Thesis + appendices (with third-party copyright material removed)

466 Pages·2009·6.06 MB·English

Risk and Protective Factors for the
Psychological Well-being of Children
Orphaned by AIDS
in Cape Town, South Africa

Lucie Dale Cluver

Green College, Trinity Term 2007

Thesis submitted for the degree of D.Phil in Evidence-Based
Social Work in the Social Sciences Division at the University of
Oxford

1
Abstract

Background: Orphanhood is a major consequence of the HIV/AIDS epidemic in sub-Saharan
Africa. There is little evidence concerning psychological problems for AIDS-orphaned children.
This thesis explores the relationship between orphanhood status and mental health. It also
examines mediating influences of environmental risk and protective factors, and interactions
between factors, on children(cid:146)s psychological problems.

Methods: 1200 isiXhosa-speaking children were interviewed, using standardised questionnaires, in
deprived urban settlements of Cape Town. A qualitative stage with 60 AIDS-orphaned children, 42
caregivers and 20 professionals explored participant perceptions of risk and protective factors. A
quantitative stage compared 1025 AIDS-orphaned children to control groups of other-orphans and
non-orphans. Data were analysed with t-tests, chi-sq, anovas, regression and log-linear analyses.
The study took place in collaboration with Cape Town Child Welfare.

Results: AIDS-orphaned children reported more depression (p<.001), peer relationship problems
(p<.001), post-traumatic stress (p<.001), suicidal ideation (p<.05), delinquency (p<.001) and
conduct problems (p<.001) than other-orphans and non-orphans. Anxiety showed no differences.
Compared to Western norms, AIDS-orphaned children showed higher levels of internalising
problems and delinquency, but lower levels of conduct problems. These differences remained
when controlling for socio-demographic factors.

A number of factors strongly mediated the relationship between AIDS-orphanhood and mental
health. These include poverty-related factors (food, education and social security, p<.001).
caregiving-related factors (caregiver illness, p<.001, excessive housework p<.001, being a
streetchild, p<.001) and AIDS-related stigma (p<.001). Cumulative effects were also found. Food
insecurity and AIDS-related stigma interacted to raise likelihood of disorder from 19% to 83%,
and orphanhood status and bullying interacted to raise likelihood from 12% to 76%.

Conclusions: This thesis shows clear evidence of heightened psychological problems amongst
AIDS-orphaned children. It also indicates mediating factors and points to areas of possible
intervention. The South African Ministry of Social Development plans to scale up the study to a
national survey of AIDS-orphanhood.

2
Acknowledgements
This study would not have been possible without one thousand, two hundred and seventy children,
and their caregivers, in Cape Town. They gave their time and talked about difficult aspects of their
lives, knowing that it was unlikely to help them directly, but may help other children like them.

I would like to thank colleagues at the Department of Social Policy and Social Work. In particular,
I have been lucky to have had Dr Frances Gardner as my supervisor since this study began. She
has been unfailingly encouraging, and has brought to the study an intellectual thoughtfulness
which I lack. Thanks to Dr Don Operario and Professor Alan Stein for their helpful comments as
examiners for Transfer and Confirmation of Status. Don has also patiently dug me out of statistical
quagmires(cid:133).

I would like to thank the staff at Cape Town Child Welfare, and especially their dynamic CEO,
Niresh Ramklass. Cape Town Child Welfare have been the ideal community-based collaborators,
and have reminded me constantly of the reasons for undertaking this study. I must also thank them
for giving me an office and a computer whenever I arrived in town without warning. I was lucky to
have had an excellent team of interviewers: my thanks to Nomhle, Hilda, Nontobeko, Zethu, Julia,
Mantombi and Katie for their energy, commitment and hard work in difficult and sometimes
dangerous research conditions. I am grateful to the school principals, teachers and NGO staff who
gave their time and effort to ensure that the research happened.

