Sexual debut and risk behaviors among orphaned and vulnerable children in Zambia: which protective deficits shape HIV risk?

Figures & data

Figure 1. Protective deficits framework for sexual behavior among orphaned and vulnerable children

Table 1. Operationalization of dichotomous explanatory variables included in analysis, by corresponding domain in the protective deficits framework

Explanatory Variable	Operationalization
Social Adversity
Does not have a birth certificate	Compares OVC who self-report not having a birth certificate to those who do
Caregiver meets child’s needs worse than other households	Responses to a single-item, five-point scale (‘much worse’ to ‘much better’) were dichotomized, with responses of ‘much worse’ and ‘a bit worse’ compared to others
Caregiver too sick for daily activities, past month	Caregiver self-reports being too sick to perform daily activities ≥1 weekly in the past month
Never discussed sex with caregiver	Compares OVC who never discussed sex with a caregiver to those who have
Never discussed HIV/AIDS with caregiver	Compares OVC who never discussed HIV/AIDS with a caregiver to those who have
Educational Attrition
Currently out-of-school	Captures all OVC who are currently unenrolled or have never been enrolled in school
Missed any school	Among school-attending OVC, compares OVC who missed ≥1 school days in the past week for any reason compared those who had perfect attendance
Withdrew from school	Among OVC who had ever attended school, compares OVC who discontinued attendance to those currently enrolled
Did not progress in school previous year	Includes school-attending OVC who either 1) did not advance to the next grade in school or 2) withdrew from school in the previous year
Financial Instability
Engaged in income-generating activities	Includes OVC who currently participate in any form of non-household labor for money or kind
Caregiver could not afford food expenses	Compares caregivers who are unable to access money for food expenses to those who can
Household less financially secure than others	Responses to a single-item, three-point scale (‘less secure’ to ‘more secure’) were dichotomized, with ‘less secure’ responses compared to others
Food Insecurity
No food in household	Caregivers report any episode of not having food in the home ≥1 weekly in the past month
Ate a smaller meal	OVC report eating a smaller meal than desired ≥1 weekly in the past month
Went whole day and night without eating	OVC report spending an entire day and evening without eating ≥1 weekly in the past month
Skipped a meal	OVC report skipping at least one meal ≥1 weekly in the past month
Went to bed hungry	OVC report going to bed hungry ≥1 weekly in the past month
Household Permeability
Deaths in the household, past year	Captures death of household member(s) of any age in the past year
New household members, past year	Captures addition of at least one new household member of any age in the past year
Household has insufficient shelter protection	Survey enumerator observes household for incomplete roof or walls

Table 2. Descriptive statistics (%) of orphaned and vulnerable children aged 13–17 years in Zambia Family project catchment areas, by sex (N = 735)

	Total %	Male n = 367	Female n = 368	P*
Demographics
Age group				<0.001
13–14 years	46.7	40.3	53.0
15–17 years	53.3	59.7	47.0
Residence				0.287
Rural	31.7	33.5	29.9
Urban	68.3	66.5	70.1
Province				0.403
Central	38.5	37.6	39.4
Copperbelt	31.6	34.0	29.1
Lusaka	21.6	20.2	23.1
Southern	8.3	8.2	8.4
Social Adversity
Does not have a birth certificate	79.6	78.7	80.4	0.571
Caregiver meets child’s needs worse than other households^§	63.7	65.4	62.0	0.307
Caregiver too sick for daily activities, past month^§	24.8	26.7	22.8	0.253
Never discussed sex with caregiver	86.0	91.0	81.0	<0.001
Never discussed HIV/AIDS with caregiver	85.9	88.8	82.9	0.050
Educational Attrition
Currently out-of-school	17.7	19.6	15.8	0.146
Missed any school (n = 605)	49.1	45.1	52.9	0.036
Withdrew from school (n = 729)	17.0	19.2	14.8	0.080
Did not progress in school previous year (n = 643)	15.1	15.4	14.8	0.794
Financial Instability
Engaged in income-generating activities	21.0	28.9	13.0	<0.001
Caregiver could not afford food expenses^§	55.1	55.0	55.2	0.972
Household less financially secure than others^§	64.2	59.9	68.5	0.012
Food Insecurity
No food in household^§	76.1	79.0	73.1	0.140
Ate a smaller meal	65.6	66.5	64.7	0.674
Went whole day and night without eating	25.0	29.7	20.4	0.016
Skipped a meal	62.3	63.8	60.9	0.465
Went to bed hungry	51.0	53.1	48.9	0.290
Household Permeability
Deaths in the household, past year^§	19.9	19.3	20.4	0.713
New household members, past year^§	27.1	25.6	28.5	0.367
Household has insufficient shelter protection^§	11.6	14.7	8.4	0.008

