Tonya R. Thurman

Sexual Risk Behavior among South African Adolescents: Is Orphan Status a Factor?

There is concern that orphans may be at particular risk of HIV infection due to earlier age of sexual onset and higher likelihood of sexual exploitation or abuse; however, there is limited empirical evidence examining this phenomenon. Utilizing data from 1694 Black South African youth aged 14–18, of whom 31% are classified as orphaned, this analysis explores the relationship between orphan status and sexual risk. The analysis found both male and female orphans significantly more likely to have engaged in sex as compared to non-orphans (49% vs. 39%). After adjusting for socio-demographic variables, orphans were nearly one and half times more likely than non-orphans to have had sex. Among sexually active youth, orphans reported younger age of sexual intercourse with 23% of orphans having had sex by age 13 or younger compared to 15% of non-orphans. Programmatic implications of these findings for the care and protection of orphans are discussed.

Psychosocial support and marginalization of youth-headed households in Rwanda.

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

Depressive Symptoms in Youth Heads of Household in Rwanda Correlates and Implications for Intervention

OBJECTIVE To examine the level of depressive symptoms and their predictors in youth from one region of Rwanda who function as heads of household (ie, those responsible for caring for other children) and care for younger orphans. DESIGN Cross-sectional survey SETTING Four adjoining districts in Gigonkoro, an impoverished rural province in southwestern Rwanda. PARTICIPANTS Trained interviewers met with the eldest member of each household (n = 539) in which a youth 24 years old or younger was caring for 1 child or more. MAIN EXPOSURE Serving as a youth head of household. MAIN OUTCOME MEASURES Rates and severity of depressive symptoms using the Center for Epidemiologic Studies Depression scale; measures of grief, adult support, social marginalization, and sociodemographic factors using scales developed for this study. RESULTS Of the 539 youth heads of household, 77% were subsistence farmers and only 7% had attended school for 6 years or more. Almost half (44%) reported eating only 1 meal a day in the last week, and 80% rated their health as fair or poor. The mean score on the Center for Epidemiologic Studies Depression scale was 24.4, exceeding the most conservative published cutoff score for adolescents. Multivariate analysis revealed that reports of depressive symptoms that exceeded the clinical cutoff were associated with having 3 basic household assets or fewer, such as a mattress and a spare set of clothes (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.70), eating less than 1 meal per day (OR, 1.68; 95% CI, 1.09-2.60), reporting fair health (OR, 1.32; 95% CI, 0.76-2.29) or poor health (OR, 2.33; 95% CI, 1.17-4.64), endorsing high levels of grief (OR, 2.67; 95% CI, 1.73-4.13), having at least 1 parent die in the genocide as opposed to all other causes of parental death (OR, 1.83; 95% CI, 1.10-3.04), and not having a close friend (OR, 1.91; 95% CI, 1.17-3.12). There was an interaction between marginalization from the community and alcohol use; youth who were highly marginalized and did not drink alcohol were more than 3 times more likely to report symptoms of depression (OR, 3.07; 95% CI, 1.73-5.42). When models were constructed by grouping theoretically related variables into blocks and controlling for other blocks, the emotional status block of variables (grief and marginalization) accounted for the most variance in depressive symptoms. CONCLUSIONS Orphaned youth who head households in rural Rwanda face many challenges and report high rates of depressive symptoms. Interventions designed to go beyond improving food security and increasing household assets may be needed to reduce social isolation of youth heads of household. The effect of head-of-household depressive symptoms on other children living in youth-headed households is unknown.

Infants and young children living in youth‐headed households in Rwanda: Implications of emerging data

The HIV/AIDS epidemic has already produced millions of orphans in Africa and the peak of the orphan epidemic has not yet been reached. One emerging social trend associated with premature parental death is the formation of households headed by youth aged 13-24. In Rwanda, specific sociocultural factors have supported the formation of youth-headed households (YHH) in the wake of both the 1994 genocide and the ongoing HIV/AIDS epidemic. There is no published data on the health and socioemotional functioning of children under 5 living in YHH. Survey data from 692 YHH in one region of Rwanda yielded a subsample of 89 homes which contained one or more children under 5 (n=104). These data reveal that a majority of young children living in YHHs is in fair or poor health. Heads of household themselves report high levels of depressive symptoms and social isolation; reports of emotional distress among the youngest children in the homes are associated with reports of higher symptomatology among heads of household. Findings are interpreted in light of the sociocultural context of Rwanda and the implications of the data for intervention are considered.

Caregiver burden among adults caring for orphaned children in rural South Africa

The AIDS epidemic has created an unprecedented number of orphans. While largely absorbed by extended family, this additional responsibility can weigh heavily on their caregivers. The concept of caregiver burden captures multiple dimensions of well-being (e.g., physical, social and psychological). Measuring the extent and determinants of caregiving burden can inform the design of programmes to ease the negative consequences of caregiving. This study uses the baseline data from a study assessing interventions for orphans and vulnerable adolescents in the Eastern Cape, South Africa. Orphan caregivers (n = 726) completed an adapted version of the 12-item Zarit Burden Interview. In addition to basic caregiver and household demographics, the survey also collected information on AIDS-related illness and recent deaths. Descriptive data are presented, followed by multivariate Poisson regression models to explore factors associated with caregiver burden. Approximately 40% of caregivers reported high levels of orphan caregiving burden. Feelings of stress and inadequacy concerning their care responsibilities as well as anger towards the child were common. Household food insecurity was the most important predictor of orphan caregiving burden (marginal effect = 7.82; p < 0.001 for those reporting severe hunger); income was also a significant determinant. When other AIDS impacts were added to the model, only the AIDS-related illness of the caregiver was significantly associated with burden (marginal effect = 3.77; p < 0.001). This study suggests that caregivers with economic vulnerability and those struggling with their own AIDS-related illness feel most overburdened. These findings are particularly relevant to service providers who must identify caregivers in need of immediate assistance and allocate limited resources effectively. To alleviate caregiver burden, programmes must foster greater economic security (e.g., by facilitating access to social grants or directly providing cash transfers) and coordinate services with home-based care programmes serving the chronically ill.

