The association of single and double orphanhood with symptoms of depression among children and adolescents in Namibia

Adverse Childhood Experiences and Mental Distress Among Adolescents and Youth in Zimbabwe

Adverse childhood experiences (ACEs) are a global public health crisis associated with physical and poor mental health outcomes. The current study examined the prevalence and association between individual and cumulative ACEs with mental distress among adolescents and youth in Zimbabwe. Data from the 2017 Violence Against Children and Youth Survey were utilized (13-25 years old, n = 8,715). Bivariate analysis was conducted using chi-square tests to obtain the prevalence estimates. Two sets of logistic regression models were conducted to determine significant associations between independent variables (i.e., experiencing childhood physical, emotional, and sexual violence; witnessing intimate partner violence (IPV) and community violence; orphan status; and cumulative ACE exposure) and the dependent variable (i.e., mental distress in the past 30 days as measured by Kelser 6). 28.4% of the adolescents and youth reported experiencing mental distress in the past 30 days. Regarding ACEs, cumulative ACE exposure (34.7%; adjusted odds ratio [AOR] = 2.13) and individual ACEs (i.e., experiencing childhood physical violence [39.3%; AOR = 1.41], emotional violence [55.8%; AOR = 2.67], sexual violence [50.8%; AOR = 2.00], witnessing community violence [47.3%; AOR = 1.52], witnessing IPV [43.1%; AOR = 1.47], and being orphaned during childhood [33.6%; AOR = 1.24]) were significantly associated with higher prevalence rates and odds of experiencing mental distress in the past 30 days among adolescents and youth in Zimbabwe. These findings show that ACEs are highly prevalent and increases the risk of mental distress for vulnerable adolescents and youth in Zimbabwe. Effective interventions to reduce violence exposure in families, schools, and communities are essential to mitigate the negative consequences of ACEs and mental distress of adolescents and youth in Zimbabwe. Strengthening child protection policies and involving social workers, psychologists, and mental health workers are also crucial for safeguarding vulnerable children who might be impacted by ACEs in Zimbabwe. Implications for future research are further discussed.

The Relationship Between Family Cohesion and Depression Among School-Going Children With Elevated Symptoms of Behavioral Challenges in Southern Uganda

PURPOSE

Depression is among the leading causes of disability and contributes significantly to the overall disease burden affecting children. Family cohesion has been identified as a protective factor against depression. Examining this relationship is necessary in sub-Saharan Africa, specifically in Uganda-a country characterized by a high prevalence of HIV/AIDS, and high rates of chronic poverty, all of which stress family functioning and elevate child behavioral challenges. This study examined the relationship between family cohesion and depression among school-going children with elevated symptoms of behavioral challenges in southern Uganda.

METHODS

At baseline, 2089 children were enrolled in the National Institutes of Health-funded Strengthening Mental Health and Research Training Africa study in Southwestern Uganda. This article analyzed data from 626 children aged 8-13 years with elevated behavioral challenges. We conducted multilevel mixed-effects Poisson regression to determine the association between family cohesion and depression. We controlled for sociodemographic and household characteristics.

RESULTS

The mean age was 10.3 years. The overall mean depression score was 3.2 (standard deviation = 2.7, range = 0-15). Family cohesion (β = -0.03, 95% confidence interval [CI]: -0.04, -0.02, p < .001) and owning essential items by the child (β = -0.13, 95% CI: -0.23, -0.04, p = .005) were protective against depression among children. Additionally, we observed being a single orphan (β = -0.44, 95% CI: -0.03, -0.86, p = .036) and having both parents (β = -0.43, 95% CI: -0.06, -0.81, p = .023) were associated with depression among children.

DISCUSSION

Findings from this study reveal that family cohesion was protective against depression. Therefore, it is vital to strengthen family support systems by developing programs aimed at strengthening family relationships as a catalyst for addressing depression among children.

Still Standing Inside: A Local Idiom Related to Trauma among Namibian Speakers of Khoekhoegowab

Euro-centric psychiatric conceptualizations often ignore the interplay of local with universal factors in psychological suffering. Emic, locally focused perspectives can enrich etic knowledge to provide culturally sensitive care and to better elucidate the role of culture in mental illness. This study explored the idiom Tsûsa ǃNaeǃkhais xa hâǃnâ/mâǃnâ/ǂgâǃnâhe hâ (a terrible event has entered a person and remains standing inside), which was understood to relate to experiences of trauma and post-traumatic stress, among speakers of Khoekhoegowab, a southern-African click language. Semi-structured interviews were conducted with 16 participants from six urban and rural communities in Namibia. Questions probed perceptions of the idiom in terms of etiology, course, and risk and resilience factors from a socio-ecological framework. Five key themes were identified using thematic analysis: origin in a shocking event; intrusive recurrence of memories, "it keeps on coming back"; the close interplay between mental and physical suffering; the importance of active engagement in healing through prayer and acceptance; and the role of the community in both alleviating and amplifying distress. Our findings highlight local norms and strategies for adaptive coping, and the benefits of exploring local idioms to elucidate the braiding together of universal and cultural elements in psychological distress.

