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A COMPARATIVE ANALYSIS OF THE EFFECTS OF HOUSEHOLD ECONOMIC STRENGHTHENING ON WELL BEING OF ORPHANS AND

VULNERABLE CHILDREN IN MIGORI COUNTY, KENYA

HESBORNE OCHIENG OCHOLLA, (B.Sc. ENVIRONMENTAL HEALTH) P57/PT/13540/2009

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

REQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTERS IN PUBLIC HEALTH, MPH (MONITORING AND EVALUATION TRACK), IN THE SCHOOL OF PUBLIC HEALTH OF KENYATTA

UNIVERSITY.

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DECLARATION

This thesis is my original work and has not been presented for a degree in any other University

Signature ………Date ……… Name: Hesborne Ochieng Ocholla (P57/PT/13540/2009)

Department of Community Health

Supervisors:

This thesis has been submitted for review with our approval as University Supervisors

Signature.………Date ……….

Dr. John Paul Oyore

Department of Community Health

Signature………Date ……….… Dr. Joachim Osur

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DEDICATION

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ACKNOWLEDGEMENT

Special thanks to my supervisors, Dr. Paul Oyore and Dr. Joachim Osur for expert guidance through the difficult first steps of this project as my initial thesis and the thesis completion. The Kenyatta University Research Committee who reviewed my proposal and allowed me to conduct the study and the team of Research Assistants whom I relied on for the tedious exercise of data collection.

Special thanks to Prof Anastasia Gage, from Tulane University, and Kenyatta University support staff facilitated appointments with busy lecturers. The support of administrators and communities who participated, I am so grateful that they were willing to share so that we all could learn from them. Thanks to the pilot participants who were willing to share their time and insights to improve the study from Suba Central Sub County and the study Group From Migori West and East Sub Counties without who the findings this study would not have been a reality.

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TABLE OF CONTENTS

DECLARATION... ii

DEDICATION... iii

ACKNOWLEDGEMENT ... iv

TABLE OF CONTENTS ... v

LIST OF TABLES ... xi

LIST OF FIGURES ... xiii

ABBREVIATIONS AND ACRONYMS ... xiv

ABSTRACT ... 1

CHAPTER ONE : INTRODUCTION ... 2

1.1 Background of the study ... 2

1.2 Statement of the problem ... 5

1.2.1 OVC Health ... 6

1.2.2 OVC Nutrition ... 7

1.2.3 OVC Protection ... 7

1.3 Justification of the study ... 8

1.4 Research Questions ... 9

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1.5.1 The null hypotheses of the study ... 10

1.6 Objectives... 10

1.6.1 Broad Objective ... 10

1.6.2 Specific Objectives ... 10

1..7 Significance and anticipated Output ... 11

1.8 Assumptions of the study ... 12

1.9 Delimitation and limitation of the study ... 12

CHAPTER TWO: LITERATURE REVIEW ... 14

2.1 OVC Situation ... 14

2.2 Economic Strengthening Models and Effects on child health, nutrition and protection ... 15

2.2.1 Gaps of evidence of ES effects on child well-being ... 15

2.2.2 Effects by Cash Transfers schemes ... 19

2.2.3 Effects by Microfinance schemes ... 23

2.2.4 Effects by Savings and lending Schemes ... 24

2.3 The Migori HES approach to improving OVC well-being... 25

CHAPTER THREE: MATERIALS AND METHODS ... 27

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3.2 Research Design ... 27

3.2.1 Study Design Limitations... 28

3.3 Research Variables ... 28

3.3.1 Independent Variables... 28

3.3.2 Dependent Variable ... 28

3.4 Location of the Study ... 29

3.5 Study Population ... 30

3.6 Sampling Techniques and Sample Size ... 31

3.7 Inclusion and exclusion criteria ... 33

3.7.1 Inclusion Criteria ... 33

3.7.2 Exclusion Criteria ... 33

3.8 Pilot Study ... 34

3.8.1 Description of sharpening of the data collection instruments ... 34

3.8.2 Validity ... 34

3.8.3 Reliability ... 34

3.9 Recruitment of Research Assistants ... 35

3.10 Data Collection Techniques... 35

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3.12 Data analysis and presentation ... 39

CHAPTER FOUR: RESULTS ... 40

4.1 Socio-Demographic Results ... 40

4.1.1 Association of caregiver education to OVC health ... 44

4.1.2 Association of caregiver education to OVC nutrition ... 45

4.1.3 Association of caregiver education to OVC protection from abuse and neglect ... 46

4.1.4 Association of HES intervention to OVC health ... 47

4.1.5 Association of HES intervention to OVC MUAC and Immunization. ... 47

4.1.6 Association of HES intervention to OVC protection from abuse and neglect ... 48

4.2 Socio – Economic Results ... 48

4.2.1 Income generating activities (IGA) ... 48

4.3 Objective 1: Effects of Migori HES Intervention on OVC Health ... 53

4.3.1 Cases of Malaria among OVC ... 53

4.3.2 Cases of Pneumonia among OVC ... 54

4.3.3 Cases of Diarrhoea among OVC ... 56

4.3.4 Cases of Complete Immunisation of OVC ... 57

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4.4.1 Mid Upper Arm circumference (MUAC) readings of OVC ... 60

4.4.2 Wasting: Weight for Height (WHZ) of OVC ... 62

4.4.3 Stunting: Height for Age (HAZ) of OVC ... 64

4.4.4 Underweight: Weight for Age (WAZ) of OVC ... 66

4.5 Objective 3: Effects of Migori HES Intervention on protection of OVC ... 68

4.5.1 Physical abuse of OVC ... 69

4.5.2 Neglect of OVC ... 70

CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS...71

5.1 Discussion ... 71

5.1.1 Effects of Migori HES Intervention on Health of OVC ... 71

5.1.2 Effects of Migori HES Intervention on Nutrition of OVC ... 73

5.1.3 Effects of Migori HES Intervention on the protection of OVCs... 75

5.2 Conclusion ... 77

5.2.1 Effects on Migori HES Intervention on Health of OVC ... 77

5.2.2 Effects of Migori HES Intervention on Nutrition of OVC ... 78

5.2.3 Effects of Migori HES Intervention on Protection of OVC ... 79

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5.4 Further Research ... 81

REFERENCES ... 82

APPENDICES ... 86

Appendix 1: Migori County Map ... 86

Appendix 2: Consent Letter and Confidentiality ... 87

Appendix 3: Household Interview Questionnaire ... 90

Appendix 4: Check list 1 - Child Abuse and Neglect Risk Factor checklist ... 101

Appendix 5: Check list 2 – Signs and physical Abuse and Neglect ... 103

Appendix 6: KU Graduate School Research Authorization ... 104

Appendix 7: KU ERC Ethical Clearance ... 105

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LIST OF TABLES

Table 4.1: Socio-demographic data ... 44

Table 4.2: Association of caregiver education to OVC health ... 45

Table 4.3: Association of caregiver education to OVC nutrition ... 46

Table 4.4: Association of Education to OVC protection from abuse and neglect ... 46

