DHS WORKING PAPERS

2005 No. 24

Vinod Mishra

Fred Arnold

Fredrick Otieno

Anne Cross

Rathavuth Hong

Education and Nutritional Status of

Orphans and Children of HIV-Infected

Parents in Kenya

August 2005

This document was produced for review by the United States Agency for 

International Development. 

DEMOGRAPHIC

AND

HEALTH

RESEARCH
The DHS Working Papers series is an unreviewed and unedited prepublication series of papers 

reporting on research in progress based on Demographic and Health Surveys (DHS) data. 

Funding for this research was provided by the United States Agency for International 

Development (USAID) through the MEASURE DHS project (# GPO-C-00-03-00002-00). The 

views expressed are those of the authors and do not necessarily reflect the views of the United 

States Agency for International Development, the United States Government, or the organizations 

with which the authors are affiliated. 

MEASURE DHS assists countries worldwide in the collection and use of data 

to monitor and evaluate population, health, and nutrition programs. Additional 

information about the MEASURE DHS project can be obtained by contacting 

ORC Macro, Demographic and Health Research Division, 11785 Beltsville 

Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-

572-0999; e-mail: reports@orcmacro.com; internet: www.measuredhs.com). 
Education and Nutritional Status of Orphans and Children of HIV-Infected 

Parents in Kenya 

Vinod Mishra1, Fred Arnold1, Fredrick Otieno2, Anne Cross1, Rathavuth Hong1

August 2005 

Institutional affiliations: 1ORC Macro, Calverton, MD; 2Central Bureau of Statistics, Nairobi, 

Kenya 

Corresponding author: Vinod Mishra, Demographic and Health Research Division, ORC Macro, 

11785 Beltsville Drive, Suite 300, Calverton, MD 20705. Phone: (301) 572-0220, Fax: (301) 

572-0999, Email: Vinod.Mishra@orcmacro.com 

iii

ABSTRACT 

We examine how school attendance and nutritional status differ between orphaned and fostered 

children, and between children of HIV-infected parents and non-HIV-infected parents in Kenya. 

Our analysis is based on information on 2,756 children age 0-4 years and 4,172 children age 6-14 

years included in the male subsample of the 2003 Kenya Demographic and Health Survey (DHS). 

The 2003 Kenya DHS is one of the first population-based, nationally representative surveys to 

link individual HIV test results for both males (age 15-54 years) and females (age 15-49 years) in 

one-half of the sample households with the full set of behavioral, social, and demographic 

indicators included in the survey. Data are analyzed using both descriptive and multivariate 

logistic regression methods. The results indicate that orphaned and fostered children (age 6-14 

years) are significantly less likely to be attending school than nonorphaned, non-fostered children 

of HIV-negative parents. We find no clear pattern of relationship between orphanhood and 

nutritional status of children, although fostered children are somewhat more likely to be stunted, 

underweight, and wasted than children of HIV-negative parents. Children of HIV-infected parents 

are significantly less likely to be attending school, more likely to be underweight and wasted, and 

less likely to receive treatment for ARI and diarrhea than children of non-HIV-infected parents. 

We also find that children of non-HIV-infected single mothers (with no spouse) are generally 

more disadvantaged in nutrition, health care, and schooling than children who live with both nonHIV-infected parents. There is no relationship between parent HIV status and either stunting or 

immunization coverage. 

KEY WORDS: orphaned, fostered, vulnerable, children, education, nutrition, health care, HIV, 

AIDS, DHS, Kenya 
iv

HUMAN SUBJECTS INFORMED CONSENT 

Analysis presented in this paper is based on an analysis of existing survey data with all identifier 

information removed. Informed consent was obtained from all respondents in the survey before 

asking questions and separately before obtaining blood samples for HIV testing. HIV test results 

were linked anonymously to the information in the questionnaires. 

ACKNOWLEDGEMENTS 

The authors thank Eric Roth, Benny Kottiri, and Laurie Liskin for comments on an earlier draft. 

The authors also thank Noureddine Abderrahim for computer programming and Shane Khan for 

research assistance. An earlier version of this paper was presented at the 2005 Population 

Association of American Annual Meeting in Philadelphia, March 31 to April 2, 2005. 
5

INTRODUCTION 

HIV/AIDS and associated infections are reversing some of the hard-won development gains in 

many countries and leaving populations more vulnerable to poverty, malnutrition, and ill health. 

The adverse effects of the AIDS epidemic are felt most severely in some of the world’s poorest 

countries in sub-Saharan Africa. One of the consequences has been an upsurge in the number of 

orphaned children (UNICEF 2003; UNAIDS, UNICEF, and USAID 2004). In sub-Saharan 

Africa, every eighth child is an orphan, i.e., has lost one or both parents. In countries like 

Botswana, Zimbabwe, and Lesotho that are hardest hit by HIV/AIDS, up to one in every five 

children are orphaned. More than four-fifths of all children orphaned by HIV/AIDS worldwide 

live in sub-Saharan Africa, and the orphan crisis is projected to worsen in the coming years. If it 

were not for HIV/AIDS, the number of orphans in sub-Saharan countries would be decreasing 

(UNAIDS, UNICEF, and USAID 2004). 

Millions more children are fostered and made vulnerable by the epidemic in various ways. 

Children of HIV-positive parents suffer from the trauma of sickness and eventual death of a 

parent and associated hardships. The burden of caring for a sick parent often falls on children; 

many are forced to drop out of school and take on adult roles (Case et al. 2004; UNICEF 2003). 

Parental HIV-related illness and death often lead to decreased household resources due to 

treatment costs and job loss, which may affect health care and the nutritional status of children. 

Death of even one parent could result in changes in living arrangements, displacement, and lack 

of availability of resources for schooling, health care, and food for children. In sub-Saharan 

Africa, a mother’s death is more likely to result in changes in living arrangements for children, 

whereas a father’s death is more likely to reduce resource availability. Care providers for orphans 

tend to be elderly persons, who are generally less likely to know about and to be capable of 

providing proper health care and schooling. Parental HIV seropositive status also affects the 

psychosocial adjustment of children. Stigma associated with HIV/AIDS contributes further to the 

vulnerability of these children. Orphaned and fostered children are more likely to be 

discriminated against in schooling and health care, and are more prone to neglect and abuse 

(UNICEF 2003). 

Improvements in child morbidity and mortality rates achieved during the last several decades have been 

reversed in many countries in recent years due to HIV/AIDS. The epidemic influences child survival 

both directly through mother-to-child transmission and indirectly through diverting resources and 

attention away from children to the care and treatment of a sick parent. In several sub-Saharan African 

countries, infant and child mortality rates have already risen substantially and are expected to increase 

further in the coming years (Newell et al. 2004; UNAIDS, UNICEF, and USAID 2004; Foster 1998; 

Nicoll et al. 1994). Several studies have linked maternal HIV seropositive status to increased risk of 

infant and child mortality (Nakiyingi et al. 2003; Crampin et al. 2003). Another study of the association 

between adult HIV prevalence and changes in the under-5 mortality rate in 25 countries with DHS 

surveys noted that the magnitude of increase in the under-5 mortality rate was most noticeable in 

countries with high HIV prevalence (Adetunji 2000). 

Orphans tend to be at increased risk of being HIV-positive than nonorphans. HIV-infection 

transmitted at birth or in early childhood may lead to growth faltering and may contribute to 

greater morbidity and mortality. A prospective study of 184 HIV-infected and 1,403 uninfected 

children of infected mothers followed from birth to 10 years of age in eight European countries 

found that there were no significant differences in the height and weight of infected and 

uninfected children at birth, but infected children grew more slowly than the uninfected children. 

By age 10, infected children were on average 7.5 cm shorter and 7 kg lighter than uninfected 

children (Newell et al. 2003). Another prospective cohort study of growth progression in HIV-
6

infected and non-HIV-infected children in Kinshasa, Democratic Republic of Congo, arrived at 

similar conclusions (Bailey et al. 1999). However, a third prospective cohort study comparing 

HIV-positive and HIV-negative children born to HIV-positive mothers and HIV-negative 

children born to HIV-negative mothers in Nairobi, Kenya did not find any significant differences 

in feeding practices and growth of children in the three cohorts (Sherry et al. 2000). 

A number of recent studies have shown that orphans are more vulnerable than nonorphans with 

respect to schooling. A recent study on orphanhood and children’s school enrollment in 10 subSaharan African countries concluded that orphans are less likely to be enrolled in schools than 

nonorphans with whom they live (Case et al. 2004). This study also found that orphans who lived 

with distant relatives and unrelated caregivers had lower school enrollment than those who lived 

with a close relative. A descriptive study of 40 nationally representative household surveys in 

sub-Saharan Africa observed that orphans were considerably less likely to attend school than 

nonorphans, and double orphans were most likely to be disadvantaged in schooling (Monasch and 

Boerma 2004). Another study of cross-sectional survey data from five sub-Saharan African 

countries found that orphaned children were less likely to be attending the appropriate grade level 

for their age (Bicego et al. 2003). This study also noted that double orphans were particularly 

disadvantaged, and loss of a mother was more detrimental for schooling than loss of a father. The 

disadvantage was more pronounced for primary education than secondary education. 

However, not all studies have found adverse effects of orphanhood on health and education of children. 

Contrary to the findings of the Case et al. (2004), Monasch and Boerma (2004), and Bicego et al. (2003) 

studies discussed above, Ainsworth and Filmer (2002) find considerable variation in the effect of 

orphahood on school attendance, including higher school attendance rates among orphans than 

nonorphans in some countries. Another study in rural Zimbabwe found no difference between orphans 

and nonorphans in primary school completion rate, although maternal orphans but not paternal or double 

orphans were less likely to complete primary school education than nonorphans (Nyamukapa and 

Gregson 2005). 

A recent cross-sectional study in urban Uganda found no differences between orphans and 

nonorphans in reported treatment-seeking behavior and in measured anthropometric parameters 

(Sarker et al. 2005). A 3-year prospective study in southwestern Uganda also failed to find any 

significant difference in mortality between orphans and nonorphans, even though orphans and 

their surviving parents were considerably more likely to be HIV-infected than nonorphans and 

their parents (Kamali et al. 1996). The same study also noted only a small and statistically 

insignificant difference between orphans and nonorphans in the school attendance rate. 

A study in rural western Kenya compared several health and nutritional indicators for orphaned 

and nonorphaned children under age 6 and concluded that orphaned children are at no greater risk 

of poor health than nonorphaned children (Lindblade et al. 2003). This study found no difference 

between orphans and nonorphans for a number of key health indicators, including fever, malaria, 

history of illness, anemia, and stunting, but orphans were somewhat more likely to be wasted than 

nonorphans. Panpanich et al. (1999) failed to find any significant differences in health conditions 

of village orphans and nonorphans in rural Malawi. This study also looked at children in an 

orphanage and found that younger children in the orphanage were more likely and older children 

living in the orphanage were less likely to be undernourished than orphans and nonorphans living 

in the village. The Crampin et al. (2003) and Ryder et al. (1994) studies, which noted a higher 

mortality risk among children born to HIV seropositive mothers, also failed to find any 

significant differences in nutritional status and morbidity of orphans and nonorphans. 
7

In sum, there is evidence in the literature of adverse effects of orphanhood on schooling, but the 

evidence of effects of orphanhood on health and nutritional status of children is weak and 

inconclusive. 

