Perceptions of children and community members concerning the circumstances of orphans in rural Zimbabwe

Adverse Childhood Experiences and Mental Distress Among Adolescents and Youth in Zimbabwe

Adverse childhood experiences (ACEs) are a global public health crisis associated with physical and poor mental health outcomes. The current study examined the prevalence and association between individual and cumulative ACEs with mental distress among adolescents and youth in Zimbabwe. Data from the 2017 Violence Against Children and Youth Survey were utilized (13-25 years old, n = 8,715). Bivariate analysis was conducted using chi-square tests to obtain the prevalence estimates. Two sets of logistic regression models were conducted to determine significant associations between independent variables (i.e., experiencing childhood physical, emotional, and sexual violence; witnessing intimate partner violence (IPV) and community violence; orphan status; and cumulative ACE exposure) and the dependent variable (i.e., mental distress in the past 30 days as measured by Kelser 6). 28.4% of the adolescents and youth reported experiencing mental distress in the past 30 days. Regarding ACEs, cumulative ACE exposure (34.7%; adjusted odds ratio [AOR] = 2.13) and individual ACEs (i.e., experiencing childhood physical violence [39.3%; AOR = 1.41], emotional violence [55.8%; AOR = 2.67], sexual violence [50.8%; AOR = 2.00], witnessing community violence [47.3%; AOR = 1.52], witnessing IPV [43.1%; AOR = 1.47], and being orphaned during childhood [33.6%; AOR = 1.24]) were significantly associated with higher prevalence rates and odds of experiencing mental distress in the past 30 days among adolescents and youth in Zimbabwe. These findings show that ACEs are highly prevalent and increases the risk of mental distress for vulnerable adolescents and youth in Zimbabwe. Effective interventions to reduce violence exposure in families, schools, and communities are essential to mitigate the negative consequences of ACEs and mental distress of adolescents and youth in Zimbabwe. Strengthening child protection policies and involving social workers, psychologists, and mental health workers are also crucial for safeguarding vulnerable children who might be impacted by ACEs in Zimbabwe. Implications for future research are further discussed.

Risk and protective factors for mental health and wellbeing among adolescent orphans

Background

Research has demonstrated the importance of understanding risk factors for mental health and wellbeing. Less research has focused on protective factors that protect mental health and promote wellbeing in diverse contexts. Estimating structural paths from risk protective factors to psychopathology and wellbeing can inform prioritization of targeted investment in adolescent health programs that seek to modify factors that are most closely associated with mental wellbeing.

Study objective

The purpose of this study was to examine risk factors (e.g. emotional neglect, emotional abuse, physical neglect, stigma) and protective factors (e.g. community relationships, self-esteem, and autonomy) among adolescent orphans, protective associations with depression, anxiety and externalizing behaviors and promotive associations with hope, happiness, and health.

Methods

The analytic sample was collected between January and March of 2019 and included 350 adolescent orphans ages 10-15 from three districts in Tanzania. Participants completed survey interviews, 75-90 min in length, that measured risk and protective factors, psychological symptoms, and mental wellbeing measures.

Results

Results of the fitted structural equation model indicated that structural paths from protective factors to psychopathology (β = -0.53, p = 0.015) and mental wellbeing (β = 0.72, p = 0.014) outcomes were significant. Structural paths from risk factors to psychopathology (β = -0.34, p = 0.108) and mental wellbeing (β = -0.24, p = 0.405) were not significant.

Conclusion

In a sample of vulnerable youth, protective factors (e.g. community relationships, self-esteem, and autonomy) were significantly associated with reduced depression, anxiety and externalizing behaviors and increased hope, happiness, and health in a structural equation model that included risk factors (emotional neglect, emotional abuse, physical neglect). Results suggest that strong community relationships, self-esteem and autonomy may be important modifiable factors to target in intervention programs aimed at supporting adolescent mental wellbeing.

Psychometric validation of the collective asset Utu: associations with coping strategies and resilience during adolescence

BACKGROUND

Utu is a Kiswahili term with a long history of cultural significance in Tanzania. It conveys a value system of shared, collective humanity. While variants of Utu have been studied in other contexts, a measure of Utu that captures this important collective asset has not been developed in Tanzania. The aims of this study were to (1) examine dimensional constructs that represent Utu, (2) validate a measurement scale of Utu for use with adolescents, (3) examine differences between orphan and non-orphan adolescents in self-reported Utu and, (4) examine structural paths between adverse life experiences, coping strategies, Utu, and resilience.  METHODS: This study collected survey data from adolescents from three districts in peri-urban Tanzania in two samples: 189 orphan adolescents ages 10-17 in May 2020 and 333 non-orphan adolescents ages 10-14 in August 2020. Confirmatory factor analysis was used to validate the hypothesized factor structure of the developed Utu measure. Structural equation models were used to examine path associations with adverse life experiences, coping and resilience.

RESULTS

The five dimensional constructs comprising the Utu measure included Resource Sharing, Group Solidarity, Respect and Dignity, Collectivity, and Compassion. Confirmatory factor analysis of the Utu measure demonstrated excellent fit (CFI = 0.98; TLI = 0.97; SRMR = 0.024; RMSEA = 0.046) and internal consistency (α = 0.94) among adolescents in this study. Positive, significant associations were found between Utu and coping (β = 0.29, p < 0.001) and Utu and intra/interpersonal and collective resilience (β = 0.13, p < 0.014). Utu was not significantly associated with adverse life experiences, age or gender.

CONCLUSIONS

A five-dimensional measurement scale for Utu was validated in a sample of orphan and non-orphan adolescents in Tanzania. Utu is a collective asset associated with higher levels of reported resilience in both orphan and non-orphan adolescent populations in Tanzania. Promoting Utu may be an effective universal public health prevention approach. Implications for adolescent programming are discussed.

Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial

IMPORTANCE

Approximately 140 million children worldwide have experienced the death of one or both parents. These children, mostly in low- and middle-income countries, have higher rates of mental health problems than those who have not experienced parental death. Cognitive behavioral therapy (CBT) may improve the well-being of these children, but to our knowledge there have been no randomized clinical trials specifically focused on this population.

OBJECTIVES

To test the effectiveness of trauma-focused CBT (TF-CBT) for improving posttraumatic stress (PTS) in children in Kenya and Tanzania who have experienced parental death, to test the effects of TF-CBT on other mental health symptoms, and to examine the feasibility of task-shifting with greater reliance on experienced, local lay counselors as trainers and supervisors.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial conducted in urban and rural areas of Tanzania and Kenya compared TF-CBT and usual care (UC) for 640 children aged 7 to 13 years who were recruited from February 13, 2013, to July 24, 2015. All children had experienced the death of one or both parents and had elevated PTS and/or prolonged grief. Interviewers were masked to study condition. Participants were followed up for 12 months after the randomized clinical trial. Statistical analysis was performed from February 3, 2017, to August 26, 2019. All analyses were on an intent-to-treat basis.

