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HIV Knowledge Questionnaire

HIV-KQ-18

(18 item version)

Carey, M. P., & Schroder, K. E. E. (2002).


Development and psychometric evaluation of
the brief HIV knowledge questionnaire
(HIV-KQ-18). AIDS Education and
Prevention, 14, 174-184.
HIV-KQ-18

For each statement, please circle True (T), False (F), or I dont know (DK). If you do not know, please
do not guess; instead, please circle DK.

True False I dont


know

1. Coughing and sneezing DO NOT spread HIV. T F DK

2. A person can get HIV by sharing a glass of water with


someone who has HIV. T F DK

3. Pulling out the penis before a man climaxes/cums keeps


a woman from getting HIV during sex. T F DK

4. A woman can get HIV if she has anal sex with a man. T F DK

5. Showering, or washing ones genitals/private parts,


after sex keeps a person from getting HIV. T F DK

6. All pregnant women infected with HIV will have babies


born with AIDS. T F DK

7. People who have been infected with HIV quickly show


serious signs of being infected. T F DK

8. There is a vaccine that can stop adults from getting HIV. T F DK

9. People are likely to get HIV by deep kissing, putting their


tongue in their partners mouth, if their partner has HIV. T F DK

10. A woman cannot get HIV if she has sex during her period. T F DK

11. There is a female condom that can help decrease a womans


chance of getting HIV. T F DK

12. A natural skin condom works better against HIV than does
a latex condom. T F DK

13. A person will NOT get HIV if she or he is taking antibiotics. T F DK

14. Having sex with more than one partner can increase a
persons chance of being infected with HIV. T F DK

15. Taking a test for HIV one week after having sex will tell a
person if she or he has HIV. T F DK

16. A person can get HIV by sitting in a hot tub or a swimming


pool with a person who has HIV. T F DK

17. A person can get HIV from oral sex. T F DK

18. Using Vaseline or baby oil with condoms lowers the


chance of getting HIV. T F DK
Answer Key
HIV KQ 18

1 TRUE
2 FALSE
3 FALSE
4 TRUE
5 FALSE
6 FALSE
7 FALSE
8 FALSE
9 FALSE
10 FALSE
11 TRUE
12 FALSE
13 FALSE
14 TRUE
15 FALSE
16 FALSE
17 TRUE
18 FALSE
Original Spanish Translation Back Translation
1. Coughing and sneezing DO NOT spread 1. El toser o estornudar NO disemina el contagio de 1. Coughing or sneezing do not spread HIV
HIV VIH

2. A person can get HIV by sharing a glass of 2 .Una persona puede contagiarse con VIH si 2. A person can get HIV sharing a glass of water with
water with comparte un vaso de agua que ha utilizado una a person who has HIV
someone who has HIV persona infectada con VIH

3.Pulling out the penis before a man 3. Sacar el pene antes de que el varn eyacule evita 3. Pulling out the penis before a man ejaculates
climaxes/cums keeps que la mujer se contagie con el virus de VIH climax/cums keeps the woman from getting HIV
a woman from getting HIV during sex durante las relaciones sexuales. during sexual intercourse

4. A woman can get HIV if she has anal sex 4. Una mujer puede infectarse con el VIH, si tiene 4. A woman can get HIV if she has anal sex with a man
with a man Relaciones sexuales anales (sexo anal) con un
hombre

5. Showering, or washing ones genitals/private 5. Ducharse o lavarse los genitals/ partes privadas 5. Showering or washing genitals after having sex keep
parts, after sex keeps a person from getting HIV luego de una relacin sexual evita que la persona se the person from getting HIV
infecte con VIH.

6. All pregnant women infected with HIV will 6. Toda mujer embarazada, infectada con VIH, 6. All pregnant women with HIV, will have children
have babies tendr nios infectados con VIH. with HIV
born with AIDS
7. People who have been infected with HIV 7. Personas que estn infectadas con el VIH, 7. People who are infected with HIV, quickly show the
quickly show Rpidamente muestran los signos o sntomas de signs or symptoms of being infected
serious signs of being infected que est contagiado (a)

8. There is a vaccine that can stop adults from 8. Existe una vacuna que evita que la persona adulta 8. There is a vaccine that avoids adult from getting
getting HIV se infecte con el VIH HIV

9. People are likely to get HIV by deep kissing, 9. Las personas son ms propensas a infectarse 9.People are more likely to get HIV by deep kissing
putting their cuando se dan besos profundos (French kiss), o putting his/her tongue inside their partners infected
tongue in their partners mouth, if their partner colocan sus lenguas dentro de la boca de sus with HIV
has HIV parejas que est infectada con VIH

10. A woman cannot get HIV if she has sex 10. Una mujer no puede contagiarse con VIH si tiene 10. A woman can not HIV if she has sex during her
during her period relaciones sexuales durante su menstruacin menses (period)

11. There is a female condom that can help 11. Existe un condn femenino que ayuda a reducer 11. There is a female condom which can help reduce a
decrease a womans el riesgo de infectarse con VIH woman change of getting HIV
chance of getting HIV
12. A natural skin condom works better against 12. Un condn de piel es major para prevenir el 12. A swing condom is better preventing tha HIV
HIV than does contagio de VIH que un condn de latex. contagion than the latex condom
a latex condom.
13. A person will NOT get HIV if she or he is 13. Una persona que est tomando antibiticos no se 13. A person who is taking antibiotics will not get
taking antibiotics. contagiar con VIH si tiene relaciones sexuales infected with HIV if he/she has sex.

14. Having sex with more than one partner can 14. Tener relaciones sexuales con ms de una pareja 14. Having sex with more than one partner increases
increase a sexual aumenta la probalilidad de que se infecte the changes of getting infected with HIV
persons chance of being infected with HIV con VIH

15. Taking a test for HIV one week after having 15. Realizarse una prueba para determinar si se esta 15. Taking a test for HIV a week after having sex
sex will tell a infectado con VIH una semana despus de haber (sexual relations) will tell a person if he/she has HIV
person if she or he has HIV tenido relaciones sexuales, puede determinar si
la persona est infectada o no

16. A person can get HIV by sitting in a hot tub 16. Una persona puede infectarse con VIH 16. A person can get HIV by sharing a hot tub or a
or a swimming compartiendo un bao termal (yacuzzi) o una swimming pool with a person infected with HIV
pool with a person who has HIV piscina con una persona infectada con el VIH.

17. A person can get HIV from oral sex 17. Una persona puede contagiarse con VIH cuando 17. A person can get HIV from having oral sex
sostiene relaciones sexuales de forma oral

18. Using Vaseline or baby oil with condoms 18. Utilizar vaselina o aceite para beb con los 18. The use of vaseline or baby oil with condoms
lowers the chance of getting HIV condones reduce el riesgo de infectarse con VIH. reduces the risk of getting HIV
HIV Knowledge Questionnaire (HIV-K-Q)

(45 item version)

Carey, M. P., Morrison-Beedy, D., & Johnson, B.


T. (1997). The HIV-Knowledge
Questionnaire: Development and evaluation
of a reliable, valid, and practical self-
administered questionnaire. AIDS and
Behavior, 1, 61-74.
HIV-KQ-45

For each statement, please circle True (T), False (F), or I Dont Know (DK). If you do not know,
please do not guess; instead, please circle DK.

