Joanne Mueller 1, Collin Alie 2, Beatrice Jonas 2, Elizabeth Brown 2 and Lorraine Sherr 1

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1 Tropical Medicine and International Health doi: /j x volume 16 no 1 pp january 2011 A quasi-experimental evaluation of a community-based art therapy intervention exploring the psychosocial health of children affected by HIV in South Africa Joanne Mueller 1, Collin Alie 2, Beatrice Jonas 2, Elizabeth Brown 2 and Lorraine Sherr 1 1 Research Department of Infection and Population Health, University College London, UK 2 Mad About Art, Knysa, South Africa Summary objectives To evaluate the efficacy of the Make A Difference about Art programme, a community art programme in South Africa for children affected by HIV and AIDS, which aims to reduce psychosocial problems by increasing self-esteem, self-efficacy and HIV insight. methods A quasi-experimental cross-sectional post-intervention survey of 297 children aged 8 18 years (177 programme attendees and a control group of 120). Participants completed an inventory comprising standardized, validated psychosocial measures of depression, emotional and behavioural problems, self-esteem and self-efficacy and key sociodemographic variables potentially relevant as risk and protective factors. results Attending the intervention was predictive of significantly higher self-efficacy, but was not associated with differences in self-esteem, depression, or emotional behavioural problems. This association remained in the multivariate analysis, controlling for potential confounders. Double parental death exerted a powerful effect on child psychosocial health, eliminating the association between intervention attendance and higher self-efficacy. However, an interaction was found between bereavement status and intervention attendance on child self-efficacy, indicating that the intervention programme may ameliorate some of the psychosocial vulnerabilities associated with becoming an orphan. Other key risk factors for poor psychosocial health in this sample were AIDS-related stigma and community and household violence. Social connection emerged as a key protective factor. conclusions Our findings suggest that such interventions may offer opportunities to increase the selfefficacy of vulnerable children to protect their psychological health. keywords evaluation, intervention, children, HIV, therapy, South Africa Introduction The psychological health of HIV-infected and -affected children in Southern Africa is high on the research agenda (Snider 2006, Prince et al. 2007, UNAIDS & WHO 2008; JLICA 2009). Yet evidence is relatively scarce on the psychosocial health of orphaned and vulnerable children (OVC; Cluver & Gardner 2007a; Sherr & Mueller 2008). Two recent reviews suggest that HIV-affected children are at higher risk of psychological distress and to a lesser extent, behavioural problems (Cluver & Gardner 2007a; Sherr & Mueller 2008). Confusion over definitions in the literature, measurement inconsistencies and lack of control for confounding factors such as gender and HIV infection status mean that drawing conclusions is difficult (Sherr et al. 2008; Sherr et al. 2009a,b). The need for psychosocial interventions for OVC is widely acknowledged and community-based programmes in Southern Africa are mushrooming (JLICA 2009; King et al. 2009). Little is known about the content of such interventions and what impact they are having on child psychosocial health; a recent Cochrane systematic review aimed to assess the effectiveness of interventions to improve the psychosocial well-being of HIV and AIDS-affected children and found no eligible studies of such interventions (King et al. 2009). Furthermore, a recent review of published and grey literature evaluations of community interventions for OVC in Africa highlighted the variability of quality and rigour of evidence (Schenk 2009). Empirical evidence is needed to inform the development of psychosocial intervention programmes for OVC (King et al. 2009; Schenk 2009) ª 2010 Blackwell Publishing Ltd 57

2 HIV and or parental death may exert an effect on child mental health both directly and via indirect routes (e.g. Wild 2001; Stein 2003; Snider 2006; Cluver & Gardner 2007a,b; Nyamukapa et al. 2010). Indirect effects of parental death due to HIV such as poverty and stigma have been identified as partial mediating factors between AIDS orphanhood and poor psychological and behavioural outcomes (Cluver et al. 2008, 2009a). Other risk factors forming an indirect route between parental death and poor child outcome identified in the existing literature include residential caregiver instability, sibling dispersion, unequal treatment, multiple bereavement and violence. Protective factors are less well investigated but centre around peer acceptance and availability of social support (Sherr & Mueller 2008; Cluver et al. 2009b); children are particularly vulnerable to family separation and poorer social and peer support as a consequence of bereavement (Manuel 2002; Ford & Hosegood 2005; Cluver & Gardner 2006; Gilborn et al. 2006). Social support may partially mediate the association between orphanhood and psychosocial distress (Nyamukapa et al. 2006), or may mediate some outcomes and not others; peer support was associated with lower stigma and higher levels of self-concept, but not anxiety or depression (Atwine et al. 2005). In direct contrast, a recent randomized-controlled trial in Uganda (Kumakech et al. 2009) has provided some initial evidence that peer-group support interventions may reduce orphan psychological distress, but not increase self-concept. A quasi-experimental study of the impact of adult mentorship for youths