Maternal AIDS Orphans and the Burden of Parenting in Youth-headed Households; Implications for Food Security in Impoverished Areas of South Africa

The increasing number of AIDS orphans has led to an increase in child and youth headed households. Adjusting to the parenting role with no support from their extended family is a source of distress for orphans heading households. This study explored the parenting experiences of orphaned youth heading households in resource constraints environments.


INTRODUCTION
Although the incidence and prevalence of HIV are declining, AIDS is still a major cause of orphaning and orphanhood continues to be a significant problem for national governments and international AIDS organizations [1,2]. The increasing number of AIDS orphans has led to an increase in Child-Headed Households (CHH) where the person identified as the head is under 18 years of age and youth-headed households (YHHs) where the household head is above 18 years but under 25 years of age [3,4]. A youth is defined as persons between the ages of 15 and 24 years [5]. In these households, the child or youth takes the decision and other responsibilities usually borne by parents, including the provision of care to other children in the household [6 -8]. The emergence of these household deprives the children of their childhood [9].
The emergence of CHHs and YHHs is a direct consequence of the increasing number of orphans as well as the erosion and dismantling of the social support system for orphans and families by the scourge of HIV/AIDS [4,6,10]. Literature suggests that older age is presently the criteria for assuming the parenting role in the household affected by HIV/AIDS [11]. Ciganda et al. [6] argued that, many households that start as child-headed change their status when the head turns 18 years old, without qualitatively changing their situation. This observation is supported by Popoola and Mchunu [3], who argued that the deleterious effects of HIV orphanhood do not get better when children turn 18 or that they have stopped being orphans.
Orphans in CHHs and YHHs live in absolute poverty [4,10]. According to Sharp et al. [2], poverty is characterized as both a risk factor and an immediate orphanhood-related consequence. Furthermore, the impoverished living conditions of orphans in these households are often a direct result of being chased out of their homes by relatives who claim to have inherited their house from the children's deceased parents [12]. This is one of the reasons the majority of orphaned children in CHHs and YHHs live in informal settlements, rural settings, or urban slums [13,14].
Orphans heading child-headed and youth-headed households face challenges daily. They are much more economically vulnerable, more vulnerable to food insecurity, to educational disruption, to inadequate housing, to poor security, and maltreatment by extended family members than children whose parents are alive [8, 10, 15 -17]. After the death of their parents, household heads are forced to make the adjustment from being a child to assuming the role of a parent, without being prepared for it because of the lack of support from their relatives or extended family [18]. They struggle to adjust to the role of taking decisions on the health, psychological, and emotional needs of their siblings [10,19]. Although research conducted in South Africa in the past two decades has played a key role in understanding the experiences and challenges of orphans in CHHs [20], most of these studies describe how orphaned children are supported through the government's social grant system. However, once the orphaned children are above 18 years old, they are removed from the system and their social grants are terminated [21]. Therefore, there is a greater need to include older orphans in research, given the increase in households headed by young people in Sub-Saharan Africa. Youth heading households represent a unique category of orphans because they have different needs from those of orphaned children below 18 years [3]. For example, the risk to leave school prematurely is higher amongst older orphans, in particular, those heading households to find employment to provide for their siblings [10,15,22,23].
There is a gap in the knowledge of how orphaned youths heading households cope after being removed from the social grant system. Their first-hand experience of assuming or continuing to play the role of a parent while still young and having to deal with severe resource constraints has not been explored. Studies indicate that adjusting to the parenting role with no support from their extended family is a source of distress for orphans heading households [10,13,24]. This is heightened by the feeling of moral obligation to take the place of the dead parent and care for their siblings [19,25,26]. Therefore, this study explored the parenting experiences of orphaned youth heading households in resource constraints environments. The findings will contribute to the development of effective public health response to the effects of HIV orphanhood on orphans in YHHs in Sub-Saharan Africa [3].