True False Dont


Know

1. HIV and AIDS are the same thing. T F DK

2. There is a cure for AIDS. T F DK

3. A person can get HIV from a toilet seat. T F DK

4. Coughing and sneezing DO NOT spread HIV. T F DK

5. HIV can be spread by mosquitoes. T F DK

6. AIDS is the cause of HIV. T F DK

7. A person can get HIV by sharing a glass of water with


someone who has HIV. T F DK

8. HIV is killed by bleach. T F DK

9. It is possible to get HIV when a person gets a tattoo. T F DK

10. A pregnant woman with HIV can give the virus to her
unborn baby. T F DK

11. Pulling out the penis before a man climaxes/cums keeps


a woman from getting HIV during sex. T F DK

12. A woman can get HIV if she has anal sex with a man. T F DK

13. Showering, or washing ones genitals/private parts,


after sex keeps a person from getting HIV. T F DK

14. Eating healthy foods can keep a person from getting HIV. T F DK

15. All pregnant women infected with HIV will have babies
born with AIDS. T F DK

16. Using a latex condom or rubber can lower a persons


chance of getting HIV. T F DK
True False Dont
Know

17. A person with HIV can look and feel healthy. T F DK

18. People who have been infected with HIV quickly show
serious signs of being infected. T F DK

19. A person can be infected with HIV for 5 years or more


without getting AIDS. T F DK

20. There is a vaccine that can stop adults from getting HIV. T F DK

21. Some drugs have been made for the treatment of AIDS. T F DK

22. Women are always tested for HIV during their pap smears. T F DK

23. A person cannot get HIV by having


oral sex, mouth-to-penis, with a man who has HIV. T F DK

24. A person can get HIV even if she or he has sex with
another person only one time. T F DK

25. Using a lambskin condom or rubber is the best protection


against HIV. T F DK

26. People are likely to get HIV by deep kissing, putting their
tongue in their partners mouth, if their partner has HIV. T F DK

27. A person can get HIV by giving blood. T F DK

28. A woman cannot get HIV if she has sex during her period. T F DK

29. You can usually tell if someone has HIV by looking at them. T F DK

30. There is a female condom that can help decrease a womans


chance of getting HIV. T F DK

31. A natural skin condom works better against HIV than does
a latex condom. T F DK

32. A person will NOT get HIV if she or he is taking antibiotics. T F DK

33. Having sex with more than one partner can increase a
persons chance of being infected with HIV. T F DK
True False Dont
Know

34. Taking a test for HIV one week after having sex will tell a
person if she or he has HIV. T F DK

35. A person can get HIV by sitting in a hot tub or a swimming


pool with a person who has HIV. T F DK

36. A person can get HIV through contact with saliva, tears,
sweat, or urine. T F DK

37. A person can get HIV from a


womans vaginal secretions/wetness from her vagina. T F DK

38. A person can get HIV if having


oral sex, mouth on vagina, with a woman. T F DK

39. If a person tests positive for HIV, then the test site will
have to tell all of his or her partners. T F DK

40. Using Vaseline or baby oil with condoms lowers the


chance of getting HIV. T F DK

41. Washing drug use equipment/works with


cold water kills HIV. T F DK

42. A woman can get HIV if she has vaginal sex with a
man who has HIV. T F DK

43. Athletes who share needles when using steroids can


get HIV from the needles. T F DK

44. Douching after sex will keep a woman from getting HIV. T F DK

45. Taking vitamins keeps a person from getting HIV. T F DK


Answer Key HIV KQ 45
1 FALSE
2 FALSE
3 FALSE
4 TRUE
5 FALSE
6 FALSE
7 FALSE
8 TRUE
9 TRUE
10 TRUE
11 FALSE
12 TRUE
13 FALSE
14 FALSE
15 FALSE
16 TRUE
17 TRUE
18 FALSE
19 TRUE
20 FALSE
21 TRUE
22 FALSE
23 FALSE
24 TRUE
25 FALSE
26 FALSE
27 FALSE
28 FALSE
29 FALSE
30 TRUE
31 FALSE
32 FALSE
33 TRUE
34 FALSE
35 FALSE
36 FALSE
37 TRUE
38 TRUE
39 FALSE
40 FALSE
41 FALSE
42 TRUE
43 TRUE
44 FALSE
45 FALSE
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AIDS and Behavior, Vol. 1, No. 1, 1997

The HIV-Knowledge Questionnaire: Development and


Evaluation of a Reliable, Valid, and Practical
Self-Administered Questionnaire

Michael P. Carey,1*3 Dianne Morrison-Beedy,2 and Blair T. Johnson1

Received June 13, 1996; accepted July 5. 1996

We have developed and evaluated a self-administered questionnaire of knowledge about hu-


man immunodeficiency virus (HIV) infection for use in program evaluation. Formative work
led to the development of the 62-item HIV-Knowledge Questionnaire (HIV-K-Q),which was
administered to 409 women and 227 men. Item analyses resulted in the deletion of 17 items
that were either too easy or did not correlate well with the total score. Factor analysis on
the remaining 45 items resulted in a single factor labeled HIV Knowledge. The generalizability
of this one-factor solution was confirmed with data from 285 women and 76 men. Reliability
analyses revealed that the HIV-K-Q is internally consistent (alpha = .91) and stable over
1-week (r = .83), 2-week (r = .91), and 12-week (r = .90) intervals. Evidence for the validity
of the HIV-K-Q was assembled using known groups and treatment outcome analyses. Ad-
ditional evidence emerged from analyses that revealed associations between scores on the
HTV-K-Q and two related knowledge measures, and between HIV-K-Q scores and level of
educational attainment. Discriminant evidence was obtained through nonsignificant relation-
ships between the HTV-K-Q and potentially biasing constructs, including social desirability.
The HIV-K-Q requires a sixth-grade education, and 7 min to complete. The HIV-K-Q is a
reliable, valid, and practical measure of HIV-related knowledge that can be used with low-
literacy adults.
KEY WORDS: HIV; AIDS; knowledge; measurement; assessment.

INTRODUCTION tious agent that causes AIDS (Rosenberg, 1995). Al-


though rates of new infections among gay men have
The Centers for Disease Control and Prevention declined, rates among heterosexual men and women
recently announced that acquired immunodeficiency have either remained stable or increased. It has been
syndrome (AIDS) is the leading cause of death estimated that 71% of HIV-infected cases worldwide
among young adults in the United States. Estimates involve heterosexual transmission (Ehrhardt, 1992),
indicate that 3% of African American men and 1% and that poverty potentiates the risk of HIV infection
of African American women in their 30s are living (O'Leary and Jemmott, 1995). AIDS incidence has in-
with human immunodeficiency virus (HIV), the infec- creased more rapidly in recent years among individu-
als born in 1960 or later compared to individuals born
earlier (Rosenberg, 1995). These data confirm that
^Department of Psychology, Syracuse University, Syracuse, New AIDS affects people regardless of their gender, age,
York. race, or sexual orientation.
2
College of Nursing, Niagara University, Niagara University, New Because there is neither a cure nor a vaccine
York.
3
Correspondence should be directed to Michael P. Carey, Depart- against HIV and AIDS, behavioral change provides
ment of Psychology, 430 Huntington Hall, Syracuse University, the only protection against infection. Efforts to pre-
Syracuse, New York 13244-2340; e-mail: mpcarey@syr.edu vent or reduce risk of HIV infection through behav-

