“The Luggage that isn’t Theirs is Too Heavy…”:Understandings of Orphan Disadvantage in Lesotho

Abstract

In Southern Africa, high adult HIV prevalence has fueled concern about the welfare of children losing parents to the epidemic. A growing body of evidence indicates that parental, particularly maternal, death is negatively associated with child outcomes. However, a better understanding of the mechanisms is needed. In addition, the way orphan disadvantage and the mechanisms giving rise to it are understood on the ground is essential for the successful translation of research into policies and programs. This study employs data from 89 in-depth interviews with caregivers and key informants in Lesotho, a setting where approximately one-quarter of adults is infected with HIV, to elaborate understandings of orphan disadvantage. Our analysis focuses on two questions: (i) Do local actors perceive orphans to be disadvantaged compared to non-orphans, and if so, in what ways; and (ii) How do they explain orphans’ differential disadvantage?

Analyses suggest that orphans were widely perceived to be disadvantaged; respondents described this disadvantage in material as well as affective domains. Thematic analyses reveal five broad categories of explanation: poverty, love and kin connection, caregiver character, perceptions of orphans, and community norms related to orphan care. These results underscore the need for research and policy to address (i) multiple types of disadvantage, including deficits in kindness and attention; and (ii) the social embeddedness of disadvantage, recognizing that poverty, kinship, and community interact with individual attributes to shape caregiving relationships and child experiences. The findings suggest limited success for programs and policies that do not address the emotional needs of children, or that focus on child or caregiver support to the exclusion of community outreach.

Introduction

In Southern Africa, high adult HIV prevalence has fueled concern about the welfare of children losing parents to the epidemic. Estimates suggest that adult HIV prevalence ranges from 13 to 26 percent across Southern Africa (UNAIDS 2010), and that between 15 and 25 percent of children under the age of 15 are orphans¹ (DHS 2011). A growing body of evidence indicates that parental death is negatively associated with child and adolescent outcomes. Studies point to orphan disadvantage in the realms of schooling, mental and physical health, and sexual risk behavior (e.g., Birdthistle et al. 2008; Case, Paxson, and Ableidinger 2004; Miller et al. 2007; Nyamukapa et al. 2008; Thomas 2009). Research also indicates differences in association by orphan type, with results from recent longitudinal studies usually suggesting a causal effect of orphanhood for maternal but not paternal orphans (Ainsworth, Beegle, and Koda 2005; Beegle, De Weerdt, and Dercon 2010; Case and Ardington 2006; Evans and Miguel 2007).²

The mechanisms underlying these observed effects are still not well understood. Results from longitudinal studies indicate that though economic resources are consequential to orphans’ differential disadvantage, a gap between maternal orphans and non-orphans persists over and above economic controls (Beegle, De Weerdt, and Dercon 2010; Case and Ardington 2006; Evans and Miguel 2007). Related scholarship also indicates that maternal orphans are less likely than paternal orphans to live with a surviving parent (Beegle et al. 2010; Case, Paxson, and Ableidinger 2004; Hosegood et al. 2007a; Thomas 2009), and that children may experience differential schooling and health outcomes based on degree of relatedness to their caregivers (Bishai et al. 2003; Case, Paxson, and Ableidinger 2004; Thomas 2009). To date, however, little in-depth work has documented the content of caregiving relationships giving rise to these differential outcomes between children, beyond the observation that in households with both biological and non-biological children, biological children may be favored (Ansell and Young 2004; Case, Paxson, and Ableidinger 2004; Nyamukapa and Gregson 2005; Thomas 2009).

Cross-sectional analyses also indicate that orphans are at greater risk than non-orphans of psychological distress (Atwine, Cantor-Graae, and Bajunirwe 2005; Makame, Ani, and Grantham-McGregor 2002; Nyamukapa et al. 2008; Nyamukapa et al. 2010), particularly when combined with poverty and stigma (Cluver and Orkin 2009). Again, however, the processes that may contribute to psychosocial dimensions of disadvantage above the original trauma of parental loss have received little attention thus far.³ Overall, a deeper understanding of the mechanisms underlying orphan disadvantage is needed.