While many studies have focused on orphans, little is known about the health and nutritional 

status of fostered children and children living with HIV-infected parents. A study of fostered 

children in rural Mali concluded that fostering per se has little impact on children’s nutritional 

status (as measured by their weight-for-age Z-scores), but the context of fostering matters (Castle 

1995). In this study, children who were fostered due to poverty or other unfavorable 

circumstances had poorer nutritional status than other fostered children. A study in Sierra Leone 

found that fostered children were underrepresented in hospital admissions and that younger 

fostered children were more likely to be undernourished, but not the older ones (Bledsoe et al. 

1988). 

In this study, we analyze data from the most recent Demographic and Health Survey in Kenya to 

study if orphaned and fostered children and children of HIV-infected parents are more 

disadvantaged in nutrition and education than children of non-HIV-infected parents. We also 

examine if children of HIV-infected parents are less likely to receive health care than children of 

non-HIV-infected parents. 
8

DATA AND METHODS 

Data for this study come from the 2003 Kenya Demographic and Health Survey (KDHS). The 

2003 KDHS is one of the first population-based, nationally-representative surveys to link 

individual HIV test results with the full set of behavioral, social, and demographic indicators 

included in the survey. The survey collected information from 9,865 households in 400 sample 

enumeration areas selected from a list of enumeration areas in the master sample based on the 

1999 national population census. The sample was designed to represent each of the eight 

provinces in Kenya. The survey collected detailed information on marriage, fertility, family 

planning, sexual activity, nutritional status of women and young children, maternal and child 

health, and awareness and behavior regarding HIV/AIDS and STDs. 

One-half of the sample households were randomly selected to include interviews with men. In 

these households, a total of 4,303 women age 15-49 and 4,183 men age 15-54 were identified as 

eligible for individual interviews and for HIV testing. Of the eligible women and men, individual 

questionnaires were completed for 94 percent of women and for 86 percent of men, and HIV tests 

were conducted for 76 percent of women and 70 percent of men. A few drops of capillary blood 

were collected on filter paper from a finger prick from respondents who voluntarily consented to 

the blood draw. The blood spots were subsequently dried and transported to a medical laboratory 

where they were tested for HIV. The HIV test results for individual males and females were 

anonymously linked to their information in the individual and household questionnaires. The 

analysis presented in this study is based on 2,756 children age 0-4 years and 4,172 children age 6-

14 years included in the male subsample. 

The English questionnaires were translated into 12 local languages, and the survey was 

implemented in the local language of the respondents. The data collection took place from April 

to September 2003. Seventeen teams of nine members each were involved in data collection. 

Parallel teams of mobile VCT counselors provided counseling and testing for the respondents and 

others in the community who wanted to know their HIV status, based on separate tests. Details of 

the sampling design and survey implementation are provided in the basic survey report (Central 

Bureau of Statistics, Ministry of Health, Kenya, and ORC Macro 2004). 

The survey collected information on orphaned and fostered children under age 15 in the 

household schedule. For each child under age 15, the household respondent was asked: “Is 

(NAME)’s natural mother alive?” If alive, the household respondent was further asked: “Does 

(NAME)’s natural mother live in this household?” Similar information was collected about each 

child’s natural father. Information from these questions and from the HIV status of the mother 

and father (actually the mother’s current spouse if eligible for HIV testing) was used to group 

children into the following six categories: 

1. Orphaned children: one or both biological parents of the child are dead 

2. Fostered children: both biological parents are alive, but the child is not living with either 

3. Children of HIV-positive parents: both biological parents are alive and the mother is 

HIV-positive or the mother’s current husband/partner is HIV-positive (we do not have 

information on the HIV status of biological fathers living separately) 

4. Children of HIV-negative parents: both the mother and her current husband/partner are 

HIV-negative 

5. Children of HIV-negative mothers who have no spouse 

6. Children whose parents’ HIV status is unknown 
9

The six categories are mutually exclusive, i.e., a child can fall in one and only one category. 

Orphaned children were defined first, based on the survival status of their biological parents. 

Among the remaining children, fostered children are those who are not living with either 

biological parent. Non-orphaned and non-fostered children were then categorized in the 

remaining four categories based on the HIV status of the mother and her current husband or 

partner. This six category variable is the primary predictor variable in our analysis. Children of 

HIV-negative parents are used as the comparison group in all analyses. Children in households 

that were not selected for HIV testing are excluded from the analysis. 

Data are analyzed using both descriptive and multivariate logistic regression methods. First, we 

compare the six groups of children age 0-4 years on measures of nutritional status1

—stunting, 

underweight, and wasting. Next, we compare the six groups of children age 6-14 years on school 

attendance rates. Finally, we compare children of HIV-infected parents with children of non-HIVinfected parents on indicators of full immunization2

 coverage and treatment-seeking behavior for 

acute respiratory infection (ARI)3

 and diarrhea. The analysis of immunization coverage is limited 

to children age 1-4 years.4

 The analysis of treatment-seeking for ARI and diarrhea is limited to 

children age 0-4 years who were sick with diarrhea or symptoms of ARI in the two weeks 

preceding the survey interview. 

In these analyses, we control for a number of characteristics of the child, the parent(s), and the 

household. In analyses that include orphaned and fostered children, there are no controls for 

parent characteristics. Control variables included in the analysis are: child’s age, sex, birth order, 

preceding birth interval, succeeding birth interval, size at birth, wanted status of child, 

breastfeeding status, mother’s age at childbirth, mother’s education, mother’s work status, 

occupation of mother’s current or former spouse, mother’s exposure to mass media, mother’s 

marital status, mother’s body mass index (BMI), ethnicity, religion, mother’s participation in 

household decisionmaking, mother’s experience of physical mistreatment, alcohol or illegal drug 

consumption by mother’s spouse, mother’s or spouse’s experience of high-risk sexual behavior, 

whether the mother or her spouse were tested for HIV prior to the survey, sex of household head, 

family type, household wealth index, urban/rural residence, and region. It is necessary to control 

for these characteristics because they tend to be associated with the likelihood of being orphaned 

or fostered, as well as with parent HIV status, and may potentially confound the effects of child 

parentage on the outcome variables. For definitions of these variables, see Table 1. 

We use household weights when analyzing all children, including orphaned and fostered children. 

In analyses that are limited to children of interviewed mothers (i.e., not including orphaned and 

fostered children) and in analyses that involve parent characteristics, we use women’s weights. 

Results of the multivariate analyses are presented as odds ratios (OR) with significance levels. 

 

1

 A child is defined as stunted if its height-for-age is more than two standard deviations below the median 

of an international reference population recommended by the World Health Organization. Underweight 

(based on weight-for-age) and wasted (based on weight-for-height) are similarly defined (Dibley et al. 

1987a; 1987b). 

2

 A child is defined as fully immunized if he or she received a BCG vaccination, three doses of DPT 

vaccine, three doses of polio vaccine (excluding polio 0: polio vaccine given at time of birth), and a 

measles vaccination. 

3

 ARI is defined as coughing accompanied by short, rapid breathing. 

4

 Children under 12 months of age are excluded because, according to health guidelines, children should be 

fully immunized by the time they complete their first year of life. 
10

RESULTS 

Background 

HIV prevalence and its correlates 

The Kenya Demographic and Health Survey finds that 7 percent of adults in Kenya are HIV 

positive. HIV prevalence among women age 15-49 is nearly 9 percent, while for men age 15-54 it 

is under 5 percent. The female to male ratio of 1.9 is higher than ratios found in other studies in 

Africa. Young women in Kenya are particularly vulnerable to HIV infection compared with 

young men. HIV prevalence is higher among urban, more educated, and working adults. 

Household wealth status is also positively associated with HIV prevalence in both women and 

men. Muslim adults have a much lower prevalence of HIV than those from other religions. 

Among the ethnic groups, the Luo community stands out as having the highest prevalence. By 

geographic region, Nyanza has the highest prevalence, followed by Nairobi. The number of sex 

partners and the number of higher-risk partners are also associated with higher HIV prevalence. 

Adults who reported having a sexually transmitted infection (STI) or STI symptoms in the past 12 

months have much higher rates of HIV infection than other adults. Circumcised men have a much 

lower prevalence of HIV than uncircumcised men. 

Living arrangements of children 

Overall, 9 percent of children under age 15 years have lost their fathers, 4 percent have lost their 

mothers, and 2 percent have lost both of their biological parents. Altogether, 11 percent of 

children under age 15 are orphaned (i.e., they have lost one or both biological parents). Fiftyeight percent of children live with both parents, 20 percent live with their mothers only, 2 percent 

live with their fathers only, and 7 percent live with neither parent (i.e., they are fostered). The 

proportion of orphaned children in Kenya has increased from 9 percent in 1998 to 11 percent in 

2003. 

Sample Distribution 

Table 1 shows the sample distributions of children age 0-4 years and 6-14 years by orphanhood, 

fosterhood, parent HIV status, and selected child, parent, and household characteristics. Among 

children age 0-4 years, 5 percent are orphaned, 3 percent are fostered, 7 percent have an HIVpositive parent (the mother, her current spouse, or both are HIV positive), another 7 percent have 

an HIV-negative mother who is a single parent, and 39 percent have both parents HIV-negative. 

For the remaining 38 percent, parent HIV status is unknown. The proportions orphaned and 

fostered are much higher among children age 6-14 years than among children age 0-4 years. 

Higher proportions of orphaned and fostered among older children mainly reflect longer exposure 

to becoming an orphan or to being fostered. Seventeen percent of children age 6-14 years are 

orphaned and another 9 percent are fostered. The proportion of children who have an HIVpositive parent is somewhat lower for children age 6-14 years (4 percent) than for children age 0-

4 years (7 percent), which reflects increasing HIV-related mortality in the adult population. 

Twenty-nine percent of children age 6-14 have both parents HIV-negative and for another 36 

percent the HIV status of one or both parents is unknown. 
11

Table 1 Percent distribution of children age 0-4 years and 6-14 years by child parentage and selected 

child, parent, and household characteristics, Kenya 2003 

Characteristic 

Children age 

0-4 years 

Children age 

6-14 years 

Child Parentage 

Orphaned children 4.8 17.3 

Fostered children 3.4 9.4 

Children of HIV+ parents 6.9 4.3 

Children of HIV- mothers who have no spouse 7.3 3.8 

Children whose parents’ HIV status is unknown 38.0 36.3 

Children of HIV- parents 39.4 28.9 

Child Characteristics 

Age of child (years) 

0 21.6 - 

1 19.3 - 

2 18.5 - 

3 21.8 - 

4 18.8 - 

6 - 13.1 

7 - 11.9 

8 - 10.8 

9 - 10.4 

10 - 12.3 

11 - 9.7 

12 - 10.9 

13 - 11.3 

14 - 9.7 

Sex of child 

Male 49.5 50.2 

Female 50.6 49.8 

Birth order 

1 24.0 23.2 

2-3 35.9 36.5 

4-5 21.0 22.0 

6+ 19.1 18.3 

Preceding birth interval 

First birth 24.1 23.4 

< 24 months 15.7 19.1 

24-35 months 27.7 28.4 

36+ months 32.6 29.0 

Succeeding birth interval 

Last birth 69.9 14.8 

< 24 months 9.5 18.8 

24-35 months 15.1 30.9 

36+ months 5.5 35.6 

Size at birth1 

Larger than average/very large 23.8 - 

Average 60.1 - 

Smaller than average/very small 16.2 - 

Wanted status of last child 

Wanted then 56.7 - 

Wanted later 24.6 - 

Not wanted 18.6 - 

 Continued...
12

Table 1—Continued

Characteristic 

Children age 

0-4 years 

Children age 

6-14 years 

Breastfeeding duration2 

< 12 months 32.1 - 

12-23 months 45.8 - 

24+ months 22.1 - 

Parent Characteristics 

Mother’s age at childbirth (years) 

