HIV/AIDS Knowledge and Beliefs Scales for Adolescents

1. Abstract

The HIV/AIDS Knowledge and Beliefs Scales for Adolescents comprise a dual-battery psychometric instrument developed by Cheryl Koopman, Helen Reid, Elizabeth McGarvey, and Adelaida Cruz Castillo to assess cognitive comprehension, epidemiology, transmission misconceptions, and psychosocial health cognitions among vulnerable adolescent populations. Originally designed in response to the escalating pediatric and adolescent HIV/AIDS epidemic during the late 1980s and 1990s, the battery addresses key behavioral, contextual, and developmental mechanisms underpinning sexual risk exposure. The complete measurement package consists of two distinct components: the HIV/AIDS Knowledge Scale and the Beliefs About Preventing HIV/AIDS Scale (BPAS).

The HIV/AIDS Knowledge Scale contains a primary 45-item dichotomous (True/False) questionnaire organized into three empirically validated dimensions: Medical/Scientific Knowledge (23 items), Myths of HIV Transmission (9 items), and Knowledge of High-Risk and Prevention Behaviors (13 items), complemented by a supplemental 7-item Safer Alternatives forced-choice subscale evaluating comparative risk assessment. The BPAS contains 36 items scored on a 4-point Likert-type scale across five theoretically grounded constructs: Perceived Threat (6 items), Self-Control (8 items), Self-Efficacy (14 items), Peer Support for Safe Acts (4 items), and Expectation to Prevent Pregnancy (5 items). Psychometric investigations conducted with diverse cohorts of runaway, homeless, sexual minority, and incarcerated youth demonstrate robust internal consistency, with overall knowledge scale reliability coefficients ranging from α = .81 to α = .85 (1-week test-retest reliability r = .82, p < .0001) and overall beliefs scale reliability reaching α = .88 (subscale alphas spanning .56 to .90). Construct and criterion-related validity have been confirmed across longitudinal interventions, clinical evaluations, and international epidemiological adaptations, making this battery a foundational psychometric standard in adolescent sexual health research.

2. Keywords

HIV/AIDS Knowledge Scale, Beliefs About Preventing HIV/AIDS Scale, BPAS, adolescent sexual health, adolescent risk behavior, condom self-efficacy, Health Belief Model, social cognitive theory, adolescent psychometrics, HIV transmission myths, juvenile risk assessment, peer norms

3. Authors

The HIV/AIDS Knowledge and Beliefs Scales for Adolescents were authored and psychometrically validated by a collaborative team of researchers in clinical psychology, adolescent medicine, and psychiatry:

• Cheryl Koopman, Ph.D.: Professor Emerita, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA. Correspondence contact: [email protected].
• Helen Reid, Ph.D.: Department of Psychology and Neuropsychiatric Institute, University of California, Los Angeles (UCLA), Los Angeles, CA.
• Elizabeth McGarvey, Ed.D.: Associate Professor of Psychiatric Medicine and Public Health Sciences, Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA.
• Adelaida Cruz Castillo, M.A.: Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.

Key validation cohorts and intervention studies were conducted in partnership with prominent adolescent health investigators, including Mary Jane Rotheram-Borus, Ph.D. (Columbia University / UCLA), Randy J. Canterbury, M.D. (University of Virginia), and David Spiegel, M.D. (Stanford University), under research funding sponsored by the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA).

4. Purpose

The primary purpose of the HIV/AIDS Knowledge and Beliefs Scales for Adolescents is to provide behavioral health professionals, clinical psychologists, epidemiologists, and juvenile justice personnel with an empirically validated, developmentally sensitive instrument to evaluate HIV-related cognitive competencies, transmission knowledge, misperceptions, and behavioral self-regulation among youths at elevated risk for human immunodeficiency virus infection and other sexually transmitted infections (STIs).