INTERVENTIONS

In the intervention condition, 320 children received 12 weeks of group TF-CBT delivered by lay counselors who were supervised weekly. In the UC condition, 320 children received community services typically offered to this population.

MAIN OUTCOMES AND MEASURES

The primary outcome was PTS, evaluated using a continuous, standardized measure. Other mental health symptoms and child-guardian relationship were also measured.

RESULTS

A total of 640 children (320 girls and 320 boys; mean [SD] age, 10.6 [1.6] years) were included in the study. Trauma-focused CBT was more effective than UC for PTS in 3 of 4 sites after treatment (end of 3-month randomized clinical trial): rural Kenya (Cohen d = 1.04 [95% CI, 0.72-1.36]), urban Kenya (Cohen d = 0.56 [95% CI, 0.29-0.83]), and urban Tanzania (Cohen d = 0.45 [95% CI, 0.10-0.80]). At 12-month follow-up, TF-CBT remained more effective than UC in both rural (Cohen d = 0.86 [95% CI, 0.64-1.07]) and urban (Cohen d = 0.99 [95% CI, 0.75-1.23]) Kenya. At 12-month follow-up in Tanzania, children who received TF-CBT and UC had comparable rates of improvement (rural Tanzania, Cohen d = 0.09 [95% CI, -0.08 to 0.26]; urban Tanzania, Cohen d = 0.11 [95% CI, -0.09 to 0.31]). A similar pattern was seen for secondary outcomes, with stronger effects observed in Kenya, where children experienced greater stress and adversity (eg, more food scarcity, poorer guardian health, and greater exposure to traumatic events).

CONCLUSIONS AND RELEVANCE

This study found that TF-CBT was more effective than UC in reducing PTS among children who experienced parental death in 3 of 4 sites in Kenya and Tanzania. At 12-month follow-up, TF-CBT was more effective in reducing PTS only among children in rural and urban Kenya.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01822366.

Impact of care at foster homes on the health-related quality of life of HIV-infected children and adolescents: a cross-sectional study from India

PURPOSE

To assess the impact of care at foster homes on the health-related quality of life (HRQOL) of children living with HIV (CLHIV), attending a referral ART Centre, and to compare their HRQOL with children living in their own homes.

METHODS

A cross-sectional study was conducted in 144 CLHIV between 5 and 18 years of age, attending a referral ART Centre in South India to assess their HRQOL using the standard PedsQL™ 4.0 questionnaire. Data were then analysed to compare the HRQOL of children living in foster homes to those children living in their own homes. The child report and the parent proxy-report on the child's HRQOL were also compared to see for any differences in their perspectives.

RESULTS

56.25% CLHIV were brought up in different foster homes. In the child's self-report, the mean HRQOL was higher for children living in foster homes [physical score (76.54 ± 12.40), psychosocial score (71.41 ± 12.40) and total score (73.20 ± 11.13)] when compared to children living in their own homes [physical score (75.09 ± 14.76), psychosocial score (70.60 ± 13.48) and total score (72.17 ± 12.00)]. There was no statistically significant difference in the HRQOL between these two groups (p > 0.05). In the parent proxy-report also, there was no statistically significant difference in the HRQOL in all the three scores. The child self-report depicted a significantly higher HRQOL in all the domains compared to the parent proxy-report (p < 0.05).

CONCLUSIONS

HRQOL of children living in foster homes is at par with the quality of life enjoyed by children living in their own homes. Foster care manages to provide a reasonable HRQOL in CLHIV, and has become an inseparable component of quality health care delivery for these children.

Growing up HIV-positive in Uganda: "psychological immunodeficiency"? A qualitative study

BACKGROUND

This study is part of a longitudinal study among children and adolescents with HIV in both urban and rural Uganda: 'Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (CHAKA)'.

METHOD

The study is constructed of both quantitative and qualitative components. In this article we report a qualitative study on the experiences of 21 adolescents (twelve to seventeen years) living with HIV in Uganda. The purpose of the study was to investigate both the protective and the risk factors in HIV-infected adolescents' care environment in order to understand what might contribute to negative outcomes and what might provide a protective buffer against harmful life events. Semi-structured interviews with vignettes about mental disorders were employed and a phenomenological analysis was done.

RESULTS

The findings uncovered that the adolescents' families were mostly characterized by instability and diffuse relationships that provided an insecure basis for secure attachment and emotional support. Even in stable and secure family environments, there was no guarantee for getting sufficient emotional support in order to develop a positive self-concept due to the fate being the only infected child in the family. Both secure attachment and positive self-concept are known psychological protective mechanisms that provide the individual with resilience. The adolescents in this study seemed hampered in the development of protective mechanisms and consequently seemed psychologically vulnerable and badly equipped for coping with challenges, which paves the way for the possible development of mental disorders.

CONCLUSION

To change the focus towards strengthening the children and adolescents' development of psychological protective mechanisms implicates a change in focus from illness to health and has consequences for both treatment and prevention. Psychological health promotion must be systemic and aim at strengthening the family environment, but also to establish peer group support.

Health, schooling, needs, perspectives and aspirations of HIV infected and affected children in Botswana: a cross-sectional survey

BACKGROUND

Antiretroviral treatment means many HIV infected children are surviving with a highly stigmatised condition. There is a paucity of data to inform policies for this growing cohort. Hence we carried out a study on the health, schooling, needs, aspirations, perspectives and knowledge of HIV infected and affected children in Botswana.

METHODS

A cross-sectional survey using interviews and focus group discussions among HIV infected children aged 6-18 years versus HIV aged matched HIV uninfected counterparts living in the same households between August 2010 and March 2011. Supplemental clinical data was abstracted from medical records for HIV infected participants.

RESULTS

Nine hundred eighty-four HIV infected and 258 affected children completed the survey. Females predominated in the affected group (63.6 % versus 50.3 %, P < 0.001). School attendance was high in both groups (98.9 % versus 97.3 %, P = 0.057). HIV infected children were mostly in primary school (grades 3-7) while affected children were mostly in upper primary or secondary grades. Sixty percent HIV infected children reported having missed school at least 1 day in the preceding month. Significantly more infected than affected children reported experiencing problems at school (78 % versus 62.3 %, P < 0.001). Twenty-two percent of 15-18 year old HIV infected children were in standard seven and below compared to only 8 % of HIV affected children (p = 0.335). School related problems included poor grades, poor health/school attendance, stigma and inadequate scholastic materials. The wish-list for improving the school environment was similar for both groups and included extra learning support; better meals; protection from bullying/teasing; more scholastic materials, extracurricular activities, love and care; structural improvements; improved teacher attendance and teaching approaches. Significantly more HIV infected children reported feeling hungry all the time (50.6 % versus 41 %, P = 0.007) and more trouble hearing (26.8 % versus 12.5 %, P = 0.028). The mean age for HIV disclosure 10 years was high. Sexual activity (9.2 % versus 3 %, P = 0.001) and emotions of anger (71 % versus 55.3 %, P < 0.001) were significantly higher among HIV affected children. Future perspectives were equally positive (93 % versus 96 %, P = 0.080), were predicated on children's school performance, self-belief/determination and/or ARVs and preference for medical or military careers was common.

