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Assessment	of	Emotional	Status	of	Orphans
and	Vulnerable	Children	in	Zambia
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WORLD HEALTH
Assessment of Emotional Status of Orphans and Vulnerable
Children in Zambia
Sharon M. Kirkpatrick, PhD, RN, FAAN1
, Wilaiporn Rojjanasrirat, PhD, RNC2
,
Beverly J. South, MSN, RN-BC, CNE3
, Jeri A. Sindt, MSN, RN4
, & Lee A. Williams, MA, MLIS, AHIP5
1 Pi Eta, Professor Emerita, Graceland University, and Executive Director, HealthEd Connect, Independence, MO
2 Pi Eta, IBCLC Associate Professor of Nursing, Graceland University, Independence, MO
3 Pi Eta, Assistant Professor of Nursing, Graceland University, Independence, MO
4 Pi Eta, Assistant Professor of Nursing, Graceland University, Independence, MO
5 Library Director, Graceland University, Independence, MO
Key words
Orphans and vulnerable children (OVC), AIDS
orphans, OVC caregivers, psychological needs,
Zambia, Africa
Correspondence
Dr. Sharon Minton Kirkpatrick, Executive
Director, HealthEd Connect, 1401 West Truman
Road, Independence, MO 64050 USA.
E-mail: kirkpat@graceland.edu
Accepted April 5, 2012
doi: 10.1111/j.1547-5069.2012.01447.x
Abstract
Purpose: To describe the emotional status of orphans and vulnerable children
(OVC) in two communities in Zambia.
Methods: The Health Ed Connect Adaptation Questionnaire (HECAQ) was
used to interview 306 OVC and 158 primary caregivers in Zambia in 2010.
Findings: Child participants and caregivers reported evidence of emotional
distress behaviors in the majority of OVC.
Conclusions: More research to evaluate the efficacy of intervention programs
for loss and grief, normal and abnormal reactions to grief, and positive coping
skills is needed to assist both children and their caretakers. In the population
studied, caregivers and OVC could benefit from additional support for promoting
emotional health and managing emotional distress in vulnerable children.
Clinical Relevance: Healthcare professionals play a key role in promoting
the emotional health of OVC through identification of deviant behaviors and
the development of interventions to alleviate emotional and psychological
distress.
Zambia is one of the world’s poorest countries, with
68% of the population living below the international
poverty line (World Bank, 2011). In addition to the
challenges of poverty, the country is faced with caring
for 1.3 million orphans 0 to 17 years of age (United
Nations Children’s Fund [UNICEF], 2009). With a total
population of 12.9 million (UNICEF, 2009) there is one
orphan for every nine people.
The people in the Copperbelt Province of Zambia are
challenged with the burden of orphaned children as well
as major negative social and economic changes in the
region. Although once a thriving mining province, the
closure of the copper mines in the 1980s, the evaporation
of jobs, and the devastation caused by AIDS have left the
small communities in the Copperbelt Province struggling
to survive. Even though providing the basics of food and
shelter for these orphans and vulnerable children (OVC)
is a strain on the resources of the community, caregivers
express concern about the unmet emotional needs of
the children. The challenges and emotional needs of
OVC and their caregivers in Chipulukusu and Kasompe,
Zambia, have not been well documented. If the status
of emotional health and distress were better understood,
more efficacious programs and interventions could be
developed that are specific for meeting the needs of this
vulnerable population.
The purpose of this study was to identify the emotional
status of OVC in the communities of Chipulukusu and
Kasompe, Zambia. The research questions addressed
were: (a) What are the characteristics and background
of the OVC in Chipulukusu and Kasompe? (b) How is
emotional health expressed by the OVC? (c) What are
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Kirkpatrick et al. Orphans and Vulnerable Children in Zambia
the characteristics of the caregivers? and (d) What are
the caregivers’ perceptions of the emotional health of the
OVC?