Contextual and Clinical Rationale

During late childhood and adolescence, youths undergo complex biopsychosocial transitions characterized by sexual awakening, increased sensation-seeking, and peer conformity, frequently coinciding with cognitive vulnerabilities concerning personal invulnerability and inaccurate risk assessment. Adolescents who experience institutionalization, structural marginalization, homelessness, or involvement in the juvenile justice system face compounded risks of pathogen exposure driven by early sexual debut, substance use, transactional sex, and coercive sexual dynamics. Standard adult HIV assessments often possess inflated reading levels, inappropriate jargon, and clinical irrelevance, failing to capture the unique developmental dynamics of adolescents. The Koopman et al. scales were explicitly engineered to dismantle these barriers, offering clear readability, clinical accuracy, and content tailored to marginalized youth environments.

Research and Diagnostic Applications

The instruments serve multiple diagnostic, evaluative, and empirical functions:

• Baseline Epidemiological Profiling: Differentiating between genuine deficits in biomedical comprehension (e.g., how the immune system is degraded by HIV) versus entrenched urban folklore or transmission myths (e.g., transmission via swimming pools or mosquito bites).
• Intervention Outcome Evaluation: Serving as standardized pre-test and post-test outcome metrics for behavioral prevention programs, community empowerment interventions, and curriculum-based sex education trials in schools, detention facilities, and residential shelters.
• Risk Stratification and Clinical Screening: Identifying specific cognitive and psychosocial deficits—such as low condom negotiation self-efficacy or heightened fatalism—that predispose youth to unprotected intercourse, needle sharing, and substance-involved sexual encounters.
• Cross-Cultural and Longitudinal Adaptations: Providing a modular framework that has been systematically adapted for international public health initiatives in Kenya, India, and Botswana, as well as collegiate screening batteries across the United States.

5. Psychological Construct

The battery measures two overarching psychological domains: Factual and Epidemiological HIV/AIDS Knowledge and Psychosocial Beliefs Governing Sexual Risk and Prevention. Rather than treating HIV/AIDS prevention as a purely informational deficit, the authors operationalize risk behavior as an intricate nexus of biomedical facts, normative pressures, subjective risk appraisal, self-regulatory agency, and perceived capability.

Dimensions of the HIV/AIDS Knowledge Scale

The Knowledge Scale assesses 45 True/False statements categorized across three primary cognitive dimensions, alongside a 7-item comparative decision-making subscale:

• Medical/Scientific Knowledge (23 items): Measures factual understanding of HIV pathology, viral etiology, bodily fluid transmission mechanisms, immunology, and diagnostic testing parameters. Sample topics evaluate understanding that AIDS is caused by a virus (Item 2), that an asymptomatic seropositive individual can transmit the virus (Item 34), and the definition of a false-positive antibody result (Item 41).
• Myths of HIV Transmission (9 items): Gauges endorsement of pervasive, non-scientific cultural fallacies regarding casual, environmental, or vector-borne transmission. Items probe unfounded fears of acquiring HIV through insect bites (Item 29), swimming pools (Item 23), shared toilet seats (Item 11), eating at restaurants staffed by infected individuals (Item 37), or donating blood (Item 43).
• Knowledge of High-Risk and Prevention Behaviors (13 items): Assesses comprehension of behavioral practices that directly moderate transmission risk. Items examine the preventive efficacy of barrier methods, risks associated with concurrent substance abuse (Item 44), condom use during oral and anal sex (Items 40 and 42), and the limitations of partner inquiry or monogamy assumptions (Items 13 and 14).
• Safer Alternatives (7 forced-choice items): Explores practical harm reduction reasoning by asking participants to select the comparatively less hazardous behavioral option between two scenarios (e.g., comparing giving blood versus receiving a blood transfusion, or unprotected vaginal intercourse versus sharing an injection needle).

