Brian H. Howard1*, Carl V. Phillips 2 , Nelia Matinhure3, Karen J. Goodman2,

1. Barriers and Incentivesto Orphan Care in a Timeof AIDS and Economic CrisisA Survey of Caregiversin Rural Zimbabwe Brian H. Howard1*, Carl V. Phillips2, Nelia Matinhure3, Karen J. Goodman2, Sheryl A. McCurdy1, Cary Alan Johnson4 1 University of Texas-Houston School of Public Health, Houston, USA 2 Department of Public Health Sciences, University of Alberta, Edmonton, Canada 3 Department of Sociology, University of Zimbabwe, Harare, Zimbabwe 4 Africare Zimbabwe, Harare, Zimbabwe * Corresponding author: brianhoward58@hotmail.com

2. Abstract • Background: In Zimbabwe, where 1/4 of adults are HIV+ and 1/5 of children are orphans, AIDS and economic decline are straining society’s ability to care for orphans. • Methods: A cross-sectional quantitative survey of 371 caregivers, including 212 caring for double orphans, to explore barriers and incentives to orphan care in rural Zimbabwe. • Findings: 1) Foster caregivers are disproportionately female, older, poor, and without a spouse; 2) 98% of non-fosterers are willing to foster orphans; 3) poverty is the primary barrier to fostering; 4) financial need may be greatest in single-orphan households; and 5) families lack external support. • Conclusions: Incentives should focus on financial assistance, starting with free schooling, and development of community mechanisms to identify and support children in need, to evaluate and strengthen families’ capacity to provide orphan care, and to initiate placement outside the family when necessary.

3. Orphan-care crisis in Zimbabwe • 22% of adults HIV+; life expectancy 39 yrs (63 yrs in 1994). • Epidemic exacerbated by economic crash, political isolation. • 19% of children have lost one parent (single orphans) or both parents (double orphans), 80% due to AIDS (2003). • Almost ¼ of rural households foster orphans. Number of street children and child-headed households growing. • Preferred, most cost-effective form of orphan care – the extended family – is straining. “Diminished or non-existent forms of external support” (WHO). • Limits of family’s capacity and obligation are unstudied. • Caregivers’ views of barriers and incentives to orphan care can inform policies and programs to avert “an impending calamity” (USAID): that millions of children will grow up without the nutrition, education, and social nurturing necessary to sustain a healthy society.

4. Methods • Cross-sectional survey (2003) for Africare in rural East. • 371 caregivers of students at 34 prim./sec. schools: • 2/3 randomly selected from among future beneficiaries of Africare AIDS project (school fees, psychosocial support, and income generation for households identified by school/community as most severely affected by AIDS). • 1/3 caregivers of classmates, matched by grade level and gender. • 62 closed-ended questions. In Shona at caregivers’ homes. Written consent. No incentives. Response rate: 92.3%. • Analysis by group: • Group A (“foster caregivers”): 212 fostering double orphans • Group B (“Africare parents”): 85 Africare project participants, 2/3 widowed with single orphans • Group C (“control parents”): 74 not caring for orphans, not selected for AIDS project – most promising pool of potential fosterers.

5. Who is fostering? • Female: 53% grandmothers, 22% aunts (14% siblings) • Older (or very young): 34% age 60+ (vs. 4% of non-fosterers); 15% in their 70s or 80s • 5% in their teens (vs. 0 non-fosterers); 3% <17 yrs • Single: 48% (most widowed), vs. 21% of controls • Limited education: only 22% had > primary school • Poor: • 54% subsistence farming • 20% of households contained skilled or general wage employee, vs. 38% of controls • 20% had no regular income, vs. 12% of controls

6. Physical and emotional well-being • All 3 groups struggling; >1/3 reported hunger in household > once a week. • Priorities for assistance were financial: school fees (84%), food (70%).

7. Attitudes toward fostering 98% of 357 respondents said they were willing to foster a child, even if already fostering.

8. Fostering beyond the family Group C control parents were most likely to have a spouse and a wage-earner in the household and to be in good health. Their responses reflected attitudes that may limit motivation to step forward for fostering, especially from outside the family.

9. Discussion and conclusions • Overwhelming willingness to foster orphans, motivated by family obligation and compassion and constrained by poverty, is a strong foundation for a system of orphan support ensuring a home for every child. • Kinship obligation is most important motivation to foster. But > 2/3 said other factors – most often financial capacity – mattered more. • Greatest barriers to fostering are lack of money and organization. • Fostering stipend, including free schooling. • Early intervention for single orphans in AIDS-impoverished homes. • Support building community mechanisms to routinely respond to families in need, to identify and intervene early in support of households severely affected by AIDS, to evaluate and strengthen families’ capacity to provide good orphan care, and to initiate placement outside the family when necessary. • Serve all orphans, regardless of cause. • Above all, avoid damaging extended family’s sense of responsibility for and control over decisions regarding care of their young.

10. Discussion and conclusions • AIDS fear/stigma not cited as major factors in a fostering decision but may inhibit initiative to foster “AIDS orphan,” esp. from outside the family. • No reservoir of financially secure households that must simply be persuaded to take in orphans. Based on their reservations about fostering, non-fostering parents may be target for outreach emphasizing AIDS-stigma reduction, rewards of fostering (plus guaranteed school fees). • Affordable, accessible ART: In orphan care, too, nothing beats prevention. • Limitations: Small convenience sample, cross-sectional survey design, lack of qualitative depth. Excludes households without children and households too poor, sick, or disarrayed to send their children to school. Zimbabwe’s unique combination of economic crisis, AIDS dispersal, and political isolation limits generalizability. • In decisive ways for Zimbabwe, orphans are the foreseeable future and strengthened families their best hope. How communities, the country, and the world move to help the too-old and too-poor nurture the too-young through the double disaster of AIDS and poverty will shape the nation’s health and prospects for generations to come.

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