A Systematic Review of the Mental Health of Orphans and Vulnerable Children within the Context of HIV/AIDS in Africa International Journal of Psychiatry Corresponding author

Global information on the HIV/AIDS epidemic indicates the existence of an ever-increasing number of orphans and vulnerable children. It has been suggested that by the end of 2020 there will be more than 25 million AIDS orphans globally. However, there is a scarcity of reliable empirical data on the mental health of orphans and vulnerable children in the context of HIV/AIDS epidemic. This systematic review provides a synthesis of empirical findings related to mental Health of Orphans and Vulnerable Children within the context of HIV/AIDS in developing countries. A bibliographic database using keywords of the research area was searched on various databases, including Medline, PsychINFO and PsycARTICLES from 1980 to 2013. Twenty-eight (28) empirical quantitative studies were identified which addressed the mental health challenges of HIV AIDS orphans and vulnerable children. The studies are mainly crosssectional with few longitudinal. Standardized measures were used in all of the studies reviewed. Findings show that, in the context of HIV/AIDS, children are found to suffer anxiety, worrying and fear during parental infection and to express trauma and grief after parental death. Compared to other children, orphans were observed to be more depressed, anxious, and less optimistic and to display angry feelings and disruptive behaviours. There is an urgent need for rigorous, research into mental health, and risk and protective factors for children affected by AIDS. The review findings also highlighted the need for an evidence-based, coordinated approach, interventions to promote the mental health of these children. www.opastonline.com Volume 4 | Issue 2 | 1 of 20 Int J Psychiatry, 2019 However, there have been a growing number of studies in the past few years and there is a need to update our knowledge. Therefore, we conducted a systematic review to expand the previous reviews by examining the existing global literature on the psychological well-being of children affected by HIV/AIDS. The objective of this review is to synthesize the major findings of the impact of parental HIV/AIDS on children’s psychological well-being. The current systematic review differs from earlier works in many ways. First is that this review builds upon the published reviews by moving away from grey literature to mainly peer-reviewed research, offering a more critical analysis of research studies, placing research in the appropriate context, and exploring the limitations of data sources and measurement tools. The articles were critically reviewed, with specific attention to study design, sampling methods, research tools and study context. The papers included in the review were evaluated using adapted components of SIGN checklist provided by the Scottish Intercollegiate Guideline Network (SIGN). The SIGN checklist outlines guidelines and criteria for assessing the quality of cross-sectional designs and control studies. Describing the situation of orphans and vulnerable children, UNICEF recounted that they are struggling to cope with significant loss, poverty, hardship, poor psychological functioning, stigma and discrimination, violence, economic exploitation and are at heightened risk for their mortality [11, 12]. Lin, Zhao, Li suggested that AIDS orphans and those living with infected parents suffer elevated levels of psychological difficulties and that perceived stigma, lower SES, child labour and abuse might put them at additional risk for psychological disorders. In line with these observations, this is the first known systematic review that also critically reviewed the evidence on risks and protective factors for mental health outcomes. Method Review Strategy and Works Included A bibliographic database using keywords of the research area was searched on various databases, including Medline, PsychINFO and PsycARTICLES from 1980 to 2013. The review was limited to this period because the first case of HIV/AIDS was identified in Africa in early 1980s and research into the HIV problem has seen some decline after 2013 when many African countries have reported a significant reduction in new infection rates. See (Appendix 1) for the search terms. This yielded various published studies on mental and psychological well-being of orphans and vulnerable children. The search was automatically updated using Ovid whenever there was a new related publication until June 2014. Searches were done on Google, websites of key NGOs (UNICEF, USAID, UNESCO, Action Aid and many others as well as other opened educational websites, and African Journal Online. Theses and dissertation searches were also searched on British theses database, PhD.com, Dissertation Abstract international. Some useful reports and grey literature were retrieved from HIV/AIDS Conference websites and published books. As part of the review email requests for ongoing studies were also made to key academics who have published papers relevant to the current study. The papers retrieved were filtered to include only articles that met pre-defined criteria. Because mental health and OVC do not represent homogenous and constant constructs, the literature search was operationalized and studies were included if:  The study participants involved children between 8 -18 years  It was written in English language  Mental health outcomes included either externalizing (eg Attention Deficit Hyperactivity Disorder, conduct problems) and/or internalizing (eg depression, anxiety) problems  Mental health was measured as dependent variable  The study involved children, adolescents, orphans, AIDS orphans, children affected by AIDS, HIV/AIDS or vulnerable children.  