In addition, knowledge of the way orphan disadvantage is understood on the ground is critical. Such knowledge has the potential to broaden our understandings of dimensions of vulnerability beyond that which is most easily measured in survey data (UNICEF 2010). It is also essential for successful translation of the orphan research to date into policies and programmatic interventions in support of orphans and other vulnerable children.

To expand our understanding of the processes giving rise to the differential disadvantage of orphans and to investigate how orphan disadvantage is viewed on the ground, this paper employs data from in-depth interviews in Lesotho, a country where roughly one-quarter of the adult population is HIV-infected (UNAIDS 2010). The analysis draws on conversations with 89 caregivers of children and community key informants, and asks two related questions. First, do local actors perceive orphans to be disadvantaged compared to non-orphans, and if so, in what ways? Second, how do they explain orphans’ differential disadvantage?

Rather than centering our analysis on one or two specific child outcomes, as has been done in most empirical analyses of orphan wellbeing to date, this paper focuses broadly on the concept of orphans’ differential disadvantage, abstracting understandings of the ways in which orphan disadvantage exists and operates across outcomes. Thus, this paper complements and extends the existing literature by 1) drawing on in-depth interviews to uncover processes that give rise to orphans’ differential disadvantage; 2) focusing on differential disadvantage in its different and often interrelated manifestations; and 3) examining how individuals on the ground in a setting with high orphan prevalence perceive orphans’ differential disadvantage and the mechanisms giving rise to it.

Data and Methods

Study Design and Procedures

This analysis utilizes in-depth interviews conducted in 2004 as part of the Lesotho Children’s Project, a qualitative data collection effort aimed at a better understanding of family reorganization in the context of HIV/AIDS and its implications for child wellbeing. Lesotho is one of the countries in the world most affected by HIV/AIDS, with an estimated adult prevalence of 24 percent (UNAIDS 2010). Life expectancy in Lesotho was 46 years in 2009, down from roughly 60 years in 1996 (UNICEF 2007; UNICEF 2011). In 2009, one-quarter of children between the ages of 0 and 14 in the country had lost at least one parent to death (Ministry of Health and Social Welfare and ICF Macro 2010), with two-thirds of orphans estimated to be orphaned by AIDS (UNICEF 2011).

In-depth interviews were organized around 74 children ages 0–15 who were selected purposively for variation along three axes: presence or absence of biological parents, socioeconomic status, and residence in a “town” or “rural” village. The town village was located approximately one hour from the capital city of Maseru. Its main road was partially paved, and its village center offered numerous services, including regular buses to the capital. Some respondents relied primarily on subsistence agriculture and lived in one-room dwellings, while others received substantial income from household members working in Maseru or destinations in South Africa and lived in highly-furnished multi-room houses with indoor plumbing. In contrast, the rural village was two hours from the town village by foot up a mountain. Respondents in the rural village lived in small village dwellings without electricity or running water and most worked at farming.

Semi-structured interviews were conducted with the primary caregiver of each of the selected children. These were most commonly mothers and maternal grandmothers, followed by paternal grandmothers, aunts, and fathers. In addition, those 35 children who were seven years of age or older were interviewed directly. Finally, interviews were conducted with 15 key informants. These were community members familiar with the situation of children, such as teachers, health care workers, village chiefs, and police.⁴ Due to its potential sensitivity, the topic of differential disadvantage was most extensively covered in the caregiver and key informant interviews. Though all interviews were read and coded, and thus provide a broad frame for analysis, for this paper we rely primarily on the interviews with these two groups.

One of the strengths of this data source is that respondent perspectives on the differential care of children and orphan wellbeing were elicited systematically across all of the in-depth interviews. These perspectives were obtained in multiple ways. First, all caregivers were asked about child preference generally. Conceptually, the differential treatment of orphans within households may arise from many of the same factors that would give rise to other forms of child preference; thus, caregivers were asked about the factors that lead caregivers to favor one child over another. In addition, direct questions were posed to the caregivers and key informants soliciting their views on orphan wellbeing. Finally, two hypothetical situations, or vignettes, were used in all of the caregiver interviews. In the first of these vignettes, respondents were told a story about three children whose mother died, and were asked a series of questions about their situation and the best living arrangements for them. In the second vignette, a multi-generational household with two non-orphan and three orphan children was described, and respondents were asked questions about the experiences of the children in this household.

