000 people are infected with HIV each year, one in four of these new infections occurs in youth aged 13 to 24 years, and more than half (57.4%) of new infections occur in African Americans [2]. Most of HIV-infected youth (59.5%) are unaware of their infection [2], thus are unlikely to be receiving antiretroviral treatment. This predisposes them to sickness, early death, or unknowingly infecting others.

The CDC [3] , the American Academy of Pediatrics [4], and the U.S. Preventive Task Force [5], all recommend making HIV testing a routine part of health care encounter irrespective of patient’s reasons for visit and of presence of risk factors. Routine HIV testing is buttressed by strong evidence from trials showing that a consistently suppressed HIV viral load through initiation of antiretroviral therapy is associated with reduced morbidity, mortality and probability of HIV transmission to sex partners [6]. Despite these recommendations, the rate at which adolescents are tested has not changed significantly [7]. Only about 35% of 18-24 year olds tested for HIV, and only 13% of high school students have ever been tested [2]. Accurate and age-appropriate information on risk factors for HIV infection, risk reduction, and access to HIV testing resources are important in making decision about HIV testing [8].

Communication of health messages such as routine HIV testing requires effective dissemination tools. Printed materials have been used to disseminate health messages to patients [9,10], however, their readability, content and appearance have been questioned [11- 14]. For example, American Academy of Pediatric Dentistry patient education materials were found to be difficult to read and written above the recommended level for the general public [15]. In a study evaluating 21 HPV-related educational materials, it was found that readability levels were too high, content lacked clear purpose or “take home” messages, graphics were out of place, and unexplained medical terminology were included [16]. To date, we are not aware of any systematic investigation on the impact of brochures as an educational tool for disseminating health messages. The purpose of this study was to develop evidence-based brochures for dissemination of information about routine HIV testing of youth and to evaluate their effectiveness and acceptability in fulfilling this function.


Study setting

The first author is engaged in the evaluation of all Florida/ Caribbean AIDS Education Training Center programs. Thus, data for this study were collected as part of a larger HIV testing initiative special project whose goal was to design, produce, and pilot promotional and educational materials to assist youth, parents, and providers in implementing routine HIV testing in medical settings. The current data are based on educational brochures distributed between January and April 2013 by outreach and clinical staff and providers to youth aged 13-24 years and adults (parents/guardians) who accompanied them at two clinical settings and two community events. The first site, Ybor Youth Clinic, provides care to underserved and at-risk youth ages 13- 24 years including Lesbian, Gay, Bisexual, Transgender youth (LGBT); homeless and street youth; and sexually exploited youth. The second site, Children’s Medical Services, located within a public university, is a clinic for children with specialty medical conditions. The first community event, the Black History Festival, took place in the Sweet Bay parking lot in Tampa, Florida. This event targeted African American families and drew a crowd of about 100 people. It included free food, health screenings, children’s activities, and live entertainment. The second event, It’s a Family Affair, took place in a public parking lot in Tampa, Florida. It attracted about 250 people, mostly minority families. After reading the brochures, participants completed a 1-page paper-pencil survey assessing the effectiveness and acceptability of the brochure.

Definition of purpose

Two sets of tri-fold brochures were developed using Adobe Photoshop software, to target youth and adults. Both sets were designed to be similar in various aspects including content, readability and appearance. The development of brochures was undertaken in five steps outlined next.

Definition of purpose

For both sets of brochures, the objective was to disseminate information about routine HIV testing of youth and to call participants to take action. To communicate this purpose, the front face was titled, “Making HIV Testing Routine.” The phrases, “Stop the Spread of HIV” and “Get Tested Today” in youth brochure and “Learn why it is important for your adolescent to get tested for HIV,” “Make it part of his/her regular medical checkup,” and “Empower your teen” in the adult brochure were intended to call participants to take action: youth to decide to be tested for HIV and adults to encourage youth to be tested.

