Extended families and perceived caregiver support to AIDS orphans in Rakai district of Uganda

Child Fostering and Family Size Preferences in Uganda

Mothers who exceed their ideal family size (IFS) may find themselves caring for more children than desired. In the absence of reliable and desirable prenatal controls of family size, mothers may foster-out children to reduce burdens of childrearing, particularly in contexts where fostering is common. Using six rounds of Demographic and Health Surveys collected in Uganda between 1988 and 2016, I explore the relationship between exceeding IFS and child out-fostering, proposing that fostering-out may serve to manage excess fertility and that this relationship may change as actual and desired fertility declines. Models are run separately for mothers and children aged 0-17 to explore mothers' overall out-fostering behavior versus out-fostering strategies for children. Results at the mother level suggest a strong positive relationship between exceeding IFS and out-fostering that remains relatively stable over time, but results at the child level indicate children's age explains the relationship between mothers' exceeding IFS and being fostered-out, demonstrating the nuances of how family size preferences might impact family life in practice. Though mothers report a desire for smaller families over time, childbearing and childrearing behaviors, including high fertility and child out-fostering, remain consistent over the course of Uganda's fertility transition, signifying the central role out-fostering plays in Ugandan families.

Psychosocial health in adolescent unmarried motherhood in rural Uganda: Implications for community-based collaborative mental health education, and empowerment strategies in the prevention of depression and suicide

Teenage pregnancy rates in Uganda are among the highest in sub-Saharan Africa. Child marriage is often the result of unmarried teenage pregnancy and is recognised by Uganda's government as a form of sexual violence and an outcome of inequality. However, unmarried motherhood incurs stigma and shame within traditionally living rural communities. Using co-produced Open Space and ethnographic methods, we examined the psychosocial impact of unmarried motherhood on girls and their communities, and explored problem-solving with key local stakeholders. Findings indicate that girls experience extreme stress, social exclusion and rejection by their families, and experience bereavement from school expulsion and the loss of their career aspirations. Depressive symptoms and suicidal behaviour are reportedly not uncommon among this population group. Community and family efforts to promote marriage for these mothers to avoid social stigma increased the mothers' feelings of depression, whereas mothers who became independent appeared to fare better psychologically. Community members and local stakeholders demonstrated a willingness to act locally to reduce the negative impacts of unmarried motherhood but lacked knowledge and support resources. Our findings indicate that mental health promotion for teenage mothers is likely to be better served through empowerment strategies rather than marriage and, in a context of poor mental health service access, there is a substantial role for community mobilisation and the promotion of self-help strategies to support teenage mothers. This study raises important points regarding different community understandings of depression and indicates collaboration between professionals and communities for a values-based approach.

Social Support Networks for Adolescents Orphaned by HIV: Definitions, Barriers, Challenges and Lessons from Uganda

Social support is a key element to the health wellbeing of individuals, especially those experiencing major life transitions and crises. Prior evidence has demonstrated that orphaned adolescents are socially isolated with limited supportive networks. This study focused on how orphaned adolescents define social support, the nature of relationships with non-kin ties, barriers and challenges to seeking support. In-depth interviews from 38 orphaned adolescents (14-19 years) were analyzed using thematic analysis. Findings demonstrated that 1) orphaned adolescents define support in terms of "giving and receiving material and non-material assistance", and "helping individuals overcome problems", 2) relationships are initiated by family members, 3) economic hardships, stigma, and lack of trust deter adolescents from seeking support outside of the family unit. Study findings point to the need to integrate social support strengthening components within programming for orphaned adolescents living in HIV impacted communities.

Suubi4StrongerFamilies: A study protocol for a clustered randomized clinical trial addressing child behavioral health by strengthening financial stability and parenting among families in Uganda

Background

Children in Sub-Saharan Africa are burdened by significant unmet mental health needs. Across the region, high rates of poverty, HIV/AIDS, food insecurity, stigma, and an inadequate health safety net system exacerbate serious child behavioral health needs and impede an effective response. Disruptive behavioral disorders are particularly concerning as they persist through adolescence and adulthood. Hence, addressing the context-specific social influences on child behavioral health is critical given that children in the region comprise more than half of the total regional population. Against this backdrop, this study protocol describes a randomized clinical trial that will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial, and context-specific drivers affect the mental health of children in Uganda.

Methods

The study uses an experimental, longitudinal design across 30 cluster-randomized primary schools to compare single and combination intervention options; influences of economic empowerment and family strengthening on economic, perceptual, and functioning mediators; and context-specific moderators. The study will be conducted with 900 Ugandan children in mid-upper primary school (10-14 years). The three study conditions (n = 300 each) are: (1) economic empowerment only (EE only), (2) multiple family group-based family strengthening only (MFG-based FS only), and (3) combined EE + MFG-based FS. The interventions will be provided for 12 months; and assessments will occur at baseline, 12, 24, and 36 months.

Conclusion

Children in Sub-Saharan Africa are burdened by significant unmet mental health needs, including disruptive behavior disorders that persist through adolescence and adulthood if left untreated. The proposed study will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial and context-specific drivers affect the mental health of children in mid-upper primary schools in Uganda. Findings from this study can inform group, community, and population approaches that are needed for scalable solutions to address the social drivers negatively impacting child behavioral health in low-resource settings, including in Sub-Saharan Africa.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT053 68714].

