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• W2078706731 abstract "Objectives To undertake a case–control analysis of the health, nutrition and caring practices of orphans enrolled in primary schools in Ethiopia. Methods Pupils of both sexes aged 7–17 who were randomly selected from Grades 3 and 4 of primary school during a national survey of schoolchildren in Ethiopia and who were classified as an orphan were matched by age, sex and school with non-orphans. Logistic regression was used to compare children in terms of indicators of anthropometric and nutritional status, chronic infections, personal hygiene, diet, caring practices and self-reported sensory disability. Results Of the 7752 children in the national survey, 1283 (16.9%) had lost either both parents or one parent. Of these orphans, 1048 were uniquely pair matched for the case–control analysis. About 60% of orphans had lost their father, and about 20% each had lost their mother or both parents. Orphans had better anthropometric measurements and indices than non-orphans, although the differences were small, and they were less likely to have a goitre (OR = 0.68, P = 0.011). There were no differences in the odds of infections. Orphans were less likely than non-orphans to have eaten breakfast or fruit and vegetables on the previous day and were more likely to report having trouble seeing and hearing. Conclusion Orphans were slight better nourished than non-orphans, but this could have been a result of asystematic bias in underestimating the age of orphans. The indicators suggested that orphans were less well cared for than non-orphans, but the differences were small. Analyse cas-témoins de la santé et la nutrition des écoliers orphelins en Ethiopie Objectifs: Entreprendre une analyse cas-témoins de la santé, la nutrition et des pratiques de soins chez les orphelins scolarisés dans le primaire en Ethiopie. Méthodes: Les écoliers des deux sexes, âgés de 7 à 17 ans qui ont été choisis aléatoirement dans les 3e et 4e années de l’école primaire au cours d’une enquête nationale auprès des écoliers en Éthiopie et classés comme un orphelin, ont été appariés pour l’âge, le sexe et l’école avec des non-orphelins. La régression logistique a été utilisée pour comparer les enfants en termes d’indicateurs des statuts anthropométriques et nutritionnels, d’infections chroniques, d’hygiène corporelle, d’alimentation, des pratiques de soins et de déficience sensorielle auto-déclarée. Résultats: Sur les 7.752 enfants dans l’enquête nationale, 1.283 (16,9%) avaient perdu soit l’un ou les deux parents. De ces orphelins, 1048 ont été appariés de façon unique pour l’analyse cas-témoins. Environ 60% des orphelins avaient perdu leur père et environ 20% avaient perdu soit leur mère ou leurs deux parents. Les orphelins avaient de meilleures mesures et d’indices anthropométriques que les non-orphelins, bien que les différences étaient faibles, et ils étaient moins susceptibles d’avoir un goitre (OR= 0,68; P = 0,011). Il n’y avait aucune différence dans la probabilité d’infections. Les orphelins étaient moins susceptibles que les non-orphelins d’avoir pris un petit déjeuner ou des fruits et légumes le jour précédent et étaient plus susceptibles de rapporter des troubles de la vue et de l’audition. Conclusion: Les orphelins étaient légèrement mieux nourris que les non-orphelins, mais cela pourrait être le résultat d’un biais systématique dans la sous-estimation de l’âge des orphelins. Les indicateurs suggéraient que les orphelins étaient moins bien traités que les non-orphelins, mais les différences étaient minimes. Análisis caso control de la salud y el estado nutricional de niños huérfanos en Etiopía. Objetivos: Realizar un estudio caso control de la salud, el estado nutricional y los cuidados recibidos entre huérfanos que asisten a las escuelas primarias de Etiopía. Métodos: Alumnos de ambos sexos con edades entre los 7 – 17 años fueron seleccionados de forma aleatoria entre los asistentes a los grados 3 y 4 de la escuela primaria en una encuesta nacional de niños en edad escolar en Etiopía, y clasificados como huérfanos, y fueron pareados por edad, sexo y colegio con niños no-huérfanos. Se utilizó la regresión logística para comparar a los niños en términos de indicadores antropométricos y de estado nutricional, infecciones crónicas, higiene personal, dieta, cuidados y discapacidad sensorial auto-reportada. Resultados: De los 7,752 niños en la encuesta nacional, 1,283 (16.9%) habían perdido a uno o a ambos progenitores. De estos huérfanos, 1,048 fueron pareados para el análisis caso control. Aproximadamente un 60% de los huérfanos habían perdido a su padres, y alrededor del 20% habían perdido a su madre o a ambos padres. Los huérfanos tenían mejores medidas antropométricas e índices que los no-huérfanos, aunque las diferencias eran pequeñas, y tenían menos probabilidad de sufrir bocio (OR=0.68, P=0.011). No había diferencias en la probabilidad de infecciones. Los huérfanos tenían menor probabilidad que los no-huérfanos de haber tomado desayuno, o fruta y vegetales en el día anterior, y solían reportar más a menudo el tener problemas de vista u oído. Conclusión: Los huérfanos estaban mejor nutridos que los no-huérfanos, pero esto podría deberse a una parcialidad sistemática debida a la subestimación de la edad de los huérfanos. Los indicadores sugieren que los huérfanos estaban menos cuidados que los no-huérfanos, pero las diferencias eran pequeñas. The most recent data from UNICEF suggest that there