heading a household in Rwanda found an increase in reports of community support and connectedness, whilst the impact on emotional well-being was less clear (Brown et al. 2007). A randomized controlled familybased social support and coping skills intervention for children and adolescents affected by HIV and AIDS in the USA had significant protective effects against substance use at a 6-year follow-up, with more social support predicting lower levels of emotional and behavioural problems (Rotheram-Borus et al. 2006; Lee et al. 2007). These studies (Brown et al. 2009; Kumakech et al. 2009; Rotheram-Borus et al. 2006) are the few methodologically rigorous, published evaluations of social support programmes and provide some evidence to support the efficacy of psychosocial interventions for OVC. Further research is needed in sub-saharan Africa to replicate findings from the USA as HIV and poverty are widespread, treatment is less readily available and factors such as family structure may vary. Research has highlighted the importance of child resilience in the African context (e.g. Snider 2006; Rutter 2007). Resilient children have strong self-esteem, self-efficacy (Bandura 1997) and coping ability in stressful environments (Rutter 1985; Bandura 1997; Luthar et al. 2000). Children with poorer self-efficacy and self-esteem are at greater risk of anxiety and depression (Muris 2001; Mann et al. 2004). A longitudinal study of HIV-infected mothers and their children in the USA found that maternal illness was a risk factor for low resiliency (Murphy & Marelich 2008). Few studies of OVC in Africa have reported resilience outcomes such as self-esteem and self-efficacy. This study aimed to evaluate empirically the effect of a community-based psychosocial intervention for children affected by HIV and AIDS using quasi-experimental crosssectional post-intervention survey design. This research also aimed to identify key psychosociodemographic factors that impact upon children s psychosocial health in order to help structure and evaluate future interventions effectively. Method Intervention A community-based intervention called MAD ( Make A Difference ) About Art aims to increase children s selfesteem and self-efficacy and thereby improve their psychosocial health. The project, for children aged 8 18 years, is based in a deprived community in South Africa since Children attend sessions for 6 months (50+ sessions), led by a team of trained and supervised youth ambassadors. The project runs art and education activities to build a sense of self-worth (self-esteem), self-concept, empowerment and emotional control (self-efficacy). These activities include children creating hero books about their own life journey and group HIV education activities focused on selfadvocacy and empowerment. Participants Two hundred and ninety-seven children aged 8 18 years living in the Nekkies township near Knysna, South Africa, participated. Children were originally allocated to the school-based programme according to arbitrary class timetabling based on the day of the week that the project was available for this school. There were no reasons to suggest that children in those classes allocated to the intervention were different from those who were not. Two hundred and nine children were on the programme attendance register. Of these, 177 (85%) were recruited (59.6% of total sample). The comparison group was recruited from the classes of children at the school who were not allocated to the programme, and consisted of 120 of 169 eligible (71%) children. Inclusion depended on parental guardian consent, child assent and attendance during the study period. 58 ª 2010 Blackwell Publishing Ltd

3 Study design This study employed a quasi-experimental, cross-sectional post-intervention design. Ethical and practical issues promoted our selection of this design. The established delivery of the intervention to school classes precluded the randomization of the intervention first at individual level, and secondly at class level, due to arbitrary (as opposed to random) timetabling. Ethical, practice effect and resource limitations regarding the repeated completion of the standardized questionnaire measure opposed a longitudinal design. The need for rigorous evaluation of community interventions for OVC (JLICA 2009; King et al. 2009; Schenk 2009) points to an ethical need to adopt pragmatic approaches to such research (Kirkwood et al. 1997). Similar methods have been used in previous OVC studies, cited above (e.g. Gilborn et al. 2006; Brown et al. 2009). The use of rigorous quasi-experimental designs has been supported in the research methods literature, particularly in the context of community-based interventions, for both ethical and pragmatic reasons (e.g. Kirkwood et al. 1997; Victora et al. 2004). Procedure and ethical considerations Ethical approval was gained from The University of Cape Town and University College London ( ). Informed, voluntary caregiver (parent guardian) and personal assent from each participant was required. The information sheet emphasized voluntary participation. Children self-completed the questionnaire guided by two qualified researchers. Children were able to choose forms in English, Afrikaans or isi-xhosa (translations by bilingual translators and back-checked for accuracy by a second bilingual translator). A drawing and colouring activity, refreshments and verbal debrief ended the session. Support structures for children after completing the questionnaire included researchers, teachers who were informed and alerted to the issues raised by the questionnaire, and availability of MAD about Art staff and youth workers. Measures Given the lack of existing