The longitudinal impact of an evidence-based multiple family group intervention (Amaka Amasanyufu) on oppositional defiant disorder and impaired functioning among children in Uganda: analysis of a cluster randomized trial from the SMART Africa-Uganda scale-up study (2016-2022)

BACKGROUND

Oppositional Defiant Disorders (ODDs) and other Disruptive Behavior Disorders (DBDs) are common among children and adolescents in poverty-impacted communities in sub-Saharan Africa. Without early intervention, its progression into adulthood can result in dire consequences. We examined the impact of a manualized family strengthening intervention called Amaka Amasanyufu designed to reduce ODDs and other DBDs among school-going children residing in low-resource communities in Uganda.

METHODS

We used longitudinal data from the SMART Africa-Uganda study (2016-2022). Public primary schools were randomized to: (1) Control condition (receiving usual care comprising generalized psychosocial functioning literature), 10 schools; (2) intervention delivered via parent peers (Amaka-parents), 8 schools or; (3) intervention delivered via community healthcare workers (Amaka-community), 8 schools. All the participants were blinded. At baseline, 8- and 16-weeks postintervention initiation, caregivers completed the Iowa Conners Scale, which measured Oppositional Defiant Disorder (ODD) and Impairment Rating Scale to evaluate children's overall impairment and impaired functioning with peers, siblings, and parents; impaired academic progress, self-esteem, and family functioning. Three-level linear mixed-effects models were fitted to each outcome. Pairwise comparisons of postbaseline group means within each time point were performed using Sidak's adjustment for multiple comparisons. Only children positive for ODD and other DBDs were analyzed.

RESULTS

Six hundred and thirty-six children screened positive for ODDs and other DBDs (Controls: n = 243; Amaka-parents: n = 194; Amaka-community: n = 199). At 8 weeks, Amaka-parents' children had significantly lower mean scores for overall impairment compared to controls, (mean difference: -0.71, p = .001), while Amaka-community children performed better on ODD (mean difference: -0.84, p = .016). At 16 weeks, children in both groups were performing better on ODD and IRS than controls, and there were no significant differences between the two intervention groups.

CONCLUSIONS

The Amaka Amasanyufu intervention was efficacious in reducing ODD and impaired functioning relative to usual care. Hence, the Amaka Amasanyufu intervention delivered either by Amaka-community or Amaka-parents has the potential to reduce negative behavioral health outcomes among young people in resource-limited settings and improve family functioning.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03081195. Registered on 16 March 2017.

A Multilevel Integrated Intervention to Reduce the Impact of HIV Stigma on HIV Treatment Outcomes Among Adolescents Living With HIV in Uganda: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda.

OBJECTIVE

The proposed intervention-Multilevel Suubi (MSuubi)-has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants' experiences with HIV stigma, HIV treatment adherence, and intervention and educators' attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training.

METHODS

MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months.

RESULTS

This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025.

CONCLUSIONS

MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40101.

Hunger and Adherence to Antiretroviral Therapy: Learning From HIV Positive Caregivers of Orphans and Vulnerable Children in Tanzania

The association between hunger and adherence to antiretroviral therapy (ART) is less known especially in vulnerable populations receiving HIV care and treatment services. Caregivers of orphans and vulnerable children (OVC) are vulnerable and likely to experience hunger due to additional economic pressure in caring for OVC. Using data from the community–based, USAID–funded Kizazi Kipya project, this study assesses the association between hunger and ART adherence among caregivers of OVC in Tanzania. HIV positive caregivers enrolled in the project from January to July 2017 were analyzed. The outcome variable was adherence to ART, defined as “not having missed any ART dose in the last 30 days,” and household hunger, measured using the Household Hunger Scale (HHS), was the main independent variable. Data analysis included multivariable logistic regression. The study analyzed 11,713 HIV positive caregivers who were on ART at the time of enrollment in the USAID Kizazi Kipya project in 2017. Aged 48.2 years on average, 72.9% of the caregivers were female. While 34.6% were in households with little to no hunger, 59.4 and 6.0% were in moderate hunger and severe hunger households, respectively. Overall, 90.0% of the caregivers did not miss any ART dose in the last 30 days. ART adherence rates declined as household hunger increased (p < 0.001). Multivariable analysis showed that the odds of adhering to ART was significantly lower by 42% among caregivers in moderate hunger households than those in little to no hunger households (OR = 0.58, 95% CI 0.50–0.68). The decline increased to 47% among those in severe hunger households (OR = 0.53, 95% CI 0.41–0.69). Hunger is an independent and a significant barrier to ART adherence among caregivers LHIV in Tanzania. Improving access to adequate food as part of HIV care and treatment services is likely to improve ART adherence in this population.