For the purpose of this study, an orphan was defined as
a child who had lost one or both parents through death. A
vulnerable child was defined as a child whose well-being
was significantly jeopardized through abandonment, who
had a terminally ill parent, or who was living at a high
level of poverty. The caregiver was defined as the person
living in the same household who was the primary caregiver
of the child (Family Health International, 2005).
Evidence of Emotional and Psychological
Distress in OVC
Previous studies of OVC have focused almost exclusively
on the economic well-being of children orphaned
by parents with AIDS. The few studies published on the
psychological well-being of OVC found that children
orphaned by AIDS displayed symptoms of high levels of
anxiety, depression, and anger. The physical care and
support given to them was not enough to manage these
emotions (Atwine, Cantor-Graae, & Bajunirwe, 2005;
Cluver & Gardner, 2007; Li et al., 2008; Murray, 2010;
Nyamukapa et al., 2008).
Orphanhood by AIDS has been associated with depression,
delinquency, conduct problems, stigmatization, and
post-traumatic stress. Some OVC were diagnosed with
post-traumatic stress disorder (PTSD) at a rate similar
to the PTSD reported in children who experienced war
(Cluver, Fincham, & Seedat, 2009). PTSD symptoms, particularly
nightmares, were more strongly associated with
AIDS orphans than other orphans (Cluver & Gardner,
2007; Cluver, Gardner, & Operario, 2007, 2008).
AIDS orphans suffered more psychological distress
than nonorphans in both short-term and long-term studies.
Depression, anxiety, and withdrawal from society
inhibited the normal grieving process and contributed to
greater anxiety and other internal and external symptoms
of distress (Li et al., 2008; Nyamukapa et al., 2008).
Common factors that affect the psychological wellbeing
of AIDS orphans have been categorized into the
following themes: bereavement, caregiving, new homes,
belonging, contact with extended family, abuse, poverty,
access to services, school and peers, physical safety,
crime, stigma and gossip, and positive activities (Cluver &
Gardner, 2007). Cluver and Orkin (2009) and Li et al.
(2008) found a particularly strong relationship between
negative mental health and poverty. They also identified
the following factors that contributed to negative mental
health status: food insecurity, AIDS-related stigma,
bullying, vulnerability to sexually transmitted diseases,
and multiple deaths in the family.
Caregivers who were nurturing lessened the impact of
negative factors (Cluver & Orkin, 2009). Many families
and community members have indicated a willingness
to care for orphaned children but identified the need for
assistance with providing food, shelter, education, and
physical care, and with addressing the emotional needs
of the children (Freeman & Nkomo, 2006).
Conceptual Framework
The “Ten Elements of Mental Health Promotion and
Demotion,” a conceptual mental health model developed
by MacDonald and O’Hara (1998), was used as a guide
to identify mental health promoting and demoting
factors. This model has been used (Somerville, Illsley,
Kennedy, Smillie, & Robbie, n.d.) in the development of
interventions to promote mental health for individuals,
families, and communities. According to the Ten Element
Map (MacDonald & O’Hara, 1998), the mental health of
a person of any age is dependent on the balance between
elements that promote mental health and elements
that are barriers to mental health. Promoting factors
include interplay of environmental quality, self-esteem,
emotional processing, self-management, and social
participation. Demoting factors include environmental
deprivation, emotional abuse, emotional negligence,
stress, and social alienation. Improvements in mental
health can be made by strengthening promoting factors
and reducing demoting factors, with the best outcomes
resulting from attending to both sets simultaneously
(Keleher & Armstrong, 2005).
Methods
Setting and Sample
Surveys of the children and caregivers were conducted
in the communities of Chipulukusu and Kasompe in the
Copperbelt Province of Zambia. These densely populated
communities are primarily composed of small crude-brick
homes with tin roofs and dirt or cement floors. Study
participants in this convenience sample were selected
by the community health workers and teachers at the
community schools. The inclusion criteria consisted of
(a) caregivers of children interviewed for the study or (b)
children 6 to 12 years of age living within a 20-min walk
of a free community school in the target communities.