psychosocial intervention evaluations, the questionnaire tool was developed specifically after a thorough literature review. The questionnaire aimed to capture psychosocial health, focusing specifically on selfesteem, self-efficacy, depression and emotional behavioural difficulties. Self-esteem was measured using the Rosenberg Self- Esteem Scale, a 10-item Likert scale with extensive validity and reliability data (Rosenberg 1965; Bagley et al. 1997; Gray-Little et al. 1997; Griffiths et al. 1999). This scale has not been validated in Africa. Alpha reliabilities for this scale have been previously reported between 0.72 and 0.90 (Robins et al. 2001). Self-efficacy was measured using The Self-Efficacy Questionnaire for Children, a 14-item Likert scale. The validity has been internationally demonstrated (Muris 2001; Suklo & Shaffer 2007). The emotional and social self-efficacy domains were used. Crohnbach s alpha for the adapted scale with this sample was Child depression was measured by an adapted version of the Child Depression Inventory (CDI; Kovacs 1992), validated for use with children and adolescents in Zimbabwe and South Africa (Snider (2006). This version had an alpha of for the study sample, compared with an alpha of 0.64 for the original 10-item questionnaire (Snider 2006). Emotional behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ; Goodman 1997). The 25 items each load onto one of five subscales: Emotional Symptoms, Conduct Problems, Hyperactivity, Peer problems and Prosocial Behaviour. The SDQ is specifically designed for children of the appropriate age group to this study and has been extensively validated in several languages (including African languages) and in both developed and developing countries (e.g. Goodman et al. 2000; Mathai et al. 2003; Smedje et al. 1999; see also The Youth self-report version used in this study has been validated for self-completion and for adolescent populations and has a reported alpha coefficient of 0.82 (Goodman et al. 1998). HIV status for both child and parents was recorded using self-report, generating a standardized measure of perceived HIV state, but is limited in that it does not accurately reflect infection levels with a biological test. At the time of study, no standardized AIDS-related stigma scale for children had been published (Cluver et al. 2008). The scale used was adapted from Snider (2006), originally comprising six yes no response items (e.g. do you feel that people speak badly about you or your family? ). All scales from Snider s (2006) work were developed and validated with children and adolescents of ages comparable with those in this study in Zimbabwe and South Africa. Four positively framed items were added to the scale (e.g. do you feel that you have lots of good friends in your community? ) to balance the negative bias of the scale. The original scale has an alpha reliability of (Snider 2006), and with this sample. The adapted scale has an alpha of with this sample, indicating increased reliability. ª 2010 Blackwell Publishing Ltd 59

4 No standardized social connection scale for children in sub-saharan Africa has been used previously in the psychosocial literature (Snider 2006). The scale used is a three-item binary-response question (yes no) developed by Snider (2006) to measure whether children have a person (peer, other adult or caregiver) who provides them with support (e.g. do you have someone in your life you can depend on to comfort you when you feel sad or sick? ). The scale has a reported alpha reliability of Witnessing and experiencing violence questions used were those developed by Snider (2006) from the Straus Conflict Tactics Scale (P-C CTS; Straus et al. 1998) and the South African DHS (1998). Positive items were added into the questionnaire to redress the negative bias. Children s responses were captured on a scale of frequency (weekly monthly less often never), and recoded into a binary prevalence score ( weekly monthly less often score 1; never score 0). The risk behaviour items measuring violence towards others, substance abuse and criminality were selected from Social and Health Assessment scales, which summarize externalizing and risk behaviours (Ruchkin et al. 2004) Children responded to the three items on a scale of 0 5+ times. Items were later recoded into a binary prevalence score (ever occurred score 1; never occurred score 0). Study-specific questions measured psychosociodemographic characteristics of the sample. Demographic items included age and gender. Sociological factors included school enrolment, housing, household size and mobility. Socio-psychological parameters included caring responsibilities, feelings of belonging, illness and parental bereavement. Items were modelled on those recommended by the Snider (2006) review and similar items have been validated in previous research (e.g. Cluver et al. 2008). Statistical analyses Key psychosocial outcome variables were depression, emotional behavioural problems, self-esteem and selfefficacy. The statistical analysis followed four key steps. Differences between the intervention group and the comparison group on psychosociodemographic variables (Table 1) were calculated using Chi-squared tests and anovas. The second step investigated the association between intervention attendance and psychosocial outcomes (depression, emotional and behavioural problems, self esteem, self-efficacy) using univariate linear regression analyses (Table 2). Self-efficacy was the only psychosocial outcome to be significantly predicted by intervention attendance and therefore adjusted multivariate linear regression models are shown only for this outcome. The adjusted multivariate models (Table 3) control for psychosociodemographic cofactors found to be significant predictors of self-efficacy in the unadjusted model (Table 3), or were significantly associated with the intervention group (Table 1). The first adjusted model investigates the association between intervention attendance and self-efficacy when controlling for all relevant psychosociodemographic variables except for parental bereavement. The second model additionally controls for parental bereavement. Finally, an interaction between intervention attendance and parental bereavement status on self-efficacy score was examined using multivariate linear regression analysis. Data analysis was conducted using SPSS (version 15.0). All tests were two-tailed and significance was set at the P < 0.05 level. Results Psychosociodemographic characteristics Descriptive data on sociodemographic, community and psychosocial characteristics for both the intervention and comparison children are set out in Table 1. Children attending the intervention (mean 12.7 years) were significantly older than the comparison group [mean 11.7 years; F(1,241) = 17.9, P<0.001]. The total sample comprised 48.1% (n = 143) girls, with significantly more girls in the comparison group [43.5% of intervention group vs. 55% comparison, F(1,285) = 7.92, P = 0.01]. The majority of children completed a questionnaire in Afrikaans (n = 279, 93.9%), five in isi-xhosa (1.7%) and 13 in English (4.4%). Levels of bereavement were high, with 22.2% (n =66) experiencing the death of a mother, a father, or both (25.5% of intervention group, 17.5% of comparison). No statistically significant differences were found between the intervention and comparison groups on parental bereavement status, (v 2 = 1.94, P=0.16). Few further differences were found between the intervention and comparison groups on the psychosociodemographic parameters. Overall, 12.1% (n =36) of the sample reported that they were HIV+ (11.3% of intervention group, 13.3% of comparison), and intervention and comparison children reported similar AIDS-related stigma scores. The intervention group lived in significantly larger households [mean 8.36 people vs. 5.69, F(1,285) = 7.92, P = 0.01] and were more likely to look after younger children at their home than were comparison children (57.6% vs. 44.2%, v 2 = 5.19, P=0.02). The majority of children had looked after unwell people at home (67.7%, n=201), with no differences between groups. Levels of violence at home and in the community were similarly high across both groups, with over a third of children reporting being physically abused at home (35%), 60 ª 2010 Blackwell Publishing Ltd

5 Table 1 Whole-sample characteristics, and intervention and comparison group differences on psychosociodemographic variables All children Intervention Group Comparison Group Group difference (n = 297) Children attending MAD programme (n = 177, 59.6%) Children not attending MAD programme (n = 120, 40.4%) Test statistic P-value* Demographic factors Age (years; mean, 95% CI) 12.2 (12.0, 12.5) 12.7 (12.3, 12.0) 11.7 (11.5, 12.0) F(1,241) = 17.9 <0.001 Female [n (%)] 143 (48.1) 77 (43.5) 66 (55.0) v 2 = Household size (mean, 95% CI) 7.26 (6.33, 8.19) 8.36 (6.83, 9.88) 5.69 (5.20, 6.19) F(1,285) = Enrolled in school [n (%)] 292 (98.3) 175 (98.9) 117 (97.5) Fisher s exact 1.00 Moved home in the last year [n (%)] 105 (35.4) 67 (37.9) 38 (31.7) v 2 = Believe self is HIV positive No [n (%)] 182 (61.3) 109 (61.6) 73 (60.8) v 2 = Yes [n (%)] 36 (12.1) 20 (11.3) 16 (13.3) v 2 = Did not want to answer HIV question [n (%)] 65 (21.9) 41 (23.2) 24 (20.0) v 2 = Believe someone in family has HIV [n (%)] 24 (8.10) 17 (9.60) 7 (5.80) v 2 = Bereavement Has mother or father died No [n (%)] 215 (72.4) 126 (71.2) 89 (74.2) v 2 = Mother died [n (%)] 17 (5.70) 12 (6.80) 5 (4.20) v 2 = Father died [n (%)] 33 (11.1) 24 (13.6) 9 (7.50) v 2 = Both died [n (%)] 16 (5.40) 9 (5.10) 7 (5.80) v 2 = Household and Community factors Stayed out of school to help with household duties in last 82 (27.6) 52 (29.4) 30 (25.0) v 2 = year [n (%)] Look after younger children at home [n (%)] 155 (52.2) 102 (57.6) 53 (44.2) v 2 = Look after unwell people at home [n (%)] 201 (67.7) 119 (67.2) 82 (68.3) v 2 = Feeling of belonging at home [n (%)] 258 (86.9) 150 (84.7) 108 (90.0) v 2 = Treated the same as other children in your home [n (%)] 238 (80.1) 144 (81.4) 94 (78.3) v 2 = Ever been slapped, punched or hit on the head by an adult at home [n (%)] 104 (35.0) 59 (33.3) 45 (37.5) v 2 = Ever seen adults at home hit each other [n (%)] 115 (38.7) 60 (33.9) 55 (45.8) v 2 = Ever been attacked outside home [n (%)] 116 (39.1) 68 (38.4) 48 (40.0) v 2 = Drunk or high in the past 6 months [n (%)] 54 (18.2) 37 (20.9) 17 (14.2) v 2 = Arrested by the police in the past 6 months [n (%)] 41 (13.8) 27 (15.3) 14 (11.7) v 2 = Threatened or beaten somebody up in the past 6 months [n (%)] 138 (46.5) 88 (49.7) 50 (41.7) v 2 = Helped somebody in the past 6 months [n (%)] 251 (84.5) 152 (85.9) 99 (82.5) v 2 = Psychosocial factors Social Connection (mean, 95% CI) 2.48 (2.35, 2.55) 2.45 (2.32, 2.57) 2.46 (2.30, 2.61) F(1,295) = AIDS-related Stigma (mean, 95% CI) 3.12 (2.91, 3.38) 3.21 (2.90, 3.53) 3.04 (2.67, 3.41) F(1,295) = *Chi-squared tests are used to test categorical data and anovas are used for continuous variables. MAD, Make A Difference. ª 2010 Blackwell Publishing Ltd 61