Impact of household economic strengthening intervention on food security among caregivers of orphans and vulnerable children in Tanzania

About 2 billion people worldwide suffer moderate or severe forms of food insecurity, calling for correctional measures involving economic strengthening interventions. This study assessed the impact of household economic strengthening (HES) intervention on food security among caregivers of orphans and vulnerable children (OVC) in Tanzania. The study was longitudinal in design, based on OVC caregivers’ baseline (2017–2018) and midline (2019) data from the USAID Kizazi Kipya project. Food security, the outcome, was measured using the Household Hunger Scale (HHS) in three categories: little to no hunger (food secure), moderate hunger, and severe hunger. Membership in the USAID Kizazi Kipya-supported economic strengthening intervention (i.e. WORTH Yetu) was the main independent variable. Data analysis involved generalized estimating equation (GEE) for multivariate analysis. With mean age of 50.3 years at baseline, the study analyzed 132,583 caregivers, 72.2% of whom were female. At midline, 7.6% of all caregivers enrolled at baseline were members in WORTH Yetu. Membership in WORTH Yetu was significantly effective in reducing household hunger among the caregivers: severe hunger dropped from 9.4% at baseline to 4.1% at midline; moderate hunger dropped from 65.9% at baseline to 62.8% at midline; and food security (i.e., little to no hunger households) increased from 25.2% at baseline to 33.1% at midline. In the multivariate analysis, membership in WORTH Yetu reduced the likelihood of severe hunger by 47% (OR = 0.53, 95% CI 0.48–0.59), and moderate hunger by 21% (OR = 0.79, 95% CI 0.76–0.83), but increased the likelihood of food security by 45% (OR = 1.45, 95% CI 1.39–1.51). The USAID Kizazi Kipya’s model of household economic strengthening for OVC caregivers was effective in improving food security and reducing household hunger in Tanzania. This underscores the need to expand WORTH Yetu coverage. Meanwhile, these results indicate a potential of applying the intervention in similar settings to address household hunger.

Anzansi family program: a study protocol for a combination intervention addressing developmental and health outcomes for adolescent girls at risk of unaccompanied migration

BACKGROUND

The International Labor Organization (ILO) estimates that 11% of children (ages 5 to 17) worldwide are child laborers. ILO recently drew attention to migrant child laborers as an underreported, but more vulnerable group to adverse outcomes relative to children working locally. Sub-Saharan Africa (SSA) continues to be the continent with the highest rates of child labor, with Ghana registering one of the highest incidence rates at 22%, including unaccompanied child migrants engaged in labor. Adolescent girls make up the majority of unaccompanied rural-to-urban migrants in search of better economic opportunities. Studies document the myriad of serious threats to health and emotional well-being experienced by adolescent girls who migrate to engage in child labor. These threats underline the urgent need for theoretically informed preventive interventions, specifically tailored to address the root causes of female child migrant labor and the needs of girls from economically insecure families and communities.

METHODS

A two-arm cluster randomized control trial will be conducted to assess the feasibility, acceptability, and preliminary impact of ANZANSI (family economic empowerment + multiple family groups) among 100 adolescent girls and their caregivers in the Northern Region of Ghana. Ten schools will be randomly selected from a list of eligible schools, and randomized to one of two study arms: (1) control arm (n = 5 schools, n = 50 adolescent-caregiver dyads); (2) treatment arm (n = 5 schools, n = 50 adolescent-caregiver dyads) receiving ANZANSI over a 9-month period. Adolescents (ages 11 to 14) in the same school will be assigned to the same study condition to avoid contamination.

DISCUSSION

The primary aim of the study is to address the urgent need for theoretically and empirically informed interventions that prevent adolescent girls' unaccompanied rural-to-urban migration for child labor. Existing programs are not preventive and primarily target children who already migrated to the city and are living and working on the streets. This study is one of the first studies to pilot test a combination intervention, integrating family economic empowerment targeting household poverty with multiple family groups addressing family cohesion and perceptions on gender norms, child education/labor, all of which are factors, when combined, force girls to drop out of school and migrate.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT04231669 ; Registered January 18, 2020.

Prevalence and correlates of depressive symptoms among high school adolescent girls in southern Uganda

Background

In sub-Saharan Africa (SSA), adolescent girls and young women are three times more likely than boys to have depressive disorders. Understanding adolescents’ unique and common vulnerabilities and protective factors is essential for the development of appropriate interventions and programming focused on child and adolescent mental health. This paper examines the prevalence and predictors of depressive symptoms among high school adolescent girls in southern Uganda.

Methods

Baseline data from a longitudinal cluster randomized study involving 1260 adolescent girls (14–17 years), recruited from 47 secondary schools were utilized. Depressive symptoms were estimated using the 21-item Beck’s Depression Inventory. Hierarchical linear regression modelling was utilized to estimate key predictors of depressive symptoms among adolescent girls.

Results

Of the total sample, 16.35% (n = 206) reported severe depressive symptoms and almost one in every three adolescent girls interviewed (29.68%, n = 374) reported moderate symptoms. These symptoms were more prevalent among older adolescents (16 years and above). In addition, family relationships, social support, as well as measures of psychological wellbeing (self-concept and self-esteem) were all associated with lower levels of depressive symptoms. Hopelessness was associated with higher levels of depressive symptoms among adolescent girls.

