Socio-economic status and hunger among orphans and vulnerable children households in Lagos State, Nigeria.

BACKGROUND: HIV/AIDS has contributed to increasing orphans and vulnerable children in Nigeria. A measure of vulnerability is household hunger. OBJECTIVE: To assess level of household hunger and associated factors among OVC households in Lagos State. METHODS: A cross-sectional survey of 1300 OVC households in 5 selected Local Government Areas. The LGAs were selected using the Household Vulnerability Assessment index. Data collection was by personal interview of households' heads/caregivers using a structured questionnaire capturing socio-demographic, household economic profile and food-related variables. A multivariate logit model was fitted to identify independent predictors of household hunger after adjusting for confounding variables. RESULTS: The population density was 5.1 and 52.8% were females. A larger proportion of females (84.6%) than males (78.3%) reported that they had no food to eat in the last four weeks prior the survey. Poor household economic status (OR=1.41, CI: 1.03-1.92), age and marital status of caregiver were independent predictors of household hunger. The odds of hunger increased with caregiver's age; higher in households headed by never married (OR=3.99, CI: 1.15-13.89) and divorced/separated caregivers (OR=2.39, CI: 1.11-5.12). CONCLUSION: OVC households experienced severe hunger. Household economic strengthening would be useful strategy to mitigate the nutrition challenges of OVC in Lagos state.

Challenges of developing a district child welfare plan in South Africa: lessons from a community-engaged HIV/AIDS research project.

The Amajuba Child Health and Wellbeing Research Project measured the impact of orphaning due to HIV/AIDS on South African households between 2004 and 2007. Community engagement was a central component of the project and extended through 2010. We describe researcher engagement with the community to recruit participants, build local buy-in, stimulate interest in study findings, and promote integration of government social welfare services for families and children affected by HIV/AIDS. This narrative documents the experience of researchers, drawing also on project reports, public documents, and published articles, with the objective of documenting lessons learned in this collaboration between researchers from two universities and a community in South Africa during a period that spanned seven years. This experience is then analyzed within the context of an applied research, community-engagement framework.

Poverty, economic strengthening, and mental health among AIDS orphaned children in Uganda: Mediation model in a randomized clinical trial.

Some evidence points to the positive effects of asset accumulation programs on mental health of children living in low-resource contexts. However, no evidence exists as to why and how such impact occurs. Our study aims to understand whether child poverty, child work, and household wealth serve as pathways through which the economic strengthening intervention affects the mental health of AIDS-orphaned children. The study employed a cluster-randomized experimental design with a family-based economic strengthening intervention conducted among 1410 school-going AIDS-orphaned children ages 10 and 16 years old in 48 primary schools in South Western Uganda. To test the hypothesized relationships between the intervention, mediators (household wealth, child poverty, and child's work) and mental health, we ran structural equation models that adjust for clustering of individuals within schools and account for potential correlation among the mediators. We found significant unmediated effect of the intervention on children's mental health at 24 months (B = -0.59; 95% CI: 0.93, -0.25; p < 0.001; ß = -0.33). Furthermore, the results suggest that participation in the intervention reduced child poverty at 12 months, which in turn improved latent mental health outcome at 24 months (B = -0.14; 95% CI: -0.29, -0.01; p < 0.06; ß = -0.08). In addition, though not statistically significant at the 0.05 level, at 36 and 48 months, mental health of children in the treatment group improved by 0.13 and 0.16 standard deviation points correspondingly with no evidence of mediation. Our findings suggest that anti-poverty programs that aim solely to improve household income may be less advantageous to children's mental health as compared to those that are specifically targeted towards reducing the impact of poverty on children. Further studies using more comprehensive measures of child work and age-appropriate child mental health may shed more light on understanding the link between asset accumulation interventions, child labor and children's mental health.

The impact of school support on depression among adolescent orphans: a cluster-randomized trial in Kenya.