Table 4.5: Association of intervention to OVC health outcomes ... 47

Table 4.6: Association of intervention to OVC MUAC and complete immunization ... 47

Table 4.7: Association of intervention to OVC protection from abuse and neglect ... 48

Table 4.8: HH monthly median Income by type of Income Generating Activity (IGA) .. 49

Table 4.9: Association of IGA type to OVC Nutrition ... 50

Table 4.10: Association of HH income to OVC Health ... 51

Table 4.11: Association of HH Income to OVC Nutrition ... 52

Table 4.12: Association of HH income to OVC protection from abuse and neglect... 52

Table 4.13: Cases of Malaria between intervention and non-intervention ... 54

Table 4.14: Cases of Pneumonia among OVC ... 55

Table 4.15: Cases of Diarrhea among OVC ... 56

Table 4.16: Cases of complete Immunization among OVC ... 57

Table 4.17: Classification of Malnutrition prevalence and Interpretation by WHO ... 58

Table 4.18: Distribution of children by age groups and their sexes ... 59

Table 4.19: OVC MUAC variation according to the WHO classification ... 60

Table 4.20: t – test for Mid Upper Arm Circumference (MUAC) readings ... 61

Table 4.21: t – test for weight for height; wasting (WHZ) ... 63

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Table 4.23: Nutritional status of OVC by WHO reference standards (2005) ... 67

Table 4.24: t-test for means of weights for age; underweight among OVC ... 68

Table 4.25: chi-square test for cases of abuse among OVC ... 69

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LIST OF FIGURES

Figure 1.1: Household Economic Strengthening Conceptual Framework. ... 13

Figure 4.2: Distribution of Caregiver age ... 41

Figure 4.3: Distribution of Caregiver education Status ... 42

Figure 4.4: Distribution of Orphans and Vulnerable Children (OVC) by sex ... 42

Figure 4.5: Distribution of OVC age ... 43

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ABBREVIATIONS AND ACRONYMS

ANOVA: Analysis of Variance ART: Anti-Retroviral Therapy CRS: Catholic Relief Services CHW: Community Health Worker

HAZ: Height for Age Nutritional Measurement (stunting)

HIV/AIDS: Human Immune Deficiency Virus/Acquired Immune-Deficiency Syndrome

HES: Household Economic Strengthening HH/hh: Household

IGA: Income Generating Activity KNASP: Kenya National Strategic Plan KAIS: Kenya AIDS Indicator Survey KNH: Kinder Not Hilfe

MOGCSD: Ministry of Gender, Children and Social Development MUAC: Mid Upper Arm Circumference

OGAC: Office for Global AIDS Coordination OVC: Orphan and Vulnerable Children

PEPFAR: Presidential Emergency Plan for AIDS Relief PLWHA: Person Living with HIV/AIDS

SD: Standard Deviation

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SILC: Savings and Internal Lending Committee

USAID: United States Agency for International Development UNAIDS: United Nations AIDS Program

UNICEF: United Nations Children Education Fund

WAZ: Weight for Age nutritional measurement (Underweight) WHZ: Wight for Height (Wasting)

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ABSTRACT

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CHAPTER ONE : INTRODUCTION

1.1 Background of the study

An orphan is defined as any child who has lost one or both parents and is under the age of 18 years. Orphans belong to the groups known as "orphans and vulnerable children," or OVC. According to Brigitte (2007) OVC is defined as children that have one or more of the following characteristics: have parents or caregivers who are ill or dying; do not have parents; do not have family; do not have a home; are traumatized; live in an area with high HIV prevalence or proximity to high-risk behaviors; live on the street; are in jail or prison; are exploited or abused; are discriminated against or are at risk of social exclusion.

UNAIDS (2004) estimates that AIDS has orphaned more than 11 million children in the developing world, and each year another 1.6 million children become orphans. UNICEF (2007), estimates that 1 in 3 of these children is 5 years old or younger. There are approximately 15 million children in Kenya, out of which about 1,700,000 are orphans, a third of who are under five years old, (Children on the Brink, 2010). Addressing the needs of OVC and mitigating negative outcomes of the growing OVC population worldwide is a high priority for national governments and international stakeholders that recognize this as an issue with social, economic, and human rights dimensions (UNICEF, 2007).

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levels, is one of the main contributors to OVC incidence in Kenya. The Government of Kenya has responded by putting in place the National Plan of Action on OVC (2007) which helps to strengthen the capacity of families to protect and care for OVC, provide economic, psychosocial and other forms of social support, as well as mobilize and support community based responses to increase OVC access to essential services such as food and nutrition, education, health care, housing, water and sanitation. Kenya AIDS Indicators Survey (KAIS) 2007 reported that 21.4 percent of OVC lived in households that received at least one type of free external support to help care for the children, while the majority of OVC and their households (78.6 percent) had never received any kind of support. In addition, the department of Children Services, within the Ministry of Gender, Children and Social Development, in collaboration with the National Steering Committee on OVC developed the OVC Policy, a key aspect of which is the provision of a direct predicTable and regular monthly cash subsidy to households caring for OVC (UNICEF, 2007).

According to Irwin (2007), when children lose parents, they are at risk of losing the vital support needed for their development. Left without a mother, and often without both parents, children may become dependent on extended family members or the wider community which may not provide them the support equivalent to the support they would get from the biological parents.

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services including education and healthcare. Their willingness to accept additional children into their family is typically determined by their ability to feed and clothe them, and to provide them with care and shelter, even while they struggle to care for their own offspring. Preliminary evidence from elsewhere in the region suggests that providing small cash grants to families prepared to take in children might dramatically reduce the number of children living in 'child-headed households', through encouraging relatives or other community members to take responsibility in providing care. Such care is crucial to avoiding OVCs falling into a vicious cycle, whereby they have no choice but to live and work on the streets or engage in risky behavior in order to survive (UNICEF, 2007)

There is widespread recognition of the urgency to address problems of orphans and vulnerable children (OVC) within the context of HIV/AIDS epidemic, especially in sub-Saharan Africa (Hunter & Williamson, 2010). Many countries in the region, including Kenya, in collaboration with development agencies and non-governmental organizations (NGOs) have outlined policy guidelines and identified models of interventions. Models for OVC response stress the central role of mobilizing community based interventions to keep affected children within the extended family. Keeping children within the family framework requires economic strengthening of these households in order to be able to cope with the burden of care for OVC.