Conclusion

Findings from this study indicate a high prevalence of depressive symptoms, especially among older adolescent girls. In addition, family support factors and adolescents’ psychological wellbeing were associated with low levels of depressive symptoms –pointing to the need to strengthen family functioning and adolescent’s psychological wellbeing to mitigate risks. Taken together, findings support increasing calls for early screening and detection of depressive symptoms to facilitate timely referral to care and treatment. Findings may also inform the development and incorporation of gender-specific mental health components in programming targeting adolescent girls, in low-resource communities in SSA.

Trial registration

This trial was prospectively registered with ClinicalTrials.gov (registration number: NCT03307226) on 11 October 2017.

Social and Economic Equity and Family Cohesion as Potential Protective Factors from Depression Among Adolescents Living with HIV in Uganda

Adolescents living with HIV in Uganda are impacted by poverty and face a number of health and social challenges including access to medication, health complications, and social stigma. These stressors have been linked to depression, which can lead to lower HIV treatment adherence. This study seeks to determine how social and economic equity, family cohesion, and social supports may be related to depression among adolescents living with HIV. We used baseline data from the Suubi + Adherence study, a 5-year longitudinal randomized controlled trial among adolescents living with HIV in southwestern Uganda (n = 675; ages 10-16 years). Hierarchical logistic regression models were conducted separately among in-school adolescents and out-of-school adolescents to assess the hypothesized associations between economic and social equity, social support, and depression. About half of the participants meet the criteria for depression. Adolescents with depression were found to have fewer economic and social supports. Our findings indicate that social and economic equity [odds ratio (OR) = 0.85, 95% confidence interval (CI) 0.74, 0.99], family cohesion (OR = 0.94, 95% CI 0.91-0.96), and social support from friends (OR = 0.95, 95% CI 0.91-0.998) are associated with depression for in-school HIV infected adolescents and could be protective factors. The results of this study suggest that social and economic equity may play a protective role against depression and other poor mental health outcomes. Potential interventions for adolescents living with HIV should consider these social and familial factors as they may be protective of depression in this population.

Relationship Between Food Insufficiency and HIV Infection Among Caregivers of Orphans and Vulnerable Children in Tanzania

Background

Although Tanzania experiences a general decline in HIV prevalence, some populations such as caregivers of orphans may be at a higher risk than the general population, suggesting that infection pathways still need further exploration. This study examines how food insufficiency relates to HIV infection among caregivers of orphans and vulnerable children (OVC) in Tanzania.

Data and Methods

Data are from a community-based, USAID-funded Kizazi Kipya project that aims at increasing the uptake of HIV services, as well as other health and social services by OVC and their caregivers in Tanzania. Caregivers who were enrolled in the project from January to July 2017 in seven regions of Tanzania, and had reported their HIV status to the project, were included in the analysis. While HIV status was the outcome, the main independent variable was food insufficiency which was assessed using the Household Hunger Scale (HHS). Using Stata (version 14.0; StataCorp LP, College Station, TX, USA), data analysis involved multilevel mixed-effects logistic regression..

Results

Of the 47,617 caregivers analyzed (73.7% females), 61.8% and 4.6% were experiencing moderate and severe hunger, respectively. The overall HIV prevalence among the caregivers was 28.3%. Nevertheless, the prevalence was as high as 34.2% among caregivers in severe hunger households. Multivariate analysis revealed an increasing likelihood of being HIV positive as hunger increased (moderate hunger: OR=1.10, 95%CI: 1.03–1.18; severe hunger: OR=1.51, 95%CI: 1.32–1.74). These observations were adjusted for marital status, age, sex, education, place of residence, family size, disability status, and health insurance.

Conclusion

Food insufficiency is associated with a higher likelihood of HIV infection among OVC caregivers in Tanzania, suggesting that improving access to adequate food has a potential to reduce HIV risks among them. Furthermore, food insufficiency could be considered an important criterion for targeting HIV testing and treatment services to expand coverage.

The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda

Background

Adolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence.

Methods

Data from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy.

Results

The average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART.

Conclusion

Findings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV.

Trial registration

This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

Ugandan Jajjas: Antecedents and rewards of caring for grandchildren in the context of HIV

AIMS AND OBJECTIVES

The findings presented in this manuscript address two key research questions: (a) What factors contribute to the initiation and maintenance of the caregiving role as performed by the grandparent-caregivers; and (b) What are the perceived benefits of caregiving as reported by grandparent-caregivers?

BACKGROUND

Grandparents in sub-Saharan Africa have cared for their grandchildren for generations, yet little is known about this role in the context of the HIV epidemic. Although the impact of the epidemic is overwhelmingly negative, specifically in Uganda, knowledge of familial context and underlying motivations and rewards that incentivise grandparent-caregivers remains limited in the literature.

METHODS

Using a constructivist grounded theory approach, we explored the experiences of 32 Ugandan grandparents of grandchildren affected by HIV. Data were collected using a semi-structured and open-ended interview guide, participant observation and fieldnotes. Data analysis included open, focused and axial coding.

FINDINGS

The data revealed the influences of extended familial structures and of cultural and gender expectations on the decision-making processes and rewards of caregiving as perceived by the grandparent-caregivers.