61
1090-7165/97ABMX)61J12.5(M> O 1997 Plenum Publishing Corporation
62 Carey, Morrison-Beedy, and Johnson

ior change begin with an understanding of the de- and evidence of the validity of this measure has been
terminants of risk behavior. Several models have modest. Moreover, the ARBKT uses a "true-or-false"
been proposed to explain HIV-related risk behavior. response format, increasing the likelihood that respon-
Prominent among these are the AIDS Risk Reduc- dents may guess, which adds error variance to test
tion Model (Catania et al., 1990) and the Informa- scores. Finally, for our purposes (i.e., use with low-lit-
tion-Motivation-Behavioral Skills model (Fisher and eracy adults), the ARBKT is limited because it was
Fisher, 1992). Both models identify knowledge (in- developed with participants who were relatively well-
formation) as an important determinant of risk be- educated (M = 14.4 years; Kelly et al., 1989).
havior. Accordingly, most intervention programs Dancy (1991) developed the AIDS Knowledge,
provide information about HIV-related transmission Feelings, and Behavior Questionnaire (AKFBQ) spe-
and prevention to help participants to reduce their cifically for use with African American women. The
risk of infection. In addition, these models invoke AKFBQ contains 107 items, of which 40 items are de-
motivational constructs, such as perceived threat or voted to the assessment of HIV-related knowledge. Al-
risk, which require an accurate knowledge of the con- though few details were provided regarding scale
sequences of HIV infection. To evaluate the validity development or item analyses, factor analysis on the
of these models and to determine the effectiveness Knowledge subtest of the AKFBQ yielded a 15-factor
of interventions guided by them requires a reliable solution; this solution was not rotated or replicated,
and valid measure of HIV knowledge. and there was no discussion of its interpretation. Cron-
Several authors have developed measures to as- bach's alpha (.66) was reported for the entire subtest,
sess HIV-related knowledge. Zimet (1992) described despite the factor solution. The validity of the
a 22-item measure for adolescents that was based AKFBQ Knowledge subtest has not been examined.
upon a Centers for Disease Control (1988) brochure. Thus, although several measures of HIV-related
He reported that the test was internally consistent knowledge have been developed and described, few
(Kuder-Richardson formula 20 coefficient of .77), have been adequately evaluated. The measure that has
but did not provide information on test development been evaluated most thoroughly, namely the ARBKT
or refinement. Item, factor, or validity analyses were (Kelly et al., 1989), was evaluated primarily with data
not conducted (or reported). Koopman et al. (1990) provided by well-educated gay men. Given (a) the dif-
also developed a measure for adolescents, the AIDS fusion of HIV disease into multiple communities (in-
Knowledge Test (AKT), a 52-item measure of HIV- cluding heterosexual women), (b) the need to evaluate
and AIDS-related knowledge. The AKT assesses six educational and risk reduction programs, and (c) the
domains (i.e., definitions, outcomes, risk behavior, absence of an appropriate measure of HIV-related
transmission, prevention, and HIV testing); however, knowledge, the purpose of this program of research
no factor analyses have been reported to confirm this was to develop and evaluate a self-administered ques-
tionnaire to measure knowledge about HIV infection.
factor structure. Moreover, reliability analyses within
We sought to develop a measure that was reliable and
these domains indicated poor internal consistencies
valid, understandable to those with low-literacy skills,
(Cronbach's coefficient alphas ranged from .00 to
and appropriate for use regardless of respondent age,
.57, M = .43); collapsing across these domains
gender, and/or sexual orientation. Our aim was to de-
yielded a more reliable coefficient (alpha = .82) that
velop a measure that was brief but sensitive, so that
was stable (i.e., test-retest reliability of .82 for 1 week
it could be used in the evaluation of focused HlV-edu-
[Koopman et al., 1990]). The validity of the AKT has
cational, risk reduction, testing, and counseling pro-
not been examined.
grams. We anticipated that such a measure might also
Kelly et al. (1989) described the AIDS Risk Be- be useful in theoretical model building and testing,
havior Knowledge Test (ARBKT), a standardized 40-
and in clinical (e.g., primary care) settings.
item measure that they developed for use with gay
men. These authors provided detailed information re-
garding test construction and development; they also
conducted item, factor, and reliability analyses and at- STUDY 1. SCALE CONSTRUCTION AND
tempted to validate the ARBKT by examining pre- (M FORMATIVE EVALUATION
= 87%) and post-scores (M = 93%) of 33 men who
underwent an AIDS education seminar. However, the The initial phase of the research involved an ex-
factor structure of the ARBKT has not been replicated plicit articulation of the domain to be evaluated and
HIV-Knowledge Questionnaire 63

the generation of items (Dawis, 1987; Haynes et al., infection (Rosenberg, 1995). These focus groups
1995). New information regarding HIV and AIDS were cofacilitated by a culturally diverse team of two
emerges daily, but most of this information is not di- women, a doctoral-level nurse and a masters-level
rectly relevant to the general public (i.e., non-health social worker; both facilitators had extensive expe-
professionals). Because our primary interest involves rience in women's sexual health. Material provided
direct service delivery to the general public, particu- by the participants confirmed that myths about cas-
larly economically disadvantaged individuals who ual transmission (e.g., by insect bite, hugging, or
tend to be less well-educated, we sought to develop kissing) and incorrect ideas regarding prevention
a measure that assessed basic knowledge rather than (e.g., using birth control pills or douching) remained
the more sophisticated knowledge required of a prevalent. In addition, we learned that accurate
health-care provider. Therefore, the generation of knowledge regarding accepted transmission vectors
items was informed by three sources. (e.g., anal sex) and effective prevention strategies
First, we studied carefully several existing meas- (e.g., male and female condom) remained incom-
ures (e.g., Dancy, 1991; Kelly et al., 1989; Koopman plete. Participants also were poorly informed about
et al., 1990; Zimet, 1992). We noted that prior meas- the role of antibody testing, and the treatment of
ures (a) unintentionally encouraged guessing be- HIV disease.
cause they did not provide an "I don't know" option; Guided by these archival, professional, and gen-
(b) contained attitudinal as well as knowledge items; eral public sources, we developed the HIV-Knowl-
(c) included items for which the correct answer was edge Questionnaire (HIV-K-Q), a 68-item
unclear due to newly emerging facts; and (d) con- self-administered questionnaire that tapped HIV
tained few items relevant to women's concerns. We transmission (e.g., vaginal, anal, and oral sexual in-
remained mindful of these limitations as we devel- tercourse; blood products; needle sharing; and per-
oped items. inatal), nontransmission (e.g., saliva, insect bites,
Second, we consulted with eight local and na- touching, sharing food), effective risk reduction
tional HIV and AIDS educators and researchers, in- strategies (e.g., male and female condom, absti-
cluding faculty at the Center for AIDS Intervention nence, monogamy following antibody testing), inef-
Research (Milwaukee, WI) and Syracuse University, fective (e.g., douching, birth control pills, vaccine)
and HIV educators from a local AIDS service or- prevention methods, and consequences of infection
ganization. These experts were interviewed to deter- (e.g., asymptomatic period, treatment, disease
mine what they perceived to be the most relevant course).
and immutable facts. More than ten overlapping do- These 68 items were then distributed to six
mains were identified. These domains comprised HIV experts who provided critiques of the items'
transmission vectors, myths regarding casual trans- wording, content, and relevance to HIV risk reduc-
mission, risk reduction strategies, consequences of in- tion. Based upon this feedback, 6 items were
dropped because they were redundant with other
fection, and treatment of HIV disease.
items, or were deemed not sufficiently important.
Third, we held a series of eight focus groups
Minor revisions were made to the remaining 62
with 45 low-income women to learn what informa-
items to clarify the content and reduce the reading
tion and myths were widely held in the community
level of the items; the final set of 62 items appears
(Carey et al., in press a; see Zeller, 1993). The av-
in Table I.
erage participant was 26 years old, with a high
school education, who had two children; the major-
ity of participants were African American, single,
unemployed, with a family income of less than $8000 STUDY 2. ITEM AND FACTOR ANALYSES
per year. Most of the women reported that they had
been tested for HIV, but none reported that she was The purposes of Study 2 were (a) to obtain a
infected. We purposely included ethnic minority sample that was diverse with respect to age, gender,
women with limited educational backgrounds be- ethnicity, income, educational attainment, and antici-
cause prior instrument development had tended not pated HIV-related knowledge; (b) to administer the
to include participants from this socioeconomic 62-item HIV-K-Q; and (c) to conduct item and factor
background, and current epidemiological evidence analyses on these data in order to reduce and refine
suggested that such persons are at increased risk of the measure, and determine its factor structure.
64 Carey, Morrison-Beedy, and Johnson

