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December 2007, Vol. 13, No. 3HIV and AIDS Some 15 million children under age 18 have lost one or both parents to AIDS. The vast majority—more than 12 million—are in sub-Saharan Africa. By 2010, the number of children orphaned by AIDS is expected to exceed 20 million. A much larger number of children will be made vulnerable by the epidemic, as their parents become sick and household stability is threatened. In the countries most affected by HIV, children’s social support systems have been left in tatters as the virus affects relatives, teachers, healthcare workers, and other people essential to children’s well-being. In the past, programs for orphans and vulnerable children provided mainly school fees, food, and healthcare. But increasingly program managers are recognizing the importance of psychological and social (psychosocial) services. The Population Council’s Horizons Program recently assessed psychosocial support programs for orphans and vulnerable youth in Zimbabwe and Rwanda. The research points both to effective approaches and to program challenges that demand special attention. The USAID-funded Horizons Program of operations research is implemented by the Population Council in partnership with the International Center for Research on Women, the International HIV/AIDS Alliance, the Program for Appropriate Technology in Health, Tulane University, Family Health International, and Johns Hopkins University. Horizons research findings are intended to enable USAID and its partners to allocate limited funds to the most effective interventions.
Zimbabwe Exposure to psychosocial support was associated with greater self-confidence among males. For example, 96 percent of males in the counselor/leader group reported feeling self-confident compared to 77 percent of those in the comparison group, a statistically significant difference. Similarly, males in the Kids’ Club group were significantly more likely to report feeling self-confident in the last month than were their peers in the comparison group (85 vs. 77 percent). “This finding among males reflects the aims of the interventions,” said Laelia Gilborn, formerly of Horizons/Population Council, a principal investigator. “But more rigorous research is needed to find out whether the programs attracted more self confident youth or whether the programs are responsible for increasing self-confidence.” Because the study did not follow the young people over time, it is not possible to determine whether the program caused any of the psychosocial outcomes. “We also need to find out why the results were not as pronounced among females,” added Gilborn. Intriguingly, respondents in each of the three intervention groups reported more psychosocial distress than young people in the comparison group. This unexpected finding stimulated extensive discussion among the researchers and program implementers. One possible explanation is that the programs help vulnerable youth become more aware of and articulate about their feelings. “Psychosocial support programs may help youth become emotionally literate, which allows them to better express emotions,” said Leslie Snider, another study investigator, who was at Tulane University at the time of the study. “If so, psychosocial support programs need to ensure that activities do not simply bring out emotions, but also help youth to cope with such feelings over time.” The additional responsibilities taken on by the young leaders/counselors, such as mentoring and counseling younger children, could also contribute to their comparatively higher levels of distress. “We learned that psychosocial strengths coexist— in individuals and in the study population— with psychosocial distress. This was especially true of the leaders,” said Gilborn. Females in the study reported more traumatic life events. They also demonstrated greater psychosocial distress and were more likely to manifest their distress through physical complaints, such as fatigue and poor appetite. Program managers should be aware of girls’ heightened vulnerability to hopelessness and poor self-esteem. Crucially, the findings from Zimbabwe show that many youth, particularly those who have been orphaned, feel that they do not receive adequate guidance and support from adults. An important role for psychosocial support programs would then be to link young people with trusted adults. This is precisely the step that World Vision, a faith-based organization, took in Rwanda