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entail economic strengthening as an important component (strengthening family capacities, strengthening community capacities, and ensuring children’s access to

essential services).

Household Economic Strengthening (HES) implies strengthening the capacity of caregivers and communities to address the financial issues to ensure vulnerable children are able to access essential services, including safety, healthcare, nutrition, education, and other basic needs (UNICEF, 2012). The Migori HES models appear promising and sustainable and includes; a) self-managed savings and lending groups which apply techniques to safeguard funds, b) micro-leasing which involves providing loans to enable women to lease income-generating assets, c) provision of training to facilitate those engaged in production and service activities to identify and establish links with potential buyers, and d) approaches to nutritional gardens and simple will-writing to protect the assets of widows and orphans also appear promising for scaling up.

1.2 Statement of the problem

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risks involved (Hashemi & de Montesquiou, 2011). Livelihood and economic strategies need to be implemented at a community level and target those in most financial need, (Sebstad and Cohen, 2010).

To date, OVCs have been primarily absorbed into the extended family system, but this social safety mechanism is now under threat due to the twin menaces of economic stagnation and the HIV/AIDS epidemic. Household economic strengthening programs have been developed to improve the caregiving capacity of families caring for OVC. However, it is not known whether the well-being of OVC has improved following these initiatives. Little research has been conducted to evaluate the impacts of economic strengthening programs on households and key target groups affected by HIV/AIDS (Anderson, 2012, Maluccio, 2010). According to Thurman (2009), the impacts on child well-being of OVC programs, both immediate and sustained impacts over time, remains poorly understood.

1.2.1 OVC Health

It is not known whether Household Economic Strengthening (HES) interventions improve the health status of orphans and vulnerable children. The Migori Household Economic Strengthening Program has not been evaluated to show its outcomes on OVC well-being in Migori County.

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in developing countries. HES Intervention is expected to help improve the health situation of OVC, however this is not known.

1.2.2 OVC Nutrition

Malnutrition also poses a grave risk to the health of these children. Prevalence of under-nutrition in children under-five is reported through three conventional categories; stunting, wasting and underweight. Studies report that orphans aged below 60 months are more likely to be stunted or malnourished than non-orphans (Tembo & Kakungu, 2009), but Foster (2003) reported no difference. Malnutrition that occurs during the first few years causes irreversible stunting and impaired cognitive functioning well into late childhood (Mendez and Adair 2009). HES intervention is also expected to improve the levels of malnutrition among OVC aged below five years; however this is also not known.

1.2.3 OVC Protection

UNICEF (2005) uses the term ‘child protection’ to refer to preventing and responding to

violence, exploitation and abuse against children – including commercial sexual exploitation, trafficking, child labor and harmful traditional practices, such as female genital mutilation/cutting and child marriage.

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Surveys (Berger, 2012). For example, families deemed to have low socio-economic status in the NIS-4 were five times more likely to experience child maltreatment than families of higher socioeconomic status (Sedlak et al., 2010). Extant literature has further demonstrated that child maltreatment risk is associated with various indicators of economic hardship; including welfare receipt (Martin and Lindsey, 2013) unemployment (Sidebotham et al., 2012) and single-parent family structure (Berger, 2005; and Gromoske 2009. Existing evidence compels the question of whether income plays a causal role in the etiology of child maltreatment. Prior research, however, has only been able to assess the correlation between income and maltreatment. To my knowledge, there has never been an experimental evaluation that explores the causal role of income on child maltreatment.

To address these gaps in knowledge, this study attempts show that HES interventions lowers the level child maltreatment, improves nutritional status and positively affects the health of OVC.

1.3 Justification of the study

This study provides knowledge (and evidence) of the effects of household economic strengthening in improving the health, nutrition and protection of OVC. It will also inform whether HES programs are good in improving the well-being of OVC.

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Africa. Many countries in the region including Kenya in collaboration with development partners have outlined guidelines and models for intervention. OVC programs that include substantive household economic strengthening (HES) components, aim at improving the economic capacity of households to provide for a larger share of overall needs for their families. However, as is the case with OVC programs in general, it is not known if they actually make a difference. Little information exists to document the effects or benefits achieved beyond counting of services received. It would be important in informing if these interventions could be scaled up to the entire country.

Examining the effects of an OVC support program is critical in understanding whether interventions are fulfilling the needs and improving the lives of vulnerable children. This research provides evidence that household economic strengthening improves the health, nutrition and protection of OVC aged between 6 – 60 months.

1.4 Research Questions

 What is the effect of household economic strengthening on the health status; cases of

malaria, pneumonia, diarrhea and complete immunization, of OVC aged between 6 – 60 months?

 What is the effect of household economic strengthening on the nutritional status;

MUAC, wasting, stunting and underweight, of OVC aged between 6 – 60 months?

 What is the effect of household economic strengthening on child protection form

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1.5 Hypotheses

1.5.1 The null hypotheses of the study

1. Household economic strengthening has no effect on health status; cases of malaria, pneumonia, diarrhea and complete immunization, of OVC aged between 6 – 60 months

2. Household economic strengthening has no effect on the nutrition status; MUAC, wasting, stunting and underweight, of OVC between 6 – 60 months

3. Household economic strengthening has no effect on the protection from abuse and neglect of OVC aged between 6 – 60 months

1.6 Objectives

1.6.1 Broad Objective

The main objective of the study was to compare the effects of economic strengthening on the well-being of OVC aged between 6 - 60 months, among households in the economic strengthening intervention and those not in the economic strengthening intervention in Migori County.

1.6.2 Specific Objectives

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2. To find out and compare the effect of household economic strengthening on the nutrition status; MUAC, wasting, stunting and underweight, of OVC aged between 6 – 60 months.

3. To establish and compare the effect of household economic strengthening on protection from abuse and neglect of OVC aged between 6 – 60 months.

1..7 Significance and anticipated Output

The study will highlight the effects of household economic strengthening on the quality of life and well-being of OVC aged between 6 – 60 months as far as their health, nutrition and protection is concerned. The findings will also highlight practical evidence that will contribute towards informing policy makers and program implementers to make decisions about how best to direct funding and program activities and maximize positive outcomes for children and their caregivers.

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1.8 Assumptions of the study

The study assumed that all participants gave consent to participate in the study and the information they provide to the researcher was correct

1.9 Delimitation and limitation of the study

Important limitations of the study were identified at the beginning, and the survey was designed in part in response to these limitations, i.e. a) only those households that had been in the HES program for more than three years were considered in the study population, b) households that had at a child or children orphaned as a result of HIV/AIDS (OVC) and, c) finally, only one OVC aged between 6 – 60 months, per household was randomly selected and included in the study.

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1.10 Conceptual framework

Figure 1.1: Household Economic Strengthening Conceptual Framework.