<20 17.1 18.5 

20-24 30.8 34.0 

25-29 23.6 25.1 

30-34 17.5 14.9 

35+ 11.0 7.4 

Mother’s education 

No education 15.2 21.2 

Incomplete primary 36.5 33.8 

Complete primary 26.6 24.0 

Secondary+ 21.6 21.0 

Mother’s work status in past 12 months 

Employed for cash 44.9 52.5 

Employed but not for cash 20.1 20.4 

Not employed 35.0 27.1 

Occupation of mother’s current or former spouse3 

White collar 21.1 22.5 

Agriculture 35.4 37.2 

Other 38.1 38.5 

Never married 5.4 1.8 

Mother’s regular exposure to mass media4 

2+ sources 23.4 23.1 

< 2 sources/no information 76.6 76.9 

Mother's marital status 

In union 89.5 92.9 

Separated/divorced/widowed 5.1 5.4 

Never married 5.4 1.8 

Mother’s BMI5 

<18.5 13.0 10.1 

18.5-24.9 68.5 61.4 

25+ 18.5 28.5 

Ethnicity 

Kalenjin 12.5 11.9 

Kamba 12.8 12.4 

Kikuyu 18.0 20.8 

Luhya 15.1 13.6 

Luo 11.5 10.4 

Other6 30.1 30.8 

Religion 

Roman Catholic 23.4 23.2 

Protestant/other Christian 64.6 65.1 

Muslim 8.6 8.8 

Other/missing 3.3 2.9 

Mother’s participation in household decisionmaking7 

No decision 24.1 16.1 

1-2 decisions 39.4 37.8 

3-4 decisions 36.5 46.1 

 Continued...
13

Table 1—Continued

Characteristic 

Children age 

0-4 years 

Children age 

6-14 years 

Mother’s experience of physical mistreatment8 

Never 35.9 36.0 

More than 12 months ago 16.1 18.6 

Once in past 12 months 10.4 6.6 

Two or more times in past 12 months 17.5 18.1 

No information 20.2 20.7 

Alcohol/illegal drug consumption by mother’s 

current or former spouse 

Never 52.9 47.3 

Occasionally 19.3 21.2 

Often 7.9 11.0 

No information 19.9 20.6 

Mother’s or current spouse’s experience of higher 

risk sex in past 12 months9

 

Either or both parents 8.8 7.0 

Neither 81.9 85.2 

No information 9.3 7.8 

Mother or current spouse tested for HIV 

Never (neither parent) 67.7 74.3 

Ever (either or both parents) 23.3 18.6 

No information 9.0 7.2 

Household Characteristics 

Sex of household head 

Male 73.8 64.3 

Female 26.2 35.7 

Family type10 

Nuclear 61.1 58.2 

Non-nuclear 39.0 41.8 

Wealth index (quintile)11 

Lowest 23.8 22.5 

Second 21.8 22.3 

Middle 19.1 19.9 

Fourth 18.1 21.2 

Highest 17.3 14.0 

Residence 

Urban 17.8 14.8 

Rural 82.2 85.2 

 Continued...
14

Table 1—Continued

Characteristic 

Children age 

0-4 years 

Children age 

6-14 years 

Region 

Nairobi 5.6 4.1 

Central 11.1 13.3 

Coast 7.8 7.6 

Eastern 16.3 17.0 

Nyanza 15.6 16.6 

Rift Valley 27.9 25.4 

Western 13.0 12.6 

North Eastern 2.9 3.5 

Number of children12 2,756 4,172 

1

Where available, size at birth uses actual birth weight. Children <2500 g are categorized as smaller 

than average or very small; 2500-2999 g as average; and 3000+ g as larger than average or very large. 

If the birth weight is not available, the size at birth is based on the mother’s report. 2

Breastfeeding duration includes current breastfeeding. A child under age 12 months who was 

currently breastfeeding is categorized is having a duration of <12 months, and so on. Sixteen children 

who were never breastfed or had inconsistent or missing information on breastfeeding duration are 

excluded. 

3

Occupation of mother’s current or former spouse is based on mother’s report. ‘White collar’ includes 

professional/technical/managerial, clerical, and sales and service; ‘Other’ includes skilled manual, 

unskilled manual, and domestic service. 

4

Media sources include newspaper, television, and radio. Regular exposure to a media source is 

defined as exposure at least once a week. 

5

The body mass index (BMI) is defined as a woman’s weight in kilograms divided by the square of 

her height in meters (kg/m2

). 6

Other category includes Embu, Kisii, Maasai, Meru, Mijikenda/Swahili, Somali, Taita/Taveta, 

Turkana, Kuria, and others. 

7

Mother’s participation in decisionmaking includes decisions made by herself only, jointly with her 

husband, or jointly with someone else. Four household decisions are considered here: own health 

care, large household purchases, daily household purchases, and visits to family and relatives. 8

Physical mistreatment includes pushing, shaking, throwing something at, slapping, arm twisting, 

punching with fist or something else, kicking, dragging, attempt to strangle or burn, threaten with 

knife, gun, or other weapon, attack with a knife, gun, or other weapon, physically forced to have 

sexual intercourse when the woman did not want, forced to perform other sexual acts that the woman 

did not want. 

9

Higher risk sex is defined as sex with a nonmarital, noncohabiting partner. 

10A nuclear household includes any combination of household head, spouse, cospouse, children, and 

fostered or adopted children. 

11The wealth index measures a household’s relative economic status based largely on household 

ownership of durable assets. For details on the methodology of calculating the index, see Rutstein and 

Johnson (2004). 

12The number of children varies slightly for individual characteristics depending on the number of 

missing cases. For parent characteristics and for child characteristics derived from individual 

questionnaires, orphans and fostered children are excluded. 

Children are about evenly distributed by child’s age and sex. About one in four children are first 

order births and two-fifths are of birth order four or higher. For about three-fifths of children in 

both age groups, the preceding birth interval was over 24 months. The proportion of children that 

are reported as a last birth is much greater among children age 0-4 years (70 percent) than among 

children age 6-14 years (15 percent), reflecting the longer exposure period for older children to 

have a sibling born. Among children age 0-4 years, 16 percent were identified as smaller than 

average or very small at birth, and 19 percent were reported to be not wanted at the time of 
15

conception. For more than two-thirds of children age 0-4 years, the breastfeeding duration was 

reported to be over 12 months. 

Among children whose mothers were interviewed, mothers of more than one-half of children 

were illiterate or had less than primary education. Mothers of about one-half of children (45 

percent for children age 0-4 and 53 percent for children age 6-14) were employed for cash in the 

past 12 months. Mothers of less than one-quarter of children were regularly exposed to two or 

more media sources. Mothers of younger children were somewhat less likely to participate in 

household decisionmaking and slightly more likely to have experienced physical mistreatment in 

the past 12 months. Among children age 0-4 years, 26 percent lived in a female-headed 

household, 61 percent in a nuclear family, and 82 percent in a rural area. The corresponding 

proportions for children age 6-14 years are 36, 58, and 85 percent, respectively. 

Orphaned and fostered children are more likely to live in female-headed and non-nuclear 

households than children of HIV-negative parents (results in this paragraph not shown). Mothers 

of children of HIV-positive parents are less likely to be illiterate and undernourished (BMI<18.5), 

and more likely to be employed for cash, exposed to two or more media sources regularly, and 

participate in household decisionmaking than mothers of children of HIV-negative parents. Also, 

for children of HIV-positive parents, the current or former spouse of the mother is more likely to 

be a white-collar worker than for children of HIV-negative parents. The proportion of mothers 

reporting physical mistreatment since age 15 is about the same for children of HIV-positive and 

HIV-negative parents, but the proportion reporting physical mistreatment in the past 12 months is 

greater for children of HIV-negative parents (35 percent) than for children of HIV-positive 

parents (24 percent). Mothers are more likely to report alcohol or illegal drug consumption by 

their current or former spouse if they are HIV positive or their spouse is HIV positive. Children of 

HIV-positive parents are more likely to live in urban areas than children of HIV-negative parents. 

Also, children of HIV-positive parents are much more likely than children of HIV-negative 

parents to belong to the Luo ethnic group and to live in the Nyanza province. 

Bivariate Results 

Table 2 shows how indicators of child nutritional status—stunting, underweight, and wasting—

vary by child parentage and other selected characteristics for children age 0-4 years. Overall, 32 

percent of children are stunted, 21 percent are underweight, and 5 percent are wasted. As 

expected, prevalence of stunting is higher among fostered children (42 percent) than among 

children of HIV-negative parents (37 percent). But contrary to the expectation, stunting is less 

prevalent among orphaned children (22 percent) and children of HIV-positive parents (29 

percent) than among children of HIV-negative parents. Children of HIV-negative mothers with 

no spouse are also less likely to be stunted than children of HIV-negative parents. As in the case 

of stunting, fostered children are more likely to be underweight (32 percent) than children of 

HIV-negative parents (23 percent), but the underweight prevalence is about the same in orphaned 

children, children of HIV-positive parents, and children of HIV-negative parents. The prevalence 

of wasting does not vary much by child parentage status, except it is somewhat higher among 

children of HIV-positive parents than among children of HIV-negative parents. 

Due to the small number of orphans age 0-4 years in our sample, we are unable to examine how 

stunting, underweight, and wasting levels differ for paternal orphans (only father dead), maternal 

orphans (only mother dead), and double orphans (both parents dead). 
16

Table 2 Prevalence of stunting, underweight, and wasting among children age 0-4 years, by child parentage and 

selected child, household, and parent characteristics, Kenya 2003 

Characteristic Stunting Underweight Wasting 

Child Parentage 

Orphaned children 21.6 21.2 5.1 

Fostered children 41.8 32.2 5.5 

Children of HIV+ parents 29.2 22.4 5.9 

Children of HIV- mothers who have no spouse 25.8 21.2 5.6 

Children whose parents’ HIV status is unknown 27.3 17.7 4.4 

Children of HIV- parents 37.2 22.7 5.1 

Child Characteristics 

Age of child (years) 

0 14.2 9.7 4.8 

1 42.1 27.7 8.8 

2 39.4 26.4 3.6 

3 32.3 21.8 4.5 

4 30.9 20.1 3.0 

Sex of child 

Male 35.4 23.8 6.2 

Female 27.9 18.3 3.7 

Birth order 

1 25.7 17.9 5.4 

2-3 30.4 19.6 4.7 

4-5 36.5 22.9 4.5 

6+ 36.7 23.7 5.6 

Preceding birth interval 

First birth 25.8 18.1 5.3 

< 24 months 39.0 26.1 6.5 

24-35 months 33.3 20.5 4.8 

36+ months 31.3 20.1 4.1 

Succeeding birth interval 

Last birth 29.9 19.3 5.5 

< 24 months 34.9 22.2 4.2 

24-35 months 36.3 22.6 3.4 

36+ months 36.5 29.8 4.1 

Size at birth1 

Larger than average/very large 26.4 12.1 3.9 

Average 30.6 20.3 4.9 

Smaller than average/very small 44.8 35.7 7.2 

Wanted status of last child 

Wanted then 30.7 21.9 5.9 

Wanted later 35.4 17.9 3.1 

Not wanted 30.2 20.7 4.8 

Breastfeeding duration2 

< 12 months 19.6 12.4 4.5 

12-23 months 38.7 24.6 5.7 

24+ months 34.1 23.6 3.9 

Parent Characteristics 

Mother’s age at childbirth (years) 