BACKGROUND: The objective of this study was to determine if a school support intervention for adolescent orphans in Kenya had effects on mental health, a secondary outcome. METHODS: In this paper, we analyzed data from a 4-year cluster-randomized trial of a school support intervention (school uniforms, school fees, and nurse visits) conducted with orphaned adolescents in Siaya County, western Kenya, who were about to transition to secondary school. 26 primary schools were randomized (1:1) to intervention (410 students) or control (425 students) arms. The study was longitudinal with annual repeated measures collected over 4 years from 2011 to 2014. We administered five items from the 20-item Center for Epidemiologic Studies Depression Scale Revised, a self-reported depression screening instrument. RESULTS: The intervention prevented depression severity scores from increasing over time among adolescents recruited from intervention schools. There was no evidence of treatment heterogeneity by gender or baseline depression status. The intervention effect on depression was partially mediated by higher levels of continuous school enrollment among the intervention group, but this mediated effect was small. CONCLUSIONS: School support for orphans may help to buffer against the onset or worsening of depression symptoms over time, promoting resilience among an important at-risk population.

Risk Factors and Treatment Needs among Orphan School Children.

AIM: The aim of the study was to identify risk factors and treatment needs of orphan children of Selangor, Kuala Lumpur, Malaysia. Ob ectives: (1) To identify the association between the frequency of snacking and caries among orphan schoolchildren, (2) To assess Streptococcus mutans and Lactobacilli (microbiological assessment) in saliva of orphan children, and (3) To formulate treatment needs for orphan children. MATERIALS AND METHODS: A cross-sectional study was done among 253 children of 5-, 12-, and 15-year-olds living in various orphanage houses of Selangor, Kuala Lumpur, Malaysia. Demographic data, and dietary and oral hygiene practices were collected through a structured questionnaire. Clinical examinations of children were conducted to assess oral health status and recorded in the World Health Organization oral health assessment form (1997). Stimulated saliva was collected for S. mutans and Lactobacilli levels. The statistical software, namely, Statistical Package for the Social Sciences version 19.0 was used for the analysis of the data. RESULTS: The final data analysis included 253 children of which 116 (45.8%) were boys and 137 (54.2%) were girls. Overall, 140 (55.33%) children were caries-free and 113 (44.66%) children presented with caries (decayed/missing/filled surface >0). High levels of salivary microbiological counts (S. mutans and Lactobacilli), i.e., ≥105, stress the importance of necessary preventive oral health services. Treatment needs among orphan children showed that most of the children, i.e., 58 (22.9%), need preventive or caries-arresting care followed by 49 (19.4%) who require two-surface filling as an immediate measure. CONCLUSION: From the results of our study, orphan children have low utilization of preventive and therapeutic oral health services. Urgent attention is required to plan a comprehensive dental health-care program to improve their oral health status. CLINICAL SIGNIFICANCE: Parents are the primary caretakers of children, but woefully some of them have to lead their lives without parents, the latter either being dead or incapable of bringing up their children. Such a group of children is known as orphans. As oral health is an integral part of general health, it is essential for health-care policy makers to address oral health needs of this underprivileged group of society. This article highlights the risk factors and treatment needs among orphan schoolchildren.

Invisible work: Child work in households with a person living with HIV/AIDS in Central Uganda.

BACKGROUND: HIV/AIDS has led to increased mortality and morbidity, negatively impacting adult labour especially in HIV/AIDS burdened Sub-Saharan Africa. There has been some exploration of the effects of HIV/AIDS on paid child labour, but little empirical work on children's non-paid child work. This paper provides quantitative evidence of how child and household-level factors affect children's involvement in both domestic and family farm work for households with a person living with HIV/AIDS (PLWHA) compared to non-PLWHA households using the 2010/2011 Centre for Health Economics Uganda HIV questionnaire Survey. METHOD: Descriptive analysis and multivariate logistic modelling is used to explore child and household-level factors that affect children's work participation. RESULTS: This research reveals greater demands on the labour of children in PLWHA households in terms of family farm work especially for boys. Results highlight the expected gendered social responsibilities within the household space, with girls and boys engaged more in domestic and family farm work, respectively. Girls shared a greater proportion of household financial burden by working more hours in paid work outside the household than boys. Lastly, the study revealed that a household head's occupation increases children's participation in farm work but had a partial compensatory effect on their involvement in domestic work. Wealth and socio-economic standing is no guarantee to reducing child work. CONCLUSION: Children from PLWHA households are more vulnerable to child work in family farm work especially boys; and girls are burdened beyond the household space through paid work. Differing perspectives and solutions need to consider the contextual nature of child work.