The above framework above demonstrates that the dependent variables i.e. child health, nutrition and protection status are dependent on the economic strengthening intervention (independent variable). As such an intervention that improves household income would be expected to positively change child’s health, nutrition and protection status.

Change / No change in OVC Wellbeing:

 Health status

(incidences of Malaria, Diarrhea, Pneumonia, & Immunization)

 Nutrition status

 Protection status

 IGA

 Income

 Education

 Nutrition

 Protection

HH Economic Strengthening

 Business skills educ

 Business loans & IGAs

 IGA start up

 Child health educ on

IMCI, Immunization etc

 Child nutrition educ

 Child Protection educ

 HH income

 Child health

(incidences of malaria, diarrhea and pneumonia)

 Child Nutrition

status

 Child

Protection Status No HH Economic

Strengthening Independent

variables

Intervening Variables Dependent

Variables

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CHAPTER TWO: LITERATURE REVIEW

2.1 OVC Situation

Globally, AIDS has orphaned over 11 million children in developing countries. Annually, a further 1.6 million become orphans (UNAIDS, 2007). One in three of these are aged 5 years or younger, (UNICEF, 2007). Nutritional, health and psycho-social challenges threaten AIDS-affected children aged under 5 years, of whom majority live in Africa.

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2.2 Economic Strengthening Models and Effects on child health, nutrition and protection

2.2.1 Gaps of evidence of ES effects on child well-being

Economic strengthening (ES) approaches (microcredit, cash transfers, skills training, etc.) are aimed at achieving a wide variety of socio-economic goals, which may or may not explicitly include goals for children’s well – being; health, nutrition and protection. Programs are implemented by a variety of actors from various sectors such as early recovery, child protection, health, nutrition, gender-based violence, etc., on the assumption that greater household wealth can lead to better outcomes in their category of focus (HIV, psychosocial, etc.).

Engaging children or their households in economic programs can have positive effects. In programs engaging caregivers, even when they are deemed effective at the level of the household, they may be ineffective in reaching the youngest in the house, and can even put children at greater risk of exploitation or harm (Labour at al., 2000).

Due to the broad range of approaches, the methodological difficulties and cost implications, the impact of economic interventions on children’s welfare is not often

assessed. Evaluation and research often focus on first-order effects like changes in knowledge, attitudes and practices, which are as indicated inn as preconditions for achievement of second-order like improved nutritional status or greater educational attainment. Rigorous research on the impacts on children’s welfare from economic

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Outside the context of an economic intervention, basic research from various disciplines has found that owning assets leads to increased wealth and better options for the future, political participation, educational attainment, diet, and health (Chowa & Gina, 2007). Multiple studies have also found that well-being is improved among children when their caregivers own assets, as reflected in lower rates of child mortality. Increased income in the household has been found to be a main determinant of how much children work or go to school (Göteborg University, 2007).

There also appears to be a positive association between exposure to economic strengthening interventions and child well-being. That is, intervening to grow people’s income and assets can often have positive effects on their children, in various categories of indicators. For example, findings from a multi-country qualitative survey of beneficiaries of an integrated education and savings program said the program made the difference between being able to afford medicines or not, being able to send a child to school, and the number of meals in a day, and having sufficient savings to gird against future economic shocks (Jarrell & Lynne, et al., 2011)

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Two major multi-country impact studies of microfinance programs found that the resulting new spending generally benefits children. Significant numbers of beneficiaries in the Freedom from Hunger study reported that they use their increased income to pay for children’s education or to purchase more food (Jarrell, Lynne et al., 2011). In the

Canadian International Development Agency (CIDA) cross-sectional study, education was the first priority for spending, followed by health care (CIDA, 2007).

Child-specific information is less available than household level information, especially in developing countries, 84 and affordable methodologies that unpack the impact of economic programs on individual household members have yet to be developed (USAID, 2008).

No common approach to indicators for children’s outcomes emerges from the impact literature on ES approaches. Child health and education (attendance, enrolment, etc.), followed by nutrition (meals consumed, variety, etc.), child labour and early marriage are the most popular, but other indicators associated with child protection, such as exposure to violence and abuse, are not found (USAID, 2008).

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Recent literature review of household economic strengthening programs identified 3 complementary and/or competing approaches (PEPFAR, 2011)

1. Household Economic Strengthening: Project interventions that target the family as the beneficiary and are led by projects or NGO's that do not prioritize long-term sustainability and aim for sustainable impact on shorter-term outcomes (how families get and spend money). Examples of these interventions include: savings, credit, income-generating activities (IGAs) and jobs.

Household economic strengthening programs should consider a family's level of readiness and capacity to succeed when determining whether a particular economic strengthening activity is appropriate.

2. Social Protection: Systemic interventions targeting the family as beneficiary, led by governments that prioritize sustainable interventions and aim for a sustainable impact on longer-term outcomes such as behavior change or human capital outcomes. Examples include cash transfers and access to services.

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Economic strengthening activities generate money that helps families care for their children by increasing food security, access to school and access to essential health services. Household Economic Strengthening (HES) implies building capacity of caregivers and communities to generate finances to ensure vulnerable children are able to access essential services, including safety, healthcare, Nutrition, education, and other basic needs (UNICEF, 2004). There are various models of household economic strengthening. The most noTable ones include cash transfer, microfinance, savings and lending schemes, and skills transfer /training, just to mention a few.

2.2.2 Effects by Cash Transfers schemes

According to Barns (2005), one model of economic strengthening involve Direct transfers of assets—most often cash—to identified low-income families to support costs related to the care of vulnerable children. Such transfers can be either conditional or unconditional, depending on whether recipients are required to engage in specific behaviors as a condition for access.

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Africa, the magnitude of their impact in other regions strongly points to their potential for HIV/AIDS programs on the continent. Cash transfers have been found to be quite effective in improving the wellbeing of HIV/AIDS affected households. Even small grants can have dramatic impacts on the nutritional status, cognitive growth, and development of young children. Cash transfer programs have demonstrated a reduction in severity of destitution as measured by improvements in food consumption, a reduction in child labor and small increases in health expenditures (Schubert, 2007).

The Mchinji Pilot Social Cash Transfer scheme in Malawi is an example of a cash transfer effort that has been designed to reach HIV/AIDS-affected families within a broader mandate of reaching the most vulnerable. Preliminary baseline data indicate that 70% of the households are HIV/AIDS affected and care for OVC or the chronically ill, or have had an AIDS-related death in the household (Schubert, 2007).

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Health effects included decline in reported Incidences of illness by 7.9% per month among adults and 10.9% per month among children. Children’s health status reported to be better among intervention groups as opposed to non-intervention group. Caregivers reported children in excellent health 34.6% of time in intervention vs. non-intervention s 20.8%. Good health reported among 54.6% of intervention group as opposed to Non-Intervention s (48.3%). Households also reported greater demand for health care and higher health care expenditures.