Dimensions of the Beliefs About Preventing HIV/AIDS Scale (BPAS)

The BPAS encapsulates 36 items spanning five empirically derived attitudinal and motivational dimensions:

• Perceived Threat (6 items): Evaluates an individual’s subjective appraisal of personal vulnerability to HIV infection and the perceived severity of the disease. Sample items probe perceived 5-year acquisition probability (Item 8), emotional dread of the illness (Item 18), and subjective past-history vulnerability (Item 15).
• Self-Control (8 items): Quantifies impulse control, emotional regulation, and behavioral restraint during heightened sexual arousal or relational conflict. Sample items capture emotional disinhibition during sexual arousal (Item 28), partner abandonment concerns (Item 9), and perceived loss of mastery over sexual drives (Item 13).
• Self-Efficacy (14 items): Based on Bandura’s social cognitive theory, this dimension operationalizes an adolescent’s perceived confidence in executing safe sex behaviors across challenging interpersonal circumstances. It measures confidence in purchasing condoms (Item 1), carrying them consistently (Item 2), refusing sex in the absence of a condom (Item 4), and persisting with protection despite peer ridicule (Items 3 and 6).
• Peer Support for Safe Acts (4 items): Captures subjective social norms and perceived peer behaviors regarding risk reduction. Items examine whether friends practice safe sex (Item 12), have modified sexual practices due to the epidemic (Item 5), or consider condom application excessively burdensome (Item 14).
• Expectation to Prevent Pregnancy (5 items): Measures intentionality, motivation, and behavioral priority regarding contraception and pregnancy avoidance during heterosexual intercourse (Items 32, 33, 34, 35, and 36), acknowledging the developmental interplay between reproductive health goals and disease prophylaxis.

6. Theoretical Framework

The construction of the HIV/AIDS Knowledge and Beliefs Scales for Adolescents integrates two foundational models in health psychology: the Health Belief Model (HBM) originally formulated by Rosenstock, Hochbaum, and Kegeles, and the Social Cognitive Theory (SCT) articulated by Albert Bandura.

The Health Belief Model (HBM)

The HBM posits that health-protective behavioral change is mediated by cognitive appraisals across several core dimensions:

1. Perceived Susceptibility: Subjective belief regarding one’s likelihood of contracting a disease. In BPAS, this is captured by the Perceived Threat subscale, reflecting personal acquisition risk.
2. Perceived Severity: Beliefs regarding the physical, clinical, and social gravity of an infection, reflected in items probing the irreversibility, lethality, and emotional dread of AIDS.
3. Perceived Benefits vs. Perceived Barriers: Weighing the protective utility of condoms against barriers such as decreased physical sensation, relational embarrassment, or partner distrust.
4. Cues to Action: Environmental triggers, peer discussions, and health education that catalyze decision-making processes.

Social Cognitive Theory (SCT) and the Information-Motivation-Behavioral Skills (IMB) Paradigm

While the HBM provides a cognitive expectancy-value foundation, Koopman and colleagues recognized that intellectual awareness alone is insufficient to govern complex interpersonal behaviors. SCT establishes that behavioral enactment requires high self-efficacy—the internalized conviction that one can execute necessary actions in the face of impediments—and favorable outcome expectancies. The BPAS Self-Efficacy and Self-Control subscales directly operationalize these mechanisms, capturing an adolescent’s interpersonal assertiveness, negotiation skills, and sexual self-regulation.

Furthermore, this architecture anticipates Fisher and Fisher’s Information-Motivation-Behavioral Skills (IMB) model of HIV prevention. In this model, HIV-related information is necessary but distal; motivation (attitudes, perceived peer norms) and behavioral skills (self-efficacy, self-control) serve as the direct, proximal drivers of actual condom use and risk avoidance.

7. Validity

Extensive psychometric investigations have established content, construct, convergent, discriminant, and criterion-related validity for both scales across high-risk and general adolescent populations.