Investments in children's health and the Kenyan cash transfer for orphans and vulnerable children: evidence from an unconditional cash transfer scheme.

Child mortality is one of the most pressing global health and policy issues in the developing world. The leading drivers of death-pneumonia, diarrhea and malaria-are preventable and treatable. However, these illnesses are exacerbated by a lack of accessible nutrition, water, basic and preventive health services, and sanitary living conditions-all factors which are more likely to disproportionately impact the poor. We examine whether Kenya's largest social protection impacts children's incidence of upper respiratory illness. The Kenya Cash Transfer for Orphans and Vulnerable Children was designed to support orphans affected by HIV/AIDS and has covered over 240,000 households as of 2014. Using longitudinal, cluster-randomized program data from 2007 to 2009, we run a generalized linear latent and mixed method estimation model on a sample of children 0-7 years and under-5 years of age. We find that the program is associated with a decrease in illness in children 0-7 years of age (P < 0.05), but found no effects on a stratified sample of under-5 children. Furthermore, no impacts on health care seeking in the event of illness were detected. This study is one of few examining children's health using data from a large scale unconditional cash transfer program. With the widespread adoption of over 123 cash transfer programs across sub-Saharan Africa, these findings suggest social cash transfer programs are capable of promoting the multidimensional well-being for the world's most vulnerable populations.

Child-headed households in Rakai District, Uganda: a mixed-methods study.

OBJECTIVE: An important but neglected consequence of the AIDS pandemic that continues across sub-Saharan Africa is the phenomenon of child-headed households (CHH). This study aims to describe the challenges to health and well-being for young people living in child-headed households. METHODS: A mixed-methods research approach linked common themes using qualitative and quantitative instruments to provide a broad picture of the location and challenges of CHH in Kabira, Kyotera and Kamuganja in the Rakai District of southern Uganda. Local knowledge was used to locate CHH. RESULTS: 163 children living in 40 CHH were traced: 42·5% of the household heads were double orphans caring for younger siblings, and 43% were also caring for chronically ill or disabled grandparents who were economically unproductive and largely dependent on the eldest child for survival. It was found that those heading households were more likely not to attend school than children living at home with a parent. Their immediate needs ranged from food and shelter to health-care and education. Fear was a major theme: 38% of those interviewed reported fear of 'violence'. Children as young as 13 were responsible for navigating through complex decision-making processes from everyday basic necessities to decisions on the health care of younger siblings and grandparents. CONCLUSION: Children and young people living in CHH are a largely invisible and highly vulnerable population. Clear, officially accepted definitions of CHH are a first step in recognising this vulnerable group for whom safeguards will be necessary as social work develops in lower- and middle-income countries (LMICs). The precise numbers of CHH are unknown and further examination of this undocumented group is needed.

Improved water and household water purification practices among orphans and vulnerable children in a multi-sectoral empowerment program in Eastern province, Kenya.

Water quality is an important determinant of diarrheal illnesses, especially affecting children in sub-Saharan Africa. Orphans and vulnerable children (OVC) in sub-Saharan Africa are at increased risk of poor quality drinking water, and therefore of diarrheal illness. The present study assesses primary drinking water source and typical household water purification among OVC households involved in a multi-sectoral empowerment program in semi-rural Kenya. Findings show water purification practices, but not water source, significantly increase with more time in the program. Other factors associated with safer water include household income, orphan type, food consumption and security, school completion, psychological resilience, engaging in sexual intercourse with more than one partner in the past 12 months, and previous year's financial status. Incorporating water quality improvements in a community-based empowerment program such as the one described may be one method of improving water quality and decreasing diarrheal illnesses among OVCs in sub-Saharan Africa.

The Anticipated Clinical and Economic Effects of 90-90-90 in South Africa.