*Bolded values indicate statistically significant (p < 0.05) differences by sex, per design-based Pearson’s chi-square tests of association. ^§ Variables generated from interviews with adult (18+ years) caregivers of OVC.

Figure 2. Proportion of sexually debuted orphaned and vulnerable children aged 13–17 who report sexual risk behaviors (early sexual debut [before age 15], unprotected last sex, and multiple past-year sex partners), by sex and residence (N = 100)

Table 3. Unadjusted and adjusted proportional odds ratios (pOR) of sexual risk behaviors (0 – no sexual debut, 1 – sexual debut only, 2 – sexual debut and unprotected last sex and/or multiple past-year sex partners) derived from ordered logistic regression, by demographic and protective deficit factors, among orphaned and vulnerable children (N = 735)

	Unadj. pOR (95% CI)	P	Adj. pOR* (95% CI)	P
Demographics
Age group
13–14 years	1.00	Ref.	1.00	Ref.
15–17 years	2.69 (1.76, 4.11)	<0.001	2.08 (1.32, 3.27)	0.002
Sex
Female	1.00	Ref.	1.00	Ref.
Male	2.39 (1.63, 3.49)	<0.001	1.90 (1.22, 2.96)	0.005
Social Adversity
Does not have a birth certificate	2.29 (1.17, 4.44)	0.016	2.05 (1.03, 4.09)	0.042
Caregiver meets child’s needs worse than other households	0.89 (0.61, 1.26)	0.470
Caregiver too sick for daily activities, past month	1.02 (0.62, 1.68)	0.940
Never discussed sex with caregiver	0.88 (0.50, 1.53)	0.636
Never discussed HIV/AIDS with caregiver	1.01 (0.55, 1.84)	0.975
Educational Attrition
Currently out-of-school	3.40 (2.22, 5.19)	<0.001	2.63 (1.66, 4.16)	<0.001
Missed any school (n = 605)	0.86 (0.49, 1.53)	0.610
Withdrew from school (n = 729)^§	3.50 (2.28, 5.36)	<0.001
Did not progress in school previous year (n = 643)^§	2.07 (1.16, 3.70)	0.014
Financial Instability
Engaged in income-generating activities	2.80 (1.63, 4.81)	<0.001	1.84 (1.01, 3.38)	<0.001
Caregiver could not afford food expenses	1.00 (0.65, 1.54)	0.999
Household less financially secure than others	0.74 (0.48, 1.14)	0.167
Food Insecurity
No food in household	0.88 (0.54, 1.43)	0.597
Ate a smaller meal	1.14 (0.70, 1.84)	0.599
Whole day and night without eating	1.09 (0.70, 1.70)	0.699
Skipped a meal	1.21 (0.73, 1.72)	0.593
Went to bed hungry	1.13 (0.74, 1.75)	0.567
Household Permeability
Deaths in the household, past year	0.87 (0.51, 1.49)	0.612
New household members, past year	1.02 (0.62, 1.67)	0.938
Household has insufficient shelter protection	1.34 (0.67, 2.66)	0.396

* Model adjusted for all covariates presented in the column. ^§ Covariate excluded from multivariable model due to multicollinearity.