Content Validity

Content validity was established through a rigorous two-tier expert advisory process. Two independent panels consisting of clinical psychologists, pediatricians, epidemiologists, and adolescent health educators evaluated the preliminary item pool. Items were systematically evaluated for biomedical accuracy, linguistic clarity, developmental appropriateness, and reading level. Following iterative revisions, prototype instruments underwent pilot testing with diverse focus groups of adolescents to eliminate ambiguity, outdated youth colloquialisms, and cultural bias.

Construct and Criterion-Related Validity

Empirical validation studies conducted by Koopman et al. (1990) with 450 runaway, homeless, and gay-identified youth in New York City (mean age = 16.0 years; 49% African American, 35% Hispanic/Latino, 10% White) and subsequent studies by Canterbury et al. (1998) and Chang et al. (2003) with 893 incarcerated adolescents in Virginia confirmed robust construct and discriminant patterns:

• Subscale Intercorrelations: Correlations among the HIV/AIDS Knowledge subscales ranged from r = .26 to r = .61 (p < .0001), indicating cohesive yet conceptually distinct cognitive domains. Within the BPAS, correlations among subscales ranged from r = .37 to r = .74 (p < .0001).
• Knowledge-Belief Divergence (Discriminant Validity): Correlations between the Knowledge subscales and the Beliefs subscales were modest to negligible, ranging from r = .00 to r = .19. This empirical divergence provides compelling discriminant validity evidence, proving that biomedical knowledge and psychosocial prevention beliefs are distinct constructs requiring independent assessment.
• Known-Groups Validity: Significant group differences emerged aligning with theoretical risk gradients. Gay and bisexual male youth scored significantly higher on every Knowledge subscale compared to heterosexual homeless peers, reflecting targeted community health awareness. Homeless females exhibited significantly lower scores on Expectation to Prevent Pregnancy relative to gay males, mirroring disparate reproductive priorities.
• Developmental Sensitivity: Statistically significant positive correlations were observed between age and knowledge subscale scores (r = .12 to r = .34, p < .05), reflecting cognitive maturation and cumulative health education, whereas pregnancy prevention expectations remained independent of age within these cohorts.

8. Reliability

The psychometric evaluation of both scales indicates moderate to high internal consistency and stable test-retest reliability across multiple independent adolescent samples.

Internal Consistency (Cronbach’s Alpha)

Psychometric evaluations across distinct research samples yielded the following reliability statistics:

• Homeless and Gay-Identified Adolescents (N = 450):
  • Full 45-Item Knowledge Scale: α = .85
  • Medical/Scientific Knowledge (23 items): α = .71
  • Myths of HIV Transmission (9 items): α = .72
  • Knowledge of High-Risk/Prevention Behaviors (13 items): α = .68
  • Safer Alternatives Subscale (7 items): α = .69
  • Beliefs: Perceived Threat: α = .81
  • Beliefs: Self-Control: α = .82
  • Beliefs: Self-Efficacy: α = .90
  • Beliefs: Peer Support for Safe Acts: α = .61
  • Beliefs: Expectation to Prevent Pregnancy: α = .72
• Incarcerated Adolescents (N = 893):
  • Overall 45-Item Knowledge Scale: α = .81
  • Overall Beliefs Measure (36 items): α = .88
  • Beliefs: Perceived Threat: α = .58
  • Beliefs: Self-Control: α = .75
  • Beliefs: Self-Efficacy: α = .79
  • Beliefs: Peer Support for Safe Acts: α = .56
  • Beliefs: Expectation to Prevent Pregnancy: α = .60

Test-Retest Stability

Temporal stability was evaluated across a 1-week test-retest interval among homeless and runaway adolescents. The 45-item Knowledge Scale demonstrated strong temporal stability (r = .82, p < .0001). The 7-item Safer Alternatives subscale showed acceptable stability given its brief item count (r = .40, p < .01). The overall Beliefs About Preventing HIV/AIDS measure demonstrated stable longitudinal performance across the 1-week interval (r = .49, p < .001), consistent with dynamic psychosocial states in high-stress adolescent cohorts.

