The NCTC, established in 1981, is a professional theater arts school, educational touring program and performing arts nonprofit dedicated to the social well-being of young people from ages 4 through 19. NCTC’s experience with AIDS Prevention includes its teen HIV Educational Touring Division program The Inner Circle, its middle school program Get Real! and the elementary school programGet Real Too!, which are all HIV theater-in-training touring productions designed by and for young people.
The plays communicate information about HIV/AIDS and other issues related to HIV such as discrimination or stigmatization, transmission of HIV, grief over loss of loved ones, self esteem, and the importance of independent decision-making. To date the HIV programs combined have reached over 4.5 million youth worldwide.
CAPS/NCG Project – Where Are the Parents in HIV Education?
Mark, a teen with AIDS, tells his friend to protect herself and her loved ones from HIV in the play “The Inner Circle.”
Adolescents want to improve parent-adolescent communication about HIVAdolescents feel that seeing an AIDS awareness drama with their parents would encourage communicationDo parents get involved in HIV education programs for adolescents?
“I think it’s sad I can’t talk to my mom about it — but it’s her loss, I can always go other places. I think that is a lot of the problem, because when you go “other places”, sometimes you get the wrong information.”(Quotes are taken directly from student responses, with no corrections made to spelling or punctuation.)
“I think it would just make them more aware of AIDS and what it does and how hard it is on the teenager to have to deal with it.”
“My dad wouldn’t care — he wouldn’t want to waste his time watching a play. I’m sure he’d much rather be out drinking with his buddies.”
- Where are the parents in HIV education?
- Where are adolescents getting their information about HIV?
- Does an AIDS awareness drama increase parent-adolescent communication?
The theatrical intervention used in this study is designed for young audiences between the ages of 13 and 19 years, a group that is increasingly at risk for contracting HIV. Recent statistics show an alarming increase in AIDS cases involving young people, indicating a lack of effectiveness of AIDS prevention measures directed at this high risk population.
When New Conservatory Theatre Center became the first organization in the nation to develop and produce AIDS theatre education and prevention programs in 1985, the Centers for Disease Control and Prevention (CDC) had only reported five AIDS cases among youth in the nation. By the time the proposal for this study had been developed in 1994, the CDC reported that an estimated 34,000 American adolescents were HIV-positive. (HIV/AIDS Surveillance Report, Centers for Disease Control, February 1993)
Currently one out of every four new infections in the USA involves people between the ages of 13 and 20. (Presidential Report on Young People and AIDS, Office of National AIDS Policy, March 1996 (wherein National AIDS Policy Director Patricia S. Fleming stated that “at least one American teenager is becoming infected with HIV every hour of every day.”)). With youth AIDS cases rising exponentially, it is clear that current prevention and education methods have failed to reach–or persuade–adolescents. (Di Clemente, Ralph (excerpt from Harvard AIDS Letter, February 1993))
Studies have also shown that adolescents’ perceptions of their family relationships are associated with health risk behaviors — that perceived or actual support of adolescent autonomy, such as encouraging the expression of opinions and avoiding overprotection, is inversely related to sexual behavior. In one study, adolescents who were less likely to initiate sexual intercourse were the same ones who perceived their parents as more encouraging of their independence and skill development. (Turner, R.A., Irwin, C.E. Jr., Tschann, J.M., and Millstein, S.G., 1993. “Autonomy, Relatedness, and the Initiation of Health Risk Behaviors in Early Adolescence”. Health Psychology, Vol. 12, No. 3, 100-208.)
Parents are often unaware of their children’s sexual experience: a 1996 poll of 2,000 mothers and daughters found that 71% of the mothers believed that their daughters were virgins, but only 37% of the daughters claimed that they had not yet become sexually active. This report by the Henry J. Kaiser Family Foundation states that roughly 75% of American high school students have engaged in sex by the time they complete the 12th grade. (The Kaiser Survey on Americans and AIDS/HIV, March 1996, The Henry J. Kaiser Family Foundation)
Sample. A 1,643-student high school in the U.S. college and agricultural town of Chico, California (pop. 40,000) was shown an AIDS awareness drama. The school mailed an invitation to parents for a preview performance, informing them that their children would be seeing the same drama at school. All students present on the day of performance whose parents did not give negative consent saw the drama and took the surveys (n=1,276). Data were collected at baseline (1,031 completed surveys), six we students saw the drama (585 completed surveys). Fifty-four percent of the students were female, 81% were white; mean ag = 16 years.