are some 23 million orphans in Africa alone, many of them a result of the global epidemic of HIV/AIDS (UNICEF 2008). It seems reasonable to expect that the loss of one or both parents, the definition of an orphan used by UNAIDS/UNICEF (2002), will increase a child’s vulnerability to poverty, reduce access to health services and expose the child to a greater risk of malnutrition and ill health because the child is less well cared for than the one with both parents (Andrews et al. 2006). During a national survey of the health of schoolchildren in Ethiopia, a substantial number of children reported that they had lost one or both parents (Hall et al. 2008). This paper reports a case–control analysis of data collected during the survey to examine the hypothesis that orphans are less healthy, more malnourished and less well cared for than non-orphans. During a national survey of the health of children in primary schools in Ethiopia, a total of 7572 children were studied in 142 schools in all 11 regions (Hall et al. 2008). The number of schools selected in each region was in proportion to the square root of the total number, a method used in a recent Demographic and Health Survey (CSA/ORC 2001). This number was then adjusted so that an arbitrary minimum of six schools were selected in the five small rural regions and three urban administrations of Addis Ababa, Harare and Dire Dawa. In each school, equal numbers of boys and girls were randomly selected for study from all children in grades 3 and 4 to provide a sample of 400–1600 children in each region, depending on the size. Ethical approval for the survey was given by the Ethiopian Science and Technology Commission and by the Ethical Review Committee of Westminster University, London. Each subject was asked questions to determine with whom the child lived and whether the child’s parents were alive; a child whose father, mother or both parents were dead was classified as an orphan (UNAIDS/UNICEF 2002). The proportion of orphans was calculated in two ways: in exclusive categories in which children were counted only once, depending on whether they had lost their mother, father or both parents; or in the inclusive categories used by agencies such as UNICEF which classifies any child whose mother or father has died as a maternal or paternal orphan, respectively, and then identifies as double orphan children who are in both categories. To provide the cases and controls for the analysis described here, each orphan was matched randomly and uniquely with a non-orphan in the same school, of the same sex and year of age, if there was a suitable child. The health, nutritional status and responses to questions of the orphans were then compared with non-orphans using data collected during the survey. During the survey, the following measurements, samples and information were collected from each child (details of the methods and quality control procedures are given in Hall et al. 2008): body weight was measured to a precision of 0.1 kg and height to a precision of 0.1 cm to calculate body mass index (BMI) as weight divided by the square of height in kg/m2. The new World Health Organization (WHO) growth references were applied to the data using a programme written by the WHO for stata version 9 which calculates the z-scores of height-for-age and BMI-for-age (de Onis et al. 2007). Z-scores of weight-for-age were also calculated, but only for children <10 years as the WHO do not provide reference values of this index for older children (de Onis et al. 2007). Children with a z-score of <−2 were classified as stunted, thin or underweight, respectively. An age-for-grade score was calculated in which a child of the correct age for grade was given a score of zero, if 1 year late −1, if 2 years late −2, and so on (Partnership for Child Development 1999). The haemoglobin concentration of a finger prick blood sample was measured to a precision of 1 g/l using a Hemocue haemoglobinometer (Angelholm, Sweden). A faecal sample was collected, fixed in 10% formalin in saline and then processed by an ether sedimentation method to diagnose infections with intestinal nematode worms (Hall 1981). Each child was given a physical examination for an enlarged thyroid gland (goitre), a Bacillus Calmette-Guérin scar on the upper arm, and for mottling of the teeth because of fluorosis. The rear eight molars on both jaws were examined to see whether any were decayed, missing or filled (DMF) to give a DMF index. The upper eyelids were everted and examined for signs of trachoma (Chlamydia trachomatis), the skin on the hands, and arm was examined for signs of scabies (Sarcoptes scabei) and the hair at the back of the neck was examined for nits (the egg cases of Pediculus humanus). To assess the quality of the diet and as an indicator of caring practices, each child was interviewed and asked: have you had breakfast before coming to school today; did you bring any money to buy food at school today; and yesterday did you eat the following foods: fruit, vegetables, and meat, fish, or eggs of any kind? Each child was also asked: did you wash your face and your hands before coming to school today; do you have trouble seeing at night (nightblindness), seeing the blackboard (refractive error) and hearing the teacher (poor hearing)? Each child was also asked whether there was a radio at home and asked to estimate how long it took to walk to school. Whether the child was wearing shoes was recorded. The data were analysed using stata version 9 (StataCorp 