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I. PROGRAM RESOURCES
1. Family Planning, HIV/AIDS & STIs, and Gender Matrix: A Tool for Youth Reproductive Health Programming
2. A Framework for Integrating Reproductive Health and Family Planning into Youth Development Programs
3. Youth Research Working Paper No. 8. Early Sexual Debut, Sexual Violence, and Sexual Risk-taking among Pregnant Adolescents and Their Peers in Jamaica and Uganda
4. Community Pathways to Improved ASRH: A Conceptual Framework and Suggested Outcome Indicators
5. Leave No Woman Behind: Ethiopia
II. RESEARCH SUMMARIES
1. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial
2. Adolescent and adult participation in an HIV vaccine trial preparedness cohort in South Africa
3. Adolescent pregnancy in Argentina: evidence-based recommendations for public policies
4. Assessing acceptability of parents/guardians of adolescents towards introduction of sex and reproductive health education in schools at Kinondoni Municipal in Dar es Salaam city
5. 'Boys will be boys': traditional Xhosa male circumcision, HIV and sexual socialisation in contemporary South Africa
6. Correlates of ever had sex and of recent sex among teenagers and young unmarried adults in the Democratic Republic of Congo
7. Does female schooling reduce fertility? Evidence from Nigeria
8. Effectiveness of web-based education on Kenyan and Brazilian adolescents' knowledge about HIV/AIDS, abortion law, and emergency contraception: Findings from TeenWeb
9. Geographical variations and contextual effects on age of initiation of sexual intercourse among women in Nigeria: a multilevel and spatial analysis
10. Lithuanian general practitioners' knowledge of confidentiality laws in adolescent sexual and reproductive healthcare: a cross-sectional study
11. Opinions on early-age marriage and marriage customs among Kurdish-speaking women in southeast Turkey
12. Prevalence and correlates of condom use at last sexual intercourse among in-school adolescents in urban areas of Uganda
13. Relative contribution of intrapersonal and partner factors to contraceptive behavior among Taiwanese female adolescents
14. Sexual and reproductive health service needs of university/college students: updates from a survey in Shanghai, China
15. Sexual risk and bridging behaviors among young people in Hai Phong, Vietnam
16. Study of knowledge, perception and attitude of adolescent girls towards STIs/HIV, safer sex and sex education: (a cross sectional survey of urban adolescent school girls in South Delhi, India)
17. The Iranian female high school students' attitude towards people with HIV/AIDS: a cross-sectional study
18. Miscarriage but not stillbirth rates are higher among younger nulliparas in rural Southern Nepal
19. Sex education via computer-aided instruction for early secondary school students
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I. PROGRAM RESOURCES
1. Family Planning, HIV/AIDS & STIs, and Gender Matrix: A Tool for Youth Reproductive Health Programming (2008, PDF, 618 KB)
The purpose of the matrix is to provide youth-serving organizations with a guide of topics on family planning, HIV/AIDS, sexually transmitted infections (STIs) and gender; segmenting them by age and marital status. The matrix can assist technical experts, program managers, health providers, peer educators and others to determine what topics and interventions best fit into their own respective programs while taking cultural paradigms into consideration. The tool can be applied in any setting or program serving youth such as schools, outreach and peer education programs, community-based youth services or youth-friendly clinics.
Organization: International Youth Foundation
Contact: youth@iyfnet.org
2. A Framework for Integrating Reproductive Health and Family Planning into Youth Development Programs (2008, PDF, 1.4 MB)
Positive youth-focused programs, combined with reproductive health information and services, can motivate youth to postpone sexual activity and practice safer sexual behavior. Evidence demonstrates that positive youth reproductive health outcomes are closely linked with educational and economic opportunities. The framework identifies guiding principles for integration of reproductive health, key programmatic elements and an organizational self-assessment tool.