The Mchinji Cash Transfer scheme in Malawi also produced a 10%t reduction in child labor outside the home, which may contribute to improved child wellbeing, and also signal reduced destitution (Shubert, 2007 and Miller, 2008).

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Carbohydrate, protein, fat, protein and vitamin consumption increased. Health Status: Illness incidence decreased, especially for the aged (65+). Partial blindness reduced by more than half, and may be due to affordability of transport to eye clinics. Cash used primarily to buy food (42%), invest in small livestock/income-generation activities (29%), access health services (including transport to health facilities) and on school uniforms, books, pens, fees and soap, debt repayment.

Cash transfers have the strongest impact on the poorest households with nutrition being the first component of well-being to improve. Among the poorest households, which may spend up to 80% of their income on food, improved nutritional status is one of the first outcomes to respond to cash transfers. Number of meals consumed, and self-reported levels of satiation at meal time increased dramatically, with young children exhibiting some of the strongest, immediate effects (Adato & Bassett, 2007).

Cash transfer programs that target ultra-poor and labor-constrained households often result in better wellbeing for children living in those households. (Schubert, 2007). Anecdotal evidence from the cash transfer programs in Zambia and Malawi show that elderly men and women, and even headed households spend assets wisely on child-oriented health, nutrition, and educational expenditures (Schubert, 2007, Barrientos and DeJong, 2004). The slogan of the Kalomo cash transfer scheme (Zambia), “The poor are not irresponsible,” challenges the belief that the poor households will not optimally use resources to benefit the household’s and children’s wellbeing. This is a departure from

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required households to allocate resources for children’s health and education, to ensure

that assets were spent on children’s wellbeing, which also relates with the Kenyan situation.

2.2.3 Effects by Microfinance schemes

Among the economic strengthening programs reviewed, microfinance has the most established correlative link with HIV/AIDS mitigation behaviors and attitudes, (Kim et al, 2008). Integrated health and microfinance programs have led to some positive behavior change outcomes and reduction of risk factors associated with HIV/AIDS (Pronk, 2006). These initiatives have also led to improved food consumption and increased utilization of healthcare services especially among orphans and vulnerable children (Bronson, 2008).

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An evaluation of Project HOPE, a large scale microfinance program for small business activities in Namibia and Northern Mozambique targeting OVC caregivers, revealed improved economic status and quality of life for families caring for 45,000 OVCs in Namibia and Mozambique. In Namibia, caregivers reported improvements in 12 of 14 indicators of economic status and achieved 50% growth in income. Based on self-reported data collected in northern Namibia among 86 children and 146 caregivers (at baseline and a one year follow-up), caregivers as indicated inking needed medical care increased from 40% to 49%. Impacts on OVCs were even greater with those reporting using hospital services the last three times as needed, increasing from 39% to 94%, and full immunization (96% to 99%). Reports of eating 4 meals in past 2 days increased 24%-58%. OVC specific nutritional indicators: Reports of 4 meals in last 2 days increased (55%-87%), 6 meals in last 2 days children under 5 years increased (49% - 77%) (Bronson, 2008).

2.2.4 Effects by Savings and lending Schemes

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2.3 The Migori HES approach to improving OVC well-being

Migori Household Economic Strengthening (HES) Program is an innovative microfinance and empowerment program through which OVC caregivers generate savings, gain access to business skills training and loans for small businesses. Through the Migori HES Program, poor OVC households in rural areas with few financial services, form savings and loaning groups, or “village banks,” of 15-30 members. They meet on a weekly basis to deposit savings, borrow loans, are trained on business management, and book keeping skills, and also participate in “mobile workshops” on issues ranging from HIV/AIDS to family health. As their collective savings grows members take out loans to support income-generating activities, while others in the group gain by earning interest on these loans. After one year of training, groups are self-sustaining. The defining features of the program are its sustainability and its ability to holistically empower households as wealth generators, caregivers, decision-makers and agents of change in their homes and communities.

In comparison to traditional microfinance programs, the Migori HES Program intervention specializes in serving “hard-to-reach” caregivers and children in rural areas often left out by other programs or services. Since the trained caregivers / members use their own collective savings to make loans, they do not need outside support to sustain them; making the program sustainable in the poorest areas that need it the most.

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begins with business and book keeping skills training, and then builds on this foundation to expand caregiver’s knowledge and capabilities in other critical areas, such as parenting

skills, hygiene and nutrition, HIV/AIDS prevention and community leadership. The Migori HES Program becomes an “empowering space” where Caregivers gather together

to save, to learn and to support each other. The strength of this approach is that this “space” can be used to address any number of issues in the lives of Caregivers. For this project the focus was on HIV/AIDS and women’s role as OVC caregivers, but other

issues can also be incorporated into the mobile workshop curriculums depending on the goals of a project.

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CHAPTER THREE: MATERIALS AND METHODS

3.1 Introduction

This chapter presents the materials and methods used in assessing the effects of Household Economic Strengthening Program on the wellbeing of OVC in Migori County. It gives the overall research process including the design, sampling procedure, the research tools and how the data collection, management, analysis and presentation of findings

3.2 Research Design

The study design was a comparative cross sectional study that compared households in the economic strengthening (ES) intervention to those households not in the ES intervention, in the rural areas of Migori County (Suba East and Suba West sub counties). The intervention comprised households exposed to HES interventions at the time of the study while non-intervention comprised households in similar areas but did not get access to HES interventions, but were later expected to receive services in future phases of the HES Intervention. All participants comprised households taking care of OVC aged between 6 – 60 months, and interventions households had been in the HES intervention for at least three years.

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micro-business and book keeping skills. IGAs aimed at improving the household income.

3.2.1 Study Design Limitations

The study was limited to measuring effects on OVC a) Health; malaria, diarrhea, pneumonia and immunization), b) Nutrition; wasting (MUAC), underweight (WAZ) and stunting (HAZ), Wasting (WHZ) and c) Child protection from abuse and neglect. Participants were randomly selected from the intervention and non-intervention households; therefore minimizing the risk of selection bias. Mean of differences on the effects of being in the intervention and non-intervention groups were analyzed.

3.3 Research Variables

3.3.1 Independent Variables

Independent variable in this study was household involvement in the economic strengthening intervention. This was measured on whether the household was a beneficiary of the Migori HES intervention or not, but had been earmarked for involvement in the subsequent phase of the intervention. Involvement was collected by a score of one, whereas zero to non-involvement.