DISCUSSION AND RECOMMENDATION

These findings provide a broad foundation for policy, practice, research and education interventions needed to support grandparents so they can enjoy the benefits of raising their grandchildren.

IMPLICATIONS FOR PRACTICE

Our findings can guide education programs and clinical practice for nurses, nursing students, and other health providers on cultural considerations for holistic care provided for older adults-especially older caregivers.

Young Children’s Social Networks in an Informal Urban Settlement in Kenya: Examining Network Characteristics Among Kamba, Kikuyu, Luo, and Maasai Children

Children’s social networks comprise a variety of social partners who interact with the child in unique ways and contribute distinctly to her social and emotional development. This study examines the structure of children’s social networks from four different ethnic groups (Kamba, Kikuyu, Luo, and Maasai) residing in an informal urban settlement in Kenya. Twenty boys and 24 girls ( M = 40 months) were observed on three different weekdays for 2 hr each day, to assess children’s experiences across daylight hours. Children’s social networks predominantly consisted of nonrelative children and nonrelative adults. However, larger social networks did not necessarily mean more highly involved members. Peers were observed to be in close proximity and to engage in play and conversation with the focal children more often than did adult social partners. The findings have implications for intervention programs that focus predominantly on nuclear family members, as they may overlook important roles that other social network members play in children’s lives. The low occurrence of play between adults and children in this study is consistent with studies in other non-Western contexts, where play is generally not considered part of parents’ role nor a fundamental characteristic of parent–child interactions.

Examining the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in Uganda

In this study, we examined the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in HIV-impacted communities in Uganda. We analyzed data from a cluster randomized experimental study for orphaned adolescents aged 11-17 years. Participants were randomly assigned to either the control condition, which received bolstered standard of care (BSOC) services, or the treatment condition, which received BSOC services plus an economic-strengthening intervention. We conducted binary logistic regression analyses to examine the effect of the intervention on participants' nonkin support networks. Results indicated that the existing social support networks for orphaned adolescents are small, limited, and usually comprised individuals with similar socioeconomic situations and challenges. Because orphaned adolescents are socially isolated and the threshold for nonkin supportive services is very low, the BSOC services provided to the control condition appeared to be instrumental in their survival and well-being. Availability of personal savings was associated with higher odds of identifying at least one supportive nonkin tie. The extended family system is still the primary and major source of social support to orphaned children in HIV-affected communities. In the absence of public safety nets, building social assets, over and above offering economic opportunities to extended families supporting orphaned children, is critical.

The feelings and experiences of hospitalized patients regarding informal caregivers: a qualitative study

The purpose of this study was to understand the views of hospitalized patients regarding family/informal caregivers (ICs). In this study thematic content analysis was used, interviews were audio-recorded, transcribed verbatim, and coded. The 4 themes and 11 subthemes were determined. Themes: Identity of IC, expectations of IC, feelings about the presence or absence of an IC. Along with feeling positive emotions when ICs were present, patients also felt as though they were a burden on caregivers. Family caregivers are an important social support for patients and they may lead to more meaningful patient outcomes globally.

Kin support and child health: Investigating two approaches in an African slum

Extensive research from sub-Saharan Africa shows that mothers frequently rely on help from other family members to ensure their children's health and well-being. Yet, there is considerable debate about the relative importance of support from grandmothers versus fathers. Using an innovative survey instrument to interview 462 unmarried mothers in a slum area of Nairobi, Kenya, we provide insight into this debate by showing that a status versus transfers approach to measuring kin support asks subtly different questions and yields different results. A status approach reflects an evolutionary perspective that argues that maternal grandmothers have a greater incentive than non-residential fathers to provide material and practical support for young children. In contrast, a transfers approach is consistent with social support theories whereby the social capital provided by fathers may be more beneficial to children's health than that afforded by grandmothers. Demonstrating that different approaches to measuring kin support matter highlights the need for kin research that crosses disciplinary boundaries and encourages the development of more nuanced family policies designed to protect children's health in Africa.

Social support and school outcomes of adolescents orphaned and made vulnerable by HIV/AIDS living in South Western Uganda

The goal of this study is to examine the role of social support from multiple sources, including the extended family, caregivers, classmates, peers and teachers, in improving the school outcomes (grades and attendance) of children orphaned by AIDS in Uganda. Data for this study comes from a 4-year randomized control trial, called Suubi-Maka (Hope for families), conducted in the Southwestern part of Uganda from 2008 to 2012. Using multivariate regression modeling - controlling for several individual-level and school-level characteristics, we find that social support (perceived emotional and information support received from parents, classmates and teachers), caregiver's acceptance and warmth, and family cohesion have positive effects on children's school grades and attendance. This finding underscores the importance of strengthening relationships within the extended family and the school environment to serve as a net of strength that can influence not only family functioning but also vulnerable adolescents' educational trajectories.

Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS, sexually transmitted infections, and risky sexual behavior in sub-Saharan Africa: a systematic review

PURPOSE

To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa.