Our analysis is based on the perspectives of those currently resident as well as those not currently resident with orphans.⁵ We wished to frame and interpret discussions of orphan disadvantage within the larger context of family organization and caregiving in this setting, and thus collected information on the experiences of children with resident biological parents, nonresident biological parents, and deceased parents. Overall, the ability to triangulate information on orphan care across question formats in interviews conducted with a diverse set of respondents provides nuanced perspectives on differential disadvantage in this context.

Data Analysis

All interviews were taped and transcribed in English by project team members fluent in both Sesotho and English. Transcripts were coded and analyzed thematically using the QSR NVIVO 7 software package. In all analyses, we attend to the circumstances of our informants, but do not use the data to summarize patterns of disadvantage by orphan status or other characteristics. We judge such comparisons more appropriate for non-purposive, larger samples. Instead, we use our detailed data to focus on perceptions about orphan wellbeing and explanations for orphan disadvantage that emerged in the interviews, interpreting each comment in context.

This analysis centers on the concept of differential disadvantage, which encompasses but is not limited to differential treatment. This conceptualization recognizes that differential disadvantage may arise for reasons that do not involve the active discrimination against or prioritization of certain children. For example, orphan households may have fewer resources compared with non-orphan households. The two terms will thus not be used interchangeably throughout the paper, but will signify different but related concepts.

Findings

Do local actors perceive orphans to be disadvantaged compared to non-orphans, and if so, in what ways?

Study respondents consistently perceived orphans to be at a disadvantage compared to their non-orphan counterparts. They described orphans’ differential disadvantage in material as well as affective terms. Material differences encompassed disparities between orphan and non-orphan households as well as differential treatment of orphans within households. With respect to the former, they spoke of the material difficulties faced by households in which a key breadwinner has died and of households already strapped for resources that have taken in orphans. Material differential treatment of orphans within households included differences in the clothing orphans wear when compared with other children in the household (“ragged,” “old,” “light”), and differences in food given (orphans were said to “often be hungry” and to “not be given proper food”). Respondents also asserted that orphans are made to do more household chores than other children in the family, and are less likely to be sent to school. The following comments based on hypothetical situations are illustrative:

“After school, [the caregivers’ biological children] will sit and rest and [the orphans] will go collect firewood.” (Maternal grandmother) ⁶

“[The children of the caregivers] will be given papa [staple food made of cornmeal] and vegetables, and [the orphans] will be given a little papa and a teaspoon of vegetables only to ensure they can say they’ve eaten.” (Mother)

Respondents also made reference to affective differential treatment of orphans within households, including being told that they do not “belong” in a family, being criticized or punished more frequently, and being exposed to a general lack of “kindness.” For example, one mother said that orphans “will always be scolded. They [caregivers] never talk to them politely. They are rude and harsh to them.” Another mother suggested that a stepmother described hypothetically would tell the orphans in her care that, “They are not her kids. She’ll keep on reminding them, you know. It’s going to be their daily bread.” A maternal grandmother elaborated and suggested that such differences can arise unintentionally: “When your child has done something wrong you don’t see it, but when it’s done by someone else you see it and the treatment provided will be unfair.”

The importance of material and affective dimensions of disadvantage is particularly salient in respondent comments. Demographic research to date, due primarily to the availability of measures in survey data, most frequently has quantified disadvantage with regard to the allocation of schooling and health care. Our interviews with caregivers and key informants suggest qualitative differences in the care that children receive, too. Such caregiving differences merit closer attention. At a minimum, differences in kindness and care could be relevant to orphans’ mental health outcomes. Indeed, a 2010 study (Kaggwa and Hindin) found that children’s reports of parent/guardian connectedness and ill treatment mediated the association between orphanhood and depressive symptoms in Uganda. Qualitative dimensions of caregiver-child relationships might well contribute to other forms of disadvantage, also, including those more frequently examined in the demographic literature, such as educational outcomes.

