Tim Quinlan

Exploring the Cinderella myth: intrahousehold differences in child wellbeing between orphans and non-orphans in Amajuba District, South Africa.

Objective:To determine whether differences in wellbeing (defined by a variety of education and health outcomes) exist between recent school-aged orphans and non-orphans who live in the same household in a context of high HIV/AIDS mortality in KwaZulu Natal, South Africa. Design:The data come from the first 2 years (2004–2006) of an ongoing 3-year longitudinal cohort study in a district in KwaZulu-Natal, the Amajuba Child Health and Well-being Research Project. Using stratified cluster sampling based on school and age, we constructed a cohort of 197 recent orphans and 528 non-orphans aged 9–16 years and their households and caregivers. Household heads, caregivers, and children were interviewed regarding five domains of child wellbeing: demographic, economic, educational, health/nutrition/lifestyle, and psychosocial status. Methods:The analytical sample consists of 174 children (87 orphans and 87 comparable non-orphans who live together) at baseline and 124 children in round 2. We estimated a linear regression model using household fixed effects for continuous outcomes (grade adjusted for age, annual expenditure on schooling and body mass index) and a logit model using household fixed effects for categorical variables (malnutrition) to compare co-resident orphans and non-orphans. Results:We found no statistically significant differences in most education, health and labour outcomes between orphans and the non-orphans with whom they live. Paternal orphans are more likely to be behind in school, and recent mobility has a positive effect on schooling outcomes.

Children’s psychosocial wellbeing in the context of HIV/AIDS and poverty: a comparative investigation of orphaned and non-orphaned children living in South Africa

BackgroundRecent studies have questioned whether orphanhood is primarily associated with key dimensions of psycho-social wellbeing in children living in circumstances of material deprivation and high prevalence of HIV and AIDS.MethodsThis study uses cross-sectional data from a longitudinal study conducted between 2004-2007 to examine the psychosocial well-being of orphans and non-orphans in the Amajuba District of KwaZulu-Natal, South Africa. Psychosocial wellbeing included an assessment of orphans’ and non orphans’ level of anxiety and depression, affability and resilience. Stratified cluster sampling, based on both school and age, was used to construct a cohort of recent orphans and non-orphans and their households, randomly selected from schools.ResultsLevels of anxiety and depression, affability and resilience did not differ significantly between orphans and non-orphans, nor did salient household, poverty and caregiver characteristics vary substantially amongst orphans and non-orphans. Multivariate analyses indicated that children’s psychosocial outcomes, when controlling for orphan status and related demographic variables were more strongly influenced by household composition/size, living above or below the poverty threshold and factors associated with the caregiver-child relationship and caregiver health.ConclusionsThe results muster additional evidence for moving beyond narrow definitions of vulnerability associated exclusively with orphanhood to consider the multitude of material, social and relational factors affecting the psycho-social well-being of children in general who are living in circumstances of poverty and HIV and AIDS.

Vulnerability of orphan caregivers vs. non-orphan caregivers in KwaZulu-Natal

Abstract Using data from a cohort of schoolgoing children, their households and caregivers (the Amajuba Child Health and Wellbeing Project, ACHWRP) in KwaZulu-Natal, South Africa, we compared demographic characteristics, care burden, health, physical function and social capital of caregivers of orphans (n = 300) with those of non-orphans (n = 298). This analysis presents cross-sectional findings from questions for caregivers that were added for the studys second round, conducted between September 2005 and June 2006. Caregivers of all children were overwhelmingly women (87%). Compared to non-orphan caregivers, caregivers of orphans were on average older (49.5 vs. 45.2 years, p = 0.0002), had fewer years of education (6.7 vs. 7.8 years, p = 0.0042) and were less likely to be married or cohabiting (29% vs. 46%; p < 0.0001). Caregivers of orphans reported caring for more children than those of non-orphans (4.8 vs. 3.8 children, p < 0.0001). A larger proportion of orphan caregivers reported having cared for an ill adult in the previous year (28% vs. 19%), and for that adult to have been a biological child (p = 0.0531). There was a high prevalence (55%) of self-reported poor health among all caregivers; caregivers of orphans were more likely to report poor general health and chronic illness. Although there was a high prevalence of functional impairment (self-reported inability to perform primary activity) among all caregivers (59%), there was no difference between groups. In terms of social capital, although similar proportions of orphan and non-orphan caregivers reported having friends outside the household, orphan caregivers were less likely to have a source of a small emergency loan [51% vs. 63%; adjusted odds ratio: 0.60 (0.41–0.88)]. Our results suggest that orphan caregivers are indeed more vulnerable, and that their particular limitations and needs must be considered when developing strategies for assisting vulnerable households to ensure better support for both caregivers and the children in their care.