6 Table 2 Univariate associations between group type and psychological outcomes Depression Emotional and behavioural problems Self esteem Self-efficacy Unadjusted model (B, 95% CI) P-value Unadjusted model (B, 95% CI) P-value Unadjusted model (B, 95% CI) P-value Unadjusted model (B, 95% CI) P-value Intervention Attended MAD )0.16 ()0.90, 0.57) ()1.16, 1.61) ()0.93, 1.29) (0.53, 6.75) 0.02 Items in bold are statistically significant at the 0.05 level. Model odds are presented for intervention group compared with comparison group as reference category. MAD, Make A Difference. 38.7% children witnessing domestic violence and 39.1% children being attacked outside their home. Intervention group children were less likely than children from the comparison group to report that they had witnessed domestic violence (33.9% vs. 45.8%, v 2 = 4.29, P=0.04). Levels of personally exhibiting threatening behaviour were also universally high (46.5% of all children; 49.7% of intervention group, 41.7% of comparison). The intervention and comparison children also reported similar levels of social support and connection [F(1,295) = 0.01, P = 0.91]. Psychological outcome associations with group type and psychosociodemographic characteristics Depression and emotional and behavioural problems. No statistically significant differences were found between those who attended the intervention and those who did not on the CDI (depression), the SDQ (emotional and behavioural problems) and the Rosenberg Self Esteem Scale (Table 2). Self-efficacy. Children attending the intervention showed significantly higher self-efficacy scores with an effect size of B = 3.61 (P < 0.05) (Table 2). This can be seen as a small-medium effect size (Cohen 1992). Several other variables were significant predictors of self-efficacy in the unadjusted model (Table 3). Compared with children who have both parents alive, children who have lost both parents had significantly lower self-efficacy (B = )12.25, P < 0.001). Believing oneself to be HIV-positive was predictive of lower self-efficacy (B = )8.34, P < 0.001), as was higher AIDS-related stigma (B = )1.07, P < 0.01), experience of violence at home (being physically assaulted: B = )4.46, P < 0.01; witnessing physical violence: B = )6.57, P<0.001), and in the community (being attacked: B = )5.27, P < 0.01). However, threatening beating up others was associated with higher efficacy (B = 3.40, P<0.05). Higher social connection was predictive of higher self-efficacy (B = 4.81, P < 0.001), as was being treated the same as other children at home (B = 8.07, P < 0.001), and helping others (B = 9.48, P < 0.01). The significant relationship between intervention attendance and higher self-efficacy was explored using multivariate regression analyses (Table 3). The first adjusted model controlled for psychosociodemographic variables associated with either intervention attendance or with selfefficacy, with the exception of parental bereavement. The positive association between MAD attendance and selfefficacy remained significant in the adjusted model 1 (B = 3.71, P < 0.05). Social connection and AIDS-related stigma also remained independent predictors of selfefficacy, whilst believing oneself to be HIV-positive disappeared as an independent predictor. Threatening somebody or beating them up remained independently associated with higher self-efficacy, whilst witnessing domestic violence remained associated with lower scores. Adjusted model 2 controlled additionally for the effect of parental bereavement. Once parental bereavement was considered, the positive effect of the intervention on self-efficacy became non-significant (B = 2.63, P = 0.09). The death of both parents remained a significant predictor of lower self-efficacy, whilst the death of one parent remained insignificantly associated. The other independent psychosociodemographic predictors from adjusted model 1 remained significant after controlling for the effects of parental death. Self-efficacy vs. bereavement As the significantly positive effect of the intervention on selfefficacy disappeared only in the final adjusted model (due to the introduction of parental bereavement), the data were tested for an interaction between attendance and parental bereavement. Children were grouped by bereaved vs. not bereaved, against intervention vs. comparison, and these two factors plus the interaction factor were entered into a linear regression model of self-efficacy. A significant interaction was found between MAD attendance and bereavement (P = 0.02). Whilst for comparison children, parental 62 ª 2010 Blackwell Publishing Ltd

7 Table 3 Multivariate associations between group type and self-efficacy, controlling for psychosociodemographic factors Self-efficacy Unadjusted model (B, 95% CI) P-value Adjusted Model 1* (B, 95% CI) P-value Adjusted Model 2 (B, 95% CI) P-value Intervention Attended MAD 3.61 (0.53, 6.75) (0.62, 6.79) ()0.40, 5.66) 0.09 Bereavement Parental death status No parental death REFERENCE REFERENCE REFERENCE Mother died )3.28 ()8.87, 2.32) ()4.44, 10.1) 0.44 Father died 0.31 ()3.84, 4.46) 0.88 )1.32 ()5.83, 3.19) 0.56 Both parents died )12.25 ()18.0, )6.50) <0.001 )7.10 ()13.9, )0.30) 0.04 Socio-demographic factors Believe self is HIV positive No REFERENCE REFERENCE REFERENCE Yes )8.34 ()12.6, )4.05) < ()3.42, 6.80) ()1.89, 8.61) 0.21 Did not want to answer HIV question )0.83 ()4.23, 2.58) ()3.44, 3.44) 1.00 )0.12 ()3.45, 3.21) 0.94 Treated the same as other children in your home (Y N) 8.07 (3.91, 12.2) < ()1.84, 6.69) ()2.86, 5.58) 0.53 Ever been slapped, punched or hit by an adult at )4.46 ()7.65, )1.27) )1.91 ()5.23, 1.41) 0.26 )0.97 ()4.25, 2.30) 0.56 home (Y N) Ever seen adults at home hit each other (Y N) )6.57 ()9.64, )3.50) <0.001 )5.41 ()8.65, )2.18) )4.44 ()7.61, )1.27) Ever been attacked outside home (Y N) )5.27 ()8.37, )2.17) )1.14 ()4.38, 2.09) 0.49 )0.44 ()3.58, 2.71) 0.79 Threatened or beaten somebody up in the past 6 months (Y N) 3.40 (0.55, 6.24) (1.42, 7.47) (0.34, 