What do local actors perceive to be the reasons for orphans’ differential disadvantage?

Five themes emerged in the interviews as reasons for orphans’ differential material and affective disadvantage: poverty in orphan households, love and kin connection, caregiver character, perceptions of orphans, and the normative environment surrounding orphan care. Notably, these themes identify multiple, overlapping mechanisms of disadvantage. These mechanisms emphasize the relevance of individual, relationship, and household characteristics, but also highlight disadvantage as a socially embedded process shaped by factors such as poverty, kinship, and community norms regarding orphans and orphan care.

Poverty in Orphan Households

The interviews make clear that resource scarcity permeates the lives of the majority of the study respondents. However, several themes related to resource constraint did emerge in relation to orphan households in particular. First, as mentioned earlier, respondents spoke of the impact of the death of a key breadwinner or breadwinners on a household. The words of a paternal grandmother who was caring for three double orphans are illustrative:

What does a person responsible for children’s up-bringing do?

She gives them love to keep them from missing their parents… [restarts in first person, referring to her grandchildren] if their parents were alive, they could have given them all they needed…

How were the parents helping the children when they were alive?

They were helping them by providing for all their needs.

Were they working?

Their father was a mine-worker and their mother was working at [a local business].”

Though respondents more frequently mentioned the financial contributions of men, the above quotation illustrates that the role of mothers as important breadwinners was also referenced.

Second, respondents spoke of resource dilution in households that take orphans in. A common metaphor when referring to households receiving orphans was that of “luggage.” The presence of orphans was said to dilute households’ already scarce resources, increasing the already “heavy luggage” of those who take them in. For example, a religious leader said, “Orphans are left with relatives but it’s really hard since they also have their own big luggage of many children.” A mother said of a hypothetical family receiving multiple orphans, “The luggage that isn’t theirs is too heavy for them.” In response to a vignette, a paternal grandmother used the luggage metaphor to explain why relatives often do not agree to take in orphans in need, despite kinship ties:

Let’s suppose the second wife didn’t want to stay with the [orphaned] children and she expelled them. Who’ll stay with them now?

Anyone who has mercy on them.

…

What about their relatives?

It’s a problem because we fear the heavy luggage.

Third, respondents underscored the potential for extreme resource scarcity in those households in which the elderly in particular, who were often perceived as unable to work, have taken in orphans. For example, a mother said of orphan care by a grandmother, “They [the orphans] are going to wonder about the quality of their life, as their guardian is now old and is not able to look for a job.” However, respondents also noted that grandparents were sometimes helped financially with the care of orphans by other non-resident family members, such as the children’s aunts and uncles. This observation is in line with other research that has highlighted the importance of support from non-resident kin to AIDS-affected households (Hosegood et al. 2007b; Seeley et al. 2008).

Love and Kin Connection

Another common explanation was that orphans’ differential disadvantage arises because of differential “love.” Differential love was often explained by variation in kin connection. A frequent theme was the uniqueness of parental—particularly maternal—love. As a maternal grandmother explained, “Because they don’t have parents, the love and care they [orphans] would be given by other people is not going to be the same as the love that their parents would provide them.”

Given the stated uniqueness of parental love, our informants contended that if a non-parental caregiver has biological children in the house as well as more distant kin or non-kin, it is difficult to love both equally. The words of a caregiver are illustrative:

“It’s difficult for [women] to raise children who aren’t their own. Yeah, the love they provide to those children is not enough. They only look after their own children.” (Step-grandmother)

Respondents equated this differential love with differential treatment. They discussed differential love most often with regard to aunts and uncles and stepmothers, caregiver types also likely to have biological children in the house. One mother said of a stepmother depicted in the first vignette, “I believe the affection will always be for her own children…When out shopping she will always start with her own children’s needs and end with the [orphans].” Another mother said of care by an aunt, “The love she gives to her children will not be the same as the love she gives to her sister’s children…For example, she might complain about her sister’s child, even though the mistake could have been made by her own children.”(Mother)

In contrast, maternal grandmothers were often said to care for orphans “like their real mother.” This assertion is consistent with empirical analysis of the 2004 Lesotho DHS, which suggests that maternal orphans who live with a grandmother are as likely to be in school as children living with a mother (Parker and Short 2009). Notably, in Lesotho, similar to many other sub-Saharan African settings (e.g., see Beegle et al. 2010; Case, Paxson, and Ableidinger 2004; Schatz 2007), children who do not live with parents are most likely to live with grandparents (Parker et al. 2007).

