The Collaborative HIV Adolescent Mental Health Program, South Africa (CHAMPSA)

CHAMPSA is a South African youth and family centered HIV prevention program modeled after the Collaborative HIV Adolescent Mental Health Program (CHAMP) developed in Chicago, Illinois and implemented in Chicago and New York.

Dr. Carl Bell M.D., Psych., Clinical Professor of Psychiatry and Public Health at the University of Illinois, and president and CEO of Community Mental Health Council and Foundation, Inc. has over thirty years of psychiatric practice and was the principal investigator for CHAMP USA. He directed the CHAMPSA project as well.

The CHAMP initiative is based on the idea that the spread of HIV can be halted by addressing underlying behavior patterns and influences which encourage the kinds of risky behaviors which in turn can lead to HIV transmission. Examples include weak family structure and communication between children and parents, difficulty for children resisting peer pressure, and uncertainty about how HIV is transmitted.

Below: Sample panel from CHAMPSA manual issue #9, which focuses on bereavement  Download full manual

Sample panel from the CHAMPSA manual,which focuses on bereavement

 The CHAMP intervention project did not rely exclusively on academic support. Researchers believed that consulting with and engaging the community is essential to the success of any initiative involving its members, and a collaborative board was formed that included community leaders and representatives as well as researchers and mental health professionals.

As a result of this collaboration, a program and accompanying educational manual were developed and implemented, and youths and families who participated in the program showed promising results. CHAMP South Africa is based on this model.

In 2001, the National Institute of Mental Health (NIMH) awarded South African and American researchers grant #2RO1 MH-01-004 (principal investigator: Bell, Carl C. $2,179,890) to discover if CHAMP could be successful in Kwa-Zulu Natal, South Africa as well.

Researchers hypothesized that there were universal field principles developed from Brian Flay’s Triadic Theory of Influence (TTI) necessary to support health behavior change. These universal field principles were:

  • communities needed social fabric developed by “rebuilding the village;”
  •  communities needed access to modern technology, e.g. the prevention intervention should be delivered in multiple family groups;
  • families needed connectedness between caregivers and their children for families to work on the HIV risks as a team;
  • families and youth needed social skills, specifically skills to support frequent and comfortable communication between members about risky behaviors;
  • members of families needed self esteem, i.e. activities that would generate a sense of power, models and uniqueness;
  • communities, families, and youth needed a sense of safety in the form of an “adult protective shield” that monitored youth’s behaviors; and
  • communities, families, and youth need a way to “minimize their trauma” and bereavement by “turning learned helplessness into learned helpfulness.”

Further, the most important factor in implementing an intervention program internationally lies in a solid understanding of the culture and in presenting the material in a way that is acceptable to the community.

Research colleagues in South Africa, led by Dr. Arvin Bhana, PhD conducted ethnographic studies to determine what lay behind the spread of HIV, and saw similarities with the Chicago researchers’ previous discoveries.

But before attempting to adapt CHAMP for South Africa, the team engaged the community and hired teachers and experts from local colleges, notably University of Kwa-Zulu Natal, social workers, mental health experts, and parents to help shape and present the program by answering questions such as: What is appropriate for our community? How should we handle traditionally sensitive issues and what is the best way to disseminate this information?

With this input, an intervention program, workshops, and an accompanying educational manual were produced. Because of possible low literacy levels, the manual and its lessons were presented as illustrated storylines.

Based on the ethnographic study findings and a pilot study, the manual was revised three times with the final version including additional topics not included in the Western version: stigma associated with contracting HIV, possible child abuse, and difficulty handling bereavement. Characters and behaviors had been modified to accurately reflect the Zulu community’s culture and values. Additionally, the manual is presented in the local language, Zulu.

For the actual study, the program focused on personal empowerment, relationships with community, and parent-child relationships, and researchers were looking for differences in these key areas.

CHAMPSA Collaborative board community leaders approached schools and met with principals, teachers, and parents, explaining the study and asking if they would like to take part. Participating students were required to be between the ages of nine and thirteen, and were to live with a parent or caregiver over eighteen years of age. Consent of caregivers and student assent were necessary.

The indigenous college graduates and local community Zulu who were trained co-facilitated the multiple-family groups that were conducted, and presented the ten lessons which lasted an hour and a half every weekend for ten weeks.

During these sessions participants covered the materials and participated in discussion groups, etc. Participants were paid for their time. The families that consented to participate were randomly assigned to an experimental and control intervention.

By the study’s end, 94% of participants who had began the intervention remained, and researchers found that caregivers in the intervention group displayed significantly higher frequency and comfort levels discussing sensitive topics such as sexuality and HIV, increases in knowledge of HIV transmission, and decreased stigma toward HIV-infected individuals.

In addition, the caregivers in the intervention were significantly more likely to provide closer observation and supervision of children, and also reported a significantly greater sense of social fabric as a result of the intervention. All are key areas which protect against risky behaviors.

The youth in the intervention reported significantly more knowledge of HIV transmission and significantly less stigma toward HIV-infected individuals.

This immediate improvement seems to illustrate the universality of the health behavior change field principles developed from Flay’s Triadic Theory of Influence that influence both positive and negative behaviors, and has promising implications for future HIV prevention programs in South Africa.

Additionally, by using sound business principles, at the end of the study, CHAMPSA received private funding and the control group received the intervention as well.

The CHAMPSA Manual is comprised of 10 issues. Issue number 9, focusing on bereavement; is pictured above and at the request of Dr. Bell, has been translated into English.

The study is featured in the August 2008 edition of the Journal of the National Medical Association. Dr. Bell M.D., is the lead author; Robert Gibbons, Ph.D., and Anup Amatya, MA; are among the co-authors of the article, titled: “Building Protective Factors to Offset Sexually Risky Behaviors among Black Youths: A Randomized Control Trial.” The piece contains more details and reports the effectiveness of the Collaborative HIV Adolescent Mental Health Program - South Africa (CHAMPSA) developed in the US to prevent HIV in South Africa. Read the article in its entirety here. 

Read the article in its entirerty in the August 2008 edition of the Journal of the National Medical Association here.

Download CHAMPSA Issue #9 here.