9. Factor Analysis

The dimensionality of both the Knowledge and Beliefs scales was confirmed through exploratory factor analytic (EFA) procedures utilizing principal components extraction with orthogonal (Varimax) rotation, followed by multi-sample verification.

Factor Structure: HIV/AIDS Knowledge Scale

From an initial pool of 49 knowledge items, 45 met stringent psychometric retention criteria (factor loadings ≥ .35 and absence of ambiguous cross-loadings), resolving into three stable orthogonal factors accounting for the majority of shared variance:

1. Factor 1: Medical/Scientific Knowledge (23 items): Primary loadings clustered around biological facts, diagnostic testing procedures, immune mechanisms, and retroviral transmission.
2. Factor 2: Myths of HIV Transmission (9 items): Items loaded cleanly on casual contact misconceptions, non-vector transmission, and domestic environmental scenarios.
3. Factor 3: Knowledge of High-Risk and Prevention Behaviors (13 items): Factor loadings captured behavioral risks, unprotected intercourse modalities, barrier efficacy, and substance co-factors.

Factor Structure: Beliefs About Preventing HIV/AIDS Scale (BPAS)

The factor analysis of the beliefs pool isolated 36 retained items across five distinct, conceptually coherent factors:

1. Factor 1: Self-Efficacy (14 items): Exhibited the highest proportion of explained variance, with heavy loadings from items assessing confidence in condom procurement, carrying, and refusal of unprotected sex under pressure.
2. Factor 2: Self-Control (8 items): Loaded with items assessing impulse regulation, sexual excitation effects, and boundary maintenance.
3. Factor 3: Perceived Threat (6 items): Dominated by items measuring personal vulnerability, 5-year acquisition probability, and fear of infection.
4. Factor 4: Expectation to Prevent Pregnancy (5 items): Clustered around contraception use, pregnancy avoidance values, and heterosexual birth control management.
5. Factor 5: Peer Support for Safe Acts (4 items): Defined by items measuring peer norms, social circle condom use, and peer protective habits.

10. Instrument / Measurement Tool

• Instrument Name: HIV/AIDS Knowledge and Beliefs Scales for Adolescents
• Component Measures:
  • HIV/AIDS Knowledge Scale: 45 True/False items + 7-item forced-choice Safer Alternatives subscale.
  • Beliefs About Preventing HIV/AIDS Scale (BPAS): 36 Likert-type items.
• Administration Format: Standardized self-report pencil-and-paper questionnaire or structured clinical interview for populations with low reading literacy.
• Administration Time: Approximately 20 minutes for the Knowledge Scale; approximately 15 minutes for the Beliefs Scale (total 35 minutes).
• Target Population: Adolescents and emerging adults aged 11 to 24 years, including clinical, juvenile justice, homeless, and community samples.
• Response Modes:
  • Knowledge Scale: Dichotomous (True [T] vs. False [F]).
  • Safer Alternatives: Forced-choice paired comparison (Option A vs. Option B).
  • Beliefs Scale (BPAS): 4-point Likert scale (1 = Agree Strongly, 2 = Agree Somewhat, 3 = Disagree Somewhat, 4 = Disagree Strongly).
• Scoring and Transformation Procedures:
  • Knowledge Scale: Items are scored as correct = 1, incorrect = 0. Total and subscale scores are derived by summing correct responses. Maximum score = 45 on the primary scale, 7 on Safer Alternatives. Higher scores reflect greater biomedical accuracy and fewer transmission misconceptions.
  • Beliefs Scale (BPAS): 19 items must be reverse-scored prior to computation: Items 3, 4, 5, 6, 7, 11, 12, 16, 18, 20, 23, 25, 26, 27, 29, 31, 32, 33, and 35 (recoded as 1 = 4, 2 = 3, 3 = 2, 4 = 1). Items are summed or averaged within subscales. Higher transformed scores denote stronger endorsement of protective, preventive beliefs.

