Orphan care in Malawi: current practices

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'.

Models of care for orphaned and separated children and upholding children's rights: cross-sectional evidence from western Kenya

BACKGROUND

Sub-Saharan Africa is home to approximately 55 million orphaned children. The growing orphan crisis has overwhelmed many communities and has weakened the ability of extended families to meet traditional care-taking expectations. Other models of care and support have emerged in sub-Saharan Africa to address the growing orphan crisis, yet there is a lack of information on these models available in the literature. We applied a human rights framework using the United Nations Convention on the Rights of the Child to understand what extent children's basic human rights were being upheld in institutional vs. community- or family-based care settings in Uasin Gishu County, Kenya.

METHODS

The Orphaned and Separated Children's Assessments Related to their Health and Well-Being Project is a 5-year cohort of orphaned children and adolescents aged ≤18 year. This descriptive analysis was restricted to baseline data. Chi-Square test was used to test for associations between categorical /dichotomous variables. Fisher's exact test was also used if some cells had expected value of less than 5.

RESULTS

Included in this analysis are data from 300 households, 19 Charitable Children's Institutions (CCIs) and 7 community-based organizations. In total, 2871 children were enrolled and had baseline assessments done: 1390 in CCI's and 1481 living in households in the community. We identified and described four broad models of care for orphaned and separated children, including: institutional care (sub-classified as 'Pure CCI' for those only providing residential care, 'CCI-Plus' for those providing both residential care and community-based supports to orphaned children , and 'CCI-Shelter' which are rescue, detention, or other short-term residential support), family-based care, community-based care and self-care. Children in institutional care (95%) were significantly (p < 0.0001) more likely to have their basic material needs met in comparison to those in family-based care (17%) and institutions were better able to provide an adequate standard of living.

CONCLUSIONS

Each model of care we identified has strengths and weaknesses. The orphan crisis in sub-Saharan Africa requires a diversity of care environments in order to meet the needs of children and uphold their rights. Family-based care plays an essential role; however, households require increased support to adequately care for children.

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.

The relationship between orphanhood and child fostering in sub-Saharan Africa, 1990s-2000s

In countries most afflicted by HIV/AIDS in sub-Saharan Africa, orphanhood has increased dramatically, but the potential consequences of the increase have been mitigated by the ability of households to absorb orphans. This paper examines what the rising levels of orphanhood mean for the common practice of non-orphan child fostering in regions of high and low HIV prevalence in sub-Saharan Africa, which has a long history of child fostering. Using Demographic and Health Survey data from 135 regions within 14 sub-Saharan countries that undertake HIV testing and have had at least two surveys, we examine changes in fostering patterns. In most regions, we find a more accommodating relationship between orphan and non-orphan fostering: communities are able to absorb the demand for both orphans and non-orphans. Where HIV prevalence exceeds 10 per cent there is some evidence that the need to care for orphans is beginning to reduce opportunities for non-orphan fostering.

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.

Positive care? HIV and residential care for children in South Africa

Responses to the HIV epidemic leading to an increase in the number of residential care facilities for children across sub-Saharan Africa have prompted concerns that large numbers of orphaned children are being placed in institutional care. There is little empirical research into the role that institutions are playing in the provision of care to children affected by HIV in the region. This paper draws on an exploratory study of the provision of residential care for children in the context of the HIV epidemic in South Africa. The analysis characterises the population of children in a small sample of residential care facilities in four provinces, and, after identifying a disproportionate number of HIV-positive children in care, examines the circumstances that led to their admission and the nature of HIV-related interventions in the facilities. The analysis reveals missed opportunities for non-institutional placements for HIV-positive children and identifies important gaps in the HIV prevention, treatment, care, and support interventions within the facilities. The article argues that a global and local preoccupation with orphans as being the children most severely affected by HIV, and as the primary category of children requiring alternative care as a result of the HIV epidemic, may have diverted attention away from the extent to which HIV-positive children populate institutions in South Africa. Furthermore, we suggest that adjustments are required to both decision-making regarding placement of HIV-positive children requiring alternative care and the provision of HIV-related interventions in residential facilities in order to ensure an adequate response to children's health and wellbeing.

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.

Interventions for improving the psychosocial well-being of children affected by HIV and AIDS

BACKGROUND

As a result of HIV-related mortalities more than 13 million children under the age of 15 have lost a parent due to HIV and AIDS. There are also many children who have HIV-positive parents or primary caregivers; these children are affected by HIV and AIDS and are potentially vulnerable to HIV transmission. Children affected by HIV and AIDS are more vulnerable and face greater challenges to their psychosocial well-being compared to other children of the same age. Interventions have been adopted with the aim of improving the psychosocial well-being of children affected by HIV and AIDS.

OBJECTIVES

The primary objective of this review was to assess the effectiveness of interventions that aim to improve the psychosocial well-being of children directly affected by HIV and AIDS.