BACKGROUND: The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 global treatment target aims to achieve 73% virologic suppression among HIV-infected persons worldwide by 2020. OBJECTIVE: To estimate the clinical and economic value of reaching this ambitious goal in South Africa, by using a microsimulation model of HIV detection, disease, and treatment. DESIGN: Modeling of the "current pace" strategy, which simulates existing scale-up efforts and gradual increases in overall virologic suppression from 24% to 36% in 5 years, and the UNAIDS target strategy, which simulates 73% virologic suppression in 5 years. DATA SOURCES: Published estimates and South African survey data on HIV transmission rates (0.16 to 9.03 per 100 person-years), HIV-specific age-stratified fertility rates (1.0 to 9.1 per 100 person-years), and costs of care ($11 to $31 per month for antiretroviral therapy and $20 to $157 per month for routine care). TARGET POPULATION: South African HIV-infected population, including incident infections over the next 10 years. PERSPECTIVE: Modified societal perspective, excluding time and productivity costs. TIME HORIZON: 5 and 10 years. INTERVENTION: Aggressive HIV case detection, efficient linkage to care, rapid treatment scale-up, and adherence and retention interventions toward the UNAIDS target strategy. OUTCOME MEASURES: HIV transmissions, deaths, years of life saved, maternal orphans, costs (2014 U.S. dollars), and cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Compared with the current pace strategy, over 5 years the UNAIDS target strategy would avert 873 000 HIV transmissions, 1 174 000 deaths, and 726 000 maternal orphans while saving 3 002 000 life-years; over 10 years, it would avert 2 051 000 HIV transmissions, 2 478 000 deaths, and 1 689 000 maternal orphans while saving 13 340 000 life-years. The additional budget required for the UNAIDS target strategy would be $7.965 billion over 5 years and $15.979 billion over 10 years, yielding an incremental cost-effectiveness ratio of $2720 and $1260 per year of life saved, respectively. RESULTS OF SENSITIVITY ANALYSIS: Outcomes generally varied less than 20% from base-case outcomes when key input parameters were varied within plausible ranges. LIMITATION: Several pathways may lead to 73% overall virologic suppression; these were examined in sensitivity analyses. CONCLUSION: Reaching the 90-90-90 HIV suppression target would be costly but very effective and cost-effective in South Africa. Global health policymakers should mobilize the political and economic support to realize this target. PRIMARY FUNDING SOURCE: National Institutes of Health and the Steve and Deborah Gorlin MGH Research Scholars Award.

Orphanhood and fertility in young adults: Evidence from South Africa.

I study the relation between orphanhood and fertility patterns in young adults using a longitudinal survey from the city of Cape Town, South Africa. The data set combines two survey waves with a year-by-year life history calendar that records key outcomes (e.g., schooling, work, fertility). It also provides information on so-called 'parental investments' (time and material support), family background, and literacy and numeracy test scores. I find that orphans exhibit significantly higher rates of teenage pregnancy. In particular, teenage motherhood is 19% points more likely among (female) orphans. These results suggest that orphanhood may leave a long-lasting 'imprint' in terms of premature fertility, especially in teenage females.

Sexual Behavior Among Young Carers in the Context of a Kenyan Empowerment Program Combining Cash-Transfer, Psychosocial Support, and Entrepreneurship.

This study examined associations between sexual initiation, unprotected sex, and having multiple sex partners in the past year with participation in a three-year empowerment program targeting orphan and vulnerable children (OVC). The Kenya-based program combines community-conditioned cash transfer, psychosocial empowerment, health education, and microenterprise development. Program participants (n = 1,060) were interviewed in a cross-sectional design. Analyses used gender-stratified hierarchical logit models to assess program participation and other potential predictors. Significant predictors of increased female sexual activity included less program exposure, higher age, younger age at most recent parental death, fewer years of schooling, higher food consumption, higher psychological resilience, and lower general self-efficacy. Significant predictors of increased male sexual activity included more program exposure, higher age, better food consumption, not having a living father, and literacy. Findings support a nuanced view of current cash transfer programs, where female sexual activity may be reduced through improved financial status but male sexual activity may increase. Targeting of OVC sexual risk behaviors would likely benefit from being tailored according to associations found in this study. Data suggest involving fathers in sexual education, targeting women who lost a parent at a younger age, and providing social support for female OVC may decrease risk of human immunodeficiency virus (HIV) transmission.

Orphans and Vulnerable Children Affected by Human Immunodeficiency Virus in Sub-Saharan Africa.