CONCLUSIONS

In Botswana almost all school-age HIV infected and affected children are attending school but many face daunting challenges that call for the creation of an empowering, empathetic, supportive, caring, and non-discriminating school environment.

Perceived social support, hopefulness, and emotional regulations as mediators of the relationship between enacted stigma and post-traumatic growth among children affected by parental HIV/AIDS in rural China

Some previous studies have revealed a negative impact of enacted stigma on post-traumatic growth (PTG) of children affected by HIV/AIDS, but little is known about protective psychological factors that can mitigate the effect of enacted stigma on children's PTG. This study aims to examine the mediating effects of perceived social support, hopefulness, and emotional regulation on the relationship between enacted stigma and PTG among HIV-affected children. Cross-sectional data were collected from 790 children affected by parental HIV (382 girls, 408 boys) aged 6-17 years in 2012 in rural central China. Multiple regression was conducted to test the mediation model. The study found that the experience of enacted stigma had a negative effect on PTG among children affected by HIV/AIDS. Emotional regulation together with hopefulness and perceived social support mediated the impact of enacted stigma on PTG. Perceived social support, hopefulness, and emotional regulation offer multiple levels of protection that can mitigate the impact of enacted stigma on PTG. Results suggest that future psychological intervention programs should seek strategies to reduce the stigmatizing experience of these children and promote children's level of PTG, and health professionals should also emphasize the development of these protective psychological factors.

Psychological and behavioral interventions to reduce HIV risk: evidence from a randomized control trial among orphaned and vulnerable adolescents in South Africa

Evidence-based approaches are needed to address the high levels of sexual risk behavior and associated HIV infection among orphaned and vulnerable adolescents. This study recruited adolescents from a support program for HIV-affected families and randomly assigned them by cluster to receive one of the following: (1) a structured group-based behavioral health intervention; (2) interpersonal psychotherapy group sessions; (3) both interventions; or (4) no new interventions. With 95% retention, 1014 adolescents were interviewed three times over a 22-month period. Intent-to-treat analyses, applying multivariate difference-in-difference probit regressions, were performed separately for boys and girls to assess intervention impacts on sexual risk behaviors. Exposure to a single intervention did not impact behaviors. Exposure to both interventions was associated with risk-reduction behaviors, but the outcomes varied by gender: boys reported fewer risky sexual partnerships (β = -.48, p = .05) and girls reported more consistent condom (β = 1.37, p = .02). There was no difference in the likelihood of sexual debut for either gender. Providing both psychological and behavioral interventions resulted in long-term changes in sexual behavior that were not present when either intervention was provided in isolation. Multifaceted approaches for reducing sexual risk behaviors among vulnerable adolescents hold significant promise for mitigating the HIV epidemic among this priority population.

The relationship between parental presence and child sexual violence: Evidence from thirteen countries in sub-Saharan Africa

There are compelling reasons to believe that orphans - many millions due to the AIDS epidemic - are more likely to be sexually victimized during childhood. Few studies have empirically investigated sexual violence disparities, and those that do suffer from methodological limitations and limited geographic scope. We used nationally representative data on female adolescents (15-17 years) from 13 countries in sub-Saharan Africa. We built multilevel logistic models to test for an association between the dependent variables (orphanhood and parental absence) and sexual violence, both within countries and pooled across all countries. Approximately 10% of adolescent girls reported past experiences of sexual violence; a third of those victimized were 14 years or younger at the time of their first forced encounter. Paternal orphaning (OR 1.36, p≤0.01), double orphaning (OR 1.47, p≤0.05), and paternal absence (OR 1.28; p≤0.05) were significantly associated with experiencing sexual violence in pooled analyses. Fewer findings reached significance within individual countries. Our findings suggest that the lack of a father in the home (due to death or absence) places girls at heightened risk for childhood sexual abuse; further research identifying pathways of vulnerability and resilience specific to this population is needed. Our findings also indicate that abuse often starts at an early age; thus promising programs should be adapted for younger age groups and rigorously tested.

A Qualitative Study of Mental Health Problems Among Orphaned Children and Adolescents in Tanzania

Low- and middle-income countries have a high number of orphans, many of whom have unmet mental health needs. Effective mental health interventions are needed; however, it is necessary to understand how mental health symptoms and needs are perceived locally to tailor interventions and refine measurement of intervention effects. We used an existing rapid ethnographic assessment approach to identify mental health problems from the perspective of orphans and guardians to inform a subsequent randomized controlled trial of a Western-developed, evidence-based psychosocial intervention, Trauma-focused Cognitive Behavioral Therapy. Local Kiswahili-speaking interviewers conducted 73 free list interviews and 34 key informant interviews. Results identified both common cross-cultural experiences and symptoms as well as uniquely described symptoms (e.g., lacking peace, being discriminated against) not typically targeted by the intervention or included on standardized measures of intervention effects. We discuss implications for adapting mental health interventions in low- and middle-income countries and assessing effectiveness.

Bereavement, silence and culture within a peer-led HIV/AIDS-prevention strategy for vulnerable children in South Africa

In addressing the psychosocial effects of the HIV and AIDS pandemic among vulnerable children, the issue of bereavement appears inadequately addressed. Amid the global discourse on children orphaned and made vulnerable by HIV and AIDS, this paper explores how cultural contexts and social environments in South Africa shape children's experience of grief. The argument draws on a number of qualitative studies and uses empirical evidence from an evaluation of a peer-led HIV/AIDS-prevention strategy aimed at providing psychosocial support for 10- to 13-year-old South African children living in resource-poor communities. The paper reveals a central paradox regarding how the intervention's objective of talking about death and eliciting memories of deceased loved ones with young children is confounded by cultural practices located in notions of silence and the need to protect children. The paper acknowledges the 'culture of silence' surrounding death in some African contexts, but concludes that peer-led strategies have the potential to naturally circumvent these cultural taboos, simultaneously creating a much-needed space for young children to cry and talk among themselves, even if remaining silent at home in the presence of adults.

Does the Orphan Disadvantage "Spill Over?" An analysis of whether living in an area with a higher concentration of orphans is associated with children's school enrollment in sub-Saharan Africa

BACKGROUND

Despite considerable concern regarding the social consequences of sub-Saharan Africa's high orphan prevalence, no research investigates how living in a community densely populated with orphans is more broadly associated with children's-including nonorphans'-acquisition of human capital.

OBJECTIVE

We provide a new look at the implications of widespread orphanhood in sub-Saharan Africa by examining whether living in an area with a high concentration of orphans is associated with children's likelihood of school enrollment.