METHODS

Ten databases were searched through May 29, 2016. Two reviewers completed screening and full-text review. Studies examining the influence of contextual factors on HIV/AIDS, STIs, and RSB and using MLMs for analysis were included. The Quality Assessment Tool for Quantitative Studies was used to evaluate study quality.

RESULTS

A total of 118 studies met inclusion criteria. Seventy-four studies focused on HIV/AIDS-related topics; 46 focused on RSB. No studies related to STIs other than HIV/AIDS met the eligibility criteria. Of five studies examining HIV serostatus and community socioeconomic factors, three found an association between poverty and measures of inequality and increased HIV prevalence. Among studies examining RSB, associations were found with numerous contextual factors, including poverty, education, and gender norms.

CONCLUSIONS

Studies using MLMs indicate that several contextual factors, including community measures of socioeconomic status and educational attainment, are associated with a number of outcomes related to HIV/AIDS and RSB. Future studies using MLMs should focus on contextual-level interventions to strengthen the evidence base for causality.

Who Helps Single Mothers in Nairobi? The Role of Kin Support

Single mothers often turn to their extended kin for financial assistance and to help with child care. Such support may be especially important in areas of high poverty and poor environmental conditions. Using novel kinship data, this paper assesses the extent of support given by over 3,000 relatives to 462 single mothers living in a slum area of Nairobi, Kenya. Contrary to stereotypes about families in sub-Saharan Africa, the active kin network of single mothers is relatively small and nearly a fifth of mothers do not receive any financial or child care assistance. Different types of kin offer different kinds of support according to culturally proscribed roles. However, support also depends heavily on kin's employment status, geographic proximity, and age. These findings offer a nuanced picture of how single women living in slum areas draw upon their kin network to cope with their daily demands as mothers.

Orphanhood by AIDS-Related Causes and Child Mental Health: A Developmental Psychopathology Approach

While the number of new HIV infections has declined, the number of orphans as a result of AIDS-related deaths continues to increase. The aim of this paper was to systematically review empirical research on the mental health of children affected by HIV/AIDS in the developing world, specifically with an eye on developing a theoretical framework to guide intervention and research. Articles for review were gathered by following the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA standards), reviewed and then organized and synthesized with a Developmental Psychopathology framework. Results showed that the immediate and longterm effects of AIDS orphanhood are moderated by a number of important risk and protective factors that may serve as strategic targets for intervention. Research and clinical implications are discussed.

Children of the postwar years: A two-generational multilevel risk assessment of child psychopathology in northern Uganda

In postconflict settings risk factors at multiple levels of the social ecology, including community, family, and relationship factors, potentially affect children's mental health. In addition, intergenerational risk factors such as guardians' history of childhood family violence, war exposure, and psychopathology may contribute to children's psychopathological symptoms. In this study, we aimed to identify risk constellations that predict child internalizing and externalizing behavior problems, depression, and posttraumatic stress symptoms in the postconflict setting of northern Uganda. In a cross-sectional epidemiological study, 513 second-grade students and their female guardians were interviewed using standardized clinical questionnaires. A higher exposure to traumatic events, more witnessed or experienced violence within the family, and lower child-reported care from female guardians independently predicted psychopathological symptoms in children. While controlling for intergenerational risk factors in female guardians, serial mediation modeling revealed that the effect of trauma exposure on children's psychopathological symptoms was partially mediated by higher exposure to family violence and lower child-perceived care from female guardians. The mediation appeared to be stronger for children's depression symptoms and internalizing and externalizing behavior problems than for posttraumatic stress symptoms. The current findings support the need for targeted interventions at the individual and family system levels that are matched to children's psychopathological symptoms.

COMMUNICATION IN THE CONTEXT OF FAMILY CAREGIVING: AN EXPLORATORY STUDY OF UGANDAN CHILDREN ON ANTIRETROVIRAL THERAPY

It is important to consider the complexities of family dynamics when deciding when and how to communicate with HIV-infected children about their illness and treatment. Previous research has focused on providers' and caregivers' perspectives on whether, when and how to disclose HIV/AIDS diagnosis and treatment to HIV-infected children. From the perspective of HIV-infected children, communication does not mean just giving information about illness and treatment, but also encompasses emotional and material care. This paper places communication within the broader framework of caregiving in family situations. This exploratory study was conducted in Jinja district, Uganda, between November 2011 and December 2012. Through participant observation and in-depth interviews, communication by, and with, HIV-infected children in the context of family situations was explored from the perspectives of 29 HIV-infected children aged 8-17 years on antiretroviral therapy (ART) using content thematic analysis. Children's communication with caregivers about their illness and treatment varied depending on whom they were living with and the nature of caregiving. Although a mother's care was considered best, children described others who cared 'like a mother'. For some, caregiving was distributed among several relatives and non-relatives, while others felt they had hardly anyone to care for them. Caregiving from the children's perspective involved emotional support, expressed verbally and explicitly in messages of concern, encouragement conveyed in reminders to take medicines, attention when sick and confidential conversations about the challenges of having HIV and taking ART. Caregiving was also communicated implicitly in acts of provision of food/drinks to take with medicines, counting pills to confirm they had taken the medicines and accompanying children to treatment centres. Children's communication about their health and medicines and the care they received was to a large extent shaped by the nature of their relatedness to their caregivers, the extent to which caregiving was dispersed among several people and who else in the household was infected with HIV and on medication.

