Lucie Cluver

Risk and protective factors for psychological well-being of children orphaned by AIDS in Cape Town: a qualitative study of children and caregivers' perspectives

Abstract By 2020, an estimated 2.3 million South African children will be orphaned by HIV/AIDS (Actuarial Society of South Africa, 2005), but little is known about risk and protective factors for their emotional and behavioural well-being. This qualitative study explores perspectives of affected families. Orphaned children (n = 60), caregivers of orphaned children (n = 42) and social care professionals (n = 20) completed semi-structured interviews and focus groups. Participants were recruited from schools, shelters and welfare services. Findings from multiple sources indicate potential risk and protective factors in a range of dimensions, including bereavement, family functioning, social support, poverty, access to education and perceived stigma. Many factors reflected international literature on children experiencing similar stressors (e.g. non HIV/AIDS-related bereavement). However, this study also identified factors which may be specific to this group, notably stigma, abuse and peer factors. Current research is quantitatively testing associations between these identified factors and psychological outcomes.

Improving positive parenting skills and reducing harsh and abusive parenting in low- and middle-income countries: a systematic review.

Family and youth violence are increasingly recognized as key public health issues in developing countries. Parenting interventions form an important evidence-based strategy for preventing violence, both against and by children, yet most rigorous trials of parenting interventions have been conducted in high-income countries, with far fewer in low- and middle-income countries (LMICs). This systematic review, conducted in line with Cochrane Handbook guidelines, investigated the effectiveness of parenting interventions for reducing harsh/abusive parenting, increasing positive parenting practices, and improving parent–child relationships in LMICs. Attitudes and knowledge were examined as secondary outcomes. A range of databases were systematically searched, and randomized trials included. High heterogeneity precluded meta-analysis, but characteristics of included studies were described according to type of delivery mode and outcome. Twelve studies with 1580 parents in nine countries reported results favoring intervention on a range of parenting measures. The validity of results for most studies is unclear due to substantial or unclear risks of bias. However, findings from the two largest, highest-quality trials suggest parenting interventions may be feasible and effective in improving parent–child interaction and parental knowledge in relation to child development in LMICs, and therefore may be instrumental in addressing prevention of child maltreatment in these settings. Given the well-established evidence base for parenting interventions in high-income countries, and increasingly good evidence for their applicability across cultures and countries, there is now an urgent need for more rigorously evaluated and reported studies, focusing on youth outcomes as well as parenting, adapted for contexts of considerable resource constraints.

The mental health of children orphaned by AIDS: a review of international and southern African research

This paper reviews research on the mental health and psychological outcomes of children who are orphaned by AIDS. Studies are limited, scattered and often unpublished. The review focuses on research which is quantitative and based on primary research with uninfected children who are parentally bereaved by AIDS. Due to the limited available quantitative research in this area, both controlled and uncontrolled studies are included. Selected qualitative and related literature is also reviewed, with a focus on work relevant to the southern African context. This paper builds upon and updates Wilds seminal review, published in this journal in 2001 (Wild 2001). We found 24 studies worldwide, with wide variations in sample characteristics, outcome measurements and control groups. Three of these studies are ongoing. Internalising problems in orphaned children were found in 16 studies (of the 19 studies which measured them) and externalising problems were found in five studies (of 10 which measured them). There is a clear need for further, and rigorous, research into mental health, and risk and protective factors for children orphaned by AIDS. Furthermore, it is critical that research adopts a more coordinated approach, which allows for meaningful comparisons of child outcomes in different areas.

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

BackgroundAn estimated 2 million children are parentally bereaved by AIDS in South Africa. Little is known about mental health outcomes for this group.MethodsThis 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 Pearsons chi-square.ResultsBoth 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.ConclusionFindings suggest important areas for larger-scale research for parentally-bereaved children.

