Authors: Caroline Kuo & Don Operario

Abstract: In South Africa, an estimated 2.5 million children have been orphaned by AIDS and other causes of adult mortality. Although there is a growing body of research on the well-being of South African orphaned children, few research studies have examined the health of adult individuals caring for children in HIV-endemic communities. The cross-sectional survey assessed prevalence of general health and functioning (based on Short-Form 36 version 2 scale), depression (based on Center for Epidemiologic Studies-Depression scale), anxiety (using Kessler-10 scale), and post-traumatic stress (using the Harvard Trauma Questionnaire) among a representative community sample of adults caring for children in Umlazi Township, an HIV-endemic community in South Africa. Of 1599 respondents, 33% (n=530) were carers of orphaned children. Results showed that, overall, carers reported poor general health and functioning and elevated levels of depression, anxiety, and post-traumatic stress. Carers of orphaned children reported significantly poorer general health and functioning and higher rates of depression and post-traumatic stress compared with carers of non-orphaned children. In multivariate analyses, orphan carer and non-orphan carer differences in general health were accounted for by age, gender, education, economic assets, and source of income, but differences in depression were independent of these cofactors. Interventions are needed to address physical and mental health of carers in general. Greater health problems among orphan carers appeared to be fully explained by socioeconomic characteristics, which offer opportunities for targeting of programs. More research is needed to understand determinants of mental health disparities among orphan carers, which were not explained by socioeconomic characteristics.

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Authors: Caroline Kuo, Jane Fitzgerald, Don Oerario, & Marisa Casale

Abstract: Drawing upon a sample of 1,599 adults caring for children in HIV-endemic Umlazi Township in South Africa, this cross-sectional survey investigated whether perceived social support varied among caregivers of AIDS-orphaned children (n=359) as compared to caregivers of children orphaned by other causes (n=171) and caregivers of non-orphaned children (n=1,069). Results of multivariate linear regressions indicate that caregivers of AIDS-orphaned children reported significantly lower levels of social support compared to caregivers of other-orphaned children and non-orphaned children independent of socio-demographic covariates. Caregivers of other-orphaned and non-orphaned children reported similar levels of social support. In terms of sources of support, all caregivers were more likely to draw support from family and significant others rather than friends. These findings indicate a need to develop interventions that can increase levels of social support for caregivers of AIDS-orphaned children, particularly networks that include friends and significant others.

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Background: 

Prior research—mostly on the US and Europe—suggests that children who grow up without one or both parents in the household are at risk for a host of negative educational outcomes (Magnuson and L. M. Berger, 2009).  This essay builds on this research to explore whether this finding holds true in all regions of the world.

Key questions:

1. Is family structure associated with children’s educational outcomes, even when other possible factors explaining differences are taken into account (for example, parental education, family wealth, and parental employment)?

2. Is family structure associated with children’s feelings of being connected to their school and their perceptions of how relevant school is for them?

3. Are there important differences in the association between family structure and children’s education between major world regions?

Data Sources: 

This essay draws on original analyses of two international datasets to answer these questions. The first was the 2009 Program for International Student Assessment (PISA), conducted by the Organization for Economic Cooperation and Development (OECD), which was used to examine the effect of family structure on educational outcomes among 15-year-olds in countries that are mostly considered middle- or high-income countries, though some countries in PISA may be considered low income.  The 2000 PISA data were also used to supplement these analyses.The second was from the Demographic and Health Surveys (DHS), which was used to examine the effect of family structure on educational outcomes among similar youth in low-income countries.

Results & Discussion: 

As expected, among high- and middle-income countries, children living with two parents are more likely than are those living with one or no parents to follow a normal progression though school, and to experience higher levels of reading literacy. These results suggest that in many countries, parents serve as an important source of support and resources that can benefit their children’s education, with greater resources coming from two parents. In many European countries, parents’ skills and resources have a strong association with children’s cognitive abilities, and family conditions during childhood (including the number of parents children live with) play a key role in children’s long-term life chances.

However, the results of this study also indicate that the positive effects of living with two parents were much less consistent in low-income countries. There were few differences between children living with one versus two parents in many low income countries once all family and individual background factors were considered, and there was even an advantage to living with a single parent for some educational outcomes in some countries.