Overall, the interviews make clear that respondents perceive differential treatment of children based on kin connection. They also highlight the special nature of maternal love. These reports suggest that the associations observed in survey data may well reflect differences in the affective bonds caregivers share with children. More specifically, they indicate that caregivers are inclined to give more love and attention to children that they parent or grandparent, and that this dynamic is most evident when caregivers take care of their “own” children in combination with “other” children or “orphan” children. This portrayal is consistent with that of a new study from Kenya, in which orphaned adolescent girls equated parental love with matchless levels of care, emotional support, discipline, guidance, and resource provision (Mojola 2011).

At the same time, the significant role of extended kin in the care of orphans is ultimately what made such reflections possible, and provides a larger backdrop against which to interpret their comments. Our respondents highlight how extended kin can be a source of support and coping for orphans (e.g., Skovdal et al. 2009), while simultaneously reinforcing the dangers in romanticizing the African extended family system without attention to its constraints (Abebe and Aase 2007).

Linking Poverty and Kin Connection in Orphan Households

Several respondents linked the first two explanations, poverty in orphan households and love and kin connection, by describing the decisions of non-parental caregivers to prioritize their biological children in the face of resource scarcity. They suggested that kin connection matters most when resources are scarce and caregivers need to decide to whom they should be allocated. For example, in response to a hypothetical question on orphan treatment, a paternal grandmother explained, “If life becomes tougher, I’ll only look after my own children.” Several other studies based on open-ended interview questions (Ansell and Young 2004; Foster et al. 1997) have also made the point that families may ration scarce resources to benefit biological rather than non-biological children.

The intersection between poverty, love, and kin connection also was explored through questions related to orphan inheritance. Although inheriting resources from parents upon their death is uncommon for children in this setting, these questions allowed respondents to consider a situation in which orphans might not impose resource burdens on households – and whether and how kinship connection would matter in such situations. There was some indication that inherited resources could lessen caregiver burden. A maternal grandmother said of such a situation: “There is nothing I will have to do with my own money, meaning the upbringing of the children will be easy. I will just act like an ‘eye’ to those children.” However, orphan inheritance was seen only to mitigate differential treatment in the presence of a trustworthy caregiver. Other, less trustworthy, caregivers were said to use orphans’ resources for themselves and/or their biological children. For example, a paternal aunt explained: “It depends on who is left with the money because some will spend it on their biological children and give none to the orphaned children, but others will use it for the orphaned children’s needs.” Grandparents were seen by the respondents as the most trustworthy with orphan money, despite the fact that they were often also seen as the most likely to be poor. In general, comments regarding the trustworthiness of caregivers link to numerous comments regarding the importance of caregiver character, a theme we elaborate further below.

In sum, our respondents emphasize the importance of placing kin connection in context. Differential disadvantage may be associated with kin connection, but whether and how this happens likely depends upon other factors. That the informants’ comments on kin connection and the circumstances under which it leads to orphan disadvantage link with explanations that reference poverty and caregiver character underscores the interconnectedness of the five categories of explanation from our interviews.

Caregiver Character

Respondents spoke of attributes that, beyond kinship connection and socio-economic status, refer to caregivers’ character traits. A mother insisted, “When facing a shortage of money, one may buy things for her/his child only, but it depends on a person’s character.” A step-grandmother explained, “If she has God with her, she can live with them [orphans] even if there is no money for the children.” Notably, several respondents linked generosity with spiritual or religious themes, echoing recent qualitative work in Botswana highlighting a shift in discourse with regard to orphan care from providing for orphans out of familial duty (something widely viewed to have come up short) to providing for orphans out of pure Christian goodwill (Dahl 2009b).

