Skip to main content

Advertisement

SpringerLink
Log in

Mental Health of Children Living in Foster Families in Rural Rwanda: The Role of HIV and the Family Environment

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript

Abstract

Fostering children is common in sub-Saharan Africa, but few studies examine these children’s mental health needs. This study investigated the impact of living in a foster family on the mental health of HIV-positive, HIV-affected and HIV-unaffected children (n = 681 aged 10–17) in rural Rwanda. Regression analyses assessed the impact of living in a foster family on mental health, parenting, and daily hardships; multiple mediation analyses assessed whether family factors mediated the association between foster status and mental health. HIV-positive children were eight times more likely to live in foster families than HIV-unaffected children. Being HIV-affected was predictive of depression and irritability symptoms after controlling for family factors. Controlling for HIV-status, foster children had more symptoms of depression, anxiety, and irritability than non-fostered children. Positive parenting fully mediated the association between foster status and mental health. Mental health and parenting interventions for foster children and HIV-affected children may improve child outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

References

  1. UNICEF. Children and AIDS: Fifth Stocktaking Report. New York: UNICEF, UNAIDS, World Health Organization, UNFPA, UNESCO 2010.

  2. UN High Commissioner for Refugees (UNHCR). UNHCR CDR Background Paper on Refugees and Asylum Seekers from Rwanda. Geneva: UNHCR, 1998.

  3. Binagwaho A, Fuller A, Kerry V, et al. Adolescents and the right to health: eliminating age-related barriers to HIV/AIDS services in Rwanda. AIDS Care. 2012;24(7):936–42.

    Article  PubMed  Google Scholar 

  4. UNAIDS. HIV and AIDS estimates (2014) Available from: http://www.unaids.org/en/regionscountries/countries/rwanda.

  5. Ji G, Li L, Lin C, Sun S. The impact of HIV/AIDS on families and children—a study in China. AIDS. 2007;21(Suppl 8):S157–61.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Monasch R, Boerma JT. Orphanhood and childcare patterns in sub-Saharan Africa: an analysis of national surveys from 40 countries. AIDS. 2004;18(Suppl 2):S55–65.

    Article  PubMed  Google Scholar 

  7. Heymann J, Earle A, Rajaraman D, Miller C, Bogen K. Extended family caring for children orphaned by AIDS: balancing essential work and caregiving in a high HIV prevalence nations. AIDS Care. 2007;19(3):337–45.

    Article  CAS  PubMed  Google Scholar 

  8. Wakhweya A, Dirks R, Yeboah K. Children thrive in families: family centered models of care and support for orphans and other vulnerable children affected by HIV and AIDS. Joint Learning Initiative on Children and HIV/AIDS, 2008.

  9. Stover J, Bollinger L, Walker N, Monasch R. Resource needs to support orphans and vulnerable children in sub-Saharan Africa. Health Policy Plan. 2007;22:21–7.

    Article  PubMed  Google Scholar 

  10. Cluver L, Gardner F, Operario D. Poverty and psychological health among AIDS-orphaned children in Cape Town, South Africa. AIDS Care. 2009;21:732–41.

    Article  PubMed  Google Scholar 

  11. Abebe T, Aase A. Children, AIDS and the politics of orphan care in Ethiopia: the extended family revisited. Soc Sci Med. 2007;64(10):2058–69.

    Article  PubMed  Google Scholar 

  12. Gray CL, Pence BW, Ostermann J, et al. Prevalence and incidence of traumatic experiences among orphans in institutional and family-based settings in 5 low- and middle-income countries: a longitudinal study. Glob Health Sci Pract. 2015;3(3):395–404.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Foster G. The capacity of the extended family safety net for orphans in Africa. Psychol Health Med. 2000;5(1):55–62.

    Article  CAS  Google Scholar 

  14. Bicego G, Rutstein S, Johnson K. Dimensions of the emerging orphan crisis in sub-Saharan Africa. Soc Sci Med. 2003;56(6):1235–47.

    Article  PubMed  Google Scholar 

  15. Ardington C, Leibbrandt M. Orphanhood and Schooling in South Africa: trends in the vulnerability of orphans between 1993 and 2005. Econ Dev Cult Change. 2010;58(3):503–36.

    Article  Google Scholar 

  16. Cluver L, Gardner F. The mental health of children orphaned by AIDS: a review of international and southern African research. J Child Adolesc Mental Health. 2007;19(1):1–17.

    Article  Google Scholar 

  17. Onuoha FN, Munakata T, Serumaga-Zake PA, Nyonyintono RM, Bogere SM. Negative mental health factors in children orphaned by AIDS: natural mentoring as a palliative care. AIDS Behav. 2009;13(5):980–8.

    Article  PubMed  Google Scholar 

  18. Betancourt T, Scorza P, Kanyanganzi F, et al. HIV and child mental health: a case-control study in Rwanda. Pediatrics. 2014;134(2):e464–72.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Adna RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences: a convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2005;256:174–86.

