This paper has examined the relationship between a set of pertinent factors categorized in terms of household characteristics, poverty, caregiver characteristics and child characteristics, on the psychosocial wellbeing of children living amidst an HIV epidemic. The purpose has been to contribute to debates on whether orphaned children are more prone to negative psychosocial outcomes than non-orphans. Our analysis of a data set from a relatively large cohort of children showed no significant differences in outcomes between orphans and non-orphans using three dimensions of psychosocial wellbeing (depression and anxiety, resilience and affability). Our analysis also showed very few significant differences in the effects of the range of social, psychological and material factors on orphans and non-orphans (e.g. orphaned children were more likely to be female and to live with more children in the household). These findings support recent research [13, 14] which questions the primacy of orphanhood as a determinant of psychological outcomes in children living in high HIV prevalence settings.
There was a strong correlation between caregivers’ physical health, their caregiving capacities and children’s psychosocial wellbeing. Children with relatively high levels of anxiety and depression, irrespective of their orphan status, were those whose caregivers reported mental or physical impairment in the last month (p < 0.01). Children with lower affability were those whose caregivers reported poorer levels of health (p < 0.01).
Older children (between 16 -18 years) were more likely to have lower scores on affability (p < 0.01) and higher scores on anxiety/depression (p < 0.01) than children in lower age categories those below the age of 15. Of importance, the findings of the mediation analysis further suggest that more frequent communication with caregivers about personal problems and challenges may be responsible for younger children’s lower anxiety/depression and higher affability scores compared with their older counterparts. The latter finding highlights the protective role of caregiver-child communication in contexts of disadvantage and adversity .
There is a lot of research in sub-Saharan Africa highlighting the importance of the extended family as a safety net for orphans and, critically, the increasing burden, in terms of depletion of household resources and the strain on household resources resulting from accommodating more dependents [36–40]. Our results affirm quantitatively the findings in that literature. Household composition, whether it be larger households (p < 0.05), larger numbers of people in the household (p < 0.05) or larger dependency ratios (p < 0.05) had more deleterious effects on anxiety and depression scores than on the other two psychosocial outcomes irrespective of orphan status. The extended family remains a vital social security mechanism for care of orphans in the context of HIV/AIDS , yet the increasing size of extended families can bring with it an increasing likelihood of experiencing anxiety and depression among children and an increasing the risk of ill-health amongst caregivers. Accordingly, one must question assumptions about the capacity and capability of extended families to continuously absorb shocks to family welfare and recognize potential disadvantages for children as they enter adulthood.
While caregiver health was seen to be determinant in child psychosocial wellbeing, in the hierarchical regression analysis (see Table 3) it was evident that caregiver impairment rather than ill health was responsible for more deleterious effects on anxiety/depression (Caregiver impairment: β = 0.12, p < 0.01; caregiver health: -0.11, p > 0.05) and affability (Caregiver impairment: β = -0.12, p < 0.01; caregiver health: 0.03, p > 0.05). Given that the primary tasks or activities of the majority of caregivers were housework and child care, it is important to understand that the inability to fulfill the demands of caregiving and housework may be a more proximal predictor of poor psychosocial outcomes for children rather than the caregivers’ health status. In short, witnessing poor health and incapacitation in caregivers is stressful for children irrespective of whether they are orphans or not.
Orphan status was significant as a factor affecting psycho-social outcomes in two instances. First, the relationship between caregiver health and affability was significantly different for orphans and non-orphans (p < 0.05). Non-orphans had higher affability scores than orphans when their respective caregivers were in fair to good health but, in households where caregivers were in excellent health, orphans had more pronounced and higher affability scores than non-orphans (see Table 2). The intimation here is that orphans may require more emotional care than non-orphans, having experienced bereavement and change in living conditions [38, 39]; hence, caregivers who are in ‘excellent’ health are more capable of meeting that need amongst orphans. Secondly, orphans’ resilience scores remain relatively stable across different levels of caregiver help and assistance (p < 0.05) but amongst non-orphans’, resilience scores are strongly, yet inversely, influenced by the level of help and assistance they receive from their caregivers (p < 0.05). Notably, orphans who reported not receiving any help or assistance from their caregivers had the highest resilience scores; higher than non-orphans and orphans who ‘sometimes’ and ‘always’ received help and assistance from caregivers. It appears that orphans’ resilience outcomes in this sample may be less reliant on interpersonal assets such as caregiver help and assistance, which could stem from the experience of losing parents and caregivers in the past. Hence, they may have learnt to rely on other assets – internal psychological assets or other interpersonal and social assets – to sustain their wellbeing after experiencing the loss of adult attachments in the past [42, 43].
The extent to which the role of the caregiver could promote resilience in this sample of children was also found to vary according to the socio-economic status of the household (p < 0.05). Figure 1 illustrates that the role of the caregiver is a key resilience-promoting asset among children who were very poor. While low to moderate levels of caregiver help and assistance, including communication about personal problems, were associated with higher resilience scores for children who were not so poor, high levels of caregiver help and assistance, including communication about problems, were associated with better resilience outcomes for very poor participants. Furthermore, the wider variation in resilience scores across different levels of caregiver help and assistance and caregiver communication about problems for children who were very poor, suggests that their resilience scores are more strongly influenced by the level of support and assistance received from their caregivers. In accordance with Ungar’s theory on the ‘social ecology of resilience’, we can speculate perhaps that children living above the poverty threshold may have other social, material and interpersonal assets in their environment they can navigate towards to build resilience, but for adolescents living below the poverty line, who probably have fewer social and environmental resilience assets at their disposal, their relationship with their caregivers is a key resilience-promoting asset .
Indeed, being very poor was a significant contextual factor that was found to contribute to poorer mental health outcomes, in this study, higher anxiety/depression scores in children. Living below the poverty line can be associated with a myriad of stressors such as food insecurity, poor and inadequate housing, poor health, etc. all of which can thwart the satisfaction of adolescents’ basic needs and create worry and concern.