Adverse Childhood Experiences and Associated Mental Distress and Suicide Risk: Results From the Zambia Violence Against Children Survey

Purpose: Adverse childhood experiences (ACEs) are a global public health concern. Little research exists on the prevalence and health consequences of ACEs in Zambia. The current study examined associations between individual and cumulative ACEs, mental distress, and suicide risk among Zambian youth. Methods: Data from Zambia Violence Against Children and Youth Survey were used (18-24 years old, n=1034). Bivariate and adjusted logistic models were performed with independent variables (i.e., experienced physical violence (PV), sexual violence (SV), and emotional violence (EV); witnessed intimate partner violence (IPV) and community violence (CV); orphan status; cumulative ACE exposure) and dependent variables (i.e., mental distress and suicide risk). Adjusted models controlled for demographic and social characteristics. Results: 76.8% of Zambian youth experienced one or more ACEs, and more than 30% witnessed CV (38.4%) or IPV (30.2%), or experienced PV (35.1%), prior to age 18. 27.5% were orphans, and less than 20% experienced EV (17.3%) or SV (15.4%) in childhood. 42.4% experienced mental distress in the past 30 days, and 12.5% reported lifetime suicidal thoughts or suicide attempts. PV, EV, cumulative ACE exposure, older age, being single, and stronger friendships were significantly related to experiencing mental distress. Cumulative ACEs exposure was associated with significantly higher suicide risk. Conclusions: Preventing ACEs can reduce mental distress and suicide risk among Zambian youth. Youth with cumulative ACE exposure can be prioritized for mental health intervention. More research is warranted to investigate the broad-based prevention of ACEs, especially PV and EV, and protective factors that can promote resilience among youth who have experienced ACEs.

A scoping review of community-based mental health intervention for children and adolescents in South Asia

Children and adolescents in South Asia are exposed to significant mental health risks. Yet, policy to prevent or treat youth mental health problems in this context is underdeveloped, and services are difficult to access. Community-based mental health treatment may offer a potential solution, by increasing resource capacity in deprived settings. However, little is known about the current community-based mental health provision for South Asian youth. A scoping review was conducted across six scientific databases and hand searching of reference lists to identify relevant studies. Study selection and data extraction were performed by three independent reviewers using predefined criteria, an adapted version of the template for intervention description and replication checklist and the Cochrane Risk of Bias Tool. The search identified 19 relevant studies published from January 2000 to March 2020. Studies most frequently addressed PTSD and autism, were conducted in India and Sri Lanka, used education-based intervention and were based in urban school settings. Community-based mental health provision for the South Asian youth is in its infancy, but holds promise for providing essential resources to treat or prevent mental health disorder. New insights on approaches are discussed, which are valuable for South Asian settings, primarily task-shifting and stigma reduction, with implications for policy, practice and research.

Stunting, double orphanhood and unequal access to public services in democratic South Africa

Orphans who lack household or community support face significant socio-economic disadvantages. In particular, they are at greater risk of malnutrition and stunting in developing countries. Children who have no living parents, also called double orphans, are most likely to require support from extended families or public institutions. This paper explores how WASH infrastructure, and public health and social services relate to stunting. It is one of the first studies to analyse these factors with a specific focus on double orphans, who tend to live in under-serviced areas with high stunting rates and poor access to public resources. We collate a cross sectional spatial dataset with local child stunting rates from 2013, rates of double orphanhood, private household resources, and public services from 2011 for South Africa, a country where the HIV/AIDS pandemic has led to high rates of double orphanhood. We estimate spatial econometric models that account for unobserved regional shocks and measurement bias, but which do not address other biases. Our results show that high stunting rates, particularly in areas with high proportions of double orphans, overlap strongly with poor provision of WASH and the availability of household resources. By contrast, other softer services accessed outside the home, such as access to health, social welfare and early childhood development facilities are not correlated with stunting in the same way. WASH is more strongly related to reduced stunting when infrastructure covers larger geographic areas and with the combined use of services from adjacent areas. This occurs because of economies of scale in provision and preventing transmission of disease across regions. Policy makers can explore the option to reduce stunting by expanding geographic networks of WASH service delivery into under-serviced areas where double orphans tend to locate.

"How Can We Help You": Mental Health Practitioners' Experiences of Service Provision in Northern Namibia

Although 12-13% of Namibians are reported to struggle with psychological distress, very few practitioners are available to provide mental health services in Namibia. Those practitioners who are available are often trained from Western counseling and psychiatric perspectives that may not readily align to beliefs about illness held constructed in Namibian cultures. Institutional effort is invested in the education and use of mental health practitioners, including counselors, social workers, nurses, psychologists, and psychiatrists. However, little is known about the experiences of these providers. Therefore, this study, a grounded theory ethnography, was undertaken as part of broader ethnographic work to understand how mental health practitioners (N = 7) in Northern Namibia view their work with Aawambo Namibians given that Namibian mental health practitioners are few but embedded in the country's health care system. Four categories were identified in analyses: Provision of Mental Health Services in the North, Practitioners' Conceptualizations of Psychological Distress: Western and Aawambo Influences, Beliefs about Mental Health Services in the North, and Integration of Traditional Treatment and Counseling. Results are discussed with respect to cultural competence in Namibian mental health practice and potential for integrating traditional practices and mental health services.

Factors affecting the psychosocial well-being of orphan and separated children in five low- and middle-income countries: Which is more important, quality of care or care setting?