Organization: International Youth Foundation
Contact: youth@iyfnet.org
3. Youth Research Working Paper No. 8. Early Sexual Debut, Sexual Violence, and Sexual Risk-taking among Pregnant Adolescents and Their Peers in Jamaica and Uganda (2008, PDF, 559 KB)
This study first identified contextual factors and circumstances that influence pregnancy among young adolescents (15-17 years old in Jamaica and Uganda) and then in Jamaica used a quantitative case-control study to measure the relationships between sexual debut, sexual coercion/violence, and sexual risk-taking among pregnant adolescents and their never pregnant, but sexually active peers. The study found an association between pregnancy and early sexual debut but not between pregnancy and sexual violence. Despite this lack of statistical association, the high prevalence of sexual violence among both pregnant and never pregnant girls led to recommendations for more focus on this issue.
Organization: Interagency Youth Working Group
Contact: youthwg@fhi.org
4. Community Pathways to Improved ASRH: A Conceptual Framework and Suggested Outcome Indicators (2008, 42 pages)
This working paper by the Interagency Working Group on Community Involvement in Adolescent Sexual and Reproductive Health is intended as a resource for program planners, evaluators, donors, and policy-makers who want to strengthen their understanding of how community involvement contributes to adolescent and sexual and reproductive health program outcomes. It also encourages greater application and measurement of interventions that focus on community involvement and change.
Organization: Pathfinder International
Contact: tech-comm@pathfinder.org
5. Leave No Woman Behind: Ethiopia (2007, PDF, 40 pages, 1.8 MB)
This document reports some baseline results of the Leave No Woman Behind project, which addresses women's and girls' skills, schooling, and ability to manage reproductive health in rural areas of Amhara Region, Ethiopia. The project reaches out to girls and women aged 10 to 45, encouraging them to form women's groups through which nonformal education and reproductive health information is passed along.
Organization: The Population Council
Contact: publications@popcouncil.org
II. RESEARCH SUMMARIES
1. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. Jewkes R, Nduna M, Levin J, et al. BMJ 2008;337:a506.
The authors used a cluster-randomized controlled trial to assess the impact of Stepping Stones, an HIV prevention program, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behavior. Participants included 1,360 men and 1,416 women aged 15-26 years, who were mostly attending schools, from 70 villages in the Eastern Cape province of South Africa. Stepping Stones, a 50-hour program, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills, and to stimulate critical reflection. Villages were randomized to receive either this or a three-hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months, and blood was tested for HIV and HSV-2. There was no evidence that Stepping Stones lowered the incidence of HIV. The program was associated with a reduction of about 33% in the incidence of HSV-2; that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1,000 people exposed. Stepping Stones significantly improved a number of reported risk behaviors in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women, desired behavior changes were not reported and those in the Stepping Stones program reported more transactional sex at 12 months.
2. Adolescent and adult participation in an HIV vaccine trial preparedness cohort in South Africa. Middelkoop K, Myer L, Mark D, et al. J Adolesc Health 2008;43(1):8-14.
The authors analyzed data from a cohort study conducted to assess the feasibility of involving adolescents and adults in HIV vaccine-related studies. Two hundred HIV-negative participants aged 16 to 40 years were enrolled, including 86 (43%) adolescents. At baseline, questionnaires on sexual risk behavior and willingness to participate (WTP) in future HIV vaccine trials were administered. Three monthly HIV counseling sessions and pregnancy, HIV, and syphilis tests were performed. Risk questionnaires were repeated at 6 months and WTP at 12 months. No significant difference in retention between adults (83%) and adolescents (87%) was noted. Initially, more adults (40%) reported WTP than adolescents (13%). At the end of the study, both groups reported higher levels of WTP; increasing to 40% among adolescents. HIV incidence during the study was 9.2 infections per 100 person-years among adolescents compared to 5.8 in adults. The authors conclude that retention of high-risk HIV-negative adolescents in a cohort study is feasible. After receiving education, adolescents reported improved WTP.
3. Adolescent pregnancy in Argentina: evidence-based recommendations for public policies. Gogna M, Binstock G, Fernandez S, et al. Reprod Health Matters 2008;16(31):192-201.
This article presents the findings of a large quantitative and qualitative study conducted in five northern provinces and two metropolitan areas of Argentina in 2003-2004. Based on the results of a survey of adolescent mothers (n=1,645) and 10 focus group discussions with adolescent girls and boys, it addresses the connections between school dropout, pregnancy, and poverty and makes recommendations on how to tailor health care and sexuality education to address the local context. The findings indicate a need to develop educational activities to promote safer sex and address gender power. Sexuality education with a gender and rights perspective and increasing accessibility to contraceptive methods for adolescent girls and boys are also crucial. Antenatal and post-partum care, as well as post-abortion care, should be improved for young women and viewed as opportunities for contraceptive counseling and provision. Male participation in pregnancy prevention and care also needs to be promoted.