Table 4. Unadjusted and adjusted relative risk ratios (RRR) of early (before age 15) and later (at or after age 15) sexual debut derived from multinomial logistic regression, by demographic and protective deficit factors, among older (ages 15–17) orphaned and vulnerable children (N = 392)

	Later (15+) Sexual Debut (vs. No Sexual Debut)				Early (<15) Sexual Debut (vs. No Sexual Debut)
	Unadj. RRR (95% CI)	P	Adj. RRR* (95% CI)	P	Unadj. RRR (95% CI)	P	Adj. RRR* (95% CI)	P
Demographics
Sex
Female	1.00	Ref.	1.00	Ref.	1.00	Ref.	1.00	Ref.
Male	1.08 (0.54, 2.16)	0.830	0.84 (0.39, 1.78)	0.641	3.25 (1.59, 6.66)	0.002	2.72 (1.23, 6.04)	0.015
Social Adversity
Does not have a birth certificate	1.19 (0.44, 3.25)	0.726	1.08 (0.38, 3.11)	0.884	3.72 (1.06, 13.09)	0.041	3.14 (0.85, 11.65)	0.086
Caregiver meets child’s needs worse than other households	0.79 (0.40, 1.58)	0.500			0.84 (0.44, 1.61)	0.593
Caregiver too sick for daily activities, past month	0.93 (0.40, 2.19)	0.870			1.13 (0.46, 2.80)	0.781
Never discussed sex with caregiver
Never discussed HIV/AIDS with caregiver
Educational Attrition
Currently out-of-school	3.22 (1.48, 7.01)	0.004	2.89 (1.25, 6.67)	0.014	2.17 (1.04, 4.53)	0.039	1.84 (0.82, 4.12)	0.134
Missed any school (n = 298)	1.78 (0.62, 5.17)	0.281			0.73 (0.29, 1.85)	0.505
Withdrew from school (n = 387)^§	3.18 (1.48, 6.85)	0.004			2.31 (1.12, 4.83)	0.026
Did not progress in school previous year (n = 324)	2.39 (0.91, 6.28)	0.075			1.67 (0.63, 4.38)	0.295
Financial Instability
Engaged in income-generating activities	2.48 (1.09, 5.63)	0.031	2.44 (1.00, 5.95)	0.050	2.83 (1.41, 5.70)	0.004	1.93 (0.90, 4.18)	0.092
Caregiver could not afford food expenses	3.39 (1.28, 8.96)	0.015	3.32 (1.28, 8.60)	0.014	0.67 (0.38, 1.17)	0.157	0.70 (0.39, 1.27)	0.238
Household less financially secure than others	0.84 (0.43, 1.68)	0.624			0.87 (0.45, 1.67)	0.664
Food Insecurity
No food in household	0.65 (0.28, 1.49)	0.303			1.13 (0.53, 2.39)	0.746
Ate a smaller meal	1.35 (0.58, 3.16)	0.481			0.69 (0.37, 1.27)	0.232
Whole day and night without eating	0.69 (0.28, 1.73)	0.425			1.30 (0.64, 2.62)	0.464
Skipped a meal	1.20 (0.52, 2.79)	0.663			1.32 (0.69, 2.55)	0.397
Went to bed hungry	1.13 (0.53, 2.40)	0.749			1.28 (0.62, 2.63)	0.495
Household Permeability
Deaths in the household, past year	1.02 (0.41, 2.54)	0.968			0.58 (0.22, 1.55)	0.274
New household members, past year	1.18 (0.55, 2.56)	0.665			0.79 (0.32, 1.93)	0.597
Household has insufficient shelter protection	1.24 (0.39, 3.94)	0.709			1.68 (0.64, 4.41)	0.289

* Model adjusted for all covariates presented in the column. ^§ Covariate excluded from multivariable model due to multicollinearity.

Data availability

Data presented for this study are available from the corresponding author (MTM) upon reasonable request.