Data Collection
The Graceland University Institutional Review Board
approved the study prior to data collection. Gaining
access to visit the homes and conduct interviews was
facilitated by community leaders and HealthEd Connect,
Journal of Nursing Scholarship, 2012; 44:2, 194–201. 195
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Orphans and Vulnerable Children in Zambia Kirkpatrick et al.
a nongovernmental organization active in Zambia. Since
many of the participants in this study were illiterate,
verbal consent was obtained. In low-literacy populations
where participants may be unable to read and sign formal
documents, verbal consent is acceptable (Family Health
International, 2005). Caregivers gave verbal consent for
children to participate in the study. All interviews took
place in the participants’ homes over a 4-day period in
June 2010. Each interview took approximately 1 hr to
conduct.
Two U.S. World Service Corps (WSC) volunteers organized
and supervised the data collection. The WSC volunteers
solicited local interviewers from a group of respected
community health workers who were the first to recognize
the needs of the OVC in the communities. The WSC
volunteers met with the local volunteers in community
churches for 2-hr training sessions. Role play was used
to demonstrate ways to establish rapport, obtain consent,
avoid bias, and fill out questionnaires. Immediately
following the training, local volunteers formed teams of
two or three and walked to a neighboring home to conduct
their first interview. Upon completion of the pilot
interview, the process and findings were critiqued. When
satisfied with the pilot interview, each team of volunteers
returned to the field to conduct additional interviews.
Measurement
The Health Ed Connect Adaptation Questionnaire
(HECAQ), was based on the Strengthening Community
Participation for the Empowerment of Orphans and
Vulnerable Children (SCOPE-OVC) questionnaire and
the Scope and Family Health International Quantitative
(SFHIQ) interview (Family Health International, 2005).
The SFHIQ questionnaire was developed by an international
research team and pilot tested in Lusaka, Zambia.
Reliability and construct validity of the instrument were
not published in the report (Tembo & Banda, 2002).
Permission to adapt the questionnaire was granted
by Family Health International-Arlington (I. Kabore,
personal communication, May 24, 2010). For the current
study, the internal consistency of the 12 items measuring
the child’s emotional health status was analyzed and
Cronbach’s α was .75. The fifteen items measuring caregivers’
perception of child emotional health status also
has an acceptable internal consistency, with Cronbach’s
α of .76. Construct validity was evidenced through a
known group comparison in this study. Boys reported
significantly more feelings of unhappiness or sadness and
more difficulty making friends than girls (p < .01). These
findings were consistent with study results from Cluver
et al. (2007) in that girls reported more depression
and anxiety than boys, whereas boys reported more
delinquency and conduct problems than girls.
The HECAQ used in this study consists of 43 questions
answered by the child and 38 questions answered by
the caregiver. The children’s four-part survey addresses
demographics and the child’s perceptions of his or her
emotional distress. The caregivers’ survey asks about demographics
and includes an 18-item checklist that measures
their perception of the child’s emotional well-being.
Data Analysis
Statistical analyses were conducted using SPSS version
17.0 software package for Windows (SPSS, Inc. Chicago,
IL, USA). Demographic data and background related to
caregivers and children were analyzed using descriptive
statistics. Psychosocial issues and perceived psychological
or emotional status were examined.
Results
OVC Characteristics
The convenience sample of children in this study
consisted of 156 boys (51%) and 150 girls (49%), with
ages ranging from 6 to 12 years. Many of the children
interviewed did not know or report their age. This is not
uncommon in developing countries, where birth records
are frequently nonexistent. When the exact age of a child
could not be determined, the interviewers based eligibility
on child’s size and language ability. The primary language
spoken by 73% of the participants and used in the
survey was ChiBemba, commonly referred to as Bemba.
Most OVC were living with their widowed mother
or grandmother (73%) and facing the daily reality of
poverty. Ninety-two (37%) of OVC reported having only
one meal a day for 2 to 3 days prior to the interview;
five OVC reported having no meals recently. Fifty-four
(21%) of OVC, although of school age, had never
attended school, and an additional 47 (18%) who had
once attended school were not currently attending. The
primary reason given for not attending school was the
death of a parent or guardian (Table 1).
