Title: Building orphan competent communities: experiences from a community-based capital cash transfer initiative in Kenya
Authors: Morten Skovdal, Winnie Mwasiaji, Albert Webale, Andrew Tomkins
Abstract: As a result of the increasing number of orphans in sub-Saharan Africa, numerous programmes have been initiated to facilitate the care and support of orphaned and vulnerable children. This paper reports on a community-based capital cash transfer initiative in Kenya and explores its role in building orphan competent and supportive communities through its participatory project cycle. Using a mixture of individual and group interviews, 300 orphaned children and 110 adults involved in this initiative were interviewed using open-ended questions. A thematic analysis of the data revealed that many of the communities participating in this programme had become more united and active in the support of orphaned children following the mobilization of much needed economic, political and social support resources. Despite many difficulties, largely due to the complexity of communities, we conclude that community-based capital cash transfer initiatives can facilitate the building of orphan competent communities.
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Title: Building adherence-competent communities: factors promoting children’s adherence to anti-retroviral HIV/AIDS treatment in rural Zimbabwe
Authors: Catherine Campbell, Morten Skovdal, Zivai Mupambireyi, Claudius Madanhire, Constance Nyamukapa, Simon Gregson
Abstract: Given relatively high levels of adherence to HIV treatment in Africa, we explore factors facilitating children’s adherence, despite poverty, social disruption and limited health infrastructure. Using interviews with 25 nurses and 40 guardians in Zimbabwe, we develop our conceptualisation of an ‘adherence competent community’, showing how members of five networks (children, guardians, community members, health workers and NGOs) have taken advantage of the gradual public normalisation of HIV/AIDS and improved drug and service availability to construct new norms of solidarity with HIV and AIDS sufferers, recognition of HIV-infected children’s social worth, an ethic of care/assistance and a supporting atmosphere of enablement/empowerment.
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Title: Evaluation of the orphans reunification project in Eritrea
Authors: E Morah, S Mebrathu, K Sebhatu
The evidence clearly shows that the status of assisted orphans compares favorably with that of non-orphans, thus indicating that the psychosocial integration between the host families and the orphans has been successful. Although orphan boys were indicated to be slightly better off, the gender differences were not dramatic. Substantial evidence also suggests that the project has built capacities of the relevant government ministry on a number of key areas’ research skills and appreciation of the importance of solid operational research before social interventions, participatory planning, monitoring and management tools, community mobilization and advocacy for child protection. Finally, the reunification project is found to be significantly more cost-effective, psychosocially acceptable and sustainable than the alternative strategy of keeping the children in orphanages.
Title: Prevalence and predictors of HIV-related stigma among institutional- and community-based caregivers of orphans and vulnerable children living in five less-wealthy countries
Authors: Lynne Messer, Brian Pence, Kathryn Whetten, Rachel Whetten, Nathan Thielman, Karen O’Donnell, Jan Ostermann
In the face of the HIV/AIDS epidemic that has contributed to the dramatic increase in orphans and abandoned children (OAC) worldwide, caregiver attitudes about HIV, and HIV-related stigma, are two attributes that may affect caregiving. Little research has considered the relationship between caregiver attributes and caregiver-reported HIV-related stigma. In light of the paucity of this literature, this paper will describe HIV-related stigma among caregivers of OAC in five less wealthy nations.
Baseline data were collected between May 2006 through February 2008. The sample included 1,480 community-based and 192 institution-based caregivers. Characteristics of the community-based and institution-based caregivers are described using means and standard deviations for continuous variables or counts and percentages for categorical variables. We fit logistic regression models, both for the full sample and separately for community-based and institution-based caregivers, to explore predictors of acceptance of HIV.
Approximately 80% of both community-based and institution-based caregivers were female; and 84% of institution-based caregivers, compared to 66% of community-based caregivers, said that they would be willing to care for a relative with HIV. Similar proportions were reported when caregivers were asked if they were willing to let their child play with an HIV-infected child. In a multivariable model predicting willingness to care for an HIV-infected relative, adjusted for site fixed effects, being an institution-based caregiver was associated with greater willingness (less stigma) than community-based caregivers. Decreased willingness was reported by older respondents, while willingness increased with greater formal education. In the adjusted models predicting willingness to allow one’s child to play with an HIV-infected child, female gender and older age was associated with less willingness. However, willingness was positively associated with years of formal education.
