Grandmother Co-Residence and School Enrollment in sub-Saharan Africa

Parenting in place: Young children's living arrangement and migrants' sleep health in South Africa

Migration research tends to treat childrearing as a secondary role for migrants. By prioritising the economic objectives of migration, most models present migrants as either delaying childbearing or, if they have young children, not living with them. However, migration has become increasingly feminised, the types of mobility more varied, while the returns to migration remain uncertain at best. At the same time, norms around childrearing are shifting, and the capacity of kin to take care of children may be weakening. In such contexts, migrants may not want to or be able to be separated from their children. Confronting such difficult decisions and their consequences may be reflected in poor sleep health for the migrant parent. We draw on data from the Migration and Health Follow-Up Study (MHFUS) in South Africa to examine the following questions: (i) To what extent is children's coresidence associated with sleep health for migrant parents? (ii) Do effects vary by sex of migrant? and (iii) Do effects vary by location of migrant? Results from propensity score matching confirm that migrants who coreside with all their young children are more likely to experience healthy sleep compared to those who have nonresident or no young children. However, stratified analysis shows that these effects are only significant for women and those not living in Gauteng province. The value of these findings is underscored by the need for research on the well-being of migrant parents who are negotiating multiple agendas in economically precarious and physically insecure destinations.

Using the intergenerational solidarity framework to understand the grandparent-grandchild relationship: a scoping review

Intergenerational interactions and exchange are major components of grandparenting, and the present study sought to examine how the intergenerational solidarity framework has been used to investigate grandparenting practices across the lifespan and in different cultures. This framework is widely used across cultures and provides a basis to discuss the future of grandparenting research, considering cultural intermingling and changes in society. Following PRISMA-ScR guidelines, we searched three databases (PsycInfo, PubMed, and Web of Science). Finally, 42 empirical studies that met the inclusion criteria were included in this scoping review. They were published between 1991 and 2020 and assessed intergenerational solidarity between grandparents and their grandchildren. Our findings show that research on grandparenting based on the intergenerational solidarity framework has increased in the last 30 years, and that this model provides a comprehensive approach to studying grandparenting across the lifespan in different cultures. The present study identified cross-cultural differences in the prevalence of the types of intergenerational solidarity. Affectual solidarity was shown to be the most studied dimension of intergenerational solidarity in North America, Europe and Israel, while normative solidarity was the most represented in Asian studies. The only Australian study investigated affectual and functional solidarity. This model is thus suitable for studying grandparenting, but further studies are needed to investigate changes in intergenerational solidarity between grandparents and their grandchildren at different stages of development and account for cultural specificities.

Grandchild Caregiving and Cognitive Health Among Grandparents in Rural South Africa

Objectives: We investigate how caregiving for grandchildren is associated with cognitive function among rural South Africans, and whether the association differs by gender. We further investigate whether measures of physical activity or social engagement mediate this association. Methods: Data were from interviews with 3668 Black, South African grandparents in the "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" study, conducted between 2014 and 2015. Results: We find that caregiving grandparents have better cognitive function than non-caregiving grandparents, and this association does not differ by grandparent gender. Although grandchild caregiving is associated with physical activity and social engagement measures, and some of these measures are associated with cognitive function, we do not find conclusive evidence of mediation. Discussion: Providing care for grandchildren may stimulate cognitive function for both grandmothers and grandfathers. Neither physical activity nor social engagement explains the association between caregiving and cognitive function.

Evaluating potential mediators for the impact of a family-based economic intervention (Suubi+Adherence) on the mental health of adolescents living with HIV in Uganda

INTRODUCTION

Many adolescents living with HIV in sub-Saharan Africa (SSA) experience poverty and have access to limited resources, which can impact HIV and mental health outcomes. Few studies have analyzed the impact of economic empowerment interventions on the psychosocial wellbeing of adolescents living with HIV in low resource communities, and this study aims to examine the mediating mechanism(s) that may explain the relationship between a family economic empowerment intervention (Suubi + Adherence) and mental health outcomes for adolescents (ages 10-16 at enrollment) living with HIV in Uganda.