2005). If any value was missing for either the case or the control, then the pair was dropped from the analysis of that variable. A maximum sample size of 1048 matched pairs allows an odds ratio of 1.374 to be detected as statistically significant assuming an initial prevalence of 50%, a power of 90% and a level of significance of P = 0.05. This odds ratio is equivalent to an effect size of about 8% (Chinn 2000). Differences between proportions for the sample were tested for statistical significance using the survey module in stata in which the schools were specified as clusters and the regions as strata. The differences between mean values were tested for statistical significance using paired t-tests or, if variables were not normally distributed, using Wilcoxon’s rank sum test. The differences between cases and controls were tested for statistical significance as paired data by calculating McNemar’s Chi-squared and odds ratios using the matched case–control (mcc) module. To check for interactions between age, sex, urban residence and ownership of a radio and the statistical effect of being an orphan, the mixed effects regression procedure in stata was applied using the xtmixed module for continuous outcomes and the gllamm module for binary outcomes. Differences between types of orphans were examined for 15 key indicator variables in five categories: anthropometry (stunted or thin); nutritional status (anaemic or a goitre); infection (intestinal nematode worms, nits and trachoma); personal hygiene (brushed teeth, washed face); diet and caring practices (eaten breakfast, fruit or vegetables, meat) and reported sensory disability (trouble seeing at night, seeing the blackboard and hearing the teacher). To investigate whether the type of orphan had any association with the 15 key indicator variables, logistic regression was applied to compare orphans who had lost their father (because this group provided the largest sample size) with the two other types: maternal or double orphans. To investigate whether the person caring for the orphan had any association with the 15 key indicator variables, logistic regression was applied to compare orphans living with a parent (again, because this group provided the largest sample size) with orphans living with a relative or another family. Of the 7572 children studied in the national survey, 1283 or 16.9% (95% CI 15.6, 18.3) were classified as orphans; 52.1% (95% CI 49.6, 54.7) were boys and 47.9% (95% CI 45.2, 50.4) were girls, a difference that was not statistically significant (χ2 = 3.3, P = 0.07). Of the 1283 orphans, 229 had lost their mother, 798 had lost their father and 256 had lost both parents. In the terms used by UNICEF, there were 485 maternal orphans, 1054 paternal orphans and 256 double orphans. Table 1 presents by region the number and percentage of orphans by exclusive type using two denominators: the total number of children in the survey (n1) and the number of orphans (n2). Table 1 shows that 10.5% (95% CI 9.6, 11.5) of all children had lost their father, 3.0% (95% CI 2.6, 3.4) had lost their mother and 3.4% (95% CI 2.8, 4.0) had lost both parents. About three times as many orphans had lost their father only (62.2%, 95% CI 59.5, 64.9) as had lost their mother only (17.8%, 95% CI 15.8 19.9), a highly significant difference (P < 0.001). Table 1 also shows the number and percentage of orphans who were pair matched with non-orphan controls and studied in the present analysis. Table 1 shows that there was a considerable range between regions in the proportions of orphans of different types. In the three largest, rural regions, Amhara, Oromiya and Southern Nations Nationalities and Peoples, which contain about 85% of all schoolchildren, about 14% of the total sample were orphans while the highest proportion was 34% in Addis Ababa, the capital of Ethiopia. The highest proportions of orphans who had lost their father alone were in the rural regions of Tigray (75%), Beneshangul-Gumuz and Oromiya (both 70%), and the lowest proportions in Addis Ababa (42%) and Harare (49%), both urban areas. Only 5% of orphans in Beneshangul-Gumuz had lost both parents compared with 44% in Harare and Addis Ababa. Figure 1a shows the age distribution of all orphans in the survey, which is similar to the age distribution described for the total sample of children (Hall et al. 2008), while Figure 1b shows the age distribution of the orphan cases by sex. (a) The age distribution by sex of all orphans in the survey (n = 1283). (b) The age distribution by sex of all the orphans in the case–control analysis (n = 1048); the distribution of the matched non-orphans is identical. Figure 2 presents the distribution of orphans by age and sex and shows that there was a rising proportion of orphans of all types with age so that 8.1% of children aged 7–8 had lost their father compared with 16.3% of children aged 16–17. The rise in proportion among children who had lost their father only was about twice the increase in children who has lost their mother only. The distribution of the types of orphans by age as a percentage of the total sample of children in each year of age. The two lowest and two highest age groups have been merged. For the purposes of the case–control analysis, 1048 orphans were matched with non-orphans by age, sex and school: 63.6% of these orphans had lost their father, 18.2% had lost their mother and 18.1% had lost both parents. Table 2 shows the means of variables describing the health status of orphans and