3.3.2 Dependent Variable

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Circumference (MUAC), weight for age (WAZ), Weight for Height (WHZ)and height for age (HAZ) and c) Protection from abuse and neglect

These depend variables resulted from effects of caregivers socio-demographic and economic factors such household IGA type, income, caregiver knowledge on business management and book keeping, caregiver awareness of the importance of complete immunization, and good child nutrition, and caregiver awareness of child protection issues due to support received from the intervention. Intervention respondents were asked on what type of business they were engaged in after taking loans, and also whether they had been trained on business and book keeping skills at the initiation of the IGA, as well as average income per month from the IGA, and how they utilized this income to attend to OVC health care, nutrition and protection from abuse and neglect.

3.4 Location of the Study

The study took place in Migori County which is located in Nyanza Province, and covers an area of 21505 sq Km. It borders Homa Bay and Kisii Central Counties to the north; Gucha and mara Counties to the east; and to the south it borders Kuria, Trans-mara, and Republic of Tanzania to the west. It touches Lake Victoria and Suba district on its Western boundaries. It lies between 0º 40’ and 0º South and longitude 34º and 34º 50¹

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The population of Migori stands at 514,897 (1999 Population and Housing Census) and an inter-censal growth rate of 3.1 percent. Population is expected to rise to 656,525 by 2010. The high population growth rate puts a lot of pressure on land and provision of services. The average household size in Migori is 4.5 compared to the national average of 4.3. The dependency ratio in the District is 100:98 that is for every 100 persons in the labour force there are 98 dependents. The district has a life expectancy of 50 years for women, 48 for males, a total fertility rate (TFR) of 7.1 children per woman and infant mortality rate (IMR) of 137/1000 live births, and under 5 Mortality Rate 213/1000 live births. Crude Birth Rate (CBR) stands at 42 per 1000, while Crude Death Rate (CDR) at 17 per 1000, and HIV prevalence rate of 30%. The district’s administrative areas and corresponding population density pattern is shown in Map 1 (Appendix 3).

3.5 Study Population

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for study comprised 200 households in the intervention group and 200 households in the non-intervention group (total 400 households).

3.6 Sampling Techniques and Sample Size

3.6.1 Sampling techniques

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3.6.2 Sample Size

Fischer et al method of 1999 was used to calculate the sample size. Three values are necessary to determine the required sample size (n):

 Margin of error (e) on the estimate, as specified by the investigator or decision maker  Confidence level (1-level of significance)

 Proportion (or percentage) of the sample that have (or expected to develop) the

condition of interest.

Where in the case of this study:-

Z is the Z value for the corresponding confidence level (e.g., 1.96 for 95% confidence for this study); e is the margin of error (e.g., 0.05 = ± 5% for this study) and p is the estimated value for the proportion of a sample that have the condition of interest/selection criteria (e.g., .50 for 50%). Theoretically this is based on the assumption that the test that estimates this proportion is perfectly sensitive and specific, but the calculation can also assume the proportion estimated is the apparent (test-based) prevalence.

Thus the sample size would be:

n = (1.96)2 x 0.5(1- 0.5) --- (0.05)2

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The formula above assumes random sampling and that the sample size is small relative to the population size (practically this is true when the sample size is less than about 10% of the population size).

3.7 Inclusion and exclusion criteria

3.7.1 Inclusion Criteria

Households must be in the Migori HES Program intervention areas, either in the intervention or have been earmarked for future intervention (non-intervention area). Households must have been affected by HIV/AIDS (has lost one or both parents) and has at least one OVC aged 6- 60 months under the care of a biological parent, foster parent, or grandparent as the caregiver. For intervention area, household must have been enrolled in the HES program for more than three years and are beneficiaries who have benefited from the savings and loaning scheme, and are willing to take part in the study.

3.7.2 Exclusion Criteria

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3.8 Pilot Study

3.8.1 Description of sharpening of the data collection instruments

Pretesting of the data collection tools was done in Suba District with similar earlier intervention, but a different district from where the actual study took place. This was to check whether the tools were good enough to collect what they were intended to collect, as well as identify errors associated with the tools design, and also estimate the average time required to complete the one data collection process. The tools were revised in terms of rephrasing questions which prompted ambiguous responses and also timing of the interview sessions.

3.8.2 Validity

The instruments were pretested to as indicated in if they are suiTable to gather the information they were meant to collect and in a manner that does not alter the response received. It put into consideration issues of translation to the local language without distorting the questions.

3.8.3 Reliability

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3.9 Recruitment of Research Assistants

Ten research assistants aged 18 – 30 years; who comprised of six form four graduates assisted with administration of questionnaires and four nursing college student interns, who conducted anthropometric tests, were recruited and assisted in data collection. The nursing interns were taught how to conduct anthropometric tests by a clinical officer at the Migori district health centre, while the six students were trained on administration of the questionnaire in the local language. They could all speak the local language; dholuo fluently, as they were natives from Migori, and also had good knowledge of the area. The training was conducted for one day and covered overall research design, communication skills interviewing and recording, and how to obtain informed consent and the ethics of confidentiality and anonymity in research.

3.10 Data Collection Techniques

The study employed household questionnaires, anthropometric measurements and observation checklists (as indicated in Annex 5). The questionnaire was used to collect quantitative data on household income and child health status. Anthropometric measurements were done for child nutritional assessment, as well as recording of weights and heights of children. Checklists were used to observe and record signs of physical abuse on the child.

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measurements which will included weight, height, age, and mid-upper arm circumference (MUAC) measurements of children aged 6 – 60 months years were done. General nutritional assessment was done by by four nursing interns from Migori Sub district hospital who took anthropometric measures of for weight, height and MUAC tape for upper arm circumference.

Height was measured at home as follows; to calculate height for age (H/A)

1. Removed the child's shoes, bulky clothing, and hair ornaments, and unbraid hair that interferes with the measurement.

2. Took the height measurement on flooring that is not carpeted and against a flat surface such as a wall with no molding.

3. Had the child stand with feet flat, together, and against the wall. Made sure legs were straight, arms were at sides, and shoulders were level.

4. Made sure the child was looking straight ahead and that the line of sight was parallel with the floor.

5. Took the measurement while the child stood with head, shoulders, buttocks, and heels touching the flat surface (wall). Depending on the overall body shape of the child, all points did not touch the wall.

6. Used a flat headpiece to form a right angle with the wall and lower the headpiece until it firmly touches the crown of the head.

7. Made sure the measurer's eyes were at the same level as the headpiece.

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9. Accurately record the height to the nearest 0.1 centimeter.

Weight was measured at home as follows to calculate Weight for age (W/A): 1. Used a digital scale. Placed the scale on firm flooring rather than carpet. 2. Had the child remove shoes and heavy clothing, such as sweaters. 3. Had the child stand with both feet in the center of the scale.