Weighing up the burden of care on caregivers of orphan children: The Amajuba District Child Health and Wellbeing Project, South Africa

This paper assesses the burden on orphan caregivers relative to non-orphan caregivers in the context of high HIV/AIDS mortality in South Africa. It presents findings from the third round of a study conducted in the Amajuba District of KwaZulu-Natal between 2003 and 2007. Significant differences were found between orphan and non-orphan caregivers; the former being more likely to care for more children, have poorer health, higher levels of chronic illness, less adult help and they appeared to have more daily responsibilities. Orphan caregivers were also more likely to indicate that children in their care needed help for mental or behavioural problems but overall results showed that only 3.4% of all households had contact with child welfare agencies. The findings question assumptions about the capacity and capability of the extended family to absorb shocks to individuals and families.

Playing the role of a ??boundary organisation??: getting smarter with networking

BackgroundThis paper discusses the practices of organisations that cross the boundary between research and politics, to promote evidence-based policies and programmes.MethodsIt uses the experience of a network of organisations in Africa to describe the methodology, challenges and successes of efforts to promote utilisation of research on the inter-connections between HIV/AIDS, food security and nutrition in South Africa. It emphasises that crossing the boundary between science and politics can be done systematically and is inevitable for any attempt that seeks influence policy making.ResultsThe paper reveals the complexity of the research-policy making interface and identifies key lessons for the practice of networking and engaging policy and decision-makers.ConclusionThe concept of boundary organisation is a helpful means to understand the methodological underpinnings of efforts to get research into policy and practice and to understand the ‘messy’ process of doing so.

Integration of community home based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South-Africa and Zambia: a comparative assessment

BackgroundIn 2008, the WHO facilitated the primary health care (PHC) revitalisation agenda. The purpose was to strengthen African health systems in order to address communicable and non-communicable diseases. Our aim was to assess the position of civil society-led community home based care programmes (CHBC), which serve the needs of patients with HIV, within this agenda. We examined how their roles and place in health systems evolved, and the prospects for these programmes in national policies and strategies to revitalise PHC, as new health care demands arise.MethodsThe study was conducted in Ethiopia, Malawi, South Africa and Zambia and used an historical, comparative research design. We used purposive sampling in the selection of countries and case studies of CHBC programmes. Qualitative methods included semi-structured interviews, focus group discussions, service observation and community mapping exercises. Quantitative methods included questionnaire surveys.ResultsThe capacity of PHC services increased rapidly in the mid-to-late 2000s via CHBC programme facilitation of community mobilisation and participation in primary care services and the exceptional investments for HIV/AIDS. CHBC programmes diversified their services in response to the changing health and social care needs of patients on lifelong anti-retroviral therapy and there is a general trend to extend service delivery beyond HIV-infected patients. We observed similarities in the way the governments of South Africa, Malawi and Zambia are integrating CHBC programmes into PHC by making PHC facilities the focal point for management and state-paid community health workers responsible for the supervision of community-based activities. Contextual differences were found between Ethiopia, South Africa, Malawi and Zambia, whereby the policy direction of the latter two countries is to have in place structures and mechanisms that actively connect health and social welfare interventions from governmental and non-governmental actors.ConclusionsCountries may differ in the means to integrate and co-ordinate government and civil society agencies but the net result is expanded PHC capacity. In a context of changing health care demands, CHBC programmes are a vital mechanism for the delivery of primary health and social welfare services.