Matched Child Savings Accounts in Low-Resource Communities: Who Saves?

This study examines variations in saving behavior among poor families enrolled in a Child Savings Account program for orphaned and vulnerable school-going children in Uganda. We employ multilevel analyses using longitudinal data from a cluster-randomized experimental design. Our analyses reveal the following significant results: (1) given the average number of months during which the account was open (18 months), families saved on average, USD 54.72, which, after being matched by the program (2:1 match rate) comes to USD 164.16-enough to cover approximately five academic terms of post-primary education; (2) children's saving behavior was not associated with quality of family relations; it was, however, significantly associated with family financial socialization; (3) family demographics were significantly associated with children's saving behavior in the matched Child Savings Account program; and (4) children enrolled in some schools saved better compared to children enrolled in other schools within the same treatment group.

Relationship Between Family Economic Resources, Psychosocial Well-being, and Educational Preferences of AIDS-Orphaned Children in Southern Uganda: Baseline Findings

This study examines the relationship between economic resources, psychosocial well-being, and educational preferences of AIDS-orphaned children in southern Uganda. We use baseline data from a sample of 1410 AIDS-orphaned children (defined as children who have lost one or both biological parents to AIDS) enrolled in the Bridges to the Future study, a National Institute of Child Health and Human Development (NICHD) funded study. Analyses from both bivariate and multiple regression analyses indicate the following: 1) despite the well-documented economic and psychosocial challenges AIDS-orphaned children face, many of these children have high educational plans and aspirations; 2) educational aspirations differ by orphanhood status (double orphan vs. single orphan); 3) regardless of orphanhood status, children report similar levels of psychosocial well-being; 4) high levels of family cohesion, positive perceptions of the future, school satisfaction, and lower levels of hopelessness (hopefulness) are associated with high educational aspirations; and 5) reported family economic resources at baseline, all seem to play a role in predicting children's educational preferences and psychosocial well-being. These findings suggest that the focus for care and support of orphaned children should not be limited to addressing their psychosocial needs. Addressing the economic needs of the households in which orphaned children live is equally important. Indeed, in the context of extreme poverty-in which most of the children represented in this study live-addressing structural factors, including poverty, may be a key driver in addressing their psychosocial functioning.

Family structure and sexual and reproductive health outcomes among adolescents in rural Sierra Leone

Orphanhood is common in sub-Saharan Africa, and is a critical issue shaping global assistance for children. Care arrangements for children are often fluid, and many 'orphaned' children have a surviving biological parent. This study examines the protective effects of family-level factors on early sex and pregnancy in rural Sierra Leone. A survey of 530 adolescents in 2 districts in Sierra Leone was analysed to evaluate associations between living arrangement and orphanhood on recent sexual activity and pregnancies out of wedlock. After controlling for confounders, living with one's mother (AOR = 0.46, 95% CI: 0.22-1.00) and living with both parents (AOR = 0.36, 95% CI: 0.17-0.73) were protective against recent sexual activity. Orphan status was not significantly associated with recent sexual activity. Among 164 sexually active adolescents, neither living arrangement nor orphanhood was associated with pregnancy. This study demonstrates the protective effect of living with a surviving biological parent to delay early sexual debut. Once an adolescent becomes sexually active; however, living arrangement is not associated with the risk of pregnancy out of wedlock. The findings suggest that supporting family connectedness and preventing unnecessary family separation may benefit at least some aspects of adolescent sexual and reproductive health in Sierra Leone.

Closing the health gap in a generation: exploring the association between household characteristics and schooling status among orphans and vulnerable children in Swaziland

Swaziland has one of the highest HIV/AIDS prevalences in the world, which has contributed to many Swazi children being left as "orphans and vulnerable children" (OVC). In 2010, there were 78,000 AIDS orphans in the country and the number is expected to increase given the current HIV prevalence. The WHO aims to close the gap in a generation and eliminate health inequality; as a result the Swazi Government began in 2005 to provide financial support to the education of OVC. Prior research has indicated that household characteristics are some of the major determinants with respect to schooling status among children. We have examined the association between household characteristics and schooling status of OVC. Schooling status may vary by gender and by age, as well as by other sociodemographic factors, in sub-Saharan African societies, and therefore we have also included a comprehensive set of appropriate variables in all of our multivariate analyses. Using existing data from the Swaziland Multiple Indicator Cluster Survey 2010, a total of 5890 children aged 7-18 years old were analyzed. The results from the multivariate logistic regressions showed that non-OVC were more likely than OVC to be in school (OR = 2.18, p < 0.001), even after taking other variables into considerations. The OVC in socioeconomically disadvantaged households, such as those with lower levels of household wealt, and those who resided in an urban area, were less likely to be in school. These findings suggest that education programs for OVC need to be household-appropriate.

The role of perceived social support in loneliness and self-esteem among children affected by HIV/AIDS: a longitudinal multilevel analysis in rural China

OBJECTIVES

To delineate the trajectories of loneliness and self-esteem over time among children affected by parental HIV and AIDS, and to examine how their perceived social support (PSS) influenced initial scores and change rates of these two psychological outcomes.