Table I. Items in the HIV-Knowledge Questionnaire: Study 2


Item
number*
Scale Scale Percent s for Item-
A B correct item total^ Item
1 1 80.42 .40 .41 HIV and AIDS are the same thing
2 2 91.63 .28 .33 There is a cure for AIDS
3 3 89.09 .31 .34 A person can get HIV from a toilet seat
4 4 75.78 .43 .34 Coughing and sneezing DO NOT spread HIV1'
5 97.91 .14 A person can get HIV by sharing an injection needle with someone who has HIV*
6 80.87 .39 .17 A person can get HIV if she or he has sex with someone who shoots up drugs+
7 5 65.47 .48 .31 HIV can be spread by mosquitoes
8 6 64.28 .48 .35 AIDS is the cause of HIV
9 7 85.35 .35 .33 A person can get HIV by sharing a glass of water with someone who has HIV
10 96.41 .19 A person can get HIV by shaking hands with someone who has HIV
11 8 18.98 .39 .29 HIV is killed by bleach*
12 9 69.81 .46 .26 It is possible to get HIV when a person gets a tattoof
13 96.56 .18 A man can get HIV if he has sex with another man who has HIV1'
14 10 94.92 .22 .32 A pregnant woman with HIV can give the virus to her unborn baby+
15 11 85.20 .36 .40 Pulling out the penis before a man climaxes keeps a woman from getting HIV during sex
16 12 76.83 .42 .35 A woman can get HIV if she has anal sex with a man*
17 13 90.58 .29 .45 Showering, or washing one's genitals after sex keeps a person from getting HIV
18 95.07 .22 A man can get HIV if he has vaginal sex with a woman who has HIV*
19 14 93.27 .25 .29 Eating healthy foods can keep a person from getting HIV
20 15 66.22 .47 .45 All pregnant women infected with HIV will have babies born with AIDS
21 16 93.27 .25 .34 Using a latex condom or rubber can lower a person's chance of getting HIV*
22 95.22 .21 .34 Taking the Birth Control Pill keeps a woman from getting HIV
23 59.34 .49 .21 A diaphragm and the Birth Control Pill provide the same protection against HIV infection
24 91.18 .28 .12 Most people with AIDS will die from it*
25 17 91.48 .28 .40 A person with HIV can look and feel healthy*
26 29.30 .46 .22 There are more cases of AIDS in the USA than in the rest of the world
27 18 83.41 .37 .48 People who have been infected with HIV quickly show serious signs of being infected
28 19 90.28 .30 .48 A person can be infected with HIV for 5 years or more without getting AIDS*
29 20 81.32 .39 .42 There is a vaccine that can stop adults from getting HIV
30 21 78.62 .41 .33 Some drugs have been made for the treatment of AIDS*
31 96.41 .19 There is a blood test to tell if a person has been infected with HIV*
32 22 46.93 .50 .37 Women are always tested for HIV during their pap smears
33 23 71.30 .45 .34 A person cannot get HIV by having oral sex, mouth-to-penis, with a man who has HIV
34 32.59 .47 .15 In the. USA, most cases of AIDS resulted from sex between men and women
35 24 94.17 .23 .32 A person can get HIV even if she or he has sex with another person only one time*
36 39.61 .49 .13 A mother with HIV can pass it on to her baby by breast feeding*
37 25 54.56 .50 .40 Using a lambskin condom or rubber is the best protection against HIV
38 26 62.93 .48 .32 People are likely to get HIV by deep kissing, putting their tongue in their partner's mouth, if
their partner has HIV
39 87.89 .33 .25 Infection with HIV leads to AIDS*
40 27 56.05 .50 .38 A person can get HIV by giving blood
41 28 81.17 .39 .42 A woman cannot get HIV if she has sex during her period
42 29 94.02 .24 .39 You can usually tell if someone has HIV by looking at them
43 78.18 .41 .12 A person can get HIV by getting blood during surgery*
44 30 58.89 .49 .34 There is a female condom that can help decrease a woman's chance of getting HIV*
45 31 57.10 .50 .45 A natural skin condom works better against HIV than does a latex condom
46 32 86.55 .34 .49 A person will NOT get HIV if she or he is taking antibiotics
47 33 80.12 .40 .35 Having sex with more than one partner can increase a person's chance of being infected with HIV*
48 34 69.51 .46 .41 Taking a test for HIV 1 week after having sex will tell a person if she or he has HIV
49 35 83.70 .37 .42 A person can get HIV by sitting in a hot tub or a swimming pool with a person who has HIV
50 36 54.71 .50 .36 A person can get HIV through contact with saliva, tears, sweat, or urine
51 37 62.78 .48 .27 A person can get HIV from a woman's vaginal secretions (wetness from her vagina)1'
52 29.75 .46 .07 A person is more likely to get HIV if she or he has another STD (VD), such as herpes or
the clap*
HIV-Knowledge Questionnaire 65

Table I. Continued
Item
number*
Scale Scale Percent s for Item-
A B correct item total/' Item
53 21.82 .41 .11 Taking the AIDS drug AZT lowers the chance of a pregnant woman with HIV giving it to
her baby*
54 18.83 .39 .24 Outside of the USA, most cases of AIDS resulted because of IV (needle) drug use or men
having sex with men
55 38 63.53 .48 .36 A person can get HIV if having oral sex, mouth on vagina, with a woman*
56 39 51.27 .50 .34 If a person tests positive for HIV, then the test site will have to tell all of his or her partners
57 40 79.97 .40 .47 Using Vaseline or baby oil with condoms lowers the chance of getting HIV
58 41 80.57 .40 .40 Washing drug-use equipment with cold water kills HIV
59 42 93.42 .25 .33 A woman can get HIV if she has vaginal sex with a man who has HIV*
60 43 89.39 .31 .32 Athletes who share needles when using steroids can get HIV from the needles*
61 44 87.59 .33 .45 Douching after sex will keep a woman from getting HIV
62 45 90.58 .29 .46 Taking vitamins keeps a person from getting HIV
"Items marked with daggers (t) are true, those without are false.
*Items were dropped due either to low item-total correlations or to restriction of range.
Tor total of 56 items remaining after dropping the items with restriction of range (5, 10, 13, 18, 22, and 31) and subtracting the item
to be correlated.