6.32) 0.03 Helped somebody in the past 6 months (Y N) 9.48 (3.41, 15.5) ()0.76, 13.5) ()6.15, 8.51) 0.75 Psychosocial factors Social Connection (Y N) 4.81 (3.08, 6.54) < (0.26, 4.23) (0.99, 4.97) AIDS-related Stigma (Y N) )1.07 ()1.80, )0.34) )0.93 ()1.70, )0.15) 0.02 )0.93 ()1.68, )0.18) 0.02 Items in bold are statistically significant at the 0.05 level. Model odds are presented for intervention group compared with comparison group as reference category. Variables were included in the adjusted models if they had been found to be either significantly associated with Group Type (see Table 1), or with self-efficacy. *Adjusted model 1: adjusting for age, gender, household size, moved home, HIV status, look after younger children, how treated at home, hit at home, adults hit each other at home, attacked outside home, threatened someone, helped someone, social connection, stigma. Adjusted model 2: additionally adjusting for bereavement group. MAD, Make A Difference. ª 2010 Blackwell Publishing Ltd 63

8 bereavement was associated with significantly lower selfefficacy (P = 0.003), the self-efficacy of bereaved children attending the intervention was equal to their non-bereaved counterparts (P = 0.43). The intervention is most strongly predictive of higher self-efficacy in children who have lost one or more parents, and may ameliorate the effect of parental bereavement on children s sense of personal control. Discussion Children attending the intervention programme displayed significantly higher self-efficacy than children who did not. This association remained even after controlling for potential psychosociodemographic confounders. This study found no evidence for an association between programme exposure and increased self-esteem, depression or emotional and behavioural problems. Increased selfefficacy and resilience may impact upon psychological outcomes over time (Mann et al. 2004; Murphy & Marelich 2008); longitudinal research into psychosocial interventions in sub-saharan Africa is clearly needed. Parental bereavement levels were high with over 22% children having lost at least one parent. The negative impact of parental death on child psychosocial health was robust after controlling for psychosociodemographic confounders, and furthermore outweighed the positive association between the intervention and greater self-efficacy. Nevertheless, the significant interaction between intervention attendance and bereavement on self-efficacy scores (where bereavement predicted poorer self-efficacy among comparison children only) highlights the potential role of such interventions in ameliorating some of the impact of parental death. Consistent with existing research, child HIV infection and AIDS-related stigma were identified as significant risk factors for poorer sense of personal control (e.g. Cluver et al. 2008; Sherr et al. 2009b; Nyumakapa et al. 2010). Of these two factors, only stigma remained in the adjusted models: the effect of HIV infection may be indirect, where AIDS-affected children are rendered more vulnerable to poorer psychosocial outcomes (e.g. Stein 2003; Snider 2006; Wild et al. 2006). Reduction of community stigma is important in addressing these vulnerabilities. This study provides further evidence to suggest that social and peer support increase self-efficacy (Nyamukapa et al. 2006; Cluver & Gardner, 2007b; Lee et al. 2007; Ward et al. 2007). Better social connection significantly predicted higher self-efficacy in both multivariate models. This research also contributes to the evidence base on the impact of violence on children s psychosocial health. Levels of witnessing, expressing or being victimized by violence were high among all children, both at home and in the community. Being violent towards others and witnessing violence in the home were key predictors of self-efficacy in the multivariate models. This study found no evidence that children attending the intervention were more likely to exhibit threatening behaviour than comparison group children. The increased self-efficacy associated with attending the intervention may offer children better ability to cope with high levels of violence, and alternative forms of emotional expression may divert aggression. This study attempted to control for child HIV infection via a self-report measure, and whilst this may offer interesting findings in itself, biological testing would be necessary to accurately control for the potential effects of infection on mood and other functional variables. Another limitation of measures used in this study is that the alpha coefficients of two scales (CDI, Kovacs 1992; AIDS-related stigma scale, Snider 2006) fell below the adequate range (>0.7) (Clark- Carter 1997). This indicates that the items within these scales may not all measure the same underlying construct, and therefore interpretations of stigma as a key risk factor for poorer self-efficacy should be tentative. Given the centrality of the concept of stigma in OVC and HIV contexts (Snider 2006), future research should seek to explore the facets of stigma, and prioritize the development of a more highly reliable and valid AID-related stigma measure. The findings of this study should be interpreted with caution. A key limitation is the quasi-experimental, crosssectional post-intervention methodological approach, which precludes firm conclusions over direction and validity of causation between intervention attendance and higher self-efficacy. Furthermore, significant group differences on demographic variables such as age, gender and household size indicate possible biases, as do the dropout rates of 15% and 29% in the intervention and comparison groups respectively. We aimed