<20 34.1 23.0 5.8 

20-24 31.5 20.4 5.4 

25-29 31.5 21.8 4.6 

30-34 29.1 20.0 4.3 

35+ 33.9 16.5 4.7 

 Continued...
17

Table 2—Continued

Characteristic Stunting Underweight Wasting 

Mother’s education 

No education 38.7 32.8 13.6 

Incomplete primary 36.1 23.8 4.9 

Complete primary 30.5 17.2 1.3 

Secondary+ 21.1 11.3 3.8 

Mother’s work status in past 12 months 

Employed for cash 32.4 19.6 3.6 

Employed but not for cash 35.0 24.5 5.9 

Not employed 29.0 20.0 6.3 

Occupation of mother’s current or former spouse3 

White collar 25.4 13.7 3.2 

Agriculture 36.4 28.0 7.1 

Other 32.3 18.5 3.8 

Never married 22.5 15.1 6.3 

Mother’s regular exposure to mass media4 

2+ sources 22.4 15.0 3.7 

< 2 sources/no information 34.5 22.3 5.3 

Mother’s marital status 

In union 32.1 20.4 4.9 

Separated/divorced/widowed 35.0 30.5 4.3 

Never married 22.5 15.1 6.3 

Mother’s BMI5 

<18.5 43.4 38.1 12.7 

18.5-24.9 32.9 20.7 4.0 

25+ 20.0 9.0 3.6 

Ethnicity 

Kalenjin 36.6 27.8 5.6 

Kamba 35.0 23.6 1.9 

Kikuyu 27.3 15.7 3.0 

Luhya 28.0 14.4 3.6 

Luo 32.0 13.9 2.3 

Other6 32.7 25.2 8.9 

Religion 

Roman Catholic 34.5 21.5 2.8 

Protestant/other Christian 29.7 18.9 4.1 

Muslim 33.0 23.5 11.5 

Other/missing 52.0 45.0 22.4 

Mother’s participation in household decisionmaking7 

No decision 32.1 23.5 8.2 

1-2 decisions 33.5 22.3 4.1 

3-4 decisions 29.8 17.2 3.8 

Mother’s experience of physical mistreatment8 

Never 26.1 16.2 4.1 

More than 12 months ago 31.7 21.8 4.8 

Once in past 12 months 39.5 21.2 7.0 

Two more times in past 12 months 42.4 29.6 4.5 

No information 28.1 19.5 6.0 

Alcohol/illegal drug consumption by mother’s current 

spouse 

Never 31.9 19.0 5.1 

Occasionally 32.3 22.8 4.0 

Often 39.8 29.6 3.7 

No information 27.5 19.3 6.1 

 Continued...
18

Table 2—Continued

Characteristic Stunting Underweight Wasting 

Mother’s or current spouse’s experience of higher risk 

sex in past 12 months9 

Either or both parents 33.8 22.5 3.6 

Neither 31.8 20.2 4.5 

No information 29.0 23.3 10.6 

Mother or current spouse tested for HIV 

Never (neither parent) 33.5 22.1 4.5 

Ever (either or both parents) 25.9 16.4 5.1 

No information 34.3 20.9 8.3 

Household Characteristics 

Sex of household head 

Male 32.7 21.2 5.4 

Female 28.5 20.6 3.8 

Family type10 

Nuclear 33.7 22.0 4.9 

Non-nuclear 28.3 19.4 5.1 

Wealth index (quintile) 11 

Lowest 41.5 30.6 9.4 

Second 33.8 22.3 5.3 

Middle 32.1 19.8 3.2 

Fourth 25.4 18.4 2.8 

Highest 20.0 9.1 2.4 

Residence 

Urban 23.4 13.9 3.3 

Rural 33.2 22.4 5.3 

Region 

Nairobi 20.3 6.2 2.1 

Central 26.2 14.6 3.4 

Coast 36.7 25.0 5.5 

Eastern 32.2 22.5 3.2 

Nyanza 30.9 15.3 2.1 

Rift Valley 34.0 26.4 7.5 

Western 33.0 21.2 4.2 

North Eastern 30.7 36.8 23.5 

Total 31.6 21.0 5.0 

Number of children12 2,464 2,464 2,464 

Note: See Table 1 for list of footnotes. 

Boys are more likely to be stunted, underweight, and wasted than girls. Undernutrition rates also 

vary strongly and expectedly with mother’s education, media exposure, BMI, household wealth 

status, and urban/rural residence. Among other characteristics, children age one year, children of 

higher birth orders, children with a smaller than average or very small birth size, children of 

mothers whose current or former spouse worked in agriculture, children of 

separated/widowed/divorced mothers, children of Kalenjin mothers, children whose mothers 

experienced physical mistreatment, children in male-headed households, and children in nuclear 

families are more likely to be undernourished than other children. 

Overall, the school attendance rate for children age 6-14 years is quite high (91 percent). 

Consistent with expectations, orphaned and fostered children and children of HIV-negative 

mothers who have no spouse are somewhat less likely to be attending school than children of 

HIV-negative parents (Table 3). However, contrary to the expectation, children of HIV-positive 

parents are somewhat more likely to be attending school than children of HIV-negative parents. 
19

Also, contrary to expectations, double orphans are more likely to be attending school (95 percent) 

than paternal orphans (89 percent) or maternal orphans (80 percent). These differentials occur 

independent of household wealth status, urban/rural residence, and other factors (results not 

shown). Reasons for this unexpected finding are not clear. 

Table 3 School attendance rate (%) among children age 6-14 years, by child parentage 

and selected child, parent, and household characteristics, Kenya 2003 

Characteristic 

Percentage 

attending school 

Child Parentage 

Orphaned children 88.8 

Fostered children 87.3 

Children of HIV+ parents 95.5 

Children of HIV- mothers who have no spouse 88.4 

Children whose parents’ HIV status is unknown 91.6 

Children of HIV- parents 91.0 

Child Characteristics 

Age of child (years) 

6 85.4 

7 89.1 

8 88.8 

9 94.9 

10 91.0 

11 95.6 

12 93.0 

13 90.0 

14 89.2 

Sex of child 

Male 90.7 

Female 90.4 

Birth order 

1 93.4 

2-3 92.8 

4-5 89.1 

6+ 88.9 

Preceding birth interval 

First birth 93.5 

< 24 months 86.5 

24-35 months 91.4 

36+ months 92.9 

Succeeding birth interval 

Last birth 97.1 

< 24 months 86.9 

24-35 months 92.0 

36+ months 90.8 

Parent Characteristics 

Mother’s age at childbirth (years) 

<20 90.3 

20-24 92.4 

25-29 92.1 

30-34 89.8 

35+ 90.1 

Mother’s education 

No education 68.1 

Incomplete primary 96.1 

Complete primary 98.2 

Secondary+ 99.3 

Continued...
20

Table 3—Continued

Characteristic 

Percentage 

attending school 

Mother’s work status in past 12 months 

Employed for cash 95.7 

Employed but not for cash 93.6 

Not employed 81.3 

Occupation of mother’s current or former spouse3 

White collar 94.8 

Agriculture 85.4 

Other 95.4 

Never married 87.5 

Mother’s regular exposure to mass media4 

2+ sources 98.3 

< 2 sources/no information 89.3 

Mother’s marital status 

In union 91.4 

Separated/divorced/widowed 92.4 

Never married 87.5 

Mother’s BMI5 

<18.5 75.8 

18.5-24.9 91.6 

25+ 97.8 

Ethnicity 

Kalenjin 91.3 

Kamba 97.7 

Kikuyu 98.8 

Luhya 96.1 

Luo 99.0 

Other 79.1 

Religion6 

Roman Catholic 92.4 

Protestant/other Christian 95.8 

Muslim 63.8 

Other/missing 67.8 

Mother’s participation in household decisionmaking7 

No decision 83.0 

1-2 decisions 91.7 

3-4 decisions 94.1 

Mother’s experience of physical mistreatment8 

Never 90.2 

More than 12 months ago 92.7 

Once in past 12 months 95.5 

Two or more times in past 12 months 89.2 

No information 92.9 

Alcohol/illegal drug consumption by mother’s 

current spouse 

Never 89.6 

Occasionally 94.4 

Often 90.7 

No information 92.9 

Mother’s or current spouse’s experience of higher 

risk sex in past 12 months9

Either or both parents 91.1 

Neither 92.5 

No information 79.8 

Continued...
21

Table 3—Continued

Characteristic 

Percentage 

attending school 

Mother or current spouse tested for HIV 

Never (neither parent) 91.5 

Ever (either or both parents) 95.5 

No information 79.6 

Household Characteristics 

Sex of household head 

Male 90.1 

Female 91.5 

Family type10 

Nuclear 90.5 

Non-nuclear 90.6 

Wealth index (quintile) 11 

Lowest 75.8 

Second 93.2 

Middle 95.3 

Fourth 95.4 

Highest 96.0 

Residence 

Urban 92.2 

Rural 90.3 

Region 

Nairobi 93.0 

Central 97.1 

Coast 83.4 

Eastern 94.9 

Nyanza 97.8 

Rift Valley 85.9 

Western 95.7 

North Eastern 37.7 

Total 90.6 

Number of children12 4,165 

Note: See Table 1 for list of footnotes. 

As expected, the school attendance rate is strongly positively correlated with mother’s education, 

work status, media exposure, BMI, degree of participation in household decisionmaking, and 

household wealth status. The school attendance rate is noticeably lower for Muslim children and 

for children in the North Eastern province. The rate does not vary much by other characteristics. 

Table 4 shows that among children age 1-4 years, the likelihood of being fully immunized does 

not vary much by parent HIV status. Children of HIV-positive parents (64 percent) and children 

of HIV-negative parents (63 percent) are about equally likely to be fully immunized. Proportion 

fully immunized is strongly positively associated with mother’s education and household wealth 

status. It is also positively associated with mother’s work status, media exposure, BMI, mother’s 

participation in household decisionmaking, and urban residence. Higher birth order, preceding 

birth interval of < 36 months, succeeding birth interval of <24 months, mother’s older age at birth 

(35+ years), agricultural occupation of mother’s current or former spouse, separated/widowed/ 

divorced status of mother, Luo ethnicity, Muslim religion, mother’s experience of physical 

mistreatment, parents’ experience of higher risk sex, nuclear family status, and residence in the 

North Eastern and Nyanza provinces is associated with lower likelihood of being fully 

immunized. Only 8 percent of children in the North Eastern province are fully immunized 

compared with 85 percent in the Central province. 
22

Table 4 Immunization coverage among children age 1-4 years and treatment-seeking for ARI and diarrhea among 

children age 0-4 years who were sick with ARI or diarrhea in the past two weeks, by child parentage and selected 

child, parent, and household characteristics, Kenya 2003 

Characteristic 

Percentage 

fully 

immunized 

Percentage 

received 

treatment for 

ARI 

Percentage 

received 

treatment for 

diarrhea 

Child Parentage 

Children of HIV+ parents 63.7 37.8 17.8 

Children of HIV- mothers who have no spouse 63.5 41.5 15.0 

Children whose parents’ HIV status is unknown 61.4 56.3 33.6 

Children of HIV- parents 63.2 53.7 26.9 

Child Characteristics 

Age of child (years) 

