The relationship between social support and anxiety among caregivers of children in HIV-endemic South Africa

Abstract

Caring for children can be a source of joy and fulfilment, but also a source of stress, especially for caregivers living with illness and/or coping with difficult socio-economic conditions. Risks for poor caregiver mental health are especially salient in many parts of southern Africa affected by a generalised HIV-epidemic, high rates of physical illness, difficult livelihood conditions and an increasing number of orphaned and vulnerable children in need of care. Given limited availability and low uptake of formal mental health services in South Africa, the potential protective role of informal community or “social” resources for caregiver populations requires greater attention. To our knowledge, this is the first study to quantitatively assess the relationship between social support and symptomatic anxiety among caregivers of children living in HIV-endemic southern African communities. The data are from household survey interviews with 2477 adult primary caregivers of children aged 10–17 years living in two (urban and rural) resource-deprived HIV-endemic South African communities. Hierarchical logistic regression analysis with interaction terms was conducted to assess whether HIV and other illness were significant stressors for caregiver anxiety, whether social support had main or stress-buffering protective effects on anxiety and whether gender moderated the association between social support and anxiety. Our findings showed significant main effects of social support on caregiver anxiety, but no evidence of stress-buffering effects of support or of gender moderating the support-anxiety relationship. This suggests that social support is a general mental health resource for both male and female caregivers of children in these HIV-endemic communities, regardless of whether they are facing specific stressors related to HIV or other illness. Our results highlight the importance of paying greater attention to the social environment when designing and implementing caregiver health interventions, and indicate that social support could be a valuable component of such interventions.

Keywords:

• anxiety
• social support
• HIV and AIDS
• caregivers of children

Acknowledgements

This Young Carers study was funded by the Health Economics and HIV and AIDS Research Division (HEARD) at the University of Kwazulu-Natal, the Economic and Social Research Council (UK), the National Research Foundation (SA), the National Department of Social Development (South Africa), the Claude Leon Foundation and the John Fell Fund. The study in the KwaZulu-Natal provincial site was generously funded by HEARD. In addition, additional support was provided to Dr. Kuo in support of analysis and writing by the National Institute for Mental Health grant, “Family Prevention of HIV Risk and Depression in HIV-endemic South Africa” (K01 MH096646-01A1, PI: Kuo). We would like to acknowledge the important contribution of our entire Young Carers KwaZulu-Natal research team and our local NGO partner in the rural site, Tholulwazi Uzivikele, to this research. We would also like to thank the children and their families who welcomed us into their homes.

Notes

1. Main effects occur when social support is directly associated with better health outcomes, indicating that people with more social support have better mental health outcomes regardless of the presence or level of stress (Casale & Wild, 2013; House et al., 1988). Stress-buffering indicates that social support attenuates the negative effects of stress or specific stressors on the mental health outcome (House et al., 1988; Kaplan, Cassel, & Gore, 1977), so that the association between stress/stressors and worse mental health is stronger for individuals with low social support than for individuals with high social support.

2. A primary caregiver was defined as the individual who takes responsibility for primary childcare duties to address the economic, social and psychological needs of the child, whether a biological or foster parent.

3. The research was a partnership between the Health Economics and HIV and AIDS Research Division (HEARD) at the University of KwaZulu-Natal, the University of Oxford, Brown University and various South African government departments and NGOs. The survey aim was to examine the impact of living in an AIDS-affected family on the health of children and their caregivers, in order to identify risk and protective factors. Further information on the survey research project is available at the following website: www.youngcarers.org.za.

4. Wards within the urban municipality were narrowed down to those with only urban households and that fell within the top quintile (20%) of deprived wards, according to the Noble et al. (2006) provincial health deprivation indices. The latter selection criterion served to avoid selection of a ward with “pockets” of wealth, given the high level of socio-economic inequality within the urban municipality.

5. The smallest political boundaries in the urban site were (census) wards, headed by Ward Councillors, and in turn divided into multiple census enumeration areas. The smallest political boundaries in the rural site were represented by tribal communities or “Isigodi”, each headed by a tribal leader or “Induna”. Approval to conduct the research was sought and obtained from each individual gatekeeper (Ward Councillor or tribal leader/Induna). Two wards, consisting of 34 enumeration areas, were covered in the urban site, while 12 communities or “Isigodi” were covered in the rural site.

6. Socio-economic status was measured using Booysen’s (2001) South African economic asset index, based on factor and principal component analysis of variables relating to ownership of consumer goods, household size and dwelling characteristics, and access to services and resources (Booysen, 2001; Filmer & Pritchett, 2001); this has been found to be a reliable tool in the South African context (Filmer & Pritchett, 2001; Montgomery, Gragnolati, Burke, & Paredes, 2000).

7. Herman et al. (2009) reported on the South African Stress and Health study that measured anxiety using the Composite International Diagnostic Interview. Kuo and Operario (2011) measured anxiety using the Kessler scale (K10).