Methods were recruited by a research assistant as they waited


to see a health care provider to receive medical care
Participants and Procedures at an urban primary care setting. Participants were
paid $5 to complete the HIV-K-Q and a demo-
Participants were recruited from three subsam- graphic survey in a waiting room as they waited to
ples (primary care, university, and HIV/AIDS ex- be seen. The undergraduate students were self-re-
perts) so that we could assemble a diverse sample that cruited in response to posted announcements, and
would permit generalization to the general popula- were provided with course credit to complete a
tion. Combining the subsamples, participants (N = longer survey that included the HIV-K-Q and a
669) included 409 women and 227 men (33 subjects demographic survey. They completed their survey in
did not identity their gender). Their ages ranged from groups of 20 or fewer in large classrooms on cam-
15 to 76 years (M = 28.50 years, SD = 12.10). The pus. The experts received a written invitation from
sample was diverse with respect to ethnic/racial back- the first author asking them to complete the HIV-
ground (64% European American, 25% African K-Q and a brief demographic questionnaire. The ex-
American, 3% Native American, 3% Hispanic Ameri- perts completed these measures in private, and
can, 4% Other, 2% did not identity), income (16% returned them by mail. No compensation was pro-
less than $10,000; 16% $10,000-$19,999; 11% vided to the experts.
$20,000-30,000; 5% greater than $30,000; 53% did
not report income), and educational level (range =
6-20 years, M = 12.27, SD = 2.36). Demographic Results
characteristics by subsample are provided in Table II.
Item Analyses

Procedures
Means and standard deviations for the 62 HIV-
All participants completed a self-administered K-Q items from the primary care, university students,
survey that included the 62-item HIV-K-Q. Proce- and experts (N = 669) were calculated (see Table I).
dures for recruitment of participants and data col- Examination of the percent correct reveals that six
lection varied by setting. The primary care patients items were too easy (i.e., Mean >95% correct); these
66 Carey, Morrison-Beedy, and Johnson

Table II. Demographic Characteristics and HIV-Knowledge Questionnaire Scores Overall and Within Samples0
Study and sample
Study 2 Study 3
Community
Overall HIV/AIDS Primary care University Couples women
Demographic characteristic (N = 1033) experts (n = 40) (n = 350) (n = 279) (n = 152) (n = 212)
M age in years (s) 30.59 (11.56) 36.66 (9.38) 34.99 (12.97) 20.11 (1.95) 34.70 (6.79) 33.85 (11.18)
Gender
Females 694 (67%) 23 (58%) 241 (69%) 145 (52%) 76 (50%) 212 (100%)
Males 303 (29%) 16 (40%) 87 (25%) 124 (44%) 76 (50%) 0 (0%)
Not specified 36 (3%) 1 (3%) 22 (6%) 10 (4%) 0 (0%) 0 (0%)
Race
European American 591 (57%) 19 (48%) 190 (54%) 218 (78%) 141 (93%) 23 (11%)
African American 329 (32%) 16 (40%) 119 (34%) 29 (10%) 6 (4%) 159 (75%)
Native American 31 (3%) 1 (3%) 17 (5%) 0 (0%) 0 (0%) 13 (13%)
Hispanic American 30 (3%) 1 (3%) 11 (3%) 10 (4%) 0 (0%) 8 (4%)
Other or not specified 52 (5%) 3 (8%) 13 (4%) 22 (8%) 5 (3%) 9 (4%)
M number of children (s) 1.99 (1.68) 1.92 (1.73) 1.88 (1.52) 2.17 (1.71)
M education in years (s) 12.54 (2.40) 16.46 (2.72) 11.80 (1.78) 14.22 (2.37) 11.82 (1.89)
Household income level
Less than $10,000 228 (22%) 104 (30%) 0 (0%) 124 (58%)
$10,001-20,000 165 (16%) 104 (30%) 7 (5%) 54 (25%)
$20,001-30,000 134 (13%) 72 (21%) 45 (30%) 17 (8%)
$30,001-40,000 89 (9%) 30 (9%) 52 (34%) 7 (3%)
Greater than $40,000 60 (6%) 7 (2%) 48 (32%) 5 (2%)
Unknown 357 (35%) 40 (100%) 33 (9%) 279 (100%) 0 (0%) 3 (1%)
Internal consistency, .91 .85 .88 .83 .93 .91
45-item HIV-K-Q (a)
M HIV-K-Q proportion .72 (.18) .91 (.10) .69 (.17) .82 (.12) .52 (.14) .72 (.19)
correct (s)
"Due to rounding of individual percentage values, the sum of percentages sometimes differs from 100%.

items (numbered 5,10,13,18, 22, and 31 under Scale as acceptable; 11 items whose item-total correlations
A, Table I) were deleted.4 were less than .30 were deleted (numbered 6, 23, 24,
The standard deviations of the remaining 56 26, 34, 36, 39, 43, 52, 53, 54 under Scale A, 'Eible I).
items revealed that there was sufficient variability to The remaining 45 items (Scale B, Table I) were used
retain these items. Next, point-biserial correlations of in subsequent analyses.
each item with the 56-item total score were calcu-
lated. An item-total correlation > .25 was established
Factor Analyses

4Because the primary use of the HIV-K-Q will be for the evalu- We performed a principal factor analysis on the
ation of educational and risk reduction programs, it is appropri- 45-item HIV-K-Q and employed two criteria to de-
ate to delete items that the vast majority of respondents answer termine the number of factors to be retained: (a)
correctly. This approach allows the generation of a relatively Kaiser-Guttman's criterion (i.e., factors with an
brief test that results in a more normalized distribution of scores
eigen value of greater than 1), and (b) examination
for the general population. However, this item-analytic approach
may be less appropriate for some clinical applications where the of the scree plot. Four factors met the Kai-
questionnaire will be used for ideographic assessment purposes ser-Guttman criterion, explaining 59%, 13%, 10%,
(e.g., to identify high-risk knowledge deficits). Thus, although the and 8% of the variance, respectively. Because the
items deleted at this stage of scale development do not add ap- scree plot confirmed that eigen values leveled off af-
preciably to the scale for its primary purpose, they remain "criti-
ter the fourth factor, only four factors were retained.
cal" knowledge items for clinical use; these items can and should
be used in settings where an assessor needs to be certain that An oblique rotation revealed highly intercorrelated
respondents have the essential knowledge necessary to avoid in- factors |.42 < r < .581 that each correlated highly
fection with HIV. with the 45-item total score (| r \s < .72), and the
HIV-Knowledge Questionnaire 67

individual factors were difficult to interpret as unique Procedures


factors; we tested whether the four factors might be
reduced further by conducting a secondary factor All participants completed a self-administered
analysis on the four factor scores (see Floyd and Wi- survey that included the 45-item HIV-K-Q. Proce-
daman, 1995). This analysis produced only one factor dures for recruitment of participants and composi-
that exceeded the Kaiser-Guttman criterion. More- tion of the survey varied by sample. The urban
over, each of the original four factors loaded heavily women responded to posted announcements in a va-
on this general factor, | .63 to .771, and the general riety of community-based settings (e.g., laundromats,
factor produced by the secondary factor analysis cor- grocery stores, beauty shops, health and social service
related almost perfectly with the raw knowledge clinics, bus stops). The announcements invited
score, r = .99. women to participate in a Women's Health Project
A confirmatory factor analysis fitting a latent to be held at an urban community-based organiza-
one-factor model to the 45 items revealed that (a) tion. Women completed the survey in small groups,
goodness of fit was conventionally high (GFI = .810), and were paid $15. The couples responded to news-
and adding factors failed to increase fit substantially paper announcements requesting participants in a
(GFI = .833 with two factors, .811 with three factors, study of marital communication. One male and one
and .864 with four factors). Thus, one core factor female member of the research team visited couples
emerged from this analysis, which we labeled HIV in their homes, and supervised the independent com-
Knowledge. pletion of the survey. Each couple was paid $20 for
their participation.