to minimize the impact of these methodological limitations on study conclusions by controlling for a wide range of potential confounding factors. The lack of group differences on the other three psychological outcome variables (depression, emotional behavioural problems, self-esteem) also lends some support to the conclusion that the project has a genuinely positive and targeted effect on self-efficacy. These limitations can be viewed within the context of the need to employ a pragmatic research design (Kirkland et al. 1997; Victora et al. 2004). The arbitrary class composition and timetabling of the school-based provision and the lack of group differences on the majority of psychosocial and demographic variables suggest that the intervention and comparison groups were well matched. However, it remains possible that children attending the 64 ª 2010 Blackwell Publishing Ltd

9 project were initially more resilient, or that less resilient children would have been more likely to drop out of the programme. Gathering longitudinal evidence to inform causative speculations should now be a priority for this emerging research focus. This study has shown that rigorous, systematic evaluation of community-based psychosocial interventions in the field is possible and desirable. The data log the positive impact of such programmes, and this information is crucial for strategy planning and scale-up of such provision. References Atwine B, Cantor-Graae E & Bajunirwe F (2005) Psychological distress among AIDS orphans in rural Uganda. Social Science and Medicine 61, Bagley C, Bolitho F & Bertrand L (1997) Norms and construct validity of the Rosenberg Self-Esteem Scale in Canadian high school populations: implications for counselling. Canadian Journal of Counselling 31(1), Bandura A (1997) Self-efficacy: The Exercise of Control. Freeman, New York. Brown L, Rice J, Boris N, Thurman T, Snider L, Ntaganira J, Lyirazinyoye N, Kalisa E & Nshizirungu E (2007) Psychosocial benefits of a mentoring program for youth-headed households in Rwanda. Horizons Research Summary Washington,DC: Population Council. Clark-Carter D (1997) Doing Quantitative Psychological Research: From Design to Report. Psychology Press, Hove. Cluver L & Gardner F (2006) The psychological well-being of children orphaned by AIDS in Cape Town, South Africa. Annals of General Psychiatry 5(8) PubMed PMID: ; PubMed Central PMCID: PMC Cluver L & Gardner F (2007a) Mental health of children orphaned by AIDS: a review of international and Southern African research. Journal of Child & Adolescent Mental Health 19(1), Cluver L & Gardner F (2007b) Risk and protective factors for psychological well-being of children orphaned by AIDS in Cape Town: a qualitative study of children and caregivers perspectives. AIDS Care 19(3), Cluver L, Gardner F & Operario D (2007) Psychological distress amongst AIDS-orphaned children in urban South Africa. Journal of Child Psychology and Psychiatry and Allied Disciplines 48(8), Cluver LD, Gardner F & Operario D (2008) Effects of stigma on the mental health of adolescents orphaned by AIDS. Journal of Adolescent Health 42(4), Cluver L, Gardner F & Operario D (2009a) Poverty and psychological health among AIDS-orphaned children in Cape Town, South Africa. AIDS Care 21(6), Cluver L, Operario D & Gardner F (2009b) Parental illness, caregiving factors and psychological distress amongst children orphaned by AIDS in South Africa. Vulnerable Children and Youth Studies: An International Interdisciplinary Journal for Research, Policy and Care, 4(3), Cohen J (1992) A power primer. Psychological Bulletin 112, Ford K & Hosegood V (2005) Aids mortality and the mobility of children in Kwazulu Natal, South Africa. Demography 42(4), Gilborn L, Apicella L, Brakarsh J et al. (2006) Orphans and Vulnerable Youth in Bulawayo, Zimbabwe: An Exploratory Study of Psychosocial Well-being and Psychosocial Support Programs. Horizons Final Report, Population Council, Washington, D.C. Goodman R (1997) The strengths and difficulties questionnaire: a research note. Journal of Child Psychology and Psychiatry 38, Goodman R, Meltzer H & Bailey V (1998) The strengths and difficulties questionnaire: a pilot study on the validity of the selfreport version. European Child and Adolescent Psychiatry 7, Goodman R, Renfrew D & Mullick M (2000) Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. European Child and Adolescent Psychiatry 9, Gray-Little B, Williams VSL & Hancock TD (1997) An item response theory analysis of the Rosenberg Self-Esteem Scale. Personality and Social Psychology Bulletin 23, Griffiths RA, Beumont PJ, Giannakopoulos E et al. (1999) Measuring self-esteem in dieting disordered patients: the validity of the Rosenberg and Coopersmith contrasted. International Journal of Eating Disorders 25(2), JLICA (2009) What have we learnt?: a review of evaluation evidence on community interventions providing care and support to children who have been orphaned and rendered vulnerable. 20paper%20Schenk%2023Sept%20(1).pdf?PHPSESSID= e921d9c8245afcc48c1d9cb316dc56f3 King E, De Silva M, Stein A & Patel V (2009) Interventions for improving the psychosocial well-being of children affected by HIV and AIDS. Cochrane Database of Systematic Reviews (2), CD DOI: / CD pub2. Kirkwood BR, Cousens SN, Victora CG & de Zoysa I (1997) Issues in the design and interpretation of studies to evaluate the impact of community-based interventions. Tropical Medicine & International Health 2(11), Kovacs M (1992) Children s Depression Inventory. Multi-health Systems, Niagara Falls, NY. Kumakech E, Cantor-Graae E, Maling S & Bajunirwe F (2009) Peer-group support intervention improves the psychosocial wellbeing of AIDS orphans: cluster randomized trial. Social Science & Medicine 68(6), Lee S, Detels R, Rotheram-Borus M & Duan N (2007) The effect of social support on mental and behavioural outcomes among adolescents with parents with HIV AIDS. American journal of public health 97(10), Luthar S, Cicchetti D & Becker B (2000) The construct of resilience: a critical evaluation and guidelines for future work. Child Development 71, ª 2010 Blackwell Publishing Ltd 65