Impact of a mentoring program on psychosocial wellbeing of youth in Rwanda: Results of a quasi-experimental study

Addressing the psychosocial needs of vulnerable children and youth is viewed increasingly as a priority of humanitarian programs, particularly in Africa, where the scale of the problem necessitates community-based solutions. This quasi-experimental study tested a model of adult mentorship and support to improve psychosocial outcomes among youth-headed households in a rural area of Rwanda. Two rounds of data were collected from youth who served as heads of their households. Following the baseline survey in 2004 (n = 692), an adult mentorship program was implemented among half the sample. A follow-up survey was conducted after 18 months of intervention exposure (n = 593). Through regular home visits, mentors developed a stable, caring relationship with youth in their community living without an adult caregiver. Each mentor was assigned 2–3 youth-headed households located within their own community to visit at least once a month for 2–3 hours in the home. Over an 18-month period, 156 trained adult mentors (60% male, 40% female) visited and supported 441 households. Multivariable analyses explored linkages between exposure to the intervention and four key psychosocial outcomes: perceptions of adult support, marginalization, grief and symptoms of depression. Over time, youth with a mentor reported a significant increase in perceptions of available adult support and decreases in marginalization. While grief in the comparison group grew significantly over time, grief levels in the intervention group remained stable, suggesting that the mentorship program may have mitigated grief among youth in the intervention areas. Intervention respondents also reported a slight, but significant, decrease in depressive symptoms. Findings suggest that the mentoring program enhanced available support and community connectedness among youth in this study. However, program impact on emotional wellbeing was more modest. More intensive interventions may be needed to reduce grief symptoms and for those with high levels of depressive symptoms.

Respondent-driven sampling: A new method for studying street children with findings from Albania

Sampling methods to study street children often rely on convenience approaches. Respondent-driven sampling (RDS) is a relatively new methodology for sampling hard-to-reach populations utilizing peer-driven recruitment. It includes both field and analytical procedures to account for non-random recruitment patterns and generates statistically valid samples. This article describes RDS and assesses its effectiveness to recruit a diverse sample of street children, defined as children aged 10–17 years who engage in economic activity on the street in Tirana, Albania. This is the first publication on the use of RDS among street children. This article describes the demographic profile of street children and assesses whether they are sufficiently networked to justify the use of RDS as a sampling approach. Beginning with 10 initial recruits, 293 street children were recruited within 9 weeks. The sample included children of various ethnicities and principal work activities, as well as those with both a short and long history of street work. Males greatly outnumbered females (93.9% vs. 6.1%) and 20.6% of children reported sometimes sleeping away from home. Children had dense social network ties, irrespective of whether they slept at home every day. They also formed social networks related to ethnicity and type of work, but less so with respect to gender. Examination of recruitment patterns revealed important biases that may exist in other methods utilized to study this population. The importance of analytical adjustments applied in RDS is also demonstrated. RDS could be an important breakthrough for researchers and policymakers, providing a more accurate profile of street childrens characteristics.

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

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

Home visiting programs for HIV-affected families: a comparison of service quality between volunteer-driven and paraprofessional models

Home visiting is a popular component of programs for HIV-affected children in sub-Saharan Africa, but its implementation varies widely. While some home visitors are lay volunteers, other programs invest in more highly trained paraprofessional staff. This paper describes a study investigating whether additional investment in paraprofessional staffing translated into higher quality service delivery in one program context. Beneficiary children and caregivers at sites in KwaZulu-Natal, South Africa were interviewed after 2 years of program enrollment and asked to report about their experiences with home visiting. Analysis focused on intervention exposure, including visit intensity, duration and the kinds of emotional, informational and tangible support provided. Few beneficiaries reported receiving home visits in program models primarily driven by lay volunteers; when visits did occur, they were shorter and more infrequent. Paraprofessional-driven programs not only provided significantly more home visits, but also provided greater interaction with the child, communication on a larger variety of topics, and more tangible support to caregivers. These results suggest that programs that invest in compensation and extensive training for home visitors are better able to serve and retain beneficiaries, and they support a move toward establishing a professional workforce of home visitors to support vulnerable children and families in South Africa.

Promoting uptake of child HIV testing: an evaluation of the role of a home visiting program for orphans and vulnerable children in South Africa

ABSTRACT HIV counseling and testing (HCT) is critical for children in generalized epidemic settings, but significant shortfalls in coverage persist, notably among orphans and others at disproportionate risk of infection. This study investigates the impact of a home visiting program in South Africa on orphaned and vulnerable children’s uptake of HCT. Using propensity score matching, survey data for children receiving home visits from trained community-based care workers were compared to data from children living in similar households that had not yet received home visits (n = 1324). Home visits by community-based care workers increased the odds of a child being tested by 97% (OR = 1.97, 95% CI = 1.34–2.92). The home visitation program had an especially pronounced effect on orphans, more than doubling their odds of being tested (OR = 2.12, 95% CI = 1.00–4.47) compared to orphans living in similar households that did not receive home visits. Orphan status alone had no effect on HCT independent of program exposure, suggesting that the program was uniquely able to increase testing in this subgroup. Results highlight the potential for increasing HCT access among children at high risk through targeted community-based initiatives.