4. Assessing acceptability of parents/guardians of adolescents towards introduction of sex and reproductive health education in schools at Kinondoni Municipal in Dar es Salaam city. Mbonile L, Kayombo EJ. East Afr J Public Health 2008;5(1):26-31.
A structured questionnaire was used to interview 150 parents and was supplemented with guided focus group discussions to determine how parents felt about sex education in schools. The findings show that parents had mixed feelings about this topic. Participants strongly believed that they themselves should talk with their adolescents about sexuality and reproductive health (88.6%), but 76.7% felt that their culture prohibits them from doing so. They also believed that condoms could protect against HIV/AIDS and sexually transmitted infections (82%), but were strongly opposed to the use of condoms by their adolescents on the basis that this would encourage promiscuity (78%). Participants preferred that adolescents receive information about sex and reproductive health from parents/guardians (86%), religious leaders (70%), media (62%), health workers (61%), and school teachers (59%). Generally, parents favored the provision of education about sex and reproductive health within the community, but the approach must take into account cultural and religious factors. Parents/guardians, religious leaders, and traditional charismatic leaders should take part in designing the program and be involved in teaching.
5. 'Boys will be boys': traditional Xhosa male circumcision, HIV and sexual socialisation in contemporary South Africa. Vincent L. Cult Health Sex 2008;10(5):431-46.
This paper examines how cultural and social components of ritual male circumcision, as practiced by the Xhosa of South Africa, have shifted. Ritual circumcision is often defended on the basis that it helps maintain social order, particularly in relation to the perceived crisis in youth sexuality marked by extremely high levels of gender-based violence and HIV infection. However, this paper suggests two key ways in which traditional Xhosa circumcision has changed: (1) the erosion of the role that circumcision schools once played, and (2) the emergence of the idea that initiation gives men the unlimited and unquestionable right to sex rather than marking the point at which sexual responsibility and restraint is introduced into the lifestyle of young men.
6. Correlates of ever had sex and of recent sex among teenagers and young unmarried adults in the Democratic Republic of Congo. Kayembe KP, Mapatano MA, Busangu FA, et al. AIDS Behav 2008;12(4):585-93.
The authors examined the premarital sexual activity of 13,091 teenagers and young adults aged 15-24 years. Logistic regression models were used to identify the correlates of ever had sex and recent sex. Ever had sex and recent sex were associated with older individuals, males, school dropouts, those addicted to alcohol or drugs, those living alone or with friends, those involved in an income-generating activity, those with low capacity to resist sex, those with low socioeconomic status, and those living in permissive milieu. Controlling access to alcohol and drugs, teaching teenagers the skills to resist sex, and getting schools involved in teaching about abstinence and delayed sex could affect the age at first sex and trigger the adoption of lower-risk behavior.
7. Does female schooling reduce fertility? Evidence from Nigeria. Osili UO, Long BT. J Dev Econ 2008;87(1):57-75.
This paper tests whether there is a causal relationship between fertility and education by investigating the introduction of universal primary education in Nigeria. The analysis suggests that increasing female education by one year reduces early fertility by 0.26 births.
8. Effectiveness of web-based education on Kenyan and Brazilian adolescents' knowledge about HIV/AIDS, abortion law, and emergency contraception: Findings from TeenWeb. Halpern CT, Mitchell EM, Farhat T, et al. Soc Sci Med 2008;67(4):628-37.
