Community interventions providing care and support to orphans and vulnerable children: a review of evaluation evidence

Abstract

Children affected by HIV in their families and communities face multiple risks to their health, education and psychosocial wellbeing. Community interventions for children who have been orphaned or rendered vulnerable take many forms, including educational assistance, home-based care, legal protection and psychosocial support. Despite a recent influx of funding for programme implementation, there exists little evidence to inform policymakers about whether their investments are improving the lives of vulnerable children and meeting key benchmarks including the Millennium Development Goals.

This paper reviews the current evidence base on evaluations of community interventions for orphans and vulnerable children (OVC) in high HIV-prevalence African settings, focusing on studies’ methodologies. Sources reviewed include published research studies and evidence from the unpublished programmatic “grey literature” located through database and internet searches.

A total of 21 studies, varying in scope and generalisability, were identified. Interventions reviewed address children's wellbeing through various strategies within their communities. Evaluation methodologies reflect quantitative and qualitative approaches, including surveys (with and without baseline or comparison data), costing studies, focus groups, interviews, case studies, and participatory review techniques. Varied study methodologies reflect diverse research questions, various intervention types, and the challenges associated with evaluating complex interventions; highlighting the need to broaden the research paradigm in order to build the evidence base by including quasi-experimental and process evaluation approaches, and seeking further insights through participatory qualitative methodologies and costing studies.

Although findings overall indicate the value of community interventions in effecting measurable improvements in child and family wellbeing, the quality and rigour of evidence is varied. A strategic research agenda is urgently needed to inform resource allocation and programme management decisions. Immediate imperatives include building local technical capacity to conduct quantitative and qualitative evaluation research, and strengthening monitoring and evaluation systems to collect process and outcome data (including costing) on key support models. Donors and implementers must support the collection of sound empirical evidence to inform the development and scale-up of OVC programmes.

Keywords:

• care and support
• community-based
• intervention
• evaluation
• orphaned and vulnerable children

Acknowledgements

Many thanks to Minki Chatterji (Mathematical Policy Research), Candace Miller (Boston University), Charlotte Watts (London School of Hygiene and Tropical Medicine) and Ellen Weiss (International Center for Research on Women) for helpful review comments on earlier drafts, and to the two anonymous reviewers for constructive feedback.

This study was made possible through support provided by the President's Emergency Plan for AIDS Relief through the Office of HIV/AIDS, U.S. Agency for International Development. The opinions expressed herein are those of the author and do not necessarily reflect the views of USAID.

Disclaimer

The author of this review article is also the author of evaluation numbered [18].

Notes

1. To reduce inequities and avoid stigma, impact mitigation interventions should aim to reach all children affected by HIV, not just those who have been orphaned (Foster, 2006). The operational term “orphans and vulnerable children” (OVC) was therefore coined to recognise the varied causes of children's vulnerability; including not only children who are demographically orphans following parental death, but also children who have been rendered vulnerable due to other household or individual factors, such as parental illness.

2. Websites and databases searched were: AED/SARA, AIDSPortal, Better Care Network, GH Tech, Google, Google Scholar, HIV/AIDS Impact on Education Clearinghouse, ISI Web of Knowledge, ISI Web of Science, OVCsupport.net, PubMed, Synergy Resource Centre, UNICEF Evaluation and Research database, USAID Development Experience Clearinghouse.

3. The literature search also revealed examples of quantitative baseline surveys conducted in association with interventions in Mozambique, Namibia, Tanzania, Uganda, Rwanda and Zimbabwe and but for which no plans for follow-up post-intervention outcome data appeared to be available (Bronson, Sherer, R., Dalebout, S., Roussaux, A., & Prada, 2006; Chatterji et al., 2005; Dougherty et al., 2005; Howard et al., 2006; Population Council, 2006a). Such baseline data is useful to inform a needs assessment and the development of ongoing interventions, and could still add to this evidence base if post-intervention data are collected, but were not included in the review since they did not meet the inclusion criterion of having at least one round of post-intervention data collection.

4. Numbers in square brackets refer to the study numbers in Table 1.

5. New and ongoing studies in Zambia, Kenya and Tanzania (Chatterji et al., 2007; MEASURE Evaluation, 2007; Population Council, 2006b) promise to add new quantitative outcomes data on programmatic effects in the near future.

6. Ethical difficulties include creating a control group not receiving the intervention in a resource-poor setting – it is preferable to use a comparison group receiving the best available local services rather than a control group not receiving any services. Should the intervention prove beneficial, the comparison site must eventually have access to it (Connell, Turner, & Mason, 1985; Horizons et al., 2004; Schenk & Williamson, 2005; Schenk et al., 2006; Stimson & Power, 1992). Practical difficulties include randomising recipients within pre-set programme realities (Kippax & Van de Ven, 1998; Nutbeam, 1998) and preventing contamination between groups when interventions are social in nature (Kippax & Van de Ven, 1998; Torgerson, 2001). Such contamination was acknowledged to be a considerable problem in the above-mentioned succession planning evaluation in Uganda, where discussion of the ideas proposed by the intervention spread rapidly into neighbouring communities intended as comparison groups not exposed to such discussions (Horizons et al., 2004).

7. This dearth of evidence provided motivation for the recent formation of the Joint Learning Initiative for Children Affected by AIDS, tasked with “mobilizing the scientific evidence base and producing actionable recommendations for policy and practice” (JLICA, 2007).

8. The costs of a public good are borne by individual organisations, but the benefit of results is shared diffusely among many stakeholders.