STUDY 3. GENERALIZABILITY OF THE Results


FACTOR SOLUTION
We performed a confirmatory factor analyses to
The purpose of Study 3 was to cross-validate the determine the generalizability of the one-factor
factor structure of the 45-item HIV-K-Q obtained in model that emerged in Study 2. This analysis re-
Study 2 with data from two additional community- vealed that the the goodness of fit for a one-factor
based samples. model was adequate (GFI = .660), and that adding
factors failed to increase fit (GFI = .658 with two
factors, .604 with three factors, and .666 with four
Methods factors). Thus, one core factor emerged from this
analysis, which we again labeled HIV Knowledge.
Participants

Participants were recruited from two subsamples STUDY 4. RELIABILITY


(urban women and married couples), so that we
could evaluate the stability of the factor structure The purpose of Study 4 was to determine the
with adults living in the community, the target audi- internal consistency and the test-retest stability of
ence for the HIV-K-Q. Combining these two samples, the 45-item HIV-K-Q.
participants (N = 364) included 285 women and 76
men. Their ages ranged from 15 to 72 years (M =
34.2 years, SD = 9.6). The sample was diverse with Methods
respect to ethnic/racial background (45% European
American, 45% African American, 4% Native Participants and Procedures
American, 2% Hispanic American, 3% Other, 1%
did not identify), income (34% less than $10,000; Participants from all five subsamples described
17% $10,000-$19,999; 17% $20,000-30,000; 31% in Studies 2 and 3 provided data for analyses of the
greater than $30,000; 1% did not report income), and internal consistency of the 45-item HIV-K-Q. Com-
educational level (range = 6-20 years, M = 12.8, SD bining subsamples yielded N = 1,033 participants, in-
= 2.4). Demographic characteristics by subsample cluding 694 women and 303 men (36 subjects did not
appear in Table II. identify their gender). Additional demographic char-
68 Carey, Morrison-Beedy, and Johnson

acteristics for the entire sample and for each sub- strate more knowledge than the college students,
sample can be found in Table II. who, in turn, would demonstrate more knowledge
Analyses of the test-retest stability made use of than the community samples.
data from two sources. First, a subset of the urban
women's sample ( = 33) completed the HIV-K-Q
Methods
on three occasions; the first occasion as described in
Study 3, and then again at 2-week and 12-week retest
Participants from the five subsamples described
sessions. Second, a subset of the university students
in Studies 2 and 3 (N = 1,033) provided data for
also completed the HIV-K-Q on two occasions, sepa-
these analyses.
rated by approximately one week. Procedures for the
retest sessions were identical to those used for the
initial data collection. Results

A one-way (group: primary care patients; urban


Results
women; university students; HIV experts, community
couples) analysis of variance (ANOVA) revealed a
Internal Consistency
significant effect for group status, F(4, 1021) =
111.83, p < .0001. As expected, pairwise comparisons
Internal consistency was determined with Cron- revealed that the experts (91%) were significantly
bach's (1951) alpha. Alpha for the total sample (N better informed than the other four groups, and the
= 1,033) was .91, which reflects a high degree of in- university students (82%) were more knowledgeable
ternal consistency. Alpha was also calculated sepa- than were the primary care patients (69%), urban
rately for each subsample, and ranged from .83 to women (72%), and community couples (52%). Al-
.93 across the five subsamples. though the primary care and urban women did not
differ from each other, both groups were more
knowledgeable than the community couples. All five
Test-Retest Stability
groups exceeded the score that would be achieved
by chance (i.e., 33%).
A Pearson product-moment correlation coeffi-
cient was calculated for the urban women who took
the HIV-K-Q on three occasions, with 2-week and
3-month retest intervals ( = 33 and n = 25, re- STUDY 6. VALIDITY: CHANGE RESULTING
spectively). These calculations indicated high FROM A PSYCHOEDUCATIONAL
test-retest reliability (r = .91 and r = .90 at 2 and INTERVENTION
12 weeks, respectively; both ps < .0001). The
test-retest correlation for the university students To provide treatment-related evidence, data
was r(130) = .83, p < . 0001. from a sample of urban women who participated in
an HIV-risk-reduction program were used (Carey et
al., in press b). Because a component of the program
involved education about HIV and AIDS, we ex-
STUDY 5. VALIDITY: COMPARISON OF
pected that treated participants would demonstrate
KNOWN GROUPS
knowledge increases, whereas the control partici-
pants would not change on this dimension.
The purpose of Study 5 was to assemble evi-
dence for the validity of the HIV-K-Q using "known
groups," that is, groups expected to differ with re- Methods
spect to their HIV-related knowledge. Therefore, we
compared HIV-K-Q scores among "HIV experts," A subset of the urban women's sample (n = 78)
relatively well-educated college students, and three participated in a controlled clinical trial of an HIV-
community samples; we expected these groups to dif- risk-reduction program. This intervention program was
fer in their HIV-related knowledge as a function of designed primarily to enhance HIV-related motivation
prior education and experience related to HIV and and skills, but also included one-half session (i.e., 45
AIDS. We predicted that the experts would demon- min) devoted to basic facts regarding HIV and AIDS.
HIV-Knowledge Questionnaire 69

The women completed the HIV-K-Q independently 1 the entire battery in order to minimize the response
week before and 1 week after the program. burden placed on participants.
The Social Desirability Scale (SDS; Crowne and
Marlowe, 1960) contains 33 true/false items and
Results
measures the tendency to present oneself in a socially
Scores on the HIV-K-Q indicated that women desirable manner. The SDS is internally consistent
(alpha = .88) and stable (test-retest reliability r =
assigned to the intervention condition significantly
.89 at 1 month).
unproved their scores from pre- (M = 75%) to post-
intervention (M = 87%) assessments, f(42) = 6.08, The Center for Epidemiological Studies Depressed
p = .0001, d = 0.90. In contrast, women in the con- Mood Scale (CES-D; Radloff, 1977) contains 20
trol condition of this study did not improve their items designed to measure depressive symptoms in
the general population. When used with the general
scores, M = 71% and M = 72%, respectively, f(31)
population, the CES-D has an alpha of .85, with
= 0.79, p > .10, d = 0.13.
test-retest correlations that range from .51 to .67
when tested over 2-8 weeks.
The Positive and Negative Affect Scale (PANAS;
STUDY 7. VALIDITY: DISCRIMINANT Watson et al., 1988) contains two 10-item mood
EVIDENCE scales that provide independent measures of positive
and negative affect. Positive affect reflects the extent
The purpose of Study 7 was to assemble dis- to which an individual feels enthusiastic, active, and
criminant evidence to evaluate the validity of the alert, whereas negative affect provides an index of
HIV-K-Q. Discriminant evidence obtains when meas- subjective distress, anger, and nervousness. Both
ures not expected to correlate or not to correlate PANAS scales are internally consistent (alphas range
very highly with the target measure show this ex- from .84 to .90), and stable (rs = .86 to .87).
pected pattern (Kazdin, 1995; Campbell and Fiske, The Rosenberg Self-Esteem Scale (RSES; Wylie,
1959). Therefore, we selected reliable and valid in- 1977) is a widely used measure that provides an in-
struments that measure important psychological con- dex of an individual's sense of his or her general
structs (i.e., social desirability, mood, and self- worth or value.
esteem) that might influence responses to the HIV- The Multidimensional Condom Attitudes Scale
K-Q as well as other constructs (i.e., dyadic and sex- (MCAS; Helweg-Larson and Collins, 1994) contains
ual adjustment, attitudes toward condoms) that, 25 statements about condoms and yields five attitude
although not directly related to HIV knowledge, are scores: reliability of condoms, pleasure of condom
indirectly related because of a common association use, identity stigma associated with condom use, em-
with sexual health. We did not expect to find signifi- barrassment about negotiation and use of condoms,
cant associations between any of these variables and and embarrassment about the purchase of condoms.
the HIV-K-Q. Internal consistency of factors range from .67 to 94
for men and .44 to .92 for women.
The Dyadic Adjustment Scale (DAS; Spanier,
Methods 1976) contains 32 items and provides a general meas-
ure of satisfaction in an intimate relationship. The
Participants from the university student and cou- DAS has an alpha of .96, with a test-retest of .87.
ple subsamples described in Studies 2 and 3 provided The Index of Sexual Satisfaction (ISS; Hudson et
data for these analyses. These participants completed al., 1981) is a 25-item measure of the degree, sever-
additional measures at the same time that they had ity, or magnitude of problems in the sexual compo-
completed the HIV-K-Q. The university students nent of a couple's relationship. The ISS has a mean
completed the Social Desirability Scale, Positive and alpha of .92, with a 2-hr test-retest of .94.
Negative Affect Scale, Rosenberg Self-Esteem Scale,
and Multidimensional Condom Attitudes Scale,
whereas the couples completed the Social Desirabil- Results
ity Scale, Center for Epidemiological Studies Depres-
sion Scale, Index of Sexual Satisfaction, and Dyadic Discriminant evidence was provided by the ab-
Adjustment Scale. No sample was asked to complete sence of significant correlations between the HIV-K-
70 Carey, Morrison-Beedy, and Johnson