The caregiver-child relationship is central to a child’s development. OAC already face stigma as a result of their orphaned or abandoned status; the addition of HIV-related stigma represents a double burden for these children. Further research on the prevalence of HIV-related acceptance and stigma among caregivers and implications of such stigma for child development will be critical as the policy community responds to the global HIV/AIDS orphan crisis.
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Title: A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6–12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations
Authors: Kathryn Whetten, Jan Ostermann, Rachel Whetten, Brian Pence, Karen O’Donnell, Lynne Messer, Nathan Thielman, The Positive Outcomes for Orphans (POFO) Research Team
Leaders are struggling to care for the estimated 143,000,000 orphans and millions more abandoned children worldwide. Global policy makers are advocating that institution-living orphans and abandoned children (OAC) be moved as quickly as possible to a residential family setting and that institutional care be used as a last resort. This analysis tests the hypothesis that institutional care for OAC aged 6–12 is associated with worse health and wellbeing than community residential care using conservative two-tail tests.
The Positive Outcomes for Orphans (POFO) study employed two-stage random sampling survey methodology in 6 sites across 5 countries to identify 1,357 institution-living and 1,480 community-living OAC ages 6–12, 658 of whom were double-orphans or abandoned by both biological parents. Survey analytic techniques were used to compare cognitive functioning, emotion, behavior, physical health, and growth. Linear mixed-effects models were used to estimate the proportion of variability in child outcomes attributable to the study site, care setting, and child levels and institutional versus community care settings. Conservative analyses limited the community living children to double-orphans or abandoned children.
Health, emotional and cognitive functioning, and physical growth were no worse for institution-living than community-living OAC, and generally better than for community-living OAC cared for by persons other than a biological parent. Differences between study sites explained 2–23% of the total variability in child outcomes, while differences between care settings within sites explained 8–21%. Differences among children within care settings explained 64–87%. After adjusting for sites, age, and gender, institution vs. community-living explained only 0.3–7% of the variability in child outcomes.
This study does not support the hypothesis that institutional care is systematically associated with poorer wellbeing than community care for OAC aged 6–12 in those countries facing the greatest OAC burden. Much greater variability among children within care settings was observed than among care settings type. Methodologically rigorous studies must be conducted in those countries facing the new OAC epidemic in order to understand which characteristics of care promote child wellbeing. Such characteristics may transcend the structural definitions of institutions or family homes.
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Title: Difference in psychosocial well-being between paternal and maternal AIDS orphans in rural China
Authors: Qun Zhao, Xiaoming Li, Xiaoyi Fang, Guoxiang Zhao, Junfeng Zhao, Xiuyun Lin, Bonita Stanton
Abstract: This study compares psychosocial well-being between paternal and maternal orphans in rural China in a sample (n = 459) of children who had lost one parent to HIV and who were in family-based care. Measures included academic marks, education expectation, trusting relationships with current caregivers, self-reported health status, depression, loneliness, posttraumatic stress, and social support. No significant differences were reported between maternal and paternal orphans, except that paternal orphans reported better trusting relationships with caregivers than maternal orphans. Children with a healthy surviving parent reported significantly better scores for depression, loneliness, posttraumatic stress, and social support than children with a sick parent. Analyses showed significance with regard to orphan status on academic marks and trusting relationships with caregivers while controlling for age, gender, surviving parent’s health status, and family socioeconomic status. Results underscore the importance of psychosocial support for children whose surviving parent is living with HIV or another illness.
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Title: Are orphans at increased risk of malnutrition in Malawi?