That differential treatment reflects poorly on caregiver character is also consistent with many respondents’ insistence that while they saw others around them treating orphans in a differential manner, they themselves would not do so, distancing themselves from the practice. Illustrative are the words of a maternal grandmother, who distinguished her family from others in her community by saying:

When children of different families stay together, like here in my family, I teach them that they are one entity so they should share everything among themselves.

So, what happens in other families?

It seldom happens. Most of them have favoritism.

Another caregiver, a 24-year-old sibling with her own biological child, commented that orphan treatment “only depends on how rude or polite the person staying with the children is, because if I were the one, I’d treat them like my own children.”

Taken together, these observations suggest that differences in personal orientation toward the care of orphans may be relevant to orphan care. At the same time, they suggest the existence of norms of shared responsibility for the care of children in need. Most significantly, these comments highlight the potential role of community expectations with regard to what is considered good character in shaping caregiving relationships.

Perceptions of Orphans: Orphan Behavior and Orphan Labeling

While the explanations for disadvantage described thus far largely emphasize caregivers and their households, respondents also referenced the characteristics of orphans themselves. A frequently recurrent theme was that orphans exhibit difficult behaviors. Orphans were, for example, sometimes described as “troublesome,” “stubborn,” and not accepting of discipline or punishment. As a mother said of her experience with an orphan, “He didn’t want to do anything. He couldn’t listen to what we were saying…I don’t know, maybe it’s because he knew that I’m not the mother. …” A teacher providing care for an orphan described her experience in these terms:

“I’m trying to give him love because when a child gets quite lonely, it’s hard for him to be…on the right track…I don’t know why he’s so troublesome…When you ask him to do things, he’ll say (shouting) why me, why me, why don’t you ask someone else. Me, no!’”

Respondents also frequently described orphans as “dissatisfied” or “ungrateful.” “Even if you are kind to an orphan,” a mother lamented, “he’ll say he’s mistreated since that’s not his mom.” A step-grandmother said, “Orphans are never satisfied. Even if you do good things for them, they won’t say thank you…”

Altogether, orphans as a group were perceived by our informants to be less obedient and respectful of caregivers, traits highly valued in children. In an open-ended question about raising children, respondents were asked why some children are loved more than others in a family. The traits said most frequently to engender caregiver love were respect and obedience. A maternal grandmother asserted, “You end up giving more love to the one who is listening to you and obeying your rules.” A mother explained, “If one misbehaves and when you talk to him he doesn’t listen, you just have to favor the other one.”

Our informants’ depictions of orphan behavior are similar to descriptions by Dahl (2009a) of perceptions of orphans in Botswana as difficult, disobedient, and self-centered. Depictions of orphans as troublesome could arise though children who are orphaned exhibit similar behavior to other children, if the stigma associated with orphan status leads others to interpret their behavior more negatively. Thurman and colleagues (2008) found in southwest Rwanda that though there was little evidence of delinquency among the orphans they studied, perceptions of orphans as unruly and engaging in socially unacceptable behaviors limited the support they received from their communities. Alternatively, it is plausible that some orphans exhibit the difficult behaviors respondents described due to distress related to parental illness, death, and family transition, or factors correlated with but not directly due to parental death. Indeed, previous research has suggested a link between orphan psychosocial distress and orphan behavior (Ansell and van Blerk 2004; Wood, Chase, and Aggleton 2006).

Whether reference to orphan behavior is a function of stigma and orphan labeling, psychological distress, other factors that differ systematically between orphans and non-orphans, or some combination, our interviews suggest the connection between orphan behavior and orphan disadvantage was widely salient. Orphan misbehavior was referenced not only in interviews with caregivers, but also in interviews with key informants, who in their professional capacities work with children. A policewoman in the town village said that orphans “break into houses so that they can go and buy alcohol” and a teacher asserted that orphans “disrespect, and they are drug abusers and even have bad weapons like knives.” Although these portrayals are particularly extreme, the pervasiveness of references to orphan behavior among those who interact with children in the community reinforces the need to support and engage community workers. Interventions targeted only at orphans or their caregivers are unlikely to address the difficulties faced by local institutions and the disadvantages that can stem from the perceptions of orphans in the community.

