Poverty, AIDS and child health: Identifying highest-risk children in South Africa
1 Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, UK
2 Department of Psychiatry and Mental Health, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
3 Health Economics and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
4 School of Public and Development Management, University of the Witwatersrand, Johannesburg, South Africa
Free and University College Medical School, University College
Background. Identifying children at the highest risk of negative health effects is a prerequisite to effective public health policies in Southern Africa. A central ongoing debate is whether poverty, orphanhood or parental AIDS most reliably indicates child health risks. Attempts to address this key question have been constrained by a lack of data allowing distinction of AIDS-specific parental death or morbidity from other causes of orphanhood and chronic illness.
Objectives. To examine whether household poverty, orphanhood and parental illness (by AIDS or other causes) independently or interactively predict child health, developmental and HIV-infection risks.
Methods. We interviewed 6 002 children aged 10 - 17 years in 2009 - 2011, using stratified random sampling in six urban and rural sites across three South African provinces. Outcomes were child mental health risks, educational risks and HIV-infection risks. Regression models that controlled for socio-demographic co-factors tested potential impacts and interactions of poverty, AIDS-specific and other orphanhood and parental illness status.
Results. Household poverty independently predicted child mental health and educational risks, AIDS orphanhood independently predicted mental health risks and parental AIDS illness independently predicted mental health, educational and HIV-infection risks. Interaction effects of poverty with AIDS orphanhood and parental AIDS illness were found across all outcomes. No effects, or interactions with poverty, were shown by AIDS-unrelated orphanhood or parental illness.
Conclusions. The identification of
children at highest risk requires recognition and
measurement of both poverty and parental AIDS. This
study shows negative impacts of poverty and
AIDS-specific vulnerabilities distinct from
orphanhood and adult illness more generally.
Additionally, effects of interaction between family
AIDS and poverty suggest that, where these co-exist,
children are at highest risk of all.
Afr Med J 2013;103(12):910-915.
Child public health policy in Southern Africa faces a key question in decisions regarding targeting of interventions and resources, namely which indicators most reliably identify child vulnerability? Debate has centred on the question of whether household poverty, or orphanhood and household illness (AIDS-related or otherwise), are the best criteria to use.1 , 2
An important contribution to this question was published by the United Nations Children’s Fund (UNICEF) in 2010.3 This paper analysed pre-2008 Demographic and Household Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data (with some AIDS Indicator Survey (AIS) data) from 36 countries to determine whether orphanhood, or living with an HIV-positive or chronically ill adult, predicted child vulnerability in three outcomes: wasting among 0 - 4-year-olds, school attendance among 10 - 14-year-olds, and early sexual debut among 15 - 17-year-olds. Results were summarised: ‘In terms of wasting, early sexual debut, and to a lesser extent, school attendance, in the majority of surveys there were few significant differences between orphans and non-orphans or children living with chronically ill or HIV-positive adults and children not living with chronically ill or HIV-positive adults. Importantly, besides household wealth, no other potential markers of vulnerability consistently showed association or power to differentiate across the age-disaggregated outcomes.’ (p.1078). The authors concluded that ‘In many countries, targeting resources to children based solely on orphan status or co-residence with a chronically ill or HIV-positive adult in the household is not the most effective way of identifying vulnerable children’.
valuable findings, and those of other contributions
to the debate, were constrained by several
limitations of the datasets that were available.
Firstly, data such as DHS, MICS and AIS identify
whether children are orphaned, but do not
distinguish between orphanhood by AIDS and by
non-AIDS causes. Secondly, some datasets identify
chronic illness (and sometimes HIV status) of
someone in the household, but none identify AIDS
illness, or identify the child’s primary caregiver.
These are important limitations as evidence has
subsequently demonstrated negative effects on
children related to AIDS orphanhood and parental
AIDS illness but not to asymptomatic HIV-positive
status, other causes of orphanhood or chronic
parental illness.4-6 Thirdly, broad
national household surveys are of great value in
providing representative and comparable
cross-country data, but can only measure a limited
set of child outcomes. These may not reflect the
range of child vulnerabilities recently shown to be
associated with parental AIDS, particularly mental
7 educational risks
such as missing school to care for sick family
members,5 and specific
HIV-infection risks such as transactional sex.6 Indeed, some of these
risks cannot be accurately assessed in surveys that
use the household head as the respondent; adults are
often unaware of the extent of some child risks,
particularly internalising psychological distress
and sexual behaviour.8 Finally, the UNICEF
paper notes that ‘the analysis did not examine the
interaction effects of some variables, in particular
the interaction of wealth and orphan status’3 and recommends that
this be conducted in future analyses: ‘As a whole,
the data speak to the need for a multivalent
approach to defining child vulnerability, such as
combining wealth indicators with dimensions of
To (i) determine whether household poverty, orphanhood (by AIDS or other causes), and parental illness (by AIDS or other causes) independently predict child mental health, educational and HIV-infection risks; and (ii) to identify whether poverty interacts with orphanhood and/or parental illness status to exacerbate child risks.