METHOD

We utilized data from Suubi + Adherence, a large-scale six-year (2012-2018) longitudinal randomized controlled trial (N = 702). Generalized structural equation models (GSEMs) were conducted to examine 6 potential mediators (HIV viral suppression, food security, family assets, and employment, HIV stigma, HIV status disclosure comfort level, and family cohesion) to determine those that may have driven the effects of the Suubi + Adherence intervention on adolescents' mental health.

RESULTS

Family assets and employment were the only statistically significant mediators during follow-up (β from -0.03 to -0.06), indicating that the intervention improved family assets and employment which, in turn, was associated with improved mental health. The proportion of the total effect mediated by family assets and employment was from 42.26% to 71.94%.

CONCLUSIONS

Given that mental health services provision is inadequate in SSA, effective interventions incorporating components related to family assets, employment, and financial stability are crucial to supporting the mental health needs of adolescents living with HIV in under-resourced countries like Uganda. Future research should work to develop the sustainability of such interventions to improve long-term mental health outcomes among this at-risk group.

The contribution of grandmother involvement to child growth and development: an observational study in rural Pakistan

INTRODUCTION

Early childhood interventions primarily focus on the mother-child relationship, but grandmothers are often critical in childcare in low-resource settings. Prior research is mixed on how grandmother involvement influences child outcomes and there is a paucity of research on grandmother caregiving in low-income and middle-income countries. We examined the role of grandmother involvement on child growth and development in the first 2 years of life cross sectionally and longitudinally in rural Pakistan.

METHODS

We used data from the Bachpan Cohort, a longitudinal birth cohort in rural Pakistan. Maternally reported grandmother involvement in daily instrumental and non-instrumental caregiving was collected at 3 and 12 months. A summed score was created and categorised into non-involved, low and high. Outcomes included 12-month and 24-month child growth, 12-month Bayley Scales of Infant and Toddler Development and 24-month Ages and Stages Questionnaire-Socioemotional. We used multivariable generalised linear models to estimate mean differences (MD) at 12 months (n=727) and 24 months (n=712). Inverse probability weighting was used to account for missingness and sampling.

RESULTS

In our sample, 68% of children lived with a grandmother, and most grandmothers were involved in caregiving. Greater 3-month grandmother involvement was positively associated with 12-month weight z-scores; however, greater involvement was associated with lower 24-month weight z-scores. High 12-month grandmother involvement was associated with improved 12-month cognitive (MD=0.38, 95% CI -0.01 to 0.76), fine motor skills (MD=0.45, 95% CI 0.08 to 0.83) and 24-month socioemotional development (MD=-17.83, 95% CI -31.47 to -4.19). No meaningful associations were found for length z-scores or language development.

CONCLUSION

In rural Pakistan, grandmothers provide caregiving that influences early child development. Our findings highlight the complex relationship between grandmother involvement and child weight, and suggest that grandmothers may positively promote early child cognitive, fine motor and socioemotional development. Understanding how grandmother involvement affects child outcomes in early life is necessary to inform caregiving interventions.

Access and utilization of financial services among poor HIV-impacted children and families in Uganda

With high prevalence of both poverty and HIV, Sub-Saharan Africa (SSA) has one of the highest numbers of unbanked individuals and families. Although the use of savings products to promote financial inclusion among poor individuals and families has increasingly become more important to policy makers in SSA, limited research exists about the mechanisms and relative importance of institutional and individual-level factors associated with access and utilization of financial services. Using survey data and administrative bank records from a randomized controlled trial in southwestern Uganda, we find that given an opportunity, poor HIV-impacted families and individuals can engage with financial institutions and accumulate savings. Additionally, individual-level factors (e.g., household wealth, child poverty, child work, and attitudes towards savings) were significantly associated with three of the eight outcomes (i.e. saved any money, average monthly total savings, and total number of deposits). Furthermore, institutional-level factors (e.g., access and proximity to the bank, matching incentive rate, and financial education) were associated with all the eight outcomes included in the analysis. Our findings indicate that poor HIV-impacted families can engage with financial institutions and save for their children, if opportunities and institutional arrangements are in place. Findings have implications for financial inclusion policy and programming that target vulnerable youth and families to engage with financial institutions and accumulate savings.