Normative Environment

Finally, some respondents highlighted the importance of normative expectations regarding appropriate care for children. In particular, they portrayed the pressure of community norms as a force capable of counteracting the differential treatment of orphans because of caregivers’ fears of community judgment. For example, a paternal aunt caring for an orphan suggested that a caregiving couple discussed hypothetically “might have argued when seeing that their burden is heavy and they don’t have enough money. But still they treat the orphans the same way as their biological children out of fear that the villagers will talk about their family.”

Conversely, some respondents also spoke of the stress this community pressure can put on caregivers who are struggling to provide for orphans in the face of resource scarcity. Several referred to unfair judgments by the community. For example, one lamented:

“Even when raising orphans in a good way, other people never encourage you; instead, they let you down by saying that you’re not treating them fairly. [They say things like,] ‘Just see, it’s winter and this orphan doesn’t have blankets and shoes,’ though you are struggling to find ways of buying those things for the child.” (Mother)

In general, as with their comments on caregiver character, respondents made it clear that caregiving relationships do not occur in isolation. They are embedded within community institutions and social relationships that can both support and undermine successful care. The perceived power of community pressure in influencing the caregiving behavior of families is consistent with previous literature emphasizing the importance of engaging communities in fostering a nurturing environment for orphans (e.g., Skovdal et al. 2011; Thurman et al. 2008).

Contextual Contingencies: The Relevance of Orphan Type, Living Arrangements, and Orphan Age and Sex

The five explanations for orphan disadvantage presented by local informants are broad and thematic. As a final step, we consider the intersection of these themes with variation in orphan contexts including orphan type (maternal, paternal, double), orphan living arrangements, and orphan age and sex.

With regard to distinctions by orphan type, our interviews highlight the importance of living arrangements. As cited earlier, maternal orphans are more likely than paternal orphans to have extended kin and non-kin serving as primary caregivers. Many of the explanations for orphans’ differential disadvantage given by our respondents apply most readily to orphans not under the care of a surviving parent. Our respondents also stress the uniqueness of maternal love, which could have implications for distress following maternal loss beyond the caregiving arrangements of maternal orphans. Finally, the breadwinner of the family before parental death—whether the mother, father, or both—also has potential implications for differences in disadvantage by orphan type. While respondents underscored the importance of the financial contributions of men to children’s well-being, they also made clear that the breadwinner role was played by both mothers and fathers.

The salience of living arrangements to local explanations of disadvantage connects our research to a broader literature on child fosterage in Africa. An important lesson from the fosterage literature is that the reasons children are fostered are relevant to their care (Castle 1995; Madhavan 2004). Children fostered to non-parental caregivers due to parental death may face different circumstances than children fostered for other reasons. Several recent papers have highlighted the large number of non-orphans across sub-Saharan Africa that do not live with their parents (e.g., Grant and Yeatman 2008; Hosegood et al. 2007a; Madhavan 2004; Monasch and Boerma 2004; Parker and Short 2009). Our interviews with caregivers suggest that children fostered in situations of parental migration may face less resource constraint in their foster households than children fostered in situations of parental death because of remittances from their migrant parents. Children fostered in circumstances of parental migration may also be less affected by differential treatment because absent parents may be able to monitor the treatment of their children in the foster household. Nonetheless, children in the region are fostered for reasons other than parent migration, and the extent to which they experience advantage or disadvantage likely depends in part on these reasons.