non-orphans. Orphans were significantly heavier and taller than non-orphans and had a higher mean z-score of both height-for-age and BMI-for-age, although the magnitude of the differences was small. There were no significant differences between orphans and non-orphans in their BMI or haemoglobin concentration. Table 3 shows indicators of anthropometric status, micronutrient deficiencies and infections. A larger proportion of non-orphans than orphans were classed stunted or thin (both P < 0.05), and a greater proportion of non-orphans had an enlarged thyroid gland (P = 0.028). There were no significant differences in the prevalence of infections between orphans and non-orphans. Table 4 shows indicators of personal hygiene, diet, reported sensory disability and socio-economic status. Orphans had significantly lower odds than non-orphans of reporting to have washed their hands or face before coming to school; eaten breakfast before school; eaten fruit or vegetables the day before; and to have a radio at home. Orphans had significantly higher odds than non-orphans of reporting to have trouble seeing at night, seeing the blackboard and hearing the teacher. The mixed effects regression analyses of the association between being an orphan and age, sex, urban residence and the ownership of a radio did not find any more statistically significant interactions than would be expected by chance alone, so no results are shown here. Table 5 shows the prevalence of the 15 indicator variables for three types of orphans and their controls with the odds ratios for the differences in proportions. Most of the differences were not statistically significant and even when they were significant, the differences between orphans and non-orphans were small. For paternal orphans, five variables were statistically significant, while for maternal or double orphans, one variable each was statistically significant. Table 6 shows the results of a logistic regression analysis in which the 15 key indicators were compared between types of orphan, using paternal orphans as the reference category, and between place of residence of the orphans, using living with a parent as the reference category. The comparisons indicated that double orphans were the most vulnerable of the three types of orphans because the odds for three of the 15 variables were lower for double orphans than for paternal orphans. The analysis also indicated that orphans living with a relative were the most vulnerable of the three types because the odds for three of the 15 variables were lower for orphans living with a relative that for orphans living with a parent. The national survey of over 7500 schoolchildren in all 11 regions of Ethiopia found that 1283 children, or nearly 17% of the total, had lost either one parent or both parents and were classified as orphans (UNAIDS/UNICEF 2002). This number enabled 1048 pair-matched orphans and controls to be compared in one of the largest analyses of orphans of its kind in Africa. Generally, Ethiopian orphan schoolchildren seemed to have a better anthropometric status than non-orphans, although the significant differences that were observed were relatively small. Although orphans were significantly heavier and taller than non-orphans and had a higher z-score of height-for-age and BMI-for-age, there was no difference in haemoglobin concentration (Table 2). The only difference in health indicators was in the prevalence of goitre, which was slightly but significantly less common in orphans than non-orphans (Table 3). Orphans were less likely than non-orphans to report having washed their face and hands before school, were less likely to report having eaten fruit or vegetables and were more likely to report problems with vision and hearing (Table 4). These differences in proportions were not large, either in absolute or in relative terms. There were no differences in health, nutrition or anthropometric status between orphans by type except that maternal and double orphans were less likely to be thin than paternal orphans. The percentage of each exclusive type of orphan recorded in the present survey differed from the percentages that can be calculated from national data estimated by UNICEF for Ethiopia in 2006 (UNICEF 2006). In the present survey, 17.8% had lost their mother, 62.2% had lost their father and 20.0% of children had lost both parents, compared with 33.9%, 52.2% and 13.6%, respectively, estimated from UNICEF data. The same percentages calculated for data published by UNICEF for 45 African countries (UNICEF 2006) suggest that on average 33.2%, 48.6% and 18.3% of children had lost their mother, father or both parents. There are three possible explanations for these differences in proportions. First, the UNICEF figures include pre-school children, some of whom may be infected with HIV and are likely to die before they reach school age. Second, the apparent excess of children who had lost their father may be partly explained by the deaths of perhaps more than 70 000 men during a conflict with Eritrea from May 1998 to June 2000, a number that is impossible to verify. Such men are likely to have been in the age range 18–30 years and could have fathered children who were in Grades 3 and 4 in school in 2007. Third, the relatively smaller proportion of orphans who had lost their mother and the larger proportion who had lost their father might be explained by the fact that a smaller proportion of children who had lost their mother were actually enrolled in school. As the sex