11. Permissions & Fee and Test Year

The HIV/AIDS Knowledge and Beliefs Scales for Adolescents were first formally published and standardized in 1990 by Cheryl Koopman and colleagues at Columbia University and Stanford University. The validation research was sponsored through public federal research grants administered by the National Institute of Mental Health (NIMH Grant Nos. 1P50MH43520, 1R01MH54930) and the National Institute on Drug Abuse (NIDA Grant No. 1R01DAO7900-01A1).

As federally funded instruments published in academic literature, the scales reside in the public domain for non-profit academic research, epidemiological surveillance, and clinical evaluation purposes. No commercial licensing fees or proprietary royalties are required. Researchers and health practitioners seeking to utilize, adapt, or translate the scales are requested to cite the foundational validation publications (Koopman et al., 1990; Canterbury et al., 1998) and direct correspondence regarding archival psychometric materials to:

Cheryl Koopman, Ph.D.
Department of Psychiatry and Behavioral Sciences, MC 5718
Stanford University School of Medicine
Stanford, CA 94305-5718
Email: [email protected]

12. References

Ananth, P., & Koopman, C. (2003). HIV/AIDS knowledge, beliefs, and behavior among women of childbearing age in India. AIDS Education and Prevention, 15(6), 529–546. https://doi.org/10.1521/aeap.15.7.529.24046

Canterbury, R. J., Clavet, G. J., McGarvey, E. L., & Koopman, C. (1998). HIV risk-related attitudes and behaviors of incarcerated adolescents: Implications for public school students. The High School Journal, 82(1), 1–10. https://www.jstor.org/stable/40364426

Chang, V. Y., Bendel, T. L., Koopman, C., McGarvey, E. L., & Canterbury, R. J. (2003). Delinquents’ safe sex attitudes: Relationships with demographics, resilience factors, and substance use. Criminal Justice and Behavior, 30(2), 210–229. https://doi.org/10.1177/0093854802250785

Greig, F. E., & Koopman, C. (2003). Multilevel analysis of women’s empowerment and HIV prevention: Quantitative survey results from a preliminary study in Botswana. AIDS and Behavior, 7(2), 195–208. https://doi.org/10.1023/A:1023906411210

Koopman, C., Rotheram-Borus, M. J., Henderson, R., Bradley, J. S., & Hunter, J. (1990). Assessment of knowledge of AIDS and beliefs about AIDS prevention among adolescents. AIDS Education and Prevention, 2(1), 58–70. https://pubmed.ncbi.nlm.nih.gov/2372489/

Otto-Salaj, L. L., Gore-Felton, C., McGarvey, E., & Canterbury, R. J. (2002). Psychiatric functioning and substance use: Factors associated with HIV risk among incarcerated adolescents. Child Psychiatry and Human Development, 33(2), 91–106. https://doi.org/10.1023/A:1020738604321

Patel, V. L., Gutnik, L. A., Yoskowitz, N. A., O’Sullivan, L. F., & Kaufman, D. R. (2006). Patterns of reasoning and decision making about condom use by urban college students. AIDS Care, 18(8), 918–930. https://doi.org/10.1080/09540120600569766

Patel, V. L., Yoskowitz, N. A., & Kaufman, D. R. (2007). Comprehension of sexual situations and its relationship to risky decisions by young adults. AIDS Care, 19(7), 916–922. https://doi.org/10.1080/09540120701209861

Volk, J. E., & Koopman, C. (2001). Factors associated with condom use in Kenya: A test of the health belief model. AIDS Education and Prevention, 13(6), 495–508. https://doi.org/10.1521/aeap.13.6.495.21441

Whaley, A. L. (1999). Preventing the high-risk behavior of adolescents: Focus on HIV/AIDS transmission, unintended pregnancy, or both? Journal of Adolescent Health, 24(6), 376–382. https://doi.org/10.1016/S1054-139X(98)00150-1

13. Items of the Scale (Questionnaire)