DESIGN

We collected longitudinal data from children affected by parental HIV/AIDS in rural central China. Children 6-18 years of age at baseline were eligible to participate in the study and were assessed annually for 3 years.

METHODS

Multilevel regression models for change were used to assess the effect of baseline PSS on the trajectories of loneliness and self-esteem over time. We employed maximum likelihood estimates to fit multilevel models and specified the between-individual covariance matrix as 'unstructured' to allow correlation among the different sources of variance. Statistics including -2 Log Likelihood, Akaike Information Criterion and Bayesian Information Criterion were used in evaluating the model fit.

RESULTS

The results of multilevel analyses indicated that loneliness scores significantly declined over time. Controlling for demographic characteristics, children with higher PSS reported significantly lower baseline loneliness score and experienced a slower rate of decline in loneliness over time. Children with higher PSS were more likely to report higher self-esteem scores at baseline. However, the self-esteem scores remained stable over time controlling for baseline PSS and all the other variables.

CONCLUSIONS

The positive effect of PSS on psychological adjustment may imply a promising approach for future intervention among children affected by HIV/AIDS, in which efforts to promote psychosocial well being could focus on children and families with lower social support. We also call for a greater understanding of children's psychological adjustment process in various contexts of social support and appropriate adaptations of evidence-based interventions to meet their diverse needs.

Physical and sexual abuse in orphaned compared to non-orphaned children in sub-Saharan Africa: a systematic review and meta-analysis

This systematic review assessed the quantitative literature to determine whether orphans are more likely to experience physical and/or sexual abuse compared to non-orphans in sub-Saharan Africa (SSA). It also evaluated the quality of evidence and identified research gaps. Our search identified 10 studies, all published after 2005, from Zimbabwe, South Africa, Kenya and Uganda. The studies consisted of a total 17,336 participants (51% female and 58% non-orphans). Of those classified as orphans (n=7,315), 73% were single orphans, and 27% were double orphans. The majority of single orphans were paternal orphans (74%). Quality assessment revealed significant variability in the quality of the studies, although most scored higher for general design than dimensions specific to the domain of orphans and abuse. Combined estimates of data suggested that, compared to non-orphans, orphans are not more likely to experience physical abuse (combined OR=0.96, 95% CI [0.79, 1.16]) or sexual abuse (combined OR=1.25, 95% CI [0.88, 1.78]). These data suggest that orphans are not systematically at higher risk of experiencing physical or sexual abuse compared to non-orphans in sub-Saharan Africa. However, because of inconsistent quality of data and reporting, these findings should be interpreted with caution. Several recommendations are made for improving data quality and reporting consistency on this important issue.

Knowledge brokers, companions, and navigators: a qualitative examination of informal caregivers' roles in medical tourism

Introduction

Many studies examining the phenomena of medical tourism have identified health equity issues associated with this global health services practice. However, there is a notable lack of attention in this existing research to the informal care provided by the friends and family members who typically accompany medical tourists abroad. To date, researchers have not examined the care roles filled by informal caregivers travelling with medical tourists. In this article, we fill this gap by examining these informal caregivers and the roles they take on towards supporting medical tourists’ health and wellbeing.

Methods

We conducted 21 interviews with International Patient Coordinators (IPCs) working at medical tourism hospitals across ten countries. IPCs work closely with informal caregivers as providers of non-medical personal assistance, and can therefore offer broad insight on caregiver roles. The interviews were coded and analyzed thematically.

Results

Three roles emerged: knowledge broker, companion, and navigator. As knowledge brokers, caregivers facilitate the transfer of information between the medical tourist and formal health care providers as well as other staff members at medical tourism facilities. The companion role involves providing medical tourists with physical and emotional care. Meanwhile, responsibilities associated with handling documents and coordinating often complex journeys are part of the navigation role.

Conclusions

This is the first study to examine informal caregiving roles in medical tourism. Many of the roles identified are similar to those of conventional informal caregivers while others are specific to the transnational context. We conclude that these roles make informal caregivers an integral part of the larger phenomenon of medical tourism. We further contend that examining the roles taken on by a heretofore-unconsidered medical tourism stakeholder group sheds valuable insight into how this industry operates and that such knowledge is necessary in order to respond to the health equity debates that surround this particular global health services practice.

Imagining the future: Community perceptions of a family-based economic empowerment intervention for AIDS-orphaned adolescents in Uganda

AIDS-orphaned children and adolescents in sub-Saharan Africa have inadequate access to basic services, including health and education. Using a qualitative approach, the study explores the meaning of education in rural Uganda, obstacles faced by AIDS-orphaned adolescents and their caregivers to access secondary education, and the potential of an economic empowerment intervention SEED in addressing the challenges of accessing educational opportunities for AIDS-orphaned adolescents. The findings come from 29 semi-structured interviews conducted with eleven adolescents study participants, four caregivers and fourteen community leaders involved in the pilot SEED intervention. Study participants and community members indicated that the savings accounts offer a unique opportunity for orphaned adolescents to stay in school and imagine the future with optimism.