Psychosocial well-being of orphans in HIV/AIDS-afflicted Eastern Zimbabwe

Almost 21% of Zimbabwe's population of roughly 13 million people live with HIV infection while 1.6 million children (23%) have been orphaned. The epidemic is fuIther worsening children's lives by decreasing access to health selvices, education, shelter, clothing, vocational training, legal protection, psychosocial support, good nmtming-and care from family members. Undelstanding the psychosocial effects on chiidIen of being oiphaned or made vulneIable by the epidemic is vital if fwther problems in childhood and later life are to be averted. Objectives 1. To develop a theoretical framework for understanding the relationships between OIphan expelience, psychosocial distress, and child expeIiences and adult life chances. . 2. To compare and contJ:ast levels of psychosocial distIess by fOIm (Le. patemal only, matemal only and double) and dUIation of oIphanhood in Zimbabwe. 3. To assess the cumulative impact of psychosocial distress experienced in childhood on risky behaviour outcomes in adolescence and adult life expeliences. . 4. To assess how appropriate and sensitive the methods and tools used in the study were to the children's plight. Methods Stata version 9.0 was used to conduct statistical analyses of data from three survey sources: the Zimbabwe Oye Baseline Smvey 2004, the Manicaland Child Cohort Study, arid the Manicaland HIV/SID Prevention Project. Qualitative data were collected and used to aid inteIpretation of the statistical results. Results In the national ayC survey (ages 12-17 years), psychosocial distress was more common in . females and younger children. Otphans ovetall and each fOIm of orphan were at greater risk of developing psychosocial distress than non-OIphims. In multivariate analyses, being resident in an urban area (Coeff, 0.16; 95% CI, 0.04-0.28), on a commercial farm (Cooff, 0.46; 95% CI, 0.08-0.84), in the poorest 20% of households (Coeff, 0.14; 95% CI, 0.04-0.24), in a household that had received external SUppOIt (Coeft', 0.21; 95% CI, -0.01-0.44) and not being related to the closest caregiveI (Coeff, 0.14; 95% CI, 0.03-0.24) were associated with psychosocial distress. Being in a female-headed household (Cooff; -0.11; 95% CI, -0.19- -0.02) and receiving psychosocial SUppoIt from the closest caregiver (Cooff, -0.05; 95% CI, -0.09- -0.01) had protective effects against psychosocial distress. Maternal and paternal OIphans were significantly more likely than non-OYC to have engaged in sexual activity. These differences weIe reduced after contJ:olling for psychosocial distress. In Manicaland, eastern Zimbabwe, paternal and double OIphans were at increased risk of psychosocial distJ:ess. OIphans were more likely to have started sex and to have engaged in substance abuse. However, the only (borderline) significantlesult was increased likelihood of patemal orphans having engaged in substance abuse [p=O .056]. Conclusion Orphaned children in Zimbabwe suffer greater psychosocial distress which may lead to incleased likelihood of sexual debut and HIV.infection. The impact of strategies to provide psychosocial support should be evaluated scientifically.Imperial Users onl

Children's role in the community response to HIV in Zimbabwe

Introduction: Recent debates on how to achieve an optimal HIV response are dominated by intervention strategies that fail to recognize children’s role in the community response to HIV. Whilst formal responses are key to the HIV response, they must recognize and build on indigenous community resources. This study examines adult’s perspectives on the role of children in the HIV response in the Matobo District of southern Zimbabwe. Methods: Through a mix of individual interviews (n = 19) and focus group discussions (n = 9), 90 community members who were active in social groups spoke about their community response to HIV. Transcripts were subjected to a thematic analysis and coding to generate key concepts and representations. Findings: In the wake of the HIV epidemic, traditional views of children’s social value as domestic ‘‘helpers’’ have evolved into them being regarded as capable and competent actors in the care and support of people living with HIV or AIDS, and as integral to household survival. Yet concurrent representations of children with excessive caregiving responsibilities as potentially vulnerable and at risk suggest that there is a limit to the role of children in the HIV response. Conclusion: Community volunteers and health staff delivering HIV services need to recognize the ‘‘behind the scene’’ role of children in the HIV response and ensure that children are incorporated into their modus operandi — both as social actors and as individuals in need of support

The role of community conversations in facilitating local HIV competence: case study from rural Zimbabwe

Background This paper examines the potential for community conversations to strengthen positive responses to HIV in resource-poor environments. Community conversations are an intervention method through which local people work with a facilitator to collectively identify local strengths and challenges and brainstorm potential strategies for solving local problems. Methods We conducted 18 community conversations (with six groups at three points in time) with a total of 77 participants in rural Zimbabwe (20% HIV positive). Participants were invited to reflect on how they were responding to the challenges of HIV, both as individuals and in community groups, and to think of ways to better support openness about HIV, kindness towards people living with HIV and greater community uptake of HIV prevention and treatment. Results Community conversations contributed to local HIV competence through (1) enabling participants to brainstorm concrete action plans for responding to HIV, (2) providing a forum to develop a sense of common purpose in relation to implementing these, (3) encouraging and challenging participants to overcome fear, denial and passivity, (4) providing an opportunity for participants to move from seeing themselves as passive recipients of information to active problem solvers, and (5) reducing silence and stigma surrounding HIV. Conclusions Our discussion cautions that community conversations, while holding great potential to help communities recognize their potential strengths and capacities for responding more effectively to HIV, are not a magic bullet. Poverty, poor harvests and political instability frustrated and limited many participants’ efforts to put their plans into action. On the other hand, support from outside the community, in this case the increasing availability of antiretroviral treatment, played a vital role in enabling communities to challenge stigma and envision new, more positive, ways of responding to the epidemic