In Sub-Saharan Africa, 15.1 million children have been orphaned because of human immunodeficiency virus (HIV). They face significant vulnerabilities, including stigma and discrimination, trauma and stress, illness, food insecurity, poverty, and difficulty accessing education. Millions of additional children who have living parents are vulnerable because their parents or other relatives are infected. This article reviews the current situation of orphans and vulnerable children, explores the underlying determinants of vulnerability and resilience, describes the response by the global community, and highlights the challenges as the HIV pandemic progresses through its fourth decade.

Effect of savings-led economic empowerment on HIV preventive practices among orphaned adolescents in rural Uganda: results from the Suubi-Maka randomized experiment.

Improving economic resources of impoverished youth may alter intentions to engage in sexual risk behaviors by motivating positive future planning to avoid HIV risk and by altering economic contexts contributing to HIV risk. Yet, few studies have examined the effect of economic-strengthening on economic and sexual behaviors of orphaned youth, despite high poverty and high HIV infection in this population. Hierarchal longitudinal regressions were used to examine the effect of a savings-led economic empowerment intervention, the Suubi-Maka Project, on changes in orphaned adolescents' cash savings and attitudes toward savings and HIV-preventive practices over time. We randomized 346 Ugandan adolescents, aged 10-17 years, to either the control group receiving usual orphan care plus mentoring (n = 167) or the intervention group receiving usual orphan care plus mentoring, financial education, and matched savings accounts (n = 179). Assessments were conducted at baseline, 12, and 24 months. Results indicated that intervention adolescents significantly increased their cash savings over time (b = $US12.32, ±1.12, p < .001) compared to adolescents in the control group. At 24 months post-baseline, 92% of intervention adolescents had accumulated savings compared to 43% in the control group (p < .001). The largest changes in savings goals were the proportion of intervention adolescents valuing saving for money to buy a home (ΔT1-T0 = +14.9, p < .001), pursue vocational training (ΔT1-T0 = +8.8, p < .01), and start a business (T1-T0 = +6.7, p < .01). Intervention adolescents also had a significant relative increase over time in HIV-preventive attitudinal scores (b = +0.19, ±0.09, p < .05), most commonly toward perceived risk of HIV (95.8%, n = 159), sexual abstinence or postponement (91.6%, n = 152), and consistent condom use (93.4%, n = 144). In addition, intervention adolescents had 2.017 significantly greater odds of a maximum HIV-prevention score (OR = 2.017, 95%CI: 1.43-2.84). To minimize HIV risk throughout the adolescent and young adult periods, long-term strategies are needed to integrate youth economic development, including savings and income generation, with age-appropriate combination prevention interventions.

Educational Outcomes for Orphan Girls in Rural Zimbabwe: Effects of a School Support Intervention.

Educational achievement has important implications for the health and well-being of young women in sub-Saharan Africa. The authors assessed the effects of providing school support on educational outcomes of orphan girls in rural Zimbabwe. Data were from a randomized controlled trial offering the intervention group comprehensive schooling support and controls no treatment initially and then fees only. Results indicated comprehensive support reduced school dropout and absence but did not improve test scores. Providing support to orphan girls is promising for addressing World Health Organization Millennium Development Goals, but further research is needed about contextual factors affecting girls' school participation and learning.

Do Savings Mediate Changes in Adolescents' Future Orientation and Health-Related Outcomes? Findings From Randomized Experiment in Uganda.

PURPOSE: This present study tests the proposition that an economic strengthening intervention for families caring for AIDS-orphaned adolescents would positively affect adolescent future orientation and psychosocial outcomes through increased asset accumulation (in this case, by increasing family savings). METHODS: Using longitudinal data from the cluster-randomized experiment, we ran generalized estimating equation models with robust standard errors clustering on individual observations. To examine whether family savings mediate the effect of the intervention on adolescents' future orientation and psychosocial outcomes, analyses were conducted in three steps: (1) testing the effect of intervention on mediator; (2) testing the effect of mediator on outcomes, controlling for the intervention; and (3) testing the significance of mediating effect using Sobel-Goodman method. Asymmetric confidence intervals for mediated effect were obtained through bootstrapping-to address the assumption of normal distribution. RESULTS: Results indicate that participation in a matched Child Savings Account (CSA) program improved adolescents' future orientation and psychosocial outcomes by reducing hopelessness, enhancing self-concept, and improving adolescents' confidence about their educational plans. However, the positive intervention effect on adolescent future orientation and psychosocial outcomes was not transmitted through saving. In other words, participation in the matched CSA program improved adolescent future orientation and psychosocial outcomes regardless of its impact on reported savings. CONCLUSIONS: Further research is necessary to understand exactly how participation in economic strengthening interventions, for example, those that employ matched CSAs, shape adolescent future orientation and psychosocial outcomes: what, if not savings, transmits the treatment effect and how?