How do grandparents influence child health and development? A systematic review

Grandparents are often a key source of care provision for their grandchildren, yet they are sidelined in caregiving research and policy decisions. We conducted a global, systematic review of the literature to examine the scope and quality of studies to date (PROSPERO database CRD42019133894). We screened 12,699 abstracts across 7 databases, and identified 206 studies that examined how grandparents influence child health and development. Indicators of grandparent involvement were contact, caregiving behaviors, and financial support. Our review focused on two research questions: how do grandparents influence child health and development outcomes, and what range of child outcomes is reported globally? We examined study design, sample characteristics, key findings, and outcomes pertaining to grandchildren's physical health, socio-emotional and behavioral health, and cognitive and educational development.  Our search captured studies featuring grandparent custodial care (n = 35), multigenerational care (n = 154), and both types of care (n = 17). We found substantial heterogeneity in the data provided on co-residence, caregiving roles, resources invested, outcomes, and mechanisms through which "grandparent effects" are manifested. We identified two important issues, related to operationalizing indicators of grandparent involvement and conceptualizing potential mechanisms, leading to gaps in the evidence base. Currently, our understanding of the pathways through which grandparents exert their influence is constrained by limited data on what grandparents actually do and insufficient attention given to interpersonal and structural contexts. We present a conceptual framework to explicitly measure and theorize pathways of care, with a view to inform research design and policy implementation. We underscore the need for more robust data on three indicators of caregiver involvement-contact, behavior, and support-and for careful description of structural and interpersonal contexts in caregiving research.

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.

Perceived quality of life and living arrangements among older rural South Africans: do all households fare the same?

This study explores how living arrangements influence perceived quality of life in an elderly population in rural South Africa. We use data from the longitudinal World Health Organization Study of Global Ageing and Adult Health Survey (WHO-SAGE) and from the Agincourt Health and Socio-Demographic Surveillance System (HDSS). On average, older men and women who reside in single-generation and complex-linked multigenerational households report worse quality of life than those in two-generation and linear-linked multigenerational households. However, after controlling for prior wellbeing status, we find living arrangements to have a significant impact on women's perceived quality of life only, and that it is moderated by age. We conclude that not all multigenerational arrangements are protective of older adults’ wellbeing and highlight the gendered impact of living arrangements on quality of life. These results suggest the necessity to understand how living arrangements influence the social roles of older adults and change with age.

Grandmothers and Children's Schooling in Sub-Saharan Africa

Under poor circumstances, co-residence of a grandmother is generally considered to be beneficial for (grand)children. Empirical evidence does not unequivocally support this expectation and suggests that the grandmother’s importance depends on the family’s circumstances. We study the relationship between grandmother’s co-residence and children’s schooling in sub-Saharan Africa under a broad range of circumstances. Results make clear that the effect of a co-residing grandmother varies but is almost always positive. Grandmothers over age 60 are most effective in helping their (grand)children. They are particularly important for girls, and when the mother is deceased or not living in the household. Grandmothers are less effective in situations with few opportunities, as in very poor regions or in communities with few schooling opportunities. Our findings indicate that providing support to grandmothers should not be overlooked when designing policies aimed at strengthening the position of women and children in the sub-Saharan African context.

Grandparents and Children's stunting in sub-Saharan Africa

Globally an estimated 159 million children under 5 years of age are being too short for one's age (stunted). More than one third of these children is living in Africa. Given the substantial number of sub-Saharan African (SSA) children living in households with co-residing grandparents and the negative effects of stunting on productivity and economic growth, gaining insight into the role grandparents play for children's stunting, has become increasingly important. By applying multilevel logistic regression analysis on a database with information on 344,748 children aged 6-60 months living in 31 SSA countries, the strength of the relationship between grandparental co-residence and children's stunting is examined. Interaction analysis is used to explore how this relationship is moderated by characteristics of the household and of the context in which the household is situated. Children in households with a co-residing grandmother have significantly lower odds of being stunted than other children, provided that the grandmother is in the 50-75 age range. When the grandmother is very young or very old, the likelihood of being stunted is higher. For grandfathers, no significant overall relationship is found, but our findings show that co-residence of a grandfather is associated with less stunting of girls, in poor households and in polygamous households.