The intervention. The 45-minute play is about four close adolescent friends — one discovers he has HIV and eventually dies from AIDS. Characters in the play call an AIDS information hotline, decide whether to take the AIDS antibody test, share their feelings of shock, grief and denial, and make decisions about how to protect themselves. After the presentation the young actor-educators and an additional educator with HIV lead a brief discussion with the student audience.
Consent procedure. To prepare for the theatre presentation, meetings were held with the school principal, faculty and parent-teacher organization (PTA). Parents were sent information concerning the play and study, and were given the option of withdrawing permission for their child to participate (“negative consent”). Information was mailed home in Spanish and in English to parents on school letterhead, including consent forms and a description of the study and intervention. The invitation itself was printed on brightly-colored paper, the PTA’s shared information about the preview with other parents, and the principal made himself available for discussion, referring parents to the preview evening. The parental preview evening was selected to avoid weekends, Monday football nights or Friday evenings which might make it harder to attend. Although some pre-viewing apprehension was expressed, only 42 students were withdrawn from seeing the play and none of the parents who saw the play later pulled their child out of the process.
Survey administration. Students in grades 9 through 12 were pre-tested in November 1994, and the theatrical production was shown shortly thereafter. The play was shown to 400-500 students at a time for three back-to-back assemblies occuring during class periods. Data were collected at baseline (1,031 completed surveys), six weeks and three months after the students saw the drama (585 completed surveys). All surveys were administered on the same days in classrooms during school hours. The school was given a teachers’ guide in advance of the presentation and information sheets in Spanish and in English were placed in the principal’s office for interested parents and students. Unique student identification numbers, which are assigned by the school district, were used as ID codes in order to link students’ surveys across instruments. Fift-four percent of the students were female, 81% were white; mean age = 16 years.
Instrument. A core questionnaire containing over 40 structured questions and several open-ended questions was designed, pretested, and put into suitable form for three survey waves and the presence or absence of the intervention. Questionnaire items included student communication with parents and peers about HIV and sexual-risk-taking (6 Likert-scaled questions such as “never”, “rarely”, “occasionally”, “often”), HIV-related knowledge (20 true-false questions), student self-assessments of how well they were informed about HIV/AIDS (2 questions), concerns about the risk of HIV infection (2 Likert-scaled questions), sources of information about HIV/AIDS (2 checklist questions), and several open-ended questions regarding suggestions for improving HIV education programs and parent- adolescent communications. Open-ended responses were coded separately by the project coordinator and research assistant. Agreement on coding exceeded 95%, and for disagreements the project coordinator made the final coding decision.
Statistical analysis. Chi-square tests were used for group comparisons involving categorical data, and t tests for continuous data. Because of the very large sample sizes at baseline and follow-up, the statistical power was very high to detect even relatively small and potentially educationally unimportant group and sub-group differences. Therefore, we set our significance level at a more conservative level of .01. In addition, we also discuss the size of the effects found in the analyses in terms of their educational and clinical importance, particularly as to how they may guide future interventions for increasing parent involvement and improving parent-teen communication.
At baseline we were able to collect a total of 1,031 completed surveys (61% response rate). Non-participation was due to absences (331), negative consent (42), and false or changed identification codes (276). At the three-month survey point, we were able to collect 585 questionnaires. The percentage of those who completed baseline questionnaires and who also completed a three-month questionnaire was 59%. The students we lost were identical to those in our cohort in terms of age and gender distribution. However, white students were slightly more likely to be attritors (at baseline 75% of the entire sample was composed of white students compared to 71% of those who participated in all 3 waves of data collection).
Parental participation. Only 39 parents came to see the performance out of over 3,000 invited. We were therefore unable to test the effects of parental participation on parent-adolescent communication, which had been our original intent.
Parent-adolescent communications. A major focus of the study was to determine the degree to which students could and did discuss HIV and related topics with others. Overall, 46% of students reported talking with parents three or more times during the past year about such topics, and 67% reported talking with peers. Females were much more likely to have talked with parents (52% vs. 38%; p<.0001), as well as with peers (78% vs. 55%; p<.001). The differences in degree of communication with parents and peers were less pronounced when broken down by ethnicity; slightly larger percentages of white students reported talking with parents (47% vs. 40%; p<.01) and with peers (69% vs. 62%; p<.01). Students were always more likely to talk with peers than parents. Non-white students reported having greater difficulty than white students (35% vs. 24%; p<.001).