Study Design and Setting
Descriptive phenomenology was used to explore the lived experiences of YHHs [27]. The study setting was households headed by youths located in informal settlements of a township in the City of Tshwane. The township is multi-cultural with a wide diversity of ethnic groups due to the migration of people from rural areas to urban areas. It is surrounded by several informal settlements with a total population of approximately 200 000 people.
We used purposive sampling to select participants, which is consistent with phenomenological inquiry [28]. We selected only participants from whom we could learn and understand the lived experiences of household heads. The participants were selected to participate if they were between 15 and 25 years old, were the heads of their households, and taking care of siblings.
The participants were recruited with the help of Non-profit Organisations (NGOs), which assisted the researchers to identify household heads living in informal settlements. The NGOs are located in informal settlements and provide services to Orphans and Vulnerable Children (OVC). They assist with school programmes, food parcels, and obtaining birth registrations and social grants. We excluded orphans younger than 15 years and those above 25 years old. Eighteen household heads were interviewed, and the data acquired provided a comprehensive understanding of the context of being a youth heading a household. The sample size is in line with the phenomenological approach, recommends a sample size ranging from 1-10 participants [29] because the aim is to acquire information that is useful for understanding the complexity, depth, variation, or context surrounding a phenomenon [30].

Data Collection
An interview schedule of open-ended questions was used to conduct semi-structured in-depth interviews with the household head. All the authors collected data, but the lead author (ES) conducted most of the interviews. The household heads were interviewed in their language of choice (Sepedi, IsiZulu or IsiXhosa). In line with the tradition of phenomenology [31], the household heads were asked two key questions about what was it like to be a youth heading a household, and about their experiences of caring for their siblings. However, other questions were asked and probes were used to verify or clarify the responses. The interview schedule was semi-structured and allowed the household heads to speak freely about their experiences [31]. The household heads were interviewed in their homes or at the premises of the NGOs, depending on what was convenient for them. The interviews were conducted in private, lasted for 30-45 minutes, and were recorded with consent of the household head. Written informed consent was obtained before the interviews took place. Youth under the age of 18 years signed an assent form and social workers acted as legal guardians and signed the consent form.
In addition, sociodemographic variables included age, gender, schooling status, number of siblings, access to social grants, type of housing, and employment status.

Data Analysis
The data analysis was inductive and followed the thematic approach summarised by Sundler et al. [32]. All the authors were involved in the data analysis. First, the transcripts were translated into English by the lead author (ES), while listening to the recordings to ensure accuracy. The authors independently read a few of the transcripts repeatedly to develop familiarity with the data. Next, they searched for statements of meanings to uncover emergent themes that described the lived experiences of YHHs. The identified units of meaning were then categorised into themes. NVivo (QSR International, Melbourne, Australia), a qualitative data analysis package, was utilised for the analysis process. The emergent themes were integrated and synthesised into meaningful wholeness, reflecting the phenomena of the experiences of the participants.
Various credibility methodologies, including peerdebriefing sessions, conducting the interviews in local languages, transcribing the responses verbatim, and taking the extensive field and interview notes were employed to ensure rigour. All the authors analysed the data to ensure that the interpretation was free of bias. Rigour in qualitative research ensures that the study findings are credible and, therefore, transferable to other settings in similar contexts.

Demographic Profile of Youths Heading Households
The average age of the youth was 21 years, with an age range of 15-24 years, thirteen were females and five were males. Twelve youth reported that they had dropped out of school and six were attending school. Concerning the source of their income, three youth reported that they were receiving child support grants on behalf of their siblings, and none reported to be receiving child foster grants. Two of the youths reported that their source of income was part-time jobs.

Emergent Themes
Three themes emerged from the analysis of the interviews: (1) parenting is overwhelming, (2) being a parent is difficult, and (3) longing for support ( Fig. 1).

Parenting is Overwhelming
The responsibility of heading a household is generally the role of adult parents. When this function is performed by the household head, they are deprived of their childhood and forced to take on adult roles without support. The participants reported that the adjustment from being a young person to being the head of a household was overwhelming. Their experiences of parenting were that it deprived them of their youth. The following sub-themes, in particular, feeling obliged to care and feeling compelled to put their siblings first amplify their reports of the feeling of being overwhelmed.

Feeling Morally Obliged to Care
Upon assuming the role of a parent in the household, the household head in the study expressed a feeling of being morally obligated to care for their siblings. They felt that it was their responsibility to keep their younger siblings out of harm's way, and to protect and love them, thus closing the void left by the absence of their parents.
After the death of my mother, my siblings were looking upon me for everything; it is my responsibility to stay with my sibling. Our stepfather chased us from his house, I am obliged to care for my sibling and I will make sure that I work hard for my sister and brother to have a better life; they must not drop school; Kgaogelo, a 24-years-old female.
It's a burden that is heavy to carry because now I'm all over the streets asking for food and my friend was also trying to hustle money from the neighbourhood but we never got it, eish... This is one of those days that I hate because now my sibling will come to an empty home with no food; Repholositswe, a 23-year-old female.

