Asset ownership and health and mental health functioning among AIDS-orphaned adolescents: Findings from a randomized clinical trial in rural Uganda☆
Introduction
Throughout the world, the number of children directly affected by the AIDS pandemic is increasing exponentially. It is estimated that by the year 2010, there will be 30 million AIDS-orphans (defined as children who have lost a parent or both parents to AIDS)—constituting 68% of the total number of orphans worldwide (44 million) (Porter, 2000). About 80% of the world's AIDS-orphans reside in sub-Saharan Africa and more than half of them are between the ages of 10 and 15 (UNICEF, 2005). Uganda is one of the countries where a considerable number of children are orphaned due to AIDS. UNICEF (2008) estimates that 2.3 million Ugandan children below age 18 are orphans (having lost one or both parents), with about half of these (51 percent) a direct result of the AIDS pandemic. Moreover, despite the falling rates of HIV infection in the country, it is projected that the number of AIDS-orphans will remain high or even increase because many parents are already infected, and most of them will die.
Death of a parent due to AIDS has many effects on the children. Financially, children affected by AIDS are vulnerable due to long episodes of illness which often precede death of the parents. As a result, such children are at an elevated risk of living in poverty (Case, Paxson, & Ableidinger, 2004). In addition, there are negative effects of parent death on children's health functioning and psychosocial development (Atwine, Cantor-Graae, & Banunirwe, 2005). Children whose parent(s) die due to AIDS may be subject to high levels of stress, which can threaten mental and physical health functioning. Further, children orphaned as a result of AIDS are more likely to suffer recurrent trauma, anxiety, depression, and academic difficulties (Atwine et al., 2005, Matshalaga, 2002, Rotheram-Borus et al., 2001).
Parental death due to AIDS may also have significant implications for children's self-concept and self-esteem. The death of a parent may foster negative inferences about the self in orphans (Rotheram-Borus et al., 2001). The negative inferences, in turn, may increase distress and negatively influence mental health functioning (Kim & Cicchetti, 2006). On the other hand, a positive self-concept and self-esteem may play a critical role in promoting mental health and buffering distress from parents' death. Self-esteem can alleviate negative effects of distress and help the child to maintain adequate relationships with others (Cast & Burke, 2002). In addition, self-esteem may influence general health behaviors and values among adolescents (Rivas Torres and Fernandez Fernandez, 1995, Rivas Torres et al., 1995). Therefore, interventions that help orphaned children to overcome stress and that promote aspects of mental health such as positive self-concept and self-esteem may be critical not only to the children's positive health functioning, but also their development into competent adults.
Several organizations working in countries heavily affected by AIDS—including Uganda—are exploring and experimenting with new strategies for caring for the orphaned children resulting from AIDS. These strategies range from those that focus exclusively on therapeutic counseling—either within a family environment or an institutional setting—to those that incorporate economic empowerment approaches into usual family-based care. Although the therapeutic counseling approaches have been in existence for a long time, the economic empowerment approaches—as a form of care and support for orphaned children—are relatively new (see Booysen and Van Der Berg, 2005, Sherer et al., 2004, Ssewamala et al., 2008). The assumption of the new approaches is that support for families caring for orphaned children should go over and above therapeutic counseling and incorporate economic empowerment opportunities in their interventions. Specifically, such families should be given opportunities for accumulating financial-related resources (herein referred to as asset-building) because assets may offer children hope for brighter futures through education and investment. Indeed, “asset-building”, which refers to efforts that enable people with limited financial and economic resources or opportunities to acquire and accumulate long-term productive assets, is increasingly viewed as a critical factor for reducing poverty, improving one's psychosocial functioning, and positively impacting attitudes and behaviors (Ssewamala et al., 2008). Moreover, interventions that incorporate economic opportunities in their design may also help reduce the risk of HIV/AIDS in the next generation by reducing mental health problems and discouraging engagement in risky sexual behaviors (Ssewamala, 2005, Ssewamala et al., 2008).
