International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 2

Multi-informant Perspective on Psychological Distress among Ghanaian Orphans and Vulnerable Children (OVC) within the Context of HIV/AIDS

Paul Narh Doku*
Department of Psychology, University of Ghana, Ghana
Corresponding author : Paul Narh Doku
Department of Psychology, University of Ghana, Box LG 84, Legon - Ghana
E-mail: [email protected]
Received: January 20, 2016 Accepted: April 22, 2016 Published: April 26, 2016
Citation: Doku PN (2016) Multi-informant Perspective on Psychological Distress among Ghanaian Orphans and Vulnerable Children (OVC) within the context of HIV/AIDS. Int J Ment Health Psychiatry 2:2. doi:10.4172/2471-4372.1000122


There is little knowledge about the psychosocial distress of children affected by HIV/AIDS in Ghana, to aid planning of services. This study investigated mental health problems among children affected by HIV/AIDS in Ghana, compared to control groups of children orphaned by other causes, and non-orphans. It employed a cross-sectional survey that interviewed 291 children and their caregivers on their psychosocial wellbeing using standardized scales. The results indicated that controlling for relevant socio-demographic factors both children’s self-reports and caregivers reports indicate that both children living with HIV/AIDS-infected caregivers and children orphaned by AIDS were at heightened risk for mental health problems than both children orphaned by other causes and non-orphans. The findings further indicated that significant proportion of orphaned and vulnerable children (OVC) exhibited symptoms for depression and other psychiatric disorders (approximately 63%) compared with 7% among the non-orphaned group. Caregivers gave higher ratings for children on externalizing problems and lower on internalizing problems, and vice versa when the children’s self-reports were analyzed. These findings suggest that both children and their informants have diverse yet complementary perspectives on psychological outcomes. The study discusses the theoretical and practical implications of these findings andurgently called for necessary intervention programs that targets all children affected by HIV/AIDS to effectively alleviate psychological distress and enhance the mental health of these children.

Keywords: Orphans; HIV/AIDS; Mental health; Psychological distress; Ghana; Africa; Vulnerable children


Orphans; HIV/AIDS; Mental health; Psychological distress; Ghana; Africa; Vulnerable children


In some countries which are badly affected by the epidemic, a large percentage of all orphaned children - for example 74 percent in Zimbabwe and 63 percent in South Africa - are orphaned due to AIDS. Loss of parents permeates all aspects of a child’s life and often marks the beginning a drastic change in their lives. Prior work have highlighted that children orphaned by AIDS are at risks for a range of adjustment difficulties including emotional problems [1,2], behavioural difficulties [3,4], self-esteem [5], anxiety [6], conduct problems, suicide ideation, post-traumatic stress disorder [1], delinquency problems [7].
Most of these studies, however, were unable to establish if the AIDS-related cause of death of parents confers effects additional to those of parent-bereavement because they compared the plight of the so-called AIDS orphans with non-orphaned children only without a comparison group of children orphaned by causes other than AIDS [2]. Furthermore, this evidence almost entirely came from urban towns in Africa with high HIV/AIDS prevalence (the so called hardest hit countries). The current paper addresses the bias of HIV/ AIDS affected children literature towards highly prevalent countries and differs from earlier works in many ways. First, the present paper focused on children affected by HIV/AIDS in a low or moderate prevalence country. Secondly, the geography of the HIV/AIDS infection is changing rapidly and research must keep to this flow. Ampofo et al. and the UNAIDS [8] both stated that in Ghana ARVT is available but it is not readily accessible as costs remain prohibitive and unaffordable even with government subsidies. Currently only 5% of people that are in need of ARVT have access to it [9,10].
Unfortunately, there is no published work on HIV/AIDS related stigma in Ghana. It is, however, reasoned that because HIV/AIDS prevalence is low in Ghana and it is mainly transmitted through heterosexual affairs, this could increase community intolerance of persons with HIV/AIDS and hence place high stigma on these few people and the children of their families. In these instances of high stigma, AIDS orphans and children living with HIV/AIDS-infected adults in Ghana could feel more isolated and distressed. Things would seemingly be different in the hardest hit countries or in Asian where transmission is mainly through poverty driven blood donation or transfusion. This is another reason why study on these children in Ghana is much needed.
Furthermore, most studies collected data from either the affected children or their caregivers. The current study is the first elsewhere to focus on reports from multiple informants (children and their caregiver). This strategy increases the validity and reliability of variables of interest and also captures important information about contextual effects that may have implications for interventions [11]. Because child and caregivers reports could account for unique variances in predicting relevant child outcomes (Ferdinand et al.), the findings in this paper reflects more accurate child behaviours across settings that could be generalized. The study employed a battery of widely used standardized scales that are culturally sensitive to assess symptoms of common mental health disorders.