As millions of children continue to live without parental care in under-resourced societies in low- and middle-income countries (LMICs), it is important for policymakers and practitioners to understand the specific characteristics within different care settings and the extent to which they are associated with outcomes of orphan and separated children (OSC). This study was designed to (1) examine if the psychosocial well-being of OSC in under-resourced societies in LMICs is more dependent on the availability of certain components of quality of care rather than the care setting itself (i.e. the residential care-based or community family-based setting), and (2) identify the relative significance of certain components of quality of care that are associated with a child's psychosocial well-being across different OSC care settings. This study drew from 36-month follow-up data from the Positive Outcomes for Orphans (POFO) Study and used a sample population of 2,013 (923 institution- and 1,090 community-based) OSC among six diverse study sites across five LMICs: Cambodia, India (Hyderabad and Nagaland), Kenya, Tanzania, and Ethiopia. Analyses showed that all four components of quality of care significantly predicted child psychosocial well-being. Child psychosocial well-being across "high" and "low" levels of quality of care showed negligible differences between residential- and community-based care settings, suggesting the important factor in child well-being is quality of care rather than setting of care. Practical and policy implications and future research are discussed.

Mental health among adolescents living with HIV in Namibia: the role of poverty, orphanhood and social support

The mental health needs of children and adolescents living with HIV (ALHIV) in Namibia are poorly understood, despite the dramatic improvement in their survival. ALHIV in resource poor contexts face particular risk factors, such as poverty, orphanhood, and poor social support. This study examines the mental health of ALHIV in Namibia, and the factors that contribute to mental health problems. A case-control design assessed emotional and behavioural symptoms of distress, risk and protective factors among adolescents aged 12-18 years. Case participants were 99 HIV-positive adolescents. Case controls were 159 adolescents from the same community who were not known to be HIV seropositive at the time of the study. Control group participants were selected from schools using a stratified random sampling. A larger proportion of HIV-positive adolescents were orphaned (62.6% vs. 20.8%, p < .001); the groups showed no differences in poverty factors. HIV-positive adolescents scored lower than the control group on total perceived social support (p < .05) and caregiver support (p < .05), but no differences in perceived friend support and support from a self-selected person were present. HIV-positive adolescents reported significantly more total emotional and behavioural difficulties (p = .027) and conduct problems (p = .025), even after controlling for socio-demographic factors. However, after controlling for the effects of orphanhood, group differences in mental health outcomes were no longer significant. Furthermore, mediation analysis suggested that social support completely mediated the relationship between HIV status and mental health (standardised pathway coefficients = .05, p = .021). Policies and programmes that aim to strengthen social support and take orphanhood status into consideration may improve the mental health of adolescents living with HIV.

Predictors of mental health problems in adolescents living with HIV in Namibia

BACKGROUND

Little research in sub-Saharan Africa has looked at factors that predict mental health problems in adolescents living with HIV (ALHIV). This study examines the psychological impact of HIV in adolescents in Namibia, including risk and protective factors associated with mental health.

METHODS

Ninety-nine fully disclosed ALHIV between the ages of 12 and 18 were interviewed at a State Hospital in Windhoek. A structured questionnaire assessed mental health, using the SDQ (Goodman, 1997), sociodemographic factors, poverty, social support, adherence and stigma.

RESULTS

Mean age was 14.3 years, 52.5% were female and most were healthy. Twelve percent scored in the clinical range for total mental health difficulties and 22% for emotional symptoms. Poverty was associated with more total mental health difficulties, t(96) = -2.63, p = .010, and more emotional symptoms, t(96) = -3.45, p = .001, whereas better social support was a protective factor, particularly caregiver support (r = -.337, p = .001). Adherence problems, HIV-related stigma and disclosing one's own HIV status to others were also associated with more total mental health difficulties. Poverty (β = -.231, p = .023) and stigma (β = .268, p = .009) were the best predictors for total mental health difficulties, whereas stigma (β = .314, p = .002) predicted emotional symptoms. Social support had a protective effect on peer problems (p = .001, β = -.349).

CONCLUSIONS

Several contextual factors associated with poorer mental health in ALHIV are identified.

Orphanhood and Self-Esteem: An 18-Year Longitudinal Study From an HIV-Affected Area in Tanzania

BACKGROUND

The HIV epidemic exacerbated the prevalence of prime-aged adult death in many parts of sub-Saharan Africa, resulting in increased rates of orphanhood. Little is known about whether this will coincide with adverse psychosocial well-being in adulthood for those who were orphaned at childhood.

METHODS

We studied a cohort of 1108 children from Kagera, a region of Tanzania that was heavily affected by HIV early in the epidemic. During the baseline data collection in 1991-1994, these children were aged 0-16 years and had both parents alive. We followed them roughly 16-19 years later in 2010, by which time 531 children (36%) had lost either one or both parents before their 19th birthday. We compared the 2010 10-item Rosenberg Self-Esteem Scale (RSES) score between children who lost a parent before the age of 19 and those who did not. We used the baseline data to control for preorphanhood confounders. This is important because we find that children who will lose their fathers in the future before age 19 came from somewhat lower socioeconomic backgrounds.

RESULTS

We found no correlation between maternal death and self-esteem measured through RSES. Paternal death was strongly correlated with lower levels of self-esteem (0.2 SDs lower RSES 95% confidence interval: 0.059 to 0.348), and the correlation was stronger when the death occurred during the child's teenage years. These effects are a net of socioeconomic differences that existed before the orphanhood event.

CONCLUSIONS

Our study supports the further development and piloting of programs that address psychosocial problems of orphans.