4. Recorded the weight to the nearest decimal fraction (for example, 25.1 kilograms). The mid upper arm circumference (MUAC) of children aged 6 –60 months gives an indication of the degree of wasting and is a good predictor of mortality. MUAC is the circumference of the left upper arm and was measured at the mid-point between the tips of the shoulder and elbow. The MUAC tape was used to asses MUAC. The tape had colour coded cut off points indicating various levels of malnutrition for young children. It was done as follows.

1. Bent the left arm, fond and mark with a pen the olecranon process and acromium. 2. Marked the mid-point between these two marks.

3. With the arm hanging straight down, wrapped a MUAC tape around the arm at the midpoint mark.

4. Measured to the nearest 1 mm.

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young children with, or at risk of, severe acute malnutrition. In children 6-60 months old, MUAC <110 mm indicates severe malnutrition and is recommended as a criterion of admission to therapeutic feeding programmes. Values between 110 and 120/125 mm indicate moderate malnutrition. Weights and heights of respective ages were also recorded differences in their means tested statistically, to find out which groups of children between intervention and non-intervention were better for by respective weights and heights.

3.11 Logistical and Ethical Considerations

Ethical approval for the research study was obtained from the Kenyatta University Graduate School, Kenyatta University Research and Ethics Committee KU-ERC, and the National Commission for Science Technology and Innovation (NACOSTI). Willful informed consent of respondents was sought before the interviews and, confidentiality was also assured and observed. To maintain confidentiality, the study cover sheet, which included identifying information, also included unique numerical identifiers. No respondent names were documented to assure confidentiality. In this case, nonresponse was traced back to the respective respondent. The feedback from these respondents was only be used for purposes of this academic research

All respondents were informed of voluntary participation and that choice of participation would not affect their eligibility to receive program services, then and in future. Participant’s verbal consent for participation was obtained. Caregivers granted consent

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clear respondents. Consent was also acquired from children themselves, using child-friendly language to support their understanding. Once consent was granted, the interviewer signed the consent form for the participant.

Raw data (filled tools) was solely kept by the student and computerized (electronic) data was also kept solely by the student and password protected for safeguarding and protection from unauthorized access by third parties.

3.12 Data analysis and presentation

Descriptive and inferential statistical techniques were used for quantitative data analysis for both socio-economic, demographic information, and anthropometry measures to generate means, frequencies and percentages. Data analysis was done using STATA software package version 13. Frequencies were used to describe results.

Statistical tests including T-tests and Pearson’s chi-squares tests were used to test association of categorical variables and significance levels on variables. Summaries of findings have been presented in Tables, bar graphs, pie charts and text. All p-values ≤ 0.05 were considered statistically significant.

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CHAPTER FOUR: RESULTS

4.1 Socio-Demographic Results

The Migori HES program was a five years program, at the time of the study; intervention had run for between three to four years. Intervention group was Suba West and Non-Intervention Group was Suba East Divisions of Migori County, which included household caring for orphans and vulnerable children. The study population comprised a total of 400 households, of whom 200 (50%) households benefitted from Intervention and the other 200 (50%) did not benefit, but had been ear-marked for the next phase of programming. All respondents were selected from a beneficiary list of households in Suba West (intervention) sub-county and Suba East (non-intervention) sub-county.

As indicated in the Figure 4.1; most caregivers were female as shown in the intervention (with 64% female, and 36% male) and Non-Intervention group (with 57% female, and 43% male). A total 400 caregivers (who were either biological Parents or foster Parents) aged between 15–49 years, and 400 Children took part in the study. The children had either lost one or both parents; hence under the care of foster parents).

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Majority of caregivers were aged 30-39 years, with intervention having 52% and Non-Intervention having 48% followed by 20 – 29 Years with intervention having 16% and Non-Intervention having 22%. Senior citizens aged 50 years over comprised the least proportion of caregivers, who were relatives, as shown in Figure 4.2 below.

Figure 4.2: Distribution of caregiver age 2

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Figure 4.3: Distribution of Caregiver Education Status 3

Similarly, female OVCs in the intervention (55%) and non-intervention (53%) groups comprised more than half of all children in the study. This is indicted in Figure 4.4 below.

Figure 4.4: Distribution of Orphans and Vulnerable Children (OVC) by sex 4

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Non-Intervention (27%) groups. Ages 24-35 months and 48-60 months had a somewhat similar proportion of children, between 20% and 24%, in both groups. This is indicated in Figure 4.5 below.

Figure 4.5: Distribution of OVC age 5

The average family size for OVC households maintained a steady decline, most household in both the intervention and non-intervention groups had between 1 – 5 people, with fewer households having less family members as the average household climbed beyond five, as indicated in Figure 4.6 below.

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Further statistical analysis of this socio-demographic data, as shown in Table 4.1 below, indicated that the two groups were similar and not different by way of age, sex and caregiver education except in the case of OVC household size, as shown by p value >0.005, and so there were no differences that could be attributed to differences observed in the outcomes of health, nutrition and protection of OVC.

Variable Intervention HH Non-intervention HH Parametric tests

Mean group

Median Prop. (%)

Median Prop. (%) Chi-square, p value Caregiver sex

2*=female

2* 2 54 2 57 ᵪ2 = 0.0154

p value = 0.619 Caregiver age 30-39

Years

34.5 52 34.5 48 ᵪ2 = 0.0142

p value = 0.389 Caregiver educ.

1**=Male

1** 1 48 1 54 ᵪ2 = 0.0261

p value =0.276 OVC sex

2*=Female

2* 2 55 2* 52 ᵪ2 = 0.0135

p value = 0.579 OVC Age 37-48

Months

42.5 28 42.5 27 ᵪ2 = 0.0182

p value =0.713 OVC HH

Family size

1-5 5.5 58 5.5 46 ᵪ2 = 0.0161

p value = 0.00198

Table 4.1: Socio-demographic data 1

4.1.1 Association of caregiver education to OVC health

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p value were greater than 0.05 in both groups implying a weak relationship, except in the case of pneumonia verses caregiver education in the intervention group which showed a significant negative association as indicated by the p value that was less than 0.05. In the case of the relationship between Immunization and caregiver education for the intervention group there was a positive association implying that increase in caregiver education was associated with completion of immunization, as indicated in Table 4.2

Variable Intervention Non

Intervention

Equality of correlations Malaria vs caregiver

education

ᵪ2 -0.0705 -0.0108 Negatively associated but not significant p value 0.321 0.8795

Pneumonia vs caregiver education

ᵪ2 -0.1499 -0.0006 Significant difference in intervention

p value 0.0341 0.9937 Diarrhea vs caregiver

education

ᵪ2 -0.1286 -0.1058 Negatively associated but not significant p value 0.0696 0.1359

Immunization vs caregiver education

ᵪ2 0.0832 -0.0583 No significant difference p value 0.2415 0.4121

Table 4.2: Association of caregiver education to OVC health 2

4.1.2 Association of caregiver education to OVC nutrition

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Weight for Age, however this was not significant due to the p value that was greater than 0.05, as indicated in Table 4.3.