OVC Emotional Distress
The top five areas of emotional distress experienced
by OVC “often” and “sometimes” included acting angry
(85%), having scary dreams (71%), worrying (71%),
feeling unhappy or sad (71%), and preferring to be alone
(67%). Many OVC (62%) also reported they refused
to eat “often” or “sometimes.” Questions to determine
reasons for refusal were not included in the survey. Areas
196 Journal of Nursing Scholarship, 2012; 44:2, 194–201.
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Kirkpatrick et al. Orphans and Vulnerable Children in Zambia
Table 1. Demographic Variables of Orphans and Vulnerable Children
in Kasompe and Chipulukusu
Frequency Percentage
Age (years)
6–9 85 27
10–12 102 33
Not known 88 29
Missing 31 11
Gender
Male 156 51
Female 150 49
Have been in school
Yes 206 79.5
No 53 20.5
Currently in school
Yes 221 81.9
No 47 17.4
Reasons for not attending school
Awaiting exam results 13 14.8
Death of parents 38 43.2
Death of guardians 14 15.9
Financial problems 15 17.0
Lack of support 2 2.3
Other 6 6.8
Recent frequency of meals/day
None 5 2.0
1 meal 92 37.1
2 meals 119 48.6
3 meals 30 12.2
Relationship to guardian
Mother 143 52.6
Father 37 13.6
Aunt 22 8.1
Uncle 2 7.0
Grandmother 54 19.9
Grandfather 6 2.2
Others (sister/cousin) 7 2.5
of least distress reported “often” or “sometimes” included
running away from home (17%) and difficulty making
friends (33%). Table 2 summarizes the psychological and
emotional distress frequency and percentage for the OVC.
Caregiver Characteristics
The convenience sample of caregivers in this study
consisted of 42 men (28%) and 109 women (72%). The
majority of caregivers (62%) were women struggling
to support an average of four children per household.
Table 3 illustrates demographic data and characteristics
of caregivers. Caregivers primarily ranged in age from
25 to 50 years and reported themselves to be heads
of the household. The majority of caregivers were
self-employed, for example, selling bananas, small bags
of laundry soap, charcoal, and day-to-day necessities.
Some were supported by institutions and relatives, with
the support being primarily food (56.5%) and finances
(31.9%). Caregivers reported the biggest challenge in
everyday life to be resources (64.2%) and that caring for
additional children placed economic stress on the family.
Caregiver Perceptions of OVC Emotional
Distress
Overall the caregivers’ perceptions corroborated the
reports of the child participants’ reports of psychological
and emotional distress (Table 4). Caregivers reported
81% of the OVC were “often” or “sometimes” angry and
78% “often” or “sometimes” had scary dreams. While
caregivers reported the OVC as having frequent episodes
of scary dreams and displaying anger, they also reported
them as being disobedient at home, crying, and stating
that they were unhappy or worried.
Discussion
Emotional distress among the OVC was expressed
through a number of socially deviant behaviors. These
findings are consistent with previous studies reporting
emotional distress and behavioral symptoms in orphans
(Cluver & Gardner, 2007; Li et al., 2008).
The similarity between the children’s and caregivers’
perception of the child’s behaviors and the child’s feelings
is noteworthy. Both groups indicated anger was the most
frequently exhibited behavior and running away was the
least frequently observed behavior. Only one category,
fighting, had a significant difference between perceptions,
with 75% of the caregivers compared to 55% of
the children indicating the behavior occurred “often” or
“sometimes.” This difference may be accounted for by a
difference in perception of fighting. The caregivers may
have viewed fighting as any type of disagreement that
occurred among or between children, while the children
may have differentiated between playful disagreements
and more serious ones. Another difference in perceptions
between children and their caregivers related to the ability
of the caregiver to detect the child’s mood. Children
reported being unhappy more often than the caregivers
observed. Unhappiness is not always manifested in an
outward behavior, so caregivers may not have always
known how the children were feeling. In spite of the everyday
pressures to feed, clothe, and care for the children,
the caregivers were also perceptive and aware of the
signs and symptoms of the children’s emotional distress.