Many thanks, also, to the National Department of Social Development for their engagement with
the findings of this research. In particular, Minister Zola Skweyiya for conceptualising the scaling-
up of this study to a national survey and Director-General Vusi Madonsela for his intellectual
engagement and for arranging meetings with key officials. I would also like to Deputy Director-
General Vuyelwa Nhlapo, Chief Director of HIV/AIDS Dr Connie Kganakga and Chief Director
of Children, Youth and Families Dr Maria Mabetoa for their contribution and input in the proposed
design of the future research.

Many academics and leading NGOs generously gave their time and expertise. I would especially
like to thank Professor Renfrew Christie; for sample sizes, for the French Ambassador(cid:146)s cocktail
party, and for being consistently and infuriatingly right. He also read every word of my first draft,
and gave valuable corrections, and corrections of corrections. I would like to thank Professor Mark
Orkin for tolerantly teaching me log-linear and solving the cumulative effect puzzle in 60 hours of
very hard work. Jonathan Polonsky taught me to do power calculations in apology for forgetting
something 12 years ago. Dr Soraya Seedat, Dr Lauren Wild, Professor Brian Robertson, Jane
Roberts and Dr Debbie Kaminer were incredibly helpful in designing questionnaires. Professor
Melvyn Freeman and Patrice Engle helped with survey items. Thank you to Naomi, Joel and my
parents for last-minute proof-reading. Dr Rene Brandt lent me staff, read a very long chapter, and
gave me calm and reasoned advice when I was ready to quit and become a car mechanic.

Further thanks are due to Professor Andrew Dawes, Professor Leslie Swartz, Professor Melvyn
Freeman, Dr Harriet Deacon and Brendan Maughan-Brown for their advice and input. Professor
Sally Grantham-McGregor, Tamsen Rochat, Dr Cathy Ward, Dr Julie Carter and Mark Tomlinson
3
gave valuable thoughts from their own similar studies. Chris Desmond gave helpful criticism of
policy implications, and Kate Orkin clarified my conceptual confusion regarding services.
Professor Lorraine Sherr gave wise advice on talking to children about bereavement.

I am grateful for the generous funding of my D.Phil from the Economic and Social Research
Council. I would also like to thank the Department of Social Policy and Social Work, for sending
money when I was beset by shack fires, taxi wars and power cuts. With thanks also to South
African Airways, for waiving the excess baggage charge for 90kg of completed questionnaires!

Thank you to my mother, who called me every day I worked in the townships to check I was still
alive. And to my father, who saved endless emailed drafts of chapters, and limited himself to
occasionally asking whether I was ever planning to get a proper job. Many thanks to Andy, for
always making me feel welcome in Cape Town. Finally, I would like to thank my friends, my
flatmates and my family, for putting up with three years of orphans. I suspect there may be many
more to come.

Figure 1: (cid:145)Has anyone close to you died? Could you tell us who they were?(cid:146) Girl, aged 13,
Macassar.
4
Publications and Presentations arising from this Thesis

The work in this thesis has resulted in the following peer-reviewed articles and publications:

Cluver, L, Gardner, F & Operario, D (2007) Psychological distress amongst AIDS-orphaned
children in urban South Africa. Journal of Child Psychiatry and Psychology and Allied Disciplines
48(8) 755-763.

Cluver, L, Gardner, F & Operario, D (in press) AIDS-related stigma: Effects on mental health of
AIDS-orphaned children. Journal of Adolescent Health.

Cluver, L & Gardner, F (2007) The Mental Health of Children orphaned by AIDS: A review of
International and South African Research. Journal of Child and Adolescent Mental Health. 19 (1)
1-17

Cluver, L. & Gardner, F. (2007) Risk and protective factors for well-being of children orphaned by
AIDS in Cape Town, South Africa: a qualitative study of children(cid:146)s views. AIDS Care 19(3) 318-
325.

Cluver, L. & Gardner, F. (2006) Psychological well-being of children orphaned by AIDS in Cape
Town, South Africa. Annals of General Psychiatry. 5, 8. BioMed Press.

Dowdney, L (ed) Adok, N, Arias, J, Castelli, L, Coulter, C, Cluver, L et al (2006) Trauma,
Resilience and Cultural Healing: How do we move forward? Coalition to stop the use of child
soldiers.