SEARCH STRATEGY

Electronic databases were systematically searched using pre-defined search terms. Internet searches of relevant organizations involved in HIV and AIDS work were conducted and experts in the field and were contacted directly. Searches were conducted between January and September 2008.

SELECTION CRITERIA

Randomised controlled trials, crossover trials, cluster-randomised trials and factorial trials were eligible for inclusion. If no controlled trials were found, data from well-designed non-randomised intervention studies (such as before and after studies), cohort, and case-control observational studies were considered for inclusion. Studies which included male and female children under the age of 18 years of age, either orphaned due to AIDS (one or more parents died of HIV related-illness or AIDS), or vulnerable children (one or more parents living with HIV or AIDS) were eligible for review.Interventions that aim to improve the psychosocial well-being of children affected by HIV and AIDS were included in the review. This included psychological therapy, psychosocial support and/or care, medical interventions and social interventions. Psychosocial outcomes were defined as any intervention that measures psychological and/or social factors.

DATA COLLECTION AND ANALYSIS

Two of the authors independently screened the results of the search. The full text of all potentially relevant studies were obtained and were independently assessed by the two reviewers using pre-determined criteria.

MAIN RESULTS

No studies of interventions for improving the psychosocial well-being of children affected by HIV and AIDS were identified.

AUTHORS' CONCLUSIONS

Current practice is based on anecdotal knowledge, descriptive studies and situational analyses. Such studies do not provide a strong evidence base for the effectiveness of these interventions.

IMPLICATIONS FOR RESEARCH

This systematic review has identified the need for high quality intervention studies. In order to increase the quality and quantity of such studies there is a need for greater partnerships between program implementers and researchers.

IMPLICATIONS FOR PRACTICE

In the absence of rigorous intervention studies, the body of knowledge available consists of "lessons learned," child psychological theory and other related research in the adult population. However, such knowledge should not replace the urgent need for rigorous monitoring and evaluation of existing programs and intervention studies to ensure evidence-based practice and policy, and prevent subjecting children to interventions which show no benefit or interventions that could unintentionally lead to harm.

Facing adolescence and adulthood: the importance of mental health care in the global pediatric AIDS epidemic

With the increasing global accessibility of antiretrovirals, many HIV-positive children now face a future once thought impossible. As these children grow, they face unique psychosocial stressors that differ from any previous chronic or incurable childhood illness. Studies have already described an increased prevalence of mental health disorders among this population. In addition, other studies have illustrated the known future health consequences of adverse childhood experiences, similar but not related to the HIV/AIDS epidemic. This article connects these studies and predicts the grave future health consequences likely to be faced if pediatric mental health care is not addressed. Practical solutions are described that often go hand-in-hand with the current global scale-up of antiretroviral accessibility. These include scaling-up mental health services, educating communities, supporting school-based programs, promoting the role of nongovernmental organizations, and strengthening families and the community to provide a safe and secure home environment for children. HIV-positive children are likely to face future physical and psychological health consequences related to the psychosocial challenges they face as children if mental health care is not made a priority in the current global fight against AIDS.

Factors associated with religious congregation members' support to people living with HIV/AIDS in Kumasi, Ghana

Physical, social and economic constraints often limit the ability of people living with HIV/AIDS to meet their basic needs. Community members are a valuable source of support for people living with HIV/AIDS, although little is known about the types of support they provide or how to mobilize this support. To examine this issue, a survey of 1200 members of 6 religious congregations was conducted in Kumasi, Ghana. A fifth of congregation members reported providing some support to people with HIV/AIDS in the last 6 months, mostly through prayer, financial support, and counseling. Factors associated with providing support include having heard a congregation or tribal chief speaking about HIV/AIDS, collective efficacy related to HIV/AIDS, and perceived risk of becoming infected with HIV. To enhance support to people with HIV/AIDS, programs should involve community leaders and encourage dialogue on ways to address the epidemic.

Rights of HIV positive people to sexual and reproductive health: parenthood

In many areas of the globe most HIV infection is transmitted sexually or in association with pregnancy, childbirth and breastfeeding, raising the need for sexual and reproductive health and HIV/AIDS initiatives to be mutually reinforcing. Many people with HIV, who are in good health, will want to have children, and highly active antiretroviral therapy provides women and men living with AIDS the possibility of envisaging new life projects such as parenthood, because of a return to health. However, there are still difficult choices to face concerning sexuality, parenthood desires and family life. Structural, social and cultural issues, as well as the lack of programmatic support, hinder the fulfilment of the right to quality sexual and reproductive health care and support for having a family. This paper addresses the continuum of care involved in parenthood for people living with HIV, from pregnancy to infant and child care, and provides evidence-based examples of policies and programmes that integrate sexual and reproductive health interventions with HIV/AIDS care in order to support parenthood. Focusing on parenthood for people living with and affected by HIV, that is, focusing on the couple rather than the woman as the unit of care, the individual or the set of adults who are responsible for raising children, would be an innovative programmatic advance. Going beyond maternal and child health care to providing care and support for parents and others who are responsible for raising children is especially relevant for those living with HIV infection.