Toward "Age-Friendly Slums"? Health Challenges of Older Slum Dwellers in Nairobi and the Applicability of the Age-Friendly City Approach

A majority of urban residents in sub-Saharan Africa (SSA) and other developing regions live in informal settlements, or slums. Much of the discourse on slum health centres on younger generations, while an intensifying agenda on healthy ageing as yet lacks a systematic focus on slums. Similarly, the global age-friendly cities (AFC) movement does not, thus far, extend to slums. This paper examines the particular challenges that a slum-focused age-friendly initiative in SSA may need to address, and the relevance of present AFC indicators and domains for initiatives to advance the health and well-being of older slum dwellers. The analysis builds on the case of two slum communities in Nairobi, Kenya. It analyzes two bodies of relevant evidence from these settlements, namely on the health and social circumstances of older residents, and on the local application and measurement of AFC indicators. The findings point to a set of unsurprising, but also less obvious, core health and social adversities that an age-friendly initiative in such settlements would need to consider. The findings show, further, that the current AFC domains and indicators framework only partly capture these adversities, but that there is potential for adapting the framework to be meaningful for slum settings. The paper concludes by underscoring the need for, and opportunities inherent in, the pursuit of an “age-friendly slums” initiative going forward.

Beyond Orphanhood: Parental Nonresidence and Child Well-being in Tanzania

This article used data from the Rufiji Health and Demographic Surveillance System in Tanzania to examine the influence of parental non-residence on child survival and school entry. Using survival analysis methods, the article tested variations by parent and by cause, examining parental death, non-residence due to parental relationship status, and migration. In general, maternal non-residence was more consequential for child survival, while paternal non-residence influences school entry. This is consistent with gendered parenting patterns in the setting. There was important variation by cause and by outcome, particularly for paternal non-residence. Paternal non-residence due to non-marital birth was associated with increased risk of child death, while paternal migration was associated with improved survival. Paternal death and migration were associated with lower odds of school entry. This article moves beyond orphanhood to consider multiple causes of parental non-residence simultaneously, demonstrating that parental non-residence is not uniformly deleterious for children.

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.

Household structure vs. composition: Understanding gendered effects on educational progress in rural South Africa

BACKGROUND

Demographers have long been interested in the relationship between living arrangements and gendered outcomes for children in sub-Saharan Africa. Most extant research conflates household structure with composition and has revealed little about the pathways that link these components to gendered outcomes.

OBJECTIVES

First, we offer a conceptual approach that differentiates structure from composition with a focus on gendered processes that operate in the household; and second, we demonstrate the value of this approach through an analysis of educational progress for boys and girls in rural South Africa.

METHODS

We use data from the 2002 round of the Agincourt Health and Demographic Surveillance System. Our analytical sample includes 22,997 children aged 6-18 who were neither parents themselves nor lived with a partner or partner's family. We employ ordinary least squares regression models to examine the effects of structure and composition on educational progress of girls and boys.

RESULTS

The results suggest that non-nuclear structures are associated with similar negative effects for both boys and girls compared to children growing up in nuclear households. However, the presence of other kin in the absence of one or both parents results in gendered effects favouring boys.

CONCLUSION

The absence of any gendered effects when using a household structure typology suggests that secular changes to attitudes about gender equity trump any specific gendered processes stemming from particular configurations. On the other hand, gendered effects that appear when one or both parents are absent show that traditional gender norms and/or resource constraints continue to favour boys.

CONTRIBUTION

Despite the wealth of literature on household structure and children's educational outcomes in sub-Saharan Africa, the conceptual basis of these effects has not been well articulated. We have shown the value of unpacking household structure to better understand how gender norms and gendered resource allocations impact education.