Childhood Risk of Parental Absence in Tanzania.

Although parents might not live with their children for a variety of reasons, existing accounts of parental absence often examine one cause in isolation. Using detailed longitudinal demographic surveillance data from Rufiji, Tanzania, this article examines parental absence due to death, migration, child relocation, union dissolution, and union formation from 2001-2011. Employing survival analysis, the article quantifies children's risk of absence by cause and investigates sociodemographic variation in this risk. Of children born into two-parent households, 25% experience maternal absence by age 10, and 40% experience paternal absence by the same age. Roughly one-quarter of children are born into single-mother families with an absent father at birth, and nearly 70% of these children experience maternal absence as well by age 10. Despite the emphasis on orphanhood in the research and policy communities, parental death is the least common cause of absence. Furthermore, although demographic and socioeconomic characteristics are strong predictors of absence, variation in these relationships across causes underscores the distinctiveness and similarity of different reasons for absence.

Perceived social support disparities among children affected by HIV/AIDS in Ghana: a cross-sectional survey.

BACKGROUND: The study investigated whether perceived social support varied among children who have lost their parents to AIDS, those who have lost their parents to other causes, those who are living with HIV/AIDS-infected caregivers and children from intact families (comparison group). METHOD: This study employed cross-sectional, quantitative survey that involved 291 children aged 10-18 years in the Lower Manya Krobo District of Ghana and examined their social support disparities. RESULTS: Multivariate linear regressions indicate that children living with HIV/AIDS-infected caregivers reported significantly lower levels of social support compared with AIDS-orphaned children, other-orphaned children and non-orphaned children independent of socio-demographic covariates. Children who have lost their parents to other causes and other-orphaned children reported similar levels of social support. In terms of sources of support, all children orphans and vulnerable children were more likely to draw support from friends and significant others rather than from the family. CONCLUSION: The findings indicate a need to develop interventions that can increase levels of social support for orphaned and vulnerable children within the context of HIV/AIDS in Ghana, particularly networks that include the family.

The impacts of maternal mortality and cause of death on children's risk of dying in rural South Africa: evidence from a population based surveillance study (1992-2013).

BACKGROUND: Maternal mortality, the HIV/AIDS pandemic, and child survival are closely linked. This study contributes evidence on the impact of maternal death on children's risk of dying in an HIV-endemic population in rural South Africa. METHODS: We used data for children younger than 10 years from the Agincourt health and socio-demographic surveillance system (1992 - 2013). We used discrete time event history analysis to estimate children's risk of dying when they experienced a maternal death compared to children whose mother survived (N=3,740,992 child months). We also examined variation in risk due to cause of maternal death. We defined mother's survival status as early maternal death (during pregnancy, childbirth, or within 42 days of most recent childbirth or identified cause of death), late maternal death (within 43-365 days of most recent childbirth), any other death, and mothers who survived. RESULTS: Children who experienced an early maternal death were at 15 times the risk of dying (RRR 15.2; 95% CI 8.3-27.9) compared to children whose mother survived. Children under 1 month whose mother died an early (p=0.002) maternal death were at increased risk of dying compared to older children. Children whose mothers died of an HIV/AIDS or TB-related early maternal death were at 29 times the risk of dying compared to children with surviving mothers (RRR 29.2; 95% CI 11.7-73.1). The risk of these children dying was significantly higher than those children whose mother died of a HIV/AIDS or TB-related non-maternal death (p=0.017). CONCLUSIONS: This study contributes further evidence on the impact of a mother's death on child survival in a poor, rural setting with high HIV prevalence. The intersecting epidemics of maternal mortality and HIV/AIDS - especially in sub-Saharan Africa - have profound implications for maternal and child health and well-being. Such evidence can help guide public and primary health care practice and interventions.