Depressive symptoms among older caregivers raising children impacted by HIV/AIDS in the Omusati Region of Namibia

The study of depressive symptoms among caregivers raising HIV/AIDS-orphans is emerging as an important area of research. However, it has not been explored at length in generational and cultural contexts. In this study, the authors explore the role of financial strain, raising a HIV-infected and/or impacted child, and caregiver knowledge on the depressive symptoms of 89-older caregivers raising HIV/AIDS-orphans in Namibia, Africa. In this study, we found elevated levels of depressive symptoms among this population. Using hierarchical regression, a significant positive association between financial strain and depressive symptoms was found. A significant negative association between caring for an HIV-infected orphan and depression was shown. Our work suggests the need for economic assistance programs and psychosocial interventions for older caregivers.

Caring for perinatally HIV-infected children: call for mental care for the children and the caregivers

Antiretroviral therapy has dramatically improved the survival rate of perinatally HIV-infected children. For them to thrive, it is necessary to understand better their mental health issues. Caregivers play an important role in children's daily care and caregiver mental health may relate to children's mental health. However, this association has rarely been studied. Accordingly, the present study examined the associations between depression of caregivers and that of perinatally HIV-infected children in Kigali, Rwanda. We conducted a cross-sectional study of 475 perinatally HIV-infected children aged 7-14 years and their caregivers. We collected children's depression score data via face-to-face interviews with children using the Beck Depression Inventory for Youth. We also collected sociodemographic data using a semi-structured questionnaire with caregivers. In addition, we measured children's weight, height, and collected their clinical records. Data were analyzed via linear and logistic regression analyses. Of all children, 22% had symptoms of depression. Among those who had depressive symptoms (n= 105), 49% had never received psychological support. In both the linear and logistic regression analysis, caregiver's high depression scores were positively associated with children's higher depression scores (AOR: 3.064, 95% CI: 1.723, 4.855, and AOR: 1.759, 95% CI: 1.129, 2.740, respectively). Taking Efavirenz and low height-for-age were also positively associated with higher depression scores among HIV-infected children. Mental health needs to be addressed to improve quality of life of perinatally HIV-infected children. Caregiver's depression was positively associated with children's depressive symptoms. Caring for both children and the caregivers' mental health may prevent the mutual fostering of depression.

Madness (Eemwengu) and Its Sources

Integrating indigenous cultural knowledge into conceptualizing mental illness offers fruitful avenues to better contextualize mental health. What is abnormal and indicative of psychological distress varies in the meaning given to symptoms and the actual identification of disorders. This is no less true in Ovambo culture in Namibia, Southern Africa. The Namibian government, however, has noted that little is known about the mental health needs throughout the country. Although some researchers have identified symptoms of psychological distress in Namibian men and women, cultural tradition and belief systems are typically missing. The purpose of this study was to use ethnographic data to develop an understanding of what Ovambo men and women living in a rural area of Northern Namibia believe about mental illness. Informal discussions and formal interviews served as data. Participants ( N = 14) were all Ovambo men or women who were sampled after ongoing engagement in a rural community in northern Namibia. Data from field observations and interviews were analyzed using grounded theory open coding, resulting in two key categories: (a) Eemwengu (madness) and Omunanamwengu (the mad one) and (b) Where Madness Comes From: Explanations of Mental Illness. The first category offers insight into a culturally embedded way of identifying mental illness in Ovambo culture. The second category includes several subcategories oriented to the etiology of mental illness in Ovambo culture. Etiological beliefs about mental illness, eemwengu as a culturally embedded construct, and social control in the beliefs about psychological distress in Ovambo culture are discussed.

Maltreatment and Mental Health Outcomes among Ultra-Poor Children in Burkina Faso: A Latent Class Analysis

Objectives

Research about the mental health of children in Francophone West Africa is scarce. This paper examines the relationships between adverse childhood experiences, including exposure to violence and exploitation, and mental health outcomes among children living in ultra-poverty in rural Burkina Faso.

Methods

This paper utilizes baseline data collected from 360 children ages 10–15 and 360 of their mothers recruited from twelve impoverished villages in the Nord Region of Burkina, located near the Sahel Desert and affected by extreme food insecurity. We used a Latent Class Analysis to identify underlying patterns of maltreatment. Further, the relationships between latent classes and mental health outcomes were tested using mixed effected regression models adjusted for clustering within villages.

Results

About 15% of the children in the study scored above the clinical cut-off for depression, 17.8% for posttraumatic stress disorder (PTSD), and 6.4% for low self-esteem. The study identified five distinct sub-groups (or classes) of children based on their exposure to adverse childhood experiences. Children with the highest exposure to violence at home, at work and in the community (Abused and Exploited class) and children not attending school and working for other households, often away from their families (External Laborer class), demonstrated highest symptoms of depression and trauma. Despite living in adverse conditions and working to assist families, the study also identified a class of children who were not exposed to any violence at home or at work (Healthy and Non-abused class). Children in this class demonstrated significantly higher self-esteem (b = 0.92, SE = 0.45, p<0.05) and lower symptoms of trauma (b = -3.90, SE = 1.52, p<0.05).

Conclusions

This study offers insight into the psychological well-being of children in the context of ultra-poverty in Burkina Faso and associated context-specific adverse childhood experiences. Identifying specific sub-groups of children with increased exposure to life stressors has implications for program developers. Study findings indicate a further need to explore the mental health consequences of traumatic experiences within the context of ultra-poverty and to develop integrated economic and psychosocial interventions that prevent or mitigate childhood adversities linked with the family-level poverty and violence in the family.