    Google Scholar 

  20. Schilling EA, Alseltine RH, Gore S. Adverse childhood experiences and mental health in young adults: a longitudinal survey. BMC Public Health. 2007;7(30):1–10.

    Google Scholar 

  21. Jewkes RK, Dunkle K, Nduna M, Jama PN, Puren A. Associations between childhood adversity and depression, substance abuse and HIV and HS2 incident infections in rural South African youth. Child Abuse Negl. 2010;34:833–41.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Shonkoff JP, Garner AS, Siegel BS, et al. the lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–46.

    Article  PubMed  Google Scholar 

  23. Kaggwa EB, Hindin MJ. The psychological effect of orphanhood in a matured HIV epidemic: an analysis of young people in Mukono, Uganda. Soc Sci Med. 2010;70:1002–10.

    Article  PubMed  Google Scholar 

  24. Betancourt TS, Meyers-Ohki S, Stulac SN, et al. Nothing can defeat combined hands (Abashize hamwe ntakibananira): protective processes and resilience in Rwandan children and families affected by HIV/AIDS. Soc Sci Med. 2011;73(5):693–701.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Betancourt TS, Rubin-Smith JE, Beardslee WR, et al. Understanding locally, culturally, and contextually relevant mental health problems among Rwandan children and adolescents affected by HIV/AIDS. AIDS Care. 2011;23(4):401–12.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Betancourt T, Scorza P, Meyers-Ohki S, et al. Validating the center for epidemiological studies depression scale for children in Rwanda. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1284–92.

    Article  PubMed  Google Scholar 

  27. Scorza P, Stevenson A, Canino G, et al. Validation of the “World Health Organization Disability Assessment Schedule for Children, WHODAS-Child” in Rwanda. PLoS One. 2013;8(3):e57725.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Ng LC, Kanyanganzi F, Munyanah M, Mushashi C, Betancourt TS. Developing and validating the youth conduct problems scale-rwanda: a mixed methods approach. PLoS One. 2014;9(6):e100549.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Betancourt TS, Rubin-Smith J, Beardslee WR, et al. Understanding locally, culturally, and contextually relevant mental health problems among Rwandan children and adolescents affected by HIV/AIDS. AIDS Care. 2012;23(4):401–12.

    Article  Google Scholar 

  30. Radloff LS. The use of the center for epidemiological studies depression scale in adolescents and young adults. J Youth Adolesc. 1991;20(2):149–66.

    Article  CAS  PubMed  Google Scholar 

  31. Sheehan DV, Shytle D, Milo K, Janavs J, Lecrubier Y. MINI International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). J Clin Psychiatry. 2010;71(3):313–26.

    Article  PubMed  Google Scholar 

  32. Achenbach TM. Manual for the Youth Self-Report and 1991 profile. Burlington: University of Vermont, Department of Psychiatry; 1991.

    Google Scholar 

  33. Craig KJ, Hietanan H, Markova IS, Berrios GE. The Irritability Questionnaire: a new scale for the measurement of irritability. Psychiatr Res. 2008;159:367–75.

    Article  Google Scholar 

  34. Rohner RP. Parental Acceptance-Rejection Questionnaire (PARQ) Test Manual. In: Rohner RP, Khaleque A, editors. Handbook for the study of parental acceptance and rejection, vol. 4. Sorrs: Rohner Research Publications; 2005. p. 43–105.

    Google Scholar 

  35. UNICEF. Multiple Indicator Cluster Surveys - Round 4 New York, NY: UNICEF; 2009. Available from: http://www.childinfo.org/mics4_background.html.

  36. Layne CM, Stuvland R, Saltzman W, Djapo N, Pynoos RS. Adolescent Post War Adversities Scale. Unpublished instrument, 1999.

  37. Rutstein SO, Johnson K. The DHS Wealth Index. Calverton: ORC Macro; 2004.

    Google Scholar 

  38. Bolton P. Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. J Nerv Mental Dis. 2001;189(4):238–42.

    Article  CAS  Google Scholar 

  39. Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008;40(3):879–91.

    Article  PubMed  Google Scholar 

  40. StataCorp. Stata Statistical Software: Release 120. College Station: StataCorp LP; 2011.

    Google Scholar 

  41. Betancourt TS, Meyers-Ohki SE, Charrow A, Hansen N. Annual Research Review: mental health and resilience in HIV/AIDS-affected children—a review of the literature and recommendations for future research. J Child Psychol Psychiatry. 2013;54(4):423–44.

    Article  PubMed  Google Scholar 

  42. Cluver LD, Orkin M, Gardner F, Boyes ME. Persisting mental health problems among AIDS-orphaned children in South Africa. J Child Psychol Psychiatry. 2012;53(4):363–70.

    Article  PubMed  Google Scholar 

  43. Cluver L, Orkin M. Cumulative risk and AIDS-orphanhood: interactions of stigma, bullying and poverty on child mental health in South Africa. Soc Sci Med. 2009;69(8):1186–93.