METHODS

We use data from the Demographic and Health Survey (DHS) and the Multiple Indicators Cluster Survey (MICS) to estimate multilevel logistic regression models to assess whether living in a setting with a higher concentration of orphans is associated with school enrollment among 383,010 children in 336 provinces in 34 sub-Saharan African countries.

RESULTS

Orphan concentration has a curvilinear association with children's school enrollment in western and eastern Africa: the initially positive association becomes negative at higher levels. In central and southern Africa, orphan concentration has a positive linear association with children's school enrollment.

CONCLUSION

In western and eastern Africa, the negative association between living in a setting more densely populated with orphans and children's school enrollment provides suggestive evidence that the orphan disadvantage "spills over" in the communities most heavily affected. Conversely, in central and southern Africa, the positive association between living in a setting more densely populated with orphans and children's school enrollment highlights the resiliency of these relatively wealthier communities with high levels of orphans. Although longitudinal research is needed to confirm these findings and clarify the underlying mechanisms, this study lays the groundwork for a new body of research aimed at understanding the broader social implications of widespread orphanhood in sub-Saharan Africa.

Child abuse and neglect among orphaned children and youth living in extended families in sub-Saharan Africa: What have we learned from qualitative inquiry?

Researchers and aid organizations have reported that orphans in sub-Saharan Africa (SSA) are particularly vulnerable to abuse and neglect. This article is a review of qualitative studies that address experiences of maltreatment among orphaned children and youth living in extended families in SSA. It aims to inform policy and programming by providing a better understanding of the types of maltreatment encountered and the perceived risk factors. A literature search was carried out using Google, PubMed, Scholars Portal Search and Scopus. Searches of relevant bibliographies and publications of authors were also undertaken. Studies from peer-reviewed journals and the grey literature were reviewed for relevance and quality. Eligible studies had to include orphans living with extended family in SSA as participants, explore their maltreatment experiences and employ a sound qualitative methodology. Findings were coded, extracted, compared and synthesized. Twenty articles, representing 15 studies, were selected. These studies, from diverse SSAn countries, reported similar forms of maltreatment among orphaned children and youth: experiences of intra-household discrimination; material and educational neglect; excessive child labour; exploitation by family members and psychological, sexual and physical abuse. The perceived risk factors were poverty, living with a non-biological caregiver, stigma and alcohol abuse. The findings of the included studies suggest that awareness, prevention and intervention initiatives aimed to curb child abuse and neglect within communities in SSA are needed and should be coupled with efforts to promote education and reduce poverty and stigma.

Can AIDS stigma be reduced to poverty stigma? Exploring Zimbabwean children's representations of poverty and AIDS

OBJECTIVE

We use children's drawings to investigate social stigmatization of AIDS-affected and poverty-affected children by their peers, in the light of suggestions that the stigmatization of AIDS-affected children might derive more from the poverty experienced by these children than from their association with AIDS.

METHODS

A qualitative study, in rural Zimbabwe, used draw-and-write techniques to elicit children's (10-12 years) representations of AIDS-affected children (n= 30) and poverty-affected children (n= 33) in 2009 and 2010 respectively.

RESULTS

Representations of children affected by AIDS and by poverty differed significantly. The main problems facing AIDS-affected children were said to be the psychosocial humiliations of AIDS stigma and children's distress about sick relatives. Contrastingly, poverty-affected children were depicted as suffering from physical and material neglect and deprivation. Children affected by AIDS were described as caregivers of parents whom illness prevented from working. This translated into admiration and respect for children's active contribution to household survival. Poverty-affected children were often portrayed as more passive victims of their guardians' inability or unwillingness to work or to prioritize their children's needs, with these children having fewer opportunities to exercise agency in response to their plight.

CONCLUSIONS

The nature of children's stigmatization of their AIDS-affected peers may often be quite distinct from poverty stigma, in relation to the nature of suffering (primarily psychosocial and material respectively), the opportunities for agency offered by each affliction, and the opportunities each condition offers for affected children to earn the respect of their peers and community. We conclude that the particular nature of AIDS stigma offers greater opportunities for stigma reduction than poverty stigma.

Behavioral and emotional problems among children aged 6-14 years on highly active antiretroviral therapy in Addis Ababa: a cross-sectional study

Children infected with human immunodeficiency virus (HIV) are at particular risk for psychological disturbance. Little is known about the mental health status of children on highly active antiretroviral therapy (HAART). A hospital-based cross-sectional study of 318 children aged 6-14 on HAART in Addis Ababa was conducted. Behavioral and emotional problem was assessed using the child behavior check list (CBCL/6-18). Logistic regression analysis was done to select the best subset of predictor variables and determine their association with behavioral and emotional problems. Of the 318 caregivers of children aged 6-14 on HAART, 39.3% of the children had behavioral and emotional problems. Low family monthly income (AOR, 3.44, 95% CI, 1.89-6.25), older age (AOR, 2.27, 95% CI, 1.34-3.83), and parental loss (AOR, 1.89, 95% CI, 1.10-3.25) were found to be determinants of behavioral and emotional problems in the multivariate logistic regression. There is high prevalence of behavioral and emotional problems in children on HAART in Addis Ababa. More support is needed to children from families of low income and those who lost their parents. Further research should be carried out to enhance better understanding and appropriate response to behavioral and emotional problems.

"The Luggage that isn't Theirs is Too Heavy…":Understandings of Orphan Disadvantage in Lesotho

In Southern Africa, high adult HIV prevalence has fueled concern about the welfare of children losing parents to the epidemic. A growing body of evidence indicates that parental, particularly maternal, death is negatively associated with child outcomes. However, a better understanding of the mechanisms is needed. In addition, the way orphan disadvantage and the mechanisms giving rise to it are understood on the ground is essential for the successful translation of research into policies and programs. This study employs data from 89 in-depth interviews with caregivers and key informants in Lesotho, a setting where approximately one-quarter of adults is infected with HIV, to elaborate understandings of orphan disadvantage. Our analysis focuses on two questions: (i) Do local actors perceive orphans to be disadvantaged compared to non-orphans, and if so, in what ways; and (ii) How do they explain orphans' differential disadvantage?Analyses suggest that orphans were widely perceived to be disadvantaged; respondents described this disadvantage in material as well as affective domains. Thematic analyses reveal five broad categories of explanation: poverty, love and kin connection, caregiver character, perceptions of orphans, and community norms related to orphan care. These results underscore the need for research and policy to address (i) multiple types of disadvantage, including deficits in kindness and attention; and (ii) the social embeddedness of disadvantage, recognizing that poverty, kinship, and community interact with individual attributes to shape caregiving relationships and child experiences. The findings suggest limited success for programs and policies that do not address the emotional needs of children, or that focus on child or caregiver support to the exclusion of community outreach.