Q and (a) the SDS, using either the undergraduate Knowledge Test, and a demographic survey in a wait-
sample, r(271) = -.09, or the couples, r(148) = -.09; ing room as they waited to be seen.
(b) positive or negative mood subscales from the The AIDS Risk Behavior Knowledge Test
PANAS, r(277) = .00 and r(277) = -.05, respec- (ARBKT; Kelly et al., 1989) is a 40-item measure of
tively; (c) the RSES, r(268) = -.05; (d) any of the AIDS risk behavior knowledge. The ARBKT has
five subscales from the MCAS, rs ranging from -.05 been judged to be internally consistent (KR-20 =
to .11; (e) the CESD, r(148) = -.11; (f) the DAS, .74) and stable (i.e., test-retest r = .84 over 2 weeks
r(148) = .16; or (g) the ISS, r(148) = -.05. [Kelly et al., 1989]).
The AIDS Knowledge Test (AKT; Koopman et al.,
1990) is a 52-item measure of HIV- and AIDS-related
STUDY 8. VALIDITY: CONVERGENT EVIDENCE knowledge. The AKT has been judged to be internally
consistent (i.e., Cronbach's alpha = .82) and stable
The purpose of Study 8 was to assemble con- (i.e., test-retest r = .82 over 1 week [Koopman et al.,
vergent evidence for the validity of the HIV-K-Q. 1990]).
Convergent evidence obtains when the measure be- These two measures were selected as the best
ing validated correlates with other measures that are available similar measures of HIV-related knowledge.
designed to assess the same or related constructs As we noted in the Introduction, these measures
(Kazdin, 1995; Campbell and Fiske, 1959). We an- have proven useful with the populations for whom
ticipated strong, positive associations between scores they were developed, but they may be less appropri-
on the HIV-K-Q and two extant measures of HIV- ate for low-literacy adult men and women.
related knowledge. However, because such correla-
tions between self-administered questionnaires may
also occur as a result of shared method variance Results
(Kazdin, 1995), we also examined the association be-
tween HIV-knowledge scores and level of educa- HIV-K-Q scores correlated with both the AIDS
tional attainment. Prior research (Peruga and Risk Behavior Knowledge Test, r(48) = .42, p < .005,
Celentano, 1993) suggested a positive association be- and the AIDS Knowledge Test, r(47) = .56, p <
tween these two variables, which is what we expected .0001. Using the larger sample, the HIV-K-Q scores
to find. were correlated with higher levels of educational at-
tainment, r(386) = .48, p < .0001.
Methods

Participants from the subsamples described in STUDY 9. READING LEVEL


Studies 2, 3, and 4 provided data for the analyses
that examined the relationship between HIV-K-Q Several studies have demonstrated that health
score and education level. For the analyses that ex-
education and assessment materials are often writ-
amined the relations between the HIV-K-Q and
ten at levels that exceed respondents' reading abili-
other measures, we collected data from a fresh sam-
ple of 50 primary care patients at an urban clinic. ties (e.g., Williams et al., 1995; Powers, 1988; Meade
The sample was 52% female, and diverse with re- and Byrd, 1989). Doak and Doak (1980) reported
spect to ethnic/racial background (52% European that respondents' report of the number of years of
American, 41% African American, 6% Other) and formal education tends to be four or five levels
income (39% less than $10,000; 32% higher than their actual reading ability based on the
$10,000-$19,999; 7% $20,000-30,000; 21% greater Wide Range Achievement Test, a word pronuncia-
than $30,000). Only one third had any college edu- tion and recognition test. Given these findings, and
cation (range = 7-17 years, M = 12.57, SD = 2.37). our desire to develop a measure that would be prac-
The patients were recruited by a research assistant tical for urban, economically disadvantaged adults
as they waited to see a health care provider to re- (who tend to have the lowest functional literacy
ceive medical care at an urban primary care setting. skills [Williams et al., 1995]), the purpose of Study
Participants were paid $5 to complete the HIV-K-Q, 9 was to determine the reading level of the 45-item
the AIDS Risk Behavior Knowledge Test, the AIDS HIV-K-Q.
HIV-Knowledge Questionnaire 71

Methods clinic. Participants were administered the HIV-K-Q


individually in a waiting room. They were instructed
The instructions and all 45 items of the HFV-K- to answer each question carefully and, when finished,
Q were entered in a text file and split into passages to return this survey and request the next one. A re-
of approximately 100 words each. For purposes of search assistant privately recorded the time required
readability analysis, HIV AIDS, and Vaseline were to complete the HIV-K-Q. Respondents were not
treated as proper names. Two formulas, the Flesch told that they were being timed.
and the Spache, were used to determine the read-
ability of the material. These readability formulas use
common features of words and passages (e.g., College Sample
number of syllables, number of words, number of
sentences) to measure the difficulty of the material. Participants were 28 female and 21 male under-
graduates (M age = 18.63 years, SD = 0.88) from
Results the same university population that was sampled for
Study 2. Participants expected to participate in a se-
Analysis of the 45-item HTV-K-Q with the Flesch ries of studies on "Social Attitudes" and were seated
formula indicated that the material was at the pri- in individual cubicles that precluded visual contact
mary-grade level, with most passages in the "fairly with any other participant. Each cubicle contained a
easy" to "Very easy" range. Analysis using the Spache computer through which all instructions and ques-
formula revealed that the majority of the material tions were administered. After a brief introduction
was below 4th-grade level. However, several "for- to the computer, the questionnaire was introduced
eign" words increased the level to approximately the without participants' foreknowledge. Participants
7th-grade level; these "foreign" words include vac- were simply instructed that they should "answer the
cine, antibiotics, genitals, and pap smears, that is, following true-false items about HIV and AIDS."
words that are either medical or sexual in nature. Al- Respondents were not told that their responses were
though these words increase the reading level, they being timed. Each question from the 45-item HIV-
are likely to be understood by low-literacy readers K-Q was then presented individually, with a unique
due to their common use in the popular culture. random order of items for each participant. Partici-
pants pressed the "a" key for a "True" response, "b"
for a "False" response, and "c" for a "Don't Know"
response. The computer recorded latencies to re-
STUDY 10. COMPLETION TIME REQUIRED spond to each question.