ratio of the overall sample of children in the national survey was balanced by the sampling procedure, the lack of a significant difference in the sex ratio among orphans suggests that female orphans are equally likely to go to school as male orphans, which is a small but encouraging sign. There was no difference between cases and controls in the mean age-for-grade score (Table 2), which reflects later enrolment and retention. Most studies comparing the anthropometric status of orphans and non-orphans either have focussed on children <5 years old or have studied relatively small samples of children who have been less well matched than in the present study. The few studies of school-age children have not found major differences in anthropometric status. An analysis of data on 9-year-old children in western Kenya found no differences (Zidron et al. 2009) while a comparison of orphans with non-orphans living in villages in Malawi also found no difference between them, although orphans living in orphanages were more malnourished (Panpanich et al. 1999). An analysis of Demographic and Health Survey (DHS) data on children <5 years old from 23 African countries found that orphans in Nigeria, Mali and Sierra Leone had a better z-score of weight-for-age than non-orphans, while in the other twenty countries, there was no significant difference between orphans and non-orphans (Rivers et al. 2008). It is possible that in the present study, the apparently better anthropometric indices of orphans, which are crucially dependent on the age of the child, occurred as a result of a systematic bias in estimating the age of orphans which affected the reliability with which they were pair matched for age. The national survey provided evidence that the age of most children was estimated rather than known when they enrol in school because the prevalence of stunting in 7-year-old children of about 2% (Hall et al. 2008) was substantially lower than the prevalence of about 50% reported for 4–5-year-old children in the previous national DHS (CSA/ORC 2006). This difference is unlikely to be rectified by a growth spurt in 2–3 years. If orphan children are sent to school systematically later than non-orphans or if their date of birth is systematically underestimated in other such surveys, the age of orphans could be underestimated to a greater degree than non-orphans and they would appear to be similarly nourished or perhaps better nourished in terms of weight- or height-for-age. The lack of difference in the haemoglobin concentration (although it was almost significantly lower in orphans, Table 2) may also be explained by this bias because the haemoglobin concentration tends to increase with age, especially among Ethiopian boys (Hall et al. 2008). So, if older orphan boys were matched with younger non-orphan controls, it could serve to even out any differences between the two groups for variables that are associated with age or, if there were no differences by age, it could make the orphans appear to be better nourished. There was evidence that the orphans were slightly less well cared for than non-orphans and were more likely to report having problems seeing or hearing (Table 4), but the differences in proportions were not large. The major drawback of this survey was that it did not include non-enrolled orphans and non-orphans. A UNICEF report indicates that only 26% of all double orphans in Ethiopia are enrolled in school (UNICEF 2006). An analysis of data from 40 countries indicates that orphans were 13% less likely to enrol in school than non-orphans (Monasch & Boerma 2004). It is possible that being enrolled in school is itself an indicator that such children come from better-off households, but studies comparing enrolled with non-enrolled children have not always found differences in their health status, so differences should not be assumed (Beasley et al. 2000; Fentiman et al. 2001). Differences in enrolment between orphans and non-orphans in Tanzania and Burkina Faso were better explained in a multivariate analysis by age, religion, the dependency ratio and the relationship between the child and the head of household than by orphan status (Kurzinger et al. 2008) indicating that social factors were a more important influence on enrolment than orphanhood. It will be necessary to undertake a household survey to estimate correctly the proportion of school-age children that are orphans and are not enrolled in school in Ethiopia. This survey also did not specifically focus on the needs of orphans either, and the questions asked were not specific to their circumstances. Nor did we ask how long each child had been an orphan, a factor that may affect the impact of orphanhood on health status in particular. But, this survey has estimated that about 17% of the 15.3 million schoolchildren in Ethiopia are orphans, and there are an estimated 17.5 million children of school-age in Ethiopia (Population Census Commission 2008), a difference of some 2.2 million. Community-based research specifically on enrolled and non-enrolled orphans would be very useful, particularly in the light of the Millennium Development Goal to achieve universal primary education by 2015. The survey was funded by the Ethiopian Education Donors Group, administered by the UNDP." @default.
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• W2078706731 title "Case-control analysis of the health and nutrition of orphan schoolchildren in Ethiopia" @default.
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