Using the World Health Organization's 4S-Framework to Strengthen National Strategies, Policies and Services to Address Mental Health Problems in Adolescents in Resource-Constrained Settings

BACKGROUND

Most adolescents live in resource-constrained countries and their mental health has been less well recognised than other aspects of their health. The World Health Organization's 4-S Framework provides a structure for national initiatives to improve adolescent health through: gathering and using strategic information; developing evidence-informed policies; scaling up provision and use of health services; and strengthening linkages with other government sectors. The aim of this paper is to discuss how the findings of a recent systematic review of mental health problems in adolescents in resource-constrained settings might be applied using the 4-S Framework.

METHOD

Analysis of the implications of the findings of a systematic search of the English-language literature for national strategies, policies, services and cross-sectoral linkages to improve the mental health of adolescents in resource-constrained settings.

RESULTS

Data are available for only 33/112 [29%] resource-constrained countries, but in all where data are available, non-psychotic mental health problems in adolescents are identifiable, prevalent and associated with reduced quality of life, impaired participation and compromised development. In the absence of evidence about effective interventions in these settings expert opinion is that a broad public policy response which addresses direct strategies for prevention, early intervention and treatment; health service and health workforce requirements; social inclusion of marginalised groups of adolescents; and specific education is required. Specific endorsed strategies include public education, parent education, training for teachers and primary healthcare workers, psycho-educational curricula, identification through periodic screening of the most vulnerable and referral for care, and the availability of counsellors or other identified trained staff members in schools from whom adolescents can seek assistance for personal, peer and family relationship problems.

CONCLUSION

The predominant endorsed action is not that dedicated mental health services for adolescents are required, but that mental health care should be integrated using cross-sectoral strategies into the communities in which adolescents live, the institutions they attend and the organisations in which they participate.

Perceived discrimination and stigma toward children affected by HIV/AIDS and their HIV-positive caregivers in central Haiti

In many settings worldwide, HIV-positive individuals have experienced a significant level of stigma and discrimination. This discrimination may also impact other family members affected by the disease, including children. The aim of our study was to identify factors associated with stigma and/or discrimination among HIV-affected youth and their HIV-positive caregivers in central Haiti. Recruitment of HIV-positive patients with children aged 10-17 years was conducted in 2006-2007. Data on HIV-related stigma and/or discrimination were based on interviews with 451 youth and 292 caregivers. Thirty-two percent of caregivers reported that children were discriminated against because of HIV/AIDS. Commune of residence was associated with discrimination against children affected by HIV/AIDS and HIV-related stigma among HIV-positive caregivers, suggesting variability across communities. Multivariable regression models showed that lacking social support, being an orphan, and caregiver HIV-related stigma were associated with discrimination in HIV-affected children. Caregiver HIV-related stigma demonstrated a strong association with depressive symptoms. The results could inform strategies for potential interventions to reduce HIV-related stigma and discrimination. These may include increasing social and caregiver support of children affected by HIV, enhancing support of caregivers to reduce burden of depressive symptoms, and promoting reduction of HIV-related stigma and discrimination at the community-level.

Multiple transitions and HIV risk among orphaned Kenyan schoolgirls

Why are orphaned girls at particular risk of acquiring HIV infection? Using a transition-to-adulthood framework, this study employs qualitative data from Nyanza Province, Kenya, to explore pathways to HIV risk among orphaned and nonorphaned high-school girls. It shows how simultaneous processes such as leaving their parental home, negotiating financial access, and relationship transitions interact to produce disproportionate risk for orphaned girls. The role of financial provision and parental love in modifying girls' trajectories to risk are also explored. A testable theoretical model is proposed based on the qualitative findings, and policy implications are suggested.

More than the loss of a parent: potentially traumatic events among orphaned and abandoned children

This study examines rates of potentially traumatic events and associated anxiety and emotional/behavioral difficulties among 1,258 orphaned and abandoned children in 5 low- and middle-income countries. The study quantifies the types of events the children experienced and demonstrates that anxiety and emotional/behavioral difficulties increase with additional exposure. As policies for orphaned and abandoned children are being implemented, this study helps policy makers and care providers recognize that (a) children and caregivers are willing to report experiences of potentially traumatic events, (b) those who report such events are at higher risk for experiencing additional events, (c) resulting symptomatology indicates a need for appropriate mental health services, and (d) boys are as vulnerable as girls, indicating an equal need for protection.

Power and empowerment: fostering effective collaboration in meeting the needs of orphans and vulnerable children

In sub-Saharan Africa, HIV/AIDS has resulted in a rapidly growing population of orphans and vulnerable children (OVC). These OVC have strained the traditional safety net provided by extended families to its breaking point. Increasingly, community-based initiatives are emerging to fill the gap. However, relatively little is known about these efforts and their effectiveness. This article looks at one such initiative in rural Tanzania, and explores the relationship between local communities that seek to empower themselves to address the needs of their OVC and external organisations that have the resources and power to help them. This case study describes the successful effort of a community to build a Centre housing its orphans, and the subsequent closure of that Centre despite its evident success, because of a conflict between internal and external interests. This case study is used as the basis of a broader discussion on how those with power, and communities seeking empowerment, are complexly intertwined.

Life in institutional care: the voices of children in a residential facility in Botswana

As a result of the HIV/AIDS pandemic, there are now more than 12 million orphans in sub-Saharan Africa. The majority of these children have been absorbed into their extended families. A minority of AIDS orphans and other vulnerable children are living in residential care facilities. Although concerns have been raised regarding the care received in such facilities, very little is known about children's perspectives on their own experiences residing in these institutions. As part of an ongoing initiative to better understand the impact of HIV/AIDS in Southern Africa and what can be done to address needs, one-on-one interviews were conducted with the children and youth residents, and graduates of a residential care facility in Botswana. The children report on the importance of having uninterrupted access to food, shelter and schooling and a sense of belonging. However, they also reveal a profound ambivalence towards their paid caregivers, and the other children residents. They describe being separated from siblings, missing their families and feeling disconnected from the community at large. Their narratives offer insight into ways in which we can better meet their complex needs. Policy implications are discussed.

Care arrangements of AIDS orphans and their relationship with children's psychosocial well-being in rural China

There is an estimated 100,000 children orphaned by AIDS in China, but data on the care arrangement of these orphans are limited. In this study, we examine the relationship between AIDS orphans' care arrangement and their psychosocial well-being among a sample of AIDS orphans in rural China. A total of 296 children who lost both parents to AIDS participated in the study, including 176 in orphanages, 90 in kinship care and 30 in community-based group homes. All participants completed a cross-sectional survey assessing their traumatic symptoms, physical health and schooling. Data reveal that the AIDS orphans in group homes reported the best outcomes in three domains of psychosocial well-being, followed by those in the orphanages and then the kinship care. The differences in psychosocial well-being among the three groups of children persist after controlling for key demographic characteristics. The findings suggest that the appropriate care arrangement for AIDS orphans should be evaluated within the specific social and cultural context where the orphans live. In resource-poor regions or areas stricken hardest by the AIDS epidemic, kinship care may not sufficiently serve the needs of AIDS orphans. Community-based care models, with appropriate government and community support preserving the family style and low child-to-caregiver ratio may constitute an effective and sustainable care model for the best interest of the AIDS orphans in developing countries.

