Psychological distress and its predictors in AIDS orphan adolescents in Addis Ababa city : A comparative survey

Back ground: In developing countries the number of children orphaned by AIDS is growing rapidly. Consequently, the psychological well-being of these children has become a serious concern. Objectives: To assess the psychological distress of AIDS orphans as compared to non-AIDS orphan adolescents and factors related to it, in Addis Ababa. Methods: Comparative cross-sectional design combining both quantitative and qualitative methods was used. An equal number of 438 subjects were included in this study with each group of AIDS and non-AIDS orphan adolescents between 11-18 age groups. Structured interviewer administered questionnaire and scales including HAD, Rosenberg’s and MPSS scales were used to measure the orphans’ level of depression, anxiety, self-esteem and their perceived social support. Result: Among the study participants, 279 (34.7%) orphan adolescents where 157 (39.1%) of AIDS and 122 (30.3 %) of non-AIDS orphan adolescents were depressed in the week before the survey. Moreover, 301(37.4%) orphan adolescents where 164 (40.8%) of AIDS and 137 (34.1%) of non-AID once were anxious. However, the difference observed in depression and anxiety [OR (95% CI) =1.164(0.733, 1.754) & 0.88(0.57, 1.33)] was not statistically significant. The main predicator variables of depression and anxiety in both study groups were their perceived social support and self-esteem. Factors such as discrimination, school enrollment, physical abuse, child labor were also identified as predicators. Conclusion : A large proportion of orphan adolescents are having psychological problems that can affect their present and future life. Thus, a more focused and concerted effort is needed to improve their mental health. [Ethiop. J. Health Dev. 2011;25(2):135-142] Introduction HIV remains a global health problem of unprecedented dimensions (1). The epidemic can be depicted as a succession of three waves. The first wave of HIV infections was followed by the second wave of AIDS illness and death which in turn was followed by a wave of HIV/AIDS orphaned children (2). In 2007, there were 15 million officially reported AIDS orphans globally (3). An estimated 5,459,139 orphans of whom 16 % were HIV and AIDS orphans existed in Ethiopia in 2008 (3,4). In Addis Ababa alone, there were 112,617 AIDS orphans in 2007 (5). Orphan-hood is frequently accompanied with multidimensional problems including prejudice, reduced access to health and school services, inadequate food, sexual abuse and others that can further jeopardize children’s prospects of completing school (1, 2). Moreover, the death of one or both parents has a profound and lifelong impact on the psychological wellbeing of children. Adolescents in particular are at increased risk for unresolved or complicated bereavement because of their developmental vulnerability and emotional dependency. Being an AIDS orphan may further place them at heightened risk of prolonged mental problems (6, 2). Presently, there is very little research undertaken in Africa despite the growing concern about the psychological well-being of orphans (7). In light of this, the general objective of this study was to assess psychological distress of AIDS orphan adolescents as compared to non-AIDS orphans and to identify factors associated with the distress. More specifically, the study was intended to assess and compare the level of depression and anxiety between AIDS and non-AIDS orphan adolescents, identify factors related to depression and anxiety, indicate main intervention areas for improving their situation and make concrete recommendations to help them in asserting their rights. Moreover, the result of the study can point out areas for further research by future investigators and provide insight into program planners and policy makers to review and change or strengthen existing care and support programs for the orphans in the country. Ethiop. J. Health Dev. 136 Ethiop. J. Health Dev. 2011;25(2) Methods The study was conducted in Addis Ababa, Ethiopia in March 2010. An institution-based comparative crosssectional survey with both quantitative and qualitative methods was used. Out of thirty nine organizations that have been providing care and support to orphans in Addis Ababa as of 2008, thirty five were included in the study (8). Four organizations were excluded from the study as they only donated money and coordinated the care and support programs. For the qualitative study, the population included AIDS and non-AIDS orphans adolescents aged 11-18 years sampled from orphan adolescents that were registered in the randomly selected organizations. AIDS orphan adolescents included in the study were children between 11-18 years who have lost one or both parents due to the HIV AIDS. The non-AIDS orphan adolescents were also from same age category, but had lost one or both parents due to other causes. The total number of orphan adolescents selected for the study was 876 