Mental Health in Namibia

Psychological distress is inherently constructed within contexts and the unique, cultural meaning systems that have developed to understand mental illness. Moreover, cultures naturally develop their own systems of healing, grounded in traditional practices. Western psychology and psychiatry have, through globalisation and colonial histories, imposed systems of mental health care and definitions of mental illness. In doing so, local understandings and ways of being regarding mental health have often been eclipsed. This is no less true in Namibia. However, much of the existing mental health literature from Namibia explores mental illness from a Western lens of psychopathology. This article discusses the relevant research about mental illness in Namibia and situates this within related literature from other Southern African countries. Several cultural factors across diverse groups in Namibia are important to more fully understand what mental illness and treatment are throughout this country. The cultural role of diverse conceptualisations of mental illness is discussed in order to explore potential areas of growth in Namibian mental health and intervention. The nature of traditional healing in other Southern African contexts is also addressed, given that although traditional healing exists in Namibia, researchers have not yet explored it within the context of psychological distress. Recommendations for mental health and psychological treatment in Namibia are discussed.

Orphanhood by AIDS-Related Causes and Child Mental Health: A Developmental Psychopathology Approach

While the number of new HIV infections has declined, the number of orphans as a result of AIDS-related deaths continues to increase. The aim of this paper was to systematically review empirical research on the mental health of children affected by HIV/AIDS in the developing world, specifically with an eye on developing a theoretical framework to guide intervention and research. Articles for review were gathered by following the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA standards), reviewed and then organized and synthesized with a Developmental Psychopathology framework. Results showed that the immediate and longterm effects of AIDS orphanhood are moderated by a number of important risk and protective factors that may serve as strategic targets for intervention. Research and clinical implications are discussed.

Factors associated with depression among adolescents living with HIV in Malawi

BACKGROUND

Prior research suggests that a high prevalence of depression, with a detrimental impact on treatment outcomes exists among HIV-infected youth. Data on potential risk factors of depression among HIV-infected youth in sub-Saharan Africa are scarce. This cross-sectional study aimed to identify contributory/protective factors associated with depression in Malawian adolescents 12-18 years old living with HIV.

METHODS

Depression was measured by a validated Chichewa version of the Beck Depression Inventory version-II (BDI-II) and the Children's Depression Rating Scale-Revised (CDRS-R). Data on variables thought to potentially be contributory/protective were collected and included: socio-demographics, past traumatic events/stressors, behavioural factors/social support, and bio-clinical parameters. Chi-square test or two-sample t-test was used to explore associations between factors and depression. Additional testing via linear/logistic regression, adjusting for age and sex, identified candidate variables (p < 0.1). Final regression models included variables with significant main effects and interactions.

RESULTS

Of the 562 participants enrolled (mean age, 14.5 years [SD 2.0]; 56.1% female), the prevalence of depression was 18.9%. In multivariate linear regression, the variables significantly associated with higher BDI-II score were female gender, fewer years of schooling, death in the family/household, failing a school term/class, having a boyfriend/girlfriend, not disclosed or not having shared one's HIV status with someone else, more severe immunosuppression, and bullied for taking medications. Bullying victimization was reported by 11.6% of respondents. We found significant interactions: older participants with lower height-for-age z-scores and dissatisfied with their physical appearance had higher BDI-II scores. In multivariate logistic regression, factors significantly associated with depression were: older age, OR 1.23 (95% CI 1.07-1.42); fewer years of schooling, OR 3.30 (95% CI 1.54-7.05); and bullied for taking medications, (OR 4.20 (95% CI 2.29-7.69).

CONCLUSION

Having fewer years of schooling and being bullied for taking medications were most clearly associated with depression. Programmes to support the mental health needs of HIV-infected adolescents that address issues such as disclosure, educational support, and, most notably, bullying may improve treatment outcomes and are recommended.

Development of a psychosocial distress measure for Ugandan adolescents living with HIV

Psychological distress among adolescents living with HIV (ALH) has been associated with risky behaviors including non-adherence to anti-retroviral therapy, leading to increased risk for AIDS morbidity and mortality. Efforts to establish the nature, prevalence, and impact of psychological distress among ALH in Uganda are hindered by the lack of culturally relevant assessment tools. The purpose of this study was to develop and test a measure for psychological distress for Ugandan ALH aged 12-19 years (N = 508; 53.1 % female). Using a mixed method approach, we developed and tested a 25-item checklist with six subscales-anhedonia, depressive-anxiety, isolation, suicidal ideation, sleep problems, and somatization. We found adequate reliability for the scale (α = 0.89), and a satisfactory measurement structure in our confirmatory factor analyses (RMSEA <1.0, and CFI and TLI >0.90). We discuss the potential use of this culturally sensitive scale to examine psychological distress among ALH in Uganda.

Depression among AIDS-orphaned children higher than among other orphaned children in southern India

Background

Systematic data on mental health issues among orphaned children are not readily available in India. This study explored depression and its associated risk factors among orphaned children in Hyderabad city in south India.

Methods

400 orphaned children drawn equally from AIDS and non-AIDS orphan groups aged 12–16 years residing in orphanages in and around Hyderabad city in southern India were recruited to assess depression and associated risk factors using the Center for Epidemiologic Studies-Depression Scale (CES-DC). Variation in the intensity of depression was assessed using multiple classification analysis (MCA).