For the purposes of this paper, ‘orphanhood’ refers
to death of a biological parent, and ‘parental
AIDS-illness’ refers to a parent or primary caregiver
of the child.
Participants and procedures
Between 2009 and 2011, we interviewed 6 002 children (56% female) aged 10 - 17 years, using door-to-door household sampling of entire census enumeration or designated tribal areas. These were randomly selected from six health districts with >30% antenatal HIV-prevalence, in three SA provinces – Mpumalanga, Western Cape and KwaZulu-Natal. Health districts comprised deep rural, dense rural, commercial farming, peri-urban, urban and urban-homeland areas. One randomly selected child per household completed a 60 - 70 min face-to-face interview. All interviewers were trained and had prior experience of working with vulnerable children. Voluntary informed consent was obtained from both children and primary caregivers (response rate 97.2% of those approached). All questionnaires, information and consent forms were translated into Xhosa, Zulu, Sotho, SiSwati and Tsonga and back-translated, and children participated in the language of their choice. Confidentiality was maintained, except where participants were at risk of significant harm or requested assistance. Where participants reported abuse, rape or risk of significant harm, immediate referrals were made to child protection and health services. For past abuse or rape, referrals were made to support and counselling services and to HIV/AIDS testing and treatment services where appropriate.
Ethical protocols were
approved by Oxford University, University of Cape
Town, University of KwaZulu-Natal and Provincial
Health and Education Departments of the Western Cape,
Mpumalanga and KwaZulu-Natal. No participant
incentives were given, apart from refreshments and
certificates of participation.
Household poverty was measured using an index of
access to the eight highest socially-perceived
necessities for children in SA. These were identified
through focus groups,9 followed by
corroboration by >80% of the population in the
nationally representative South African Social
Attitudes Survey.10 Necessities
comprised: 3 meals/day, a visit to the doctor and
medicines when needed, enough clothes to remain warm
and dry, soap to wash every day, money for school
fees, school uniform and one pair of shoes. This index
was combined into a dichotomised variable of lacking
more than half of child necessities to identify severe
The United Nations definition of orphanhood was
used – i.e. loss of one or both parents.11
In SA, death certificates rarely define AIDS
mortality and retrospective clinical data are
limited.12 Cause of
parental death was therefore determined using the
verbal autopsy method,13
validated in SA with sensitivity of 89% and
specificity of 93%.14
Determination of AIDS-related parental death
required a conservative threshold of ≥3
AIDS-defining illnesses; e.g. Kaposi’s sarcoma or
Parent/primary caregiver illness status
chronic illness, self-report of HIV/AIDS is also
unreliable due to low levels of HIV-testing, with an
estimated two-thirds of HIV-positive people unaware
of their current status.15 Parental AIDS illness
was thus determined using a verbal symptom
checklist, parallel to the verbal autopsy method, to
identify stage 4 AIDS illness through opportunistic
infections such as diarrhoea, oral candidiasis and
Kaposi’s sarcoma, as well as a range of other
chronic illnesses such as diabetes. In this study,
determination of parental AIDS illness required
either (i) a conservative
threshold of ≥3 AIDS-defining illnesses; or (ii) parent
self-identification of symptomatic AIDS or CD4+ count of <300 cells/ml.
Socio-demographic co-factors were child age, gender, urban/rural location and formal/informal housing following census definitions.
Child outcome measures
Mental health disorder
was measured by
standardised scales used previously with children in
SA. Depression was measured using the ten-item Child
Depression Inventory (CDI) short form,16 which is highly
correlated with the full CDI, has strong
psychometric properties and showed reliability in
the current sample of α=0.73. Anxiety was measured
using the Revised Children’s Manifest Anxiety Scale17 which has been
validated for use in SA,18 and reduced using
factor analysis to 14 items (current sample
reliability α=0.84).19 Suicidal planning or
attempts were measured with the Mini-International
Neuropsychiatric Interview for Children and
Adolescent Suicidality subscale20 (current sample
reliability α=0.80). Each scale was dichotomised
using standardised clinical cut-offs into 0 = no
disorder or 1 = presence of disorder and combined
into an overarching scale of number of disorders.