0 - 62.0 26.7 

1 61.4 51.6 32.3 

2 60.8 48.6 20.3 

3 60.7 38.3 29.8 

4 68.0 64.1 21.8 

Sex of child 

Male 63.2 54.1 24.5 

Female 62.0 51.0 31.1 

Birth order 

1 67.6 52.7 30.5 

2-3 65.1 54.9 26.6 

4-5 61.6 52.0 33.6 

6+ 52.5 49.5 19.1 

Preceding birth interval 

First birth 67.6 52.7 30.5 

< 24 months 58.8 52.9 23.4 

24-35 months 56.2 50.4 30.4 

36+ months 65.6 54.5 24.6 

Succeeding birth interval 

Last birth 64.2 55.2 28.6 

< 24 months 56.7 58.3 16.8 

24-35 months 61.7 38.6 26.6 

36+ months 61.5 43.4 23.6 

Size at birth1 

Larger than average/very large 63.5 56.0 28.4 

Average 62.7 51.0 25.8 

Smaller than average/very small 61.4 52.6 30.6 

Wanted status of last child 

Wanted then 62.7 52.8 30.6 

Wanted later 60.2 51.4 28.1 

Not wanted 65.6 53.5 17.6 

Breastfeeding duration2 

< 12 months 62.9 62.3 26.3 

12-23 months 62.2 48.0 26.3 

24+ months 64.2 45.5 31.6 

Parent Characteristics 

Mother’s age at childbirth (years) 

<20 61.9 54.2 23.6 

20-24 62.3 54.3 31.0 

25-29 63.7 48.9 32.9 

30-34 65.9 56.2 25.4 

35+ 56.7 48.3 17.2 

 Continued...
23

Table 4—Continued

Characteristic 

Percentage 

fully 

immunized 

Percentage 

received 

treatment for 

ARI 

Percentage 

received 

treatment for 

diarrhea 

Mother’s education 

No education 32.3 48.3 26.1 

Incomplete primary 58.7 51.6 27.1 

Complete primary 71.7 56.0 25.7 

Secondary+ 78.2 53.9 33.2 

Mother’s work status in past 12 months 

Employed for cash 66.8 52.4 26.3 

Employed but not for cash 63.4 50.3 27.2 

Not employed 56.3 54.0 28.3 

Occupation of mother’s current or former spouse3 

White collar 69.6 65.8 32.1 

Agriculture 54.1 49.1 23.9 

Other 65.5 51.6 29.7 

Never married 71.6 32.2 15.1 

Mother’s regular exposure to mass media4 

2+ sources 75.7 66.9 39.3 

< 2 sources/no information 58.7 48.8 24.5 

Mother’s marital status 

In union 62.4 53.9 28.5 

Separated/divorced/widowed 57.7 46.9 21.6 

Never married 71.6 32.2 15.1 

Mother’s BMI5 

<18.5 52.1 50.0 43.2 

18.5-24.9 61.6 49.3 23.5 

25+ 74.0 64.7 32.8 

Ethnicity 

Kalenjin 76.7 53.7 18.1 

Kamba 70.2 69.3 37.2 

Kikuyu 76.8 53.0 23.5 

Luhya 56.2 45.0 18.0 

Luo 46.5 50.7 27.0 

Other6 53.4 54.1 35.9 

Religion 

Roman Catholic 64.3 54.9 29.4 

Protestant/other Christian 64.9 51.6 25.6 

Muslim 45.7 49.6 35.9 

Other/missing 46.6 62.1 11.9 

Mother’s participation in household decisionmaking7 

No decision 54.8 43.4 33.2 

1-2 decisions 60.7 54.9 25.6 

3-4 decisions 69.2 57.7 24.0 

Mother’s experience of physical mistreatment8 

Never 67.7 49.2 33.0 

More than 12 months ago 62.8 60.4 32.6 

Once in past 12 months 54.4 47.0 22.4 

Two or more times in past 12 months 52.7 57.2 24.8 

No information 66.0 48.9 21.1 

 Continued...
24

Table 4—Continued

Characteristic 

Percentage 

fully 

immunized 

Percentage 

received 

treatment for 

ARI 

Percentage 

received 

treatment for 

diarrhea 

Alcohol/illegal drug consumption by mother’s current 

spouse 

Never 60.4 51.9 31.3 

Occasionally 65.6 60.0 30.1 

Often 60.1 43.4 10.1 

No information 66.4 49.9 21.4 

Mother’s or current spouse’s experience of higher risk 

sex in past 12 months9 

Either or both parents 51.8 47.1 18.6 

Neither 64.3 54.1 29.9 

No information 56.3 43.9 16.8 

Mother or current spouse tested for HIV 

Never (neither parent) 61.0 50.2 25.4 

Ever (either or both parents) 69.5 59.0 24.4 

No information 56.4 55.4 51.3 

Household Characteristics 

Sex of household head 

Male 62.0 53.6 29.5 

Female 64.4 48.5 20.9 

Family type10 

Nuclear 60.1 52.4 27.5 

Non-nuclear 67.3 52.9 27.3 

Wealth index (quintile) 11 

Lowest 48.3 50.3 25.7 

Second 59.5 47.2 23.2 

Middle 66.1 39.9 21.6 

Fourth 70.1 60.5 31.4 

Highest 73.7 70.6 41.1 

Residence 

Urban 69.6 72.6 27.4 

Rural 61.1 49.1 27.4 

Region 

Nairobi 69.2 80.2 40.0 

Central 84.7 55.4 40.7 

Coast 68.5 63.9 42.4 

Eastern 69.5 72.0 45.7 

Nyanza 49.0 48.8 23.6 

Rift Valley 61.6 51.6 19.5 

Western 56.6 38.4 18.8 

North Eastern 8.1 17.9 4.8 

Total 62.6 52.6 27.4 

Number of children12 1,869 445 396 

Note: See Table 1 for list of footnotes. 

Table 4 also shows treatment-seeking for children age 0-4 years who have ARI and diarrhea. 

Overall, children with ARI were more likely to receive medical advice or treatment (53 percent) 

than children with diarrhea (27 percent). Among children who were sick with ARI in the two 

weeks preceding the survey, children of HIV-positive parents were considerably less likely to 

have received medical advice or treatment for ARI (38 percent) than children of HIV-negative 

parents (54 percent). Children of HIV-negative mothers with no spouse were also less likely to 

have received ARI treatment (42 percent) than children of HIV-negative parents. A similar 
25

pattern is observed for diarrhea treatment. Children of HIV-positive parents (18 percent) and 

children of HIV-negative mothers with no spouse (15 percent) were considerably less likely to 

have received medical advice or treatment when sick with diarrhea in the two weeks preceding 

the survey than children of HIV-negative parents (27 percent). 

Mother’s education, media exposure, and household wealth status are associated with a greater 

likelihood of receiving advice or treatment for ARI and diarrhea. Children in male-headed 

households are more likely to have received ARI and diarrhea treatment than children in femaleheaded households. Mother’s participation in household decisionmaking and urban residence are 

associated with a greater likelihood of treatment-seeking for ARI, but not for diarrhea. Children 

in the North Eastern province are much less likely to have received treatment for ARI and 

diarrhea than children in other provinces. 

Multivariate Results 

Nutritional status 

Fostered children tend to have higher prevalence of stunting (OR=1.37; n.s.), underweight 

(OR=1.96; p=0.031), and wasting (OR=1.64; n.s.) than children of HIV-negative parents (Table 

5). However, the results on the relative nutritional status of orphaned children are mixed. 

Orphaned children are less likely to be stunted (OR=0.46; p=0.011), about equally likely to be 

underweight (OR=1.01; n.s.), and more likely to be wasted (OR=1.59; n.s.) than children of HIVnegative parents. A lack of association between orphanhood status and nutritional status may 

reflect the fact that for more than four-fifths of the orphaned children one of the parents was alive. 

A significantly lower prevalence of stunting among orphaned children is unexpected, however. 

Children of HIV-positive parents are significantly more likely to be underweight (OR=1.57; 

p=0.061) and significantly more likely to be wasted (OR=2.37; p=0.043) than children of HIVnegative parents. Children of HIV-negative mothers who have no spouse also tend to have higher 

prevalence of underweight (OR=1.37; n.s.) and wasting (OR=1.57; n.s.), but these effects are not 

statistically significant. Contrary to expectations, children of HIV-positive parents and children of 

HIV-negative mothers with no spouse tend to have lower prevalence of stunting than children of 

HIV-negative parents, but these effects are also not statistically significant. 

When the analysis is limited to children of interviewed mothers by additionally controlling for 

several child and parent characteristics, children of HIV-positive parents remain significantly 

more likely to be underweight (OR=1.69; p=0.055) and wasted (OR=3.48; p=0.004) than children 

of HIV-negative parents (Table 6). These effects are much stronger than in the previous model. 

Children of HIV-negative mothers with no spouse also remain more likely to be underweight 

(OR=1.91; p=0.074) and more likely to be wasted (OR=1.51; n.s.) than children of HIV-negative 

parents. Again, children of HIV-positive parents and children of HIV-negative mothers with no 

spouse have lower prevalence of stunting than children of HIV-negative parents, but these effects 

are not statistically significant. 

With parent HIV status and other factors controlled in Table 6, girls are significantly less likely to 

be stunted, underweight, and wasted than boys. Diarrhea in the past two weeks, mother’s 

nutritional status, and household wealth status are also significantly associated with stunting, 

underweight, and wasting. Child’s age, birth order, birth size, mother’s age at childbirth, 

occupation of mother’s current or former spouse, and mother’s experience of physical violence 

are significantly associated with stunting and underweight, but not wasting. On the other hand, 

mother’s regular exposure to two or more media sources is significantly associated with 

underweight and wasting, but not with stunting. 
26

Table 5 Odds ratios for effects of child parentage and selected child and household characteristics on the risk of 

stunting, underweight, and wasting among children age 0-4 years, Kenya 2003 

Characteristic Stunting Underweight Wasting 

Child parentage 

Orphaned children 0.46** 1.01 1.59 

Fostered children 1.37 1.96** 1.64 

Children of HIV+ parents 0.90 1.57* 2.37** 

Children of HIV- mothers who have no spouse 0.78 1.37 1.57 

Children whose parents’ HIV status is unknown 0.70*** 0.85 1.06 

Children of HIV- parents† 1.00 1.00 1.00 

Child characteristics 

Age of the child (years) 

0† 1.00 1.00 1.00 

1 4.63  3.75** ** 2.10** 

2 4.06  3.53** ** 0.74 

3 3.09  2.73** ** 0.90 

4 2.70  2.31** ** 0.65 

Sex of child 

Male† 1.00 1.00 1.00 

Female 0.70  0.70** * 0.57*** 

Household characteristics 

Sex of household head 

Male† 1.00 1.00 1.00 

Female 1.01 0.99 0.71 

Family type10 

Nuclear† 1.00 1.00 1.00 

Non nuclear 0.84 0.82 1.17 

Wealth index (quintile) 11 

Lowest† 1.00 1.00 1.00 

Second 0.74** 0.71** 0.72 

Middle 0.64*** 0.57*** 0.40** 

Fourth 0.48  0.49** ** 0.30  

Highest 0.29** ** 0.20  0.23**  

Residence 

Urban† 1.00 1.00 1.00 

Rural 0.81 0.71 0.86 

Region 

Nairobi† 1.00 1.00 1.00 

Central 0.89 1.41 1.20 

Coast 1.16 2.22** 1.32 

Eastern 0.96 2.05* 0.87 

Nyanza 0.84 1.06 0.42 

Rift Valley 0.97 2.32** 1.90 

Western 0.80 1.55 0.92 

North Eastern 0.65 3.09*** 5.89*** 

Number of children12 2,349 2,349 2,349 

Note: See Table 1 for list of footnotes. 