A final issue that merits mention is the extent to which differential disadvantage and the explanations associated with it differ by orphan age or sex. Differences along these lines might be expected due to a well-established literature showing sex and age as loci of differential treatment of children (e.g., Backstrand et al. 1997; Borooah 2004; Dreze and Sen 1989). In our interviews, evidence of their relevance to the differential disadvantage of orphans was limited. None of the respondents differentiated between male and female orphans when speaking of orphans and orphan disadvantage,⁷ and a few, but not many, differentiated between older and younger orphans. Those who did described younger orphans as less “troublesome” and older orphans as more able to work and more independent. Other research similarly suggests a limited role for orphan sex (Beegle, De Weerdt, and Dercon 2010; Case, Paxson, and Ableidinger 2004; Case and Ardington 2006). It does indicate increased disadvantage as orphans age (Case, Paxson, and Ableidinger 2004; Yamano and Jayne 2005), though this could reflect other phenomena including cumulative disadvantage over time.

Discussion

The body of empirical work on orphan wellbeing in sub-Saharan Africa in the wake of the AIDS epidemic suggests that parental—particularly maternal—death is negatively associated with a range of child and adolescent outcomes, in the areas of education, child health, and adolescent sexual behavior. Cross-sectional studies in settings of high HIV prevalence have also linked orphan status with increased risk of HIV infection (Birdthistle et al. 2008; Gregson et al. 2005; Operario et al. 2007), suggesting that the disadvantages faced by orphans may predispose them to contracting the illness themselves. As efforts to translate these findings into policy and intervention are mounted, it is essential to understand better the mechanisms underlying the observed patterns, and especially how those most affected on the ground understand and explain the circumstances that give rise to orphan disadvantage. This study draws on in-depth interviews to describe the differential disadvantage of orphans, and the processes giving rise to it, from the perspective of caregivers of children and community key informants in Lesotho, a setting where approximately one-quarter of adults is HIV-positive and one-quarter of children are orphans.

Overall, the study’s respondents perceived orphans to be disadvantaged compared to their non-orphan counterparts. While they described material disadvantage, a dimension of frequent investigation by demographic researchers, respondents also described affective types of disadvantage, using the language of kindness, love, and attention. Affective disadvantage has been examined far less frequently in the orphan literature to date, and our analyses suggest more attention to the qualitative dimensions of care is needed.

Respondents identified five broad categories of explanation for the material and affective disadvantage experienced by orphans: poverty, love and kin connection, caregiver character, perceptions of orphans, and community norms related to orphan care. These explanations are overlapping and span levels of analysis from the individual to the institutional. Taken together, the results highlight the need to consider the social embeddedness of disadvantage: poverty, kinship, and community interact with individual attributes to shape caregiving and child experiences.

While this paper focuses on parental death, the analysis does not address differences in orphan differential disadvantage by cause of parent death. We did not attempt to collect such information in our interviews. Nonetheless, we think it reasonable that the explanations we describe apply broadly to all orphans. It is certainly possible, however, that the intensity of effect could be different for AIDS orphans. For example, cause of parental death may have implications for the intensity of orphan labeling, orphan stigma, and psychological distress. In addition, resource constraint could be more intense for orphan households in which parental death is due to AIDS because of the long period of illness before death or the clustering of deaths, or both. However, Madhavan, Schatz, and Clark (2009) challenge the view that HIV/AIDS has a greater negative effect on household welfare than other causes of death beyond the impact of its age distribution.

In closing, we consider implications of this work for policies and programmatic interventions. One implication is that policies and programs that focus on child or caregiver support to the exclusion of community outreach may meet with limited success. The interviews indicate that normative context, including community pressure, influences the actions of community members with respect to orphan care, and orphan labeling disadvantages children. In addition, our interviews underscore a need for more programmatic attention to differential disadvantage in affective realms. The pervasiveness of comments suggesting differential love and attention and orphan labeling in our interviews suggests the importance of providing psychological support for orphans, as well as sensitization and support for orphan caregivers and others that interact with children in handling the distress associated with parental loss. The comments related to material differential treatment within households also reinforce the well-recognized importance of programs that provide direct support for the schooling and health care of orphans and other vulnerable children.

Finally, while interventions in support of orphans are suggested by this analysis, the analysis itself is driven by the high orphan prevalence in this setting. Progress since 2004 toward increasing HIV/AIDS prevention, testing, and treatment is considerable (National AIDS Commission 2010; UNAIDS/WHO 2009) and offers hope that in the coming decades the prevalence of young people who are orphans will decline in turn.