Many of the OVC’s behaviors identified by this study
may be unrecognized signs and symptoms of depression
and anxiety developed in response to a loss. These
signs and symptoms should be measured in greater
Journal of Nursing Scholarship, 2012; 44:2, 194–201. 197
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Orphans and Vulnerable Children in Zambia Kirkpatrick et al.
Table 2. Orphans’ and Vulnerable Children’s View of Their Psychological and Emotional Status
Indication of Psychological or emotional statusa
Often Sometimes Rarely or never
Fighting 36 (13.2%) 113 (41.6%) 122 (45%)
Being unhappy or sad 33 (12.5%) 154 (58.7%) 75 (28.6%)
Worrying 27 (9.8%) 175 (63.8%) 72 (26.2%)
Preferring to be alone 18 (6.7%) 160 (60.3%) 87 (32.8%)
Acting angry 18 (6.3%) 223 (78.2%) 44 (15.4%)
Having nightmares 12 (4.3%) 182 (66%) 80 (29%)
Difficulty making friends 8 (2.6%) 85 (28.1%) 172 (56.9%)
Refusing to eat 6 (2.1%) 165 (59.7%) 105 (38%)
Running away from home 5 (2.6%) 28 (14.7%) 157 (82.6%)
a
OVC and caregivers were asked different questions.
Table 3. Demographic Variables of Caregivers
Frequency Percentage
Age (years)
< 25 6 3.8
25–50 67 47.4
> 50 8 5.1
Not known 42 26.5
Missing 35 22.2
Head of household
Yes 114 74.5
No 38 24.8
Marital status
Married 36 25.0
Single 19 13.2
Divorced or separated 40 27.9
Widowed 49 34.0
Education completed
Primary 71 60.7
Secondary 34 29.1
Postsecondary 3 2.6
Other 4 3.5
Gender
Male 42 27.6
Female 109 71.7
Financial status
Self-employed 81 56.6
Family member working 26 18.2
Institutional support 13 9.1
Support from relatives 23 16.1
Caregiver challenges
Discipline 21 17.1
Shortage of finances 79 64.2
Sickness 4 3.3
School requirements 9 7.3
Adjusting to situation 5 4.1
Recent frequency of meals/day
None 9 8.2
1 meal 46 41.8
2 meals 42 38.2
3 meals 13 11.8
Note. Some variables do not add up to 100% due to incomplete surveys.
detail to form a basis for interventions. Community
health workers and caregivers should be trained to recognize
problems in the early stages and work with the
community to plan and implement interventions.
Kumakech, Cantor-Graae, Maling and Bajunirwe
(2009) found that support groups were successful as
interventions in decreasing psychological distress among
OVC in Africa. Support groups share common factors
that help facilitate therapeutic change and empowerment
while encouraging social participation and reducing social
exclusion as a means of promoting mental health.
These factors include the instillation of hope and a sense
of universality through contact with others who have
survived similar situations. Therapeutic groups provide
socialization and support. Catharsis, the safe ventilation
of feelings, is encouraged, allowing the person to feel
accepted. Through interpersonal learning and imitative
behavior, individuals learn how others have resolved
situations similar to their own. Therapeutic groups also
provide group cohesiveness, allowing individuals to
develop a sense of belonging (Kumakech et al., 2009;
Ten Element Map of Mental Health Promotion, n.d.;
American Group Psychotherapy Association, 2007).
Education regarding normal and abnormal reactions
to loss is critical for OVC and their caregivers. Caregivers
need to be assured, for example, that anger is a normal
reaction to loss and can be expressed in nondestructive
ways (Varcarolis & Halter, 2010). Interventions through
school or community programs must be implemented
to enhance culturally appropriate coping skills in OVC.
Educating OVC and their caregivers could diminish
the demoting element of emotional negligence while
also increasing self-esteem and encouraging emotional
processing (MacDonald & O’Hara, 1998).