†Reference category. 

* p<.1, ** p<.05, *** p<.01, **** p<.001 
27

Table 6 Odds ratios for effects of child parentage and selected child, parent, and household characteristics on the risk of 

stunting, underweight, and wasting among children age 0-4 years (excluding orphans and foster children), Kenya 2003 

Characteristic Stunting Underweight Wasting 

Parent HIV status 

Children of HIV+ parents 0.79 1.69* 3.48*** 

Children of HIV- mothers who have no spouse 0.64 1.91* 1.51 

Children whose parents’ HIV status is unknown 0.63*** 1.10 1.20 

Children of HIV- parents† 1.00 1.00 1.00 

Child characteristics 

Age of the child (years) 

0† 1.00 1.00 1.00 

1 6.09  5.02** ** 1.83 

2 4.80  4.45** ** 0.74 

3 3.86  3.65** ** 0.96 

4 3.35  3.21** ** 0.50 

Sex of child 

Male† 1.00 1.00 1.00 

Female 0.64  0.65** * 0.62** 

Birth order 

1† 1.00 1.00 1.00 

2-3 1.51** 1.31 0.87 

4-5 2.41**** 1.78* 0.76 

6+ 2.56*** 2.05** 0.76 

Size at birth1 

Larger than average/very large† 1.00 1.00 1.00 

Average 1.23 1.75*** 1.09 

Smaller than average/very small 2.07  3.41** ** 1.16 

Wanted status of last child 

Wanted then† 1.00 1.00 1.00 

Wanted later 1.32* 0.81 0.73 

Not wanted 0.92 0.98 1.54 

Breastfeeding duration2 

< 12 months† 1.00 1.00 1.00 

12-23 months 0.92 0.89 1.10 

24+ months 1.00 1.15 1.21 

Had ARI in last 2 weeks 

No† 1.00 1.00 1.00 

Yes 1.17 1.46** 1.28 

Had diarrhea in last 2 weeks 

No† 1.00 1.00 1.00 

Yes 1.38** 2.07  2.30** ** 

Parent characteristics 

Mother’s age at childbirth 

<20† 1.00 1.00 1.00 

20-24 0.68* 0.73 1.01 

25-29 0.46*** 0.58* 0.78 

30-34 0.46*** 0.60 1.02 

35+ 0.48** 0.32*** 0.90 

Mother’s education 

No education† 1.00 1.00 1.00 

Incomplete primary 1.04 1.07 0.85 

Complete primary 0.97 0.81 0.25*** 

Secondary+ 0.88 0.66 0.66 

Mother’s work status in past 12 months 

Employed for cash† 1.00 1.00 1.00 

Employed but not for cash 0.91 1.19 1.04 

Not employed 0.70** 0.75 0.68 

 Continued...
28

Table 6—Continued

Characteristic Stunting Underweight Wasting 

Occupation of mother’s current or former spouse3 

White collar† 1.00 1.00 1.00 

Agriculture 1.19 1.93*** 1.75 

Other 1.35* 1.45* 1.68 

Never married 1.41 0.91 1.65 

Mother’s regular exposure to mass media4 

2+ sources† 1.00 1.00 1.00 

< 2 sources/no information 1.07 0.69* 0.52** 

Mother’s BMI5 

<18.5† 1.00 1.00 1.00 

18.5-24.9 0.80 0.60*** 0.50** 

25+ 0.50*** 0.30**** 0.65 

Ethnicity 

Kalenjin† 1.00 1.00 1.00 

Kamba 1.83* 1.77 0.59 

Kikuyu 1.31 0.92 0.67 

Luhya 0.72 0.43** 0.91 

Luo 1.07 0.65 0.99 

Other6 0.97 1.06 1.68 

Religion 

Roman Catholic† 1.00 1.00 1.00 

Protestant/other Christian 0.73** 0.80 1.28 

Muslim 1.13 0.67 3.12 

Other/missing 1.80* 1.75 7.91**** 

Mother’s participation in household decisionmaking7 

No decision † 1.00 1.00 1.00 

1-2 decisions 1.38** 1.16 0.51** 

3-4 decisions 1.11 0.80 0.61 

Mother’s experience of physical mistreatment8 

Never/no information† 1.00 1.00 1.00 

More than 12 months ago 1.60*** 1.76*** 1.24 

Once in past 12 months 1.65** 1.08 1.73 

Two or more times in past 12 months 1.98  1.62**  0.99 

Alcohol/illegal drug consumption by mother’s current or 

former spouse 

Never/no information† 1.00 1.00 1.00 

Occasionally 0.78 1.08 1.00 

Often 1.10 1.37 0.59 

Mother’s or current spouse’s experience of higher risk 

sex in past 12 months9 

Either or both parents† 1.00 1.00 1.00 

Neither 0.83 0.77 1.01 

No information 0.76 0.77 1.73 

Mother or current spouse tested for HIV 

Never (neither parent) † 1.00 1.00 1.00 

Ever (either or both parents) 0.83 0.96 1.71* 

No information 1.48* 0.99 1.96* 

Household Characteristics 

Sex of household head 

Male† 1.00 1.00 1.00 

Female 1.18 0.96 0.66 

Family type10 

Nuclear† 1.00 1.00 1.00 

Non-nuclear 1.06 1.03 1.11 

 Continued...
29

Table 6—Continued

Characteristic Stunting Underweight Wasting 

Wealth index (quintile)11 

Lowest† 1.00 1.00 1.00 

Second 0.75* 0.79 0.81 

Middle 0.67** 0.74 0.52 

Fourth 0.58** 0.65* 0.33** 

Highest 0.47*** 0.41** 0.21** 

Residence 

Urban† 1.00 1.00 1.00 

Rural 0.92 0.59* 0.64 

Region 

Nairobi† 1.00 1.00 1.00 

Central 1.02 1.97 2.39 

Coast 1.19 2.21 0.32 

Eastern 0.76 1.63 1.01 

Nyanza 0.73 1.21 0.45 

Rift Valley 1.05 2.61* 1.47 

Western 0.99 2.59* 0.87 

North Eastern 0.67 4.29** 1.89 

Number of children12 2,054 2,054 2,054 

Note: See Table 1 for list of footnotes. 

†Reference category 

* p<.1, ** p<.05, *** p<.01,   p<.001 

School attendance 

Model 1 in Table 7 shows that orphaned and fostered children are significantly less likely to be 

attending school than children of HIV-negative parents (OR=0.53; p=0.003 for orphaned 

children; OR=0.49; p=0.008 for fostered children). Children of HIV-positive parents (OR=0.82) 

and children of mothers with no spouse (OR=0.62) are also less likely to be attending school than 

children of HIV-negative parents, but these effects are not statistically significant. In Model 2, 

additionally controlling for several child and parent characteristics and limiting the analysis to 

nonorphaned and non-fostered children of interviewed mothers sharpens the effect of parent HIV 

status on school attendance considerably. With all child, parent, and household characteristics 

controlled in Model 2, children of HIV-positive parents are significantly less likely to be 

attending school than children of HIV-negative parents (OR=0.37; p=0.039). Children of HIVnegative mothers with no spouse also have a lower school attendance rate (OR=0.66) than 

children of HIV-negative parents, but this effect is not statistically significant. 

Among the control variables, mother’s education and household wealth status are strongly 

positively associated with the likelihood of attending school, as expected. Girls, children of 

unemployed mothers, children of undernourished mothers, and children of mothers whose current 

spouse consumes alcohol or illegal drugs often are significantly less likely to be attending school 

than other children. With other factors in the table controlled, urban residence is associated with a 

significantly lower school attendance rate than rural children. Child’s age, birth order, mother’s 

age at childbirth, religion, and ethnicity are also significantly associated with the school 

attendance rate. 
30

Table 7 Odds ratios for effects of child parentage and selected child, parent, and household characteristics on the likelihood of 

school attendance among children age 6-14 years, Kenya 2003 

Characteristic Model 1 Model 2 

Child Parentage 

Orphaned children 0.53** * n/a 

Fostered children 0.49*** n/a 

Children of HIV+ parents 0.82 0.37** 

Children of HIV- mothers who have no spouse 0.62 0.66 

Children whose parents’ HIV status is unknown 1.03 1.50* 

Children of HIV- parents† 1.00 1.00 

Child Characteristics 

Age of the child (years) 

6-8† 1.00 1.00 

9-11 2.22**** 3.49  

12-14 1.45**  2.69**** 

Sex of child 

Male† 1.00 1.00 

Female 0.83 0.62** 

Birth order 

1† 1.00 

2-3 0.86 

4-5 0.47** 

6+ 0.41** 

Parent Characteristics 

Mother’s age at childbirth 

<20† 1.00 

20-24 1.22 

25-29 1.07 

30-34 1.49 

35+ 4.21*** 

Mother’s education 

No education† 1.00 

Incomplete primary 3.68  

Complete primary 6.22** ** 

Secondary+ 10.93  

Mother’s work status in past 12 months 

Employed for cash† 1.00 

Employed but not for cash 0.78 

Not employed 0.40** ** 

Occupation of mother’s current or former spouse3 

White collar† 1.00 

Agriculture 0.69 

Other 1.43 

Never married 0.58 

Mother’s regular exposure to mass media4 

2+ sources† 1.00 

< 2 sources/no information 1.14 

Continued...
31

Table 7—Continued

Characteristic Model 1 Model 2 

Mother’s BMI5 

<18.5† 1.00 

18.5-24.9 1.55* 

25+ 2.60** 

Ethnicity 

Kalenjin† 1.00 

Kamba 3.43* 

Kikuyu 1.84 

Luhya 0.37 

Luo 1.72 

Other6 0.75 

Religion 

Roman Catholic† 1.00 

Protestant/other Christian 1.79** 

Muslim 1.99* 

Other/missing 0.79 

Mother’s participation in household decisionmaking7 

No decision † 1.00 

1-2 decisions 0.95 

3-4 decisions 0.88 

Mother’s experience of physical mistreatment8 

Never/no information† 1.00 

More than 12 months ago 0.59* 

Once in past 12 months 1.34 

Two or more times in past 12 months 1.18 

Alcohol/illegal drug consumption by mother’s current or former spouse 

Never/no information† 1.00 

Occasionally 0.80 

Often 0.47** 

Mother’s or current spouse’s experience of higher risk sex in past 

12 months9 

Either or both parents† 1.00 

Neither 1.02 

No information/remaining 0.68 

Mother or current spouse tested for HIV 

Never (neither parent) † 1.00 

Ever (either or both parents) 0.69 

No information 0.77 

Household Characteristics 

Sex of household head 

Male† 1.00 1.00 

Female 1.26 0.84 

Family type10 

Nuclear† 1.00 1.00 

Non-nuclear 0.97 1.03 

Wealth index (quintile)11 

Lowest† 1.00 1.00 

Second 2.81  2.42** ** 

Middle 4.13  2.35** * 

Fourth 5.26**** 4.75  

Highest 13.04** ** 4.54*** 

Continued...
32

Table 7—Continued

Characteristic Model 1 Model 2 

Residence 

Urban† 1.00 1.00 

Rural 1.44 2.14** 

Region 

Nairobi† 1.00 1.00 

Central 5.31  0.91 

Coast 1.23 0.37 

Eastern 4.51** ** 0.76 

Nyanza 13.59  4.63 

Rift Valley 1.67 0.78 

Western 5.61** ** 6.10** 

North Eastern 0.24  0.13**  

Number of children12 4,024 2,693 

Note: See Table 1 for list of footnotes. 