Moving beyond the household: Innovations in data collection on kinship

Across settings, it has been shown that the co-residential household is an insufficient measure of family structure and support. However, it continues to be the primary means of population data collection. To address this problem, we developed a new instrument, the Kinship Support Tree (KST), to collect kinship structure and support data on co-residential and non-residential kin and tested it on a sample of 462 single mothers and their children in a slum community in Nairobi, Kenya. This instrument is unique in four important ways: (1) it is not limited to the co-residential household; (2) it distinguishes potential from functional kin; (3) it incorporates multiple geospatial measures; and (4) it collects data on kin relationships specifically for children. In this paper, we describe the KST instrument, assess the data collected in comparison to data from household rosters, and consider the challenges and feasibility of administration of the KST.

Children Living with HIV-Infected Adults: Estimates for 23 Countries in sub-Saharan Africa

Background

In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children’s health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children’s health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods

Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results

The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion

Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

Dependent or Productive? A New Approach to Understanding the Social Positioning of Older South Africans Through Living Arrangements

South Africa's population is aging. Most of the older Black South Africans continue to live in extended household structures with children, grandchildren, and other kin. They also constitute a source of income through a means-tested noncontributory state-funded pension available at age 60. Using census data from the Agincourt Health and Demographic Surveillance System in 2000, 2005, and 2010, we develop a typology of living arrangements that is reflective of the social positioning of elderly persons as dependent or productive household members and analyze changes in the distribution over time. Older persons, in general, live in large, complex, and multigenerational households. Multigenerational households with "productive" older persons are increasing in proportion over the period, although there are few differences by gender or pension eligibility at any time point.

Childhood Risk of Parental Absence in Tanzania

Although parents might not live with their children for a variety of reasons, existing accounts of parental absence often examine one cause in isolation. Using detailed longitudinal demographic surveillance data from Rufiji, Tanzania, this article examines parental absence due to death, migration, child relocation, union dissolution, and union formation from 2001-2011. Employing survival analysis, the article quantifies children's risk of absence by cause and investigates sociodemographic variation in this risk. Of children born into two-parent households, 25% experience maternal absence by age 10, and 40% experience paternal absence by the same age. Roughly one-quarter of children are born into single-mother families with an absent father at birth, and nearly 70% of these children experience maternal absence as well by age 10. Despite the emphasis on orphanhood in the research and policy communities, parental death is the least common cause of absence. Furthermore, although demographic and socioeconomic characteristics are strong predictors of absence, variation in these relationships across causes underscores the distinctiveness and similarity of different reasons for absence.

Family structure effects on early sexual debut among adolescent girls in Rakai, Uganda

This study assessed the association between household family structure and early sexual debut among adolescent girls, ages 15-19, in rural Rakai District, Uganda. Early sexual debut is associated with detrimental physical, emotional and social outcomes, including increased risk of HIV. However, research on the family's role on adolescents' sexual risk behaviors in sub-Sahara Africa has been minimal and rarely takes into account the varying family structures within which African adolescents develop. Using six rounds of survey data (2001-2008) from the Rakai Community Cohort Study, unmarried adolescent girls (n=1940) aged 15-17 at their baseline survey, were followed until age 19. Parametric survival models showed that compared to adolescent girls living with both biological parents, girls who headed their own household and girls living with step-fathers, grandparents, siblings, or other relatives had significantly higher hazards of early sexual debut before age 16. Adolescent girls were significantly more likely to debut sexually if neither parent resided in the household, either due to death or other reasons. In addition, absence of the living biological father from the home was associated with higher risk of sexual debut, regardless of the biological mother's presence in the home. Our study's findings suggest that family structure is important to adolescent girls' sexual behavior. There is need for research to understand the underlying processes, interactions and dynamics of both low and high risk family structures in order to devise and strategically target interventions targeted for specific types of family structures.