Compelled to Put Siblings First
The household head reported feeling compelled to put their siblings' needs first ahead of their own in all their decisions. For example, they dropped out of school and avoided engaging in a romantic relationship.

Dropping Out of School to Care for the Siblings
Putting others first involved the household head dropping out of school and sacrificing the money they received to buy things for their siblings. Onthatile, a 25-year-old female who had dropped out of college to work in a restaurant, said: I want my siblings to be like other children. I don't want them to be left out when other children have Christmas clothes and they don't have. When I lay-bye clothes for my children, I also lay-bye clothes for them. Even myself, I wish to dress nice clothes, but I can't because I have a lot of children to care for.
Repholositswe, a 23-year-old female explained the situation further and said: I dropped school because I had to take care of my younger sister. At times when I look at her complaining that her school shoes are worn out and she wants new ones, I just look at her and feel sad. She does not understand that it is tough to get a job. I dropped school to find a job, to be able to work and take care of her, I am trying… I can't even buy myself anything. I wish one day she could see the struggle I do for her.

Avoiding Romantic Relationships
The household head, particularly the males, reported that they chose not to be involved in romantic relationships. They believed that being in a relationship required one to have money to spend on the partner, and that compelled them to forego having romantic relationships in order to save money to meet the basic needs of the household.
It is difficult to have a relationship. I find it hard to engage in relationship… I will not have time to see her because I am always at the taxi rank washing taxis. There is no time. I once had a girlfriend but the relationship did not work. It just died a silent death. I was hurt, and I decided to stop issues of relationship." ; Repholositswe, a 23-year-old male.

Being a Parent is Difficult
After the death of the parents, the elder child instinctively feels obliged to take on the adult parenting role to provide for the siblings. Assuming the parenting role forced the household head to make complex decisions on what and when to eat, how to spend the little money they have, and how to instil discipline. They found the parenting role to be difficult and were unable to provide food or to discipline their siblings. These emerged as the major sub-themes.

Inability to Provide Food
Most of the household heads talked about the lack of food as one of the greatest difficulties they experienced after assuming the role of parenting. They recounted incidents when there would be no food for the children after school and when they would go to bed without food; Reyagoboka, a 22-year-old female had this to say; It's heartbreaking to see the siblings coming home without food. One day when she [her sibling] came back from school…, there was no food. She looked tired…, and she was not talking. I asked her what was wrong. She said nothing is wrong. It pained me. One day I found her diary. I read it. She wrote about the situations in the house. She said she wished that every day she could come home to find food. I am not working and looking for a job, there is nothing we can do. We rely on her social grant. Unfortunately, she is not talkative, she dies inside." Tshepang, a 25-years-old female who dropped out of school to care for her three siblings, her own child, and her brother's child said.
Sometimes when the children come back from school, there is nothing to eat. They eat at school but that does not last them for long. When I know there is no food, I force the little ones to sleep early and they will get their next meal the following day at school.

Inability to Discipline
The household head reported finding instilling discipline in their siblings very difficult for various reasons. Some said that because they had been physically abused by members of their extended families when they resided in the same households, they would not do that to their siblings. In addition, they felt that they did not have the skills to talk to them or discipline them, since they had not been prepared to assume the parenting role. Furthermore, the female said that they were afraid to discipline their siblings for fear that they might retaliate. Lerato, a 25-year-old female taking care of two brothers, said: It is difficult to discipline the siblings, as sometimes they do not want to listen. It is even more complex if the siblings are boys because as they grow older, you become fearful to punish them. Remember they are boys, and they are grown-ups. Even when I shout at them, I do that with caution. Imagine if they try to beat me!

Unable to Support Regular School Attendance
While most household heads dropped out of school to care for their siblings and ensure they attended school, they found that supporting their siblings to attend school regularly was a challenging task.

Living Under Impoverished Conditions
The household heads were living in shacks in informal settlements after they had been chased out of their mothers' houses by their uncles, aunts or stepfathers.