Intervention as a catalyst for parent-adolescent communcation about HIV/AIDS. Even with the low parental response, students initiated discussion with their parents after seeing the drama — 50% of the students who had felt it was “difficult” or “impossible” to talk to parents about HIV and related topics (28% of all the student respondents) nonetheless went home to discuss the play with their parents. Sixty-two percent of students who saw the drama felt that if parents were also to see it, their mutual experience would be a catalyst for discussion between parents and teens. Only 4% thought it would be more difficult and the remaining 34% thought that seeing the play would have no effect on parent-teen communications (Although the number is small, it is interesting to note that 30 students didn’t know if their parents attended the play, indicating a possible lack of communication overall. It is also interesting that 75% of those students who did say their parents came to the play were girls.). Of the students whose parents did indeed see the play, their own baseline response indicated that 24% felt it was difficult or impossible to talk to their parents, but after both parent and child saw the play, that figure went down to 12.5%.
Sources of information. Students ranked parents as the fifth most frequent source of information about HIV. Students were asked to select and prioritize their most important sources of HIV-related information. From a checklist of 15 possible choices, sources ranked in descending order were: school (86%), television/movies (73%), pamplets/posters/leaflets/ flyers (63%), newspapers/magazines (62%), parents/guardians/adult relatives (60%).
“Go directly to parents and tell them some parents don’t care and some other ones don’t even know if there child has ever had sex with someone else. Just talk to them.”
Intervention impact on knowledge, opinions and actions. Students who responded at the six-week follow-up that the drama significantly affected their knowledge, opinions or actions regarding HIV (176 or 42%) offered the following top three reasons as to how: Seeing the drama 1) helped them realize that AIDS can affect anyone, even themselves or their friends (23%); 2) sensitized them to the emotional aspects of the disease — how it can affect not only the person with the disease but also their friends (14%); and 3) made the situation real to them — it was a “wake-up call” or a “reality check” (12%).
“I think the presentation made a lot of us wake up and think about this problem. I don’t think I have aids but I should go get a test but I am to scared. My boyfriend and I have already had sex w/o a condom.”"The play just made me think twice about sex & drugs. My best friend worries me a lot. She has had sex w/many (over 20) different partners I don’t know how to help her. I’m very scared for her. We’ve discussed these surveys and the play before.”
“It was more of a personal thing. My friend had told me over the summer that she was HIV+ and during the play they played our song “Circle of Friends.” It made me think a lot more about making good choices in my life so that I don’t end up like my friend.”
Student suggestions for improving communications about HIV/AIDS between adolescents and adults. Students made over 1,200 spontaneous comments in the open-ended question portion of the survey about how to improve parent-adolescent communication and HIV education in the schools.
Based on the analysis of the 363 open-ended responses to a question in the last follow-up survey about how to improve parent-adolescent communication, a number of suggestions were made by students. Approximately one third of students wanted more discussion and information about HIV/AIDS. Other suggestions included: needing a more open environment for discussion (12%), having an HIV+ speaker come to the school (9%), and teaching young people the facts without watering down the information (7%).
“…Inform…adults of the importance of talking to your kids. Your not saying its okay, but rather if and when Protect yourself. Knowledge is the key to life, don’t allow young people to be ignorant.”
RESULTS FROM THE SURVEYS
See some of the answers given by the students at the Chico, CA school involved in the project. Two of the questions asked were:
- Do you have any suggestions for how to improve communication about AIDS between young people and adults?
- Do you have any suggestions for how schools can improve AIDS education to make it more relevant and meaningful to young people?
- The absence of the parents in HIV education is striking. Educators must find better ways to get parents involved in students’ education about HIV. It is clear that adolescents would like to improve parent-adolescent communication and HIV education — the overwhelming number of spontaneous student comments on this survey attest to the students’ concern.
“Parents need to talk to their kids …If parents don’t want you to do something they consider morrally wrong, parents & kids need to be encouraged to work together.”
- Information about HIV is not coming from the source our qualitative data suggest adolescents want.
“Most adults don’t want to here about it. My mom doesn’t and I would really like to talk about it with her.”
- Theatre-in-education programs should be considered as a vehicle to promote communication and deliver HIV information to adolescents. Qualitative data indicated that adolescents identify with the characters, get involved emotionally and absorb the information. Quantitative data indicated that this experience is an effective catalyst for discussion between adolescents and their parents.
“After the play, I went home and talked to my parents about AIDS (and my boyfriend) and scheduled an AIDS test.”
New Conservatory Theatre Center’s study was part of a collaboration between funders, scientists, and service providers (Northern California Grantmakers AIDS Task Force, the Center for AIDS Prevention Studies (CAPS) University of California, San Francisco, and eleven community-based organizations), with a goal of piloting novel prevention programs, evaluating their success, and disseminating the results so that effective programs could be replicated and ineffective programs modified. The research questions were community generated, scientist modified, and private-sector funded.
Last modified: February 24, 2011