Results

397 (99%) orphans provided complete interviews in the study of whom 306 (76.5%) were aged 12 to 14 years, and 206 (51.8%) were paternal orphans. Children orphaned by AIDS were significantly more likely to report being bullied by friends or relatives (50.3%) and report experiencing discrimination (12.6%) than those orphaned due to other reasons (p < 0.001). The overall prevalence of depression score >15 with CES-DC was 74.1% (95% CI 69.7-78.4) with this being significantly higher for children orphaned by AIDS (84.4%, 95% CI 79.4 – 89.5) than those due to other reasons (63.6%, 95% CI 56.9 – 70.4). Mean depression score was significantly higher for children orphaned by AIDS (34.6) than the other group (20.6; p < 0.001). Among the children orphaned by AIDS, the bulk of depression score was clustered in 12–14 years age groups whereas in the children orphaned by other reasons it was clustered in the 15–16 years age group (p = 0.001). MCA analysis showed being a child orphaned by AIDS had the highest effect on the intensity of depression (Beta = 0.473).

Conclusions

Children orphaned by AIDS had significantly higher depressive symptoms than the other orphaned children. These findings could be used for further planning of mental health interventions to meet the mental health needs of orphaned children, that could include preventive, diagnostic and treatment services.

Impact of parental HIV/AIDS on children's psychological well-being: a systematic review of global literature

This review examines the global literature regarding the impact of parental HIV/AIDS on children's psychological well-being. Fifty one articles reporting quantitative data from a total of 30 studies were retrieved and reviewed. Findings were mixed but tended to show that AIDS orphans and vulnerable children had poorer psychological well-being in comparison with children from HIV-free families or children orphaned by other causes. Limited longitudinal studies suggested a negative effect of parental HIV on children's psychological well-being in an early stage of parental HIV-related illness and such effects persisted through the course of parental illness and after parental death. HIV-related stressful life events, stigma, and poverty were risk factors that might aggravate the negative impact of parental HIV/AIDS on children. Individual coping skills, trusting relationship with caregivers and social support were suggested to protect children against the negative effects of parental HIV/AIDS. This review underlines the vulnerability of children affected by HIV/AIDS. Culturally and developmentally appropriate evidence-based interventions are urgently needed to promote the psychological well-being of children affected by HIV/AIDS.

Resilience through participation and coping-enabling social environments: the case of HIV-affected children in sub-Saharan Africa

Many children and youths living in low-resource and high-HIV-prevalence communities in sub-Saharan Africa are presented with daily hardships that few of us can even imagine. It is therefore no surprise that most research reporting on the experiences of HIV-affected children in resource-poor settings focuses on their poor health and development outcomes, casting them as victims. However, there is a growing trend to draw on more strengths-based conceptualisations in the study and support of HIV-affected children and youths. In this introduction to a special issue of The African Journal of AIDS Research, we cement this trend by providing a theoretical exposition and critique of the ‘coping’ and ‘resilience’ concepts and draw on the 11 empirical studies that make up this special issue to develop a framework that appropriates the concepts for a particular context and area of study: HIV-affected children in sub-Saharan Africa. The articles included here show, albeit in different ways and to different degrees, that the resilience of HIV-affected children in the region is an outcome of their agency and interactions with their social environment. Policy actors and practitioners working to support HIV-affected children in Africa should take heed of the proposed framework and draw on the research presented here to build coping-enabling social environments—presenting children and youths in Africa with greater opportunity to actively deal with hardship and work towards a more promising future.

Pathologising healthy children? A review of the literature exploring the mental health of HIV-affected children in sub-Saharan Africa

This article reviews the expanding body of literature that examines the mental health of HIV-affected children in sub-Saharan Africa. Focusing on primary research across disciplines and methodologies, the review examines the use of universalistic assumptions about childhood adversity and mental health in driving forward this body of research. Of the 31 articles identified for this review, 23 had a focus on the psychological distress experienced by HIV-affected children, while only 8 explored social psychological pathways to improved mental health, resilience and coping. The article argues that this preoccupation with pathology reflects global assemblages of definitions, understandings and practices that constitute the global mental health framework. While such a focus is useful for policy interventions and the mobilisation of resources to support children living in HIV-affected communities, it overshadows more culturally relevant and strengths-based conceptualisations of how mental health is understood and can be achieved in different parts of Africa. Furthermore, a continued focus on the psychological distress experienced by HIV-affected children runs the risk of medicalising their social experiences, which in turn may transform the social landscape in which children give meaning to loss and difficult experiences. The article concludes that mental health professionals and researchers need to take heed of the biopolitical implications of their work, and argues for more community-oriented and resilience-enhancing research that brings forward the voices of local people to inform interventions tackling the psychosocial challenges inevitably experienced by many children in sub-Saharan Africa.

Incidence of orphanhood before and after implementation of a HIV care programme in Rakai, Uganda: Alpha Network HIV Supplement

OBJECTIVE

To compare the incidence of orphanhood among children <15 years of age before and after implementing HIV care in Rakai, Uganda.

METHODS

Annual household censuses and surveys were conducted on January 2001 to September 2009 in a community cohort, where HIV care including antiretroviral therapy (ART) started in June 2004. Data included parental survival of children aged 0-14 years and HIV status from consenting adults aged 15-49 years. The incidence of orphanhood was estimated as the number of new orphans divided by person-years, determined during three time periods: Pre-HIV care roll-out (January 2001-June 2003) 1-3 years before the advent of HIV care in Rakai programme, HIV care transition from September 2003-May 2006, and the expanded HIV care period from August 2006-September 2009. Poisson regression was used to estimate incidence rate ratios (IRR) of orphanhood and 95% confidence intervals, and the Population attributable fraction (PAF) of incident orphanhood due to HIV+ parental status was estimated as pd*(RR-1)/RR.