Studies were excluded if they involve:  Children under 8 or over 18 years. This is in line with the age range (8-18 years) of the present study because of comprehension and literacy issues.  Intervention studies  Non-English language  Quality of life in general Study Selection and Data Collection Using the search strategy described above, all titles and abstracts retrieved were scanned for relevance. Duplicates articles not relevant, and articles that did not meet the inclusion criteria were removed. Fulltext-papers were obtained for studies that were selected for inclusion. Two reviewers assessed the studies to ensure that they met the inclusion criteria set out for this review. Data Analysis As the studies and papers included in this review were too diverse to allow a quantitative synthesis of the study findings, a narrative synthesis was undertaken. The papers included in the review were evaluated using adapted components of SIGN checklist provided by the Scottish Intercollegiate Guideline Network (SIGN). The SIGN checklist outlines guidelines and criteria for assessing the quality of cross-sectional designs and control studies. The checklist appraised each included paper for internal validity, sampling/ selection of participants, control group, assessment of independent variables, assessment of dependent variables, control of all possible confounders, appropriate statistical analysis, participation rates, comparability of subgroups, appropriate interpretation of research findings, source of funding and conflict of interest. Studies were assessed for selection bias, study design, confounders, blinding, data collection and withdrawals and drop-outs. Each study was rated independently by two reviewers. The quality assessments were compared and disagreements were resolved through discussion. Based on the ratings of each of the six components, each study received an overall global rating of strong, moderate or weak. Following the quality assessment stage, the inclusion of studies and extraction of key findings was finalized. Extracted data were entered into a table of study characteristics (Table 1) including the quality assessment ratings for each study. The SIGN checklist compares reliably with other established quality appraisal scales such as the National Institute for Clinical Excellence (NICE), CONSORT (Altman et al 2001) and CASP (Critical Appraisal Skills Program, 2006). Results and Discussions The Concept of Orphanhood Orphanhood is difficult to define. It is not an absolute state of development and also has cultural, legal and political dimensions [13]. Sherr et al noted that the current situation is one fraught with a lack of clarity over definitions of orphanhood within the context of HIV/AIDS. The definition of an orphan varies in the literature, with regard to age and parental loss. Generally, an orphan is defined as a child who has experienced the death of both parents. The UNAIDS defines an orphan as a child under 15 years of age who has lost a mother or both parents [14]. Most researchers used the Volume 4 | Issue 2 | 2 of 20 www.opastonline.com Int J Psychiatry 2019 UNAIDS definition. Others have increased the age to 18 years [1517]. They argued that the UNAIDS use of 15 years was statistical and methodologically linked to the availability of primary data for that age categorization (0-15 years) in most Demographic and Health Surveys. They concluded that this statistical and methodological necessity or convenience should not limit observations that children still have unmet needs beyond 15 years and the fact that most countries have 18 years as the boundary for adulthood. It is also generally accepted among researchers that loss of a father would also place children at heightened vulnerability for psychological distress. Finding in Uganda shows that paternal orphans (children who lost their fathers) are seriously affected than children who lost their mothers. Consequently, UNAIDS revised its definition, and now refer to any child age 18 and below whose mother or father had died as an orphan. Several layers and classification systems for orphans have been identified as attempts to understand their situations [18]. These include the nature of their careers, namely, extended families, foster parents, child-headed household and instit