Further research is needed to determine the impact of
caregiving on the caregivers’ psychological well-being.
Symptoms such as depression, anxiety, feelings of stigmatization,
and shame related to a child’s or spouse’s death
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Kirkpatrick et al. Orphans and Vulnerable Children in Zambia
Table 4. Caregivers’ View of Orphans’ and Vulnerable Children’s Psychological and Emotional Status
Indication of psychological/emotional status Often Sometimes Rarely or never
Acting angry 20 (13.6%) 99 (67.3%) 28 (19.1%)
Fighting 18 (13.6%) 81 (61.4%) 33 (25%)
Disobedient at home 17 (11.6%) 91 (61.9%) 39 (26.5%)
Worrying 16 (11.7%) 87 (63.5%) 34 (24.8%)
Disobedient at school 15 (11.7%) 44 (34.4%) 69 (53.9%)
Preferring to be alone 15 (11.7%) 71 (55.5%) 42 (32.8%)
Crying 15 (11.0%) 90 (66.2%) 31 (22.8%)
Refusing to eat 15 (10.2%) 85 (57.8%) 47 (32%)
Being unhappy/sad 13 (9.4%) 89 (64.5%) 36 (26.1%)
Refusing to go to school 11 (8.2%) 69 (51.5%) 54 (40.3%)
Having nightmares 9 (6.3%) 102 (71.8%) 31 (21.8%)
Difficulty making friends 7 (5.5%) 30 (23.6%) 90 (70.9%)
Running away from home 6 (5.3%) 15 (13.3%) 93 (81.4%)
Being bullied 4 (2.9%) 46 (33.6%) 87 (63.5%)
caused by AIDS should be assessed. Careful assessment
and accurate diagnoses make it easier to identify and
implement appropriate early interventions (Varcarolis &
Halter, 2010).
Findings from this study support previous findings of
a strong relationship between negative mental health
status and poverty or food insecurity (Atwine et al.,
2005; Cluver et al., 2007; Cluver & Orkin, 2009). Lack of
food was a major concern, with 37% of OVC and 42%
of caregivers reporting having only one meal per day.
Ways to improve access to nutritional resources need to
be identified for this group. By fulfilling basic needs, the
demoting element of emotional deprivation would be
reduced (MacDonald & O’Hara, 1998).
Limitations
The findings of this study need to be interpreted with
limitations. Based on Zambian government requirements
that all schools teach English and ChiBemba, both
languages were represented on the questionnaire. The
survey instruments were translated from English to
ChiBemba by a professional translator. However, they
were not back-translated, which would have verified
accuracy of translation (Editorial Team, 2011). In addition,
data collection revealed that a number of primary
languages, other than Bemba, were spoken among interviewees,
which could have limited their understanding
of the questions and compromised the findings. Close
proximity and open-air housing construction, as well
as the caregivers’ presence in some instances, precluded
the maintenance of privacy, which may have influenced
OVC’s answers. Many of the OVC did not know how
old they were, which made it impossible to maintain a
pure cohort age group. Generalization of the findings is
limited since the convenience sample was not random.
Despite these limitations, this study provides valuable
insights into the emotional status of OVC in the two
communities surveyed.
Conclusions
Findings from this study provide a valid foundation
for further research and interventions. Documentation
of the emotional status of OVC was necessary before
appropriate interventions could be implemented to alleviate
reported distress. This research provides clarity on
the real problems and a basis for appropriate responses
to the emotional status of OVC in Kasompe and Chipulukusu,
Zambia. Once interventions are identified and
implemented, they must be evaluated for effectiveness
and revised as appropriate.
The World Health Organization recommends that
every country have policies and agencies with financial
backing in place to address mental health issues (Skolnik,
2008). Collaboration and support among local, national,
and international resources are needed to address these
complex issues. Nursing education has an obligation to
nurture nurses who have interests and skills to work in
developing countries. Nurses should provide leadership
in mentoring colleagues in other countries and in leading
efforts that empower grass-roots initiatives. As a result
of this study, members of the two communities studied
have requested training to organize small support groups
to address the needs of OVC. It is essential that sustainable
follow-up measures be instituted immediately to
capitalize on the new awareness and concern voiced
within the communities themselves.