†Reference category 

* p<.1, ** p<.05, *** p<.01, **** p<.001 

Immunization and treatment-seeking for ARI and diarrhea 

Information on immunization coverage and treatment-seeking for ARI and diarrhea was collected 

only for the children (under age five years) of interviewed mothers. When estimating the effect of 

parent HIV status on the likelihood of being fully immunized, children under 12 months of age 

are excluded. Table 8 shows that, with other variables controlled, children of HIV-positive 

parents are about as likely to be fully immunized as children of HIV-negative parents (OR=0.99; 

n.s.). Children whose parents’ HIV status is unknown are significantly less likely to be fully 

immunized than children of HIV-negative parents (OR=0.66; p=.011). 
33

Table 8 Odds ratios for parent HIV status and selected child, parent, and household characteristics on the likelihood of being

fully immunized (children age 1-4 years) and on the likelihood of receiving treatment when sick with ARI and diarrhea in the 

two weeks preceding the survey (children age 0-4 years), Kenya 2003 

Received treatment for 

Characteristic

Fully 

immunized ARI Diarrhea 

Parent HIV status 

Children of HIV+ parents 0.99 0.44* 0.31* 

Children of HIV- mothers who have no spouse 0.67 0.82 0.59 

Children whose parents’ HIV status is unknown 0.66** 0.96 1.48 

Children of HIV- parents† 1.00 1.00 1.00 

Child Characteristics 

Age of the child (years)a 

0† na 1.00 1.00 

1 1.00 1.94 2.41 

2 1.12 1.60 0.67 

3 1.01 0.90 0.56 

4 1.53** 4.63** 0.31 

Sex of child 

Male† 1.00 1.00 1.00 

Female 0.98 0.91 2.48*** 

Birth order 

1† 1.00 1.00 1.00 

2-3 1.15 1.05 0.48 

4-5 1.24 0.96 0.80 

6+ 1.19 1.26 0.77 

Size at birth1 

Larger than average/very large† 1.00 1.00 1.00 

Average 0.90 1.03 0.67 

Smaller than average/very small 1.05 1.39 0.60 

Wanted status of last child 

Wanted then† 1.00 1.00 1.00 

Wanted later 0.87 0.79 1.06 

Not wanted 0.97 1.53 0.74 

Breastfeeding duration2 

< 12 months† 1.00 1.00 1.00 

12-23 months 1.07 0.31** 0.31 

24+ months 0.98 0.31* 0.91 

Parent Characteristics 

Mother’s age at childbirth 

<20† 1.00 1.00 1.00 

20-24 0.69* 0.68 2.20 

25-29 0.76 0.57 1.71 

30-34 0.83 0.65 0.99 

35+ 0.83 0.39 0.90 

Mother’s education 

No education† 1.00 1.00 1.00 

Incomplete primary 2.33**** 0.70 0.47 

Complete primary 3.75  0.54 0.15** * 

Secondary+ 4.50**** 0.46 0.75 

Mother’s work status in past 12 months 

Employed for cash† 1.00 1.00 1.00 

Employed but not for cash 1.11 1.03 1.50 

Not employed 0.87 1.09 0.62 

 Continued...
34

Table 8—Continued

Received treatment for 

Characteristic 

Fully 

immunized ARI Diarrhea 

Occupation of mother’s current or former spouse3 

White collar† 1.00 1.00 1.00 

Agriculture 0.82 0.54* 0.95 

Other 1.02 0.44** 1.43 

Never married 1.54 0.34 0.77 

Mother’s regular exposure to mass media4 

2+ sources† 1.00 1.00 1.00 

< 2 sources/no information 0.88 0.43** 0.34** 

Mother’s BMI5 

<18.5† 1.00 1.00 1.00 

18.5-24.9 1.16 0.95 0.25** 

25+ 1.42 1.63 0.22** 

Ethnicity 

Kalenjin† 1.00 1.00 1.00 

Kamba 0.34*** 1.01 0.25 

Kikuyu 0.32**** 0.32* 0.50 

Luhya 0.26**** 1.11 0.63 

Luo 0.20  0.65 3.06 

Other6 0.38** ** 0.86 1.30 

Religion 

Roman Catholic† 1.00 1.00 1.00 

Protestant/other Christian 0.97 1.39 0.55 

Muslim 1.34 1.51 4.41* 

Other/missing 0.67 2.14 0.39 

Mother’s participation in household decisionmaking7 

No decision † 1.00 1.00 1.00 

1-2 decisions 1.03 1.28 0.51 

3-4 decisions 1.26 1.21 0.47 

Mother’s experience of physical mistreatment8 

Never/no information† 1.00 1.00 1.00 

More than 12 months ago 0.83 1.82 1.43 

Once in past 12 months 0.65* 0.89 0.72 

Two or more times in past 12 months 0.66** 1.42 1.14 

Alcohol/illegal drug consumption by mother’s current or former 

spouse 

Never/no information† 1.00 1.00 1.00 

Occasionally 1.17 1.55 1.19 

Often 1.16 0.53 0.09** 

Mother’s or current spouse’s experience of higher risk sex in past 

12 months9

 

Either or both parents† 1.00 1.00 1.00 

Neither 2.13*** 1.46 1.92 

No information 1.97** 0.88 0.47 

Mother or current spouse tested for HIV 

Never (neither parent) † 1.00 1.00 1.00 

Ever (either or both parents) 1.07 1.54 0.80 

No information 0.86 0.86 2.51 

 Continued...
35

Table 8—Continued

Received treatment for 

Characteristic 

Fully 

immunized ARI Diarrhea 

Household Characteristics 

Sex of household head 

Male† 1.00 1.00 1.00 

Female 1.10 0.99 0.67 

Family type10 

Nuclear† 1.00 1.00 1.00 

Non-nuclear 0.98 1.02 0.92 

Wealth index (quintile)11 

Lowest† 1.00 1.00 1.00 

Second 1.19 0.89 1.76 

Middle 1.10 0.61 1.09 

Fourth 1.34 1.44 1.99 

Highest 1.71 0.87 2.75 

Residence 

Urban† 1.00 1.00 1.00 

Rural 0.95 0.66 2.94 

Region 

Nairobi† 1.00 1.00 1.00

Central 2.77** 1.07 2.88 

Coast 1.77 0.63 0.19* 

Eastern 1.58 0.76 2.64 

Nyanza 0.80 0.48 0.18* 

Rift Valley 0.86 0.32 0.29 

Western 1.18 0.16* 0.21 

North Eastern 0.13**** 0.03*** 0.00****

Number of children12 1,695 437 367 

Note: See Table 1 for list of footnotes. 

†Reference category * p<.1, ** p<.05, *** p<.01, **** p<.001 

a

Reference category for the immunization model is age 1, because children age 0 are excluded from the analysis. 

na = Not applicable

With parent HIV status and other factors controlled, children of more educated mothers, Kalenjin 

children, and children in the Central province are significantly more likely to be fully immunized 

than other children. On the other hand, children of mothers who experienced physical 

mistreatment, children whose mother or her current spouse engaged in higher risk sex in the past 

12 months, and children living in the North Eastern province are significantly less likely to be 

fully immunized. 

Among children who were sick with symptoms of an acute respiratory infection in the two weeks 

preceding the survey, children of HIV-positive parents were significantly less likely to have 

received medical advice or treatment for ARI than children of HIV-negative parents (OR=0.44; 

p=0.098). Similarly, among children who were sick with diarrhea in the two weeks preceding the 

survey, children of HIV-positive parents were significantly less likely to have received medical 

advice or treatment for diarrhea than children of HIV-negative parents (OR=0.31; p=0.099). 

Large p-values for these adjusted odds ratios partly reflect small numbers of ARI and diarrhea 

cases in our sample. 
36

With other factors controlled, mother’s media exposure is the only variable that is significantly 

associated with the likelihood of having received treatment for both ARI and diarrhea. Children 

of mothers regularly exposed to two or more media sources are significantly more likely to have 

received treatment for ARI and diarrhea than children of mothers not so exposed. Among other 

variables, girls are more likely to have received diarrhea treatment than boys, and a longer 

duration of breastfeeding is associated with a significantly lower likelihood of treatment-seeking 

for ARI. Contrary to expectations, children of undernourished mothers (BMI<18.5) are 

significantly more likely to have received diarrhea treatment. Again, children in the North Eastern 

province are much less likely to have received treatment for ARI and diarrhea. Contrary to 

expectations, the adjusted effects of mother’s education and household wealth status on 

treatment-seeking for ARI and diarrhea are mostly not statistically significant. 
37

DISCUSSION 

Results of our analyses show that in Kenya orphaned and fostered children age 6-14 years are 

significantly less likely to be in school than children of HIV-negative parents. This finding is 

consistent with other recent research in sub-Saharan Africa (Case et al. 2004; Monasch and 

Boerma 2004; Bicego et al. 2003). We also find that children of HIV-positive parents are 

significantly less likely to be attending school than children of HIV-negative parents. This is a 

new finding, which suggests that children of HIV-infected parents (irrespective of the parents’ 

knowledge of their HIV status) are more disadvantaged in schooling than children of non-HIVinfected parents. It is noteworthy that in the bivariate analysis the school attendance rate was 

higher for children of HIV-positive parents than for children of HIV-negative parents. A reversal 

in the association between bivariate and multivariate results occurs because the HIV-infected 

population in Kenya appears to be more socioeconomically advantaged than the uninfected 

population. This is contrary to the situation in many western countries, where HIV-infected 

population tends to be socioeconomically disadvantaged. 

Our study finds no consistent relationship between orphanhood status and the nutritional status of 

children. Contrary to expectations, we find that orphaned children are significantly less likely to 

be stunted than nonorphaned children of HIV-negative parents, and orphaned children are about 

equally likely to be underweight and somewhat more likely to be wasted than nonorphaned 

children of HIV-negative parents. This lack of a clear relationship between orphanhood and 

nutritional status of children is in line with the findings of the Lindblade et al. (2003) study in 

western Kenya and other studies in sub-Saharan Africa (Sarker et al. 2005; Crampin et al. 2003; 

Panpanich et al. 1999; Ryder et al. 1994). The study finds that fostered children are more likely to 

be stunted, underweight, and wasted, but the effects are not statistically significant for stunting 

and wasting. 

We find that children of HIV-infected parents are significantly more likely to be underweight and 

wasted than children of non-HIV-infected parents, but we do not find a relationship between 

parent HIV status and stunting. This may be because stunting, which is an indicator of chronic 

undernutrition, is largely determined early in life, possibly before the parents were infected with 

HIV. Wasting, on the other hand, indicates acute undernutrition, and underweight combines the 

effects of acute and chronic undernutrition. These two indicators are likely to be affected more by 

current HIV status. 

We also find that children of HIV-positive parents are significantly less likely than children of 

HIV-negative parents to receive medical advice or treatment when they get sick with an acute 

respiratory infection or diarrhea, but we find no relationship between parent HIV status and the 

likelihood of being fully immunized. Again, as in the case of stunting, a lack of association 

between parent HIV status and immunization coverage may be because most children are fully 

immunized within the first year of life, possibly before their parents were infected with HIV or 

before the parents became symptomatic. 

Consistent with expectations, our analyses show that children of non-HIV-infected single mothers 

(with no spouse) are more likely to be underweight and wasted, less likely to attend school, less 

likely to be fully immunized, and less likely to receive medical advice or treatment for ARI and 

diarrhea, although most of these effects were not statistically significant. 