Cumulative risk and AIDS-orphanhood: Interactions of stigma, bullying and poverty on child mental health in South Africa

Research shows that AIDS-orphaned children are more likely to experience clinical-range psychological problems. Little is known about possible interactions between factors mediating these high distress levels. We assessed how food insecurity, bullying, and AIDS-related stigma interacted with each other and with likelihood of experiencing clinical-range disorder. In South Africa, 1025 adolescents completed standardised measures of depression, anxiety and post-traumatic stress. 52 potential mediators were measured, including AIDS-orphanhood status. Logistic regressions and hierarchical log-linear modelling were used to identify interactions among significant risk factors. Food insecurity, stigma and bullying all independently increased likelihood of disorder. Poverty and stigma were found to interact strongly, and with both present, likelihood of disorder rose from 19% to 83%. Similarly, bullying interacted with AIDS-orphanhood status, and with both present, likelihood of disorder rose from 12% to 76%. Approaches to alleviating psychological distress amongst AIDS-affected children must address cumulative risk effects.

Effects of stigma on the mental health of adolescents orphaned by AIDS.

PURPOSE By 2010, an estimated 18.4 million children in Sub-Saharan Africa will be orphaned by AIDS. Research in South Africa shows that AIDS orphanhood is independently associated with heightened levels of psychological problems. This study is the first to explore the mediating effects of stigma and other factors operating on a community level, on associations between AIDS orphanhood and mental health. We assessed the associations of four risk factors that can potentially be addressed at a community level (bullying, stigma, community violence, and lack of positive activities) with psychological problems and orphanhood status. METHOD One thousand twenty-five participants aged 10-19 were recruited from deprived urban settlements in South Africa. The sample included adolescents orphaned by AIDS (n = 425), adolescents orphaned by non-AIDS causes (n = 241), and nonorphaned adolescents (n = 278). Participants were interviewed using standardized psychological measures of depression, anxiety, posttraumatic stress, peer problems, delinquency, and conduct problems. Information on risk factors and demographic characteristics were also assessed. RESULTS AIDS-orphaned adolescents reported higher levels of stigma and fewer positive activities than other groups. There were no reported differences on bullying or community violence. All community-level risk factors were associated with poorer psychological outcomes. Multivariate analyses controlling for age and gender showed that experience of stigma significantly mediated associations between AIDS orphanhood and poor psychological outcomes. CONCLUSIONS Reduction of AIDS-related stigma could potentially reduce adverse psychological outcomes among AIDS-orphaned adolescents.

Persisting mental health problems among AIDS-orphaned children in South Africa

BACKGROUND   By 2008, 12 million children in sub-Saharan Africa were orphaned by AIDS. Cross-sectional studies show psychological problems for AIDS-orphaned children, but until now no longitudinal study has explored enduring psychological effects of AIDS-orphanhood in the developing world. METHODS   A 4-year longitudinal follow-up of AIDS-orphaned children with control groups of other-orphans and non-orphans. 1021 children (M = 13.4 years, 50% female, 98% isiXhosa-speaking) were interviewed in 2005 and followed up in 2009 with 71% retention (49% female, M = 16.9 years), in poor urban South African settlements. Children were interviewed using sociodemographic questionnaires and well-validated standardised scales for assessing depression, anxiety, and post-traumatic stress. Data were analysed using mixed-design ANOVA and backward-stepping regression. RESULTS   AIDS-orphaned children showed higher depression, anxiety, and post-traumatic stress disorder (PTSD) scores in both 2005 and 2009 when compared with other-orphans and non-orphans. Backward-stepping regression, controlling for baseline mental health, and sociodemographic cofactors such as age, gender, and type of bereavement, revealed that being AIDS-orphaned in 2005 was associated with depression, anxiety, and PTSD scores in 2009. This was not the case for other-orphaned or non-orphaned children. Age interacted with orphan status, such that there was a steep rise in psychological distress in the AIDS-orphaned group, but no rise with age amongst other-orphans and non-orphans. CONCLUSIONS   Negative mental health outcomes amongst AIDS-orphaned children are maintained and worsen over a 4-year period. It is important that psychosocial support programmes are sustained, and focus on youth as well as young children.

Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study

BACKGROUND Effective and scalable HIV prevention for adolescents in sub-Saharan Africa is needed. Cash transfers can reduce HIV incidence through reducing risk behaviours. However, questions remain about their effectiveness within national poverty-alleviation programmes, and their effects on different behaviours in boys and girls. METHODS In this case-control study, we interviewed South African adolescents (aged 10-18 years) between 2009 and 2012. We randomly selected census areas in two urban and two rural districts in two provinces in South Africa, including all homes with a resident adolescent. We assessed household receipt of state-provided child-focused cash transfers, incidence in the past year and prevalence of transactional sex, age-disparate sex, unprotected sex, multiple partners, and sex while drunk or after taking drugs. We used logistic regression after propensity score matching to assess the effect of cash transfers on these risky sexual behaviours. FINDINGS We interviewed 3515 participants (one per household) at baseline, and interviewed 3401 at follow-up. For adolescent girls (n=1926), receipt of a cash transfer was associated with reduced incidence of transactional sex (odds ratio [OR] 0·49, 95% CI 0·26-0·93; p=0·028), and age-disparate sex (OR 0·29, 95% CI 0·13-0·67; p=0·004), with similar associations for prevalence (for transactional sex, OR 0·47, 95% CI 0·26-0·86; p=0·015; for age-disparate sex, OR 0·37, 95% CI 0·18-0·77; p=0·003). No significant effects were shown for other risk behaviours. For boys (n=1475), no consistent effects were shown for any of the behaviours. INTERPRETATION National, child-focused cash transfers to alleviate poverty for households in sub-Saharan Africa can substantially reduce unsafe partner selection by adolescent girls. Child-focused cash transfers are of potential importance for effective combination strategies for prevention of HIV. FUNDING UK Economic and Social Research Council, South African National Research Foundation, Health Economics and AIDS Research Division at University of KwaZulu-Natal, South African National Department of Social Development, Claude Leon Foundation, John Fell Fund, Nuffield Foundation, and Regional Interagency Task Team for Children affected by AIDS-Eastern and Southern Africa.

Transactional Sex Amongst AIDS-Orphaned and AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty

Little is known about impacts of familial AIDS on abuse and sexual health outcomes amongst adolescents. Objectives were to determine whether familial AIDS is: (1) associated with severe physical, emotional, and sexual abuse; (2) associated with transactional sexual exploitation; and (3) explore whether relationships between familial AIDS and transactional sex are mediated by extreme poverty and abuse. DesignAdolescent self-report study in deprived South African communities. MethodsA 2009 follow-up of a 2005 study achieved 71% retention (n = 723). The 2009 sample included AIDS-orphaned (n = 236), other-orphaned (n = 231), and non-orphaned (n = 220) adolescents, whose primary caregivers were AIDS sick (n = 109), other sick (n = 147), and healthy (n = 220). Abuse and transactional sex were measured using widely used and validated self-report measures. ResultsAIDS orphanhood and parental AIDS sickness predicted emotional and physical abuse and transactional sexual exploitation. Orphanhood or parental sickness by non-AIDS causes, and having healthy caregivers, did not predict any abuse outcomes. Adolescents “dually” affected by AIDS orphanhood and sickness showed a 3-fold likelihood of severe emotional and physical abuse and, amongst girls, a 6-fold likelihood of transactional sexual exploitation, compared with those in healthy families. Heightened risk of transactional sex amongst adolescents in AIDS-affected families was mediated by extreme poverty and abuse exposure. In combination, the effects of familial AIDS, food insecurity, and exposure to abuse raised prevalence of transactional sex amongst girls from 1% to 57%. ConclusionsAdolescents from AIDS-affected families are highly vulnerable to severe physical and emotional abuse and transactional sex. This has implications for policy and programming in child protection and HIV prevention services.

Posttraumatic stress in AIDS-orphaned children exposed to high levels of trauma: The protective role of perceived social support†

Poor urban children in South Africa are exposed to multiple community traumas, but AIDS-orphaned children are at particular risk for posttraumatic stress. This study examined the hypothesis that social support may moderate the relationship between trauma exposure and posttraumatic stress for this group. Four hundred twenty-five AIDS-orphaned children were interviewed using standardized measures of psychopathology. Compared to participants with low perceived social support, those with high perceived social support demonstrated significantly lower levels of PTSD symptoms after both low and high levels of trauma exposure. This suggests that strong perception of social support from carers, school staff, and friends may lessen deleterious effects of exposure to trauma, and could be a focus of intervention efforts to improve psychological outcomes for AIDS-orphaned children.