Enhancing adolescent self-efficacy and collective efficacy through public engagement around HIV/AIDS competence: A multilevel, cluster randomized-controlled trial
Highlights
► Adolescents in Tanzania increased their communicative and deliberative self-efficacy through public discourse on HIV/AIDS. ► This enhanced self-efficacy was developed through community education and mobilization they initiated to address HIV/AIDS. ► Adults recognized adolescent contributions to a scientific understanding of transmission, testing and treatment of HIV/AIDS. ► This health promotion approach increased collective efficacy (intergenerational closure) between adolescents and adults. ► Local government involvement legitimized and sustained the Young Citizens Program as a structural intervention.
Introduction
Interventions to address the impact of the Human Immune Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic on children and adolescents commonly target their vulnerabilities, such as their orphan status. The potential capacity of children to confront the epidemic is rarely considered (Earls, Raviola, & Carlson, 2008). Given the availability of HIV testing, counseling and antiretroviral treatment for all ages, circumstances exist for children and adolescents to contribute through civic engagement to HIV/AIDS competence around prevention, testing and treatment (AIDS Competence Programme, 2005). The Young Citizens Program (the YC Program) established in Moshi in 2003, a midsized municipality in the Kilimanjaro Region of Tanzania, adopts a health promotion framework (WHO, 1986) to foster critical, intergenerational public discourse about HIV/AIDS (Earls & Carlson, 2001). In this paper, the YC Program is evaluated by a cluster randomized-controlled trial (CRCT) in which the science and social context of HIV/AIDS become topics of public deliberation and social action within geopolitically defined neighborhoods. These preexisting neighborhood units are referred to as mitaa, plural, and mtaa, singular, in KiSwahili. The rationale for the cluster design is to treat these mitaa as units of analysis as part of a structural intervention, using multilevel modeling. The term, neighborhood, will be used when referring conceptually to these units while the terms, mtaa and mitaa, will be adopted when referring specifically to them. Reporting of this trial follows the CONSORT Working Group guidelines (Campbell, Elbourne, Altman, & for the CONSORT Group, 2004).
The YC Program originated in the Project on Human Development in Chicago Neighborhoods, a multilevel, longitudinal study that documented the important role of collective efficacy as a neighborhood-level protective mechanism for health and well-being (Sampson, Raudenbush, & Earls, 1997). Defined as the combination of social cohesion and the willingness to take civic action, the health benefits of collective efficacy have been shown to impact violence (Molnar, Buka, Brennan, Holton, & Earls, 2003; Sampson, Morenoff, & Raudenbush, 2005); asthma (Cagney & Browning, 2004; Sternthal, Jun, Earls, & Wright, 2010), birth weight (Buka, Brennan, Rich-Edwards, Raudenbush, & Earls, 2003); mental health (Xue, Leventhal, Brooks-Gunn, & Earls, 2005) the age of onset of sexual intercourse (Browning, Leventhal, & Brooks-Gunn, 2005) and mortality (Lochner, Kawachi, Brennan, & Buka, 2003). The encouraging results of this observational study challenged us to design an experimental intervention to enable young adolescents to strengthen collective efficacy in their local neighborhoods (Earls & Carlson, 2002). To achieve this, the YC Program established its feasibility, safety and acceptability within a framework grounded in theory and empirical research necessary to guide implementation and multilevel outcome measurement (Carlson & Earls, 2011a; Chan, Trickett, Carlson, & Earls, 2003).
Several social and behavioral science theories are foundational to the YC Program. The capability theory of Sen provides the critical concepts of human agency at the individual level and of social choice in the context of local opportunity structures as the basis for remedying human inequality (Sen, 1992, 1999). The communicative action theory of Habermas stresses the use of reason, perspective taking and deliberative communication to achieve mutual understanding in the public sphere (Habermas, 1984, 1987). He emphasizes rational argumentation to achieve shared social action, in contrast to strategic or instrumental approaches. Through the participatory drama method of Boal (1979), adolescents are able to portray the biological complexity of HIV infection and confront the social stigma surrounding AIDS through critical engagement with public audiences (Kamo, Carlson, Brennan, & Earls, 2008). The multilevel design was informed by the ecological theory of Bronfenbrenner (1979) in which reciprocal interaction between children and their social environment forms the crux of human development (Bronfenbrenner & Ceci, 1994). According to Bandura's theory of self- and collective efficacy (Bandura, 2000; Sampson, Morenoff, & Earls, 1999), the attainment of perceived personal and collective competence in the face of specific environmental challenges determines well-being (Earls & Carlson, 2001). These constructs informed the outcome measures of the YC Program. In combination, these theories provide a developmental framework to explore how enhanced personal knowledge and control transfer to the larger social context in which the maturing child is embedded. A detailed curriculum was devised to achieve these intersecting aims (Carlson & Earls, 2011b).
The objectives were to increase the competence of youth participants in the YC Program and to evaluate their impact at the neighborhood level. Adolescents' positive mental health, as reflected in the motivation and skills required to be effective HIV health agents, was evaluated by structured interviews in pre- and post-treatment assessments. The hypotheses are that the YC Program enhances: 1) adolescents' confidence to deliberate on the biological and social issues related to the prevention, testing and treatment of HIV infection with residents of all ages and 2) the recognition by adult residents of adolescents' capabilities as health agents to promote collective efficacy and HIV/AIDS competence.
Section snippets
Study setting
The eligible population for program participants consisted of all children between the ages of 9 and 14 living in households in the Moshi Urban District in the Kilimanjaro Region of northern Tanzania. The eligible clusters were the 60 residential mitaa with a total population of 144,739 in the 2002 census (Census of Tanzania, 2002). HIV seroprevalence was 10.4 percent at the beginning of the study period in 2003 (Kapiga, Sam, Mlay, & Larsen, 2006). The mitaa were composed of 2000–4000 residents
Pre- and post-treatment dates and response rates
The response rate for pre-treatment community survey was 95% yielding a sample of 2205 from 2320 households across 60 mitaa (January–March, 2004). In the post-treatment community survey, conducted in the 30 treatment and control mitaa, 1119 adult residents were interviewed, representing a response rate of 96.8% (September–November, 2005).
In recruiting adolescent participants for the YC Program across the 30 mitaa, 2656 households were screened, yielding 827 (31.1%) age-eligible children of
Discussion
The YC Program was conceived as a structural intervention aimed at strengthening personal and collective efficacy to promote HIV/AIDS community competence (Carlson & Earls, 2011a). The participatory curriculum enabled young adolescents to acquire the scientific knowledge and the communicative and critical thinking skills needed engage in informed public deliberations around HIV/AIDS in their neighborhoods.
Acknowledgments
This research was supported by a grant from the National Institute of Mental Health (R01 MH66801). Members of the Moshi Municipality Council are acknowledged for their official endorsement of this project. We thank members of the Data Safety and Monitoring Board, chaired by Esther Mwaikambo, for their thoughtful and timely advice. The study benefited from its partnerships with Kilimanjaro Christian Medical College and the National Bureau of Statistics. We are indebted to several scientific
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