RESULTS

A total of 20,823, 21,770 and 23,700 children aged 0-14 years were censused at the three periods, respectively. The prevalence of orphanhood significantly declined; 17.2% during Pre-HIV care roll-out, 16.0% at HIV care transition and 12.6% at expanded HIV care period (chi2 trend, P < 0.0001). The incidence of orphanhood also declined significantly with increasing HIV care from 2.10/100 person-years (py), 1.57/100 py and 1.07/100 py (chi2 trend, P < 0.0001). The largest declines were observed among children with HIV+ parent(s), 8.2/100 pyr, 5.2/100 pys and 3.4/100 pyr. PAF also declined from 35.3% in the pre-HIV care to 27.6% in the expanded HIV care periods.

CONCLUSION

After the availability of ART, there was a decline in PAF of incident orphanhood due to parental HIV+ status, and in the incidence of orphanhood especially among children with HIV-infected parents.

Longitudinal evaluation of the psychosocial wellbeing of recent orphans compared with non-orphans in a school-attending cohort in KwaZulu-Natal, South Africa

To assess differences in psychosocial wellbeing between recent orphans and non-orphans, we followed a cohort of 157 school-going orphans and 480 non-orphans ages 9-15 in a context of high HIV/AIDS mortality in South Africa from 2004 to 2007. Several findings were contrary to published evidence to date, as we found no difference between orphans and non-orphans in anxiety/depression symptoms, oppositional behavior, self-esteem, or resilience. Female gender, self-reported poor health, and food insecurity were the most important predictors of children's psychosocial wellbeing. Notably, girls had greater odds of reporting anxiety/depression symptoms than boys, and scored lower on self-esteem and resilience scales. Food insecurity predicted greater anxiety/depression symptoms and lower resilience. Perceived social support was a protective factor, as it was associated with lower odds of anxiety/depression symptoms, lower oppositional scores, and greater self-esteem and resilience. Our findings suggest a need to identify and strengthen psychosocial supports for girls, and for all children in contexts of AIDS-affected and economic adversity.

The impact of a comprehensive microfinance intervention on depression levels of AIDS-orphaned children in Uganda

PURPOSE

By adversely affecting family functioning and stability, poverty constitutes an important risk factor for children's poor mental health functioning. This study examines the impact of a comprehensive microfinance intervention, designed to reduce the risk of poverty, on depression among AIDS-orphaned youth.

METHODS

Children from 15 comparable primary schools in Rakai District of Uganda, one of those hardest hit by HIV/AIDS in the country, were randomly assigned to control (n = 148) or treatment (n = 138) conditions. Children in the treatment condition received a comprehensive microfinance intervention comprising matched savings accounts, financial management workshops, and mentorship. This was in addition to traditional services provided for all school-going orphaned adolescents (counseling and school supplies). Data were collected at wave 1 (baseline), wave 2 (10 months after intervention), and wave 3 (20 months after intervention). We used multilevel growth models to examine the trajectory of depression in treatment and control conditions, measured using Children's Depression Inventory (Kovacs).

RESULTS

Children in the treatment group exhibited a significant decrease in depression, whereas their control group counterparts showed no change in depression.

CONCLUSIONS

The findings indicate that over and above traditional psychosocial approaches used to address mental health functioning among orphaned children in sub-Saharan Africa, incorporating poverty alleviation-focused approaches, such as this comprehensive microfinance intervention, has the potential to improve psychosocial functioning of these children.

Child and adolescent mental health worldwide: evidence for action

Mental health problems affect 10-20% of children and adolescents worldwide. Despite their relevance as a leading cause of health-related disability in this age group and their longlasting effects throughout life, the mental health needs of children and adolescents are neglected, especially in low-income and middle-income countries. In this report we review the evidence and the gaps in the published work in terms of prevalence, risk and protective factors, and interventions to prevent and treat childhood and adolescent mental health problems. We also discuss barriers to, and approaches for, the implementation of such strategies in low-resource settings. Action is imperative to reduce the burden of mental health problems in future generations and to allow for the full development of vulnerable children and adolescents worldwide.

The association of chronic adversity with psychiatric disorder and disorder severity in adolescents

The purpose of this paper is to estimate the impact of chronic adversity on psychopathology in adolescents, taking into account the type of adversity, number of adversities experienced and type of psychiatric disorder, as well as to estimate the impact on severity of the disorder. A total of 3,005 male and female adolescents from the Mexican Adolescent Mental Health Survey aged 12-17 years were interviewed in a stratified multistage general population probability survey. Assessment of 20 DSM-IV disorders, disorder severity and 12 chronic childhood adversities were assessed with the adolescent version of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI-A). Family dysfunction adversities including abuse presented the most consistent associations between chronic adversity and psychopathology and their impact was generally non-specific with regard to the type of disorder. Parental divorce, parental death and economic adversity were not individually associated with psychopathology. Among those with a psychiatric disorder, sexual abuse and family violence were associated with having a seriously impairing disorder. The odds of having a psychiatric disorder and a serious disorder increased with increasing numbers of adversities; however, each additional adversity increased the odds at a decreasing rate. While the study design does not allow for conclusions regarding causality, these findings suggest general pathways from family dysfunction to psychopathology rather than specific associations between particular adversities and particular disorders, and provide further evidence for the importance of family-focused intervention and prevention efforts.