10 Mann M, Hosman CM, Schaalma HP & de Vries NK (2004) Selfesteem in a broad-spectrum approach for mental health promotion. Health Education Research 19, Manuel P (2002) Assessment of Orphans and Their Caregivers Psychological Well-Being in a Rural Community in Central Mozambique. Unpublished MSc, Institute of Child Health, London. Mathai J, Anderson P & Bourne A (2003) Use of the strengths and difficulties questionnaire as an outcome measure in a child and adolescent mental health service. Australasian Psychiatry 11, Muris P (2001) A brief questionnaire for measuring self-efficacy in youths. Journal of Psychopathology and Behavioral Assessment 23(3), Murphy D & Marelich W (2008) Resiliency in young children whose others are living with HIV AIDS. AIDS Care 20(3), Nyamukapa CA, Gregson S, Wambe M, Mushore P, Lopman B, Mupambireyi Z, Nhongo K & Jukes MCH (2010) Causes and consequences of psychological distress among orphans in eastern Zimbabwe. AIDS Care, 22(8), Nyamukapa C, Gregson S, Lopman B et al. (2006) HIV-associated Orphanhood and Children s Psychosocial Disorders: Theoretical Framework Tested with Data From Zimbabwe Biomedical Research and Training Institute Harare, Imperial College London and UNICEF Zimbabwe. Prince M, Patel V, Saxena S et al. (2007) No health without mental health. Lancet 370(9590), Robins RW, Hendin HM & Trzesniewski KH (2001) Measuring Global Self-Esteem: Construct Validation of a Single-Item Measure and the Rosenberg Self-Esteem Scale. Personality and Social Psychology Bulletin 27, Rosenberg M (1965) Society and the Adolescent Self-image. Princeton University Press, Princeton, NJ. Robertson L, Gregson S & Garnett GP (2010) Sexual risk among orphaned adolescents: is country-level HIV prevalence an important factor? AIDS Care 22(8), Rotheram-Borus MJ, Stein JA & Lester P (2006) Adolescent adjustment over six years in HIV-infected families. Journal of Adolescent Health 39, Ruchkin V, Schwab-Stone M & Vermeiren R (2004) Social and Health Assessment (SAHA): Psychometric Development Summary Yale University, New Haven. Rutter M (1985) Resilience in the face of adversity. Protective factors and resistance to psychiatric disorder. British Journal of Psychiatry 147, Rutter M (2007) Resilience, competence, and coping. Child Abuse & Neglect 31, Schenk K (2009) Community interventions providing care and support to orphans and vulnerable children: a review of evaluation evidence. AIDS Care 21(7), Sherr L & Mueller J (2008) Where is the evidence base? Mental health issues surrounding bereavement and HIV in children. Journal of Public Mental Health 7(4), Sherr L, Varrall R & Mueller J, JLICA Working Group 1. (2008) A systematic review on the meaning of the concept AIDS Orphan : confusion over definitions and implications for care. AIDS Care 20(5) AIDS Impact Special Issue, Sherr L, Mueller J & Varrall R (2009a) Evidence based gender findings for children affected by HIV and AIDS a systematic overview. AIDS Care 21(s1), s83 s97. Sherr L, Mueller J & Varrall R (2009b) A systematic review of cognitive development and child human immunodeficiency virus infection. Psychology, Health & Medicine 14(4), Smedje H, Broman J-E, Hetta J & von Knorring A-L (1999) Psychometric properties of a Swedish version of the Strengths and Difficulties Questionnaire. European Child and Adolescent Psychiatry 8, Snider L (2006) Psychosocial vulnerability and resilience measures for national level monitoring of orphans and other vulnerable children. UNICEF Publications. Stein J (2003) Sorrow makes children of us all: a literature review on the psychosocial impact of HIV AIDS on children. Working paper no. 47. Centre for social science research, University of Cape Town. Straus M, Hamby S, Finkelhor D, Moore D & Runyan D (1998) Identification of child maltreatment with the Parent-Child Conflict Tactics Scales: development and psychometric data for a national sample of American parents. Child Abuse and Neglect 22, Suklo SM & Shaffer EJ (2007) Evaluation of the self-efficacy questionnaire for children in two samples of American adolescents. Journal of Psychoeducational Assessment 25(4), UNAIDS & WHO. (2008) Sub-Saharan Africa: AIDS Epidemic Update. Regional Summary UNAIDS WHO publications, Geneva. epibriefs_subsaharanafrica_en.pdf Victora CG, Habicht J-P & Bryce J (2004) Evidence-based public health: moving beyond randomized trials. American Journal of Public Health 94(3), Ward C, Martin E, Theron C & Distiller G (2007) Factors affecting resilience in children exposed to violence. South African Journal of Psychology 37(1), Wild L (2001) The psychosocial adjustment of children orphaned by AIDS. Southern African Journal of Child and Adolescent Mental Health 13(1), Wild L, Flisher A, Laas S & Robertson B (2006) The psychosocial adjustment of adolescents orphaned in the context of HIV AIDS. Poster presented at the International Society for the Study of Behavioural Development Biennial Meeting, Melbourne, Australia, July Corresponding Author Lorraine Sherr, Health Psychology Unit, Research Department of Infection & Population Health, Royal Free and UC Medical School, UCL, Rowland Hill St, London NW32PF, UK. Tel.: ; Fax: ; 66 ª 2010 Blackwell Publishing Ltd

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