Negative educational outcomes
Negative educational outcomes were school
non-enrolment, extended periods (>1 week) of
past-year school non-attendance, being ≥2 years
behind age-appropriate school grade and inability to
concentrate in school due to worry about home
circumstances. 21 The
dichotomies were combined into an overarching scale
of number of educational risks.
were measured using a
checklist of items from the National Survey of HIV
and Risk Behaviour among Young South Africans and
the South African DHS.22
23 Items included
transactional sexual exploitation (sex in exchange
for food, shelter, school fees, transport or money),
sexual debut at age <15 years, ≥3 past-year
sexual partners, more than half of sexual acts
unprotected in past month, pregnancy/making someone
pregnant and having a sexual partner >5 years
older than the child. The dichotomies were combined
into an overarching scale of number of HIV-infection
Analyses were conducted in three stages. First, descriptive statistics summarising mental health, educational and HIV-infection risks as a function of orphanhood and parental health status were calculated. Second, multivariate regressions were conducted for each risk domain, controlling for child age, gender, rural/urban location and formal/informal dwelling. Household poverty, AIDS orphanhood, other orphanhood, parental AIDS illness and parental other illness were entered as independent predictors applying dummy coding, alongside four hypothesised interaction terms: poverty with AIDS orphanhood, other orphanhood, parental AIDS illness and parental other illness. Main effects for all independent variables, as well as any interactions between poverty, orphanhood and parental illness status are reported for each outcome. Dummy coding was retained for ease of interpretation, after checking that the pattern of effects was unchanged compared with contrast coding.24
statistics for all socio-demographic and risk
outcome variables (as a function of orphanhood and
parental sickness status) are summarised in Table 1. We noted
differences associated with cause of orphanhood:
among AIDS-orphaned children, 54% were maternally
bereaved and 22% double orphaned (both maternally
and paternally bereaved), while among other orphaned
children, 32% were maternally bereaved and 12%
double orphaned. There was also notable overlap
between relevant groups: 35% of AIDS-orphaned
children lived with a surviving, AIDS-unwell parent
or primary caregiver. Risk outcomes showed gender
differences, with girls reporting more mental health
and concentration problems, transactional sex and
older sexual partners and boys reporting more school
grade delay. All childhood risks increased with
child age. Therefore, gender and age were controlled
for in all further analyses.
Associations of poverty, orphanhood status and caregiver sickness status on child risks
Mental health risks
regression confirmed that poverty, AIDS orphanhood
and parental AIDS illness all predicted increased
likelihood of mental health disorder independently
of each other and of socio-demographic co-factors
(Table 2). Other orphanhood and other chronic
parental illness were not significant predictors of
mental health risks. Exacerbating interaction
effects were shown between poverty and AIDS
orphanhood (p<0.001; β=0.06) and
between poverty and parental AIDS illness (p<0.001; β=0.06):
children who were simultaneously AIDS-orphaned or
living with an AIDS-ill parent, and living in severe
poverty, reported more mental health disorders
(Fig. 1A). There was no interaction between
poverty and other orphanhood or parental other
chronic illness. Fig. 2A shows that presence of
poverty alone increases mental health disorder risk
by 0.08 standard deviations (SDs). The middle point
on the topmost line shows that this would increase
to 0.20 SDs if the main effects only of both
parental AIDS illness and poverty were at work.
However, the regression indicated two significant
interactions, between poverty and AIDS illness and
between poverty and AIDS orphanhood. The far point
on the topmost line shows the combined effect – an
increase up to 0.30 SDs in mental health risk.
Fig. 1. Group comparisons of child risk of (A) ≥1 mental health disorders; (B) ≥1 educational disorders or (C) ≥1 sexual risk.
Poverty and parental AIDS illness predicted increased
likelihood of educational risks independently of each
other and of socio-demographic co-factors. Orphanhood
status (by AIDS or other causes) and other parental
chronic illness were not significant predictors of
educational risk. There were no interactions between
poverty and orphanhood status. An exacerbating
interaction effect of poverty and parental AIDS
illness was shown – children who were simultaneously
living with an AIDS-ill parent and in severe poverty
reported more educational risks (Figs 1B and 2B).
There was no interaction effect between poverty and
other parental chronic illness.
Parental AIDS illness was the only independent
predictor of increased HIV-infection risks,
controlling for socio-demographic co-factors. Poverty,
orphanhood status (by AIDS or other causes) and other
parental chronic illness did not independently predict
likelihood of HIV-infection risks. However, an
exacerbating interaction effect of poverty and AIDS
orphanhood was also shown – children who were
simultaneously AIDS orphaned and living in severe
poverty reported more HIV-infection risks (Figs 1C and
2C). There was no interaction effect between poverty
and parental illness status.
This research is the first known to allow simultaneous disaggregation of children living in households below and above a poverty line, in urban and rural, formal and informal settlements, as well as involving six (frequently overlapping) groups of children: those non-orphaned, orphaned by AIDS or by non-AIDS causes; living with healthy parents, AIDS-ill or other-ill parents. We measured a wide range of child health and developmental outcomes, allowing investigation of mental health risks (depression, anxiety, suicidality); educational risks (non-enrolment, low school attendance, grade delay and concentration difficulties); and HIV-infection risks (transactional sex, childhood pregnancy or making someone pregnant, multiple sexual partners, early debut, low condom use, and having sexual partners ≥5 years older than the child).