This paper reports results from an evaluation of the TeenWeb project, a multi-year, Web-based health education intervention implemented in two urban settings: Nairobi, Kenya (N=1,178 school students) and Rio de Janeiro, Brazil (N=714 school students). A quasi-experimental, school-based pretest/posttest design was implemented at each study site to determine if easy access to Web-based reproductive health information, combined with intellectual "priming" about reproductive health topics, would result in improved knowledge and attitudes about these topics. Students in Web-access schools completed one Web-based module approximately every 6-8 weeks, and in return, had access to the Internet for at least 30 minutes after completing each module. Although students were encouraged to access project-supplied Web-based health information, freedom of web navigation was an incentive, so they could choose to access other Internet content as well. Most measures showed statistically significant differences between students in "Web" and "comparison" conditions at posttest, but only about half of the differences were in the hypothesized direction. Review of URL logs suggests that the modest results were due to inadequate exposure to educational materials. Future intervention should focus on teen's purposeful searching for health information when they are in personal circumstances of unmet health needs.
9. Geographical variations and contextual effects on age of initiation of sexual intercourse among women in Nigeria: a multilevel and spatial analysis (PDF, 616 KB). Uthman OA. Int J Health Geogr 2008;7(Article No. 27):12 p.
The purpose of this study was to examine the extent of regional and state disparities in age of initiation of sexual intercourse among Nigerian women and to examine individual- and community-level predictors of early sexual debut. Multilevel logistic regression models were applied to data on 5,531 ever or currently married women who had participated in 2003 Nigeria Demographic and Health Survey. Coital debut at 15 years or younger was used to define early sexual debut. Exploratory spatial data analysis methods were used to study geographic variation in age at first sexual intercourse. After adjusting for both individual-level and contextual factors, the probability of starting sex at an earlier age was associated with respondents' current age, education attainment, ethnicity, region, and community median age of marriage. The authors conclude that interventions to reduce adolescent high-risk sexual behavior should focus on high-risk places as well as high-risk groups of people.
10. Lithuanian general practitioners' knowledge of confidentiality laws in adolescent sexual and reproductive healthcare: a cross-sectional study. Lazarus JV, Jaruseviciene L, Liljestrand J. Scand J Public Health 2008;36(3):303-9.
The authors sent a 41-item questionnaire to a random sample of 607 Lithuanian general practitioners (GPs) to determine how much they knew about legal issues surrounding confidentiality for minors in sexual and reproductive healthcare. The response rate was 73.5%. Of this, 49.3% proved to be knowledgeable about legal standards that protect the confidentiality of adolescents in healthcare. Knowledge was found to be higher among GPs who had a written office policy that was based on the law. Respondents stated that the most important measure to improve confidentiality in adolescent healthcare would be the development of an explicit legal framework to address it. GPs' unfamiliarity with existing confidentiality regulations implies that there are ways to improve confidentiality in sexual and reproductive care beyond merely changing the law. This study suggests the need for a comprehensive strategy, including the development of professional guidelines and written office policies coupled with legal educational programs directed at GPs.
11. Opinions on early-age marriage and marriage customs among Kurdish-speaking women in southeast Turkey. Ertem M, Kocturk T. J Fam Plann Reprod Health Care 2008;34(3):147-52.
According to a national survey, about 50% of all women in Eastern Turkey were aged less than 18 years at first marriage. This study explored women's opinions and experiences of early marriage and culture-specific marriage customs in the province of Diyarbakir, a region of Turkey populated mostly by people of Kurdish ethnicity. A random sample of 966 women aged 15 years or older living in urban and rural areas of the province completed a questionnaire on age at marriage and social status. Qualitative data on women's opinions and experiences were also collected through focus group interviews with 90 women. The frequency of early marriage ranged from 19% in the youngest age group to 63% in women aged 60 years or older. Protecting family honor was one key factor that led parents to arrange the early marriage of their daughters, sometimes without their consent. Some culture-specific marriage customs included cradle betrothal, cousin marriage, and berdel (exchange of brides between two families). There is a need for public health and family planning workers to create greater awareness of the adverse consequences of early marriage through parental arrangements.
12. Prevalence and correlates of condom use at last sexual intercourse among in-school adolescents in urban areas of Uganda. Twa-Twa JM, Oketcho S, Siziya S, et al. East Afr J Public Health 2008;5(1):22-5.