There are several potential non-competing explanations for why family structure seems to matter less in low-income countries. It is possible that family structure simply does not matter as much for children’s education in low-income countries where many obstacles to good educational outcomes remain. These obstacles are likely to affect children in all types of families, and include the availability and cost of schools, teacher quality, parental health, children’s health and nutrition, seasonal labor demands, and attitudes toward work and school. Thus, rates of school enrollment and children’s normal progression through school in low-income countries may be much more sensitive to these types of factors than to the number of parents in the household.

Labor migration may also play a role in the relationship between family structure and educational outcomes in low-income countries. When a parent is absent from the household because he or she is sending money home while working in a more economically-advanced area, children may experience less disadvantage from a parent’s absence than may children whose parent was never part of the household or whose parents divorced. Additional income may even place such households at an advantage. For example, in South Africa, households receiving remittances were found to be 50 percent more likely to keep children in school.51 Thus, in low-income countries, incentives for separating the family in order to support it are greater than in high- and middle-income countries. Further exploration of the reasons that children may be living with only one or no parents, and more detail on who is in these households (many children that are not living with their parents may be living with grandparents, for example) will help us understand the processes occurring within these families that may benefit or harm children’s educational attainment and achievement.

Investigators: Mindy E. Scott, Laurie F. DeRose, Laura H. Lippman, and Elizabeth Cook

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Authors: Dorsey S, Kerns SE, Trupin EW, Conover KL, Berliner L.

Date: 2012

Abstract: Youth in the foster care system have substantially higher rates of mental health needs compared to the general population, yet they rarely receive targeted, evidence-based practices (EBPs). Increasingly emerging in the literature on mental health services is the importance of “brokers” or “gateway providers” of services. For youth in foster care, child welfare caseworkers often play this role. This study examines caseworker-level outcomes of Project Focus, a caseworker training and consultation model designed to improve emotional and behavioral outcomes for youth in foster care through increased linkages with EBPs. Project Focus was tested through a small, randomized trial involving four child welfare offices. Caseworkers in the Project Focus intervention group demonstrated an increased awareness of EBPs and a trend toward increased ability to identify appropriate EBP referrals for particular mental health problems but did not have significantly different rates of actual referral to EBPs. Dose of consultation was associated with general awareness of EBPs. Implications for practice and outcomes for youth are discussed.

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Authors: Knerr W, Gardner F, Cluver L

Date: 2013

Abstract: 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.

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Authors: Mannarino AP, Cohen JA, Deblinger E, Runyon MK, Steer RA.

Date: 2012

Abstract: This study presents the findings from 6- and 12-month follow-up assessments of 158 children ages 4-11 years who had experienced sexual abuse and who had been treated with Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) with or without the inclusion of the trauma narrative (TN) treatment module and in 8 or 16 treatment sessions. Follow-up results indicated that the overall significant improvements across 14 outcome measures that had been reported at posttreatment were sustained 6 and 12 months after treatment and on two of these measures (child self-reported anxiety and parental emotional distress) there were additional improvements at the 12-month follow-up. Higher levels of child internalizing and depressive symptoms at pretreatment were predictive of the small minority of children who continued to meet full criteria for posttraumatic stress disorder at the 12-month follow-up. These results are discussed in the context of the extant TF-CBT treatment literature.

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Authors: Hallfors DD, Cho H, Mbai I, Milimo B, Itindi J.

Date: 2012

Abstract: We conducted a 2-year pilot randomized controlled trial (N = 105) in a high HIV-prevalence area in rural western Kenya to test whether providing young orphan adolescents with uniforms, school fees, and community visitors improves school retention and reduces HIV risk factors. The trial was a community intervention, limited to one community. In this paper, we examined intervention implementation and its association with outcomes using longitudinal data. We used both quantitative and qualitative methods to evaluate the community-based model for orphan HIV prevention, with recommendations for future studies. Despite promising effects after 1 year, GEE analyses showed null effects after 2 years. Volunteer community visitors, a key element of the intervention, showed little of the expected effect although qualitative reports documented active assistance to prevent orphans’ school absence. For future research, we recommend capturing the transition to high school, a larger sample size, and biomarker data to add strength to the research design. We also recommend a school-based intervention approach to improve implementation and reduce infrastructure costs. Finally, we recommend evaluating nurses as agents for improving school attendance and preventing dropout because of their unique ability to address critical biopsychosocial problems.

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