Getting off on the wrong foot? How community groups in Zimbabwe position themselves for partnerships with external agencies in the HIV response

Background: Partnerships are core to global public health responses. The HIV field embraces partnership working, with growing attention given to the benefits of involving community groups in the HIV response. However, little has been done to unpack the social psychological foundation of partnership working between well-resourced organisations and community groups, and how community representations of partnerships and power asymmetries shape the formation of partnerships for global health. We draw on a psychosocial theory of partnerships to examine community group members’ understanding of self and other as they position themselves for partnerships with non-governmental organisations. Methods: This mixed qualitative methods study was conducted in the Matobo district of Matabeleland South province in Zimbabwe. The study draws on the perspectives of 90 community group members (29 men and 61 women) who participated in a total of 19 individual in-depth interviews and 9 focus group discussions (n = 71). The participants represented an array of different community groups and different levels of experience of working with NGOs. Verbatim transcripts were imported into Atlas.Ti for thematic indexing and analysis. Results: Group members felt they played a central role in the HIV response. Accepting there is a limit to what they can do in isolation, they actively sought to position themselves as potential partners for NGOs. Partnerships with NGOs were said to enable community groups to respond more effectively as well as boost their motivation and morale. However, group members were also acutely aware of how they should act and perform if they were to qualify for a partnership. They spoke about how they had to adopt various strategies to become attractive partners and ‘supportable’ – including being active and obedient. Conclusions: Many community groups in Zimbabwe recognise their role in the HIV response and actively navigate representational systems of self and other to showcase themselves as capable actors. While this commitment is admirable, the dynamics that govern this process reflect knowledge encounters and power asymmetries that are conditioned by the aid architecture, undermining aspiring efforts for more equitable partnerships from the get-go

Do risk, time and prosocial preferences predict risky sexual behaviour of youths in a low-income, high-risk setting?

Young people in sub-Saharan Africa are particularly at high risk of sexually transmitted infections. Little is known about their preferences and even less about their association with risky sexual behaviour. We conducted incentivized economic experiments to measure risk, time and prosocial preferences in Zimbabwe. Preferences measured at baseline predict biomarker and self-reported measures of risky sexual behaviour gathered 12 months later. We find robust evidence that individuals more altruistic at baseline are more likely to be Herpes Simplex Virus Type-2 (HSV-2) positive 12 months later. Analysis by sex shows this association is driven by our sample of women. Having more sexual partners is associated with greater risk tolerance amongst men and greater impatience amongst women. Results highlight heterogeneity in the association between preferences and risky sexual behaviour

A good patient? How notions of ‘a good patient’ affect patient-nurse relationships and ART adherence in Zimbabwe

Background: While patient-provider interactions are commonly understood as mutually constructed relationships, the role of patient behaviour, participation in interactions, and characteristics, particularly ideals surrounding notions of ‘good’ and ‘bad’ patients, are under-examined. This article examines social representations of ‘a good patient’ and how these representations affect patient-healthcare provider relationships and antiretroviral treatment (ART) for people living with HIV. Methods: Using thematic network analysis, we examined interview and focus group transcripts involving 25 healthcare staff, 48 ART users, and 31 carers of HIV positive children, as well as field notes from over 100 hours of ethnographic observation at health centres in rural Zimbabwe. Results: Characteristics of a good patient include obedience, patience, politeness, listening, enthusiasm for treatment, intelligence, physical cleanliness, honesty, gratitude and lifestyle adaptations (taking pills correctly and coming to the clinic when told). Many patients seek to perform within the confines of the ‘good patient persona’ to access good care and ensure continued access to ART; in this way, the notion of a ‘good ART patient’ can have positive effects on patient health outcomes. However, for people not conforming to the norms of the ‘good patient persona’, the productive and health-enabling patient-nurse relationship may break down and be detrimental to the patient. Conclusion: We conclude that policy makers need to take heed of the social representations that govern patient-nurse relationships and their role in facilitating or undermining ART adherence

Can schools support HIV/AIDS-affected children? Exploring the ‘ethic of care’ amongst rural Zimbabwean teachers