Understanding and responding to HIV/AIDS stigma and disclosure: an international challenge for mental health nurses

Stigma and discrimination are challenges in the care and treatment of persons with HIV infection worldwide. Fear of negative social consequences often causes persons with HIV/AIDS to keep their infection secret, resulting in negative psychological and physical outcomes and continued spread of the disease. Mental health nurses have a unique opportunity to influence the trajectory of HIV/AIDS though counseling and interventions that address HIV/AIDS stigma with clients, communities, and society. This article provides an in-depth examination of HIV/AIDS stigma and its relationship to nondisclosure as well as strategies to deal with these issues at individual and group levels.

Life improvement, life satisfaction, and care arrangement among AIDS orphans in rural Henan, China

The Chinese government's response to the increasing number of children orphaned in the HIV epidemic included setting up AIDS orphanages and supporting community-based group homes for double orphans (children who lost both parents to HIV). The impact of these strategies, compared to traditional kinship care, on children's outcomes has not been studied in China. The purpose of this study was to compare perceived life improvement and life satisfaction among double orphans in three main care arrangements (group home, AIDS orphanage, kinship care) in two rural Chinese counties. Participants included 176 children from four orphanages, 30 from eight group homes, and 90 from kinship households. Results indicated that children living in government-supported group homes were more likely to report greater life improvement and positive attitudes toward their current lives than children in orphanages and kinship care. Results suggested that perceived life improvements may have resulted from access to basic needs in extremely poor communities.

Caregivers' and non-caregivers' knowledge regarding HIV/AIDS and attitude towards HIV/AIDS and orphans in Nigeria

Nigeria has an estimated 930,000 AIDS orphans, which has a marked impact on family and community. This study was performed to characterise caregivers' knowledge regarding HIV/AIDS and their attitude towards HIV/AIDS, orphans in general and AIDS orphans in particular. Caregivers and non-caregivers aged 25-70 years in Nigeria were interviewed from January and March 2003, and logistic regression analysis was used to determine associations between caregivers' knowledge regarding HIV/AIDS and attitudes towards HIV/AIDS, orphans and AIDS orphans, and demographic characteristics and background status regarding HIV/AIDS and orphans. A total of 824 interviewees participated in the survey (82.4% response rate), of whom 290 (35.2%) were current caregivers of orphans. The mean number of orphans per current caregiver was 1.8 (standard deviation 1.4). Factors related to higher knowledge level regarding HIV/AIDS were female gender [odds ratio (OR) = 3.49; 95% confidence interval (CI): 2.33, 5.22] and belief that AIDS is a common disease (OR = 3.39; 95% CI: 2.19, 5.26). Factors associated with positive attitudes towards HIV/AIDS, orphans in general and AIDS orphans in particular were age 35-44 years (OR = 1.73; 95% CI: 1.11, 2.69), Koranic schooling (OR = 8.69; 95% CI: 2.42, 31.19), polygamy (OR = 1.76; 95% CI: 1.17, 2.62), belief that there are increasing numbers of orphans in the community (OR = 2.59; 95% CI: 1.32, 5.08) and having relatives or friends with HIV/AIDS (OR = 2.88; 95% CI: 1.61, 1.58). There was a slight correlation (r = 0.17, P < 0.001) between caregivers' knowledge regarding HIV/AIDS and positive attitudes towards HIV/AIDS, orphans and AIDS orphans. Demographic characteristics and personal experience should be taken into consideration to improve attitudes and behaviour related to HIV/AIDS and caring for orphans and AIDS orphans.

A developmental psychopathology framework of the psychosocial needs of children orphaned by HIV

In addition to the obstacles to a successful resolution of grief normally faced by children whose parents have died, children orphaned by AIDS may face additional psychological and social challenges. However, limited attention has been paid to psychosocial and developmental needs of children orphaned by HIV/AIDS, particularly in resource-poor countries or regions. In this article the authors review the global literature on child bereavement and AIDS orphan care experiences in developing countries and present a developmental psychopathology model of the psychosocial issues facing AIDS orphans. The authors identify gaps in the literature and provide suggestions for future research on AIDS orphans in resource-poor countries and regions. They emphasize that future studies need to assess the status of behaviors and mental health of children orphaned by AIDS within a developmental framework, identify those individual and social factors associated with grief, and examine the long-term impact of quality of care, developmental maturation, and attachment with caregivers on the psychosocial well-being of AIDS orphans.

The social context of children's nutritional status in rural South Africa

AIM

To investigate the relationship between children's nutritional status and a series of measures capturing both the current status and the lifetime history of their connection with adult caregivers in the Agincourt sub-district of rural South Africa.

METHODS

Using data on a sample of 202 children from a recent ethnographic study of children's social connections and well-being, the authors (1) compare height for age and weight for age to an accepted international standard and (2) conduct bivariate analyses of the relationships between selected measures of social connection and extreme deviations below expected weight and expected height.

RESULTS

Fitted curves for weight for age and height for age fall between the 5th and 50th percentiles of CDC growth curves. Compromised nutrition, defined as being more than two standard deviations below expected height or weight, is associated with the death or non-co-residence of the mother, and with the absence of financial support from the father. The co-residence of maternal female kin as substitutes for the mother do not fully compensate for her absence.

CONCLUSIONS

The findings highlight the importance of parental living arrangements, parental financial support, birth order and the composition of sibling sets, and lifetime residential patterns in facilitating access to nutrition.

Psychological distress amongst AIDS-orphaned children in urban South Africa

BACKGROUND

South Africa is predicted to have 2.3 million children orphaned by Acquired Immune Deficiency Syndrome (AIDS) by 2020 (Actuarial Society of South Africa, 2005). There is little knowledge about impacts of AIDS-related bereavement on children, to aid planning of services. This study aimed to investigate psychological consequences of AIDS orphanhood in urban township areas of Cape Town, South Africa, compared to control groups of children and adolescents orphaned by other causes, and non-orphans.

METHOD

One thousand and twenty-five children and adolescents (aged 10-19) were interviewed using socio-demographic questionnaires and standardised scales for assessing depression, anxiety, post-traumatic stress, peer problems, delinquency and conduct problems.

RESULTS

Controlling for socio-demographic factors such as age, gender, formal/informal dwelling and age at orphanhood, children orphaned by AIDS were more likely to report symptoms of depression, peer relationship problems, post-traumatic stress, delinquency and conduct problems than both children orphaned by other causes and non-orphaned children. Anxiety showed no differences. AIDS-orphaned children were more likely to report suicidal ideation. Compared to Western norms, AIDS-orphaned children showed higher levels of internalising problems and delinquency, but lower levels of conduct problems.