Relationships Parametric test

Intervention Non Intervention

Equality of Correlation MUAC vs caregiver

education

ᵪ2 0.0974 0.0273 Positively association

but not significant

p value 0.1699 0.7008

Weight /Age vs caregiver education

ᵪ2 0.0502 0.1281 Positively associated

but not significant

p value 0.4806 0.0706

Table 4.3: Association of caregiver education to OVC nutrition 3

4.1.3 Association of caregiver education to OVC protection from abuse and neglect

There was a weak negative association between caregiver education with protection of OVC from abuse and neglect, because the p value in all cases were greater than 0.05. It was observed that in both groups, as caregiver education improved, cases of OVC abuse and neglect went down, however this was not significant, as indicated below in Table 4.4.

Variable Parametric

test

Intervention Non

Intervention

Relationship

OVC Abuse vs caregiver educ.

ᵪ2 -0.0687 -0.0619 Negatively associated

but not significant

p value 0.334 0.3836

OVC Neglect vs caregiver educ.

ᵪ2 -0.0477 -0.0946 Negatively associated

but not significant

p value 0.502 0.1828

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4.1.4 Association of HES intervention to OVC health

Being in the intervention had a positive association with reduction in the cases malaria, pneumonia and diarrhea, as indicated with negative correlations, and the associations were significant as shown by the p value < 0.05, as indicated in Table 4.5 below.

Disease Parametric tests Chi-square, p value Relationship

Malaria ᵪ2 -0.163 Significantly

Associated

p value 0.0211

Pneumonia ᵪ2 -0.2033 Significantly

Associated

p value 0.0039

Diarrhea ᵪ2 -0.1345 Significantly

Associated

p value 0.0575

Table 4.5: Association of intervention to OVC health outcomes 5

4.1.5 Association of HES intervention to OVC MUAC and Immunization.

Being in the intervention positively associated to OVC Mid Upper Arm Circumference (MUAC) and completion of immunizations, and the association was significant as indicated by the p value < 0.05, as shown in Table 4.6 below.

Variable Chi-square p value Relationship

MUAC ᵪ2 0.3091 Significantly

associated

p value 0.0000

Complete Immunization ᵪ2 0.3203 Significantly

associated

p value 0.0000

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4.1.6 Association of HES intervention to OVC protection from abuse and neglect

Intervention reduced cases of OVC Protection from abuse and neglect, but this was only significant in the cases of abuse, but not in neglect as shown in Table 4.7 below

Variable Parametric test Chi-square, p value Relationship

Abuse Cases ᵪ2 -0.2406 Strongly

Associated

p value 0.0000

Neglect ᵪ2 -0.049 Not strongly

Associated

p value 0.372

Table 4.7: Association of intervention to OVC protection from abuse and neglect 7

4.2 Socio – Economic Results

4.2.1 Income generating activities (IGA)

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significant differences between intervention and non-intervention HH which were involved in peasant farming, operating a retail shop, Food kiosk and selling cereals, indicating that intervention significantly affected HH income.

Variable Intervention Non-intervention Parametric

Tests IGA / Socio-Econ. Activity Mean Income Group (Kes‘000) Median Income (Kes’000) HH Prop. (%) Mean Income group (Kes’000) Median Income (Kes’000) HH Prop. (%)

Mining 10k-30k 20k 5 10k-30k 20k 18

ᵪ2 = 0.0146 p = 0.0689 Selling

Cereals 31k + 44.5k 28 11k-20k 15.5k 22

ᵪ2 = 0.0142 p = 0.0001 Peasant

Farming 1.0k-11k 6k 13 1.0k-11k 6k 28

ᵪ2 = 0.0252 p = 0.0001 Fish

Mongering 11k-20k 15.5k 16 11k-20k 15.5k 14

ᵪ2 = 0.0148 p = 0.5793 Food

Kiosk 31k + 44.5k 20 21k-30k 25.5k 10

ᵪ2 = 0.0193 p = 0.0001 Retail

Shop 20k-30k 25k 18 11k-20k 15.5k 8

ᵪ2 = 0.0151 p = 0.0001

Table 4.8: HH monthly median Income by type of Income Generating Activity (IGA) 8

4.2.1.1 Association of HH IGA type to OVC Nutrition

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fish mongering, peasant farming and selling cereals where the p value was greater than 0.05, as indicated in Table 4.9 below. This observation could be explained that when food remains after sale, then parents take what is left to be consumed at household level and thus improving the OVC nutrition status.

IGA Type Nutrition Non -Intervention mean

Intervention mean

t-test p value

Fish

Mongering

MUAC 12.196 12.625 -2.6491 0.0104*

WAZ 0.474423 0.656597 -0.0408 0.9676

Food kiosk MUAC 12.625 12.454 -4.8025 0.0001*

WAZ 0.911932 0.529983 2.1413 0.0426

Peasant farming

MUAC 12.153 12.621 -2.5965 0.0114*

WAZ 0.517522 0.529983 -0.1911 0.8491

Selling cereals

MUAC 11.490 12.564 -3.7066 0.0003*

WAZ 0.428464 0.416721 0.3373 0.7365

* Significant difference

Table 4.9: Association of IGA type to OVC Nutrition 9

4.2.1.2 Association of household Income to OVC Health

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pneumonia and diarrhea with income in both intervention and non-intervention, p value were greater than 0.05, indicating weak association. There was also weak positive association of income and complete immunization for the intervention group, as shown a p value greater than 0.05, but a strong positive association in the non-intervention, as indicated by a p value less than 0.05, implying that as income increased, cases of OVC with complete immunization also increased, as indicated in Table 4.10.

Relationship Parametric test Intervention Non-intervention Equality of correlations Malaria vs HH

Income

ᵪ2 -0.2645 0.0153 Significant association

p value 0.0002 0.8298

Pneumonia vs HH Income

ᵪ2 -0.0216 -0.0197 No association

p value 0.761 0.7821

Diarrhea vs HH Income

ᵪ2 -0.1219 -0.1058 No association

p value 0.0856 0.1359

Immunization vs HH Income

ᵪ2 0.0562 0.1455 Significant association

p value 0.04293 0.0398

Table 4.10: Association of HH income to OVC Health 10

4.2.1.3 Association of Household Income to OVC Nutrition

Figure

Figure 1.1:
Figure 4.1: Distribution of caregivers by sex
Figure 4.2: Distribution of caregiver age
Figure 4.4: Distribution of Orphans and Vulnerable Children (OVC) by sex
+7

References

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