Research design and setting
The study was given ethical approval by the institutional Research Ethics Review Boards of the University of Glasgow and the Research Unit of the Ghana Health Service. The details of the study’s methodology including the study settings, participants and sampling have been described elsewhere [12]. But briefly, the present study was designed and conducted as a community based cross-sectional survey design utilizing questionnaires. The study was conducted in the rural and urban areas of the Lower Manya Krobo District of Ghana. An orphan in the present study refers to a child between 10 and 17 years who is bereft of at least one parent to death. OVC is used to identify a child who is 17 years or below and has either lost at least a parent or is living with HIV/AIDS-infected parents whilst AIDS-orphans is defined as children who have lost at least one parent to AIDS. The latter term is used interchangeably as children orphaned by AIDS or AIDS-orphaned children.
Mental health problems: These were assessed using the Strengths and Difficulties Questionnaire (SDQ) which has been well validated against other screening instruments and against psychiatric diagnosis [13]. It is a 25-item self-report and relevant informant screening instrument for investigating common child mental health problems. The SDQ is an internationally recognized measure, translated into 62 languages and used already in 40 countries. It contains 5 subscales, namely, emotional problems (depression and anxiety), conduct problems, hyperactivity, problems with peer relationships and prosocial behaviour.
Demographics: A number of socio-demographic factors such as age, gender, family size, number of other minors living at home, number of changes in residence and age at which children were orphaned (where applicable) were measured using items from the Demographic and Health Survey Questionnaire [14].
The study procedures
There was a pilot preceding the present study to validate the study instruments in the research setting. The main surveys worked with four categories of households: ‘AIDS orphaned households’ (those that contained orphans only), ‘other orphans households’ (those containing orphans from causes other than AIDS), “HIV/ AIDS-infected caregiver households” (those containing a caregiver infected with HIV/AIDS) and ‘non-orphan households’ (those containing no orphaned children). Participants were first screened for study eligibility. Written informed assents and consents were then obtained from both the participants and caregivers, respectively. Upon assenting/consenting, participants completed the survey questionnaires separately that followed the steps described by [15]. The entire assessment inventory took about 30 to 45 minutes to complete. ‘Caregiver’ was defined as the adult in the household who primarily cared for the child participant and was not necessarily a biological parent. Caregiver is used interchangeably as parent in this study. To identify whether children lost one or both parents from AIDS, a verbal autopsy (VA) was used [16] because caregivers were often unaware of or did not wish to disclose the parental cause of death and there was difficulty in obtaining accurate death certificates and because.
Statistical analyses
The analyses followed 5 key steps. First, the relationships between the various [17] socio-demographic factors and the continuous psychological outcomes were examined using independent t-tests, Pearson correlations, chi-squared and ANOVA. Second, differences between the OVC groups on socio-demographic factors were also established using ANOVA and chi-square. Third, linear regressions were performed to develop models that investigate the association between vulnerability types and psychological outcomes controlling for relevant socio-demographic factors. This was done independently for children orphaned by AIDS, other-orphans and living with HIV/AIDS-infected parents compared to non-OVC for each of the psychological outcomes. Inclusion of socio-demographic co-factors into the models was guided by their significant association (p<0.05) with the psychological outcome or significant differences between the OVC groups. Analyses of data from children and caregivers present similar results and so the present paper reports only the findings from the children. Fourth, proportions of children scoring within the clinical range using standardized recommended clinical cut-off scores for each of the psychological outcome scales were investigated. Finally, paired sample statistics and Pearson correlations were used to establish whether reports of young people differed from those of their parents and caregivers.


Socio-demographic characteristics of participants (Table 1)
The majority of the children (81.8%) were currently attending school. Approximately 58% of caregivers had no more than senior secondary level education. The Children have a mean age of 13.03 years (SD = 2.87), with age range 10-18, there were 51% female, and ethnic origin was 63% krobos. There was an average of 4.3 people living in the household. Overall, 62% of all children had moved between 2 or more times. Majority of caregivers (62%) worked mainly in farming, driving, trading or as artisans whilst 13% of them were unemployed. The proportion of households with unemployed parents was higher among children living with HIV/AIDS-infected parents (38%) than AIDS-orphans (9.5%), other-orphans (9%) and non-orphaned children (7%). The socio-demographic statistics of the participants are summarized in Table 1.
Table 1: Socio-demographic Characteristics of the Participants.
Association between socio-demographic factors and psychological outcomes
Age was positively associated with scores on all the psychological variables (p<0.001) except for pro-social behaviours where the correlation was negative (p<0.001). Similarly, smaller household size was correlated with higher depression, delinquency, conduct problems, peer problems and hyperactivity. Girls were higher on depression than boys (p<0.001). Furthermore, the age at bereavement was positively correlated with depression, conduct problems, peer problems and hyperactivity. Unadjusted regression analyses indicated a strong association between the various vulnerability groups and psychological outcomes.
OVC’s Mental Health outcomes when controlling for relevant socio-demographic factors (Tables 2 and 3)
Multivariate regression analyses of the children’s self-reports indicate that orphanhood by AIDS, orphanhood by other causes and living with HIV/AIDS-infected parents were all, independently significantly associated with total difficulties in the adjusted model (Table 2) that controlled for relevant socio-demographic factors. Results of the analyses of the subscales of the SDQ revealed a similar pattern except for prosocial behaviour where there were no significant associations between the OVC groups and self-reported prosocial/ helping-out behaviours in both unadjusted and adjusted models. Similar results were obtained from the caregivers report (Table 3).
Table 2: Adjusted models on associations between orphanhood by AIDS, orphanhood by other causes, living with an HIV/AIDS-infected parents, and psychological outcomes based on children’s self-reports.
Table 3: Adjusted models on associations between orphanhood by AIDS, orphanhood by other causes, living with an HIV/AIDS-infected parents, and psychological outcomes based on caregivers reports.
Applying recommended SDQ self-reports clinical cut-off for overall psychological distress in the sample, 72% of children living with HIV/AIDS-infected parents, 76% of children orphaned by AIDS, 49% of children orphaned by other causes, and 28% of non-orphaned children met the criteria for “likely psychiatric diagnosis”.
Cross-informant agreements (Tables 4 and 5)
The inter-informant correlations for the SDQ scores in present sample were low (Table 5). There were significant positive correlations between children’s self-reports and caregivers’ account on total difficulties, emotional problems and hyperactivity. Compared with children’s self-reports, caregivers reported significantly higher total difficulties, conduct problems and impact: all at p<0.001 but lower prosocial behaviours (p<0.001). However, children’s self-reports indicated significantly higher depression and peer problems than caregivers’ scores (Table 4).
Table 4: Comparisons of Scale scores across respondents using the t test Statistics (n = 286).
Table 5: Cross-informant correlations (Pearson) for SDQ scores for children and adolescents in the sample.