This study reports results from one of the newly-initiated economic interventions for adolescents orphaned as a result of AIDS in Uganda. The program is called SUUBI, which means “hope” in one of the local languages spoken in Uganda. The SUUBI program involves creating asset-building opportunities and promoting life options for AIDS-orphaned adolescents. Adolescents in the SUUBI program are offered the opportunity to open a savings account for secondary education or for microenterprise development. The SUUBI program also provides twelve 1–2 hour training sessions on career planning, and financial planning. Data are collected on a range of outcomes, including adolescents' mental health and self-rated health functioning status. Therefore, the SUUBI program offers an important opportunity to explore the possible relationship between asset accumulation and adolescents' health and mental health functioning. In this regard, this study examines the extent to which the economic empowerment intervention program being tested by SUUBI influences health and mental health functioning among AIDS-orphaned adolescents. The experimental design of the SUUBI program (assigning adolescents to either a control or experimental condition) makes it possible to compare program impacts on health and mental health functioning of the participants in the treatment condition vis-à-vis participants in the control condition.
Section snippets
Adolescents' self-esteem, mental health functioning, and health
Self-esteem generally refers to an individual's overall evaluation of the self (Davis-Kean and Sandler, 2001, Gecas, 1982, Rosenberg et al., 1995). While high self-esteem refers to a favorable evaluation of the self, low self-esteem refers to an unfavorable appreciation of the self. Self-esteem has been regarded as a buffer, providing protection from harmful experiences (Longmore and Simmons, 1997, Thoits, 1994) and a “boost” of mental heath and psychosocial functioning. Distress in the form of
SUUBI program in Uganda
Approaches to orphan care fall primarily into two categories: institutionalization and reactive strategies. Institutionalization involves placing children into orphanages or similar settings, while reactive strategies involve organizations providing “aid” mainly for physical needs including recreation services (a place to learn and play), counseling and provision of food aid (Drew et al., 1998, United Nations Children's Fund [UNICEF], 2004a, United Nations Children's Fund [UNICEF], 2004b,
Data and sample
This study uses longitudinal data from two time points—data collected at baseline/pre-SUUBI intervention (herein referred to as Wave 1) and 10 months post-SUUBI intervention (herein referred to as Wave 2)—to examine how the SUUBI program influenced: (1) mental health functioning among AIDS-orphaned children participating in the program. We specifically tested the extent to which the children's self-concept changes—over time—and whether participants in the treatment condition showed different
Descriptive and bivariate analysis
As noted earlier, the sample analyzed in the study was reduced from 286 to 267 due to attrition and missing data on some variables (see Table 1). The average age of the children was 13.7. The sample was fairly evenly balanced between girls (57%) and boys (43%). These percentages are a reflection of the “point of entry” for the SUUBI intervention, which was primary school level. Generally, because of the Ugandan government policy of free universal primary school, there are more girls enrolled in
Discussion
This study provides the first evidence of the effects of an economic empowerment intervention—over and above usual care for orphaned children—on children's well-being, including self-rated health and mental health functioning. It is important to note that since the study used a randomized experimental design, the observable differences between the two groups during the study period could, with some degree of confidence, be attributable to the effects of the economic intervention as implemented.
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The SUUBI-project was funded by a grant from the National Institute of Mental Health: 2005–2008 (RFA # R21 MH076475-01, PI: Fred M. Ssewamala). The study received IRB approval from Columbia University (AAA5337), and the Uganda National Council of Science and Technology (SS 1540). We are grateful to the SUUBI Research Staff for monitoring the study implementation process, specifically, Ms. Proscovia Nabunya and Reverend Fr. Kato Bakulu. We thank Professors Jane Waldfogel, Nabila El-Bassel, Irv Garfinkel, Mary McKay and Michael Sherraden for their help at different stages of the study intervention design and implementation. Our thanks to Jane Waldfogel for her contribution in revising the manuscript for intellectual content.