CONCLUSIONS

Children orphaned by AIDS may be a particularly vulnerable group in terms of emotional and, to a lesser extent, behavioural problems. Intervention programs are necessary to ameliorate the psychological sequelae of losing a parent to AIDS.

Extended family caring for children orphaned by AIDS: balancing essential work and caregiving in a high HIV prevalence nations

While over 90 per cent of the 15 million children who have been orphaned by HIV/AIDS are cared for by family members, there is little information about whether adults can meet orphans' essential caregiving needs while working to economically survive. Using a survey we conducted in Botswana of 1033 working adults, we analyse the experience of adults who are caring for orphans. Over one-third of working adults were caring for orphans and many with few financial resources: 82% were living on household incomes below US$10 purchasing power parity adjusted per person per day. Because of their caregiving responsibilities, they were less able to supplement income with overtime, weekend, evening, or night work. At the same time caregiving responsibilities meant orphan caregivers spent fewer hours caring for their own children and other family members. Nearly half of orphan caregivers had difficulties meeting their children's needs, and nearly 75% weren't able to meet with children's teachers. Pay loss at work compounded the problems: One-quarter of orphan caregivers reported having to take unpaid leave to meet sick childcare needs and nearly half reported being absent from work for children's routine health care. This paper makes clear that if families are to provide adequate care for orphans while economically surviving there needs to be increases in social supports and improvements in working conditions.

Africa's orphan crisis: two community-based models of care

The AIDS epidemic has created a crisis for children, severely threatening the health and development of children whose parents are ill, have died and whose communities have lost a large percentage of their adults. Even when extended family can serve as guardians, their need to work in the context of widespread poverty decreases the amount of time they are able to spend with children. Other children live in child-headed households or with seniors unable to provide adequate care. Relative to the size of the need there are few interventions that provide support to orphans in sub-Saharan Africa. We report on two different models of community-based care that have emerged to fill this caregiving gap, and highlight the relative advantages of each. These programmes, one centralized and the other decentralized, are an effective means of caring for orphans and could be scaled up in other communities to meet the magnitude of the crisis.

Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers

Increasing numbers of orphaned and vulnerable children resulting from AIDS deaths requires practical placement strategies. While the extended family is regarded as both the most likely and the preferred option by most key planners and organizations, warnings of the limitations of this alternative have been increasing. This study assessed the views of 1400 adults (both current and prospective caregivers) regarding the placement of children. Most current caregivers believed that either their partner (30%), a grandparent (25%) or another family member (33%) would look after the child/children if they were no longer able to. However, 12% of parents could not identify a carer or predicted only a bleak future for their children. There was strong willingness amongst adults of various relational proximity to take in children if required to -71% of both fathers and grandparents, 63% of siblings and 23% of best friends said they would take in children. Nonetheless this research suggests that the willingness may not necessarily be translated into reality. Most prospective caregivers identified significant additional stressors (most importantly financial) and expressed a strong need for assistance if they were to take in additional children. The HIV status of the child is also likely to sway placement decisions for some people. Nonetheless opportunities to keep children in families are clearly high, but people will need considerable help to realize this potential. For some children alternatives other than the extended family will be required.

Living environment and schooling of children with HIV-infected parents in southwest China

A cross-sectional household survey was conducted in Longchuan County, China, to study the lives of children with HIV-infected parents. Registered HIV-infected drug users and their households were approached and information about the living environment of children < or =15 years of age was collected. Of the 266 households interviewed, there were 213 children < or =15 years old. Forty percent of the children had lost at least one parent. Most of the children resided in a household with low economic status and a high dependency ratio. One-half of the children experienced discordant family relations, family anxiety and shame. Compared to orphans, non-orphans and their families were less likely to receive social support from the community. Orphans and older children were less likely to attend school and more likely to be truant if enrolled in school. Findings in the current study suggest that many children whose parents are infected with HIV or have died from HIV are living in stressful environments with minimal support from the community. Efforts should be taken to provide support and supervision to these children.

Sexual risk behavior among South African adolescents: is orphan status a factor?

There is concern that orphans may be at particular risk of HIV infection due to earlier age of sexual onset and higher likelihood of sexual exploitation or abuse; however, there is limited empirical evidence examining this phenomenon. Utilizing data from 1,694 Black South African youth aged 14-18, of whom 31% are classified as orphaned, this analysis explores the relationship between orphan status and sexual risk. The analysis found both male and female orphans significantly more likely to have engaged in sex as compared to non-orphans (49% vs. 39%). After adjusting for socio-demographic variables, orphans were nearly one and half times more likely than non-orphans to have had sex. Among sexually active youth, orphans reported younger age of sexual intercourse with 23% of orphans having had sex by age 13 or younger compared to 15% of non-orphans. Programmatic implications of these findings for the care and protection of orphans are discussed.

Assitance needed for the integration of orphaned and vulnerable children--views of South African family and community members

Guardianship within families is often regarded as the most viable and preferred option for orphaned and vulnerable children (OVC). However, this will place a considerably increased burden on the new caregivers of these children. This study examines whether assistance to prospective families would incline them towards incorporating children and, if so, what would act as 'threshold' incentives for them. Adults (N=1400) in diverse locations and of various 'relational proximity' to children were interviewed in three high HIV/AIDS prevalence provinces in South Africa. Close relatives were more inclined to take in children and would generally require lower levels of assistance than more distanced adults. Nonetheless, for most poor families, no matter their relation to the child, help is critical. More distanced families, friends and strangers also showed a strong willingness to incorporate children--provided they receive sufficient help. For all categories, the greater the assistance the more likely they would be to take in children. While direct financial assistance was important, assistance with education-related costs and having a trained and caring person come in 'now and then' to help were also significant factors. The age and HIV status of the child were viewed as important intervening factors in deciding whether or not to take in an additional children by some people.

Psychosocial support and marginalization of youth-headed households in Rwanda

This research aims to characterize the psychosocial aspects of well-being among youth-headed households (YHH) in Gikongoro, Rwanda, through examination of social support and marginalization. Data is presented on perceived availability of support from relatives, an unidentified adult, peers, and other community members and an index of social marginalization. A total of 692 interviews were completed with YHH age 13-24 who are beneficiaries of a basic needs program. Sixteen percent of youth reported there was no one they felt they could go to with a problem. In times of need, only 24% felt relatives would help them, while 57% felt neighbors would offer assistance. Most youth reported significant caring relationships: 73% reported access to trusted adult who offers them advice and guidance, and most indicated close peer relationships. However, many youth also perceived a lack of community support, with 86% feeling rejected by the community and 57% feeling the community would rather hurt them than help them. Social support is a low-cost critical resource for the care of vulnerable youth and an understanding of existing social support networks would enhance the design and implementation of psychosocial and community-based care initiatives.