Authors: Ratana Panpanich, Bernard Brabin, Andrew Gonani, Stephen Graham
Abstract: The objective of this study was to compare the nutritional status and health problems of village orphans, non-orphans and orphanage children, and to identify factors associated with undernutrition. A cross-sectional study was conducted in three orphanages and two villages near Blantyre, Malawi. Seventy-six orphanage children, 137 village orphans and 80 village non-orphans were recruited. Anthropometric measurement was done and guardians were interviewed. In the group of children aged <5 years, the prevalence of undernutrition in orphanage children was 54.8% compared with 33.3% and 30% of village orphans and non-orphans, respectively. Sixty-four per cent of young orphanage children were stunted compared with 50% of village orphans and 46.4% of non-orphans. The mean (SD) Z-score of height/age was significantly lower in the orphanage group, -2.75 (1.29) compared with -2.20 (1.51) and -1.61 (1.57) in the village orphan and non-orphan groups (p<0.05). Conversely, older orphanage children (>5 years) were less stunted and wasted than orphans and non-orphans in villages. Illness of children in the last month was reported to be higher in the non-orphan group, especially diarrhoeal disease, which occurred in 30% compared with 10.8% of village orphans and 6.6% of orphanage children. More than three children in a family being cared for by guardians was significantly associated with undernutrition. Orphanage girls were more likely to be malnourished than orphanage boys. Children who had been admitted to an orphanage for more than a year were less malnourished. In village orphans, there was no association between undernutrition and duration of stay in extended families. Age and education of guardians were not associated with the nutritional status of children. We conclude that young orphanage children are more likely to be undernourished and more stunted than village children. Older orphanage children seem to have better nutrition than village orphans. There was no significant difference in nutritional status between village orphans and non-orphans.
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Study Title: Positive Outcomes for Orphans (POFO): Longitudinal study of orphaned and abandoned children (OAC) from ages 6-12 to ages 15-21 living in 6 diverse settings
Context: International policymakers are struggling to find solutions for the estimated 153 million children worldwide who have had at least one parent die, largely due to high mortality rates from conditions such as malaria, tuberculosis, HIV/AIDS and pregnancy complications. Millions more do not know the whereabouts of their parents. In light of the large presence of orphaned and abandoned children, especially in low- and middle-income countries continued research is needed that allows policy makers and providers to understand and develop locally feasible and appropriate ways to care for the children.
Study Aims: Positive Outcomes for Orphans (POFO) is longitudinal study conducted in five countries over a period of 9-10 years thanks to 2 consecutive National Institutes of Child Health and Development (NICHD) funded studies. OAC were ages 6-12 at baseline and will be ages 15-21 at the conclusion of the study. This unique population-based study is the only one of its kind that follows orphaned and abandoned children (OAC) for up to 9 years in culturally and structurally diverse settings allowing for a glimpse into what current care options are and the effects of that care and other life events over time on: health, cognition, emotion, educational attainment, labor force participation (including forced labor), sexual risk taking, marital patterns and community engagement.
Methods: OAC ages 6-12 and living in family settings were recruited from six diverse study areas in five countries: Addis Ababa (Ethiopia), Bungoma District (Kenya), Kilimanjaro Region (Tanzania), Battambang District (Cambodia), and Hyderabad and Nagaland (India) (N=1480). The sampling strategy involved the selection of 50 sampling areas (‘‘clusters’’) at each site and five OAC from each cluster. From comprehensive lists of residential facilities in study area, 83 facilities were randomly selected for including in the study with 1,357 OAC then randomly selected from lists of children of the appropriate age from each facility. Baseline assessments were collected for children and caregivers being in May 2006: enrollment continued for 22 months. OAC were defined as children who had at least one parent die or who were abandoned by both parents. In households with multiple eligible children, one child was selected as the child whose first name started with the earliest letter in the alphabet. Interviews with children’s self-identified primary caregivers were conducted in their respective native language in the child’s residence. Six-month follow-up assessments were conducted in 5 of the 6 study sites and 12-months follow-up assessments in all sites. Interview windows for follow-up assessments were open from one month prior to two months after the scheduled follow-up date.