Rwanda World Vision Rwanda had already instituted a basic needs program for youth-headed households in several districts, which included assistance with housing, education, healthcare, and food. It then identified four of these districts to participate in a study. In two of the districts, young household heads received additional help in the form of an adult mentor, a trusted member of the community, who would visit at least once a month, and usually more often. The other two districts served as a comparison in the study. Mentors were trained to serve as caring and interested adults and to help solve problems. The researchers collected data from the households at the beginning of the program—March 2004—and again 18 months later. “This study is ground-breaking in two major ways,” said Katie D. Schenk of Horizons/ Population Council. “It is the first rigorous research to evaluate a community-based intervention for orphans and vulnerable children by comparing data collected before and after the intervention. There is also a notable focus on the psychosocial domain and developing appropriate measurement approaches. It indicates a practical way in which we really can make a valuable difference in the lives of children affected by HIV and AIDS.” During the first round of data collection, 692 young heads of household between the ages of 12 and 24 responded; 608 responded in the follow-up round of data collection. An almost equal number of males and females responded, and more than 60 percent of these young people reported having served as the head of their household for four or more years. Seventy percent of the respondents reported that both of their parents were dead. The remainder had been abandoned or did not know their parents’ whereabouts. Nearly a third cared for three or more children, with females more likely than males to care for several children. Findings from this study suggest that mentoring by adults within the community can measurably alleviate adverse psychological and social outcomes among young males and females who serve as heads of household. “Despite disturbingly high levels of depression, maltreatment, and marginalization, as well as low levels of adult support reported at baseline,” elaborated researcher Lisanne Brown of Horizons/Tulane University, “follow-up data collected 18 months into the intervention, a relatively short time, indicate significant positive changes in psychosocial outcomes among youth participating in the mentor program.” Overall, the mentoring program appears to have enhanced social protection and community connectedness and minimized psychological problems among participants. Young heads of households in the mentorship program perceived a significant increase in adult support. They also reported a significant decrease in feelings of isolation and stigma from the community. Youth who did not have mentors reported significant increases in feelings of grief, while those with mentors did not. Participants also reported a significant decrease in depressive symptoms. One participant, a 17-year-old boy, stated, “Before, we had no hope for the future. After being advised, we felt courageous. . . . This program helped us a lot.” World Vision Rwanda expanded the mentoring program to all youth-headed households in the four communities after the second survey. Similar to the study in Zimbabwe, the Rwanda study revealed that females were more susceptible to depressive symptoms. The researchers agreed that female orphans may need special assistance to prevent and overcome severe psychological problems. Further, children whose parents were murdered in the genocide, a particularly traumatic loss, were much more likely than other children to experience depression and other severe symptoms, and may require more specialized attention. During the 18 months between data collection in Rwanda, there was no positive impact of the mentoring program on the health status of other children in the household. There were improvements in other variables, however, such as increased school attendance and increased willingness to help with household chores. The program may need to be in place for a longer period of time to register an impact on the health of other children in the household. “This study highlights the needs children have for someone to talk to about their feelings, relationships, and life decisions,” said Edward Kalisa of World Vision Rwanda. “Orphans are often left with this critical need unmet. Mentorship programs are a low-cost way to significantly improve the lives and wellbeing of orphaned young people.” Sources Brown, Lisanne, Janet Rice, Neil Boris, Tonya Thurman, Leslie Snider, Joseph Ntaganira, Laetitia Nyirazinyoye, Edward Kalisa, and Emmanuel Nshizirungu. 2007. “Psychosocial benefits of a mentoring program for youth-headed households in Rwanda,” Horizons Research Summary. Washington, DC: Population Council. (PDF) Brown, Lisanne, Tonya R. Thurman, Edward Kalisa, Janet Rice, Jean de Dieu Bizimana, Neil Boris, Leslie Snider, and Joseph Ntaganira. 2007. “Supporting volunteer mentors: Insights from a mentorship program for youth-headed households in Rwanda,” Horizons Research Summary. Washington, DC: Population Council. (PDF) Gilborn, Laelia, Lou Apicella, Jonathan Brakarsh, Linda Dube, Kyle Jemison, Mark Kluckow, Tricia Smith, and Leslie Snider. 2006. “Orphans and vulnerable youth in Bulawayo, Zimbabwe: An exploratory study of psychosocial well-being and psychosocial support,” Horizons Final Report. Washington, DC: Population Council. (PDF) Thurman, Tonya R., Leslie Snider, Neil Boris, Edward Kalisa, Eleazer Nkunda Mugarira, Joseph Ntaganira, and Lisanne Brown. 2006. “Psychosocial support and marginalization of youth-headed households in Rwanda,” AIDS Care 18(3): 220–229. (offsite abstract) Outside funding Related Projects
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