We don't have a home now and rent other people's shack because of my uncle. He took my child's birth certificate to get an RDP house for himself. I cannot apply for a house now. He stays in the family house and has an RDP house as well;
Omphemetse, a 22-years-old female.
As mentioned, when an orphan turns 18 years old, their social grants are terminated, and some household siblings under 18 years do not receive the grant because they lack documentation to apply. However, narratives revealed that in some instances, their extended families take the money from the social grant from those who receive it, for their personal use. Keamogetswe, a 24-year-old female who had four siblings, had this to say: My siblings receive child social grants, but my aunt takes it. She does not give us anything. She supports her children and husband with that money.

Longing for Support
The household heads' narratives revealed that although some had extended families in their locality or where they migrated to after the death of their parents, they received no financial or emotional support from these relatives. They recounted how the relationships they had with their parents' families ended the day their parents died: When my father was still alive, we used to go to them and they would help us and give us food here and there. However, after he died, they kicked us out. We did not have a place to call home as the house belonged to my grandmother. I asked if we can stay in her yard and she refused. When I told her that we don't have a place to live and food, she told us that she does not care and does not want to be involved; Olerato, a 22-yearold female.
My aunt stays in the same area and she is a hawker. She passes by this street every day as it is a main street, but she does not help us with food. She can't even buy us electricity; Kgaogelo, a 24-year-old female.

DISCUSSION
In this study, the YHHs occurred in an underprivileged environment in an informal settlement. The household heads and their siblings lived in absolute poverty in one-roomed shacks and or sharing free government houses [13,33]. The state of poverty is exacerbated by the forceful removal of orphans from their parents' homes after the death of the mother. Moreover, most of the household heads did not receive any child support or foster grants for their siblings because they lacked proper birth registration documentation and knowledge of the process of application for foster grants. The lack of foster grants renders the household heads financially incapacitated and more vulnerable to exploitation and abuse (Popoola, 2016). Studies show that a significant number of orphans in children and YHHs fail to receive government social grants to balance their income [7,34]. There is a need to review the age-based criteria and definitions for determining support eligibility for HIV orphans [3].
Our findings are consistent with those from previous studies that the parenting role is burdensome, partly because household heads take on the roles and tasks of parenting without material resources, social support for survival, and a lack of decision making skills [10,13,24]. Masondo [19] indicates that household heads struggle to adjust to the role of taking decisions on the health and the psychological needs of their siblings. The parenting role was a source of emotional stress for household heads who experience role adjustment from being a child to a parent as difficult [4,9]. They have to manage multiple responsibilities of surviving economic hardships and to keep their siblings together [8,26,35]. Therefore, it is crucial to provide psychosocial support to enable household heads to carry out their caregiving roles without adverse impact on their own wellbeing [36].
Poverty is a common theme in YHHs and affects the ability and capacity for basic caregiving [17]. Since household heads are likely to drop out of school early [15,34,37], they lack the skills for the job market and remain unemployed. This perpetuates the economic challenges and material deprivation of the households [7]. The current study found that the economic hardships of orphans in YHHs are compounded by the lack of child and foster grants.
Consistent with other studies [8,14,38], the household heads found it difficult to provide adequate food to feed their siblings. Orphans in these households frequently go to bed hungry and go to school on an empty stomach. Not being able to provide food resulted in constant hunger among household siblings. The frequency of going to bed hungry was the most difficult part of the parenting role and a source of great pain and sadness for the household heads, which increased their risk of mental distress [39]. Often times, orphans in these households depended on the daily meal provided by the schoolfeeding scheme, which provides food to learners from disadvantaged communities during school hours [40,41]. Similarly, in Zimbabwe, increasingly, learners are dependent on school nutrition programmes because of hunger and poverty [42].
Studies confirm that being maternal orphan increases a child's vulnerability to food insecurity and poor nutritional outcomes [43 -45]. It is important to note that the school nutrition programme is not the answer to poverty and hunger for orphans in YHHs because of evidence of persistently high levels of malnutrition among children at NSNP schools [41]. Previous studies found that food insecurity increases the risk of psychological problems for HIV orphans and established the link between poverty and distress among orphans [46]. Similarly,Maraise et al. [47] found an association between the mental health status of orphans and poverty and malnutrition. Cluver and Orkin [48] argued that interventions addressing food insecurity may potentially improve mental health outcomes of orphans in children or YHHs. Nkomo [26] identified the feeling of an obligation to take the place of the deceased parents as one of the components of role adjustment in YHHs. Our findings are consistent with those from previous studies that observed similar conduct; the household heads felt morally obliged to care for their siblings in an attempt to close the void caused by the absence of their parents [8,49]. We found that the obligation to care led to some of the household heads dropping out of school to find employment. They self-sacrificed their desire to complete school by putting the economic needs of their households and siblings first, and by so doing, missed the chance of tertiary education.
Dropping out of school was a source of emotional distress for the household heads. Parental responsibilities come at a price to the educational pursuits and psychosocial well-being for household heads [24]. In a study conducted in Zimbabwe Shava et al. [7] reported that orphans are forced to leave school early due to the pressure of looking after siblings. Similarly, Robson et al. [14] reported that the impoverished living conditions of orphans force household heads into work and prevent them from attending school. The findings from the current study and others explain the high rate of school dropout in YHHs reported in the literature [9,13,15,23,37]. Early withdrawal from school reduces employment opportunities for orphans [42], has a negative effect on their psychosocial wellbeing [7], and further exacerbates the economic deprivation and continues the vicious cycle of poverty.
The study found that the household heads also selfsacrifice engaging in romantic relationships. Their narratives revealed feeling compelled to avoid engaging in romantic relationships because that would compete with the needs to care for their siblings. The males, in particular, felt that relationships are expensive to maintain and require one to have money to spend on the partner. Popoola and Mchunu [25] found that the assumption of parental roles leads to selfneglect, which gives rise to isolation, loneliness, and mental distress among household heads [50]. Whereas the male household heads avoided engaging in romantic relationships, the economic deprivation of females in these households renders them vulnerable to sexual exploitation [8,16] and engage in transactional sex for economic survival [16,51]. This behaviour was not common in the current study; however, a few household heads were reliant on their boyfriend to fulfil their economic needs.
The current study and others found that orphans in YHHs live without proper guidance, discipline and control. The household heads lack the skills and willingness to instil discipline in their siblings. Other findings suggest that a lack of disciplinary measures in YHHs leads to bad behaviour in school [9]. The implications of the lack of discipline are that the household heads spent more time performing household chores than their siblings [33,49]. This has a negative impact on their health.