To determine how long the HTV-K-Q (and indi- Results


vidual items) take to complete, we administered the
questionnaire to two samples. With the community Community respondents' mean proportion of
sample of adults used in Study 8, we recorded the correct answers to the HIV-K-Q was .74 (SD = .14),
time to complete the paper-and-pencil questionnaire which does not differ significantly from the mean for
in a natural environment. With a fresh sample of col- the earlier primary care sample (M = .69), F(l,
lege students, we used a computer to administer and 398) = 2.95, p = .0869. It took an average of 6.98
record the time required to complete each item as min (SD = 2.19) to complete the HIV-K-Q, with
well as the entire questionnaire when it is computer- times ranging from 3.50 to 12.00 min. The correlation
administered. between time to complete the HIV-K-Q and the
score attained on it was moderate in magnitude,
r(45) = -0.29, p = .0536.
Method College student respondents' mean proportion of
correct answers to theHlV-K-Qwas .85 (SD = .07),
Community Sample which does not differ from the mean for the earlier
university sample (M = .82), F (1,326) = 3.17, p =
Participants were those subjects described in .0762. It took an average of 4.12 min (SD = 0.77) to
Study 8, namely, 50 primary care patients at an urban complete the HIV-K-Q, ranging from 1.37 to 5.85
72 Carey, Morrison-Beedy, and Johnson

min. The time to complete the HIV-K-Q was unre- two related measures, the ARBKT (Kelly et at., 1989)
lated to the score attained on it, r (48) = .02. The and the AKT (Koopman et al., 1990). The magnitude
mean time to respond to any given item ranged from of these associations (r = .42 and r = .56, respectively)
a low of 2.73 sec (for item 2 on Scale B, see Table I) is in the "moderate" range, and provides adequate
to a high of 10.28 sec (for item 41). support for the validity of all three measures (Kazdin,
1995).5 However, it is interesting that these correla-
tions did not differ from the correlation between the
DISCUSSION HIV-K-Q and level of educational attainment (r =
.48). It cannot be determined whether these moderate
correlations reflect upon the HIV-K-Q, ARBKT; or
The purpose of this study was to develop and AKT However, we can say that the magnitude of a
evaluate the psychometric properties of the HIV- validity coeffient is limited by the underlying reliabili-
Knowledge Questionnaire. Formative research ties of the measures being associated (Nunnally and
guided the generation of a 62-item scale that as- Bernstein, 1994). It is also likely that the reliability of
sessed knowledge about the transmission, prevention, self-report of level of educational attainment is greater
and consequences of HIV infection. Item analyses in- than are the reliabilities of the three knowledge meas-
dicated that 17 of the 62 items should be deleted be- ures. Mindful of these considerations, the relatively
cause of item ease or poor association with the total equivalent correlations among the knowledge meas-
scale. Many of the items deleted can be considered ures and educational attainment are logical.
"critical items," that is, items containing essential As expected, analyses of known groups indicated
public health knowledge regarding HIV transmission that experts were better informed that college stu-
and prevention. These items describe risk associated dents, who in turn were more knowledgeable than
with needle-sharing, men who have sex with men, were the community samples. An unexpected finding,
and heterosexual vaginal sex (Scale A, items 5, 13, however, was that primary care and urban women
and 18, respectively). It is comforting to know that were more knowledgeable than were the community
more than 95% of our sample answered these items couples. One explanation for this finding is that, rela-
correctly, and it is appropriate to delete such items tive to the two other samples, the community couples
for our purposes (i.e., program evaluation). However, might feel less compelled to stay informed regarding
these items may prove useful in certain clinical set- HIV because of (a) their (presumably) exclusive sexual
tings where idiographic assessment of high-risk indi- relationship with a partner and (b) the relatively lower
viduals is necessary; knowledge of such material rates of HIV infection in middle-income communities.
should never be assumed in clinical and counseling Overall, the results reported herein demonstrate
settings with an individual client. that the HIV-K-Q is a psychometrically strong instru-
Principal factor analyses of the remaining 45 ment that compares favorably to extant measures.
items suggested that a single-factor could account for That is, although several authors have developed in-
a significant amount of the variance; this single-factor struments to assess HIV-related knowledge, none of
solution was replicated in a cross-validation sample. these measures has been thoroughly evaluated; for
Thus, these analyses demonstrate that the HIV-K-Q is example, most extant measures have not been factor
a unidimensional instrument that measures HlV-re- analyzed nor evaluated for validity. The psychomet-
lated knowledge. Reliability analyses indicated that the rically strongest measure is the ARBKQ (Kelly et al.,
HIV-K-Q is internally consistent and stable over inter- 1989), but this measure was developed only with col-
vals as long as 3 months. Validity analyses revealed, as lege students and gay men and is written at a 9th-
expected, that the HIV-K-Q is not associated with or 10th-grade reading level. Although this measure
other constructs, including social desirability, negative has proven useful with the population with which it
or positive mood, self-esteem, depression, dyadic ad- was developed, it is less appropriate for low-literacy
justment, sexual satisfaction, or attitudes toward con- men and women, groups most at risk in the second
doms. As expected, however, the HIV-K-Q is wave of the AIDS epidemic (Kelly et al., 1993).
associated with level of educational attainment, with
better educated respondents scoring higher on the
HIV-K-Q (Peruga and Celentano, 1993).
An additional source of validity evidence was pro- Confidence in the validity of the HIV-K-Q can be much greater
vided by the association between the HIV-K-Q and due to the other sources of evidence described previously.
HIV-Knowledge Questionnaire 73

It is increasingly apparent that many diseases Nursing Research to D.M.B. The authors thank
pose a disproportionate threat to those who are eco- Thomas Bazydlo, Jesse Dowdell, Ann Goodgion,
nomically disadvantaged (Marmot et al., 1987; Wil- Gary Urquhart, and Monique Wright-Williams for
liams, 1990); the epidemiology of HIV disease their assistance with recruitment; Laura Braaten,
(Rosenberg, 1995) provides but one illustration of Lauren Durant, Andrew Forsyth, Christopher Gor-
this pattern. The economically disadvantaged, in don, Beth Jaworksi, Daniel Purnine, Lance Wein-
turn, are more likely to be functionally illiterate, or hardt, and Ednita Wright for their help with data
at least unable to read at levels required by many collection; Jack Gleason for developing the data-
self-administered questionnaires (Williams et al., checking software; June Crawford for assistance with
1995). Therefore, to the extent that test developers the readability formulas; Kathy Sikkema, Seth Ka-
seek to provide instruments that are relevant to those lichman, Tim Heckman, David Rompa, David Wag-
most in need, it is essential that self-report measures staff, Nina Wright, Sue Taylor-Brown, Deborah
be designed with low-literacy respondents in mind. McLean, Andrew Forsyth, Christopher Gordon, and
For those adults and adolescents who cannot read at Jeffrey Kelly for their expert consultation; and
even a 6th grade level, new assessment modalities Stephen Haynes for his thoughtful suggestions re-
will need to be developed. For example, audiotaped garding the improvement of this manuscript, espe-
(Boekeloo et al., 1994) or compact disc-administered cially the caveats contained in footnote 4.
questionnaires may prove helpful in some contexts.
The development and psychometric evaluation of
a reliable and valid knowledge measure, based upon
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