The psychological well-being of children orphaned by AIDS in Cape Town, South Africa

BACKGROUND

An estimated 2 million children are parentally bereaved by AIDS in South Africa. Little is known about mental health outcomes for this group.

METHODS

This study aimed to investigate mental health outcomes for urban children living in deprived settlements in Cape Town. 30 orphaned children and 30 matched controls were compared using standardised questionnaires (SDQ) on emotional and behavioural problems, peer and attention difficulties, and prosocial behaviour. The orphan group completed a modified version of a standardised questionnaire (IES-8), measuring Post-Traumatic Stress symptoms. Group differences were tested using t-tests and Pearson's chi-square.

RESULTS

Both groups scored highly for peer problems, emotional problems and total scores. However, orphans were more likely to view themselves as having no good friends (p = .002), to have marked concentration difficulties (p = .03), and to report frequent somatic symptoms (p = .05), but were less likely to display anger through loss of temper (p = .03). Orphans were more likely to have constant nightmares (p = .01), and 73% scored above the cut-off for Post-Traumatic Stress Disorder.

CONCLUSION

Findings suggest important areas for larger-scale research for parentally-bereaved children.

Barriers and incentives to orphan care in a time of AIDS and economic crisis: a cross-sectional survey of caregivers in rural Zimbabwe

Background

Africa is in an orphan-care crisis. In Zimbabwe, where one-fourth of adults are HIV-positive and one-fifth of children are orphans, AIDS and economic decline are straining society's ability to care for orphans within their extended families. Lack of stable care is putting thousands of children at heightened risk of malnourishment, emotional underdevelopment, illiteracy, poverty, sexual exploitation, and HIV infection, endangering the future health of the society they are expected to sustain.

Methods

To explore barriers and possible incentives to orphan care, a quantitative cross-sectional survey in rural eastern Zimbabwe asked 371 adults caring for children, including 212 caring for double orphans, about their well-being, needs, resources, and perceptions and experiences of orphan care.

Results

Survey responses indicate that: 1) foster caregivers are disproportionately female, older, poor, and without a spouse; 2) 98% of non-foster caregivers are willing to foster orphans, many from outside their kinship network; 3) poverty is the primary barrier to fostering; 4) financial, physical, and emotional stress levels are high among current and potential fosterers; 5) financial need may be greatest in single-orphan AIDS-impoverished households; and 6) struggling families lack external support.

Conclusion

Incentives for sustainable orphan care should focus on financial assistance, starting with free schooling, and development of community mechanisms to identify and support children in need, to evaluate and strengthen families' capacity to provide orphan care, and to initiate and support placement outside the family when necessary.

Challenges of a pandemic: HIV/AIDS-related problems affecting Kenyan widows

The paper reports the findings of a qualitative study using focus group discussions and in-depth interviews about the challenges faced by widows as they confront the direct and indirect impacts of HIV/AIDS in Nyanza, Kenya. Two focus groups were conducted with widows from two community-based organizations. This was followed by in-depth interviews with four members and two leaders from each of the community-based organizations. The contents were analysed using grounded theory. The findings reveal several challenges encountered by widows in their struggles with the direct and indirect impacts of HIV/AIDS. Widows who know or do not know their HIV status are conscious about the possibility of contracting or transmitting the virus. Wife inheritance (a Luo custom), emerged as an outstanding issue for the widows in the context of HIV/AIDS transmission. The widows employ various strategies to resist being inherited. Widows in the current epidemic navigate issues of sexuality in various ways, such as insisting their partners use condoms or permanently abstaining from sexual intercourse.

Psychological distress among AIDS orphans in rural Uganda

More than 11 million children under 15 years in sub-Saharan Africa have lost at least one parent to AIDS. In Uganda, about 2 million children are orphans, with one or both parents dead. The objective of this study was to investigate the psychosocial consequences of AIDS orphanhood in a rural district in Uganda and to identify potential areas for future interventions. The study was conducted in a randomly selected sub-county in Bushenyi District in Uganda. The study population consisted of 123 children aged 11-15 years whose parents (one or both) were reported to have died from AIDS and 110 children of similar age and gender living in intact households in the same neighbourhood. Symptoms of psychological distress were assessed using the Beck Youth Inventories of Emotional and Social Impairment (BYI). The standardized interview also included questions concerning current and past living conditions. A multivariate analysis of factors with possible relevance for BYI outcome showed that orphan status was the only significant outcome predictor. Orphans had greater risk (vs. non-orphans) for higher levels of anxiety (odds ratios (OR)=6.4), depression (OR=6.6), and anger (OR=5.1). Furthermore, orphans had significantly higher scores than non-orphans on individual items in the Beck Youth Depression Inventory that are regarded as particularly "sensitive" to the possible presence of a depressive disorder, i.e. vegetative symptoms, feelings of hopelessness, and suicidal ideation. High levels of psychological distress found in AIDS orphans suggest that material support alone is not sufficient for these children.

The social situation of motherless children in rural and urban areas of Guinea-Bissau

With the increasing prevalence of HIV infection and the high maternal mortality, orphans are a rapidly growing problem in Africa. However, few studies describe the social conditions of these children. Our study focuses on motherless children in urban and rural areas of Guinea-Bissau. A rural and an urban cohort of children (128 and 192, respectively) that had been followed by demographic surveillance since 1990 were identified and the relatives of these children interviewed. A control cohort of 808 individuals was also identified. Although orphan children remained disadvantaged, there were few differences between surviving motherless and control children in nutritional status, use of health care services, school attendance, quality of housing, and clothing. Motherless children moved more frequently and were more likely to live in small families, often with an older grandmother. The traditional extended family system appears to be capable of handling motherless children in a non-discriminatory fashion. However, the AIDS epidemic will continue to stress the extended family system and social services to the limit.

Fosterage patterns in the age of AIDS: continuity and change

An estimated 4 million children, or about 10% of the entire South African population, will be orphaned by the year 2015. There is growing consensus that the extended family system is no longer capable of providing for orphans given severe economic constraints. There is, therefore, an urgency to develop appropriate interventions to support families and take care of these children. This article examines some of the existing literature on child fosterage and uses it to highlight understudied aspects of the current situation of children orphaned through AIDS in South Africa. Of particular concern are the points of continuity and change in fosterage patterns before and after the onset of the epidemic in South Africa. I suggest that an understanding of the short- and long-term consequences for children orphaned by AIDS in South Africa calls for historical contextualisation given that child fostering, both voluntarily and involuntarily, has been a feature of black family life since well before the onset of HIV/AIDS. In addition, I demonstrate the value of examining kinship, family, and networks in order to fully understand the circumstances of fostering these children. The paper concludes with a call for more research on children orphaned by AIDS in South Africa that will provide not only more data, but also enrich theoretical approaches to studying patterns of child fosterage in Africa and elsewhere.