Goodman, R, Cluver, L, Tshandu, V & Vondani, P (2004) Xhosa version of the Strengths and
Difficulties Questionnaire (Child and Parent report). Institute of Psychiatry, London.

The following papers arising from this thesis are currently under review

Cluver, L, Gardner, F and Operario, D (under review) Effects of poverty on the psychological
health of AIDS-orphaned children.

Cluver, L and Orkin, M (under review) Cumulative risk and AIDS-orphanhood: Interactions of
stigma, bullying and poverty on child mental health in South Africa.

The work in this thesis has been presented at the following international conferences:

Cluver, L, Gardner, F and Operario, D. Psychological distress amongst children orphaned by
AIDS: Effects of stigma and other community factors in South Africa. Paper presented at: AIDS
Impact Conference, 2007; Marseilles, France.

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Cluver, L, Gardner, F and Operario, D. Poverty and psychological health for AIDS-orphaned
children: Potential benefits of state poverty alleviation programmes in South Africa. Paper
presented at: 3rd South African AIDS Conference, 2007, Durban, South Africa.

Awarded Discovery Clinical Excellence Prize for (cid:145)Best Oral Presentation(cid:146) (open category)

Cluver, L & Gardner, F. Risk and protective factors in the mental health of children orphaned by
AIDS in South Africa. Paper presented at: AIDS Impact Conference, 2005; Cape Town, South
Africa.

6
Contents
Chapter 1: Introduction and Outline

Summary of findings(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 15

1.1 Preface(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 20
1.2 Definitions(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 20
1.3 HIV/AIDS and orphanhood prevalence in South Africa(cid:133)(cid:133).(cid:133)(cid:133).. 22
1.4 Research location(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 27
1.5 Theoretical framework(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 27
Environmental influences on child mental health(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 28
Cumulative effects of risk and protective factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 31
An ecological framework of risk and protective factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 32
Further theoretical sources: HIV/AIDS, bereavement & orphanhood 34
Summary(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 38
1.6 The policy debate: Orphans, vulnerable children and AIDS(cid:133)(cid:133)(cid:133).. 38
1.7 Overview of research questions(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 40
1.8 Overview of methodology(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 41
Methodological requirements(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 41
1.9 Overview of chapter contents (cid:133)(cid:133)..(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 43
1.10 Conclusion(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 44

Chapter 2: Literature review 1: AIDS-orphaned children and
mental health

2.1 Introduction(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 47
2.2 Definitions and parameters of the review(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 48
2.3 Reviewing and search strategy(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 49
2.4 Results: Review of studies(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 49
Controlled studies in Africa(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 50
Controlled studies in the US(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 54
Descriptive studies in Africa(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 55
Descriptive studies in the US(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 57
Non-quantitative literature(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 57
Distress prior to parental death (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 58
2.5 Discussion(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 59
2.6 Summary and conclusions(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 62

7
Chapter 3: Literature Review 2: Potential Risk and Protective
Factors

3.1 Introduction(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 70
3.2 Search strategy(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 72
3.3 Overview of types of literature reviewed....(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 73
3.4 Results of the review(cid:133).(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 76
Individual/child factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 76
Demographic factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 76
Physical health(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 77
Caregiver/Family network factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 79
Bereavement factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 79
Parental characteristics(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 83
Economic factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 84
School attendance factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 85
Housework and Employment(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 87
Household factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 88
Placement of children(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 89
Caregiving factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 91
Abuse and domestic violence(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 94
Community-level factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 96
Community traumas(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 96
AIDS-related stigma(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 98
Positive activities and other community factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 98
Social support(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 100
3.4 Summary and conclusions(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 101

Chapter 4: Risk and Protective Factors: A qualitative study of
children and caregivers(cid:146) perspectives