    Article  PubMed  Google Scholar 

  44. Heymann J, Earle A, Rajaraman D, Miller C, Bogen K. Extended family caring for children orphaned by AIDS: balancing essential work and caregiving in a high HIV prevalence nations. AIDS Care. 2007;19:337–45.

    Article  CAS  PubMed  Google Scholar 

  45. Whetten K, Whetten RA, Ostermann J, Itemba D. Trauma, anxiety and reported health among HIV-positive persons in Tanzania and the US Deep South. AIDS Care. 2008;20(10):1233–41.

    Article  CAS  PubMed  Google Scholar 

  46. Ssewamala FM, Nabunya P, Ilic V, Mukasa MN, Ddamulira C. Relationship between family economic resources, psychosocial well-being, and educational preferences of AIDS-orphaned children in Southern Uganda: baseline findings. Glob Soc Welfare. 2015;2(2):75–86.

    Article  Google Scholar 

  47. Block E. Flexible kinship: caring for AIDS orphans in rural Lesotho. J R Anthropol Inst. 2014;20(4):711–27.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Merkel E, Gupta N, Nyirimana A, et al. Clinical outcomes among HIV-positive adolescents attending an integrated and comprehensive adolescent-focused HIV Care Program in Rural Rwanda. J HIV AIDS Soc Serv. 2013;12(3–4):437–50.

    Article  Google Scholar 

  49. Doku P. Parental HIV/AIDS status and death, and children’s psychological wellbeing. Int J Mental Health Syst. 2009;3(1):26.

    Article  Google Scholar 

  50. Lester P, Rotheram-Borus MJ, Lee SJ, et al. Rates and predictors of anxiety and depressive disorders in adolescents of parents with HIV. Vulnerable Child Youth Stud. 2006;1(1):81–101.

    Article  Google Scholar 

  51. Foster G, Williamson J. A review of current literature of the impact of HIV/AIDS on children in sub-Saharan Africa. AIDS. 2000;14(suppl 3):S275–84.

    PubMed  Google Scholar 

  52. Ministry of Gender and Family Promotion. Strategy for National Child Care Reform. Kigali: Government of Rwanda; 2010.

    Google Scholar 

  53. Betancourt TS, Ng L, Kirk CM, et al. Family-based prevention of mental health problems in children affected by HIV and AIDS: an open trial. AIDS. 2014;28(Suppl 3):S359–68.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

This work was made possible by the collaboration and dedication of the Rwandan Ministry of Health and Partners In Health/Inshuti Mu Buzima. We are endlessly grateful to the local research team who carried out these interviews and to the study participants and their families who shared their experiences with us. We also wish to express our deep gratitude to the Honorable Minister of Health, Dr. Agnes Binagwaho and Dr. Yvonne Kayiteshonga, Mental Health Division Manager at the Rwandan Biomedical Center. This study was funded by the Harvard University Center for AIDS Research (CFAR) Grant numbers P30 AI060354, 1K01MH07724601 A2, R34MH084679 03S1, and 5T32MH093310 from the National Institute of Mental Health, the François-Xavier Bagnoud Center for Health and Human Rights, the Peter C. Alderman Foundation, the Harvard Center for the Developing Child, the Harvard School of Public Health Career Incubator Fund, and the Julie Henry Family Development Fund. The funders had no role in study design, data collection, analysis or interpretation, manuscript writing, or the decision to publish.

Author information

Author notes

    Authors and Affiliations

    1. Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda

      Estella Nduwimana & Sylvere Mukunzi

    2. FXB Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, Boston, MA, USA

      Lauren C. Ng

    3. Department Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, 12th Floor, Boston, MA, 02115, USA

      Catherine M. Kirk & Theresa S. Betancourt

    4. Rwinkwavu District Hospital, Ministry of Health, Rwinkwavu, Rwanda

      Justin I. Bizimana

    Authors
    1. Estella Nduwimana
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Sylvere Mukunzi
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Lauren C. Ng
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Catherine M. Kirk
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Justin I. Bizimana
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Theresa S. Betancourt
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding author

    Correspondence to Theresa S. Betancourt.

    Ethics declarations

    Conflict of Interest

    Theresa S. Betancourt has received funding from Harvard University Center for AIDS Research (Grant number P30 AI060354) and the National Institutes of Mental Health (Grant numbers 1K01MH07724601 A2, R34MH084679 03S1), and Lauren C. Ng’s time was supported by NIMH Grant #5T32MH093310).

    Ethical Approval

    All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

    Additional information

    Estella Nduwimana and Sylvere Mukunzi have contributed equally to this work.

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Nduwimana, E., Mukunzi, S., Ng, L.C. et al. Mental Health of Children Living in Foster Families in Rural Rwanda: The Role of HIV and the Family Environment. AIDS Behav 21, 1518–1529 (2017). https://doi.org/10.1007/s10461-016-1482-y

    Download citation

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s10461-016-1482-y

    Keywords

    Search

    Navigation