Overall, depressive symptoms, peer problems, delinquency, self-esteem and future orientation were all higher amongst both AIDS orphaned children and those living with HIV/AIDS infected parents than other orphaned children and non-OVC. This suggests that children living with HIV/AIDS infected parents, who face the potential of losing their parents and children orphaned by AIDS are at statistically equal, heightened risk of psychological difficulties compared to orphans of other causes. The clinical cut-offs applied in the present study indicated very high proportions of likely psychiatric disorders in both externalising and internalising domains. Although it may be contested that the recommended clinical cut-offs were not validated for the Ghanaian population, the observed proportions are far-above expectations. Goodman et al. [13], demonstrated that these clinical cut-offs perform very well in most cultures. These indicate that there is likely to be a high prevalence of psychiatric disorders among OVC within the study area.
The findings support a growing global literature, largely quantitative self-reports and qualitative, that children orphaned suffer heightened internalizing problems such as depression, fear, suicide ideation, anxiety, anger, and hopelessness than children who do not experience AIDS in their families [1,2,4,5,7]. The high levels of conduct problems found in the present study as reported by informants are worrying when the low crime and non-violent context within which the present sample was drawn is considered.
The present study reported none to low inter-informant agreement on the SDQ scores. The non-significant correlations between adult reports and children self-reports indicate that children’s self-reports are not providing the same data as adult informants, and therefore both perspectives are important [17]. This suggests that an emotional and behavioural problem probably exists as situation-specific variables that may not be easily compared across different informants even within the same setting.
In this study, the informants rated children higher on scales assessing externalizing problems compared to youths themselves, whereas youths reported higher internalizing symptoms about themselves than informants did about them. This finding should be taken with caution as it points to a two-fold interpretation. It is either that the children in the present study were less able to identify their individual behavioural problems and deficits that were rightly identified by informants or that the informants exaggerated these symptoms in the children [18]. Consequently, an important implication for health service workers and researchers is that, none should place more value on one information source compared to another but rather see both self-reports and informant reports as complementary sources offering vitally differing perspectives of psychological symptoms within the same setting [19].


The first limitation of this study is that all the data reported in this present study were based on self-reporting by both children and their parents or caregivers. With self-reported data, the shortcomings are related to self-selection, recall bias, and social desirability effect. The second limitation is related to the nature of cross-sectional study designs. The direction of any causation is problematical in cross-sectional associations. Third, the study population included only samples from one district in Ghana. The findings of this study, therefore, may not be generalizable to other settings. Future research need to recruit samples from the other districts. Finally, the findings should be interpreted cautiously as assessments of mental health outcomes were not diagnostic but pencil and paper measures. These measurement tools do not identify specific mental disorders but symptoms of psychological illnesses. Despite these limitations, the present study is the first to use multi-informant techniques within an epidemiological framework to demonstrate that both children orphaned by AIDS and those living with HIV/AIDS-infected parents suffer higher internalizing problems compared to other children. This strategy increases the validity and reliability of the constructs measured.


Findings from this study speak to both theoretical and practical issues of current importance. At a theoretical level, we have provided good evidence for the plausibility of viewing the effects of HIV/AIDS on children as starting early in life before they are orphaned. At a practical level, one implication of the present findings is that efforts aimed at improving the psychological wellbeing of AIDS-affected children should be a holistic approach that is applicable to all children affected by AIDS and not the usual “selective action” targeted at only AIDS-orphaned children [20]. Many have argued that formulating interventions for only AIDS-orphaned children places a tag on these children. Consequently, such interventions are not only recipes for discrimination and stigmatisation but also highlight the danger of failed efforts for other vulnerable children affected by the HIV/AIDS pandemic in our society [3,20].


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