Practicalities and challenges in re-orienting the health system in Zambia for treating chronic conditions

BackgroundThe rapid evolution in disease burdens in low- and middle income countries is forcing policy makers to re-orient their health system towards a system which has the capability to simultaneously address infectious and non-communicable diseases. This paper draws on two different but overlapping studies which examined how actors in the Zambian health system are re-directing their policies, strategies and service structures to include the provision of health care for people with chronic conditions.MethodsStudy methods in both studies included semi-structured interviews with government health officials at national level, and governmental and non-governmental health practitioners operating from community-, primary health care to hospital facility level. Focus group discussions were conducted with staff, stakeholders and caregivers of programmes providing care and support at community- and household levels. Study settings included urban and rural sites.ResultsA series of adaptations transformed the HIV programme from an emergency response into the first large chronic care programme in the country. There are clear indications that the Zambian government is intending to expand this reach to patients with non-communicable diseases. Challenges to do this effectively include a lack of proper NCD prevalence data for planning, a concentration of technology and skills to detect and treat NCDs at secondary and tertiary levels in the health system and limited interest by donor agencies to support this transition.ConclusionThe reorientation of Zambia’s health system is in full swing and uses the foundation of a decentralised health system and presence of local models for HIV chronic care which actively involve community partners, patients and their families. There are early warning signs which could cause this transition to stall, one of which is the financial capability to resource this process.

Early impacts of orphaning: Health, nutrition, and food insecurity in a cohort of school-going adolescents in South Africa

We recruited a cohort of 157 recent orphans and 480 non-orphans aged 9–15 in a region of high HIV/AIDS mortality in South Africa using stratified cluster sampling to determine the impact of recent parental death on health and food insecurity of school-going orphans compared to non-orphans over time. Between September 2004 and June 2007, household heads, caregivers, and children were interviewed at three annual intervals. Bivariate associations and multivariate models were assessed using generalized estimating equations (GEE). In the health domain, compared to non-orphans, double orphans were more likely to report worse health status and being very ill in the previous 12 months. For those who reported being very ill, maternal or paternal orphans were more than twice as likely not to seek care than non-orphans; no differences were found for double orphans. For nutrition and food insecurity, maternal or paternal orphans were more likely not to have eaten dinner and to have gone to bed hungry the previous night compared to non-orphans; no differences were found for double orphans. Overall, recent school-aged orphans were disadvantaged in health and food insecurity within two years after the death of a parent, compared to their non-orphaned counterparts, but the disparities were smaller than expected. No changes in health, nutritional status, or food insecurity were apparent over the three study rounds. Longer term effects into adulthood may well be more pronounced and warrant careful longitudinal investigation.

The impact of ART scale upon health workers: evidence from two South African districts.

Abstract This study explores the effects of antiretroviral treatment (ART) programmes on health-care human resources in South Africa. The study included two parts, a questionnaire-based survey of 269 health workers published earlier and a qualitative study of 21 purposively selected health practitioners involved in ART scale up. Contrary to what has been presented in literature, our survey showed that health workers in ART programmes experienced higher levels of morale, lower stress, lower sickness absenteeism and higher levels of job satisfaction. This paper uses qualitative data to provide insights into the working environment of ART workers and examines some possible explanations for our survey findings. The key factors that contribute to the different perception of working environment by ART workers identified in this study include bringing hope to patients, delaying deaths, acquiring training and the ability to better manage and monitor the disease.

Comparative economic positions of orphan, non-orphan and mixed households: Findings from round 3 of the Amajuba District Study in KwaZulu-Natal, South Africa

The HIV and AIDS pandemic in sub-Saharan Africa has orphaned many children, leaving the extended family responsible for their care. We use findings from a longitudinal study on child welfare in South Africa to compare the economic status of households that support only orphaned children (orphan households), those that support both orphan and non-orphan children (mixed households), and households that support only children whose parents are alive (non-orphan households). We ask the question “Which household type is the worst off?” We also discuss the extent to which the social grants system is assisting in poverty reduction, with particular reference to households’ abilities to provide material care for its children. Generally, the situation is one of dire poverty; 64% of all households fell below the poverty line. While mixed households appear to be the “worst off”, this is due mainly to them being larger and, therefore, carrying a greater burden. Government social grants provide an economic safety net but our data suggests that child support grants, in particular, are not being accessed by many in need of them.