Journal of Nursing Scholarship, 2012; 44:2, 194–201. 199
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Orphans and Vulnerable Children in Zambia Kirkpatrick et al.
Acknowledgments
The authors wish to acknowledge the volunteer community
health workers who conducted the interviews, as
well as the caregivers and OVC who willingly shared their
stories. Appreciation is also extended to World Service
Corps volunteers, who supervised the interviews, and to
Dr. Thelma Sword and Dr. Nancy Crigger, who provided
valuable suggestions in the writing of the article. The
on-site research was funded by HealthEd Connect.
Clinical Resources
r HealthEd Connect: www.healthedconnect.org
r UNICEF Data on Orphans by Region to 2010
in Children and Youth in History, item #293:
http://chnm.gmu.edu/cyh/primary-sources/293
r U.S. Department of State, Background Note:
Zambia (April 11, 2011): http://www.state.
gov/r/pa/ei/bgn/2359.htm
References
American Group Psychotherapy Association. (2007). Practice
guidelines for group psychotherapy: Therapeutic factors and
therapeutic mechanisms. Retrieved from http://www.agpa.
org/guidelines/factorsandmechanisms.html
Atwine, B., Cantor-Graae, E., & Bajunirwe, F. (2005).
Psychological distress among AIDS orphans in rural
Uganda. Social Science & Medicine, 61, 555–564.
doi:10.1016/j.socscimed.2004.12.018
Cluver, L., Fincham, D., & Seedat, S. (2009). Posttraumatic
stress in AIDS-orphaned children exposed to high levels of
trauma: The protective role of perceived social support.
Journal of Traumatic Stress, 22, 106–112.
doi:10.1002/jts.20396
Cluver, L., & Gardner, F. (2007). Risk and protective factors
for psychological well-being of children orphaned by AIDS
in Cape Town: A qualitative study of children and
caregivers’ perspectives. AIDS Care, 19(3), 318–325.
doi:10.1080/09540120600986578
Cluver, L., Gardner, F., & Operario, D. (2007). Psychological
distress amongst AIDS-orphaned children in urban South
Africa. Journal of Child Psychology and Psychiatry, 48(8),
755–763. doi:10.1111/j.1469–7610.2007.01757.x
Cluver, L., Gardner, F., & Operario, D. (2008). Effects of
stigma on the mental health of adolescents orphaned by
AIDS. Journal of Adolescent Health, 42, 410–417.
doi:10.1016/j.jadohealth.2007.09.022
Cluver, L., & Orkin, M. (2009). Cumulative risk and
AIDS-orphanhood: Interactions of stigma, bullying and
poverty on child mental health in South Africa. Social
Science & Medicine, 69, 1186–1193.
doi:10.1016/j.socscimed.2009.07.033
Editorial Team. (2011). Back translation for clinical trial
documentation– Informed consent forms. Retrieved from
http://globalhealthtrials.tghn.org/articles/back-translation-
clinical-trial-documentation-informed-consent-forms/
Family Health International. (2005). Conducting a participatory
situation analysis of orphans and vulnerable children affected by
HIV/AIDS: Guidelines and tools. Retrieved from
http://www.fhi360.org/NR/rdonlyres/ebkv627
kkethzvtb7u6geatgcd3m6v5ilur6smufou63ey7 kociufxxa-
jkcsvfs4nvgug44zqvnvrh/ConductOVCSitAnalysisHV.pdf
Freeman, M., & Nkomo, N. (2006). Guardianship of orphans
and vulnerable children. A survey of current and
prospective South African caregivers. AIDS Care, 18(4),
302–310. doi:10.1080/09540120500359009
Kumakech, E., Cantor-Graae, E., Maling, S., & Bajunirwe, F.