with 438 in each study group. To calculate the total sample size, a two population proportion formula, 1:1 ratio for both the study and comparison groups, confidence level of 95%, a power of 80%, nonresponse rate of 10% design effect of two have been utilized. Furthermore, a multi-stage cluster sampling technique was employed to reach the study units. Following WHO’s recommendation, a maximum of 50 respondents per Primary Sampling Unit (PSU) (9), a total of sixteen organizations were randomly selected to satisfy the sample size (9). Then, proportional allocation to size technique was applied to decide the number of AIDS and non–AIDS orphans to be included in the study for each organization. Finally, simple random sampling technique was used to select the study subjects. Registration books or files of the organizations were used to separate AIDS orphan adolescents from non-AIDS orphan ones. However, orphan adolescents whose parents died within the past six months point to the study and diagnosed as HIV positive or who were apparently sick during data collection were excluded from the study. The quantitative data were collected using a pretested structured interviewer-administered questionnaire by trained research assistants recruited from candidates who had completed grade twelve. For qualitative methods, five in-depth interviews were conducted with purposively selected key informants that were involved in giving care and support within the caretaker organizations. A semi-structured interviewerguided checklist was used to collect the qualitative data. The major focus areas of the in-depth interview were identifying the type of support provided, the risk factors in psychological distress, the major challenges that organizations faced in providing the psychological support service. The dependent variables of the study were anxiety and depression statuses of the orphans. These variables were measured using the Hospital Anxiety and Depression Scale (HADS) and was used to measure feelings of depression and anxiety levels in the week prior to the survey. The scale included 14 items, consisting of 7 anxiety and 7 depression items from which a separate anxiety and depression sub-scale scores were calculated. Each item score ranged from zero to three. Scores above seven on the subscales were classified as having depression or anxiety. This scale had been used within community settings for all age groups from adolescence upwards (12, 13,14). The internal consistency of the scales in our study subjects were Cronbach’s alpha of 0.87 and 0.76 for the anxiety and depression subscales respectively. The independent variables included socio-demographic characteristics (age, sex, ethnicity, house hold size, education status); individual factors included perceived social support, self-esteem, changing residence place, type of care giver, providing care for sick parents, witnessing the death of parents, and visiting their siblings and relatives. On the other hand, Rosenberg’s scale was used to measure the self-esteem of the orphan adolescents. Consisting of 10 items, with a four-point response ranging from strongly agree to strongly disagree, the scale has been translated into many languages and used internationally for over thirty years. Over years of application, it has consistently been found to be reliable and valid. The internal consistency in our scale was Cronbach’s Alpha= 0.65 and after removal of item number-eight, it became 0.73. Furthermore, the score of the items were distributed normally for both study groups. This scale has also been used in Ethiopia in the past (15, 10). To measure their perceived social support, a multidimensional scale of perceived social support (MSPSS) was adopted. Responses for the items in the scale ranged from strongly agree to strongly disagree and the possible scores for the scale ranged from 12 to 60 (16). What is more, the scale manifested adequate reliability and validity across a variety of population (17). In this study, the scale had an internal consistency of 0.89 in Cronbach’s alpha and the scores were also distributed normally for both study groups. Social factors such as friends/community/family discriminations, physical and sexual violence, and child labor were assessed using a questionnaire that was developed on the basis of information obtained from of the review relevant literature. The questionnaire was prepared first in English and then translated into Amharic (local language) with the help of a language expert. To check the accuracy of translation, the Amharic version was retranslated back to English by another person who 137 Psychological distress and its predictors in AIDS orphan adolescents in Addis Ababa city Ethiop. J. Health Dev. 2011;25(2) had not had any access to the original English version of the questionnaire prior to taking up this task. Data entry and processing was done using SPSS 16 version. Descriptive statistics were used for describing the socio-demographic factors, independent sample t-test was used to comp