4.1 Introduction(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 110
4.2 Research questions and aims(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 112
4.3 Qualitative methodology(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) . 113
Sample group: children(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 113
Sample group: caregivers(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 114
Sample group: professionals(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 114
Procedures(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 115
Interviewers(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 118
Ethical considerations(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 118
Analysis strategy(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 119
4.4 Results from qualitative research(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 119
4.5 Discussion(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 126
Limitations of the study(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 126
4.6 Summary and conclusions(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 129
8
Chapter 5: Quantitative Stage: Methodology

5.1 Introduction(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 132
5.2 Research Questions, hypotheses and aims(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)... 132
5.3 Sampling and data collection: (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 134
Sample Group(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 134
Control groups and matching(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 143
Sampling strategies(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 147
Determining AIDS death(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 152
Research staff(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 155
5.4 Fieldwork challenges and research constraints(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 159
5.5 Research ethics(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 164
5.6 Ethical considerations(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 165
Giving back: to organisations, children(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 171
5.7 Instruments: (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 177
Questionnaire design and piloting, child-friendly presentation(cid:133)(cid:133).. 177
Choice of instruments: collaborations and added items(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 181
Risk and protective factors (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 181
Standardised mental health scales(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 190
5.8 Methodological limitations(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 199
5.9 Data entry and data cleaning (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 199
5.10 Analysis strategy (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 200
5.11 Dissemination of findings (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 214
5.12 Summary and conclusions (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 217

Chapter 6: Quantitative stage: Results

6.1 Introduction and structure (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 219
6.2 Question 1: Demographic data: overall results .(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 220
6.3 Question 2: Do AIDS-orphaned children have more
6.4 psychological problems?(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 224
6.5 Question 3: Poverty (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 235
6.6 Question 4: Caregiving(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 247
6.7 Question 5: Community factors and stigma.(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 264
6.8 Question 6: Interactions between factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 277
6.9 Summary and conclusion(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 387

Chapter 7: Policy Implications and Conclusions

7.1 Summary of findings(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 290
7.2 Limitations of the study(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 293
9
7.3 Theoretical implications(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 308
7.4 Policy implications of study findings(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 314
7.5 Recommendations for future research(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 314
7.6 Background and plan for national survey(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 316
7.7 Conclusions(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) . 322

List of tables

Table 1: Selected HIV/AIDS estimates for South Africa(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 23
Table 2: Proportions of orphans in South Africa(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 25
Table 3: Predictions of orphan numbers in South Africa(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 26
Table 4: Estimates and predictions of orphan numbers in the Western Cape 26
Table 5: Psychological research with AIDS-orphaned children: a brief
summary of controlled studies(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 65
Table 6: Studies of mental health amongst AIDS-orphaned children which
measure risk and protective factors(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 103
Table 7: Differences between groups on demographic variables(cid:133)(cid:133).. 223
Table 8: Associations between demographic factors and mental health
outcomes(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 227
Table 9: Multivariate associations between orphanhood by AIDS,
orphanhood by other causes, and psychological outcomes,
controlling for socio-demographic cofactors (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 232
Table 10: Differences between orphanhood groups on poverty variables 239
Table 11: Associations between poverty-related factors and mental health
Outcomes (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 240
Table 12: Multivariate associations between orphanhood by AIDS,
orphanhood by other causes, and psychological outcomes,
controlling for sociodemographic cofactors and poverty-related
variables (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 243
Table 13: Differences between groups on type of caregiving
arrangement and caregiving-related variables (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 254
Table 14: Associations between caregiving factors and mental health
outcomes (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)... 255
Table 15: Multivariate associations between AIDS-orphanhood and
psychological outcomes, adjusting for type of caregiving
arrangement and controlling for sociodemographic co-factors(cid:133) 258
Table 16: Multivariate associations between orphanhood by AIDS,
orphanhood by other causes, and psychological outcomes,
controlling for age, gender, caregiver illness and minutes of
child housework per day (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 259
Table 17: Differences between orphanhood groups and community risk
factors (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 269
Table 18: Correlations between community factors and mental health
outcomes (cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 272
Table 19. Multivariate associations between orphanhood by AIDS,
orphanhood by other causes, and psychological outcomes,
10