(2009). Peer-group support intervention improves the
psychosocial well-being of AIDS orphans: Cluster
randomized trial. Social Science & Medicine, 68, 1038–1043.
doi:10.1016/j.socscimed.2008.10.033
Keleher, H., & Armstrong, R. (2005). Evidence-based mental
health promotion resource. Index of health promotion downloads.
Report for the Department of Human Services and Vic
Health, Melbourne, Australia. Retrieved from http://www.
google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=
1&ved=0CD4QFjAA&url=http%3A%2F%2Fwww.health.
vic.gov.au%2Fhealthpromotion%2Fdownloads%
2Fmental health resource.pdf&ei=HOaWT5-
3CcSi2QWv55jPDQ&b2”usg=
AFQjCNFkyw8nPzWnzyfrHG zLEYnWXUD7A&
sig2=tAo0i3O4 hpqzzGxZS0Erg
Li, X., Naar-King, S., Barnett, D., Stanton, B., Fang, X., &
Thurston, C. (2008). A developmental psychopathology
framework of the psychosocial needs of children orphaned
by HIV. Journal of the Association of Nurses in AIDS Care,
19(2), 147–157. doi:10.1016/j.jana.2007.08.004
MacDonald, G., & O’Hara, K. (1998, March). Ten elements of
mental health, its promotion and demotion: implications for
practice. Retrieved from http://www.google.com/url?sa=t&
rct=j&q=&esrc=s&source=web&cd=1&ved=0CCQQFjAA&
url=http%3A%2F%2Fwww.hcc.uce.ac.uk%2Fwebmodules%
2Fhd resources%2Fhealth%2Ften%2520element%
2520map.doc&ei=D-eWT7yqK4jA2gXemvnbDQ&usg=
AFQjCNGCjqlB9drYTdoV5zUwtt0anaX6sA&sig2=tF2upP
VQea Q0aoiisE3A
Murray, J. (2010). Collaborative community-based care for
South African children orphaned by HIV/AIDS. Journal for
Specialists in Pediatric Nursing, 15(1), 88–92.
doi:10.1111/j.1744–6155.2009.00222.x
Nyamukapa, C., Gregson, S., Lopman, B., Saito, S., Watts, H.,
Monasch, R., & Jukes, M. (2008). HIV-associated
orphanhood and children’s psychological distress:
Theoretical framework tested with data from Zimbabwe.
200 Journal of Nursing Scholarship, 2012; 44:2, 194–201.
C 2012 Sigma Theta Tau International
Kirkpatrick et al. Orphans and Vulnerable Children in Zambia
American Journal of Public Health, 98(1), 133–141.
doi:10.2105/AJPH.2007.116038
Skolnik, R. (2008). Essentials of global health. Sudbury, MA:
Jones and Bartlett.
Somerville, S., Illsley, T., Kennedy, J., Smillie, S., & Robbie, D.
(n.d.). Tayside mental health promotion framework. Retrieved
from http://www.thpc.scot.nhs.uk/Priorities Topics/
Mental%20Wellbeing/tayside mental health promotion.htm
Tembo, S., & Banda, A. (2002). Results of the Orphans and
Vulnerable Children Head of Household Baseline Survey in four
districts in Zambia (USAID/Zambia Research Report). Retrieved
from http://www.fhi360.org/en/HIVAIDS/pub/Archive/
OVCDocuments/ovczambia.htm
United Nations Children’s Fund. (2009). Zambia: Statistics.
Retrieved from
http://www.unicef.org/infobycountry/zambia statistics.html
Varcarolis, E., & Halter, M. (2010). Foundations of psychiatric
mental health nursing: A clinical approach (6th ed.). St. Louis,
MO: Saunders Elsevier.
World Bank. (2011, February 25). Zambia at a glance
[summary data]. Retrieved from http://devdata.worldbank.
org/AAG/zmb aag.pdf
Journal of Nursing Scholarship, 2012; 44:2, 194–201. 201
C 2012 Sigma Theta Tau International
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