Limitations of the Study
The limitation of the study is that the study was conducted in under resourced informal settlements and challenges and lived experiences of household heads were not compared to heads of households in the environment with resources. While the study assessed the burden of care on youth heading household, the implications thereof on their physical health was not assessed. Furthermore, the views of the siblings in the household head-headed household were not captured to explore how they experience living in the household head-headed household.

CONCLUSION
Although, the child support and foster grant are widely recognised for improving children's access to food, education and basic services in South Africa, in the current study, the orphaned children were not recipients of these grants. This contributed to the economic hardships and vulnerability to food insecurity and hunger. The Department of Social Development should consider funding community NGOs to fast track access to social grants for orphans in YHHs.
Parenting was difficult and burdensome and increased the risk of mental distress for the household heads. It is important that support systems, especially the provision of child and foster grants, are evaluated to include older orphans above 18 years old. Multi-sectoral interventions are needed to address food insecurity, and in so doing, improve the psychosocial wellbeing of orphans in CHHs or YHHs.
In a country that provides subsidised housing for citizens, we found that the living conditions of orphans in YHHs were unpleasant, as they live in absolute poverty in impoverished informal settlements. It is important that the Department of Human Settlement and Housing should prioritise the provision of houses to orphaned children living in CHHs and YHHs.

AUTHORS' CONTRIBUTION
All the authors contributed to the design of the study, analysis and interpretation. ES collected the data. BN and SM supervised the study. ES wrote the first draft of the manuscript, SM revised and refined the manuscript and contributed to the edition of the manuscript. All the authors critically revised the manuscript and have approved the final manuscript

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
Ethical clearance was obtained from the Research and Ethics Committee of Sefako Makgatho Health Science University, South Africa (SMUREC/H/53/2016: PG). Permission was also sought from the Department of Social Development and from the NGOs. Confidentiality was maintained and pseudonyms were used to protect their identities.

HUMAN AND ANIMAL RIGHTS
Not applicable.

CONSENT FOR PUBLICATION
Written informed consent was obtained from the participants and participation was voluntary.