Content topic identification

Based on review and synthesis of literature on HIV testing [2,3,5,7,17-23], existing guidelines and policies [3-5], frequently asked questions [24], existing materials on HIV testing [1,25], and professional experience of our research team, nine topics were identified: (1) Teens & HIV – The Facts, statistics on HIV infection among youth; (2) What is HIV/AIDS? (3) You can get HIV from\ you cannot get HIV from; (4) Why get an HIV test? [Youth brochure]/ Why encourage your teen to test for HIV? [Adult brochure]; (5) How can I get tested? [Youth] How can my teen be tested for HIV? [Adult] (6); what is HIV tests like? [Youth]/Types of HIV tests [adults]; (7) What if the test comes back positive? (8) Remember, a reiteration of take homes messages; and (9) References.

Message organization

Messages under each content topic were organized based on three criteria for effective printed materials: content, readability, and appearance [16,25]. Regarding content, we ensured that the texts were thematically simple (contained a single theme and clear action expected after reading the texts), brief (contained unambiguous, non-technical, and consolidated information packages), accurate (based on up-to-date and credible information sources including evidence-based clinical practice guidelines), and organized (e.g., information is delivered and displayed into easily digestible pieces; most important information is placed at the beginning and repeated at the end; title indicate purpose of text; headers are used to facilitate reading; and contact details are provided). To enhance readability, the degree to which the reader and writer shared meaning of text, we avoided the use of technical words and ensured that ideas within and between sentences cohered. To enhance attractive appearance of brochures, we included a clear purpose (title) in the front face; muted color of paper; ensured there was sufficient white space around each face; left-justified all text; and used readable font size and bullets for cueing. We also ensured the graphics contained enough detail, were culturally appropriate, and portrayed the life world of target audience.

Content validation

A panel of experts (3 clinicians; 2 social workers; 2 faculty members, one with expertise in measurement and another in public health) and sample of intended end-users (4 youth and 3 adults) reviewed the brochures for readability, clarity of language, cultural appropriateness, and usefulness for the intended purpose. The brochures were modified based on triangulated feedback from these reviewers and the panel.

Survey development and administration

Two sets of surveys were developed, for youth and for adults. After reading the brochures, participants completed a 1-page paper-pencil survey designed to assess the effectiveness and acceptability of the brochure in disseminating information about routine HIV testing of youth. Data were collected on participant demographics; youth’s sexual orientation; awareness of youth’s HIV status; participants’ perception of the impact of brochures on knowledge and attitude about routine HIV testing; and perception of brochure content, readability, and appearance. It is important to note that both surveys focused on youth and most of the items were similar. A few items were worded slightly differently to suit the respondent. For example, “I now know where to go for routine HIV testing” in youth survey corresponded to “I now know where my youth can go for routine HIV testing” in adult survey.

Because there was no plan to collect identifying information, this study was exempt from the requirement of Institutional Review Board review process. Verbal consent was obtained after the purpose of the study was explained to potential respondents. No monetary incentives were given for participation. A typical encounter involved a clinical provider or community outreach staff approaching a potential participant, screening them for eligibility (youth aged 13-24; parent/ guardian of youth), describing the purpose of the brochure, handing a brochure to read, and asking for voluntary feedback through the completion of the survey. All participants read through the brochure and completed the survey before meeting with their physician (for those in clinics) or before the end of the community event.


Descriptive analyses (frequencies) were conducted to compare demographics and responses to the questions about youth sexual orientation, prior testing for HIV, and awareness of HIV status for two groups (youth and adults). Effect of reading the brochure (9 items) and acceptability of brochure (7 items) were compared using Chi-square tests. Responses to items was based on a 5-point Likert-type scale (1=Disagree Strongly to 5=Agree Strongly), with affirmative responses (“Agree” + “Agree Strongly”) being used to index the odds of agreement with the statement among youth compared to adults. All analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC).


Participant demographics

Fifty-six participants completed the surveys. Youth were predominantly African American female ages 13- 24 years. Adults were predominantly African American women aged over 25 years (Table 1). Ninety percent of the adults indicated that they were youth’s biological parents. Whereas over two-thirds of the youth self-identified as heterosexual, less than half of the adults reported that their youth were heterosexual. No youth considered themselves bisexual or gay but a few adults reported that their youth was bisexual (6%) or gay (3%). About a quarter of the participants did not respond to the question about youth’s sexual orientation.