Validation of the Pediatric Symptom Checklist in HIV-infected Batswana

OBJECTIVE: To determine the validity of the Pediatric Symptom Checklist (PSC), a brief measure of psychosocial health, for screening HIV+ Batswana children. METHOD: Setswana versions of the parent and child PSC were administered to 509 HIV+ Batswana children (age 8-16) and their parents/guardians. Test properties were evaluated and cut-off scores were derived using receiver operating characteristic curve analysis. Scores on the parent-completed PSC and the child-completed PSC-Y were compared to parental and clinic staff reports of concern about the child's psychosocial health and to scores on the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale. RESULTS: The Setswana PSC has high internal consistency (Cronbach's alpha 0.87 for the parent-completed version). Comparing PSC scores to parental reports of concern and child-reported depression symptoms, a cut-off score of 20 on the PSC and PSC-Y maximised the sensitivity and specificity. CONCLUSIONS: The PSC performed well in Setswana-speaking children and is a promising screening tool for paediatric psychosocial problems in busy clinical settings. Screening with the PSC may allow for early detection and treatment of psychosocial problems. This is likely to be of particular value for HIV+ children for whom HIV treatment non-adherence may result from untreated psychosocial dysfunction.

Estimating the impact of expanded access to antiretroviral therapy on maternal, paternal and double orphans in sub-Saharan Africa, 2009-2020

Background

HIV/AIDS has orphaned 11.6 million children in sub-Saharan Africa. Expanded antiretroviral therapy (ART) use may reduce AIDS orphanhood by decreasing adult mortality and population-level HIV transmission.

Methods

We modeled two scenarios to measure the impact of adult ART use on the incidence of orphanhood in 10 sub-Saharan African countries, from 2009 to 2020. Demographic model data inputs were obtained from cohort studies, UNAIDS, UN Population Division, WHO and the US Census Bureau.

Results

Compared to current rates of ART uptake, universal ART access averted 4.37 million more AIDS orphans by year 2020, including 3.15 million maternal, 1.89 million paternal and 0.75 million double orphans. The number of AIDS orphans averted was highest in South Africa (901.71 thousand) and Nigeria (839.01 thousand), and lowest in Zimbabwe (86.96 thousand) and Côte d'Ivoire (109.12 thousand).

Conclusion

Universal ART use may significantly reduce orphanhood in sub-Saharan Africa.

Psychosocial functioning among HIV-affected youth and their caregivers in Haiti: implications for family-focused service provision in high HIV burden settings

The study is an analysis of baseline data from a pilot psychosocial support intervention for HIV-affected youth and their caregivers in Haiti. Six sites in Haiti's Central Department affiliated with Partners In Health/Zanmi Lasante (PIH/ZL) and the Haitian Ministry of Health were included. Participants were recruited from a list of HIV-positive patients receiving care at PIH/ZL. The baseline questionnaire was administered from February 2006 to January 2007 with HIV-affected youth (n = 492), ages 10-17, and their caregivers (n = 330). According to findings at baseline, the youth reported high levels of anxiety, including constant fidgeting (86%), restlessness (83%), and worrying a lot (56%). Their parents/caregivers also reported a high level of depressive symptoms, such as low energy (73%), feeling everything is an effort (71%), and sadness (69%). Parents' depressive symptoms were positively associated with their children's psychological symptoms (odds ratio [OR] =1.6-2.4) and psychosocial functioning (OR =1.6 according to parental report). The significant levels of anxiety and depression observed among HIV-affected youth and their caregivers suggest that psychosocial interventions are needed among HIV-affected families in central Haiti and other high HIV burden areas. The results suggest that a family-focused approach to service provision may be beneficial, possibly improving quality of life, as well as psychosocial and physical health-related outcomes among HIV-affected youth and their caregivers, particularly HIV-positive parents.

"I washed and fed my mother before going to school": understanding the psychosocial well-being of children providing chronic care for adults affected by HIV/AIDS in Western Kenya

With improved accessibility to life-prolonging antiretroviral therapy, the treatment and care requirements of people living with HIV and AIDS resembles that of more established chronic diseases. As an increasing number of people living with HIV and AIDS in Kenya have access to ART, the primary caregivers of poor resource settings, often children, face the challenge of meeting the requirements of rigid ART adherence schedules and frequent relapses. This, and the long-term duty of care, has an impact on the primary caregiver's experience of this highly stigmatized illness - an impact that is often described in relation to psychological deprivation. Reflecting the meanings attached to caregiving by 48 children in Western Kenya, articulated in writing, through photography and drawing, individual and group interviews, this paper presents three case studies of young caregiving. Although all the children involved in the study coped with their circumstances, some better than others, we found that the meanings they attach to their circumstances impact on how well they cope. Our findings suggest that only a minority of young caregivers attach either positive or negative meanings to their circumstances, whilst the majority attaches a mix of positive and negative meanings depending on the context they are referring to. Through a continuum of psychosocial coping, we conclude that to provide appropriate care for young carers, health professionals must align their understanding and responses to the psychosocial cost of chronic care, to a more nuanced and contextual understanding of children's social agency and the social and symbolic resources evident in many African communities.