How realistic is the international policy emphasis on schools ‘substituting for families’ of HIV/AIDS-affected children? We explore the ethic of care in Zimbabwean schools to highlight the poor fit between the western caring schools literature and daily realities of schools in different material and cultural contexts. Interviews and focus groups were conducted with 44 teachers and 55 community members, analysed in light of a companion study of HIV/AIDS-affected pupils’ own accounts of their care-related experiences. We conceptualise schools as spaces of engagement between groups with diverse needs and interests (teachers, pupils and surrounding community members), with attention to the pathways through which extreme adversity impacts on those institutional contexts and social identifications central to giving and receiving care. Whilst teachers were aware of how they might support children, they seldom put these ideas into action. Multiple factors undermined caring teacher-pupil relationships in wider contexts of poverty and political uncertainty: loss of morale from low salaries and falling professional status; the inability of teachers to solve HIV/AIDS-related problems in their own lives; the role of stigma in deterring HIV/AIDS-affected children from disclosing their situations to teachers; authoritarian teacher-learner relations and harsh punishments fuelling pupil fear of teachers; and lack of trust in the wider community. These factors undermined: teacher confidence in their skills and capacity to support affected pupils and motivation to help children with complex problems; solidarity and common purpose amongst teachers, and between teachers and affected children; and effective bridging alliances between schools and their surrounding communities–all hallmarks of HIV-competent communities. We caution against ambitious policy expansions of teachers' roles without recognition of the personal and social costs of emotional labour, and the need for significant increases in resources and institutional recognition to enable teachers to adopt support roles. We highlight the need for research into how best to create opportunities for teacher recognition in deprived and disorganised institutional settings, and the development of more culturally appropriate notions of carin

Relationships between changes in HIV risk perception and condom use in East Zimbabwe 2003-2013: population-based longitudinal analyses

Background: Perceiving a personal risk for HIV infection is considered important for engaging in HIV prevention behaviour and often targeted in HIV prevention interventions. However, there is limited evidence for assumed causal relationships between risk perception and prevention behaviour and the degree to which change in behaviour is attributable to change in risk perception is poorly understood. This study examines longitudinal relationships between changes in HIV risk perception and in condom use and the public health importance of changing risk perception. Methods: Data on sexually active, HIV-negative adults (15-54 years) were taken from four surveys of a general-population open-cohort study in Manicaland, Zimbabwe (2003-2013). Increasing condom use between surveys was modelled in generalised estimating equations dependent on change in risk perception between surveys. Accounting for changes in other socio-demographic and behavioural factors, regression models examined the bi-directional relationship between risk perception and condom use, testing whether increasing risk perception is associated with increasing condom use and whether increasing condom use is associated with decreasing risk perception. Population attributable fractions (PAFs) were estimated. Results: One thousand, nine hundred eighty-eight males and 3715 females participated in ≥2 surveys, contributing 8426 surveys pairs. Increasing risk perception between two surveys was associated with higher odds of increasing condom use (males: adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 0.85-2.28, PAF = 3.39%; females: aOR = 1.41 [1.06-1.88], PAF = 6.59%), adjusting for changes in other socio-demographic and behavioural factors. Those who decreased risk perception were also more likely to increase condom use (males: aOR = 1.76 [1.12-2.78]; females: aOR = 1.23 [0.93-1.62]) compared to those without change in risk perception. Conclusions: Results on associations between changing risk perception and increasing condom use support hypothesised effects of risk perception on condom use and effects of condom use on risk perception (down-adjusting risk perception after adopting condom use). However, low proportions of change in condom use were attributable to changing risk perception, underlining the range of factors influencing HIV prevention behaviour and the need for comprehensive approaches to HIV prevention

Re-thinking children’s agency in extreme hardship: Zimbabwean children’s draw-and-write about their HIV-affected peers

We compare two analyses of ‘draw-and-write’ exercises in which 128 Zimbabwean children represented their HIV-affected peers. The first, informed by the ‘new social studies of childhood’, easily identified examples of independent reflection and action by children. The second, informed by Sen’s understandings of agency, drew attention to the negative consequences of many of the choices available to children, and the contextual limits on outcomes children themselves would value: the support of caring adults, adequate food, and opportunities to advance their health and safety. Conceptualisations of agency need to take greater account of children’s own accounts of outcomes they value, rather than identifying agency in any form of independent reflection and action per se

Community resistance to a peer education programme in Zimbabwe

Background: This paper presents community perceptions of a state-of-the-art peer education programme in Manicaland, Zimbabwe. While the intervention succeeded in increasing HIV knowledge among men and condom acceptability among women, and reduced HIV incidence and rates of unprotected sex among men who attended education events, it did not succeed in reducing population-level HIV incidence. To understand the possible reasons for this disappointing result, we conducted a qualitative study of local perspectives of the intervention. Methods: Eight focus group discussions and 11 interviews with 81 community members and local project staff were conducted. Transcripts were interrogated and analysed thematically. Results: We identified three factors that may have contributed to the programme’s disappointing outcomes: (1) difficulties of implementing all elements of the programme, particularly the proposed income generation component in the wider context of economic strain; (2) a moralistic approach to commercial sex work by programme staff; and (3) limitations in the programme’s ability to engage with social realities facing community members. Conclusions: We conclude that externally-imposed programmes that present new information without adequately engaging with local realities and constraints on action can be met by resistance to change