CONTEXT MATTERS: FOSTERING, ORPHANHOOD AND SCHOOLING IN SUB-SAHARAN AFRICA

A growing body of research suggests that orphanhood and fostering might be (independently) associated with educational disadvantage in sub-Saharan Africa. However, literature on the impacts of orphanhood and fostering on school enrolment, attendance and progress produces equivocal, and often conflicting, results. This paper reports on quantitative and qualitative data from sixteen field-sites in Ghana and Malawi, highlighting the importance of historical and social context in shaping schooling outcomes for fostered and orphaned children. In Malawi, which has been particularly badly affected by AIDS, orphans were less likely to be enrolled in and attending school than other children. By contrast, in Ghana, with its long tradition of 'kinship fostering', orphans were not significantly educationally disadvantaged; instead, non-orphaned, purposively fostered children had lower school enrolment and attendance than their peers. Understanding the context of orphanhood and fostering in relation to schooling is crucial in achieving 'Education for All'.

Re-focusing the gender lens: caregiving women, family roles and HIV/AIDS vulnerability in Lesotho

Gender and HIV risk have been widely examined in southern Africa, generally with a focus on dynamics within sexual relationships. Yet the social construction of women's lives reflects their broader engagement with a gendered social system, which influences both individual-level risks and social and economic vulnerabilities to HIV/AIDS. Using qualitative data from Lesotho, we examine women's lived experiences of gender, family and HIV/AIDS through three domains: (1) marriage; (2) kinship and social motherhood, and (3) multigenerational dynamics. These data illustrate how women caregivers negotiate their roles as wives, mothers, and household heads, serving as the linchpins of a gendered family system that both affects, and is affected by, the HIV/AIDS epidemic. HIV/AIDS interventions are unlikely to succeed without attention to the larger context of women's lives, namely their kinship, caregiving, and family responsibilities, as it is the family and kinship system in which gender, economic vulnerability and HIV risk are embedded.

Household context and child mortality in rural South Africa: the effects of birth spacing, shared mortality, household composition and socio-economic status

BACKGROUND

Household characteristics are important influences on the risk of child death. However, little is known about this influence in HIV-endemic areas. We describe the effects of household characteristics on children's risk of dying in rural South Africa.

METHODS

We use data describing the mortality of children younger than 5 years living in the Agincourt health and socio-demographic surveillance system study population in rural northeast South Africa during the period 1994-2008. Using discrete time event history analysis we estimate children's probability of dying by child characteristics and household composition (other children and adults other than parents) (N=924,818 child-months), and household socio-economic status (N=501,732 child-months).

RESULTS

Children under 24 months of age whose subsequent sibling was born within 11 months experience increased odds of dying (OR 2.5; 95% CI 1.1-5.7). Children also experience increased odds of dying in the period 6 months (OR 2.1; 95% CI 1.2-3.6), 3-5 months (OR 3.0; 95% CI 1.5-5.9), and 2 months (OR 11.8; 95% CI 7.6-18.3) before another household child dies. The odds of dying remain high at the time of another child's death (OR 11.7; 95% CI 6.3-21.7) and for the 2 months following (OR 4.0; 95% CI 1.9-8.6). Having a related but non-parent adult aged 20-59 years in the household reduces the odds (OR 0.6; 95% CI 0.5-0.8). There is an inverse relationship between a child's odds of dying and household socio-economic status.

CONCLUSIONS

This detailed household profile from a poor rural setting where HIV infection is endemic indicates that children are at high risk of dying when another child is very ill or has recently died. Short birth intervals and additional children in the household are further risk factors. Presence of a related adult is protective, as is higher socio-economic status. Such evidence can inform primary health care practice and facilitate targeting of community health worker efforts, especially when covering defined catchment areas.

The impact of the declining extended family support system on the education of orphans in Lesotho

This paper examines the impact of the weakening of the extended family on the education of double orphans in Lesotho through in-depth interviews with participants from 3 of the 10 districts in Lesotho. The findings reveal that in Lesotho the extended family has not yet disintegrated as the literature suggests. However, it shows signs of rupturing, as many orphans reported that they are being taken into extended family households, the incentive for these households being, presumably, the financial and other material assistance that they receive from the government and non-governmental organisations (NGOs) which supplements household income and material wellbeing. The findings show that financial and other assistance given by the government and NGOs have resulted in conflict between the orphans and caregivers. This has also prompted many extended families to shift responsibilities to the government and NGOs. Most of the extended households provided the orphans with poor living conditions, such as unhygienic houses, poor nutrition, and little or no provision of school materials, which has had a negative impact on the education of the orphans. The combined effects of economic crisis and HIV and AIDS have resulted in extended families not being able to care for the needs of the orphans adequately, whilst continuing to accept them into their households. It is recommended that although extended families are still accepting orphans, the government should strengthen and recognise the important role played by families and the communities in caring for these vulnerable children. The government should also introduce social grants for orphans and other vulnerable children and review the current meagre public assistance (R100) it provides for orphans and vulnerable children in Lesotho. Other stakeholders should concentrate on strengthening the capacity of families and communities through programmes and projects which could be more sustainable than the current handouts given by many NGOs.

