Psychological distress among AIDS orphans in rural Uganda

Abstract

More than 11 million children under 15 years in sub-Saharan Africa have lost at least one parent to AIDS. In Uganda, about 2 million children are orphans, with one or both parents dead. The objective of this study was to investigate the psychosocial consequences of AIDS orphanhood in a rural district in Uganda and to identify potential areas for future interventions. The study was conducted in a randomly selected sub-county in Bushenyi District in Uganda. The study population consisted of 123 children aged 11–15 years whose parents (one or both) were reported to have died from AIDS and 110 children of similar age and gender living in intact households in the same neighbourhood. Symptoms of psychological distress were assessed using the Beck Youth Inventories of Emotional and Social Impairment (BYI). The standardized interview also included questions concerning current and past living conditions. A multivariate analysis of factors with possible relevance for BYI outcome showed that orphan status was the only significant outcome predictor. Orphans had greater risk (vs. non-orphans) for higher levels of anxiety (odds ratios (OR)=6.4), depression (OR=6.6), and anger (OR=5.1). Furthermore, orphans had significantly higher scores than non-orphans on individual items in the Beck Youth Depression Inventory that are regarded as particularly “sensitive” to the possible presence of a depressive disorder, i.e. vegetative symptoms, feelings of hopelessness, and suicidal ideation. High levels of psychological distress found in AIDS orphans suggest that material support alone is not sufficient for these children.

Introduction

Although HIV most often infects adults of reproductive age, the illness has important consequences for younger family members dependent on these adults for parental support. In sub-Saharan Africa, more than 11 million children under the age of 15 have lost at least one parent to AIDS, representing one-third of the total number of children who have been orphaned world wide. More than half of those orphaned by AIDS in sub-Saharan Africa are between the ages of 10 and 15. The orphan crisis in sub-Saharan Africa is expected to increase dramatically within the coming years. By 2010, there will be approximately 20 million children in sub-Saharan Africa who have lost at least one parent to AIDS (Bhargava & Bigombe, 2003; UNAIDS, 2003).

In an estimated total population of 23 million, 1.05 million people living in Uganda are now estimated to have HIV, and about 120,000 have already developed AIDS. Nearly 80% of those infected with HIV are between the ages of 15 and 45 years. In Uganda, about 2 million children under the age of 18 years are orphans, with one or both parents dead. These children experience orphanhood at an age when parental guidance and socialization is most desirable (Uganda AIDS Commission, 2003). Little is known about the psychosocial consequences of AIDS orphanhood, in Uganda or in other low-income countries. Concerns about the socioeconomic impact of AIDS on children in low-income countries have overshadowed the psychological impact, in so far as physiological and safety needs may seem to require more immediate attention than psychosocial problems. Nevertheless, due to the severity of the epidemic in Africa, many African children face recurrent losses among family members and guardians, as well as the loss of familiar surroundings and schooling. Thus, the psychological impact may well be recurrent also (Makame, Ani, & Grantham-McGregor, 2002).

The experience of loss and bereavement is generally difficult for young children (Siegel & Gorey, 1994), with psychological reactions developing sometimes months or years following these events (Goodman, 2001). Children's mourning behaviour tends to fluctuate, making it difficult for adoptive parents and teachers to recognize symptoms and to provide appropriate support (Foster, 2002). Psychological well-being is, nevertheless, a prerequisite for sustainable programs seeking to provide material and educational support to AIDS orphans. Interrupted schooling may have long-term effects on household poverty and may increase the risk for HIV infection (Gilborn, 2002). Also, although the extended family remains the principle orphan-care unit, some relatives may exploit the children's labour and fail to meet their educational and medical needs (Bedri, Kebede, & Negassa, 1995; Foster et al., 1995). Thus, the growing magnitude of AIDS orphanhood in Africa has implications for current and future mental health.

Despite the need for a comprehensive assessment of these children's vulnerability, previous studies of AIDS orphans in Uganda/East Africa have primarily focused upon orphans’ living circumstances, rather than upon psychological health (Foster, 2002). One study conducted in Zimbabwe did however show that orphans have a number of emotional and behavioural concerns, including stigmatization, exploitation, and problems at school (Foster, Makufa, Drew, Mashumba, & Kambeu, 1997). Sengendo and Nambi's study in Uganda (1997) found that children confronted with an ill parent felt sad and helpless, and upon adoption, many felt angry and depressed. Likewise, Makame et al. (2002) found higher levels of negative mood and pessimism in AIDS orphans compared to non-orphans, utilizing selected items from the Beck Depression Inventory for Adults (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961).

The overall pattern of results across studies indicates that AIDS orphanhood may be accompanied by an increased risk for the development of depressive symptoms. Although symptoms of depression, guilt, and anger are part of the normal bereavement process, bereavement is especially complicated when a child loses a parent in AIDS (Siegel & Gorey, 1994). AIDS is a stigmatising disorder, and discussion of the illness is often avoided. Moreover, a large number of AIDS orphans lose more than one family member to AIDS, and children may even themselves worry about becoming ill. No previous study has assessed AIDS orphans’ psychological status using an instrument covering a broad range of symptoms and one that is developed specifically for use in children.

The aim of the present study was to conduct a comprehensive assessment of the current psychological status of AIDS orphans using an instrument developed for children, the Beck Youth Inventories of Emotional and Social Impairment (BYI) (Beck, Beck, & Jolly, 2001). The study concerns children within a restricted age range (11–15), i.e. that corresponding to middle childhood. Orphans who are younger than 11 may not be able to express their feelings as well as older orphans, and orphans who are older than 15 might face additional challenges, due to the onset of sexual activity and the risk of HIV infection. Most estimates of AIDS orphanhood concern children under 15 years old (Foster & Williamson, 2000). We hypothesized that orphans would have lower self-esteem and higher levels of psychological distress than non-orphans, controlling for other factors such as low socioeconomic status.

A secondary aim of the study was to identify background factors related to current symptom levels that might potentially be targeted in future intervention programs for orphans. We hypothesized that orphans with additional stressors, e.g. AIDS mortality among other relatives, increased household burdens, perceived neglect, or poor communication with elders, would have more symptoms of psychological distress than orphans without such stressors (Siegel & Gorey, 1994; Siegel, Mesagno, & Christ, 1990).