Due to the small number of orphans under age 5 years in the sample, we were unable to 

differentiate between the nutritional status of paternal orphans, maternal orphans, and double 

orphans. However, contrary to expectations, we find that double orphans are more likely to be 
38

attending school than paternal or maternal orphans. We also find that boys are more 

disadvantaged in nutrition, but girls are more disadvantaged in schooling. 

In sum, we find clear evidence that orphaned and fostered children are disadvantaged in 

schooling compared with children of non-HIV-infected parents in Kenya. We find no clear 

relationship between orphanhood and the nutritional status of children, but fostered children tend 

to be more undernourished than children of non-HIV-infected parents. Children of HIV-infected 

parents are more likely to be underweight and wasted, less likely to be attending school, and less 

likely to receive medical advice or treatment when sick with ARI or diarrhea than children of 

non-HIV-infected parents. We also find that children of non-HIV-infected single mothers are 

generally more disadvantaged in nutrition, health care, and schooling than children who live with 

both non-HIV-infected parents. However, we find no relationship between parent HIV status and 

stunting or the likelihood of being fully immunized. 

Several measurement constraints must be kept in mind when considering the findings of this 

study. First, our estimated results may be affected by the survival bias. Our analysis of orphaned 

children is limited to children who survived the death of their parent(s). Orphans tend to be at an 

increased risk of contracting HIV than nonorphans, and are therefore more likely to die from it. 

Our analysis is also biased to the extent that fostered children and children of single-mothers are 

more likely to have died than children of non-HIV-infected parents. Children of HIV-infected 

mothers also tend to have higher mortality rates than children of uninfected mothers (Newell et al. 

2004). Our estimated effects are underestimated to the extent that such survival bias occurs in our 

data. 

Results of this study may also be biased due to nonresponse in the survey. Thirty percent of males 

and 24 percent of females eligible for HIV-testing in the survey were not tested, mainly due to 

refusal and absence from the house during repeated visits. There is evidence that nonresponder 

males in the Kenya survey are somewhat more likely to be HIV-infected than the responder males 

(Mishra et al. 2005). Although, the effect of such nonresponse on the overall HIV prevalence in 

the population tends to be small, children of HIV-positive parents are likely to be 

underrepresented in our sample. To the extent that this occurs, it may have contributed to an 

underestimation of the effects of parent HIV status. 

Cross-sectional data used in our study do not allow an examination of transitional effects. For 

example, a parent’s getting sick with HIV or some other serious illness may lead to job loss and 

considerable expenses for treatment and care, which may affect children’s schooling, health care, 

and nutrition even before they become orphans. The nonorphaned groups in our analysis include 

such children in transition, which may have further diluted some of our estimated effects. 

Persons who tested positive for HIV in the survey may not know that they are infected with HIV 

(either they were not previously tested or they were tested but did not obtain the results). It is 

likely that the relationship between HIV-positive parents and children’s education and health 

would have been stronger if only those children whose parents knew that they were HIV positive 

could be identified and compared with children whose parents were not HIV positive. 

Another limitation is that for orphaned and fostered children who have changed households, we 

only have information on the current household. While school enrollment, treatment-seeking for 

recent illness, and wasting are more likely to be associated with the characteristics of the current 

household, more chronic conditions such as stunting and immunization coverage (which mostly 

occurs in the first year of life when the child’s biological mother and father are more likely to 
39

have been alive and living with the child) are more likely to be associated with the characteristics 

of the previous household. 

Finally, our analysis excludes street children and children living in institutions. Our estimated 

effects of orphanhood and parent HIV status are likely to be underestimated to the extent these 

excluded children are more likely to be orphans or have HIV-infected parents and more likely to 

be disadvantaged in schooling, nutrition, and health care. However, proportions of such children 

tend to be small. Recent pilot surveys of children in Blantyre, Malawi and Kingston, Jamaica that 

included household children, street children, and children in institutions, found that only 0.2 

percent of children in Malawi and only 0.5 percent of children in Jamaica were street children or 

lived in institutions. Although, the non-household children were much more disadvantaged on a 

range of health and economic indicators, their inclusion in the sample made virtually no 

difference to the indicators derived from children in households (UNICEF and ORC Macro, 

2005). Therefore, the exclusion of street children and children in institutions in our analysis is 

unlikely to alter the findings of this study. 

Despite these limitations, the findings of this study reinforce the need to target child welfare 

programs to address the needs of children made vulnerable due to parent death, displacement, or 

parent HIV infection. There is already considerable attention given to the needs of orphaned 

children, but our findings indicate that fostered children are equally, if not more, disadvantaged in 

schooling and nutrition. Our findings that children of HIV-infected parents are disadvantaged in 

nutrition, schooling, and health care, irrespective of parents’ knowledge of their HIV status, 

highlight the need to make voluntary counseling and testing (VCT) services more widely 

available, so that such children can be identified and their needs addressed. Children of single 

mothers also tend to be disadvantaged on all outcome measures and need attention. Programs also 

need to take into account differential vulnerabilities of children by other characteristics. For 

example, girls tend to be disadvantaged in schooling, but boys tend to be disadvantaged in 

nutrition. Our inability to examine nutritional differences between paternal orphans, maternal 

orphans, and double orphans, and the unexpected finding that double orphans are more likely to 

be attending school than single orphans call for further, more in-depth research on orphaned 

children. 
40

REFERENCES 

Adetunji, J. 2000. Trends in under-5 mortality rates and the HIV/AIDS epidemic. Bulletin of the 

World Health Organization 78: 1200-6. 

Ainsworth, M., and D. Filmer. 2002. Poverty, AIDS and Children’s Schooling: A Targeting 

Dilemma. World Bank Policy Research Working Paper 2885. Washington, D.C: World Bank. 

Bailey, R.C., M.C. Kamenga, M.J. Nsuami, P. Neiburg, and M.E. St. Louis. 1999. Growth of 

children according to maternal and child HIV, immunological and disease characteristics: a 

prospective cohort study in Kinshasa, Democratic Republic of Congo. International Journal of 

Epidemiology 28: 532-540. 

Bicego, G., S. Rutstein, and K. Johnson. 2003. Dimensions of the emerging orphan crisis in subSaharan Africa. Social Science and Medicine 56: 1235-1247. 

Bledsoe, C.H., D.C. Ewbank, and U.C. Isiugo-Abanihe. 1988. The effect of child fostering on 

feeding practices and access to health services in rural Sierra Leone. Social Science and 

Medicine 27: 627-36. 

Case, A., C. Paxson, and J. Ableidinger. 2004. Orphans in Africa: parent death, poverty, and 

school enrollment. Demography 41: 483-508. 

Castle, S.E. 1995. Child fostering and children’s nutritional outcomes in rural Mali: the role of 

female status in directing child transfers. Social Science and Medicine 40: 679-93. 

Central Bureau of Statistics, Ministry of Health, Kenya and ORC Macro. 2004. Kenya 

Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro. 

Crampin, A.C., S. Floyd, J.R. Glynn, N., Madise A. Nyondo, M.M. Khondowe, C.L. Njoka, H. 

Kanyongoloka, B. Ngwira, B. Zaba, and P.E.M. Fine. 2003. The long-term impact of HIV and 

orphanhood on the mortality and physical well-being of children in rural Malawi. AIDS 

17: 389-397. 

Dibley, M.J., J.B. Goldsby, N.W. Staehling, and F.L. Trowbridge. 1987a. Development of 

normalized curves for the international growth reference: Historical and technical 

considerations. American Journal of Clinical Nutrition 46: 736-48. 

Dibley, M.J., N.W. Staehling, P. Neiburg, and F.L. Trowbridge. 1987b. Interpretation of z-score 

anthropometric indicators derived from the international growth reference. American Journal of 

Clinical Nutrition 46: 749-62. 

Foster, G. 1998. Today’s children—challenges to child health promotion in countries with 

severe AIDS epidemics. AIDS Care 10: S17-23. 

Kamali, A., J.A. Seeley, A.J. Nunn, J.F. Kengeya-Kayando, A. Ruberantwari, and D.W. Mulder. 

1996. The orphan problem: experience of a sub-Saharan Africa rural population in the AIDS 

epidemic. AIDS Care 8: 509-15. 

Lindblade, K.A., F. Odhiambo, D.H. Rosen, and K.M. DeCock. 2003. Health and nutritional 

status of orphans <6 years old cared for by relatives in western Kenya. Tropical Medicine 

International Health 8: 67-72. 
41

Mishra, V., et al. 2005. HIV testing in population-based surveys: issues and challenges. (To be 

published). 

Monasch, R., and J.T. Boerma. 2004. Orphanhood and childcare patterns in sub-Saharan Africa: 

an analysis of national surveys from 40 countries. AIDS 18: S55-65. 

Nakiyingi, J.S., M. Bracher, J.A. Whitworth, A. Ruberantwari, J. Busingye, S.M. Mbulaiteye, 

and B. Zaba. 2003. Child survival in relation to mother’s HIV infection and survival: evidence 

from a Uganda cohort study. AIDS 17: 1827-34. 

Newell, M.L., M.C. Borja, and C. Peckham. 2003. European Collaborative Study. Height, 

weight, and growth in children born to mothers with HIV-1 infection in Europe. Pediatrics 111: 

e52-60. 

Newell, M.L., H. Brahmbhatt, and P.D. Ghys. 2004. Child mortality and HIV infection in 

Africa: a review. AIDS 18: S27-34. 

Nicoll, A., I. Timaeus, R.M. Kigadye, G. Walraven, and J. Killewo. 1994. The impact of HIV-1 

infection on mortality in children under 5 years of age in sub-Saharan Africa: a demographic and 

epidemiologic analysis. AIDS 8: 995-1005. 

Nyamukapa, C., and S. Gregson. 2005. Extended family's and women's roles in safeguarding 

orphans' education in AIDS-afflicted rural Zimbabwe. Social Science and Medicine 60: 2155-67. 

Panpanich, R., B. Brabin, A. Gonani, and S. Graham. 1999. Are orphans at increased risk of 

malnutrition in Malawi? Annals of Tropical Paediatrics. 19: 279-285. 

Rutstein, S.O., and K. Johnson. 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. 

Calverton, Maryland: ORC Macro. 

Ryder, R.W., M. Kamenga, M. Nkusu, V. Batter, and W.L. Heyward. 1994. AIDS orphans in 

Kinshasa, Zaire: incidence and socioeconomic consequences. AIDS 8: 673-679. 

Sarker, M., C. Neckermann, and O. Muller. 2005. Assessing the health status of young AIDS 

and other orphans in Kampala, Uganda. Tropical Medicine International Health 10: 210-5. 

Sherry, B., J.E. Embree, Z. Mei, J.O. Ndinya-Achola, S., Njenga E.R. Muchunga, J. Bett, and 

F.A. Plummer. 2005. Sociodemographic characteristics, care, feeding practices, and growth of 

cohorts of children born to HIV-1 seropositive and seronegative mothers in Nairobi, Kenya. 

Tropical Medicine International Health 5: 678-686. 

UNAIDS, UNICEF, and USAID. 2004. Children on the brink 2004: a joint report of new 

orphan estimates and a framework for action. New York: United Nations Children’s Fund. 

UNICEF. 2003. Africa’s orphaned generations. New York: United Nations Children’s Fund. 

UNICEF and ORC Macro. 2005. Methodological report on the results of the pilot surveys 

testing indicators and methodology for collecting data on children orphaned and made 

vulnerable by HIV/AIDS. New York: United Nations Children’s Fund (To be published).