These findings demonstrate five key implications for our understandings of child vulnerability in a high HIV-prevalence context.
First, they show both poverty-specific and AIDS-specific vulnerabilities for children. In this study, severe household poverty independently predicted child mental health and educational risks, AIDS orphanhood independently predicted mental health risks and parental AIDS illness independently predicted all three child outcomes of mental health, educational and HIV-infection risk. In other words, both poverty and family AIDS illness will lead us to the most vulnerable children, but a focus restricted to one or the other will exclude some of those most vulnerable.
Second, these findings demonstrate that there are indeed parental AIDS-specific health vulnerabilities for children. They support previous findings that orphanhood and parental chronic illness per se do not consistently predict child risks; indicators of orphanhood and parental illness that were not AIDS-related showed no predictive value for any child risk. For these children, poverty is a more important indicator of their vulnerability and using orphanhood or chronic illness alone as an indicator would exclude some children who may be vulnerable, and include others who may not be. However, disaggregation by AIDS-related illness and death showed that AIDS orphanhood and parental AIDS illness do predict child risks. Family AIDS has impacts on child health and development that are not only independent of the impacts of poverty, but also independent of illness and orphanhood more generally.
Third, analyses suggest that living with an AIDS-ill parent has stronger negative impacts than AIDS orphanhood on child mental health, educational and HIV-infection risks. This needs to be interpreted in the context of high levels of overlap between AIDS orphanhood and parental AIDS illness, but supports arguments that children may be at highest risk when a parent is alive but extremely unwell.25
Fourth, when poverty is co-present in a family with either parental AIDS illness or death, the result is an even greater threat to children than the additive effect of the two indicators. Findings indicate that severe poverty interacts variously with AIDS orphanhood and parental AIDS illness to exacerbate child mental health, educational, and HIV-infection risks. As would be expected in a non-experimental setting, interaction effects are not large, but given the adequate sample they are strongly significant.26 No interactions were found between poverty and other-orphanhood or other chronic parental illness.
findings have implications for the data that we
collect on child vulnerability. They demonstrate the
value of including broad, validated and sensitive
measures of child outcomes – in particular, mental
health risks such as depression and suicidality that
are closely linked with traumatic child experiences.
They support the measurement of household poverty as
an important indicator of child outcomes. They also
suggest that indicators focusing on orphanhood per se and household adult
chronic illness may require additional ‘AIDS
sensitivity’ to identify child vulnerability. It
could be of great value in future national surveys
to collect data that allow disaggregation of the
cause of orphanhood and of primary caregiver illness
and thus identify key indicators of AIDS orphanhood
and parental AIDS illness.
This study had a number of limitations. First, it would be important to conduct similar studies or analyses in additional countries.
Second, all cross-sectional data are limited in determining causality, although in this case, reverse causality is extremely unlikely (i.e. child mental health, educational and HIV-infection risks do not cause household poverty or parental AIDS illness or death).27
Third, there are no validated clinical cut-offs for child mental health disorder in Africa, although all scales had been extensively used or validated in SA.
Fourth, the study did not measure whether children were themselves infected with HIV. Only a small proportion of this sample would have been peri-natally HIV infected, owing to their birth 4 - 14 years before the beginning of the antiretroviral rollout in SA and low rates of survival in the pre-antiretroviral period,28 but others could have been infected during childhood or adolescence. Future research could valuably examine whether childhood HIV infection interacts with family factors to further exacerbate child risks.
Fifth, the measure of household poverty in this sample was primarily identifying ‘severe’ poverty, as all six of the study sites were in low-income areas.
Lastly, while many
child risks can only be accurately reported by
children themselves (such as sexual behaviour and
mental health), child self-reporting should ideally be
supplemented by adult reporting and administrative
data such as school registers, where this is available
limitations, the findings of this study strongly
support international policies and research
emphasising the need for accurately targeted
‘AIDS-sensitive’ health and social protection
programmes for children.29
30 They also suggest a
re-framing of some debates that posit poverty,
orphanhood or family AIDS as competing indicators of
child vulnerability in sub-Saharan Africa. If we are
to identify children at high risk, it is essential
that both poverty and parental
AIDS are recognised and measured. And where poverty
and AIDS interact – as is so often seen – we find
the children at the highest risk of all.
authors wish to thank our fieldwork teams in the
Western Cape, KwaZulu-Natal and Mpumalanga. Most
importantly, we thank the all the participants and
their families. This study was funded by the UK
Economic and Social Research Council, the SA
National Research Foundation, the Health Economics
AIDS Division at the University of KwaZulu-Natal,
the SA National Department of Social Development,
the Claude Leon Foundation, the John Fell Fund and
the Nuffield Foundation.
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30 September 2013.
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