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

PURPOSE: To understand the role of extended family in responding to problems of AID-orphaned children and adolescents in Uganda, the study examines who are the primary caregivers of AIDS-orphaned children and adolescents, what are the types of caregiving provided to orphans and whether the quality of caregiving varies by the primary caregiver's gender and type. METHODS: The study uses bivariate analyses and mixed effects models utilizing baseline data from a cluster randomized experimental design including 283 orphaned adolescents in Uganda. RESULTS: The analysis revealed a generally dominating role of female caregivers for both single and double orphans. In the absence of biological parents - as in the case of double orphans - grandparents' role as caregivers prevail. On average, the study participants indicated receiving the high level of perceived caregiver support: the average score of 3.56 out of 4 (95% CI=3.5, 3.65). Results of mixed effect models (adjusting for school effects) revealed significant differences in perceived caregiver support by caregiver's gender. Compared to their male counterparts, female participants with whom the child/adolescent lives (B=0.22, 95% CI=0.11, 0.34) and women who are currently taking care of a child/adolescent (B=0.15, 95% CI=0.05, 0.26) provide greater caregiver support as perceived and reported by a child/adolescent. Similarly, female financiers - compared to male source of financial support - provide greater caregiver support as perceived and reported by a child/adolescent (B=0.16, 95% CI=0.04, 0.3). CONCLUSIONS: Our findings demonstrate that extended families are still holding up as an important source of care and support for AIDS orphaned children and adolescents in Uganda. The findings support the argument about importance of matrilineal and grandparental care for AIDS orphans.

Child mobility, maternal status, and household composition in rural South Africa

This article examines the influence of maternal status, socioeconomic status of the household, and household composition on the mobility of children aged 0-14 in Mpumalanga Province, South Africa, from 1999 to 2008. Using data from the Agincourt Health and Demographic Surveillance System, we found that children whose mothers were temporary migrants, living elsewhere, or dead had higher odds of moving than children whose mothers were coresident. Older children and children living in richer households faced lower odds of mobility. For children whose mothers were coresident, there was no effect of maternal substitutes on child mobility. However, among children whose mothers were temporary migrants or living elsewhere, the presence of prime-aged and elderly females lowered the odds of mobility. For maternal orphans, the presence of elderly women in the household lowered their odds of mobility. The results underscore the importance of examining the conditions under which children move in order to strengthen service delivery targeted at safeguarding children's well-being.

The impact of HIV/AIDS on children's educational outcome: a critical review of global literature

The number of children losing one or both parents to HIV/AIDS has continued to rise in the past decade, with most of them being school-aged children. This study reviews global literature on the effects of HIV/AIDS (e.g., parental HIV-related illness or death) on children's schooling. Systematic review procedures generated 23 studies for examination. Existing studies show educational disadvantages among children affected by AIDS in various educational outcomes, including school enrollment and attendance, school behavior and performance, school completion, and educational attainment. A number of individual and contextual factors potentially moderate or mediate the effect of HIV/AIDS on children's education. These factors include gender of child, pattern of parental loss (maternal vs. paternal vs. dual), living arrangement (relationship with caregivers, gender of the household head), and household poverty. Current literature indicates limitations in number and scope of existing studies and in educational outcome measurements. There is a lack of studies with longitudinal design and data collection from multiple sources (e.g., students, teachers, caregivers), and a lack of studies on the relationship between psychosocial well-being of children affected by AIDS and their educational outcomes. Future studies need to employ more rigorous methodology and incorporate both individual and contextual factors for children affected by AIDS in various regions. More efforts are needed to design and implement culturally appropriate and context-specific approaches to improve the educational outcomes of children affected by AIDS.