The authors used secondary data from the Uganda Global School-based Health Survey (UGSHS) conducted in 2003 to determine the prevalence and correlates of condom use at last sexual intercourse in urban areas of Uganda. A two-stage cluster sampling technique was used to obtain a representative sample. Altogether, 1,709 students participated in the survey in urban areas; of these, 179 (14.9% of males, and 7.9% of females) had engaged in sexual intercourse within 12 months before the survey. Overall, 77.3% (79.7% of male, and 72.3% of female) adolescents used a condom at last sexual intercourse. Adolescents who drank alcohol and used drugs were 64% and 68% more likely to have used a condom, respectively. Meanwhile, adolescents who ever got drunk, and who reported to ever have had two or more sex partners were 55% and 35% less likely to have used a condom compared to those who had never got drunk, and who had one sex partner, respectively. Finally, adolescents who reported receiving no parental supervision were 45% less likely to have used a condom compared to those who reported receiving parental supervision. The authors conclude that parental supervision may be effective in promoting condom use among adolescents. Furthermore, drinking alcohol was associated with condom use, probably due to peer pressure and easy access to condoms in drinking places (condoms are not actively promoted in schools). There is need for more research on how in-school adolescents can access condoms.
13. Relative contribution of intrapersonal and partner factors to contraceptive behavior among Taiwanese female adolescents. Wang R-H, Chiou C-J. J Nurs Scholarsh 2008;40(2):131-6.
The authors used a cross-sectional design and recruited Taiwanese female adolescents (N=375) who had a steady male sexual partner in the past three months. Participants were given anonymous questionnaires that asked about demographic data, sexual history, contraceptive behavior, self-efficacy for contraception, perceptions of support from sexual partner for contraception, and perceptions of relationship power. Participants who had their first sexual experience at less than 14 years of age and were from one-parent families had the least comprehensive contraceptive behavior. Number of steady sexual partners was significantly negatively correlated with contraceptive behavior. Self-efficacy, perceptions of support from sexual partner for contraception, and relationship power all were positively correlated with contraceptive behavior. The important explanatory variables of contraceptive behavior were self-efficacy, age of first sexual intercourse, intervals between sexual intercourse, and perceptions of support from sexual partner for contraception. These accounted for 39.1% of variance in contraceptive behavior. Intrapersonal factors (self-efficacy, age of first sexual intercourse, and intervals between sexual intercourse) were more important than were partner factors (perceptions of support from sexual partners for contraception and relationship power) in influencing contraceptive behavior.
14. Sexual and reproductive health service needs of university/college students: updates from a survey in Shanghai, China. Chen B, Lu Y-N, Wang H-X, et al. Asian J Androl 2008;10(4):607-15.
From July 2004 to May 2006, 5,243 students from 14 universities in Shanghai took part in a survey on their demand for reproductive health services, attitudes toward and experience with sex, exposure to pornographic material, and knowledge on sexual health and sexually transmitted infections (STIs)/AIDS. Of the 5,067 students who provided valid answer sheets, 50% were female and 50% were male, 15% were medical students, and 85% had non-medical backgrounds. A total of 38% of respondents had received reproductive health education previously. The majority of students supported school-based reproductive health education, and also acquired information about sex predominantly from books, schoolmates, and the Internet. Premarital sexual behavior was opposed by 18% of survey participants, and 38% could identify all the three types of STIs listed in the questionnaire. Although 84% knew how HIV is transmitted and 58% knew that the use of condoms could reduce the risk of HIV infection, only 56% knew when to use a condom. The authors conclude that reproductive health service is lagging behind current attitudes and demands of university students. Although students' attitudes toward sexual matters are liberal, their knowledge about reproductive health and STIs/AIDS is still limited.
15. Sexual risk and bridging behaviors among young people in Hai Phong, Vietnam. Duong CT, Nguyen TH, Hoang TT, et al. AIDS Behav 2008;12(4):643-51.
The risk of the HIV epidemic spreading from high-risk groups to the general population in Vietnam depends on sexual risk and bridging behaviors between high- and low-risk individuals. A cross-sectional study was used to describe sexual activities of youth aged 18-29 years. Nearly half were sexually active. Premarital sex was reported by 43.3% of them — 78.3% of sexually active males and 13.5% of sexually active females. Multiple sex partners were reported by 31.0% — 56.7% of males and 9.2% of females. Almost 27% of males and 5% of females engaged in sexual bridging behaviors. Being unmarried was significantly associated with having sex with non-regular partners. Being unmarried and early age at first intercourse were associated with having sex with a sex worker. Consistent condom use was high with commercial sex workers but low with regular partners. Education to delay early sexual debut, increased employment, and strategies to inform young sexually active people to adopt safer behaviors are urgently needed.