- The study seeks to determine which environmental characteristics (e.g. home, community, culture, social networks, etc.) promote positive and negative outcomes for OAC as they transition through to young adulthood. With this knowledge, more appropriate local, national and international policies can be created for this age group and appropriate care options can be more actively supported.
- The study will seek to examine how personal factors, including life events, (e.g. number of potentially traumatic events experienced, emotional health, and cognitive development) affect orphans and identify potential interventions that could improve outcomes for the adult lives of orphans.
Principal Investigator: Kathryn Whetten (Duke University)
Investigators: Bernard Agala (Duke University), Cyrilla Amanya (ACE Africa, Kenya), Misganaw Eticha (SVO Ethiopia), Amy Hobbie (Duke University), Dafrosa Itemba (TAWREF, Tanzania), Rachel Manongi (KCMC, Tanzania), Lynne Messer (Duke University), (KCMC, Tanzania), Karen O’Donnell (Duke University), Jan Ostermann (Duke University), Brian Pence (Duke University), Nathan Thielman (Duke University), Vanroth Vann (Homeland, Cambodia), Augustine Wasonga (ACE Africa, Kenya), Rachel Whetten (Duke University)
Contact Information: [email protected]
Study Title: Child transitions from residential facilities to other communities: predictors of child wellbeing
Context: Globally, one hundred and fifty three million children are estimated to have been orphaned as defined by the death of one or both parents due to diseases such as malaria, tuberculosis, and cancers, maternal mortality, unintentional injuries, natural disasters and armed conflict: AIDS accounts for 16.6 million of these children. We can anticipate that numbers of orphaned children will increase with factors such as economic declines, decreased agricultural output due to environmental changes and increased natural disasters. In Ethiopia, an estimated 650,000 children have lost one or both parents to AIDS. The majority of orphaned children and children whose biological parents have left them are cared for by the remaining parent, other family members, or non-relatives in family settings: a small proportion live in residential facilities
Study Aims: The primary goal of this pilot study is to understand the emotional and physical well-being of children transitioning out of residential care to better inform good policy and practice on the protection of children. The intent is to understand factors associated with positive and negative transition outcomes. Care transitions occur for a variety of reasons, such as family placement, aging out (reaching the maximum age allowed in residential facilities), child self-initiated departures, community or family initiated retrievals, residential facility initiated expulsions, and residential facility closures. This study attempts to assess children’s mental and physical well-being while still living in residential care and then follow them out of residential facility care into other living environments.
Methods: This initial study is designed to determine the feasibility of finding, following and maintaining communication with children as they leave residential facilities, to examine the different living environments they transition into, and to examine if there are trends or associations in how well transitions are made. In particular, pre-transition child characteristics (e.g., age of entry into residential care, years in residential care, age at placement in a community setting), facility characteristics, transition planning characteristics, community placement characteristics, and child wellbeing outcomes will be analyzed and compared to data from matched controls in community-family settings. Short-term descriptive information such as documenting the range of living environments children transition into is vital. However, short-term outcomes may not reflect longer-term physical or emotional trends. If the pilot study methodology proves successful, i.e., children are able to be followed over time and useful measurements obtained, a longer, multi-country longitudinal study will be proposed.
- To examine the positive and negative physical and mental health trajectories of children and young adults transitioning out of residential facility care for a variety of reasons, including residential facility closures, aging out and self-other initiated departures.
- To determine how different types of residential facility-to-community transition experiences (e.g., types of preparation, planning process, availability of resources) affect children and families’ mental and physical wellbeing.
- To better understand associations between characteristics of the residential facilities and post-residential facility care, and child emotional, physical and social well-being before and after re-location.
- If the pilot study methodology proves successful and children are able to be followed over time, researchers may propose a larger multi-country study.
Principal Investigator: Sumi Ariely (Duke University)
Investigators: Misganaw Eticha (Stand for the Vulnerable Organization, Ethiopia), Charles Nelson (Harvard University), Jan Ostermann (Duke University), Lorraine Sherr (University College London), Kathryn Whetten (Duke University), Rachel Whetten (Duke University)
Project Coordinator: Andrew Goodall
Contact Information: [email protected]