"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.

Exploring antiretroviral treatment adherence in an urban setting in South Africa

Antiretroviral treatment requires high levels of adherence to be effective. This qualitative study explores the reasons for poor adherence among 22 purposively selected poor urban participants in South Africa. Over a 4-month period in 2009, we prospectively investigated experiences of HIV diagnosis and treatment, adherence, and withdrawal from treatment. Patients with no stable food sources faced significant barriers in adhering to treatment regimens and staying sufficiently healthy to search for, obtain or retain a job. The narratives also identify the influence on adherence of self-esteem and social support, vulnerability generated by ill health, gendered conflict, social inequities amplified by HIV, and exhaustion due to the social burden of the epidemic. Multi-dimensional, inter-sectoral programs that tackle the social determinants of health, such as food insecurity, poverty, gendered inequities, and treatment adherence are more likely to be successful, than single interventions to support adherence.

The impact of the HIV/AIDS epidemic on kinship resources for orphans in Zimbabwe

The extended family has been recognized as a major safety net for orphans in sub-Saharan Africa. However, the mortality crisis associated with HIV/AIDS may drastically reduce the availability of relatives and thus undermine traditional forms of mutual support. In this article, the microsimulator SOCSIM is used to estimate and project quantities such as the number of living uncles, aunts, siblings, and grandparents available to orphans. The model is calibrated to the setting of Zimbabwe, using data from demographic and Health Surveys and estimates and projections of demographic rates from the United Nations. The article shows that there is a lag of more than ten years between the peak in orphanhood prevalence and the peak in scarcity of grandparents for orphans. The results indicate that a generalized HIV/AIDS epidemic has a prolonged impact on children and orphans that extends well beyond the peak in mortality. A rapid increase in the number of orphans is followed by a steady reduction in the number of living grandparents for orphans. Consequently, the burden of double orphans (both of whose parents have died) is likely to shift to uncles and aunts. In Zimbabwe, the number of living uncles and aunts per double orphan decreased between 1980 and 2010, but it is expected to increase progressively during the next few decades. Changes in kinship structure have important social consequences that should be taken into account when seeking to address the lack of care for orphans.

The quality of material care provided by grandparents for their orphaned grandchildren in the context of HIV/AIDS and poverty: a study of Kopanong municipality, Free State

A pervasive argument in the literature on AIDS orphans in South Africa is that grandparents, who often care for their orphaned grandchildren, lack the material means to provide adequate care. This study investigated that claim in an area of ubiquitous poverty and very high unemployment. It is based on the analysis of data obtained from two surveys carried out by the HSRC in the semi-rural municipality of Kopanong in the Free State. The first study was a census which targeted the whole population. The second, smaller survey sampled households which accommodated orphaned and vulnerable children. Based on four proxy indicators for material care: possession of birth certificates, uptake of welfare grants, levels of school attendance, and the number of meals consumed daily, the study revealed that there was very little difference in the quality of care provided by grandparents and other carers, including biological parents. Indeed, since the old age pension is much higher than the child support grant and the foster care grant it may be that grandparents who are pensioners generally have higher incomes than most other adults. In line with the findings of other research, the study found that poverty is a major problem confronting all carers in the area. It concludes that interventions that primarily target orphans overlook the material needs of all poor children. It therefore joins the calls of other researchers for greater state support for all poor children, irrespective of whether they are orphans and who their carers are.

Migrants' competing commitments: sexual partners in urban Africa and remittances to the rural origin

Migrants form nonfamilial ties in urban destinations, which could compete with origin families for a share of remittances. A framework of competing commitment predicts that new relationships affect remittances depending on the extent to which they substitute for the benefits provided by origin families. Analyses of data from urban migrants in Kenya show that serious nonmarital sexual partners substitute for psychosocial support from the rural family and that material transfers migrants give to these partners significantly reduce remittances. The findings have implications for the ways scholars conceive of competition, the nature of exchange, and substitution of support across intimate relationships.