16. Study of knowledge, perception and attitude of adolescent girls towards STIs/HIV, safer sex and sex education: (a cross sectional survey of urban adolescent school girls in South Delhi, India) (PDF, 225 KB). McManus A, Dhar L. BMC Womens Health 2008;8(Article No. 12):6 p.
A cross sectional study was carried out in 2007 in South Delhi, India to investigate the perception, knowledge, and attitude of adolescent urban schoolgirls toward sexually transmitted infections (STIs), HIV/AIDS, safer sex practices, and sex education. A self-administered questionnaire was completed by 251 female students from two senior secondary schools. More than one-third of students in this study had no accurate understanding about the signs and symptoms of STIs other than HIV/AIDS. About 30% of respondents believed HIV/AIDS could be cured, 49% felt that condoms should not be available to youth, 41% were confused about whether the contraceptive pill could protect against HIV infection, and 32% thought contraceptive pills should only be taken by married women. Though controversial, there is an immense need to implement gender-based sex education regarding STIs, safe sex options, and contraceptives in schools in India.
17. The Iranian female high school students' attitude towards people with HIV/AIDS: a cross-sectional study (PDF, 214 KB). Ghabili K, Shoja MM, Kamran P. AIDS Res Ther 2008;5(Article No. 15):5 p.
The authors evaluated female high school students' attitudes towards HIV/AIDS in Tabriz, Iran to assess the cultural issues that need to be addressed in related educational programs and to discover sources of students' information about AIDS. Anonymous, self-administered questionnaires were completed by 300 students. Among these, 91% agreed that being HIV-positive should not be an obstacle to obtaining education and employment. About 73% of the students, however, declared that the community should be informed of HIV-positive people. In addition, one-tenth declared that they would feel extremely uncomfortable towards their HIV infected classmate, and only 16% of the students stated that they would continue to shop at HIV infected grocer's store. The mass media and the experts were the major source and the most reliable source of information about AIDS, respectively.
18. Miscarriage but not stillbirth rates are higher among younger nulliparas in rural Southern Nepal. Katz J, Khatry SK, LeClerq SC, et al. J Adolesc Health 2008;42(6):587-95.
Pregnancies, miscarriages, and stillbirths were prospectively identified in two randomized trials of maternal micronutrient supplementation. This analysis included 5,861 women of parity 0 (nulliparas) and 4,459 of parity 1 (primiparas) who were less than or equal to 26 years of age. Among nulliparous women, 5.7% and 4.6% of pregnancies ended in miscarriage and stillbirth, respectively. The adjusted relative risk of miscarriage was 2.07 for girls less than or equal to 15 compared with those 18 and 19 years, and was 1.40 (95% CI = 1.06-1.84) among those 15-17 years. Stillbirth rates did not differ significantly by maternal age. There were no differences in miscarriage or stillbirth rates by maternal age among primiparas. Young maternal age increased the risk of miscarriages but not stillbirths for nulliparas. Miscarriages and stillbirths did not differ by maternal age for primiparous women.
19. Sex education via computer-aided instruction for early secondary school students. Eamratsameekool W. J Med Assoc Thai 2008;91(5):759-63.
Development and use of computer-aided instruction (CAI) about sex education may facilitate learning and provide an additional education channel to early secondary school students. The author used a randomized control-group pretest-posttest design with four student groups from different schools: 1) CAI, 2) CAI control, 3) teacher, and 4) teacher control groups. The CAI was developed and organized in accordance with new sex education concepts. Questionnaires were also developed accordingly. Analysis of covariance (ANCOVA) was employed. One hundred and eighty three students from four rooms from four different schools were enrolled. The pretest scores were 24.65, 27.44, 31.51, and 33.66; and posttest scores were 25.00, 25.74, 33.80, and 34.77 for CAI, CAI control, teacher, and teacher control groups, respectively. The ANCOVA revealed there was no significant difference between the CAI and the CAI control groups and between the teacher and the teacher control groups. The author concludes that the knowledge of CAI group did not differ from the control group.
