Who is the vulnerable child? Using survey data to identify children at risk in the era of HIV and AIDS

Abstract

Over the past decade, there has been increasing global attention to mitigating the impacts of the HIV/AIDS epidemic on children's lives. Within this context, developing and tracking global child vulnerability indicators in relation to HIV and AIDS has been critical in terms of assessing need and monitoring progress. Although orphanhood and adult household illness (co-residence with a chronically ill or HIV-positive adult) are frequently used as markers, or definitions, of vulnerability for children affected by HIV and AIDS, evidence supporting their effectiveness has been equivocal. Data from 60 nationally representative household surveys (36 countries) were analyzed using bivariate and multivariate methods to establish if these markers consistently identified children with worse outcomes and also to identify other factors associated with adverse outcomes for children. Outcome measures utilized were wasting among children aged 0–4 years, school attendance among children aged 10–14 years, and early sexual debut among adolescent boys and girls aged 15–17 years. Results indicate that orphanhood and co-residence with a chronically ill or HIV-positive adult are not universally robust measures of child vulnerability across national and epidemic contexts. For wasting, early sexual debut, and to a lesser extent, school attendance, in the majority of surveys analyzed, 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. Of other factors analyzed, children living in households where the household head or eldest female had a primary education or higher were significantly more likely to be attending school, better household health and sanitation was significantly associated with less wasting, and greater household wealth was significantly associated both with less wasting and better school attendance. Of all marker of child vulnerability analyzed, only household wealth consistently showed power to differentiate across age-disaggregated outcomes. Overall, the findings indicate the need for a multivalent approach to defining child vulnerability, one which incorporates household wealth as a key predictor of child vulnerability.

Keywords:

• orphans
• vulnerable children
• HIV/AIDS
• global markers and indicators
• definitions

Notes

1. Because of the sensitivities and stigma associated with HIV and AIDS, it is not possible to accurately measure AIDS-specific orphanhood or chronic illness directly. Thus, since 2005 UNAIDS has facilitated a process of developing global measures of child vulnerability within the context of HIV and AIDS, and orphanhood and adult chronic illness in the household have become internationally accepted proxies for AIDS-affectedness.

2. West and Central Africa (15 countries), Eastern and Southern Africa (14 countries), Latin America and the Caribbean (five countries), as well as Thailand and Ukraine.

3. Wasting among young children is defined as those aged 0–59 months who are below minus two standard deviations from the median weight for height of the NCHS/WHO reference population (WHO, 2006).

4. The DHS and the MICS are typically implemented by a country once every 5 years. There have been five rounds of DHS and three rounds of MICS. For more information, see http://www.childinfo.org/mics.html and http://www.measuredhs.com, respectively.

5. There is a small amount of variability in how orphans are defined. In most countries the age range is 0–17. A few countries (e.g., Guinea and Mali) define orphans among children aged 0–14. Also, the age definition of orphans changed in 2004 to include children aged 15–17. Prior to that time orphans were defined as those children aged 0–14 (UNICEF/UNAIDS, 2004).

6. Cameroon 2004, Côte d'Ivoire 2005, Haiti 2005–2006, Malawi 2004–2005, Mali 2006, Rwanda 2005, Tanzania 2003–2004, Uganda 2004, and Zimbabwe 2005–2006.

7. For questions one and two, multivariate analysis was used to determine whether being an orphan (Question 1) or having an HIV positive or chronically ill adult in the household (Question 2) were significantly associated with the three outcome indicators. As the assumption of the paper is that orphanhood and co-residence with HIV positive or chronically adult are not good predictors of negative outcomes for children, the more lenient 0.10 significance level was used in an attempt to identify evidence to the contrary. Given that the intent of the third research question is to identify other factors (i.e., household wealth) associated with poor outcomes for children, assessments of significance were made at the 0.05 level to strengthen the validity of the findings and to be in line with the conventional approach in most studies.